The U.S. Global AIDS Initiative is working in more than 120 countries around the world, but concentrates resources in 15 focus countries so as to have an impact on their epidemics at the national level.1 The scope of this evaluation is limited to the implementation of PEPFAR in the focus countries and does not include the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is also overseen by the Coordinator. Although direct evaluation of the Leadership Act was beyond its scope, the Committee examined and reached conclusions about factors that appeared to be having a pronounced effect on the implementation of PEPFAR, some of which have their roots in the legislation.

PEPFAR’s 5-year performance targets for the focus countries are to support the prevention of 7 million HIV infections; treatment for 2 million people with HIV/AIDS with antiretroviral therapy (ART); and care for 10 million people infected with and affected by HIV/AIDS, including orphans and other vulnerable children (United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st Sess.; OGAC, 2004). The Committee intended its evaluation to be appropriate for a program early in its implementation, and to provide insight into whether PEPFAR is making reasonable progress toward meeting these targets and positioning the U.S. Global AIDS Initiative to achieve the ultimate goal of the Leadership Act—sustainable gains against the HIV/AIDS pandemic.

At the core of the complex structure and approach of PEPFAR—which involves numerous U.S. government agencies and is centrally coordinated by the Office of the U.S. Global AIDS Coordinator (OGAC), but implemented by the U.S. teams in the focus countries (Country Teams)—is the U.S. commitment to the principles of harmonization (The Rome Declaration, 2003; UN, 2003; Tobias, 2003a, 2004; UNAIDS, 2004a; OGAC, 2005a; The Paris Declaration, 2005). The central tenet of harmonization is that sustainable gains against the HIV/AIDS pandemic will require that each country own and lead its response to its epidemic. The role of donors is to support and participate in the three country-determined elements critical for an effective response—one national AIDS plan, one national AIDS coordinating mechanism, and one national AIDS monitoring and evaluation framework (UNAIDS, 2004a). Therefore, the Committee evaluated the implementation of PEPFAR primarily through the lens of harmoniza-

1

The 15 focus countries are the Republic of Botswana, the Republic of Côte d’Ivoire, the Federal Democratic Republic of Ethiopia, the Cooperative Republic of Guyana, the Republic of Haiti, the Republic of Kenya, the Republic of Mozambique, the Republic of Namibia, the Federal Republic of Nigeria, the Republic of Rwanda, the Republic of South Africa, the United Republic of Tanzania, the Republic of Uganda, the Socialist Republic of Vietnam, and the Republic of Zambia. With the exception of Vietnam, these countries are named in the Leadership Act.



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