latedness of these program areas in a continuum of services. Part IV places these major programmatic areas in the context of a discussion of key issues that are not explicitly stated in the legislative mandate for the evaluation but that are integral to the committee’s consideration of the future of U.S. government (USG) involvement in the global response to HIV/AIDS. Here, there is particular emphasis on the evolution of PEPFAR to support sustainable, evidence-informed management of HIV and AIDS in partner countries. The Summary, preceding this chapter, synthesizes the major messages of this report, in particular highlighting key issues that cut across chapters; captures the overall achievements and challenges of PEPFAR; and presents together in one place the recommendations of the committee.


The first documentation of what became known as acquired immune deficiency syndrome (AIDS) was in 1981, and several years later the cause of the disease was discovered to be a virus, now called human immunodeficiency virus (HIV) (Barre-Sinoussi et al., 2004; CDC, 1981, 1982; Levy et al., 1984; Popovic et al., 1984). Since then, the pandemic nature of the virus has been recognized, and the effort to control its spread has become a leading global health priority (UNAIDS, 2012).

In 2011, an estimated 34 million people were living with HIV and about 2.5 million people became newly infected with the virus. Of those newly infected, 330,000 were children. Worldwide, the estimated annual number of new HIV infections peaked in 1997. While the number of new infections has declined steadily, the number of people living with HIV has continued to rise, in part because of increased access to antiretroviral therapy (ART) treatment and declines in the number of deaths due to AIDS-related causes. Nonetheless, despite the increased availability of treatment, HIV/AIDS is still a major cause of death across the world. In 2011, AIDS led to the deaths of an estimated 1.7 million people (UNAIDS, 2012).

Although HIV continues to affect all regions of the world, the greatest burden of HIV falls on sub-Saharan Africa, which is home to 69 percent of people living with HIV and, in 2011, had the highest number of new HIV infections. Asia is the second most affected region because of the large size of its population, with nearly 5 million people living with HIV in South, South-East, and East Asia combined; the Caribbean follows sub-Saharan Africa in prevalence of HIV in adults (UNAIDS, 2012).

The impact of HIV is felt at all levels within countries—it shortens life expectancy, changes population demographics, and overloads health and social systems. The epidemic has had a drastic socioeconomic effect on countries that are already under-resourced and has required significant

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