The U.S. Spent Billions Fighting AIDS. What Now?

Earlier this week, our colleague Nicholas Barrio went to visit an HIV-AIDS clinic in Kampala, Uganda. Everything is quiet.
The clinic was closed, shut down after President Trump froze almost all foreign aid money. Only a security guard and a cleaner were on the premises.
The security guard at the gate says he's not allowed to let anyone inside. Now he tells me that people have been coming and being turned away, and as a result, no one now comes.
Before it closed, it was providing care to hundreds of patients with HIV-AIDS every day. In the meantime, all the medicine that's sitting inside this clinic is just locked away.
Yes, all the medicine, yes, all the supplies because people who have been working there were told not to return. Since its founding, this clinic has been funded almost entirely by U.S.
foreign aid. For more than 20 years, it's been part of a program known as PEPFAR,

a multi-billion dollar U.S. effort specifically designed to stop the spread of HIV-AIDS globally.
And how important are the services provided by this clinic? So they are very, very important because it helps people who live in rural areas, people who have no money to pay for these tests, and most importantly, expectant mothers. People who are pregnant and these treatments help them from passing the virus on to their unborn children.
PEPFAR has been swept up in President Trump's 90-day freeze on foreign aid. Although the administration has signaled that it didn't intend to pause PEPFAR entirely, the order is having that effect.
At this moment, PEPFAR programs are mostly at a halt all across Africa. I asked her other colleague, Michael Phillips, about the effect of the funding freeze in Kenya, where he's based.
Well, I think there's been a general sense of panic. So I spoke to somebody the other day.

This person has family members who are HIV positive,

and they've been on antiretrovirals through PEPFAR.

And some of those family members are literally going out and picking out grave sites for themselves

because they don't think they're going to make it.

Oh, my goodness.

So imagine that.

You thought you were okay. You thought you'd gotten past this disease.
You could live with it. You're not transmitting it to anybody.
And suddenly you're looking around and thinking, I can't afford to buy drugs, and no one's going to give them to me anymore. So, well, I'll save my family the trouble, and I'll pick a place to bury myself.
Wow. And, you know, it's a stunning thought.

Welcome to The Journal,

our show about money, business, and power.

I'm Ryan Knudsen.

It's Friday, February 14th.

Coming up on the show,

America has spent billions

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Fighting HIV AIDS has been a big part of America's foreign aid spending for decades. Many hospitals tell people, you've got AIDS.
We can't help you. Go home and die.
In an age of miraculous medicines, no person should have to hear those words. In 2003, then-President George W.
Bush announced a new governmental initiative called the President's Emergency Plan for AIDS Relief, or PEPFAR. PEPFAR is a program that the United States government finances to combat AIDS worldwide and to treat people who have HIV to prevent them from becoming AIDS patients and then ultimately from dying.
And Bush started this program as a way sort of to reach out to people who cared about Africa. He was exhibiting his own concern about Africa.
Yet across that continent, only 50,000 AIDS victims, only 50,000 are receiving the medicine they need. And the real innovation of PEPFAR was that the U.S.
agreed to pay to keep poor Africans who had HIV infections alive. And the results have been really astounding.
Something like 25 or 26 million people in Africa are alive today because the United States helped them stay alive. PEPFAR is the largest commitment by any nation to address a single disease in the world.
It's credited with not only saving millions of lives in Africa, but also helping prevent HIV from spreading across the globe, in Asia and Latin America. Congress has reauthorized funding for the program every few years since its inception.
Last year, funding for PEPFAR was estimated at about $6.5 billion, which is less than a tenth of a percent of the U.S. government's $7 trillion total budget.
So how successful would you say this program has been? I think that most people would say it's been extraordinarily successful. People who would otherwise be dead, by the millions, are alive today.
So I think, medically speaking, and for many, many, many years, politically speaking, it was a very popular project. I had some disagreements with my predecessor.
But one of the outstanding things that President Bush did was to initiate the PEPFAR program. Its supporters have also included former Vice President Mike Pence.
PEPFAR was an extraordinary bipartisan achievement of compassion. Former President Joe Biden.
George W. Bush deserves great credit.
And even Trump during his first administration. What we've done for AIDS in Africa is unbelievable.
But when Trump took office a second time,

cutting foreign aid funding was one of his first actions.

He signed an executive order that essentially froze

all of the roughly $65 billion the government spends on foreign aid

in total around the world, including PEPFAR.

I think there are people in the administration

who believe that the aid industry or the world of foreign assistance was beyond repair in some way, wasn't achieving what they wanted to achieve, wasn't oriented enough towards American self-interest, which is clearly what the America First agenda is. They just thought that you couldn't fix it a little bit at a time, and you had to fix it or kill it all at once.
One reason the Trump administration says it paused aid is that much of it doesn't align with Trump's politics. Last week, Press Secretary Caroline Levitt stood in front of the White House and listed off international aid programs that the Trump administration sees as wasteful.
$70,000 for a production of a DEI musical in Ireland.

$47,000 for a transgender opera in Colombia.

$32,000 for a transgender comic book in Peru.

I don't know about you, but as an American taxpayer,

I don't want my dollars going towards this crap.

And I know the American people don't... U.S.
federal funds did go to all these programs

through the State Department.

Although the amount of federal money spent

on that opera in Colombia was actually closer to $25,000, not $47,000. So was PEPFAR just caught in the crossfire then? Because obviously it's not a program that's supposed to have anything to do with DEI.
I think the freeze on PEPFAR and everything else was very intentional. You'd have to know absolutely nothing about U.S.
foreign assistance to not know about PEPFAR. I don't know what percentage of foreign aid has anything to do with diversity and those issues.
It's not very large. I think we can be confident of that.
Most of it is simply helping other people. And then, you know, there's a debate about whether that's what you want to do with taxpayer money.
I won't make a judgment about that, but the administration has clearly signaled what their judgment is. On PEPFAR specifically, the Trump administration has sent mixed messages.
Clinics around the world are closed, and there isn't much guidance from the State Department. But Trump's Secretary of State, Marco Rubio, said he supports PEPFAR and the administration says that some life-saving activities can get a waiver to resume work.
The problem is the waiver itself has to be approved. It's not just a blanket waiver go out and spend the money that was already allocated.
Meaning each PEPFAR program has to get specific approval. And since so much work has stopped back in Washington, D.C.
because of the freeze, in some cases, people on the ground don't know who to call for help. You've got nobody to call up and say, okay, you know, you and I have been working together for five years, here's my new budget.
Who's going to approve it? There's no one that answered the phone. So it's like a promise of a waiver has been issued, but the waivers themselves have not.
So there's a lot of confusion amongst the people who implement these AIDS programs as to whether they can actually go ahead and give out drugs to people who are sick. And so the chaos around these programs is extraordinary.
The State Department says some waivers for life-saving programs have been issued. And yesterday, a judge ruled that USAID funding should be allowed to flow again temporarily.
But our colleagues in Africa say that doesn't seem to be happening yet. In Uganda, Zambia, and the Democratic Republic of the Congo, hundreds of health workers who were being paid under PEPFAR were told to go home, and they haven't gone back to work.
I think that most of the people who have been involved in PEPFAR, when asked, what does this mean, would say, people are going to die. Lots of people are going to die.
There's nobody that's stepping in to provide these drugs that the U.S. government provided.

And once you're off the drugs,

you know, HIV will get you.

Coming up, we talked to the CEO of a nonprofit

that got a lot of its funding from PEPFAR

about what this shift in policy

will mean for America standing overseas. Carl Hoffman is CEO of the public health organization HealthX Partners.
He's also a former U.S. diplomat.
How many countries have you lived in? Probably 10 or 15. Not a crazy number.

I mean, that's a pretty crazy number for countries too.

When the aid freeze went into effect, HealthX Partners was hit particularly hard.

Carl's organizations work on HIV, AIDS, and other health programs in more than 40 countries.

And roughly half of their nearly $500 million budget comes from the U.S. government, including through PEPFAR.

So how would you describe and how would you characterize what traditionally has been the role of U.S. aid abroad? The U.S.
foreign aid enterprise, not just U.S. aid, but the other parts of it too, are really about improving conditions in places far away so that threats don't manifest close to home.
That's the underlying principle. It's better for Americans if people far away are healthier, more productive, safer, because that makes us healthier, more productive, and safer.
This is sometimes called know, sometimes called soft power. But as somebody said to me the other day, soft power is power, and we should not be throwing it away at a time of great power competition for hearts and minds around the world.
So what do you make of the fact that, like, the Trump administration and a number of his supporters seem to think that this is not money that the U.S. taxpayer should be spending money on? That's a very understandable point of view, and it's been a longstanding view, I think.
I mean, a lot of Americans are under the misimpression that foreign aid is a huge part of the federal budget. And we should be spending that money at home.
But the whole foreign aid expenditure of the U.S., including the cost of the entire State Department, all of our contributions to the U.N., all the investments in global health, everything the U.S. does under the broad definition of foreign aid, foreign engagement, on the civilian side is 1% of the federal budget.
It's still tens of billions of dollars, though. Yeah, it's true.
It's a lot of money. But the idea that we can sort of balance the budget by eliminating foreign aid, which you sometimes hear, is a fallacy.
In Carl's view, the billions of dollars the U.S. spends on foreign aid has compounding benefits.
I remember when many countries in Africa were contemplating almost a societal collapse because of HIV and AIDS. That, of course, has been largely managed because of innovations in drugs and a huge political commitment and financial commitment led by the U.S., but not only by the U.S., right?

And so instead of collapsing societies from an infectious disease like HIV, you have societies

that can manage their own affairs increasingly.

That's good for us when people far away can manage their own public health crises, because otherwise they

become our problem.

But if you listen to the stuff that Elon Musk has been saying, he said that there's also

a lot of examples of corruption, waste, money that's being spent on things that Trump and

a lot of his supporters don't believe in, like diversity, equity, and inclusion efforts. Have you seen things like that? What do you make of that? My organizations, the ones that I'm responsible for, haven't been hired to deliver anything like that.
We've been hired to deliver better health outcomes in countries around the world. And I think we do it pretty costively.
Do you think there's a lot of waste in the foreign aid system?

I think there's a possibility of waste in everything the government does,

and also in everything that the private sector does. That's why ideas around reform and improving

and shifting the burden of these challenges onto host governments, those are all good

agendas. Pushing for efficiency and cost-effectiveness, that's all totally legitimate.
Carl says he's trying to keep his organization afloat. It's had to lay off or furlough thousands of employees, and they're looking for sources of new funding.
Meanwhile, his organization has received waivers to resume some life-saving activities, but no funding to allow that to happen yet. What do you think might step in to fill this void, if anything? Well, it's early to make predictions, but I think it's a mistake to assume that other players in this space are going to step up to gap fill and to come in behind the gap that's been created by the absence of the U.S.
government. Everybody else has seen these actions of beginning to dismantle the U.S.
Agency for International Development, freezing all foreign assistance. And a lot of other donor governments, I think, are saying, ah, this is our time to pull back too.
Other governments around the world. Yes.
Yes, I think so. The U.S.
was getting bigger and bigger as a relative share of this. And now the U.S.
tentpole has been pulled out of the tent. And I think the whole tent is going to get considerably smaller.
And so you're going to have a vacuum that's filled by misery. You'll have a vacuum that's filled by increased death, misery, and poverty.
And yes, it's far away, but ultimately it's going to be bad for us, I think. And that's one thing that I worry about.
Right now, the future of PEPFAR is unclear. McCarl says most people with diseases like HIV-AIDS don't have time to wait.
The thing about infectious disease, be it HIV or malaria or TB, there's no option of just like pausing. Freezing is an odd concept in the case of infectious disease work, because if you're not moving forward, then you're falling behind.
If you're not pushing against the disease, the disease is pushing back against you.

That's right.

That's true on the geopolitical playing field as well.

We're either gaining yards or we're losing yards.

And right now we're sort of, we're putting the ball down and walking back

and not even fighting for valuable terrain on this competitive landscape. And I think that's a mistake for us.
That's all for today. Friday, February 14th.
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