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; to date, its funding has totaled more than $110 billion, including contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), to which the U.S. government is the largest donor.¹ 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 $1.9 billion in FY 2004 to $6.9 billion in FY 2023; FY 2023 funding includes $4.8 billion provided for bilateral HIV efforts and $2.05 billion for multilateral efforts ($50 million for UNAIDS and $2.0 billion for the Global Fund).² The President requested $6.8 billion for PEPFAR in FY 2024.
• The COVID-19 pandemic further complicated global HIV efforts, and 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 38.4 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: 38.4 million Number of people newly infected with HIV: 1.5 million Number of AIDS-related deaths: 680,000 Number of people with HIV on treatment: 28.7 million

NOTES: Reflects 2021 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, and the PEPFAR Extension Act of 2018, which goes through FY 2023 (see Table 1 and KFF brief on PEPFAR reauthorization). This year, Congress will consider reauthorization of PEPFAR for a fourth time.

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/.

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 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.⁹ Currently the Coordinator is dual-hatted as the U.S. Special Representative for Global Health Diplomacy.¹⁰ 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 December 2022, the Secretary of State announced plans for a new Bureau of Global Health Security and Diplomacy; it would bring together the functions of several coordinators and offices, including OGAC/Global Health Diplomacy and the Coordinator for Global COVID-19 Response and Health Security, and be led by Dr. Nkengasong.

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 is intended to align with the UNAIDS Global AIDS Strategy 2021-2026, as one of PEPFAR’s goals is to reach the 95-95-95 targets (see the KFF dashboard monitoring progress toward global HIV targets, including PEPFAR’s epidemic control target, in PEPFAR countries), and the Global Fund Strategy for 2023-2028.¹²

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).^13,14 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.

Table 2: Key PEPFAR-Funded HIV Interventions
HIV Testing & Prevention	Treatment & Care	Health Systems Strengthening	Socio-Economic
HIV testing services (facility- and community-based) Risk reduction for youth, including sexual violence prevention Sexual prevention programs, including condom and lubricant programming, contraceptive counseling, and pre-exposure prophylaxis (PrEP) Harm reduction efforts and injection safety for injecting drug users (IDUs) and non-injecting drug use Voluntary medical male circumcision (VMMC)	Antiretroviral (ARV) drugs for adults and children Care and support for adults and children living with HIV TB screening and TB preventative therapy for people living with HIV Cervical cancer screening and treatment for women living with HIV	Health workforce Strategic information systems Laboratory infrastructure Surveys Surveillance Research and evaluation Procurement and supply chain management Public financial management	Case management, including legal support Economic strengthening programs, including cash transfers Youth livelihood initiatives for out-of-school adolescents Education assistance Food and nutrition support, including nutrition counseling, micronutrient supplementation, and support for pregnant and postpartum women Psychosocial support, including peer support groups Assessing laws, regulations, and policy environment related to preventing stigma, violence, and HIV

The latest results reported by PEPFAR indicate that it has:

• supported testing services for 64.7 million people in FY 2022;
• 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 and vulnerable children (OVC);
• supported training for nearly 340,000 new health care workers; and
• supported antiretroviral treatment for 20.1 million people.¹⁵

Additionally, it reports that 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%.¹⁶

Countries Reached

PEPFAR bilateral programs span more than 50 countries.¹⁷ More countries are reached through U.S. contributions to the Global Fund. PEPFAR currently requires 25 countries¹⁸ 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.¹⁹ OGAC reviews and the Global AIDS Coordinator approves COP/ROPs.

Funding²⁰

Total PEPFAR funding²¹ includes bilateral funding for HIV activities conducted by U.S. implementing agencies as well as U.S. contributions to the Global Fund and UNAIDS,²² as specified by Congress for PEPFAR in annual appropriations bills.²³ It represents the majority of U.S. global health funding (ranging from 52% to 57% over the past five years²⁴) 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 $6.9 billion in FY 2023 (see figure and the KFF fact sheet on the U.S. Global Health Budget: HIV/PEPFAR). The President requested $6.8 billion for PEPFAR in FY 2024.

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:

• Bilateral HIV Funding: The majority of PEPFAR funding (ranging from 70-77% 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 2023 ($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. 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-19.²⁵

Spending Directives²⁶

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 $28.2 billion from FY 2001 through FY 2023.²⁷ As shown 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 HIV for COVID-19-related efforts).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 120 countries³⁰ have received Global Fund grants. Most Global Fund support (52%) has been committed to HIV and HIV/TB programs,³¹ followed by 29% to malaria, 15% to TB, and 3% to other health issues.³² 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;³³ this requirement is in effect through FY 2023 (see the KFF fact sheet on the Global Fund).³⁴

PEPFAR & COVID-19

COVID-19 has had profound effects in the countries that receive PEPFAR support and on HIV efforts, especially with regard to HIV prevention.³⁵ Soon after the COVID-19 pandemic emerged, PEPFAR acted to respond to and mitigate its impacts on the HIV response. This 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.^36,37

PEPFAR’s capacity to respond to COVID-19 received an important boost in March 2021, when Congress provided PEPFAR with $250 million in COVID-19 emergency funding for these efforts (Congress also provided $3.5 billion in emergency funds to the Global Fund).³⁸

Key Issues for the U.S.³⁹

The U.S. government is the largest donor to international HIV efforts in the world, including the largest donor to the Global Fund,⁴⁰ and PEPFAR is viewed as one of the most significant and successful global health initiatives ever undertaken. Now, twenty years after its creation, PEPFAR is at a turning point. There have been important shifts in the HIV and broader global health landscape since the program was launched, including the impacts and lessons of the COVID-19 pandemic, and ongoing discussions about how PEPFAR, and other vertical, disease-focused programs, should be part of efforts to bolster pandemic preparedness. PEPFAR also is operating under a new strategy and reauthorization discussions are underway. As PEPFAR enters its next phase, there are several key interrelated issues and challenges facing the program that will likely have implications for its future, including:  

• addressing the short- and long-term impacts of COVID-19 on the HIV response in PEPFAR countries;
• 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 pandemic preparedness 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.