The U.S. Program That Brought H.I.V. Treatment to 20 Million People

In the 20 years since its inception, the President’s Emergency Plan for AIDS Relief has delivered lifesaving treatment to more than 20 million people in 54 countries, the most successful global health campaign of its kind, according to a report released on Tuesday.

The $7.5 billion program, housed in the State Department, is due for reauthorization by Congress this year. In the past, it has received strong bipartisan support.

President George W. Bush announced the establishment of Pepfar in January 2003, when treatment for H.I.V. was unavailable in many parts of the world. In 2004, the program began providing antiretroviral drugs to people in Africa.

The initial goal was to treat two million people with H.I.V. over five years. Now, Pepfar is estimated to have saved as many as 25 million lives.

“I knew it was going to be big, but I think it turned out to be even bigger and better than we thought,” Dr. Anthony S. Fauci, the program’s architect, said in an interview. “It should serve as a model of what can be done when you make a major commitment.”

About 38 million people were living with H.I.V. in 2021, and about 29 million of them were receiving treatment. About 650,000 people died from an H.I.V.-related cause that year, and about 1.5 million people became newly infected with the virus.

Antiretroviral drugs can suppress H.I.V. levels, prevent transmission of the virus to sexual partners and cut the risk of transmission from infected pregnant women to their babies.

Pepfar “was trying to do something that had never been done before, to provide treatment to millions of persons with H.I.V. in Africa where there was no care infrastructure,” said Dr. Carlos del Rio, an infectious-disease expert at Emory University in Atlanta and chair of Pepfar’s scientific advisory board.

“Americans should be proud of this amazing program,” Dr. del Rio said.

To assess Pepfar’s success, researchers from the Centers for Disease Control and Prevention analyzed data from six countries that received funding from the program. Between January 2004 and September 2022, the program increased the number of people receiving treatment by 300 times, the team found.

“Pepfar’s efforts have dramatically altered the course of the global H.I.V. epidemic,” the C.D.C.’s chief medical officer, Dr. Debra Houry, said in a statement.

In Uganda, one of the first countries supported by Pepfar, the program has prevented nearly half a million H.I.V. infections since 2004 and saved more than 600,000 lives. In Eswatini, the rate of new H.I.V. infections fell by half from 2011 to 2016.

In Nigeria, the number of people newly diagnosed with H.I.V. who started treatment increased by eight times in 18 months.

Still, H.I.V. treatment is patchy among some vulnerable groups, including young children, pregnant women, men who have sex with men and transgender people. “Eliminating H.I.V. as a global public health threat demands that we understand and address the root causes of health disparities, including stigma, discrimination and social inequities,” Hank Tomlinson, director of the Division of Global H.I.V. & Tuberculosis at the C.D.C., said in a call with reporters on Tuesday.

The C.D.C. is a key implementing agency of Pepfar and has provided treatment to 62 percent of those who have received it. The agency also supports more than 10,000 labs or testing sites worldwide, trains health care workers and strengthens surveillance to detect areas of high need.

The infrastructure Pepfar built “has been critical to confront other infections like Covid and now will be used to tackle other major problems like hypertension and diabetes,” Dr. del Rio said.

The Biden administration named Dr. John Nkengasong to lead the program in 2021, about 18 months after Dr. Deborah Birx, the program’s previous director, left to join the White House coronavirus task force. Dr. Nkengasong is the first person of African origin to head the program.