The President's Emergency Plan for AIDS Relief (PEPFAR) is one of the few foreign policy initiatives inherited by the Obama Administration that is not in crisis-not yet anyway. The recent buzz about the unceremonious dismissal of PEPFAR's well-respected director1,2 and concern about the effects of the global financial crisis on upcoming appropriations has cast an uncertain pall over the USA's global AIDS programme. But these issues are unlikely to derail PEPFAR. What could subvert PEPFAR is failure to adequately emphasise maintenance and adherence in patients now receiving treatment through the programme. The Obama Administration has committed to a robust AIDS programme, which in addition to strong leadership and sustained funding will require a paradigm shift as PEPFAR evolves from an emergency initiative (ie, short-term) into a chronic care programme for developing countries. As a first step, the incoming Global AIDS Coordinator could score a quick win for PEPFAR and the public's health by ensuring that treatment partners devote more resources to supporting patients already on treatment.
Starting 2 million people on treatment also means keeping 2 million on treatment for years (and hopefully decades); failure to do so will undermine the public health and foreign policy achievements of the first 5 years of PEPFAR. PEPFAR's biggest success-support for more than 2 million people on HIV treatment-is also its largest liability.