What Has PEPFAR Actually Accomplished in the Fight Against HIV/AIDS?
Since its launch in 2003, the U.S. President’s Emergency Plan for AIDS Relief has saved an estimated 26 million lives, put 20.6 million people on antiretroviral therapy, and enabled 7.8 million babies to be born HIV-free. These are not aspirational targets. They are documented outcomes from what many researchers consider the single most successful public health initiative in history.
In the early 2000s, the AIDS crisis was devastating sub-Saharan Africa. Antiretroviral therapy existed, but it was out of reach for the vast majority of people living with HIV in low-income countries. Treatment cost over $10,000 per patient per year in high-income nations, and fewer than 50,000 people in all of Africa were receiving it. PEPFAR changed that equation almost overnight. This article examines what the peer-reviewed evidence shows about the program’s impact, how it worked, and what recent research reveals about the consequences of disrupting it.
This article accompanies Episode 40 of The Dr Kumar Discovery, in which Dr. Kumar interviews Keith Hourihan, an international audit and fraud investigation expert who spent nearly 20 years working inside USAID-funded programs across 45 to 50 countries.
Dr. Kumar’s Take
PEPFAR is, in my view, one of the most impressive things the United States has ever done. It took a death sentence and turned it into a manageable chronic condition for millions of people. The numbers are staggering, but what strikes me most is the ripple effect. When you put a mother on antiretroviral therapy, you keep her alive to raise her children. When you prevent an infant from contracting HIV at birth, you give that child a full life. PEPFAR did not just treat a disease. It stabilized families, communities, and economies across an entire continent. The fact that this program had bipartisan support for over two decades speaks to how clearly effective it was. The evidence is overwhelming.
The Scale of PEPFAR’s Treatment Expansion
When PEPFAR was authorized in 2003, the idea of providing antiretroviral therapy across sub-Saharan Africa was considered logistically impossible by many experts. Infrastructure was limited, supply chains were unreliable, and the number of trained healthcare workers was far below what was needed.
A landmark peer-reviewed study published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS) in 2012 by El-Sadr and colleagues documented how PEPFAR achieved what many considered impossible. Between 2004 and 2011, the number of individuals initiating antiretroviral therapy through PEPFAR-supported programs grew from 66,700 to 3.9 million, with 63% being women and girls. The researchers found that this scale-up produced benefits extending well beyond the clinical, including societal improvements in economic productivity, household stability, and childhood welfare.
By September 2024, PEPFAR was supporting antiretroviral therapy for 20.6 million people across 55 countries, including 566,000 children living with HIV. In that same fiscal year, PEPFAR provided HIV testing services to 83.8 million people, 12 million more than the previous year. New annual initiations of pre-exposure prophylaxis (PrEP) increased by more than 500% between 2020 and 2024, reaching 2.5 million people.
Mortality Reductions Documented in Peer-Reviewed Research
The Lancet published a comprehensive retrospective analysis in 2025 by Cavalcanti, Rasella, and colleagues titled “Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030.” This study analyzed data from 133 low- and middle-income countries across two decades and found that programs supported by USAID, of which PEPFAR was the flagship, prevented an estimated 91 million deaths overall.
In countries that received the highest levels of USAID funding, the study documented a 65% reduction in HIV/AIDS mortality compared to countries with low or no funding. The reductions extended beyond HIV: malaria mortality fell by 53%, neglected tropical diseases by 51%, and tuberculosis, nutritional deficiencies, diarrheal diseases, and lower respiratory infections all showed substantial declines.
AIDS-related deaths specifically decreased by 59% in PEPFAR-supported countries between 2010 and 2023, compared with 51% globally. New HIV infections fell by 52% in those same countries during the same period, compared with a 39% reduction worldwide.
What Happens When PEPFAR Funding Is Disrupted
In January 2025, an executive order froze all U.S. foreign assistance, including PEPFAR. A mathematical modeling study published in eClinicalMedicine in April 2025 by Hontelez and colleagues at Erasmus MC examined the consequences across seven sub-Saharan African countries that represent approximately half of Africa’s HIV-positive population: Ethiopia, Kenya, Malawi, South Africa, Tanzania, Zambia, and Zimbabwe.
The researchers modeled several scenarios. Under the most realistic scenario reflecting the actual freeze conditions, the model projected 74,000 excess HIV deaths and up to 103,000 additional new HIV infections between 2025 and 2030. Even under the most optimistic scenario, where programs resumed quickly after a four-week interruption, the model still projected 21,000 excess deaths and 35,000 new infections.
A separate study published in The Lancet HIV found that removing PEPFAR-funded PrEP programs in 2025 would result in 9,407 additional primary HIV infections in sub-Saharan Africa, with the total rising to 14,543 when secondary infections were included.
These projections are not hypothetical. As Keith Hourihan described in his interview on The Dr Kumar Discovery, he personally witnessed clinics shutting down and supply chains collapsing in countries that depended on PEPFAR-funded programs for their antiretroviral supplies.
The Bipartisan Legacy
PEPFAR was created under President George W. Bush and reauthorized under every subsequent administration, Republican and Democratic alike. It is worth pausing on what that means. In a political environment where almost nothing enjoys bipartisan consensus, PEPFAR was supported across the aisle for over 20 years because the evidence of its effectiveness was so clear that disagreement was difficult to sustain.
The program operated in over 55 countries and became the largest commitment by any nation to address a single disease in history. It built laboratory networks, trained healthcare workers, strengthened supply chains, and created monitoring systems that many countries continue to rely on for broader public health functions.
Practical Takeaways
- PEPFAR has saved an estimated 26 million lives and enabled 7.8 million HIV-free births since 2003, making it one of the most effective public health investments in modern history.
- Disruptions to PEPFAR funding, even brief ones, are projected to cause tens of thousands of additional HIV deaths and new infections across sub-Saharan Africa, according to peer-reviewed modeling studies.
- The program’s benefits extend beyond HIV treatment to include broader health system strengthening, economic stabilization, and improved childhood outcomes in recipient countries.
Related Studies and Research
- The projected death toll from cutting U.S. foreign aid examines the broader Lancet study projecting 14 million additional deaths by 2030.
- How foreign aid builds soft power: the evidence for health diplomacy explores the peer-reviewed research showing that health aid uniquely improves international perceptions of the United States.
- USAID and the reduction of maternal and child mortality worldwide examines how U.S.-funded programs contributed to saving 30 million children and 200,000 mothers.
FAQs
How many people are currently on PEPFAR-supported HIV treatment?
As of September 2024, PEPFAR was supporting antiretroviral therapy for 20.6 million people across 55 countries. This includes 566,000 children living with HIV. The program also provided HIV testing services to 83.8 million people in fiscal year 2024 and supported 2.5 million people on pre-exposure prophylaxis to prevent new infections.
What happens to people on HIV treatment if PEPFAR funding stops?
Antiretroviral therapy must be taken consistently and indefinitely to suppress the virus. When treatment is interrupted, viral loads rebound, the disease progresses, drug resistance can develop, and transmission rates increase. Modeling studies published in eClinicalMedicine project that even temporary disruptions could cause tens of thousands of excess deaths and new infections. In many of the 55 countries where PEPFAR operates, there is no alternative source of funding to maintain treatment programs at scale.
Was PEPFAR a Democratic or Republican program?
PEPFAR was created by Republican President George W. Bush in 2003 and reauthorized under every subsequent administration through 2024, with strong bipartisan support. It is one of the few major government programs in recent history that enjoyed consistent backing from both parties for over two decades.
Bottom Line
PEPFAR is one of the most well-documented public health successes in history. Peer-reviewed research published in The Lancet, JAIDS, eClinicalMedicine, and The Lancet HIV consistently shows that the program saved millions of lives, dramatically reduced HIV transmission, and produced benefits that extended far beyond disease treatment. The evidence also shows that disrupting this program, even temporarily, carries measurable costs in human lives.
Listen to the full conversation with Keith Hourihan on Episode 40 of The Dr Kumar Discovery.
Sources:
- El-Sadr WM, et al. “Scale-up of HIV treatment through PEPFAR: A historic public health achievement." Journal of Acquired Immune Deficiency Syndromes. 2012;60(Suppl 3):S89-S96.
- Cavalcanti DM, Rasella D, et al. “Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030." The Lancet. 2025.
- Hontelez JAC, et al. “The impact of the PEPFAR funding freeze on HIV deaths and infections: a mathematical modelling study of seven countries in sub-Saharan Africa." eClinicalMedicine. April 2025.
- PEPFAR Latest Global Results and Projections Factsheet, U.S. Department of State, December 2024.
