The path forward: Three case studies to guide PEPFAR into the future | George W. Bush Presidential Center

Examining the impact that over 20 years of U.S. global health engagement has had on the HIV/AIDS pandemic and the tools needed to sustain these efforts for years to come.

Many low- and middle-income countries were experiencing unprecedented death and despair in 2003 because of the HIV/AIDS pandemic. The United States responded through a data-driven response that changed the course of history.

Thanks to two decades of generous investment by the American people through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, fewer people were newly diagnosed with HIV in 2023 than in any year since before 1990. PEPFAR has saved over 25 million lives and prevented over 5.5 million babies from being born with HIV since 2003. And AIDS-related deaths were at their lowest level since the peak in 2004 in the latest assessment of the global pandemic by UNAIDS in 2023.

The HIV pandemic hit Africa the hardest. While the continent is home to more than half of all people living with HIV, Africa also has made the greatest progress toward eliminating HIV as a public health threat. Since 2015, HIV infections in Africa have declined by 56%, and, for the first time in history, there are more new HIV cases outside of sub-Saharan Africa than within the region. Thanks to PEPFAR-supported programs to prevent mother-to-child transmission of the virus, the number of children infected with HIV across Eastern and Southern Africa has declined by 73% since 2010.

Source: UNAIDS

Source: UNAIDS

In addition, UNAIDS projects that more than 30 million people were receiving highly effective antiretroviral therapy (ART) in 2023, a record high. This means that 77% of people with HIV were on ART last year, compared with only 47% in 2015.

But the world needs to chart an aggressive course to achieve the target set in the U.N.’s sustainable development goals (SDGs) to end AIDS as a public health threat by 2030. Despite significant investments and resources, many countries are not on track to meet the 2025 interim targets for AIDS-related deaths and new HIV infections.

High-level global and regional data can only tell us so much about the successes and struggles that really matter – the actual progress made toward ending AIDS as a public health threat in each country. In 2016, the U.N. General Assembly endorsed three ambitious goals meant to help governments, civil society, and communities focus their efforts through 2030:

Data recently published by UNAIDS show that progress toward these “95-95-95” targets is dramatically uneven. This article will use case studies to examine what national governments, donors, and communities have done in countries to support the achievement of the 95-95-95 goals. We explore what is left to do in countries that are within striking distance of meeting the targets by 2030 and what has gone wrong in countries that are still far behind. Each case study includes recommendations for urgent action.

The key findings of the “PEPFAR Beyond 2030” case studies highlight the importance of data-driven, community-focused approaches to achieve the 95-95-95 targets for HIV. Success stories like Botswana and Zambia demonstrate that reinforcing political will, tailoring interventions, and decentralizing resources have significantly reduced new infections and improved treatment outcomes. However, countries like the Philippines and Ghana remain off track, facing barriers such as stigma, inadequate policies, and limited national funding. The studies underscore the need for continuous adaptation, evidence-based policy reforms, and stronger partnerships to sustain progress and meet future goals.

The leaders – countries achieving the 95-95-95 targets

On the right path – countries on track to achieve the 95-95-95 targets

Off-track – countries currently not close to achieving the 95-95-95 targets

*Not available at time of publication.

The Republics of Botswana and Zambia have made steady progress toward achieving the 95-95-95 targets. Both teach us several lessons for combating HIV and the clear role of PEPFAR’s leadership:

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Several countries are on the right path to meet the 95-95-95 targets by 2030 due to PEPFAR support – including the United Republic of Tanzania and Vietnam – and can teach us important lessons:

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Some countries are struggling to meet the 95-95-95 targets by 2030, including the Republics of the Philippines and Ghana. Without immediate change, these countries will continue to lag behind and fail to achieve international goals. Both countries teach us several lessons:

Read the full case study

The Bush Institute would like to thank Neeta Bhandari, Senior Program Officer, Global Health at the Gates Foundation; Crystal Cazier, Manager, Business Strategy and Development, Global Tuberculosis Program at Baylor College of Medicine; and Dr. Jirair Ratevosian, Hock Infectious Disease Fellow at the Duke Global Health Institute for their review of this paper.