The 2008 Leadership Act called on the U.S. Global AIDS Coordinator to develop a 5-year strategy to combat global HIV/AIDS, including a plan to achieve a number of prevention, treatment, and care program goals. The 5-year PEPFAR strategy, which OGAC released in December 2009, specifies multiyear program goals and outlines multiyear targets including those listed in the Leadership Act. The 2008 Leadership Act, which amends the 2003 Leadership Act, requires that OGAC submit an annual report to Congress, including an assessment of progress toward the achievement of annual goals. If annual goals are not being met, the 2008 Leadership Act states that the report should identify the reasons for such failure. GPRA and our prior work identify practices related to performance planning and reporting. GPRA calls for the use of several performance management practices intended to improve federal program effectiveness, accountability, and service delivery and to enhance congressional decision making by requiring federal agencies to provide more objective information on program performance. In addition, our prior work suggests the use of a practice to bolster program performance reporting. These practices include the following, among others:  Performance planning. GPRA calls for preparation of public annual performance plans that articulate goals for the upcoming fiscal year. These plans should link annual program goals to program activities, include indicators that will be used to measure performance, provide information on the operational processes and resources required to meet the performance goals, and identify the procedures that will be used to verify and validate performance information.  Performance reporting. GPRA calls for annual performance reports reviewing the success of achieving the performance goals of the fiscal year. The reports are to describe and review results compared with performance goals, provide explanations for any unmet goals and actions needed to address them, and include summaries of completed program evaluations. In addition, our prior work found that explaining any limitations of performance information can provide context for understanding and assessing program performance and the costs and challenges faced in gathering, processing, and analyzing data. This practice can help identify the actions needed to address any inadequacies in the completeness and reliability of performance data and thereby improve program performance reporting. In August 2009, OGAC issued its Next Generation Indicators Reference Guide, providing an updated list of indicators for establishing targets and reporting on results of PEPFAR prevention, care, treatment, and health systems strengthening programs. The guidance classifies 32 indicators as essential and reported—that is, indicators that PEPFAR country or regional teams must use in submitting data on program results to OGAC. (See app. III for a list of the 32 essential reported PEPFAR indicators.) The guidance advises PEPFAR country and regional teams to require PEPFAR implementing partners to submit data for an additional set of indicators, if applicable, but does not require country and regional teams to submit these data to OGAC. The guidance also provides a list of recommended indicators for implementing partners and PEPFAR program managers who need additional information for program management. The guidance states that PEPFAR interagency country or regional teams determine how to collect data from PEPFAR implementing partners and relevant national systems, as well as how to aggregate, store, and use the PEPFAR program monitoring indicators in country. OGAC, USAID, and CDC officials share responsibility for PEPFAR planning and reporting activities—including developing and approving PEPFAR operational plans and reports—and conduct agency-specific planning and reporting procedures. The procedures support agencies’ internal program management and provide data for external reporting on PEPFAR results. OGAC’s Strategic Information (SI) office guides and coordinates PEPFAR performance planning and reporting for countries and regions receiving U.S. HIV/AIDS assistance. SI advisors—as of July 2011, 20 CDC and USAID officials—provide technical support and assistance to country and regional teams for developing annual operational plans for PEPFAR programs. In helping to develop the country-level and regional operational plans, when requested, SI advisors work with the country and regional teams to describe partner-level PEPFAR activities during the preceding fiscal year and establish country-level and regional targets for the coming year. When OGAC receives the operational plans (typically in October), SI advisors review the performance targets. After the plans are approved by the U.S. Global AIDS Coordinator, OGAC aggregates budget, program activity, and planned performance information in the plans to create an annual PEPFAR operational plan to be submitted to Congress. When requested, OGAC’s SI office also guides and assists PEPFAR teams in preparing and submitting data on program results to the U.S. Global AIDS Coordinator. SI advisors work with PEPFAR country and regional teams to submit data on program results semi-annually (typically in May) and annually (typically in November). The semi-annual data consist of targets and results for a subset of eight PEPFAR essential indicators; the annual data consist of targets and results for all 32 essential reported PEPFAR indicators. SI advisors review the submitted data, and SI office staff further review and reconcile treatment data with data from the Global Fund, UNAIDS, and the World Health Organization. Once the data are confirmed, OGAC considers them to be PEPFAR’s final results for the year. These data, which OGAC maintains internally, are intended to support PEPFAR program monitoring, midcourse correction, and planning for subsequent fiscal years. PEPFAR program results data also supply information for public reports and other documents, including OGAC’s annual report to Congress on PEPFAR performance, typically published in February, as well as a World AIDS Day (December 1) press release on PEPFAR results. USAID’s Office of HIV/AIDS, in Washington, D.C., and USAID officials in regional and country missions share responsibility for global HIV/AIDS performance planning and reporting, including oversight of USAID implementing partners. The Office of HIV/AIDS comprises four divisions, two of which—the Implementation Support Division and the Strategic Planning, Evaluation, and Reporting Division—provide assistance to the agency and field missions in managing programs and incorporating programmatic best practices. USAID uses PEPFAR program results data for its annual performance plans and reports. USAID also conducts foreign assistance performance planning and reporting jointly with State’s Office of the Director of U.S. Foreign Assistance, using State’s and USAID’s Foreign Assistance Framework. In addition to producing multiyear country assistance strategies and mission strategic plans, USAID country or regional missions complete annual operational plans and annual performance plans and reports for monitoring, evaluating, and reporting progress in achieving the agency’s foreign assistance objectives. USAID guidance further specifies required elements of mission performance management plans, including indicators, baseline values and targets, data sources, any known data limitations, and data quality assessment procedures. State’s and USAID’s master list of standard indicators specifies 46 HIV/AIDS- related indicators for setting targets and reporting results. According to USAID officials, the HIV/AIDS-related indicator descriptions are aligned with those for PEPFAR. Through its audits of USAID’s global HIV/AIDS program activities, from fiscal year 2008 to 2011, USAID’s OIG has made recommendations related to performance planning and reporting. We identified 130 USAID OIG recommendations regarding performance monitoring of USAID- administered PEPFAR activities for fiscal years 2008 to 2011, which we categorized using 12 components of HIV/AIDS program monitoring and evaluations systems, as defined by UNAIDS. Of these recommendations, 94 recommendations, or 72 percent, are related to routine program monitoring or data quality—specifically, 39 percent are related to routine program monitoring (producing timely and high-quality program monitoring data); 11 percent are related to supportive supervision and data auditing (monitoring data quality periodically and addressing any obstacles to producing high-quality data); and 22 percent are related to both routine program monitoring and supportive supervision and data auditing. (See fig. 1.) For example, the OIG reported in 2009 that the USAID mission in one country did not sufficiently verify and validate implementing partner performance data and, as a result, recommended that the mission establish procedures, including site visits, for validating these data. (We categorized this recommendation as relating to both routine program monitoring and supportive supervision and data auditing.) In addition, we found that a number of recommendations related to human capacity for monitoring and evaluation, often in combination with recommendations for improving program monitoring. For example, a 2010 audit of another USAID country mission’s PEPFAR program found that inadequate training of implementing partner staff resulted in weak data collection methods and reporting of inaccurate performance data. The OIG recommended that the mission develop a training plan for implementing partner staff in charge of data collection and reporting. Routine program monitoring (51 recommendations) Routine program monitoring and supportive supervision and data auditing (29 recommendations) Supportive supervision and data auditing (14 recommendations) Supportive supervision and data auditing and human capacity (10 recommendations) Human capacity (5 recommendations) Human capacity and routine program monitoring (6 recommendations) Partnerships for monitoring and evaluation (3 recommendations) Routine program monitoring and partnerships for monitoring and evaluation (2 recommendations) Organizational structures and routine program monitoring (2 recommendations) According to data provided by USAID, as of June 2011, the agency had implemented about two-thirds (65 percent) of USAID OIG report recommendations related to program performance monitoring and evaluation; about a third (35 percent) of the remaining recommendations are due for final action by December 2011. (See fig. 2.) CDC’s Division of Global HIV/AIDS (DGHA), in Atlanta, Georgia, is responsible, along with CDC officials in 41 overseas offices, for global HIV/AIDS programs in more than 75 countries. DGHA comprises a regional and country management office and eight headquarters-based technical and operational branches, including epidemiology and strategic information; health economics, systems, and integration; and country operations. These offices and branches manage and provide technical assistance and support to CDC country teams and partner governments, coordinate DGHA involvement in PEPFAR interagency activities and partnerships with international organizations, and support regional and country offices with implementing partner selection and performance monitoring. CDC uses PEPFAR program results data for its annual performance plans and reports. In addition, in 2010, CDC instituted quarterly program reviews for all CDC divisions, and DGHA underwent its first quarterly program review in November 2010. For these CDC management reviews, DGHA selected 16 1-year and 14 4-year goals under four priority strategies: strengthen public health systems globally; scale up combination prevention programs and treat HIV globally in a cost- effective manner; transition HIV/AIDS treatment programs to host-country governments; and support the Global Health Initiative. DGHA reports quarterly to the Office of the Associate Director for Program on eight PEPFAR indicators, representing 31 PEPFAR countries and three regions. According to CDC officials, the quarterly program review is intended to inform CDC’s annual performance plan and report. Beginning in February 2011, DGHA officials initiated a series of in-country reviews—called country management and support visits—of CDC country office management of global HIV/AIDS programs. DGHA officials completed eight visits by the end of June 2011 and planned to complete up to 17 additional visits over the next several months, with up to 34 country visits being completed by the end of fiscal year 2012. DGHA plans to make summaries of the country visits available to the public. In addition, CDC develops annual interagency programmatic planning and monitoring documents called country assistance plans. In February 2010, CDC technical and budget officials and senior management reviewed country assistance plans for seven countries: Afghanistan, Brazil, Laos, Mali, Papua New Guinea, Senegal, and Sierra Leone. These plans provide information on planned activities and country targets and results, among other things. CDC’s country assistance plan guidance recommends that CDC country offices refer to PEPFAR indicators in the plans, as appropriate, when reporting results. During a pilot project for assessing the quality of treatment program data, CDC found that data quality varied across CDC-funded treatment sites. CDC examined the reliability of the numbers of patients reported as currently on treatment at 31 CDC-funded PEPFAR treatment sites in Mozambique, Tanzania, and Côte d’Ivoire. CDC found that counting actual patient visit or drug pickup data at the 31 sites yielded a lower total than the method used by some implementing partners (39,577 patients versus 48,796 patients, respectively). The implementing partners sometimes summed the number of people who ever started treatment and subtracted those known to have left the program, resulting in misclassification of patients’ treatment status and inflation of reported results. Based on these assessments, CDC recommended (1) refining definitions of indicators and acceptable methods for deriving the information; (2) developing a data quality assessment program with a standardized protocol for evaluating data; (3) completing the treatment data quality assessment at all PEPFAR-supported sites; and (4) sharing the assessments’ findings with all PEPFAR country teams, implementing partners, and ministries of health. OGAC, USAID, and CDC have issued several performance management planning and reporting documents in response to the requirements included in the 2008 Leadership Act and practices specified in GPRA. (See app. IV for a list of targets and results reported by OGAC, USAID, and CDC.)  OGAC. OGAC has issued annual PEPFAR operational plans for fiscal years 2009 and 2010. According to OGAC officials, the PEPFAR operational plan—which aggregates information from country and regional operational plans—serves as its annual performance plan. OGAC also issues an annual PEPFAR performance report to Congress. OGAC’s most recent annual report to Congress, for fiscal year 2010, includes a series of tables showing programwide PEPFAR results for prevention, treatment, and care indicators; the annual report for fiscal year 2009 also includes results for health systems strengthening indicators. In most cases, these results are also displayed by country or region.  USAID. In March 2011, USAID issued, jointly with State, the “Foreign Operations FY 2010 Performance Report, FY 2012 Performance Plan” (State-USAID APR/APP) as part of State’s and USAID’s congressional budget justification for fiscal year 2012. The document provides, among other things, information on 2010 targets and results for two PEPFAR indicators: (1) number of individuals receiving antiretroviral treatment, and (2) number of individuals infected or affected by HIV/AIDS, including orphans and vulnerable children, who were receiving care and support services. The State-USAID APR/APP cites PEPFAR’s 5-year target for number of HIV infections averted and provides an annual target for 2010 but does not report on annual results.  CDC. CDC’s “Fiscal Year 2012 Justification of Estimates for Appropriation Committees” and “FY 2012 Online Performance Appendix” constitute its performance report and performance plan for fiscal years 2010 and 2012, respectively. In these documents, CDC reports on 2010 targets and results using four PEPFAR indicators: (1) number of individuals receiving antiretroviral treatment; (2) number of individuals infected and affected by HIV/AIDS, including orphans and vulnerable children, receiving care and support services; (3) number of pregnant women receiving HIV counseling and testing; and (4) number of HIV-positive pregnant women receiving antiretroviral prophylaxis. OGAC’s most recent annual performance documents do not provide information related to annual targets, as required by the 2008 Leadership Act and consistent with GPRA. (See fig. 3.) PEPFAR country and regional operational plans contain country-level and regional targets for the coming year and data showing program targets and results, measured by PEPFAR indicators. However, the annual PEPFAR operational plans and reports that OGAC submitted to Congress for fiscal years 2009 and 2010 do not contain any information on annual targets. Moreover, OGAC’s annual reports to Congress for fiscal years 2009 and 2010 do not compare annual results with annual targets. According to the 2008 Leadership Act, these reports are to include an assessment of progress toward the achievement of annual goals and, if annual goals are not being met, the reasons for such failures. In addition, GPRA calls for annual performance reports to compare results with previously established targets. State-USAID’s and CDC’s annual performance documents present some information on PEPFAR targets and results (see fig. 3). The State-USAID APR/APP cites two targets for treatment and care programs for fiscal year 2010. CDC’s fiscal year 2010 performance report and fiscal year 2012 performance plan cite four fiscal year targets—two for prevention, and one each for treatment and care programs. Both agencies’ performance documents compare PEPFAR 2010 results with targets set for the same year and rate PEPFAR’s performance against those targets. For example, the documents report that PEPFAR exceeded its 2010 target for number of individuals on antiretroviral treatment but did not meet its target for number of individuals receiving care and support services. The State- USAID APR/APP states that the reason for the shortfall is being evaluated, while CDC’s fiscal year 2010 performance report and fiscal year 2012 performance plan states that trend analysis shows constant progress in expanding care with significant increases each year. In addition, CDC reports that PEPFAR exceeded its 2010 targets for number of pregnant women receiving counseling and testing and number of pregnant women receiving antiretrovirals. For the 2010 PEPFAR prevention target reported in the State-USAID APR/APP, the document states that data are not available for the indicator. Further, the document states that, because an infection averted is a nonevent, this estimate needs to be modeled based on surveillance reports and that the estimate of impact through 2010 is expected to be available in 2012 at the earliest. OGAC has not publicly provided, consistent with GPRA practices, information on efforts to verify and validate reported performance data. However, State-USAID’s and CDC’s annual performance documents cite OGAC efforts to verify and validate some PEPFAR performance data.  OGAC. Although OGAC internal guidance summarizes PEPFAR country teams’ and OGAC’s roles in verifying and validating reported data, OGAC’s two most recent PEPFAR operational plans and annual reports to Congress, covering fiscal years 2009 and 2010, contain no information on these efforts.  USAID. The State-USAID APR/APP states that the results data reported for the two PEPFAR indicators are corroborated with data from other sources. The document also notes that OGAC expects to report the estimated number of HIV infections averted using a U.S. Census Bureau model.  CDC. CDC’s fiscal year 2010 performance report and fiscal year 2012 performance plan sources the data it reports to PEPFAR annual program results data, noting that OGAC manages and validates results data at the headquarters level. Moreover, even with the data reliability weaknesses noted by USAID OIG reviews and CDC’s treatment program data quality pilot project, OGAC’s, USAID’s, and CDC’s performance reports do not contain information on these weaknesses or on steps taken to address the weaknesses. Credible performance information is essential for accurately assessing agencies’ progress toward the achievement of their goals and, in cases where goals are not met, identifying opportunities for improvement or whether goals need to be adjusted. As we have reported previously, without such information, and absent strategies to address identified limitations, Congress and other decision makers cannot assess the validity and reliability of reported performance information. PEPFAR’s commitment to transparent reporting of program results, clearly stated in its 5-year strategy, is also reflected in OGAC planning, reporting, and indicator guidance to PEPFAR country teams. In addition, OGAC, USAID, and CDC procedures for program performance planning and reporting are intended to help a broad range of stakeholders— including PEPFAR implementing agency headquarters and country team officials, partner country governments, and Congress—manage and oversee PEPFAR programs and demonstrate the U.S. government’s contribution to the global fight against HIV/AIDS. OGAC, USAID, and CDC performance plans and reports serve as key sources of public information on their efforts to monitor PEPFAR program performance. However, OGAC can improve its annual performance planning and reporting. First, by discussing annual results alongside established targets in its annual report to Congress, OGAC would provide important context for understanding PEPFAR’s annual achievements and areas needing attention. Second, by providing information on its own and implementing agencies’ efforts to ensure the quality of their performance data, OGAC would give decision makers greater insight into the quality and value of the reported performance information. In accordance with requirements and practices set forth in the 2008 Leadership Act and GPRA, and to improve transparency and accountability, we recommend that the Secretary of State direct the U.S. Global AIDS Coordinator to modify the annual report to Congress on PEPFAR performance in the following two ways: (1) include comparisons of annual PEPFAR results with previously established annual targets and (2) include information on efforts to verify and validate PEPFAR performance data and address data limitations. We provided a draft of this report to State, USAID, and HHS for comment. Responding jointly with HHS and USAID, OGAC provided written comments (see app. V for a copy of these comments). OGAC agreed with our second recommendation to include in PEPFAR’s annual report to Congress information on efforts to verify and validate PEPFAR performance data and address data limitations, and stated that PEPFAR will provide this information in future annual reports and on its Web site. Citing the need to consider various related issues and their consequences in consultation with Congress and other stakeholders, OGAC partially agreed with our first recommendation to include in PEPFAR’s annual report to Congress comparisons of annual PEPFAR results with previously established targets, consistent with a 2008 Leadership Act requirement and a key GPRA practice. OGAC’s comments suggested that specific action in response to this recommendation would be contingent on the outcome of these discussions. OGAC also provided additional background information on PEPFAR indicators and data validation efforts. Finally, OGAC, in coordination with HHS and USAID, provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the Secretary of State, the Office of the U.S. Global AIDS Coordinator, USAID Office of HIV/AIDS, HHS Office of Global Affairs, CDC Division of Global HIV/AIDS, and appropriate congressional committees. In addition, the report will be available at no charge on GAO’s Web site at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-3149 or gootnickd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix VI. In response to directives in the Consolidated Appropriations Act of 2008 and the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership Act) to review global HIV/AIDS program monitoring, this report (1) describes the Office of the U.S. Global AIDS Coordinator’s (OGAC), U.S. Agency for International Development’s (USAID), and the Centers for Disease Control and Prevention’s (CDC) key procedures for planning and reporting on the President’s Emergency Plan for AIDS Relief (PEPFAR) program performance and (2) examines published PEPFAR performance plans and reports. To describe OGAC, USAID, and CDC procedures for planning for, and reporting on, PEPFAR program performance, we reviewed PEPFAR and agency-specific guidance documents such as PEPFAR country operational plan guidance for fiscal years 2009 and 2010, Next Generation Indicators guidance, and semi-annual and annual program results guidance; USAID’s Automated Directives System guidance; and CDC’s quarterly program measures guidance. We also reviewed documents provided by OGAC, USAID, and CDC to describe their organizational structures and procedures, and we interviewed OGAC and USAID officials in Washington, D.C., as well as CDC officials in Atlanta, Georgia. To categorize USAID Office of Inspector General (OIG) audit report recommendations related to program performance planning and reporting, we identified 24 USAID OIG reports from fiscal years 2008 through 2011 published on USAID’s Web site. We also interviewed cognizant USAID OIG officials in Washington, D.C., and two regional offices in Africa (Pretoria, South Africa, and Dakar, Senegal) to gain additional information on past and current USAID OIG audit work on PEPFAR. We identified the countries and programs covered by each report and found that the 24 reports covered prevention, treatment, and care programs in 19 PEPFAR countries: Botswana, Cambodia, Côte d’Ivoire (two reports), Dominican Republic, Ethiopia, Ghana, Guyana, Haiti, Kenya (two reports), Mozambique (two reports), Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, Zambia (two reports), and Zimbabwe. In addition, one USAID OIG report reviewed USAID’s implementation of PEPFAR’s New Partners Initiative. We identified the recommendations in these reports and entered this information into a spreadsheet database. To identify and describe types of performance management-related themes, we utilized the Joint United Nations Programme on HIV/AIDS (UNAIDS) 12 components of a national HIV monitoring and evaluation system as categories. (See app. II for a list of these categories and their definitions.) Two analysts independently assigned each recommendation to not more than two of these categories. The two analysts then met to discuss the results of their analysis; in cases where the analysts’ categorizations differed, the analysts discussed and came to agreement on final categories. We determined that 74 recommendations addressed one category, and 56 addressed two of the categories—totaling 130 recommendations. We also determined that 43 recommendations—related, for example, to disposal of expired medications and to requirements for USAID branding and marking—did not fall into any of the categories. Furthermore, three of the 12 categories—national multisectoral monitoring and evaluation plan; annual costed national monitoring and evaluation workplan; and advocacy, communication, and culture for monitoring and evaluation—were not used to categorize any of the recommendations. To determine the extent to which USAID has taken steps to implement the recommendations, we interviewed cognizant USAID OIG officials in Washington, D.C., to gain understanding of recommendation tracking, and we analyzed data provided by USAID specifying dates for final action, target dates for final action, and target dates for management decisions. To examine published PEPFAR performance plans and reports and the extent to which they adhere to established practices, we identified OGAC’s, USAID’s, and CDC’s most recent publicly available annual performance plans and reports: for OGAC, the PEPFAR annual operational plans and annual reports to Congress for fiscal years 2009 and 2010; for USAID, the “Foreign Operations FY 2010 Performance Report, FY 2012 Performance Plan” that it issued with the Department of State as part of their joint congressional budget justification for fiscal year 2012; and for CDC, the “Fiscal Year 2012 Justification of Estimates for Appropriation Committees” and “FY 2012 Online Performance Appendix.” We systematically reviewed these documents using a matrix with a series of questions about key performance management practices, as defined by the 2008 Leadership Act, the Government Performance and Results Act of 1993, and previous GAO work. We also interviewed OGAC, USAID, and CDC officials in Washington, D.C., and Atlanta, Georgia, regarding the information contained in these documents and the procedures they followed to produce them. We conducted this performance audit from October 2010 to July 2011 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. To identify and describe types of performance management-related themes in our analysis of USAID OIG report recommendations (see app. I), we used as categories 12 components of a national HIV monitoring and evaluation system established by UNAIDS. Table 1 provides a list of these categories and their descriptions. According to OGAC’s Next Generation Indicators guidance and OGAC officials, PEPFAR country and regional teams are to use 32 essential indicators for annual target setting and regular reporting to OGAC. The guidance distinguishes between direct and national indicators. National indicators are intended to measure the collective achievements of all contributors (i.e., host country government, donors, and civil society) to a program or project, while direct indicators are intended to measure results attributable to PEPFAR alone. Table 2 provides a list of these indicators. OGAC provides information on PEPFAR program results in its annual reports to Congress, which are typically published in February. USAID reports on PEPFAR program results in the “Foreign Operations FY 2010 Performance Report FY 2012 Performance Plan” that it issued with the Department of State as part of their joint congressional budget justification for fiscal year 2012 (State-USAID APR/APP). CDC reports on PEPFAR program results in its “Fiscal Year 2012 Justification of Estimates for Appropriation Committees” and “FY 2012 Online Performance Appendix.” The indicators used to report on PEPFAR results are a subset of the 32 essential reported indicators listed in appendix III. Table 3 summarizes PEPFAR results for fiscal year 2010 reported by OGAC, USAID, and CDC in their most recent performance reports. In addition to the contact named above, Audrey Solis (Assistant Director), Todd M. Anderson, David Dornisch, Lorraine Ettaro, Brian Hackney, Fang He, Reid Lowe, Grace Lui, and Reina Nuñez made key contributions to this report. Lisa Helmer and Keesha Egebrecht provided technical assistance. 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.

Summary: U.S. assistance through the President's Emergency Plan for AIDS Relief (PEPFAR) has helped provide treatment, care, and prevention services overseas to millions affected by HIV/AIDS. In 2008, Congress reauthorized PEPFAR with the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership Act). The act requires the Department of State's Office of the U.S. Global AIDS Coordinator (OGAC) to report to Congress annually on PEPFAR performance. The U.S. Agency for International Development (USAID) and the Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) also report on PEPFAR program performance. Responding to legislative directives, GAO (1) described key procedures for planning and reporting on PEPFAR performance and (2) examined published PEPFAR performance plans and reports. GAO analyzed performance management documents and interviewed officials at OGAC, USAID, and CDC. Officials in several offices and divisions in OGAC, USAID, and CDC coordinate and manage PEPFAR program planning and reporting procedures at headquarters and in PEPFAR countries and regions. These procedures, which include PEPFAR-wide annual operational planning and periodic results reporting, support internal agency-specific program management as well as provide information for external reporting on PEPFAR results. OGAC, USAID, and CDC publicly issued plans and reports on PEPFAR performance in recent years consistent with 2008 Leadership Act requirements and GPRA practices; however, 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. In addition, the Government Performance and Results Act (GPRA) of 1993 calls for federal agency performance reports to compare program results with established targets. Performance documents published by USAID, jointly with State, and by CDC report program targets and results for two and four PEPFAR indicators, respectively. Second, 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 refers to noted data reliability weaknesses or efforts to address these weaknesses. GPRA and prior GAO work emphasize the importance of providing information in public performance documents on data verification and other efforts to address identified weaknesses. GAO recommends that OGAC include in its annual report to Congress (1) comparisons of annual PEPFAR results with established targets and (2) information on efforts to verify and validate PEPFAR performance data and address data limitations. OGAC partially agreed with the first recommendation, pending discussions with stakeholders about implementation issues and consequences, and agreed with the second recommendation.