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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
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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.
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or
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Library of Congress Catalog Card Number 97-XXXXX
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Suggested citation: IOM (Institute of Medicine). 2013. Evaluation of PEPFAR. Washington, DC:
The National Academies Press.
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www.national-academies.org
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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.
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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
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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.
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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.
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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
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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
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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
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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).
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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
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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
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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
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