Impact of US elections and executive orders on global health: waiver covers PEPFAR with restrictions
7 February 2025. Related: Special reports, Treatment access, Treatment advocacy.
STOP PRESS: This report was updated later on 1 February after confirmation that PEPFAR will be covered by the temporary waiver. [12]
Simon Collins, HIV i-Base
The first week of the Trump administration included using dozens of shocking presidential executive orders to dictate policy changes designed to wreck the lives of millions. This includes withdrawing the US from WHO and the Paris Agreement on climate change, attempting to deny the existence of transgender, non-binary and intersex people, and cancelling all diversity, equity, and inclusion (DEI) programmes. [1]
On 20 January 2025, another executive order was just as clear. Whether legal or not, it froze spending on all ongoing foreign aid programmes, cancelling budgets already approved by Congress. This resulted in the international PEPFAR programme closing overnight. PEPFAR was established by President Bush in 2003. It currently provides antiretroviral treatment to more than 20 million people living with HIV in over 50 countries and directly supports many clinics’ services. [2, 3]
Many government staff, including at senior levels, were either fired or put on administrative leave, without notice or due process. [4]
Major health agencies, including the US CDC, were prevented from communicating externally about the order that went out to foreign aid programmes. Some measures have already been challenged in the courts, and more will follow, but this is against a background of a Supreme Court that is now weighted with a conservative majority.
For every day that PEPFAR remains closed more than 220,000 people will be forced to stop ART, including approximately 7500 children. PEPFAR is currently supporting ART for almost 670,000 pregnant women and shutting services for 90 days could lead to 135,000 babies born with HIV. [5]
Stopping ART on such a scale will undo years of HIV prevention work based on U=U and could destabilise commercial markets that negotiated the annual price of ART to less than US $50 per person. The countries most affected by cancelling PEPFAR are South Africa, Mozambique, Kenya, Tanzania, Uganda, Nigeria and Zimbabwe. PEPFAR employs more than 270,000 health workers, all of whom have been told to stop work. [5]
The logic to the executive order to stop foreign aid is simple; it states that Trump was elected with a majority of the popular vote, and with a mandate to put America first. Public policy should now only be based on ideas that match the new ideology as other views will not be in America’s new interests. The order states that no further foreign aid will be provided to countries that are “not fully aligned” with new US foreign policy. Rather than initiate an ongoing review, an immediate 90-day pause was imposed on all spending until the Office of Management and Budget (OMB) checks whether the current programmes fully align with the policies of the new administration.
On 24 January 2025, USAID issued a notice on the implementation of the executive order on reevaluating and realigning US foreign aid to all USAID contracting staff and implementing partners to “immediately issue stop-work orders” and suspend existing awards with waivers for some staff costs and emergency food assistance. [6]
This notice was accompanied by other directives putting senior staff on administrative leave, preventing any external communications and taking the main PEPFAR database offline. Staff were fired without notice and clinics were closed.
On 26 January 2025, a Department of State press statement on implementing the ban quoted Secretary of State Marco Rubio saying, “Every dollar we spend, every program we fund, and every policy we pursue must be justified with the answer to three simple questions: Does it make America safer? Does it make America stronger? Does it make America more prosperous?” [7]
An example of the communications freeze, in this case for a CDC-funded project, included:
“This Centers for Disease Control and Prevention (CDC) award is funded in whole or in part with United States Government foreign assistance funds.
In accordance with the President’s Executive Order on Reevaluating and Realigning United States Foreign Aid, you must immediately cease all activities on this award, which includes activities conducted under subawards and contracts.
Activities are suspended until further notice. Further activities will be subject to additional guidance and the future availability of funds. The grant funds on this award are restricted until further notice. No additional costs may be incurred. Any costs incurred prior to January 24, 2025, may be allowable for payment.
This action is not subject to appeal.” [8]
Then at 9 pm on 29 January, again without notice, Marco Rubio announced a temporary waiver “to continue life-saving humanitarian assistance programs” – but language in this waiver is general and it is dependent on interpretation. In order for this waiver to take effect, each project might need to be individually assessed to know whether they qualify. The waiver wasn’t specific to HIV, and could primarily be intended to cover Gaza or natural disasters. [9]
Although it has been widely reported that the waiver reverses the PEPFAR stop-work order, it remained uncertain. Many HIV programmes are based on people who the administration is now actively targeting by removing the DEI framework and DEI documents. The elimination of key populations from HIV programmes, including LGBTQ+ people, sex workers and people who use drugs, appears to be an implicit outcome. Many US State Department webpages referencing earlier PEPFAR work with LGBTQI+ populations have already been removed. [10]
As of 1 February 2025, PEPFAR clinics remain closed. Evaluations due to start on Monday 3 February might easily decide to look at every grant individually, rather than looking at PEPFAR as a single project.
Finally, late on 1 February 2025, an info memo for PEPFAR coordinators from the US Department of State, marked sensitive but unclassified, confirmed that “…PEPFAR has been granted a limited waiver to implement urgent lifesaving HIV treatment services in alignment with the Secretary of State’s January 28 memo […] and subsequent January 30 confirmation…”. [12]
This states that the waiver covers HIV treatment and related services including HIV testing, TB and other infections. It also covers PMTCT services and PrEP for pregnancy and breastfeeding women. Reasonable implementing costs are also included. The memo emphasises that the waiver itself is still temporary and includes restrictions.
The waiver doesn’t cover “activities that involve abortions, family planning, conferences, other administrative costs, gender or WEI ideology programmes [sic], transgender surgeries or other non-life saving assistance”.
Thanks to Tracy Swan for editorial comments and to HealthGAP and IAS for coordinating hundreds of international community activists who have been meeting daily to share the latest information and updates and to work on emergency response strategies. Much of this report is based on information shared at these meetings.
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Although these actions are incredulous the new administration is just enacting many of the threats raised during the election campaign.
A community website tracking the impact of the PEPFAR ban is already online – with estimated people affected updated in real time. [11]
Many people forced to stop ART will have been diagnosed with CD4 counts <100 and will be at high risk of rapid viral load rebound and having their CD4 cell count return to baseline levels. This will leave them vulnerable to severe illness and death. Although late diagnosis (CD4 <350) is still common, the median CD4 count in many low- and middle-income PEPFAR countries was well below 200.
These programmes need to be immediately covered by national governments in the affected countries and by international donor countries.
Many organisations, largely independent of US funding or reach, notably the International AIDS Society, have released statements condemning the new proposals. Others have remained understated or silent – with limited responses from UNAIDS and no online statements from the Global Fund for AIDS, TB and Malaria, the Bill and Melinda Gates Foundation and PEPFAR itself (now banned from public statements).
There is now an urgent need for governments to respond.
Other important announcements since this article was first posted includes that the organisation USAID has been taken off-line and the US offices have been closed. “In fiscal year 2023, USAID’s budget was over $40 billion, with a workforce of more than 10,000 — with about two-thirds working overseas. The agency works with more than 4,000 organizations in over 100 countries.” [13]
References
- Kates J et al. Overview of President Trump’s Executive Actions on Global Health. Kaiser Family Foundation. Global Health Policy. (28 January, updated 31 January 2025).
www.kff.org/global-health-policy/fact-sheet/overview-of-president-trumps-executive-actions-on-global-health/ - The White House. Reevaluating and realigning United States foreign and executive order. January 20, 2025.
www.whitehouse.gov/presidential-actions/2025/01/reevaluating-and-realigning-united-states-foreign-aid/ - President’s Emergency Plan for AIDS Relief (PEPFAR) website.
www.state.gov/pepfar/ - ProPublica. “People Will Die”: The Trump Administration Said It Lifted Its Ban on Lifesaving Humanitarian Aid. That’s Not True. (31 January 2025).
https://www.propublica.org/article/trump-state-department-usaid-humanitarian-aid-freeze-ukraine-gaza-sudan - amFAR. Impact of Stop Work Orders forPEPFAR Programs. (Undated but after 20 January 2025).
www.amfar.org/wp-content/uploads/2025/01/Impact-of-Stop-Work-Orders-for-PEPFAR-Programs-2.pdf - USAID. Notice on Implementation of Executive Order on Reevaluating and Realigning United States Foreign Aid. (24 January 2025).
drive.google.com/file/d/1KjEOrhFRzGCXQKVDc0wXWTHLpRIe6Qn4/view - US Department of State press statement. Implementing the President’s Executive Order on Reevaluating and Realigning United States Foreign Aid. (26 January 2025).
www.state.gov/implementing-the-presidents-executive-order-on-reevaluating-and-realigning-united-states-foreign-aid/ - Internal CDC email.
- Marco Rubio press statement. Emergency Humanitarian Waiver to Foreign Assistance Pause. (29 January 2025).
www.state.gov/emergency-humanitarian-waiver-to-foreign-assistance-pause-2/ (webpage)
www.state.gov/wp-content/uploads/2025/01/Final-Signed-Emergency-Humanitarian-Waiver.pdf (PDF) - US Department of State press release. PEPFAR Stands with LGBTQI+ Individuals Planned Programming for COP22 surpasses $235 million. (22 June 2022)
Original:
web.archive.org/web/20230204112407/https://www.state.gov/pepfar-stands-with-lgbtqi-individuals-planned-programming-for-cop22-surpasses-235-million-new-partnership-with-undp-to-counter-punitive-and-discriminatory-laws/
Removed:
www.state.gov/pepfar-stands-with-lgbtqi-individuals-planned-programming-for-cop22-surpasses-235-million-new-partnership-with-undp-to-counter-punitive-and-discriminatory-laws - PEPFAR Impact Tracker.
pepfarimpact.vercel.app/ - US Department of State. Info memofor the PEPFAR implementing agencies and PEPFAR country coordinators. (1 February 2025).
https://docs.google.com/document/d/e/2PACX-1vQgNTpC6F5oaOnkebQokJ_2eYgM_IcQNT7alIL6R3P16Ef4Z0pmQby3Y1eHbJcTxK_yJ8EPVNiibxON/pub - Devex.com. USAID closes headquarters Monday amid Trump transition chaos. (3 February 2025).
https://www.devex.com/news/scoop-usaid-closes-headquarters-monday-amid-trump-transition-chaos-109252
This article was first posted on 31 January 2025 and was updated on 1 February with further details on the waiver covering PEPFAR and to add reference 4..