If the US wanted to be the world’s police officer, then why not try to be its doctor too? 

Just two months before the invasion of Iraq in 2003, George W. Bush announced an ambitious plan to pump $15 billion into the global fight against HIV, stunning his allies in Congress, health advocates, and heads of state of the program’s intended beneficiaries. 

The President’s Emergency Plan for AIDS Relief, or PEPFAR, was the largest commitment by any nation in history dedicated to addressing a single disease, a disease that killed about 3 million people in 2003, most of them living in sub-Saharan Africa, and infected 5 million more. “Ladies and gentlemen,” Bush proclaimed in his State of the Union address that year, “seldom has history offered a greater opportunity to do so much for so many.”

On that, he was right. In the two decades to follow, PEPFAR would save an astounding 25 million people’s lives through lifesaving HIV therapies, and prevent millions of babies from being born with HIV in the first place, all at a cost of about 0.08 percent of the federal budget. 

And yet, in the wake of the Trump administration’s foreign aid cuts, one of the greatest achievements in American history is now at risk. PEPFAR, mercifully, still exists, saved from the sledgehammer by an outpouring of bipartisan support last February. But experts say the program has been transformed beyond recognition by countless small cuts, and the abrupt gutting of global health architecture, reshaped not by decades of accumulated wisdom around HIV prevention, but by at times absurdly petty ideology.

Over the past year, more than 77 percent of PEPFAR grantees have lost funding or had their payments delayed, according to a survey released Tuesday by the HIV research group amfAR. 

Nearly two-thirds of grantees — especially those supporting vulnerable populations such as LGBTQ people, young women, and sex workers — said the cuts had disrupted their ability to offer HIV treatments and other services. The Trump administration released limited data showing a deep reduction in HIV prevention services, but a relative consistency in access to treatment earlier this year. However, this new survey paints one of the first pictures available of how PEPFAR cuts are actually being felt on the ground, and how the administration’s priorities are reshaping who and what gets funded.

According to the survey’s authors, at least 1,700 HIV-related sites or clinics have shut down as a result of cuts. Well over 16,000 health workers — including those going door to door to make sure pregnant parents get tested for HIV or children get on treatment — have lost their jobs. 

Many organizations surveyed reported receiving emails when their PEPFAR grants were terminated, noting that their work violated President Donald Trump’s executive order against “unlawful diversity, equity, and inclusion.” It appears, they say, that many of these groups were flagged not because they embraced the distinctly American concept of DEI in their work, but because their name or mission description included a phrase like “gender” or “LGBTQ.”  

A health clinic serving survivors of domestic violence in Mozambique, for example, might now be flagged just for using the phrase “gender-based violence” in their name. This may be part of the reason why even pregnant women — who even the Trump administration has emphasized as a critical demographic in its HIV goals — have lost access to services. 

Back in 2003, Bush defied conservative critics in his own party who attempted to redirect PEPFAR funding to abstinence-only programs. For decades, American presidents have been able to see past their ideology in service of saving lives. They largely understood that contraceptives like condoms and special interventions for those most at risk, including LGBTQ people, were necessary for stopping the spread of HIV. Under the Trump administration, this norm is unraveling. 

“This administration has zero interest in addressing clinical outcomes for vulnerable people with HIV,” said Asia Russell, executive director of the advocacy group Health GAP, who noted that “to be effective, HIV prevention and treatment services actually have to go where the disease is, and that risk is not evenly distributed,” surging in certain geographies like South Africa or within key populations like trans people or young women. Getting support to these groups is “morally right,” she said, but it is also “the only way to do effective HIV work, regardless of your stance on the morals or the merits.”

The fight against HIV is running on fumes

When HIV aid does get doled out these days, it is distributed with far less transparency than in the past, and in ways that often appear to be ideologically or politically driven, both in terms of the populations they serve and the countries they operate in, rather than guided by best practices. 

In theory, lifesaving HIV care was exempted from sweeping aid cuts last year. But in reality, access to even the most basic HIV services and treatments has also atrophied across the board, while falling disproportionately on at-risk populations. 

That’s come both in the form of direct cuts and as a byproduct of broader disruptions to the kind of outreach services, testing, and socioeconomic programs that get patients in the door to begin with. 

“You can’t cut pieces of the architecture of how PEPFAR functions and expect to maintain a really robust treatment program in the long term,” said Jennifer Sherwood, director of research and public policy at amfAR. “If you cut the testing program, the prevention programs, the kind of services that allow people to stay in care and return to care, you’re going to see that you can’t maintain a treatment program.”

The number of people getting on treatment for the first time has sharply declined over the past year, even according to the administration’s own limited data drop, while access to testing, contraceptives, and other preventative services — all critical to keeping infections down in the long run — face cuts that threaten their ability to function at all. 

To make matters worse, amfAR’s survey shows that services designed for the populations most at risk of HIV — such as sex workers, LGBTQ people, young women, and teenage girls — have been disproportionately affected by PEPFAR cuts. Among those who lost funding, a staggering 90 percent of organizations that serve gay and bisexual men were forced to slash access to PrEP — which strongly protects against HIV infection — and many stopped offering it entirely. The same was true for over half of organizations serving pregnant women, whose children now face a higher risk of contracting HIV in the womb.  

The majority of new HIV infections are concentrated in these “key populations,” as they’re known in public health parlance, many of whom face stigma or other obstacles to obtaining care. “One really powerful aspect” of how PEPFAR used to work, said Thomas McHale, public health director at Physicians for Human Rights, was that it consistently “followed the science and followed the epidemiology” to serve “groups that are at the margins of society.” That approach appears to have been thrown out under the new administration, and in at least some cases, actively discouraged.

McHale has been documenting the impact of PEPFAR cuts in South Africa in recent months, and “what we saw was a system under severe stress and strain,” he said. It is one in which a bisexual man stopped taking his HIV medications for weeks because the LGBTQ clinic he used to go to closed. “He just couldn’t bear the stigma of accessing services in a place that’s not meant for him,” according to McHale. Similarly, a young woman was forced to wait in line for 10 hours just to refill her PrEP prescription. 

“If we’re not focusing on preventing disease,” McHale said, “it’s just a more expensive and more devastating challenge to address in the future.”

Some countries may soon stop receiving PEPFAR funding altogether

As I’ve written previously, the Trump administration has attempted to remake foreign aid into a dealmaking enterprise, one in which money flows directly through national governments rather than through large, western-led non-governmental organizations or NGOs. 

In theory, there are benefits to this approach, because it prioritizes the expertise of local health groups and policymakers who are often best equipped to evaluate and address the needs of those in their care. In practice, however, amfAR’s survey shows that so far, under the Trump administration, local organizations have actually lost more funding and been forced to close more sites than international groups have. “These cuts fell heavily on locally-based organizations” while NGOs have fared somewhat better, said Sherwood, “and that really runs counter to all of our global health goals.”  

“I’m concerned because public health is no longer how we’re measuring success” when it comes to reaching PEPFAR’s goals, said Jirair Ratevosian, a senior fellow at the Duke Global Health Institute who served as chief of staff of PEPFAR under the Biden administration. He is especially alarmed by the decision last month to end PEPFAR support for South Africa, which has the largest HIV epidemic in the world. The administration appears to have done so in part because of Trump’s insistence that the nation is waging a nonexistent “genocide” against white Afrikaners. 

“If we’re not focused on preventing disease, it’s just a more expensive and more devastating challenge to address in the future.”

Thomas McHale, Physicians for Human Rights

“HIV control is not their chief concern,” said Ratevosian, who recently ran the numbers on a separate fissure with Zimbabwe, finding that cutting PEPFAR would lead to 75,000 new HIV infections in just one year. In South Africa, similar cuts could lead to over 2 million more infections over the next two decades, a toll that would invariably cross borders, and could threaten the world’s immense, hard-won progress against HIV. “You can’t have a global HIV strategy,” said Ratevosian, “if you’re not engaging these countries.”

Priorities shift under any new administration, and it’s not abnormal for an organization to tweak its language or services to adapt. But PEPFAR, the bipartisan program which began under Republican leadership, and thrived and expanded under three successive presidencies, including during Trump’s first term, has never faced such turmoil. 

“Even among organizations who didn’t lose US funding, we’re still picking up changes to the way they work, the populations they serve, the words they use,” said Sherwood of amfAR. Her group’s survey showed that nearly 80 percent of organizations that did not lose funding still altered the way their organization worked to comply with new policies. “This network of changes from the US,” she said, “are prompting a lot of changes on the ground.”

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