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Diagonal Investments in Health Systems: PEPFAR's Approach to Sustaining the HIV Response and Enhancing Global Health
Maureen Bartee1,2, Lindsey Yessick1, James Maloney1,3
1Bureau of Global Health Security and Diplomacy, US Department of State.
The Journal of Infectious Diseases
|September 21, 2025
Summary
Achieving global HIV elimination requires strengthening national health systems. A diagonal approach, blending HIV-specific funding with system-wide investments, is crucial for sustained progress and broader health security.
Area of Science:
- Global Health
- Public Health Policy
- Epidemiology
Background:
- Progress towards the UNAIDS 95-95-95 goals advances global HIV elimination efforts.
- Strong health systems are vital for maintaining HIV gains and preventing disruptions from other health threats.
- The US President's Emergency Plan for AIDS Relief (PEPFAR) has impacted various health capabilities, but national health system integration remains uneven.
Purpose of the Study:
- To evaluate the impact of disease-specific initiatives on national health systems.
- To propose a strategic approach for integrating HIV response into broader health system strengthening.
- To enhance resilience against multiple health threats through integrated strategies.
Main Methods:
- Analysis of PEPFAR's contributions to health system components (laboratories, supply chain, surveillance, data, workforce).
- Assessment of the uneven impact of disease-specific programs on national health systems.
- Conceptualization of a diagonal approach for funding and implementation.
Main Results:
- While PEPFAR has built significant health capabilities, its effect on overall national health systems has been inconsistent.
- A "diagonal approach" is proposed to better integrate HIV programs with national health infrastructure.
- This approach aims to leverage HIV-specific investments for broader health system strengthening.
Conclusions:
- Integrating HIV response into national public health institutions is key for sustainable progress.
- A diagonal strategy, combining disease-specific funding with system strengthening, can improve health security.
- This integrated approach benefits not only the HIV response but also other priority diseases and overall health system resilience.
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