The Committee believes these improvements are necessary to create conditions that will facilitate the access of women and girls to HIV/AIDS services; support them in changing behaviors that put them at risk for HIV transmission; allow them to better care for themselves, their families, and their communities; and enhance their ability to lead and be part of their country’s response to its HIV/AIDS epidemic (WHO, 2007).

Expanded Capacity Is Necessary to Meet Current and Future Needs

The impact of capacity constraints on the implementation of PEPFAR is a common theme of this report. PEPFAR’s initial emergency approach was to rely heavily on U.S.- and country-based contractors who had existing operations that could be scaled up relatively quickly with an infusion of resources and to strengthen the existing capacity in the focus countries. Through this approach, the initiative has supported the delivery of counseling and testing, ART, prevention of mother-to-child transmission, and other HIV/AIDS services to millions of people; the renovation and equipping of hundreds of counseling and testing, treatment, pharmacy, information technology, laboratory, and other facilities; and the training of thousands of clinicians, pharmacists, laboratory technologists, epidemiologists, information technology specialists, and other health care workers (OGAC, 2005a, 2006a, 2007). OGAC reported that to date PEPFAR has provided nearly $350 million for capacity building including training and the development of networks, human resources, and local organizations (OGAC, 2007). However, the growing consensus is that existing capacity for HIV/AIDS services is nearing exhaustion, and donors need to focus more on helping to expand capacity. During its visits to the focus countries, the Committee saw many programs of all varieties, but particularly those providing ART, that were overflowing their capacity, had long waiting lists, and had insufficient numbers of staff who were highly stressed. The shortage of health care workers of all kinds was particularly acute. To be successful over the long term, the U.S. Global AIDS Initiative will need to continue to help increase the capacity of the focus countries to sustain and expand their gains against the epidemic, both directly by investing in capacity building and indirectly by implementing PEPFAR in a way that strengthens and does not undermine existing public health systems. “Capacity” needs to be conceptualized broadly and will need to be expanded at all levels: individual, family/household, community, and country.

Initially, the Leadership Act assumed that the primary challenge of the U.S. Global AIDS Initiative would be to afford and provide ARVs—hence the budget allocation of 55 percent of total PEPFAR funding for treatment, 75 percent of this for ARVs. As implementation has progressed, that challenge has remained, while many other challenges to providing ART and other services have come to the fore. These include prevailing conditions

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