The United States President's Emergency Plan For AIDS Relief (PEPFAR) is the global health funding by the United States to address the global HIV/AIDS epidemic and help save the lives of those suffering from the disease. According to the United States government, as of 2023, PEPFAR has saved over 25 million lives, primarily in sub-Saharan Africa.
Launched by U.S. President George W. Bush in 2003, as of August 2024, PEPFAR has provided cumulative funding of $120 billion for HIV/AIDS treatment, prevention, and research since its inception, making it the largest commitment by any nation focused on a single disease in history. PEPFAR is implemented by a combination of U.S. government agencies in over 50 countries and overseen by the Global AIDS Coordinator at the United States Department of State.
PEPFAR supports HIV prevention, testing and antiretroviral treatment, as well as prevention of mother-to-child transmission, care for orphans and vulnerable children, tuberculosis services for people with HIV and broader health-system strengthening. The program initially focused on emergency treatment and prevention, later shifting toward partnership frameworks with recipient governments, epidemic control targets and long-term sustainability. By September 2025, PEPFAR was credited with saving more than 26 million lives and preventing 7.8 million infants from acquiring HIV at birth.
In 2025, the second Trump administration put USAID on a 90-day freeze, initially halting PEPFAR activities, before granting a waiver for HIV medicines and other essential medical services. Only about half of PEPFAR programs were later estimated to have restarted in February. For the July to September 2025 reporting period, the budget cuts led to declines in HIV testing, new diagnoses, treatment enrolment and prevention services, although the overall number of people receiving antiretroviral therapy remained broadly stable.
History History until 2025 PEPFAR began with President George W. Bush and First Lady Laura Bush, and their interests in AIDS prevention, Africa, and what Bush termed "compassionate conservatism." According to his memoir Decision Points the two of them developed a serious interest in improving the fate of the people of Africa after reading Alex Haley's Roots and visiting The Gambia in 1990. In 1998, while pondering a run for the U.S. presidency, he discussed Africa with Condoleezza Rice, his future secretary of state. Rice said that, if elected, working more closely with countries on that continent should be a significant part of his foreign policy. She also told him that HIV/AIDS was a central problem in Africa but that the United States was spending only $500 million per year on global AIDS, with the money spread across six federal agencies, without a clear strategy for curbing the epidemic.
George W. Bush became president in 2001. In April 2003, the United States House of Representatives passed what would become PEPFAR by a 375-41 majority, although with an amendment that one-third of the prevention money had to go to sexual abstinence programs. 20 percent of the overall money would go to prevention, 15% to palliative care, 10% to orphans, and 55% to treatment.
In May 2003, both the House and Senate passed and President Bush signed the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (“Global AIDS Act”). This specified a series of broad and specific goals, and alternated between specifying measurable goals and time periods in some areas and delegating authority to the president for identifying goals in other areas. This legislation also established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming.
PEPFAR's first phase was emergency response. In its first five years, it allocated $15 billion to 15 countries in sub-Saharan Africa, Asia and the Caribbean, with targets including treatment for 2 million people with HIV, prevention of 7 million new infections, and care for 10 million people affected by HIV/AIDS, including orphans and vulnerable children.
PEPFAR was reauthorized in 2008, with up to $48 billion over five years for HIV/AIDS, tuberculosis and malaria programs. Its second phase emphasized sustainability and cooperation with partner governments, with targets including treatment for at least 3 million people, prevention of 12 million new infections, and care for 12 million people, including 5 million orphans and vulnerable children. Between 2009 and 2012, US teams and host governments signed Partnership Frameworks in 22 countries to define shared responsibilities and priorities. This phase also placed greater emphasis on health-system strengthening, expanded antiretroviral therapy, prevention of mother-to-child transmission and voluntary medical male circumcision.
In 2013, PEPFAR entered a third phase, known as "Controlling the Epidemic", with a focus on reaching the UNAIDS 90-90-90 targets by 2020: 90% of people with HIV diagnosed, 90% of those diagnosed receiving antiretroviral therapy, and 90% of those on treatment achieving viral suppression. The strategy used data to target geographic areas and populations where interventions were expected to have the greatest effect. PEPFAR 3.0 emphasized epidemic control, efficiency, transparency, sustainability, partnerships with national governments and global actors, and protection of human rights, including for LGBT people and other vulnerable groups.
In September 2022, PEPFAR issued "Reimagining PEPFAR's Strategic Direction", setting out a strategy to help end HIV/AIDS as a public health threat by 2030. The plan aimed to reach 95-95-95 treatment targets, reduce new infections through prevention and treatment, address stigma, discrimination, gender-based violence and other inequalities, and shift PEPFAR toward greater long-term sustainability by strengthening the leadership of governments, civil society and local partners. It also emphasized using PEPFAR investments to strengthen public health systems and health security in partner countries.
In 2024, some Republican lawmakers sought to block PEPFAR's reauthorization, alleging that the program promoted abortion.
In January 2025, more than 20 million people living with HIV globally, including 550,000 children under 15, depended on daily services provided with support from the PEPFAR program. Experts from the Center for Global Development estimated that USAID programs annually prevented approximately 1,650,000 deaths from HIV/AIDS.
The second Trump presidency
Funding freeze and waiver
On January 20, 2025, President Trump signed an executive order to withdraw the United States from the World Health OrganizationExecutive Order 14155, signed by President Trump on January 20, 2025, started the process to withdraw the United States from the World Health Organization. and a separate order freezing foreign aid for 90 days. On January 24, the State Department announced a comprehensive freeze on new funding for most foreign aid programs worldwide, with exemptions for emergency food aid and military assistance to Israel and Egypt, but not for PEPFAR. The freeze halted PEPFAR activities and took its computer systems offline.
On January 28, the administration granted a waiver for essential medicines and medical services, including HIV medicines, but it remained unclear whether the waiver covered preventive drugs or additional services provided through PEPFAR.
In February 2025, President Trump's task force "Department of Government Efficiency (DOGE)" had engaged in such actions as large staff layoffs and the seizure of finance systems, which essentially led to the collapse of USAID by April. The disruption to PEPFAR went further than advocated in Project 2025, which instead had praised PEPFAR as "America's most successful aid program."
Later estimates indicated that only about half of PEPFAR programs restarted in February."Crucial aid sits in warehouses worldwide as USAID employees are told to stop working," For example, Zambia had not had its PEPFAR program restarted by mid-April. In July 2025, four congressional aides said that many contracts had remained on hold, that promised waivers had not always translated into resumed services, and that about 50% of budgeted PEPFAR funding had not reached providers.
Concern about humanitarian consequences The freeze led to widespread concern about the future of HIV/AIDS programs and the potential reversal of progress made in combating the epidemic. The International AIDS Society warned that the immediate halting of funding to PEPFAR, including a stop-work order for existing grants and contracts, threatened millions of lives. The freeze in HIV relief programs, including PEPFAR, was estimated to jeopardize treatment access for 20 million people, including 500,000 children. A study in The Lancet estimated that the discontinuing PEPFAR could lead to up to 10.75 million new HIV infections and 2.93 million HIV-related deaths, and warned that the impact on low and middle-income countries could be comparable to a global pandemic or a major armed conflict. Another study projected that the suspension of PEPFAR could raise HIV-related deaths to 630,000 per year.
July 2025 amendment to exempt PEPFAR from budget cuts In June 2025, the White House requested that Congress pass a rescissions package, or "claw backs", of approximately $8 billion in foreign aid and $1 billion for the Corporation for Public Broadcasting. The House of Representatives passed the cuts as requested. The Senate removed the proposed PEPFAR cuts from the rescissions package, then advanced the revised package in two 51 to 50 procedural votes, with Vice President JD Vance casting the tie-breaking votes. The package could advance with 51 votes because rescissions bills are exempt from the Senate’s usual 60-vote threshold.
On July 15, 2025, Office of Management and Budget Director Russell Vought announced that the "White House is on board with a substitute amendment to [a] rescissions package that would exempt PEPFAR, the global anti-AIDS initiative from cuts."
In a late night session on July 17, the Senate voted 51-48 in favor of the "claw backs" for both USAID and Corporation for Public Broadcasting. The next day, the House of Representatives voted 216 - 213 for the Senate version, leaving $400 million in PEPFAR funding protected."Senate to vote to formalize DOGE cuts to public broadcasting, USAID", ABC News, July 14, 2025.
Draft to phase out PEPFAR In July 2025, The New York Times reported that the State Department was working on a draft plan to phase out PEPFAR. During the transition, the plan assumed a 42% cut of PEPFAR's annual budget of $4.7 billion, with Secretary of State Marco Rubio saying this 42% cut was his goal. The plan called for transitioning countries off PEPFAR in two, three, four, or five to eight years, depending on how far along each country was in managing its HIV epidemic. The plan acknowledged that these timelines are "ambitious". There was also discussion of using the Global Fund to Fight AIDS, Tuberculosis and Malaria, although the United States had provided about a third of its funding.
PEPFAR has spent billions of dollars over the years developing electronic records. After the transition, if partner countries fail to maintain records that meet Congressional reporting standards, their funding would end immediately. According to the New York Times, partner countries are unlikely to be able to maintain these records.
Withholding of appropriated funds