Outbreaks, Alerts & Hot Topics: The President’s Emergency Plan for AIDS Relief (PEPFAR)

Column Author and Editor: Chris Day, MD | Medical Director, Immune Compromised Service & Special Immunology Clinic, Infectious Diseases; Medical Director, International Travel Clinic, Infectious Diseases; Medical Director, Travel Medicine Program, Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

The President’s Emergency Plan for AIDS Relief (PEPFAR) was started under the George W. Bush administration during the ongoing HIV crisis. The crisis was particularly acute in parts of Africa. At PEPFAR’s founding in 2003, HIV had caused life expectancies to decline in many countries in sub-Saharan Africa. For example, life expectancy in Botswana had declined from 62 to 51 years and in Lesotho from 59 to 44.¹ Half of children infected with HIV were dying before their second birthday.² PEPFAR’s initial goal was to “turn the tide in combating the global HIV/AIDS pandemic”: assisting African and Caribbean countries by treating 2 million people infected with HIV, preventing 7 million new infections, and providing care for an additional 10 million people including both the HIV-infected and children orphaned by HIV. At the time, “fighting the HIV/AIDS pandemic” was “a priority of U.S. foreign policy” and PEPFAR tripled the financial commitment from the United States to combat HIV outside the United States (prior funding commitments included contributions to the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria).

Assisted by rapidly declining costs in HIV treatment (by the time of PEPFAR’s founding, the cost of a year of antiretroviral therapy had declined from $12,000 to less than $300),³ PEPFAR has been instrumental in controlling the HIV epidemic, especially in Africa. For a total cost to date of around $110 billion, an estimated 26 million lives have been saved, 7.8 million cases of pediatric HIV have been prevented, and more than 8 million children have avoided being orphaned.⁴ In 2024, PEPFAR was allocated $4.9 billion (a cost of around $14 dollars per resident of the United States, 0.08% of the federal budget). As of early January 2025, PEPFAR was providing HIV treatment in 55 countries for more than 20 million people living with HIV including more than half a million children.⁵ Botswana now has its longest-ever life expectancy.¹ It is now true in much of the world that people with HIV who receive antiretroviral therapy have similar life expectancies to people without HIV.

Within the first weeks following inauguration, the current presidential administration ordered organizations in other countries to stop disbursing all HIV medications purchased with United States aid as part of a 90-day pause in foreign aid generally. These included medications already available on shelves in clinics and medications available through PEPFAR. U.S. officials were also directed to stop providing technical assistance to foreign ministries of health and to stop communicating with representatives of the World Health Organization. PEPFAR’s data systems were shut down.⁶

At this point, the future of PEPFAR is unclear. Services remain disrupted despite some temporary relief from U.S. courts and a limited waiver to continue some services. The current authorization for the program expired on March 25, though parts of the program can continue without reauthorization if Congress continues to provide funding.⁷ It has been estimated that the disruptions to HIV care caused by the administration’s 90-day pause in foreign aid programs (including PEPFAR) could lead to 100,000 HIV deaths and 135,000 infants born with HIV infections that could have been prevented with peripartum medications. These estimates may be overestimates if some services and treatment continue, but gross underestimates if programs do not resume at prior levels.⁸

From a longer-term perspective, it has been estimated that “eliminating PEPFAR would lead to 601,000 HIV-related deaths and 565,000 new infections in South Africa alone over 10 years.” These estimates are for a country where PEPFAR provides only 18% of the HIV budget. Impacts throughout the 55 countries in which PEPFAR provides support would clearly be much, much larger.⁹ Even countries not currently supported by PEPFAR would be affected. Inadequate care or sporadic care will lead not only to new infections but to changes in the virus itself. HIV variants that are less susceptible to antiretroviral therapy will increase and will not be confined to their country of origin. Although HIV vaccines are being developed, these may be less effective in a world with more HIV. Increased infections in any country will lead to increased infections in others, since HIV does not respect national borders.

References:

1. Gilbert L, Wein T, Lovely G. Trump has put George W. Bush’s lifesaving legacy in danger. Foreign Policy. February 5, 2025. https://foreignpolicy.com/2025/02/05/pepfar-trump-lifesaving-hiv-aids-soft-power-danger/
2. Newell M, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet. 2004;364(9441). doi:10.1016/S0140-6736(04)17140-7
3. Fact sheet: the president’s Emergency Plan for AIDS Relief. News release. Office of the Press Secretary (The White House). January 29, 2003. https://georgewbush-whitehouse.archives.gov/news/releases/2003/01/20030129-1.html
4. Nkengasong J, Bunnell R, Nandakumar A, Katz I, Sanhokwe H, Reid M. PEPFAR’s mission. Lancet. 2024;404(10469). https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02438-3/abstract
5. World Health Organization. WHO statement on potential global threat to people living with HIV. WHO.int. January 28, 2025. https://www.who.int/news/item/28-01-2025-who-statement-on-potential-global-threat-to-people-living-with-hiv
6. Mandavilli A. Trump administration halts H.I.V. drug distribution in poor countries. New York Times. January 29, 2025. https://www.nytimes.com/2025/01/27/health/pepfar-trump-freeze.html
7. Kates J, Moss K. The Outlook for PEPFAR in 2025 and Beyond. KFF. February 20, 2025. https://www.kff.org/policy-watch/the-outlook-for-pepfar-in-2025-and-beyond/
8. Tram KH, Ratevosian J, Beyrer C. By executive order: the likely deadly consequences associated with a 90-day pause in PEPFAR funding. J Int AIDS Soc. 2025;28(3):e26431. PMID: 39996580. PMCID: PMC11851316. doi:10.1002/jia2.26431
9. Neilan A, Bekker L. We tried to quantify the impact of abrupt PEPFAR cuts. The results startled even us. STAT. March 1, 2025. https://www.statnews.com/2025/03/01/pepfar-usaid-funding-cuts-trump-hiv-aids/