The HIV/AIDS pandemic has beleaguered the world for more than three decades. The countries most affected continue to be in sub-Saharan Africa, home to an estimated two-thirds of people living with HIV. There have been major increases in international aid assistance as well as in national commitments to and investments in HIV prevention, treatment, care, and capacity building activities, yet funding remains insufficient to meet the estimated immediate and projected needs.

In 2003, in response to the devastating consequences of the HIV pandemic, the U.S. Congress funded a major new U.S. global health initiative, which became known as the President's Emergency Plan for AIDS Relief, or PEPFAR.¹ PEPFAR remains the largest bilateral initiative aimed at addressing HIV/AIDS. At the time of its initial authorization, PEPFAR was seen as a bold initiative, testing, among other strategies, whether treatment could be successfully and intensively scaled up in low-resource settings. The initial authorizing language mandated that the Institute of Medicine (IOM) assess the progress of PEPFAR implementation to help guide the future directions of this innovative program. The findings and recommendations of that IOM study, published in 2007, informed PEPFAR processes, policies, and activities as well as the legislation that reauthorized the initiative, known as the Lantos-Hyde Act of 2008.²

The reauthorization legislation mandated that the IOM assess the performance of U.S.-assisted global HIV/AIDS programs and evaluate the impact on health of prevention, treatment, and care efforts supported by U.S. funding (see Appendix A for the statement of task). This report is intended to provide a rigorous, evidence-based, multidisciplinary, and independent evaluation of PEPFAR to Congress and the Department of State as well as to the scientific community, program implementers, policy makers, civil society, people living with and affected by HIV/AIDS, and international stakeholders in global public health.

In response to its mandate, IOM first convened a planning committee to develop a strategic approach for conducting the evaluation. This approach, published in a 2010 report, addressed the complexities of evaluating an initiative with the scale and diversity of programs that PEPFAR supports and with the range of countries in which it operates. The dynamism of an initiative that was operating and evolving over the course of the evaluation presented additional complexity.

To carry out the evaluation, the IOM convened a diverse expert committee that included considerable overlap with the members of the planning committee. Guided by the strategic approach, the committee, IOM staff, and consultants carried out a mixed-methods approach. The qualitative data that were collected included extensive document review and more than 400 semi-structured interviews conducted from 2010 to 2012. Each member of the committee visited at least one PEPFAR partner country, and in total the evaluation team conducted 13 data collection visits to partner countries, hearing the perspectives of a wide range of stakeholders. PEPFAR headquarters and mission staff, partner country stakeholders, and global partners all generously contributed their time and experience to the committee. Quantitative data included financial data, program and clinical monitoring data, and epidemiological information. The committee struggled to find quantitative data to address some of the elements of the statement of task. Beyond the specific issues of available data to address the legislated task, however, there is also the critical imperative that PEPFAR be able to determine the key questions to ask in order to assess its own performance and effectiveness and to plan in advance for the collection of meaningful data to answer those questions and guide the ongoing evolution of PEPFAR.

The 2008 reauthorization of PEPFAR emphasized that the program must transition from its initial goal of providing an emergency response to longer-term goals of enhancing sustainability, promoting country ownership, and strengthening health systems. One of the clear findings that emerged from this evaluation is that as PEPFAR evolves in this way, major dilemmas are emerging that create tensions for decision making related to a country's HIV response; these dilemmas will require attention as the program moves forward. As the HIV response becomes more country-driven, PEPFAR—and any other external donor effort—will need to focus its contributions on national efforts rather than on the direct provision of services and attribution of results. This will have consequences for program planning, implementation, and evaluation. Furthermore, focusing on country ownership will require relinquishing some control over the response, which in turn will have unknown consequences for quality and access to services; PEPFAR and its partner countries will have to grapple with these issues together.

PEPFAR has been globally transformative—changing in many ways the paradigm of global health and what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis. As it moves forward, PEPFAR must continue to be bold in its vision, implementation, and global leadership, but now toward its aims of continuing to strengthen the capacity of partner countries to respond to the pandemic. The committee hopes that this evaluation will serve as a tool to achieve these aims.

The committee extends its gratitude to all those who provided information to assist in the evaluation. The committee has continuing deep admiration for those carrying out the difficult work of responding to the pandemic. I was privileged to serve as the chair for both the planning committee and the evaluation committee. I would like to express my appreciation to the members of both committees for the expertise and perspective they contributed, for their robust participation in discourse and deliberation, and for the immeasurable time and energy they volunteered. The IOM committee staff, very ably led by study co-directors Bridget Kelly and Kimberly Scott, have been highly professional, thoughtful, and committed to ensuring the most responsive and rigorous evaluation possible. I thank the entire staff and the committee consultants for their tireless efforts in support of the committee.

Robert E. Black, Chair

Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs Implemented Under the Lantos-Hyde Act of 2008