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and Other Health Assistance in Fiscal Years 2001-2008' which was 
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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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