Sustaining sexual health programs: practical considerations and lessons from the President’s Emergency Plan for AIDS Relief

PEPFAR, the President’s Emergency Plan for AIDS Relief, is the world’s largest sexual health program.¹ Since the program was launched in 2003, PEPFAR has provided US$90 billion in support for comprehensive HIV services in over 50 countries. PEPFAR has previously experienced authorisation lapses, underlining the importance of sustainability in sexual health programs. What can we do to sustain sexual health programs over time? Moore et al. defined sustainability as some part of an implementation strategy or program enduring for a period of time, along with a continued benefit to the patient and health system.² This Editorial builds on this by considering the drivers of sustainability of sexual health programs, introducing barriers to some of these drivers, and highlighting lessons from PEPFAR. We focus on PEPFAR because it has endured over two decades and may provide some illustrations of key factors to consider in planning for sustainability.

Understanding the sustainability of sexual health programs is important for several reasons.³ First, stopping programs known to be effective in the face of persistent public health needs can lead to a resurgence in disease. Second, substantial initial costs (financial, social, and human personnel) are often associated with launching new sexual health programs that make stopping interventions inefficient. Third, the closure of effective sexual health programs could dampen community interest in the topic. These issues are also relevant to re-launched programs because of the loss in momentum. Building on a working group organised by the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA), this commentary leverages data and examples from PEPFAR. This commentary proposes four distinct but interconnected ideas that researchers can use to increase the sustainability of sexual health programs (Fig. 1).

Fig. 1.

Overview of ideas to increase the likelihood of sustaining implementation strategies. Return on Investment.

Early planning during the design of a sexual health program is important for sustainability because it provides an opportunity for the team to build factors relevant to sustainability into the strategy itself from the onset. A systematic review of sustainability studies found that early planning during the design and adoption phases increased the likelihood of sustainability.⁴ Early planning for sustainability requires an operational definition of sustainability, metrics, and strategies that can be institutionalised or otherwise embedded in community practice.³ Potential barriers to early planning include uncertainty about the effectiveness of the strategy, lack of understanding related to implementation, and limited stakeholder interest in early-stage ideas. Sustainability requires consideration of which strategies are intended as a temporary service and which should be continued over a longer time. Implementation research can provide preliminary data on effectiveness and implementation. From PEPFAR’s inception in 2003, the program was designed with a clear strategic vision on the global HIV epidemic.⁵ This paved the way for sustaining the program over the past two decades.

Equitable community engagement is a second critical factor for ensuring the sustainability of sexual health programs. We define equitable community engagement as cultivating a diverse network of communities of who are interested in the health topic and may be affected by the health outcome. Equitable community engagement can expand public partnerships for institutionalisation, identify allies for implementation, and strengthen relationships between beneficiaries and researchers. Several studies have suggested that locally relevant community engagement enhances sustainability.^6–8 Meaningful, enduring community engagement increases local ownership and collective self-efficacy.⁹ This sense of community ownership may facilitate adaptations in response to community needs. Potential barriers to equitable community engagement include lack of funding to ensure robust community participation, low research literacy among some community members, and entrenched inequities. At the same time, there are innovative methods for community engagement (e.g. co-creation, crowdsourcing)^10,11 that require fewer resources and do not require extensive community literacy. PEPFAR invests in community-based organisations, trains local health workers, and supports youth programs.⁵ Several tools exist for measuring community engagement in the context of sustainability (Table 1).

Considering the return on investment is another important dimension of sustainability. Return on investment measures the profitability of a program. Few sexual health programs generate revenue. Research studies evaluating sexual health programs often depend entirely on monetary support from a research grant for continuation. Sexual health researchers may not be interested in or know how to develop ways to finance a sexual health program. There may be limited data to prioritise funding decisions or limited political will to allocate more funds. Deepening relationships with the public sector, identifying alternative sources of revenue, cross-subsidisation, and innovative financing (i.e. giving a gift of free services and asking for donations to support subsequent people;¹⁵ crowdfunding¹⁶) could help to increase the likelihood of sustainability.¹⁷ Several social entrepreneurship programs have been used to increase the sustainability of sexual health programs.¹⁸ Potential barriers to considering the return on investment include lack of understanding financial aspects of an implementation strategy. Mapping promising existing funding mechanisms may be a helpful starting point for researchers and an opportunity to understand potential local solutions (e.g. microfinancing, leveraging community assets). PEPFAR’s clear demonstration of return on investment has been important in sustaining the program over time.⁵ Financing for sustainability can be measured in several ways (Table 1).

Building partnerships outside of health is also important for sustainability.¹⁹ Health strategies are often dependent on the social, educational, and economic capacity for continued implementation. Creation of a shared goal between potential partners may be one opportunity for enhancing sustainability by clarifying the mutually beneficial outcomes of a program. In addition, intentionally planning and building a platform for continued communication between partners may be helpful, with a focus on mutual accountability and transparency. For example, PEPFAR has developed partnerships with a diverse range of communities, including governments, private sector companies, faith-based organisations, and civil society groups.²⁰ Potential barriers to partnerships outside of health are implementation silos in many jurisdictions, health goals that do not recognise the social determinants of health, and health-focused financing structures. These barriers can be reduced by using a social innovation approach²¹ that decreases silos, uses sustainable development goals, and considers the social impact of health interventions.

Examining how PEPFAR and other sexual health programs have been sustained during periods of uncertainty may also be useful. For example, during COVID-19, many sexual health programs were temporarily stopped. However, early planning in PEPFAR-supported countries ensured that programs were sustained during this period. HIV self-testing, multi-month dispensing of ART, and enhanced patient tracking were used to sustain essential HIV services.²² More recently, political threats related to reproductive health services stalled the reauthorisation of PEPFAR.²³ In response, the creation of a Bureau of Global Health Security and Diplomacy by the Biden administration further reinforced PEPFAR’s role in global health security, integrating it more deeply in US foreign policy and consolidating efforts for sustainability.²³

Sustainability needs to be considered in the local context and may be particularly important in resource-limited settings where there are fewer means to support new strategies and less existing infrastructure.²⁴ This underscores the importance of considering sustainability in sexual health programs. More formal consideration of sustainability within implementation research can help to increase the likelihood of sustainability.