On Friday, Jan. 24, a Trump Administration funding freeze on most of the U.S.’s foreign aid projects went into effect. This directive, at first, included one of the most successful, lauded health programs in U.S. history—the U.S. President’s Emergency Plan for Aids Relief, or PEPFAR, launched by President George W. Bush in 2003 and supported by a majority of both parties in the 10 Congresses since then.
Data from the State Department suggests PEPFAR, at a current cost of about $6.5 billion a year, has saved 25 million lives and brought the AIDS epidemic under control in several countries. In 2023, more than 20 million people, including 500,000 children, were on antiretroviral therapy with help from the program, and almost 2 million were newly enrolled on pre-exposure preventative medications.
On Tuesday evening, less than a week later, Secretary of State Marco Rubio granted PEPFAR a waiver to provide some services, but it’s unclear if preventative measures will still be provided or whether the program has a long-term future. The last time the reauthorization of the program came before Congress, its funding was only approved for one year, until March 2025, instead of the usual five, and some members of Congress have expressed doubts the way the funding is being used.
TIME spoke with Dr. Deborah Birx, who headed up PEPFAR from 2005 to 2014 and served in the first Trump Administration as an adviser on pandemic procedures, on Wednesday morning. She is currently a senior fellow at the George W. Bush Institute, which released a statement warning of “interrupting life-saving access to treatment, potentially placing millions of lives in danger” on Tuesday and a follow-up statement today welcoming the waiver.
This interview has been condensed and edited for clarity.
Can you explain what the current situation is with PEPFAR?
There’s medication that’s released for the current treatment of everyone in PEPFAR. And then there’s the importance of prevention through mother-child transmission, and I’m sure that funding has also been released. So you’re asking, I guess, about PrEP (pre-exposure prophylaxis), and I haven’t seen a definitive answer.
Do you think PEPFAR has a viable future, or is it endangered at this point?
If it didn’t have a viable future, it wouldn’t have received the waiver. But I also think programs really should be continuously reviewing themselves and allowing outside reviewers during a transition. I have been through many such reviews. They were critical in aligning the program again towards specific goals. We have a habit in federal government to never stop things that aren’t working. PEPFAR has achieved amazing things, and during the first Trump Administration we probably added the most individuals to treatment and made the most progress. But as you make progress, you’ve got to constantly change how the program looks, and you have to constantly be looking for efficiencies. So I’m hoping that the team takes this as a time to really look over the last four years and see, can they do some things better? Can they do some things cheaper? We were able to go from 7 million people on treatment in 2014, and 10 years later have 20 million people on treatment with no new money. With, of course, inflation. You do that by finding what are the core needs to execute the program.
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It sounds to me like you’re saying that PEPFAR has actually done the kind of work it needs to do in aligning and revisiting its priorities. Does it surprise you that it’s on the chopping block?
No, it doesn’t. If you look at the number of people on treatment over the last two years, it is the lowest number of people that we’ve added in the history of the program. Secondly, in all of the years of PEPFAR, we’ve never had an issue like occurred in Mozambique [where nurses paid by PEPFAR funds were found to have provided 21 abortions, in violation of the Hyde Amendment]. So it’s right for the administration to step back and say, How did that happen? We’re very data driven in the program historically, and these are the things that we think we can do better. And so we do need less funding to do these things better and to refocus the program.
We need less funding to do things better?
Let me put it in a very clear way. You can always figure out how to do better in your funding envelope. We’re in 2025 and many countries have hit their goals for 2030, so the team really needs to come forward with a program. None of these programs were meant to be forever. They were meant to solve a problem. HIV is a chronic disease, so it’s no different than what you would do with diabetes or hypertension, you have to keep people on treatment.
Given the nature, as you say, of chronic disease, is it a good idea to withdraw from the World Health Organization?
This is a moment for the WHO to be reflective and to be transparent about how they could do better in the future, and take that information to the U.S. government of what they’re going to change and how they’re going to increase their efficiency and effectiveness.
Is the freezing of USAID funds for humanitarian assistance productive or counterproductive for the fights against future worldwide pandemics?
I’m sure you got Rubio’s statements last night that there would be waivers during this review period for humanitarian assistance and life-saving medical treatments. That doesn’t change the fact that they want to see a review, so that they can really see if something can be more effective and efficient. I’m hoping that what comes out of all of these reviews across USAID, State Department, CDC, Peace Corps, everybody who is investing in foreign assistance, is ensuring that we’ve eliminated all duplications with all the other international and bilateral programs that are working in the same spaces, so we can serve more people.
As a specialist in preventing future pandemics, do you have any concerns about Robert F. Kennedy Jr.’s nomination to the Department of Health and Human Services?
I haven’t seen his hearings, and so I’m going to watch his hearings today and tomorrow, because, just like programs can change and people’s perceptions and opinions can change, I want to see what he has to say now that he has heard people’s concerns.
It does seem like he has an articulated position already, so if it doesn’t change, you would be opposed to it?
I’m not going to speak about Robert Kennedy. I’m a very data-driven person, and I know a lot of people have made assumptions based on past statements, and I want to see what he says under oath, because this is my first chance to really hear him under oath. I think everybody takes their hearings quite seriously and the fact that they’re under oath.
