PEPFAR at Twenty

This month marks the twentieth anniversary of President George W. Bush’s signature global HIV/AIDS initiative, the President’s Emergency Plan for AIDS Relief, or PEPFAR. From the outset, PEPFAR was profoundly ambitious in its vision, rejecting conventional wisdom about the viability of providing treatment on a massive scale in Africa. Its transformative impact is undeniable, but so too are the ways PEPFAR has come to constrain and distort U.S.-Africa relations. 

When he announced the initiative in his 2003 State of the Union address, President Bush painted a devastating picture of the AIDS crisis in Africa at that time, highlighting the disparity between the nearly thirty million Africans with the virus and the mere fifty thousand Africans accessing treatment at that time. Twenty years and over $110 billion later, twenty-five million lives have been saved around the world. In many cases, PEPFAR has helped to strengthen health systems in partner countries overall, and as the COVID-19 pandemic made clear, those gains affect health security everywhere, including in the United States. PEPFAR enjoys sustained bipartisan support because it delivers real, quantifiable results, and every American can feel proud of what it has accomplished. 

But while celebrating all that the United States and partners overseas have achieved with PEPFAR resources, Washington must reckon with an uncomfortable reality. By the numbers, PEPFAR has made fighting HIV/AIDS the undisputed top priority of the United States in Africa. Roughly 70 percent of U.S. assistance on the continent over the past decade has been aimed at addressing health issues, primarily through PEPFAR. But in 2023, fighting HIV is not the top priority of African governments. It is not the top priority of African citizens, as revealed in poll after poll showing that job creation and, in a number of countries, security issues, are front and center. This mismatch is hard to square with the Biden administration’s rhetoric around building stronger partnerships in the region by recognizing African agency, and policymakers’ sincere desire to base U.S. relations with African states on shared interests, responding to the priorities that Africans themselves have identified. What the United States actually does on the continent, and where we direct the lion’s share of our resources, simply do not comport with that vision. In some contexts, our health spending sits uncomfortably beside the message that U.S. leaders are sending about the degree to which we value democratic governance—a fact that is not lost on our African partners.

The divergence between U.S. and African priorities also means that the contributions U.S. taxpayers are making to assistance in Africa yield less influence than they might otherwise. Over a decade ago, Princeton Lyman and Stephen Wittels wrote in Foreign Affairs about the paradox of PEPFAR, noting how it provided Washington with less leverage than other forms of assistance because no reasonable actor believes that the United States would accept the costs in human life of curtailing it. In other words, the PEPFAR assistance continues to flow regardless of whether the bilateral relationship is positive or not.

But the problem is not just about a reduced capacity to signal a lack of confidence. Resources are finite, and with health programs consuming the majority of them—both in terms of dollars and focus for embassy teams on the ground, the United States is perpetually pursuing all other interests on the continent with what is left over, leading to a proliferation of often under-funded initiatives that may be destined to disappoint on both sides of the Atlantic. Of course foreign assistance is not the only tool in the foreign policy toolbox—but it is an important one, and one that public servants careful about stewardship of taxpayer dollars spend a great deal of their time and attention tracking.

It is not as if PEPFAR is unwelcome or unsupported on the continent, or as if this remarkable U.S. investment has been received with indifference. To the contrary, plenty of African partners, from public health officials to civil society groups devoted to improving the health of their communities appreciate and value the partnership and resources that flow from the United States through PEPFAR. But as most African societies skew younger and younger, a greater proportion of Africans have no memory of the worst of the HIV crisis. When they think of the United States, they are unlikely to think of America’s extraordinary and admirable commitment to fighting AIDS even as it continues on a massive scale, simply because that fight doesn’t factor into the discourse in their communities the way it once did.  PEPFAR is not irrelevant. But its outsized role in U.S. assistance on the ground does not meet the moment. Washington’s efforts to be a relevant, credible partner on the continent will require confronting the PEPFAR dilemma, and finding a responsible path to recalibrating foreign assistance in the region.