President's Emergency Plan for AIDS Relief: Efforts to Align Programs with Partner Countries' HIV/AIDS Strategies and Promote Partner Country Ownership
Published: 2010-09-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The President's Emergency Plan for AIDS Relief (PEPFAR), reauthorized at $48 billion for fiscal years 2009 through 2013, supports HIV/AIDS prevention, treatment, and care services overseas. The reauthorizing legislation, as well as other key documents and PEPFAR guidance, endorses the alignment of PEPFAR activities with partner country HIV/AIDS strategies and the promotion of partner country ownership of U.S.-supported HIV/AIDS programs. This report, responding to a legislative directive, (1) examines alignment of PEPFAR programs with partner countries' HIV/AIDS strategies and (2) describes several challenges related to alignment or promotion of country ownership. GAO analyzed PEPFAR planning documents and national strategies for four countries--Cambodia, Malawi, Uganda, and Vietnam--selected to represent factors such as diversity of funding levels and geographic location. GAO also reviewed documents and reports by the U.S. government, research institutions, and international organizations and interviewed PEPFAR officials and other stakeholders in headquarters and the four countries.
section_title: What GAO Found
paragraphs: PEPFAR activities are generally aligned with partner countries' national HIV/AIDS strategies. GAO's analysis of PEPFAR planning documents and national HIV/AIDS strategies, as well as discussions with PEPFAR officials in the four countries GAO visited, showed overall alignment between PEPFAR activities and the national strategy goals. In addition, statements by global and country-level PEPFAR stakeholders indicate that PEPFAR activities support the achievement of partner countries' national strategy goals. PEPFAR officials noted that a number of factors may influence the degree to which PEPFAR activities align with national strategy goals, including the activities of other donors, the size of the PEPFAR program, and policy restrictions. PEPFAR may also support activities not mentioned in the national HIV/AIDS strategies but that are addressed in relevant sector- or program-specific strategies. PEPFAR officials reported various efforts to help ensure that PEPFAR activities support the achievement of national strategy goals, including assisting in developing national strategies, participating in formal and informal communication and coordination meetings, engaging regularly with partner country governments during the annual planning process, and developing a new HIV/AIDS agreement, known as a partnership framework, between PEPFAR and partner country governments. PEPFAR stakeholders highlighted several challenges related to aligning PEPFAR programs with national HIV/AIDS strategies or promoting country ownership of U.S.-supported HIV/AIDS programs. First, PEPFAR indicators, including indicator definitions and timeframes, sometimes differ from those used by partner countries and other international donors. Second, gaps may exist in the sharing of PEPFAR information with partner country governments and other donors. Third, limitations in country leadership and capacity, such as lack of technical expertise to develop strategies and manage programs, affect country teams' ability to ensure that PEPFAR activities support achievement of national strategy goals. Fourth, Office of the U.S. Global AIDS Coordinator (OGAC) guidance to country teams regarding development of partnership frameworks does not include indicators for establishing baseline measures of country ownership prior to implementation of partnership frameworks. Without baseline measures, country teams may have limited ability to measure the frameworks' impact and make needed adjustments.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of State direct OGAC to develop and disseminate a methodology for establishing baseline measures of country ownership prior to implementing partnership frameworks. OGAC concurred with this recommendation.

section_title: Letter
paragraphs: In 2008, approximately 2 million people worldwide died of HIV-related  causes and an estimated 2.7 million people were newly infected with HIV.  The first 5-year phase of the President’s Emergency Plan for AIDS Relief  (PEPFAR) was authorized by Congress in 2003 at $3 billion for each of 5  fiscal years. In July 2008, Congress passed the Tom Lantos and Henry J.  Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis,  and Malaria Reauthorization Act of 2008 (2008 Leadership Act),  authorizing PEPFAR appropriations of $48 billion through fiscal year 2013  and strengthening the U.S. government’s efforts to combat the global  HIV/AIDS pandemic and other diseases. The U.S. government reported  that in 2009, PEPFAR directly supported treatment for more than 2.4  million patients with HIV/AIDS and care and support for more than 11  million people affected by the disease. Although PEPFAR initially targeted  15 countries, known as focus countries, since its establishment PEPFAR  has made significant investments in more than 30 partner countries and  regions.
U.S. policy for combating global HIV/AIDS emphasizes the alignment, or  harmonization, of PEPFAR programs with the countries’ HIV/AIDS  strategies and the promotion of partner country ownership of U.S.- supported HIV/AIDS programs. The 2008 Leadership Act, among its other  purposes and findings, endorses the principles of harmonization and  coordination to combat HIV/AIDS and cites improving harmonization of  U.S. efforts with national strategies of partner governments and other  public and private entities as an element in strengthening and enhancing  U.S. leadership and the effectiveness of the United States response to  HIV/AIDS. The Paris Declaration on Aid Effectiveness (Paris Declaration),  which the U.S. government signed in 2005, calls on developed and  developing countries to take steps to improve aid effectiveness, such as by  increasing alignment of foreign assistance programs with partner  countries’ priorities, strategies, and procedures. In addition, PEPFAR’s  new 5-year strategy, released in December 2009, and other PEPFAR  guidance highlight the principles of the Paris Declaration and reaffirm the  U.S. government’s commitment to support partner country ownership of  the programs, in part by aligning PEPFAR with national HIV/AIDS  strategies and programs.
In response to a directive in the 2008 Leadership Act, this report (1)  examines alignment of PEPFAR programs with partner countries’  HIV/AIDS strategies and (2) describes several challenges related to  alignment of PEPFAR programs with the national strategies or promotion  of partner country ownership.
We analyzed U.S. agency documents and relevant studies and interviewed  PEPFAR stakeholders (i.e., PEPFAR officials, representatives of partner  government ministries, HIV/AIDS donors, and PEPFAR implementing  partners). We reviewed the 2008 Leadership Act, PEPFAR guidance, and  the Paris Declaration to define alignment and to identify criteria for  examining alignment of PEPFAR programs with partner countries’  HIV/AIDS strategies. We interviewed PEPFAR officials in Washington,  D.C., and Atlanta, Georgia, regarding their processes for developing  PEPFAR plans and efforts to align PEPFAR programs with country  strategies. In addition, we interviewed PEPFAR stakeholders in Cambodia,  Malawi, Uganda, and Vietnam regarding alignment of goals and objectives,  program activities, and indicators. To select the four countries we  considered a number of factors including funding levels, geographic  diversity, and whether or not the country was designated a focus country  during the first phase of PEPFAR. To examine alignment of PEPFAR  activities with national HIV/AIDS strategies, we analyzed key PEPFAR and  national strategy documents for these four countries. Specifically, we  reviewed the goals and objectives outlined in each country’s national  multisectoral HIV/AIDS strategy and compared this information with the  activities and programs laid out in key sections of corresponding PEPFAR  documents for each country. In addition, in our visits to the four countries,  we discussed our analysis with PEPFAR officials to identify reasons for  identified areas of divergence between the national strategies and  PEPFAR documents. To identify PEPFAR alignment efforts as well as  challenges related to alignment and promotion of country ownership, we  reviewed the PEPFAR 5-year strategy, prior GAO reports, a relevant study  by the Institute of Medicine, and the results of our interviews with  PEPFAR stakeholders. (See app. I for further details of our scope and  methodology.)
We conducted this performance audit from July 2009 to September 2010 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  we obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
subsections: section_title: PEPFAR Leadership and Implementation
paragraphs: The Department of State’s Office of the U.S. Global AIDS Coordinator  (OGAC) establishes overall PEPFAR policy and program strategies,  coordinates PEPFAR programs, and allocates resources to several U.S.  agencies to implement PEPFAR activities. These agencies (referred to in  this report as implementing agencies) include, among others, the U.S.  Agency for International Development (USAID) and the U.S. Department  of Health and Human Services’ (HHS) Centers for Disease Control and  Prevention (CDC). OGAC coordinates U.S. government implementing  agencies and resources, establishes policy and guidance for the PEPFAR  program, and is responsible for allocating resources to implementing  agencies. OGAC executes its coordinating role in part by providing  implementing agencies, both in the United States and in PEPFAR  countries, annual guidance on reporting program results, and guidance on  planning. In addition, OGAC collaborates with implementing agency  officials through technical working groups on a range of issues. OGAC  also disseminates weekly updates to implementing agency staff in  PEPFAR countries regarding topics such as deadlines and changes to  official guidance. USAID and CDC, which oversee most PEPFAR-funded  programs, are among PEPFAR’s primary implementing agencies. Of almost  $16.5 billion obligated for HIV/AIDS activities in fiscal years 2004 through  2009, $9.6 billion was obligated by USAID and $6.4 billion was obligated by  HHS.
In each partner country, teams of implementing agency officials (PEPFAR  country teams) jointly develop country operational plans (COP) for use in  coordinating, planning, reporting, and funding PEPFAR programs. The  COP is the vehicle for documenting annual investments in HIV/AIDS, and  serves as the basis for approving, allocating, tracking, and notifying  Congress of budgets and targets.
section_title: U.S. Policy Documents Endorsing PEPFAR Alignment or Country Ownership
paragraphs: 2008 Leadership Act. The 2008 Leadership Act, PEPFAR’s reauthorizing  legislation, cites improving harmonization of U.S. efforts with national  strategies of partner governments and other public and private entities as  an element in strengthening and enhancing United States leadership and  the effectiveness of the U.S. response to HIV/AIDS. The act requires the  President to report to Congress on OGAC’s strategy. The act specifies  that the report must discuss many elements of the strategy including a  description of the strategy to promote harmonization of U.S. assistance  with that of other international, national, and private actors; and to  address existing challenges in harmonization and alignment. The act also  requires the President to report on efforts to improve harmonization, in  terms of relevant executive branch agencies, coordination with other  public and private entities, and coordination with partner countries’  national strategic plans.
Paris Declaration. In 2005, 133 countries and territories, including the  United States, and 28 participating international organizations, endorsed  the Paris Declaration on Aid Effectiveness, an international agreement  committing countries to increase efforts in supporting country ownership,  harmonization, alignment, results, and mutual accountability.  Specifically, donors committed to taking a number of steps to implement  the principles of the Paris Declaration: to respect partner country  leadership and help strengthen their capacity to exercise it; base support  on national strategies; implement common arrangements for reporting to  partner governments on donor activities and aid flows; harmonize  monitoring and reporting requirements; and provide timely, transparent,  and comprehensive information on aid flows to enable partner authorities  to present comprehensive budget reports to their legislatures and citizens.
Three Ones. In 2004, key donors, including the United States, reaffirmed  their commitment to strengthening national HIV/AIDS responses led by the  affected countries themselves and endorsed the “Three Ones” principles.  These principles aim to achieve the most effective and efficient use of  resources and greater collaboration among donors in order to avoid  duplication and fragmentation. Specifically, the donors agreed to base  support on one HIV/AIDS action framework that provides the basis for  coordinating the work of all partners, one national AIDS coordinating  authority with a broad multisectoral mandate, and one country-level  monitoring and evaluation system in each country.
PEPFAR 5-year strategy. PEPFAR’s updated 5-year strategy, released in  2009 as mandated by the 2008 Leadership Act, highlights alignment with  national strategies as a key component of promoting sustainability of U.S.- supported HIV/AIDS efforts through partner country ownership. In the  first 5 years of the program, PEPFAR focused on establishing and scaling  up prevention, care, and treatment programs. During the second 5-year  phase, PEPFAR will focus on transitioning from an emergency response to  promotion of sustainable country programs. PEPFAR’s emphasis on  country ownership includes ensuring that the services PEPFAR supports  are aligned with the national plans of partner governments and integrated  with existing health care delivery systems. The new 5-year strategy  acknowledges that during the first phase of PEPFAR, PEPFAR  implementation did not always fully complement existing national  structures and some PEPFAR programs and services were established  apart from existing health care delivery systems. The new strategy affirms  the principles of the Paris Declaration and states that PEPFAR is working  with its multilateral and bilateral partners to align responses and support  countries in achieving their nationally defined HIV/AIDS goals.
section_title: PEPFAR Partnership Frameworks
paragraphs: The Leadership Act authorized the U.S. government to establish  partnership frameworks with host countries to promote a more  sustainable approach to combating HIV/AIDS, characterized by  strengthened country capacity, ownership, and leadership. Partnership  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, support for service delivery,  policy reform, and coordinated funding commitments.
PEPFAR guidance states that the partnership framework process should  involve significant collaboration with the partner government and may  also include active participation from other key partners from civil society,  community-based and faith-based organizations, the private sector, other  bilateral and multilateral partners, and international organizations.  PEPFAR guidance further states that a key objective of the partnership  framework is to ensure that PEPFAR programs reflect country ownership,  with partner governments at the center of decision making, leadership,  and management of their HIV/AIDS programs and national health systems.  The expectation is that at the end of the partnership framework, in  addition to achieving results in HIV/AIDS prevention, treatment, and care,  partner country governments will be better positioned to assume primary  responsibility for the national responses to HIV/AIDS in terms of  management, strategic direction, performance monitoring, decision  making, coordination, and, where possible, funding support and service  delivery. The partnership framework is meant to support government  coordination of different funding streams under the framework of a  national strategy. The partnership framework should be fully in line with  the national HIV/AIDS plan of the country and emphasize sustainable  programs with increased country decision-making authority and  leadership.
PEPFAR guidance defines the partnership framework as consisting of two  interrelated documents, the partnership framework and the partnership  framework implementation plan. The partnership framework is to focus  on establishing a collaborative relationship, negotiating the overarching 5- year goals of the framework and the commitments of each party, and  setting forth these agreements in a concise signed document. The  partnership framework implementation plan is to include a more detailed  description of the approach to supporting increased country ownership,  baseline data, specific strategies for achieving the 5-year goals and  objectives, and a monitoring and evaluation plan.
section_title: PEPFAR Country Operational Plans
paragraphs: The COP is used for planning annual U.S. investments in HIV/AIDS and  approving annual U.S. bilateral HIV/AIDS funding, and it serves as the  annual work plan for PEPFAR activities. The COP database, which houses  all COP information submitted by PEPFAR country teams, provides  information for funding review and approval and serves as the basis for  congressional notification, allocation, and tracking of budget and targets.  According to OGAC, PEPFAR country teams in 31 countries completed  COPs for fiscal year 2010. In addition three regions developed and  submitted regional operational plans for fiscal year 2010: Caribbean,  Central America, and Central Asia.
The COP development process involves interagency coordination as well  as consultation with other PEPFAR stakeholders. The U.S. Ambassador  leads the development of COPs, which are created through a collaborative  process involving PEPFAR country teams. The COP development process  also involves collaboration with country and international partners in an  annual review and planning process. According to PEPFAR COP guidance,  developing an annual COP provides an opportunity to bring the U.S.  country team together with partner government authorities, multilateral  development partners, and civil society as an essential aspect of effective  planning, leveraging resources, and fostering sustainability of programs.  The draft COPs are ultimately reviewed by interagency headquarters  teams, which make recommendations to OGAC regarding final review and  approval.
PEPFAR 2010 COP guidance notes that PEPFAR programs should be fully  in keeping with developing countries’ national strategies and that PEPFAR  country teams should identify areas of partner countries’ national  HIV/AIDS programs for U.S. government investment and support. The  guidance also states that the U.S. government is firmly committed to the  principles of alignment with national programs, including alignment with  other international partners.
section_title: National HIV/AIDS Strategies
paragraphs: At the 2001 United Nations General Assembly Special Session on HIV/AIDS  (UNGASS), member countries committed to developing multisectoral  HIV/AIDS strategies and finance plans. In our four case study countries— Cambodia, Malawi, Uganda, and Vietnam—the multisectoral strategy  serves as a multiyear broad outline of its HIV/AIDS prevention, treatment,  and care objectives. While a national commission may be the lead  coordinating authority for HIV/AIDS policy and programs, the  development and implementation of such a strategy can also involve many  government ministries and offices. Additional strategy documents, such as  sector-specific strategies and HIV program-specific strategies or action  plans can also provide further guidance for national programs to combat  HIV/AIDS (see table 1 for information on national HIV/AIDS strategies in  four countries). Other government ministries and agencies, such as the  Ministry of Health, may also be charged with implementing sector- or  program-specific strategies and programs.
section_title: PEPFAR Programs Generally Support Partner Countries’ National HIV/AIDS Strategies
paragraphs: PEPFAR activities generally support the goals laid out in partner  countries’ national HIV/AIDS strategies. Our analysis of PEPFAR  documents and national strategies and discussions with PEPFAR country  teams in the four countries we visited showed overall alignment between  PEPFAR activities and the national strategy goals. In addition, PEPFAR  officials—including officials at OGAC, USAID, and CDC in headquarters  and in four countries—as well as partner government ministry officials,  other HIV/AIDS donors, and civil society representatives whom we  interviewed also said that PEPFAR activities generally support the goals  and objectives set forth in national strategies. According to PEPFAR  officials, a number of factors may influence the degree to which PEPFAR  activities align with national strategy goals. As a result, PEPFAR may  support activities to achieve some, but not all, goals and objectives  outlined in national strategies. Conversely, PEPFAR may support activities  not mentioned in the national HIV/AIDS strategy but that are addressed in  relevant sector- or program-specific strategies. PEPFAR country teams  have engaged in various efforts to help ensure that PEPFAR activities  support the achievement of national strategy goals, including assisting in  developing national strategies, participating in formal and informal  communication and coordination meetings, engaging regularly with  partner country governments during the COP development process, and  developing new partnership frameworks.
subsections: section_title: PEPFAR and Country Documents and Statements by PEPFAR and HIV/AIDS Stakeholders Indicate Alignment of Program Activities with National HIV/AIDS Goals
paragraphs: Our analysis shows that PEPFAR activities described in the 2010 COPs for  Cambodia, Malawi, Uganda, and Vietnam directly or partially address most  of the goals and objectives outlined in the countries’ national HIV/AIDS  strategies. (See table 2.)
Statements and analysis by a number of PEPFAR and HIV/AIDS  stakeholders further indicate that PEPFAR program activities are aligned  with partner countries’ HIV/AIDS strategies. PEPFAR officials—including  officials at OGAC, USAID, CDC, and HHS—and other HIV/AIDS  stakeholders and experts operating at a global level, as well as partner  government ministry officials, other donors, civil society representatives,  and PEPFAR officials in four countries told us that PEPFAR activities are  aligned with the goals and objectives outlined in partner countries’  national strategies and support the overall national program. Moreover, a  2007 Institute of Medicine (IOM) review of PEPFAR in the 15 focus  countries also found that PEPFAR programs were generally congruent  with these countries’ national strategies. IOM reported that partner  government representatives in the 13 countries they visited generally  expressed satisfaction with the level of alignment between PEPFAR and  national strategies.
section_title: PEPFAR Officials Noted Several Factors Influencing Alignment of PEPFAR Activities with National Strategy Goals
paragraphs: Several factors may influence the degree to which PEPFAR activities align  with national HIV/AIDS strategy goals, according to PEPFAR officials.
Other partner activities. PEPFAR country programs are planned with  consideration of other donors’ and groups’ activities in the countries, and  therefore PEPFAR activities may not address all national strategy goals. In  many PEPFAR countries a number of other bilateral and multilateral  development partners also fund and implement programs to support the  national program. Country team officials noted that in planning PEPFAR  programs, they coordinate with other partners so that PEPFAR and  partner activities will complement, rather than duplicate, one another and  together support the national program. For example, the PEPFAR Malawi  team explained that although the Malawi national strategy contains a goal  of expanding workplace programs on HIV and AIDS in the public and  private sectors and civil society, the 2010 PEPFAR Malawi COP does not  include activities that directly address this goal because other donors and  groups are implementing programs that address it.
Size of PEPFAR program. The portion of a national strategy supported by  PEPFAR activities also depends in part on the size of the PEPFAR  program in that country relative to other donors’ activities in the country.  For example, OGAC and country team officials told us that PEPFAR is  more likely to cover larger portions of the national strategy in former  focus countries where PEPFAR is generally the largest donor of HIV/AIDS  funds. This corresponds with our finding that in the 2010 COPs for former  focus countries Uganda and Vietnam, where U.S. funding makes up a large  share of the national HIV/AIDS response—75 percent in Uganda and 59  percent in Vietnam from 2004 to 2008—the activity descriptions directly  address most national strategy goals and objectives. OGAC and PEPFAR  country team officials also noted that in non-focus countries, PEPFAR  programs may support the achievement of priority goals, rather than cover  every national strategy goal. For instance, in the non-focus countries  Cambodia and Malawi, where U.S. funding makes up a smaller share of the  national HIV/AIDS response—47 percent in Cambodia and 22 percent in  Malawi from 2004 to 2008—we found that PEPFAR activities generally  supported national strategy goals by filling resource gaps and focusing on  interventions in which country teams have technical expertise.
Policy restrictions. PEPFAR may not support particular activities because  of PEPFAR policy restrictions or other conflicts. For example, according  to country team officials in Vietnam, until recently PEPFAR funds could  not be used to support needle exchange programs for intravenous drug  users. As a result, PEPFAR has not supported this component of Vietnam’s  national strategy.
PEPFAR programs also may involve activities that are not specifically  addressed in the national strategy but that support national strategy goals.  In the four countries we visited, PEPFAR officials, government officials,  donors, and PEPFAR implementing partners generally agreed that national  strategies outline broad principles, goals, and objectives rather than  specific programs or activities. According to these officials, the general  nature of the national strategies allows flexibility to support specific  programs to achieve these goals and respond to countries’ evolving  HIV/AIDS epidemics. For example, according to PEPFAR officials, the  Malawi PEPFAR program has prioritized male circumcision for many  years as an effective means of preventing the spread of HIV, although this  activity was not mentioned in Malawi’s previous national strategy.  However, PEPFAR officials told us that these programs support Malawi’s  broad goal to reduce the number of new infections. Moreover, as a result  of the country team’s working with the Malawi government and sharing  information and data, male circumcision has since been incorporated into  Malawi’s most recent strategy. Similarly, in Uganda, PEPFAR supports  prevention and treatment activities for a potentially high-risk target group,  men who have sex with men, although Uganda’s national strategy does not  address prevention and treatment for this group. PEPFAR officials told us  they consider these activities aligned with Uganda’s high-level goal to  reduce the number of new infections and treat HIV-positive patients.  PEPFAR team officials in the four countries we visited told us they take  into account sector- or program-specific subcomponents of national  strategies—such as a protocol for prevention of mother-to-child  transmission of HIV—as well as relevant epidemiological and evaluation  data, all of which may be more up to date or detailed than the broad  national HIV/AIDS strategy.
section_title: PEPFAR Stakeholders Reported Various Efforts to Align PEPFAR Activities with National Strategy Goals
paragraphs: PEPFAR country teams and other stakeholders described several means  by which the country teams work to achieve alignment of PEPFAR  activities with partner country HIV/AIDS goals.
Participation in development of national strategies. PEPFAR country  teams actively participate in the development and revision of partner  countries’ national HIV/AIDS strategies, according to PEPFAR officials,  partner government officials, and civil society groups. When host  governments are developing or reformulating their strategies, they often  invite HIV/AIDS stakeholders in the country, including bilateral and  multilateral donors and civil society and private sector groups, to  participate in the strategy’s development. As part of this process,  according to PEPFAR officials in headquarters, the PEPFAR country team  often participates heavily in the development of such strategies through  direct advising as well as technical assistance through implementing  partners. For example, the CDC officials in-country often help with  surveillance activities and providing data to the host government in order  to base the strategy on the most updated information on the epidemic.  PEPFAR officials and other stakeholders in three of the four countries we  visited also spoke about heavy PEPFAR involvement in the development  of the strategies in those countries. These officials told us that PEPFAR’s  participation in these processes both improves the quality of the national  strategy and creates buy-in among program stakeholders, ultimately  enhancing PEPFAR alignment with national strategies. PEPFAR country  team officials also told us that national strategy time frames may affect  PEPFAR’s ability to align its programs. For example, in Malawi, PEPFAR  country officials were able to generate the 2010 COP based on Malawi’s  newly revised and updated multisectoral national strategy. Conversely,  PEPFAR officials in Cambodia told us that Cambodia’s outdated strategy,  which was undergoing revision at the time of COP development and  submission, complicated the country team’s ability to base the current  year COP on the dated strategy.
Meetings with partner governments and other stakeholders. PEPFAR  country team participation in periodic meetings with partner country  government officials, other donors, and civil society organizations helps to  ensure that PEPFAR program activities support national strategies,  according to PEPFAR officials and other HIV/AIDS stakeholders.  Country team officials, partner government officials, and other donor  representatives in the four countries we visited told us that PEPFAR  country team officials participate in periodic advisory and technical area  meetings with government officials and other donor representatives. For  example, in the four countries we visited, we heard that PEPFAR officials  participate in HIV/AIDS or health sector committees, which generally are  led by the host government and include other relevant donors. In addition,  PEPFAR officials participate in government-led technical working groups  focused on specific HIV/AIDS-related areas, such as prevention of mother- to-child transmission or monitoring and evaluation.
Informal engagement with partner government officials. Regular  informal engagement with partner country government officials helps  PEPFAR country teams to be aware of the needs and goals of the national  HIV/AIDS program, according to PEPFAR country team officials. For  example, the officials noted that in-country CDC staff are embedded in the  Ministry of Health and thus have daily interaction with partner  government officials. This daily communication helps the PEPFAR team  focus on the needs of the partner government and align its activities with  such needs. Country team officials also noted the importance of other  regular interaction and communication between PEPFAR officials and  partner government officials. For example, regular interaction with a  number of ministry officials involved in the national HIV/AIDS program  enables the PEPFAR team to better coordinate with the national program.
COP development process. PEPFAR country teams engage with country  officials and implementing partners throughout the annual COP  development process, according to PEPFAR officials, partner government  officials, and civil society groups. PEPFAR guidance states that developing  the annual COP provides an opportunity to share information with partner  government officials, which is an essential aspect of effective planning.  In the four countries we visited, officials from ministries including the  national AIDS authority and Ministry of Health told us that they had  discussed the fiscal year 2010 COP with PEPFAR officials. PEPFAR  country team officials and implementing partners in the four countries  also told us that the country teams share information with their  implementing partners in a collaborative process during the annual COP  development process. For example, in the four countries we visited,  PEPFAR officials told us they convened technical working group meetings  of PEPFAR, partner government, and implementing partner officials  throughout the COP process. Through these technical working groups and  ongoing collaboration throughout the COP development process,  implementing partners are able to provide input on the PEPFAR program  and alignment with national strategies.
Partnership framework development. Development of partnership  frameworks has had a positive effect on PEPFAR alignment and  coordination with other donors, according to OGAC, USAID, and CDC  officials and other PEPFAR stakeholders. OGAC officials reported in June  2010 that 24 countries and two regions had been invited to develop  partnership frameworks and that 7 of these countries, as well as both  regions—Angola, Caribbean, Central America, Ghana, Kenya, Lesotho,  Malawi, Swaziland, and Tanzania—had completed and signed a framework  document. PEPFAR officials—including OGAC, USAID, and CDC  officials—told us that partnership framework development in these  countries created a vehicle for more open dialogue among PEPFAR, the  country governments, and other donors. PEPFAR officials also stated that  alignment of PEPFAR activities with these countries’ national HIV/AIDS  strategies improved as a result of close interaction with a range of  stakeholders. Likewise, during our visit to Malawi, PEPFAR and  government officials, as well as other donors, noted improvement in  PEPFAR alignment with national strategies as well as coordination with  other donors’ HIV/AIDS programs as a result of the partnership framework  development process. In addition, our review of the Malawi partnership  framework showed that the goals and objectives are closely aligned with  those laid out in the national strategy. However, OGAC officials noted that  the impact of partnership frameworks on country ownership remained to  be seen. As of August 2010, Malawi had completed and signed a  partnership framework implementation plan.
section_title: PEPFAR Stakeholders Noted Several Factors That Can Hinder PEPFAR Alignment with National Strategies
paragraphs: PEPFAR stakeholders highlighted several factors that can make it difficult  to align PEPFAR activities with national HIV/AIDS strategies. First,  PEPFAR indicators sometimes differ from indicators used by partner  countries and other international donors. Second, gaps may exist in the  sharing of PEPFAR information with partner country governments and  other donors. Third, lack of country leadership and capacity to develop  strategies and manage programs affects PEPFAR country teams’ ability to  ensure that PEPFAR activities align with national strategy goals. Fourth,  OGAC’s guidance to PEPFAR country teams on developing partnership  frameworks and implementation plans does not include indicators for  measuring progress toward country ownership.
subsections: section_title: Differences between PEPFAR Indicators and National and International Indicators
paragraphs: Many PEPFAR stakeholders noted differences between PEPFAR  performance indicators and national and international performance  indicators. Other PEPFAR stakeholders, including partner country  officials, other donors, and PEPFAR implementing partners in the four  countries we visited highlighted difficulties in harmonizing PEPFAR  indicators with the national indicators, owing to variance between  indicator definitions and reporting time frames used to collect and report  data. For example, according to Vietnamese government officials,  PEPFAR defines orphans and vulnerable children using different age  groupings than the government of Vietnam. In addition, other HIV/AIDS  stakeholders and experts noted that PEPFAR often relies on indicators  that can be compiled to report globally but may differ from those used by  individual countries. A PEPFAR official also noted that national strategy  indicators may not always align with international indicators.
Moreover, PEPFAR’s 5-year strategy states that PEPFAR’s extensive  performance reporting requirements were not always harmonized with  other international indicators. The PEPFAR strategy also states that  PEPFAR will support transition to a single, streamlined national  monitoring and evaluation system. To address this problem, OGAC  published an updated guide for indicators in August 2009, intended to  increase both the inclusion of quality PEPFAR indicators and the  alignment of such indicators with those of other development partners.  OGAC collaborated with international donors and organizations including  the Global Fund, UNAIDS, WHO, and UNICEF to align most PEPFAR- essential indicators with international standards. Specifically, OGAC is  working internationally with multilateral partners to achieve a minimum  core set of global reporting indicators that provides standardized data for  comparison across countries and allows for aggregation at the global level.  According to PEPFAR guidance, through the UNAIDS Monitoring and  Evaluation Reference Group, OGAC and 18 other international multilateral  and bilateral agencies have agreed on a minimum set of standardized  indicators. In addition, PEPFAR will continue to work with this group on  global harmonization of indicators. OGAC’s updated indicator guidance  also notes that a second wave of recommended indicators will be released  in 2010, providing additional indicators that PEPFAR country teams may  choose to monitor at a country level.
section_title: Gaps in Partner Countries’ Access to PEPFAR Information
paragraphs: Some partner government officials told us they lack information about  PEPFAR programs and funding in their country and expressed concern  over this lack of access to PEPFAR data. For example, government  officials in Vietnam reported they do not have sufficient information on  PEPFAR spending and are not able to fully account for PEPFAR funding  to local civil society organizations. In addition, in one country we visited,  officials from some ministries told us they had not received copies of the  COP. However, according to PEPFAR officials, this may be caused by lack  of information sharing within or among the partner government ministries  and agencies. UNGASS 2010 progress reports for the four countries we  visited, which detail the progress in the national HIV/AIDS response,  appear to include PEPFAR funding information, indicating that PEPFAR  had shared such information with the partner governments. However, two  of these countries’ 2008 UNGASS progress reports included estimated or  partial information on PEPFAR activities and aid flows; all four countries’  reports noted difficulties in obtaining international donors’ HIV/AIDS  spending data. In addition, IOM reported in 2007 that other donors had  expressed concern about the degree of information on PEPFAR programs  that could be shared due to procurement rules.
PEPFAR’s 5-year strategy states that PEPFAR is committed to transparent  reporting of investments and notes that opportunities exist to improve  reporting mechanisms. The strategy also states that PEPFAR will work to  expand publicly available data. According to COP guidance, the extent to  which the information in the COP can be shared with stakeholders is  limited because procurement-sensitive information must be protected to  adhere to U.S. competitive acquisition and assistance practices.
section_title: Capacity Limitations in Partner Country Governments
paragraphs: Limited resources and partner country capacity to develop, lead, and  implement the national HIV/AIDS program affects PEPFAR’s ability to  effectively coordinate with the host country government, according to  PEPFAR officials in headquarters and in the countries we visited.  PEPFAR officials, as well as donors, PEPFAR implementing partners, and  other HIV/AIDS stakeholders, mentioned one or more of the following  challenges to engaging with partner governments: unwillingness or  inability to commit resources, public corruption and financial  mismanagement, and lack of technical expertise.
PEPFAR’s 5-year strategy states that PEPFAR will work to assist partner  governments, in part through technical assistance and mentoring, to  support increases in government sustainability and partner country  capacity. The strategy also notes that full transition to partner country  ownership and increased financing will take longer than 5 years to  achieve.
section_title: Guidance for Measuring Progress of Partnership Frameworks Does Not Include Metrics of Country Ownership
paragraphs: PEPFAR guidance on developing partnership frameworks and  implementation plans includes detailed instructions for developing  baseline assessments of partner countries’ HIV/AIDS epidemics and of  efforts to respond to the epidemics. For example, the guidance directs  PEPFAR country teams to measure these efforts’ outputs or outcomes,  such as the number of newly trained healthcare workers. However, the  guidance does not address the establishment of baselines, including  indicators, for measuring progress toward country ownership—one of  OGAC’s stated goals for the frameworks. In keeping with various Paris  Declaration resolutions, the guidance that OGAC has provided to PEPFAR  country teams for developing the frameworks describes promotion of  country ownership as expanding partner government’s capacity to plan,  oversee, manage, deliver, and eventually finance HIV/AIDS programs. The  guidance requires country teams to link partnership framework goals with  partner countries’ national HIV/AIDS and health strategies and states that  partnership frameworks should emphasize sustainable programs with  increased country decision-making authority and leadership. The guidance  also specifies that the framework should outline plans to assess progress  in achieving the goals agreed to in the partnership framework, including  country ownership.
However, the guidance does not provide instructions for developing  indicators needed to establish baseline measures of country ownership  and to assess progress toward this goal. According to an OGAC official,  OGAC has not yet devised an approach for developing such indicators or  for measuring progress toward country ownership. Moreover, developing  indicators to measure aspects of country ownership, such as capacity to  plan, oversee, manage, deliver, and eventually finance HIV/AIDS programs,  can be—as has been recognized by development experts—a difficult and  complex undertaking. An OGAC official acknowledged that generating  such indicators would involve a process of working with development  partners and PEPFAR country teams to develop a consensus on both  definitions and measurements. Prior GAO work suggests that performance  reports are likely to be more useful if they provide baseline and trend data.  By providing baseline and trend data—which show an agency’s progress  over time—the agency can give decision makers a more historical  perspective within which to compare the year’s performance with  performance in past years. PEPFAR country teams that begin  implementing partnership frameworks without baseline assessments of  country ownership will have limited ability to track progress and make  necessary adjustments to the frameworks.
section_title: Conclusions
paragraphs: PEPFAR’s commitment to the principles of alignment with national  HIV/AIDS strategies and country ownership of U.S.-supported programs is  reflected in the new 5-year PEPFAR strategy and in OGAC guidance to  PEPFAR country teams. According to our analysis of PEPFAR and  national strategy documents as well as interviews with multiple PEPFAR  stakeholders, PEPFAR efforts to align its activities have resulted in  programs that are generally supportive of partner countries’ national  strategy goals and objectives. In addition, the partnership frameworks that  OGAC recently introduced are designed to, among other goals, enhance  partner country ownership of PEPFAR programs. In particular, OGAC  expects that at the conclusion of the 5-year partnership frameworks,  country governments will be better positioned to assume primary  responsibility for national responses to HIV/AIDS in terms of management,  strategic direction, performance monitoring, decision making,  coordination, and, where possible, funding support and service delivery.  OGAC also expects the development of partnership frameworks to  ultimately enhance alignment of PEPFAR programs with national  HIV/AIDS strategies. In Malawi, PEPFAR stakeholders, including PEPFAR  and partner government officials, as well as other donors, observed that  the partnership framework development process improved alignment with  national strategies as well as on coordination with other donors.
However, OGAC has not yet established an approach for PEPFAR country  teams to use in developing indicators needed for baseline measurements  of country ownership, although the development of such indicators and  baselines is recognized as difficult and complex. Without these indicators  and baselines, country teams that implement the frameworks may be  constrained in their ability to measure progress in promoting country  ownership and to make adjustments to the frameworks to enhance such  progress.
section_title: Recommendation for Executive Action
paragraphs: To enhance PEPFAR country teams’ ability to achieve the goal of  promoting partner country ownership of U.S.-supported HIV/AIDS  activities, we recommend that the Secretary of State direct OGAC to  develop and disseminate a methodology for establishing indicators needed  for baseline measurements of country ownership prior to implementation  of partnership frameworks.
section_title: Agency Comments and Our Evaluation
paragraphs: Responding jointly with HHS and USAID, State provided written  comments on a draft of this report (see app. VI for a copy of these  comments). In addition, State’s OGAC, in coordination with HHS and  USAID as well as the PEPFAR country teams in Cambodia, Malawi,  Uganda, and Vietnam, provided technical comments, which we  incorporated as appropriate. In their joint written comments, State, HHS,  and USAID concurred with our findings and recommendation to develop a  methodology for establishing baseline measures of country ownership.  The joint written comments also note that the departments plan to  incorporate such a methodology into the broader Global Health Initiative,  in consultation with their field offices.
We are sending copies of this report to the Secretary of State, the Office of  the Global AIDS Coordinator, USAID Office of HIV/AIDS, HHS Office of  Global Health Affairs, and CDC Global AIDS Program. In addition, the  report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-3149 or gootnickd@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 VII.
section_title: Appendix I: Scope and Methodology
paragraphs: In response to a directive in the 2008 Leadership Act, this report (1)  examines alignment of the President’s Emergency Plan for AIDS Relief  (PEPFAR) programs with partner countries’ HIV/AIDS strategies and (2)  describes several challenges related to alignment of PEPFAR programs  with the national strategies or promotion of partner country ownership.
To identify guidance for alignment of U.S. programs to national programs  and country ownership, we reviewed the Tom Lantos and Henry J. Hyde  United States Global Leadership Against HIV/AIDS, Tuberculosis, and  Malaria Reauthorization Act of 2008 (2008 Leadership Act); the previous  and current PEPFAR 5-year strategy; the Paris Declaration on Aid  Effectiveness (Paris Declaration); the “Three Ones” principles; PEPFAR  partnership framework guidance; and fiscal year 2010 country operational  plan (COP) guidance.
To examine the extent to which PEPFAR programs support the goals laid  out in partner countries’ national strategies and to identify country teams’  challenges in aligning PEPFAR programs with national strategies and  promoting country ownership, we performed the following:  Interviewed PEPFAR officials, including the Office of the U.S. Global AIDS  Coordinator (OGAC), Centers for Disease Control and Prevention (CDC),  and U.S. Agency for International Development (USAID); and U.S.  Department of Health and Human Services (HHS) officials in Washington,  D.C., and Atlanta, Georgia, using a questionnaire regarding alignment of  PEPFAR programs globally with national strategies at three levels: goals  and objectives, program activities, and indicators.
Interviewed representatives of other key PEPFAR stakeholders, including  the Joint United Nations Programme on HIV/AIDS (UNAIDS); the Global  Fund to Fight AIDS, Tuberculosis and Malaria; the Center for Global  Development; and the Bill & Melinda Gates Foundation, regarding global  PEPFAR alignment at these three levels.
Analyzed U.S. agency documents, including guidance and strategy  documents, and performed a literature review of other studies that  examined PEPFAR alignment with national strategies. Among these  studies was a 2007 Institute of Medicine (IOM) study that reviewed a  number of aspects of PEPFAR implementation in all 15 focus countries,  including alignment with national programs. The IOM review involved  discussions with PEPFAR officials and other stakeholders and an analysis  of PEPFAR documents as well as field visits to 13 of the 15 countries.
Conducted case studies in Cambodia, Malawi, Uganda, and Vietnam. This  work included assessing the level of correspondence between goals and  objectives laid out in the national multisectoral HIV/AIDS strategy and the  2010 PEPFAR COP for each country. During our visits to these countries,  we conducted semi-structured interviews with PEPFAR country team  officials, including the PEPFAR coordinator in each country as well as  USAID and CDC officials. We also met with partner government officials in  various ministries involved in the national HIV/AIDS program in each  country. In addition, we interviewed representatives of other international  donors working in HIV/AIDS and of PEPFAR implementing partners in  each country. With each of these groups, we conducted semi-structured  interviews regarding PEPFAR support for the national strategy at three  levels: goals and objectives, program activities, and indicators.
To select the four countries for case studies, we considered a number of  factors, including funding levels, geographic diversity, progress in  developing partnership frameworks, and focus country status. Regarding  funding levels, the four countries we selected represent both high and mid- range levels of PEPFAR funding. Regarding geographic diversity, the four  countries represent variations in the epidemic and programs that exist  across regions, including Africa and Asia. Regarding progress in  developing partnership frameworks, the four countries were at different  phases, enabling us to observe the impact of the partnership framework  development process on alignment. Regarding focus country status, two of  the four countries we selected were focus countries during the first phase  of PEPFAR, while the other two were not. Although OGAC has noted that  there will no longer be a distinction between PEPFAR focus countries and  non-focus countries, we theorized that differences in programming and  alignment might exist between the 15 former focus countries and non- focus countries.
In evaluating alignment of PEPFAR activities with national HIV/AIDS  strategies, we considered PEPFAR program activities that are supportive  of the achievement of national strategy goals and objectives and generally  complementary of the national HIV/AIDS program to be well aligned. Our  analysis involved several steps.  1.  For each of the four case study countries, we reviewed the national  multisectoral HIV/AIDS strategy to identify goals and objectives. We  then analyzed the technical assistance narratives, which describe the  ongoing and planned activities for each PEPFAR technical area, in the  fiscal year 2010 COP for each of the four countries. Our analysis of the  COP narratives focused on whether each objective and goal in the  national strategy was fully, partially, or not addressed by activities  described in the technical assistance narratives of the 2010 COP. Two  of our staff independently analyzed the COP narratives to identify  areas of alignment between the PEPFAR activities and the national  strategy goals and objectives.  2.  During our visits to the four countries, we discussed our analysis of  national HIV/AIDS strategies and PEPFAR COPs with PEPFAR  officials to identify reasons for identified areas of divergence between  the documents. In particular, we discussed every goal and objective in  the national strategy that our analysis deemed only partially or not  supported by activities described in the technical assistance narratives  of the COP. These conversations enabled us to identify four general  reasons why the technical assistance narratives did not describe  activities that fully support the particular goal or objective: (a) The  goal was being supported by activities of other donors, so PEPFAR  had chosen not to focus in that area. (b) The goal was generally the  responsibility of the national government, or the national government  was not interested in receiving PEPFAR support in that area. (c)  PEPFAR policy restrictions prevented PEPFAR from supporting  certain areas of the national program. (d) PEPFAR activities fully  supported the goal, but owing to space limitations for COP reporting,  these activities were not described in the COP or were described in a  different area of the document, such as the activity descriptions. One  of these four explanations by the PEPFAR team applied in each  instance where we found no or partial alignment between the COP and  the national strategy. We did not find any national strategy goals and  objectives that were accidentally or deliberately not considered or  supported by PEPFAR for reasons other than the four listed above.  3.  We used our interviews with PEPFAR officials in headquarters and  with other HIV/AIDS stakeholders, as well as our literature and  document review, to verify and complement the results of the case  study work.
We conducted this performance audit from July 2009 to September 2010 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  we obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
section_title: Appendix II: Cambodia Case Study
paragraphs: GDP per capita (PPP):  Life expectancy at birth:   ye (rnk 177 ot of 224)
HIV/AIDS adult prevalence rate:  0.% (rnk 56 ot of 170)
Number of people livin with HIV/AIDS:  75,000 (rnk 54 ot of 165)
Number of AIDS orphan:  HIV/AIDS epidemic: HIV prevlence in Codi mong the highet in A.  Codia’s HIV/AIDS epidemic i pred primrily throgh heteroexual trmission nd  revolvergely rond the ex trde. A low prevlence rte in the generl poption  masr higher prevlence rte in certin subpoption, such as injecting druser,  people in protittion, men who hve ex with men, koke hotess, nd moile nd  migrnt poption.
Estimate as of 2010.
Estimate as of 2007.
subsections: section_title: National HIV/AIDS Program
paragraphs: Although Cambodia is one of the poorest countries in the world, HIV  prevention and control efforts exerted by the Government of Cambodia  and its partners have helped to reduce the spread of HIV. Cambodia is  recognized as one of the few countries that has been successful in  reversing the HIV epidemic, as the adult prevalence decreased from a high  of 2 percent in 1998 to 0.8 percent in 2008. The Cambodia HIV/AIDS  strategy—the National Strategic Plan for a Comprehensive and  Multisectoral Response to HIV/AIDS 2006-2010, developed under the  leadership of the National AIDS Authority—guides the national response  to the epidemic. The national strategy outlines three main goals: to reduce  new infections of HIV; to provide care and support to people living with  and affected by HIV; and to alleviate the socioeconomic and human impact  of AIDS on the individual, family, community, and society. In addition, the  multisectoral strategy also lays out seven complementary strategies to (1)  increase coverage of effective prevention interventions; (2) increase  coverage of effective interventions for comprehensive care; (3) increase  coverage of effective interventions for impact mitigation; (4) develop  effective leadership by government and nongovernment sectors for  implementation of the response to AIDS at central and local levels; (5)  create a supportive legal and public policy environment for the AIDS  response; (6) increase the availability of information for policy makers and  for program planners through monitoring, evaluation, and research; and  (7) enhance sustainable and equitable resource allocation for the national  response to AIDS.
A large number of institutions are involved in Cambodia’s national  multisectoral response to HIV and AIDS. These include ministries and  other government departments, such as the Ministry of Health, Ministry of  Women’s Affairs, Ministry of Rural Development, Ministry of Interior, and  the National Center for HIV/AIDS, Dermatology, and STD. In addition,  there are a number of other strategies and documents that support and  elaborate on the national multisectoral strategy including, the Ministry of  Interior HIV/AIDS strategy, Medical Laboratory Services National Strategic  Plan, and the National Blood Transfusion Services of Cambodia Strategic  Plan. Each of these successive plans and strategies has been supported by  technical assistance and financial support from multilateral and bilateral  donors, including the U.S. government.
section_title: HIV/AIDS Partners and Donors
paragraphs: In addition to the support of the U.S. government, the Cambodian  HIV/AIDS program is supported by a number of other multilateral and  bilateral donors. Funding from the Global Fund has comprised over 30  percent of all HIV/AIDS development assistance to Cambodia from 2004 to  2008 (see fig. 2). In addition, the Global Fund has continued to scale up its  funding and programs in Cambodia in recent years, and in 2009 Global  Fund contributions comprised 53 percent of HIV funding in Cambodia  according to PEPFAR officials. The United Kingdom has also provided  significant financial support for Cambodia’s national HIV/AIDS program  for many years, contributing 13 percent of all HIV/AIDS development  assistance in Cambodia from 2004 to 2008. In addition, other donors in  HIV/AIDS in Cambodia include, Belgium, UNAIDS, UNICEF, the United  Nations Development Programme (UNDP), Spain, Denmark, France and  Germany.
section_title: PEPFAR Program
subsections: section_title: PEPFAR Funding
paragraphs: The U.S. government has been working in HIV/AIDS in Cambodia for many  years, even prior to PEPFAR, making the U.S. government one of the  largest funders of HIV/AIDS programs in Cambodia dating back to the mid- 1990s. Thus, while Cambodia was not a PEPFAR focus country during the  first phase of PEPFAR, funding in Cambodia went from $16.8 million in  2004 to $18.5 million in 2010. As noted above, in recent years, the Global  Fund has emerged as the largest funder of HIV/AIDS in Cambodia.
section_title: PEPFAR Program Information
paragraphs: The PEPFAR program in Cambodia supports an array of activities for  HIV/AIDS prevention, treatment, and care. For example, PEPFAR focuses  on peer education activities for the most at-risk population including sex  workers, men who have sex with men, drug users, and clients of sex  workers. PEPFAR Cambodia also supports programs such as condom  social marketing, HIV counseling and testing services, prevention of  mother-to-child transmission, prevention of tuberculosis and HIV co- infection, surveillance for planning, laboratory support, and blood safety.  In addition, PEPFAR funds community- and clinic-based care activities  such as home care, care for orphans and vulnerable children, and pediatric  AIDS.
section_title: Partnership Framework
paragraphs: Cambodia is one of several countries with smaller PEPFAR investments  and programs focused largely on technical assistance that are pursuing a  strategy document instead of a partnership framework. According to  PEPFAR officials in Cambodia, there are currently no plans to initiate a  partnership framework in Cambodia.
section_title: Appendix III: Malawi Case Study
paragraphs: GDP per capita (PPP):  Life expectancy at birth:  51 ye (rnk 211 ot of 224)
HIV/AIDS adult prevalence rate:  11.9% (rnk 9 ot of 170)
Number of people livin with HIV/AIDS:  0,000 (rnk 15 ot of 165)
Number of AIDS orphan:  HIV/AIDS epidemic: The highet HIV prevlence exi mong vlnerable gro like ex  worker nd their client. However, the mjority of new infection occr in cople nd  mong prtner of people who hve mltiple concrrent prtner. In ddition, mother-to- child trmission itimted to ccont for lmouarter of new infection. Of the  lmot 1 million people who re etimted to live with HIV in Mwi, 10 percent of them  re children.
Estimate as of 2010.
subsections: section_title: National HIV/AIDS Program
paragraphs: According to Malawi’s national strategy, the Malawi government program  to address HIV/AIDS seeks to prevent the spread of HIV infections in  Malawi, provide access to treatment for people living with HIV and  mitigate the health, socio-economic and psychosocial impact of HIV and  AIDS on individuals, families, communities, and the nation. Specifically,  there are seven priority areas that drive the national response, which  include prevention and behavior change; treatment, care, and support;  impact mitigation; mainstreaming and decentralization; research,  monitoring, and evaluation; resource mobilization and utilization; and  policy and partnerships. The President leads the government HIV/AIDS  efforts and the Department of Nutrition, HIV, and AIDS in the Office of the  President and Cabinet is the lead government agency responsible for  policy, oversight, and advocacy. In 2001, the government established the  National AIDS Commission as a national coordinating authority to provide  leadership and coordinate the national program. This commission is  comprised of members from the private and public sector, civil society,  and people living with HIV. A number of key ministries implement the  national program, including the Ministry of Health, Ministry of Finance,  and the Ministry of Economic Planning and Development.
The current HIV/ AIDS national strategy for Malawi covers 2010 through  2012. While the Malawi HIV/AIDS National Action Framework is the  primary HIV/AIDS strategy, other Malawi government documents also  comprise the complete HIV/AIDS strategy for the country. For example,  other components of the national strategy include the National HIV  Prevention Strategy for 2009 through 2013, integrated annual work plans, a  national monitoring and evaluation framework for 2006 to 2010, as well as  other frameworks, technical strategies, and guidelines.
section_title: HIV/AIDS Partners and Donors
subsections: section_title: Bilateral and Multilateral Donors in HIV/AIDS
paragraphs: Malawi’s national HIV/AIDS program receives support from a variety of  bilateral and multilateral donors in addition to PEPFAR. The Global Fund  is the largest donor for HIV/AIDS programs in Malawi, spending almost  $190 million on HIV programs in Malawi from 2004 to 2008, which  comprised almost 40 percent of all HIV development assistance over that  period (see figure 5). Other major donors in the HIV/AIDS area in Malawi  include the United Kingdom, Norway, and the World Bank. The Malawi  government has a funding arrangement whereby each of these donors  contributes to a pooled fund managed by the National AIDS Commission.
section_title: Civil Society and Private Sector
paragraphs: Civil society and private sector organizations also play a role in carrying  out the national program. Civil society organizations implement activities,  carry out advocacy, mobilize resources, document community practices,  and support capacity-building programs. In addition, private sector  organizations have the responsibility to mainstream HIV/AIDS through  workplace policies and programs.
section_title: PEPFAR Program
subsections: section_title: PEPFAR Funding
paragraphs: While Malawi was not one of the original 15 PEPFAR focus countries,  PEPFAR maintained a presence in Malawi with funding increasing from  $15 million in 2004 to $55.3 million in 2010 (see fig. 6). U.S. government  development assistance for HIV/AIDS comprised 22 percent of total  development assistance to Malawi for HIV/AIDS from 2004 to 2008. As  noted above, the majority of the HIV/AIDS program in Malawi is funded by  other donors such as the Global Fund.
section_title: PEPFAR Program Information
paragraphs: The PEPFAR program in Malawi supports interventions for HIV/AIDS  prevention, treatment, and care. PEPFAR intervention strategies include  strengthening care services provided by the public sector and indigenous  organizations, expanding and strengthening services for orphans and  vulnerable children in urban and rural areas, and building capacity to  support strengthening of critical areas, including laboratory infrastructure  and strategic information. According to PEPFAR officials, the Malawi  PEPFAR program takes into consideration the programs and funding  support provided by the other donors and focuses resources on filling gaps  in the national program.
section_title: Partnership Framework
paragraphs: Malawi was the first country to complete a partnership framework, which  was signed in May 2009. The framework lays out a 5-year strategic  agreement between PEPFAR and the Malawi government, which focuses  on reducing new HIV infections, improving the quality of treatment and  care, mitigating the impacts of HIV/AIDS on individuals and households,  and supporting systems needed to achieve these goals. Malawi signed a  partnership framework implementation plan in July 2010 that provides  additional detail including specific strategies for achieving the 5-year goals  and objectives. According to PEPFAR officials in Malawi, additional  funding was made available to Malawi for implementing this partnership  framework.
The development of the partnership framework in Malawi coincided with  the update and revision of the National Action Framework. According to  PEPFAR and Malawi government officials, the timing of the two processes  resulted in close collaboration between government officials that  increased alignment of the PEPFAR program with the national program.  For example, as a result of the partnership framework development  process, the PEPFAR country team was invited by the Malawi government  to participate in the pooled donors meetings, even though PEPFAR does  not participate in the pooled funding arrangement.
section_title: Appendix IV: Uganda Case Study
paragraphs: GDP per capita (PPP):  Life expectancy at birth:   ye (rnk 205 ot of 224)
HIV/AIDS adult prevalence rate:  5.4% (rnk 14 ot of 170)
Number of people livin with HIV/AIDS:  940,000 (rnk 14 ot of 165)
Number of AIDS orphan:  HIV/AIDS epidemic: Ugndce  generlized HIV epidemic. There were rp  decline in HIV prevlence in the mid- nd lte-1990, but in recent ye, prevlence  trendve abilized. Ntionwide, HIV prevlence i higher in bareas thn in rreas. Mjor vlnerable poption gro inclde yong women, people in protittion nd  militry peronnel.
Estimate as of 2010.
subsections: section_title: National HIV/AIDS Program
paragraphs: According to its national HIV/AIDS strategy, Uganda aims to reduce new  HIV infection by 40 percent, expand social support, and provide care and  treatment services to 80 percent of needy individuals by 2012. The strategy  outlines four areas: prevention, care and treatment, social support, and  systems strengthening. Each area sets out specific objectives and targets.  For example, under the prevention area, the strategy states that Uganda  will reduce mother-to-child transmission of HIV by 50 percent by 2012.  Under the systems strengthening area, the strategy includes several  objectives, such as effectively coordinating and managing the response at  various levels. The Uganda AIDS Commission, established in 1992,  coordinates the multisectoral response to the HIV/AIDS epidemic. The  National AIDS Policy has yet to be approved by the Ugandan parliament.  However, in addition to Uganda’s National HIV&AIDS Strategic Plan  2007/8-2011/12, Uganda has developed national policies related to HIV  counseling and testing, antiretroviral therapy, and orphans and other  vulnerable children. The Ministries of Health; Gender, Labour, and Social  Development; and Finance, Planning, and Economic Development, among  others, are involved in the national multisectoral HIV/AIDS strategy.  Coordinated by the Uganda AIDS Commission, these ministries, along with  UNAIDS and other stakeholders, make up the Partnership Committee,  which is in turn made up of various technical working groups and  subcommittees.
section_title: HIV/AIDS Partners and Donors
subsections: section_title: Bilateral and Multilateral Donors
paragraphs: Although the United States is by far the largest bilateral HIV/AIDS program  donor in Uganda, the United Kingdom, Ireland, and many other countries  also contribute to Uganda’s national HIV/AIDS program. In addition, the  Global Fund spent over $72 million in Uganda for HIV/AIDS programs  from 2004 to 2008.  strategic framework. In 2007, with financial support from various  development partners, the government of Uganda established a Civil  Society Fund (CSF) and since has issued a number of grants to civil  society organizations, including community- and faith-based organizations,  and district governments to support provision of specific services by civil  society groups in these areas.
section_title: PEPFAR Program
subsections: section_title: PEPFAR Funding
paragraphs: Uganda was selected in 2004 as one of the original PEPFAR focus  countries. As such, U.S. support for HIV/AIDS programs in Uganda  increased rapidly, from about $90.8 million in 2004, to $286.3 million in  2010. As noted above, the U.S. government is the largest HIV/AIDS  development partner in Uganda.
section_title: PEPFAR Program Information
paragraphs: PEPFAR-supported programs span a number of HIV program areas,  including prevention, treatment, care, laboratory services, health systems  strengthening, and strategic information. In collaboration with the  government of Uganda, as of March 2009, PEPFAR supports antiretroviral  treatment for more than 150,000 HIV-positive Ugandans.
section_title: Partnership Framework
paragraphs: The government of Uganda plans to develop new national development,  health, and HIV/AIDS strategies. PEPFAR officials in Uganda indicated  that these revisions create opportunities for the government of Uganda to  demonstrate renewed leadership and build relationships with its  development partners. In this context, PEPFAR envisions that it could  pursue a Partnership Framework with Uganda.
section_title: Appendix V: Vietnam Case Study
paragraphs: ppendix V: Vietnam Case Study  GDP per capita (PPP):  $2,900 (rnk 165 ot of 227)
Life expectancy at birth:  72 ye (rnk 12t of 224)
HIV/AIDS adult prevalence rate:  0.5% (rnk 7t of 170)
Number of people livin with HIV/AIDS:  290,000 (rnk 24 ot of 165)
Number of AIDS orphan:  HIV/AIDS epidemic: Vietnm has  concentrted HIV epidemic, with the highet  prevlence mong key poption t higher rik. Thee inclde injecting druser with   prevlence rte of 2.6 percent, femle ex worker with  prevlence rte of 4.4 percent,  nd men who hve ex with men with  prevlence of 9 percent in H Noi nd 5 percent in  Ho Chi Minh City. Injecting druse i jor fctor driving the pred of HIV in Vietnm,  poing er of complex chllenge.
Estimate as of 2010.
Estimate as of 2007.
subsections: section_title: National HIV/AIDS Program
paragraphs: The Vietnam national HIV strategy, the National Strategy on HIV/AIDS  Prevention and Control in Vietnam until 2010 with a Vision to 2020,  lays out objectives and priorities for the government response to the  HIV/AIDS epidemic in Vietnam. The strategy’s goals are to control the HIV  prevalence among the general population to below 0.3 percent by 2010 and  with no further increase after 2010, and to reduce the adverse impacts of  HIV on socio-economic development. In addition, the strategy also lays out  a number of specific priority areas in the area of prevention, treatment and  care, and HIV governance. In the HIV prevention area, the government  program focuses on prevention and behavior change through information,  education and communication, harm reduction targeting high-risk  populations, prevention of mother-to-child transmission, management and  treatment of sexually transmitted infections, and safe blood transfusion.  The treatment and care elements of the strategy focus on care and support  for people living with HIV and access to HIV treatment including  antiretroviral drugs. The strategy highlights HIV governance issues  including HIV surveillance, monitoring and evaluation, capacity building,  and international cooperation enhancement. The government of Vietnam  supports activities and services in each of these areas.
The National Committee for AIDS, Drugs, and Prostitution Prevention and  Control is the multisectoral body leading the government HIV program.  This multisectoral body is headed by a Deputy Prime Minister, and  members include vice-ministers from relevant line ministries. Technical  coordination of activities is delegated to the Vietnam Administration for  AIDS Control within the Ministry of Health. There are also a number of  other ministries and entities involved in coordinating and implementing  various aspects of the national program including, the Ministry of Public  Security; the Ministry of Labor, War Invalids, and Social Affairs; the  Ministry of Health; the Ministry of Education and Training; the Ministry of  Finance; and the Ministry of Planning and Investment. While the current  multisectoral national HIV strategy for Vietnam covers 2004 to 2010 with a  vision to 2020, according to the Vietnam PEPFAR country team there are a  number of other strategies, documents, and laws that guide the national  program including, the Law on the Prevention and Control of HIV/AIDS  and Vietnam’s Comprehensive Poverty Reduction and Growth Strategy.
section_title: HIV/AIDS Partners and Donors
paragraphs: While U.S. funding comprises the majority of HIV/AIDS development  assistance funding in Vietnam, the national HIV/AIDS program receives  support from a variety of other bilateral and multilateral donors as well.  After PEPFAR, the United Kingdom is the largest HIV/AIDS donor in  Vietnam, spending over $24 million from 2004 to 2008, which comprised 12  percent of all HIV development assistance over that period (see fig. 11).  The United Kingdom HIV development assistance is focused largely in the  area of HIV prevention and harm reduction. In addition, the Global Fund  comprised 9 percent of all HIV development assistance from 2004 to 2008,  and this funding was focused in areas including prevention of mother-to- child transmission, and HIV counseling and testing. Other major donors in  Vietnam include the World Bank, which funds programs in HIV prevention,  harm reduction, blood safety, and care and treatment; and Germany,  which funds HIV prevention activities and procures test equipment for HIV  counseling and testing services. However, according to PEPFAR officials,  donor support in Vietnam is decreasing because of a number of factors,  including Vietnam’s progress towards becoming a middle-income country.
section_title: PEPFAR Program
subsections: section_title: PEPFAR Funding
paragraphs: During the first phase of PEPFAR, Vietnam was classified as one of the 15  PEPFAR focus countries. PEPFAR funding in Vietnam has grown from  $17.7 million in 2004 to $97.8 million in 2010 (see fig. 12). In addition, U.S.  funding in Vietnam comprised most HIV/AIDS development assistance to  etnam comprised most HIV/AIDS development assistance to  Vietnam from 2004 to 2008.  Vietnam from 2004 to 2008.
section_title: PEPFAR Program Information
paragraphs: Since 2004, the PEPFAR program has provided more than $320 million to  support the delivery of comprehensive HIV/AIDS prevention, care,  treatment, and support activities in Vietnam. PEPFAR activities in Vietnam  have included assisting Vietnam to develop comprehensive prevention,  treatment, care and support networks; supporting the government of  Vietnam’s efforts to reduce stigma and discrimination against people living  with and affected by HIV/AIDS; training Vietnamese physicians in clinical  HIV/AIDS treatment and care; assisting the Ministry of Health to develop  peer outreach for at-risk populations; increasing the public health  management capacity of Vietnamese government workers; assisting the  Ministry of Health to develop a national HIV reference laboratory; and  providing support in establishing one national surveillance and monitoring  and evaluation system.
According to the Vietnam PEPFAR country team, over the next 5 years,  PEPFAR will place a renewed emphasis on partnering with Vietnam to build  Vietnam’s national HIV/AIDS response, and continue to work together with  all sectors of Vietnam as they craft strategies and programs to stop  HIV/AIDS. In addition, as part of the new Global Health Initiative, PEPFAR  will support Vietnam as it works to further integrate and expand access to  other health care services, such as those that address tuberculosis, malaria,  maternal and child health, and family planning with HIV/AIDS programs.
section_title: Partnership Framework
paragraphs: The Vietnam country team recently negotiated and signed a partnership  framework with the Vietnam Administration for AIDS Control within the  Ministry of Health. Development of the partnership framework  implementation plan is currently under way, with completion scheduled  for October 2010.
section_title: Appendix VI: Comments from the U.S. Department of State, Office of the U.S. Global AIDS Coordinator
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Audrey Solis (Assistant Director),  Todd M. Anderson, Diana Blumenfeld, Giulia Cangiano, David Dornisch,  Lorraine Ettaro, Etana Finkler, Reid Lowe, Grace Lui, and Mark Needham  made key contributions to this report. Additional technical assistance was  provided by Chad Davenport, Marissa Jones, Bruce Kutnick, Mae Liles,  Ellery Scott, and Michael Simon.
section_title: Related GAO Products
paragraphs: 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 2009.
Global HIV/AIDS: A More Country-Based Approach Could Improve  Allocation of PEPFAR Funding. GAO-08-480. Washington, D.C.: April 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 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 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 2005.
Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications  Provided under U.S. Emergency Plan Is Limited. GAO-05-133.  Washington, D.C.: January 2005.
Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges  to Expanding Treatment, but Others Remain. GAO-04-784. Washington,  D.C.: June 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 2003.