History[edit]
PEPFAR began with President George W. Bush and his wife, Laura, and their interests in AIDS prevention, Africa, and what Bush termed “compassionate conservatism.” According to his 2010 memoir, Decision Points, the two of them developed a serious interest in improving the fate of the people of Africa after reading Alex Haley’s Roots, and visiting The Gambia in 1990. In 1998, while pondering a run for the U.S. presidency, he discussed Africa with Condoleezza Rice, his future secretary of state; she said that, if elected, working more closely with countries on that continent should be a significant part of his foreign policy. She also told him that HIV/AIDS was a central problem in Africa but that the United States was spending only $500 million per year on global AIDS, with the money spread across six federal agencies, without a clear strategy for curbing the epidemic.[6]
The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003[7] (or the Global AIDS Act) specified a series of broad and specific goals, alternately delegating authority to the president for identifying measurable outcomes in some areas, and specifying by law the quantitative benchmarks to be reached within discrete periods of time in others. The legislation also established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming.
PEPFAR continues to be a cornerstone of U.S. global health efforts. On April 4, 2014, Ambassador Deborah L. Birx was sworn in as United States Global AIDS Coordinator.[8] She held the position until January 2021 when Angeli Achrekar filled the Acting role, from being Principal Deputy.[9]
In May 2022, Dr. John N. Nkengasong was confirmed by the U.S. Senate as the U.S. Global AIDS Coordinator and was officially sworn in on June 13, 2022. A little over a year later, Ambassador Nkengasong joined U.S. Secretary of State Anthony J. Blinken to launch State Department’s Bureau of Global Health Security and Diplomacy (GHSD) August 1, 2023, which he leads. [10]
In December 2014, PEPFAR announced a program PEPFAR 3.0 focusing on Sustainable Control of the AIDS epidemic. This program was designed to address the UNAIDS "90-90-90" global goal: 90 percent of people with HIV diagnosed, 90 percent of them on ART and 90 percent of them virally suppressed by the year 2020.[11]
Focus countries[edit]
When PEPFAR was signed into law 15 resource-limited countries with high HIV/AIDS prevalence rates were designated to receive the majority of the funding. The 15 "focus countries" were Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. Most of the $15 billion for the program was to be spent on these focus countries, $4 billion was allocated for programs elsewhere, and for HIV/AIDS research (the other $1 billion was contributed to the Global Fund).
With the reauthorization of PEPFAR in 2008 there was a shift away from the "focus country" approach by authorizing the development of a Partnership Framework model for regions and countries, with the aim of ensuring long-term sustainability and country leadership. Through bilaterally-funded programs, PEPFAR works in partnership with host nations to support treatment, prevention and care for millions of people in more than 85 countries. Partnership Frameworks provide a 5-year joint strategic framework for cooperation between the U.S. Government, the partner government, and other partners to combat HIV/AIDS in the host country through service delivery, policy reform, and coordinated financial commitments.See the PEPFAR World Wide Activities Map and PEPFAR Dashboard.
The results of the program include:
The U.S. is the first and largest donor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. To date, the U.S. has provided more than $7 billion to the fund.
Of the estimated 8 million individuals in low- and middle-income countries who currently receive treatment, nearly 6.8 million receive support through PEPFAR bilateral programs, the Global Fund, or both.
There is additional evidence in the published literature that funding towards PEPFAR vis-a-vis antiretroviral therapy also affirmed maternal and child health in addition to HIV treatment outcomes[28][29]
Accountability and funding[edit]
PEPFAR reports to Congress on an annual basis, providing programmatic and financial data as required by law. The Fourteenth Annual Report to Congress on the President's Emergency Plan for AIDS Relief is available on the official PEPFAR website,[30] as are more specific reports, financial information and other information.
Global AIDS funding is provided in the Foreign Operations and Labor, Health and Human Services appropriations bills, which, if the process goes smoothly, are agreed to by the House and Senate in advance of the federal fiscal year beginning October 1. The Office of the Global AIDS Coordinator (OGAC) budgets according to the allocations provided by Congress and the policy of the Administration. Funding figures by program are reported to Congress by the Office of the Global AIDS Coordinator.
For FY 2013, President Obama requested $6.42 billion, including more than $4.54 billion for bilateral HIV/AIDS programs and $1.65 billion for the Global Fund. For FY 2014, President Obama requested $6.73 billion, including more than $4.88 billion for bilateral HIV/AIDS programs and $1.65 billion for the Global Fund.[31]
PEPFAR was exempt from the Mexico City Policy.[32]
Funding data[edit]
Annual data on the PEPFAR budget, spending by budget code, and impact estimates are available online at PEPFAR Panorama Spotlight. Funding amounts to specific in-country implementing mechanisms and partners are only available for the year 2013 onward.
In 2008, funding data was obtained by the Center for Public Integrity from PEPFAR's own information system COPRS. The data were obtained after CPI sued the U.S. State Department to gain access to the data. The data were analyzed by the HIV/AIDS Monitor team at the Center for Global Development, who also share the full dataset.