ROB SCHMITZ, HOST:
When the Trump administration announced its America First global health strategy, it set out a deadline - six months to hammer out new contracts with governments receiving aid and to develop detailed implementation plans. Well, the self-imposed deadline passed earlier this week, but as NPR's Gabrielle Emanuel reports, things are still in flux.
GABRIELLE EMANUEL, BYLINE: When Caspian Chouraya became a doctor in the early 2000s in Southern Africa, specializing in HIV/AIDS was a no-brainer. In his hospital...
CASPIAN CHOURAYA: The wards where I was working in, almost everyone admitted in there was an HIV patient.
EMANUEL: In the tiny nation that was Swaziland, now named Eswatini, he dealt with some of the highest HIV/AIDS prevalence rates in the world. More than a quarter of adults were infected with the virus.
CHOURAYA: Projections were that HIV was just going to wipe out the entire nation.
EMANUEL: Fast forward a few decades, and the situation has improved dramatically, in large part thanks to U.S. health aid, the largest chunk of which has gone to HIV treatment and prevention. But this past year has scrambled much of the work. Chouraya now works for the Elizabeth Glazer Pediatric AIDS Foundation. From Eswatini, he oversees HIV work.
CHOURAYA: We are in Uganda, Malawi, Tanzania. We are in Lesotho, Kenya, Mozambique, C'ote d'Ivoire.
EMANUEL: U.S. funding cuts this past year have meant many of his projects shut down - like support groups for teenagers with HIV, cell phone plans so clinics could stay in touch with patients. But even the projects that survived, Chouraya says, have been caught in a vicious cycle of uncertainty. Will U.S. funds keep flowing or not?
CHOURAYA: Am I in? Am I out? Am I in? Am I out? What's happening?
EMANUEL: What's happening is that the Trump administration is ditching the decades-old system, which involved partnering with lots of nonprofits and large international organizations. Instead, it's negotiating new agreements directly with individual governments. In the meantime, lifesaving efforts on the ground were given six months of so-called bridge funding to keep going. But a big issue - the second installment of the bridge funds for the last three months was supposed to arrive in December. It was late, often weeks, sometimes months. For one country...
CHOURAYA: We only managed to get that in March. So we're already, I mean, just winding and closing and all those kind of things.
EMANUEL: They were shutting down the program, which included 53 health facilities, when the funds finally arrived. Now it's supposed to be the end of the bridge funding period when everything - including new procurement systems, new digital health strategies - were supposed to be worked out by the U.S. and the other governments and ready to go.
EMILY BASS: It was totally unrealistic.
EMANUEL: Emily Bass wrote the book "To End A Plague: America's Fight To Defeat AIDS In Africa." She says, in many places, plans are still not ready. So projects were told, OK, you have permission to keep working three more months until June. The funds - who knows? She says, this is no way to run a health initiative.
BASS: If you want to talk about waste and abuse, this is really extraordinary. If you do six months and then another three months, you are getting less return on your investment than you'd get if you were investing in a stable program.
EMANUEL: In a statement to NPR, the state department called this a mischaracterization and said funds are being directed more strategically. Chouraya is worried about costly litigation. Countries often require a certain number of months' notice before layoffs.
CHOURAYA: So we have to work on giving notices to staff so that we can prepare for possible termination of their contracts.
EMANUEL: If the U.S. funds don't come through, his organization may be in trouble for labor law violations.
CHOURAYA: It's a stressful process. I don't want to lie.
EMANUEL: This is all happening despite the fact that Congress pushed back against Trump's cuts and gave $6 billion this fiscal year to fight HIV AIDS worldwide, same as the previous year. K.J. Seung is at the Division of Global Health Equity at Brigham and Women's Hospital.
K J SEUNG: There's no difference in the amount of money.
EMANUEL: The difference, he says, is the appropriated money is not always getting sent out like it has been for years.
SEUNG: They could transfer it tomorrow, but I'm guessing this is actually a planned sunset.
EMANUEL: Seung and other experts in the HIV world say their sense is that the U.S.'s prized and praised HIV/AIDS response is on the brink and will be shut down to be replaced by still vague government-to-government agreements. The State Department told NPR that every dollar appropriated for global HIV is being spent and that there is no systematic plan to shut down the work. But Chouraya says the uncertainty of the past few months is affecting his staff.
CHOURAYA: People are getting to a point where, like, I don't think there's future, you know, in the field that I'm in right now.
EMANUEL: And that has a lot to do with exactly how the U.S. has implemented its new global health strategy. Gabrielle Emanuel, NPR News. Transcript provided by NPR, Copyright NPR.
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