Next steps on PEPFAR and a reflection on the 25 million lives saved

Learn more about Deborah L. Birx, M.D..
Deborah L. Birx, M.D.
Senior Fellow
George W. Bush Institute
Learn more about Dr. William R. Steiger.
Dr. William R. Steiger
Advisor, Global Health
George W. Bush Institute

In 2023, the President’s Emergency Plan for AIDS Relief (PEPFAR) is up for reauthorization again, and Congress must support it.

Twenty years ago, House and Senate leaders from both parties stood next to President George W. Bush in the East Room of the White House when he signed into law the largest and most successful global health initiative in U.S. history – PEPFAR.

PEPFAR has seen continuous bipartisan support through two Republican and two Democratic administrations, 11 Congresses, and three reauthorizations. PEPFAR is recognized for its unparalleled success, and many have validated its remarkable impact.

Role of Congress – more than reauthorizations and annual funding appropriations

  • Reauthorizations provide an opportunity to reflect on PEPFAR’s success, what didn’t work, and what still needs to be done.
  • Both the House and Senate have remained closely engaged with PEPFAR over the last two decades, providing unique insights, driving greater efficiencies and effectiveness, and ensuring continued accountability and transparency to the American taxpayer.
  • Congress has driven continuous programmatic improvement and evolution essential to PEPFAR’s success with each reauthorization and each fact-finding delegation.

PEPFAR’s data-driven evolution

  • PEPFAR has saved more than 25 million lives, prevented over 5.5 million babies from acquiring HIV at birth, and driven down deaths and new infections to change the course of the HIV pandemic in sub-Saharan Africa, the Caribbean, and beyond.
  • Driven by national security and moral imperatives, PEPFAR has stabilized countries devastated by the pandemic and offered hope and opportunity for hundreds of millions of people.
  • PEPFAR uses real-time data and measurement as a management tool:
    • It set a new standard for collaboration that moved beyond host governments to full engagement with affected communities by transparently publishing the collected data and linking funding to outcome performance during the annual PEPFAR reviews in each country.
    • The use of granular, age- and sex-disaggregated data provides the evidence base for PEPFAR and its partners to adopt the innovation needed to address gaps in coverage.

The path to sustainability – local community partnership

  • In its first years, PEPFAR concentrated on reaching both urban and rural communities with lifesaving drugs. By 2008, PEPFAR worked to create sustainability by building partnerships with governments, faith-based organizations, and local communities, while ensuring every taxpayer dollar was spent without waste and abuse.
  • PEPFAR created the conditions for local organizations to compete for implementation awards. At one time, 90% of PEPFAR’s country-level spending went to large international partners, but now 60% of bilateral PEPFAR funds go to local organizations.
  • PEPFAR continues to increase cost sharing with national governments and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In particular, the governments
    of middle- and upper-middle-income countries across the globe where PEPFAR is active have taken on a greater share of responsibility for HIV/AIDS programs over the
    last decade, which has allowed PEPFAR to decrease its spending significantly in those places.
  • Public-private partnerships have become essential to ensuring the maximum impact of U.S. taxpayer dollars, as they continuously bring the best business insights and new approaches to tackling persistent gaps.

Through these efforts, PEPFAR has expanded to additional countries and saved more lives while operating under a flat budget. The program went from supporting 7 million to 20 million individuals in only eight years and dramatically expanded primary prevention efforts across the globe at the same time.

Lessons learned

  • PEPFAR has reached the most stigmatized, vulnerable, and disenfranchised communities while bringing the voices of beneficiaries to discussions around planning, funding, and performance.
  • PEPFAR’s focus on sustainability, building local capacity, transparency, and ensuring local impact allowed the program to manage COVID-19 without major disruptions.
  • PEPFAR’s in-country infrastructure ensured clients continued to receive lifesaving treatment while its partners conducted a comprehensive COVID-19 response.

The next five years – recommendations to eradicate AIDS

  • Reauthorization should ensure that PEPFAR continues to reach the most vulnerable communities with prevention services and lifesaving treatment and creates regional and local supply chains through public-private partnerships that are sustainable in the future.
  • Reauthorization should focus on making sure host-country governments can sustain this health platform needed for the future.
  • Reauthorization also should drive continued increases in host-country contributions by asking that PEPFAR track and annually report on the financing of country-level programs by the Global Fund and national governments.

Once PEPFAR is reauthorized, Congress has an opportunity to do the following:

  • Translate the lessons learned from PEPFAR to U.S. foreign-assistance more broadly by requiring other programs, where
    appropriate, to shift resources to local implementers and adopt data-driven decision-making based on real-time, site-level
  • Improve the health of marginalized populations in the United States by implementing PEPFAR structures and adopting
    PEPFAR’s high-impact model of prevention and treatment service delivery.