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PEPFAR Implementation: Progress and Promise (2007)

Chapter: 4 PEPFAR's Prevention Category

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Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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4

PEPFAR’s Prevention Category

Summary of Key Findings

  • PEPFAR’s ambitious prevention target—to support the prevention of a total of 7 million infections in the 15 focus countries—differs from the treatment and care targets in several respects: the target represents long-term impact, it is to be estimated at the national level by modeling, and it is to be measured for the year 2010. To achieve this target, PEPFAR is implementing a wide variety of HIV prevention activities, including those related to preventing mother-to-child transmission, preventing sexual transmission and transmission through injecting drug use, and reducing the risk of transmission through blood transfusion and medical injection. While many of these activities have been shown to lead to a decrease in the transmission of HIV, it is difficult to report on short-term progress for most prevention activities because of the long-term nature of their impact and a lack of indicators that can easily be linked to national declines in incidence.

  • PEPFAR is making progress in prevention of mother-to-child transmission, one of the few areas of preventive activity for which specific indicators exist that allow relatively direct estimation of infections averted. Thus far, PEPFAR has supported the provision of services aimed at preventing mother-to-child transmission to women during more than 6 million pregnancies. These efforts have included providing prophylactic antiretroviral therapy to more than 530,000 women, estimated to have resulted in more than 100,000 infant infections averted.

  • PEPFAR’s approach to achieving the prevention target involves planning and implementing prevention programs and activities that are evidence-based, harmonized with country plans and priorities, and appropriate to each country’s unique epidemiologic and cultural context. However, the abstinence-until-marriage budget allocation in the Leadership Act hampers these efforts and thus PEPFAR’s ability to meet the target. Despite the efforts of the Office of the U.S. Global AIDS Coordinator to administer the allocation judiciously, it has greatly limited the ability of Country Teams to develop and implement comprehensive prevention programs that are well integrated with each other and with counseling and testing, care, and treatment programs and that target those populations at greatest risk.

  • PEPFAR has contributed substantially to improvements in HIV surveillance that enables an overview of the epidemiologic context in the focus countries and can be used to measure progress. However, the focus countries are not conducting adequate behavioral surveillance surveys, which are critical for obtaining information on patterns of exposure and at-risk populations. PEPFAR could provide more support for such surveys.

  • PEPFAR is supporting targeted evaluation of some prevention programs, but could be doing more program evaluation and operations research, particularly for unproven interventions, to ensure that prevention funds are being used most efficiently to have the greatest impact on the focus countries’ HIV/AIDS epidemics.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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Recommendation Discussed in This Chapter


Recommendation 4-1: The U.S. Global AIDS Initiative should enhance and intensify HIV prevention through a planning process that links timely national information on the epidemic to the selection of the most appropriate intervention packages and to the optimal targeting of interventions to populations in whom infections are most likely to occur. The U.S. Global AIDS Coordinator should enhance current data on HIV prevalence by supporting quality behavioral surveys to identify patterns of risk. The Coordinator should support country plans to identify where infections are to be averted to achieve prevention targets and should track progress toward achieving prevention goals by measuring risk behaviors, the prevalence and incidence of other sexually transmitted infections, and ultimately the prevalence and incidence of HIV.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

4
PEPFAR’s Prevention Category

CATEGORY, TARGET, AND RESULTS

The Prevention Category

The prevention category encompasses five funding and reporting subcategories: (1) abstinence/be faithful, (2) condoms and other prevention, (3) prevention of mother-to-child transmission, (4) blood safety, and (5) injection safety. Funding for these subcategories for fiscal years 2004–2006 is shown in Table 4-1. Corresponding to these subcategories are four types of prevention activities funded by the President’s Emergency Plan for AIDS Relief (PEPFAR): promotion of behavior change aimed at risk avoidance and risk reduction, provision of comprehensive programs for people who engage in high-risk behavior, prevention of mother-to-child transmission of HIV, and reduction of medical transmission of HIV by ensuring safe blood supplies and safe medical injections and providing training in universal medical precautions (see Table 4-2). Strategies guiding these activities include scaling up existing prevention programs, advancing policy initiatives that support prevention of HIV infection, and collecting strategic information needed to monitor and evaluate progress and ensure compliance with PEPFAR policies and strategies (OGAC, 2006d). PEPFAR’s authorizing legislation requires that 33 percent of total prevention funding be spent on abstinence-until-marriage activities; PEPFAR allocates these funds under the abstinence/be faithful subcategory.

Voluntary counseling and testing, typically a key component of HIV

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

TABLE 4-1 PEPFAR Prevention Funding (in millions of U.S. dollars) and Percent by Subcategory for Fiscal Years 2004–2006

Subcategory

Fiscal Year 2004

Fiscal Year 2005

Fiscal Year 2006

Total Fiscal Years 2004–2006

Funding

Percent

Funding

Percent

Funding

Percent

Funding

Percent

Abstinence/Be Faithful

63

31

76

26

104

33

243

30

Condoms and Other Prevention

45

22

66

22

72

23

183

22

Prevention of Mother-to-Child Transmission

44

21

66

23

71

23

181

22

Blood Safety

27

13

53

18

31

10

111

14

Injection Safety

27

13

33

11

34

11

94

12

Total*

$207

100

$294

100

$311

100

$812

100

*Numbers may not add to the totals shown because of rounding.

SOURCE: OGAC, 2005d, 2006c.

prevention programs, is listed as a prevention activity in PEPFAR’s authorizing legislation. However, PEPFAR budgets and reports on voluntary counseling and testing under the care category, and those activities are therefore discussed in Chapter 6. Also included under the care category is secondary preventive care for HIV-positive people and their family members/caregivers. Likewise, prevention activities specifically targeting orphans

TABLE 4-2 PEPFAR Activities Corresponding to Funding and Reporting Subcategories

Prevention Activities

Prevention Funding and Reporting Categories

Promotion of behavior change aimed at risk avoidance and risk reduction

Abstinence/be faithful; condoms and other prevention

Provision of comprehensive programs for people who engage in high-risk behavior

Condoms and other prevention

Prevention of mother-to-child transmission of HIV

Prevention of mother-to-child transmission of HIV

Reduction of medical transmission of HIV by ensuring safe blood supplies and safe medical injections and providing training in universal medical precautions

Blood safety; injection safety

SOURCE: OGAC, 2004, 2005a, 2006a.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

and other vulnerable children are included in that category and thus are discussed in Chapter 7.

Target

The overall target for PEPAR prevention programs, as described in the legislation, is to prevent approximately 7 million HIV infections in the 15 focus countries by 2010. Each country has a target that represents roughly 50 percent of the expected incidence of HIV. These country targets are to be achieved through both PEPFAR-supported activities and the prevention activities of the host government and other donors.

The Office of the U.S. Global AIDS Coordinator (OGAC) plans to measure achievement of the prevention target by using U.S. Census Bureau statistical models of country-level prevalence trends at intervals until 2010. Mathematical models of 10 transmission dynamics of the virus will play a central role in calculating HIV infections averted. A range of models representing the spread of HIV through populations have been developed and used over the course of the HIV/AIDS pandemic (Anderson and Garnett, 2000). Models for the expected trends in HIV can be compared with observed trends to determine whether reductions in incidence have occurred. To calculate the expected infections averted by interventions, the predicted HIV epidemic without changes in patterns of exposure is compared with that predicted when interventions are in place. Such a modeling exercise requires epidemiologic and behavioral data to capture patterns of risk and measures of the efficacy of interventions in changing behaviors among individuals and populations. PEPFAR’s initial targets for HIV prevention were based on mathematical models of this type, which used the best available epidemiologic evidence (Stover et al., 2002).

To evaluate achievements in HIV prevention, models are used to predict the prevalence of HIV in the near future, which is compared with the estimated prevalence. The latter estimates are based on HIV prevalence in antenatal clinics and in general populations-based surveys, such as the Demographic and Health Surveys, as well as in generalized HIV epidemics. In concentrated epidemics, the size of high-risk groups and the prevalence of HIV in these groups is estimated. The models, developed in part by the Joint United Nations Programme on HIV/AIDS (UNAIDS), use a highly simple representation of an epidemic, which is fit to prevalence data. Such a model extrapolates the previous epidemic trend and determines whether the current trend has diverged from this. Such an approach is reasonable for evaluation, but cannot distinguish between the natural dynamics of an HIV epidemic and the impact of interventions (UNAIDS, 1999, 2002; Garnett et al., 2006). A conservative approach would be to use models to predict the lowest prevalence expected from natural dynamics and see whether

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

observed trends fall below this prediction. Such an approach has been used to identify the impact of changes in risk behavior on epidemics in Uganda, Zimbabwe, and urban Kenya (Kilian et al., 1999; Hallett et al., 2006).

PEPFAR has established intermediate targets for the focus countries by setting yearly, country-level targets that are used to estimate numbers of infections prevented in infants. These numbers represent part of the total 7 million infections the program aims to prevent.

Results

As noted above, achievement of the prevention target will be measured in 2010. In the interim, the only result framed in terms of infections prevented is the infections averted through prevention of mother-to-child transmission. The other results are similar to those for treatment and care in that they provide a count of people who have received prevention services, but do not allow determination of the quality of those services or whether they will translate into infections prevented. PEPFAR’s prevention results are summarized in Table 4-3.

PEPFAR’s indicators for activities related to prevention of sexual transmission, though generally consistent with globally agreed-upon indicators, have changed over time. The program’s first annual report included measures in addition to those shown in Table 4-3, such as number of mass media HIV/AIDS prevention programs, but these indicators were subsequently dropped in the evaluation guidance published by OGAC and not reported in subsequent annual reports. In 2005, the Center for Strategic and International Studies studied the indicators being used by PEPFAR, comparing them with those included in the United Nations General Assembly Special Session on HIV/AIDS, Global Fund guidance, and Millennium Challenge Goals. The study found that, with regard to indicators for activities related to prevention of sexual transmission, PEPFAR was the only initiative to collect program data based on the components of the ABC model.1 While many of the initiatives did collect information on condom distribution and outlets separately, none of the other initiative separated A, B, and C in the tracking of prevention activities (Morrison et al., 2005).

The Committee was unable to evaluate data related to specific at-risk populations because the data collected by PEPFAR are not broken down by these populations. See Chapter 3 for further discussion.

1

The ABC model was developed by the Government of Uganda in 1986 for a national prevention program encouraging Ugandans to abstain from sex until marriage (A), be faithful to one partner (B), and use condoms (C). Uganda’s program is referenced in the Leadership Act.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

TABLE 4-3 PEPFAR Prevention Results by Fiscal Year, 2004–2006

Subcategory

Fiscal Year 2004

Fiscal Year 2005

Fiscal Year 2006

Abstinence/Be Faithful

 

 

 

Number of people reached by PEPFAR-supported abstinence-only community outreach programs for HIV/AIDS prevention

11,530,400

Not available

Not available

Number of people reached by PEPFAR-supported abstinence/be faithful community outreach programs for HIV/AIDS prevention

24,041,800

24,861,700

40,247,500

Number of people receiving PEPFAR-supported training or retraining to promote HIV/AIDS prevention through abstinence and/or being faithful

116,600

174,400

299,300

Condoms and Other Prevention

 

 

 

Number of people reached with community outreach programs that promote HIV/AIDS prevention through condom promotion, related, and other services

11,899,900

17,941,100

21,203,300

Number of people receiving PEPFAR-supported training or retraining to provide condoms and related services

51,200

93,200

129,300

Prevention of Mother-to-Child Transmission

 

 

 

Number of women receiving prevention of mother-to-child transmission services

1,271,300

1,957,900

2,814,700

Number of women receiving a complete course of antiretroviral prophylaxis for prevention of mother-to-child transmission

125,100

122,600

285,600

Number of infant infections averted

23,800

23,400

54,400

Number of people receiving PEPFAR-supported training or retraining in prevention of mother-to-child transmission

24,600

28,600

32,600

Number of service outlets supported by PEPFAR providing the minimum package of prevention of mother-to-child transmission services according to national or international standards

2,200

2,500

4,863

Blood Safety

 

 

 

Number of service outlets related to blood safety supported by PEPFAR

249

585

3,848

Number of people receiving PEPFAR-supported training or retraining in blood safety

2,200

8,000

6,600

Injection Safety

 

 

 

Number of people receiving PEPFAR-supported training or retraining in injection safety

4,300

12,300

52,100

SOURCE: OGAC, 2005b, 2006b, 2007a, 2007b.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

REVIEW OF PROGRESS TO DATE

This section reviews the progress of PEPFAR’s activities to prevent HIV infection according to the primary routes of transmission of HIV: sexual, through injecting drug use, from mother-to-child, and medical. Also discussed is PEPFAR’s progress in the crucial area of removing gender barriers to prevention.

Prevention of Sexual Transmission of HIV
Promotion of Behavior Change

Sexual transmission accounts for more than 80 percent of all HIV infections worldwide (Piot et al., 1988). Behavioral interventions designed to reduce the risk of sexual transmission of HIV are tailored to specific groups and to be effective require a current understanding of HIV epidemiology, in particular those people at highest risk of infection. These interventions include providing counseling and testing; encouraging risk reduction in people who are both HIV-positive and HIV-negative; and reducing HIV risk cofactors, such as the presence of another sexually transmitted infection (JHU AIDS Service, 2006).

The Leadership Act describes activities to be supported by the U.S. Global AIDS Initiative to prevent HIV transmission. These activities focus on “delay of sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual violence and coercion, including child marriage, widow inheritance, and polygamy, and where appropriate, use of condoms” (P.L. 108-25, p. 729).

As described in the strategy for the program, PEPFAR’s primary approach to preventing sexual transmission of HIV is aimed at changing ABC behaviors. Largely in response to the Leadership Act’s requirement that 33 percent of funding for prevention of sexual transmission go to support abstinence-until-marriage (A) programs, PEPFAR divides activities related to preventing sexual transmission into two funding and reporting subcategories: abstinence/be faithful and condoms and other prevention (GAO, 2006).

Abstinence/Be Faithful

Operational plans for the 15 focus countries incorporate a variety of activities funded under the abstinence/be faithful subcategory, including school-based, community, and media interventions aimed at delaying sexual activity among youths; promoting fidelity and reduction of the number of partners among sexually active adults; addressing gender norms and HIV-

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

related issues, such as intergenerational and coercive sex; increasing family and community involvement in HIV prevention; and promoting counseling and testing, especially for family members of people living with HIV/AIDS (OGAC, 2006c). Funding under abstinence/be faithful also supports technical assistance and capacity building activities, such as the formulation of culturally appropriate school curriculum focused on developing students’ life skills, training of adults (teachers and community counselors) to promote abstinence/be faithful messages in their communities, and strengthening of the capacity of local organizations to enable them to receive U.S. government funding under the abstinence/be faithful subcategory (OGAC, 2006c). Examples of abstinence/be faithful activities in selected focus countries are presented in Box 4-1.

BOX 4-1

Selected Examples of PEPFAR-Supported Abstinence/Be Faithful Activities

In Ethiopia, PEPFAR is funding programs that address negative social norms that lead to increased risk of HIV infection for young girls. Behavior change activities are directed at older men who seek sexual relationships with younger girls and the communities that explicitly or implicitly condone such relationships.

In South Africa, a number of PEPFAR partners are bringing tailored AB messages into communities with door-to-door counseling on risk assessment and behavior change, as well as the use of traditional healers to deliver prevention messages that reinforce traditional values.

In Uganda, PEPFAR has supported the development and tailoring of school-based prevention curriculum. Support for the Presidential Initiative on AIDS Strategy for Communication to Youth, a school-based HIV/AIDS communication initiative for youths, has provided training for a large number of primary school teachers on abstinence and life skills messages, as well as related teaching and reading materials.

In Namibia, a PEPFAR partner is focusing on prevention by strengthening AB messages at counseling and testing sites in the community setting, providing counseling and testing for partners and family members of people who are HIV-positive, offering risk reduction counseling, and stressing the importance of being faithful to a partner of known HIV status.


SOURCE: OGAC, 2006c.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
Condoms and Other Prevention

Activities aimed at preventing sexual transmission of HIV under the condoms and other prevention subcategory include interventions for a number of priority groups, such as sero-discordant couples, people living with HIV, the military, police, commercial sex workers and their clients, truck drivers, and refugees. These interventions include mass media campaigns, peer-to peer counseling, condom promotion, and communication interventions targeting behavior change in high-risk venues and along transportation corridors. There are a number of examples of comprehensive and appropriate PEPFAR-funded programs addressing the needs of these populations. However, because of a lack of systematic data on these programs and on the needs of populations most at risk in the focus countries, it is not possible to determine the extent to which these programs are addressing the needs.

According to OGAC, the total number of U.S. government–funded male and female condoms shipped to the focus countries increased from 115 million in 2001 to 198 million in 2005 (OGAC, 2006b) with a total of nearly 407 million condoms purchased for the focus countries in the first 3 years of PEPFAR (OGAC, 2007). The number of U.S. government–funded condoms shipped to individual focus countries in 2005 ranged from 0 to nearly 70 million (OGAC, 2006b). It is unclear how much of the increase in condoms provided to the focus countries is due to PEPFAR. The relevant data for 2002 through 2004 were not available to the Committee, and in many of the countries, U.S. government agencies are funding other development programs, such as family planning programs, that include the distribution of condoms. As of June 2006, PEPFAR had supported nearly 86,000 condom outlets (OGAC, 2006a).

OGAC reports that the lack of data with which to determine the number of condoms provided specifically under PEPFAR is linked to rules that apply to the focus countries’ access to a commodities fund that is generally used to purchase condoms for U.S. Agency for International Development (USAID) programs. According to discussions with OGAC and Country Teams, USAID programs in countries other than the PEPFAR focus countries typically pool worldwide condom orders and procure the condoms centrally for both family planning and HIV prevention programs. Because the focus countries are reportedly not eligible to receive condoms from the commodities fund because of the interpretation of legislative intent, a number of PEPFAR-supported programs use their PEPFAR funds to purchase condoms. OGAC officials also reported that family planning and HIV prevention programs promote the use of condoms for health generally, including prevention of both disease and pregnancy. Thus all of the condoms shipped to the focus countries are used for both purposes.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

In addition to the interventions described above, PEPFAR is supporting the development of a number of new prevention technologies, such as microbicides (female-controlled chemical barriers to prevent transmission of HIV). The U.S. Global AIDS Initiative, through the National Institutes of Health, supports scaling up for clinical trials of three microbicide candidates as well as the HIV Prevention Trials Network, a worldwide collaborative that develops and tests the safety and efficacy of nonvaccine interventions designed to prevent HIV transmission (OGAC, 2005b).

A variety of other prevention activities are funded under the condoms and other prevention subcategory. For example, PEPFAR is supporting studies of risk reduction associated with male circumcision and of alcohol consumption as a risk factor for HIV transmission in a few of the focus countries. PEPFAR is also supporting the training of clinicians and peer counselors in how to communicate comprehensive ABC-based prevention messages. Workplace prevention programs funded by PEPFAR are focused on the development of workplace strategies and training for how to deal with the personal and potential commercial impacts of HIV/AIDS in the workplace.

Comprehensive and integrated approaches drawing on all components of ABC and targeting specific populations have been shown to be effective in increasing healthy behaviors and decreasing transmission of HIV, especially when integrated with other HIV services, such as counseling and testing, treatment of other sexually transmitted infections, and antiretroviral therapy (ART) (Stanton et al., 1998; Furguson et al., 2004; Bunnell et al., 2006; Riedner et al., 2006). There is, however, little evidence to show that ABC when separated out into its components is as effective as the comprehensive approach (Bollinger et al., 2004).

Examples of condoms and other prevention activities in selected focus countries are presented in Box 4-2.

Information Campaigns and Training

Overall, OGAC has reported reaching more than 140 million people in the 15 focus countries with messages intended to prevent the sexual transmission of HIV, a number that represents over one-fourth of the combined population of more than half a billion people in the focus countries. Of this total, roughly two-thirds of people received abstinence-until-marriage/be faithful messages and roughly one-third received condoms and other prevention messages. PEPFAR has supported the training or retraining of more than 864,000 people for prevention programs related to preventing sexual transmission of HIV. Roughly two-thirds of those trained were trained for abstinence-until-marriage/be faithful programs (OGAC, 2005b, 2006a,b, 2007).

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

BOX 4-2

Selected Examples of PEPFAR-Supported Condoms and Other Prevention Activities

In Mozambique, PEPFAR has supported a condom social marketing program through which condoms are sold in bars, hotels, and shops along transportation corridors and other areas of high-risk behavior. The program includes behavior change communication targeting those most at risk of transmission, such as uniformed services and mobile populations.

In South Africa, a PEPFAR-funded program is supporting the scale-up of postrape services, including postexposure HIV prophylaxis. This program also includes policy development and training for health and social workers and police.

In Haiti, a comprehensive PEPFAR-funded program targets commercial sex workers. The sex workers are provided some services, including counseling and testing and condoms, on site, and are referred to sex worker–friendly sites for the provision of other services, including counseling and testing and clinical treatment of sexually transmitted and opportunistic infections. People who are HIV-positive and their partners are referred through strong networks for care and treatment services, as needed.

In Botswana, PEPFAR is supporting two programs aimed at reducing the contribution of alcohol use to the HIV/AIDS epidemic—one targeting health care workers and another targeting drinking establishments and their patrons.

In Uganda, PEPFAR is funding a number of prevention programs focused on prevention for sero-discordant couples in which counseling and testing, including a door-to-door counseling and testing program piloted in 2005, is the key entry point for other prevention programming.

In Namibia, PEPFAR has partnered with the Namibian Defense Force and the Ministry of Defense to fund “edutainment” events; training of Ministry of Defense personnel in home-based care, peer education, and gender sensitivity; policy discussions with the Ministry’s higher echelons; and provision of materials for information, education, and communication.


SOURCE: OGAC, 2006c.

Prevention of HIV Transmission Through Injecting Drug Use

One of the most-at-risk populations for HIV transmission is people who use injection drugs. Current U.S. policy prohibits the U.S. Global AIDS Initiative from funding needle or syringe exchange programs (OGAC, 2006f), and thus from supporting all aspects of the complete recommended comprehensive package of services for people who use injection drugs (UNAIDS, 2005b). However, the PEPFAR strategy acknowledges the need for comprehensive HIV prevention and care programs for people who use injection drugs, especially in countries such as Vietnam where HIV infection

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

is at low levels in the general population, and those who use injection drugs are pivotal in increasing HIV infection rates among the general population (OGAC, 2004). PEPFAR-supported activities targeted to people who use injection drugs include working with ministries of health on relevant national policies and supporting assessments of the contribution of substance use to the HIV epidemic globally; development of culturally appropriate 12-step programs to decrease drug use; education of health professionals and policy makers regarding best practices for HIV prevention strategies for people who abuse substances; peer-to-peer counseling on HIV; confidential, routine HIV counseling and testing in substance abuse programs; community-based outreach that addresses HIV prevention, risk reduction, and substance use with links to appropriate care services; prevention education on the risks of injecting drugs and sharing syringes; education and counseling on how to reduce or stop injecting drugs; HIV treatment or referral to treatment for an HIV-infected person who uses drugs; and substance abuse treatment programs for HIV-infected people, including medication-assisted treatment with methadone, buprenorphine, and naltrexone. For people who are HIV-negative, PEPFAR can only support medication-assisted treatment on a pilot basis, and support for all medication-assisted substance abuse therapy requires prior approval from OGAC (OGAC, 2006f).

Prevention of Mother-to-Child Transmission

In 2005, approximately 700,000 children under age 15 worldwide became infected with HIV, mainly through mother-to-child transmission. Approximately 90 percent of these infections due to mother-to-child transmission occurred in Africa. Studies have shown that transmission can take place during pregnancy, labor, or delivery and through breastfeeding. In the absence of any intervention, rates of mother-to-child transmission of HIV can vary from 15 to 30 percent without breastfeeding and from 30 to 45 percent with prolonged breastfeeding (WHO, 2002a). A comprehensive set of activities—including counseling and testing, prophylactic antiretroviral therapy in late pregnancy and delivery, as well as for the newborn; safe delivery practices; and use of breastmilk substitutes when safe water is available—has been found to be effective in preventing transmission of HIV to infants. The United Nations Children’s Fund (UNICEF) has estimated that only 9 percent of pregnant women who were HIV-positive in low- and middle-income countries received antiretroviral prophylaxis for prevention of mother-to-child transmission in 2005 (UNICEF et al., 2007).

Successful prevention of mother-to-child transmission of HIV requires that each mother–infant pair participate in a cascade of events that begins with HIV testing and continues through postdelivery follow-up and testing for the infant at age 18 months (Stringer et al., 2005). Dadian

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

and colleagues (2003) have identified the following steps in the process: attendance at an initial antenatal care visit, pretest counseling related to HIV and mother-to-child transmission, receipt of an HIV test, provision of antiretroviral prophylaxis, counseling on methods for reducing transmission through breastfeeding, follow-up with mother and child postdelivery, and HIV testing or assessment for the infant after age 18 months. Declines in participation have been found at each of these steps as the result of a variety of factors, including denial of HIV infection, opposition from male partners, women’s fear of disclosure of HIV status to their partner and fear of being “found out” if they are taking drugs or not breastfeeding, concern about taking drugs in pregnancy, failure to return for checkups in the month before delivery, home delivery, and premature delivery before treatment can be given (GHPWG, 2004). Because failure to complete all steps can result in reduced coverage and diminished program effectiveness, it is crucial to collect information at each step to enable tracking of the points at which mothers are discontinuing services (Stringer et al., 2005).

Country Operational Plans describe PEPFAR support for national efforts to prevent mother-to-child transmission through a number of avenues. At the national level, PEPFAR provides technical assistance to host governments in the development and adoption of guidelines and policies aimed at improving the standardization and quality of such efforts. In addition, by helping to strengthen commodity management systems, PEPFAR partners increase the availability of many commodities essential to these prevention efforts, including antiretroviral medications and test kits (OGAC, 2006c).

At the community level, PEPFAR-funded programs are expanding the numbers of sites providing services related to prevention of mother-to-child transmission and antenatal care in an attempt to expand the utilization of these services. Such services are crucial in settings where relatively few women give birth in health care facilities and would otherwise miss the opportunity to receive prophylactic antiretroviral medications at birth and reduce the risk of transmission to their infants. PEPFAR programs are working with national leaders and local health care workers to find ways of providing the medications and of offering follow-up and postpartum care in nontraditional settings, including giving the medications to pregnant women to take home and training traditional birth attendants in prevention of mother-to-child transmission. PEPFAR programs also give pregnant women information on how to reduce the risk of transmission to their infants through breastfeeding. Finally, in some focus countries, PEPFAR is supporting the improvement and expansion of information management systems and conducting evaluations to assess the effectiveness of specific preventive programs for mothers (OGAC, 2006c). Box 4-3 provides some examples of PEPFAR-supported activities aimed at preventing mother-to-child transmission in selected focus countries.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

BOX 4-3

Selected Examples of PEPFAR-Supported Activities Aimed at Preventing Mother-to-Child Transmission

In Kenya, PEPFAR-supported programs are adopting a family approach to reduce stigma, increase uptake of services, and improve adherence to ART through couples counseling and testing, male involvement, and community-based promotion of HIV care. In addition, pregnant women with World Health Organization (WHO) stage III and IV disease will be referred to comprehensive care centers for ART as a strategy for preventing mother-to-child transmission; these services will be provided in provincial, district, and high-volume health centers.

In Rwanda, PEPFAR is supporting the national program through interpersonal and mass media communications that promote early antenatal clinic attendance, delivery in health care facilities, safe infant feeding practices, early infant diagnosis, and male involvement.

In Nigeria, PEPFAR is supporting antenatal services, laboratories, and training of personnel involved in counseling and testing and obstetric and gynecologic services at designated hospitals. PEPFAR funding also covers the procurement of prophylactic antiretroviral medications and breastmilk substitutes, as well as the costs of laboratory tests for diagnosis and monitoring.

In Botswana, PEPFAR is supporting the expansion of psychosocial support services for women who are HIV-positive, their partners, and their families that include encouraging partners to be tested. This multicomponent project also supports a peer-counseling program, trains counselors to promote adherence to ART, offers support services to other people living with HIV/AIDS who are receiving ART, and links between ART programs and programs focused on prevention of mother-to-child transmission.


SOURCE: OGAC, 2006c.

According to OGAC, since the start of the program, PEPFAR has supported services to women during 6 million pregnancies to prevent mother-to-child transmission of HIV; and more than 533,000 of these women received antiretroviral prophylaxis. Overall, in the focus countries the proportion of eligible women who are receiving services to prevent mother-to-child transmission has increased from 2004 to 2006. Specifically, the proportion of eligible pregnant women receiving services such as counseling and testing has increased from 7 to 16 percent, and the proportion of HIV-positive pregnant women receiving antiretroviral prophylaxis has increased from 9 to 21 percent (OGAC, 2007).

Prevention of mother-to-child transmission is the only subcategory of prevention activities that has specific targets per country per year. Yet it is unclear how PEPFAR will factor these results into the model being used to

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

measure progress toward the overall prevention target. Given results thus far and the targets through 2007, it appears that the contribution of this subcategory to the overall target may be small. OGAC estimates infant infections averted by assuming, based on the cascade discussed earlier, that only 19 percent of the women who have been provided with antiretroviral prophylaxis will subsequently give birth to an infant who is HIV-negative. Through September 30, 2006, OGAC has estimated that PEPFAR-supported programs have prevented 101,500 infant infections (OGAC, 2007).

Training for prevention of mother-to-child transmission supported by PEPFAR has included in-service training of health care providers in antenatal clinics in counseling and testing and in the administration of antiretroviral medications. In addition, PEPFAR is working to expand the capacity of training facilities to meet personnel needs for these preventive programs by supporting the development of related curriculum. OGAC reports that PEPFAR has funded the training of more than 85,000 people to provide a variety of these preventive services, including HIV counseling and testing for pregnant women, antiretroviral prophylaxis, counseling and support for safe infant feeding practices, and family planning counseling and referral (OGAC, 2005b, 2006b, 2007).

Prevention of Medical Transmission of HIV
Blood Safety

The safety and availability of blood for transfusions has been negatively affected by the emergence and spread of HIV. Unsafe blood disproportionately impacts women (who often need transfusions for pregnancy-related complications) and children (who experience high rates of malnutrition, malaria, and severe life-threatening anemia). An inadequate supply of safe blood products results in many deaths in medical settings in developing countries (WHO, 2006a).

PEPFAR sees improving the availability and safety of blood as crucial to reducing the spread of HIV and to enabling the focus countries to develop basic infrastructure and strengthen their health care systems (Ryan, 2006). PEPFAR’s blood safety activities have included supporting the development of associated governance structures, increasing laboratory capacity to screen blood supplies for HIV and other diseases, training health care workers in safe blood transfusion methods, increasing the number of voluntary donors through awareness campaigns, and conducting quality evaluations to ensure the effective implementation of blood safety procedures. OGAC reports that PEPFAR funds have contributed to the establishment of more than 4,600 blood safety service outlets in the focus countries through support for infrastructure, equipment, and supplies; donor recruitment

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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activities; blood collection and distribution logistics; testing, screening, and transfusion; waste management; training; and management to ensure a safe and adequate blood supply. In addition, PEPFAR has supported the training of more than 16,700 people in blood safety procedures and services (OGAC, 2005b, 2006b, 2007). Examples of PEPFAR-supported blood safety activities in selected focus countries are presented in Box 4-4.

Injection Safety

Among sources of HIV infection associated with health care, injections with nonsterile equipment are of particular concern. In addition, protection of health care workers is an essential component of any strategy to prevent workers from discriminating against HIV-infected patients (WHO, 2006b).

PEPFAR has identified medical injection safety as a key component of its prevention strategy. Related activities provide a wide range of support to host countries, including the development of improved policies for safe injection practices and medical waste management, enhanced training of health workers, procurement of safe injection supplies, and support for the development and dissemination of communications addressing safe medical practices for both medical professionals and the public. OGAC reports that PEPFAR has supported the training of more than 68,000 people in injection

BOX 4-4

Selected Examples of PEPFAR-Supported Blood Safety Activities

In South Africa, PEPFAR supports the National Blood Service Program, which is coordinating with the National Department of Health and the Department of Education to provide prevention education to potential young donors to assist them in protecting themselves from infection and enable them to be “certified” as safe donors.

In Namibia, PEPFAR supported the addition of a blood donation site and a laboratory. PEPFAR funds also supported training in the recruitment of donors, processing of donated units, and purchase of blood safety equipment.

In Haiti, PEPFAR has supported a number of blood safety activities, including introducing new legislation to return supervision of the blood transfusion system to the Ministry of Health, increasing participation of voluntary donors through blood collection and public awareness campaigns, renovating blood clinics, increasing blood screening, and training clinicians and nurses in the clinical use of blood.


SOURCE: OGAC, 2006c.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

safety procedures and services (OGAC, 2005b, 2006b, 2007). Other accomplishments, such as supporting the establishment of government entities responsible for adopting national guidelines, monitoring injection safety practices, and overseeing the development of nursing school curriculum on medical injection, are described in the Country Operational Plans (OGAC, 2005d, 2006a,c). Examples of PEPFAR-supported injection safety activities are presented in Box 4-5.

Increased Focus on Gender Issues in Prevention

OGAC has provided Country Teams with guidance on ways to address gender issues in prevention programming appropriate to the context of each country. The Gender Technical Working Group identified review criteria for PEPFAR-supported prevention activities for the fiscal year 2007 Country Operational Plans. These include the following (OGAC GTWG, 2006):

  • Ensure equitable access to gender-appropriate prevention messages and services by girls and boys, women and men.

  • Support comprehensive, integrated efforts to reduce the practices of cross-generational and transactional sex, multiple sexual partners,

BOX 4-5

Selected Examples of PEPFAR-Supported Medical Injection Safety Activities

In Mozambique, PEPFAR has supported the Ministry of Health Biosafety Program and provided technical assistance and training to Ministry of Health staff to introduce a standards-based approach to biosafety in central and provincial referral hospitals, as well as technical assistance and training on injection safety at all levels of health facilities.

In Uganda, PEPFAR supported the development of a comprehensive medical safety program that included strengthening national leadership and medical safety bodies; implementing related policy and guidelines; constructing 10 incinerators in 10 districts in partnership with WHO; and procuring adequate supplies, such as auto-disabling syringes and needles.

In Vietnam, PEPFAR supports collaboration with the National Institute of Occupational and Environmental Health in Hanoi on medical safety that has been ongoing since 1999. Currently, PEPFAR supports staff exchanges aimed at training institute staff in occupational safety and health research techniques.


SOURCE: OGAC, 2006c.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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and gender-based violence, including activities to change male norms and behaviors.

  • Support interventions aimed at eradicating gender-based violence and the exploitation of women and girls by prostitution, sex trafficking, rape, and sexual abuse; provide postrape prophylaxis.

  • Ensure that vulnerable girls and women are reached by services that empower them to prevent HIV infection, including strategies to increase women’s access to employment and income generation.

  • Provide behavior change education on male norms, violence, and alcohol abuse to military, uniformed services, and mobile populations.

  • Address the unique needs of male and female users of injection drugs.

OGAC has identified the need to design prevention programs targeting women and girls, such as programs to prevent mother-to-child transmission of HIV and to provide voluntary counseling and testing. OGAC is also suggesting that PEPFAR programs create opportunities to establish connections with nonpregnant women and adolescent girls by using reproductive health and family planning programs as entry points. Many gender issues are being addressed in some PEPFAR-supported activities. The fiscal year 2006 Country Operational Plans contain many examples of PEPFAR prevention programs that include gender components. Without specific gender indicators or good data on which gender-focused interventions work best, however, OGAC will be unable to report what impact these programs are having on women’s risk of contracting HIV (OGAC GTWG, 2006; OGAC, 2006e). Moreover, programmatic barriers remain to reaching women who are at risk of contracting HIV, such as young girls engaging in transactional sex, commercial sex workers, and sero-discordant couples. Examples of gender-related activities supported by PEPFAR in selected focus countries are presented in Box 4-6.

ISSUES AND OPPORTUNITIES FOR IMPROVEMENT

Although it is difficult to report on the short-term progress of national prevention activities supported by PEPFAR, the Committee identified a number of issues and associated adjustments to the program that could enhance the quality, accountability, and flexibility of PEPFAR’s prevention efforts. These include collection of surveillance data, integration of prevention with treatment and care, greater flexibility to select country-appropriate prevention activities through removal of the abstinence-until-marriage budget allocation, and targeting of populations at greatest risk. Evaluation of prevention interventions, discussed in Chapter 8, represents another opportunity for improvement.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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BOX 4-6

Selected Examples of PEPFAR-Supported Prevention Activities That Include Gender Components

In Botswana, a PEPFAR-supported call center used to link people with HIV/AIDS services is being expanded to offer anonymous counseling for mental health problems and gender-based violence.

In Zambia, PEPFAR is supporting a weekly interactive national radio show, Club New Teen Generation, which is designed to promote a dialogue among and between youth, parents, teachers, and some high-profile public figures. Key themes of the show include gender issues such as cross-generational sex and means of improving sexual negotiation skills.

In Ethiopia, PEPFAR is supporting a program focused on addressing sexual violence against women, the delivery of postexposure prophylaxis, cross-generational and coercive sexual relationship behaviors, and substance abuse and sexual risk-taking behaviors.


SOURCE: OGAC, 2006c.

Collection of Surveillance Data

Data from sentinel and behavioral surveillance surveys are essential if national policy makers are to design responses to HIV/AIDS that appropriately address the risk behaviors fueling their country’s epidemic. For PEPFAR, such data are necessary to identify and target programs to those most at risk of contracting HIV. PEPFAR highlights the need to incorporate these data in the planning of prevention programs in each focus country in its guidance to the Country Teams. According to this guidance, the following steps are to be followed in the planning stage (OGAC, 2005e):

  • Estimate the proportion of new infections that are associated with specific behaviors, such as prostitution, early onset of sexual activity among youths, and transmission through sexual networks.

  • Review prevalence data available from national serosurveys, antenatal clinic surveillance, and/or voluntary counseling and testing clinics to assess infection burdens by age and gender.

  • Understand who is engaging in risk-related activities, how to reach these people, and what individual and structural factors can be leveraged to promote change.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

PEPFAR and other U.S. government–funded programs before it have supported the collection of surveillance data in many of the focus countries. However, the collection, analysis, and appropriate application of both sentinel and behavioral surveillance data pose a number of challenges. For example, methodological issues arise, such as low utilization of antenatal clinics, which compromises the representativeness of surveillance data, and the difficulty of accurate sampling of at-risk and/or marginalized groups for behavioral surveys of at-risk populations. Host countries’ capacity to analyze the data collected and apply the findings may be limited, and there may be political opposition to collecting accurate information on the epidemic.

Since 2000, a majority of the 15 focus country governments have been leading the collection of sentinel surveillance data, primarily in antenatal clinics. In addition, the Demographic and Health Surveys have been conducted in the majority of focus countries in the last 6 years. However, only a few of the countries have conducted behavioral surveys focused specifically on high-risk populations. Without behavioral data on these populations, it is difficult for countries and donors to know what specific factors are driving each epidemic and what particular interventions would be most successful for each country in preventing the further spread of HIV.

PEPFAR funds have directly supported the collection of surveillance data in all of the focus countries through technical assistance; updating of infrastructure to manage the data collected; and procurement of supplies, such as test kits, to be used in conducting the surveys. In addition, grantees are working to strengthen the capacity of ministries of health and the national AIDS agencies to develop and conduct surveys both on a national scale and for targeted populations. In a number of countries, PEPFAR has supported the placement of experts in the ministry of health or other relevant agencies to assist with specific projects, as well as to train staff in how to improve their data collection activities. PEPFAR has also supported the focus countries in appropriate use of the data being collected and to develop strategies for dissemination (OGAC, 2005c). In addition, slots have been created for PEPFAR Country Team staff with expertise in surveillance to coordinate all PEPFAR-funded surveillance activities and help direct the gathering of data at the country level (OGAC, 2005c).

In accordance with its own guidance, PEPFAR will need to use all available information on key risk behaviors and vulnerable populations in planning and implementing tailored prevention programs that address the needs of each focus country. PEPFAR’s continued support for the collection of sentinel surveillance and Demographic and Health Survey data in the focus countries, as well as for Country Operational Plans to conduct more frequent behavioral surveillance surveys, is required to ensure the availability of this information.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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Recommendation 4-1: The U.S. Global AIDS Initiative should enhance and intensify HIV prevention through a planning process that links timely national information on the epidemic to the selection of the most appropriate intervention packages and to the optimal targeting of interventions to populations in whom infections are most likely to occur. The U.S. Global AIDS Coordinator should enhance current data on HIV prevalence by supporting quality behavioral surveys to identify patterns of risk. The Coordinator should support country plans to identify where infections are to be averted to achieve prevention targets and should track progress toward achieving prevention goals by measuring risk behaviors, the prevalence and incidence of other sexually transmitted infections, and ultimately the prevalence and incidence of HIV.

Integration of Prevention with Treatment and Care

PEPFAR has increasingly emphasized the importance of integrating its prevention, treatment, and care interventions. However, the separation of counseling and testing from prevention in both budgeting and reporting creates a challenge to implementing the optimal package of integrated prevention activities. Even so, PEPFAR programs are working to improve the integration of services. It is, however, difficult to assess the success of these efforts as information on the extent of such programmatic linkages is not being collected.

Integration of HIV/AIDS prevention, treatment, and care programs has become more important with the scale-up of treatment and care programs, which has created opportunities to capitalize on prevention interventions (GHPWG, 2004). If countries do not succeed in stemming the tide of new infections, the need for treatment will continue to increase and outpace their ability to develop the capacity to meet it (Mathers and Loncar, 2006). Key integration points include ART, counseling and testing, prevention of mother-to-child transmission, and diagnosis and treatment of sexually transmitted infections. The Global HIV Prevention Working Group (2004) made the following recommendations for integrating HIV prevention and treatment programs:

  • Integrate HIV prevention and treatment. Health care settings, including HIV treatment sites, should deliver HIV prevention services that will train health care workers in the delivery of HIV prevention interventions. There should be significant expansion and aggressive promotion of voluntary HIV testing and counseling, which should be universally offered in all health care settings. Conversely, prevention programs should promote HIV testing, educate communities about HIV treatments, and facilitate linkages to ART and other care.

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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  • Develop prevention strategies for people who are HIV-positive. Programs tailored to the needs of people living with HIV/AIDS should be developed and implemented. These programs should involve people living with HIV/AIDS and combat stigma with enforceable laws.

  • Adapt prevention for people who are HIV-negative. New strategies must emphasize the continued importance of risk reduction and stress that ART is not a cure.

  • Monitor impact. Surveillance systems should closely monitor the behavioral impact of ART.

Integrated HIV/AIDS programs have been shown to improve the effectiveness of national programs in decreasing rates of HIV infection and death from AIDS. A UNAIDS (2005a) study projects numbers of new HIV infections and AIDS deaths through 2019 based on models for treatment-centered, prevention-centered, and joint prevention/treatment global responses. The latter model results in the largest number of infections averted and the lowest number of AIDS deaths over a 15-year projection. Similarly, an optimistic model developed by Mathers and Loncar (2006), which assumes increased prevention activity, projects a decline in HIV/AIDS deaths as of 2030 from an estimated baseline of 6.5 million to 3.7 million. Likewise, a conference of Christian Aid HIV partners underscored the need to shift the focus of HIV interventions from a prevention-specific ABC approach to a comprehensive approach developed by the African Network of Religious Leaders Living with or Personally Affected by HIV/AIDS called SAVE (Safer practices, Available medications, Voluntary counseling and testing, and Empowerment).

In most of the focus countries, HIV infection is hyperendemic, with transmission occurring from those unaware of their infection status to others unaware of the risk (often spouses of either gender). Counseling and testing are therefore essential to achieving a long-term, sustainable impact on reducing HIV transmission, as well as meeting treatment and care goals. Given its placement in the care category, it appears that PEPFAR views counseling and testing primarily as a means of identifying HIV/AIDS cases eligible for treatment and care. In addition to case finding, however, counseling and testing represents an opportunity to provide HIV education, including prevention messages to people testing both positive and negative for HIV.

PEPFAR continues to struggle with how to integrate prevention, treatment, and care activities and how to measure the level of integration both among PEPFAR-funded services and between those services and the broader health care system in each focus country. For example, OGAC has endeavored to afford Country Teams greater flexibility in planning and budgeting their fiscal year 2007 ABC programs. Country Teams will

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

be able to use combined abstinence/be faithful and condoms and other prevention funds from the same partner to implement integrated interventions. PEPFAR’s continued attention to the barriers involved is required to improve the integration of prevention with treatment and care services, especially with regard to counseling and testing.

Greater Flexibility to Select Country-Appropriate Prevention Activities

In addition to epidemiologic data and evidence on specific interventions typically used in the development of prevention programs, PEPFAR’s prevention planning is controlled in part by budgetary allocations outlined in its authorizing legislation. The variability of the epidemics in the focus countries underscores the need for specific and timely information in designing prevention programs that address the most important needs and can result in the most infections averted. Even when sufficient data are available, however, Country Teams are not completely free to target funding and interventions to those at greatest risk of acquiring HIV and to prevent transmission from people living with HIV and within sero-discordant couples through improved integration with counseling and testing, care, and treatment.

Since the beginning of the program, concern has been raised about the ability to implement appropriate, integrated, and comprehensive prevention programs given the restriction created by the 33 percent abstinence-until-marriage budgetary allocation. In 2005, OGAC provided guidance to Country Teams for implementing this allocation. This guidance included the implementation definitions of abstaining from sex until marriage (A), being faithful to one partner (B), and using condoms (C), as well as details on how to fund tailored, country-specific prevention activities through the appropriate mix of those components. Nonetheless, confusion and frustration in the field caused by the abstinence-until-marriage allocation have persisted, as reflected in the Committee’s discussions with PEPFAR Country Teams during its country visits in which staff indicated that the allocation did not allow them sufficient flexibility to create the appropriate prevention portfolio based on the available data. The Government Accountability Office (GAO, 2006) reached a similar conclusion. OGAC has attempted to provide the Country Teams with greater flexibility through a variety of management policies, but the problem remains. See Chapter 3 for further discussion of and the Committee’s recommendation related to the budget allocations.

Targeting Prevention Interventions

The proportions of total PEPFAR prevention funding allocated to each subcategory—abstinence/be faithful (30 percent), condoms and other

Suggested Citation:"4 PEPFAR's Prevention Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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prevention (22 percent), prevention of mother-to-child transmission (22 percent), blood safety (14 percent), and medical injection safety (12 percent)—are not well-aligned with the estimated proportions of new infections from the major routes of transmission. For example, it is estimated that in sub-Saharan Africa, transmission through sexual contact, from mother-to-child, and via health care procedures (including blood transfusions and medical injections) account for 80–90 percent, 5–35 percent, and 5–10 percent of new infections, respectively, with regional variation (NAS, 1994; Quinn et al., 1994; Quinn, 1996, 2001; WHO, 2002b; Askew and Berer, 2003; Bertozzi et al., 2006).

Together, the two subcategories related to sexual transmission—abstinence/be faithful and condoms and other prevention (which also includes funds for activities related to people who use injecting drugs), account for approximately 52 percent of PEPFAR’s prevention funding, well below the estimated contribution of sexual transmission to new infections. In contrast, the blood safety and safe injection subcategories make up 25 percent of PEPFAR prevention funding but are responsible for a much smaller proportion of new infections.

CONCLUSION

In its effort to achieve the target of preventing 7 million infections in the 15 focus countries by 2010, PEPFAR supports the implementation of various prevention interventions, including voluntary counseling and testing, prevention of mother-to-child transmission, and many ABC-related programs, that have been shown to lead to a decrease in the transmission of HIV when targeted to the appropriate populations. It is difficult to know whether these activities will lead to the necessary national declines in incidence, however, because of a lack of information on both the short-term progress of the interventions and the extent to which PEPFAR has been able to target these interventions to those populations most at risk. To support the implementation of comprehensive and evidence-based prevention interventions appropriate to each country’s unique epidemiologic and cultural context in order to achieve the prevention target, PEPFAR will need to make a number of adjustments to enhance its surveillance efforts, integrate prevention with treatment and care, and allow greater flexibility in its prevention programs.

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In 2003, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, which established a 5-year, $15 billion initiative to help countries around the world respond to their AIDS epidemics. The initiative is generally referred to by the title of the 5-year strategy required by the act--PEPFAR, or the President's Emergency Plan for AIDS Relief.

PEPFAR Implementation evaluates this initiative's progress and concludes that although PEPFAR has made a promising start, U.S. leadership is still needed in the effort to respond to the HIV/AIDS pandemic. The book recommends that the program transition from its focus on emergency relief to an emphasis on the long-term strategic planning and capacity building necessary for a sustainable response. PEPFAR Implementation will be of interest to policy makers, health care professionals, special interest groups, and others interested in global AIDS relief.

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