Global Health
Trends in U.S. Spending for Global HIV/AIDS and Other Health Assistance in Fiscal Years 2001-2008 Gao ID: GAO-11-64 October 8, 2010U.S. funding for global HIV/AIDS and other health-related programs rose significantly from 2001 to 2008. The President's Emergency Plan for AIDS Relief (PEPFAR), reauthorized in 2008 at $48 billion through 2013, has made significant investments in support of prevention of HIV/AIDS as well as care and treatment for those affected by the disease in 31 partner countries and 3 regions. In May 2009, the President proposed spending $63 billion through 2014 on global health programs, including HIV/AIDS, under a new Global Health Initiative. The Office of the U.S. Global AIDS Coordinator (OGAC), at the Department of State (State), coordinates PEPFAR implementation. The Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID), among other agencies, implement PEPFAR as well as other global health-related assistance programs, such as maternal and child health, infectious disease prevention, and malaria control, among others. Responding to legislative directives, this report examines U.S. disbursements (referred to as spending) for global HIV/AIDS- and other health-related bilateral foreign assistance programs (including basic health and population and reproductive health programs) in fiscal years 2001-2008. The report also provides information on models used to estimate HIV treatment costs. GAO analyzed U.S. foreign assistance data, reviewed HIV treatment costing models and reports, and interviewed U.S. and UNAIDS officials.
In fiscal years 2001-2008, bilateral U.S. spending for HIV/AIDS and other health-related programs increased overall, most significantly for HIV/AIDS. From 2001 to 2003--before the establishment of PEPFAR--U.S. spending on global HIV/AIDS programs rose while spending on other health programs dropped slightly. From fiscal years 2004 to 2008, HIV/AIDS spending grew steadily; other health-related spending also rose overall, despite declines in 2006 and 2007. As would be expected, U.S. bilateral HIV/AIDS spending showed the most increase in 15 countries--known as PEPFAR focus countries--relative to other countries receiving bilateral HIV/AIDS assistance from fiscal years 2004 through 2008. In addition, GAO's analysis showed that U.S. spending on other health-related bilateral foreign assistance also increased most for PEPFAR focus countries. Spending growth rates varied among three key regions--sub-Saharan Africa, Asia, and Latin America and the Caribbean--as did these regions' shares of HIV/AIDS and other health foreign assistance spending following establishment of PEPFAR. OGAC, USAID, and UNAIDS have adopted three different models to estimate and project antiretroviral therapy (ART) costs. The three models--respectively known as the PEPFAR ART Costing Project Model, the HIV/AIDS Program Sustainability Analysis Tool, and Spectrum--are intended to inform policy and program decisions related, in part, to expanding efforts to provide ART in developing countries.
GAO-11-64, Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other Health Assistance in Fiscal Years 2001-2008
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
October 2010:
Global Health:
Trends in U.S. Spending for Global HIV/AIDS and Other Health
Assistance in Fiscal Years 2001-2008:
GAO-11-64:
GAO Highlights:
Highlights of GAO-11-64, a report to congressional committees.
Why GAO Did This Study:
U.S. funding for global HIV/AIDS and other health-related programs
rose significantly from 2001 to 2008. The President‘s Emergency Plan
for AIDS Relief (PEPFAR), reauthorized in 2008 at $48 billion through
2013, has made significant investments in support of prevention of
HIV/AIDS as well as care and treatment for those affected by the
disease in 31 partner countries and 3 regions. In May 2009, the
President proposed spending $63 billion through 2014 on global health
programs, including HIV/AIDS, under a new Global Health Initiative.
The Office of the U.S. Global AIDS Coordinator (OGAC), at the
Department of State (State), coordinates PEPFAR implementation. The
Centers for Disease Control and Prevention (CDC) and the U.S. Agency
for International Development (USAID), among other agencies, implement
PEPFAR as well as other global health-related assistance programs,
such as maternal and child health, infectious disease prevention, and
malaria control, among others.
Responding to legislative directives, this report examines U.S.
disbursements (referred to as spending) for global HIV/AIDS--and other
health-related bilateral foreign assistance programs (including basic
health and population and reproductive health programs) in fiscal
years 2001-2008. The report also provides information on models used
to estimate HIV treatment costs. GAO analyzed U.S. foreign assistance
data, reviewed HIV treatment costing models and reports, and
interviewed U.S. and UNAIDS officials.
What GAO Found:
In fiscal years 2001-2008, bilateral U.S. spending for HIV/AIDS and
other health-related programs increased overall, most significantly
for HIV/AIDS. From 2001 to 2003”before the establishment of PEPFAR”
U.S. spending on global HIV/AIDS programs rose while spending on other
health programs dropped slightly. From fiscal years 2004 to 2008,
HIV/AIDS spending grew steadily; other health-related spending also
rose overall, despite declines in 2006 and 2007.
Figure: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars), Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $204 million;
Other health: $1.3 billion.
Year: 2002;
HIV/Aids: $310 million;
Other health: $1.4 billion.
Year: 2003;
HIV/Aids: $700 million;
Other health: $1.2 billion.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $1.2 billion;
Other health: $1.4 billion.
Year: 2005;
HIV/Aids: $1.7 billion;
Other health: $1.7 billion.
Year: 2006;
HIV/Aids: $2.2 billion;
Other health: $1.6 billion.
Year: 2007;
HIV/Aids: $2.7 billion;
Other health: $1.5 billion.
Year: 2008;
HIV/Aids: $3.3 billion;
Other health: $1.7 billion.
Total spending: 2001-2003:
HIV/Aids: $1.2 billion;
Other health: $3.9 billion.
Total spending: 2004-2008:
HIV/Aids: $11.1 billion;
Other health: $7.9 billion.
Source: GAO analysis of data from the Foreign Assistance Database.
[End of figure]
As would be expected, U.S. bilateral HIV/AIDS spending showed the most
increase in 15 countries”known as PEPFAR focus countries”relative to
other countries receiving bilateral HIV/AIDS assistance from fiscal
years 2004 through 2008. In addition, GAO‘s analysis showed that U.S.
spending on other health-related bilateral foreign assistance also
increased most for PEPFAR focus countries. Spending growth rates
varied among three key regions”sub-Saharan Africa, Asia, and Latin
America and the Caribbean”as did these regions‘ shares of HIV/AIDS and
other health foreign assistance spending following establishment of
PEPFAR.
OGAC, USAID, and UNAIDS have adopted three different models to
estimate and project antiretroviral therapy (ART) costs. The three
models”respectively known as the PEPFAR ART Costing Project Model, the
HIV/AIDS Program Sustainability Analysis Tool, and Spectrum”are
intended to inform policy and program decisions related, in part, to
expanding efforts to provide ART in developing countries.
View [hyperlink, http://www.gao.gov/products/GAO-11-64] or key
components. For more information, contact David Gootnick at (202) 512-
3149 or gootnickd@gao.gov.
[End of section]
Contents:
Letter:
Background:
U.S. Spending on HIV/AIDS and Other Health Assistance Increased in
2001-2008 and Varied by Time Frame, Country Status, and Region:
Three Key HIV Treatment Costing Models Used to Inform Policy and
Program Decisions:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: U.S. Spending on Global HIV/AIDS and Other Health-Related
Programs:
Appendix III: ART Patient and Cost Categories, by Costing Model:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Countries That Received U.S. Assistance for HIV/AIDS
Programs, Fiscal Years 2001-2008:
Table 2: Average Annual Growth Rates for U.S. Global HIV/AIDS and
Other Health Spending, Fiscal Years 2001-2008:
Table 3: Average Annual Growth Rates for U.S. Global HIV/AIDS and
Other Health Spending, Fiscal Years 2001-2008:
Table 4: Average Annual Growth Rates for Global U.S. HIV/AIDS and
Other Health-Related Foreign Assistance Spending, by Region, Fiscal
Years 2001-2008:
Table 5: HIV Treatment Costing Models Used by OGAC, USAID, and UNAIDS:
Table 6: U.S. Foreign Assistance Spending on HIV/AIDS Programs, by
Country, Fiscal Years 2001-2008 (2010 constant U.S. dollars):
Table 7: U.S. Foreign Assistance Spending on Other Health-Related
Programs, by Country, Fiscal Years 2001-2008 (2010 constant U.S.
dollars):
Table 8: PACM ART Patient and Cost Categories:
Table 9: HAPSAT ART Patient and Cost Categories:
Table 10: Spectrum ART Patient and Cost Categories:
Figures:
Figure 1: PEPFAR-Approved Funding for Prevention, Treatment, and Care
Programs, Fiscal Years 2006-2009:
Figure 2: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars), Fiscal Years 2001-2008:
Figure 3: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in PEPFAR Focus Countries, Fiscal Years 2001-2008:
Figure 4: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Nonfocus Countries and Regional Programs with PEPFAR
Operational Plans, Fiscal Years 2001-2008:
Figure 5: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Other Countries Receiving HIV/AIDS Assistance, Fiscal
Years 2001-2008:
Figure 6: U.S. Health-Related Foreign Assistance Spending (in Constant
Dollars), by Region, Fiscal Years 2001-2008:
Figure 7: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Sub-Saharan Africa, Fiscal Years 2001-2008:
Figure 8: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Asia, Fiscal Years 2001-2008:
Figure 9: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Latin American and the Caribbean, Fiscal Years 2001-2008:
Abbreviations:
ART: antiretroviral therapy:
ARV: antiretroviral drugs:
CD4: cluster of differentiation antigen 4:
CDC: Centers for Disease Control and Prevention:
COP: country operational plan:
FADB: Foreign Assistance Database:
GHI: Global Health Initiative:
Global Fund: Global Fund to Fight AIDS, Tuberculosis, and Malaria:
HAPSAT: HIV/AIDS Program Sustainability Analysis Tool:
HHS: Department of Health and Human Services:
Leadership Act: Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization
Act of 2008:
OECD: Organisation for Economic Cooperation and Development:
OGAC: Office of the U.S. Global AIDS Coordinator:
PACM: PEPFAR ART Costing Project Model:
PEPFAR: President's Emergency Plan for AIDS Relief:
ROP: regional operational plan:
UNAIDS: Joint United Nations Programme on HIV/AIDS:
USAID: United States Agency for International Development:
WHO: World Health Organization:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
October 8, 2010:
Congressional Committees:
In 2008, approximately 2 million people worldwide died of HIV-related
causes, and an estimated 2.7 million people were newly infected with
HIV. The first 5-year phase of the President's Emergency Plan for AIDS
Relief (PEPFAR), authorized by Congress at $15 billion for fiscal
years 2004 through 2008,[Footnote 1] contributed significantly to the
global response to the pandemic. PEPFAR reported that in 2009, it
supported treatment for more than 2.4 million patients with HIV/AIDS
and care and support for more than 11 million people affected by the
disease.
U.S. and other donor funding for global health increased significantly
from 2001 to 2008, largely because of increases in funding for
HIV/AIDS programs.[Footnote 2] The Tom Lantos and Henry J. Hyde United
States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (2008 Leadership Act) authorized PEPFAR at
$48 billion through fiscal year 2013 and extended the U.S.
government's efforts to combat the global HIV/AIDS epidemic and other
diseases.[Footnote 3] Among its other purposes, the 2008 Leadership
Act sets new targets for treatment programs and calls for a plan to
increase the number of individuals on antiretroviral therapy (ART)
proportional to available funding and decreases in cost per patient.
[Footnote 4] In May 2009, the President announced the creation of a
new Global Health Initiative and proposed $63 billion in funding for
all global health programs through fiscal year 2014, including more
than $51 billion for HIV/AIDS, tuberculosis, and malaria programs. For
fiscal year 2011, the President has proposed spending $8.5 billion on
global health and child survival programs, including $5.9 billion for
HIV/AIDS.
Responding to directives in the Consolidated Appropriations Act of
2008 and the 2008 Leadership Act,[Footnote 5] this report examines
trends in U.S. bilateral spending for global HIV/AIDS and other global
health programs in fiscal years 2001 through 2008. In addition, this
report provides information on models used to estimate the cost of
providing ART.
To address trends in U.S. spending on global HIV/AIDS and other health
programs, we analyzed data from the Foreign Assistance Database (FADB)
[Footnote 6] provided by the U.S. Agency for International Development
(USAID) on U.S. spending for health-related foreign assistance
programs. Specifically, we examine disbursement levels[Footnote 7] and
growth trends from 2001 to 2008 for bilateral HIV/AIDS and other
health-related foreign assistance programs by time period (pre-PEPFAR
and first 5 years of PEPFAR for all countries); countries grouped
approximately by level of PEPFAR focus and funding; and region (sub-
Saharan Africa, Latin America and the Caribbean, and Asia). We
determined the FADB disbursement data to be sufficiently reliable for
the purposes of reporting them in this manner. For this report, we
defined U.S. spending for global HIV/AIDS programs as foreign
assistance for HIV/AIDS control, testing, prevention, treatment, and
care; we defined U.S. spending for other global health programs as
foreign assistance to support general and basic health and population
and reproductive health policies and programs (except those related to
HIV/AIDS). (See appendix I for more information on these categories.)
We converted the spending amounts provided to 2010 constant dollars to
account for inflation and allow the comparison of levels of assistance
in different time periods. We also consulted data on other donor and
U.S. foreign assistance. In addition, we interviewed State Department,
USAID, and Centers for Disease Control and Prevention (CDC) officials
and representatives of research organizations. To describe three key
models used to estimate costs related to providing ART in developing
countries, we reviewed the models and examined reports on the models.
We also interviewed officials of the U.S. government and the Joint
United Nations Programme on HIV/AIDS (UNAIDS), as well as developers
of the models, in Washington, D.C.; Atlanta; and Geneva, Switzerland.
We conducted our work from July 2009 to October 2010 in accordance
with all sections of GAO's Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence
to meet our stated objectives and to discuss any limitations in our
work. We believe that the information and data obtained, and the
analysis conducted, provide a reasonable basis for any findings and
conclusions. See appendix I for a more detailed description of our
scope and methodology.
Background:
President's Global Health Initiative:
In May 2009, the President announced the creation of a new Global
Health Initiative (GHI) and proposed $63 billion in funding for all
global health programs, including HIV/AIDS, malaria, tuberculosis, and
maternal and child health, through 2014. According to the proposal,
the majority of this funding--$51 billion, or 81 percent--is slated
for global HIV/AIDS, tuberculosis, and malaria programs. For fiscal
year 2009, State and USAID allocated about $7.3 billion for global
health and child survival programs, including more than $5.6 billion
for HIV/AIDS programs. For fiscal year 2010, State and USAID allocated
approximately $7.8 billion for global health and child survival
programs, including $5.7 billion for HIV/AIDS. For fiscal year 2011,
the President proposed spending $8.5 billion on global health and
child survival programs, including $5.9 billion for HIV/AIDS.[Footnote
8]
In February 2010, the administration released a consultation document
on GHI implementation, focusing on coordination and integration of
global health programs, among other things, and setting targets for
achieving health outcomes. The document also proposed selection of up
to 20 countries--known as GHI Plus countries--that will receive
additional funding and technical assistance under the GHI.[Footnote 9]
PEPFAR:
Congress first authorized PEPFAR in 2003 and, in doing so, created
within State a Coordinator of the U.S. Government Activities to Combat
HIV/AIDS Globally, which State redesignated the Office of the U.S.
Global AIDS Coordinator (OGAC). OGAC establishes overall PEPFAR policy
and program strategies; coordinates PEPFAR programs; and allocates
PEPFAR resources from the Global Health and Child Survival account to
U.S. implementing agencies, including USAID and the Department of
Health and Human Services' (HHS) CDC.[Footnote 10] USAID and CDC also
receive direct appropriations to support global HIV/AIDS and other
global health programs, such as tuberculosis, malaria, and support for
maternal and child health.
In fiscal years 2004 through 2008--the first 5 years of PEPFAR--the
U.S. government directed more than $18 billion to PEPFAR implementing
agencies and the Global Fund to Fight AIDS, Tuberculosis and Malaria
(Global Fund).[Footnote 11] In 2008, Congress reauthorized PEPFAR at
$48 billion to continue and expand U.S.-funded HIV/AIDS and other
programs through fiscal year 2013.[Footnote 12]
Although PEPFAR initially targeted 15 countries, known as focus
countries, since its establishment PEPFAR has made significant
investments in 31 partner countries and 3 regions.[Footnote 13]
Representatives of PEPFAR implementing agencies (country teams)
jointly develop country operational plans (COP) for the 15 focus
countries and an additional 16 nonfocus countries, as well as regional
operational plans (ROP) for three regions, to document U.S.
investments in, and anticipated results of, U.S.-funded programs to
combat HIV/AIDS. The country teams submit the operational plans to
OGAC for review and ultimate approval by the U.S. Global AIDS
Coordinator. As such, these operational plans serve as the basis for
approving annual U.S. bilateral HIV/AIDS funding, notifying Congress,
and allocating and tracking budgets and targets. Some nonfocus
countries receiving U.S. HIV/AIDS funding do not submit a PEPFAR
operational plan; OGAC reviews and approves HIV/AIDS-related foreign
assistance funding through foreign assistance operational plans. Table
1 shows the countries and regions that received U.S. foreign
assistance for HIV/AIDS programs in fiscal years 2001-2008.
Table 1: Countries That Received U.S. Assistance for HIV/AIDS
Programs, Fiscal Years 2001-2008A:
15 PEPFAR focus countries:
Botswana;
Côte d'Ivoire;
Ethiopia;
Guyana;
Haiti;
Kenya;
Mozambique;
Namibia;
Nigeria;
Rwanda;
South Africa;
Tanzania;
Uganda;
Vietnam;
Zambia.
16 nonfocus countries and 3 regions with PEPFAR operational plans:
Angola;
Cambodia;
Caribbean Region[B];
Central American Region[C];
Central Asian Region[D];
China;
Democratic Republic of the Congo;
Dominican Republic;
Ghana;
India;
Indonesia;
Lesotho;
Malawi;
Russia;
Sudan;
Swaziland;
Thailand;
Ukraine;
Zimbabwe.
47 other nonfocus countries receiving U.S. foreign assistance for
HIV/AIDS:
Afghanistan;
Albania;
Armenia;
Azerbaijan;
Bangladesh;
Benin;
Bolivia;
Brazil;
Burkina Faso;
Burma (Myanmar);
Burundi;
Cameroon;
Colombia;
Congo-Brazzaville;
Croatia;
Djibouti;
Egypt;
Eritrea;
Estonia;
Gabon;
Gambia;
Georgia;
Guinea;
Kosovo;
Laos;
Liberia;
Macedonia;
Madagascar;
Mali;
Mauritania;
Mexico;
Moldova;
Montenegro;
Morocco;
Nepal;
Pakistan;
Papua New Guinea;
Paraguay;
Peru;
Philippines;
Romania;
Sao Tome and Principe;
Senegal;
Serbia;
Sierra Leone;
Sri Lanka;
Timor-Leste.
Source: GAO analysis of OGAC and Foreign Assistance Database
information.
[A] Countries received U.S. foreign assistance funding in any of these
years. Some countries may not have received HIV/AIDS-related funding
for all years.
[B] Countries in the Caribbean region are Antigua and Barbuda, the
Bahamas, Barbados, Belize, Dominica, Grenada, Jamaica, Saint Kitts and
Nevis, Saint Lucia, Saint Vincent, Suriname, and Trinidad and Tobago.
[C] Countries in the Central American region are Belize, Costa Rica,
El Salvador, Guatemala, Honduras, Nicaragua, and Panama. (PEPFAR
funding for Belize is approved jointly through the Caribbean and
Central American regional operational plans).
[D] Countries in the Central Asian region are Kazakhstan, the Kyrgyz
Republic, Tajikistan, Turkmenistan, and Uzbekistan.
[End of table]
Funding for HIV Treatment:
In 2009, UNAIDS estimated that $7 billion would be needed in
developing countries in 2010 to reach HIV/AIDS treatment and care
program targets, which are generally defined as 80 percent of the
target population requiring treatment. Sub-Saharan Africa makes up
about half (49 percent) of estimated needs for all HIV/AIDS programs
in developing countries. UNAIDS's estimate includes provision of ART,
testing and counseling, treatment for opportunistic infections,
nutritional support, laboratory testing, palliative care, and the cost
of drug-supply logistics. The costs for CD4 blood tests are also
included.[Footnote 14]
In fiscal years 2006-09, PEPFAR funding for ART made up nearly half
(46 percent) of PEPFAR's approved budget for prevention, treatment,
and care programs. (See figure 1.) ART funding generally comprised
treatment services[Footnote 15] (about 55 percent of approved
treatment funding); ARV drug[Footnote 16] procurement (about 32
percent of approved treatment funding); and laboratory infrastructure
(about 13 percent of approved treatment funding).
Figure 1: PEPFAR-Approved Funding for Prevention, Treatment, and Care
Programs, Fiscal Years 2006-2009:
[Refer to PDF for image: pie-chart and sub-chart]
Care[A]: 29% ($3.5 billion);
Prevention: 25%; ($2.9 billion);
Treatment: 46% ($5.5 billion):
- Treatment services: 55% ($3.1 billion);
- ARV drug procurement: 32% ($1.8 billion);
- Laboratory infrastructure: 13% ($709 million).
PEPFAR-approved funding for prevention, treatment, care, all
countries, FY 2006-09: $11.9 billion.
PEPFAR-approved funding for treatment, all countries, FY 2006-09: $5.6
billion.
Source: GAO analysis of OGAC information.
[A] For 2006 and 2007, PEPFAR care program figures reported by OGAC
included funding for pediatric AIDS programs. In 2008 and 2009,
pediatric care funding was included in care and pediatric treatment
funding was included in treatment.
[End of figure]
In 2008, OGAC reported that tentative approval of generic ARV drugs
had generated significant savings for PEPFAR. As of September 2010,
HHS's Food and Drug Administration had approved, or tentatively
approved, 116 ARV formulations under its expedited review process,
which allows all ARV drugs to be rapidly reviewed for quality
standards and subsequently cleared for purchase under PEPFAR.[Footnote
17]
According to PEPFAR's Five-Year Strategy, released in December 2009,
PEPFAR plans to provide direct support for more than 4 million people
on ART, more than doubling the number of people directly supported on
treatment during the first 5 years of PEPFAR. The strategy seeks to
focus PEPFAR support on specific individuals requiring ART by
prioritizing individuals with CD4 cell counts under 200/mm3 to prevent
as many immediate deaths as possible.[Footnote 18] In addition, in
countries with high coverage rates that are expanding eligibility for
treatment, PEPFAR will provide technical assistance and support for
the overall treatment infrastructure. PEPFAR also will expand efforts
to better link testing and counseling with treatment and care and, in
conjunction with its prevention of mother-to-child transmission
programs, will support expanded treatment to pregnant women.
Costing Models:
As we have previously reported, federal financial standards call on
agencies to use costing methods in their planning to determine
resources needed to evaluate program performance, among other things.
[Footnote 19] Program managers should use costing information to
improve the efficiency of programs. In addition, such information can
be used by Congress to make decisions about allocating financial
resources, authorizing and modifying programs, and evaluating program
performance.[Footnote 20] In 2008, we found that PEPFAR country teams
identified and analyzed program costs in varying ways, and we
recommended that the Secretary of State direct OGAC to provide
guidance to PEPFAR country teams on using costing information in their
planning and budgeting.
U.S. Spending on HIV/AIDS and Other Health Assistance Increased in
2001-2008 and Varied by Time Frame, Country Status, and Region:
Overall, U.S. bilateral spending on global HIV/AIDS and other health
programs generally increased in fiscal years 2001 through 2008,
particularly for HIV/AIDS programs. From 2001 through 2003, U.S.
bilateral spending on global HIV/AIDS rose, while spending on other
global health programs dropped slightly. As would be expected given
PEPFAR's significant investment, from fiscal years 2004 through 2008,
U.S. bilateral HIV/AIDS spending showed the greatest increase in
PEPFAR focus countries, relative to nonfocus countries and regions
with PEPFAR operational plans and other countries receiving HIV/AIDS
assistance. In addition, our analysis determined that U.S. spending
for other health-related health assistance also increased most for
PEPFAR focus countries. Spending growth rates varied among three key
regions--sub-Saharan Africa, Asia, and Latin America and the
Caribbean--as did these regions' shares of bilateral HIV/AIDS and
other health spending following establishment of PEPFAR. (See appendix
II for additional information on U.S. bilateral foreign assistance
spending on HIV/AIDS and other health programs in fiscal years 2001
through 2008.)
U.S. Spending on HIV/AIDS and Other Health Programs Grew Overall,
Despite Decreases in Other Health Foreign Assistance Spending:
Overall, U.S. bilateral foreign assistance spending on both global
HIV/AIDS and other health programs increased in fiscal years 2001
through 2008. Although spending on other health programs decreased
slightly from 2001 through 2003, U.S. spending on both HIV/AIDS and
other health-related foreign assistance programs grew from 2004
through 2008, the first 5 years of PEPFAR. Annual growth in U.S.
spending on global HIV/AIDS was more robust and consistent than annual
growth for other global health spending (see table 2 and figure 2).
Table 2: Average Annual Growth Rates for U.S. Global HIV/AIDS and
Other Health Spending, Fiscal Years 2001-2008:
Pre-PEPFAR period:
Percentage growth in HIV/AIDS spending: 89;
Percentage growth in other health spending: -3;
Percentage growth in all health spending: 12.
PEPFAR period (first 5 years):
Percentage growth in HIV/AIDS spending: 38;
Percentage growth in other health spending: 8;
Percentage growth in all health spending: 22.
Source: GAO analysis of data from Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of table]
Figure 2: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars), Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $204 million;
Other health: $1.3 billion.
Year: 2002;
HIV/Aids: $310 million;
Other health: $1.4 billion.
Year: 2003;
HIV/Aids: $700 million;
Other health: $1.2 billion.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $1.2 billion;
Other health: $1.4 billion.
Year: 2005;
HIV/Aids: $1.7 billion;
Other health: $1.7 billion.
Year: 2006;
HIV/Aids: $2.2 billion;
Other health: $1.6 billion.
Year: 2007;
HIV/Aids: $2.7 billion;
Other health: $1.5 billion.
Year: 2008;
HIV/Aids: $3.3 billion;
Other health: $1.7 billion.
Total spending: 2001-2003:
HIV/Aids: $1.2 billion;
Other health: $3.9 billion.
Total spending: 2004-2008:
HIV/Aids: $11.1 billion;
Other health: $7.9 billion.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
2001-2003. Prior to the implementation of PEPFAR, U.S. bilateral
spending on HIV/AIDS programs grew rapidly, while U.S. spending on
other health programs fell slightly.
* HIV/AIDS. The U.S. government spent less on global HIV/AIDS programs
than on other health-related programs in fiscal years 2001-2003.
However, spending on HIV/AIDS grew rapidly prior to implementation of
PEPFAR.
* Other health. U.S. spending on other health-related programs
decreased from 2001 to 2003. However, total spending for these
programs during this period was more than three times greater than the
total for HIV/AIDS-related foreign assistance programs.
2004-2008. Following implementation of PEPFAR, U.S. bilateral spending
on both global HIV/AIDS and other health-related programs increased
overall, with more rapid and consistent growth in spending for
HIV/AIDS programs.
* HIV/AIDS. In fiscal year 2004, U.S. spending on HIV/AIDS programs
was roughly equivalent to the total for the previous 3 years combined;
in fiscal year 2008, annual U.S. spending on global HIV/AIDS programs
was nearly three times the 2004 total. In addition, U.S. spending on
HIV/AIDS programs in 2005 was, for the first time, higher than
spending on other health programs. By 2008, almost twice as much was
spent on HIV/AIDS programs as on other health programs.
* Other health. Although U.S. spending on other health programs also
increased overall from fiscal year 2004 through 2008, annual spending
was less consistent and decreased in 2006 and 2007.
U.S. Spending on HIV/AIDS and Other Health Programs Grew Most Rapidly
in PEPFAR Focus Countries:
Our analysis shows differences in growth trends in U.S. bilateral
spending on HIV/AIDS and other health programs before and after
implementation of PEPFAR for three distinct groups of
countries:[Footnote 21] PEPFAR focus countries, nonfocus countries and
regions with PEPFAR operational plans, and all other countries
receiving HIV/AIDS foreign assistance (i.e., nonfocus countries
receiving HIV/AIDS assistance that do not submit PEPFAR operational
plans to OGAC).[Footnote 22] In fiscal years 2001 through 2003, U.S.
bilateral spending on global HIV/AIDS programs grew for countries in
all three groups, while spending on other health programs increased at
lower rates. From 2004 through 2008, the average annual growth rate in
U.S. bilateral spending on global HIV/AIDS programs was, predictably,
greatest in focus countries, as was spending on other health programs
in these countries (see table 3).
Table 3: Average Annual Growth Rates for U.S. Global HIV/AIDS and
Other Health Spending, Fiscal Years 2001-2008:
Pre-PEPFAR period:
Focus countries;
Percentage growth in HIV/AIDS spending: 152;
Percentage growth in other health spending: 21;
Percentage growth in all health spending: 79.
Nonfocus countries and regions with PEPFAR operational plans;
Percentage growth in HIV/AIDS spending: 111;
Percentage growth in other health spending: 11;
Percentage growth in all health spending: 28.
All other countries receiving HIV/AIDS foreign assistance;
Percentage growth in HIV/AIDS spending: 196;
Percentage growth in other health spending: 1;
Percentage growth in all health spending: 7.
PEPFAR period (first 5 years):
Focus countries;
Percentage growth in HIV/AIDS spending: 46;
Percentage growth in other health spending: 18;
Percentage growth in all health spending: 40.
Nonfocus countries and regions with PEPFAR operational plans;
Percentage growth in HIV/AIDS spending: 12;
Percentage growth in other health spending: 4;
Percentage growth in all health spending: 6.
All other countries receiving HIV/AIDS foreign assistance;
Percentage growth in HIV/AIDS spending: 7;
Percentage growth in other health spending: 12;
Percentage growth in all health spending: 11.
Source: GAO analysis of data from Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of table]
PEPFAR Focus Countries:
For the 15 countries that would become PEPFAR focus countries, U.S.
bilateral spending on both HIV/AIDS and other health programs
increased steadily from 2001 through 2003, with higher growth for
HIV/AIDS spending. From 2004 through 2008, U.S. bilateral spending on
global HIV/AIDS-related foreign assistance programs continued to
increase significantly, while spending on other health programs grew
modestly overall. From 2004 through 2008, total U.S. bilateral
spending on HIV/AIDS-related foreign assistance programs in PEPFAR
focus countries was more than seven times greater than spending on
other health programs. (See figure 3.)
Figure 3: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in PEPFAR Focus Countries, Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $53 million;
Other health: $82 million.
Year: 2002;
HIV/Aids: $91 million;
Other health: $107 million.
Year: 2003;
HIV/Aids: $303 million;
Other health: $119 million.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $348 million;
Other health: $104 million.
Year: 2005;
HIV/Aids: $636 million;
Other health: $89 million.
Year: 2006;
HIV/Aids: $902 million;
Other health: $111 million.
Year: 2007;
HIV/Aids: $1.3 billion;
Other health: $162 million.
Year: 2008;
HIV/Aids: $1.9 billion;
Other health: $233 million.
Total spending: 2001-2003:
HIV/Aids: $447 million;
Other health: $308 million.
Total spending: 2004-2008:
HIV/Aids: $5.1 billion;
Other health: $699 million.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
Nonfocus Countries and Regional Programs with PEPFAR Operational Plans:
For the 16 nonfocus countries and three regions that eventually would
submit operational plans to receive PEPFAR funding, U.S. bilateral
spending on both HIV/AIDS and other health-related foreign assistance
programs increased from 2001 through 2003 (see figure 4), but at lower
rates and less consistently than for the focus countries. From 2001
through 2003, U.S. bilateral spending on other health-related foreign
assistance programs was about three times greater than spending on
HIV/AIDS programs in these countries and regions, although spending on
HIV/AIDS programs grew more rapidly. From 2004 through 2008, U.S.
bilateral spending on both global HIV/AIDS and other health programs
increased overall, with greater spending on other health programs for
the 5-year period.
Figure 4: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Nonfocus Countries and Regional Programs with PEPFAR
Operational Plans, Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $30 million;
Other health: $209 million.
Year: 2002;
HIV/Aids: $53 million;
Other health: $226 million.
Year: 2003;
HIV/Aids: $131 million;
Other health: $259 million.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $133 million;
Other health: $251 million.
Year: 2005;
HIV/Aids: $204 million;
Other health: $210 million.
Year: 2006;
HIV/Aids: $198 million;
Other health: $227 million.
Year: 2007;
HIV/Aids: $227 million;
Other health: $236 million.
Year: 2008;
HIV/Aids: $209 million;
Other health: $302 million.
Total spending: 2001-2003:
HIV/Aids: $215 million;
Other health: $695 million.
Total spending: 2004-2008:
HIV/Aids: $972 million;
Other health: $1.2 billion.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
Other Countries Receiving U.S. Assistance for HIV/AIDS Programs:
In all other countries that received some U.S. assistance for HIV/AIDS
programs from 2001 through 2008 but did not submit PEPFAR operational
plans--a total of 47 countries--U.S. bilateral spending on both HIV/
AIDS and other health-related foreign assistance programs fluctuated
from year to year but increased overall (see figure 5). In addition,
U.S. bilateral spending for other health programs greatly exceeded
spending for HIV/AIDS programs both before and after the establishment
of PEPFAR. From 2001 through 2003, U.S. bilateral spending on HIV/AIDS
programs in these countries nearly quadrupled; spending on other
health programs amounted to more than 12 times that for HIV/AIDS
programs and increased slightly over the period. From 2004 through
2008, U.S. bilateral spending on other health programs continued to
greatly exceed spending on HIV/AIDS-related programs in these
countries; spending on both HIV/AIDS and other health programs
fluctuated from year to year and grew at similar rates overall.
Figure 5: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Other Countries Receiving HIV/AIDS Assistance, Fiscal
Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $11 million;
Other health: $250 million.
Year: 2002;
HIV/Aids: $8 million;
Other health: $246 million.
Year: 2003;
HIV/Aids: $42 million;
Other health: $246 million.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $62 million;
Other health: $288 million.
Year: 2005;
HIV/Aids: $70 million;
Other health: $392 million.
Year: 2006;
HIV/Aids: $66 million;
Other health: $352 million.
Year: 2007;
HIV/Aids: $47 million;
Other health: $457 million.
Year: 2008;
HIV/Aids: $50 million;
Other health: $420 million.
Total spending: 2001-2003:
HIV/Aids: $61 million;
Other health: $752 million.
Total spending: 2004-2008:
HIV/Aids: $294 million;
Other health: $1.9 billion.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
Spending Levels and Growth Rates Varied among Three Key Regions:
In fiscal years 2001 through 2008, the majority of U.S. bilateral HIV/
AIDS program spending was in sub-Saharan Africa, Asia, and Latin
America and the Caribbean--three regions where the 15 PEPFAR focus
countries and 14 of the 16 nonfocus countries with PEPFAR operational
plans are located[Footnote 23]--with the greatest U.S. spending on
global HIV/AIDS foreign assistance programs in sub-Saharan Africa.
From 2004 through 2008, following the establishment of PEPFAR, the
share of U.S. bilateral spending on other health programs directed to
countries in sub-Saharan Africa and Latin America and the Caribbean
declined, while the share of U.S. spending on other health programs in
Asia and in other regions increased. (See figure 6.)
Figure 6: U.S. Health-Related Foreign Assistance Spending (in Constant
Dollars), by Region, Fiscal Years 2001-2008:
[Refer to PDF for image: 4 pie-charts]
Fiscal years 2001–2003:
HIV/AIDS:
Sub-Sarhan Africa: 79% ($691 million);
Asia: 15% ($127 million);
Latin American and Caribbean: 6% ($54 million);
All other regions[A]: 0.4% ($4 million).
Other health:
Sub-Sarhan Africa: 34% ($797 million);
Asia: 29% ($687 million);
Latin American and Caribbean: 18% ($434 million);
All other regions[A]: 19% ($465 million).
Fiscal 2004-2008:
HIV/AIDS:
Sub-Sarhan Africa: 81% ($5.5 billion);
Asia: 10% ($677 million);
Latin American and Caribbean: 7% ($457 million);
All other regions[A]: 2% ($101 million).
Other health:
Sub-Sarhan Africa: 25% ($1.4 billion);
Asia: 32% ($1.8 billion);
Latin American and Caribbean: 11% ($631 million);
All other regions[A]: 32% ($1.8 billion).
Source: GAO analysis of data from the Foreign Assistance Database.
Notes: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[A] Other regions include Europe, Eurasia, North Africa, and the
Middle East.
[End of figure]
Average annual growth rates in spending on HIV/AIDS and other health
programs also varied significantly across these three regions (see
table 4).
Table 4: Average Annual Growth Rates for Global U.S. HIV/AIDS and
Other Health-Related Foreign Assistance Spending, by Region, Fiscal
Years 2001-2008:
Pre-PEPFAR period:
Sub-Saharan Africa;
Percentage growth in HIV/AIDS spending: 104;
Percentage growth in other health spending: -2.
Asia;
Percentage growth in HIV/AIDS spending: 182;
Percentage growth in other health spending: 9.
Latin America and the Caribbean;
Percentage growth in HIV/AIDS spending: 187;
Percentage growth in other health spending: -7.
PEPFAR period (first 5 years):
Sub-Saharan Africa;
Percentage growth in HIV/AIDS spending: 37;
Percentage growth in other health spending: 18.
Asia;
Percentage growth in HIV/AIDS spending: 13;
Percentage growth in other health spending: 10.
Latin American and the Caribbean;
Percentage growth in HIV/AIDS spending: 29;
Percentage growth in other health spending: 1.
Source: GAO analysis of data from Foreign Assistance Database.
[End of table]
Sub-Saharan Africa:
U.S. bilateral foreign assistance spending on HIVAIDS programs in sub-
Saharan Africa--which includes 12 of the 15 focus countries and 8 of
the 16 nonfocus countries with PEPFAR operational plans[Footnote 24]--
increased rapidly both before and after the establishment of PEPFAR.
In 2003, U.S. bilateral spending on HIV/AIDS programs was nearly two
times greater, and by 2008 was more than four times greater than
spending on other health programs. U.S. bilateral spending on other
health programs declined overall from 2001 to 2003 and remained steady
from 2004 to 2007, but began to grow substantially in 2008. (See
figure 7.)
Figure 7: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Sub-Saharan Africa, Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $111 million;
Other health: $252 million.
Year: 2002;
HIV/Aids: $159 million;
Other health: $326 million.
Year: 2003;
HIV/Aids: $421 million;
Other health: $218 million.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $440 million;
Other health: $226 million.
Year: 2005;
HIV/Aids: $729 million;
Other health: $207 million.
Year: 2006;
HIV/Aids: $961 million;
Other health: $221 million.
Year: 2007;
HIV/Aids: $1.4 billion;
Other health: $268 million.
Year: 2008;
HIV/Aids: $1.9 billion;
Other health: $452 million.
Total spending: 2001-2003:
HIV/Aids: $691 million;
Other health: $797 million.
Total spending: 2004-2008:
HIV/Aids: $5.5 billion;
Other health: $1.4 billion.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
Asia:
U.S. bilateral foreign assistance spending on both HIVAIDS and other
health-related foreign assistance programs in Asia--where 1 of the 15
focus countries as well as 5 nonfocus countries and 1 region that
submit PEPFAR operational plans are located[Footnote 25]--increased
overall from 2001 to 2008. Overall bilateral spending on other health
programs was three times larger than spending on HIV/AIDS programs
throughout the period. (See figure 8.)
Figure 8: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Asia, Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $11 million;
Other health: $219 million.
Year: 2002;
HIV/Aids: $31 million;
Other health: $212 million.
Year: 2003;
HIV/Aids: $86 million;
Other health: $257 million.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $92 million;
Other health: $293 million.
Year: 2005;
HIV/Aids: $128 million;
Other health: $357 million.
Year: 2006;
HIV/Aids: $147 million;
Other health: $337 million.
Year: 2007;
HIV/Aids: $158 million;
Other health: $435 million.
Year: 2008;
HIV/Aids: $153 million;
Other health: $383 million.
Total spending: 2001-2003:
HIV/Aids: $127 million;
Other health: $687 million.
Total spending: 2004-2008:
HIV/Aids: $677 million;
Other health: $1.8 billion.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
Latin America and the Caribbean:
From 2001 through 2008, total U.S. bilateral foreign assistance
spending on HIVAIDS programs in Latin American and the Caribbean--
where 2 of the 15 focus countries as well as a nonfocus country and
two regions with PEPFAR operational plans are located[Footnote 26]--
increased continuously. During this period, U.S. bilateral spending on
other health programs in these countries and regions fluctuated from
year to year and declined overall. Bilateral spending on other health
programs was consistently greater than spending on HIV/AIDS programs
during this period; however, in 2008, annual spending on HIV/AIDS
programs was nearly equal to spending for other health programs (see
figure 9).
Figure 9: U.S. Health-Related Foreign Assistance Spending (Constant
Dollars) in Latin American and the Caribbean, Fiscal Years 2001-2008:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2001;
HIV/Aids: $8 million;
Other health: $152 million.
Year: 2002;
HIV/Aids: $8 million;
Other health: $151 million.
Year: 2003;
HIV/Aids: $38 million;
Other health: $131 million.
PEPFAR established: July 2003.
Year: 2004;
HIV/Aids: $44 million;
Other health: $131 million.
Year: 2005;
HIV/Aids: $81 million;
Other health: $125 million.
Year: 2006;
HIV/Aids: $100 million;
Other health: $109 million.
Year: 2007;
HIV/Aids: $107 million;
Other health: $134 million.
Year: 2008;
HIV/Aids: $24 million;
Other health: $132 million.
Total spending: 2001-2003:
HIV/Aids: $54 million;
Other health: $434 million.
Total spending: 2004-2008:
HIV/Aids: $457 million;
Other health: $631 million.
Source: GAO analysis of data from the Foreign Assistance Database.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of figure]
Three Key HIV Treatment Costing Models Used to Inform Policy and
Program Decisions:
To inform policy and program decisions related, in part, to expanding
efforts to provide ART in developing countries,[Footnote 27] OGAC,
USAID, and UNAIDS have adopted three different models for ART cost
analyses.
* OGAC uses the PEPFAR ART Costing Project Model (PACM) to estimate
and track PEPFAR-supported ART costs in individual PEPFAR countries
and across these countries.[Footnote 28]
* USAID and its partners use the HIV/AIDS Program Sustainability
Analysis Tool (HAPSAT) to estimate resources needed to meet individual
countries' ART goals, among other things.
* UNAIDS and USAID use a suite of models referred to as Spectrum
[Footnote 29] to project ART costs in individual countries and
globally.
Table 5 provides information on the three costing models. For
additional information on the components of these three models, see
appendix III.
Table 5: HIV Treatment Costing Models Used by OGAC, USAID, and UNAIDS:
Background:
PACM: OGAC began using PACM in 2008. PACM was developed by CDC and its
implementing partner ICF Macro as part of the PEPFAR ART Costing
Project, a public health evaluation intended to guide PEPFAR in
program and policy development, inform the global community, and
identify areas for possible further research;
HAPSAT: USAID began using HAPSAT in Zambia in 2008. HAPSAT was created
by Abt Associates as part of USAID's Health Systems 20/20 program,
which aims to strengthen health systems in developing countries by
addressing financing, governance, operational, and capacity
constraints of developing countries' health systems;
Spectrum: UNAIDS began using Spectrum in 2001. Spectrum comprises a
suite of policy models that UNAIDS and The Futures Group, with USAID's
support, integrated as part of USAID's Health Policy Initiative.[A]
The initiative aims to improve the policy environment for health in
partner countries, specifically in family planning and reproductive
health, HIV and AIDS, and maternal health.
Scope and purposes:
PACM: Scope;
* Individual PEPFAR countries (4 countries to date);
* All PEPFAR countries;
Purposes;
* Estimate average annual per-patient costs of current HIV treatment
programs;
* Project cost of program expansion;
* Estimate PEPFAR and non-PEPFAR shares of treatment costs;
* Explore financial effects of potential program and policy changes;
HAPSAT: Scope;
* Individual countries (10 to date);
Purposes;
* Identify differences between total financial and human resources
needed and those currently available (i.e., gap analysis);
* Assist partner country policymakers in assessing the financial and
human resources required to deliver HIV treatment services, among
other things[B];
Spectrum: Scope;
* Individual countries (132 countries to date);
* Global;
Purposes;
* Estimate the need for HIV treatment and other HIV/AIDS services;
* Report on the status of the global HIV/AIDS epidemic[C].
Data sources:
PACM: PEPFAR-supported studies and expenditure analyses;
HAPSAT: Various sources, including implementing partners, partner
country information, and international, regional and national studies;
Spectrum: Various sources, including UNAIDS Reference Group on
Estimates Modeling and Projections,[D] UNAIDS, and national and
international studies.
Source: GAO synthesis of information from OGAC, CDC, USAID, and The
Futures Institute.
[A] The Futures Institute currently maintains the Spectrum Policy
Modeling System.
[B] HAPSAT also estimates resources needed for prevention of mother-to-
child transmission, HIV testing and counseling, care for orphans and
vulnerable children, prevention, and care and support to people living
with HIV and AIDS.
[C] UNAIDS uses the Estimation and Projection Package to estimate and
report on the status of the global HIV/AIDS epidemic. UNAIDS uses the
Resource Needs Model to estimate and report on the resources needed to
meet annual targets.
[D] In May 2008, the UNAIDS Reference Group on Estimates, Modeling and
Projections, which advises UNAIDS and the World Health Organization on
HIV/AIDS estimates, recommended several changes to Spectrum's
epidemiological and ART costing model components.
[End of table]
Although the models have different purposes, a 2009 comparison study
conducted by their developers found that the three models produced
similar overall ART cost estimates given similar data inputs.
According to the models' developers, data used for one model can be
entered into another to generate cost estimates and projections. For
example, cost data collected in Nigeria for use in HAPSAT were also
used in PACM to inform PEPFAR global average treatment cost estimates.
Such cost projections also can help decision makers to estimate the
cost-related effects of policy and protocol changes, such as changes
made in response to the World Health Organization's November 2009
recommendation that HIV patients initiate ART at an earlier stage of
the disease's progression.
Agency Comments and Our Evaluation:
In coordination with HHS and USAID, State's OGAC reviewed a draft of
this report and provided technical comments, which we incorporated as
appropriate.
We are sending copies of this report to the Secretary of State, the
Office of the Global AIDS Coordinator, USAID Office of HIV/AIDS, HHS
Office of Global Health Affairs, and CDC Global AIDS Program. In
addition, the report will be available at no charge on the GAO Web
site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-3149 or gootnickd@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix IV.
Signed by:
David Gootnick:
Director, International Affairs and Trade:
List of Committees:
The Honorable John Kerry:
Chairman:
The Honorable Richard Lugar:
Ranking Member:
Committee on Foreign Relations:
United States Senate:
The Honorable Patrick Leahy:
Chairman:
The Honorable Judd Gregg:
Ranking Member:
Subcommittee on State, Foreign Operations, and Related Programs:
Committee on Appropriations:
United States Senate:
The Honorable Howard Berman:
Chairman:
The Honorable Ileana Ros-Lehtinen:
Ranking Member:
Committee on Foreign Affairs:
House of Representatives:
The Honorable Nita Lowey:
Chairwoman:
The Honorable Kay Granger:
Ranking Member:
Subcommittee on State, Foreign Operations, and Related Programs:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
Responding to legislative directives, this report examines U.S.
bilateral foreign assistance spending on global HIV/AIDS and other
health-related programs in fiscal years 2001-2008. The report also
provides information on models used to estimate HIV treatment costs.
To examine trends in U.S. bilateral spending on global HIV/AIDS-and
other health-related foreign assistance programs, we analyzed data
from the Foreign Assistance Database (FADB) provided by the U.S.
Agency for International Development (USAID),[Footnote 30] interviewed
State Department, USAID, and Health and Human Services (HHS) officials
in Washington, D.C., and Centers for Disease Control and Prevention
(CDC) officials in Atlanta. We also interviewed representatives of the
Kaiser Family Foundation who have conducted similar research and
analysis. We reviewed relevant articles and reports regarding
international and U.S. global health assistance funding and examined
relevant data on other donor and U.S. foreign assistance.
Congress, U.S. agencies, and research organizations use varying
definitions of global health programs,[Footnote 31] with inclusion of
safe water and nutrition programs being one varying factor among
definitions. Congress funds global health programs through a number of
appropriations accounts: Foreign Operations; Labor, Education and
Health; and Defense; and through several U.S. agencies. The State
Department, USAID, and the HHS' CDC are the primary U.S. agencies
receiving congressional appropriations to implement global health
programs, including programs to combat HIV/AIDS. Through foreign
operations accounts administered by USAID and State, Congress
specifies support for five key global health programs: child survival
and maternal health, vulnerable children, HIV/AIDS, other infectious
diseases, and family planning and reproductive health. In addition,
Congress specifies support for five key CDC global health programs:
HIV/AIDS, malaria, global disease detection, immunizations, and other
global health. CDC also allocates part of its tuberculosis and
pandemic flu budget for international programs, and State and USAID
may transfer funds to CDC for specific activities. In addition to
these programs, USAID and CDC include other programs related to global
health. For example, USAID reports specific nutrition and
environmental health programs in its global health portfolio.
Likewise, CDC also uses its resources to provide international
technical assistance when requested, such as for disease outbreak
response (e.g., pandemic influenza preparedness and prevention), or
reproductive health.
The Committee on the U.S. Commitment to Global Health at the Institute
of Medicine (IOM) defined global health programs as those aimed at
improving health for all people around the world by promoting wellness
and eliminating avoidable disease, disability and death. According to
the Organisation for Economic Cooperation and Development (OECD),
global health includes the following components: health care; health
infrastructure; nutrition; infectious disease control; health
education; health personnel development; health sector policy,
planning and programs; medical education, training and research; and
medical services. In its report on donor funding for global health,
the Kaiser Family Foundation combined data from four OECD categories
to construct its definition of global health: health; population
policies and programs and reproductive health (which includes HIV/AIDS
and sexually transmitted diseases); water supply and sanitation; and
other social infrastructure and services.[Footnote 32]
For the purposes of this report, we defined U.S. global spending for
HIV/AIDS programs as foreign assistance for activities related to HIV/
AIDS control, including information, education, and communication;
testing; prevention; treatment; and care. We defined U.S. spending for
other health-related programs as foreign assistance for general and
basic health and population and reproductive health policies and
programs (except those related to HIV/AIDS). General and basic health
includes health policy and administrative management, medical
education and training, medical research, basic health care, basic
health infrastructure, basic nutrition, infectious disease control,
health education, and health personnel development. Population and
reproductive health policies and programs include population policy
and administrative management, reproductive health care, family
planning, and personnel development for population and reproductive
health.
The specific analyses presented in this report examine disbursement
levels and growth trends from fiscal years 2001 to 2008 for bilateral
HIV/AIDS and other health-related foreign assistance programs by time
period (pre-PEPFAR and first 5 years of PEPFAR for all countries);
PEPFAR country status (focus countries with PEPFAR operational plans,
nonfocus countries with PEPFAR country or regional operational plans,
[Footnote 33] and other nonfocus countries receiving HIV/AIDS-related
foreign assistance from 2001 to 2008); and region (sub-Saharan Africa,
Latin America and the Caribbean, and Asia, which received the majority
of U.S. spending on bilateral HIV/AIDS-related foreign assistance).
We examined disbursements--amounts paid by federal agencies to
liquidate government obligations[Footnote 34]--of U.S. bilateral
foreign assistance for global HIV/AIDS and other health programs,
because, unlike other data, disbursement data directly reflect the
foreign assistance reaching partner countries. We used USAID's
deflator to convert nominal dollar amounts to constant 2010 dollar
amounts, which are appropriate for spending trend analysis.[Footnote
35] As such, it is important to remember that the disbursement figures
for HIV/AIDS-and other health-related foreign assistance programs
presented in this report differ from appropriation or commitment data
which may be reported elsewhere. Because we focused on bilateral
disbursements, our analysis excludes U.S. contributions to the Global
Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. In addition, about
$4.7 billion and $3.3 billion in disbursements for HIV/AIDS programs
and other health-related foreign assistance programs, respectively,
from 2001 to 2008, were not specified for an individual country or
region in the FADB. As such, our analysis of bilateral spending levels
and growth trends by PEPFAR country status and geographical region
excludes these disbursements.
We assessed the reliability of disbursement data from the FADB and
determined them to be sufficiently reliable for the purposes of
reporting in this manner. In assessing the data, we interviewed USAID
officials in charge of compiling and maintaining the FADB, reviewed
the related documentation, and compared data to published data from
other sources.[Footnote 36] We also determined that, in general, USAID
takes steps to ensure the consistency and accuracy of the
disbursements data reported by U.S. government agencies, including by
verifying possible inconsistencies or anomalies in the data received,
providing guidance and other communications to agencies about category
definitions, and comparing the data to other data sources. Although we
did not assess the reliability of the data for complex statistical
analyses, we determined that the data did not allow the identification
of causal relationships between funding levels over time or among
relevant categories; as such, we did not attempt an empirical analysis
of the impact of PEPFAR on other health funding.
To describe models used to estimate the cost of providing
antiretroviral therapy (ART), we interviewed State Office of the
Global AIDS Coordinator, USAID and CDC officials in Washington, D.C.,
and Atlanta. We also interviewed Joint United Nations Programme on
HIV/AIDS (UNAIDS) officials in Washington, D.C. and Geneva,
Switzerland, as well as developers of the costing models. We analyzed
user manuals and guides for these models, as well as spreadsheets and
additional information and technical comments provided by the U.S.
agencies and model developers. We reviewed relevant literature for
information on ART costing models, as well as the Leadership Act and
previous GAO work regarding requirements and importance of cost
information for program decision making.
[End of section]
Appendix II: U.S. Spending on Global HIV/AIDS and Other Health-Related
Programs:
For fiscal years 2001 to 2008, U.S. bilateral foreign assistance
spending for HIV/AIDS-related health programs varied significantly by
country for both the 15 PEPFAR focus countries and the 16 countries
and three regions with PEPFAR operational plans.
Table 6 presents U.S. bilateral foreign assistance spending in
constant dollars, by country, on HIV/AIDS programs, for fiscal years
2001-2008. As noted in appendix I, we converted nominal dollar amounts
to constant 2010 dollars, which are appropriate for analysis of trends
in U.S. foreign assistance spending in global health, but do not
represent in-year actual spending amounts.
Table 6: U.S. Foreign Assistance Spending on HIV/AIDS Programs, by
Country, Fiscal Years 2001-2008 (2010 constant U.S. dollars):
15 PEPFAR focus countries:
South Africa;
2001: $16,048,632;
2002: $18,483,702;
2003: $42,365,523;
2004: $38,049,723;
2005: $74,108,994;
2006: $122,224,063;
2007: $199,153,449;
2008: $293,828,532;
Total 2001-2003: $76,897,857;
Total 2004-2008: $727,364,762.
Nigeria;
2001: $1,337,867;
2002: $14,295,252;
2003: $47,830,438;
2004: $62,885,643;
2005: $74,995,768;
2006: $80,850,916;
2007: v158,901,929;
2008: $255,684,352;
Total 2001-2003: $63,463,557;
Total 2004-2008: $633,318,607.
Kenya;
2001: $8,831,314;
2002: $19,070,399;
2003: $46,998,263;
2004: $44,474,157;
2005: $63,051,042;
2006: $124,738,409;
2007: $167,107,618;
2008: $227,969,937;
Total 2001-2003: $74,899,976;
Total 2004-2008: $627,341,162.
Uganda;
2001: [Empty];
2002: [Empty];
2003: $25,560,558;
2004: $44,206,989;
2005: $103,268,290;
2006: $108,890,976;
2007: $166,286,916;
2008: $190,623,547;
Total 2001-2003: $25,560,558;
Total 2004-2008: $613,276,718.
Zambia;
2001: $15,330,545;
2002: $22,791,657;
2003: $36,020,408;
2004: $33,931,371;
2005: $62,458,419;
2006: $90,897,679;
2007: $106,636,519;
2008: $131,714,977;
Total 2001-2003: $74,142,610;
Total 2004-2008: $425,638,966.
Tanzania;
2001: $11,160,709;
2002: $15,161,132;
2003: $27,593,455;
2004: $37,227,079;
2005: $52,334,139;
2006: $74,660,768;
2007: $110,452,172;
2008: $113,026,745;
Total 2001-2003: $53,915,296;
Total 2004-2008: $387,700,903.
Ethiopia;
2001: $15,037;
2002: $467,557;
2003: $19,353,078;
2004: $22,041,516;
2005: $39,642,795;
2006: $62,021,132;
2007: $72,331,271;
2008: 122,474,184;
Total 2001-2003: $19,835,672;
Total 2004-2008: $318,510,899.
Mozambique;
2001: [Empty];
2002: $361;
2003: $7,516,469;
2004: $15,276,546;
2005: $35,750,077;
2006: $39,485,643;
2007: $66,382,310;
2008: $102,513,531;
Total 2001-2003: $7,516,830;
Total 2004-2008: $259,408,108.
Botswana;
2001: [Empty];
2002: [Empty];
2003: $12,539,884;
2004: $6,545,700;
2005: $20,130,412;
2006: $18,008,236;
2007: $40,585,239;
2008: $162,401,023;
Total 2001-2003: $12,539,884;
Total 2004-2008: $247,670,611.
Rwanda;
2001: [Empty];
2002: [Empty];
2003: $6,781,692;
2004: $11,767,714;
2005: $28,287,289;
2006: $34,878,486;
2007: $70,635,859;
2008: $56,516,620;
Total 2001-2003: $6,781,692;
Total 2004-2008: $202,085,968.
Haiti;
2001: [Empty];
2002: $73,859;
2003: $5,285,590;
2004: $7,107,505;
2005: $24,804,871;
2006: $45,064,398;
2007: $52,808,689;
2008: $57,850,119;
Total 2001-2003: $5,359,448;
Total 2004-2008: $187,635,583.
Namibia;
2001: $227,997;
2002: $994,597;
2003: $8,064,561;
2004: $8,862,223;
2005: $18,809,931;
2006: $35,812,414;
2007: $45,494,188;
2008: $63,352,251;
Total 2001-2003: $9,287,155;
Total 2004-2008: $172,331,006.
Côte d'Ivoire;
2001: [Empty];
2002: [Empty];
2003: $9,149,444;
2004: $4,153,285;
2005: $12,594,137;
2006: $23,422,109;
2007: $26,240,893;
2008: 80,191,655;
Total 2001-2003: $9,149,444;
Total 2004-2008: $146,602,079.
Vietnam;
2001: [Empty];
2002: [Empty];
2003: $4,045,502;
2004: $7,082,079;
2005: $14,362,056;
2006: $24,233,691;
2007: $26,026,779;
2008: $40,953,716;
Total 2001-2003: $4,045,502;
Total 2004-2008: $112,658,322.
Guyana;
2001: $13,127;
2002: $58,656;
2003: $3,554,819;
2004: $4,663,648;
2005: $11,332,843;
2006: $16,876,466;
2007: $16,424,763;
2008: $23,834,016;
Total 2001-2003: $3,626,601;
Total 2004-2008: $73,131,736.
Other countries and regions with PEPFAR operational plans:
India;
2001: [Empty];
2002: $4,574,166;
2003: $17,909,477;
2004: $26,451,046;
2005: $28,021,107;
2006: $23,373,610;
2007: $27,053,726;
2008: $30,786,736;
Total 2001-2003: $22,483,643;
Total 2004-2008: $135,686,225.
Zimbabwe;
2001: $5,088,552;
2002: $4,944,123;
2003: $19,349,541;
2004: $8,814,916;
2005: $28,705,833;
2006: $18,339,247;
2007: $38,242,293;
2008: $19,858,432;
Total 2001-2003: $29,382,216;
Total 2004-2008: $113,960,721.
Malawi;
2001: $10,852,744;
2002: $21,075,277;
2003: $20,290,520;
2004: $19,316,688;
2005: $22,752,913;
2006: $24,130,246;
2007: $23,833,371;
2008: $21,911,449;
Total 2001-2003: $52,218,541;
Total 2004-2008: $111,944,665.
Cambodia;
2001: $1,353,765;
2002: $5,824,861;
2003: $16,244,556;
2004: $10,174,775;
2005: $21,423,537;
2006: $21,606,071;
2007: $25,229,684;
2008: $18,779,954;
Total 2001-2003: $23,423,182;
Total 2004-2008: $97,214,021.
Russia;
2001: [Empty];
2002: $18,922;
2003: $1,218,611;
2004: $4,954,941;
2005: $8,947,172;
2006: $16,311,757;
2007: $13,094,370;
2008: $11,771,196;
Total 2001-2003: $1,237,533;
Total 2004-2008: $55,079,436.
Angola;
2001: $616,384;
2002: $3,934,991;
2003: $8,089,555;
2004: $11,365,570;
2005: $13,737,866;
2006: $12,162,630;
2007: $7,680,294;
2008: $8,170,418;
Total 2001-2003: $12,640,929;
Total 2004-2008: $53,116,778.
Indonesia;
2001: $2,302,976;
2002: $6,180,037;
2003: $9,449,889;
2004: $12,872,946;
2005: $10,859,871;
2006: $9,069,841;
2007: $9,357,305;
2008: $9,633,627;
Total 2001-2003: $17,932,901;
Total 2004-2008: $51,793,590.
Caribbean Region;
2001: [Empty];
2002: $1,134,134;
2003: $6,309,198;
2004: $5,730,494;
2005: $8,661,130;
2006: $8,322,490;
2007: $7,189,362;
2008: $10,189,546;
Total 2001-2003: $7,443,332;
Total 2004-2008: $40,093,022.
Democratic Republic of the Congo;
2001: [Empty];
2002: [Empty];
2003: $2,977,438;
2004: $5,902,646;
2005: $5,457,622;
2006: $7,984,419;
2007: $7,436,350;
2008: $8,876,260;
Total 2001-2003: $2,977,438;
Total 2004-2008: $35,657,296.
Thailand;
2001: $46,851;
2002: $198,146;
2003: $7,280,801;
2004: $1,816,064;
2005: $9,886,758;
2006: $6,163,900;
2007: $8,339,482;
2008: $6,084,086;
Total 2001-2003: $7,525,798;
Total 2004-2008: $32,290,291.
Central American Region;
2001: $7,792,189;
2002: $3,529,346;
2003: $4,693,362;
2004: $3,961,230;
2005: $4,453,498;
2006: $6,281,997;
2007: $8,030,335;
2008: $8,538,223;
Total 2001-2003: $16,014,896;
Total 2004-2008: $31,265,283.
Ghana;
2001: $2,217,333;
2002: $586,135;
2003: $5,317,071;
2004: $5,653,412;
2005: $4,982,731;
2006: $8,855,386;
2007: $6,681,921;
2008: $4,197,732;
Total 2001-2003: $8,120,539;
Total 2004-2008: $30,371,183.
Ukraine;
2001: [Empty];
2002: [Empty];
2003: $489,945;
2004: $1,216,802;
2005: $4,905,134;
2006: $8,068,000;
2007: $5,648,097;
2008: $6,815,554;
Total 2001-2003: $489,945;
Total 2004-2008: $26,653,587.
Dominican Republic;
2001: [Empty];
2002: $545,935;
2003: $3,261,054;
2004: $5,529,282;
2005: $6,196,222;
2006: $5,770,205;
2007: $4,986,430;
2008: $2,559,043;
Total 2001-2003: $3,806,989;
Total 2004-2008: $25,041,183.
Honduras;
2001: [Empty];
2002: $409,553;
2003: $1,760,789;
2004: $3,077,523;
2005: $7,556,126;
2006: $3,011,259;
2007: $5,412,683;
2008: $4,690,969;
Total 2001-2003: $2,170,342;
Total 2004-2008: $23,748,561.
China;
2001: [Empty];
2002: [Empty];
2003: $2,597,832;
2004: [Empty];
2005: $3,953,439;
2006: $3,500,436;
2007: $5,025,160;
2008: $6,852,195;
Total 2001-2003: $2,597,832;
Total 2004-2008: $19,331,231.
Sudan;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: $114,552;
2005: $1,776,580;
2006: $3,240,105;
2007: $5,592,162;
2008: $7,438,980;
Total 2001-2003: [Empty];
Total 2004-2008: $18,162,379.
Central Asian Region;
2001: [Empty];
2002: $6,865;
2003: $402,535;
2004: $1,709,819;
2005: $1,901,328;
2006: $2,954,038;
2007: $2,396,795;
2008: $1,748,053;
Total 2001-2003: $409,400;
Total 2004-2008: $10,710,033.
Swaziland;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: $114,552;
2005: $1,471,576;
2006: $343,126;
2007: $2,202,730;
2008: $5,310,586;
Total 2001-2003: [Empty];
Total 2004-2008: $9,442,571.
Lesotho;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: $114,552;
2005: $1,138,509;
2006: $399,764;
2007: $2,856,823;
2008: $4,225,066;
Total 2001-2003: [Empty];
Total 2004-2008: $8,734,715.
Kazakhstan;
2001: [Empty];
2002: [Empty];
2003: $331,547;
2004: $834,161;
2005: $880,922;
2006: $2,406,394;
2007: $783,873;
2008: $1,316,426;
Total 2001-2003: $331,547;
Total 2004-2008: $6,221,776.
Tajikistan;
2001: [Empty];
2002: [Empty];
2003: $679,646;
2004: $410,867;
2005: $2,067,015;
2006: $712,412;
2007: $1,994,454;
2008: $906,020;
Total 2001-2003: $679,646;
Total 2004-2008: $6,090,768.
Jamaica;
2001: [Empty];
2002: $465,430;
2003: $1,566,703;
2004: $1,400,820;
2005: $444,642;
2006: $866,133;
2007: $1,286,451;
2008: $1,809,118;
Total 2001-2003: $2,032,133;
Total 2004-2008: $5,807,163.
Uzbekistan;
2001: [Empty];
2002: [Empty];
2003: $(105,763);
2004: $536,764;
2005: $1,097,456;
2006: $772,614;
2007: $1,636,799;
2008: $1,168,706;
Total 2001-2003: $(105,763);
Total 2004-2008: $5,212,339.
Kyrgyzstan;
2001: [Empty];
2002: [Empty];
2003: $64,797;
2004: $611,399;
2005: $792,761;
2006: $630,079;
2007: $1,844,453;
2008: $1,240,418;
Total 2001-2003: $64,797;
Total 2004-2008: $5,119,111.
Guatemala;
2001: [Empty];
2002: [Empty];
2003: $349,345;
2004: $197,605;
2005: $616,200;
2006: $1,086,397;
2007: $771,707;
2008: $2,285,135;
Total 2001-2003: $349,345;
Total 2004-2008: $4,957,044.
El Salvador;
2001: [Empty];
2002: [Empty];
2003: $118,012;
2004: $460,073;
2005: $875,283;
2006: $666,294;
2007: $1,046,442;
2008: $849,494;
Total 2001-2003: $118,012;
Total 2004-2008: $3,897,586.
Nicaragua;
2001: [Empty];
2002: [Empty];
2003: $590,059;
2004: [Empty];
2005: $334,339;
2006: $396,152;
2007: $947,395;
2008: $896,028;
Total 2001-2003: $590,059;
Total 2004-2008: $2,573,914.
Turkmenistan;
2001: [Empty];
2002: [Empty];
2003: $122,543;
2004: $19,795;
2005: $160,387;
2006: $17,142;
2007: $145,069;
2008: $317,816;
Total 2001-2003: $122,543;
Total 2004-2008: $660,209.
Trinidad and Tobago;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: $252;
2006: $105,718;
2007: $156,306;
2008: $109,131;
Total 2001-2003: [Empty];
Total 2004-2008: $371,407.
Barbados;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: $68,772;
2007: $130,091;
2008: $63,753;
Total 2001-2003: [Empty];
Total 2004-2008: $262,615.
Suriname;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: [Empty];
2007: $64,935;
2008: [Empty];
Total 2001-2003: [Empty];
Total 2004-2008: $64,935.
Panama;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: $4,852;
2006: $60,112;
2007: $1,448;
2008: [Empty];
Total 2001-2003: [Empty];
Total 2004-2008: $66,412.
Spending not directed to specific country or region;
2001: $73,859,916;
2002: $112,633,502;
2003: $150,881,844;
2004: $619,850,317;
2005: $783,272,254;
2006: $918,934,546;
2007: $1,007,153,610;
2008: $1,068,106,489;
Total 2001-2003: $337,375,262;
Total 2004-2008: $4,397,317,218.
Source: GAO synthesis of Foreign Assistance Database data.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of table]
For fiscal years 2001 to 2008, U.S. bilateral foreign assistance
spending for other health programs also varied significantly by
country for both the 15 PEPFAR focus countries and the 16 countries
and three regions with PEPFAR operational plans.
Table 7 presents U.S. bilateral foreign assistance spending in
constant dollars, by country, on other health-related (i.e., non-
HIV/AIDS) programs, for fiscal years 2001-2008. As noted in appendix
I, we converted nominal dollar amounts to constant 2010 dollars, which
are appropriate for analysis of trends in U.S. foreign assistance
spending in global health, but do not represent in-year actual
spending amounts.
Table 7: U.S. Foreign Assistance Spending on Other Health-Related
Programs, by Country, Fiscal Years 2001-2008 (2010 constant U.S.
dollars):
15 PEPFAR focus countries:
South Africa;
2001: [Empty];
2002: $642,928;
2003: $536,924;
2004: $637,184;
2005: $1,711,210;
2006: $315,783;
2007: $692,179;
2008: $2,610,367;
Total 2001-2003: $1,179,853;
Total 2004-2008: $5,966,723.
Nigeria;
2001: $7,071,754;
2002: $8,981,092;
2003: $5,132,871;
2004: $9,494,428;
2005: $11,751,580;
2006: $22,267,741;
2007: $27,650,724;
2008: $39,819,797;
Total 2001-2003: $21,185,717;
Total 2004-2008: $110,984,270.
Kenya;
2001: [Empty];
2002: $1,307,939;
2003: $596,414;
2004: $871,479;
2005: $6,188,546;
2006: $4,155,779;
2007: $7,776,767;
2008: $11,438,335;
Total 2001-2003: $1,904,353;
Total 2004-2008: $30,430,906.
Uganda;
2001: $13,334,327;
2002: $26,646,363;
2003: $21,591,590;
2004: $7,492,819;
2005: $4,103,926;
2006: $5,757,087;
2007: $6,269,648;
2008: $25,367,559;
Total 2001-2003: $61,572,280;
Total 2004-2008: $48,991,038.
Zambia;
2001: [Empty];
2002: [Empty];
2003: $1,130,907;
2004: $970,414;
2005: $6,918,035;
2006: $9,010,464;
2007: $15,849,677;
2008: $24,603,244;
Total 2001-2003: $1,130,907;
Total 2004-2008: $57,351,834.
Tanzania;
2001: $86,967;
2002: $465,462;
2003: $1,180,118;
2004: $1,176,758;
2005: $1,772,919;
2006: $9,232,670;
2007: $21,394,144;
2008: $29,188,137;
Total 2001-2003: $1,732,547;
Total 2004-2008: $62,764,630.
Ethiopia;
2001: $17,889,719;
2002: $27,070,713;
2003: $23,079,023;
2004: $33,581,494;
2005: $22,394,202;
2006: $23,901,143;
2007: $22,581,696;
2008: $26,594,142;
Total 2001-2003: $68,039,455;
Total 2004-2008: $129,052,678.
Mozambique;
2001: $14,172,689;
2002: $17,683,920;
2003: $27,015,156;
2004: $19,205,643;
2005: $8,283,073;
2006: $11,687,475;
2007: $17,287,779;
2008: $29,465,820;
Total 2001-2003: $58,871,765;
Total 2004-2008: $85,929,790.
Botswana;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: $218,190;
2005: [Empty];
2006: [Empty];
2007: [Empty];
2008: $1,351,797;
Total 2001-2003: [Empty];
Total 2004-2008: $1,569,986.
Rwanda;
2001: $8,024,114;
2002: $9,885,196;
2003: $8,892,109;
2004: $5,176,306;
2005: $3,610,692;
2006: $5,207,555;
2007: $11,758,852;
2008: $24,993,875;
Total 2001-2003: $26,801,419;
Total 2004-2008: $50,747,281.
Haiti;
2001: $21,647,890;
2002: $14,791,259;
2003: $29,180,754;
2004: $18,872,184;
2005: $21,286,606;
2006: $17,918,642;
2007: $29,149,488;
2008: $17,024,611;
Total 2001-2003: $65,619,903;
Total 2004-2008: $104,251,531.
Namibia;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: [Empty];
2007: $53,977;
2008: $44,292;
Total 2001-2003: [Empty];
Total 2004-2008: $98,269.
Côte d'Ivoire;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: $5,397,186;
2005: $962,707;
2006: [Empty];
2007: $255,510;
2008: $85,546;
Total 2001-2003: [Empty];
Total 2004-2008: $6,700,949.
Vietnam;
2001: $6,135;
2002: [Empty];
2003: $333,774;
2004: $661,542;
2005: $336,112;
2006: $1,237,627;
2007: $1,437,274;
2008: $537,785;
Total 2001-2003: $339,909;
Total 2004-2008: $4,210,340.
Guyana;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: [Empty];
2007: [Empty];
2008: [Empty];
Total 2001-2003: [Empty];
Total 2004-2008: [Empty].
Other countries and regions with PEPFAR operational plans:
India;
2001: $39,436,982;
2002: $38,363,965;
2003: $60,811,954;
2004: $45,179,946;
2005: $46,575,546;
2006: $51,836,433;
2007: $53,668,877;
2008: $51,863,556;
Total 2001-2003: $138,612,900;
Total 2004-2008: $249,124,358.
Indonesia;
2001: $20,969,410;
2002: $31,158,393;
2003: $36,698,269;
2004: $34,366,143;
2005: $19,196,268;
2006: $11,300,430;
2007: $8,958,503;
2008: $29,507,966;
Total 2001-2003: $88,826,072;
Total 2004-2008: $103,329,310.
Democratic Republic of the Congo;
2001: $2,903,118;
2002: $2,093,357;
2003: $1,848,945;
2004: $2,568,284;
2005: $13,192,309;
2006: $23,278,589;
2007: $11,572,186;
2008: $31,232,665;
Total 2001-2003: $6,845,420;
Total 2004-2008: $81,844,032.
Cambodia;
2001: $10,478,340;
2002: $5,735,954;
2003: $12,353,640;
2004: $13,653,855;
2005: $15,287,869;
2006: $16,050,879;
2007: $16,511,453;
2008: $16,566,756;
Total 2001-2003: $28,567,933;
Total 2004-2008: $78,070,812.
Russia;
2001: $5,551,752;
2002: $3,852,078;
2003: $11,575,772;
2004: $11,570,558;
2005: $10,785,144;
2006: $16,469,615;
2007: $15,921,013;
2008: $13,734,915;
Total 2001-2003: $20,979,602;
Total 2004-2008: $68,481,246.
Ghana;
2001: $8,900,493;
2002: $27,922,188;
2003: $16,884,294;
2004: $17,564,377;
2005: $11,261,719;
2006: $12,430,681;
2007: $9,666,559;
2008: $14,993,433;
Total 2001-2003: $53,706,974;
Total 2004-2008: $65,916,770.
Guatemala;
2001: $17,953,097;
2002: $13,293,495;
2003: $17,305,016;
2004: $13,756,172;
2005: $7,378,114;
2006: $11,039,665;
2007: $13,286,846;
2008: $16,215,611;
Total 2001-2003: $48,551,608;
Total 2004-2008: $61,676,409.
Sudan;
2001: $4,169,807;
2002: $3,696,536;
2003: $4,117,388;
2004: $4,696,917;
2005: $8,374,372;
2006: $7,358,296;
2007: $18,623,479;
2008: $16,383,150;
Total 2001-2003: $11,983,731;
Total 2004-2008: $55,436,214.
Ukraine;
2001: $14,141,759;
2002: $10,525,226;
2003: $9,551,119;
2004: $11,393,648;
2005: $6,582,653;
2006: $11,535,442;
2007: $10,631,224;
2008: $6,217,093;
Total 2001-2003: $34,218,104;
Total 2004-2008: $46,360,059.
El Salvador;
2001: $16,163,250;
2002: $12,629,439;
2003: $8,989,099;
2004: $8,949,460;
2005: $8,602,628;
2006: $4,364,329;
2007: $9,627,072;
2008: $13,569,480;
Total 2001-2003: $37,781,787;
Total 2004-2008: $45,112,970.
Nicaragua;
2001: $14,340,486;
2002: $14,545,548;
2003: $11,721,469;
2004: $9,166,913;
2005: $9,121,104;
2006: $7,522,834;
2007: $8,256,773;
2008: $7,801,058;
Total 2001-2003: $40,607,503;
Total 2004-2008: $41,868,682.
Honduras;
2001: $12,435,410;
2002: $11,525,763;
2003: $8,810,391;
2004: $11,065,723;
2005: $7,669,492;
2006: $8,838,321;
2007: $8,049,523;
2008: $5,816,343;
Total 2001-2003: $32,771,563;
Total 2004-2008: $41,439,401.
Uzbekistan;
2001: $6,333,206;
2002: $7,436,859;
2003: $10,743,800;
2004: $18,611,847;
2005: $10,159,145;
2006: $7,152,350;
2007: $3,202,060;
2008: $3,114,916;
Total 2001-2003: $24,513,865;
Total 2004-2008: $42,240,319.
Angola;
2001: $1,685,074;
2002: $1,916,323;
2003: $1,561,393;
2004: $330,118;
2005: $2,271,732;
2006: $2,614,691;
2007: $7,412,588;
2008: $23,672,142;
Total 2001-2003: $5,162,791;
Total 2004-2008: $36,301,270.
Dominican Republic;
2001: $6,512,502;
2002: $8,469,387;
2003: $7,725,266;
2004: $8,544,942;
2005: $7,939,986;
2006: $5,816,901;
2007: $6,815,686;
2008: $6,701,638;
Total 2001-2003: $22,707,155;
Total 2004-2008: $35,819,153.
Tajikistan;
2001: $1,545,894;
2002: $2,396,069;
2003: $4,239,750;
2004: $9,697,111;
2005: $5,060,773;
2006: $4,474,397;
2007: $4,469,502;
2008: $2,215,686;
Total 2001-2003: $8,181,713;
Total 2004-2008: $25,917,469.
Malawi;
2001: $284,245;
2002: $103,554;
2003: $581,854;
2004: $468,267;
2005: $728,616;
2006: $1,113,923;
2007: $1,504,793;
2008: $19,707,663;
Total 2001-2003: $969,653;
Total 2004-2008: $23,523,262.
Kazakhstan;
2001: $8,206,508;
2002: $6,806,391;
2003: $9,429,147;
2004: $6,509,797;
2005: $5,717,303;
2006: $5,613,269;
2007: $4,434,685;
2008: $1,941,887;
Total 2001-2003: $24,442,046;
Total 2004-2008: $24,216,942.
Kyrgyzstan;
2001: $3,541,978;
2002: $4,151,040;
2003: $4,579,973;
2004: $5,165,386;
2005: $4,407,559;
2006: $5,214,893;
2007: $3,362,503;
2008: $4,274,822;
Total 2001-2003: $12,272,991;
Total 2004-2008: $22,425,164.
Central Asian Region;
2001: $8,163,766;
2002: $6,724,978;
2003: $10,488,611;
2004: $8,549,673;
2005: $3,499,533;
2006: $3,112,175;
2007: $2,810,935;
2008: $2,373,481;
Total 2001-2003: $25,377,355;
Total 2004-2008: $20,345,796.
China;
2001: $1,318,618;
2002: $5,373,978;
2003: $3,869,050;
2004: $4,411,845;
2005: $1,111,719;
2006: $2,145,173;
2007: $6,995,093;
2008: $3,786,521;
Total 2001-2003: $10,561,646;
Total 2004-2008: $18,450,352.
Jamaica;
2001: $4,028,637;
2002: $5,460,021;
2003: $2,895,379;
2004: $2,807,180;
2005: $3,048,744;
2006: $2,566,568;
2007: $3,060,361;
2008: $1,950,008;
Total 2001-2003: $12,384,037;
Total 2004-2008: $13,432,861.
Thailand;
2001: [Empty];
2002: [Empty];
2003: $347,576;
2004: [Empty];
2005: $64,956;
2006: $3,573,859;
2007: $3,614,376;
2008: $3,812,777;
Total 2001-2003: $347,576;
Total 2004-2008: $11,065,968.
Turkmenistan;
2001: $256,620;
2002: $1,900,526;
2003: $1,967,380;
2004: $1,787,071;
2005: $1,339,246;
2006: $1,892,409;
2007: $2,213,880;
2008: $1,701,114;
Total 2001-2003: $4,124,526;
Total 2004-2008: $8,933,720.
Central American Region;
2001: [Empty];
2002: [Empty];
2003: ($14,918);
2004: [Empty];
2005: $334,339;
2006: [Empty];
2007: $820,584;
2008: $685,493;
Total 2001-2003: $(14,918);
Total 2004-2008: $1,840,416.
Costa Rica;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: [Empty];
2007: $90,366;
2008: $801,184;
Total 2001-2003: [Empty];
Total 2004-2008: $891,549.
Zimbabwe;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: [Empty];
2007: $10,634;
2008: $860,160;
Total 2001-2003: [Empty];
Total 2004-2008: $870,794.
Lesotho;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: [Empty];
2007: $181,512;
2008: $562,420;
Total 2001-2003: [Empty];
Total 2004-2008: $743,932.
Caribbean Region;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: $237,718;
2006: [Empty];
2007: [Empty];
2008: $71,736;
Total 2001-2003: [Empty];
Total 2004-2008: $309,455.
Panama;
2001: [Empty];
2002: [Empty];
2003: [Empty];
2004: [Empty];
2005: [Empty];
2006: $718;
2007: [Empty];
2008: [Empty];
Total 2001-2003: [Empty];
Total 2004-2008: $718.
Spending not directed to specific country or region;
2001: $533,774,432;
2002: $592,821,990;
2003: $409,542,728;
2004: $448,234,645;
2005: $486,709,664;
2006: $487,205,335;
2007: $322,427,663;
2008: $555,125,445;
Total 2001-2003: $1,536,139,150;
Total 2004-2008: $2,299,702,752.
Source: GAO synthesis of Foreign Assistance Database data.
Note: For this analysis, nominal dollar amounts were adjusted to
reflect 2010 constant dollar values.
[End of table]
[End of section]
Appendix III: ART Patient and Cost Categories, by Costing Model:
To estimate total cost of ART, three key models--the PEPFAR ART
Costing Project Model (PACM), HIV/AIDS Program Sustainability Analysis
Tool (HAPSAT), and Spectrum--all consider the number of
patients[Footnote 37] and various drug and nondrug cost estimates.
PACM and HAPSAT also address overhead costs in total cost
calculations. This appendix presents the specific drug and nondrug
costs that each model considers in making estimates.
PACM:
PACM categorizes ART patients as adult or pediatric, new or
established, receiving first-or second-line ARV drugs, receiving
generic or innovator ARV drugs, and living in a low-or middle-income
country. In addition, PACM considers the following cost categories:
* Drug costs.[Footnote 38] PACM categorizes ARV drug costs as generic
or innovator and first-or second-line.[Footnote 39] For each of these
categories, PACM accounts for costs associated with supply chain,
wastage, inflation, and ARV buffer stock.
* Nondrug costs. PACM categorizes nondrug costs as recurrent and
investment costs. Recurrent costs include personnel, utilities,
building, lab supplies, other supplies, and other drugs; facility-
level management and overhead costs are also captured. Investment
costs include training, equipment, and construction.
* Overhead. PACM categorizes above-facility-level overhead costs as
U.S. government, partner government, and implementing partner
overhead, as well as U.S. government indirect support to partner
governments (e.g., U.S. government support for system strengthening or
capacity building of the national HIV/AIDS program).
Table 8 summarizes how PACM categorizes numbers of patients and
various unit costs to calculate the total cost of ART based on
estimates of PEPFAR and non-PEPFAR shares of costs derived from PEPFAR-
funded empirical studies.
Table 8: PACM ART Patient and Cost Categories:
Further categorized by: [Empty];
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of patients
categorized as new or established;
multiplied by:
Unit cost of ART: Average annual per patient recurrent costs
(including personnel, utilities, building, lab supplies, travel,
contracted services, other supplies, and other drugs) for each
subcategory of ART patients times annual inflation rate for non-ARV
costs[A];
equals:
Cost subtotals: Non-ARV recurrent costs;
Total cost of ART: Nondrug costs.
Further categorized by: Established;
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of
established patients;
multiplied by:
Unit cost of ART: Average annual per patient investment costs
(including training, equipment, and new infrastructure) for each
subcategory of established ART patients times annual inflation rate
for non-ARV costs;
equals:
Cost subtotals: Non-ARV investment costs[B].
Total cost of ART: Nondrug costs.
Further categorized by: New;
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of new
patients;
multiplied by:
Unit cost of ART: Average annual per patient investment costs
(including training, equipment, and new infrastructure) for each
subcategory of ART patients times the percent of future scale-up not
within existing capacity times annual inflation rate for non-ARV costs;
equals:
Cost subtotals: Non-ARV investment costs[B].
Total cost of ART: Nondrug costs.
Further categorized by: First-line and supply chain management;
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of patients
receiving generic first-line ARVs;
multiplied by:
Unit cost of ART: Average cost of generic first-line ARVs for each
subcategory of ART patients. (ARV wastage, ARV markup for supply
chain, and annual ARV price inflation also included);
equals:
Cost subtotals: ARV costs;
Total cost of ART: Drug costs.
Further categorized by: First-line and supply chain management;
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of patients
receiving innovator first-line ARVs;
multiplied by:
Unit cost of ART: : Average cost of innovator first-line ARVs for each
subcategory of ART patients. (ARV wastage, ARV markup for supply
chain, and annual ARV price inflation also included);
equals:
Cost subtotals: ARV costs;
Total cost of ART: Drug costs.
Further categorized by: Second-line and supply chain management;
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of patients
receiving generic second-line ARVs;
multiplied by:
Unit cost of ART: Average cost of generic second-line ARVs for each
subcategory of ART patients. (ARV wastage, ARV markup for supply
chain, and annual ARV price inflation also included);
equals:
Cost subtotals: ARV costs;
Total cost of ART: Drug costs.
Further categorized by: Second-line and supply chain management;
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: : Number of patients
receiving innovator second-line ARVs;
multiplied by:
Unit cost of ART: : Average cost of innovator second-line ARVs for
each subcategory of ART patients. (ARV wastage, ARV markup for supply
chain, and annual ARV price inflation also included);
equals:
Cost subtotals: ARV costs;
Total cost of ART: Drug costs.
Further categorized by: Buffer stock and supply chain management[C];
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of new
patients expected to receive generic ARVS;
multiplied by:
Unit cost of ART: Average cost of generic first-line ARVs for each
subcategory of ART patients;
equals:
Cost subtotals: ARV costs;
Total cost of ART: Drug costs.
Number of ART patients, categorized by quarter for adult or vs.
pediatric and low-or vs. middle-income countries: Number of new
patients expected to receive innovator ARVs;
multiplied by:
Unit cost of ART: : Average cost of innovator first-line ARVs for each
subcategory of ART patients;
equals:
Cost subtotals: ARV costs;
Total cost of ART: Drug costs.
Cost subtotals: Implementing partner overhead (estimated as a
percentage of non-ARV costs)[D].
Cost subtotals: PEPFAR agency overheads, (estimated as a percentage of
ARV and non-ARV costs)[E].
Cost subtotals: Country government overheads (estimated as a
percentage of ARV and non-ARV costs)[F,G].
Cost subtotals: U.S. government indirect support[H].
Total cost of ART: Overhead[I].
Source: GAO synthesis of OGAC information.
[A] PACM distinguishes between newly initiated ART patients and
established patients because newly initiating patients represent a
greater expense due to intensive clinical and laboratory follow-up in
the first 6 months of ART.
[B] PACM estimates non-ARV investment costs for established patients
as resources needed to maintain existing capital stock, taking into
consideration annual depreciation. For new patient slots, PACM
estimates a unit cost of investment in new laboratories, treatment
clinics, and trained personnel.
[C] PACM also accounts for transition of established patients to new
regimens and the addition of new patient slots.
[D] PACM includes a percentage value for implementing partner
overhead. OGAC officials told us they are working with PEPFAR
implementing officials to better understand implementing partners'
administrative expenses.
[E] PACM typically leaves the value for PEPFAR agency overheads at
zero within the model because PEPFAR administrative costs are budgeted
across programs later.
[F] PACM estimates country government overheads only for those program
costs that are paid by the partner country.
[G] PACM includes the percentage value for country government
overheads of 25 percent for demonstrative purposes.
[H] PACM does not generate an estimate for USG annual contribution for
country indirect support. This is a policy input.
[I] PACM does not include the cost of host country government
overheads when the user of the model chooses to estimate only PEPFAR
funding with the model.
[End of table]
HAPSAT:
HAPSAT categorizes current ART patients as those receiving first-or
second-line ARV drugs. In addition, HAPSAT considers the following
cost categories:
* Drug costs. HAPSAT categorizes drug costs as first-or second-line
ARV drugs.
* Nondrug costs. HAPSAT categorizes nondrug costs as labor[Footnote
40] (e.g., doctor, nurse, lab technician salaries) and laboratory
costs.
* Overhead. HAPSAT categorizes overhead as administrative costs, drug
supply chain, monitoring and evaluation, and training, based on
country data. Overhead estimates are applied at both the facility and
above-facility level.
Table 9 summarizes how HAPSAT categorizes numbers of patients and
various unit costs to calculate the total cost of ART.
Table 9: HAPSAT ART Patient and Cost Categories:
Number of ART patients: Number of known eligible people receiving
first-line ARVs;
multiplied by:
Unit cost of ART: Average first-line ARV cost per patient per year
times 15% markup on drugs for supply chain management overhead and
freight;
equals:
Cost subtotals: Drugs and supplies;
Total cost of ART: Drug costs.
Number of ART patients: Number of known eligible people receiving
second-line ARVs;
multiplied by:
Unit cost of ART: Average second-line ARV cost per patient per year
times 15% markup on drugs for supply chain management overhead and
freight;
equals:
Cost subtotals: Drugs and supplies;
Total cost of ART: Drug costs.
Number of ART patients: Number of known eligible people receiving ART;
multiplied by:
Unit cost of ART: Unit cost of each labor cadre times health worker
annual percentage salary escalation;
equals:
Cost subtotals: Labor;
Total cost of ART: Nondrug costs.
Number of ART patients: Number of known eligible people receiving
first-line ARVs, second-line ARVs, and number of people for whom
treatment failed;
multiplied by:
Unit cost of ART: ART lab test unit cost;
equals:
Cost subtotals: Laboratory;
Total cost of ART: Nondrug costs.
Cost subtotals: General overhead (estimated to be 10% of total cost of
labor, drugs and supplies, and laboratory).
Cost subtotals: Monitoring and evaluation (estimated to be 10% of
total cost of labor, drugs and supplies, and laboratory).
Cost subtotals: Drug supply chain overhead and freight (estimated to
be 10% of total cost of labor, drugs and supplies, and laboratory).
Cost subtotals: HIV service training (estimated to be 0% of total cost
of labor, drugs and supplies, and laboratory).
Cost subtotals: Implementing partner and donor overhead (estimated to
be 20% or less of total cost of labor, drugs and supplies, and
laboratory, depending on donor).
Total cost of ART: Overhead.
Source: GAO synthesis of USAID information.
[End of table]
Spectrum:
Spectrum[Footnote 41] categorizes current ART patients as adult or
pediatric and receiving first-or second-line ARV drugs. In addition,
Spectrum considers the following cost categories:
* Drug costs. Spectrum categorizes drugs costs as first-or second-line
ARV drugs.
* Nondrug costs. Spectrum categorizes nondrug costs as laboratory and
service delivery (i.e., hospital and clinic stays). Service delivery
costs include inpatient hospital and outpatient clinic costs.
Table 10 summarizes how Spectrum categorizes numbers of patients and
various unit costs to calculate the total cost of ART.
Table 10: Spectrum ART Patient and Cost Categories:
Number of ART patients, categorized as adult or pediatric: Number of
patients on first-line ARVs;
multiplied by:
Unit cost of ART: Average cost of first-line ARVs per patient;
equals:
Cost subtotals: ARVs;
Total cost of ART: Drug costs.
Number of ART patients, categorized as adult or pediatric: Number of
patients on second-line ARVs;
multiplied by:
Unit cost of ART: Average cost of second-line ARVx per patient;
equals:
Cost subtotals: ARVs;
Total cost of ART: Drug costs.
Number of ART patients, categorized as adult or pediatric: Number of
patients on first-and second-line ARVs;
multiplied by:
Unit cost of ART: Average lab cost per patient;
equals:
Cost subtotals: Laboratory;
Total cost of ART: Nondrug costs.
Number of ART patients, categorized as adult or pediatric: Number of
days per year the average first-line patient is in the hospital;
multiplied by:
Unit cost of ART: unit cost for the hospital;
equals:
Cost subtotals: Service delivery;
Total cost of ART: Nondrug costs.
Number of ART patients, categorized as adult or pediatric: Number of
outpatient clinic visits per year for an average first-line patient;
multiplied by:
Unit cost of ART: unit cost for the clinic services;
equals:
Number of ART patients, categorized as adult or pediatric: Number of
days per year the average second-line patient is in the hospital;
multiplied by:
Unit cost of ART: unit cost for the hospital;
equals:
Cost subtotals: Service delivery;
Total cost of ART: Nondrug costs.
Number of ART patients, categorized as adult or pediatric: Number of
outpatient clinic visits per year for an average second-line patient;
multiplied by:
Unit cost of ART: unit cost for clinic services;
equals:
Cost subtotals: Service delivery;
Total cost of ART: Nondrug costs.
Source: GAO synthesis of information provided by UNAIDS and the
Futures Institute.
[End of table]
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
David Gootnick, (202) 512-3149 or gootnickd@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Audrey Solis (Assistant
Director), Todd M. Anderson, Diana Blumenfeld, Giulia Cangiano, Ming
Chen, David Dornisch, Lorraine Ettaro, Etana Finkler, Kendall Helm,
Heather Latta, Reid Lowe, Grace Lui, Jeff Miller, and Mark Needham
made key contributions to this report.
[End of section]
Related GAO Products:
President's Emergency Plan for AIDS Relief: Efforts to Align Programs
with Partner Countries' HIV/AIDS Strategies and Promote Country
Ownership. [hyperlink, http://www.gao.gov/products/GAO-10-836].
Washington, D.C.: September 20, 2010.
President's Emergency Plan for AIDS Relief: Partner Selection and
Oversight Follow Accepted Practices but Would Benefit from Enhanced
Planning and Accountability. [hyperlink,
http://www.gao.gov/products/GAO-09-666]. Washington, D.C.: July 15,
2009.
Global HIV/AIDS: A More Country-Based Approach Could Improve
Allocation of PEPFAR Funding. [hyperlink,
http://www.gao.gov/products/GAO-08-480]. Washington, D.C.: April 2,
2008.
Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved
Its Documentation of Funding Decisions but Needs Standardized
Oversight Expectations and Assessments. [hyperlink,
http://www.gao.gov/products/GAO-07-627]. Washington, D.C.: May 7, 2007.
Global Health: Spending Requirement Presents Challenges for Allocating
Prevention Funding under the President's Emergency Plan for AIDS
Relief. [hyperlink, http://www.gao.gov/products/GAO-06-395].
Washington, D.C.: April 4,2006.
Global Health: The Global Fund to Fight AIDS, TB and Malaria Is
Responding to Challenges but Needs Better Information and
Documentation for Performance-Based Funding. [hyperlink,
http://www.gao.gov/products/GAO-05-639]. Washington, D.C.: June 10,
2005.
Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications
Provided under U.S. Emergency Plan Is Limited. [hyperlink,
http://www.gao.gov/products/GAO-05-133]. Washington, D.C.: January 11,
2005.
Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to
Expanding Treatment, but Others Remain. [hyperlink,
http://www.gao.gov/products/GAO-04-784]. Washington, D.C.: July 12,
2004.
Global Health: Global Fund to Fight AIDS, TB, and Malaria Has Advanced
in Key Areas, but Difficult Challenges Remain. [hyperlink,
http://www.gao.gov/products/GAO-03-601]. Washington, D.C.: May 7, 2003.
[End of section]
Footnotes:
[1] United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003, Pub. L. No. 108-25, § 401, 117 Stat. 711, 745.
Approximately two-thirds of funding appropriated for PEPFAR's first 5-
year phase was directed to HIV/AIDS programs in 15 countries, known as
focus countries: Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti,
Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania,
Uganda, Vietnam, and Zambia. In the 2003 authorizing legislation (Pub.
L. No. 108-25), Congress assigned an HIV/AIDS Response Coordinator
(later called U.S. Global AIDS Coordinator) the duty of directly
approving all activities of the United States related to combating
HIVAIDS in 14 of these countries. Vietnam was selected as the 15th
country in 2008.
[2] Donor funding for health-related development assistance programs
tripled between 2001 and 2007, from $7.2 billion in 2001 to $22.1
billion in 2007. Funding for HIV/AIDS and other sexually transmitted
diseases drove growth over this period and accounted for one-third of
all global health-related development assistance in 2007. This trend
continued into 2008, as donors' HIV/AIDS-related development
assistance commitments reached their highest levels. See Donor Funding
for Health in Low-and Middle-Income Countries, 2001-2007 (Menlo Park,
CA: The Henry J. Kaiser Family Foundation, July 2009), [hyperlink,
http://www.kff.org/globalhealth/upload/7679-03.pdf] and Financing the
response to AIDS in low-and middle-income countries: International
assistance from the G8, European Commission and other donor
Governments in 2008 (Menlo Park, CA: The Henry J. Kaiser Family
Foundation, July 2009), [hyperlink,
http://www.kff.org/hivaids/upload/7347-052.pdf].
[3] Pub. L. No. 110-293, § 401(a), 122 Stat. 2918, 2965.
[4] Pub. L. No. 110-293, § 101. ART generally involves provision of
multiple antiretroviral drugs (ARV) to HIV-infected patients to
suppress the virus and slow the progression of the disease. In
addition to the cost of ARV drug procurement, ART-related costs also
include treatment services and laboratory infrastructure.
[5] Pub. L. No. 110-161, § 668(d), 121 Stat. 1844, 2353 (2007); Pub.
L. No. 110-293, § 101(d), 122 Stat. 2918, 2931. The acts directed us
to assess impact of global HIV/AIDS funding and programs on other U.S.
global health programming. For additional information on analysis of
impact, see appendix I.
[6] The FADB is maintained by USAID's Economic Analysis and Data
Services and is the source of the U.S. Overseas Loans and Grants
report and the U.S. Annual Aid Review for the Development Assistance
Committee of the Organisation for Economic Cooperation and Development.
[7] We focus on disbursement levels because, unlike other data,
disbursements more directly reflect U.S. spending and activities in
countries receiving U.S. assistance. Disbursements are amounts paid by
federal agencies to liquidate government obligations. For purposes of
this report, we refer to disbursements as spending. See appendix I for
additional details.
[8] Amounts for fiscal years 2009-2011 include U.S. contributions to
the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, but do
not include Department of Health and Human Services (HHS)
appropriations for global HIV/AIDS. When HHS funding for global
HIV/AIDS is included, totals for fiscal years 2009, 2010, and 2011 are
$6.5 billion, $6.6 billion, and $6.7 billion, respectively.
[9] On June 18, 2010, the administration announced the first set of
GHI Plus countries: Bangladesh, Ethiopia, Guatemala, Kenya, Malawi,
Mali, Nepal, and Rwanda. Beginning in fiscal year 2013, a second set
of up to 10 Phase II GHI Plus countries will be selected.
[10] Other implementing agencies include the Departments of State,
Defense, Labor, and Commerce and the Peace Corps. In addition, other
HHS offices and agencies receiving PEPFAR resources include the Office
of Global Health Affairs, the Food and Drug Administration, the Health
Resources and Services Administration, the National Institutes of
Health, and the Substance Abuse and Mental Health Services
Administration.
[11] The United States is the largest contributor to the Global Fund
to Fight AIDS, Tuberculosis, and Malaria. From 2001 to 2008, the
United States has contributed about $3.5 billion to the organization.
For 2009 and 2010, the United States has pledged $1 billion and $1.05
billion, respectively, to the Global Fund.
[12] Pub. L. No. 110-293.
[13] According to OGAC, for PEPFAR's second 5-year phase, no
distinction exists between focus countries and other countries
receiving bilateral assistance through PEPFAR. For the purposes of
reporting trends for a period including the first 5-year phase of
PEPFAR, we are keeping the designation for the 15 focus countries and
referring to these countries as "focus" and "nonfocus" countries.
[14] CD4 (cluster of differentiation antigen 4) cells are a type of
white blood cell that fights infection. The CD4 count measures the
number of CD4 cells in a sample of blood. Along with other tests, the
CD4 count helps determine the strength of the immune system, indicates
the stage of the HIV disease, guides treatment, and predicts how the
disease may progress. Normal CD4 counts range from 500-1,000 cells/mm.3
[15] Treatment services include both adult and pediatric treatment
services.
[16] Although no cure exists for HIV/AIDS, the use of multiple ARVs in
combination has been shown to suppress the virus and slow the
progression of the disease. The World Health Organization (WHO) has
recommended certain drug treatment regimens for settings in which
resources are limited. For people receiving ARVs for the first time in
such settings, WHO recommends one of several first-line regimens. For
people who have developed strains of HIV that are resistant to their
initial treatment regimen, WHO recommends one of several second-line
regimens, which use a different set of ARVs. Second-line regimens can
have disadvantages, which may be magnified in resource-limited
settings, including the need to take more pills, potential additional
side effects, the need for refrigeration during transportation and
storage, and generally higher prices. See GAO, Global HIV/AIDS
Epidemic: Selection of Antiretroviral Medications Provided under U.S.
Emergency Plan Is Limited, [hyperlink,
http://www.gao.gov/products/GAO-05-133] (Washington, D.C.: Jan. 11,
2005).
[17] See Report to Congress by the U.S. Global AIDS Coordinator on the
Use of Generic Drugs in the President's Emergency Plan for AIDS Relief
(Washington, D.C.: Office of the Global AIDS Coordinator, May 2008),
[hyperlink, http://www.pepfar.gov/documents/organization/105842.pdf].
In addition, PEPFAR's 2009 annual report noted that use of generics
varied by country and cited significant challenges, such as relatively
high prices for pediatric and second-line medications. See Celebrating
Life: The U.S. President's Emergency Plan for AIDS Relief: 2009 Annual
Report to Congress (Washington, D.C.: Office of the Global AIDS
Coordinator), [hyperlink,
http://www.pepfar.gov/press/fifth_annual_report/].
[18] Based on evidence of improved survival and reduced HIV-related
illnesses with the earlier initiation of antiretroviral therapy, as
well as the impact of ART on the prevention of HIV transmission, the
World Health Organization (WHO) recommended initiation of ART in all
patients with HIV who have CD4 count less than or equal to 350 cells/
mm3 irrespective of clinical symptoms. See Rapid Advice:
Antiretroviral therapy for HIV Infection in Adults and Adolescents
(Geneva: WHO, 2009), [hyperlink,
http://www.who.int/entity/hiv/pub/arv/rapid_advice_art.pdf/.
[19] In 2008, we reported that most PEPFAR country teams were using
costing information in their planning and budgeting; some country
officials also reported using costing information to review
implementing partner effectiveness and complement other funding
sources for HIV/AIDS programs. See GAO, Global HIV/AIDS: A More
Country-Based Approach Could Improve Allocation of PEPFAR Funding,
[hyperlink, http://www.gao.gov/products/GAO-08-480] (Washington, D.C.:
Apr. 2, 2008).
[20] See Office of Management and Budget, Statement of Federal
Financial Accounting Standards No. 4, Managerial Cost Accounting
Standards and Concepts (Washington, D.C., 2007).
[21] About $4.7 billion and $3.3 billion in foreign assistance
disbursements for HIV/AIDS-and other health-related programs,
respectively, from 2001 to 2008, were not specified for an individual
country or region in the FADB. As such, our analysis of bilateral
spending levels and growth trends by PEPFAR country status and
geographical region excludes these disbursements.
[22] As noted in Background, we identified 47 nonfocus, non-PEPFAR
operational plan countries in the FADB that received U.S. foreign
assistance disbursements for HIV/AIDS programs from 2001 to 2008.
[23] From 2001-2008, U.S. disbursements for HIV/AIDS programs in
Europe and Eurasia were less than 2 percent of all U.S. disbursements
for HIV/AIDS programs worldwide and in North Africa and the Middle
East were less than 1 percent of all U.S. disbursements for HIV/AIDS
programs worldwide.
[24] Sub-Saharan African focus countries are Botswana, Côte d'Ivoire,
Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa,
Tanzania, Uganda, and Zambia. Countries in sub-Saharan Africa that
submit COPs are Angola, the Democratic Republic of the Congo, Ghana,
Lesotho, Malawi, Sudan, Swaziland, and Zimbabwe.
[25] Vietnam is the only focus country in Asia. Nonfocus countries
with COPs are Cambodia, China, India, Indonesia, and Thailand. In
addition, countries in Central Asia (Tajikistan, Uzbekistan,
Kazakhstan, Kyrgyz Republic, and Turkmenistan) submit a ROP.
[26] Focus countries in Latin American and the Caribbean are Guyana
and Haiti. The Dominican Republic is the only nonfocus country in
Latin America and the Caribbean that submits a COP. In addition,
countries in Central America (Belize, Guatemala, El Salvador,
Honduras, Nicaragua, Costa Rica, and Panama) and the Caribbean
(Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada,
Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent, Suriname, and
Trinidad and Tobago) submit ROPs.
[27] As previously noted, the 2008 Leadership Act called for a plan to
increase the number of individuals on ART proportional to available
funding and cost per patient. In addition, UNAIDS estimated that
significant resources would be required to meet developing countries'
HIV treatment and care goals in 2010.
[28] Using PACM, PEPFAR reported on average HIV treatment costs in
July 2010. See Report to Congress on Costs of Treatment in the
President's Emergency Plan for AIDS Relief (PEPFAR), [hyperlink,
http://www.pepfar.gov/documents/organization/144993.pdf].
[29] Spectrum is an integrated policy modeling software system,
composed of several models that interact with one another to produce
various health-and HIV/AIDS-related projections and estimates. The
Spectrum system includes, for example, a demographic projection module
(DemProj); a module for estimating key HIV/AIDS trends in new
infections, deaths, treatment needs, and AIDS orphans (AIM); and a
module for estimating the impact of prevention and treatment
interventions on HIV incidence (Goals). For the purposes of this
report, we refer to the Spectrum system as a single model.
[30] As required by the Foreign Assistance Act of 1961, USAID collects
and reports on U.S. foreign assistance, which is defined in the Act as
"any tangible or intangible item provided by the United States
Government to a foreign country or international organization under
this or any other Act, including but not limited to any training,
service, or technical advise, any item of real, personal or mixed
property, any agricultural commodity, United States dollars, and any
currencies of any foreign country which are owned by the United States
Government." USAID uses the FADB to track and report U.S. foreign
assistance data to the Organisation for Economic Cooperation and
Development (OECD) and supply data for the U.S. Overseas Loans and
Grants, Obligations and Loan Authorizations database, commonly known
as the Greenbook. See [hyperlink,
http://www.usaid.gov/policy/greenbook.html]. The FADB includes data
from State, USAID, HHS, and other U.S. agencies submitting data to
USAID.
[31] See U.S. Global Health Assistance: Background, Priorities, and
Issues for the 111th Congress, Congressional Research Service:
Washington, D.C. (July 2009).
[32] See The Henry J. Kaiser Family Foundation, U.S. Global Health
Policy: Donor Funding for Health In Low-and Middle-Income Countries,
2001-2007 (Menlo Park, CA: July 2009).
[33] According to OGAC, for PEPFAR's second 5-year phase, no
distinction exists between focus countries and other countries
receiving bilateral HIV/AIDS-related foreign assistance.
[34] According to OECD guidelines, a disbursement is the placement of
resources at the disposal of a recipient country or agency. See OECD
Development Assistance Committee, Reporting Directives for the
Creditor Reporting System (Paris: 2007).
[35] The official deflator for the U.S. Overseas Loans and Grants data
is the "GDP Chain Price Index" deflator, which is produced and
reported annually by the Department of Commerce, Bureau of Economic
Analysis. This index is currently used by the Development Assistance
Committee (DAC) of OECD to convert U.S. foreign assistance flows into
constant dollars.
[36] In the course of our investigations into the reliability of the
FADB data, we determined that in 2007 USAID switched from using
strategic objective foreign assistance categories to F Framework
categories. Despite this change, we determined that the data provided
by USAID are consistently categorized across the entire 2001-2008
timeframe, as USAID uses common identifiers to match the data from the
two time periods (2001-2006 and 2007-2008).
[37] The number of ART patients in a given country is a subset of the
number of people who are eligible to receive ART. This group is a
subset of the number of people who are HIV positive, which is in turn
a subset of a country's general population.
[38] PACM further categorizes drug and nondrug costs as costs
associated with adult or pediatric patients, and costs in low-or
middle-income countries. In addition, PACM monitors changes in drug
and nondrug unit costs by quarter and year.
[39] These categories are not mutually exclusive. For example, a
patient could receive ARV medication that is both first line and
generic.
[40] HAPSAT labor cadre categories include each type of labor
required, including doctors, nurses, and pharmacists.
[41] Spectrum is an integrated policy modeling software system,
composed of several models that interact with each other to produce
various health-and HIV/AIDS-related projections and estimates. The
Spectrum system includes the AIDS Impact Model and DemProj, among
other components. For this report, we refer to the Spectrum system as
one model.
[End of section]
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