expand HIV/AIDS services (OGAC, 2004). COP guidance through 2009 emphasized a programmatic focus on increasing the availability and quality of laboratory services at various levels of the health system in partner countries through the purchase of equipment and commodities, the provision of quality assurance, staff training, and technical assistance (OGAC, 2008a). During PEPFAR II, the focus shifted to the strengthening of broader laboratory systems and included such activities as “quality management systems, equipment maintenance, training, and infrastructure” (Justman et al., 2009, p. S30). PEPFAR country programs were directed to focus on increasing quality assurance of laboratory services, on efforts to achieve accreditation, on training for laboratory technicians and management, and on the transition of laboratory programs to in-country partners (OGAC, 2011b). The second Five-Year Strategy recognized the potential to leverage increased laboratory capacity for other diseases, such as malaria and TB, and highlighted support for laboratories as one of PEPFAR’s contributions to the U.S. Global Health Initiative (OGAC, 2009f).

PEPFAR indicators for laboratory infrastructure During PEPFAR I, laboratory-related indicators were limited to the following output measures:

•   the number of laboratories with capacity to perform HIV tests and CD4 tests and/or lymphocyte tests,

•   the number of individuals trained in laboratory-related activities, and

•   the number of tests performed at USG-supported laboratories in the areas of HIV testing, TB diagnostics, syphilis testing, and HIV disease monitoring (OGAC, 2007b).

In 2009, OGAC released the Next Generation Indicator Guidance, which included two slightly modified indicators for laboratory infrastructure to reflect this new focus:

•   the number of testing facilities (laboratories) with capacity to perform clinical laboratory tests and

•   the percent of testing facilities (laboratories) that are accredited according to national or international standards (OGAC, 2009c).

PEPFAR’s reauthorization legislation included a new target for the training of 140,000 health care workers, including laboratory experts (Birx et al., 2009).

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