President's Emergency Plan for Aids Relief: Millions Being Treated, but Better Information Management Needed to Further Improve and Expand Treatment
Published: 2013-07-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: PEPFAR, first authorized in 2003, has supported significant advances in HIV/AIDS prevention, treatment, and care in over 30 countries, including directly supporting treatment for about 5.1 million people; however, millions more people still need treatment. Congress reauthorized PEPFAR in 2008authorizing up to $48 billion over 5 yearsdirecting OGAC to continue expanding the number of people receiving care and treatment through PEPFAR while also making it a major policy goal to help partner countries develop independent, sustainable HIV programs. As a result, PEPFAR began shifting efforts from directly providing treatment services toward support for treatment programs managed by partner countries. GAO completed a series of reports between 2011 and 2013 covering PEPFAR treatment program costs, results, and supply chains for ARV drugs, and PEPFAR program evaluations and planning and reporting. GAO was asked to summarize the key themes of these reports relating to (1) PEPFARs successes in expanding and improving treatment programs and (2) information management challenges to further improving and expanding treatment programs.
section_title: What GAO Found
paragraphs: The President's Emergency Plan for AIDS Relief (PEPFAR) has expanded treatment programs and increased their efficiency and effectiveness.
According to the Department of State's (State) Office of the U.S. Global AIDS Coordinator (OGAC), from 2005 to 2011, PEPFAR's per-patient treatment costs declined from about $1,053 to about $339. PEPFAR's increasing use of generic products and declining antiretroviral (ARV) drug prices have been a key source of savings. Programs also benefited from economies of scale and program maturity.
PEPFAR and partner countries have achieved substantial increases in the number of people on ARV drug treatment and have increased the percentage of eligible people receiving treatment. According to OGAC, treatment retention rates are at or above 80 percent at PEPFAR-supported treatment facilities in 10 partner countries.
PEPFAR has also worked with U.S. implementing agencies, international donors, and partner countries to increase the efficiency and reliability of ARV drug supply chains.
PEPFAR implementing agencies have evaluated a wide variety of PEPFAR program activities, demonstrating a clear commitment to program improvements.
Better information management is crucial to helping countries improve and expand treatment programs to meet the needs of the estimated 23 million people eligible for ARV treatment under 2012 international guidelines. GAO's reviews of PEPFAR treatment costs, results, and ARV drug supply chains have revealed limitations in the completeness, timeliness, and consistency of key program information. GAO also found important information lacking in PEPFAR program evaluations, plans, and results reporting. GAO has made a series of recommendations to improve the quality of this information in order to make PEPFAR programs more efficient and effective. The potential benefits that could be realized if GAO's recommendations are implemented include the following:
More complete and timely cost data could help countries manage costs and plan treatment expansion more effectively.
More consistent, complete, and timely information on treatment results could enhance the quality of treatment programs, including patient, clinic, and program management.
Plans to help countries improve inventory management and record keeping and tracking their progress could help supply chains operate more efficiently.
A more systematic and rigorous approach to planning and conducting program evaluations could result in evaluations that better inform PEPFAR stakeholders about how to improve programs.
OGAC could provide better context for understanding PEPFAR's achievements and challenges by comparing program results with targets and discussing efforts to ensure the quality of reported information.
section_title: What GAO Recommends
paragraphs: GAO previously made 13 recommendations to State to improve PEPFAR treatment programs, program evaluations, and reporting of program results. State generally agreed with these recommendations and has begun implementing some of them.

section_title: Letter
paragraphs: A decade since it was established in 2003 and nearing the end of its  second 5-year authorization, the President’s Emergency Plan for AIDS  Relief (PEPFAR) has supported the rapid expansion of programs that  provide access to life-saving antiretroviral (ARV) drugs and other  treatment and care services to millions of people living with HIV/AIDS in  low- and middle-income countries. However, millions more are still in  need of treatment, and challenges remain as PEPFAR transitions from an  emergency program to supporting sustainable treatment programs in  partner countries.
As of September 2012, the Department of State’s (State) Office of the  U.S. Global AIDS Coordinator (OGAC) reported that PEPFAR’s  multibillion dollar investments in partner countries’ programs had provided  treatment for about 5.1 million people, more than half of all individuals  enrolled in treatment in low- and middle-income countries.assistance, PEPFAR purchased over $1.2 billion in ARV drugs during  fiscal years 2005 through 2011 to treat people living with HIV. In part  because of this assistance, the estimated number of AIDS-related deaths  worldwide declined from 2.3 million in 2005 to 1.7 million in 2011,  according to data reported by the United Nations Joint Programme on  HIV/AIDS (UNAIDS).
OGAC is leading PEPFAR’s shift from an emergency program primarily  providing direct treatment to one that increasingly supports partner  countries’ capacity to manage their treatment programs. In passing the  Tom Lantos and Henry J. Hyde United States Global Leadership Against  HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008  Leadership Act), Congress directed OGAC to continue to expand the  number of people receiving HIV care and treatment support while also  making it a major policy goal to build partner-country capacity to deliver  services and promote a transition toward greater sustainability of country- owned HIV/AIDS programs. On the basis of recent World Health  Organization (WHO) guidelines, an estimated 15 million people in low-  and middle-income countries are eligible for ARV treatment. Moreover, 23  million would be eligible if programs expand eligibility to include groups  such as all pregnant and breastfeeding women and certain high-risk  populations, consistent with recommendations in 2012 updates to World  Health Organization guidelines. In December 2011, the President  announced an increase in PEPFAR’s target for the number of people  receiving treatment directly supported by PEPFAR—from 4 million to 6  million by the end of fiscal year 2013.
In 2013 we completed a series of reports on PEPFAR treatment  programs covering costs, results, and supply chains for ARV drugs. In  addition, we conducted other work in 2011 and 2012 on PEPFAR  evaluations and program planning and reporting.summarize the common themes from this body of work. This report  includes information on (1) PEPFAR’s successes in expanding treatment  programs and increasing their efficiency and effectiveness, and (2)
You asked us to  information management challenges that need to be addressed in order  to further improve and expand treatment programs.
We performed the work on which this report is based 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 the evidence obtained provides  a reasonable basis for our findings and conclusions based on our audit  objectives. Detailed information on the scope and methodology for each  of the reports used to prepare this overview appears in the respective  reports.
subsections: section_title: Background
subsections: section_title: PEPFAR Structure and Purpose
paragraphs: PEPFAR’s original authorization in 2003 established OGAC at State and  gave OGAC primary responsibility for the oversight and coordination of all  resources and international activities of the U.S. government to combat  the HIV/AIDS pandemic. OGAC also allocates appropriated funds to  PEPFAR implementing agencies, particularly the Department of Health  and Human Services’ (HHS) Centers for Disease Control and Prevention  (CDC) and the U.S. Agency for International Development (USAID). CDC  and USAID obligate the majority of PEPFAR funds for HIV treatment,  care, and prevention activities through grants, cooperative agreements,  and contracts with selected implementing partners, such as U.S.-based  nongovernmental organizations (NGO) and partner-country governmental  entities and NGOs.
PEPFAR supports the national HIV response in more than 30 countries.  The levels and types of PEPFAR support for these countries’ treatment  programs vary on the basis of each country’s capacity and the state of its  HIV epidemic. For example, for a given country’s program, PEPFAR may  directly deliver the majority of HIV treatment services; it may be one of  many entities delivering those services; or it may primarily provide  support to other partners such as the country government and other  bilateral and multilateral organizations—for example, the Global Fund to  Fight AIDS, Tuberculosis and Malaria (Global Fund)— that also provide  support to HIV programs. Moreover, UNAIDS data indicate that support  for HIV programs in many countries is increasingly a mix of resources  from the country government, Global Fund, PEPFAR, and other donors.PEPFAR strategy stresses the importance of having the partner-country  government play the coordinating role.
section_title: HIV/AIDS Treatment
paragraphs: PEPFAR supports a broad continuum of HIV care and treatment services  in partner countries. This continuum begins with HIV testing and the  counseling given to patients learning their HIV status. If patients are HIV  positive, their eligibility for treatment must be determined on the basis of  clinical criteria (symptoms associated with HIV), laboratory criteria  (strength of patients’ immune systems), or both clinical and laboratory criteria. WHO establishes international guidelines on when to initiate  treatment for specific groups of HIV-positive people, such as adult  patients who have never been on treatment, pediatric patients, and  pregnant and breastfeeding women. In November 2010, WHO updated its  guidelines by reducing the minimum eligibility threshold in its laboratory  criteriaHIV and tuberculosis, thereby expanding the number of people eligible for  treatment. Based on WHO guidelines, each country is expected to  establish country-specific guidelines on when to initiate treatment for  these groups. UNAIDS estimated at the end of 2011 that, on the basis of  WHO’s 2010 guidelines, 15 million people in low- and middle-income  countries needed treatment; of these, an estimated 8 million people are  on treatment.   and by recommending treatment for all people coinfected with  PEPFAR country teams report to OGAC semiannually, usually in May,  and annually, usually in November, on PEPFAR program results. These  reports, containing data and narratives, are intended to support program  monitoring, midcourse correction, and planning for subsequent fiscal  years. Data on PEPFAR program results also supply information for  OGAC’s annual report to Congress on PEPFAR performance.
section_title: ARV Drug Supply Chains
paragraphs: . Prior to 2010, WHO’s guidelines recommended treatment for all people with  CD4 counts of less than 200 cells/mm. contractors. PEPFAR’s efforts to develop and augment partner  countries’ supply chain systems are critical to support continued progress  in the fight against HIV/AIDS because inadequate or poorly functioning  supply chains pose risks to individual as well as to public health  outcomes. Patients on treatment receive daily doses of ARV drugs on a  continuing, lifelong basis. Skipped doses due to gaps in supply and  expired or otherwise unusable ARV drugs can lead to ineffective  treatment and increased viral resistance, necessitating newer, more  expensive drugs.health resources. For example, overstocking of drugs can lead to waste  as drugs expire and can no longer be used, potentially resulting in fewer  patients receiving treatment.
section_title: PEPFAR Has Helped Countries Expand Treatment Programs and Increase Their Efficiency and Effectiveness
paragraphs: Our recent reports have concluded that PEPFAR has helped partner  countries expand treatment programs and increase program efficiency  and effectiveness. PEPFAR’s per-patient treatment costs have declined  significantly, facilitating substantial increases in the number of people on  ARV treatment. In addition, PEPFAR has helped partner countries  increase the percentage of eligible people receiving treatment and has  reported high treatment retention rates at facilities in some countries.  PEPFAR has also worked with U.S. implementing agencies, international  donors, and partner countries to increase the efficiency and reliability of  ARV drug supply chains.
subsections: section_title: Declining Per-Patient Treatment Costs
paragraphs: According to OGAC, PEPFAR’s per-patient treatment costs declined from  about $1,053 to about $339 from 2005 to 2011, based on budget  calculations. As we reported, detailed studies of the estimated costs of  providing HIV treatment services in eight countries also show declining  per-patient treatment costs. Purchasing generic ARV drugs, together with  declining drug prices, has led to substantial savings. OGAC estimates  that PEPFAR has saved $934 million since fiscal year 2005 by buying  generic versions of ARV drugs instead of equivalent branded products.  Moreover, declining prices for specific ARV products have led to declining  prices for the ARV treatment regimens recommended for use in resource- limited settings. For example, figure 1 shows how average prices have  declined for three comparable first-line treatment regimens.
PEPFAR’s analyses of data from eight country treatment-cost studies  indicate that per-patient costs also declined as programs realized  economies of scale while taking on new patients. Furthermore, the  analyses suggest that costs decreased as countries’ treatment programs  matured, particularly in the first year after programs expanded, and  reduced one-time investments.
section_title: Expanded Treatment and Contributions to Treatment Quality
paragraphs: Our recent work also concluded that per-patient cost savings have  facilitated substantial increases in the number of people on ARV  treatment. Since the end of fiscal year 2008 – the year it was reauthorized  – PEPFAR has directly supported ARV treatment for over 3.3 million  additional people. Moreover, in fiscal year 2012, PEPFAR added more  people to ARV treatment than in any previous year. In September 2012,  an estimated 8 million were on ARV treatment in low- and middle-income  countries, of which PEPFAR directly supported about 5.1 million   (see fig. 2).
PEPFAR and UNAIDS data indicate a steady increase in the number of  people on treatment, improved treatment coverage rates, and high rates  of patient retention at many facilities. Increases in the number of people  on treatment have helped improve partner countries’ national treatment   coverage rates—generally defined as the percentage of eligible people  receiving treatment. According to the most current UNAIDS and  PEPFAR data available at the time of our April 2013 review, 8 of the 23  countries where PEPFAR directly supported treatment services in 2011  achieved estimated treatment coverage rates of 80 percent or more,  and almost all of the remaining countries have increased their estimated  treatment coverage rates since 2009, according to our analysis of  UNAIDS data.
We also found that PEPFAR’s additional contributions to partner  countries’ treatment programs include technical assistance to build  capacity, such as implementing revised treatment guidelines, assisting  partner-country district and national health officials with treatment facility  oversight, and training and mentoring treatment facility staff. In several  PEPFAR partner countries, PEPFAR implementing partners providing  direct treatment services have begun transferring stable patients to other  treatment providers, including an often expanding number of local public  and private health clinics, many of which receive PEPFAR-funded  technical assistance and other support. In part because of this PEPFAR  assistance, these providers also have begun increasing the number of  people they enroll in treatment.
Retention, defined as the percentage of adults and children known to be  alive and on treatment 12 months after starting treatment, is used by  OGAC and PEPFAR country teams as a proxy for treatment program  quality. Of the 23 PEPFAR country teams directly providing treatment  services, 20 provided data on this indicator in their fiscal year 2012  reports to OGAC, and 10 of the 20 reported retention rates at or above 80  percent for facilities where PEPFAR implementing partners directly  support treatment services.
section_title: More Efficient and Reliable Drug Supply Chains
paragraphs: Our work shows that PEPFAR has worked with U.S. implementing  agencies, international donors, and partner countries to increase the  efficiency and reliability of ARV drug supply chains. It has done so by  improving drug supply planning and procurement as well as in-country  distribution of drugs (see figure 3 for elements of the PEPFAR drug  supply chain).
First, PEPFAR has consolidated supply chains for ARV drugs by pooling  procurement across more than 20 partner countries to enhance efficiency  and reduce costs and has begun further consolidation with other U.S.  global health programs. Second, PEPFAR has improved coordination  among donors by creating an information-sharing network to help detect  and resolve supply gaps and other supply chain weaknesses and by  developing an emergency drug procurement mechanism. Third, PEPFAR  has provided partner countries with technical assistance, such as  assessment tools and training, to help them better manage drug supply  planning, procurement, and distribution. In each of the three partner  countries we visited for our April 2013 report, PEPFAR’s technical  assistance has increased efficiencies by strengthening specific steps in  the supply chain process. For example, in South Africa, which represents  more than one-fifth of the total world demand for ARV drugs, PEPFAR  helped the government institute procurement reforms that enabled it to  cut in half the prices it pays for these drugs. In Uganda and Kenya,  PEPFAR implementing agencies report that PEPFAR has helped  implement streamlined distribution networks and has implemented or is in  the process of implementing additional mechanisms to reduce or prevent  shortages.
section_title: Better Information Management Is Key to Helping Countries Improve and Expand Treatment Programs
paragraphs: Our recent work has found that, as PEPFAR partner countries assume  greater responsibility for managing their treatment programs, better  information management remains crucial to helping countries improve  and expand treatment programs. Our reviews of PEPFAR treatment  costs, results, and ARV drug supply chains have revealed some  limitations in the completeness, timeliness, and consistency of key  program information. We also found important information lacking in  PEPFAR program evaluations, plans, and results reporting.
subsections: section_title: More Complete and Timely Cost Data Could Help Countries Manage Costs and Plan Treatment Expansion More Effectively
paragraphs: Despite substantial declines in per-patient treatment costs, it is important  that countries continue to improve the efficiency of their programs to  expand to meet the needs of the estimated 23 million people eligible for  ARV treatment under recent WHO guidelines. PEPFAR uses two  approaches to obtain treatment cost information: cost estimation and  expenditure analysis. These approaches provide complementary  information that can help partner countries expand treatment and identify  potential cost savings. However, as currently applied, these approaches  do not capture the full costs of treatment. Cost estimation provides in- depth information, but data are limited because detailed cost studies have  been done in only eight partner countries, at a small number of sites.  Moreover, although treatment programs are changing rapidly, key data for  most of the studies are no longer timely, since they were collected in  2006 and 2007. We reported that PEPFAR does not have a plan for  systematically conducting or repeating cost studies in partner countries.  Data from expenditure analyses, while more timely, are limited because  they do not include non-PEPFAR costs. We concluded that without more  timely and comprehensive information on treatment costs, PEFPAR may  be missing opportunities to identify potential savings, which are critical for  expanding HIV treatment programs to those in need.
To improve PEPFAR’s ability to help countries expand their HIV treatment  programs to address unmet need, and do so through the efficient  allocation of resources and effective program planning, we recommended  that State direct PEPFAR to develop a plan for (1) expanding the use of  in-depth cost studies to additional countries and sites, where appropriate,  and (2) broadening expenditure analysis to include non-PEPFAR costs,  as feasible.that PEPFAR is developing guidance on an optimal schedule for  evaluating costs to balance in-depth analysis with more timely data from  expenditure analysis, and that it has collaborated with multilateral  partners in a few countries to plan expenditure analyses that will capture  non-PEPFAR spending.
section_title: More Consistent, Complete, and Timely Information on Treatment Results Could Enhance the Quality of Treatment Programs
paragraphs: OGAC has reported on PEPFAR treatment program results primarily in  terms of (1) numbers of people on treatment directly supported by  PEPFAR, (2) percentages of eligible people receiving treatment, and (3)  percentages of people alive and on treatment 12 months after starting  treatment. However, these indicators do not provide complete information  about PEPFAR results. First, although the number of people on treatment  directly supported by PEPFAR grew from about 1.7 million to 5.1 million  in fiscal years 2008 through 2012, this indicator alone does not provide all  the information needed for assessing PEPFAR’s contributions to partner  countries’ treatment programs. Second, although 10 PEPFAR country  teams reported that percentages of people alive and on treatment after 12  months exceeded 80 percent, data for this indicator are not always  complete and have other limitations.to OGAC officials, OGAC clarified its guidance and conducted data  quality assessments. However, we found that OGAC has not yet  established a common set of indicators to monitor the results of  PEPFAR’s efforts to improve the quality of treatment programs. For  example, in the three countries we visited, we found that PEPFAR  implementing partners were using a wide range of indicators to report on  their quality assurance activities, and that even where indicators were  generally the same, definitions varied.
To improve these data, according  Fully functioning monitoring and evaluation (M&E) systems are critical for  tracking results and ensuring treatment program effectiveness. PEPFAR  country teams assist partner countries in carrying out their M&E  responsibilities by providing staff, training, technical assistance, and other  support. With this assistance, partner countries have made some  progress in expanding and upgrading these M&E systems. Nevertheless,  we found that partner countries’ M&E systems often are unable to  produce complete and timely data, thus limiting the usefulness of these  data for patient, clinic, or program management. Our review concluded  that OGAC has not yet established minimum standards for partner  countries’ M&E systems, particularly relating to data completeness and  timeliness, in order for PEPFAR country teams to assess those systems’  readiness for use in treatment program management and results  reporting.
To ensure the outcomes and quality of treatment programs supported by  PEPFAR, we recommended that State direct OGAC to (1) develop a  method that better accounts for PEPFAR’s contributions to partner- country treatment programs, (2) establish a common set of indicators to  measure the results of treatment program quality improvement efforts,  and (3) establish a set of minimum standards for data generated by  partner countries’ M&E systems. State generally agreed with these  recommendations, and stated that PEPFAR has recently begun an effort  to revise its monitoring, evaluation, and reporting framework and is taking  steps to develop a harmonized PEPFAR strategy on treatment quality as  well as taking steps to improve treatment retention measurement,  evaluation, and performance.
section_title: Establishing Plans to Help Countries Improve Inventory Management and Track Progress Could Help Supply Chains Operate More Efficiently
paragraphs: Evaluations of partner-country supply chains reflect weaknesses in  inventory controls and record keeping, which may increase the risk of  drug shortages, waste, and loss. OGAC has issued guidance for  PEPFAR emphasizing the importance of effective information  management for efficient ARV drug supply chain operations. However, 11  of the 16 supply chain evaluations we reviewed cited weaknesses in  partner countries’ inventory controls; 7 of these 11 evaluations also cited  weaknesses in record keeping, including incomplete or inaccurate data  on the consumption of ARV drugs. These weaknesses can increase the  risks of drug shortages, waste, and loss of inventory. In one country we  reviewed, an evaluation team identified losses valued at about $265,000.  We determined that human resource constraints, including heavy  workload, inadequate training, and insufficient oversight, contribute to  these weaknesses, and that PEPFAR is addressing them through  technical assistance and training. However, OGAC does not specifically  require PEPFAR interagency teams in each country to develop plans to  strengthen inventory controls and record keeping. Nor does OGAC  require country teams to track the progress partner countries are making  in measuring ARV drug consumption, waste, and loss. Thus, we  concluded that OGAC cannot ascertain the extent of partner-country  supply chain weaknesses and take appropriate action to mitigate risks.  For PEPFAR and partner countries to continue expanding treatment  programs to serve up to 23 million eligible people, further improving drug  supply chains is critical, particularly the efficiency of elements managed  by partner countries. These improvements will become increasingly  important as partner countries assume more responsibility for managing  supply chains.
To help ensure that drug supply chains in PEPFAR partner countries  function efficiently and mitigate the risks of shortages and wasted and lost  drugs, we recommended that State direct OGAC to require PEPFAR  country teams to (1) develop and implement plans to help partner  countries improve inventory controls and record keeping and (2) track the  progress partner countries are making in measuring ARV drug  consumption, waste, and loss. State generally agreed with the intent of  both recommendations, and confirmed that inventory controls are not  optimized in all PEPFAR countries. State indicated that it will further  assess these controls and focus technical assistance on improving them  where they are found lacking. State also noted that PEPFAR has begun a  more systematic investment in health supply chain metrics to identify risks  and weaknesses in partner-country supply chains and assess progress in  reducing risks and enhancing performance.
section_title: More Systematic and Rigorous Program Evaluations Could Better Inform PEPFAR Stakeholders about How to Improve Programs
paragraphs: OGAC, CDC, and USAID have evaluated a wide variety of PEPFAR  program activities, demonstrating a clear commitment to evaluation.  However, we found that the findings, conclusions, and recommendations  were not fully supported in many PEPFAR evaluations. Agency officials  provided us with nearly 500 evaluations addressing activities ongoing in  fiscal years 2008 through 2010 in all program areas relating to HIV/AIDS  treatment, prevention, and care. Our assessment of a nonrandom sample  of 7 OGAC-managed evaluations found that they generally adhered to  common evaluation standards, as did most of a nonrandom sample of 15  evaluations managed by CDC and USAID headquarters. Based on this  assessment, we determined that these evaluations generally contained  fully supported findings, conclusions, and recommendations. However,  based on a similar assessment of a randomly selected sample taken from  436 evaluations provided by PEPFAR country and regional teams, we  estimated that 41 percent contained fully supported findings, conclusions,  and recommendations, while 44 percent contained partial support and 15  percent were not supported. In addition, while State, OGAC, CDC, and  USAID have established detailed evaluation policies, as recommended by  the American Evaluation Association (AEA), PEPFAR does not fully  adhere to AEA principles relating to evaluation planning, independence  and qualifications of evaluators, and public dissemination of evaluation  results. For example, OGAC does not require country and regional teams  to include evaluation plans in their annual operational plans, limiting its  ability to ensure that evaluation resources are appropriately targeted. We  therefore concluded that more systematic and rigorous program  evaluations could better inform PEPFAR stakeholders about how to  improve programs.
To enhance PEPFAR evaluations, we recommended that State direct  OGAC to work with CDC and USAID to (1) improve adherence to  common evaluation standards, (2) develop PEPFAR evaluation plans, (3)  provide guidance for assessing and documenting evaluators’  independence and qualifications, and (4) increase online accessibility of  evaluation results.steps it would take to implement them.
section_title: OGAC Could Provide Better Context for Understanding PEPFAR’s Achievements and Challenges
paragraphs: OGAC, USAID, and CDC publicly issued plans and reports on PEPFAR  performance in recent years consistent with the 2008 Leadership Act  requirements and Government Performance and Results Act of 1993  (GPRA) practices; however, we found that two key elements are lacking.  First, although OGAC has internally specified annual performance  targets, its most recent annual reports to Congress did not identify these  targets or compare annual results with them. According to the 2008  Leadership Act, OGAC’s annual reports on PEPFAR program results  must include an assessment of progress toward annual goals and  reasons for any failure to meet these goals. federal agency performance reports to compare program results with  established targets. We found that performance documents published by  USAID, jointly with State, and by CDC, report program targets and results  for two and four PEPFAR indicators, respectively. Second, we found that  OGAC’s most recently published performance plans and reports do not  provide information on efforts to validate and verify reported data, while  USAID’s and CDC’s published performance documents cite such efforts  by OGAC. In addition, none of the plans or reports refer to noted data  reliability weaknesses or efforts to address these weaknesses. GPRA and  prior GAO workpublic performance documents on data verification and other efforts to  address identified weaknesses. Thus, we concluded that OGAC could  provide better context for understanding PEPFAR’s achievements and  challenges by comparing program results with targets and discussing  efforts to ensure the quality of reported information.
Pub. L. No. 110-293, § 301(e). limitations.pending discussions with stakeholders about implementation issues and  consequences, and agreed with the second recommendation.
section_title: Concluding Observations
paragraphs: PEPFAR is at a critical juncture as it transitions from providing direct,  emergency services to primarily providing guidance and advice to help  countries develop independent, sustainable programs. PEPFAR has  taken steps toward greater integration with partner-country health  systems, overall health systems strengthening, and greater partner- country responsibility for addressing HIV/AIDS. If the recommendations  we have made for actions are implemented effectively, we believe these  actions will help ensure that PEPFAR continues to help partner countries  improve and expand treatment to more of the 23 million people in low-  and middle-income countries who are living with HIV/AIDS and in need of  treatment or who are in at-risk groups eligible for treatment.
section_title: Agency Comments
paragraphs: We provided a draft of this report to OGAC, USAID, HHS, and CDC for  review. We received limited technical information, which we incorporated  as appropriate.
We will send copies of this report to the Secretary of State and the U.S.  Global AIDS Coordinator and interested congressional committees. The  report also will be available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-3149 or gootnickd@gao.gov, or contact Marcia Crosse at  (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix I.
section_title: Appendix I: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
paragraphs: David Gootnick, (202) 512-3149 or gootnickd@gao.gov, or Marcia  Crosse, (202) 512-7114 or crossem@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, Jim Michels, Assistant Director,  Kay Halpern, and David Dayton made key contributions to this report. In  addition, Todd M. Anderson, Chad Davenport, David Dornisch, Etana  Finkler, Katherine Forsyth, Brian Hackney, Grace Lui, and Jane Whipple  provided technical assistance and other support.
section_title: Related GAO Products
paragraphs: President’s Emergency Plan for AIDS Relief: Drug Supply Chains Are  Stronger, but More Steps Are Needed to Reduce Risks. GAO-13-483.  Washington, D.C.: April 26, 2013.
President’s Emergency Plan for AIDS Relief: Shift Toward Partner- Country Treatment Programs Will Require Better Information on Results.  GAO-13-460. Washington, D.C.: April 12, 2013.
President’s Emergency Plan for AIDS Relief: Per-Patient Costs Have  Declined Substantially, but Better Cost Data Would Help Efforts to  Expand Treatment. GAO-13-345. Washington, D.C.: March 15, 2013.
Health Care: Ensuring Drug Quality in Global Health Programs.   GAO-12-897R. Washington, D.C.: August 1, 2012.
Defense Infrastructure: The Navy’s Use of Risk Management at Naval  Stations Mayport and Norfolk. GAO-12-710R. Washington, D.C.: July 13,  2012.
President’s Emergency Plan for AIDS Relief: Agencies Can Enhance  Evaluation Quality, Planning, and Dissemination. GAO-12-673.  Washington, D.C.: May 31, 2012.
President’s Emergency Plan for AIDS Relief: Program Planning and  Reporting. GAO-11-785. Washington, D.C.: July 29, 2011.
Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other  Health Assistance in Fiscal Years 2001-2008. GAO-11-64. Washington,  D.C.: October 8, 2010.
President’s Emergency Plan for AIDS Relief: Efforts to Align Programs  with Partner Countries’ HIV/AIDS Strategies and Promote Partner  Country Ownership. GAO-10-836. Washington, D.C.: September 20,  2010.
President’s Emergency Plan for AIDS Relief: Partner Selection and  Oversight Follow Accepted Practices but Would Benefit from Enhanced  Planning and Accountability. GAO-09-666. Washington, D.C.: July 15,  2009.
Global HIV/AIDS: A More Country-Based Approach Could Improve  Allocation of PEPFAR Funding. GAO-08-480. Washington, D.C.: April 2,  2008.
Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved  Its Documentation of Funding Decisions but Needs Standardized  Oversight Expectations and Assessments. GAO-07-627. Washington,  D.C.: May 7, 2007.
Global Health: Spending Requirement Presents Challenges for Allocating  Prevention Funding under the President’s Emergency Plan for AIDS  Relief. GAO-06-395. Washington, D.C.: April 4, 2006.
Global Health: The Global Fund to Fight AIDS, TB and Malaria Is  Responding to Challenges but Needs Better Information and  Documentation for Performance-Based Funding. GAO-05-639.  Washington, D.C.: June 10, 2005.
Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications  Provided under U.S. Emergency Plan Is Limited. GAO-05-133.  Washington, D.C.: January 11, 2005.
Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges  to Expanding Treatment, but Others Remain. GAO-04-784. Washington,  D.C.: June 12, 2004.
Global Health: Global Fund to Fight AIDS, TB and Malaria Has Advanced  in Key Areas, but Difficult Challenges Remain. GAO-03-601. Washington,  D.C.: May 7, 2003.