The successful HIV/AIDS treatment program that supports 20 million people on antiretroviral drugs, mostly in Africa, had to rapidly shut down this week after the Trump administration froze all foreign assistance pending a review.
Clinics supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) closed and laid off staff. Distribution of drugs halted in rural communities. Prevention and outreach programs all stopped, according to Christian organizations interviewed by CT.
Many Christian clinics and nonprofits implement this program and partner with local churches for outreach and treatment.
But on Tuesday night, the State Department issued a memo, obtained by The Washington Post, creating an exemption for life-saving assistance in foreign aid. The new communication did not specify whether PEPFAR would qualify.
Secretary of State Marco Rubio has previously supported PEPFAR, although the program has come under opposition from Republicans.
On Wednesday, Christian staff working in HIV/AIDS were unsure what the exemption memo meant for their PEPFAR-funded work. Organizations on the ground received specific orders from the US to stop their work but have not yet received specific orders to restart.
Gibstar Makangila leads Circle of Hope (COH) in Lusaka, Zambia, a Christian organization that provides treatment and prevention services through PEPFAR. COH facilitates treatment for 50,000 HIV patients.
COH had to halt some of its US-funded operations on Monday. Its “community posts” that offer HIV prevention and treatment are closed. On Tuesday, Makangila met with 300 staff members to try to explain the situation of the aid freeze. The meeting was supposed to be 45 minutes but lasted two hours.
Some of the thousands of patients on treatment have supplies for a month or so, he said.
“The news, of course, has been received with shock,” he said. He worries about not only the increased spread of HIV during a pause, but also the “despondency and discouragement among those receiving treatment.”
The organization is hoping the waiver will take effect soon for their work.
“We are very optimistic that our beloved new president and his team will be able to consider all factors,” he said. “American Christians must embrace and encourage their congressmen and -women and their presidency, so that we ensure we don’t stop doing good.”
Makangila supports the administration’s decision to review the program but had hoped it could be done without putting lives at risk. He said PEPFAR represents “the best of America’s foreign diplomatic action.”
The halting of the program has been unprecedented since then-president George W. Bush began it more than 20 years ago. PEPFAR is credited with saving more than 25 million lives over the last two decades.
Pauses in HIV treatment are serious. Antiretroviral drugs must be taken every day to keep the virus at bay.
“It is breathtaking,” said Doug Fountain, executive director of Christian Connections for International Health (CCIH), in an interview before the exemption memo went out. “It feels abjectly reckless. I can’t see any context where this is a good way to manage something.”
CCIH has supported African clinics fighting HIV/AIDS for decades but does not receive PEPFAR funding. On Tuesday, Fountain spoke to local leaders of Christian health organizations in two countries, whom he promised not to identify to protect their programs from retribution if overall funding is restored.
Both reported that PEPFAR-supported programs were allowed to distribute any medicine they had sitting on their shelves, but they had to stop paying the salaries of health workers.
If a health worker needed to take antiretrovirals (ARVs) to a rural community on a motorcycle, that work has stopped due to lack of funding, he said. In one of the countries that reported to Fountain, all the health workers supported by PEPFAR were sent home without pay, effective last Friday.
But the freeze on pay is playing out differently in different countries, where some national governments operate under requirements to cover these health workers’ salaries short-term in the event of a layoff, Fountain said.
Staff members of operations on the ground, some of whom could not speak on the record for fear of retaliation against their programs, said it will be difficult to restart programs when clinics have laid off staff or shut down completely. Bringing the infrastructure of a $6 billion program online again after such a sudden shutdown is not simple, they said, and has already broken trust with local partners.
Fountain is not opposed to a review of PEPFAR’s effectiveness or to reforms of the program—CCIH has had recent discussions with then-senator Rubio about development reform—but Fountain said the government should have given organizations some time to prepare.
That’s especially true when pausing a program threatens people’s lives, he said. The freeze also halted global health funding that treats millions of patients with tuberculosis and malaria.
On a daily basis, PEPFAR serves 222,000 patients seeking ARVs and administers 224,000 HIV tests, according to AIDS research organization amfAR. Missed doses of ARVs increase the risk that a drug-resistant strain of HIV could develop, a longtime fear of HIV doctors.
HIV patients can receive up to six months’ worth of medication at a time, so some may have medicine to last through a funding freeze.
Of particular concern are pregnant mothers with HIV. A brief interruption of treatment exponentially increases a baby’s chance of being born with HIV, and babies have weak immune systems.
Unlike adults, who can live with HIV for years, babies born with the virus have a peak mortality at 8 to 12 weeks of age without treatment. Half die before age 2.
Before treatment became available through PEPFAR starting in 2003, Christian groups in Africa often provided palliative care to HIV patients. Then they switched to providing treatment. One Christian clinic in Malawi now, Partners in Hope, administers PEPFAR funds and oversees 123 facilities that provide 20 percent of the country’s HIV treatment.
Progress, Fountain said, is “easily reversible.”
Some Democratic members of Congress have protested the overall foreign-assistance freeze.
“Congress has appropriated and cleared these funds for use, and it is our constitutional duty to make sure these funds are spent as directed,” wrote Democratic representatives Gregory Meeks and Lois Frankel in a letter to Rubio.
Stop-work orders on projects are not unprecedented if there is an issue with a contract that needs to be investigated, said a senior official working at an HIV-aid organization, who could not speak publicly for concerns of retribution against the organization. But stopping all foreign assistance is unprecedented.
PEPFAR was already in troubled waters after Republicans opposed its five-year reauthorization, and Congress passed a one-year renewal last year instead. The program would need to be renewed in March.
Makangila remembers before PEPFAR when he would see multiple hearses on his drive to work every day at the peak of HIV/AIDS-related deaths. Now his own family members have survived with ARVs, including a nephew who is just enrolling in college.
“I am touching real Zambians who otherwise would have died. … These humans are here, some in my home as I speak,” Makangila said.
He added, “Someone can give you a road or a bridge or a house. But someone who gives you back your lost life, that is incredible.”
