Killing PEPFAR means killing millions of people

A lot has happened in the last six weeks, to put it mildly, and it can be hard to see through the dust and tell what’s actually ongoing.

The government threatened tariffs, backed off, then did the tariffs, and then started carving out tariff exceptions for connected-enough constituencies.

We did showy military deportation flights then stopped because they’re incredibly expensive. Donald Trump’s flurry of executive orders tried to end birthright citizenship (a judge put that on hold), and froze the issuing of passports to transgender Americans (this is being slowly resolved as people individually appeal to their representatives or the media for help). Elon Musk’s Department of Government Efficiency (DOGE) team slashed the federal workforce, then sent emails hiring many people back.

One result has been that it is very hard to communicate as a journalist — or to learn as an interested member of the public — which of the harmful things that the government is doing are actually ongoing and actually worth pushing back on.

But here is an enormously high-stakes problem that is clear and still ongoing: the cancellation of our best-performing overseas programs to treat infectious disease.

My colleague Dylan Matthews has written for a decade about PEPFAR, the underrated star of George W. Bush’s otherwise ignominious presidency. PEPFAR helps partner countries offer HIV testing and lifesaving treatment at an extraordinary scale: More than 20 million people were receiving lifesaving antiretrovirals from PEPFAR when the administration took office.

No one in Marco Rubio’s State Department or in DOGE has said they want to cancel PEPFAR — Rubio has in fact repeatedly spoken out in favor of it in the past — but it was hit by a stop-work order. And even after many PEPFAR programs were issued waivers, funding wasn’t unfrozen, contacts at USAID had been fired or placed on leave, and work in most cases wasn’t able to resume.

Some PEPFAR programs were then sent termination notices. The Elizabeth Glaser Pediatric AIDS Foundation, which treats HIV+ pregnant women to prevent their babies from contracting HIV in the US and overseas, got a cancellation notice for programs serving more than 350,000 people.

For people like myself who have long taken pride in PEPFAR, it’s been painful and horrifying to watch this lifesaving work grind to a halt without a justification or even acknowledgment that it’s happening. It’s gutting to know that people are dying for no reason, and maddening to hear Musk assure everyone that every legitimate program has been restored while contacts on the front lines of the fight against HIV tell us that isn’t so.

So in response to the PEPFAR confusion, some economists, technologists, and policy experts I know got together for a weekend hackathon last month online. We aimed to do a couple of things: Get some independent confirmation of the eye-popping numbers being thrown around about the lives saved by PEPFAR, understand the current status of the programs, and make some updatable public resource explaining all this, because it was (perhaps intentionally) extremely unclear. (The State Department, which oversees PEPFAR, hasn’t been returning my requests for comment.)

That weekend the hackathon team produced an independent estimate: that PEPFAR saves around a million lives a year, and an independent site explaining what we concluded and why, including long technical appendices with a ton of details on the studies the team looked at. (You can read the report here.)

I had already assumed that PEPFAR was a good program because of Matthews’s reporting, but looking into the numbers, I was taken aback by how strong the case for it is. PEPFAR’s funding in real dollars peaked in 2009; every year since then it’s been increasing the number of patients treated with less funding (if you adjust for inflation), thanks to falling drug prices.

In many countries, PEPFAR has successfully handed over responsibilities to local governments — in South Africa, for example, the program provides only 25 percent of the medications, with the rest funded and provided by the South African government.

But the effectiveness and importance of PEPFAR underscore the devastation that is unfolding as it is withdrawn — even just 25 percent of patients being thrown out of clinics overnight still causes mass chaos and mass deaths, as heartbreaking coverage of the effects of the sudden PEPFAR closures has made clear.

And South Africa is relatively fortunate — in some other countries, like Nigeria, where PEPFAR is 90 percent of HIV funding, there’s no viable way for most people to get antiretrovirals once PEPFAR shuts down.

Some of the 20 million people we threw off their lifesaving medication will find other sources, but many won’t. And every day, 1,400 babies will be born with HIV who would otherwise be HIV-free if we hadn’t frozen the programs meant to help their mothers.

Here’s what our 44-page report boils down to: About 1 million additional people will die terrible deaths every single year for the foreseeable future if PEPFAR doesn’t get reversed.

In the first Trump administration, there were a lot of large-scale protests. This time around, I’ve seen less energy, though there are still plenty of protests. I think this is partially due to a perception that those first-term protests didn’t really work; after all, Trump eventually got reelected with more support than before.

But I think “do protests work?” is too complicated to have a “yes” or “no” answer. Protests can draw attention to an issue; whether that attention is good or bad depends on whether the public and policymakers are on your side or not.

Protests are therefore at their most useful when they’re about something that’s being done half by accident or out of carelessness. Musk has claimed that the USAID freeze didn’t kill anyone, and that they’re reauthorizing all programs that are legitimate.

But PEPFAR clinics are still closed. Sen. Lindsey Graham has reportedly pressed the government on the PEPFAR closures. Unlike much else Trump and Musk are doing, slashing PEPFAR really doesn’t even appear to be a partisan act, and it’s not even clear it’s intentional.

For that reason, many of the PEPFAR report authors, along with pro-life groups, Effective Altruism DC, and lots of concerned citizens protested Friday at Foggy Bottom Metro station, trying to raise awareness of the PEPFAR program freezes.

I didn’t participate (it’s Vox policy not to do so, plus I’m on the wrong coast), but I want to make the intellectual case for what they’re doing. Protesting the Trump administration works best when you’re able to cut through the noise and tell people about something indefensible that they didn’t know happened, didn’t know was ongoing, or didn’t know was unpopular.

The administration hasn’t defended the PEPFAR cuts, and indeed has mostly insisted that PEPFAR is still operating and got waivers. That makes it an unusually good target for public pressure.

When considering a protest, like considering any other way to improve the world, I use the framework, “Is it important? Is it tractable? Is it neglected?”

When you find something that’s all three — a million unnecessary deaths a year, as a product of a policy that most people aren’t aware of and that no one in government has endorsed and that Republicans along with Democrats are opposed to — it’s worth making some noise, even amid the terrible roar of noise which is the defining feature of this moment.

A version of this story originally appeared in the Future Perfect newsletter. Sign up here!