PRESIDENT’S 

EMERGENCY PLAN 

FOR AIDS RELIEF

Shift toward PartnerCountry Treatment 

Programs Will Require 

Better Information on 

Results

Report to Congressional Requesters

April 2013

GAO-13-460

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-460, a report to 

congressional requesters

April 2013 

PRESIDENT’S EMERGENCY PLAN FOR AIDS 

RELIEF

Shift toward Partner-Country Treatment Programs 

Will Require Better Information on Results

Why GAO Did This Study

PEPFAR, first authorized in 2003, has 

supported significant advances in 

HIV/AIDS prevention, treatment, and 

care in more than 30 countries. In 

reauthorizing the program in 2008, 

Congress directed OGAC to continue 

to expand the number of people 

receiving care and treatment through 

PEPFAR while also making it a major 

policy goal to help partner countries 

develop independent, sustainable HIV 

programs. As a result, PEPFAR began

shifting efforts from directly providing 

treatment services toward support for 

treatment programs managed by 

partner countries. GAO was asked to 

review PEPFAR treatment programs.

GAO examined (1) PEPFAR treatment

program results and how OGAC 

measures them and (2) PEPFAR 

assistance to improve partner 

countries’ M&E systems. GAO 

reviewed PEPFAR plans, performance 

reports, and guidance and interviewed 

officials from OGAC, the Centers for 

Disease Control and Prevention

(CDC), and the U.S. Agency for 

International Development (USAID). 

GAO also synthesized findings of 

treatment program studies and 

conducted fieldwork in three countries.

What GAO Recommends

The Secretary of State should direct 

OGAC to (1) develop a method that 

better accounts for PEPFAR’s 

contributions to partner-country 

treatment programs, (2) establish a 

common set of indicators to measure 

the results of treatment program quality 

improvement efforts, and (3) establish 

a set of minimum standards for data 

generated by partner countries’ M&E 

systems. Commenting jointly with CDC 

and USAID, State generally agreed 

with the report’s recommendations.

What GAO Found

The Department of State’s (State) Office of the U.S. Global AIDS Coordinator 

(OGAC) has reported on President’s Emergency Plan for AIDS Relief (PEPFAR)

treatment program results primarily in terms of (1) numbers of people on 

treatment directly supported by PEPFAR, (2) percentages of eligible people 

receiving treatment, and (3) percentages of people alive and on treatment 12 

months after starting treatment (see table for recently reported results). However, 

these indicators do not reflect some key PEPFAR results. First, although the 

number of people on treatment directly supported by PEPFAR grew from about 

1.7 million to 5.1 million in fiscal years 2008 through 2012, this indicator alone 

does not provide complete information needed for assessing PEPFAR’s 

contributions to partner countries’ treatment programs. Second, although 10 

PEPFAR country teams reported that percentages of people alive and on 

treatment after 12 months exceeded 80 percent, data for this indicator are not 

always complete and have other limitations. To improve these data, according to 

OGAC officials, OGAC clarified its guidance and conducted data quality 

assessments. However, OGAC has not yet established a common set of 

indicators to monitor the results of PEPFAR’s efforts to improve the quality of 

treatment programs.

PEPFAR Treatment Indicators 

Indicator Source of data Target Reported results

Number of people currently 

on treatment directly 

supported by PEPFAR

PEPFAR direct

treatment 

programs

5 million

(fiscal year 2012)

5.1 million

(as of fiscal year 2012)

Percentage of eligible people 

receiving treatment

Partner country 

treatment 

programs

80 percent 8 of 23 partner countries 

reported rates at or above

80 percent (as of 2011)

Percentage of people alive 

and on treatment 12 months

after starting treatment

PEPFAR direct

treatment 

programs

No target 10 of 23 partner countries 

reported rates at or above

80 percent (as of fiscal year

2012)

Source: GAO synthesis of guidance and data from OGAC and data from the Joint United Nations Programme on HIV/AIDS. 

Notes: In fiscal year 2012, 23 PEPFAR country teams providing direct support for treatment services were required 

to report to OGAC on these indicators. All 23 country teams provided data on number of people currently on 

treatment directly supported by PEPFAR and percentage of eligible people receiving treatment. Twenty country 

teams provided data on percentage of people alive and on treatment 12 months after starting treatment; 3 countries 

reported that data were not available for this indicator.

As PEPFAR partner countries assume greater responsibility for managing their 

treatment programs, fully functioning monitoring and evaluation (M&E) systems

are critical for tracking results and ensuring treatment program effectiveness. 

PEPFAR country teams assist partner countries in carrying out their M&E 

responsibilities by providing staff, training, technical assistance, and other 

support. With this assistance, partner countries have made some progress in 

expanding and upgrading these M&E systems. Nevertheless, partner countries’ 

M&E systems often are unable to produce complete and timely data, thus limiting 

the usefulness of these data for patient, clinic, or program management. OGAC 

has not yet established minimum standards for partner countries’ M&E systems, 

particularly relating to data completeness and timeliness, in order for PEPFAR 

country teams to assess those systems’ readiness for use in treatment program 

management and results reporting. 

View GAO-13-460. For more information, 

contact David Gootnick at (202) 512-3149 or 

gootnickd@gao.gov, or Marcia Crosse at 

(202) 512-7114 or crossem@gao.gov. 
Page i GAO-13-460 PEPFAR Treatment Results

Letter 1 

Background 3

Data Indicate Progress in Achieving Treatment Program Results, 

but Some Indicators Have Limitations 8

PEPFAR Supports Countries’ M&E Systems, but Weaknesses Limit 

the Timeliness and Completeness of Treatment Results Data 18

Conclusions 22

Recommendations for Executive Action 23

Agency Comments and Our Evaluation 23

Appendix I Objectives, Scope, and Methodology 27

Appendix II Criteria for Assessing PEPFAR Direct Support 32

Appendix III Summaryof Studies 33

Appendix IV Comments from the Department of State 35

Appendix V GAO Contacts and Staff Acknowledgments 40

Related GAO Products 41

Tables

Table 1: Key PEPFAR Treatment Indicators 8

Table 2: Numbers of People on Treatment Directly Supported by 

PEPFAR and Numbers of PEPFAR Countries Reporting on 

This Indicator, Fiscal Years 2004 through 2012 10

Table 3: Estimated PEPFAR Partner-Country Treatment Coverage 

Rates, 2011 14

Table 4: Reported PEPFAR Treatment Retention Rates, Fiscal Year 

201215

Contents 
Page ii GAO-13-460 PEPFAR Treatment Results

Table 5: Checklist to Determine Whether to Count Service Delivery 

Support as PEPFAR Direct 32

Figure

Figure 1: Number of People on Treatment Directly Supported by 

PEPFAR, Fiscal Years 2004-2012, and Total Number of 

People on Treatment in Low- and Middle-Income 

Countries, Calendar Years 2004-2011 11

Abbreviations

2008 Leadership Act Tom Lantos and Henry J. Hyde United 

States Global Leadership Against 

HIV/AIDS, Tuberculosis, and Malaria 

Reauthorization Act of 2008

ARV antiretroviral

CD4 cluster of differentiation antigen 4

CDC Centers for Disease Control and Prevention

Global Fund Global Fund to Fight AIDS, Tuberculosis 

and Malaria

HHS Department of Health and Human Services

M&E monitoring and evaluation

OGAC Office of the U.S. Global AIDS Coordinator

PEPFAR President’s Emergency Plan for AIDS Relief

State Department of State 

UNAIDS Joint United Nations Programme on 

HIV/AIDS

USAID U.S. Agency for International Development

WHO World Health Organization

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Page 1 GAO-13-460 PEPFAR Treatment Results

United States Government Accountability Office

Washington, DC 20548

April 12, 2013

Congressional Requesters

As the President’s Emergency Plan for AIDS Relief (PEPFAR) nears the 

end of its second 5-year authorization,1 it has made significant 

contributions to international treatment targets for HIV/AIDS.2

Nevertheless, important challenges remain as PEPFAR continues to help 

build partner countries’ capacity to manage their treatment programs. 

First, the estimated number of new HIV infections worldwide each year 

(2.5 million in 2011) continues to exceed the estimated increase in the 

number of people on treatment (about 1.4 million from 2010 to 2011), and 

about 6.8 million people eligible for treatment have not yet been treated.

The 

Department of State’s (State) Office of the U.S. Global AIDS Coordinator 

(OGAC) reported that, as of September 30, 2012, the U.S. government, 

through PEPFAR’s multibillion dollar investments in partner countries’ 

treatment and care programs, had directly supported treatment for more 

than 5.1 million people—more than half of all people on treatment for 

HIV/AIDS in low- and middle-income countries. In part because of these 

investments, more than half of eligible people in low- and middle-income 

countries (54 percent) receive treatment, and the estimated number of 

AIDS-related deaths worldwide (1.7 million) declined in 2011, according 

to data reported by the United Nations Joint Programme on HIV/AIDS 

(UNAIDS).

3

In addition, in passing the Tom Lantos and Henry J. Hyde United States 

Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria 

Reauthorization Act of 2008 (2008 Leadership Act),4

 

1

Congress first authorized PEPFAR in 2003. Pub. L. No. 108-25, § 401, 117 Stat. 711, 

745.

Congress directed 

2

In this report, “treatment” refers to the services delivered to HIV-positive people who are 

receiving treatment with antiretroviral (ARV) drugs. “Care and treatment” refers to 

treatment plus a set of additional services provided to improve the quality of life for HIVinfected people, including clinical, psychological, spiritual, social, and prevention services.

3

See UNAIDS, UNAIDS 2012 Global Report: UNAIDS Report on the Global AIDS 

Epidemic (Geneva, Switzerland: 2012). See also WHO, The Strategic Use of 

Antiretrovirals to Help End the HIV Epidemic (Geneva, Switzerland: 2012).

4

Pub. L. No. 110-293, 122 Stat. 2918.

 
 

Page 2 GAO-13-460 PEPFAR Treatment Results

OGAC to continue to expand the number of people receiving PEPFAR 

HIV care and treatment services while also making it a major policy goal 

to build partner-country capacity to deliver services and promote a 

transition toward greater sustainability of country-owned HIV/AIDS 

programs. In December 2011, the President announced an increase in 

PEPFAR’s target for the number of people receiving treatment directly 

supported by PEPFAR—from 4 million to 6 million by the end of fiscal 

year 2013.

OGAC sets overall PEPFAR policy and strategies. OGAC also 

coordinates PEPFAR programs and activities, allocating funds to 

PEPFAR implementing agencies, particularly the Centers for Disease 

Control and Prevention (CDC) of the Department of Health and Human 

Services (HHS) and the U.S. Agency for International Development 

(USAID). OGAC is leading PEPFAR’s transition from an early focus on 

directly providing treatment services as part of an emergency response, 

to building partner countries’ capacity to manage treatment programs. 

During this transition, ensuring HIV care and treatment program quality 

remains critical to achieving patient and public health outcomes, even as 

annual allocations to PEPFAR remain unchanged or decline.5

You asked us to review HIV/AIDS treatment programs supported through 

PEPFAR. This is the second of three reports responding to your request. 

We recently issued a related report on PEPFAR treatment program costs6

 

5

For fiscal years 2009 through 2012, State, USAID, and HHS (CDC and the National 

Institutes of Health) allocated the following amounts for global HIV/AIDS programs: $6.5 

billion, $6.6 billion, $6.5 billion, and $6.4 billion, respectively. For fiscal year 2013, these 

agencies requested $6.2 billion for global HIV/AIDS programs. Amounts include U.S. 

contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria. 

and will soon issue a report on PEPFAR supply chains. In this report, we 

examine (1) PEPFAR treatment program results and how OGAC 

measures them and (2) PEPFAR assistance to improve partner countries’ 

monitoring and evaluation (M&E) systems. We also provide information—

related to treatment program retention, patient-level health outcomes, and 

6

See GAO, President’s Emergency Plan for AIDS Relief: Per-Patient Costs Have Declined 

Substantially, but Better Cost Data Would Help Efforts to Expand Treatment, GAO-13-345

(Washington, D.C.: March 15, 2013). 
 

Page 3 GAO-13-460 PEPFAR Treatment Results

strengths and weaknesses of partner-country M&E systems—drawn from 

studies of treatment programs in PEPFAR partner countries.7

To address our objectives, we reviewed PEPFAR guidance issued by 

OGAC regarding PEPFAR indicators, definitions, and planning and 

reporting requirements, and we reviewed prior GAO reports on PEPFAR. 

We examined PEPFAR partnership frameworks and PEPFAR’s most 

recent operational plans and performance reports as well as data 

provided by OGAC. We determined that these data were sufficiently 

reliable for the purposes of our reporting. We interviewed OGAC, CDC, 

and USAID officials in Atlanta, Georgia, and Washington, D.C., and 

conducted field work in South Africa, Uganda, and Kenya. (See app. I for 

further details of our scope and methodology.)

We conducted this performance audit from May 2012 to April 2013 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

OGAC is responsible for establishing overall PEPFAR policy and program 

strategies and allocating funds from the Global Health and Child Survival 

account to PEPFAR implementing agencies, primarily CDC and USAID.8

 

7

In this report, “studies” refers to evaluations, assessments, and other studies of treatment 

programs and M&E systems in PEPFAR partner countries.

These agencies execute PEPFAR program activities through agency 

headquarters offices and in-country interagency teams (PEPFAR country 

8

Other PEPFAR implementing agencies are the Departments of State, Defense, Labor, 

and Commerce and the Peace Corps. Additional HHS offices and agencies involved in 

PEPFAR implementation are the Office of Global Affairs, the Food and Drug 

Administration, the Health Resources and Services Administration, the National Institutes 

of Health, and the Substance Abuse and Mental Health Services Administration.

Background 
 

Page 4 GAO-13-460 PEPFAR Treatment Results

teams) and their implementing partners9 in the 33 countries and three 

regions with PEPFAR-funded programs as of fiscal year 2012.10

To promote a more sustainable approach to combating HIV/AIDS, 

characterized by PEPFAR countries’ strengthened capacity, ownership, 

and leadership, the 2008 Leadership Act authorized the U.S. government 

to establish partnership frameworks with partner countries.

OGAC 

coordinates these activities through its approval of operational plans, 

which document work plans, budgets, and the anticipated results of 

HIV/AIDS-related programs. OGAC also provides annual guidance to 

PEPFAR country teams on how to develop and submit operational plans. 

For fiscal years 2009 through 2012, OGAC approved country operational

plan budgets totaling over $16 billion. Country operational plan activities 

fit broadly in three areas: prevention, treatment, and care. Other program 

budget areas are laboratory infrastructure, strategic information, and 

health systems strengthening.

11

 

9

In this report, “PEPFAR country teams” refers to PEPFAR country and regional teams 

and their implementing partners collectively. PEPFAR implementing agencies obtain 

services for PEPFAR activities through grants, cooperative agreements, and contracts 

with selected implementing partners. These partners include U.S.-based nongovernmental 

organizations and host-country governmental and nongovernmental organizations. For 

more information, see GAO, President’s Emergency Plan for AIDS Relief: Partner 

Selection and Oversight Follow Accepted Practices but Would Benefit from Enhanced 

Planning and Accountability, 

These 

frameworks are 5-year joint strategic agreements for cooperation 

between the U.S. government and partner governments to combat 

HIV/AIDS in the partner country through technical assistance and support 

for service delivery, policy reform, and coordinated funding

GAO-09-666 (Washington, D.C.: July 15, 2009).

10The 33 countries were Angola, Botswana, Burundi, Cambodia, Cameroon, China, Côte 

d’Ivoire, the Democratic Republic of the Congo, the Dominican Republic, Ethiopia, Ghana, 

Guyana, Haiti, India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, 

Russia, Rwanda, South Africa, South Sudan, Swaziland, Tanzania, Thailand, Uganda, 

Ukraine, Vietnam, Zambia, and Zimbabwe. The three regions were the Caribbean, Central 

America, and Central Asia. 

11Pub. L. No. 110-293, § 301(c)(6).
 

Page 5 GAO-13-460 PEPFAR Treatment Results

commitments.12 As of February 2013, the U.S. government had signed 22 

PEPFAR partnership frameworks.13 According to OGAC guidance, a key 

expectation of the frameworks is that partner-country governments will 

become better prepared to assume primary responsibility for their 

responses to HIV/AIDS. Moreover, PEPFAR’s 2012 “blueprint”14

PEPFAR supports a broad continuum of HIV care and treatment services 

in partner countries. This continuum begins with HIV testing and the 

counseling given to patients learning their HIV status. If patients are HIV

positive, their eligibility for treatment must be determined on the basis of 

clinical criteria (symptoms associated with HIV), laboratory criteria 

(strength of patients’ immune systems),

defines 

country ownership as the end state in which partner countries lead, 

manage, and coordinate the efforts needed to ensure that the AIDS 

response is effective, efficient, and durable.

15

 

12According to OGAC guidance, partnership frameworks and their associated partnership 

framework implementation plans are not intended to be legally binding. Rather, they are 

intended as nonbinding joint strategic-planning documents that outline the collaborative 

relationship between the U.S. government and partner countries and reflect overarching 5-

year goals and the commitments of each party. See U.S. Department of State, Office of 

the U.S. Global AIDS Coordinator, Guidance for PEPFAR Partnership Frameworks and 

Partnership Framework Implementation Plans, Version 2.0 (Sept. 14, 2009), accessed 

January 28, 2013, 

or both clinical and laboratory 

criteria. The World Health Organization (WHO) establishes international 

guidelines on when to initiate treatment for specific groups of HIV-positive 

people, such as adult patients who have never been on treatment, 

pediatric patients, and pregnant and breastfeeding women. In November 

2010, WHO updated its guidelines by reducing the minimum eligibility 

http://www.pepfar.gov/documents/organization/120510.pdf. 

13As of February 2013, partnership frameworks had been signed with the following 22 

partner countries and regions: Angola, Botswana, the Caribbean region, the Central 

American region, the Democratic Republic of the Congo, the Dominican Republic, 

Ethiopia, Ghana, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, 

South Africa, Swaziland, Tanzania, Ukraine, Vietnam, and Zambia.

14U.S. Department of State, Office of the U.S. Global AIDS Coordinator, PEPFAR 

Blueprint: Creating an AIDS-free Generation (Washington, D.C.: November 2012).

15This is typically measured by CD4 (cluster of differentiation antigen 4) count in a sample 

of blood. CD4 cells are a type of white blood cell that fights infection. Along with other 

tests, the CD4 count helps determine the strength of the immune system, indicates the 

stage of the HIV disease, guides treatment, and predicts the disease’s progress. 
 

Page 6 GAO-13-460 PEPFAR Treatment Results

threshold in its laboratory criteria16 and by recommending treatment for all 

people coinfected with HIV and tuberculosis, thereby expanding the 

number of people eligible for treatment. Based on WHO guidelines, each 

country is expected to establish country-specific guidelines on when to 

initiate treatment for these groups. UNAIDS estimated at the end of 2011 

that, on the basis of WHO’s 2010 guidelines, 15 million people in low- and 

middle-income countries needed treatment; of these, an estimated 8 

million people are on treatment. People who are HIV positive but not yet 

eligible for treatment generally may seek access to care and support 

services as well as regular checkups and laboratory monitoring. People 

eligible for treatment should receive antiretroviral (ARV) drugs as well as 

checkups and monitoring to assess the effectiveness of treatment.17

PEPFAR country teams report to OGAC semiannually, usually in May, 

and annually, usually in November, on PEPFAR program results. These 

reports, containing data and narratives, are intended to support program 

monitoring, midcourse correction, and planning for subsequent fiscal 

years. Data on PEPFAR program results also supply information for 

OGAC’s annual report to Congress on PEPFAR performance.

People on treatment also receive various care and support services such 

as treatment of opportunistic infections including tuberculosis coinfection, 

nutritional support, and programs to promote adherence to treatment and 

remaining on treatment (patient retention). People on treatment are 

expected to take ARV drugs on a continuing, lifelong basis.

18

 

16WHO recommended treatment for all people with CD4 counts of less than 350 

cells/mm3

. Prior to 2010, WHO’s guidelines recommended treatment for all people with 

CD4 counts of less than 200 cells/mm3

. Normal CD4 counts range from 500-1,000 

cells/mm3

. 

Since 

fiscal year 2010, OGAC’s Next Generation Indicators Reference Guide

has provided an updated list of indicators for establishing targets and 

17In some cases, this may be done through laboratory assessments of the severity of the 

patient’s HIV infection, as measured by viral load. Viral load is a measure of the severity of 

a viral infection and can be calculated by estimating the amount of virus in an involved 

body fluid.

18See GAO, President’s Emergency Plan for AIDS Relief: Program Planning and 

Reporting, GAO-11-785 (Washington, D.C.: July 29, 2011).
 

Page 7 GAO-13-460 PEPFAR Treatment Results

reporting on PEPFAR results.19 According to the guidance, these 

indicators are intended to demonstrate progress in the fight against 

HIV/AIDS while also promoting responsible program management. In 

addition, among other things, the guidance establishes a distinction 

between national results and PEPFAR direct results. The guidance 

defines national results as achievements of all contributors to a partner 

country’s HIV/AIDS program and defines PEPFAR direct results as 

achievements of the PEPFAR program through its funded activities. (See 

app. II for a summary of OGAC criteria for assessing PEPFAR direct 

support.) With regard to treatment programs, the guidance instructs 

PEPFAR country teams providing direct support for treatment services20

to report to OGAC using the PEPFAR direct indicators.21 In addition, the 

guidance directed these country teams, as well as PEPFAR country 

teams providing technical assistance and other support to build partnercountry capacity for managing treatment programs, to report on one 

national indicator. Table 1 summarizes these indicators.

 

19Office of the U.S. Global AIDS Coordinator, The President’s Emergency Plan for AIDS 

Relief, Next Generation Indicators Reference Guide: Planning and Reporting, Version 1.1 

(August 2009), accessed March 20, 2013, 

http://www.pepfar.gov/documents/organization/81097.pdf. The guidance went into effect 

for the fiscal year 2010 planning and reporting cycle and was updated in February 2013.

20According to OGAC, 23 PEPFAR country teams provided direct support for treatment 

services in fiscal years 2011 and 2012: Botswana, Cambodia, China, Côte d’Ivoire, the 

Democratic Republic of the Congo, the Dominican Republic, Ethiopia, Guyana, Haiti, 

India, Kenya, Lesotho, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Swaziland, 

Tanzania, Uganda, Vietnam, Zambia, and Zimbabwe. OGAC provides guidance to country 

teams for determining whether people receive direct services through PEPFAR 

implementing partners. See appendix II for more information.

21OGAC also requires PEPFAR country teams to collect and maintain data on two 

additional treatment-related indicators: (1) percentage of health facilities offering treatment 

services and (2) percentage of health facilities providing treatment services using CD4 

monitoring in line with national guidelines, on site, or through referral. These data are not 

reported to OGAC.
 

Page 8 GAO-13-460 PEPFAR Treatment Results

Table 1: Key PEPFAR Treatment Indicators 

Indicator Source of data Definition Target

Number of people 

currently on treatmenta PEPFAR direct treatment 

programs

Number of adults and children with advanced HIV 

infection who are currently receiving treatment 

directly supported by PEPFAR

Fiscal year 2012: 5 million

Fiscal year 2013: 6 million

Treatment coverage Partner country treatment 

programs

Percentage of adults and children with advanced 

HIV infection receiving treatment

80 percentb

Treatment retention PEPFAR direct treatment 

programs

Percentage of adults and children known to be 

alive and on treatment 12 months after starting 

treatment

Nonec

Source: GAO synthesis of guidance and information provided by OGAC.

a

Since fiscal year 2010, PEPFAR country teams providing direct support for treatment services have 

also been required to report the number of adults and children newly enrolled in treatment programs 

in the previous year, disaggregating by age and sex. This indicator permits OGAC and country teams 

to monitor trends in treatment initiation and, thus, treatment program expansion. Because data are 

also disaggregated by pregnancy status, the indicator also provides data linking treatment programs 

with programs to prevent the transmission of HIV from mother to child.

b

Each country sets its own targets for national treatment coverage rates. According to UNAIDS, most 

countries have set 80 percent as their target for treatment coverage.

c

High retention rates indicate that more people on treatment are surviving. However, targets for 

treatment retention generally are not established.

From fiscal year 2010 through 2012, OGAC reported PEPFAR results in 

terms of three primary indicators: (1) the number of people currently on 

treatment directly supported by PEPFAR (PEPFAR direct number of 

people on treatment), (2) the percentages of eligible people receiving 

treatment in partner countries (national treatment coverage rates), and (3) 

the percentage of adults and children known to be alive and on treatment 

12 months after starting treatment (PEPFAR direct treatment retention 

rates). However, two of these indicators have limitations that could affect 

their usefulness. Regarding the first indicator, although the number of 

people on treatment directly supported by PEPFAR has increased 

significantly, this indicator alone does not provide complete information 

needed for assessing PEPFAR’s contributions to partner countries’ 

treatment programs. Regarding the third indicator, 10 PEPFAR country 

teams reported percentages of adults and children known to be alive and 

on treatment 12 months after starting treatment that exceeded 80 

percent. However, the treatment retention data are not always complete 

and have other limitations, which OGAC acknowledged and is taking 

steps to address. In addition to these limitations, OGAC lacks a common 

set of indicators for monitoring quality assurance efforts. Although OGAC 

indicated in 2010 that it would establish a common set of indicators to 

Data Indicate 

Progress in Achieving 

Treatment Program 

Results, but Some 

Indicators Have 

Limitations 
 

Page 9 GAO-13-460 PEPFAR Treatment Results

monitor the results of PEPFAR’s efforts to improve the quality of 

treatment programs, it has not yet done so.

Responding to treatment-related requirements in the 2008 Leadership 

Act,22 OGAC reports on the number of people currently on treatment 

directly supported by PEPFAR as a key indicator of program results.23

This number is calculated by determining the number of people who ever 

started treatment at facilities where PEPFAR directly supports treatment 

services, minus patients who died, stopped treatment, transferred out, or 

have unknown treatment outcomes.24 (See app. II for a summary of 

OGAC guidance on determining whether people can be counted as 

receiving direct services through PEPFAR.) PEPFAR met or exceeded 

annual targets for this indicator in fiscal years 2004 through 2012. 

Currently, this indicator is used to track treatment program expansion and 

to assess progress toward PEPFAR’s target of providing direct support 

for treatment for 6 million people by the end of fiscal year 2013.25

 

22These requirements include a plan to increase the number of people receiving 

treatment, annual reporting requirements, and PEPFAR’s annual treatment target. Pub. L. 

No. 110-293, §§ 101, 301, 403.

For 

fiscal year 2012, PEPFAR’s target for this indicator was 5 million people. 

According to data provided by OGAC, the number of people currently on 

treatment directly supported by PEPFAR has steadily increased from 

23In addition to tracking the number of people currently on treatment, in fiscal year 2010, 

OGAC also began tracking the number of people newly enrolled in treatment that is 

directly provided by PEPFAR. Data reported for this indicator—which OGAC 

disaggregates by age, sex, and pregnancy status for women—provide additional 

information on treatment program expansion and links treatment programs to special 

efforts aimed at preventing mother-to-child transmission of HIV. 

24PEPFAR country teams also report data disaggregated by age, sex, and pregnancy 

status for women.

25In December 2011, the President announced an increase in PEPFAR’s 5-year target for

the number of people receiving treatment supported directly by PEPFAR—from 4 million 

to 6 million by the end of fiscal year 2013.

PEPFAR Exceeded Its 

Fiscal Year 2012 Direct 

Treatment Target, but This 

Indicator Does Not Fully 

Reflect PEPFAR 

Contributions to PartnerCountry Treatment 

Programs
 

Page 10 GAO-13-460 PEPFAR Treatment Results

about 67,000 people in 11 countries in fiscal year 2004 to more than 5.1 

million in 23 countries in fiscal year 2012.26

Table 2: Numbers of People on Treatment Directly Supported by PEPFAR and Numbers of PEPFAR Countries Reporting on 

This Indicator, Fiscal Years 2004 through 2012

(See table 2.)

2004 2005 2006 2007 2008 2009 2010 2011 2012

PEPFAR direct number of 

people currently on 

treatment 66,700 249,200 541,300 1,091,600 1,743,600 2,485,300 3,195,000 3,905,000 5,057,500

Number of PEPFAR 

country teams reporting on 

this indicatora 11 12 18 24 24 24 23 23 23

Source: OGAC.

Note: Numbers of people on treatment directly supported by PEPFAR have been rounded to the 

nearest hundred.

a

In 2004, OGAC reported direct treatment results for 11 PEPFAR partner countries and added 

countries as PEPFAR’s investments in them increased. Twenty-three PEPFAR country teams 

provided direct treatment services in fiscal year 2012: Botswana, Cambodia, China, Côte d’Ivoire, the 

Democratic Republic of the Congo, the Dominican Republic, Ethiopia, Guyana, Haiti, India, Kenya, 

Lesotho, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Uganda, 

Vietnam, Zambia, and Zimbabwe

Furthermore, the number of people on treatment directly supported by 

PEPFAR was about half of the total number of people on treatment in all 

low- and middle-income countries, which UNAIDS estimated at 8 million 

in 2011 (see fig. 1).

 

26The number of people on treatment directly provided by PEPFAR includes an estimate 

of the results of treatment programs supported by the Global Fund to Fight AIDS, 

Tuberculosis and Malaria (Global Fund). To estimate the overlap, OGAC and the Global 

Fund together analyze available treatment program data, taking into account the 

contribution each makes to partner countries’ treatment programs to determine likely 

overlap. For example, for fiscal year 2010, OGAC reported that PEPFAR had directly 

provided treatment for about 3.2 million people, which includes an estimated overlap with 

the Global Fund of about 1.5 million.
 

Page 11 GAO-13-460 PEPFAR Treatment Results

Figure 1: Number of People on Treatment Directly Supported by PEPFAR, Fiscal 

Years 2004-2012, and Total Number of People on Treatment in Low- and MiddleIncome Countries, Calendar Years 2004-2011

Notes: We estimated the total number of people that received treatment in 2012, because UNAIDS 

data for low- and middle-income countries are reported for calendar years and were not available for 

2012 at the time of this report’s publication. PEPFAR data are reported for U.S. government fiscal 

years.

As PEPFAR has begun to shift resources toward providing technical 

assistance and other support to help partner countries build their capacity 

to manage treatment programs, PEPFAR’s direct treatment indicator has 

increasingly fallen short of reflecting results of PEPFAR’s contributions to 

partner countries’ treatment programs. Specifically, this indicator does not 

reflect the expansion of partner countries’ treatment programs that 

PEPFAR technical assistance and other support for building treatment 

program management capacity have made possible. These efforts 
 

Page 12 GAO-13-460 PEPFAR Treatment Results

include, among others, activities such as implementing revised treatment 

guidelines, assisting partner-country district and national health officials 

with treatment facility oversight, and training and mentoring treatment 

facility staff. In several PEPFAR partner countries, for example, PEPFAR 

implementing partners providing direct treatment services have begun 

transferring stable patients to other treatment providers, including an 

often expanding number of local public and private health clinics, many of 

which receive PEPFAR-funded technical assistance and other support. In 

part because of this PEPFAR assistance, these providers also have 

begun increasing the number of people they enroll in treatment. In such 

cases, the PEPFAR direct treatment indicator may not account for these 

people. In the past, PEPFAR’s direct results often were equivalent to the 

national number of people receiving services, including treatment, 

according to PEPFAR’s 2010 Next Generation Indicators Reference 

Guide. However, as PEPFAR increases its efforts to build partner-country 

capacity to manage treatment programs through technical assistance and 

other support, PEPFAR’s direct treatment indicator alone does not 

provide complete information for assessing PEPFAR’s contributions to 

partner countries’ treatment programs.

PEPFAR’s 2010 Next Generation Indicators Reference Guide noted that 

OGAC was working on a method for deriving PEPFAR direct results from 

partner-country national-level indicators but had not yet devised one.27

 

27A recent version of the guidance, dated February 2013, does not include this statement. 

In its technical comments, OGAC indicated that this statement reflected initial thinking 

about alternative methods for representing PEPFAR’s contributions to partner countries’ 

HIV/AIDS programs.

The guidance stated that the new method would take into account the 

percentage of PEPFAR funding that contributes to partner-country 

programs. In addition, OGAC and PEPFAR country teams have 

considered other factors to determine PEPFAR’s contribution to partnercountry treatment programs. For example, in their fiscal year 2011 annual 

reports to OGAC, seven PEPFAR country teams reported the proportion 

of all treatment facilities receiving PEPFAR support or the percentage of 

all patients on treatment directly supported by PEPFAR. Some country 

teams noted that neither method fully accounted for PEPFAR’s 

contributions in these countries. As of February 2013, according to a 

senior OGAC official, OGAC had drafted a method for representing

PEPFAR contributions based on proportional financial support to partner-
 

Page 13 GAO-13-460 PEPFAR Treatment Results

country program results but had not finalized the method or revised its 

guidance to PEPFAR country teams.

Increases in the number of people on treatment have helped improve 

partner countries’ national treatment coverage rates—generally defined 

as the percentage of eligible people receiving treatment.28 According to 

the most current UNAIDS and PEPFAR data,29 8 of the 23 countries 

where PEPFAR directly supported treatment services in 2011 achieved 

estimated treatment coverage rates of 80 percent or more (see table 3).30

Although the remaining 15 countries fell short of this target, almost all of 

these countries have increased their estimated treatment coverage rates 

since 2009, according to our analysis of UNAIDS data.

 

28This percentage is calculated by dividing the number of adults and children currently 

receiving treatment by an estimate (typically derived from epidemiological data and 

modeling) of the number of adults and children eligible to receive treatment (i.e., those 

with advanced HIV infection). Population coverage indicators generally depict regional or 

national program results and are to be disaggregated by age and sex.

29The most recent available information on national treatment coverage are from UNAIDS. 

We consulted UNAIDS’s most recent report on the global AIDS epidemic and crossreferenced this information with national treatment coverage data available on the 

UNAIDS website as well data in PEPFAR country teams’ fiscal year 2011 annual reports 

to OGAC. Data on China’s 2011 national coverage rate were not available from UNAIDS. 

In its fiscal year 2011 report to OGAC, the PEPFAR country team provided information on 

China’s 2010 national treatment coverage rate, which we used for this report.

30Each country sets its own targets for national treatment coverage rates. According to 

UNAIDS, most countries have set 80 percent as their target for treatment coverage. 

PEPFAR Has Helped 

Increase Partner 

Countries’ National 

Treatment Coverage Rates
 

Page 14 GAO-13-460 PEPFAR Treatment Results

Table 3: Estimated PEPFAR Partner-Country Treatment Coverage Rates, 2011

Less than 20% 20-39% 40-59% 60-79% 80% or more

Partner countries where PEPFAR supports direct treatment services

 Chinaa Côte d’Ivoire Kenya Botswana

 Democratic Republic of the 

Congob Ethiopia Malawi Cambodia

 Nigeria Haiti South Africa Dominican Republic

 Lesotho Zimbabwe Guyana

 Mozambique Namibia

 Tanzania Rwanda

 Uganda Swaziland

 Vietnam Zambia

Partner countries where PEPFAR provides only technical assistance and other support for treatment

South Sudan Angola Belized Costa Ricad

 Indonesia Burundi El Salvadord 

 Kazakhstanc Congo Jamaicad 

 Kyrgyzstanc Ghana Nicaraguad 

 Russia Guatemalad Thailand 

Tajikistanc Hondurasd 

 Ukraine India 

 Panamad 

Surinamee

Source: UNAIDS 2012 Global Report: UNAIDS Report on the Global AIDS Epidemic and UNAIDS data.

Note: All PEPFAR countries providing direct treatment services, as well as those building partnercountry treatment program management capacity through technical assistance and other support, 

report estimated national coverage rate information to OGAC.

a

Data on China’s 2011 national coverage rate were not available from UNAIDS. In its fiscal year 2011 

report to OGAC, the PEPFAR country team provided information on China’s 2010 national treatment 

coverage rate. Based on this information, we placed China in the 20-39 percent category in this table.

b

Data on the Democratic Republic of the Congo’s 2011 national coverage rate were not available 

from UNAIDS. In its fiscal year 2011 report to OGAC, the PEPFAR country team provided information 

on the national treatment coverage rate as of June, 2011. Based on this information, we placed the 

Democratic Republic of the Congo in the 20-39 percent category in this table.

c

PEPFAR’s Central Asian region comprises Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and 

Uzbekistan. Treatment coverage data were not available for Turkmenistan and Uzbekistan.

d

PEPFAR’s Central American region comprises Belize, Costa Rica, El Salvador, Guatemala, 

Honduras, Nicaragua, and Panama. PEPFAR funding for Belize is approved jointly through the 

Caribbean and Central American regional operational plans.

e

PEPFAR’s Caribbean region comprises Antigua and Barbuda, the Bahamas, Barbados, Belize, 

Dominica, Grenada, Jamaica, Saint Kitts and Nevis, Saint Lucia, Saint Vincent, Suriname, and 

Trinidad and Tobago. Of these countries, treatment coverage data were available for Jamaica and 

Suriname only.
 

Page 15 GAO-13-460 PEPFAR Treatment Results

Since fiscal year 2010, OGAC has required PEPFAR country teams 

providing direct support for treatment services to track treatment retention 

rates, an indicator defined as the percentage of adults and children 

known to be alive and on treatment 12 months after starting treatment. In 

addition to being an essential indicator of treatment program outcomes—

a higher retention rate indicates that more people on treatment are 

surviving—facilities’ retention rates are used by OGAC and PEPFAR 

country teams as a proxy indicator of treatment program quality. Of the 23 

PEPFAR country teams directly providing treatment services, 20 provided 

data on this indicator in their fiscal year 2012 reports to OGAC. Ten of the 

20 teams reported retention rates at or above 80 percent for facilities 

where PEPFAR implementing partners support direct treatment services. 

(See table 4.)

Table 4: Reported PEPFAR Treatment Retention Rates, Fiscal Year 2012

Less than 60% 60-69% 70-79% 80-89% More than 90%

Côte d’Ivoire Malawi

Tanzania

Zambia

South Africa

Cambodia 

Lesotho

Mozambique

Nigeria

Uganda

Democratic Republic of the Congo

Ethiopia

Guyana

Haiti

Namibia

Swaziland

Vietnam

Botswana

China

Rwanda

Source: GAO analysis of PEPFAR country teams’ fiscal year 2011 and 2012 annual reports and information provided by OGAC.

Note: PEPFAR country teams for the Dominican Republic, Kenya, and Zimbabwe reported that 

treatment retention data were not available for fiscal year 2012.

However, PEPFAR patient retention data have several key limitations.

• The data are not always complete. PEPFAR’s reported retention rates 

reflect only the rates at facilities where PEPFAR directly supported

treatment services and that were able to properly collect and report 

retention data. In addition, in their fiscal year 2012 reports to OGAC, 

three PEPFAR country teams reported that data for this indicator were 

not available. Several country teams noted problems in obtaining data 

from partner-country systems or from all sites where PEPFAR directly 

supports treatment services. Several country teams also reported 

concerns about data quality, including limited understanding of how to 

collect these data.

• Methods and definitions vary. For example, PEPFAR country teams 

accounted for patients transferring to or from treatment facilities 

differently. In addition, country teams used different definitions to 

PEPFAR Data on 

Treatment Retention 

Indicate Some Progress 

but Have Limitations
 

Page 16 GAO-13-460 PEPFAR Treatment Results

count numbers of patients lost to follow-up (i.e., those with unknown 

outcomes, including possible death, treatment cessation, or selftransfer to another treatment facility). Under the current WHO 

definition, a patient may be considered lost to follow-up 90 days after 

the last scheduled appointment, but the definition may be adjusted 

depending on the stage of a patient’s treatment. 

• Data on treatment retention are rarely available for key populations, 

including children and adolescents, injecting drug users, men who 

have sex with men, and sex workers. These populations are at higher 

risk for HIV infection and may face specific challenges that make it 

more difficult to retain them in treatment programs.

• Few data on long-term retention (after 24 months from the start of 

treatment) are available. Although OGAC guidance encourages 

PEPFAR country teams to use data for cohorts of patients to track 

retention and survival at 24, 36, and 48 months, PEPFAR does not 

have a retention indicator that extends beyond 12 months.31

OGAC officials stated that OGAC has taken several steps to improve the 

fiscal year 2012 PEPFAR treatment retention data. First, OGAC clarified 

guidance to PEPFAR country teams regarding how to calculate and 

report on this indicator. Second, PEPFAR implementing agencies 

conducted data quality assessments in three PEPFAR countries. As a 

result, according to OGAC officials, three more PEPFAR country teams 

were able to report on the treatment retention indicator in fiscal year 2012 

than in fiscal year 2011. Furthermore, OGAC officials stated that data 

completeness is a priority for the current fiscal year 2013 and that they 

will help PEPFAR country teams with reporting retention data.

In addition to routinely reported information on treatment program results, 

various studies of treatment programs, although they may not represent 

national treatment program conditions and may be limited by incomplete 

data, provide information that can be useful for improving the results of 

treatment programs. Appendix III contains examples of information 

provided by studies we identified.

 

31See World Health Organization, Retention in HIV Programmes: Defining the Challenges 

and Identifying Solutions (Geneva, Switzerland: 2011).
 

Page 17 GAO-13-460 PEPFAR Treatment Results

PEPFAR country teams engage in a number of activities, often 

characterized as technical assistance or support, whose aim is to assure 

the quality of treatment programs. Seventeen of the 22 countries with 

PEPFAR partnership frameworks identified efforts to improve treatment 

program quality as a key goal shared by partner countries and PEPFAR. 

However, OGAC has not established a common set of indicators to 

assess results of these activities. We identified several examples of 

quality assurance activities, such as

• developing and implementing partner-country quality improvement 

strategies, including roles and responsibilities for health facility 

supervision;

• establishing treatment site-level performance improvement plans, 

including quality improvement council meetings to identify solutions to 

problems affecting service quality; and

• training health facility managers and staff to track and use facility-level 

performance data.

OGAC’s 2010 Next Generation Indicators Reference Guide sought to 

emphasize program quality indicators to help strengthen partner 

countries’ HIV/AIDS programs. To this end, the guidance added patient 

retention rate to the list of essential, reported treatment program 

indicators. The same guidance also recommended tracking data for 

several indicators of treatment program quality—for example, the number 

of patients with a documented CD4 or viral load test, the number of 

patients who have attended the recommended number of clinical visits, 

and the percentage of health facilities providing treatment using CD4 

monitoring in line with partner-country guidelines or policies.

In the three countries we visited, we found that PEPFAR implementing 

partners were using a wide range of indicators to report on their quality 

assurance activities. Examples of such indicators include percentages of 

(1) HIV-positive patients assessed for treatment eligibility, (2) patients on 

treatment who adhere to the dosing instructions and other requirements 

for taking ARV medicines, and (3) patients with good clinical outcomes. 

However, even where indicators in the three countries were generally the 

same, definitions varied slightly. For example, in reporting on the indicator 

of appointments kept, three PEPFAR implementing partners—all 

providing quality assurance assistance to treatment facilities in the same 

country—used two different definitions. One implementing partner 

reported on the percentage of HIV-positive patients who kept their 

appointments in the previous month or quarter, while the other two 

PEPFAR Supports Efforts 

to Improve Treatment

Program Quality, but 

OGAC Has Not Established 

Indicators to Assess 

Results 
 

Page 18 GAO-13-460 PEPFAR Treatment Results

implementing partners reported on the percentage of HIV-positive 

patients who missed their appointments.

OGAC’s 2010 Next Generation Indicators Reference Guide stated that 

additional guidance on quality assurance indicators for PEPFAR 

implementing agencies would be forthcoming. However, as of February 

2013, OGAC has not issued this additional guidance. The lack of 

PEPFAR-wide guidance on quality assurance indicators and definitions 

inhibits development of standardized measurement tools used by 

PEPFAR country teams to monitor treatment facilities supported by 

PEPFAR and ultimately track the results of PEPFAR’s quality assurance 

efforts, including technical assistance and other support. 

To track the results of partner-country treatment programs and to help 

ensure that they are effective, PEPFAR supports countries’ monitoring 

and evaluation (M&E) systems. While some progress has been made in 

expanding and upgrading them, these systems often are unable to 

produce timely and complete treatment data, limiting their usefulness for 

managing programs and reporting program results. PEPFAR country 

teams fulfill many M&E functions at facilities where PEPFAR supports

direct treatment services, and they assist partner countries in carrying out 

their M&E responsibilities by providing staff, training, and technical 

assistance and other support. Nevertheless, partner countries’ M&E 

systems continue to face a number of weaknesses. Consequently, 

PEPFAR country teams primarily use data drawn from PEPFAR-specific 

systems to report on PEPFAR treatment program results. OGAC has not 

yet issued guidance needed to support PEPFAR’s continued progress in 

transitioning to using partner-country M&E systems for program 

management and results reporting.

PEPFAR Supports 

Countries’ M&E 

Systems, but 

Weaknesses Limit the 

Timeliness and 

Completeness of 

Treatment Results 

Data
 

Page 19 GAO-13-460 PEPFAR Treatment Results

Among other activities, OGAC technical guidance to PEPFAR country 

teams calls for the development of partner countries’ M&E systems, 

among other activities. Fully functioning M&E systems are essential for 

effective patient monitoring and patient management32 and also generate 

data that PEPFAR country teams and partner countries need to track 

treatment program results.33 All countries and regions with PEPFAR 

partnership frameworks identified strengthening M&E systems as a key 

goal shared by partner countries and PEPFAR.34 To support this goal, 

according to fiscal year 2012 PEPFAR operational plans, PEPFAR 

country teams provide, among other things, technical assistance, training, 

and staff to treatment facilities, district health offices, and national 

ministries of health to collect, aggregate, and report treatment program 

information through partner countries’ M&E systems (see sidebar). This 

support included recruiting, mentoring, and training health facility staff and 

district health officials responsible for collecting, analyzing, aggregating, 

and reporting data through the country’s M&E system. PEPFAR country 

teams were also assisting partner countries with conducting surveys and 

surveillance, such as those needed to estimate the number of people with 

advanced HIV infection. In addition, according to OGAC officials, as of 

February 2013, 15 PEPFAR partner countries have expressed interest in 

a single, open-source data system, and several of these countries have 

started implementation. This health information software tool supports 

collecting, analyzing, and reporting national health data, including data on 

treatment programs. According to these officials, PEPFAR will support 

partner-country expansion of the software tool to include PEPFAR and 

Global Fund reporting in two additional PEPFAR partner countries. 

 

32Patient monitoring is the routine collection, compilation, and analysis of patient data over 

time and across service delivery points, using information from paper forms or entered into 

a computer. Patient management—also referred to as clinical management or clinical 

monitoring—is the relationship between health providers and patients over time, assisted 

by written records.

33The process of routinely tracking information about a program and its outcomes is 

referred to as program monitoring. Program monitoring at facility, district, and national 

levels requires many types of information, including aggregated patient data.

34As of March 2013, partnership frameworks had been signed with the following 22 

partner countries and regions: Angola, Botswana, Caribbean region, Central American 

region, Democratic Republic of the Congo, Dominican Republic, Ethiopia, Ghana, Haiti, 

Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, 

Swaziland, Tanzania, Ukraine, Vietnam, and Zambia.

PEPFAR Provides 

Technical Assistance, 

Training, and Staff to 

Strengthen Partner 

Countries’ M&E Systems
 

Page 20 GAO-13-460 PEPFAR Treatment Results

PEPFAR country teams have documented weaknesses in a number of 

partner countries’ M&E systems, which are at various stages of 

implementation. Our review of PEPFAR country teams’ fiscal year 2011 

annual reports to OGAC and fiscal year 2012 operational plans identified 

two key challenges for partner countries’ M&E systems.

Partner countries’ M&E systems often are unable to produce complete 

and timely data, thus limiting their usefulness for patient, clinic, or 

program management. In their 2011 annual reports to OGAC, 12

PEPFAR country teams cited timeliness of partner-country treatment 

program data as a challenge, often because partner-country reporting 

time frames differed from the U.S. government fiscal year. In addition, 

three PEPFAR country teams noted that data provided by partner 

countries’ M&E systems were incomplete—not all provinces or treatment 

facilities reported data into the system. In addition, one PEPFAR country 

was not able to collect data on the number of patients currently receiving 

treatment, because the partner country provided data only on the 

cumulative number of patients who had ever started treatment; the 

country team noted that this had the likely effect of inflating the partner 

country’s treatment coverage rate.

Furthermore, partner-country health officials, often lacking technical 

capacity, do not always use available data for decision making. Our 

review of the PEPFAR country teams’ operational plans found that 23 

teams cited the need to improve data use at treatment facilities or other 

levels of the health care system. For example, one country team reported 

that partner-country health officials tended to focus on data collection for 

reporting rather than for policy, planning, and program decision making. 

Another country team reported that lack of data reporting by treatment 

facilities limited analysis of treatment patients across facilities, and a third 

country team noted that human resource limitations and weak research 

capacity impeded use of M&E data. In addition, studies of PEPFAR 

partner countries’ M&E systems that we identified provided additional 

information; appendix III provides a summary of this information.

Weaknesses Remain in 

Partner Countries’ M&E 

Systems
 

Page 21 GAO-13-460 PEPFAR Treatment Results

Because of the limitations associated with the data from national M&E 

systems, PEPFAR country teams primarily use data drawn from systems 

created specifically for reporting PEPFAR treatment program results. 

OGAC’s 2010 Next Generation Indicators Reference Guide states that 

PEPFAR country teams may need to rely on these systems in the short 

term but should continue working to integrate these systems into partner 

countries’ M&E systems. Our review of PEPFAR country teams’ 

operational plans found that PEPFAR country teams maintained PEPFAR 

program performance management systems to routinely collect, compile, 

and analyze patient monitoring and management data from the health 

facilities where PEPFAR directly supports treatment services. In addition, 

PEPFAR country teams use these data to generate their semiannual and 

annual reports to OGAC. PEPFAR country teams supplement information 

from their own systems with data from partner countries’ M&E systems, 

including numbers of patients on treatment and rates of treatment 

coverage.

OGAC’s 2010 Next Generation Indicators Reference Guide recommends 

several indicators for tracking partner-country outcomes related to 

strengthening health systems, such as the existence of M&E plans and 

the percentage of health facilities with record-keeping systems for 

monitoring HIV/AIDS programs.35

 

35In addition, OGAC technical guidance cites an assessment tool established by UNAIDS, 

with PEPFAR support, which partner countries can use to develop their M&E systems for 

HIV/AIDS programs. See UNAIDS, Organizing Framework for a Functional National HIV 

Monitoring and Evaluation System (Geneva: April 2008).

In addition, OGAC’s technical guidance 

to country teams for developing partner countries’ M&E systems identifies 

a number of key efforts, such as developing M&E leadership and 

organizations, improving the policy environment, and ensuring the 

advancement and sustainability of technical capacity in PEPFAR partner 

countries. The technical guidance states that these efforts should support 

national capacity building. However, OGAC has not issued guidance 

identifying minimum standards that data generated by partner countries’ 

M&E systems should meet—such as standards related to completeness 

and timeliness—in order for PEPFAR country teams to assess, together 

with partner countries and other donors, whether the systems are ready 

for use in PEPFAR program management and results reporting. The lack 

of such standards leaves uncertain the point at which partner-country 

M&E systems are mature enough for PEPFAR to rely on them. This 

uncertainty is likely to delay achievement of PEPFAR’s goal of using 

PEPFAR Country Teams 

Aim to Integrate M&E 

Systems, but OGAC Has 

Not Established Minimum 

Standards to Guide This 

Effort 
 

Page 22 GAO-13-460 PEPFAR Treatment Results

partner-country M&E systems to generate data for PEPFAR treatment 

program management and reporting.

Ensuring that PEPFAR treatment programs continue to improve and to 

operate as effectively as possible requires careful, complex monitoring 

and evaluation (M&E), not only of program results but also of quality 

assurance efforts. Available data on PEPFAR program results show 

some progress. In particular, PEPFAR and UNAIDS data indicate a 

steady increase in the number of people on treatment, improved 

treatment coverage rates, and high rates of patient retention at many 

facilities. However, PEPFAR’s contributions to expansion of partner 

countries’ treatment programs are not fully reflected in its results data 

because OGAC’s current method for deriving PEPFAR’s direct treatment 

indicator does not fully account for PEPFAR’s efforts to improve partner 

countries’ capacity to manage their treatment programs. This limits the 

usefulness of PEPFAR’s direct treatment indicator for assessing progress 

toward expanding partner-country treatment programs. Furthermore, 

OGAC has not yet established a common set of indicators to measure the 

results of PEPFAR technical assistance and other support intended to 

improve the quality of treatment programs. Lacking a standard set of 

quality assurance indicators, PEPFAR is limited in its ability to track the 

results of PEPFAR’s quality assurance efforts.

As PEPFAR continues to shift responsibility for managing treatment 

programs to partner countries, those countries will need robust M&E 

systems to generate the data that are indispensable for ensuring effective 

treatment and efficient program management. PEPFAR has dedicated 

resources specifically for these efforts, but problems with untimely and 

incomplete data collection, as well as with data use, persist. As a result, 

PEPFAR has to rely on the M&E systems its implementing partners have 

developed rather than on country-managed systems for collecting and 

reporting results data. In its guidance, OGAC has not yet established 

minimum standards that data generated by partner countries’ M&E 

systems should meet in order for PEPFAR country teams to assess these 

systems. Without such standards, uncertainty remains as to when 

partner-country M&E systems will be ready to be integrated with PEPFAR 

systems, thus delaying the achievement of PEPFAR’s goal of using 

partner-country M&E system data for PEPFAR treatment program 

management and reporting.

Conclusions 
 

Page 23 GAO-13-460 PEPFAR Treatment Results

To ensure the outcomes and quality of treatment programs supported by 

PEPFAR, we recommend that the Secretary of State direct the U.S. 

Global AIDS Coordinator to take the following three actions in 

collaboration with PEPFAR implementing agencies:

• develop a method that better accounts for PEPFAR’s contributions to 

partner-country treatment programs;

• establish a common set of indicators to measure the results of 

treatment program quality improvement efforts; and

• establish a set of minimum standards for data generated by partner 

countries’ M&E systems, to enable PEPFAR country teams to assess 

those systems’ readiness for use in treatment program management 

and reporting.

We provided a draft of this report to State, USAID, and CDC. 

Responding jointly with CDC and USAID, State provided written 

comments (see app. IV for a copy of these comments). State and CDC 

also provided technical comments and supplementary information relating 

to our findings and recommendations. In response to the technical 

comments, we incorporated changes to the draft report, as appropriate. 

After reviewing the supplementary information, we clarified our findings 

and recommendations relating to PEPFAR’s direct treatment indicator 

and its support for partner countries’ M&E systems.

In its written comments, State generally agreed with our three 

recommendations. First, State affirmed that it supports our 

recommendation to develop a method for fully accounting for PEPFAR’s 

contributions to partner-country treatment programs. Observing that 

PEPFAR’s direct treatment indicator was intended to capture only 

essential components of direct treatment services, State noted that 

PEPFAR has recently begun an effort to revise its monitoring, evaluation, 

and reporting framework, including an expansion of indicators that would 

allow for implementing partners to report on their efforts to help partner 

countries build capacity and develop sustainable treatment programs. 

Second, State also agreed with the finding leading to our 

recommendation regarding the development of indicators to measure the 

results of treatment program quality improvement efforts. State cited the 

need for a harmonized PEPFAR strategy on treatment quality, including 

key indicators, and noted steps it is taking to develop such a strategy. In 

addition, stressing that treatment retention indicators are relatively new 

and difficult to operationalize, State detailed steps PEPFAR is taking to 

help improve treatment retention measurement, evaluation, and 

Recommendations for 

Executive Action

Agency Comments

and Our Evaluation
 

Page 24 GAO-13-460 PEPFAR Treatment Results

performance. Third, State noted that PEPFAR supports the strengthening 

of partner country reporting systems and works with partner countries to 

help them develop such systems, both to support national programs as 

well as to provide data for PEPFAR and other donors. As part of these 

efforts, PEPFAR also works with WHO and the Global Fund on system 

standardization and standards for data exchange. State specifically 

identified an indicator developed by WHO for documenting data 

completeness and timeliness and stated that this indicator can be used to 

monitor efforts to develop these reporting systems. We agree that such 

an indicator could be useful for PEPFAR country teams trying to 

determine when partner-country M&E systems are ready to be integrated 

with PEPFAR systems. However, we note that PEPFAR guidance does 

not instruct country teams to use the WHO indicator or any other indicator 

for this purpose. We believe that specifying one or more indicators for 

PEPFAR country teams to use is important to ensure a consistent 

approach to systems integration across the program. Doing this would 

emphasize for country partners the importance of harmonizing M&E 

systems for mutually beneficial purposes.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of State and 

the U.S. Global AIDS Coordinator. The report also will be available at no 

charge on the GAO website at http://www.gao.gov. 
 

Page 25 GAO-13-460 PEPFAR Treatment Results

If you or your staff have any questions about this report, please contact 

me at (202) 512-3149 or gootnickd@gao.gov or contact Marcia Crosse at 

(202) 512-7114 or crossem@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix V.

David Gootnick

Director, International Affairs and Trade

Marcia Crosse

Director, Health Care
 

Page 26 GAO-13-460 PEPFAR Treatment Results

List of Requesters

The Honorable Lamar Alexander

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Tom Coburn, MD

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Richard Burr

Ranking Member

Subcommittee on Primary Health and Aging

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Michael B. Enzi

Ranking Member

Subcommittee on Children and Families

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Johnny Isakson

Ranking Member

Subcommittee on Employment and Workplace Safety

Committee on Health, Education, Labor, and Pensions 

United States Senate
Appendix I: Objectives, Scope, and 

Methodology

Page 27 GAO-13-460 PEPFAR Treatment Results

In this report, we examine the President’s Emergency Plan for AIDS 

Relief’s (PEPFAR) (1) treatment program results and how the Department 

of State’s (State) Office of the U.S. Global AIDS Coordinator (OGAC) 

measures them and (2) assistance to improve partner countries’ 

monitoring and evaluation (M&E) systems. To address both of these 

objectives, we collected and analyzed information from the following 

sources: interviews and fieldwork; guidance documents and past GAO 

work; PEPFAR partnership frameworks, operational plans, and 

performance reports; and studies of treatment programs.

We interviewed officials from OGAC, the Department of Health and 

Human Services’ (HHS) Centers for Disease Control and Prevention 

(CDC), and the U.S. Agency for International Development (USAID) in 

Washington, D.C., and Atlanta, Georgia. We also conducted fieldwork in 

three PEPFAR partner countries—Kenya, South Africa, and Uganda—in 

June 2012 to obtain information on PEPFAR efforts to support partnercountry treatment program outcomes and quality as well as challenges 

faced by PEPFAR implementing agencies and stakeholders. We selected 

these countries based on program size, availability of cost data, travel 

logistics, and other factors. We interviewed U.S. agency officials, 

representatives of key implementing partners, and partner government 

health officials and conducted visits to selected treatment facilities in 

these countries.

We reviewed guidance provided to PEPFAR country teams1 by OGAC in 

collaboration with CDC, USAID, and other PEPFAR implementing 

agencies and previous GAO work to identify criteria related to 

requirements for collecting, validating, and reporting treatment program 

results and their measures.2

 

1

In this report, “PEPFAR country teams” refers to PEPFAR country and regional teams

and their implementing partners collectively.

These guidance documents also provided 

criteria for examining PEPFAR assistance to improve partner countries’ 

M&E systems. Guidance documents included OGAC’s 2010 Next 

Generation Indicators Reference Guide, issued in August 2009; fiscal 

years 2011 and 2012 operational plan guidance and associated technical 

considerations; and annual and semiannual performance reporting 

guidance. We also consulted relevant guidance and reports issued by 

2

GAO, Tax Administration: IRS Needs to Further Refine Its Tax Filing Season 

Performance Measures, GAO-03-143 (Washington, D.C.: Nov. 22, 2002).

Appendix I: Objectives, Scope, and 

Methodology 
Appendix I: Objectives, Scope, and 

Methodology

Page 28 GAO-13-460 PEPFAR Treatment Results

international organizations such as the United Nations Joint Programme 

on HIV/AIDS (UNAIDS) and the World Health Organization (WHO). 

These included Global Report: UNAIDS Report on the Global AIDS 

Epidemic, 2012 and Organizing Framework for a Functional National HIV 

Monitoring and Evaluation System as well as WHO’s 2010 Antiretroviral 

Therapy for HIV Infection in Adults and Adolescents: Recommendation 

for a Public Health Approach and 2006 Patient Monitoring Guidelines for 

HIV Care and Antiretroviral Therapy. We also reviewed WHO’s 2011 

Retention in HIV Programmes: Defining the Challenges and Identifying 

Solutions. 

We examined PEPFAR operational plans, performance reports, and 

partnership frameworks. First, to identify key PEPFAR treatment program 

goals—including those related to treatment program supervision, M&E 

systems, and quality assurance—we reviewed partnership framework 

agreements between the United States and 22 PEPFAR partner countries 

and regions.3

 

3

As of February 2013, the United States had signed partnership frameworks with the 

following 22 partner countries and regions: Angola, Botswana, the Caribbean region, the 

Central American region, the Democratic Republic of the Congo, the Dominican Republic, 

Ethiopia, Ghana, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, 

South Africa, Swaziland, Tanzania, Ukraine, Vietnam, and Zambia.

Next, to identify ongoing and planned PEPFAR activities, as 

well as challenges, related to treatment programs and M&E systems, we 

reviewed relevant sections of PEPFAR operational plans for fiscal year 

2012 for the 33 PEPFAR countries and three regions. We documented 

instances where the operational plans addressed these activities, and we 

summarized the information for all PEPFAR countries and regions. 

Finally, to identify PEPFAR treatment program results, as well as 

challenges associated with these program activities and PEPFAR 

assistance to improve partner countries’ M&E systems, we reviewed 

PEPFAR semiannual and annual reports for fiscal years 2011 and 2012 

submitted by PEPFAR country teams to OGAC as well as aggregate 

PEPFAR data provided to us by OGAC. In fiscal years 2011 and 2012, 

the 33 PEPFAR country and three regional teams provided semi-annual 

and annual reports to OGAC containing data and narrative descriptions of 

each country’s or region’s PEPFAR activities. We reviewed all PEPFAR 

countries’ and regions’ fiscal year 2011 annual reports to identify 

strengths and weaknesses of partner countries’ M&E systems. In 

addition, the 23 PEPFAR country teams that provided direct support for

treatment services reported PEPFAR treatment indicator data and 
Appendix I: Objectives, Scope, and 

Methodology

Page 29 GAO-13-460 PEPFAR Treatment Results

narrative descriptions to OGAC regarding (1) the number of adults and 

children with advanced HIV infection who are currently receiving 

treatment directly supported by PEPFAR (PEPFAR direct number of 

people currently on treatment); (2) the percentage of adults and children 

with advanced HIV infection who are receiving treatment in partner 

countries’ treatment programs (national coverage rates); and (3) the 

percentage of adults and children known to be alive and on treatment 12 

months after starting treatment directly supported by PEPFAR (PEPFAR 

direct treatment retention rates). We reviewed and summarized the 23 

country teams’ narrative descriptions accompanying each of these three 

PEPFAR indicators for information related to treatment program results 

and assistance to improve PEPFAR partner countries’ M&E systems.

In the case of the number of people on treatment directly supported by 

PEPFAR, to show changes over time, we analyzed aggregate data for 

fiscal years 2004 through 2012 provided by OGAC, which it derived from 

PEPFAR country teams’ semi-annual and annual reports. We previously 

have reviewed OGAC guidance and procedures for collecting, analyzing, 

and assessing these data.4

www.unaids.org

In addition, to identify factors considered by 

PEPFAR country teams when reporting on PEPFAR treatment program 

results, we reviewed the narrative descriptions provided in these PEPFAR 

country teams’ fiscal year 2011 annual reports. On the basis of these 

reviews, as well as interviews with OGAC officials, we determined that the 

PEPFAR data on number of people on treatment were sufficiently reliable 

for reporting totals rounded to the nearest hundred. In addition, to 

illustrate PEPFAR’s contribution to the number of people on treatment in 

low- and middle-income countries, we obtained data on the numbers of 

people on treatment in all low- and middle-income countries from the 

UNAIDS website ( ) for calendar years 2004 through 

2011. UNAIDS sets international standards for these data, which it 

collects from national governments and uses to report on estimated 

numbers of people on treatment; therefore, we deemed them sufficiently 

reliable for the purposes of our reporting. Data on the number of people 

on treatment in low- and middle-income countries were not available for 

2012 at the time of this report’s publication. To be able to illustrate 

PEPFAR’s contribution to the number of people on treatment in low- and 

middle-income countries in 2012, we derived a rough estimate based on 

 

4

See GAO, President’s Emergency Plan for AIDS Relief: Program Planning and 

Reporting, GAO-11-785 (Washington, D.C.: July 29, 2011).
Appendix I: Objectives, Scope, and 

Methodology

Page 30 GAO-13-460 PEPFAR Treatment Results

changes in PEPFAR’s and UNAIDS’s reported numbers of people on 

treatment from 2010 to 2011. We observed that the number of people on 

treatment directly supported by PEPFAR made up about half of the 

increase in the number of people on treatment in low- and middle-income 

countries in these years. For fiscal years 2011 to 2012, the number of 

people on treatment directly supported by PEPFAR increased by about 

1.2 million; if we had assumed that this number continued to make up half 

of the increase in low- and middle-income countries in these years, the 

estimated increase would have been 2.4 million. Thus, our estimate of an 

increase of about 1.5 million people on treatment from 2011 to 2012—

leading to an estimate of 9.5 million people on treatment in low- and 

middle-income countries in those years—represents a conservative 

projection of possible scenarios.

In the case of partner countries’ treatment coverage rates, we analyzed 

data provided in UNAIDS’s 2012 Global Report: UNAIDS Report on the 

Global AIDS Epidemic as well as data available for 2009 through 2011 on 

UNAIDS’s website (www.unaids.org). UNAIDS sets international 

standards for these data, which it collects from national governments and 

uses to report on national treatment coverage rates. On the basis of 

review of treatment coverage rates reported by PEPFAR country teams to 

OGAC, as well as discussions with OGAC officials, we determined that 

UNAIDS’s treatment coverage data were the most complete and current 

data available and were thus sufficiently reliable for the purposes of our 

reporting.

In addition to information provided by PEPFAR country teams and 

reported by OGAC, we also drew on information from a selected set of 

studies of treatment programs and M&E systems in PEPFAR partner 

countries. We used the information from these studies to identify 

illustrative examples of factors affecting treatment program outcomes and 

M&E system strengths and weaknesses. Appendix III contains examples 

of information provided by studies we reviewed. 

First, although we did not intend to develop an exhaustive list of all 

available studies, we took a number of steps to identify relevant and upto-date studies assessing treatment programs and M&E systems in 

PEPFAR countries. These studies included: (1) studies collected under 

our previous review of evaluations of PEPFAR programs; (2) studies 

provided by PEPFAR country teams in the three countries we visited; (3) 

articles published in special issues of Health Affairs and the Journal of 

Acquired Immune Deficiency Syndromes dedicated to PEPFAR 

programs, both published in 2012; and (4) a citations review for PEPFAR 
Appendix I: Objectives, Scope, and 

Methodology

Page 31 GAO-13-460 PEPFAR Treatment Results

public health evaluations, evaluations provided by CDC headquarters, 

and relevant articles appearing in Health Affairs and the Journal of 

Acquired Immune Deficiency Syndromes from 2009 through 2012. We 

identified more than 200 studies addressing our objectives. 

To perform our review, we first reviewed the studies’ titles and abstracts 

to categorize each study according to one or more topics, such as M&E 

systems or treatment program retention. Focusing on studies that fell into 

categories related to M&E systems and to treatment program retention 

and patient-level outcomes, we then reviewed key sections—such as 

findings and conclusions—of each study to identify common themes. We 

also targeted studies that addressed topics covered in the body of the 

report, such as factors affecting treatment program retention and loss to 

follow-up and strengths and weaknesses of M&E systems. Having 

identified subsets of relevant studies, we reviewed them in more depth to 

verify our initial judgments about the studies’ findings and to select 

illustrative examples of the themes we had identified. This additional 

review included the development of narrative work papers synthesizing 

and categorizing more detailed findings and results from the selected 

studies. We then presented these findings and examples in appendix III. 

Our analysis is not a summary of the full set of studies we identified in the 

initial phase but rather a presentation of several key, high-level results 

derived from a select set of studies in both areas, supported with citations 

to illustrative studies.

We conducted this performance audit from May 2012 to April 2013 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.
Appendix II: Criteria for Assessing PEPFAR 

Direct Support

Page 32 GAO-13-460 PEPFAR Treatment Results

The Department of State’s (State) Office of the U.S. Global AIDS 

Coordinator’s (OGAC) Next Generation Indicators Reference Guide, 

effective beginning in fiscal year 2010 and updated in February 2013, 

provides a list of indicators for setting targets, monitoring results, and 

reporting to OGAC. The guidance distinguishes between President’s 

Emergency Plan for AIDS Relief (PEPFAR) direct indicators and national 

indicators. PEPFAR direct indicators describe the results of PEPFAR 

programs through its funded activities. National indicators describe the 

achievements of all contributors—including public and private sector 

organizations and other donors—to a partner country’s HIV/AIDS 

programs.

Furthermore, OGAC’s guidance provides a checklist for determining 

whether a site-specific service supported by PEPFAR can be counted in 

reporting on PEPFAR direct indicators. According to the guidance, to be 

characterized as PEPFAR direct, an activity must fulfill at least one 

criterion in each of the two panels shown in table 5. If an activity meets at 

least one of each set of criteria, PEPFAR support is assumed to be direct 

and to likely provide sufficient support for claiming 100 percent of the sitespecific results. If an activity meets a criterion in only one of the panels, 

PEPFAR support may be insufficient for claiming 100 percent of sitespecific results. In that case, country teams must (1) determine whether 

there is sufficient justification to claim the results as direct and, if there is, 

(2) justify the method used to estimate the appropriate fraction of the total 

commensurate with PEPFAR support to the site and (3) document the 

estimation procedures used. 

Table 5: Checklist to Determine Whether to Count Service Delivery Support as PEPFAR Direct

Assessment criteria

Panel 1 Panel 2

Compared with other donors/partners, the dollar value that PEPFAR 

invests at the service delivery site is substantial.

Quality prevention, care, and/or treatment services at the 

site(s) would not occur in the absence of PEPFAR support.

PEPFAR has frequent (i.e., more than 1 day per week) contact with 

service delivery site personnel, patients, and/or clients.

The quality of the services provided at the service delivery 

site(s) would be unacceptably low without PEPFAR support.

PEPFAR staff regularly assists with essential M&E functions provided at 

the service delivery site.

The support provided represents a substantial contribution 

toward sustainability of services at the service delivery 

site(s).

Source: PEPFAR Next Generation Indicators Reference Guide, version 1.1, August 2009.

Appendix II: Criteria for Assessing PEPFAR 

Direct Support
Appendix III: Summary of Studies

Page 33 GAO-13-460 PEPFAR Treatment Results

In addition to analyzing information provided by President’s Emergency 

Plan for AIDS Relief (PEPFAR) country teams and reported by the 

Department of State’s (State) Office of the U.S. Global AIDS Coordinator 

(OGAC), we also performed reviews of a selected set of studies.

1

Although these studies may not represent national treatment program 

conditions and may be limited by incomplete data, they provide additional 

information related to treatment retention and patient-level health 

outcomes, as well as strengths and weaknesses of partner-country 

monitoring and evaluation (M&E) systems. (See app. I for information on 

how we identified and used these studies for the purposes of our 

reporting.)

Treatment retention rates2 reported by PEPFAR country teams indicate 

some progress but have certain limitations related to data completeness 

and varying methods and definitions. Treatment program studies—which 

use treatment facility data not routinely reported by PEPFAR country 

teams to OGAC—also provide information about treatment retention, 

adherence, and patient loss-to-follow-up.3

Several studies, although not representative of national program 

conditions, identified factors associated with patient loss-to-follow-up, 

such as advanced illness and personal economics. They also noted 

measures that could potentially reduce the number of patients lost to 

follow-up and thus increase retention rates, such as starting treatment 

earlier, shortening the distance to health care facilities, expanding 

personal outreach by community health volunteers, and using mobile 

phone messaging for patient follow-up. In addition, several studies that 

we reviewed identified interventions found to be successful for reducing 

the occurrence of drug resistance and treatment failure, including (1) 

increased outreach to patients to increase adherence to medications and 

(2) effective supervision and training of lower-level health facility staff. 

Other studies identified factors that may limit the positive health effects of 

 

 

1

In this report, “studies” refers to evaluations, assessments, and other studies of treatment 

programs and M&E systems in PEPFAR countries.

2

OGAC defines treatment retention as the percentage of adults and children known to be 

alive and on treatment 12 months after treatment initiation. 

3

Patient loss-to-follow-up is defined as patients with unknown treatment outcomes, 

including possible death, treatment cessation, or self-transfer to another treatment facility.

Appendix III: Summary of Studies

Treatment Retention and 

Patient-Level Outcomes
Appendix III: Summary of Studies

Page 34 GAO-13-460 PEPFAR Treatment Results

treatment, such as poor access to nutrition and clean water. Such 

findings can serve as the basis for adopting new treatment program 

policies and management approaches.

Incomplete data may limit studies’ ability to fully examine patient-level 

health outcomes and the factors that affect them. For example, we 

identified one study that reported some positive adult treatment program 

outcomes, based on a nationally representative sample of treatment 

facilities in Rwanda, but noted incomplete data on patient weight and CD4 

cell count, among other limitations. Another study on the prevalence of 

drug-resistant HIV strains noted that very few published data on drug 

resistance are available, particularly for the HIV strains that tend to be 

prevalent in low- and middle-income countries. Devising mitigation 

strategies for drug resistance can be difficult without these data. Likewise, 

one study noted a lack of data on potential adverse effects of treatment 

on the growth and development of pediatric patients.

Studies of partner countries’ M&E systems note that some progress has 

been made in expanding and upgrading these systems. The studies cite 

increased use of electronic systems for health information management 

and reporting. For example, one study found that electronic systems, 

where in use, enabled health facilities to report on health indicators more 

easily as well as to support patient and facility management.

Nevertheless, these studies also found that partner countries’ M&E 

systems are unable to produce timely and complete treatment data, thus 

limiting their usefulness for patient, clinic, or program management. 

These studies cited several challenges, including the following:

• Human resource limitations can hinder the full use of M&E system 

data. For example, one study noted that health facility staff lacked 

trained data managers to regularly analyze basic data.

• Data may not always be analyzed when reported from the facility to 

the district; and data may not always be disseminated properly, or 

may not be used in decision making. For example, one study noted

limited access to data and lack of capacity as factors negatively 

affecting data use.

• Health facility staff may prioritize data reporting to districts, national 

ministries, and donors over data use, including use for improving the 

quality of treatment services. For example, one study found that data 

were used for decision making at 38 percent of health facilities 

reviewed and in 44 percent of districts reviewed.

Strengths and Weaknesses 

of Partner-Country M&E 

Systems
Appendix IV: Comments from the Department 

of State

Page 35 GAO-13-460 PEPFAR Treatment Results

Appendix IV: Comments from the 

Department of State
Appendix IV: Comments from the Department 

of State

Page 36 GAO-13-460 PEPFAR Treatment Results
Appendix IV: Comments from the Department 

of State

Page 37 GAO-13-460 PEPFAR Treatment Results
Appendix IV: Comments from the Department 

of State

Page 38 GAO-13-460 PEPFAR Treatment Results
Appendix IV: Comments from the Department 

of State

Page 39 GAO-13-460 PEPFAR Treatment Results
Appendix V: GAO Contacts and Staff 

Acknowledgments

Page 40 GAO-13-460 PEPFAR Treatment Results

David Gootnick, (202) 512-3149 or gootnickd@gao.gov

Marcia Crosse, (202) 512-7114 or crossem@gao.gov

In addition to the contacts named above, Jim Michels (Assistant Director), 

Todd M. Anderson, David Dayton, Brian Hackney, and Grace Lui made 

key contributions to this report. In addition, the following GAO staff 

provided technical assistance and other support: Sada Aksartova, Chad 

Davenport, David Dornisch, Lorraine Ettaro, Katherine Forsyth, Kay 

Halpern, Erika Navarro, and Jane Whipple.

Appendix V: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts

Staff 

Acknowledgments 
Related GAO Products

Page 41 GAO-13-460 PEPFAR Treatment Results

President’s Emergency Plan for AIDS Relief: Per-Patient Costs Have 

Declined Substantially, but Better Cost Data Would Help Efforts to 

Expand Treatment. GAO-13-345. Washington, D.C.: March 15, 2013.

President’s Emergency Plan for AIDS Relief: Agencies Can Enhance 

Evaluation Quality, Planning, and Dissemination. GAO-12-673. 

Washington, D.C.: May 31, 2012.

President’s Emergency Plan for AIDS Relief: Program Planning and 

Reporting. GAO-11-785. Washington, D.C.: July 29, 2011.

Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other 

Health Assistance in Fiscal Years 2001-2008. GAO-11-64. Washington, 

D.C.: October 8, 2010.

President’s Emergency Plan for AIDS Relief: Efforts to Align Programs 

with Partner Countries’ HIV/AIDS Strategies and Promote Partner 

Country Ownership. GAO-10-836. Washington, D.C.: September 20, 

2010.

President’s Emergency Plan for AIDS Relief: Partner Selection and 

Oversight Follow Accepted Practices but Would Benefit from Enhanced 

Planning and Accountability. GAO-09-666. Washington, D.C.: July 15, 

2009.

Global HIV/AIDS: A More Country-Based Approach Could Improve 

Allocation of PEPFAR Funding. GAO-08-480. Washington, D.C.: April 2, 

2008.

Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved 

Its Documentation of Funding Decisions but Needs Standardized 

Oversight Expectations and Assessments. GAO-07-627. Washington, 

D.C.: May 7, 2007.

Global Health: Spending Requirement Presents Challenges for Allocating 

Prevention Funding under the President’s Emergency Plan for AIDS 

Relief. GAO-06-395. Washington, D.C.: April 4, 2006.

Global Health: The Global Fund to Fight AIDS, TB and Malaria Is 

Responding to Challenges but Needs Better Information and 

Documentation for Performance-Based Funding. GAO-05-639. 

Washington, D.C.: June 10, 2005.

Related GAO Products
Related GAO Products

Page 42 GAO-13-460 PEPFAR Treatment Results

Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications 

Provided under U.S. Emergency Plan Is Limited. GAO-05-133. 

Washington, D.C.: January 11, 2005.

Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges 

to Expanding Treatment, but Others Remain. GAO-04-784. Washington, 

D.C.: June 12, 2004.

Global Health: Global Fund to Fight AIDS, TB and Malaria Has Advanced 

in Key Areas, but Difficult Challenges Remain. GAO-03-601. Washington, 

D.C.: May 7, 2003.

(320913)
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