The President's Emergency Plan for AIDS Relief: Second Annual Report to Congress
The President's Emergency Plan for AIDS Relief: Second Annual Report to Congress
Office of the U.S. Global AIDS Coordinator
Office of the U.S. Global AIDS Coordinator
February 8, 2006
February 8, 2006

members of Emergency Plan team pose for group photo after being awarded Spirit of PEPFAR award

"We're making good progress, and none of it would be possible without the devotion and professionalism of our partners on the ground: courageous leaders of African nations who care about their people and who tell the truth; doctors and pharmacists who work without rest in overcrowded wards; health workers, often with HIV themselves, who visit homes and make sure people are taking their medicine; people who run youth groups and clubs that encourage abstinence and help children with HIV face the challenges of life."
-- President George W. Bush,
World AIDS Day December 1, 2005

Implementation and Management

Goal: Efficient, effective, and accountable use of resources

Achievements in Fiscal Year 2005:

  • Obligated approximately $2.9 billion
  • Expanded PEPFAR strategic vision to all bilateral HIV/AIDS programs and transferred key country team best practices beyond the focus countries
  • Developed new tools to strengthen and improve performance-based budgeting
  • Established a task force to streamline reporting burdens on field personnel and implementing partners and streamlined the semi-annual results reporting process
  • Established a technical working group on commodities procurement
  • Established a consortium of partners for supply chain management
  • Held second annual field meeting to facilitate flow of lessons learned and best practices among Emergency Plan personnel and with key implementing partners

At the inception of the Emergency Plan, the imperative to embrace a "new way of doing business" created numerous implementation and management challenges. New organizations were created within the U.S. Government (USG), and existing organizations began to work together in new ways, in order to implement the unified PEPFAR approach to global HIV/AIDS.

At the end of the second year of PEPFAR implementation, structures and practices are continuing to evolve. Yet in light of the early results achieved by the Emergency Plan, there is a broad recognition - widely shared within and beyond the USG - that the interagency PEPFAR model is working and should be maintained. Credit for this belongs to the people of the Emergency Plan's primary implementing agencies - the Departments of State, Defense, Health and Human Services, Commerce, and Labor; the U.S. Agency for International Development; and the Peace Corps. Both in the field and in Washington, they have demonstrated the power of a unified USG response.

The character of the implementation and management challenges facing the Emergency Plan has changed. Increasingly, the issues are no longer the organizational "startup" issues of a new venture, but the challenges of a highly successful venture that must manage rapid growth. With leadership from the Office of the U.S. Global AIDS Coordinator (OGAC) and the commitment of the implementing agencies, the Emergency Plan is focused on these operations challenges.

Operations initiatives
Key policy structures established during fiscal year 2004 were maintained and strengthened. The U.S. Global AIDS Coordinator continues to chair a weekly policy meeting of principals from the lead implementing agencies, while OGAC senior staff chair a weekly meeting of deputy principals focused on program management issues. A Scientific Steering Committee also meets regularly to ensure the highest quality technical approaches and leadership. Decision-making processes have been formalized and overall communication has been strengthened.

Technical and operations working groups, co-chaired by OGAC and agency personnel with headquarters and field representation, formulate technical guidance and support implementation in the field. An interagency Core Team also continues to serve as a channel for information to flow between the field and headquarters, as well as a source of technical assistance. Weekly News to the Field email messages also serve as a vehicle for dissemination of guidance and other information to the field.

Policy guidance for program implementation in the field was issued or is in the final stages of development in the following areas: Prevention of Sexual Transmission of HIV using the Abstinence, Be Faithful, and correct and consistent use of Condoms (ABC) approach; Palliative Care; Orphans and Vulnerable Children (OVC); Preventive Care Packages for Adults and Children; Injecting Drug Use; Procurement of Commodities; and Food and Nutrition.

The Coordinator decided not to pursue appointment of a Chief Operating Officer, as was contemplated at the time of last year's Annual Report to Congress. Instead, an operations division was established within OGAC to troubleshoot issues and devise systematic solutions.

In the focus countries where the interagency country team approach has been pioneered, it has sharpened the focus of programming, helping to ensure that decisions are made in a strategic fashion. This model has also helped to promote a unified strategy and voice for interactions with host governments and other partners. The expansion of this successful approach to a growing number of countries will be a PEPFAR priority in fiscal year 2006 and beyond. In the field, PEPFAR is working to disseminate best practices developed in the focus countries to the larger group of nations in which the Emergency Plan operates. One of these best practices is the country team leadership model. While this model is expected to be in place in all USG bilateral programs, in eleven additional countries in fiscal year 2005, additional steps were taken to consolidate a strategic interagency approach.

The heart of this approach is Ambassadorial leadership of a unified interagency team, which produces a five-year country USG strategy and an annual Country Operating Plan (COP) outlining the allocation of budget and activities to describe how the strategy is made operational. In keeping with the principles of the Three Ones, these are developed in close consultation with implementing partners in country, in particular the host country government, to 1) reflect unique challenges and opportunities for each country; 2) ensure support of host-country HIV/AIDS strategies; 3) effectively build on the comparative advantage of USG expertise; and 4) complement other international partners' programs. Eleven additional countries outside of the 15 focus countries submitted five-year country strategies and five of these countries also submitted modified COPs for fiscal year 2006 planning.

The COP, submitted by U.S. Ambassadors in their capacities as leaders of PEPFAR country teams, is a statement of annual targets for the coming year, along with detailed program and budget plans to achieve them. Because they offer a detailed description of what the USG expects of each implementing partner for the year, the COPs have proven to be a key tool for tracking partner performance in-country. Fiscal year 2006 is the third year for which COPs have been required in the focus countries, and both the COPs themselves and the process for their review continue to improve with each year of experience. After submission of the COPs to OGAC, an interagency technical team assessed the technical quality of proposed activities and management as well as consistency with Emergency Plan strategies. Programmatic teams then reviewed entire COPs from a more strategic perspective, incorporating the technical findings. The findings were then discussed in detail with country teams. Program review teams submitted recommendations and comments to an interagency principals committee chaired by the Coordinator, who made final funding decisions.

Ambassador Tobias views drugs stored at medical facility in Namibia
The results reporting system is critical to Emergency Plan accountability and is another key element of this country team approach. It is being expanded in stages to the bilateral programs outside of the focus countries. In fiscal year 2006, all bilateral programs that receive $1 million or more in USG HIV/AIDS funding will report against a set of indicators standardized across the Emergency Plan. Specific reporting requirements by country are determined by funding level and are detailed in the general policy guidance document for all bilateral programs that is explained in the chapter on Strengthening Bilateral Programs Worldwide.

In order to facilitate transparent communication with the general public as well as PEPFAR personnel and partners, OGAC significantly upgraded its website in fiscal year 2005, making a growing amount of information on program activities available. Further website improvements are planned for fiscal year 2006. OGAC is also developing an Information Technology Strategic Plan. This will promote use and dissemination of relevant PEPFAR information to the public and to personnel and partners in the field, as well as addressing the operational needs and data management issues of PEPFAR.

In order to evaluate the staffing required to implement and manage PEPFAR, OGAC is examining current staffing requirements at headquarters and in the field, with the goal of developing a long-term USG staffing plan for implementation of HIV/AIDS programs.

Performance-based budgeting From its inception, the Emergency Plan has insisted on tying funding to results, a practice not always characteristic of international development initiatives. Funding and continuation of partnerships with individual partners depends on their performance against the targets set by country teams and partners and finalized in the COPs.

In the field, country teams conducted annual reviews of partner performance prior to submitting COPs for the succeeding year. In particular countries, these reviews have included:

  • Pipeline analysis to assess partner efficiency in putting funds to work

  • Assessment of cost-effectiveness of partner activities

  • Performance of partners against targets established in the COPs

The Emergency Plan has developed significant new tools to strengthen this performance-based budgeting approach. Based on analysis conducted during fiscal year 2005, select high-performing countries received additional resources for fiscal year 2006, while others that performed below expectations were maintained at their base levels. In fiscal year 2006, PEPFAR will continue to apply and refine its tools for performance-based budgeting to ensure optimal use of prevention, treatment, and care resources.

As of September 30, 2005, the Emergency Plan had obligated approximately $2.9 billion during fiscal year 2005.

Annual field meeting
"Building on Success: Supporting National Strategies," the Second Annual Field Meeting of the Emergency Plan, was held in Addis Ababa, Ethiopia in May 2005, providing an opportunity for an exchange of information in many directions. Ambassador Tobias presents Against All Odds Award to Haiti Country Team Members
The Field Meeting, which had been limited to USG personnel in 2004, was opened to representatives from selected PEPFAR partners, including those from host governments and indigenous community- and faith-based organizations. In addition to extensive programmatic presentations and papers, representatives of the Emergency Plan teams in each focus country - led by their Ambassadors - reported on their implementation challenges, successes, and lessons learned. This sharing of information generated invaluable dialogue among the teams.

Streamlining reporting requirements
The Field Meeting included significant opportunities for conversation between field teams and OGAC headquarters personnel. One recurring theme expressed by personnel in the field was concern about the burdens they face in reporting information to OGAC, host governments, their home USG agencies, and other entities that conduct reviews of PEPFAR operations. Many personnel described these reporting obligations as limiting their efforts to manage other activities.

In response, OGAC organized a Reporting Burden Task Force, which conducted field visits and discussions with personnel in the implementing agencies and with partners to investigate the reporting requirements - both from the Emergency Plan and from other sources - facing PEPFAR personnel.

This Task Force has already completed an initial assessment in four countries and is working on several recommendations to the Coordinator on opportunities for streamlining reporting requirements while ensuring continued collection of information needed for such purposes as accountability and quality assurance. Already, the reporting requirements for the March semi-annual report have been significantly streamlined.

Commodities procurement PEPFAR efforts to build capacity for the delivery of services in the focus countries have succeeded to such a degree that capacity in many countries now exceeds USG funds to provide services. This situation makes it essential to ensure that available funds are being used with maximum efficiency. With the rapid growth in the availability of treatment services under PEPFAR, management issues around the procurement of commodities - including antiretroviral drugs (ARVs) - are important. Interruptions in the supply of ARVs are potentially disastrous for people who are receiving life-saving treatment services and the Emergency Plan is committed to supporting a supply system that avoids this situation.

To address any issues as they arise while also planning for the future, the Emergency Plan established an interagency commodity procurement technical working group in fiscal year 2005. This working group is actively engaged and has worked closely in countries such as Haiti, Zambia, Vietnam and South Africa to prevent any interruption in ARV supply. In addition, the working group has identified as a best practice the need to have one member of the USG in-country team designated as the point person for commodity procurement across USG agencies. In fiscal year 2006 the group will work with the Partnership for Supply Chain Management to help establish standard commodity projection and procurement plans for countries, as well as guiding implementation of the new partnership, described in the chapter on Building Capacity for Sustainability, as it improves commodities procurement.

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Implementing Departments and Agencies
For the President's Emergency Plan for AIDS Relief

Department of State
The U.S. Global AIDS Coordinator reports directly to the Secretary of State. At the direction of the Secretary, the Department of State's support for the Office of the Global AIDS Coordinator (OGAC) includes providing human resources services; tracking budgets within its accounting system; transferring funds to other implementing agencies; and providing office space, communication, and information technology services. Chiefs of Mission provide essential leadership to interagency HIV/AIDS teams in the focus countries and, along with other U.S. officials, engage in policy discussions with host-country leaders to generate additional attention and resources for the pandemic and ensure strong donor coordination. The Coordinator has also created the President's Emergency Plan for AIDS Relief Small Grants Programs to make 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. The Department's programs under the FREEDOM Support Act and the Support for Eastern European Democracies Act also contribute to combating the HIV/AIDS pandemic under the Emergency Plan.

The Department also implements a variety of diplomatic initiatives and other community-based HIV/AIDS programs through its embassies in 162 countries. Most of these activities focus on prevention. Embassies also use the 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 (HHS)
HHS has a long history of HIV/AIDS work within the United States. Under the Emergency Plan, through its Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), and Substance Abuse and Mental Health Services Administration (SAMHSA), HHS implements prevention, care, and treatment programs in developing countries and conducts HIV/AIDS research. HHS field staff also work 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 (USG) programs.

Examples of HHS programs and activities follow:

  • The CDC Global AIDS Program (GAP) has highly trained physicians, epidemiologists, public health advisors, behavioral scientists, and laboratory scientists working in offices in 24 countries (including the 15 focus countries) as part of USG teams implementing the Emergency Plan. Additionally, GAP Headquarters supports 25 countries through its regional offices in Asia, the Caribbean, Central America, and Southern Africa and provides technical and financial support to six additional countries through GAP offices in neighboring countries. With technical assistance from regional and headquarters offices, CDC's Global AIDS Program assists with surveillance, laboratory capacity building, training, monitoring, evaluation, and implementation of HIV/AIDS prevention, treatment, and care programs through partnerships with host governments, ministries of health, non-governmental organizations, international organizations, U.S.-based universities, and the private sector to help implement the Emergency Plan, including supporting the Global Fund to Fight AIDS, Tuberculosis and Malaria. GAP is uniquely positioned to coordinate with CDC's other global health programs, such as global disease detection, public health training, and prevention and control of other infectious diseases such as malaria and tuberculosis, as well as with CDC's domestic HIV/AIDS prevention programs in the United States.
  • NIH supports a comprehensive program of basic, clinical, and behavioral research on HIV infection and its associated opportunistic infections, coinfections, and malignancies. This research will lead to a better understanding of the basic biology of HIV, the development of effective therapies to treat it, and the design of better interventions to prevent new infections, including vaccines and microbicides. NIH supports an international research and training portfolio that encompasses more than 90 countries and is the lead federal agency for biomedical research on AIDS.
  • HRSA builds human capacity for scaling up care and treatment based on its more than 20 years of experience in providing quality comprehensive HIV/AIDS care to underserved communities. Strategies are implemented 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 manages an expedited review process to ensure that OGAC can buy safe and effective antiretroviral drugs for the Emergency Plan at the lowest possible prices. FDA's medical reviewers, scientists, and inspectors are uniquely qualified to do this work.
  • SAMHSA works domestically through domestic State and community programs to treat addiction and dependence, to prevent substance abuse, and to provide mental health services, including support of an educational and training center network that disseminates state-of-the-art information and best practices. This technical expertise and program experience is being applied to the program areas of drug and alcohol abuse in the Emergency Plan.
  • The Office of Global Health Affairs in the Office of the Secretary coordinates all of the HHS agencies to be sure all of the Department's resources are working effectively and efficiently under the leadership of the Coordinator.

U.S. Agency for International Development (USAID)
USAID currently supports the implementation of Emergency Plan HIV/AIDS programs in nearly 100 countries, through direct in-country presence in 50 countries and through seven regional programs in the remaining countries. As a development agency, USAID has focused for many years on strengthening primary health care systems to prevent and more recently treat a number of communicable diseases, including HIV/AIDS. Under the Emergency Plan, USAID's staff of foreign service officers, trained physicians, epidemiologists, and public health advisors works with governments, nongovernmental organizations and the private sector to provide training, technical assistance, and commodities, including pharmaceuticals, to prevent and reduce the transmission of HIV/AIDS and provide care and treatment to people living with HIV/AIDS. As the HIV/AIDS epidemic in most countries outside of the focus countries is still limited to high-risk groups, USAID focuses considerable resources on reducing high-risk behaviors in high-risk groups and the general population.

USAID is uniquely positioned to support multisectoral responses to HIV/AIDS that address the widespread impact of HIV/AIDS outside the health sector in highprevalence countries. In these countries, USAID is supporting programs in areas such as agriculture, education, democracy, and trade that link to HIV/AIDS and mutually support the objective of reducing the impact of the pandemic on nations, communities, families, and individuals.

Under the Emergency Plan, USAID also supports a number of 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; and works with local coordinating committees of the Global Fund to improve implementation of Fund programs and their complementarity to USG programs. Finally, USAID supports targeted research, development and dissemination of new technologies (including microbicides), and packaging and distribution mechanisms for antiretroviral drugs.

Department of Defense
The Department of Defense (DoD) implements a number of 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 in more than 70 countries encompassed by the Emergency Plan. These activities are accomplished through direct military-to-military assistance, engagement of nongovernmental organizations, and universities. Under the Emergency Plan, in addition to supporting a broad spectrum of military-specific HIV prevention programs, infrastructure assistance (including laboratory space, equipment, and training), and care activities, the DoD HIV/AIDS Prevention Program (DHAPP) hosts a one-month HIV/AIDS training program for military clinicians providing HIV-related care. DoD international HIV/AIDS programs support six clinical trial and vaccine research sites and have established permanent laboratory and research capabilities in nine countries. Under its humanitarian assistance programs, DoD also provides rudimentary construction to support civilian HIV programs.

Members of the Defense Forces in thirteen Emergency Plan focus countries have been the recipients of DoD military-specific HIV/AIDS prevention, care and treatment programs designed to address their unique risk factors. In these thirteen countries alone, military programs have the potential to impact over 1.2 million active duty troops. With PEPFAR support and in collaboration with the USG, ministries of defense in Emergency Plan countries have developed culturally-appropriate peer education, drama, video, and interactive "edutainment" methods of sharing comprehensive prevention messages with their troops. Military members have been trained to promote HIV prevention on an individual level, and country military programs have supported targeted condom service outlets, with some countries even developing a military-specific theme for packaging and distribution to appeal to soldiers. In 13 of the focus countries, ministries of defense and DHAPP have jointly supported counseling and testing centers. Integrating HIV testing into routine care is also being supported through successful peer-based prevention and education efforts and large-scale efforts to reduce stigma and discrimination in military communities.

Department of Labor
The Department of Labor implements Emergency Plan projects that target the workplace for prevention education and strengthen the response to HIV/AIDS by providing technical assistance to governments, employees, and labor leaders. Under the Emergency Plan, the Department also supports an international assistance program to reduce workplace stigma and discrimination against people living with HIV/AIDS. Another extensive international technical assistance program focuses on child labor and works with the International Labor Organization, UNICEF, and nongovernmental and faithbased organizations to implement programs targeting HIV-affected children forced to work and children involved in prostitution. The International HIV/AIDS Workplace Education Program (IHWEP) works with leaders of business, government, and labor to combat HIV/AIDS through prevention education and promotion of antidiscrimination policies. The program focuses on three major components:

  • Education - Increasing awareness and knowledge of HIV/AIDS by focusing on a comprehensive workplace education program, including the ABC approach and linkages with testing, counseling, and other support services
  • Policy - Improving the workplace environment by helping business, government, and labor develop and implement workplace policies that reduce stigma and discrimination associated with HIV/AIDs
  • Capacity - Building capacity within employer associations, government, and trade unions to replicate workplace-based programs in other enterprises; improving worker access to testing, counseling, and other supportive HIV/AIDS services

Peace Corps
The Peace Corps is heavily involved in the fight against HIV/AIDS, having programs in over 90% of its 71 posts, serving 77 countries throughout the world. The Peace Corps implements Emergency Plan programs in 9 of the 15 Emergency Plan focus countries-Botswana, Zambia, Namibia, South Africa, Mozambique, Kenya, Tanzania, Uganda, and Guyana. The Peace Corps posts in these countries are using Emergency Plan resources to enhance their HIV/AIDS programming and in-country training; field additional Crisis Corps and Peace Corps volunteers specifically in support of Emergency Plan goals; and provide targeted support for community-initiated projects.

The Peace Corps is uniquely positioned as a grassroots capacity-building organization to play an essential role in any country strategy aimed at combating HIV/AIDS. The Peace Corps' involvement in the Emergency Plan acts as a catalyst as Peace Corps volunteers provide long-term capacity development support to nongovernmental, community-based, and faith-based organizations with particular emphasis on ensuring that community-initiated projects and programs provide holistic support to people living with and affected by HIV/AIDS. Peace Corps volunteers also aim to develop the necessary management and programmatic expertise at recipient and beneficiary organizations to ensure long-lasting support, particularly in rural communities.

Department of Commerce
The Department of Commerce has provided and continues to provide in-kind support to the President's Emergency Plan for AIDS Relief aimed at furthering private sector engagement by fostering public-private partnerships. Recent activities include:

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

  • The creation and dissemination of sector-specific strategies for various industries (e.g., consumer goods, oil and extractives, health care) detailing to companies concrete examples of how the private sector can be engaged in HIV/AIDS
  • Departmental support for various private sector activities such as the Business-Higher Education Forum and events with the Global Business Coalition on HIV/AIDS
  • 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 has been able to reach out to businesses and industry and what other organizations might do
  • Regular contact with dozens of companies working in an HIV/AIDS capacity around the world to discuss coordination and identify opportunities for public-private partnerships

The U.S. Census Bureau, within the Department of Commerce, is also an important partner in the Emergency Plan. Activities include assisting with data management and analysis, survey support, estimating infections averted, and supporting mapping of country-level activities.