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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  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),2 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),3 as well as UNAIDS.4  It has since been reauthorized twice – first, in 2008, 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, and again in 2013, by the PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56) for the FY 2014-2018 period.6

To date, PEPFAR funding has totaled more than $70 billion; in FY 2017, funding was $6.56 billion.7 PEPFAR represents the vast majority of U.S. global health funding (62% in FY 2017) and is the largest commitment by any nation to address a single disease in the world.8 PEPFAR is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic.

Results & Targets

During the 2015 U.N. General Assembly, PEPFAR released updated treatment and prevention targets for 2016 and 2017, which included, for the first time, an emphasis on addressing the epidemic among adolescent girls and young women (see Table 1). PEPFAR’s latest results indicate that as of September 2017, it has supported antiretroviral treatment for 13.3 million people; performed 15.2 million voluntary medical male circumcisions (VMMC); provided care for 6.4 million orphans and vulnerable children (OVC); supported training for 250,000 new health care workers; and supported testing services for 85.5 million people, including 11.2 million pregnant women.9 Additionally, in 2017, PEPFAR reported a 25-40% decline in new HIV diagnoses among adolescent girls and young women through the DREAMS initiative, an initiative launched in 2015 aiming to reduce HIV infections in adolescent girls and young women.10 There is also evidence that several African countries are approaching control of their HIV epidemics, in large part due to PEPFAR support.11 PEPFAR’s current strategy aligns with the UNAIDS 90-90-90 framework, and emphasizes accelerating testing and treatment strategies, expanding prevention, using data to increase PEPFAR’s impact and effectiveness, engaging with faith-based organizations and the private sector, and strengthening policy and financial contributions by partner countries.12

Table 1: Current PEPFAR Targets13
Prevention Treatment
  • By the end of 2016, jointly with partner countries, the Global Fund, and the private sector, achieve a 25% reduction in HIV incidence among adolescent girls and young women (aged 15-24) within the highest burden geographic areas of 10 sub-Saharan African countries, and by the end of 2017, achieve a 40% reduction.
  • By the end of 2016, provide 11 million VMMCs,14 cumulatively, and by the end of 2017, provide 13 million VMMCs,15 cumulatively.
  • By the end of 2016, PEPFAR will support 11.4 million children, pregnant women receiving “B+”16, and adults on life-saving anti-retroviral treatment,17 of which 7.2 million are directly supported by PEPFAR funding, and by 2017 treat 12.9 million people,18 of which 8.5 million are directly supported by PEPFAR funding.
  • By the end of 2017, jointly with partner countries and the Global Fund, support more than 18.5 million men, women, and children on treatment.

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.19

The U.S. Global AIDS Coordinator & OGAC

The Leadership Act created the position of “U.S. Global AIDS Coordinator,” a Presidential appointee, requiring Senate confirmation. The Coordinator holds the rank of Ambassador and reports directly to the Secretary of State.20  The law also established the Office of the Global AIDS Coordinator (OGAC) at the Department of State (State).21 (Lantos-Hyde also codified the position of a U.S. Malaria Coordinator; there is no legislatively mandated coordinator for TB).22

Implementing Agencies23

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

In FY 2016, PEPFAR bilateral support for HIV was provided to 41 countries, as well as regional programs in Africa, Asia, Europe, the Americas, and the Caribbean, thus reaching additional countries (Figure 1).24 More countries are reached through U.S. contributions to the Global Fund. Most FY 2016 funding was concentrated in 31 countries.25, 26 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.27 Any country that receives $5 million or more in annual PEPFAR funding prepares a COP/ROP.28 OGAC reviews all COP/ROPs and when approved, they are incorporated into an annual PEPFAR “Operational Plan”.29

In its 2017-2020 strategy, PEPFAR aims to accelerate implementation of HIV/AIDS efforts in a subset of 13 countries (Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) that, according to PEPFAR data, show the greatest potential to achieve HIV/AIDS control by 2020.30

Figure 1: U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Countries, FY 2016

Funding

Total PEPFAR funding includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS.31  To date, PEPFAR funding for bilateral HIV and the Global Fund alone has totaled more than $70 billion. 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 ($6.62 billion), its peak level, but has decreased somewhat since then and been level for the past several years (Figure 2). In FY 2017, $6.56 billion was appropriated for PEPFAR.32

Of the approximately $6.56 billion appropriated for PEPFAR in FY 2017: 33

  • $5.21 billion (79%) is for bilateral HIV and $1.35 billion (21%) for the Global Fund.
  • 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 NIH ($420.5 million), USAID ($330 million), CDC ($128 million), and a small amount to DoD ($8 million).
  • The current Administration has proposed to significantly reduce PEPFAR funding for FY 2018.

Figure 2: U.S. Funding for the President’s Emergency Plan for AIDS Relief (PEPFAR), FY 2004-FY 2018 Request

Spending Directives/Earmarks

PEPFAR has included several spending directives, or earmarks, from Congress over the course of its history, many of which have changed over time:

  1. The Leadership Act, PEPFAR’s original authorization, included the following spending directives: 55% of funds were to 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.34 While these were included as “sense of Congress” recommendations, the treatment, OVC, and abstinence-until-marriage earmarks were made requirements as of FY 2006.
  2. Lantos-Hyde relaxed some of these directives for the FY 2009-2013 period: while still requiring that 10% of funds be spent on programs targeting OVCs, it changed the treatment earmark from 55% to requiring that at least half of bilateral HIV assistance be spent on treatment and care. It removed the 33% abstinence-until-marriage directive and replaced it with 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.35
  3. The PEPFAR Stewardship and Oversight Act has maintained these spending directives.36

PEPFAR & The Global Fund

The U.S. is the single largest donor to the Global Fund. Congressional appropriations to the Fund totaled $15.3 billion through FY 2017.37 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; 50% of Global Fund support has been committed to HIV programs, 28% to malaria, 16% to TB, 4% to HIV/TB, and 2% to other health issues.38 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.39

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 the current Presidential Administration will continue to support PEPFAR’s ongoing efforts, particularly in light of its budget proposal to significantly reduce PEPFAR funding, including funding for the Global Fund. Other issues include:  

  • How best to support PEPFAR’s shift from an “emergency” response to a sustained, country-led model;40
  • 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.41
Endnotes
  1. PEPFAR. 2009 Annual Report to Congress; January 2009. KFF. The U.S. Government Engagement in Global Health: A Primer; January 2017.

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  2. U.S. Congress. Public Law No: 108-25; May 27, 2003.

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  3. The Global Fund is an independent, multilateral institution, providing grants to combat HIV/AIDS, TB, and malaria.

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  4. PEPFAR. 2009 Annual Report to Congress; January 2009.

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  5. U.S. Congress. Public Law No: 110-293; July 30, 2008.

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  6. U.S. Congress. Public Law No: 113-56; December 2, 2013.

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  7. Includes bilateral funding for HIV as well as U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Kaiser Family Foundation analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard [website], available at: www.foreignassistance.gov.

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  8. 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.

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  9. PEPFAR. Fact Sheet: 2017 PEPFAR Latest Global Results; November 2017.

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  10. PEPFAR. Fact Sheet: 2017 PEPFAR Latest Global Results; November 2017.

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  11. PEPFAR. Fact Sheet: PEPFAR Latest Global Results, 2016. PEPFAR. Five African Countries Approach Control of Their HIV Epidemics as U.S. Government Launches Bold Strategy to Accelerate Progress; September 2017.

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  12. UNAIDS. 90-90-90- An Ambitious Treatment Target to Help End the AIDS Epidemic; 2014. PEPFAR. Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); September 2017.

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  13. PEPFAR. Fact Sheet: 2015 United Nations General Assembly Sustainable Development Summit; September 2015.

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  14. PEPFAR exceeded its 2016 target and provided 11.7 million VMMC procedures in Eastern and Southern Africa. PEPFAR. Fact Sheet: World AIDS Day 2016: PEPFAR Latest Results; December 2016.

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  15. PEPFAR exceeded its 2017 target and provided 15.2 million VMMC procedures in Eastern and Southern Africa as of September 2017. PEPFAR. Fact Sheet: 2017 PEPFAR Latest Global Results; November 2017.

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  16. Option B+ offers pregnant or breastfeeding women who are infected with HIV lifelong antiretroviral treatment, regardless of their stage of infection. UNAIDS. Treatment 2015; Accessed from: http://www.unaids.org/en/resources/campaigns/treatment2015.

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  17. PEPFAR exceeded its 2016 target and provided nearly 11.5 million men, women, and children on ART. PEPFAR. Fact Sheet: World AIDS Day 2016: PEPFAR Latest Results; December 2016.

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  18. PEPFAR exceeded its 2017 target and provided ART to more than 13.3 million men, women, and children as of September 2017. PEPFAR. Fact Sheet: 2017 PEPFAR Latest Global Results; November 2017.

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  19. KFF. The U.S. Government Engagement in Global Health: A Primer; January 2017. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; January 2009.

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  20. U.S. Congress. Public Law No: 108-25; May 27, 2003.

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  21. PEPFAR. About OGAC: https://www.pepfar.gov/about/ogac/.

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  22. U.S. Congress. Public Law No: 110-293; July 30, 2008.

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  23. KFF. The U.S. Government Engagement in Global Health: A Primer; January 2017.

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  24. 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.

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  25. Of these 31 countries, 14 were “focus countries” targeted in PEPFAR’s first phase (Botswana, Cote d’Ivoire, Ethiopia, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia).

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  26. PEPFAR. 2009 Annual Report to Congress; January 2009. 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. PEPFAR Country/Regional Operational Plan (COP/ROP) 2016 Guidance; January 2016.

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  27. PEPFAR COP/ROP guidance for FY2017 is now available for the same 31 countries. PEPFAR. PEPFAR Country/Regional Operational Plan (COP/ROP) 2017 Guidance; January 2017.

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  28. PEPFAR. PEPFAR Country/Regional Operational Plan (COP/ROP) 2017 Guidance; January 2017.

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  29. PEPFAR. Fiscal Year 2011: PEPFAR Operational Plan; December 2011.

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  30. PEPFAR. Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); September 2017.

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  31. While overall PEPFAR funding technically includes bilateral funding for HIV, TB, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, this analysis focuses on funding for bilateral HIV and the Global Fund.

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  32. 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. 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.

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  33. 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.

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  34. U.S. Congress. Public Law No: 108-25; May 27, 2003.

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  35. U.S. Congress. Public Law No: 110-293; July 30, 2008.

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  36. U.S. Congress. Public Law No: 113-56; December 2, 2013.

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  37. 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.

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  38. The Global Fund. Grant Portfolio; accessed December 2017: http://www.theglobalfund.org/en/portfolio/.

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  39. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; December 2, 2013.

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  40. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; January 2009.

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  41. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; January 2009.

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