PEPFAR: The anti-AIDS program that changed the world now under threat

Twenty years ago, President George W. Bush launched a massive public health initiative – known as PEPFAR.

Some health workers in Africa say the results have been miraculous.

"PEPFAR is equal to the United States. People know you say PEPFAR, people know PEPFAR is USA," Nkatha Njeru, CEO of the Africa Christian Health Associations Platform, says. "So it's been a very good thing that the Americans have done."

Now, a small group in Congress wants to kill the plan.

Today, On Point: Why one of the most successful public health programs is in peril.

Nkatha Njeru, CEO of the Africa Christian Health Associations Platform, an umbrella group which serves Christian Health Associations and Church Health Networks in Sub-Saharan Africa.

Shepherd Smith, co-founder of Children’s AIDS Fund International. Co-author of the forthcoming book "A Journey of Faith."

Sarah Owermohle, Washington correspondent at the health and medical news website STAT.

Dr. Mark Dybul, U.S. Global AIDS Coordinator during the Bush Admin.

Part I

DEBORAH BECKER: One of the most successful public health programs in history is under threat. The program started 20 years ago and it's saved millions of lives. It's called PEPFAR, short for the President's Emergency Plan for AIDS Relief. In his State of the Union address in 2003, then President George W. Bush explained why help was needed to stem the devastation from HIV and AIDS.

GEORGE W. BUSH: Today on the continent of Africa, nearly 30 million people have the AIDS virus, including 3 million children under the age of 15. There are whole countries in Africa where more than one third of the adult population carries the infection. More than 4 million require immediate drug treatment. Yet across that continent, only 50,000 AIDS victims, only 50,000, are receiving the medicine they need.

BECKER: Bush chose Dr. Mark Dybul to design and implement the program, and Dr. Dybul remembers that State of the Union address well.

DYBUL: And I remember thinking two things. One, this is one of the most extraordinary acts of mercy, which is what the president called it, one of the greatest things in the history of humankind.

And secondly, "Oh my God, now we actually have to get it done."

BECKER: In the two decades since, PEPFAR has saved millions from disease, death, and orphanhood. Congress has reauthorized PEPFAR every five years since, and it's always enjoyed broad bipartisan support. Not this year. It's up for renewal in just two days.

And a former chief supporter, Republican New Jersey Congressman Chris Smith, says the Biden administration has turned the program into a slush fund for abortion programs in Africa.

CHRIS SMITH: In comes Joe Biden. He puts out brand new guidance to all of the recipients of PEPFAR, 6.7 billion, and says, "You have to now try to change the laws in the countries you're operating under for sexual and reproductive health and rights." Which means on the LGBTQ agenda and on the abortion agenda. And they're not trying to protect life. Believe me.

BECKER: But many dispute those claims, including former President Bush himself, who is urging Congress to reauthorize PEPFAR. I'm Deobrah Becker, in for Meghna Chakrabarti, and this is On Point. This hour, the PEPFAR program, the new pushback, and what happens if it goes away.

Joining me from Nairobi, Kenya is Nkatha Njeru. From 2002 to 2008, she ran an HIV clinic at Nazareth Hospital, near Nairobi. Since then, she's been CEO of the Africa Christian Health Associations Platform.

That's an umbrella group serving Christian health associations and church health networks in Sub-Saharan Africa. Nkatha, thanks for being on Point.

NKATHA NJERU: Thank you for having me.

BECKER: And joining us from Washington is Shepherd Smith. He's co-founder of Children's AIDS Fund International. He's an evangelical Christian who says he's opposed to abortion in most circumstances, and he's worked on this issue for decades.

Shepherd, welcome.

SHEPHERD SMITH: Thank you for having me.

BECKER: So I want to start with reminding folks of what it was like 20 years ago and why PEPFAR was so needed. So let's start with the intent of the program. And I think perhaps the best person to explain this is former President George W. Bush. Here's a little bit more from that State of the Union address and his vision for what PEPFAR was going to be.

BUSH: This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life extending drugs, and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.

I ask the Congress to commit $15 billion over the next 5 years, including nearly $10 billion in new money. To turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.

BECKER: I want to ask you, Nkatha, you have a history of working in health care even before PEPFAR. I wonder, can you tell us about what it was like before this program was put in place and how AIDS and HIV care in Africa has changed since?

NJERU: Thanks. I'm very nostalgic about what was and what has been since PEPFAR. I remember working in conditions where we knew there was HIV and AIDS. And we could test people and know that they were HIV positive. But we did not have much to offer. So we would tell someone that you have tested HIV positive and talk about, counsel them and make sure they have the right mind to go on with their life.

Talk about their nutrition. And then we would tell them that you can access treatment, but it's going to cost about $100 a month at the time, just before PEPFAR. And then we had women who tested HIV positive. We would advise them not to get pregnant because if they were pregnant, their children would be born HIV positive.

BECKER: And we should say

NJERU: That was before.

BECKER: We should say, was it difficult, I would assume for many people to afford the $100 a month for treatment?

NJERU: Definitely. Definitely. With many people living below $1 a day, $100 was out of question. And so people didn't even want to test because they couldn't afford the treatment.

BECKER: They wouldn't test because they couldn't do anything about it anyway.

NJERU: Yes. Yeah.

BECKER: And so did you see a lot of destruction?

NJERU: Yes, there was a lot of death. There was a lot of stigma. I remember a woman whose family had abandoned her in the house, and they had a plate that they would put food on the door, and they had a basin that she would use as her toilet, and they would come and look every day to see if she had died.

But this was just a few months after PEPFAR and we were going around villages and trying to get people to get tested and get treated. And exactly one month after we put her on treatment, she was back on her feet and she's alive today.

BECKER: Yeah. So you've seen remarkable changes, then, since PEPFAR.

So then it allowed people to get treatment for free instead of paying $100 a month and it allowed women to get treatment, especially pregnant women. Is that right?

NJERU: Yes, that's right.

BECKER: Would you call. I've heard many folks say it's one of the most successful public health programs in history. Would you agree?

What, why?

NJERU: Tremendous success. Having provided access to treatment, both financially and also because now we were able to get treatment to everybody through the various, for health facilities that were able to offer treatment. We were also able to get a lot of advancement in healthcare because with PEPFAR came advancement in technology.

We were able to collect data on our patients. We were able to train health workers to diagnose as well as treat people and HIV really is, you have a collection of other things that come with the immune syndrome. Because you need to be able to treat all the opportunistic infection. So there was advancement because health workers were trained on how to treat a lot of the different opportunistic infections and then there was availability and there was choice.

And hope for families, because if a woman had never had a child live beyond 2 years, because a lot of the children who were born HIV positive without any intervention would die before they got to 2 years, if at all they survived, then a woman is able to hold her child and at two years you graduate.

We say we graduate them out. Because at two years you test a child as having tested HIV negative, having been born of an HIV positive mother, then they're definitely HIV negative. The joy of those women was something to me. So there was a lot of hope. PEPFAR came with tremendous hope.

BECKER: Shepherd Smith, I'm wondering what you think of what you just heard from Nkatha. And your work really before PEPFAR and what you think, why you think it's been so successful.

SMITH: I want to reiterate what Nkatha said in respect to the conditions prior to PEPFAR and what President Bush pointed out.

We first went to Africa, we started in this issue in 1985. We went to Africa in about 1995 and saw a great need there. And in the villages, the people, the only people really making money were the coffin makers. And they were seen virtually in any country along the sides of the roads. It was a very desperate situation for the African communities.

And we had the good fortune of traveling with Secretary Thompson in March of 2002 to assess what sort of health facilities were in Africa that could treat large numbers of people. And what we saw was that there were a few bright spots in government facilities, but the facilities that offered the most were faith-based clinics and hospitals.

And so PEPFAR was partly designed to get resources directly to these facilities, which was really brilliant. Because it allowed the program to expand quickly and reach a lot of people. It really was miraculous how many people were able to access treatment and have their lives turned around.

People would come in with what was called then, slim disease, because people with AIDS, their bodies would just wither. And after treatment, it wasn't long at all that when they came back, they were healthy. It was really what's known as a Lazarus effect, but it was just incredibly gratifying to be a part of this program to save so many lives.

And globally, this is the largest health effort in history by any country and to consider that we have saved over 20 million lives and probably 5 million children or so. It is a very much life affirming and lifesaving program.

BECKER: Okay. PEPFAR is up for reauthorization. In fact, reauthorization is supposed to be done by the end of this month, which is in two days.

Yet there are some political forces in Congress who might hold that up. We're going to talk about that when we come back. I'm Deborah Becker. This is On Point.

Part II

BECKER: I wonder if we could talk a little bit about why PEPFAR, the program that we've been discussing, is under threat in Washington right now. There are some who say that PEPFAR funding is going for abortions in Africa. Here's Republican Congressman Chris Smith on a radio show in June, accusing the Biden administration of ruining PEPFAR.

CHRIS SMITH: They have hijacked a great program and now turn it into an abortion promoting program, and the Africans don't want it. But if you give enough money and enough of the deception that they're so capable of, we see it in our own country, how deceptive the abortion lobby is. In Africa, they're just as deceptive using well-honed skills to lie and deceive in order to kill unborn babies.

BECKER: Shepherd Smith. I wonder what do you make of the allegations that you're hearing in the U.S. as reauthorization of PEPFAR is going forward?

And you've actually looked into some of these allegations. So tell us about that.

SMITH: Yeah, when we first heard the rumor that was put out by the Heritage Foundation and FRC, we were stunned. We've had involvement in this issue now for 38 years and in Africa for 21 years at least, or actually more than that.

And I never ever heard the word abortion mentioned in Africa, let alone ever knowing that abortions had occurred anywhere. Because, first, it's illegal in most countries in Africa. Second, the family is a critical element for that society and wanting to have more children. You have high infant mortality and morbidity.

And so large numbers of children are needed for families, particularly those that are related to agriculture and small trades. So it didn't, it just didn't make sense. It did not add up. And the more we looked at The Heritage letter, The Heritage backgrounder an op-ed that was written by somebody from Heritage, It was clear they didn't really understand Africa, they really didn't understand the PEPFAR program, but unfortunately, they convinced the pro-life community here that was something that was happening when it wasn't.

We went to PEPFAR. We went to find out what sort of oversight they've had on specifically on this issue and the most recent head of PEPFAR and then the person that acted as the interim director, first [Deborah] Birx, and then Angeli [Achrekar] shared how scrupulously were with all the groups to look for any indication that abortion was occurring.

I went to some of the organizations that Congressman Smith had asserted might be doing these things, none of them wanted to jeopardize large multimillion dollar contracts to spend a few thousand dollars on an abortion where they would then lose that contract. It just made; it made no sense.

BECKER: Or could they have been indirectly related to lobbying for abortion?

Is there any threat of truth to any of this or is it just made up?

SMITH: Yeah. It's really all made up. I found no evidence whatsoever that PEPFAR is related to abortion in any way. And in respect to what was found in the reimagining PEPFAR, when I saw both the references to reproductive sexual health, and then one that has the word rights included with it, the first part of PEPFAR that the U. S. folks don't understand is that reproductive sexual health is, has no reference or relationship to PEPFAR, to abortion, excuse me.

You have women who have HIV, who often have other STDs. And you have to look at that. You have mother to child transmission that saves all these babies. And they have to be involved in reproductive sexual health.

It's only when the word rights comes in that leads people to believe. I brought that to the attention of the present head of PEPFAR.

Ambassador John Nkengasong, just a wonderful human being, if I can say that. Who immediately looked at this, immediately found nothing in all the people he interviewed, had groups were potentially suspect examined again, and there was no evidence anywhere for abortion.

BECKER: Excuse me for interrupting, but Congressman Smith, right?

He was a friend of yours. Did you say, did you talk to him about this? Did you say, and why do you think he's making these allegations if you did and pointed out that they're false?

SMITH: We've known Chris for, or Congressman Smith, for close to 40 years probably. And, we traveled to Africa, to Uganda with he and his wife.

We've been good friends, and I am mystified, absolutely mystified by why he went down this road. I think when you have a lot of the core conservative groups, and the pro-life groups who he's worked with forever all say this is a problem, he had to jump in. He didn't have a choice but to look at this.

But when due diligence wasn't fully done as completely as I think it should have been. He just acquiesced to the narrative that was being presented to him. And I think it's a terrible mistake.

BECKER: Did you ask him?

SMITH: Pardon? Did you ask him?

BECKER: With a decades-long friendship, did you say, "Hey, Chris, what's going on?"

SMITH: I've interacted with his staff. I would rather not get into what would probably be a heated argument with him. And I would rather get through this without that happening, but he's just totally mistaken.

BECKER: And Nkatha, I wonder what do you think about these allegations and what are you hearing about suspicions of the misuse of PEPFAR funding?

NJERU: Being respectful of the concerns we have been looking ourselves and waiting to hear of any evidence that has not come forth. And I have worked on PEPFAR now for 20 years, since 2003 and the rules of PEPFAR are stringent. In general, U.S. government funding has very stringent guidelines for its application and I do not have any evidence of the funds being used against the rules. And so for me, my message to the people that have these allegations is, "Can we get any evidence and use that evidence to correct whatever it is, if there is any?" Which I do not think is there, but let's not throw out a pro-life initiative like this.

Which is what, if they are pro-life, PEPFAR is really pro-life.

BECKER: Yeah. Let's talk a little bit about the politics.

I want to bring in Sarah Owermohle to the conversation. She's a Washington correspondent at the health and medical news website STAT. Sarah, let's talk about why. We can't quite understand why these accusations are coming forward right now for a very successful public health initiative like PEPFAR.

Tell us what's at risk here and what might be happening. Is reauthorization truly at risk or do you think we're going to see some sort of compromise from lawmakers in the next two days?

SARAH OWERMOHLE: Thank you, Deborah. I think the why is really interesting because, as Shepherd has said before, this has been a bipartisan effort.

This has been supported by Republicans since President Bush. And also this policy that Representative Smith is talking about is not new. Every Democratic President has rescinded the so-called Mexico City policy or global gag rule, as it's called, which limits funds from going to providers who do abortion counseling or services, and every Republican has implemented it again.

So this is not new. What's new is that we're in a post Roe America, and I think this is pretty emblematic of where the Republican Party is as a whole on how far they want to go on abortion limits. And so Representative Smith is taking this sort of domestic conversation and applying it to PEPFAR. In terms of the authorization, two things are going to happen this Saturday.

It's authorization for PEPFAR, and then also the budget. We're looking at the moment, a total shutdown. The good news is that PEPFAR is considered one of the government's essential programs. In the event of a shutdown, money will still be going to it, but the question is what PEPFAR is allowed to do.

Even Democrats at this point are saying that a five-year authorization, reauthorization I should say, is looking increasingly unlikely. They're pushing for maybe three years. Representative Smith is pushing for one year with these limits put back in place. And even some of his own Republican colleagues are saying that's totally unrealistic.

I think it's worth noting that in the Senate, Lindsey Graham, who is a Republican and the co-sponsor on the Senate version of this, has been asked about these allegations by my colleague, John Wilkerson, and he said, "I have seen no evidence of that." So Smith is not acting with the full support of his party at this point either.

BECKER: And we should mention former president George W. Bush, who started PEPFAR has been talking with lawmakers. He's written an op-ed urging Congress to reauthorize PEPFAR. Is that, do you think that's affecting deliberations or does that have any impact here?

OWERMOHLE: It's an interesting question because, obviously this was, it is an example of course, President Bush being the champion of this, that this has been so historically bipartisan, but this is a different Republican party than the one that he knew when he was president.

And there's a lot of, I think, social politics going on here. Like I said earlier, in a post Roe America, this is pretty emblematic of where the Republican Party is. And you even see that playing out on the debate stage for the Republican presidential candidates, where each of them is saying that they are anti-abortion, but then having to define what they mean by that and how far they're willing to go with limits.

And so I think that, as Shepherd said earlier, this isn't necessarily, PEPFAR has never been about an abortion debate. I think the problem is though, and to politely push back on something Shepherd said. Republicans have sought to untether family planning from abortion, especially in the wake of Roe.

And I think it's very difficult to do that. Because you see there is data from when the Mexico City policy was in place, that more unintended pregnancies happen and potentially more abortions happen. So you can't really untangle these two things. Family planning, contraceptives and abortion from each other.

BECKER: Okay we'll let Shepherd talk about that in just a minute. I just want to get into a little bit more about this political debate, because I think it's fascinating. I think that what you're saying here is this is really an example of abortion politics affecting this program, despite its success, and despite the fact that many involved in PEPFAR, actually dispute the accusations that there's any connection to abortion at all.

Albeit it may be hard to disentangle family planning and other things from abortion. But I do want to play a piece of tape here from Travis Weber with the Family Research Council. He's among the anti-abortion groups who have been talking to lawmakers about this. Here he is speaking with his boss, Tony Perkins, on a radio show, Washington Watch.

And he had a warning to Republican lawmakers. Let's listen.

WEBER: Anyone who wants to be pro-life in their political voting record, we have to say PEPFAR cannot go as it has been. It has to be amended to include the protecting life and global health assistance policy, expanding Mexico City policy to prevent it from funding abortion.

It's really clear.

So Tony, this is, it's important and it's important that Congress be aware and take this step.

BECKER: Sarah Owermohle, I just wonder, is this really a referendum on abortion for Republican lawmakers? And will they take that threat seriously and could it affect deliberations?

OWERMOHLE: I think it is fair to say that it's a bit of a referendum on abortion because we've even seen, you know, at the same time, as this conversation is happening around PEPFAR, we do have the budget discussions and House Republicans have sought to put things into a previously uncontroversial defense bill that would further limit abortion federally, as well as other sort of social political things like gender affirming care.

And so this is something that's already playing out in the United States, and now it's just been tacked on to the PEPFAR discussion when the international discussion about abortion. I think what's interesting is that both of these things are coming to a head on Saturday with both the budget, the funds for any of this, and then the authorities for PEPFAR.

And like I said earlier, PEPFAR will still keep its doors open in the event of a shutdown, but we're really talking about what they're allowed to do going forward.

BECKER: And Nkatha mentioned earlier that the rules on this program are already very stringent, and we certainly know that there are amendments preventing funding for abortion from various U. S. programs. I'm wondering, could there be some sort of compromise here in terms of strengthening the regulations? I know you mentioned the Mexico City policy. Is that on the table as well?

OWERMOHLE: Going back to what Senator Lindsey Graham said to one of my colleagues when he was asked about re-implementing the Mexico City policy during this administration, he simply said, "That is not realistic."

So if even other Republicans are saying that's not on the table right now, I don't think that it is. I think that what we're talking about now is probably a pretty narrow reauthorization. Normally, PEPFAR is authorized for five years. And I think that probably what is going to happen as we move forward is that Representative Smith and other House members, because this really is a House Republican driven conversation at the moment, are going to probably have to negotiate down on what they are talking about, especially since Republican senators don't seem as moved by this argument.

Of course, I don't mean to speak for all Republican senators, but the ones who are leading on this debate are. But I would also note that there is a little bit of a hitch as well because in for Democrats, because in the Senate, Senator Bob Menendez is the sponsor on this and he's embroiled in his own scandal at the moment.

BECKER: Of course. Big trouble.

All right. Sarah Owermohle, Washington correspondent for the health and medical news website, STAT. Sarah, thanks so much for being with us.

OWERMOHLE: Thank you for having me.

Part III

BECKER: We've been talking about this earlier and about the politics and abortion politics really affecting the program known as PEPFAR.

And I wonder Shepherd Smith, let's start with you. We heard from Sarah Owermohle earlier in the show, and she said, five-year reauthorization, which has been done for the past 20 years, is unlikely. How will that affect what's happening on the ground, do you think?

SMITH: It's extremely unfortunate that we're in this battle over essentially nothing.

The program already has legal protections against abortion. There's a Helms Amendment, a Siljander Amendment and other amendments that prohibit the funds being used for abortion. And by all accounts, everyone has abided by those rules. Where we are right now for those of us in the faith community who work in Africa and are pro-life, we're at a point where it's hugely frustrating and embarrassing that the pro-life community here in the U.S. has made an issue of this.

Where abortion wasn't talked about in Africa much at all, it's now being talked about a lot. So the pro-life community at least has done what other groups haven't been able to do, to get people to talk about the issue. What it means without a reauthorization, it will reduce the confidence in the countries where we're working, that we're going to fulfill our commitment.

And I might add that PEPFAR is extremely important in the geopolitics of the world these days with China coming into so many countries. PEPFAR is really the battle line in Africa to limit China's influence. Without it, you'll see Africa lost to China. That's one downside of this debate that's going on.

More importantly, you have people who are on life saving medications. And think about people, here in the U. S. who are on life saving medications. If their medications are threatened, it means their life. And here we're holding hostage right now 20 million or more people so that somebody can get a protection that isn't needed, to a problem that doesn't exist.

It is, that's got to be close to the definition of insane.

BECKER: But no one's saying that these, but no one's saying that these medications will go away right away. That that will happen right away, right?

SMITH: Not right away, but you have a structure right now that funds the medications.

It's very intricate, and we're trying to transition countries into doing more themselves. The Global Fund is helping, other countries are helping, but not to the degree that PEPFAR does. So to replace that is going to take time. You need a five-year reauthorization so that you can plan to be able to do that.

Right now, with no reauthorization, we don't know here, nor do people in Africa know that there'll be any money the following year. We're in a budget mayhem in respect to people wanting to cut money, cut programs, and this is one that is really life dependent for many people without it.

BECKER: Nkatha, what do you think the effects will be if PEPFAR is not reauthorized for five years? If it is perhaps one year or three as Sarah mentioned, might be likely.

NJERU: Yeah. Just to reiterate what Shepherd has said, it is lives of people that I know that are going to be affected, that are going to not have certainty. There'll be a lot of uncertainty with the lives of people. I'm going to use an example of hypertension. And because more people might be able to relate to that, if you do not know where you're going to get your meds for hypertension for the following month, it's tragic.

If you depend on them for life, the same thing with your antiretroviral treatment. So it's going to be more people infected. It's going to be a generation of children who would have otherwise not gotten HIV that are going to get HIV, because their mothers could not access lifesaving treatment.

It's uncertainty in always, if we don't get five years, because what happens when we get the five-year authorization? Then we start thinking about the next five years. But now when we have an authorization, let's say for one year, and maybe budget cuts, you have to start thinking about what of the lifesaving program are you going to cut?

Is it the meds? Is it the counseling? Is it treatment for opportunistic infections? Is it the labs? So you have to cut something, and I'm not sure what in the whole arena of the life-saving PEPFAR is going to be cut with. Within a year, you have to sit down and plan and think through what we prioritize and what do we cut.

And it's important that we have that certainty for us to be able to plan.

BECKER: I wonder though, as we said, this is a 20-year-old program. Perhaps it may need some revising. And I've read some studies where folks have questioned whether PEPFAR is actually taking resources away from other diseases or health care workers who perhaps don't go into primary care.

But go into AIDS and HIV care because there are resources there to pay for medical and health care workers where there may not be as many in primary care. So I wonder, does this affect the infrastructure of the health infrastructure in Africa? And could it be up for some revising at this point in and of itself?

Shepherd Smith, what do you say to that?

SMITH: The impact of PEPFAR on health generally in Africa beyond HIV/AIDS is really remarkable and the improvements made in virtually all areas where people really didn't for example, weren't really concerned about cancer before, because AIDS was killing people at early ages.

It's now an issue and is being dealt with. PEPFAR has strengthened health care systems already and continues to improve them across the board in Africa. There's a study I saw where they took 22 different health conditions where PEPFAR was operating and 21 of them, non-related to HIV/AIDS, showed improvement, vast improvement, in fact.

It's already doing what people are saying needs to be done. It really monitors regularly itself very carefully on where it can improve. Dr. Birx, when she headed PEPFAR, was, I won't quite say tyrant, but whatever, it's close to that.

BECKER: (LAUGHS)

SMITH: In making sure everybody is performing as they said they were, would perform.

We've been involved in lots of government grants over the last 40 years with different agencies and departments. And there's none that is as well run as this. There's none that has all the contractors and grantees working together so closely for a set, for a common goal. It's a remarkable program.

BECKER: You know what, when you say that, it makes me wonder a little bit that there may be some listeners who are thinking of course you're going to defend this program, right? You're, working with organizations that rely on its funding. And so you have a different viewpoint.

How can we ensure your objectivity here, Shepherd Smith?

SMITH: Okay, first and I've seen that accusation. I had an organization called the Institute for Youth Development. It was never a grantee of PEPFAR. My wife's organization, the Children's AIDS Fund, that I helped found, was a grantee formerly of PEPFAR.

But I was never on the payroll, so I don't, I haven't had a financial benefit other than a few consulting times that I've had with the program that might be a few thousand dollars. So I don't have a financial interest personally. I've just witnessed this program. I've witnessed all the tragedy of AIDS over the last 38 years.

And this is just miraculous, is the only way to describe it, and to denigrate it in the way that it's been denigrated is unfair to the people in Africa, it's unfair to the people that have worked in this program, and to all the people of faith who have been behind it and working hard on it and are pro-life themselves.

BECKER: Nkatha, I wonder what you would say to folks who say, "Do you have a conflict defending this program, Nkatha?"

NJERU: No, I don't because what the project, what PEPFAR has done as a program has been quite some good work. And just to actually add to what Shepherd was saying about the argument that the PEPFAR of 2003 needs to change.

The PEPFAR that I implemented when I worked at a health facility in 2003 is not the same as what we have now. There have been improvements, there have been strategies, PEPFAR has strategic plans, five-year strategic plans that help to make sure that what we are implementing has been thought through very well.

And I no longer work directly with facilities or benefit from funding, but there are human beings, people, like I said, that I can name that are benefiting from these funds. And so I'm personally very concerned about what that could mean for these lives. And if people can think about it as human lives that we are talking about and think about the damage that happened, even with a brief interruption of treatment during COVID, then we are able to see what kind of damage we could do to human beings if we interrupted PEPFAR.

BECKER: We've certainly heard about the United Nations goal of ending AIDS by 2030. And the pandemic's effects, I think, are still being measured in terms of whether that goal is still achievable.

BECKER: But what would you say is achievable and how does PEPFAR's role in all of that affect that goal, Nkatha?

NJERU: It's definitely achievable, one of the things that we currently have on our plate that we're discussing very well is ensuring that we take care of the children with HIV, because those are the ones that have right now, we have a big challenge.

There are countries that have made quite tremendous progress in ending AIDS. And so we are picking, we're not picking who have we not yet addressed, who are we leaving behind and addressing that. So it is an achievable goal, but we need to have concerted efforts towards the same thing, all of us.

Like we have had in the faith sector, which were the faith sectors, we started working on HIV, even before we had PEPFAR, we had nuns going to see people with HIV and ensure they have food and they have comfort. And the faith communities would continue to do this even beyond PEPFAR, if ever there's an end to PEPFAR. But we need to all be working towards the same goal for us to end AIDS.

BECKER: And Shepherd Smith, you get the last word, the last minute we have here. What would you say about this goal of ending AIDS by 2030 and PEPFAR's role?

SMITH: It's going to be a real challenge with a fully functioning PEPFAR program. Without that, I think, because of the demographics in Africa with so many young people, more than half the population, I think, is under 15.

You will have a huge epidemic of HIV/AIDS if the program falters. It's, to me, still a close call to get the containment that's necessary. And we're on track to do that. But if we have a damaged program, it means millions of lives potentially will be lost.

BECKER: Okay.

SMITH: That's why I'm embarrassed by this argument by my friends here.