How PEPFAR helped to save Botswana from extinction 

Twenty years ago, Botswana was facing an existential threat: the HIV/AIDS pandemic. In a speech to the United National General Assembly in June 2001 as president of Botswana, one of us observed: “We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the first magnitude.”    

At the time, Botswana was the most severely infected country in the world; adult HIV prevalence was at 40 percent, with similar levels of HIV transmission from HIV-infected mothers to newborns. Weekends had become one unending funeral service. And it wasn’t just the mortality rate alone that was concerning. Households collapsed as parents succumbed to disease, leaving a generation of orphans. And HIV/AIDS especially was affecting educated professionals and the working population, threatening to erode development gains that Botswana had proudly achieved since attaining independence from Great Britain in 1966.    

While Botswana was an acute case, it was not alone. Southern Africa had become the epicenter of the global pandemic, and there were no obvious solutions to stem this demographic catastrophe. New treatments were beginning to make a difference in high-income countries, but they were not yet available in Africa, and the prices were prohibitive.    

Against this backdrop, as U.S. Health and Human Services secretary, one of us traveled to Botswana in 2002 to see what could be done. While there was immense death and suffering, Botswana was willing to partner with the U.S. government, the private sector, philanthropists, and faith-based organizations to help stem this crisis. Moreover, the government of Botswana was willing to invest its own resources and adopt assertive policies for testing and treating its people. 

Along with Dr. Anthony Fauci and others, we recommended to President Bush that the U.S. provide antiretroviral drugs to assist African countries with a high prevalence of AIDS. The president agreed. He had already made the founding pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2001, but he wanted to do much more. The result was the U.S. President’s Emergency Program for AIDS Relief (PEPFAR), which celebrates its 20th anniversary this year.   

There is no doubt that PEPFAR is the most successful global health and development initiative established by any nation in history. The people of Botswana and other nations in sub-Saharan Africa, Asia, Latin America, and elsewhere have been the essential partners in this generous, unprecedented and bipartisan effort by American taxpayers. PEPFAR has saved more than 25 million lives, helped 5.5 million babies to be born HIV-free, provided HIV testing services to nearly 65 million people, and delivered critical care and support to 7 million orphans and vulnerable children.  

In Botswana, we did our part in cooperation with PEPFAR. As president, one of us provided visionary leadership and increased budgetary resources, mobilized a whole-of-society effort, and identified and eliminated roadblocks to testing and service delivery. The Bill & Melinda Gates Foundation and Merck & Co., Inc., also combined forces with the government in 2000 to create the African Comprehensive HIV/AIDS Partnerships (ACHAP), which continues to save lives.   

As a result of these collective efforts, Botswana became the first African country to achieve the “95-95-95” targets set by UNAIDS and is well on its way to achieving epidemic control. Maternal-fetal transmission of HIV infection has become rare, rather than a worrying daily reality. And health life-expectancy has returned to levels not seen since before the AIDS epidemic began.     

PEPFAR’s support was absolutely critical to helping the people of Botswana in their fight against HIV/AIDS. PEPFAR also has been a smart investment for the American people, one that delivers high levels of return that reverberate far beyond HIV alone, as we discovered during the COVID-19 pandemic, when the contributions to health care infrastructure and the health workforce made by PEPFAR helped countries like Botswana to weather the storm.    

Throughout its 20-year history, PEPFAR has provided an innovative model that has brought meaningful change to the HIV and health landscapes in Botswana and other partner countries. It has been an honor for us to work side-by-side with PEPFAR and its many implementing partners to transform the approach to what was once a dreaded disease.   

The U.S. Congress and the American people have shown exemplary leadership in the global fight against HIV/AIDS. There is still more work to do — and an expeditious, bipartisan, five-year reauthorization of PEPFAR will help us to reach our shared goal of an HIV-free world.   

Festus Mogae was president of the Republic of Botswana from 1998 to 2008. Tommy Thompson was secretary of the U.S. Department of Health and Human Services from 2001 to 2005.