One of the Cheapest Ways To Save a Life Is Going Away

What's the price to save a human life? We examine the monumental legacy of the U.S. President's Emergency Plan For AIDS Relief (PEPFAR) with journalist Jon Cohen, who traveled to Eswatini and Lesotho to learn how cuts under the Trump Administration are hitting people at the clinic door.

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Transcript

ANNOUNCER: NPR.

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DARIAN WOODS: In rich countries like the US, we spend millions of dollars to save a life. People with health insurance enjoy befuddlingly expensive surgeries and medication regimens. Governments shell out for highway improvements to reduce crashes. But there's a program that has been saving millions of lives for a fraction of that cost — just $4,600 to save a human life. That program is called PEPFAR, the US President's Emergency Plan for AIDS Relief.

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GEORGE W. BUSH: Ladies and gentlemen.

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WOODS: George W. Bush started it in 2003.

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BUSH: Seldom has history offered a greater opportunity to do so much for so many.

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WOODS: At this State of the Union, President Bush asked Congress to commit $3 billion a year to fight AIDS in Africa and the Caribbean. It's now given an estimated 26 million people another chance at life by preventing and treating HIV and AIDS. Under President Trump, that program is being gutted. The president paused foreign assistance in January. DOGE then demolished USAID, which delivered a majority of the program's assistance. And now there's a bill going through Congress that would codify much of these cuts. So what's happening on the ground? Journalist Jon Cohen went to Southern Africa to find out.

JON COHEN: They're reeling. They're dizzy. They're like, what — what? This is our trusted partner, the United States government. How can they be doing this?

WOODS: This is The Indicator from Planet Money. I'm Darian Woods. Today on the show, HIV/AIDS prevention under Trump, and a trip to an African clinic to learn about the cost of these cuts.

WOODS: Not everyone remembers this acutely, but in the 1990s AIDS was one of the leading causes of death, including in the US. And then came game-changing drugs to treat HIV, the virus that causes AIDS. These drugs were what's called antiretroviral therapy. Jon Cohen is a senior correspondent for Science Magazine and has been covering public health for over 30 years.

COHEN: They could basically allow people who had HIV to live normal lifespans.

WOODS: Antiretroviral therapy saved millions of lives in wealthy countries.

COHEN: Well, that wasn't available to most people living with HIV in the world, because the drugs were so incredibly expensive, about $15,000 a year per person.

WOODS: So that's manageable in a rich country, but just completely inaccessible for people from low-income countries.

COHEN: Worked great in the United States, Europe, Australia, Japan. Had no meaning for most of sub-Saharan Africa, for most of Asia. And that's where most people who have HIV infections live.

WOODS: There were still millions of deaths a year across those countries, and that's what impelled George W. Bush to start PEPFAR. And what's made PEPFAR successful is that the program is heavily monitored for its outcomes.

COHEN: The metrics that we're talking about here are 95% of people know their status, 95% of those people start treatment, 95% of those people reach undetectable levels. 95, 95, 95.

WOODS: Program managers can look at a country and see where it's succeeding, where it's failing, and what could be changed. And even some of the countries hardest hit by AIDS have reached these targets.

COHEN: To date, the program has spent over $120 billion and has saved an estimated 26 million lives. It's a phenomenally successful program.

WOODS: That success is now under grave threat. The hope had been that American assistance could start phasing down around 2030. But some Republican lawmakers didn't like that some money was targeting higher-risk groups, like sex workers and LGBT people, so that glide path has now turned more into a crash landing. Earlier this year, many HIV/AIDS organizations in places like Africa received emails terminating their contracts with the USAID. The emails were signed off, "God bless America." So in May, Jon went to two African countries to find out what the reality was at the hospital door. He flew to Eswatini and Lesotho. These are two countries within South Africa.

COHEN: They're small, 1 to 2 million people each. They have the highest prevalence of HIV anywhere in the world.

WOODS: About one in four adults in Eswatini and Lesotho have HIV. Believe it or not, that is a major improvement from a decade ago.

COHEN: I'm not sure the countries would exist today had these medications not arrived there when they did.

WOODS: In some places in Southern Africa, entire villages have been run by orphans. In Eswatini, Jon spoke to a nurse at a clinic in a brick building, [INAUDIBLE]. The PEPFAR cuts were starting to bite.

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COHEN: On this scale, how serious is the situation?

NURSE: Oh, this is really serious.

COHEN: Is this a five-alarm fire?

NURSE: No, this is really serious, and it's worrisome.

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WOODS: Now, the Trump administration has said it is allowing life-saving treatments to still be funded. And yes, the clinic still has the antiretroviral drugs, but they don't have the funds to promote HIV testing to know who needs those drugs. Jon saw a young woman named Temalangeni Dlamini, who came into the clinic for her pregnancy checkup. She tested positive for HIV, so she was swiftly given antiretrovirals.

COHEN: So when I went to the clinic, I was talking to them and said, well, that's great. You know, it's — the system's working. And this outreach worker there said, no, it's not. We need to now go test the contacts in her home. And typically, we would drive out to her home and do the testing.

WOODS: Temalangeni has two children, plus more in the home. It would be important to make sure they were being tested too. Without testing, a child with HIV would probably only be seen once it had progressed to AIDS. And with the cuts, the clinic didn't have the means to send anyone over to test those children. This time, though, there was kind of an unusual solution.

COHEN: I said, well, we have a car. How about if we took you? Would you — would you want to do that? And the outreach worker said, yeah, I'd love to do that. So we went out to the home.

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COHEN: And the woman tested eight children. And, you know, my heart was in my throat. You know, I really — it's crushing to see positive tests come up, especially in children. And here were eight children being tested, and they all came out negative, which was just wonderful.

WOODS: If Jon hadn't been there, and if those children did have HIV, the outcome could have been quite different, especially once it's progressed to AIDS.

COHEN: At that point, they already would have suffered irreparable damage to their bodies. When they grew older, they would probably be stunted, if they survived. That's what's happening. It's a little harder to see than, hey, are there drugs on a pharmacy shelf? But that's the reality of what these cuts are doing. As the head of the UNAIDS program said to me in Eswatini, it's like pulling someone off a life-support machine, and just pulling the plug.

WOODS: White House budget director Russ Vought said the US is in $37 trillion in debt, and at some point, the continent of Africa needs to absorb more of the burden of providing this healthcare. So could African countries fund HIV/AIDS treatment and prevention themselves?

COHEN: Sure, and they want to, and they're moving toward that. But to think that this is going to solve our debt problem, I mean, come on. Do the math. This is a drop in the ocean. Now, you can argue that, hey, it's a charity, as Marco Rubio has said, and it's not our job to be a charity. Well, this is more than simply being a charity. It's more than simply soft diplomacy. It's creating a stable world where you don't have military conflicts and you don't have countries falling apart because of health.

WOODS: We reached out to the Department of State asking if its leadership was concerned. A spokesperson said PEPFAR continues to support life-saving HIV testing, care, and treatment approved by the secretary of state. But they also said that other PEPFAR-funded services are currently being reviewed for efficiency and consistency with US foreign policy. Jon says like any large system, there were always wrinkles, like leadership in Washington pushing too hard for those metrics sometimes, or debates over abstinence promotion. But overall, he says, this was an extremely well-run program. In its hobbled state now, though, researchers from the HIV Modeling Consortium estimated 70,000 people have already died.

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WOODS: This episode was produced by Julia Ritchey and Cooper Katz McKim, with engineering by Cena Loffredo. It was fact-checked by Sierra Juarez. Kate Concannon edits the show, and The Indicator is a production of NPR.

Music by Drop Electric.