July 25, 2014
The President’s Emergency Plan for AIDS Relief (PEPFAR):
Summary of Recent Developments
treatment (ART) for 6.7 million people, and in FY2013,
Background
PEPFAR funds enabled:
The President’s Emergency Plan for AIDS Relief
• 17 million people affected by HIV/AIDS to access
(PEPFAR)—the world’s largest bilateral HIV/AIDS
care and support services, including more than 5
assistance program—was proposed in 2003 by former
million orphans and vulnerable children;
President George W. Bush. Congress authorized the
program and has since continuously funded it. PEPFAR is
• 57.7 million people to receive HIV testing and
implemented by multiple U.S. agencies and departments,
counseling; and
including the U.S. Agency for International Development,
Peace Corps, and the Departments of State, Defense, and
• 780,000 HIV-positive pregnant women to receive
Health and Human Services (including its implementing
ART to prevent mother to child HIV transmission
agencies). The program supports a wide range of bilateral
(PMTCT)—averting 240,000 infant HIV
HIV/AIDS prevention, treatment, and care activities,
infections.
including those that address malaria and TB co-infection. It
also supports multilateral efforts, such as the Global Fund
Figure 1. U.S. Global HIV/AIDS, TB, and Malaria
to Fight AIDS, Tuberculosis, and Malaria (Global Fund).
Funding: FY2004-FY2015
(current U.S. $ mil ions and percent)
The United States has spent nearly $57 bil ion on
FY2004- FY2009- FY2014 FY2004- FY2015
fighting HIV/AIDS worldwide through PEPFAR,
F72008 FY2013 Estimate FY2014 Request
including more than $10 bil ion on the Global Fund.
HIV/AIDS
18,
130 32,
304 6,
536 56,
970 6,
205
TB & Malaria
1,
363 3,
975 912
6,
249 865
Under P.L. 108-25, the U.S. Leadership Against
HIV,TB, Malaria
19,
493 36,
279 7,
448 63,
219 7,
070
HIV/AIDS, Tuberculosis, and Malaria Act (the Leadership
Global Fund (GF)
3,
003 5,
965 1,650 10,617 1,350
Act), as amended, Congress authorized $15 billion to be
spent on bilateral and multilateral HIV/AIDS, tuberculosis
GF Share of HTAM
15%
16%
22%
17%
19%
(TB), and malaria (HTAM) programs between FY2004 and
Source: Created by CRS from correspondence with the Office of
FY2008. In 2008, Congress passed P.L. 110-293, the Tom
Management and Budget (OMB), and analysis of appropriations and
Lantos and Henry J. Hyde United States Global Leadership
budget justifications.
Against HIV/AIDS, Tuberculosis, and Malaria
Notes: Congress provides funds for the Global Fund through the
Reauthorization Act (the Lantos-Hyde Act), which
State Department as part of its global HIV/AIDS appropriation. Funds
authorized $48 billion to be spent on global HTAM
for bilateral HTAM programs are outlined in the table above to
programs between FY2009 and FY2013. The PEPFAR
compare Global Fund support against bilateral HTAM funding levels.
Stewardship and Oversight Act of 2013 (P.L. 113-56),
enacted in December 2013, strengthened congressional
Figure 2. Number of New HIV Infections and AIDS
oversight of PEPFAR. It also extended through FY2018
Deaths Worldwide: 2001-2012
spending requirements mandating that at least 50% of
HIV/AIDS funds be used on care and treatment and that at
least 10% of HIV/AIDS funds be used to support orphans
and vulnerable children. The Act did not include a specific
funding amount for global HIV/AIDS programs.
PEPFAR Results and Impact
From FY2004 through FY2014, Congress has provided
nearly $57 billion for global HIV/AIDS programs (Figure
1), including more than $10 billion for the Global Fund.
These investments have contributed to significant
reductions in new HIV infections and AIDS deaths
worldwide (Figure 2), as well as improvements in life
expectancy in several PEPFAR countries (Figure 3). As of
Source: Adapted by CRS from the Joint United Nations Program on
the end of FY2013, PEPFAR had supported antiretroviral
AIDS (UNAIDS), 2013 Global Report, 2013.
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The President’s Emergency Plan for AIDS Relief (PEPFAR): Summary of Recent Developments
Figure 3. Life Expectancy Changes in Selected PEPFAR
at adhering to the law may imperil improvements in health
Countries: 1960-2013
systems made through PEPFAR.
Transparency. PEPFAR is widely viewed as a successful
program. Nonetheless, observers, including the Institute of
Medicine (IOM) and the GAO, have recommended that the
State Department improve transparency and accountability
in PEPFAR programs to facilitate evaluation and oversight.
In January 2014, PEPFAR released a report outlining its
plans for improving evaluation of its programs, and in July
2014, the State Department launched the PEPFAR
Dashboards, an online tool under which PEPFAR spending
and outcomes data are publicly available.
Impact. Ambassador Birx is leading a comprehensive
review of PEPFAR to ensure optimal use of its resources.
Source: Adapted by CRS from Ambassdor Deborah Birx,
Part of this process entails shifting from broad-based
“Delivering an AIDS-Free Generation,” Slide Presentation, Kaiser
support to concentrated efforts focusing on high-burden
Family Foundation Town Hal Forum, June 23, 2014.
areas and communities. This new approach also emphasizes
country ownership through partnership frameworks—
The Future of PEPFAR
agreements that outline the role of all stakeholders,
including recipient countries, in financing and
PEPFAR has expanded rapidly since being launched a
implementing national HIV/AIDS plans. Birx also aims to
decade ago and has undergone several transitions. During
expand the application of evidence-based programming to
the first five-year phase, critics urged the State Department
deepen the impact of PEPFAR.
to consider the impact U.S.-funded HIV/AIDS programs
(which operated largely outside of publically funded health
Despite assurances by the Administration that PEPFAR will
facilities) were having on national health systems. In its
not reduce funding to recipient countries that have not
second phase, PEPFAR invested more heavily in
completed transition plans, some global health experts are
strengthening health systems and sought to align more
concerned that existing partnership frameworks include
closely U.S. efforts with national HIV/AIDS activities. In
planned funding reductions, even in instances when
its third phase, PEPFAR is emphasizing country capacity
PEPFAR recognizes insufficient government capacity to
and focusing on building a sustainable program that
assume full financial and administrative responsibility for
recipient countries can maintain. Through Partnership
life-saving programs.
Frameworks and Country Operation Plans, PEPFAR and
implementing partners outline the role each will play in
Questions also persist about what will happen to people in
transitioning ownership of HIV/AIDS responses from the
areas with relatively low HIV prevalence rates. Will
United States to recipient countries.
countries maintain or extend support to people living in
these areas, given plans to concentrate PEPFAR resources
In April 2014, Ambassador Deborah Birx was confirmed as
in high-prevalence areas? Recognizing the sizable role that
the U.S. Global AIDS Coordinator. In that role, she is
PEPFAR plays in global HIV/AIDS responses (accounting
responsible for overseeing all bilateral HIV/AIDS funds
for roughly 73% of all bilateral HIV/AIDS aid and nearly
and for achieving PEPFAR goals, as laid out in the
half of all international HIV/AIDS spending) and the
PEPFAR Blueprint (the PEPFAR plan for working toward
uncertainty of future U.S. funding, PEPFAR is working
the global goal of creating an “AIDS-free generation” by
with countries to identify alternative funding sources for
2015—meaning that no children will be born with HIV in
closing HIV/AIDS funding gaps and boost national
2015). Ambassador Birx has said that she plans to achieve
HIV/AIDS investments. Some health experts are concerned
the Blueprint goals with a focus on three key areas:
not only that a number of countries may not be able to
accountability, transparency, and impact. These areas are
maintain support for HIV-affected people as PEPFAR
summarized below.
funding wanes, but also that countries may draw resources
from other health areas (like maternal and child health) to
Accountability. In March 2013, the Government
supplement PEPFAR spending reductions. For more
Accountability Office (GAO) released a report indicating
information on PEPFAR, see CRS Report R43115, U.S.
that roughly 21% of PEPFAR funds in FY2012 were spent
Global Health Assistance: FY2001-FY2015 Funding and
on capacity-building projects under the “other” budgetary
Issues for Congress.
category. The report noted that it was unclear what portions
of these funds were spent on care, treatment, and prevention
Tiaji Salaam-Blyther, tsalaam@crs.loc.gov, 7-7677
activities. At her confirmation hearing, Ambassador Birx
Briana Savage, Intern, contributed to this report.
asserted that under her leadership, 50% of all PEPFAR
resources, including those funded through other accounts,
IF00042
would be spent on care and treatment activities, as
mandated in the Leadership Act. Some global health
advocates expressed concern that budgetary reforms aimed
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