Who's on the frontline?
The Trump administration spent months eliminating community health worker programs. Now officials recognize their importance
Handsome Chale has memories of the time when the high cost of treatment for HIV was essentially a death sentence.
Chale, who is now 53, was severely ill when he received his HIV diagnosis in 1990. He only survived because his family scraped together enough money to buy him anti-retroviral therapy, or ART, over years. It was both an emotional and financial relief when the United States, through the President’s Emergency Plan for AIDS Relief, or PEPFAR, and other donors began underwriting the cost of the drugs in the early 2000s.
Chale’s experience made him an eager volunteer when the Pamodzi Project started recruiting community health workers, or CHWs, in his area four years ago. The project, which was also funded by PEPFAR, wanted CHWs to visit people living with HIV who were having a hard time sticking to treatment.
Chale’s job was to try to convince them to return to the Chitedze Health Clinic, where he was based, and restart their ART.
Their reasons for defaulting often had to do with the area where they are living. Chitedze is a sparsely populated and poor area of central Malawi. Some patients complained that the distance to the clinic was too far and transportation costs too dear. Others had been met with job opportunities that they couldn’t afford to turn down, even if it took them out of town for months.
As he met with people, Chale drew on his own memories to try and make them understand what a privilege it was to even have access to affordable ART. He encouraged them to prioritize their health. He allayed any fears they had about the drugs’ side effects. He even held their hand and walked them back to the clinic.
“I would visit them again and again until they came back for treatment,” he says.
He did this three days every week, leaving a little time for his work as a motorcycle taxi driver. The CHW gig covered his fuel and paid for a meal, but little else.
Earlier this year, he was abruptly fired from the project when the Trump administration cut its funding.
“They are saying we may have an increase in the death of people with HIV,” he says. “There are no people to encourage at the facility, no outreach activities so people should be encouraged to come here and get the medication.”
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It is confounding then, that the Trump administration would recognize the importance of CHWs in its new America First Global Health Strategy after it just got done terminating Pamodzi and dozens of similar programs across the African continent.
The plan goes out of its way to emphasize its commitment to sustaining frontline health workers, including nurses and CHWs. Indeed, it places CHWs at the vanguard of its integration efforts.
It calls on those who were focusing on HIV services to also take on the responsibility of running malaria tests and to keep an eye out for people who might have tuberculosis, so they can refer them to the clinic.
This vision of integration makes sense. It costs less and saves households time, while addressing myriad threats simultaneously. And it has been well received by the broader global health community.
But who do the authors of the strategy envision will now deliver these comprehensive services after it let people like Chale go? CHW programs that provided services around malaria, TB and childhood vaccinations have been similarly devastated.
Will countries now have to reconstitute their CHW networks to deliver these integrated services? And will America help in this effort? Or is the promise to support an integrated CHW workforce a hollow one, preempted by the administration’s actions before it was even drafted?
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Back in Chitedze, Violet Mbewe has not heard anything about rebuilding or replacing the Pamodzi Project. She is the health promoter at the health center where Chale worked.
She does agree with the Trump administration that CHWs are necessary. In fact, as a direct result of Washington’s actions they are needed now more than ever.
When President Trump froze U.S. foreign aid in late January for a three-month spending review, he did not initially include any exemptions for lifesaving HIV services. That fueled rumors in Malawi that HIV treatment had been completely withdrawn. Assurances by Malawian health officials that the country had plenty of ART on hand to maintain treatment did little to stem the flow of misinformation.
“The message the people got was that the ARVs are not going to be there again,” Mbewe says.
As this false information spread on social media and over community radio, some people living with HIV decided not to bother returning to the clinic for their appointments. Why take the time if there was no treatment available?
In the last three months of 2024, 82 of the roughly 4,500 clients on ARVs at the Chitedze clinic defaulted on their treatment. As rumors of shortages spread, that number climbed to 115 in the first three months of 2025.
“Since we are less here” following the closure of the Pamodzi Project, “we can’t go to everyone and follow them to come back,” Mbewe says.
The rise in people falling off treatment prompted the clinic to call its cadre of former CHWs and ask if they might resume their work. Several agreed, no matter that they would no longer be paid. Chale was among them.
“They need to know what is happening,” he says. “They need people to be coming, giving them that information.”
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I also wrote in-depth for Devex this week on all the ways the America First Global Health Strategy would affect PEPFAR.