On the first day of his second term in office, President Donald Trump issued an executive order mandating an immediate “pause” of new foreign aid while programs were evaluated for whether they were “fully aligned with the foreign policy of the President of the United States.” And on January 24, Secretary of State Marco Rubio issued an order for foreign aid programs to stop work even on programs for which funds had already been distributed.
One program swept up in these broad orders has been wildly successful in combating the global HIV/AIDS epidemic since it was first signed into law by President George W. Bush in 2003. PEPFAR, the President’s Emergency Plan for AIDS Relief, costs $7.5 billion annually, or about 0.1 percent of the federal budget, and is credited with having saved an estimated 26 million lives over two decades. Before the program was implemented, half of all infants in Africa infected with HIV at birth died by their second birthday, and PEPFAR is estimated to have saved nearly 8 million infants from being born with HIV. While PEPFAR is a worldwide operation, most resources are devoted to sub-Saharan Africa, and it has provided a measure of economic and political stability to a region of the world susceptible to the advance of Islamic extremism and the encroachment of geopolitical adversaries of the United States.
After Trump’s order prompted a public outcry over the halting of such humanitarian programs, Rubio issued two waivers designed to exempt some foreign-aid programs from the “stop work” orders: one on January 28 for lifesaving care in general and another on February 1 specifically exempting many but not all activities of PEPFAR programs. But since the order and despite the waivers, relief groups that administer PEPFAR have struggled to get money needed to continue their work, and some aid sites have shut down.
“PEPFAR is the epitome of soft power,” Louisiana GOP Sen. Bill Cassidy wrote on X on February 3. “It is a Republican initiative, it is pro-life, pro-America and the most popular U.S. program in Africa. There’s even a waiver acknowledging this, yet I’m told that drugs are still being withheld at clinics in Africa. This must be reversed immediately!!”
The next day, Rubio appeared to blame relief groups for the snag. He pointed to his blanket waiver for lifesaving aid and said that if an aid organization “does not know how to apply a waiver, then I have real questions about the competence of that organization — or I wonder whether they’re deliberately sabotaging it for purposes of making a political point.”
But more than a month after Rubio’s waivers were put in place, PEPFAR groups operating around the world are still having trouble accessing funds that are supposed to be available under the waivers, and some contracts that initially qualified for waivers have been canceled. “There are lots of clinics that have closed their doors, forcing people to either pay cash for their drugs or go without. And the places that are working, no one knows for sure if they’re going to get paid,” Dr. Matthew Loftus, who has worked in Africa for the past decade, told The Dispatch.
“A waiver is kind of useless without the ability to have some cash flow. You can’t ship a waiver to a clinic as an antiretroviral medicine.”
Emily Chambers Sharpe
“What happened with the institutions that I know best,” Loftus said, is that “there was a sudden halt on January 24, and then when the waiver was announced, nothing came through.” As of the first week of March, Loftus said, “I’ve not heard that anybody got any money yet.”
The Dispatch asked the State Department last week how many PEPFAR programs have been able to withdraw funds since February 1 but did not receive a reply.
Emily Chambers Sharpe, who now works on international aid programs at the evangelical charity World Relief and previously worked in the Office of the U.S. Global AIDS Coordinator at the State Department, told The Dispatch that aid groups that have qualified for waivers for lifesaving work have been unable to actually draw down funds from the U.S. Agency for International Development’s (USAID) payment system.
“A waiver is kind of useless without the ability to have some cash flow,” Chambers Sharpe said. “You can’t ship a waiver to a clinic as an antiretroviral medicine.”
World Relief, which has contracts with the U.S. government to administer some lifesaving programs but doesn’t currently handle PEPFAR programs, has been able to keep those programs afloat with cash from its own coffers. But not all PEPFAR programs have funding in reserve to keep going for long. The U.N. AIDS program reported at the end of February that in Haiti, where foreign aid accounts for almost all of the country’s anti-HIV/AIDS programs, “128 sites, previously funded by PEPFAR, had completely halted services, out of 181 total sites nationally.”
Elon Musk’s Department of Government Efficiency (DOGE) has played a role in blocking approved funds. On February 24, Matt Bai reported in the Washington Post that on multiple occasions USAID managers prepared PEPFAR payments “and got the agency’s interim leaders to sign off on them with support from the White House,” but each time two DOGE employees who had been embedded at the State Department “would veto the payments — a process that required them to manually check boxes in the payment system one at a time, the same tedious way you probably pay your bills online.”
The problems with PEPFAR funding have only marginally improved over the last two weeks. A source who has been in contact with groups implementing PEPFAR programs told The Dispatch that some PEPFAR funding has finally begun to trickle out, but at a slow pace due to staffing shortages at State. “The bottlenecks are caused through the termination of staff, and there’s limited staff that are reviewing these things,” said the source, who was granted anonymity to share details of private conversations. “From what we understand some folks have been able to draw down funds for previously completed work—if their work falls under the PEPFAR-specific waiver. These payments are taking very long to process and going through on a one-by-one basis, which is why we know some folks have been able to get funds while others haven’t.”
A House Republican raised the issue of ongoing problems with PEPFAR and the waiver process in a meeting last week with Peter Marocco, deputy administrator-designate at USAID. When Marocco met with the House Foreign Affairs Committee, Republican Rep. Mike McCaul of Texas pressed him on why “the waiver process for life-saving foreign aid wasn’t working effectively,” The Bulwark’s Sam Stein reported.
Some PEPFAR groups with work approved by Rubio’s waivers had their contracts canceled without explanation. At the end of February, the Elizabeth Glaser Pediatric AIDS Foundation “received award termination notices for three of its primary USAID agreements, which had previously received approval to resume limited work under the PEPFAR waiver for lifesaving work from the Department of State,” according to the organization. “These projects are supporting more than 350,000 people on HIV treatment, including nearly 10,000 children and more than 10,000 HIV-positive pregnant women” in Lesotho, Eswatini, and Tanzania.
Catherine Connor, vice president for public policy and advocacy at the Glaser Pediatric AIDS Foundation, said the State Department later rescinded the termination, but provided no funding. Only one of the foundation’s 17 government-funded projects has received any new funding since January 24. Last week, a foundation project funded by the Centers for Disease Control and Prevention got a new tranche of funding, Connor told The Dispatch. The U.S. government owes the foundation $7 million, she said, including invoices for work done as far back as October.
Some PEPFAR groups that are continuing to operate under the hope they will eventually be reimbursed by the U.S. government have been unwilling to speak up out of fear of retribution from the Trump administration. Loftus told The Dispatch that he had spoken recently with individuals at a “really big site that gets a lot of funding in Kenya because I knew some people there, and they said, ‘we have been instructed not to say anything to any media person on or off the record.’ I think they were just afraid of retaliation.”
Loftus, who helped lead a rally for PEPFAR on Friday in Washington, is begging the administration to resolve all issues holding up the program’s funding. “Missionaries who were working in the ‘90s and early 2000s … used to be watching people die of AIDS all day, every day,” Loftus said of conditions in some African countries before the creation of PEPFAR. Now, with testing, prevention, and antiretroviral medications, the diagnosis of HIV is not devastating for many people if caught early enough.
“Most of the time, I get to see the medications working, and I see normal people who are living otherwise functional and hard-working lives—people in my church, people in the community, my patients, and some of my colleagues,” Loftus said. But every once in a while, Loftus sees a patient with AIDS whose condition is “too far gone, and that is really sad because it tends to be a fairly grisly and quick death. I do get to see every now and then, what it could be like if these medications weren’t widely available.”
