The IOM’s PEPFAR Evaluation: Implications for the Global Fund

March 12, 2013

Todd Summers
Senior Adviser, Global Health Policy Center at CSIS

The U.S. Institute of Medicine of the National Academy of Sciences recently completed a congressionally-mandated impact evaluation of the PEPFAR HIV/AIDS program, which is the single largest ever health initiative of the U.S. government.  PEPFAR is a big and complex program, and so it’s not surprising that the IOM Evaluation of PEPFAR is itself big and complex – the full volume weighs in at a hefty 850 pages.

Four key points in the IOM evaluation should resonate with Global Fund leadership:

1. Prevention of new HIV infections must be a higher priority, and must reach beyond a strictly medicalized approach.  Despite an overall laudatory review, the evaluation notes that PEPFAR continues to emphasize treatment and clinical care over prevention, and often fails to address the challenges patients face in accessing and retaining HIV/AIDS services, including prevention.  While the Global Fund’s new five-year strategy smartly identifies the need to focus spending on high-impact prevention interventions, that insight can’t be allowed to translate into a narrow biomedical approach that, while easier to measure, misses opportunities to address behavioral, structural, and human rights challenges that can often frustrate prevention and treatment efforts. 

2. We have to get better at measuring success.  PEPFAR, like the Global Fund, relies heavily on monitoring program activities, which don’t necessarily translate into positive health outcomes.  The IOM evaluation notes that the indicators currently used to gauge success may help “to monitor implementation of activities but do not reflect quality, efficiency, or effectiveness.”  This is a particular challenge for prevention, which still lacks adequate tools for determining impact -- it's inherently difficult to measure infections that don't occur.  For “most at risk” populations such as men who have sex with men and injection drug users, we still use the number of “people reached” rather than prevention or treatment outcomes that more accurately measure whether a program is succeeding.

3. Even when we can measure impact, attribution of benefits to specific funders is rarely possible.  While U.S. politicians understandably expect to know how many lives PEPFAR has saved, it’s hard to do because there are few places where PEPFAR is the only funder.  As we push for a more integrated approach among funders, and for countries to do more for themselves, it’s only going to get more complicated.  That’s certainly true for the Global Fund, which provides only about one-quarter of donor assistance for HIV/AIDS.  The IOM calls on PEPFAR to help “develop appropriate ways to assess contributions to the improved performance and effectiveness of national efforts” that include the totality of the response, not just that which is financed by PEPFAR.  That kind of evaluation approach is really needed by the Global Fund, too, which is always asked by its donors to show what their own individual investments produce – how many lives saved and infections averted – even as they press the Global Fund to sublimate its own needs to those of the countries it is seeking to help.

4. Higher investment is needed to equip countries to collect and analyze data to measure progress and inform decision-making.  The Global Fund’s new funding mechanism relies heavily on high quality national strategies that are based on careful analyses to determine how best to invest resources for maximum health impact.  Many countries do not yet really have this capacity and would certainly benefit from help from PEPFAR and other technical partners like UNAIDS and the World Health Organization in strengthening their ability to measure progress. 

It was heartening to read the IOM conclusion that PEPFAR “has played a transformative role with its contribution to the global response to HIV.”  Our recent CSIS trip to South Africa, the country that carries the highest burden of HIV in the world, confirmed how big an impact PEPFAR has had in saving lives, not to mention the positive impact it’s had on the US relationship with South Africa.  The Global Fund needs to pore over the IOM evaluation and absorb its well-crafted recommendations for achieving even more in the future.  Especially in lean economic times, our forward progress in fighting AIDS will depend more than ever on being smart about our approach.

Read more posts by Todd Summers.