Why Fund AIDS Relief? A Q&A with Matthew Loftus

As the Trump administration has functionally frozen The President’s Emergency Plan for AIDS Relief (PEPFAR), Matthew Loftus speaks with The Vital Center editor-in-chief Thomas D. Howes about what this means for Africa, the USA, and the world. Loftus shares insights from his knowledge and experience as a family doctor living in Kenya. You can learn more about his work on his blog.

Thomas Howes: What got you interested in missionary work in this part of the world?

Matthew Loftus: I wanted to be a part of medical education missions to help train African medical professionals, and there is a strong Family Medicine residency based in Kenya.

TH: Is HIV a major factor in people’s daily lives?

ML: Thankfully, not at this point. We still see people who come to the hospital with AIDS-defining illness (meaning that they didn’t know they had HIV or they were not taking their medication, and they are very ill. People living with HIV have to take their medication every day or risk losing control of their illness, but PEPFAR and other programs help them to keep their HIV under control.

TH: How does the prevalence of HIV in Kenya impact your practice as a physician?

ML: We are always considering HIV as a possible diagnosis for our patients, and it occasionally is the culprit. In some cases, it is then fatal. More often, though, we are seeing patients for their diabetes, hypertension, heart disease, COPD, etc. who are also living with HIV, and the virus is suppressed because they’ve been faithfully taking their medication.

TH: Do you have a specific patient story that illustrates how access to HIV medication and counseling has changed someone’s life? How did they feel when they learned about treatment options—frightened, relieved, hopeful?

ML: I think about a friend of mine who now works as part of a Christian ministry to help underprivileged women. Finding out that she was HIV-positive was a huge blow, but she was really hopeful to hear that she could be treated. Now she is anxious that she’ll lose access to the drugs that have kept her healthy and strong for years.

TH: Your master’s thesis dealt with the role of government in public health. What can you tell our readers about that?

ML: There are some things that the government is very good at doing when it comes to health, like managing big projects affecting large groups of people (e.g. vaccines, sewer systems, distributing medications). There are other things that have a huge impact on health that the government isn’t very good at doing, like encouraging people to eat a healthy diet or having good relationships with others. I think that the government should do what it can to prevent unnecessary deaths, but it should be very cautious about intervening in areas where there’s weak evidence or limited possibility for impact.

“There are a lot of important strategic priorities for our nation on the African continent, so having some ‘soft power’ and goodwill goes a long way. Preventing death is a good thing that I think a lot of Americans are willing to invest in, but it also keeps African economies from going south and pressuring even more people to migrate.“

TH: Indeed, many Americans have concerns about government involvement in public health precisely for the reasons you mentioned. They are concerned that the government will spend large sums of money only to have little impact, or worse—a negative impact.  But it sounds like PEPFAR closely fits the description of a big project affecting large groups of people. In your experience, how well-managed is it?

ML: In my experience, PEPFAR is very well-managed. They are very careful about how they spend their money and how they hold people accountable for money that is spent.

TH: What would you say to those who are concerned PEPFAR is costing Americans too much with little benefit at home?

ML: First, PEPFAR is a tiny fraction of the federal budget (about 0.1 percent of federal spending overall). Cutting it won’t allow us to balance our budget or pay for other domestic priorities. It’s a small investment with huge, lifesaving benefits.

Second, the benefits to US citizens may not be immediately obvious, but they accumulate over time. Containing a deadly virus is an important public health priority for the world—if HIV were to mutate and become resistant to medications (or spread via droplet), it would come to our shores and wreak havoc here. There are a lot of important strategic priorities for our nation on the African continent, so having some “soft power” and goodwill goes a long way. Preventing death is a good thing that I think a lot of Americans are willing to invest in, but it also keeps African economies from going south and pressuring even more people to migrate.

TH: And what would you say to those who say that programs like PEPFAR enable risky behavior, thereby exacerbating the problem? 

ML: Most people diagnosed with HIV become much more careful after they learn that they have it. It’s a huge wake-up call for people who were engaging in risky behavior. Taking medication faithfully will actually suppress the virus to the point where people cannot spread it to someone else. People in PEPFAR treatment programs aren’t just handed their drugs—they’re actively counseled to change their behaviors by the healthcare providers who are treating them.

TH: It’s remarkable that drugs can now keep an infected individual from spreading HIV to others. Is it fair to say, then, that treatments provided by initiatives such as PEPFAR are also a form of prevention?

ML: Absolutely. I think that the greatest benefits we will see from PEPFAR in the years to come will be from the power of suppressing the virus in preventing the spread.

TH: You also mentioned that patients receiving aid through PEPFAR are not just handed medication but are provided counseling on topics such as risky behavior. Is such counseling or education the choice of doctors and nurses in your area, or is it a standard part of PEPFAR programs everywhere?

ML: Counseling like I described is a standard part of PEPFAR programs everywhere. There is still a lot of stigma and shame around HIV diagnosis and treatment, so counseling is a critical part of making sure that people start and remain adherent to their medications.

TH: As of 2023, about 3.2 percent of Kenyan adults ages 15–49 are living with HIV. By comparison, the prevalence rate in the USA is .0037 percent. Striking as these numbers are, HIV infection in Kenya is actually down from its peak in the mid-1990s. Did PEPFAR play a role in this progress? Is there still a role for it in the future?

ML: Yes, PEPFAR played a huge role in bringing these numbers down. There is still a role for PEPFAR in the future—it’s conceivable that in our lifetime, HIV might go the way of smallpox and polio if we continue to invest in treatment and prevention.

TH: For those who want to see PEPFAR continue, what actions can be taken?

ML: Right now, the Secretary of State Marco Rubio has the final say when it comes to reviewing PEPFAR contracts and grants. Many have already been canceled. However, as Congress discusses the new budget for next year, PEPFAR will have to be appropriated funds. For many years, funds were approved on a 5-year cycle but last year only a 1-year appropriation was given.

For now, we should ask that all PEPFAR care and treatment partners that received termination notices have their grants reinstated and be allowed to continue their activities without further interruption. In the weeks to come, we should ask for support from Congress for PEPFAR by reauthorizing the program for five years

TH: What can the world expect if PEPFAR remains defunded?

ML: People are resourceful, and I suspect that other foundations and governments may step up and help fill in the gap. But PEPFAR has been doing a lot to help people, and people can expect to see deaths due to HIV/AIDS rise in the next few years. There will subsequently be poor economic growth and perhaps worsening conflicts in some African countries. They may see more virulent or dangerous HIV mutations. They will see less capable and cooperative American allies across the world. They will see America lose its position as a leader in global health, which simply makes us... less great.