On World AIDS Day, December 1, 2009, the Office of the U.S. Global AIDS Coordinator (OGAC) released the much anticipated Five-Year Strategy of the President's Emergency Plan for AIDS Relief (PEPFAR) and on December 7, 2009 released three annexes which outlined additional “high-level direction.” While the underlying tenets of the President's Emergency Plan for AIDS Relief (PEPFAR) are codified in law through the Lantos-Hyde Act, the more specific guidelines and implementation directives are outlined in such secondary policy interpretations as the strategy documents.
The strategy comes at a particularly important point in the evolution of the PEPFAR program as the U.S. response to the global HIV/AIDS epidemic is being considered within the broader framework of the Global Health Initiative (GHI). The GHI, which was announced by President Obama in May 2009, is a $63 billion plan to be rolled out over six years (2009 to 2014) which supports existing programs focusing on neglected tropical diseases, maternal and child health, and family planning and HIV/AIDS. The GHI seeks to foster a more holistic and integrated approach among these key pillars. Mindful of the need to support such interconnections, PEPFAR is transitioning from an emergency response to one promoting a more sustainable approach with “greater engagement with and capacity building of governments… to oversee, manage and eventually finance these programs.” In this next phase of PEPFAR, OGAC seeks to expand prevention, care, and treatment in both the concentrated and generalized epidemics in the more than 30 countries where PEPFAR programs are in place. Ambassador Eric Goosby, U.S. Global AIDS Coordinator, has expressed that integrating HIV/AIDS programs within broader global health and development programs will maximize the impact on health systems in partner countries.
The three annexes to the Five-Year Strategy address the following areas: “PEPFAR and Prevention, Care and Treatment”; “PEPFAR and the Global Context of HIV”; and “PEPFAR’s Contributions to the Global Health Initiative” and spell out in greater detail the fundamental elements of the vision of the next five-years of PEPFAR.
The “PEPFAR and Prevention, Care and Treatment” annex spells out a strong commitment to scaling up prevention efforts, including those which have been proven highly effective, such as male circumcision and prevention of mother-to-child transmission. The most-at-risk populations within each country’s epidemic will be given particular attention, and OGAC will work with in-country partners to determine the locations where greater incidence of HIV infection emerge. Treatment continues to play a major role in the PEPFAR response, with a target of reaching more than four million people. While PEPFAR programs will gradually scale up to reach this, the initial focus will be on those who are in more advanced stages of illness, pregnant women in general who are HIV-positive, and HIV/TB co-infected individuals.
The annex entitled “PEPFAR and the Global Context of HIV” addresses the relationship of PEPFAR to other significant actors at the international and national levels including public-private partnerships, leveraging support from multilateral institutions, and cost-saving measures and improved efficiencies in the management and mobilization of resources. The U.S. government is the single largest donor for global HIV/AIDS programs, and Ambassador Goosby has expressed that in the long-term the U.S. will not be able to sustain this level of support. Improving harmonization among U.S.-sponsored intervention and other partners, such as the Joint United Nations Programme on HIV/AIDS (UNAIDS) and Global Fund to Fight AIDS, Tuberculosis and Malaria will allow PEPFAR to incorporate best-practices from those entities as well as coordinate efforts for optimum effectiveness.
The third annex, “PEPFAR’s Contributions to the Global Health Initiative,” sheds more light on the GHI. A “woman centered approach” is central to the GHI and in the context of PEPFAR-sponsored programs will mean a continued effort towards meeting the needs of women and girls as well as taking a “woman and girl-centered approach to health and gender equity.” PEPFAR’s gender strategy focuses on five-cross-cutting areas: increasing gender equity, reducing violence and coercion, addressing male norms, increasing legal protection for women, and increasing means of livelihood for women. Another central element of the GHI is strengthening health systems by leveraging both HIV/AIDS resources and general funding, instead of focusing exclusively on disease-specific programs and services.
The strategy documents outline the thinking for moving the global HIV/AIDS program forward in the next five years, presenting a road map for transitioning from an emergency response to a more sustainable one, and mitigating the potential harms from the global economic crisis. This kind of big-picture framework sets the tone for the breadth of engagement over the next five years and we hope to see additional technical documents, such as the Country Operational Plan Guidance and Policy Guidance, that spell out directives for the pragmatic application of these overarching themes.
 U.S. Department of State, “U.S. President's Emergency Plan for AIDS Relief Launches Five-Year Strategy Annexes,” Press Release published 7 Dec 2009 < http://www.state.gov/r/pa/prs/ps/2009/dec/133231.htm>.
The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy Annex: PEPFAR and Prevention, Care, and Treatment, Office of the Global AIDS Coordinator, December 2009, <http://www.pepfar.gov/documents/organization/133434.pdf>.
 The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy Annex: PEPFAR and the Global Context of HIV, Office of the Global AIDS Coordinator, December 2009, <http://www.pepfar.gov/documents/organization/133436.pdf >.