An Oral History of PEPFAR

How a "Dream Big" Partnership is Saving the Lives of Millions

In 2001, the HIV/AIDS crisis in Africa had reached new heights. Death tolls were in the tens of millions. Hospitals were overwhelmed. And the infection rates continued to rise. The United States faced a choice: respond to a call for help or watch a generation of lives be lost.

Authors
Learn more about Crystal Cazier.
Crystal Cazier
Former Deputy Director, Global Health
George W. Bush Institute
Learn more about Andrew Kaufmann.
Andrew Kaufmann
Director, Communications and Marketing
George W. Bush Presidential Center

Twenty years after the passage of the United States President’s Emergency Plan for AIDS Relief, what was once a death sentence is no longer one. Thanks to the generosity of the American people’s investments in PEPFAR, along with the political will of national leaders, dedication of communities, and commitment of engaged stakeholders, people with HIV/AIDS are able to live long and hopeful lives. Incredible gains have been made in the fight against HIV/AIDS. Recent estimates place the number of lives saved so far at 25 million.

But challenges remain1. More than 1.5 million people worldwide were newly infected with HIV in 2021; children, adolescent girls and young women, and key populations are bearing a disproportionate share of the burden; and people living with HIV remain vulnerable to other life-threatening diseases including cervical cancer and tuberculosis.

When we look back to the situation in the early 2000s — when saying that an entire generation of lives could be lost was no exaggeration — we realize how far we’ve come. And as importantly, that we need to keep going. In this oral history, compiled from multiple first-person accounts*, we look back at the decisions facing leaders in the U.S. and abroad — and how those decisions saved millions of lives.

*Accounts include memoirs, speeches, Congressional records, documentaries, conference speaking opportunities, written articles, and government updates from more than 40 speakers. Some quotes are adjusted slightly for clarity and abridged for brevity. Speakers are attributed by their title or role in the global AIDS response.

This piece was originally published November 2018, and has been updated since then.

2000-2001

A Generation in Peril

In the early 2000s, an estimated 36 million people were living with HIV/AIDS and nearly 22 million lives had been claimed2. Without proper access to treatment and resources, AIDS was a death sentence. And while those drugs were available in developed countries, few in Africa had any hope of receiving treatment.

George W. Bush
U.S. President (2001-2009)

“Condi Rice and I spent long hours discussing foreign policy on the back porch of the Governor’s Mansion. One day our conversation turned to Africa. Condi had strong feelings on the subject. She felt Africa had great potential, but had too often been neglected. We agreed that Africa would be a serious part of my foreign policy.”
Source

Condoleezza Rice
U.S. National Security Advisor (2001-2005)
U.S. Secretary of State (2005-2009)

“At one of my first meetings with then Governor Bush in 1999, we agreed that our agenda in Africa would go nowhere if we did not address the scourge of AIDS… there were estimates of up to 100 million deaths over the next twenty years if something was not done to arrest the plague.”
Source

Festus Mogae
President of Botswana (1998-2008)

“We really are in a national crisis. We are threatened with extinction. People are dying in chillingly high numbers. We are losing the best of young people. It is a crisis of the first magnitude.”
Source

Mark Dybul
PEPFAR Architect
A principal architect of PEPFAR while with the U.S. National Institute of Allergy and Infectious Diseases
U.S. Global AIDS Coordinator (2006-2009)
Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2012-2017)

“At one point, 75 percent of pregnant women had HIV in Botswana. Most diseases kill the very old and the very young. But this disease was killing the most productive and reproductive parts of society. So not only were many households run by orphans, but entire villages were run by orphans, because everyone [else] was dead.”
Source

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“You’d go to towns, and you’d see grandparents and grandchildren. And the entire intervening generation was gone. Like a neutron bomb that destroyed a generation… we were facing a cresting wave of death.”
Source

George W. Bush
U.S. President (2001-2009)

“The statistics were horrifying. Some ten million people in sub-Saharan Africa had died. In some countries, one out of every four adults carried HIV… the United Nations projected that AIDS could be the worst epidemic since the bubonic plague of the Middle Ages.”
Source

Barbara Lee
U.S. Representative (D-California, 1998-present)

“We cannot sacrifice this generation of children on the altar of indifference. The AIDS epidemic has cut life expectancy by 25 years in some countries. It is a crisis of biblical proportions in Africa and puts the very survival of the continent at stake. This is not only a humanitarian crisis, it is a looming economic, political and social catastrophe. It is a national security threat. We must continue to raise awareness about the global crisis and this deadly disease and escalate our efforts to find solutions. HIV-AIDS is not a Democratic or Republican issue. It is a disease that threatens the entire human family.”
Source

2001-2002

First Steps

On May 11, 2001, President Bush announced action to fight the devastation across the globe by making the first contribution to the Global Fund to Fight AIDS, Malaria, and Tuberculosis. Joined by Nigerian President Olusegun Obasanjo and U.N. Secretary General Kofi Annan, he noted that “the sheer number of those infected and dying is almost beyond comprehension.” AIDS alone had left more than 11 million orphans in sub-Sahara Africa, and in several African countries, as many as half of the 15-year-olds could die of AIDS.

“We have the power to help.”

George W. Bush
U.S. President (2001-2009)

“We have the power to help. The United States is committed to working with other nations to reduce suffering and to spare lives. And working together is the key…Our high-level task force chaired by Secretaries (Colin) Powell and (Tommy) Thompson has developed a proposal that we have shared with U.N. officials, developing nations and our G-8 partners. We will need ideas from all sources. We must all show leadership and all share responsibility.

“For our part, I am today committing the United States of America to support a new worldwide fund with a founding contribution of $200 million. This is in addition to the billions we spend on research and to the $760 million we’re spending this year to help the international effort to fight AIDS. This $200 million will go exclusively to a global fund, with more to follow as we learn where our support can be most effective.”
Source

Kofi Annan
U.N. Secretary General (1997-2006)

“To defeat this epidemic that haunts humanity and to give hope to the millions infected with the virus, we need a response that matches the challenge. We should now build on the remarkable progress over the last year in galvanizing global awareness of the threat of HIV/AIDS.”
Source

Olusegun Obasanjo
President of Nigeria (1999-2007)

“Today, Mr. President, you have begun to concreteize that hope for Africa, and particularly for millions of Africans infected and affected by HIV/AIDS.”

A year later, President Bush escalated the fight on HIV/AIDS. On June 19, 2002, he announced a new Mother and Child HIV Prevention Initiative, under The Global Fund to Fight AIDS, Tuberculosis, and Malaria that was intended to treat HIV-infected women with an antiretroviral drug to block transmission of the virus from pregnant or nursing mother to child. By building the healthcare delivery capacity, this new effort was expected to greatly expand the reach of care. As importantly, the administration set a concrete benchmark — as it would do with future investments.

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-2022)

“President Bush sent (Secretary of Health and Human Services) Tommy Thompson and I, together with a group, on a fact-finding mission to various African countries to scope out what was going on down there. When we came back, he asked me to put together a mother-to-child transmission initiative, because it was just then that Nevirapine was shown in a single dose to mother followed by a single dose to baby right after birth had a major impact on blocking transmission from mother to child.

“I made a proposal to the President… that a $500 million investment in mother to child transmission would be a very important contribution.”
Source

George W. Bush
U.S. President (2001-2009)

“The wasted human lives… are a call to action for every person on the planet and for every government. So, today, my administration is announcing another important new initiative in the fight against HIV/AIDS.

“Our initiative will focus on 12 countries in Africa and others in the Caribbean where the problem is most severe and where our help can make the greatest amount of difference. We’ll pursue medical strategies that have a proven track record. We’ll define specific goals. We will demand effective management. When the lives of babies and mothers are at stake, the only measure of compassion is real results.”
Source

Mark Dybul
PEPFAR Architect
A principal architect of PEPFAR while with the U.S. National Institute of Allergy and Infectious Diseases
U.S. Global AIDS Coordinator (2006-2009)
Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2012-2017)

“The world was moving, but moving slowly. People weren’t thinking big. They were thinking a little here, a little there… no one was thinking billions… that we have to really get after this thing. We were thinking $500 million was a lot of money. But the President was thinking something much bigger.”
Source

Joshua Bolten
White House Deputy Chief of Staff for Policy (2001-2003)
Director of the Office of Management and Budget (2003-2006)
White House Chief of Staff (2006-2009)

“President Bush thought the mother-to-child transmission program was a great start, but he wanted to do more to address the problem of AIDS in Africa. His exact words were, ‘Think big.'”
Source

The HIV/AIDS pandemic continued to worsen. By the end of 2002, more than 40 million people were living with HIV and the death toll was rising, leaving more than 14 million children orphaned. Hospitals throughout sub-Saharan Africa were overwhelmed by the number of people needing help. In the worst-affected countries, life expectancy had decreased by 20 years.

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“The mother to child transmission announcement had a strange effect. It was a great program, but it revealed how pitiful what we were doing was. The scale of the need, compared to what we were doing… it was just not sufficient.”
Source

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-2022)

“President Bush told me, ‘Make it something much bigger, I want a game changer for Africa. I want you to go and get multiple models and come back and work with the staff to see what we can do to really turn things around in Africa. I want it to be feasible, I want it to be implementable, and I want it to be accountable. I don’t want to just give money to foreign countries and say go do it.'”
Source

Joshua Bolten
White House Deputy Chief of Staff for Policy (2001-2003)
Director of the Office of Management and Budget (2003-2006)
White House Chief of Staff (2006-2009) Full bio

“He wanted to do something game-changing. Something that, instead of at the margins assuaging everybody’s conscience, might actually change the trajectory of this disease which, from the reports we were getting, was headed to destroy a whole continent.”
Source

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“The President wanted measurable outputs, which translated into numerical goals. Which was just completely unknown in foreign assistance. It was a revolution in the way foreign assistance was done.”

Up to this point, Anthony Fauci and Mark Dybul had worked on clinical trials in Africa to research the feasibility of various approaches of delivering antiretroviral care. Modeled after a clinic in Uganda’s capital created by Peter Mugyenyi and a program in rural Uganda from the AIDS Support Organization, Dybul and Fauci formed the early versions of what would eventually become the foundation of PEPFAR.

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-2022)

“Peter Mugyenyi had a model that had a central core of treatment, with clinics, and it became less sophisticated care as you went out farther and farther from the center. But everything was linked together.”
Source

Mark Dybul
PEPFAR Architect
A principal architect of PEPFAR while with the U.S. National Institute of Allergy and Infectious Diseases
U.S. Global AIDS Coordinator (2006-2009)
Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2012-2017)

“[The trials] showed me that it was possible to treat AIDS both in clinic and through rural outreach.”
Source

Planning in earnest for an approach that leveraged new developments in antiretrovirals that could prolong the life of AIDS patients began in August of 2002, with Fauci and Dybul making regular visits to the White House to work through details. In November, Joshua Bolten asked Fauci and Dybul to provide a panel of experts that had real-world experience in delivering the drugs in developing nations.

This meeting — whose topic was intended to be a surprise to its guests, though Fauci secretly gave them warning — would serve as a final litmus test before White House officials made their recommendations to the President.

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-2022)

“They wanted validation of this plan from people who are implementing treatment and care in the developing world. They want to know whether I am giving them a completely unrealistic pie-in-the-sky fantasy.”
Source

Eric Goosby
CEO and Chief Medical Officer of Pangaea Global AIDS Foundation (2001-2009), who worked in Rwanda
U.S. Global AIDS Coordinator (2009-2013)

“The discussion was real blood and guts. It was things like, ‘What do you confront most often, what did you put in place, why did you think you could do it, what kind of lab support did you need, how did you keep track of the patients, how many patients stopped taking medicine?”
Source

Paul Farmer
Co-Founder of Partners in Health

“We don’t have doctors posted in villages now where people are treated and monitored. We have community health workers, and they deliver a higher standard of care from what I have seen in many U.S. settings. In fact, we have introduced this same model with community health workers in Boston, in the shadows of the teaching hospitals, and we can do it much more quickly and efficiently than they do it here.”
Source

Peter Mugyenyi
Co-Founder, Joint Clinical Research Center in Uganda

“The carnage of AIDS in Africa constituted a moral imperative to act; that it was a catastrophe of astronomical proportions of people dying when they could have been saved, and the U.S. was in a position to stop it. AIDS could be treated in Africa and treated with as good an outcome as was achievable in the US.”
Source

In early December, a small team made their recommendations to the President in the Oval Office. After discussion, the President told them he was ready to announce a plan at the State of the Union address in January. The advisory team had moved quickly in part because it had moved quietly, dodging the bureaucracy of the federal government.

Condoleezza Rice
U.S. National Security Advisor (2001-2005)
U.S. Secretary of State (2005-2009)

“The President turned to each of us and asked whether he should proceed [with the plan, knowing that drugs could prolong life but a cure was not available]. When he turned to me, I said, ‘Mr. President, one of the saddest days of my life was when my mother died. But I have always been grateful that she survived her initial bout with cancer. She died when I was thirty, not fifteen. That meant she saw me grow up, graduate from college, and become a professor at Stanford. You may not be able to cure those mothers in Africa, but maybe they’ll live long enough to see their kids grow up. That will matter.”
Source

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“I remember thinking in the aftermath of that meeting, that from a historical perspective… there had been other meetings around tables of government leaders in Moscow, and Beijing, and Berlin in the 20th century, where plans had been made to murder millions of people. And I got to be in a meeting where the President of the United States made the decision to save millions of people.”
Source

George W. Bush
U.S. President (2001-2009)

“I was confident I could explain how saving lives in Africa served our strategic and moral interests. Healthier societies would be less likely to breed terror or genocide. They would be more prosperous and better able to afford our goods and services. People uncertain of America’s motives would see our generosity and compassion. And I believed the American people would be more supportive if we could show that their tax dollars were saving lives.”
Source

2003

Making the Leap

In 2003, with Dr. Mugyenyi at the side of Mrs. Bush at the State of the Union, the President unveiled the President's Emergency Plan for AIDS Relief (PEPFAR). In his speech, the President requested $15 billion for combating global HIV/AIDS primarily in fifteen countries, twelve of them in Africa. The plan was designed to prevent seven million new HIV infections, treat at least two million people with life-extending antiretroviral drugs, and provide humane care for 10 million people suffering from AIDS and for children who had lost one or both parents to AIDS.

George W. Bush
U.S. President (2001-2009)

“Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many. We have confronted, and will continue to confront, HIV/AIDS in our own country. And to meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief, a work of mercy beyond all current international efforts to help the people of Africa. I ask the Congress to commit $15 billion over the next five years… to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.”
Source

Peter Mugyenyi
Head of the Joint Clinical Research Center in Uganda

“We will save the others. Help is coming.”
Source

Jim Yong Kim
Co-founder, Partners in Health

“I was blindsided. I couldn’t believe it. I mean this was really an incredibly gutsy decision to make, and it was done, as far as we can tell, I’ve never spoken to him about this, it was done on the basis of compassion.”
Source

President Bush had announced his plan – but now had to make sure that the American taxpayers and their representatives would be on board as the bill went through the legislative process. Both houses of Congress recognized the urgency of the matter, and the bill received bipartisan support.

Henry Hyde
U.S. Representative (R-Illinois, 1975-2007) and Chairman of the House Foreign Affairs Committee (2001-2007)

“Today we have an opportunity to do something significant and of lasting importance. Today we have an obligation to do something reflecting our commitment. We have a privilege – the privilege of doing something truly compassionate. The HIV/AIDS pandemic is not only a humanitarian crisis. Increasingly, it’s a threat to the security of the developing world.”
Source

Tom Lantos
U.S. Representative (D-California, 1981-2008)

“I rise in strong support of this grand humanitarian legislation and I urge all of my colleagues to make history today by securing its passage.”
Source

Richard Lugar
U.S. Senator (R-Indiana, 1977-2013) and Chairman of the Senate Foreign Relations Committee (2003-2007)

“[HIV/AIDS] has imposed a crushing burden on the economies of numerous African nations; it has exacerbated undercurrents of political instability that weaken the fundamentals of responsible government; and it has destroyed millions of family units… The President has recognized the urgency of moving forward at this moment in history and has announced his support very solidly… We must join him in this effort.”
Source

Joe Biden
U.S. Senator (D-Delaware, 1973-2009)

“HIV/AIDS is the worst epidemic that mankind has ever seen. It is a source of instability. It is highly damaging to economic development in some of the poorest countries of the world. It is a humanitarian disaster. It is, in short, a national security issue, and will be for the foreseeable future. It is right and proper that the Congress and the President work together to develop a comprehensive program of assistance. As the world’s leading economic power, we have a responsibility to lead the world in fighting this plague.”
Source

Tom Daschle
U.S. Senator (D-South Dakota, 1987-2005) and Senate Minority Leader (2003-2005)
“This bill offers the beginning of real hope. This bill holds out the promise that some of those children will grow to be adults and perhaps have children on their own. I am convinced that, if we combine America’s resources and technology and the great compassion of the American people with the courage and hope shown by (South African) Mary and so many others, we will defeat this disease.

“HIV/AIDS is the great humanitarian crisis of our time. But it is more than a humanitarian crisis. AIDS is a national security issue. It is a public health issue. It is an economic issue. And it is a moral issue. We have the tools to fight this disease. It is our duty and our obligation to use them.”
Source

Bill Frist
U.S. Senator (R-Tennessee, 1995-2007) and Senate Majority Leader (2003-2007)

“History will judge whether a world led by America stood by and let transpire one of the greatest destructions of human life in recorded history — or performed one of its most heroic rescues. President Bush has opened the door to that latter possibility. We must pass this legislation now and get this program established without further delay. The President’s Global AIDS Initiative is a rare opportunity to enact legislation that will save hundreds of thousands – millions – of lives.

“This is our moment.”
Source

2003-2007

Turning a Pledge into Actions and Results

PEPFAR was signed into law with bipartisan support in May of 2003. America would lead the way in addressing HIV/AIDS with PEPFAR, the largest commitment in the history of any nation for a single disease.

It began by ensuring PEPFAR had the freedom and resources to be effective. By placing PEPFAR within the State Department of the U.S. government, it was ensured both programmatic and budget oversight of the HIV response across multiple implementing agencies including USAID, the Department of Defense, Health and Human Services, and the Food and Drug Administration. Those agencies each had different missions, but PEPFAR was able to harness diplomatic, developmental, and health expertise from across the government.

PEPFAR changed the development paradigm from donor-recipient to the ethic of a partnership; this required strong leadership to move from a fragmented response with various players to the oversight and coordination by a non-implementing entity of multiple budget lines across several implementing agencies.

In support of PEPFAR, President and Mrs. Bush traveled to Africa multiple times during, and since, their time in office and saw the effects of the HIV/AIDS pandemic firsthand – as well as the hope brought through progress.

George W. Bush
U.S. President (2001-2009)
“Laura and I had met Mohamad in Entebbe, Uganda, at a clinic run by The AIDS Support Organization (TASO). Like most suffering the advanced stages of the disease, Mohamad was wasting away.

“I expected TASO to be a place of abject hopelessness. But it was not… a choir of children, many of them orphans who had lost parents to AIDS, sang hymns that proclaimed their faith and hope. They ended with a sweet rendition of ‘America the Beautiful.’

“‘I have a dream,’ Mohamed told me from his hospital bed. ‘One day, I will come to the United States.’”
Source

Laura Bush
U.S. First Lady (2001-2009)

“The toll from AIDS is enormous, but the numbers cannot capture the consequences. One in particular is orphan children running their own households. In Rwanda I met a girl named Tatu, who had lost her father to genocide when she was only two; her mother had died of AIDS when she was eleven. Now twelve, she was caring for three small half brothers, ages eight, six and three. She had been abandoned a third time by an older brother, who after their mother’s death had returned to the family house, sold it, and disappeared with the money. Tatu had dropped out of school to work and was hawking fruit at a market stand to provide for her younger siblings. She sobbed as she spoke, and I took her into my arms.”

Barbara Bush
Daughter of President and Mrs. Bush

“In Uganda, I was talking to a woman who had brought her little beautiful daughter to the launch of PEPFAR. As I was talking to the mother, [who] had dressed her little girl up, I said, ‘How old is your daughter, she’s so beautiful. Is she 3?’ And the mom said, ‘No, she’s 7.’

“She was just small, not because she was young but small because she was born [HIV positive] at the wrong place at the wrong time.”
Source

Intended as a medical version of the Marshall Plan after World War II, the intent of PEPFAR was not to simply send money overseas. Key components of PEPFAR were its innovative methods of delivering aid as Fauci and Dybul envisioned it, including its partnerships with the countries involved.

George W. Bush
U.S. President (2001-2009)

“Africa has the will to fight AIDS, but it needs the resources, as well. You are not alone in this fight. America has decided to act… we’ll work with governments and private groups and faith-based organizations to put in place a comprehensive system to prevent, to diagnose, and to treat AIDS.”
Source

Mark Dybul
PEPFAR Architect
A principal architect of PEPFAR while with the U.S. National Institute of Allergy and Infectious Diseases
U.S. Global AIDS Coordinator (2006-2009)
Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2012-2017)

“We were doing work in Africa, we saw people delivering ARVs by motor scooter… we knew it was possible. We knew it was possible to treat. We knew prevention was possible.”
Source

George W. Bush
U.S. President (2001-2009)

“The traditional model of foreign aid was paternalistic: A wealthy donor nation wrote a check and told the recipient how to spend it. I decided to take a new approach in Africa and elsewhere in the developing world. We would base our relationships on partnerships, not paternalism. We would trust developing countries to design their own strategies for using American taxpayer dollars. In return, they would measure their performance and be held accountable.”
Source

Paul Farmer
Co-Founder of Partners in Health

“We had faith in this, almost unwavering faith, about the slender amount of data on which to base a major health initiative. There was no reason to believe that the treatment of Africans would be any different than the treatment of Americans.”
Source

Carol Thompson
Director, White House Office of National AIDS Policy (2004-2006)

“Faith-based organizations have made, and continue to make, incredible contributions to the fight against HIV/AIDS. Combined evidence suggests that religious organizations and other opinion leaders in African nations who advocated abstinence and fidelity have had a significant effect on the overall decline in the HIV infection rate.”
Source

Marked results were not seen immediately, as predicted by the plan President Bush put forward. Early foundation building such as strategizing, mobilizing manpower, and building infrastructure were necessary first steps.

But by the end of 2005, the numbers started to quickly ramp up: 401,000 individuals were receiving antiretroviral treatment in the 15 focus countries of PEPFAR, leading to 319,950 estimated cumulative years of life added by 2009; 1.7 million individuals were receiving care, including 630,000 orphans and vulnerable children; and 6.6 million individuals received counseling and testing – more than double that of 2004.

The hope in the voices of many HIV/AIDS patients returned – and since PEPFAR relied on local community resources rather than far-away governments, the voices also felt heard and empowered. As a patient in Rehoboth, Namibia, noted, "We are usually invisible here. But we are all being hurt by this disease. Now our ideas are being heard."

George W. Bush
U.S. President (2001-2009)

“By the fall of 2005, our African partners were fully engaged. Faith-based and other groups supported by PEPFAR, both African and American, helped staff clinics and spread prevention messages to millions across the continent. Orphans and the dying were receiving compassionate care. Some four hundred thousand people were taking antiretroviral drugs. We were on pace to reach our goal.”
Source

Eleda Mukamurara
First antiretroviral receiving patient in Rwanda treated with U.S. government support

“I forget that I have HIV, I feel so well. Then I hear it is World AIDS Day and I remember, that includes me! I tell [those newly diagnosed with HIV], look at me! I am well. Don’t worry, you can be healthy and carry on with your lives.”
Source

Babalwa Mbono
Maternity Unit Site Coordinator, South Africa Clinic

“We would like to say to Mrs. Bush, keep up the work that you’re doing with HIV/AIDS. We want to be able to help groups like this that we have in South Africa in Cape Town, who can be strong and beat up HIV.”
Source

John Kufuor
President of Ghana (2001-2009)

“I want to thank the President for understanding Africa. His works, for the past five years or so, have done so much in terms of contributing to the fight against HIV/AIDS… the fund you set up, $15 billion fund, some of which has helped to, in a way, save and also make life easier over 400,000 afflicted people.”
Source

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-2022)

“When I started taking care of AIDS patients it was the dark years of my life, there were no therapies and no interventions. When President Bush sent me to Africa to see if this was even feasible, it was bringing me back to the dark days of the 1980’s (before treatments were available anywhere). PEPFAR was able to turn it around.”
Source

PEPFAR has been reauthorized three times since its initial passage, and has found consistent support in the halls of Congress. PEPFAR has represented a place where Americans from both sides of the aisle can come together and feel good about the work they are doing.

In 2007, with PEPFAR coming up for reauthorization, President Bush was again thinking big.

George W. Bush
U.S. President (2001-2009)

“Doubling funding would be a big commitment. But the AIDS initiative was working, and I decided to keep the momentum going… I stepped into the Rose Garden and called for Congress to reauthorize the initiative with a new commitment of $30 billion over the next five years.”
Source

Laura Bush
U.S. First Lady (2001-2009)

“I visited the Mututa Memorial Center, which is supported by PEPFAR. At this center, caregivers fan out on bicycle and foot to all the neighborhoods around, and they go door to door with care kits and with antiretroviral drugs. They tend to the people who are sick and they encourage their clients to be tested for HIV. And they literally just cold-call door to door, and often find people who are so sick in bed they can’t get up to get help for themselves…” “These are stories of courage and hope, and they’re also stories being written with the help of the American people. Both in Africa and here at home, Americans share their time and their money with those in need.”
Source

Jendayi Frazer
Assistant Secretary for African Affairs (2005-2009)

“These countries have responded by trying to build their own health infrastructure and developing their own national plans to address HIV and AIDS. So I think that the picture which was quite hopeless in 2000 when we were spending $300 million a year globally on HIV/AIDS, to today with the President’s commitment and pushing for reauthorization … is an incredible change in the response, the international response and the African response to this.”
Source

Mark Dybul
PEPFAR Architect
A principal architect of PEPFAR while with the U.S. National Institute of Allergy and Infectious Diseases
U.S. Global AIDS Coordinator (2006-2009)
Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2012-2017)

“One of the extraordinary things about PEPFAR — and I think it’s because it really represents who the American people are — is its belief in dignity and worth in every human life. The belief in people, otherwise ordinary people who will do extraordinary things. Americans deeply believe in that… and I think those values are reflected in PEPFAR and that’s why such an overwhelming majority of our Congress in both the House and Senate voted for PEPFAR from all ideological perspectives.”

George W. Bush
U.S. President (2001-2009)

“To highlight the progress, I invited a South African woman named Kunene Tantoh (to the Rose Garden when calling for reauthorization). Kunene was HIV-positive, but thanks to medicine she received through the mother and child initiative, she had given birth to an HIV-free boy.

“After the speech, I held four-year-old Baron in my arms and smiled at the thought that this precious life had been saved by the American taxpayers.”
Source

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-2022)

“With the Congress, we’ve been very fortunate to have bipartisan support for the AIDS effort. In every Congress that I have interacted with from the summer of 1981 up until this current day, with a split government, even though sometimes the hearings got a little tense, at the end of the day the support for HIV was always there both on the part of Congress and on the part of the Administration.”
Source

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“The fight against AIDS has been a refuge from the bitterness and cynicism of our politics. A great shared moral objective that has made other differences seem small.”
Source

Nita Lowey
U.S. Representative (D-New York, 1989-2021)

“Five years ago, only 50,000 people living with HIV/AIDS were receiving antiretroviral treatment. Today with American leadership, almost 2 million people are receiving treatment. Clearly, we are making a difference.”
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Patrick Leahy
U.S. Senator (D-Vermont, 1975-present)
“What we’ve tried to do is establish in a more and more polarized Congress that there’s one thing that is truly bipartisan and that’s finding funding to combat HIV/AIDS.”
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Barbara Lee
U.S. Representative (D-California, 1998-present)

“PEPFAR is arguably one of the most efficient foreign assistance programs in history. I met an individual named John Roberts in Uganda… He is now alive and so happy and raised a family. I believe he was a teacher. He had tears and told me to make sure I thank the United States of America for these life-saving drugs. We can’t allow these successes to lull us into complacency.”
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Tom Daschle
U.S. Senator (D-South Dakota, 1987-2005) and Senate Minority Leader (2003-2005)

“PEPFAR helped enhance the infrastructure within any country to address not only the challenges of the illness but also the concept of making a healthier society more productive again. And that was a very big part of what people began to see. There have been studies showing the correlation of presence of PEPFAR and economic growth and vitality. We’ve seen an enormous appreciation of what this can do, and it has macroeconomic effects that we’re still beginning to appreciate today 15 years after the fact.”
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Bill Frist
U.S. Senator (R-Tennessee, 1995-2007) and Senate Majority Leader (2003-2007)

“I think what we increasingly realize because of the success of this government-led and bipartisan-supported program is that caring and compassion and health can be a true currency for peace and understanding. On the ground, you have some kind of aid coming in that saves the life of your child for $1.50. And it comes from people you don’t know. That breeds faith in humanity. You don’t go to war with someone who’s just saved the life of your child.”
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Laura Bush
U.S. First Lady (2001-2009)

“These men, women, and children have now found new courage knowing this: that those who are orphaned, those who are sick, those who have been abandoned will always have a friend in the people of the United States.

“That is the commitment that PEPFAR has made — and it’s a commitment that we reaffirm today.”
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George W. Bush
U.S. President (2001-2009)

“Some people call this a success. I call this a good start.”
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As the Bush Administration came to a close in 2009, PEPFAR had supported life-saving treatment for more than 2.1 million people and care for more than 10.1 million people worldwide. While U.S. taxpayers funded the aid, in 2007 alone, more than 2,200, or 87 percent, of the partners were local community groups – and one-quarter were faith-based.

Upon reauthorization in 2008, PEPFAR was expanded to support treatment for an additional three million people, the prevention of 12 million new infections, and care for 12 million people, including five million orphans and vulnerable children.

Numbers don’t tell the story, however. The results were visible in the people.

Condoleezza Rice
U.S. Secretary of State (2005-2009)
National Security Advisor (2001-2005)

“Just five years later, thanks to strong partnerships between the American people and the host nations around the world, we’ve seen what was once thought to be impossible become truly possible.”
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Laura Bush
U.S. First Lady (2001-2009)

“I have been changed by Africa on each visit, in large measure because of the tremendous hope I have seen among its people in the midst of overwhelming despair. When George and I returned in 2008, we traveled again to Rwanda, where we stopped at a school for teenagers. Some were orphans who had lost a parent to AIDS or to genocide. As we left the school, we saw a group of teenagers waiting outside to greet us. One had a sign, ‘God is Good.’ George nodded and said, ‘God is good.’ And these teenage children replied, in unison, ‘All the time.’ To suffer as they have suffered, with genocide, disease and poverty, and to still believe ‘God is good. All the time’!”
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Ellen Johnson Sirleaf
President of Liberia (2006-2018)

“You know the work of PEPFAR in Africa has made such a tremendous difference, has saved so many lives, have given thousands and thousands of people, particularly women, hope for the first time in their lives that they can pursue their dreams, that they can become normal again. The importance of this continuing can make a big difference in a country achieving its development goals, particularly as they relate to the improvement of health in the nation. … This particular program touched the lives of the ordinary people and made a difference.”
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Paul Kagame
President of Rwanda (2000-present)

“Thanks to American support and partnership, thousands of Rwandan children and mothers are alive and have hope because of the President’s Emergency Plan for AIDS Relief program.”
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John Kufuor
President of Ghana (2001-2009)

“We note with great admiration your commitment to the respect of human rights, democracy, and good governance, as well as your humanitarian support for the drive towards poverty alleviation. We recognize also your exemplary dedication to the fight against diseases, like malaria and the HIV/AIDS pandemic.”
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Jakaya Kikwete
President of Tanzania (2005-2015)

“PEPFAR is helping us tackle the HIV/AIDS scourge. Many lives – many, many children who would have been orphaned are no longer orphaned because of that.”
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George W. Bush
U.S. President (2001-2009)

“On July 30, 2008, Mohamad Kalyesubula sat in the front row of the East Room. He was a tall, trim African man. He had a big, bright smile. And he was supposed to be dead… I hardly recognized him. His shriveled body had grown robust and strong. He had returned to life…. They called it the Lazarus Effect.”
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Under President Barack Obama, PEPFAR expanded and continued to express American compassion for those affected by HIV/AIDS around the world. Between 2009 and 2011, the number of partner countries expanded from the original 15 focus countries to 33 countries. Today, PEPFAR partners with over 50 countries around the world.

On World AIDS Day 2011, President Obama announced ambitious new goals for the program. Among these was a 50 percent increase in PEPFAR’s treatment target, to six million people supported by the end of 2013.

In 2018, because of PEPFAR, more than 14.6 million people were receiving lifesaving antiretroviral treatment, 95 million people had been tested for HIV, 2.4 million babies had been born HIV-free to infected mothers, and 6.8 million orphans, vulnerable children, and their caregivers had received support. The $80 billion investment has saved an estimated 17 million lives between 2003 to 2018.

On December 12, President Donald Trump signed the latest re-authorization of PEPFAR, ensuring that the United States will continue its leadership in the fight against HIV/AIDS through 2022.

Barack Obama
U.S. President (2009-2017)

“When we help African countries feed their people and care for the sick it’s the right thing to do, and it prevents the next pandemic from reaching our shores. Right now, we’re on track to end the scourge of HIV/AIDS. That’s within our grasp.”
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Hillary Clinton
U.S. Secretary of State (2009-2013)

“The goal of an AIDS-free generation may be ambitious, but it is possible with the knowledge and interventions we have right now. And that is something we’ve never been able to say without qualification before. Imagine what the world will look like when we succeed.”
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Eric Goosby
U.S. Global AIDS Coordinator (2009-2013)
CEO and Chief Medical Officer of Pangaea Global AIDS Foundation (2001-2009)

“I am extremely proud of all that we have accomplished together. Since 2008, we have more than tripled the number of individuals receiving lifesaving antiretroviral therapy through support from PEPFAR. (By 2013) We have surpassed one million babies being born without HIV due to PEPFAR-supported programs. And perhaps most importantly, we have arrived at a moment in which creating an AIDS-free generation is truly within our reach.”
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Deborah Birx
U.S. Global AIDS Coordinator (2014-2021)
White House Coronavirus Response Coordinator (2020-2021)
Senior Fellow, The George W. Bush Institute (2021 – present)

“PEPFAR will continue to invest in over 50 countries, maintain life-saving antiretroviral treatment (ART) for all of the people we support, provide services for orphans and vulnerable children, ensure that the most vulnerable and key populations have access to essential services to prevent and treat HIV, and accelerate progress toward controlling the pandemic in a subset of countries.”
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Mike Pence
U.S. Vice President (2017-2021)

“This is a cause that’s close to the heart of the American people and close to my heart… bipartisan majorities in the House and Senate voted to reauthorize PEPFAR, and President Donald Trump will soon sign it into law.

“We’re grateful for the strong and bipartisan support in the Congress for this extraordinary humanitarian effort by the American people.”
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As much progress had been made in the battle with HIV/AIDS, other health issues remain a concern. Some, like cervical cancer, are becoming more prevalent as women living with HIV are more susceptible to the disease. The Bush Institute’s Go Further partnership founded with PEPFAR and UNAIDS, extended the work of PEPFAR to address women’s cancers, and serve women living with HIV across their lives. The work had started in 2011, and was renewed with a greater focus and an infusion of resources from PEPFAR in 2018.

PEPFAR had also established the DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) partnership in 2014 to reduce new HIV infections among adolescence girls and young women who were at a significantly higher risk than boys and young men their same age.

One of the factors contributing to high rates of infection in this young female population was uncontrolled HIV infection among men. To reach men with testing, treatment, and continued care services to achieve viral suppression, PEPFAR launched the MenStar Coalition in 2018.

George W. Bush
U.S. President (2001-2009)

“Laura and I were struck by the fact that many women that had the HIV virus – and were living – got cervical cancer, and nothing was being done about it. Imagine the despondency in a village when a mother lives… and then needlessly dies.”
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Holly Kuzmich
Executive Director, George W. Bush Institute (2014-2021)

“Building on the success of Pink Ribbon Red Ribbon, the Bush Institute is thrilled to enter this renewed partnership with PEPFAR and UNAIDS, which will have an even greater impact and save more lives. Our work has saved thousands, but this partnership will reach millions… there is not a more appropriate time to deepen our partnership and see the vision of President and Mrs. Bush come full circle – that women who survive AIDS also live full lives free of cervical cancer.”
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Deborah Birx
U.S. Global AIDS Coordinator (2014-2021)
White House Coronavirus Response Coordinator (2020-2021)
Senior Fellow, The George W. Bush Institute (2021 – present)

“We must ensure the women – mothers, daughters, aunts, and grandmothers – who are living with HIV and thriving do not succumb to cervical cancer.”
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Michel Sidibe
Executive Director of UNAIDS and Undersecretary General of the United Nations (2009-2019)

“The partnership will allow us to respond to cervical cancer among women living with HIV like never before.”
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Deborah Birx
U.S. Global AIDS Coordinator (2014-2021)
White House Coronavirus Response Coordinator (2020-2021)
Senior Fellow, The George W. Bush Institute (2021 – present)
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Aida Carlos Lemos
DREAMS Ambassador, Mozambique

“I carried on in the streets until one day DREAMS came across in my life. When DREAMS came, it has changed a lot of my life, a lot of things. Today I support the other girls so that they can also pursue the ideal path, with determination, resistance, empowerment, with lots and lots of security.”
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Janet
DREAMS Beneficiary, Uganda

“I had just woken up after a busy night of work when a DREAMS coordinator came to me during her routine home visits in search of girls like me. I for once felt loved and cared for. She gave me hope to live. I felt that the time had come for me to live a real happy life. … I have learnt a lot about HIV/AIDS and how I can protect myself. I did not know about using condoms. I could not tell any man to put on a condom. Today, DREAMS has empowered me to make right healthy choices and negotiate for safe sex.”
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Thanduxolo Doro
Senior PLHIV/Civil Society Advisor
USAID Southern Africa

“Some of the barriers that make it difficult for men to access HIV care are actually perceptions. … Men when they go to the clinic, they put on a mask. They put on this strong appearance as though they are still in control, but deep inside, they are scared to bits.”
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Rodney Knotts
Senior Marketing Advisor, USAID

“What we’re dealing with is clinicians who are under resourced. What we’re trying to do …is give them the tools that they need in order to engage with men in a friendly way. … The aim is to wholistically upgrade the healthcare experience for men by providing the clinicians with support, having men only waiting areas in the facilities, work friendly clinic hours, as well as male friendly clinicians. And outside the clinic space is really change the narrative that living with HIV is just like living with any other chronic disease.”
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Sir Elton John
Singer/songwriter
Founder, Elton John Foundation

“Four years ago, at the international AIDS Conference in Amsterdam, the Duke of Sussex and I ere proud to announce a bold new partnership, the MenStar Coalition. Made up of seven organizations, including my own, our goal was to reach a million men who were not testing for HIV or accessing care. I am deeply proud to share that the collective efforts of the MenStar partners have tripled that goal enabling an extra three million men to start lifesaving HIV treatment, and of those 95% are virally suppressed. This has not only saved lives, it has also given us unique insights to progress our fight to end the AIDS epidemic.”
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In 20 years since the creation of PEPFAR, the program had achieved remarkable results in the fight against disease. Today, because of the commitment of foreign governments, investments by partners, the resilience of the communities, and the generosity of the American people, millions of lives have been saved. Millions more babies have been more HIV-free to infected mothers.

In 2017, President and Mrs. Bush traveled to Windhoek, Namibia and met with newborns and their moms. Almost all of the mothers were living with HIV, but their babies were disease free. He noted:

“It was so heartwarming to see those hopeful young lives and their proud, relieved mothers – and it was a powerful reminder that we need to not only keep this effort alive, but also do more.

“The American people deserve credit for this tremendous success and should keep going until the job is done.”

Part III coming soon: PEPFAR in the age of COVID-19.