This article is part of our series exploring the role of faith-based organizations in providing vital support and care to those affected by HIV/AIDS through PEPFAR. Throughout this series, we will highlight the importance of a clean, five-year reauthorization of PEPFAR to ensure the stability and continuity of lifesaving treatment.
Comfort to Care: ACT’s Early Days
Genet* was only six the first time Alemu visited the room she shared with her mother. He brought food, checked on her health, and ensured that both were taking an antibiotic to prevent pneumonia. Infected with HIV, Genet and her mother were at high risk of dying from even simple infections. Antiretrovirals, the medications to treat HIV/AIDS, were unavailable in Ethiopia.
Alemu has made thousands of home visits as a program manager with Ethiopia Aids Care and Treatment (ACT), a small Christian nonprofit providing healthcare support and poverty alleviation to families in Addis Ababa. ACT was initially founded in 2002 to provide care to those dying of acquired immunodeficiency syndrome, or AIDS, the disease caused by the human immunodeficiency virus (HIV). Without antiretrovirals, infection with HIV leads to a slow decline, weight loss, and eventual death from infections that no longer respond to treatment.
ACT’s early work involved visiting homes to provide comfort and prolong lives by treating infections, relieving pain, and supplementing food. Staff and volunteers mourned the dead at funerals, purchased caskets, and identified relatives to take in orphaned children. They also prayed at bedsides and facilitated Bible studies and support groups for those still well enough to leave their homes. The model was that of the early church, and of Jesus’ instructions in Matthew 25:36, visiting the sick and remaining in the cities to care for the plague victims when others fled. In AD 260, faced with an urban epidemic, Dionysius of Alexandria, a third-century bishop and early church leader, wrote in his Easter letter “Most of our brother Christians showed unbounded love and loyalty, never sparing themselves and thinking only of one another. Heedless of danger, they took charge of the sick, attending to their every need and ministering to them in Christ.” Stigma and fear had left most of those cared for by ACT isolated and alone, often bedridden. By 2003, an estimated 950,000 people in Ethiopia were HIV positive. Of these, 69,000 were children under 15. Twenty-three years later, instead of funerals, ACT staff regularly attend graduations and weddings. They provide grants for small businesses; they help families start savings accounts. What changed? PEPFAR.
The Emergence of PEPFAR
The latter part of the twentieth century saw broad geographic, social, and economic factors, such as migration, civil war, gender dynamics, and food insecurity, creating a ready landscape for the AIDS pandemic to take hold in Ethiopia. The number of new HIV cases occurring in the country reached its height in 1995, leveling out after 2005. The death rate from AIDS peaked in the early 2000s, with more than an estimated 50,000 deaths annually, killing 1-2 in every 1000 people.
While HIV/AIDS had been identified and well-documented by the mid-to-late 1980s, it wasn’t until 1995 that effective treatments, medicines called antiretrovirals, were developed. At the time, the new medications were too expensive for the majority of AIDS patients in Ethiopia and much of the world to access; in fact, the consensus among many scientists and public health professionals in the 1990s was that HIV/AIDS was too expensive to treat on a global scale, that is, antiretroviral therapy was considered “not cost-effective.” Yet global advocacy movements for HIV/AIDS awareness and access to antiretrovirals, renewed support from big donors in the early 2000s, and political pressure resulted in a profound shift in the global outlook on the AIDS pandemic. With bipartisan support in both the U.S. House and the Senate, US President George W. Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, authorizing $15 billion over five years to address the pandemic globally.
As of December 2024, PEPFAR has helped prevent an estimated 26 million deaths and enabled 7.8 million children to be born without HIV, a marker of progress toward an HIV-free generation.
Expanding Access: ACT’s Work with PEPFAR
March 1, 2005, is a date that ACT’s Country Director, Theodros Alemayehu, can’t forget. That was the day ACT started a pediatric treatment program. Antiretrovirals were only recently available and ACT staff were determined to find a way to treat the HIV-positive children in the project. Genet was among the first four to receive treatment. With assistance from physicians in the United States, ACT determined the correct doses, obtained the medications at the central government hospital, and began a directly observed therapy program. A staff member gave the children their medications each morning before school and measured out the evening dose to take later. By the end of 2005, PEPFAR funding had ensured that the medications were being provided for free through the Ethiopian government health system. Yet the distribution systems were rudimentary and patients received very little counseling about the medications. Some of the drug regimens were complicated and skipping doses could lead to resistance, making the medications ineffective. ACT staff filled the gap by providing pill boxes and watches, as well as training through support groups and one-on-one counseling. Staff at the nearest HIV clinic approached ACT to learn more about the unusual group of patients, all taking their medications consistently, wearing identical watches, and carrying white pillboxes.
This led to an invitation in 2007 to design and implement a treatment support system for 13 government health centers and the country’s largest hospital. The three-year project was funded by PEPFAR. ACT trained 26 “expert patients” (HIV-positive community members who helped newly diagnosed patients understand their medications), 14 case managers, five data clerks, and two program managers. Many of the expert patients were individuals initially cared for by ACT. Over three years, 57,000 patients received treatment counseling and 30,000 of them were provided with watches and pill boxes. Seven government health centers received laboratory equipment to improve the speed and quality of care that could be provided. In 2010, ACT turned the management of the program over to the Addis Ababa Health Bureau; now, 15 years later, the program’s components remain in place, and the expert patients trained by ACT continue to counsel new patients.
ACT’s reputation led to another opportunity to partner with PEPFAR in 2023: this time to create a patient feedback process for the HIV treatment programs at two health centers, allowing local communities to identify problems and advocate for needed changes.
While readily available treatments have made HIV a manageable chronic disease, ACT continues to serve the “least of these” in Addis Ababa. The majority enrolled are still HIV positive but the focus has expanded to include other diseases like tuberculosis and cancer.
No longer just caring for the dying, ACT’s work now includes economic empowerment and support for children’s education, enabling families to become healthy and self-sufficient. ACT has helped 2,019 households reach these goals through its three-year empowerment program. As individuals responded to treatment and began to rebuild their lives, ACT’s spiritual ministry expanded as well. The early Bible studies ACT facilitated became church plants, and these church plants have grown into an entire church-planting denomination, Grace of the Messiah, now an independent organization.
These fundamental shifts were catalyzed by PEPFAR, which provided the financing, logistics, supplies, and government relationships that enabled widespread AIDS treatment in Ethiopia. This created space for faith-based organizations like Ethiopia ACT to use their community knowledge and relationships to design empowering, restorative programs that address the impacts of poverty beyond physical ill health.
The Rollback of PEPFAR: A Critical Setback for HIV/AIDS Programs in Ethiopia
On January 20, an executive order froze funding and stopped work on all foreign aid programs, including PEPFAR. Today, some PEPFAR programs have resumed under emergency waivers, but many are still shuttered or permanently closed. On March 25, PEPFAR’s congressional reauthorization expired, casting uncertainty on the long-term future of the program.
The rollback of PEPFAR has devastating implications for HIV response in Ethiopia, disrupting testing, treatment, and prevention, interrupting supply chains, and straining other health facilities and programs.
Tens of thousands of Ethiopians will no longer have access to antiretrovirals and preventative drugs. Many thousands more, who maintained health information systems and collected essential data on HIV/AIDS, are no longer employed due to layoffs in January and February. This number includes many of the expert patients that ACT trained.
But the PEPFAR pause goes beyond service disruption. As the health system braces for immediate impacts, critical work—such as building capacity, developing systems, training new workers, raising awareness, and disrupting vertical (mother-to-child) transmission—is being interrupted, halting progress toward a generation free of HIV. For ACT, this could very likely mean a return to a focus on palliation and damage control rather than restoration and flourishing.
The Lazarus Effect: The Role of Civil Society
The work of organizations like Ethiopia ACT will continue whether PEPFAR continues or not. They will follow Jesus’ call in Matthew 25 to visit the sick and care for the poor, but something of value will have been lost. Physicians often refer to the response of patients when they first receive antiretrovirals as “the Lazarus effect.” Previously on their deathbeds, they rapidly gain weight, recover from illnesses, and return to work and community. Because of the availability of antiretrovirals, whole families and communities experienced a Lazarus effect, the restoration of life from death.
This physical restoration, alongside the economic empowerment and spiritual restoration that ACT’s work enables, is the human flourishing that we believe we are called to as a matter of public justice. This notion of public justice challenges us to consider what roles government and civil society, for example, faith-based organizations, and churches, can play in a world afflicted by HIV/AIDS.
A five-year reauthorization of PEPFAR is a critical step that the U.S. government can take to facilitate this work. What’s more, governments can respond at scale to pandemics and operate health systems, opening avenues for civil society participation.
While faith-based organizations are private sector institutions, they operate at a critical junction where their partnership with government can enable community outreach that governments may struggle to achieve on their own. ACT’s extensive community knowledge allows a tailored approach to address the needs of each family.
Just as PEPFAR has transformed ACT’s work, civil society is essential to the success and sustainability of PEPFAR.
Ethiopia ACT works to ensure that every person is treated with the respect of someone created in God’s image. This means seeing the relational and spiritual aspects of people, not just their physical and financial needs. The church planting activities begun out of ACT’s work have now grown to be a separate organization, because the Ethiopian government currently requires to funding for spiritual ministries and development to be separate. Thankfully, ACT has a formal memorandum of understanding to continue partnering with the Grace of the Messiah churches and continues to work in partnership with these local churches to address both physical as well as spiritual needs. This, too, is what we believe human flourishing can look like.
Genet’s Story, 14 Years Later
Genet is now in her twenties. She has completed her masters degree and was recently married, events that were both greeted with great fanfare at the Ethiopia ACT offices. She regularly provides counseling to HIV positive teenagers struggling with the reality of having a chronic disease. Over the last twenty years, Genet’s life has been transformed by PEPFAR’s far-reaching impacts, but this impact is not guaranteed. It is critical that PEPFAR be reinstated and not subject to cancellations again, as its existence is essential to the life-changing work of Ethiopia ACT.
*This is an alias. Name has been changed to protect the individual’s privacy.
Davy Codington is a graduate from Covenant College and the Johns Hopkins School of Public Health, where he studied health systems. He currently works at the Maryland Department of Health on one of many teams that operate the State’s Medicaid waivers for people with intellectual and developmental disabilities. Davy loves to run, travel, go to baseball games, and gather friends in shared spaces. He lives with his wife Sara in Baltimore, Maryland.
Hannah Bansil, MD, MPH is the executive director of Ethiopia ACT. She completed her medical degree and surgical training at East Tennessee State University and her public health degree with a focus in global health at the Harvard T.H. Chan School of Public Health. She lives in Boston, MA with her husband and two daughters.
