6

Care and Treatment

One of the cornerstones of PEPFAR has been making a major investment in meeting the tremendous challenge of supporting and scaling up services for HIV care and treatment in countries with limited resources and infrastructure and a high burden of disease. The congressional charge for this evaluation, as laid out in the Lantos-Hyde Act of 2008, requested an evaluation of the impact of treatment and care efforts on health, including an assessment of progress toward treatment and care targets and an evaluation of the effects of treatment and care programs on survival rates, drug adherence, and the emergence of drug resistance.1

This chapter describes the committee’s assessment of PEPFAR’s support for testing, care, and treatment services together, as part of a continuum of access to and delivery of HIV-related services (see Figure 6-1) (Das, 2011; Eldred and Malitz, 2007; Gardner et al., 2011; IOM, 2012). All along this continuum there are interventions and efforts supported by PEPFAR: testing and diagnosis as the entry point into care and treatment services; referrals and linkages to care services; the provision of clinical care services, nonclinical support services, and monitoring for those not eligible for antiretroviral therapy (ART); the initiation of ART for those who are eligible; maintenance and retention on ART with the continuation of non-ART clinical care and nonclinical support services; and monitoring for treat-

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1 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008), img101(c), 22 U.S.C. 7611(c)(2).



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6 Care and Treatment One of the cornerstones of PEPFAR has been making a major invest- ment in meeting the tremendous challenge of supporting and scaling up services for HIV care and treatment in countries with limited resources and infrastructure and a high burden of disease. The congressional charge for this evaluation, as laid out in the Lantos-Hyde Act of 2008, requested an evaluation of the impact of treatment and care efforts on health, including an assessment of progress toward treatment and care targets and an evalu- ation of the effects of treatment and care programs on survival rates, drug adherence, and the emergence of drug resistance.1 This chapter describes the committee’s assessment of PEPFAR’s support for testing, care, and treatment services together, as part of a continuum of access to and delivery of HIV-related services (see Figure 6-1) (Das, 2011; Eldred and Malitz, 2007; Gardner et al., 2011; IOM, 2012). All along this continuum there are interventions and efforts supported by PEPFAR: testing and diagnosis as the entry point into care and treatment services; referrals and linkages to care services; the provision of clinical care services, nonclinical support services, and monitoring for those not eligible for anti- retroviral therapy (ART); the initiation of ART for those who are eligible; maintenance and retention on ART with the continuation of non-ART clinical care and nonclinical support services; and monitoring for treat- 1  Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008), §101(c), 22 U.S.C. 7611(c)(2). 243

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244 EVALUATION OF PEPFAR Antiretroviral Virologic Testing Diagnosis Care Therapy Suppression Linkages to Care and Retention in Care and Treatment Services Treatment Services FIGURE 6-1 Implementation cascade for the continuum of care. SOURCE: Adapted from Das, 2011, and IOM, 2012. ment failure with the initiation of second-line treatment as needed. This chapter describes the committee’s assessment of PEPFAR’s efforts, focused on its activities to support the scale-up of service delivery, in each of the components of this continuum sequentially, providing for each some brief background and then following the program impact pathway framework of inputs, activities, and, to the extent possible, outcomes and impact of PEPFAR’s efforts. The continuum of care described here is directed toward virological suppression and improved health, well-being, and survival for individuals who are HIV positive; however, another ultimate goal of the HIV response is a population-level reduction of the burden of HIV and of mortality due to HIV/AIDS. The contribution of PEPFAR to this aim, to the extent that it can be assessed, is discussed at the end of this chapter. Although this chapter will focus on PEPFAR’s support for the provision of testing, care, and treatment services, it is also important to note that this continuum for care and treatment intersects with other services supported by PEPFAR programming and other opportunities where PEPFAR has a role in facilitating an effective response as well as where interrelated chal- lenges that affect care and treatment can arise. These other program areas are discussed elsewhere in this report, including prevention services (Chap- ter 5), programs for orphans and vulnerable children (Chapter 7), and ef- forts to address gender-specific aspects of HIV (Chapter 8). Along with the intersection with these other services, care and treatment programs also are inextricably linked to elements of the health system, including infrastruc- ture, commodities and supply chain, workforce, management, leadership, and financing that are required to support service delivery; these areas are

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CARE AND TREATMENT 245 touched upon only briefly in this chapter, while the primary discussion can be found in Chapter 9 on health systems strengthening. Finally, a multisec- toral response to HIV also relies on other, non-health systems and oper- ates in the broader context of the economic, social, cultural, and political environments, which are all part of the broader context of a multisectoral response to HIV. This broader context both contributes to and poses chal- lenges for the effectiveness of the HIV response. HIV COUNSELING AND TESTING Early in the HIV epidemic, voluntary HIV testing programs were in- tended to increase the number of people aware of their HIV status and to serve as an entry point for counseling and other prevention services, both for those who were HIV positive and those who were HIV negative, with the aim of reducing HIV transmission and infection. Early programs faced such challenges as the fear of stigma and discrimination, complex labora- tory methods, and a lack of available care and treatment services. With the introduction of more widespread access to care and treatment services and support for laboratory and other related services, HIV testing now serves as a crucial gateway to HIV care and treatment and to services for the prevention of mother-to-child transmission (PMTCT), while still serv- ing the initial major purpose of providing counseling and an entry point to prevention services (Marum et al., 2012). Access to testing early in the course of HIV infection is of particular importance given that people living with HIV (PLHIV) who receive treatment later in their disease consequently have poorer outcomes (WHO, 2012d). The following section presents the committee’s assessment of PEPFAR- supported HIV counseling and testing programs, with information on PEPFAR’s funding history and activities as well as on the effects of these activities, including achievements and challenges. This section focuses pri- marily on testing services because it was difficult to comprehensively assess the effects of counseling services, such as discussions that take place before and after an HIV test with the purpose of increasing knowledge, conveying prevention and risk reduction messages, providing supportive counseling, and facilitating referrals to services. There is very little information avail- able to track this component of counseling and testing in terms of how PEPFAR-supported activities have been implemented and what the out- comes of these activities have been. PEPFAR Guidance for Supported Activities for Counseling and Testing PEPFAR does not issue specific programmatic guidance on counseling and testing, but instead refers programs to the World Health Organization

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246 EVALUATION OF PEPFAR (WHO) standards. PEPFAR provides operational guidance in its annual Country Operational Plan (COP) guidance (OGAC, 2011a,b). HIV coun- seling and testing is part of the package of services in a range of PEPFAR technical areas, including medical male circumcision, prevention for PLHIV, preventing mother-to-child transmission, services for populations at high risk, adult treatment, care and support, pediatric treatment, and tubercu- losis (TB) services. Guidance for counseling and testing was also included in PEPFAR’s recent Guidance for the Prevention of Sexually Transmitted HIV Infections (OGAC, 2011c). The available guidance includes HIV testing and counseling provided through both client-initiated approaches and provider-initiated approaches and describes a range of settings for counseling and testing, such as health facilities (e.g., antenatal clinics, TB clinics, and outpatient clinics); stand- alone counseling and testing sites; and home-based, mobile, and outreach programs, including special events, campaigns, and promotional activities to create demand. Related activities may include training or refresher train- ing in areas such as retesting recommendations, couples counseling and testing, and quality assurance; strengthening and monitoring referrals and linkages, including tracking or follow-up of HIV-positive individuals not enrolling in care or treatment services; and activities for quality assurance of both testing and counseling. For planning activities through implementing partners, the guidance also states that target populations should be speci- fied along with information, if available, on the HIV prevalence and testing coverage in those populations and that the linkages should be specified between testing and services in other technical areas (OGAC, 2011a,b,c). PEPFAR Funding History for Counseling and Testing PEPFAR’s funding for counseling and testing is captured in a single budget code. Figure 6-2 shows the funding over time in this budget code in both the dollar amount and as a proportion of all PEPFAR funding. The total for this budget code increased substantially over time during the first phase of PEPFAR, then leveled off starting in FY 2008 at just more than $200 million per year (OGAC, 2005, 2006g, 2007c, 2008b, 2010c, 2011d,e). Effects of PEPFAR-Supported HIV Testing PEPFAR Testing Indicator Data: Targets and Results PEPFAR has limited central reporting of indicators to provide informa- tion about the performance of its testing programs. The primary indicator is an overall output indicator that captures the number of individuals who re-

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CARE AND TREATMENT 247 $250 9% 8% Constant 2010 USD Millions $200 7% 6% $150 5% 4% $100 3% $50 2% 1% $0 0% FY05 FY06 FY07 FY08 FY09 FY10 FY11 Counseling & Testing Counseling & Testing as % of total PEPFAR funding FIGURE 6-2 Planned/approved funding over time for counseling and testing services. NOTES: This figure represents funding for all PEPFAR countries as planned/approved through PEPFAR’s budget codes. The budget codes are the only available source of funding information disaggregated by type of activity, and are therefore used in this report as the most reasonable and reliable approximation of PEPFAR investment by programmatic area. Data are presented in constant 2010 USD for comparison over time. Cur- rently, funding for testing and counseling in the context of PMTCT can be included under the PMTCT budget code or the Counseling and Testing budget code, and so some investment in testing in that context may not be reflected here. Similarly, funding for testing and counseling in the context of tuberculosis (TB) services is under the TB/HIV budget code and is not reflected here (OGAC, 2010b). See Chapter 4 for a more detailed discussion of PEPFAR’s budget codes and the available data for tracking PEPFAR funding. SOURCES: OGAC, 2005, 2006g, 2007c, 2008b, 2010c, 2011d,e. ceived counseling and testing for HIV and who received test results (OGAC, 2007b, 2009d). Table 6-1 shows that the number tested with the support of PEPFAR has increased notably over time and that since the initial year of implementation the annual target has been consistently met or exceeded. TABLE 6-1 Number of Individuals Who Received Counseling and Testing for HIV and Received Test Results (in Millions) FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 Result 1.3 2.5 5.1 9.3 16.4 21.2 32.7 Target — 2.6 4.8 6.1 9.0 13.2 25.8 % of Target — 96 106 153 182 160 127 NOTES: This table represents data for the 31 countries identified as the focus of this evaluation (see Chapter 2). Results and targets for FY 2004–FY 2009 correspond to OGAC indicator 9.2 (direct) (OGAC, 2007b). Results and targets for FY 2010 correspond to OGAC indicator P11.1.D (OGAC, 2009d). SOURCE: Program monitoring indicators provided by OGAC.

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248 EVALUATION OF PEPFAR Challenges in Monitoring of Testing Services The monitoring of testing services and outcomes affects planning and management not only for testing services but also for other target areas that are dependent on the estimates of the numbers of people identified as living with HIV. There are a number of challenges in the accurate monitoring of testing services, especially where there are not unique patient identifiers. In tracking the number of individuals who have received testing services, for example, there is the potential for double counting of testing clients, some of whom may be accessing testing services repeatedly, either because of a lack of confidence in the results or because they have tested negative but are getting tested periodically because of high, ongoing, or new risks of exposure. In addition, without unique identifiers it is difficult to track whether individuals are being successfully referred for additional services once they have received their test results; the data are largely cross-sectional and do not allow for longitudinal individual follow-up. These challenges were identified by interviewees in several countries, who described that patients will be tested more than once, will go to more than one commu- nity to be tested, or will hide previous testing (587-18-PCGOV; 587-2-USG; 587-9-USG; 2 331-23-USNGO; 461-16-USG). The lack of unique identifiers for the people tested makes it difficult to adjust reported numbers appropriately (461-16-USG; 587-2- USG), and also poses a challenge for tracking whether people reach care and treatment programs after being tested (116-9-PCNGO; 587-3-USG; 461-7-PCNGO; 587-13-USG; 396-21-USG). Other issues that interfere with the collection of quality data on testing services, as identified by interviewees in various countries, are the use of different counseling and testing reporting systems by PEPFAR and the national system (587-9-USG) and the practice of only registering those who test positive in patient-tracking databases (272-21-PCNGO). PEPFAR Achievements in the Scale-Up of Testing WHO estimates indicate that there has been an increase in the numbers and proportion of individuals in PEPFAR partner countries who are aware of their HIV status (WHO, 2012f; WHO et al., 2011), which is consistent with the considerable expansion of HIV testing through the implementa- 2  Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-Country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Coun- try) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

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CARE AND TREATMENT 249 tion of PEPFAR-supported services. Although challenges related to HIV testing remain (discussed later in this chapter), interviewees in the countries visited for this evaluation overall considered PEPFAR’s efforts in testing a success that has led to increased access to testing and counseling services, with the result that many more individuals have learned their HIV status and, if positive, have been linked to clinical services. Interviewees in several countries observed that before PEPFAR there had been no counseling and testing program, or, if available, it had existed on only on a small scale with few facilities to provide this service and the uptake of counseling and testing was low (240-2-USG; 396-23-USG; 116-16-PCGOV). PEPFAR has helped partner countries initiate counseling and testing programs and scale up the number of facili- ties and other venues providing this service (461-14-USG; 396-23-USG; 116-16-PCGOV; 272- ES; 331-32-PCNGO; 935-17-USG; 240-2-USG). As a contribution to this scale-up, PEPFAR has not only supported testing services but has also helped develop guide- lines related to counseling and testing, promoted the implementation of innovative approaches and emergent testing methods, and advocated for more aggressive policies for HIV testing in the setting of not only high- prevalence countries but also concentrated epidemics (196-11-USNGO; 396-23-USG; 272-13-USG; 542-8-USNGO; 396-23-USG; 331-18-USNGO). By supporting activities related to the scale-up of testing PEPFAR has also contributed to increased public awareness of both HIV and the availability of HIV counseling and testing in partner countries. Awareness efforts have involved a variety of strategies and settings, such as the use of hotlines, national testing initiatives, drop-in centers, health fairs, posters, and media channels as well as the engagement of peer educators, worksites and employers, community service organiza- tions, and faith-based organizations (587-14-PCGOV; 166-5-USG; 331-7-PCNGO; 331-22-PCNGO; 396-32-PCGOV; 196-20-PCNGO; 166-14-PCNGO; 240-2-USG; 272-24-USG; 587-8-PCGOV; 636-6-USG; 636-17-PCGOV; 331-38-USPS; 934-17-PCGOV; 331-22-PCNGO; 396-12-USG; 396-44-PCGOV; 196-23-PCNGO) . Evolution of Testing Approaches Over Time In scaling up testing services, PEPFAR has supported both client- initiated approaches and, increasingly over time, provider-initiated ap- proaches. Initially most PEPFAR-supported testing was client-initiated testing based in separate testing facilities; later the integration of testing with other key services was recognized as a way to facilitate access to and provide a less stigmatized environment for HIV testing and efforts were made toward more integration with, for example, antenatal care, child health programs, primary health care, and TB services (272-24-USG; 331-28-PC- GOV; 272-24-USG; 587-5-PCGOV; 636-17-PCGOV; 396-18-USG). As another way to increase the access to and availability of HIV testing, PEPFAR moved to implement more client-initiated testing services outside of facilities. These approaches include home-based testing, testing in community settings, and testing in

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250 EVALUATION OF PEPFAR mobile clinics (116-12-PCNGO; 116-13-PCNGO; 331-11-PCNGO; 461-7-PCNGO; 461-24-PCNGO; 935-17-USG; 240-2-USG). Interviewees identified these approaches as ways to expand test- ing, allow for earlier detection of HIV, and facilitate access to testing and referrals to services for specific populations at high risk, including those who are highly mobile or transient (166-13-PCGOV; 542-11-PCNGO; 935-17-USG; 542-14-PCGOV; 396-44-PCGOV; 196-25-PCNGO). Home-based counseling and testing has been imple- mented on an increasingly larger scale recently in several countries, and interviewees pointed to the initial achievements of adopting a home-based approach as an indication of this approach’s potential to better integrate HIV treatment and prevention and to reach more couples, especially male partners (935-17-USG; 461-7-PCNGO; 116-12-PCNGO). In addition to expanding client-initiated testing services, as the adop- tion of provider-initiated counseling and testing (PICT) emerged globally (Marum et al., 2012; WHO and UNAIDS, 2007), PEPFAR widely sup- ported its implementation in partner countries in both outpatient and inpatient health facilities (935-17-USG; 116-12-PCNGO; 240-8-USG; 272-24-USG; 240-24-USG). This approach was encouraged as another means to increase access to testing; to improve coverage in facility-based testing in general; and to reduce missed opportunities to test those patients who present to health facilities under circumstances where there is reason to consider them at high risk for HIV, such as TB patients or patients hospitalized with illnesses that could be due to opportunistic infections (196-11-USNGO; 196-17-PCGOV; 934-21-PCGOV; 935-17-USG). In ad- dition to PEPFAR’s support of PICT in PEPFAR-supported service delivery, interviewees also mentioned PEPFAR’s contributions to the inclusion of PICT in the national strategy, the scaling up of training for PICT to the na- tional level, and the development of training guidelines (196-11-USNGO; 636-6-USG). Targeted Testing Interviewees highlighted several efforts to target vulnerable or difficult- to-serve populations for counseling and testing. In addition to the above- mentioned use of targeted community-based and mobile testing to reach populations at high risk, interviewees offered such examples of specific efforts as a campaign to offer counseling and testing services in locations and at times that guarantee privacy for men who have sex with men, night- time mobile testing services to reach sex workers and their clients, a referral system for sex workers to increase their access to testing, efforts to improve referrals and access to testing services specifically for women who inject drugs, and mobile outreach services that include testing for street children (396-44-PCGOV; 196-25-PCNGO; 935-17-USG; 935-16-USNGO; 331-22-PCNGO; 542-11-PCNGO; 196-24-PCNGO; . PEPFAR’s support for services for these populations is discussed 542-14-PCGOV) in more depth in Chapter 5 on prevention and Chapter 8 on gender.

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CARE AND TREATMENT 251 Another important population for counseling and testing is pregnant women; reaching this population ideally provides an entry point into both services for PMTCT and care and treatment services for women who are HIV positive. Interviewees noted PEPFAR’s achievements in the effort to reach pregnant women with HIV testing, especially in antenatal clinics and in the health facilities where they give birth. Interviewees said that pregnant women are increasingly likely to be offered and to accept testing for HIV when receiving antenatal care, particularly during their first antenatal visit (166-5-USG; 331-28-PCGOV; 166-27-PCNGO; 587-5-PCGOV; 636-22-PCNGO; 636-1-USG; 636-6-USG). Despite the relative success and progress in testing for this population, interviewees emphasized that coverage gaps remain, especially for pregnant women who do not make a visit to antenatal care clinics or to facilities for delivery (240-ES; 240-2-USG; 240-13-PCGOV; 240-19-USACA; 240-24-USG; 636-2-USG; 461-7-PCNGO; 396-42-PCGOV; 587-5-PCGOV; . Issues related to access to testing and PMTCT services for pregnant 636-6-USG) women are discussed in more depth in Chapter 5 on prevention. There are also gaps in linking testing for pregnant women with testing for their male partners; PEPFAR has supported efforts to involve male partners in PMTCT services (331-27-PCGOV; 587-9-USG; 636-9-USACA; 116-15-USNGO). Infants and children are another critical and challenging population with respect to HIV testing; efforts for this population are discussed in depth later in this section of the chapter. In some cases interviewees described the targeting of testing services as resulting in some conflict and lack of alignment with national priorities and planning in partner countries. In these cases, generalized testing was typi- cally a priority for the partner government, while PEPFAR was advocating that the most strategic use of available resources for testing would be to prioritize identified high-risk populations or higher-prevalence geographic areas (587-22-USG; 240-2-USG; 396-23-USG). Other Efforts Related to Testing In addition to its support for the delivery of counseling and testing services to clients, PEPFAR has provided support in partner countries at the level of health systems for activities in other areas that are critical for test- ing. These are noted briefly here; health systems strengthening is discussed in more depth in Chapter 9. Interviewees across countries described PEPFAR’s contribution to test- ing through the construction of laboratories, strengthening central labora- tory services to receive district samples, and capacity building of technical staff (935-8-PCGOV; 542-8-USNGO; 396-25-PCGOV; 934-5-USG). Beyond training laboratory staff, other workforce activities funded by PEPFAR with respect to test- ing have included the training of counselors in counseling and testing, the training of health care providers and supervisors on PICT, and the training

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252 EVALUATION OF PEPFAR of health care workers and lay counselors to do rapid HIV testing (272-13- USG; 116-12-PCNGO; 935-17-USG; 240-ES). The training of non-laboratory workers to do testing was described by one interviewee as having a ‘huge impact’3 (272-13-USG), but this approach has encountered barriers related to policies on scope of work that limit the ability of programs to expand home-based testing and testing in facilities without laboratory staff (935-ES). PEPFAR has also supported the supply chain for testing through the provision of test kits as well as through transportation solutions for delivery of samples (166-11-USG; 935-8-PCGOV; 935-13-PCGOV). Other examples include PEPFAR support for the strengthening of information systems and providing access to elec- tronic tools used to track samples and to register the positive cases tested (396-36-PCGOV; 935-17-USG). Interviewees also mentioned several examples of PEPFAR introducing counseling and testing quality-assurance strategies, including efforts such as setting up quality-assurance programs at the national level, the use of the HIVQUAL system, internal and external quality management systems, quality checks of test kit batches, and training of supervisors on PICT and HIV testing and counseling to ensure providers maintain quality services (461-18-USG; 116-12-PCNGO; 587-9-USG; 935-17-USG; 272-13-USG; 934-5-USG). At the same time, inter- viewees noted that in some countries there were challenges associated with quality assurance, due, for example, to the lack of a system to measure the quality of services and issues with standardization for counseling and test- ing and services (166-5-USG; 272-25-USG). Ongoing Challenges with Coverage of HIV Testing Despite the achievements in the scale-up of HIV testing in PEPFAR partner countries, challenges remain in achieving adequate coverage, in- cluding low rates of testing and low knowledge of HIV serostatus (particu- larly among HIV-infected persons), which contribute to gaps in achieving coverage goals of HIV treatment and prevention programs (Gilliam et al., 2012; OGAC, 2011b). This limits the ultimate success of testing services as part of the continuum of HIV prevention, care, and treatment services in a comprehensive response to HIV. Several interviewees on country visits remarked that, although the progress in testing coverage since the ini- tiation of PEPFAR has been a notable achievement, there continue to be large numbers of people who do not know their HIV status (196-14-PCGOV; 331-10-PCGOV; 240-9-USG; 935-8-PCGOV; 636-11-PCNGO; 166-13-PCGOV). As one interviewee put 3  Singlequotations denote an interviewee’s perspective with wording extracted from tran- scribed notes written during the interview. Double quotations denote an exact quote from an interviewee either confirmed by listening to the audio-recording of the interview or extracted from a full transcript of the audio-recording.

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CARE AND TREATMENT 253 it, a ‘key challenge is getting more people access to counseling and testing’ (166-13-PCGOV). Interviewees noted a host of factors that, in their experience supporting the implementation and delivery of these services, affect whether people access counseling and testing services. In most cases these are barri- ers that PEPFAR has been attempting to overcome and, as described above, PEPFAR’s contribution has led to remarkable progress. Nonetheless, the ongoing challenge of coverage remains an important factor to address as it will otherwise hinder efforts to further advance PEPFAR’s efforts and to achieve future HIV-related goals. Many of the factors affecting coverage that interviewees mentioned had to do with availability of testing services. This availability is affected by long wait times; the availability of trained counseling and testing and labo- ratory personnel; the availability of laboratory equipment and commodities such as test kits and reagents; and the necessity in some geographic loca- tions of referring clients to another, more distant site for testing which can lead to barriers related to cost and transportation (240-2-USG; 396-25-PCGOV; 587-5-PC- GOV; 396-21-USG; 934-5-USG; 272-13-USG; 196-24-PCNGO; 196-27-USG; 166-5-USG; 166-15-USACA; 196-10-PCGOV; 461-10-PCNGO; 636-22-PCNGO; 935-17-USG; 935-24-USNGO; 935-14-USG; 461-14-USG; 166-10-USNGO; 272-25-USG; . Other factors described by inter- 116-20-USNGO; 636-17-PCGOV; 196-17-PCGOV; 542-8-USNGO) viewees had more to do with the engagement of individuals in accessing these services, which they described as affected by stigma, concern about discrimination, cultural norms about accessing health services, fear of ex- periencing violence or separation from a spouse or partner, and fear of los- ing family support (636-11-PCNGO; 331-7-PCNGO; 935-15-ONGO; 166-5-USG; 240-ES; 166-27-PCNGO; 331-6-CCM). These interviewee perspectives on barriers leading to a lack of coverage of HIV testing are consistent with the research literature, which has shown that even when HIV testing is available, discrepancies persist between the intention to be tested and actually being tested (Obermeyer and Osborn, 2007) and that engagement in testing is affected by complex factors such as the awareness of and access to testing and health care as well as perceived risk, stigma, fear, discrimination, and threat of violence (Bartlett et al., 2008; Padian et al., 2011). Women are particularly vulnerable to stigma, domestic violence, and abandonment related to testing outcomes and dis- closure (Medley et al., 2004; Visser, 2012; WHO, 2006a), yet they are more likely to report having had an HIV test than men (WHO et al., 2011). One contributing factor to this increased likelihood of testing among women is their greater access to testing services as a result of more frequent contact with health services, such as participation in antenatal care (WHO, 2012d). The fear of violence or abandonment as a result of an HIV diagnosis was raised by interviewees in several countries as a salient and critically important issue for some women, and it is discussed in more depth in

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332 EVALUATION OF PEPFAR poor laboratory infrastructure, inadequate human resources for health in many low- and middle-income countries, and challenges relating to ensur- ing patient adherence to treatment. In addition, challenges with retention and adherence, the emergence of drug resistance, and the co-infection of HIV patients with tuberculosis continue to undermine care and treatment efforts. Interviewees conveyed their awareness of a desire by PEPFAR to foster sustainability and, in that light, to reduce or eliminate support for the HIV response in partner countries. Their central concern was the continuing availability of funding for ARVs. As one interviewee stated, “Obviously, absolutely, we should be looking at long-term sustain- ability. But at the same time, don’t let that be the catchall. And right now, PEPFAR, we have the money, and one of the most im- portant things right now is saving lives. We’ve lost too many lives here in [this country]. It was an absolute horror and a tragedy. And we’re stopping that now. And we should continue to stop it. But treatment is one of the most important things that we can do. Obviously, as we all know, it’s not the only thing. We’ve also got to focus on prevention. But this is an inexpensive way to stop the deaths.” (934-5-USG) Interviewees described initiatives they had undertaken that would even- tually become self-sustaining such as, in the case of one country, imple- menting fees to subsidize a laboratory quality-assurance program (934-5-USG). Overall, however, interviewees across countries questioned the readiness of their countries for anticipated sustainability-related funding reductions or cessation (240-15-USG; 396-21-USG; 934-5-USG) and made recommendations or raised concerns about the pace or timeframe for such reductions (272-5-PCGOV; 272-22- USG). As one interviewee explained, ‘It’s not that sensible for PEPFAR to leave tomorrow [. . .] it would be difficult to keep scaling up and adding money and replace PEPFAR funding at the same time. If PEPFAR pulled out, the funding would probably just not be replaced. If done over time, it’s far more likely it would be a smooth process to sustainability.’ (272-5-PCGOV) Barriers to partner country readiness for sustainability included such issues as funding treatment scale-up efforts that are currently under way (272-5-PCGOV), a lack of partner government capacity to ‘take over the re- sponse’ (240-24-USG), meeting salary expectations of those previously employed by PEPFAR (240-15-USG), and absorbing demands for services (272-32/35-PCNGO). One interviewee observed that ‘a weak [ART] program is not sustain-

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CARE AND TREATMENT 333 able,’ implying the need for program strengthening as a pre-condition for sustainability (396-21-USG). Another interviewee focused on facilitating drug treatment adherence, noting that making treatment ‘easier and cheaper is sustainability’ (272-22-USG). In summary, the all-encompassing challenge for care and treatment, as for other HIV services, is that despite the remarkable scale-up in PEPFAR partner countries, there remains substantial unmet need. The large numbers of currently enrolled patients who need to be maintained, those currently eligible but not yet enrolled, and the potential for expansion of eligibility if changing WHO guidelines are adopted and implemented are fundamental challenges for achieving adequate coverage and for the sustainability of care and treatment across PEPFAR partner countries. Intrinsic limitations in the health system and other systems involved in the response continue to be barriers to the delivery of services, as do the realities of resource constraints, especially with the possible flattening or decreasing of external resources. Therefore, for care and treatment, as with other HIV programs, the most critical challenge for the future is for PEPFAR to work with partner countries and global partners to sustain the gains made, to continue to make progress, and to ensure the ongoing quality of services provided and programs implemented. Given that this challenge must be confronted while facing limited resources, contributing stakeholders will need to allocate resources with a strategic and ethical balance among coverage priorities. Critically important issues related to this overarching challenge for the fu- ture, including strengthening systems, building capacity, and considerations and efforts related to achieving a sustainable, country-led response to HIV in PEPFAR partner countries, are discussed in depth in Chapters 9 and 10. REFERENCES AIDSTAR-One (AIDS Support and Technical Assistance Resources Project). 2011a. Summary table of HIV treatment regimens: Pediatric and adult national treatment guidelines: Janu- ary 2011. Arlington, VA: AIDSTAR-One Project, Sector I, Task Order 1. AIDSTAR-One. 2011b. Summary table of HIV treatment regimens: Pediatric and adult treat- ment guidelines for PEPFAR focus and non-focus countries: June 2011. Arlington, VA: AIDSTAR-One Project, Sector I, Task Order 1. AIDSTAR-One. 2012. Summary table of HIV treatment regimens: Pediatric and adult treat- ment guidelines for PEPFAR focus and non-focus countries: October 2012. Arlington, VA: AIDSTAR-One Project, Sector I, Task Order 1. Bartlett, J., B. M. Branson, K. Fenton, B. C. Hauschild, V. Miller, and K. H. Mayer. 2008. Opt-out testing for human immunodeficiency virus in the United States: Progress and challenges. Journal of the American Medical Association 300(8):945-951. Bendavid, E., and J. Bhattacharya. 2009. The President’s Emergency Plan for AIDS Relief in Africa: An evaluation of outcomes. Annals of Internal Medicine 150(10):688-695.

OCR for page 243
334 EVALUATION OF PEPFAR Bendavid, E., C. B. Holmes, J. Bhattacharya, and G. Miller. 2012. HIV development as- sistance and adult mortality in Africa. Journal of the American Medical Association 307(19):2060-2067. Botswana Ministry of Health. 2008. Botswana national HIV/AIDS treatment guidelines: 2008 version. Gaborone: Botswana Ministry of Health, Department of HIV/AIDS Prevention and Care. Brahmbhatt, H., G. Kigozi, F. Wabwire-Mangen, D. Serwadda, T. Lutalo, F. Nalugoda, N. Sewankambo, M. Kiduggavu, M. Wawer, and R. Gray. 2006. Mortality in HIV-infected and uninfected children of HIV-infected and uninfected mothers in rural Uganda. Journal of Acquired Immune Deficiency Syndromes 41(4):504-508. Bussmann, H., C. W. Wester, N. Ndwapi, N. Grundmann, T. Gaolathe, J. Puvimanasinghe, A. Avalos, M. Mine, K. Seipone, M. Essex, V. Degruttola, and R. G. Marlink. 2008. Five- year outcomes of initial patients treated in Botswana’s national antiretroviral treatment program. AIDS 22(17):2303-2311. Cambodia Ministry of Health. 2003. National guidelines for the use of antiretroviral therapy in adults and adolescents. Phnom Penh: Cambodia Ministry of Health, National Center for HIV/AIDS, Dermatology and STD. Cambodia Ministry of Health. 2007. National guidelines for the use of pediatric antiretroviral therapy in Cambodia. Phnom Penh: Cambodia Ministry of Health, National Center for HIV/AIDS, Dermatology and STD. Chang, L. W., J. Kagaayi, G. Nakigozi, V. Ssempijja, A. H. Packer, D. Serwadda, T. C. Quinn, R. H. Gray, R. C. Bollinger, and S. J. Reynolds. 2010. Effect of peer health workers on AIDS care in Rakai, Uganda: A cluster-randomized trial. PLOS One 5(6):e10923. Chen, S. C., J. K. Yu, A. D. Harries, C. N. Bong, R. Kolola-Dzimadzi, T. S. Tok, C. C. King, and J. D. Wang. 2008. Increased mortality of male adults with AIDS related to poor compliance to antiretroviral therapy in Malawi. Tropical Medicine & International Health 13(4):513-519. China CDC (Chinese Center for Disease Control and Prevention). 2005. China free ART manual. Beijing: China CDC. Das, M. 2011. Intensifying HIV prevention in the communities where HIV is most heavily concentrated. Presented at the 2011 National HIV Prevention Conference, Atlanta, Georgia. Duber, H. C., T. J. Coates, G. Szekeras, A. H. Kaji, and R. J. Lewis. 2010. Is there an associa- tion between PEPFAR funding and improvement in national health indicators in Africa? A retrospective study. Journal of the International AIDS Society 13:21. El-Khatib, Z., D. Katzenstein, G. Marrone, F. Laher, L. Mohapi, M. Petzold, L. Morris, and A. M. Ekstrom. 2011. Adherence to drug-refill is a useful early warning indicator of vi- rologic and immunologic failure among HIV patients on first-line ART in South Africa. PLOS ONE 6(3):e17518. Eldred, L., and F. Malitz. 2007. Introduction. AIDS Patient Care & STDs 21:S1-S2. Ethiopia Ministry of Health. 2003. Guidelines for use of antiretroviral drugs in Ethiopia. Addis Ababa: Ethiopia Federal HIV/AIDS Prevention and Control Office, Ministry of Health. Ethiopia Ministry of Health. 2007. Guidelines for paediatric HIV/AIDS care and treatment in Ethiopia. Addis Ababa: Ethiopia Federal HIV/AIDS Prevention and Control Office, Ministry of Health. Fatti, G., G. Meintjes, J. Shea, B. Eley, and A. Grimwood. 2012. Improved survival and anti- retroviral treatment outcomes in adults receiving community-based adherence support: 5-year results from a multicentre cohort study in South Africa. Journal of Acquired Im- mune Deficiency Syndromes 61(4):50.

OCR for page 243
CARE AND TREATMENT 335 Fox, M. P., and S. Rosen. 2010. Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: Systematic review. Tropical Medicine & International Health 15(Suppl 1):1-15. G, U. L., and A. Adewumi. 2004. Nigeria country presentation. Presented at Pharmacovigi- lance: First Training workshop to introduce monitoring of safety and efficacy of antiret- rovirals in Africa, Pretoria, South Africa. Gardner, E. M., M. P. McLees, J. F. Steiner, C. del Rio, and W. J. Burman. 2011. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Diseases 52(6):793-800. Geng, E. H., P. W. Hunt, L. O. Diero, S. Kimaiyo, G. R. Somi, P. Okong, D. R. Bangsberg, M. B. Bwana, C. R. Cohen, J. A. Otieno, D. Wabwire, B. Elul, D. Nash, P. J. Easterbrook, P. Braitstein, B. S. Musick, J. N. Martin, C. T. Yiannoutsos, and K. Wools-Kaloustian. 2011. Trends in the clinical characteristics of HIV-infected patients initiating antiretro- viral therapy in Kenya, Uganda and Tanzania between 2002 and 2009. Journal of the International AIDS Society 14:46. George W. Bush Institute, U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), Susan G. Komen for the Cure, and Joint United Nations Programme on HIV/AIDS (UNAIDS). 2012. Pink Ribbon, Red Ribbon. http://www.pinkandredribbon.com (accessed May 31, 2013). Ghana Ministry of Health. 2002. Guidelines for antiretroviral therapy in Ghana. Accra: Ghana Ministry of Health/Ghana Health Service. Gilliam, B. L., D. Patel, R. Talwani, and Z. Temesgen. 2012. HIV in Africa: Challenges and directions for the next decade. Current Infectious Disease Reports 14(1):91-101. Global Fund (The Global Fund to Fight AIDS, Tuberculosis, and Malaria). 2009. Global Fund ARV fact sheet: 1st December, 2009. Geneva: Global Fund. Global Fund. 2013. Government donors. http://www.theglobalfund.org/en/donors/public/ (accessed May 31, 2013). Government of India. 2007. Antiretroviral therapy guidelines for HIV-infected adults and ado- lescents including post-exposure prophylaxis. New Delhi: Government of India Ministry of Health & Family Welfare. Grundmann, N., P. Iliff, J. Stringer, and C. Wilfert. 2011. Presumptive diagnosis of severe HIV infection to determine the need for antiretroviral therapy in children less than 18 months of age. Bulletin of the World Health Organization 89(7):513-520. Gupta, R. K., M. R. Jordan, B. J. Sultan, A. Hill, D. H. J. Davis, J. Gregson, A. W. Sawyer, R. L. Hamers, N. Ndembi, D. Pillay, and S. Bertagnolio. 2012. Global trends in antiret- roviral resistance in treatment-naive individuals with HIV after rollout of antiretroviral treatment in resource-limited settings: A global collaborative study and meta-regression analysis. Lancet 380(9849):1250-1258. Guyana Ministry of Health. 2009. National guidelines for management of HIV-infected and HIV-exposed adults and children. Georgetown: Guyana Ministry of Health. Haiti Ministry of Public Health and Population. 2008. Manuel de normes de prise en charge clinique et thérapeutique des adultes et adolescents vivant avec le VIH. Port-au-Prince: Haiti Ministry of Public Health and Population. Hamers, R. L., C. L. Wallis, C. Kityo, M. Siwale, K. Mandaliya, F. Conradie, M. E. Botes, M. Wellington, A. Osibogun, K. C. Sigaloff, I. Nankya, R. Schuurman, F. W. Wit, W. S. Stevens, M. van Vugt, T. F. de Wit, and PharmAccess African Studies to Evaluate Re- sistance. 2011. HIV-1 drug resistance in antiretroviral-naive individuals in sub-Saharan Africa after rollout of antiretroviral therapy: A multicentre observational study. Lancet Infectious Diseases 11(10):750-759. Hamers, R. L., C. Kityo, J. M. A. Lange, T. F. de Wit, P. Mugyenyi. 2012. Global threat from drug resistant HIV in sub-Saharan Africa. British Medical Journal 344:e4159.

OCR for page 243
336 EVALUATION OF PEPFAR Hawkins, C., G. Chalamilla, J. Okuma, D. Spiegelman, E. Hertzmark, E. Aris, T. Ewald, F. Mugusi, D. Mtasiwa, and W. Fawzi. 2011. Sex differences in antiretroviral treatment out- comes among HIV-infected adults in an urban Tanzanian setting. AIDS 25(9):1189-1197. Herbst, A. J., G. S. Cooke, T. Barnighausen, A. KanyKany, F. Tanser, and M. L. Newell. 2009. Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa. Bulletin of the World Health Organization 87(10):754-762. Hong, S. Y., A. Jonas, E. Dumeni, A. Badi, D. Pereko, A. Blom, V. S. Muthiani, A. N. Shiningavamwe, J. Mukamba, G. Andemichael, R. Barbara, D. E. Bennett, and M. R. Jordan. 2010. Population-based monitoring of HIV drug resistance in Namibia with early warning indicators. Journal of Acquired Immune Deficiency Syndromes 55(4):27-31. Igumbor, J. O., E. Scheepers, R. Ebrahim, A. Jason, and A. Grimwood. 2011. An evaluation of the impact of a community-based adherence support programme on ART outcomes in selected government HIV treatment sites in South Africa. AIDS Care 23(2):231-236. Indonesia Ministry of Health. 2007. National guidelines for antiretroviral therapy: A guide to clinical management of HIV infection in adults and youth (Panduan tatalaksana klinis Infeksi HIV pada orang dewasa dan remaja). Jakarta: Directorate General of Disease Control and Environmental Health, Indonesia Ministry of Health. Indonesia Ministry of Health. 2008. Guidelines for treatment of HIV infection and antiret- roviral therapy in children in Indonesia (Pedoman tatalaksana infeksi HIV dan terapi antiretroviral pada anak di Indonesia). Jakarta: Directorate General of Disease Control and Environmental Health, Indonesia Ministry of Health. Indonesia Ministry of Health. 2011. National guidelines for the clinical management of HIV infection and antiretroviral therapy in adults (Pedoman nasional tatalaksana klinis infeksi HIV dan terapi antiretroviral pada orang ewasa). Jakarta: Directorate General of Disease Control and Environmental Health, Indonesia Ministry of Health. IOM (Institute of Medicine). 2007. PEPFAR implementation: Progress and promise. Wash- ington, DC: The National Academies Press IOM. 2012. Monitoring HIV care in the United States: A strategy for generating national estimates of HIV care and coverage. Washington, DC: The National Academies Press. IOM and NRC (National Research Council). 2010. Strategic Approach to the Evaluation of Programs Implemented under the Tom Lantos and Henry J. Hyde U.S. Global Leader- ship Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. Wash- ington, DC: The National Academies Press. Jahn, A., S. Floyd, A. C. Crampin, F. Mwaungulu, H. Mvula, F. Munthali, N. McGrath, J. Mwafilaso, V. Mwinuka, B. Mangongo, P. E. Fine, B. Zaba, and J. R. Glynn. 2008. Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet 371(9624):1603-1611. Kapstein, E. B., and J. Busby. 2009. Making markets for merit goods: The political economy of antiretrovirals. Washington, DC: Center for Global Development (CGD). Kaur, G., and A. Singh. 2010. The “see and treat” approach to cervical cancer. http://www. thelancetstudent.com/legacy/2010/02/16/the-see-and-treat-approach-to-cervical-cancer (accessed May 31, 2013). Kayigamba, F. R., M. I. Bakker, H. Fikse, V. Mugisha, A. Asiimwe, and M. F. Schim van der Loeff. 2012. Patient enrolment into HIV care and treatment within 90 days of HIV diagnosis in eight Rwandan health facilities: A review of facility-based registers. PLOS ONE 7(5):e36792. Kenya Ministry of Health. 2001. Guidelines to antiretroviral drug therapy in Kenya. Nairobi: National Aids and STD Control Programme, Kenya Ministry of Health.

OCR for page 243
CARE AND TREATMENT 337 Kimmel, A. D., M. C. Weinstein, X. Anglaret, S. J. Goldie, E. Losina, Y. Yazdanpanah, E. Messou, K. L. Cotich, R. P. Walensky, and K. A. Freedberg. 2010. Laboratory monitoring to guide switching antiretroviral therapy in resource-limited settings: clinical benefits and cost-effectiveness. Journal of Acquired Immune Deficiency Syndromes 54(3):258-268. Koole, O., S. Tsui, F. Wabwire-Mangen, G. Kwesigabo, J. Menten, M. Mulenga, A. Auld, S. Agolory, Y. D. Mukadi, R. Colebunders, D. R. Bangsberg, E. Van Praag, K. Torpey, S. Williams, J. Kaplan, A. Zee, and J. Denison. 2012. Retention and risk factors for attrition among adults in antiretroviral treatment programs in Tanzania, Uganda and Zambia. Presented at the XIX Inernational AIDS Conference, Washington, DC. Malawi Ministry of Health. 2006. Treatment of AIDS: Guidelines for the use of antiretroviral therapy in Malawi. Second Edition: April 2006. Lilongwe: National AIDS Commission, Malawi Ministry of Health. Marum, E., M. Taegtmeyer, B. Parekh, N. Mugo, S. Lembariti, M. Phiri, J. Moore, and A. Cheng. 2012. “What Took You So Long?” The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa. Journal of Acquired Immune Deficiency Syndromes 60(Suppl 3):S63-S69. Mat Shah, R., A. Bulgiba, C. K. C. Lee, J. Haniff, and M. Mohamad Ali. 2012. Highly active antiretroviral therapy reduces mortality and morbidity in patients with AIDS in Sungai Buloh Hospital. Journal of Experimental & Clinical Medicine 4(4):239-244. McCullough, R., and L. Miller. 2009. Surveying the global HIV/AIDS landscape. http:// ftguonline.org/ftgu-232/index.php/ftgu/article/view/2050/4096 (accessed June 10, 2011). McMahon, J., J. Elliott, S. Hong, and M. Jordan. 2012. Effects of patient tracing on estimates of lost to follow-up, mortality and retentation in antiretroviral therapy programs in low- middle income countries: A systematic review. Abstract no. MOAC0302. Presented at the XIX International AIDS Conference, Washington, DC. Medley, A., C. Garcia-Moreno, S. McGill, and S. Maman. 2004. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Bulletin of the World Health Organization 82(4):299-307. Menzies, N. A., A. A. Berruti, R. Berzon, S. Filler, R. Ferris, T. V. Ellerbrock, and J. M. Blandford. 2011. The cost of providing comprehensive HIV treatment in PEPFAR- supported programs. AIDS 25(14):1753-1760. Mermin, J., W. Were, J. P. Ekwaru, D. Moore, R. Downing, P. Behumbiize, J. R. Lule, A. Coutinho, J. Tappero, and R. Bunnell. 2008. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: A pro- spective cohort study. Lancet 371(9614):752-759. Namibia Ministry of Health and Social Services. 2010. National guidelines for antiretroviral therapy. Third edition. Windhoek: Directorate of Special Programmes, Namibia Ministry of Health and Social Services. Newell, M. L., H. Coovadia, M. Cortina-Borja, N. Rollins, P. Gaillard, and F. Dabis. 2004. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: A pooled analysis. Lancet 364(9441):1236-1243. Nigeria Ministry of Health. 2007. Guidelines for HIV and AIDS care and treatment in ado- lescents and adults. Abuja: Nigeria Federal Ministry of Health. Obama, B. 2011. Remarks by the President on World AIDS Day, December 1, Washington, DC. Obermeyer, C. M., and M. Osborn. 2007. The utilization of testing and counseling for HIV: A review of the social and behavioral evidence. American Journal of Public Health 97(10):1762–1774. 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.

OCR for page 243
338 EVALUATION OF PEPFAR OGAC. 2005. Emergency Plan for AIDS Relief Fiscal Year 2005 operational plan: June 2005 update. Washington, DC: OGAC. OGAC. 2006a. Guidance for United States government in-country staff and implementing partners for a preventive care package for adults. Washington, DC: OGAC. OGAC. 2006b. Guidance for United States government in-country staff and implementing partners for a preventive care package for children aged 0-14 years old born to HIV- infected mothers. Washington, DC: OGAC. OGAC. 2006c. HIV/AIDS palliative care guidance #1 for the United States government in- country staff and implementing partners. Washington, DC: OGAC. OGAC. 2006d. Orphans and other vulnerable children programming guidance for the United States government in-country staff and implementing partners. Washington, DC: OGAC. OGAC. 2006e. The President’s Emergency Plan for AIDS Relief FY 2007 supplemental COP guidance resource guide. Washington, DC: OGAC. OGAC. 2006f. The President’s Emergency Plan for AIDS Relief: FY 2007 country operational plan guidance. Washington, DC: OGAC. OGAC. 2006g. The U.S. President’s Emergency Plan for AIDS Relief Fiscal Year 2006: Op- erational plan. 2006 August update. Washington, DC: OGAC. OGAC. 2007a. The President’s Emergency Plan for AIDS Relief: FY 2008 country operational plan Guidance. Washington, DC: OGAC. OGAC. 2007b. The President’s Emergency Plan for AIDS Relief: Indicators, reporting require- ments, and guidelines. Indicators reference guide: FY 2007 Reporting/FY 2008 Planning. Washington, DC: OGAC. OGAC. 2007c. The U.S. President’s Emergency Plan for AIDS Relief Fiscal Year 2007: Op- erational plan. 2007 June update. Washington, DC: OGAC. OGAC. 2008a. The President’s Emergency Plan for AIDS Relief: FY 2009 country operational plan guidance. Washington, DC: OGAC. OGAC. 2008b. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Fiscal Year 2008: PEPFAR operational plan. June 2008. Washington, DC: OGAC. OGAC. 2009a. Celebrating life: Fifth annual report to Congress on PEPFAR. Washington, DC: OGAC. OGAC. 2009b. PEPFAR: State of the program area. Washington, DC: OGAC. OGAC. 2009c. The President’s Emergency Plan for AIDS Relief: FY 2010 country operational plan guidance: Programmatic considerations. Washington, DC: OGAC. OGAC. 2009d. The President’s Emergency Plan for AIDS Relief: Next generation indicators reference guide. Version 1.1. Washington, DC: OGAC. OGAC. 2009e. The U.S. President’s Emergency Plan for AIDS Relief: Five-year strategy. Washington, DC: OGAC. OGAC. 2009f. The U.S. President’s Emergency Plan for AIDS Relief: Five-year strategy. An- nex: PEPFAR and prevention, care and treatment. Washington, DC: OGAC. OGAC. 2009g. The U.S. President’s Emergency Plan for AIDS Relief Five-year strategy. An- nex: PEPFAR’s contribution to the Global Health Initiative. Washington, DC: OGAC. OGAC. 2010a. The President’s Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance. Washington, DC: OGAC. OGAC. 2010b. The President’s Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance appendices. Washington, DC: OGAC. OGAC. 2010c. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Fiscal Year 2009: PEPFAR operational plan. November 2010. Washington, DC: OGAC. OGAC. 2011a. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance and appendices. Washington, DC: OGAC. OGAC. 2011b. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance technical considerations. Washington, DC: OGAC.

OCR for page 243
CARE AND TREATMENT 339 OGAC. 2011c. The President’s Emergency Plan for AIDS Relief: Guidance for the prevention of sexually transmitted HIV infections. Washington, DC: OGAC. OGAC. 2011d. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Fiscal Year 2010: PEPFAR operational plan. April 2011. Washington, DC: OGAC. OGAC. 2011e. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Fiscal Year 2011: PEPFAR operational plan. December 2011. Washington, DC: OGAC. OGAC. 2012. The President’s Emergency Plan for AIDS Relief: FY 2013 country operational plan guidance. Washington, DC: OGAC. OGAC. 2013. Partners. http://www.pepfar.gov/funding/budget/partners/index.htm (accessed May 31, 2013). Padian, N. S., S. I. McCoy, S. S. Karim, N. Hasen, J. Kim, M. Bartos, E. Katabira, S. M. Bertozzi, B. Schwartlander, and M. S. Cohen. 2011. HIV prevention transformed: the new prevention research agenda. Lancet 378(9787):269-278. PEPFAR (The President’s Emergency Plan for AIDS Relief). 2005. Focusing on our future: Prevention, diagnosis, and treatment of pediatric HIV/AIDS. Washington, DC: OGAC. PEPFAR. 2010. Technical note on PEPFAR’s reporting methodology: Results of USG Global Fund contributions. http://www.pepfar.gov/2009results (accessed October 5, 2012). PEPFAR. 2012. Report on costs of treatment in the President’s Emergency Plan for AIDS Relief (PEPFAR). Washington, DC: OGAC PEPFAR and USAID (U.S. Agency for International Development). 2007. Data quality assur- ance tool for program-level indicators. Washington, DC: USAID. PEPFAR/Mozambique. 2009. Country operational plan FY 2010. Washington, DC: OGAC. PEPFAR/Sudan. 2009. Country operational plan FY 2010. Washington, DC: OGAC. PMI (President’s Malaria Initiative). 2009. Global Health Initiative and President’s Malaria Initiative. http://www.pmi.gov/about/ghi/increase.html (accessed May 31, 2013). PMI. 2013. Fast facts: The President’s Malaria Initiative (PMI). Washington, DC: PMI. PNPEC (National Program for Medical Care for People Living with HIV/AIDS). 2005. Guide de prise en charge de l’infection a VIH/SIDA de l’adulte et de l’enfant. Yamoussoukro: PNPEC Côte d’Ivoire. Renaud-Théry, F. 2010. Annual 2010 survey on ARV use and trends in implementation of WHO 2010 ART recommendations. Presented at WHO & UNAIDS Annual Consulta- tion with Pharmaceutical Companies—Global Forecasts of Antiretroviral Demand 2011- 2012, Geneva, Switzerland. Rosen, S., and M. P. Fox. 2011. Retention in HIV care between testing and treatment in sub- Saharan Africa: A systematic review. PLOS Medicine 8(7). Rosen, S., M. P. Fox, and C. J. Gill. 2007. Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLOS Medicine 4(10):e298. Rossi, V., and B. Ojikutu. 2011. HIV treatment guidelines in Guyana: The fast track to diag- nosis and treatment. Arlington, VA: AIDSTAR-One. Sessions, M. 2006. Overview of the President’s Emergency Plan for AIDS Relief (PEPFAR). Washington, DC: CGD. Sharer, M., Fullem, A. 2012. Transitioning of Care and Other Services of Adolescents Living with HIV in Sub-Saharan Africa. Arlington, VA: USAIDS’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order I. Stadeli, K. M., and D. D. Richman. 2012. Rates of emergence of HIV drug resistance in resource-limited settings: A systematic review. Antiviral Therapy 18(1):115-123. Stanecki, K., J. Daher, J. Stover, M. Beusenberg, Y. Souteyrand, and J. M. Garcia Calleja. 2010. Antiretroviral therapy needs: The effect of changing global guidelines. Sexually Transmitted Infections 86(Suppl 2):ii62-ii66.

OCR for page 243
340 EVALUATION OF PEPFAR Sungkanuparph, S., W. Techasathit, C. Utaipiboon, S. Chasombat, S. Bhakeecheep, M. Leechawengwongs, K. Ruxrungtham, and P. Phanuphak. 2010. Thai national guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents 2010. Asian Biomedi- cine 4(4):515-528. Swaziland Ministry of Health and Social Welfare. 2006. National guidelines for antiretroviral treatment and post exposure prophylaxis for adults and adolescents. Mbabane: Swazi- land Ministry of Health and Social Welfare. Talam, N. C., P. Gatongi, J. Rotich, and S. Kimaiyo. 2008. Factors affecting antiretroviral drug adherence among HIV/AIDS adult patients attending HIV/AIDS clinic at Moi Teaching and Referral Hospital, Eldoret, Kenya. East African Journal of Public Health 5(3):74-78. Tanzania Ministry of Health. 2005. National guidelines for the clinical management of HIV and AIDS. Dar es Salaam: National AIDS Control Programme, Ministry of Health, United Republic of Tanzania. Taylor-Smith, K., H. Tweya, A. Harries, E. Schoutene, and A. Jahn. 2010. Gender differences in retention and survival on antiretroviral therapy of HIV-1 infected adults in Malawi. Malawi Medical Journal 22(2):49-56. Uganda Ministry of Health. 2008. National antiretroviral treatment guidelines for adults, adolescents, and children. Second edition. Kampala: Uganda Ministry of Health. Ukraine Ministry of Health. 2004a. Clinical protocol for ARV therapy for HIV infection in adults and teens. Kiev: Ukraine Ministry of Health. Ukraine Ministry of Health. 2004b. Clinical protocol for conducting antiretroviral therapy in children with HIV infection and AIDS. Kiev: Ukraine Ministry of Health. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2011. AIDS at 30: Nations at a crossroads. Geneva: UNAIDS. UNAIDS. 2012a. AIDSinfo. http://www.aidsinfoonline.org (accessed October 4, 2012). UNAIDS. 2012b. Global report: UNAIDS report on the global AIDS epidemic 2012. Geneva: UNAIDS. UNAIDS. 2012c. Together we will end AIDS. Geneva: UNAIDS. UNAIDS. 2012d. UNAIDS World AIDS Day report 2012. Geneva: UNAIDS. UNAIDS. 2013. Email communication between UNAIDS staff and IOM: “FW: U.S. Institute of Medicine (IOM) Request for Permission to Use Figure in Upcoming PEPFAR Evalua- tion Report.” Washington, DC: IOM. UNITAID. 2013. About UNITAID. http://www.unitaid.eu/en/who/about-unitaid (accessed May 31, 2013). USAID and DoS (U.S. Department of State). 2009. Addressing water challenges in the devel- oping world: A framework for action. Washington, DC: Bureau of Economic Growth, Agriculture, and Trade, USAID and Bureau of Oceans, Environment and Science, DoS. Violari, A., M. F. Cotton, D. M. Gibb, A. G. Babiker, J. Steyn, S. A. Madhi, P. Jean-Philippe, and J. A. McIntyre. 2008. Early antiretroviral therapy and mortality among HIV-infected infants. New England Journal of Medicine 359(21):2233-2244. Visser, M. 2012. Women, HIV and stigma. Future Virology 7(6):529-532. WHO (World Health Organization). 2004a. Scaling up antiretroviral therapy in resource limited settings: Treatment guidelines for a public health approach, 2003 revision. Ge- neva: WHO. WHO. 2004b. Summary country profile for HIVAIDS treatment scale-up: Sudan. Geneva: WHO. WHO. 2005a. Summary country profile for HIVAIDS treatment scale-up: Angola. Geneva: WHO. WHO. 2005b. Summary country profile for HIVAIDS treatment scale-up: Democratic Repub- lic of the Congo. Geneva: WHO.

OCR for page 243
CARE AND TREATMENT 341 WHO. 2005c. Summary country profile for HIVAIDS treatment scale-up: Rwanda. Geneva: WHO. WHO. 2006a. Addressing violence against women in HIV testing and counselling: A meeting report. Geneva: WHO. WHO. 2006b. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults: Recommendations for a public health approach. Ge- neva: WHO. WHO. 2008. Essential prevention and care interventions for adults and adolescents living with HIV in resource-limited settings. Geneva: WHO. WHO. 2010a. Antiretroviral drugs for treating pregnant women and preventing HIV infec- tion in infants: Recommendations for a public health approach. 2010 revision. Geneva: WHO. WHO. 2010b. Antiretroviral therapy for HIV infection in adults and adolescents: recommen- dations for a public health approach. 2010 revision. Geneva: WHO. WHO. 2010c. Antiretroviral therapy for HIV infection in infants and children: Towards uni- versal access. Recommendations for a public health approach. 2010 revision. Geneva: WHO. WHO. 2012a. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: Recommendations for a public health approach. Geneva: WHO. WHO. 2012b. Programmatic update: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Geneva: WHO. WHO. 2012c. Retention in HIV programmes: Defining the challenges and identifying solu- tions: meeting report, 13-15 September 2011. Geneva: WHO. WHO. 2012d. Service delivery approaches to HIV testing and counselling (HTC): A strategic HTC programme framework. Geneva: WHO. WHO. 2012e. Tuberculosis fact sheet. http://www.who.int/mediacentre/factsheets/fs104/en/ (accessed November 17, 2012). WHO. 2012f. WHO policy on collaborative TB/HIV activities: Guidelines for national pro- grammes and other stakeholders. Geneva: WHO. WHO. 2013. WHO definition of palliative care. http://www.who.int/cancer/palliative definition/en (accessed May 31, 2013). WHO and UNAIDS. 2007. Guidance for provider-initiated testing and counseling in health facilities. Geneva: WHO and UNAIDS. WHO, UNAIDS, and UNICEF (United Nations Children’s Fund). 2009. Towards universal ac- cess: Scaling up priority interventions in the health sector. Progress Report 2009. Geneva: WHO, UNAIDS, and UNICEF. WHO, UNAIDS, and UNICEF. 2010. Towards universal access: Scaling up priority interven- tions in the health sector. Progress Report 2010. Geneva: WHO, UNAIDS, and UNICEF. WHO, UNAIDS, and UNICEF. 2011. Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access. Progress report 2011. Geneva: WHO.

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