WASHINGTON -- The President's Emergency Plan for AIDS Relief (PEPFAR) has saved and improved millions of lives worldwide and offered proof that HIV/AIDS services can be effectively delivered on a large scale even in countries with high rates of disease and resource constraints, says a new congressionally mandated evaluation conducted by the Institute of Medicine.
Moving forward, PEPFAR needs to intensify efforts to help its partner countries develop the capacity to manage their own programs, sustain the gains that have been made in controlling the HIV epidemic, and improve their citizens' access to services, said the committee that wrote the report.
Even with PEPFAR's substantial contributions to the global scale-up of HIV/AIDS services, many needs remain, the report notes, and future progress will require partner countries and donors to work together to make difficult but necessary decisions on how to allocate finite resources. As PEPFAR increases its focus on fostering countries' ability to take on greater long-term responsibility, results may not occur as rapidly or dramatically as in the past, the committee cautioned.
"During our visits to partner countries, we repeatedly heard PEPFAR described as a lifeline," said committee chair Robert Black, chair, department of international health, Johns Hopkins Bloomberg School of Public Health, Baltimore. "People credit the initiative with restoring hope. As it moves forward, PEPFAR must continue to be bold in its vision, implementation, and global leadership."
PEPFAR was established in 2003 through legislation that authorized $15 billion for HIV/AIDS and other related global health issues over five years. In 2008, the legislation was reauthorized, providing up to $39 billion through 2013 for PEPFAR bilateral HIV/AIDS programs as well as U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. PEPFAR has supported HIV/AIDS programs in over 100 countries, with the largest share of the investment currently in 33 partner countries. As part of the reauthorization, Congress requested that IOM evaluate various aspects of the initiative, a task that IOM's international committee of experts carried out through visits to 13 partner countries as well as the review of volumes of documentation and data. IOM previously evaluated PEPFAR in its initial implementation phase and issued a report in 2007.
Overall, PEPFAR has reset the world's expectations for what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis, the committee concluded. Working with a wide range of international and local partners, PEPFAR has expanded HIV testing and increased the number of people living with HIV who are receiving care and being treated with antiretroviral drugs. The initiative has trained hundreds of thousands of service providers, strengthened partner countries' health systems, provided additional nonclinical support services for people living with HIV, and made an unprecedented investment in programs for orphans and vulnerable children living with or affected by HIV.
PEPFAR has successfully increased services to prevent HIV transmission from mothers to their children during pregnancy and birth. The initiative has become increasingly flexible over time in its approach to other prevention strategies, and it has achieved positive results by supporting data collection to better understand the factors driving the epidemic in each country and scaling up prevention programs for the general population and for populations at elevated risk. However, greater attention to a range of prevention strategies is needed, the report says. In particular, countries need to increase the focus on prevention of sexual transmission, which is responsible for the majority of new infections. PEPFAR should lead the way by supporting innovations in strategies to decrease risk factors that contribute to HIV transmission.
The committee underscored the importance of partner countries receiving support to take on greater responsibility for and management of their own HIV/AIDS programs. In recent years, PEPFAR has begun providing less direct support and more technical assistance and support for strengthening partner countries' health systems and capacity to lead their efforts, a shift that the report deems reasonable and appropriate. PEPFAR's guidance should reorient from prescribing specific activities to outlining key outcomes and enabling partner countries to determine how to prioritize their efforts to achieve these outcomes.
The study was sponsored by the U.S. Department of State. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The Institute of Medicine, National Academy of Sciences, National Academy of Engineering, and National Research Council together make up the private, nonprofit National Academies. For more information, visit http://national-academies.org or http://iom.edu. A committee roster follows.
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Pre-publication copies of Evaluation of PEPFAR are available from the National Academies Press on the Internet at http://www.nap.edu or by calling tel. 202-334-3313 or 1-800-624-6242. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). Additional information is available at http://www.iom.edu/pepfar2.
INSTITUTE OF MEDICINE
Board on Global Health
and
NATIONAL RESEARCH COUNCIL
Division of Behavioral and Social Sciences and Education
Board on Children, Youth, and Families
Committee on Planning the Assessment/Evaluation of HIV/AIDS Programs Implemented Under U.S. Global Leadership Against HIV/AIDS, TB, and Malaria Reauthorization Act of 2008
Robert E. Black, M.D., M.P.H. (chair)
Edgar Berman Professor and Chair
Department of International Health
Bloomberg School of Public Health
Johns Hopkins University
Baltimore
Judith D. Auerbach, Ph.D.
Former Vice President of Research and Evaluation
San Francisco AIDS Foundation
San Francisco
Mary T. Bassett, M.D., M.P.H.
Director for the African Health Initiative
Medical Research Program
Doris Duke Charitable Foundation
New York City
Ronald Brookmeyer, Ph.D.
Professor
Department of Biostatistics
School of Public Health
University of California
Los Angeles
Lola Dare M.D., M.Sc.
CEO
Center for Health Sciences Training, Research, and Development International
Ibadan, Nigeria
Alex C. Ezeh, Ph.D., M.Sc.
Executive Director
African Population and Health Research Center
Nairobi, Kenya
Sofia Gruskin, J.D., M.I.A.
Professor of Preventive Medicine
Keck School of Medicine;
Professor of Law and Preventive Medicine
Gould School of Law; and
Director
Program on Global Health and Human Rights Institute for Global Health
University of Southern California
Los Angeles
Angelina Kakooza, M.B.Ch.B., M.D.
Pediatrician and Lecturer
Department of Pediatrics and Child Health
School of Medicine
Makerere University College of Health Sciences
Kampala, Uganda
Jennifer Kates, M.A., M.P.A.
Vice President, and
Director
Global Health Policy and HIV
Henry J. Kaiser Family Foundation
Washington, D.C.
Ann Kurth, Ph.D., C.N.M.
Professor and Director
Global Health Initiatives
New York University College of Nursing
New York City
Anne C. Petersen, Ph.D.
President
Global Philanthropy Alliance, and
Research Professor
Center for Human Growth and Development
University of Michigan
Kalamazoo
Douglas D. Richman, M.D.
Director
Center for AIDS Research
VA San Diego Healthcare System, and
Florence Seeley Riford Chair in AIDS Research and
Distinguished Professor of Pathology and Medicine
University of California
San Diego
Jennifer Prah Ruger, Ph.D.
Associate Professor
Division of Health Policy and Administration
Yale School of Public Health
New Haven, Conn.
Deborah L. Rugg, Ph.D., M.A.
Director
Inspection and Evaluation Division
United Nations
New York City
Papa Salif Sow, M.D., M.Sc.
Senior Program Officer, HIV
Global Health Program
Bill & Melinda Gates Foundation
Seattle
Dawn K. Smith, M.D., M.S., M.P.H.
Biomedical Interventions Implementation Officer
Epidemiology Branch, DHAP, NCHSTP
Centers for Disease Control and Prevention
Atlanta
Taha E. Taha, M.D., Ph.D.
Professor and Co-Director
Infectious Disease Epidemiology
Department of Epidemiology
Bloomberg School of Public Health
Johns Hopkins University
Baltimore
Kathryn Whetten, Ph.D., M.P.H.
Associate Professor of Public Policy Studies, Community and Family Medicine, and Nursing, and
Director
Health Inequalities Program
Center for Health Policy
Duke University
Durham, N.C.
Catherine M. Wilfert, M.D.
Scientific Director Emerita
Elizabeth Glaser Pediatrics AIDS Foundation, and
Professor Emerita
Duke University Medical Center
Chapel Hill, N.C.
STAFF
Kimberly Scott
Study Co-Director
Bridget B. Kelly
Study Co-Director