PLHIV as well as increased efforts to “strengthen commodity systems, train providers, and expand access to opioids for pain management” (OGAC, 2009f, p. 19). Many of the home- and community-based care programs described in the next section include pain management among the services they provide. PEPFAR has also supported partners to assist in national efforts to improve palliative care and pain management through guidelines and training of providers and to participate in advocacy (116-12-PCNGO; 116-13-PCNGO; 396-18-USG). One interviewee described a local association’s role as a pain control advocate as follows:

‘They have been successful through advocacy, so that [the country] is now procuring morphine. Through PEPFAR funding, [the country] now has morphine. Talking about morphine is a taboo, but the association has managed to convince the government. Using the PEPFAR funding, they sent the director for the “medicine and poison fund” to go to [another country] to learn about how they are doing with morphine. After that exposure, the government was convinced.’ (116-13-PCNGO)

Home- and Community-Based Care and Support Services

PEPFAR supports the provision of care and support services through home- and community-based mechanisms across the spectrum of both the clinical services described earlier (when a health facility is not required) and nonclinical services, which are also critical for the health of people who are HIV positive and for their adherence to treatment once initiated. One interviewee emphasized the need for these services, describing that the initiation of HIV treatment can be associated with ‘a cascade of effects—lack of social support, loss of income, hard to maintain adequate nutrition(331-8-PCNGO).

Across the countries visited for this evaluation, a review of COPs and information gathered from interviewees revealed a wide range of clinical and nonclinical services and activities provided through home- and community-based care, which some interviewees indicated were first introduced or funded by PEPFAR (396-18-USG; 272-32/35-PCNGO). To offer just a few examples (not a comprehensive listing), interviewees mentioned the management and prevention of opportunistic infections, pain assessment, palliative care, nutrition, the treatment of STIs, adherence monitoring, home-based care kits, psychosocial and social support, and home visits for persons who are bedridden (461-3-USG; 396-21-USG; 272-32/35-PCNGO; 395-56-USNGO; 240-29-USNGO; 331-32-PCNGO; 587-13-USG).

This section first describes the overall findings from interview data collected for this evaluation that apply generally to home- and community-based care, then discusses some findings for specific subsets of PEPFAR-

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