The Status of President Trump’s Pause of Foreign Aid and Implications for PEPFAR and other Global Health Programs

Starting on day one of his second term, President Trump began to issue several executive orders and other actions that affect global health. One was “Reevaluating and Realigning United States Foreign Aid” which calls for a 90-day pause in new foreign assistance obligations and disbursements pending review of all foreign aid programs. A notice sent to all diplomatic and consular officials on January 24 implementing the order went further, requiring stop-work orders to be issued for all existing foreign assistance awards, effectively halting implementation of U.S. global health efforts, including PEPFAR, in low and middle-income countries around the world. While PEPFAR was issued a limited waiver a week later, allowing it to restart some services, the situation remains fluid and fast-moving, intersects with several other executive orders and an apparent effort to dissolve USAID (the U.S. international development agency which implements most U.S. global health programs) as an independent agency. In addition, no waivers for other global health programs have been announced. This policy watch provides an overview of what has happened to date, as of February 3, 2025.

What does the Executive Order (EO) pausing foreign aid do? The order, issued on January 20, 2025, was one of the first to be issued by the President. It states that “It is the policy of United States that no further United States foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States” and calls for two main actions:

• A 90-day pause in U.S. foreign development assistance (new obligations and disbursements) to assess programmatic efficiencies and consistency with U.S. foreign policy.
• A review of U.S. foreign assistance programs under guidelines provided by the Secretary of State, in consultation with the Director of the Office of Management and Budget (OMB).

Determinations are to be made within 90 days about whether to continue, modify, or cease programs based on the review, with the concurrence of the Secretary of State. New obligations and disbursements may resume prior to the end of the 90-day period if a review and a determination are made to do so. The EO also allows the Secretary of State to waive the pause for specific programs but does not provide criteria for waivers.

Why was the executive order issued? The rationale for the order appears to be based on both economic efficiency and ideological grounds. According to its preamble, the U.S. “foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values. They serve to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations internal to and among countries.” A media note issued by the State Department states that the EO is “rooting out waste” and “blocking woke programs.” It also states that “Every dollar we spend, every program we fund, and every policy we pursue must make America safer, stronger, and more prosperous”, a statement made Secretary Rubio during his confirmation hearing and one that underpins the current department’s mission and priorities in Trump’s second term. These ideas also echo several that were included in Project 2025’s Mandate for Leadership, a set of recommendations for the next Republican president released in 2023 by a coalition of conservative organizations. For example, Project 2025 called for freezing foreign aid pending a review by political appointees (p. 174), refocusing “attention away from the special interests and social experiments that are used in some quarters to capture U.S. foreign policy” (p. 196), realigning U.S. foreign assistance “with American national interests and the principles of good governance” and undoing “the gross misuse of foreign aid by the current Administration to promote a radical ideology that is politically divisive at home and harms our global standing” (p. 279).

What is the “stop-work”order and is that different than the pause of new funds? While the EO calls for a pause on new foreign assistance obligations and disbursements (funds that have already been appropriated by Congress usually for specific programs or activities but have not yet gone to programs), a notice sent to all diplomatic and consular officials on January 24 went further. It requires all grant and contract officers to immediately issue stop-work orders for all existing foreign assistance awards (not just new obligations and disbursements) until a review is conducted. This means that work already underway with funding provided to organizations must be immediately stopped, such as clinics providing services, health care workers being funded, and other activities. The notice indicates that waivers had been granted for foreign military financing for Israel and Egypt and emergency food assistance (as well as some salaries and administrative costs).

Have any waivers been granted? While the EO notice indicates that waivers for foreign military financing for Israel and Egypt and emergency food assistance have been granted, it does not provide any further detail or indicate what the process is for requesting a waiver. Separately, on January 28, Secretary Rubio announced that he had issued an additional emergency humanitarian waiver, which allows implementers of “existing life-saving humanitarian assistance programs” to continue or resume work. The waiver is temporary and does not apply to new contracts (unless a separate waiver is granted). Life-saving humanitarian assistance is defined as “core life-saving medicine, medical services, food, shelter, and subsistence assistance, as well as supplies and reasonable administrative costs as necessary to deliver such assistance.”

While additional waivers could be requested through the Director of Foreign Assistance at the Department of State, several activities are not eligible for waivers at all, including those that involve: abortions (which are not paid for using U.S. government funds anyway), family planning, conferences, administrative costs other than those covered by the humanitarian assistance waiver, gender or DEI ideology programs, transgender surgeries, or other non-life saving assistance. Some of these services are also the subject of other executive orders and actions issued by the President include (including “Ending Radical And Wasteful Government DEI Programs And Preferencing” and “Defending Women from Gender Ideology Extremism And Restoring Biological Truth to The Federal Government”).

Despite the emergency humanitarian waiver specifying life-saving medicine and medical services, it was still unclear what programs it actually applied to and whether it included services provided by PEPFAR, the President’s Malaria Initiative, and other health programs, since under the State Department’s framework for foreign aid, health programs and humanitarian assistance efforts are categorized separately. As a result, the PEPFAR program applied for a specific waiver, which was granted on February 1, for certain activities. No other waivers have been announced for any other U.S. global health program, such as for the President’s Malaria Initiative (PMI), TB, maternal and child health, and nutrition activities.

What does PEPFAR’s limited waiver allow for? PEPFAR’s limited waiver, granted on February 1, allows for some PEPFAR services to resume during the 90-day period (unless other guidance is issued). Specifically, the waiver was granted to “implement urgent life-saving HIV treatment services in alignment with the Secretary of State’s January 28 memo “Emergency Humanitarian Waiver to Foreign Assistance Pause.” Life-saving HIV treatment is defined by the waiver as follows:

• Life-saving HIV care and treatment services (including antiretroviral treatment), inclusive of HIV testing and counseling, prevention and treatment of opportunistic infections including TB, laboratory services, and procurement and supply chain for commodities/medicines. This includes health care workers providing these services.
• Prevention of mother-to-child transmission services, inclusive of commodities/test kits, medicines and PrEP for pregnant and breastfeeding women.

Activities covered by the waiver may be resumed, including new disbursements and limited obligations (only where pre-planned obligations already existed for the activities or where they otherwise could not be restarted without new obligations). No other activities can be resumed. The waiver indicates that the PEPFAR program will create an interagency team to provide ongoing guidance to programs. 

What are the implications of stopping U.S. global health programs? The stop-work orders on existing awards and pause on new obligations and disbursements have, for the time being, halted current U.S. global health (and other foreign assistance) programs, other than activities permitted under PEPFAR’s limited waiver. This is because health care workers have been told to stop work, clinics are having to close, and commodities and other supplies cannot be provided to clients, affecting access for millions of individuals around the world, many of whom are women and children. Some of the interventions at risk of interruption and discontinuation are:

• PEPFAR/HIV: services not included in the limited waiver such as cervical cancer screening, PrEP (other than for pregnant women), and services for orphans and vulnerable children.
• PMI/Malaria: bed-nets, indoor residual spraying, seasonal malaria chemoprevention, intermittent preventive treatment in pregnancy.
• Tuberculosis: diagnosis of TB and drug-resistant TB, provision of life-saving medicines.
• Polio: identification of polio cases, vaccination of children.
• Maternal and child health: emergency obstetric care, prenatal and antenatal care, essential newborn care, skilled birth attendants.
• Family planning: contraception, birth spacing counseling, prevention and repair of obstetric fistula, linkage to maternal health services.
• Nutrition: nutrition education, nutrition during pregnancy, exclusive breastfeeding, and micronutrient supplementation.
• Outbreak investigations: halting investigations of and responses to current outbreaks of Ebola, Marburg, and mpox.

Beyond these direct impacts on access to services for people, hundreds of health care and aid workers have lost their jobs and it is expected that many more will as well, and there are widespread reports of confusion as criteria are not often specified, changes are rapid, and high level health officials at the agency which has historically overseen implementation of many of these programs, have been placed on leave.

What happens next? The implications of the pause in global health efforts will likely increase over the 90-day period, as additional programs and activities — those without waivers — are forced to shut down and lay off staff, and more people are unable to get services. The review of foreign aid programs is also underway. Depending on the results of the review, some programs may be recommended for continuation, modification, or may be discontinued. For those that are allowed to continue, it is not clear whether they will still have the capacity (staff, clinic infrastructure, systems) to be able to do so. There is also some confusion regarding the legal status of the foreign aid EO, given that a separate administrative action requiring all federal agencies to temporarily pause all new obligations and disbursements of all Federal financial assistance to ensure compliance with EOs has been successfully challenged in court and temporary restraining orders are in effect, preventing any pause. There are also reports that a lawsuit may be brought specifically challenging the foreign aid EO. Finally, Congress could step in. Congress has oversight of foreign aid programs and, in some cases, Congressional notification is required for program changes. Still, only Democratic Senators have publicly weighed in on the foreign aid freeze and other changes underway thus far (https://www.foreign.senate.gov/press/dem/release/ranking-members-shaheen-schatz-meeks-frankel-we-cannot-afford-to-take-a-timeout-from-usaid-programs and https://www.coons.senate.gov/news/press-releases/senator-coons-decries-president-trumps-freeze-on-almost-all-foreign-assistance-in-speech-on-senate-floor) and it is unclear if additional oversight efforts will be made.