What does PEPFAR’s future look like in the Trump administration?

0:00Dr. Deborah Birx:2.4 million. That is the number of Africans estimated to have died from AIDS in the year 2002 alone.

0:07Juana Summers:It was even worse than what they described. I mean, you cannot imagine 20 percent of a village dying again in their 30s and 40s.

0:16Dr. Deborah Birx:That's Dr. Deborah Birx. Most recently, she worked on the coronavirus pandemic and the Trump administration. But for decades, she fought a different virus. As a young HIV vaccine researcher in the 80s and 90s, she saw the toll of the AIDS crisis firsthand in East Africa. And then in 2003, as hundreds of thousands of Africans were dying and hundreds of thousands of African children were being orphaned, then President George W. Bush announced a program to help combat the epidemic.

0:46Juana Summers:Out of the blue, I hear the State of the Union with President Bush saying we're going to do something.

0:52Dr. Deborah Birx:And to meet a severe and urgent crisis abroad tonight, I propose the emergency plan for AIDS relief. A work of mercy beyond all current international efforts to help the people of Africa.

1:03Juana Summers:I was so proud in that moment that someone saw the crisis. The president believed that we could do things that I really thought were impossible.

1:12Dr. Deborah Birx:Soon, Deborah Birx turned to implementing the president's emergency plan for AIDS relief, or PEPFAR. Today, PEPFAR has saved nearly 26 million lives, according to the State Department. But the Trump administration has made major changes to the way the U.S. distributes foreign aid, disrupting HIV care, and leaving many health workers uncertain about the future of PEPFAR. Consider this. What do the Trump administration's changes to foreign assistance mean for the fight against HIV and AIDS around the world?

1:49Dr. Deborah Birx:From NPR, I'm Juana Summers.

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2:52Dr. Deborah Birx:It's Consider This from NPR. Dr. Deborah Birx came to oversee the U.S. efforts to fight the global AIDS pandemic from 2014 to 2021. Dr. Birx, who is now a senior fellow at the George W. Bush Policy Institute, joined me to talk about the worldwide fight against HIV and AIDS and where that fight stands today. Okay. The guiding ambition of PEPFAR was to end HIV as a public health crisis by the year 2030. I know you're not in government anymore, but I do want to ask you, do you believe that is possible?

3:23Juana Summers:Well, you know, this is the brilliance about when you allow yourself to see the potential of a program. It started out as life-saving, and it was. And then we realized if we use data in real time, we can find the people who are early infected and preventing, and we can suppress their viral load, and we can prevent them from ever passing on the virus. And so if you look today in some of the highest burdened countries, the actual what we call prevalence, the number of people who have HIV is declining because we turned off the tap. People are living to normal age and are dying from other causes, natural causes.

4:07Juana Summers:What I have to also believe is we spent 20 years, I did 30 more, working in partnership with countries. I can tell you the countries we have worked in across the globe know more about HIV care, treatment and prevention than anywhere in the United States. So when people say, can Africa, can Asia sustain the program? Yes, because they're better than us.

4:33Dr. Deborah Birx:This is something we've been watching play out in real time as the State Department has been working with individual countries to sign memorandums of understand-um, saying that if they meet certain conditions, they'll receive funds from the United States. There have been some countries, of course, that have signed. There have been others that have pushed back. How would you evaluate that as a public health strategy? All of us who have worked around the globe have looked for how do you ensure that the governments value the program as much as you do?

5:02Juana Summers:Do governments value the HIV program, the malaria program, the TB program that is primarily funded by the U.S. and the Global Fund? Do they evaluate it as much as we do? The other thing that I found reassuring is seeing the Uganda agreement. There is funding out to 2030, 2031. So it says to the government, because I think there was a lot of rumor and perception that the U.S. government was just going to, you know, pack up and leave.

5:35Dr. Deborah Birx:From what you're understanding, that's not what this is, because there has been reporting that has suggested that the U.S. government is simply just working to dismantle PEPFAR.

5:43Juana Summers:Yeah. But I can see from the agreements that are going out multiple years. So I don't worry so much about the U.S. agencies. I worry about the embassies that will really be responsible for the oversight. And I worry about the data because some people that don't understand PEPFAR think you do data to collect data. Now, data is what you use to improve your program. It's not to show how great you are. I worry that there's not as much emphasis on really making those constant, constant changes to ensure that you're having a maximum impact for the taxpayer dollars. Our colleagues and I have been speaking with folks who are working in various parts of the world, and particularly in Africa, about their work on the ground.

6:31Dr. Deborah Birx:And one thing that I keep hearing in the conversations that I'm having is uncertainty, that there's a lot of uncertainty out there about the future of USAID and that that uncertainty and instability is hampering care and making it harder to make sure people have consistent treatment. What would you say to that?

6:47Juana Summers:You know, change management in the federal government is tough, not for the pain of heart. I've done it a few times. It's tough. And this was a huge change. I'm hoping that what the MOUs are doing, these agreements between the US and the countries, is eliminating that uncertainty and saying, no, there's a plan and this is what we're doing. But they have to be successful. I mean, treatment's been flat for five years. New infections haven't been flat for five years. So you're losing a lot of young people from treatment and you have to really constantly work on that. I think if we get back to where what is the money doing and how can we do it better, because no program is perfect, I have every confidence that things will go well.

7:36Juana Summers:But the longer we have people asking still about what's happening, the more I worry.

7:44Dr. Deborah Birx:I do want to ask about the money, though, because our colleagues reported last week that PEPFAR funding is being slowly throttled. They quoted a number of folks on the record who raised concerns about that. Does that square with what you hear in your work?

7:57Juana Summers:I'm just going to be frank. When the waiver came through, but the funds did not move, there was a huge gap in funding moving. And I have to applaud the people on the ground that worked. I would say there are people on the ground that worked for free for over the last year. And now the money finally is moving again with those MOUs. But I understand people's concerns. And I think the bottom line for me is now that they have the MOUs, do they work? And is the program being and all these programs being implemented?

8:33Dr. Deborah Birx:What do you think would be lost in a world where PEPFAR isn't funded or there is no PEPFAR?

8:39Juana Summers:You know, I think what PEPFAR did for all of us, hopefully in the global health world, is it taught us that if you collect and utilize outcome and impact data, you can change the future of infectious diseases. I'm hoping we have learned that, but I worry we haven't learned that. Because I know when we looked at COVID, when we looked at avian flu, when we've looked at measles lately, we're not using that data-driven analysis. And so, to me, data is a unifying concept. It doesn't matter what your perception is. If you're getting more cases and more young people getting infected, you're failing. That's what PEPFAR taught us, is how not to fail.

9:25Dr. Deborah Birx:Dr. Debra Burks is a senior fellow at the George W. Bush Center. Thank you so much.

9:30Juana Summers:Great to be with you.

9:31Dr. Deborah Birx:This episode was produced by Vincent Acovino and Karen Zamora. It was edited by Patrick Jaron Watanon and Courtney Dorning. Our executive producer is Sammy Yenigan.

9:48Dr. Deborah Birx:It's Consider This from NPR. I'm Juana Summers.