If the US wanted to be the world’s police officer, then why not try to be its doctor too? 

Just two months before the invasion of Iraq in 2003, George W. Bush announced an ambitious plan to pump $15 billion into the global fight against HIV, stunning his allies in Congress, health advocates, and heads of state of the program’s intended beneficiaries. 

The President’s Emergency Plan for AIDS Relief, or PEPFAR, was the largest commitment by any nation in history dedicated to addressing a single disease, a disease that killed about 3 million people in 2003, most of them living in sub-Saharan Africa, and infected 5 million more. “Ladies and gentlemen,” Bush proclaimed in his State of the Union address that year, “seldom has history offered a greater opportunity to do so much for so many.”

On that, he was right. In the two decades to follow, PEPFAR would save an astounding 25 million people’s lives through lifesaving HIV therapies, and prevent millions of babies from being born with HIV in the first place, all at a cost of about 0.08 percent of the federal budget. 

And yet, in the wake of the Trump administration’s foreign aid cuts, one of the greatest achievements in American history is now at risk. PEPFAR, mercifully, still exists, saved from the sledgehammer by an outpouring of bipartisan support last February. But experts say the program has been transformed beyond recognition by countless small cuts, and the abrupt gutting of global health architecture, reshaped not by decades of accumulated wisdom around HIV prevention, but by at times absurdly petty ideology.

Over the past year, more than 77 percent of PEPFAR grantees have lost funding or had their payments delayed, according to a survey released Tuesday by the HIV research group amfAR. 

Nearly two-thirds of grantees — especially those supporting vulnerable populations such as LGBTQ people, young women, and sex workers — said the cuts had disrupted their ability to offer HIV treatments and other services. The Trump administration released limited data showing a deep reduction in HIV prevention services, but a relative consistency in access to treatment earlier this year. However, this new survey paints one of the first pictures available of how PEPFAR cuts are actually being felt on the ground, and how the administration’s priorities are reshaping who and what gets funded.

According to the survey’s authors, at least 1,700 HIV-related sites or clinics have shut down as a result of cuts. Well over 16,000 health workers — including those going door to door to make sure pregnant parents get tested for HIV or children get on treatment — have lost their jobs. 

Many organizations surveyed reported receiving emails when their PEPFAR grants were terminated, noting that their work violated President Donald Trump’s executive order against “unlawful diversity, equity, and inclusion.” It appears, they say, that many of these groups were flagged not because they embraced the distinctly American concept of DEI in their work, but because their name or mission description included a phrase like “gender” or “LGBTQ.”  

A health clinic serving survivors of domestic violence in Mozambique, for example, might now be flagged just for using the phrase “gender-based violence” in their name. This may be part of the reason why even pregnant women — who even the Trump administration has emphasized as a critical demographic in its HIV goals — have lost access to services. 

Back in 2003, Bush defied conservative critics in his own party who attempted to redirect PEPFAR funding to abstinence-only programs. For decades, American presidents have been able to see past their ideology in service of saving lives. They largely understood that contraceptives like condoms and special interventions for those most at risk, including LGBTQ people, were necessary for stopping the spread of HIV. Under the Trump administration, this norm is unraveling. 

“This administration has zero interest in addressing clinical outcomes for vulnerable people with HIV,” said Asia Russell, executive director of the advocacy group Health GAP, who noted that “to be effective, HIV prevention and treatment services actually have to go where the disease is, and that risk is not evenly distributed,” surging in certain geographies like South Africa or within key populations like trans people or young women. Getting support to these groups is “morally right,” she said, but it is also “the only way to do effective HIV work, regardless of your stance on the morals or the merits.”

The fight against HIV is running on fumes

When HIV aid does get doled out these days, it is distributed with far less transparency than in the past, and in ways that often appear to be ideologically or politically driven, both in terms of the populations they serve and the countries they operate in, rather than guided by best practices. 

In theory, lifesaving HIV care was exempted from sweeping aid cuts last year. But in reality, access to even the most basic HIV services and treatments has also atrophied across the board, while falling disproportionately on at-risk populations. 

That’s come both in the form of direct cuts and as a byproduct of broader disruptions to the kind of outreach services, testing, and socioeconomic programs that get patients in the door to begin with. 

“You can’t cut pieces of the architecture of how PEPFAR functions and expect to maintain a really robust treatment program in the long term,” said Jennifer Sherwood, director of research and public policy at amfAR. “If you cut the testing program, the prevention programs, the kind of services that allow people to stay in care and return to care, you’re going to see that you can’t maintain a treatment program.”

The number of people getting on treatment for the first time has sharply declined over the past year, even according to the administration’s own limited data drop, while access to testing, contraceptives, and other preventative services — all critical to keeping infections down in the long run — face cuts that threaten their ability to function at all. 

To make matters worse, amfAR’s survey shows that services designed for the populations most at risk of HIV — such as sex workers, LGBTQ people, young women, and teenage girls — have been disproportionately affected by PEPFAR cuts. Among those who lost funding, a staggering 90 percent of organizations that serve gay and bisexual men were forced to slash access to PrEP — which strongly protects against HIV infection — and many stopped offering it entirely. The same was true for over half of organizations serving pregnant women, whose children now face a higher risk of contracting HIV in the womb.  

The majority of new HIV infections are concentrated in these “key populations,” as they’re known in public health parlance, many of whom face stigma or other obstacles to obtaining care. “One really powerful aspect” of how PEPFAR used to work, said Thomas McHale, public health director at Physicians for Human Rights, was that it consistently “followed the science and followed the epidemiology” to serve “groups that are at the margins of society.” That approach appears to have been thrown out under the new administration, and in at least some cases, actively discouraged.

McHale has been documenting the impact of PEPFAR cuts in South Africa in recent months, and “what we saw was a system under severe stress and strain,” he said. It is one in which a bisexual man stopped taking his HIV medications for weeks because the LGBTQ clinic he used to go to closed. “He just couldn’t bear the stigma of accessing services in a place that’s not meant for him,” according to McHale. Similarly, a young woman was forced to wait in line for 10 hours just to refill her PrEP prescription. 

“If we’re not focusing on preventing disease,” McHale said, “it’s just a more expensive and more devastating challenge to address in the future.”

Some countries may soon stop receiving PEPFAR funding altogether

As I’ve written previously, the Trump administration has attempted to remake foreign aid into a dealmaking enterprise, one in which money flows directly through national governments rather than through large, western-led non-governmental organizations or NGOs. 

In theory, there are benefits to this approach, because it prioritizes the expertise of local health groups and policymakers who are often best equipped to evaluate and address the needs of those in their care. In practice, however, amfAR’s survey shows that so far, under the Trump administration, local organizations have actually lost more funding and been forced to close more sites than international groups have. “These cuts fell heavily on locally-based organizations” while NGOs have fared somewhat better, said Sherwood, “and that really runs counter to all of our global health goals.”  

“I’m concerned because public health is no longer how we’re measuring success” when it comes to reaching PEPFAR’s goals, said Jirair Ratevosian, a senior fellow at the Duke Global Health Institute who served as chief of staff of PEPFAR under the Biden administration. He is especially alarmed by the decision last month to end PEPFAR support for South Africa, which has the largest HIV epidemic in the world. The administration appears to have done so in part because of Trump’s insistence that the nation is waging a nonexistent “genocide” against white Afrikaners. 

“If we’re not focused on preventing disease, it’s just a more expensive and more devastating challenge to address in the future.”

Thomas McHale, Physicians for Human Rights

“HIV control is not their chief concern,” said Ratevosian, who recently ran the numbers on a separate fissure with Zimbabwe, finding that cutting PEPFAR would lead to 75,000 new HIV infections in just one year. In South Africa, similar cuts could lead to over 2 million more infections over the next two decades, a toll that would invariably cross borders, and could threaten the world’s immense, hard-won progress against HIV. “You can’t have a global HIV strategy,” said Ratevosian, “if you’re not engaging these countries.”

Priorities shift under any new administration, and it’s not abnormal for an organization to tweak its language or services to adapt. But PEPFAR, the bipartisan program which began under Republican leadership, and thrived and expanded under three successive presidencies, including during Trump’s first term, has never faced such turmoil. 

“Even among organizations who didn’t lose US funding, we’re still picking up changes to the way they work, the populations they serve, the words they use,” said Sherwood of amfAR. Her group’s survey showed that nearly 80 percent of organizations that did not lose funding still altered the way their organization worked to comply with new policies. “This network of changes from the US,” she said, “are prompting a lot of changes on the ground.”

A decade’s worth of grudges and feuds between the Democratic establishment and the insurgent left is coming to a head in one election this year: Michigan’s Senate primary.

The contest between Rep. Haley Stevens and Abdul El-Sayed has somehow unearthed every fault line that’s divided the two factions over the years — from gender and racial politics, to Israel and Gaza, to questions of electability and fair play, to money in politics, and much more.

On one side there’s Stevens, a four-term House member who is the preferred candidate of the Democratic establishment — and of AIPAC, which has spent nearly $30 million to support her campaign. 

On the other is El-Sayed, a former public health official who’s been backed by Sen. Bernie Sanders, Rep. Alexandria Ocasio-Cortez, and their network of supporters and fans. 

But the race has quickly gone beyond just them and become about something bigger — the national struggle for influence in the Democratic Party. 

“This is the quintessential contest between the establishment wing of the Democratic Party and the economically populist wing,” said Joseph Geevarghese, executive director of the left group Our Revolution.

In contrast, Jonathan Cowan, president of the center-left group Third Way, argued that nominating El-Sayed — a “super extreme candidate who will alienate lots of voters in the middle” — is a dangerous risk.

In this one race, the Democratic factions are relitigating the 2016 presidential primary, the 2020 presidential primary, and several major controversies of the past few years, all at once. And whoever wins will have to find a way to somehow unite the party and win a competitive general election against presumptive Republican nominee Mike Rogers. 

On gender and racial politics, we’re doing 2016 again

When Sanders challenged Hillary Clinton for the 2016 presidential nomination, her supporters frequently implied he had blind spots related to gender and race. They argued, for instance, that certain criticisms of Clinton (and remarks by Sanders) were sexist, and that Sanders’s poor performance with Black voters demonstrated the limits of his appeal. 

The discourse also sometimes focused on so-called “Bernie Bros” — online Sanders supporters who, critics argued, directed toxic abuse and vitriol toward people not in his camp. Sanders’s backers argued that the accusations of sexism were themselves a dishonest and inaccurate smear to distract from Clinton’s own shortcomings. 

All of this is happening again now in Michigan.

On gender, a comment from El-Sayed a few weeks back — he said Stevens was unable to “string together two coherent sentences” — was criticized by the Stevens camp as sexist. 

Then, last week, a video of an enthusiastic speech by Stevens on the campaign trail went viral as online El-Sayed supporters mocked her diction and delivery, viewing her way of speaking as self-evidently ridiculous. 

Seeking to tamp down this behavior, El-Sayed posted Friday that the way “people online” were making fun of Stevens “for things that have nothing to do with her policies” was “unkind and unhelpful.” He also told Vox’s America, Actually podcast that the accusations of him being disrespectful to women have gotten back to his daughter, and been hurtful.

Meanwhile, on race, a poll last week shows Black Democrats splitting 67 percent for Stevens, and 21 percent for El-Sayed. Days later, the Congressional Black Caucus PAC endorsed Stevens. Just like Clinton in 2016, Stevens is hoping support among Black voters who are longtime stalwarts of the Democratic base will be enough to carry her to victory. And just like Sanders in 2016 and 2020, El-Sayed is facing questions about whether the party’s left vanguard can expand its support beyond white, college-educated voters. 

“The progressive brand really, really underperforms with Black voters all around the country,” said Adrian Hemond of the Democratic advocacy firm Grassroots Midwest. “I think it’s worth Democrats, media, and people in the nonprofit blob asking themselves why that is.”

The establishment vs. insurgent tension, and the Obama of it all

In both of Sanders’s presidential runs, his team griped about the behavior of the Democratic establishment, arguing that they weren’t truly playing fair. For instance, they pointed to how the DNC initially scheduled very few debates for the 2016 presidential contenders, arguing the supposedly neutral committee was in fact trying to help the frontrunner, Clinton, by limiting attention on her opponents.

To Sanders’s supporters, the bitterest pill was the perceived late intervention of former President Barack Obama into the 2020 campaign just as Sanders appeared well-positioned to win the nomination. (Days before the crucial Super Tuesday primaries, two other candidates, Pete Buttigieg and Amy Klobuchar, dropped out and endorsed Joe Biden. Obama was publicly neutral, but privately called Biden and Buttigieg during this key period, raising speculation about his role.)

In Michigan, again, the Democratic Senatorial Campaign Committee is officially neutral, but Senate Minority Leader Chuck Schumer has long been understood to favor Stevens, and reportedly has privately asked donors to back her.

Obama, too, has become a flashpoint. An AIPAC-linked group has spent millions on an ad showing Obama praising Stevens — even though he has not endorsed her in this race. The praise is from comments Obama made during Stevens’s first House campaign, in 2018. (Stevens had worked on his presidential task force to rescue the auto industry during the Great Recession.)

El-Sayed’s supporters have argued that this is an attempt to mislead Michigan voters into thinking Stevens has Obama’s backing. “It is disgusting that AIPAC — which spent tens of millions attacking Obama — is now spending like crazy to lie and suggest he endorsed Haley Stevens,” Ben Rhodes, a former Obama White House official who supports El-Sayed, posted on X.

Others suspect that Obama does in fact tacitly support Stevens, and that’s why he’s letting the ad stand without clarifying things. (El-Sayed thought Obama was too “centrist” and “middle of the road,” he told Vox in 2017.) And yet again, people are fighting over 2016: Some Stevens supporters point out that Sanders used footage of Obama praising him in a 2020 primary ad despite the senator’s own criticism of the former president. 

Israel/Gaza, AIPAC, antisemitism, money in politics, Hasan Piker, etc…

Of course, the issue that has come up repeatedly in tense Democratic primaries this cycle — Israel — is present in this race in a major way. 

Many on the left argue that the war in Gaza contributed to former Vice President Kamala Harris’s defeat by disillusioning some of her potential supporters and dissuading them from turning out. The evidence that this phenomenon occurred in significant numbers due to Gaza specifically is thin. But it arguably may have been a factor in Michigan, where 2 percent of the population is Muslim and Trump worked hard to court disaffected voters with vague promises to end the war.

Here, Stevens is an unapologetically pro-Israel candidate who wants to continue US military aid to the country and does not believe Israel committed genocide in Gaza. (She said during a Hanukkah event once that “Israel comes to me in my dreams.”) El-Sayed, in contrast, has been sharply critical of Israel throughout this race.

The center-left group Third Way has spent months attacking El-Sayed for campaigning with left-wing streamer Hasan Piker, arguing that comments of Piker’s — that “America deserved 9/11,” and that a certain sect of Israeli Orthodox Jews was “inbred” — are un-American and antisemitic. (Piker has said he calls lots of different groups he dislikes inbred.)

Meanwhile, Stevens has been the beneficiary of that nearly $30 million in AIPAC-linked spending — a topic she generally tries to avoid discussing. The ads in question don’t talk about Israel at all and instead praise Stevens on other issues. “It is just a clear indication of where the base of the party is right now that AIPAC has to continually do this spending through their allied outside groups,” Dani Negrete of Indivisible, a progressive group backing El-Sayed, told me.

Electability and the question of: who can’t win?

After a decade of factional squabbling, the left and the mainstream factions have each honed their talking points for why, when a Democrat loses the general election, it’s the other faction’s fault.

To the establishment, left candidates are risky bets: They’ve taken positions that may alienate swing voters and are less dependable than candidates with longer electoral pedigrees. 

In endorsing Stevens this month, Sen. Gary Peters (D-MI) warned they needed someone who was “fully vetted.” El-Sayed’s supporters viewed these and other remarks from Stevens supporters as baselessly linking their candidate to Graham Platner, who dropped out of his race in Maine over sexual assault allegations that he denies. However, unlike Platner, who was plucked from obscurity, El-Sayed has been a political figure for nearly a decade and faced significant media scrutiny already. 

Another version of the critique is more about whether El-Sayed’s policy positions — for instance, his past support for defunding the police, and his backing of Medicare-for-all — are too far left for this swing state in the general election.

Meanwhile, the left’s argument for why establishment candidates flop is that they fail to excite the base and stimulate turnout. Therefore, they claim, El-Sayed is the safer choice.

Lately, this argument has focused on Israel and Gaza. Left commentators argue that the Biden administration’s support of Israel and failure to stop what they call a genocide in Gaza was a major — perhaps the major — reason Harris lost in 2024, because part of the Democratic base was disillusioned and didn’t turn out. So, some on the left have suggested, if Stevens is the nominee, Democrats are risking the seat by disillusioning the same voters.

The mirror of this argument, from the establishment, blames the left for causing this disillusionment. By criticizing rival Democrats in harsh terms and casting them as pawns of special interests, they prime their voters to sit out the general election after their own candidates fail to win the nomination. “Bernie Sanders is the reason that Donald Trump is president,” famed Democratic consultant James Carville said last week, arguing this was because Sanders convinced his own supporters the Democratic Party was corrupt. 

This fight has played out in miniature in Michigan. Stevens has accused El-Sayed of undermining Democrats in 2024 by backing the “Uncommitted” movement, which sought to protest Biden’s Israel policy in the primaries. El-Sayed, conscious of this criticism, has gone out of his way to emphasize his early support for Harris in 2024, in contrast to others who sat out the race. But he’s also warned that the wrong Senate candidate could recreate the conditions that led to her loss.  

Last week, a post from one El-Sayed supporter that he would not vote for Stevens in the general election went viral. “The Democratic Party needs to be anti-AIPAC, not pro-AIPAC, and it only happens if candidates like Haley Stevens don’t win in general elections,” Adeeb Hafeez posted on X.

The next day — after critics argued this could lead to an even bigger conservative Supreme Court majority — Hafeez walked it back a bit. He posted that he “may hold my nose and end up voting for” Stevens after all in the general if she advances — but that he’d “be very uncomfortable in doing so.”

The exchange underscored the challenge for Democrats in coming together after the primary. No matter who wins, they’ll carry the scars of not only this race, but election after election pitting left-wing candidates against moderates, each of which have left behind bruised feelings and mutual suspicion.