Update: At the time of publication, the State Department released a new “America First Global Health Strategy”; while it requires a deeper reading, it seems broadly consistent with our takeaways below.
Upon taking office, President Trump, acting via deputies including Secretary of State Marco Rubio and the DOGE team, made quick work of demolishing USAID and much of the existing US global health infrastructure. The Trump administration paused and then terminated thousands of awards—which included support to essential lifesaving health services—with immediate and widespread consequences.
In this context, prospects for future US engagement on global health appeared dire. Yet, recent moves from the administration and Congress sketch the broad outlines of a potentially constructive path forward from the upheaval of the last eight months. The implications are clearest for PEPFAR, the US flagship global health program—and a rare (continuing) source of bipartisan support.
Below, we unpack three big strategic shifts implied or stated in recent policy announcements, and how they could serve as the foundation for PEPFAR’s next chapter—if adequately resourced and well operationalized.
1. Support for global roll-out of lifesaving (American) innovation
Amid continued operational upheaval, the administration recently signaled a renewed, forward-leaning role in advancing access to high-impact medical innovations—particularly American-developed technologies.
Most explicit is the State Department’s plan to support the global roll-out of Lenacapavir, a game-changing HIV prevention drug, to up to two million people by 2028. The commitment is modest relative to global need and focused on preventing mother-to-child transmission, without explicit prioritization of other high-risk groups like adolescent girls and key populations. Nevertheless, it is encouraging that the administration sees a continued role for the US to support global access to lifesaving HIV innovations—and we are hopeful this might cross-apply to breakthrough health technologies against other deadly diseases, such as tuberculosis.
Under this emerging model, the US will supply transformative products in-kind, coupled with investments in government health systems to deliver them. Undersecretary Jeremy Lewin emphasized this shift at the press conference for the announcement: “This is where our focus is going to be: On the purchasing, at scale, of commodities that can really help have an outsized impact in fighting HIV and across our various global health disease areas.”
But to deliver real health impact, this model will require stable resourcing, transparency in delivery strategies, and careful alignment with country priorities—especially in light of deep cuts to overall funding and programmatic infrastructure.
2. Country partnerships (“Global Health Compacts”) that put funding on budget and gradually phase out support
The Trump administration—with Congress’s support—seems to have two high-level strategic goals for PEPFAR:
First, the administration wants to cut out the middleman. The administration has long expressed its distaste for NGOs and so-called “beltway bandits” that have historically implemented PEPFAR programs. Now, they are advancing a vision for PEPFAR’s future that sidesteps the role of such organizations almost entirely—at least in some countries.
Undersecretary Lewin expanded on the administration’s perspective at a press conference for the Lenacapavir announcement: “For too long, PEPFAR’s budget has been drained by sort of NGO implementing partners that are charging very high indirect cost rates and has been sort of focused on non-core activities . . . We help the countries have the tools to fight the epidemic but also help them build their own national . . . healthcare systems, rather than distributing medication through NGOs that were operating as a shadow healthcare system.”
Congress seems willing to support a model that mostly bypasses implementing partners. A House Foreign Affairs Committee (HFAC) draft bill—a component of a multipart State Department reauthorization package—authorizes the provision of grants, contracts, or cooperating agreements directly to partner governments. This represents a seismic shift in US development policy that could get far more funding “on budget” for country-owned systems.
Second, the administration wants a PEPFAR exit path, at least for most countries. The administration had already articulated its ambition for major cuts to PEPFAR vis-à-vis the budget request, which suggested a 62 percent overall cut for global health, and a 59 percent cut to PEPFAR specifically. What’s new here is a congressionally endorsed proposal and explicit timeline for PEPFAR to “wind down.” The draft House bill (mostly written by committee Republicans) suggests that all global health funding should be under the auspices of “global health compacts,” with three objectives:
- “support policies and programs that 'burden shift' global health programs to partner countries;
- perpetuate the wind-down of the President’s Emergency Plan for AIDS Relief (PEPFAR) under the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108–25); and
- address health security and tuberculosis, malaria, HIV/AIDS, neglected tropical diseases, and any disease or additional global health assistance as determined by the Assistant Secretary.”
How fast would PEPFAR phase out? The HFAC draft legislation weighs in here, explicitly indicating a 50 percent overall reduction in spending by FY2028. The GOP-led House Appropriations Committee has also endorsed the idea of PEPFAR transition—albeit without formally invoking a compact approach or specifying the timeframe.
And there’s at least an opening for a results-based approach: the bill suggests Compacts should include “metrics to determine the success of the compact and benchmarks to reevaluate the continued funding.”
3. A smaller PEPFAR footprint for the poorest and fragile countries
In the poorest, most fragile, and conflict-affected settings, a full transition to country-led delivery—or an on-budget financing structure—may not be feasible. Beyond the headline budget cut (50 percent by FY2028), the draft legislation is silent about the potential for longer-term engagement in such settings—including countries like Mozambique, the Democratic Republic of the Congo, Haiti, and Mali, for example.
We suggest there is a need to sustain a smaller PEPFAR footprint in the poorest and most fragile countries, with more direct support and flexible implementation models over a longer time horizon. In essence, this would be a “legacy track” within PEPFAR, where the US continues to support direct delivery of essential HIV services in settings where state capacity is weak, health systems are underdeveloped, or conflict impedes routine health service delivery. House Republican and administration language suggests a potentially larger role here for faith-based organizations and other non-traditional implementing partners.
Conclusion
A new PEPFAR blueprint is beginning to take shape, offering a surprisingly strong foundation for a constructive path forward. If backed by real resources and well implemented, it could lay the groundwork for a sustainable PEPFAR transition and a pathway to real country ownership. But the details matter, and an underfunded or rushed effort could unnecessarily drive financing cliffs and service gaps, undermining decades of gains in the fight against HIV.
Stay tuned for the PEPFAR edition of Tough Times, Tough Choices, where we’ll lay out a detailed vision to make the most of PEPFAR’s next chapter.
