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PEPFAR Implementation: Progress and Promise
on integration. Funding for PEPFAR-supported treatment activities includes ART and laboratory infrastructure and has roughly tripled from 2004 to 2006 (see Chapter 3).
PEPFAR’s 5-year treatment target, as described in the program’s authorizing legislation, is to support the focus countries in providing ART to 2 million people. This target represents a count of the number of people receiving ART that is supported directly or indirectly by PEPFAR, and is a globally accepted and widely used early indicator of program implementation. This count provides limited information and does not indicate how well people receiving ART are doing or how the availability of ART affects a country and its HIV/AIDS epidemic. Challenges to obtaining this count are discussed in this chapter; measures of treatment success are addressed in the discussion of impact evaluation in Chapter 8.
Similar to other donor programs, PEPFAR has had to balance its need to be accountable to the U.S. Congress with its accountability to the people of the focus countries within the framework of harmonization. The program has faced the dilemma of needing information that is not readily or routinely available from clinics or ministries of health, and has imposed unprecedented reporting requirements on both urban and rural treatment centers that often have severe shortages of personnel at all levels.
At the global level, PEPFAR requirements for monitoring the number of people receiving ART are reasonably well harmonized with the recommended indicators of the World Health Organization (WHO) and their definitions. PEPFAR generally supports the WHO-recommended tools, including patient records and ART registers, for monitoring and evaluating ART.
Information systems in the focus countries are generally in need of substantial development and strengthening, and PEPFAR is supporting improved HIV-related information systems from the level of rural clinics to that of ministries of health. Although PEPFAR is supporting some innovative information system projects, paper-based records and limited computer access are still the prevailing norm in the focus countries. Provision of even basic monitoring data therefore remains a challenge in most of the countries.
PEPFAR has had to work closely with host countries and other donors to determine which people on ART it can fairly count as having received its support. Host countries are understandably sensitive to donors appearing to take credit for the country’s accomplishments, and it is important at both the country and global levels to avoid double-counting if an accurate accounting of the proportion of eligible patients who are receiving ART is to be obtained. Initially, PEPFAR did create ill will in a few focus countries