Mere hours after taking office, the Trump administration announced a crippling freeze on new spending for virtually all U.S. foreign assistance.
The action, which the White House called “incredibly important,” caught development experts and implementers completely off-guard, and plunged the future of foreign assistance, which accounts for roughly $60 billion annually, or roughly 1% of the U.S. budget, into chaos.
AIDS advocates in particular raised concerns about the move and its potential impact on critical programs like the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The program, which was first launched by George W. Bush, has saved over 25 million lives and provides antiretroviral treatment to nearly 20 million people around the world.
At first, PEPFAR was not included among the few waivers that accompanied the announcement. Last week, the administration was forced to backtrack, announcing an exemption for “life-saving humanitarian assistance” while the government continues reviewing all foreign assistance programming. Advocates welcomed the news, which allows life-saving medicines and medical services to continue under the waiver, but remain desperate for answers amid great uncertainty.
Clarity is a critical leadership attribute, and the recent ambiguity has left many concerned about the potential irreversible harm that’s been done.
What’s At Stake
Not since the early 2000s, when doctors would tell patients, “We have no medicine. We can’t help you. Go home and die,” has the AIDS fight been in such a precarious position.
Nearly two-thirds of people living with AIDS reside in sub-Saharan Africa and many local healthcare clinics in the region rely heavily on PEPFAR funding. Every day, 220,000 people pick up their HIV medicines from clinics that are funded by PEPFAR.
It’s essential that those who are living with HIV continue taking their antiretroviral treatment in order to suppress their viral load. Even a short break in treatment adherence can trigger an immediate spike, compromising the immune system and increasing the risk of the virus progressing and spreading.
The fear of not being able to access life-saving treatment is already causing panic. “I’m now thinking of dying,” one person told The New York Times after their health clinic remained shuttered following the new administration’s order. “What am I going to do without this treatment?”
Not all clinics have closed, but those that remain open now face a new reality where they must navigate the care patients need and the administration’s loosely defined orders. In addition to providing medicine, many clinics offer other critical services that help prevent and stop the spread of HIV. Every day, 224,000 people rely on HIV testing from PEPFAR and these tests diagnose 4,374 people — giving these individuals critical information to better protect themselves and their loved ones. Beyond AIDS, clinics typically offer vital lifelines for women seeking cervical cancer screenings and support from gender-based violence.
On Saturday, the State Department issued a memo which attempted to provide more certainty around what PEPFAR-funded activities are permissible under the agency’s new guidelines. According to the memo that was viewed by Reuters, providers will be allowed to continue “life-saving HIV care and treatment services, including testing and counseling, prevention and treatment of infections including tuberculosis (TB), laboratory services, and procurement and supply chain for commodities/medicines. It also allows prevention of mother-to-child transmission services.”
Just as the situation appeared to be stabilizing, on Tuesday, the administration announced plans to put nearly all of USAID’s employees on administrative leave. Roughly two-thirds of the agency’s 10,000 employees work overseas, raising further questions over who will be left to implement the programs that are permitted under the waiver.
Why It Matters
Collectively, the flurry of actions from the new administration have created confusion, disorder, and delays in care that could threaten nearly a quarter century of progress against HIV/AIDS.
Going back to the Clinton administration, there has been a bipartisan consensus around addressing AIDS, which still claims one life every minute. The steadfast support for organizations like PEPFAR has continued through different administrations across both parties.
In President Donald Trump’s first term, Republicans and Democrats in Congress united to dismiss his administration’s efforts to slash foreign assistance. This time around, President Trump has mostly bypassed the legislative branch, unilaterally freezing aid programs while threatening to impound federal funds that were congressionally authorized.
In addition to the obvious health ramifications, the attacks on foreign aid could also upend the geopolitical landscape. For years, China’s Belt and Road Initiative has tried to strengthen ties with low-income countries. In the absence of U.S. leadership, China and other countries may seek to fill the vacuum, creating long-term national security implications.
As the situation in Washington evolves by the day, global health implementers are anxiously waiting for the next domino to fall. For now, USAID’s doors remain shut, and employees have turned to Signal to speculate about their job security and the agency’s future.
“The news, of course, has been received with shock,” Gibstar Makangila, who leads the organization Circle of Hope in Lusaka, Zambia, told Christianity Today reacting to the aid freeze. Like Circle of Hope, many of PEPFAR’s most important implementers are Christian organizations whose faith and concern for the world’s most vulnerable call them to heal the sick.
In these challenging times, Makangila is pleading for better angels to prevail. “American Christians must embrace and encourage their congressmen and -women and their presidency, so that we ensure we don’t stop doing good.”