the precursor for adaptive, evidence-based programming, would better enable the initiative to have an optimal impact.

Although they may have been helpful initially in ensuring a balance of attention to activities within the four categories of prevention, treatment, care, and orphans and vulnerable children, the Committee concludes that rigid congressional budget allocations among categories, and even more so within categories, have also limited PEPFAR’s ability to tailor its activities in each country to the local epidemic and to coordinate with the level of activities in the countries’ national plans. Congress should remove the budget allocations and replace them with more appropriate mechanisms that ensure accountability for results from Country Teams to the U.S. Global AIDS Coordinator and to Congress. These mechanisms should also ensure that spending is directly linked to and commensurate with necessary efforts to achieve both country and overall performance targets for prevention, treatment, care, and orphans and vulnerable children. (3.3)

Expansion, Improvement, and Better Integration of Services Are Needed for Sustainability

If the U.S. Global AIDS Initiative is to succeed, it is essential that PEPFAR support programs and services that are evidence-based; strategically planned using the best data available; and implemented equitably, efficiently, and effectively (UNAIDS, 1998, 2004b). Although PEPFAR does not necessarily categorize activities in accordance with global norms, it is supporting all of the major components of a comprehensive HIV/AIDS program recommended by global consensus (UNAIDS, 2001, 2005b; WHO, 2004). The Committee observed much promise in the programs PEPFAR supports, as well as room for improvement and a need for expansion. Of particular importance is for PEPFAR to support programs in a manner that fosters integration both within and among the program categories of prevention, treatment, care, and orphans and vulnerable children—or, more appropriately, regardless of categorization. Neither the congressional budget allocations discussed above nor the budgeting, planning, and reporting mechanisms the Coordinator established to ensure that PEPFAR complies with these allocations facilitate integration. Optimal integration is critical to achieve not only the success of individual interventions and services, but also to realize the additional benefits that derive from the synergy among them (Salomon et al., 2005). The Committee’s recommendation for improving PEPFAR’s approach to prevention was discussed earlier; recommendations for improving its approach to treatment, care, and services for

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