The President's Emergency Plan for AIDS Relief (PEPFAR) has begun providing money (United States tax dollars) for male circumcision programs. Focus countries have been invited to request program funding to increase access to the procedure. According to Kent Hill (assistant administrator for USAID), funding will increase to be "an important part" of PEPFAR programs in coming years.
- 1 World AIDS Day (2010) Announcements
- 2 FACT SHEET: The Beginning of the End of AIDS 2011
- 3 President Obama announces bold new AIDS commitment 2011
- 4 Swaziland
- 5 PEFPAR promoting infant circumcision
- 6 PEPFAR's African Safaris
- 7 Investigations by the Office of Inspector General (OIG)
- 8 More revelations to come
- 9 CircWatch
- 10 References
World AIDS Day (2010) Announcements
PEPFAR Press Conference
“ I'm pleased to note that USAID will play a signifigant role, with NIH, PEPFAR, and others [...] Swaziland, where we're all working in partnership to increase circumcision [...] to more than 80% in less than one year. It's the kind of example of a rapid scale-up [...] that can really make a difference [...] we can scale them up rapidly and do that in a successful and focussed way. [...] I want to share with you my deep respect for what you do, for your work and commitment. For proving to the world, that often didn't believe you could reach such high treatment numbers, or you could acheive such rapid scale-up of circumcision [...] We take great inspiration from that [...] ”
– (The White House) 
PEPFAR Press Conference
“ Here's some concrete things I think we need to do. Anything that happens to black men affects black women. [...] Circumcision. We need to make sure circumcision is paid for. We clearly need to reimburse circumcision of male infants. About 3/4 of black men in the U.S. are already circumcised, I mean, this is clearly an issue. ”
– (The White House) 
FACT SHEET: The Beginning of the End of AIDS 2011
“ PEPFAR is leading the world in support for a rapid expansion of voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent—and the benefit is life-long. Approximately one million male circumcisions for HIV prevention have been done in recent years, with the United States providing the support for three-quarters of them. Building on this, over the next two years, PEPFAR will support more than 4.7 million voluntary medical male circumcisions in Eastern and Southern Africa. ”
– (The White House) 
Note that the 60% is a relative risk reduction (absolute risk reduction 1.31%) during 18 months - not life-long.
President Obama announces bold new AIDS commitment 2011
President Obama commemorated World AIDS Day by stepping up America’s commitment to the fight against AIDS, both domestically and internationally. In addition to his broad rhetoric on the importance — and feasibility — of ending AIDS, he made a number of specific commitments. The US will (among other commitments) provide support for more than 4.7 million voluntary medical male circumcisions in Eastern and Southern Africa over the next two years.
PEPFAR is helping fund the "Accelerated Saturation Initiative", a program to circumcise 80% of the men ages 18 to 49 within the year 2011. Additionally, it is working with the Swaziland Ministry of Health to introduce and scale up neonatal circumcision.
Point of Interest: In recent studies, HIV transmission was found to be more prevalent in circumcised males in Swaziland. The drive to circumcise the majority of Swazi men continues none the less.
PEFPAR promoting infant circumcision
"Typically, USAID’s policy is to circumcise males between the ages of 15 to 49, as one part of a comprehensive HIV/AIDS program. However, with encouragement from PEPFAR, the Raleigh Fitkin Memorial Hospital in Manzini, has led the way on infant circumcision, circumcising all male children born at the hospital since 2009 unless the parents opt out. This is a health facility delivering 8,000 babies a year where half of the women are HIV-positive). Prevention of mother to child transmission is now complemented with infant circumcision."
From the PEPFAR Swaziland Operational Plan Report FY 2011 (emphasis added):
“ 4. Women and girl-centered Approach: ...Neonatal circumcision counseling for women who give birth to baby boys will be included in the nationwide campaign. ”
From the PEPFAR Blueprint: Creating an AIDS-free Generation (emphasis added):
“ Action Step: Increase the number of males who are circumcised for the prevention of HIV....
10. Build the capacity of partner governments to begin planning for and financing an integrated, long-term early infant male circumcision (EIMC) program as the adult V[oluntary ]M[edical ]M[ale ]C[ircumcision] program is being scaled-up. PEPFAR’s financial support is prioritized to the adult VMMC program. However, once the adult program has progressed sufficiently, PEPFAR funds may be used to support EIMC activities. ”
PEPFAR's African Safaris
From a blog.AIDS.gov entry by Jeffrey S. Crowley, M.P.H., Director, Office of National AIDS Policy dated 26 May 2011:
“ Last week, I wrote about my attendance at the PEPFAR annual meeting in South Africa, the country that has more people living with HIV (over 5 million) than any other country in the world. After this meeting, I visited the neighboring country of Swaziland, which has the unwelcome distinction of having the highest HIV and TB prevalence rates in the world.
The United States Ambassador to Swaziland, the Honorable Earl Irving, was an incredible host. I attended a large reception at the Ambassador’s residence with the Honorable Minister of Health, Benedict Xaba and other Swazi leaders working on HIV, as well as representatives from PEPFAR, Peace Corps, CDC, USAID, DoD, and private American institutions, including Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP) project. Another evening, the Ambassador hosted a dinner with leaders from the Swazi Cabinet, the Ministry of Health and the national AIDS commission. I participated in a handover ceremony where the Ambassador ceremoniously transferred nine vehicles from PEPFAR to the government of Swaziland that will support their HIV work in the field. Through this event I also had the opportunity to meet His Excellency the Right Honorable Prime Minister of Swaziland.
A major focus of PEPFAR’s work is to assist the Swazi government’s plan to scale up adult male circumcision. This lowers the risk that men will acquire HIV infection and research models indicate that if the country can get up to 80% of its adult men circumcised, they could observe a substantial decline in HIV transmission. I visited one of several mobile sites that enabled Swaziland and PEPFAR to quickly expand access to circumcision. ”
Investigations by the Office of Inspector General (OIG)
On the 15 June 2011, the OIG published a report critical of the Centers for Disease Control and Prevention's (CDC's) failure to oversee recipients’ use of PEPFAR funds. The report read in part:
“ Our review found that CDC did not always monitor recipients’ use of President’s Emergency Plan for AIDS Relief (PEPFAR) funds in accordance with departmental and other Federal requirements. CDC implements PEPFAR, working with ministries of health and other public health partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries in Africa, Asia, Central and South America, and the Caribbean. HHS receives PEPFAR funds from the Department of State through a memorandum of agreement.
There was evidence that CDC performed some monitoring of recipients’ use of PEPFAR funds. However, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring on all cooperative agreements. Of the 30 cooperative agreements in our sample, the award file for only 1 agreement contained all required documents. The remaining 29 award files were incomplete. In addition, 14 of 21 files were missing audit reports. (A report was not yet due for 9 of the 30 cooperative agreements.) The lack of required documentation demonstrates that CDC has not exercised proper stewardship over Federal PEPFAR funds because it did not consistently follow departmental and other Federal requirements in monitoring PEPFAR recipients. ”
On the 19 November 2012, the OIG published a report critical of the CDC Namibia Office's failure to properly monitor recipients' use of PEPFAR funds . The report read in part:
“ CDC's office in Windhoek, Namibia (CDC Namibia), is responsible for PEPFAR funds awarded to government agencies and for-profit and nonprofit organizations (recipients) in Namibia.
Our audit found that CDC Namibia did not always monitor recipients' use of PEPFAR funds in accordance with HHS and other Federal requirements. There was evidence that CDC Namibia performed some monitoring of recipients' use of PEPFAR funds. However, most of the recipient cooperative agreement files did not include required documents or evidence that CDC Namibia had monitored all cooperative agreements. CDC Namibia did not consistently monitor the cooperative agreements in accordance with HHS and other Federal requirements because it did not have written policies and procedures for the monitoring process. As a result, CDC Namibia did not have assurance that PEPFAR funds were used as intended by law. ”
On the 4 February 2013, the OIG published a report critical of Namibia's Ministry of Health and Social Services failure to manage PEPFAR funds and meet program goals in accordance with award requirements . The report read in part:
“ Through its Global HIV/AIDS Program, CDC implemented the President's Emergency Plan for AIDS Relief (PEPFAR), working with ministries of health and other in-country partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries. Through a 5-year cooperative agreement, CDC awarded PEPFAR funds totaling $20.6 million to the Republic of Namibia, Ministry of Health and Social Services (the Ministry) for the budget period September 30, 2009, through September 29, 2010.
Our audit found that the Ministry did not always manage PEPFAR funds or meet program goals in accordance with award requirements. With respect to financial management, specifically financial transaction testing, we found that $3.7 million of the $4 million reviewed was allowable, but $243,000 was not. Additionally, the Ministry used PEPFAR funds to pay $565,000 of potentially unallowable value-added taxes (VAT) on purchases, did not accurately report PEPFAR expenditures for this cooperative agreement on its financial status report (FSR) submitted to CDC, and did not obtain an annual financial audit as required by Federal regulations.
Our program management review showed that 12 of the 30 accomplishments sampled from the annual progress report were not related to the goals and objectives of the cooperative agreement. Seven accomplishments were not supported by documentation and six were only partially supported. Also, the Ministry did not submit its annual progress report to CDC within the allotted time frame in accordance with Federal regulations.
The Ministry’s policies and procedures did not ensure that it:
(1) Maintained adequate supporting documentation for allowable expenditures under the cooperative agreement and accurately reported costs on its FSR,
(2) Submitted its progress report timely and included only items related to the agreement that it could fully support, and
(3) Obtained an annual financial audit and submitted the report as required by Federal regulations. ”
On the 12 February 2013, the OIG published a report critical of the CDC South Africa Office's failure to properly monitor recipients' use of PEPFAR funds . The report read in part:
“ Our audit found that CDC South Africa did not always monitor recipients' use of PEPFAR funds in accordance with HHS and other Federal requirements. There was evidence that CDC South Africa performed some monitoring of recipients' use of PEPFAR funds. However, most of the recipient cooperative agreement files did not include required documents or evidence that CDC South Africa had monitored all cooperative agreements.
CDC South Africa did not have written policies and procedures to help ensure that it consistently monitored the cooperative agreements for recipients in accordance with HHS and other Federal requirements. As a result, CDC South Africa did not have assurance that PEPFAR funds were used as intended by law. ”
More revelations to come
From "Spotlight on... Grants Management and Oversight" published by the OIG on 4 February 2013:
President's Emergency Plan for AIDS Relief Funds
“ The President's Emergency Plan for AIDS Relief (PEPFAR) program authorized $78 billion from 2003 through 2014 in support of international programs for prevention, treatment, and care to combat HIV/AIDS, tuberculosis, and malaria. OIG examined the funds spent through this program in a 2011 report focusing on whether the Centers for Disease Control and Prevention's (CDC) oversight met departmental and Federal regulations. OIG found that while CDC performed some oversight of recipients' fund use, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring. Because of these concerns, OIG expanded its audits internationally to include CDC's monitoring of PEPFAR funds by offices in other countries as well as audits of recipient organizations abroad. OIG issued two audits on Namibia, one in 2012 and another in 2013, and has an additional eight audits conducted there and in South Africa and Vietnam that are near completion." OIG is also planning seven more audits of PEPFAR grantees in Ethiopia and Zambia for FY 2013. ”
- The White House (1 October 2010).
World AIDS Day at the White House. Retrieved 10 April 2011.
- Medical News TODAY (22 August 2007).
PEPFAR To Begin Providing Funds For Male Circumcision Programs In Some African Countries, Officials Say. Retrieved 30 March 2011.
- World AIDS day at the White House. (2010)
- World AIDS day at the White House. (2010)
- FACT SHEET: The Beginning of the End of AIDS 2011
Boyle, GJ and Hill, G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Retrieved 29 December 2012.
- (1 December 2011).
President Obama announces bold new AIDS commitments. Retrieved 29 December 2012.
- Mazzotta, Meredith (4 March 2011)."Swaziland embarks on ambitious plan to circumcise 80 percent of men 18 to 49 this year", Science Speaks: HIV & TB News. Retrieved 6 May 2011. "Much attention has been paid to the launch of an aggressive medical male circumcision (MC) campaign in Swaziland that starts this month, a program aiming to circumcise 80 percent of the small nation’s men aged 18-49 by the year’s end with significant support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program."
- Mazzotta, Meredith (4 March 2011)."Swaziland embarks on ambitious plan to circumcise 80 percent of men 18 to 49 this year", Science Speaks: HIV & TB News. Retrieved 6 May 2011. "The Ministry of Health, supported principally by UNICEF and PEPFAR, is currently working to introduce and scale up neonatal circumcision."
- (2008): Swaziland Demographic and Health Survey 2006-07, in: Mbabane, Swaziland: Central Statistical Office and Macro International Inc.. Retrieved 6 May 2011. Quote:
As Table 14.10 shows, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher HIV infection rate than men who are not circumcised (22 percent compared with 20 percent
- (14 November 2011).
The PEFPAR ripple effect. Retrieved 29 December 2012.
- (3 October 2012).
PEPFAR Swaziland Operational Plan Report FY 2011. Retrieved 19 November 2012.
- (30 November 2012).
PEPFAR Blueprint: Creating an AIDS-free Generation. Retrieved 30 December 2012.
- (May 2011).
My Visit to Swaziland: The Country with the World’s Highest HIV Prevalence Rate. Retrieved 17 October 2011.
- (June 2011).
Review of the Centers for Disease Control and Prevention’s Oversight of the President’s Emergency Plan for AIDS Relief Funds for Fiscal Years 2007 Through 2009 (A-04-10-04006). Retrieved 25 June 2011.
- (November 2012).
The Centers for Disease Control and Prevention's Namibia Office Did Not Always Properly Monitor Recipients' Use of the President's Emergency Plan for AIDS Relief Funds (A-04-12-04020). Retrieved 7 December 2012.
- (February 2013).
The Republic of Namibia, Ministry of Health and Social Services, Did Not Always Manage the President’s Emergency Plan for AIDS Relief Funds or Meet Program Goals in Accordance With Award Requirements (Audit A-04-12-04019. Retrieved 4 February 2013.
- (February 2013).
The Centers for Disease Control and Prevention's South Africa Office Did Not Always Properly Monitor Recipients' Use of the President's Emergency Plan for AIDS Relief Funds (Audit A-04-12-04022). Retrieved 27 February 2013.
- (February 2013).
Spotlight on... Grants Management and Oversight. Retrieved 4 February 2013.