Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa.

BACKGROUND: Since 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the impact of antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) programmes on survival, mortality, new infections and the number of orphans from 2004 to 2013 in 16 PEPFAR countries in Africa. METHODS: PEPFAR indicators tracking the number of persons receiving ART for their own health, ART regimens for PMTCT and biomedical prevention of HIV through VMMC were collected across 16 PEPFAR countries. To estimate the impact of PEPFAR programmes for ART, PMTCT and VMMC, we compared the current scenario of PEPFAR-supported interventions to a counterfactual scenario without PEPFAR, and assessed the number of life years gained (LYG), number of orphans averted and HIV infections averted. Mathematical modelling was conducted using the SPECTRUM modelling suite V.5.03. RESULTS: From 2004 to 2013, PEPFAR programmes provided support for a cumulative number of 24 565 127 adults and children on ART, 4 154 878 medical male circumcisions, and ART for PMTCT among 4 154 478 pregnant women in 16 PEPFAR countries. Based on findings from the model, these efforts have helped avert 2.9 million HIV infections in the same period. During 2004-2013, PEPFAR ART programmes alone helped avert almost 9 million orphans in 16 PEPFAR countries and resulted in 11.6 million LYG. CONCLUSIONS: Modelling results suggest that the rapid scale-up of PEPFAR-funded ART, PMTCT and VMMC programmes in Africa during 2004-2013 led to substantially fewer new HIV infections and orphaned children during that time and longer lives among people living with HIV. Our estimates do not account for the impact of the PEPFAR-funded non-biomedical interventions such as behavioural and structural interventions included in the comprehensive HIV prevention, care and treatment strategy used by PEPFAR countries. Therefore, the number of HIV infections and orphans averted and LYG may be underestimated by these models.

Replicating PEPFAR's success: how interventions shown to be effective abroad can be applied to the AIDS epidemic in the US.

The President's Emergency Plan for AIDS Relief (PEPFAR), which began in 2003, initially responded to the global AIDS epidemic by applying lessons learned in treating the disease in the United States to addressing the emergency abroad. As the program expanded, it evolved to support interventions increasingly tailored to local needs in countries receiving PEPFAR assistance. This global experience has created a knowledge base of how to provide HIV/AIDS prevention, care, and treatment services in low-resource settings. It underscored the importance of treatment adherence, family-centered care, and integration of HIV into broader health care delivery systems. Applying these lessons can help US policy makers address existing gaps in HIV care in the United States, where the availability of HIV treatment has at times masked the continued need for testing, early diagnosis, targeted prevention for key populations, and a solid array of social services for people living with HIV/AIDS and their families. This article identifies PEPFAR practices that merit further exploration for adoption in the United States, including strategies to increase adherence to drug treatment regimens and to ensure that HIV services are broadly integrated with other aspects of health care.

PEPFAR's evolving HIV prevention approaches for key populations--people who inject drugs, men who have sex with men, and sex workers: progress, challenges, and opportunities.

In most countries, the burden of HIV among people who inject drugs, men who have sex with men, and sex workers is disproportionately high compared with that in the general population. Meanwhile, coverage rates of effective interventions among those key populations (KPs) are extremely low, despite a strong evidence base about the effectiveness of currently available interventions. In its first decade, President's Emergency Plan for AIDS Relief (PEPFAR) is making progress in responding to HIV/AIDS, its risk factors, and the needs of KPs. Recent surveillance, surveys, and size estimation activities are helping PEPFAR country programs better estimate the HIV disease burden, understand risk behavior trends, and determine coverage and resources required for appropriate scale-up of services for KPs. To expand country planning of programs to further reduce HIV burden and increase coverage among KPs, PEPFAR has developed a strategy consisting of technical documents on the prevention of HIV among people who inject drugs (July 2010) and prevention of HIV among men who have sex with men (May 2011), linked with regional meetings and assistance visits to guide the adoption and scale-up of comprehensive packages of evidence-based prevention services for KPs. The implementation and scaling up of available and targeted interventions adapted for KPs are important steps in gaining better control over the spread and impact of HIV/AIDS among these populations.

The United States President's Emergency Plan for AIDS Relief: a story of partnerships and smart investments to turn the tide of the global AIDS pandemic.

The United States President's Emergency Plan for AIDS Relief (PEPFAR) has played a key leadership role in the global response to the HIV/AIDS pandemic. PEPFAR was inspired by the principles of the historic Monterrey Consensus (United Nations. Monterrey Consensus on Financing for Development, Monterrey, Mexico, March 18-22, 2002. New York: United Nations; 2002. Available at: http://www.un.org/esa/ffd/monterrey/MonterreyConsensus.pdf. Accessed April 21, 2012), which changed the underlying conceptual framework for international development, and therefore global health--a shift from paternalism to partnership that begins with country ownership and requires good governance, a results-based approach, and engagement of all sectors of society. PEPFAR began with a focus on the growing emergency of the HIV/AIDS pandemic by rapidly expanding HIV services, building clinical capacity, implementing strategic information systems, and building a coalition of partners to lead the response. Within the first years of implementation, there was a shift to sustainability, including the advent of Partnership Frameworks. The PEPFAR reauthorization in 2008 codified into law, the evolution in policies and programs for the next phase of implementation. In 2011 alone, PEPFAR supported nearly 4 million people on treatment, supported programs that provided more than 1.5 million HIV-positive pregnant women with antiretroviral drugs to prevent HIV transmission to their children, and supported HIV testing for more than 40 million people. This article provides an overview of how smart investments and partnerships across sectors and US agencies have helped achieve unprecedented results in increasing HIV/AIDS services and engaging partner countries and organizations in sharing the responsibility for an AIDS-free generation.