PEPFAR IMPLEMENTATION PROGRESS AND PROMISE Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation Board on Global Health Board on Children, Youth, and Families Jaime Sepúlveda, Charles Carpenter, James Curran, William Holzemer, Helen Smits, Kimberly Scott, and Michele Orza, Editors THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by Contract No.SAQMPD05D1147 between the National Acad- emy of Sciences and the U.S. Department of State. Any opinions, fndings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not neces- sarily refect the view of the agency that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation. PEPFAR implementation : progress and promise / Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation, Board on Global Health, Board on Children, Youth, and Families ; Jaime Sepúlveda ... [et al.] editors. p. ; cm. Includes bibliographical references. ISBN-13: 978-0-309-10982-6 (hardback : alk. paper) ISBN-10: 0-309-10982-5 (hardback : alk. paper) 1. AIDS (Disease)—Prevention— Government policy—United States. 2. HIV infections—Prevention—Government policy— United States. 3. AIDS (Disease)—Prevention—International cooperation. [DNLM: 1. Government Programs—organization & administration—United States. 2. HIV Infections—prevention & control—United States. 3. Disease Outbreaks—prevention & control—United States. 4. Emergencies—United States. 5. International Coopera- tion—United States. 6. World Health—United States. WC 503.6 I585p 2007] I. Sepúlveda Amor, Jaime. II. Title. RA643.83.I57 2007 362.196´9792—dc22 2007023493 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. COVER: The fags of the 15 PEPFAR focus countries are overlaying the global symbol of the red ribbon for HIV/AIDS awareness arranged in alphabetical order by country. Suggested citation: IOM (Institute of Medicine). 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health. The National Academy of Sciences is a private, nonproft, self-perpetuating society of distinguished scholars engaged in scientifc and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. 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Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org COMMITTEE FOR THE EVALUATION OF PEPFAR IMPLEMENTATION Jaime Sepúlveda (Chair), 2007 University of California, San Francisco Presidential Chair and Visiting Professor Helen Smits (Vice Chair), Former Faculty of Medicine, Eduardo Mondlane University, Mozambique Charles Carpenter (Treatment Subcommittee Chair), Professor of Medicine, Director of the Brown University AIDS Center, Brown University, Providence, Rhode Island James Curran (Preention Subcommittee Chair), Dean, Professor of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia William L. Holzemer (Care Subcommittee Chair), Professor of Nursing and Associate Dean, International Programs, School of Nursing, University of California, San Francisco Stefano M. Bertozzi, Director of Health Economics, National Institutes of Health, Mexico Geoff Garnett, Professor of Microparasite Epidemiology, Faculty of Medicine, Imperial College, London, United Kingdom Ruth Macklin, Head, Division of Bioethics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York Affette McCaw-Binns, Professor, Reproductive Health Epidemiology, Section of Community Health, University of the West Indies, Jamaica A. David Paltiel, Professor, Yale School of Medicine, Yale School of Management, New Haven, Connecticut Priscilla Reddy, Director, Health Promotion Research and Development Unit, Medical Research Council of South Africa David Ross, Director, Public Health Informatics Institute, Decatur, Georgia Heather Weiss, Director, Harvard Family Research Project, Harvard University, Boston, Massachusetts Subcommittee Members, Liaisons, and Study Consultants Maureen Black, John A. Scholl Professor of Pediatrics, University of Maryland School of Medicine, Baltimore Hoosen Coovadia, Victor Daitz Professor of HIV/AIDS Research, Centre for HIV/AIDS Networking, Doris Duke Medical Research Institute, University of Kwazulu/Natal, Durban, South Africa Henry Fomundam, Regional Director, Howard University/PACE Centre, Washington DC/South Africa Paul Gertler, Professor of Economics, Haas School of Business, Professor of Health Services Finance, School of Public Health, University of California, Berkley Carl A. Latkin, Professor, Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland James Ntozi, Professor, Department of Population Studies, Makerere University, Uganda James Sherry, Professor of Global Health, School of Public Health and Health Services, The George Washington University, Washington, D.C. Olaitan Soyannwo, Professor of Anesthesia and Consultant Anesthetist, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria Burton Wilcke, Jr., Chair and Associate Professor, Department of Medical Laboratory and Radiation Sciences, University of Vermont, Burlington Michael Merson (Board on Global Health Liaison), Founding Director, Global Health Institute, Duke University, North Carolina Elena O. Nightingale (Board on Children, Youth, and Families Liaison), Scholar-in-Residence, Institute of Medicine, The National Academies, Washington, D.C. Julia Coffman (Consultant), Independent Evaluation Consultant, Alexandria, Virginia Thomas Denny (Consultant), Research Associate Professor, Chief Operating Offcer, Duke Human Vaccine Institute and Center for HIV/AIDS Vaccine Immunology, Duke University Medical Center, Durham, North Carolina Florencia Zulberti (Consultant), Assistant Director for Global Health, National Institutes of Health, Mexico Study Staff Patrick Kelley, Board Director, Global Health Rosemary Chalk, Board Director, Children, Youth and Families Michele Orza, Study Director Kimberly Scott, Senior Program Offcer Lucía Fort, Program Offcer (through November 2006) J. Alice Nixon, Program Offcer (through November 2006) Angela Mensah, Senior Program Assistant Kimberly Weingarten, Senior Program Assistant (through September 2006) Sheyi Lawoyin, Senior Program Assistant (May 2006 through July 2006) Jessica Manning, Mirzayan Science and Technology Policy Fellow (May 2006 through August 2006) Keren Ladin, Mirzayan Science and Technology Policy Fellow (June 2006 through August 2006) i Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s (NRC) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confdential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Roberto Arduino, Division of Infectious Diseases, The University of Texas Health Science Center at Houston Solomon R. Benatar, Department of Medicine, University of Cape Town, South Africa Alan Berkman, Mailman School of Public Health, Columbia University, New York Jo Ivey Boufford, Robert F. Wagner Graduate School of Public Service, New York University Fred Carden, International Development Research Centre, Ottawa, Canada Ambassador Johnnie Carson, National Intelligence Council of the Offce of the National Director of Intelligence, Washington, District of Columbia Thomas J. Coates, David Geffen School of Medicine, University of California, Los Angeles ii iii REVIEWERS Susan A. Cohen, Guttmacher Institute, Washington, District of Columbia Carlos del Rio, Emory AIDS International Training and Research, Rollins School of Public Health of Emory University and Grady Memorial Hospital, Atlanta, Georgia Christopher J. Elias, PATH, Seattle, Washington Helene Gayle, CARE, Atlanta, Georgia Geeta Rao Gupta, International Center for Research on Women, Washington, District of Columbia Grace John-Stewart, Department of Medicine, International AIDS Research and Training Program, University of Washington, Seattle, Washington James W. Kazura, Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio Mary Anne Koda-Kimble, School of Pharmacy, University of California, San Francisco Adel A. F. Mahmoud, Merck Vaccines, Merck & Co., Inc., Whitehouse Station, New Jersey Anne Mills, London School of Hygiene & Tropical Medicine, London Roeland Monasch, United Nations Children’s Fund, Harare, Zimbabwe J. Stephen Morrison, HIV/AIDS Task Force, Center for Strategic & International Studies, Washington, District of Columbia Anne Peterson, World Vision International, Washington, District of Columbia Robert Redfeld, Institute of Human Virology/Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland Catherine M. Wilfert, Duke University Medical Center, Duke University, Chapel Hill, North Carolina; The Elizabeth Glaser Pediatric AIDS Foundation Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the fnal draft of the report before its release. The review of this report was overseen by Bernard Guyer, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, and Charles E. Phelps, University of Rochester, New York. Ap- pointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the fnal content of this report rests entirely with the authoring committee and the institution. Preface Only a quarter of a century after frst reported, HIV/AIDS has become one of the largest global health scourges of all times. This preventable viral disease caused the death of almost 3 million people last year alone, while over 4 million others became infected. The majority of this disease burden occurs in the developing world, with sub-Saharan Africa carrying the larg- est burden. As a result, life expectancy in that region has decreased, caus- ing enormous human suffering and long-lasting demographic, social, and economic consequences. The very rapid scientifc discoveries on the etiology and modes of trans- mission, and later the development of effective treatment against HIV/AIDS are a tribute to human ingenuity. Our collective social response, however, has taken longer to get organized. Although still far from adequate, the global response to the epidemic is fnally growing and progress is evident on a number of fronts. Hope has been restored based on a broad awakening of international commitment and strong evidence that the technical challenges can be met on a large scale. A major factor in the increasing global response is “The President’s Emergency Plan for AIDS Relief,” or PEPFAR. This plan derives from novel legislation, passed by the U.S. Congress in 2003, which also mandated an evaluation of progress on this initiative. It has been the challenge and privilege of our Institute of Medicine to be charged with the conduct of this independent evaluation. The Emergency Plan set ambitious goals. It seeks to support the pre- vention of 7 million HIV infections, the treatment of 2 million people with ix