Global Health Watch: US government shuts down, foreign aid funding expires, Jeanne Marrazzo fired from NIH, issue 36

The US government shutdown that began at midnight on October 1 has stalled key public health operations just as the Supreme Court issued a ruling in AVAC v. Department of State that allowed $4 billion dollars in foreign aid to expire, eroding both health and human services and constitutional checks and balances. Meanwhile, Jeanne Marrazzo was officially fired as Director of NIAID, underscoring how politically motivated attacks on science are dismantling the infrastructure that has underpinned decades of progress in HIV prevention and research. 

US Government Shuts Down as Federal Funding Expires

At midnight on October 1, US federal funding expired and a government shutdown began after Congress failed to agree to pass a Fiscal Year 2026 (FY26) budget or even a temporary continuing resolution. The shutdown is largely rooted in disagreements over healthcare policy, especially access to healthcare coverage under the Affordable Care Act and Medicaid. The shutdown means “nonessential” federal work is stopped, including many public health operations. Approximately 750,000 federal employees are furloughed, including 40% of Health and Human Services (HHS) staff. CDC disease surveillance is disrupted, many NIH clinical trials are on hold, as is NIH grantmaking and basic research. Many PEPFAR staff have been furloughed as well, but essential “lifesaving” work is continuing. 

IMPLICATIONS: The shutdown further destabilizes the US health system and public health infrastructure already weakened by deep cuts. It now comes against the backdrop of a Presidential administration that is using official federal agency websites and social media as propaganda to blame Democrats for the crisis, while the Office of Management and Budget (OMB) director openly threatens mass firings across federal agencies, which is part of the Project 2025 vision he led. For the global health field, the situation highlights how fragile US commitments have become, with billions in foreign aid still frozen and HIV research and prevention programs facing uncertainty. Beyond the immediate loss of services, intimidation tactics on display during this crisis threaten to erode trust and stall science, which will extend beyond the US with consequences for health and human services worldwide. 

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US Supreme Court Grants Administration Request to Keep Foreign Aid Frozen as Clock Runs Out 

Just prior to the US government shutdown, the US Supreme Court (SCOTUS) handed down a decision in AVAC v. Department of State and Global Health Council v. Trump cases, challenging the foreign aid freeze. In a 6-3 decision by emergency order, the court granted the Administration’s request to not spend $4 billion of Congressionally appropriated foreign assistance funds before they expired on September 30, as required by law. This means that, despite the law, and a lower court order, those funds remain unspent. In its statement, AVAC’s Executive Director, Mitchell Warren, warned that the ruling gave the Administration a “free pass” to block disbursement of foreign aid, citing devastation with clinic closures, disruptions in essential services, and lives lost. Moreover, Warren said the ruling undermines constitutional checks on presidential power. “This is beyond foreign assistance; the Court’s decision is a chilling one for anyone who cares about the US Constitution.” In a dissent from the three other Justices, Justice Kagan cautioned that the stakes are too consequential to be decided through emergency orders without full briefing and oral argument and argued that the Administration has not met the stringent standards for such relief. 

IMPLICATIONS: While the SCOTUS ruling is not a final judgment, it signals a willingness to allow the President and the Executive branch to withhold funds that Congress has appropriated, potentially whenever it chooses. If unchecked, this precedent could erode the checks and balances that constrain executive overreach and jeopardize not only global health funding but every area of federal spending. 

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Jeanne Marrazzo Fired from NIAID 

Jeanne Marrazzo, former Director of the National Institute of Allergy and Infectious Diseases (NIAID), was terminated on October 1 by Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. after being placed on administrative leave in April. This comes 22 days after Marrazzo and former Fogarty International Center’s director, Kathy Neuzil, filed a whistleblower complaint with the Office of Special Counsel. In her complaint, Marrazzo detailed the Administration’s unlawful cancellation of critical research grants, politicization of science, hostility toward vaccines, and censorship of research. Marrazzo’s lawyers claim that her firing was an act of clear retaliation for her defense of scientific integrity and public health research. Marrazzo succeeded Anthony Fauci as the director of the NIAID in 2023. 

IMPLICATIONS: The Office of Special Counsel has been severely weakened by the Administration as have other oversight mechanisms- leaving few pathways for federal scientists and other federal employees to resist politically motivated attacks on research. Holding federal offices accountable to standards of practice that protect the scientific enterprise from political and ideological gamesmanship is essential. Without those standards enforced, decades of progress in science and research are at risk. Marrazzo’s dismissal represents another blow to the independence of US science agencies.  

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FOLLOWING: The US May Expand Mexico City Policy / Global Gag Rule 

According to the Daily Signal, the US Department of State plans to extend the scope of the Global Gag Rule (often referred to as the Mexico City Policy), which is an executive order that restricts foreign non-governmental organizations (NGOs) from receiving US global health assistance if they provide, refer, or advocate for abortion services. The Global Gag Rule first enacted by the Reagan administration, has been rescinded by every Democratic president and put back in place under every Republican president. Reportedly, the language in this latest iteration of the policy would be expanded to also ban US funding for foreign assistance that promotes “gender ideology” or DEI initiatives. The inclusion of gender affirming care and DEI continues this Administration’s ongoing mischaracterization of existing foreign assistance programs, and attacks on programs that are trans inclusive or seek to address racial and gender disparities.  

IMPLICATIONS: This expansion of the Global Gag Rule would fulfill a long-standing conservative goal, explicitly named in Project 2025, to reshape US global public health funding away from evidence-based programs that affirm the needs and dignity of sexual and gender minorities. Turning away from these vulnerable populations further threatens and sets back progress towards ending the global HIV epidemic.   

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What We’re Reading:

Resources

Global Health Watch: A generic price for LEN, Future of UNAIDS, UNGA 80, AI for Health, Issue 35

The stakes are high as the US approaches the start of a new fiscal year (FY26) on October 1, currently mired in stalled White House negotiations and a looming government shutdown; the Supreme Court’s pending decision on AVAC’s lawsuit; and the new US “America First” strategy to reshape foreign aid. This issue highlights major global health developments at the UN General Assembly, from debate over the future of UNAIDS to commitments from the Gates Foundation and Unitaid to accelerate access to injectable lenacapavir for PrEP (LEN), alongside new discussions on AI ethics and health. 

Gates Foundation and Unitaid Commit to Accelerate Market Development for Lenacapavir for PrEP 

The Gates Foundation and Unitaid announced new strategic investments to accelerate the development of, access to and price reduction for generic versions of injectable lenacapavir (LEN), the highly effective six-monthly injection for HIV PrEP. As AVAC’s Mitchell Warren said in its statement, “this could be a transformational moment in HIV prevention if political will, coordination, and further procurement investment meet this moment to deliver LEN with speed, scale and equity to all communities and populations who need and want prevention options.”  

IMPLICATIONS: While this progress is encouraging, it is only meaningful if momentum leads to real access. These agreements get LEN closer to the $40 per person per year price of daily oral PrEP for many, but not all, low and middle-income countries, and hopefully will accelerate large scale programs by 2027. AVAC’s publication, Now What with Injectable LEN for PrEP How to Translate Ambition into Accelerated Delivery and Impact, includes forecasts demonstrating that instead of 2 million people in three years that is currently being planned by the Global Fund and PEPFAR with initial supplies from Gilead, the world could reach at least 1.5 million people in just one year, rising to at least five million people per year by 2030. These numbers suggest what is possible and what is necessary to accelerate access, achieve real impact, build a sustainable market, and drive prices down even further.  

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UN General Assembly Updates

The UN General Assembly (UNGA 80) kicked off this week in New York with global health taking center stage. The US began the rollout of its new “America First Global Health Strategy,” which shifts toward bilateral aid models. Meanwhile, HIV innovation and access, especially for lenacapavir, are being debated in side events as delegates push for clarity on price, procurement, and equity. The WHO is accelerating its health agenda on noncommunicable diseases (NCDs) and mental health and will help lead discussions on a new global declaration.  

In its annual Goalkeepers event, the Gates Foundation announced its $912 million commitment in the current round of replenishment to the Global Fund for AIDS, TB and Malaria. The Foundation also recognized ten champions in global health, including AVAC’s partner Jerop Limo, a leading HIV and sexual and reproductive rights activist from Kenya. 

Next week, a new topic will take center stage at the UNGA’s high-level meetings: inclusive and accountable governance of artificial intelligence (AI). Ethics and equity will be central to deploying responsible AI for health, with advocates emphasizing that progress must be measured not only by rollout speed but by how well it protects patient privacy and addresses real-life challenges and needs. Development of AI governance to shape how digital tools are designed, regulated, and financed is a key part of the next generation of HIV and health programming. 

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United Nations Secretary-General Proposes to “Sunset” UNAIDS 

The UN Secretary-General shared a proposal in his new UN80 progress report to “sunset” UNAIDS by the end of 2026 and fold its mandate into broader UN structures in the face of funding cuts. The NGO delegation to the UNAIDS Programme Coordinating Board (PCB) strongly opposes this move, and was joined by nearly 800 civil society organizations warning that dismantling UNAIDS now would undermine leadership, coordination and accountability at a time of escalating funding cuts, growing inequalities, and service disruptions. UNAIDS was originally created to bring coherence across 11 UN agencies, avoid duplication, and ensure that communities most affected by HIV had a formal voice at the table. The plan endorsed by the UNAIDS PCB would downsize the Secretariat, embed staff in select UN Resident Coordinator offices and relocate programmatic expertise to regional hubs to align with the UN80 “Shifting Paradigms” vision of a more integrated, coherent UN system. As UNAIDS reminded all stakeholders in its statement, it is member states and governing bodies who should determine the way forward on how UN80 reforms are implemented.  

IMPLICATIONS: Achieving the UNAIDS goal of ending AIDS by 2030 depends on many factors, including clear accountability; knowing which UN agencies retain their strengths; ensuring they have the resources to deliver; and safeguarding coordination. Sustaining trusted partnerships with civil society and continuing to prioritize equitable rights-based programs, which have been central to UNAIDS’s role for two decades, will also be essential, and all of this risks being undermined if UNAIDS’ functions are dispersed without a coherent strategy. This debate marks a critical inflection point for how the global community organizes and funds the HIV response going forward. 

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Africa CDC Announces Grant to Support Local Drug and Vaccine Manufacturers 

The Africa CDC plans to invest approximately $3.2 billion dollars to support the development of local drug and vaccine manufacturing across the continent. The initiative includes funding and grant support for African manufacturers. This grant aims to reduce dependence on imported pharmaceuticals by strengthening domestic production and establishing a pooled procurement mechanism to guarantee market demand. 

IMPLICATIONS: This move could be a turning point for health sovereignty in Africa, offering the promise of more reliable supply chains, lower costs, and greater independence from external donor trends. But it also presents real challenges: scaling production to meet global standards, navigating regulatory harmonization, and maintaining quality assurance and sustainability will be essential. If successful, it could shift power in global health — giving African countries more leverage in pricing and access negotiations for prevention tools such as ARVs and vaccines, while reducing vulnerability during global supply disruptions. 

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What We’re Reading

Press Release

AVAC Applauds Agreements to Accelerate Market Development for Lenacapavir for PrEP

New York, NY, September 24, 2025 — AVAC welcomes parallel announcements from the Gates Foundation and Unitaid on strategic investments to accelerate the development of, access to and price reduction for generic versions of injectable lenacapavir (LEN), the highly effective six-monthly injection for HIV PrEP.   

“These investments are a vitally important step in translating the remarkable science of LEN into public health impact,” said Mitchell Warren, executive director of AVAC. “With these agreements, injectable LEN for PrEP gets closer to the price of daily oral PrEP, $40 per person per year, for low and middle-income national governments. This means national programs in many, but not all, countries can begin planning for 2027, at which time ongoing oral PrEP and LEN use will be available at similar prices, meaning many countries will be truly able to offer people who need prevention choice  when it comes to the PrEP method that best meets their needs. This could be a transformational moment in HIV prevention if political will, coordination, and further procurement investment meet this moment to deliver LEN with speed, scale and equity to all communities and populations who need and want prevention options. Many questions remain, but in this current environment, we need to seize opportunities and good news when we can.”   

These new commitments to accelerate access to generic versions of LEN come on the heels of the Global Fund and PEPFAR re-committing to their December 2024 announcement of reaching two million people with LEN for PrEP within three years, with drug supplies coming from the originator company, Gilead Sciences. Among the outstanding questions from these new commitments is the price of the required oral loading dose for LEN, which is needed to achieve high efficacy. While the cost of ongoing use of LEN for PrEP would be similar to the cost of a year of daily oral PrEP, anyone initiating or restarting LEN for PrEP needs an oral loading dose of LEN. This oral loading dose is not included in the $40 price mentioned in the Gates and Unitaid deals and will add between $15-$17 in the first year of anyone initiating or re-starting LEN, and supply chains and purchasers need to include this extra cost in their calculations.

“The ‘two million in three years’ ambition from Global Fund and PEPFAR must be seen as a floor and not a ceiling,” said Warren. “The global PrEP data that AVAC tracks show a more ambitious goal, getting LEN to at least 1.5 million next year alone, is achievable and necessary. Ultimately, LEN must reach more than five million people per year to have real impact, build a sustainable market, and drive prices down even further. This means we must act faster and think bigger.” 

AVAC calls on all stakeholders to do their part. Next steps require coordinated action and further investment to ensure the creation of a viable and sustained market. 

“This is the moment to ensure that LEN for PrEP lives up to its full potential, and to hold each other accountable for what must happen next,” said Wawira Nyagah, AVAC’s director of product introduction & access.  “Demand creation and program design for LEN must be fully resourced, evidence-based and community-centered. Volume commitments, manufacturing, and supply chains must be sustained and stable. But to make a difference at a global level, the HIV response must go beyond these essential, but minimum, steps with a bold vision to accelerate the entry of generics and trigger a virtuous cycle of price drops, which further drive-up PrEP use.”  

LEN, developed by Gilead Sciences, is a twice-yearly injectable PrEP option that showed nearly complete protection against HIV in the landmark PURPOSE 1 and 2 trials. Science Magazine named LEN the “Breakthrough of the Year” in 2024, a recognition that reflects its enormous potential. But fulfilling this potential is far from certain, and all stakeholders have critical work to do, as detailed in AVAC’s 2024 publication, Gears of Lenacapavir for PrEP Rollout. 

AVAC’s publication, Now What with Injectable LEN for PrEP How to Translate Ambition into Accelerated Delivery and Impact, includes forecasts demonstrating that instead of 2 million people in three years, the world could reach at least 1.5 million people in just one year. Gilead has confirmed that they can manufacture enough injectable LEN to reach in excess of 5 million LEN users over the next three years. These numbers suggest what is possible and this is no time to think small. 

“To achieve true impact against HIV requires early commitments from additional donors to procure large volumes of LEN, which will enable a bigger rollout, exceeding targets, and reaching more people who need PrEP in more places, which in turn secures the kind of market scale that accelerates further prices reductions,” said Nyagah. “It requires country regulators, ministries of health, implementers, advocates and communities where HIV prevention is needed to prepare with policies and programs that will succeed in connecting people with products that work in the context of their lives. The field has learned these lessons before. Technology alone gets you nowhere; it’s delivering the product with speed, scale and equity that gets the job done.” 

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About AVAC 

AVAC is an international non-profit organization that provides an independent voice and leverages global partnerships to accelerate ethical development and equitable delivery of effective HIV prevention options, as part of a comprehensive and integrated pathway to global health equity. Follow AVAC on Bluesky and Instagram. Find more at www.avac.org and www.prepwatch.org. 

Lenacapavir Regulatory Approval

Regulatory approvals, pending decisions, and appeals as of September 2025, including US Food and Drug Administration approval. For product approvals, volumes, implementation, and price comparisons of long-acting PrEP, visit our dashboard on PrEPWatch.org.

Cabotegravir Regulatory Approval

Regulatory approvals and those pending for cabotegravir as of September 2025. For product approvals, volumes, implementation, and price comparisons of long-acting PrEP, visit our dashboard on PrEPWatch.org.

Dapivirine Vaginal Ring Regulatory Approval

Regulatory approvals, pending decisions, and appeals as of September 2025. For product approvals, volumes, implementation, and price comparisons of long-acting PrEP, visit our dashboard on PrEPWatch.org.

Avac Event

South African AIDS Conference (SAAIDS)

The 12th SAAIDS Conference 2025, under the theme: Unite for Change – Empower Communities and Redefine Priorities for HIV/AIDS will be held in Johannesburg 8-11 September.

Resources

If you’re attending, don’t miss a keynote plenary where AVAC’s Mitchell Warren will share perspectives on the future of HIV prevention, and an important satellite on Wednesday, Bridging the Gap and Identifying Opportunities: Innovative Strategies to Accelerate HIV Prevention, Treatment, and Care for Key and Vulnerable Populations in South Africa.  

Press Release

AVAC Condemns US Administration’s ‘Pocket Rescission’ Request to Withhold Billions in Foreign Aid 

AVAC calls on Congress to reassert its constitutional power

Contact: [email protected]

New York, NY, September 2, 2025 – AVAC condemns the US Administration’s intent to withhold billions of dollars in federal foreign assistance through the proposed ‘pocket rescission’ request sent to Congress last Friday. AVAC calls on Congress to reassert its constitutional power in appropriating federal spending and counteracting this executive overreach by the Administration. The Administration is seeking to cancel any Congressionally-appropriated funding at its discretion, with zero oversight or accountability from a co-equal branch of government. 

“This is a true constitutional crisis, advancing the Administration’s assault on Congress’ ‘power of the purse’ and putting millions of lives at risk,” said Mitchell Warren, executive director of AVAC, lead plaintiff in AVAC v. State Department. “We have already seen the devastating consequences of the foreign aid freeze: interrupted treatment, shuttered clinics, prevention efforts stalled, and lives lost. Now, by attempting to usurp Congress of its constitutional role and granting the President unilateral authority to decide which appropriations to honor and which to ignore, the Administration is setting a dangerous precedent—one that, if unless prevented, will reverberate globally, jeopardize lives, and undermine the very foundations of US governance.” 

The Administration continues to attempt to use questionable budgetary maneuvers to “run out the clock” on the fiscal year and avoid disbursing nearly $4.2 billion of Congressionally-appropriated foreign assistance. These maneuvers are illegal, and represent another step in the Administration’s reckless efforts to pull back billions in unspent foreign assistance funds which were already approved by Congress.   

“This crisis has been building since January 20, when the Administration froze foreign assistance funding and forced AVAC and partners to turn to the courts,” said Warren. This past week marked one of the worst yet. On August 28, the D.C. Circuit Court of Appeals denied AVAC’s petition to rehear its case en banc and vacated the District Court’s preliminary injunction that had required the Administration to release billions in Congressionally-appropriated foreign assistance funds. That decision came only two days after the Administration filed an emergency petition to the Supreme Court of the United States seeking permission to continue withholding the funds. While last week’s ruling was a setback, the Court did significantly modify a prior opinion from August 13, paving the way for AVAC, the Global Health Council (GHC), and co-plaintiffs to return to the District Court to pursue relief. Lawyers representing AVAC and GHC have already filed motions for a renewed preliminary injunction. 

“AVAC and GHC have gone back to the District Court to seek a new injunction. And our fight doesn’t stop there,” Warren said. “We will continue to press our case in courtrooms, in Congress, and alongside communities to defend global health and the rule of law. The courts must act swiftly to send a strong message against this executive overreach, and Congress must defend democracy by reasserting its constitutional role as the arbiter of how funds are appropriated and spent.” 

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About AVAC: Founded in 1995, AVAC is an international non-profit organization that provides an independent voice and leverages global partnerships to accelerate ethical development and equitable delivery of effective HIV prevention options, as part of a comprehensive and integrated pathway to global health equity. Follow AVAC on Bluesky and Instagram. Find more at www.avac.org and www.prepwatch.org.

Where We Are Now with LEN for PrEP

The chaos in foreign assistance programs (including discontinuation of major PrEP programs), cuts in staffing and new demands on donor commitments will make decisions on the procurement of LEN for PrEP more complex and uncertain.

In December 2024, the Global Fund and PEPFAR announced a plan to reach 2 million people with LEN for PrEP over three years. Exactly how funding to support this unprecedented introduction program will move forward is far from certain. The other stakeholders, including Global Fund, Gilead, CIFF and the Gates Foundation expressed commitments to the deal and are making progress, but major questions remain.

Press Release

AVAC Responds to Government’s Emergency Appeal to SCOTUS

In response to the US government’s August 26 emergency application to the US Supreme Court seeking to stay the preliminary injunction in the AVAC v Department of State legal case against the foreign aid freeze, AVAC’s Executive Director, Mitchell Warren wrote:

“It is no surprise that the administration has taken our case directly to the Supreme Court, especially after the District Court’s very clear and firm denial of their request yesterday to suspend the requirement to obligate Congressionally appropriated funding for foreign assistance. Time and again, this administration has shown their disdain for foreign assistance and a disregard for people’s lives in the United States and around the world. But even more broadly and dangerously, this administration’s actions further erode Congress’s role and responsibility as an equal branch of government. The question being put to SCOTUS is whether they will be complicit in further eroding the constitutional commitment to checks and balance.”