In May 2023, about a year before the President’s Emergency Plan for AIDS Relief was up for congressional renewal, a Heritage Foundation report alleged that PEPFAR funding was being secretly used for abortions by recipients as a part of a systematic, covert agenda endorsed by U.S. counterparts. Separately, concerns about insufficient commitment to the efficient use of U.S. taxpayer dollars in foreign aid were growing, despite efforts within organizations administering foreign aid to evaluate, strengthen, and streamline services.
PEPFAR has been a key component of global health since it was founded by President George W. Bush in 2003. Amid the new criticisms of the program, many of us working in global health wondered: Do people really understand what would happen if funding were abruptly stopped? Do members of the U.S. Congress have the data they need?
So in late 2023, a core group of physicians, researchers (including the two of us), global health leaders, and an intrepid medical student set out to measure the potential impact abruptly stopping PEPFAR would have on HIV transmission, deaths, and health care dollars. Twenty-five years of collaboration and work with simulation modeling uniquely positioned us to examine this in one PEPFAR country: South Africa.
Our goal was to provide information to policymakers and the U.S. public. South Africa has the largest HIV epidemic of any one country globally, with an estimated 8 million people living with the virus today. With more than $8 billion invested in South Africa and $110 billion worldwide since its inception in 2003, PEPFAR has supported more than 20 million people with HIV in 55 countries. It has been acclaimed as preserving global security by addressing an epidemic that could destabilize entire countries and continents, as well as a bridge to country-led self-sustaining HIV programs. In 2022, $460 million from PEPFAR represented 18% of South Africa’s $2.56 billion HIV budget.
Our resulting study underwent the rigorous and often long process of academic peer review, with one anonymous expert doubting the premise: “It is highly unlikely that PEPFAR will not be reauthorized, given its bipartisan support since its creation in 2003 during the Bush administration.”
Little did we know how prescient the study would be: The final results were published in Annals of Internal Medicine on Feb. 11, days after suspension of all foreign aid.
We report that eliminating PEPFAR would lead to 601,000 HIV-related deaths and 565,000 new HIV infections in South Africa alone over 10 years. It would also increase population-level health care expenditure by $1.7 billion due to increased HIV prevalence and a less healthy population over the next decade in South Africa. These are the projections for just one country, where PEPFAR supports 18% of the HIV budget. Others have also now quickly tried to quantify the mind-boggling impact of stoppages in all 55 countries, including those like Zimbabwe where the HIV funding profile supported by PEPFAR is much larger.
While the exact numbers of future adverse HIV outcomes are uncertain, our published model-based results represent a conservative, lower bound of just how much policy decisions put lives at risk. Even in South Africa, our outcomes project just the tip of the iceberg — we did not, for example, capture moms, children, and babies. We also did not capture the impacts on data systems, supply chains, personnel, decreased employment, the programs that don’t function without PEPFAR, or future resulting decreases in GDP growth.
Even with these limitations, our research shows that abruptly stopping PEPFAR is turning the clock back on decades of investment and progress toward ending the HIV epidemic. HIV is predictable: Even in the short span of the foreign aid pause, someone’s child, parent, or sibling has already become collateral damage and will experience a lifetime with HIV.
Decades of PEPFAR support — as well as NIH and global research and humanitarian organizations — have developed incredible tools that have made the treatment of HIV one of the greatest success stories of our lifetimes, saving an estimated 25 million lives.
You might be wondering: What is the status of PEPFAR at the time of this publication? It’s a little unclear. Our understanding is that USAID-funded PEPFAR implementing partners — the nongovernmental organizations that are funded through cooperative agreements to execute the PEPFAR activities that they are tasked with — have received termination orders. Many of these implementing partners have laid off staff and are moving toward close out. The CDC-funded PEPFAR implementing partners have received a variety of temporary resumption orders. The previously publicly available data that helped make the modeling study possible remain offline. PEPFAR’s current short-term authorization will expire March 25. The foreign aid review is expected by be completed April 19.
We hope the review will take our research into account. The strength of simulation modeling is perhaps greatest in its qualitative, rather than quantitative, insights. We found that programs that expand and promote adherence to treatment are powerful. Prevention efforts among key populations are vital. Cases must be identified through HIV testing programs. The future of PEPFAR should be both as a lifesaving foreign aid program efficiently deploying evidence-based interventions and a bridge to self-sustaining national HIV programs.
Anne Neilan is an infectious diseases clinician and associate professor of pediatrics and assistant professor of medicine at Harvard Medical School. Linda-Gail Bekker is a professor of medicine and chief executive officer of the Desmond Tutu HIV Foundation in South Africa.