Envisioning the Future for a Celebrated Global AIDS Program

As Congress deliberates the future of PEPFAR, the President’s Emergency Plan for AIDS Relief, a group of Duke University public and global health researchers has drafted a plan to refresh the 22-year-old government program’s strategy and operations to better fit a new era in the global fight against AIDS and HIV. 

The report, “Reform and Renewal: Five Recommendations for PEPFAR,” offers a roadmap for Congress to sustain PEPFAR’s remarkable legacy while realigning it for a changing global landscape in HIV prevention and treatment, says Chris Beyrer, M.D., director of the Duke Global Health Institute and one of the report’s authors. 

Launched in 2003, PEPFAR has been a cornerstone of U.S. global health efforts, providing life-saving treatment and prevention services to more than 20 million people living with HIV across 54 countries. The program has been credited with saving more than 26 million lives and slowing the spread of HIV in many countries, particularly in sub-Saharan Africa. 

With increased scrutiny on U.S. foreign aid programs, however, it is unclear if Congress will vote to continue the program as it exists now before its one-year authorization expires on March 25.

The report -- written by Duke Global Health Institute researchers Beyrer, Dorothy Dow, M.D.; Osondu Ogbuoji, MBBS, ScD, Jirair Ratevosian, DrPH; and Gavin Yamey, M.D., and Lance Okeke, M.D., of the Duke Center for AIDS Research – outlines reforms that would reduce program costs by 20 percent within five years and create clearer paths to transition program management to local leadership. It also calls for increasing HIV prevention and treatment activities in Latin America, Eastern Europe, and Central and Southeast Asia, where HIV infection rates remain high and in some cases are rising.

“Our proposed reforms will strengthen PEPFAR’s life-saving HIV mission while accelerating a strategic transition to local ownership and sustainability," says Ratevosian, the Hock Postdoctoral Research Fellow at DGHI and the report's lead author. "By enabling PEPFAR to adapt to a rapidly changing global landscape, these reforms will ensure high-impact, cost-effective solutions while achieving $3 billion to $4 billion in budget savings over the next five years. To realize this vision, Congress must support PEPFAR’s evolution, safeguarding its legacy as a model of effective American leadership.”

“Without bold reforms, the program risks losing the momentum that has defined its success over the past two decades,” the researchers write in the report. “To ensure its lasting impact, PEPFAR must work with governments and implementing partners to accelerate the sustainability of its health investments, while realigning with broader U.S. economic and diplomatic priorities.”