Trump’s foreign aid freeze halted a crucial program fighting HIV in Africa. Here’s what’s at stake

HARARE, Zimbabwe — Florence Makumene held a plastic container of HIV medication and wondered whether it would be her last as fears swelled of a return to a time decades ago when millions across sub-Saharan Africa died of AIDS.

As a young adult in Zimbabwe, Makumene watched loved ones succumb to a diagnosis that was viewed back then as a death sentence. But the 53-year-old didn’t have to suffer the same fate when she tested positive for the virus in 2016. A community group funded by the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, ensured she received lifesaving treatment.

“People around me, including my own children, had written me off and were preparing to bury me, but I bounced back stronger,” Makumene said.

Since its launch in 2003, PEPFAR has been credited with saving more than 26 million lives and helping change the course of AIDS globally. But the 90-day freeze on foreign aid ordered by President Trump in effect halted one of the world’s most successful responses to a disease. His administration subsequently promised waivers to keep lifesaving treatment going, and a judge has ordered the administration to lift the freeze.

But in Africa, thousands of U.S.-funded health workers have been laid off and clinics have closed, restricting access to HIV testing and treatment. African health officials and experts have pleaded for PEPFAR to resume, fearing services that have become a key part of the healthcare system will be stripped in a way that sets countries back decades.

“People are finding doors closed. They are desperate,” said Simon Bwanya of the Zimbabwe National Network of People Living with HIV.

Fears of a return to the bad days

Globally, AIDS-related deaths have been reduced by 69% since the peak in 2004 and new HIV infections have been reduced by 60% since 1995, according to the United Nations AIDS program. Many experts see PEPFAR, which was introduced by Republican President George W. Bush, as a key part of that turnaround, especially in sub-Saharan Africa, the most severely affected region.

“PEPFAR is the most efficient deployment of health resources I have seen,” said professor Francois Venter of the University of the Witwatersrand, Johannesburg, who has worked in the HIV sector in South Africa, the country with the most people living with HIV, for more than 20 years. “I challenge anyone to tell me how we could have used the money better.”

PEPFAR’s focus is Africa and the vast majority of lives have been saved there, largely through a program that helps get medication that keeps HIV in check to millions of people. Now their ability to keep taking that medication is in peril.

The nongovernmental organization that helps Makumene has been closed for weeks, as has almost every PEPFAR-funded NGO across Africa while their fates are decided in Washington.

“We are like orphans. We have no one to turn to,” said Makumene, who has a small stockpile of medication. “I fear we might be going back to the old days when being HIV [positive] was equated with death.”

She is one of some 20 million people worldwide who receive antiretroviral medications, or ARVs, with PEPFAR help. The drugs keep HIV from spreading in the body. Stopping them lets the virus start multiplying again and could lead to the emergence of drug-resistant strains.

“HIV is a simple disease,” Venter said. “You stop your ARVs, you get AIDS.”

Without the drugs, HIV can rise again to detectable levels in a person’s blood, increasing the chance of its spread.

United Nations AIDS program Executive Director Winnie Byanyima said in an interview that the funding freeze could bring a surge in AIDS and has caused “panic, fear and confusion” in many African countries.

Dismantling a system

PEPFAR funds thousands of NGOs but also directly supports countries’ public health systems — in many cases, by paying the salaries for tens of thousands of health workers who are part of the national HIV programs.

In South Africa, PEPFAR pays for 15,000 HIV-specialist health workers in government hospitals and clinics. They represent just 5% of the total number of health workers in South Africa’s HIV response program but are crucial components: doctors and nurses providing ARVs, social workers and counselors, along with community-based workers reaching people far from hospitals and clinics. Removing them breaks the system.

“Critical healthcare infrastructure is being dismantled, clinics forced to close, front-line workers without support, all while lives hang in the balance,” said Sibongile Tshabalala, chairperson of the Treatment Action Campaign, one of a coalition of HIV advocacy groups that have come together since the funding freeze.

The coalition said basic HIV services, including testing and treatment, were “crumbling” in one of the country’s main hospitals in Johannesburg.

The South African government said it is looking at plans to avert a crisis by finding money to keep the health workers in place. Other African countries face even bigger problems.

In Kenya, more than 40,000 workers face being laid off after the aid freeze, officials said. In Lesotho, a small, poor nation in southern Africa, 1,500 health workers — about 7% of the country’s entire health staff — have already been dismissed. Lesotho’s Health Ministry has asked final-year medical students and recent graduates to volunteer at local health centers to stand in for them.

Waiting on waivers

On Jan. 28, U.S. Secretary of State Marco Rubio announced waivers to keep lifesaving treatment and other parts of PEPFAR going. Rubio has said he is a “supporter of PEPFAR” — though he has some questions about it — and the Trump administration wants to see it continue.

Last week, a federal judge ordered the administration to temporarily lift the foreign funding freeze and rejected the argument that the administration was offering waivers to allow some funding to keep flowing. The judge cited testimony that no such waiver system yet existed.

Officials with the U.S. Agency for International Development, which provides much of PEPFAR’s funding, and aid groups say they know of no payments getting through for that or any program.

Experts and health activists have also criticized the content of the waivers published by the Trump administration, which restrict access to treatment for some.

As well as ARVs, PEPFAR funds pre-exposure prophylaxis, a newer preventive medication. But the waivers allow PEPFAR-funded NGOs to give the preventive medication to pregnant or breastfeeding women only and not to gay men or sex workers, high-risk groups for contracting and spreading HIV. Contraception services through PEPFAR have also been halted.

“The fight against HIV is not over yet,” said Dr. Kebby Musokotwane, director general of the National AIDS Council in Zambia. “There’s a lot of progress that has been made, but there’s still a lot that needs to be done.”

Mutsaka and Imray write for the Associated Press. Imray reported from Cape Town, South Africa. AP writers from across Africa contributed to this report.