Eighth Annual Report to Congress
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was created out of the generosity of the American people, with the leadership of President Bush and a bipartisan Congress. Under President Barack Obama, it has expanded and continues to be an essential expression of American compassion for those affected by HIV/AIDS in the developing world.
Scientific breakthroughs in 2011 demonstrated the power of evidence-based interventions to dramatically drive down the rate of new infections and save more lives. The U.S. Government has contributed to the science that identified these interventions and, through PEPFAR, is leading the world in their implementation.
With strong endorsements by President Obama on World AIDS Days and Secretary of State Hillary Rodham Clinton at the National Institutes of Health (NIH) in November, the goal of an AIDS-free generation is now U.S. policy. PEPFAR is pursuing that goal, saving lives by moving science into programs through smart investments.
Saving lives is the ultimate metric of success. PEPFAR has continued to expand life-saving programs, as shown by fiscal year (FY) 2011 program results. At the end of the fiscal year, through PEPFAR the United States supported over 3.9 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 continue to be the leaders in the dramatic increase in availability of treatment. UNAIDS estimated that in 2011, the number of people in low-and-middle-income countries receiving treatment rose to nearly 5.6 million.
With a heightened focus on preventing children from being born with HIV and keeping mothers alive, PEPFAR directly supported HIV testing and counseling for more than 9.8 million pregnant women in FY 2011. Antiretroviral drug prophylaxis to prevent mother-to-child transmission was supported for more than 660,000 of these women who tested positive for HIV, allowing approximately 200,000 infants to be born HIV-free. PEPFAR also provided care and support for nearly 13 million people, including more than 4.1 orphans and vulnerable children.
On World AIDS Day 2011, the President announced ambitious new goals for the program. Among these was an extraordinary 50 percent increase in PEPFAR’s treatment target, to six million people supported 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 women, and provision of a billion condoms. These are ambitious targets and represent the extraordinary U.S. commitment to a vigorous global effort to meet our shared responsibility.
Leading with Science
All of PEPFAR’s achievements rest on the foundation of science. Encouraging scientific advances have created a critical moment on global AIDS, with an opportunity to use existing tools to push the rate of new infections downward dramatically. In 2011, PEPFAR issued guidance on ‘combination prevention’ – supporting each country in developing a mix of activities, based on sound scientific evidence, that will have the maximum impact on reducing new HIV infections and saving lives.
Interventions PEPFAR gave special emphasis to in 2011 included treatment for HIV infection, prevention of mother-to-child transmission, and voluntary medical male circumcision. These interventions are central to the relationship between science and impact through PEPFAR programs. They are being expanded in concert with other proven interventions, such as HIV testing and counseling, programs focused on people living with HIV and populations at higher risk for infection, and behavioral supports.
Treatment as prevention. In May 2011, a randomized control trial sponsored by NIH and others documented for the first time that treatment also works as an extraordinarily successful tool for prevention. Initiation of treatment by HIV-positive individuals lowers their viral load, substantially protecting their HIV-negative sexual partners from acquiring HIV. 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; now it is clear that this benefit is accompanied by an extraordinary prevention effect. This finding underlies PEPFAR’s commitment to expand its already massive treatment effort even further, as demonstrated in the new treatment goal announced by President Obama.
Prevention of mother-to-child transmission (PMTCT). The scientific foundation for PMTCT has long been established, and some countries – such as Botswana – have achieved virtual elimination on a national scale. To expand the benefits of PMTCT further, PEPFAR has increased investments and worked with Ministries of Health to develop Acceleration Plans to address critical bottlenecks. To strengthen these efforts, in 2011 PEPFAR issued guidance on integration of PMTCT with maternal, neonatal, and child health and pediatric HIV services.
PEPFAR’s work led to a Global Plan towards the Elimination of New Pediatric Infections and Keeping Mothers Alive, launched with UNAIDS and others in June 2011. The Global Plan’s central goal is to reduce the number of new pediatric infections by 90 percent by 2015 in 22 countries which 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 ambitious but achievable targets to chart progress.
Voluntary Medical Male Circumcision. In recent years, PEPFAR has led the global scale-up of male circumcision for prevention, providing over one million circumcisions to date, with a particular acceleration of the pace in 2011. Modeling studies predict that the benefits of male circumcision are great in populations with high prevalence of primarily heterosexually-driven HIV and low male circumcision. There are numerous countries and regions, particularly in eastern and southern Africa, in this category. PEPFAR supports male circumcision activities in 14 countries, working side-by-side with countries and other partners in program planning and implementation. It is estimated that one HIV infection is averted for every five to 15 circumcisions, providing a lifetime benefit, and making it a cost-effective intervention. And 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. In 2011, PEPFAR’s Scientific Advisory Board provided important guidance for the program’s response to the new data on the prevention impact of treatment. This guidance has informed PEPFAR’s plans for program expansion.
PEPFAR awarded three groundbreaking grants for trials of combination prevention, using the best available tools of implementation science, scaled to high levels, to allow for rigorous evaluation of population level effects of combination prevention. Also launched in 2011 was an in-country impact evaluation effort. Through this process, interagency PEPFAR country teams use a fraction of their budget to work with academic and local program experts to apply the rigorous methods of impact evaluation to critical programs. By opening up another avenue for research, PEPFAR hopes to have a burst of public health-relevant data over the next several years that can shape the program to be as impactful as possible in the future.
Saving lives requires not only reliance on the latest science, but a commitment to stretch each dollar as far as possible. PEPFAR is making smart investments by investing in the interventions that will have the biggest impact on prioritized outcomes. For PEPFAR, those outcomes are human lives saved and reductions in HIV infection. This is being achieved by focusing dollars on interventions that have been shown to have the greatest impact. In addition, PEPFAR is improving its efficiency, reducing costs through steps such as lowering commodities costs, switching from air to sea and land freight, and collection and use of economic and financial data in programming. PEPFAR’s costs of supporting an individual on treatment have fallen from over $1100 per year to $335, with an expectation of further reductions. PEPFAR continues to aggressively accelerate the development of costing studies of treatment and other programs, and has funded innovative work examining the cost-effectiveness of service delivery models.
PEPFAR has also pioneered the use of outcome-linked expenditure analysis exercises among prevention, care and treatment partners in several countries and is working to quickly routinize this activity program-wide. These data are shared with partner governments, and used in decision-analytic and cost-projection modeling sponsored by PEPFAR and other partners to improve national program planning. Better access to updated economic and financial data and indicators will allow for governments and partners to make better rapid course corrections to improve planning and effectiveness, and avoid inefficient use of resources.
Focus on gender. Investing in gender programming is a smart investment, addressing an essential component in reducing the vulnerability of women and men to HIV infection. A central principle of the Global Health Initiative is a focus on women, girls and gender equality. PEPFAR is a key partner in implementing this principle, seeking to redress gender imbalances related to health, promote the empowerment of women and girls, and improve health outcomes for individuals, families, and communities. PEPFAR has strengthened programming for gender within country portfolios, as demonstrated in Partnership Frameworks and Country Operational Plans. For example, PEPFAR supports significant work in the field to address gender-based violence activities in existing HIV programs. In addition to mainstreaming gender throughout all programs, PEPFAR has invested in special gender initiatives in order to pilot specific approaches, build the evidence base and encourage additional programming at the country level.
Private sector engagement. Public-private partnerships (PPPs) are a tool that can enhance country approaches to HIV/AIDS and strengthening of overall health systems, while extending the impact of PEPFAR resources. Businesses have skills that complement PEPFAR's technical focus, including marketing and distribution networks. Many 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 September 2011 PEPFAR launched Pink Ribbon Red Ribbon along with the George W. Bush Institute, Susan G. Komen for the Cure, and UNAIDS. This innovative partnership leverages public and private investments to combat cervical and breast cancer – two of the leading causes of cancer death in women -- in developing nations. PEPFAR’s contribution to Pink Ribbon Red Ribbon will expand the availability of vital cervical cancer screening and treatment—especially for HIV-positive women, who face a dramatically heightened risk of cervical cancer.
The second phase of PEPFAR has emphasized supporting countries in moving beyond a strictly emergency response, and expanding efforts to build sustainable and integrated health programs. Through deeper strategic engagement with partner governments, PEPFAR is supporting them to build country-owned systems and workforce that will endure.
In 2011, 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 recent increases in investments in their HIV program. To date, PEPFAR has signed 21 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 groups of people affected by PEPFAR programs.
PEPFAR is one of the key platforms upon which the Obama Administration is building the Global Health Initiative, supporting one-stop clinics offering an array of health services. This means driving down costs, driving up impact, and saving more lives. Through PEPFAR investments, systems of care have been put in place that countries are leveraging to improve their citizens’ overall health. PEPFAR is part of a larger development context, building an evidence base, evaluating impact, and direct programs in ways that can strengthen the entire domain of development.
Improving public health requires creating a lasting improvement in the capacity of partner countries to address their needs. Thus part of the challenge is to ensure that as PEPFAR moves science into programs, the development of capable leadership is supported, as well as a context of good governance, peace and stability, and sensible economic and social policies.
Investments in global health are a pillar of American leadership, advancing national interests and making other countries more stable and the U.S. more secure. Even so, the global AIDS response is a shared responsibility that cannot be met by one nation alone. President Obama has called on the global community -- including governments, civil society, and the private sector -- to join the United States in this undertaking. Around World AIDS Day 2011, the President wrote to leaders of other nations that have demonstrated notable leadership on HIV/AIDS, expressing U.S. commitment to work together to meet the shared global responsibility. The International AIDS Conference, returning to U.S. soil for the first time in over 20 years in July 2012, will provide an important platform at which the United States will communicate the message of shared responsibility.
The contribution of partner countries to meeting the shared responsibility is an essential one. As noted above, PEPFAR is working with countries to improve capacity to lead their national responses and increase their funding to meet the needs of their people. Shared responsibility also means includes supporting and strengthening the Global Fund. The Global Fund represents a critical vehicle for other donors to contribute to the shared global responsibility to address this global burden. The United States is the largest contributor to the Fund, and is now working closely with it to ensure that each dollar achieves maximum benefit as part of a common effort to support our partner nations. This is being done through an intentional process of prioritizing smart investments, making programming more efficient, and leveraging the investments of complementary funding streams, such as those of governments and the Global Fund. In 2011, U.S. support for Global Fund reform began to bear fruit, as the Fund’s Board adopted the recommendation of its independent High-Level Panel. Through this work and the daily efforts of PEPFAR country teams, PEPFAR investments are being leveraged through better coordination with the Fund and elimination of parallel systems.
President Obama has made it clear that continued strong leadership from the United States, along with heightened commitment by other partners, is creating an unprecedented opportunity for dramatic progress toward an AIDS-free generation. In 2012 and beyond, the United States will continue to seize that opportunity.
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