Which PEPFAR investments drive HIV outcomes? Informing PEPFAR transition and scale-down

As PEPFAR faces increased pressure to transition and scale down, understanding which of its investments most effectively drive HIV outcomes can help inform future directions. An analysis by KFF examines PEPFAR spending and HIV viral suppression rates in 22 countries from 2018–2023, looking at spending in three areas: (1) core-services; (2) targeted/stand-alone programs; and (3) non-service delivery/institutional strengthening. Overall, it finds that targeted program spending, which accounts for the smallest share of PEPFAR spending, was associated with the biggest improvement in viral suppression, followed by spending on core-services. Further, targeted programs appear to be most important for “last-mile” gains (in countries closer to sustained epidemic control) while core-services appear to be most important in countries where HIV outcomes remain below optimal levels and are lower income. By contrast, spending on non-service delivery was negatively associated with viral suppression, suggesting diminishing returns at this point in PEPFAR’s trajectory. These findings provide new information about how future PEPFAR investments could best be tailored to support transition while maintaining HIV outcomes. Additional research on the relationship between specific activities within each spending category and HIV outcomes could further aid these efforts. Finally, it is important to note that despite the strength of the analytic model, it is possible that other factors may be contributing to the results.

Read the full analysis here.