I hope you never have to watch someone die of AIDS.
I’ve seen it happen too many times during my years as a medical missionary in Kenya. Whether it’s a little boy whose every breath carries a horrifying squelch because his lungs are full of fluid or a young mother whose body seizes and shakes from brain inflammation, a sense of helplessness hits me every time. Once someone’s immune system is fully destroyed by HIV, all the medical interventions in the world can’t help.
I’m grateful, though, that in my daily work I am able to help HIV-positive people live normal, healthy lives because they’re on antiretroviral medications. These medications are paid for by an American program, the President’s Emergency Plan for AIDS Relief, commonly known as PEPFAR. Funded by the US government since it began under the Bush administration in 2003, PEPFAR provides medication to HIV-positive people across the world, keeping them alive and preventing the spread of HIV to their families, including their unborn babies.
My patients, colleagues, and even fellow church members in Kenya rely on PEPFAR for these essential medications, and at my hospital we aggressively test people suspected of having HIV so that we can avoid those ugly, terrible deaths. My salary as a missionary is covered by private donations from churches and friends back in the States, but many of the drugs and supplies we use in our daily work come from programs funded by the US government as well as international institutions.
I’ve been reminded of that sense of helplessness and horror at imminent death from AIDS over the past few weeks as I have considered the future of PEPFAR. The program is not part of USAID, the federal foreign aid agency singled out by the Trump administration for particularly aggressive budget cuts, but USAID does distribute PEPFAR funding, and its inspector general monitors the program’s work.
On January 24, clinics around the world that are funded by PEPFAR via USAID received a stop-work order. That directive has thrown HIV-positive patients across the world into confusion and chaos. Secretary of State Marco Rubio put out a waiver a few days later, but it has not resulted in any clinics on the ground receiving funds they need. The situation seems to be that unelected bureaucrats were actively trying to stop those payments; many other contracts for lifesaving work have been canceled.
Even if that obstruction goes away, however, resuming proper patient care won’t be as simple as flipping the on-off switch. The infrastructure and supply chains that clinics and hospitals like mine rely on to distribute medication were also affected by the stop-work order. Some providers won’t be able to get medications even if the money does come through.
The situation is further complicated by a legitimate scandal inside PEPFAR: A few weeks ago, it came to light that PEPFAR-funded service providers in Mozambique had performed abortions. This is absolutely forbidden under US law and represents a grave violation of the spirit by which PEPFAR has worked for the past two decades.
Investigations are still ongoing, but concerns about smuggling abortion care into PEPFAR’s mission first came to a head during the Biden administration. Last year’s reauthorization of the program was only accomplished after a tense battle, and it was given a one-year reauthorization rather than continuing the previous pattern of five-year reauthorizations.
The good news is that this scandal, bad as it is, reveals just how carefully PEPFAR has been spending its money over the years. It is demonstrably not a wasteful or corrupt program.
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On the contrary, the abortions were uncovered because the program has always been strictly scrutinized, and this is the first time in two decades anyone has found this kind of violation. (You can read their previous oversight reportsyourself.) Any attempts by pro-choice activists to misuse PEPFAR have run into the ironclad structures built in from the beginning. And in the brief time since this scandal came to light, PEPFAR has already instituted new compliance measures to ensure this doesn’t happen again.
My own experience matches this public record of accountability. From what I’ve seen, PEPFAR runs the tightest ship around when it comes to foreign aid. And I’ve never seen PEPFAR interfere with Christian ministry. In fact, many medical facilities receiving PEPFAR funds are explicitly Christian institutions where hospital chaplains preach the gospel to people while they’re waiting for their appointments. The legacy of Christian medical missions in Africa means that a lot of critical health infrastructure—including care for HIV and tuberculosis—happens in clinics and hospitals run by Christian denominations. PEPFAR has not tried to change that model.
Decades ago, American Christians rallied in support of PEPFAR. A key moment came when Senator Jesse Helms—a small-government, pro-life conservative if ever there was one—held a tiny, HIV-positive, African baby in his arms.
He immediately became a supporter of the initiative that would become PEPFAR, writing, “I know of no more heartbreaking tragedy in the world today than the loss of so many young people to a virus that could be stopped if we simply provided more resources.” Helms knew that a small portion of the federal budget could make a huge impact, just as we know today that cutting PEPFAR will barely make a dent in our national debt—or even one year’s budget deficit.
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(The national debt is over $36 trillion. Annual federal spending is north of $6 trillion. This year’s deficit is around $2 trillion. PEPFAR’s entire annual budget is around $6 billion. That’s 0.1 percent of annual spending and 0.3 percent of this year’s deficit.)
Helms’s realization is just as necessary today, and American Christians’ advocacy for PEPFAR remains necessary too. Millions of people rely on this program for medications keeping them alive. At minimum, if the US is going to stop funding PEPFAR’s work, we must have a plan for slowly transitioning the financial responsibility to other payers (perhaps through missions organizations like African Mission Healthcare). Simply letting this work lapse—letting millions of fellow Christians and others of all ages, including presently unborn children, die a painful death from a preventable and manageable illness—is not a morally defensible approach.
One of Christianity’s greatest practical accomplishments is the very idea of a hospital—a place where sick people would receive care regardless of their ability to pay. And, historically, this work was often the product of what we’d now call public-private partnerships. Throughout late antiquity, Christians in Rome and Byzantium used government funds to build institutions of incredible generosity. PEPFAR is only the latest chapter in the legacy of Christian charity using state capacity to bring about incredible, lifesaving changes.
HIV and AIDS are elements of a fallen world. They are, in a real sense, already defeated by Christ and will be finally eradicated in the new creation. But for now, God is glorified when HIV is suppressed and new infections are prevented.
The capacity that PEPFAR has built over the past two decades has convinced me that this federal program is the most prudent way to accomplish that good work. Yet at the very least, there is an infrastructure here that must be preserved, even if the federal government no longer provides this vital funding. Our African brothers and sisters who depend on PEPFAR’s medication are hoping and praying, however, that American Christians will not allow our government to renege on this commitment.
I wish I could bring everyone who has power over PEPFAR’s survival to my mission hospital. I wish they could see how a relatively small amount of money has done incredible good. I wish they could meet the hardworking people who rely on PEPFAR to survive. God has blessed America richly with an abundance of resources. There are few better ways to steward that blessing than keeping people alive.
Matthew Loftus lives with his family in Kenya, where he teaches and practices family medicine. You can learn more about his work and writing at MatthewAndMaggie.org.
