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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, tuberculosis (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.⁶

PEPFAR continues to be a cornerstone of U.S. global health efforts and of the HIV response around the world. PEPFAR represents the vast majority of U.S. global health funding (nearly 67% of FY 2016 funding)⁷ and is the largest commitment by any nation to address a single disease.⁸ 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. PEPFAR’s latest strategy aligns with global goals related to the epidemic and reflects shifts in its approach to controlling the epidemic, including the further targeting of resources to key populations, especially adolescent girls and young women, and geographic areas that are most affected by HIV. ^{9,10, 11, 12}

Results & Targets

In 2016, PEPFAR reports that it has supported antiretroviral treatment for more than 11.5 million and performed 11.7 million voluntary medical male circumcisions (VMMC). In FY 2016, PEPFAR provided care for 6.2 million orphans and vulnerable children (OVC), training for 220,000 new health care workers, and supported testing and counselling for 74.3 million people, including 11.5 million pregnant women.¹³ In December 2014, PEPFAR, along with partners, launched the DREAMS initiative, which aims to reduce HIV infections in adolescent girls and young women, and 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 among adolescent girls and young women (see Table 1).^12,14

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.^2,18

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).¹⁹ (Lantos-Hyde also codified the position of a U.S. Malaria Coordinator; there is no coordinator for TB).⁵

Implementing Agencies²

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.

Countries

PEPFAR bilateral support for HIV is provided to 41 countries and regional programs in Africa, Asia, Europe, the Americas, and the Caribbean (in FY 2016) (Figure 1).²⁰ Most FY 2016 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.

Operational Plans

These 31 countries and the Asian, Central Asian, Caribbean, and Central American regions are required to develop “Country Operational Plans” (COPs) and “Regional Operational Plans” (ROPs) to document annual investments and anticipated results.²¹  Any country that receives $5 million or more in annual PEPFAR funding prepares a COP/ROP. ²¹ OGAC reviews all COP/ROPs and when approved, they are incorporated into an annual PEPFAR “Operational Plan”.²²

Partnership Frameworks²³

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 U.S. Government (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 had signed Partnership Frameworks. For countries and regions with signed Frameworks, COP/ROPs serve as a yearly plan outlining USG responsibilities to the Partnership.²¹ 

Funding

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).  PEPFAR’s creation marked a significant increase in the amount of funding provided by the U.S. for global HIV, which rose from $1.10 billion in FY 2003 (the year before PEPFAR) to $1.64 billion in FY 2004, a nearly 50% increase. Total PEPFAR funding continued to increase steeply through FY 2010 ($6.87 billion), its peak level, but has decreased somewhat since then and been level for the past several years (Figure 2). In FY 2016, $6.81 billion was appropriated for PEPFAR.^20,24,25

Of the approximately $6.76 billion appropriated for PEPFAR in FY 2016:

• $5.22 billion (77%) is for HIV, $240 million (4%) for TB,²⁶ and $1.35 billion (20%) for the Global Fund.²⁰
• The majority of PEPFAR funding is channeled by Congress to the State Department ($5.67 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, of which $330 million is for HIV and $240 million is for TB), NIH ($431 million), CDC ($128 million), and a small amount to DoD ($8 million).^{20, 27}

  Figure 2: U.S. Global Health Funding: President’s Emergency Plan for AIDS Relief (PEPFAR), FY 2004-FY 2016

Spending Directives/Earmarks

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 $13.9 billion through FY 2016.²⁰ 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; 51% of Global Fund support has been committed to HIV programs, 28% to malaria, 16% to TB, 3% to HIV/TB, and 2% to other health issues.²⁸ 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}

Looking Ahead

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 ever undertaken. Looking ahead, there are several issues and challenges facing PEPFAR, starting with questions about the extent to which a new Presidential Administration will support increased or even sustained funding for the program as well as seek any programmatic changes. Other issues include:  

• How best to support PEPFAR’s shift from an “emergency” response to a sustained, country-led model;¹⁸
• The need to continue moving toward a more outcomes-based, data-driven system to assess impact and targeting;
• The ongoing need to coordinate PEPFAR with other U.S. global health and sustainable development investments and applying lessons learned from PEPFAR more broadly; and
• How to strike the right 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 U.S. global health portfolio.¹⁸