Restoring PEPFAR remains essential—not as an end in itself but as a vital bridge to support countries as they shift toward self-sustaining health systems.

by Ayushi Vig '25 for Annotations Blog

The freeze on PEPFAR (President’s Emergency Plan for AIDS Relief) funding marks a turning point for the global fight against HIV/AIDS. Since 2003, PEPFAR has been a cornerstone of international HIV treatment and prevention, covering over 88% of HIV/AIDS-related funding in some African countries and supplying more than half of HIV medications in nations like Zambia, Mozambique, and the Democratic Republic of the Congo. Now, as the program stalls due to political gridlock in the United States, the future of millions of lives hangs in the balance.

The implications are immediate and alarming: rising viral loads, increased transmission rates, disrupted medication access, and a potential resurgence of AIDS-related deaths. For many countries, dependence on a single donor has exposed a structural vulnerability. Crises like this reveal the fragility of externally driven systems—but also offer a chance to hone in on the long-term goal: resilient, inclusive, and nationally owned HIV responses. Now is the time to invest in systems that are sustainable, rights-based, and locally led. 

One country offers a powerful blueprint: Brazil.

Brazil’s Alternative Path

In the early 2000s, Brazil made headlines by declining $40 million in PEPFAR funding due to U.S. policy restrictions that conflicted with its rights-based approach to health—specifically, limitations on treating sex workers and implementing harm reduction programs. Rather than accepting funding with ideological strings attached, Brazil doubled down on a nationally led response built around three key pillars: universal healthcare integration, domestic drug manufacturing, and civil society advocacy.

Through its Unified Health System (SUS), Brazil guarantees universal access to healthcare, including antiretroviral therapy (ART). HIV care is embedded within the national health system, not treated as a separate vertical program. This integration has ensured continuity, equity, and resilience, in contrast to countries where HIV services remain siloed and dependent on project-based funding.

Brazil also invested significantly in domestic pharmaceutical production. By manufacturing generic antiretroviral drugs at scale, it reduced its reliance on multinational drug companies and foreign procurement chains. This self-reliance proved essential during global supply chain disruptions and now offers a model for how countries might protect their treatment pipelines.

Perhaps most distinctive is Brazil’s culture of rights-based activism. Civil society organizations—such as ABIA (the Brazilian Interdisciplinary AIDS Association)—played a pivotal role in shaping policy, challenging corporate patent regimes and pharmaceutical monopolies, and advocating for marginalized communities. While many donor-led responses focus narrowly on biomedical interventions, Brazil’s model paired medicine with political mobilization and legal reform, reframing HIV as an issue of citizenship and social justice.

Crucially, Brazil did not reject foreign assistance outright—it redefined its terms. In the 1990s and early 2000s, the country received two major World Bank loans (AIDS I and II) to support HIV infrastructure and services. These funds came with notable restrictions, particularly limitations on prevention programs targeting key populations. Rather than allowing external priorities to dictate its response, Brazil strategically used international financing to build national systems, while relying on domestic resources to fund the more politically sensitive, but essential, components of care. 

Brazil also never fully disengaged from PEPFAR. While it declined direct programmatic funding, it remained involved through PEPFAR-funded research collaborations and treatment development (such as self-testing for HIV), which has been significantly disrupted by the freeze. And yet, Brazil has been able to continue HIV diagnosis and treatment services, because unlike many peers, it treated foreign aid as a tool to advance its own agenda—not as the foundation of HIV response. The long-term goal was always clear: to build a sustainable, universal system capable of withstanding political shifts both domestically and abroad.

Applying Lessons Learned

Brazil’s experience is not a plug-and-play solution. Each country faces distinct epidemiological, political, and economic conditions. HIV prevalence remains higher in parts of Sub-Saharan Africa than in Latin America, and Brazil’s public health infrastructure is the product of decades of sustained investment and activism. Still, Brazil’s strategic use of domestic funding, its refusal to compromise on rights-based care, and its focus on integration over fragmentation offer critical lessons for countries navigating healthcare financing in the post-PEPFAR era:

1. Prioritize Universal Health Systems

HIV should be embedded within national healthcare systems—not managed as a separate, donor-funded emergency. Integration improves continuity, efficiency, and sustainability. Brazil’s SUS model demonstrates that universal coverage is a critical foundation, not a luxury.

2. Invest in domestic or regional drug manufacturing

Producing or collectively procuring generic antiretrovirals (ARVs) is key to reducing costs and avoiding global supply disruptions. Brazil’s pharmaceutical capacity helped maintain access during periods of global volatility. Other countries might pursue regional procurement consortia or scale up local manufacturing.

3. Center community advocacy and civil society

Civil society is not optional—it is essential. Grassroots advocacy helps ensure inclusive policies, protects the rights of key populations (including LGBTQ+ individuals, sex workers, and drug users), and holds governments accountable when political climates shift. Brazil demonstrates the importance of addressing HIV as a social and political issue in building sustainable response.

4. Strengthen subnational and regional resilience strategies

During periods of federal inaction, Brazil’s states and municipalities carried the HIV response forward—developing policy, delivering services, and protecting gains. This kind of decentralization can serve as a vital safeguard in politically unstable environments. Regional collaboration–sharing knowledge, policy strategies, and procurement mechanisms—can further bolster resilience.

Brazil has shown that it’s possible—the challenge now is to adapt those lessons to diverse contexts, and leverage this moment to build stronger, more self-sustaining HIV responses across the Global South.

5. Expand domestic financing for healthcare

Countries must gradually reduce donor dependence by increasing domestic investment. Even small, phased reallocations can build momentum. South Africa, which funds 74% of its HIV program domestically, shows that progress is possible. Governments can start by incorporating health and HIV spending into broader national health insurance schemes, exploring innovative financing mechanisms (like sin taxes or health bonds), and ensuring that HIV services are prioritized in medium-term budget planning.

A Call to Action

Amidst evolving financing systems for HIV and global health more broadly, we have an opportunity to reassess and strengthen the foundation of HIV response. This is not to downplay the severity of the U.S. government’s actions or the unjust and extremely dangerous consequences of disrupted funding. Restoring PEPFAR remains essential—not as an end in itself, however, but rather as a vital bridge mechanism to support countries as they shift toward self-sustaining health systems.

Ultimately, this is about reclaiming health sovereignty. It’s about building systems that don’t collapse when geopolitics shift. Brazil has shown that it’s possible—the challenge now is to adapt those lessons to diverse contexts, and leverage this moment to build stronger, more self-sustaining HIV responses across the Global South.

Meet the Author: Ayushi Vig

Ayushi Vig is a second-year MPA student at Princeton University's School of Public and International Affairs, where she studies development finance at the intersections of climate and health. Before arriving at Princeton, she was a philanthropic advisor for foundations working across a range of environmental, economic, health, and gender justice issues. She earned her BA at Stanford University.