HIV Policy Alignment with International Standards in PEPFAR Countries

Introduction
  1. For more information on PEPFAR, see KFF’s The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fact sheet.

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  2. U.S. Department of State, PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for All PEPFAR Countries, updated February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR-COP21-Guidance-Final.pdf.

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  3. U.S. Department of State, PEPFAR 2021 Annual Report to Congress, February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR2021AnnualReporttoCongress.pdf.

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  4. U.S. Department of State, Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020), September 2017, accessed: https://www.state.gov/wp-content/uploads/2019/08/PEPFAR-Strategy-for-Accelerating-HIVAIDS-Epidemic-Control-2017-2020.pdf.

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  5. U.S. Department of State, PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for All PEPFAR Countries, updated February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR-COP21-Guidance-Final.pdf.

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  6. U.S. Department of State, PEPFAR 2021 Annual Report to Congress, February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR2021AnnualReporttoCongress.pdf.

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  7. Specific examples of normative, evidence-based guidance and policies developed by international bodies include the WHO’s Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach (see: https://www.who.int/publications/i/item/9789240031593) and Key Considerations for Differentiated ART Delivery for Specific Populations jointly produced by the WHO, U.S. Centers for Disease Control and Prevention, PEPFAR, USAID, and the International AIDS Society (see: https://www.who.int/publications/i/item/WHO-HIV-2017.34), among others. All guidelines and policies that the HIV Policy Lab uses as benchmarks with which to assess countries are included in their codebook (see: https://hivpolicylab.org/codebook).

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  8. PEPFAR is administered through the Office of the U.S. Global AIDS Coordinator and Health Diplomacy within the U.S. Department of State, led by a Senate-confirmed coordinator with the rank of ambassador, and is housed within U.S. diplomatic missions under the oversight of the U.S. ambassador in country.

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  9. For more information on differentiated service delivery, see https://www.differentiatedservicedelivery.org/.

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  10. U.S. Department of State, PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for All PEPFAR Countries, updated February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR-COP21-Guidance-Final.pdf.

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  11. U.S. Department of State, PEPFAR 2021 Annual Report to Congress, February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR2021AnnualReporttoCongress.pdf.

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  12. U.S. Department of State, U.S. Embassy and Consulate in Nigeria. “U.S. Urges Removal of User-fees for People Living with HIV,” October 2019, accessed: https://ng.usembassy.gov/u-s-urges-removal-of-user-fees-for-people-living-with-hiv/.

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  13. Ahonkhai AA, et al. “The impact of user fees on uptake of HIV services and adherence to HIV treatment: Findings from a large HIV program in Nigeria,” PLOS ONE, September 2020, accessed: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238720.

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  14. USAID, “Sustainable Financing: Controlling the HIV/AIDS Epidemic Through Shared Responsibility,” webpage, accessed: https://www.usaid.gov/global-health/health-areas/hiv-and-aids/technical-areas/sustainable-financing-initiative (August 5, 2021).

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  15. U.S. Department of State, Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020), September 2017, accessed: https://www.state.gov/wp-content/uploads/2019/08/PEPFAR-Strategy-for-Accelerating-HIVAIDS-Epidemic-Control-2017-2020.pdf.

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  16. U.S. Department of State, PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for All PEPFAR Countries, updated February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR-COP21-Guidance-Final.pdf.

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  17. U.S. Department of State, “Statement from Ambassador Deborah Birx, M.D., U.S. Global AIDS Coordinator, on the Principles of PEPFAR's Public Health Approach,” April 2014, accessed: https://web.archive.org/web/20150905071637/http:/www.pepfar.gov/press/releases/2014/224738.htm.

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  18. U.S. Department of State, Draft PEPFAR COP 2022 Guidance.

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  19. Institute of Medicine, Evaluation of PEPFAR, February 2013, accessed: https://www.nap.edu/catalog/18256/evaluation-of-pepfar.

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  20. O’Neill Institute for National and Global Health Law at Georgetown University Law Center, Reorganization and the Future of PEPFAR; Implications of State and USAID Reform, 2018.

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  21. Kolker J. “A Diplomat’s Perspective on Use of Science and Evidence in Implementing PEPFAR,” Science and Diplomacy, April 2018, accessed: https://www.sciencediplomacy.org/article/2018/kolker-pepfar.

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  22. Daschle T, Frist B, Building Prosperity, Stability, and Security Through Strategic Health Diplomacy: A Study of 15 Years of PEPFAR, Bipartisan Policy Center, 2018, accessed: https://bipartisanpolicy.org/wp-content/uploads/2019/03/Building-Prosperity-Stability-and-Security-Through-Strategic-Health-Diplomacy-A-Study-of-15-Years-of-PEPFAR.pdf.

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  23. Collins C et al, “Four Principles for Expanding PEPFAR’s Role as a Vital Force in U.S. Health Diplomacy Abroad,” Health Affairs, July 2012, accessed: https://www.healthaffairs.org/doi/10.1377/hlthaff.2012.0204.

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  24. Daschle T, Frist B, The Case for Strategic Health Diplomacy: A Study of PEPFAR, 2015, Bipartisan Policy Center, November 2015, accessed: https://bipartisanpolicy.org/wp-content/uploads/2019/03/BPC_Strategic-Health-November-2015.pdf.

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  25. The COP/ROP documents serve as annual strategic plans for U.S. HIV/AIDS efforts in host countries, as well as serve as the basis for the approval of U.S. funding. Each COP focuses on PEPFAR’s efforts in one county in most cases, whereas the ROPs focus on a group of countries. Most, but not all, COP countries receive a greater level of investment than ROP countries.

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  26. PEPFAR’s 2020 Country Operational Plan Guidance for all PEPFAR Countries includes a list of 55 countries that were required to submit a COP or ROP that year. This list served as the basis for our “PEPFAR countries” group. Two countries on this list (Barbados and Suriname) were excluded from our analysis following communication with staff in the Office of the Global AIDS Coordinator that confirmed that direct bilateral support had been discontinued to those countries in recent years.

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  27. U.S. Department of State, PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for All PEPFAR Countries, updated February 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR-COP21-Guidance-Final.pdf.

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  28. According to the U.S. government database www.foreignassistance.gov, three countries that were not required to develop a COP or ROP received some HIV funding in FY 2020 – Colombia, Peru, and Venezuela. These countries were not included in the PEPFAR group.

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  29. Only low- and middle-income countries, as defined by the World Bank (https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups) were included in this analysis, with the exception of two high-income countries (Panama and Trinidad and Tobago) that receive PEPFAR support and were required to submit a ROP in 2020.

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  30. U.S. Department of State, “PEPFAR Update – Stakeholder Townhall,” presentation delivered on August 2, 2012.

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  31. O’Neill Institute for National and Global Health Law at Georgetown University Law Center, HIV Policy Lab, accessed: https://hivpolicylab.org/.

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  32. Kavanagh M, et al, “Understanding and comparing HIV-related law and policy environments: cross-national data and accountability for the global AIDS response,” BMJ Global Health, 2020, accessed: https://gh.bmj.com/content/5/9/e003695.

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  33. UNAIDS, Laws and Policies Analytics, web platform, accessed: http://lawsandpolicies.unaids.org/.

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  34. PEPFAR’s 2020 Country Operational Plan Guidance for all PEPFAR Countries includes a list of 55 countries that were required to submit a COP or ROP that year. This list served as the basis for our “PEPFAR countries” group. Two countries on this list (Barbados and Suriname) were excluded from our analysis following communication with staff in the Office of the Global AIDS Coordinator that confirmed that direct bilateral support had been discontinued to those countries in recent years.

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  35. According to the U.S. government database www.foreignassistance.gov, three countries that were not required to develop a COP or ROP received some HIV funding in FY 2020 – Colombia, Peru, and Venezuela. These countries were not included in the PEPFAR group.

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  36. Only low- and middle-income countries, as defined by the World Bank (see: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups), were included in this analysis, with the exception of two high-income countries (Panama and Trinidad and Tobago) that receive PEPFAR support and were required to submit a ROP in 2020.

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