The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
Although the U.S. has been involved in efforts to address the global AIDS crisis since the mid 1980s, the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic.1, 2 First proposed by President George W. Bush in January 2003, PEPFAR was authorized by the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25),3 a 5-year, $15 billion initiative to combat global HIV/AIDS, TB, and malaria primarily for 15 hard hit “focus countries,” and multilateral contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund)4 as well as UNAIDS.1
In 2008, PEPFAR was reauthorized by the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293 or “Lantos-Hyde”),5 for an additional 5 years (FY 2009-FY 2013) at up to $48 billion, including $39 billion for HIV and the Global Fund, $4 billion for TB, and $5 billion for malaria. Reauthorization also relaxed prior spending directives, emphasized country partnerships and health systems strengthening (HSS), mandated 5-year strategic plans for HIV, TB, and malaria, and ended the statutory ban on HIV-positive visitors and immigrants wishing to come to the United States. In 2013, the PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56) extended a number of existing authorities and strengthened the oversight of the program through updated reporting requirements, among other things.6
PEPFAR continues to be a cornerstone of U.S. global health efforts and of HIV/AIDS efforts around the world – it is the largest commitment by any nation to address a single disease. In 2011, U.S. Secretary of State Hillary Clinton announced the goal of creating an “AIDS-free generation” and in 2012 released the PEPFAR blueprint for achieving this goal.7, 8 Most recently, during the 2015 United Nations General Assembly (UNGA) Sustainable Development Summit where all countries committed to implementing the Sustainable Development Goals, which include targets for HIV, the U.S. announced new PEPFAR targets.9
Results & Targets
As of September 2014, PEPFAR reports that it has supported antiretroviral treatment for more than 7.7 million and performed 6.5 million voluntary medical male circumcisions (VMMC). In FY 2014, PEPFAR provided care for 5 million orphans and vulnerable children (OVC), training for 140,000 new health care workers, and supported testing and counselling for 56.7 million people, including 14.2 million pregnant women.10 During the 2015 U.N. General Assembly, PEPFAR released updated treatment and prevention targets for 2016 and 2017, which include for the first time an emphasis on addressing the epidemic in adolescent girls and young women (see Figure 1). 9
|Figure 1: Current PEPFAR Targets9|
Key Structures & Mechanisms
PEPFAR’s original authorization established new structures and authorities, consolidating all U.S. bilateral and multilateral activities and funding for global HIV/AIDS. Several U.S. agencies, host country governments, and other organizations are involved in implementation.2, 11
The U.S. Global AIDS Coordinator & OGAC
PEPFAR’s original authorization created the position of “U.S. Global AIDS Coordinator,” a Presidential appointee, requiring Senate confirmation and holding the rank of Ambassador who reports directly to the Secretary of State.3 The law also established the Office of the Global AIDS Coordinator (OGAC) at the Department of State (State).12 (Lantos-Hyde also codified the position of a U.S. Malaria Coordinator; there is no coordinator for TB).5
In addition to State, other implementing departments and agencies for HIV activities include: USAID; the Department of Health and Human Services, primarily through the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH); the Departments of Labor, Commerce, and Defense (DoD); and the Peace Corps.
PEPFAR bilateral funding is provided to 41 countries and regional programs in Africa, the Middle-East, Asia, Europe, the Americas, and the Caribbean (in FY 2014).13 Most FY 2013 funding is concentrated in 31 countries, including 15 “focus countries” targeted in PEPFAR’s first phase (Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia).1 More countries are reached through U.S. contributions to the Global Fund.
These 31 countries and the Central Asian, Caribbean, and Central American regions are required to develop “Country Operational Plans” (COPs) to document annual investments and anticipated results.14 OGAC reviews all COPs and when approved, they are incorporated into an annual PEPFAR “Operational Plan”.15
Lantos-Hyde included a new emphasis on country ownership to help foster sustainability and accountability by authorizing “Partnership Frameworks” with recipient countries, 5-year joint strategies for cooperation between the USG, the partner (“host”) government, and other partners that outline the responsibilities of each party in achieving a country’s national HIV/AIDS strategy. Countries must be invited to develop Partnership Frameworks and, as of December 2013, 20 countries and 2 regions have signed Partnership Frameworks. For countries and regions with signed Frameworks, COPs serve as a yearly plan outlining USG responsibilities to the Partnership.14
Total PEPFAR funding includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS (bilateral funding for TB is also counted in PEPFAR’s totals). Congressional appropriations for PEPFAR increased from $2.3 billion in FY 2004 to a high of $6.9 billion in FY 2010. In FY 2015, $6.8 billion was appropriated for PEPFAR, remaining essentially flat compared to FY 2014.13, 17, 18 While appropriations for PEPFAR have fluctuated in recent years, funding has remained essentially flat since 2010. PEPFAR represents the vast majority of U.S. global health funding (nearly 68% of FY 2015 funding).19 The President’s FY 2016 budget request for PEPFAR is $6.5 billion, which would represent a decrease of almost $286 million (4%) below FY 2015 and is attributable to decreased funding for TB and the Global Fund.13, 20
Of the approximately $6.8 billion appropriated for PEPFAR in FY 2015:
- $5.2 billion (77%) is for HIV, $240 million (4%) for TB,21 and $1.35 billion (20%) for the Global Fund.13
- The majority of PEPFAR funding is channeled by Congress to State ($5.7 billion– most of which is then transferred to other agencies and includes the $1.35 billion contribution to the Global Fund), followed by USAID ($570 million), NIH ($451 million), CDC ($128 million), and a small amount to DoD ($8 million).13
In PEPFAR’s original authorization, Congress recommended that 55% of funds be spent on treatment, 15% on palliative care, 20% on prevention, of which at least 33% be spent on abstinence-until-marriage programs, and 10% on OVCs.3 For FY 2006-2008, Congress required 55% to be spent on treatment, 10% on OVCs, and 33% of prevention funding on abstinence-until-marriage. Lantos-Hyde relaxed some of these directives: while requiring that 10% of funds be spent on programs targeting OVCs and at least half on treatment and care, the 33% abstinence-until-marriage directive was removed and replaced by a requirement of “balanced funding” for prevention to be accompanied by a report to Congress if less than half of prevention funds were spent on abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities in any host country with a generalized (high prevalence) epidemic.5 The PEPFAR Stewardship and Oversight Act continues the spending directives for OVCs and requires at least 50% of bilateral HIV assistance to be spent on treatment and care.6
PEPFAR & The Global Fund
The U.S. is the single largest donor to the Global Fund. Congressional appropriations to the Fund totaled $11.2 billion through FY 2014.13 In 2010, President Obama pledged a 3-year, $4 billion (FY 2011-FY 2013) contribution to the Global Fund.22 The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and HSS programs in addition to (and beyond their linkage with) HIV. To date, over 150 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV programs, 29% to malaria, 15% to TB, 1% to HIV/TB, and 2% to other health issues.23 The initial authorization of PEPFAR included a cap on cumulative U.S. contributions at 33% of the Global Fund’s total contributions, a provision retained in the 2008 reauthorization and extended in the PEPFAR Stewardship and Oversight Act.3, 5, 6
Since PEPFAR’s launch in 2003, many successes have been achieved and lessons learned and PEPFAR is viewed as one of the most significant and successful global health initiatives undertaken. Looking ahead, there are several issues to consider:
- Continue to support the shift from an “emergency” response to a sustained, country-led model;11
- Move toward a more outcomes-based system to assess impact, including the challenge of attributing results in the field directly to PEPFAR support;
- Coordinate PEPFAR with other U.S. global health investments and applying lessons learned from PEPFAR more broadly;
- Strike the appropriate balance in funding and programming between HIV treatment, prevention, and care; between bilateral HIV programs and the Global Fund; and between HIV and other parts of the global health portfolio;11 and
- Achieve the vision of an AIDS Free Generation, particularly within a challenging U.S. and global fiscal climate.
PEPFAR. 2009 Annual Report to Congress; January 2009.
KFF. The U.S. Government Engagement in Global Health: A Primer; June 2015.
U.S. Congress. Public Law No: 108-25; May 27, 2003.
The Global Fund is an independent, multilateral institution, providing grants to combat HIV/AIDS, TB, and malaria.
U.S. Congress. Public Law No: 110-293; July 30, 2008.
U.S. Congress. Public Law No: 113-56; December 2, 2013.
Department of State. Fact Sheet: The Path to an AIDS-Free Generation; November 8, 2011.
PEPFAR. PEPFAR Blueprint: Creating an AIDS-free Generation; November 2012.
- PEPFAR. Fact Sheet: 2015 United Nations General Assembly Sustainable Development Summit; September 2015.
PEPFAR. Fact Sheet: 2014 Latest Results; December 2014.
CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; January 2009.
PEPFAR. About OGAC: http://www.pepfar.gov/c22835.htm.
KFF analysis, of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.
PEPFAR. Fiscal Year 2014 Country Operational Plan (COP) Guidance; October 2013.
PEPFAR. Fiscal Year 2011: PEPFAR Operational Plan; December 2011.
PEPFAR. Partnership Frameworks: http://www.pepfar.gov/frameworks/index.htm.
U.S. Congress. Public Law No: 112-25; August 2, 2011.
White House Office of Management and Budget (OMB). OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013; March 1, 2013.
- Global Health represents total known funding provided through the State Department, USAID, CDC, NIH, and DoD. Malaria funding through the DoD is not yet known for FY15 and is assumed to remain at FY14 levels. Some global health funding provided through the Economic Support Fund (ESF) and Development Assistance (DA) accounts is not yet known for FY15. The FY15 global health total assumes that the ESF and DA accounts are funded at levels equivalent to the FY16 request.
- While HIV funding is essentially flat in the FY16 Request compared to FY15, TB funding is $191 million, or $45 million below the FY15 enacted level, and funding for the Global Fund is $1,106.5, which is $243.5 million below the FY15 enacted level. The FY16 budget request states that the $1,106.5 million would fulfill “President Obama’s pledge to provide $1 for every $2 pledged by other donors to the Global Fund and completing the U.S. commitment to the 2014-2016 replenishment,” which was made at the Global Fund’s 4th Replenishment Conference held in December 2013.
- Additional tuberculosis funding provided through the Economic Support Fund (ESF) account is not yet known (in prior years, it has ranged between $8 and $20 million).
Department of State. Obama Administration’s Pledge to Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis; October 5, 2010. Available at: http://www.state.gov/r/pa/prs/ps/2010/10/148642.htm.
The Global Fund. Grant Portfolio; accessed October 2015: http://portfolio.theglobalfund.org/en/Home/Index. Numbers may not equal 100% due to rounding.