I. Overview: The Role of America’s Partnerships in the Worldwide Fight Against HIV/AIDS

	“The money that you have spent is being spent wisely and saving lives. Some call this a remarkable success. I call it a good start.” President George W. Bush World AIDS Day Observance November 30, 2007  Partnerships Create Hope Just five years ago, many wondered whether prevention, treatment and care could ever successfully be provided in resource-limited settings where HIV was a death sentence. Only 50,000 people living with HIV in all of sub-Saharan Africa were receiving antiretroviral treatment. President George W. Bush and a bipartisan, bicameral Congress reflected the compassion and generosity of the American people as together they led our nation to lead the world in restoring hope. They recognized that HIV/ AIDS was and is a global health emergency requiring emergency action. Their creation, the U.S. President’s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR), holds a unique place in the history of public health for its size and scope: In size, with an original commitment of $15 billion across 5 years, and a final funding level of $18.8 billion, it is the largest international health initiative in history dedicated to a single disease. PEPFAR also went beyond a commitment to allocating resources to a commitment to achieving results, with ambitious goals to support prevention of 7 million new infections, treatment of 2 million and care for 10 million, including orphans and vulnerable children;   In scope, it is the first large-scale effort to tackle a chronic disease in the developing world. And it moves beyond isolated efforts and pendulum swings that had led programs to focus on prevention or treatment or care for HIV/AIDS to sound public health — integrated prevention, treatment and care.
The success of the Emergency Plan is firmly rooted in partnerships between the American people and the people of the countries in which we are privileged to serve — governments, non-governmental organizations including faith- and community-based organizations, and the private sector. Together, we are building systems and empowering individuals, communities and nations to tackle HIV/AIDS. And in just four years, it is working. We have acted quickly. We have obligated 94 percent of the funds appropriated to PEPFAR so far, and expended or outlayed 59 percent of them. Figure 1 depicts the allocation of program resources in the 15 PEPFAR focus countries in Fiscal Year (FY) 2007. But success in not measured in dollars spent: it is measured in services provided and lives saved.
PEPFAR is on its way to achieve its aggressive goals. On many fronts, the progress to date has been remarkable, and, as the Institute of Medicine noted, the Emergency Plan has already achieved what many thought was impossible. In FY2007, PEPFAR-supported programs reached 57.6 million people with support for prevention of sexual transmission using the ABC approach (Abstain, Be faithful, correct and consistent use of Condoms). The U.S. Government (USG) has supplied nearly 1.9 billion condoms worldwide from 2004 through 2007 — as Dr. Peter Piot of UNAIDS has said, more than all other developed countries combined. From FY2004 through FY2007, PEPFAR has supported prevention of mother-to-child transmission (PMTCT) for women during more than 10 million pregnancies. For PMTCT clients who have been found to be HIV-positive, antiretroviral prophylaxis has been provided in over 827,000 pregnancies, preventing an estimated 157,000 infant HIV infections. With Emergency Plan support, focus countries have scaled up their safe blood programs, and 11 of them can now meet more than half of their annual demand for safe blood — up from just four when PEPFAR started. PEPFAR has supported HIV counseling and testing for over 33 million people to date, and supported care for more than 6.6 million people infected or affected by HIV/AIDS, including 2.7 million orphans and vulnerable children. Through September 2007, PEPFAR partnerships have supported antiretroviral treatment (ART) for approximately 1.45 million men, women, and children — approximately 1.36 million of whom live in 15 PEPFAR focus countries, and over 1.33 million of whom are in sub-Saharan Africa. Illustrating the broader effect of treatment, PEPFAR treatment support is estimated to save nearly 3.2 million adult years of life through September 2009, and many more beyond that time frame. These additional years of life are ones in which people can play their vital roles as parents, teachers, or caregivers. Trends in Health The developing world faces a wide range of health and development issues, and some have questioned whether HIV/AIDS merits the intensive focus that the Emergency Plan has brought to it. In the 15 PEPFAR focus countries, home to approximately half of the world’s HIV-infected persons, valuable perspective is gained by examining changes in infant mortality over the past two decades. As seen in Figure 2, infant mortality has declined in 12 of the 15 focus countries since 1987; in most of them, the decline has been very substantial. This is a major achievement for these nations and one that should be expected to reflect an overall improvement in health. Yet Figure 3 shows that strikingly few of these countries have experienced significant improvements in life expectancy. Tragically, seven of the 15 have actually seen life expectancy drop, and those declines have been especially dramatic in Botswana, Mozambique, Namibia, and South Africa — the four focus countries in southern Africa, where HIV prevalence is the highest in the world. Even if nations are having success in improving some health indicators for their people — and many are — the impact of HIV/AIDS is offsetting, or far more than offsetting, those improvements.
In many regions, 50 percent or more of hospitalizations are due to HIV/AIDS. In the hardest-hit countries, 50 years of public health gains have been wiped out. In Botswana, HIV/AIDS drove an increase in infant mortality despite significant increases in health resources committed by the Government (as shown in Figure 4). Similarly, life expectancy dropped by 30 percent during the 1990s and early 2000s (as shown in Figure 5).
In recent years, however, the Government of Botswana reports that those trends have turned around at the same time as it led a major assault on HIV/AIDS — primarily with its own resources, but also as HIV/AIDS program spending from international partners rose. It is clear that an effective response to the unique challenge of HIV/AIDS is a necessity for real progress on health in the developing world. The data are increasingly compelling that as countries scale up their HIV/AIDS prevention, treatment and care programs, they are making progress toward reversing the course of the epidemic. Their efforts are paying off as life expectancy once again begins to rise and infant mortality continues to fall. The good news is that aggressively confronting HIV/AIDS can have a broad impact.
	Trends in HIV/AIDS UNAIDS recently revised its estimate of the number of people living with HIV/AIDS worldwide downward to 33.2 million from a previous estimate of 39.5 million. For the most part, the revision reflects the strengthening of surveillance and monitoring and evaluation capacity over the past few years, as countries have implemented population- based surveys (in many cases with PEPFAR support) to supplement the antenatal clinic surveillance they have used to estimate prevalence in the past. Even with the new prevalence estimates, however, the number of people living with HIV/AIDS worldwide in 2007 was roughly 4.2 million more than in 2001. Prevention remains the central challenge. Prevention Sexual transmission Of the countless developments taking place in the global fight against the pandemic, perhaps the most important in recent years is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior. According to UNAIDS’ 2007 AIDS Epidemic Update, “In most of sub- Saharan Africa, national HIV prevalence has either stabilized or is showing signs of a decline. Côte d’Ivoire, Kenya and Zimbabwe have all seen declines in national prevalence, continuing earlier trends.” The report continues: “Global HIV incidence likely peaked in the late 1990s at over 3 million new infections per year, and was estimated to be 2.5 million new infections in 2007... This reduction in HIV incidence likely reflects natural trends in the epidemic as well as the result of prevention programmes resulting in behavioural change in different contexts.” In Kenya, for example, prevalence declined from roughly 14 percent in the mid-1990s to 5 percent in 2006, corresponding to significant reductions in sexual risk-taking behavior — increased age at sexual debut, decreased numbers of sexual partners, and increased condom use in higher-risk sex (as shown in Figure 6).
Another key trend in HIV/AIDS is the growing importance of HIV-discordant regular partnerships, in which one partner is living with HIV and the other is not, as a means of transmission. According to Uganda’s 2005 National HIV Survey, approximately 50 percent of new infections there occurred within discordant regular partnerships. Many HIV-discordant couples do not know their HIV status. Several studies in Africa have shown that provision of voluntary counseling and testing for couples reduces HIV transmission by 56 percent and that consistent condom use in discordant couples is associated with an 80 percent reduction in HIV transmission. However, the rate of condom usage in regular partnerships is very low — in Uganda, it rose from 0 percent in the early 1990s to 1.9 percent in the late 1990s. Despite massive provision of condoms by the USG and others, increasing usage has proven difficult, even when couples know their HIV status. A promising new prevention approach is safe male circumcision, which lowers transmission rates where the man is the HIV-negative partner. Discordant couples represent an extremely important opportunity for prevention, so further innovation is needed to address this vulnerable population. This could include the use of antiretroviral treatment — as pre-exposure prophylaxis for the HIV-negative partner, or to reduce the level of HIV, and therefore the transmission rate, in the HIV-positive partner. For all populations, multiple concurrent partnerships remain a significant challenge. While, on average, Africans have numbers of life-time partners comparable to Americans or Europeans, in certain areas multiple concurrent partnerships are common, and this practice promotes more rapid spread of HIV. The challenges of multiple concurrent partnerships parallel those of discordant couples. Data show that decreases in partnerships could have a significant impact on HIV transmission, and this issue will continue to be a key focus for PEPFAR in the coming year. As the epidemic changes, the global community must constantly adapt and improve its programs to keep up. One of the central themes of PEPFAR programming over the past year has been “Knowing Your Epidemic” — understanding where, why and in whom infections are occurring, both in terms of geography and in terms of vulnerable populations, and tailoring programs accordingly. An HIV prevention program in Vietnam, where the epidemic is largely concentrated among injecting drug users and people in prostitution and their clients, must have a very different approach from a prevention program in Uganda, where most infections occur through sexual partnerships in the general population (and, increasingly, within discordant couples). But regardless of the key factors in transmission, in the absence of an effective vaccine and microbicide — and in 2007 the global community experienced setbacks in identifying either — behavior change will remain the keystone of success. Even with the new advances in prevention related to male circumcision, behavior change — and maintenance of behavior change — is essential. Armed with data from UNAIDS and others showing encouraging trends, PEPFAR is promoting lifeskills and HIV prevention programs beginning with the very young, because it is easier to influence the behavior of a 25 year old if educational programs begin at age 10. Life skills and HIV prevention programs teach youth to respect themselves, to respect others — including the opposite sex — and to practice personal responsibility. Such programs are being scaled up nationally, both in- and out-of-school, in several focus countries. In many countries, adults continue to face elevated risk of HIV infection, and PEPFAR is supporting the expansion of programs for them as well. PEPFAR prevention programs target different age groups with interventions tailored to the risks they face, recognizing that effective prevention is a life-long matter. Prevention of mother-to-child transmission Mother-to-child transmission remains the leading source of child HIV infections, and prevention of mother-to-child transmission (PMTCT) remains an essential challenge. According to UNAIDS, the global number of children who became infected with HIV has dropped slightly, from 460,000 in 2001 to 420,000 in 2007. PEPFAR supports host nations’ efforts to provide PMTCT programs, including HIV counseling and testing, for all women who attend antenatal clinics (ANCs), and sharply increased its PMTCT resources in FY2007. PEPFAR has supported PMTCT interventions for women during approximately 10 million pregnancies to date, providing antiretroviral prophylaxis for over 827,000 women who were determined to be HIV-positive, preventing an estimated 157,000 infections of newborns. Despite significant resources from PEPFAR, levels of PMTCT coverage continue to vary dramatically from country to country. While all PEPFAR focus countries have scaled up services significantly in recent years, the results in some countries remain disappointing. A central obstacle in many nations is failure to fully implement policies allowing “opt-out,” provider-initiated counseling and testing, under which all women who visit ANCs routinely receive voluntary HIV testing unless they decline. Nations that have adopted and implemented opt-out testing have dramatically increased the rate of uptake among pregnant women, from low levels to around 90 percent at many sites. Under the highly successful national program in Botswana, where approximately 13,000 HIV-infected women give birth annually, the country has increased the proportion of pregnant women being tested for HIV from 49 percent in 2002 to 92 percent in 2007. The percentage of infants born infected has declined to approximately four percent, compared to about 35 percent without PMTCT interventions. This type of change can be seen in other countries as well. It reflects a combination of political leadership, and implementation of opt-out and rapid testing. Without these changes of policy — and effective implementation of the policies — success similar to that achieved by Botswana is unlikely to occur.
	Treatment AIDS is still among the most deadly infectious diseases in the world. In sub-Saharan Africa, the epicenter of the pandemic, it is the leading cause of death. More than 22 million of those infected — more than two-thirds of all people living with HIV/AIDS — live in the region, and approximately 1.6 million people die of AIDS there each year — more than three-quarters of the global total. However, there is new reason for hope. On a global basis, UNAIDS also estimates that the number of people dying of AIDS-related causes has declined over the past two years, from 2.2 million in 2005 to 2.1 million in 2007. This is the first time such a decline has occurred, and the change is due largely to the increased availability of antiretroviral treatment — though improved prevention and care programs have contributed as well. Although the World Health Organization (WHO) has not yet released updated numbers on global treatment coverage, PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria are supporting treatment for nearly 2 million persons as of September 2007. Because of the commitment of resources and talented people in-country, many of the focus countries have achieved massive improvements in their national levels of ART coverage in recent years as shown in Table 1, and the Emergency Plan has supported their leadership. Data on morbidity and mortality naturally lag behind expansions of treatment. However, in Botswana, where President Festus Mogae was an early leader, with both resources and national treatment scale-up beginning in 1999, a treatment-driven decline in adult mortality has already begun to occur. Prolonged lives through treatment do not affect only those on treatment, but also those for whom they are parents, teachers, or caregivers. The ultimate measurement of treatment is not simply the number people receiving treatment, but the daily impact on individual lives — and therefore on families, communities and nations. Perhaps the best way to assess the impact of treatment is to estimate its effect on peoples’ life spans. In 2007, PEPFAR, working with the UNAIDS Reference Group on Modeling and Projections, improved its methodology for calculating the impact over time of antiretroviral treatment programs. Unlike treatment for malaria or tuberculosis (TB), treatment for HIV/AIDS cannot cure people, but only extend their lives. To reflect this, PEPFAR measures the impact of its treatment programs through “life-years saved” rather than “lives saved” — a small but important distinction. As Figure 8 shows, PEPFAR support for treatment in the focus countries is estimated to save nearly 3.2 million adult years of life through the end of September 2009 (as many as were saved by treatment in the United States from 1989 through 2006) — and undoubtedly will have much greater effects beyond that time frame. Those are additional years in which people can play their vital roles for their loved ones. Along with its bilateral support for treatment programs, the Emergency Plan is also the largest contributor to the Global Fund, providing approximately 30 percent of all resources to date. The Global Fund has reported support for treatment for approximately 1.45 million people globally as of the end of 2007, of whom 864,000 were in PEPFAR focus countries.
Care As the pendulum of debate on HIV/AIDS interventions swings between prevention and treatment, it is often care that is lost. Yet care is a critical element of a truly comprehensive approach. There are three key dimensions to care: care for orphans and vulnerable children (OVCs); care (other than antiretroviral treatment) for people living with HIV/AIDS; and HIV counseling and testing. All are essential to a comprehensive global response to HIV/ AIDS. Despite significant progress by PEPFAR in all three areas, much more needs to be done.
	Orphans and vulnerable children (OVC) Even the best OVC program cannot replace parents. Because HIV/AIDS predominantly affects people of childbearing age, its impact on children, extended families, and communities is devastating. If a child’s parent dies of AIDS, the child is three times more likely to die, even if he or she is HIV-negative. Besides increased risk of death, children whose parents have died of AIDS face stigmatization and rejection, and often suffer from emotional distress, malnutrition, inadequate health care, poor or no access to education, and a lack of love and care. They may also be at high risk for labor exploitation, sex trafficking, homelessness, and exposure to HIV. Extended families and communities in highly affected areas are often hard-pressed to care for all the children. In communities hard-hit by both HIV/AIDS and poverty, there are many children who are not orphans, but who have been made more vulnerable by HIV/AIDS. For example, children whose parents are chronically ill with HIV/AIDS might not receive the care and support they require, and may instead become caregivers for parents and younger siblings, dropping out of school and assuming the responsibilities of the head of the household. Research indicates that these children, caring for sick and dying parents, are among the most vulnerable. The best way to support children is to keep parents alive and healthy, through effective HIV prevention and treatment. In order to capture the role that treatment programs can play in protecting children from orphanhood, PEPFAR has developed a methodology to estimate the number of orphans averted through treatment programs. Through FY2007, the number is nearly 1.7 million, and many more have been saved from orphanhood due to prevention and care programs. Through FY2007, PEPFAR supported care for approximately 2.7 million OVCs — a major commitment, particularly relative to the 630,000 supported in FY2004. Yet the number reached still falls far short of the need.
Although there is uncertainty around OVC estimates in light of UNAIDS’ recent HIV prevalence reestimates, by 2010, the number of children orphaned by AIDS globally may exceed 20 million, and the number of other children made vulnerable because of HIV/AIDS may be more than double that number. In addition to scaling up HIV/AIDS programs for OVCs on a larger scale than has been attempted previously, PEPFAR has also sought to strengthen the quality of OVC programs. OVC programs must now report on how many of seven key services they provide and strive to ensure that these services are making a difference in the lives of the children they serve. Among the areas of support for OVCs in PEPFAR programs are support for food and nutrition and for education. PEPFAR’s investments in these areas, and its linkages with other USG programs addressing these needs, are discussed below. Care for people living with HIV/AIDS (PLWHA) An often-overlooked reality of HIV/AIDS care is that many people infected with HIV at a given time do not meet the clinical criteria for antiretroviral treatment. Therefore it is critical to establish programs and services for HIV-positive people that address the needs of those not yet on treatment. A key aspect of caring for PLWHA who are not yet on treatment is ensuring that they receive treatment soon after they are eligible. Studies and program reports show that patients who start treatment late, often when their immune systems are already severely compromised and they have serious opportunistic illnesses, do not fare as well as those who start on treatment soon after becoming eligible. PEPFAR programs seek to enroll PLWHA in care programs that include regular evaluations for treatment eligibility — programs that do so experience fewer early illnesses and deaths than other programs. Care efforts support HIV-positive people — many of whom are in HIV-discordant partnerships — through “prevention with positives” programs, providing them with information and condoms so they can take appropriate steps to avoid infecting others. Care programs also provide a platform for a range of services to allow PLWHA to stay healthy and delay the need for treatment. These care services can include pain and symptom management; treatment and prevention of opportunistic infections (OIs) and other diseases; social, spiritual and emotional support; and compassionate end-of-life care. With PEPFAR support, some countries are standardizing their approach and working to ensure that all HIV-positive people who receive care, even if they are not eligible for treatment, receive a “basic preventive care package” that provides an array of lifesaving interventions. PEPFAR has scaled up its support for national efforts to provide high-quality care for OIs related to HIV/ AIDS. HIV/TB co-infection is a leading cause of death among HIV-positive people in the developing world, and multi-drug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis are growing threats. PEPFAR increased its funding for HIV/TB five-fold, from $26 million to $131 million, from FY2005 to FY2007.
	Counseling and testing Knowing one’s status provides a gateway for critical prevention, treatment, and care. Since inception, PEPFAR programs supported testing for over 33 million people, including over 10 million pregnant women at antenatal clinics, a key population to target. Impressive as these results are, millions more must be tested in order for PEPFAR to meet its ambitious prevention, treatment, and care goals. Success depends on widespread testing in medical settings, including TB and sexually transmitted infection (STI) clinics, ANCs, and hospitals. People in these settings are far more likely than the general population to be HIV-positive and in need of care and treatment. PEPFAR has worked with host nations to build support for the “opt-out” model of provider-initiated testing for patients in these settings. Another key policy is use of rapid HIV tests, which improve the likelihood that those who are tested will actually receive their results. Even as PEPFAR scales up confidential counseling and testing programs, addressing these policy and implementation constraints around testing is essential for success in prevention, treatment, and care. Social Impact of HIV/AIDS HIV/AIDS is more than an issue of health alone. It is among the most serious economic development and security threats of our time — one reason why the United States and PEPFAR host nations have made addressing it such a priority. As President Bush said at the World AIDS Day 2007 observance, “When we support nations seeking to replace chaos and despair with progress and hope, we reduce the appeal of extremism. When we replace despair with progress, when we replace hopelessness with hope, we add to the security of our country. As well, we make friends who will always remember that America stood with them in their hour of need.” Unlike many diseases, HIV/AIDS predominantly hits people who are 15 to 49 years, the most productive and reproductive years. In the hardest-hit countries, the epidemic is taking a generation of parents, teachers, health care workers, bread-winners and peacekeepers and is rending the social fabric of communities, nations and even a continent. This is a dangerous mix that promotes hopelessness and despair — and can breed extremism. Economic impact Businesses in the developing world are faced with absenteeism, declines in skilled workers, high rates of turnover, expenses to train new workers, reduced revenue, and increased health care costs due to HIV/AIDS. The International Labor Organization has estimated that 41 percent of worldwide labor force participants (and 43 percent in sub-Saharan Africa) living with HIV are women. Forty-three countries heavily affected by HIV/AIDS lost a yearly average of 0.5 percent in their rate of economic growth between 1992 and 2004 due to the pandemic, and as a result forfeited 0.3 percent per year in employment growth. Among them, 31 countries in sub-Saharan Africa lost 0.7 percentage points of their average annual rate of economic growth and forfeited 0.5 percentage points in employment growth. The pandemic is not only affecting current growth; it also threatens the future economic prosperity of countries that are particularly hard-hit by the disease because of its devastating impact on teachers. A study in the late 1990s, for example, reported that in Zambia the equivalent of two-thirds of each year’s newly trained teachers were being lost to HIV/AIDS.
Impact on peacekeepers In addition, many nations suffer from high HIV prevalence among defense forces, losing their soldiers — and their leadership — to AIDS. Militaries, fundamental to peacekeeping and protecting civilian populations, are often unable to keep their own personnel alive and healthy. A study done by a Commandant of the Nigerian Army Medical Command in the late 1990s showed that HIV infection rates among peacekeeping troops deployed in Sierra Leone increased from seven percent for those deployed for one year to 10 percent for those deployed for two years and more than 15 percent for those deployed for more than three years. Deaths due to HIV/AIDS are estimated to have reduced the size of Malawi’s armed forces by 40 percent. In South Africa, HIV/AIDS accounts for 70 percent of military deaths, and prevalence in the armed forces is estimated at between 17 and 23 percent, with some battalions tested in 2004 showing prevalence rates near 80 percent. In Uganda, more soldiers are believed to have died from AIDS than from the nation’s 20-year insurgency. These realities are discouraging. Yet against this background, PEPFAR reflects the recognition of hard-hit nations and the United States that, in this era, confronting HIV/AIDS is fundamental to development and security.
	PEPFAR: One Element of a New Era in Development PEPFAR is the largest international public health initiative aimed at a single disease that any nation has ever undertaken. It represents a bold change from traditional thinking about HIV/AIDS and development, and is part of a new era of partnerships for international development. Under the leadership of President Bush, and with the bipartisan support of Congress, this new era — with a particular focus on Africa — represents both a massive commitment of treasure and a change of heart. The United States is changing the paradigm for development, rejecting the flawed “donor-recipient” mentality and replacing it with an ethic of partnership. Partnership is rooted in hope for and faith in people. Partnership means honest relationships between equals based on mutual respect, understanding and trust, with obligations and responsibilities for each partner. Partnership is the foundation of PEPFAR’s success and of what Secretary of State Condoleezza Rice has called “transformational diplomacy.” The Emergency Plan is central to U.S. efforts to “connect the dots” of international development. PEPFAR programs are increasingly linked to other important programs — including those of other USG agencies and other international partners — that meet the needs of people infected or affected by HIV/AIDS in such areas as nutrition, education and gender.
But while PEPFAR is an important part of connecting the development dots, it does not — and could not — replace USAID, MCC, PMI, or any of its sister initiatives or agencies. Nearly every person affected by HIV/AIDS can benefit from additional food support, greater access to education, economic opportunities and clean water, but so could the broader communities in which they live. In order to respond effectively to the many interrelated causes and effects of the epidemic, PEPFAR must integrate with other development programs as part of a larger whole. Linking PEPFAR with food and nutrition In FY2007, PEPFAR advanced the integration of food and nutrition services, as well as longer-term food security interventions, into its programs. A conceptual framework to guide integration of PEPFAR programs with USAID’s Food for Peace (FFP) program was developed and disseminated. PEPFAR significantly changed its policy guidance regarding parameters for food support to HIV-positive adult patients, and adapted its data system to enable reporting on beneficiaries as well as include an accounting of dollars planned for actual food purchases with PEPFAR resources. PEPFAR has convened an interagency, multisectoral technical working group on food and nutrition to guide incorporation of key components into HIV programs. In addition to the primary PEPFAR implementing agencies, the group includes other agencies and offices that work directly with issues of food security and nutrition, including USAID’s FFP program and Bureau for Economic Growth, Agriculture, and Trade, as well as the U.S. Department of Agriculture (USDA). The group’s first task was to develop a food and nutrition strategy through a consultative process, described in the report to Congress entitled “Food and Nutrition for People Living with HIV/ AIDS.” The group also provides guidance to PEPFAR country teams on integrating food and nutrition activities into HIV/AIDS programs. In terms of its own targeted nutritional support to people infected and affected by HIV/AIDS, PEPFAR guidance designates three priority populations for food support using PEPFAR resources: 1) orphans and vulnerable children born to an HIV-infected parent, regardless of the child’s HIV or nutritional status; 2) HIV-positive pregnant and lactating women, regardless of nutritional status; and 3) HIV-positive adult patients in treatment and care programs who have evidence of malnutrition, which is defined by WHO as a Body Mass Index (BMI) at or below 18.5 (this cutoff point is new this year — in previous years, only those adult patients with a BMI under 16 were eligible for nutritional support under PEPFAR). PEPFAR also supports nutrition counseling and multivitamin supplementation as part of a preventive care package for adult PLWHA. FY2007 marked the first year that PEPFAR requested specific information regarding food and nutrition programming through the country reporting process. According to this data, in FY2007, PEPFAR supported food and nutritional supplementation in the 15 focus countries for approximately: 50,000 HIV-positive pregnant or lactating women; 332,000 OVCs; and 20,000 people receiving ART (with evidence of severe malnutrition as defined by the guidance at the time). This likely underestimates the actual number of beneficiaries in each country, and further refinements will be undertaken for reporting in FY2008. There are numerous examples of integration of food and nutrition and PEPFAR. In partnership with the World Food Program (WFP) in Ethiopia, PEPFAR partners ensured that more than 3,400 OVCs and 4,000 PLWHA along the transport corridor received nutritional assistance in addition to home-based care services. In Haiti, PEPFAR worked with USAID/FFP and WFP to determine food rations, geographical coverage, and eligibility criteria for PEPFAR beneficiaries. Because of this, future food coverage needs for PLWHA were included in the new USAID/FFP plans as well as WFP’s 2008 plan. Through its partners, USAID/FFP provided 1,492 metric tons of food support to PLWHA and OVCs in 12 food-insecure districts in Rwanda. PEPFAR partners leveraged this support to provide food and nutrition to 3,787 OVCs and 1,926 HIV-positive pregnant or lactating women. This support also improved food security for 19,750 people affected by HIV — 3,950 of whom are PLWHA. In Uganda, a new USAID/FFP program awarded in FY2007 will focus on food security issues in conflict-affected Northern, Central, and Eastern Uganda. This five-year program will work with PEPFAR partners in these areas to link services and increase access for PLWHA. In Kenya, the Emergency Plan supports a “food-by-prescription” approach and is working with the government, WFP and others to ensure that broader communities, as well as individuals who may fall outside of PEPFAR guidelines for support, are reached. In FY2008, further expansion of these programs is anticipated, and the Emergency Plan will collect information on PEPFAR dollars spent and leveraged for food in addition to the number of people served.
	Linking PEPFAR and education PEPFAR is working with the State Department’s Office of the Director of Foreign Assistance, which is developing an action plan for interagency work on education issues. This effort is expected to lead to a unified USG strategy in 2008, in which PEPFAR will play a role. PEPFAR has developed a strong partnership with the President’s AEI, implemented through USAID. One example of this partnership in action is in Zambia, where PEPFAR and AEI fund a scholarship program that helps to keep in school nearly 4,000 orphans in grades 10 to 12 who have lost one or both parents to AIDS or who are HIV-positive, in addition to support for pre-school programs and orphans in primary school. Similar partnerships exist in Uganda, where PEPFAR and AEI are working together to strengthen life-skills and prevention curricula in schools. This program, with $2 million in funding in FY2007, targeted four million children and 5,000 teachers. Approximately $180 million in PEPFAR funding supported education activities in FY2007, and this figure is expected to rise to over $300 million in FY2008. PEPFAR works through OVC programs to ensure children’s attendance at school. Barriers to school attendance that are addressed by OVC programs include the provision of school fees and scholarships, materials and supplies, uniforms, meals, mentoring and even child care programs to free up older siblings to attend school. At the primary and secondary school level, PEPFAR supports life skills training and HIV prevention messages, as well as programs to teach older students vocational skills, enabling them to provide economically for their families — especially important given the proliferation of child-headed households brought about by the HIV/AIDS epidemic. In Zambia and Namibia, scholarship programs help girls continue their education beyond primary into secondary school. Also in Zambia, PEFPAR has provided 53 schools with small grants to assist OVCs. In Uganda, through The AIDS Support Organization (TASO), PEPFAR reaches almost 1,000 children with school fees for both primary and secondary school, boarding fees for those in secondary schools, uniforms, and school supplies. Support of school feeding for OVCs is also a common intervention.
In Nigeria, where an estimated one-third of all children are not in primary school, PEPFAR’s support of non-formal schools, focusing on literacy and numeracy for vulnerable children, plays an important role not only in providing basic education but in assisting children to transition to formal schools when ready. Along with its efforts in primary and secondary school settings, PEPFAR also supports pre-service and in-service training for health care workers provided through institutes of higher learning in host countries. PEPFAR support of education is a good example of “diagonal” impact — so-called vertical programs that have a substantial impact in a horizontal way. One example is where block grants are given to schools for specific purposes, such as desks, books, lab equipment or school refurbishment, in exchange for the schools admitting an agreed number of OVCs to attend school without fees or with reduced fees for a certain period of time. Such block grants are a way of enabling thousands of OVCs to attend school while benefiting the broader school population.
	Linking PEPFAR with the President’s Malaria Initiative and the Millennium Challenge Corporation PEPFAR and the PMI have worked together to identify countries with joint opportunities for leveraging. Currently, seven PEPFAR focus countries are also PMI focus countries: Ethiopia, Kenya, Mozambique, Rwanda, Tanzania, Uganda, and Zambia. PMI and PEPFAR efforts currently overlap in three major areas: insecticide-treated net (ITN) distribution and education to pregnant women through ANCs; ITN distribution and education to PLWHA; and coordination of lab services. Together, PMI and PEPFAR are now working with Malaria No More to add a private sector component to this cooperation. In Zambia, by using the PEPFAR-supported distribution infrastructure, the RAPIDS consortium led by World Vision, PMI, PEPFAR and the private sector delivered more than 485,000 bed nets before this malaria season at a 75 percent savings — and the USG saved half the remaining cost of nets through a public-private partnership led by the Global Business Coalition on HIV/AIDS, TB and Malaria. The two programs are also coordinating on surveys and surveillance to reduce the cost of monitoring program results. Other examples include: In Uganda, PEPFAR and PMI are providing joint funding of a nationwide health facility survey. Several PEPFAR partners have gained access to free ITNs through PMI support, and PEPFAR and PMI are providing joint support for ANC interventions for malaria and HIV/AIDS (e.g., distribution of ITNs through ANCs, and integrated training linking PMTCT and malaria prevention to maternal and child health curriculums).   In Kenya, in addition to PEPFAR-PMI support for ANC interventions, PEPFAR is also supporting partners in the distribution of ITNs to PLWHA as part of a basic care package in Nyanza Province.   In Tanzania, PEPFAR and PMI are working together to support the inclusion of a malaria indicator module in the HIV/AIDS indicator survey, and PMI is providing vouchers for ITNs to PLWHA.
MCC is another key USG partner with which PEPFAR is seeking opportunities for coordinated effort. In Lesotho, PEPFAR is co-locating staff with those of MCC to ensure joint support for expansion of health and HIV/AIDS services, and the two programs are also contributing to the cost of Lesotho’s Demographic Health Survey. Promoting Sustainability and Accountability A central issue for sustainability is the capacity of host nations to finance HIV/AIDS and other health efforts. At present, their ability to do so on the scale required varies widely. Many deeply-impoverished nations are years from being able to mount comprehensive programs with their own resources alone, yet it is essential that these countries appropriately prioritize HIV/AIDS and do what they can to fight the disease with locally-available resources, including financial resources. A growing number are doing so. Many other nations do have significant resources, and are in a position to finance much of their own HIV/AIDS responses. Some countries are making progress, and a growing number of nations are investing in fighting HIV/AIDS on a scale commensurate with their financial capacity. In some cases, for example, host nations are procuring all or a portion of their own antiretroviral drugs (ARVs), while PEPFAR provides support for other aspects of quality treatment. These developments within hard-hit nations build sustainability in each country’s fight against HIV/AIDS. With support from PEPFAR, host countries are developing and expanding a culture of accountability that is rooted in country, community, and individual ownership of and participation in the response to HIV/AIDS. PEPFAR is collaborating with host nations, UNAIDS and the World Bank to estimate the cost of national HIV/ AIDS plans, a key step toward accountability. Businesses are increasingly eager to collaborate with the Emergency Plan, and public-private partnerships are fostering joint prevention, treatment, and care programs. This culture of accountability bodes well not only for sustainable HIV/AIDS programs, but also for an ever-expanding sphere of transparency and accountability that represents transformational diplomacy in action. While HIV/AIDS is unmistakably the focus of PEPFAR, the initiative’s support for technical and organizational capacity-building for local organizations has important spillover effects that support nations’ broader efforts for sustainable development. Organizations whose capacity is expanded in order to meet fiduciary accountability requirements are also in an improved position to apply for funding for other activities or from other sources. Expanded health system capacity improves responses for diseases other than HIV/AIDS. Capacity-building in supply chain management improves procurement for general health commodities. Improving the capacity to report on results fosters quality and systems improvement, and the resulting accountability helps to develop good governance and democracy. As the name of the Emergency Plan frankly acknowledges, HIV/AIDS is a global emergency, and PEPFAR has sought to save as many lives as rapidly as possible. At the same time, it is essential to look to the future and sustain an effective response. HIV/AIDS is a chronic disease requiring lifelong prevention, treatment, and care, and so PEPFAR supports not one-time interventions but enduring contributions that build health systems as part of a broader development approach. PEPFAR is working to ensure a sustainable response by building the capacity of public and private institutions in host nations to respond to HIV/AIDS.
	Building health systems Discussions of global HIV/AIDS efforts have sometimes pitted “vertical,” disease-specific programs against “horizontal” programs to build health systems. This is a false dichotomy. Disease-specific programs, if appropriately designed, can strengthen overall health systems — as PEPFAR and host nations are demonstrating. Preliminary analysis by a health expert from Rwanda estimates that 60 percent of PEPFAR resources had an impact beyond HIV/AIDS. According to Dr. Jaime Sepulveda, Chairman of the U.S. Institute of Medicine Committee that recently completed a congressionally-mandated study of the Emergency Plan, “PEPFAR is contributing to make health systems stronger… doing good to the health systems overall.” As noted previously, the data from Botswana suggest that HIV/AIDS resources contributed to a decline in infant mortality and increase in life expectancy — significant gains in general health indicators. While much evaluation remains to be done, the only data available clearly indicate that HIV/AIDS resources are having a positive impact on general health care. For this reason, health experts are now talking about “diagonal” programs that have broad effects on the health system even as they focus on a specific disease. PEPFAR is such a program. PEPFAR estimates that approximately $638 million in FY2007 resources were investments in capacity-building in the public and private health sectors in support of service delivery sites for prevention, treatment and care. A recent study of PEPFAR-supported treatment sites in four countries found that PEPFAR supported a median of 92 percent of the investments in health infrastructure to provide comprehensive HIV treatment and associated care, including building construction and renovation, lab and other equipment, and training (see Figure 10). PEPFAR also supported a median of 57 percent of personnel costs (salaries and retention bonuses) at those sites. Discussions of health systems are often bogged down not only in the “vertical” versus “horizontal” debate, but also a sense that the public sector is the only valid “horizontal” system. This is not true for two significant reasons: much of the health care in the developing world is not provided through the public sector, and non-governmental partners can strengthen the public health system. WHO has estimated that faith-based organizations alone provide 30-70 percent of health care in sub-Saharan Africa. For example, in Kenya, it is estimated that half of health care is provided by faith-based institutions. However, the public sector is an essential component of health care, and data from four countries showed that PEPFAR support as a percentage of total resources was higher in public sector facilities than it was in private sector ones (Figure 10). This reflects PEPFAR’s commitment to supporting nations’ efforts to expand public sector health infrastructure. In addition, for a variety of reasons, it is often more cost-effective to use non-governmental partners to strengthen the public sector. In South Africa, a snapshot of non-governmental PEPFAR partners demonstrated that 19 of 22 were supporting services in the public sector across a range of program areas (Figure 11). Impact of HIV/AIDS investment on non-HIV/AIDS health — “diagonal programs” Perhaps the most striking data on the false dichotomy of the “vertical/horizontal” debate come from a recent Family Health International study in Rwanda showing that the addition of basic HIV services to primary health centers contributed to an increase in the use of maternal and reproductive health, prenatal, pediatric, and general health care (see Figure 12). The study collected data from 30 primary health centers that had at least six months of experience providing basic HIV care interventions and controlled for possible influences from other health initiatives. It found statistically significant increases in delivery of 17 non-HIV interventions, including a 24 percent increase in outpatient consultations, and a rise in syphilis screenings of pregnant women, from one test in the six months prior to the introduction of HIV care to 79 tests after HIV programs began. Large jumps were also seen in non-HIV related lab testing and provision of family planning.
Improving the health sector by reducing burdens on it In the hardest-hit regions, 50 percent or more of hospital admissions are due to HIV/AIDS. As effective HIV programs are implemented, hospital admissions plummet, easing the burden on health care staff throughout the system. In the Rwanda study cited above, the average number of new hospitalizations at 7 sites that had been offering antiretroviral therapy for more than two months dropped by 21 percent (see Figure 13).
	Building human resources for health Functioning health systems depend upon a workforce that can carry out the many tasks and build the systems that are needed. The lack of sufficient health workforce in many of the countries where PEPFAR is working presents a serious challenge not only to HIV/AIDS programs, but to every area of health. PEPFAR cannot solve the overall health workforce crisis, but it contributes by making large capacity-building investments that, while focused on HIV/AIDS, have a broader impact. From FY2004 through FY2007, PEPFAR supported nearly 2.6 million training and retraining encounters for health care workers. In FYs 2006 and 2007, PEPFAR provided approximately $281 million to support training activities. PEPFAR focuses on areas that most directly impact HIV/ AIDS programs: HIV/AIDS training for existing clinical staff such as physicians, nurses, pharmacists, lab technicians; management and leadership development for health care workers; and building new cadres of health workers. This effort to support local efforts to build a trained and effective workforce has provided the foundation for the rapid scale-up of prevention, treatment, and care that national programs are achieving, and provides a solid platform on which other health programs can build. A workforce pyramid Recognizing the continued importance of human capacity development, for FY2008 PEPFAR country teams were asked to estimate the amount of training they planned to support. They reported that they plan to support nearly 2.7 million training and retraining encounters in FY2008 alone, more than the cumulative total in the preceding four years. Pre-service training: The expansion of care and treatment requires an expansion in the workforce to provide these services. In FY2008 the amount of funds each PEPFAR country program could use to support long-term pre-service training was increased threefold, to $3 million. Unfortunately, few PEPFAR programs took advantage of this opportunity, and long-term pre-service training will be a focus for the coming year. Namibia is one country that took advantage of this new allowance. There are no schools of medicine and pharmacy in Namibia, so in FY2008, there are plans to scale up an existing scholarship program for students in these disciplines to attend training institutions in South Africa, with a requirement to return. In Kenya, an HIV fellowship program has been developed to train senior HIV program managers. In Vietnam, PEPFAR is working with the Hanoi School of Public Health to increase the number of health professionals receiving advanced degrees in public health and management. There has also been a significant increase in support for expanding HIV curricula in pre-service training programs. These efforts reflect the increase in resources dedicated to training of new doctors, nurses, clinical officers, laboratory technicians and pharmacists in HIV/AIDS. Task-shifting: While building cadres of new highly trained professionals is a long-term objective of PEPFAR and other development initiatives, that takes years and we do not have years to wait. As experts from PEPFAR and the WHO argued in an article published in the New England Journal of Medicine, policy change to allow task-shifting from more specialized to less-specialized health workers is the one strategy that will have the most significant and immediate effect on increasing the pool of health workers in resource-limited settings. Changing national and local policies to support task-shifting can foster dramatic progress in expanding access to HIV prevention, treatment, and care, as well as other health programs. The Emergency Plan supported WHO’s efforts to develop the first-ever set of task-shifting guidelines, released in January 2008. This continues and expands PEPFAR’s support for the leadership of its host country partners in broadening national policies to allow trained members of the community — including PLWHA — to become part of clinical teams as community health workers. Support for salaries: Along with support for training, supporting new highly-trained health professionals and task-shifting, PEPFAR supports the growing number of personnel necessary to provide HIV/AIDS services. To capture this support more comprehensively, in the FY2008 Country Operational Plans (COPs), PEPFAR country teams estimated the number of health care workers whose salaries PEPFAR is supporting. They reported support for over 111,000 workers (see Table 3), illustrating PEPFAR’s commitment. PEPFAR has worked to ensure that these positions are sustainable for the long term. In Kenya, for example, PEPFAR has reached an agreement with the Ministry of Health to incrementally absorb these personnel into the public health system, providing long-term sustainability while also allowing for rapid hiring and deployment. Examples of support for salaries in the focus countries include the following: Government sector: Namibia: PEPFAR supports the salaries of nearly all clinical staff doing treatment work and counseling and testing in the public sector.
Kenya: PEPFAR supports the Government’s hiring plan to train and deploy retired physicians, nurses and other health care workers for the public sector; 800 were deployed in 2007.   Ethiopia: PEPFAR supports the Government’s program to train 30,000 health extension workers in order to place two of these community health workers in every rural village; 16,000 have already been trained.   Côte d’Ivoire: PEPFAR supported the development of the Government’s plan to redeploy health workers from the south back to the north and west following the peace agreement. Non-government sector: Uganda: One of the largest HIV/AIDS service providers, TASO, has increased staff from 16 in the early 1980s to several thousand today, and PEPFAR supports salaries for nearly all of them.
	Building supply systems Procurement capacity is another key element of national health systems. PEPFAR’s Supply Chain Management System (SCMS) project strengthens the capacity of local systems to deliver an uninterrupted supply of high-quality, low-cost products that flow through a transparent and accountable system. SCMS’s activities include supporting the purchase of lifesaving ARVs, including low-cost generic ARVs; capacity-building for quantification of needs, safer storage and distribution systems, and effective stock and inventory control systems to avoid “stock outs”; drugs for care for PLWHA, including drugs for opportunistic infections such as TB; laboratory materials, such as rapid test kits; and supplies, including gowns, gloves, injection equipment, and cleaning and sterilization items. By pooling procurement across countries, SCMS is able to stabilize supply, plan for capacity expansion, and achieve economies of scale. In FY2007, 73 percent of antiretroviral drugs delivered through PEPFAR, and 93 percent delivered through SCMS, were generic formulations (See Table 4 and 5). By using generics, PEPFAR partners were able to save an estimated $64 million — a 46 percent reduction in cost if they had purchased only innovator drugs. Additionally, by augmenting and improving country supply chains, rather than replacing functioning systems, SCMS strengthens the capacity of health systems to deal with other health and development issues. These country supply chains are strengthened through the use of regional distribution centers, which distribute commodities in quantities that existing infrastructure can handle reliably and safely. Figure 14 shows the locations of these regional distribution centers in sub-Saharan Africa. Building data systems to improve programs Evidence-based programming depends on strong data. PEPFAR is addressing this need from many directions; the results will benefit not only PEPFAR programs but all programs. Surveillance and mapping PEPFAR support has enabled countries to better understand the dynamics of their epidemics. PEPFAR has supported Demographic and Health Surveys and AIDS Indicator Surveys in 30 countries, including Botswana, Côte d’Ivoire, Ethiopia, and Vietnam, helping to improve not only prevalence estimates — as demonstrated by the recent revision of UNAIDS global estimates mentioned previously — but also incidence data. Markers for incidence have been validated and are now being calibrated, and will be available for the field soon. These markers will improve evaluation of prevention programs and overall impact, creating tools that can strengthen not only PEPFAR programs but also those of others. PEPFAR is also supporting countries as they map the locations of treatment and care sites in order to identify regional gaps in service provision. Figure 15 shows a sample map that depicts treatment delivery sites in Ethiopia. Next generation of indicators Constant evaluation to improve programs must characterize all HIV/AIDS efforts, including those of PEPFAR. PEPFAR is thus working with a wide variety of stakeholders to update the performance measures used to evaluate programmatic progress. The new measures will move PEPFAR toward the challenging goal of measuring program outcomes and impacts. The continuum of indicators is depicted in Figure 16. Sharing lessons learned Public health evaluation and operations research Through Public Health Evaluations (PHE) — also called “implementation research” or “operations research” — PEPFAR is supporting research on strategic priority questions that can inform and change how PEPFAR and others deliver prevention, treatment and care programs. Because of its size and scope, PEPFAR offers unique opportunities to address and resolve issues related to the implementation of scientifically sound, cost-effective programs. PEPFAR is thus heightening its emphasis on these “big picture” questions. PEPFAR believes it can do better in this area than it has to date, and a process is under way to prioritize research questions, focus PHE resources and coordinate research activities across countries. In FY2007, approximately $46 million was directed toward PHE and operations research. Guidance to teams in PEPFAR focus countries suggests one to four percent as a reasonable spending range to support operations research in the COP planning process. This level is comparable to those of USG domestic HIV/AIDS service delivery programs. While there is much to learn, we also know how to save lives today. Spending more on research is thus not well justified in an implementation program. However, as noted above, we can do better at asking the important questions that will change how we — and others — implement programs to save more lives. International HIV/AIDS Implementers’ Meeting The Emergency Plan seeks to build the capacity of local people and organizations to evaluate their work and present their findings to their colleagues from around the world. In June 2007, the Emergency Plan convened an HIV/AIDS Implementers’ Meeting in Kigali, Rwanda. The meeting was the first to be co-sponsored by PEPFAR, the World Bank, the Global Fund, UNAIDS, UNICEF, and WHO, and was hosted by the Government of Rwanda. The Global Network of People Living with HIV/AIDS served as the official advisory group, helping to ensure representation of PLWHA as expert implementers. Nearly 1,600 implementers from 83 countries gave more than 540 scientific presentations on their programs, and the vast majority of the presenters were from severely affected nations in Africa, Asia, Eastern Europe, and Latin America. The presenters included representatives from governments and non-governmental organizations, including faith- and community-based groups, and the private sector.
	Building partnerships Expanding the circle of local partners An important part of systems-strengthening is PEPFAR’s support for local organizations, including host government institutions, organizations of PLWHA and faith- and community-based organizations. Review of annual COPs includes evaluation of efforts to increase the number of indigenous organizations partnering with the Emergency Plan. In FY2007, PEPFAR partnered with 2,217 local organizations — up from 1,588 in FY2004 — and 87 percent of partners were local. Reliance on such local organizations, while sometimes challenging, is essential for PEPFAR to fulfill its promise to partner with host nations to develop sustainable responses. As another step in the direction of sustainability, PEPFAR country programs may devote a maximum of eight percent of funding to a single partner (with exceptions made for host government partners, commodity procurement, and “umbrella contractors” for smaller organizations). This requirement is helping to expand and diversify PEPFAR’s base of partners, and to facilitate efforts to reach out to new partners, particularly local partners — a key to sustainability. The exception for umbrella contracts is based on a desire to support large organizations in mentoring smaller local organizations, supporting capacity- building in challenging areas such as management and reporting. PEPFAR has also worked with its international implementing partners to ensure that they have strategies to hand over programs to local organizations as those groups develop the capacity to work directly with the USG. New Partners Initiative On World AIDS Day 2005, President Bush launched the New Partners Initiative (NPI), part of PEPFAR’s broader effort to increase the number of local organizations, including faith- and community-based organizations (FBOs and CBOs), that work with the Emergency Plan. The first 23 NPI grants were awarded on World AIDS Day 2006, and a second round of 14 grants were awarded on World AIDS Day 2007. A third round will follow in 2008. Through NPI, PEPFAR is enhancing the technical and organizational capacity of local partners, and is working to ensure sustainable, high-quality HIV/AIDS programs by building community ownership. NPI supports organizations that have previously worked as PEPFAR subpartners— receiving PEPFAR funds through larger organizations — in graduating to prime partner status. Nearly half of NPI grantees to date had previously been PEPFAR sub-partners. Each grantee receives comprehensive technical and organizational support through NPI, including support for financial and reporting capacity, enabling them to compete not only for PEPFAR resources but also for grants and contracts from other sources of funding. Public-private partnerships Public-private partnerships (PPPs) are collaborative endeavors that combine public- and- private sector resources to accomplish HIV/AIDS prevention, care, and treatment goals. PPPs help ensure sustainability of PEPFAR programs, facilitate scale-up of interventions, and leverage private sector resources to multiply impact. In addition to an array of country-level PPPs and workplace programs with local private-sector entities, PEPFAR supported seven large-scale, multi-country PPPs in 2007. These include the “Phones for Health” partnerships with cell-phone manufacturers and technology-based companies to develop health-management and information systems for HIV/AIDS; the “PlayPumps” partnership with the Case Foundation to bring clean water to schools and clinics in HIV-affected areas; and a new partnership with Becton Dickinson and Company to deploy experts to train technicians and build laboratory capacity. Goals for future PPPs include advancing innovative HIV-prevention efforts; developing new gender-focused partnerships; supporting OVCs; and strengthening health systems, including improving human resource capacity. PEPFAR also remains dedicated to expanding workplace programs that provide HIV/AIDS prevention, treatment and care. Working with international partners It is important to note that the United States is not the only international partner of host nations. Other key international partners include: The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); the World Bank; United Nations agencies, led by the Joint United Nations Programme on HIV/AIDS (UNAIDS); the World Health Organization (WHO); other national governments; and — with growing commitment — the businesses and foundations of the private sector. All have vital contributions to make to the work of saving lives in the field. The Global Fund: The USG is the largest contributor to the Global Fund, having given over $2.5 billion since 2001, or about 30 percent of total contributions. USG representatives chair the Global Fund Board’s Finance and Audit Committee, and represent the USG on the Board’s Policy and Strategy Committee. Recent Board achievements that the USG had strongly supported include the hiring of a new Inspector General and the adoption of a disclosure policy for Inspector General documents; a requirement that grants track budgets and expenditures by program area; implementation of the new “Rolling Continuation Channel” for extended funding of high-performing grants; and re-tendering of the Local Fund Agent contracts with expanded requirements for oversight and accountability.
The USG also provides direct technical assistance to Global Fund grants that are experiencing implementation bottlenecks, using U.S. legislative authority to withhold up to five percent of contributions for this purpose. Such funds are used to improve institutional and program management; strengthen governance and transparency; strengthen procurement and supply-chain management; and improve monitoring and evaluation systems. In view of the close link between TB and HIV/AIDS, the USG also provides technical assistance funding to improve treatment for multi-drug resistant TB (MDR-TB), and to enhance the Advocacy, Communication and Social Mobilization (ACSM) components of country TB programs. The USG also provides funds for Global Fund technical assistance through the Roll Back Malaria international partnership, and through the three UNAIDS Technical Support Facilities in sub-Saharan Africa. PEPFAR country teams work closely with the Global Fund grant programs in-country. Embassy representatives sit on Global Fund Country Coordinating Mechanisms (CCMs) in 87 percent of PEPFAR countries that submit COPs or mini-COPs, and PEPFAR country programs have allocated about $10 million annually to technical assistance for Global Fund grants. To promote deeper coordination, the USG has entered into Memoranda of Understanding (MOUs) in several countries. These documents bring together Ministries of Health, PEPFAR, and the Global Fund to clarify collaboration and partnership activities, particularly in the area of drug procurement for antiretroviral treatment. UNAIDS: The United States was a driving force behind the creation of UNAIDS’ “Three Ones” principles for support of national HIV/AIDS leadership, and continues to support UNAIDS’ work in a variety of ways. The USG is one of the largest contributors to UNAIDS’ all-voluntary budget each year, having provided over $30 million in FY2007. The USG was elected Vice Chair of the UNAIDS Programme Coordinating Board (PCB) in 2007, and will assume the Chair in 2008. This will give the USG the opportunity to work with UNAIDS to highlight critical priorities for the international community’s response, such as TB/HIV co-infection, reforms to maximize UNAIDS’ effectiveness at the country level, and guidance for leaders as they convene in June 2008 at the U.N. General Assembly for a High-Level Meeting on HIV/AIDS. WHO: WHO provides evidence-based technical leadership, sound management, and as norms and standards within the international public health response to HIV/ AIDS. As a WHO Member State with considerable expertise in HIV/AIDS, the USG has been intimately involved in formulating HIV/AIDS-related policy and guidelines, and partnering with WHO and host countries to adapt and implement such policies. The USG provides not only technical expertise but also financial support to WHO in multiple areas including OVCs, male circumcision, laboratory research, PMTCT, and counseling and testing. Such support in FY2007 totaled more than $14 million, including the USG portion of funds provided to WHO from UNAIDS’ Unified Budget and Workplan.
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