PEPFAR — 26 million lives, one bipartisan program.

There is a short list of things the United States government has done that almost nobody, across almost the whole political spectrum, argues about. For more than twenty years, the President's Emergency Plan for AIDS Relief — PEPFAR — was on that list. A Republican president proposed it. A Democratic Congress expanded it. Four reauthorizations passed under three presidents of both parties. Faith-based groups and sex-positive harm-reduction outfits both took its money. And the result, by the U.S. government's own accounting, is more than 26 million lives saved.1

These estimates describe a large human impact. The 7.8 million figure refers to babies born HIV-free to mothers living with HIV; it does not mean that every one of those babies would otherwise have acquired HIV. For people living with HIV in the United States, PEPFAR also connects domestic advocacy with the global work of expanding treatment access.231

And PEPFAR is now living through the hardest stretch of its existence. Eight time-bound provisions expired in March 2025.3 A foreign-aid freeze, the transfer of USAID programs to the State Department, and a new strategy document reshaped how the program operates.5 This page tells the whole story — the launch, the math, the countries, the honest critiques, and where things actually stand.

What PEPFAR actually is

Start with the plainest description, which is also the one the U.S. State Department and KFF both use: PEPFAR is the largest commitment by any nation to address a single disease in the world.17 This is the program’s own description of the scale of the U.S. commitment.

Mechanically, it is three things bolted together. First, a bilateral program: U.S. money, staff, and technical assistance flowing directly into HIV prevention, testing, treatment, and care in partner countries — historically more than 50 of them.7 Second, a multilateral contribution: the U.S. share of the Global Fund to Fight AIDS, Tuberculosis and Malaria, plus support to UNAIDS. Third, a coordination office inside the State Department that is supposed to make U.S. agencies — USAID, CDC, Defense, Peace Corps, HRSA — stop tripping over each other.

The money is genuinely large. Congress has appropriated more than $130 billion for PEPFAR since it began, growing from $1.9 billion in FY 2004 to roughly $6.0 billion in FY 2026 — of which about $4.7 billion is bilateral HIV work and $1.3 billion is multilateral, including $1.25 billion for the Global Fund and $45 million for UNAIDS.1 In recent years PEPFAR has accounted for 53% to 55% of all U.S. global health funding, and bilateral work has been 70% to 79% of the PEPFAR total.1

Why "emergency plan" was the right words

The name matters. In 2003, sub-Saharan Africa was in the middle of a mass-casualty event with a treatment that already existed. Antiretroviral therapy had been transforming survival in wealthy countries since 1996. It simply had not arrived where most people living with HIV actually lived. PEPFAR was designed as a war-footing response to that specific gap: buy the drugs, build the clinics, train the workers, and do it fast.

That framing produced PEPFAR's greatest strength — rapid expansion of HIV services — and its most persistent weakness, which we cover honestly further down: a program built as an emergency response tends to build vertical, disease-specific structures rather than whole health systems.17

January 2003 — the State of the Union that started it

On January 28, 2003, President George W. Bush devoted a section of the State of the Union address to HIV in Africa. He described a continent where, at the time, nearly 30 million people were living with the virus, where whole countries had more than a third of the adult population carrying the infection, and where more than 4 million people needed treatment immediately — while roughly 50,000 people across the continent were actually receiving it.2

He then made the argument that turned the moral case into a fiscal one. The cost of antiretroviral drugs had dropped from $12,000 a year to under $300 a year. "Ladies and gentlemen," he said, "seldom has history offered a greater opportunity to do so much for so many."2

The specific promises

The 2003 speech was unusually concrete for a State of the Union. Bush committed to three measurable targets: prevent 7 million new HIV infections, treat at least 2 million people with life-extending drugs, and provide care for millions of people living with AIDS and for children orphaned by AIDS.2 Twenty-three years later, PEPFAR has reported supporting antiretroviral treatment for 20.6 million people in a single fiscal year — an order of magnitude beyond the original treatment target.1

Who built it before the speech

Nothing that big appears in a speechwriter's draft from nowhere. Ambassador John Nkengasong, who later ran PEPFAR himself, described the ground the program grew from: "Years of HIV/AIDS research, coordinated humanitarian efforts, bipartisan support from Congress and engagement from community and faith-based organizations, and the private sector, created a fertile ground for PEPFAR." He added the part that policy histories sometimes skip: "And it was the bold action and compassion of President Bush that established a program that has changed the world."13

Three streams converged, by the account of the people who were there. A small group inside the White House pushed the moral framing in an administration otherwise preoccupied with Iraq. Federal HIV/AIDS researchers and public-health officials — several of whom would later help run the program — supplied the technical answer to the objection that delivering HIV treatment in low-income settings was logistically impossible.13 And a genuinely unusual coalition of evangelical Christian groups, Black churches, HIV activists, and global-health advocates made the politics survivable on both sides of the aisle.

Congress then acted fast by Washington standards. The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act — the Leadership Act — was signed on May 27, 2003 as Public Law 108-25, authorizing $15 billion over FY 2004–FY 2008.13

The architecture — how PEPFAR is actually built

PEPFAR is not an agency. That confuses people, and it matters enormously for understanding the 2025 lapse. PEPFAR is a program created by statute, funded by annual appropriations, coordinated from the State Department, and implemented by several different U.S. agencies plus thousands of local partners.

There is one more design feature worth naming, because it is the reason PEPFAR data is unusually checkable: the program reports granular, site-level program results publicly, which is why independent groups can audit its own numbers against its own claims — and have.12

Reported results — and what “lives saved” means

The December 2024 State Department fact sheet reports the following cumulative and FY 2024 results. HIV.gov continues to cite these dated figures; they are not all measurements made in 2026.23

• More than 26 million lives saved since 2003.18
• 7.8 million babies born HIV-free to mothers living with HIV (cumulative estimate reported in December 2024).1
• 20.6 million people supported with antiretroviral treatment as of September 30, 2024, in more than 50 countries.17
• 83.8 million people supported with HIV testing services in FY 2024.1
• More than 6.6 million orphans, vulnerable children, and their caregivers provided care in FY 2024.1
• About 342,000 health workers directly supported in FY 2024.1
• Almost 5 million new HIV infections averted through 2024, across 55 countries of investment.8

You will see "25 million lives saved" in a great deal of writing about PEPFAR, including in the program's own twentieth-anniversary materials, alongside "5.5 million babies born HIV-free."13 Those were the 2023 figures. The current figures are higher. These are dated program estimates; use the figure and reporting year together.

The trajectory PEPFAR helped bend

The global numbers give the shape of it. At the end of 2025, 32.1 million people were accessing antiretroviral therapy worldwide, up from 7.6 million in 2010. New HIV infections have fallen 65% from the 1994 peak — from 3.5 million a year to 1.2 million. AIDS-related deaths reached 570,000 in 2025, down 57% from 2010.109

PEPFAR did not do that alone: national governments, the Global Fund, communities and other partners contributed. The Institute of Medicine found that PEPFAR provided almost two-thirds of external HIV funding in the 31 countries examined in 2010. That is a dated finding about those countries, not a measure of every country or every subsequent year.17

Country by country — where the work happens

PEPFAR has operated bilateral programs in more than 50 countries, reaching additional countries through the Global Fund.1 Before the 2025 reorganization, 25 countries were required to submit annual Country Operational Plans: Angola, Botswana, Burundi, Cameroon, Côte d'Ivoire, the Democratic Republic of the Congo, the Dominican Republic, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.1

South Africa — the largest treatment program on Earth

South Africa’s response is a national program supported in part by PEPFAR. The May 2026 Thembisa 5.0 national model estimates HIV prevalence at 12.3% of the total population in 2025 (95% interval 11.8–12.8%). These are modeled estimates, revised when inputs and assumptions change.20

The same model estimates that in 2025, 95.9% of people living with HIV were diagnosed, 82.0% of those diagnosed were on ART, and 95.0% of people on ART were virally suppressed. Its authors describe a leveling-off of reported treatment numbers during 2025, but say it is too early to determine the medium-term effects of U.S. funding disruptions. These findings should not be presented as proof that the funding changes alone caused a national treatment decline.20

Eastern and southern Africa — where the epidemic and the response are largest

Eastern and southern Africa remain central to the global response. UNAIDS’s July 2026 report identifies seven countries with almost 80% reductions in new infections since 2010: Benin, Eswatini, Kenya, Lesotho, Nepal, Rwanda and Zimbabwe. This list spans several regions. UNAIDS also reports that 11 countries reached 95–95–95. Across low- and middle-income countries collectively, around 60% of HIV funding came from domestic sources in 2025; that aggregate does not mean most PEPFAR partner countries individually finance a majority of their response.109

Nigeria and Ethiopia — scale without saturation

West and East Africa's population giants present a different problem: enormous absolute numbers of people living with HIV spread across low-prevalence populations, which makes case-finding expensive and treatment coverage harder to push toward 95%. Both are long-standing PEPFAR partner countries. UNAIDS specifically names Ethiopia and Uganda among countries acting to protect prevention access as external aid contracted; that statement should not be read as a finding about Nigeria.9

Twenty years of bipartisanship — and how it held

PEPFAR's political record is genuinely remarkable, and worth laying out as a timeline because the pattern is the point.

• January 2003 — President George W. Bush announces PEPFAR in the State of the Union.2
• May 27, 2003 — The Leadership Act is enacted, Public Law 108-25, authorizing $15 billion over five years.1
• July 30, 2008 — The Lantos-Hyde Act, Public Law 110-293, reauthorizes PEPFAR under Bush and authorizes $48 billion for FY 2009–FY 2013.13
• December 2, 2013 — The PEPFAR Stewardship Act, Public Law 113-56, reauthorizes under President Obama, with changes focused largely on reporting requirements.13
• December 11, 2018 — The PEPFAR Extension Act, Public Law 115-305, reauthorizes under President Trump's first term.1
• 2023 — The fourth five-year reauthorization stalls in Congress over an abortion dispute; the September 30 deadline passes without a full reauthorization.6
• March 2024 — A one-year short-term reauthorization is enacted inside a spending package, Public Law 118-47, extending time-bound provisions to March 25, 2025.1
• March 25, 2025 — The short-term authorization expires. Eight time-bound provisions lapse. PEPFAR's core authorities remain permanent law.14

What kept it bipartisan for two decades

Four things, roughly. Measurable results — PEPFAR published numbers, and the numbers were good, which starved the "foreign aid is a black hole" argument of oxygen. Faith-based buy-in — evangelical and Catholic networks were implementing partners from the beginning, not adversaries, and PEPFAR leadership said so out loud. National-security framing — a stable Africa was a bipartisan interest, and PEPFAR's public-health infrastructure was later leveraged for the COVID-19 and Ebola responses, which made the argument concrete.13 And continuity of leadership — Nkengasong publicly credited the incremental progress of each of his predecessors, Randall Tobias, Mark Dybul, Eric Goosby, and Deborah Birx, across administrations of both parties.13

That coalition worked because HIV treatment is unusually resistant to ideological capture: an undetectable viral load is an undetectable viral load regardless of who paid for the pills. Where PEPFAR ran into ideological trouble was almost entirely on the prevention side, and on who counts as deserving of it. We come to that below.

2023 to 2025 — the politicization, the short-term fix, and the lapse

2023: the abortion fight that stalled a program that does not fund abortion

In 2023, PEPFAR came up for its fourth five-year reauthorization and did not get one. A coalition of organizations opposed to abortion rights, a conservative think tank report, and members of Congress argued that the Biden administration was using PEPFAR to advance abortion — pointing to the restoration of funding to the UN Population Fund, to language about sexual and reproductive health and rights in PEPFAR's September 2022 strategy document and February 2023 operational guidance, and to grantees that had expressed general support for abortion rights.6

U.S. foreign-assistance law already contained restrictions during the 2023 debate: Helms prohibits funding abortion as a method of family planning, Siljander restricts abortion lobbying, and the Leahy clarification permits information and counseling about pregnancy options where otherwise lawful. KFF’s September 2023 review reported that no evidence had been provided that PEPFAR supported prohibited abortion activities. That is a dated assessment of the claims in that debate, not an assurance about every later grant or event.6

The dispute was followed by a stalled five-year renewal and a shorter extension in March 2024.

March 2024: the one-year patch

Congress eventually attached a short-term PEPFAR reauthorization to a March 2024 spending package, Public Law 118-47, extending certain time-bound provisions for a single year, to March 25, 2025.1 KFF's assessment was blunt: the short-term reauthorization represented a departure from PEPFAR's prior history of strong bipartisan support across multiple Congresses and administrations.1

March 25, 2025: the lapse — what did and did not happen

This is the part most commonly reported wrong, in both directions. Here is the accurate version.

The parallel shock: the 2025 foreign-aid freeze

The authorization lapse did not happen in a quiet room. It happened in the middle of the largest disruption to U.S. foreign assistance in modern memory, and the timeline matters:

• January 20–24, 2025 — An executive order imposes a 90-day pause on U.S. foreign development assistance, including PEPFAR activities. A stop-work order freezes payments and services already under way, halting field work including antiretroviral therapy delivery. Many implementers terminate staff.58
• January 28 – February 6, 2025 — An emergency humanitarian waiver, then a PEPFAR-specific limited waiver, permit "life-saving HIV services": treatment and care, prevention of vertical transmission, PrEP for pregnant and breastfeeding women, and HIV testing. The waiver does not cover PrEP for anyone else — including people already taking it — broader prevention, or non-clinical support for orphans and vulnerable children.58
• February 27, 2025 — UNAIDS receives a letter terminating the U.S. agreement with UNAIDS, effective immediately.8
• March 28 – July 2025 — The administration notifies Congress of its intent to dissolve USAID; global health activities are folded into the State Department's Bureau of Global Health Security and Diplomacy; programs move in July.5
• Early 2025 — KFF reported that 86% of USAID awards were canceled. In its analysis of available award lists, 379 of 770 identified global health awards included HIV activities, and 71% of those HIV-related awards were listed as terminated — including several treatment awards and most prevention awards.5

amfAR’s PEPFAR Pulse Study surveyed 166 prime implementing partners in 46 countries. Respondents reported at least 1,714 site closures; 73% stopped at least one key-population service and 67% stopped outreach. Among responding organizations, prevention spending fell 51% between FY 2024 and FY 2025. Even services covered by the limited waiver were disrupted: 64% reported interruptions to treatment, testing or prevention of vertical transmission, and 22% reported stopping vertical-transmission prevention. The survey was self-reported and not representative of every partner; its findings are not a census of all PEPFAR services.11

A peer-reviewed analysis of 31,628 facilities and community service sites compared 2024–2025 PEPFAR data. It found 14.7 million fewer reported HIV tests, a 33% fall in PrEP initiations, and 62,541 fewer direct service delivery health workers. Treatment totals were more stable: about 1.3% lower overall between the fourth quarters, with a 0.3% increase at continuously reporting facilities. The analysis used unofficial earlier-quarter 2025 data alongside the official fourth-quarter release; missing data and reporting changes limit interpretation, and these are not nationally representative service measures.12

Where PEPFAR stands now — FY 2026 and the road ahead

Congress continued appropriating funds

KFF’s FY 2026 accounting puts enacted PEPFAR appropriations at approximately $6.0 billion: about $4.7 billion for bilateral HIV work, $1.25 billion for the Global Fund and $45 million for UNAIDS. These are appropriations, not evidence that every dollar has reached implementing partners. KFF calculates that the bilateral amount is $316 million below the FY 2010 peak and the Global Fund line is $400 million below FY 2025.15

The America First Global Health Strategy

In September 2025 the administration released the America First Global Health Strategy as its roadmap for future U.S. global health engagement. Under it, the United States is negotiating bilateral, multi-year agreements with recipient countries, with the stated aim of transitioning the majority of countries to full self-reliance by the end of the agreement period. HIV programs are described as an anchor of the strategy and have been included in most agreements signed so far — though, as KFF notes, little information is publicly available about the activities and funding those agreements actually contain.5

Two other policy moves shape the current environment. In January 2025 the expanded Mexico City Policy was reinstated; in January 2026 it was further expanded under the "Promoting Human Flourishing in Foreign Assistance" policy to apply to almost all non-military foreign assistance, many more entities, and additional restrictions involving diversity, equity and inclusion and "gender ideology."5 Whatever your politics, the practical effect on prevention programming for LGBTQ+ people, sex workers, and people who use drugs is what advocates are documenting.

Long-acting PrEP expansion

The September 2025 PEPFAR–Global Fund announcement set a goal of reaching up to 2 million people with long-acting PrEP by 2028. UNAIDS’s July 2026 report describes a broader rollout goal of 3 million by 2028 and only a few thousand people reached at that reporting point. These are different scopes, and an interim count alone does not establish that a 2028 commitment has missed its timetable.59

The UNAIDS read on 2026

UNAIDS's July 2026 special report for the International AIDS Conference in Rio de Janeiro provides a global assessment. Global development assistance fell 23% in 2025 — the sharpest drop on record. International financing for HIV fell from $8.8 billion in 2024 to $7.3 billion in 2025, an 18% reduction and the lowest level in nearly two decades. New HIV infections rose in three regions and 21 countries in 2025. A study across 47 countries cited by UNAIDS reported community-led support falling by half, with services for gay men and other men who have sex with men down 85%, sex-worker services down 82%, and services for survivors of gender-based violence down 72%. These are findings from that study, not a census of all services worldwide or all PEPFAR countries.9

UNAIDS Executive Director Winnie Byanyima framed the moment without softening it: "The era of relying on international aid is over. Countries cannot wait and they cannot go backwards. The world must urgently fix the broken financial system and accelerate debt restructuring so that governments can invest in what matters most — the health, education and futures of their people."9 She also named the choice: "retreat and risk resurgence, or rethink, rebuild and rise to end AIDS as a public health threat by 2030."9

Who runs PEPFAR — and the leadership vacancy

Congress.gov records checked September 21, 2026 show Johnny Figueroa’s nominations for Global Health Security and Diplomacy and Global AIDS Coordinator still pending. The latest listed action for each is referral to the Senate Foreign Relations Committee on June 1, 2026. This date-specific record should be checked again for later confirmation actions.19

The Global AIDS Coordinator role is designed to coordinate U.S. global HIV activities across agencies and represent the United States on the Global Fund Board. Stable leadership and clear responsibility can help partners plan.1

The people who held the job before

PEPFAR has had a short, consequential list of Global AIDS Coordinators: Randall Tobias, Mark Dybul, Eric Goosby, Deborah Birx, and John Nkengasong.13 Nkengasong — a Cameroonian virologist who had run the Africa CDC before taking the post — offered the most useful single sentence anyone in the role has said about what PEPFAR is for. Reflecting on the twentieth anniversary, he recalled that when PEPFAR was announced in 2003 he was working on HIV/AIDS for the U.S. CDC in Côte d'Ivoire as a young public health expert, and concluded simply: "Truly, PEPFAR has changed the world."13

The implementing partners are the actual program

Implementation includes governments, clinics, universities and community organizations. In the subset of financial data available to the 2013 Institute of Medicine evaluation, partner-country-based prime partners’ share rose from 22% in 2004 to 36% in 2010, while U.S.-based prime partners’ share fell from 75% to 61%. The committee could not trace the final distribution to subpartners, so these percentages do not describe where all program spending ultimately occurred.17

The Pulse Study shows why service continuity and partner financing matter. Respondents reported substantial lost funding and site closures, but its sampling limitations prevent a conclusion that the smallest local organizations were universally the hardest hit.11

PEPFAR, the Global Fund, and Gavi — complementary, not duplicative

A recurring critique of global health funding is that it is a crowded room of overlapping acronyms. On HIV specifically, that critique is mostly wrong, and it is worth understanding why.

Gavi, the Vaccine Alliance, focuses on vaccine access and immunization alongside these HIV, TB and malaria programs. The division of labor is real — bilateral operational muscle, multilateral pooled financing and country-led proposals, and market-shaping for vaccines. Where they overlap, they overlap on purpose: the PEPFAR–Global Fund long-acting PrEP partnership announced in September 2025 is a deliberate attempt to use both mechanisms on the same problem.5

All of it points at one shared target: Sustainable Development Goal target 3.3, ending AIDS as a public health threat by 2030. In June 2026, 149 UN Member States adopted a new Political Declaration on HIV and AIDS aligned with the UNAIDS Global AIDS Strategy 2026–2031, committing to 40 million people on treatment and 20 million with access to antiretroviral-based prevention by 2030, alongside separate targets addressing discriminatory laws, stigma and discrimination, and gender inequality. Those targets have different country and population denominators.9

The honest reckoning — what PEPFAR got wrong

A program can save 26 million lives and still have done real harm along the way. Both things are true here, and a site written by and for people living with HIV has no business pretending otherwise. Three critiques deserve serious treatment.

Critique 1: the abstinence-until-marriage earmark

The 2003 Leadership Act required that at least 33% of PEPFAR prevention funds be spent on abstinence-until-marriage programs, a spending requirement mandatory from FY 2006 until the 2008 reauthorization removed that earmark24.3 This was not a minor line item. Between 2004 and 2013, PEPFAR invested more than $1.4 billion in abstinence and faithfulness programming, making it the largest funder of that approach in sub-Saharan Africa.15

One observational evaluation examined population-level sexual-risk outcomes. Lo, Lowe, and Bendavid, writing in Health Affairs in 2016, used nationally representative surveys from 22 sub-Saharan African countries covering 1998–2013 to compare five indicators of sexual risk — number of partners in the past twelve months for men and for women, age at first sexual intercourse for men and for women, and teenage pregnancies — between countries that received PEPFAR abstinence-and-faithfulness funding and countries that did not. They found no evidence that the funding was associated with population-level reductions in any of the five outcomes, and concluded that alternative funding priorities for HIV prevention may yield greater health benefits.15

The 2008 Lantos-Hyde Act relaxed the earmark, removing the 33% directive and replacing it with a "balanced funding" requirement plus a reporting trigger if less than half of funding for prevention of sexual transmission in a generalized-epidemic country went to abstinence, delay of sexual debut, monogamy, fidelity, and partner-reduction activities.3 Later reauthorizations relaxed spending directives further.3 The $1.4 billion study total covers 2004–2013; it must not be treated as spending incurred entirely before the 2008 change.

Critique 2: the anti-prostitution pledge

The Leadership Act contains two separate provisions about sex work, and conflating them muddies the argument. Section 7631(e) bars using Leadership Act funds "to promote or advocate the legalization or practice of prostitution or sex trafficking" — a spending restriction separate from the organization-wide policy requirement.14 Section 7631(f) is different: it limited funding to organizations that have "a policy explicitly opposing prostitution and sex trafficking." That organization-wide speech requirement became known as the Policy Requirement, or the anti-prostitution pledge.14

In 2013, in Agency for International Development v. Alliance for Open Society International, the Supreme Court held the Policy Requirement unconstitutional as applied to U.S. organizations, finding that it required recipients to "pledge allegiance" to a government-sponsored message and to "profess a specific belief," conditioning funding on an across-the-board distortion of the recipient's own message — and that it therefore "violates the First Amendment and cannot be sustained."14 In 2020, in a second round of the same litigation, the Court held that the plaintiffs' legally distinct foreign affiliates possess no First Amendment rights, so applying the Policy Requirement to them is not unconstitutional.14 The practical result: the pledge is unenforceable against American organizations and enforceable against foreign ones. The 2020 decision concerns the legally distinct foreign affiliates in that litigation; it does not establish what share of PEPFAR implementers are foreign organizations.

The programmatic consequences were documented well before the litigation ended. Ditmore and Allman's analysis in the Journal of the International AIDS Society found that organizational responses to the clause included ending services for sex workers outright, gradual phase-out of services, ceasing to seek U.S. HIV funding at all, and increasing isolation of sex workers — and that 2010 guidance failed to clarify what was actually permitted, leaving implementation dependent on the interpretations of individual U.S. government representatives and organizational staff. Different readings of the same clause produced different programming, affecting the effectiveness of work with sex workers.16

UNAIDS’s July 2026 release separately cites a 47-country study reporting large reductions in services for sex workers and gay men and other men who have sex with men. Those findings concern the later funding shock; they do not quantify the causal effect of the earlier pledge. Both raise questions about access for communities facing exclusion.9

Critique 3: vertical programs versus health systems

The third critique is structural rather than moral. Built as an emergency response to one disease, PEPFAR built one-disease infrastructure. The 2013 Institute of Medicine evaluation documented what that looked like on the ground: PEPFAR and the Global Fund together sometimes supplied 90% of a country's total HIV response funding; some partner governments felt PEPFAR was driving national HIV priorities; some governments wanted support for a broader approach to health while receiving substantial HIV-specific funding; and multiple implementing partners sometimes delivered separate but related services — prevention of vertical transmission, HIV care, TB/HIV — in the same district, with separate chiefs of party, finance directors, offices, and monitoring systems, duplicating positions and complicating integration.17

The evaluation also flagged PEPFAR's own dominance as a risk in itself: one donor could drive the HIV agenda in partner countries, leaving country responses vulnerable to changes in that donor's investments or policies.17 Written in 2013. Read it again in the context of 2025.

PEPFAR did respond. The evaluation recorded steadily increasing funding for health systems strengthening, and PEPFAR II initiatives — the New Partners Initiative, the Medical Education Partnership Initiative, the Nursing Education Partnership Initiative — reflected a deliberate shift from direct service provision toward technical assistance to governments.17 The Obama-era pivot to "country ownership" was the policy expression of the same insight. It was incomplete, and the current push toward "self-reliance" is a much more abrupt version of the same idea, whose timing and consequences need to be assessed against current evidence, rather than attributed to evaluators writing in 2013.

Why U.S. people living with HIV should care

If you live with HIV in Tampa or Detroit or Jackson, PEPFAR can feel like someone else's policy. It is not. Four concrete connections.

Drug access. The 2003 launch speech described a steep fall in antiretroviral prices before PEPFAR began. The program subsequently financed large-scale treatment access. That does not establish that a particular U.S. patient’s prescription price fell because of PEPFAR; domestic pricing and coverage operate through different arrangements.2

Prevention access. The PEPFAR–Global Fund long-acting PrEP commitment is a practical example of international implementation of HIV prevention. Readers can follow both the announced target and reported uptake, without assuming that the entire evidence base or every U.S. clinical practice originated in PEPFAR.5

Community infrastructure. The 2013 evaluation described investment in health systems, workforce development and coordination. These experiences can inform discussion across countries; they do not establish that most U.S. peer-navigation or adherence practices were first developed through PEPFAR.17

Solidarity. Advocates can care about equitable access across borders. The large service reductions in the 47-country study cited by UNAIDS are a reason to ask which communities are losing support and how it can be restored. They are not evidence that 85% of all services in every PEPFAR country disappeared.9

How advocates engage — and who to follow

PEPFAR advocacy is unusually accessible, because the program's own transparency gives outside groups something to hold it to. A few of the most useful:

• amfAR's Public Policy Office publishes independent quantitative work on PEPFAR, including the PEPFAR Pulse Study and the Journal of the International AIDS Society analysis of PEPFAR's own monitoring data.1112 If you want numbers rather than adjectives, start there.
• AVAC publishes Global Health Watch, a running policy tracker that follows appropriations, budget requests, procurement mechanisms, and Global Fund replenishment developments in close to real time — including the FY 2027 request proposing roughly 46% cuts to global health under a consolidated account, elimination of funding lines for voluntary medical male circumcision and LGBTQ+-focused programming, and a proposed change in the period for which appropriated funds remain available, from five fiscal years to three — not a three-year limit on PEPFAR’s existence.22
• KFF's Global Health Policy program maintains the fact sheets, reauthorization side-by-sides, and officials trackers this article leans on throughout. It is nonpartisan and it is the reference U.S. policy staff actually use.13
• UNAIDS publishes the global epidemiological estimates, the impact-of-funding-cuts portal covering 55 countries, and the annual and special reports that set the international frame.89
• Community publications — POZ and TheBody — carry the voices of people living with HIV from the affected countries, which the policy documents do not. Read them for the human register; anchor the facts to the primary sources above.

The advocacy ask itself has narrowed to something quite specific. Not "save PEPFAR" — PEPFAR has permanent authorities and appropriators keep funding it. The ask is a real multi-year reauthorization with restored oversight and reporting provisions, a protected Global Fund match, a confirmed Ambassador in place of an acting one, and prevention funding that includes the populations most likely to acquire HIV rather than only the ones easiest to defend politically.

What you can actually do

Concrete, in rough order of leverage.

1. Learn the two-word distinction and use it. Authorization is not appropriation. When someone says PEPFAR "expired," the accurate reply is that its short-term authorization lapsed on March 25, 2025, eight time-bound provisions lapsed with it, and the program continues under permanent authorities so long as Congress appropriates.14 Precision is a form of advocacy; overstatement gets discounted.
2. Contact your senators specifically about the reauthorization and the nomination. Both are live: PEPFAR has no confirmed Ambassador at Large, with Johnny Figueroa's nominations pending before the Senate Foreign Relations Committee since June 1, 2026.19 A named ask about a named pending item is worth more than a general expression of support.
3. Track appropriations, not headlines. The FY 2026 outcome — roughly $6.0 billion across PEPFAR accounts, $1.25 billion for the Global Fund — happened because appropriators declined to follow much lower budget requests.15 That is where the decisions are made. AVAC's Global Health Watch is the least painful way to follow it.22
4. Support the organizations doing measurement. The Pulse survey’s 1,714 reported site closures and the separate analysis’s staffing and testing declines come from different datasets. Read their methods and limitations alongside the headline numbers.1112 Documentation is what makes accountability possible later.
5. Tell your own story where it connects. If you are a person living with HIV in the U.S., you are the most credible possible witness to what treatment access means. Legislators hear from lobbyists constantly and from people living with HIV rarely.
6. Stay in your own care. This is not a throwaway line. Global solidarity does not require self-neglect, and the U.S. domestic response — Ryan White, ADAP, your clinic — is a separate system with its own pressures. If you need help finding care, start with our Find Care page.

PEPFAR demonstrates the scale of a sustained public investment in HIV treatment and prevention. Its reported impact deserves attention alongside evidence about service gaps, policy restrictions and dependence on donor funding. Defending treatment access is compatible with asking hard questions about which programs work, who is excluded and how reliable the evidence is.1