Can the global HIV/AIDS fight recover from Trump's cuts?

Summary

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Podcast Summary

Episode Overview

Podcast: Consider This from NPR
Episode Title: Can the global HIV/AIDS fight recover from Trump's cuts?
Date: September 12, 2025
Host: Ari Shapiro
Main Guest: Emily Bass, author of To End a Plague: America’s Fight to Defeat AIDS in Africa
Summary:
This episode explores the impact of the Trump administration’s cuts to U.S. global HIV/AIDS assistance programs, especially PEPFAR and USAID, focusing on the resulting disruption in HIV prevention and treatment efforts. With new U.S. investments in a promising preventative drug, the discussion centers on whether such measures can reverse or even stabilize increasingly dire HIV trend lines worldwide.

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Key Discussion Points and Insights

1. A Human Story Illustrates the Crisis

• [00:00–01:14]
  The episode opens with an urgent plea: Pastor Billience Chandwe in Zambia contacting Dr. Susan Hillis for help finding HIV medication for a nine-year-old orphan. The difficulty in obtaining basic medicine underscores the human impact of U.S. aid cuts.
  • Quote:
    Emily Bass: "She has no chance unless someone can get her medicine in the middle of rural Zambia. Who's going to do that? ... She's going to die." [00:32]

2. Background: U.S. Leadership and Recent Changes

• [03:08–04:17]
  • The U.S. has historically been a global leader in HIV/AIDS prevention and treatment, mainly through PEPFAR.
  • Under Trump, most foreign assistance, especially to orphans with AIDS, was abruptly halted, though PEPFAR continued at a diminished capacity.
  • The U.S. recently announced support for Lenacapavir, a new injectable prevention drug.

3. Trend Lines and Uncertainty in Data

• [04:06–05:09]
  • Emily Bass discusses progress through 2024, noting many sub-Saharan countries were nearing public health goals for HIV eradication.
  • Since the cuts, data reporting has stopped, creating a “blackout” where the current situation is largely unknown.
    • Quote:
      Emily Bass: "In the past nine or 10 months, the lights have gone out. ... The data that would normally have been made available ... have not been made available. ... All of the reports from the ground tell the same story of massive disruptions." [05:09]

4. Service Disruptions and Their Ripple Effects

• [05:09–06:35]
  • HIV service delivery is more than drugs and clinics; it is built on a network of trained staff, community relationships, and peer support.
  • Many community workers lost their jobs; clinics remain but are overcrowded, with patients waiting long hours and some being turned away.

5. Promise and Limits of New HIV Prevention Drug

• [06:35–07:49]
  • The new drug Lenacapavir is “good news” but insufficient alone without comprehensive infrastructure and community outreach.
    • Emily Bass emphasizes the effectiveness of PEPFAR was rooted in supporting human infrastructure, not just drugs:
      "The infrastructure is human beings. It's the community, it's the clinic staff, it's the clinic buildings. ... The people who are being paid to support the ecosystem have lost their jobs or have been rehired temporarily." [06:36]

6. Targeted Rollout and Exclusion of NGOs

• [07:49–08:46]
  • The U.S. plans to focus the rollout of Lenacapavir on pregnant and breastfeeding women, seemingly without involvement from NGOs or nonprofit orgs.
  • Bass stresses that while these groups do need access, many others at risk will be left out by such a narrow focus.

7. Transition Plans and Global Responsibility

• [08:46–09:45]
  • There were existing plans to help countries eventually take ownership of their HIV response (“transition planning”), but the abrupt U.S. withdrawal has derailed these.
    • Quote: Emily Bass compares it to a car speeding off track:
      "That's an off ramp. What we did is take the car off the off ramp ... and just drive it into a wall." [09:21]

8. Worsening Situation: Predictions and Realities

• [09:45–11:01]
  • Due to the disruption, new HIV infections are rising, especially among infants—where transmission is preventable.
  • Bass shares firsthand accounts from Uganda and Tanzania: up to 25% of pregnant women giving birth to HIV-positive babies, after years with zero cases.
    • Quote:
      Emily Bass: "I spoke to clinic directors who had seen 25% of their pregnant women give birth to babies with HIV, which is preventable. Which is preventable. And they had had none for years prior. So we're going to see new infections, but we're also going to see people with interruptions in their treatment." [10:16]
  • People are skipping or hoarding medication, disengaging from care, and facing worse health outcomes.

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Notable Quotes & Memorable Moments

• [00:32] Emily Bass: "She has no chance unless someone can get her medicine in the middle of rural Zambia. Who's going to do that? ... She's going to die."
• [05:09] Emily Bass: "In the past nine or 10 months, the lights have gone out ... The data ... have not been made available. ... massive disruptions, particularly in the service delivery approaches."
• [06:36] Emily Bass: "The infrastructure is human beings. ... The people who are being paid to support the ecosystem have lost their jobs or have been rehired temporarily."
• [09:21] Emily Bass: "That's an off ramp. What we did is take the car off the off ramp ... and just drive it into a wall."
• [10:16] Emily Bass: "I spoke to clinic directors who had seen 25% of their pregnant women give birth to babies with HIV, which is preventable. And they had had none for years prior."

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Important Timestamps

• 00:00–01:14 – Pastor Chandwe’s plea for medicine in Zambia captures the episode’s stakes.
• 03:08–04:17 – Overview of U.S. leadership in global HIV efforts and Trump-era changes.
• 05:09–06:35 – Loss of infrastructure, data blackout, and real-world results.
• 06:36–07:49 – The limits of new medication without restored systems.
• 09:21 – “Drove the car into a wall”: Analogy for abrupt end to transition planning.
• 10:16–11:01 – Shocking reversal in mother-to-child prevention progress.

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Conclusion

The episode delivers a sobering account of how quickly progress in global HIV/AIDS can unravel when funding and essential infrastructure are pulled out from under vulnerable communities. While a new drug offers hope, both Emily Bass and host Ari Shapiro make clear that medical advances cannot compensate for missing data, fractured care ecosystems, and the loss of U.S. leadership—leaving millions at increased risk. The future of the HIV/AIDS fight hangs in the balance, with the trend lines already threatening to reverse hard-won gains.

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Transcript

[Ari Shapiro]

Earlier this year, Susan Hillis got a voice message from Pastor Billience Chandway. Calvary greetings.

[Emily Bass]

Calvary greetings. Dr. Susan, how are you?

[Ari Shapiro]

Pastor Chandwe was at his home in Zambia. Dr. Hillis was at an airport in Thailand where she'd been attending a conference of Christian mission hospitals. She could hear the worry in his voice.

[Emily Bass]

I had tears in my eyes and was choked up.

[Ari Shapiro]

Pastor Chandway was urgently trying to find HIV medication for a nine year old orphan with aids.

[Emily Bass]

She has no chance unless someone can get her medicine in the middle of rural Zambia. Who's going to do that? I was thinking she's going to die.

[Ari Shapiro]

For years, the US has funded global efforts to prevent and treat hiv. When President Trump took office, the new administration stopped most foreign assistance, including much of the program that serves orphans with aids. That left Pastor Chandwe scrambling.

[Emily Bass]

Then, by chance, it would say miracle.

[Ari Shapiro]

He found someone who agreed to share their remaining pills with the child.

[Emily Bass]

God saved Diana that she doesn't develop symptoms because the dosage was too much or was less.

[Ari Shapiro]

Since the start of the year, millions of people have faced situations like this one. Scrambling after the U.S. slashed global HIV prevention and treatment programs. Now the U.S. says it will support a new HIV prevention drug that the medical community calls a game changer. Consider for decades, the U.S. led global efforts to end HIVAIDS. Where will the trend lines go from here? From NPR, I'm Ari Shapiro. On the Throughline podcast from NPR. Immigration enforcement might be more visible now, but this moment didn't begin with President Trump's second inauguration or even his first, a series from Throughline about how immigration became political and a cash cow. Listen to Throughline in the NPR app or wherever you get your podcasts.

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[Ari Shapiro]

It's Consider this from npr. HIV has been in retreat around the world. Fewer people are dying of the disease. New infections are decreasing. More HIV positive people have access to life saving medicine. Those trend lines have been moving in the right direction for decades. And US investment is one big reason it's less clear where the trend lines go from here. While the Trump administration dismantled foreign assistance through usaid, it continued pepfar, the President's emergency plan for AIDS relief. But much of that work is either no longer happening or happening at a very reduced capacity. And last week the US said it will invest in a new drug that can prevent HIV with just two injections a year. So to understand where things stand and where they are going. And Emily Bass is here. She's author of To End a Plague. America's Fight to Defeat AIDS in Africa. Welcome.

[Emily Bass]

Hi.

[Ari Shapiro]

Okay, if you could draw a chart showing the trend line since the 90s on HIV transmission and treatment, where do things stand right now and where do they need to get to eradicate hiv?

[Emily Bass]

Well, let's talk about where they stood in December of 2024, because that's what we can really talk about with confidence, as I'll explain in a little bit. But in December 2024, on the brink of the new year, the year we're currently in, we were looking in many countries in sub Saharan Africa in particular, which is where PEPFAR has focused its investments, at countries being on the path towards or having achieved a set of milestones that were associated with ending HIV as a public health threat by 2030.

[Ari Shapiro]

So, like the finish line in sight?

[Emily Bass]

Yes, very much so.

[Ari Shapiro]

So we've seen people fired and rehired, we've seen grants frozen and unfrozen. Can you say right now what the US role in global AIDS prevention is and will continue to be? Or is it all just totally murky and uncertain?

[Emily Bass]

In the past nine or 10 months, the lights have gone out. We don't know what has happened in the countries where PEPFAR has been supporting programs. We simply don't know. The data that would normally have been made available on a quarterly basis have not been made available. It's very difficult to get a clear picture. All of the reports from the ground tell the same story of massive disruptions, particularly in the service delivery approaches. So the ecosystem within which HIV services are delivered is not just the clinic and is there a drug on the shelf? It's how does a person get to the clinic? Are they greeted there by somebody who is friendly and nonjudgmental? Are the drugs delivered to their community? Is there a peer, someone with their lived experience who can help them understand the importance of accessing prevention or treatment and who will follow up with them if they stop accessing.

[Ari Shapiro]

Okay, so even if the program still exists, its infrastructure has been partially or largely dismantled. The the data is in some cases non existent. And then you have this announcement that the United States is going to support this new HIV prevention drug, Lenacapavir, which the medical community calls a breakthrough and a game changer. Is that enough to keep the trend lines moving in the right direction?

[Emily Bass]

So absolutely not. It's good news. A couple things about that. It's good news. It is affirmation of a commitment that was actually made in the Biden administration and it's only a piece of what we could have expected pepfar, if we were speaking a year ago, to be doing to create an environment where a drug like Lenocapavir could be part of a truly game changing approach to hiv. And I just want to say when you say the infrastructure isn't there, I think it's really important to be clear. The infrastructure is human beings. It's the community, it's the clinic staff, it's the clinic buildings. All of those things are there. PEPFAR did not have. You know, it's not like McDonald's. There aren't PEPFAR sort of branded buildings across sub Saharan Africa. The infrastructure, the human beings and the clinics and the community connections are all still there, but the people who are being paid to support the ecosystem have lost their jobs or have been rehired temporarily. And the clinics are still there, but they're overcrowded and people are now waiting 10 or 12 hours a day to get their drugs or to be told that the nurses are done and they're going home.

[Ari Shapiro]

To continue this conversation about Elena Capavir, the US says it plans to focus the rollout of this new medication on pregnant and breastfeeding women. They say in plans released last week that they plan to do it without NGOs, without nonprofit organizations. Is that possible?

[Emily Bass]

Well, there's two things there, right? So let's take them one by one. Prior to 2025, PEPFAR was an evidence based, evidence driven, data driven program that invested its resources in the most impacted communities and the communities where there was the most need for HIV prevention and treatment. Pregnant and breastfeeding women absolutely need access to pre exposure prophylaxis or prep, which is what we're talking about with this injectable. But there are many other communities in all of these countries who are not pregnant, who are not breastfeeding, who are at tremendous risk of hiv.

[Ari Shapiro]

The Trump administration has been talking about transition plans and reducing global reliance on the US can other countries Step in to fill the gap that the US Is leaving.

[Emily Bass]

You know, transition planning was underway before all of these changes occurred. When we were Talking about ending HIV as a public health threat as 2030, that was the horizon line for moving countries first towards control of their HIV epidemics and then to a maintenance phase where they would be able to increasingly manage that continuation of HIV in the community, in the country, but with their own resources and perhaps with additional overseas development aid, but in different ways or diminished levels. That's an off ramp. What we did is take the car off the off ramp, if you will, and just drive it into a wall. Right. So, sure, transition is possible. It's less possible now than it was at the end of 2024.

[Ari Shapiro]

So where do you think the trend lines are gonna go in the next few years?

[Emily Bass]

I think the trend lines are already going in terrible directions, Ari. I think the trend lines are going in the direction of new HIV infections, including for infants and newborns. I know this from my own work. I was in Uganda and Tanzania in the first hundred days after the freeze, where drug supply was incredibly unstable in some contexts. And I spoke to clinic directors who had seen 25% of their pregnant women give birth to babies with HIV, which is preventable. Which is preventable. And they had had none for years prior. So we're going to see new infections, but we're also going to see people with interruptions in their treatment. People with HIV that I've spoken to are skipping doses. They're hoarding their medic, seeing the news. They're anticipating a point where they won't have medications anymore, or they can't wait 12 hours at a clinic, or the community support that brought the drugs to their community is no longer there. And when people disengage from care, they get ill. And unfortunately, the way that the data blackout has happened, some of this is already happening, and we can't tell the story of it yet.

[Ari Shapiro]

Emily Bass is author of the book To End a America's Fight to Defeat AIDS in Africa, and she's also co author of a Physicians for Human Rights report on the impacts of the foreign aid transitions in Uganda and Tanzania. Thank you so much for speaking with us.

[Emily Bass]

Thank you.

[Ari Shapiro]

Before we go, a few notes. First, a favor to ask. Something you can do to support our work at NPR that costs you absolutely nothing other than a minute or two of your time is. If you value the show, help us out and rate and review. Consider this on the podcast platform where you listen. That will help new listeners find us. Second, some news especially for our NPR supporters. This Saturday, for the first time, you'll see a new bonus episode in your podcast feed. We're going to share those every other weekend. They'll feature extended interviews and conversations that you have not heard in the podcast. And they are another perk for our NPR supporters, who also hear every episode of the show without sponsor messages. The regular show hasn't changed and will always remain free and available every weekday. You heard reporting in this episode from Zambia by NPR's Gabriela Emanuel. The episode was produced by Jeffrey Pierre. It was edited by Courtney Dorning and Rebecca Davis. Our executive producer is Sami Yenigun. It's CONSIDER this from npr. I'm Ari Shapiro. On how to Do Everything, we take your questions and find phenomenal experts to answer them. Because we love you.

[Emily Bass]

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