“The United States Congress and the American people have been generous in this effort, and Americans can know that their generosity is making a significant difference."
--President George W. Bush World AIDS Day December 1, 2005

The global HIV/AIDS pandemic has been a destroyer of hope, casting the shadow of suffering and death upon families, communities, and even nations. In much of the developing world, hope for the future has been a victim of this scourge.

At last, however, hope has begun to be reborn. Around the world, partnerships between the President’s Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) and host nations are proving that there is hope of winning this fight – even in the most difficult places.

President Bush’s announcement of PEPFAR in 2003, it is now clear, marked a turning point in the worldwide response to HIV/AIDS. The Emergency Plan represents historic leadership in terms of financial resources: no nation has ever undertaken a larger international health initiative directed at a single disease. With the strong support of Congress and the American people, the United States leads all international partners in its financial commitment to the fight. In fiscal year 2005, the United States committed approximately $2.8 billion to the Emergency Plan, up from $2.4 billion in fiscal year 2004, the first year of implementation. President Bush has requested, and Congress has appropriated, approximately $3.2 billion for fiscal year 2006, keeping the Emergency Plan on track to meet the President’s five year, $15 billion commitment.

Yet money alone can never defeat HIV/AIDS, nor bring about the societal transformation needed in nations devastated by the pandemic. The Emergency Plan thus invests in partnerships with host nations to build locally led HIV prevention, treatment and care strategies. As President Bush put it, “This effort is succeeding because America is providing resources and Africans are providing leadership. Local health officials set the strategy and we're supporting them.”

In the world’s hardest-hit nations, HIV/AIDS will be a tragic fact of life for many years to come. The fight against it will succeed today, and be sustainable tomorrow, only if the local population takes ownership. PEPFAR is working in partnership with host nations to bring high quality programs to scale today, while supporting the development of sustainable local capacity for these programs to continue in the future.

The Emergency Plan’s efforts to build high quality, sustainable programs in fiscal year 2005 took place through bilateral programs in 123 countries, and in additional countries through support for multilateral efforts. Bilateral programs include a special emphasis on 15 focus countries in Africa, the Caribbean, and Asia that together account for approximately one-half of the world’s 40 million HIV infections.¹ In these focus countries over 5 years, the Emergency Plan has set goals of supporting prevention of 7 million new infections, supporting treatment for 2 million HIV-infected people, and supporting care for 10 million individuals, including orphans and vulnerable children as well as people living with HIV/AIDS.

To reach these ambitious goals, the Emergency Plan is implementing the most complex and diverse prevention, treatment and care strategy in the world. The lessons learned from the intensive application of the Emergency Plan strategy in the focus countries are now being extended to other PEPFAR nations, helping to fuel transformation of HIV/AIDS responses in nations around the world.

Across all activities, accountability is a hallmark of PEPFAR. When the United States undertook the Emergency Plan, our nation did not promise good intentions, but results – and accountability for achieving them. Accountability depends on accurate information. The Emergency Plan is thus investing heavily in the tools needed to ensure that accurate information on results is gathered and fully utilized by the Emergency Plan and its host nations.

After two years of the Emergency Plan, there can be no doubt that the action of the United States has produced results. These results may be measured in numbers, but what these numbers represent are children, women, and men who are alive today because of America’s action.

Results

Prevention
Slowing the rate of new HIV infections is the most difficult challenge facing the world in the fight against HIV/AIDS. The U.S. is rising to this challenge with support for the most diverse portfolio of HIV/AIDS prevention strategies of any international partner. Strategies include the ABC approach (Abstain, Be faithful, correct and consistent use of Condoms where appropriate) developed in Africa to prevent sexual transmission; prevention of mother-to-child transmission (PMTCT); prevention of medical transmission through blood safety and safe medical injections programs; and programs that focus on intravenous drug users, on HIV-discordant couples, on women, on men, and on alcohol abuse, among other key issues. The United States has also maintained its position as the global leader in HIV/AIDS research and innovations, with an emphasis on developing safe and effective vaccines and microbicides.

Growing evidence of all three of the ABC behaviors, and of corresponding reductions in HIV prevalence in certain countries, highlight the importance of support for ABC programs to prevent sexual transmission of HIV. In the focus countries in fiscal year 2005, PEPFAR supported balanced, evidence-based ABC community outreach activities that reached over 42 million people.

PEPFAR supported PMTCT services for over 1.9 million women during the reporting period, including antiretroviral prophylaxis for over 122,600 women, averting an estimated 23,400 infant infections. In the first two years of the Emergency Plan overall, approximately 3.2 million women received PEPFAR-supported PMTCT services, with over 248,000 women receiving antiretroviral prophylaxis, preventing an estimated 47,100 infant HIV infections to date.

Addressing the special vulnerability of women to HIV/AIDS is a key focus of prevention and other activities. Across all program areas in the focus countries in the reporting period, PEPFAR implementing partners reported that 203 program activities sought to address violence and coercion, 305 activities sought to address male norms and behaviors, 105 activities promoted increased legal protection for women, and 107 activities sought to increase women’s access to productive resources.

The Emergency Plan devoted 28 percent of all focus country program funding to prevention in fiscal year 2005.

Treatment
At the time President Bush announced the Emergency Plan, only an estimated 50,000 people in all of sub-Saharan Africa were receiving life-extending antiretroviral treatment (ART). Yet at the end of just two years of implementation, the Emergency Plan supported treatment for approximately 401,000 people in the 15 focus nations, including 395,000 in the 12 sub-Saharan African focus nations. PEPFAR has also provided support for treatment for approximately 70,000 additional people through U.S. bilateral programs in other nations, for a worldwide total of approximately 471,000 people receiving bilateral treatment support from the United States.

Quality assurance, essential in the context of treatment, is a key focus of Emergency Plan efforts, with major investments in strengthening systems to ensure quality. High-quality generic antiretroviral drugs (ARVs) are increasingly used in PEPFAR-supported programs. 15 generic products, including four pediatric formulations, are now eligible for purchase by Emergency Plan programs under the expedited U.S. Government ARV review process established in 2004.

Highlighting PEPFAR’s commitment to pediatric treatment, approximately 7 percent of those receiving treatment at U.S.-supported sites in the focus countries in fiscal year 2005 were children – a number that is expected to rise as pediatric programs are scaled up in the coming years. In terms of gender equity in services, approximately 60 percent of ART clients whose gender was reported were women.

In fiscal year 2005, PEPFAR devoted 46 percent of focus country program funding to support for treatment.

 Care
As the numbers of orphans and vulnerable children (OVCs) and people infected with HIV continue to grow, the Emergency Plan is urgently scaling up support for effective interventions. In fiscal year 2005, PEPFAR supported care for nearly 3 million people in the focus countries. This number included over 1.2 million orphans and vulnerable children and over 1.7 million people living with HIV/AIDS.

Counseling and testing is a key gateway to treatment and care for people living with HIV/AIDS, as well as an important venue for prevention education. To date, the Emergency Plan has provided support for HIV counseling and testing services for over 9.4 million people in the focus countries. Of these, over 6.6 million received services in fiscal year 2005 – over 1.9 million in PMTCT settings and over 4.6 million through other counseling and testing activities. An estimated 69 percent of those counseled and tested in all settings were women.

Building Capacity
An intensive focus on helping communities and nations develop their own capacity for sustainable, high-quality HIV/AIDS interventions remains essential. Many developing
countries face common barriers to expanding and sustaining responses. While supporting the intensive scale-up of prevention, treatment, and care now, PEPFAR is a vital partner with host nations as they develop tools to sustain responses in the future.

Supporting the development of the institutional capacity of the civil society sector in host nations is a key strategy for sustainability. Approximately 82 percent of all implementing
partners in fiscal year 2005 were indigenous organizations. PEPFAR is pursuing strategies to drive this number even higher in coming years. Faith- and community-based organizations, including ones that have not previously worked with the U.S. Government, bring key strengths to the HIV/AIDS fight. The New Partners Initiative, launched by President Bush on World AIDS Day 2005, will help PEPFAR expand and diversify its partner base.

The leadership of host governments is critical for an effective national response to HIV/AIDS. The Emergency Plan is partnering with ministries of health, national HIV/AIDS coordinating authorities, and other governmental entities to foster multisectoral, intensive national responses. Over 20 percent of host country partners during the reporting period were public sector entities. In many countries, the fragile but growing private sector also has important contributions to make to the fight, and PEPFAR is intensifying efforts to build public private partnerships.

The Emergency Plan is providing focused support for the development of human capacity to deliver HIV/AIDS services. In fiscal year 2005, the Emergency Plan supported training or retraining for more than 536,000 service providers (with individuals being trained in multiple areas in certain cases). This total included support for training or retraining of approximately:

• 267,600 individuals in prevention of sexual transmission
• 28,600 individuals in prevention of mother-to-child transmission (PMTCT)
• 20,300 individuals in prevention of medical transmission
• 36,500 individuals to support antiretroviral treatment
• 74,800 individuals to care for orphans and vulnerable children
• 86,300 individuals to care for HIV-positive people
• 22,200 individuals to provide counseling and testing (in addition to those trained in PMTCT)

Strengthening essential health care systems through health care network and infrastructure development is another key to sustainability. In the reporting period, PEPFAR worked with its governmental and nongovernmental partners to support a minimum of 14,900 service sites in the focus countries. Among these sites were 2,500 PMTCT service outlets, 600 sites that carry out blood safety activities, 800 treatment sites, 6,800 palliative care sites, and 4,200 sites for counseling and testing in settings other than PMTCT.

PEPFAR also supports health system development in the areas of laboratories, clinical quality assurance, and procurement of commodities. The new Partnership for Supply Chain Management will assist host nations in growing their capacity to assure the quality of ARVs and other commodities.

Many developing nations face deficits in the areas of surveillance, reporting, evaluation, and other areas of strategic information needed for accountability and program improvement. In fiscal year 2005, the Emergency Plan supported training or retraining of approximately 17,900 individuals in the focus countries in strategic information.

Another area of continuing focus is “wraparound” programs. Through these programs, PEPFAR coordinates with and leverages resources from other agencies and sectors, such as nutrition and education, to promote comprehensive and effective responses.

Beyond the Focus Countries
The Emergency Plan encompasses all existing and new U.S. Government international HIV/AIDS activities. Bilateral programs operate in 123 countries, including the 15 focus countries and 108 additional countries. Of the $15 billion over five years that President Bush committed to the Emergency Plan, $5 billion represents support for HIV/AIDS programs in these 108 additional countries, as well as support for international research, international partnerships (including the Global Fund), and other activities.

In its first year, PEPFAR established a Five-Year Global AIDS Strategy for achieving the President's goals; since then, the strategy has been implemented in the focus countries. In fiscal year 2005, similar communication, coordinated strategic planning, resource allocation and evaluation mechanisms began to be extended formally to bilateral HIV/AIDS programs in the other 108 countries. After an interagency development process, the Emergency Plan issued general policy guidance for programs in all nations receiving bilateral resources, in order to ensure consistency of all bilateral programs with PEPFAR principles.

In fiscal year 2005, PEPFAR directed $293 million to HIV/AIDS program activities in these 108 nations. Five countries received more than $10 million, 13 received between $5 and $10 million, 20 received between $1 million and $5 million, and 70 received less than $1 million. Going forward, requirements for reporting and documentation are dependent upon fiscal year 2005 HIV/AIDS funding levels. Nations that received over $10 million – Cambodia, India, Malawi, Russia, and Zimbabwe – will have requirements most similar to those of the focus nations.

India remains the largest Emergency Plan program outside the focus nations, with over $26 million in support in fiscal year 2005, up from approximately $17 million in fiscal year 2003. PEPFAR funding for Russia in fiscal year 2005 was almost $14 million, or about twice the level in fiscal year 2003. Emergency Plan coordination with China continues to expand.  

Emergency Plan bilateral programs support a range of prevention, treatment, and care activities and capacity building in the group of 108 countries. In addition to the 15 focus nations, for example, 17 other nations have launched U.S.-financed treatment programs since the beginning of the Emergency Plan, and PEPFAR has provided support for treatment for 70,000 people in these
nations.

This bilateral support is in addition to support provided by the United States through the Global Fund, to which the United States remains the largest contributor, having provided approximately one-third of its funding through fiscal year 2005. Roughly one-third of results achieved by the Global Fund worldwide are thus attributable to U.S. contributions.

Multilateral Leadership
The United States, as a founding member of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and its first and largest donor, continues to play a leadership role in ensuring its success. The United States has already contributed nearly 50 percent more to the Global Fund in just three years than President Bush’s 2003 pledge of $1 billion over five years – a contribution that is in addition to massive U.S. bilateral efforts.

In contrast to some nations, for which the Fund may be the most viable mechanism for matching HIV/AIDS resources to needs in the developing world, the U.S. contribution to the Fund is just one part of a diverse portfolio of investments in HIV/AIDS. In the near term, the most effective use of U.S. resources is through bilateral programs, but support for the success of the Fund is a key part of the overall Emergency Plan strategy. Particularly for nations without strong bilateral programs, the Fund provides a vital mechanism to increase financial commitments to the global HIV/AIDS fight.

At the country level, PEPFAR works to coordinate its bilateral programs with those of the Global Fund under the Three Ones principles for cooperation, under which international partners have agreed to support one national HIV/AIDS framework, one national coordinating authority, and one country-level monitoring and evaluation system in each host nation. In the focus countries, where the United States has committed resources intended to bring prevention, care and treatment programs up to national scale, coordination with the Fund based on comparative advantages is a central focus. Outside the focus countries, PEPFAR bilateral support and technical assistance leverage Fund financing and help to bring prevention, care and treatment programs up to full national scale. Recognizing the importance of U.S. technical assistance to the success of the Global Fund, approximately $14 million is being directed to partners in the field worldwide to provide technical assistance to Fund grantees. These funds will fill a critical need expressed by many grantees and support the success of their grants.

In addition to funding and support for implementation at the country level, the Emergency Plan also offers leadership to assist the Global Fund in such areas as achieving maximum effectiveness, operating with appropriate transparency and accountability, maintaining its performance based funding approach and unique financing role, and supporting country-driven processes and participation. PEPFAR also coordinates programs under the Three Ones principles with UNAIDS, the World Health Organization, and others, and has been a co-sponsor of a number of activities in support of the Three Ones with UNAIDS and other partner nations.

Conclusion
Many doubted that HIV/AIDS programs could ever be successful on a broad scale in the world’s poorest nations.

After two years of the Emergency Plan, it is clear that high-quality programs can work – and are working – in many of the world’s most difficult places. On World AIDS Day 2005, President Bush welcomed a South African mother, son, and daughter to the White House. All three are HIV-positive – and all three are alive and well, thanks to the extraordinary efforts of those in their country who developed their treatment program and the support of the United States. This was one family among millions that have been touched in just the first two years of PEPFAR.

Through the President’s Emergency Plan, the American people are partners with families, communities, and nations that are reclaiming their future.