When Bipartisanship Saved 25 Million Lives

Twenty-five million lives saved. Five and a half million babies born HIV-free. PEPFAR (the President’s Emergency Plan for AIDS Relief) has been the most effective foreign-aid medical program in history. It is also one of the largest testaments to what sustained bipartisan cooperation can achieve.

That cooperation reflected—and continues to reflect—broader public sentiment:

This is the story of how bipartisan agreement became life-saving policy at a scale never before seen. It is also a story of new challenges for a long-successful program.

The History

When Republican President George W. Bush asked Congress for authorization to pursue war in response to the September 11, 2001 terrorist attacks, a single Congress member voted against: Democratic Representative Barbara Lee from Oakland, California. Eighteen months later, the unlikely pair found common ground on AIDS relief in Africa.

Lee was a member of the Congressional Black Caucus. She and others in the Caucus were concerned that AIDS was devastating many African countries that did not have the resources to fight it. In 2001, she brought up the issue with President Bush in the Oval Office. As she recalled in 2022:

I was fortunate enough to see President George Bush — a man whose policy I rarely agreed with over the years, including our largest disagreement over engaging in the wars in Iraq and Afghanistan. Despite our policy differences however, President Bush and I did connect on the shared goal of tackling the HIV/AIDS crisis.

Along with the Congressional Black Caucus, I worked with President Bush and others in Congress — both Republicans and Democrats — to craft a global HIV/AIDS legislative package. He pledged the investment at his State of the Union Address, and in May 2003, we passed H.R. 1298, the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act. That legislation established what we now know as PEPFAR, the President’s Emergency Plan for AIDS Relief. Since then, because of bipartisan, bicameral efforts in Congress, PEPFAR has provided billions to address the HIV and AIDS pandemic.

As Lee put it in a 2002 speech urging passage of the original bill: “HIV-AIDS is not a Democratic or Republican issue. It is a disease that threatens the entire human family.”

President Bush later recalled, “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.”

An architect of PEPFAR, Mark Dybull recalled Bush saying, “Don’t tell me how much it’s going to cost, tell me what you're going to do, how you’re going to do it, what your timelines are, and I’ll find the money. Tell me how much it’ll cost to achieve big goals.”

With Republicans controlling both houses of Congress at the time, H.R. 1298 was ushered through the House, and its companion bill through the Senate, by Republican sponsors with bipartisan co-sponsors, including Representative Lee in the House. It passed by wide margins.

PEPFAR became the largest initiative to fight a single disease in human history. Its initial stage allocated $15 billion over five years for HIV treatment, prevention, and care programs, primarily in sub-Saharan Africa. Most of the money went to providing antiretroviral treatment to people with HIV, preventing mother-to-child transmission, and supporting care for orphans and vulnerable children affected by the epidemic. PEPFAR also provided funding for global HIV/AIDS research and to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

PEPFAR still exists today. It has been reauthorized several times on a bipartisan basis, under every president to serve since Bush and under varying configurations of congressional control. As of 2023, the State department reported that PEPFAR had saved 25 million lives and allowed 5.5 million babies to be born HIV-free.

The Outlook

Despite PEPFAR’s successes, the program’s future is uncertain. It was caught in the second Trump administration’s January 2025 stop-work order for all foreign aid. The program quickly received a limited waiver but then took an additional hit in February 2025 when Elon Musk’s DOGE rapidly dismantled USAID, the main implementing agency for PEPFAR.

Critics said that although PEPFAR has done much good, it had created a culture of dependency and “progressive agendas” around itself. They claimed the “E” in PEPFAR—“Emergency”—had been superseded in practice by an expansive, multi-billion-dollar aid machine that relieved recipient countries from creating their own sustainable health systems. They complained about calls for coordination between PEPFAR and programs for “reproductive health and rights, gender equality, LGBTQI+, and human rights.”

PEPFAR supporters said these claims were misleading and ignored evidence of the program’s existing transition plans, the increases in domestic health spending by recipient countries, and PEPFAR’s core focus on saving lives rather than promoting ideology. But the current reality is, the critics are in charge.

As of late July 2025, the Trump administration was reportedly planning to recast PEPFAR along the lines of a “trade over aid” strategy. The program would transition away from medical aid, replaced by trading relationships with recipient countries for American drugs and technologies.

However, earlier that month the administration hit a wall when it tried to claw back $400 million in already allocated PEPFAR dollars. A group of senators, including enough Republicans to tip the balance, successfully blocked that move. Republican Senator Susan Collins of Maine said, “This program remains a bipartisan priority of Congress. After years of commitment and stable investment, the finish line is in sight. The United States has the tools to fulfill PEPFAR’s mission and get the job done, while transitioning HIV/AIDS treatment and prevention to country ownership by the year 2030.”

There will be further twists and turns in the PEPFAR story. But whatever the go-forward outcome, PEPFAR’s first twenty years stand as a monument to the possibility of sustained bipartisan collaboration on matters of literal life and death—from the program’s unlikely early partners to its long run of life-saving results.

As Bush’s adviser Michael Gerson said in 2015, “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.”