In early December, the US President's Emergency Plan for AIDS Relief—better known as PEPFAR—released a new strategy that prioritizes HIV prevention, partnerships with national governments and operations research. The five-year strategy represents a major shift from PEPFAR's initial goal of getting millions of people on antiretroviral treatment.

Research has been a component of PEPFAR since its inception, but it was previously “neglected,” said US Global AIDS Coordinator Eric Goosby at a Kaiser Family Foundation town hall meeting on 4 December. Now, he says, it's a “high priority.” Exactly how much money will be available for research and how those funds will be distributed is not yet clear.

In the town hall session, Goosby emphasized that operations research, which is used to assess the effectiveness or impact of programs, needs to play a larger part. Operations research, the strategy points out, does not include clinical or basic research. It is also distinct from monitoring and evaluation. “With operations research, you're making a comparative evaluation rather than just charting trends,” says Willard Cates, president of research at Family Health International, a public health and development organization that receives PEPFAR funds.

These comparative assessments will be especially important in the arena of prevention, says Nandini Oomman, an HIV expert at the Center for Global Development, an independent think tank in Washington, DC, that aims to reduce global poverty. Prevention strategies exist, she says, but “we haven't done the good research job of trying to understand how these can be offered in different combinations to maximize prevention efforts and to bring them to scale.”

For the past two years, PEPFAR has dedicated $40 million a year to operations research out of its annual $6.6 billion budget. In 2008, PEPFAR decided to revise its operations research program to improve quality and coordination and to eliminate redundancies. That revision is ongoing. In the coming years, PEPFAR will encourage studies that involve multiple countries and coordinated methodologies.

According to Ronald Gray, an epidemiologist at Johns Hopkins University in Baltimore who works in Uganda, the program is in need of revision. Last year, he and his colleagues received PEPFAR funding through the Atlanta-based US Centers for Disease Control and Prevention (CDC) to look at male circumcision as an HIV prevention strategy. The long-distance micromanagement was such a “bureaucratic nightmare” that Gray and his colleagues ultimately decided to return the money.

The new emphasis on research “is a step forward,” Gray says. But, he warns, “if this is going to be managed from Atlanta... then it's going to be a very bureaucratic process and possibly dysfunctional.”

Not all of PEPFAR's research funds are distributed by the CDC; the US National Institutes of Health received $4.9 million from the PEPFAR office last year. That money went to support, among other research, a study that looked at two ways of managing HIV infection—viral load testing versus the current standard of care, CD4 testing and clinical evaluation.

Part of the new commitment to research will entail making more PEPFAR data publicly available so that researchers can mine it. How and when that data will be accessible is still up in the air. The new strategy does not contain any information about how the new priorities will be implemented.

PEPFAR's new strategy also emphasizes coordination with national governments. PEPFAR programs must be “country owned and country driven,” Goosby said at the 4 December meeting. He emphasized that national governments take a leadership role in responding to the epidemic. Given that government corruption is a problem in many PEPFAR countries, careful accounting will be important, says Cates.

Overall, the new strategy is a good first step, Oomman says. “This is a major shift in the direction that many of us were calling for.” But it remains to be seen whether the priorities outlined in the strategy will be implemented. “The proof of the pudding,” says Cates, “is over the next several years.”