On March 30, 2007, the Institute of Medicine (IOM) released a report finding major flaws with the President’s Emergency Plan for AIDS Relief (PEPFAR). The findings, released in a report titled PEPFAR Implementation: Progress and Promise, provide an in-depth analysis of the implementation of prevention, care, and treatment programs in the15 focus countries. 

PEPFAR, a five year program with a budget of 15 billion dollars, funds HIV prevention, care, and treatment services in over 120 countries, including 15 focus countries.1  PEPFAR has several mandates indicating how funds need to be allocated including a requirement that 33% of all prevention funding must be spent on programs that promote abstinence as the only way to stop the spread of HIV.  One of the key finding s of the IOM report is that “the abstinence-until-marriage budget allocation in the Leadership Act hampers [prevention] efforts and thus PEPFAR’s ability to meet the [HIV prevention] target.”

According to the IOM, the earmark “has greatly limited the ability of Country Teams to develop and implement comprehensive prevention programs that are well integrated with each other.”  As a result of this earmark, PEPFAR “has supported some preventive interventions that are not firmly evidence-based.”

The report concludes that, to support and implement comprehensive interventions appropriate to each country, “congress should remove the budget allocations and replace them with more appropriate mechanisms that ensure accountability for results.”

“The findings of the IOM report are welcome news for efforts to put evidence, not politics, back into the driver’s seat in our country’s HIV-prevention programs,” said William Smith, vice president for public policy at SIECUS. “In 2005, SIECUS’ analysis of PEPFAR’s abstinence-until-marriage earmark resulted in the similar recommendation that this funding allocation should be abandoned.”  The recommendation was one of six made in SIECUS’ PEPFAR Country Profiles: Focusing in on Prevention and Youth, released in 2005.

The IOM’s report also provides several recommendations for ensuring the sustainability of the PEPFAR program, including expansion, improvement, and better integration of prevention, care, and treatment services.  Although the report’s researchers agree that PEPFAR has great potential, they suggest that the program’s current reporting mechanisms do not facilitate integration or linkages between existing components. 

The report also indicates that more resources need to be spent on collecting epidemiologic data about behavior and disease transmission in each of the focus countries.  This data, according to the authors, is crucial in determining individualized HIV interventions for each country, rather than the current tactic of applying a “one-size-fits-all” model irrespective of the nature of the epidemic.

In addition, the report makes a major recommendation regarding PEPFAR’s use of generic anti-retroviral drugs (ARVs).  Currently, all other major international donors rely on the World Health Organization’s drug certification process.  The Office of the Global AIDS Coordinator (OGAC), the U.S. agency that directs PEPFAR, however, requires that all drugs purchased and distributed under PEPFAR be qualified by the U.S. Food and Drug Administration (FDA).  According to the report, the FDA approval process limits access to generic drugs and presents a major challenge to country teams who are unable to purchase as much medication as is needed. The IOM recommended that transition to using the WHO process, in order to meet treatment goals and enhance sustainability of the program.

The full IOM report can be accessed at www.iom.gov.

The SIECUS PEPFAR Country Profiles can be accessed at www.siecus.org/inter/pepfar.

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