There is much concern about the future of the President’s Emergency Plan for AIDS Relief, or PEPFAR, under the new administration. Since the creation of PEPFAR in 2003, the US has been the global leader in responding to the urgent need for the treatment and prevention of HIV/AIDS, and the care of orphaned and vulnerable children affected by the disease. With bipartisan support in Congress, PEPFAR was initiated under the Bush administration and continued under the Obama administration.

While the initial goals of the program were emergency relief to respond to the devastating consequences of the unfolding AIDS crisis, the program created new aims to strengthen health systems and make country programs more sustainable when it was re-authorized in 2008. In the Institute of Medicine’s evaluation of PEPFAR, released in 2013, Chair of the Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs Robert Black cited PEPFAR as a “globally transformative” program that changed the paradigm of global health by achieving ambitious goals while demonstrating humanitarian commitment to a public health crisis.

Health Affairs has published a number of articles on PEPFAR’s impact over the years, and in 2012 we published a theme issue that reviewed the first 10 years of PEPFAR implementation. At a time when the future of the program is in doubt due to possibly severe budget cuts to the US State Department (where PEPFAR is based) proposed by the new administration, we thought it would be an opportune moment to highlight some of the key studies we have published exploring PEPFAR’s role in fighting the HIV/AIDS epidemic.

1. Investment In PEPFAR Contributed To Economic Stability In Countries That Received Funding

The PEPFAR program has had important, documented health effects, but economic impacts of the program have not been widely studied. Zachary Wagner, Jeremy Barofsky, and Neeraj Sood published research in Health Affairs in 2015 that showed that PEPFAR funding was associated with an increase in employment of almost 10 percentage points among males in ten Sub-Saharan African countries. This research finding makes the case that the economic impact of the PEPFAR program should be taken into account when making aid allocation decisions, as the rise in employment generates economic benefits to workers, their families and communities, and the population level impact is estimated to be equal to about half of PEFPAR’s costs. PEPFAR stimulates employment growth, strengthens local health system capacity, and is an efficient use of aid resources.

Results from an earlier Health Affairs study by Jacob Bor and colleagues found that PEPFAR support led to a return to nearly full recovery of employment of HIV patients on antiretrovirals in South Africa. This means that the economic benefits of receiving treatment are large, as patients are able to lead economically productive lives to the benefit of their families, communities, and countries.

Harsha Thirumurthy and colleagues also found that PEPFAR support for HIV treatment produces economic returns through increased work and increased access to education for children living with infected adults, and these benefits should be considered when weighing program costs and warrants continued US support. PEPFAR has proved to be a key instrument for investing in economic development.

2. PEPFAR Has Made Major Investments In Support Of Health Governance And Health Systems

With the 2008 Congressional reauthorization of PEPFAR funding, PEPFAR was mandated to transition from an emergency response program to place greater emphasis on country ownership and sustainability. In an article by Corrina Moucheraud and colleagues published in Health Affairs in 2016, the authors analyzed PEPFAR budgets from 2004-2014, and found that the share of planned funding for governance and health systems increased from about 15 percent on average in 2004 to more than 25 percent in 2013, although the share of planning funding declined to about 21 percent in 2014. The PEPFAR program responded to the Congressional mandate to provide greater support for health system strengthening, and has made major commitments to health system improvements.

3. PEPFAR’s Health Impacts Include Improving Access To Critical Health Services Such As Maternal-Child Care For African Women Not Infected With HIV

In addition to prevention programs and care of persons with HIV/AIDS, Margaret Kruk and colleagues analyzed maternal health services in eight African countries that received PEPFAR support, and found a positive effect with more deliveries at health facilities by women not infected with HIV. PEPFAR investments in infrastructure, laboratories, and HIV treatment supported a broader range of health services to improve maternal and newborn care and provide other essential health services.

4. The US Congressional Mandate To Fund Abstinence And Faithfulness Programs In Sub-Saharan Africa With PEPFAR Was Not Effective

Research conducted by Nathan Lo and colleagues showed that the PEPFAR mandate imposed by Congress to create and promote abstinence and faithfulness was not associated with reductions in HIV risk behavior in countries that received funding. The purpose of that mandate was to reduce the risk of HIV transmission, but when authors compared trends in 22 Sub-Saharan African countries in countries that received abstinence and faithfulness funding to those countries that did not receive PEPFAR funding, there was no evidence of impact in reduction of risky behavior. The authors suggested shifting funds to alternative priorities to more effectively prevent the spread of HIV. It is not yet clear whether the new administration or congress will eliminate the ineffective mandate.

5. PEPFAR Is A Vital Force In US Health Diplomacy That Has Provided Important Lessons For US And Global Health

PEPFAR has become a global symbol of America’s humanitarian and diplomatic commitment, and a positive force to promote US interests. Chris Collins and colleagues reported on how the program became a vital tool for health diplomacy while it laid the groundwork for an AIDS-free generation.

PEPFAR experience also provided lessons for combating the disease in low-resource settings in the US, to improve prevention and treatment outcomes.

In summary, there are many reasons for the US government to continue to fund the PEPFAR program. PEPFAR has provided prevention services and treatment for those with HIV, as well as support for programs for orphans and vulnerable children at a critical time of need, but there is still much to accomplish to achieve an AIDS-free generation. Health Affairs’ published research demonstrates the program’s contributions to economic stability in recipient countries, support for strengthened health systems and governance, and increased access to health services. In addition, PEPFAR boosts global health security and strengthens US health diplomacy. In determining the future course of investment in PEPFAR, it is essential to consider the program’s multiple impacts on the economies and health systems of recipient countries.