When PEPFAR was introduced in 2003, it represented the largest health initiative by any nation focused on one disease (PEPFAR 2006). The original $15 billion commitment proposed $5 billion for existing bilateral programs throughout the world, $1 billion for the Global Fund to Fight AIDS, Tuberculosis, and Malaria ($200 million per year), and $9 billion for new programs in target countries in Africa and the Caribbean. It was adopted by Congress with three provisions. An amendment required that at least a third of all prevention funds be spent to promote sexual abstinence. A second amendment allowed faith-based groups to reject strategies they considered objectionable, such as condom distribution. Third, the law authorized, but did not require, up to $1 billion per year for the Global Fund, five times the amount requested.
PEPFAR funds are authorized by Congress and are provided to participating agencies that implement HIV/AIDS programs in 15 focus countries that together represent approximately 50 percent of HIV infections worldwide. Twelve of the countriesBotswana, Côte dIvoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambiaare in Africa. The remaining three are Guyana, Haiti, and Vietnam. Full implementation of PEPFAR began in June 2004 and includes support for HIV/AIDS programs and services in approximately 100 other countries (IOM 2007, PEPFAR website n.d.).
The U.S. Global AIDS Coordinator reports directly to the Secretary of State and is mandated to provide coordination and oversight for the work of U.S. government agencies implementing HIV/AIDS programs in the focus countries. These implementing agencies are USAID, the Peace Corps, and the U.S. Departments of State, Health and Human Services, Commerce, Defense, and Labor.
Prior to the implementation of PEPFAR, the U.S. government was spending significant sums of money on combating HIV/AIDS outside of the U.S. but through numerous government agencies that did not necessarily coordinate their activities. The rationale behind this new U.S. strategy derived from the widespread belief that more effective coordination, greater resources, and a more focused and concerted effort were required to combat the HIV/AIDS pandemic (OGAC 2004). PEPFAR officials acknowledge the role and importance of existing multilateral and bilateral programs in a number of countries, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) and USAID, but there was no overarching system in place to connect the development dots, to ensure programs were based on evidence and a consistent and uniform framework of principles, or that they achieved results (OGAC 2004, 2008).