The Trump Administration’s Foreign Aid Review: Status of U.S. Global Tuberculosis Efforts

Background on U.S. Global Tuberculosis (TB) Efforts

• The U.S. government has been involved in global TB activities for decades and began ramping up its efforts in the late 1990s when a global TB program was created at USAID.
• TB, an infectious disease caused by bacteria, causes more deaths than any other infectious agent worldwide, including 1.25 million people who died in 2023, and is among the 10 leading causes of death worldwide. TB is the leading cause of death among people with HIV.
• U.S. government efforts have contributed significantly to improving TB health outcomes, including contributing to a 29% decline in TB incidence and 47% decline in TB mortality in USAID TB priority countries since 2000.  
• The FY 2025 Continuing Resolution that passed in March included level funding for bilateral TB activities at USAID and CDC of $406 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. has been the top donor government to TB efforts, through its bilateral funding and contributions to the Global Fund. The administration’s FY 2026 budget request includes $178 million for TB, a decrease of $228 million (final appropriation levels are determined by Congress).
• USAID had served as the lead implementing agency for U.S. TB efforts, focusing on 24 priority countries – with activities in 50 (including at least 20 of the 30 high burden countries) – to support prevention, detection, and treatment of TB, including drug-resistant TB. The Centers for Disease Control and Prevention (CDC) also carries out global TB efforts and the State Department’s Bureau of Global Health Security and Diplomacy (GHSD), which oversees PEPFAR, leads U.S. efforts to address TB-HIV co-infection.

Current Status of U.S. Global TB Efforts

The following administration actions have had a significant impact on TB program operations:

• Funding freeze/stop-work order: The stop-work order initially froze all bilateral TB programming and services, halting existing work in the field. Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waiver: Some TB activities were included in a limited waiver issued by the State Department on February 4 allowing “life-saving services” to continue, which are defined as “Essential screening, testing, and treatment for tuberculosis (TB) and drug resistant TB (DR-TB) including provision and monitoring of laboratory services, drug susceptibility testing, clinical visits, dispensing of essential medicines to avert near-term mortality and spread of infection.” HIV/TB activities were also allowed under PEPFAR’s limited waiver. Even with the waivers, services remain disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: As the main government implementer of TB efforts, the dissolution of USAID and loss of most staff have significantly affected TB program implementation capacity and operations. In addition, announcements of reductions at CDC could further affect global TB efforts.
• Canceled awards: In early 2025 it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 162 included TB activities, 79% of which were terminated.

• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards. On August 13, the U.S. Court of Appeals for the D.C. Circuit overturned the district judge’s preliminary injunction, ruling that plaintiffs lacked legal standing to challenge the administration’s termination of funding. While a District Court subsequently found that the plaintiffs could seek relief through another legal avenue and granted a preliminary injunction ordering the government to obligate expiring funds, the Supreme Court ultimately ruled that the government could withhold these funds.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan and programs moved in July.
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy. Per the new strategy, the U.S. will:
  • Negotiate bilateral, multi-year agreements with countries receiving U.S. assistance, with implementation and monitoring plans in place by March 31, 2026. Agreements will include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period;
  • Provide 100% of current levels of funding for TB commodities [TB diagnostics (including innovations in molecular diagnostics), TB treatments (including for drug-resistant TB) and TB preventive therapy] and frontline healthcare workers through FY 2026 and reduced funding thereafter;
  • Rapidly reduce funding for activities other than health commodities and frontline health personnel.

Impact on Global TB Services and Outcomes

• An internal USAID memo reported that the cessation of USAID’s TB control programs would increase global TB incidence by 28-32% and have a similar effect on new cases of multi-drug-resistant TB.
• According to WHO, the 30 highest TB-burden countries reported that U.S. funding withdrawals were affecting services, including the loss of thousands of health workers, and disruptions of the drug supply chain and laboratory services.
• A rapid assessment survey of 108 WHO country offices found that approximately 40% reported moderate or severe disruptions to TB services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• Several modeling studies have found that cuts or termination in U.S. TB funding could result in significant numbers of additional TB cases and deaths in coming years.

What to Watch

• Reorganization: The dissolution of USAID and integration of any remaining USAID global health activities, including for TB, into GHSD raises several questions, including whether additional capacities will be provided to allow for the management and implementation of TB and these other health programs at the State Department.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $228 million reduction for TB (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress in June, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including TB, from the rescission.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop bilateral agreements with countries and plans to scale down funding, including for TB-related activities, the details of which will significantly shape the future of the global TB response.