Key Facts

• Although the U.S. has been involved in efforts to address the global AIDS crisis since the mid-1980s, the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic.
• PEPFAR is the largest commitment by any nation to address a single disease in the world; to date, its funding has totaled more than $110 billion, including funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), to which the U.S. government is the largest donor. PEPFAR is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic.
• U.S. funding for PEPFAR grew from $2.2 billion in FY 2004 to $7.0 billion in FY 2022; FY 2022 funding includes $5.4 billion provided for bilateral HIV efforts and $1.6 billion for multilateral efforts ($50 million for UNAIDS and $1.56 billion for the Global Fund).
• As the COVID-19 pandemic continues to have profound effects across the world, PEPFAR has acted to respond to COVID-19 in countries that receive support in order to minimize HIV service disruptions and leverage the program’s capabilities to address COVID-19 more broadly.
• Looking ahead, PEPFAR faces several issues and challenges, including how best to: address the short- and long-term impacts of COVID-19 on PEPFAR and the HIV response; accelerate progress toward epidemic control in the context of flat funding; support and strengthen community-led responses and the sustainability of HIV programs; define its role in global health security and broader health systems strengthening efforts; and continue to coordinate with other key players in the HIV ecosystem, including the Global Fund.

Global Situation

HIV, the virus that causes AIDS (acquired immunodeficiency syndrome), has become one of the world’s most serious health and development challenges. Today, there are approximately 37.7 million people living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic (see the KFF fact sheet on the global HIV epidemic).

U.S. Government Efforts

Although the U.S. has been involved in efforts to address the global HIV/AIDS crisis since the mid-1980s, the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic. PEPFAR, the U.S. government’s global effort to combat HIV and the largest global health program devoted to a single disease, is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic. It was announced in January 2003 during President George W. Bush’s State of the Union and authorized by Congress that same year through the Leadership Act (see Table 1). The Leadership Act governs PEPFAR’s HIV response, as well as U.S. participation in the Global Fund (an independent, international multilateral financing institution that provides grants to countries to address HIV, TB, and malaria) and bilateral assistance for TB and malaria programs. Congress has updated, extended, and made changes to the program through the Lantos-Hyde Act of 2008, the PEPFAR Stewardship Act of 2013, and the PEPFAR Extension Act of 2018, which goes through FY 2023 (see Table 1 and KFF brief on PEPFAR reauthorization).

Organization

PEPFAR’s original authorization established new structures and authorities, consolidating all U.S. bilateral and multilateral activities and funding for global HIV/AIDS. Several U.S. agencies, host country governments, and other organizations are involved in implementation.

PEPFAR is overseen by the U.S. Global AIDS Coordinator, who is appointed by the President, confirmed by the Senate, and reports directly to the Secretary of State, as established through PEPFAR’s authorizing legislation. The Coordinator, Dr. John Nkengasong who was sworn in on June 13, 2022, holds the rank of Ambassador and leads the Office of the Global AIDS Coordinator (OGAC) at the Department of State. Currently the Coordinator is dual-hatted as the U.S. Special Representative for Global Health Diplomacy. The Coordinator has primary responsibility for the oversight and coordination of all U.S. global HIV activities and funding across multiple U.S. implementing agencies and departments. In addition, the Coordinator serves as the U.S. Government’s board member to the Global Fund (the U.S. Government holds a permanent seat on the Global Fund’s Board).

In addition to the Department of State, other implementing departments and agencies for HIV activities include: the U.S. Agency for International Development (USAID); the Department of Health and Human Services, primarily through the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH); the Departments of Labor, Commerce, and Defense (DoD); and the Peace Corps.

Strategy

Currently, PEPFAR is guided by two main strategies: the overarching strategy laid out in PEPFAR 3.0 – Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation and a complementary, more targeted strategy for accelerating implementation of PEPFAR efforts in certain high-burden countries laid out in The PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020).

PEPFAR 3.0 focuses on achieving epidemic control (defined by the program to be reached when the total number of new HIV infections falls below the total number of deaths from all causes among people with HIV) of the global HIV epidemic through a focus on transparency, accountability, and impact. PEPFAR’s 2017-2020 strategy outlines its plan to accelerate implementation in a subset of 13 PEPFAR countries that, according to PEPFAR data, show the greatest potential to achieve epidemic control by 2020: Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. The strategy emphasizes accelerating testing and treatment strategies, expanding prevention, using quality data, engaging with faith-based organizations and the private sector, and strengthening policy and financial contributions by partner countries. It is also intended to align with the UNAIDS 90-90-90 and 95-95-95 targets (see KFF dashboard monitoring global HIV targets, including PEPFAR’s epidemic control target, in PEPFAR countries).

This year, the U.S. government is expected to release a new PEPFAR strategy for its next phase. According to a draft overview, this strategy will “support the international community’s efforts to put countries on track to reach the Sustainable Development Goal 3 target of ending the global AIDS epidemic as a public health threat by 2030, through the attainment of key milestones by 2025.”

Key Activities and Results

PEPFAR activities focus on expanding access to HIV prevention, treatment, and care interventions. These include provision of antiretroviral treatment, pre-exposure prophylaxis, voluntary male circumcision, condoms, and other commodities related to HIV services (see Table 2).^, In addition, PEPFAR has launched specific initiatives in key strategic areas. For example, in 2015, PEPFAR launched DREAMS, a public-private partnership that aims to reduce HIV infections in adolescent girls and young women.

The latest results reported by PEPFAR indicate that it has:

• supported testing services for 63.4 million people in FY 2021;
• prevented 2.8 million babies from being born with HIV, who would have otherwise been infected;
• provided care for more than 7.1 million orphans and vulnerable children (OVC);
• supported training for nearly 300,000 new health care workers; and
• supported antiretroviral treatment for 18.96 million people.
• In the 15 countries implementing the DREAMS initiative, new diagnoses among adolescent girls and young women have declined with most DREAMS areas (96%) experiencing declines greater than 25% and nearly two-thirds with declines greater than 40%.

Countries Reached

PEPFAR bilateral programs span more than 50 countries. More countries are reached through U.S. contributions to the Global Fund. PEPFAR currently requires 25 countries and the Asia, Western Hemisphere, and West Africa regional programs to develop “Country Operational Plans” (COPs) and “Regional Operational Plans” (ROPs), respectively, to document annual investments and anticipated results. OGAC reviews and the Global AIDS Coordinator approves COP/ROPs.

Funding

Total PEPFAR funding includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS. It represents the majority of U.S. global health funding (ranging from 56% to 62% over the past five years) and is the largest commitment by any nation to address a single disease in the world. To date, PEPFAR funding has totaled more than $110 billion, with funding reaching $7.0 billion in FY 2022 (see Figure 1).

PEPFAR’s creation marked a significant increase in the amount of funding provided by the U.S. for HIV. Bilateral HIV funding through regular appropriations, which accounts for the majority of PEPFAR funding (averaging approximately 80% each year), rose rapidly from $1.1 billion in FY 2003 (the year before PEPFAR) to a peak of $5.5 billion in FY 2010. Between FY 2010 and FY 2013, it declined by more than $800 million. While it has risen since then, bilateral funding in FY 2022 ($5.4 billion) was still $94 million below its peak level, and funding has been mostly flat for the past several years. Funding for the Global Fund through regular appropriations also increased rapidly, rising from $347 million in FY 2003 (the year before PEPFAR) to a peak level of $1.65 billion in FY 2014 before declining to $1.35 billion in FY 2015. It was level for several years before it increased to $1.56 billion in FY 2020 and has since remained flat. In FY 2021, additional emergency funding for bilateral HIV and the Global Fund was provided to address COVID-19. (For more detail on historical appropriations for PEPFAR, see the KFF budget tracker and KFF brief on historical trends.)

Of the approximately $7.0 billion appropriated for PEPFAR in FY 2022:

• $5.4 billion (77%) is for bilateral HIV, $50 million is for UNAIDS (1%), and $1.56 billion (22%) is for the Global Fund.
• The majority of PEPFAR funding is channeled to the Department of State ($5.95 billion, which includes $4.3 billion for bilateral HIV— most of which is then transferred to other agencies; $50 million for UNAIDS; and a $1.56 billion contribution to the Global Fund), followed by NIH ($628 million), USAID ($330 million), CDC ($128.9 million), and a small amount to DoD ($10 million).
• For FY 2023, the Biden administration has requested $7.4 billion ($5.4 billion for bilateral HIV and $2 billion for the Global Fund) from Congress, which would represent an increase, all for the Global Fund, from the FY 2022 level.

Spending Directives

PEPFAR has included several spending directives, or earmarks, from Congress over the course of its history, many of which have changed over time:

1. The Leadership Act, PEPFAR’s original authorization, included the following spending directives: 55% of funds were to be spent on treatment; 15% on palliative care; 20% on prevention, of which at least 33% be spent on abstinence-until-marriage programs; and 10% on OVC. While these were included as “sense of Congress” recommendations, the treatment, OVC, and abstinence-until-marriage earmarks were made requirements as of FY 2006.
2. The Lantos-Hyde Actrelaxed some of these directives for the FY 2009 – FY 2013 period: while still requiring that 10% of funds be spent on programs targeting OVC, it changed the treatment earmark from 55% to requiring that at least half of bilateral HIV assistance be spent on treatment and care. It removed the 33% abstinence-until-marriage directive and replaced it with a requirement of “balanced funding” for prevention to be accompanied by a report to Congress if less than half of prevention funds were spent on abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities in any host country with a generalized (high prevalence) epidemic.
3. The PEPFAR Stewardship Act and The PEPFAR Extension Act have maintained the language in the Lantos-Hyde Act.

PEPFAR & The Global Fund

The U.S. is the single largest donor to the Global Fund. Appropriations for the U.S. contribution to the Global Fund totaled approximately $26.2 billion from FY 2001 through FY 2022. The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and health systems strengthening (HSS) programs in addition to (and beyond their linkage with) HIV. To date, over 120 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV and HIV/TB programs, 30% to malaria, 15% to TB, and <3% to other health issues. The original authorization of PEPFAR, and subsequent reauthorizations, included a limit on annual U.S. contributions to the Global Fund that prevented them from causing cumulative U.S. contributions to exceed 33% of the Global Fund’s total contributions; this requirement is in effect through FY 2023 (see the KFF fact sheet on the Global Fund). As shown in Figure 1 above, in FY 2021 the U.S. government provided $3.5 billion in emergency funding to the Global Fund to help the organization address the impacts of COVID-19 (in addition to the $250 million in emergency funds provided to bilateral COVID-19-related efforts).

PEPFAR & COVID-19

COVID-19 continues to have profound effects in the countries that receive PEPFAR support and on HIV efforts, especially with regard to HIV prevention. Since the beginning of the pandemic, PEPFAR has acted to respond to and mitigate the impacts of COVID-19. Steps have included: developing – and regularly updating – guidance to field teams aimed at ensuring continuity of care and leveraging PEPFAR’s infrastructure to respond to COVID-19; accelerating the use of strategies to minimize service disruption, such as multi-month dispensing of antiretrovirals and decentralized distribution of HIV self-testing kits; implementing new strategies, such as telemedicine; and allowing for some program flexibility in reporting requirements, staffing, and funding re-allocation.^,

PEPFAR’s capacity to respond to COVID-19 received an important boost in March 2021, when COVID-19 emergency funding provided the program with $250 million in emergency funding for its bilateral COVID-19-related efforts (in addition to $3.5 billion in emergency funds provided to the Global Fund).

Key Issues for the U.S.

The U.S. government is the largest donor to international HIV efforts in the world, including the largest donor to the Global Fund, and PEPFAR is viewed as one of the most significant and successful global health initiatives ever undertaken. Now, almost twenty years after its creation, PEPFAR is at a turning point. There have been important shifts in the global HIV and broader global health landscape since the program was launched, including COVID-19. PEPFAR also is operating under a new administration and will be releasing a new strategy, and reauthorization discussions are expected to begin in the near future. As PEPFAR enters its next phase, there are several key interrelated issues and challenges facing the program that will likely have implications for the future shape and direction of the program. These include:  

• addressing the short- and long-term impacts of COVID-19 on PEPFAR and the HIV response;
• accelerating progress toward epidemic control in the context of flat funding;
• achieving the optimal mix of services provided, populations served, and geographies targeted;
• supporting and strengthening community-led responses and sustainability;
• defining PEPFAR’s role in global health security and broader health systems strengthening efforts, while ensuring synergies with other U.S. global health and development programs; and
• continuing to coordinate with other donors and entities in the HIV ecosystem, especially the Global Fund.