‘Save PEPFAR’ Goes Too Far
The program does not deserve the full-throated endorsement of Christian conservatives.
By Carmel Richardson, contributing editor of The American Conservative
Just before Ash Wednesday last month, a Christian missionary doctor to Kenya published a blog post. Preparing for the holiest season of the liturgical calendar, he announced his intention to fast during daylight hours for a very particular cause: renewed U.S. funding for global HIV prevention.
The doctor, Matthew Loftus, explained his reasoning in the New York Times in a piece co-authored with Dr. Kristin Collier, National Review’s Kathryn Lopez, and Catholic writer Leah Sargeant. The Christian case for saving HIV aid, they argued, lies in its provision to protect unborn babies from contracting the sexually transmitted disease from their infected mothers. Indeed, of the millions of babies born globally to HIV-positive mothers since the program’s inception in 2003, an estimated 8 million did not contract HIV, thanks to antiretroviral medicine paid for by the U.S. government. The authors argued, “we think PEPFAR should be a special priority of the pro-life movement.”
PEPFAR, shorthand for the President’s Emergency Plan for AIDS Relief, was enacted by President George W. Bush and is one of countless USAID programs halted this spring by President Donald Trump. While “intense bipartisan lobbying” convinced the Trump administration to allow some PEPFAR programs to continue, its primary drug pipeline through USAID has been cut off, at least for now.
Bush’s program aimed to reduce global HIV infections at their peak—a time when the disease was thought to be a threat to any healthy person, not just those engaging in unhealthy sexual acts. Today, the center-right case for keeping PEPFAR is more nuanced: it protects vulnerable women and children in third-world countries from an unhealthy environment they neither created nor seek to perpetuate—and often can’t escape from. Undeniably, the desire to save children from the effects of their parents’ sins and illnesses is a good one. Still, even without considering if the U.S. government has a duty to all women and children of the world, it is not clear PEPFAR is the way to accomplish such a goal. Indeed, for conservatives and Christians, the program contains several morally dubious elements that should elicit further scrutiny—not unbridled endorsement.
The primary work of PEPFAR providing medication to those already infected with HIV: roughly half of the program’s annual funding goes to that cause. This is because an HIV-infected man typically will not spread the STD to sexual partners if his viral load is undetectable, as it can become if he is on medication for long enough. The same is true of an HIV-infected mother on disease-suppressing medication: she should not, under ordinary circumstances, burden her unborn child with the same disease, which makes common illnesses potentially deadly for small children.
But other top-tier PEPFAR expenses include “prevention services,” such as pre-exposure prophylaxis medication, more commonly known as “PrEP,” which purports to prevent HIV infection in the user if he takes it at least two hours before being exposed to HIV. In the United States, PrEP is marketed to gay men to take shortly before a sexual encounter with an HIV-infected, or likely-infected, partner. In sub-Saharan Africa, PrEP is marketed to anyone and everyone. For those at greater risk, defined by the World Health Organization as “cisgender men and trans and gender diverse people assigned male at birth who are not taking exogenous estradiol-based hormones”—that is, men—there is “event-driven” PrEP, which is taken 2–24 hours before “potential sexual exposure.”
As PEPFAR strategists wrote in one technical government-issued report:
The use of PrEP is an important part of a package of comprehensive primary prevention services that includes condom and lubricant promotion, post-exposure prophylaxis (PEP), [voluntary medical male circumcision], risk reduction education, harm reduction, and other structural interventions to reduce vulnerability to HIV infection. In [2020], PEPFAR made oral PrEP a core programmatic requirement and set and met an overall goal of newly initiating over one million people on PrEP in FY 2021. With countries successfully adapting programs to continue prevention service delivery in the time of COVID-19, the global scale up of PrEP continues in [2022].
Male circumcision has been shown to be somewhat effective in reducing HIV transmission, but the same cannot be said for condoms. This is partly because, when statisticians have attempted to study the effects of condoms on HIV transmission, the majority of clinical subjects fail to use them. PrEP, on the other hand, can be effective if used correctly, though it is only good for preventing new infections; it does not stop HIV-infected persons from spreading the disease. In a country where more women might be subject to rape, and therefore more sexually transmitted diseases, it seems sensible, at one level, to make effective HIV prevention easy for women to access. Yet PEPFAR triages this medicine in a different way: aid program leaders recommend event driven PrEP “for [men who have sex with men] only.” All other individuals—that is, women—are recommended a more long-acting form of the same drug, one which must be taken daily for a full week before HIV exposure, as well as the week following, to prevent infection.
Regardless, “women with HIV are more likely than men to engage successfully with the health care system” in the countries where PEPFAR works. This is even more remarkable considering that, where the side effects of HIV medication vary by sex, they are almost always worse for women. Yet PEPFAR strategists noted data “show persistent gaps among men, especially those aged 25 to 40 years old.” To overcome male clients’ “emotional barriers to treating their disease,” PEPFAR has sought to make pre-exposure medication extremely easy to access, through multi-month dispensing of the prescription drug; fewer in-person consultations for men; having peers, “lay providers,” and “community health workers” conduct any needed check-ins; as well as “community-based PrEP distribution models.” In other words, it is not an exaggeration to say PEPFAR hands out PrEP like candy.
In the abstract, such prevention products put health in the hands of individuals, but in reality, they have the effect of making otherwise risky sexual behaviors suddenly risk-free. This does not come without trade-offs. Like the advent of hormonal contraceptive pills in the 1960s, such an approach has a way of doing more than mere prevention. Indeed, it is a kind of prevention that evokes the word’s Latin root, praevenire, or “go before,” with the connotation of preparing the way. Focusing on PrEP and throwing condoms at people prepares them to continue to engage in risky sexual behaviors, this time without consequences. By doing so, PEPFAR has prepared the way for more incidence of sexual promiscuity, not less. This might be fine while the U.S. government is willing to pay to medicate millions in sub-Saharan Africa, South America, Southern Asia, and Ukraine for HIV, but like so many foreign aid programs, it has a way of perpetuating the problem such that there is no off-ramp.
The Pill made sex risk free—or rather, child free—for heterosexual women, and with that came a backfire: now one of the age-old deterrents for casual sex was eliminated.. Safe, legal abortion added a further backstop for casual promiscuity, one too often most beneficial to abusive and irresponsible men. It is not yet clear what liberal PrEP usage will do, but what is clear is that the initiative has been very popular: PEPFAR is responsible for more than 90 percent of all new PrEP prescriptions across the globe. According to a 2024 factsheet, demand for this product is increasing.
Of course, government numbers are slippery. As with COVID-19, the U.S. government has seen fit to obscure simple digits with semantics. “New HIV infections,” or “HIV incidence,” refers to “the estimated number of people who newly acquired HIV during a given period… not the number of people diagnosed with HIV during a year,” according to the PEPFAR website. The State Department claims to have saved 25 million lives from HIV. An independent study done by the authors of the Times op-ed found this number to be… within the possible range. “PEPFAR has saved between 7.5 and 30 million lives,” they wrote.
Meanwhile, though the incidence of new HIV infections has decreased, the total number of people living with HIV continues to increase: in 1995, an estimated 14 million people were living with HIV. Today, the estimated number of people living with HIV is just under 40 million. Between 1995 and 2013 alone, HIV infections among people aged 50 and older more than doubled. Sick children, the strongest cause for keeping the program, comprise a tiny fraction of the HIV epidemic: of the estimated 39.9 million people living with HIV globally, 38.6 million of them are adults. PEPFAR and the WHO prefer to call those new infections “prevented deaths,” but how many were preventable infections? If we consider the latter alternative, this is not a picture of a disease being eradicated but of one being suppressed.
The irony of a Lenten fast for the preservation of risk-free sexual encounters should not be missed. Christians should not confuse liberalism for charity, nor progressivism for prevention. It is right to rally around protecting women and children who are vulnerable to this disease. But a full-throated approval of PEPFAR goes too far.