Study Details

PEPFAR Implementation: Progress and Promise


Sepulveda J. 


March 2007



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Institute of Medicine (IOM)


HIV/AIDS services, health systems strengthening, human resources; governance; access; vulnerable groups, funding, civil society

Study Type

An external evaluation


To provide the U.S Congress with an independent evaluation of PEPFAR.


This evaluation consisted of a literature review, review and analysis of budgetary and programmatic data, discussions with relevant parties, and (from Oct 2005 Feb 2006) visits by small delegations from the team to 13 of PEPFARs 15 focus countries.


The Institute of Medicine’s external evaluation of highlights PEPFAR’s achievements, but argues that the initiative’s programmes impede donor partners’ efforts to coordinate and harmonise their activities.

The report starts by describing the performance targets of PEPFAR: to treat 2m people with ART; support prevention of 7m HIV/AIDS infections; care for 10m people with HIV/AIDS (the 2-7-10 targets), including orphans and vulnerable children (OVCs) PEPFAR has gone some way to achieving these targets: it has supported getting >800,000 adults and children on ART; HIV/AIDS testing and counselling for 19m; PMTCT services for > 6m women; and care and support for 4.5m. The report suggests that this provides evidence that scale up particularly of treatment in resource-poor settings is possible. The Report notes that PEPFAR itself states a commitment to harmonization, and support for country ownership and UNAIDS three ones principles (one national HIV/AIDS plan, one coordinating mechanism, and one M&E framework).

The report suggests the reality of PEPFARs programmes is rather different to the initiatives claims. For example, PEPFARs budget allocations "limit the Country Teams ability to harmonize PEPFARs activities with those of the partner government and other donors", and PEPFARs ABC (Abstinence, Be faithful, and correct and consistent Condom use) priorities "fragment the natural continuum of needs and services, often in ways that do not correspond with global standards" (p.79)

The Report also criticises PEPFARs requirement for FDA approval of ARVs (rather than accepting WHO approval) as an impediment to coordination and harmonization. The report says that PEPFAR "should work to support WHO prequalification as the accepted global standard for assessing the quality of generic medication".

Rigid congressional budget allocations among and, more importantly, within control categories have also limited PEPFARs ability to coordinate (33% of funding must be on HIV/AIDS treatment; 20% on HIV prevention of which 33% must go on abstinence-until-marriage programmes; 15% on palliative care, and 10% on OVCs).

Conclusions /

The report concludes that PEPFARs one size fits all approach does not work, and evidence-based strategies should guide its interventions instead.

Sponsored by DFID, Danida, Irish Aid