for ART, tuberculosis, and opportunistic infections; and monitor adherence (OGAC, 2006c).

PEPFAR’s support of ministries of health in making such changes and its dissemination of information on their success are important elements of the development of an efficient cadre of workers to carry out treatment (OGAC, 2006c). While task shifting is an important step toward addressing the shortage of health care workers, however, there are also a number of ways in which existing personnel can improve efficiency without practice rules being altered. These include changes in protocols to reduce the number of repeat visits made by stable patients, reductions in the requirements for what must take place during a visit, and improvements in record keeping and the efficiency with which facilities operate. In this area as well, PEPFAR’s emphasis on identifying and sharing the most successful innovations is particularly important.

Improvements in efficiency through training Since the beginning of the program, PEPFAR has supported training of more than 100,000 service providers in ART. Also, the program supported more than 1,900 sites for ART in the 15 focus countries (OGAC, 2005a, 2006c, 2007). As of July 2006, OGAC estimated that $140 million had been committed to training (OGAC, 2006c).

Twinning, which pairs educational institutions to build cooperation in development, was proposed by WHO as an attractive approach to policy reform in sub-Saharan Africa as early as 1997. Twinning between industrialized and developing countries, across developing countries, and between institutions within a country has been a mainstay of PEPFAR policy (WHO, 2001; OGAC, 2005a, 2006a,c). Support in this area includes curriculum development that integrates HIV/AIDS care into nursing and medical school curricula.

Training of more personnel As described, PEPFAR’s initial emergency approach to personnel was to focus on HIV-specific training of existing clinicians and other health care workers. Contributions to expansion of the general workforce have been very limited, even when such expansion has been an explicit part of the country’s AIDS plan and the effort has been endorsed and supported by other donors. As noted earlier, during its visits to the focus countries, the Committee saw many programs of all varieties—particularly ART programs—in need of additional staff. Some Country Teams expressed concern that they were not allowed to fund activities unless they were specifically part of the HIV/AIDS effort and thus could not support, for example, the training of new clinical officers, who in some countries are the mainstay of the treatment effort.

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