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The US President’s Emergency Plan for AIDS Relief (PEPFAR) is threatened with closure
GFO issue 437

The US President’s Emergency Plan for AIDS Relief (PEPFAR) is threatened with closure


Christian Djoko

Article Type:

Article Number: 6

PEPFAR is being held hostage by an ideological war between Republicans and Democrats

This article reminds us of the importance of PEPFAR in the fight against HIV/AIDS at a time when its future hangs on the conservatism and culture war and political partisanship underway in the United States’ House of Representatives.

Created in 2003 at the instigation of the then United States President George W. Bush, PEPFAR (the US President’s Emergency Plan for AIDS Relief) is an American foreign policy program aimed at the global eradication of HIV/AIDS. Through its support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (of which PEPFAR is the lead donor), national governments, the Joint UN Program on HIV/AIDS (UNAIDS) and other United Nations agencies, PEPFAR aims to provide sexual and reproductive health (SRH) services such as: prevention of mother-to-child transmission of HIV (PMTCT) and access to condoms, education and care for sexually transmitted infections (STIs), cervical cancer screening and treatment, and prevention of gender-based violence (GBV).


This program, which has saved millions of lives around the world, particularly in sub-Saharan Africa, is now in danger of disappearing. The bipartisan support (Democrats and Republicans) that has enabled it to be maintained for 20 years is now far from guaranteed, as articles in The New York Times and The Washington Post show. Some Republicans in the House of Representatives, pushed by a number of influential conservative groups, are threatening to block a new five-year reauthorization on the grounds that PEPFAR has become a means of promoting and indirectly funding abortions, which goes against their beliefs. These allegations are contested by numerous health experts, Democrats and PEPFAR officials.


At this stage, one thing is certain: if this political wrangling against a backdrop of ideological warfare results in the non-renewal of the program by 30 September 2023, the fight against HIV worldwide will necessarily be weakened. In other words, the cancellation of the program or the delay in launching a new five-year cycle will inevitably constitute a major risk to global health and security, and a death sentence for millions of people. But before dwelling on the consequences of PEPFAR’s eventual demise, it is perhaps worth taking a closer look at what this program is all about, and the achievements and successes that can be objectively attributed to it after 20 years of existence.


PEPFAR: what does it actually stand for?


PEPFAR is not only the world’s largest health programme dedicated to a single disease, it has also saved more lives than any other US government program in the 21st century. Since its inception, PEPFAR has spent more than $100 billion in more than 50 countries, distributed millions of drugs to prevent and treat HIV, and collected data that have helped to better understand and contain the spread of HIV.


According to the US government’s most recent estimates, it has saved up to 25 million lives since it came into force. It currently supports the treatment of more than 20 million people who depend on the program to continue to have access to medicines.


Above all, experts point out that PEPFAR has helped to stabilize healthcare systems in regions such as sub-Saharan Africa, which was devastated by the spread of HIV in the 1990s, and to strengthen the world’s capacity to deal with future crises. “This isn’t about abortion at all, it’s about building healthcare infrastructures in countries to deal with pandemic-type challenges,” said Maryland Democratic Senator Benjamin L. Cardin.


More specifically, PEPFAR has helped to improve maternal and child health (MCH) and is associated with significant reductions in mortality in the countries where it has been implemented.


20 years of impact


For children, the death of a parent often gives way to family breakdown/separation, poverty, delayed education or dropping out of school, abuse, mental health problems, sexual exploitation and high exposure to STIs. According to UNAIDS data, the PEPFAR era has significantly reversed these devastating effects on the life trajectory of orphaned children.


Figure 1. PEPFAR program results showing improvement in incidence of children orphaned by AIDS

Source :


The number of new HIV infections in children in the reviewed countries has fallen from 1.7 million in 2010 to 820,000 in 2022, representing 94% of all HIV infections in children prevented worldwide thanks to vertical transmission programs.


Figure 2. Prevalence of children orphaned by AIDS attributed to PEPFAR program

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In 2022, PEPFAR provided life-saving antiretroviral drugs (ARVs) to 20 million people, most of them parents and children.


Figure 3.  Paediatric AIDS deaths before and after introduction of PEPFAR program

Source :


It should be pointed out that the most significant progress in preventing new infections and reducing AIDS-related deaths has been made in countries supported by PEPFAR. Between 2010 and 2022, the number of new HIV infections in PEPFAR-supported countries fell by 57%, compared with 38% globally. And although PEPFAR’s annual funding has not changed significantly over the last decade, it is clear that PEPFAR has had a significant influence on the mobilization of additional government funding for HIV/AIDS prevention and treatment (see p. 27). In the vast majority of countries supported by PEPFAR, one can see an increase in national funding for the fight against HIV/AIDS. This is all the more remarkable given that international funding for health and development in low- and middle-income countries is falling overall.


PEPFAR’s progress and continued success have a systemic impact, supporting global efforts to end AIDS as a public health threat.


The dangers associated with the disappearance of PEPFAR


As PEPFAR’s current congressional authorization expired on 20 September 2023, some Republicans and conservatives want to impose the so-called “Mexico City” policy on PEPFAR, which prohibits the Federal Government from funding any organization that supports abortion, even with non-federal funds. Others are calling for PEPFAR’s operational window to be reduced, by requiring it to be reauthorized every year rather than every five years. These two proposals have nothing to do with the reality of the situation.


Firstly, PEPFAR has always been prohibited from funding abortion. The programme steers clear of many controversial social issues relating to HIV/AIDS, a legacy of its bipartisan creation in 2003.


Secondly, imposing annual votes on the program would inevitably create opportunities to weaken it. As Congress debates the future of the program, there is a great deal of confusion and anxiety on the ground for organizations trying to plan their five-year operations. Clearly, if PEPFAR becomes yet another casualty of America’s internal conservatism and culture wars, tens of millions of people will suffer and potentially die from a disease we already know how to fight. The loss of PEPFAR would inevitably lead to the death, orphanhood and suffering of millions of children. Epidemiological models for children under 15 predict that a 6-month interruption in supply would result in 107,300 additional paediatric HIV infections and 20,600 additional child deaths from AIDS in the space of a year.


The Republicans, who often present themselves as pro-life, should know that PEPFAR saves lives.