Night had fallen hours ago, but Billiance Chondwe was not slowing down.
On Feb. 20, he frantically tapped out texts on WhatsApp, dialed distant acquaintances and left voice messages from his home in Zambia. He'd pause only to close his eyes and think of whom else he could reach out to for help.
He urgently needed to find medication for Diana Lungu. She's an orphan, she's 9 — and she's HIV-positive. She'd run out of the daily pills she takes to suppress the virus. Without the pills, the virus would surge back.
"I called the whole night … calling everyone," remembers Chondwe, 53, a reverend known in his community simply as Pastor Billy. "I slept around 3 a.m."
One of his messages found its way to Thailand, where Susan Hillis was standing in an airport check-in line. It was the wee hours of the morning there, and she was heading home to the U.S. from a conference of Christian mission hospitals. As she listened to the message, Hillis could sense the exhaustion and fear in Pastor Billy's voice — and she knew how much Diana means to him.
"I was about four people from checking in, and I had tears in my eyes and was choked up," recalls Hillis, an epidemiologist who has spent years on HIV/AIDS work. "I was thinking: 'She's going to die. She is going to die.'"
It was through her work in the faith community that she first connected with Pastor Billy — and learned about Diana, a girl with short cropped hair and a cautious but bright smile.
Over the years, Pastor Billy and his wife, Catherine Nanyangwe Chondwe, have taken more than 15 orphans into their home — raising them for periods of time alongside their own five children. "Some were sleeping in the kitchen, others in the sitting room," he says.
Diana stayed with them on and off for four years. There was something different about her, they say — a generosity that took them both by surprise. "Maybe there is tea, or there is porridge, but any child nearby — [Diana] would share with them," Pastor Billy says. The same thing happened when they gave her toys.
An AIDS orphan who is HIV-positive herself, Diana has lost her mother to HIV and her grandmother to COVID-19. She never knew her father. Pastor Billy says whatever stability she has had in her life is in large part thanks to the U.S. government.
Diana's HIV medications and her medical care have been provided by a U.S.-funded clinic with a big salmon-colored gate in her town of Kapiri Mposhi. And a U.S. program supporting AIDS orphans provided Diana with monthly food packages — often fish, beans and cornmeal. Proper nutrition is critical when taking HIV drugs.
PEPFAR — the President's Emergency Plan for AIDS Relief — paid for all of it.
Then came inauguration night.
Half a world away, in Washington, D.C., President Trump signed an executive order with a Sharpie, freezing almost all foreign aid. A flurry of stop-work orders followed, as did program terminations for billions of dollars of international health programs.
From one day to the next, Diana's HIV clinic went from providing lifesaving medications to closing its doors. There was no warning and no time to get her medical file and transfer it to another clinic. The monthly package of food also stopped without warning.
By that time, Pastor Billy's church had transferred him to a different town. He'd found someone in Diana's community — Jennifer Mukuka — to welcome her in.
"I don't have much, but I just have this big heart," says Mukuka. She has been able to bear the cost of raising Diana because of the aid from PEPFAR, which also covered fees for her school books and uniform.
And that kind of security has given Diana space to dream of her own future. On her 20-minute walk to school — down dusty, craggy roads — she often imagines becoming a doctor, with a white coat and stethoscope, moving from one bedside to the next.
On that February night — when Pastor Billy reached out to Hillis and almost a dozen others — he had just learned that Diana had run out of her daily HIV medications.
Hillis remembers thinking to herself in that airport line: "If it's happening to her, it's happening to a lot of people."
"Successful" and "unsung"
Diana was one of 6.6 million orphans and vulnerable children supported last year by PEPFAR.
PEPFAR spokespeople often point out that the program has saved more than 26 million lives since its launch in 2003. And it has also helped children on a massive scale. Starting in 2006 — just a few years after then-President George W. Bush created the initiative — a bipartisan team of Democrats and Republicans made sure that 10% of the funding each year was set aside for AIDS orphans and vulnerable children. Last fiscal year, PEPFAR spent just over $200 million on these youngsters — about $31 per child supported.
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AIDS often kills people in their childbearing years and has left millions of orphaned children in its wake. PEPFAR's vision was to enable local families to take in these orphans by providing basics — not only medicine but also food, clothing and school fees, as well as psychosocial support to address stigma. The program defined orphans as children who had lost one or both parents to AIDS, and the children did not necessarily have HIV themselves.
Eric Goosby — the infectious disease physician who oversaw PEPFAR from 2009 to 2013 — says it's hard to overstate the impact of this program that is at once "very successful" and "largely unsung."
"The orphan-and-vulnerable-children response that PEPFAR created was bigger than the Catholic Church, all added up in every country, in terms of the number of orphans saved," says Goosby, now a professor of medicine at the University of California, San Francisco. "That was the largest effort on the planet."
Now it's mostly on hold.
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In an emailed statement, the U.S. State Department said that while HIV treatment and care are allowed to continue, as well as prevention of mother-to-child transmission, "all other PEPFAR-funded services are being reviewed for assessment of programmatic efficiencies and consistency with United States foreign policy."
The department did not respond to NPR's questions about when the review would be completed and what the 6.6 million orphans and vulnerable children, as well as their caregivers, should do in the meantime. The statement did say that children and adults who are both HIV-positive and malnourished can get food support. While Diana has lost her food packages and is often hungry, she is not considered malnourished, according to Pastor Billy and Mukuka.
How budget negotiations unfold will likely impact which parts of PEPFAR continue.
"Everything was stopped, and it's not coming back — except [HIV] treatment," says one U.S. civil servant who has spent years working at high levels on the United States' HIV/AIDS efforts and who requested anonymity because they are concerned that speaking out could harm their career. This civil servant said none of the staff members involved in the orphans program was moved to the State Department when the U.S. Agency for International Development (USAID) was dismantled as an independent agency.
Since the foreign aid freeze was announced, Hillis has been reaching out to her network of colleagues and friends all over the world to better understand their situation. That network was built up during the 25 years she spent at the U.S. Centers for Disease Control and Prevention as a senior adviser with a focus on HIV and vulnerable children. She then spent seven years at PEPFAR. During Trump's first term, she was picked to lead a $100 million initiative to use faith-based groups to advance HIV/AIDS work. She was let go on the ninth day of Trump's second term.
Between emails, phone calls and text messages, Hillis has been keeping track of the situation on the ground in a variety of countries. "Now, a lot of families with orphans are hungry," she says.
In that airport line in Thailand, Hillis remembers panicking about Diana's fate.
"I just thought, 'This little girl's gonna die. She has no chance unless someone can get her medicine in the middle of rural Zambia. Who's gonna do that?'" she says.
Flashing back to the death of his twin
For Pastor Billy, there was a very personal sense of urgency.
Growing up in Kitwe, Zambia, he was one of 13 children. During meals in the family's three-room house, he always sat next to his twin sister and best friend: Charity. "We [would] eat from the same plate," he says. And they'd play. She'd kick the soccer ball with him. He'd skip rope with her. "We were so close. It was lovely."
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When the twins became teenagers, Pastor Billy says that a businessman lured Charity away. This businessman promised a more luxurious lifestyle than their family could offer. The twins' father was a cook at the local hospital.
But when Charity returned from spending time with the businessman, she was sick.
"She developed something like a rash — when she pressed [the lesions], water [came out]," remembers Pastor Billy. The rash spread all over her face and arms and soon down to her legs.
At the clinic in Kitwe, she was diagnosed with HIV/AIDS. At the time, in 1989, there were no medications or treatments for AIDS in Zambia.
So Billy nursed her at home in their kitchen. Soon, she couldn't walk or even stand. Still today, he can instantly conjure up the image of her skeletal frame and the smell that permeated through the house as her condition deteriorated.
"Sometimes if I [was] out, she would be calling for me," he says. "There was one time I stopped going to school, like for a month, because she only wants me to be around."
Two years after her symptoms started, Charity died. "It brought me to my knees," Pastor Billy remembers. "It brought me to a point where [I realized] no matter what I can do as a human being, there is a limit. But at that time of sensing that limitation, I turned to God."
He became a pastor in 1994 as HIV/AIDS pounded the country and region. Until the 1980s, life expectancy had been steadily rising in Zambia. But as the HIV epidemic took off, life expectancy plummeted from 56 to 46 over the course of 15 years, according to Mary Mahy of the Joint United Nations Programme on HIV/AIDS.
When PEPFAR was founded in 2003, there were more than 10 million children globally who had lost one or both parents to AIDS. "When children are deprived of a parent early in life, they have a significantly increased risk of exposure to violence, abuse, neglect, exploitation, school dropout, poverty," explains Hillis. She co-authored a paper in The Lancet in May citing research showing that, across 14 countries, children who have lost one or both parents are at six times the risk of contracting HIV.
Part of what drove Bush to incorporate orphans and vulnerable children into PEPFAR was a religious sense of compassion, says John Stover, vice president at Avenir Health, a group that analyzes data and policies for public health programs. "[Bush] had a lot of support from Christian groups — evangelicals and others — who were largely focused on improving the lot of children in Africa," he says.
There was also a practical reason for caring for this group of children, says Dr. Chris Beyrer, director of the Duke Global Health Institute. Children who had lost their parents were "perceived to be very vulnerable to groups like militias and extremist organizations and gangs," he explains, pointing out that this was one of the reasons President Bill Clinton declared AIDS a threat to national security.
"No, no, no, no, no"
Pastor Billy also saw AIDS as a threat. As a new pastor, he saw members of his congregation start falling ill just like Charity had. "They were showing symptoms of my twin sister," he recalls. "I was like, 'No, no, no, no, no.'"
The funerals became so frequent that Pastor Billy was sometimes burying people several times a week. Even on Sunday, it would be a quick Mass and, then, to the graveyard.
When services wrapped up, he'd often have another time-sensitive task: figuring out what would happen to the orphaned children. He'd scramble to find relatives and community members to take them in, given the stigma of being associated with an AIDS death. And if nothing else worked, he and his wife would open their home.
"My wife's nursing our first child — [and] she's now a mother of seven," he remembers.
"It felt like a miracle"
In 1996, far from Zambia, there was an extraordinary turn of events, says Beyrer. Fifteen years after AIDS came on the scene, a very effective treatment was discovered: a combination of drugs that could suppress the virus's replication to extremely low levels.
The results are often described in biblical terms.
"People who are on their deathbeds, wasting away with diarrhea and thrush and fevers, would get on these meds and, literally, rise up off their deathbeds," says Beyrer. "That's what was called the Lazarus effect — like Lazarus raised from the dead." The patients, he says, would "gain weight and go back to school and parenting and working. And it felt like a miracle."
But this was a miracle only for high-income countries. Prior to PEPFAR, the treatment cost so much that it was essentially unavailable for people in sub-Saharan Africa, where the epidemic was the worst. Only when PEPFAR was established did low- and middle-income countries partake in the miracle.
"In Scripture, Jesus said, 'I will not leave you as orphans,'" says Pastor Billy, recalling the passage that captured his relief when, in 2004, PEPFAR arrived in Zambia. "Despair was taken away from families."
Hillis remembers a trip to Africa, after PEPFAR was launched, where she realized that the roadside carpenters were no longer displaying caskets for sale — a brisk business when AIDS was at its height. Instead, they were lining the street with handmade beds. "Both of them you lay down in," Hillis remembers thinking to herself. But one, "you lay down to rest because you're going to get up in the morning and live a vibrant life."
As the drugs enabled parents to survive and give birth to children who were not infected with the virus, Pastor Billy focused more fully on the orphans who'd been left behind.
It was in 2016 when he met Diana, just days after she was born. He'd been helping her mother during a rough pregnancy where she was "always sick." And he went to the hospital hoping to celebrate another child born HIV-free to an HIV-positive mother, thanks to modern medications.
But as Diana's first year unfolded, it became clear that she needed to be tested for HIV. She "was always suffering from diarrhea. She was weak, always underweight," recalls Pastor Billy. He was left wondering whether her mother hadn't taken her HIV medicine as consistently as necessary. He helped get Diana tested for HIV, and then, once the results confirmed his suspicion, he made sure she got on medication to suppress the virus at one of the U.S.-funded clinics in town.
Diana's life stabilized until two devastating family deaths. The girl's mother passed away as she neared her third birthday. Diana moved in with her grandmother — and Pastor Billy and his wife started to help more. For several years, Diana and her grandmother stayed in the pastor's house whenever they walked the 7 miles into town to access the clinic. And in 2021, when Diana's grandmother died, Diana moved in.
"You see pieces of brokenness at different stages in her life," says Pastor Billy. "My heart usually bends toward brokenness."
For a year, Diana grew up among his own children. She often reminded Pastor Billy of his twin sister.
Then, in 2022, Pastor Billy and his wife faced a difficult decision. The church asked them to move to a city four hours away. He wanted to take Diana but also felt she would benefit from staying in Kapiri Mposhi, the only place she'd really known. Plus, he had dreams of continuing his religious studies in the U.S. and knew it could be logistically challenging to formally adopt Diana so that she could travel with his family.
So Pastor Billy took the new assignment — but makes a point to visit Diana in her new home regularly. Whenever he does, Diana's face lights up. In that smile, he felt a sense of hope: Diana's generation might be the last one so badly scarred by AIDS, he thought.
Others felt the same. "We've been so close to truly having an AIDS-free generation of kids," says Dr. Rachel Vreeman, chair of the Department of Global Health and Health Systems Design at the Icahn School of Medicine at Mount Sinai. "And that is completely at risk right now."
"There isn't enough food"
In February of this year, Diana had her first hint that something was amiss.
On that 20-minute walk to school, dreams of her future stethoscope were accompanied by pangs of hunger. The monthly packages of food the U.S. had provided for Diana had stopped. And Jennifer Mukuka had lost the stipend she got for transporting medications from Diana's U.S.-funded HIV clinic to far-flung patients.
Now, there's often not enough food in the three-room house they share with Mukuka's adult daughter and two young grandchildren.
"Sometimes we just have one meal per day," explains Mukuka. "In the evening, we just cook porridge."
In a quiet voice and speaking in Bemba, her native language, Diana says, "Because there isn't enough food, I sometimes don't feel well." HIV medication must be taken with food; otherwise it can make the person feel very unwell — one of the reasons PEPFAR usually provided food along with drugs.
It's not just food that's in short supply. Her drugs are no longer readily available. Diana's U.S.-funded clinic closed so quickly after the stop-work orders came out in late January that Mukuka couldn't get Diana's medical file or a transfer letter allowing her to restart care at a Zambian government-run clinic. So Mukuka travels to nearby clinics begging for medication to last Diana until they can get the documents she needs to transfer to the government clinic — or until the U.S.-funded clinic reopens, if it does.
The State Department has issued waivers that lifesaving treatment can continue, including treatment and care for HIV. In an emailed statement, the department said that the organizations implementing lifesaving HIV programs "were notified and urged to resume approved service delivery. Agencies have been working with their implementers to resume activities as quickly as possible."
However, many U.S.-funded clinics have not resumed services yet. Where Diana lives, PEPFAR funding for HIV clinics came via USAID, which has been dismantled by Trump's Department of Government Efficiency. Without USAID, it has been hard for services and programs to resume even if they receive a waiver. Diana's former clinic has not reopened. Pastor Billy has lost hope that it might open its doors again. "It's closed forever," he says.
"We go to different centers, and [we're] just literally scrounging for medication. Sometimes they give us a two-week supply, sometimes a one-week supply," says Mukuka, also speaking in Bemba.
!["I stress myself [out] thinking about Diana — and me, myself, we are almost the same," says Jennifer Mukuka, who is also HIV-positive and who takes care of Diana. When she couldn't get Diana HIV medications because of the U.S. aid cuts, she shared her own medicine.](https://npr.brightspotcdn.com/dims4/default/7d0fcbb/2147483647/strip/true/crop/7435x5576+0+0/resize/840x630!/format/webp/quality/90/?url=https%3A%2F%2Fnpr.brightspotcdn.com%2Fdims3%2Fdefault%2Fstrip%2Ffalse%2Fcrop%2F7435x5576%20465%200%2Fresize%2F7435x5576%21%2F%3Furl%3Dhttp%3A%2F%2Fnpr-brightspot.s3.amazonaws.com%2F6d%2Ff5%2F53d894d14efda9285d1d8b756d15%2Fdiana-and-billy-jennifer-outside-house-1.jpg)
But a handful of times, the scrounging hasn't yielded anything. That means they are sometimes entirely out of Diana's medications. Mukuka says she wakes up in the middle of the night worried about what to do.
"I stress myself [out] thinking about Diana — and me, myself, we are almost the same," says Mukuka, who is also HIV-positive. She recalls her nighttime debate about whether she should give Diana her own HIV pills that she gets from a government hospital.
She weighs the dilemma: Diana is young with her whole life ahead of her — she needs the pills. But Diana is also reliant on her, as are her daughter and grandchildren. In the end, she settled on an answer: "Rather than letting her go without medication, I give her my medication," says Mukuka.
That worries Pastor Billy, who says: "God save Diana. That she doesn't develop symptoms because the dosage was too much or was less or it might be wrong."
Even then there are crisis points — like the night of Feb. 20, when Pastor Billy learned that Diana was entirely out of medicine. Eventually that night, he found a man one town over from Diana who could help. "He said, 'We can share for five days,'" recalls Pastor Billy, who quickly went to his church to solicit donations for the money needed to transport the medications in a shared taxi from the nearby town to Diana's town.
Diana has, at times, gone a week or two without her medication, Mukuka admits. She knows that when people skip their daily HIV medications, the virus can become drug resistant. "When I couldn't get medication for Diana, I was extremely stressed," she says.
Pastor Billy and Mukuka have spent months trying to get Diana's file from the clinic so she can register at the closest government hospital. The Zambian Ministry of Health did not respond to requests for comment about why its medical facilities require past medical files, given the situation.
As they navigate the process, Diana has been taking whatever supply they can get. "Two weeks, one week, two weeks, sometimes even days," says Pastor Billy.
But this past week, he says, he breathed a sigh of relief when he got a phone call announcing that she had been able to get a month's supply of her medication from the district hospital. "She's now getting the medicine, but the consistency is [still] not there," he says, noting that she used to get a six-month supply.
He says he feels surrounded by warnings about what might happen. At his church, others are falling ill without their HIV medications. And he has sent Hillis a message about how he's starting to notice that carpenters are displaying caskets again on the roadside.
"Kids will go hungry"
While the Trump administration has, in the days and weeks following the inaugural proclamations about frozen aid, made a commitment to providing lifesaving treatment like Diana's drugs, the prospect of other support for AIDS orphans — food, clothing, bedding, school fees, counseling — is less promising.
"Kids will go hungry. Kids will drop out of school. Kids will be subjected to transactional sex to be able to survive. This is exactly what will happen," says the U.S. civil servant who requested anonymity for fear of retribution. "It's just absolutely atrocious, in my opinion, that we're now bringing back, potentially, another generation of HIV-positive young people, which could have been totally avoided."
Goosby, who used to run PEPFAR, is adamant that the entirety of the program for orphans and vulnerable children should be allowed as part of the waiver for lifesaving aid.
"What could be more lifesaving than taking a child, feeding them and educating them?" he says, arguing that interventions that aren't a pill can still be lifesaving.
"It really, truly does feel that we are going backward," adds Beyrer of Duke.
For Diana and Mukuka, their hope is pinned to small snacks and thin plastic baggies — some filled with about a quarter cup of flour, others with a similar amount of sugar. They use whatever money Pastor Billy can spare to buy the supplies and sell them to neighbors. Each goes for under 20 cents. They hope it will add up to enough money for food and the basics for school — books, notebooks and a uniform. But Mukuka must also feed her daughter and grandchildren — and pay rent.
On a Wednesday in April, Pastor Billy got up early to make the hourslong drive to check on Diana. He caught her before she set off on her walk to school. She lit up, as usual, when she saw him. She calls him "father." They took pictures together, making goofy faces.
Then it was time for her to head to school — and for Pastor Billy to drive back home, wondering what to do next. These months of uncertainty, along with the frantic searches for medicine and food, have highlighted the vulnerability of the systems he used to depend on — and also Diana's vulnerability.
He got into the car thinking that his plans to study religion in the U.S. might need to take a back seat to Diana's needs.
"Love is not somebody who visits and takes a picture and puts it on the fridge," he says. Perhaps, he thinks, he and his wife should stay in Zambia — and adopt Diana.
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