Vital Signs

Progress Toward Eliminating HIV as a Global Public Health Threat Through Scale-Up of Antiretroviral Therapy and Health System Strengthening Supported by the U.S. President's Emergency Plan for AIDS Relief

Worldwide, 2004-2022

Helen M. Chun, MD; Emilio Dirlikov, PhD; Mackenzie Hurlston Cox, MSPH; Michelle Williams Sherlock, MPH; Yaa Obeng-Aduasare, MPH; Kimi Sato, MPH; Andrew C. Voetsch, PhD; Abraham D. Ater, DrPH; Erin Rottinghaus Romano, PhD; Hank Tomlinson, PhD; Surbhi Modi, MD; Angeli Achrekar, DrPH; John Nkengasong, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2023;72(12):317-324. 

In This Article

Abstract and Introduction

Abstract

Introduction: In 2004, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), with CDC as a major U.S. government implementing agency, began providing HIV antiretroviral therapy (ART) worldwide. Through suppression of HIV viral load, effective ART reduces morbidity and mortality among persons with HIV infection and prevents vertical and sexual transmission.

Methods: To describe program impact, data were analyzed from all PEPFAR programs and from six countries that have conducted nationally representative Population-based HIV Impact Assessment (PHIA) surveys, including PEPFAR programmatic data on the number of persons with HIV infection receiving PEPFAR-supported ART (2004–2022), rates of viral load coverage (the proportion of eligible persons with HIV infection who received a viral load test) and viral load suppression (proportion of persons who received a viral load test with <1,000 HIV copies per mL of blood) (2015–2022), and population viral load suppression rates in six countries that had two PHIA surveys conducted during 2015–2021. To assess health system strengthening, data on workforce and laboratory systems were analyzed.

Results: By September 2022, approximately 20 million persons with HIV infection in 54 countries were receiving PEPFAR-supported ART (62% CDC-supported); this number increased 300-fold from the 66,550 reported in September 2004. During 2015–2022, viral load coverage more than tripled, from 24% to 80%, and viral load suppression increased from 80% to 95%. Despite increases in viral load suppression rates and health system strengthening investments, variability exists in viral load coverage among some subpopulations (children aged <10 years, males, pregnant women, men who have sex with men [MSM], persons in prisons and other closed settings [persons in prisons], and transgender persons) and in viral load suppression among other subpopulations (pregnant and breastfeeding women, persons in prisons, and persons aged <20 years).

Conclusions and implications for public health practice: Since 2004, PEPFAR has scaled up effective ART to approximately 20 million persons with HIV infection in 54 countries. To eliminate HIV as a global public health threat, achievements must be sustained and expanded to reach all subpopulations. CDC and PEPFAR remain committed to tackling HIV while strengthening public health systems and global health security.

Introduction

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) was announced in January 2003 and remains the largest commitment by any nation to address a single disease. PEPFAR's core aim is to address health inequities in access to HIV services. The initial goal was to prevent 7 million infections, treat 2 million persons, and provide humane care for persons suffering from AIDS and for children orphaned by AIDS. At the time, approximately 30 million persons with HIV infection were estimated to live on the African continent, including 3 million children and adolescents aged <15 years; however, only 50,000 were receiving antiretroviral therapy (ART).§ Since 2004, PEPFAR has supported partner governments' expansion of ART delivery while strengthening health systems. Through viral load suppression, effective ART reduces morbidity and mortality among persons with HIV infection;[1] it also prevents vertical transmission from mothers with HIV infection to their infants if the mother is on ART and the HIV-exposed infant receives prophylaxis; and prevents sexual transmission when viral load is undetectable (<200 copies per mL of blood).[2–5]

PEPFAR, led and coordinated by the U.S. Department of State, uses a whole-of-government approach for global HIV/AIDS response, implemented by seven U.S. government departments and agencies, including CDC. As the U.S. agency responsible for protecting public health, CDC couples its core area investments in public health workforce development, surveillance, and laboratory capacity with scientific and technical expertise and data-driven approaches to fight the global HIV epidemic and other threats to global health security.**

PEPFAR supports the Sustainable Development Goals and the Joint United Nations Programme on HIV/AIDS' (UNAIDS) fast-track strategy to end the AIDS epidemic as a global threat by 2030: that 95% of persons with HIV infection know their status, that 95% of those with known status receive ART, and that 95% of those receiving ART achieve viral load suppression.†† Worldwide in 2021, an estimated 38.4 million persons had HIV infection; 650,000 AIDS-related deaths and 1.5 million new infections occurred.§§ An estimated 28.7 million persons with HIV infection were receiving ART, and among those receiving ART, an estimated 92% had suppressed viral loads. To assess PEPFAR-supported program impact and health system–strengthening investments, programmatic data from all PEPFAR programs and survey data for six countries with more than one Population-based HIV Impact Assessment (PHIA) survey were analyzed.¶¶

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