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Evaluation of PEPFAR Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs Implemented Under the Lantos-Hyde Act of 2008 Board on Global Health Board on Children, Youth, and Families PREPUBLICATION COPY: UNCORRECTED PROOFS

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract/Grant No. SAQMMA09M0693 between the National Academy of Sciences and the U.S. Department of State. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data or International Standard Book Number 0-309-0XXXX-X Library of Congress Catalog Card Number 97-XXXXX Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. PREPUBLICATION COPY: UNCORRECTED PROOFS

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PREPUBLICATION COPY: UNCORRECTED PROOFS

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org PREPUBLICATION COPY: UNCORRECTED PROOFS

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COMMITTEE ON THE OUTCOME AND IMPACT EVALUATION OF GLOBAL HIV/AIDS PROGRAMS IMPLEMENTED UNDER THE LANTOS-HYDE ACT OF 2008 ROBERT E. BLACK (Chair), Johns Hopkins University, Baltimore, MD JUDITH D. AUERBACH, Consultant, San Francisco AIDS Foundation, CA MARY T. BASSETT, Doris Duke Charitable Foundation, New York, NY RONALD BROOKMEYER, University of California, Los Angeles LOLA DARE, Center for Health Sciences Training, Research and Development International, Ibadan, Nigeria ALEX C. EZEH, African Population and Health Research Center, Nairobi, Kenya SOFIA GRUSKIN, University of Southern California, Los Angeles ANGELINA KAKOOZA, Makerere University College of Health Sciences, Kampala, Uganda JENNIFER KATES, Henry J. Kaiser Family Foundation, Washington, DC ANN KURTH, New York University, New York, NY ANNE C. PETERSEN, University of Michigan and Global Philanthropy Alliance, Ann Arbor, MI DOUGLAS D. RICHMAN, VA San Diego Healthcare System and University of California, San Diego JENNIFER PRAH RUGER, Yale University, New Haven, CT DEBORAH L. RUGG, United Nations Inspection and Evaluation Division, New York, NY DAWN K. SMITH, U.S. Centers for Disease Control and Prevention, Atlanta, GA PAPA SALIF SOW, Bill and Melinda Gates Foundation, Seattle, WA SALLY K. STANSFIELD, 1 Independent Consultant, Geneva, Switzerland TAHA E. TAHA, Johns Hopkins University, Baltimore, MD KATHRYN WHETTEN, Duke University, Durham, NC CATHERINE M. WILFERT, Retired, Elizabeth Glaser Pediatric AIDS Foundation, Durham, NC Consultants SHARON KNIGHT, East Carolina University, Greenville, NC JANET WITTES, Statistics Collaborative, Inc., Washington, DC KATHRYN TUCKER, Statistics Collaborative, Inc., Washington, DC Staff KIMBERLY A. SCOTT, Study Co-Director BRIDGET B. KELLY, Study Co-Director MARGARET HAWTHORNE, Program Officer LIVIA NAVON, Program Officer C. CECILIA MUNDACA, Post-Doctoral Fellow IJEOMA EMENANJO, Senior Program Associate (through January 2011) MILA GONZÁLEZ, Associate Program Officer (through August 2012) KRISTEN DANFORTH, Research Associate REBECCA MARKSAMER, Research Associate (from August 2012) KATE MECK, Research Associate COLLIN WEINBERGER, Research Associate (April 2011 through June 2012) LEIGH CARROLL, Research Assistant (from October 2011) TESSA BURKE, Senior Program Assistant (through May 2011) ANGELA CHRISTIAN, Program Associate 1 Committee member through August 2012. PREPUBLICATION COPY: UNCORRECTED PROOFS v

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WENDY KEENAN, Program Associate JULIE WILTSHIRE, Financial Associate KIMBER BOGARD, Board Director, Board on Children, Youth, and Families (from October 2011) ROSEMARY CHALK, Board Director, Board on Children, Youth, and Families (through July 2011) PATRICK KELLEY, Senior Board Director, Boards on Global Health and African Science Academy Development PREPUBLICATION COPY: UNCORRECTED PROOFS vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: PIERRE BARKER, Institute for Healthcare Improvement CHRIS BEYRER, Johns Hopkins University ANASTASIA TZAVARAS CATSAMBAS, EnCompass LLC DAVID CELENTANO, Johns Hopkins University PAUL DE LAY, Joint United Nations Programme on HIV/AIDS WAFAA M. EL-SADR, Columbia University KURT FIRNHABER, Right To Care MITCHELL H. GAIL, National Institutes of Health ROBERT GROSS, University of Pennsylvania JOHN E. LANGE, Bill & Melinda Gates Foundation CHEWE LUO, United Nations Children’s Fund JONATHON LEE SIMON, Boston University RJ SIMONDS, Elizabeth Glaser Pediatric AIDS Foundation SHOSHANNA SOFAER, City University of New York MIRIAM WERE, University of Nairobi Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Kristine M. Gebbie, Flinders University School of Nursing and Midwifery and Ann M. Arvin, Stanford University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

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Acknowledgments The committee, project staff, and consultants are deeply appreciative of the diverse and valuable contributions made by so many who assisted with this study. For information and support provided throughout the project, we thank the staff of the Office of the U.S. Global AIDS Coordinator, with particular gratitude to Paul Bouey and Tiffany Parker, who facilitated our engagement during the study, as well as staff from other PEPFAR implementing agencies. We are also grateful to the leadership of the U.S. Missions and the PEPFAR staff in the countries visited for this evaluation, whose hospitable and gracious assistance was essential to the success of our country visits. We also thank the many other individuals in the countries visited who assisted us with logistics and support during our visits. We are grateful to Eran Bendavid from Stanford University for his valuable consultation during the study. We appreciate the essential technical support provided to the project by Danielle Beaulieu, Jessica Case, Megan Somerday, Jeff Steen, and Neil Wohlford from Statistics Collaborative, Inc. We thank Kathryn Stadeli from University of California, San Diego School of Medicine for her assistance with research for the study. We also thank Megan Perez and Meredith Cantwell for their excellent work on this study as interns at the Institute of Medicine, as well as Wyatt Smith and Peter Dull, who provided temporary assistance during the project. We are grateful to Teresa Bergen and Diane Wellman for their diligent work as transcriptionists. We appreciate the creativity and effort of Jay Christian and LeAnn Locher for their design work. In addition, we convey our deep gratitude and appreciation for the hard work of the many staff in various offices of the Institute of Medicine and the National Academies who lent their support to the project. There are a number of other individuals who were crucial for the administrative and logistical success of this project. For help with scheduling and communication for the committee, we thank Sharon Abbruscato, Lola Adedokun, Philomena Agaloi, Jillian Albertolli, Michele Augustus, Nkiru Azikiwe, Anna Both, Cindy Chu, Kyle Hamilton, Jennifer Heflin, Maria Male, Sheila Mwero, Catherine Nyawire, Audrey Palix, Jessica Raback, Mary Rybczynski, Fortuna Salinas, Abir Shady, Theresa Teague, Cassie Toner, Rachel Upton, Kevin Vavasseur, Jackylene Wegoki, and Marie Young. We are also immensely grateful to Anthony Mavrogiannis and the staff at Kentlands Travel for their assistance with the complex travel needs of this project. Finally, although we cannot name them here for reasons of confidentiality, we offer our most profound thanks to the hundreds of individuals who participated in interviews and site visits as part of the evaluation data collection effort. Their generosity with their time and their willingness to share their insights were fundamental to the evaluation; it was a privilege and an inspiration to hear directly from those whose dedication and tremendous effort underlie the successes of the response to HIV globally and in PEPFAR partner countries. PREPUBLICATION COPY: UNCORRECTED PROOFS ix

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Contents PREFACE xv ACRONYMS AND ABBREVIATIONS xvii SUMMARY ............................................................................................................................................. S-1 Evaluation Approach ............................................................................................................. S-1 Evaluation Conclusions and Recommendations .......................................................................... S-2 Conclusion .............................................................................................................................. S-11 PART I: INTRODUCTION 1 BACKGROUND .........................................................................................................................1-1 Global Burden of HIV ....................................................................................................................... 1-2 History of U.S. Investment to Respond To Global HIV/AIDS................................................... 1-2 References.................................................................................................................................. 1-15 2 EVALUATION SCOPE AND APPROACH ............................................................................2-1 Congressional Charge ...................................................................................................................2-1 Planning Phase for the Evaluation ................................................................................................2-2 Interpretation of the Charge ..........................................................................................................2-3 Operational Planning Phase ..........................................................................................................2-5 Conceptual Framework for the Evaluation ...................................................................................2-6 Evaluation Methods ....................................................................................................................2-11 Overarching Evaluation Challenges and Limitations .................................................................2-15 Summation ..................................................................................................................................2-18 References...................................................................................................................................2-20 PART II: PEPFAR ORGANIZATION AND INVESTMENT 3 PEPFAR ORGANIZATION AND IMPLEMENTATION.....................................................3-1 Organization of PEPFAR at the Central/Headquarters Level.......................................................3-3 Organization of PEPFAR at the Country Level............................................................................3-8 Perspectives on Interagency Implementation .............................................................................3-10 PEPFAR Implementation in the Context of the HIV Epidemic in Partner Countries ................3-12 PEPFAR Implementation and the Policy Environment..............................................................3-15 Summation ..................................................................................................................................3-18 References...................................................................................................................................3-19 4 U.S. FUNDING FOR THE PEPFAR INITIATIVE ................................................................4-1 Introduction...................................................................................................................................4-1 PEPFAR’s Contribution Relative to Other Donors ......................................................................4-2 Overview of the PEPFAR Funding Process .................................................................................4-4 PEPFAR funding Levels and Distribution by Programs and Partners..........................................4-8 PEPFAR Funding By Country Characteristics ...........................................................................4-34 Summation ..................................................................................................................................4-51 References...................................................................................................................................4-52 PREPUBLICATION COPY: UNCORRECTED PROOFS xi

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PART III: PEPFAR PROGRAMMATIC ACTIVITY 5 PREVENTION............................................................................................................................5-1 Evolution of HIV Prevention Science...........................................................................................5-2 Overview of PEPFAR-Supported Prevention Programs ..............................................................5-4 Prevention of Sexual Transmission ..............................................................................................5-7 Prevention of Mother-to-Child Transmission.............................................................................5-24 Injection Drug Use......................................................................................................................5-33 Blood and Medical Injection Safety ...........................................................................................5-39 HIV Counseling and Testing ......................................................................................................5-40 Analysis of Prevention Impact....................................................................................................5-41 Interventions on the Horizon for Prevention Strategies..............................................................5-44 Summation ..................................................................................................................................5-47 References...................................................................................................................................5-50 6 CARE AND TREATMENT.......................................................................................................6-1 HIV Counseling and Testing ........................................................................................................6-2 Clinical Care and Nonclinical Support Services.........................................................................6-12 Antiretroviral Therapy ................................................................................................................6-33 Summation for PEPFAR’s Support for Care and Treatment Services .......................................6-60 Ongoing Challenges with ART Coverage ..................................................................................6-62 Sustainability of Care and Treatment .........................................................................................6-69 References...................................................................................................................................6-72 7 CHILDREN AND ADOLESCENTS.........................................................................................7-1 Background...................................................................................................................................7-2 Funding History for PEPFAR Support for Children and Adolescents .........................................7-5 PEPFAR’s Programs and Services for Orphans and Vulnerable Children...................................7-8 PEPFAR’s Programs and Child Survival....................................................................................7-24 Summation ..................................................................................................................................7-28 References...................................................................................................................................7-31 8 GENDER .....................................................................................................................................8-1 Introduction...................................................................................................................................8-1 Background...................................................................................................................................8-1 PEPFAR’S Approach to Gender...................................................................................................8-5 Men Who Have Sex with Men....................................................................................................8-17 Measurement and Evaluation of Gender Efforts.........................................................................8-20 Summation ..................................................................................................................................8-24 References...................................................................................................................................8-26 9 STRENGTHENING HEALTH SYSTEMS FOR AN EFFECTIVE HIV/AIDS RESPONSE ...................................................................................................................................................................9-1 Background and Context for Systems Development and Functioning for Health........................9-1 Overview of PEPFAR’s Health Systems Strengthening Activities .............................................9-5 Leadership & Governance ............................................................................................................9-9 Financing ....................................................................................................................................9-20 Health Information......................................................................................................................9-31 Medical Products and Technologies ...........................................................................................9-40 Workforce ...................................................................................................................................9-49 Service Delivery .........................................................................................................................9-60 PREPUBLICATION COPY: UNCORRECTED PROOFS xii

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Summation ..................................................................................................................................9-74 References...................................................................................................................................9-76 PART IV: FUTURE OF U.S. GOVERNMENT INVOLVEMENT IN THE GLOBAL RESPONSE TO HIV/AIDS 10 PROGRESS TOWARD TRANSITIONING TO A SUSTAINABLE RESPONSE IN PARTNER COUNTRIES ........................................................................................................10-1 Evolution of the U.S. Response to Global HIV ..........................................................................10-2 Country Ownership: : A Fundamental Element of Progress Toward Sustainability ..................10-9 Other Key Elements for Achieving Sustainability....................................................................10-25 Key Barriers to Achieving Country Ownership and Sustainability..........................................10-41 Summation ................................................................................................................................10-43 References.................................................................................................................................10-46 11 PEPFAR’S KNOWLEDGE MANAGEMENT ......................................................................11-1 Introduction.................................................................................................................................11-1 Program Monitoring Data ...........................................................................................................11-8 PEPFAR Support for Epidemiological Data.............................................................................11-24 PEPFAR Support for Data Use by Partner Country Stakeholders............................................11-25 PEPFAR-Supported Evaluation and Research Activities .........................................................11-26 Knowledge Transfer and Learning Within PEPFAR................................................................11-48 PEPFAR’s Knowledge Dissemination External to PEPFAR ...................................................11-63 Summation ................................................................................................................................11-75 Recommendations.....................................................................................................................11-81 References 11-87 APPENDIXES A STATEMENT OF TASK ............................................................................................................A-1 B RECOMMENDATIONS ............................................................................................................. B-1 Prevention .................................................................................................................................... B-1 Care and Treatment...................................................................................................................... B-3 Children and Adolescents ............................................................................................................ B-6 Gender.......................................................................................................................................... B-8 Strengthening Health Systems ..................................................................................................... B-9 Transitioning to a Sustainable Response in Partner Countries .................................................. B-10 PEPFAR’s Knowledge Management......................................................................................... B-12 C EVALUATION METHODS .......................................................................................................C-1 Overview...................................................................................................................................... C-1 PEPFAR Programmatic Indicator Data ..................................................................................... C-10 Track 1.0 Partner Data ............................................................................................................... C-15 Global Data Sources .................................................................................................................. C-19 Document Review...................................................................................................................... C-25 Interview Data............................................................................................................................ C-26 References.................................................................................................................................. C-39 D COMMITTEE, CONSULTANT, AND STAFF BIOGRAPHIES ..............................................D-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii

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Preface The HIV/AIDS pandemic has beleaguered the world for over three decades. The countries suffering most continue to be in sub-Saharan Africa, home to an estimated two-thirds of people living with HIV. There have been major increases in both international aid assistance and national commitments and investments for HIV prevention, treatment, care, and capacity building activities. Yet, a funding gap persists relative to meeting the estimated immediate and projected needs. In 2003, in response to the devastating consequences of the HIV pandemic, the U.S. Congress funded a major new U.S. global health initiative that became known as the President’s Emergency Plan for AIDS Relief (PEPFAR). 2 PEPFAR remains the largest bilateral initiative to address HIV/AIDS. At the time of initial authorization, PEPFAR was seen as a bold initiative, testing, among other strategies, whether treatment could be successfully and intensively scaled up in low-resource settings. To help guide this innovative program, the initial authorizing language mandated that the Institute of Medicine (IOM) assess the progress of PEPFAR implementation. The findings and recommendations of that study, published in 2007, informed PEPFAR processes, policies, and activities and subsequently, the reauthorization legislation, known in short as the Lantos-Hyde Act of 2008. 3 The reauthorization legislation mandated the Institute of Medicine (IOM) to assess the performance of United States–assisted global HIV/AIDS programs and evaluate the impact on health of prevention, treatment, and care efforts supported by U.S. funding (see Appendix A for the Statement of Task). This report aims to inform Congress and the Department of State and also to provide the scientific community, program implementers, policy makers, civil society, people living with and affected by HIV/AIDS, and international stakeholders in global public health with a rigorous, evidence-based, multidisciplinary, and independent evaluation of PEPFAR. In response to this mandate, the IOM first convened a planning committee to develop a strategic approach for the evaluation, which was published in 2010. This strategic approach addressed the complexities of evaluating an initiative with the scale and diversity of programs that PEPFAR supports and with the range of countries in which it operates. The dynamism of an initiative that was operating and evolving over the course of the evaluation presented additional complexity. To carry out the evaluation, the IOM convened a diverse expert committee, with considerable overlap with the planning committee. Guided by the strategic approach, the committee, IOM staff, and consultants carried out a mixed-methods approach. Qualitative data included extensive document review and over 400 semi-structured interviews conducted from 2010 to 2012. Each member of the committee visited at least one PEPFAR partner country, and in total the evaluation team conducted thirteen data collection visits to partner countries and heard the perspectives of a wide range of stakeholders. PEPFAR headquarters and mission staff, 2 United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st sess. (May 27, 2003). 3 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008). PREPUBLICATION COPY: UNCORRECTED PROOFS xv

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partner country stakeholders and global partners all generously contributed their time and experience to the committee. Quantitative data included financial data, program and clinical monitoring data, and epidemiological information. The committee struggled with the quantitative data available to address some of the elements of the statement of task. Beyond whether or not the specificity of this legislated task could be answered, however, is the critical imperative that, as the initiative moves forward, PEPFAR determine the key questions to ask in order to assess its own performance and effectiveness, and to plan in advance for the collection of meaningful data to answer those questions and guide the ongoing evolution of PEPFAR. The 2008 reauthorization of PEPFAR placed an increased emphasis on transitioning the program from an initial emergency response to a longer-term model of enhancing sustainability, promoting country ownership, and strengthening health systems. One of the clear findings that emerged from this evaluation is that as PEPFAR evolves in this vein, major dilemmas emerge that create tensions for decision making related to a country’s HIV response; these dilemmas require attention going forward. As the HIV response becomes more country-driven, PEPFAR— and any other external donor effort—will need to focus its contribution on national efforts, rather than direct provision of services and attribution of results. This has consequences for program planning, implementation, and evaluation. Furthermore, focusing on country ownership will require relinquishing some control over the response with unknown consequences for quality and access to services that PEPFAR and partner countries will have to grapple with together. PEPFAR has been globally transformative—changing in many ways the paradigm of global health and what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis. As it moves forward, PEPFAR must continue to be bold in its vision, implementation, and global leadership, this time towards its aim of continuing to strengthen capacity in partner countries in responding to the pandemic. The committee hopes that this evaluation will serve as a tool to achieve these aims. The committee extends its gratitude to all those who provided information to assist in the evaluation. The committee has continuing deep admiration for those carrying out the difficult work of responding to the pandemic. I was privileged to serve as the chair for both the planning committee and the evaluation committee. I would like to express my appreciation to the members of both committees, for the expertise and perspective they contributed, for their robust participation in discourse and deliberation, and for the immeasurable time and energy they volunteered. The IOM committee staff, very ably led by study co-directors Bridget Kelly and Kimberly Scott, have been highly professional, thoughtful, and committed to ensuring the most responsive and rigorous evaluation possible. I thank the entire staff and the committee consultants for their tireless efforts in support of the committee. Robert E. Black, Chair Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs Implemented Under the Lantos-Hyde Act of 2008 PREPUBLICATION COPY: UNCORRECTED PROOFS xvi

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Acronyms and Abbreviations AIDS acquired immune deficiency syndrome APR annual program results ART antiretroviral therapy ARV antiretroviral BCC behavior change communication CD4 cluster of differentiation 4 CDC U.S. Centers for Disease Control and Prevention COP country operational plan COPRS Country Operational Plan Reporting System CRC Committee on the Rights of the Child CTX cotrimoxazole DHS Demographic and Health Surveys DoS U.S. Department of State EID early infant diagnosis of HIV FY fiscal year GHI The U.S. Global Health Initiative Global Fund The Global Fund to Fight AIDS, Tuberculosis, and Malaria HAPSAT HIV/AIDS Program Sustainability Analysis Tool HIV human immunodeficiency virus IOM Institute of Medicine IPTp intermittent preventive treatment of malaria for pregnant women ITNs insecticide-treated nets M&E monitoring and evaluation MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MSM men who have sex with men NGO nongovernmental organization OECD Organisation for Economic Co-operation and Development OGAC Office of the U.S. Global AIDS Coordinator OI opportunistic infection OMB Office of Management and Budget OVC orphans and vulnerable children PCR polymerase chain reaction PEP post-exposure prophylaxis PEPFAR The President’s Emergency Plan for AIDS Relief PEPFAR I The President’s Emergency Plan for AIDS Relief (2004–2008) PEPFAR II The President’s Emergency Plan for AIDS Relief (2009–2013) PHE public health evaluation PLHIV people living with HIV/AIDS PMI The President’s Malaria Initiative PMTCT prevention of mother-to-child transmission PrEP pre-exposure prophylaxis PREPUBLICATION COPY: UNCORRECTED PROOFS xvii

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SI strategic information SAPRs semi-annual program results TAB Technical Advisory Board TB tuberculosis TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government WHO World Health Organization INTERVIEW CITATION ABBREVIATIONS Country Visit Exit Synthesis: Country # + ES Country Visit Interview: Country # + Interview # + Organization Type Non–country Visit Interview: “NCV” + Interview # + Organization Type Organization Types USG U.S. government USNGO U.S. nongovernmental organization USPS U.S. private sector USACA U.S. academia PCGOV partner country government PCNGO partner country nongovernmental organization PCPS partner country private sector PCACA partner country academia CCM country coordinating mechanism ML multilateral organization OBL other (non-U.S. and non–partner country) bilateral OGOV other government ONGO other (non-U.S. and non–partner country) nongovernmental organization PREPUBLICATION COPY: UNCORRECTED PROOFS xviii