PEPFAR funding for focus countries

PEPFAR (the President's Emergency Plan for AIDS Relief) is America's $15 billion initiative to combat the global HIV/AIDS pandemic. AVERT.org has a general introduction to PEPFAR, and a page looking at PEPFAR's partners who are implementing its plans. This page looks at how funds are being allocated.

In each of its 15 "focus countries", PEPFAR supports country-managed programmes in the following areas:

Prevention of mother-to-child transmission
Abstinence/Be faithful education
Blood and injection safety
Other prevention activities, including condom promotion to high risk groups
Palliative care, including tuberculosis treatment
Care for orphans and vulnerable children
HIV counselling and testing
Antiretroviral drugs, treatment services and laboratory infrastructure
Strategic information, policy analysis, system strengthening, management and staffing.

PEPFAR's assistance comes in two forms: "downstream" support that directly benefits specific sites; and "upstream" support that consists of contributions to national, regional or local activities such as training, laboratory support, monitoring and evaluation, logistics and distribution systems, and protocol and curriculum development.

What varies between countries is the proportion of the budget allocated to each area of prevention, care and treatment. This variation reflects how PEPFAR is using different strategies to respond to different types of HIV and AIDS epidemics, in a diverse collection of focus countries that spans three continents. This page describes some of PEPFAR's highest priority activities in each focus country. In the table below, total budgets for Fiscal Year 2006 are given in brackets, rounded to the nearest million dollars.

Southern Africa	East Africa	West Africa	Caribbean & Asia
Botswana ($55m)	Ethiopia ($123m)	Côte d'Ivoire ($47m)	Guyana ($22m)
Mozambique ($94m)	Kenya ($208m)	Nigeria ($164m)	Haiti ($56m)
Namibia ($57m)	Rwanda ($72m)		Vietnam ($34m)
South Africa ($222m)	Tanzania ($130m)
Zambia ($149m)	Uganda ($170m)

Southern Africa

Botswana ($55m)

Profile:	Small population; relatively prosperous Exceptionally high HIV prevalence
Adults living with HIV/AIDS (2005):	24.1%
PEPFAR funding priorities (2005):	Antiretroviral drugs (21%) HIV counselling and testing (15%) Prevention of mother-to-child transmission (9%)

Only Swaziland has a higher HIV prevalence rate than Botswana, where nearly one in four adults is infected. Faced with such an exceptionally severe epidemic, the government has made fighting AIDS a top priority, and has succeeded in providing antiretroviral therapy to more than 80% of those in need. Partly because the treatment programme is already well supported by the government and other donors (in particular the Gates and Merck foundations), treatment services account for a smaller proportion of PEPFAR funds in Botswana than in any other focus country. Conversely, the proportion of funds allocated to prevention is higher than in most other focus countries.

Botswana receives an especially large amount of money per head of population – around twenty times more than Ethiopia and Nigeria, for example. Most of this money comes from the Centers for Disease Control and Prevention (CDC) through a programme called BOTUSA; there is no bilateral USAID presence in Botswana.¹

Voluntary HIV testing with same-day results and counselling is offered by the Tebelopele network of testing centres, which were first established by the CDC and the Botswana government in 2000. The network has since expanded to 16 centres and 8 satellites, and received over 90,000 visits in 2005. Tebelopele became an independent organisation in late 2004, but continues to receive US support.

PEPFAR has worked for several years with the Ministry of Education to develop abstinence-focused HIV education materials for schools, and has supported the Makgabaneng prevention project, which uses a popular radio drama to deliver its message. Programmes to prevent mother-to-child transmission are also given high priority; in particular, PEPFAR has helped to implement early infant HIV diagnosis using PCR testing of dried blood spots.

Departments of the Botswana government were obligated nearly $20 million in 2005 and nearly $22 million in 2006 - nearly 40% of all money allocated to the country by PEPFAR.

Mozambique ($94m)

Profile:	Large, sprawling country; thinly populated Higher prevalence along borders and trade routes
Adults living with HIV/AIDS (2005):	16.1%
PEPFAR funding priorities (2005):	Treatment services (17%) Prevention of mother-to-child transmission (11%) Orphans and vulnerable children (11%)

Programmes to help orphans and vulnerable children accounted for a higher proportion of funds in Mozambique than in any other focus country during 2005. These programmes reached around 147,500 children in 2006.

PEPFAR has supported a project to promote condoms in bars, hotels and shops along transport corridors and other areas of high HIV prevalence or high-risk behaviour. PEPFAR has also enabled cooperation between Brazilian experts and the Ministry of Health and National AIDS Council to help strengthen responses to HIV and AIDS. Around 208,800 people received PEPFAR-supported HIV counselling and testing in 2006.

Columbia University was obligated more than $9 million for work in Mozambique in 2005, and more than $7 million in 2006.

Namibia ($57m)

Profile:	Small population Very high HIV prevalence
Adults living with HIV/AIDS (2005):	19.6%
PEPFAR funding priorities (2005):	Treatment services (27%) HIV counselling and testing (18%) Basic palliative care and support (10%)

Like Botswana, Namibia has fewer than 3 million inhabitants; has a high prevalence of HIV; and receives a large amount of PEPFAR money per person. The national treatment programme in Namibia has recently undergone quite rapid expansion, and was providing therapy to around 70% of people in need by the end of 2005. Many of these people were benefiting from site-specific support from PEPFAR.

PEPFAR aims to continue increasing the number of people on treatment primarily by raising the number of trained health care staff and by improving infrastructure. Another high priority is caring for orphans, vulnerable children and people living with HIV. PEPFAR supported care for around 142,700 such people in Namibia in 2006.

Departments of the Namibian government were obligated more than $10 million by PEPFAR in 2006.

South Africa ($222m)

Profile:	Most prosperous focus country, but has widespread poverty More than five million people living with HIV/AIDS
Adults living with HIV/AIDS (2005):	18.8%
PEPFAR funding priorities (2005):	Treatment services (34%) Antiretroviral drugs (13%) HIV counselling and testing (10%)

More people live with HIV in South Africa than in any other country in the world, and every day more than 800 South Africans die from AIDS, according to UNAIDS estimates. Yet only 21% of those in need were receiving antiretroviral treatment at the end of 2005, and many of those relied on private facilities. Providing treatment to the three-quarters of a million others who are in immediate need presents a massive challenge.

In 2005, PEPFAR planned to provide more than $61 million to support antiretroviral treatment, the majority of which was to be spent on services rather than on the drugs themselves (which are mostly paid for by the South African government). In March 2005, the US announced a $50 million, five-year grant towards Project Phidisa, which is a clinical research project focusing on the management and treatment of HIV in South Africa's defence force.²

During 2006, PEPFAR supported HIV testing and counselling for around 763,200 people, and provided site-specific support for around 98,600 people receiving treatment (more than in any other focus country). PEPFAR also supported the provision of preventive drugs to around 144,400 pregnant women in 2006 (far more than in any other focus country), averting an estimated 27,400 HIV infections in infants. Community activities to prevent sexual transmission of HIV reached nearly 11 million South Africans during the same year, and 122,900 individuals were trained or retrained to provide HIV prevention services.

The non-governmental organisation Right To Care, South Africa was obligated $15 million to provide treatment, care and testing services in South Africa in 2006. Wits Health Consortium (a wholly owned subsidiary of the University of the Witwatersrand, Johannesburg) was obligated more than $18 million in the same year.

Zambia ($149m)

Profile:	Sparsely populated; extremely poor HIV prevalence has stabilised at very high level
Adults living with HIV/AIDS (2005):	17.0%
PEPFAR funding priorities (2005):	Treatment services (34%) Antiretroviral drugs (12%) HIV counselling and testing (9%)

Zambia is one of the world's poorest and least developed countries, and has had a high prevalence of HIV for many years. In 2006, PEPFAR helped 20,900 pregnant women to receive antiretroviral drugs (preventing around 4,000 infant infections); reached around 315,600 orphans and vulnerable children; and trained or retrained 11,700 people to provide palliative care. Efforts have also been made to improve HIV counselling and testing facilities, and to improve their accessibility by using mobile services and by linking them to TB and STI programmes.

Significant grants have included $54 million for Family Health International and seven other partners (including the International HIV/AIDS Alliance) for the years 2004-2010, to build sustainable HIV/AIDS prevention, care and treatment service delivery systems.³ Also in late 2004, Population Service International's Zambian affiliate, Society for Family Health, was awarded $24 million over six years for social marketing campaigns to improve health among low-income and vulnerable Zambians in the areas of HIV/AIDS, malaria, safe water and family planning.⁴

In January 2005, the newly launched RAPIDS project was awarded $39 million to be spread over six years, for providing assistance to orphans and vulnerable children. The project, which aims to reach 350,000 such children by 2010, involves government institutions and a consortium of NGOs including Catholic Relief Services, the Salvation Army and World Vision.⁵

The Elizabeth Glaser Pediatric AIDS Foundation, Family Health International and John Snow, Inc. were each obligated more than $16 million for work in Zambia in 2005. The first two of these organisations also received more than $11 million each in 2006. The Partnership for Supply Chain Management was obligated more than $15 million in 2006.

East Africa

Ethiopia ($123m)

Profile:	Large, mostly rural population; extremely poor HIV prevalence varies widely and is much higher in cities
Adults living with HIV/AIDS (2005):	0.9-3.5%
PEPFAR funding priorities (2005):	Antiretroviral drugs (30%) Treatment services (19%) Basic palliative care and support (8%)

Ethiopia receives relatively little PEPFAR money in proportion to its total population of 70 million. Around half of the 2005 budget was allocated to antiretroviral treatment – a higher proportion than in any other focus country except Nigeria – and much of this was used to purchase drugs. PEPFAR provided site-specific support for around 50,100 people receiving treatment in 2006.

Prevention activities are mainly targeted at high risk groups, and include condom promotion to military personnel, truckers and sex workers. Other groups specifically targeted by prevention campaigns include students at Addis Ababa University and communities living along the transport corridor from Addis Ababa to Djibouti.

In 2005 Management Sciences for Health was obligated more than $22 million for work in Ethiopia, while Johns Hopkins University was obligated more than $7.5 million. In 2006 Management Sciences for Health was obligated another $7.5 million, and the Partnership for Supply Chain Management was obligated nearly $18 million for procuring and delivering antiretroviral drugs.

Kenya ($208m)

Profile:	Trading hub of East Africa; refugees in north HIV prevalence has stabilised at high level
Adults living with HIV/AIDS (2005):	6.1%
PEPFAR funding priorities (2005):	Treatment services (23%) Antiretroviral drugs (19%) Basic palliative care and support (10%)

Kenya was the second-best funded focus country in 2006, close behind South Africa. PEPFAR directly supported treatment for around 87,800 people in 2006. Also supported were around 33,300 pregnant women receiving drugs to prevent mother-to-child transmission of HIV, averting an estimated 6,300 infant infections.

PEPFAR has worked with more than 100 local community- and faith-based organisations to implement HIV prevention programmes. Specialised prevention programmes target members of Kenya's armed forces, prisoners and people with disabilities. During 2006 prevention messages encouraging abstinence, fidelity and condom use reached more than 7.3 million people via community outreach. HIV testing and counselling services supported by PEPFAR reached nearly three quarters of a million people during the same year.

PEPFAR has increased the supply of safe blood in Kenya by supporting six regional blood transfusion centres. Emergency Plan funds have also been used to improve injection safety at 105 medical facilities, and to provide prevention and care services for injecting drug users.

JHPIEGO was awarded a three-year $24 million cooperative agreement with USAID in August 2006 to implement a wide-ranging programme called APHIA II in Eastern Province, Kenya. In this project JHPIEGO will work with other partners including the Elizabeth Glaser Pediatric AIDS Foundation and FHI.⁶

In 2006 the Mission for Essential Drugs and Supplies - a Christian organisation based in Nairobi - was obligated more than $30 million to purchase and distribute antiretroviral drugs in Kenya. Another very large grant - of $60 million - was awarded in November 2007 to the AMPATH programme, run by Indiana University School of Medicine and Moi University.⁷

Rwanda ($72m)

Profile:	Most densely populated country in Africa High HIV prevalence since the late 1980s
Adults living with HIV/AIDS (2005):	3.1%
PEPFAR funding priorities (2005):	Treatment services (29%) Antiretroviral drugs (11%) HIV counselling and testing (9%)

In Rwanda in 2006 PEPFAR supported activities to prevent mother-to-child transmission of HIV at 103 sites. Around 7,700 pregnant women received preventive drugs, averting an estimated 1,500 infant infections. PEPFAR has also worked to prevent HIV transmission among mobile populations - such as drivers, sex workers and the armed forces - who travel along major transport corridors. The safety of the blood supply and of medical injections has been improved.

Site-specific support from PEPFAR helped around 14,700 people to receive antiretroviral treatment in 2006. In the same year PEPFAR supported HIV counselling and testing for around 465,500 people. Care services for orphans and vulnerable children included school fees, healthcare, livestock support, food and basic household supplies.

Columbia University was obligated more than $10 million for work in Rwanda in 2005. The Partnership for Supply Chain Management was obligated more than $9 million in 2006. The Elizabeth Glaser Pediatric AIDS Foundation was awarded $27 million for a five-year HIV counselling and testing project in the Eastern Province of Rwanda.⁸

Tanzania ($130m)

Profile:	Extremely poor HIV prevalence has stabilised at high level
Adults living with HIV/AIDS (2005):	6.5%
PEPFAR funding priorities (2005):	Treatment services (32%) Laboratory infrastructure (8%) Antiretroviral drugs (8%)

In 2005, prevention activities in Tanzania included providing over $6.3 million funding for improving blood safety (more than in any other focus country), and promoting HIV prevention messages to nearly 10 million people. PEPFAR contributed to over 80% of programme expenses for preventing mother-to-child transmission of HIV in Tanzania in 2005. A total of 1,289 health workers were trained or retrained in injection safety and proper waste handling during the same year.

PEPFAR provided around 680,600 people with HIV counselling and testing services in 2006, and around 568,800 people received care services, including 395,300 orphans (more than in any other focus country). PEPFAR is advocating a shift towards routine (opt-out) HIV testing in Tanzania, and is also promoting mobile counselling and testing units.

Emergency Plan funds have been used to help renovate 18 laboratories, and all six national referral laboratories have been equipped with high-volume CD4 testing equipment for monitoring patients receiving treatment.

The Partnership for Supply Chain Management was obligated more than $14 million for work in Tanzania in 2006. In October 2006, Family Health International was awared a $25 million over five years to manage a project called UJANA, which will encourage sexual behaviour change among young people.⁹

Uganda ($170m)

Profile:	Mostly rural population; many displaced people HIV prevalence higher in the northern conflict area
Adults living with HIV/AIDS (2005):	6.7%
PEPFAR funding priorities (2005):	Antiretroviral drugs (17%) Treatment services (17%) Basic palliative care and support (16%)

Uganda succeeded in cutting its HIV prevalence from around 15% in the early 1990s to around a third of that level by 2001. However, this rate is still very high and is no longer falling, and AIDS killed an estimated 91,000 Ugandans in 2005.

Prevention programmes in Uganda are largely based on the US interpretation of the "ABC" approach, which Uganda is itself credited with inventing. In 2006, PEPFAR supported community outreach programmes that promoted abstinence and being faithful (known as "AB") to around 5.7 million people. Around 1.7 million people were reached by programmes that promoted condoms and related services. The US supplied more than 47 million condoms to Uganda in 2005, and nearly 23 million in 2006.

In 2005, PEPFAR allocated more than three times as much money to care and treatment as to prevention. Site-specific support for counselling and testing benefited around a million people in 2006. Site-specific support for antiretroviral treatment helped 51,400 people to receive drugs in 2006.

The CORE Initiative has received $15.6 million to expand focused HIV/AIDS services for youth, and critical services for orphans and vulnerable children, from December 2005 to September 2008.¹⁰ The AIDS Integrated Model District Program (AIM), run by John Snow, Inc., is expected to receive at least $38 million from USAID over five years. The goal of AIM is to give Ugandans access to affordable and quality HIV/AIDS prevention, care and support services.¹¹

The AIDS Support Organisation (TASO) of Uganda was obligated more than $14 million by PEPFAR in 2005, and nearly $17 million in 2006. The Joint Clinical Research Center was obligated more than $13 million for treatment and care services in 2006.

West Africa

Côte d'Ivoire ($47m)

Profile:	Divided after civil war; many displaced people Highest HIV prevalence in West Africa
Adults living with HIV/AIDS (2005):	7.1%
PEPFAR funding priorities (2005):	Treatment services: 33% Blood safety: 12% Antiretroviral drugs: 12%

Côte d'Ivoire has suffered from conflict and related social and economic crises for the last few years. The country is now divided into two zones and requires UN forces to keep the peace. This situation is making Côte d'Ivoire's HIV/AIDS problem - which is the worst in the region - even more severe.

PEPFAR has supported HIV prevention campaigns targeting rural and underserved areas, the uniformed services and other highly vulnerable populations. PEPFAR has also supported the Ministry of National Education as it launched an initiative to include HIV prevention within a new school curriculum.

The first antiretroviral treatment centre outside the city of Abidjan was set up in 2004 as part of the newly-launched national treatment access programme, which is supported by PEPFAR. In 2006, the Emergency Plan gave site-specific support allowing around 20,900 people to receive treatment.

In 2005 the Elizabeth Glaser Pediatric AIDS Fund was obligated nearly $17 million for work in Côte d'Ivoire (around 38% of the national PEPFAR budget). In 2006 the same organisation received more than $10 million.

Nigeria ($164m)

Profile:	Largest population of all African countries 3.6 million people living with HIV/AIDS
Adults living with HIV/AIDS (2005):	3.9%
PEPFAR funding priorities (2005):	Treatment services: 28% Antiretroviral drugs: 17% Laboratory infrastructure: 11%

Although Nigeria's HIV prevalence is much lower than that of Botswana, Mozambique, Namibia and Zambia, it has far more people living with HIV than those four countries put together. Nigeria receives around three times as much funding as Botswana, but its total population is around 85 times greater.

In 2005 the proportion of PEPFAR funding allocated to treatment in Nigeria was, at 57%, the highest of all focus countries. Site-specific support helped around 50,100 people to receive treatment in 2006.

PEPFAR also supports a range of HIV prevention activities including the "Zip Up" mass media campaign, and care activities including those led by the Catholic Church.

Family Health International (FHI) has received an especially large USAID grant of $193 million for a five-year Nigerian project called GHAIN, which has been described as "the largest comprehensive HIV/AIDS project ever implemented in a developing country setting". GHAIN aims to provide antiretroviral treatment to more than 68,000 people; to care for 1,500,000 including orphans and vulnerable children; and to prevent 800,000 new HIV infections by 2009.¹² FHI was obligated more than $29 million in 2005, and more than $24 million in 2006.

Harvard University was obligated more than $27 million for work in Nigeria in 2005 and nearly $20 million in 2006. The University of Maryland was obligated nearly $12 million in 2005; more than $23 million in 2006; and around $43 million in 2007.¹³

Caribbean & Asia

Guyana ($22m)

Profile:	Small South American country with very small population Growing HIV/AIDS epidemic; highest prevalence in Latin America
Adults living with HIV/AIDS (2005):	2.4%
PEPFAR funding priorities (2005):	Treatment services: 24% Blood safety: 13% HIV counselling and testing: 12%

Guyana has a growing HIV epidemic which has now become generalised within the population, and women represent an increasing proportion of those affected. The country receives a great deal of PEPFAR money relative to the size of its population, which is approximately 750,000. Around 45% of all funds for Guyana are allocated for HIV prevention activities – a higher proportion than in any other focus country.

PEPFAR has helped to expand the number of service providers for preventing mother-to-child transmission of HIV in Guyana, and has supported efforts to upgrade facilities. Much effort is being made to encourage abstinence and fidelity among young people, and to encourage condom use among high risk groups. The "Me-to-You" campaign, which is supported by PEPFAR, has obtained 86,000 personal pledges to abstain from sex, to stay faithful to one partner, or to use condoms and attend HIV counselling and testing.

The Emergency Plan provided site-specific support to twelve treatment centres in 2006, helping around 1,600 people to access treatment. PEPFAR has also helped to improve laboratory facilities, staff training and treatment management systems.

USAID supports the Guyana HIV/AIDS Reduction Project (GHARP), which is run by Medical Sciences for Health, Family Health International, Cicatelli Associates Incorporated and Howard Delafield International. The project will receive $34 million over five years for prevention and care activities.¹⁴ Guyana's Central Medical Center is the core of an expanding treatment programme, which aims to offer state of the art HIV care and antiretroviral treatment.

Haiti ($56m)

Profile:	Poorest country in Western Hemisphere; densely populated Highest HIV prevalence of any country outside Africa
Adults living with HIV/AIDS (2005):	3.8%
PEPFAR funding priorities (2005):	Antiretroviral drugs (20%) Treatment services (17%) Basic palliative care and support (11%)

Haiti's HIV prevalence is on a par with some of PEPFAR's African focus countries, and its population is similarly very poor. Responses to HIV and AIDS have in the past been hampered by government instability.

In Haiti PEPFAR has supported efforts to prevent mother-to-child transmission, including the distribution of food as an added incentive for pregnant women to attend antenatal clinics. Abstinence and fidelity have been promoted through diverse routes including radio soap operas and youth groups, and more than six million condoms were supplied in 2006. Mobile HIV counselling and testing clinics have benefited from training and provision of supplies. Around 193,600 people in Haiti were helped to receive testing and counselling in 2006, at 93 sites.

In December 2004, doctors at Immaculate Conception Hospital in Cayes began delivering ART to 17 patients. This was the first public hospital in Haiti to provide such services, and before doing so it required an 18-month renovation project, which was led by Family Health International. PEPFAR now supports 30 treatment sites, helping around 8,000 people to access treatment in 2006.

Vietnam ($34m)

Profile:	The only Asian focus country; densely populated HIV mostly concentrated among drug users and sex workers
Adults living with HIV/AIDS (2005):	0.5%
PEPFAR funding priorities (2005):	Basic palliative care and support (24%) Condoms and related activities (18%) Antiretroviral drugs (15%)

Vietnam is a unique focus country for two reasons: it is in Asia and it does not currently have a generalised HIV epidemic. In fact, Vietnam's HIV prevalence is probably lower than that of the USA. However, rates are extremely high among sex workers and injecting drug users, and the virus is rapidly spreading to the rest of the population. If prevention campaigns are not given top priority then the number of Vietnamese living with HIV could explode from the total of 260,000 in 2005.

PEPFAR's prevention efforts consist of promoting abstinence and fidelity through programmes based in schools and workplaces, and targeting other campaigns at high risk groups. The latter includes encouraging condom use, injection safety and prevention of mother-to-child transmission. PEPFAR will not support needle exchanges, but it is helping to develop pilot schemes to support HIV-positive drug users as they leave rehabiliation centres.

The proportion of funds allocated to antiretroviral treatment is relatively small; around 3,700 people benefited from site-specific support for treatment provision in 2006 (up from 700 in 2005).

Management Sciences for Health was obligated more than $6 million for work in Vietnam in 2006.