The President's Emergency Plan for AIDS Relief (PEPFAR) provides assistance for combating HIV/AIDS in 15 focus countries and elsewhere, with global targets for prevention, treatment, and care. The U.S. Leadership Against HIV/AIDS, TB and Malaria Act of 2003, which authorizes the $15 billion program, contains directives to guide the Office of the U.S. Global AIDS Coordinator's (OGAC) allocation of this funding. The act expires in September 2008. The President announced his intention to ask Congress to authorize $30 billion for these efforts for the next 5 years. In 2007, the Institute of Medicine (IOM) recommended eliminating the directives. GAO was asked to describe (1) the views of HIV/AIDS experts on these directives, (2) an alternative approach to allocating funds, and (3) potential challenges related to this approach. GAO interviewed 22 experts, surveyed PEPFAR officials in the 15 focus countries, and reviewed pertinent documentation.

HIV/AIDS experts recognized that the Leadership Act's spending directives have ensured funding for prevention and treatment. However, many expressed concern about a directive to spend 33 percent of prevention funding on activities promoting abstinence and fidelity. Overall, the experts advocated replacing PEPFAR's current allocation process--based on the spending directives--with an approach based more on country-level data and needs. Experts also advocated that OGAC continue providing guidance and technical assistance to PEPFAR country teams. An alternative approach to allocating PEPFAR funds would include three elements of the current allocation process--setting targets, selecting interventions, and considering costs--but give country teams more responsibility for planning PEPFAR programs. OGAC would retain its leadership role, including reviewing and approving country plans. Teams would use country-level data to propose targets, and OGAC would work with teams to ensure these targets align with PEPFAR's global targets. Teams would select interventions to meet the proposed targets, without the constraints of spending directives but subject to OGAC review. Teams would consider country-specific data on interventions' costs using a consistent, OGAC-defined methodology; teams currently identify and analyze costs in varying ways. OGAC has not provided formal guidance or a methodology for identifying and analyzing costs, in contrast to federal standards that call for use of consistent methodologies to develop cost information. Most country team officials surveyed reported that the alternative approach to allocating funds would be feasible. However, some officials noted that reaching consensus on targets with external partners and within country teams could be a challenge. Officials also noted some ongoing challenges--including lack of host country capacity and limited cost data--that they would likely continue to face in implementing the alternative approach.

Status Legend:

Review Pending-GAO has not yet assessed implementation status.

Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.

Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.

Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.

• Review Pending
• Open
• Closed - implemented
• Closed - not implemented

Matter for Congressional Consideration

Matter: If Congress decides to remove the spending directives as IOM recommended, Congress may wish to encourage OGAC to adopt a more country-based and evidence-based approach to allocating funding, with OGAC providing overall leadership and guidance for setting country-specific targets, selecting interventions, and considering costs, as discussed in this report.

Status: Review Pending

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation for Executive Action

Recommendation: To help ensure that PEPFAR country teams are better able to provide consistent and accurate cost estimates to OGAC, the Secretary of State should direct OGAC to provide appropriate guidance to PEPFAR country teams for identifying and using cost-related information in planning and budgeting PEPFAR programs.

Agency Affected: Department of State

Status: Review Pending

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.