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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