In order to support HIV/AIDS prevention, care and treatment programs in developing countries United States Government proposed a five year bilateral plan called PEPFAR or the Emergency Plan. According to this plan $15 billion is authorized to spend in five years (2004-2008) for the treatment of HIV/AIDS. This is the largest-ever global health initiative focusing on a single disease. PEPFAR is an initiative taken by US government to help patients suffering from this epidemic in developing countries who cannot afford the medical supervision.1
THE WORLD BEFORE 2003
Never before had the world faced an epidemic with such high magnitude. Lifesaving medicines were largely inaccessible in developing nations. Less than 50,000 people with HIV infection in sub-Saharan Africa had access to anti-retroviral drugs in year 2001. HIV related medical needs absorbed almost all the medical facilities in such regions. Hospitals were filled with HIV patients. Helpless healthcare professionals had to send patients back home to die due to insufficient treatment facilities. The impact of this monster was beyond health sector. AIDS created millions of orphans and robbed the children from the love of their parents. Youth had to leave their education to help their parents and siblings suffering from AIDS. This epidemic paralysed the global economy. People in schools, industries, army, and other occupation were dying more quickly than they could be replaced. Citizens of the country were dying at the age where they could be at the peak in terms of income. Life expectancy in the sub-Saharan region dropped, so did its economy.2
In the time of such crisis a miracle was needed and PEPFAR turned up to be one.
HISTORY AND POLITICAL FRAMEWORK
In May 2003 President George W. Bush signed “U.S. Leadership against AIDS, Tuberculosis and Malaria Act of 2003”. According to this law funds up-to $15 billion were authorized for prevention and treatment of AIDS for over 5 year and OGAC (Office of the Global AIDS Coordinator) was created to manage programs supported by US government for the treatment of HIV/AIDS in developing countries. As per the law an executive branch should also be created that develops a five year strategy and plan the progress that will help in this combat against AIDS.1
The law described the priorities that are to be taken into consideration for PEPFAR funding.
55% of the funding should be for the treatment of the patients suffering from HIV/AIDS.
20% should be dedicated for the prevention of HIV.
15% of the funding for the care of people suffering with HIV.
10% of the funding should be dedicated for the support of orphan and vulnerable children.1
WHAT PEPFAR SUPPORTS?
PEPFAR only supports the programs that are directly linked with HIV/ AIDS prevention, treatment and care.1
Main goals of PEPFAR are to expand partnership with various countries which will spread prevention, treatment and care at a global level. Investments should be made in innovation and operational research to get better outcomes.3
EMERGENCY RESPONSE PHASE I (2003-2008)
A total funding of more than $18 billion had been received by PEPFAR since the time of its creation (September 30, 2008). In a short span of 5 years various hospitals and clinics were built, doctors and nurses were trained and many infected were given treatment. Various educational programs were carried out. Pregnant women received education and proper testing. If they were found to be HIV positive a proper treatment was given to them in order to avoid transmission to their babies. In the first 5 years because of PEPFAR’s tremendous efforts to stop mother to child AIDS transmission around 240,000 babies of HIV positive mothers were born HIV free. Around 4 million orphans and vulnerable children were helped with this program.2
OUTCOMES OF PHASE-I
‘Annals of Internal Medicine’ published in May 2009 found that there was a drop of 10.5% of HIV related mortality in 12 PEPFAR focus countries. Around 1.2 million deaths were averted due to work of PEPFAR.2
COUNTRIES UNDER FOCUS
Around 14 countries were selected by Congress for the PEPFAR resources and these were Cote d’Ivoire, Ethiopia, Haiti, South Africa, Mozambique, Tanzania, Kenya, Namibia, Nigeria, Guyana, Rwanda, Botswana, Uganda and Zambia. Vietnam was the fifteenth country that was added later.
These countries were decided keeping geographical location, HIV prevalence and incidence among general population in mind. Mainly Sub-Saharan African countries were targeted because of its high population and high prevalence. These data were obtained from the demographic health survey.4
Except Vietnam and to some extent Guyana a rapid scale up in the PEPFAR program was observed in all the focus countries.1
While the 6 focus countries (Nigeria, Kenya, Uganda, South Africa, Tanzania, and Zambia) had an annual budget of $100 million and greater, Guyana had $19 million and Uganda had $148 million which were the smallest and largest annual budget of fiscal year 2005.
Around $293 million were dedicated to non-focus country in fiscal year 2005. Of these countries five countries like India, China, Russia, Malawi and Zimbabwe received more than $10 million each.
PARTNERSHIP FRAMEWORKS (PHASE II)
‘Tom Lantos and Henry J. Hyde United States Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act’ was signed in July 30, 2008. This act authorised usage up-to $48 billion from 2009 to 2013 to combat global HIV/AIDS, malaria and tuberculosis. This act authorized the government of United States to establish partnership with host countries and combat HIV/AIDS with joint hands.
A new era of collaborative planning started when PEPFAR signed 22 partnership frame work with various countries in a short span of 2009 to 2013.
Compared to other focus countries Vietnam and Guyana were provided with less funding and increment in the funds over one year was also less compared to other partners.5
90-90-90 GLOBAL TREATMENT TARGET (PHASE III) PEFAR 3.0
UNAIDS (Joint United Nations Programme on HIV/AIDS) has announced 90-90-90 global treatment target. According to this mission 90 percent of people living with HIV will be diagnosed, 90 percent of people diagnosed with HIV will be provided with Antiretroviral Therapy (ART) and viral suppression of 90 percentage of people on ART should be observed.6
Impact, Efficiency, Sustainability, Partnership and Human rights are the 5 action agenda of PEPFAR 3.0.
Impact action agenda
Doing right things at the right place and at the right time is the driving force of PEPFAR’s impact action agenda.
The right thing: This mainly includes providing better quality treatment to the key population who are more prone to HIV like children, adolescent girls etc. A great progress has been made in reducing mother to child HIV transmission. Number of babies born with HIV is reduced to half each year after the launch of PEPFAR.
The right place: this means that the efforts should be made on specific geographic areas where the burden of this disease is high in order to save more life which will in turn change the course of the epidemic.
The right time: The impact of this program should be immediate before there is any further expansion of this deadly disease. This goal can be achieved only if proper partnership is achieved at the right time.6
Efficiency action agenda
The efficiency action agenda mainly focuses on increasing the transparency of the program and to ensure that every taxpayer’s dollar is properly invested and can be tracked.
PEPFAR dashboards are established that will enable any U.S. citizen, donor, host country government, civil society organization and U.S. government agencies to view any PEPFAR funding plans. PEPFAR posts its financial data online in an accessible and easy to use format.6
Sustainability Action Agenda
Once PEPFAR successfully achieves epidemic control this agenda ensures continuous availability of resources and financial assistance for sustained control.6
Partnership action agenda
Partnership is the major weapon of PEPFAR to control HIV/AIDS epidemic. The following are the partners of PEPFAR that works on the control of HIV/AIDS.
Public private partnership: Main aim is to develop partnership with the private sector to obtain large donations and will help in curing the epidemic.
Multilateral partnership: Partnership between the Global Fund, UNAIDS and PEPFAR program helps to support this cause of HIV/ AIDS eradication.
The Global Fund to fight AIDS, Tuberculosis and Malaria: It is an international financing organization that aims to gain and distribute additional resources for the prevention and treatment of AIDS, malaria and tuberculosis.
Co-sponsoring agencies of UNAIDS is important partner to PEPFAR and help in the cause of prevention and treatment of AIDS.
PEPFAR countries: Combined funds by PEPFAR and its partner countries helps for the common cause.6
Human rights action agenda
This agenda mainly focuses on the cultural and social obstacles that hinder in abolishing this epidemic. To achieve this it is very important that PEPFAR works closely with the government of the partner countries.
The main goals of this human rights agenda are:
To expand the reach of this PEPFAR program to all people including LGBT.
Reduction in domestic violence and increase in gender equality for obtaining HIV services.6
STRUCTURE OF THE ORGANIZATION
Office of the US Global Aids Coordinator (OGAC) along with other United State government agencies manages PEPFAR. US Embassies and US government agency offices of partner countries bear the responsibility of implementing this program in their respective countries.1
Headquarters: Dedicated staffs at USG agencies such as Office of HIV/AIDS at USAID and Global AIDS program at CDC along with the collaboration and support by OGAC manages PEPFAR. President and the Senate appoint the Global AIDS co-ordinator who reports directly to the Secretary of State. The funding within focus and non-focus countries is controlled by OGAC.1
Field: US ambassador signs off on all the documents and planning of PEPFAR in the focus countries and directly reports to the Global AIDS co-ordinator.
US Agency for International Development helps in testing of HIV in various regions. It also aims at providing home based care for the patients infected with HIV. Support to orphan and vulnerable children are taken care by this agency.1
Centres for Disease Control and Prevention: CDCP mainly focuses on improvement of the infrastructure and the facilities that could aid in treatment of the disease. It helps in improving the safety during the injection and blood transfusion that could resist the spread of HIV through transfusions in the hospitals. CDCP focuses its strength in developing various laboratories in the host countries. With the support of the host government CDCP helps in bringing improvement in the disease surveillance program and in bringing advanced anti-retroviral treatment programs in the host countries.1
Department of Defence: Efforts in improving the facilities for HIV testing and anti-retroviral treatment in militaries and military family is carried out by DOD.1
Department of Labour: Department of labour with the help of PEPFAR resources provide technical help and education at various workplace in various areas of the focus countries. One of the main aim of this department is to reduce the discrimination by increasing the awareness amongst the workers.1
Peace Corps: Additional volunteers to help at the health centres or in HIV/AIDS prevention activities are provided by Peace Corps with the help of PEPFAR resources.1
US Embassy: US Embassy supports the PEFAR program by approving certain community grants or individual grants based on the proposal that could help in the prevention of the disease.1
Before each fiscal year (October 1st) a meeting is held between US agencies and the partner country government to plan and discuss the budget of the PEPFAR program. The proposed budget is approved with the host country government and then sent to the approval to the OGAC.1 The programs in the focus countries are comprised of a mix of three types of management approaches:
Country Managed, Country Funded Programs: These programs are funded and managed by United State agencies in the host countries. Many of these funds are because of the direct agreement between the United State Government and the host countries.
Centrally Managed, Country Funded: These projects are managed centrally but maximum amounts of the funds are obtained from the host countries. These projects are either pre-existing between the US government and the host countries before PEPFAR or new projects are established with the focus countries keeping the necessity of the program into consideration.
Centrally Managed Centrally Funded: These programs were implemented in year 2004 to achieve a rapid scale up in treatment and prevention of AIDS in focus countries. These programs were designed by OGAC and implemented by one of the central US government agencies.1
Two result reports are submitted to the OGAC by USG’s every year:
a) Semi-annual report is submitted to the OGAC covering the results of the first six months of the fiscal year in the month of May.
b) Annual report is submitted covering the results of the entire fiscal year in November.
Generally the data are provided on
No. of service outlet assisted.
No. of patient served.
No. of technically assisted organisation.
No. of trained personal.1
PEPFAR latest global results
There are clear evidence of decrease in the epidemic in many African countries and are slowly heading towards the 90/90/90 target. Because of the support of PEPFAR, by 2016 around 11.5 HIV patients are on anti-retroviral treatment, nearly 2 million babies are born HIV free which otherwise would have been infected, 1.1 million children are getting the anti-retroviral treatment, around 1 million adolescent girls and women were contacted and proper education and awareness was spread, 220,000 workers were trained with the support of Department of Labour. With the support of PEPFAR in the year 2016 around 74.3 million people were tested for HIV infection which included 11.5 million pregnant women.7
PEPFAR partnership to fight HIV/AIDS in India
Although national HIV prevalence in India is low (0.3%) because of its large population it makes India the third largest epidemic in the world. In India an estimate number of people living with HIV are 2.4 million. Around 68,000 people die in India because of AIDS.2 In India this epidemic is concentrated to certain key population that includes men who have sex with men, sex workers and their clients, transgenders and people who are under the influence of drugs. 90% of the new infection are because of the sexual transmission.8
The main goal of PEPFAR program in India is to provide technical assistance to the HIV program implemented by government of India. PEPFAR has recognised certain regions in India that has high prevalence of HIV infection and need an accelerated epidemic control. As per the research performed in year 2015, districts in the states of Maharashtra, Andhra Pradesh, Manipur, Mizoram and Nagaland were identified as focus areas and of high priority. With the support of PEPAR and many other government plans to curb AIDS, India has successfully reduced the national prevalence of AIDS to 0.26% by year 2015 which once was 0.38 in 2001-2003.9
The HIV infection prevailing in children is one of the most important and unique challenge that the world is trying to resolve.
Keeping our future in mind PEPFAR is aiming to protect children from HIV/AIDS infection and to provide proper treatment to the ones who are already infected.
The host nations have remarkably accomplished the task of controlling HIV infection with the aid of governmental and non-governmental organisations. PEPFAR has brought the people of the United States together for a common cause to curb this epidemic. Thus PEPFAR is the most generous gift the United States has provided to future generations of those countries most in need.