Seventh Annual Report to Congress: Narrative in HTML format


From the day it was first announced eight years ago, the story of PEPFAR – the President’s Emergency Plan for AIDS Relief – has demonstrated the remarkable generosity of the American people. Congress’ continuing bipartisan support for PEPFAR, and President Barack Obama’s continuing stewardship of the program originally launched by President George W. Bush, have shown the world that this is a vital, durable element of our foreign policy.

2010 was a crucial chapter in the global response, providing many reasons for hope about the future. As has been true throughout the past decade, the commitment of the American people was central to virtually all of the year’s breakthroughs. In the following text, hyperlinks to key documents are provided to facilitate access to additional information. Additional data can be found at

Saving Lives

Numbers are not the whole story of PEPFAR, but when those numbers represent children, women and men whose lives are being saved, they are critical. The people implementing PEPFAR in the field continued to expand life-saving programs this year, as shown by 2010 program results. At the end of the fiscal year, PEPFAR supported over 3.2 million people on treatment through bilateral programs, an increase of more than 700,000 over the previous year. PEPFAR and the U.S.-supported Global Fund to Fight AIDS, Tuberculosis and Malaria continue to be the leading engines of the dramatic increase in availability of treatment. UNAIDS estimated that at least 5.2 million people in low- and middle-income countries were receiving treatment by late 2010.

Reflecting a top priority, PEPFAR programs provided more than 600,000 pregnant women with drugs to prevent mother-to-child transmission of HIV (PMTCT). As a result, it is estimated that over 114,000 babies were born free of HIV in 2010 – representing continued sharp acceleration of PMTCT efforts relative to earlier years. PEPFAR also provided care and support for over 11 million people in FY 2010, including approximately 3.8 million orphans and vulnerable children.

When one reflects that each of the numbers represents a real person -- with a story, a family, a community -- the impact of this work is too vast to comprehend through numbers alone. The stories of program clients in the field provide a window into the human impact of America’s effort. There continue to be many more people in need of support, and with them in mind, PEPFAR will push on toward the ambitious goals in our Five-Year Strategy and expand the numbers reached in the coming year.

Smart Investments

One encouraging aspect of these life-saving results is that they were achieved despite the difficult economic environment. A key element has been a heightened commitment to smart investments – that is, stretching each dollar as far as we can to save as many lives as we can. Key examples include cheaper ways of procuring and shipping drugs, as well as increasing use of generic drugs, as described in a recent paper in the Journal of the American Medical Association. PEPFAR also conducted a ‘State of the Program Area’ review as part of its ongoing efforts to identify best practices across all activities. In July, the program reported on antiretroviral treatment costs, based on groundbreaking studies of PEPFAR-supported treatment sites across 12 countries. This data, indicating an estimated mean cost to PEPFAR of $436 for each patient supported, provides a baseline for efforts to identify treatment efficiencies. PEPFAR will continue to make it a priority to expand efficiencies and heighten impact in every program area in 2011.

Smart investments in effective prevention are essential, and this year brought much encouraging news. UNAIDS reported significant declines in new HIV infections in over 30 countries, including 22 in Africa – a remarkable turnaround from the trends of a few years ago. As part of its ‘combination prevention’ approach, PEPFAR is seeing the payoff from heavy investments in high-impact prevention activities tailored to the needs of specific countries, with PMTCT a key example. Also critical is support for male circumcision, with the promise of significant infections averted and cost savings. In 2010, PEPFAR heightened its focus on most-at-risk populations, supporting efforts to meet the HIV needs of vulnerable populations such as sex workers, men who have sex with men, and injecting drug users, for whom the program supports a comprehensive prevention approach. PEPFAR also strengthened efforts to rigorously evaluate the impact of prevention activities, in order to target investments to save more lives.

Looking to the future, 2010 offered new hope of adding much-needed new tools to the global prevention toolkit. Especially encouraging were proof of concept of a woman-controlled microbicide, based on a study funded by PEPFAR through USAID, and highly positive research findings on pre-exposure prophylaxis, funded by the National Institutes of Health. As it previously did with male circumcision, in 2011 PEPFAR will continue to aggressively pursue formative work that prepares for implementation of these new tools as they become available, based upon scientific and regulatory guidance.

Across all programs, PEPFAR recognizes that gender inequalities fuel the spread of HIV. Gender-based violence (GBV), in particular, limits women’s ability to negotiate sexual practices, disclose HIV status, and access medical services and counseling. In 2010 PEPFAR intensified its focus on GBV with a $30 million commitment that builds on PEPFAR platforms in all countries, with a particular focus on Mozambique, Tanzania, and the Democratic Republic of Congo – and with strong governmental and civil society engagement in all three countries. As part of its strong and growing portfolio of innovative partnerships with the private sector, PEPFAR also joined the Together for Girls public-private partnership to work with countries to inform and implement a coordinated approach to policy and programs for ending sexual violence against girls.

Country Ownership

An area of striking progress in 2010 has been movement toward country ownership, with developing countries taking the lead in responding to HIV/AIDS, while the U.S. and other external partners play key supportive roles. PEPFAR used every opportunity to promote the centrality of country ownership, including both governments and civil society. PEPFAR country teams initiated processes to assess and support countries, across many sectors and functions, in defining their needs for health systems capacity development and targeted technical support. For governments, key areas of focus included surveillance, planning, analysis, management, and budgeting, at key national ministries as well as other levels of government.

To address one central facet of the multifaceted health systems challenge – severe shortages of well-trained health workers -- PEPFAR and NIH teamed up to launch Medical and Nursing Education Partnership Initiatives. Fostering partnerships between African and other universities to enhance the quality of training of health professionals and increase the numbers trained, these initiatives will be a key part of wide-ranging U.S. support for health systems in 2011 and beyond.

Through Partnership Frameworks, PEPFAR and partner governments have documented mutual commitments for the next five years, promoting accountability. 21 Partnership Frameworks have been signed to date, with still more to follow in 2011. Our deepening partnership with South Africa – the nation with the largest number of people living with HIV in the world – deserves special note. Turning a decisive page, the South African Government has assumed increasing leadership, including a dramatically heightened financial contribution to HIV/AIDS. PEPFAR has been privileged to play a key role in this transformation, as reflected in the December signing of a South Africa Partnership Framework to guide our joint efforts. Secretary of State Hillary Rodham Clinton personally signed the document, as she did earlier Frameworks with Angola and Vietnam, signaling commitment to country ownership as part of U.S. foreign policy at the highest level. The U.S. also signed regional Frameworks for the Caribbean and Central America, spurring increased collaboration among the nations in those regions, with technical support from the U.S. In other key nations, PEPFAR increased its commitment to hard-hit Zimbabwe, and implemented a plan to overcome obstacles in order to expand treatment in Uganda.

Shared Responsibility

In addition to the contributions of the U.S. and partner nations, a truly global response requires commitment by other developed nations and the private sector. The Global Fund is a critical vehicle for all to heighten their commitment to the fight, as the U.S. has done over the past decade. In 2010, the U.S. made its first-ever multi-year pledge of $4 billion to the Fund, and we hope this strong support for the Fund’s work will generate increased commitments by others. Equally as important, we issued a Call to Action, launching a process to improve the Fund’s operations, especially at the country level. This statement was greeted by widespread positive reaction and the Board’s creation of a Reform Working Group, and pushing this agenda forward is a top priority for 2011. While the U.S. holds only one vote on the Fund’s Board, it is promoting reform on the Working Group as well through its leadership of the Board’s Portfolio and Implementation Committee. Simply put, the world needs a highly effective, efficient Global Fund.

The U.S. has promoted the theme of shared global responsibility in its dialogues with other international partners. Through deepened participation in global fora in 2010 (including the United Nations General Assembly meeting on the Millennium Development Goals and the International AIDS Conference in Vienna), the U.S. has used its opportunities to leverage more engagement by others. PEPFAR is working with partners throughout the government to ensure that this message is featured prominently at the 2012 International AIDS Conference in Washington.

Broader Context of Health and Development

Like all others engaged in this work, PEPFAR has encountered the reality that HIV/AIDS is linked to the wide range of health and development challenges in hard-hit countries. In December, Secretary Clinton issued the inaugural Quadrennial Diplomacy and Development Review (QDDR), which recognizes development as one of the three pillars of U.S. foreign policy, along with diplomacy and defense. The QDDR strongly affirmed PEPFAR’s mission and interagency model led by the Department of State, and built on President Obama’s Presidential Policy Directive on Global Development and Global Health Initiative, of which PEPFAR is the largest component. All of these reflect a vision of better integrated and linked U.S. development investments -- an emphasis that is great news for PEPFAR, because our implementers have long known that people affected by HIV face a range of broader health and development challenges, and have seen the opportunities to ensure that our other programs are meeting their needs. Creating further opportunities, the health systems platforms established under PEPFAR have much to contribute in meeting the broader health and development challenges of partner nations.

Knowledge and Program Management

After seven years of implementation, PEPFAR is generating a growing body of data and lessons learned, and is redoubling its efforts to apply and disseminate these. In 2010, PEPFAR reformed its Public Health Evaluation process to better allow for both U.S. Government- and externally-generated studies that will provide timely operations research on urgent questions, and instituted a Scientific Advisory Board to ensure that programs reflect the latest science. In response to a mandate in the U.S. National AIDS Strategy, PEPFAR reported on best practices from its programs that may have relevance to the U.S. domestic response. It also implemented its Next Generation Indicators, strengthening program monitoring and evaluation, and began merging PEPFAR’s reporting system with the FACTS Info system used by other State Department and USAID foreign assistance programs to simplify reporting for the field. In response to requests from field staff, PEPFAR moved to a two-year planning cycle, allowing staff more time to engage with programs. As part of strengthening program management, PEPFAR launched an initiative to understand and clear unobligated balances, and to streamline interagency budget execution processes to speed the availability for programs. As noted in testimony before Congress on PEPFAR’s progress in March and September, the driving force behind these efforts in 2010 was a desire to maximize the life-saving impact of each dollar entrusted to PEPFAR by Congress and the American people, and PEPFAR will maintain this focus on the people we serve in 2011 and beyond.

Photo Gallery

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In Lesotho, the PEPFAR-supported Horse Riding for Health program engages local pony riders - selected with input from the community - to transport blood tests, drugs, and supplies between remote mountain health clinics and better-equipped hospitals at sea level.
Reverie Zurba / 2011
In Lesotho, the PEPFAR-supported Horse Riding for Health program engages local pony riders - selected with input from the community - to transport blood tests, drugs, and supplies between remote mountain health clinics and better-equipped hospitals at sea level. The transport system allows people to receive HIV test results sooner and ensures an uninterrupted supply of medicines. Maamohelang Hlaha, a beneficiary of the program, is pictured inside her home with three of her children. Maamohelang and her husband are HIV-positive, but their four surviving children are HIV-free.

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