A massive slice of America’s H.I.V. relief funds is frozen. Lawmakers had approved $6 billion for an internationally acclaimed prevention and treatment program credited with saving millions of lives. Yet, thanks to a shocking move from the Office of Management and Budget, only half of that money will be disbursed. For the countries relying on those grants, the shortfall sends them into a tailspin—confusion, closure of vital clinics, and fear that infections could surge once more.

At the heart of this funding freeze is the administration’s broader strategy to reevaluate foreign aid. Advocates for the program say the measure is not only a betrayal of long-standing U.S. commitments but risks erasing gains built over two decades. Despite the protestations, Russell T. Vought at the budget office remains adamant that the White House can hold back the money until it sees a plan that “aligns with Administration priorities.” To critics, that’s code for slashing support and fulfilling the president’s pledge to either get other nations to pony up more or do without.

The repercussions of slashing nearly $3 billion from these programs are already being felt. Clinics braced for dramatic cutbacks in lifesaving drugs and outreach services, especially in areas of Africa where the pandemic remains a crisis. Overworked staff talk about being told to expect layoffs, with some sites forced to stop hospital admissions for severely ill patients. Critics argue that these cutbacks hurt America’s image abroad, as the H.I.V. initiative was once heralded as a great public health success with bipartisan support dating to nearly a generation ago.

But from an America First vantage point, restricting foreign handouts resonates with many voters who question why billions should flow overseas, particularly if some of that money is earmarked for groups they deem questionable. The White House contends that every program receiving U.S. funds must meet stringent new objectives. Some top officials say countries on the receiving end of relief have had it too easy, pointing to alleged mismanagement or corruption. By hitting the pause button on a chunk of the funding, they’re demanding reforms or co-investments.

Supporters of the cut also highlight that this new cost control measure is consistent with the president’s prior approach to foreign assistance. They see a reevaluation of PEPFAR, the venerable H.I.V. program, as overdue, claiming it needs to be streamlined or replaced by a structure that puts Washington in a better negotiating position. Opponents predict a wave of negative outcomes: disease flare-ups, overwhelmed local health systems, and reputational damage for the United States. Some note there is also a moral dimension—the notion that withholding funds for H.I.V. tends to hurt the world’s poorest, who have few other options.

The White House is unmoved by these appeals, maintaining it needs maximum leverage to extract changes from the program. Aid organizations are scrambling, hoping that enough lawmakers stand up to push back, or that the administration eventually relents. For now, the billions remain in limbo, a sobering reminder that in this climate of reexamined alliances and tightened budgets, not even the most prestigious health initiative is safe. As the administration’s allies cheer this as a sign of tough negotiating, the program’s front-line workers quietly brace for a cascade of hardships. With no immediate indication of a change in policy, the world can only watch as the future of a flagship H.I.V. program hangs by a thread.