Thanks for writing this, but apparently the waiver is not totally effective (I have this on good authority, but can't really say more right now). See this paragraph from the NYT article: "The waiver, announced by Secretary of State Marco Rubio, seemed to allow for the distribution of H.I.V. medications, but whether the waiver extended to preventive drugs or other services offered by the program, the President’s Emergency Plan for AIDS Relief, was not immediately clear."
I am following this issue and, like everyone else here, am also extremely concerned. I am very interested in what I can do right now to help. Are there useful places to donate right now? I am an ETGer who normally gives about $100-200k per year and I would be willing to donate that amount or more if there were a good opportunity.
I’m not sure “sharing articles on PEPFAR as widely as you can” won’t have some negative consequences.
I’ve been following the posts around this on Twitter/X & they routinely get disdain & hate from MAGA users. Like if one put up a link to contact Congress, I wouldn’t put it past some people to contact Congress to say the program is wasteful, doesn’t prioritize US citizens, only helps irresponsible gay people, etc. The ignorance & selfish cruelty on display has been very disheartening. It has shaken my faith in humanity, not even a faith in people being really empathetic & good, but the faith that people won’t hatefully oppose something so good because of a warped world-view.
The support on places like Bluesky has been much better.
I don't think the situation is actually properly resolved by the recent waivers (as @Garrison points out below). See e.g. this thread and the linked ProPublica article. From the thread:
There is mass confusion and fear, both in and outside government. The aid organizations say they either don’t know how to get a waiver exempting them from Trump’s order or have no idea if/when theirs might get approved.
And from the article:
Despite an announcement earlier this week ostensibly allowing lifesaving operations to continue, those earlier orders have not been rescinded.
Many groups doing such lifesaving work either don’t know the right way to request an exemption to the order, known as a waiver, or have no sense of where their request stands. They’ve received little information from the U.S. government, where, in recent days, humanitarian officials have been summarily ousted or prohibited from communicating with the aid organizations.
...
By Tuesday evening, Trump and Rubio appeared to heed the international pressure and scale back the order by announcing that any “lifesaving” humanitarian efforts would be allowed to continue.
Aid groups that specialize in saving lives were relieved and thought their stop-work orders would be reversed just as swiftly as they had arrived.
But that hasn’t happened. Instead, more stop-work orders have been issued. As of Thursday, contractors worldwide were still grounded under the original orders and unable to secure waivers. Top Trump appointees arrested further funding and banned new projects for at least three months.
“We need to correct the impression that the waiver was self-executing by virtue of the announcement,” said Marcia Wong, the former deputy assistant administrator of USAID’s humanitarian assistance bureau.
Aid groups that had already received U.S. money were told they could not spend it or do any previously approved work. The contractors quoted in this article spoke on the condition of anonymity because they feared the administration might prolong their suspension or cancel their contracts completely.
(Thanks for writing the post! I referenced it in a mini thread on Twitter/X.)
What further actions would Trump/Rubio need to take to properly execute the waiver?
Hi Rebecca. I believe the issue is that Trump/Rubio do not want to properly execute this waiver. Everyone who has congressional representation should contact their members of Congress and the media to raise awareness about this issue with the broader American public.
The Trump administration is taking deliberate steps to undermine USAID and its ability to process these urgent waivers. More than half the staff has been fired or terminated in the past week. They're also purging the Legislative and Public Affairs (LPA) division, making it harder for Members of Congress to get answers about USAID's work.
This weekend, the USAID site and X account were removed. USAID now has a pared down sub-page under the State Department site, solidifying claims in earlier reporting that this Administration want to dismantle USAID as an independent agency (which many argue would require an act of Congress). But Republican members so far are being very silent about this direct attack on checks and balances and their duties under the constitution.
NYT Gift Link: End Appears Near for U.S. Aid Agency, Democratic Lawmakers say. (2/1/25) "Two incoming Trump administration officials familiar with the matter said the president’s team is exploring subsuming the agency into the State Department. Five others close to the administration said they weren’t aware of specific plans but that USAID’s independence is definitely not guaranteed. All were granted anonymity because they weren’t authorized to speak about the issue."
New broader waiver to the freeze for life-saving assistance announced
https://www.reuters.com/world/us/us-issues-new-waiver-humanitarian-aid-amid-freeze-2025-01-29/
Yeah this is solved for now but will need a concerted push for Congressional reauthorization in a few months.
Thanks Tyler, I was wrong as I didn't expect that to happen so fast - good to see I wonder what people were in Rubio/Tump's ear to help tip them over that line
Checking back in. Contractors have started some discussions on what specific activities can resume, but with all USAID staff put on admin leave & recalled it is very uncertain what is actually happening with PEPFAR. Right now the waivers make for some PR for Rubio, but aid is still functionally blocked.
Also…
“Rubio claims that @USAID lifesaving assistance for health and humanitarian needs will continue. But his team just communicated that the entire agency will be imminently reduced from 14,000 to 294 people. Just 12 in Africa.”
This is such good news!! I'm so relieved, even if there will still be a fight in the near future.
Edit 1/29: Funding is back, baby!
A recent article in The Economist (archive) claims PEPFAR funding hasn't actually been restored. It seems like the "restore funding to PEPFAR" lever is sorta no longer attached to anything :-(
I have written a post to address the President of the European Comission to prepare to totally or partially cover the gap if the US defunds the program. The program is expensive, but there shall be a replacement prepared if finally the worst happens.
https://forum.effectivealtruism.org/posts/CCHwPXCTRNKdnyYbk/the-anti-aids-program-pepfar-the-european-union-shall
We should ask our elected officials to oppose the Stop-Work order and actively push for its reversal. It's not enough for some programs to receive limited waivers. All key programs run by USAID are implicated in this Stop-Work order, including maternal and child health, nutrition and vitamin A supplementation, and the President's Malaria Initiative. ProPublica released a good piece on this today: "People Will Die": The Trump Administration Said It Lifted Its Ban on Lifesaving Humanitarian Aid. That's Not True.
The information about the waivers is chaotic and insufficient for implementing partners to resume work - many are confused about guidance from the U.S. government and cannot proceed. The waivers must be submitted internally to the State Department (from USAID). Over the past week, around 50% of the USAID Global Health Bureau staff were fired or furloughed (~450 technical experts). A similar proportion has probably been fired from the Bureau for Humanitarian Assistance. The administration also put 50+ senior career foreign service officers on administrative leave (some of whom had dozens of staff in their reporting line), undermining the leadership at a key time. (NPR / CNN).
In a press conference on Wednesday, January 29 (and reported by NPR on January 31), the Health Minister from South Africa (the largest PEPFAR portfolio) said, "So far, we haven't received any letter from the American government. Tried to contact the embassy of the U.S. We couldn't get them."
The General State of PEPFAR
PEPFAR has never been in a more precarious position since it was created in 2003. The program has been reauthorized three times, each for 5 years, and last year was the first time it was only reauthorized for one year (until March 2025). A big part of that fight was around false information that PEPFAR-funded partners provided abortions - which would be illegal under U.S. law. Earlier in January (before the inauguration or aid freeze - it feels like another life), U.S. officials briefed Congress that 4 nurses in Mozambique had provided 21 abortions (which is legal there) and had not been trained on compliance with US-funded programs. Procedures have already been put in place to prevent this from happening again. This is the first time this is known to have occurred with a PEPFAR-funded partner in 20 years. This indicates that the monitoring and compliance systems are working as intended.
Republicans in Congress immediately responded. Rep. Chris Smith, Chairman of the House Foreign Affairs Subcommittee on Africa and Global Health Security and Diplomacy, led the charge in the last Congress to delay PEPFAR's reauthorization. He promised a congressional investigation into the CDC for violating the Helms Amendment. Senator Risch, Chairman of the Senate Foreign Relations Committee, stated: "I will not support one dollar of American money going toward abortion anywhere in the world, and I will do all I can to ensure this never happens again."
More USAID staff ousted after Trump administration dismantles aid agency (Reuters) --- https://neuters.de/world/us/more-usaid-staff-ousted-trump-administration-dismantles-aid-agency-2025-02-02/
Executive summary: The proposed cuts to PEPFAR, a highly effective HIV/AIDS treatment and prevention program, could result in the deaths of millions, including vulnerable children, but public awareness and advocacy may reverse the decision.
Key points:
This comment was auto-generated by the EA Forum Team. Feel free to point out issues with this summary by replying to the comment, and contact us if you have feedback.
See here (https://forum.effectivealtruism.org/posts/FTTPCtkizkAQ9fkvM/unicode-wvyp) for the Rapid Response Fund: https://www.founderspledge.com/funds/rapid-response-fund. It's an opportunity to donate to help mitigate the worst immediate consequences of the aid freeze.
Also in my post and in the post below here:
It's not so clear if funding has come back...
Edit 1/29: Funding is back, baby!
Crossposted from my blog.
(This could end up being the most important thing I’ve ever written. Please like and restack it—if you have a big blog, please write about it).
A mother holds her sick baby to her chest. She knows he doesn’t have long to live. She hears him coughing—those body-wracking coughs—that expel mucus and phlegm, leaving him desperately gasping for air. He is just a few months old. And yet that’s how old he will be when he dies.
The aforementioned scene is likely to become increasingly common in the coming years. Fortunately, there is still hope.
Trump recently signed an executive order shutting off almost all foreign aid. Most terrifyingly, this included shutting off the PEPFAR program—the single most successful foreign aid program in my lifetime. PEPFAR provides treatment and prevention of HIV and AIDS—it has saved about 25 million people since its implementation in 2001, despite only taking less than 0.1% of the federal budget. Every single day that it is operative, PEPFAR supports:
- More than 222,000 people on treatment in the program collecting ARVs to stay healthy;
- More than 224,000 HIV tests, newly diagnosing 4,374 people with HIV – 10% of whom are pregnant women attending antenatal clinic visits;
- Services for 17,695 orphans and vulnerable children impacted by HIV;
- 7,163 cervical cancer screenings, newly diagnosing 363 women with cervical cancer or pre-cancerous lesions, and treating 324 women with positive cervical cancer results;
- Care and support for 3,618 women experiencing gender-based violence, including 779 women who experienced sexual violence.
The most important thing PEPFAR does is provide life-saving anti-retroviral treatments to millions of victims of HIV. More than 20 million people living with HIV globally depend on daily anti-retrovirals, including over half a million children. These children, facing a deadly illness in desperately poor countries, are now going to be left on their own, and a lot of them are going to die.
Imagine a baby you care about having to face that. Imagine them having a horrible disease, a disease that will likely kill them if untreated. But they have been getting treatment—treatment that makes it so that they will not die from the disease but be able to grow and flourish. Now, with the stroke of a pen, their medicine will be cut off—probably they will die in a few months. Kelsey Piper writes:
There are five hundred thousand kids who PEPFAR provides HIV drugs that keep their immune system working. AIDS kills babies very quickly if they aren't on antivirals. Two to six months, which is also about when most babies with SCID die. It's about how long you can make it in this world without an immune system.
[Context: Kelsey’s baby has a cold].
I've spent a lot of time yesterday and today in the shower - the hot steam helps the baby - cradling her to my chest while she whimpers "why, why, why?" and knowing that she will be completely fine. The world where this cold could have killed her feels like it is terribly nearby. The children that immunodeficiencies do kill don't feel very far away, either.
Earlier I said PEPFAR has saved 25 million people. In fact, the 25 million people saved number is probably an underestimate. It doesn’t take into account that PEPFAR has built up infrastructure in poor countries that makes it easier for them to combat other diseases. As a result, the little-known PEPFAR program is probably the single most effective federal program per dollar. A temporary pause in PEPFAR means a temporary pause in providing life-saving medicine—it means a lot of people will die. Many of those will be vulnerable children.
About half a million people died in the Iraq war. The PEPFAR program saved about 50 times that number of people. A program might be gutted that saved enough lives to offset the Iraq war 50 times over. The end of PEPFAR will kill, in a year, more people than died during the entire Iraq war. PEPFAR was responsible for kicking the crap out of AIDS in Africa, for making it so that the number of victims of AIDS over time looked like this:
Fortunately, the end of PEPFAR is not inevitable. Rubio kept up famine relief and military aid to Morocco and Israel. With the stroke of a pen, Trump or Rubio could do the same for PEPFAR. If either Trump or Rubio wanted to, they could make sure PEPFAR relief continues. Neither has any special reason to be opposed to PEPFAR—the program is traditionally bipartisan! The only reason they’re cutting it is likely that they haven’t heard about it.
So let’s get the word out! The PEPFAR cut is unpopular; it can only thrive in the darkness. Help make it a national issue so that people know what PEPFAR does. Honestly, if Rubio just read one article about PEPFAR, I think he could be talked into keeping up the program rather than cutting it. Time is of the essence—the longer PEPFAR is cut, the more people—many of them children—will die.
Being against kids dying isn’t a partisan issue. Help make sure that no mothers have to clutch their sick babies to their chest, knowing that they have only weeks to live, because of an executive order’s collateral damage. Rather than surrendering, let’s win the war against this wretched disease—this killer of children. No more babies need to die of this scourge, this plague that we could wipe out if we put in the effort—as we’ve been doing for decades. If Trump takes pivotal action on AIDS, he could be one of the only people in history to successfully eradicate a disease!
The stakes are high—I cannot describe just how horrible it is that many children might die because of this, but hopefully this poem from a grieving mother can help show some of the seriousness of this issue. If PEPFAR is cut, she will not be the only mother to grieve a dead child.
In fields where once you played and ran,
Where first you walked, my little man,
I see your footprints in the sand,
And feel the warmth of your small hand.
Your first steps wobbly, yet so brave,
The joy of learning, waves you gave,
To ride a bike, your laughter free,
Each memory, now bittersweet to me.
The mud beneath the summer rain,
You splashed and played, forgot the pain,
Catching bugs in the hot sun's glow,
Your spirit bright, your heart aglow.
We built a snowman in the yard,
And shared a bond, so true, so hard,
But now those moments turn to dust,
As grief engulfs, as memories rust.
The years we had, I'm thankful for,
Yet sorrow knocks at every door,
For now your life on earth is done,
Your journey ceased, my precious son.
I did not see your end draw near,
And guilt, it whispers in my ear,
I should have known, I should have seen,
The shadows fall where light had been.
Your goodbye letter in my hand,
A testament to dreams unplanned,
I long to tell you, one last time,
How much you're loved, my dear, sublime.
You're needed here, your laugh, your light,
Your absence turns my days to night,
So many questions, answers few,
The pain so deep, I can't construe.
(If you want to do something to help stop PEPFAR cuts, share this article and as other sources about PEPFAR’s importance as widely as you can, especially if you know someone who might be influential on this issue. Additionally, contact your local congresspeople and donate to other charities helping save children from disease!)
Thanks @Omnizoid for highlighting this important moment. I've received a bunch of Whatsapp messages from Ugandan friends who are very very worried about what this might mean not only for patients (the main issue), but also for jobs and the livelihood of many local NGOS.
One small comment is that I think the title might be slightly misleading. If these steps happened (none of which have happened yet), then millions could die. But I think all these steps all happening is pretty unlikely
And to reiterate, thanks for the article and its still a very very big deal
I think it could be pretty effective for your Ugandan friends to record videos interviewing people who have been helped by the program, and post the videos online.
A lot of skepticism of foreign aid is driven by the fear that the aid is being captured somewhere along the way, either here in the US or in the target country. Hearing directly from the aid recipients helps address that fear.
As an American, it feels like good things the US does are taken for granted, and the US will be criticized relentlessly by people in other countries no matter what we do. So I wouldn't suggest scolding the US for withdrawing funds. And in any case, rewards usually work better than punishments for modifying behavior. I think saying thanks, and talking about what it would mean for the program to continue, would be a lot more powerful than scolding. Even for Americans who aren't particularly altruistic, this would provide tangible evidence that the program is improving America's reputation.
One mental model I have is that the US is suffering from something akin to EA burnout, and the solution to both "US burnout" and "EA burnout" is a stronger culture of gratitude. In principle, I could imagine that a really good response to this PEPFAR situation actually ends up motivating the US to fund additional effective aid programs.
Strongly second this - it helps a lot to hear from people on the ground as many details as they can share while respecting patient privacy about who they serve and what it's like.
That's a good point about patient privacy. On X, you suggested that PEPFAR has had a sizable macro impact on AIDS in Africa. Maybe Africans who are old enough to remember could talk about what AIDS was like in Africa before and after PEPFAR, as a way to illustrate that macro impact without violating the privacy of any individual patients.
Of course, insofar as individual patients are willing to speak about their experiences, possibly with some light anonymization such as looking away from the camera, that seems really good to me too.
A couple other thoughts:
If access to ARV drugs is interrupted, I imagine that could lead to drug-resistant HIV strains, same way your doctor tells you to take your antibiotics consistently.
Having a big population of immunocompromised people in Africa seems bad in terms of mutation speed for future pandemics. Here's a paper I just found on Google, about COVID variants which are thought to have arisen from immunocompromised patients.
This really speaks my mind. I think rather than scolding Trump, we might need to know why the Congress is taking the decision. What if the funding are actually being "captured somewhere along the way"? That might truly be the fear.
Hmm, I guess none of those happening seems decently likely to me--around 50% probability.
Wow that's interesting! I have no inside information but would have guessed like 70-80 percent chance that funding for HIV meds would continue but maybe I'm way off the mark
To throw some numbers in here, point no2 would need for a lot of countries to all decide it's not worth it to fill the funding gap even a little. Let's say there are 50 countries that could (I'd estimate half of them to be in Europe), and they decide not to fund with probability 1−p.
The probability that they all decide not too fund is then (1−p)50. If p is something like half a percent, there's a 78% risk of no country filling the funding gap. If all three steps have 78% probability then yeah, we do approach 50% of them all happening.
How sure are you on #1? I want to organize US folks to contact their representatives and senators, but want to be specific with the ask. Is it 1) waive the pause or 2) just ensure it comes back at the end of the pause? This link makes me believe that the pause itself is stopping PEPFAR-related work, but it sounds like you think NGOs will have funding to make it through the next month?
My understanding is that #1 is false – PEPFAR funding is authorized by congress, the executive can't (legally) unilaterally cut it off. However, their funding is currently paused as part of a broader pause on all US foreign aid. Organizing people to call their senators and representatives (especially if these are Republicans) is a great thing to do right now – the ask is to exempt PEPFAR from the foreign aid pause. You might also tell them to say that PEPFAR is a program initiated by a Republican president which has enjoyed widespread bipartisan support for 25 years.
I think this is an OK ask, but the bigger long term issue is that PEPFAR stays funded after the review - that seems to me both a bigger deal and perhaps more tractable than "unpausing" right now. It seems pretty unlikely that decision would be reversed but I don't know much about the US political system or Trump's way of operating
It would not be legal for USAID to cancel funding for PEPFAR after the reverse! Their funding comes from congress, executive agencies don't have the power to do that. It still might happen – such are the times – but it would be definitely flagrantly illegal.
Sorry I wasn't talking specifics of agencies, I just meant congress cutting their funding, will edit thanks!
I think we are in uncharted territory here. It's true that Congress has the power of the purse. But Trump's pick for Office of Management and Budget Director (Russell Vought) supports impoundment - unilateral action taken by the exectuve branch to delay or cancel appropriations enacted into law.
When asked about Trump's funding freeze the other day, Rep. Tom Cole, Chairman of the House Appropriations Committee, said “Appropriations is not a law, it’s the directive of Congress."
Some Republican members of Congress may not push back on illegal actions without pressure from their constituents.
Ok thanks, that matches my prior belief. However, I don't know if receiving organizations have the funding runway to keep programs running during the pause. Do we have good (back of the envelope) calculations about the effects of the full 90 day pause (even if it is reinstated)?
I really doubt we have the info yet even for a BOTEC. The situation will vary wildly from org to org and country to country. The best place people to comment here might be staff in USAID conduits like Chemonics and ABT associates, who would know the financial situation at scale for USAID funded orgs in low income countries.
Thanks for the pointers!
Many implementing partners will not be able to make it the full 90 days. Several are under a communications gag order as part of the stop work order and can't speak freely about the impacts. This Devex article quotes heads of NGOs (who spoke under condition of anonymity to reduce the risk of retribution): "I don't think anyone can survive for 90 days": Aid's grim new reality (1/30/25).
Almost every contractor is already furloughing or laying off staff. On 1/31/25, The CEO of DT Global said that most firms are furloughing +80% of their staff with up to 3,000 in the DC area losing jobs by next week.
Those who have announced furloughs include:
Those who have announced layoffs include:
You're right that the funding has stopped, although there will be a bunch of dedicated money in foreign accounts which will keep paying many people. There will be chaos though. For example we have 3 nursing staff under a contract paid by USAID and I'd be very surprised if they just don't get paid now (I'll tell you in a week).
What I mean by 1 (sorry I phrased it wrong at first, is that HIV meds in Uganda are still available and probably in other supported countries for the next few months. Its only after the pause that the shit will really hit the fan if USAID decides to permanently stop funding.
My ask would be to ensure PEPFAR funding continues after the pause.
I agree that a permanent stop is worse. Thanks for clarifying the situation during the pause; that sounds reassuring. Please keep the EA community updated!