2

The U.S. Global AIDS Initiative: Context and Background

Summary of Key Points

  • PEPFAR, the largest bilateral initiative for HIV/AIDS funding, is one of many efforts taking concerted action against the pandemic. Multiple donor efforts eventually led the Joint United Nations Programme on HIV/AIDS (UNAIDS) to propose a framework and set forth principles for supporting countries’ ownership of their responses to their epidemics and harmonizing national HIV/AIDS responses.

  • The development, implementation, monitoring, and evaluation of global HIV/AIDS programming are complicated by contextual challenges, such as concurrent public health epidemics; poor nutrition; poverty; capacity constraints with respect to human, fiscal, technical, and infrastructure/system resources; and sociocultural challenges of stigma and discrimination, and the vulnerable status of women, girls, orphans, and other children in many of the focus countries.

  • PEPFAR’s landmark authorizing legislation prescribes many aspects of the program, including development of a comprehensive global strategy for programming based on sound science and available best practices, budgetary allocations for categories of programmatic activities, creation of the oversight position of the U.S. Global AIDS Coordinator, expectations for unprecedented coordination among U.S. government agencies and international stakeholders, assignment of responsibilities to involved U.S. government agencies and programs, and identification of the priority countries for action.

  • The U.S. Global AIDS Coordinator is charged with coordinating all U.S. international activities to combat HIV/AIDS. The Office of the U.S. Global AIDS Coordinator (OGAC) is the central headquarters for the initiative. It consists of a small staff of experts in areas critical to headquarters-level coordination of the different agencies involved, as well as the development of policy and programmatic guidance for the field. Program implementation is accomplished primarily by teams in the focus countries. These Country Teams are based in the embassy and led by the ambassador, and are supported by core teams and technical working groups based at OGAC.



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PEPFAR Implementation: Progress and Promise 2 The U.S. Global AIDS Initiative: Context and Background Summary of Key Points PEPFAR, the largest bilateral initiative for HIV/AIDS funding, is one of many efforts taking concerted action against the pandemic. Multiple donor efforts eventually led the Joint United Nations Programme on HIV/AIDS (UNAIDS) to propose a framework and set forth principles for supporting countries’ ownership of their responses to their epidemics and harmonizing national HIV/AIDS responses. The development, implementation, monitoring, and evaluation of global HIV/AIDS programming are complicated by contextual challenges, such as concurrent public health epidemics; poor nutrition; poverty; capacity constraints with respect to human, fiscal, technical, and infrastructure/system resources; and sociocultural challenges of stigma and discrimination, and the vulnerable status of women, girls, orphans, and other children in many of the focus countries. PEPFAR’s landmark authorizing legislation prescribes many aspects of the program, including development of a comprehensive global strategy for programming based on sound science and available best practices, budgetary allocations for categories of programmatic activities, creation of the oversight position of the U.S. Global AIDS Coordinator, expectations for unprecedented coordination among U.S. government agencies and international stakeholders, assignment of responsibilities to involved U.S. government agencies and programs, and identification of the priority countries for action. The U.S. Global AIDS Coordinator is charged with coordinating all U.S. international activities to combat HIV/AIDS. The Office of the U.S. Global AIDS Coordinator (OGAC) is the central headquarters for the initiative. It consists of a small staff of experts in areas critical to headquarters-level coordination of the different agencies involved, as well as the development of policy and programmatic guidance for the field. Program implementation is accomplished primarily by teams in the focus countries. These Country Teams are based in the embassy and led by the ambassador, and are supported by core teams and technical working groups based at OGAC.

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PEPFAR Implementation: Progress and Promise 2 The U.S. Global AIDS Initiative: Context and Background The first half of this chapter provides a brief overview of the HIV/AIDS pandemic; identifies some of the key partners responding to the pandemic; and explores the global context for implementing HIV/AIDS programs, including challenges faced by all donor programs. The second half provides an introduction to the President’s Emergency Plan for AIDS Relief (PEPFAR) focus countries and describes the legislation that created the program. THE HIV/AIDS PANDEMIC The HIV/AIDS pandemic has already claimed more than 25 million lives. Cases have been reported in all regions of the world, but most people living with HIV/AIDS (95 percent) reside in low- and middle-income countries, where most new HIV infections and AIDS-related deaths occur. The year 2006 marks the twenty-fifth anniversary of the description of acquired immunodeficiency syndrome (AIDS). AIDS was first recognized among gay men in the United States. By 1983, the etiological agent of the disease, the human immunodeficiency virus (HIV), had been identified. By 1985, at least one case of HIV infection had been reported in each region of the world (UNAIDS, 2006). The 1980s also marked the pandemic status of HIV/AIDS, which has been increasing in incidence and prevalence globally ever since. The nature of the virus is such that without intervention, only a minuscule proportion of HIV-positive individuals will not progress to AIDS, and predictably to death from AIDS and its complications. The twenty-fifth

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PEPFAR Implementation: Progress and Promise anniversary of the identification of AIDS was marked by numerous histories, perspective reviews, and publications. Appendix D provides a short list of sources offering more detailed global overviews. Figure 2-1 shows a global view of the prevalence of HIV/AIDS, with the majority of cases occurring in low- and middle-income countries (UNAIDS, 2006; WHO, 2006a). The nations of sub-Saharan Africa are the hardest hit, but concern is increasing about the next wave of the pandemic that is emerging in parts of Eastern Europe and Asia. AIDS is the leading cause of death worldwide among those aged 15 to 59 (UNAIDS, 2006). The pandemic is also considered a threat to the economic well-being and social and political stability of many nations (UN, 2003b; CSIS, 2005; Rice, 2006). The stark facts are these (UNAIDS, 2006): More than 39 million people are living with HIV/AIDS worldwide, twice the number in 1995. During 2006, more than 4 million people became infected with HIV, including more than half a million children. Nearly 3 million people died of AIDS-related illnesses in 2006. Worldwide, most people living with HIV are unaware that they are infected. At any given time, many more people are infected—are HIV-positive—than are clinically ill with AIDS. Although undeniably pandemic, HIV/AIDS can best be addressed if it is viewed as many separate epidemics with distinct origins and characteristics of spread. The epidemics can be described in terms of geography or of subpopulations affected within larger populations, and involve different transmission patterns that result from varying patterns of behaviors conducive to spread of the virus. The main methods of transmission are sexual contact, blood exposure from injecting drug use involving shared needles, and transmission from mother to child before or during childbirth. Other methods of transmission that may be especially important focally are blood transfusions from people who are HIV-positive, medical accidents, and unsafe medical injection practices. It is estimated that in sub-Saharan Africa, transmission through sexual contact, from mother to child, and via health care procedures (including blood transfusions and medical injections) account for 80–90 percent, 5–35 percent, and 5–10 percent of new infections, respectively, with regional variation (NAS, 1994; Quinn et al., 1994; Quinn, 1996, 2001; WHO, 2002b; Askew and Berer, 2003; Bertozzi et al., 2006). Bertozzi and colleagues (2006) classified country-level AIDS epidemics into three states: low, concentrated, and generalized, with numeric indicators for HIV prevalence among populations (see Table 2-1). In the low state, HIV infection has not spread to significant levels in any subpopulation and

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PEPFAR Implementation: Progress and Promise FIGURE 2-1 Global view of the prevalence of HIV/AIDS. SOURCE: Reprinted with the kind permission of UNAIDS, 2006.

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PEPFAR Implementation: Progress and Promise TABLE 2-1 Classification of Country-Level AIDS Epidemics Extent of HIV Infection Highest Prevalence in a Key Population (percentage)* Prevalence in the General Population (percentage) Low <5 <1 Concentrated >5 <1 Generalized Low ≥5 1–10 Generalized High ≥5 ≥10 *Key populations include sex workers, men who have sex with men, and people who use injecting drugs. SOURCE: Bertozzi et al., 2006. is largely confined to individuals with higher-risk behaviors, such as sex workers, people who use injecting drugs, and men who have sex with other men. This epidemic state suggests that networks of those at high risk are diffuse (that is, low levels of partner exchange or sharing of drug-injecting equipment) or that the virus has been introduced relatively recently. No focus country epidemic is characterized by this state. In the concentrated state, HIV has spread rapidly in a defined subpopulation but is not well established in the general population. This state suggests active networks of risk within the subpopulation, and the future course of the epidemic is determined by the frequency and nature of links between the highly infected subpopulation and the general population. In the generalized state, HIV is firmly established in the general population. Although subpopulations at high risk may continue to contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic independent of subpopulations at higher risk of infection. Low and high subcategories of the generalized epidemic are recognized. THE GLOBAL RESPONSE TO HIV/AIDS IN THE DEVELOPING WORLD Major Funding Sources for HIV/AIDS Assistance In response to the intensifying global HIV/AIDS crisis, international funding for HIV/AIDS programs has increased steadily since 2001. In 2005, commitments from donor governments to respond to HIV/AIDS rose to $4.3 billion, up from $3.6 billion in the previous year (Kates and Lief, 2006). U.S. funding to combat global HIV/AIDS has steadily increased since 2001 (see Table 2-2). In 2006 PEPFAR contributed 26 percent of official

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PEPFAR Implementation: Progress and Promise TABLE 2-2 Total U.S. Funding for Global HIV/AIDS for Fiscal Years 2001–2007 (in millions of U.S. dollars) 2001 2002 2003 2004 2005 2006 2007 2008* 785 1,083 1,540 2,311 2,719 3,290 4,556 5,400 *Proposed. SOURCE: OGAC, 2007a. development assistance1 from donor governments for programs to address global HIV/AIDS (OGAC, 2005b, 2006a; Kates and Lief, 2006). The U.S. Global AIDS Initiative is one of several significant sources of international HIV/AIDS assistance. Multilateral organizations—such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); the World Bank; and UNAIDS, which coordinates the various United Nations (UN) agencies2—are also primary providers of international HIV/AIDS funding (UNAIDS, 2005b). These key global partners for the U.S. Global AIDS Initiative are briefly described in Box 2-1. Governments of affected countries have also increased their spending, with amounts depending on, among other factors, gross national income, national debt, political stability, and the status of the working class (Kates and Lief, 2006). The private sector (including foundations, corporations, international nongovernmental organizations, and individuals) represent another vital funding stream for responses to HIV/AIDS. U.S.-based philanthropies committed an estimated $395 million in 2003 to HIV/AIDS activities in the United States and internationally, with the Bill and Melinda Gates Foundation making the greatest contribution. International development banks, including the Inter-American Development Bank, the Asian Development Bank, and the African Development Bank, play contributory roles as well (Kates and Lief, 2006). The Joint United Nations Programme 1 Official development assistance is defined as those flows to developing countries and to multilateral institutions for developing countries (1) which are provided by official agencies, including state and local governments, or by their executing agencies; and (2) each transaction of which (a) is administered with the promotion of the economic development and welfare of developing countries as its main objective, and (b) is concessional in character and conveys a grant element of at least 25 percent (OECD, 2006). 2 The agencies coordinated by UNAIDS are the United Nations Refugee Agency; United Nation’s Children Fund; World Food Programme; United Nations Development Programme; United Nations Population Fund; United Nations Office on Drugs and Crime; International Labour Organization; United Nations Educational, Scientific, and Cultural Organization; World Health Organization; and World Bank.

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PEPFAR Implementation: Progress and Promise BOX 2-1 Multilateral Organizations Contributing to Responses to Global HIV/AIDS The Global Fund was created in 2001 as an independent public–private partnership with the intent of providing grants to countries to finance programs targeting AIDS, tuberculosis, and malaria. As of July 2006, about $9 billion had been pledged to the Global Fund from all sources, and $5.5 billion had been committed to 132 countries. Fifty-seven percent of the funds had been allocated to HIV/AIDS (Global Fund, 2005, 2006). The World Bank began supporting HIV/AIDS programming in 1986, and has since launched major efforts in Africa (2000) and the Caribbean (2001) through its Multi-Country AIDS Program. The World Bank also offers financial assistance for HIV/AIDS programs through the Inter national Development Association, which provides grants and interest-free loans to the world’s poorest countries, and through the Inter national Bank for Reconstruction and Development, which offers nonconcessional loans to countries able to repay them. The majority of funds are derived directly from member country contributions, primarily from the G8. As of April 2006, the World Bank had committed a total of $2.6 billion to combat HIV/AIDS, approximately $1.9 billion of which was distributed through the International Development Association (Kates and Lief, 2006). UNAIDS, the Joint United Nations Programme on HIV/AIDS, brings together the efforts and resources of 10 UN agencies to help the world prevent new HIV infections, care for those already infected, and mitigate the impact of the pandemic. UNAIDS is based in Geneva and works on the ground in more than 75 countries. Established in 1994 by a resolution of the UN Economic and Social Council and launched in January 1996, the organization is guided by a Programme Coordinating Board including representatives of 22 governments from all geographic regions; the UNAIDS Cosponsors; and five representatives of nongovernmental organizations, including associations of people living with HIV (UNAIDS, 2007). HIV/AIDS funding from the UN increased from $1.3 billion for 2004–2005 to $2.6 billion for the 2006–2007 budget (UNAIDS, 2003, 2005c). on HIV/AIDS (UNAIDS) estimates spending from all of these sources at approximately $2.1 billion for 2005. Despite the large sums of money available, funding is far below what is needed (UNAIDS, 2006). A publication from the Henry J. Kaiser Family Foundation entitled International Assistance for HIV/AIDS in the Developing World: Taking Stock of the G8, Other Donor Governments and the European Commission, available at http://www.kff.org, provides an in-depth review of international donor assistance for HIV/AIDS efforts.

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PEPFAR Implementation: Progress and Promise Global Efforts to Improve Coordination Among Donors The scope and size of the U.S. Global AIDS Initiative are closer to the scale of a multilateral than a bilateral effort, and while the United States is not the only donor of funding for HIV/AIDS programs, in some countries its magnitude makes it a dominant source and thus influential in policy and program development. In 2005, the UNAIDS Secretariat convened leaders from governments and the civil sector, UN agencies, and other multinational and international organizations to review the global response to HIV/AIDS. Issues such as the absorptive capacity of developing countries, duplication of effort among donors, gaps in funding, and the burden on countries for reporting results and administering the funds were examined. The magnitude of PEPFAR and its contributions to the increase in funding were also recognized and considered. These examinations prompted the formation of the Global Task Team, whose primary purpose was to improve HIV/AIDS coordination among multilateral institutions and international donors. The ultimate goal was to accelerate global action to achieve significant progress toward international goals for the delivery of services to people affected by the epidemics in low- and middle-income countries by making recommendations for addressing the above issues (UNAIDS, 2005a). The Global Task Team comprised representatives from 24 countries and institutions, and its work was facilitated by three working groups. Officials from the Office of the U.S. Global AIDS Coordinator (OGAC) participated in the working group on harmonization of monitoring and evaluation, which made recommendations for improving policies, systems, and practices of multilateral institutions, as well as global initiatives to coordinate and improve monitoring and evaluation systems (UNAIDS, 2005a). The expectation for aligning the work of the Global Task Team with the Three Ones principles of harmonization (discussed further later in this chapter) was expressed early in the process (UNAIDS, 2005a). To implement the recommendations of the Global Task Team, the Global Implementation Support Team was formed in July 2005. By November 2006, the Global Implementation Support Team had expanded and included additional representatives from the civil sector and bilateral donors, including the U.S. Global AIDS Initiative. The Global Implementation Support Team “centers on country-driven problem solving to unblock obstacles to accelerated grant implementation … [with] members meeting on a monthly basis to review immediate and medium-term technical support needs, make decisions on joint and coordinated technical support to be provided, evaluate progress and assess performance of such support, and look at ways to improve interaction between Global Implementation Support Team member organizations and countries” (GIST, 2006, p. 1).

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PEPFAR Implementation: Progress and Promise HARMONIZATION IN THE GLOBAL RESPONSE TO HIV/AIDS Evolution of the Three Ones Principles of Harmonization Significant global events and economic development agreements were the precursors to the formal drafting of and commitment to what would become known as the Three Ones principles of harmonization (see Box 2-2). These principles were “specifically developed to cope with the urgency and need to ensure effective and efficient use of resources and focus on delivering results—in ways that will also enhance national capacity to deal with the AIDS crisis long-term” (UNAIDS, 2004b, p. 1). Though developed to foster improved coordination of HIV/AIDS responses, the principles were designed to be fully compatible with the guidelines of the Organisation for Economic Co-operation and Development’s Development Assistance Committee for “Harmonising Donor Practices for Effective Aid Delivery” and the February 2003 “The Rome Declaration on Harmonisation” by “accommodating different aid modalities while ensuring effective management procedures and reducing transaction costs for countries” (OECD, 2003; The Rome Declaration, 2003; UNAIDS, 2004b, p. 1), as well as with the concept of national ownership described in the “Monterrey Consensus,” which provides the framework for national ownership of social and economic development (UN, 2003a). In April 2004, UNAIDS, the United Kingdom, and the United States co-hosted a high-level meeting at which all major donors and programs (including PEPFAR) formally endorsed the Three Ones principles of harmonization (UNAIDS, 2004a). A primary intent of harmonization is to reinforce the consistency and simplification of policies, practices, and procedures among donors (UNAIDS, 2004b). BOX 2-2 The Three Ones Principles for the Harmonization of National HIV/AIDS Responses One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners One National HIV/AIDS Coordinating Authority, with a broad-based multisectoral mandate One agreed HIV/AIDS country-level Monitoring and Evaluation System SOURCE: UNAIDS, 2004a.

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PEPFAR Implementation: Progress and Promise One HIV/AIDS Action Framework The first principle of harmonization requires broad participation in the development, review, and periodic update of the national framework for HIV/AIDS response, as well as in its successful implementation. Broad participation of key stakeholders in the governmental, private, civil, and international sectors is also expected to contribute to the quality and comprehensiveness of the framework (UNAIDS, 2005d). Stakeholder participation applies not only to implementation and innovation, but also to public policy, advocacy, and oversight functions such as monitoring and evaluation (UNAIDS, 2004b). National ownership of participatory planning and execution, which is becoming increasingly common, is critical. National ownership has many elements, but key is both the respect and continued support of donors for national governments, as well as strong leadership, governance, communication, and transparency on the part of both national entities and donors (UNAIDS, 2004a, 2005d). National frameworks require work plans and budgets that can be tracked, especially to coordinate the support of donors and other stakeholders (UNAIDS, 2005d). Frameworks that have these plans and budgets are often characterized as being prioritized and costed. One National HIV/AIDS Coordinating Authority UNAIDS has stated that developing, reviewing, and updating national plans requires human resource capacity for coordination and calls for strong leadership and commitment, which are ideally provided by the highest level of government. This highest level of government is also expected to delegate its authority to a national AIDS authority, which may include a governing council and a secretariat, that also has a mandate to broadly recruit other national, local, and international stakeholders from all sectors into the collaborative process and to coordinate all action related to that process. The complex dynamics seen in several countries among the various stakeholders have demonstrated the need for effective leadership and coordination to maximize the contributions made by all (UNAIDS, 2005d). One Monitoring and Evaluation System Monitoring and evaluation of activities can facilitate the allocation of limited resources to the best advantage and provide information needed for a country and its partners to respond to emerging trends in the epidemic in a timely manner. UNAIDS recommends that monitoring and evaluation occur in the context of a unified national strategic plan for these activities, with the country adopting a single set of standardized indicators endorsed

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PEPFAR Implementation: Progress and Promise could change in response to changes in the HIV/AIDS pandemic and the knowledge and tools available. The strategy has four main emphases: (1) rapidly expanding services, building on existing successful programs; (2) identifying new partners and building capacity for sustainable, effective, and widespread HIV/AIDS responses; (3) encouraging bold leadership and fostering a sound enabling policy environment for combating HIV/AIDS and mitigating its consequences; and (4) implementing strong strategic information systems that will contribute to continued learning and identification of best practices. The strategy also stresses collaboration and coordination with a wide range of partners, including relevant parts of the U.S. government, nongovernmental organizations of all types, the private sector, and international organizations. Responsiveness to local needs as well as to national priorities and strategies is also key (OGAC, 2004). As required, the strategy assigns priorities for and allocates resources to relevant executive branch agencies, including the Departments of State, Defense, Commerce, Labor, Health and Human Services (specifically, the Centers for Disease Control and Prevention, National Institutes of Health, U.S. Food and Drug Administration, and Health Resources Services Administration), the U.S. Agency for International Development, and the Peace Corps. Most of these agencies were already involved in global HIV/AIDS efforts prior to PEPFAR (OGAC, 2004) (see Box 2-6). The PEPFAR strategy is responsive to legislative imperatives while containing the major elements of an HIV/AIDS strategy recommended by normative entities such as the World Health Organization and UNAIDS. The Network Model PEPFAR’s 5-year strategy describes a network model developed to deliver prevention, treatment, and care services for HIV/AIDS, consistent with the priorities and requirements of the Leadership Act. The basic design, adopted from a successfully implemented model in Uganda, relies on centralized, core facilities (staffed by different practitioners of varying skill) from which technical support and products flow to facilities in the periphery, especially to rural and underserved areas. In turn, facilities and staff at different points in the network identify and refer people needing more complex care to the more advanced central facilities (OGAC, 2004) (see Figure 2-3). The model relies on existing medical facilities, such as district-level hospitals and local health clinics, for basic services. Private—often faith-based—medical facilities are relied upon to rapidly scale up existing palliative care services for adults and children with AIDS, with the aim of ensuring long-term sustainability. Finally, information systems are to be set

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PEPFAR Implementation: Progress and Promise BOX 2-6 HIV/AIDS Activities of U.S. Government Agencies Implementing PEPFAR Department of State: HIV/AIDS prevention activities and small-scale programs in 162 countries through U.S. embassies in those countries Diplomatic exchanges to generate more resources for HIV/AIDS Exchange programs and community involvement Support for the Office of the U.S. Global AIDS Coordinator in coordinating global HIV/AIDS efforts Department of Health and Human Services: Centers for Disease Control and Prevention: Prevention, surveillance, infrastructure development, care, and field activities through its Global AIDS Program; field staff work with the Global Fund’s Country Coordinating Mechanisms National Institutes of Health: Basic, clinical, and behavioral research on HIV, opportunistic infections, and other HIV-associated conditions; development of therapies, vaccines, and microbicides Health Resources and Services Administration: Training, technical assistance, twinning, and palliative care programs U.S. Food and Drug Administration: Advisory resource on HIV/AIDS drug quality, safety, and efficacy, and conduct of related HIV/AIDS activities Department of Defense: Military-to-military HIV/AIDS awareness and prevention education Policy development for HIV/AIDS issues in military settings Construction of facilities used for HIV/AIDS activities Department of Labor: Workplace HIV/AIDS prevention education and stigma reduction Technical assistance to governments, employees, and labor leaders Capacity building to improve worker access to testing, counseling, and other support services Multilateral programs targeting HIV-infected children forced to work and child prostitution Cross-sector collaboration Reduction of trade barriers to facilitate delivery systems for health care products U.S. Agency for International Development: Bilateral programs in 50 countries; regional programs including 48 countries Expertise in pharmaceutical logistics management Operational and biomedical research Health care system strengthening in host countries Coordination with other development programs Peace Corps: 3,000+ volunteers working on HIV/AIDS (PEPFAR commits 1,000 more) Training of African volunteers as HIV/AIDS educators and advocates Building of community-level capacity Short-term Crisis Corps that can be harnessed to address HIV/AIDS SOURCE: OGAC, 2004.

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PEPFAR Implementation: Progress and Promise FIGURE 2-3 PEPFAR’s network model. SOURCE: OGAC, 2004. up to monitor progress and ensure that programs comply with PEPFAR’s stated policies and strategies (OGAC, 2004, 2006g). The network model envisions information systems in facilities at all levels, with links and regular feedback loops to provide information to health providers and policy makers (OGAC, 2006g). Recognizing the severe shortages of health care personnel in focus countries, the model includes training for community health workers to deliver routine care, manage symptoms, and monitor for treatment adherence. The description of the network model focuses on medical services, with less attention to social services. The model states the intent to use and strengthen linkages among the levels of support, but does not explain how this will be accomplished. Home-based services, largely for palliative care, are acknowledged as important and cost-effective, but are otherwise not elaborated upon. Organizational Structure The U.S. Global AIDS Coordinator The first U.S. Global AIDS Coordinator, Randall Tobias, was sworn in with the rank of Ambassador on October 6, 2003; on February 23, 2004, he presented to Congress the U.S. 5-year global HIV/AIDS strategy. The Coordinator’s office, OGAC, is responsible for maintaining the focus of

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PEPFAR Implementation: Progress and Promise PEPFAR by leading policy development, program oversight, and coordination both among U.S. government departments and agencies and with other donors and governments (Box 2-5). The Coordinator is responsible for the allocation of funds that are distributed through the U.S. government departments and agencies cited earlier. Coordination and Support Within the Office of the U.S. Global AIDS Coordinator Within OGAC, staff are organized into several groups, all of which include OGAC staff and representatives from the other U.S. government departments and agencies coordinated by OGAC (Table 2-5). These groups include the Policy Group, incorporating representation from the U.S. Agency for International Development, the Department of Health and Human Services, the White House, and the National Security Council; the Deputy Principals Group, handling program management and logistics, with representation from the majority of the government department and agencies cited above; and a Scientific Steering Committee, consisting of representatives from the two largest of the above implementing departments and agencies and the Department of Defense (Moloney-Kitts, 2005). Finally, Core and Technical Teams, which draw members from a wide range of U.S. government agencies, are responsible for supporting programs in PEPFAR countries in addressing specific technical and implementation issues. PEPFAR Focus Country Teams Each focus country has a U.S. Government Country Team that is responsible for coordinating PEPFAR-sponsored programs in the country. The Country Team is led by the U.S. ambassador to the country and includes representatives from all of the implementing departments and agencies. The staff of Country Teams serve in foreign-service posts. The Committee observed that the teams varied in size, expertise, and length of time served in the country. The Country Team is supported by a core team at OGAC headquarters. Often, an ambassadorial steering committee works with the in-country team and the minister of health on HIV/AIDS efforts (in some countries this committee also serves as the Country Coordinating Mechanism for the Global Fund) (OGAC, 2005a). Funding The Leadership Act authorized $15 billion, including about $10 billion in new resources, for efforts to combat global HIV/AIDS. The majority of the funding is intended to be concentrated in the 15 focus countries.

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PEPFAR Implementation: Progress and Promise TABLE 2-5 Structure for Coordination and Support Within the Office of the U.S. Global AIDS Coordinator Group Responsibility Involved Agencies Ambassador Leadership of Initiative Ensure policy and program coordination at the highest levels Holds strong mandate for accountability U.S. Global AIDS Coordinator, Ambassadors Agency Principals Policy Office of the U.S. Global AIDS Coordinator, U.S. Agency for International Development, Department of Health and Human Services, National Security Council, White House Deputy Principals Management/Programs Addresses how to operationalize programs Can move policy issues up to agency principals Office of the U.S. Global AIDS Coordinator, U.S. Agency for International Development, Department of Health and Human Services, Peace Corps, Department of Defense, Department of Labor Scientific Steering Committee Scientific Integrity Assesses evidence base for policies and programs Can be involved in evaluation and monitoring Office of the U.S. Global AIDS Coordinator, U.S. Agency for International Development, National Institutes of Health, Department of Health and Human Services, Department of Defense Core Teams General Field Support Channels information Addresses problems Leverages technical support as needed by the field Office of the U.S. Global AIDS Coordinator, U.S. Agency for International Development, Department of Health and Human Services, Peace Corps, Department of Defense, Department of State Technical Working Groups Technical Assistance and Review to Support the Field Addresses specific program components (e.g., care, prevention, food, orphans and vulnerable children) Office of the U.S. Global AIDS Coordinator, U.S. Agency for International Development, Department of Health and Human Services, Peace Corps, Department of Defense, National Institutes of Health, U.S. Department of Agriculture SOURCE: Moloney-Kitts, 2005. PEPFAR funds are appropriated through several agencies, with the bulk of the funding appropriated through the State Department’s Global HIV/AIDS Initiative account. Foreign operations (such as the Peace Corps) are funded by the Global HIV/AIDS Initiative account, but are not generally under the PEPFAR umbrella. As noted, the Leadership Act directs most PEPFAR funding to the focus countries. The roughly $10 billion that is intended for the focus countries is

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PEPFAR Implementation: Progress and Promise directed primarily either centrally from OGAC or locally from the Country Teams, with a 7 percent cap for OGAC and the Country Teams for operating costs (P.L. 108-25). Most focus country funding comes from the State Department’s Global HIV/AIDS Initiative account. Funding concentrated in the focus countries in the first 3 years totaled over $3.4 billion (see Table 2-2). This total includes funding to the Country Teams, centrally funded programs, strategic information activities, and technical management and oversight funding for the U.S. agencies involved in the program’s implementation. As the program scaled up, the annual funding directed to the focus countries increased from $470 million in fiscal year 2004 to more than $1.6 billion in fiscal year 2006. The remaining $5 billion is intended for other bilateral activities, including the Global Fund and activities in non-focus countries. Chapter 3 provides greater detail about PEPFAR funding. REFERENCES Abu-Raddad, L. J., P. Patnaik, and J. Kublin. 2006. Dual infection with HIV and malaria fuels the spread of both diseases in sub-Saharan Africa. Science 314:1603–1606. Africa Renewal (formerly Africa Recovery). 1999 (December). AIDS saps Africa’s educational system. http://www.un.org/ecosocdev/geninfo/afrec/ (accessed January 3, 2007). Africa Renewal (formerly Africa Recovery). 2007. Education in Africa: Africa Recovery special report. Schools struggling with crises: Financial constraints hamper expansion of primary education in Africa. http://www.un.org/ecosocdev/geninfo/afrec/ (accessed January 3, 2007). Askew, I., and M. Berer. 2003. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: A review. Reproductive Health Matters 11(22):51–73. Bertozzi, S., P. Padian, J. Wegbreit, L. M. DeMaria, B. Feldman, H. Gayle, J. Gold, R. Grant, and M. T. Isbell. 2006. HIV/AIDS prevention and treatment. In Disease control priorities in developing countries. 2nd ed., edited by D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove. New York and Washington, DC: Oxford University Press and World Bank. Bollinger, L., K. Cooper-Arnold, and J. Stover. 2004. Where are the gaps? The effect of HIV-prevention interventions on behavior change. Studies in Family Planning 35(1):27–38. Castro, A., and P. Farmer. 2005. Understanding and addressing AIDS-related stigma: From anthropological theory to clinical practice in Haiti. American Journal of Public Health 95(1):53–59. CIA (Central Intelligence Agency). 2006. CIA World Factbook. http://www.cia.gov/cia/publications/factbook/index.html (accessed June 10, 2006). CSIS (Center for Strategic and International Studies). 2005. More than humanitarianism: A strategic U.S. approach toward Africa. Washington, DC: CSIS. Dybul, M. 2005 (April 21). Remarks at the second meeting of the Institute of Medicine Committee for the Evaluation of PEPFAR Implementation, Washington, DC. Evans, R., M. Barer., and T. Marmor. 1994. Why are some people healthy and others not? The determinants of health populations. New York: Aldine de Gruyter. GIST (Global Implementation Support Team). 2006. Fact sheet: The Global Implementation Support Team: Coordinating UN action and provision of technical support for accelerating HIV/AIDS responses in countries. http://data.unaids.org/pub/BrochurePamphlet/2006/2006_gist_en.pdf (accessed January 12, 2007).

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PEPFAR Implementation: Progress and Promise Global Fund. 2005. Global Fund ARV fact sheet: 1st December, 2005. Geneva, Switzerland: Global Fund. http://www.theglobalfund.org/en/files/publications/factsheets/aids/ARV_Factsheet_2006.pdf (accessed November 3, 2006). Global Fund. 2006. Distribution of funding after 5 rounds. Geneva, Switzerland: Global Fund. http://www.theglobalfund.org/en/funds%5Fraised/distribution/ (accessed November 3, 2006). Grassly, N., G. Garnett, B. Schwartlander, S. Gregson, and R. Anderson. 2001. The effectiveness of HIV prevention and the epidemiological context. Bulletin of the World Health Organization 79:1121–1132. IOM (Institute of Medicine). 2005. Scaling up treatment for the global AIDS pandemic: Challenges and opportunities. Washington, DC: The National Academies Press. Johns Hopkins School of Public Health. 2000. Population reports: Series A, number 9 oral contraceptives. Baltimore, MD: Johns Hopkins University. http://www.infoforhealth.org/pr/a9/a9chap5_3.shtml (accessed January 31, 2007). Kates, J., and E. Lief. 2006. International assistance for HIV/AIDS in the developing world: Taking stock of the G8, other donor governments and the European Commission. Washington, DC: Kaiser Family Foundation. Kaye, G., and T. Wolff. 2002. From the ground up! A workbook on coalition building and community development. Amherst, MA: AHEC/Community Partners. Kindig, D. 1997. Purchasing population health: Paying for results. Ann Arbor, MI: University of Michigan Press. Letamo, G. 2003. Prevalence of, and factors associated with, HIV/AIDS-related stigma and discriminatory attitudes in Botswana. Journal of Health, Population, and Nutrition 21(4):347–357. Lyman, P. 2005. Remarks at the second meeting of the Institute of Medicine Committee for the Evaluation of PEPFAR Implementation, Washington, DC. Moloney-Kitts, M. 2005 (April 19). Office of the Global AIDS Coordinator. Presentation at the second meeting of the Institute of Medicine Committee for the Evaluation of PEPFAR Implementation, Washington, DC. Myer, L., L. Denny, R. Telerant, M. Souza, T. C. Wright, Jr., and L. Kuhn. 2005. Bacterial vaginosis and susceptibility to HIV infection in South African women: A nested case-control study. The Journal of Infectious Diseases 192(8):1372–1380. NAS (National Academy of Sciences). 1994. Population migration and the spread of types 1 and 2 human immunodeficiency viruses. Proceedings of the National Academy of Sciences (USA) 91(7):2407–2414. National Bureau of Statistics Dar es Salaam, Tanzania and Macro International, Inc. 2000. Tanzania 1999 reproductive and child health survey. Calverton, MD: Macro International, Inc. Newman, P., O. Grusky, S. J. Roberts, and I. Rivkin. 2002. Organizational factors in the early detection of HIV. Presentation provided at the XIV International AIDS Conference, Barcelona, Spain. NIAID/NIH (National Institute of Allergy and Infectious Diseases/National Institutes of Health). 2006. HIV infection in women. Rockville, MD: NIAID/NIH. http://www.niaid.nih.gov/factsheets/womenhiv.htm (accessed January 12, 2007). NWHRC (National Women’s Health Resource Center). 2006. National women’s health report: Women & HIV. Red Bank, NJ: NWHRC. OGAC (Office of the U.S. Global AIDS Coordinator). 2004. The President’s Emergency Plan for AIDS Relief: U.S. five-year global HIV/AIDS strategy. Washington, DC: OGAC. OGAC. 2005a. The President’s Emergency Plan for AIDS Relief: Compassionate action provides hope through treatment success. Washington, DC: OGAC. OGAC. 2005b. PEPFAR first annual report to Congress. Washington, DC: OGAC.

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PEPFAR Implementation: Progress and Promise OGAC. 2005c. The President’s Emergency Plan for AIDS Relief: Indicators, reporting requirements, and guidelines for focus countries (revised for FY2006 reporting). Washington, DC: OGAC. OGAC. 2006a. PEPFAR second annual report to Congress. Washington, DC: OGAC. OGAC. 2006b. PEPFAR report on food and nutrition for people living with HIV/AIDS. Washington, DC: OGAC. OGAC. 2006c. PEPFAR report on work force capacity and HIV/AIDS. Washington, DC: OGAC. OGAC. 2006d. Bringing hope: Supplying antiretroviral drugs for HIV/AIDS treatment: The President’s Emergency Plan for AIDS Relief report on antiretroviral drugs for HIV/AIDS treatment. Washington, DC: OGAC. OGAC. 2006e. Report on education: The President’s Emergency Plan for AIDS Relief. Washington, DC: OGAC. OGAC. 2006f. Report on refugees and internally displaced persons: The President’s Emergency Plan for AIDS Relief. Washington, DC: OGAC. OGAC. 2006g. HIV/AIDS palliative care guidance #1: An overview of comprehensive HIV/AIDS care services in the President’s Emergency Plan for AIDS Relief. Washington, DC: OGAC. OGAC. 2007a. Office of the Global AIDS Coordinator’s Suggested Factual Changes to the PEPFAR Implementation: Progress and Promise Report. Email communication to IOM staff on March 29, 2007. OGAC. 2007b. PEPFAR third annual report to Congress. Washington, DC: OGAC. OECD (Organisation for Economic Co-operation and Development). 2003. Harmonising donor practices for effective aid delivery good practice papers: A DAC reference document. Paris, France: OECD. OECD. 2006. Aid activities: CRS user’s guide: Basic concepts—official development assistance, official aid. http://www.oecd.org/document/28/0,2340,en_2649_34469_15070940_1_1_1_1,00.html (accessed November 1, 2006). PRB (Population Reference Bureau). 2005. 2005 world population data sheet. Washington, DC: PRB. http://www.prb.org/pdf05/05WorldDataSheet_Eng.pdf (accessed May 25, 2006). Project Siyam’kela. 2003. Siyam’kela: A report on the fieldwork leading to the development of HIV/AIDS stigma indicators and guidelines. http://www.poplicyproject.com/siyamkela.cfm (accessed November 1, 2006). Quinn, T. C. 1996. Global burden of the HIV pandemic. The Lancet 348:99–106. Quinn, T. C. 2001. AIDS in Africa: A retrospective. Bulletin of the World Health Organization. Geneva, Switzerland: World Health Organization. Quinn, T. C., A. Ruff, and N. Halsey. 1994. Special considerations for developing nations. In Pediatric AIDS: The challenge of HIV infection in infants, children, and adolescents. Edited by P. A. Pizzo and C. M. Wilfert. Baltimore, MD: Williams & Wilkins. Pp. 31–49. Rice, S. 2006. Global poverty, weak states and insecurity; The Brookings Blum Roundtable. Washington, DC: The Brookings Institution. Schwebke, J. R. 2005. Abnormal vaginal flora as a biological risk factor for acquisition of HIV infection and sexually transmitted diseases. The Journal of Infectious Diseases 192(8):1315–1317. The Rome Declaration on harmonization. 2003. High level forum on harmonization, February 24–25, 2003, Rome, Italy. http://www.aidharmonization.org (accessed November 10, 2006).

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PEPFAR Implementation: Progress and Promise UN (United Nations). 2003a. Monterrey Consensus of the International Conference on Financing for Development: The final text of agreements and commitments adopted at the International Conference on Financing for Development, Monterrey, Mexico, 18–22 March 2002. Geneva, Switzerland: UN. UN. 2003b. Organizing the UN response to the triple threat of food insecurity, weakened capacity for governance and AIDS, particularly in southern and eastern Africa. Document discussed at the UN High-Level Committee on Programmes, 6th session, Rome, Italy, 18–19 September 2003. Geneva, Switzerland: UN. UNAIDS (Joint United Nations Programme on HIV/AIDS). 1998. UNAIDS best practice collection: Guide to the strategic planning process for a national response to HIV/AIDS, modules 1–4. Geneva, Switzerland: UNAIDS. UNAIDS. 2001. The global strategy framework on HIV/AIDS. Geneva, Switzerland: UNAIDS. UNAIDS. 2003 (April 29). Unified budget and workplan 2004–2005, UNAIDS/PCB(14)/03.3. Geneva, Switzerland: UNAIDS. UNAIDS. 2004a. “Three ones” key principles. Conference paper 1, Washington consultation of April 4, 2004. Geneva, Switzerland: UNAIDS. http://www.unaids.org/NetTools/Misc/DocInfo.aspx?LANG=en&href=http://gva-doc-owl/WEBcontent/Documents/pub/UNA-docs/Three-Ones_KeyPrinciples_en.pdf (accessed September 20, 2006). UNAIDS. 2004b. Clearing the common ground for the “three ones”: Report of a consultation process. Conference paper 2, Washington consultation of April 25, 2004. Geneva Switzerland: UNAIDS. http://data.unaids.org/UNA-docs/Three-Ones_ConsultationReport_en.pdf (accessed September 20, 2006). UNAIDS. 2005a. Global task team on improving AIDS coordination among multilateral institutions and international donors. Geneva, Switzerland: UNAIDS. UNAIDS. 2005b. Resource needs for an expanded response to AIDS in low- and middle-income countries. Geneva, Switzerland: UNAIDS. UNAIDS. 2005c (June 27–29). Unified budget and workplan 2006–2007, UNAIDS/PCB(17)/05.4. Geneva, Switzerland: UNAIDS. UNAIDS. 2005d. The “three ones” in action: Where we are and where we go from here. Geneva, Switzerland: UNAIDS. UNAIDS. 2006. 2006 report on the global AIDS epidemic. Geneva, Switzerland: UNAIDS. UNAIDS. 2007. About UNAIDS. Geneva, Switzerland: UNAIDS. http://www.unaids.org (accessed January 10, 2007). UNAIDS, UNICEF, USAID (Joint United Nations Programme on HIV/AIDS, United Nations Children’s Fund, U.S. Agency for International Development). 2002. Children on the brink: A joint report on orphan estimates and program strategies. Washington, DC: TVT Associates. UNAIDS, UNICEF, USAID. 2004. Children on the brink: A joint report on new orphans estimates and a framework for action. New York: UNICEF. UNDP (United Nations Development Programme). 2005. Human development report 2005. http://hdr.undp.org/reports/global/2005/pdf/HDR05_complete.pdf (accessed May 25, 2006). UNICEF (United Nations Children’s Fund). 2006a. Information by country (Côte d’Ivoire, Ethiopia, Haiti, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia). http://www.unicef.com (accessed June 10, 2006). UNICEF. 2006b. Africa’s orphaned and vulnerable generations: Children affected by AIDS. New York: UNICEF. U.S. DOS (U.S. Department of State). 2006. Office of the Global AIDS Coordinator: Focus countries. Washington, DC: U.S. DOS. http://www.state.gov/s/gac/countries/fc/index.htm (accessed May 25, 2006).

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PEPFAR Implementation: Progress and Promise USAID (U.S. Agency for International Development). 2005. Working report: Measuring HIV stigma: Results of a field test in Tanzania. Washington, DC: USAID. Weiss, M. G., and J. Ramakrishna. 2001. Conference examines need for more study of AIDS stigma. AIDS Policy Law 16(18):4. WHO (World Health Organization). 2002a. Perth framework for age-friendly community-based primary health care. http://www.who.int/ageing/projects/perth/en/ (accessed January 13, 2007). WHO. 2002b. Blood safety: Aide-memoire for national blood programmes. Geneva, Switzerland: WHO. WHO. 2006a. Fact sheet: Progress in scaling up access to HIV treatment in low- and middle-income countries. Geneva, Switzerland: WHO. WHO. 2006b. WHO global health atlas. http://www.who.int/globalatlas/DataQuery/default.asp (accessed August 1, 2006). World Bank. 2006. 2006 world development indicators. Washington, DC: World Bank. http://devdata.worldbank.org/wdi2006/contents/index2.htm (accessed November 1, 2006).

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