PEPFAR's Five-Year Strategy

Tanzanian President Jakaya Kikwete launched the PEPFAR-supported Angaza Zaidi HIV counseling and testing program in April 2009. This program provides urban and rural communities in Tanzania with HIV counseling and testing services, post-test support groups, and referrals for HIV-positive individuals to care and treatment facilities. Photo by Tanzania PEPFAR Team


The HIV/AIDS epidemic that confronted the world at the beginning of this decade was a humanitarian crisis of a magnitude never before faced in modern history. Despite significant advances in treatment and care in countries like the United States, the life-saving medications available in developed countries were largely inaccessible in developing nations. In 2001, fewer than 50,000 people living with HIV in sub-Saharan Africa had access to antiretroviral medication. As a result, many national health systems were overwhelmed. HIV-related needs absorbed almost all health care services available. Hospitals were packed with people dying from AIDS, spilling forth from beds onto floors and into hallways. Demoralized health care workers turned away severely ill patients, sending them home to die, because they had no treatment to offer.

The impact of the epidemic extended far beyond the health sector and those who were sick. AIDS created millions of orphans and robbed children of the stability and love of their parents. Many youth were forced to drop out of school and assume caregiver status for ailing parents and younger siblings. In addition, the AIDS epidemic paralyzed economies. At the country level, AIDS decimated national gains in economic growth. At a community level, AIDS created poverty among widows and families, and devastated schools, factories, armies and businesses whose employees were dying more quickly than they could be replaced. Adults were dying from AIDS during the time in their life when they should have been at the peak of their earning and production potential. Life expectancy in sub-Saharan Africa overall plummeted, reversing hard-earned gains of other health and development programs.

In 2003, President George W. Bush and a bipartisan Congress created the U.S. President's Emergency Plan for AIDS Relief to address this growing crisis. This program holds a place in the history of public health as the largest commitment by any nation to combat a single disease, establishing and expanding the infrastructure necessary to deliver prevention, care, and treatment services in lowresource settings. PEPFAR works to address HIV/AIDS in countries with a diversity of need in these service areas. It operates both in countries where epidemics are concentrated among specific populations and those where HIV infection occurs among the general population. In many countries where HIV infection prevalence rates are above 1% - the accepted threshold for generalized epidemics - PEPFAR also works to address the epidemic among most at-risk populations.

The achievements of PEPFAR are remarkable by any measure. From its creation through September 30, 2008, PEPFAR received total funding of more than $18 billion. In FY 2009, the USG invested more than $6.4 billion in bilateral HIV/AIDS programming and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In FY 2009 alone, PEPFAR directly supported more than 2.4 million patients on treatment, and more than 11 million people with care and support programs.* During its first five years, PEPFAR's efforts around prevention of motherto- child transmission programs allowed nearly 240,000 babies of HIV-positive mothers to be born HIV-free. In addition, during this time, more than 4 million orphans and vulnerable children were assisted by the program. PEPFAR also supported over 16,000 laboratories, approximately 3.7 million training and retraining encounters for health care workers, and more than 256 million prevention outreach encounters.

In addition to achieving Congressionally-mandated targets, the program has also had far-reaching health impacts in countries. A May 2009 study published in the Annals of Internal Medicine found that HIV-related mortality had dropped by 10.5% in 12 PEPFAR focus countries analyzed by researchers - implying that about 1.2 million deaths were averted due to the work of PEPFAR.5 Studies presented at a July 2009 International AIDS Society conference illustrated that investments in fighting HIV/AIDS, including those of PEPFAR, contributed to population-level reductions in child and infant mortality.6 For example, in Eastern Uganda, the increase in HIV/AIDS services is associated with a 83% reduction in non HIV-related infant mortality.7 In addition, Botswana experienced declines in infant mortality and increases in life expectancy as HIV spending rose in the country.8

Figure 1: Infant Mortality and HIV Spending in Botswana, Figure 2: Life Expectancy and Spending in Botswana

Beyond these contributions, PEPFAR also had a significant impact on the way health-related foreign assistance is delivered. Its interagency implementation model is overseen at the headquarters level by the Office of the U.S. Global AIDS Coordinator at the Department of State, and by the U.S. Ambassador at the country level. Through this interagency collaboration, PEPFAR has drawn upon the core strengths of agencies from across the USG to embody sound public health and development principles in its programming. PEPFAR integrates HIV prevention, treatment, and care services in a manner that supports an inclusive, multisectoral response. Its work draws upon the knowledge, access, and talents of local community- and faith-based organizations. The program leverages other development initiatives, including those in nutrition, education, and economic development, to maximize the overall impact of USG investments in HIV programming.

From its beginning, PEPFAR has demonstrated the clear role and impact of USG HIV/AIDS investments upon the larger global health arena. Prior to PEPFAR, many had given up on low-resource settings in the developing world as places where HIV infection was untreatable. The program has been successful in delivering HIV services, and created a new cadre of experts among local health care providers. The systems of care established and strengthened by PEPFAR can serve as a platform to expand, integrate, and co-locate primary and specialty care services to best serve the needs of infected and affected populations.

Through the PEPFAR-supported Mothers to Mothers (M2M) program at Bella Hospital in Ethiopia, mothers living with HIV/AIDS provide advice to pregnant women about prevention of mother-to-child transmission services. Through the M2M program, mentor mothers such as Merima Abrar and Messelu Ketema, pictured above, bravely share their life experiences with pregnant women, counsel those who have just learned their HIV status, encourage them to live positively, and ensure they take their antiretroviral drugs regularly. Despite the challenges of this work, the program provides mentor mothers with the skills and confidence to teach their neighbors, and the ability to support their families economically through income generating activities. Merima and Messelu agree that the best reward of all is to see the birth of a child who is free of HIV. Photo by Ethiopia PEPFAR Team

Challenges and Opportunities

Due to the investments through PEPFAR, the Global Fund to Fight AIDS, Tuberculosis, and Malaria and other stakeholders, much has been accomplished. HIV is no longer overwhelming the day-to-day operations of health systems in many heavily burdened countries. Because of these very successes, however, PEPFAR can and must do more. PEPFAR is evaluating its response to inform a next phase that emphasizes country capacity and sustainable responses while continuing support for existing and emerging prevention, care and treatment needs. PEPFAR's second phase builds upon its strengths and addresses some of the challenges faced by the program. This strategy examines how to best achieve PEPFAR's enormous potential as a health, development, and diplomatic tool.

Given the magnitude of the challenge faced at its creation, PEPFAR's initial emergency approach was critically needed, but had both positive and negative impacts on country-level health systems and budgets. At the beginning of the program, a focus on

establishing services took precedence over prolonged engagement in planning and coordination with some country governments or other donors. At times, implementation did not fully complement existing national structures or plans. While the program has been applauded for its focus on service delivery targets, in some countries, this focus did not fully translate to a broader service delivery impact across the health sector. Access to quality services for all health conditions remains problematic in some areas. Given the innovative nature of many of PEPFAR's activities, there remains a need for a broad evaluation of program effectiveness and long-term impact.

PEPFAR places a premium on programming that responds to the country-level epidemic, but has faced challenges in achieving this goal. Responding to the country-level epidemic requires cooperation with other implementers and stakeholders. Barriers have sometimes existed to coordinating and providing technical assistance to Global Fund-financed programs at the country level. PEPFAR is strengthening multilateral collaboration and cooperation, and more fully incorporating high-level principles of the Paris Declaration. These include donor support of partner-country leadership and shared accountability for results. Such goals are a central aspect of PEPFAR's new Partnership Framework process, which promotes a more sustainable approach to the fight against AIDS at the country level.

While the interagency process has been one of PEPFAR's strengths, there has been some degree of interagency conflict at both country and headquarters level. PEPFAR was launched as a new way of doing business, causing some uncertainty among health and development experts who were unclear about their role in the new model. Field perspective and input have not always been reflected in policy or planning decisions. PEPFAR's extensive reporting requirements were not always harmonized with other USG development programs or other international indicators. Partner governments and country teams appropriately raised concerns about the impact of reporting requirements on field programming. Finally, the program has represented a significant scale-up of resources at Embassies without always having the commensurate increase in staff.

Increased investments in various disease- and issuespecific programs over the past decade have resulted in immense gains. There has been expanded interest in strengthening health systems as a way to reduce illness and death, particularly maternal mortality and childhood infectious diseases. PEPFAR now has the opportunity to strategically plan programs with greater consideration for the larger health systems impact. PEPFAR holds great potential for better across-the-board integration with broader health systems and development assistance, such as food, nutrition, and economic strengthening activities. Integration can contribute to larger goals involving infrastructure, governance, sustainability, and communitylevel health impacts, and allows PEPFAR to leverage its impact within a larger development context. In particular, the Global Health Initiative affords an opportunity to support expanded integration of PEPFAR programming with other USG health and development programming.

There is now a track record of success for bilateral initiatives like PEPFAR, multilateral funding vehicles like the Global Fund, and private donors like the Gates Foundation. Rather than emphasizing separate donor identities, opportunities exist to integrate, collaborate, and coordinate to support country-owned, country-guided programs. PEPFAR is working to evaluate existing data to replicate best practices, determine areas of efficiency, and support countries in a coordinated scale-up of proven and promising interventions. Learning from these successes is particularly important as the USG begins to consider larger foreign assistance reform. Lessons from PEPFAR can help to create systems that allow both PEPFAR and other health programs to be better integrated with all types of foreign assistance.

Investments in PEPFAR and the global AIDS fight overall, were and continue to be necessary. Six years after the creation of PEPFAR, AIDS is still a leading cause of death in many countries, and a continued threat around the world. 33.4 million people are living with HIV worldwide, and approximately 2.7 million new infections occurred in 2008.9 For every two people who start treatment, five more are infected.10 There still remain millions of children who have been orphaned by AIDS. Women and girls continue to face disproportionate impact of new infections, and WHO reports that AIDS is the leading cause of death worldwide for women in their reproductive years (ages 15-44).11 Most-at-risk populations - including men who have sex with men (MSM), sex workers, and injecting drug users - continue to face stigma that limit their ability to obtain services, contributing to the wider transmission of HIV. The AIDS crisis is far from over. It will not end during the five year period covered by this strategy. Rather, the world will continue to struggle with continued need for prevention, care and treatment services - need which can only be addressed through a truly global response to the AIDS crisis.

PEPFAR has clearly proven that partnerships between the U.S. government and communities can provide comprehensive prevention, care, and treatment on a wide scale in low-resource countries. The program can now intensify collaboration with partner country governments and establish the conditions necessary to maintain these programs in both rural and urban areas. This strategy is designed to facilitate long-term sustainability and allow partner countries (formerly called "host countries") to lead their national and regional HIV/AIDS responses.

PEPFAR's Strategy

PEPFAR's Vision:

In order to turn the tide of this global pandemic, PEPFAR will work through partner governments to support a sustainable, integrated, and country-led response to HIV/AIDS.

PEPFAR's Goals:

Over the next five years, PEPFAR will work to achieve these five overarching goals:

  1. Transition from an emergency response to promotion of sustainable country programs.
  2. Strengthen partner government capacity to lead the response to this epidemic and other health demands.
  3. Expand prevention, care, and treatment in concentrated and generalized epidemics.
  4. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems.
  5. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.
Two-year old Chipo is learning to walk, which is remarkable given the challenges of her early life. Chipo's mother passed away a month after her birth, and Chipo was diagnosed with HIV in addition to severe malnutrition, and was constantly sick. Chipo was cared for by her grandmother who lives in the remote village of Chitanda in Zambia's Central Province. To get Chipo the care she needed, they had to travel 82 kilometers to the nearest hospital because the Rural Health Center had no medication. In April 2008, mobile antiretroviral therapy (ART) outreach began at nearby Chitanda Rural Health Center and Chipo started obtaining treatment in her community. PEPFAR-supported mobile ART outreach currently covers seven remote locations across Central Province. As the mobile ART team provides services, they also train local health center staff. Over time, program responsibility will shift to the health center, freeing the mobile team to expand services to new locations. Photo by Zambia PEPFAR Team

Key Concepts:

As PEPFAR works in its next phase to achieve its goals and targets, it will be guided by the following key concepts. PEPFAR is working with its country teams to identify the best ways to implement these concepts as appropriate at the country level.

PEPFAR supports true partnerships with governments, in order to assist them as they lead and guide the response to their epidemics.

President Obama and Secretary Clinton have spoken of the need to work with governments in Africa and around the world to support good governance and leadership. The AIDS epidemic represents a shared global burden among nations, and PEPFAR represents an opportunity for the United States to support partner countries in assuming leadership of the response to their epidemics.

In the first five years of the program, PEPFAR focused on establishing and scaling up prevention, care and treatment programs. In some cases, it established programs and services outside of existing, often limited, health care delivery systems. Over this next

phase, PEPFAR is focusing on transitioning from an emergency response to a sustainable one. It is working through bilateral, regional, and multilateral channels to improve and expand partner country capacity, enabling them to implement and manage a holistic response to the epidemic within the context of broader health sector concerns. PEPFAR's major goal is to enable governments to manage and coordinate quality health service delivery across all geographic regions within a country.

PEPFAR's role is to support partner government leadership to organize, develop, and coalesce donors and multilateral agencies around country-driven, countryresponsive plans for the epidemic. Prevention, care and treatment activities are being supported with a focus on strengthening health systems and building sustainable partner country capacity. PEPFAR is expanding technical assistance and mentoring with country governments. Doing so supports a capable cadre of government professionals who can carry out the tasks necessary for a functioning health system, including financing and governance. The program is also facilitating partnerships between governments and a strong civil society, to ensure that citizens can work to provide support to and demand accountability from governments. Finally, the program is working to foster stronger regional collaboration and South-to-South technical assistance.

In many of the countries where PEPFAR works, full transition of operations to partner country ownership and increased financing will take longer than five years to accomplish, but steps are being taken now to create the capacity for sustainability.

PEPFAR is expanding its emphasis on HIV prevention, and matching interventions and investments with epidemiological trends and needs in order to improve impact.

Prevention remains the paramount challenge of the HIV epidemic. While advances in treatment have revolutionized our response to AIDS, truly halting and reversing this epidemic will require a comprehensive, multisectoral prevention, care and treatment response.

There is no single population level intervention that can prevent HIV infection. A successful prevention program requires a combination of mutually reinforcing, continually evaluated interventions that are tailored to the needs and risks of different target populations. Since the beginning of the program, PEPFAR has worked to ensure that its interventions meet the need that exists in countries. Given that the epidemic is not static, changes within countries and regions - including the beneficial impact of prevention efforts - require a prevention response that identifies and deploys interventions to meet these new conditions.

This next phase of PEPFAR presents the opportunity to support countries in reassessing prevention portfolios in order to ensure that they are targeted for maximum impact. The major priority for PEPFAR's prevention programs in the short term is to support countries in mapping and documenting prevention needs. Doing so ensures that interventions are aligned to existing and emerging situations.

By working with countries to identify current drivers, including epidemics among subpopulations that may not be reached by general behavioral prevention messages, PEPFAR can target investments to greatest needs. PEPFAR is also expanding investments into high-impact prevention interventions, such as prevention of mother- to-child transmission (PMTCT), male circumcision (MC), and services for injecting drug users. Finally, the program is working to identify, implement, and evaluate promising and innovative prevention methods, to expand our existing toolkit of interventions and advance the science around HIV prevention.

PEPFAR is committed to expanding access to highquality prevention, care and treatment and immediate health needs while laying the groundwork for future sustainability.

In recognition of the integrated nature of prevention, care and treatment in PEPFAR, the USG continues to support a portfolio of activities tailored to the country context. PEPFAR is working with countries to ensure an appropriate balance among prevention, care and treatment activities. All of these activities are routinely monitored and evaluated in order to ensure that they are of high quality. They are also being analyzed to identify efficiencies and opportunities for integration with broader health and development efforts. PEPFAR targets its evidence-based prevention activities to the specific drivers of the epidemic, and supports pilots of new and innovative prevention programming.

In its care programming, PEPFAR works with countries to support a quality, integrated package of basic care and support interventions for people living with HIV and their caregivers. It also meets the care and support needs of OVCs. In the area of treatment, PEPFAR is working with partner countries to continue scale up, with a focus on specific populations.

PEPFAR's prevention, care and treatment activities are planned with consideration of how they may impact the overall health system, particularly human resources for health. To the extent possible, PEPFAR will incorporate mentoring and increased technical assistance into its programming. Doing so supports development of a cadre of partner country personnel - clinical, community-based, and civil service employees - with the skills to plan, finance, and operate these programs.

PEPFAR is responsive to people, not just to a virus.

Individuals who are infected and affected by HIV/AIDS experience the epidemic along with the other realities of their lives. PEPFAR activities must be responsive to the breadth of needs experienced by people living with HIV/AIDS, their families, and the communities hardest hit by the epidemic. High-quality prevention, care, and treatment activities will be implemented with consideration for their overall health systems impact. In addition, PLWHA are a critical part of the response, and must be involved in planning and implementation.

All PEPFAR programs - prevention, care, treatment, and linkages to larger health care services - must be evidence-based and driven by the needs of the people impacted by this epidemic. As a component of the Global Health Initiative, PEPFAR is working to implement womencentered care, and to ensure that its services are genderequitable. Its programs address the particular vulnerabilities faced by women and girls, especially those who are impacted by gender-based violence. In order to make it easier for people with HIV to access all types of care they need, PEPFAR increases access to high-quality, low-cost care and treatment services. These services are responsive to the public health needs of marginalized communities, including injecting drug users, persons in prostitution, and men who have sex with men. PEPFAR also utilizes its services as a mechanism through which to advance the rights of populations that face stigma, and expand equal access to care.

PEPFAR is also expanding capability of existing service sites by linking HIV/AIDS services to other health interventions, rather than establishing and maintaining parallel systems of care. Given the larger structural barriers that exist in implementing effective HIV programming, PEPFAR is integrating services to respond to the nutrition, education, and economic development needs of AIDS-impacted communities.

Like many street youth in Vietnam, 20 year old Sang has led a difficult life. For several years, he lived in a city park and spent his days stealing to support himself. He was the leader of a street youth gang that frequently fought with rival groups. Sang and his friends are among thousands of children and youth who live and work on the streets of Ho Chi Minh City. Life changed for Sang when a friend invited him to participate in Project N.A.M, a PEPFAR-supported peer education group. With training and support from the project's adult mentors, Sang and 20 others now work as HIV prevention peer educators. The project supports them to use a gender-based approach to help young men reduce risky sexual and drug use practices. The gender-based approach is two-fold: first, it promotes HIV prevention among young men themselves by helping them to reflect on and challenge gender norms that put young men, and consequently their partners, at risk. Second, it asks young men to question gender inequities. Sang has gained confidence and a sense of purpose: 'As a peer educator, I know I'm a positive role model to other street youth and that I can help them make healthier decisions in their lives,' he says. Photo by Vietnam PEPFAR Team

In order to maximize U.S. investments, PEPFAR supports integration with other U.S. government programs in health and broader development sectors.

The success of PEPFAR is unambiguously linked to development mechanisms that expand the reach of bilateral HIV/AIDS assistance, promote country ownership, and increase sustainability of national health programs. PEPFAR is improving its own effectiveness by expanding efficiencies, engaging in joint programming, and working to transition programs to countries in both management and financial contexts. Over this second phase, PEPFAR is increasing efforts to integrate HIV services with existing country, USG-sponsored, and multilateral-financed programs. It is engaging in greater wraparound and joint programming with larger development initiatives, including the Global Hunger and Food Security Initiative, education, economic development, and legal and political reform. Doing so helps to create the structural changes that reduce risks for HIV transmission and expand access to quality care and support. This strategic integration also results in broader impact for both PEPFAR and the programs which it is leveraging.

PEPFAR has strong and robust engagement with multilateral partners and other external partners.

The challenges posed by the global AIDS crisis must be addressed as part of a shared global responsibility. PEPFAR is engaging in enhanced coordination with multilateral, regional, and bilateral partners, ensuring that USG efforts are not duplicative, and that donors are truly sharing the burden of the epidemic. In an affirmation of high level principles of the Paris Declaration, PEPFAR is working with its multilateral and bilateral partners to harmonize and align responses and support countries in achieving their nationally-defined HIV/AIDS goals.

PEPFAR is expanding involvement with the Global Fund, UNAIDS, World Health Organization, and other mechanisms. Doing so supports international consensus and action, progress toward joint programming and harmonized processes, and achievement of global goals such as reduction of commodity prices. PEPFAR also engages with foundations, public-private partnerships, regional bodies, and other civil society donors. Such collaboration supports partner country efforts to utilize all possible partners in developing a national response to HIV and to maximize the effectiveness of all funding streams. PEPFAR's overarching goal is to ensure that the actions of the donor community support efforts to enable countries to lead the response to their epidemics.

PEPFAR supports accountability, monitoring and evaluation, and implementation of efficiencies and best practices.

PEPFAR is committed to clear and transparent reporting of investments and results to ensure that its programs are accountable to taxpayers. PEPFAR works with independent auditors, including agency Inspectors General and the Government Accountability Office, and independent nongovernmental organizations to identify areas for improvement. Its next phase represents the opportunity to improve reporting mechanisms, data use, and monitoring and evaluation to maximize impact and investments. Now that PEPFAR has achieved success in prevention, care and treatment, programs are being reviewed for efficiencies to determine where more can be achieved with existing resources.

PEPFAR is objectively identifying best practices in quality service delivery, and looking for opportunities to replicate and establish cost-effective programs tailored to the country context. In addition, PEPFAR supports innovation, piloting new interventions to establish and expand the evidence base. The program is working to create greater transparency with its data, in order to facilitate identification of best practices and trends in PEPFAR that can contribute to larger systematic knowledge. PEPFAR is not a research initiative, but is expanding its current partnerships with implementers, researchers, and academic organizations to improve the science that guides this work. In keeping with the goal of sustainability, PEPFAR also supports the enhancement of local capacity to carry out monitoring and evaluation activities.

PEPFAR supports greater involvement of USG country teams and a strong interagency model.

PEPFAR has worked to decentralize programming and ensure that decisions on country-level activities are made by the USG country teams that are leading the groundlevel response to the epidemic. For the past five years, these country teams have worked to rapidly expand and ensure quality health and social service delivery, while facing heavy reporting requirements. PEPFAR's interagency country teams ensure that programs meet the needs of the countries and communities where they work. PEPFAR is working to further integrate the field perspective into its policy and communications and reduce the reporting burdens and paperwork requirements placed on the field. Over the next few months, PEPFAR will be working closely with country teams to assist them in identifying the ways to best translate and implement these key concepts at the country level.

In order to enable USG country teams to respond to the best of their ability, PEPFAR continues to stress the importance of its interagency model. As a "whole of government" program, PEPFAR has coordinated efforts from multiple agencies to respond to global HIV. It is expanding coordination and linkages with broader USG health and development efforts as part of the Global Health Initiative. PEPFAR is assessing its innovative approaches to determine what elements contributed to interagency success at both the field and headquarters level, in order to replicate these more broadly. PEPFAR is also working to emphasize the core competencies of each agency. By achieving better coordination and building upon the strengths of USG personnel, PEPFAR can maximize its country-level impact.

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