PEPFAR: A Legacy of American Goodwill and Influence
Image credit: PEPFAR
When the US President’s Emergency Plan for AIDS Relief (PEPFAR) launched in 2003, few anticipated the profound global impact it would have. President George W. Bush championed a brand of “compassionate conservatism” that resonated with many. However, when applied to PEPFAR, compassionate conservatism faced criticism from both parties particularly for the PEPFAR program’s initial abstinence-only approach and conditional aid requirements.
Despite these debates, the program grew and accomplished tremendous success. The recent threats to PEPFAR’s existence, including a funding pause and a changed attitude toward US humanitarian aid, necessitate a discussion of the program’s extraordinary impact on the world. At the time of PEPFAR’s inception, highly active antiretroviral therapy (HAART) had already transformed HIV from a fatal disease into a manageable chronic condition in high-income countries. However, this was far from reality for much of the world. In 2003, sub-Saharan Africa was the epicenter of the HIV pandemic, accounting for 70% of new infections.1 That year alone, 3.2 million new infections and 2.5 million AIDS-related deaths were recorded. In some regions, prevalence rates reached 25% to 30%, foreshadowing a catastrophic future without urgent intervention.1
PEPFAR was the turning point. This US-led initiative provided desperately needed resources for HIV prevention, treatment, and care, fundamentally altering the trajectory of the pandemic. The results have been astounding: More than 26 million lives were saved through US intervention. As of December 2024, more than 20.6 million people receive ART through PEPFAR, including approximately 566,000 children, with 95% of adults and 89% of children on ART achieving viral suppression.2 Additionally, PEPFAR supports preexposure prophylaxis (PrEP) for 2.5 million people, and with the advent of long-acting injectable PrEP, a new era of lower infection rates and a potential end to the pandemic is within reach.2
Beyond its direct health impact, PEPFAR has played a crucial role in stabilizing recipient countries’ social and economic structures. The consequences of an unchecked HIV epidemic extend far beyond public health. In regions where a quarter of the population was infected, economies faced potential collapse due to workforce depletion, orphaned children, and overwhelmed health care systems. PEPFAR’s intervention prevented these outcomes and enabled sustainable economic growth. The program’s economic impact has been profound. By reducing the burden of HIV-related illness and mortality, PEPFAR has stabilized workforces, boosted productivity, and alleviated pressure on public health infrastructures. Studies estimate that PEPFAR investments have contributed to a 2.1 percentage point increase in gross domestic product growth per capita in recipient countries.3 Although specific figures on return per dollar vary, some analyses suggest a return of $3 to $7 per dollar spent.4 Total investments exceed $120 billion over PREFAR’s life span. However, despite these achievements, recent funding freezes threaten to undo decades of progress. A resurgence of new infections and treatment interruptions could destroy years of progress, leading to widespread suffering and economic hardship.
PEPFAR is a testament to how US humanitarian assistance can change the world. It exemplifies American policy as a force for good, demonstrating that strategic intervention can yield health benefits and far-reaching economic advantages. Moreover, it is a valuable tool of soft power, extending US influence and fostering goodwill in historically vulnerable regions. Allowing PEPFAR to falter would be cruel and self-defeating—a failure to uphold a legacy of American leadership and compassion in global health.
