The Department of State’s Office of the U.S. Global AIDS Coordinator (OGAC) establishes overall PEPFAR policy and program strategies, coordinates PEPFAR programs, and allocates resources to several U.S. agencies to implement PEPFAR activities. These agencies (referred to in this report as implementing agencies) include, among others, the U.S. Agency for International Development (USAID) and the U.S. Department of Health and Human Services’ (HHS) Centers for Disease Control and Prevention (CDC). OGAC coordinates U.S. government implementing agencies and resources, establishes policy and guidance for the PEPFAR program, and is responsible for allocating resources to implementing agencies. OGAC executes its coordinating role in part by providing implementing agencies, both in the United States and in PEPFAR countries, annual guidance on reporting program results, and guidance on planning. In addition, OGAC collaborates with implementing agency officials through technical working groups on a range of issues. OGAC also disseminates weekly updates to implementing agency staff in PEPFAR countries regarding topics such as deadlines and changes to official guidance. USAID and CDC, which oversee most PEPFAR-funded programs, are among PEPFAR’s primary implementing agencies. Of almost $16.5 billion obligated for HIV/AIDS activities in fiscal years 2004 through 2009, $9.6 billion was obligated by USAID and $6.4 billion was obligated by HHS. In each partner country, teams of implementing agency officials (PEPFAR country teams) jointly develop country operational plans (COP) for use in coordinating, planning, reporting, and funding PEPFAR programs. The COP is the vehicle for documenting annual investments in HIV/AIDS, and serves as the basis for approving, allocating, tracking, and notifying Congress of budgets and targets. 2008 Leadership Act. The 2008 Leadership Act, PEPFAR’s reauthorizing legislation, cites improving harmonization of U.S. efforts with national strategies of partner governments and other public and private entities as an element in strengthening and enhancing United States leadership and the effectiveness of the U.S. response to HIV/AIDS. The act requires the President to report to Congress on OGAC’s strategy. The act specifies that the report must discuss many elements of the strategy including a description of the strategy to promote harmonization of U.S. assistance with that of other international, national, and private actors; and to address existing challenges in harmonization and alignment. The act also requires the President to report on efforts to improve harmonization, in terms of relevant executive branch agencies, coordination with other public and private entities, and coordination with partner countries’ national strategic plans. Paris Declaration. In 2005, 133 countries and territories, including the United States, and 28 participating international organizations, endorsed the Paris Declaration on Aid Effectiveness, an international agreement committing countries to increase efforts in supporting country ownership, harmonization, alignment, results, and mutual accountability. Specifically, donors committed to taking a number of steps to implement the principles of the Paris Declaration: to respect partner country leadership and help strengthen their capacity to exercise it; base support on national strategies; implement common arrangements for reporting to partner governments on donor activities and aid flows; harmonize monitoring and reporting requirements; and provide timely, transparent, and comprehensive information on aid flows to enable partner authorities to present comprehensive budget reports to their legislatures and citizens. Three Ones. In 2004, key donors, including the United States, reaffirmed their commitment to strengthening national HIV/AIDS responses led by the affected countries themselves and endorsed the “Three Ones” principles. These principles aim to achieve the most effective and efficient use of resources and greater collaboration among donors in order to avoid duplication and fragmentation. Specifically, the donors agreed to base support on one HIV/AIDS action framework that provides the basis for coordinating the work of all partners, one national AIDS coordinating authority with a broad multisectoral mandate, and one country-level monitoring and evaluation system in each country. PEPFAR 5-year strategy. PEPFAR’s updated 5-year strategy, released in 2009 as mandated by the 2008 Leadership Act, highlights alignment with national strategies as a key component of promoting sustainability of U.S.- supported HIV/AIDS efforts through partner country ownership. In the first 5 years of the program, PEPFAR focused on establishing and scaling up prevention, care, and treatment programs. During the second 5-year phase, PEPFAR will focus on transitioning from an emergency response to promotion of sustainable country programs. PEPFAR’s emphasis on country ownership includes ensuring that the services PEPFAR supports are aligned with the national plans of partner governments and integrated with existing health care delivery systems. The new 5-year strategy acknowledges that during the first phase of PEPFAR, PEPFAR implementation did not always fully complement existing national structures and some PEPFAR programs and services were established apart from existing health care delivery systems. The new strategy affirms the principles of the Paris Declaration and states that PEPFAR is working with its multilateral and bilateral partners to align responses and support countries in achieving their nationally defined HIV/AIDS goals. The Leadership Act authorized the U.S. government to establish partnership frameworks with host countries to promote a more sustainable approach to combating HIV/AIDS, characterized by strengthened country capacity, ownership, and leadership. Partnership frameworks are 5-year joint strategic agreements for cooperation between the U.S. government and partner governments to combat HIV/AIDS in the partner country through technical assistance, support for service delivery, policy reform, and coordinated funding commitments. PEPFAR guidance states that the partnership framework process should involve significant collaboration with the partner government and may also include active participation from other key partners from civil society, community-based and faith-based organizations, the private sector, other bilateral and multilateral partners, and international organizations. PEPFAR guidance further states that a key objective of the partnership framework is to ensure that PEPFAR programs reflect country ownership, with partner governments at the center of decision making, leadership, and management of their HIV/AIDS programs and national health systems. The expectation is that at the end of the partnership framework, in addition to achieving results in HIV/AIDS prevention, treatment, and care, partner country governments will be better positioned to assume primary responsibility for the national responses to HIV/AIDS in terms of management, strategic direction, performance monitoring, decision making, coordination, and, where possible, funding support and service delivery. The partnership framework is meant to support government coordination of different funding streams under the framework of a national strategy. The partnership framework should be fully in line with the national HIV/AIDS plan of the country and emphasize sustainable programs with increased country decision-making authority and leadership. PEPFAR guidance defines the partnership framework as consisting of two interrelated documents, the partnership framework and the partnership framework implementation plan. The partnership framework is to focus on establishing a collaborative relationship, negotiating the overarching 5- year goals of the framework and the commitments of each party, and setting forth these agreements in a concise signed document. The partnership framework implementation plan is to include a more detailed description of the approach to supporting increased country ownership, baseline data, specific strategies for achieving the 5-year goals and objectives, and a monitoring and evaluation plan. The COP is used for planning annual U.S. investments in HIV/AIDS and approving annual U.S. bilateral HIV/AIDS funding, and it serves as the annual work plan for PEPFAR activities. The COP database, which houses all COP information submitted by PEPFAR country teams, provides information for funding review and approval and serves as the basis for congressional notification, allocation, and tracking of budget and targets. According to OGAC, PEPFAR country teams in 31 countries completed COPs for fiscal year 2010. In addition three regions developed and submitted regional operational plans for fiscal year 2010: Caribbean, Central America, and Central Asia. The COP development process involves interagency coordination as well as consultation with other PEPFAR stakeholders. The U.S. Ambassador leads the development of COPs, which are created through a collaborative process involving PEPFAR country teams. The COP development process also involves collaboration with country and international partners in an annual review and planning process. According to PEPFAR COP guidance, developing an annual COP provides an opportunity to bring the U.S. country team together with partner government authorities, multilateral development partners, and civil society as an essential aspect of effective planning, leveraging resources, and fostering sustainability of programs. The draft COPs are ultimately reviewed by interagency headquarters teams, which make recommendations to OGAC regarding final review and approval. PEPFAR 2010 COP guidance notes that PEPFAR programs should be fully in keeping with developing countries’ national strategies and that PEPFAR country teams should identify areas of partner countries’ national HIV/AIDS programs for U.S. government investment and support. The guidance also states that the U.S. government is firmly committed to the principles of alignment with national programs, including alignment with other international partners. At the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), member countries committed to developing multisectoral HIV/AIDS strategies and finance plans. In our four case study countries— Cambodia, Malawi, Uganda, and Vietnam—the multisectoral strategy serves as a multiyear broad outline of its HIV/AIDS prevention, treatment, and care objectives. While a national commission may be the lead coordinating authority for HIV/AIDS policy and programs, the development and implementation of such a strategy can also involve many government ministries and offices. Additional strategy documents, such as sector-specific strategies and HIV program-specific strategies or action plans can also provide further guidance for national programs to combat HIV/AIDS (see table 1 for information on national HIV/AIDS strategies in four countries).