Donald Trump sent shockwaves across the world in his first week as president. Of all the domestic and international executive orders he signed, arguably the most consequential was the executive order that froze all US foreign assistance programs for 90 days while his administration reviewed their alignment with his policy goals. This order, signed on his first day in office, was also accompanied by others that are detrimental to global health equity and outcomes, such as withdrawing the US from the World Health Organization and reinstating the Mexico City Policy, also known as the Global Gag Rule. Most devastatingly, the US foreign aid freeze also applied to the President’s Emergency Plan for AIDS Relief (PEPFAR) and all USAID programs, which have been instrumental in the fight against HIV for over two decades. 

The foreign aid freeze and the subsequent stop work order memo sent out by the US Secretary of State Marco Rubio days later set off a chain reaction of uncertainty and alarm across the globe—including here in South Africa, where some US aid-funded HIV non-profits announced they would stop operating to comply. In the last few days of these perilous times, Rubio signed a partial waiver for “life-saving humanitarian assistance,” which applies to the continuation of “antiretroviral medications and treatment to prevent mother-to-child transmission of HIV,” Devex reported. But anxieties continue to loom as many local non-profit organizations await official communication from Washington before resuming services. Many were oblivious to the extent of assistance and influence that PEPFAR and USAID programs had in our local fight against HIV until the Trump executive order. About 44% of PEPFAR allocations (equating to approximately $3.1 billion) in 2020 were made to South African NGOs, according to the Foundation of AIDS Research (amFAR).

But how did we get here? 

South Africa’s dependence on foreign aid for health is not an accident; it’s a consequence of history. The country’s public health system was deliberately underfunded and fragmented under colonialism and apartheid, leaving deep structural inequalities. Even in a post-apartheid era, it remains challenging to bridge these gaps. In this vacuum, foreign aid became the solution. Programs like PEPFAR and USAID stepped in to fund massive HIV interventions. This dynamic turns what should be a partnership into a hierarchical relationship where donor countries hold power and enable ideological and political soft power to rear its head. US foreign assistance isn’t just about altruism—it’s also about influence. Aid serves as a form of soft power that advances US political, ideological, and economic interests.

PEPFAR was established in 2003 under President George W. Bush as a response to the global HIV crisis, particularly in Africa. Leading Democrats, including Barbara Lee and the Congressional Black Caucus, had been advocating for a worldwide HIV program for several years and, through the Bush administration, were able to reach common ground that received bipartisan support that became PEPFAR. It was the most significant commitment ever made by a single country to combat a disease internationally. Initially funded with $15 billion over five years, PEPFAR aimed to provide antiretroviral treatment, HIV prevention services, and care for those affected by the epidemic. However, from its inception, PEPFAR was tied to conservative and evangelical values that restricted how the funds could be used. This included funding abstinence-only programs and limiting support for comprehensive sexual and reproductive health services.

Its bipartisan support hinged on Republican demands that its programs reflect faith-based morality. This compromise resulted in significant restrictions on how funds could be used. For instance, early PEPFAR legislation mandated that one-third of all prevention funding be allocated to “abstinence and be faithful” programs driven more by religious ideology than scientific evidence. 

One of the most overt examples of ideological coercion through aid is the Global Gag Rule, which prohibits organizations receiving US funding from providing, discussing, or advocating for abortion services. Formally known as the Mexico City Policy, it was first introduced in 1984 by President Ronald Reagan. It prevents foreign organizations that receive US government funding from providing, discussing, or advocating for abortion services, even if those services are funded through non-US sources. The policy has been rescinded and reinstated multiple times depending on the political party in power in the US. Republican administrations have historically enforced the rule, while Democratic administrations have repealed it. The policy has had a chilling effect on global health organizations, forcing many to choose between receiving funding or providing essential reproductive health services. South African NGOs that depend on PEPFAR funding have had to navigate these restrictions, often choosing between financial survival and comprehensive service provision. 

In 2019, I reported on an amFAR survey of one-third of 247 global HIV organizations funded through the PEPFAR and how they had altered their services due to the policy. The study found that about one-third of the changes made by NGOs were unrelated to abortion. The Gag Rule led to a reduction in critical HIV services, including testing, cervical cancer screening, and adolescent health care. A key issue was the over-implementation of the rule, where organizations—fearing the loss of funding—applied it more strictly than required. The ambiguity of the policy was intentional, creating a chilling effect that limited reproductive health services even beyond what was mandated. This strategic vagueness allowed the US government to indirectly influence compliance through fear and uncertainty. Although South Africa’s liberal abortion law provided some room for organizations to offer abortion referrals, the policy remained restrictive. NGOs feared losing US funding, with nearly one-third of surveyed organizations reporting that 90% of their budgets depended on US global health funds. This financial dependency forced organizations to choose between compliance and survival, severely impacting countries with high HIV prevalence.

Marginalized groups, including young women and LGBTQ+ communities, were (and will be yet again) disproportionately affected. Trump’s iteration of the gag rule also fractured civil society, isolating organizations that continued advocating for reproductive rights. The study dismissed claims that the policy did not impact PEPFAR-funded organizations, revealing a widespread suppression of health information and sexual rights advocacy.

While it is unsurprising that Christian evangelical ideology played a role in shaping US policy on abortion, its broader ethos of morality also influenced PEPFAR’s approach to other issues, including sex work. PEPFAR includes an Anti-Prostitution Pledge, a policy that works to silence sex worker advocacy by opposing sex work and requiring PEPFAR-funded organizations not to use funds to promote or advocate for the decriminalization of sex work. Not only does this clause conflate sex work with human trafficking—a well-documented tactic used by Christian conservatives—this provision has forced many HIV organizations to sever ties with sex worker advocacy groups, despite the well-documented role of sex work in HIV transmission.

These policies illustrate how foreign aid undermines national health sovereignty by dictating who organizations can serve and how. Foreign aid structures maintain a neo-colonial dynamic of donor control and recipient compliance. When donors set the agenda, recipients face pressure to conform or risk losing vital resources. However, this influence extends beyond public health. The US has used aid for broader political leverage, shaping civil society landscapes in recipient countries. Evangelical organizations have disproportionately benefited from PEPFAR funding in its earlier years, enabling their expansion and reinforcing conservative social norms.

The history of PEPFAR is a cautionary tale of how foreign aid, even when beneficial, can be wielded as an instrument of control. While donors may not explicitly dictate policy choices, they exert pressure through funding requirements, reporting mandates, and performance benchmarks. The long-term impact is a constrained policy environment where national priorities are shaped not by local needs but by the strategic interests of foreign governments.

But there’s a golden thread running through this history and the Trump administration’s actions since January 20: the foreign aid freeze and the reinstatement of the global gag rule are not just politics. This isn’t just Trump pushing an “America First” agenda. This is part of a bigger project: the platforming and expansion of right-wing evangelical beliefs. It is about advancing right-wing evangelical Christian nationalist ideology. Trump hasn’t just cut funding to global health in various ways—he has also slashed funding for LGBTQI programs, DEI initiatives, and reproductive health services. These cuts are tools to reinforce conservative Christian values across the world.

The promotion of a broader evangelical Christian nationalist worldview is about positioning the US as a divine protector of traditional family and biblical values. It aligns with right-wing evangelical interpretations of biblical prophecy, the idea of American exceptionalism, and the belief that the US is God’s chosen nation. It is a way to entrench a worldview that extends beyond international assistance into ideological warfare. And we need to see it for what it is. This is about rewarding those who uphold conservative Christianity, particularly evangelical conservatism, and punishing those who do not. The message is clear: countries that align with conservative Christian values will be rewarded; those with progressive social policies will be punished.