Insights and Impact

3 Minutes on PEPFAR 

School of International Service dean Shannon Hader breaks down the groundbreaking HIV/AIDS initiative, which has saved more than 21 million lives since 2003

Shannon Hader

As the United States President’s Emergency Plan for AIDS Relief (PEPFAR) approaches its 20th anniversary in January, the groundbreaking program—which has invested more than $100 billion to fight HIV/AIDS in more than 50 countries—remains the largest commitment by any nation to address a single disease in history.
By 2003, the US and other wealthy nations were seven or eight years into AIDS no longer being a death sentence. We had finally developed an effective HIV treatment around 1995—and while those early pills were complicated and unforgiving, they were miracle drugs. It was like the Lazarus effect: people who looked like skeletons on their deathbed would recover. And yet these drugs—which we now know also prevent ongoing transmission of HIV—were virtually unavailable in developing countries. 
Africa had been the hardest hit by the virus. In Zimbabwe—where I first worked as a medical student and where I later led the CDC from 2003 to 2006—one in four adults was living with HIV, and up to 40 percent of people in some age groups—especially those of parenting and core working ages—were dying from AIDS. It ravished communities. Cemeteries were overwhelmed, with burials scheduled every two hours during the weekends. It became customary to pour cement on the graves to keep the coffins from being dug up and reused. It left lots of young children with only their grandparents to raise them. 
President George W. Bush announced the creation of PEPFAR during his State of the Union address in January 2003. As a Republican, Bush played a distinctive role in mobilizing a broad range of stakeholders on the right to not only get on board, but to help lead. He also put a lot of his personal and political capital into PEPFAR. In fact, he and his family are still heavily involved with crossover work between cervical cancer and HIV in Africa.
PEPFAR, which has enjoyed bipartisan support across three more presidential administrations and 10 US congresses, is managed by the US State Department’s Office of the US Global AIDS Coordinator and Health Diplomacy. Congress codified the authorizing language—which includes streams for both bilateral and multilateral aid—and attaches a budget to PEPFAR. In addition to the original authorization, we’ve had three five-year reauthorizations, most recently in 2018. 
PEPFAR’s design may have been inspired by the Joint Chiefs of Staff model. The global AIDS ambassador, currently John Nkengasong, who’s served in the position since June, meets with leaders of all the partner agencies, including the Centers for Disease Control and Prevention (CDC), Peace Corps, and the US Agency for International Development, to develop a coordinated approach focused on results, accountability, and transparency. The coalition also includes faith-based organizations, private sector, and philanthropic organizations like Bono’s ONE Campaign and the Bill and Melinda Gates Foundation. This innovative model—in which many different stakeholders feel ownership over the problem and its solutions—is one of the reasons the initiative has been so effective. 
Another reason is that PEPFAR is simply a multi-sectoral miracle. People who cared about humanitarian and health care issues had long advocated for the US to invest more in fighting the global AIDS epidemic, but suddenly they were joined by others with vastly different interests and worldviews who were nonetheless motivated to align politically and address the crisis. For example, it became clear to national security experts that when you have entire generations of people dying and leaving children in poverty, without a stable family, those communities are ripe for radicalization. And those who cared about business realized that when everyone of working age is dying or caring for friends and relatives who are, it’s very difficult to expand economic markets in those places. 
PEPFAR and the scale of its impact have transformed many people’s view of the US, especially those in sub-Saharan Africa. In the first five years after its launch, many families saw their loved ones brought back to life and knew that partnership came from the US government—or rather, the American people. Under the program—which also supported the use of quality generic drugs for those still on patent. This helped increase access, grew the overall global market, and lowered prices. We’ve seen the death rate drop and the number of people on treatment skyrocket. Today’s drugs today more effective and have been proven to prevent HIV transmission, and most people in developing countries can take one combination pill a day that costs less than $70 per year—compared to more than $9,000 per year 20 years ago.
We’ve made tremendous progress without a vaccine and without a cure: today, nearly 29 million people worldwide—75 percent of all those living with HIV—are on lifesaving treatment, compared to fewer than 40,000 in 2003. But we’re not done yet. There are at least 10 million more people who aren’t on treatment, about 60 percent of whom don’t even know they’re HIV-positive. Even though HIV infections have dropped by more than half since their peak, they remain too high.
One of the groups we’ve done the worst job reaching is children: nearly half of the 1.7 million children living with HIV are not on treatment. There’s been a successful focus on preventing transmission from mothers to babies and identifying infants who become infected, half of whom will die before age two. But we forgot about the half who won’t die as quickly. Many are older than five, so they’re not being found by routine infant and toddler care. It’s possible that they are the children of parents who have been marginalized and discriminated against, including sex workers and drug users. So addressing the social and legal barriers to access is important. 
The AIDS pandemic is not over. What’s left to do—working through social, structural, and human rights issues to reach everyone who’s HIV-positive and ending the epidemic as a public health threat without a vaccine or cure—may be the hardest push yet. But back in 2003, no one could’ve imagined everything we’ve accomplished today. With the right investment and enough political will, we’ve proven that this challenge is well within our grasp.

PEPFAR at a glance:

  • The US has invested more than $100 billion in the global HIV/AIDS response. 
  • PEPFAR has saved more than 21 million lives since 2003. 
  • PEPFAR directly supports nearly 19 million women, men, and children on lifesaving antiretroviral treatment. 
  • PEPFAR has helped train 300,000 new health care workers.
  • More than 2.8 million babies have been born HIV-free because of PEPFAR.
  • More than 40 million people have died from AIDS, including 650,000 in 2021 alone.