President's Emergency Plan for AIDS Relief

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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. According to the United States government, as of 2023, PEPFAR has saved over 25 million lives, primarily in sub-Saharan Africa.

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. 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.

PEPFAR supports HIV prevention, testing and antiretroviral treatment, as well as prevention of mother-to-child transmission, care for orphans and vulnerable children, tuberculosis services for people with HIV and broader health-system strengthening. The program initially focused on emergency treatment and prevention, later shifting toward partnership frameworks with recipient governments, epidemic control targets and long-term sustainability. By September 2025, PEPFAR was credited with saving more than 26 million lives and preventing 7.8 million infants from acquiring HIV at birth.

In 2025, the second Trump administration put USAID on a 90-day freeze, initially halting PEPFAR activities, Only about half of PEPFAR programs were later estimated to have restarted in February.

George W. Bush was elected as president in 2001. In April 2003, the United States House of Representatives passed what would become PEPFAR by a 375-41 majority, although with an amendment that one-third of the prevention money had to go to sexual abstinence programs. 20 percent of the overall money would go to prevention, 15% to palliative care, 10% to orphans, and 55% to treatment.

In May 2003, both the House and Senate passed passed and President Bush signed the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (“Global AIDS Act”). This specified a series of broad and specific goals, and alternated between specifying measurable goals and time periods in some areas and delegating authority to the president for identifying goals in other areas. This legislation also established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming.

PEPFAR's first phase was emergency response. In its first five years, it allocated $15 billion to 15 countries in sub-Saharan Africa, Asia and the Caribbean, with targets including treatment for 2 million people with HIV, prevention of 7 million new infections, and care for 10 million people affected by HIV/AIDS, including orphans and vulnerable children.

PEPFAR was reauthorized in 2008, with up to $48 billion over five years for HIV/AIDS, tuberculosis and malaria programs. Its second phase emphasized sustainability and cooperation with partner governments, with targets including treatment for at least 3 million people, prevention of 12 million new infections, and care for 12 million people, including 5 million orphans and vulnerable children. Between 2009 and 2012, US teams and host governments signed Partnership Frameworks in 22 countries to define shared responsibilities and priorities. This phase also placed greater emphasis on health-system strengthening, expanded antiretroviral therapy, prevention of mother-to-child transmission and voluntary medical male circumcision.

In September 2022, PEPFAR issued "Reimagining PEPFAR's Strategic Direction", setting out a strategy to help end HIV/AIDS as a public health threat by 2030. The plan aimed to reach 95-95-95 treatment targets, reduce new infections through prevention and treatment, address stigma, discrimination, gender-based violence and other inequalities, and shift PEPFAR toward greater long-term sustainability by strengthening the leadership of governments, civil society and local partners. It also emphasized using PEPFAR investments to strengthen public health systems and health security in partner countries.

In 2024, some Republican lawmakers sought to block PEPFAR's reauthorization, alleging that the program promoted abortion.

In January 2025, 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. Experts from the Center for Global Development estimated that USAID programs annually prevented approximately 1,650,000 deaths from HIV/AIDS.

The second Trump presidency

Funding freeze and waiver

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On January 20, 2025, President Trump signed an executive order to withdraw the United States from the World Health Organization and a separate order freezing foreign aid for 90 days. On January 24, the State Department announced a comprehensive freeze on new funding for most foreign aid programs worldwide, with exemptions for emergency food aid and military assistance to Israel and Egypt, but not for PEPFAR. The freeze halted PEPFAR activities and took its computer systems offline. but it remained unclear whether the waiver covered preventive drugs or additional services provided through PEPFAR.

Later estimates indicated that only about half of PEPFAR programs restarted in February. In July 2025, four congressional aides said that many contracts had remained on hold, that promised waivers had not always translated into resumed services, and that about 50% of budgeted PEPFAR funding had not reached providers.

Concern about humanitarian consequences

The freeze led to widespread concern about the future of HIV/AIDS programs and the potential reversal of progress made in combating the epidemic. The International AIDS Society warned that the immediate halting of funding to PEPFAR, including a stop-work order for existing grants and contracts, threatened millions of lives. The freeze in HIV relief programs, including PEPFAR, was estimated to jeopardize treatment access for 20 million people, including 500,000 children. A study in The Lancet estimated that the discontinuing PEPFAR could lead to up to 10.75 million new HIV infections and 2.93 million HIV-related deaths, and warned that the impact on low and middle-income countries could be comparable to a global pandemic or a major armed conflict. Another study projected that the suspension of PEPFAR could raise HIV-related deaths to 630,000 per year.

July 2025 amendment to exempt PEPFAR from budget cuts

In June 2025, the White House requested that Congress pass a rescissions package, 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 removed the proposed PEPFAR cuts from the rescissions package, then advanced the revised package in two 51 to 50 procedural votes, with Vice President JD Vance casting the tie-breaking votes. The package could advance with 51 votes because rescissions bills are exempt from the Senate’s usual 60-vote threshold.

On July 15, 2025, Office of Management and Budget Director Russell Vought 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."

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, leaving $400 million in PEPFAR funding protected.

Draft to phase out PEPFAR

In July 2025, The New York Times reported that the State Department was working on a draft plan to phase out PEPFAR. During the transition, the plan assumed a 42% cut of PEPFAR's annual budget of $4.7 billion, with Secretary of State Marco Rubio saying this 42% cut was his goal. The plan called for transitioning countries off PEPFAR in two, three, four, or five to eight years, depending on how far along each country was in managing its HIV epidemic. The plan acknowledged that these timelines are "ambitious". There was also discussion of using the Global Fund to Fight AIDS, Tuberculosis and Malaria, although the United States had provided about a third of its funding.

America First global health strategy

In September 2025, the second Trump administration released a global health strategy framed around "America First". This strategy focused largely on HIV, tuberculosis and malaria, and called for new bilateral agreements by the end of 2025 with countries previously supported by PEPFAR. Although the strategy was linked to a $4.6 billion US pledge to the Global Fund, it committed only $1 billion for local diagnostic services, treatment and related support for one year, while describing much of the remaining funding as wasteful and subject to rapid reduction.

The 2025 strategy criticized PEPFAR as inefficient, saying that about 40% of PEPFAR's budget supported direct service delivery through health commodities and frontline health workers. It said that, out of a $4.7 billion bilateral budget, about $1 billion went to commodities and delivery, about $600 million to more than 270,000 clinic-based workers, and the remaining $3.1 billion to activities such as training, technical assistance, program management and US government staff. The strategy also argued that implementing partners had become duplicative, with high overhead costs, and that disease-specific programs for HIV/AIDS, tuberculosis, malaria and outbreak response had often operated separately rather than being integrated into national health systems.

Budget cuts consequences

In April 2026, the US State Department released PEPFAR data for July to September 2025. The figures showed that treatment access had remained broadly stable despite funding disruptions, with 20.3 million people receiving antiretroviral therapy, compared with 20.4 million in the same quarter of 2024. Other indicators, however, declined. PEPFAR-supported HIV testing fell from 23.7 million to 19.6 million, and new diagnoses dropped from 450,000 to 380,000, raising concerns that reduced testing was causing infections to go undetected rather than reflecting a fall in transmission.

Treatment and prevention indicators also weakened. New antiretroviral therapy enrolments fell by 16%, and the number of pregnant women who tested positive for HIV and received treatment fell by 14%. New initiations of PrEP, preventive HIV medication for people at risk of infection, fell by 41%. The number of adolescent girls and young women completing a PEPFAR prevention package fell by 86%, while the number of children and family members served by the Orphans and Vulnerable Children program also dropped sharply. PEPFAR also stopped reporting some prevention indicators, including services for key and priority populations and voluntary medical male circumcision.

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.

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.

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.

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.

Programs

thumb|350px|The stabilisation of the [[HIV/AIDS in South Africa|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.

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.

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.

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

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, Columbia University's International Center for AIDS Care & Treatment Programs (ICAP), the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and the AIDSRelief consortium of Catholic Relief Services.

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. 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. 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.

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.

Tuberculosis

Tuberculosis continues to be the primary cause of death among people living with HIV globally. Since 2003, PEPFAR has helped lower tuberculosis incidence indirectly by strengthening overall population health and expanding access to care in regions heavily affected by HIV. In 2018, PEPFAR accelerated efforts focused specifically on tuberculosis prevention, including broad implementation of routine symptom screening, increased availability of TB diagnostic testing, and provision of preventive therapy to all eligible individuals with HIV.

Between 2003 and 2024, PEPFAR’s combined indirect and targeted efforts are estimated to have prevented about 11.0 million tuberculosis cases (11,040,549; 95% CI: 5,546,614–16,568,420) and roughly 2.1 million TB-related deaths (2,136,192; 95% CI: 1,093,622–3,264,782) among people living with HIV.

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.
In 2024, PEPFAR supported 2.5 million people newly enrolled on PrEP to prevent HIV infection.

Indirect results

PEPFAR has also been associated with broader economic and political effects in recipient countries. One assessment found that countries receiving PEPFAR support had higher GDP per capita growth than they would have been expected to achieve without the program. The State Department also stated that PEPFAR-supported countries saw a larger reduction in political instability from 2004 to 2011 than non-PEPFAR countries in the same region. 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.

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.

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.

PEPFAR was exempt from the Mexico City Policy.

Funding data

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

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.

Criticism

Controversial requirements

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. A number of AIDS organizations felt such a policy would alienate their efforts to reduce HIV contraction rates among sex workers.

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.

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. 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.

The requirement for prevention spending was lifted with the PEPFAR reauthorization in 2008,

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". 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.

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.

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. On the November 19, 2012, the OIG published a report critical of the CDC Namibia Office's monitoring of the use of PEPFAR funds.

References

External links

Official

Office of the Global AIDS Coordinator
A USA government fact sheet on the project
AIDS.gov—The U.S. Federal Domestic HIV/AIDS Resource
HIVtest.org—Find an HIV testing site near you