In his second State of the Union address, President Joe Biden asked Americans to come together in a spirit of collaboration to continue progress toward solving some of the most critical social, political, economic and even medical challenges facing the country and the world. His call to “finish the job” extended to reducing inflation, tackling climate change and codifying access to safe and legal abortion services. In proposing that Americans on both sides of the aisle can also cooperate to end cancer, he invoked one of the most successful U.S. foreign aid initiatives in history.
“Twenty years ago, under the leadership of President Bush and countless advocates and champions, we undertook a bipartisan effort through PEPFAR to transform the global fight against HIV/AIDS,” Biden said. “It’s been a huge success.”
Indeed, it has. In 2003, when President George W. Bush launched The President’s Emergency Plan for AIDS Relief (PEPFAR), HIV was ravaging countries throughout sub-Saharan Africa. In that year alone, the World Health Organization reported that 5 million people became newly infected with HIV worldwide and 3 million died. One in five adults across southern Africa was living with HIV/AIDS and, in some countries, more than 1 in 3 people were infected.
In his 2003 address, President Bush asked Congress to support the launch of PEPFAR by committing “$15 billion over the next five years … to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.” According to the president, the creation of PEPFAR would “prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.”
Two decades later, PEPFAR’s accomplishments actually dwarf those originally anticipated by President Bush. Since it was launched, this landmark global health effort has invested over $100 billion in the global HIV/AIDS response, saving an estimated 21 million lives, enabling more than 5.5 million babies to be born free of HIV, and providing over 19 million people with lifesaving antiretroviral treatment that simultaneously allows them to live long, healthy lives while preventing transmission of the virus.
Yes, PEPFAR has been a success, a rousing one at that. Beyond its vast impact measured in lives saved, PEPFAR has served as a model for the possibilities of public health, and, not incidentally, as a shining example of Americans from across the political spectrum coming together to put in place a global effort informed by both fidelity to science and profound compassion.
But the mission is not yet complete. Despite the steady, measurable progress PEPFAR has made possible, HIV is still an ongoing threat to people around the world. Globally, more than 38 million people were living with HIV at the end of 2021. Africans remain the most severely, with nearly 1 in every 25 adults (3.4 percent) living with HIV and accounting for more than two-thirds of the people living with HIV worldwide.
The Joint United Nations Program on HIV/AIDS (UNAIDS) has created a roadmap to lead us to eventual control of the epidemic. The heart of this plan is the 95-95-95 targets that call for 95 percent of all people living with HIV to know their HIV status, 95 percent of all people with diagnosed HIV infection to receive sustained antiretroviral therapy, and 95 percent of all people receiving antiretroviral therapy to have viral suppression by 2025.
These targets, while achievable, will not be reached without persistence, commitment and continued investment. Obstacles ranging from persistent stigma to unproductive national health policies have left significant gaps in coverage. To reach vulnerable groups — including men who have sex with men, adolescent girls and young women, people who inject drugs and others — we must employ intensive and innovative new approaches. And, for those approaches to be effective, all those working in the global HIV response depend on the continued support and vision of PEPFAR.
To be clear, the combination of prevention, care and treatment of HIV that PEPFAR makes possible is a lifeline for individuals, families, communities and nations. But it is much more. By addressing structural gaps in national health systems, training new cadres of health care workers, improving diagnostic capabilities, streamlining management of health data and making disease surveillance more effective, the health strengthening projects that PEPFAR funds lead to economic growth, more vibrant democracies and more just and stable societies — all of which helps lift up countries that have struggled with HIV for decades.
And, as we look at the improving status of the HIV epidemic around the world, we cannot forget that HIV remains an ongoing challenge here at home. Currently, approximately 1.2 million people in the U.S. are living with HIV and about 13 percent of them are unaware of their status and need testing. In 2019, an estimated 34,800 new HIV infections occurred in this country. In addition, Black men who have sex with men are at high risk for acquiring HIV infection, facing formidable structural impediments to accessing HIV prevention, care and treatment services. So, as PEPFAR continues its global response, the White House’s National HIV/AIDS Strategy has set a goal of ending the HIV epidemic in the U.S. by 2030. This will require a similarly vigorous response, with a commensurate commitment of resources.
We are at a pivotal moment in this long struggle to bring HIV/AIDS to heel. We’ve invested much and come so far. Now is not the time to take our foot off the accelerator. Congress and the American people must continue to support PEPFAR — as well as domestic HIV response efforts — until this threat is behind us. Ending AIDS is in the interest of every American and the entire world. Let’s finish the job.
Wafaa El-Sadr, MD, MPH, MPA is the founder and director of the global health center ICAP at Columbia University, professor of Epidemiology and Medicine and the Dr. Mathilde Krim-amfAR Chair of Global Health at Columbia University, and executive vice president of Columbia Global.