The Journal. - The U.S. Spent Billions Fighting AIDS. What Now?

Episode Date: February 14, 2025

At the beginning of his presidency, Donald Trump suspended most U.S. foreign aid, causing vast confusion and concern around the world. One affected program was PEPFAR, the bipartisan initiative that works to fight HIV/AIDS globally. WSJ’s Nicholas Bariyo from Uganda and Michael M. Phillips from Kenya report. And we hear from Karl Hoffman, the CEO of the public health organization HealthX Partners.  Further Listening: -Inside USAID as Elon Musk and DOGE Ripped It Apart  Further Reading: -Trump Aid Whiplash Hits Refugees, AIDS Patients Worldwide  -Trump Order Freezing Foreign Aid Halts Programs Worldwide, Prompts Confusion and Rush for Waivers  Learn more about your ad choices. Visit megaphone.fm/adchoices

Earlier this week, our colleague Nicolas Barrio went to visit an HIV AIDS clinic in Kampala, Uganda. The clinic was closed, shut down after President Trump froze almost all foreign aid money. Only a security guard and a cleaner were on the premises. The security guard at the gate says he's not allowed to let anyone inside now. He tells me that people have been coming and being turned away, and as a result, no one now comes. Before it closed, it was providing care to hundreds of patients with HIV AIDS every day. In the meantime, all the medicine that's sitting inside this clinic is just locked away.

Yes, all the medicine, yes, all the supplies, because people have been working there, we are told not to return. Since its founding, this clinic has been funded almost entirely by U.S. foreign aid. For more than 20 years, it's been part of a program known as PEPFAR, a multi-billion dollar U.S. foreign aid. For more than 20 years, it's been part of a program known as PEPFAR, a multi-billion dollar U.S. effort specifically designed to stop the spread of HIV AIDS globally.

And how important are the services provided by this clinic? So they are very, very important because it helps people who live in rural areas, people who have no money to pay for these tests, and most importantly, expectant mothers, people who are pregnant, and these treatments help them from passing the virus onto their unborn children. PEPFAR has been swept up in President Trump's 90-day freeze on foreign aid. Although the administration has signaled that it didn't intend to pause PEPFAR entirely, the order is having that effect. At this moment, PEPFAR programs are mostly at a halt all across Africa. I asked our other colleague, Michael Phillips, about

the effect of the funding freeze in Kenya, where he's based. Well, I think there's been a general sense of panic. So I spoke to somebody the other day. This person has family members who are HIV positive, and they've been on antiretrovirals through PEPFAR. And some of those family members are literally going out and picking out grave sites for themselves because they don't think they're going to make it. Oh my goodness.

So imagine that. You thought you were okay. You thought you'd gotten past this disease. You could to make it. Oh my goodness. So imagine that. You thought you were OK. You thought you'd gotten past this disease. You could live with it. You're not transmitting it to anybody. And suddenly you're looking around and thinking, I can't afford to buy drugs, and no one's going to give them to me anymore.

So well, I'll save my family the trouble, and I'll pick a place to bury myself. Wow. And it's a stunning thought. Welcome to The Journal, our show about money, business, and power. I'm Ryan Knudson. It's Friday, February 14.

Coming up on the show, America has spent billions combating AIDS around the world. Is that era now over? Fighting HIV AIDS has been a big part of America's foreign aid spending for decades. Many hospitals tell people, you've got AIDS. We can't help you. Go home and die. In an age of miraculous medicines, no person should have to hear those words. In 2003, then President George W. Bush announced a new governmental initiative called the President's Emergency Plan for AIDS Relief, or PEPFAR.

PEPFAR is a program with the United States government finances to combat AIDS worldwide and to treat people who have HIV to prevent them from becoming AIDS patients and then ultimately from dying. And Bush started this program as a way sort of to reach out to people who cared about Africa. He was exhibiting his own concern about Africa. Get across that continent, only 50,000 AIDS victims, only 50,000 are receiving the medicine they need.

And the real innovation of PEPFAR was that the US agreed to pay to keep poor Africans who had HIV infections alive. And the results have been really astounding. Something like 25 or 26 million people in Africa are alive today because the United States helps them stay alive. HEPFAR is the largest commitment by any nation to address a single disease in the world. It's credited with not only saving millions of lives in Africa, but also helping prevent HIV from spreading across the globe in Asia and Latin America. Congress has reauthorized funding for the program every few years since its inception.

Last year, funding for PEPFAR was estimated at about $6.5 billion, which is less than a tenth of a percent of the U.S. government's $7 trillion total budget. So how successful would you say this program has been? I think that most people would say it's been extraordinarily successful. People who would otherwise be dead, by the millions, are alive today. So I think, medically speaking, and for many, many, many years, politically speaking, it was a very popular project. I had some disagreements with my predecessor, but one of the outstanding things that President

Bush did was to initiate the PEPFAR program. Its supporters have also included former Vice President Mike Pence. PEPFAR was an extraordinary bipartisan achievement of compassion. Former President Joe Biden. George W. Bush deserves great credit. and even Trump during his first administration. What we've done for AIDS in Africa is unbelievable. We spent six million dollars. But when Trump took office a second time,

cutting foreign aid funding was one of his first actions. He signed an executive order that essentially froze all of the roughly $65 billion the government spends on foreign aid in total around the world, including PEPFAR. I think there are people in the administration who believe that the aid industry or the world of foreign assistance was beyond repair in some way,

wasn't achieving what they wanted to achieve, wasn't oriented enough towards American self-interest, which is clearly what the America First agenda is. They just thought that you couldn't fix it a little bit at a time, and you had to fix it or kill it all at once. One reason the Trump administration says it paused aid is that much of it doesn't align with Trump's politics. Last week, press secretary Caroline Levitt

stood in front of the White House and listed off international aid programs that the Trump administration sees as wasteful. — 70,000 for a production of a DEI musical in Ireland, 47,000 for a transgender opera in Colombia, 32,000 for a transgender comic book in Peru. I don't know about you, but as an American taxpayer, I don't want my dollars going towards this crap,

and I know the American people don't. U.S. federal funds did go to all these programs through the State Department. Although the amount of federal money spent on that opera in Colombia was actually closer to $25,000, not $47,000. So was PEPFAR just caught in the crossfire then? Because obviously, it's not a program that's supposed to have anything to do with DEI.

I think the freeze on PEPFAR and everything else was very intentional. You'd have to know absolutely nothing about US foreign assistance to not know about PEPFAR. I don't know what percentage of foreign aid has anything to do with diversity and those issues. It's not very large I think we can be confident of that most of it is simply helping other people and Then you know, there's there's a debate about whether that's what you want to do with taxpayer money I won't make a judgment about that, but the administration has clearly signaled what their judgment is on PEPFAR specifically the Trump administration has sent mixed messages. Clinics around the world are closed and there isn't much guidance from the State Department. But Trump's Secretary of State

Marco Rubio said he supports PEPFAR and the administration says that some life-saving activities can get a waiver to resume work. The problem is the waiver itself has to be approved. It's not just a blanket waiver, go out and spend the money that was already allocated. Meaning each PEPFAR program has to get specific approval. And since so much work has stopped back in Washington, DC because of the freeze, in some cases people on the ground

don't know who to call for help. You've got nobody to call up and say, okay, you know, you and I have been working together for five years, here's my new budget. Who's gonna approve it? There's no one that answered the phone. So it's like a promise of a waiver has been issued, but the waivers themselves have not.

So there's a lot of confusion amongst the people who implement these AIDS programs as to whether they can actually go ahead and give out drugs to people who are sick. And so the chaos around these programs is extraordinary. The State Department says some waivers for life-saving programs have been issued. And yesterday, a judge ruled that USAID funding

should be allowed to flow again temporarily. But our colleagues in Africa say that doesn't seem to be happening yet. In Uganda, Zambia, and the Democratic Republic of the Congo, hundreds of health workers who were being paid under PEPFAR were told to go home, and they haven't gone back to work. I think that most of the people who have been involved in PEPFAR, when asked, what does this mean? Would say, people are going to die. Lots of people are going to die.

There's nobody that's stepping in to provide these drugs that the US government provided. And once you're off the drugs, you know, HIV will get you. Coming up, we talked to the CEO of a nonprofit that got a lot of its funding from PEPFAR about what this shift in policy will mean for America standing overseas. Carl Hoffman is CEO of the public health organization Health X Partners. He's also a former U.S. diplomat. How many countries have you lived in? Probably 10 or 15. Not a crazy number.

I mean, that's a pretty crazy number for countries to... When the aid freeze went into effect, HealthX Partners was hit particularly hard. Carle's organizations work on HIV AIDS and other health programs in more than 40 countries. And roughly half of their nearly $500 million budget comes from the US government, including through PEPFAR. So how would you describe and how would you characterize what traditionally has been the role of USAID abroad? The US foreign aid enterprise, not just USAID, but the other parts of it too, are really

about improving conditions in places far away so that threats don't manifest close to home. That's the underlying principle. It's better for Americans if people far away are healthier, more productive, safer, because that makes us healthier, more productive and safer. This is sometimes called soft power, but as somebody said to me the other day, soft power is power, and we should not be throwing it away

at a time of great power competition for hearts and minds around the world. So what do you make of the fact that the Trump administration and a number of his supporters seem to think that this is not money that the U.S. taxpayer should be spending money on? That's a very understandable point of view, and it's been a long-standing view, I think. I mean, a lot of Americans are under the misimpression that foreign aid is a huge part of the federal budget and we should be spending that money at home.

But the whole foreign aid expenditure of the U.S., including the cost of the entire State Department, all of our contributions to the UN, all the investments in global health, everything the U.S. does under the broad definition of foreign aid, foreign engagement on the civilian side is 1% of the federal budget. It's still tens of billions of dollars though. Yeah, it's true.

It's a lot of money. But the idea that we can sort of balance the budget by eliminating foreign aid, which you sometimes hear, is a fallacy. In Carl's view, the billions of dollars the U.S. spends on foreign aid has compounding benefits. I remember when many countries in Africa were contemplating almost a societal collapse because of HIV and AIDS. That, of course, has been largely managed because of innovations in drugs and a huge political commitment and financial commitment led by the U.S., but not only by the U.S., right?

And so instead of collapsing societies from an infectious disease like HIV, you have societies that can manage their own affairs increasingly. That's good for us when people far away can manage their own public health crises. Because otherwise they become our problem. But if you listen to the stuff that Elon Musk has been saying, he said that there's also a lot of examples of corruption, waste, money that's being spent on things that Trump and a lot of his supporters don't believe in, like diversity, equity, and inclusion efforts. Have you seen things like that?

What do you make of that? My organizations, the ones that I'm responsible for, haven't been hired to deliver anything like that. My organizations, the ones that I'm responsible for, haven't been hired to deliver anything like that. We've been hired to deliver better health outcomes in countries around the world, and I think we do it pretty cost effectively. Do you think there's a lot of waste in the foreign aid system? I think there's a possibility of waste in everything the government does and also in everything that the private sector does. That's why ideas around reform and improving and shifting the burden of these challenges onto host governments, those are all good agendas. Pushing for efficiency and cost-effectiveness, that's all totally legitimate.

Carl says he's trying to keep his organization afloat. It's had to lay off or furlough thousands of employees, and they're looking for sources of new funding. Meanwhile, his organization has received waivers to resume some life-saving activities, but no funding to allow that to happen yet. What do you think might step in to fill this void, if anything? Well, it's early to make predictions, but I think it's a mistake to assume that other players in this space are going to step up to gap fill and to come in behind the gap that's been created by the absence of the U.S. government.

Everybody else has seen these actions of beginning to dismantle the US Agency for International Development, freezing all foreign assistance. And a lot of other donor governments, I think, are saying, ah, this is our time to pull back too. Other governments around the world. Yes. Yes, I think so. The US was getting bigger and bigger as a relative share of this.

And now the US tent poll has been pulled out of the tent. And I think the whole tent is going to get considerably smaller. And so you're going to have a vacuum that's filled by misery. You'll have a vacuum that's filled by increased death, misery and poverty. And yes, it's far away, but ultimately it's going to be bad for us, I think. And that's one thing that I worry about. Right now, the future of PEPFAR is unclear. McCarl says most people with diseases like HIV AIDS don't have time to wait.

The thing about infectious disease, be it HIV or malaria or TB, there's no option of just like pausing. Freezing is an odd concept in the case of infectious disease work because if you're not moving forward, then you're falling behind. If you're not pushing against the disease, the disease is pushing back against you. That's right. That's true on the geopolitical playing field as well.

We're either gaining yards or we're losing yards and right now we're sort of we're putting the ball down and walking back and not even fighting for valuable terrain on this competitive landscape and I think that's a mistake for us. That's all for today, Friday, February 14th. The Journal is a co-production of Spotify and The Wall Street Journal. The show is made by Catherine Brewer, Gia Gadkari, Rachel Humphries, Sophie Codner, Jessica Mendoza, Matt Kwong, Kate Linebaugh, Colin McNulty, Annie Minoff, Laura Morris, Enrique Perez de la Rosa, Sarah Platt,

Alessandra Rizzo, Alan Rodriguez-Espinosa, Heather Rogers, Pier Singy, Jeevika Verma, Lisa Wang, Katherine Whalen, Tatiana Zamis, and me, Ryan Knudsen, with help from Trina Menino. Our engineers are Griffin Tanner, Nathan Singapok, and Peter Leonard. Our theme music is by So Wiley. Additional music this week by Katherine Anderson, Peter Leonard, Bobby Lord, and Nathan Singapok. Fact-checking by Mary Mathis.

Thanks for listening. We're off for Presidents Day. We'll be back with a new episode on Tuesday. See you then.