In 2003, amidst a groundswell of activism on behalf of children living with HIV, the United States initiated the President’s Emergency Plan for AIDS Relief (PEPFAR). Suddenly, children who were born with HIV in PEPFAR-supported countries had access to antiretroviral medication. Those children are now considered the first generation of people born with HIV to live into adulthood. Drawing on ethnographic fieldwork and a twelve-year-relationship with Mwana Mwema, a network of faith-based pediatric HIV clinics across Nairobi that were supported by PEPFAR and the United States Agency for International Development (USAID) before their abrupt closure in 2024, I explore the ways PEPFAR and USAID policy became imbedded in the lives of some of these young adults. Analyzing the fragile social, financial, and spiritual ecosystems instituted through global health and development policy, I illuminate how young adults and practitioners widened the impact of PEPFAR and made the initiative work despite its deeply contingent nature. Despite the tumult Mwana Mwema experienced before its closure, peer mentors and practitioners alike “coopted policy from below” to create myriad opportunities both within and outside United States funding mechanisms (Mosse 2005, 239). Ultimately, Mwana Mwema’s story coupled with our current global health context issues an invitation to imagine new forms of global health and development that are not contingent upon the strength of American democracy.
I begin with a brief overview of PEPFAR, as it was the most consistent and primary funder for Mwana Mwema. At the time of writing this abstract, the networks created by PEPFAR recipients face a new level of precarity. Initiated under President George W. Bush, PEPFAR came into the world with much bipartisan aplomb. Today, PEPFAR provides antiretroviral care for approximately 26 million people living with HIV across the globe. But its future is deeply uncertain. PEPFAR is typically renewed every five years. Historically, it has received strong support from administration to administration. However, it's protocols shift each time a new president is elected. In 2024, lawmakers accused PEPFAR programs of funding abortion. These accusations led to a temporary, one-year authorization. The initiative, which relies heavily on the embattled United States Agency for International Development, is up for reauthorization in March 2025. The fragility of PEPFAR and USAID are likely to causes increases in HIV prevalence, unemployment, and poverty. Moreover, it will fracture civil society in the Global South.
To illustrate this fracture, I highlight stories from Phillip and Lucas. Both former patients at Mwana Mwema, these two men help contextualize the global social worlds into which they were born. Exploring their experiences alongside the work of public health historian Randall Packard and oral histories from veteran practitioners, I explore how the first years of Phillip and Lucas’s lives were marked by an ongoing struggle between AIDS activists and the many entities (pharmaceutical companies, the United States, and the World Trade Organization) that initially prevented lifesaving antiretrovirals from reaching Kenya. During this time, the founder of Mwana Mwema, an American Jesuit priest, became a relentless advocate for pediatric antiretroviral medication. Phillip and Lucas’s later childhood is connected to a surge of Western promises made to those living with HIV in Sub-Saharan Africa. Perhaps the most significant of these promises was the creation of PEPFAR, which began funding Mwana Mwema when Phillip and Lucas were around six and seven years old.
Then, I examine the adult lives of Phillip, Lucas, and other former Mwana Mwema patients who served as peer mentors at the organization. Peer mentors offered counseling to adolescents and teenagers who are struggling with social stigma for a small stipend of $15 per month. Peer mentors are passionate about their work because they too once struggled to take their antiretroviral medication. But peer mentors are also deeply aware that this work is important to their economic survival. Drawing on the notion of “hustling,” I explore the way young adults cobble together resources and volunteer opportunities at multiple NGOs, FBOs, and churches to create a living. Hustling is the process of identifying immediate and long-term opportunities. It ekes out possibilities that are not always immediately visible to outsiders. The practice of hustling animates what I call “contingent moral imaginations.” Contingent moral imaginations envision a field of possibilities rooted in acknowledgement that each moral possibility threatens collapse at any moment. Rather than eschewing vulnerable or even nascent moral possibilities, hustlers instead make multiple investments in social, economic, even spiritual resources at the same time. Drawing on the work of Susan Reynolds White, Richard Rorty, and Michel de Certeau, I examine how these contingent investments “find niches” and become more permanent possibilities for peer mentors (Rorty 1989,16). Because each opportunity can always be otherwise, peer mentors know that no one investment will deliver them from precarity. In many ways, contingent moral imaginations are cultivated over and against the care structure of PEPFAR, which emphasizes stasis for the purposes of biomedical continuity. Neither peer mentors nor practitioners trust that stability. Instead, they seize opportunities to hustle.
I conclude by returning to the current United States global health context. Opportunities for hustling have been severely hampered by a USAID stop work order from the newly initiated Department of Government Efficiency. Access to antiretrovirals is in jeopardy. While I maintain that PEPFAR is vital for the physical health of its recipients and to curb of wider spread of HIV, I grapple with the reality that PEPFAR has been effective because of the practitioners and peer mentors that work on and in global health policy. Any pause on PEPFAR work will have far-reaching biomedical consequences. But also any pause that risks losing the practitioners and peer mentors that make PEPFAR work will cause irreparable harm. The most recent pause in health and development funding is one instance in a long string of organizational whiplash among practitioners and patients at FBOs like Mwana Mwema. Ultimately, I suggest global health and development models (such as cash transfers and investment in infrastructure) that are not contingent on policies that change from administration to administration.
In 2003, amidst a groundswell of activism on behalf of children living with HIV, the United States initiated the President’s Emergency Plan for AIDS Relief (PEPFAR). Suddenly, children who were born with HIV in PEPFAR-supported countries had access to antiretroviral medication. Those children are now considered the first generation of people born with HIV to live into adulthood. Drawing on ethnographic fieldwork and a twelve-year-relationship with Mwana Mwema, a network of faith-based pediatric HIV clinics across Nairobi that were supported by PEPFAR and the United States Agency for International Development (USAID) before their abrupt closure in 2024, I explore the ways PEPFAR and USAID policy became imbedded in the lives of some of these young adults. Analyzing the fragile social, financial, and spiritual ecosystems instituted through global health policy, I illuminate how young adults and practitioners widened the impact of PEPFAR and made the initiative work despite its contingent nature.