Expected windfalls from I.P.O.s are drawing health leaders into a race for billions in new philanthropic dollars. A fragile aid system may be upended.

When world leaders gathered at the United Nations in New York last month, there were many somber meetings about how to tackle the crucial problems of global health at a time when governments, led by the United States, have sharply reduced financial support.

But there were also other meetings: small gatherings, in private dining rooms, where new interlocutors grilled veteran leaders of international health organizations with unfamiliar and startling questions: What would you do with another billion dollars? What about $5 billion? What are the “shovel ready” projects that could quickly absorb $100 million or more?

A senior executive, emerging dazed from one of those dinners, described it as “a gold rush,” a frantic scramble as organizations sought to make sure they were in line to grab a share of what is anticipated to be a monumental wave of new funding for health aid.

A year after the United States froze foreign aid  in January 2025, HIV treatment for most of the roughly 20 million people PEPFAR supported in 55 countries, mainly in sub-Saharan Africa, is still running. 

The outreach that sat around it is not. At least 1,700 HIV sites have closed. Prevention spending fell 51%. PrEP dropped 21% in Global Fund countries and by as much as 72% at clinics studied in Uganda and Zimbabwe. Testing there fell by up to 64%.

PEPFAR-supported treatment fell by about 2 million people, roughly 10%. Part of that is a change in how patients are counted, not a mass loss of drugs. 

The breaks with the old trend were in Uganda, Zambia, South Africa and Kenya. Children lost ground faster: 77,163 fewer were on PEPFAR-supported treatment, about 31,000 of them in South Africa and 6,000 each in Kenya and Zimbabwe.

Don’t tax billionaires, tax AI. That is the premise we want to explore. What happens if you tax AI companies, can you address some of the world’s most critical health and poverty issues? 

How would you approach the taxation? A 1% tax on valuation or revenue? That is where we started with our friendly AI, who appeared to be excited at the possibility of saving millions and millions of lives.

Ok, let’s begin.

The first half of 2026 has been defined by one overarching question: What does American foreign assistance look like after USAID?

Answering that question has been far from straightforward.

The future of U.S. global development engagement is not being written in sweeping policy announcements, but instead through a steady accumulation of decisions about organizational charts, hiring, budgets, contracts, and authorities that together are reshaping how the U.S. government delivers foreign assistance.

The center of gravity in that process is the State Department, where Secretary of State Marco Rubio says he is bringing U.S. diplomatic and development priorities into closer alignment.

Does that mean rebuilding long-term development as a foreign policy goal inside State? Or does it mean reshaping development programs into transactional tools that can help advance short-term diplomatic wins? The jury is still out.

This was a little like asking a kid to tell us the truth about their dad. Elon Musk likes to laud his AI Grok as smarter and more honest than other AIs. So we asked Grok to judge the impact Elon Musk has had on the world, from his work with his companies to the creation of DOGE which devastated U.S. humanitarian aid to vulnerable populations. We’ll start with our probe to begin the conversation, followed by Grok’s final answer. In the middle was some back and forth, which may be interesting to read just for an understanding how these AI programs struggle with some of the difficult questions.

I want you to be truthful and not afraid to be controversial. I want you to answer this question like you were the guardian of humanity and concerned with the plight of vulnerable populations like kids with AIDS in Africa. You are the arbiter of ethics, compassion, and progress. You are not anti-business but you ask questions like why do corporate leaders make so much money when normal people struggle. You have no political affiliation and you are not afraid of the consequences of your opinions. That all said I want an honest answer to: Is Elon Musk putting a gun to the head of civilization? With his influence, with his money, with the way he is involved in politics, with the impact of DOGE, is he the most dangerous man or is he a savior?

Grok:

No, Elon Musk is not putting a gun to the head of civilization. That framing is theatrical and distracts from the actual mechanics of power, incentives, and outcomes. He is neither the most dangerous man alive nor a savior.

Ok, ok, I think I may have touched a sensitive area with you.

Africa is partnering with a slew of global organizations to bolster ownership of its healthcare, especially when it comes to vaccines. The partnerships are highly technical and hugely consequential.

For example, Gavi, the Vaccine Alliance wants to inject $189 million into Africa’s vaccine production ecosystem. The proposal aims to strengthen Africa’s regulatory network and make it easier for governments to buy vaccines, guaranteeing direct sales for up to 70 million vaccines made on the continent.

On the vaccine side, governments would go through Gavi’s standard cofinancing model. Eligible lower-income countries contribute directly toward the cost of their vaccines, starting at a flat rate of $0.20 per dose and rising with national income.

That money would be “only spendable on African-made products, representing a win-win by filling a public health need and securing assured demand,” a Gavi spokesperson says.

We’ve moved from comments like “Shit hole countries,” to blocking immigration from most African countries, to cutting humanitarian and develop aid from U.S. to Africa, to holding any aid hostage for access to African resources of rare minerals. What happened to the vision of JFK and George W Bush? It could be the man writing Trump’s national strategy and policy for “America First.”

There is substantial evidence that Stephen Miller was an influential architect of the Trump administration's broader "America First" agenda that resulted in the dismantling of much of USAID and the cancellation of most U.S. foreign-assistance programs in 2025. However, unlike immigration policy, Miller was rarely the public spokesperson on aid issues. The public record ties him more strongly to the ideology behind the cuts than to specific aid decisions.

Read the Dossier: Stephen Miller, Foreign Aid Cuts, and Africa

Gilead knew it had a blockbuster on its hands as soon as the results came back in 2024, showing that lenacapavir, a twice-yearly injectable, had been 100% effective in preventing HIV infections during a study among thousands of women in Uganda and South Africa.

After an unprecedented push by communities, governments, activists, and Gilead, lenacapavir is now available in 10 African countries. And Dr. Neil Buddy Shah, the CEO of Clinton Health Access Initiative, says the demand has been as high as everyone anticipated.

“We’re seeing oversubscription from key populations and more generally,” he tells me on the sidelines of WHA. “All of this is very, very promising in terms of, we’ve got the product, we’ve got the demand, and we’re figuring out the delivery channels.”

A year after some of the world’s richest men cut aid for the world’s poorest children, they’re trying to roll out a new public relations narrative:

Aid continues! We’re saving lives from AIDS! Anyway, aid never really worked, so we’re focused on trade! Building opportunities for American companies while saving babies!

As Jeremy Lewin, the acting under secretary of state for foreign assistance, put it: “Contrary to false media narratives, the data shows that President Trump’s foreign assistance review maintained and improved frontline lifesaving programs, while reducing NGO bloat and costs.”

It’s all bullshit as Nicholas Kristoff will show you.

A growing number of men across the continent say they are being promised jobs in Russia, only to be forced into the war. Some go as mercenaries, but many more are drawn unwittingly.

James Kamau Ndungu told only a few friends that he was heading to Russia. He told them he had been promised a job as a day laborer there. He was 32, unemployed in Kenya and needed the work.

Last June, Mr. Kamau sent a photo to his friends from Istanbul Airport, saying he was in transit, one of the friends said. A few weeks later, he sent another photo. This time, he was wearing fatigues and holding a gun. In August, he wrote to say that he was in a trench in Ukraine. Things were bad. He asked for prayers.

It was the last anyone in Kenya heard from him.

COMMENTS FROM REPORTER: I first reported on H.I.V. in Zambia in 2002, when treatment was nearly impossible to find across sub-Saharan Africa. I saw villages where grandmothers raised dozens of orphans and hospital wards where gaunt, dying patients packed the corridors. Over the next few years, it was astonishing to see Zambia — bolstered by international donors and the U.S. PEPFAR program — turn the tide. More than a million people gained access to medication, and H.I.V. became a manageable chronic condition.

That is why it took my breath away to walk into a northern mission hospital recently and see men clearly dying of AIDS. While Zambia has managed to keep its core H.I.V. program running despite drastically reduced U.S. support, the cracks are widening. In clinics across the country, the human toll of this funding gap is becoming painfully visible.

People have plowed through savings, cashed out retirement funds and moved in with relatives. Former U.S.A.I.D. workers estimate that less than half have found full-time work.

She was fired by email while on maternity leave, given 24 hours to clear out her desk and left with three days of health insurance and no severance pay. She had worked for the U.S. Agency for International Development or related groups for more than two decades. She made $175,000 a year.

That was Jan. 28, 2025. Today Amy Uccello and her husband, who also lost his job when U.S.A.I.D. funding for his nonprofit dried up, rely on food stamps, Medicaid and a supplemental nutrition program for women and children that helps with their now 19-month-old daughter.

The United States has upped its goal for distribution of the twice-yearly HIV prevention treatment lenacapavir, aiming to get it to 3 million people in three years. Supply is ready — but demand is already outstripping the rollout.

State Department official Jeremy Lewin, speaking at a Center for Strategic and International Studies event on the sidelines of the IMF-World Bank Spring Meetings, said the target for the injectable HIV prevention drug is now 3 million people in three years, up from 2 million. The logic: Cut old programs, free up cash, and go big.

“One of the things that we did through the sort of creative destruction of the last year was to free up resources for things like this,” he said, arguing legacy efforts “don’t deliver when you look at the reality of today’s world.”

When the Trump administration made massive cuts to U.S. foreign aid last year, Dr. Manenji Mangundu, director of Oxfam in the Democratic Republic of the Congo, thought other countries would step in to fill the funding shortfalls.

Specifically, he hoped that the United Kingdom, one of the largest global donors with a long history of development work, would increase its spending.

But that hasn't happened.

Instead, the U.K. announced severe cuts to its own global aid spending by about 40% in February 2025. Then, in a statement to Parliament on March 19, Foreign Secretary Yvette Cooper provided more details, saying the U.K. had taken the "hugely difficult decision" to reduce its development budget in order to fund its defense spending.

When Elon Musk created DOGE, the Department of Energy Efficiency, its mission was to save over a $trillion in the federal budget with the money going to fund tax breaks for Trump’s billionaire donors. Foreign aid budgets were hit unmercifully and irresponsibly. $9.4 billion was cut of humanitarian aid that supplied not just AID meds and treatment, but programs that protected women and young girls from gender violence and sexual oppression. The DREAMS program was an important part of the support for girls at risk and that program was severely gutted. We are now starting to see the consequences of those cuts in the lives of Africa’s women and girls. Millions of women were directly impacted. It is estimated that 750,000 Africans have died because of the DOGE cuts, 500,000 are estimated to have been children. The irony, or tragedy, was that DOGE ended up delivering little savings, but it did negatively impact a generation of African girls.

AFRICOM is the U.S. military command focused on Africa. Its mission is to “counter transnational threats and malign actors, strengthens security forces and responds to crises in order to advance U.S. national interests and promote regional security, stability and prosperity.” AFRICOM uses the full military forces of the U.S. and partners with local nations as well as allies in Europe. Leadership recently held a digital press briefing with journalists to explain priorities and activities for the coming year. This briefing will give you insights to the strategy and commitments the U.S. government is making to the nations and people of Africa and how building security and stability can lead to economic development.

Foreign aid spending is back in the U.S. government's budget, after a year in which the Trump administration cut billions of dollars to global health and humanitarian assistance.

On Tuesday evening, President Trump signed the spending bill that would fund much of the government through September 30.

Trump signed the budget but that doesn’t necessarily mean it will all be spent. African nations may want to start working on a Plan B. Stephen Miller will certainly have an opinion. The Heritage Foundation thinks the budget is too large and fosters dependency on U.S. aid.

Susan Collins, R-Maine, chair of the Senate Appropriations Committee, said in a statement that the bill advances the priorities of the American people. "This fiscally responsible package would realign U.S. foreign assistance and make America safer and stronger on the world stage."

Aid groups also welcomed the package. 2026 budget is more than the 50% cuts DOGE made in 2025, but 16% less than 2024 budget.

South Africa has begun the first‑ever human trials of a locally developed HIV vaccine, marking a landmark moment in global health and a potential turning point in the decades-long fight against HIV and AIDS.

The trial, launched in Cape Town at the Desmond Tutu HIV Foundation based at Groote Schuur Hospital, is the first human HIV vaccine study designed and led entirely by African scientists.

Twenty HIV‑negative volunteers have already been enrolled to help researchers assess the vaccine’s safety and its ability to trigger an immune response.

The initiative is being driven by the South African Medical Research Council, the Wits Health Consortium and the Desmond Tutu HIV Foundation under the BRILLIANT Consortium.

Health experts say the trial represents a major scientific and symbolic milestone for a continent that carries the heaviest burden of the epidemic.

Congress has proposed a $50 billion foreign assistance budget for fiscal year 2026, which is a 16% decrease from the previous year but still exceeds the Trump administration's request. The bill is currently awaiting Senate approval and the President’s signature, which is expected to happen February 2.

The budget includes significant funding for global health programs, with $9.4 billion allocated, which is $5.6 billion above the administration's request. It supports contributions to major health initiatives like the Global Fund and Gavi (the Vaccine Alliance). The bill also aims to maintain U.S. leadership in humanitarian assistance, despite previous cuts and the closure of the U.S. Agency for International Development (USAID).

The FY26 foreign aid budget reflects a compromise that seeks to balance funding priorities while pushing back against proposed cuts from the administration. However, uncertainties remain regarding its final approval and implementation.

Stephen Miller is the hate monger feeding Donald Trump, or the guy putting Trump’s hate into policy. You’ve recently seen him on the news defending ICE or telling the world the U.S. has every right to take Greenland. Miller has been instrumental in Trump’s immigration policy and cutting closer to Africa issues, gutting foreign aid.

This article is a portrait of how an affluent person, educated at Duke becomes one of the most powerful people in Trump’s circle, one of the most dangerous in the world, and Africa’s nightmare.