Dr. Caspian Chouraya didn’t expect to be dealing with labor law when he entered medical school. He has devoted over twenty years to HIV/AIDS treatment and now manages programs in twelve African countries for the Elizabeth Glaser Pediatric AIDS Foundation. Lately, though, he’s been finding himself in conversations with legal advisors regarding layoffs because U.S. funding has been inconsistent.
This fluctuation in funding is jeopardizing a vital global health initiative aimed at tackling HIV/AIDS. The core of this mission is PEPFAR, President’s Emergency Plan for AIDS Relief, credited with saving 26 million lives since its start under President George W. Bush in 2003.
Congress has made efforts to protect this funding, notably pushing back against proposed cuts in 2025 and allocating nearly $6 billion for global HIV/AIDS work in 2026, ensuring PEPFAR funding remained strong. Nonetheless, insiders claim the State Department is withholding some of these funds, threatening critical HIV programs that were even labeled “lifesaving” by previous administrations.
This situation is complicated by a major deadline set by the Trump administration for new health aid systems, which are now running behind schedule. This adds to the financial instability for NGOs that depend on these funds, making their anti-HIV efforts increasingly uncertain.
“Projections were that HIV was just going to wipe out the entire nation”
Chouraya recalls that when he started his medical career, focusing on HIV/AIDS seemed obvious, especially since nearly all the patients he treated were HIV-positive. In what was then Swaziland, over a quarter of adults were infected. The outlook was grim: “Projections were that HIV was just going to wipe out the entire nation,” he noted.
Fortunately, thanks to U.S. aid, the situation has improved significantly in many places, including Eswatini. Since 2003, the U.S. has contributed over $100 billion to global health, creating extensive delivery systems across Africa. Yet, recent cuts have forced Chouraya to halt crucial projects, such as support groups for HIV-positive teenagers and communication plans for clinics to reach patients.
Chouraya often questions the reliability of future funding, wondering, “Am I in? Am I out? What’s happening?”
“It’s a stressful process”
Currently, the Trump administration is overhauling the long-standing global health aid system, which relied on partnerships with NGOs and health entities. This includes dismantling the U.S. Agency for International Development (USAID), which previously oversaw substantial foreign aid and programs.
The aim is to shift more financial responsibility to local governments, but this strategy raises concerns about its implementation. Jennifer Kates from KFF points out the plan could reduce U.S. investment in global health, transferring burdens to countries that may not yet be ready to handle them effectively.
While the State Department has initiated new contracts with governments receiving aid, the promised “bridge funding”— intended to ensure that life-saving programs continue—has often arrived late or not at all. In Chouraya’s case, critical funding for programs in Cote d’Ivoire came so late that efforts to stabilize operations had already been abandoned.
With ongoing uncertainty, he has faced difficult decisions regarding staff notices in preparation for potential contract terminations.
With the six months of planned bridge funding recently concluding, many organizations have been left in the dark. Reports indicate that the CDC advised nonprofits in low-income countries to slow their spending due to anticipated lapses in funding. While organizations can continue operation, the actual timing of any future funds is still uncertain, raising red flags for many involved.
Some experts highlight that these funding disruptions not only waste resources but also negatively affect workforce stability as individuals seek more reliable job opportunities elsewhere. More than two dozen countries have signed agreements with the U.S. for cooperation, but implementing these plans has proven slow.
The State Department defended its strategies, claiming a transition to a model emphasizing accountability over merely disbursing funds without scrutiny. However, some insiders believe this is more a systematic dismantling of established aid structures rather than an improvement.
Chouraya and others worry that ongoing delays and unpredictabilities could discourage future medical professionals from specializing in HIV care, indicating that the direction of U.S. health investments is becoming increasingly critical for those living with HIV.
