The commitment of the U.S. Global AIDS Initiative to work toward reducing stigma and discrimination against people living with HIV/AIDS requires that marginalized and difficult-to-reach groups receive prevention, treatment, and care services. These groups include sex workers, prisoners, those who use injection drugs, and men who have sex with men—groups that not only are characterized by their high-risk behavior, but also tend to be stigmatized and subject to discrimination. The U.S. Global AIDS Coordinator should document how these groups are included in the program planning, implementation, and evaluation of PEPFAR activities. (3.2)

Expanded Capacity Is Necessary to Meet Current and Future Needs

Severe human resource shortages are a continuing challenge to PEPFAR implementation (OGAC, 2005b, 2006b; WHO, 2006c). Plans for ART scale-up that have been developed by some partner countries and are now being formulated in others include specific efforts to increase the health care workforce, with an emphasis on increasing the numbers of nurses, clinical officers, and pharmacists, among others. Training periods for these vital personnel are typically 2 to 3 years. Expansion of class sizes and repetition of existing programs are, in some partner countries, easily identified and cost-effective means for workforce expansion. In other countries, the lack of clinical faculty mirrors the lack of overall personnel, and increases in the numbers of teachers are badly needed (UNAIDS, 2006).

PEPFAR’s initial emergency approach to meeting personnel needs has been to focus on HIV-specific training of existing clinicians and other health care workers (OGAC, 2006d). Support for expansion of the professional clinical workforce has been limited, even when such expansion is an explicit part of the country’s HIV/AIDS plan, and the effort is endorsed and supported by other donors (OGAC, 2005c, 2006g). During its visits to the focus countries, the Committee saw many programs of all varieties—particularly ART programs—that were overflowing their capacity, had long waiting lists, and had insufficient numbers of staff who were highly stressed. PEPFAR Country Teams often expressed concern that they were not allowed to fund activities unless those activities were specifically part of the HIV/AIDS effort and so could not support, for example, the training of new clinical officers, who in some countries are the mainstay of the treatment effort.

PEPFAR reports that its response to the shortage of health workers to date has been to provide support, within national plans and priorities and the principles of harmonization, for policy reform to promote task shifting from physicians and nurses to community health workers; for

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