The boy is twelve. The clinic gate is chained at four in the morning. He does not need the clinic yet. He will need it in eleven years, when his blood is drawn and the result comes back and no one is there to start the treatment. You signed your name on the paper that closed the gate. You called it reform. You called it restructuring. You called it bringing American tax dollars home. The boy’s mouth is dry. The gate is cold.
PEPFAR, the President’s Emergency Plan for AIDS Relief, was created in 2003 under President George W. Bush. It is credited with saving at least 26 million lives. In January 2025 the Trump administration began dismantling the United States Agency for International Development, which managed more than half of PEPFAR’s grants — a process already reshaping HIV/AIDS efforts across the continent. The dismantling was completed in July 2025. A waiver issued by the administration in February 2025 theoretically permitted programs providing life-saving treatment or preventing mother-to-child HIV transmission to continue. The theory did not reach the ground.
The amfAR PEPFAR Pulse report, presented at the 26th International AIDS Conference in Rio de Janeiro, surveyed 166 organizations across 46 countries that had been due to receive PEPFAR funding in 2025. More than half had at least one terminated award. More than 1,700 clinics and drop-in centers closed. More than 16,000 full-time staff lost their jobs. Almost two-thirds of organizations providing services to prevent mother-to-child HIV transmission reported disruption; a fifth ended those services entirely. The report documents what happened after the signature was dry.
Donald, you signed your name on the paper in February. The waivers promised to protect life-saving treatment. The clinics closed anyway. The supply chains broke. The cold chain for antiretrovirals — the chain of custody that keeps the medicine viable in the heat of sub-Saharan Africa — was severed at a link the people who severed it had not considered because the people who severed it had not stood where the medicine was kept. In those months, children were born HIV-positive whose mothers would have received the antiretroviral prophylaxis the waivers were written to protect. The promise exists on paper. The infection exists in the blood.
Your throat, Donald. The residue of the promise is under your tongue when you drink your morning coffee. It does not dissolve. The 1,700 clinics your signature closed are 1,700 gates. The 16,000 workers your signature dismissed are 16,000 hands that held the needle, that drew the blood, that started the child on the regimen before the child’s body was destroyed by what the regimen was designed to prevent. You did not touch those hands. You did not see those gates. Your diaphragm did not drop when you signed. The signature was clean.
Elise Lankiewicz, policy associate for amfAR and co-lead author of the report, told the room what your people could not be bothered to learn: “It was incredibly hard to cut one award without there being ripple effects throughout the system.” “No part of the program really escaped unscathed — and that includes areas of the program that this administration intended to protect.”
Nearly 80 percent of the organizations still operating reported they had been asked to restrict their work to comply with additional U.S. policies. The executive orders on diversity, equity, and inclusion. The expanded global gag rule. The restrictions on reproductive rights and gender-affirming care. They stopped reaching sex workers. They stopped testing gay and transgender people. They stopped distributing clean needles. They stopped taking the calls from women fleeing partner violence. They stopped the work your waivers were written to protect. The populations most vulnerable to HIV — the very people PEPFAR was built to reach — were the first to be cut. Your document said life-saving. Your document meant the life-saving we approve of. The child’s blood is not interested in your approval.
This is the oldest trick the powerful know. Frame abandonment as protection. Frame the closing of the clinic as the safeguarding of the clinic. Frame the gag order as the condition under which aid is delivered. Dress the cruelty as principle. The principle is that sex workers and people who inject drugs and gay and transgender people are populations your administration has decided do not warrant the expenditure of American compassion. The cruelty is that children will be born with HIV in countries where the treatment existed and your signature closed the clinic. The document does not say we are abandoning the most vulnerable. The document says compliance. The word is a cloth over a wound. The wound is the child’s blood. The cloth does not stop the bleeding.
In the Gospel of John, Jesus says: The hireling fleeth, because he is an hireling, and careth not for the sheep.
You did not flee. You walked into the office. You signed the paper. You scheduled the press conference. The sheep did not flee either. The sheep stood at the clinic gate at four in the morning while the chain was put on. The sheep did not know the name of the man who ordered the chain. The sheep knew the name of the nurse who was no longer there — and the boy, too, knows a name. Yours.
Donald, your name is on the paper. The clinic gate is locked. The child is standing outside. The gate is cold.