New PEPFAR 5-Year Strategy Analysis

Yesterday the Obama administration announced a very positive step forward with their new five year strategy for the President’s Emergency Plan For AIDS Relief.  The long-awaited, revamped strategy reflects President Obama’s priorities for PEPFAR, grounded in the reality from the field. Pragmatism and public health approach are back.  The era of going it alone and “abstinence-until-marriage” is over.

The new PEPFAR strategy stresses prevention throughout, with clear language about youth, women and children’s health, gender-based violence, country ownership, and integration of HIV/AIDS with the rest of USG health assistance and in coordination with other donors and multilaterals. In a welcome shift towards a more comprehensive approach to global health challenges, the strategy states that “As a component of the Global Health Initiative, PEPFAR will be carefully and purposefully integrated with other health and development programs….PEPFAR is working to implement women-centered care, and to ensure that its services are gender-equitable.”
In addition, at the December 1 State department briefing, Ambassador Eric Goosby, MD, the U.S. Global AIDS Coordinator said:

“We are going to expand services in all areas, but we are going to become more efficient in our ability to prevent vertical transmission from mother to child. We are going to start targeting high-risk populations as opposed to general public service announcements that have dominated PEPFAR 1 as one of the central strategies – the abstinence, be faithful type of activity. We’re linking family planning, reproductive health services to our prevention efforts because they are more effective. Those needs are going largely unaddressed, and where interfaced with populations that need both, we should overlap them.”

Below follows Population Action International’s highlights and analysis of how PEPFAR’s strategy is changing under the Obama administration and may affect family planning, reproductive and maternal health.


PEPFAR’s Goals:

(note especially goal #4 on integration)

  • “Transition from an emergency response to promotion of sustainable country programs.” (p.6)
  • “Strengthen partner government capacity to lead the response to this epidemic and other health demands.” (p.6, local civil society capacity not specifically mentioned)
  • “Expand prevention, care, and treatment in both concentrated and generalized epidemics.” (p.6)
  • “Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems.” (p.6)
  • “Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.” (p.6)

Family Planning

(in the Linking HIV/AIDS to Women’s and Children’s Healthsection)

  • “Women and children living with HIV also face other conditions, ranging from inadequate access to family planning to lack of antenatal care to the need for food and nutrition support.” (p.7)
  • “PEPFAR is leveraging and linking HIV services to broader delivery mechanisms to improve health outcomes for women and children” with activities that include “expanding integration of HIV prevention, care and support, and treatment services with family planning and reproductive health services, so that women living with HIV can access necessary care, and so that all women know how to protect themselves from HIV infection.”  (p.7)


  • “Integration expands country capacity to address a broader array of health demands and to response to new and emerging challenges presented by HIV.” (p.6)
  • Calls for co-location of services and expanded training of health care workers. (p.9)
  • Identifies expanded access to care for women and children as a particular focus for integration efforts. (p.9)
  • “PEPFAR is also expanding capability of existing services site by linking HIV/AIDS services to other health interventions, rather than establishing and maintaining parallel systems of care.”  (p.16)

Prevention – Strategy

  • “Successful prevention programs require a combination of evidence-based, mutually reinforcing biomedical, behavioral, structural interventions.  PEPFAR is expanding its prevention activities with an emphasis on the following…Emphasizing prevention strategies that have been proven effective and targeting interventions to most at-risk populations with high incidence rates.”  (p.7)
    • This is particularly promising for the scale up of prevention efforts targeted at women and girls as later in the document it states that they “continue to face disproportionate impact of new infections, and WHO reports that AIDS in the leading cause of death worldwide for women in their reproductive years (ages 15-44).” (p.13)
  • Throughout the prevention sections of the document, it clearly states the need for prevention programs to be flexible, evidence-based, and comprehensive to meet the needs of diverse and changing target populations. (p.15)

Prevention - Targets – FY2010-2014

  • “Support the prevention of more than 12 million new HIV infections;” (p.6)
  • “Ensure that every partner country with a generalized epidemic has both 80% coverage of testing for pregnant women at the national level, and 85% coverage of antiretroviral drug (ARV) prophylaxis and treatment, as indicated, of women found to be HIV-infected;” (p.6)
  • “Double the number of at-risk babies born HIV-free, from the 240,000 babies of HIV-positive mothers who were born HIV-negative during the first five years of PEPFAR;” (p.6)
  • “In every partner country with a generalized epidemic, provide 100% of youth in PEPFAR prevention programs with comprehensive and correct knowledge of the ways HIV/AIDS is transmitted and ways to protect themselves, consistent with Millennium Development Goal indicators in this area.” (p.6)


  • Activities designed to support the link between HIV/AIDS and women and children’s health include: “expanding PEPFAR’s commitment to cross-cutting integration of gender equity in its programs and policies, with a new focus on addressing and reducing gender-based violence.” (p.7)

Country Ownership and Sustainability

  • The strategy reflects Ambassador Goosby’s emphasis on creating a sustainable program by investing in country ownership, stating “Sustainable programs must address HIV/AIDS within a broader health and development context” (p.5) and “This second phase of PEPFAR, a new program strategy is underway that supports the Administration’s overall emphasis on improving health outcomes, increasing program sustainability and integration, and strengthening health systems.” (p.7)
  • The strategy does however acknowledge the leadership role that the U.S. Government has to play in “ensur[ing] that in every partner country with a Partnership Framework, each country will change policies to address the larger structural conditions, such as gender-based violence, or low male partner involvement, which contribute to the spread of the epidemic,” (p.6-7)
  • The strategy also acknowledged areas within PEPFAR where there was room for improvement “Field perspective and input have not always been reflected in policy of planning decisions.  PEPFAR’s extensive reporting requirements were not always harmonized with other USG development programs or other international indicators.  Partner government and country teams appropriately raised concerns about the impact of reporting requirements on field programming.  Finally, the program has represented a significant scale-up of resources at Embassies without always having the commensurate increase in staff.”  (p.13)

In early 2010, Population Action International will be releasing an unofficial guide for NGOs and colleagues in the field detailing the changes to PEPFAR under the Obama administration, and as more information is available, additional analysis of the Global Health Initiative.

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