Key Issues and Questions for PEPFAR’s Future
Key Findings
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Issue Brief
PEPFAR’s definition of epidemic control is when “the total number of new HIV infections fall below the total number of deaths from all causes among HIV-infected individuals.” For more information, see U.S. Department of State, PEPFAR 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 and KFF, KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries, August 2021.
U.S. Department of State, PEPFAR Latest Global Results, July 2021, accessed: https://www.state.gov/wp-content/uploads/2021/06/PEPFAR-Latest-Global-Results_JUNE-2021-1.pdf.
Institute of Medicine, Evaluation of PEPFAR, 2013, accessed: https://www.nap.edu/catalog/18256/evaluation-of-pepfar.
Institute of Medicine, PEPFAR Implementation: Progress and Promise, 2007, accessed: https://www.nap.edu/catalog/11905/pepfar-implementation-progress-and-promise.
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U.S. Department of State, Guiding Principles for the Next Phase of PEPFAR, December 2020, accessed: https://www.state.gov/wp-content/uploads/2020/12/Guiding-Principles-for-the-Next-Phase-of-PEPFAR.pdf.
U.S. Department of State, Draft Overview – PEPFAR Strategy: Vision 2025, accessed: https://www.state.gov/development-of-the-next-pepfar-strategy-vision-2025/ (September 10, 2021).
KFF, PEPFAR Reauthorization: Side-by-Side of Legislation Over Time, January 2019.
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UNAIDS further analysis of Global Health Estimates 2019: Deaths by Cause, Age, Sex, by Region, 2000-2019, 2020.
UNAIDS AIDSInfo database, accessed: https://aidsinfo.unaids.org (August 12, 2021).
KFF, KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries, August 2021.
UNAIDS, Evidence Review: Implementation of the 2016-2021 UNAIDS Strategy On the Fast Track to End AIDS, 47th meeting of the UNAIDS Program Coordinating Board, UNAIDS/PCB(47)/CRP3, accessed: https://www.unaids.org/sites/default/files/media_asset/PCB47_CRP3_Evidence_Review_EN.pdf (May 16, 2021).
UNAIDS, Seizing the Moment: Tackling Entrenched Inequalities to End Epidemics, 2020, accessed: https://www.unaids.org/sites/default/files/media_asset/2020_global-aids-report_en.pdf (accessed on May 16, 2021).
Data for figure sourced from One World in Data, U.S. Department of State, United Nations, World Bank.
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The World Bank, The World Bank in Africa, 2020, accessed: https://www.worldbank.org/en/region/afr/overview (May 9, 2021).
U.S. Department of State, PEPFAR Technical Guidance in Context of COVID-19 Pandemic (version dated February 24, 2021, accessed: https://www.state.gov/wp-content/uploads/2021/02/02.24.21-PEPFAR-Technical-Guidance-During-COVID.pdf (August 12, 2021).
U.S. Department of State, PEPFAR 2021 Country & Regional Operational Plan (COP/ROP) Guidance for All PEPFAR Countries, pages 11-13, accessed: https://www.state.gov/wp-content/uploads/2021/02/PEPFAR-COP21-Guidance-Final.pdf.
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The Global Fund, Results Report 2021, September 2021, accessed: https://www.theglobalfund.org/en/news/2021-09-08-global-fund-results-report-reveals-covid-19-devastating-impact-on-hiv-tb-and-malaria-programs/ (September 8, 2021).
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The Global Fund, The Impact of COVID-19 on HIV, TB and Malaria Services and Systems for Health: A Snapshot from 502 Health Facilities Across Africa and Asia, April 2021, accessed: https://www.theglobalfund.org/media/10776/covid-19_2020-disruption-impact_report_en.pdf.
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The Global Fund launched an immediate response to COVID-19 to help mitigate the impact of COVID-19 on HIV, TB, and malaria programs and support national COVID-19 responses. This includes new funding and grant flexibilities, among other measures. For more information, see: “The Global Fund, Our COVID-19 Response,” accessed: https://www.theglobalfund.org/en/our-covid-19-response/ (August 12, 2021).
Golin R, et al, “PEPFAR’s response to the convergence of the HIV and COVID‐19 pandemics in Sub‐Saharan Africa,” Journal of the International AIDS Society, accessed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405155/.
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U.S. Department of State, PEPFAR Update – Stakeholder Townhall (presentation on August 2, 2021), provided to KFF by the Office of the Global AIDS Coordinator.
U.S. Department of State, PEPFAR Update – Stakeholder Townhall (presentation on August 2, 2021), provided to KFF by the Office of the Global AIDS Coordinator.
Mehta N et al., “Impact of COVID-19 on HIV treatment interruption in seven PEPFAR countries, April-June 2020,” 11th IAS Conference on HIV Science, 2021, Abstract ALX01LB04.
U.S. Department of State, PEPFAR Update – Stakeholder Townhall (presentation on August 2, 2021), provided to KFF by the Office of the Global AIDS Coordinator.
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U.S. Department of State, PEPFAR Update – Stakeholder Townhall (presentation on August 2, 2021), provided to KFF by the Office of the Global AIDS Coordinator.
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KFF, Breaking Down the U.S. Global Health Budget by Program Area, May 2021.
Not including emergency funding appropriated in FY 2021 for COVID-19.
KFF, “White House Releases Full FY 2022 Budget Request,” June 2, 2021.
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Igoe M, “PEPFAR to 'accelerate' implementation in 13 countries under new strategy,” September 19, 2017, Devex, accessed: https://www.devex.com/news/pepfar-to-accelerate-implementation-in-13-countries-under-new-strategy-91064#:~:text=The%20initiative%20will%20maintain%20lifesaving,treating%20HIV%2C%20the%20official%20said (August 12, 2021).
KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2020, July 2021.
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KFF, Forthcoming analysis, 2021.
See, for example, the discussion by Members of Congress during consideration of PEPFAR’s 2018 reauthorization, accessed: https://www.govinfo.gov/content/pkg/CREC-2018-11-13/pdf/CREC-2018-11-13-pt1-PgH9488.pdf; a letter from Representative Kay Granger, accessed: https://kaygranger.house.gov/2018/12/bipartisan-achievement-s-saving-lives-0; and this Devex article, accessed: https://www.devex.com/news/opinion-we-started-pepfar-politicizing-aids-would-be-a-disaster-91659.
See, for example, the House of Representatives’ Committee Report accompanying the 2018 reauthorization of PEPFAR, that states, “While goals such as strengthening health systems, combatting non-communicable diseases, and establishing social safety nets for children in adversity are worthy objectives—and PEPFAR and the Global Fund clearly have had corollary, net-positive effects on these and other global health and development priorities—these objectives can and should be addressed through different initiatives. PEPFAR’s past and future success is contingent on remaining focused upon the three core diseases.” See: https://www.congress.gov/115/crpt/hrpt1014/CRPT-115hrpt1014.pdf.
KFF calculations on member composition of the U.S. Congress.
UNAIDS, Seizing the Moment: Global AIDS Update 2020, accessed: https://www.unaids.org/sites/default/files/media_asset/2020_global-aids-report_executive-summary_en.pdf.
PEPFAR’s initial focus countries were primarily those that were targeted by President Clinton’s 1999 “LIFE” Initiative, see: https://clintonwhitehouse4.archives.gov/media/pdf/2pager.pdf), and President George W. Bush’s 2002 “International Mother and Child HIV Prevention Initiative,” see: https://georgewbush-whitehouse.archives.gov/news/releases/2002/06/20020619-3.html.
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14 countries were specified in PEPFAR’s 2003 authorizing legislation: Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. Viet Nam was added in 2004.
These 13 countries are: Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. Nine are original focus countries.
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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This was a sense of Congress for FY 2004-2005 and a requirement as of FY 2006.
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The program is now required to spend at least half of bilateral funding on treatment and care and the 33% abstinence earmark was replaced with a requirement for “balanced funding” for prevention, although PEPFAR is still required to report to Congress if it spends less than 50% of its prevention funding on abstinence and related activities.
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Based on analysis of data from the PEPFAR Panorama Spotlight Dashboards, accessed: https://data.pepfar.gov/ (September 9, 2021).
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“Index testing” is a testing strategy that works to notify partners of people who test HIV-positive and offer them HIV testing services.
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The 95-95-95 targets were adopted by U.N. member states at the U.N. General Assembly High-Level Meeting on HIV/AIDS in 2021, are successors to the earlier 90-90-90 targets for 2020. The new targets provide that: by 2025, 95% of all people living with HIV will know their HIV status, 95% of people with an HIV diagnosis will receive antiretroviral therapy, and 95% of people receiving HIV treatment will achieve viral suppression.
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