We must fill the void in global HIV care without PEPFAR

Since its inception in 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has stood as a cornerstone of the global fight against HIV, channeling $110 billion into prevention, detection, and care programmes worldwide.1 PEPFAR is credited with saving more than 25 million lives, preventing 5.5 million babies from being born with HIV, and providing critical support for 7 million orphans, vulnerable children, and their care givers.2

PEPFAR received bipartisan support across four presidential administrations.3 But, with the recent expiration of re-authorisation and the announced freezes in US international aid, PEPFAR’s future is uncertain.4 The termination of US government support necessitates immediate, coordinated action from the international community to ensure that we remain on track to achieve the sustainable development goal of ending the HIV epidemic by 2030.5

We were part of a recent report forecasting the negative health impact of suspending PEPFAR funding in South Africa. Our findings are chilling: suspending the US annual contribution of $460 million would result in 600 000 additional HIV-related deaths and 570 000 excess HIV infections in South Africa alone over the next decade.6 Other studies corroborate these findings.7

It is hard to grasp the harm underlying such staggering numbers. We estimate that elimination of PEPFAR will save US taxpayers $2.3 billion over the next five years.6 We further estimate that the elimination of PEPFAR will result in 15 million years of life lost in South Africa over five years. If you divide the $2.3 billion by 15 million life-years, you get $153. That’s how much the US government can expect to save for every additional year of life that will be lost.

In the US, health economists extensively debate the monetary “value” of human life and what Americans are willing to pay for one extra year of survival (a “life-year”). Estimates vary widely, but the evidence shows that just about everyone agrees with paying at least $50 000 of society’s money to save a single American life-year.8 In stark contrast, not renewing PEPFAR would mean that the US government is unwilling to pay even $153 to save a South African life-year.

The asymmetry will be starker in other sub-Saharan African countries, where PEPFAR covers a far greater share of the HIV budget.5 It will be even starker if we consider PEPFAR’s role in reducing all-cause mortality, increasing child vaccination rates, providing for care of diseases such as malaria and tuberculosis, building over 3000 laboratories, and training more than 340 000 healthcare workers. It also decreases soft power influence and harms goodwill towards the US in the world’s most vulnerable regions.

Amid the damage caused by the suspension of PEPFAR, we must not lose sight of the objective to bring HIV under control as a public health threat by 2030. The international community—both individual nations and civil society working collaboratively—must urgently galvanise action to maintain momentum and protect and build on the gains made to date by committing to the following priority actions.

Maintaining access to antiretroviral therapy (ART) for over 30 million people, along with preventing vertical transmission through rigorous testing and provision of ART and pre-exposure prophylaxis (PrEP), is a critical priority. Reaching key populations bypassed by traditional healthcare due to stigma and restrictive laws will require innovative community-based approaches. Primary prevention efforts must focus on scaling up longer acting PrEP and continuous monitoring to sustain epidemic control. A robust funding strategy, tapping into new international and private sources, alongside increased commitments from existing donors, is necessary to financial sustainability. Additionally, strengthening health systems by securing supply chains, integrating services, and promoting self-reliance through bulk purchasing and financial incentives is paramount. These comprehensive efforts will help to fill the gaps left by the cessation of US support and help to keep us on track towards our collective HIV targets.

These steps won’t replace PEPFAR but they will cushion the blow. It will then fall to the humanity of decision makers in the US to decide whether $153 really is an unbearable price to do the right thing.