PEPFAR Bridge Plans Extended, Possibly Without New Money

America First Global Health Strategy deadlines didn't work out.

PEPFAR partners can continue implementing HIV services for another three months in countries that have not signed or received funding for America First Global Health Strategy activities, according to several country-based groups. Previously, PEPFAR programs did not have permission to operate after March 31 2026, when AFGHS was supposed to be in place. The permission to keep operating comes weeks before this deadline, at a time when many countries have missed deadlines for developing AFGHS implementation plans.

The go-ahead to keep operating means HIV programs reliant on US government funding can keep doing what they’ve been doing in the past six months. However, based on Office of Management and Budget (OMB) reports, it is highly likely that this permission has not come with corresponding financial resources.

In this post, I explain why I think PEPFAR programs may be being asked to stretch six months of funding (plus whatever they have in reserve) over nine months of work.

But before I go further, please know this: my explanation isn’t enough.

It is of the utmost importance that Congress exercise its power to obtain accurate, up to date information.

If the updates provided Congress confirm what the OMB reports suggest, then these elected officials should take action to alleviate a crisis of uncertainty that will destabilize already-fragile programs, cause needles suffering, and waste US taxpayer dollars.

How did we get here?

How did we get here again?

A year ago, the chaos of the foreign aid freeze, stop work orders, dismantling of USIAD and waiver-ing of PEPFAR activities brought HIV programs running with support from the US government to the brink of disaster. It was lethal and horrible and it seemed like there would never be anything but destruction.

But then, in September 2025, the Department of State Bureau of Global Health Security declared that PEPFAR programs could operate for six more months under a “Bridge Plan” that came with a slimmed down set of indicators and metrics, and additional funding. And then the same folks launched the America First Global Health Strategy which was, and is, the largest visible humanitarian-ish program in AmericaFirstlandia. Things didn’t look great but it wasn’t endless destruction.

So how, after the windsprint to sign MoUs, and the Bridge Plan funding that extended PEPFAR services for HIV treatment and wee bit of prevention for six months, from October 1 through March 31, did we end up—again—on the crumbling edge of a precipice of uncertainty and destabilization?¹

Besides (variously) hubris, grandiosity, compliance, desperation, not listening to technical experts who told you it wasn’t possible or realistic, and not knowing what you don’t know

Here’s an explanation:

Things got off schedule.

Alt text: A person with short dark hair, white skin, a dark blazer, white shirt and khaki pants standing in a glass-walled box that says “phone” on it. That’s a phone booth. The text on the image says, “No, we had a problem. We tried to do everything we could.” That’s what the person on the other end of the phone is saying to the guy in the phone booth. This is the movie Goodfellas. The actor is Robert De Niro. It’s a mob movie, so the problem isn’t a leaky faucet. De Niro gets super upset and starts whacking the receiver into the phone box. Really whaling on it. It’s senseless violence and also grief. In my family, the guy on the other end says “Didn’t work out,” in this scene. That line isn’t in the scene. But for us, it is. Sometimes you all remember something and the memory is right and the movie is wrong. Didn’t work out. Is the Trump Administration the guy? Who is the phone? Am I the guy? Not sure. Mostly I’m putting this here because it’s 9:03 pm and I’m still not home. Hey, guess what? If 10 people became paid subscribers this month, I’d be able to work on the next stack during regular work hours. Last month was slow and low on paid subscriptions. Please consider converting to paid if you can.

Under the Bridge Plan, PEPFAR programs did not have permission to operate a day past March 31 2026. The folks that authorized the Bridge Plan also authored the America First Global Health Strategy, which both lauded and condemned PEPFAR, and declared that it needed to change—dramatically and fast.

These same folks flew all over Africa in November and December negotiating Memoranda of Understanding with countries to receive money from AFGHS, with the understanding that the plans, funding arrangements and staffing for implementation starting on April 1.

In January these folks put out a schedule declaring that the implementation plans for countries that signed in late 2025 were due on February 27 2026. Around the same time, senior leadership from GHSD (these folks) held a call with a whole bunch of US government staff working in countries that had signed Memoranda of Understanding to explain the implementation planning process.

According to people on that call, Brad Smith, the State Department advisor driving AFGHS strategy, said that the implementation plan deadlines were flexible in a way that the MoU deadlines hadn’t been. Every country’s different, he reportedly conveyed. We know things take time. However he does not appear to have specified, at that time, that PEPFAR programs in countries would be allowed to continue operating after March 31.

As far as I can tell, it was another couple of weeks before country-based PEPFAR programs got official permission from their agencies to keep on operating for another three months—from April through June 2026.

It’s a good thing that permission came through, because no country met the February 27 deadline for submitting its implementation plan. As far as I know, no country has turned in their plans this week, either.

There are huge problems with running a program, business or any other enterprise with this kind of uncertainty and short timeframes. Your staff may get a little stressed out not knowing whether they’ll be paid at the end of the following month. Your operations people may feel frazzled about how to plan program activities when it’s not clear how long your program will exist. Your clients panic or despair or just move on.

It’s bad business for any business. It’s a terrible, inhumane way to run a public health program.

If funding is only guaranteed for 90 days, the people who need ARV refills in 91 days cannot be sure they will receive their drugs from the place they’re used to going and the people they’re used to seeing.

As risky and short-sighted as Bridge Plan Brinksmanship is this may only be part of the problem. There are alarming indications that the countries which have permission to keep operating for another three months have not received any additional money to do so.

Here’s why I’m worried:

OMB’s SF 133 Report on Budget Execution and Budgetary Resources is a regular accounting of federal expenditures. You can head over to the website², select Department of State and FY2026, download the Excel, and head to the “TAFS Detail” tab. Once you’re there, mosey down to the account codes “75-19-1031” and “97-19-1031,”which are for CDC and Department of Defense respectively.³

Really, please do this. Find something I’m missing. Prove me wrong.

Now that you’re there, you will see entries with those codes that have “25/29” next to them. That’s shorthand for 2025-2029: the most current five-year appropriation for the Global Health Programs account that funds PEPFAR.⁴

If you look the “25/29” entries for those account codes, it shows that each agency received a single transfer in November 2025, presumably for the six-month Bridge Plan. As of late January, no new transfers had been recorded in the OMB log.⁵

This means that in late January, even as GHSD was telling US government staff in countries that they could miss their implementation plan deadlines, these folks had not taken any OMB-documented steps to move additional money to the agencies that support the country programs. A fuller update would have been: You can miss your deadlines, but you’ll have to find a way to pay for your work with whatever money you have on hand.

It is also possible that money moved to agencies in January after the OMB uploaded this report, or even February. I wouldn’t know.

Congress should not wait for OMB to update its portal to find out.

Have the agencies that receive PEPFAR funding via State Department received additional resources to support program continuity and quality? How are piecemeal payments and shifting timelines affecting both headquarters and country-level work, including on areas of global health security that have direct implications for the health and wellbeing of people in the US and around the world?

These are answerable questions. Equipped with this information, Congress can take stabilizing steps, such as specifying minimum agency allocations from the GHP budget, before it is too late.

Every piecemeal extension of what remains of PEPFAR does further damage to the program’s core value of providing long-term, predictable financing and neutral, evidence-based technical partnership so that countries, clinics and communities could make, implement and iterate on lifesaving plans.

Most agencies have reserves or “pipeline” that they can use to cover activities after March. But the pipeline is not infinite. If pipeline funds run out before countries have implementation plans, and GHSD extends permission for programs to keep on going, many will be unable to do so.

Waiting until February to clarify that all programs could continue after March 31 created an enormous strain. Granting permission without further funds and a longer time horizon is more than the programs, their staff, clients and technical support people should be asked to bear.

It is good that PEPFAR programs can continue to operate past the original Bridge Plan end point of March 31, and yes, it is good that there are five year plans for further US foreign aid for global health. It’s also good that the Department of State understands that country context should dictate planning timelines, and that the first tranches of funding should be used to support continuity through functional mechanisms, even if those are not government-to-government agreements.

But as this week’s total lunar eclipse reminded us, the bright side is sometimes also the bloodied side. A belated extension of the Bridge Plan period that may have no new funding is not a maintenance phase. It’s abuse and waste of resources that can’t go as far as they should because no one is able to plan.

The moon during this week’s full lunar eclipse. The surface is peach, orange, red. It is shining between two towers of a Gothic looking building with Hogwarts vibes. It’s insulting to this glorious “blood moon” to drag it into this stack. But let’s find beauty where we can.

Many signs point to the timelines slipping even more. In the last week one country (Zambia) has stayed mired in MoU negotiations; Zimbabwe has stayed firm in bowing out of its talks; Rwanda, which had a signed MoU filled with sweet potential private sector deals that also positioned the country as the cornerstone of a health security surveillance hub in the region, has severed diplomatic relations with the United States; and Kenya’s MoU is still tied up in court.

It is time, I submit, to do what should have been done back in September: extend the Bridge Plan for the full fiscal year, top up agency accounts so that work on other health areas can happen; and take the time to do government to government agreements and transition planning responsibly and well. Well. A girl can dream.

1. The US has been living on that edge for a long time. And then took several steps closer about 14 months ago. And then a heedless, giant leap in the last week by starting a war in the Middle East. The precipice isn’t new. We’ve never left it. But in terms of the widening gyre of wars and intimidation and the application of America First stratagems to US foreign aid for global health in general and HIV in particular, we are so close to the edge that little pebbles are falling down and the tips of our sneakers are hanging in midair and our parents are standing somewhere behind us screaming, “Get away from there, get away from there, don’t move, get away from there.” Oh, how we wish we were in a world where safety was as simple as following their directions. Didn’t work out.

2. https://portal.max.gov/portal/document/SF133/Budget/FACTS%20II%20-%20SF%20133%20Report%20on%20Budget%20Execution%20and%20Budgetary%20Resources.html

3. The code 19 signifies that the money in question is tied to the State Department’s Global Health Program appropriation. 1031 is the code for the specific Global Health Program account. 75 is the code for CDC. 97 is the code for Department of Defense. So 75-19-1031 is: CDC getting funds appropriated to the State Department from the Global Health Program budget line.

4. There are also entries with other date ranges (ie 24/28, 23/27)—and they show balances brought forward from previous appropriations cycles.

5. If you actually follow these instructions - which I really hope you do - you will see the same number repeated under November, December, January. That is not new money. That’s the total budgetary resources available that month. (This doesn’t tell us anything about how much money has been spent.)