Greetings from Uganda, where an HIV response built over decades — and with billions of dollars in investments from the United States — is in disarray. The stop-work order issued by the Trump administration more than three weeks ago has sown absolute chaos.
For two weeks, I have traveled the country, encountering confusion, panic, and despair.
Despite a waiver that allowed for the continuation of lifesaving antiretroviral treatment, dozens of clinics remain shuttered. Many of those that are open are rationing the pills they have because the pipeline for new deliveries is stalled. Facilities are running out of HIV testing kits and are unable to provide the viral load tests that confirm if a patient’s HIV medicines are actually working.
These same problems are occurring around the world, my colleagues Elissa Miolene and Adva Saldinger confirm. “Lifesaving programs are not receiving lifesaving waivers,” they write. And even when waivers do come through, many programs simply don’t have the funding available to resume work.
Meanwhile, here in Uganda, the waiver is causing other problems. That’s because it left out almost all prevention services, which have now ground to a standstill.
I interviewed a sex worker on Tuesday morning just after she took the last of her supply of pre-exposure prophylaxis, or PrEP, medicine that prevents her from acquiring HIV. She does not know where she will get more, but she also cannot stop working despite the heightened risk. It is the only source of income she has to support her five children. She told me that all that is left to her is to pray that she does not get infected.
A U.S. judge ordered the Trump administration to restart funding by Tuesday, and a patchwork of services is starting to emerge, including some prevention efforts. But the U.S. Agency for International Development, one of two primary funders of HIV services, has still not told most of the programs it supports that they can resume work.
My colleague Sara Jerving has traced this back to a critical USAID payment system that’s been frozen, meaning many services allowed under the waiver haven’t been getting funding. And those involved in implementing programs, such as contracting and agreement officers, haven’t gotten clear guidance from Washington.
It will be difficult to get USAID staff members to tell you what’s going on, though. Mark Kevin Lloyd, who has essentially taken over Atul Gawande’s job as administrator for the agency’s Bureau for Global Health, has warned staffers that they will be fired for any unauthorized engagement with the media.
None of this is doing much to mitigate the chaos caused by what Ugandans are calling “Trump’s order.” And though it has been nearly a month since that order, it has done little to dispel the shock that the United States would just completely abandon the people it has been helping to keep alive for more than two decades.
“I thank the American people for their support. For 22 years we have been happy knowing that we have a life,” the head of an organization for people living with HIV tells me. “But you don’t just wake up without consulting and you just throw us away.”
Read: A month after stop-work order, Uganda’s HIV response in chaos
Read more: ‘Immediate relief’ for USAID programs not expected despite court order
Plus: The mess inside Rubio's 'lifesaving' waivers
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It’s not just HIV programs that are in chaos. Malaria and tuberculosis programs that also relied on U.S. funding are facing massive disruptions.
When it comes to malaria, even a short interruption in programs that distribute bed nets or conduct indoor spraying can translate into illness and death. But far larger programs are also at risk.
Cameroon was on the eve of launching a seasonal malaria chemoprevention program when the funding freeze was announced. The program must be meticulously timed if it is going to do its job and prevent as many children as possible from getting infected. Now, that schedule has been completely thrown off.
Meanwhile, global gains in fighting TB are also in jeopardy.
Programs around the world are paused. The Stop TB Partnership has been able to continue placing orders of TB medicines and diagnostics, but there’s no certainty those supplies are reaching the people who need them. And research and clinical trials that would help accelerate the fight against TB are also shut down.
There is a call for countries to take more funding responsibility for their own malaria and TB responses. But they’re also being pushed to take over responsibility for all the other services the U.S. funded. At some point, there’s simply not enough money to go around.
Read: ‘Malaria thrives on chaos’ – and the US aid freeze is creating it
Plus: How Trump’s TB aid freeze is threatening tuberculosis programs
As you can imagine, the global health sector is also being decimated by the funding freeze.
The positions of thousands of health workers across Africa are in jeopardy. In Kenya alone, one politician says 54,000 health workers could lose their jobs. Their positions were propped up by U.S. funding that is no longer available, and now there is no one to take over their salaries.
It’s even less clear what will happen to their patients.
The impact extends beyond Africa. Boston-based JSI laid off about 1,100 staffers across both the United States and the rest of the world, representing about half of its staff. The global health nonprofit had been one of USAID’s top bilateral grantees, receiving more than $111.2 million during fiscal year 2024.
Read: Thousands of African health workers lose jobs due to US aid funding freeze
Read more: Global health org JSI laid off half of staff due to US aid freeze
Finally, I’m not the only one at Devex who has been on the road. Sara recently returned from Rwanda, and she has a fascinating story about visiting the infamous “Tunnel 12.”
The abandoned tin mining tunnel was the source of Rwanda’s recent Marburg outbreak, which began when the disease spilled over from an Egyptian rousette bat to a human. A 27-year-old miner who was working in Tunnel 12 is suspected to have been the first person to get infected.
Marburg is a particularly frightening disease. Fatality rates can be as high as 88%, and there are no licensed vaccines or therapeutics. Rwandan officials moved quickly to contain the outbreak, bringing it under control by December 2024 after only three months. That was after 66 cases and 15 confirmed deaths.
Meanwhile, officials have closed Tunnel 12 to make sure the bats are no longer disturbed. Mining continues in the 11 other tunnels, but the Rwanda Biomedical Centre and the mining company are making sure to build a buffer zone between the bats and the workers.
Read: Inside the infamous ‘Tunnel 12’ — the source of Rwanda’s Marburg outbreak
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Amid all of the uncertainty, the Global Fund to Fight AIDS, Tuberculosis and Malaria launched a replenishment campaign to raise $18 billion this week. It is nowhere near certain that the fund, which has been highly dependent on the U.S., will reach its goal. [Devex]
The U.S. Department of Agriculture accidentally fired several experts helping coordinate the ongoing avian flu outbreak. The department is now scrambling to hire them back. [NBC News]
After promising not to touch the childhood vaccine schedule during his confirmation hearing, new Department of Health and Human Services Secretary Robert F. Kennedy, Jr. says he will investigate the schedule after all. [Associated Press]