implementing pharmacovigilance work and many partners tracking genome changes (272-22-USG). WHO was implementing an HIV drug-resistance protocol survey through a national care and treatment center, with plans to distribute the survey to sentinel sites in order to facilitate routine data collection on drug resistance (587-13-USG; 587-18-PCGOV). PEPFAR supported drug-resistance surveillance activities using the WHO early warning indicators in several countries (240-21-PCGOV; 116-1-USG; 587-18-PCGOV), including pediatric drug-resistance surveillance activities (116-1-USG). The Global Fund was also mentioned as supporting drug-resistance studies in drug-naïve patients in one partner country (331-24-PCGOV; 331-28-PCGOV).

Conclusion: The expansion of treatment has an ancillary effect of increasing drug resistance. The earlier that ART programs were implemented in a region, the more drug resistance is present. Because of the limited availability of second-line antiretroviral drugs in resource-limited settings, as drug resistance increases, the need for an expanded pharmaceutical arsenal for effective treatment intensifies. The emergence of HIV drug resistance is cause for greater efforts to improve the effectiveness and expand the implementation of adherence support, treatment-failure and drug-resistance monitoring strategies, and treatment options in resource-limited settings.

Impact of PEPFAR-Supported Care and Treatment Programs on Mortality

Across countries, many interviewees of all stakeholder types identified the lives saved through HIV care and treatment programs as one of the greatest successes of PEPFAR (935-ES; 636-ES; 461-ES; 240-ES; 331-ES; 116-ES; 166-ES; 272-ES; 396-ES; 934-ES). As one interviewee simply put it: ‘people are not dying because they are on ART(272-22-USG).

The congressional mandate for this evaluation requested an evaluation of the impact of care and treatment programs on 5-year survival rates. As described earlier in this chapter, the benefits of ART in reducing mortality have been well established (Bussmann et al., 2008; Herbst et al., 2009; Jahn et al., 2008; Mat Shah et al., 2012; Mermin et al., 2008). However, in general for ART programs, data on 5-year survival rates is very limited in any setting and for any population, and it is not available across PEPFAR countries and programs. Therefore, it was not possible to assess this outcome comprehensively for PEPFAR beneficiaries. One of the four Track 1.0 partners was able to share with the committee an analysis of survival from a subset of patients enrolled in ART representing facilities in nine PEPFAR countries. Figure 6-12 shows survival by population, and Figure 6-13 shows survival by year of ART start.



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