The US administration initiated a significant reorganization of the US State Department, aiming to consolidate its 28 divisions into 15. This restructuring is part of a broader effort to streamline operations and reduce redundancy within the department. The plan situates the Bureau of Global Health Security and Diplomacy Office, which includes PEPFAR, under the undersecretary of State for economic growth and environment. This goes against the 2003 law that created PEPFAR, which placed PEPFAR and its Ambassador reporting directly to the Secretary of State.  
​At the same time, the new Department of Government Efficiency (DOGE) implemented a "Defend the Spend" initiative, which imposes stringent new protocols on disbursing federal healthcare grants. The policy requires detailed justifications for each payment, effectively delaying or halting funding for programs such as salaries for healthcare workers at federal health centers. ​ 

IMPLICATIONS: The reorganization and funding constraints could affect the delivery of essential services, including those related to HIV prevention and treatment, both domestically and internationally and continue to raise concerns about potential disruptions to critical health services and the overall impact on public health infrastructure. And removing PEPFAR from the direct line to the Secretary of State potentially diminishes the program’s authority and visibility. 

READ:  

• Rubio unveils sweeping reorganization of State Department—Washington Post 
• How does butchering the State Department ‘make America great’?—The Hill 
• DOGE begins to freeze health-care payments for extra review—Washington Post 
• Rubio Downgrades PEPFAR in Proposed State Department Reorganization—Politico Pro

The administration extended its supposed “foreign aid review” by an additional 30 days, pushing the conclusion to May 20. This follows the initial 90-day pause initiated by executive orders said to be assessing the alignment of US foreign assistance with the administration's "America First" policy. An internal State Department email from Jeremy Lewin, the newly appointed Director of Foreign Assistance, indicated that the additional time would be used for further bureau feedback and to align recommendations with the upcoming budget proposal.​ 

IMPLICATIONS: This extension continues amid continued uncertainty around HIV and global health programs. Organizations reliant on this funding remain in limbo, hindering their ability to plan and deliver essential programs and services. The extension also raises concerns about the potential for further cuts or restructuring of foreign assistance. 

READ:  

• Trump administration extends foreign aid review for another 30 days—Devex  

Approximately 50,000 federal employees will be reclassified under "Schedule F," a designation that would strip them of longstanding civil service protections and render them "at-will" employees. These actions target career staff in policy-influencing roles across agencies like the Department of Health and Human Services (HHS), aligning with the administration's broader agenda to reshape the federal workforce and consolidate executive control.  

IMPLICATIONS: This reclassification could undermine the nonpartisan expertise essential for effective governance, particularly in areas like health research and service delivery. The potential impact on global health initiatives is significant, as the loss of experienced personnel could disrupt programs critical to HIV prevention and pandemic preparedness. 

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• Thousands of federal workers would be easier to fire under Trump rule change—NPR  
• Trump imposes Schedule F to more easily remove federal workers—Fierce Healthcare  

Many news outlets and advocates this week are calling attention to South Africa’s HIV response, which is in crisis as the US funding freeze takes effect. Francois Venter argues in an opinion piece that key HIV services are collapsing, including community outreach, PrEP access, and clinic operations, leaving thousands without care. A pre-print journal article, The cost of the plunge, estimates that the termination of PEPFAR-supported services could result in over 13,000 additional deaths and more than 25,000 new infections each year in South Africa. The South African government's response has been criticized for its lack of coordination and contingency planning, with civil society advocates calling for urgent action, increased transparency, and new domestic investments to prevent the collapse of two decades of progress against HIV.  

READ: 

• Our HIV programme is collapsing — and our government is nowhere to be seen—GroundUp   
• The cost of the plunge: The impact and cost of a cessation of PEPFAR-supported services in South Africa—medRxiv  
• Inside government’s confused response to the US funding crisis—Spotlight  

The US National Institutes of Health (NIH) has restricted research programs in South Africa from enrolling new participants in its major HIV clinical trial networks. South Africa is a leader in trial participation and lab analysis, has been a critical partner in advancing HIV prevention and treatment strategies and has one of the world’s largest HIV epidemics. Experts, including Glenda Gray of the South African Medical Research Council, warn that this action is “petty and punitive,” especially given South Africa’s longstanding contributions to US and global HIV guidance. 

IMPLICATIONS: This NIH decision, coupled with foreign aid cuts and the dismantling of USAID, risks sidelining one of the most capable research partners in the HIV field. It could slow progress in biomedical innovation, disrupt current trial pipelines, and further erode trust in US global health partnerships—at a moment when scientific collaboration and inclusive research are more critical than ever. 

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• NIH halts more collaborations with South Africa on HIV/AIDS trials—Science 
• We do the sums: The NIH funds $350-million (R6.65-billion) of research in SA—Bhekisisa  

In the US, arguments just began in the Supreme Court on the Kennedy v. Braidwood Management case, which is challenging the Affordable Care Act’s (ACA) mandate that requires insurers to cover certain preventive services, including PrEP, at no cost. The case is brought by fundamentalist Christian business owners who oppose no-cost PrEP on religious grounds.  

IMPLICATIONS: If the Court strikes down the mandate, insurers may no longer be required to fully cover services recommended since 2010, including new long-acting PrEP options. This could severely limit access, raise out-of-pocket costs, and threaten hard-won public health gains in HIV prevention and beyond. 

READ:  

• What to know about the Supreme Court case that could take away your access to PrEP and other care—The Advocate  
• Use of No-Cost Preventive Services Jeopardized by Kennedy v Braidwood—JAMA