Q And A Forum: Know About PEPFAR

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

Key Facts sourced from www.kff.org

  • 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 $80 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.
  • First authorized in 2003, the program has been reauthorized three times: in 2008, 2013, and most recently in December 2018.
  • While viewed as one of the most significant and successful global health initiatives ever undertaken, PEPFAR faces several issues and challenges, including how best to: accelerate progress toward epidemic control in the context of flat or potentially reduced budgets; support and strengthen country ownership and sustainability; address the needs of young women and adolescents, as well as key populations; and leverage partnerships with the public and private sectors.


PEPFAR is currently 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 sustainable control of the global HIV epidemic through a focus on transparency, accountability, and impact. It also sets five core priorities for the program:
  1. Focusing on adolescent girls and women, with an emphasis on creating gender equity;
  2. Improving the lives of children living with and affected by HIV/AIDS;
  3. Addressing the needs of key populations, with an emphasis on ensuring human rights and leaving no one behind;
  4. Using data for impact in order to accelerate progress; and
  5. Leveraging partnerships to enhance sustainability of PEPFAR and other global HIV efforts.
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 HIV/AIDS 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 targets.

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, and condoms. 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, as of September 2018:
  • supported testing services for nearly 95 million people;
  • prevented more than 2.4 million babies from being born with HIV, who would have otherwise been infected;
  • provided care for more than 6.8 million orphans and vulnerable children (OVC);
  • supported training for more than 270,000 new health care workers; and
  • supported antiretroviral treatment for more than 14.6 million people.
The latest results from the DREAMS initiative show declines in new HIV diagnoses among adolescent girls and young women in 85% of the highest HIV burden districts in the 15 African countries implementing DREAMS.


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 and The PEPFAR Extension Act have maintained the language in the Lantos-Hyde Act.


The U.S. is the single largest donor to the Global Fund. Congressional appropriations to the Global Fund totaled $16.6 billion from FY 2001 through FY 2018. 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 150 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV and HIV/TB programs, 29% to malaria, 16% to TB, and 2% 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.

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. Looking ahead, there are several issues and challenges facing PEPFAR, starting with questions about the extent to which the current Administration will continue to support PEPFAR’s ongoing efforts, particularly in light of its budget proposal to significantly reduce bilateral HIV funding and U.S. contributions to the Global Fund. Other issues and challenges include:
  • maintaining a focus on sustainable country-led efforts that emphasizes greater country financing of HIV responses over time;
  • continuing to expand access to HIV services;
  • meeting the needs of key populations;
  • targeting PEPFAR funding based on data-driven analyses of how the epidemic is unfolding, in order to inform the right balance among HIV prevention, treatment, and care;
  • supporting research and development efforts to advance new drugs and interventions;
  • ensuring synergies with other U.S. global health and development programs; and
  • closely coordinating efforts with other donors, including the Global Fund, which will have its next replenishment in 2019.


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