generalized epidemics. This “balanced funding” directive replaced the 20 percent earmark for prevention, which included one-third earmarked for abstinence programs, from the original 2003 legislation. Instead of identifying a specific requirement for the distribution of funds for prevention of sexual transmission, programs in countries with generalized epidemics are now required to provide a compelling explanation, justified by the Coordinator, if less than 50 percent of prevention funding is directed toward activities promoting (a) abstinence, (b) delay of sexual debut, (c) monogamy, (d) fidelity, and (e) partner reduction. These programs are to be “implemented and funded in a meaningful and equitable way . . . based on objective epidemiological evidence as to the source of infections and in consultation with the government of each host country involved in HIV/AIDS prevention activities.”28

Second PEPFAR Five-Year Strategy

In December 2009, Ambassador Goosby released a new legislatively required PEPFAR Five-Year Strategy, which included the targets written into the reauthorization legislation, but specified that the treatment target should provide direct support for more than 4 million people (OGAC, 2009a). Unlike the legislation, this Five-Year Strategy extended the timeframe of these performance targets through FY 2014, rather than FY 2013 (OGAC, 2009a). The new strategic plan established the future direction of PEPFAR II and, based on the areas of emphasis in the reauthorization legislation, identified the need to “(1) transition from an emergency response to promotion of sustainable country programs; (2) strengthen partner government capacity to lead the response to this epidemic and other health needs; (3) expand prevention, care, and treatment in concentrated and generalized epidemics; (4) integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems; [and] (5) invest in innovation and operations research to evaluate impact, improve service delivery, and maximize outcomes” (OGAC, 2009a, p. 14).

The evolution of PEPFAR’s goals, budgetary allocations, and targets over time is summarized in Table 1-2.

Changes in PEPFAR Since the Lantos-Hyde Act and the Second Five-Year Strategy

Since the reauthorization of PEPFAR, as the implementation of the second Five-Year Strategy has progressed, some additional key developments

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28Supra, note 1 at img403(1), 22 U.S.C. 7673(a).



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