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President's Emergency Plan for AIDS Relief (PEPFAR): An Overview
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Overview
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transparent imagePEPFAR: A Comparison of the First and Second 5-Year Authorizations
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transparent imageFederal Agencies Participating in PEPFAR
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transparent imageApproved Generic Antiretroviral Drugs
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Selected Documents and Links
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transparent imageOverviews
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transparent imageCore Documents
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transparent imageReports, Papers, and Briefs
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transparent imagePEPFAR Partners and Funding
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transparent imageProgram Management Materials
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transparent imageSupply Chain Management
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transparent imagePEPFAR Focus Countries
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transparent imageIndependent Reviews of the PEPFAR Program
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transparent imageLinks
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Journal Articles
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Overview
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PEPFAR: A Comparison of the First and Second 5-Year Authorizations
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    The Tom Lantos and Henry J. Hyde United States Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 was signed into law on July 30, 2008. The act extends legislation passed in 2003, also known as The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), for a second 5-year period. Differences between the original law and the reauthorized version are shown in the table below.
First 5-Year AuthorizationSecond 5-Year Authorization
Title
  • United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003

  • Tom Lantos and Henry J. Hyde United States Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008

Enacted
  • May 27, 2003

  • July 30, 2008

Funding Authorization Period/Amount
  • FY 2004 to FY 2008

  • $15 billion ($3 billion/year)

  • $1 billion for Global Fund in FY 2004 (and such sums as necessary for FY 2005-2008)

  • FY 2009 to FY 2013

  • $48 billion (in total)

  • $2 billion for Global Fund in FY 2009 (and such sums as necessary for FY 2010-2013)

  • $4 billion for tuberculosis (in total)

  • $5 billion for malaria (in total)

  • Authorizes $2 billion for emergency plan for safety and health in India

Spending Directives

    Recommends ("Sense of Congress"):

  • 20% of funds be spent on prevention

  • 15% of funds be spent on palliative care

  • Requires (for FY 2006-2007):

  • At least 55% be spent on treatment

  • At least 10% be spent on orphans and vulnerable children

  • At least 33% of appropriated prevention funds be spent on abstinence-until-marriage programs

    Requires:

  • At least 10% be spent on orphans and vulnerable children

  • Half of bilateral aid be spent on AIDS treatment and care

  • Balanced funding for prevention activities for sexual transmission of HIV/AIDS, and that "activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction are implemented and funded in a meaningful and equitable way in the strategy for each host country"

  • A report to Congress if less than half of prevention funds go to abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction in any host country with a generalized epidemic

  • Removes:

  • 33% abstinence-until-marriage directive

Targets/Goals
  • Prevent 7 million new HIV infections

  • Treat 2 million people living with HIV/AIDS

  • Care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children

  • Prevent 12 million new HIV infections

  • Provide treatment to more than 2 million people with HIV/AIDS (original PEPFAR 2003 target) by at least the percentage increase in the amount appropriated for bilateral global HIV/AIDS assistance in any FY as compared with FY 2008; treatment goal to be increased above this calculated number in proportion to the decrease in the per patient cost to the United States government of providing treatment in countries receiving bilateral aid, as compared with FY 2008

  • Care for 12 million, including 5 million orphans and vulnerable children

  • Help partner countries reach prevention of mother-to-child-transmission (PMTCT) coverage target of at least 80% of pregnant women in affected countries

  • Help partner countries provide care and treatment to children with HIV/AIDS in proportion to their share of the HIV-infected population in country

  • Help partner countries train at least 140,000 new health workers

  • Equip teachers with skills needed to address HIV

Global Fund to Fight AIDS, Tuberculosis, and Malaria
  • Authorization of up to $1 billion in FY 2004 and such sums as necessary for FY 2005-2008

  • 1/3 cap on U.S. contribution to Global Fund (cannot exceed 33% of contributions from all sources)

  • Authorization doubled from up to $1 billion in FY 2004 (and such sums as necessary for FY 2005-2008) to up to $2 billion in FY 2009, and such sums as necessary for FY 2010-2013

  • Retains 1/3 cap on U.S. contribution

  • Includes provision that would allow for withholding 20% of annual contribution, pending certification to certain accountability and transparency benchmarks

Focus Countries/Regions
  • Designates 14 countries as focus countries: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia

  • Vietnam later designated as focus country by President as matter of policy

  • Adds Vietnam as focus country

  • Adds Central Asia, Eastern Europe, and Latin America, in addition to Sub-Saharan Africa and the Caribbean, as regions of importance for provision of foreign assistance

Program Coordinator
  • Establishes Global HIV/AIDS Coordinator at Department of State with oversight of all U.S. government programs and resources for combating HIV/AIDS

  • Adds Malaria Coordinator at USAID, with oversight of all U.S. government programs and resources for combating malaria

Immigration and Travel Ban of HIV-Positive Individuals
  • Not referenced in PEPFAR; was governed by Immigration and Nationality Act which prohibits HIV-positive individuals from visiting or immigrating to the United States (unless a waiver is granted); HIV is only health condition specifically named as inadmissible in the law; for all others, the Secretary of Health and Human Services is given the authority to decide what conditions pose public health threats

  • Ends statutory prohibition against HIV-positive visitors and immigrants by amending the Immigration and Nationality Act to strike clause that "shall include infection with the etiologic agent for acquired immune deficiency syndrome"; returns decision about whether HIV should be considered a threat to public health to the Secretary of Health and Human Services, as is the case for all other health conditions

Prevention and Abstinence-Until-Marriage Directive
  • Recommends ("Sense of Congress") that 20% of bilateral assistance be spent on prevention

  • Requires that 33% of funds appropriated for prevention be spent on abstinence-until-marriage programs

  • Requires that prevention activities supported are designed or intended "to impart knowledge with the exclusive purpose of helping individuals avoid behaviors that place them at risk of HIV infection, including integration of such programs into health programs and the inclusion in counseling programs of information on methods of avoiding infection of HIV, including delaying sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual violence and coercion, including child marriage, widow inheritance, and polygamy, and where appropriate, use of condoms"

    Requires:

  • "Balanced funding" for prevention activities for sexual transmission of HIV/AIDS; and that "activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction are implemented and funded in a meaningful and equitable way in the strategy for each host country"

  • A report to Congress if less than half of prevention funds in any host country go to abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction

  • Funds used for new prevention technologies/modalities excepted from balanced funding requirement

  • Removes:

  • 33% requirement for prevention funds

  • Adds:

  • Authority for microbicide research at the National Institutes of Health and Centers for Disease Control and Prevention

  • Male circumcision as a prevention method

  • Addressing multiple concurrent sexual partnering as supported prevention activity

  • That supported activities include female and male condoms (change from "condoms" in PEPFAR 2003)

Family Planning
  • Mexico City exemption to allow family planning groups to receive PEPFAR funds for HIV services only

  • Maintains current law (family planning not mentioned)

Prostitution Pledge
  • Organizations must have policy opposing prostitution to be eligible for funding

  • Maintains current law and includes language stating that no funds to provide assistance "to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking"

Gender/Women and Girls

  • "Gender" not mentioned

  • Requires PEPFAR strategy to specifically address needs and vulnerability of women and girls

  • Requires reporting of indicators related to reaching women and girls in annual reports

  • PMTCT emphasized and annual reports on PMTCT required; includes target of "meeting or exceeding the goal to reduce the rate of mother-to-child transmission of HIV by 20% by 2005 and by 50% by 2010"

  • Addressing multiple concurrent sexual partnering as supported prevention activity

  • Includes greater emphasis and more explicit emphasis on women and girls, particularly related to PMTCT and families, and adds language about gender and gender-related vulnerabilities to HIV

  • Changes subtitle B of legislation from "Assistance for Children and Families" to "Assistance for Women, Children and Families" with target of 80% coverage for PMTCT, annual report on PMTCT, and establishment of PMTCT expert panel

  • Specifically requires that global HIV/AIDS prevention strategy address vulnerabilities of women and youth to HIV infection, and seek to reduce factors that lead to gender disparities in HIV

  • Adds more detailed accountability measures on reaching women and girls and gender-specific accountability measures

  • Requires Institute of Medicine to include assessment of efforts to address gender-specific aspects of HIV/AIDS, including gender-related constraints to accessing services and addressing underlying social and economic vulnerabilities of women and men, in its evaluation

  • Includes "Sense of Congress" concerning need and urgency of expanding range of female-controlled HIV prevention

Health Systems/ Workforce
  • Mentioned briefly; not major focus

  • Includes significantly greater emphasis on health work force training and capacity building, with specific work force target (training at least 140,000 new health workers)

Food and Nutrition
  • Support for food and nutrition assistance given as "Sense of Congress"

  • Support for food and nutrition assistance strengthened; more strongly authorizes use of assistance for purchase of food as a component of treatment; requires nutritional assessments in all HIV programs

Partnerships or "Compacts" with Recipient Countries
  • N/A

  • Adds "compacts" and "framework agreements" with recipient countries to promote host government commitment to deeper integration of HIV/AIDS services into health systems, contribute to health systems overall, enhance sustainability

Tuberculosis
  • Control of tuberculosis cited as "major objective of the foreign assistance program of the United States"; priority given to directly observed treatment short-course (DOTS)

  • No bilateral funding authorization is specified (President authorized to determine) but requirement that at least 75% of the amount made available for tuberculosis each year must be spent on drugs, supplies, direct patient services, DOTS training, treatment of multidrug resistant tuberculosis using DOTS-Plus, including substantially increased funding for the Global Tuberculosis Drug Facility

  • Support for tuberculosis also provided through U.S. government contributions to Global Fund

  • Authorizes $4 billion over 5 years

  • Significantly strengthens and elevates focus on tuberculosis

  • Adds specific tuberculosis goals

  • Requires 5-year tuberculosis strategy

Malaria
  • Prevention, control, and cure of malaria cited as "major objective of the foreign assistance program of the United States"; no bilateral funding authorization is specified (President authorized to determine)

  • Support for malaria also provided through U.S. government contributions to Global Fund

  • Authorizes $5 billion over 5 years

  • Adds Malaria Coordinator at USAID, with oversight of all U.S. government programs and resources for combating malaria

  • Strengthens, embraces President's Malaria Initiative

  • Requires 5-year malaria strategy

Advanced Market Commitments
  • N/A

  • Requires the United States to participate in negotiations for advanced market commitments for the development of future vaccines

Institute of Medicine (IOM) Study and Other Required Evaluations and Research
  • IOM study required

  • IOM studies required for: data evaluation plan, performance assessment, impact evaluation

  • Requires Best Practices report

  • Requires Comptroller General report

Source: Kaiser Family Foundation. Reauthorization of PEPFAR, The United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Act: A Side-by-Side Comparison to Prior Law.
Menlo Park, CA: Kaiser Family Foundation; 2008.

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Federal Agencies Participating in PEPFAR
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The following table shows the types of programs that each federal agency manages:

Government Agency Implementation
Department of State
Secretary of State
  • Provides support for Office of the Global AIDS Coordinator (OGAC)

  • Human resources services

  • Tracking budgets within its accounting system

  • Transferring funds to other implementing agencies

  • Providing office space, communication, and information technology services

Chiefs of Mission and U.S. officials
  • Provide essential leadership to interagency HIV/AIDS teams in focus countries

  • Engage in political discussions with host-country leaders to ensure additional attention and resources for the pandemic and ensure strong donor coordination

OGAC
  • Makes funds available for Ambassadors to support local projects developed with extensive community involvement, targeted at the specific needs of the host country, and developed in coordination with local nongovernmental organizations and municipalities

  • Administers programs under FREEDOM Support Act and Support for Eastern European Democracies Act

  • Implements a variety of diplomatic initiatives and other community-based HIV/AIDS programs through its embassies in 162 countries

  • Provides embassies with tools of public diplomacy to reach out through print and electronic media, facilitate exchange programs, and engage new partners

Department of Health and Human Services (DHHS)
  • Responsible for all U.S. domestic HIV/AIDS programs

  • Implements prevention, care, and treatment programs in developing countries and HIV/AIDS research through CDC, NIH, HRSA, FDA

  • Works with the country coordinating mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria to improve implementation of Global Fund grants and programs and their coordination with U.S. government programs

CDC
  • Global AIDS Program: highly trained physicians, epidemiologists, public health advisors, virologists, and other laboratory scientists provide technical assistance in areas of prevention; laboratory capacity building; surveillance and infrastructure development; and care, support and treatment

NIH
  • Supports a comprehensive program of basic, clinical, and behavioral research on HIV infection and its associated opportunistic infections, co-infections, and malignancies

  • Supports an international research and training portfolio

HRSA
  • Builds human capacity for scaling up care and treatment in providing quality comprehensive HIV/AIDS care to underserved communities

  • Implements strategies through activities such as twinning, training and technical assistance, rapid roll-out of antiretroviral drugs, mentoring for nursing leadership, and enhancement of the continuum of palliative care

FDA
  • Implements new, expedited review of pharmaceuticals to ensure that the U.S. Global AIDS Coordinator can buy safe and effective antiretroviral drugs for the Emergency Plan at the lowest possible prices

USAID
  • Supports the implementation of Emergency Plan HIV/AIDS programs through direct in-country presence in strengthening primary health care systems to prevent and treat communicable diseases, including HIV/AIDS

  • Works with governments, nongovernmental organizations and the private sector to provide training, technical assistance, and commodities, including pharmaceuticals

  • Supports programs in high-prevalence countries in areas such as agriculture, education, democracy, and trade that link to HIV/AIDS

  • Supports international partnerships such as the International AIDS Vaccine Initiative and UNAIDS; provides staff support to the U.S. delegation to the Global Fund to Fight AIDS, Tuberculosis, and Malaria; works with local coordinating committees of the Global Fund to improve implementation of Fund programs

  • Supports targeted research, development and dissemination of new technologies (including microbicides), and packaging and distribution mechanisms for antiretroviral drugs

Department of Defense
  • Implements Emergency Plan programs by supporting HIV/AIDS prevention, care, treatment, strategic information, human capacity development, and program and policy development in host militaries and civilian communities through direct military-to-military assistance, engagement of nongovernmental organizations, and universities

  • Supports a broad spectrum of military-specific HIV prevention programs, infrastructure assistance (including laboratory space, equipment, and training), and care activities, hosting of a 1-month HIV/AIDS training program for military clinicians providing HIV-related care

  • Provides rudimentary construction to support civilian HIV programs

Department of Labor
  • Implements elements of Emergency Plan that target the workplace for prevention education and strengthen the response to HIV/AIDS by providing technical assistance to governments, employees, and labor leaders

  • Supports an international assistance program to reduce workplace stigma and discrimination against people living with HIV/AIDS

  • Supports an international technical assistance program focusing on child labor and works with the International Labor Organization, UNICEF, and nongovernmental and faith-based organizations to implement programs targeting HIV-affected children forced to work and children involved in prostitution

  • Works with International HIV/AIDS Workplace Education Program (IHWEP), leaders of business, government, and labor to combat HIV/AIDS through prevention education and promotion of antidiscrimination policies focusing on education, policy, and capacity

Peace Corps
  • Implements Emergency Plan programs in 10 of the 15 focus countries--Botswana, Zambia, Namibia, South Africa, Mozambique, Kenya, Tanzania, Uganda, Haiti, and Guyana

  • Employs Emergency Plan resources to enhance and in-country HIV/AIDS programming training; field additional Crisis Corps and Peace Corps volunteers specifically in support of Emergency Plan goals; and provide targeted support for community-initiated projects

  • Provides long-term capacity development support to nongovernmental, community-based, and faith-based organizations with a particular emphasis on ensuring that community-initiated projects and programs provide holistic support to people living with and affected by HIV/AIDS

Department of Commerce
  • Fosters public-private partnerships

  • Presents to industry trade advisory committees on HIV/AIDS with discussions on how the private sector can contribute

  • Creates and disseminates sector-specific strategies for various industries detailing to companies concrete examples of how the private sector can be engaged in HIV/AIDS

  • Provides departmental support

  • Participates in regular meetings with multilateral organizations such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria to discuss how the Department of Commerce has been able to reach out to business and industry

U.S. Census Bureau
  • Assists with data management and analysis, survey support, estimating infections averted, and supporting mapping of country-level activities

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Approved Generic Antiretroviral Drugs
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A complete list of antiretroviral drugs approved and tentatively approved by the U.S. Food and Drug Administration (FDA) for purchase with PEPFAR funds can be found on the FDA website.

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Selected Documents and Links
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Overviews
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Core Documents
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Reports, Papers, and Briefs
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  • PEPFAR Issue Briefs
    Regularly updated summary of policy issues from PEPFAR. New briefs address monitoring and evaluation, circumcision, and TB.

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PEPFAR Partners and Funding
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Program Management Materials
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Supply Chain Management
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  • Supply Chain Management System website
    Funded by PEPFAR, the SCMS is comprised of private sector, nongovernmental, and faith-based organizations that are engaged in the field of supply chain management and international public health and development.

  • SCMS Focus Country Profiles
    Overviews and progress reports on SCMS activities in the PEPFAR focus countries.

  • Procurement and Supply Management Toolbox
    A repository for a wide range of health-related procurement and supply management tools. The project was initiated by the World Health Organization AIDS Medicines and Diagnostic Service and its partner organizations.

  • WHO Global Price Reporting Mechanism
    A transaction database launched by the WHO/AMDS in April 2005. It contains information on transaction prices and quantities of antiretroviral medicines, tuberculosis and malaria drugs, and commodities purchased by HIV, malaria, and TB programs in low- and middle-income countries.

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PEPFAR Focus Countries
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Independent Reviews of the PEPFAR Program
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  • PEPFAR Watch
    A joint project of the Center for Health and Gender Equity (CHANGE) and Health GAP (Global Access Project). PEPFAR Watch is intended as an up-to-date and accurate source of information and debate on U.S. global AIDS policies and critical issues related to the prevention and treatment of HIV and AIDS. The most basic goals of PEPFAR Watch are to promote accountability of U.S. global AIDS policies to health and human rights concerns.

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Links
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Journal Articles
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