President Bush's Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) embodies the compassion and generosity of the American people. As the largest international health initiative in history initiated by one nation to address a single disease, the Emergency Plan's bold leadership and action mark a turning point in the response to the global HIV/AIDS pandemic. With the endorsement of the U.S. Congress, this effort has moved rapidly to fulfill the United States' promise of leadership, providing new hope for millions.
The Emergency Plan represents urgent action and a sharpened focus. Going beyond financial leadership, the United States has fundamentally changed the way it is attacking this disease by bringing its global HIV/AIDS efforts together under a unified strategy with consolidated leadership. This new interagency approach enables the United States to more cohesively support the national strategies of host governments and adapt itself to the individual needs and challenges of each nation where the Emergency Plan is at work. The United States' decades of experience combating the HIV/AIDS pandemic, combined with the new integrated approach, are helping the Emergency Plan achieve unprecedented success in HIV/AIDS prevention, treatment, and care today, while at the same time supporting the development of sustainable capacity to ensure continued scaleup in the future. Early achievements build the foundation for later success.
The early results of the United States' focused action offer tremendous hope. The President's Emergency Plan is on target to achieve its ambitious goals in the 15 focus countries in Africa, Asia, and the Caribbean.1 In these nations, the Emergency Plan aims to support treatment for 2 million people living with HIV/AIDS, prevent 7 million new HIV infections, and support care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children, by 2008 (the "2-7-10" goals). These 15 focus countries are among the world's most severely affected and home to approximately half of the world's 39 million HIV-positive people and almost 8 million children orphaned or made vulnerable by HIV/AIDS. The Emergency Plan has also strengthened U.S. leadership through bilateral HIV/AIDS efforts and support for key multilateral organizations. With an eye to the future, the United States has maintained its position as the global leader in HIV/AIDS research and innovation, with an emphasis on developing safe and effective vaccines and microbicides. The 2004 Emergency Plan data will be the baseline for comparison for all future Emergency Plan annual reports.
This first Annual Report describes the rapid progress of the President's Emergency Plan from the first appropriation of funds from the Congress on January 23, 2004 through September 30, 2004. In fiscal year 2004, the United States committed $2.4 billion to the Emergency Plan. That total included more than $865 million to support national scale-up of integrated prevention, treatment, and care programs in the 15 focus countries. The remaining $1.54 billion was used to support HIV/AIDS programs in 96 additional countries, international research, and other HIV/AIDS efforts, including the Global Fund to Fight AIDS, Tuberculosis and Malaria.
On February 23, 2004, one month after receiving its first appropriation, the Office of the U.S. Global AIDS Coordinator (OGAC) announced the President's Five-Year Global HIV/AIDS Strategy for the Emergency Plan. The Strategy outlined a unified U.S. Government response to the global pandemic constituting a "new way of doing business" and emphasizing evidence-based interventions, accountability, and performance toward goals. Simultaneously, OGAC released the first $350 million for the focus countries. After an intense period of field-based program planning and development, an additional $515 million was released in June 2004; thus, June 2004 marks the beginning of full implementation.
The United States' rapid and strategically targeted deployment of resources has led to remarkable results. In December 2002, one month before President Bush announced the Emergency Plan, an estimated 50,000 people were receiving lifesaving antiretroviral therapy (ART) in all of sub-Saharan Africa. By September 30, 2004, just eight months after the first appropriation of funds by Congress, the Emergency Plan worked under national strategies in the 15 focus countries to support ART for 155,000 HIV-positive adults and children, on target to exceed its Year One goal to support ART for at least 200,000 by June 2005.
The pandemic has also created an unprecedented need for care for those infected and affected by HIV/AIDS, including orphans and vulnerable children. The Emergency Plan supported care for more than 1,727,000 adults and children in the period ending September 30, to support care for 1.15 million by June 2005. Of those served, 1,096,900 were HIV-positive people and more than 630,000 were orphans and vulnerable children.
Prevention is a critical component of the Emergency Plan. With 14,000 new HIV infections every day, the tide cannot be turned without effective evidence-based prevention efforts. The vast majority of new infections in the focus countries occur through sexual transmission. The centerpiece of the President's prevention strategy, the balanced "ABC" approach (Abstinence, Being faithful, and, as appropriate, correct and consistent use of Condoms) -- first developed in Uganda -- is a highly effective way to prevent infections. In its first eight months, the President's Emergency Plan supported national strategies to reach well over 120 million people with ABC messages through mass media campaigns and other interventions.
The United States has led the global effort to prevent mother-to-child transmission (PMTCT) of HIV/AIDS, which began with President Bush's International Mother and Child HIV Prevention Initiative. This groundbreaking initiative remains a key component of prevention efforts, and in fiscal year 2004 the Emergency Plan for AIDS Relief supported programs under national strategies to reach 1.2 million women with PMTCT services. More than 125,000 of these women received primarily short-course antiretroviral preventive therapy, averting an estimated 23,766 newborn infections. Preventing infections through blood transfusions and unsafe medical injections is another important component of the Emergency Plan's prevention strategy. In the first eight months of the Plan, more than 4,000 individuals have been trained in injection safety and more than 2,000 in blood safety.
It is worth noting that U.S. personnel and Emergency Plan partners on the ground, including host governments, have achieved these early successes under extraordinarily challenging circumstances. Challenges faced vary country by country and range from those related to under-resourced settings -- limited availability of human resources, poor infrastructure, and inconsistent access to transportation, electricity, clean water, and other necessary supplies -- to the civil unrest experienced by countries such as Haiti and C�te d'Ivoire, where Emergency Plan staff stayed to keep essential programs going even as many others evacuated. The commitment of people on the ground to stop HIV/AIDS, even under difficult circumstances, makes them the true heroes of this fight.
A guiding principle of the President's Emergency Plan is to build local and host-nation capacity so that national programs can achieve results, monitor and evaluate their activities, and sustain their programs for the long term. While rapidly moving to support prevention, treatment, and care services now, the Emergency Plan has an eye to the future, supporting the development of capacity to achieve, and sustain, success for years to come. Without local capacity, nations cannot fully "own" the fight they must lead against HIV/AIDS.
In the Plan's first eight months, 80 percent of the more than 1,200 partners working on the ground were indigenous organizations. The Emergency Plan promoted the expansion of existing health care networks and the development of new public and private network systems to enhance the delivery of HIV/AIDS services in remote areas. The Plan supported 3,800 programs offering prevention services, including media campaigns, community outreach, and 2,200 sites for PMTCT; 300 sites for treatment; and more than 8,000 sites for care, including 700 sites for orphans and vulnerable children and 2,100 sites for counseling and testing.
Responding to the critical shortage of trained health workers at all levels, the Emergency Plan supported training for 312,000 providers in its first eight months. Among these were 227,200 individuals trained in providing prevention services, including 24,600 health workers trained in PMTCT. Training in providing ART reached 12,200 health workers, while 36,700 individuals received training in palliative care, 14,100 in counseling and testing, and 22,600 in orphan care. In under-resourced settings, providers may have more than one area of responsibility. As such, it is likely that the number of providers trained includes overlap in some areas.
The President's Emergency Plan has fostered indigenous leadership in the fight against the HIV/AIDS pandemic, which is indispensable to a sustainable and effective response. Plan efforts have included technical assistance for appropriate policy development, including policies protecting women and girls, and for strengthening local institutions and organizations, including organizations of people living with HIV/AIDS. In the first eight months of the Emergency Plan, 3,500 programs provided technical assistance and more than 24,000 individuals were trained in skills for institutional and organizational development, including program management.
Other important components of building local capacity include surveillance, reporting, evaluation, and other strategic information needs. These tools allow accountability and provide the information necessary for databased adjustments that enhance program effectiveness. In fiscal year 2004, 9,300 individuals were trained in strategic information.
The Emergency Plan continues its efforts to foster "wrap around" HIV/AIDS programs by coordinating with and leveraging resources from other agencies and sectors, including food and nutrition, education, and microfinance, to ensure a comprehensive response to the pandemic and further promote program sustainability and effectiveness.
Emergency Plan Programs Beyond the Focus Countries
The Emergency Plan's investments outside the focus nations are substantial. The Plan maintains active HIV/AIDS programs in an additional 96 countries beyond the 15 focus countries, encouraging bold leadership, innovation, and accountability in the fight against the HIV/AIDS pandemic. It also supports key multilateral organizations, including the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Joint United Nations Program on HIV/AIDS (UNAIDS).
The Plan's historic increase in resources for HIV/AIDS, with the United States contributing more than all other donor governments combined, mandates a U.S. leadership role in donor coordination. In April 2004 in Washington, D.C., OGAC cosponsored the UNAIDSinitiated "Three Ones" agreement for cooperation among donors in support of one national strategy, one national coordinating mechanism, and one monitoring and evaluation system in each host country. Since that time, the President's Emergency Plan has led efforts to advance all three objectives. Furthermore, the U.S. strategy recognizes that the private and public sectors in host nations must own the fight against the HIV/AIDS pandemic in 14 their countries. By continuing to work shoulder-to-shoulder with in-country partners to increase local capacity under national strategies, the Emergency Plan will continue to build on its early success.
Recognizing that HIV/AIDS does not respect borders, the Emergency Plan incorporates bilateral programs in countries around the world that are heavily burdened by the effects of HIV/AIDS, including, but not limited to, India, Russia, and China. In India, where the United States has its largest bilateral program outside the 15 focus nations, the Plan increased the U.S. commitment by nearly 25 percent from fiscal year 2003 to fiscal year 2004. In Russia, the United States increased funding by nearly 50 percent from fiscal year 2003 to fiscal year 2004. The U.S. commitment in fiscal year 2004 of $37 million for bilateral health assistance to China for HIV/AIDS and other diseases has had an impressive impact on U.S.-Chinese health cooperation. In all, the Emergency Plan increased resources for HIV/AIDS programs in nearly 30 countries beyond the focus nations, including India, Russia, Cambodia, Swaziland, and Lesotho.
In addition, the United States remains the largest single country donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which provides grant support to more than 130 countries. In 2004, one-third of the Fund's grant support came from U.S. contributions. In China, India, and Russia alone, for example, where the Fund has made more than $350 million available in twoyear approved grants, the U.S. contribution amounted to approximately $117 million.
The President's Emergency Plan is a leader in multilateral efforts against HIV/AIDS. The United States recognizes that the Global Fund offers an opportunity for other nations to sharply increase their commitment to global HIV/AIDS, as the United States has done. The success of the Fund is thus central to the Plan's vision of turning the tide against the HIV/AIDS pandemic.
Therefore, the Emergency Plan is helping to provide the leadership to ensure the Fund's success. President Bush made the founding contribution to the Fund in 2002, available in two-year grants. In fiscal year 2004 the United States remained by far the Fund's largest single country donor, with the American people contributing one-third of all of the Fund's resources. To ensure the full participation of our international partners, U.S. law limits the American contribution to the Fund to 33 percent of total contributions. Unfortunately, insufficient contributions from the world community in 2004 -- even after the U.S. Global AIDS Coordinator extended the time in which other donors could make qualifying contributions by two months -- limited the maximum U.S. contribution appropriated by Congress in fiscal year 2004.
In addition to its financial contribution, the United States also provided significant technical assistance to the Global Fund Secretariat in Geneva and to numerous countries where the Fund operates throughout the world. The Emergency Plan also coordinates programs with UNAIDS, the World Health Organization, the United Nations Children's Fund, the World Bank, and others.
Less than two months after the first congressional appropriation of resources for the President's Emergency Plan for AIDS Relief, a former hospice in South Africa was transformed into an HIV/AIDS treatment clinic when it began providing antiretroviral therapy to its dying patients. With support from the peoples and governments of South Africa and the United States, the site honored World AIDS Day on December 1, 2004, as a celebration for the living rather than a day of remembrance.
The President's Emergency Plan has turned despair into hope, leading the world from an era of concern into an era of compassionate action - the "decisive, historic action" the President envisioned. American leadership is proving to be a catalyst for action. Around the world, success is spreading rapidly, and hope, which breeds further success, quickly follows. Many challenges remain, and much hard work lies ahead. But the United States will not waver in its resolve to work with our friends incountry, and across the globe, as together we turn the tide against the HIV/AIDS pandemic.