The Trump administration’s destruction of the U.S. government’s foreign aid programming began with an executive order the day Trump returned to office, and has continued with the dismantling of the U.S. Agency for International Development (USAID). These moves have wrought chaos for humanitarian programs around the world.
Even after U.S. Secretary of State Marco Rubio released an “Emergency Humanitarian Waiver” a week later, organizations supported by U.S. foreign aid still had no authorization to resume their lifesaving work. Caught in the chaos are programs supported by the President’s Emergency Plan for AIDS Relief, or PEPFAR. Apparently an additional instruction specific to PEPFAR issued after the waiver has not been enough to get organizations to resume distributing life-saving medication in more than 50 countries.
Watching the challenges facing PEPFAR the last two weeks highlights the confusion and disruption sowed by Trump’s executive orders – and how these orders have literal life-and-death implications.
What is PEPFAR?
PEPFAR is the largest bilateral effort against HIV and AIDS. HIV is the acronym for human immunodeficiency virus, which causes acquired immunodeficiency syndrome, or AIDS. While there have been many scientific breakthroughs since the identification of HIV/AIDS in the early 1980s, there is no vaccine for HIV and there is no cure for AIDS. AIDS was a leading cause of death globally for many years. The introduction in the mid-1990s of antiretroviral therapy generated a remarkable decline in AIDS death rates in rich countries. Efforts like PEPFAR extended access to these life-lengthening drugs to people living in poorer countries.
In his Jan. 29, 2003, State of the Union address, President George W. Bush initiated PEPFAR by asking Congress to commit $15 billion over the next five years. The eventual bill introduced in the House of Representatives – H.R. 1298 (108th): United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 – received wide bipartisan support and was signed into law May 27, 2003. PEPFAR has since been reauthorized multiple times by multiple Congresses and presidents.
PEPFAR dominates the global response to AIDS and is the largest commitment by any country to any single disease response. Among other activities, PEPFAR funds the purchase and distribution of antiretroviral therapy. PEPFAR reports saving 25 million lives and is actively providing more than 20 million adults and children life-saving drug therapy.
Some PEPFAR activities may be covered by the waiver, but their programs haven’t resumed
The chaos caused by the Trump administration has now left PEPFAR in limbo. Even leadership at the George W. Bush Presidential Center is unclear about the implications of the executive order pausing foreign aid and the humanitarian waiver. In an op-ed published in the Dallas Morning News on Jan. 29, Executive Director of the George W. Bush Institute David Kramer initially applauded the Trump administration “granting PEPFAR a waiver from a freeze.”
There is an “updated” version of the letter posted to the George W. Bush Presidential Center’s website, however. This Jan. 31 update demonstrated a renewed understanding that the waiver did not – in fact – lead to a resumption of PEPFAR programming.
In his original op-ed, Kramer wrote, “But it’s vital that the administration keep [PEPFAR] exempt from the pause in funding so that it can continue to ensure that those on treatment receive uninterrupted care.” The updated version replaces that sentence with “But we urge the Department of State to resume PEPFAR programming immediately so that those on treatment can receive uninterrupted care.”
The U.S. Embassy in South Africa created a PEPFAR Frequently Asked Questions page on Feb. 10 that illustrates that even as some PEPFAR activities should be able to resume, they haven’t yet:
Our teams are working as fast as we can to prepare the administrative documentation needed to resume activities covered under the limited waiver.
People will die without the drugs PEPFAR supports
The title of my book, Doomed Interventions: The Failure of Global Responses to AIDS in Africa, should make clear that I’m not generally confident about global interventions to improve the human condition, including those targeting HIV and AIDS in Africa. In my book, I detail multiple failed interventions (like a condom social marketing campaign in Mozambique) or interventions with unintended negative consequences (like how Gates Foundation grants diverted healthcare workers from basic care to HIV/AIDS care in Lesotho).
But having studied AIDS interventions in Africa for more than 20 years now, and critically analyzing multiple datasets, I have to admit that PEPFAR has had a tremendous positive effect in the fight against AIDS. Without the drugs PEPFAR supports, people will die.
The figure below includes the impact of all antiretroviral medication (not just that supported by PEPFAR), but it indicates the tremendous effect these drugs have in keeping people alive.
If you’re not familiar with the incredible “Lazarus effect” that antiretroviral therapy has on people with HIV/AIDS, watch the documentary below. The reality is stark: Every delay, every bureaucratic hurdle, and every political maneuver that delays or blocks PEPFAR operations translates directly into lost lives. Millions of people rely on these medications to survive. Without PEPFAR programs, the world will see a resurgence of preventable deaths.
This isn’t a debate about policy nuances or budgetary concerns – it’s a matter of life and death. The success of PEPFAR has been undeniable, and its disruption is catastrophic. The longer this chaos continues, the more people will suffer.
