Will the United States remain committed to a landmark health program it started 20 years ago that saved more than 25 million lives around the world? For a younger generation of physicians, nurses, and researchers today, the depth of despair wrought by the HIV/AIDS epidemic at that time is almost unimaginable. Even more profoundly, for countries in Africa, the epidemic presented an existential threat. Without access to antiretroviral therapy or efficacious prevention tools, new infections continued unfettered, and people with HIV/ AIDS faced near-certain death. Yet, somehow out of this anguish came a ray of hope. In 2003, President George W. Bush announced the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR), committing billions of dollars to fight the epidemic in the poorest countries around the world. The initiative has been a shining example of global collaboration in the face of adversity. Yet, as of this September, the US Congress has yet to reauthorize PEPFAR. The Biden administration, individuals from both sides of the political divide, and former President Bush himself have urged Congress to support PEPFAR’s lifesaving work. The scientific and public health communities must do the same before it is too late.
PEPFAR, by all accounts, has been a resounding success. At its inception, only 50,000 persons living with HIV in sub-Saharan Africa had access to treatment. Today, this number has reached over 20 million. This achievement altered the face of the continent, saving families and reviving communities. Beyond these direct effects, PEPFAR has transformed health systems around the world by working with numerous governments, in-country partners and civil society groups, and global organizations including the Global Fund to Fight AIDS, Tuberculosis and Malaria. These partnerships trained hundreds of thousands of health workers, equipped thousands of laboratories and pharmacies, and established numerous surveillance and data systems. Indeed, countries used these resources to jump-start their COVID-19 responses and save millions more lives.
PEPFAR’s work is not finished. There were 1.3 million new HIV infections and 630,000 HIV-related deaths reported in 2022. Population surveys in African countries consistently show that children, young people, and men lag in accessing HIV prevention and treatment services. In addition, stigmatized, at-risk populations have been left behind, including men who have sex with men, transgender persons, people who inject drugs, and sex workers. In response, PEPFAR has charted a way forward that is anchored in fully engaging affected communities and expanding access to high-quality prevention and treatment programs that are tailored to their needs.
Beyond PEPFAR’s undisputed benefits in the more than 50 countries that it supports, the program’s accomplishments offer lessons to guide the path to a successful HIV response in the United States. Rapid adoption of innovations will improve the quality and reach of services. These include the scale-up of self-testing, differentiated service-delivery methods to meet the needs and preferences of specific populations, and the dynamic use of up-to-date data to direct resources and inspire action in a timely manner. And expanding the scope of work for community health workers and peer educators, which includes people living with HIV and persons from affected communities, will help reach those facing stigma and who are in denial.
From day one, PEPFAR has been distinguished by the bipartisan support it has garnered over successive administrations, which has led to its enthusiastic reauthorization by Congress every 5 years for over two decades. Congressional support has rested on the program’s remarkable achievements as well as its standing as exemplary of the US global health commitment. Yet, current reauthorization is at an impasse because of misperceptions and inaccurate assertions that have no bearing whatsoever on PEPFAR’s purpose and work. Some conservative voices contend that PEPFAR funds support access to abortions, assertions that PEPFAR staff and public health leaders repeatedly affirm are groundless. Other concerns point to PEPFAR language regarding groups that scientific data have shown to be at-risk for HIV and whose members need HIV prevention and treatment services, including transgender people and sex workers. These concerns were not raised in previous reauthorizations.
Scientists, health care experts, global health leaders, and advocates must stand up at this critical moment, learn more about PEPFAR, and articulate with clarity what the program does and does not do. Now is the time to meet and share information with lawmakers and Congressional staff. Write letters. Speak out. The lives of millions hang in the balance.