Ensuring PEPFAR's success beyond 2030

Since its launch more than two decades ago, the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved an estimated 26 million lives and prevented 7.8 million babies from contracting HIV. Generous investments by the American people through PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria have moved countries closer to ending AIDS as a public health threat by 2030, a sustainable development goal.

But PEPFAR’s work is not complete. Gaps persist in access to HIV prevention, treatment, and care. Challenges such as conflict, emerging pandemics, and noncommunicable diseases threaten progress against HIV and require tailored solutions. The incoming administration and Congress can pursue policy solutions that ensure PEPFAR’s future and foster continued, sustainable progress at the country level over the long term.

As one of the most successful U.S.-led foreign aid programs since the Marshall Plan, PEPFAR has prevented HIV/AIDS from hollowing out whole societies, trained and supported thousands of health workers, strengthened democratic values abroad, and helped build public health infrastructure and community networks that address challenges beyond HIV.

By working alongside communities and governments to increase access to screening and treatment informed by granular, disaggregated data, PEPFAR has dramatically decreased AIDS-related deaths and the number of people newly diagnosed with the disease. According to UNAIDS, fewer people were newly diagnosed with HIV in 2023 than in any year since before 1990, and AIDS-related deaths were at their lowest level since their peak in 2004. As the number of new infections declines, so do out-year programmatic costs. This makes HIV programming more affordable for more national governments.

The United States – through PEPFAR and the Global Fund – must maintain its status as a leader in the global effort to end AIDS as a public health threat. Over the years, more clinics, laboratories, and human resources funded by PEPFAR have begun to serve broader health needs – a welcome advancement in health integration and the dual use of resources. But to create sustainable programs, national governments must fund much more of the cost of this infrastructure. In parallel, PEPFAR and country partners must focus on effective health programming with clear metrics and measurable, verified results.

Continued U.S. investment in global health not only protects our national security, but also acts in direct opposition to authoritarian regimes like Russia and China. Chinese lending structures and health programming lack accountability, transparency, and long-term sustainability. Russian mercenaries such as the Wagner Group (now known as the Africa Corps) have bred instability and violence across the African continent for years increasing the spread of infectious diseases and destroying health infrastructure in the process.

In contrast, over half of PEPFAR’s country-level funding goes to local organizations – building local implementation and governance capacity. Rather than taking lives, the program has ensured that babies born HIV free over 20 years ago not only survived, but now thrive. Because of programs like PEPFAR, an estimated one-third of the world’s working- age population will be African by the 2030s.

Despite PEPFAR’s tremendous success, several challenges need attention: a stagnation of HIV treatment, a drift from data-driven programming, and possible mission creep. Even some of the most successful PEPFAR-supported countries are seeing widening gaps along the continuum of care, especially among young adults.

The George W. Bush Institute’s new series – PEPFAR Beyond 2030 – examines critical lessons learned from PEPFAR and recommendations for future HIV programming by PEPFAR, host-country governments, implementers, and the private sector. These recommendations summarize those offered in the series and should guide the Trump Administration, PEPFAR, and Congress as they work alongside other stakeholders to create a sustainable transition for PEPFAR in the coming years.

Congress should support a five-year reauthorization of PEPFAR that requires transparent reporting and a clear, data-driven pathway to sustainability by 2030

Over two decades of dedication from PEPFAR has led the international community closer to controlling HIV without a cure. But PEPFAR’s work is not done. Abruptly scaling back or losing focus would risk U.S. taxpayers’ investment and the people served by PEPFAR.

Given the internationally agreed-upon goal to end HIV/AIDS as a public health threat by 2030, Congress should pass a five-year PEPFAR reauthorization in 2025. Reauthorization would incentivize active oversight of the program by the legislative branch and transparent reporting to ensure PEPFAR and its partners get the job done. It would do this by requiring PEPFAR to advance and sustain its results, address gaps, improve efficiency across all programmatic areas through real-time data, and increase the accountability and financial responsibility of host-country governments.

Reauthorization would also ensure the United States maintains its results-oriented leadership in the global HIV response. It would demonstrate continued bipartisan support for PEPFAR – a necessary message to combat the rising influence of authoritarian adversaries across the globe.

PEPFAR and its partners must continue to collect and validate data in a timely fashion from all sites, broken down by gender, age, and geographic location, to improve programs and increase their impact

To address gaps, create innovative solutions, and track progress, PEPFAR and its partners must continue to implement data-driven programming with strong monitoring frameworks.

Each community, age group, vulnerable population, and gender has unique needs and faces specific barriers to access HIV services. Granular data can continue to inform PEPFAR and its partners of the communities most affected by the HIV pandemic as countries approach self-sustainability. PEPFAR has collaborated with partner countries’ governments and implementers to use granular data in real time to evaluate progress; determine if programs are working; and make quick decisions, based on evidence, on whether to scale them up or discard them.

Over the past three years, the absolute number of people on PEPFAR-supported HIV treatment has stagnated. PEPFAR must follow the data to determine who is being left behind, push partners to find them and put them in care, and shift funding accordingly. This will not only ensure people living with HIV continue to access treatment, but that U.S. taxpayer dollars achieve results.

PEPFAR’s funding and investment should align with disease burden and need – not simply the size of a population or geography. These decisions are only possible with robust data systems, continuous analysis, and interpretation of the data to improve programmatic impact. PEPFAR’s leadership in Washington and at the country level must use data in real time to ensure that those urgently in need receive care and that limited resources have the greatest impact. Only through this model can national governments and PEPFAR continue to develop innovative, cost-effective solutions that meet the needs of all people living with HIV.

PEPFAR should finish the job it started by remaining laser-focused on HIV/AIDS and helping partner countries reach international goals by the end of this decade

Diluting or shifting PEPFAR’s mission would put decades of progress at risk. To ensure U.S. investments have the right impact in a sustainable way, PEPFAR – now housed within the new Bureau for Global Health Security and Diplomacy in the U.S. Department of State – must remain focused on HIV/AIDS. The incoming administration needs to ensure that PEPFAR’s resources and funding are protected and not diverted for other purposes within the new bureau. This should begin with the quick nomination of a new U.S. Global AIDS Coordinator who can lead transition planning immediately.

To ensure countries successfully reach international goals, the incoming administration must determine if the current process for assembling and reviewing Country Operational Plans (COPs) and Regional Operational Plans (ROPs) needs changes to increase efficiencies and design sustainable transition programming. PEPFAR teams will begin assembling COPs and ROPs in early 2025. In these structured sessions, policymakers, civil society, implementers, bilateral partners, and the private sector come together to review the data, allocate resources, and adjust programming. These meetings create a forum for all levels of society – including everyday citizens – to express their perspectives, share their needs, and advocate for policy changes that will increase their access to care.

PEPFAR should prioritize increasing national financing and community ownership in partner countries

PEPFAR must envision and establish country-level, geographic and population-specific programming and funding targets by which it can begin to increase national financial ownership and transition the program to a needs-based approach. Because of decades of PEPFAR’s partnership, political will, and community dedication, several countries have reached, or are close to reaching, the international targets. Although progress significantly varies across countries, these results give PEPFAR a historic opportunity to transition responsibility to national partners over the next few years.

The governments of upper-middle-income countries must increase their investments in health care significantly to sustain gains already made and move quickly toward transition. Alternatively, the governments of low- and lower-middle-income countries must address the specific gaps along the HIV continuum of care that are preventing them from achieving the internationally agreed-upon goals for prevention, care, and treatment. Local communities and civil society across all countries must have an active role in strategic planning, programmatic implementation, and monitoring and oversight of HIV programs to ensure their needs are met and to hold their governments and other partners accountable.

PEPFAR, the Global Fund, and other donors should increase engagement with finance ministries, health ministries, and the private sector to ensure they are collecting and spending public resources efficiently and improving the oversight and effectiveness of national health and development programs. Several upper- and middle-income countries have already demonstrated that these methods can lead to sustainable results that reduce the burden on the American taxpayer.

Once countries are in a position for epidemic control, PEPFAR should adjust its programming and investments regularly based on a country’s progress. This progress should be independently verified through survey data. PEPFAR should then create binding compacts with national governments, modeled after those negotiated by the Millennium Challenge Corporation (MCC), to link funding to specific results on a defined timeline for transition.

The world is just five years away from 2030 and the goal to end HIV/AIDS as a public health threat. Thankfully, over 20 years of U.S. global health engagement through PEPFAR have given national governments, communities, and implementers the tools they need.

PEPFAR and its partners must finish the job at hand by staying focused on HIV/AIDS through a successful, multiyear transition. To sustain efforts for years to come, PEPFAR must support and empower people in low- and middle-income countries to address HIV with a growing share of their own national resources, maintain data-driven programming, and advocate for investments geared toward other chronic diseases and future pandemics.