As we reflect on 30 years of HIV/AIDS, it is clear that a major part of the story over the past decade has been the central role the United States has played in scaling up the response at the global level. Building on lessons learned during the earlier years of the domestic response, the US President's Emergency Plan for AIDS Relief (PEPFAR) has contributed to remarkable progress. We stand at a moment of great opportunity to continue to move toward the goal, articulated by President Barack Obama and Secretary Hillary Rodham Clinton, of an AIDS-free generation.
THE GLOBAL RESPONSE: A SHARED RESPONSIBILITY
In its early years, in order to save as many lives as possible, PEPFAR focused on scaling up interventions rapidly. Thanks to the hard work of many dedicated people, the achievements have been extraordinary. We were fortunate that budgets also increased rapidly to support this emergency response. However, these successes challenge us to do even more, and in the current era of constrained resources, advocacy for resources will continue to be critical, as it has been throughout the HIV/AIDS epidemic. We have found that results are the best argument for heightened commitment.
As we consider the opportunities created by recent scientific advances, we must remember that the global AIDS response is a shared responsibility that cannot be met by one nation alone. On World AIDS Day 2011, President Obama called on the global community to join the United States in this undertaking. Three key funding sources must contribute to meeting this shared responsibility as follows: bilateral programs such as PEPFAR (the main focus of this paper), multilateral efforts, and the contributions of the partner countries themselves.
As a multilateral mechanism, the Global Fund to Fight AIDS, Tuberculosis, and Malaria provides a mechanism for other donors to expand their commitment as the United States has done. In addition to our bilateral PEPFAR effort, the United States is the Global Fund's largest supporter, providing about 27% of all its contributions to date. Through this investment, we extend our impact because each dollar invested in the fund leverages $2.50 from other donors. In October 2010, the United States tied a multiyear pledge to the Global Fund to successful implementation of reforms that increase the impact of grants. The fund took decisive action in adopting comprehensive reforms in 2011 and is now rapidly moving forward with reform. Several donors, with growing assurance that the impact of their donations will be maximized, have increased their contributions; others have stepped up and contributed for the first time.
It is also essential for hard-hit countries to build their commitment and capacity to lead their national responses, increasing national AIDS funding based on their level of economic resources. In particular, middle-income countries have begun to increase their investments. South Africa, with the world's largest population of individuals living with HIV, is the leading example of a country that has ramped up its investment (now more than US $1 billion) and is continuing to do so. Progress toward country ownership—in financing and in other dimensions—is essential for AIDS programs to be sustainable over the long term.
SMART INVESTMENTS: ASKING OURSELVES THE KEY QUESTIONS
Those involved in program implementation can best support the case for the world to meet our shared responsibility by making the most of our current resources. For PEPFAR, this means making smart investments that maximize the life-saving impact of each dollar entrusted to PEPFAR by Congress and the American people. The challenge of maximizing impact is faced by all partners involved in the response in resource-limited countries. It is borne in a special way by country governments and civil society, yet external partners such as PEPFAR and the Global Fund face it as well.
Drawing on PEPFAR's experience, this article briefly surveys some of the key questions that have proved useful in guiding our efforts to maximize our impact as we support partner countries. They are offered to accelerate the progress achieved by all global partners—the key to an expanded response in the fourth decade of the HIV/AIDS epidemic.
A guiding principle for maximizing the impact of resources is that all partners in each country need to assess whether allocations are appropriately tailored to that country's context. This assessment becomes more difficult in countries with generalized epidemics and substantial investments across the spectrum of prevention, treatment, and care from multiple partners, which may include the government, the private sector, and civil society (including faith-based groups and groups of people living with HIV) in addition to external partners.
PEPFAR's Impact and Efficiency Acceleration Plan, launched in 2011, is serving as a framework for making smart investments.1 Using this plan as a guide, we have asked our teams to consider a series of questions about their portfolio.
Generation and Use of Economic and Financial Data
* Have we targeted special costing studies to examine areas of activity with the greatest investments and/or the least information?
* Do we have annually updated information, by cost category, on the costs of producing each of our program outputs and outcomes?
* Have we prioritized expenditure analysis and support to governments for understanding national funding streams?
We must generate and use economic and financial data to drive program decision-making. Helpfully, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has emphasized the need to “know your epidemic.” Now, all partners in a country response must with equal intensity “know our budget” and “know what our budget is buying us.” Within PEPFAR, we are rapidly expanding expenditure analyses, targeted costing studies, and other information to understand our expenditures and the outputs being generated.2–4 Better information leads to better decision-making and actions to improve efficiency. Better information also supports partner countries as they make the best use of diverse funding streams, including their own.
Allocation of Resources Based on Impact
* Are our program and funding decisions based on scientific evidence as to the impact of each intervention on human life and on the epidemic?
* How is the epidemic changing, and are we properly targeting elements of the continuum of response that are the current priorities?
* Have inertia and perceived long-term funding commitments to agreements or contracts dissuaded potential efforts to make more strategic allocation decisions? If so, what changes can be made immediately to change that situation?
Informed by an understanding of our programs' costs, we can apply the science to allocate our resources based on the impact of interventions in the country context.
Collaboration with Governments, the Global Fund, and Others to Align Programs
* Are we engaging the appropriate local stakeholders, including the partner government, in selecting the interventions in the country strategy that we will cover?
* What additional resources, monetary and otherwise, are national governments contributing to their response to HIV?
* Have we made appropriate adjustments to ensure complementarity of all investments (including those of the national government, the Global Fund, and bilateral programs such as PEPFAR)?
Individual partners should not make program decisions in a vacuum. Through deeper country engagement, we can make strategic investment choices that support national strategies, complement other donor investments, and create synergies. Engaging the appropriate local stakeholders allows us to better coordinate resources and programs among national governments, the Global Fund, and bilateral donors. PEPFAR's Partnership Framework process has provided a forum for this dialogue.
Streamlining Operations at the Individual Partner Level
* How can we improve our own effectiveness and efficiency?
* How well do our staffing patterns and other elements of our footprint in country match country priorities?
Each partner must continue to streamline its own operations in support of the country's agenda. For example, PEPFAR has renewed emphasis on a “whole of government” response, ensuring that implementing agencies comprise a fully coordinated high-functioning team. We have also asked whether our country presence is appropriately sized and tailored to the national response.
Maximizing Impact at the Country Level
The country-driven process outlined here—asking and gathering the right information to answer the right questions—can strengthen allocation decisions across programs, improve efficiency, and ultimately save more lives.
PEPFAR has applied these principles in the context of decision-making around scale-up of antiretroviral therapy. Successful treatment scale-up has saved millions of lives and remains central to further success in reducing morbidity and mortality. In 2011, new evidence made it clear that antiretroviral therapy also dramatically reduces the infectivity of people living with HIV, ending the tired “treatment versus prevention” debate by making it clear that treatment is a highly effective form of prevention.5 This strong evidence led to President Obama's decision to increase PEPFAR's treatment goal, committing to support 6 million people by the end of 2013.
As PEPFAR scales up treatment toward this goal, Table 1 provides an example of the application of insights gained from the questions above.6 In this table, countries with a generalized epidemic have been categorized using economic, fiscal, and epidemiologic data. The vertical axis of the table reflects disease burden, along with treatment coverage. The table's horizontal axis reflects current Global Fund disbursements per person living with HIV and World Bank income level.
Countries whose names are boldfaced are among those with the highest disease burden, lower treatment coverage levels, and the lowest internal and disbursed Global Fund resources. On the basis of this framework, these countries' PEPFAR teams were advised to consider raising budgetary allocations to treatment over time as needed.
On the other hand, we indicated that countries clearly at the other end of the spectrum in terms of available resources and disease burden would not be expected to propose an increase in their treatment budget allocations beyond existing levels. In these countries in particular, we would expect substantial and increasing government commitments to funding, strong Global Fund applications, and efforts to fully absorb these programs into the national systems.
Considerations will be different for different partners (eg, host governments versus external partners) in different country contexts, and this categorization provides only one lens, albeit an important one, through which decisions are considered. Greater treatment funding may be required by other circumstances, such as the need for rapid acceleration of initiatives for prevention of mother-to-child transmission of HIV or major increases in counseling and testing to facilitate male circumcision scale-up. These and other factors contribute to decision-making for countries in the middle zone of the table, where there may be less clarity about whether to continue expansion of treatment investments. In all cases, funding allocations should also reflect deep engagement with government and agreements over projected needs and shared responsibilities.
It is a reality that the availability of resources for HIV/AIDS will always depend on a wide range of factors—among them global economic factors far beyond the influence of program implementers. As we move into the fourth decade of the response to HIV/AIDS, the driving force behind all efforts must be the impulse to maximize the life-saving impact of the treatments and protocols we have with the resources available.
Over the last decade, the global partners confronting this epidemic have had an extraordinary impact on people infected and affected by HIV/AIDS. This success remains the most compelling argument for the world to do even more going forward. If we keep our eye on the ball by making smart investments that maximize the impact of the resources entrusted to us, we will be able to obtain the resources needed to achieve an AIDS-free generation.