PEPFAR Represents Pragmatic Compassion

Why we need to promote realism in foreign aid and global health

By Matthew Loftus, MD

Conservatives know that when it comes to U.S. foreign aid, as with any other federal policy, there are always trade-offs. The United States cannot—and should not—single-handedly end hunger around the world, and giving food aid to starving people runs the risk of suppressing local agriculture and discouraging people from growing their own food. It cannot mediate an end to every civil war, and every foreign conflict it attempts to intervene in runs the risk of empowering a dictator. It cannot save every baby from dying of malaria, and every bed net it gives out could make mosquitoes more resistant to insecticides.

But none of these are reasons to never act. Rather, we have to carefully judge the risks of harm and the chances of benefit that any intervention might provide and weigh our decisions appropriately.

Carmel Richardson’s recent article in Commonplace on the downsides of providing pre-exposure prophylaxis (PrEP) through the President’s Emergency Plan for AIDS Relief (PEPFAR) illustrates a trade-off global health faces in treating HIV/AIDS. I appreciate Richardson’s engagement with the argument that conservatives like myself and Leah Libresco Sargeant have been making when it comes to PEPFAR, given the lack of substantive debate about the destruction of USAID and other foreign aid programs in recent months.

So far no one disputes that America’s foreign aid apparatus needed significant changes, and I have not been able to find anyone arguing that the stop-work order tied to DOGE and subsequent chaos were prudent or wise. Even now, the on-again-off-again whiplash of termination and reinstatement of U.S. foreign aid is harmful to recipients of the aid. It is not clear what criteria have been used to decide between which programs were axed and which were continued. While some programs are still being supported, including the one which provides PrEP at the hospital I work at in Kenya, other hospitals where programs have similar or even greater impact and stricter accountability controls have had their grants terminated. There hasn’t been adequate time or attention given to the correct ways to reform and restrain, rather than simply gut, foreign aid.

Richardson’s piece illustrates how an important question can get oversimplified. She is right to note that PrEP has been scaled up very rapidly, and perhaps it is fair to say that in some places PrEP is being handed out “like candy.” But even this scale up has barely covered 20% of the estimated need for the treatment. A majority of new PrEP users are adolescent girls and young women—among the most vulnerable to HIV infection—because they often lack the power to choose their sexual partners or insist on condom use. Living in a world full of sin means that sometimes we cannot change the hearts of sinners, but we can protect the victims of sin.

While the typical PrEP user in a Western country may be a man looking to have more risky sexual encounters, from my experience as a missionary and a doctor, the typical PrEP user in Africa is a woman whose husband refuses to get tested for HIV and threatens her with violence if she asks whether he’s sleeping with other women. Other common situations include serodiscordant couples (where one partner has HIV and the other does not), prisoners of all sexes who are at risk of sexual violence, and young women who can’t say “no” to their uncles, teachers, or other men in their life for fear of being beaten, all of whom are also very vulnerable to HIV infection. I want PrEP to be easily accessible to them, perhaps as easily accessible as candy.

Our public health interventions must be realistic. History makes clear that letting people die of diseases contracted through risky behavior doesn’t discourage those behaviors enough to make a difference at a population-wide level. If the goal is to reduce HIV infections, we have to bring PrEP to those at the highest risk. 

With a project as massive as PEPFAR, it’s difficult to know how best to trim the fat in an already highly efficient program—one that spends just a few hundred dollars per year to keep each person with HIV alive. While some foreign aid programs have had serious problems, their scope has varied: for instance, funds promoting sexual deviancy barely reached a million dollars, whereas those appropriated for terrorists were much higher. In contrast, PEPFAR has spent billions and carefully accounted for how the money was used. The USAID project that supplied drugs to the hospital where I work spent over $7 million and found that only $167,463 could not be properly accounted for. A scalpel, not a chainsaw, was what the situation demanded

HIV is best suppressed when as many people as possible are on antiretroviral drugs (ARVs), and we are just now beginning to see long-term effects as children who would have been infected at birth come of age. One of the best ways to maximize PEPFAR’s impact is to invest in research on long-acting injectable ARVs, which removes the need for people to take a daily pill in order to keep the virus suppressed in their bodies. This could be cheaper and more effective in the long term at preventing new infections, and perhaps make AIDS as rare as tetanus.

Richardson rightly notes that there are trade-offs between what foreign aid can do and what it should do. Accordingly, PEPFAR commitments should try to scale back some of its more expensive and potentially imprudent social interventions with nebulous mandates such as DREAMS, which focused on giving women and girls more economic opportunities so that they would be less vulnerable to HIV. These interventions might sound appealing to conservatives who emphasize the social and moral aspects of disease prevention, but if our mandate now is to focus on leaner foreign aid, then providing medications is going to be far more efficient. Churches and other social institutions, funded by private charitable donations, are going to be more effective at helping enact the cultural change necessary to decrease violence against women and girls.

I understand this trade-off firsthand. I’ve dedicated my career to the longitudinal training of health care providers to strengthen healthcare systems in low-income countries because I believe this work is the best use of my abilities. However, unlike PEPFAR, it hasn’t been proven to be efficacious or efficient, so I don’t believe that U.S. taxpayers should fund it (although it’d be worthwhile for USAID to fund a 10-year study so that we could demonstrate its value). I am deeply grateful for the churches, individuals, and charitable organizations like MedSend and African Mission Healthcare that support me, my colleagues, and the health professionals I train. I am also extremely grateful that USAID and PEPFAR have used American taxpayer dollars for investments with immediate payoffs, such as building classrooms for nursing school on our campus and providing for HIV drugs, so I can teach my interns and residents what good HIV care looks like without worrying whether patients can scrounge up half their month’s salary for drugs.

Lent is over and my time spent focusing my prayers for people living with HIV has mostly yielded lessons for me about gratitude. I’m grateful that Carmel Richardson wrote a piece opposing my view, as it represents serious interrogation of what American foreign aid ought to do rather than slogans and emotional manipulation. I’m grateful that PEPFAR has reflected American greatness, and I’ll keep praying for it to do so. I’m grateful that America is wealthy enough that a tiny percentage of its budget can save millions of lives. I’m grateful that one of my kids’ closest Kenyan friends doesn’t have HIV even though his mother does, and I’m grateful that he’s not an orphan, even if his life remains difficult.

Like other Americans, I want to balance our budget and make sure our social insurance programs like Medicare and Social Security are solvent when I retire. If I thought that taking ARVs away from people like my friend would accomplish those goals, I would support it. If I saw that PrEP was encouraging people to harm themselves and others through risky behavior more than they would otherwise, I would oppose it. Americans have an opportunity now to reshape foreign aid for the better. However, doing so will require careful attention and vigorous debate about the world as it is and what is realistically achievable with the resources at hand.