Appendix B

Recommendations
1

PREVENTION

Recommendation 5-1: To contribute to the sustainable management of the HIV epidemic in partner countries, PEPFAR should support a stronger emphasis on prevention. The prevention response should prioritize reduction of sexual transmission, which is the primary driver of most HIV infections, while maintaining support for interventions targeted at other modes of transmission. The response should incorporate an approach balanced among biomedical, behavioral, and structural interventions that is informed by epidemiological data and intervention effectiveness evidence. PEPFAR should support advances in prevention science to expand the availability of effective interventions where knowledge is lacking.

Further considerations for implementation of this recommendation:

PEPFAR has made a commitment to overarching goals for prevention and for achieving an AIDS-free generation, but this does not constitute a long-term prevention strategy that clearly states prevention objectives and the pathways to achieving them. The following elements will be

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1 The recommendation numbers represent the chapters in which the recommendations appear and their order within each chapter.



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Appendix B Recommendations1 PREVENTION Recommendation 5-1: To contribute to the sustainable management of the HIV epidemic in partner countries, PEPFAR should support a stron- ger emphasis on prevention. The prevention response should prioritize reduction of sexual transmission, which is the primary driver of most HIV infections, while maintaining support for interventions targeted at other modes of transmission. The response should incorporate an approach balanced among biomedical, behavioral, and structural in- terventions that is informed by epidemiological data and intervention effectiveness evidence. PEPFAR should support advances in preven- tion science to expand the availability of effective interventions where knowledge is lacking. Further considerations for implementation of this recommendation:  EPFAR has made a commitment to overarching goals for prevention P and for achieving an AIDS-free generation, but this does not constitute a long-term prevention strategy that clearly states prevention objectives and the pathways to achieving them. The following elements will be 1  The recommendation numbers represent the chapters in which the recommendations ap- pear and their order within each chapter. 723

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724 EVALUATION OF PEPFAR critical for a more comprehensive strategy to achieve successful execu- tion of prevention programs: • PEPFAR should continue to enhance its efforts to involve partner country stakeholders and incorporate country-specific epidemiol- ogy, context, and priorities in planning appropriately matched prevention programs that achieve a balanced approach to HIV prevention across the available modalities. To provide greater tech- nical and operational clarity, the Office of the U.S. Global AIDS Coordinator (OGAC)2 should provide mechanisms to support the development, implementation, and monitoring of comprehensive prevention portfolios, including how to determine what popula- tions need which directed prevention activities in which settings. Areas of prevention where current interventions are successful and effective, such as prevention of mother-to-child transmission (PMTCT), should be continued and scaled up to ensure access, cov- erage, and quality. As new PEPFAR-supported prevention activities are adopted, OGAC should communicate its objectives and the methods for introducing or scaling up with specified populations. • OGAC should improve mechanisms to collect and incorporate evidence on the effectiveness of prevention activities implemented in partner countries. The key components for future assessment and evaluation of HIV prevention should include need, coverage of need, quality of services provided, and behavioral and epidemio- logical outcomes. OGAC should provide clearly defined process and outcome measures as well as impact assessment methods to evaluate progress. • PEPFAR’s prevention strategy should include balanced support for innovation, research, and evaluation to contribute to the evolving evidence base and advance understanding of the effectiveness of interventions within all prevention modalities. To define and en- sure this balance, OGAC should, through its existing mechanisms, convene and use expertise spanning behavioral, structural, and bio- medical prevention intervention approaches. PEPFAR-supported research and evaluation activities should employ appropriate meth- odologies and study designs, without unduly emphasizing random assignment designs. PEPFAR should support innovations in preven- 2  It is the committee’s intent that actions recommended to be taken by OGAC should be carried out through PEPFAR’s interagency coordination mechanism, which involves not only the OGAC staff but also the leadership and technical staff of the U.S. government (USG) implementing agencies.

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APPENDIX B 725 tion science methodologies where needed to achieve its program- matic research aims (see also Recommendation 11-1). CARE AND TREATMENT Recommendation 6-1: To improve the implementation and assessment of nonclinical care and support programs for adults and children, including programs for orphans and vulnerable children,3 the Office of the U.S. Global AIDS Coordinator should shift its guidance from specifying allowable activities to instead specifying a limited number of key outcomes. The guidance should permit country programs to select prioritized outcomes to inform the selection, design, and imple- mentation of their activities. The guidance should also specify how to measure and monitor the key outcomes. Further considerations for implementing this recommendation: • Outcomes for consideration for OGAC’s guidance should reflect the aims of care and support programs, which are to optimize quality of life, promote health, slow the progression of AIDS, and reduce HIV-related complications and mortality. • To enable this shift to a more outcomes-oriented approach, part- ner countries will need support and assistance to prioritize out- comes and targeting of services. PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to as- sess country-specific needs and to select a subset of the core key outcomes to focus on when planning, selecting, and developing evidence-informed activities and programs for implementation. • OGAC should provide general guidance for country programs on continuous program evaluation and quality improvement to help them measure and monitor achievement of the key outcomes. This guidance may include, for example, template evaluation plans and methodological guidance. To allow for comparability across countries and programs, evaluation plans should include (but not be limited to) the defined indicators or other measures of the core key outcomes. Evaluations should emphasize the use of in-country local expertise (e.g., local implementing partners and subpartners and local academic institutions) to enhance capacity building and 3  The discussion of the care of orphaned and vulnerable children (OVC) care leading to this aspect of this recommendation can be found in Chapter 7 and the parallel Recommendation 7-1.

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726 EVALUATION OF PEPFAR contribute to country ownership. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.) • PEPFAR should develop a system for active dissemination and sharing of evaluation outcomes and best practices both within and across countries that is driven as much by country-identified needs for information as by opportunities for exchange of informa- tion identified by headquarters (HQ)-level leadership and technical working groups. (See also recommendations for PEPFAR’s knowl- edge management in Chapter 11.) Recommendation 6-2: To contribute to sustainable care and treatment programs in partner countries, PEPFAR should build on its experience and support efforts to develop, implement, and scale up more effective and efficient facility- and community-based service delivery models for the continuum of adult and pediatric testing, care, and treatment. These efforts should aim to enhance equitable access, improve reten- tion, increase clinical and laboratory monitoring, ensure quality, and implement cost-efficiencies. Further considerations for implementation of this recommendation: • This recommendation should be implemented in coordination with recommendations and considerations discussed in Chapter 9 on health systems strengthening. •  EPFAR should develop a system for active dissemination and P sharing of best practices in service delivery both within and across countries. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.) Recommendation 6-3: To assess PEPFAR-supported HIV care and treatment programs and to evaluate new service delivery models, the Office of the U.S. Global AIDS Coordinator should support an en- hanced, nested program monitoring effort in which additional longi- tudinal data on core outcomes for HIV-positive adults and children enrolled in care and treatment are collected and centrally reported from a coordinated representative sample across multiple countries and implementing partners. Further considerations for implementation of this recommendation: • This activity would serve as a targeted, nested evaluation within routine program monitoring systems to allow for long-term op-

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APPENDIX B 727 erational assessment of performance and outcomes for care and treatment, across a representative sample of PEPFAR-supported programs. The aim would be to focus on key areas for evalua- tion and improvement of programs going forward, including as PEPFAR supports innovations in service delivery and as PEPFAR- supported programs transition to new models of implementation. • Data collected and reported for this sample should be harmonized with existing data collection whenever possible, including data al- ready collected by implementing partners but not centrally reported (e.g., see the discussion of Tier 3 data in the implementation con- siderations for Recommendation 11-1A). Collaborative opportuni- ties may be feasible with existing or new large-scale national and multi-country samples. • This data collection effort should be designed by first identifying and prioritizing the key questions that require longitudinal data and then focusing on relevant key outcomes with measures that are standardized across the sample. Priorities should include core out- comes related to clinical care and treatment, including adherence and retention; outcomes related to the reduction of HIV transmis- sion through biomedical and behavioral prevention interventions for people living with HIV; quality measures; and program mea- sures, such as the costs of services, that can help inform strategies for efficiencies, sustainable management, and resource planning for the trajectory of need. • There may also be opportunities for an established data collection effort of this kind to serve as a synergistic platform for targeted implementation research studies in subset samples to assess inno- vations and advance those best practices that are most ready for translation and scale-up. • In addition to implementing this approach prospectively, OGAC should explore working with and coordinating Track 1.0 partners to pool data for retrospective outcome analyses. CHILDREN AND ADOLESCENTS Recommendation 7-1: To improve the implementation and assessment of nonclinical care and support programs for adults4 and children, including programs for orphans and vulnerable children, the Office 4 The discussion of nonclinical care and support for adults leading to this aspect of this recommendation can be found in Chapter 6 and the parallel Recommendation 6-1.

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728 EVALUATION OF PEPFAR of the U.S. Global AIDS Coordinator should shift its guidance from specifying allowable activities to instead specifying a limited number of key outcomes. The guidance should permit country programs to select prioritized outcomes to inform the selection, design, and imple- mentation of their activities. The guidance should also specify how to measure and monitor the key outcomes. Further considerations for implementing this recommendation: • For OVC, the new guidance and the ongoing developments for program evaluation already represent advances in addressing some of the challenges identified in this evaluation; this recommenda- tion and the further considerations are intended to reinforce and further inform and support progress in achieving PEPFAR’s goals for children and adolescents. • Outcomes for consideration should be linked to the aims of OVC programs and therefore could include, for example, increased rates of staying in school, decreased excessive labor, reduced rates of exposure to further traumas, increased immunization completion, and increased coverage of HIV testing and treatment. With a con- tinued focus on supporting developmentally informed programs, consideration should be given to identifying appropriate core out- comes for different age groups and for achieving developmental milestones. The program evaluation indicators currently being de- veloped already offer a reasonable opportunity to link measures to core target outcomes for OVC programs. • The core key outcomes should also include quality of services and measures to reflect the potential sustainability of programs. • A shift to a more outcomes-oriented implementation model will require that partner countries receive support to define their pri- oritized outcomes and their target population and then to conduct baseline assessments so that progress toward outcomes can be measured. • PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to assess country-specific needs and to select a subset of the core key outcomes to focus on when planning, selecting, and developing evidence-informed activities and programs for implementation. • Prioritization is critical in the presence of great need and finite resources. When planning with partner countries, PEPFAR should

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APPENDIX B 729 improve targeted coverage and the quality of supported services for affected children and adolescents by not only prioritizing outcomes and activities but also by more explicitly, clearly, and narrowly defining the eligibility for PEPFAR-supported services. This priori- tization should be based on an assessment of country-specific needs with a process that consistently applies considerations and criteria across countries and programs. This prioritization should be done in coordination across program areas that address the needs and vulnerabilities of children and adolescents. These areas, which may target and serve a broader eligible population of children and adolescents than is determined for specific OVC programs, include care and treatment, PMTCT, other prevention services, and gender programs. • To improve the targeted coverage and sustainability for chil- dren and adolescents, PEPFAR and its implementing partners should continue to enhance services through existing systems and infrastructure and to support national governments in ex- panding social support services and the workforce to meet the health, education, and psychosocial needs of affected children and adolescents. • OGAC should provide general guidance for country programs on continuous program evaluation and quality improvement in order to measure and monitor the achievement of key outcomes. This may include, for example, template evaluation plans and method- ological guidance. To allow for comparability across countries and programs, evaluation plans should include (but not be limited to) the defined indicators or other measures of the core key outcomes. Evaluations should emphasize the use of in-country local expertise (e.g., local implementing partners and sub-partners as well as local academic institutions) to enhance capacity building and contribute to country ownership. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.) • PEPFAR should develop a system for the active dissemination and sharing of evaluation outcomes and best practices both within and across countries that is driven as much by country-identified needs for information as by opportunities for exchange of information identified by HQ-level leadership and technical working groups. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

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730 EVALUATION OF PEPFAR GENDER Recommendation 8-1: To achieve PEPFAR’s stated aim of addressing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services, the Office of the U.S. Global AIDS Coordina- tor (OGAC) should develop and clearly state objectives and desired outcomes for gender-focused efforts. OGAC should issue guidance for how to operationalize, implement, monitor, and evaluate activities and interventions to achieve these objectives. Further considerations for implementation of this recommendation: • The objectives and guidance should be informed by the available evidence on how gender dynamics influence both HIV outcomes and the implementation of activities and services, as well as evi- dence on intervention effectiveness from the existing knowledge base, expert consultation, and experiences from pilot programs in partner countries. • OGAC’s guidance on gender-focused efforts should encompass programs specific to addressing gender norms and inequities and efforts to incorporate gender-focused objectives within prevention, care, and treatment activities. • The development of guidance for gender-focused efforts should take advantage of lessons learned from the processes used for PEPFAR’s recent updates to guidance for prevention and OVC programs. • PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to strategically plan, select, de- velop, implement, and measure evidence-informed activities and programs to achieve the gender-focused objectives. • Strategic implementation of gender-focused efforts will require strong technical leadership, and as such additional capacity in gen- der expertise will be needed at both the OGAC and U.S. mission team levels. If gender efforts are to be appropriately integrated into all the aspects of service delivery and effectively implemented, then this capacity cannot be limited to gender-specific experts but should also be incorporated as part of the core competencies of mission team staff across PEPFAR’s programmatic areas. • As an engaged participant with other global and partner country stakeholders, through its implementation PEPFAR should contrib- ute to generating evidence to inform gender-focused efforts through

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APPENDIX B 731 research and evaluation. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.) STRENGTHENING HEALTH SYSTEMS Recommendation 9-1: To support the delivery of HIV-related services, make progress toward sustainable management of the HIV response, and contribute to other health needs, PEPFAR should continue to implement and leverage efforts that have had positive effects within partner country health systems. PEPFAR should maintain efforts in all six building blocks but have a concerted focus on areas that will be most critical for sustaining the HIV response, especially workforce, supply chain, and financing. Further considerations for implementation of this recommendation: • An important focus for PEPFAR’s future activities and policies should be support for partner country capacity to locally produce and retain clinical, nonclinical, and management professionals whose training and scope of practice are appropriate and opti- mized for the tasks needed. The Medical Education Partnership Initiative (MEPI) and Nursing/Midwifery Education Partnership Initiative (NEPI) have provided a starting point for the training of physicians and nurses; however, the training of associate clinicians and other cadres will also be critical to sustainable management of the response. In addition, PEPFAR needs to augment its efforts to build partner country capacity to track the placement of trained workers, to promote retention, and to develop long-term human resources plans. (See also the discussion and recommendation for capacity building in Chapter 10.) • Building on the progress made through the public–private partner- ship with Supply Chain Management System (SCMS), PEPFAR should enhance and expand efforts with a greater focus on capac- ity building for accountable supply chain management in partner countries. The aim of this improved capacity should be to gradually shift to local or regional leadership, coordination, and manage- ment to ensure a reliable supply chain for essential medicines and commodities. • Financing and leadership and governance are particularly critical for sustainable management of the HIV response, and this area is addressed in Recommendation 10-1 (see Chapter 10).

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732 EVALUATION OF PEPFAR • To contribute to the knowledge base for health systems strengthen- ing, PEPFAR should include this area in its research and evaluation agenda and its knowledge dissemination efforts. (See also recom- mendations for PEPFAR’s knowledge management in Chapter 11.) TRANSITIONING TO A SUSTAINABLE RESPONSE IN PARTNER COUNTRIES Recommendation 10-1: To contribute to a country-owned and sustain- able HIV response, the Office of the U.S. Global AIDS Coordinator should develop a comprehensive plan for long-term capacity building in partner countries. The plan should target four key areas: service delivery, financial management, program management, and knowledge management. Further considerations for implementation of this recommendation: • In all four key areas, OGAC should invest more resources in ini- tiatives for long-term capacity building and infrastructure devel- opment such as strengthening in-country academic institutions, degree programs, and long-course trainings, to improve in-country capacity and to accelerate progress toward country ownership and sustainability. These investments should foster the placement and retention of trained personnel in partner countries. • These initiatives should be monitored routinely at the country level to assess progress and identify necessary modifications. Special pe- riodic multi-country studies could be used to evaluate the outcome and impact of the PEPFAR capacity-building initiative. To achieve this, OGAC should, using input from country programs, identify milestones toward achieving specified goals, define core metrics to assess capacity-building efforts, encourage innovative approaches through pilot initiatives and develop tools to help country pro- grams monitor and evaluate these efforts: Recommendation 10-2: Building on the Partnership Framework imple- mentation process, PEPFAR should continue to work with partner country governments and other stakeholders to plan for sustainable management of the response to HIV. PEPFAR should support and participate in comprehensive country-specific planning that includes the following: •  scertain the trajectory of the epidemic and the need for preven- A tion, care and treatment, and other services.

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APPENDIX B 733 • I dentify gaps, unmet needs, and fragilities in the current response. • E  stimate costs of the current response and project resource needs for different future response scenarios. • D  evelop plans for resource mobilization to increase and diversify funding, including internal country-level funding sources. • E  ncourage and participate in country-led, transparent stakeholder coordination and sharing of information related to funding, activi- ties, and data collection and use. • E  stablish and clearly articulate priorities, goals, and benchmarks for progress. Further considerations for implementing this recommendation: • PEPFAR is not alone in trying to achieve locally led, sustainable health and development objectives. Contributing stakeholders, in- cluding partner countries, will need mutually agreed, principle- based resource allocation to achieve a strategic and ethical balance among the priorities of maintaining current coverage, expanding to meet existing unmet needs, and increasing coverage eligibility. Hav- ing processes in place to support this arduous decision making is a critical part of achieving sustainable HIV programs and sustainable management of the HIV epidemic in partner countries. • Partners in developing resource mobilization plans and potential sources for more diverse funding and other resources could include national and sub-national governments other bilateral donors, mul- tilateral agencies, global and regional development banks, and private-sector consultants. • There may be learning opportunities at both the HQ and country levels for PEPFAR and other USG entities involved in development assistance to exchange strategies, best practices, and lessons learned for sustaining development objectives. PEPFAR’S KNOWLEDGE MANAGEMENT Recommendation 11-1: The Office of the U.S. Global AIDS Coor- dinator should develop a comprehensive knowledge management framework, including a program monitoring and evaluation strategy, a prioritized and targeted research portfolio, and systems for knowledge dissemination. This framework should adapt to emerging needs to as-

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734 EVALUATION OF PEPFAR sess PEPFAR’s models of implementation and contribution to sustain- able management of the HIV response in partner countries. This knowledge management framework will require that PEPFAR implement and strategically allocate resources for the following: A. o better document PEPFAR’s progress and effectiveness, OGAC T should refine its program monitoring and evaluation strategy to streamline reporting and to strategically coordinate a complemen- tary portfolio of evaluation activities to assess outcomes and ef- fects that are not captured well by program monitoring indicators. Efforts should support innovation in methodologies and measures where needed. Both monitoring and evaluation should be specifi- cally matched to clearly articulated data sources, methods, and uses at each level of PEPFAR’s implementation and oversight. B.  contribute to filling critical knowledge gaps that impede ef- To fective and sustainable HIV programs, OGAC should continue to redefine permitted research within PEPFAR by developing a prioritized portfolio with articulated activities and methods. The planning and implementation process at the country and program level should inform and be informed by the research portfolio, which should focus on research that will improve the effectiveness, quality, and efficiency of PEPFAR-supported activities and will also contribute to the global knowledge base on implementation of HIV/AIDS programs. C.  o maximize the use of knowledge created within PEPFAR, T OGAC should develop systems and processes for routine, active transfer and dissemination of knowledge both within and exter- nal to PEPFAR. As one component, OGAC should institute a data-sharing policy, developed through a consultative process. The policy should identify the data to be included and ensure that these stipulated data and results generated by PEPFAR or through PEPFAR-supported activities are made available in a timely manner to PEPFAR stakeholders, external evaluators, the research commu- nity, and other interested parties. F  urther considerations for implementation of Recommendation 11-1A: Program monitoring and evaluation • OGAC’s current tiered program monitoring indicator reporting structure should be further streamlined to report upward only those indicators essential at each PEPFAR level:

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APPENDIX B 735 o 1: A small set of core indicators, fewer than the current 25, T  ier to be reported to central HQ level. These data should be used to monitor performance across PEPFAR as a whole, for congres- sional reporting, and to document trends; as such, these indica- tors should remain consistent over time. Whenever possible and appropriate, these indicators should be harmonized with exist- ing global indicators and national indicators; therefore, some centrally reported indicators will reflect PEPFAR’s contribution rather than aiming to measure direct attribution. o 2: A larger menu of indicators defined in OGAC guidance, T  ier from which a subset are selected for their applicability to coun- try programs to be reported by implementing partners to the U.S. mission teams but not routinely reported to HQ. These data should be used to monitor the effectiveness of the in-country response and to support mutual accountability with partner countries and their citizens. These data could be considered for occasional centralized use to inform special studies or respond to congressional requests but aggregation and comparability across countries may be limited in this tier because all mission teams may not collect the same data. o 3: Indicators selected by implementing partners to monitor T  ier and manage program implementation and effectiveness that are not routinely reported to mission teams. Implementing partners should select appropriate indicators defined in OGAC guidance and augment these with other indicators as needed for their pro- grams. Implementing partners should work with mission teams in developing their program monitoring plans with selected indi- cators. Mission teams should provide oversight and technical as- sistance to ensure implementation of these plans and to promote local quality data collection, use, and mutual accountability. Although not routinely reported, some of these data could be considered for occasional country-level and centralized use. O  GAC should create mechanisms for implementing partners, o mission teams, and agency HQ to mutually contribute to a periodic review across all tiers of indicator development, ap- plicability, and utility and to make modifications if necessary. o 1 indicators should be harmonized whenever possible and T  ier appropriate with existing global indicators and national indica- tors. For indicators that are not routinely reported centrally (Tiers 2 and 3), country program planning should facilitate

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736 EVALUATION OF PEPFAR alignment of indicator selection and data collection with partner country HIV monitoring and health information systems. • OGAC should complement program monitoring with a unified evaluation portfolio that includes periodic program evaluation at the PEPFAR country program and implementing partner levels to assess process, progress, and outcomes as well as periodic impact evaluations at the country, multi-country, and HQ levels. O  GAC evaluation guidance should provide information about o prioritizing areas for evaluation, the types of evaluation ques- tions, methodological guidance, potential study designs, tem- plate evaluation plans, examples of key outcomes, and how evaluation results should be used and disseminated. PEPFAR should support a range of appropriate methodologies for pro- gram evaluation, including mixed qualitative and quantitative methods, and should shift emphasis from probability designs to plausibility designs that provide valid evidence of impact. n To  allow for some comparability across countries and pro- grams, OGAC and HQ technical working groups should, with input from country teams, strategically plan and co- ordinate a subset of evaluations within programmatic ar- eas that include (but are not limited to) a minimum set of centrally identified and defined outcome measures and methodologies. n  ithin W PEPFAR-supported evaluation activities there should be an emphasis on the use of in-country local expertise to enhance capacity building for program evaluation and con- tribute to country ownership. • For both program monitoring and evaluation OGAC should continue its work on defining and developing measures to assess progress in the currently under-measured areas of country owner- ship, sustainability, gender, policy, capacity building and technical assistance. F  urther considerations for implementation of Recommendation 11-1B: Research • OGAC should clearly define which activities and methodologies will be included under the umbrella of PEPFAR-supported re- search, as distinguished from program evaluation.

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APPENDIX B 737 • OGAC should draw on input from implementing agencies, mission teams, partner countries, implementing partners, the Scientific Ad- visory Board, and other experts to identify and articulate research priorities and appropriate research methodologies. The research proposals and funding mechanisms should be designed to ensure that these priorities are met and that methodologies are applied through requests for applications and other investigator-driven research proposals as well as through targeted solicitations of re- search in gap areas not met through open requests. • Given PEPFAR’s legislative and programmatic objectives to sup- port research that assesses program quality, effectiveness, and population-based impact; optimizes service delivery; and contrib- utes to the global evidence base on HIV/AIDS interventions and program implementation, at the time of this evaluation the com- mittee identified the following gaps in PEPFAR’s research activities: B ehavioral and structural interventions, especially in areas such o as prevention, gender, nonclinical and OVC care and support, and treatment retention and adherence. These research activities should employ appropriate methodologies and study designs, without being unduly limited to random assignment designs. C  osts, benefits, and feasibility of integrating gender-focused pro- o grams with clinical and community-based activities. H  ealth systems strengthening interventions across the World o Health Organization (WHO) building blocks, with a prioritized goal of determining setting- and system-specific feasibility, ef- fectiveness, quality of services, and costs for innovative models. • To contribute to country ownership, PEPFAR should facilitate in- country local participation and research capacity building through simplified, streamlined, and transparent application and review processes that encourage submissions from country-based imple- menting partners and researchers. F  urther considerations for implementation of Recommendation 11-1C: Knowledge transfer and dissemination • The knowledge created within PEPFAR that should be more widely documented and disseminated includes program monitoring data, financial data, research results, evaluation outcomes, best practices, and informal knowledge such as implementation experience, and lessons learned.

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738 EVALUATION OF PEPFAR • To institutionalize internal and external knowledge transfer and learning, PEPFAR should develop appropriate systems and pro- cesses for the most needed types and scale of knowledge transfer. To achieve this, PEPFAR should draw on broad stakeholder input to assess the strengths and weaknesses in current processes and to identify needs and opportunities for improved knowledge transfer. • PEPFAR should invest in innovative mechanisms and technol- ogy to facilitate knowledge transfer across partner countries and implementing partners. Mechanisms currently used successfully on a small scale and an ad hoc basis could be formally scaled up across PEPFAR. OGAC should also look to other organizations with wide geographic reach and organizational complexity, such as multi-country PEPFAR implementing partners, other large global health initiatives, and global corporations, for models of successful knowledge transfer systems. • OGAC should develop a policy for data sharing and transparency that facilitates timely access to PEPFAR-created knowledge for analysis and evaluation. The purpose of this policy would be to ensure that, within a purposefully and reasonably defined scope, specified program monitoring data and financial data, evaluation outcomes, and research data and results generated with PEPFAR support by contractors, grantees, mission teams, and USG agencies be made available to the public, research community, and other external stakeholders. OGAC and the PEPFAR implementing agen- cies should consult with both internal and external parties that would be affected by this policy to help identify the data that are most critical for external access and that can be reasonably subject to data-sharing requirements, as well as to help develop feasible mechanisms to implement a data-sharing policy. o routinely collected financial and program monitoring data, a F or limited set of essential data should be identified and made avail- able for external use in a timely way. E valuation and research reports and publications using data col- o lected through PEPFAR-supported programs should be tracked and made available in a publicly accessible central repository. USG agencies with similar repositories can be considered as models. o research data and other information that is expressly gener- F or ated for new knowledge, the policy should respect time-bound exclusivity for the right to engage in the publication process, yet

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APPENDIX B 739 also ensure the timely availability of data, regardless of publica- tion, for access and use by external evaluators and researchers. OGAC should look to USG agencies with similar research data policies as models. o developing the policy and specifying the scope of data to In  be included, several key factors and potential constraints that can affect the implementation of the policy will need to be ad- dressed. These include patient and client information confiden- tiality; the financial resources, personnel, and time needed to make data available; and issues of data ownership, especially in the context of increasing responsibility in partner countries and the provision of PEPFAR support through country systems or through activities and programs supported by multiple funding streams.

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