Introduction: Locally led and owned development is considered the best practice for international aid. As an implementing agency for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. Agency for International Development (USAID) supported the goal of transitioning 70% of its portfolio funding directly to local organizations by 2020, including part-ner country governments. However, limited evidence or evalua-tion exists on how such a transition can help achieve HIV-related health outcomes.Methods: We evaluated monitoring, evaluation, and reporting performance; calculated indicators; and quality of service across the HIV/AIDS treatment cascade for local and international part-ners in the USAID/PEPFAR portfolio implementing similar pro-grams during the U.S. Government fiscal years (FY) 2019 to 2020 (October 1, 2018-September 30, 2020). We compared results aggregated globally, by country, and across individual partners.Results: Globally, local partners met a lower proportion of their treatment targets than international partners and did not meet targets for pre-exposure prophylaxis or voluntary medical male circumcision in FY2020. However, local partners exceeded tar-gets in programs supporting orphans, vulnerable children, and key populations affected by HIV/AIDS. Local partners also had testing positivity, linkage rates, and viral load suppression that were equivalent to or higher than that of international partners. Based on available assessments, local partners displayed quality of service delivery comparable to international partners.Conclusion: Local partners faced challenges, including unfamil-iarity with USAID funding, increasing targets across several indi-cators, and the syndemics of HIV/AIDS and COVID-19. A higher percentage of targets and funding led South African local part-ners to yield an outsized effect on global percent target achieve-ment. While these findings should be interpreted cautiously due to limited sample size and short time horizon, they are a key first step in evaluating the local partner transition support of the long-term goal of sustained epidemic control of HIV/AIDS.

We discuss 5 key factors that have facilitated efforts to transition the majority of the USAID HIV/AIDS portfolio to direct funding through local organizations, including partner country governments. Key Messages Strengthening local systems through direct partnerships with local organizations and partner governments is a critical pathway to locally led development and achieving sustained epidemic control of HIV/AIDS. The U.S. Agency for International Development (USAID) has made substantial progress toward the U.S. President’s Emergency Plan for AIDS Relief goal of funding 70% of its portfolio directly through local organizations, including partner country governments. Five key factors that facilitated localization of the HIV/AIDS portfolio include: (1) developing strategic and intentional plans grounded in local reality; (2) customizing data systems to monitor progress toward goals and adapting them as needed; (3) investing in strengthening local partner organization and financial management capacity; (4) changing the way USAID does business; and (5) ensuring consistent USAID and local leadership and advocacy. Efforts in the first part of the HIV local partner transition have focused on reducing barriers on the USAID side; over the next 3 years, the HIV programs will need to focus on reducing barriers on the local partner side.

This paper aims to describe and analyse progress with domestic HIV-related policies in PEPFAR partner countries, utilising data collected as part of PEPFAR's routine annual program reporting from U.S. government fiscal years 2010 through 2016. 402 policies were monitored for one or more years across more than 50 countries using the PEPFAR policy tracking tool across five policy process stages: 1. Problem identification, 2. Policy development, 3. Policy endorsement, 4. Policy implementation, and 5. Policy evaluation. This included 219 policies that were adopted and implemented by partner governments, many in Africa. Policies were tracked across a wide variety of subject matter areas, with HIV Testing and Treatment being the most common. Our review also illustrates challenges with policy reform using varied, national examples. Challenges include the length of time (often years) it may take to reform policies, local customs that may differ from policy goals, and insufficient public funding for policy implementation. Limitations included incomplete data, variability in the amount of data provided due to partial reliance on open-ended text boxes, and data that reflect the viewpoints of submitting PEPFAR country teams.

The Accelerating Children's HIV/AIDS Treatment (ACT) Initiative was an ambitious joint donor initiative to increase the number of HIV-positive children and adolescents on treatment over a 2-year period from 2014 to 2016. The funding was provided by the US Government's President's Emergency Plan for AIDS Relief (PEPFAR) and the private Children's Investment Fund Foundation (CIFF). Great gains were achieved across the 9 ACT focus countries in pediatric treatment coverage. This article assesses the status of sustainability in the ACT countries after the pediatric treatment surge using PEPFAR sustainability data and a CIFF independent evaluation of sustainability. Although a focus on treatment is critical for pediatric HIV and HIV broadly, there is also a need to support the host country ability to maintain the progress gained once donor funds and initiatives transition. It uses the case of the ACT Initiative to argue that although surge activities are successful in rapidly scaling treatment results, there are concerns related to the health system's ability to maintain the progress along the full cascade. It shares important lessons for planning for and management of transition to support future donor efforts in pediatric HIV, overall HIV programming, and broader global health initiatives.

The Accelerating Children's HIV/AIDS Treatment (ACT) Initiative was an ambitious joint donor initiative to increase the number of HIV-positive children and adolescents on treatment over a 2-year period from 2014 to 2016. The funding was provided by the US Government's President's Emergency Plan for AIDS Relief (PEPFAR) and the private Children's Investment Fund Foundation (CIFF). Great gains were achieved across the 9 ACT focus countries in pediatric treatment coverage. This article assesses the status of sustainability in the ACT countries after the pediatric treatment surge using PEPFAR sustainability data and a CIFF independent evaluation of sustainability. Although a focus on treatment is critical for pediatric HIV and HIV broadly, there is also a need to support the host country ability to maintain the progress gained once donor funds and initiatives transition. It uses the case of the ACT Initiative to argue that although surge activities are successful in rapidly scaling treatment results, there are concerns related to the health system's ability to maintain the progress along the full cascade. It shares important lessons for planning for and management of transition to support future donor efforts in pediatric HIV, overall HIV programming, and broader global health initiatives.

To maintain high circumcision prevalence, voluntary medical male circumcision programs in Eastern and Southern Africa need to plan for sustainability and conduct transition assessments early on, rather than waiting until the saturation of priority targets at the end of the program.