America's global AIDS relief program is on the brink

Politico

23-03-2025

America's most celebrated global health program is on life support, former U.S. government officials and global health advocates say.
President Donald Trump's decision to suddenly halt and then terminate most U.S. foreign aid, and GOP concerns that organizations receiving government grants to combat HIV and AIDS were performing abortions, have key congressional Republicans broaching what was once unthinkable: ending PEPFAR, the program President George W. Bush created to combat HIV and AIDS in the developing world. Bush has long championed it and the 25 million lives it's saved as the best example of his 'compassionate conservatism.'
But Trump has lumped the President's Emergency Plan for AIDS Relief in with other foreign aid programs he sees as indicative of the way Washington has put the needs of foreigners over Americans and the seismic shift in GOP attitudes since Trump took over the party.
The Bush Institute, an arm of the center that promotes Bush's legacy, is pleading with the administration and Republicans to keep the program alive, making the case that it's good for America.
'PEPFAR is a strategic investment in our own national security,' Hannah Johnson, a senior program manager for global policy at the institute,
wrote earlier this month
, arguing that 'it engenders goodwill toward the United States at a time when Russia and China are competing for greater influence, in ways that are not beneficial in the long-term for the African continent.'
She called on the administration to continue the program — 'whether through USAID, the CDC, the Pentagon, or the State Department. It is a matter of life and death.'
Since late February, the Trump administration has terminated hundreds of millions of dollars in PEPFAR grants and contracts amid its rapid effort to align foreign aid with its 'America First' policy, according to a list obtained by POLITICO. Next week, the 2003 law that established PEPFAR is set to expire with no indication it'll be renewed anytime soon.
Congress did appropriate funding to cover PEPFAR's expenses through September earlier this month. Its programs can continue even if the law authorizing it expires, but only if Trump wants to spend the money. PEPFAR's budget is between $6 and $7 billion per year.
Trump has halted most programs overseen by the U.S. Agency for International Development,
which handled a majority of PEPFAR's projects
, but so far hasn't touched the Centers for Disease Control and Prevention's, which run nearly $2 billion a year.
The cuts the administration has made have alarmed public health advocates. A sudden end to PEPFAR could kill six million people in the next four years, reverse decades of progress and lead to growing HIV epidemics across the world, over 500 AIDS physicians and researchers
warned in a letter
to Secretary of State Marco Rubio.
'Over time, these policy decisions may be proven illegal in U.S. courts but the human suffering and loss of lives happening now cannot be reversed by any court order,' they wrote, asking Rubio to restart all PEPFAR projects.
The State Department did not respond to a request for comment on the letter.
Abortion politics
PEPFAR enjoyed bipartisan support until two years ago, when congressional Republicans accused then-President Joe Biden of indirectly funding abortion abroad by providing PEPFAR funds to groups that support or provide abortions. After allowing the law that authorizes the program to expire in 2023, Congress ended up reupping it for one year last March. Every previous renewal was for five.
Then in January, the Biden administration acknowledged that a routine check on grant compliance in the southeast African country of Mozambique found that four nurses in a small province whose salaries were funded by PEPFAR provided abortions, which is legal in the country.
Mozambique refunded the money — $4,100 — but Senate Foreign Relations Chair Jim Risch (R-Idaho), whose panel oversees PEPFAR and would lead any effort to renew it,
said it called into doubt his support
for the program. 'This violation means that the future of the PEPFAR program is certainly in jeopardy,' he said in a statement at the time.
Advocates of PEPFAR have in the past turned to Rep. Michael McCaul, an 11-term Texan representing a swath of suburbia from Austin to Houston and friend of Bush's who'd helped convince fellow Republicans in 2024 to reup PEPFAR for a year despite their misgivings.
But in January, GOP term limits for committee chairs forced McCaul to give up his post atop the House Foreign Affairs Committee. McCaul's replacement, Florida Republican Brian Mast, told POLITICO earlier this year that he wants to rethink the U.S. investment in PEPFAR.
'If Americans are spending billions of dollars for multiple decades funding extremely expensive HIV medication for 20 million Africans, there should be a conversation about that,' he said. 'At what point do some or all countries start to handle that on their own?'
The bottom dropped out for PEPFAR shortly after Trump's inauguration in January when, as one of his first actions, he closed the agency that sponsors most foreign aid, USAID, and then terminated billions in State Department funding.
The cuts included grants and contracts supporting HIV prevention for teenage girls and gay men, who are at high risk of acquiring HIV in some countries in Africa; efforts to control the spread of HIV in Nepal, Uganda and Ukraine, and clinical trials researching a vaccine and other HIV prevention measures.
A State Department spokesperson said a list of the programs obtained by POLITICO 'is inaccurate and unverified' but didn't provide more details.
Payments for some of the PEPFAR projects still intact, such as a major contract to supply and deliver HIV drugs, aren't flowing to the organizations running them, keeping crucial lifelines effectively frozen, according to a person familiar with the USAID programs allowed to speak anonymously for fear of reprisal from the administration.
Eight countries already face significant disruptions to HIV drugs and are expected to run out in the coming months, the World Health Organization, an arm of the United Nations, said Monday, listing Kenya, Lesotho, and Ukraine among them.
The Trump administration has argued in court that it needed to verify most payments manually to ensure there's no fraud involved but a federal judge ordered it
to pay a large batch of backlogged invoices
for foreign aid programs. In many cases, those payments are still pending: There are about 10,000 payments that need to be processed, the State Department
said in a court document on March 19.
The administration has kept a few hundred USAID employees out of more than 10,000. Trump is folding what's left of the agency into the State Department. Just over a dozen PEPFAR
specialists from USAID's global health bureau will be hired
at the State Department office managing the program, according to a State Department memo obtained by POLITICO.
Mast told POLITICO that he's considering reupping the law undergirding PEPFAR in September when the State Department will also come up for reauthorization.
Mast suggested he'll prioritize shifting responsibility for HIV and AIDS prevention and care to the countries that have relied on PEPFAR: 'There's countries — and their leaders — that have just taken it for granted that the United States is just going to pay for their HIV medication forever.' Some of those countries have worked with China on mineral extraction and other things, Mast said, suggesting America's PEPFAR investment didn't serve the U.S. as many tout it.
He said those countries could borrow money to provide HIV-prevention services that were funded by PEPFAR to their citizens.
The Trump administration's shock-and-awe approach in freezing and then cutting most of foreign aid, and, with it, many PEPFAR programs, has left global health advocates and some on Capitol Hill wondering what's left of the program that until recently was fiercely supported by most Republicans and Democrats.
'It's hard to understand how PEPFAR, as we know it, can continue at this moment,' said a House Democratic aide granted anonymity to speak candidly.
Trump's plans
PEPFAR is an ecosystem of services that goes beyond providing medication and includes testing and reaching out to vulnerable groups, such as teenage girls, the aide said. The program 'is not going to be as successful if we chip away at pieces along the way and strip it down to something that is just, perhaps a straight provision of medication,' the aide added.
Pete Marocco, the foreign assistance director at the State Department who has led the foreign aid cuts and USAID's dismantling, told lawmakers from the House and Senate foreign affairs committees in meetings earlier this month that around $4 billion from PEPFAR's annual funding wasn't spent on lifesaving treatment and went to advocacy instead, according to two people with knowledge of the conversation speaking anonymously because they aren't allowed to publicly comment on private meetings. Marrocco also said the program only needed about $2 billion to provide lifesaving treatment, according to the two people.
Marocco didn't provide a list of terminated or retained programs to lawmakers, Rep. Sydney Kamlager-Dove (D-Calif.) and Sen. Jeanne Shaheen (D-N.H.) said after meeting him.
The State Department said it doesn't comment on its officials' communications and briefings with Congress.
While uncertainty about what's been eliminated and what remains persists, the cuts will damage the foreign aid system, including the programs that the administration may want to keep, said Andrew Natsios, a Republican who ran USAID in the Bush administration.
Dr. Atul Gawande, who ran USAID's global health programs in the Biden administration, said the funding freeze and terminations are putting the whole program at risk.
'This is the end of PEPFAR as we know it, and if certain issues aren't addressed, it's just the plain end of PEPFAR,' he told reporters in a call in late February.
Some global health advocates and lawmakers are holding out hope Gawande is wrong.
'PEPFAR, unlike the health programs that are based at USAID, is based at the State Department; does still have a team there overseeing the program; was given, at least on paper, the ability to continue some care and treatment,' said Jen Kates, senior vice president and director of the Global Health & HIV Policy Program at KFF, a health policy think-tank.
Sen. Chris Coons (D-Del.), a member of the Senate Foreign Relations Committee, acknowledged that it will be difficult for the program to recover from the blows it has suffered over the past few weeks.
'But I'm determined that it's not the end for PEPFAR. It is too important, too valuable, too effective a program for us to give up on,' he said.