The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) saved more than 740,000 African lives between 2004 and 2008, according to a new report published in the May 16 issue of The Journal of the American Medical Association (JAMA).

“We were surprised and impressed to find these mortality reductions,” said Eran Bendavid, MD, MS, assistant professor of medicine at Stanford University and an author of the paper. According to an accompanying news release, he added: “While many assume that foreign aid works, most evaluations of aid suggest it does not work or [that it] even causes harm. Despite all the challenges to making aid work and to implementing HIV treatment in Africa, the benefits of PEPFAR were large and measurable across many African countries.”

The study is the first to show a decline in death rates, from any cause, related to the program.

Bendavid and his colleagues analyzed health and survival information for more than 1.5 million adults in 27 African countries, including nine countries where PEPFAR has focused its efforts. The researchers examined data collected by the Demographic and Health Surveys, a USAID-funded project that involves a representative sampling of in-person interviews among women in which they discuss their health and the health of their family members. These surveys form the foundation of many health measurements in developing countries.

The researchers found the odds of death from any cause among adults were 16 to 20 percent lower in the PEPFAR-targeted countries.

Bendavid and his colleagues also conducted a focused analysis using data from PEPFAR programs in Rwanda and Tanzania. They compared regions of the two countries where PEPFAR’s investments led to widespread increases in the number and size of sites providing antiretroviral therapy, with areas where PEPFAR had fewer services available.

In Tanzania, the researchers noted, the odds of death were found to be 17 percent lower and in Rwanda 25 percent lower in the districts with greater support from PEPFAR.

Bendavid speculates that the program’s commitment to building health-care delivery infrastructure—including new drug distribution systems and new clinics, pharmacies, laboratories and testing facilities—has been an important factor for its success.

The finding that PEPFAR has reduced all-cause mortality rates—deaths not necessarily attributed to HIV infection—may stem from the fact that the program may be benefiting people with a variety of other health concerns. For example, one study cited by Bendavid and his colleagues noted that some pregnant, HIV-negative women in Ethiopia, Rwanda and Tanzania chose to deliver their babies in facilities supported by PEPFAR.

Historically, the authors point out, few other large-scale health initiatives have succeeded to such an extent; smallpox, which was eradicated by 1979, is among the rare and more notable examples.

“PEPFAR’s success with HIV…may be considered the clearest demonstration of aid’s effectiveness in recent years,” Bendavid and his colleagues explain.

PEPFAR was begun in 2003 under the administration of President George W. Bush with a five-year, $15 billion investment in global AIDS and a focus on treatment and prevention in 15 countries. It was reauthorized by Congress in 2008 and has expanded its reach to 31 countries.

In 2009, PEPFAR was folded into a new Global Health Initiative that calls for a broader agenda, with some resources redistributed to other programs, such as maternal and child health. Its budget, which rose dramatically in the early years, has remained relatively flat or declined slightly since then. It reached a peak at $6.8 billion in fiscal year 2010, then declined to $6.7 billion and $6.6 billion in fiscal years 2011 and 2012, respectively, according to figures from the Kaiser Family Foundation. The administration’s budget request for the 2013 fiscal year is $6.4 billion.

While the program appears to have had an impact within a few years of its implementation, Bendavid noted that reduced investments in global AIDS, both through PEPFAR and other international aid programs, could have implications for the future of the epidemic.

“Some have argued that focusing resources on a specific disease, such as AIDS, may detract efforts from other diseases and activities, undermining some of the benefits of such programs,” the researchers write. “But the latest study does not support this argument; indeed, it suggests that PEPFAR helped to prevent additional deaths from causes other than HIV/AIDS.”

“Whether disease-specific programs like PEPFAR have synergies with other health improvement efforts—or instead undermine them, as some have worried—is really an open question,” said Grant Miller, PhD, MPP, associate professor of medicine and the senior author of the paper. “There are reasons to think either scenario is possible, and more research is needed. We don’t find much evidence of PEPFAR undercutting other initiatives; if anything, we see hints of synergies.”