Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other Health Assistance in Fiscal Years 2001-2008
Published: 2010-10-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: U.S. funding for global HIV/AIDS and other health-related programs rose significantly from 2001 to 2008. The President's Emergency Plan for AIDS Relief (PEPFAR), reauthorized in 2008 at $48 billion through 2013, has made significant investments in support of prevention of HIV/AIDS as well as care and treatment for those affected by the disease in 31 partner countries and 3 regions. In May 2009, the President proposed spending $63 billion through 2014 on global health programs, including HIV/AIDS, under a new Global Health Initiative. The Office of the U.S. Global AIDS Coordinator (OGAC), at the Department of State (State), coordinates PEPFAR implementation. The Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID), among other agencies, implement PEPFAR as well as other global health-related assistance programs, such as maternal and child health, infectious disease prevention, and malaria control, among others. Responding to legislative directives, this report examines U.S. disbursements (referred to as spending) for global HIV/AIDS- and other health-related bilateral foreign assistance programs (including basic health and population and reproductive health programs) in fiscal years 2001-2008. The report also provides information on models used to estimate HIV treatment costs. GAO analyzed U.S. foreign assistance data, reviewed HIV treatment costing models and reports, and interviewed U.S. and UNAIDS officials.
section_title: What GAO Found
paragraphs: In fiscal years 2001-2008, bilateral U.S. spending for HIV/AIDS and other health-related programs increased overall, most significantly for HIV/AIDS. From 2001 to 2003--before the establishment of PEPFAR--U.S. spending on global HIV/AIDS programs rose while spending on other health programs dropped slightly. From fiscal years 2004 to 2008, HIV/AIDS spending grew steadily; other health-related spending also rose overall, despite declines in 2006 and 2007. As would be expected, U.S. bilateral HIV/AIDS spending showed the most increase in 15 countries--known as PEPFAR focus countries--relative to other countries receiving bilateral HIV/AIDS assistance from fiscal years 2004 through 2008. In addition, GAO's analysis showed that U.S. spending on other health-related bilateral foreign assistance also increased most for PEPFAR focus countries. Spending growth rates varied among three key regions--sub-Saharan Africa, Asia, and Latin America and the Caribbean--as did these regions' shares of HIV/AIDS and other health foreign assistance spending following establishment of PEPFAR. OGAC, USAID, and UNAIDS have adopted three different models to estimate and project antiretroviral therapy (ART) costs. The three models--respectively known as the PEPFAR ART Costing Project Model, the HIV/AIDS Program Sustainability Analysis Tool, and Spectrum--are intended to inform policy and program decisions related, in part, to expanding efforts to provide ART in developing countries.

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), authorized by Congress at $15 billion for fiscal years 2004  through 2008, contributed significantly to the global response to the  pandemic. PEPFAR reported that in 2009, it 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.
U.S. and other donor funding for global health increased significantly from  2001 to 2008, largely because of increases in funding for HIV/AIDS  programs. The Tom Lantos and Henry J. Hyde United States Global  Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization  Act of 2008 (2008 Leadership Act) authorized PEPFAR at $48 billion  through fiscal year 2013 and extended the U.S. government’s efforts to  combat the global HIV/AIDS epidemic and other diseases. Among its  other purposes, the 2008 Leadership Act sets new targets for treatm ent  programs and calls for a plan to increase the number of individuals on  antiretroviral therapy (ART) proportional to available funding and  decreases in cost per patient. In May 2009, the President announced the  creation of a new Global Health Initiative and proposed $63 billion in  funding for all global health programs through fiscal year 2014, including  more than $51 billion for HIV/AIDS, tuberculosis, and malaria programs.  For fiscal year 2011, the President has proposed spending $8.5 billion on  global health and child survival programs, including $5.9 billion for  HIV/AIDS.
Responding to directives in the Consolidated Appropriations Act of 2008  and the 2008 Leadership Act, this report examines trends in U.S. bilateral  spending for global HIV/AIDS and other global health programs in fiscal  years 2001 through 2008. In addition, this report provides information on  models used to estimate the cost of providing ART.
To address trends in U.S. spending on global HIV/AIDS and other health  programs, we analyzed data from the Foreign Assistance Database  (FADB) provided by the U.S. Agency for International Development  (USAID) on U.S. spending for health-related foreign assistance programs.  Specifically, we examine disbursement levels and growth trends from  2001 to 2008 for bilateral HIV/AIDS and other health-related foreign  assistance programs by time period (pre-PEPFAR and first 5 years of  PEPFAR for all countries); countries grouped approximately by level of  PEPFAR focus and funding; and region (sub-Saharan Africa, Latin America  and the Caribbean, and Asia). We determined the FADB disbursement data  to be sufficiently reliable for the purposes of reporting them in this  manner. For this report, we defined U.S. spending for global HIV/AIDS  programs as foreign assistance for HIV/AIDS control, testing, prevention,  treatment, and care; we defined U.S. spending for other global health  programs as foreign assistance to support general and basic health and  population and reproductive health policies and programs (except those  related to HIV/AIDS). (See app. I for more information on these  categories.) We converted the spending amounts provided to 2010  constant dollars to account for inflation and allow the comparison of  levels of assistance in different time periods. We also consulted data on  other donor and U.S. foreign assistance. In addition, we interviewed State  Department, USAID, and Centers for Disease Control and Prevention  (CDC) officials and representatives of research organizations. To describe  three key models used to estimate costs related to providing ART in  developing countries, we reviewed the models and examined reports on  the models. We also interviewed officials of the U.S. government and the  Joint United Nations Programme on HIV/AIDS (UNAIDS), as well as  developers of the models, in Washington, D.C.; Atlanta; and Geneva,  Switzerland. We conducted our work from July 2009 to October 2010 in  accordance with all sections of GAO’s Quality Assurance Framework that  are relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions.  See appendix I for a more detailed description of our scope and  methodology.
subsections: section_title: Background
subsections: section_title: President’s Global Health Initiative
paragraphs: In May 2009, the President announced the creation of a new Global Health  Initiative (GHI) and proposed $63 billion in funding for all global health  programs, including HIV/AIDS, malaria, tuberculosis, and maternal and  child health, through 2014. According to the proposal, the majority of this  funding—$51 billion, or 81 percent—is slated for global HIV/AIDS,  tuberculosis, and malaria programs. For fiscal year 2009, State and USAID  allocated about $7.3 billion for global health and child survival programs,  including more than $5.6 billion for HIV/AIDS programs. For fiscal year  2010, State and USAID allocated approximately $7.8 billion for global  health and child survival programs, including $5.7 billion for HIV/AIDS.
For fiscal year 2011, the President proposed spending $8.5 billion on global  health and child survival programs, including $5.9 billion for HIV/AIDS.
In February 2010, the administration released a consultation document on  GHI implementation, focusing on coordination and integration of global  health programs, among other things, and setting targets for achieving  health outcomes. The document also proposed selection of up to 20  countries—known as GHI Plus countries—that will receive additional  funding and technical assistance under the GHI.
Congress first authorized PEPFAR in 2003 and, in doing so, created within  State a Coordinator of the U.S. Government Activities to Combat HIV/AIDS  Globally, which State redesignated the Office of the U.S. Global AIDS  Coordinator (OGAC). OGAC establishes overall PEPFAR policy and  program strategies; coordinates PEPFAR programs; and allocates PEPFAR  resources from the Global Health and Child Survival account to U.S.  implementing agencies, including USAID and the Department of Health  and Human Services’ (HHS) CDC. USAID and CDC also receive direct  appropriations to support global HIV/AIDS and other global health  programs, such as tuberculosis, malaria, and support for maternal and  child health.
In fiscal years 2004 through 2008—the first 5 years of PEPFAR—the U.S.  government directed more than $18 billion to PEPFAR implementing  agencies and the Global Fund to Fight AIDS, Tuberculosis and Malaria  (Global Fund). In 2008, Congress reauthorized PEPFAR at $48 billion to  continue and expand U.S.-funded HIV/AIDS and other programs through  fiscal year 2013.
Although PEPFAR initially targeted 15 countries, known as focus  countries, since its establishment PEPFAR has made significant  investments in 31 partner countries and 3 regions. Representatives of  PEPFAR implementing agencies (country teams) jointly develop country  operational plans (COP) for the 15 focus countries and an additional 16  nonfocus countries, as well as regional operational plans (ROP) for three  regions, to document U.S. investments in, and anticipated results of, U.S.- funded programs to combat HIV/AIDS. The country teams submit the  operational plans to OGAC for review and ultimate approval by the U.S.  Global AIDS Coordinator. As such, these operational plans serve as the  basis for approving annual U.S. bilateral HIV/AIDS funding, notifying  Congress, and allocating and tracking budgets and targets. Some nonfocus  countries receiving U.S. HIV/AIDS funding do not submit a PEPFAR  operational plan; OGAC reviews and approves HIV/AIDS-related foreign  assistance funding through foreign assistance operational plans. Table 1  shows the countries and regions that received U.S. foreign assistance for  HIV/AIDS programs in fiscal years 2001-2008.
section_title: Funding for HIV Treatment
paragraphs: In 2009, UNAIDS estimated that $7 billion would be needed in developing  countries in 2010 to reach HIV/AIDS treatment and care program targets,  which are generally defined as 80 percent of the target population  requiring treatment. Sub-Saharan Africa makes up about half (49 percent)  of estimated needs for all HIV/AIDS programs in developing countries.  UNAIDS’s estimate includes provision of ART, testing and counseling,  treatment for opportunistic infections, nutritional support, laboratory  testing, palliative care, and the cost of drug-supply logistics. The costs for  CD4 blood tests are also included.
In fiscal years 2006-09, PEPFAR funding for ART made up nearly half (46  percent) of PEPFAR’s approved budget for prevention, treatment, and  care programs. (See fig. 1.) ART funding generally comprised treatment  services (about 55 percent of approved treatment funding); ARV drug  procurement (about 32 percent of approved treatment funding); and  laboratory infrastructure (about 13 percent of approved treatment  funding).
In 2008, OGAC reported that tentative approval of generic ARV drugs had  generated significant savings for PEPFAR. As of September 2010, HHS’s  Food and Drug Administration had approved, or tentatively approved, 116  ARV formulations under its expedited review process, which allows all  ARV drugs to be rapidly reviewed for quality standards and subsequently  cleared for purchase under PEPFAR.
According to PEPFAR’s Five-Year Strategy, released in December 2009,  PEPFAR plans to provide direct support for more than 4 million people on  ART, more than doubling the number of people directly supported on  treatment during the first 5 years of PEPFAR. The strategy seeks to focus  PEPFAR support on specific individuals requiring ART by prioritizing  individuals with CD4 cell counts under 200/mm In addition, in countries with high  coverage rates that are expanding eligibility for treatment, PEPFAR will  provide technical assistance and support for the overall treatment  infrastructure. PEPFAR also will expand efforts to better link testing and  counseling with treatment and care and, in conjunction with its prevention  of mother-to-child transmission programs, will support expanded  treatment to pregnant women.
section_title: Costing Models
paragraphs: As we have previously reported, federal financial standards call on  agencies to use costing methods in their planning to determine resources  needed to evaluate program performance, among other things. Program  managers should use costing information to improve the efficiency of  programs. In addition, such information can be used by Congress to make  decisions about allocating financial resources, authorizing and modifying  programs, and evaluating program performance. In 2008, we found that  PEPFAR country teams identified and analyzed program costs in varying  ways, and we recommended that the Secretary of State direct OGAC to  provide guidance to PEPFAR country teams on using costing information  in their planning and budgeting. irrespective of  clinical symptoms. See Rapid Advice: Antiretroviral therapy for HIV Infection in Adults  and Adolescents (Geneva: WHO, 2009),  www.who.int/entity/hiv/pub/arv/rapid_advice_art.pdf.
section_title: U.S. Spending on HIV/AIDS and Other Health Assistance Increased in 2001- 2008 and Varied by Time Frame, Country Status, and Region
paragraphs: Overall, U.S. bilateral spending on global HIV/AIDS and other health  programs generally increased in fiscal years 2001 through 2008,  particularly for HIV/AIDS programs. From 2001 through 2003, U.S. bilateral  spending on global HIV/AIDS rose, while spending on other global health  programs dropped slightly. As would be expected given PEPFAR’s  significant investment, from fiscal years 2004 through 2008, U.S. bilateral  HIV/AIDS spending showed the greatest increase in PEPFAR focus  countries, relative to nonfocus countries and regions with PEPFAR  operational plans and other countries receiving HIV/AIDS assistance. In  addition, our analysis determined that U.S. spending for other health- related health assistance also increased most for PEPFAR focus countries.  Spending growth rates varied among three key regions—sub-Saharan  Africa, Asia, and Latin America and the Caribbean—as did these regions’  shares of bilateral HIV/AIDS and other health spending following  establishment of PEPFAR. (See app. II for additional information on U.S.  bilateral foreign assistance spending on HIV/AIDS and other health  programs in fiscal years 2001 through 2008.)
subsections: section_title: U.S. Spending on HIV/AIDS and Other Health Programs Grew Overall, Despite Decreases in Other Health Foreign Assistance Spending
paragraphs: Overall, U.S. bilateral foreign assistance spending on both global HIV/AIDS  and other health programs increased in fiscal years 2001 through 2008.  Although spending on other health programs decreased slightly from 2001  through 2003, U.S. spending on both HIV/AIDS and other health-related  foreign assistance programs grew from 2004 through 2008, the first 5 years  of PEPFAR. Annual growth in U.S. spending on global HIV/AIDS was more  robust and consistent than annual growth for other global health spending  (see table 2 and fig. 2).  2001-2003. Prior to the implementation of PEPFAR, U.S. bilateral  spending on HIV/AIDS programs grew rapidly, while U.S. spending on  other health programs fell slightly.
HIV/AIDS. The U.S. government spent less on global HIV/AIDS programs  than on other health-related programs in fiscal years 2001-2003. However,  spending on HIV/AIDS grew rapidly prior to implementation of PEPFAR.
Other health. U.S. spending on other health-related programs decreased  from 2001 to 2003. However, total spending for these programs during this  period was more than three times greater than the total for HIV/AIDS- related foreign assistance programs.  2004-2008. Following implementation of PEPFAR, U.S. bilateral spending  on both global HIV/AIDS and other health-related programs increased  overall, with more rapid and consistent growth in spending for HIV/AIDS  programs.
HIV/AIDS. In fiscal year 2004, U.S. spending on HIV/AIDS programs was  roughly equivalent to the total for the previous 3 years combined; in fiscal  year 2008, annual U.S. spending on global HIV/AIDS programs was nearly  three times the 2004 total. In addition, U.S. spending on HIV/AIDS  programs in 2005 was, for the first time, higher than spending on other  health programs. By 2008, almost twice as much was spent on HIV/AIDS  programs as on other health programs.
Other health. Although U.S. spending on other health programs also  increased overall from fiscal year 2004 through 2008, annual spending was  less consistent and decreased in 2006 and 2007.
section_title: U.S. Spending on HIV/AIDS and Other Health Programs Grew Most Rapidly in PEPFAR Focus Countries
paragraphs: Our analysis shows differences in growth trends in U.S. bilateral spending  on HIV/AIDS and other health programs before and after implementation  of PEPFAR for three distinct groups of countries: PEPFAR focus  countries, nonfocus countries and regions with PEPFAR operational  plans, and all other countries receiving HIV/AIDS foreign assistance (i.e.,  nonfocus countries receiving HIV/AIDS assistance that do not submit  PEPFAR operational plans to OGAC). In fiscal years 2001 through 2003,  U.S. bilateral spending on global HIV/AIDS programs grew for countries in  all three groups, while spending on other health programs increased at  lower rates. From 2004 through 2008, the average annual growth rate in  U.S. bilateral spending on global HIV/AIDS programs was, predictably,  greatest in focus countries, as was spending on other health programs in  these countries (see table 3).
For the 15 countries that would become PEPFAR focus countries, U.S.  bilateral spending on both HIV/AIDS and other health programs increased  steadily from 2001 through 2003, with higher growth for HIV/AIDS  spending. From 2004 through 2008, U.S. bilateral spending on global  HIV/AIDS-related foreign assistance programs continued to increase  significantly, while spending on other health programs grew modestly  overall. From 2004 through 2008, total U.S. bilateral spending on  HIV/AIDS-related foreign assistance programs in PEPFAR focus countries  was more than seven times greater than spending on other health  programs. (See fig. 3.)
For the 16 nonfocus countries and three regions that eventually would  submit operational plans to receive PEPFAR funding, U.S. bilateral  spending on both HIV/AIDS and other health-related foreign assistance  programs increased from 2001 through 2003 (see fig. 4), but at lower rates  and less consistently than for the focus countries. From 2001 through  2003, U.S. bilateral spending on other health-related foreign assistance  programs was about three times greater than spending on HIV/AIDS  programs in these countries and regions, although spending on HIV/AIDS  programs grew more rapidly. From 2004 through 2008, U.S. bilateral  spending on both global HIV/AIDS and other health programs increased  overall, with greater spending on other health programs for the 5-year  period.
In all other countries that received some U.S. assistance for HIV/AIDS  programs from 2001 through 2008 but did not submit PEPFAR operational  plans—a total of 47 countries—U.S. bilateral spending on both HIV/AIDS  and other health-related foreign assistance programs fluctuated from year  to year but increased overall (see fig. 5). In addition, U.S. bilateral  spending for other health programs greatly exceeded spending for  HIV/AIDS programs both before and after the establishment of PEPFAR.  From 2001 through 2003, U.S. bilateral spending on HIV/AIDS programs in  these countries nearly quadrupled; spending on other health programs  amounted to more than 12 times that for HIV/AIDS programs and  increased slightly over the period. From 2004 through 2008, U.S. bilateral  spending on other health programs continued to greatly exceed spending  on HIV/AIDS-related programs in these countries; spending on both  HIV/AIDS and other health programs fluctuated from year to year and  grew at similar rates overall.
section_title: Spending Levels and Growth Rates Varied among Three Key Regions
paragraphs: In fiscal years 2001 through 2008, the majority of U.S. bilateral HIV/AIDS  program spending was in sub-Saharan Africa, Asia, and Latin America and  the Caribbean—three regions where the 15 PEPFAR focus countries and  14 of the 16 nonfocus countries with PEPFAR operational plans are  located—with the greatest U.S. spending on global HIV/AIDS foreign  assistance programs in sub-Saharan Africa. From 2004 through 2008,  following the establishment of PEPFAR, the share of U.S. bilateral  spending on other health programs directed to countries in sub-Saharan  Africa and Latin America and the Caribbean declined, while the share of  U.S. spending on other health programs in Asia and in other regions  increased. (See fig. 6.)
Average annual growth rates in spending on HIV/AIDS and other health  programs also varied significantly across these three regions (see table 4). ble 4: Average Annual Growt Ta Related Foreign Assistance Spending, by Region, Fiscal Years 2001-2008  h Rates for Global U.S.
Latin America and the  Caribbean  PEPFAR period (first 5 years)
subsections: section_title: Sub-Saharan Africa
paragraphs: U.S. bilateral foreign assistance spending on HIVAIDS programs in sub- Saharan Africa—which includes 12 of the 15 focus countries and 8 of the  16 nonfocus countries with PEPFAR operational plans— increased  rapidly both before and after the establishment of PEPFAR. In 2003, U.S.  bilateral spending on HIV/AIDS programs was nearly two times greater,  and by 2008 was more than four times greater than spending on other  health programs. U.S. bilateral spending on other health programs  declined overall from 2001 to 2003 and remained steady from 2004 to 2007,  but began to grow substantially in 2008. (See fig. 7.)
U.S. bilateral foreign assistance spending on both HIVAIDS and other  health-related foreign assistance programs in Asia—where 1 of the 15  focus countries as well as 5 nonfocus countries and 1 region that submit  PEPFAR operational plans are located—increased overall from 2001 to  2008. Overall bilateral spending on other health programs was three times  larger than spending on HIV/AIDS programs throughout the period. (See  fig. 8.)
From 2001 through 2008, total U.S. bilateral foreign assistance spending on  HIVAIDS programs in Latin American and the Caribbean—where 2 of the  15 focus countries as well as a nonfocus country and two regions with  PEPFAR operational plans are located— increased continuously. During  this period, U.S. bilateral spending on other health programs in these  countries and regions fluctuated from year to year and declined overall.  Bilateral spending on other health programs was consistently greater than  spending on HIV/AIDS programs during this period; however, in 2008,  annual spending on HIV/AIDS programs was nearly equal to spending for  other health programs (see fig. 9).
section_title: Three Key HIV Treatment Costing Models Used to Inform Policy and Program Decisions
paragraphs: To inform policy and program decisions related, in part, to expanding  efforts to provide ART in developing countries, OGAC, USAID, and  UNAIDS have adopted three different models for ART cost analyses.
OGAC uses the PEPFAR ART Costing Project Model (PACM) to estimate  and track PEPFAR-supported ART costs in individual PEPFAR countries  and across these countries.
USAID and its partners use the HIV/AIDS Program Sustainability Analysis  Tool (HAPSAT) to estimate resources needed to meet individual countries’  ART goals, among other things.
UNAIDS and USAID use a suite of models referred to as Spectrum to  project ART costs in individual countries and globally.
Table 5 provides information on the three costing models. For additional  information on the components of these three models, see appendix III.
Although the models have different purposes, a 2009 comparison study  conducted by their developers found that the three models produced  similar overall ART cost estimates given similar data inputs. According to  the models’ developers, data used for one model can be entered into  another to generate cost estimates and projections. For example, cost data  collected in Nigeria for use in HAPSAT were also used in PACM to inform  PEPFAR global average treatment cost estimates. Such cost projections  also can help decision makers to estimate the cost-related effects of policy  and protocol changes, such as changes made in response to the World  Health Organization’s November 2009 recommendation that HIV patients  initiate ART at an earlier stage of the disease’s progression.
section_title: Agency Comments and Our Evaluation
paragraphs: In coordination with HHS and USAID, State’s OGAC reviewed a draft of  this report and provided technical comments, which we incorporated as  appropriate.
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 IV.
section_title: Appendix I: Scope and Methodology
paragraphs: Responding to legislative directives, this report examines U.S. bilateral  foreign assistance spending on global HIV/AIDS and other health-related  programs in fiscal years 2001-2008. The report also provides information  on models used to estimate HIV treatment costs.
To examine trends in U.S. bilateral spending on global HIV/AIDS- and  other health-related foreign assistance programs, we analyzed data from  the Foreign Assistance Database (FADB) provided by the U.S. Agency for  International Development (USAID), interviewed State Department,  USAID, and Health and Human Services (HHS) officials in Washington,  D.C., and Centers for Disease Control and Prevention (CDC) officials in  Atlanta. We also interviewed representatives of the Kaiser Family  Foundation who have conducted similar research and analysis. We  reviewed relevant articles and reports regarding international and U.S.  global health assistance funding and examined relevant data on other  donor and U.S. foreign assistance.
Congress, U.S. agencies, and research organizations use varying  definitions of global health programs, with inclusion of safe water and  nutrition programs being one varying factor among definitions. Congress  funds global health programs through a number of appropriations  accounts: Foreign Operations; Labor, Education and Health; and Defense;  and through several U.S. agencies. The State Department, USAID, and the  HHS’ CDC are the primary U.S. agencies receiving congressional  appropriations to implement global health programs, including programs  to combat HIV/AIDS. Through foreign operations accounts administered  by USAID and State, Congress specifies support for five key global health  programs: child survival and maternal health, vulnerable children,  HIV/AIDS, other infectious diseases, and family planning and reproductive  health. In addition, Congress specifies support for five key CDC global  health programs: HIV/AIDS, malaria, global disease detection,  immunizations, and other global health. CDC also allocates part of its  tuberculosis and pandemic flu budget for international programs, and  State and USAID may transfer funds to CDC for specific activities. In  addition to these programs, USAID and CDC include other programs  related to global health. For example, USAID reports specific nutrition and  environmental health programs in its global health portfolio. Likewise,  CDC also uses its resources to provide international technical assistance  when requested, such as for disease outbreak response (e.g., pandemic  influenza preparedness and prevention), or reproductive health.
The Committee on the U.S. Commitment to Global Health at the Institute  of Medicine (IOM) defined global health programs as those aimed at  improving health for all people around the world by promoting wellness  and eliminating avoidable disease, disability and death. According to the  Organisation for Economic Cooperation and Development (OECD), global  health includes the following components: health care; health  infrastructure; nutrition; infectious disease control; health education;  health personnel development; health sector policy, planning and  programs; medical education, training and research; and medical services.  In its report on donor funding for global health, the Kaiser Family  Foundation combined data from four OECD categories to construct its  definition of global health: health; population policies and programs and  reproductive health (which includes HIV/AIDS and sexually transmitted  diseases); water supply and sanitation; and other social infrastructure and  services.
For the purposes of this report, we defined U.S. global spending for  HIV/AIDS programs as foreign assistance for activities related to HIV/AIDS  control, including information, education, and communication; testing;  prevention; treatment; and care. We defined U.S. spending for other  health-related programs as foreign assistance for general and basic health  and population and reproductive health policies and programs (except  those related to HIV/AIDS). General and basic health includes health  policy and administrative management, medical education and training,  medical research, basic health care, basic health infrastructure, basic  nutrition, infectious disease control, health education, and health  personnel development. Population and reproductive health policies and  programs include population policy and administrative management,  reproductive health care, family planning, and personnel development for  population and reproductive health.
The specific analyses presented in this report examine disbursement levels  and growth trends from fiscal years 2001 to 2008 for bilateral HIV/AIDS  and other health-related foreign assistance programs by time period (pre- PEPFAR and first 5 years of PEPFAR for all countries); PEPFAR country  status (focus countries with PEPFAR operational plans, nonfocus  countries with PEPFAR country or regional operational plans, and other  nonfocus countries receiving HIV/AIDS-related foreign assistance from  2001 to 2008); and region (sub-Saharan Africa, Latin America and the  Caribbean, and Asia, which received the majority of U.S. spending on  bilateral HIV/AIDS-related foreign assistance).
We examined disbursements—amounts paid by federal agencies to  liquidate government obligations—of U.S. bilateral foreign assistance for  global HIV/AIDS and other health programs, because, unlike other data,  disbursement data directly reflect the foreign assistance reaching partner  countries. We used USAID’s deflator to convert nominal dollar amounts to  constant 2010 dollar amounts, which are appropriate for spending trend  analysis. As such, it is important to remember that the disbursement  figures for HIV/AIDS- and other health-related foreign assistance programs  presented in this report differ from appropriation or commitment data  which may be reported elsewhere. Because we focused on bilateral  disbursements, our analysis excludes U.S. contributions to the Global  Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. In addition, about $4.7  billion and $3.3 billion in disbursements for HIV/AIDS programs and other  health-related foreign assistance programs, respectively, from 2001 to  2008, were not specified for an individual country or region in the FADB.  As such, our analysis of bilateral spending levels and growth trends by  PEPFAR country status and geographical region excludes these  disbursements.
We assessed the reliability of disbursement data from the FADB and  determined them to be sufficiently reliable for the purposes of reporting in  this manner. In assessing the data, we interviewed USAID officials in  charge of compiling and maintaining the FADB, reviewed the related  documentation, and compared data to published data from other sources.  We also determined that, in general, USAID takes steps to ensure the  consistency and accuracy of the disbursements data reported by U.S.  government agencies, including by verifying possible inconsistencies or  anomalies in the data received, providing guidance and other  communications to agencies about category definitions, and comparing  the data to other data sources. Although we did not assess the reliability of  the data for complex statistical analyses, we determined that the data did  not allow the identification of causal relationships between funding levels  over time or among relevant categories; as such, we did not attempt an  empirical analysis of the impact of PEPFAR on other health funding.
To describe models used to estimate the cost of providing antiretroviral  therapy (ART), we interviewed State Office of the Global AIDS  Coordinator, USAID and CDC officials in Washington, D.C., and Atlanta.  We also interviewed Joint United Nations Programme on HIV/AIDS  (UNAIDS) officials in Washington, D.C. and Geneva, Switzerland, as well  as developers of the costing models. We analyzed user manuals and guides  for these models, as well as spreadsheets and additional information and  technical comments provided by the U.S. agencies and model developers.  We reviewed relevant literature for information on ART costing models, as  well as the Leadership Act and previous GAO work regarding  requirements and importance of cost information for program decision  making.
section_title: Appendix II: U.S. Spending on Global HIV/AIDS and Other Health-Related Programs
paragraphs: For fiscal years 2001 to 2008, U.S. bilateral foreign assistance spending for  HIV/AIDS-related health programs varied significantly by country for both  the 15 PEPFAR focus countries and the 16 countries and three regions  with PEPFAR operational plans.
Table 6 presents U.S. bilateral foreign assistance spending in constant  dollars, by country, on HIV/AIDS programs, for fiscal years 2001-2008. As  noted in appendix I, we converted nominal dollar amounts to constant  2010 dollars, which are appropriate for analysis of trends in U.S. foreign  assistance spending in global health, but do not represent in-year actual  spending amounts.
For fiscal years 2001 to 2008, U.S. bilateral foreign assistance spending for  other health programs also varied significantly by country for both the 15  PEPFAR focus countries and the 16 countries and three regions with  PEPFAR operational plans.
Table 7 presents U.S. bilateral foreign assistance spending in constant  dollars, by country, on other health-related (i.e., non-HIV/AIDS) programs,  for fiscal years 2001-2008. As noted in appendix I, we converted nominal  dollar amounts to constant 2010 dollars, which are appropriate for analysis  of trends in U.S. foreign assistance spending in global health, but do not  represent in-year actual spending amounts.
section_title: Appendix III: ART Patient and Cost Categories, by Costing Model
paragraphs: To estimate total cost of ART, three key models—the PEPFAR ART  Costing Project Model (PACM), HIV/AIDS Program Sustainability Analysis  Tool (HAPSAT), and Spectrum—all consider the number of patients and  various drug and nondrug cost estimates. PACM and HAPSAT also address  overhead costs in total cost calculations. This appendix presents the  specific drug and nondrug costs that each model considers in making  estimates.
PACM categorizes ART patients as adult or pediatric, new or established,  receiving first- or second-line ARV drugs, receiving generic or innovator  ARV drugs, and living in a low- or middle-income country. In addition,  PACM considers the following cost categories:    Drug costs. PACM categorizes ARV drug costs as generic or innovator  and first- or second-line. For each of these categories, PACM accounts costs associated with supply chain, wastage, inflation, and ARV buffer  stock.
Nondrug costs. PACM categorizes nondrug costs as recurrent and  investment costs. Recurrent costs include personnel, utilities, building, lab  supplies, other supplies, and other drugs; facility-level management and  overhead costs are also captured. Investment costs include training,  equipment, and construction.
Overhead. PACM categorizes above-facility-level overhead costs as U.S.  government, partner government, and implementing partner overhead, as  well as U.S. government indirect support to partner governments (e.g.,  U.S. government support for system strengthening or capacity building of  the national HIV/AIDS program).
Table 8 summarizes how PACM categorizes numbers of patients and  various unit costs to calculate the total cost of ART based on estimates of  PEPFAR and non-PEPFAR shares of costs derived from PEPFAR-funded  empirical studies.
HAPSAT categorizes current ART patients as those receiving first- or  second-line ARV drugs. In addition, HAPSAT considers the following cost  categories:    Drug costs. HAPSAT categorizes drug costs as first- or second-line ARV  drugs.
Nondrug costs. HAPSAT categorizes nondrug costs as labor (e.g., doctor,  nurse, lab technician salaries) and laboratory costs.
Overhead. HAPSAT categorizes overhead as administrative costs, drug  supply chain, monitoring and evaluation, and training, based on country  data. Overhead estimates are applied at both the facility and above-facility  level.
Table 9 summarizes how HAPSAT categorizes numbers of patients and  various unit costs to calculate the total cost of ART.
subsections: section_title: Spectrum
paragraphs: Spectrum categorizes current ART patients as adult or pediatric and  receiving first- or second-line ARV drugs. In addition, Spectrum considers  the following cost categories:    Drug costs. Spectrum categorizes drugs costs as first- or second-line ARV  drugs.
Nondrug costs. Spectrum categorizes nondrug costs as laboratory and  service delivery (i.e., hospital and clinic stays). Service delivery costs  include inpatient hospital and outpatient clinic costs.
Table 10 summarizes how Spectrum categorizes numbers of patients and  various unit costs to calculate the total cost of ART.
section_title: Appendix IV: 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, Ming Chen, David  Dornisch, Lorraine Ettaro, Etana Finkler, Kendall Helm, Heather Latta,  Reid Lowe, Grace Lui, Jeff Miller, and Mark Needham made key  contributions to this report.
section_title: Related GAO Products
paragraphs: President’s Emergency Plan for AIDS Relief: Efforts to Align Programs  with Partner Countries’ HIV/AIDS Strategies and Promote 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.
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.: July 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.