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Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding

GAO-08-480 Published: Apr 02, 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.


Matter for Congressional Consideration

Matter Status Comments
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.
Closed – Implemented
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.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of State 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.
Closed – Implemented
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

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AIDSAllocation (Government accounting)Appropriated fundsBudget outlaysCost analysisDisease controlDisease detection or diagnosisDisease surveillanceFederal aid to foreign countriesForeign aid programsHealth care programsInfectious diseasesInternational cooperationInternational relationsProgram evaluationStrategic planningCost estimates