document such programs (see Chapter 3 for discussion of the Committee’s recommendation).

Need to Address Tuberculosis/HIV Coinfection

Another large group of people who are benefiting greatly from PEPFAR programs are those coinfected with tuberculosis and HIV. The immunodeficiency associated with HIV/AIDS has fueled a rapid resurgence of tuberculosis in both children and adults throughout sub-Saharan Africa. In several focus countries, the most frequent cause of death in people with HIV/AIDS is rapidly progressive tuberculosis (Elliott et al., 1993; Harries et al., 2001). In some communities, up to 75 percent of people newly diagnosed with active tuberculosis have concomitant HIV/AIDS infection (Lawn et al., 2006), and an effective response to therapy for tuberculosis depends on concomitant treatment of HIV/AIDS. This poses a challenge, since rifampicin, one of the most effective anti-tuberculosis medications, decreases the plasma levels of several first- and second-line ARVs (Aaron et al., 2004). The Committee learned that effective dosing schedules to overcome this problem are now being introduced at PEPFAR-supported treatment sites.

PEPFAR categorizes tuberculosis/HIV coinfection and other opportunistic infections under its care category. Therefore, these issues are discussed more fully in Chapter 6.

Limited Direct Support for Nutrition

Inadequate caloric intake is a major problem in some regions of all the focus countries and has been clearly identified as a principal reason for failure of clinical response to ART in several regions (Wools-Kaloustian et al., 2006). PEPFAR has recognized this problem and supported many programs in undertaking initiatives to address it. Many patients identified as having HIV infection in the focus countries have lost considerable amounts of weight, and are severely malnourished by the time the diagnosis has been established and ART initiated. Several focus country programs are using PEPFAR funds to develop and implement innovative nutritional support programs for patients receiving ARVs, and additional sites have requested that PEPFAR provide funds to increase nutritional support.

OGAC reported that when possible, PEPFAR has been coordinating with other U.S. government partners such as the U.S. Department of Agriculture and with United Nations agencies, private volunteer organizations, and other international and local partners to ensure that nutritional support is being provided to people living with HIV/AIDS. Additionally, in cases where no other food support resources are available, PEPFAR directly funds the provision of nutritional support both to patients receiving ART and



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