President's Emergency Plan for AIDS Relief: State Should Improve Data Quality and Assess Long-term Resource Needs
Fast Facts
About 1.7 million people—mostly in Sub-Saharan Africa—were newly infected with HIV in 2019. The region has experienced significant population growth, including among youth, who are more vulnerable to acquiring HIV infections.
The U.S. President's Emergency Plan for AIDS Relief provided about $6 billion annually for efforts to combat HIV from FY 2015-20.
We found that the program should ensure its program-level budget data is complete and accurate, including in reports to Congress. We recommended it establish procedures and a plan to improve data quality, and assess long-term resource needs (given factors like the growing youth population).
The President’s Emergency Plan for AIDS Relief (PEPFAR) supported activities to combat HIV/AIDS in 54 countries as of FY 2020.
Highlights
What GAO Found
While HIV infection rates have declined in Sub-Saharan Africa since 2010, the doubling of the youth population—a group particularly vulnerable to acquiring new HIV infections—partially offset the rate of decline, according to the Joint United Nations Program on HIV/AIDS (UNAIDS). The youth population in Sub-Saharan Africa is growing as part of overall population growth, which more than doubled from 1990 to 2020 and is projected to nearly double again by 2050.
Estimated Population Growth in Sub-Saharan Africa, 2020 to 2050
The Department of State, through the President's Emergency Plan for AIDS Relief (PEPFAR), allocated an estimated $4 billion from fiscal years 2016 through 2020 to three key interventions that officials identified as PEPFAR's response to reach the growing youth population. These interventions aim to address the cycle of HIV transmission among youth. For example, through MenStar, PEPFAR aims to treat HIV-positive men to prevent HIV transmission.
State's Office of the Global AIDS Coordinator (S/GAC) lacks procedures to reasonably assure PEPFAR program-level budget data, including data for congressional reporting, are reliable for a resource trends analysis to inform future programing. Specifically, GAO found issues with data completeness and accuracy. Officials said they are taking steps to improve data quality, but the steps do not fully address the issues and S/GAC does not have a plan to ensure timely implementation of data quality improvements. Without sufficient data quality procedures or a documented plan, S/GAC lacks reasonable assurance that its data are reliable for analysis of resource trends.
PEPFAR officials analyze data to inform short-term decisions; however, officials have not performed long-term resource planning to assess how known factors—including the growing youth population—may affect resource needs. Officials said they generally do not assess long-term resource needs, due in part to uncertainty about future PEPFAR funding levels. Without assessing long-term resource needs, PEPFAR officials cannot adequately advocate, coordinate, and plan resources in response to known challenges to controlling the HIV epidemic.
Why GAO Did This Study
To address the HIV epidemic, the U.S. Global AIDS Coordinator oversees about $6 billion annually across several U.S. implementing agencies and two international organizations through the PEPFAR program. According to S/GAC, without concentrated efforts to reach the growing youth population, progress achieved toward controlling the HIV epidemic could be reversed.
GAO was asked to review PEPFAR's response to the growing youth population for achieving its goals. This report examines (1) what is known about the growing youth population and HIV in Sub-Saharan Africa, (2) PEPFAR's response to reach the growing youth population, (3) the extent to which S/GAC's PEPFAR program-level budget data are reliable for a resource trends analysis to inform future programing, and (4) the extent to which PEPFAR officials have determined the long-term resources needed to achieve and sustain HIV epidemic control given known factors.
GAO reviewed PEPFAR documents and budget data, and reports by UNAIDS and other entities. GAO also interviewed PEPFAR officials from State, implementing agencies, and country teams in Kenya, Mozambique, South Africa, and Uganda.
Recommendations
GAO recommends that State establish documented procedures and develop a plan to improve budget data, and assess the long-term resources it needs to continue progress toward HIV epidemic control. State accepted all three recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of State |
Priority Rec.
The Secretary of State should ensure the U.S. Global AIDS Coordinator establishes standard, documented procedures to fully track and verify PEPFAR program-level budget data, including data used for reporting to Congress, to ensure that these data are complete and accurate. (Recommendation 1) |
State accepted our recommendation and told us they are making improvements in establishing standards and procedures and improving systems to track program level budget data. On March 6, 2024, State officials from the Office of the Global AIDS Coordinator briefed GAO on updates to the system to improve management and tracking of budget data. In April 2024 State provided GAO with standard operating procedures (SOP) that provide definitions, establishes protocol, and provides instruction to complete the annual verification of program-level budget data to ensure these data are complete and accurate for quarterly Congressional obligation and outlay reporting. The SOP describes the purpose, policies, roles and responsibilities, procedures, and data analysis the office uses to compare and reconcile agency data with the report on budget execution and budgetary resources, a U.S. government-wide standard form containing balances for each appropriation. Following the SOP should better allow the Office of the Global AIDS Coordinator to ensure its data are complete and accurate.
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| Department of State | The Secretary of State should ensure the U.S. Global AIDS Coordinator develops a documented plan with a timeline for implementing data improvements to fully track and verify PEPFAR program-level budget data, including data used for reporting to Congress, to ensure that these data are complete and accurate. (Recommendation 2) |
State accepted our recommendation. In its November 21 letter State stated that starting with funds appropriated for FY 2021 and for funds appropriated in subsequent fiscal years, its system will keep track of the current status of all appropriated funds, allowing for more accurate status of funds in real-time. In April 2024 State officials from the Global AIDS Coordinators Office provided a timeline for implementation of revisions for tracking changes in the budget data. State provided GAO support for changes it made that will allow PEPFAR Operating Units to request changes to (budget) control numbers and allows Management and Budget to track budget data from approvals to allocations, including a timeline of upgrades to FACTS-Info-NextGen the PEPFAR budget tracking system. The revisions S/GAC made according to this timeline will ensure more complete and accurate program level budget data to enable resource trend analysis to inform future programing and ensure data for congressional reporting are reliable
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| Department of State | The Secretary of State should ensure the U.S. Global AIDS Coordinator assesses the long-term resources PEPFAR needs to continue progress toward the goal of HIV epidemic control, given known factors, including the growing youth population, that affect PEPFAR's ability to achieve its goals. (Recommendation 3) |
State accepted our recommendation and told us they are working to validate forecasts of funding needs and implement activity based costing for more accurate quantification of its resource needs. In its November 21 letter State repeated that as far as long-term resource needs, S/GAC utilizes different forecasts of funding needs and is simultaneously working to validate those forecasts and implement activity-based costing for more accurate quantification of the resource needs but also to drive efficiencies in the program to maximize resources. On February 14, 2023 State informed GAO that the Office of the U.S. Global AI(S/GAC) reiterated that it utilizes different forecasting method and is simultaneously working to forecast and implement activity for more accurate quantification to drive efficiencies in the process for determining resources. On March 6, 2024 State officials discussed their approach to responding to the recommendation and agreed to provide more information needed to close the recommendation. GAO met with State (PEPFAR) officials on August 29, 2024, to discuss information related to recommendation #3. Overall, GAO determined that information provided did not meet criteria for demonstrating that PEPFAR had assessed PEPFAR long term resource needs. PEPFAR officials described country-by-country road maps that host country governments are to complete later this year that may inform PEPFAR resource assessments; GAO agreed to contact PEPFAR officials in spring 2025 to obtain updated information and review the extent it addresses recommendation 3.
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