PEPFAR: 20 years of saving lives and investing in strengthening health systems

Since it was established in 2003, the United States President's Emergency Plan for AIDS Relief (PEPFAR) has saved more than 25 million lives, prevented millions of HIV infections, and slowed the spread of the HIV epidemic even though no vaccine or cure is available, making it one of the most successful global health initiatives in history.

Much has been written about the remarkable impact of the program, which marked its 20th anniversary in January 2023. Through the provision of timely testing and prophylaxis for pregnant women, PEPFAR has helped ensure 5.5 million children were born HIV-free despite their mother’s HIV positive status. It has supported HIV testing for more than 64 million people, ensuring they know their status and can take precautions to prevent spreading HIV. It has provided care and support to seven million orphans and vulnerable children. It has provided life-saving antiretroviral treatment for more than 20 million people.

But the program has also profoundly reshaped health systems, strengthening them in ways that have made them more effective, efficient, and sustainable – and positioned them to more effectively respond to health crisis.

Initially, from 2004 to 2009, according to the Office of the U.S. Global AIDS Coordinator and Health Diplomacy, PEPFAR’s health system strengthening work was “largely ad hoc in nature” and also lacked “a strategic focus on strengthening each building block of the health system.” Responding to critics, the program quickly adjusted to include a strategic focus on “strengthen overall health systems in high-prevalence countries, including support for workforce training, retention, and effective deployment, capacity building, laboratory development, equipment maintenance and repair, and public health and related public financial management systems and operations” and sought to partner with country governments toward a “deeper integration” of HIV services into existing national programs and systems.

As PEPFAR matured, larger and larger portions of its budget were earmarked for health system strengthening. By 2022, the program was investing more than $1 billion annually in strengthening health systems.

Researchers writing in the Journal of Acquired Immune Deficiency Syndromes noted that evidence "demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up.”

Perhaps the most tangible evidence of this is PEPFAR’s support for training more than 340,000 new health care workers to deliver and improve HIV care and other health services.

For example, in South Africa, PEPFAR helped support the recruitment and training of HIV lay counselors, peer educators, and home-based caregivers during the early days of its response to the AIDS epidemic. Many of these workers have since been retrained as part of a national cadre of 15,000 community health workers and fully integrated into the national health system.

In Rwanda, funds from PEPFAR were used to launch the Human Resources for Health program to combat shortages in health personnel with investments in mentoring and training health workers.

And PEPFAR’s technical support helped ensure these health workers were retained. In Uganda, for example, PEPFAR helped the country improve payment systems for health workers. As a result, the percentage of new health workers receiving their first payment within three months of recruitment increased from 32% in 2009 to 75% in 2013.

These new health care workers, in addition to PEPFAR-supported labs, data collection, and program management systems have helped countries achieve and maintain HIV/AIDS epidemic control and positioned them to respond more nimbly and effectively to future health challenges, researchers say.

That became apparent during the COVID-19 pandemic.

When Tanzania’s leaders decided to roll out COVID vaccinations, they relied on systems initially developed and supported by PEPFAR said Dr. Mahesh Swaminathan, an infectious disease specialist who led the US Center for Disease Control’s partnership with the Tanzanian Ministry of Health to accelerate the pace of COVID-19 vaccinations.

Building on that foundation allowed Tanzania to quickly roll out vaccinations at an exceptional pace. Over the course of four months, from June to September 2022, COVID-19 vaccination rates in Tanzania surged from an average of 15% to 70% of the eligible population (ages 18 and over). By December, 98.9% of adults had received at least one dose. Since that time, the COVID-19 vaccination rate has continued to climb. Today, Tanzania has reached more than 104% of its eligible population with at least one dose of a COVID-19 vaccine, according to US Center for Disease Control data.

According to the Center for Global Development, around the world, PEPFAR-funded laboratories have reportedly conducted millions of COVID-19 screenings and tests, PEPFAR-trained community health workers helped their communities understand the risks of COVID and access testing, and PEPFAR-supported health information systems collected and analyzed data on COVID-19 cases, mortality, and vaccinations.

These same resources were harnessed more recently during the Mpox (formerly known as monkeypox) outbreak, when PEPFAR’s surveillance and diagnostic platforms were again leveraged to support a more robust response.

In its five-year strategy document released in December 2022, PEPFAR pledged to continue its work to strengthen health systems by, in part, better integrating “PEPFAR-funded laboratory, surveillance and data systems, and supply chains within national public health infrastructure. We will help laboratory systems move towards a multiplexed, networked approach to diagnostics across disease areas…” and to “strengthening the health workforce.”