Sweeping cuts to foreign aid programs have doctors concerned that the world could backslide in the fight against HIV/AIDS.
Dr. Lisa Abuogi, an associate professor in the Department of Pediatrics at the University of Colorado and the medical director for Children’s Hospital HIV prevention work, says cuts to USAID and the President’s Emergency Plan for AIDS Relief were “done with so much chaos and confusion and really cruelty.”
PEPFAR was launched under President George W. Bush and is credited with saving millions of lives in the continent of Africa. Abuogi worked on PEPFAR programs during the early days of the initiative to control the HIV/AIDS crisis and says the program has had “the most profound effect on a global illness.”
“When I first went to Kenya as a pediatric resident in 2004, I went to a very rural place called Suba on Lake Victoria — one of the hardest hit places by HIV — and in the hospital wards there were two people to a bed and people underneath the bed, patients. The wards were full, villages of people were dying off of HIV and we turned that around through PEPFAR and USAID and that's what American dollars did,” Abuogi said.
Abuogi spoke with Colorado Matters senior host Ryan Warner about what the cuts could mean abroad and how cuts domestically could undo successes in Colorado.
This interview has been edited for length and clarity
Ryan Warner: I understand you were actually in Kenya when PEPFAR funding was cut. What was that like?
Dr. Lisa Abuogi: That's right. I was there at the end of January and beginning of February and it was shocking and disturbing. I was in clinics that normally serve 200 patients a day and they were just deserted and staff were walking around very confused at what was happening, and it was really awful to see it happen in real time.
Warner: Deserted. Why? Because the funding had just been cut and treatment stopped?
Dr. Abuogi: That's right. The funding had stopped and people had been told you can't go to work. They received termination letters on a Friday and the clinics opened on Monday and weren't sure what to do.
Warner: What does that mean practically for Kenyans?
Dr. Abuogi: Practically, it means that people aren't getting their lifesaving HIV medications. It's not treating people, it's not preventing transmission to babies and it's not preventing HIV. Kenya has started using medications to prevent HIV called PrEP. So those things all stopped. Now, Kenya responded quickly and tried to restart treatment very quickly, but just in sort of a haphazard way, because this was done with so much chaos and confusion and, really, cruelty.
Warner: Why do you say cruelty?
Dr. Abuogi: Because if you're providing services that save lives and keep people healthy, to stop them overnight with no plan at all about how to continue or without talking with people themselves who are affected or who are running programs or governments that are relying on this funding. To me that's cruel.
Warner: I want to remind folks that someone who's properly medicated can have an undetectable viral load, meaning they can't transmit HIV. So prevention is powerful. And you talked about PrEP, pre-exposure prophylaxis, but treatment is powerful. Would you say that both of those avenues, then, are at risk?
Dr. Abuogi: Absolutely. So in HIV, we talk about treatment being prevention. So when a person with HIV can take their medicines and get their virus undetectable so that you can't find it in their blood, like you said, they won't pass it on to anyone. So that's preventing the spread of HIV, including to other partners and to infants in pregnant women. And then when you stop HIV testing, you stop education about HIV and you stop oral prevention medicines, then you're breaking that cycle of prevention and new HIV infections will happen. People will get sick and people will die.
Warner: I hear two issues that I want to break down with you a little bit. One is the how: how this was done, how the cuts were implemented? And, then I'd like to ask you about the core of the cuts themselves, but I hear you saying that this was done in a cruel way because it gave people no warning and no options when it comes to, as you've said, lifesaving medication. To the question of why the United States has to be the leader on this. Why, when funding is cut from and in the U.S. it has this effect so profoundly on Kenya. Why is that the U.S.' role? Speak to perhaps the Trump voter who thinks, ‘Why should that be us given any of the problems that we have domestically?’
Dr. Abuogi: Sure. So I'm happy to talk about this and I think it's a really interesting conversation to have with each other as U.S. citizens. What is our role in the world and what does our funding do? I think in terms of funding HIV care and treatment and prevention, the President's Emergency Plan for AIDS Relief that was launched by George (W.) Bush had the most profound effect on a global illness. It has saved so many lives and in the process it has fostered security for the U.S. in terms of economic security. When so many people are ill and dying, governments and countries become unstable and having stable countries across the world benefits the United States. It reduces poverty so that, again, there are stronger economies that feed back into our global economy and promote health for a very small investment. Less than one percent of the American budget goes to foreign aid overall and even less of that to HIV. If you can promote health worldwide, everywhere I go in Kenya and other countries in Africa have USAID stickers everywhere, on medicines, on buildings, on boxes, on supplies. The influence and the soft power that you have when you do that for other countries is incredible. And we are losing all of that.
Warner: I'd not considered the global economic and political stability aspect of this, so thanks for opening my eyes to that.
Dr. Abuogi: Yeah. I'll just point out, when I first went to Kenya as a pediatric resident in 2004, I went to a very rural place called Suba on Lake Victoria — one of the hardest hit places by HIV. In the hospital wards there were two people to a bed and people underneath the bed, patients. The wards were full, villages of people were dying off of HIV and we turned that around through PEPFAR and USAID and that's what American dollars did. But you have to keep investing. Maybe not the same way. Maybe you change how you're doing it, but if you just stop, it totally reverses all of those gains.
Warner: Are you saying that the clinics were so crowded, people were sleeping under beds, so people were on beds and people were under them?
Dr. Abuogi: That's right. On the concrete floor, people dying of AIDS.
Warner: I am dependent on a medical clinic. It's down the street from my house and if all of a sudden everybody working there was gone, I'm thinking about my continuity of care, I'm thinking about my medical records, I'm thinking about where I take them, where I go. To some extent that has to be a scramble on the ground in Kenya.
Dr. Abuogi: Absolutely. And most of the funding is going to public health clinics, so they're all interconnected. If you cut them all off at once, there is no place to go. When I was there in January, and this was just starting to happen already, patients were what we call “clinic shopping,” trying to go to a new clinic and say, “Hey, I'm traveling,” or “Hey, I'm a new patient, can you give me six months of drugs?” Because they knew that their medicines were threatened and they were trying to already compensate.
Editor’s Note: After the freeze on foreign aid, the State Department issued a limited waiver permitting care and treatment to continue for mother-to-child transmission services. However experts, including the former USAID director under George W. Bush, have said that money is still not flowing to clinics and that the PEPFAR implementation relied heavily on USAID, which was essentially eliminated by the Department of Government Efficiency.
Warner: Let's turn our attention to our own shores for a bit. Can you put the HIV/AIDS epidemic into some specific U.S. context and what are your concerns about preventing and treating the disease domestically?
Dr. Abuogi: Sure. So we have our own HIV epidemic in the United States. Over 1 million Americans are living with HIV and over 30,000 new infections happen every year. In Colorado, we have over 15,000 people living with HIV and 500 new diagnoses each year and all of that funding that treats those folks and prevents infections here in the U.S. and Colorado is also threatened. There are rumors of plans of shutting down the CDC’s division of HIV prevention, who does most of the prevention work through local state health agencies and public health departments. If we shut that down and terminate that — especially if it's so chaotic as it has been done for all the other grants and funding — it is really going to hurt people.
Warner: Are there groups or other nations that would step forward to fill the vacuum? Why don't we start domestically, and then I'll have you answer that from a global perspective.
Dr. Abuogi: Let's talk about our budget in Colorado, and I think you know more about it than I do, but I understand the state budget is short by a billion dollars or something.
So, when we're trying to decide how the Colorado Department of Public Health and Environment is going to fill the gap, how we are going to do that when we already have a billion dollar budget gap, that's why, when we pay federal taxes, we expect some of that money to come back to our state and those federal dollars help us do HIV prevention and treatment and tons of other public health and education and other things in our state. So in some ways we're owed it, we pay it and it helps us. If it's cut off, then we're really stuck. There's nobody to fill that gap when we're already struggling with our own budget deficits in Colorado.
Warner: And then globally, are you seeing other nations step forward? That may very well be a goal of this administration is not to carry as much of the responsibility and burden and let others pick up the mantle? Are you seeing that?
Dr. Abuogi: Not immediately. Let's just talk about it. So in terms of HIV funding globally, about 60 percent comes from countries themselves that are dealing with the epidemic. Probably 40 percent or something like that comes from the U.S. itself. And then we have like four percent coming from donors. Like people want to ask Bill and Melinda Gates or George Soros. four percent is what they're filling. So for other countries to fill in that 40 percent gap, and remember this happened overnight — overnight, people have been given stop work orders, termination orders — if we want to transition, I support that. I support countries owning their own response to HIV and other public health. Let's have that discussion. Let's make it happen. Let's do it strategically. This was not strategic. This was chaotic and cruel.
Warner: I do understand that China may play a role here.
Dr. Abuogi: That's absolutely right. China is already making a lot of investments in countries globally and including those with large HIV epidemics. And to my understanding, the Trump administration feels that China is a threat and is in some ways someone that we don't want having more influence. So if China steps in and takes all of that influence, I was talking about all of that soft power, then why did we do this?
Warner: How much of this has to do with the stigma that still exists around HIV/AIDS?
Dr. Abuogi: I don't know because I don't know the reason for this administration's policies and approach to all of this. There certainly remains a lot of stigma about HIV and anything that is sexually transmitted. Somehow as human beings, we just tend to attach sin to things that are spread through sex or through drug use, and also that are heavily affecting populations that we stigmatize; men who have sex with men and transgender women. We can't even talk about them anymore. So we can't serve them, we can't help them. We can't address the HIV epidemic essentially because we can't use certain words.
Warner: Can you say more about the 500 people a year in Colorado contracting HIV?
Dr. Abuogi: Those are the estimates. It's probably pretty stable. Diagnoses went down in the COVID era because we weren't doing as much testing and have climbed up a bit. So right now I would say we don't know, are the infections increasing or are they stable? But groups in Colorado, community groups, hospitals, doctors, have done a ton of work to increase HIV prevention and to make sure that everybody is in treatment. At our clinic, we take care of children living with HIV, with pregnant mothers living with HIV, and we help them to prevent passing that to their own children. We know that kids who get HIV and don't get treatment, 50 percent of them will die by the time they're two years old. So there are programs in place to make sure that doesn't happen. If that funding goes away, I don't know how we do that very well.
Warner: And talk to me about transmission to the youngest kiddos that happens at birth? In utero?
Dr. Abuogi: It can happen in all of those time periods. So transmission can happen when a woman is pregnant if she's not on treatment. It can happen and frequently happens during delivery if she doesn't get treatment. And then it could happen during breastfeeding. And recently, in the U.S., we have liberalized our guidelines to say that women who are on medications and virally suppressed should be allowed or should have the option if they choose to breastfeed.
Warner: So that, in your mind, is another success story. And also in jeopardy, you fear.
Dr. Abuogi: Absolutely. Five or six years ago, in Colorado, we had three transmissions to babies, three new babies born with HIV and we hadn't had that happen in years. We used a process that the CDC first championed and we brought together the public health department doctors from across the state that were involved in the cases, community groups, advocacy groups, and we sat down and we discussed those cases together and we found out the gaps. And we've made a difference in making sure those things don't happen again. And since then, knock on wood, we have not had any additional transmissions, but if we don't have the resources to provide the services again, those transmissions will happen.
Warner: Doctor, I'm struggling with the phrasing of my next question, so I'll just ask for your forgiveness in advance. But Donald Trump, in a somewhat infamous interview with Howard Stern, likened dating during New York's AIDS crisis to being at war in Vietnam, and I think I'm hesitant with this question in part because I don't want to add to stigma that all HIV is about promiscuity, but it does strike me perhaps that there's a disconnect that cuts to STI prevention and treatment are coming from a man, from an administration who has boasted about his sexual exploits.
Dr. Abuogi: I think it's an interesting irony that a president who was alive and very much at the epicenter of the HIV epidemic in the U.S. — who really championed a program called “Ending the HIV Epidemic in the U.S.” in his first term that's made a huge difference, that has reduced infections by 30 percent in youth in the U.S. — and now is sort of saying, “We should end this all. We should just cut it off to save money for tax cuts.” I'm not sure why we're doing this. The other thing I would say is that I do a lot of HIV education. I talk to youth and college students and others, and I always tell them: I understand this is a sensitive area, but if you all can tell me that every single time you've had sex, you've known the HIV status of the person you had sex with and you used a condom every single time, then stand up and tell me how you did it. Because human behavior is natural and we all have opportunities to acquire sexually transmitted infections, and so we can't judge others and we shouldn't.
Warner: Will you speak to the accomplishments of the Trump administration in its first go round? Just say more about that commitment to AIDS domestically and HIV domestically.
Dr. Abuogi: In 2019, the Trump administration championed a program called “Ending the HIV Epidemic in the U.S.” and it focused on the highest-burden cities and counties and states in the US that accounted for over 50 percent of HIV infections and people living with HIV. And they really put money and effort behind an approach to really drilling down and trying to prevent new infections and to get people on treatment. And it's working, like I said, 30 percent reduction in new infections in youth, 10 percent reduction in new infections in other groups. And so the president should be really proud of those accomplishments and should continue them.
Warner: Before we go, doctor, I want to ask you about a cure. This has been a question I'm sure that you've entertained for as long as you've been in the profession and certainly a conversation that has been bubbling since frankly the discovery of HIV and AIDS. Are we any closer to a cure and does what the administration is doing here jeopardize that or change that timeline?
Dr. Abuogi: Absolutely. So every year we get closer to a cure and that takes dedicated incredible science and it takes funding to do that science. There is amazing research being done in vaccines that could prevent and/or cure HIV, in things we call broadly neutralizing antibodies that could help prevent or even cure HIV. But the funding is being cut across (National Institutes of Health) across the federal agencies. And so this research can't continue if we're not putting money into it. The result again is we're going to have more people living with HIV and when they're not treated, it passes to others. So we're really shooting ourselves in the foot by cutting this all out.
Warner: Are you headed back to Kenya anytime soon?
Dr. Abuogi: That's dependent on my funding. So I am funded by NIH research grants and I need to know that those are still going to be around if I'm able to go back to Kenya, but I have family there, so I will undoubtedly go back and I will continue advocating for the people there.
