Ninth Annual Report to Congress (2013)


PEPFAR Annual Report

9th Annual Report to Congress

In 2013, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) will mark nearly ten years of success with an extraordinary year of achievements. None of this would have been possible without the vision and leadership of President Bush, President Obama, and the bipartisan support of Congress. A decade ago AIDS was wiping out an entire generation in Africa; today, PEPFAR’s efforts and those of its many partners have brought the world to a new era—a time when new HIV infections and AIDS-related deaths are on the steep decline, and an AIDS-free generation is both U.S. policy and a goal within our reach.

Building off recent scientific breakthroughs, which demonstrated the power of key evidence-based interventions to drive down the rate of new infections and save more lives, the Administration released its landmark “PEPFAR Blueprint: Creating an AIDS-Free Generation” in November 2012. This document reflects lessons learned from almost ten years of experience in supporting countries to rapidly scale-up HIV prevention, treatment, and care services. It demonstrates the opportunity for the world to help move more countries toward and beyond the tipping point in their epidemics and put them on the path to achieving an AIDS-free generation. The Blueprint sends an unequivocal message that the U.S. commitment to the global AIDS response will remain strong, comprehensive, and driven by science—and clearly outlines what PEPFAR is doing and will continue to do to help make an AIDS-free generation a reality.

Saving Lives

Saving lives continues to drive PEPFAR’s core work, and PEPFAR continues to expand life-saving programs as shown by fiscal year 2012 (FY 2012) program results. At the end of FY 2012, the United States directly supported over 5.1 million men, women, and children on antiretroviral treatment (ART) through bilateral programs. PEPFAR and the U.S.-supported Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) continue to be the leaders in the significant increase in availability of treatment. UNAIDS estimated that in 2011, the number of people in low-and-middle-income countries receiving treatment rose to more than 8 million.

PEPFAR’s commitment to preventing children from being born with HIV and keeping mothers alive is demonstrated by its direct support for HIV testing and counseling for more than 11 million pregnant women in FY 2012. In FY 2012, PEPFAR supported antiretroviral drug prophylaxis to prevent mother-to-child transmission for more than 750,000 of those women who tested positive for HIV, allowing approximately 230,000 infants to be born HIV-free. PEPFAR also provided care and support for nearly 15 million people, including more than 4.5 million orphans and vulnerable children, and HIV testing and counseling for more than 46.5 million people.

In 2012, PEPFAR aggressively pursued the President’s ambitious new goals that were announced on World AIDS Day 2011. Among these goals was a 50 percent increase in PEPFAR’s treatment target to support 6 million people on treatment by the end of 2013. Other new goals for these two years include 4.7 million voluntary medical male circumcisions, antiretroviral prophylaxis to prevent vertical transmission for 1.5 million pregnant and breast-feeding women, and provision of a billion condoms. PEPFAR’s progress toward these goals is outlined in the accompanying charts.

Driving Results with Science

All of PEPFAR’s interventions and achievements are rooted in evidence. Dramatic scientific advances have brought the world to the point where an AIDS-free generation is in sight. This provides an unprecedented opportunity to use existing tools to push the rate of new infections downward dramatically. Through its continued support for a scale-up of key combination prevention and treatment interventions in high burden countries, as detailed in PEPFAR’s 2011 program guidance and summarized below, PEPFAR will help countries to reduce new HIV infections and decrease AIDS-related mortality. PEPFAR’s support for service scale-up, along with its efforts to increase countries’ capacity to sustain and support their own AIDS responses over time, will significantly contribute to moving more countries past the programmatic tipping point in their HIV epidemics. This is the point at which the annual increase in new patients on ART exceeds annual new HIV infections, and is one measure that a country is getting ahead of its epidemic. Strategic investments in implementation science evaluations will ensure PEPFAR that continues to lead in producing and applying evolving evidence in its programming.

Treatment as prevention. In 2011, an exciting randomized control study sponsored by the National Institutes of Health and others demonstrated that early initiation of ART produced an astonishing 96 percent reduction in risk of HIV transmission, better than most vaccines. The lifesaving benefit of treatment for the person receiving it has long been established; the study made it clear that this benefit is accompanied by an extraordinary prevention effect. This scientific discovery has reaffirmed the broad prevention benefits from achieving the treatment goal of 6 million persons, as announced by President Obama. PEPFAR is on the path to meet this target based on its 2012 World AIDS Day results.

Prevention of mother-to-child transmission (PMTCT). The scientific foundation for PMTCT has long been established. Several countries in sub-Saharan Africa, including Botswana, have achieved virtual elimination of new pediatric HIV infections on a national scale while improving maternal health and survival through lifelong ART for eligible mothers. To expand the number of mothers and babies benefiting from PMTCT services further, PEPFAR has increased its investments in this area, and worked with Ministries of Health to develop Acceleration Plans to address critical bottlenecks, scale-up services, and improve quality. In June 2011, PEPFAR and UNAIDS joined with other partners in co-launching the Global Plan towards the Elimination of New HIV Infections among Children and Keeping their Mothers Alive. The Global Plan’s two central goals are to reduce the number of new pediatric infections by 90 percent and reduce AIDS-related maternal mortality by 50 percent by 2015 in the 22 countries that carry 90 percent of the global burden. The Global Plan focuses on country ownership, calls for unified action and leadership at all levels, and includes coordinated support for countries to reach ambitious but achievable targets.

Voluntary Medical Male Circumcision (VMMC). In recent years, PEPFAR has led the global scale-up of voluntary medical male circumcision for prevention. As of the end of FY 2012, PEPFAR had directly supported approximately 2 million male circumcision procedures cumulatively worldwide, with a particular acceleration of the pace of progress since 2011. Modeling studies predict that the benefits of VMMC are greatest in settings with high HIV prevalence, primarily heterosexually-driven epidemics, and low rates of male circumcision. Many countries and regions, particularly in eastern and southern Africa, are in this category. PEPFAR supports VMMC activities in 14 countries, working side-by-side with countries and other partners in program planning and implementation. In these settings, it is estimated that one HIV infection is averted for every five to 15 circumcisions, providing a lifetime benefit, and making it a highly cost-effective intervention. Moreover, as HIV prevalence decreases among circumcised men there is an indirect protective effect against HIV for women, women’s uncircumcised male sexual partners, and ultimately the whole population, especially over a ten- to twenty-year time horizon.

Science and research. PEPFAR continues to fund a diverse portfolio of implementation science research through its implementing agencies. Priorities for this research include PEPFAR’s key programmatic questions, and are informed by inputs from the PEPFAR Scientific Advisory board (SAB). The SAB will next meet in the fall of 2013; agenda topics will include: maximizing cost-effective strategies for linkage and retention of patients in care and treatment, and providing services to key populations. PEPFAR is also working with multiple stakeholders to invest in research capacity building in its partner countries so they are better able to produce and apply evidence to their program management

Smart Investments

Saving lives requires not only reliance on the latest science, but a commitment to stretch each dollar as far as possible. To achieve an AIDS-free generation, countries must target efforts where the virus is—reaching and supporting those populations at greatest risk and urgently in need of services. PEPFAR is making smart investments in the interventions that will maximize impact toward priority outcomes. In addition, PEPFAR is improving its efficiency, reducing commodity costs, and applying best practices to implementation. PEPFAR’s cost of supporting an individual on treatment has fallen from over $1,100 per year to $338, with an expectation of further reductions through the maturing of programs currently in the rapid scale up phase. PEPFAR continues to fund innovative work on program costs, HIV financing, and cost-effectiveness of service delivery models.

In 2012, PEPFAR pioneered the use of results-linked expenditure analysis as part of routine program reporting. Phase I included nine high investment countries that account for more than 75 percent of PEPFAR’s global budget. This will be expanded to a total of 20 countries (accounting for 95 percent of PEPFAR’s global budget) in 2013, and to the entire program in 2014. These data are shared with partner governments and used in program planning and cost-projection modeling sponsored by PEPFAR and other partners. Better access to real-time economic and financial data will allow for partner governments and partners to make better rapid course corrections to coordinate donor and public funds to program resources more strategically.

Focus on gender. Investing in gender programs to reduce vulnerability to HIV infection is a smart investment. HIV remains the leading cause of disease and death for women of reproductive age in low- and middle-income countries, and women and girls represent nearly 60 percent of people living with HIV in sub-Saharan Africa. Gender inequalities and gender-based violence increase vulnerability to HIV. Addressing such inequities increases access to services and improves health outcomes for individuals, families, and communities. PEPFAR has strengthened gender programming within its country portfolios, as demonstrated in Partnership Frameworks and Country Operational Plans. The interagency PEPFAR Gender Technical Working Group encourages country programs to focus on five key areas: increasing gender equity in HIV/AIDS programs and services, including reproductive health, preventing and responding to gender-based violence, engaging men and boys to address norms and behaviors, increasing women and girls’ legal protection, and increasing women and girls’ access to income and productive resources, including education. These investments and partnerships are having a major impact for women, girls, and gender equity. For example, over the past three years PEPFAR has reached almost 85,000 individuals with post-exposure prophylaxis to prevent HIV in sexual violence survivors in 19 countries.

Private sector engagement. Public-private partnerships (PPPs) are a tool that can enhance country approaches to HIV/AIDS and strengthen overall health systems. PPPs also offer the opportunity to complement PEPFAR's technical expertise and extend the impact and reach of PEPFAR’s resources. Since 2006, PEPFAR has supported more than 170 PPPs, and leveraged more than $229 million from the private sector. Many partners have specific technical expertise to contribute in areas such as laboratory capacity and information technology. PEPFAR has worked to link their capabilities with areas of program emphasis to leverage not just dollars, but results that can be sustained in the long term. For example, in 2012, PEPFAR partnered with USAID, UNITAID, and the Bill & Melinda Gates Foundation on an agreement to expand access to GeneXpert®, a molecular diagnostic system that provides two-hour rapid diagnostic information on tuberculosis (TB) and TB/HIV. The partnership will reduce by 40 percent the cost of a new, highly accurate, rapid diagnostic test for TB, the leading cause of death among people living with HIV in Africa. In addition, greater access to this test will allow for faster diagnosis, and help reduce TB transmission and premature TB deaths.

Together for Girls is another example of an innovative PPP. As a partnership that addresses violence against children, Together for Girls focuses on three pillars: conducting national surveys to document the magnitude of violence against children, supporting coordinated program actions at the country level in response to the data, and leading global advocacy efforts to raise awareness and promote evidence-based solutions. Launched in 2009, the partnership brings together private sector organizations, including the Nduna Foundation, Becton, Dickinson and Company, the CDC Foundation, and Grupo ABC; five United Nations agencies; and the U.S. Government. The partnership is active in Tanzania, Kenya, Swaziland, Zimbabwe, and Haiti, and will soon be up and running in Malawi.

Country Ownership

During its second phase, PEPFAR continues to prioritize moving beyond a strictly emergency response, and expanding efforts to build sustainable and integrated health programs. This approach, jointly emphasized by Congress and the Administration, promotes deeper strategic engagement with partner governments to build country-owned systems and workforces that will endure.

In 2012, PEPFAR continued to work closely with governments and civil society, encouraging them to bring complementary resources to the table. In some cases, they have responded with strong financial commitments, such as the South African government’s (SAG) recent increases in investments in its HIV program. This commitment was clearly articulated in the Partnership Framework Implementation Plan (PFIP), which was signed by the SAG and U.S. government in August 2012. To date, PEPFAR has signed 22 Partnership Frameworks with partner countries and is working to ensure that they rise to the challenge of leading their national HIV responses. For HIV, as for other development issues, countries must lead their own responses, including embracing the efforts of civil society, such as faith-based groups and networks of people living with HIV. Moving forward, PEPFAR will continue to support capable leadership, a context of good governance, peace and stability, and sensible economic and social policies based in science within the partner countries with which it works.

Shared Responsibility. The world can only hope to create an AIDS-free generation if all partners share in the responsibility. President Obama’s call to the global community, formalized in the PEPFAR Blueprint, has made clear that the global AIDS response must be supported by the commitment of partner countries and reinforced with support from donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations, and multilateral organizations. Shared responsibility requires political will and effective coordination at the country level, amongst multiple partners inside and outside the health sector, and meaningful involvement of those living with and affected by HIV. PEPFAR continues to work with countries to improve their capacity to lead their national responses and increase domestic funding to meet the needs of their people.

Shared responsibility also means supporting and strengthening the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). The Global Fund provides a clear opportunity for other donors to contribute in addressing the global burden of AIDS, tuberculosis, and malaria. The United States is the largest contributor to the Fund, and works closely with the Fund to ensure that each dollar invested achieves maximum impact as part of a common effort to support our partner nations. The Obama Administration is a leader in promoting reform of the Global Fund as an efficient, long-term channel for funding evidence-based, high impact interventions. The United States has tied its financial support to successful implementation of reforms, and supports the Global Fund’s decisive actions on rigorous fiduciary controls and becoming a more active investor through its new funding model. This model streamlines processes, promotes country ownership and emphasizes strategic investments for impact. Through these efforts, PEPFAR investments are better coordinated with the Global Fund resulting in greater impact on the ground.

Conclusion

As PEPFAR enters its tenth year, it demonstrates the unprecedented opportunity for significant progress toward achieving an AIDS-free generation. PEPFAR is saving lives by investing in HIV interventions targeted at populations at greatest risk and promoting sustainability, efficiency, and effectiveness across our programs. These efforts maximize the impact of each dollar we spend. By partnering with countries on country-led and managed responses, and working closely with the Global Fund and other partners around the world on shared responsibility, we are collectively moving measurably closer to achieving an AIDS-free generation. There is no doubt that the path already charted by PEPFAR allows us to anticipate even more remarkable achievements in the coming year.

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