Key Info
- Though the U.S. has been concerned in efforts to handle the worldwide AIDS disaster because the mid-Eighties, the creation of the President’s Emergency Plan for AIDS Aid (PEPFAR) in 2003 marked a major improve in funding and a focus to the epidemic.
- PEPFAR is the most important dedication by any nation to handle a single illness on the earth; thus far, its funding has totaled greater than $100 billion, together with funding for the World Fund to Battle AIDS, Tuberculosis and Malaria (World Fund), to which the U.S. authorities is the most important donor. PEPFAR is credited with saving thousands and thousands of lives and serving to to alter the trajectory of the worldwide HIV epidemic.
- U.S. funding for PEPFAR, which incorporates contributions to the World Fund, grew from $2.2 billion in FY 2004 to $10.8 billion in FY 2021; FY 2021 funding contains $7.0 billion supplied by way of common appropriations and $3.8 billion in emergency funding to handle the influence of COVID-19 on HIV efforts, $250 million of which was for bilateral efforts and $3.5 billion was for the World Fund.
- Because the COVID-19 pandemic continues to have profound results internationally, PEPFAR has acted to answer COVID-19 in international locations that obtain assist with a view to reduce HIV service disruptions and leverage this system’s capabilities to handle COVID-19 extra broadly.
- Trying forward, PEPFAR faces a number of points and challenges, together with how finest to: deal with the short- and long-term impacts of COVID-19 on PEPFAR and the HIV response; speed up progress towards epidemic management within the context of flat funding; assist and strengthen community-led responses and the sustainability of HIV applications; outline its position in world well being safety and broader well being methods strengthening efforts; and proceed to coordinate with different key gamers within the HIV ecosystem, together with the World Fund.
World Scenario
HIV, the virus that causes AIDS (acquired immunodeficiency syndrome), has develop into one of many world’s most critical well being and improvement challenges. Immediately, there are roughly 37.7 million folks residing with HIV, and tens of thousands and thousands of individuals have died of AIDS-related causes because the starting of the epidemic (see the KFF truth sheet on the worldwide HIV epidemic).
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NOTES: Displays 2020 information. |
U.S. Authorities Efforts
Though the U.S. has been concerned in efforts to handle the worldwide HIV/AIDS disaster because the mid-Eighties, the creation of the President’s Emergency Plan for AIDS Aid (PEPFAR) in 2003 marked a major improve in funding and a focus to the epidemic. PEPFAR, the U.S. authorities’s world effort to fight HIV and the most important world well being program dedicated to a single illness, is credited with saving thousands and thousands of lives and serving to to alter the trajectory of the worldwide HIV epidemic. It was introduced in January 2003 throughout President George W. Bush’s State of the Union and licensed by Congress that very same yr by way of the Management Act (see Desk 1). The Management Act governs PEPFAR’s HIV response, in addition to U.S. participation within the World Fund (an unbiased, worldwide multilateral financing establishment that gives grants to international locations to handle HIV, TB, and malaria) and bilateral help for TB and malaria applications. Congress has up to date, prolonged, and made adjustments to this system by way of the Lantos-Hyde Act of 2008, the PEPFAR Stewardship Act of 2013, and the PEPFAR Extension Act of 2018, which fits by way of FY 2023. See Desk 1 (see KFF transient on PEPFAR reauthorization).
United States Management Towards HIV/AIDS, Tuberculosis, and Malaria Act of 2003 “The Management Act” |
$15 billion | P.L. 108-25 | FY04-FY08 |
Tom Lantos and Henry J. Hyde United States World Management Towards HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 “The Lantos-Hyde Act” |
$48 billion | P.L. 110-293 | FY09-FY13 |
PEPFAR Stewardship and Oversight Act of 2013 “The PEPFAR Stewardship Act” |
Didn’t specify authorization for funding* | P.L. 113-56 | FY14-FY18 |
PEPFAR Extension Act of 2018 “The PEPFAR Extension Act” |
Didn’t specify authorization for funding* | P.L. 115-305 | FY19-FY23 |
NOTES: * Congress successfully authorizes funding when it appropriates funding for a objective. See the KFF transient on PEPFAR Reauthorization, https://www.kff.org/global-health-policy/issue-brief/pepfar-reauthorization-side-by-side-of-existing-legislation/. |
Group
PEPFAR’s unique authorization established new constructions and authorities, consolidating all U.S. bilateral and multilateral actions and funding for world HIV/AIDS. A number of U.S. companies, host nation governments, and different organizations are concerned in implementation.
PEPFAR is overseen by the U.S. World AIDS Coordinator, who’s appointed by the President, confirmed by the Senate, and stories on to the Secretary of State, as established by way of PEPFAR’s authorizing laws. The Coordinator holds the rank of Ambassador and leads the Workplace of the World AIDS Coordinator (OGAC) on the Division of State. At the moment the Coordinator is dual-hatted because the U.S. Particular Consultant for World Well being Diplomacy. The Coordinator has main accountability for the oversight and coordination of all U.S. world HIV actions and funding throughout a number of U.S. implementing companies and departments. As well as, the Coordinator serves because the U.S. Authorities’s board member to the World Fund (the U.S. Authorities holds a everlasting seat on the World Fund’s Board).
Along with the Division of State, different implementing departments and companies for HIV actions embrace: the U.S. Company for Worldwide Growth (USAID); the Division of Well being and Human Providers, primarily by way of the Facilities for Illness Management and Prevention (CDC), Well being Assets and Providers Administration (HRSA), and Nationwide Institutes of Well being (NIH); the Departments of Labor, Commerce, and Protection (DoD); and the Peace Corps.
Technique
This yr, the U.S. authorities is predicted to launch a brand new PEPFAR technique for its subsequent part. In accordance with a draft overview, this technique will “assist the worldwide neighborhood’s efforts to place international locations on monitor to succeed in the Sustainable Growth Objective 3 goal of ending the worldwide AIDS epidemic as a public well being risk by 2030, by way of the attainment of key milestones by 2025.” At the moment, PEPFAR is guided by two most important methods: the overarching technique specified by PEPFAR 3.0 – Controlling the Epidemic: Delivering on the Promise of an AIDS-free Era and a complementary, extra focused technique for accelerating implementation of PEPFAR efforts in sure high-burden international locations specified by The PEPFAR Technique for Accelerating HIV/AIDS Epidemic Management (2017-2020).
PEPFAR 3.0 focuses on attaining epidemic management (outlined by this system to be reached when the full variety of new HIV infections falls beneath the full variety of deaths from all causes amongst folks with HIV) of the worldwide HIV epidemic by way of a deal with transparency, accountability, and influence. PEPFAR’s 2017-2020 technique outlines its plan to speed up implementation in a subset of 13 PEPFAR international locations that, based on PEPFAR information, present the best potential to attain epidemic management by 2020: Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. The technique emphasizes accelerating testing and remedy methods, increasing prevention, utilizing high quality information, participating with faith-based organizations and the non-public sector, and strengthening coverage and monetary contributions by associate international locations. Additionally it is meant to align with the UNAIDS 90-90-90 and 95-95-95 targets (see KFF dashboard monitoring world HIV targets, together with PEPFAR’s epidemic management goal, in PEPFAR international locations).
Key Actions and Outcomes
PEPFAR actions deal with increasing entry to HIV prevention, remedy, and care interventions. These embrace provision of antiretroviral remedy, pre-exposure prophylaxis, voluntary male circumcision, condoms, and different commodities associated to HIV providers (see Desk 2)., As well as, PEPFAR has launched particular initiatives in key strategic areas. For instance, in 2015, PEPFAR launched DREAMS, a public-private partnership that goals to scale back HIV infections in adolescent ladies and younger ladies.
The newest outcomes reported by PEPFAR point out that it has:
- supported testing providers for practically 50 million folks in FY 2020;
- prevented 2.8 million infants from being born with HIV, who would have in any other case been contaminated;
- supplied take care of greater than 6.7 million orphans and weak kids (OVC);
- supported coaching for practically 290,000 new well being care staff; and
- supported antiretroviral remedy for practically 18.2 million folks.
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Among the many 15 international locations implementing the DREAMS initiative, the newest outcomes present a decline in new HIV diagnoses amongst adolescent ladies and younger ladies in all the areas implementing DREAMS. Additional, practically all (96%) areas have skilled declines better than 25%, and practically two-thirds of the areas present a decline of better than 40%.
International locations Reached
PEPFAR bilateral applications span greater than 50 international locations (see Determine 1). Extra international locations are reached by way of U.S. contributions to the World Fund.
PEPFAR requires 25 international locations and the Asia, Western Hemisphere, and West Africa regional applications to develop “Nation Operational Plans” (COPs) and “Regional Operational Plans” (ROPs), respectively, to doc annual investments and anticipated outcomes. OGAC opinions and the World AIDS Coordinator approves COP/ROPs.
Funding
Whole PEPFAR funding contains all bilateral funding for HIV in addition to U.S. contributions to the World Fund and UNAIDS. It represents nearly all of U.S. world well being funding (starting from 56% to 62% over the previous 5 years) and is the most important dedication by any nation to handle a single illness on the earth. To this point, PEPFAR funding has totaled greater than $100 billion, with funding reaching $10.8 billion in FY 2021 (together with $7.0 billion by way of common appropriations and $3.8 billion in emergency funding in response to the COVID-19 pandemic) (see Determine 2).
PEPFAR’s creation marked a major improve within the quantity of funding supplied by the U.S. for HIV. Bilateral HIV funding by way of common appropriations, which accounts for almost all of PEPFAR funding (averaging roughly 80% annually), rose quickly from $1.1 billion in FY 2003 (the yr earlier than PEPFAR) to a peak of $5.5 billion in FY 2010. Between FY 2010 and FY 2013, it declined by greater than $800 million. Whereas it has risen since then, non-emergency bilateral funding in FY 2021 ($5.4 billion) was nonetheless $122 million beneath its peak stage, and funding has been principally flat for the previous a number of years. Funding for the World Fund by way of common appropriations additionally elevated quickly, rising from $347 million in FY 2003 (the yr earlier than PEPFAR) to a peak stage of $1.65 billion in FY 2014 earlier than declining to $1.35 billion in FY 2015. It was stage for a number of years earlier than it elevated to $1.56 billion in FY 2020 after which remained flat in FY 2021. Further emergency funding for bilateral HIV and the World Fund was supplied in FY 2021 to handle COVID-19. (For extra element on historic appropriations for PEPFAR, see the KFF funds tracker and KFF transient on historic traits.)
Of the roughly $10.8 billion appropriated for PEPFAR in FY 2021, together with common and emergency funding:
- $7.0 billion is supplied by way of common appropriations, of which $5.4 billion (77%) is for bilateral HIV, $45 million is for UNAIDS (1%), and $1.56 billion (22%) is for the World Fund.
- $3.8 billion is supplied by way of emergency funding to handle the impacts of COVID-19 on HIV, of which $250 million is for bilateral HIV and $3.5 billion is for the World Fund.
- The vast majority of PEPFAR funding is channeled to the Division of State ($9.7 billion, which incorporates $4.6 billion for bilateral HIV— most of which is then transferred to different companies; $45 million for UNAIDS; and a $5.06 billion contribution to the World Fund), adopted by NIH ($617 million), USAID ($330 million), CDC ($128.4 million), and a small quantity to DoD ($8 million).
- For FY 2022, the present Administration has proposed $7.0 billion ($5.4 billion for bilateral HIV, $45 million for UNAIDS, and $1.56 billion for the World Fund), matching the FY 2021 stage when emergency funding is excluded (see KFF truth sheets on the S. World Well being Finances: HIV/PEPFAR and the U.S. World Well being Finances: The World Fund).
Spending Directives
PEPFAR has included a number of spending directives, or earmarks, from Congress over the course of its historical past, lots of which have modified over time:
- The Management Act, PEPFAR’s unique authorization, included the next spending directives: 55% of funds had been to be spent on remedy; 15% on palliative care; 20% on prevention, of which at the least 33% be spent on abstinence-until-marriage applications; and 10% on OVC. Whereas these had been included as “sense of Congress” suggestions, the remedy, OVC, and abstinence-until-marriage earmarks had been made necessities as of FY 2006.
- The Lantos-Hyde Act relaxed a few of these directives for the FY 2009 – FY 2013 interval: whereas nonetheless requiring that 10% of funds be spent on applications focusing on OVC, it modified the remedy earmark from 55% to requiring that at the least half of bilateral HIV help be spent on remedy and care. It eliminated the 33% abstinence-until-marriage directive and changed it with a requirement of “balanced funding” for prevention to be accompanied by a report back to Congress if lower than half of prevention funds had been spent on abstinence, delay of sexual debut, monogamy, constancy, and associate discount actions in any host nation with a generalized (excessive prevalence) epidemic.
- The PEPFAR Stewardship Act and The PEPFAR Extension Act have maintained the language within the Lantos-Hyde Act.
PEPFAR & The World Fund
The U.S. is the one largest donor to the World Fund. Appropriations for the U.S. contribution to the World Fund totaled roughly $24.6 billion from FY 2001 by way of FY 2021. The World Fund gives one other mechanism for U.S. assist by funding applications developed by recipient international locations, reaching a broader vary of nations, and supporting TB, malaria, and well being methods strengthening (HSS) applications along with (and past their linkage with) HIV. To this point, over 150 international locations have obtained World Fund grants; 53% of World Fund assist has been dedicated to HIV and HIV/TB applications, 30% to malaria, 15% to TB, and <3% to different well being points. The unique authorization of PEPFAR, and subsequent reauthorizations, included a restrict on annual U.S. contributions to the World Fund that prevented them from inflicting cumulative U.S. contributions to exceed 33% of the World Fund’s whole contributions; this requirement is in impact by way of FY 2023 (see the KFF truth sheet on the World Fund). As famous above, the U.S. authorities supplied $3.5 billion in emergency funding to the World Fund to assist the group deal with the impacts of COVID-19.
PEPFAR & COVID-19
COVID-19 continues to have profound results within the international locations that obtain PEPFAR assist and on HIV efforts, particularly with regard to HIV prevention. Because the starting of the pandemic, PEPFAR has acted to answer and mitigate the impacts of COVID-19. Steps have included: growing – and recurrently updating – steering to area groups geared toward guaranteeing continuity of care and leveraging PEPFAR’s infrastructure to answer COVID-19; accelerating the usage of methods to reduce service disruption, equivalent to multi-month dishing out of antiretrovirals and decentralized distribution of HIV self-testing kits; implementing new methods, equivalent to telemedicine; and permitting for some program flexibility in reporting necessities, staffing, and funding re-allocation.,
PEPFAR’s capability to answer COVID-19 obtained an essential enhance in March 2021, when COVID-19 emergency funding supplied this system with $250 million in emergency funding for its bilateral COVID-19-related efforts (along with emergency funds supplied to the World Fund).
Key Points for the U.S.
The U.S. authorities is the most important donor to worldwide HIV efforts on the earth, together with the most important donor to the World Fund, and PEPFAR is seen as one of the important and profitable world well being initiatives ever undertaken. Now, virtually twenty years after its creation, PEPFAR is at a turning level. There have been essential shifts within the world HIV and broader world well being panorama because the program was launched, together with COVID-19. PEPFAR additionally is working below a brand new administration and might be releasing a brand new technique, and reauthorization discussions are anticipated to start within the close to future. As PEPFAR enters its subsequent part, there are a number of key interrelated points and challenges dealing with this system that may doubtless have implications for the longer term form and route of this system. These embrace:
- addressing the short- and long-term impacts of COVID-19 on PEPFAR and the HIV response;
- accelerating progress towards epidemic management within the context of flat funding;
- attaining the optimum mixture of providers supplied, populations served, and geographies focused;
- supporting and strengthening community-led responses and sustainability;
- defining PEPFAR’s position in world well being safety and broader well being methods strengthening efforts, whereas guaranteeing synergies with different U.S. world well being and improvement applications; and
- persevering with to coordinate with different donors and entities within the HIV ecosystem, particularly the World Fund.