(The Hill) — A legacy bipartisan initiative to combat HIV and AIDS in Africa is collateral damage from President Donald Trump’s directive to halt all U.S. foreign assistance, despite efforts to exempt humanitarian assistance and lifesaving medication from being caught up in the three-month funding freeze. 

The State Department issued a memo implementing the pause for new and obligated State and U.S. Agency for International Development (USAID) funding following Trump’s executive order calling for a 90-day pause on new foreign aid to allow the government to determine if programming aligns with Trump’s foreign policy.

The pause in global health funding has frozen activities at health clinics across Africa that rely on the President’s Emergency Plan for AIDS Relief (PEPFAR), raising immediate fears of a rapid spread of HIV around the continent.

It’s not unusual for a new administration to order a review of existing programs or even to pause new spending, and PEPFAR shouldn’t be immune from that, said Jirair Ratevosian, a fellow at Duke University’s Global Health Institute who formerly worked as a chief of staff for the PEPFAR program. 

“But, you know, there’s a distinction between reviewing a program, asking questions about a program, and completely freezing its lifesaving mission,” Ratevosian said. “What’s transpired over the last [few days] is something completely different, which is chaos, confusion and potential reversal of one of America’s greatest accomplishments.” 

The $6.5 billion PEPFAR is considered to be one of America’s most consequential programs in Africa. It is credited with saving 25 million lives and with scaling back the AIDS epidemic.

Experts and aid organizations are sounding the alarm over the sudden halt. The stop-work orders came without warning, sowing immediate chaos and confusion.

PEPFAR employs more than 270,000 health workers. They have been told to stop serving patients and not go to work.

Clinics shut their doors and turned patients away. The administration even told them to stop dispensing antiretroviral HIV medication that they had in stock because it was supplied with PEPFAR funds.

Some entities have private funding and other stopgap measures to fall back on, but for others, the situation is more difficult. 

“There are programs all over the continent providing treatment and prevention that are now not delivering what they normally do,” said Mitchell Warren, executive director of AVAC, an international nonprofit focused on HIV prevention. “There will be people, beginning this week, who come back into the clinic, or thought they had an appointment to come back to clinic to get more medication, and won’t be able to get it.”

Just as suddenly as the stop-work memo was released, the State Department appeared to somewhat reverse course, announcing Tuesday that lifesaving treatments and medications were not subject to the freeze. But the waiver provided no specific guidance on what services qualified for exemption, deepening the confusion on the ground.

Warren said the waiver appears to allow clinics to resume dispensing HIV medication, but it’s not entirely clear. Without clarification, he said, clinics are continuing to withhold medication.  

“If you said lifesaving medication, I would tell you that anyone on antiretroviral therapy or anyone getting antiretroviral prevention, it’s lifesaving. But it’s open to interpretation,” Warren said.

“And we do not yet have any official notification from PEPFAR or from USAID or from [the Centers for Disease Control and Prevention] which programs qualify for that waiver,” he added.

If a person with HIV stops taking the medication, the virus is no longer suppressed and can multiply, leading to weakened immune systems, illness and then potential spread to others. 

The foreign aid freeze comes at a precarious time for the PEPFAR program, as some of its authorizations expire in March. PEPFAR has traditionally been reauthorized for five-year periods, but the March 2024 omnibus funding bill only extended it for a year.

“Historically, PEPFAR has had tremendous bipartisan support that allowed it to kind of sit outside of regular politics,” said Jen Kates, a senior vice president and director of the Global Health & HIV Policy Program at KFF. “That is no longer the case.”

Republicans have put the aid program in their crosshairs in recent weeks following the State Department notifying Congress last month that it discovered that nurses working in PEPFAR-funded clinics in Mozambique had carried out nearly a dozen abortions.   

While abortion is legal in Mozambique, U.S. law bars any PEPFAR aid recipients from providing abortion services. 

Rep. Brian Mast (R-Fla.), the chair of the House Foreign Affairs Committee, has called for an investigation. 

Mast entered the chair position promising to scrutinize U.S. foreign assistance abroad alongside Trump’s “America First” foreign policy push. 

And Sen. Jim Risch (R-Idaho), chair of the Senate Foreign Relations Committee, said earlier this month that PEPFAR “is certainly in jeopardy.” 

Yet Sen. Chris Coons (D-Del.), a member and former chair of the Senate Appropriations subcommittee that funds the State Department, said there are still Republican colleagues who support the program. 

“Some very much so. I’ve spoken with a number of my colleagues who respect and recognize the decades-long impact PEPFAR has had on saving literally millions of lives across several administrations back to President George W. Bush, who launched it,” he told The Hill. 

He said he hoped “decisions that are being made yesterday, today, going forward, do not hamstring the program from being able to continue to carry out its critical lifesaving mission.”

Sen. John Cornyn (R-Texas) spoke in support of the program during Robert F. Kennedy Jr.’s confirmation hearing on Wednesday before the Senate Finance Committee and asked the Health and Human Services nominee if he supported PEPFAR. 

Kennedy said he’d “absolutely” support the program and seek to strengthen it.