Introduction   For several decades, the United States has positioned itself as a major player in global public health, notably through the United States Agency for International Development (USAID). Thanks to massive funding, this agency has supported essential programs to combat major infectious diseases such as HIV, tuberculosis and malaria. Its commitment has saved millions of lives and improved access to healthcare in many low- and middle-income countries.   However, the recent suspension of USAID funding is plunging activists, international organizations, community and civil society organizations and patients into growing uncertainty. Concern is growing about the repercussions of such a decision, the scale of which still seems to be underestimated by the governments of the recipient countries.   Indeed, these governments have not fully grasped the consequences of the American freeze. They are struggling to grasp the extent of the problem and to devise an appropriate response. This is partly due to the fact that, until now, these governments have had limited visibility and control over these funds, which were often implemented in parallel with national schemes.   While this shock could, in time, encourage these governments to strengthen their resilience and invest more in their own health systems, the major difficulty lies in the fact that these cuts are not limited to the health sector. In a context of multiple and often competing budget priorities, it will be extremely difficult to compensate for this loss.   This article offers an up-to-date analysis of the consequences of this suspension. But before getting to the heart of the matter, it takes a closer look at the role and functioning of USAID, in order to better grasp the scale of the impending disaster.   Setting the scene   The United States has historically played a leading role in official development assistance, particularly in the field of health. USAID manages a budget of $42.8 billion, accounting for 42% of global humanitarian aid. This aid is divided into three main sectors: economic development, humanitarian assistance and health.     In the field of healthcare, the United States is the world's leading contributor, investing massively in the fight against HIV, tuberculosis and malaria. Their commitment is particularly influential in the ecosystem of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The African continent is the main beneficiary of this funding, illustrating the scale of the United States' impact on global public health.     However, the freezing of this aid jeopardizes the fragile balance of many public health programs. This suspension has dramatic consequences for patients, healthcare workers and healthcare systems in many countries, particularly on the African continent.   The impact   HIV: a care system in peril The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funds a major part of the fight against HIV in many countries. The freezing of this aid has immediate and severe repercussions, as evidenced by the UNAIDS Public Brief   More specifically, this note, with data updated to February 17, 2025, highlights three key points:

• Critical dependence on US funding: In countries such as Côte d'Ivoire, Haiti and Tanzania, over 90% of the HIV budget comes from PEPFAR. Other nations such as Ethiopia, Nigeria and Uganda also rely heavily on this program.
• Frontline healthcare workers affected: In South Africa, 15,374 PEPFAR-funded healthcare workers are directly affected. In Cameroon, 2,332 professionals, including 258 doctors and nurses, have been laid off.
• Compromised access to treatment: At least 14 countries are reporting serious disruptions in access to antiretroviral treatment. Haiti and Ukraine report dangerously low stocks, putting thousands of patients at risk.
• Discontinuation of prevention programs: the DREAMS program, designed to prevent HIV infection among young women, has been suspended in Kenya, Malawi and South Africa.

An article published on February 18, 2025 in the Journal of the International AIDS Society entitled "Early impacts of the PEPFAR stop-work order: : a rapid assessment" is also very alarming about the consequences of this freeze.     Tuberculosis: screening and treatment under threat According to a STOP TB Watch Note of February 14, 2025, the USAID freeze has caused serious interruptions in the global response to tuberculosis (TB), particularly in 12 high-burden countries.

• A drop in screening: in Bangladesh, paediatric screening projects have been suspended, while in Cambodia, 100,000 people have not been tested, increasing the risk of undetected transmission.
• Infrastructures in crisis: Ukraine has lost USAID support for its laboratories, seriously disrupting case detection.
• Impending drug shortages: Kenya faces an imminent shortage of tuberculosis drugs, while in Ukraine, a crisis is expected as early as September 2025.
• An interruption in prevention: In Pakistan, all prevention activities have been suspended in 27 districts, increasing the risk of future infections.
• Closure of specialized care units and mass layoffs of health workers. In Ethiopia, 5,000 USAID-funded health workers are no longer working. In Nigeria, 1,800 health workers in 18 states with high TB prevalence have been laid off.

  Malaria: a regression in health progress   USAID funding plays a crucial role in the fight against malaria, notably through the distribution of impregnated mosquito nets, spraying campaigns and access to treatment. The malaria activists and community health workers we interact with in countless webinars claim that the freeze has already led to :

• Major interruptions: The suspension of funding has led to shortages of essential tests and treatments, particularly in rural areas.
• A step backwards in prevention: awareness campaigns and mosquito net distribution are cancelled, increasing the risk of epidemics in vulnerable regions.
• Economic repercussions: The regression in the fight against malaria affects the productivity of exposed populations, aggravating poverty and limiting economic development.

  In addition to these aspects, the freeze on US aid funding has led to the suspension of a flagship malaria vaccine development program, disrupting global health research. USAID's Malaria Vaccine Development Program (MVDP), which funds collaborative research between institutions such as Johns Hopkins University in the USA and Oxford University in the UK, has been forced to halt its work. This interruption affects important research aimed at improving the efficacy and duration of recently introduced malaria vaccines.   The MVDP's aim is "to reduce the impact of malaria on children living in malaria-endemic areas of the world". In sub-Saharan Africa, approximately 450,000 under-5s are killed by malaria each year". Researchers warn that this pause could lead to the further spread of drug-resistant HIV and a significant setback to medical progress. Although the funding freeze was initially scheduled to last 90 days in order to re-evaluate spending, the absence of expert staff in US health agencies to lead this review is causing uncertainty about the future. Other projects, such as the production of active pharmaceutical ingredients for antiretrovirals in Africa, are also threatened by the loss of funds and personnel. The scientific community is calling for a reconsideration of this decision to avoid decades of setbacks in the fight against infectious diseases.   Polio Finally, the United States plays an essential role in the Global Polio Eradication Initiative (GPEI), which enables hundreds of millions of children to be vaccinated against polio in over 40 countries every year. They contribute more than a quarter of the initiative's annual budget. During the 90-day freeze period, up to 110 million children who were due to receive polio vaccines could now find themselves unprotected.   Conclusion   The USAID funding freeze is a major threat to global public health. By jeopardizing essential programs in the fight against HIV, tuberculosis and malaria, this suspension of aid puts millions of lives at risk. It accentuates health inequalities, weakens already vulnerable healthcare systems and hampers global efforts to control infectious diseases.   In the face of this crisis, it is imperative that alternatives are found to guarantee the continuity of care and the sustainability of public health initiatives. Increased domestic funding, greater mobilization of other international donors, strategic reallocation of resources and vigorous political advocacy are essential to avoid, at least in the short term, a large-scale humanitarian catastrophe. Global health cannot afford to take a step backwards: action is urgently needed.