The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
- 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 $100 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, which includes contributions to the Global Fund, grew from $2.2 billion in FY 2004 to $10.8 billion in FY 2021; FY 2021 funding includes $7.0 billion provided through regular appropriations and $3.8 billion in emergency funding to address the impact of COVID-19 on HIV efforts, $250 million of which was for bilateral efforts and $3.5 billion was 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.
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).1
|Box 1: Snapshot of Global Epidemic Today|
|NOTES: Reflects 2020 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,2 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.3 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.4 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 (see KFF brief on PEPFAR reauthorization).
|Table 1: PEPFAR Legislation|
|Full Title||Authorization Level||Public Law #||Years|
|United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003
“The Leadership Act”
|$15 billion||P.L. 108-25||FY04-FY08|
|Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008
“The Lantos-Hyde Act”
|$48 billion||P.L. 110-293||FY09-FY13|
|PEPFAR Stewardship and Oversight Act of 2013
“The PEPFAR Stewardship Act”
|Did not specify authorization for funding*||P.L. 113-56||FY14-FY18|
|PEPFAR Extension Act of 2018
“The PEPFAR Extension Act”
|Did not specify authorization for funding*||P.L. 115-305||FY19-FY23|
|NOTES: * Congress effectively authorizes funding when it appropriates funding for a purpose. See the KFF brief on PEPFAR Reauthorization, https://www.kff.org/global-health-policy/issue-brief/pepfar-reauthorization-side-by-side-of-existing-legislation/.|
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.5
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.6 The Coordinator 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.7 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.8
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.”9 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).10
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.11 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.12 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.13 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).14
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).15,16 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 nearly 50 million people in FY 2020;
- prevented 2.8 million babies from being born with HIV, who would have otherwise been infected;
- provided care for more than 6.7 million orphans and vulnerable children (OVC);
- supported training for nearly 290,000 new health care workers; and
- supported antiretroviral treatment for nearly 18.2 million people.17
|Table 2: Key PEPFAR-Funded HIV Interventions|
|Prevention||Treatment & Care||Other Activities|
Among the 15 countries implementing the DREAMS initiative, the latest results show a decline in new HIV diagnoses among adolescent girls and young women in all of the areas implementing DREAMS. Further, nearly all (96%) areas have experienced declines greater than 25%, and nearly two-thirds of the areas show a decline of greater than 40%.18
PEPFAR bilateral programs span more than 50 countries (see Figure 1).19 More countries are reached through U.S. contributions to the Global Fund.
PEPFAR requires 25 countries20 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.21 OGAC reviews and the Global AIDS Coordinator approves COP/ROPs.
Total PEPFAR funding23 includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS.24 It represents the majority of U.S. global health funding (ranging from 56% to 62% over the past five years)25 and is the largest commitment by any nation to address a single disease in the world. To date, PEPFAR funding has totaled more than $100 billion, with funding reaching $10.8 billion in FY 2021 (including $7.0 billion through regular appropriations and $3.8 billion in emergency funding in response to the COVID-19 pandemic) (see Figure 2).
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, non-emergency bilateral funding in FY 2021 ($5.4 billion) was still $122 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 then remained flat in FY 2021. Additional emergency funding for bilateral HIV and the Global Fund was provided in FY 2021 to address COVID-19.26 (For more detail on historical appropriations for PEPFAR, see the KFF budget tracker and KFF brief on historical trends.)
Of the approximately $10.8 billion appropriated for PEPFAR in FY 2021, including regular and emergency funding:
- $7.0 billion is provided through regular appropriations, of which $5.4 billion (77%) is for bilateral HIV, $45 million is for UNAIDS (1%), and $1.56 billion (22%) is for the Global Fund.
- $3.8 billion is provided through emergency funding to address the impacts of COVID-19 on HIV, of which $250 million is for bilateral HIV and $3.5 billion is for the Global Fund.
- The majority of PEPFAR funding is channeled to the Department of State ($9.7 billion, which includes $4.6 billion for bilateral HIV— most of which is then transferred to other agencies; $45 million for UNAIDS; and a $5.06 billion contribution to the Global Fund), followed by NIH ($617 million), USAID ($330 million), CDC ($128.4 million), and a small amount to DoD ($8 million).
- For FY 2022, the current Administration has proposed $7.0 billion ($5.4 billion for bilateral HIV, $45 million for UNAIDS, and $1.56 billion for the Global Fund), matching the FY 2021 level when emergency funding is excluded (see KFF fact sheets on the S. Global Health Budget: HIV/PEPFAR and the U.S. Global Health Budget: The Global Fund).
PEPFAR has included several spending directives, or earmarks, from Congress over the course of its history, many of which have changed over time:
- 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.
- 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.
- 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 $24.6 billion from FY 2001 through FY 2021.28 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.29 To date, over 150 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV and HIV/TB programs,30 30% to malaria, 15% to TB, and <3% to other health issues.31 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;32 this requirement is in effect through FY 2023 (see the KFF fact sheet on the Global Fund).33 As noted above, 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.
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.34 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.35,36
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 emergency funds provided to the Global Fund).37
Key Issues for the U.S.38
The U.S. government is the largest donor to international HIV efforts in the world, including the largest donor to the Global Fund,39 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.
UNAIDS. 2021 UNAIDS Global AIDS Update: Confronting inequalities — Lessons for pandemic responses from 40 years of AIDS; July 2021.
The U.S. first provided funding to address the global HIV epidemic in 1986. Then, in 1999, President Bill Clinton announced the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative to address HIV in 14 African countries and in India. Later, in 2002, President George W. Bush announced the International Mother and Child HIV Prevention Initiative focused on 12 African and two Caribbean countries.
PEPFAR. 2009 Annual Report to Congress; Jan. 2009.
U.S. Congress. P.L. 108-25; May 27, 2003.
KFF. The U.S. Government Engagement in Global Health: A Primer; Feb. 2019. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; Jan. 2009.
U.S. Congress. Public Law No: 108-25; May 27, 2003.
PEPFAR. “About Us,” webpage, https://www.state.gov/about-us-pepfar/.
PEPFAR. “About Us,” webpage, https://www.state.gov/about-us-pepfar/.
PEPFAR, “Development of the Next PEPFAR Strategy: Vision 2025,” webpage, https://www.state.gov/development-of-the-next-pepfar-strategy-vision-2025/.
PEPFAR, PEPFAR 3.0 Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation, Dec. 2014. PEPFAR. Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); Sept. 2017.
PEPFAR, PEPFAR 3.0 Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation, Dec. 2014. PEPFAR. PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries, January 2020.
PEPFAR. Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); Sept. 2017. PEPFAR. Fact Sheet: PEPFAR Latest Global Results, 2016. PEPFAR. “Five African Countries Approach Control of Their HIV Epidemics as U.S. Government Launches Bold Strategy to Accelerate Progress,” press release; Sept. 2017.
PEPFAR. PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); Sept. 2017.
The 90-90-90 targets were set in 2014 and aim to achieve, by 2020, “90% of people living with HIV knowing their HIV status; 90% of people who know their HIV-positive status on treatment; and 90% of people on treatment with suppressed viral loads,” and ultimately to reach 95-95-95 by 2030. UNAIDS. Fast-Track: ending the AIDS epidemic by 2030; 2014. See also United Nations. Transforming our world: the 2030 Agenda for Sustainable Development; 2015, which discusses the Sustainable Development Goals (SDGs) adopted in 2015 and include a target aiming to end the AIDS epidemic by 2030 under SDG Goal 3 (“ensure healthy lives and promote well-being for all at all ages”). UNAIDS, 2025 AIDS Targets, accessed: https://aidstargets2025.unaids.org/#.
Table 2 categorization is based on interventions laid out in the PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries budget codes. Budget codes will be phased out beginning in COP21. See: PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries for further detail.
KFF. Funding for Key HIV Commodities in PEPFAR Countries; July 2021.
PEPFAR. PEPFAR Latest Global Results; June 2021.
The 15 African countries that are implementing DREAMS include Botswana, Cote d’Ivoire, Eswatini, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. PEPFAR. DREAMS Country Fact Sheets; June 27, 2020; PEPFAR, PEPFAR Latest Global Results; June 2021; PEPFAR, “DREAMS Partnership” webpage, https://www.state.gov/pepfar-dreams-partnership/.
KFF analysis of data from congressional budget justification documents; PEPFAR, “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/; PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries; and CDC’s “Where We Work” webpage, https://www.cdc.gov/globalhivtb/where-we-work/index.html.
The 25 countries that are required to complete a FY20 COP are Angola, Botswana, Burundi, Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Dominican Republic, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe. Of these 25 countries, 14 were “focus countries” targeted in PEPFAR’s first phase: Botswana, Cote d’Ivoire, Ethiopia, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. Guyana, the 15th initial PEPFAR focus country, is now supported through a PEPFAR regional program. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication; PEPFAR. 2009 Annual Report to Congress; Jan. 2009; and PEPFAR. “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/.
PEPFAR. PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries; Jan. 2020.
U.S. Congress. Public Law No: 112-25; Aug. 2, 2011. White House Office of Management and Budget (OMB). OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013; March 1, 2013. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.
While overall PEPFAR funding technically includes bilateral funding for HIV, TB, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, this analysis focuses on funding for bilateral HIV and the Global Fund.
UNAIDS is the Joint United Nations Programme on HIV/AIDS, the U.N. system’s coordinating body that serves to help galvanize worldwide attention to AIDS.
Includes bilateral funding for HIV as well as U.S. contributions to UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria through regular appropriations.
KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2).
U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. U.S. Congress. Public Law No: 115-305; Dec. 11, 2018.
Includes funding through regular appropriations and emergency supplemental funding. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.
Congress states that the Global Fund is the multilateral component of PEPFAR in the following: U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013.
Of the 53% committed to HIV and HIV/TB programs, 43% was for HIV activities and 10% was for HIV/TB activities.
In 2020, some donor governments provided COVID-specific emergency contributions to the Global Fund in addition to their contributions to core activities. For the purposes of this fact sheet, these COVID-specific amounts have been excluded as they cannot be attributed to a specific area, such as HIV, TB, or malaria. Percentages may not sum to 100 due to rounding. The Global Fund. Data Explorer; accessed July 2021: https://data.theglobalfund.org/investments/home.
U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. KFF. PEPFAR Reauthorization, brief.
See the KFF. The U.S. & The Global Fund to Fight AIDS, TB and Malaria, fact sheet; and KFF. PEPFAR Reauthorization, brief.
The Global Fund to Fight AIDS, Tuberculosis and Malaria, Results Report 2021; September 2021.
PEPFAR. PEPFAR Technical Guidance in the Context of COVID-19 Pandemic; updated August 18, 2021.
PEPFAR. PEPFAR 2021 Annual Report to Congress; February 2021.
KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2).
KFF. Key Issues and Questions for PEPFAR’s Future, September 2021.
KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. PEPFAR totals include funding for HIV and the Global Fund. KFF/UNAIDS. Donor Government Funding for HIV in Low- and Middle-Income Countries in 2020, July 2021.