PEPFAR and the future of the global fight against HIV

PEPFAR was launched in 2003 to stop the spread of HIV in Africa. Now, although some funding remains for the program, many of PEPFAR’s prevention and support services have stalled, as Dr. Atul Gawande, who led global health at USAID during the Biden administration, explains to The World’s Host Marco Werman.

The World

July 17, 2025

By Joyce Hackel

The Trump administration’s decision to shutter USAID halted vital aid programs in more than a hundred countries around the world. The long-term impact of that move could be noticeable for decades, but the short-term consequences are already being documented, especially in the effort to prevent and treat AIDS and HIV.

In 2003, former Republican President George W. Bush had launched the President’s Emergency Plan for AIDS Relief (PEPFAR) to combat HIV and AIDS. And a vote early on Thursday may have spared PEPFAR from funding cuts.

The World’s Host Marco Werman discussed the program and its future with Dr. Atul Gawande, a renowned surgeon who led public health programs at USAID during the Biden administration.

Marco Werman: People have called PEPFAR a revolutionary program. Why do you think it deserves that description?

Dr. Atul Gawande: Well, this was a program that President Bush started and brought bipartisan support behind, really, a Marshall Plan-level effort for Africa to stop HIV, which had become the number one cause of death for people on the continent.

The result of that program is that 25 million people with HIV had their lives saved because they could get access to medicines that were available around the world, and they survived. It transformed the continent and the health of the people.

You called it a Marshall Plan for HIV-AIDS. What specifically was brought to bear to the continent to make it work?

Number one, life-saving medicines. Number two, preventive treatments that stop HIV from spreading, which are not just treatments but basic things. It can be condoms or it can be preventive medications for high-risk populations. It’s the medicines to prevent a mother with HIV from transmitting to her child. And then, the third thing is providing support to building stronger systems that do everything from helping keep people on their treatment to being able to take over these programs as time goes on.

A pharmacist holds a vial of Lenacapavir, at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, July 23, 2024.Nardus Engelbrecht/AP/File photo

So, the arc of HIV and AIDS changed dramatically over time. How much was PEPFAR responsible for that change, and how did PEPFAR, itself, change over time?

Probably well over three-quarters of the improvement in survival from HIV and [its] control came from the PEPFAR program, which continues to this day. USAID is part of it, and the Department of Defense is even involved in it. That whole-of-government effort included work to discover the next treatments.

One of the most powerful things we have right now is the discovery of a medication, which is a single-shot medication called Lenacapavir, that can stop HIV, approved by the FDA for six months. New research indicates it can last a year. So, it’s a “flu shot” that can stop HIV if you take it every year. And that was going roll out to millions of people. And that represented an opportunity to end the HIV pandemic in the next five to 10 years.

That kind of work, however, has been completely halted. The work on the HIV vaccine that PEPFAR and NIH did was completely halted as well.

This interview has been lightly edited and condensed for clarity.

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