LAGOS/JOHANNESBURG, (Thomson Reuters Foundation) – President Donald Trump’s decision to put a halt to U.S. foreign aid sparked intense and swift panic last month, but a partial U-turn has done little to calm nerves, fuelling a debate about the viability of the global aid system.

Hours after his inauguration on Jan. 20, Trump ordered a 90-day pause in foreign aid, including the supply of drugs for HIV treatment under the President’s Emergency Plan for AIDS Relief (PEPFAR), the world’s leading HIV initiative.

As charities and development agencies reeled at the speed and scale of the policy change, people like Harrison Ibeh, a 32-year-old gay Nigerian who is HIV positive, wondered how they would cope without life-saving antiretroviral (ARV) therapies.

“I’m mentally down right now,” Ibeh told the Thomson Reuters Foundation in Lagos, Nigeria.

“With no job at the moment, how can I afford to buy ARV?”

Daniel Chukwuka, a HIV-positive bisexual man who lives in Port Harcourt in southern Nigeria, said he was due to pick up new medication in two weeks.

“I am scared. I don’t want to die,” Chukwuka said.

Then, as aid agencies grappled with the effect of Trump’s executive order on their operations, U.S. Secretary of State Marco Rubio issued an emergency waiver for life-saving humanitarian assistance on Jan. 28. Ibeh and Chukwuka spoke to the Thomson Reuters Foundation before the waiver was announced.

UNAIDS welcomed the waiver and said it would allow access to HIV treatment for people in 55 countries worldwide that are funded by the U.S. But there was still some confusion over what treatments would be exempted from the freeze and concern over what it all meant for the future of U.S. aid funding.

On Saturday, the State Department confirmed PEPFAR was covered by Rubio’s waiver and clarified what activities were allowed, including life-saving HIV care and treatment services, prevention and treatment of infections including tuberculosis (TB), laboratory services, and procurement and supply chain for commodities/medicines.

PEPFAR directly supports more than 20 million people living with HIV, or around two-thirds of all people receiving HIV treatment globally, according to UNAIDS.

In Nigeria, around 2 million people were living with HIV in 2023, according to UNAIDS, and around 1.6 million of those are on treatment.

Although there has been a reprieve for PEPFAR for now, Trump’s decision to pause foreign aid, and other orders and declarations relating to LGBTQ+ rights, have forced NGOs to wonder how secure future U.S. funding will be.

On Saturday, Reuters quoted two sources as saying that Trump’s administration was also moving to put USAID under State Department control in what would be a significant overhaul of how Washington allocates U.S. foreign aid.

And on Monday, billionaire Elon Musk, who is heading Trump’s drive to shrink the federal government, said work is underway to shut down USAID, which he described in a social media talk as “beyond repair”.

For some, the damage has already been done.

Nigerian community worker Moses, who did not want to give his last name for fear of repercussions, said he was let go from his job helping those living with HIV just days after Trump’s original announcement of a freeze.

“We knew something like this might happen but we didn’t imagine it would be so sudden,” he said.

“This funding freeze on PEPFAR would greatly reduce the quality of life and we would see more new cases if nothing urgent is done about this,” he said last Tuesday.

Experts warn that interruptions in ARV treatment can lead to increased viral loads and transmission rates and could even see the development of drug-resistant strains of HIV.

“The ripple effects of this decision could undermine global efforts to end AIDS as a public health threat,” Moses said.

Before Rubio’s waiver was announced, the World Health Organization expressed similar concerns, saying a prolonged funding halt for HIV programmes could lead to rises in new infections and deaths, “reversing decades of progress”.

Compounding international uncertainty, Trump also pledged to pull out of the WHO – although he later said he might rejoin – and promised to put a halt to a U.S. refugee resettlement programme.

The United States is by far the largest donor of aid globally. In fiscal year 2023, it disbursed $72 billion of assistance worldwide on everything from women’s health in conflict zones to access to clean water, HIV/AIDS treatments, energy security and anti-corruption work.

‘URGENT NEED FOR ALTERNATIVE FUNDING’

In South Africa, at the Triangle Project, a rights organisation advocating for LGBTQ+ communities, the effects of Trump’s orders are already filtering through.

Even though the Project does not receive funding directly from PEPFAR or USAID, it works closely with groups that do, and they have already been affected.

“Community health workers were immediately told to stop working, leaving gaps in care,” said Ling Sheperd, the Triangle Project’s communications director, noting that the affected organisations included those working on HIV prevention, substance abuse programmes and maternal health.

“People who rely on these services are now left without clarity on where to turn,” she said.

“The funding pause puts people’s lives at risk. Access to HIV treatment and prevention is already a challenge for many LGBTQ+ people due to stigma and discrimination in healthcare,” she said.

Aurora Krotoa Moses, a 23-year-old South African transgender activist, found out on Facebook last week that the health clinic where she gets her hormone medication was closing its doors for now.

Her hormone therapy is funded by the local government but administered at a clinic that’s also funded by USAID and PEPFAR, just one example of the broader impacts of an aid shutdown.

“I was hit by a brick of emotions … I had to rush to the clinic to go at least take some medication for the time being and I did luckily,” she said.

“My friend, she only has two weeks of medication. If you don’t take it every day, the process of de-transitioning starts and the stress of gender dysphoria and all of that starts creeping back,” she added.

The clinic told Moses and her friend that they would have to seek the medication at a private hospital, an expense many cannot afford, or go through the public healthcare system – but this made her fearful.

“Are they willing to accept us as we are? Will they understand us? I don’t know.”

The Triangle Project’s Sheperd said the funding freeze also exposes a deeper problem – local reliance on foreign aid, a dependency, she said, that mirrored the dynamics of resource exploitation.

“The recent freeze in U.S. aid shows just how vulnerable this system makes us: vital programmes like HIV treatment, maternal health, and TB prevention could come to a halt, putting millions at risk with a stroke of a pen,” she said.

“We need urgent alternative funding solutions, both from local government and international partners committed to sustaining health programmes.”

Transgender activist Moses agreed that local authorities needed to step up, particularly on gender-affirming care, and she said the aid freeze had already taken a toll.

“It’s the hopelessness on people’s faces. Looking at the clinic staff, they have to smile and to kind of keep us at ease. But they are also now jobless.”

(Reporting by Kim Harrisberg and Nelson Chigozirim; Writing by Clar Ni Chonghaile; Editing by Ana Nicolaci da Costa. The Thomson Reuters Foundation is the charitable arm of Thomson Reuters.)