Much of the legacy of President George W. Bush is wrapped around the war on terror and military action in Iraq and Afghanistan, but what many consider his greatest achievement is a public health effort steeped in humanitarianism that won accolades across the political spectrum: Bush has probably done more than any other president to combat AIDS, particularly in Africa.

Bush was already interested in fighting African poverty, but his concern widened during the 2000 campaign when Condoleezza Rice presented him with the details of the AIDS crisis in Africa and stressed the need for more action. The United States had already devoted $500 million to the problem.

Bush led the UN efforts in creating a global fund to fight AIDS.

Following talks with United Nations Secretary-General Kofi Annan in early 2001, the United States became the first contributor to a global fund to fight HIV/AIDS, pledging $200 million. That amount more than doubled the next year, but Bush felt the problem required more spending and believed the UN was not speedy enough in its efforts.

In 2002 Bush unveiled the Mother and Child HIV Prevention Initiative targeting one million mothers in Africa and the Caribbean for treatment in an effort to save the lives of 150,000 babies.

Bush then pushed to devote $15 billion over the next five years. These funds would go to drugs and medical care for about 10 million patients, and also help millions of children orphaned by their parents’ deaths from AIDS. It was considered the largest health initiative ever to target one single disease.

President George W. Bush shaking hands with one of the 14 HIV positive mothers who were able to prevent passing their disease on to their children with the help of PEPFAR, 2003. (Credit: Tim Sloan/AFP/Getty Images)

Bush’s PEPFAR effort received strong bipartisan support.

That initiative became known as the President’s Emergency Plan for AIDS Relief, or PEPFAR. Bush selected 12 countries in sub-Saharan Africa and two in the Caribbean to receive its help and announced PEPFAR in his 2003 State of the Union address.

The bill passed the House of Representatives the following May, 375 to 41. Forty of the no votes came from Bush’s fellow Republicans, but it was otherwise a popular bipartisan effort.

PEPFAR proved to be an impressive achievement: In 2007, the program was considered so successful that Bush asked for a funding increase, totaling $30 billion for the following five year period. In 2008, $39 billion was marked for PEPFAR.

George W Bush World AIDS Day
President George W. Bush making a statement with first lady Laura Bush on World AIDS Day, 2008. (Credit: Chuck Kennedy/MCT/Getty Images)

PEPFAR was successful, but far from perfect.

PEPFAR did have some controversies, such as abstinence-only programs that were shown to make no impact. Funding for these has shrunk to a quarter of previous numbers.

PEPFAR also initially placed a condition requiring private groups to enact policies opposing sex work, but this was struck down as unconstitutional by the Supreme Court in 2013.

A Stanford University analysis of PEPFAR’s first three years calculated 1.1 million lives saved with a 28 percent reduction in HIV/AIDS. Other studies have revealed that adult mortality rates have improved in Africa as much as 20 percent thanks to PEPFAR programs.

Funding levels have since come under attack.

By the time of the election of Barack Obama, PEPFAR had treated 2 million AIDS patients and assisted to 10 million more, with further millions receiving help during pregnancies and being tested for HIV/AIDS.

Under Obama, funding for PEPFAR fell. More recent developments have seen the program included in attempts by President Donald Trump to weaken the broader swathe of global health initiatives.

Congress overruled the cuts in the 2018 budget, voting to continue funding PEPFAR at the same level, but the pressure for spending cuts and the reality of budget deficits continue to threaten the effectiveness of President Bush’s public health legacy.