PEPFAR delivers outsized returns—it deserves more funding

The U.S. President’s Emergency Relief Plan for AIDS Relief, or PEPFAR, is possibly the single most successful policy to date in U.S.-Africa relations. It is one also one of the most successful foreign policy programs in U.S. history. Yet very few people have heard of it, and its future funding is currently on shaky ground in the current U.S. political climate. As Congress decides on spending allocations and discretionary spending for the following fiscal years, and with the March 25, 2025 PEPFAR reauthorization deadline looming, at the top of the agenda should be one key mandate: Fund PEPFAR. Why? For the following three key reasons:

1. PEPFAR is an extremely popular foreign policy program with historical bipartisan support that has saved over 25 million lives¹ and boosted the global economy.
2. PEPFAR is a cost-effective program that provides positive net benefits to the U.S. and the world. At very low cost to the U.S., it provides outsized returns in health security and strengthened diplomatic relations with PEPFAR country partners in Africa.
3. PEPFAR is an indispensable tool to strengthen national and global health security by reducing not just HIV epidemic risk, but also strengthening pandemic preparedness globally.

A bipartisan program that saved 25 million lives

When the U.S. government, under the administration of then Republican President George W. Bush, launched PEPFAR in 2003, it marked the largest investment in combatting a single disease in the world. At its launch, the HIV epidemic was still horrifically endemic globally, and one of the program’s goals included preventing 7 million new HIV infections and providing care for both millions of people suffering from AIDS and children who lost their parents due to HIV/AIDS.² Initially, $15 billion was authorized for spending on the program over its first 5 years, passed with almost unanimous bipartisan support at its inception.³

The discovery of highly effective antiretroviral drugs in the 1990s completely transformed the landscape for the HIV epidemic. The combination treatments known as highly active antiretroviral therapy (HAART) have significantly reduced the risk of infection transmission and increased survival probabilities of people with HIV. While the drugs were highly effective, they were also often prohibitively expensive for most of the people affected by the AIDS epidemic globally with the yearly cost of treatment at around $20,000 in the 1990s.⁴

In 2002, President George W. Bush put together a panel of advisers to come up with efficient ways to scale up HIV treatment and combat the epidemic globally. The lessons gathered by the panel set the groundwork for what would become PEPFAR, a U.S.-led program that partnered with local governments to construct the supply chains, infrastructure, and networks needed to boost HIV treatment coverage while lowering costs of treatment globally.⁵

Today, PEPFAR has become one of the most measurable policy successes of U.S. foreign diplomacy, with most of the U.S. HIV funding for PEPFAR being through bilateral agreements (89%), and the program partnering with and supporting more than 50 countries around the world.⁶ Nearly a quarter of countries globally (22%) receive PEPFAR funding, including countries like Ukraine, Haiti, and Uganda as shown in Figure 1.⁷ African countries make up 27 of the 55 (49%) PEPFAR-supported countries globally. The global health impacts of PEPFAR have extended beyond HIV treatment and prevention to the creation of some of the most sophisticated data collection, pandemic preparedness, and health institutional infrastructures in the world. The efforts from PEPFAR have helped train healthcare workers and boost treatment for many other diseases from malaria and tuberculosis to recent epidemics like Ebola, COVID-19, and mpox.⁸

Figure 1. Nearly a quarter of countries globally receive PEPFAR funding

PEPFAR provides outsized returns to the US in health security and strengthened diplomatic relations with PEPFAR country partners in Africa

And the success of PEPFAR has been one of the most striking and positive exercises of U.S. soft power in Africa and around the world.⁹ The program has boosted the image of the United States globally and created allies and supporters of the U.S. across its partner countries, particularly in democratically fragile regions. PEPFAR marked the beginning of structured efforts towards using global health as a tool for both increasing U.S. national security and also boosting U.S. diplomacy abroad. The program assigned a dedicated U.S.-based global AIDS coordinator that was tasked with data collection and providing detailed, careful reports on the program’s progress to Congress. The program’s initiatives helped shift to the generic procurement of drugs that significantly reduced the cost of HIV medication around the world.¹⁰

Under the program, the costs of antiretroviral treatment (ART) in low- and middle-income countries fell from $1,200 per person per year in 2003 to just $58 in 2023.¹¹ Conservative estimates put the lives saved by the PEPFAR’s HIV and AIDS treatment and prevention initiatives at 25 million people with around 20 million people currently living and dependent on medication from the program.¹² African countries, which make up the majority of new HIV cases, have significantly benefited from PEPFAR, with the program becoming an undeniable part of U.S. diplomacy in these regions.

PEPFAR is cost-effective at less than 0.08% of US spending

PEPFAR funding falls under discretionary spending in the U.S. budget—funding that needs formal approval by Congress and the President each year. Broadly, PEPFAR funding is specified by Congress in an annual appropriations bill that is run through the Department of State. The Department of State administers PEPFAR and global HIV funding efforts through the Bureau for Global Health Security and Diplomacy (GHSD).

The U.S. government is the largest donor to global health in the world and provides funding for diseases like HIV, tuberculosis, and malaria and for population health initiatives like maternal and child health, nutrition, and family planning and reproductive health.¹³ While the creation of PEPFAR led to a significant increase in U.S. investment in global health in the early 2000s, over the last decade, U.S. funding for global health has largely stagnated, except for temporary boosts in fiscal years (FY) 2015, 2016, and 2020-2021, due to the Ebola, Zika, and COVID-19 epidemics respectively as shown in Figure 2. In FY 2024, funding for global health totaled $12.3 billion or just 0.2% of total U.S. spending in FY 2024.¹⁴ HIV spending was the largest area of that, making up 44% of total global health funding as shown in Figure 3. This amount was a tiny fraction of total U.S. spending at just 0.08% of total U.S. spending in FY 2024. Of the total amount allocated to global HIV funding (around $5.4 billion), $4.9 billion or 91% was allocated for PEPFAR.

Figure 2. US global health funding has largely stagnated over the past decade, except for temporary boosts for Ebola, Zika, and COVID-19

Figure 3. HIV spending made up 44% of total US global health funding in FY 2024

Compared to other foreign policy spending (e.g., defense spending which made up 13% of federal spending in FY 2024), global health and HIV/PEPFAR funding makes up an almost negligible part of the federal budget, at less than 0.1% of U.S. spending currently. And yet, this spending has had outsized positive impacts for the U.S. and global community, making it arguably the United States’ most successful foreign policy program of all time. How has PEPFAR done this? Based on the research evidence we have to date, three major ways stand out.¹⁵

1. PEPFAR strengthens national and global health security through reducing not just HIV epidemic risk, but also strengthening pandemic preparedness globally.¹⁶
2. PEPFAR saves lives by reducing mortality risk, extending life expectancy, and reducing the incidence of orphanhood around the world.¹⁷
3. PEPFAR boosts economic growth.¹⁸ Not only is HIV treatment expansion associated with an increase in life expectancy, extending ART coverage to an additional 1% of a country’s population also increases GDP per capital growth rates by about 1.4 percentage points.¹⁹ This is a significant boost to countries’ economic growth with the effects in sub-Saharan Africa corresponding to an increase in per capita income of $14 each year.²⁰

If PEPFAR is so great, why is its funding being contested?

While PEPFAR was created by a Republican president and passed with bipartisan congressional support in 2003, its existence has always been debated by members of both the left and the right. While funding for PEPFAR has historically been approved with majority congressional consensus since its inception, both Democratic and Republican administrations have debated both its form and function. Democratic policymakers have argued that PEPFAR should be housed in a different government agency, like USAID instead of the State Department for example, and Republican policymakers have debated the funding amounts and use by PEPFAR programs.²¹

These discussions took a sharp turn with the release of a June 2023 report by the Heritage Foundation, which alleged reportedly without any substantiated evidence, that funds allocated to PEPFAR were being used to pay for abortions overseas.²² This purportedly prompted a small group of Republican policymakers to boost accusations which further stymied the most recent reauthorization process and resulted in a 1-year extension of PEPFAR. This put future funding of, arguably the U.S.’ most successful foreign policy program, at risk. The Biden administration in response, was more conservative in its discussion of PEPFAR, framing it as solely an HIV program, and not emphasizing its essential role in global health security and pandemic preparedness around the world.²³ Some Republican lawmakers have demanded that the program move to a yearly authorization schedule that would allow a Republican president to modify the program substantially. This would significantly disrupt health planning and life-saving treatment for millions of people globally. It would also cause the U.S. to fail in its commitment to eradicating the HIV epidemic globally by 2030.²⁴

Moving forward, what are some policy recommendations?

On March 23, 2024, PEPFAR was reauthorized for one year as part of an omnibus funding bill, but the program has become increasingly at risk of not being reauthorized.²⁵ Ending PEPFAR would be both short-sighted and a very costly policy move for the United States. It would needlessly cut off a relatively low-cost foreign policy lever for the U.S. and lead to significant health and economic declines for millions of people around the world. So, what can Congress do? Congress can continue to fund PEPFAR:

1. Congress could support the proposed 5-year clean (with no changes to the prior language or text of the legislation) reauthorization of PEPFAR to ensure that the U.S. will continue to lead in the global HIV response. The U.S. president and president’s administration, Secretary of State, and the U.S. Global AIDS Coordinator and Senior Bureau Official for Global Health Security and Diplomacy (GHSD) could take a strong, united, and vocal stance in defense and support of PEPFAR funding and highlight its significant contributions to domestic and global health and economic security.
2. The U.S. government, State Department, and Senior Bureau Official for GHSD could work with USAID, the Centers for Disease Control and Prevention (CDC), and partner country CDC and foreign ministries of health for the creation of an easily accessibly database to share the data, information, and knowledge from PEPFAR with and across partner countries. More funding could be allocated to research initiatives to analyze lessons from PEPFAR around the world.
3. The U.S. government and State Department could urge and engage partner country finance ministers to increase health spending along with PEPFAR allowances. Particularly in African countries, where government spending on health is very low,²⁶ boosting health spending is a crucial part of pandemic preparedness and global health security. This includes allocations to employ more healthcare workers, nurses, and doctors needed to manage treatment and prevention for not just HIV, but routine health care that is severely underfunded and often leads to comorbidities for those living with HIV infection.

Securing long-term, uninterrupted funding for PEPFAR and enacting these policies will ensure the continuity of a highly successful and impactful U.S. foreign policy program with long-run benefits for Americans and the global community.