America's Greatest Success Story Faces the Axe
The program that united Republicans and Democrats for 20 years becomes Trump's ultimate loyalty test on July 18.
In 2003 President George W. Bush launched the United States President’s Emergency Plan For AIDS Relief, or PEPFAR. Initially a 5-year commitment to increase support for HIV/AIDS prevention, care, and treatment.
PEPFAR was passed unanimously in the Senate and faced no significant opposition in Congress, a rare show of extremely high bipartisan support in modern US congressional proceedings. Since 2003 bipartisan support for PEPFAR has continued as it has proven itself to be not only effective but extremely efficient; in 2024 PEPFAR cost the average taxpayer $20.88, less than 1/100th of what the US Military costs the average taxpayer, $2605.88.
Globally AIDS deaths peaked the year after PEPFAR’s inception in 2004, and have been decreasing significantly since. In total PEPFAR funding has helped to save 91 million people, including 26 million people saved directly, the remainder through matching donations to The Global Fund. PEPFAR doesn’t simply treat patients though, it helps the nations in which it operates build self-sufficiency and develops infrastructure which these nations can take over as they stabilize and are able to increase healthcare funding. An example of this is Botswana, where AIDS deaths are at roughly 20% of what they were during the peak of the AIDS crisis in Sub-Saharan Africa in the mid-2000s, and new infections are even lower. However the reason Botswana stands out isn’t these impressive numbers; it's the fact that these trends continued while the US decreased PEPFAR funding as the programs were handed off to the Ministry of Health and Wellness. Funding for PEPFAR has actually been decreasing in real terms since 2010. Despite this, primarily due to technological and medical improvements, deaths and complications from HIV/AIDS are down dramatically in nations where PEPFAR operates.
An example of this technological development comes from Gilead Sciences, an American biopharmaceutical company. With significant funding support from various governments and health organizations, since 2009 Gilead has been developing a drug known as Lenacapavir; a twice-annual drug that has nearly 100% efficacy in preventing HIV infection. A journal article released at the International AIDS Conference in 2024 revealed that, if mass produced under a generic model, Lenacapavir could cost as little as $25 annually while maintaining healthy profit margins for producers. A prevention method this effective and with potential to be this affordable could have substantially reduced the prevalence of HIV/AIDS and could have been a huge step towards ending the HIV/AIDS crisis in Sub-Saharan Africa through previously unattainable levels of prevention.
Instead, HIV/AIDS related deaths are expected to increase in 2025 for the first time in a generation. Since 2005 every single year fewer people have died of HIV/AIDS. It is now likely we will experience at least 5 consecutive years of increases in deaths due to HIV/AIDS, totaling over 4 million excess deaths. The progress made over the last 20 years was not inevitable, and we are about to see proof of that as it unravels.
It’s impossible to tell the stories of each of the 4 million people who will die. But as they do, one by one, (over 70,000 so far since January 24, when the Trump administration first froze PEPFAR funding) it’s important to remember what caused these deaths. It wasn’t, as will be reported, HIV/AIDS; it was injustice. Had these people been born elsewhere, they would have received care. Had these people needed care in 2024, no one would have wondered whether or not it was worth $20 to save their lives; their lives would have just been saved.
These lives could have been saved; in fact they were already saved, Trump chose to gut PEPFAR despite the fact that it has bipartisan support among both lawmakers and constituents. Trump didn’t gut PEPFAR because it cost too much. Trump has shown no interest in operating a balanced budget. His ‘One Big Beautiful Bill’ will add between $4.1 trillion to $5.5 trillion to the national deficit, more than any other bill in modern history. And yet Trump has decided to gut a program that is literally an order of magnitude away from even being a rounding error on the increase to the deficit caused by the bill he pushed through Congress.
Republicans have already missed their opportunity to take a strong moral stance; that chance passed when they were silent on the temporary cuts Trump installed on January 24. But they have one more opportunity for reconciliation.
By July 18 the Senate has to vote on massive, permanent rescissions to PEPFAR suggested by Trump. If these cuts pass they won’t just be a policy reversal, and they won't just cause the deaths of millions of people, though they will do both of those things. If these cuts pass they will show that the Republican Party is willing to abandon principles and chase Trump wherever his whims lead it. For two decades Democrats and Republicans have stood together in their commitment to PEPFAR. Trump is handing Republicans a loyalty test, either abandon PEPFAR, or abandon him.
The cruel irony of the situation is Trump’s timing. Just as breakthrough treatments like Lenacapavir offered the possibility of a breakthrough, and a real shot at the end of a decades-long epidemic that has killed millions, Trump has decided to use those millions of lives as a bargaining chip in this test for his Republicans.
The Trump Administration will serve as a stark reminder that progress in global health is neither inevitable nor irreversible. History will remember PEPFAR as America at her best; compassionate, caring, compromising, generous, and effective. It will also remember the Senate's vote, whether or not America stood up for the poor, for the sick, and for the needy. The question is not whether or not we can afford to save these lives, but whether we can afford to live with ourselves if we don’t.
This is not a moment for political calculations or party loyalty. It is a moment in which we depend on our Senators for moral courage. Within 5 days, the Senate will vote on whether 4 million lives are worth saving. That vote may well come down to Senator Thom Tillis of North Carolina; he has shown that he is willing to stand up to Trump when principles demand it, and principles demand it again. If you live in North Carolina, call him. Tell him that America’s greatest humanitarian achievement cannot be sacrificed for a loyalty test; tell him that $20 per taxpayer is not too much to ask for millions of lives; tell him that some principles are worth defying a president over; tell him that the world is watching this vote, and that history will remember him for what he chooses.