The most terrifying event in all my years as a physician was a needle stick injury from an HIV-positive patient. 

It happened at midnight on a Saturday when a patient coded and was rushed to the surgical intensive care unit (ICU) where the only available bed was. Even though his heart had stopped and he had full-blown AIDS, factors that made his odds of recovery low, we were in the United States. That meant doctors “did everything” to save a patient’s life: CPR, breathing tube, and multiple invasive procedures involving big needles to deliver powerful medications to try to save him. In the chaos, I stuck myself with one of those big needles. 

I quickly found out just how bad this was. This patient had a well-documented history of noncompliance with medication, resulting in multidrug resistant HIV. His viral load was so high that it went above the machine limit. He died within a few hours. It is difficult to imagine a worse-case scenario. 

It is also difficult to imagine a better place for this to have happened: a massive teaching hospital in the United States. A highly trained pharmacist worked on site 24/7 and administered my first two drugs of post-exposure prophylaxis (PEP) within an hour of exposure. Given the patient’s drug resistance profile in the electronic record, we knew I needed more than the standard regime. The next day, a doctor specializing in HIV prescribed two more drugs. Later that week, I got so sick that I fainted and had a seizure during ICU rounds. I went to the emergency room for a battery of tests. When everything came back normal by the next day, I was sent home with a fifth bottle of pills—antinausea medicine so I could continue taking all four antiretrovirals. I was intermittently tested for HIV for a full year after the exposure. This influenced my decision of when to start a family, though I was already in my thirties with plummeting fertility. 

That needle stick cost my employer thousands of dollars, but whether they would cover my care and whether that care was adequate were never in question. I am also a valuable asset. It took around half a million dollars to train me as a trauma surgeon. 

I don’t live in the United States anymore. I live in Malawi where funding for HIV prevention and care has been decimated by the recent drastic cuts to the U.S. Agency for International Development (USAID). As HIV care diminishes, the number of patients, like the one I was exposed to, will likely grow and drug-resistant HIV could quickly become an overwhelming problem. 

Malawi, HIV, and U.S. Foreign Aid 

Half of Malawi’s HIV services are funded through the U.S. Centers for Disease Control and Prevention and half through USAID. President Donald Trump’s executive order for a 90-day review of foreign aid programs forced the immediate closure of essentially all HIV treatment centers, stranding thousands of patients needing refills of medication for at least a full week. USAID partners were then terminated, compromising hundreds of clinics. Even with some programs now being reinstated (again), the result has been chaos. 

The Malawi Ministry of Health (MoH) scrambled to deploy personnel from other health services to HIV clinics and programs that relied on donor funds—mostly from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), a program credited with saving more than 26 million lives in 55 countries since the early 2000s. Although a transition to increased local support has always been the plan through PEPFAR’s sustainability road map, making a change this massive overnight is impractical and dangerous. 

The government is trying to fill the gaps, but there just aren’t enough trained workers. Malawi has a population of 20 million, but only about 600 registered medical doctors—far below the World Health Organization’s recommendation of one doctor per 1,000 people. Because nearly 10% of Malawians are HIV positive, it takes thousands of trained health-care workers to efficiently run these HIV programs. Malawi already exists amid a crisis of human resources for health. The abrupt withdrawal of USAID funds means MoH staff have to quickly learn a new system of HIV management, data entry, and patient care as other areas of health care suffer from even greater staffing shortages. 

Malawi’s HIV Patients Feel the Loss of USAID 

Positions previously held by USAID-funded workers are being filled by people with little to no training or experience, if any. The government cannot afford to rehire all the experts working for donor agencies to continue in their roles. In some places, nongovernmental organizations have tried to step in, but the scale and complexity of the downsized services cannot easily be assumed by someone else. 

One implementing partner delivering HIV care had 1,200 of their staff terminated overnight. There’s zero chance they can bridge the gap, especially on short notice. As a result, some HIV patients are receiving treatment from a health surveillance assistant (HSA)—who has only 12 weeks of training after high school—rather than a doctor or nurse with advanced medical training. 

Because HSAs are responsible for evaluating some of the most complicated HIV patients, including those on three or more medications for resistant disease, the quality of care is declining and countless lives are put at risk. Routine HIV testing is suffering across entire regions, and adequate data is not being gathered, leaving huge gaps in management plans. The data collection of who got what medicine, how much, and when now has a permanent gap of at least three weeks. Not having this information disrupts planning for medication orders and checking which patients missed their refills and are at risk of developing drug resistance. 

Newborn babies can no longer being adequately tested for HIV because the resources have evaporated. The only reliable way to check a baby’s status is with a more expensive polymerase chain reaction (PCR) test. Doctors are now starting all at-risk babies on HIV treatment at birth, knowing that some will ultimately be negative, rather than wait for babies to show signs of illness before starting treatment. The risks here flow in both directions. Babies need to stop treatment at some point for several months for the virus to replicate enough to give a positive test. Stopping treatment that long can risk drug resistance or the health of the baby but is the only way to test without the PCR test. Yet, without treatment, a third of HIV positive babies will die by age 1, and half will die by age 2.

Without USAID support, health programs cannot perform enough routine viral load testing, which measures the number of HIV viruses actually circulating in a patient’s blood. This $25 process is one of the most important and more expensive pieces of HIV care. Checking viral loads is how physicians know if someone is taking their medicine, whether patients are developing drug resistance, and their likelihood of infecting someone else. My exposure was so incredibly dangerous because the patient’s viral load was off the chart. 

It’s too early to know when and how bad Malawi’s situation will get. HIV is a relatively slow-moving disease. Although resistance can develop after just a few days of missed medication, obvious signs can take months to appear, at which point it is too late to prevent drug resistance or keep the patient healthy. Because advanced testing is happening less than it should, health-care professionals can only wait and see when people get noticeably sick. One local expert said, “We’re just handing out medicine and crossing our fingers.” 

The Sustained Omen of Suspended Foreign Aid 

Drug-resistant strains will spread beyond borders as so many other infectious diseases have done, at great cost—in millions of lives and billions of dollars. Creating a cadre of effective new drugs is a far-off and costly endeavor. 

Currently, PEP is largely available to health-care staff in Malawi after an exposure, paid for by The Global Fund. The United States provides 30% of the money for The Global Fund, and many local experts say they fear that it is only a matter of time before cuts are made there too as Europe refocuses on its own defense and security.

Malawi is a hardship posting for a reason, not because of any external security risk, but because it is a health-care desert. A heart attack here can mean a 24-hour evacuation to South Africa for care that really should happen within three hours. Advanced critical care is equally impossible to find. A bad car accident is frequently lethal for lack of infrastructure to handle emergencies. 

The health-care desert reality stifles development and economic growth. Investors may not come to Malawi if they could easily die of treatable causes. Few will start a megafarm if their workers can’t get safe surgery if they are injured by machinery. Malawi’s existing professionals cannot remain healthy and productive as they age without access to health care. It is no wonder so many people leave. 

We’re just handing out medicine and crossing our fingers

As for specialist physicians who choose to stay instead of seeking safer and better opportunities elsewhere, they are the rarest gems, impossible to replace. Take, for example, my colleague Ken-Keller Kumwenda, the only fully trained Malawian neurosurgeon covering a population of 8 to 10 million people. He spent significant time away from his young family training in Ethiopia, Norway, Tanzania, and Zambia to become the professional he is. 

Once back in Malawi, he single-handedly started a residency program at the government hospital to train more neurosurgeons. His training journey was supported by many sources—from the Malawi government to multiple external donors and universities, to his own scrappiness and willingness to live on little in pursuit of his commitment to improving his country’s health care. 

The world needs Africa to be healthy. Malawi and Africa in general have much to offer a changing world. Malawi has one of the largest reservoirs of fresh water on earth, at a time when many foresee conflicts erupting as water resources are depleted. Africa has more unused arable land than any continent, not to mention minerals. As energy access becomes its own crisis, Africa has a burgeoning solar energy sector and more sunlight than any continent. Where other countries do not have enough people to care for their elderly, Africa’s culture of caregiving will be needed even more. 

If foreign aid programs are not restored, or at least temporarily reinstated with achievable transition plans, Africa could be unable to respond when its people, goods, and services are needed elsewhere. That day is not a matter of if, but when. 

Let’s ensure that Africa is ready to offer aid to its global neighbors when that day comes.