The President's Emergency Plan for AIDS Relief (PEPFAR) is arguably the most effective foreign-aid programme ever introduced. It was created in 2003 by President George W. Bush to fight HIV/AIDS and is thought to have saved some 26m lives by providing anti-retroviral (ARV) treatment to those infected and helping to reduce new HIV infections.
About three-quarters of foreign aid devoted to combating HIV in poor and middle-income countries comes from America's taxpayers, disbursed both directly by PEPFAR and indirectly via a grant to the Global Fund. PEPFAR also contributes to the fund, though this contribution cannot now exceed 20% of total contributions (down from about 33%).
America supplied more than two-thirds of the bilateral aid for public health in sub-Saharan Africa. In 21 African countries American aid equalled at least 20% of government health spending; in eight it exceeded 50%; and in three—Somalia, South Sudan and Malawi—it exceeded government spending outright. America was also the largest single donor to UN agencies including Unicef, the World Health Organisation and the World Food Programme.
In early 2025 PEPFAR fell victim to Donald Trump's cull of American foreign aid. A "stop-work" order halted its activities. A waiver was soon issued to continue "life-saving humanitarian assistance"--mainly dispensing ARV drugs and offering pre-exposure prophylactic (PrEP) medicine to pregnant women and nursing mothers to prevent mother-to-child transmission. A subsequent threat to claw back $400m from the current year's budget was averted. The administration asked Congress for $2.9bn for the following year, down $1.9bn.
The stop-work order caused scores, probably hundreds, of PEPFAR-supported clinics and community-based projects to lay off staff and close. Even after re-opening for more limited operations, restarting proved tricky: staff had to be re-recruited, systems rebooted and trust re-established among patients.
The administration's "America First Global Health Strategy" aimed to protect Americans from infectious disease while bypassing the "wasteful" projects of NGOs. The strategy routes assistance mainly through recipient-country governments—in effect copying China's playbook—and pledges that most will reach "full self-reliance". The administration proposed cutting bilateral health-aid funding by two-thirds. Marco Rubio, the secretary of state, denied that the dismantling of USAID had caused any deaths.
A 2025 study in the Lancet estimated that 500,000 additional children could die by 2030 if PEPFAR ceased operations. UNAIDS suggested an extra 6m HIV infections and 4m deaths by 2029. In practice PEPFAR is scaling back rather than ceasing, but a rise in infections in the short run seems inevitable.
The main consequence of budget reductions is to throw responsibility back to recipient countries. Of 61 countries surveyed by UNAIDS, 26 responded by increasing their AIDS budgets. Nigeria, Tanzania and Zimbabwe have earmarked certain tax receipts specifically for AIDS. Ethiopia, Tanzania and Zambia are integrating their AIDS programmes into mainstream national-health services.
It is better never to have been born. But who among us has such luck? One in a million, perhaps.