On 20 January, American President Donald Trump signed an executive order initiating a 90 day freeze and review of all U.S foreign development assistance programmes, including the U.S. Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR) programmes. As has been internationally reported, the result of the review was announced on 10 March, where the American Secretary of State announced that 83% of USAID programmes – around 5,200 – would be cancelled, with only 1,000 to continue under new supervision of his State Department.
The impact of the suspension of all aid programmes is unclear and still being measured in detail. However, given the dimensions of USAID’s programmes – it was the world’s largest donor organisation, operating for six decades in 70 countries – the global impact of its end will be massive. The freeze has halted the delivery of critical humanitarian assistance, particularly of key medical supplies, to vulnerable populations.
For instance, UNAIDS has reported that funding termination has not only reduced the country’s HIV testing, care, and treatment capacity, it’s effectively ended the employment contracts for almost 9,000 employees, whose livelihoods were likely dependent on these stable income streams. With a US Supreme Court decision ruling that ongoing USAID contracts which were not cancelled would not need to be paid according to their contracts, and the new Department of Government Efficiency (DOGE) ending USAID’s payment system, many more people are expected to continue working with no guaranteed wages.
The end of PEPFAR has also endangered the lives of millions across the world. Founded in 2003, PEPFAR supplied an estimated 20 million people with life-saving antiretroviral medication; it’s believed to have saved around 26 million lives and reduced HIV transmission rates in over 50 countries. “This is a matter of life or death”, as the International AIDS Society described the importance of PEPFAR. Its end is likely to reverse decades of public health progress, and unless funding is restarted, a 400% increase in AIDS deaths (around 6.3 million people) are expected to occur in the four years after 2025.
From 1 July, certain foreign aid functions will continue, although realigned under the State Department’s international mission of “America First”. This has translated into continued military aid to Israel, Egypt and other Middle Eastern allies, as well as “life-saving” humanitarian aid. However, experts have confirmed that the State Department uses a narrow definition of what constitutes a “life-saving” programme, meaning the majority of the programmes that have been protected from defunding are for arms sales, military assistance, and counter-narcotic programmes.
These inconveniences ripple out to affect vulnerable populations, aid workers, and broader geopolitical dynamics. The full scope of the damage continues to evolve as organizations scramble to adapt.
Human costs
The weight felt by those in Africa will be significant, particularly as health spending was the largest single component of US aid in the continent. Life-saving aid was and has been critical to those living under the extreme poverty line (living on less than USD$2.15 per day), which defines nearly 36% of African citizens in 2023 – around 455 million people. If aid funding is not resumed, an additional 1.3% – or 5.7 million – African citizens are forecasted to fall below the extreme poverty line.
Ending aid funding will be especially felt by key populations, like people who use drugs and members of LGBT+ communities, who may face discrimination and persecution in their countries. In Burundi, USAID-funded HIV programmes like Ngirankabandi Activity – run by Association Nationale de Soutien aux séropisitifs et malades du Sida Santé-Plus (ANSS-Santé Plus) – connect community-based organisations with internationally funded organisations to identify new cases of HIV transmission, integrate them into health services, as well as support those in current ARV treatment. This includes drug-user led organisations that work with sex workers, people injecting drugs and other vulnerable groups. These programmes are expected to be hit the hardest. These costs are already documented: of the nearly 300 people funded by American aid grants in ANSS- Santé Plus, 218 have lost their jobs. Those remaining will have to continue working to hit grant targets from other donors with almost two-thirds less staff.
Daniel Nizigiyimana, the focal point member for the countryside division of Ngirankabandi, confirmed that the end of USAID funding has severely disrupted their operations in Burundi. Funding cuts have meant peer workers are no longer employed to bring people in to health centres for HIV screenings, and also ended access to HIV self-testing kits which were bought by USAID.
Public health progress undone
The disruption of funding is expected to reverse many of the hard-fought gains made in public health over the past decades. The head of UNAIDS, Winnie Byanyima, warned that aid suspension will lead to 2,000 new daily HIV infections. This was echoed by Tedros Ghebreyesus, the head of the World Health Organisation (WHO), who feared that “disruptions to HIV programs could undo 20 years of progress”. With people who inject drugs already facing a risk of HIV infection that is 35 times than those who don’t inject drugs worldwide, costs will be felt by those already at the margins of society.
A return to the public health situation of the early 2000s would be a humanitarian crisis. A 20-year regress would spell disaster for global goals like the 2030 Sustainable Development Goals, including those of ending HIV infections and deaths by 2030.
This global change in funding must be accepted as the new reality of the future; organised advocacy and new funders are needed to secure progress already made and to save more lives from preventable harm.
