Global HIV/AIDS:

A More Country-Based Approach Could Improve Allocation of PEPFAR Funding

GAO-08-480: Published: Apr 2, 2008. Publicly Released: Apr 28, 2008.

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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.

Matter for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25) requires that President's Emergency Plan for AIDS Relief (PEPFAR) spend at least 33 percent of funds for the prevention of HIV/AIDS on abstinence-until-marriage programs. In April 2006, GAO reported that this spending requirement presented challenges for country teams that manage PEPFAR in the field (GAO-06-395). GAO suggested that Congress consider information from the Office of the Global AIDS Coordinator (OGAC) on the spending requirement's effect on country teams' efforts to prevent sexual transmission of HIV and use this information to assess the extent to which the spending requirement supports the Leadership Act's endorsement of the ABC model (abstain, be faithful, or use condoms) and strong abstinence-until-marriage programs. In April 2008, GAO reported that HIV/AIDS experts expressed concerns about the effects of the abstinence-until-marriage spending requirement on country-based and evidence-based programming (GAO-08-480). In the event that Congress removed PEPFAR's spending directives, GAO suggested that Congress encourage OGAC to adopt a more country-based and evidence-based approach to allocating funds. In July 2008, the President signed the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act (H.R. 5501) into law. The act reauthorizes PEPFAR for another 5 years. It removes the abstinence-until-marriage spending requirement and calls for the Global AIDS Coordinator to ensure that abstinence and fidelity programs are evidence-based and country-based. After the House of Representatives passed the original version of this bill in April 2008, a press release from the House Committee on Foreign Affairs noted that the bill removed the abstinence-until-marriage spending requirement, citing recent GAO reports about the spending requirement's negative effect on PEPFAR efforts in the field.

    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.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: State's Office of Global Aids Coordinator (OGAC) agreed with our recommendation to help provide consistent and accurate cost estimates to the field by strengthening guidance for identifying and using cost information for planning and budgeting. Specifically, State noted that PEPFAR already had a number of costing models in use, including a multi-country study that was being utilized in the development of a cost projection model for use by PEPFAR country teams to estimate resource needs for treatment, and indicated that OGAC could start to distribute guidance that sets minimum standards for cost analyses and also provide options for more intensive studies by fiscal year 2010. Indeed, in our non-audit review of costing models in October 2010 (GAO-11-64), we found that OGAC had developed and deployed the PEPFAR antiretroviral therapy (ART) costing model in four countries. Additionally, in December 2011, a briefing by the PEPFAR Finance and Economics Work Group

    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


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