A requirement of the act which established PEPFAR was that the Institute of Medicine (IOM) provide Congress with an evaluation of the initiative’s progress three years after the passage of the Leadership Act. In response, the IOM Committee for the Evaluation of PEPFAR Implementation examined the initiative, including visits to most of the fifteen PEPFAR focus countries.

Overall, the Committee concludes that PEPFAR has made a promising start, but it warns that there is an enduring need for U.S. leadership in the effort to respond to the HIV/AIDS pandemic. To that end, the Committee has made a number of recommendations, including the following:

• A transition from its focus on emergency relief to an emphasis on long-term strategic planning and capacity building for a sustainable response.
• Addressing the long term factors that underlie the epidemics in each country including:
  • Emphasizing and enhancing prevention with accumulation of better data to determine the most appropriate interventions needed in the countries.
  • Empowering women and girls by increasing focus on the factors that put them at greater risk of HIV/AIDS, and to support improvements in their legal, economic, educational, and social status.
  • Building workforce capacity by increasing its support and including the education of new health care workers in addition to AIDS-related training for existing health care workers.
  • Expanding the knowledge base by emphasizing evidence-based approaches, learning from experience, and adaptation to new developments; as well as conducting operations research and robust program monitoring and evaluation.
• Improving Harmonization by improving coordination with partner governments and other donors and supporting the WHO Prequalification Process for medications obtained through PEPFAR.  In addition, the Committee recommends that Congress remove the budgetary allocations but replace them with alternative mechanisms for accountability to ensure results and to permit Country Teams the maximum flexibility to achieve the 5-year performance targets for supporting prevention of 7 million infection, providing antiretroviral therapy to 2 million people, and care for 10 million people affected by HIV/AIDS including orphans and vulnerable children.
• Expanding, improving, and integrating prevention, treatment, care, and orphan and vulnerable children services; and increasing attention to marginalized populations including commercial sex workers, people who use injecting drugs, prisoner, and men who have sex with men.