Non-governmental organisations that receive US government funds across a range of sectors – including HIV, LGBTQ support and climate change – have been told to cease operations immediately.

Over the past two days, letters have been sent to US grant recipients following a “stop-work order” issued late Friday by the US State Department’s Office of Foreign Assistance.

While US President Donald Trump’s executive order on 20 January ushered in a 90-day pause on disbursements of foreign aid, the “stop-work order” approved by US Secretary of State Marco Rubio four days later has unexpectedly ordered all current work to stop immediately. 

Chilling effect on HIV clinics

Among the worst affected will be people living with HIV, over 20 million of whom depend on the US President’s Emergency Plan for AIDS Relief (PEPFAR) for antiretroviral medicine (ARVs) to keep their HIV in check.

“Any interruption in antiretrovirals is harmful to people with HIV. The degree of harm depends on how sick they are, how long they have been on treatment, how long the interruption is – but there is definite harm, with risk of illness, death and transmission,” South African HIV Clinician Dr Francois Venter told Health Policy Watch.

South Africa is one of the biggest recipients of PEPFAR aid, receiving $332.6 million in 2024.

HIV clinics across South Africa notified their shocked clients this week that they have been forced to close immediately.

Many people depend on these clinics for life-saving ARVs that they need to take every day for life to keep their immune systems healthy, prevent drug-resistant HIV – and stop them from transmitting HIV to others once their viral load is undetectable.

Some clinics gave clients until the end of Tuesday to fetch ARVs while others directed them to government clinics.

Many South African recipients of PEPFAR funds provide HIV services to “key populations” –  people most vulnerable to infection including men who have sex with men (MSM), sex workers and trans people. Others focus on young women, who bear the brunt of new infections, and men in rural areas, who are unlikely to seek healthcare.

Fear and confusion

On Monday, OUT and Engage Men’s Health, which provides HIV services to MSM, notified clients that, “due to an immediate ‘stop-work order’ issued by our funder, we cannot provide any services until further notice.

“We understand the urgency of your health needs and urge clients to seek care and access ARVs or PrEP [pre-exposure HIV prophylaxis] at their nearest public health facility or healthcare provider,” the NGO urged, providing contact details for mental health services including a suicide crisis hotline.

The University of the Witwatersrand confirmed that USAID had issued it with a stop-work order for some of its HIV programmes.

However, several large organisations with significant PEPFAR funding declined to comment, afraid to jeopardise the review of their grants by the US State Department.

The reviews, to be completed within 90 days, will decide whether to “continue, modify, or cease each foreign assistance program”. 

Aside from being told to stop work, grantees have also been told to cease any “radical and wasteful” “diversity, equity, inclusive, accessibility” programmes.

Global ‘havoc’

“The stop-work orders, which apply broadly to all grantees and sub-awardees, are wreaking havoc across the globe,” Dr Jirair Ratevosian, a former PEPFAR chief of staff, told Health Policy Watch.

“From Tanzania to Ukraine, I’ve heard from colleagues forced to comply with directives that carry deadly consequences. According to an analysis by amfAR, some 220,000 people – including women and children – present daily to PEPFAR programs to receive HIV medications, which are lifesaving and must be taken consistently to ensure viral suppression. Now, many are being turned away,” added Ratevosian, who is currently the Hock Infectious Disease Fellow at Duke Global Health Institute.

“In the early days of this crisis, we worried about empty shelves in pharmacies. Today, we face the opposite problem: the shelves are full, but our hands are tied. I urge the administration to find a way to reverse the pause while simultaneously reviewing funding—because we can and must do both.”

Just worried about where and how will People Living With HIV and I be accessing ARVs from if USAID stops the HIV funding permanently?🥺🥺

I honestly can’t do without ARVs. @Winnie_Byanyima, @UNAIDS pic.twitter.com/aiiIKwibR1

— Hadad Da HIV Activist. (@OfficialHadad) January 28, 2025

Using PEPFAR’s 2024 dispensing data, the Foundation for AIDS Research (amFAR) said that “222,333 people pick up new supplies of ARVs every single day, 365 days per year. This is the number of people who will lose access to treatment for every day that the stop work order is in effect.”

Half of these (101,368) are South Africans, while 7,445 are children under the age of 15. “Critically, getting people back onto treatment after the stop work order is lifted will take enormous effort,” noted amFAR.

PEPFAR to close?

PEPFAR is the most successful US aid programme ever, credited with saving over 26 million lives since its launch by Republican president George W Bush in 2003. By last September, PEPFAR was funding ARVs for 20.6 million people.

However, PEPFAR’s data systems were closed down late Monday, according to the New York Times. Officials worldwide were given around three hours’ notice of this, heightening speculation that the plan might be heading for permanent closure. 

Over the past two years, PEPFAR has been under huge pressure from conservatives, which reduced its five-year reauthorisation mandate to a single year in 2024. 

PEPFAR is due for renewal in March, which falls within the 90-day review period.

The influential conservative think-tank, the Heritage Foundation, which authored the Trump takeover plan, Project 2025, spelt out in a 2023 paper its view that HIV is “primarily a lifestyle disease” that “such should be suppressed through education, moral suasion, and legal sanctions”. 

According to the foundation, “as with any venereal disease, education and abstinence could end the AIDS epidemic” – although this approach has failed miserably in both the US and Africa.

Beatriz Grinsztejn, president of the International AIDS Society (IAS), said that stopping PEPFAR funding essentially stops HIV treatment for over 20 million people: “If that happens, people are going to die and HIV will resurge. It makes no sense to suddenly stop this incredible catalyst of our global progress towards ending HIV as a threat to public health and individual well-being.”

Not just HIV

However, the stop-work order extends far beyond PEPFAR recipients. People working for a range of PEPFAR-funded projects in southern and East Africa told Health Policy Watch that there was chaos at their workplaces. 

Some staff have been told to stay at home as there is no work. In some cases, soon there will be no money to pay them. One organisation was told it would need to repay money spent on air tickets to attend a forthcoming conference.

Dr Atul Gawande, who ran USAID’s health programmes under the Biden Administration, noted a range of other activities that would be affected including monitoring bird flu in 49 countries, assisting Tanzania in addressing its Marburg outbreak, and assisting over 90 million women and children to get “low cost vaccinations, prenatal care, safe childbirth, contraception, and other basic lifesaving health needs”.

I ran @USAID health programs for the last 3 years. Trump’s 90 day Stop Work Order on foreign assistance does serious damage to the world and the US. Examples:🧵

— Atul Gawande (@Atul_Gawande) January 25, 2025

Gawande added that the order would also “furlough all USAID contract staff — which includes half of its global health bureau”.

“This Administration is trashing US standing, alliances with scores of countries built over half a century, world-leading capacity and expertise, and American security,” said Gawande.

Meanwhile, the Trump Administration also announced a freeze on all federal grants and loans on Tuesday pending reviews, according to the Washington Post.

Image Credits: The Global Fund/ Saiba Sehmi.