PEPFAR Implementation Progress and Promise (2007) / Chapter Skim
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2 The U.S. Global AIDS Initiative: Context and Background
2 The U.S. Global AIDS Initiative: Context and Background
Pages 35-78
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Global AIDS Coordinator, expectations for unprecedented coordination among U.S. government agencies and international stakeholders, assignment of responsibilities to involved U.S.
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reside in low- and middle-income countries, where most new HIV infections and AIDS-related deaths occur. The year 2006 marks the twenty-fifth anniversary of the description of acquired immunodeficiency syndrome (AIDS)
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. In the low state, HIV infection has not spread to significant levels in any subpopulation and
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Adult prevalence % 15.0 – .34.0% 5.0 – <15.0% 1.0 – <5.0% 0.5 – <1.0% 0.1 – <0.5% <0.1% FIGURE 2-1 Global view of the prevalence of HIV/AIDS. SOURCE: Reprinted with the kind permission of UNAIDS, 2006.
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SOURCE: Bertozzi et al., 2006. is largely confined to individuals with higher-risk behaviors, such as sex workers, people who use injecting drugs, and men who have sex with other men.
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Global AIDS Initiative are briefly described in Box 2-1. Governments of affected countries have also increased their spending, with amounts depending on, among other factors, gross national income, national debt, political stability, and the status of the working class (Kates and Lief, 2006)
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. UNAIDS, the Joint United Nations Programme on HIV/AIDS, brings together the efforts and resources of 10 UN agencies to help the world prevent new HIV infections, care for those already infected, and mitigate the impact of the pandemic.
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By November 2006, the Global Implementation Support Team had expanded and included additional representatives from the civil sector and bilateral donors, including the U.S. Global AIDS Initiative.
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. Though developed to foster improved coordination of HIV/AIDS responses, the principles were designed to be fully compatible with the guidelines of the Organisation for Economic Co-operation and Development's Development Assistance Committee for "Harmonising Donor Practices for Effective Aid Delivery" and the February 2003 "The Rome Declaration on Harmonisation" by "accommodating different aid modalities while ensuring effective management procedures and reducing transaction costs for countries" (OECD, 2003; The Rome Declaration, 2003; UNAIDS, 2004b, p.
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One National HIV/AIDS Coordinating Authority UNAIDS has stated that developing, reviewing, and updating national plans requires human resource capacity for coordination and calls for strong leadership and commitment, which are ideally provided by the highest level of government. This highest level of government is also expected to delegate its authority to a national AIDS authority, which may include a governing council and a secretariat, that also has a mandate to broadly recruit other national, local, and international stakeholders from all sectors into the collaborative process and to coordinate all action related to that process.
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. Strategic Planning and Major Elements of HIV/ AIDS Programs at the Country Level As early as 1998, UNAIDS published a guide for countries to assist them in developing national strategic plans for their response to HIV/AIDS.
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2. A response analysis, in which relevant initiatives in priority areas are examined, including those that augment or supplement "official national programs," including activities organized by the community, the private sector, civil society, academic organizations, and nongovernmental organizations.
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This support includes primary and secondary education for children and skills training for out-of-school youths; routine and specific health care, including sexual and reproductive health for older children; family and home support, including income generation or support; community support, including training and support of full-time community workers and child care; and administrative costs for birth certificates, as well as for other administrative and institutional arrangements necessary for the implementation for child care (see Chapter 7 for discussion of PEPFAR's programs for orphans and vulnerable children)
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These challenges include economic and social conditions; the capacity of health care systems; the capacity of the health care workforce; competing health priorities, the increasing burden of HIV/AIDS on women and girls; growing numbers of orphans and other vulnerable children; the increasing need for children and grandmothers to serve as caregivers; stigma and discrimination; and gaps in the current evidence base for the prevention, care, and treatment of people with HIV/ AIDS. These challenges are highlighted briefly here and discussed further in the subsequent chapters.
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found that repeated and transient increases in HIV viral load resulting from coinfection with malaria can amplify HIV prevalence, suggesting that malaria may be an important factor in the rapid spread of HIV infection in sub-Saharan Africa (see Chapter 6 for further discussion of this issue)
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Capacity of the Health Care Workforce Stephen Lewis, the UN Special Envoy for AIDS in Africa, remarked at the close of the 16th International AIDS Conference in 2006: What has clearly emerged as the most difficult of issues, almost every where, certainly in Africa, is the loss of human capacity. In country after country, the response to the pandemic is sabotaged by the paucity of doc tors, nurses, clinicians and community health workers.
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continue to be at the center of the epidemic with heavy concentrations among those newly infected, accounting for more than 40 percent of new adult HIV infections in 2000. In sub-Saharan Africa, three young women are infected for every young man in this age group.
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In a 1999 national reproductive and child health survey in Tanzania, 62 percent of married women reported that they perceived the greatest risk factor for HIV infection to be their partners having other sexual contacts (National Bureau of Statistics Dar es Salaam, Tanzania and Macro International, 2000)
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. Kenya, South Africa, Tanzania, and Uganda each have more than 1 million children orphaned because of AIDS.
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The cascading effects of academic vulnerability often lead to economic vulnerability, including loss of income and/or property and lack of adequate shelter and food, which in turn may lead to increased risk of HIV exposure and infection through transactional or transgenerational sex in exchange for food, money, shelter, and other basic needs. Psychosocial vulnerability may develop from the need for emotional support due to HIV/AIDS from the individual child as well as the family and the burden of caregiving and guardianship for younger siblings.
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Moreover, health care workers may be stigmatized because they care for HIV patients (Project Siyam'kela, 2003; USAID, 2005)
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However, significant gaps exist in understanding of the epidemic, how to best address it, and how to expand what is working. These gaps relate to every aspect of implementing an HIV/AIDS program, from precisely how HIV infections are spreading to how to assess clinical status without the capacity to measure viral load or CD4 (Bertozzi et al., 2006)
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. PEPFAR has established 5-year targets for its prevention, treatment, and care programs in these countries to support prevention of 7 million new HIV infections; treatment of 2 million HIV-infected people with antiretroviral therapy; and care for 10 million people infected and affected by HIV/AIDS, including orphans and other vulnerable children.3 Among the 12 PEPFAR focus countries in sub-Saharan Africa, the adequacy of the health workforce varies considerably.
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TABLE 2-3 Density of Selected Health Care Workers in the PEPFAR Focus Countries Other Health Medical Community Physicians Nurses Midwives Workers Assistants Health Workers Country Health (year Care Density Density Density Density Density represented Workers Per Per Per Per Per by data) (Total)
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aEstimated number of total health care workers in each country including physicians, nurses, midwives, dentists, pharmacists, public and en vironmental health workers, community health workers, laboratory technicians, other health care workers, and health management and support workers. bThe data provided is only for the year 2004.
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91.23 South Africa 47,432,000 Upper middle 10,960 52 18.8 [16.8–20.7] 61.81 Tanzania 38,329,000 Low 660 44 6.5 [5.8–7.2]
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through the establishment of a Global Fund to Fight Against HIV/AIDS, Malaria and Tuberculosis.4 The second was the Kerry-Frist Global AIDS bill (S.15) , formally known as the U.S.
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For example, the Leadership Act underscores the importance of involving faith-based organizations in the initiative and also exempts them from participating in activities to which they hold 6 S.1099, United States Emergency Plan for AIDS Relief Act of 2003 and HR 1298, United States Emergency Plan for AIDS Relief Act of 2003, accessed from http://thomas.loc.gov on September 11, 2006.
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In particular, the act recognized that the new resources being provided could not meet all needs, and it sought to complement existing programs that might already be meeting some needs. The legislation stated that the Global AIDS Coordinator would collaborate and coordinate with civil sector organizations to plan, fund, implement, monitor, and evaluate all programs addressing HIV/AIDS.
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108-25 for Strategy Development • Include specific objectives, designed to develop and implement national and community-based multisectoral approaches, and specific strategies to treat individuals infected with HIV/AIDS and to prevent the further spread of HIV infections, with a particular focus on the needs of families with children (including the prevention of mother-to-child transmission) , women, young people, and children (such as unaccompanied minor children and orphans)
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Global AIDS Coordinator to be appointed by the President, with the advice and consent of the Senate. The Office of the U.S.
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They include the following: • 55 percent for "therapeutic medical care of individuals infected with HIV, of which such amount at least 75 percent should be expended for the purchase and distribution of antiretroviral pharmaceuticals and at least 25 percent should be expended for related care" • 20 percent for "HIV/AIDS prevention, of which such amount at least 33 percent should be expended for abstinence-until-marriage programs" • 15 percent for "palliative care of individuals with HIV/AIDS" • Not less than 10 percent for "assistance for orphans and vulnerable children affected by HIV/AIDS, of which such amount at least 50 percent shall be provided through non-profit, nongovernmental organizations, including faith-based organizations, that implement programs on the community level" THE 5-YEAR STRATEGY: THE PRESIDENT'S EMERGENCY PLAN FOR AIDS RELIEF The Leadership Act required development of a comprehensive 5-year strategy, guided by the legislation (Box 2-3)
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The Network Model PEPFAR's 5-year strategy describes a network model developed to deliver prevention, treatment, and care services for HIV/AIDS, consistent with the priorities and requirements of the Leadership Act. The basic design, adopted from a successfully implemented model in Uganda, relies on centralized, core facilities (staffed by different practitioners of varying skill)
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Global AIDS Coordinator in coordinating global HIV/AIDS efforts Department of Health and Human Services: • Centers for Disease Control and Prevention: Prevention, surveillance, infrastructure development, care, and field activities through its Global AIDS Program; field staff work with the Global Fund's Country Coordinating Mechanisms • National Institutes of Health: Basic, clinical, and behavioral research on HIV, opportunistic infections, and other HIV-associated conditions; development of therapies, vaccines, and microbicides • Health Resources and Services Administration: Training, technical assistance, twinning, and palliative care programs • U.S. Food and Drug Administration: Advisory resource on HIV/AIDS drug quality, safety, and efficacy, and conduct of related HIV/AIDS activities Department of Defense: • Military-to-military HIV/AIDS awareness and prevention education • Policy development for HIV/AIDS issues in military settings • Construction of facilities used for HIV/AIDS activities Department of Labor: • Workplace HIV/AIDS prevention education and stigma reduction • Technical assistance to governments, employees, and labor leaders • Capacity building to improve worker access to testing, counseling, and other support services • Multilateral programs targeting HIV-infected children forced to work and child prostitution • Cross-sector collaboration • Reduction of trade barriers to facilitate delivery systems for health care products U.S.
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70 PEPFAR IMPLEMENTATION: PROGRESS AND PROMISE FIGURE 2-3 PEPFAR's network model.
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Global AIDS Coordinator Within OGAC, staff are organized into several groups, all of which include OGAC staff and representatives from the other U.S. government departments and agencies coordinated by OGAC (Table 2-5)
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Agency for International Development, operationalize programs Department of Health and Human Services, • Can move policy issues up Peace Corps, Department of Defense, to agency principals Department of Labor Scientific Office of the U.S. Global AIDS Coordinator, Scientific Integrity Steering • Assesses evidence base for U.S.
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GIST (Global Implementation Support Team)
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. Office of the Global AIDS Coordinator.
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2007a. Office of the Global AIDS Coordinator's Suggested Factual Changes to the PEPFAR Implementation: Progress and Promise Report.
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2006. Office of the Global AIDS Coordinator: Focus countries.
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GLOBAL AIDS INITIATIVE: CONTEXT AND BACKGROUND USAID (U.S. Agency for International Development)
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