On U.S. President Donald Trump’s first day back in office, he announced a 90-day freeze on all foreign aid. This sudden freeze caught one of America’s most successful and strategically vital global health programs in the crosshairs: the President’s Emergency Plan for AIDS Relief (PEPFAR).
PEPFAR was created in 2003 in a moment of crisis. AIDS was ascendent, and life expectancies across sub-Saharan Africa were in precipitous decline. In Botswana, life expectancy had declined from a peak of 62 to 51 that year; in Lesotho, from a peak 59 to 44. Nearly 3 million people died of AIDS in 2003, 76 percent of them in sub-Saharan Africa. And experts predicted that the death count could continue to rise, reaching perhaps 100 million by 2020.
Twenty years later, largely thanks to PEPFAR and other U.S.-led programs, the world is winning the war on AIDS. Deaths have dropped by 69 percent since 2004, and life expectancy in Botswana is at its highest-ever level. PEPFAR alone—costing less than 0.1 percent of the U.S. federal budget—is credited with saving 25 million lives. As Trump took office, some 21 million people received antiretroviral drugs, ARVs, through PEPFAR. ARVs are crucial to controlling the epidemic, as they disable the HIV retrovirus. People on ARVs have no symptoms of HIV, nor can they transmit it to others.
This helped advance U.S. health security by taming the AIDS epidemic, saving American lives in the process—but it has also advanced U.S. interests more broadly. Political leaders in sub-Saharan Africa look much more fondly on the United States than their North African neighbors do, and PEPFAR has served as an important source of soft power in a region increasingly contested by America’s geopolitical rivals.
All of that ground to a halt during the first week of Trump’s second term. By Jan. 24, his day-one halt to foreign aid became a stop-work order—meaning that all organizations had to halt any U.S.-funded work. Even if organizations already had the HIV medications in hand, they had to turn patients away—they were not allowed to give them out. Overnight, the AIDS epidemic was back on.
The administration then began to walk back its sudden change of policy, stating that “life-saving medicine, medical services, food, shelter, and subsistence” assistance could continue. But significant questions remained; no one was entirely sure if PEPFAR was allowed to keep operating or not.
On Feb. 1, a PEPFAR-specific waiver was finally issued, but it lacks clarity on specific aspects. According to the waiver, medication and testing are to continue – though nearly a week after the waivers were announced, implementers report that the stop work order remains in effect. Even if the waiver is eventually implemented, though, there could still be difficulties. Only medication and testing receive a carve-out; other services are still paused. With only barebones administrative funding allowed by the waiver: will clinics even be able to keep the lights on for the next three months?
Nor do questions stop with the current aid freeze. PEPFAR’s current congressional authorization expires in March 2025, before foreign aid is currently set to resume. What happens then? The program has traditionally had strong bipartisan support, but that has weakened over time. No one knows how it will fare in the Trump era.
Indeed, all aid—including PEPFAR—is at risk now. Elon Musk has tweeted that the U.S. Agency for International Development (USAID) must “die” and that Trump has given him permission to shut down the agency. Each day seems to bring new threats to the agency; as this piece goes to press, the majority of Washington-based USAID employees will be put on leave and staff based abroad are to be recalled. Many staff are uncertain if USAID will survive the week.
And if USAID dies, PEPFAR would, too.
The immediate health consequences of this would be dire. Every day, PEPFAR provides access to ARVs for 222,000 individuals. Each day another quarter of a million people miss a dose, the virus begins to rebound in their system. Within weeks, viral load would increase enough to make them infectious again. Thousands—if not hundreds of thousands—of new cases of HIV would result, undoing decades of progress.
Perhaps those in the most immediate danger are the children of HIV-positive mothers. PEPFAR currently supports around 680,000 pregnant women with ARV treatment—without access to these drugs, some 20-40 percent of them will transmit HIV to their babies. Without ARV treatment, about half of those infants will die within their first two years of life, most within the first few months. We could very well return to the world of the mid-2000s, where AIDS is once again a death sentence for a large percentage of those infected with HIV.
Nor would the consequences of ending PEPFAR stay in Africa. In up to 20 percent of individuals who inconsistently take ARVs, HIV becomes drug-resistant. It would not be long before drug-resistant HIV reached the United States, which could undermine decades of progress in HIV prevention and treatment domestically.
Even if PEPFAR manages to make it through this, though, and is renewed in March, the freeze has already delivered a significant, and entirely avoidable, strategic blow to U.S. global influence.
To date, PEPFAR has been a tangible demonstration of U.S. commitment to the well-being of African nations, fostering trust and goodwill that extend far beyond health outcomes. This kind of positive engagement contrasts sharply with China’s engagement on the continent. While China has invested heavily in infrastructure throughout the region, these projects often come with strings attached and can be seen as exploitative. PEPFAR represented a different model of engagement: one focused on partnership, capacity building, and genuine concern for human well-being.
The confusing and chaotic implementation of this freeze undermines this image of the United States as a reliable partner genuinely concerned for the well-being of Africans. Instead, the last week has shown Africans a confused, incoherent America. The waiver, while welcomed by partners on the ground, has been perceived as reactive and insufficient, failing to fully mitigate the damage already inflicted. The lack of clear communication and guidance has sown uncertainty at both USAID and implementing partners.
As Atul Gawande, a former USAID assistant administrator for global health, warned in a recent interview, the stop-work order could destroy U.S. global health infrastructure. The perception of instability and unreliability erodes confidence in the United States as a dependable partner, not just in health but across the spectrum of international engagement. In a world increasingly characterized by geopolitical competition, such self-inflicted wounds are strategically disastrous.
While the United States falters in its commitment to global health, China can readily step in to portray itself as a reliable partner, willing to fill the void left by U.S. retrenchment. This is not merely a matter of public perception; it translates into real geopolitical leverage, undermining U.S. strategic interests in a crucial region.
After all, not just PEPFAR is in danger. Even as the waiver allows vital ARV programs to (maybe) continue, all other aid programs remain on ice. That includes vaccination campaigns, basic health care in some of the world’s poorest places, and even programs that directly support national security. Foreign aid also supports demobilization programs for ex-militants who would otherwise threaten American lives.
Some may see this freeze as a fiscally responsible move, restoring focus to the American homeland instead of abroad. It is true that it is important to make sure that government resources are not wasted and that each taxpayer dollar is used wisely. However, a blanket 90-day freeze is a blunt and counterproductive instrument for achieving these aims.
A temporary halt to lifesaving programs is not a necessary precondition for reviewing their cost-effectiveness or identifying areas for improvement. Indeed, the chaos caused by the freeze actively undermines program efficiency and effectiveness, potentially increasing long-term costs and hindering the U.S. ability to deliver aid effectively in the future.
Trump and Secretary of State Marco Rubio have consistently emphasized the importance of American strength and global leadership and rightly so. The United States remains the world’s indispensable nation, and programs such as PEPFAR clearly demonstrate why, exemplifying smart, strategic investment of U.S. resources. For less than 0.1 percent of the federal budget, this single program has saved 25 million lives, built enduring partnerships across Africa, and helped contain a global health crisis that threatened U.S. security.
Now, the United States risks dismantling one of its most effective tools of global influence. At a moment when China is aggressively expanding its presence in Africa, when new health threats are emerging, and when U.S. leadership is being tested worldwide, America cannot afford such a devastating self-inflicted wound.
U.S. foreign aid isn’t mere charity. Aid programs are strategic investments that yield significant returns for U.S. security and prosperity. By strengthening health systems, fostering economic growth, and building goodwill, these initiatives create a more secure and stable world—a world in which U.S. interests are more likely to thrive. To undermine these programs with shortsighted freezes and budget cuts is to dismantle a crucial pillar of U.S. power and influence.
Saloni Dattani contributed research to this piece.
