supported nonclinical services for adults. Nonclinical services for children are discussed in full in the section on OVC programs in Chapter 7.

Evolution of Care and Support Services: From Caring for the Dying to Supporting the Living

One common theme that emerged across many countries and types of interviewees was that a shift has occurred over time in the nature of care services. Initially, in most countries home-based care focused on the critically ill and on providing end-of-life care and hospice. Although there is still a need for services for the critically ill, the increased availability of care and treatment services, the move from inpatient to outpatient care, and the generally improved health status of PLHIV have led to a decline in patient populations requiring end-of-life care and to a change in the needs to different kinds of care and support services (272-32/35-PCNGO; 272-7-USG; 240-2-USG; 935-10-USG). As described by one interviewee,

‘For the first 5 years, the beginning of PEPFAR, the care and support activities were very much focused on the late stages of illness through palliative and hospice care. As the lay of the land has changed, so have the care activities. They are focusing on a wider range of care aspects.’ (272-7-USG)

One implementing partner described home-based care as divided into three categories: one in which the patient can perform all activities without any assistance, one in which the patient needs minimal assistance, and one in which the patient is bedridden. Currently the majority of patients fall into the middle category, although at the beginning of PEPFAR the implementing partner was mostly providing home-based care and hospice, mostly for terminal patients discharged from the hospital (272-32/35-PCNGO). Home- and community-based care has shifted its focus to keeping those infected with HIV healthy as well as to case management and to more integrated services, such as chronic disease management (461-3-USG; 240-2-USG; 587-18-PCGOV). One interviewee stated that just as the introduction of ART has reduced the need for home-based care, the need for such care may also be reduced by effective care for PLHIV who are pre-ART, consistent with the concept that ‘care starts at diagnosis(272-7-USG).

Implementation with a Focus on the Community and Using Local NGOs

Another overall characteristic of PEPFAR-supported home- and community-based care programs that was highlighted across countries is that these programs have been implemented with a strong focus on

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