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What is PEPFAR?

George W Bush signs the PEPFAR initiative, 2003

The President's Emergency Plan for AIDS Relief, also known as PEPFAR, is America's initiative to combat the global HIV/AIDS epidemic and is now part of the Global Health Initiative.

Since 2004 PEPFAR has committed more than $30 billion to funding for the AIDS epidemic. 1 PEPFAR continues to represent the largest financial commitment by a single country to responding to HIV and AIDS worldwide.

So what has PEPFAR achieved so far and what does it aim to achieve in the future? Why has PEPFAR caused controversy and how has it changed since it was first implemented?

PEPFAR and the Global Health Initiative

The creation of PEPFAR

In 2003, despite the availability of antiretroviral therapy, very few people with HIV/AIDS were receiving treatment for HIV in the poorer parts of the world. The situation was regarded as a serious health and human rights crisis. In light of this, former President George W. Bush made a commitment to substantially increase US support for addressing HIV and AIDS worldwide. 2

"I ask the Congress to commit $15 billion over the next five years, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean" - President George W. Bush

In May 2003, the US Congress approved a five-year, $15 billion programme that launched the 'US Global AIDS initiative'. 3 However, the initiative soon became known by the name of its five-year strategy presented to Congress in 2004, 'the President's Emergency Plan for AIDS Relief' or PEPFAR. Although the act incorporates funding for other diseases, its main focus is HIV/AIDS and it has often been referred to as the "largest commitment by any nation to a single disease in history". 4

Full implementation of PEPFAR began in June 2004. PEPFAR was reauthorised for a further five years in July 2008. 5 The years 2004-2008 are now sometimes referred to as 'PEPFAR I' while the term 'PEPFAR II' is used to refer to PEPFAR after it was renewed in 2008. The distinction arises from various changes introduced when it was renewed and changes that have occurred since then, which have transformed PEPFAR from what it was in its initial five years. 6

There are several differences evident in the 2008 reauthorisation act compared to the original act signed by President Bush in 2003. These include; a commitment to address multiple concurrent partnerships as a way of preventing new infections; accountability measures that demonstrate the positive impact of PEPFAR programmes on women and girls; and a greater focus on TB, including specific TB goals and the creation of a TB strategy. 7

Creation of the Global Health Initiative

Among the main criticisms of PEPFAR and US global health assistance have been the lack of coordination between health programmes in partner countries, a need for greater focus on the sustainability of health programmes, and a lack of partner country involvement. 8 9

Just a few months after PEPFAR was reauthorised in 2008, the Obama administration announced a new approach to the US government's delivery of its health assistance worldwide, which seemed designed to address these criticisms. 10 Termed 'the Global Health Initiative' or GHI, it provides a framework for increased coordination of strategies related to health and development in the more than 80 countries which receive US aid for health. One of the main rationales behind the Global Health Initiative is to provide a set of overall guiding principles. 11 These include:

  • A focus on women, girls and gender equality
  • Integration between health programmes with an emphasis on overall health systems strengthening
  • Greater coordination with other organisations such as multilateral organisations like the Global Fund and the private sector.
  • Promotion of country ownership by involving country leadership in the planning and implementation of PEPFAR funded health programmes.

PEPFAR's role within the Global Health Initiative

PEPFAR is often referred to as the 'cornerstone of the GHI', due to the large share of the funding it receives. In 2010, for example, it received 77 percent of US global health funding. Over the six-year period of the GHI, it has been estimated that 70 percent of the GHI budget will go to PEPFAR, or $51 billion over six years. 12 Activists have criticised President Obama for this, claiming that he has reneged on his campaign promise to provide $50 billion over 5 years. 13

PEPFAR's Phase II five-year (2009-2013) strategy is also reflective of the principles of the GHI outlined above. 14 The strategy aims to change PEPFAR's focus from the rapid scale up of treatment which characterised Phase I as 'an emergency response' to a new focus on sustainability and greater country involvement. PEPFAR's Phase II prevention, care and treatment targets are also incorporated into the GHI's broader health targets.

How PEPFAR works


The administration of PEPFAR takes place within the Department of State, which is responsible for America's foreign affairs. 15 Within the Department of State, PEPFAR is coordinated by the Office of the US Global AIDS Coordinator (OGAC) which provides the strategic direction for all of PEPFAR's activities, approves activities and workplans, and ensures that monitoring and evaluation efforts are carried out. Dr Deborah Birx was appointed US Global AIDS Coordinator in April 2014. 16

Each country in which PEPFAR operates has a PEPFAR country 'field' team, made up of representatives from various US agencies. Although the OGAC is responsible for overseeing the implementation of PEPFAR and coordination of the agencies involved, a variety of US government agencies, such as USAID (US Agency for International Development) and HHS (Department for Health and Human Services) carry out PEPFAR activities on a day-to-day basis.

Focus countries

PEPFAR works in over 30 countries around the world. 17 However, when PEPFAR first began 15 countries were designated as 'focus countries'. 18

Botswana, Cô te d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia.

These countries were selected as they were seen as the 'most severely affected,' and have been assigned the majority of the funding. 19

CountryFY 2004 ($millions)FY 2005 ($millions)FY 2006 ($millions)FY 2007 ($millions)FY 2008 ($millions)FY 2009 ($millions)FY 2010 ($millions)
Côte d'Ivoire24.344.446.684.4120.5124.8119.1
South Africa89.3148.2221.5397.8590.9561.3560.4

PEPFAR continues to work in the focus countries but has broadened its engagement with other countries.

Partnership frameworks

Partnership frameworks, initiated in 2008, embody some of the major changes in the move from 'Phase I' to 'Phase II' of PEPFAR. With partnership frameworks, PEPFAR aims to more closely involve national governments and all other stakeholders (such as civil society and the private sector) in the planning, funding and implementation of the country's HIV/AIDS programmes. As such, the partnership framework should be fully in line with national HIV/AIDS strategy of the country. 20

Although Phase II of PEPFAR aims to be driven by the priorities of national governments, this does not indicate the transition to a funding structure like that of the Global Fund where funds are channelled directly to national governments. A $130 million project, the Medical Education Partnership Initiative (MEPI), coordinated by the HHS and PEPFAR, is an example of the way PEPFAR will seek to realise the goals outlined in its five-year strategy. 21 MEPI will award grants to US medical schools (its prime partners) who will identify and partner with African medical institutions. This partnership is designed to help realise PEPFAR's five-year target to train 140,000 healthcare workers in the region.

“Partnership frameworks embody some of the major changes in the move from 'Phase I' to 'Phase II' of PEPFAR”

The development of a partnership framework is led by the US ambassador in the partner country and PEPFAR's interagency field staff. However, the national government, members of civil society, multisectoral and international organisations, and any private sector actors that the government wishes to include are also involved.

The framework fits with PEPFAR's aim to move away from implementing programmes to providing technical assistance. This is in line with the stated overarching aim of Phase II of PEPFAR; increasing the sustainability of programmes and ensuring that countries are more capable of leading and implementing HIV/AIDS programmes after the five-year strategic framework comes to an end. 22

However, despite this emphasis on a 'country owned' strategy, it is still PEPFAR's field agency teams that are responsible for making sure that the partnership frameworks also achieve PEPFAR's own treatment, prevention and care targets as defined within PEPFAR's five-year strategy.

As of January 2011, twenty partnership frameworks had been signed. 23

Country operational plans

A country operational plan or COP is a detailed workplan that must be submitted by PEPFAR field staff to the OGAC for approval. They include a breakdown of the programme areas that need to be addressed by the PEPFAR team, a delegation of tasks to partners, and detail relating to the funding for each partner and programmatic area. 24 COPs have been criticised for being time consuming for all staff involved and of 'shutting off' operations for the two months during which the COPs are written. 25 However, a study looking at three main recipients of PEPFAR aid (Zambia, Mozambique and Uganda) found that, following the completion of the COP, funding is quickly and efficiently disbursed to partners with minimal bureaucracy. 26

PEPFAR funding and the funding process

How much is made available?

It is estimated that from 2003 to 2008 $18.8 billion was committed to PEPFAR by Congress, exceeding the original $15 billion first pledged. 27 This amount included commitments to the Global Fund, UNAIDS, International AIDS Vaccines Initiative (IAVI) and NIH research as well as all PEPFAR' bilateral country and regional programmes for HIV/AIDS and TB. It did not include funding for malaria.

Then in 2008, a further $48 billion was committed to PEPFAR over a five-year period. 28 This includes $39 billion for PEPFAR's bilateral HIV/AIDS programmes and U.S contributions to the Global Fund, $5 billion to the president's Malaria Initiative and $4 billion for TB.

The total funding granted for PEPFAR in FY2010 for HIV/AIDS, TB and the Global Fund was $6.8 billion. 29 It has been claimed that funding for 2009-2010 was effectively flat-lined in contrast to the much higher previous year-on-year increases in funding, especially from 2006-2009. 30 31 President Obama's proposed 2011 budget included almost $7 billion for PEPFAR, representing a 1.8 percent increase on the previous year. However, according to some activists this slight increase actually represents a 'step backwards' due to inflation and increasing demand for treatment. 32

The FY2011 budget included a 5 percent ($50 million) decrease in funding to the Global Fund compared to the previous year. 33 However, the US continues to represent the largest contribution to the Global Fund (representing on average more than a quarter of the Global Fund's budget every year). 34

How is the money spent?

The expenditure of money is coordinated by the Office of the Global AIDS Coordinator's (OGAC), but is distributed through a number of government agencies. Most money goes to USAID and Health and Human Services (HHS). 35 Within HHS a number of different agencies are involved including the Centers for Disease Control and Prevention (CDC), the Health Resource and Services Administration (HRSA), and the National Institute of Health (NIH). HHS manages the regional funding for providing care and antiretroviral therapy for HIV positive people, and prevention activities through safe blood programmes. USAID manages the regional funding for orphans and vulnerable children (OVC) and for 'behaviour change through abstinence and being faithful'. 36


Prime partners

Organisations and governments that receive PEPFAR money directly from a U.S. government agency (for example the State Department, USAID, the CDC etc.) are known as 'prime' partners. These have traditionally been large international NGOs, universities and private foundations. 37


Prime partners may grant money to other organisations, who are then known as sub-partners. These are generally more local or community-based organisations. PEPFAR has been criticised for traditionally not supporting enough community organisations. In 2008, a report published previously unreported data obtained through the Freedom of Information Act. 38 The report revealed that from 2004-2006 most funds went to international NGOs, and local community based organisations were found to have received on average only 11 percent of PEPFAR funds over this period.

However, it has been suggested that this is because in its first few years, PEPFAR sought to rapidly scale up treatment services and was therefore unwilling to engage with those organisations with less capacity to monitor and evaluate funds. In recent years, the number of indigenous organisations that PEPFAR supports has increased. 39 It is expected that the new partnership frameworks which emphasise greater government ownership will lead to greater investment of PEPFAR funds into smaller local organisations.

PEPFAR now provides information on the amount obligated to prime partners but information on what is obligated to sub partners by programme area is still not made available publicly.

Regional funding

PEPFAR money is given to Country Teams (US teams implementing PEPFAR in the focus countries), as well as regional funding mechanisms which service more than one country. These regional programmes receive their funding directly from the US agency in Washington D.C which is responsible for their coordination. They are therefore more centralised than the funding managed by the country teams. 40 Examples of central programmes are the Abstinence and Be Faithful programme, the Blood Transfusion Safety programme and the Supply Chain Management system.

The Supply Chain management system (SCMS) is a multiregional programme coordinated by USAID with the aim of providing an uninterrupted supply of high quality, low cost products such as antiretroviral drugs to PEPFAR's HIV/AIDS and TB programmes. 41 One of the SCMS' stated 'key strategies' is to improve a country's supply chains, and not build a parallel system. 42 One way it seeks to do this is by creating regional warehouses for the distribution of drugs. However, despite this commitment the SCMS has been criticised for not involving local partners enough. 43 The need for greater independent monitoring of the SCMS to ensure that it strengthens local and national systems of procurements has also been identified. 44

PEPFAR funding restrictions

Funding earmarks

Protesters advocating reform of PEPFAR

Restrictions placed on the way that PEPFAR’s prime partners and sub-partners spend the funds allocated to them have been a source of controversy since the start of PEPFAR.

From 2006-2007 it was required that 55 percent of funding was spent on treatment, 15 percent on palliative care, 10 percent on orphans and vulnerable children and 33 percent of prevention funds were spent on promoting abstinence until marriage. 45

These earmarks must be written into country operational plans but can be waived if a country’s PEPFAR team submits a report to the OGAC outlining the reasons for the waiver. A report examining PEPFAR in three countries (Mozambique, Uganda and Zambia) found that neither had adhered to the 55 percent treatment earmark. 46 However, they had similar funding allocations across programme areas (i.e. treatment, care and prevention) regardless of their country’s specific epidemic, which the report concluded was probably due to the earmarks. The 2008 authorisation is more flexible, requiring 50 percent to be allocated for treatment and care overall. 47

The focus on abstinence has resulted in a lot of criticism from diverse groups; such as HIV Medicine Association (HIVMA) and the Infectious Diseases Society of America (IDSA) and non-governmental organisations such as ActionAid International, CARE and the Elizabeth Glaser Pediatric AIDS Foundation and the EU. 48 49  50

PEPFAR partners have revealed that the funding restriction has constrained the work they carry out.

"There are perceived restrictions in PEPFAR about what you can discuss with whom, so everyone is being very cautious... People are afraid to discuss family planning, condoms, abortion - so many groups don't address them at all." 51

A study of the impacts of PEPFAR in Zambia found that several PEPFAR funded organisations had not only stopped promoting condoms, but had eliminated any reference to condoms in their programmes out of fear that they would lose their funding. The programme implementers believed that these measures were required by PEPFAR. 52

In the US, the Government Accountability Office released a report in 2006 that illustrated the difficulties PEPFAR country teams faced in implementing the spending requirements. 53 Some said they had to scale down efforts to prevent mother-to-child transmission ( PMTCT) or to improve blood safety in order to try to meet the one-third 'Abstinence and Be Faithful requirement', and many said that not enough emphasis was being placed on condoms.

When PEPFAR was re-authorised in 2008, the 10 percent spending for Orphans and Vulnerable Children (OVC) was maintained and the abstinence until marriage directive was removed. 54 However, PEPFAR still emphasises abstinence and fidelity in prevention efforts. A report must be sent to Congress “if less than half of prevention funds go to abstinence, delay of sexual debut, monogamy, fidelity and partner reduction in any host country with a generalised epidemic.” 55 Although this is not the same as the ‘abstinence until marriage’ directive, concerns have been voiced that this clause still limits the use of prevention funds, is confusing and could continue to hinder evidence based prevention efforts. 56 However, others have argued that this requirement is more flexible than the previous directive and represents a compromise. 57

Previous funding restrictions

Anti-prostitution loyalty oath

June 2013 saw an end to the funding restriction against organisations that do not explicitly state they oppose prostitution. Previously, PEPFAR refused support to organisations that would not denounce sex work. 58

For 10 years, the "Leadership" act of 2003 stated that: "No funds made available to carry out this Act, or any amendment made by this Act, may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking". 59

Over the years, various NGOs and health experts have spoken out about the harmful effects of the pledge. 60 61 The U.S. Supreme Court found that the Leadership Act violates free speech, and forms barriers between groups at risk of HIV infection (sex workers) and HIV prevention programmes. 62

Abortion and family planning

The 'Global Gag Rule', or 'Mexico City Policy', denies US international family planning funding to foreign non-governmental organisations that work on safe abortion issues. Although President Bush exempted PEPFAR from this, there remained confusion surrounding PEPFAR support for family planning services and this is thought to have caused a significant obstacle to the integration of HIV prevention with reproductive health services. 63 President Obama rescinded the Global Gag Rule after assuming office in January 2009, hopefully ending any confusion over whether organisations with particular abortion policies could receive PEPFAR funding.

The 2008 reauthorisation act, like the 2003 act, does not specifically mention family planning. However, there is a clear difference between the current guidance for family planning provided by PEPFAR and that provided before 2010. The latest guidance reflects PEPFAR’s aim to integrate health services and states that family planning “is an important component of the preventive care package of services for people living with HIV/AIDS and for women accessing PMTCT services”. 64 However, PEPFAR has been criticised for ignoring the need for greater funding and thereby comprising the ability of organisations to ‘meaningfully’ integrate HIV and family planning services. 65

Needle and syringe exchange

PEPFAR's First Annual Report (2003) stated that, "Emergency Plan funds will not support needle or syringe exchange". 66 However, in July 2010, PEPFAR reissued guidance for HIV prevention for injecting drug users (IDUs). 67 The new guidance actively encourages a "comprehensive HIV prevention package" for IDUs including needle and syringe programmes and harm reduction strategies previously disallowed under PEPFAR. According to the revised guidance, "needle exchange and syringe programs (NSPs) do not increase the numbers of persons who begin to inject drugs or increase the frequency of drug use" and "studies have shown that NSPs result in marked decreases in drug-related risk behaviour".

PEPFAR targets and achievements

Children affected by AIDS in Mozambique show support for PEPFARAfter its first five years came to an end in 2008, PEPFAR was described as the “largest and most successful bilateral HIV/AIDS program ever.” 68

In its first year progress was slow but in 2005, once PEPFAR had been fully implemented, rapid results began to be seen with regards to access to HIV treatment.

By the end of September 2008 (the end of Phase I) PEPFAR claimed to be supporting treatment for over 2.1 million people around the world, exceeding its 2 million target. 69 Treatment figures in some countries, however, fell short of their intended targets. In Nigeria, for example, 211,500 people were receiving treatment by the end of September 2008 compared to the goal of 350,000. The number on treatment in Ethiopia fell short of the 210,000 target by over 90,000. 70

However, in many cases PEPFAR provides only part of the support needed to enable people to access treatment. For example, in 2007 the Global Fund claimed to have supported treatment for around 864,000 people in the fifteen focus countries, but as the US government believed that the vast majority of these people also received some support from PEPFAR, most of these people were counted by both organisations. 71

PEPFAR's numbers include not only those assisted through site-specific support of treatment centres, but also those supported by PEPFAR through contributions to national, regional or local "system strengthening" (including such activities as staff training, laboratory support, logistics, and curriculum development). Of the 1.64 million on treatment in March 2008, some 1.29 million (79%) received direct, site-specific support. 72 In an effort to more accurately express the indirect support that PEPFAR provides and to reflect its greater investment in 'technical' assistance, PEPFAR has provided data on this indirect support through a set of 'national' health indicators since 2009. 73 The aim of these indicators is to quantify PEPFAR's role in strengthening national health programmes and distinguish this from direct, site-specific support.

With regards to prevention, PEPFAR began to measure its achievements in 2010 using US Census Bureau statistical models of country prevalence trends. 74 To date, the only estimates of prevented infections are those averted through the prevention of mother-to-child transmission ( PMTCT). It is estimated that almost 240,000 infant infections were averted over PEPFAR’s first five years. 75

The latest targets included in the second 5-year strategy (Phase II) include: 76

  • Providing direct support for more than 4 million people on treatment
  • Preventing 12 million new HIV infections
  • Providing care for 12 million people living with or affected by HIV/AIDS
  • Providing at least 80 percent of HIV positive pregnant women with treatment to prevent mother-to-child transmission
  • Training at least 140,000 new health care workers

"In FY 2010 and beyond, PEPFAR is less likely to continue scale up of treatment programs in Phase 2, particularly through provision of direct support, at the same pace as in Phase 1, in part because of the significant costs of maintaining treatment for those already support" 77




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