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

That is not a rhetorical number. It represents grandmothers in Lusaka who watched their daughters die in the 1990s and then watched their granddaughters grow up on treatment. It represents 7.8 million babies who were not born with HIV.1 If you are a person living with HIV reading this in the United States, it also represents something quieter: the global drug-price collapse, the generic supply chains, the trial networks, and the community-health-worker models that made your own care cheaper and better.

And PEPFAR is now living through the hardest stretch of its existence. Its authorization lapsed in March 2025.3 A foreign-aid freeze, the dissolution of USAID, 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 Not the largest HIV program. The largest single-disease commitment, period, by any country, ever.

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 — speed and scale that no ordinary development program achieves — 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

The verified numbers — and how "lives saved" is counted

Here is the current accounting, drawn from PEPFAR's own reporting as compiled by KFF and UNAIDS.

• More than 26 million lives saved since 2003.18
• 7.8 million babies prevented from being born with HIV who would otherwise have acquired it (FY 2024 cumulative reporting).1
• 20.6 million people supported with antiretroviral treatment in FY 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
• Nearly 342,000 new health care workers supported with training 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. Both are the same estimate, updated.

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 56% from 1.3 million in 2010.109

PEPFAR did not do that alone — the Global Fund, national governments, WHO normative guidance, generic manufacturers, and community activists all did essential parts of it. But at points in the 2000s and 2010s PEPFAR was supplying almost two-thirds of all external HIV funding across the countries it worked in.17 You cannot subtract that and keep the curve.

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 is the anchor case and deserves care, because it is often described as a PEPFAR program when it is more accurately a South African program that PEPFAR helped build and still partly funds. An estimated 7.9 million people were living with HIV in South Africa in mid-2025 — about 12.3% of the population — with roughly 6.18 million on antiretroviral treatment, according to the Thembisa model, the leading mathematical model of HIV in the country.20 That makes it the largest antiretroviral treatment program in the world by a wide margin, and it is overwhelmingly run and increasingly financed by the South African state.20

The country's own numbers show what a mature program looks like: by 2024, 95% of people living with HIV had been diagnosed, 81.5% of those diagnosed were on treatment, and 92% of those on treatment were virally suppressed — and AIDS-related deaths had fallen 66% since 2010.20 It also shows the fragility: treatment numbers grew by only about 40,000 people between 2024 and 2025, essentially flat, in the same year U.S. funding was disrupted.20

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

Kenya, Uganda, Tanzania, Zambia, Malawi, Mozambique, Zimbabwe, Lesotho, Eswatini, and Botswana carry the heaviest per-capita burdens and have seen the most dramatic reversals. UNAIDS reports that seven countries — Benin, Eswatini, Kenya, Lesotho, Nepal, Rwanda, and Zimbabwe — have achieved almost 80% reductions in new HIV infections since 2010, and 11 countries have hit the 95-95-95 treatment targets (95% diagnosed, 95% of those on treatment, 95% of those virally suppressed).9 Most of those countries are PEPFAR partners. Most also now fund a majority of their own response: the share of the global HIV response paid from domestic sources rose from 28% in 2010 to 52% in 2024.9

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 countries, and both are named among the governments that have moved to expand access with domestic and other funding as external aid contracted — Ethiopia and Uganda are specifically cited by UNAIDS for acting to protect prevention access.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

The factual position is not ambiguous. U.S. law already prohibits using foreign assistance, including PEPFAR funding, for abortion. The Helms Amendment (1973) bans the direct use of U.S. funding overseas for abortion as a method of family planning; the Siljander Amendment (1981) bans using it to lobby for or against abortion; the Leahy Amendment (1994) clarifies that "motivate" in Helms does not prohibit lawful counseling about all pregnancy options.6 KFF's review found no evidence produced that PEPFAR had supported any prohibited abortion activities. Ambassador Nkengasong stated in June 2023 that PEPFAR does not provide a platform for abortion in Africa and is implemented strictly within the laws under which it was created, and PEPFAR revised its strategy document to reiterate that "PEPFAR does not fund abortions."6

None of that unstuck it. The reauthorization stalled anyway — the first time in PEPFAR's history that its renewal became a partisan casualty.

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, 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 — 86% of all USAID awards are canceled. Of 770 identified global health awards, 379 included HIV activities, and 71% of those HIV-related awards were terminated — including several treatment awards and most prevention awards.5

The measured consequences are not speculative. amfAR's PEPFAR Pulse Study, conducted with Johns Hopkins Bloomberg School of Public Health, Funders Concerned About AIDS, and Data Etc., surveyed 166 PEPFAR-funded organizations in 46 countries. It documented at least 1,714 HIV service sites closing entirely after PEPFAR payments were terminated or delayed; almost no organizations able to replace the lost funding; 73% of implementing partners stopping at least one service for key populations; 67% stopping outreach; HIV prevention spending down 51% from FY 2024 to FY 2025; and — despite these services never being formally cut — 64% of partners providing treatment, testing, and prevention of vertical transmission reporting interruptions, with 22% stopping vertical-transmission prevention entirely.11

A companion amfAR analysis published in the Journal of the International AIDS Society compared PEPFAR's own monitoring data across more than 30,000 facilities between 2024 and 2025: the PEPFAR-supported workforce shrank by more than 60,000 staff, HIV testing fell by 14 million tests year over year, and PrEP initiations dropped 33% across all facility types.12

Where PEPFAR stands now — FY 2026 and the road ahead

Congress kept paying

The most important fact about FY 2026 is that appropriators did not follow the administration's budget requests down. Despite significantly lower requests, Congress appropriated approximately $6.0 billion across PEPFAR accounts for FY 2026 — about $4.7 billion for bilateral HIV work, $1.25 billion for the Global Fund, and $45 million for UNAIDS.1 That FY 2026 bilateral figure sits $316 million below the FY 2010 peak, and the Global Fund line is $400 million below FY 2025 — but it is not collapse, and it is the clearest surviving evidence of bipartisan floor support.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.

The one genuinely expansive move

On September 4, 2025, the administration announced a PEPFAR partnership with the Global Fund to support long-acting injectable PrEP, aiming to reach up to 2 million people in high-burden countries by 2028.5 That is a real, ambitious commitment to the most important prevention technology of the decade. It is also, so far, far behind its own curve: UNAIDS reports lenacapavir rollout targeting 3 million people by 2028 while currently reaching only a few thousand — and estimates that 20 million people need access to antiretroviral-based prevention for it to meaningfully bend new infections.9

The UNAIDS read on 2026

UNAIDS's July 2026 special report for the International AIDS Conference in Rio de Janeiro is the most authoritative independent picture. 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. Community-led support for prevention and care fell by half, with services for gay men and other men who have sex with men down 85%, services for sex workers down 82%, and services for survivors of gender-based violence down 72%.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

As of mid-2026, PEPFAR does not have a Senate-confirmed leader. Johnny Figueroa of Tennessee was nominated on June 1, 2026 to be Ambassador at Large for Global Health Security and Diplomacy and, in a companion nomination, Ambassador at Large and Coordinator of United States Government Activities to Combat HIV/AIDS Globally. Both nominations were referred to the Senate Foreign Relations Committee the same day.19 KFF's tracker lists Figueroa as designate for both roles, with Jeffrey Graham serving as Acting Global AIDS Coordinator and Rebecca Bunnell as Principal Deputy Assistant Secretary for Global Health Security and Diplomacy and Deputy Assistant Secretary for PEPFAR and Health Programs.19

A prolonged acting arrangement matters more here than in most agencies, because the statutory design gives the Coordinator personal authority to compel coordination across USAID, CDC, and other agencies, and gives the Ambassador a permanent seat on the Global Fund Board.1 Acting officials generally carry less weight in both roles.

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

Very little PEPFAR money is spent by Americans in Washington. The work is done by ministries of health, district clinics, faith-based hospital networks, university partnerships, and local NGOs — including thousands of smaller community organizations that do the outreach, adherence support, and peer navigation that keeps people in care. The 2013 Institute of Medicine evaluation tracked the shift: partner-country-based prime partners went from 22% of PEPFAR funding in 2004 to 36% in 2010, while U.S.-based prime partners fell from 75% to 61%.17

That localization trend is exactly what the 2025 disruptions hit hardest. When payments stop, the organization with three months of reserves survives and the community organization with three weeks does not — which is why amfAR found almost no organizations able to replace lost PEPFAR funding, and why 1,714 sites closed outright.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, sits alongside both and does something neither does: shape vaccine markets and finance immunization. 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, and to reducing stigma, gender inequality, and punitive legal environments below 10%.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 requirement that governed FY 2004 through FY 2009.3 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

The best available evaluation of whether it worked is unambiguous. 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 prevention funds 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 That is genuine self-correction — and it took five years and more than a billion dollars to arrive at.

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 that was never seriously contested.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 — which is to say, enforceable against most of the organizations actually doing the work.

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

Read that alongside the 2026 data — services for sex workers down 82%, for gay men and other men who have sex with men down 85%9 — and a pattern emerges that is older than the current administration. PEPFAR has always been strongest where the intervention is a pill and weakest where the intervention requires the U.S. government to be comfortable with the people receiving it.

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, executed on a timeline nobody in the 2013 evaluation would have called responsible.

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 pricing. The 2003 State of the Union hinged on antiretroviral costs having fallen from $12,000 a year to under $300.2 PEPFAR then became the largest single purchaser of HIV medicines on Earth, and that purchasing volume — alongside generic competition, voluntary licensing, and activist pressure — is a structural reason the global price of a year of first-line treatment collapsed. Global demand and global generic capacity are part of what keeps the manufacturing base for your regimen large and competitive.

Science. The evidence base American clinicians use was built substantially in PEPFAR-supported settings. Treatment-as-prevention, universal test-and-treat, dolutegravir-based first-line regimens, differentiated service delivery, multi-month dispensing, community-based adherence support — these were tested at scale in sub-Saharan Africa because that is where the epidemic and the research infrastructure were. Long-acting injectable PrEP, the most consequential prevention advance of this decade, is being rolled out through exactly the PEPFAR–Global Fund architecture described above.5

Community infrastructure. Peer navigation, community health workers, adherence clubs, differentiated care for people who fall out of care — much of the modern U.S. playbook for keeping people in HIV care was refined in high-volume, low-resource settings first. The traffic runs both directions.

Solidarity, which is not a soft argument. The virus does not recognize the border, and neither does the politics. The same arguments used to strip prevention funding for sex workers and gay men abroad are the arguments used against harm reduction and comprehensive sex education at home. When 85% of services for gay men and other men who have sex with men disappear in PEPFAR countries,9 that is a precedent, not a distant event.

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 does the most rigorous 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 language shortening PEPFAR's funding duration from five years to three.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 1,714 closed sites, the 60,000 lost health workers, the 14 million fewer HIV tests — those numbers exist because amfAR, Johns Hopkins, and partners went and counted.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 is the strongest available piece of evidence that a government can decide to stop a mass-casualty epidemic and then actually do it — on a bipartisan vote, at enormous scale, over two decades, with a modeled 26 million lives to show for it.1 It is also the strongest available evidence that ideological add-ons cost lives, that single-donor dependency is a structural risk, and that twenty years of goodwill can be spent faster than it was earned. Both lessons are worth carrying. Neither one cancels the other.