The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)

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. Now, 20 years in, PEPFAR reports saving more than 25 million lives and is currently providing HIV prevention and treatment services to millions.
• PEPFAR is the largest commitment by any nation to address a single disease in the world, credited with not only saving millions of lives but also helping to change the trajectory of the global HIV epidemic.
• PEPFAR funding is comprised of U.S. bilateral funding and U.S. contributions to multilateral organizations addressing HIV, primarily the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).¹
• To date, U.S. funding for PEPFAR has totaled approximately $120 billion, growing from $1.9 billion in FY 2004 to $6.5 billion in FY 2024; FY 2024 funding includes $4.8 billion provided for bilateral HIV efforts and $1.7 billion for multilateral efforts ($50 million for UNAIDS and $1.65 billion for the Global Fund).² The President requested $6.1 billion for PEPFAR in FY 2025.
• PEPFAR was first authorized by Congress in FY 2004 for five years, and has since been reauthorized four times, most recently in March 2024. However, unlike prior reauthorizations which were each for a period of five years, the most recent reauthorization was only for one year, the result of an increasingly partisan environment. This has introduced some uncertainty about PEPFAR’s future, even though the program will continue as long as Congress provides funding for it.
• The outcome of the upcoming election will likely shape the reauthorization discussion as well as PEPFAR’s future directions as the program seeks to define its approach to sustainability and looks toward the 2030 global goal of ending the AIDS epidemic as a public health threat.

Global Situation

HIV, the virus that causes AIDS (“acquired immunodeficiency syndrome” or Advanced HIV Disease), has become one of the world’s most serious health and development challenges. Today, there are approximately 39.9 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).³

Box 1: Snapshot of Global Epidemic Today

Number of people living with HIV: 39.9 million Number of people newly infected with HIV: 1.3 million Number of AIDS-related deaths: 630,000 Number of people with HIV on treatment: 30.7 million Notes: Reflects 2023 data.

U.S. Government Efforts

Although the U.S. has been involved in efforts to address the global HIV/AIDS crisis since the mid-1980s,⁴ 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.⁵ 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.⁶ Congress has updated, extended, and made changes to the program through the Lantos-Hyde Act of 2008, the PEPFAR Stewardship Act of 2013, the PEPFAR Extension Act of 2018, and more recently, a short-term reauthorization of PEPFAR that extends certain timebound provisions through late March 2025 (see Table 1 and the KFF brief on PEPFAR reauthorization legislation over time). This short term reauthorization signaled a departure from the program’s long history of strong bipartisan support across multiple Congresses and administrations when, in an increasingly partisan environment, it was caught up in the broader U.S. political debate over abortion (see the KFF brief on PEPFAR’s short-term reauthorization). This has introduced some uncertainty about PEPFAR’s future reauthorization prospects, though it is important to note that PEPFAR is a permanent part of U.S. law and will continue absent another reauthorization as long as Congress continues to provide funding to it.

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.⁷

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.⁸ The current Coordinator, Dr. John Nkengasong, holds the rank of Ambassador and leads the Office of the Global AIDS Coordinator (OGAC) at the Department of State.⁹ 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). Currently, the Coordinator is dual-hatted as the U.S. Special Representative for Global Health Diplomacy and also leads the broader Bureau of Global Health Security and Diplomacy, which brings together PEPFAR with global health security and global health diplomacy functions.¹⁰

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.¹¹

Strategy

In late 2022, PEPFAR released its new five-year strategy Fulfilling America’s Promise to End the HIV/AIDS Pandemic by 2030, which outlines its approach to contributing to and supporting global efforts to reach the U.N. Sustainable Development Goal 3 (SDG 3) target of ending the global AIDS pandemic as a public health threat by 2030, while also strengthening public health systems. Complemented by three “enablers” (community partnerships, innovation, and leading with data), the strategy focuses on five “strategic pillars”:

• ensuring health equity for priority populations,
• achieving long-term sustainability in the HIV/AIDS response,
• leveraging public health systems to respond to health threats,
• strengthening partnerships, and
• ensuring programs are guided by science.

The strategy aims to align U.S. efforts with the UNAIDS Global AIDS Strategy 2021-2026 (as one of PEPFAR’s goals is to reach the 95-95-95 testing and treatment targets¹² – 95% of people living with HIV knowing their HIV status; 95% of people who know their HIV positive status on treatment; and 95% of people on treatment with suppressed viral loads – by 2025) and the Global Fund Strategy for 2023-2028.¹³ (See the KFF dashboard monitoring progress toward global HIV targets, including PEPFAR’s epidemic control target, in PEPFAR countries.)

As part of implementing its strategic pillar on sustainability, PEPFAR is focused on helping countries to develop and execute country “sustainability roadmaps,” in conjunction with UNAIDS guidance; the aim for PEPFAR is to strengthen sustainability of country leadership and assets of HIV efforts in order to “sustain achievement of 95-95-95 goals; to ensure equity in its HIV response; and to protect against other public health threats” (see the KFF brief on sustainability readiness in PEPFAR countries). While the importance of sustainability has long been recognized by PEPFAR, this approach marks a new point in this evolution, shaped by greater recognition of the contribution of HIV efforts to broader pandemic response and global health security, progress in the HIV response in many countries where PEPFAR operates, and shifting U.S. views of the role of PEPFAR and other development efforts in relation to assisted countries, particularly amid projected budget constraints.

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).^14,15 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 71.1 million people in FY 2023;
• prevented 5.5 million babies from being born with HIV, who would have otherwise been infected;
• provided care for more than 7.0 million orphans, vulnerable children (OVC), and their caregivers;
• supported training for nearly 327,000 new health care workers; and
• supported antiretroviral treatment for 20.5 million people.¹⁶

Additionally, it reports that in the 15 countries implementing the DREAMS initiative, new diagnoses among adolescent girls and young women have declined, with DREAMS areas experiencing greater declines in diagnosis among women in antenatal care compared to areas without DREAMS programming.¹⁷

Countries Reached

PEPFAR bilateral programs span more than 50 countries.¹⁸ More countries are reached through U.S. contributions to the Global Fund. PEPFAR currently requires 25 countries¹⁹ 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.²⁰ OGAC reviews and the Global AIDS Coordinator approves COP/ROPs.

Funding²¹

Total PEPFAR funding²² includes bilateral funding for HIV activities conducted by U.S. implementing agencies as well as U.S. contributions to the Global Fund and UNAIDS,²³ as specified by Congress for PEPFAR in annual appropriations bills.²⁴ It represents the majority of U.S. global health funding (ranging from 51% to 55% over the past five years²⁵) and is the largest commitment by any nation to address a single disease in the world. To date, PEPFAR funding has totaled approximately $120 billion, with funding reaching $6.5 billion in FY 2024 (see figure). The President requested $6.1 billion for PEPFAR in FY 2025.

PEPFAR’s creation marked a significant increase in the amount of funding provided by the U.S. for HIV. Trends in funding for bilateral programs and contributions to multilateral organizations are as follows (see the KFF fact sheet on the U.S. Global Health Budget: Global HIV Funding, Including PEPFAR and U.S. Global Health Budget: The Global Fund):

• Bilateral HIV Funding: The majority of PEPFAR funding (ranging from 68-77% each year over the past decade) is provided for bilateral programs through the State Department (most of which is then transferred to other agencies), USAID, CDC, and DoD. Bilateral funding rose rapidly from $822 million in FY 2003 (the year before PEPFAR) to a peak of $5.0 billion in FY 2010. Between FY 2010 and FY 2013, it declined by more than $750 million. While it has risen since then, bilateral funding in FY 2024 ($4.8 billion) was still $233 million below its peak level, and funding has been mostly flat for the past several years.
• Multilateral Contributions: The U.S. also supports global HIV efforts through contributions to the Global Fund and UNAIDS. Support for the Global Fund, which accounts for most of the multilateral contributions, increased rapidly in its early years and fluctuated over time; it reached its highest level to date ($2.0 billion) in FY 2023. In FY 2024, funding for the Global Fund was $1.65 billion, $375 million less than the FY 2023 level, though this is due to a legislative requirement that limits the amount the U.S. can contribute to the Global Fund to not more than 33% of all contributions.²⁶ The U.S. contribution to UNAIDS was $45 million for most years over the past decade, but increased to $50 million in FY 2022, where it has remained.
• Emergency Funding: In FY 2021, an additional $3.8 billion in emergency supplemental funding was provided for bilateral HIV ($250 million) and the Global Fund ($3.5 billion) to address COVID-19.²⁷

Spending Directives²⁸

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 Act relaxed 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, The PEPFAR Extension Act, and recent short-term reauthorization 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 $29.8 billion from FY 2001 through FY 2024.²⁹ This includes, $3.5 billion in FY 2021 emergency funding that the U.S. government provided 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 HIV for COVID-19-related efforts).³⁰

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.³¹ To date, over 120 countries³² have received Global Fund grants. Most Global Fund support (52%) has been committed to HIV and HIV/TB programs,³³ followed by 29% to malaria, 15% to TB, and 4% to other health issues.³⁴ 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;³⁵ this requirement is in effect through FY 2023 (see the KFF fact sheet on the Global Fund).³⁶