The year was 2002 and Dr Catherine Orrell, a physician working at the Desmond Tutu HIV Foundation in Cape Town, South Africa, was loading antiretroviral therapy (ART) into the back of her car. She had procured funding for the supplies through a nongovernmental organization in the United Kingdom and was going to deliver them to the sickest patients in her care while simultaneously going to pick up pills from the families of patients who had died of AIDS. ART was too valuable to waste.
She had few success stories—like the patient she saw at the Red Cross in Cape Town who had made the thousand-mile journey from her home in rural KwaZulu Natal, to get her son treatment for tuberculosis. She was so ill when she arrived that she was tested for HIV and learned it was advanced. She was one of the first patients to start ART, and not only survived, but became an adherence counselor, going on to support hundreds of other patients on their journey with long-term therapy.
But most of Dr Orrell’s patients were not so fortunate. Funerals were a regular weekend activity for South Africans; an estimated 2.4 million Africans died from AIDS that year and the Joint United Nations Programme on AIDS (UNAIDS) reported that AIDS was the leading cause of death on the African continent.1 By 2003, the average life expectancy in southern Africa fell from 62 to 47 years due to AIDS. It was a story of 2 pandemics—one in which life and death hung in the balance. Individuals living in high-resource settings were able to access lifesaving treatment that had been available since 1996, while those who lived in low-resource settings were destined to become “the lost generation” without access to lifesaving therapy.
It was during this time that a small group of individuals, led by Dr Anthony Fauci, were meeting behind closed doors to draft a blueprint commissioned by then-President George W. Bush, that would change the course of history. In his State of the Union Address on January 28, 2003, President Bush announced the creation of the United States President’s Emergency Plan for AIDS Relief (PEPFAR)2—with $15 billion provided over a 5-year plan to combat AIDS in the countries with the greatest disease burden. President Bush set bold program targets for getting people access to HIV treatment and preventing new infections. Two decades later, PEPFAR remains the largest investment by the US government to fight a single disease. It has fundamentally shifted the paradigm of how global public health investments are made with goals and impact monitoring, and for many, it has provided a roadmap of how to build capacity in global health.
By any global health metric, PEPFAR has surpassed every milestone imagined. More than 25 million lives have been saved, 5.5 million infants have been born HIV-free, and today more than 75% of the 38.4 million people living with HIV/AIDS globally are taking ART.3 Wide-scale treatment has also meant that annual transmission rates have dropped by 52% since 2010, largely attributable to durable viral suppression preventing onward transmission, demonstrating the impact of treatment as prevention.4 PEPFAR’s investment has not only saved millions of lives, but it has also created health infrastructure, established more than 3000 laboratories, trained 340 000 health care workers, and developed a data-driven system for monitoring the HIV/AIDS pandemic. This paid off in dividends during the COVID-19 pandemic when the HIV laboratory and surveillance systems in Africa were easily extended to COVID-19 and service delivery platforms were able to offer COVID-19 vaccinations.
While there is much to celebrate, the work of PEPFAR is not yet done. A UNAIDS report released in 2023 titled In Danger revealed that the gains made in the fight against HIV/AIDS faltered during the COVID-19 pandemic, with 650 000 people dying from AIDS-related illnesses in 2021.5 Far too many people living with or at risk for acquiring HIV still do not have access to effective prevention or therapy due to structural and social barriers to care. A disproportionate number of infections continue to occur in adolescent girls and young women and key populations (including men who have sex with men, sex workers, transgender people, people who inject drugs, and incarcerated people).
Beyond the health effects of the virus, the HIV/AIDS pandemic continues to take its toll on the economies of countries that are often at the front lines of public health threats and exacerbates the impact of other infectious diseases on health systems. As of April 2023, Africa had already experienced 44 outbreaks and is currently facing an explosion of noncommunicable diseases and an ongoing mental health crisis. With more than 1.5 million new HIV infections occurring in 2021, the goal of ending the HIV/AIDS pandemic by 2030 remains precariously in the balance.
To make this vision a reality, we must continue a data-driven approach and tackle health inequities. This involves listening to the needs of communities affected by HIV/AIDS and integrating them into the response by providing them with equitable access to HIV prevention, care, and treatment services in safe and supportive spaces, free from stigma and discrimination with continuous feedback through community-led monitoring. We must also join with national and global partners to address the multiple nonmedical factors that influence health outcomes such as regressive policies, structural issues, and societal norms to reach the UNAIDS treatment target of 95-95-95 (95% of people living with HIV know their status, 95% are taking ART, and 95% of them are virally suppressed).6
This moment calls for community-led responses that incorporate locally driven solutions. Behavioral science provides a unique opportunity to engage underserved populations that benefit from an enabling environment to support HIV prevention and treatment. Programs such as Somos Iguais and DREAMS are examples that have successfully utilized a client-centered approach to care. There are also novel strategies to engage communities in tailored treatment and prevention programs through behavioral nudges, human-centered design, status-neutral testing, and streamlined approaches to dispensing medications (including multimonth pickups or home delivery). Using the tools of implementation science, PEPFAR has an opportunity to close the gaps in care by adapting to the needs of individuals and communities.
PEPFAR is committed to effective partnerships, recognizing country leadership is the key to long-term sustainability. This is operationalized in the PEPFAR Country and Regional Operational Planning meetings that occur throughout the globe, bringing key stakeholders to the table to discuss the direction and impact of each country’s response. Country leadership was recognized in the recent special convening of the African Union with African heads of state, who adopted a declaration to promote health financing in support of a sustained HIV/AIDS response, and a plan to host a dedicated summit later this year to develop a road map of action and investment to reach the goals of ending HIV/AIDS as a public health threat by 2030.
Ultimately, HIV prevention and treatment must be fully integrated into a larger health system response that ensures equitable services for all. These programs must be adaptive to external threats, including natural or synthetic disasters, that have the capacity to respond quickly and effectively to any disease outbreak to ensure global safety and security.
PEPFAR remains the optimal vehicle for strengthening global health resilience, using its new “five by three” strategy,7 with 5 strategic pillars anchored in (1) health equity for priority populations; (2) sustaining the response; (3) public health systems and security; (4) transformative partnerships; and (5) following the science. These pillars are supported by 3 enablers: (1) community leadership; (2) innovation; and (3) leading with data. Threaded through the “five by three” strategy is the recognition that the HIV/AIDS response will ultimately be most successful when the core principles of respect and humility, equity, accountability and transparency, impact, and sustained engagement are met.
We are at an inflection point in the HIV/AIDS pandemic where the pandemic can end as a public health threat, or we risk losing the gains achieved and returning to a time when funerals were far too common. PEPFAR remains committed to working with its partners to complete its mission and ensuring we achieve the goal of ending the AIDS pandemic by contributing to equitable, universal care for people living with HIV.
Corresponding Author: Ingrid T. Katz, MD, MHS, Brigham and Women’s Hospital, 1620 Tremont St, Boston, MA 02120 ([email protected]).
- A timeline of HIV and AIDS. HIV.gov, US Dept of Health & Human Services. Accessed June 5, 2023. https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/
- Bush GW. Address Before a Joint Session of the Congress on the State of the Union. Office of the Federal Register, National Archives and Records Administration. Updated February 2, 2003. Accessed June 5, 2023. https://www.govinfo.gov/content/pkg/WCPD-2003-02-03/pdf/WCPD-2003-02-03-Pg109.pdf
- Statement From Ambassador Dr. John Nkengasong on the 20th Anniversary of PEPFAR: 20 Years of Impact. US President’s Emergency Plan for AIDS Relief, US Department of State; 2023. https://www.state.gov/pepfar-20-years-of-impact/
- Cohen MS, Chen YQ, McCauley M, et al; HPTN 052 Study Team. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830-839. doi:10.1056/NEJMoa1600693PubMedGoogle ScholarCrossref
- UNAIDS. In Danger: UNAIDS Global AIDS Update 2022. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2022. https://www.unaids.org/en/resources/documents/2022/in-danger-global-aids-update
- National Institute of Allergy and Infectious Diseases, National Institutes of Health. HIV Undetectable=Untransmittable (U=U), or Treatment as Prevention. Updated May 21, 2019. Accessed June 5, 2023. https://www.niaid.nih.gov/diseases-conditions/treatment-prevention
- PEPFAR Five-year Strategy: Fulfilling America’s Promise to End the HIV/AIDS Pandemic by 2030. December 1, 2022. https://www.state.gov/pepfar-five-year-strategy-2022/