Peter Cloutier on implementing PEPFAR in Mozambique
The Lancet published an article on February 7, 2025, on the Trump administration stopping funds for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).
The authors write, "Over the past two decades, PEPFAR has been one of the most successful global health initiatives ever undertaken. By investing in HIV prevention, treatment, and care services, PEPFAR has saved about 26 million lives and strengthened health-care infrastructure across low-income and middle-income countries. However, the political landscape in the USA has become more polarised, creating challenges that threaten US global health financing and the PEPFAR programme's future sustainability. Following the Reevaluating and Realigning United States Foreign Aid Executive Order signed by Trump on Jan 20, 2025, the State Department issued a stop-work order for all foreign aid efforts, including PEPFAR, which took effect on Jan 24, 2025."
I interviewed Peter Cloutier on his experience implementing the program in Mozambique. The following transcript has been edited for clarity and conciseness.
AK: Tell me about the road that took you to working on PEPFAR in Mozambique.
PC: I had been a U.S. Foreign Service Officer abroad since 2005. I began my career in East Timor, where Portuguese was one of the national languages. I went on from there to Angola and then to Mozambique. I was fairly fluent in Portuguese at that point, and it was advantageous for the U.S. Government to stick me in a place where that Portuguese would be useful. In Mozambique, I was one of the PEPFAR country representatives.
PEPFAR is managed by the Office of the Global AIDS Coordinator at the State Department. That office is filled with some rocket-science-level technicians overseeing the overall implementation of the PEPFAR program. In each country, implementation is usually led by the Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID), but the Department of Defense and Peace Corps are also prominent players in the implementation of PEPFAR programs.
AK: I know PEPFAR was set up at the end of the George W. Bush administration and has been consistently popular and well supported, so I was shocked to learn that its funds had been frozen. My understanding is that once you get somebody into this program, you can't just cut them off because it's a life-saving, sustained responsibility and their life is kind of in your hands. Am I getting that right?
PC: Yes. When you think back on HIV/AIDS in the United States, we have the perfect exemplar of what lifelong treatment involves in the form of Magic Johnson, a prominent sports figure who acquired the HIV virus and remained somewhat resistant to AIDS, but nonetheless the question was about transmission. He was seemingly healthy and able to play basketball with phenomenal skill, but as a HIV carrier he could still potentially pass it to others and kill other people in the process who might not be so resilient.
When I started tracking this issue in the late 2010s, the scientific approach being implemented by Dr. Deborah Birx in 2014 when she took the reins as the PEPFAR ambassador was that if we test enough, treat enough, and virally suppress enough, we can both treat the disease and prevent transmission at the same time. That gave PEPFAR an equation to solve. Implementation is the hard part, but at least we had a goal that anyone’s grandma or grandpa could understand. If somebody like Magic Johnson could live with HIV, how do you keep him from transmitting it? He’ll have to take lifelong treatment in order to suppress the virus level.
AK: So as long as you take the treatment, it’s pretty reliable you won’t develop AIDS or pass the virus on to others. Is that right?
PC: Correct—that's what the data tells us. Of course, it requires a rigorous adherence to the protocol, and that is so much of the program actually—checklisting to make sure somebody got their meds this week and took their pills every day. This part is critical, and you can imagine that in the context of rural Africa. It's really a testament to Mozambique and Africa, when you look at the life expectancy curves from the 1980s to the 2020s, you see a sharp decline continuing to go down and down and all of a sudden start to slant up. That’s honestly due to lot of reasons, but predominantly because people were beginning to survive after being infected with HIV and no longer transmitting.
AK: So in terms of impact for the local population, how well did the Mozambique project work?
PC: From a health security standpoint, we can look at morbidity, mortality, incidence rate, and transmission rate. These are the top line terms for HIV and any infectious disease, and the statistics at the time I arrived in 2015 were harrowing. We're talking the worst set of statistics comparatively on the continent, holding the rest of the continent down—a ‘basket case’, as pundits in America and Europe were calling it.
So the fact that the Mozambicans were able to turn this around was nothing short of borderline impossible. That, number one, was enormous and I think number two was the economic effect of being able to flip something from where you've got reduced efficiency—people who can't work whole days or even work at all because of the effects of HIV on an immune compromised system. Swinging that around resulted in a sense of economic security which contributed to peace making.
An ‘out of control’ epidemic feeds conflicts. It gives political parties in opposition arguments and fodder to say, ‘the people in these impoverished areas are suffering and what is the government doing about it’? These things viciously cycle downwards when things are bad, and when things start to get better, they virtuously cycle upward. We saw all of that happen in the 2000s and 2010s. We saw difficult, political, irreconcilable differences smooth into a lot of peace talks. I think the upswing in life expectancy and productivity contributed to that.
AK: I appreciate your making the link between what might seem just like a pure health program and all these other factors, political stability, peace and conflict. What are some of the key factors in your mind that stand out as the reasons for the program’s success?
PC: This answer might surprise an American audience but really it was the Mozambicans. I can give you the names of three people in particular, Dr. Aleny Couto, the National HIV/AIDS Director, first and foremost. She was named as one of Newsweek’s “Women of the Future” in recognition of just how enormous of a pendulum swing this had been, and the fact that she was the mastermind of the differentiated service delivery model. In a big country with a coastline as long as the West Coast of the United States with all these different ethnicities, different populations respond to treatment and prevention interventions differently. What works in the North may not work at all in the middle part of the country. It may work very well in the South. So how do you make the adjustments? How do you scale up in certain places? And how do you rejigger the innovation and try something else in a completely different place? Dr. Couto deserves a lot of credit for that.
Dr. Francisco Mbofana, Executive Secretary of Mozambique's National HIV/AIDS Council, reports directly to the President for a comprehensive HIV approach, not just a health sector approach. Just a brilliant guy—I loved every minute I spent with him, a guy who could really think through so many of the factors in the rural lives of Mozambique. He would listen to ideas that PEPFAR was presenting as having worked in the U.S. or Ghana or even Tanzania, and be able to say, “Hey, that's not gonna work here. So we have to rethink that entirely, Pete.”
And then Dr. Eduardo Gudo, Scientific Director of the National Institute of Health, just a brilliant scientist, a guy who could run just about any equivalent program in the United States, just quietly studying the epidemic and feeding the health implementing engine with the science to figure out what courses of action to take.
So the number one thing to understand is credit lies with the Mozambicans first. Number two—and it's a big thing I mention all the time since I've been back in the United States—is data. I believe if I you asked the Mozambicans if they could only have one thing from PEPFAR—one thing—they would ask for the data.
I think Dr. Mbofana, Dr. Couto, and Dr. Gudo would all say it's the data, the investment in the data, because it made the differentiated service delivery model possible.
Because they had the data, they were able to determine whether things were working or not, and we had quarterly data compilation. It took an enormous arm of PEPFAR to do this review every quarter, and because they had high quality data at their fingertips, they could see whether things were working or not. Then they could evaluate the proposals that the technical staff were making, both Mozambicans and Americans, and say, ‘OK, let's try that in the North. But we're not going to try that in the middle. We're not going to try that in this hotbed here.
We're going to do something different there.’
The third thing, and I made this argument almost a year ago presenting on ‘Mozambican HIV Treatment as Prevention’ at the American College of Preventive Medicine, is that our most important intervention overseas or in Africa is relationships and trust. That is the portal to unlocking epidemic control. We get so dominated as Americans by the rubric, the equation, the technology, the innovation, something technical, when really the upstream factor is you’ve got to make relationships with people and earn a sense of trust so that you are, before anything else, listening to them and figuring out what they are telling you from their wisdom more so than their knowledge. When that trust is there, they'll listen to your knowledge and help apply that to their wisdom.
AK: So I heard you say that the local doctors you worked with were really the ones to listen to when it came to delivery, and that you had to have the wisdom to listen and not come barging in saying, I know how to do this. And you said data was the thing your partners said they needed most fundamentally. Is there some comparative advantage that the United States has in terms of collecting data?
PC: I think that’s the case. I want to throw the CDC a bone here because there's a scientific rigor there. The evidence base is enormous in this case, and there needs to be a balance between knowledge and wisdom, but when you're looking at viral load counts, nothing beats the evidence. So we have some reliable ways to know when it's low enough the virus won't transmit.
If the Mozambicans have enough virally suppressed, infected citizens, they're going to weave it out. It will never fully go away, but it will be something that is largely preventable and not killing off much of the population.
So in today's great power competition with China, where it seems like everyone's talking about infrastructure and dual-use ports and the like, it is somewhat peculiar to think, ‘OK, why would we focus on data then?’ It's such an intangible thing. The Chinese built a very prominent bridge in Mozambique, with an enormous economic potential unlocked as a result. It's hard to compete with that. A lot of Westerners were sort of scratching their heads wondering, how did we not jump on that? The data ended up being a kind of higher ground there.
No one had invested in data collection, without an obvious return on investment, like PEPFAR did. We had for the most part resolved our HIV epidemic in the United States, and half of The Ugly American is about the danger of the attitude that ‘if we can do it here, we can then do it anywhere in the world’. But there was also some reservation because a lot of our big, Marshall-Plan-style projects haven’t worked so well in Africa. I think the advice that President Bush got in the 2000s was—my words, not a direct quote—'go big or go home.’
And so, PEPFER had enormous funding. No foreign assistance program in history has had anything close to that type of funding. And it was bumpy and bruising, with a lot of lessons learned, but you just turn back to that life expectancy chart to see that upswing. It’s U.S. partnership that helped get to that point. And it’s ironic that because PEPFAR was so big, it actually pushed out a lot of other donors. So there wasn't another HIV donor in town. It became the US government's role. We were the HIV people.
AK: So while the Chinese were doing ports and infrastructure we were investing in trust and relationships, and that has great value for strategic competition. The
country that we're interested in might not have the same relationship with China. They may distrust China, or have a more transactional relationship. But the trouble is how do you measure trust? You can't put it in the bank and there's no trust meter to measure it. And it's probably so easily lost too. It's a perishable commodity.
PC: Well, I was reading something not too long ago about how in the American market, where it seems like so much of our commerce is strictly transactional, we are lured into thinking that the world is that way too. But why do you go to certain restaurants or stores and not others? Not everyone goes to Walmart for their hardware or Applebee’s for a burger and fries. They go to the mom-and-pop places because of the relationships, the customer service. MIT Sloan School of Management and the Harvard Business Review have decades and decades of research on soft-side approaches to compete with efficiency. I argue this all the time, and so do a lot of people that have been overseas for a while.
If we're going to get into an infrastructure game in great power competition, we better be prepared for a lot of tit for tat. At the end of the day, I do hope good quality infrastructure will help the partner nation’s economy evolve. But we shouldn't define that as being competitive. I mean, that's just good investment that's hopefully good for them and good for us and good for overall commerce.
But if we're talking about competitiveness, that's a different thing. Here’s where something like the enormous data investment that we provided in this PEPFAR example is based on a ‘higher ground’ rationale. We had to put a lot of money into that, and so many investments from our side as well as their side went into it. The medical science involved in testing and treating, and experimentation in that American spirit of wanting to solve the problem regardless of the politics and the economic ramifications of it. At both USAID and CDC, some of these technical experts would be up all day, up all night wanting to help solve this.
So how do you measure that? What I think what happens is that the Dr. Coutos, the Dr. Mbofanas, and the Dr. Gudos have the experience of seeing the mighty U.S. government willing to be in the passenger seat, willing to actually shift the ideas and templates they were trying to bring in from outside. The Americans ultimately sided with a lot of the home-grown Mozambican solutions. They actually went back to Washington and said ‘we’ve got to trust these people’, and it worked.
I wish these stories could be channeled more widely through the continent. It's like the old Churchill quote, ‘democracy's the worst form of government out there except for all the others that have been tried’. We make mistakes, and we'll continue to make mistakes, but there are cases where the effort, the sweat equity, should define that intent.
AK: Secretary of State Marco Rubio was in El Salvador answering a question about cutting off U.S. aid. He said, ‘we’re not just going to cut off all aid, but foreign assistance is not charity. It has to promote US interests.’ How do you defend foreign assistance in terms cold, hard advantage to the U.S.?
PC: Essentially, I think you would argue foreign assistance has to result in some sort of commercial or economic benefit for the country overall, right? That it would have natural implications for the foreign provider of that assistance. I think we tend to see assistance as aid, as checks, as money being transferred. But that is actually a legacy visual. Assistance can mean a lot of different things, and I really think we're in this state of liminality at the moment. We've got a very economically focused agenda ahead. Economic statecraft is a term used since the latter part of the Biden administration and even more so now. It's easy to think of the transactional, commercial, ‘business deal’ making aspect of it, but for our partner nations it's the economic resilience part that you hear them talk about. How are they actually going to break even and get over certain curves, within their own barriers, to get to economic growth, to being able to provide for their families and contribute to their economies and ultimately, in the case of HIV, be able to buy their own meds.
Part of the sustainability goals of PEPFAR, in a very good, American style of thinking, is to get our partners to pay for their meds by 2030. How do we get them to pay for their own transport now that all these systems have been established and they're able to run them? A lot of this verifiably comes back to the economy, and I think the more we move away from a donor-funded mindset, the better. Philanthropies, charities, European donor funding, and so on are not the only possible sources of funding. We can look at possible insurance schemes, industry-provided health facilities, and other models of service provision that can work for more of the population.
We saw this in Angola, where they've got oil and gas. A lot of the Angolans who were working in that industry had access to health clinics that were provided as a service of their employer. They were getting topflight health care through those channels, so they didn't need to rely on the public health system. Not everyone's got the oil reserves that Angola does, but maybe they've got mineral reserves. There's all sorts of natural resource extraction going on, so we have think about all of the possibilities and then tweak the roles that we are currently playing to satisfy the new equations.
AK: I’ve been thinking about how little support Americans generally have for foreign assistance, or really any kind of government assistance. I think of the Ronald Reagan quote about the nine scariest words in human language being “I'm from the government and I'm here to help.” Why is government help specifically seen as
something pernicious, or something suspect that will create a perverse result, contrary to whatever good intentions there may be?
PC: Well, I remember soon after returning to the United States in 2020 I was hearing so many pundits talk about the emergence of great power competition, strategic competition, integrated deterrence and the like. I remember thinking, we have ‘North American Island Syndrome’. We're up the northwest corner of the atlas, and the rest of the world is sort of in the center or the eastern side of it. So few of us have spent long periods of time in Africa, and my suspicion is that a lot of Americans think that maybe the Chinese haven’t either, or that they only do infrastructure. They cut checks, maybe send their workers to build something and then leave again. They're all sort of detached from it. There's a book by Deborah Brautigam called The Lion's Gift that documents how long the Chinese investment in Africa has been going on. It was really intended to provide an alternative model to how China itself got itself out of poverty outside of the Western Bretton Woods models. They did it their own way, and they felt compelled to share their secrets.
The Chinese approach in Africa has evolved in both healthy and perhaps unhealthy ways, but they’ve been on the ground for decades and they have gotten to know the African context and make relationships and make trust. Americans look at the dollar amounts of big Belt and Road Initiative projects and think, ‘that's how they got in, so we need to do it better and show our American engineering capacity is second to none’. I'm not arguing against that. I'm only saying we miss the fact of Beijing’s decades-long investment in Africa.
Africa has authentic partnerships with both China and the U.S, and they've also been burned by both sides. Therefore, we have a non-aligned movement with all sorts of countries saying ‘we don't want to pick.’ So now we really are competing in that sense, but sweat equity is still, I think, the higher ground that we have. Let me finalize this point with this. President Xi Jinping’s message at the last Forum on China–Africa Cooperation (FOCAC) was ‘small is beautiful’, suggesting a pivot away from big infrastructure toward smaller, more community-oriented projects. The phrase comes from an English economist's book, Small is Beautiful, that argued that big money and big infrastructure isn’t everything. It doesn't necessarily touch the lives of people, and there’s a better approach for population-centric development.
So now you've got China perhaps taking a ‘small is beautiful’ approach, which goes well with their non-interventionalist approach, a promise not to get involved in local politics like the Americans do. The implication is that the U.S. is intervening, doing distrustful things, spying, and whatever else. But we're also doing things like PEPFAR, where we’ve got our sleeves rolled up, scientist to scientist, epidemiologist to epidemiologist, working hard together to solve something with human ingenuity. We need to worry if China does start doing the small, population-centric approach. They could take that higher ground. We need to protect it.
Peace Corps is great—I was a Peace Corps volunteer myself—as a way to professionalize that ethic that you don't necessarily need tens of millions of dollars of programming. Some of the best things I've done have been on a shoestring budget.
Sweat equity is really how you make long term relationships and trust. Different types of people will rotate in and out, and disagreements will arise, but over time the legacy makes a difference. I arrived in Mozambique in 2015, and while I’m not claiming PEPFAR was entirely the cause, they did go on to get a Millennium Challenge Corporation compact. They became a Global Fragility Act target country. They got a beautiful new embassy. The U.S. has done a lot to show that this is a place to invest in, and I believe that the shift towards greater epidemic control of HIV demonstrated the kind of partnership that we wanted to invest in with other U.S. Government programs.