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The '''President's Emergency Plan For AIDS Relief''' ('''PEPFAR''') is a United States governmental initiative to address the global [[HIV ]] epidemic and help save the lives of those suffering from the disease. Launched by U.S. President George W. Bush in 2003, PEPFAR has provided more than $85 billion in cumulative funding for [[HIV]]/AIDS treatment, prevention, and research since its inception, making it the largest global health program focused on a single disease in history.

|Text=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.

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.<ref>{{REFjournal

|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

|Text=Action Step: Increase the number of males who are circumcised for the prevention of [[HIV]]....

|Text=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.

Boyle & Hill (2011) established conclusively that the randomized controlled trials had disabling methodological and statistical flaws that invalidated their findings,<ref name="boyle2011" /> therefore the PEPFAR VMMC program is based on false information. [[Robert S. Van Howe|Van Howe]] & Storms (2011) correctly forecast that institution of a circumcision program would increase the number of [[HIV ]] infections.<ref>{{REFjournal

|Text=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.

|Text=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.

|Text=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.

Garenne & Matthews (2019) reported that there is little difference in the incidence of [[HIV ]] infection between circumcised men and intact men in Zambia. The authors stated that the "effectiveness of VMMC could therefore be seriously questioned."<ref name="garrenne2019">{{REFjournal

[[George C. Denniston]], {{MD}}, {{MPH}}, the president of [[Doctors Opposing Circumcision (D.O.C.)| Doctors Opposing Circumcision]], in a letter to Ambassador Deborah L. Birx, {{MD}}, {{MPH}}, dated 29 June 2020, the head of the President’s Emergency Plan for AIDS Relief (PEPFAR), has called on PEPFAR to suspend the provision of male [[circumcision]] because it is ineffective and may increase the reception of [[HIV ]] infection due to the loss of [[Immunological and protective function of the foreskin| immunological protections]] of the [[foreskin]], and to focus on the provision of anti-retroviral therapy and condoms.<ref name="denniston2020">{{REFdocument

Campaigns to circumcise millions of boys and men to reduce [[HIV ]] transmission are

to properly consider the economic determinants of [[HIV ]] prevalence. This critical

solution” to African [[HIV ]] epidemics has more to do with cultural imperialism than with

[[David Gisselquist]] (2021) reported that "circumcising men to reduce their risk to get [[HIV ]] from sex" was an error.<blockquote>In 2007, WHO and UNAIDS recommended “male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired [[HIV ]] infection in men.” Subsequently, WHO and UNAIDS endorsed programs to circumcise 20 million men in 14 countries in sub-Saharan Africa during 2008-15.[34] After 11.7 million circumcisions were reported through 2015, UNAIDS set a new target to circumcise another 25 million men in 15 countries during 2016-20. Through 2017, the US government supported more than 80% of these circumcisions.

WHO’s and UNAIDS’ recommendation was based on three studies in Africa that reported circumcised men were less likely to get [[HIV ]] than intact men. But what happened in those studies? In two of the studies, men who reported no sexual risks (no partners or 100% condom use) got [[HIV ]] at rates more than half as fast as the rates for men who reported any unprotected sex. The third study did not report men’s sexual risks. One study tested most wives, but has not said if the wives of men getting new infections during the study were known to be [[HIV]]-positive or [[HIV]]-negative.

But criticizing these studies – how they were badly managed and reported<ref name="boyle2011" /> – does not get to the heart of the problem with circumcising millions of men to prevent [[HIV]]. Insofar as sex is a risk, men already have multiple options to protect themselves. And because there is overwhelming evidence bloodborne risks – most likely in medical settings – drive Africa’s epidemics (Chapter 6), it is irresponsible to put millions of men at risk for [[HIV ]] and other bad outcomes from unnecessary operations.<ref>{{REFbook

The United States Department of State on 10 February 2021, announced a "temporary pause" in the development of Country Operational Plans and Regional Operational Plans, which it said was caused by the COVID-19 pandemic. The Department of State affirmed that "[[HIV ]] prevention and treatment services" would continue, but made no mention of male circumcision or VMMC.<ref name="state2021">{{REFweb