Countries with longstanding partnerships under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) have seen increased economic growth and opportunity. Equally important, they have experienced an increase in average life expectancy of as much as 18 years (Figure 1) from addressing the HIV epidemic. Launched in 2003, PEPFAR has saved 26 million lives and prevented over 7.8 million babies from contracting HIV. PEPFAR’s work alongside governments, communities, and the private sector changed the tide of the HIV pandemic. However, despite significant financial investment, progress against HIV varies across countries.
Note: Countries represented in each figure have a similar HIV burden (over 1 million individuals living with HIV).
Source: World Health Organization
The dramatic increase in access to lifesaving HIV treatments and the resulting significant declines in HIV-related deaths (Figure 2) have significantly driven the life expectancy improvement in sub-Saharan Africa. Much of the credit for this progress goes to investments made by PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, to which the United States is the primary contributor. Both programs supported the significant expansion of physical health infrastructure and additional human resources for health. Greater impact is visible in countries whose governments adopted an integrated approach to health care across rural and urban areas. These include better community-level access to immunizations, maternal and child health care, and treatment for noncommunicable diseases as well as improved health care efficiency through increasing the tasks health care workers are trained to perform. Other countries lag in performance despite significant investment, continuing to have greater than 25,000 deaths per year.
Source: UNAIDS
Several countries are close to achieving the target of ending AIDS as a public health threat by 2030, part of the sustainable development goals adopted by the United Nations General Assembly in 2015. But other countries are falling behind as misdirected priorities and a lack of political will have resulted in new, preventable infections and deaths.
Four tenets have been key to PEPFAR’s success in the countries that have made the most progress and can be translated to countries still facing challenges:
- Clear, quantifiable goals that dictate strategy, both overall and at the individual country level.
- Proactive, rigorous management which ensures both quantitative and qualitative data continuously inform decision-making and the allocation of resources.
- Close collaboration with communities most affected by the pandemic, including host governments and their partners shaping programmatic implementation at the country level.
- Cooperation among global institutions (such as UNAIDS, the World Health Organization, and the Global Fund), bilateral programs (like PEPFAR), and country governments to ensure policy and funding align to maximize effectiveness.
Through the application of these four tenets, national governments and PEPFAR have together developed innovative, effective solutions that can meet the needs of all people living with HIV. Each community, age group, vulnerable population, and gender has unique needs and faces barriers to access HIV testing, prevention, and treatment services through traditional health care, PEPFAR-supported surveys have shown. Adjustments to meet these challenges have allowed the countries listed in Figure 1 and Figure 2 – including South Africa, home to the largest HIV burden in sub-Saharan Africa – to see significant positive changes to life expectancy and declines in AIDS-related deaths.
PEPFAR has worked with partner countries to consistently use granular data in real-time to evaluate progress and understand whether innovations are working to their fullest extent. This has created a culture of “failing fast” – programs can introduce changes and make quick decisions, based on evidence, on whether to scale country programs up or discard them.
In the most successful countries, PEPFAR and its partners ensure resources align with needs and support the most effective approaches. First, PEPFAR and its partners create and implement new programming and policies that improve access to HIV care and streamline the patient experience. This has resulted in the rapid adoption by national governments of new policies that expand clinic hours in public facilities, create additional and nontraditional access points outside of the public sector, and allow multiple-month prescriptions for antiretroviral drugs (ART).
Second, PEPFAR has engaged continuously with community groups that understand the specific needs of each individual population (age, gender, and marginalized communities) in the countries in Figures 1 and 2 that have experienced increases in life expectancy and reduced mortality from AIDS. In particular, PEPFAR has funded local community- and faith-based organizations to deliver prevention and treatment services in new ways that make it easier for patients to access care. The constant review of programmatic data and consistent engagement with communities allow PEPFAR to understand who is being left behind and create programming tailored toward those who need it most.
The countries that are on track to achieve the global target to end AIDS as a public health threat can maintain their progress through focused effort. Governments will need to evaluate their national HIV programs consistently, determine what will be needed post-2030, and increase sustainable public-sector funding accordingly. They will need to find cost savings across all programs and teams and use data in real time to see what efficiencies they can achieve without reducing effectiveness. Finally, governments and their partners also must validate programmatic data through community-level household surveys to ensure progress continues across all ages, genders, and risk groups and implement new policies based on the findings.
In particular, the increases in life expectancy and income in many southern African countries create a moment for transition to national financing and management. This will allow PEPFAR to expand prevention activities in specific lower-income countries and tackle the continued high level of HIV transmission among key populations.
Source: UNAIDS
To save lives and end HIV/AIDS as a public health threat, PEPFAR must focus its resources strategically and ensure governments, the private sector, and their partners sustain the health networks that PEPFAR and the Global Fund have supported. Several countries that have received long-term financial support from PEPFAR and the Global Fund have seen only modest gains in life expectancy or are still experiencing high numbers of new HIV infections (Figure 3). These countries are also not yet meeting the U.N.’s sustainable development goal to end AIDS as a public health threat by 2030. Each of these countries has specific challenges, but several common factors explain their lack of progress against HIV, both in terms of new infections and deaths and overall life expectancy, despite large investments by external donors.
The governments of most of these countries have policies in place that prevent people living with HIV from knowing their status, accessing treatment, and being virally suppressed. Some of these countries also have stigmatizing legal frameworks and high levels of discrimination that create greater vulnerabilities, lengthen the pandemic, and increase outyear costs of HIV programming. Reforms to clinical practice are needed to make care more accessible to clients. Missing elements include community engagement and the direct funding of community groups by donors and host governments.
It is disheartening that this lack of progress has resulted in new preventable infections and deaths, since most of these countries have the resources to address their current HIV epidemics. The current situation is a direct reflection of misdirected priorities and a lack of political will. PEPFAR and other donors can and must hold the governments of these countries accountable. We must demand the actions necessary to make our – and their – resources work for communities. Future PEPFAR funding in these countries should depend on an increased prioritization of people and their health – as demonstrated by policy and programmatic improvements – with specific outcome and impact measurements validated by outside groups.
Finally, we must remember that even those countries that have made significant gains over the last 20 years might not be on track to sustain that progress into the future. All countries show that money alone is never enough and that the continuous use of data to define gaps and adjust policies is critical to success. An important ongoing consideration will be ensuring that all members of marginalized communities have full access to the services they require.
The primary driver of costs in the future will be the number of individuals on antiretroviral treatment. Therefore, the key to long-term sustainability is a decline in new infections. Without reducing new infections steadily, year over year, no HIV program will remain successful. Those countries that show only small declines in deaths while experiencing persistently high new infections will have the highest long-term costs. The good news is that PEPFAR’s core tenets can be translated to countries that are still facing challenges, and efficiencies in implementation are still possible with the application of data and evidence.
The Bush Institute would like to thank Chris Collins, President and CEO, Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria; Dr. Jennifer Kates, Senior Vice President, Director of Global Health and HIV Policy, KFF; and Dr. Jirair Ratevosian, Hock Infectious Disease Fellow at the Duke Global Health Institute, for their review of this paper.
