海角大神

President George W. Bush was halfway through his State of the Union address in January 2003 when he pivoted from making promises to Americans to speak about a rural doctor on the other side of the world.聽

The man worked in South Africa, and faced an unrivaled AIDS epidemic. But with no support, the only thing he could tell his patients to do was to "go home."

Mr. Bush told Congress solemnly that this situation should be intolerable to the United States, a place whose 鈥渃alling as a blessed country鈥� was 鈥渢o make this world better.鈥�

Two decades later, the program that Mr. Bush announced that night, the President鈥檚 Emergency Plan for Aids Relief, or PEPFAR, is widely regarded as one of global health care鈥檚 great success stories. According to the Joint United Nations Programme on HIV/AIDS, the program has saved 26 million lives, and today, it directly supports more than two-thirds of all people receiving HIV treatment in the world.

But now, amid efforts by the new U.S. administration to dismantle the U.S. Agency for International Development (USAID), Washington鈥檚 foreign aid arm, PEPFAR鈥檚 future hangs in the balance. Three weeks ago, all U.S.-funded HIV relief work 鈥� from treatment and clinical trials to projects fighting domestic violence and helping teenage girls stay in school 鈥� shuddered abruptly to a halt.

Though some projects were later given permission to restart, muddled communications and bureaucratic red tape mean many have not.聽On Thursday, a federal court ordered the Trump administration to temporarily lift the aid freeze, but it remains unclear if the decision will hold, or if and when funding might be restored.

At stake in this upheaval, public health experts say, is not just work supported directly by PEPFAR, but the entire global movement against HIV that it helped create.

鈥淧EPFAR has changed the shape of the epidemic and transformed the way we deal with it,鈥� says Claire Waterhouse, regional advocacy coordinator in southern Africa for Doctors Without Borders.

鈥淚t鈥檚 really been the full package,鈥� she adds. 鈥淣ow we鈥檙e faced with the brutal fact that we don鈥檛 know which parts of that package are coming back.鈥�

Children have questions

In sub-Saharan Africa, home to 25 million of the world鈥檚 estimated 40 million people with HIV, the effects of this upheaval have been particularly profound.

When U.S. President Donald Trump temporarily blocked nearly all U.S. foreign aid in late January, every PEPFAR-funded program in the region received an order to immediately stop spending U.S. money.

In Lesotho, 1,500 doctors, nurses, and HIV counselors were instructed not to return to work. In South Africa, researchers scrambled to remove experimental vaginal rings designed to prevent HIV and pregnancy from young women enrolled in a clinical trial. In Mozambique, staff at a public hospital halted counseling and HIV tests to victims of domestic violence.

And in Accra, the capital of Ghana, the Rev. John Azumah wondered how to break the news to the children living in the home he runs there for those known as AIDS orphans. Many were HIV-positive, as is Mr. Azumah, and they received their medication through PEPFAR.

When he finally spoke to the children, they asked a lot of questions, Mr. Azumah says. 鈥淭hey asked me, 鈥楢re we going to die?鈥欌��

Since the freeze, Mr. Azumah says he has visited the U.S. Embassy a dozen times, asking to speak to someone working for USAID. Each time, he has been turned away.

Red tape

Across the continent, many individuals and organizations find themselves in a similar situation. On Jan. 28, a week after the aid freeze began, Secretary of State Marco Rubio announced that 鈥渓ife-saving humanitarian assistance鈥� was exempted from the ban, later clarifying that this included some HIV 鈥渃are and treatment.鈥�

But the directive did not automatically switch those services back on. Organizations still have to apply for a waiver from USAID, a multistep process slowed down by the fact that the aid agency itself is being eviscerated.

鈥淔or many of us, we currently have one leg in, one leg out,鈥� says one local USAID staff member in Ghana who was sent home following the aid freeze. The individual requested anonymity because they were not authorized to speak to the media.

By Feb. 9, only 5% of PEPFAR-funded organizations surveyed by one watchdog group reported that they had resumed services under the waiver. And on Feb. 11, senior USAID officials were instructed to 鈥渉old off鈥� on approving any further waivers, according to The New York Times.

In some countries, health officials were shuffling money to maintain services while they waited, and strategizing about what to do in the longer term. 鈥淚f after three months the Trump government decides to stop support totally, we must have a clear way forward,鈥� said Selibe Mochoboroane, the health minister of Lesotho, where around 1 in 5 adults live with HIV.

Trump adviser Elon Musk has rejected concerns that the administration has put the global HIV response at risk. 鈥淲e are moving fast, so we will make mistakes, but will also fix the mistakes very quickly,鈥� he told reporters in the Oval Office on Feb. 11.

鈥淭he trust is lost鈥�

But even if PEPFAR-funded projects restart, experts say permanent damage may already have been done. Activists and health workers have spent many years building trust in communities ravaged by HIV, fighting shame and stigma to bring the pandemic out of the shadows.

And then people 鈥渨oke up one morning and there was no care,鈥� says Carole Sekimpi, senior director for Africa for the global family-planning charity MSI. In an instant, 鈥淭he trust is lost.鈥�

Paulo Chimera, a program manager at Pfuka U Hanya, an HIV advocacy organization in Mozambique, says his organization had to cut its counseling programs, which helped those in treatment stay on track. They do not yet have a waiver to restart.

Meanwhile, much PEPFAR-funded work administered by USAID is not covered by waivers and has been frozen at least until April. This includes most projects designed to stop the spread of HIV.

For instance, over the last 10 years, PEPFAR has spent nearly $1 billion on a project called DREAMS to help teenage girls in 15 African countries stay in school.

鈥淚t鈥檚 not that they鈥檙e just saying, 鈥極h, this is a nice thing to do for teenage girls,鈥欌�� says Mia Malan, editor 鈥嬧�媔n chief of the Bhekisisa Centre for Health Journalism in South Africa. 鈥淚t鈥檚 based on evidence鈥� from several countries that the more education a girl has, the lower her risk of HIV infection.

PEPFAR has long recognized that countries need more than tests and medicine to stop the virus鈥檚 spread, Ms. Malan says. 鈥淵ou need to invest in a society.鈥�