PEPFAR, 2004–2022: HIV Treatment Grew 300-Fold, to 20 Million People in 54 Countries

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), announced in January 2003, is the largest commitment by any nation to fight a single disease. Led by the Department of State and carried out by seven U.S. government departments and agencies, CDC among them, it began providing HIV antiretroviral therapy (ART) in 2004. Its first goals: prevent 7 million infections, treat 2 million people, and care for people with AIDS and children orphaned by it. At the time about 30 million people in Africa had HIV — 3 million of them under 15 — and only 50,000 were on treatment.

Effective ART keeps the virus suppressed, which reduces illness and death, prevents transmission from mother to baby (with preventive treatment for the infant), and prevents sexual transmission once the virus is undetectable (under 200 copies per mL of blood).

People on lifesaving HIV treatment through PEPFAR rose 300-fold in under 20 years. CDC

The scale-up

• By September 2022, 20,166,110 people with HIV in 54 countries were on PEPFAR-supported ART — 300 times the 66,550 of September 2004. CDC's implementing partners supported 62% of them (about half in 2010).
• From 2015 to 2022, the share of eligible people who got a viral load test rose from 24% to 80% (from 2,109,749 to 14,875,130 tests a year).
• Among those tested, viral suppression (under 1,000 copies per mL) rose from 80% to 95% — reaching the UNAIDS target of 95%.

People receiving PEPFAR-supported antiretroviral therapy, by CDC and other agencies, fiscal years 2004–2022. CDC / MMWR

Population surveys in Eswatini, Lesotho, Malawi, Uganda, Zambia and Zimbabwe, each surveyed twice from 2015 to 2021, showed suppression rising across whole populations, not just among PEPFAR patients — from 59.2% (Zambia) to 73.1% (Eswatini) in the first round and 75.4% (Uganda) to 88.6% (Eswatini) in the second — generally higher in older people and in women.

The results show up in lives: in Uganda, the first PEPFAR country, ART since 2004 has helped avert an estimated 500,000 infections — about 230,000 among babies exposed to HIV — and 600,000 HIV-related deaths. In Eswatini, national HIV incidence nearly halved and suppression doubled from 2011 to 2016.

Viral load tests, coverage and suppression among people on PEPFAR-supported antiretroviral therapy. CDC / MMWR

Stronger health systems

These investments help beyond HIV. During COVID-19, PEPFAR countries kept their HIV gains while fighting the pandemic: in Nigeria, a CDC-supported push in nine states raised the number on ART by 26% (110,815) in April–September 2020 alone, and from April 2020 to March 2021 PEPFAR-supported labs and sites in 16 countries ran about 3.4 million SARS-CoV-2 tests. PEPFAR-trained workers have also tackled cholera and Ebola.

Who is left behind

Worldwide in 2021, 10 million people with HIV were not on treatment. Within PEPFAR programs:

• Viral load testing lagged among children under 10, men, pregnant women (only 31% in 2022, up from 18%), men who have sex with men, people in prisons (down from 75% to 57%, 2020–2022) and transgender people (down from 71% to 67%).
• Suppression was lower among pregnant and breastfeeding women, people in prisons (unchanged at 93%) and — much lower — people under 20.

Stigma and discrimination remain big barriers; in sub-Saharan Africa, HIV is far more common among men who have sex with men and transgender women than in the general population. Ending HIV as a global threat — PEPFAR's aim for 2030 — means sustaining the gains and reaching every group.

Limits

Definitions, data systems, sites, national guidelines and access have all changed over time; subgroup membership may be misclassified; coverage is a proxy; labs may be undercounted; and program data cannot be compared directly with survey results.

Sources

Based on Chun HM, Dirlikov E, Hurlston Cox M, et al., "Vital Signs: Progress Toward Eliminating HIV as a Global Public Health Threat Through Scale-Up of Antiretroviral Therapy and Health System Strengthening Supported by the U.S. President's Emergency Plan for AIDS Relief — Worldwide, 2004–2022," MMWR Morbidity and Mortality Weekly Report, volume 72, posted March 14, 2023, Centers for Disease Control and Prevention; a work of the United States government in the public domain.