The President's Emergency Plan for AIDS Relief (PEPFAR) has saved and improved millions of lives worldwide and offered proof that HIV/AIDS services can be effectively delivered on a large scale even in countries with high rates of disease and resource constraints, says a new congressionally mandated evaluation conducted by the Institute of Medicine.
Moving forward, PEPFAR needs to intensify efforts to help its partner countries develop the capacity to manage their own programs, sustain the gains that have been made in controlling the HIV epidemic, and improve their citizens' access to services, said the committee that wrote the report.
Even with PEPFAR's substantial contributions to the global scale-up of HIV/AIDS services, many needs remain, the report notes, and future progress will require partner countries and donors to work together to make difficult but necessary decisions on how to allocate finite resources. As PEPFAR increases its focus on fostering countries' ability to take on greater long-term responsibility, results may not occur as rapidly or dramatically as in the past, the committee cautioned.
"During our visits to partner countries, we repeatedly heard PEPFAR described as a lifeline," said committee chair Robert Black, chair, department of international health, Johns Hopkins Bloomberg School of Public Health, Baltimore. "People credit the initiative with restoring hope. As it moves forward, PEPFAR must continue to be bold in its vision, implementation, and global leadership."
PEPFAR was established in 2003 through legislation that authorized $15 billion for HIV/AIDS and other related global health issues over five years. In 2008, the legislation was reauthorized, providing up to $39 billion through 2013 for PEPFAR bilateral HIV/AIDS programs as well as U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. PEPFAR has supported HIV/AIDS programs in over 100 countries, with the largest share of the investment currently in 33 partner countries. As part of the reauthorization, Congress requested that IOM evaluate various aspects of the initiative, a task that IOM's international committee of experts carried out through visits to 13 partner countries as well as the review of volumes of documentation and data. IOM previously evaluated PEPFAR in its initial implementation phase and issued a report in 2007.
Overall, PEPFAR has reset the world's expectations for what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis, the committee concluded. Working with a wide range of international and local partners, PEPFAR has expanded HIV testing and increased the number of people living with HIV who are receiving care and being treated with antiretroviral drugs. The initiative has trained hundreds of thousands of service providers, strengthened partner countries' health systems, provided additional nonclinical support services for people living with HIV, and made an unprecedented investment in programs for orphans and vulnerable children living with or affected by HIV.
PEPFAR has successfully increased services to prevent HIV transmission from mothers to their children during pregnancy and birth. The initiative has become increasingly flexible over time in its approach to other prevention strategies, and it has achieved positive results by supporting data collection to better understand the factors driving the epidemic in each country and scaling up prevention programs for the general population and for populations at elevated risk. However, greater attention to a range of prevention strategies is needed, the report says. In particular, countries need to increase the focus on prevention of sexual transmission, which is responsible for the majority of new infections. PEPFAR should lead the way by supporting innovations in strategies to decrease risk factors that contribute to HIV transmission.
The committee underscored the importance of partner countries receiving support to take on greater responsibility for and management of their own HIV/AIDS programs. In recent years, PEPFAR has begun providing less direct support and more technical assistance and support for strengthening partner countries' health systems and capacity to lead their efforts, a shift that the report deems reasonable and appropriate. PEPFAR's guidance should reorient from prescribing specific activities to outlining key outcomes and enabling partner countries to determine how to prioritize their efforts to achieve these outcomes.
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