President’s Emergency Plan for AIDS Relief (PEPFAR), public health initiative launched by the United States in 2003 to coordinate an international response to the HIV/AIDS pandemic. The President’s Emergency Plan for AIDS Relief (PEPFAR), authorized by U.S. Pres. George W. Bush, marked a major step forward in global efforts to prevent HIV infection and to provide treatment to persons living with HIV/AIDS. The effort proved highly successful; by September 2023 some 20.5 million persons with HIV/AIDS had received antiretroviral treatment via the PEPFAR program. More than 32 million men and boys in eastern and southern Africa voluntarily underwent circumcision—a procedure that has been found to reduce risk of HIV infection—and rates of new HIV diagnoses have declined among adolescent girls and young women worldwide.

　　Development and success In the 1990s and 2000s the incidence of HIV/AIDS was increasing worldwide and particularly in Africa. When Bush was elected, addressing issues in Africa was not a priority. However, as awareness about HIV/AIDS increased in the United States and globally, Colin Powell, who was then secretary of state, brought the AIDS epidemic to Bush’s attention, describing it as a pressing problem for the new administration. In addition, Christian conservatives, who made up a large share of Bush’s political base, started adopting the cause.

　　Bush sent Tommy Thompson, then health and human services secretary, and Anthony Fauci, who was advising the administration on AIDS issues, to Africa in 2002, with the request that they develop a proposal for bringing the HIV/AIDS pandemic under control. Based on their conclusions, Bush announced plans for an AIDS program his 2003 State of the Union address. Legislation was passed that year, setting aside $15 billion for the program. Bush appointed Randall Tobias, a former pharmaceutical executive, to run PEPFAR out of the White House; the program was later transferred to the State Department. PEPFAR was reauthorized by Congress in 2008, 2013, and 2018. Rules were added and removed in different funding cycles—for instance, the original authorization required that one-third of funding be spent on abstinence-until-marriage programs; this requirement was removed in the 2008 reauthorization.

　　In the years following its implementation and reauthorizations, the program’s success grew. By 2012, for example, PEPFAR had supplied antiretroviral drugs to more than 5 million persons with HIV/AIDS, an increase from 1.7 million in 2008. Also by 2012 almost 50 million people had undergone testing for HIV infection, and an estimated 1 million infants had been protected against HIV transmission from infected mothers. In Uganda, one of the first countries to benefit from PEPFAR, nearly 500,000 HIV infections had been prevented and more than 600,000 lives had been saved by 2023.

　　Conservative backlash In 2023, however, PEPFAR, which was again up for reauthorization, came under attack from conservative groups. A report issued by the Heritage Foundation in the spring of that year charged that U.S. Pres. Joe Biden’s administration had leveraged the program to promote a radical social agenda, claiming in particular that PEPFAR funds had been given to nonprofit organizations that also support abortion. PEPFAR supporters pointed out, however, that the program does not fund abortion. The Heritage Foundation also reported that the vast majority of political donations made by employees of organizations that receive PEPFAR funds were in support of Democratic candidates and causes, alleging possible “political discrimination” and questioning whether the program could be trusted to operate in a nonpartisan manner. As a consequence of these claims, some conservative organizations demanded a change to the program that would block it from funding any group that supported abortions; such organizations threatened to consider a vote to reauthorize PEPFAR as a vote for abortion rights in their political scorecards rating members of Congress.

　　In October 2023 Congress declined to renew funding for PEPFAR. The Republican-majority House approved a one-year extension, instead of the standard five-year extension, which would have created an opportunity to make changes under a potential Republican administration in 2025. PEPFAR was able to continue operating in the short-term, though the longevity of the program’s remaining funds was unclear.

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