The President's Emergency Plan for AIDS Relief (PEPFAR), enacted by George W. Bush in 2003, is the largest bilateral aid programme targeting a single disease in history. In the first phase of PEPFAR, which ran from 2003 to 2008, aid to fifteen so-called focus countries totalled over $18 billion. The magnitude of the programme, together with its exclusive focus on HIV/AIDS, has led scholars, advocates and policy-makers to critically examine its efficacy, emphasis and unintended consequences.

In his book, Recipient States in Global Health Politics: PEPFAR in Africa, Ricardo Pereira adds to this investigation by employing case studies to demonstrate the politics underlying the implementation of PEPFAR in three African countries: Botswana, Ethiopia and South Africa. Pereira aims to contribute to literatures in international relations, particularly those relating to states' behaviour in the international system. He argues that aid-recipient states are not merely puppets of dominant actors in the international system, such as the USA, but have and pursue their own interests and agendas. He uses the implementation of PEPFAR in the three aforementioned countries to demonstrate how recipient states act in their own interests, and respond differently to aid programmes as a function of their national politics.

The main argument, regarding the interests of aid recipient states, is not particularly novel, nor does it run counter to prevailing thought in international relations today. As such, Pereira comes close to battling a straw man – most scholars of international relations today would likely agree with Pereira's notion that states, regardless of their place or standing in their international system, have their own interests and act as ‘rational agents that have policy dilemmas, devise strategies and aim at political goals …’ (p. 11). The book provides a useful reminder that foreign aid is not provided in a political vacuum, and that aid recipients have their own goals and interests with regard to aid programmes. This reminder, however, is just that, and not a new theoretical contribution, as the author seems to suggest.

The greatest potential of the book lies in its case studies. Though PEPFAR is a single US programme, its implementation looks quite different across countries, variation that is often overlooked in analyses of the programme. Pereira takes the reader through the post-colonial histories of the three cases he examines, as a means of providing the political context in which PEPFAR was implemented. He argues that each of the three governments in question had different political goals vis-à-vis PEPFAR. For Botswana, the political goal was national survival; for Ethiopia, regime survival; and for South Africa, liberal multiracial democracy. In terms of evidence, Pereira's original contribution, alongside secondary sources, comes in the form of excerpts from interviews with representatives from PEPFAR-implementing organisations, among others, which provide interesting insights. However, without information about the sample of interviewees, in particular how they were selected, it is difficult to know what we should make of these insights.

The reader is also left wondering how the three cases were selected. Table 9.1 provides some clarity in terms of the dimensions along which the three cases vary or not (policy problem, strategies and political goals), but is not accompanied by an explanation of how these cases relate to the broader set of potential cases that might have been examined, which include the other twelve of the fifteen original PEPFAR focus countries. A more constructive approach to the topic might have been to develop a framework where state responses to PEPFAR is the variation to be explained, and domestic political factors and/or the domestic policy problem explored as key explanatory factors for this variation. Then, cases could be selected such that they purposely vary along one or the other of these dimensions with the goal of developing a theory about the conditions that structure a recipient state's response to the provision of foreign aid. A theory developed along these lines – one that draws out the relevant factors underlying recipient states' behaviour as it relates to aid – would push forward our understanding of foreign aid more than using the case of PEPFAR to present the argument that recipient states act with their own interests and goals, the latter of which is uncontroversial.