Studying labor law is not why Dr. Caspian Chouraya went to medical school.
For more than two decades, he's worked in HIV/AIDS treatment and prevention. Now, he oversees HIV/AIDS programs in 12 African countries for the Elizabeth Glaser Pediatric AIDS Foundation. But in recent months, Chouraya finds himself talking to legal advisors and burying himself in the law surrounding layoffs in various African countries.
This is because for months, U.S. funding has been arriving in fits and starts. Not knowing when funds will arrive is undermining one of the U.S.'s most successful global health initiatives — the worldwide fight to combat HIV/AIDS.
The heart of this work is PEPFAR, the President's Emergency Plan for AIDS Relief. It has been credited with saving 26 million lives since it was launched in 2003 under President George W. Bush.
Congress has treated this effort with special care: In 2025, it pushed back on President Trump's proposed cuts. And, in 2026, Congress appropriated far more money than Trump had requested, allocating close to $6 billion for global HIV/AIDS work, funding PEFPAR at virtually the same level as the previous fiscal year.
Despite the money being available, people inside and outside the government say the State Department is deliberately withholding some of the funds. As a result, key HIV efforts — that even the Trump administration deemed "lifesaving" — are on the brink of shutting down.
This comes against the backdrop of a major deadline: This week marks the six-month timeline the Trump administration set for itself to have new health aid systems ready to go. That process is running behind schedule, which is exacerbating the financial uncertainty. That uncertainty, in turn, is making it impossible for many NGOs reliant on that money to conduct vital anti-HIV work.
"Projections were that HIV was just going to wipe out the entire nation"
When Chouraya became a doctor, he says specializing in HIV/AIDS was a no-brainer. It was the early 2000s and, "in the wards where I was working, almost everyone admitted in there was an HIV patient," he recalls.
In the tiny nation of Swaziland (now Eswatini), more than a quarter of adults were infected with HIV — one of the highest rates in the world. "Projections were that HIV was just going to wipe out the entire nation," he says. "It was really bad."
Thanks in large part to U.S. aid, the situation is now much better in Eswatini and many other countries.
Since 2003, the U.S. has committed more than $100 billion to the work and built among the largest global health delivery systems that exists. From Uganda to Lesotho, from Cote d'Ivoire to Malawi, Chouraya supervises programs that include HIV treatment as well as technical assistance to ministries of health.
But U.S. funding cuts this past year have meant many of his projects shut down. There were support groups for teenagers with HIV that are no longer meeting. There were cell phone plans, so clinics could stay in touch with patients — that's disappeared.
Chouraya says he even worries about the projects that are still supposedly slated to receive U.S. funding — he says he's often left wondering, "Am I in? Am I out? Am I in? Am I out? What's happening?"
"It's a stressful process"
What's happening is that the Trump Administration is ditching the decades-old system of global health aid. It was based on partnerships with entities ranging from local non-profits, large international organizations and national health systems.
After dismantling the U.S. Agency for International Development — that oversaw tens of billions of dollars of foreign aid — and canceling large numbers of programs, the Trump administration laid out its own plan for foreign aid in September.
The new strategy "is one that's putting the U.S. on a path of first transitioning down its support and transferring more financial responsibility to [individual] countries," explains Jennifer Kates, senior vice president and director of Global Health & HIV Policy at KFF.
Over time, the goal, she says, is to reduce how much the U.S. is investing in global health as country governments step into that role.
"That was always a goal [of PEPFAR]," explains Kates. The Trump administration is accelerating that transition, but the way it is unfolding carries risks, she warns.
Under the State Department's America First Global Health Strategy, the U.S. is negotiating new contracts directly with governments receiving aid, and then developing "detailed implementation plans with shared responsibilities, targets, and accountability mechanisms."
The State Department gave itself six months — until March 31 — to do all this. In the meantime, the strategy says, "bridge funding" was to be provided so that "existing life-saving activities will be continued."
But the second installment of bridge funding, slated to arrive in December of last year and cover three months, was often late. For Chouraya's work in Cote d'Ivoire — which includes 53 health facilities — the funding came in March.
He says his team had already been forced to scale back trainings and other activities in an effort to preserve essential services, like delivering drugs to patients. By the time the funds came through, he says, it was too late to make major changes to the work they'd already curtailed.
Given the uncertainty, he's had to "work on giving notices to staff so that we can prepare for possible termination of their contracts."
He worries his organization will get sued if the U.S. funds don't come but there hasn't been time to give employees the required legal warning. "It's a stressful process," he admits. "I don't want to lie."
"If you want to talk about waste and abuse, this is really extraordinary"
Now, the six months of bridge funding are over and the uncertainty is repeating itself.
Many organizations in the countries receiving aid report being told by the U.S. Centers for Disease Control and Prevention that the bridge plan is extended for another three months: April through June.
An official with a large nonprofit working in a low-income country outside of Africa told NPR that they received a notice in March from a CDC official with whom they regularly communicate. The text shared with NPR shows the CDC official recommending the nonprofit "slow spending in anticipation of this lapse in funding" and that "you can continue to use funds on hand." NPR agreed to grant the official and the nonprofit organization anonymity because they fear retaliation from the U.S. government.
While organizations have permission to keep working, it is unclear if and when money for the extension will arrive, says Emily Bass, author of To End a Plague: America's Fight to Defeat AIDS in Africa. She says this is no way to run a health program.
"If you want to talk about waste and abuse, this is really extraordinary," she says. "If you do six months, and then another three months, you are getting less return on your investment than you'd get if you were investing in a stable program." She says this stresses the workforce, who then look for more reliable jobs elsewhere rather than working most effectively.
More than two dozen countries have signed agreements with the U.S., including Uganda, Rwanda, Nigeria and Ethiopia. But Bass says developing implementation plans — that often include things like new procurement systems and new digital health strategies — has proved much slower. In the past, doing all the risk assessments and necessary evaluations to ensure funds are not misused, can take a year or more. She says the six months timeline was "totally unrealistic" from the get-go.
The State Department rejected this assessment in a statement to NPR. "Mischaracterizing such a transition as wasteful gets it backwards, as money would otherwise continue to pour into a system that resisted scrutiny, bypassed partner governments, and measured success by dollars out the door rather than lives saved." The statement went on to say that funds are now being "directed more strategically [and] with greater accountability."
"A controlled demolition"
Dr. K.J. Seung has been trying to make sense of that strategy. He's been reading the financial tea-leaves left in government spending data. He's an associate physician in the Division of Global Health Equity at Brigham and Women's Hospital.
His conclusion is that much of the money is stuck at the State Department.
Historically, global HIV/AIDS dollars generally flowed first to the State Department, as required by Congress, and then the State Department divided it primarily between CDC and USAID.
There were country and regional plans as well as regular coordinating meetings in order to make sure the work was aligned across the various agencies. But there were also rivalries — and who got to control a bigger share of the work was hotly contested. "It's really Shakespearean," says Bass.
"Historically, PEPFAR has been the source of numerous turf wars between USAID and CDC," says a former State Department official who requested anonymity for fear of retribution. "Because everyone is in survival mode, that has not helped the existing turf wars."
Now, Bass, Seung and others believe the battle is playing out in a new way with the State Department not sending the full amount of money typically sent onward to the CDC.
Because of its medical expertise, the CDC has overseen a large part of the U.S.'s global work on HIV testing and treatment. "CDC has really incredible technical expertise," explains Hannah Johnson, deputy director of Global Policy at the George W. Bush Institute. "In a lot of countries, they're some of your last technical experts on the ground."
However, in the past few months, the projects that fall under the CDC have faced a particularly high degree of funding uncertainty.
"My take is the Department of State is deliberately and systematically choking off funding [to the CDC]," Bass says. She believes the goal is "aggregating power, resources and strategic direction capacity into the Department of State."
Seung agrees. "I'm guessing that this is actually a planned sunset [of CDC programs]," he says. "It's being done with very little media fanfare." Others foresee the CDC acting more as a contractor on an as-needed-basis rather than a full partner.
A CDC official who requested anonymity because they fear retaliation, says this is an active policy choice. "What the financial data shows is not an accident or an administrative delay," the official says. "Congress appropriated these funds. The money exists. The State Department is simply not transferring enough of it to CDC to keep these programs running."
The official points out that because of the way USAID was dismantled, the CDC's HIV/AIDS work "is now carrying the last intact pillar of the program and….it could run out of funds by June. That's not a funding cliff — that's a controlled demolition. The people who will pay the price are the more than 12 million people living with HIV who depend on these programs for their treatment."
Chouraya says he does not know what's causing the funding delays but, he confirmed, the programs under the CDC have faced the most delays and financial unpredictability. He says he's been in triage mode.
"We are trying our level best right now to make sure that the frontline, the ones that are doing the direct service delivery, are as minimally affected as possible," he says. But that's not always possible. For example, he says, "in Mozambique, when we look at their funding, they don't have any money remaining."
In a statement to NPR, the CDC said it is using "available resources" to support lifesaving HIV/AIDS work but that "all additional questions regarding funding, funding processes, and the public release of data should be directed to the Department of State."
The State Department, in turn, told NPR that funds are flowing "as they have always been" and it is taking "decisive steps to ensure continuity of lifesaving" services.
Legislators are now asking questions.
"The delays and uncertainty we have already seen are cause for serious concern — and my staff and I are pushing the administration to take immediate action to prevent any interruption to lifesaving services," Sen. Patty Murray, D-Wash., told NPR in a statement. "[It is] this administration's legal responsibility to ensure PEPFAR continues to serve people and save lives — without interruption."
Kates from KFF worries reversing what the Trump administration has set in action would be difficult.
Chouraya fears the same. He says, because of all the uncertainty, it is no longer a no-brainer for clinicians to specialize in HIV.
"People are getting to a point where they're saying, 'I don't think there's a future in the field that I'm in right now,' " he admits. And that shift has a lot to do with how the U.S. is implementing its new global health strategy.
Jonathan Lambert and Fatma Tanis contributed to the reporting.
Copyright 2026 NPR
