This is the accessible text file for GAO report number GAO-11-785 entitled 'President's Emergency Plan For AIDS Relief: Program Planning and Reporting' which was released on July 29, 2011. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. United States Government Accountability Office: GAO: Report to Congressional Committees: July 2011: President's Emergency Plan For AIDS Relief: Program Planning and Reporting: GAO-11-785: GAO Highlights: Highlights of GAO-11-785, a report to congressional committees. Why GAO Did This Study: U.S. assistance through the President’s Emergency Plan for AIDS Relief (PEPFAR) has helped provide treatment, care, and prevention services overseas to millions affected by HIV/AIDS. In 2008, Congress reauthorized PEPFAR with the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership Act). The act requires the Department of State’s Office of the U.S. Global AIDS Coordinator (OGAC) to report to Congress annually on PEPFAR performance. The U.S. Agency for International Development (USAID) and the Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) also report on PEPFAR program performance. Responding to legislative directives, GAO (1) described key procedures for planning and reporting on PEPFAR performance and (2) examined published PEPFAR performance plans and reports. GAO analyzed performance management documents and interviewed officials at OGAC, USAID, and CDC. What GAO Found: Officials in several offices and divisions in OGAC, USAID, and CDC coordinate and manage PEPFAR program planning and reporting procedures at headquarters and in PEPFAR countries and regions. These procedures, which include PEPFAR-wide annual operational planning and periodic results reporting, support internal agency-specific program management as well as provide information for external reporting on PEPFAR results. OGAC, USAID, and CDC publicly issued plans and reports on PEPFAR performance in recent years consistent with 2008 Leadership Act requirements and GPRA practices; however, two key elements are lacking. First, although OGAC has internally specified annual performance targets, its most recent annual reports to Congress did not identify these targets or compare annual results with them. According to the 2008 Leadership Act, OGAC’s annual reports on PEPFAR program results must include an assessment of progress toward annual goals and reasons for any failure to meet these goals. In addition, the Government Performance and Results Act (GPRA) of 1993 calls for federal agency performance reports to compare program results with established targets. Performance documents published by USAID, jointly with State, and by CDC report program targets and results for two and four PEPFAR indicators, respectively. (See figure.) Second, OGAC’s most recently published performance plans and reports do not provide information on efforts to validate and verify reported data, while USAID ’s and CDC’s published performance documents cite such efforts by OGAC. In addition, none of the plans or reports refers to noted data reliability weaknesses or efforts to address these weaknesses. GPRA and prior GAO work emphasize the importance of providing information in public performance documents on data verification and other efforts to address identified weaknesses. Figure: PEPFAR Indicators, Targets, and Results in OGAC, USAID, and CDC Performance Plans and Reports, Fiscal Year 2010: [Refer to PDF for image: illustrated table] Agency or office: OGAC; Indicators used: 5; Specifies targets: No; Reports results: Yes; Compares results with targets: No. Agency or office: USAID; Indicators used: 2; Specifies targets: Yes; Reports results: Yes; Compares results with targets: Agency or office: CDC; Indicators used: 4; Specifies targets: Yes; Reports results: Yes; Compares results with targets: Source: GAO analysis of OGAC, State, USAID, and CDC information. [End of figure] What GAO Recommends: GAO recommends that OGAC include in its annual report to Congress (1) comparisons of annual PEPFAR results with established targets and (2) information on efforts to verify and validate PEPFAR performance data and address data limitations. OGAC partially agreed with the first recommendation, pending discussions with stakeholders about implementation issues and consequences, and agreed with the second recommendation. View GAO-11-785 or key components. For more information, contact David Gootnick at (202) 512-3149 or gootnickd@gao.gov. [End of section] Contents: Letter: Background: OGAC, USAID, and CDC Have Procedures for PEPFAR Performance Planning and Reporting: OGAC, USAID, and CDC Documented Performance Management, but Published Plans and Reports Lack Two Key Elements: Conclusions: Recommendations for Executive Action: Agency Comments and Our Evaluation: Appendix I: Objectives, Scope, and Methodology: Appendix II: UNAIDS Components: Appendix III: PEPFAR Indicators: Appendix IV: PEPFAR Program Performance Results Reported by OGAC, USAID, and CDC for Fiscal Year 2010: Appendix V: Comments from the U.S Department of State, Office of the U.S. Global AIDS Coordinator: Appendix VI: GAO Contact and Staff Acknowledgments: Related GAO Products: Tables: Table 1: UNAIDS's 12 Components of a Functional National HIV/AIDS Monitoring and Evaluation System: Table 2: PEPFAR Indicators Classified as Essential and Reported to OGAC: Table 3: PEPFAR Results Reported by OGAC, USAID, and CDC for Fiscal Year 2010: Figures: Figure 1: USAID OIG PEPFAR Program Performance Audit Report Recommendations, by Category, Fiscal Years 2008-2011: Figure 2: USAID OIG Fiscal Year 2008-2011 PEPFAR Program Performance Audit Report Recommendations, by Status, as of June 2011: Figure 3: PEPFAR Indicators, Targets, and Results in OGAC, USAID, and CDC Performance Plans and Reports, Fiscal Year 2010: Abbreviations: 2008 Leadership Act: Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008: CDC: Centers for Disease Control and Prevention: DGHA: Division of Global HIV/AIDS: GPRA: Government Performance and Results Act: HHS: Department of Health and Human Services: OGAC: Office of the U.S. Global AIDS Coordinator: OIG: Office of Inspector General: M&E: monitoring and evaluation: PEPFAR: President's Emergency Plan for AIDS Relief: SI: Strategic Information: State: Department of State: State-USAID APR/APP: "Foreign Operations FY 2010 Performance Report, FY 2012 Performance Plan" UNAIDS: Joint United Nations Programme on HIV/AIDS: USAID: U.S. Agency for International Development: [End of section] United States Government Accountability Office: Washington, DC 20548: July 29, 2011: Congressional Committees: U.S. foreign assistance through the President's Emergency Plan for AIDS Relief (PEPFAR) has helped to provide treatment to millions of people worldwide infected with HIV, prevent mother-to-infant transmission of the virus, and provide care and assistance to millions of adults and children affected by HIV/AIDS. In fiscal years 2004 through 2008--the first 5 years of PEPFAR--the U.S. government directed more than $18 billion to PEPFAR implementing agencies and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Seeking to continue and expand past efforts, Congress reauthorized PEPFAR in 2008 through passage of the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership Act),[Footnote 1] authorizing $48 billion to continue and expand U.S.-funded HIV/AIDS and other programs through fiscal year 2013. The 2008 Leadership Act includes U.S. government multiyear targets for prevention, treatment, care, and health-systems-strengthening programs supported through PEPFAR.[Footnote 2] The act also calls on the U.S. Global AIDS Coordinator to produce a plan for program monitoring and regularly report on PEPFAR program activities and performance. The Office of the U.S. Global AIDS Coordinator (OGAC) establishes overall PEPFAR policy and program strategies; coordinates PEPFAR programs; and allocates PEPFAR resources from the Global Health and Child Survival account to U.S. implementing agencies--primarily the U.S. Agency for International Development (USAID) and the Department of Health and Human Services' (HHS) Centers for Disease Control and Prevention (CDC).[Footnote 3] Responding to directives in the Consolidated Appropriations Act of 2008 and the 2008 Leadership Act to review global HIV/AIDS program monitoring,[Footnote 4] this report (1) describes OGAC's, USAID's, and CDC's key procedures for planning and reporting on PEPFAR program performance and (2) examines published PEPFAR performance plans and reports. We analyzed the most recent publicly available OGAC, CDC, and USAID performance plans and reports, as well as relevant PEPFAR and agency- specific guidance and reports. We drew on our prior work and guidance on the Government Performance and Results Act of 1993 (GPRA), as well as the 2008 Leadership Act, to identify elements and practices of program performance planning and reporting. We also analyzed USAID Office of Inspector General (OIG) reports and categorized report recommendations using monitoring and evaluation categories established by the Joint United Nations Programme on HIV/AIDS (UNAIDS) (see app. II for more information on these categories). We interviewed OGAC, USAID, and HHS officials in Washington, D.C.; CDC officials in Atlanta, Georgia; and USAID OIG officials in Washington, D.C.; Dakar, Senegal; and Pretoria, South Africa. (See appendix I for further details of our scope and methodology.) We conducted this performance audit from October 2010 to July 2011 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence we obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background: The 2008 Leadership Act called on the U.S. Global AIDS Coordinator to develop a 5-year strategy to combat global HIV/AIDS, including a plan to achieve a number of prevention, treatment, and care program goals. [Footnote 5] The 5-year PEPFAR strategy, which OGAC released in December 2009, specifies multiyear program goals and outlines multiyear targets including those listed in the Leadership Act. [Footnote 6] The 2008 Leadership Act, which amends the 2003 Leadership Act, requires that OGAC submit an annual report to Congress, including an assessment of progress toward the achievement of annual goals. [Footnote 7] If annual goals are not being met, the 2008 Leadership Act states that the report should identify the reasons for such failure.[Footnote 8] GPRA and our prior work identify practices related to performance planning and reporting. GPRA calls for the use of several performance management practices intended to improve federal program effectiveness, accountability, and service delivery and to enhance congressional decision making by requiring federal agencies to provide more objective information on program performance.[Footnote 9] In addition, our prior work suggests the use of a practice to bolster program performance reporting. These practices include the following, among others: * Performance planning. GPRA calls for preparation of public annual performance plans that articulate goals for the upcoming fiscal year. These plans should link annual program goals to program activities, include indicators that will be used to measure performance, provide information on the operational processes and resources required to meet the performance goals, and identify the procedures that will be used to verify and validate performance information.[Footnote 10] * Performance reporting. GPRA calls for annual performance reports reviewing the success of achieving the performance goals of the fiscal year. The reports are to describe and review results compared with performance goals, provide explanations for any unmet goals and actions needed to address them, and include summaries of completed program evaluations.[Footnote 11] In addition, our prior work found that explaining any limitations of performance information can provide context for understanding and assessing program performance and the costs and challenges faced in gathering, processing, and analyzing data.[Footnote 12] This practice can help identify the actions needed to address any inadequacies in the completeness and reliability of performance data and thereby improve program performance reporting. In August 2009, OGAC issued its Next Generation Indicators Reference Guide,[Footnote 13] providing an updated list of indicators for establishing targets and reporting on results of PEPFAR prevention, care, treatment, and health systems strengthening programs.[Footnote 14] The guidance classifies 32 indicators as essential and reported-- that is, indicators that PEPFAR country or regional teams must use in submitting data on program results to OGAC. (See app. III for a list of the 32 essential reported PEPFAR indicators.) The guidance advises PEPFAR country and regional teams to require PEPFAR implementing partners to submit data for an additional set of indicators, if applicable, but does not require country and regional teams to submit these data to OGAC.[Footnote 15] The guidance also provides a list of recommended indicators for implementing partners and PEPFAR program managers who need additional information for program management. The guidance states that PEPFAR interagency country or regional teams determine how to collect data from PEPFAR implementing partners and relevant national systems, as well as how to aggregate, store, and use the PEPFAR program monitoring indicators in country.[Footnote 16] OGAC, USAID, and CDC Have Procedures for PEPFAR Performance Planning and Reporting: OGAC, USAID, and CDC officials share responsibility for PEPFAR planning and reporting activities--including developing and approving PEPFAR operational plans and reports--and conduct agency-specific planning and reporting procedures. The procedures support agencies' internal program management and provide data for external reporting on PEPFAR results. OGAC: OGAC's Strategic Information (SI) office[Footnote 17] guides and coordinates PEPFAR performance planning and reporting for countries and regions receiving U.S. HIV/AIDS assistance.[Footnote 18] SI advisors--as of July 2011, 20 CDC and USAID officials--provide technical support and assistance to country and regional teams for developing annual operational plans[Footnote 19] for PEPFAR programs. [Footnote 20] In helping to develop the country-level and regional operational plans, when requested, SI advisors work with the country and regional teams to describe partner-level PEPFAR activities during the preceding fiscal year and establish country-level and regional targets for the coming year. When OGAC receives the operational plans (typically in October), SI advisors review the performance targets. [Footnote 21] After the plans are approved by the U.S. Global AIDS Coordinator, OGAC aggregates budget, program activity, and planned performance information in the plans to create an annual PEPFAR operational plan to be submitted to Congress. When requested, OGAC's SI office also guides and assists PEPFAR teams in preparing and submitting data on program results to the U.S. Global AIDS Coordinator. SI advisors work with PEPFAR country and regional teams to submit data on program results semi-annually (typically in May) and annually (typically in November).[Footnote 22] The semi- annual data consist of targets and results for a subset of eight PEPFAR essential indicators; the annual data consist of targets and results for all 32 essential reported PEPFAR indicators.[Footnote 23] SI advisors review the submitted data, and SI office staff further review and reconcile treatment data with data from the Global Fund, UNAIDS, and the World Health Organization. Once the data are confirmed, OGAC considers them to be PEPFAR's final results for the year. These data, which OGAC maintains internally, are intended to support PEPFAR program monitoring, midcourse correction, and planning for subsequent fiscal years. PEPFAR program results data also supply information for public reports and other documents, including OGAC's annual report to Congress on PEPFAR performance, typically published in February, as well as a World AIDS Day (December 1) press release on PEPFAR results. USAID: USAID's Office of HIV/AIDS,[Footnote 24] in Washington, D.C., and USAID officials in regional and country missions share responsibility for global HIV/AIDS performance planning and reporting, including oversight of USAID implementing partners.[Footnote 25] The Office of HIV/AIDS comprises four divisions, two of which--the Implementation Support Division and the Strategic Planning, Evaluation, and Reporting Division--provide assistance to the agency and field missions in managing programs and incorporating programmatic best practices. [Footnote 26] USAID uses PEPFAR program results data for its annual performance plans and reports. USAID also conducts foreign assistance performance planning and reporting jointly with State's Office of the Director of U.S. Foreign Assistance, using State's and USAID's Foreign Assistance Framework.[Footnote 27] In addition to producing multiyear country assistance strategies and mission strategic plans,[Footnote 28] USAID country or regional missions complete annual operational plans and annual performance plans and reports for monitoring, evaluating, and reporting progress in achieving the agency's foreign assistance objectives. USAID guidance further specifies required elements of mission performance management plans, including indicators, baseline values and targets, data sources, any known data limitations, and data quality assessment procedures.[Footnote 29] State's and USAID's master list of standard indicators specifies 46 HIV/AIDS-related indicators for setting targets and reporting results. According to USAID officials, the HIV/AIDS-related indicator descriptions are aligned with those for PEPFAR. Through its audits of USAID's global HIV/AIDS program activities, from fiscal year 2008 to 2011, USAID's OIG has made recommendations related to performance planning and reporting.[Footnote 30] We identified 130 USAID OIG recommendations regarding performance monitoring of USAID- administered PEPFAR activities for fiscal years 2008 to 2011,[Footnote 31] which we categorized using 12 components of HIV/AIDS program monitoring and evaluations systems, as defined by UNAIDS.[Footnote 32] Of these recommendations, 94 recommendations, or 72 percent, are related to routine program monitoring or data quality--specifically, 39 percent are related to routine program monitoring (producing timely and high-quality program monitoring data); 11 percent are related to supportive supervision and data auditing (monitoring data quality periodically and addressing any obstacles to producing high-quality data); and 22 percent are related to both routine program monitoring and supportive supervision and data auditing. (See fig. 1.) For example, the OIG reported in 2009 that the USAID mission in one country did not sufficiently verify and validate implementing partner performance data and, as a result, recommended that the mission establish procedures, including site visits, for validating these data. (We categorized this recommendation as relating to both routine program monitoring and supportive supervision and data auditing.) In addition, we found that a number of recommendations related to human capacity for monitoring and evaluation, often in combination with recommendations for improving program monitoring. For example, a 2010 audit of another USAID country mission's PEPFAR program found that inadequate training of implementing partner staff resulted in weak data collection methods and reporting of inaccurate performance data. The OIG recommended that the mission develop a training plan for implementing partner staff in charge of data collection and reporting. Figure 1: USAID OIG PEPFAR Program Performance Audit Report Recommendations, by Category, Fiscal Years 2008-2011: [Refer to PDF for image: pie-chart] Addressing one category: Routine program monitoring (51 recommendations): 39%; Supportive supervision and data auditing (14 recommendations): 11%; Human capacity (5 recommendations): 4%; Partnerships for monitoring and evaluation (3 recommendations): 2%; All other (8 recommendations): 6%. Addressing two categories: Routine program monitoring and supportive supervision and data auditing (29 recommendations): 22%; Supportive supervision and data auditing and human capacity (10 recommendations): 8%; Human capacity and routine program monitoring (6 recommendations): 5%; Routine program monitoring and partnerships for monitoring and evaluation (2 recommendations): 2%; Organizational structures and routine program monitoring (2 recommendations): 2%. Total: 130 recommendations. Source: GAO analysis of 130 recommendations from 24 USAID OIG FY 2008- FY 2011 reports. Notes: We found that 43 recommendations did not fall into any of the 12 categories used to characterize HIV/AIDS program monitoring and evaluation. Examples of these recommendations include issues related to the disposal of expired medications and USAID branding and marking requirements. Percentages do not sum to 100 because of rounding. OIG = Office of Inspector General. [End of figure] According to data provided by USAID, as of June 2011, the agency had implemented about two-thirds (65 percent) of USAID OIG report recommendations related to program performance monitoring and evaluation; about a third (35 percent) of the remaining recommendations are due for final action by December 2011. (See figure 2.)[Footnote 33] Figure 2: USAID OIG Fiscal Year 2008-2011 PEPFAR Program Performance Audit Report Recommendations, by Status, as of June 2011: [Refer to PDF for image: pie-chart] Recommendations implemented (85): 65%; Recommendations with an implementation target date by the end of December 2011 (45): 35%. Total: 130 recommendations. Source: GAO analysis of 130 recommendations from 24 USAID OIG FY 2008- FY 2011 reports. [End of figure] CDC: CDC's Division of Global HIV/AIDS (DGHA),[Footnote 34] in Atlanta, Georgia, is responsible, along with CDC officials in 41 overseas offices, for global HIV/AIDS programs in more than 75 countries. DGHA comprises a regional and country management office and eight headquarters-based technical and operational branches, including epidemiology and strategic information; health economics, systems, and integration; and country operations.[Footnote 35] These offices and branches manage and provide technical assistance and support to CDC country teams and partner governments, coordinate DGHA involvement in PEPFAR interagency activities and partnerships with international organizations, and support regional and country offices with implementing partner selection and performance monitoring.[Footnote 36] CDC uses PEPFAR program results data for its annual performance plans and reports. In addition, in 2010, CDC instituted quarterly program reviews for all CDC divisions, and DGHA underwent its first quarterly program review in November 2010. For these CDC management reviews, DGHA selected 16 1-year and 14 4-year goals under four priority strategies: strengthen public health systems globally; scale up combination prevention programs and treat HIV globally in a cost- effective manner; transition HIV/AIDS treatment programs to host- country governments; and support the Global Health Initiative. DGHA reports quarterly to the Office of the Associate Director for Program on eight PEPFAR indicators, representing 31 PEPFAR countries and three regions. According to CDC officials, the quarterly program review is intended to inform CDC's annual performance plan and report. Beginning in February 2011, DGHA officials initiated a series of in- country reviews--called country management and support visits--of CDC country office management of global HIV/AIDS programs. DGHA officials completed eight visits by the end of June 2011 and planned to complete up to 17 additional visits over the next several months, with up to 34 country visits being completed by the end of fiscal year 2012. DGHA plans to make summaries of the country visits available to the public. In addition, CDC develops annual interagency programmatic planning and monitoring documents called country assistance plans. In February 2010, CDC technical and budget officials and senior management reviewed country assistance plans for seven countries: Afghanistan, Brazil, Laos, Mali, Papua New Guinea, Senegal, and Sierra Leone. These plans provide information on planned activities and country targets and results, among other things. CDC's country assistance plan guidance recommends that CDC country offices refer to PEPFAR indicators in the plans, as appropriate, when reporting results. During a pilot project for assessing the quality of treatment program data, CDC found that data quality varied across CDC-funded treatment sites. CDC examined the reliability of the numbers of patients reported as currently on treatment at 31 CDC-funded PEPFAR treatment sites in Mozambique, Tanzania, and Côte d'Ivoire. CDC found that counting actual patient visit or drug pickup data at the 31 sites yielded a lower total than the method used by some implementing partners (39,577 patients versus 48,796 patients, respectively). The implementing partners sometimes summed the number of people who ever started treatment and subtracted those known to have left the program, resulting in misclassification of patients' treatment status and inflation of reported results. Based on these assessments, CDC recommended (1) refining definitions of indicators and acceptable methods for deriving the information; (2) developing a data quality assessment program with a standardized protocol for evaluating data; (3) completing the treatment data quality assessment at all PEPFAR- supported sites; and (4) sharing the assessments' findings with all PEPFAR country teams, implementing partners, and ministries of health. OGAC, USAID, and CDC Documented Performance Management, but Published Plans and Reports Lack Two Key Elements: Several Documents Have Been Issued to Meet Planning and Reporting Requirements: OGAC, USAID, and CDC have issued several performance management planning and reporting documents in response to the requirements included in the 2008 Leadership Act and practices specified in GPRA. (See app. IV for a list of targets and results reported by OGAC, USAID, and CDC.) * OGAC. OGAC has issued annual PEPFAR operational plans for fiscal years 2009 and 2010.[Footnote 37] According to OGAC officials, the PEPFAR operational plan--which aggregates information from country and regional operational plans--serves as its annual performance plan. OGAC also issues an annual PEPFAR performance report to Congress. OGAC's most recent annual report to Congress, for fiscal year 2010, includes a series of tables showing programwide PEPFAR results for prevention, treatment, and care indicators;[Footnote 38] the annual report for fiscal year 2009 also includes results for health systems strengthening indicators.[Footnote 39] In most cases, these results are also displayed by country or region. * USAID. In March 2011, USAID issued, jointly with State, the "Foreign Operations FY 2010 Performance Report, FY 2012 Performance Plan" (State-USAID APR/APP) as part of State's and USAID's congressional budget justification for fiscal year 2012.[Footnote 40] The document provides, among other things, information on 2010 targets and results for two PEPFAR indicators: (1) number of individuals receiving antiretroviral treatment, and (2) number of individuals infected or affected by HIV/AIDS, including orphans and vulnerable children, who were receiving care and support services. The State-USAID APR/APP cites PEPFAR's 5-year target for number of HIV infections averted and provides an annual target for 2010 but does not report on annual results. * CDC. CDC's "Fiscal Year 2012 Justification of Estimates for Appropriation Committees" and "FY 2012 Online Performance Appendix" constitute its performance report and performance plan for fiscal years 2010 and 2012, respectively.[Footnote 41] In these documents, CDC reports on 2010 targets and results using four PEPFAR indicators: (1) number of individuals receiving antiretroviral treatment; (2) number of individuals infected and affected by HIV/AIDS, including orphans and vulnerable children, receiving care and support services; (3) number of pregnant women receiving HIV counseling and testing; and (4) number of HIV-positive pregnant women receiving antiretroviral prophylaxis. OGAC's Annual Reports Do Not Compare Annual Results with Targets as Required: OGAC's most recent annual performance documents do not provide information related to annual targets, as required by the 2008 Leadership Act and consistent with GPRA. (See fig. 3.) PEPFAR country and regional operational plans contain country-level and regional targets for the coming year and data showing program targets and results, measured by PEPFAR indicators. However, the annual PEPFAR operational plans and reports that OGAC submitted to Congress for fiscal years 2009 and 2010 do not contain any information on annual targets. Moreover, OGAC's annual reports to Congress for fiscal years 2009 and 2010 do not compare annual results with annual targets. According to the 2008 Leadership Act, these reports are to include an assessment of progress toward the achievement of annual goals and, if annual goals are not being met, the reasons for such failures. [Footnote 42] In addition, GPRA calls for annual performance reports to compare results with previously established targets.[Footnote 43] Figure 3: PEPFAR Indicators, Targets, and Results in OGAC, USAID, and CDC Performance Plans and Reports, Fiscal Year 2010: [Refer to PDF for image: illustrated table] Agency or office: OGAC; Annual performance plans and reports: PEPFAR operational plan and PEPFAR annual report to Congress[A]; Indicators used: 5; Specifies targets: No; Reports results: Yes; Compares results with targets: No. Agency or office: USAID; Annual performance plans and reports: Foreign operations performance report and performance plan[B]; Indicators used: 2; Specifies targets: Yes; Reports results: Yes; Compares results with targets: Agency or office: CDC; Annual performance plans and reports: Justification of estimates for appropriation committees and online performance appendix[C]; Indicators used: 4; Specifies targets: Yes; Reports results: Yes; Compares results with targets: Source: GAO analysis of OGAC, State, USAID, and CDC information. [A] OGAC issued an operational plan and annual report for PEPFAR for fiscal year 2010. See Office of the U.S. Global AIDS Coordinator, "The U.S. President's Emergency Plan for AIDS Relief (PEPFAR): Fiscal Year 2010 PEPFAR Operational Plan" (April 2011), available at [hyperlink, http://www.pepfar.gov/about/c19388.htm]; "United States President's Emergency Plan for AIDS Relief: Seventh Annual Report to Congress" (June 2011), available at [hyperlink, http://www.pepfar.gov/press/seventhannualreport/]. [B] USAID issued, jointly with the Department of State, a PEPFAR operational plan for fiscal year 2012 and annual report for 2011 as part of the State-USAID congressional budget justification for fiscal year 2012. See Department of State, "Foreign Operations FY 2010 Performance Report FY 2012 Performance Plan," Congressional Budget Justification, Volume 2: Foreign Operations, Fiscal Year 2012 (March 2011), available at [hyperlink, http://www.state.gov/f/releases/iab/fy2012cbj/pdf/index.htm]. [C] CDC issued its fiscal year 2010 annual report for PEPFAR as part of the Department of Health and Human Services' congressional budget justification for fiscal year 2012. See Department of Health and Human Services, Centers for Disease Control and Prevention, "Fiscal Year 2012 Justification of Estimates for Appropriation Committees" and "Fiscal Year 2012 Online Performance Appendix," available at [hyperlink, http://www.hhs.gov/about/hhsbudget.html#OperatingDivisions:Congressional BudgetJustificationsandOnlinePerformanceAppendices]. [End of figure] State-USAID's and CDC's annual performance documents present some information on PEPFAR targets and results (see fig. 3). The State- USAID APR/APP cites two targets for treatment and care programs for fiscal year 2010. CDC's fiscal year 2010 performance report and fiscal year 2012 performance plan cite four fiscal year targets--two for prevention, and one each for treatment and care programs.[Footnote 44] Both agencies' performance documents compare PEPFAR 2010 results with targets set for the same year and rate PEPFAR's performance against those targets. For example, the documents report that PEPFAR exceeded its 2010 target for number of individuals on antiretroviral treatment but did not meet its target for number of individuals receiving care and support services. The State-USAID APR/APP states that the reason for the shortfall is being evaluated, while CDC's fiscal year 2010 performance report and fiscal year 2012 performance plan states that trend analysis shows constant progress in expanding care with significant increases each year. In addition, CDC reports that PEPFAR exceeded its 2010 targets for number of pregnant women receiving counseling and testing and number of pregnant women receiving antiretrovirals. For the 2010 PEPFAR prevention target reported in the State-USAID APR/APP, the document states that data are not available for the indicator. Further, the document states that, because an infection averted is a nonevent, this estimate needs to be modeled based on surveillance reports and that the estimate of impact through 2010 is expected to be available in 2012 at the earliest. Limited Information Is Available on Efforts to Validate PEPFAR Data and Address Data Limitations: OGAC has not publicly provided, consistent with GPRA practices, information on efforts to verify and validate reported performance data. However, State-USAID's and CDC's annual performance documents cite OGAC efforts to verify and validate some PEPFAR performance data. * OGAC. Although OGAC internal guidance summarizes PEPFAR country teams' and OGAC's roles in verifying and validating reported data, OGAC's two most recent PEPFAR operational plans and annual reports to Congress, covering fiscal years 2009 and 2010, contain no information on these efforts. * USAID. The State-USAID APR/APP states that the results data reported for the two PEPFAR indicators are corroborated with data from other sources. The document also notes that OGAC expects to report the estimated number of HIV infections averted using a U.S. Census Bureau model. * CDC. CDC's fiscal year 2010 performance report and fiscal year 2012 performance plan sources the data it reports to PEPFAR annual program results data, noting that OGAC manages and validates results data at the headquarters level. Moreover, even with the data reliability weaknesses noted by USAID OIG reviews and CDC's treatment program data quality pilot project, OGAC's, USAID's, and CDC's performance reports do not contain information on these weaknesses or on steps taken to address the weaknesses. Credible performance information is essential for accurately assessing agencies' progress toward the achievement of their goals and, in cases where goals are not met, identifying opportunities for improvement or whether goals need to be adjusted. As we have reported previously, without such information, and absent strategies to address identified limitations, Congress and other decision makers cannot assess the validity and reliability of reported performance information.[Footnote 45] Conclusions: PEPFAR's commitment to transparent reporting of program results, clearly stated in its 5-year strategy, is also reflected in OGAC planning, reporting, and indicator guidance to PEPFAR country teams. In addition, OGAC, USAID, and CDC procedures for program performance planning and reporting are intended to help a broad range of stakeholders--including PEPFAR implementing agency headquarters and country team officials, partner country governments, and Congress-- manage and oversee PEPFAR programs and demonstrate the U.S. government's contribution to the global fight against HIV/AIDS. OGAC, USAID, and CDC performance plans and reports serve as key sources of public information on their efforts to monitor PEPFAR program performance. However, OGAC can improve its annual performance planning and reporting. First, by discussing annual results alongside established targets in its annual report to Congress, OGAC would provide important context for understanding PEPFAR's annual achievements and areas needing attention. Second, by providing information on its own and implementing agencies' efforts to ensure the quality of their performance data, OGAC would give decision makers greater insight into the quality and value of the reported performance information. Recommendations for Executive Action: In accordance with requirements and practices set forth in the 2008 Leadership Act and GPRA, and to improve transparency and accountability, we recommend that the Secretary of State direct the U.S. Global AIDS Coordinator to modify the annual report to Congress on PEPFAR performance in the following two ways: (1) include comparisons of annual PEPFAR results with previously established annual targets and: (2) include information on efforts to verify and validate PEPFAR performance data and address data limitations. Agency Comments and Our Evaluation: We provided a draft of this report to State, USAID, and HHS for comment. Responding jointly with HHS and USAID, OGAC provided written comments (see appendix V for a copy of these comments). OGAC agreed with our second recommendation to include in PEPFAR's annual report to Congress information on efforts to verify and validate PEPFAR performance data and address data limitations, and stated that PEPFAR will provide this information in future annual reports and on its Web site. Citing the need to consider various related issues and their consequences in consultation with Congress and other stakeholders, OGAC partially agreed with our first recommendation to include in PEPFAR's annual report to Congress comparisons of annual PEPFAR results with previously established targets, consistent with a 2008 Leadership Act requirement and a key GPRA practice. OGAC's comments suggested that specific action in response to this recommendation would be contingent on the outcome of these discussions. OGAC also provided additional background information on PEPFAR indicators and data validation efforts. Finally, OGAC, in coordination with HHS and USAID, provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the Secretary of State, the Office of the U.S. Global AIDS Coordinator, USAID Office of HIV/AIDS, HHS Office of Global Affairs, CDC Division of Global HIV/AIDS, and appropriate congressional committees. In addition, the report will be available at no charge on GAO's Web site at [hyperlink, http://www.gao.gov]. If you or your staffs have any questions about this report, please contact me at (202) 512-3149 or gootnickd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix VI. Signed by: David Gootnick, Director: International Affairs and Trade: List of Committees: The Honorable John Kerry: Chairman: The Honorable Richard Lugar: Ranking Member: Committee on Foreign Relations: United States Senate: The Honorable Patrick Leahy: Chairman: The Honorable Lindsey Graham Ranking Member: Subcommittee on State, Foreign Operations, and Related Programs: Committee on Appropriations: United States Senate: The Honorable Ileana Ros-Lehtinen: Chairman: The Honorable Howard Berman: Ranking Member: Committee on Foreign Affairs: House of Representatives: The Honorable Kay Granger: Chairwoman: The Honorable Nita Lowey: Ranking Member: Subcommittee on State, Foreign Operations, and Related Programs: Committee on Appropriations: House of Representatives: [End of section] Appendix I Objectives, Scope, and Methodology: In response to directives in the Consolidated Appropriations Act of 2008 and the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (2008 Leadership Act) to review global HIV/AIDS program monitoring,[Footnote 46] this report (1) describes the Office of the U.S. Global AIDS Coordinator's (OGAC), U.S. Agency for International Development's (USAID), and the Centers for Disease Control and Prevention's (CDC) key procedures for planning and reporting on the President's Emergency Plan for AIDS Relief (PEPFAR) program performance and (2) examines published PEPFAR performance plans and reports. To describe OGAC, USAID, and CDC procedures for planning for, and reporting on, PEPFAR program performance, we reviewed PEPFAR and agency-specific guidance documents such as PEPFAR country operational plan guidance for fiscal years 2009 and 2010, Next Generation Indicators guidance,[Footnote 47] and semi-annual and annual program results guidance; USAID's Automated Directives System guidance;[Footnote 48] and CDC's quarterly program measures guidance. We also reviewed documents provided by OGAC, USAID, and CDC to describe their organizational structures and procedures, and we interviewed OGAC and USAID officials in Washington, D.C., as well as CDC officials in Atlanta, Georgia. To categorize USAID Office of Inspector General (OIG) audit report recommendations related to program performance planning and reporting, we identified 24 USAID OIG reports from fiscal years 2008 through 2011 published on USAID's Web site.[Footnote 49] We also interviewed cognizant USAID OIG officials in Washington, D.C., and two regional offices in Africa (Pretoria, South Africa, and Dakar, Senegal) to gain additional information on past and current USAID OIG audit work on PEPFAR. We identified the countries and programs covered by each report and found that the 24 reports covered prevention, treatment, and care programs in 19 PEPFAR countries: Botswana, Cambodia, Côte d'Ivoire (two reports), Dominican Republic, Ethiopia, Ghana, Guyana, Haiti, Kenya (two reports), Mozambique (two reports), Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, Zambia (two reports), and Zimbabwe. In addition, one USAID OIG report reviewed USAID's implementation of PEPFAR's New Partners Initiative. We identified the recommendations in these reports and entered this information into a spreadsheet database. To identify and describe types of performance management-related themes, we utilized the Joint United Nations Programme on HIV/AIDS (UNAIDS) 12 components of a national HIV monitoring and evaluation system as categories. (See app. II for a list of these categories and their definitions.) Two analysts independently assigned each recommendation to not more than two of these categories. The two analysts then met to discuss the results of their analysis; in cases where the analysts' categorizations differed, the analysts discussed and came to agreement on final categories. We determined that 74 recommendations addressed one category, and 56 addressed two of the categories--totaling 130 recommendations. We also determined that 43 recommendations--related, for example, to disposal of expired medications and to requirements for USAID branding and marking--did not fall into any of the categories. Furthermore, three of the 12 categories--national multisectoral monitoring and evaluation plan; annual costed national monitoring and evaluation workplan; and advocacy, communication, and culture for monitoring and evaluation-- were not used to categorize any of the recommendations. To determine the extent to which USAID has taken steps to implement the recommendations, we interviewed cognizant USAID OIG officials in Washington, D.C., to gain understanding of recommendation tracking, and we analyzed data provided by USAID specifying dates for final action, target dates for final action, and target dates for management decisions. To examine published PEPFAR performance plans and reports and the extent to which they adhere to established practices, we identified OGAC's, USAID's, and CDC's most recent publicly available annual performance plans and reports: for OGAC, the PEPFAR annual operational plans and annual reports to Congress for fiscal years 2009 and 2010; [Footnote 50] for USAID, the "Foreign Operations FY 2010 Performance Report, FY 2012 Performance Plan" that it issued with the Department of State as part of their joint congressional budget justification for fiscal year 2012;[Footnote 51] and for CDC, the "Fiscal Year 2012 Justification of Estimates for Appropriation Committees" and "FY 2012 Online Performance Appendix."[Footnote 52] We systematically reviewed these documents using a matrix with a series of questions about key performance management practices, as defined by the 2008 Leadership Act, the Government Performance and Results Act of 1993,[Footnote 53] and previous GAO work. We also interviewed OGAC, USAID, and CDC officials in Washington, D.C., and Atlanta, Georgia, regarding the information contained in these documents and the procedures they followed to produce them. We conducted this performance audit from October 2010 to July 2011 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. [End of section] Appendix II: UNAIDS Components: To identify and describe types of performance management-related themes in our analysis of USAID OIG report recommendations (see app. I), we used as categories 12 components of a national HIV monitoring and evaluation system established by UNAIDS. Table 1 provides a list of these categories and their descriptions. Table 1: UNAIDS's 12 Components of a Functional National HIV/AIDS Monitoring and Evaluation System: Category: 1. Organizational structures with HIV monitoring and evaluation (M&E) functions; Description: Establish and maintain a network of organizations responsible for HIV M&E at the national, subnational, and service delivery levels through (1) effective leadership; (2) a national commitment for system performance; (3) well-defined organizational structure and policies along with defined roles and functions; and (4) routine processes for planning and management and stakeholder coordination for monitoring performance. Category: 2. Human capacity for HIV M&E; Description: Ensure adequate and skilled human resources at all levels of the M&E system to complete all tasks in the annual costed M&E plan by (1) defining skills at national, subnational, and service delivery levels; (2) establishing workforce development plans; (3) establishing a capacity building plan that is costed and measured; and (4) providing for organizational and technical capacity curriculums and training. Category: 3. Partnerships to plan, coordinate, and manage the HIV M&E system; Description: Establish and maintain partnerships among in-country and international stakeholders through (1) technical working groups, and (2) stakeholder coordination, communication, and joint planning. Category: 4. National multisectoral HIV M&E plan; Description: Develop and update the M&E plan with data needs, national standardized indicators, and data collection procedures and tools along with roles and responsibilities through (1) multisectoral participation in the development of the M&E plan; (2) linking the M&E plan to the National Strategic Plan, the 12 Components, and international and national technical M&E standards; and (3) conducting a national M&E assessment leading to recommendations and M&E plan revisions. Category: 5. Annual costed national HIV M&E work plan; Description: Develop an annual costed national M&E work plan with specific and costed M&E stakeholder activities and funding sources for coordinating and tracking the progress of M&E implementation to include (1) activities, implementers, time frames, activity costs and funding resources; (2) links to work plans and budgets of the national AIDS coordinating authority; (3) defining human, physical, and financial resources; (4) stakeholder endorsements of the plan; and (5) revisions to the plan informed by performance monitoring. Category: 6. Advocacy, communications, and culture for HIV M&E; Description: Ensure knowledge of and commitment to HIV M&E and the system among policymakers, program managers and staff, and stakeholders by (1) establishing a national communication strategy and specific HIV communication and advocacy plan; (2) including M&E in the national HIV policies and strategic plans; (3) establishing M&E advocates in high-level government actively endorsing M&E; and (4) developing M&E materials targeting a range of audiences. Category: 7. Routine HIV programme monitoring; Description: Produce timely and high-quality routine program monitoring data by (1) linking data collection strategies with data use; (2) defining data collection and reporting mechanisms, and defining stakeholder collaboration and coordination; (3) establishing databases to capture, verify, analyze, and present program monitoring data and indicators and finances; and (4) defining procedures for data transfer from subnational to national level. Category: 8. Surveys and surveillance; Description: Produce high-quality and timely data from surveys and surveillance by establishing (1) protocols based on international standards; (2) data collection schedules; (3) tracking implementation of HIV surveys linked to stakeholder needs and resources; and (4) biological and behavioral surveillance to include cultural practices. Category: 9. National and subnational HIV databases; Description: Develop and maintain national and subnational HIV databases enabling stakeholders to access data for policymaking and program management by establishing (1) databases that respond to stakeholder reporting and decision-making needs and linking those databases to avoid duplication, and (2) databases to capture, verify, analyze and present data from all program levels. Category: 10. Supportive supervision and data auditing; Description: Periodic monitoring of data quality to address obstacles to the production of high-quality data by (1) establishing guidelines for supervising routine data collection at both facility- and community-based services delivery levels; (2) conducting routine supervision visits with data assessments and feedback for staff; and (3) conducting routine data quality audits and generating supervision and audit reports. Category: 11. HIV evaluation and research; Description: Identify key evaluation research questions, coordinate studies to meet program needs, and foster the use of evaluation and research findings by (1) establishing an inventory of completed and ongoing country-specific evaluation and research studies; (2) establishing a national HIV evaluation and research agenda and develop standards and guidance; and (3) disseminating, discussing, and referencing research and findings. Category: 12. Data dissemination and use; Description: Disseminate and use M&E system data for policy formation and programming, planning, and management by (1) including data use in the national strategic plan and national M&E plan; (2) analyzing data needs of users along with time frames for major and national data collection and reporting requirements and data dissemination schedules; (3) developing reporting formats; and (4) tailoring information products for various audiences and referring to data in proposals and planning documents. Source: UNAIDS and the Monitoring and Evaluation Reference Group, Organizing Framework for a Functional National HIV M&E System (2008), available at [hyperlink, http://www.unaids.org/en/media/unaids/contentassets/documents/document/2 010/15_JC1769_Organizing_Framework_Functional_E.pdf]. [End of table] [End of section] Appendix III: PEPFAR Indicators: According to OGAC's Next Generation Indicators guidance and OGAC officials, PEPFAR country and regional teams are to use 32 essential indicators for annual target setting and regular reporting to OGAC. The guidance distinguishes between direct and national indicators. National indicators are intended to measure the collective achievements of all contributors (i.e., host country government, donors, and civil society) to a program or project, while direct indicators are intended to measure results attributable to PEPFAR alone. Table 2 provides a list of these indicators. Table 2: PEPFAR Indicators Classified as Essential and Reported to OGAC: Prevention: * Number of pregnant women with known HIV status (including women who were tested for HIV and received their results); * Number of HIV-positive pregnant women who received antiretrovirals to reduce risk of mother-to-child transmission; * Percentage of pregnant women who were tested for HIV and know their results (national indicator); * Percentage of HIV-positive pregnant women who received antiretrovirals to reduce the risk of mother-to-child transmission (national indicator); * Number of injecting drug users on opioid substitution therapy; * Number of males circumcised as part of the minimum package of male circumcision for HIV prevention services; * Number of persons provided with post-exposure prophylaxis; * Number of people living with HIV/AIDS reached with a minimum package of prevention with people living with HIV/AIDS interventions; * Number of the targeted population reached with individual and/or small group-level preventive interventions that are based on evidence and/or meet the minimum standards required; * Number of the targeted population reached with individual and/or small group-level preventive interventions that are primarily focused on abstinence and/or being faithful, and are based on evidence and/or meet the minimum standards required; * Number of most-at-risk populations reached with individual and/or small group-level interventions that are based on evidence and/or meet the minimum standards required; * Number of individuals who received testing and counseling services for HIV and received their test results. Care: * Number of eligible adults and children provided with a minimum of one care service; * Number of eligible adults and children provided with a minimum of one care service (national indicator); * Number of HIV-positive adults and children receiving a minimum of one clinical service; * Number of HIV-positive persons receiving cotrimoxazole prophylaxis; * Number of HIV-positive clinically malnourished clients who received therapeutic or supplementary food; * Percentage of infants born to HIV-positive women who received an HIV test within 12 months of birth; * Tuberculosis/HIV: Percentage of HIV-positive patients who were screened for tuberculosis in HIV care or treatment settings; * Tuberculosis/HIV: Percentage of HIV-positive patients in HIV care or treatment (pre-antiretroviral therapy or antiretroviral therapy) who started tuberculosis treatment; * Number of eligible clients who received food and/or other nutrition services. Treatment; * Number of adults and children with advanced HIV infection newly enrolled on antiretroviral therapy; * Number of adults and children with advanced HIV infection receiving antiretroviral therapy; * Percentage of adults and children known to be alive and on treatment 12 months after initiation of antiretroviral therapy; * Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy (national indicator). Health systems strengthening; * Number of testing facilities (laboratories) with capacity to perform clinical laboratory tests; * Percentage of testing facilities (laboratories) that are accredited according to national or international standards; * Number of new health care workers who graduated from a preservice training institution; * Number of community health and parasocial workers who successfully completed a preservice training program; * Number of health care workers who successfully completed an in- service training program; * Number of new health care workers who graduated from a preservice training institution (national indicator); * Monitoring policy reform and development of PEPFAR-supported activities (required for partnership framework countries). Source: GAO synthesis of information from the PEPFAR Next Generation Indicators Reference Guide and other information provided by OGAC. [End of table] [End of section] Appendix IV: PEPFAR Program Performance Results Reported by OGAC, USAID, and CDC for Fiscal Year 2010: OGAC provides information on PEPFAR program results in its annual reports to Congress, which are typically published in February. USAID reports on PEPFAR program results in the "Foreign Operations FY 2010 Performance Report FY 2012 Performance Plan" that it issued with the Department of State as part of their joint congressional budget justification for fiscal year 2012 (State-USAID APR/APP). CDC reports on PEPFAR program results in its "Fiscal Year 2012 Justification of Estimates for Appropriation Committees" and "FY 2012 Online Performance Appendix." The indicators used to report on PEPFAR results are a subset of the 32 essential reported indicators listed in appendix III. Table 3 summarizes PEPFAR results for fiscal year 2010 reported by OGAC, USAID, and CDC in their most recent performance reports. Table 3: PEPFAR Results Reported by OGAC, USAID, and CDC for Fiscal Year 2010: Indicator: Prevention[C]: Number of pregnant women with known HIV status, including women who were tested for HIV and received their results; Target: 8,377,100; Reported by: OGAC: [Empty]; Reported by: USAID[B]: [Empty]; Reported by: CDC: [Check]; Results: 8,385,022; Reported by: OGAC: [Check]; Reported by: USAID[B]: [Empty]; Reported by: CDC: [Check]. Number of HIV-positive pregnant women receiving antiretroviral prophylaxis[D]; Target: 600,000; Reported by: OGAC: [Empty]; Reported by: USAID[B]: [Empty]; Reported by: CDC: [Check]; Results: 602,500; Reported by: OGAC: [Check]; Reported by: USAID[B]: [Empty]; Reported by: CDC: [Check]. Number of individuals who received testing and counseling services for HIV and received their test results from any service delivery point during the past 12 months; Target: None available; Reported by: OGAC: [Empty]; Reported by: USAID[B]: [Empty]; Reported by: CDC: [Empty]; Results: 32,874,600; Reported by: OGAC: [Check]; Reported by: USAID[B]: [Empty]; Reported by: CDC: [Empty]. Indicator: Treatment: Number of individuals receiving antiretroviral treatment[E]; Target: Unclear[F]; Reported by: OGAC: [Empty]; Reported by: USAID[B]: [Check]; Reported by: CDC: [Check]; Results: 3,209,700; Reported by: OGAC: [Check]; Reported by: USAID[B]: [Check]; Reported by: CDC: [Check]. Indicator: Care: Number of individuals, including orphans and vulnerable children, provided with a minimum of one care service in the past 12 months[G]; Target: Unclear[H]; Reported by: OGAC: [Empty]; Reported by: USAID[B]: [Check]; Reported by: CDC: [Check]; Results: 11,362,100; Reported by: OGAC: [Check]; Reported by: USAID[B]: [Check]; Reported by: CDC: [Check]. Source: GAO synthesis of OGAC, USAID, and CDC information. [A] Figures represent direct results. According to the Next Generation Indicators Reference Guide, to count individuals as receiving a direct service, the U.S. government-supported activity can be directly connected to site-specific service delivery. [B] USAID reported rounded numbers. [C] The State-USAID APR/APP also includes the estimated number of HIV infections prevented as a performance indicator and cites a fiscal year 2010 target of 7 million infections averted. The document states that data are not available for this indicator. Further, it states that, because an infection averted is a nonevent, this estimate needs to be modeled based on surveillance reports and that the estimate of impact through 2010 is expected to be available in 2012 at the earliest. [D] According to OGAC's annual report to Congress, the estimated number of infant HIV infections averted in fiscal year 2010 was 114,475. This figure is calculated by multiplying the total number of HIV-positive pregnant women receiving antiretroviral prophylaxis by 19 percent, based on estimated effectiveness of a single-dose nevirapine regimen. Further, this figure is likely an underestimate because many countries are beginning to use more effective drug regimens in accordance with World Health Organization guidelines. Starting in fiscal year 2011, PEPFAR will report on prevention of mother-to-child transmission uptake by regimen, allowing OGAC to develop better estimates of infant infections averted. [E] OGAC's annual report provides disaggregated figures for number of women and children receiving antiretroviral treatment: 2,040,648 and 257,694, respectively. [F] The State-USAID APR/APP cites a target of 2.5 million individuals receiving HIV/AIDS treatment, while CDC's Justification of Estimates for Appropriation Committees and Online Performance Appendix cites a fiscal year 2010 target of 3,183,100 individuals. [G] OGAC's annual report for fiscal year 2010 identifies this as a new indicator. PEPFAR care programs include support, preventative, and clinical services. The reported number of orphans and vulnerable children receiving support is 3,752,200, including all individuals under 18, reported as a subset of the total number of individuals provided with a minimum of one care service. Prior to fiscal year 2010, the number of orphans and vulnerable children served was counted in a separate indicator. The State-USAID APR/APP reports a similar figure, using the following indicator definition: "Number of people receiving HIV/AIDS care and support services, including orphans and vulnerable children." [H] For fiscal year 2010, the State-USAID APR/APP cites a target of 12.4 million individuals receiving care, while CDC's annual performance report cites a target of 11,845,700 individuals. [End of table] [End of section] Appendix V: Comments from the U.S Department of State, Office of the U.S. Global AIDS Coordinator: United Slates Department of State: Chief Financial Officer: Washington, D.C. 20520: July 18, 2011: Ms. Jacquelyn Williams-Bridgers: Managing Director: International Affairs and Trade: Government Accountability Office: 441 G Street, N.W. Washington, D.C. 20548-0001: Dear Ms. Williams-Bridgers: We appreciate the opportunity to review your draft report, "President's Emergency Plan For Aids Relief: Program Planning and Reporting," GAO Job Code 320820. The enclosed Department of State comments are provided for incorporation with this letter as an appendix to the final report. If you have any questions concerning this response, please contact Paul Bouey, Deputy Coordinator, Office of the U.S. Global AIDS Coordinator at (202) 663-2417. Sincerely, Signed by: James L. Millette: cc: GAO – David Gootnick: S/GAC – Eric Goosby: State/OIG – Evelyn Klemstine: [End of letter] Department of State Comments on GAO Draft Report: President's Emergency Plan For Aids Relief: Program Planning and Reporting (GA0-11-785, GAO Code 320820) On behalf of the U.S. Departments of State (DOS), Health and Human Services (HHS), and the U.S. Agency for International Development (USAID), we would like to express our appreciation for the opportunity to comment on the draft report from the Government Accountability Office (GAO) titled, "President's Emergency Plan For AIDS Relief Program Planning and Reporting." We have provided some background information and a response to the recommendations. Background on PEPFAR's Next Generation Indicators Project: A key objective of PEPFAR is to transition to a strategy that increases country ownership of HIV/AIDS efforts to ensure that host countries are at the center of decision-making, leadership, and management of their HIV/AIDS programs. PEPFAR's Next Generation Indicators (NGI) was designed to better align indicators and reporting requirements within the context of the national HIV/AIDS M&E plan of the host country as well as globally. The PEPFAR Next Generation Indicators (NGI) project was launched in January 2008 with a public meeting held in Washington, DC. Approximately 300 individuals participated, representing both USG staff and civil society. Following this meeting, 18 program-specific Indicator Working Groups (IWGs) were created, consisting of USG HQ and field staff and civil society representatives. These groups developed a service delivery framework for their program area and identified a selection of indicators to be considered for required reporting by PEPFAR programs. IWGs worked through existing international programmatic working groups and sought to harmonize indicators between multilateral partners wherever possible. In addition to connecting through these international working groups, the set of core HIV/AIDS UNGASS indicators were used as a starting point for each IWG to consider and incorporate, so that the resulting indicators would be based on and consistent with international measures. In early April 2009, PEPFAR country teams were asked to review and comment on the draft indicator guidance, and provide comments adding to the clarity of existing indicator definitions. A series of calls between HQ and country teams were held to review the draft guidance and allow for the opportunity for questions. Teams were encouraged to engage partner governments in review of the indicators at technical and policy levels of capacity to provide feedback on the level of harmonization, relevance, feasibility, and burden. An indicator mapping tool was provided to teams to facilitate these discussions. To the best of our knowledge, at least 14 countries completed a cross- walk exercise between the PEPFAR NGI and their current national indicator sets. During this period of review, HQ also undertook further steps to discuss the draft indicator set with international and other partners to ensure harmonization. Version 1 of the final guidance was released to the field in July 2009, with Version I.1 following in August with some minor adjustments. It was communicated to the country teams that the guidance document applies to all PEPFAR countries, including countries participating in partnership frameworks, and is consistent with partnership framework guidance. The NGI officially went into effect for the FY2010 planning and reporting cycles. Background on PEPFAR's Data validation: Data validation has been a major focus of PEPFAR, since its inception. Significant resources and effort in-country and from headquarters have been devoted to this issue, initially supporting our implementing partners and moving gradually toward our in-country counterparts. This work has included development of data quality assessment tools, standard operating procedures, technical assistance, capacity building, and increasingly stronger collaboration with Global Fund to harmonize our international and local efforts. Building these capacities in-county drives our current work, and our focus targets our counterparts to develop, support, and assist efforts regarding data quality frameworks and activities within their own countries. Procedures for validation follow a step-wise cascade and involve a number of participants. Data quality is performed at the site of service delivery by implementing partners to confirm data summarized into aggregate figures for each partner and program area. Partners have the responsibility to ensure the quality of their data, and may receive support from data quality experts. Results of these exercises may vary, depending on in-house expertise and commitment to the validation effort. These aggregated partner data are submitted to the supporting USG agency office in-country, and agency representatives evaluate these results against targets and multi-year trends, and in some instances, conduct site audits. One of the key concerns at this stage of review is double-counting, representing the multiple counting of individuals for the same programmatic area, due to the aggregation of data from different sites. This same concern continues at the next stage, when data from different partners are aggregated together by agency, and again when data are aggregated across agencies. Steps are taken to remove this effect, using both calculations based on known program relationships and on occasional data audits. The PEPFAR SI Liaison in-country, representing the Coordinator's office, is responsible for these final steps and for submission of data to Office of the Global AIDS Coordinator (OGAC). In many countries, SI Advisors from headquarters are invited to assist country teams to conduct these reviews and procedures to validate data before submission. Country teams submit performance data and accompanying narratives to OGAC on two occasions per year. These data represent summary results for the relevant required indicators, and accompanying narratives contain programmatic or data documentation descriptions, particularly those constituting problems that might account for anomalous results. The OGAC SI team enters this information into a database, and validation procedures are initiated according to country and to indicator. These results data are examined against targets and against multi-year trends, and against knowledge of program characteristics (e.g., service delivery vs. capacity building). Identified data concerns lead to communications with country teams to more completely explain the problem or to provide the correct information. In the past, some headquarter SI Advisors have contributed to these reviews, but this last year we instituted a more formal process to include all SI Advisors, as well as the SI support persons to the program technical working groups. These changes are a work in progress, but this will increase our abilities to conduct HQ validation and to improve the quality of data reported by PEPFAR. Response to Recommendations for Executive Action: The State Department appreciates these two recommendations by the GAO and understands the rationale underlying them. Regarding the recommendation to include target data in our annual reports to Congress, PEPFAR will consult with Congress and our other stakeholders regarding implementation of this recommendation. There is a variety of issues and consequences to consider moving forward, and we appreciate the GAO for bringing our attention to this detail. State partially agrees with this recommendation, pending these discussions. Regarding the recommendation around data verification and validation, State agrees with this recommendation. PEPFAR will provide information regarding efforts to verify and validate performance data in all future annual reports to Congress. This information will also be posted on the PEPFAR.gov website, www.pepfar.gov. This latter posting will be maintained as an historical reference document, since the actual procedures apply across years and countries, and changes are not expected to be substantial. [End of section] Appendix VI: GAO Contact and Staff Acknowledgments: GAO Contact: David Gootnick, (202) 512-3149 or gootnickd@gao.gov: Staff Acknowledgments: In addition to the contact named above, Audrey Solis (Assistant Director), Todd M. Anderson, David Dornisch, Lorraine Ettaro, Brian Hackney, Fang He, Reid Lowe, Grace Lui, and Reina Nuñez made key contributions to this report. Lisa Helmer and Keesha Egebrecht provided technical assistance. [End of section] Related GAO Products: Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other Health Assistance in Fiscal Years 2001-2008. [hyperlink, http://www.gao.gov/products/GAO-11-64]. Washington, D.C.: October 8, 2010. President's Emergency Plan for AIDS Relief: Efforts to Align Programs with Partner Countries' HIV/AIDS Strategies and Promote Partner Country Ownership. [hyperlink, http://www.gao.gov/products/GAO-10-836]. Washington, D.C.: September 20, 2010. President's Emergency Plan for AIDS Relief: Partner Selection and Oversight Follow Accepted Practices but Would Benefit from Enhanced Planning and Accountability. [hyperlink, http://www.gao.gov/products/GAO-09-666]. Washington, D.C.: July 15, 2009. Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding. [hyperlink, http://www.gao.gov/products/GAO-08-480]. Washington, D.C.: April 2, 2008. Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved Its Documentation of Funding Decisions but Needs Standardized Oversight Expectations and Assessments. [hyperlink, http://www.gao.gov/products/GAO-07-627]. Washington, D.C.: May 7, 2007. Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief. [hyperlink, http://www.gao.gov/products/GAO-06-395]. Washington, D.C.: April 4, 2006. Global Health: The Global Fund to Fight AIDS, TB and Malaria Is Responding to Challenges but Needs Better Information and Documentation for Performance-Based Funding. [hyperlink, http://www.gao.gov/products/GAO-05-639]. Washington, D.C.: June 10, 2005. Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications Provided Under U.S. Emergency Plan is Limited. [hyperlink, http://www.gao.gov/products/GAO-05-133]. Washington, D.C.: January 11, 2005. Global Health: U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain. [hyperlink, http://www.gao.gov/products/GAO-04-784]. Washington, D.C.: June 12, 2004. Global Health: Global Fund to Fight AIDS, TB, and Malaria Has Advanced in Key Areas, but Difficult Challenges Remain. [hyperlink, http://www.gao.gov/products/GAO-03-601]. Washington, D.C.: May 7, 2003. [End of section] Footnotes: [1] Pub. L. No. 110-293, 122 Stat. 2918. [2] Specifically, the 2008 Leadership Act specifies that PEPFAR's 5- year strategy should provide a plan to prevent 12 million new HIV infections worldwide; support the increase in the number of individuals receiving antiretroviral treatment above 2 million; support care for 12 million individuals infected with or affected by HIV/AIDS, including 5 million orphans and vulnerable children; help partner countries in the effort to achieve 80 percent access to counseling, testing, and treatment to prevent the transmission of HIV from mother to child; and help partner countries to train and retain at least 140,000 new health care professionals and paraprofessionals. See Pub. L. No. 110-293, § 101(a). [3] OGAC was established at the Department of State in response to the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, Pub. L. No. 108-25, 117 Stat. 711. In addition to receiving allocations through OGAC, USAID and CDC receive direct appropriations to support global HIV/AIDS and other global health programs, such as tuberculosis, malaria, and support for maternal and child health. Other PEPFAR implementing agencies include the departments of State, Defense, Labor, and Commerce and the Peace Corps. Additional HHS offices and agencies receiving PEPFAR resources include the Office of Global Affairs, the Food and Drug Administration, the Health Resources and Services Administration, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration. [4] Pub. L. No. 110-161, § 668(d), 121 Stat. 1844, 2353 (2007); Pub. L. No. 110-293, § 101(d). The Consolidated Appropriations Act directed GAO to review PEPFAR "results monitoring activities," among other things. The 2008 Leadership Act directed GAO to provide a report including "a description and assessment of the monitoring and evaluation practices and policies in place" for U.S. bilateral global HIV/AIDS programs, among other things. In response to these directives, we also are currently conducting a review of PEPFAR evaluation activities. A list of related products, including past work conducted in response to these congressional mandates, is provided at the end of this report. [5] Pub. L. No. 110-293, § 101(a). [6] The 5-year PEPFAR strategy lists the following goals: (1) transition from an emergency response to promotion of sustainable country programs; (2) strengthen partner government capacity to lead the response to this epidemic and other health demands; (3) expand prevention, treatment, and care in both concentrated and generalized epidemics; (4) integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems; and (5) invest in innovation and operations research to evaluate impact, improve service delivery, and maximize outcomes. [7] This report refers to annual goals as "annual targets." [8] Pub L. No. 110-293, § 301(e). [9] Pub. L. No. 103-62, 107 Stat. 285. The Government Performance and Results Act Modernization Act of 2010 amends the Government Performance and Results Act of 1993. Pub. L. No. 111-352, 124 Stat. 3866 (2011). [10] Current Office of Management and Budget guidance calls for agencies to prepare a performance budget that fully integrates the annual performance plan required by GPRA with other elements of the agency budget request. See Office of Management and Budget circulars A- 11 and A-136. [11] Current Office of Management and Budget guidance permits agencies to combine the annual performance report required by GPRA with their financial statement and accountability report into a Performance and Accountability Report. See Office of Management and Budget circulars A- 11 and A-136. [12] For more information, see GAO, Results-Oriented Government: GPRA Has Established a Solid Foundation for Achieving Greater Results, [hyperlink, http://www.gao.gov/products/GAO-04-38] (Washington, D.C.: Mar. 10, 2004). [13] Office of the U.S. Global AIDS Coordinator, "The President's Emergency Plan for AIDS Relief, Next Generation Indicators Reference Guide: Planning and Reporting, Version 1.1" (August 2009), available at [hyperlink, http://www.pepfar.gov/guidance/c21628.htm]. The guidance went into effect for the fiscal year 2010 planning and reporting cycle and will stay relevant until a new version is published. [14] The Next Generation Indicators guidance distinguishes between direct and national indicators, as well as output, outcome, and impact indicators. National indicators are intended to measure the collective achievements of all contributors (i.e., host country governments, donors, and civil society) to a program or project, while direct indicators are intended to measure results attributable to PEPFAR alone. The guidance defines outputs as results of program activities, outcomes as effects of program activities on target populations, and impacts as long-range, cumulative effects of programs. [15] In addition, the list of essential/not reported indicators includes disaggregated (e.g., by sex or age) definitions of other essential indicators. The guidance further notes that OGAC obtains these data through other sources (e.g., UNAIDS, demographic health surveys, and behavioral surveillance surveys) and uses the information for decision-making purposes. [16] The Next Generation Indicators guidance also states that most of the essential indicators are based on internationally harmonized indicators that are required for global reporting by international organizations such as UNAIDS and the Global Fund. Indicators not internationally harmonized are either required in PEPFAR legislation or are necessary to track an emergent or high-priority program (e.g., health systems strengthening or male circumcision). [17] The office coordinates the work of three interagency technical working groups on health management information systems, monitoring and evaluation, and surveys and surveillance. The health management information systems group is responsible for the flow and management of data from individual programs to national and headquarters data systems. The monitoring and evaluation group supports the generation of quality data for analysis. The surveys and surveillance team supports systematic data collection and analysis on national populations, service populations, risk populations, and service delivery locations, among others. [18] According to a May 2011 cable, as part of a broader streamlining effort, State and USAID plan to work with OGAC to establish a plan to integrate PEPFAR planning and reporting processes into State and USAID foreign assistance planning and reporting processes in time for State's and USAID's fiscal year 2014 Operational Plan. [19] The following 31 countries were to complete a country operational plan for fiscal year 2010: Angola, Botswana, Cambodia, China, Côte d'Ivoire, Democratic Republic of the Congo, Dominican Republic, Ethiopia, Ghana, Guyana, Haiti, India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Russia, Rwanda, South Africa, Sudan, Swaziland, Tanzania, Thailand, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe. Three regions also were to complete operational plans: Caribbean, Central America, and Central Asia. For fiscal year 2011, two additional countries, Cameroon and Burundi, were to submit operational plans to OGAC. [20] PEPFAR country and regional operational plans document U.S. investments in, and anticipated results of, U.S.-funded programs to combat HIV/AIDS. They serve as the basis for allocating and approving annual U.S. bilateral HIV/AIDS funding and notifying Congress. Some countries receiving U.S. HIV/AIDS assistance do not submit a PEPFAR operational plan; for these countries, OGAC reviews and approves HIV/ AIDS-related foreign assistance funding through foreign assistance operational plans. See [hyperlink, http://www.pepfar.gov/countries/cop/]. [21] According to OGAC officials, OGAC currently permits PEPFAR teams to reprogram funds once a year, typically in May or June. (In the past, PEPFAR teams submitted updates several times a year.) These updates can result in changes to targets for the fiscal year, which are then considered final. [22] PEPFAR teams submit these data to OGAC as "Semi-Annual Program Results" and "Annual Program Results." [23] According to OGAC guidance on reporting program results, the narrative for each indicator should include a description of accomplishments and challenges related to data quality and the national monitoring and evaluation system. The guidance further states that PEPFAR country or regional teams are responsible for ensuring data quality and provides guiding questions to assist teams in identifying possible data quality issues. According to a 2009 OGAC review of PEPFAR strategic information, the development and implementation of data quality assessment tools--including monitoring and evaluation systems strengthening, data quality audits, and routine data quality assessment tools--has enabled PEPFAR implementers to identify and correct issues related to data quality and, as such, has improved reporting. PEPFAR's data quality assessment tools can be found online at [hyperlink, http://www.pepfar.gov/implementer_resources/data_quality/index.htm]. [24] USAID's Office of HIV/AIDS is part of the Bureau for Global Health. [25] USAID's oversight of implementing partners includes establishing objectives and indicators, approving work and monitoring and evaluation plans, and conducting site visits, among other things. In 2009 we reported on PEPFAR implementing partner selection and oversight. For more information, see GAO, President's Emergency Plan for AIDS Relief: Partner Selection and Oversight Follow Accepted Practices but Would Benefit from Enhanced Planning and Accountability, [hyperlink, http://www.gao.gov/products/GAO-09-666] (Washington, D.C.: July 15, 2009). [26] The Office of HIV/AIDS's other two divisions are the Supply Chain Management System Division and the Technical Leadership and Research Division. [27] In 2006, to help align foreign assistance programs with the transformational diplomacy goal, State's Office of the Director of U.S. Foreign Assistance developed a framework for U.S. foreign assistance. The framework outlines five strategic objectives--Peace and Security, Governing Justly and Democratically, Investing in People, Economic Growth, and Humanitarian Assistance--and ties each objective to various category-country types, in an effort to move recipient countries to the next level. (See [hyperlink, http://www.state.gov/f/planning] and [hyperlink, http://www.usaid.gov/policy/ads/200/200.pdf].) The global HIV/AIDS program falls under the Investing in People objective. [28] State and USAID use several planning and budget documents in the consolidated planning and budget processes for State and USAID foreign assistance. According to a May 2011 cable, State's Deputy Secretary for Management and Resources and the USAID Administrator approved and directed the implementation of the State/USAID Streamlining Project, which seeks to improve the efficiency and effectiveness of foreign assistance planning and reporting by, among other things, creating a unified planning and reporting cycle, integrating PEPFAR, improving performance indicators, and designating a common information technology system. For more information on State and USAID consolidated planning and budget processes, see GAO, Foreign Aid Reform: Comprehensive Strategy, Interagency Coordination, and Operational Improvements Would Bolster Current Efforts, [hyperlink, http://www.gao.gov/products/GAO-09-192] (Washington, D.C.: Apr. 17, 2009). [29] See Automated Directives System Chapter 203, [hyperlink, http://www.usaid.gov/policy/ads/200/203.pdf]. [30] We identified 24 USAID OIG reports from fiscal year 2008 through 2011 on PEPFAR prevention, treatment, and care programs in 19 countries. See appendix I for more information. [31] We also identified 43 other report recommendations that did not fall into any of the 12 categories used to characterize HIV/AIDS program monitoring and evaluation. Examples of these recommendations include issues related to disposal of expired medications and USAID branding and marking requirements. [32] For additional information on the method we used to analyze USAID OIG report recommendations, as well as component definitions, see appendixes I and II. Also see UNAIDS, Organizing Framework for a Functional National HIV Monitoring and Evaluation System (UNAIDS: Geneva, April 2008), available at [hyperlink, http://data.unaids.org/pub/BaseDocument/2008/20090305_organizingframewor kforhivmesystem_en.pdf]. [33] According to USAID OIG officials, after reaching agreement on a report recommendation (i.e., "management decision"), USAID has 1 year to implement the recommendation. Once the USAID OIG determines that the actions taken by the agency are acceptable, then USAID's Chief Financial Officer is responsible for assigning a "final action" date. [34] CDC's Division of Global HIV/AIDS is part of the Center for Global Health. [35] DGHA leadership consists of the Offices of the Director, Management and Operations, Regional/Country Management, Science, and Policy/Communications. DGHA's technical branches are international laboratory; HIV prevention; HIV care and treatment; maternal and child health; epidemiology and strategic information; and health economics, systems, and integration. DGHA's two operational branches are country operations and program budget and extramural management. [36] CDC implementing partner performance monitoring includes pre-and postaward processes such as identification and approval of program objectives, activities, and work plans; reviewing award applications; and reviewing standard CDC reporting requirements and continuation applications. In 2009 we reported on PEPFAR implementing partner selection and oversight. See [hyperlink, http://www.gao.gov/products/GAO-09-666]. [37] Office of the U.S. Global AIDS Coordinator, "The U.S. President's Emergency Plan for AIDS Relief (PEPFAR): Fiscal Year 2009 Operational Plan," (November 2010), available at [hyperlink, http://www.pepfar.gov/about/c30152.htm]. Office of the U.S. Global AIDS Coordinator, "The U.S. President's Emergency Plan for AIDS Relief (PEPFAR): Fiscal Year 2010 PEPFAR Operational Plan" (April 2011), available at [hyperlink, http://www.pepfar.gov/about/c19388.htm/]. [38] Office of the U.S. Global AIDS Coordinator, "United States President's Emergency Plan for AIDS Relief: Seventh Annual Report to Congress" (June 2011), available at [hyperlink, http://www.pepfar.gov/press/seventhannualreport/]. [39] Office of the U.S. Global AIDS Coordinator, "The U.S. President's Emergency Plan for AIDS Relief: 2009 Annual Report to Congress on PEPFAR Program Results" (March 2010), available at [hyperlink, http://www.pepfar.gov/press/sixth_annual_report/index.htm]. [40] Department of State, "Foreign Operations FY 2010 Performance Report, FY 2012 Performance Plan," Congressional Budget Justification, Volume 2: Foreign Operations, Fiscal Year 2012 (March 2011), available at [hyperlink, http://www.state.gov/f/releases/iab/fy2012cbj/pdf/index.htm]. [41] Department of Health and Human Services, Centers for Disease Control and Prevention, "Fiscal Year 2012 Justification of Estimates for Appropriation Committees" and "FY 2012 Online Performance Appendix," available at [hyperlink, http://www.hhs.gov/about/hhsbudget.html#OperatingDivisions:Congressional BudgetJustificationsandOnlinePerformanceAppendices]. HHS's justifications of estimates for appropriation committees and online performance appendixes, together with its annual "Financial Report and Summary of Performance and Information," fulfill HHS's performance planning and reporting requirements, in accordance with Office of Management and Budget circulars A-11 and A-136. [42] Pub. L. No. 110-293, § 301(e)(2)(B). [43] Pub. L. No. 103-62, § 4(b). The Government Performance and Results Act Modernization Act of 2010 amends the Government Performance and Results Act of 1993. Pub. L. No. 111-352. [44] For the treatment and care indicators reported in both the State- USAID and CDC performance documents, the PEPFAR annual targets differ. For individuals receiving care and support services, the State-USAID APR/APP cites a 2010 PEPFAR target of 12.4 million individuals, while CDC's fiscal year 2010 performance report and fiscal year 2012 performance plan cite a target of 11.8 million. Likewise, for individuals receiving HIV/AIDS treatment, the State-USAID document cites a PEPFAR 2010 treatment target of 2.5 million, while the CDC document cites a target of 3.2 million. [45] See [hyperlink, http://www.gao.gov/products/GAO-04-38]. [46] Pub. L. No. 110-161, § 668(d), 121 Stat. 1844, 2353 (2007); Pub. L. No. 110-293, § 101(d), 122 Stat. 2918, 2931. [47] Office of the U.S. Global AIDS Coordinator, "The President's Emergency Plan for AIDS Relief, Next Generation Indicators Reference Guide: Planning and Reporting, Version 1.1" (August 2009), available at [hyperlink, http://www.pepfar.gov/guidance/c21628.htm]. [48] USAID policy directives and required procedures, as well as other, optional material, are drafted, cleared, and issued through USAID's Automated Directives System. Agency employees must adhere to these policy directives and required procedures. See [hyperlink, http://www.usaid.gov/policy/ads/]. [49] We also identified three reports that summarized findings and recommendations from previous reports. We excluded these three reports from our analysis to avoid duplication of recommendations covered in the other 24 reports. See [hyperlink, http://www.usaid.gov/oig/public/reports/hiv- aids_information_audit_and_specialrptsmemos.html]. [50] Office of the U.S. Global AIDS Coordinator, "Fiscal Year 2009 Operational Plan," " Fiscal Year 2010 PEPFAR Operational Plan," "Seventh Annual Report to Congress," and "2009 Annual Report to Congress on PEPFAR Program Results." [51] Department of State, "Foreign Operations FY 2010 Performance Report FY 2012 Performance Plan." [52] Department of Health and Human Services, Centers for Disease Control and Prevention, "Fiscal Year 2012 Justification of Estimates for Appropriation Committees" and "FY 2012 Online Performance Appendix." [53] Pub. L. No. 103-62, 107 Stat. 285. The Government Performance and Results Act Modernization Act of 2010 amends the Government Performance and Results Act of 1993. Pub. L. No. 111-352, 124 Stat. 3866 (2011). 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