PEPFAR Implementation Progress and Promise (2007) / Chapter Skim
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Abstract and Summary
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to inform Congress about the program's progress 3 years after its authorizing legislation was passed. The IOM committee found that PEPFAR has supported the expansion of HIV/AIDS prevention, treatment, and care services in the focus countries.
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• Enhanced ability to tailor interventions to the nature of the epidemic in each country and the countries' national plans through removal of the limitations imposed by congressional budget allocations for particular activities. Alternative mechanisms that allow for spending to be directly linked with the efforts necessary to achieve performance targets would improve the necessary accountability for results.
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Although the Leadership Act was passed in May 2003, Congress first appropriated funds for the program in January 2004, and the majority of the first year's funding was not obligated until September 2004. Thus at the close of the Committee's short-term evaluation, PEPFAR had been supporting the implementation of programs in the focus countries for less than 2 years.
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PEPFAR's 5-year performance targets for the focus countries are to support the prevention of 7 million HIV infections; treatment for 2 million people with HIV/AIDS with antiretroviral therapy (ART) ; and care for 10 million people infected with and affected by HIV/AIDS, including orphans and other vulnerable children (United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L.
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for more than half a million women found to be HIV-positive (estimated by OGAC to have resulted in the prevention of HIV infection in more than 100,000 infants) ; public education campaigns, school curricula, and other types of information and education community outreach that are estimated to have reached more than 140 million adults and children; care and support services for approximately 4.5 million adults, orphans, and other vulnerable children; training in HIV/AIDS care and support services for well over a million people, including physicians, nurses, clinical officers, pharmacists, laboratory workers, epidemiologists, community workers, teachers, midwives, birth attendants, and traditional healers; and expansion and strengthening of clinical laboratories, supply chain management systems, blood supply systems, safe medical practices, and monitoring and evaluation systems (OGAC, 2005b, 2006a,b, 2007)
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. Although its emergency response has allowed PEPFAR to support rapid expansion of services in the focus countries, it has not necessarily facilitated coordination with global partners, harmonization with the strategies and plans of partner countries, services that are comprehensive and integrated at the community level, sustainable programs, or adequate monitoring and evaluation.
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Global AIDS Initiative will need to emphasize effective, evidence-based prevention with the same urgency and intensity it has focused on treatment. Moreover, the initiative cannot afford to conceptualize prevention narrowly or as distinct from treatment and care, and needs to support countries in seizing the abundant opportunities for prevention throughout people's lives and regardless of their HIV status; across the full spectrum of health and social services; and in all settings, from the street to the school to the home to the clinic (Salomon et al., 2005; UNAIDS, 2005c)
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The PEPFAR Country Teams have been largely successful in aligning their plans with the partner countries' national HIV/AIDS strategies, coordinating with national AIDS coordinating agencies, and supporting national monitoring and evaluation frameworks (OGAC, 2005c, 2006g)
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. This standard posed a major challenge to implementation because most of the focus countries had selected generic versions of ARVs for their formularies, and no generic ARVs had FDA approval (GAO, 2005)
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However, one set of the Leadership Act's short-term targets -- its budget allocations -- has adversely affected implementation of the U.S. Global AIDS Initiative.
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The U.S. Global AIDS Initiative needs maximum flexibility and agility not only to adapt to a changing pandemic and be harmonized with the efforts of 15 different focus countries, but also to be able to incorporate what is learned through program implementation about how to have the greatest impact.
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Of particular importance is for PEPFAR to support programs in a manner that fosters integration both within and among the program categories of prevention, treatment, care, and orphans and vulnerable children -- or, more appropriately, regardless of categorization. Neither the congressional budget allocations discussed above nor the budgeting, planning, and reporting mechanisms the Coordinator established to ensure that PEPFAR complies with these allocations facilitate integration.
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Care The U.S. Global AIDS Coordinator should continue to promote and support a community-based, family-centered model of care in order to enhance and coordinate supportive care services for people living with HIV/AIDS, with special emphasis on orphans, vulnerable children, and people requiring end-of-life care.
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PEPFAR Country Teams often expressed concern that they were not allowed to fund activities unless those activities were specifically part of the HIV/AIDS effort and so could not support, for example, the training of new clinical officers, who in some countries are the mainstay of the treatment effort. PEPFAR reports that its response to the shortage of health workers to date has been to provide support, within national plans and priorities and the principles of harmonization, for policy reform to promote task shifting from physicians and nurses to community health workers; for
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Global AIDS Initiative should increase the support available to expand workforce capacity in heavily affected countries. These efforts should include education of new health care workers in addition to AIDS-related training for existing health care workers.
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The U.S. Global AIDS Initiative supports the full spectrum of global AIDS research, from basic to operations research, through several entities in addition to OGAC, including the National Institutes of Health, the Centers for Disease Control and Prevention, and the U.S.
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Global AIDS Initiative is making to their achievement, the initiative will need to study national trends, such as rates of new HIV and other infections; rates of survival from HIV/AIDS and other diseases; child survival, development, and well-being; and the general health status of the population and key subpopulations. Particularly within the agreed framework of harmonization, the data and analyses necessary to study these trends will have to come primarily from the partner countries themselves (UNAIDS, 2004a)
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2006. President's Emergency Plan for AIDS Relief approed and tentatiely approed antiretroirals in association with the President's emergency plan.
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global AIDS coordinator: Lessons from other U.S. emergency responses.
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2004. Guide to monitoring and ealuating HIV/AIDS care and support.
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