A global HIV/AIDS program that saved millions of lives faces cuts under the Trump administration

NBC News

2 days ago

WASHINGTON — The Trump administration is considering a dramatic cutback and eventual phasing out of the President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. program to combat HIV/AIDS in developing countries that has been widely credited with saving 26 million lives since its inception in 2003, according to multiple congressional and administration officials.
Created during the George W. Bush administration, PEPFAR was launched with star-power support from U2 frontman and advocate for developing countries, Bono, as well as the Bill and Melinda Gates Foundation and the World Bank. In the two decades since, it enjoyed strong bipartisan support in Congress.
But as the Trump administration has sought to cut costs across the U.S. government, particularly for global aid programs, PEPFAR has come up on the chopping block. The administration initially proposed a cut of $400 million from next year's budget, but that funding was restored at the last minute by the Republican-led Senate last week, keeping it going in the short term.
Four congressional aides told NBC News that the program was virtually frozen, along with most funding for USAID, in early February. Contracts with providers were put on hold and funding was reduced to what they called a 'trickle.' They said that most promised State Department waivers for critical care did not materialize, and that 51% of current PEPFAR appropriations were either terminated or were not functional.
'They're sitting on the money,' congressional officials said. 'We're not seeing it in the field.'
According to the aides, in April, the State Department's then-director of the Office of Foreign Assistance, Peter Marocco, working with Elon Musk's DOGE team to dismantle foreign aid, briefed Congress that PEPFAR would refocus on maternal and child HIV transmission, excluding LGBT individuals and most preventative care that the program has done for decades.
Earlier this month, a senior State Department official told reporters, 'The program was actually drowning in too much money, in some cases, you know, sort of going beyond its core mandate.'
The official said, 'So instead, we're going to focus on that lifesaving care' and 'work with countries on self-reliance' to ensure there is not a gap in coverage.
The senior official said that Secretary of State Marco Rubio is drawing a distinction between people who have HIV and need lifesaving direct treatment, and preventative care for sex workers as well as bisexual and gay men.
The State Department official also said, 'It doesn't mean that the United States has to pay for every single thing around the world."
"A lot of these countries, they've graduated to the point where their HIV rates are low enough and their economy is healthy enough that they can continue to pay for some of these things. We can get in, make positive change and then get out rather than paying forever so that every sex worker in Africa has PrEP," the official said, referring to HIV medication.
Deputy Secretary of State for Management and Resources Michael Rigas testified to Congress last week that, overall, in the administration's budget request for the next fiscal year there is a 54% cut in PEPFAR's administrative, nondirect care funds. That is in addition to a 15% cut in the department's budget request for direct care in the same budget request.
A global health staff of 700 people plus contractors in the field prior to President Donald Trump taking office has been reduced to 80 people after recent firings.
Last month, White House budget director Russell Vought told a Senate committee, without providing evidence, that PEPFAR spent $9.3 million 'to advise Russian doctors on how to perform abortions and gender analysis.'
Democratic Sen. Chris Coons of Delaware, a senior member of the Foreign Relations Committee and former chairman of the Africa Subcommittee, told NBC News that PEPFAR had always planned to get countries that had developed their own hospitals and health care systems, such as South Africa, to take over funding the program by 2030.
According to Coons, that transition is already underway. But he and other critics of the current budget cuts said that it is not possible in low-income conflict zones, such as South Sudan, the Democratic Republic of Congo and Haiti, to replace the U.S program anytime soon.
Still, according to a draft planning memo reported by The New York Times, the State Department would shut down U.S. support in Botswana, Namibia, South Africa and Vietnam within two years. Nations with high HIV infection rates, including Kenya, Zimbabwe and Angola, would get three to four years, the Times reported, while lower-income countries would get up to eight years under the proposal. NBC News has not viewed the draft plan and a State Department official told NBC News it has not been finalized.
Dr. Robert Black, an epidemiologist at Johns Hopkins Bloomberg School of Public Health, who evaluated PEPFAR for Congress, told NBC News, 'I think two years for a number of countries, for many countries in Africa, would be too short,' adding, 'I just can't imagine two years would be an effective transition.'
Black also said maintaining prevention is 'clearly important" and that withdrawing funding for prevention, which is contemplated under the Trump plan, would increase HIV rates and expand the burden.
Rubio, who as a senator supported PEPFAR and other foreign aid, defended $20 billion in overall proposed budget cuts to the Senate Foreign Relations committee in May, citing 'duplicative, wasteful and ideologically driven programs.'
Asked last week about the PEPFAR cuts, former Secretary of State Condoleezza Rice, who served in the Bush administration when PEPFAR was launched, told NBC News at the Aspen Security Forum, 'I do think PEPFAR is going to not only survive, I think it's going to be just fine. ... There will be some scaling back, and it's probably worth it to take a look at focusing on what we really need to focus on. We've become pretty dispersed and diffuse in the kinds of programs that we were running.'
But, she added, 'what makes America different as a great power is that we have not led just with power, but we've also led with principle.'
Later at the conference, Rice said launching PEPFAR was 'the proudest moment' in all of her government service. But she added that the U.S. also wants to build other countries' capacity and health care systems to sustain themselves.
Former President Bush, in rare criticism of Trump's policies, praised fired foreign aid workers in a video last month. He told the State Department employees who had been fired, 'You've shown the great strength of America through your work, and that is our good heart.'
Citing PEPFAR'S lifesaving work, Bush said, 'Is it in our interest that 25 million people who would have died, now live? I think it is. On behalf of a grateful nation, thank you for your hard work, and God bless you.'
In a video, Bono told the foreign aid staff in verse, 'They called you crooks — when you were the best of us, there for the rest of us. And don't think any less of us, when politics makes a mess of us. It's not left-wing rhetoric to feed the hungry, heal the sick. If this isn't murder. I don't know what is.'