Pepfar funding to fight HIV/Aids has saved 26 million lives since 2003: how cutting it will hurt Africa

The US President’s Emergency Plan for AIDS Relief has been a cornerstone of global HIV/Aids prevention, care and treatment for over two decades. 

Pepfar has enjoyed broad bipartisan support in the US, but its future is now uncertain.

Public health scholars Eric A. Friedman, Sarah A. Wetter and Lawrence O. Gostin explain Pepfar’s history and impacts, as well as what may lie ahead.

The early years

Many people today have forgotten the sheer devastation that the Aids pandemic wrought on the African continent, first spreading widely in east Africa in the 1980s. 

By the end of the 20th century, life expectancy in the region had decreased from 64 to 47 years.

Millions of children were infected and many grew up as orphans, with HIV taking the life of one or both of their parents.

Children, especially girls, were taken out of school to nurse sick relatives or because school fees were unaffordable.

Underfunded health systems were near collapse, as were the economies of many African countries.

Infection rates in several countries on the continent topped 30 percent of their adult populations.

These devastating figures persisted despite the discovery of highly effective antiretroviral therapies in the 1990s. 

These drugs rapidly became widely available in rich countries, beginning in 1996, leading to an 84 percent decline in death rates over four years.

But cost kept the drugs out of reach for African countries.

Only about 100,000 of the 20 million people infected with HIV in Africa were accessing drug treatment in 2003.

The turnaround

A major breakthrough came when US president George W Bush proposed a bold global initiative, Pepfar, in his 2003 State of the Union Address. 

Pepfar would dedicate US$15 billion over five years with the goals of preventing 7 million new infections, treating 2 million people, and caring for another 10 million infected with HIV or orphaned by the disease.

By 2005, more than 800,000 people were being treated for HIV in Africa – an eightfold increase from only two years prior. 

Under Pepfar, the costs of antiretroviral treatment per person per year in low- and middle-income countries fell from US$1,200 in 2003 to just US$58 in 2023.

Pepfar maintained bipartisan support throughout both Democratic and Republican-led administrations and Congresses. Through 2018, it had been reauthorised three times, each for five years.

The programme has lived up to its promise. The investment of over US$110 billion since being launched has been transformative, with sub-Saharan Africa benefiting the most.

Globally, Pepfar has saved 26 million lives and prevented nearly 8 million babies from being born with HIV. 

In 2024, more than 20 million people were receiving HIV treatment through Pepfar, which was also supporting well over 6 million orphans, vulnerable children and their caregivers, and enabled nearly 84 million people to be tested for HIV that year.

Its importance extends beyond Aids. The programme directly supports more than 340,000 health workers, a tremendous contribution in Africa especially, given severe health worker shortages in much of the continent.

Pepfar-supported health services integrate HIV services with tuberculosis care, treatment and prevention. 

And since 2019, Pepfar has been part of a partnership for screening and treating women with HIV for cervical cancer, focused on 12 high-burden countries in sub-Saharan Africa.

But the past two years have been ones of political discord and major disruption.

Troubles begin

The trouble began in May 2023, with Pepfar due for a five-year reauthorisation.

A key member of Congress, along with organisations against abortion, raised concerns that Pepfar was supporting abortions, even though there was no such evidence at the time. In fact, by law Pepfar is prohibited from supporting abortions.

House Republicans sought to include abortion restrictions in the Pepfar reauthorisation. But Congress passed a reauthorisation bill without abortion provisions in March 2024, to last until 25 March 2025.

Ever since then, the threats posed to a five-year Pepfar reauthorisation have grown.

The Trump effect

In January, Pepfar reported to Congress that its own investigators had found that four nurses in Mozambique had used Pepfar funding to perform abortions (which are legal in Mozambique), 21 in all.

Pepfar officials froze funds to the four nurses and required staff to attest to understanding that they were prohibited from providing abortion as part of US-funded health services.

Days later Pepfar, along with most other US foreign assistance programmes, suffered a severe blow. President Donald Trump signed an executive order pausing all further disbursements and new obligations of foreign assistance funds for 90 days, pending a sweeping review.

Four days later, secretary of state Marco Rubio issued a directive that went even further, also requiring organisations to stop work, even those that had already received funds needed to operate.

By 27 January, virtually all US foreign assistance programmes had come to a halt, including Pepfar programmes.

Following an outcry, Rubio issued a waiver for lifesaving humanitarian assistance on 28 January. 

With confusion over what was covered, including whether the waiver encompassed HIV medicines, he issued another waiver on 1 February, covering Pepfar treatment and care programmes, including prevention of and treatment for TB and other opportunistic infections, as well as prevention of mother-to-child transmission programmes.

But organisations receiving US foreign assistance funds needed to get individual approval to resume, and the administration had put much of USAid’s staff on administrative leave.

USAid (along with the US Centers for Disease Control and Prevention) has a central role in administering Pepfar.

Many others, including contractors embedded in USAid operations, have been furloughed or fired.

READ: Africa could face ARVs shortage after Trump halting funding for health initiatives

Very few people existed to process requests to resume work. Furthermore, USAid’s payment system appeared not to be working.

The decisions of the Trump administration are being challenged in court in the US on the grounds that they are illegal and unconstitutional because they are usurping Congress’s power to determine how the US government spends funds, among other violations of the law.

Nonetheless, as of this writing, despite a court order to resume funding, it remains entirely frozen, and most programmes are still shut down. 

The day after the court ordered the government to pay nearly US$2 billion it owes organisations for work already done, the administration revealed that it had terminated the vast majority of foreign assistance awards, including some for Pepfar.

Details have not been made public. Meanwhile, the US Supreme Court put a short-term pause on the lower court’s order to immediately pay the money already owed.

The impact

The impact has been immediate. People on HIV treatment could not pick up additional medicine, leading to treatment interruption. Pepfar-funded health services had to turn away patients. 

Health workers supported by Pepfar, among them 40,000 in Kenya, could no longer be paid.

Many organisations that relied on Pepfar funds also had to lay off staff. Community groups have been affected and many have suspended their services entirely.

It remains unclear what the future holds – how severe the cuts will be, and to what programmes. 

In the near term, much depends on the courts and whether the administration implements court orders, as it has yet to do. 

In the longer term, Congress could seek to resume Pepfar to its former strength, though this would mean acting against the administration’s wishes. 

Even then, it is not clear whether the administration would spend the money allocated, and the damage already done to Pepfar programmes and trust in the US government will not be repaired quickly.

Pepfar is currently funded at US$7.5 billion annually. It accounts for over 10 percent of all US foreign assistance and over half of US global health assistance.

The separate Pepfar waiver suggests the deepest support for Pepfar is for HIV treatment programmes, as well as others meant to be protected under the waiver. 

Barring vast cuts to foreign assistance and Pepfar, these programmes are most likely to be at least spared, though the administration has terminated even some grants that had been covered by the waiver.

Other Pepfar programmes, particularly with respect to HIV prevention, are most vulnerable.

Rethinking priorities

The vulnerability of different African countries to Pepfar cuts varies widely. Some fund most of their own HIV programmes. 

South Africa’s HIV programmes are 74 percent domestically funded, with the balance coming from Pepfar (17 percent) and the Global Fund (7 percent).

But Pepfar funding accounts for about 90 percent of all HIV funding in Tanzania and Côte d’Ivoire, and more than half of HIV medicines purchased for the Democratic Republic of Congo, Mozambique and Zambia are purchased by the US.

If there are significant Pepfar funding cuts, it is doubtful that other wealthy countries will be able to compensate. 

And because the US, through Pepfar, is the largest contributor to the Global Fund, it is unlikely that the Global Fund could fill the gap either.

Under these circumstances, unless countries increase their domestic HIV spending, the dramatic progress in combating HIV/Aids in Africa could begin to become undone.

The conversation in Africa must focus on ending reliance on foreign assistance and developing resilient financing mechanisms to continue the fight to end Aids.