How much bang for the PEPFAR buck?

Researchers have estimated that 1.2 million deaths in Africa were averted between 2004 and 2007 as a direct result of interventions funded by the US President's Emergency Plan for AIDS Relief (PEPFAR).

Since former President George Bush launched the programme in 2003, it has been widely praised as the largest and most ambitious health initiative dedicated to combating a single disease, but until recently the outcomes of this multibillion-dollar effort had never been measured.

Using figures from UNAIDS, researchers from Stanford University in the US compared HIV-related deaths, the number of people living with HIV, and HIV prevalence in 12 "focus" countries, selected by PEPFAR to receive funding, with 29 other countries in sub-Saharan Africa that are also experiencing generalised HIV epidemics.

They found that in the four years after PEPFAR's activities started, the annual number of HIV-related deaths in the focus countries was 10.5 percent lower.

In an article published on the website of the Annals of Internal Medicine, the authors of the study noted that nearly half of PEPFAR's expenditures went to providing antiretroviral (ARV) treatment, and that better ARV treatment coverage in the focus countries probably accounted for the lower death rates.

Based on the more than US$6 billion that PEPFAR had spent in the 12 countries by the end of 2007, the researchers estimated the cost of each death averted at $2,450.

In the focus countries, a slightly steeper increase in the number of HIV-positive people might also have been because those on ARV treatment were living longer.

However, the researchers found no evidence that PEPFAR's activities had affected prevalence rates. About one-fifth of PEPFAR's resources were spent on prevention programmes during the study period, of which one-third were earmarked for abstinence-only programmes.

The authors raised the concern that, as the number of people receiving life-long ARV treatment in the focus countries increased, the cost of treatment would become unsustainable unless the number of new HIV infections could be substantially reduced.

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"Striking the right balance between treatment and prevention, with insufficient resources for the burden of the epidemic, is a major challenge for comprehensive care programmes such as PEPFAR," said the authors, who recommended ongoing evaluation.

In July 2008 the US Senate extended PEPFAR for another five years, with an increased budget of $48 billion. "The commitment of funds by the US government is commendable," the authors noted, "but it is crucial to ascertain that PEPFAR is effective, and that the investment in this programme is cost-effective."

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