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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. Now we will ask the question, are people dying as a result of President Trump's foreign aid cuts? If so, can we know or estimate how many? We'll focus mainly on one foreign aid program that you may be familiar with. That program, created in 2003 under President George W. Bush, is known as the US President's Emergency Plan for AIDS Relief, or PEPFAR. For decades, it provided life saving treatment and preventive care for people around the world living with the disease or at risk of the disease. In March, New York Times columnist Nicholas Kristof worked with experts at the Center for Global Development to try and calculate how many lives are at risk. They estimated that within a year, 1,650,000 people could die without American foreign aid for HIV prevention and treatment. Now we'll take a look at how countries that suffer high rates of HIV and AIDS are coping now that USAID funding has dried up for PEPFAR, and how local governments, especially in places like Eswatini and Lesotho, are attempting to figure out solutions. Also, some of the politics that could wind up in some of that funding being restored.

Joining us for this are Jon Cohen, senior correspondent with medical journal, Science, and on how the cuts have impacted her organization is Dr. Wafaa El-Sadr, Director of ICAP at Columbia University. ICAP's goals are to expand access to HIV prevention, care and treatment services globally. She's also a professor of epidemiology and medicine at the Columbia Mailman School of Public Health, executive vice president of Columbia Global, and lead of the New York City Preparedness and Response Institute. Jon, welcome to WNYC, and Dr. El-Sadr, welcome back.

Dr. El-Sadr: Thank you. Appreciate it.

Brian Lehrer: Dr. El-Sadr, by way of background, can you tell us more about the work that ICAP does and what the budget cuts announced this year have done to what you are able to do?

Dr. El-Sadr: Yes, certainly. ICAP was established more than 20 years ago now. I think over the past 20 years we have seen the dramatic changes that investments by the US government as well as also investments by countries themselves have made in terms of really transforming HIV from being an immediate death sentence into a chronic, manageable condition.

Brian Lehrer: You know what, I'm going to jump in because something happened to the audio and we're hearing you faintly, so we're going to try to fix that. I'll pivot to Jon in the meantime. Jon, in May, I see you travel to Eswatini and Lesotho to see, firsthand, how these countries were responding to the cuts in foreign aid to PEPFAR. In your role with the medical journal, Science. The two countries have had the highest population of adults living with HIV, for listeners wondering why we're singling out those two places in particular. Give us a few more details on those two countries.

Jon Cohen: Sure. They're small countries. They're a million to 2 million population. Lesotho is entirely within South Africa and Eswatini borders both South Africa and Mozambique. They had about, let's say, one in four, one in five adults living with HIV in the last survey that Dr. El-Sadr's group did. With help from the US government and PEPFAR, they've turned their epidemics around.

The countries were in danger of being wiped off the map. By 50 years old, about half the people are living with HIV, and they have achieved remarkable progress in getting everyone who is living with the virus to know their status, to get on treatment and to fully suppress the virus, which means they will live normal lifespans and they likely won't transmit to other people. What I saw is the dismantling of the PEPFAR program and the thread being pulled out of the quilt.

Brian Lehrer: PEPFAR estimates it has started 21 million people on anti-HIV drugs and saved 26 million lives. What sort of support does it provide to countries on the ground broadly? How did the end of that funding impact people in countries and areas like the ones you were just discussing? I don't know if you want to tell it through the story of an individual like the young pregnant woman in her 20s, who is in your article, or if you want to try, like Nicholas Kristof cited, to cite some global number of how many people are already dying or who might within a year.

Jon Cohen: I think that it's a bit dodgy to put a hard number on how many people are dying. HIV causes disease slowly, except for in newborns and young children. These countries have medication. What they don't have are the systems to deliver the medication, to get people tested and to move samples from clinics to labs. What I saw, the woman you mentioned, she had lived about 10 kilometers, say 7 miles or so, from a clinic. Hard for her to transport from her home to the clinic.

She did get to the clinic at eight months pregnant because she wanted to give birth there and had to show up ahead of time for testing. They tested her for HIV, she was positive. Normally they would go out to her home, test all the family members, everyone else she's living with, but they didn't have transportation to do that any longer. I said, "Hey, I've got transportation. Do your outreach workers want to go?"

We went and they tested eight children. Two of the children were hers. Others were other people living in their homestead. My heart was in my throat. All of them tested negative. Had any of those children tested positive, they would have started treatment immediately and they would have prevented all sorts of maladies from occurring. If they didn't get treatment and they were living with the virus, they would likely have had stunted growth as they got older. They may well have showed up at the clinic deathly ill.

I could see, with my own eyes, the cracks here. You can easily imagine the problems that are occurring right now because they don't have a simple transportation for seven miles away from a clinic.

Brian Lehrer: Dr. El-Sadr, I think we have you back on a better line. Why don't you start at the beginning again and tell us the work that your group, ICAP at the Columbia University School of Public Health, does?

Dr. El-Sadr: Certainly. Thank you. ICAP has was established now more than 20 years ago, and over the past 20 years we have seen a remarkable transformation in terms of the situation with HIV in many countries.

We work in more than 30 countries around the world, and that's thanks to investments by external funders like the United States, for example, but also thanks to enormous investments and dedication by the people on the ground, the people in the countries themselves, who've really rolled up their sleeves and taken charge and, with the support of the United States and other funders and PEPFAR, help put together the systems that have enabled the successes that have been accomplished over the past 20 years.

Many of these successes fall along the lines of what Jon was just talking about. There's no magic bullet. It's not simply a pill. There's the whole trajectory and cascade of events that have to happen until people are able to gain the benefits of treatments or prevention, whether it be tested, whether they get the counseling they need or not. Are they able to get to a clinic or not? Are they able to get the monitoring, the lab test that they need? Are they able to see a nurse or a doctor? Are they able to get the community support from community-based workers that go out and get them and continue to engage them in their care?

These are the events that must happen and need to happen in order to have a successful program. Definitely, the medicines are absolutely critical, whether they be for treatment or prevention, but we cannot forget all of the other steps along this cascade that are absolutely critical for getting the benefits that we've seen from HIV investments to date.

Brian Lehrer: When we were getting your line hooked back up, Jon was telling us a story of one individual. I don't know if you have any stories to tell us either of individuals or the actual impact on the ICAP program on the ground in any particular countries and what you may already be seeing in terms of life and death or public health.

Dr. El-Sadr: Yes, certainly. I do think, and I agree with Jon, that the results are palpable. I think I can highlight in general the whole, maybe, deprioritization or shifting of emphasis away from prevention is very alarming, obviously. As you know, now the focus is really centrally on life-saving treatment, but because of the shifting away from using prevention methodologies for people at risk for HIV, we have seen how programs, particularly programs in the communities in different countries where we work, have now had to move away from providing some of the really critical prevention tools that we know can protect someone from getting HIV.

This includes programs that cater to young women, for example, who are really, really at high risk for HIV in southern Africa, to populations like men who have sex with men, sex workers and people who inject drugs, who also desperately need these prevention methods to stay HIV-free. We need to be careful also as we move forward that we have to provide the whole array of services, whether that be life-saving treatment or equally, life-saving prevention methods.

Seeing these community-based organizations shut down because they can't get the funding, and the people that used to go there, and they're usually really vulnerable people, often stigmatized people, have no place to go anymore to get their needs taken care of, is really heartbreaking.

Jon Cohen: Brian, may I build on that for a second?

Brian Lehrer: Please, Jon.

Jon Cohen: I was in Lesotho in a rural clinic, place called Nazareth. There were pregnant women lined up, sitting on benches against the wall. It was a day for pregnant women to come there. They were short on nurses, they were short on people to do HIV testing. They had tests, but they weren't running any HIV tests on the pregnant women. What you're seeing is what you're not seeing. That's the most important thing. They're not doing HIV tests on the women.

The easiest thing to do is to prevent transmission from a woman living with HIV who is pregnant to her baby. If you don't treat the woman and treat the baby, if she is living with the virus, she has about a 30% chance, through birth or breastfeeding, of transmitting the virus. If you do treat her and treat the baby, the risk drops to below 1%. If she tests negative, you can offer her medication to prevent her from becoming infected in the future. It's called pre-exposure prophylaxis or PrEP. None of that was happening. When you ask the question of what do you see, it's also what you don't see.

Brian Lehrer: Do I hear both of you saying that money from the United States government is still going, to some degree or to a meaningful degree, for treatment for HIV positive people or people with AIDS, but it's mostly the preventive services that have been cut? Dr. El-Sadr, is that what you were getting at before?

Dr. El-Sadr: I think that's been the shift in terms of policy shift. Again, it's not as simple as that in many ways, Brian, because as we've been saying, you can certainly pay for the medicines, but all these wraparound services that Jon has talked about and I mentioned are often outside the definition of life-saving treatment. This is the community-based program that goes out there and gets people, the civil society group that provides the education and information. It's all of the packages of services that are very important, but certainly, overall, there is a shift of priority to treatment, rather than to testing and to prevention overall.

Brian Lehrer: Jon, anything to add to that?

Jon Cohen: Eswatini and Lesotho basically pay for the bulk of their antiretroviral medication, but they have these automatic dispensing machines that send an SMS code, a text message to people to say, "Hey, come to the pharmacy any time of day or night, pick up your medicine, your medicine's ready." Those machines aren't operating because they no longer have the funding to pay for the cell service, so it all falls apart.

They have a program for teenagers that transports them one Saturday a month to the clinic. They meet with other teenagers who are living with HIV. They talk about their challenges. They get their medication. They have their pills counted to make sure they're taking their pills. They have their blood drawn to make sure their virus is suppressed. That's fallen apart. Not happening.

I met a teen in a rural mountain part of Eswatini who just wasn't taking his medication. He didn't have transport to the clinic. He's a teenager. Come on. Teenagers don't have a great reputation of taking care of their health and taking pills every day. They need support. That's just fallen apart. It's just fallen off the cliff. It's gone.

Dr. El-Sadr: Just to build on this, it's very ironic because at this moment, we're on the verge of a true transformation in terms of prevention of HIV. As probably, your audience may have heard, there's an injection that's given twice a year, only twice a year, that has been shown to work almost perfectly to prevent people from getting HIV infection. At the moment, when we have this amazing discovery, this new tool at our fingertips, it's the wrong time to shift away from prevention. This is the moment to rally around this tool, this injectable that's twice a year. There's another one that can be given every two months.

We are on the brink of really being able to make a big difference in terms of keeping people safe, these young people, the teenagers and the young people that Jon talked about and keeping them HIV free. Unfortunately, we're at risk of missing this opportunity.

Brian Lehrer: Now, Dr. El-Sadr, I asked Jon this before when we were getting your line hooked up. Now I want to ask you about The New York Times columnist Nicholas Kristof, working with experts at the Center for Global Development, trying to calculate how many lives are at risk from this pullback in the PEPFAR program. They estimated 1.6 million people could die within a year without the foreign aid for HIV prevention and treatment. I'm curious what you make of that estimate, or if anything, that you hear from your ICAP affiliates around the world. Is this happening?

Dr. El-Sadr: It's probably a very realistic estimate. There have been projections and modeling by the UNAIDS, for example, in terms of numbers of deaths and numbers of new infections. The assumptions that people have made are quite valid, so I would not be surprised that this is what we are going to see. I think it's important to keep in mind of where are we going to see these events happening? Where are going to see the death?

We're going to see them, as Jon mentioned, particularly in infants and children, because in youth, in young people, particularly the younger they are, and infants in particular, HIV can be very severe, can be devastating, and without treatment, it is a certain death and very rapid death. If pregnant women are not getting the medicines to prevent their babies from getting infected, that means that we will likely see those babies again without treatment and they will succumb to HIV.

Another group that is likely to suffer early are people with advanced HIV disease, because if they stop the medication, predictably, the virus is going to start multiplying rapidly and that means that their immune system will be weakened, and they'll succumb to HIV. I think we'll have to keep an eye on these populations in particular to see what's going to happen.

It's really important for us to be able to continue to collect the data. This is very, very important point. As we see these changes, as we note the shocks to the system, as people are trying to adjust their programming, it' really important that we continue to collect the data. The investment in collecting the data will be very important to actually measure what's happening, to see the actual numbers of deaths, to see the actual numbers of new infections, so we can course-correct as quickly as possible.

Brian Lehrer: Jon, now I want to ask you about the politics and whether the politics of US foreign aid, at least for this particular program, are starting to shift. Politico reported last week that the Trump administration, in an effort to shore up votes for its spending cuts packages, the so called big beautiful bill pieces, is, "Trying to assure House Republicans wary of plans to slash global AIDS funding that the administration will spare some prevention programs that would have been on the chopping block."

This is in the context of PEPFAR long having bipartisan support. It was started by a Republican president, George W. Bush. Further, Politico's Meredith Lee Hill reports, "In recent days, White House officials have conveyed to GOP leaders that they will not only maintain life-saving treatments under PEPFAR, but would also, in response to concerns from more than a dozen House Republicans, preserve some prevention programs as well." You've been emphasizing the prevention programs so much.

I'm curious if at your publication, Science, you also have your eye on the politics and you think this is starting to move compared to what it was at the very beginning of the Trump administration early this year, when they just cut off so much of this in such a blanket way.

Jon Cohen: Brian, there has been a signal of some more support. The president's justification, is what it's called, for the budget calls for a 30% cut in PEPFAR. USAID was thrown into the wood chipper, to borrow Elon Musk's phrase, and that was 60% of the PEPFAR budget. The hit that has been taken to date is really 60%, but now they're saying they're going to roll that back to 30%.

I think we can say with great certainty that the Trump administration is consistently inconsistent. They put out messages saying, "We're not going to support pre-exposure prophylaxis." Now they say they're going to support some prevention. I don't know. Proof's in the pudding. Let's see what happens. The whole idea of PEPFAR was to phase it out over the next five years and it happened too quickly for these countries to adjust.

These countries, as Dr. El-Sadr pointed out, they want to take over and sustain these programs with their own budgets. There's a great desire to do that and they've been putting more and more of their money into it, but the amount of money PEPFAR has been giving them dwarfs their entire health budget. The Eswatini, Lesotho, they're getting about 70 million a year from US government funds and their own investment is about 170 million a year.

If you cut that by even 30%, it's a huge hit, and they can't easily fill that gap with their budgets overnight. Over five years' time, the plan was to do just that. What's going to happen? I don't know. I wake up every day with this administration and wonder what its decisions are. It seems to change with the wind.

Brian Lehrer: Cal in Astoria, you're on WNYC. Hello, Cal.

Cal: Hi, how's it going? I was actually calling because it's both comment and question on this. When the US donates to foreign aid especially for the aid that you're speaking, the medications that are purchased in [unintelligible 00:22:33], usually those go towards US-backed companies, so it actually helps the US economy. With this cutoff of aid, I would assume that it's affecting US economy negatively in the pharmaceutical end, but at the same time, there's a gap filled in.

My question is, foreign countries like China and India that produce cheap, lower quality medications, have you seen them coming in and filling that gap? I'm sorry, the other part of the question is that, doesn't that increase their influence in these nations especially for this cold natural resource war and these African nations are naturally rich with resources?

Brian Lehrer: Very interesting questions. Let me go, because we're going to run out of time in the segment. Dr. El-Sadr, do you want to take that first? I'm going to have a version of it for Jon, too.

Dr. El-Sadr: Yes, when we think back about the accomplishments of PEPFAR, I think one of them major ones has been the enormous- the soft power, the enormous value that our country has really received in terms of goodwill by populations around the world that really understand and know and articulate gratitude to the American taxpayers. The US has gained enormous goodwill from programs like-- and particularly from PEPFAR. That's very much appreciated.

I do think you're right that there also have been benefits. There are economic benefits due to some of the procurements, whether they be medications or lab equipment or other procurements that PEPFAR has supported, that have produced some benefits to our own economy here in this country. There are tangible and intangible benefits that we have gained as a country.

Many of us fear that what we're seeing now with the erosion of confidence, the erosion of trust, the uncertainty that Jon talked about is creating a sense of dismay and disappointment amongst populations that, until recently, were really supportive and eager to work with the United States and eager to contribute to our own well-being as well.

Brian Lehrer: Related to that, Jon, we have another listener who asks basically, "Why is this the US taxpayer's responsibility only?" I don't know if it is only. I'm paraphrasing this listener now. Why don't other countries fund things like PEPFAR and pick up the slack? Why does it always have to be the US taxpayer? Do you accept the premise?

Jon Cohen: No, it's a myth. The US has been more generous than other countries, but an analysis by the Kaiser Family Foundation for last year shows that about 70% of the funding for HIV AIDS assistance came from the US and about over 20% came from Europe and other wealthy parts of the world. The US has had a disproportionate role in contributing, and that's because we are an incredibly strong, wealthy nation. We, by our actions, drove down the price of these medications from $15,000 a person per year to about $120. That was because of our actions.

As the other listener raised, we do support our own industry. ICAP is Columbia-based, employs a lot of people in the United States who helped out in other countries. It's a complex web. To think that we're just giving money away as charity, I think really undermines what's happening, which is, in part, soft power, as Dr. El-Sadr mentioned, but it's also preventing civil unrest and collapse that might involve our military if these countries were falling apart from disease. It's in our interest in a lot of ways beyond simply charity.

Dr. El-Sadr: It's a miniscule amount of our budget. I think that's really important. I think it's really important to remind everyone that people often overestimate the magnitude of foreign assistance. It is really a minuscule fraction of our US budget.

Jon Cohen: Dr. El-Sadr's group is-- they're training people. That's the other aspect to it. They're training locals to do this.

Brian Lehrer: Training people is ICAP. She's also a professor of epidemiology and medicine at the Columbia Mailman School of Public Health, among other things, and Jon Cohen, a senior correspondent at Science. Thank you both so much for joining us.

Dr. El-Sadr: Thank you, Brian.

Jon Cohen: Thank you very much, Brian.

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