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I remember the old days. As a university student in South Africa in 2005, I volunteered doing menial tasks at free clinics that served the largely impoverished nonwhite majority. Back then, South Africa’s HIV drug program was only beginning to roll out. The relief it would bring hadn’t yet come. In exam rooms, elementary schoolers panted from fungal pneumonia, terrified by their breathlessness. Toxoplasmosis, an infection caused by a parasite, formed pingpong ball–sized masses in people’s brains. Fluffy white clouds and red hemorrhages, the work of cytomegalovirus, bloomed across patients’ retinas until they went blind.
These diseases had once been extraordinary rarities. When HIV hit, they were everywhere. I remember how I blew up gloves into balloons to distract the kids, so small and polite, their hair neatly braided. I remember how they died.
The Trump administration froze all foreign aid on Jan. 20. This included funds for the U.S. President’s Emergency Plan for AIDS Relief, a bipartisan initiative launched by President George W. Bush. The program is estimated to have saved at least 25 million lives since its 2003 inception. In more than 50 countries, PEPFAR has distributed HIV drugs, improved public health capabilities, and strengthened the health workforce and infrastructure. It has done this at an annual cost of less than 0.1 percent of our national budget. The positive effects of the program span diplomacy, global economic growth, and pandemic preparedness, as well as, of course, HIV treatment. PEPFAR is arguably our single most effective, durable, and wide-reaching foreign policy success. Secretary of State Marco Rubio has since announced a waiver to allow HIV-drug distribution to continue. Other aspects of the enterprise, like educational outreach and health worker development, remain murky, and the future of PEPFAR has been plunged into jeopardy.
After medical school and residency, I moved back to South Africa in 2016, now as a full-fledged doctor. The rural public hospital where I worked lay at the epicenter of the country’s epidemic. More than 40 percent of pregnant women my colleagues and I saw were HIV positive, and I cared for many patients who died of AIDS.
But despite the jaw-dropping prevalence rates, the suffering didn’t compare to what I had witnessed 10 years prior. Thanks to the antiretroviral drugs we prescribed, I watched people so skeletal that I could single-handedly heft them onto a hospital bed transform into people who could heft me onto that same bed. Untreated, about a quarter of mothers pass the virus on to their infants—but by 2016, I rarely saw infected babies. South African co-workers with HIV led fulfilling careers. From 2003 through 2014, the life expectancy in the district where I was now living had risen by 15 years for women and 17 years for men. Without medication, nearly all people with HIV can readily transmit the virus to sexual partners and progress inexorably toward death. On effective antiretrovirals, they can’t pass on the virus, even through unprotected sex, and can expect normal lifespans. That is what HIV drugs can do.
PEPFAR provides about 20 percent of South Africa’s national funds to combat HIV. In some other countries, it accounts for the bulk of the budget: 75 percent in Zambia, for instance, or 67 percent in Mozambique, according to 2020 stats. Donations from the Global Fund to Fight AIDS, Tuberculosis, and Malaria—to which the U.S. is the largest contributor—comprise a substantial portion of the remaining shortfall.
As an HIV specialist, I find that the idea of suspending PEPFAR conjures visions of a cruel future—one that requires little effort to imagine, since I’ve spent so much of my career witnessing the ravages of the virus left untreated. But continuing PEPFAR is a matter of self-interest too. The program is widely popular the world over; many patients know that their drugs come from the Americans. As the U.S. jockeys with China for global influence, our long-standing position as the largest force for global health has won us allies and helped us forge relationships to engage around sensitive diplomatic issues. If China has Belt and Road, we have PEPFAR.
The COVID pandemic solidified awareness of our vulnerability to emerging infectious diseases, which respect no national boundaries. Public health workers have harnessed systems originally developed for HIV to address COVID and mpox. They’ve shared information indispensable to us, an exchange acutely threatened not only by the new precarity of PEPFAR but also by Trump’s withdrawal from the World Health Organization. HIV data has now vanished from the public commons; PEPFAR’s database is down. If—when—there is another pandemic, we will need all the goodwill and channels for cooperation we can get. With PEPFAR, we built that up. Now we are squandering it.
We are also directly endangering ourselves. During West Africa’s Ebola outbreak in 2014, a patient flew from Liberia to Lagos, Nigeria. Scores were exposed to the virus, presaging potential catastrophe in Africa’s most populous nation. Disaster never hit. With help from PEPFAR, the Nigerian government had set up an impressive virology lab and trained a robust epidemiologic corps. The spread was contained after only 19 cases. In contrast, in Liberia, Sierra Leone, and Guinea—countries without comparable PEPFAR investment—the outbreak lasted two and a half years, killed more than 11,000 people, and crossed the Atlantic to the U.S.
PEPFAR strengthens our security and economy. In a study of approximately 160 countries, the program’s presence was associated with a total per capita GDP growth rate 46 percent greater than expected over a 14-year period. The figure is impressive but unsurprising: The health benefits of HIV drugs are so remarkable that increasing by only 1 percentage point a country’s population on treatment has been linked to a bump of 1.4 percentage points in per capita GDP growth rate. Our trade relationships are expanding in Africa south of the Sahara; the region has a plurality of the world’s fastest-growing economies. The explosion of its working-age population has the potential to be an engine of economic growth—or a source of young men susceptible, in their desperation for income, to recruitment by extremist groups in some nations. We’d do well to support the first scenario.
America has long projected a self-image as a force for global good. You should believe in PEPFAR as consonant with our values, a measure to prevent countless, often horrific deaths. You should want a future in which doctors like me don’t try to resuscitate two babies before 7 a.m., and then, when neither makes it, gulp down their coffee to face the rest of the day. You should think of HIV treatment as a human right.
But supporting PEPFAR doesn’t require any of that. To back PEPFAR, all you need to care about is yourself and your loved ones. We are connected to the rest of the world. If PEPFAR ends, people overseas won’t be the only ones who suffer.
