President's Emergency Plan for AIDS Relief

The United States President's Emergency Plan For AIDS Relief (PEPFAR) is the global health funding by the United States to address the global HIV/AIDS epidemic and help save the lives of those suffering from the disease. As of 2023, PEPFAR has saved over 25 million lives,^[1][2] primarily in sub-Saharan Africa.^[3][4]

Logo

Launched by U.S. President George W. Bush in 2003, as of August 2024, PEPFAR has provided cumulative funding of $120 billion for HIV/AIDS treatment, prevention, and research since its inception, making it the largest commitment by any nation focused on a single disease in history.^[3] PEPFAR is implemented by a combination of U.S. government agencies in over 50 countries and overseen by the Global AIDS Coordinator at the United States Department of State.^[5]

The PEPFAR program has in recent years been criticized by members of the Republican Party who have sought to block its re-authorization. Republicans alleged that the program promoted abortion.^[6][7] In 2025, the second administration of President Donald Trump put USAID on a 90-day freeze which involved putting PEPFAR on halt and taking its computer systems offline.^[7]

On January 28, 2025, the Trump administration granted a waiver for essential medicines and medical services which included HIV medicines.^[8] However, on the ground, PEPFAR did not seem to restart.^[9][10] The Lancet has published a study about impacts of the funding freeze.^[11]

History

PEPFAR began with President George W. Bush and his wife, Laura Bush, and their interests in AIDS prevention, Africa, and what Bush termed "compassionate conservatism." According to his 2010 memoir, Decision Points, the two of them developed a serious interest in improving the fate of the people of Africa after reading Alex Haley's Roots, and visiting The Gambia in 1990. In 1998, while pondering a run for the U.S. presidency, he discussed Africa with Condoleezza Rice, his future secretary of state; she said that, if elected, working more closely with countries on that continent should be a significant part of his foreign policy. She also told him that HIV/AIDS was a central problem in Africa but that the United States was spending only $500 million per year on global AIDS, with the money spread across six federal agencies, without a clear strategy for curbing the epidemic.^[12]

The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003^[13] (or the Global AIDS Act) specified a series of broad and specific goals, alternately delegating authority to the president for identifying measurable outcomes in some areas, and specifying by law the quantitative benchmarks to be reached within discrete periods of time in others. The legislation also established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming.

PEPFAR continues to be a cornerstone of U.S. global health efforts. On April 4, 2014, Ambassador Deborah L. Birx was sworn in as United States Global AIDS Coordinator.^[14] She held the position until January 2021 when Angeli Achrekar filled the Acting role, from being Principal Deputy.^[15]

In May 2022, Dr. John N. Nkengasong was confirmed by the U.S. Senate as the U.S. Global AIDS Coordinator and was officially sworn in on June 13, 2022. On August 1, 2023, Ambassador Nkengasong joined U.S. Secretary of State Antony Blinken to launch the State Department's Bureau of Global Health Security and Diplomacy, which he led^[16] until the second cabinet of Donald Trump assumed office on January 20, 2025.

In December 2014, PEPFAR announced a program PEPFAR 3.0 focusing on Sustainable Control of the AIDS epidemic. This program was designed to address the UNAIDS "90-90-90" global goal: 90 percent of people with HIV diagnosed, 90 percent of them on ART and 90 percent of them virally suppressed by the year 2020.^[17]

PEPFAR under second Trump presidency

90-day freeze at USAID

Housing Works protestors outside the State Department building in February 2025

On January 20, 2025, President Trump signed Executive Order 14155 initiating the United States' withdrawal from the World Health Organization.^[18] This happened along with Executive Order 14169 to freeze foreign aid, impacting global health programs including PEPFAR.^[19]

Subsequently, the U.S. State Department announced a comprehensive freeze on new funding for most foreign aid programs worldwide, excluding emergency food aid and military assistance to Israel and to Egypt.^[20] This suspension affects billions of dollars allocated for health, education, development, and other aid initiatives, with no exemptions for programs like PEPFAR. Humanitarian organizations were alarmed.^[21]

Waiver for PEPFAR, in theory

On January 28, 2025 the Trump administration granted a waiver for essential medicines and medical services, temporarily restoring a global HIV treatment program that they had suspended the previous week.^[8] U.S. Secretary of State Marco Rubio announced the waiver, which appeared to permit the distribution of HIV medications.^[22]

But in practice, it did not appear that PEPFAR restarted

However, it remained unclear whether the exemption covered preventive drugs or additional services provided through PEPFAR. Senator Bill Cassidy (R-Louisiana), who is a medical doctor, posted on February 4, 2025 that money for PEPFAR did not seem to be flowing again.^[9] Through mid-April 2025, the country of Zambia had not had its PEPFAR program restarted.^[10]

President Trump's task force "Department of Government Efficiency (DOGE)" had engaged in such actions as large staff layoffs and the seizure of finance systems, which essentially led to the collapse of USAID by April. The disruption to PEPFAR went further than was suggested in Project 2025, which had praised PEPFAR as "America's most successful aid program."^[23]

Human and political consequences

The International AIDS Society (IAS) warned that the immediate halting of funding to PEPFAR, including a stop-work order for existing grants and contracts, threatened millions of lives.^[24] More than 20 million people living with HIV globally, including 550,000 children under 15, depended on daily services provided with support from the PEPFAR program.^[25] These actions led to widespread concern about the future of HIV/AIDS programs and the potential reversal of progress made in combating the epidemic.^[26]

Similar to foreign aid in general,^[27] the George W. Bush Presidential Center makes the point that as the U.S. moves out, China may move in. And therefore, the United States may lose influence.^[28]

In an early April article in The Lancet, a team of experts proposed a 5-year transition plan of moving from PEPFAR to medication provided by the national health services of the nations most affected by AIDS.^[29][30]

Brooke Nichols, a health economist and infectious disease modeler at Boston University, has created a tracking tool to address the lack of data in this area.^[31] According to her model, as of May 2025, an estimated 96,000 adults and 200,000 children have died due to reductions in government funding for aid and support organizations.^[32]

Estimates are lower for pauses

For a 4-week pause, The Lancet estimates between 15,000 and 28,000 excess deaths.^[33]

Substitute amendment to exempt PEPFAR from cuts in July 2025

In June 2025, the White House requested that Congress pass a package of rescissions, or “claw backs”, of approximately $8 billion in foreign aid and $1 billion for the Corporation for Public Broadcasting. The House of Representatives passed the cuts as requested. The Senate excluded the PEPFAR cuts and passed two preliminary votes by a 51-50 margin, with Vice President JD Vance casting tie-breaking votes. A rescission is one of the exceptions to the Senate’s 60-vote filibuster rule.^[34]

On July 15, 2025, Office of Management and Budget Director Russell Vought had announced that the "White House is on board with a substitute amendment to [a] rescissions package that would exempt PEPFAR, the global anti-AIDS initiative from cuts."^[35]

In a late night session on July 17, the Senate voted 51-48 in favor of the “claw backs” for both USAID and Corporation for Public Broadcasting. The next day, the House of Representatives voted 216 - 213 for the Senate version, meaning PEPFAR was protected in the amount of $400 million.^[36][37]

Politically, President Trump focused more on the cuts to the Corporation for Public Broadcasting, primarily PBS and NPR. On July 10 in a post he wrote, “Any Republican that votes to allow this monstrosity to continue broadcasting will not have my support or Endorsement.”^[36] For some Senators, broadcasting to rural areas became one of the specific political issues.^[37]

July reports that PEPFAR had been cut 50% back in February

In July 2025, four Congressional aides reported that cuts by the Trump administration back in February effectively put many contracts on hold. The aides stated that many of the promised waivers did not translate to action and an estimated 50% of budgeted money did not flow to providers.^[38]

Focus countries

When PEPFAR was signed into law 15 resource-limited countries with high HIV/AIDS prevalence rates were designated to receive the majority of the funding. The 15 "focus countries" were Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. Most of the $15 billion for the program was to be spent on these focus countries, $4 billion was allocated for programs elsewhere, and for HIV/AIDS research (the other $1 billion was contributed to the Global Fund).^{[citation needed]}

With the reauthorization of PEPFAR in 2008 there was a shift away from the "focus country" approach by authorizing the development of a Partnership Framework model for regions and countries, with the aim of ensuring long-term sustainability and country leadership. Through bilaterally-funded programs, PEPFAR works in partnership with host nations to support treatment, prevention and care for millions of people in more than 85 countries. Partnership Frameworks provide a 5-year joint strategic framework for cooperation between the U.S. Government, the partner government, and other partners to combat HIV/AIDS in the host country through service delivery, policy reform, and coordinated financial commitments.See the PEPFAR World Wide Activities Map and PEPFAR Dashboard.

Implementing agencies

The AIDS pandemic has been stabilised in Southern and East Africa, with life expectancy rising.

Office of the Global AIDS Coordinator

Housed in the Department of State, the Office of the Global AIDS Coordinator oversees the implementation of PEPFAR and ensures coordination among the various agencies involved in the U.S global response to HIV/AIDS. United States Ambassadors from the State Department provide essential leadership to interagency HIV/AIDS teams and engage in policy discussions with host-country leaders.^[39]

United States Agency for International Development

An independent federal agency, the United States Agency for International Development receives overall foreign policy guidance from the Secretary of State and is the agency primarily responsible for administering civilian foreign aid. USAID supports the implementation of PEPFAR programs in nearly 100 countries, through direct in-country presence in 50 countries and through seven other regional programs.^[39]

United States Department of Health and Human Services

Under PEPFAR, the United States Department of Health and Human Services (HHS) implements PEPFAR-funded prevention, treatment and care programs through the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), and Substance Abuse and Mental Health Services Administration (SAMHSA). The Office of Global Health Affairs within HHS coordinates all of the HHS agencies to be sure PEPFAR resources are being used effectively.^{[citation needed]}

Centers for Disease Control and Prevention

As part of the Department of Health and Human Services, the Centers for Disease Control and Prevention uses PEPFAR funding to implement its Global AIDS Program (GAP). GAP works with highly trained physicians, epidemiologists, public health advisers, behavioral scientists, and laboratory scientists in 29 countries, who are part of USG teams implementing PEPFAR. Through partnerships with host governments, Ministries of Health, NGOs, international organizations, U.S.-based universities, and the private sector, GAP assists with HIV prevention, treatment, and care; laboratory capacity building; surveillance; monitoring and evaluation; and public health evaluation research.

United States Department of Defense

The United States Department of Defense (DoD) implements PEPFAR programs by supporting HIV/AIDS prevention, treatment, care, strategic information, human capacity development and program/policy development in host military and civilian communities. The DoD HIV/AIDS Prevention Program (DHAPP) is the DoD Executive Agent for the technical assistance, management, and administrative support of the global HIV/AIDS prevention, care and treatment for foreign militaries.^[40]

United States Department of Commerce

The United States Department of Commerce (DoC) provides support for PEPFAR by furthering private sector engagement through public-private partnerships. Housed within DoC, the U.S. Census Bureau assists with data management and analysis, survey support, estimating infections averted and supporting mapping of country-level activities.^[41]

United States Department of Labor

The United States Department of Labor (DoL) implements PEPFAR workplace-targeted projects that focus on the prevention and reduction of HIV/AIDS-related stigma and discrimination. DoL programs (in over 23 countries) consist of three main components: increasing knowledge about HIV/AIDS, implementing workplace policies to reduce stigma and discrimination and building capacity of employers to provide support services.^{[citation needed]}

Peace Corps

With programs in 73 countries, the Peace Corps is heavily involved in the fight against HIV/AIDS. Peace Corps volunteers provide long-term capacity development support to nongovernmental, community-based, and faith-based organizations as they provide holistic support to people living with and affected by HIV/AIDS.^{[citation needed]}

Programs

The stabilisation of the AIDS pandemic in South Africa

The U.S. President's Emergency Plan for AIDS Relief: Five-Year Strategy report from 2009 outlines the PEPFAR strategy and programs for the fiscal years 2010-2014.^{[citation needed]}

Prevention

To slow the spread of the epidemic, PEPFAR supports a variety of prevention programs: the ABC approach (Abstain, Be faithful, and correct and consistent use of Condoms); prevention of mother to child transmission (PMTCT) interventions; and programs focusing on blood safety, injection safety, secondary prevention ("prevention with positives"), counseling and education.^{[citation needed]}

Initially, a recommended 20% of the PEPFAR budget was to be spent on prevention, with the remaining 80% going to care and treatment, laboratory support, antiretroviral drugs, TB/HIV services, support for orphans and vulnerable children (OVC), infrastructure, training, and other related services. Of the 20% spent on prevention, one third, or 6.7% of the total, was to be spent on abstinence-until-marriage programs in fiscal years 2006 through 2008, a controversial requirement (see below). The other two thirds was allotted for the widespread array of prevention interventions described above, including counseling, education, injection safety, blood safety and condoms.^{[citation needed]}

The 2008 reauthorization of PEPFAR eliminated the 20% recommendation for prevention efforts, including the requirement for abstinence programs.^[42]

Treatment

In addition to providing antiretroviral therapy (ART), PEPFAR supports prevention and treatment of opportunistic infections, as well as services to prevent and treat malaria, tuberculosis, waterborne illness, and other acute infections. PEPFAR supports training and salaries for personnel (including clinicians, laboratorians, pharmacists, counselors, medical records staff, outreach workers, peer educators, etc.), renovation and refurbishment of health care facilities, updated laboratory equipment and distribution systems, logistics and management for drugs and other commodities. This is intended to ensure the sustainability of PEPFAR services in host countries, enabling long-term management of HIV/AIDS.

PEPFAR-supported care and treatment services are implemented by a wide array of U.S.-based and international groups and agencies. Among the largest "Track 1.0" (treatment) partners are Harvard University,^[43] Columbia University's International Center for AIDS Care & Treatment Programs (ICAP),^[44] the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF),^[45] and the AIDSRelief consortium of Catholic Relief Services.^[46]

Care

For those who have already been infected with HIV/AIDS, PEPFAR provides HIV counseling, resources for maintaining financial stability, etc. Special care is given to orphans and vulnerable children (OVCs) and services are provided that meet the unique needs of women and girls, including victims of sex trafficking, rape, abuse, and exploitation (see fact sheet on Gender and HIV/AIDS). Finally, the Emergency Plan works closely with country leaders, military groups, faith-based organizations, etc. in an attempt to eliminate stigma.

Health Systems Strengthening

PEPFAR has directly and indirectly contributed to the health systems strengthening of recipient countries including improving laboratory capacity as well as improving monitoring and evaluation including introduction of the electronic medical record systems.^[47] Another area of health system strengthening that PEPFAR has contributed to is its ability to increase the pandemic response to other infectious diseases such as COVID-19.^[48] Research by Anand Reddi and colleagues has documented the effectiveness and sustainability of PEPFAR programs by emphasizing the need for integrated approaches to HIV care that can strengthen overall health systems in resource limited settings.^[49]

Antiretroviral local manufacturing

The U.S. government is supporting African production of antiretrovirals (ARVs) to address the continent's HIV epidemic. In July 2024, PEPFAR plans to expand its purchase of ARVs from local suppliers to serve 2 million African patients.^[50]

Results

The results of the program include:

• As of December 2024, PEPFAR has saved 26 million lives versus 25 million lives saved in 2023.^[51][52]
• As of September 30, 2024, PEPFAR supported antiretroviral treatment for 20.6 million people worldwide including 566,000 children versus the 20.47 million people worldwide on treatment in 2023.^[51][52]
• In 2024, PEPFAR supported 2.5 million people newly enrolled on PrEP to prevent HIV infection.^[52] In 2023, PEPFAR supported 1.95 million people on antiretroviral pre-exposure prophylaxis.^[51]
• PEPFAR supported 2.3 million adolescent girls and young women through the DREAM HIV prevention services in FY 2024 versus 2.5 million in FY2023.^[53][52] PrEP initiations in DREAM geographies was 475,000 clients in FY 2024.
• PEPFAR directly supported 83.8 million people with HIV testing services, an increase of 12 million more people since 2023 in which 71 million people were tested in fiscal year 2023.^[54][52]
• PEPFAR supported antiretroviral drug prophylaxis to prevent mother-to-child transmission (MTCT), resulting in 5.5 million babies born HIV-free.^[55]
• PEPFAR directly supported 6.6 million orphans, vulnerable children and their caregivers in fiscal year 2024, a slight decrease from 2023.^[55][52]
• PEPFAR directly supported approximately 35.1 million voluntary male circumcision procedures worldwide cumulatively from 2017 through Dec 2024, an increase of 2.7 million in FY 2024 from 2023.^[56][52]

The U.S. is the first and largest donor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. To date, the U.S. has provided more than $7 billion to the fund.

Of the estimated 8 million individuals in low- and middle-income countries who currently receive treatment, nearly 6.8 million receive support through PEPFAR bilateral programs, the Global Fund, or both.

There is additional evidence in the published literature that funding towards PEPFAR vis-a-vis antiretroviral therapy also affirmed maternal and child health in addition to HIV treatment outcomes^[57][58]

Accountability and funding

Since the start of PEPFAR in 2003, the program has utilized multi-year appropriations. PEPFAR reports to Congress on an annual basis, providing programmatic and financial data as required by law. The Fourteenth Annual Report to Congress on the President's Emergency Plan for AIDS Relief is available on the official PEPFAR website,^[59] as are more specific reports, financial information and other information.

Global AIDS funding is provided in the Foreign Operations and Labor, Health and Human Services appropriations bills, which, if the process goes smoothly, are agreed to by the House and Senate in advance of the federal fiscal year beginning October 1. The Office of the Global AIDS Coordinator (OGAC) budgets according to the allocations provided by Congress and the policy of the Administration. Funding figures by program are reported to Congress by the Office of the Global AIDS Coordinator.^{[citation needed]}

For FY 2013, President Obama requested $6.42 billion, including more than $4.54 billion for bilateral HIV/AIDS programs and $1.65 billion for the Global Fund. For FY 2014, President Obama requested $6.73 billion, including more than $4.88 billion for bilateral HIV/AIDS programs and $1.65 billion for the Global Fund.^[60]

For FY 2024, President Biden requested at least $4.7 billion for the PEPFAR program in its annual budget request to Congress in addition to funding for the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria.^[61]

PEPFAR was exempt from the Mexico City Policy.^[62]

Funding data

Annual data on the PEPFAR budget, spending by budget code, and impact estimates are available online at PEPFAR Panorama Spotlight.^[63] Funding amounts to specific in-country implementing mechanisms and partners are only available for the year 2013 onward.^{[citation needed]}

In 2008, funding data was obtained by the Center for Public Integrity from PEPFAR's own information system COPRS. The data were obtained after CPI sued the U.S. State Department to gain access to the data. The data were analyzed by the HIV/AIDS Monitor team at the Center for Global Development, which also share the full dataset.^[64]

Criticism

Controversial requirements

See also: Abstinence-only sex education § Global impact

Some critics of PEPFAR feel that American political and social groups with moral rather than public health agendas are behind several requirements of PEPFAR, pointing to the mandates that one-third of prevention spending in 2006–2008 be directed towards abstinence-until-marriage programs and that all funded organizations sign an anti-prostitution pledge. This pledge requires all organizations that receive PEPFAR funding to have a policy that explicitly opposes prostitution and sex trafficking which some activists compared to a loyalty oath.^[65] A number of AIDS organizations felt such a policy would alienate their efforts to reduce HIV contraction rates among sex workers.^[66]

In 2005, it was reported from United Nations' envoy leader for HIV/AIDS in Africa Stephen Lewis that the Bush administration's abstinence policy may have contributed to a shortage of condoms in Uganda.^[67][68][69]

In 2013, the U.S. Supreme Court ruled that the requirement violated the First Amendment's prohibition against compelled speech in Agency for International Development v. Alliance for Open Society International, Inc.^[70][71] According to a study presented at the 19th Conference on Retroviruses and Opportunistic Infections in 2015, the $1.3 billion that the U.S. government spent on programs to promote abstinence in sub-Saharan Africa had no significant impact.^[72][73][74]

The requirement for prevention spending was lifted with the PEPFAR reauthorization in 2008,^[42] but some critics worry that some funds could still be spent on abstinence programs. The Center for Health and Gender Equity and Health GAP outline their criticism of PEPFAR on a website known as PEPFAR Watch. The previous 33% earmark has since been replaced by a requirement that if more than 50% of PEPFAR funds are allocated to non-abstinence promotion measures, the US Global AIDS Coordinator must report to Congress. However, the new reporting requirement continues to emphasize abstinence and fidelity to the exclusion of comprehensive approaches, such as those that include education about male and female condoms. This can cause a chilling effect for organizations receiving PEPFAR funding, who may censor their prevention activities and fall short of providing comprehensive HIV prevention services to women, men, and young people.^{[citation needed]}

PEPFAR also does not fund needle exchange programs, which are widely regarded as effective in preventing the spread of HIV.^[75]

Conditions

Many have argued that PEPFAR's emphasis on direct funding from the United States to African governments (bilateral programs) have been at the expense of full commitments to multilateral programs such as the Global Fund. Reasons given for this vary, but a major criticism has been that this enables the U.S. "to maximize its leverage with other countries through the funds available for distribution" since the "Global Fund and other multilateral venues do not possess the same top-down leverage as does the United States in demanding fundamental national-level reforms".^[76] However, since the inception of PEPFAR there has been a shift away from strictly bilateral funding to more multilateral programs.

Recruitment of locals

PEPFAR has been criticized for having a negative impact on the health systems in regions receiving its funding through its recruitment practices. Although Congress made attempts to limit its impact by prohibiting "topping off" salaries and limiting funding for healthcare worker training (thereby eliminating per diems as a method of augmenting salaries), PEPFAR funded programs effectively paid its local staff up to a hundred times more than that of the local healthcare structure.^[77]

Rather than strictly through salaries, program staff received benefits such as housing and education subsidies. Countries, already stressed by the number of trained physicians and nurses emigrating to western nations, have seen the presence of PEPFAR programs significantly decrease the number of skilled medical professionals willing to work within the domestic healthcare infrastructure. As a result, the overall health of these communities are placed in jeopardy, but funds, physicians, and nurses are diverted to combat HIV/AIDS exclusively within the framework of PEPFAR.^{[citation needed]}

Investigations

On June 15, 2011, the Department of Health and Human Services Office of Inspector General (OIG) published a report critical of the Centers for Disease Control and Prevention's (CDC's) administration of PEPFAR funds. The report read in part: "Our review found that CDC did not always monitor recipients' use of [PEPFAR] funds in accordance with departmental and other Federal requirements.... [M]ost of the award files did not include all required documents" to demonstrate proper monitoring.^[78] On the November 19, 2012, the OIG published a report critical of the CDC Namibia Office's monitoring of the use of PEPFAR funds.^[79]

See also

• Africa portal
• United States portal

• Global health funding by the United States
• National Commission on AIDS
• Office of National AIDS Policy
• Presidential Advisory Council on HIV/AIDS
• President's Commission on the HIV Epidemic
• President's Malaria Initiative
• TRIPS Agreement
• United States Global AIDS Coordinator