U.S. Government's AIDS Relief Program Receives High Marks

National Research Council/U.S. National Academies

A massive report released today by the Institute of Medicine (IOM) has high praise for President's Emergency Plan For AIDS Relief (PEPFAR), the U.S. government's 10-year-old effort to help 31 "partner countries" treat their HIV-infected people and slow the spread of the virus. The report also challenges PEPFAR to better monitor the impact of its assistance, more aggressively promote prevention efforts, and develop a "comprehensive plan" to help partner countries sustain the response with their own resources.

The evaluation of PEPFAR—which stands for the President's Emergency Plan for AIDS Relief—runs 680 pages and took a 20-person committee 4 years to complete. "A committee of very diverse experts concluded that PEPFAR has been a tremendously successful effort of the U.S. government," says committee member Jennifer Kates, director of Global Health & HIV Policy at the Henry J. Kaiser Family Foundation in Washington, D.C. "It's very powerful."

The report says PEPFAR has "played a transformative role" with its contribution to the global response to HIV. And the committee members, who visited 13 partner countries and conducted some 400 interviews, stressed that they repeatedly heard gratitude and appreciation for the program, which disbursed $21.8 billion in aid between 2004 and 2010. "PEPFAR was described as a lifeline, and people credit PEPFAR for restoring hope," the report states. More than 3 million people were receiving antiretroviral drugs in fiscal year 2010 because of PEPFAR support. (The report does note that this number has some overlap with treatment provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria.) An estimated 600,000 HIV-infected pregnant women received antiretrovirals through PEPFAR to prevent transmission of the virus to their babies.

Congress mandated that IOM conduct this evaluation, which follows a similar report completed in 2007. The mandate did not ask IOM to compare PEPFAR's activities in different countries. Yet the IOM committee clearly had concerns that "in

some countries there are still challenges related to governance and management capacity for the maintenance and sustainability of the HIV/AIDS response." The report also notes great disparities in how much money PEPFAR spends per HIV-infected person in partner countries. At the low end of the scale, Zimbabwe has greater than 10% prevalence of HIV and only receives $25 per infected person from PEPFAR; in contrast, Guyana, which has an HIV prevalence below 10%, receives $3842 per infected person.

In the 2007 report, the IOM committee criticized Congress for creating "rigid budgetary allocations" that directed PEPFAR to generously support abstinence-only education, limit the provision of condoms, and ban needle-exchange programs. Congress removed these limitations when it reauthorized PEPFAR in 2008, and the new report notably makes no recommendations that require congressional action. Instead, PEPFAR itself can act on all the new recommendations.

Now, PEPFAR has funding through 2013, and some HIV/AIDS advocates worry that Congress might cut its support. Committee members stressed at a press conference today that it operated independently and did not set out to influence this debate. But Kates does hope that the report will help educate the new generation elected to Congress and their staff members, she told ScienceInsider. "There are a small number of people who were there during the first two authorizations," Kates says. "I realize that 680 pages is a lot, but there's a lot there. [PEPFAR is] a really great example of how you can deliver development assistance."