PEPFAR shutdown could kill millions

A Christian development economist’s perspective on the crisis

This blog post is based on a podcast conversation between JD Bauman, Director of Christians for Impact, and Colin Aitken, who contributed to the PEPFAR report, an independent analysis of PEPFAR’s effectiveness. The interview explores the program's remarkable effectiveness, its current suspension, and what Christians can do in response.

Colin did his PhD in algebraic topology but currently works on development economics research, particularly in the areas of water treatment and child mortality at the University of Chicago's Development Innovation Lab.

Introduction

PEPFAR (President's Emergency Plan for AIDS Relief) is a US aid program started by George W. Bush in 2004. It has been credited with saving millions of lives and transforming the global HIV/AIDS landscape. PEPFAR was recently stopped as a part of the freeze of USAID programs by the Trump administration and now faces an uncertain future.

What PEPFAR Did

PEPFAR was started to address the global HIV crisis. At the time, HIV had largely been contained in the United States through education and antiretroviral medication, but many countries in Africa were experiencing devastating death rates.

Colin:

“In some countries, most of the deaths were people dying of AIDS. This was an enormous crisis. And [President Bush] said, basically, ‘We are going to heal everybody by doing this massive drug campaign.’”

When PEPFAR started, antiretroviral HIV medication cost roughly $1,000 per month. Many economists questioned whether spreading antiretrovirals would be cost-effective and suggested that alternatives like condom distribution might be more efficient.

However, PEPFAR's massive investment in antiretrovirals drove innovation and dramatically reduced costs. "Now the cost is like $60 for an entire year of treatment compared to $1,000 for a month—something like a hundred times cheaper than it used to be," Colin notes. PEPFAR’s results have been remarkable. HIV rates have declined significantly worldwide. New infections and deaths are at approximately half their peak levels.

JD and Colin also briefly discussed HIV transmission methods and questions of personal responsibility.

Colin: "Especially in Africa, the majority of people who get HIV are women or children. Children usually get it through their mothers. A very common reason for women getting HIV is that they are in a committed marriage but their husband cheats on them and goes and gets HIV and brings it back to them."

PEPFAR's Current Status

Shortly after President Trump's January 2025 inauguration, all U.S. foreign aid was frozen across the board. Although a humanitarian waiver was later introduced to allow life-saving programs to continue, implementation problems prevented many critical programs from resuming operations.

Colin:

If your boss says there's a waiver but then the treasury says they're still not giving you any money to do your work, you don't really have a way to get things done … I think Leah Sargent, who's also part of the EA for Christians community, has described this as ‘they pushed the emergency stop button, but there wasn't an emergency start button’.

The sudden freeze created logistical challenges that aren't easily resolved. When USAID staff who were distributing PEPFAR medications were furloughed or removed from the field, restarting operations became complex. According to Colin, "the vast majority of PEPFAR activities are still stopped."

Addressing Common Criticisms

Colin and JD discussed the criticism that foreign aid creates dependency by reducing incentives for countries to develop their own solutions. Colin offers several perspectives on this issue.

First, there's an enormous wealth disparity between the U.S. and many recipient countries. Colin points out that US GDP per capita is more than a hundredfold of the GDP of Malawi. This suggests that wealthy nations have a responsibility to assist those with far fewer resources.

Second, there's a significant misconception about U.S. foreign aid spending. "When you ask people what should the government spend on aid, it's around 10%. The current spending is around 1%," Colin explains. "The problem is that people currently think the government spends about 25% on aid."

In reality, PEPFAR represents just 0.08% of the federal budget. Colin and JD estimated that if an American got the part of their taxes that paid for PEPFAR refunded, it would be 15–30 dollars.

PEPFAR has also been working toward sustainability by gradually transferring responsibility to local governments and organizations.

Colin:

Over time, we've been handing off more and more of the responsibility and the costs to the local government. Even when the US provides most of the funding, it's given to local groups who are doing the actual work, and the US does audits.

Evidence of PEPFAR's Effectiveness

To verify PEPFAR's effectiveness, Colin and his colleagues conducted an independent analysis using data sources unrelated to PEPFAR's self-reporting. Their approach examined country-level mortality data collected by other nations for their own purposes. In PEPFAR-recipient countries, they observed significant drops in mortality rates coinciding with the program's implementation. They also conducted a ground-up analysis looking at antiretroviral effectiveness and distribution rates.

Colin:

The different evidence we looked at all aligned on pretty similar numbers. We are pretty confident that between 7.5 and 30 million lives were saved by PEPFAR.

Even more remarkable is the cost-effectiveness. While U.S. domestic health programs are willing to spend around $5 million to save a life, PEPFAR has achieved results at approximately $3,600 per life saved. This makes it on par with the most effective global health charities recommended by GiveWell.

The Human Cost of Stopping PEPFAR

The sudden halt to PEPFAR has catastrophic implications in terms of human suffering. Colin’s rough back-of-the-envelope guess is one or two million deaths per year until PEPFAR is reinstated or a similarly effective foreign aid program is implemented.

To put this in perspective, JD mentions the recent plane crash in Washington DC that claimed 67 lives and made national headlines for weeks. The loss of life from PEPFAR's suspension would be equivalent to such a crash occurring every hour until the program is reinstated. The scale is difficult to comprehend.

Can Others Fill the Gap?

One natural question is whether private foundations or other entities could step in to fill the gap left by PEPFAR. Colin believes this would be challenging due to the abrupt nature of the shutdown:

If PEPFAR had been stopped with some warning, or even if they restarted it now and said, 'We are going to fund two more years of this program, and then it's going to shut down,' the people in PEPFAR could have worked with an external organization to do the handoff properly.

But because the shutdown happened so suddenly, critical information about partners, suppliers, and distribution networks is no longer readily accessible. While other entities like the EU could theoretically establish similar programs, the transition would inevitably involve significant human costs compared to simply continuing PEPFAR without interruption.

What Christians Can Do

When asked what Christians who care about impact can do about the PEPFAR suspension, Colin offers straightforward advice:

Especially if you're living in a red state, calling your representative or your senator and saying, 'Hey, this program is really important to me as a Christian. Can we find a way to bring it back?'

Colin believes that representatives do listen to constituents to determine priorities, especially when many issues compete for attention. “We're in a situation where this program has saved 19 million lives very cheaply, and it's being canceled.”

He also emphasizes the importance of increased giving to global health organizations. “I definitely think upping global health donations is going to be important. As Christians, we have some calling to try and temper [the increase in global disease and suffering] by giving more.”

Colin would prioritise PEPFAR among foreign aid programs:

If you are going to do one thing for foreign aid, saving PEPFAR should be that thing.” This relatively small investment—less than 10% of the foreign aid budget, which itself is only about 1% of the federal budget—yields extraordinary returns in lives saved.

Beyond Suffering and Saving Lives

When working at scale across millions of people, we inevitably simplify complex lives. While this is necessary for effective intervention, Colin cautions against reducing people solely to their suffering:

You can't go to every single person around the world and understand at a deep level what makes them tick. But you can go to millions of people and say, “Hey, you have HIV. It is causing you a lot of suffering, and I can help you. I can help you not give it to your baby so your baby can live a healthy life.”

This approach addresses a common criticism of effective altruism—that it focuses too narrowly on metrics like lives saved while neglecting other aspects of human flourishing. Colin acknowledges this concern but offers a nuanced perspective.

“The temptation to avoid as an effective altruist is thinking that's the only thing in people's lives. You say, 'The only thing that matters about this person is that they have HIV and I have fixed that and I am the main character in their life story.'"

Instead, Colin suggests a posture of humility.

If you start thinking, 'I need to have an impact on every aspect of someone's life,' you end up not doing much because there's no way you can affect that. But if you can take someone who was going to die and let them live a full life, you can recognize there are going to be other things important to them.”

This humble approach acknowledges both our capacity to help and our limitations. "Your lane is this thing you are able to affect as an individual," Colin concludes, "and everything else is up to them and God and their community and the people they love."