PEPFAR supports the national HIV response in more than 30 countries. PEPFAR Has Helped Countries Expand Treatment Programs and Increase Their Efficiency and Effectiveness

Our recent reports have concluded that PEPFAR has helped partner  countries expand treatment programs and increase program efficiency  and effectiveness. PEPFAR’s per-patient treatment costs have declined  significantly, facilitating substantial increases in the number of people on  ARV treatment. PEPFAR has also worked with U.S. implementing agencies, international  donors, and partner countries to increase the efficiency and reliability of  ARV drug supply chains. Declining Per-Patient Treatment Costs

According to OGAC, PEPFAR’s per-patient treatment costs declined from  about $1,053 to about $339 from 2005 to 2011, based on budget  calculations. Of the 23 PEPFAR country teams directly providing treatment  services, 20 provided data on this indicator in their fiscal year 2012  reports to OGAC, and 10 of the 20 reported retention rates at or above 80  percent for facilities where PEPFAR implementing partners directly  support treatment services. More Efficient and Reliable Drug Supply Chains

Our work shows that PEPFAR has worked with U.S. implementing  agencies, international donors, and partner countries to increase the  efficiency and reliability of ARV drug supply chains. Better Information Management Is Key to Helping Countries Improve and Expand Treatment Programs

Our recent work has found that, as PEPFAR partner countries assume  greater responsibility for managing their treatment programs, better  information management remains crucial to helping countries improve  and expand treatment programs. Our reviews of PEPFAR treatment  costs, results, and ARV drug supply chains have revealed some  limitations in the completeness, timeliness, and consistency of key  program information. We also found important information lacking in  PEPFAR program evaluations, plans, and results reporting. More Complete and Timely Cost Data Could Help Countries Manage Costs and Plan Treatment Expansion More Effectively

Despite substantial declines in per-patient treatment costs, it is important  that countries continue to improve the efficiency of their programs to  expand to meet the needs of the estimated 23 million people eligible for  ARV treatment under recent WHO guidelines. More Consistent, Complete, and Timely Information on Treatment Results Could Enhance the Quality of Treatment Programs

OGAC has reported on PEPFAR treatment program results primarily in  terms of (1) numbers of people on treatment directly supported by  PEPFAR, (2) percentages of eligible people receiving treatment, and (3)  percentages of people alive and on treatment 12 months after starting  treatment. For PEPFAR and partner countries to continue expanding treatment  programs to serve up to 23 million eligible people, further improving drug  supply chains is critical, particularly the efficiency of elements managed  by partner countries. To help ensure that drug supply chains in PEPFAR partner countries  function efficiently and mitigate the risks of shortages and wasted and lost  drugs, we recommended that State direct OGAC to require PEPFAR  country teams to (1) develop and implement plans to help partner  countries improve inventory controls and record keeping and (2) track the  progress partner countries are making in measuring ARV drug  consumption, waste, and loss. More Systematic and Rigorous Program Evaluations Could Better Inform PEPFAR Stakeholders about How to Improve Programs

OGAC, CDC, and USAID have evaluated a wide variety of PEPFAR  program activities, demonstrating a clear commitment to evaluation. Thus, we concluded that OGAC could  provide better context for understanding PEPFAR’s achievements and  challenges by comparing program results with targets and discussing  efforts to ensure the quality of reported information. We will send copies of this report to the Secretary of State and the U.S. President’s Emergency Plan for AIDS Relief: Program Planning and  Reporting. Global HIV/AIDS: A More Country-Based Approach Could Improve  Allocation of PEPFAR Funding.
Why GAO Did This Study

PEPFAR, first authorized in 2003, has supported significant advances in HIV/AIDS prevention, treatment, and care in over 30 countries, including directly supporting treatment for about 5.1 million people; however, millions more people still need treatment. Congress reauthorized PEPFAR in 2008authorizing up to $48 billion over 5 yearsdirecting OGAC to continue expanding the number of people receiving care and treatment through PEPFAR while also making it a major policy goal to help partner countries develop independent, sustainable HIV programs. As a result, PEPFAR began shifting efforts from directly providing treatment services toward support for treatment programs managed by partner countries. GAO completed a series of reports between 2011 and 2013 covering PEPFAR treatment program costs, results, and supply chains for ARV drugs, and PEPFAR program evaluations and planning and reporting. GAO was asked to summarize the key themes of these reports relating to (1) PEPFARs successes in expanding and improving treatment programs and (2) information management challenges to further improving and expanding treatment programs.

What GAO Found

The President's Emergency Plan for AIDS Relief (PEPFAR) has expanded treatment programs and increased their efficiency and effectiveness.
According to the Department of State's (State) Office of the U.S. Global AIDS Coordinator (OGAC), from 2005 to 2011, PEPFAR's per-patient treatment costs declined from about $1,053 to about $339. PEPFAR's increasing use of generic products and declining antiretroviral (ARV) drug prices have been a key source of savings. Programs also benefited from economies of scale and program maturity.
PEPFAR and partner countries have achieved substantial increases in the number of people on ARV drug treatment and have increased the percentage of eligible people receiving treatment. According to OGAC, treatment retention rates are at or above 80 percent at PEPFAR-supported treatment facilities in 10 partner countries.
PEPFAR has also worked with U.S. implementing agencies, international donors, and partner countries to increase the efficiency and reliability of ARV drug supply chains.
PEPFAR implementing agencies have evaluated a wide variety of PEPFAR program activities, demonstrating a clear commitment to program improvements.
Better information management is crucial to helping countries improve and expand treatment programs to meet the needs of the estimated 23 million people eligible for ARV treatment under 2012 international guidelines. GAO's reviews of PEPFAR treatment costs, results, and ARV drug supply chains have revealed limitations in the completeness, timeliness, and consistency of key program information. GAO also found important information lacking in PEPFAR program evaluations, plans, and results reporting. GAO has made a series of recommendations to improve the quality of this information in order to make PEPFAR programs more efficient and effective. The potential benefits that could be realized if GAO's recommendations are implemented include the following:
More complete and timely cost data could help countries manage costs and plan treatment expansion more effectively.
More consistent, complete, and timely information on treatment results could enhance the quality of treatment programs, including patient, clinic, and program management.
Plans to help countries improve inventory management and record keeping and tracking their progress could help supply chains operate more efficiently.
A more systematic and rigorous approach to planning and conducting program evaluations could result in evaluations that better inform PEPFAR stakeholders about how to improve programs.
OGAC could provide better context for understanding PEPFAR's achievements and challenges by comparing program results with targets and discussing efforts to ensure the quality of reported information.

What GAO Recommends

GAO previously made 13 recommendations to State to improve PEPFAR treatment programs, program evaluations, and reporting of program results. State generally agreed with these recommendations and has begun implementing some of them.