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How killing a global program to fight HIV/AIDS kills

In 2004 the stalls off a main road in Malawi’s capital had turned to coffin making. Rough wooden caskets lined “Coffin Row” in Lilongwe and sold for a premium as death became a growth industry and carpenters worked round the clock to meet demand.

At that time the African nation’s life expectancy was in freefall in the midst of Africa’s HIV/AIDS epidemic—dropping from 43 years in 1996 to 39 years by 2000. About 30 percent of pregnant women in some districts were testing positive for HIV, and about 70,000 Malawians a year were dying of AIDS-related illnesses.

The trend was similar in other parts of Africa. When I visited hospitals in Kenya or Sudan in those years, the hallways overflowed with AIDS victims, some sleeping on the floor, some two and three to a bed.

Yet by 2007, Lilongwe’s Coffin Row had become Furniture Row, the casket displays replaced by chairs and bed frames. What changed in three years? HIV prevalence in Malawi fell with the arrival of affordable antiretroviral medicines. The medications plus the infrastructure to administer them were made possible through the U.S.-funded President’s Emergency Plan for AIDS Relief, or PEPFAR.

Passed by Congress in 2003 at the urging of President George W. Bush and bipartisan backing, PEPFAR is widely credited with saving an estimated 26 million lives and preventing almost 8 million babies from contracting HIV. By suppressing viral load to avoid HIV/AIDS deaths, Malawi like many hard-hit countries was on the way to ending its AIDS epidemic by 2030. Now two months into the Trump administration, the lifesaving program largely has been dismantled. The shuttering of USAID, which administered most PEPFAR contracts, overnight cut the supply of antiretrovirals and forced the closing of clinics. At one warehouse in Kenya, millions of lifesaving antiretrovirals sit unused, the facility ordered closed by the State Department, forcing nearby clinics to ration treatment.

Health authorities warn there could be 2,000 new HIV infections a day across the world and a ten-fold increase in related deaths if funding isn’t restored or replaced. These will fall hardest on already-challenged places like Burkina Faso, Haiti, Kenya, Nigeria, South Sudan, and Ukraine. Related moves ordered by the Trump administration compound the challenge.

• Studies on an HIV vaccine and dozens of HIV-related research grants have been halted.

• A deadline to reauthorize PEPFAR came and went last week on March 25 without Congress taking action.

• On March 28 the government announced formal closure of USAID.

• A spreadsheet circulated via USAID shows 5,341 contracts terminated and 898 continuing, but without clarity on what money is still available to disburse.

The slashing ends partnerships with government health ministries as well as nonprofits large and small. These include prominent Christian humanitarian aid groups. The cuts further erode hospital funding in poor countries, immunizations, drugs and supplies to treat not only HIV but also tuberculosis, malaria, and others.

This small part of the federal budget is huge for health funding around the world:

In 2023, U.S. global health spending represented about 0.3 percent of federal spending ($20.6 billion out of the $6.1 trillion U.S. budget). Yet that same year, the United States was responsible for nearly three-quarters of international development assistance for HIV/AIDS, 40 percent of malaria aid, and more than a third of funding to combat tuberculosis.

For PEPFAR, the sudden halt unwinds whole healthcare systems, plus leaves 20.6 million people who are living with HIV without the medications they need to suppress the virus. Continuing these cutbacks could have a drastic toll, global experts agree: 1.6 million deaths in just the next year.

Over the last few weeks I’ve attended meetings about immigration and securing refugee camps in the wake of U.S. cutbacks. I’ve been part of discussions around deportations, emergency responsiveness, Ukraine, the dismantling of regulatory agencies, domestic flight safety, and free speech. I’ve lost my way every day along with everyone in the confusion and chaos that’s part of the Trump administration’s “flood the zone” agenda. But the likelihood—even the possibility—that 1.6 million people will die in one year’s time because the United States has broken contractual funding agreements seems like The One Thing worth attention.

Dave Thomas, who served as the director of infectious diseases at Johns Hopkins School of Medicine and continues at the schools of medicine and public health, explains it this way:

“If a person is entrusted to care for a building and decides to tear it down, there’s a moral imperative to disclose whether there are people inside. There are 20.6 million persons and 566,000 children living inside PEPFAR. I know no American, or for that matter, person of any religion, country, or political camp that would tear down the building until the safety of all the people inside was certain.”

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The PEPFAR program seemed unlikely from the start, and yet it came to be. At the outset, HIV/AIDS was hotly debated as a behavioral disease because its primary means of transmission is sexual contact. Yet Republicans and Democrats, evangelical Christian leaders and progressive human rights activists in the end supported its 2003 passage—the largest health intervention at the time to fight a single disease. And, at $5 billion a year on average, it sparked structural changes to healthcare throughout developing countries.

Its genius was providing antiretroviral therapy through community-based distribution. With U.S. funding and oversight, local caregivers, nonprofits, and churches became partners close enough to the disease to overcome weak health systems, poor transportation grids, communication gaps, and lack of education.

Over time people who never agreed on anything saw reasons to be on board. Conservative Sen. Jesse Helms, an outspoken critic of foreign aid, actually lobbied the White House for PEPFAR after conversations with U2 lead singer Bono, centered around Matthew 25. “Dick Cheney came into the Oval Office and said, ‘Jesse Helms wants you to listen to Bono’s ideas,’ ” quipped Bush when he announced the final aid package.

Evangelist Franklin Graham, who leads the relief organization Samaritan’s Purse, was a proponent too. He organized a five-day conference in 2002 where he chided the church for its slow response to the HIV/AIDS crisis then worked closely with Helms and Republican Sen. Bill Frist, a surgeon and then a ranking minority member of the Senate subcommittee on Africa.

When Saddleback Church pastor Rick Warren invited six presidential candidates to his third annual Global Summit on AIDS and the Church in 2007, Hillary Clinton was the first (and only) candidate to say yes. "Our churches have a powerful role to play in raising the consciousness of the nation and the world to this pandemic and
urge compassion for the sick and the suffering,” she said.

Despite the GOP support, with the MAGA takeover Republicans increasingly questioned whether PEPFAR’s implementation is sufficiently pro-life. “There is no program more pro-life than one which has saved more than 25 million lives,” Bush wrote in a 2023 op-ed.

Graham, now an outspoken Trump supporter, has said little about cuts to foreign aid and endorses Elon Musk’s efforts to “cut waste.” Samaritan’s Purse received a green light for emergency food programs funded by USAID, but hospitals it supports in Africa were subject to PEPFAR-funded cutbacks.

Many faith-based organizations saw contracts terminated for HIV/AIDS treatment, along with massive cuts to treatments for tuberculosis, malaria, and other general health care.

But as some treatment programs came back online in recent days of State Department sorting, leaders I spoke to are taking a cautious approach, wanting to keep doors open with the Trump administration in hopes more lifesaving programs can be saved. Said one: “The U.S. should not give up its moral leadership in the world, and nothing could be more moral than saving lives and reducing suffering.”

More:

• Researchers at Duke University have a plan to reduce PEPFAR costs by 20 percent within five years and to transition management to local leadership—without life-threatening shutoffs.

• A senior USAID officer who oversaw PEPFAR and global health funds was placed on administrative leave earlier this month after he detailed in a memo to staff how cuts to humanitarian assistance by Trump political aides were leading to preventable deaths. In a sworn statement you have to read to believe, he said:

  Our complete inability to implement lifesaving activities was the result of a series of intentional actions and obstructions taken by the Trump Administration about which the public has been misled.

• This doctor in Kenya is praying and fasting every day for PEPFAR.