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John Cohen, a veteran journalist who covers global health, was on a reporting trip last month in southern Africa.
One of his stops, a local health clinic in the small country of Lesotho.
John says in the waiting room, you could see how cuts to US HIV -AIDS funding are already playing out there.
The room, he said, was jam -packed with pregnant women.
They were waiting at a minimum, at a minimum four hours to see anyone.
And most of them were going to be there from 8 a .m. till 5 p .m. John says the clinic had been cut off from some of the U .S. funds it depended on, so it had to let go of staff, driving up wait times.
And without that personnel, he says the clinic also stopped testing these women for HIV.
Lesotho has one of the highest rates of HIV prevalence among adults in the world, around 18 % as of 2023.
23 so john says unable to be tested these women are in a very vulnerable position if they do have hiv they will not be receiving treatment because nobody knows their status their babies will have about a 30 chance of becoming infected either at birth or through breastfeeding their babies won't be tested either until they become ill most likely and that's the tragedy so i could see all that with my own eyes, not because it was visible, but because I know from having covered this since the bad old days what happens when you don't intervene.
President Trump has described foreign aid as wasteful, that the U .S. has been too generous with its foreign assistance without getting enough back in return, that aid money being spent abroad is better spent at home.
But will Trump's America First foreign policy wipe out years of progress against HIV around the globe?
This is a question that John explores in his recent story in Science magazine.
I talked to John about that reporting for an episode of The Indicator, including the monumental legacy of PEPFAR, the US president's emergency plan for AIDS relief.
There was a bunch of stuff we couldn't fit into that show, so for today's bonus episode, we're giving you an extended cut of my interview.
All right, John and I start our conversation by taking a step back.
He told me about a turning point in the treatment for HIV.
The year was 1996. That's the year that antiretroviral drugs in cocktails showed that they could basically allow people who had HIV to live normal lifespans, stave off AIDS, and the drugs also knocked back the virus so successfully that people on treatment, we later learned, don't even transmit to other people.
Well that wasn't available to most people living with HIV in the world because the drugs were so incredibly expensive, about $15 ,000 a year per person.
So that's manageable in a rich country but just completely inaccessible for people from low -income countries.
Worked great in the United States, Europe, Australia, Japan had no meaning for most of sub -Saharan Africa, for most of Asia.
And that's where most people who have HIV infections live.
So come 2003, President George Bush announces in the State of the Union address this idea for an emergency program called PEPFAR that will provide these medicines, these life -saving critical medicines, to low -income, lower -middle -income countries around the world.
And to be clear, there had been some efforts from the UN, from the Bill and Melinda Gates Foundation, trying to do something similar, right?
Right? Nothing this ambitious.
And in parallel with that, a global fund is launched to fight AIDS, tuberculosis, and malaria that has a similar ambitious agenda and asks wealthy countries to put money into the fund.
And the US, through this new pep farm mechanism, also gives money to the global fund.
So it's a one -two punch. And what happens is generic drug drug manufacturers come out making these drugs and lower the price to about $120 a person per year.
Wow. And so this was an unprecedented amount of money going into combating AIDS and HIV problems around the world.
What was maybe $100 million here and there was now in terms of billions of dollars.
That's right. And to date, the program has spent over $120 billion and has saved an estimated 26 million lives.
It's a phenomenally successful program.
In foreign assistance circles, they point to PEPFAR as kind of the poster child of the good that wealthy countries can do for the rest of the world.
26 million lives at $120 billion.
So some back -of -the -envelope maths, maths, that's around $4 ,500, maybe just a little bit above that.
That's among the very best value for money you can spend anywhere on charities to save a human life.
So what made PEPFAR so successful?
It goes way beyond the purchase of drugs.
The purchase of drugs is kind of the minor part of the program at this point.
And many countries have taken over the purchase of drugs.
It's the delivery of drugs.
It's the delivery of prevention services.
It's training people, nurses and doctors.
It's setting up labs that can run blood tests and evaluate how much virus is in a person's blood.
That's called the viral load.
All of those things, transporting people to clinics, transporting samples from clinics to laboratories, all of that is incredibly expensive and complex. Plus, charting all of that, gathering the data, figuring out where your gaps are, that's where PEPFAR has really made a difference.
And it has trained untold numbers of people around the world to do this themselves.
And now when President Trump came into office in January of this year, he paused all foreign aid for 90 days.
There were some exceptions made for life -saving treatments.
What has happened to PEPFAR and what is looking like it could happen?
So the pause on foreign aid was one blow to the program.
But then Elon Musk and Doge came in and decided to, in Elon Musk's own words, throw USAID into the woodchipper.
USAID, the U .S. Agency for International Development, receives about 60 % of PEPFAR funds.
It's the backbone of PEPFAR.
You throw that into the woodchipper, you're throwing PEPFAR into the woodchipper.
Because you've got nobody to administer it, even if some of the funding is still there.
This is a quilt. You're pulling the thread out of it.
It just starts to fall apart.
And when I visited the countries of East Swatini and Lesotho, that's what I saw.
So you wanted to see what the reality on the ground was.
Yes. And I wanted to see for myself what impact this was having, in particular on children and teenagers.
They're the most vulnerable.
They get sick the quickest. They have the least amount of ability to take care of themselves.
So let's place Lesotho and Eswatini on the map.
Where are they and how would you describe them?
So both of them are within South Africa.
They're independent countries.
One of them borders Mozambique as well.
They're small, one to two million people each. And to roll back the clock to what we were talking about earlier, the year 2003 when PEPFAR was launched, they have the highest prevalence of HIV anywhere in the world.
More adults living with the virus per capita than anywhere.
And they still do. Yeah, I saw that HIV prevalence peaked in 2015, one in three adults in Eswatini and one in four in Lesotho infected?
Yeah, it's down now to one in four in East Latin.
It's still incredibly high.
We're still in the 20%, 25 % range.
And by 50 years of age, about half the people in each country had HIV.
And without the medication, that meant that people just didn't live full lives.
The life expectancy was plummeting in both countries.
I'm not sure the countries would exist today had these medications not arrived there when they did.
Tell me about Tima Langini -Dlamini.
So she was eight months pregnant and lived in a rural area in East Waitini.
And she went to a clinic because she wanted to give birth in a clinic, not at home.
And a 20 -year -old woman and lived about 10 kilometers from the clinic.
So about six miles.
Yes, not easy to get there and lived down a dirt road in a homestead with other kind of wattle homes.
And she went to a clinic where they did an HIV test of her and they found out she had the virus.
So when I went to the clinic I was talking to them and said, well that's great, you know, it's systems working and this outreach worker there said, no, it's not.
We need to now go test the contacts in her home.
Typically, we would drive out to her home and do the testing.
She has other children.
There are other families living there.
Her partner is living there.
We typically would go out and just do all that.
I said, well, we have a car.
How about if we took you?
Would you want to do that.
And the outreach worker said, yeah, I'd love to do that.
So we went out to the home and the woman tested eight children.
And, you know, my heart was in my throat.
You know, I, I really, it's crushing to see positive tests come up, especially in children.
And here were eight children being tested.
Not all of them were her children, but, and they all came out negative, which was just wonderful.
But if any of them had tested positive, they could have started to receive treatment.
Their lives would have been dramatically better off from learning their status and starting treatment.
Had they not gone there and had any of those children been positive, what would have happened?
Well, they would have probably found out that they had HIV when they they had AIDS and were very ill, were near death, they would have sought care and somebody would have tested them.
At that point, they already would have suffered irreparable damage to their bodies.
When they grew older, they would probably be stunted if they survived.
That's what's happening.
It's a little harder to see than, hey, are there drugs on a pharmacy shelf?
But that's the reality of what these cuts are doing.
So if you hadn't been there, she wouldn't have been able to get the people to come to her home to test those eight people in her home six miles away.
And this is kind of what the funding blockages are resulting in.
Exactly. That's what the PEPFAR program was funding, the transport out to people's home.
It might seem trivial to some people to travel six miles, whatever.
whatever. Have you ever tried walking six miles?
And if you are a woman and you've had a baby, have you walked six miles when you're eight months pregnant?
It's not trivial. It's a big deal.
And the roads are not good roads.
So even if you have transport, it's hard to get from place to place.
We have to, as Americans, I think, really appreciate how much good we've done around the world and how very grateful these people are for what we've done.
And to have the plug being pulled like this, as the head of the UNAIDS program said to me is like pulling someone off a life support machine and just pulling the plug.
This seems to have been a very well -managed program in terms of outcomes and outputs, not just about how much money is going in.
Are there kind of some lessons that we can draw from PEPFAR that might help other programs or other ways to do good in the world?
You've put your finger on something critical.
The metrics that we're talking about here are how many people did you test?
How many lives did you save?
How many people knocked back the virus to undetectable levels on standard blood tests?
Those are hard numbers that you can come up with.
and you can evaluate where the program is succeeding, where it's failing.
And indeed, those data fed governments so that they could correct the problems in their programs. Let's look at the numbers out of Lesotho and Iswatini post -PEPFAR.
They went beyond achieving a goal set by UNAIDS to have 95 % of people know their status, 95 % of those people start treatment, 95 % of those people reach undetectable levels.
95 -95 -95. Both of these countries, the hardest hit countries in the world, went beyond the 95 -95 -95.
That is an astonishing accomplishment.
That is something that the world should be celebrating.
Look what the United States government should be celebrating.
Look what we did. Look what we helped them do.
Yeah, the saying is what measured gets done.
And it seems like the right things were measured and they got done in these countries.
To make the argument that this was inefficient or somehow scandalous or somehow stealing money, you know, show me the evidence.
I would love to report that.
I'm not at all a shill for anything.
I'm a journalist. I cover this critically.
If I saw problems, I would report problems. problems. And the program has had problems. And it has addressed these problems with report after report.
It's not perfect. What were some of the obstacles it's faced over the years?
Oh, there was a lot of complaints from staff about how they were being pushed by administration in Washington, D .C.
that didn't understand realities on the ground, in part to deliver data, to deliver metrics that they had a difficult time doing.
There were also political aspects to PEPFAR that were criticized where in some administrations, they didn't want funding to go to sex workers or to key populations, to highly vulnerable groups.
And there were tensions early on about promoting abstinence and behavior change as opposed to medicalizing prevention with things like like pre -exposure prophylaxis.
That's just like taking malaria pills if you're going to a malaria country.
White House budget director Russ Voigt said the U .S. is in $37 trillion in debt, and at some point the continent of Africa needs to absorb more of the burden of providing this health care.
So could African countries find HIV -AIDS treatment and prevention themselves?
Sure. And they want to.
These countries were moving toward taking care of their own.
They had a plan. It wasn't all written out and chiseled.
But the idea was that by the year 2030, the PEPFAR countries would basically be taking over the program and running things themselves.
themselves, and many of them have made great strides.
I mean, both Iswatini and Lesotho are purchasing the vast majority of their antiretrovirals.
And South Africa, which has more people living with HIV than any country, basically pays for about 85 % of everything.
Yes, countries are moving toward that.
But to think that this is going to solve our debt problem, I mean, come on, do the math.
This is a drop in the ocean.
Now, you can argue that, hey, it's a charity, as Marco Rubio has said, and it's not our job to be a charity.
Well, this is more than simply being a charity.
It's more than simply soft diplomacy.
It's creating a stable world where you don't have military conflicts, you don't have countries falling apart because of health.
One estimate is that 60 ,000 people have died so far from the PEPFAR funding blockages.
Based on what you saw, do you think that number is plausible?
It's really hard to say.
HIV causes damage slowly.
In children, it moves pretty quickly.
But, you know, in an adult, it takes years to move from becoming infected with the virus to developing severe disease.
So could people have died en masse from January 20th until today?
Yeah, not a lot, but give it a year and you'll see a lot.
I mean, I saw the two trains heading for each other.
I could see that with my own eyes.
So you got back on the plane to the U .S. What were your parting thoughts as you flew off into the sky?
I used to leave countries like Eswatini and Lesotho, having seen horrific things, 200 people dying in a warehouse with no HIV medication, when medication existed in wealthy countries.
And I'd get on the plane going home and I frankly would get depressed.
I mean, really, like, just deeply depressed at what I had seen.
this was different I was I know what's going to happen because of what I saw I didn't see 200 people dying in a warehouse but I know that if this funding isn't found elsewhere if the gaps aren't filled that there will be a rollback the clock will be turning backward and it's obvious It's obvious to anyone who knows the HIV AIDS world what happens when these things fall apart.
The center isn't holding.
We reached out to the Department of State asking if its leadership was concerned.
The spokesperson said, PetFar continues to support life -saving HIV testing, care and treatment approved by the Secretary of State.
But they also said that other PEPFAR -funded services are currently being reviewed for efficiency and consistency with U .S. foreign policy.
Thanks to John Cohen of Science Magazine for speaking with me.
And as always, thank you for being a Planet Money Plus listener.
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I'm Darian Woods, and this is NPR.
