President's Emergency Plan for AIDS Relief (PEPFAR) Policy Process and the Conversation around HIV/AIDS in the United States

In 2003, the George W. Bush administration passed the President’s Emergency Plan for AIDS Relief (PEPFAR), a US government initiative to address the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic primarily in Africa. PEPFAR’s US$18 billion budget remains the largest commitment from any nation towards a single disease and has saved countless lives. Given the historical and current political resistance to foreign aid, PEPFAR’s drastic spike in spending on HIV/AIDS raises questions over how the policy process resulted in bipartisan support. Using two policy process theories, punctuated equilibrium theory (PET) and the Narrative Policy Framework (NPF), this analysis helps explain the framing of the global HIV/AIDS epidemic and the factors that resulted in the creation of PEPFAR. The analysis of the PEPFAR policy process reveals a ‘tipping point’ in the early 2000s, when political actors, the media and advocacy coalitions benefitted from issue framing, narrative change and measures of political attention to elevate the global HIV/AIDS crisis to the public agenda. The findings highlight an increase in presidential attention, the evolution of the HIV/AIDS narrative away from stigma and the formation of powerful coalitions. Looking back on the combination of policy process factors that led to PEPFAR’s bipartisan success might lead to insights for dismantling the grand public health challenges of the present and future. This study’s findings have implications for currently stigmatised public health crises, such as the opioid epidemic.