2018 PROGRESS REPORT

PEPFAR Strategy for Accelerating HIV/AIDS

Epidemic Control (2017-2020)
ON THE COVER: PEPFAR-SUPPORTED PARENTS AND
BABY IN UGANDA (PHOTO: KATE CONSAVAGE/USAID)

PEPFAR-SUPPORTED ORPHANS AND VULNERABLE CHILDREN

IN SOUTH AFRICA (PHOTO: TISH MCCARROLL/USAID)
 2018 PROGRESS REPORT

PEPFAR Strategy for Accelerating HIV/AIDS

Epidemic Control (2017-2020)

SEPTEMBER 2018
September 27, 2018

Thanks to the generosity of the American people and the leadership of the United States, working with our
many partners around the globe, we are closer than ever to controlling the HIV/AIDS pandemic.

This year marks the 15th anniversary of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).
Since its inception, PEPFAR has been a strong bipartisan endeavor, a cause of compassion sustained and
improved across three U.S. presidents and eight U.S. congresses.

Every American should be deeply proud that our historic commitment has saved the lives of more than 16
million men, women, and children living with HIV and prevented millions of new HIV infections. We are not
only leading the transformation of the global HIV/AIDS response, but are also making the world a more
secure place, better able to respond to the global health threats of today and tomorrow.

One year ago, the Trump Administration launched the PEPFAR Strategy for Accelerating HIV/AIDS
Epidemic Control (2017-2020). I am pleased to release the 2018 PEPFAR Strategy Progress Report, which
shows the significant strides we have taken in the first year of the Strategy’s implementation. With the U.S.
government’s support, and through our collaboration with many partners, up to 13 countries are on pace
to control their HIV/AIDS epidemic by 2020. Many more of the 53 countries supported by PEPFAR are
within reach of achieving epidemic control by 2020 if they accelerate their efforts and focus resources and
policies to ensure access to HIV prevention and treatment services for those most in need.

PEPFAR’s remarkable progress demonstrates what is possible through American leadership. But our work
is not finished – indeed, every day, everyone involved in PEPFAR focuses on ways to do more and do it
better. We know the critical gaps that must be addressed and what it will take to get the job done.

Together, we can, and we will, control this pandemic – one community, one country at a time.

Sincerely,

Michael R. Pompeo
Secretary of State
Overview
The American people’s compassion and generosity have saved more than 16 million lives and brought us closer than ever to con-
trolling the HIV/AIDS pandemic – community by community, country by country.

Fifteen years ago when the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was launched this remarkable progress was
hard to imagine. At that time an HIV diagnosis was a death sentence in many countries, and entire families and communities were
falling ill. Most of the prior gains in global health and development were being lost and the very fabric of societies were being
ripped apart by the loss of teachers, doctors, and nurses. In the hardest-hit regions of sub-Saharan Africa, infant mortality dou-
bled, child mortality tripled, and life expectancy dropped by 20 years. Only 50,000 people in Africa had access to any lifesaving
antiretroviral treatment (ART).

Faced with this death and devastation, the United States has responded, resoundingly. The United States is the world’s leader –
and largest donor – in the response to the global HIV/AIDS crisis. Since PEPFAR’s establishment in 2003, with strong bipartisan
support across three U.S. presidents (George W. Bush, Barack Obama, and Donald J. Trump) and from eight U.S. congresses, the
U.S. government, through PEPFAR, has invested more than $80 billion in the global HIV/AIDS response, the largest commitment
made by any nation to address a single disease. By focusing resources where the HIV burden was the greatest and the most im-
pact could be achieved, PEPFAR has delivered remarkable results in just 15 years.

PEPFAR is a remarkable example of what is possible when we focus and join hands with countries and communities and ensure all
U.S. taxpayer dollars with which we are entrusted are held to account. It demonstrates the impact of U.S. foreign assistance when
we focus on the mission with transparency and demand greater effectiveness and efficiency.

PEPFAR has defined the core elements of successful HIV prevention and treatment programming: the full engagement of partner
governments at all levels; the rapid development and implementation of core policies that maximize the impact of our invest-
ments; the quarterly analysis of program implementation to ensure partner performance and accountability down to the level of
where lifesaving services are delivered; and the close engagement of faith and community leaders to increase HIV awareness and
provide supportive services.

PEPFAR is a leader in the use of granular data to drive results and increase impact year over year without increasing financial re-
sources (Figure 1). PEPFAR has pioneered the use of large national household surveys – Population-Based HIV Impact Assessments
(PHIAs) – to document the impact of HIV programming, surveys that have shown a nearly 50 percent decline in new HIV infections
across many of the countries in eastern and southern Africa where the epidemic was raging before PEPFAR began.

The key ingredients for this success include:

ƒƒ Rapid, data-driven expansion of HIV prevention and treatment services targeted by geography and population with
greatest need, including the rapid scale up of lifesaving ART focused on achieving viral load suppression; innovative
approaches to HIV testing services; VMMC to prevent infections in young men (and thus their subsequent partners); and
progress under the PEPFAR-led DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) public-
private partnership to prevent HIV infections among adolescent girls and young women.

ƒƒ Supportive partner country HIV policy environments, such as through the rapid adoption and implementation of Test
and Start of ART, same-day initiation of HIV treatment, differentiated service delivery models, multi-month fulfillment of
prescriptions, and the use of better and cheaper treatment regimens.

ƒƒ Political leadership from partner countries and U.S. ambassadors.

ƒƒ Meaningful engagement of civil society and communities.

ƒƒ Strategic partnerships with the private sector, faith-based leaders and organizations, and others.

PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) | 1

Application of this targeted, data-driven approach has resulted in greater impact despite a flat budget environment (Figure 1).
Figure 1. Remarkable expansion of PEPFAR’s results in a flat budget environment

18,000,000 $8,000

16,000,000 $7,000

14,000,000
$6,000

12,000,000
Number of individuals

$5,000

10,000,000

Millions
$4,000
8,000,000
$3,000
6,000,000

$2,000
4,000,000

$1,000
2,000,000

$0 $0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Year
Current on HIV Treatment Cumulative Voluntary Medical Male Circumcision PEPFAR Budget (Bilateral + Global Fund Contribution)

Today, the results speak for themselves, with PEPFAR supporting more than: 14 million men, women, and children on lifesaving
ART, ensuring the health and welfare of the family; 2.2 million babies born HIV-free to HIV-positive mothers, many of whom have
remained HIV-free into adolescence through the comprehensive DREAMS prevention programming; 6.4 million orphans, vulnera-
ble children, and their caregivers thriving; and 15.2 million men and boys to receive voluntary medical male circumcision (VMMC)
to ensure they remain HIV-negative. In community after community, death and despair have been replaced with hope and life.

PEPFAR’s investments have also strengthened the systems that drive effective, efficient, and sustainable health care provision. We
have helped train nearly 250,000 health care workers to deliver and improve HIV care and other health services, creating a last-
ing infrastructure that enables partner countries to confront current and future health challenges. In 2017 alone, PEPFAR invested
nearly $600 million* on horizontal, above-site health systems strengthening, including nearly $100 million for laboratory systems
ensuring the platform of health security.

PEPFAR’s efforts have improved the ability of countries with sizable HIV/AIDS burdens to swiftly address other outbreaks, such as
Ebola, avian flu, and cholera, ultimately enhancing global health security. The U.S. government is advancing global health by work-
ing with partners to help countries reach development goals that promote common interests and values, reinforce stability in key
regions, boost U.S. economic opportunities, and establish conditions for a more secure and prosperous world.

PEPFAR’s transformative, lifesaving impact is unassailable, but our work is not finished and must accelerate so, working together,
we can accomplish our mission. In September 2017, the Trump Administration launched the PEPFAR Strategy for Accelerating HIV/
AIDS Epidemic Control (2017-2020). The PEPFAR Strategy is focused on ensuring that every dollar we invest is maximizing impact
and hastening progress toward achieving HIV/AIDS epidemic control.

This 2018 PEPFAR Strategy Progress Report shows the significant strides we have taken in the first year of the Strategy’s implemen-
tation. With the U.S. government’s support, and through our collaboration with many partners, several African countries are on
pace to control their HIV/AIDS epidemic by 2020. Many more PEPFAR-supported countries are within reach of achieving epidemic
control by 2020 if they accelerate their efforts and focus resources and policies to ensure access to HIV prevention and treatment
services for those most in need. Together, we have the historic opportunity to make what once seemed impossible possible.

* This includes support for laboratory systems, surveillance systems, human resources for health, and other health infrastructure investments.

2 | 2018 Progress Report

PEPFAR’s Progress toward Achieving Epidemic Control
PEPFAR is committed to supporting progress toward achieving epidemic control in more than 50 countries where we work (Fig-
ure 2), including through the strategic investment of U.S. resources in countries with the highest HIV-burden and demonstrated
potential to achieve epidemic control in the next several years. This includes 23¹ countries with the largest PEPFAR investments.

Figure 2. PEPFAR-supported countries worldwide

PEPFAR World Activities, 2018

U.S. President’s Emergency Plan for AIDS Relief

PEPFAR-supported
countries

PEPFAR uses the PHIAs to track progress toward countries reaching epidemic control in high-burden countries. Through the
PHIAs we have validated PEPFAR’s impact and demonstrated important progress being made in HIV prevention.

Through the PHIAs and other data sources, we know what works and the PEPFAR Strategy is leveraging these learnings for maxi-
mum impact. Compared with the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2012 estimates, Namibia has reduced
its adult HIV incidence rate by 50 percent in the past five years, in large part due to a dramatic increase in viral load suppression
(Figure 3). Eswatini nearly halved its HIV incidence rate between 2011 and 2016 (Figure 4). Lesotho, Malawi, Zambia, and Zimba-
bwe also have all reduced their HIV incidence rates by more than half compared with the UNAIDS 2003 estimates, the year that
PEPFAR began. In Uganda, over the past five years, we have not only stabilized a rapidly expanding epidemic but also through
aggressive program realignment reduced new HIV infections dramatically in the country (Figure 5).

¹ Botswana, Burundi, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria,
Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.

PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) | 3

Figure 3. Increase in viral load suppression in northern Namibia (2015 vs. 2017)
100
90
80 74% 71%
73%
70
68%
64%
VLS Prevalence (%)

60
53%
50
43%
40
30
20
10
0
Zambezi 2015 (SISTER) Zambezi 2017 (Prelim. NAMPHIA)
Aware of HIV+ ART of HIV VLS of HIV+ on ART

Figure 4. Eswatini newly halved its HIV incidence rate and nearly doubled viral load suppression (VLS) in only five years

Population VLS more than Doubled Among Adults HIV Incidence Decreased by 44% Among Adults
18-49 years 18-49 years
100
Increase by>100% Decrease by 44%
90
p<0.0001 p=0.012
80 75.0 3.5
71.3 3.2
70 3
63.0
VLS Prevalence (%)

60 2.5
2.5
HIV Incidence (%)

50 2.0
2 1.8
40 35.9 34.8 35.9 34.8
32.7 1.5 32.7 1.4
30
1 0.9
20

10 0.5

0 0
Male Female Total Male Female Total
SHIMS 1 (2011) SHIMS 2 (2016-17) SHIMS 1 (2011) SHIMS 2 (2016-17)

Figure 5. New HIV infections in Uganda are declining dramatically

Uganda
120000

100000
Number of individuals

80000

60000

40000

20000

0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

A NUN AND YOUNG CHILD IN ZAMBIA

(PHOTO: VASCO POSSLEY, FOR THE OC REGISTER)

New HIV infections Total deaths to HIV population

4 | 2018 Progress Report

 The substantial gaps revealed by the recent PHIA results from Cameroon and Cote d’Ivoire remind us that progress toward
achieving HIV/AIDS epidemic control not only requires financial investment but also effective collaboration and mutual account-
ability between partner governments and communities. With this collaboration and accountability lacking, these countries are not
making significant strides to ensure people are aware of their HIV status. Without a supportive partner country policy environment
(e.g., the presence of formal and informal regressive fees for health services), U.S. government HIV investments cannot be as effec-
tive or efficient, thereby slowing or stalling progress.

The PHIAs show critical regional disparities toward reaching the UNAIDS 90-90-90 targets across southern, eastern, and western
Africa (Figure 6). Endorsed by United Nations member states, the 90-90-90 targets aim to have 90 percent of all people living with
HIV (PLHIV) to know their HIV status, 90 percent of all people with diagnosed HIV infection to receive sustained ART, and 90 per-
cent of all people receiving ART to have viral load suppression by 2020.

Figure 6. Progress toward UNAIDS 90-90-90 targets in adults in PHIA countries

100 96
91 92 90 88 90 91 90 91 91
89 88 88
90 86 86 87 84
87 86 85
80
80 77 76
73 73 73
VLS prevalence (%)

70 66
60
52
50 47
40 37
30
20
10
0
Namibia* Eswatini Lesotho Malawi Uganda* Zimbabwe Zambia Tanzania Cameroon Côte d'Ivoire
Ages 15-64 Ages 15+ Ages 15-59 Ages 15-64 Ages 15-64 Ages 15-64 Ages 15-59 Ages 15-64 Ages 15-64 Ages 15-64
(2018) (2017) (2016) (2016) (2017) (2016) (2016) (2017) (2018) (2018)
Aware of HIV Status Treated Virally Suppressed *ARV-adjusted data

Among the ten countries² that have released their PHIAs results, Namibia has achieved the highest level of viral load suppres-
sion among all HIV-positive adults, a widely used measure of effective HIV treatment in a population, surpassing the Joint United
Nations Programme on HIV/AIDS (UNAIDS) target of 73 percent three years early. In addition, Eswatini, Malawi, and Lesotho have
either reached or are closely approaching this target. As shown in Figure 7, other countries surveyed show varying levels of prog-
ress and highlight the additional focus and progress that is required.

Figure 7. Progress toward UNAIDS 90-90-90 viral load suppression (VLS) target in PHIA countries

100
90
80 77
73 73%
70 68 68
VLS prevalence (%)

VLS
60 60 59
60
52
50 45
40 40
30
20
10
0
Namibia Eswatini Malawi Lesotho Zimbabwe Uganda Zambia Tanzania Cameroon Côte d'Ivoire
Ages 15-64 Ages 15+ Ages 15-64 Ages 15-59 Ages 15-64 Ages 15-64 Ages 15-59 Ages 15-64 Ages 15-64 Ages 15-64
(2018) (2017) (2016) (2016) (2016) (2017) (2016) (2017) (2018) (2018)

² Cameroon, Cote d’Ivoire, Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe.

PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) | 5

With PEPFAR support, four additional countries – Ethiopia, Haiti, Kenya, and Rwanda – will release PHIA data on a rolling basis
through 2019, providing an ability to chart and validate further progress toward reaching HIV/AIDS epidemic control by 2020.

The graphics in composite below (Figure 8; Panels A-D) show countries with varying level of reductions in both mortality (as mea-
sured by total deaths among HIV-positive individuals) and new HIV infections.

ƒƒ Panel A shows countries that have achieved dramatic declines in both total deaths among HIV-positive individuals and new
infections as they rapidly approach control of their epidemics, at which point the out-year costs of their HIV/AIDS responses will
decrease.

ƒƒ Panel B shows countries where programmatic changes made over the last four years have resulted in an accelerated speed
of the declines in both total deaths among HIV-positive individuals and new HIV infections (as indicated by a steepen of the
slopes), which puts these countries on the path toward controlling their epidemics in the next 24 months.

ƒƒ Panel C shows countries with large epidemics (e.g., South Africa), where progress must accelerate; countries in conflict (e.g.,
South Sudan), where the epidemic continues unchecked due to the difficulty of taking programs to scale; and other countries,
where PEPFAR is beginning to have the type of impact needed to change the course of their epidemics.

ƒƒ Finally, Panel D shows the unacceptably slow progress toward decreasing total deaths among HIV-positive individuals as a
result of low access to HIV treatment and policies that prohibit the poor from accessing prevention and treatment services
needed, which are inhibiting efforts toward achieving epidemic control. Both formal and informal regressive fees for health
services disproportionately impact the poor and the vulnerable; progress in the epidemic will be depended on these countries
addressing this very specific disparity.

Figure 8; Panels A-D. Changes in mortality and new HIV infections in select PEPFAR-supported countries

Panel A

Ethiopia Burundi Cambodia

160000 20000 25000

18000
140000
16000 20000
120000
Number of individuals

14000 Number of individuals

Number of individuals

100000
12000 15000

80000 10000

8000 10000
60000
6000
40000
4000 5000
20000
2000

0 0 0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

Zimbabwe Rwanda Kenya

250000 40000 250000

35000
200000 200000
30000
Number of individuals
Number of individuals

Number of individuals

25000
150000 150000

20000

100000 100000
15000

10000
50000 50000
5000

0 0 0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

New HIV infections Total deaths to HIV population

6 | 2018 Progress Report

 Number of individuals Number of individuals Number of individuals

5000

0
10000
15000
20000
25000

100000
120000
140000
160000
180000
100000
120000
140000
160000
180000

0
0

20000
40000
60000
80000
20000
40000
60000
80000
1990 1990 1990

Panel C
Panel B

Namibia
1991
Tanzania
1991 1991
1992 1992 1992
1993 1993 1993
1994 1994 1994

Mozambique
1995 1995 1995
1996 1996 1996
1997 1997 1997
1998 1998 1998
1999 1999 1999
2000 2000 2000
2001 2001 2001
2002 2002 2002
2003 2003 2003
Number of individuals 2004 2004 2004
2005 2005 2005
2006 2006 2006

100000
200000
300000
400000
500000
600000

0
2007 2007 2007
1990 2008 2008 2008
1991 2009 2009 2009
1992 2010 2010 2010
1993 2011 2011 2011
1994 2012 2012 2012

South Africa
1995 2013 2013 2013
1996 2014 2014 2014
1997 2015 2015 2015
1998 2016 2016 2016
1999 2017 2017 2017
2000
2001
2002
2003
2004 Number of individuals Number of individuals Number of individuals
2005
2006

5000
5000

0
0

10000
15000
20000
25000
30000
35000
40000
10000
15000
20000
25000
30000
35000
100000
120000

0
20000
40000
60000
80000

2007
2008 1990 1990
Malawi

1990
Lesotho

2009 1991 1991

2010 1991
1992 1992

Botswana
2011 1992
1993 1993
2012 1993
1994 1994
1994
2013 1995 1995
1995
2014 1996 1996
1996
2015 1997 1997

New HIV infections

New HIV infections
1997
2016 1998 1998 1998
2017 1999 1999 1999
2000 2000 2000
2001 2001 2001
2002 2002 2002
2003 2003 2003
Number of individuals 2004 2004 2004
2005 2005 2005
2006 2006 2006

2000
4000
6000
8000

0
10000
12000
14000
16000
18000
2007 2007 2007
1991 2008 2008 2008
1992 2009 2009 2009
1993 2010 2010 2010
1994 2011 2011 2011
1995 2012 2012 2012

South Sudan
1996 2013 2013 2013
1997 2014 2014 2014
1998 2015 2015 2015
1999 2016 2016 2016
2000 2017 2017 2017
2001

Total deaths to HIV population

Total deaths to HIV population

2002
2003
2004
2005 Number of individuals Number of individuals Number of individuals
2006
2007
Haiti

2000
4000
6000
8000
2000
4000
6000
8000

0
0

10000
12000
14000
10000
12000
14000
16000
18000
20000

100000
120000

0
20000
40000
60000
80000

2008
2009 1990 1990
Zambia

1990
Eswatini

2010 1991 1991

2011 1991
1992 1992 1992
2012 1993 1993
2013 1993
1994 1994 1994
2014 1995 1995
2015 1995
1996 1996 1996
2016 1997 1997
2017 1997
1998 1998 1998
1999 1999 1999
2000 2000 2000
2001 2001 2001
2002 2002 2002
2003 2003 2003
2004 2004 2004
2005 2005 2005
2006 2006 2006
2007 2007 2007
2008 2008 2008
2009 2009 2009
2010 2010 2010
2011 2011 2011
2012 2012 2012
2013 2013 2013
2014 2014 2014
2015 2015 2015
2016 2016 2016
2017 2017 2017

PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) | 7

 Panel D

Nigeria Ghana Cameroon

350000 40000 60000

300000 35000
50000
30000
250000

Number of individuals
Number of individuals

Number of individuals
40000
25000
200000
20000 30000
150000
15000
20000
100000
10000
10000
50000 5000

0 0 0

1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Democratic Republic of the Congo Côte d’Ivoire
80000 120000

70000
100000
60000
Number of individuals

Number of individuals
80000
50000

40000 60000

30000
40000
20000
20000
10000

0 0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017

1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
New HIV infections Total deaths to HIV population

Addressing key gaps and reaching the remaining populations

To reach epidemic control, a country must achieve at least the 90-90-90 targets among all ages, genders, and at-risk groups,
ensuing that everyone at risk is accessing prevention and treatment and that progress is evident. The PHIAs reveal key gaps in
HIV prevention and treatment programming for women ages 15-24 and men ages 25-34 that require urgent action. In all coun-
tries that have released PHIAs to date, lower percentages of young women and younger men reported knowing their HIV status,
current use of ART, and had viral load suppression than among older adults (Figure 9). Data show us that children and key popu-
lations are also often left behind.
Figure 9. Composite data from select PHIA countries³ reveal key gaps in viral load suppression (VLS) among younger women and men
Males Females

100
90
80
73%
70 VLS
VLS Prevalence (%)

60
50
40
30
20
10
0
0-14 15-24 25-34 35-44 45-59 0-14 15-24 25-34 35-44 45-59
Virally Suppressed 73% VLS 100% VLS

8 | 2018 Progress Report

Adolescent Girls and Young Women
The U.S. government, through PEPFAR, continues to invest nearly one billion dollars a year in HIV
prevention, including through the DREAMS public-private partnership, which is helping to address
critical gaps among young women. On World AIDS Day 2017, PEPFAR announced that DREAMS has
reached more than 2.5 million adolescent girls and young women with critical comprehensive HIV
prevention interventions. Moreover, in the 10 African countries implementing DREAMS, the majori-
ty (over 60 percent) of the highest-HIV-burden communities or districts achieved a greater than 25
percent decline in new HIV diagnoses among young women (Figure 10). ‎Importantly, new diagnoses
declined in nearly all DREAMS intervention districts.

PHOTO: USAID UGANDA

Figure 10. DREAMS intervention districts with a greater than 25 percent decline in new HIV diagnoses among adolescent girls and
young women since 2015

0%
Cidade de Quelimane, Mozambique

Cidade de Beira, Mozambique

Chokwe, Mozambique

Cidade de XaiXai, Mozambique

Distrito de Xai-Xai, Mozambique

Mutare, Zimbabwe

Oyam, Uganda

Gulu, Uganda

Kyela DC, Tanzania

Chipinge, Zimbabwe

Lira, Uganda

Manzini North, Eswatini

Mityana, Uganda

Mubende, Uganda

Mukono, Uganda

Temeke MC, Tanzania

Homa Bay, Kenya

Lobamba Lomdzala, Eswatini

Ngwempisi, Eswatini

Lobamba, Eswatini

Siaya, Kenya

Makoni, Zimbabwe
Kwaluseni, Eswatini

Mkhiweni, Eswatini

Machinga, Malawi

Zomba, Malawi

Dvokodvweni, Eswatini
Manzini South, Eswatini

Mpolonjeni, Eswatini

Shiselweni 2 / Mbangweni, Eswatini

Siphofaneni, Eswatini

Shinyanga MC, Tanzania

Kisumu, Kenya

Mbabane East, Eswatini

Ludzeludze, Eswatini

Ntfonjeni, Eswatini

Sithobela, Eswatini
-10%

-20%

-30%

-40%

-50%

-60%

-70%

Figure 11. DREAMS intervention districts with a less than 25 percent decline in new HIV diagnoses among adolescent girls and young
women since 2015

0%
Mazowe, Zimbabwe

Berea, Lesotho

Ssembabule, Uganda

Rakai, Uganda

Ndola,
Mbabane West, Eswatini

Nairobi, Kenya

City of Johannesburg,
South Africa

Piggs Peak, Eswatini

Umkhanyakude,
Motshane, Eswatini

South Africa

Maseru, Lesotho

Ekurhuleni,
South Africa

Ushetu DC,
Tanzania

Msalala DC,
Tanzania

Lusaka Urban,
Zambia

Mbeya CC,
Tanzania

Zambia

Gweru,
Zimbabwe
-10%

-20%

-30%

-40%

-50%

-60%

-70%

³Lesotho, Malawi, Namibia, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe.

PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) | 9

Figure 12. Differential declines in new HIV diagnoses among adolescent girls and young women (AGYW) through DREAMS by
district type

100
90
80
70
60
Districts (%)

50
38.9%
40
30
20 15.3% 13.6%
10.1% 10.1% 11.9%
10
0
Districts > 25% decline Districts < 25% decline
Rural Mixed Urban

Men
To expand the diagnosis and treatment of HIV infections in men, in July 2018, PEPFAR joined the
Elton John AIDS Foundation; Unitaid; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the
Children’s Investment Fund Foundation; Johnson & Johnson; and Gilead Sciences to launch the $1.2
billion MenStar Coalition. The U.S. government will dedicate $800 million toward MenStar’s goals
through PEPFAR’s 2018 Country Operational Plans (COPs), with a goal of reaching an additional 1
million men with ART and supporting over 90 percent of men ages 24-35 to be virally suppressed
to effectively interrupt HIV transmission.

Children PHOTO: US EMBASSY MAPUTO

Only 52 percent of children ages 0-14 with HIV have access to lifesaving treatment, compared with
59 percent of adults with HIV. And 180,000 children were newly infected with HIV in 2017.

PEPFAR supports nearly 1 million children on lifesaving ART, double the number the program did in
2014. We continue to invest nearly half a billion dollars annually to ensure children are prioritized,
including by dedicating at least 10 percent of PEPFAR program funds to ensure that orphans,
vulnerable children, and their caregivers can thrive.

Key Populations PHOTO: SARAH DAY SMITH/PEPFAR

According to the latest UNAIDS data, 47 percent of new HIV infections globally occur among key
populations and their sexual partners, including 95 percent of new HIV infections in Eastern Europe
and Central Asia and the Middle East and North Africa.

PEPFAR remains deeply committed to expanding key populations’ non-discriminatory access to

quality, lifesaving HIV prevention and treatment services. In July 2018, PEPFAR announced that the
program will invest $360 million dollars in the next 12 months to expand key populations’ non-dis-
criminatory access to quality, lifesaving HIV services. This includes $260 million through our 2018
COPs and $100 million from our Key Populations Investment Fund, which will primarily support
indigenous organizations reaching key populations with HIV services in communities.
PHOTO: PSI

PEPFAR is continually evolving its program by using data to drive equity to add these critical gaps
and ensure that all at-risk populations being left behind know their HIV status, receive lifesaving HIV prevention and treatment
services, and are virally suppressed if they are HIV-positive.

10 | 2018 Progress Report

PEPFAR’s Commitment Remains Strong
PEPFAR continues to focus and align U.S. government resources and activities toward achieving HIV/AIDS epidemic control by
emphasizing the following action steps.

ƒƒ Acceleration of optimized HIV testing and treatment strategies particularly to reach men under age 35, including
through the new PEPFAR-supported Menstar Coalition. More than half of men under age 35 do not know their HIV
status and are not on ART, which is fueling the epidemic among young women ages 15-24 and young men ages
25-35.

ƒƒ Expansion of HIV prevention, particularly for young women under age 25 and men under age 30 through the
scale-up of innovative and successful PEPFAR-led DREAMS programs and the expansion of VMMC for boys and
young men in targeted age bands.

ƒƒ Renewed engagement with faith-based leaders and organizations as well as the private sector to accelerate and
improve efforts toward epidemic control.

ƒƒ Strengthened partner country policy environments for HIV/AIDS service delivery and increased partner government
financial contributions to their own HIV/AIDS responses.

ƒƒ Rapidly increasing the percentage of PEPFAR-supported implementing partners that are indigenous organizations,
with the goal of each PEPFAR implementing agency having 40 percent indigenous partners by the end of 2019
and70 percent indigenous partners by the end of 2020.

ƒƒ Continuous use of the latest and most granular epidemiologic and cost data to improve partner performance,
find additional efficiencies, and increase the impact of each dollar invested.

Over the past 15 years, PEPFAR has helped bring the HIV/AIDS pandemic from crisis toward control. As a global community, we
have the historic opportunity, for the first time in modern history, to control a pandemic without a vaccine or a cure. This will lay
the groundwork for eventually eliminating HIV once a vaccine or a cure is discovered.

Based on our progress to date, up to 13 PEPFAR-supported countries could achieve HIV/AIDS epidemic control by 2020. Given
where we were 15 years ago when PEPFAR began, this would be a remarkable accomplishment. Achieving epidemic control will
save untold lives, significantly lower the burden of HIV/AIDS in countries and communities, and begin to reduce the future costs
required to sustain the response.

With this strategy, the U.S. government will continue to drive toward HIV/AIDS epidemic control – these goals are within our grasp
and we are committed, working alongside our many partners, to filling the critical gaps that remain in order to reach them. We will
continue to both demand and demonstrate accountability and transparency at every level of our efforts, for the people who we
are privileged to serve deserve nothing less.

As U.S. Secretary of State Michael Pompeo so eloquently stated in introducing this 2018 Progress Report: “Together, we can, and
we will, control this pandemic – one community and one country at a time.”

PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) | 11

AN HIV-POSITIVE MOTHER WITH HER HIV-NEGATIVE BABY
(PHOTO: USAID KENYA)

U.S. Department of State

Office of the U.S. Global AIDS Coordinator and Health Diplomacy
SEPTEMBER 2018