Sustaining Progress: The Critical Role of PEPFAR
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) represents the largest financial commitment ever made by a single country to combat a single disease. Established in 2003 by President George W. Bush, PEPFAR has had overwhelming bipartisan support through 10 Congresses and four presidential administrations. Over the past 20 years, the U.S. government has invested more than $100 billion in the global HIV/AIDS response, saving more than 25 million lives and providing treatment to millions more.
Since 2003, PEPFAR has been a cornerstone of global health efforts. However, its future is currently uncertain. In March 2024, PEPFAR received a one-year reauthorization, a departure from the program’s historical five-year extensions, reflecting the increased politicization of the program. This short-term extension is set to expire on March 25, 2025, raising concerns about the continuity of its life-saving initiatives. Maintaining PEPFAR’s funding and bipartisan support is crucial to sustaining the progress achieved in the last two decades and ensuring the fight against HIV/AIDS remains a global health priority.
Why was PEPFAR needed?
HIV (human immunodeficiency virus) is a virus that attacks the cells that help the body fight infections, making the body more susceptible to other illnesses. It spreads through bodily fluids — including blood, semen, rectal and vaginal fluids, and breast milk — and is most commonly transmitted during unprotected sex or through sharing needles. Untreated HIV can progress to AIDS (acquired immunodeficiency syndrome), the late stage of infection caused by severe damage to the immune system. At this stage, life expectancy is about three years or even shorter — just one year — if the individual contracts an opportunistic infection.
There is no cure for HIV, but antiretroviral therapy (ART) can significantly reduce the amount of virus in the blood, lowering it to undetectable levels. When taken consistently, ART not only enables people to live long and healthy lives but also prevents HIV transmission to sexual partners. Pre-exposure prophylaxis (PrEP) offers another layer of prevention, providing protection for individuals at high risk of infection, such as those engaging in drug use or specific sexual practices. Additionally, post-exposure prophylaxis (PEP) can effectively prevent the virus from taking hold when taken within 72 hours of potential exposure.
Where is HIV relevant?
HIV is believed to have originated from chimpanzees in West Africa during the 1930s and was transmitted to humans through blood exposure while hunting. By the 1980s, doctors began noticing high rates of the virus among humans, particularly young gay men, who were dying from cancer and pneumonia at alarming rates. Initially thought to affect only men, it soon became clear that women and children — through breastfeeding — were also at risk. In 1987, the first antiretroviral drug, AZT, was introduced, but it wasn’t until the advent of highly active antiretroviral therapy (HAART) in 1996 that disease containment became a reality. Between 1996 and 1997, HIV-related deaths in the U.S. dropped by 47%.
While advancements in diagnosis and treatment have significantly curbed HIV-related mortality in the U.S., the epidemic remains a pressing issue globally. There is a need for sustained international efforts like PEPFAR, which focuses on four key priorities: achieving epidemic control, using data to guide decisions, prioritizing interventions for the most affected populations, and fostering collaboration across sectors. Known for its rigorous use of data, PEPFAR ensures that funding reaches those most in need by tracking progress through key metrics.
How has PEPFAR succeeded?
A central achievement of PEPFAR is its support for ART. In fiscal year 2023, 96% of adults and 88% of children receiving ART achieved viral suppression, significantly reducing transmission rates. ART has saved millions of lives, extended life expectancy, and played a crucial role in preventing the spread of HIV.
PEPFAR funds programs like DREAMS Next Gen, which targets adolescent girls and young women at high risk of infection. By addressing structural factors such as gender-based violence, economic exclusion, and lack of education, DREAMS has reduced HIV diagnoses in its focus areas compared to regions without similar interventions. PEPFAR also works to prevent HIV among men and boys and has supported more than 32.5 million voluntary male circumcisions as a proven preventive measure. Additionally, the program provides critical care for orphans and vulnerable children affected by the epidemic.
Beyond direct interventions, PEPFAR strengthens healthcare systems by providing training for healthcare workers, building clinics, enhancing laboratory capacity, and creating robust data reporting systems. These efforts not only aid in combating HIV/AIDS but also bolster overall healthcare infrastructure, as demonstrated during the COVID-19 pandemic. PEPFAR has also expanded access to PrEP, providing nearly two million people with this preventive medication.
- 26 million lives saved
- 20.6 million people receiving ART
- 7.8 million babies born HIV free
- 83.8 million HIV/AIDS tests administered
- 6.6 million orphans and vulnerable children supported
- 342,000 healthcare workers trained
- 2.3 million women and girls reached with preventive services
- 32.5 million voluntary male circumcisions performed
Economic analyses reveal a return of $6.44 in benefits for every dollar spent on HIV/AIDS treatment and prevention. In addition, 12 PEPFAR priority countries have achieved remarkable milestones: 95% of people living with HIV knowing their status, 95% of diagnosed individuals receiving treatment, and 95% of those treated achieving viral suppression.
Why revisit PEPFAR?
Despite these successes, the fight against HIV/AIDS is far from over. In 2023, 1.3 million people became newly infected with HIV, and an estimated 630,000 people died from AIDS-related illness. PEPFAR is currently operating under a one-year reauthorization, which creates significant challenges. Short-term reauthorizations force organizations to limit resources and curtail initiatives due to uncertainty about future funding. One organization reported that a one-year reauthorization meant turning people away from treatment because there was no guarantee of continued support. A five-year reauthorization would allow for greater flexibility, enabling organizations to reach more people and have a more substantial impact.
PEPFAR’s unparalleled achievements demonstrate the importance of large-scale investments in global health. Sustained funding and commitment are essential to ending the HIV/AIDS epidemic and ensuring a healthier, more equitable future for millions worldwide.
This article was written by EJ Johnson and Jill Fairholm, global researchers for Mormon Women for Ethical Government.