In April, I stood on the soft green lawn of the home of a retired police captain in Uganda, surrounded by older women with H.I.V. The crowd, which included many grandmothers, wore formal outfits, fit for church, a show of respect and appreciation for the team arriving from a clinic 30 minutes away to deliver the antiretroviral drugs that kept them alive. They watched in grave silence as a nurse, pharmacists and counselors from the AIDS Support Organization (TASO) in Tororo unpacked their drugs, pharmacy log books and other supplies.
When a counselor jokingly chided them, “Why aren’t you happy to see us?” the crowd offered a perfunctory cheer. Then clients said that they’d heard news of the Trump administration’s changes to foreign aid. Many of them wept as they explained their fear that TASO Tororo wouldn’t come as scheduled. A grandmother of 12, fearing for the survival of her teenage granddaughter, also living with H.I.V., pleaded to me, an American, to convince whoever in my government had put the program in jeopardy to relent. “Change the heart,” she begged repeatedly, then collapsed forward, her body shaking.
It was 20 years ago that I made my first visit to Tororo, Uganda. A rural community where roughly a third of residents live on less than a dollar a day, Tororo is a world away from Washington. But the U.S. Senate could influence the fate of H.I.V.-positive people there this week. Lawmakers have until July 18 to vote on a bill, known as a “rescission package,” that would slash $900 million for global health, including $400 million for the President’s Emergency Plan for AIDS Relief, or PEPFAR, which supports H.I.V. treatment worldwide. It has saved 25 million lives since it was established by President George W. Bush 22 years ago.
The package retroactively approves the unlawful actions of the Department of Government Efficiency, which in January and February halted foreign aid and other spending already approved by Congress. While Secretary of State Marco Rubio approved a waiver to continue PEPFAR’s lifesaving services, including the distribution of antiretrovirals, the maelstrom of grant cancellations and terminations at the U.S. Agency for International Development left the H.I.V. program in chaos.
This was evident in Tororo. When the medical team arrived with drugs for the grandmothers and other clients in April, they hadn’t received salaries for three months as a result of a canceled grant. Nor had TASO staff members, who support more than 120,000 people across the country. And yet, counselors, doctors, nurses and peer educators kept showing up. Many counselors and educators also have H.I.V., and they told me that abandoning their clients was unthinkable.
Mr. Rubio has positioned himself as a champion of PEPFAR. And indeed, his waiver, PEPFAR’s operational structure (it has been housed in the State Department and implemented by multiple government agencies since it began) and the work of volunteers like those in Tororo have kept the program operational, even as U.S.A.I.D. formally shut down this month.
But the current state of the program is far more perilous than Mr. Rubio suggested when he told the Senate Foreign Relations Committee in May that the global H.I.V. program is 85 percent operational. I have spoken to a range of experts who estimate PEPFAR is working at about 50 percent capacity. H.I.V.-prevention programs for some of the most vulnerable groups have stopped entirely at the precise moment that a game-changing prevention drug, lenacapavir, has been shown to be wildly effective. Countries that were within striking distance of ending H.I.V./AIDS as a public health threat by 2030 could be very likely to face resurgent epidemics.
In Kampala, I visited a clinic where the dreadful consequences of reduced treatment capacity were already apparent. On Good Friday, the executive director of a slum-based clinic told me it hadn’t received any antiretrovirals for almost two months. It had tried and failed to make three weeks’ worth of drugs last by giving out fewer pills to every patient. Twenty-five percent of the H.I.V.-positive mothers in a recent birth cohort had delivered babies who were already infected with H.I.V. because the clinic hadn’t had reliable drug supplies. It had previously gone years without seeing a single baby born with H.I.V.
And yet, even amid stories like this and the spectacular U.S. retreat from global aid, it’s easy to feel all hope is lost. But I believe that focusing on what can be salvaged is a powerful antidote to despair. PEPFAR is still partly functioning. It can be strengthened to save millions of lives.
This hope isn’t naïve. PEPFAR’s strong bipartisan support persists. This week, Senator Susan Collins of Maine, a Republican, said that she will reject cuts to the program in the rescission package. Other Republican senators who have long supported PEPFAR must join her; they must protect funding for H.I.V. and other global health programs. In the coming months, they must reject the Trump administration’s request to slash global H.I.V./AIDS spending by more than half and demand impact updates to ensure the program is delivering on prevention and treatment for all vulnerable groups. If they do not, it will mean the abandonment of the most effective foreign aid program for global health in this century.
Protecting PEPFAR does not obligate the United States to continue the same type of support forever. Before January 2025, all of the countries where PEPFAR works were making plans to take over the bulk of their H.I.V. programs. Over three weeks in Uganda and Tanzania, I did not meet a single person who asked for indefinite U.S. support. All people want is the chance to prepare for the future.
The commitment of people fighting H.I.V. did not freeze when Elon Musk and DOGE stopped their grants. In June, the TASO Tororo staff found out that their dedication had paid off. A restored PEPFAR grant reinstated their salaries. They did not give up hope that an extraordinary H.I.V. program would continue. Neither should we.
Emily Bass is the author of “To End a Plague: America’s Fight to Defeat AIDS in Africa.” She previously served as a senior strategy writer for the United States Bureau of Global Health Security and Diplomacy.
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