THE NUMBERS: Eswatini life expectancy at birth –
| 2023 | 64 |
| 2022 | 63 |
| 2020 | 60 |
| 2015 | 55 |
| 2010 | 48 |
| 2005 | 44 |
| 1989 | 62 |
WHAT THEY MEAN:
On this year’s World AIDS Day: The principal U.S. support program — the “President’s Emergency Plan for AIDS Relief,” or PEPFAR, for short — is a success story with an uncertain future. As a point of entry, here’s one of the countries the HIV/AIDS pandemic hit hardest:
Eswatini is a small inland kingdom of 1.3 million people bordering South Africa and Mozambique. Its HIV-positive rate, 23.4% of adults, is the world’s highest. In the early 2000s, Swazi health officers were counting 11,000 AIDS deaths a year — one in every hundred people – and reported a drop in life expectancy at birth from 62 years to 42. A grim point of comparison suggests how extreme that is: Chinese life expectancy at birth appears to have fallen by 1.5 years during World War II, and by six months during the Great Leap Forward/Cultural Revolution decade from 1959 to 1969.
Pulling back: In the early 2000s, about 40 million people were HIV-positive — 2 million in the United States and other “developed” countries, 25 million in sub-Saharan Africa, 7 million in South and Southeast Asia, 2.1 million in Latin America and the Caribbean, 4 million elsewhere around the world. Over 3 million died annually. UNAIDS’ 2005 report is a reminder:
| “Acquired Immunodeficiency Syndrome (AIDS) has killed more than 25 million people since it was first recognized in 1981, making it one of the most destructive epidemics in recorded history. Despite recent, improved access to antiretroviral treatment and care in many regions of the world, the AIDS epidemic claimed 3.1 million [2.8–3.6 million] lives in 2005; more than half a million (570 000) were children. The total number of people living with the human immunodeficiency virus (HIV) reached its highest level: an estimated 40.3 million [36.7–45.3 million] people are now living with HIV. Close to 5 million people were newly infected with the virus in 2005.” |
Governments and charities attempting to respond in lower-income countries were trying to manage multiple large challenges, each of which made all the others harder to solve:
PEPFAR, which the second Bush administration launched in 2003, and the following administrations continued through 2024, has been the U.S.’s big response. Its various national accounts — prevention and education, testing, medicine, orphan and dependent care — and contributions to the Global Fund and UNAIDS combined for just under $7 billion per year during the Biden administration. This was about a third of the world’s $22 billion in total HIV/AIDS support. Taken as a whole, it aimed to support education, make testing widely available, provide large volumes of medicine, and train staff in delivery and care. Run by seven agencies headed by the Global AIDS Coordinator at the State Department, but mainly administered by professional staff and contractors at USAID and the Centers for Disease Control, PEPFAR programs were operating in 120 countries this past January, providing anti-retroviral medicines to 20.1 million people, care and shelter for 7 million orphans, and “PrEP” preventative treatment for 1.5 million people.
Since the launch, treatment has spread to reach nearly 32 million of the 41 million people now believed HIV-positive worldwide. Annual new infection estimates have dropped from 3.4 million to about 1.3 million a year. And mortality is down from the 3 million annual deaths of the early 2000s to about 630,000 per year now. In sum, over its two decades, PEPFAR has earned a plausible claim to the mantle of the postwar Marshall Plan: an ambitious concept on a global scale, efficient practical implementation, and commitment to the common good.
This year, the Trump administration shut down the main PEPFAR administrator, the U.S. Agency for International Development. According to the U.S. government’s aid tallies, American support for global health aid fell from $13.2 billion in FY 2024 to $4.7 billion in 2025. The administration did, though, promise to preserve PEPFAR by shifting program management to the State Department. This has, in fact, happened, though with lots of transitional damage — fired contractors, lost human talent, interrupted care — over the spring and summer, with consequences such as loss of PrEP access for 2.5 million people worldwide, closed clinics in Zimbabwe, and doubling counts of secondary mpox infections in Kenya. Taking into account the much larger drop in U.S. support for health and humanitarian relief, the Gates Foundation predicts a rise in childhood deaths of about 200,000 in 2025. Looking to 2026, the administration’s September strangely titled “America First Global Health Strategy” proposes to continue PEPFAR programs but cut U.S. government spending on them by about $1.7 billion, while asking beneficiary countries to contribute more to close the resulting gaps.
Returning to Eswatini, where U.S. health support has dropped from $75 million in 2024 to $19 million this year: The pandemic is far from over. But measured both by health policy criteria and by real-world results, as of 2024, Eswatini was meeting its main challenges. A 2023 national survey showed 94% of adults with HIV were aware of their status; 97% of them were using antiretroviral medicines, and virus suppression was achieved in 96% of antiretroviral patients. More generally, (a) HIV-positivity rates have dropped from the 29.4% peak in the mid-2010s to this year’s 23.4%; (b) 213,000 Swazi were taking antiretrovirals, as against 500 in 2005; (c) 20,000 are testing each month; (d) AIDS mortality has dropped by 75%, from the 11,000 deaths per year of the early 2000s to 2,600 last year; and (e) national life expectancy in 2023 for the first time exceeded pre-HIV pandemic rates and continues to rise. And two weeks ago, residual PEPFAR money helped add a new treatment — lenacapavir, a twice-yearly injection medicine — to Eswatini’s health program.
On this World AIDS Day, the President’s Emergency Plan for AIDS Relief has accomplished an astonishing amount of good in its first two decades. PEPFAR authors and the U.S. aid staff who ran the programs should take great pride in their contribution to this 80% drop in mortality. It isn’t finished, and 630,000 deaths is still a very large number. Congress shouldn’t let it stop before it’s done.
U.S. government HIV/AIDS page.
… and the PEPFAR site.
Then and now:
UNAIDS’ grim December 2005 report.
And the 2025 edition, noting past progress, the impacts of the closure of USAID, and the risks of declining future support.
Data:
KFF (formerly Kaiser Permanente Foundation) summarizes PEPFAR goals and results.
The World Bank has published HIV/AIDS prevalence rates by country since 1990.
The U.S. government’s PEPFAR data site has numbers. As of today, they’re frozen and given an unsettling asterisk: “data.pepfar.gov is currently undergoing updates and will return soon with refreshed data and interactive dashboards.”
Foreignassistance.gov reports health, humanitarian relief, democracy, food aid, and other U.S. aid spending by country.
PPI on USAID, the 100-year American humanitarian aid tradition, and the Trump administration’s folly.
Eswatini:
2025 status report from the Health Ministry.
A report from the Global Fund.
Updates from the UNAIDS office in Mbabane.
Trump administration and PEPFAR:
The administration’s global health strategy document.
KFF’s analysis.
A mixed assessment from the George W. Bush Presidential Center.
A more critical look — “Tough Times, Tough Choices” — from the Center for Global Development.
And the Gates Foundation fears a rise of 200,000 in childhood deaths.
Ed Gresser is Vice President and Director for Trade and Global Markets at PPI.
Ed returns to PPI after working for the think tank from 2001-2011. He most recently served as the Assistant U.S. Trade Representative for Trade Policy and Economics at the Office of the United States Trade Representative (USTR). In this position, he led USTR’s economic research unit from 2015-2021, and chaired the 21-agency Trade Policy Staff Committee.
Ed began his career on Capitol Hill before serving USTR as Policy Advisor to USTR Charlene Barshefsky from 1998 to 2001. He then led PPI’s Trade and Global Markets Project from 2001 to 2011. After PPI, he co-founded and directed the independent think tank ProgressiveEconomy until rejoining USTR in 2015. In 2013, the Washington International Trade Association presented him with its Lighthouse Award, awarded annually to an individual or group for significant contributions to trade policy.
Ed is the author of Freedom from Want: American Liberalism and the Global Economy (2007). He has published in a variety of journals and newspapers, and his research has been cited by leading academics and international organizations including the WTO, World Bank, and International Monetary Fund. He is a graduate of Stanford University and holds a Master’s Degree in International Affairs from Columbia Universities and a certificate from the Averell Harriman Institute for Advanced Study of the Soviet Union.
