The President’s Emergency Plan for AIDS Relief (PEPFAR): Summary of Recent Developments

The President’s Emergency Plan for AIDS Relief (PEPFAR): Summary of Recent Developments

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July 25, 2014
The President’s Emergency Plan for AIDS Relief (PEPFAR):
Summary of Recent Developments
Background
treatment (ART) for 6.7 million people, and in FY2013,
The President’s Emergency Plan for AIDS Relief
PEPFAR funds enabled
(PEPFAR)—the world’s largest bilateral HIV/AIDS
assistance program—was proposed in 2003 by former
 17 million people affected by HIV/AIDS to access care
President George W. Bush. Congress authorized the
and support services, including more than 5 million
program and has since continuously funded it. PEPFAR is
orphans and vulnerable children;
implemented by multiple U.S. agencies and departments,
 57.7 million people to receive HIV testing and
including the U.S. Agency for International Development,
counseling; and
Peace Corps, and the Departments of State, Defense, and
Health and Human Services (including its implementing
 780,000 HIV-positive pregnant women to receive ART
agencies). The program supports a wide range of bilateral
to prevent mother to child HIV transmission
HIV/AIDS prevention, treatment, and care activities,
(PMTCT)—averting 240,000 infant HIV 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. $ in millions and percent)
The United States has spent nearly $57 billion on
fighting HIV/AIDS worldwide through PEPFAR,
including more than $10 billion on the Global Fund.

Under P.L. 108-25, the U.S. Leadership Against

HIV/AIDS, Tuberculosis, and Malaria Act (the Leadership
Source: Created by CRS from correspondence with the Office of
Act), as amended, Congress authorized $15 billion to be
Management and Budget (OMB) and analysis of appropriations and
spent on bilateral and multilateral HIV/AIDS, tuberculosis
budget justifications.
(TB), and malaria (HTAM) programs between FY2004 and
Notes: Congress provides funds for the Global Fund through the
FY2008. In 2008, Congress passed P.L. 110-293, the Tom
State Department as part of its global HIV/AIDS appropriation. Funds
Lantos and Henry J. Hyde United States Global Leadership
for bilateral HTAM programs are outlined in the table above to
Against HIV/AIDS, Tuberculosis, and Malaria
compare Global Fund support against bilateral HTAM funding level.
Reauthorization Act (the Lantos-Hyde Act), which
authorized $48 billion to be spent on global HTAM
Figure 2. Number of New HIV Infections and AIDS
programs between FY2009 and FY2013. The PEPFAR
Deaths Worldwide: 2001-2012
Stewardship and Oversight Act of 2013 (P.L. 113-56),
enacted in December 2013, strengthened congressional
oversight of PEPFAR. It also extended through FY2018
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
Source: Adapted by CRS from the Joint United Nations Program on
worldwide (Figure 2), as well as improvements in life
AIDS (UNAIDS), 2013 Global Report, 2013.
expectancy in several PEPFAR countries (Figure 3). As of

the end of FY2013, PEPFAR had supported antiretroviral

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The President’s Emergency Plan for AIDS Relief (PEPFAR): Summary of Recent Developments
Figure 3. Life Expectancy Changes in Selected
at adhering to the law may imperil improvements in health
PEPFAR 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
Source: Adapted by CRS from Ambassador Deborah Birx,
review of PEPFAR to ensure optimal use of its resources.
“Delivering an AIDS-Free Generation,” Slide Presentation, Kaiser
Part of this process entails shifting from broad-based
Family Foundation Town Hall Forum, June 23, 2014.
support to concentrated efforts focusing on high-burden
The Future of PEPFAR
areas and communities. This new approach also emphasizes
country ownership through partnership frameworks—
PEPFAR has expanded rapidly since being launched a
agreements that outline the role of all stakeholders,
decade ago and has undergone several transitions. During
including recipient countries, in financing and
the first five-year phase, critics urged the State Department
implementing national HIV/AIDS plans. Birx also aims to
to consider the impact U.S.-funded HIV/AIDS programs
expand the application of evidence-based programming to
(which operated largely outside of publically funded health
deepen the impact of PEPFAR.
facilities) were having on national health systems. In its
second phase, PEPFAR invested more heavily in
Despite assurances by the Administration that PEPFAR will
strengthening health systems and sought to align more
not reduce funding to recipient countries that have not
closely U.S. efforts with national HIV/AIDS activities. In
completed transition plans, some global health experts are
its third phase, PEPFAR is emphasizing country capacity
concerned that existing partnership frameworks include
and focusing on building a sustainable program that
planned funding reductions, even in instances when
recipient countries can maintain. Through Partnership
PEPFAR recognizes insufficient government capacity to
Frameworks and Country Operation Plans, PEPFAR and
assume full financial and administrative responsibility for
implementing partners outline the role each will play in
life-saving programs.
transitioning ownership of HIV/AIDS responses from the
United States to recipient countries.
Questions also persist about what will happen to people in
areas with relatively low HIV prevalence rates. Will
In April 2014, Ambassador Deborah Birx was confirmed as
countries maintain or extend support to people living in
the U.S. Global AIDS Coordinator. In that role, she is
these areas, given plans to concentrate PEPFAR resources
responsible for overseeing all bilateral HIV/AIDS funds
in high-prevalence areas? Recognizing the sizable role that
and for achieving PEPFAR goals, as laid out in the
PEPFAR plays in global HIV/AIDS responses (accounting
PEPFAR Blueprint (the PEPFAR plan for working toward
for roughly 73% of all bilateral HIV/AIDS aid and nearly
the global goal of creating an “AIDS-free generation” by
half of all international HIV/AIDS spending) and the
2015—meaning that no children will be born with HIV in
uncertainty of future U.S. funding, PEPFAR is working
2015). Ambassador Birx has said that she plans to achieve
with countries to identify alternative funding sources for
the Blueprint goals with a focus on three key areas:
closing HIV/AIDS funding gaps and boost national
accountability, transparency, and impact. These areas are
HIV/AIDS investments. Some health experts are concerned
summarized below.
not only that a number of countries may not be able to
maintain support for HIV-affected people as PEPFAR
Accountability. In March 2013, the Government
funding wanes, but also that countries may draw resources
Accountability Office (GAO) released a report indicating
from other health areas (like maternal and child health) to
that roughly 21% of PEPFAR funds in FY2012 were spent
supplement PEPFAR spending reductions. For more
on capacity-building projects under the “other” budgetary
information on PEPFAR, CRS Report R43115, U.S. Global
category. The report noted that it was unclear what portions
Health Assistance: FY2001-FY2015 Funding and Issues for
of these funds were spent on care, treatment, and prevention
Congress
activities. At her confirmation hearing, Ambassador Birx
asserted that under her leadership, 50% of all PEPFAR
(Note: Briana Savage, Intern, contributed to this report.)
resources, including those funded through other accounts,
would be spent on care and treatment activities, as
Tiaji Salaam-Blyther,
mandated in the Leadership Act. Some global health
advocates expressed concern that budgetary reforms aimed
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The President’s Emergency Plan for AIDS Relief (PEPFAR): Summary of Recent Developments

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