The tone of the questions was perplexing, given Secretary of State Rex Tillerson’s praise of PEPFAR in his confirmation hearing, and Vice President Mike Pence’s support of the initiative when it was first proposed in 2003 and when it was re-authorized for the first time in 2008.

And, as my colleague Ed Yong wrote after the questionnaire was made public, tragedy would unfold if PEPFAR were eliminated. The initiative funds and maintains a complex web of laboratories, supply chains, and health centers that provide a wide array of health services to millions of people around the world—all enabled by sustained funding and logistical support. As of 2016, the program helped provide life-saving antiretroviral treatment for over 11.5 million people, trained 220,000 health-care workers, and facilitated counseling and testing for over 74.3 million people.

Though keeping Birx in her post seems to demonstrate that the administration values PEPFAR, they may also have endangered its ability to function.

Three days after Birx was asked to stay on, Trump issued a presidential memorandum re-instating the Mexico City Policy, also known as the “global gag rule.” The policy has traditionally blocked NGOs from receiving funds from the U.S. government for family-planning programs unless they promise not to “perform or actively promote abortion as a method of family planning.”

This move was, in a way, expected, said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. Each president since Reagan has instituted or rescinded the policy along party lines. But Trump’s memorandum breaks precedent.

His memorandum calls for “a plan to extend the requirements … to global-health assistance furnished by all departments or agencies.” With the addition of that phrase, the policy goes from affecting $400-$600 million in U.S.-aid dollars to $10 billion, according to Morrison. That includes PEPFAR.

In the past, the Mexico City Policy has applied to funding for family-planning programs, rather than all global-health programs. And, once PEPFAR came into being, former President George W. Bush exempted it from the policy. As Scott Evertz, who served as director of the White House Office of National AIDS Policy under George W. Bush, told Slate, “It would have been impossible to treat HIV/AIDS in the developing world … if the global gag rule were to be applied to the thousands of organizations with which those of us involved in PEPFAR would be working.”

Yet this is not the first time that PEPFAR, which is funded through Congress, has come into conflict with ideology. When Pence advocated for PEPFAR in Congress, he pushed for the allocation of funding to abstinence-education programs. “Abstinence and marital faithfulness before condom distribution are the cure for what ails the families of Africa,” Pence said in a 2003 floor speech. “It is important that we not just send them money, but that we send them values that work.”