The President’s Emergency Plan for AIDS Relief in Africa

The President’s Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes.

Since 2003, the Unites States President’s Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic. However, the effect of PEPFAR on HIV-related outcomes is unknown. Bendavid and Bhattacharya set out to assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa. Comparing trends before and after the initiation of PEPFAR’s activities they examined data from 12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations). The intervention they were assessing was a 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003. Outcome measures were HIV-related deaths, the number of people living with HIV, and HIV prevalence. Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR’s activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis. The selection of the focus countries was not random, which limits the generalizability of the results. After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR’s evaluation programs.

The criteria for selecting PEPFAR focus countries appear to have been burden of disease, the country government’s commitment to responding to HIV, administrative capacity, and a willingness to partner with the US government। Nearly half of PEPFAR resources were spent on treatment and only one-fifth on prevention, of which one-third were earmarked for abstinence-only programmes for which the evidence base is questionable. It is not surprising then that mortality reduction rather than HIV prevalence declines appears to be the significant health-related outcome of PEPFAR from 2004 to 2007. The estimated 1.2 million deaths averted through improved treatment and care of people living with HIV in focus countries is nonetheless laudatory. In July 2008, a 48 million USD budget over 5 years was authorised for the next phase of PEPFAR and it includes a broader emphasis on strengthening health systems.