When growing gang violence and the kidnappings of health care workers forced Haiti’s leading organization in the treatment of HIV and AIDS-related illnesses to relocate operations from its main site in Port-au-Prince last year, infectious-disease doctors at the health service and research group faced a daunting problem.
As they tried to call patients to come get their antiretroviral treatment, the doctors at GHESKIO — the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infection — found that they had either changed their numbers, didn’t have electricity to keep cell phones powered or no longer lived close by after being forced out of their homes by armed gangs.
“We were having a big issue in finding them. We could only find 40 to 50%,” said Dr. Patrice Joseph, the physician in charge of GHESKIO’s HIV, Tuberculosis and Infectious diseases program. “So we needed to expand the way in which we contacted those patients.”
The innovative solution: a radio spot in Haitian-Creole urging patients to “Come back to care” and providing them with community health centers in Port-au-Prince where they could get their medication.
This week, following the Trump administration’s sweeping 90-day freeze on U.S. foreign assistance, doctors at GHESKIO launched another spot. This one informed its HIV/AIDS patients that the U.S.-funded President’s Emergency Plan for AIDS Relief program, commonly known as PEPFAR, has been temporarily suspended.
“This sudden decision affects all PEPFAR medical clinics in Haiti and abroad,” the spot says.
Two weeks after President Donald Trump’s executive order freezing almost all U.S. foreign aid, foreign governments and PEPFAR-funded organizations dependent on U.S. generosity are still feeling the effects of stop-work orders and a subsequent gutting of the U.S. Agency for International Development, the sprawling bureaucracy charged with delivering humanitarian assistance around the world.
The confusion and blockage has persisted despite the insistence by U.S. Secretary of State Marco Rubio that he has issued “blanket waivers” for “core life-saving medicines” and other emergency humanitarian assistance because “we don’t want to see anybody die, or have anybody be harmed in the short term.”
Rubio, who arrived in the Dominican Republic late Wednesday for a meeting with President Luis Abinader, has been asked about the freeze throughout his five-day tour of several Central American nations, his first overseas trip designed to deliver the Trump administration’s concerns about migration, China’s growing influence and how foreign aid has to benefit U.S. interests going forward. He has defended the aid freeze, pending a review, and on Tuesday, while concluding a visit in Costa Rica, pushed back at the notion the waivers were ineffective and forcing clinics in Africa to shutter services.
“If some organization is receiving funds from the United States and does not know how to apply a waiver, then I have real questions about the competence of that organization or I wonder whether they’re deliberately sabotaging it for purposes of making a political point, “ Rubio said.
In Haiti, where the U.S. has been the single largest aid donor, at least four hospitals report having received a notice to stop programs. All reported being confused about the waiver process, and whether or not they could continue working if they have medications or if they can keep funding they already have. Some said they plan to continue operating as long as medications are available, and others feel they need to stop altogether regardless. Several leaders have put out appeals to get funding for salaries related to the PEPFAR program, while others have terminated staff running their HIV programs, the head of a nonprofit told the Miami Herald.
According to figures from the Haitian Ministry of Public Health, there are 125,000 patients in the country receiving antiretroviral treatment through both the PEPFAR program and the Global Fund, a different network that also provides HIV care.
Physicians learned this week that between both programs there are enough antiretroviral drugs in Haiti to cover the three months of the Trump administration’s freeze. However, the medications, along with others, are locked away in a building controlled by Chemonics, an organization financed by USAID that has lost access to the site because of the stop-work orders.
The State Department has issued some limited waivers for PEPFAR-related activities worldwide. However, the department’s own Office of Foreign Assistance has not notified contracting officers to allow organizations in the field to restart operations. Rubio has resorted to blaming the nongovernmental organizations that are providing life-saving treatment.
“We have a blanket waiver, it’s been out for a week. And anybody who doesn’t understand it, let me repeat it in very simple words: if it saves lives, if it’s emergency, life-saving aid — food, medicine, whatever — they have a waiver,” he said. “I don’t know how much clearer we can be and if they’re not applying it, maybe they’re not a very good organization, maybe they shouldn’t be getting money at all.”
PEPFAR was started during the George W. Bush administration in 2003, and currently provides treatment to more than 20 million people in more than 50 countries. It is considered the world’s most successful foreign-aid program and has been credited with dramatically lowering HIV rates in Haiti by two-thirds and saving tens of thousands of Haitian lives. Before the program’s launch, patients died within 12 months of acquiring an AIDS-related illness, according to GHESKIO, which is a pioneer in the treatment of the disease. Now instead of being the leading cause of death in Haiti, HIV/AIDS is the seventh.
After Rubio issued the millions of dollars worth of waivers, the executive director of the George W. Bush Institute and Vice President George W. Bush Presidential Center welcomed the effort, but also acknowledged that the pause on PEPFAR had not been completely lifted. In a Jan. 31 note on the center’s website, the executive director urged the State Department “to resume PEPFAR programming immediately so that those on treatment can receive uninterrupted care. In fact, it’s a matter of life and death.”
The following day a Democratic congressional staffer told the Miami Herald that the $7.5 billion program, which enjoys both Democratic and Republican support, remained stalled.
“It’s our hope that the Trump Administration would make clear that implementers can continue providing lifesaving medicines sitting on their shelves to those who need them, but the Administration hasn’t given clarity regarding which parts of PEPFAR would be allowed to restart under the waiver,” the staffer said. “PEPFAR implementers still haven’t received guidance.”
Challenge of HIV care in Haiti
When the Herald met with Dr. Joseph, it was before Trump’s sweeping freeze and before Haiti’s displaced population hit the million mark in December, after spiraling gang violence and several massacres had tripled the number of people forced to flee their homes in Port-au-Prince and the Lower Artibonite region.
GHESKIO, which had lost 400 doctors, nurses and other health care staff to the U.S., Canada and elsewhere since the 2021 assassination of President Jovenel Moïse, was reeling.
At least two dozen of its health care workers had been kidnapped and hundreds of others had been forced to move. After years of operating out of its downtown location across from an impoverished seaside slum that had become an infamous kidnapping lair, it could no longer cope. But though its new base of operations for all its programs was not far from the U.S. embassy, there were armed gangs in surrounding neighborhoods.
With many of its patients scattered, Joseph, overseeing the PEPFAR program, was trying to figure out how to get patients to return to get care amid the ongoing civil unrest. There had been meeting with USAID and the U.S. Centers for Disease Control, whose constant presence in Haiti have helped with diseases and other health issues.
Concerned about the growing rates of tuberculosis and new HIV cases, he and other doctors were trying to figure out how to get donors to lift restrictions that prevented physicians from giving six months’ worth of medications to patients facing constant disruptions due to the violence. The reality made it difficult for some patients to stay on treatment, and for nurses and doctors to monitor viral loads.
“In order to cut the transmission in the patient and also in the community, you need to have a stock available all the time,” Joseph said explaining the risks to disruption in treatment. “After two, three, four months, the patient will get sicker.”
To reach patients, the center was trying to train and place community health care nurses. But it was neither easy nor cheap.
“Funding is very insufficient,” Joseph said. “The donors would give you some amount of dollars that they think is enough.”
Haiti had always had challenges attracting funding for its myriad problems. But with 80% of the hospitals and medical centers in metropolitan Port-au-Prince closed because of gang attacks, the situation had reached a critical state.
“We are facing the worst humanitarian crisis ever in Haiti and we see patients not worrying about their medication but their day-to-day living,” he said. “We need to have funding not only for the medication, but also to improve the quality of life and making sure those people who are displaced can go back to their homes.”
The camps that shelter Haitians who have been forced to flee their homes are often not much more than dirt floors in churches and school yards. They are “nightmares,” Joseph said as he underscored another problem: the rising incidence of rapes, which also exposed people to HIV transmissions.
“It is very unacceptable,” he said of the makeshift camps. “We need to find funding for those people.”
Dismantling of USAID
In the days since the U.S. freeze, Haiti’s health authorities have sought to calm fears. They are working on contingency plans and checking with other foreign donors. But while health officials believe their 180 sites offering HIV/AIDS treatment around the country will withstand the period of the aid freeze, they quietly admit that fears persist about the future: What happens if the freeze goes beyond 90 days, or worse, programs are cut?
Last week, efforts to learn more about USAID’s functions and contracts by Elon Musk’s Department of Government Efficiency came to a head. Trump ended up folding the agency into the State Department, and many staffers were told they would be put on leave as of Friday. The quick dismantling of the key agency for the delivery of humanitarian assistance in many countries has led to consequences in the field. The State Department, experts say, is not prepared to take over the agency’s responsibilities globally.
Rubio has described USAID as “a completely unresponsive agency,” points he stressed during stops in Costa Rica and El Salvador during his tour of the region this week.
Rubio has taken over as acting director of USAID and has stressed the need for a review of its programs.
“Before we did the freeze we couldn’t find out anything about some of these programs. USAID, in particular, they refused to tell us anything. ‘We won’t tell you what the money’s going to, who the money’s for,’” Rubio said. “ In some cases it goes to four different contractors before it reaches the intended recipient.”
He reiterated his support for foreign aid, while stressing it is not charity but meant to advance U.S. interests.
“We’re not going to eliminate foreign aid. We’re going to have foreign aid that makes sense. We’re going to have foreign aid that works, we’re going to have foreign aid that furthers the national interests,” Rubio said. “We’re going to have foreign aid that benefits our trusted partners and our allies.
“If it doesn’t make us stronger, or more prosperous, or more secure, we aren’t going to spend taxpayer money on it.”
