It’s Time for PEPFAR to Embrace Reform

In the weeks since the U.S. State Department’s Jan. 24 order to freeze nearly all foreign aid—an action a federal court has this week ruled unlawful—global HIV programs have been thrown into turmoil. Despite the court’s decision, clinics that provide life-saving HIV medications to more than 20 million people remain in crisis, struggling to reopen amid bureaucratic delays, funding uncertainty, and contradictory guidance from the administration.

The impacts of such a sudden disruption in HIV care are staggering. The administration’s 90-day pause on foreign aid programs may lead to 100,000 additional HIV-related deaths this year and cause more than 135,000 babies to be born with HIV infections that could have been prevented with medications that block mother-to-child transmission, according to an estimate by colleagues Khai Hoan Tram and Chris Beyrer and myself.

Yet as devastating and chaotic as the current situation is, it may be just a preview of a deeper, longer-lasting global health crisis to come, one that could set the global fight against AIDS and HIV back a decade or more. This crisis could begin within weeks, if Congress fails to reauthorize the President’s Emergency Plan for AIDS Relief (PEPFAR).

Since its inception in 2003, PEPFAR has been a cornerstone of U.S. global health policy, the most significant and influential action in curbing the global AIDS epidemic. It has saved an estimated 26 million lives, while also strengthening health systems in more than 50 countries, supporting more than 6.6 million orphaned and vulnerable children, and employing more than 342,000 health workers globally.

But PEPFAR’s future is in serious doubt. Last year, the U.S. Congress gave the program only a one-year reauthorization, which expires on March 25. Amid deepening political divisions and growing skepticism about foreign aid, it is unclear whether there is political support to sustain the program in its current form. 

To those of us who have seen the lifesaving impact of PEPFAR programs in countries around the world, it’s unconscionable to simply pull the plug on a program that has become so indispensable in the lives of millions of people. But this is not to say that PEPFAR is beyond critique. In fact, there are legitimate reasons to ask whether the program is ideally positioned to continue its remarkable legacy of success. With HIV infection rates still alarmingly high among vulnerable groups and rising in many regions of the world, it is becoming clear we need to rethink and refresh global HIV strategy, and PEPFAR needs to be part of that conversation.

My colleagues and I at Duke University have proposed strategic reforms that offer a reasonable path to preserving PEPFAR, while also modernizing its strategy and operations for a new era of HIV treatment and prevention. We outline recommendations for optimizing PEPFAR’s operations that we estimate can reduce program costs by 20% in five years. We also introduce new frameworks for countries to gradually assume financial responsibility for HIV prevention and treatment programs, allowing PEPFAR to strategically bridge resources to regions where HIV rates continue to rise.

Our recommendations call for increased investment in prevention, particularly through long-acting pre-exposure prophylaxis (PrEP), and leveraging digital technologies like AI to optimize resources and predict disease trends. Taken together, these reforms would reshape PEPFAR into the leaner, more sustainable operation we all need it to be to jumpstart progress in eradicating HIV. 

It's important to recall that PEPFAR was conceived as an emergency plan—a stop-gap measure to slow the deadly march of the AIDS epidemic across sub-Saharan Africa during the late 1990s and early 2000s. This is one reason critics say it’s time for the program to end and for others to assume more responsibility for the HIV efforts. But PEPFAR has evolved to be so much more than that. It is no exaggeration to say that PEPFAR has transformed the global landscape of HIV prevention and treatment, and the world now depends on its leadership. 

With rising HIV infections, geopolitical challenges, and political uncertainties in the U.S., the need for such leadership is more urgent than ever. By embracing the opportunity to reform PEPFAR, Congress can ensure this historic government program emerges stronger, more effective and more impactful than ever. 

Jirair Ratevosian, DrPH, is the Hock Research Fellow at the Duke Global Health Institute, where he focuses on policy reforms to prevent infectious diseases such as HIV/AIDS. He is a former interim chief of staff at PEPFAR. 

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