Ambassador-at-Large Deborah Birx giving a speech from a podium with an American flag and PEPFAR banner in the background

One of the Biggest Public Health Initiatives in History: PEPFAR and HIV

By Daniel Aaron

In October, the Petrie-Flom Center hosted a conference of world-leading experts in HIV/AIDS to discuss one of the biggest public health successes in history: PEPFAR, the President’s Emergency Plan for AIDS Relief. PEPFAR was launched in 2003 in response to a burgeoning global epidemic of HIV. The program offered $2 billion annually, rising to about $7 billion in 2019, to surveil, diagnose, treat, and reduce transmission of HIV around the world.

PEPFAR prevented what could have become an exponentially growing epidemic. It is estimated to have saved more than 17 million lives and avoided millions of new HIV infections. As a result, the speakers at the conference were quick to extol the virtues of the program. Professor Ashish Jha called it an “unmitigated success”; Professor Marc C. Elliott named it a “historic effort”; Dr. Ingrid Katz described PEPFAR as “nothing short of miraculous.”

However, several undercurrents within the conference, as well as more explicit points made by several panelists, suggested the importance of enlarging the discussion beyond PEPFAR itself to include other policies that impact HIV and AIDS, and even other diseases.

America’s Obligations

Dr. Anthony Fauci noted that when President Bush pushed the PEPFAR program forward, he said the following:

We as a rich nation have a moral obligation to help those who do not have access to HIV treatment and care because they lack the resources.

True to his words, Bush aggressively supported the PEPFAR program, which provided lifesaving support globally for HIV prevention and treatment. But much as PEPFAR was successful, it also left questions about why other diseases did not receive the same response. Dr. Fauci explained that the serious threats posed by malaria, tuberculosis, and diarrheal diseases could be addressed through improved funding and infrastructure dedicated to these diseases.


Dr. Anthony Fauci discusses the genesis of PEPFAR

Bush’s moral obligation also speaks nothing of a duty owed to the United States’ own people. A large contingent Americans continue to live without health care, which is essential to HIV treatment. Reductions in HIV transmission in the U.S. have stagnated at about 39,000 new cases per year. In some populations HIV transmission is increasing, particularly in African American and Latino men between the ages of 25-34 who are gay or bisexual. Medicaid is the largest insurance source for Americans with HIV, but as Professor Robert Greenwald noted, there are several threats to the integrity of Medicaid, such as work requirements and the failure to expand Medicaid in the wake of NFIB v. Sebelius.


Prof. Robert Greenwald discusses “getting to zero” efforts in the United States.

Whom is America obliged to help? Which populations, and with which diseases?

Risk Factors for HIV Transmission

Several panelists noted that PEPFAR offers a medicalized approach to HIV prevention and care. The main functions of the program are epidemiological surveillance, testing, and treatment with medication. However, as described by Dr. Shahin Lockman, people may have risk factors for HIV, including financial insecurity, sex work, and alcohol consumption/substance use. PEPFAR does not address these upstream risk factors, instead focusing on downstream treatment of HIV. While it may be too much to expect PEPFAR to tackle the social determinants of health, it is still worth asking whether PEPFAR is addressing the root causes of HIV spread, and whether that even matters.


Prof. Shahin Lockman examines the HIV epidemic response in Botswana.

Recent scholarship suggests that sex work may stem from financial problems. If that is the case, building more equal and supportive economies that offer all people a living could alleviate HIV transmission.

Rancid Partisanship

In Professor Glenn Cohen’s introduction to the conference, he noted that we live in a time of “rancid partisan division.” In contrast, the bipartisanship that enabled PEPFAR became an ongoing theme throughout the day.

Generally speaking, panelists were thrilled that bipartisanship could lead to the historic outcomes of PEPFAR. The Honorable Mark Dybul argued that when the right context is presented, legislators of different views can come together to support a transformative policy. He added that PEPFAR demonstrated the success of looking toward the future, rather than succumbing to backward-looking fear.

Hon. Mark Dybul shares his experience leading implementation of PEPFAR under Pres. George W. Bush.

While PEPFAR is no doubt a bipartisan effort, it is unclear whether political polarization is so easily avoided through being optimistic and looking forward. Many of today’s most pressing health issues pit corporate entities, and their powerful lobbying, against the public health. Examples include food, cigarettes, vaping, opioids, guns, and pollution. The lobbying creates a prisoner’s dilemma, in which candidates who do not accept campaign contributions suffer a disadvantage. As a result, policy areas that involve corporate regulation often become politically polarized. PEPFAR, on the other hand, offers a mutual relationship between pharmaceutical companies and the federal government that is inherently less controversial. PEPFAR can and should be praised for its massive global impact, but this optimism may not be translatable to other public health problems.


In the end, PEPFAR is hard to criticize. It is a landmark victory against a terrible disease, and a shining obelisk inscribed with the message that humans can work together for the common good. PEPFAR’s flaws have little to do with the program itself, but in what occurs outside the program’s four walls. If rich nations have obligations to reduce HIV in other countries, it follows that there are obligations to mitigate disease generally, within our country and abroad. In the U.S., life expectancy has been decreasing for several years, in part due to the failure to adequately address systemic health problems like obesity and the opioid crisis. New programs tackling additional diseases and populations, but implemented with the same vigor as PEPFAR, could go a long way to improving public health.

Couldn’t join us for “15+ Years of PEPFAR: How U.S. Action on HIV/AIDS Has Changed Global Health”? Check out the full playlist of video on YouTube

Daniel Aaron

Dr. Daniel Aaron grew up just outside of Boston. He graduated from Brown University and studied law and medicine between Harvard and Boston University. Dr. Aaron hopes to alleviate health injustice by studying the role of law and policy in creating and perpetuating disease. His research foci include food and drug law, obesity, opioids and related tort litigation, tobacco products, the intersections with racial health inequities, and constitutional health law. His research has been covered by the New York Times, CNN, Time Magazine, and others. Today, he is a Heyman Fellow at Harvard Law School, an attorney at the U.S. Food and Drug Administration, and a member of The Justice Initiative, a collaboration between Harvard Law School and Howard University School of Law aimed at building a community of lawyers and law students around racial justice. Publications: Tobacco Reborn: The Rise of E-Cigarettes and Regulatory Approaches, 25 LEWIS & CLARK L. REV. ___ (forthcoming 2021). Is Obesity a Manifestation of Systemic Racism? A Ten-Point Strategy for Study and Intervention, J. INTERNAL MEDICINE (2021). Ten years post-GAO assessment, FDA remains uninformed of potentially harmful GRAS substances in foods., CRITICAL REVS. OF FOOD SCIENCE & NUTRITION (2020). Constitutional Cohesion and the Right to Public Health, 53 MICHIGAN J. LAW REFORM 173 (2019). Sponsorship of national health organizations by two soda companies, 52 AM. J. PREVENTIVE MEDICINE 20 (2017). The Landscape of Genetic Variation in Dilated Cardiomyopathy as Surveyed by Clinical DNA Sequencing, 16 GENETICS IN MEDICINE 601 (2014). Nature Publishing Group.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.