A public health initiative said to have saved over 25 million lives, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has had an enormous impact on the fight against HIV/AIDS through providing HIV treatment, prevention, and education. Since its inception in 2003 PEPFAR has largely enjoyed bipartisan support within Congress, although increasing polarisation of the political discourse in the US has even led to this universally applauded program coming under fire. Amid criticisms from conservative lawmakers that PEPFAR had been hijacked by the ‘woke’ left to promote abortion, its funding was only renewed for a single year rather than the customary five, potentially posing a threat to its long-term planning and sustainability.


Historical Impact

Amid an increasingly tense political backdrop, it is worth reminding ourselves what PEPFAR has been able to achieve thus far. Speaking exclusively to PharmaBoardroom, PEPFAR’s Deputy US Global AIDS Coordinator for Program Quality Dr Emily Kainne Dokubo explains that “At the start of the HIV pandemic over 40 years ago there were rising new infections, ongoing transmission, and high morbidity and mortality, especially on the African continent due to limited access to prevention and treatment options. In response, during his 2003 State of the Union Address, then-US President George W Bush announced the establishment of PEPFAR, saying, ‘seldom has history offered a greater opportunity to do so much for so many.’ PEPFAR has lived up to that commitment.”

Others within the global health community are similarly effusive on the positive change that the seven billion or so dollars spend every year on PEPFAR has brought. Mark Green, formerly of the US Agency for International Development, the Initiative for Global Development, and US ambassador to Tanzania now heads up the Wilson Institute think tank, where he writes “In the two decades since PEPFAR was signed into law, the program has saved 25 million lives and provided life-saving antiretroviral treatment to millions more. Through its prevention efforts that target adolescent girls and young women, and initiatives to stop mother-to-child transmission, 5.5 million babies of HIV-positive mothers were born HIV-free.”

Dr Jean Kaseya, director general of the Africa Centres for Disease Control and Prevention (Africa CDC), writing in Health Policy Watch, adds, movingly that, “The spectre of AIDS that once snatched infants and young children from this world has been pushed back by a staggering 70 percent. Villages and cities have witnessed life expectancies surge by over a decade, a testament to the resilience of the human spirit when given a fighting chance. Through PEPFAR, the very fabric of our societies has been fortified. Our economies, reflected in the GDP per capita, have grown more robust by two percent faster in countries embraced by PEPFAR’s warm reach. Seven million children, who might have been orphaned due to AIDS, now find solace and support from their parents.”


Dragged into the US Abortion Debate

How best to effectively deal with the terrific burden that HIV/AIDS represents has always been a political issue. Patients living with HIV contracted through same-sex relationships or intravenous drug use were often heavily stigmatised by the Christian right while, at its outset, PEPFAR came under criticism from the left for its faith-based promotion of abstinence-until-marriage programs. While PEPFAR rode out these rocky waters and made the impact described in the previous section, late last year it found itself in the political crosshairs once more.

As the New Yorker’s Peter Slevin explains, in the wake of the federal constitutional right to abortion in the US being overturned in 2022, American opponents of abortion have become emboldened. This has led to demands from domestic pro-life groups that PEPFAR partner organisations abroad be banned from performing or even discussing abortion. Tim Meisburger, writing for conservative think tank The Heritage Foundation went so far as to say that “the Biden Administration has misused the program as a well-funded vehicle to promote its domestic radical social agenda overseas” while Republican New Jersey Congressman Christopher Smith, the leading anti-PEPFAR voice in Congress added that President Biden has “hijacked” the program “to promote abortion on demand.”

Stakeholders within the HIV community were aghast. “[The politicisation of PEPFAR] is an incredibly serious issue,” says Mitchell Warren, executive director of AVAC, a global advocacy group focused on HIV prevention. “PEPFAR and the Global Fund are the two greatest examples of global health and development in the history of the world, but I am deeply worried that for all the progress we have made, we are now at risk of falling backwards. We talk a lot about epidemic control, but if we take our eye off the prize on that aim, HIV will come roaring back. Watching the politicisation of PEPFAR, policymakers lying, and conservative think tanks intentionally misleading is terrifying. This is the quickest way to let HIV resurge, not just in Kenya, South Africa, India, and Brazil, but in the US as well.”

“It saddens me greatly to see the re-politicisation of HIV and to see PEPFAR held hostage by political ideology around reproductive rights,” adds Dr José M. Zuniga, president and CEO of IAPAC, the world’s oldest medical association dedicated to HIV. “This is an initiative that has enjoyed bipartisan support for over 20 years, even during the Trump administration,” he adds.


One Year Renewal: Pro or Con?

Despite coming under this political fire, PEPFAR did manage to secure funding for an additional year earlier in 2024. “This at least ensures that this important programme continues with Congressional approval, although it is sad to not have the standard five-year reauthorisation,” laments Zuniga. “All of this clearly signals that we must make the case to US taxpayers and taxpayers in other countries for continuing investment in HIV and the global health response more broadly.”

However, as former PEPFAR Chief of Staff Jirair Ratevosian points out, as per a Devex article from Adva Saldinger, the extension is potentially worse than not having a reauthorisation at all. Ratevosian says that it creates ambiguity and could set “a dangerous precedent” of short-term reauthorisations and risk “over politicising the program.” He adds, “It brings relief in the short term but undermines PEPFAR’s ability to forge and maintain essential partnerships required for its enduring success.”

There is also the issue of national security to consider. “Without health and wellbeing and ensuring that social programmes are not flooded by people who are uninsured or living in poverty, countries’ futures will be jeopardised,” says Zuniga. “There is therefore a national security argument to be made for continued investment in programs like PEPFAR. I would hope that argument would prevail over ideological and intolerant discussions about reproductive rights and LGBTQ human rights.”

Finally, as the New Yorker’s Slevin posits, a weakened PEPFAR may damage US soft power abroad at a moment when China and Russia are attempting to expand their spheres of influence in Africa. “PEPFAR is not only the most significant global health program ever created, it is also synonymous with American friendship and compassion across the continent,” expands Green of the Wilson Center. “PEPFAR is our brand in Africa… and one that China can never match.”

Dr Dokubo is hopeful that a new deal can be reached. “We look forward to working with Congress on a clean, five-year reauthorisation which would demonstrate the US government’s longstanding commitment to end HIV/AIDS as a public health threat by 2030,” she says. “A five-year reauthorisation would allow for improved planning so that our vital programs can be fully established, monitored, and evaluated.”


Future Directions

All this uncertainty around PEPFAR’s future comes at an inopportune time as the global HIV community works towards the ambitious 2030 targets. As Kaseya points out, “Recent reports forewarn of the catastrophic consequences of halting our march now, with nearly a million more babies at risk of HIV infection and countless lives in the balance by 2030.”

Rabih Torbay, CEO of the NGO Project Hope, suggests that PEPFAR – regardless of the length of its authorisation status – needs to adjust to offer a more “beneficiary-centric approach that includes the more holistic healthcare that people living with HIV now require.” He adds that PEPFAR, under the leadership of Ambassador John Nkengasong, is already making good progress under its updated five strategic pillars of equity, sustainability, public health security, partnerships, and science. Torbay also notes that continued investment in HIV networks can be leveraged to fight future pandemics, as was the case with COVID-19, H1N1 influenza, and Ebola.

In whatever form PEPFAR takes in the future, it seems clear that its proponents will not give up without a fight. This is, after all, just the latest challenge in a 40-year battle against not just a deadly disease, but also the host of stigma, funding, and access issues that have gone with it. “This moment should not be seen as a sign of inevitable defeat but as a wake-up call,” proclaims Ratevosian. “It is a pivotal moment to rally—to rekindle the flame of global activism and advocacy that once defined the global AIDS fight.”

Dr Dokubo concludes, “PEPFAR is the largest investment by any government to address a single disease in the history of global public health. Our programs have helped change the pandemic’s trajectory from a death sentence to a manageable chronic disease. Millions of lives have been saved, millions of people are on treatment, and millions of babies have been born HIV-free. We have achieved a lot, but there is still work to do.”