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

Summary

Summary of "The U.S. Spent Billions Fighting AIDS. What Now?" – The Journal Podcast

Release Date: February 14, 2025

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Introduction

In the February 14, 2025 episode of The Journal, hosted by Ryan Knutson with contributions from reporters Nicolas Barrio and Michael Phillips, the podcast delves into the significant implications of the United States' decision to freeze foreign aid funds, particularly those allocated to combating HIV/AIDS globally. This episode examines the ripple effects of this policy shift on healthcare infrastructure in Africa, the lives of those affected by HIV/AIDS, and the broader geopolitical ramifications.

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Background on PEPFAR

President's Emergency Plan for AIDS Relief (PEPFAR), launched in 2003 by President George W. Bush, stands as the largest commitment by any nation to address a single disease. PEPFAR has been instrumental in providing life-saving medications, preventing the spread of HIV, and supporting healthcare infrastructure across Africa, saving an estimated 25 to 26 million lives (06:53).

Michael Phillips, a contributor to the episode, underscores PEPFAR's significance:

“PEPFAR is a program that 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.”
(04:46)

Carl Hoffman, CEO of HealthX Partners and a former U.S. diplomat, highlights the program's bipartisan support and its foundational role in improving global health outcomes:

“One of the outstanding things that President Bush did was to initiate the PEPFAR program.”
(06:42)

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The Freeze on Foreign Aid

Under President Trump's administration, a 90-day freeze was imposed on nearly all foreign aid, including PEPFAR. While the administration initially signaled that it did not intend to pause PEPFAR entirely, the executive order effectively halted funding for these critical programs.

Nicolas Barrio recounts his visit to a closed 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.”
(00:05)

This freeze has led to the shutdown of clinics that once provided daily care to hundreds of HIV/AIDS patients. Medications and supplies remain locked away, rendering the facilities inoperative.

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On-the-Ground Impact

The suspension of PEPFAR funds has had immediate and devastating effects on healthcare delivery in Africa. Clinics that were once bustling with activity are now deserted, and essential medications are inaccessible to those in need.

Nicolas Barrio describes the scene at the Kampala clinic:

“All the medicine is just locked away. All the supplies. Because people who have been working there were told not to return.”
(00:37)

In Kenya, Michael Phillips shares a heartbreaking account of the human cost of the funding freeze:

“Some of those family members are literally going out and picking out grave sites for themselves because they don't think they're gonna make it.”
(02:21)

This dire situation underscores the immediate threat to lives dependent on these medications.

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Expert Analysis

Carl Hoffman emphasizes the strategic importance of foreign aid in maintaining global stability and preventing health crises from escalating:

“The US foreign aid enterprise [...] is really about improving conditions in places far away so that threats don't manifest close to home.”
(12:26)

He warns of the long-term consequences of dismantling such programs:

“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.”
(16:56)

Michael Phillips echoes these concerns, highlighting the operational chaos resulting from the freeze:

“There’s nobody to call up and say, okay, you and I have been working together for five years. Here’s my new budget. Who’s going to approve it? [...] the chaos around these programs is extraordinary.”
(10:03)

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Political Debates and Rationale

The Trump administration justified the aid freeze by criticizing certain foreign aid programs as misaligned with American interests. Caroline Levitt, the Press Secretary, listed programs deemed wasteful, targeting initiatives unrelated to PEPFAR:

“$70,000 for a production of a DEI musical in Ireland. $47,000 for a transgender opera in Colombia. [...] I don’t want my dollars going towards this crap.”
(08:11)

However, experts like Michael Phillips argue that PEPFAR is a distinct, non-partisan, life-saving program that should not be conflated with other criticized initiatives:

“Diversity and inclusion efforts represent a very small portion of foreign aid. Most of it is simply helping other people.”
(08:29)

Despite claims of misalignment, the freeze on PEPFAR seems intentional, exacerbating the crisis in healthcare provision.

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The Path Forward and Judicial Interventions

In response to the freeze, some waivers were supposed to allow life-saving activities to resume. However, Michael Phillips points out the bureaucratic hurdles:

“The waiver itself has to be approved. [...] 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.”
(09:53)

Recently, a judge ruled that USAID funding should flow again temporarily, but implementation remains uncertain. Clinics in Uganda, Zambia, and the Democratic Republic of the Congo continue to suffer due to unresolved funding issues.

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Future Implications and Conclusions

The uncertainty surrounding PEPFAR's future poses significant risks to global health and undermines the United States' influence abroad. Carl Hoffman warns that the absence of U.S. leadership in foreign aid could create a vacuum filled by increased suffering:

“You'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.”
(17:57)

The potential for increased mortality rates from HIV/AIDS and the destabilization of healthcare systems in Africa highlight the broader consequences of the aid freeze. Experts advocate for the resumption and reinforcement of PEPFAR to prevent a regression in global health achievements.

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Notable Quotes

• Ryan Knutson:
  “Before it closed, it was providing care to hundreds of patients with HIV AIDS every day.”
  (00:37)

• Michael Phillips:
  “PEPFAR was an extraordinary bipartisan achievement of compassion.”
  (06:56)

• Carl Hoffman:
  “The US tent pole has been pulled out of the tent and I think the whole tent is going to get considerably smaller.”
  (16:56)

• Michael Phillips:
  “People are going to die, lots of people are going to die.”
  (10:56)

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Conclusion

The Journal's episode on the U.S. spending billions combating AIDS critically examines the repercussions of freezing foreign aid funds on PEPFAR. Through firsthand accounts and expert analyses, the podcast illuminates the dire consequences for millions dependent on these programs and underscores the strategic importance of sustained foreign aid in maintaining global health and stability. The episode serves as a compelling call to action for policymakers to reassess and reinvest in life-saving initiatives that have proven their worth over decades.

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Transcript

[Ryan Knudson]

Earlier this week, our colleague Nicolas Barrio went to visit an HIV AIDS clinic in Kampala, Uganda.

[Nicolas Barrio]

Everything is quiet.

[Ryan Knudson]

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.

[Nicolas Barrio]

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.

[Ryan Knudson]

Before it closed, it was providing care to hundreds of patients with HIV AIDS every day. And meantime, all the medicine that's sitting inside this clinic is just locked away?

[Nicolas Barrio]

Yes. All the medicine? Yes. All the supplies. Because people who have been working there were told not to return.

[Ryan Knudson]

Since its founding, this clinic has been funded almost entirely by US foreign aid. For more than 20 years, it's been part of a program known as PEPFAR, a multi billion dollar US effort specifically designed to stop the spread of HIV AIDS globally. And how important are the services provided by this clinic?

[Nicolas Barrio]

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.

[Ryan Knudson]

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.

[Michael Phillips]

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 gonna make it.

[Ryan Knudson]

Oh, my goodness.

[Michael Phillips]

So imagine that like you thought you were okay, 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 gonna give them to me anymore. So, well, I'll save my family the trouble and I'll pick a place to bury myself.

[Ryan Knudson]

Wow.

[Michael Phillips]

And, you know, it's a stunning thought.

[Ryan Knudson]

Welcome show about money, business and power. I'm Ryan knudson. It's Friday, February 14th. Coming up on the show, America has spent billions combating AIDS around the world. Is that era now over?

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[Ryan Knudson]

I participate in restaurants for a limited time. Fighting hiv AIDS has been a big part of America's foreign aid spending for decades.

[Michael Phillips]

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.

[Ryan Knudson]

In 2003, then President George W. Bush announced a new governmental initiative called the President's Emergency Plan for AIDS Relief, or pepfar.

[Michael Phillips]

PEPFAR is a program that 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. Yet 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, you know, 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.

[Ryan Knudson]

PEPFAR 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 US government's $7 trillion total budget. So how successful would you say this program has been?

[Michael Phillips]

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.

[Carl Hoffman]

I had some disagreements with my predecessor, but one of the outstanding things that President Bush did was to initiate the PEPFAR program.

[Ryan Knudson]

Its supporters have also included former Vice President Mike Pence.

[Michael Phillips]

PEPFAR was an extraordinary bipartisan achievement of compassion.

[Ryan Knudson]

Former President Joe Biden, George W. Bush deserves great credit. And even Trump during his first administration.

[Carl Hoffman]

What we've done for AIDS in Africa is unbelievable.

[Michael Phillips]

We spent $6 million.

[Ryan Knudson]

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.

[Michael Phillips]

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, you know, clearly what 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.

[Ryan Knudson]

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.

[Angel Reese]

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.

[Ryan Knudson]

US 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.

[Michael Phillips]

Dei, I think the freeze on PEPFAR and everything else was very intentional. You'd have to know absolutely nothing about U.S. 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 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.

[Ryan Knudson]

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.

[Michael Phillips]

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.

[Ryan Knudson]

Has to get specific approval. And since so much work has stopped back in Washington, D.C. because of the freeze, in some cases, people on the ground don't know who to call for help.

[Michael Phillips]

You've got nobody to call up and say, okay, you and I have been working together for five years. Here's my new budget. Who's going to 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.

[Ryan Knudson]

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.

[Michael Phillips]

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 U.S. government provided. And once you're off the drugs, you know HIV will get you.

[Ryan Knudson]

Coming up, we talked to the CEO of a nonprofit that got a lot of its funding from pepc. Far about what this shift in policy will mean for America's standing overseas. Carl Hoffman is CEO of the Public Health Organization HealthX Partners. He's also a former U.S. diplomat. How many countries have you lived in?

[Carl Hoffman]

Probably 10 or 15. Not. Not a crazy number.

[Ryan Knudson]

I mean, that's a pretty crazy number for countries, too. When the aid freeze went into effect, Health X Partners was hit particularly hard. Carl'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 U.S. government, including through PEPFAR. So how would you describe and how would you characterize what traditionally has been the role of USAID abroad?

[Carl Hoffman]

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.

[Ryan Knudson]

So what do you make of the fact that, like the Trump administration and a number of his supporters seem to think that this is not money that the US taxpayer should be spending money on?

[Carl Hoffman]

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 US does under the broad definition of foreign aid. Foreign engagement on the civilian side is 1% of the federal budget.

[Ryan Knudson]

It's still tens of billions of dollars, though.

[Carl Hoffman]

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.

[Ryan Knudson]

In Carl's view, the billions of dollars the US spends on foreign aid has compounding benefits.

[Carl Hoffman]

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.

[Ryan Knudson]

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?

[Carl Hoffman]

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.

[Ryan Knudson]

Do you think there's a lot of waste in the foreign aid system?

[Carl Hoffman]

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.

[Ryan Knudson]

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?

[Carl Hoffman]

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 US Government. Everybody else has seen these actions of beginning to dismantle the U.S. 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.

[Ryan Knudson]

And other governments around the world.

[Carl Hoffman]

Yes, yes, I think so. The US Was getting bigger and bigger as a relative share of this. And now the US tent pole 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.

[Ryan Knudson]

Right now. The future of Pepfar is unclear. McCarl says most people with diseases like HIV, AIDS don't have time to wait.

[Carl Hoffman]

You know, 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.

[Ryan Knudson]

If you're not pushing against the disease, the disease is pushing back against you.

[Carl Hoffman]

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.

[Ryan Knudson]

That's all for today. Friday, February 14 the Journal is a co production of of Spotify and the Wall Street Journal. The show's made by Kathryn Brewer, Pia Gadkari, Rachel Humphries, Sophie Kodner, Jessica Mendoza, Matt Kwong, Kait Linebaugh, Colin McNulty, Annie Minoff, Laura Morris, Enrique Perez de la Rosa, Sarah Platt, Alessandra Rizzo, Alan Rodriguez Espinosa, Heather Rogers, Pierce Singhi, Jeevika Verma, Lisa Wang, Catherine Whalen, Tatiana Zamis and me, Ryan Knudsen, with help from Trina Menino. Our engineers are Griffin Tanner, Nathan Singapak and Peter Leonard. Our theme music is by so Wiley. Additional music this week by Katherine Anderson, Peter Leonard, Bobby Lord and Nathan Singapak. Fact Checking by Mary Mathis. Thanks for listening. We're off for President's Day. We'll be back with a new episode on Tuesday. See you then.