3
New Routes of Engagement Against Global HIV/AIDS

Much has been written about the early meager response to global HIV/ AIDS on the part of governments, donor countries, and multinational institutions. The words of one medical author typify the feelings of many:

Governments of severely affected nations have failed to provide leadership and national resources for HIV/AIDS prevention and care; donor countries have failed to increase levels of spending as the pandemic has escalated; and multinational lending and aid institutions have responded with bureaucratic lethargy and loans instead of grants. Moreover, the well-documented debate among public health experts on the relative merits and shortcomings of prevention versus [antiretroviral] management likely served to obfuscate priorities in donor and recipient governments. An additional source of consternation has been the exorbitant prices of [antiretroviral] medications for African countries (Anabwani and Navario, 2005:96–97).

In actuality, the last 3 years has witnessed dramatic breakthroughs in global HIV/AIDS assistance and control efforts: a sharp drop in the price of antiretroviral drugs, simplified drug delivery, greater political commitment among leaders in donor and recipient governments, greater involvement of the private sector, and major international initiatives. Total global spending on HIV/AIDS in low- and middle-income countries increased 500 percent between 1996 and 2003, reaching $4.7 billion in 2004 (UNAIDS, 2003), with 56 percent of this total going to Africa (IRINnews, 2004). On January 25, 2005, the U.S. Food and Drug Administration announced the tentative approval of the first generic, copackaged antiretroviral drug regimen (lamivudine/zidovudine and nevirapine, manufactured by Aspen



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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS 3 New Routes of Engagement Against Global HIV/AIDS Much has been written about the early meager response to global HIV/ AIDS on the part of governments, donor countries, and multinational institutions. The words of one medical author typify the feelings of many: Governments of severely affected nations have failed to provide leadership and national resources for HIV/AIDS prevention and care; donor countries have failed to increase levels of spending as the pandemic has escalated; and multinational lending and aid institutions have responded with bureaucratic lethargy and loans instead of grants. Moreover, the well-documented debate among public health experts on the relative merits and shortcomings of prevention versus [antiretroviral] management likely served to obfuscate priorities in donor and recipient governments. An additional source of consternation has been the exorbitant prices of [antiretroviral] medications for African countries (Anabwani and Navario, 2005:96–97). In actuality, the last 3 years has witnessed dramatic breakthroughs in global HIV/AIDS assistance and control efforts: a sharp drop in the price of antiretroviral drugs, simplified drug delivery, greater political commitment among leaders in donor and recipient governments, greater involvement of the private sector, and major international initiatives. Total global spending on HIV/AIDS in low- and middle-income countries increased 500 percent between 1996 and 2003, reaching $4.7 billion in 2004 (UNAIDS, 2003), with 56 percent of this total going to Africa (IRINnews, 2004). On January 25, 2005, the U.S. Food and Drug Administration announced the tentative approval of the first generic, copackaged antiretroviral drug regimen (lamivudine/zidovudine and nevirapine, manufactured by Aspen

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Pharmacare of South Africa) for use in the PEPFAR initiative. Whereas a mass scale-up of antiretroviral therapy (ART) was once considered unaffordable and technically unworkable, donors viewing the demography of the pandemic now view such a scale-up as possible if not essential, making it the centerpiece of several new initiatives. At the same time, however, there are daunting barriers to implementing new HIV/AIDS programs and scaled up treatment in highly affected areas. These include a lack of trained and skilled personnel on the ground; ministries resisting urgent action; and the growing burden placed on highly affected countries by proliferating donor demands for comprehensive planning, reporting, monitoring, and evaluation. For many African countries that still spend less than $10 per capita per year on health, the provision of ART far exceeds national capacities; many countries also remain uneasy over donors’ long-term commitment to (in most cases) still-growing populations of HIV-infected individuals (Morrison, 2004). This chapter summarizes the history, funding, and targets of the United States’ major international HIV/AIDS initiative (PEPFAR), as well as the World Health Organization’s (WHO) 3 × 5 initiative and the United Nations (UN) Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). The chapter also briefly summarizes other federal and research-based initiatives, and the efforts of major foundations and private-sector partners actively engaged in the international fight against HIV/AIDS, emphasizing on-the-ground building of human resource capacity. The chapter concludes with observations drawn from a survey (commissioned by this committee) of American nongovernmental organizations engaged in HIV/ AIDS projects in one or more PEPFAR focus countries (for a full report, see Appendix D). THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF (PEPFAR) As discussed in Chapter 1, PEPFAR, while encompassing activities in more than 100 countries, is focused on the development of comprehensive and integrated prevention, treatment, and care programs in 15 countries severely affected by HIV/AIDS. Box 3-1 presents the four cornerstones of the PEPFAR initiative. Key elements of the PEPFAR initiative include a Global AIDS Coordinator charged with supporting each national program using a country-specific approach, as well as coordinating U.S. and international actors (for example, bilateral donors, UN agencies, the Joint United Nations Programme on HIV/AIDS [UNAIDS], the Global Fund, and NGOs). Within the United States, the agencies primarily responsible for implementing PEPFAR are the U.S. Department of State (where the U.S. Global AIDS Coordinator is based and reports directly to the secretary of state); the

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS BOX 3-1 The Four Cornerstones of PEPFAR Rapidly expanding integrated prevention, treatment, and care in the focus countries by using existing successful programs and building new ones that are needed. Identifying new partners, including the private sector and faith- and community-based organizations, and building indigenous capacity to sustain a long-term and broad local response. Encouraging bold national leadership in every impacted country around the world, and engendering the creation of sound, enabling policy environments in every country for combating HIV/AIDS and mitigating its consequences. Implementing strong strategic information systems that will provide vital feedback and accountability, and help those fighting the epidemic in the PEPFAR countries to engage in continued learning and the identification of best practices. United States Agency for International Development (USAID); and the U.S. Department of Health and Human Services (DHHS). Within DHHS, PEPFAR also draws on expertise from the National Institutes of Health/the National Institute for Allergy and Infectious Diseases (NIH/NIAID), which is involved in HIV/AIDS research in the PEPFAR focus countries; the Health Resources and Services Administration, which has experience expanding HIV/AIDS and other health services in resource-poor settings in the United States and is providing some assistance in several of the PEPFAR focus countries; and the Office of the Secretary/Office of Global Affairs, which plays a coordinating role for HIV/AIDS efforts within DHHS. Other agencies involved in PEPFAR include the Department of Defense, the Peace Corps, and the Departments of Labor and Commerce. Recent Activities PEPFAR is currently overseen by Ambassador Randall Tobias, the Global AIDS Coordinator, who was nominated by President Bush in July 2003 and confirmed by the Senate in October 2003. In February 2004, the Office of the Global AIDS Coordinator submitted a 5-year strategic plan to Congress and awarded its first $350 million in initial funding, including new awards to NGOs with established HIV/AIDS experience in the PEPFAR focus countries. In late 2004, U.S. embassies in the focus countries submitted detailed country operations plans both for fiscal year 2005 and for the 5-year period through fiscal year 2008. At the World Economic Forum held in Davos, Switzerland, in January 2005, it was announced that 172,000 individuals had received antiretroviral drugs under PEPFAR during its first 8 months, well within the range of the projected goal of 200,000 treated

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS individuals over the first year of the initiative (O’Neill, 2005). In fiscal year 2004, the United States committed a total of $2.4 billion to the fight against global HIV/AIDS, and the projected amount for fiscal year 2005 is $2.8 billion. The budget request for fiscal year 2006 is $3.2 billion (O’Neill, 2005). Widely acknowledged as the primary obstacle to achieving PEPFAR’s 5-year goals in the hardest-hit nations (see Chapter 1) is their desperate lack of infrastructure and human resources. For this reason, a substantial portion of the U.S. funding is being invested in training health care workers, and in upgrading national and local public health infrastructure under national strategies. Cooperation with other international donors is another key element of PEPFAR. In April 2004, in response to widespread concern that proliferating external funding streams were placing untenable demands on target country capacities, more than 20 donors, including the United States, Britain, and UNAIDS, announced their commitment to three principles for concerted action on HIV/AIDS, defined as “the three ones”: one national HIV/AIDS authority including multisectoral and nongovernmental partners, one national strategy framework coordinating the work of all partners, and one monitoring and evaluation system in each country. Implementation of this agreement is intended to ensure that donors will work together while also recognizing that host nations must own the fight against HIV/AIDS. Early Assessments PEPFAR’s strengths—its extraordinary leadership and financial commitment, swiftness, and focused efforts within a relatively small number of countries—have catalyzed hope and mobilized action within the current focus countries and partner agencies. Nonetheless, the challenges facing PEPFAR are great. Although positive overall, a May 2004 report by the Council on Foreign Relations (CFR) and the Milbank Memorial Fund (CFR and Milbank Memorial Fund, 2004) underscores three key issues: PEPFAR’s underemphasis on infrastructure and human capital: The absence of hospitals, health centers, clinics, delivery services and other physical infrastructure has been crippling and will constitute a major obstacle to progress. The deficit in human capital—the health care workers necessary to treat, counsel, and care for patients, and to manage and administer health systems—has been debilitating and will continue to worsen. Many sub-Saharan countries…devote only a few dollars per capita per year to health; Ethiopia, for example, currently spends approximately $1. (p. 10)

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS PEPFAR’s underemphasis on testing: Whereas the five-year U.S. goal aims to get 2 million people on treatments, there are currently 20 million infected people in the 14 countries selected by PEPFAR…. Ninety-five percent of Africans and 95 percent of people infected globally do not know their HIV status…. Part of the reason for the lack of testing is the stigma attached to going to HIV/AIDS-specific centers for this purpose. Vast increases in health facilities, clinics and health care workers will be needed to provide the setting to test, treat, counsel, and care for all who need to be reached. (p. 11) PEPFAR’s overemphasis on services designed to deliver antiretrovirals, draining resources from other areas of the health system and creating a parallel structure. The CFR/Milbank report stresses the need for the Office of the Global AIDS Coordinator to maximize the integration of PEPFAR’s infrastructure-related investments with overall national health systems, specifically addressing the tuberculosis (TB)/HIV copandemic more broadly, and incorporating malaria into the strategy: This would mean training health workers to deal with a broad range of health problems: developing delivery systems that can accommodate drugs other than [antiretrovirals]; enhancing the testing, treatment and counseling capacities of existing health centers and clinics as much as possible before establishing separate ones for HIV/AIDS; providing incentives to retain health professionals who are leaving for developed countries; and helping national governments to develop comprehensive health systems, rather than drawing resources purely for HIV/AIDS work. (p. 13) Another early review of PEPFAR, conducted by the Center for Strategic and International Studies in collaboration with the Kaiser Family Foundation, raised concerns related to PEPFAR’s large disbursement through a collection of disparate funding mechanisms not prepared to provide urgent responses; the need for real-time monitoring and evaluation, as well as longer-term progress reports based on reliable data systems; and the need to coordinate with non-HIV/AIDS disease control activities already in place in the PEPFAR focus countries, organized by other local and international groups (Nieburg et al., 2004). An additional concern, raised by Manyeke Sengwana of KwaZulu Natal University’s Health Economics and HIV/AIDS Research Division (HEARD), is the potentially negative impact PEPFAR could have on other health programs, agency programs, and countries other than those on which PEPFAR is focused (Sengwana, 2004).

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS THE WORLD HEALTH ORGANIZATION’S 3 × 5 INITIATIVE1 On December 1, 2003, J.W. Lee, the new Director General of WHO, introduced a “detailed and concrete plan” for treating 3 million AIDS-infected patients by 2005. This plan, known as the 3 × 5 initiative emphasizes revised, simplified, and standardized guidelines for ART in resource-poor settings; support for buying, financing, and supplying antiretrovirals and diagnostic technology; and training strategies for health professionals and lay health workers. According to the most recent progress report on the 3 × 5 intiative, released in December 2004 by the second half of 2004, the number of people on ART in developing and transitional countries had increased from 440,000 to an estimated 700,000 (WHO, 2004). This latter figure equals roughly 12 percent of the estimated 5.8 million people currently in need of treatment in developing and transitional countries (see Table 3-1). The 700,000 figure includes people receiving ART supported by the Global Fund, PEPFAR, the World Bank, and other partners. Achieving the target of treating 3 million people by the end of 2005 will require that at least another 2.3 million people initiate treatment in 2005. In 2005, a total of 5.1 million adults who need treatment still are not receiving it; of these, 72 percent live in sub-Saharan Africa and 22 percent in Asia. The 3 × 5 initiative has been critiqued from several perspectives: operational applications (including treatment guidelines, drug selection, manufacturing sources, rate of patient treatment, rate of drug resistance, regimen failure, drug procurements, human resources, and inconsistent figures on HIV/AIDS prevalence); price and cost implications; and ethical and legal consistency within the framework of the initiative. The initiative’s overall intention is complicated by the fact that once AIDS treatment is initiated, those who finance and provide care become involved in chronic care management for the remainder of the patient’s life. On the other hand, one of the most innovative aspects of WHO’s 3 × 5 initiative is a method for urgently training community health workers to support the delivery and monitoring of HIV/AIDS treatment (Jong-wook, 2003). An intensive training program can enable these health workers to evaluate and monitor patients and ensure that they receive and are taking their medicines. An example that involves training lay advocates or advisors to be community health workers is described in Box 3-2. 1   This section draws heavily on WHO (2004).

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE 3-1 Estimated Number of People Receiving and Needing ART, and Percent Coverage in Developing and Transitional Countries by Region, December 2004 Region Estimated Number of People Receiving ART, December 2004 (low estimate/high estimate)a Estimated Number of People Aged 15–49 Needing ARTb ART Coverage (percent)c Estimated Number of People Receiving ART Sub-Saharan Africa 310,000 (270,000–350,000) 4,000,000 8 150,000 Latin America and the Caribbean 275,000 (260,000–290,000) 425,000 65 220,000 East, South, and Southeast Asia 100,000 (85,000–115,000) 1,200,000 8 55,000 Europe and Central Asia 15,000 (13,000–17,000) 150,000 10 11,000 North Africa and the Middle Eastd 4,000 (2,000–6,000) 55,000 7 4,000 Total 700,000 (630,000–780,000) 5,800,000 12 440,000 aA few countries report the number of children younger than age 15 receiving ART, and these children are included in this table. Preliminary data show that overall, these children represent less than 5 percent of the total number receiving ART. bThe figure presented is the midpoint of the low and high estimates of the number of AIDS deaths and the number of AIDS cases. Estimates for individual countries may differ according to the local methods used. cThis is a best coverage estimate based on the midpoints of the estimated numbers of people receiving and needing ART. dExcept for Turkey, no updates have been received from this region since June 2004. NOTE: All countries except those in western Europe and Australia, Bahamas, Bahrain, Brunei, Canada, Cyrprus, Grenada, Israel, Japan, Kuwait, New Zealand, Qatar, Republic of Korea, Singapore, United Arab Emirates, and United States of America. NOTE: Numbers do not add up due to rounding. SOURCE: World Health Organization 3 by 5 Progress Report (2004:11).

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS BOX 3-2 Community Health Workers: Augmenting Care for HIV/AIDS and Tuberculosis in Haiti Community health workers are lay advocates or advisors who educate and lead individuals and groups in their communities to attain increased health and well-being. They act as bridges between the community and the providers of clinical health care services. Community health workers increase access to care by providing outreach and cultural linkages between their communities and clinical health care providers. They reduce the costs of health care by providing education, disease screening, and detection services that promote health and prevent disease. They often improve the health status of the community by providing primary health care at a low cost in remote areas. Since 1987, Partners In Health and its sister organization Zanmi Lasante, Creole for “Partners In Health,” have been providing primary health care in the central Haitian village of Cange. Together, they run a number of programs, including a full-service hospital, rural Haiti’s only HIV/AIDS and tuberculosis treatment facilities, a women’s health center, a dozen schools, and several cottage industries. In the Central Department of Haiti, where the partners work, there are fewer than two doctors per 100,000 persons. The population relies on community health workers to deliver care. Partners In Health and Zanmi Lasante trained 750 community health workers in 2003 alone. After training, these community health workers can provide basic medical diagnoses, treatment, and if necessary, referrals to clinics. They can also provide a variety of home-based support services, including directly observed therapy for HIV/AIDS and tuberculosis. It has been noted that adherence rates of these patients are high. Based on these successful experiences, community health workers appear to be an excellent option for the future of health care in resource-poor settings, especially for the management of diseases such as HIV/AIDS. SOURCE: http://www.pih.org/wherewework/haiti/index.html and PIH annual report. THE UNITED NATIONS GLOBAL FUND In 2001, Kofi Annan, secretary general of the United Nations, proposed the Global Fund, a public–private partnership that would raise and disburse millions of dollars every year, to fight AIDS, TB, and malaria. The Global Fund aspires to be the world’s largest fundraising and grant-making operation. Its governance and working methods were developed during the last few months of 2001, and its first grants were announced at the end of April 2002. Among the guiding principles of the Global Fund is the notion of national ownership. In practice, applications for funding need to be endorsed by a group of people, known collectively as the Country Coordinating Mechanism (CCM), which typically includes a government representa-

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS tive. Such partnerships help facilitate local coordination, but they can also hinder access to funding by subgroups of HIV-infected stakeholders already marginalized within their own country, or by groups proposing public health interventions incongruent with government policies (Kerr et al., 2004). By December 2004, the Global Fund had received pledges for U.S. $5.9 billion and payments of U.S. $3.3 billion against those pledges (WHO, 2004). In four rounds of disbursements, it has already approved proposals with a 2-year value of U.S. $3.1 billion and disbursed U.S. $860 million. Of the U.S. $3.1 billion approved, U.S. $1.7 billion (56 percent) has been allocated to the fight against AIDS with 70 percent going to low-income countries and 58 percent to sub-Saharan Africa. More than half of the Global Fund’s grants to date have been allocated to national governments; 25 percent to nongovernmental and community-based organizations; 4 percent to associations of people living with HIV/ AIDS; and 5 percent each to academic institutions, the private sector, faith-based organizations, and others. EFFORTS OF OTHER ORGANIZATIONS The World Bank Since 1995, The World Bank has committed more than U.S. $1.7 billion through grants, loans, and credits to support programs to combat HIV/ AIDS (World Bank, 2005). More than U.S. $1 billion has gone to support the Multi-Country HIV/AIDS Program for Africa for 28 high-burden countries in that region and another U.S. $155 million has gone to the Caribbean Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending. The goal of these programs is to intensify action against HIV/AIDS in as many countries as possible and on all fronts, including prevention, testing, counseling, treatment, care, and support. Between July and December 2004, the World Bank supported accelerated access to treatment through ongoing financial and technical support for improving national health systems in 100 countries. It also provided direct support to ART programs in the Caribbean, 13 African countries, 3 Asian countries, and 1 country in Eastern Europe. In mid-2004, the World Bank announced the Treatment Acceleration Project; a U.S. $60 million International Development Association grant was provided to support scaling up of access to HIV/AIDS treatment in Burkina Faso, Ghana, and Mozambique. Another U.S. $15 million grant was given to Mali. Grassroots organizations, private companies such as the Private Enterprise Foundation/Pharma Access International in Ghana, faith-based groups such as the Community of Sant’ Egidio in Mozambique, and

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS a network of people living with HIV/AIDS in Burkina Faso are also involved in implementing the project, building on progress previously achieved on a smaller scale in partnership with ministries of health. THE UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT In fiscal year 2003, the budget of the USAID for global HIV/AIDS programs was $795 million, allocated to more than 50 of the most affected developing countries worldwide (USAID, 2005a). Since the announcement of PEPFAR, USAID’s work in fighting HIV/AIDS has come under a new mandate. The agency’s global HIV/AIDS grants are currently available through the following programs: Communities Responding to the HIV/AIDS Epidemic (CORE) Initiative—Through CORE, USAID provides small grants to community and faith-based groups in developing countries. Priority is given to groups that commit their own resources, and that demonstrate the ability to meet needs for care and support (especially care for orphans and vulnerable children) and to help confront and reduce stigma and discrimination (Core Initiative, 2005). Community Rapid and Effective Action Combating HIV/AIDS (REACH)—Community REACH provides grants, typically ranging from $100,000 to $500,000 over 1 to 3 years, to organizations such as regional and local NGOs, universities, and faith-based organizations involved in primary prevention and education, voluntary counseling and testing, and care for those living with HIV/AIDS (Pact, 2005). Child Survival and Health Grants Programs—This funding mechanism, open to any U.S.-based private voluntary organization, supports community-oriented child survival programs. These programs can involve initiatives targeting HIV/AIDS and support for orphans and vulnerable children (USAID, 2005b). The U.S. Department of Health and Human Services/Health Resources and Services Administration Through an intradepartmental delegation of authority from the Centers for Disease Control and Prevention (CDC), HRSA is currently charged with increasing access to international HIV/AIDS treatment, care, and support (HRSA, 2005). Examples of activities focused on fostering human resources for health include the International AIDS Education and Training Center on HIV (I-TECH; see below), an HRSA-supported program designed to achieve rapid expansion of the pool of trained providers, managers, and

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS allied health staff providing HIV/AIDS, malaria, and tuberculosis (TB) services in developing countries; and the American International Health Alliance (AIHA; see below), the lead organization currently overseeing the HRSA-supported HIV/AIDS Twinning Center and launching the Voluntary Healthcare Corps under PEPFAR. International Training and Education Center on HIV I-TECH, a collaboration of the University of Washington and the University of California, San Francisco, was initially funded by HRSA and CDC’s Control and Prevention Global AIDS Program (GAP) in 2002, and since 2003 has additionally been funded by USAID for work in the Caribbean. Its mission is to promote activities that increase human capacity for HIV/AIDS clinical care and support in countries and regions hardest hit by the HIV/AIDS pandemic (Holmes, 2004; I-TECH, 2005). I-TECH is currently working with GAP and local partners in Botswana, Ethiopia, Haiti, India, Namibia, Malawi, South Africa, Thailand, and Zimbabwe and has launched start-up activities in Guyana and Vietnam. Its principal focus is training, encompassing the following: Level I: Didactic activities (grand rounds, clinic conferences, day-long lecture series) Level II: Skill building (role plays, case studies) Level III: Hands-on clinical training (mentorship, mini-residencies) Level IV: Clinical consultation (phone, videoconference, e-mail, mobile team visits) I-TECH emphasizes training models for both physicians and nurses, recognizing that the latter provide the majority of HIV/AIDS care overseas and require both technical knowledge and empowerment. American International Health Alliance AIHA defines twinning as “a voluntary, formal, sustainable partnership between two or more similar organizations established to collaborate in providing technical assistance on HIV prevention, care, and treatment through exchange visits, training, and ongoing communications and organization support” (AIHA, 2005). AIHA-managed twinning partnerships will typically link U.S. and PEPFAR focus country partners, although partnerships between focus countries (south–south) with or without a third country (trilateral) can also be supported. With technical assistance on HIV/AIDS treatment and care provided by I-TECH, anticipated activities of AIHA twinning partnerships include needs assessments; baseline data sur-

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS veys; professional exchanges, training, and mentoring; development of curricula and other educational/training material; and scaling up or replication of successful treatment, care, and support programs. Organizations that may engage in twinning include community- and faith-based programs and clinics; hospitals or health posts; public health programs; schools of medicine, nursing, allied health, pharmacy, public health, management, public administration, etc.; HIV/AIDS education and training programs; AIDS service organizations; and others, depending on host country needs (Smith, 2005). A second program area of AIHA is the Voluntary Healthcare Corps (VHC), currently conceived as a network of individuals with expertise in health care and HIV/AIDS who will work in established twinning partnerships or in programs in other PEPFAR focus countries. Assignments will range from 3 months to 3 years, although most are expected to last 3 to 6 months (Smith, 2005). The Centers for Disease Control and Prevention CDC works collaboratively to mitigate global HIV/AIDS with other U.S. government agencies, including USAID; international health and economic organizations such as WHO, UNAIDS, and the World Bank; NGOs; and host country governments. From having had no HIV/AIDS funding in 1999, CDC currently has a $500 million portfolio of projects focused on global HIV/AIDS. In 2004, these projects were staffed by 103 direct hires (Civil Service/Commissioned Corps) in Atlanta and 100 in the field (country/regional programs), as well as contractors, fellows, and other skilled personnel in Atlanta and overseas (St. Louis, 2004). In 2003, GAP operated in 25 countries in Africa, Asia, Latin America, and the Caribbean, with regional offices/activities located in the Caribbean, Southeast Asia, Southern Africa, and Central America. GAP has three primary program foci: infrastructure and capacity development, including surveillance, laboratory support, information systems, and monitoring and evaluation; primary prevention, including voluntary counseling and testing, blood safety, and youth-targeted activities; and care and treatment, including treatment and care of TB and opportunistic infections, prevention of mother-to-child transmission, appropriate provision of antiretroviral drugs, and soothing care (CDC, 2005). Many of CDC’s cooperative agreements support expatriate human resources for health; these include the University Technical Assistance Program, I-TECH, the Association of Public Health Laboratories, and the National Association of State and Territorial AIDS Directors. A new model for international deployments is the Global AIDS fellowship (cosponsored by the American Schools of Public Health). The program attracted 63 ap-

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS plicants for 10 postings in 2005, most of whom had international experience plus a recent masters degree in public health (St. Louis, 2004). Research Programs Supported by the National Institutes of Health Early clinical and translational research investments by NIH contributed to the development of university- and community-based centers of excellence throughout the United States around which most of the initial comprehensive AIDS care centers developed. These centers (primarily the Adult and Pediatric AIDS Clinical Trials Group, the Community Program for Clinical Research on AIDS, the HIV Prevention Trials Network, the HIV Vaccine Trials Network, and the Centers for AIDS Research) enabled the development of comprehensive care programs that ultimately yielded the knowledge base that has drastically changed the prognosis of the disease. Similar NIH-funded programs are now operating in a variety of resource-limited settings, including PEPFAR focus countries. These programs have invested in the training of local investigators and clinicians through structured twinning between American academic centers and international sites; they have also provided equipment (such as flow cytometers and polymerase chain reaction [PCR] equipment) serving dual goals of research and care. In addition to providing infrastructure and training, such programs enable local investigators to frame research questions and conduct research designed to optimize local care. The research addresses, for example, approaches to preventing mother-to-child transmission of HIV that do not compromise the subsequent responsiveness of the mother to therapy, optimizing ART in treatment-naïve and -experienced patients, and monitoring and managing drug resistance.2 NIH’s Fogarty International Center (FIC) recently launched the International Clinical, Operational, and Health Services Research Training Award for AIDS and Tuberculosis (ICOHRTA-AIDS/TB). The program is designed to provide extended support to training institutions in low- and middle-income country sites where HIV/AIDS and TB or both are significant problems (Fogarty International Center, 2004). ICOHRTA-AIDS/TB is intended to build capacity for integrated clinical, operational, and health 2   Examples of such studies include AIDS Clinical Trial Group (ACTG) study 5175, which will test novel once-daily antiretroviral drug regimens in 1,200 individuals living in resource-limited settings; ACTG 5207, which seeks to delineate approaches for reducing drug resistance in mothers receiving single-dose nevirapine to prevent mother-to-child HIV transmission; and ACTG 5208, which addresses the extent to which prior perinatal nevirapine compromises a mother’s response to subsequent ART (R. Schooley, personal communication, February 14, 2005).

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS services research across the full range of conditions and issues that relate to care of adult and pediatric patients with HIV/AIDS or TB by a wide range of health professionals (e.g., nurses, midwives, physicians, dentists, health care administrators, and public health workers). With eight NIH partners, FIC also operates the Global Health Research Initiative Program for New Foreign Investigators. This program promotes the reentry of young NIH-trained foreign investigators from the developing world to their home countries, thus ensuring that developing countries do not lose their talented scientists. Foundations and Corporate Initiatives3 The Bill and Melinda Gates Foundation has focused considerable attention on HIV/AIDS since its founding in January 2000, allocating $250 million annually. The emphasis on HIV vaccine research and new technologies, such as female microbicides, that could block the sexual transmission of HIV. The Gates Foundation is the only private-sector organization to make a significant cash donation ($100 million) to the Global Fund. Beginning in 2003, President Clinton, through the William Jefferson Clinton Foundation and numerous volunteer experts, contracted with selected African and Latin American countries (and, most recently, China) to broker low-cost, high-volume delivery of generic drugs and diagnostic equipment. The Clinton Foundation also provides short- and medium-term expert teams to assist countries in preparing detailed operations plans for scaling up national treatment programs. Corporate employers such as DaimlerChrysler, Anglo American, DeBeers, Standard Charter Bank, Coca Cola, Merck, and India’s Tata and Iron and Steel with a significant presence in the southern African epicenter of the pandemic have spearheaded innovative programs in response to rising rates of HIV infection among their own workers. Drug companies such as Merck, GlaxoSmithKline, and Bristol-Myers Squibb have established reduced-price, no-profit, or free drug programs in many highly affected countries. The Pfizer Global Health Fellows program is an innovative response that goes beyond conventional industry donations of cash and drugs (see Box 3-3). First announced at the International AIDS Conference in Barcelona in 2002, it provides a mechanism for sending Pfizer employees with relevant medical and managerial expertise to support the work of leading NGOs such as Doctors of the World, the Elizabeth Glazer Pediatric AIDS Foundation, the American Jewish World Service, the African Medi- 3   Much of the information in this section is drawn from Morrison (2004).

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS BOX 3-3 Pfizer Fellows Since 2002, 51 Fellows have been deployed from 15 Pfizer sites to 18 countries. The company’s newest Global Health Fellows program sends skilled Pfizer medical and managerial volunteers to help nongovernmental organizations (NGOs) develop the health and social infrastructures required to combat HIV/AIDS in developing countries. To this end, Pfizer loans skilled employees to NGOs for up to 6 months while paying the employees’ salaries and keeping their jobs open until they return. Pfizer also covers the cost of assignment, including NGO overhead; provides orientation and cultural sensitivity training to Fellows; manages the application process and initial screening of applicants; provides logistical support to Fellows prior to their deployment; and demonstrates the value of the program to Fellows’ Pfizer managers. The partnering NGOs are responsible for identifying field needs. They then develop job descriptions and select the fellows they wish to work with from a pool of applicants. The NGOs also manage the Fellows in the field, including identifying housing, transportation, and logistics related to the Fellows’ assignments. At the end of an assignment, the NGO assesses the Fellow’s performance as part of the partnership evaluation process. SOURCE: Pfizer (2003). cal and Research Foundation, the Academic Alliance for AIDS Care and Prevention in Africa, and Health Volunteers Overseas (Pfizer, 2003). The company sees its effort as a way to apply global pharmaceutical corporate know-how to the greater needs of society through a cross-sector collaboration. Pfizer also donates medicines through its Diflucan4 Partnership Program and partnered with the Academic Alliance for AIDS Care and Prevention in Africa to build a new Infectious Diseases Institute (IDI) on the campus of Makerere University in Kampala, Uganda. Completed in 2004, the new facility is already serving as a training center for hundreds of physicians working on HIV/AIDS care and prevention in Africa. Currently, two infectious disease specialists vetted by the Infectious Diseases Society of America go to IDI every 9 weeks and teach back-to-back 1-month courses for physicians. Applicants are selected on the basis of their potential to train others after completing the program. IDI also provides 1-week and week-end training programs for nurses and other health professionals and main- 4   Diflucan™, or fluconazole, is an antifungal drug used to treat cryptococcosis, an opportunistic fungal infection that frequently causes meningitis in AIDS patients.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS tains on ground-the-clock AIDS Treatment Information Center staffed by pharmacists and physicians who respond to questions by phone, fax, and e-mail (Scheld, 2004). Other U.S. Private-Sector, Academic, and Faith- and Community-Based Programs In addition to the initiatives described above, many innovative programs focused on global HIV/AIDS have been initiated by other U.S. private-sector, academic, and faith- and community-based organizations. Certain programs that emphasize training and augmentation of human health care resources are described in greater detail in Chapter 5. The committee commissioned an independent survey of lessons learned from a range of nongovernmental sending organizations involved in HIV/AIDS activities in at least one PEPFAR focus country. During the committee’s February 2005 meeting, the findings of this survey were reported. The survey encompassed U.S. faith-based or secular NGOs with budgets of between $100,000 and $1.5 billion. In general, the larger organizations surveyed perceive HIV/AIDS as a “low to medium” issue as compared with relief for the recent tsunami in the Indian Ocean. This view reflects the projected duration of involvement on the ground for the two efforts (3–4 years following the tsunami versus 30 years or more for HIV/AIDS). Most of the surveyed organizations send volunteer doctors and nurses (as opposed to administrators, human resources personnel, information technologists, laboratory workers, or public health specialists) for less than 2 months. In some cases, however, there is a U.S. “anchor-person” who can inform future volunteers, as well as maintain ongoing electronic contact with overseas colleagues and counterparts. Additional ground-level challenges cited by the surveyed organizations were as follows: Partnering challenges Local operating obstacles (e.g., obtaining a permit to operate a truck) Lack of clarity regarding project goals Lack of local supervision of volunteers Dependency on local partners5 Negative local reactions to the size, perceived dominance, arrogance, and/or resources of very large organizations 5   For example, in some cases American health professionals may attract more patients than indigenous providers because they are perceived to have superior knowledge and skills.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Issues pertaining to local skills and infrastructure Unexpected expenses Lack of local strategic planning skills Lack of local project evaluation skills Inadequate work space High turnover of indigenous staff Contextual issues Chronic community depression over HIV/AIDS and other survival challenges, including local civil conflicts Potential for personal isolation of volunteers Impact of desperate overall situation on volunteers Issues pertaining to international bureaucracy: overevaluation of projects REFERENCES AIHA (American International Health Alliance). 2005. HIV/AIDS Twinning Center Frequently Asked Questions. [Online]. Available: http://www.twinningagainstaids.org/faq.html [accessed March 1, 2005]. Anabwani G, Navario P. 2005. Nutrition and HIV/AIDS in sub-Saharan Africa: An overview. Nutrition 21(1):96–99. CDC (Centers for Disease Control and Prevention). 2005. Global AIDS Program. [Online]. Available: http://www.cdc.gov/nchstp/od/gap/default.htm [accessed March 1, 2005]. CFR (Council on Foreign Relations) and Milbank Memorial Fund. 2004. Addressing the HIV/AIDS Pandemic: A U.S. Global AIDS Strategy for the Long Term. New York, NY: Milbank Memorial Fund. Core Initiative. 2005. Communities Responding to the HIV/AIDS Epidemic. [Online]. Available: http://www.coreinitiative.org [accessed March 1, 2005]. Fogarty International Center. 2004. FAQ: International Clinical, Operational, and Health Services Research Training Award Program for AIDS and Tuberculosis. [Online]. Available: http://www.fic.nih.gov/news/FAQ113004.html [accessed March 1, 2005]. Holmes K. 2004 (December 1). Model of Training for Grassroots Work in HIV. Presentation at the December 1, 2004, Workshop of the IOM Committee on the Overseas Placement of U.S. Health Professionals, Washington, DC. HRSA (Health Resources and Services Administration). 2005. Global HIV/AIDS Program. [Online]. Available: http://hab.hrsa.gov/special/global.htm [accessed March 1, 2005]. I-TECH (International Training and Education Center on HIV). 2005. I-TECH. [Online]. Available: http://www.go2itech.org/itech?page=home-00-00 [accessed March 1, 2005]. IRINnews. 2004. Southern Africa: Are Countries Spending Enough on HIV/AIDS? [Online]. Available: http://www.irinnews.org/report.asp?ReportID=38932&SelectRegion=SouthernAfrica&SelectCountry=SOUTHERN_AFRICA [accessed March 1, 2005]. Jong-wook L. 2003. Global health improvement and WHO: Shaping the future. Lancet 362:2083–2088. Kerr T, Kaplan K, Suwannawong P, Jurgens R, Wood E. 2004. The Global Fund to fight AIDS, tuberculosis and malaria: Funding for unpopular public-health programmes. Lancet 364:11–12.

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