Samson Mndolo

The night before my interview with Malawi’s Secretary of Health Samson Mndolo, news leaked of a secret Trump administration proposal to effectively end the President’s Emergency Plan for AIDS Relief. Under the plan, Malawi could lose all PEPFAR support within five years.

When I ask Mndolo about it the next day, he is blunt: If the funding disappears, some HIV services will not survive.

The priority for us is keeping the one million Malawians on [anti-retroviral treatment]. We have costed that, and we have had discussions at the highest level of government. We will need to increase domestic resources for this.

We have discussed and we are planning for a situation when on that day the donors may withdraw completely, we need to keep those people alive. If for some reason or the other, we are not able to sustain those on the ARVs, I think we’ll open a can of worms.

As for the rest of the HIV response? There is only so much Malawi, one of the world’s poorest nations, can do.

We need to define what is a minimum package that we can offer or should take away.

Mndolo refuses to elide just how dependent Malawi’s HIV response has been on donors like the U.S. government. There would really be no point, given how starkly that has been exposed in the six months since the U.S. first paused foreign aid.

Donors have funded 95 percent of the country’s HIV response. Before Trump’s term began, that included more than $100 million annually from PEPFAR, adding up to more than $1.8 billion in investments since the program launched in Malawi in 2006.

It follows, then, that Malawi’s HIV response has been decimated by Trump’s dramatic cuts to PEPFAR. Prevention services have been nearly eliminated. Community outreach services have shut down. Malawian officials were even temporarily locked out of the digital system for tracking HIV records that was underwritten by PEPFAR.

It’s obvious that the challenges will only metastasize if the program withdrew completely.

Mndolo is not interested, though, in dwelling on just how bad things might get. He returns to the idea of a minimum package. It will not offer everything provided during the height of PEPFAR’s support to Malawi. But it will establish a threshold to which health officials can hold the rest of the government – particularly the purse-string holders at the finance ministry – accountable.

We need to actively work. What is it that we can do as a government to make sure we continue providing the services. I go back to the concept of a minimum package. What is a minimum package that we can offer? The minimum package that we need to keep the services going? And that’s what we need to do as a government.

Even maintaining treatment, which he sees as non-negotiable, will be costly, though.

Money is becoming difficult, both domestically and internationally. So, first thing that we had to do is, in which areas can we maximize the resources? So, we did that.

That money was mainlined into hiring more health workers to compensate for the roughly 5,000 lost to U.S. funding cuts. The majority, Mndolo says, were HIV diagnostic assistants, focused on HIV testing. He is not necessarily interested in directly replacing them.

We have decided that if we need people, it should not be HIV diagnostic assistants. But we should have a lab assistant. A person who can test for HIV, can test for malaria, can do a pregnancy test, can do a full blood count. I think that’s the best use of money.

Those hires quickly exhausted the additional resources they were able to locate.

Secondly, we decided we had already started the integration agenda.

The process would move HIV services into government health clinics, where they would be offered alongside all other services. Mndolo admits that he was recently made aware of some concerns about this process.

We are pushing the integration agenda, and the key population is saying, So everybody thinks integration is a magic bullet, but how easy is it for a member of the key population to go to the general facility and get care? As government I was very interested in that.

We need to reorient our people to make sure we are able to handle all populations that we get. Our epidemic is mainly in the general population. However, for us to defeat HIV as a global health threat by 2030, we need to go into each and every corner. So yes, we must be open and listen to all the voices and see what interventions have worked everywhere that we can.

He is surprisingly confident for someone who watched entire HIV services disappear in the past six months. And who has just acknowledged the inability of the government to replace them. In fact, he is the only person I have met in that time who is still talking about ending AIDS as a public health threat by 2030.

I end the interview undecided if this is the bluster of a politician a few weeks out from national elections, or if he has some reservoir of optimism that the rest of the field is lacking.

He stops me as I’m about to leave his office.

I believe this is an opportunity for domestic governments. Opportunities are still available, efficiencies that we can do domestically to cover this.