SUPPLEMENT ARTICLE
Lessons Learned From PEPFAR
Mark Dybul, MD
Abstract: The United States President’s Emergency Plan for AIDS
Relief (PEPFAR), launched by President Bush with strong bipartisan
support, was a historic moment in development both in size and
scope. With $18.8 billion across its first 5 years, it is the largest
international health initiative in history for a specific disease. In
scope, it is the first global initiative to tackle a chronic disease and
was based in a new philosophical foundation centered in country
ownership, a results-based accountable approach, the engagement of
all sectors, and good governance. With resources and a strong
intellectual base, PEPFAR saved lives and provided lessons learned
for effective development.
Key Words: AIDS, HIV, PEPFAR
(J Acquir Immune Defic Syndr 2009;52:S12–S13)
T
he Lancet recently called the United States President’s
Emergency Plan for AIDS Relief (PEPFAR) ‘‘the largest
and most successful bilateral HIV/AIDS program worldwide.’’1 With an initial commitment of $18.8 billion over
5 years, the program set ambitious prevention, care, and
treatment goals—to support treatment for 2 million persons,
the prevention of 7 million new infections, and care for 10
million, including orphans and vulnerable children. On World
AIDS Day 2008, then-president Bush announced that the
treatment and care goals he had set had been met ahead of
schedule and that the 2010 prevention goal was on track. In
July 2008, with strong bipartisan support—including from
then-senators Obama, Biden, and Clinton—the law authorizing PEPFAR was renewed at a staggering level of $48 billion
for HIV/AIDS, tuberculosis, and malaria, with $39 billion for
HIV/AIDS. The funding for what was already the largest
international health initiative in history for a single disease
more than doubled.
Looking forward, it is important to consider the
components of the success of PEPFAR’s first 5 years. Many
details contributed, among them bureaucratic processes that
will not be addressed here, where the focus will be on the
From the O’Neill Institute for National and Global Health Law, Georgetown
University Law Center, Washington, DC.
Data presented: Not applicable.
Sources of support: None.
Correspondence to: Mark Dybul, MD, O’Neill Institute for National and
Global Health Law, Georgetown University Law Center, 1340 Wallach
Place, NW, Washington, DC 20009 (e-mail: mrd54@law.georgetown.
edu).
Copyright ! 2009 by Lippincott Williams & Wilkins
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underlying conceptual framework that promoted success.
PEPFAR’s innovative programmatic approach was rooted in
a historic global commitment on development, the Monterrey
Consensus,2 and the fundamental principles it articulated. The
first and defining principle is country ownership, and effective
country ownership requires good governance, a results-based
approach with accountability, and the engagement of all
sectors. These principles were further refined and delineated in
the Paris Declaration3 and the Accra Accord.4
Country ownership begins with a belief in the dignity
and worth of every human life and respect for, and trust in, the
people of every country to design and implement successful
programs. These truths would seem to be self-evident. But
much of development had been based in concepts of ‘‘donors’’
and ‘‘recipients’’ and a paternalistic approach that those from
the north and west were coming to ‘‘help’’ poor uneducated
people. There was even a prevalent belief that it was not
possible for Africans to develop the comprehensive chronic
care programs needed for HIV prevention, treatment, and care.
PEPFAR created what the New York Times called a
‘‘philosophical revolution’’ by definitively shattering the
notion that developing countries could not effectively lead
and implement complex chronic care programs.5 Nearly 90%
of PEPFAR’s implementing partners are local organizations,
and PEPFAR’s success is, in the end, the success of the people
in the countries whom the American people are privileged to
support. President Paul Kagame of Rwanda put it well when he
discussed the fundamental difference in this approach to
development—for the first time, countries were being held to
high standards, and leaders and countries responded to that
respect and trust by achieving goals early and on budget.
Those high standards included a focus on results, with
strong accountability measures and an expectation of good
governance. When PEPFAR began, there was actually criticism that there were preestablished goals and that development efforts could not be reduced to numeric targets.
But the goals and focus on results were fundamental to the
success of the program. They kept individuals and programs
focused and drove an on-the-ground response to achieve
them. The goals themselves had important ripple effects,
including the establishment of monitoring and evaluation
systems required for reporting. It was at the HIV clinic at
McCord Hospital in Durban, South Africa, that the first
computerized monitoring system was established to report on
results. Noticing that nonpregnant women with an elevated
mean body mass who were receiving stavudine were developing lactic acidosis, clinicians were able to identify every
woman at risk in the clinic, and after their treatment was
modified, the phenomenon disappeared. The HIV clinic’s
J Acquir Immune Defic Syndr ! Volume 52, Supplement 1, November 1, 2009
J Acquir Immune Defic Syndr ! Volume 52, Supplement 1, November 1, 2009
monitoring system was so clinically useful that the entire
hospital adopted it.
However, there is always room for improvement. The
ultimate goal of antiretroviral therapy is to decrease morbidity
and mortality. The number of persons receiving therapy is an
output that predicts to some degree these ultimate outcomes,
but an evaluation of the morbidity and mortality is needed.
Early independent analysis shows 1 million lives saved in just
3 years by treatment alone, but ongoing study is needed.7
Although ‘‘infections averted’’ is an outcome measure,
evaluating changes in gender norms is important for assessing
the overall impact of prevention programs. The past several
years saw the beginning of a process to establish a continuum
of indicators from planning to outputs to outcomes and
impact. But there is no doubt that a results base with strong
accountability was a key factor in the success of PEPFAR, not
only in addressing issues relating to HIV but also in
strengthening the monitoring and evaluation of health systems
and, therefore, in facilitating development overall.
The final principle is an essential component of country
ownership—the engagement of all sectors. A country cannot
be reduced to its government. Government engagement and
leadership are essential, and only governments can set national
guidance and norms. But the private sector and nongovernmental organizations, including faith-based and communitybased organizations, also have important roles. No health
program can be successful unless the community and its
leaders are engaged, particularly when behavior change is
required. Available data indicate that health outputs improve
when the community is involved: Utilization of services
increases and loss to follow-up decreases.6 When the private
sector contributes its expertise, innovative solutions to
problems emerge. In PEPFAR, 80% of partners are nongovernmental organizations and 23% are faith-based organizations. PEPFAR was a leader in public–private partnerships,
including perhaps the most significant new effort in prevention
in decades—the Partnership for an HIV-Free Generation—
which injects the unparalleled expertise of the private sector in
q 2009 Lippincott Williams & Wilkins
Lessons Learned From PEPFAR
reaching youth and promoting behavior change. In the end, the
heart of PEPFAR was supporting the people of a country to
tackle their problems—not just the government but people
from all sectors. And the empowerment of all sectors was at the
heart of PEPFAR’s success.
The fundamental principles of PEPFAR’s success are the
fundamental principles of a new era in development. As we
look to the next 5 years, it is important to draw on these
successes and acknowledge the countless opportunities for
improvement. If we maintain the focus on country ownership,
a results-based approach and accountability, good governance,
and the engagement of all sectors, and if the resource
commitments are met, everything is possible.
REFERENCES
1. Appointment of PEPFAR head should be merit based [editorial]. Lancet.
2009;373:354. doi:10.1016/s0140-6736(09)60112-4.
2. The Monterrey Consensus of the International Conference on Financing
for Development: The Final Text of Agreements and Commitments Adopted
at the International Conference on Financing for Development, Monterrey
Mexico, 18–22 March 2002. New York, NY: United Nations; 2003.
Available at: http://www.un.org/esa/ffd/monterrey/MonterreyConsensus.
pdf. Accessed May 16, 2009.
3. Paris Declaration on Aid Effectiveness: Ownership, Harmonization,
Alignment, Results, and Mutual Accountability. Presented at: The HighLevel Forum on Aid Effectiveness; February 28–March 2, 2005; Paris,
France. Available at: http://www1.worldbank.org/harmonization/paris/
finalparisdeclaration.pdf. Accessed May 16, 2009.
4. United Nations Conference on Trade and Development. Accra Accord.
Resolutions of UNCTAD XII. Accra, Ghana: United Nations; 2008.
Available at: http://www.unctad.org/en/docs//tdxii_accra_accord_en.pdf.
Accessed May 16, 2009.
5. Stolberg SG. In global battle on AIDS, Bush creates legacy. New York
Times. January 5, 2008. Available at: http://www.nytimes.com/2008/01/05/
washington/05aids.html?fta=y. Accessed May 16, 2009.
6. World Health Organization Maximizing Positive Synergies Collaborative
Group. An assessment of interactions between global health initiatives and
country health systems. Lancet. 2009;373:2137–2169. doi:10.1016/S01406736(09)60919-3.
7. Bendavid E, Bhattacharya J. The President’s Emergency Plan for AIDS
Relief in Africa: evaluation of outcomes. Ann Intern Med. 2009;688–695.
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