Although PEPFAR promotes integration of ART with other needed prevention, treatment, and care services, primarily through referral, PEPFAR’s programmatic division into discrete prevention, treatment, and care categories does not facilitate integrated services. The Committee observed and was told about many needed improvements in the integration of ART, for example, with counseling and testing; with treatment programs for other sexually transmitted infections, tuberculosis, and malaria; with reproductive health clinics; with home-based care programs; and with community-based programs. A particular problem resulting from the lack of integration is a disconnect between HIV testing and ART availability. The Committee visited a number of sites where large numbers of people who had been identified as HIV-positive and in need of treatment could not access it. This lack of access was due in part to the rapid scale-up of testing programs not linked to treatment sites and ARV availability. Some of the clinicians with whom the Committee met reported that knowledge of HIV infection in large numbers of people for whom no treatment was available was profoundly demoralizing to they themselves, as well as to those eligible but untreated and those already in treatment in the same areas. The need for evaluations aimed at understanding the appropriate balance between testing and treatment specifically and how to achieve better integration of programs generally is discussed in Chapter 8.
Overall, 12- to 18-month follow-up results for ART appear to have exceeded expectations in focus countries for which adequate follow-up data are available (Stringer et al., 2006; Wools-Kaloustian et al., 2006). This, however, is an area to which more attention will need to be directed, with specific information being gathered on such critical issues as ability to return to the workforce and presence or absence of long-term side effects of ART. The effectiveness and sustainability of the PEPFAR program will be dependent on the improved quality of life and return to normal daily activities of a large proportion of patients receiving ART. Data on the effectiveness of ART exist for some cohorts of patients in the focus countries, but are not yet uniformly available. PEPFAR will need to support the focus country ART programs in making such data routinely available.
Globally, the roll-out of ART to pediatric populations has lagged considerably behind that to adults (GAA, 2006; UNAIDS, 2006). The reasons