President's Emergency Plan for AIDS Relief: Shift toward Partner- Country Treatment Programs Will Require Better Information on Results
Published: 2013-04-12T00:00:00

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 more than 30 countries. In reauthorizing the program in 2008, Congress directed OGAC to continue to expand the number of people receiving care and treatment through PEPFAR while also making it a major policy goal to help partner countries develop independent, sustainable HIV programs. As a result, PEPFAR began shifting efforts from directly providing treatment services toward support for treatment programs managed by partner countries. GAO was asked to review PEPFAR treatment programs. GAO examined (1) PEPFAR treatment program results and how OGAC measures them and (2) PEPFAR assistance to improve partner countries' M&E systems. GAO reviewed PEPFAR plans, performance reports, and guidance and interviewed officials from OGAC, the Centers for Disease Control and Prevention (CDC), and the U.S. Agency for International Development (USAID). GAO also synthesized findings of treatment program studies and conducted fieldwork in three countries.
section_title: What GAO Found
paragraphs: The Department of State's (State) Office of the U.S. Global AIDS Coordinator (OGAC) has reported on President's Emergency Plan for AIDS Relief (PEPFAR) treatment program results primarily in terms of (1) numbers of people on treatment directly supported by PEPFAR, (2) percentages of eligible people receiving treatment, and (3) percentages of people alive and on treatment 12 months after starting treatment. However, these indicators do not reflect some key PEPFAR results. First, although the number of people on treatment directly supported by PEPFAR grew from about 1.7 million to 5.1 million in fiscal years 2008 through 2012, this indicator alone does not provide complete information needed for assessing PEPFAR's contributions to partner countries' treatment programs. Second, although 10 PEPFAR country teams reported that percentages of people alive and on treatment after 12 months exceeded 80 percent, data for this indicator are not always complete and have other limitations. To improve these data, according to OGAC officials, OGAC clarified its guidance and conducted data quality assessments. However, OGAC has not yet established a common set of indicators to monitor the results of PEPFAR's efforts to improve the quality of treatment programs.
As PEPFAR partner countries assume greater responsibility for managing their treatment programs, fully functioning monitoring and evaluation (M&E) systems are critical for tracking results and ensuring treatment program effectiveness. PEPFAR country teams assist partner countries in carrying out their M&E responsibilities by providing staff, training, technical assistance, and other support. With this assistance, partner countries have made some progress in expanding and upgrading these M&E systems. Nevertheless, partner countries' M&E systems often are unable to produce complete and timely data, thus limiting the usefulness of these data for patient, clinic, or program management. OGAC has not yet established minimum standards for partner countries' M&E systems, particularly relating to data completeness and timeliness, in order for PEPFAR country teams to assess those systems' readiness for use in treatment program management and results reporting.
section_title: What GAO Recommends
paragraphs: The Secretary of State should direct OGAC to (1) develop a method that better accounts for PEPFAR's contributions to partner-country treatment programs, (2) establish a common set of indicators to measure the results of treatment program quality improvement efforts, and (3) establish a set of minimum standards for data generated by partner countries' M&E systems. Commenting jointly with CDC and USAID, State generally agreed with the report's recommendations.

section_title: Letter
paragraphs: As the President’s Emergency Plan for AIDS Relief (PEPFAR) nears the  end of its second 5-year authorization, it has made significant  contributions to international treatment targets for HIV/AIDS. The  Department of State’s (State) Office of the U.S. Global AIDS Coordinator  (OGAC) reported that, as of September 30, 2012, the U.S. government,  through PEPFAR’s multibillion dollar investments in partner countries’  treatment and care programs, had directly supported treatment for more  than 5.1 million people—more than half of all people on treatment for  HIV/AIDS in low- and middle-income countries. In part because of these  investments, more than half of eligible people in low- and middle-income  countries (54 percent) receive treatment, and the estimated number of  AIDS-related deaths worldwide (1.7 million) declined in 2011, according  to data reported by the United Nations Joint Programme on HIV/AIDS  (UNAIDS).
Nevertheless, important challenges remain as PEPFAR continues to help  build partner countries’ capacity to manage their treatment programs.  First, the estimated number of new HIV infections worldwide each year  (2.5 million in 2011) continues to exceed the estimated increase in the  number of people on treatment (about 1.4 million from 2010 to 2011), and  about 6.8 million people eligible for treatment have not yet been treated.  In addition, in passing the Tom Lantos and Henry J. Hyde United States  Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria  Reauthorization Act of 2008 (2008 Leadership Act), Congress directed  OGAC to continue to expand the number of people receiving PEPFAR  HIV care and treatment services while also making it a major policy goal  to build partner-country capacity to deliver services and promote a  transition toward greater sustainability of country-owned HIV/AIDS  programs. In December 2011, the President announced an increase in  PEPFAR’s target for the number of people receiving treatment directly  supported by PEPFAR—from 4 million to 6 million by the end of fiscal  year 2013.
OGAC sets overall PEPFAR policy and strategies. OGAC also  coordinates PEPFAR programs and activities, allocating funds to  PEPFAR implementing agencies, particularly the Centers for Disease  Control and Prevention (CDC) of the Department of Health and Human  Services (HHS) and the U.S. Agency for International Development  (USAID). OGAC is leading PEPFAR’s transition from an early focus on  directly providing treatment services as part of an emergency response,  to building partner countries’ capacity to manage treatment programs.  During this transition, ensuring HIV care and treatment program quality  remains critical to achieving patient and public health outcomes, even as  annual allocations to PEPFAR remain unchanged or decline.
See GAO, President’s Emergency Plan for AIDS Relief: Per-Patient Costs Have Declined  Substantially, but Better Cost Data Would Help Efforts to Expand Treatment, GAO-13-345  (Washington, D.C.: March 15, 2013). strengths and weaknesses of partner-country M&E systems—drawn from  studies of treatment programs in PEPFAR partner countries.
To address our objectives, we reviewed PEPFAR guidance issued by  OGAC regarding PEPFAR indicators, definitions, and planning and  reporting requirements, and we reviewed prior GAO reports on PEPFAR.  We examined PEPFAR partnership frameworks and PEPFAR’s most  recent operational plans and performance reports as well as data  provided by OGAC. We determined that these data were sufficiently  reliable for the purposes of our reporting. We interviewed OGAC, CDC,  and USAID officials in Atlanta, Georgia, and Washington, D.C., and  conducted field work in South Africa, Uganda, and Kenya. (See app. I for  further details of our scope and methodology.)
We conducted this performance audit from May 2012 to April 2013 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: OGAC is responsible for establishing overall PEPFAR policy and program  strategies and allocating funds from the Global Health and Child Survival account to PEPFAR implementing agencies, primarily CDC and USAID.These agencies execute PEPFAR program activities through agency  headquarters offices and in-country interagency teams (PEPFAR country  teams) and their implementing partners in the 33 countries and three  regions with PEPFAR-funded programs as of fiscal year 2012. OGAC  coordinates these activities through its approval of operational plans,  which document work plans, budgets, and the anticipated results of  HIV/AIDS-related programs. OGAC also provides annual guidance to  PEPFAR country teams on how to develop and submit operational plans.  For fiscal years 2009 through 2012, OGAC approved country operational  plan budgets totaling over $16 billion. Country operational plan activities  fit broadly in three areas: prevention, treatment, and care. Other program  budget areas are laboratory infrastructure, strategic information, and  health systems strengthening.
To promote a more sustainable approach to combating HIV/AIDS,  characterized by PEPFAR countries’ strengthened capacity, ownership,  and leadership, the 2008 Leadership Act authorized the U.S. government  to establish partnership frameworks with partner countries. These frameworks are 5-year joint strategic agreements for cooperation  between the U.S. government and partner governments to combat  HIV/AIDS in the partner country through technical assistance and support  for service delivery, policy reform, and coordinated funding  commitments. As of February 2013, the U.S. government had signed 22  PEPFAR partnership frameworks. According to OGAC guidance, a key  expectation of the frameworks is that partner-country governments will  become better prepared to assume primary responsibility for their  responses to HIV/AIDS. Moreover, PEPFAR’s 2012 “blueprint” defines  country ownership as the end state in which partner countries lead,  manage, and coordinate the efforts needed to ensure that the AIDS  response is effective, efficient, and durable.
This is typically measured by CD4 (cluster of differentiation antigen 4) count in a sample  of blood. CD4 cells are a type of white blood cell that fights infection. Along with other  tests, the CD4 count helps determine the strength of the immune system, indicates the  stage of the HIV disease, guides treatment, and predicts the disease’s progress. threshold in its laboratory criteria and by recommending treatment for all  people coinfected with HIV and tuberculosis, thereby expanding the  number of people eligible for treatment. Based on WHO guidelines, each  country is expected to establish country-specific guidelines on when to  initiate treatment for these groups. UNAIDS estimated at the end of 2011  that, on the basis of WHO’s 2010 guidelines, 15 million people in low- and  middle-income countries needed treatment; of these, an estimated 8  million people are on treatment. People who are HIV positive but not yet  eligible for treatment generally may seek access to care and support  services as well as regular checkups and laboratory monitoring. People  eligible for treatment should receive antiretroviral (ARV) drugs as well as  checkups and monitoring to assess the effectiveness of treatment.People on treatment also receive various care and support services such  as treatment of opportunistic infections including tuberculosis coinfection,  nutritional support, and programs to promote adherence to treatment and  remaining on treatment (patient retention). People on treatment are  expected to take ARV drugs on a continuing, lifelong basis. . Prior to 2010, WHO’s guidelines recommended treatment for all people with  CD4 counts of less than 200 cells/mm. reporting on PEPFAR results. According to the guidance, these  indicators are intended to demonstrate progress in the fight against  HIV/AIDS while also promoting responsible program management. In  addition, among other things, the guidance establishes a distinction  between national results and PEPFAR direct results. The guidance  defines national results as achievements of all contributors to a partner  country’s HIV/AIDS program and defines PEPFAR direct results as  achievements of the PEPFAR program through its funded activities. (See  app. II for a summary of OGAC criteria for assessing PEPFAR direct  support.) With regard to treatment programs, the guidance instructs  PEPFAR country teams providing direct support for treatment services  to report to OGAC using the PEPFAR direct indicators. In addition, the  guidance directed these country teams, as well as PEPFAR country  teams providing technical assistance and other support to build partner- country capacity for managing treatment programs, to report on one  national indicator. Table 1 summarizes these indicators.
section_title: Data Indicate Progress in Achieving Treatment Program Results, but Some Indicators Have Limitations
paragraphs: From fiscal year 2010 through 2012, OGAC reported PEPFAR results in  terms of three primary indicators: (1) the number of people currently on  treatment directly supported by PEPFAR (PEPFAR direct number of  people on treatment), (2) the percentages of eligible people receiving  treatment in partner countries (national treatment coverage rates), and (3)  the percentage of adults and children known to be alive and on treatment  12 months after starting treatment (PEPFAR direct treatment retention  rates). However, two of these indicators have limitations that could affect  their usefulness. Regarding the first indicator, although the number of  people on treatment directly supported by PEPFAR has increased  significantly, this indicator alone does not provide complete information  needed for assessing PEPFAR’s contributions to partner countries’  treatment programs. Regarding the third indicator, 10 PEPFAR country  teams reported percentages of adults and children known to be alive and  on treatment 12 months after starting treatment that exceeded 80  percent. However, the treatment retention data are not always complete  and have other limitations, which OGAC acknowledged and is taking  steps to address. In addition to these limitations, OGAC lacks a common  set of indicators for monitoring quality assurance efforts. Although OGAC  indicated in 2010 that it would establish a common set of indicators to  monitor the results of PEPFAR’s efforts to improve the quality of  treatment programs, it has not yet done so.
subsections: section_title: PEPFAR Exceeded Its Fiscal Year 2012 Direct Treatment Target, but This Indicator Does Not Fully Reflect PEPFAR Contributions to Partner- Country Treatment Programs
paragraphs: Responding to treatment-related requirements in the 2008 Leadership  Act, OGAC reports on the number of people currently on treatment  directly supported by PEPFAR as a key indicator of program results.  This number is calculated by determining the number of people who ever  started treatment at facilities where PEPFAR directly supports treatment  services, minus patients who died, stopped treatment, transferred out, or  have unknown treatment outcomes. (See app. II for a summary of  OGAC guidance on determining whether people can be counted as  receiving direct services through PEPFAR.) PEPFAR met or exceeded  annual targets for this indicator in fiscal years 2004 through 2012.  Currently, this indicator is used to track treatment program expansion and  to assess progress toward PEPFAR’s target of providing direct support  for treatment for 6 million people by the end of fiscal year 2013. For  fiscal year 2012, PEPFAR’s target for this indicator was 5 million people.  According to data provided by OGAC, the number of people currently on  treatment directly supported by PEPFAR has steadily increased from  about 67,000 people in 11 countries in fiscal year 2004 to more than 5.1  million in 23 countries in fiscal year 2012. (See table 2.)
Furthermore, the number of people on treatment directly supported by  PEPFAR was about half of the total number of people on treatment in all  low- and middle-income countries, which UNAIDS estimated at 8 million  in 2011 (see fig. 1).
As PEPFAR has begun to shift resources toward providing technical  assistance and other support to help partner countries build their capacity  to manage treatment programs, PEPFAR’s direct treatment indicator has  increasingly fallen short of reflecting results of PEPFAR’s contributions to  partner countries’ treatment programs. Specifically, this indicator does not  reflect the expansion of partner countries’ treatment programs that  PEPFAR technical assistance and other support for building treatment  program management capacity have made possible. These efforts  include, among others, activities such as implementing revised treatment  guidelines, assisting partner-country district and national health officials  with treatment facility oversight, and training and mentoring treatment  facility staff. In several PEPFAR partner countries, for example, PEPFAR  implementing partners providing direct treatment services have begun  transferring stable patients to other treatment providers, including an  often expanding number of local public and private health clinics, many of  which receive PEPFAR-funded technical assistance and other support. In  part because of this PEPFAR assistance, these providers also have  begun increasing the number of people they enroll in treatment. In such  cases, the PEPFAR direct treatment indicator may not account for these  people. In the past, PEPFAR’s direct results often were equivalent to the  national number of people receiving services, including treatment,  according to PEPFAR’s 2010 Next Generation Indicators Reference  Guide. However, as PEPFAR increases its efforts to build partner-country  capacity to manage treatment programs through technical assistance and  other support, PEPFAR’s direct treatment indicator alone does not  provide complete information for assessing PEPFAR’s contributions to  partner countries’ treatment programs.
PEPFAR’s 2010 Next Generation Indicators Reference Guide noted that  OGAC was working on a method for deriving PEPFAR direct results from  partner-country national-level indicators but had not yet devised one.  The guidance stated that the new method would take into account the  percentage of PEPFAR funding that contributes to partner-country  programs. In addition, OGAC and PEPFAR country teams have  considered other factors to determine PEPFAR’s contribution to partner- country treatment programs. For example, in their fiscal year 2011 annual  reports to OGAC, seven PEPFAR country teams reported the proportion  of all treatment facilities receiving PEPFAR support or the percentage of  all patients on treatment directly supported by PEPFAR. Some country  teams noted that neither method fully accounted for PEPFAR’s  contributions in these countries. As of February 2013, according to a  senior OGAC official, OGAC had drafted a method for representing  PEPFAR contributions based on proportional financial support to partner- country program results but had not finalized the method or revised its  guidance to PEPFAR country teams.
section_title: PEPFAR Has Helped Increase Partner Countries’ National Treatment Coverage Rates
paragraphs: 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, 8 of the 23 countries  where PEPFAR directly supported treatment services in 2011 achieved  estimated treatment coverage rates of 80 percent or more (see table 3).Although the remaining 15 countries fell short of this target, almost all of  these countries have increased their estimated treatment coverage rates  since 2009, according to our analysis of UNAIDS data.
Since fiscal year 2010, OGAC has required PEPFAR country teams  providing direct support for treatment services to track treatment retention  rates, an indicator defined as the percentage of adults and children  known to be alive and on treatment 12 months after starting treatment. In  addition to being an essential indicator of treatment program outcomes— a higher retention rate indicates that more people on treatment are  surviving—facilities’ retention rates are used by OGAC and PEPFAR  country teams as a proxy indicator of treatment program quality. Of the 23  PEPFAR country teams directly providing treatment services, 20 provided  data on this indicator in their fiscal year 2012 reports to OGAC. Ten of the  20 teams reported retention rates at or above 80 percent for facilities  where PEPFAR implementing partners support direct treatment services.  (See table 4.)
However, PEPFAR patient retention data have several key limitations.
The data are not always complete. PEPFAR’s reported retention rates  reflect only the rates at facilities where PEPFAR directly supported  treatment services and that were able to properly collect and report  retention data. In addition, in their fiscal year 2012 reports to OGAC,  three PEPFAR country teams reported that data for this indicator were  not available. Several country teams noted problems in obtaining data  from partner-country systems or from all sites where PEPFAR directly  supports treatment services. Several country teams also reported  concerns about data quality, including limited understanding of how to  collect these data.
Methods and definitions vary. For example, PEPFAR country teams  accounted for patients transferring to or from treatment facilities  differently. In addition, country teams used different definitions to  count numbers of patients lost to follow-up (i.e., those with unknown  outcomes, including possible death, treatment cessation, or self- transfer to another treatment facility). Under the current WHO  definition, a patient may be considered lost to follow-up 90 days after  the last scheduled appointment, but the definition may be adjusted  depending on the stage of a patient’s treatment.
Data on treatment retention are rarely available for key populations,  including children and adolescents, injecting drug users, men who  have sex with men, and sex workers. These populations are at higher  risk for HIV infection and may face specific challenges that make it  more difficult to retain them in treatment programs.
Few data on long-term retention (after 24 months from the start of  treatment) are available. Although OGAC guidance encourages  PEPFAR country teams to use data for cohorts of patients to track  retention and survival at 24, 36, and 48 months, PEPFAR does not  have a retention indicator that extends beyond 12 months.
OGAC officials stated that OGAC has taken several steps to improve the  fiscal year 2012 PEPFAR treatment retention data. First, OGAC clarified  guidance to PEPFAR country teams regarding how to calculate and  report on this indicator. Second, PEPFAR implementing agencies  conducted data quality assessments in three PEPFAR countries. As a  result, according to OGAC officials, three more PEPFAR country teams  were able to report on the treatment retention indicator in fiscal year 2012  than in fiscal year 2011. Furthermore, OGAC officials stated that data  completeness is a priority for the current fiscal year 2013 and that they  will help PEPFAR country teams with reporting retention data.
In addition to routinely reported information on treatment program results,  various studies of treatment programs, although they may not represent  national treatment program conditions and may be limited by incomplete  data, provide information that can be useful for improving the results of  treatment programs. Appendix III contains examples of information  provided by studies we identified.
section_title: PEPFAR Supports Efforts to Improve Treatment Program Quality, but OGAC Has Not Established Indicators to Assess Results
paragraphs: PEPFAR country teams engage in a number of activities, often  characterized as technical assistance or support, whose aim is to assure  the quality of treatment programs. Seventeen of the 22 countries with  PEPFAR partnership frameworks identified efforts to improve treatment  program quality as a key goal shared by partner countries and PEPFAR.  However, OGAC has not established a common set of indicators to  assess results of these activities. We identified several examples of  quality assurance activities, such as developing and implementing partner-country quality improvement  strategies, including roles and responsibilities for health facility  supervision; establishing treatment site-level performance improvement plans,  including quality improvement council meetings to identify solutions to  problems affecting service quality; and  training health facility managers and staff to track and use facility-level  performance data.
OGAC’s 2010 Next Generation Indicators Reference Guide sought to  emphasize program quality indicators to help strengthen partner  countries’ HIV/AIDS programs. To this end, the guidance added patient  retention rate to the list of essential, reported treatment program  indicators. The same guidance also recommended tracking data for  several indicators of treatment program quality—for example, the number  of patients with a documented CD4 or viral load test, the number of  patients who have attended the recommended number of clinical visits,  and the percentage of health facilities providing treatment using CD4  monitoring in line with partner-country guidelines or policies.
In the three countries we visited, we found that PEPFAR implementing  partners were using a wide range of indicators to report on their quality  assurance activities. Examples of such indicators include percentages of  (1) HIV-positive patients assessed for treatment eligibility, (2) patients on  treatment who adhere to the dosing instructions and other requirements  for taking ARV medicines, and (3) patients with good clinical outcomes.  However, even where indicators in the three countries were generally the  same, definitions varied slightly. For example, in reporting on the indicator  of appointments kept, three PEPFAR implementing partners—all  providing quality assurance assistance to treatment facilities in the same  country—used two different definitions. One implementing partner  reported on the percentage of HIV-positive patients who kept their  appointments in the previous month or quarter, while the other two  implementing partners reported on the percentage of HIV-positive  patients who missed their appointments.
OGAC’s 2010 Next Generation Indicators Reference Guide stated that  additional guidance on quality assurance indicators for PEPFAR  implementing agencies would be forthcoming. However, as of February  2013, OGAC has not issued this additional guidance. The lack of  PEPFAR-wide guidance on quality assurance indicators and definitions  inhibits development of standardized measurement tools used by  PEPFAR country teams to monitor treatment facilities supported by  PEPFAR and ultimately track the results of PEPFAR’s quality assurance  efforts, including technical assistance and other support.
section_title: PEPFAR Supports Countries’ M&E Systems, but Weaknesses Limit the Timeliness and Completeness of Treatment Results Data
paragraphs: To track the results of partner-country treatment programs and to help  ensure that they are effective, PEPFAR supports countries’ monitoring  and evaluation (M&E) systems. While some progress has been made in  expanding and upgrading them, these systems often are unable to  produce timely and complete treatment data, limiting their usefulness for  managing programs and reporting program results. PEPFAR country  teams fulfill many M&E functions at facilities where PEPFAR supports  direct treatment services, and they assist partner countries in carrying out  their M&E responsibilities by providing staff, training, and technical  assistance and other support. Nevertheless, partner countries’ M&E  systems continue to face a number of weaknesses. Consequently,  PEPFAR country teams primarily use data drawn from PEPFAR-specific  systems to report on PEPFAR treatment program results. OGAC has not  yet issued guidance needed to support PEPFAR’s continued progress in  transitioning to using partner-country M&E systems for program  management and results reporting.
subsections: section_title: PEPFAR Provides Technical Assistance, Training, and Staff to Strengthen Partner Countries’ M&E Systems
paragraphs: Among other activities, OGAC technical guidance to PEPFAR country  teams calls for the development of partner countries’ M&E systems,  among other activities. Fully functioning M&E systems are essential for  effective patient monitoring and patient management and also generate  data that PEPFAR country teams and partner countries need to track  treatment program results. All countries and regions with PEPFAR  partnership frameworks identified strengthening M&E systems as a key  goal shared by partner countries and PEPFAR. To support this goal,  according to fiscal year 2012 PEPFAR operational plans, PEPFAR  country teams provide, among other things, technical assistance, training,  and staff to treatment facilities, district health offices, and national  ministries of health to collect, aggregate, and report treatment program  information through partner countries’ M&E systems (see sidebar). This  support included recruiting, mentoring, and training health facility staff and  district health officials responsible for collecting, analyzing, aggregating,  and reporting data through the country’s M&E system. PEPFAR country  teams were also assisting partner countries with conducting surveys and  surveillance, such as those needed to estimate the number of people with  advanced HIV infection. In addition, according to OGAC officials, as of  February 2013, 15 PEPFAR partner countries have expressed interest in  a single, open-source data system, and several of these countries have  started implementation. This health information software tool supports  collecting, analyzing, and reporting national health data, including data on  treatment programs. According to these officials, PEPFAR will support  partner-country expansion of the software tool to include PEPFAR and  Global Fund reporting in two additional PEPFAR partner countries.
section_title: Weaknesses Remain in Partner Countries’ M&E Systems
paragraphs: PEPFAR country teams have documented weaknesses in a number of  partner countries’ M&E systems, which are at various stages of  implementation. Our review of PEPFAR country teams’ fiscal year 2011  annual reports to OGAC and fiscal year 2012 operational plans identified  two key challenges for partner countries’ M&E systems.
Partner countries’ M&E systems often are unable to produce complete  and timely data, thus limiting their usefulness for patient, clinic, or  program management. In their 2011 annual reports to OGAC, 12  PEPFAR country teams cited timeliness of partner-country treatment  program data as a challenge, often because partner-country reporting  time frames differed from the U.S. government fiscal year. In addition,  three PEPFAR country teams noted that data provided by partner  countries’ M&E systems were incomplete—not all provinces or treatment  facilities reported data into the system. In addition, one PEPFAR country  was not able to collect data on the number of patients currently receiving  treatment, because the partner country provided data only on the  cumulative number of patients who had ever started treatment; the  country team noted that this had the likely effect of inflating the partner  country’s treatment coverage rate.
Furthermore, partner-country health officials, often lacking technical  capacity, do not always use available data for decision making. Our  review of the PEPFAR country teams’ operational plans found that 23  teams cited the need to improve data use at treatment facilities or other  levels of the health care system. For example, one country team reported  that partner-country health officials tended to focus on data collection for  reporting rather than for policy, planning, and program decision making.  Another country team reported that lack of data reporting by treatment  facilities limited analysis of treatment patients across facilities, and a third  country team noted that human resource limitations and weak research  capacity impeded use of M&E data. In addition, studies of PEPFAR  partner countries’ M&E systems that we identified provided additional  information; appendix III provides a summary of this information.
section_title: PEPFAR Country Teams Aim to Integrate M&E Systems, but OGAC Has Not Established Minimum Standards to Guide This Effort
paragraphs: Because of the limitations associated with the data from national M&E  systems, PEPFAR country teams primarily use data drawn from systems  created specifically for reporting PEPFAR treatment program results.  OGAC’s 2010 Next Generation Indicators Reference Guide states that  PEPFAR country teams may need to rely on these systems in the short  term but should continue working to integrate these systems into partner  countries’ M&E systems. Our review of PEPFAR country teams’  operational plans found that PEPFAR country teams maintained PEPFAR  program performance management systems to routinely collect, compile,  and analyze patient monitoring and management data from the health  facilities where PEPFAR directly supports treatment services. In addition,  PEPFAR country teams use these data to generate their semiannual and  annual reports to OGAC. PEPFAR country teams supplement information  from their own systems with data from partner countries’ M&E systems,  including numbers of patients on treatment and rates of treatment  coverage.
OGAC’s 2010 Next Generation Indicators Reference Guide recommends  several indicators for tracking partner-country outcomes related to  strengthening health systems, such as the existence of M&E plans and  the percentage of health facilities with record-keeping systems for   In addition, OGAC’s technical guidance  monitoring HIV/AIDS programs.to country teams for developing partner countries’ M&E systems identifies  a number of key efforts, such as developing M&E leadership and  organizations, improving the policy environment, and ensuring the  advancement and sustainability of technical capacity in PEPFAR partner  countries. The technical guidance states that these efforts should support  national capacity building. However, OGAC has not issued guidance  identifying minimum standards that data generated by partner countries’  M&E systems should meet—such as standards related to completeness  and timeliness—in order for PEPFAR country teams to assess, together  with partner countries and other donors, whether the systems are ready  for use in PEPFAR program management and results reporting. The lack  of such standards leaves uncertain the point at which partner-country  M&E systems are mature enough for PEPFAR to rely on them. This  uncertainty is likely to delay achievement of PEPFAR’s goal of using  partner-country M&E systems to generate data for PEPFAR treatment  program management and reporting.
section_title: Conclusions
paragraphs: Ensuring that PEPFAR treatment programs continue to improve and to  operate as effectively as possible requires careful, complex monitoring  and evaluation (M&E), not only of program results but also of quality  assurance efforts. Available data on PEPFAR program results show  some progress. In particular, PEPFAR and UNAIDS data indicate a  steady increase in the number of people on treatment, improved  treatment coverage rates, and high rates of patient retention at many  facilities. However, PEPFAR’s contributions to expansion of partner  countries’ treatment programs are not fully reflected in its results data  because OGAC’s current method for deriving PEPFAR’s direct treatment  indicator does not fully account for PEPFAR’s efforts to improve partner  countries’ capacity to manage their treatment programs. This limits the  usefulness of PEPFAR’s direct treatment indicator for assessing progress  toward expanding partner-country treatment programs. Furthermore,  OGAC has not yet established a common set of indicators to measure the  results of PEPFAR technical assistance and other support intended to  improve the quality of treatment programs. Lacking a standard set of  quality assurance indicators, PEPFAR is limited in its ability to track the  results of PEPFAR’s quality assurance efforts.
As PEPFAR continues to shift responsibility for managing treatment  programs to partner countries, those countries will need robust M&E  systems to generate the data that are indispensable for ensuring effective  treatment and efficient program management. PEPFAR has dedicated  resources specifically for these efforts, but problems with untimely and  incomplete data collection, as well as with data use, persist. As a result,  PEPFAR has to rely on the M&E systems its implementing partners have  developed rather than on country-managed systems for collecting and  reporting results data. In its guidance, OGAC has not yet established  minimum standards that data generated by partner countries’ M&E  systems should meet in order for PEPFAR country teams to assess these  systems. Without such standards, uncertainty remains as to when  partner-country M&E systems will be ready to be integrated with PEPFAR  systems, thus delaying the achievement of PEPFAR’s goal of using  partner-country M&E system data for PEPFAR treatment program  management and reporting.
section_title: Recommendations for Executive Action
paragraphs: To ensure the outcomes and quality of treatment programs supported by  PEPFAR, we recommend that the Secretary of State direct the U.S.  Global AIDS Coordinator to take the following three actions in  collaboration with PEPFAR implementing agencies: develop a method that better accounts for PEPFAR’s contributions to establish a common set of indicators to measure the results of  treatment program quality improvement efforts; and establish a set of minimum standards for data generated by partner  countries’ M&E systems, to enable PEPFAR country teams to assess  those systems’ readiness for use in treatment program management  and reporting.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to State, USAID, and CDC.   Responding jointly with CDC and USAID, State provided written  comments (see app. IV for a copy of these comments). State and CDC  also provided technical comments and supplementary information relating  to our findings and recommendations. In response to the technical  comments, we incorporated changes to the draft report, as appropriate.  After reviewing the supplementary information, we clarified our findings  and recommendations relating to PEPFAR’s direct treatment indicator  and its support for partner countries’ M&E systems.
In its written comments, State generally agreed with our three  recommendations. First, State affirmed that it supports our  recommendation to develop a method for fully accounting for PEPFAR’s  contributions to partner-country treatment programs. Observing that  PEPFAR’s direct treatment indicator was intended to capture only  essential components of direct treatment services, State noted that  PEPFAR has recently begun an effort to revise its monitoring, evaluation,  and reporting framework, including an expansion of indicators that would  allow for implementing partners to report on their efforts to help partner  countries build capacity and develop sustainable treatment programs.  Second, State also agreed with the finding leading to our  recommendation regarding the development of indicators to measure the  results of treatment program quality improvement efforts. State cited the  need for a harmonized PEPFAR strategy on treatment quality, including  key indicators, and noted steps it is taking to develop such a strategy. In  addition, stressing that treatment retention indicators are relatively new  and difficult to operationalize, State detailed steps PEPFAR is taking to  help improve treatment retention measurement, evaluation, and  performance. Third, State noted that PEPFAR supports the strengthening  of partner country reporting systems and works with partner countries to  help them develop such systems, both to support national programs as  well as to provide data for PEPFAR and other donors. As part of these  efforts, PEPFAR also works with WHO and the Global Fund on system  standardization and standards for data exchange. State specifically  identified an indicator developed by WHO for documenting data  completeness and timeliness and stated that this indicator can be used to  monitor efforts to develop these reporting systems. We agree that such  an indicator could be useful for PEPFAR country teams trying to  determine when partner-country M&E systems are ready to be integrated  with PEPFAR systems. However, we note that PEPFAR guidance does  not instruct country teams to use the WHO indicator or any other indicator  for this purpose.  We believe that specifying one or more indicators for  PEPFAR country teams to use is important to ensure a consistent  approach to systems integration across the program. Doing this would  emphasize for country partners the importance of harmonizing M&E  systems for mutually beneficial purposes.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of State and  the U.S. Global AIDS Coordinator. The report also will be available at no  charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-3149 or gootnickd@gao.gov or contact Marcia Crosse at  (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix V.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: In this report, we examine the President’s Emergency Plan for AIDS  Relief’s (PEPFAR) (1) treatment program results and how the Department  of State’s (State) Office of the U.S. Global AIDS Coordinator (OGAC)  measures them and (2) assistance to improve partner countries’  monitoring and evaluation (M&E) systems. To address both of these  objectives, we collected and analyzed information from the following  sources: interviews and fieldwork; guidance documents and past GAO  work; PEPFAR partnership frameworks, operational plans, and  performance reports; and studies of treatment programs.
We interviewed officials from OGAC, the Department of Health and  Human Services’ (HHS) Centers for Disease Control and Prevention  (CDC), and the U.S. Agency for International Development (USAID) in  Washington, D.C., and Atlanta, Georgia. We also conducted fieldwork in  three PEPFAR partner countries—Kenya, South Africa, and Uganda—in  June 2012 to obtain information on PEPFAR efforts to support partner- country treatment program outcomes and quality as well as challenges  faced by PEPFAR implementing agencies and stakeholders. We selected  these countries based on program size, availability of cost data, travel  logistics, and other factors. We interviewed U.S. agency officials,  representatives of key implementing partners, and partner government  health officials and conducted visits to selected treatment facilities in  these countries.
We reviewed guidance provided to PEPFAR country teams by OGAC in  collaboration with CDC, USAID, and other PEPFAR implementing  agencies and previous GAO work to identify criteria related to  requirements for collecting, validating, and reporting treatment program   These guidance documents also provided  results and their measures.criteria for examining PEPFAR assistance to improve partner countries’  M&E systems. Guidance documents included OGAC’s 2010 Next  Generation Indicators Reference Guide, issued in August 2009; fiscal  years 2011 and 2012 operational plan guidance and associated technical  considerations; and annual and semiannual performance reporting  guidance. We also consulted relevant guidance and reports issued by  international organizations such as the United Nations Joint Programme  on HIV/AIDS (UNAIDS) and the World Health Organization (WHO).  These included Global Report: UNAIDS Report on the Global AIDS  Epidemic, 2012 and Organizing Framework for a Functional National HIV  Monitoring and Evaluation System as well as WHO’s 2010 Antiretroviral  Therapy for HIV Infection in Adults and Adolescents: Recommendation  for a Public Health Approach and 2006 Patient Monitoring Guidelines for  HIV Care and Antiretroviral Therapy. We also reviewed WHO’s 2011  Retention in HIV Programmes: Defining the Challenges and Identifying  Solutions.
We examined PEPFAR operational plans, performance reports, and  partnership frameworks. First, to identify key PEPFAR treatment program  goals—including those related to treatment program supervision, M&E  systems, and quality assurance—we reviewed partnership framework  agreements between the United States and 22 PEPFAR partner countries   Next, to identify ongoing and planned PEPFAR activities, as  and regions.
As of February 2013, the United States had signed partnership frameworks with the  following 22 partner countries and regions: Angola, Botswana, the Caribbean region, the  Central American region, the Democratic Republic of the Congo, the Dominican Republic,  Ethiopia, Ghana, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda,  South Africa, Swaziland, Tanzania, Ukraine, Vietnam, and Zambia. narrative descriptions to OGAC regarding (1) the number of adults and  children with advanced HIV infection who are currently receiving  treatment directly supported by PEPFAR (PEPFAR direct number of  people currently on treatment); (2) the percentage of adults and children  with advanced HIV infection who are receiving treatment in partner  countries’ treatment programs (national coverage rates); and (3) the  percentage of adults and children known to be alive and on treatment 12  months after starting treatment directly supported by PEPFAR (PEPFAR  direct treatment retention rates). We reviewed and summarized the 23  country teams’ narrative descriptions accompanying each of these three  PEPFAR indicators for information related to treatment program results  and assistance to improve PEPFAR partner countries’ M&E systems.
In the case of the number of people on treatment directly supported by  PEPFAR, to show changes over time, we analyzed aggregate data for  fiscal years 2004 through 2012 provided by OGAC, which it derived from  PEPFAR country teams’ semi-annual and annual reports. We previously  have reviewed OGAC guidance and procedures for collecting, analyzing,   In addition, to identify factors considered by  and assessing these data.PEPFAR country teams when reporting on PEPFAR treatment program  results, we reviewed the narrative descriptions provided in these PEPFAR  country teams’ fiscal year 2011 annual reports. On the basis of these  reviews, as well as interviews with OGAC officials, we determined that the  PEPFAR data on number of people on treatment were sufficiently reliable  for reporting totals rounded to the nearest hundred. In addition, to  illustrate PEPFAR’s contribution to the number of people on treatment in  low- and middle-income countries, we obtained data on the numbers of  people on treatment in all low- and middle-income countries from the  UNAIDS website ( 2011. UNAIDS sets international standards for these data, which it  collects from national governments and uses to report on estimated  numbers of people on treatment; therefore, we deemed them sufficiently  reliable for the purposes of our reporting. Data on the number of people  on treatment in low- and middle-income countries were not available for  2012 at the time of this report’s publication. To be able to illustrate  PEPFAR’s contribution to the number of people on treatment in low- and  middle-income countries in 2012, we derived a rough estimate based on  ) for calendar years 2004 through  changes in PEPFAR’s and UNAIDS’s reported numbers of people on  treatment from 2010 to 2011. We observed that the number of people on  treatment directly supported by PEPFAR made up about half of the  increase in the number of people on treatment in low- and middle-income  countries in these years. For fiscal years 2011 to 2012, the number of  people on treatment directly supported by PEPFAR increased by about  1.2 million; if we had assumed that this number continued to make up half  of the increase in low- and middle-income countries in these years, the  estimated increase would have been 2.4 million. Thus, our estimate of an  increase of about 1.5 million people on treatment from 2011 to 2012— leading to an estimate of 9.5 million people on treatment in low- and  middle-income countries in those years—represents a conservative  projection of possible scenarios.
In the case of partner countries’ treatment coverage rates, we analyzed  data provided in UNAIDS’s 2012 Global Report: UNAIDS Report on the  Global AIDS Epidemic as well as data available for 2009 through 2011 on  UNAIDS’s website (www.unaids.org). UNAIDS sets international  standards for these data, which it collects from national governments and  uses to report on national treatment coverage rates. On the basis of  review of treatment coverage rates reported by PEPFAR country teams to  OGAC, as well as discussions with OGAC officials, we determined that  UNAIDS’s treatment coverage data were the most complete and current  data available and were thus sufficiently reliable for the purposes of our  reporting.
In addition to information provided by PEPFAR country teams and  reported by OGAC, we also drew on information from a selected set of  studies of treatment programs and M&E systems in PEPFAR partner  countries. We used the information from these studies to identify  illustrative examples of factors affecting treatment program outcomes and  M&E system strengths and weaknesses. Appendix III contains examples  of information provided by studies we reviewed.
First, although we did not intend to develop an exhaustive list of all  available studies, we took a number of steps to identify relevant and up- to-date studies assessing treatment programs and M&E systems in  PEPFAR countries. These studies included: (1) studies collected under  our previous review of evaluations of PEPFAR programs; (2) studies  provided by PEPFAR country teams in the three countries we visited; (3)  articles published in special issues of Health Affairs and the Journal of  Acquired Immune Deficiency Syndromes dedicated to PEPFAR  programs, both published in 2012; and (4) a citations review for PEPFAR  public health evaluations, evaluations provided by CDC headquarters,  and relevant articles appearing in Health Affairs and the Journal of  Acquired Immune Deficiency Syndromes from 2009 through 2012. We  identified more than 200 studies addressing our objectives.
To perform our review, we first reviewed the studies’ titles and abstracts  to categorize each study according to one or more topics, such as M&E  systems or treatment program retention. Focusing on studies that fell into  categories related to M&E systems and to treatment program retention  and patient-level outcomes, we then reviewed key sections—such as  findings and conclusions—of each study to identify common themes. We  also targeted studies that addressed topics covered in the body of the  report, such as factors affecting treatment program retention and loss to  follow-up and strengths and weaknesses of M&E systems. Having  identified subsets of relevant studies, we reviewed them in more depth to  verify our initial judgments about the studies’ findings and to select  illustrative examples of the themes we had identified. This additional  review included the development of narrative work papers synthesizing  and categorizing more detailed findings and results from the selected  studies. We then presented these findings and examples in appendix III.  Our analysis is not a summary of the full set of studies we identified in the  initial phase but rather a presentation of several key, high-level results  derived from a select set of studies in both areas, supported with citations  to illustrative studies.
We conducted this performance audit from May 2012 to April 2013 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Criteria for Assessing PEPFAR Direct Support
paragraphs: The Department of State’s (State) Office of the U.S. Global AIDS  Coordinator’s (OGAC) Next Generation Indicators Reference Guide,  effective beginning in fiscal year 2010 and updated in February 2013,  provides a list of indicators for setting targets, monitoring results, and  reporting to OGAC. The guidance distinguishes between President’s  Emergency Plan for AIDS Relief (PEPFAR) direct indicators and national  indicators. PEPFAR direct indicators describe the results of PEPFAR  programs through its funded activities. National indicators describe the  achievements of all contributors—including public and private sector  organizations and other donors—to a partner country’s HIV/AIDS  programs.
Furthermore, OGAC’s guidance provides a checklist for determining  whether a site-specific service supported by PEPFAR can be counted in  reporting on PEPFAR direct indicators. According to the guidance, to be  characterized as PEPFAR direct, an activity must fulfill at least one  criterion in each of the two panels shown in table 5. If an activity meets at  least one of each set of criteria, PEPFAR support is assumed to be direct  and to likely provide sufficient support for claiming 100 percent of the site- specific results. If an activity meets a criterion in only one of the panels,  PEPFAR support may be insufficient for claiming 100 percent of site- specific results. In that case, country teams must (1) determine whether  there is sufficient justification to claim the results as direct and, if there is,  (2) justify the method used to estimate the appropriate fraction of the total  commensurate with PEPFAR support to the site and (3) document the  estimation procedures used.
section_title: Appendix III: Summary of Studies
paragraphs: In addition to analyzing information provided by President’s Emergency  Plan for AIDS Relief (PEPFAR) country teams and reported by the  Department of State’s (State) Office of the U.S. Global AIDS Coordinator  (OGAC), we also performed reviews of a selected set of studies.  Although these studies may not represent national treatment program  conditions and may be limited by incomplete data, they provide additional  information related to treatment retention and patient-level health  outcomes, as well as strengths and weaknesses of partner-country  monitoring and evaluation (M&E) systems. (See app. I for information on  how we identified and used these studies for the purposes of our  reporting.)
subsections: section_title: Treatment Retention and Patient-Level Outcomes
paragraphs: Treatment retention rates reported by PEPFAR country teams indicate  some progress but have certain limitations related to data completeness  and varying methods and definitions. Treatment program studies—which  use treatment facility data not routinely reported by PEPFAR country  teams to OGAC—also provide information about treatment retention,  adherence, and patient loss-to-follow-up.
Several studies, although not representative of national program  conditions, identified factors associated with patient loss-to-follow-up,  such as advanced illness and personal economics. They also noted  measures that could potentially reduce the number of patients lost to  follow-up and thus increase retention rates, such as starting treatment  earlier, shortening the distance to health care facilities, expanding  personal outreach by community health volunteers, and using mobile  phone messaging for patient follow-up. In addition, several studies that  we reviewed identified interventions found to be successful for reducing  the occurrence of drug resistance and treatment failure, including (1)  increased outreach to patients to increase adherence to medications and  (2) effective supervision and training of lower-level health facility staff.  Other studies identified factors that may limit the positive health effects of  treatment, such as poor access to nutrition and clean water. Such  findings can serve as the basis for adopting new treatment program  policies and management approaches.
Incomplete data may limit studies’ ability to fully examine patient-level  health outcomes and the factors that affect them. For example, we  identified one study that reported some positive adult treatment program  outcomes, based on a nationally representative sample of treatment  facilities in Rwanda, but noted incomplete data on patient weight and CD4  cell count, among other limitations. Another study on the prevalence of  drug-resistant HIV strains noted that very few published data on drug  resistance are available, particularly for the HIV strains that tend to be  prevalent in low- and middle-income countries. Devising mitigation  strategies for drug resistance can be difficult without these data. Likewise,  one study noted a lack of data on potential adverse effects of treatment  on the growth and development of pediatric patients.
section_title: Strengths and Weaknesses of Partner-Country M&E Systems
paragraphs: Studies of partner countries’ M&E systems note that some progress has  been made in expanding and upgrading these systems. The studies cite  increased use of electronic systems for health information management  and reporting. For example, one study found that electronic systems,  where in use, enabled health facilities to report on health indicators more  easily as well as to support patient and facility management.
Nevertheless, these studies also found that partner countries’ M&E  systems are unable to produce timely and complete treatment data, thus  limiting their usefulness for patient, clinic, or program management.  These studies cited several challenges, including the following:
Human resource limitations can hinder the full use of M&E system  data. For example, one study noted that health facility staff lacked  trained data managers to regularly analyze basic data.
Data may not always be analyzed when reported from the facility to  the district; and data may not always be disseminated properly, or  may not be used in decision making. For example, one study noted  limited access to data and lack of capacity as factors negatively  affecting data use.
Health facility staff may prioritize data reporting to districts, national  ministries, and donors over data use, including use for improving the  quality of treatment services. For example, one study found that data  were used for decision making at 38 percent of health facilities  reviewed and in 44 percent of districts reviewed.
section_title: Appendix IV: Comments from the Department of State
section_title: Appendix V: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, Jim Michels (Assistant Director),  Todd M. Anderson, David Dayton, Brian Hackney, and Grace Lui made  key contributions to this report. In addition, the following GAO staff  provided technical assistance and other support: Sada Aksartova, Chad  Davenport, David Dornisch, Lorraine Ettaro, Katherine Forsyth, Kay  Halpern, Erika Navarro, and Jane Whipple.
section_title: Related GAO Products
paragraphs: President’s Emergency Plan for AIDS Relief: Per-Patient Costs Have  Declined Substantially, but Better Cost Data Would Help Efforts to  Expand Treatment. GAO-13-345. Washington, D.C.: March 15, 2013.
President’s Emergency Plan for AIDS Relief: Agencies Can Enhance  Evaluation Quality, Planning, and Dissemination. GAO-12-673.  Washington, D.C.: May 31, 2012.
President’s Emergency Plan for AIDS Relief: Program Planning and  Reporting. GAO-11-785. Washington, D.C.: July 29, 2011.
Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other  Health Assistance in Fiscal Years 2001-2008. GAO-11-64. Washington,  D.C.: October 8, 2010.
President’s Emergency Plan for AIDS Relief: Efforts to Align Programs  with Partner Countries’ HIV/AIDS Strategies and Promote Partner  Country Ownership. GAO-10-836. Washington, D.C.: September 20,  2010.
President’s Emergency Plan for AIDS Relief: Partner Selection and  Oversight Follow Accepted Practices but Would Benefit from Enhanced  Planning and Accountability. GAO-09-666. Washington, D.C.: July 15,  2009.
Global HIV/AIDS: A More Country-Based Approach Could Improve  Allocation of PEPFAR Funding. GAO-08-480. Washington, D.C.: April 2,  2008.
Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved  Its Documentation of Funding Decisions but Needs Standardized  Oversight Expectations and Assessments. GAO-07-627. Washington,  D.C.: May 7, 2007.
Global Health: Spending Requirement Presents Challenges for Allocating  Prevention Funding under the President’s Emergency Plan for AIDS  Relief. GAO-06-395. Washington, D.C.: April 4, 2006.
Global Health: The Global Fund to Fight AIDS, TB and Malaria Is  Responding to Challenges but Needs Better Information and  Documentation for Performance-Based Funding. GAO-05-639.  Washington, D.C.: June 10, 2005.
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.