II. Accountability: Report on PEPFAR Partnerships for Prevention, Treatment and Care

	Partnerships for Prevention The world cannot defeat this pandemic through treatment and care alone. The most recent UNAIDS report estimates that there were approximately 2.5 million new HIV infections in 2007, down from 2.7 million in 2006. This is a welcome trend, but at this level, new infections still far outpace the world’s ability to add people to treatment. The best approach to treatment, care and all the other challenges posed by HIV/AIDS is to prevent infection in the first place so that people do not need HIV treatment or care. Without effective prevention, the growing number of people in need of treatment and care — and the growing number of OVCs — will overwhelm the world’s ability to respond and to sustain its response. Recognizing this, the Emergency Plan supports the most comprehensive, evidence-based prevention program in the world, targeting interventions based on the epidemiology of HIV infection in each country. In the focus countries in FY2007, PEPFAR provided $601 million to support prevention activities that focus on sexual transmission, mother-to-child transmission, the transmission of HIV through unsafe blood and medical injections, and male circumcision. This investment represented 21 percent of program funding in the focus countries; if counseling and testing counted as prevention, this share increases to 29 percent. PEPFAR also integrates new prevention methods and technologies as evidence is accumulated and normative guidance provided. As noted above, in recent years the evidence of declining HIV prevalence and incidence as a result of changes in sexual behavior has grown significantly. UNAIDS’ has stated that “this reduction in HIV incidence likely reflects natural trends in the epidemic as well as the result of prevention programmes resulting in behavioral change in different contexts.” This finding reinforces the importance of comprehensive support for sexual behavior change, and provides much-needed hope for HIV prevention. But while this is undeniably good news, it cannot be allowed to produce complacency. In many cases, programs are still using prevention techniques developed 20 years ago. It is important for prevention activities to enter the 21st century, to use techniques and modalities that have been developed to change human behavior, especially those developed in the private sector for commercial marketing.
Combination prevention There is also a clear need for focused and concentrated prevention efforts that mirror progress in treatment. Just as combination therapy revolutionized treatment, combination prevention is needed to revolutionize behavior change programs. Combination prevention includes using many different modalities to affect behavior, along with geographic concentration of those different modalities to match the epidemiological, social and cultural drivers of transmission. Wherever people are, prevention programs must be there to meet and empower them at every turn with appropriate knowledge and skills. For example, many youth listen to faith leaders, while others don’t. Many youth hear prevention messages in church or in school, but then hang out with their friends and hear conflicting messages. Many have no access to either school or church. Prevention programs need to blanket geographic areas with varied prevention modalities, so that all the youth hear the messages and can change their behavior accordingly. As part of this effort to implement innovative prevention programs, while evaluating their impact, we are developing future-leaning public-private partnerships for combination prevention. Part of this effort includes “modularizing” successful prevention programs so that the components found to be most effective and easy to transfer to other geographic areas can be rapidly replicated, adapted, and scaled up. As another component of combination prevention, we are identifying populations for which safe male circumcision is especially promising and prioritizing service delivery to them within a comprehensive prevention package. We are creating effective approaches for older populations, including discordant couples, and implementing them in the same geographic locales as the youth programs. Effectively reaching these populations demands not only the use of sexual behavior change messages and biomedical interventions such as male circumcision, but also work that is outside the traditional realm of public health, such as gender, education and income-generation programs. We have made great strides to provide both linkages and direct interventions in these areas, but we also need to evaluate these combination programs to know how best to do them. Some things might be good for general development, but if they do not prevent infections in a significant way, they are the purview of other health and development programs, not those of PEPFAR.
	Prevention of Sexual Transmission Most of the focus countries have generalized epidemics, meaning that HIV infection is not concentrated in specific and identifiable groups. Long before PEPFAR was initiated, many nations with generalized epidemics had already developed their own national HIV prevention strategies that included the “ABC” approach to behavior change (Abstain, Be faithful, correct and consistent use of Condoms where appropriate). The new data — from time periods that pre-date PEPFAR scale-up — link adoption of all three of the ABC behaviors to reductions in prevalence. Figure 17 shows the changes in HIV prevalence and sexual risk behavior that took place in Zimbabwe during the late 1990s and earlier part of this decade. Learning from the evidence, PEPFAR will continue to support all three elements of the evidence-based ABC strategy in ways appropriate to the epidemiology, social and cultural context, and national strategy of each host nation. Funding for sexual transmission prevention in the focus countries in FY2007 was $345 million, or 12 percent of all program funding. In focus countries during FY2007, approximately 57.6 million people were reached by community outreach programs promoting ABC and related prevention strategies. This is a slight decrease from FY2006 results. In part, this may reflect increased emphasis on behavior change counseling, which is more time-intensive than other forms of community outreach, but is key to ensuring sustained behavior change and helps make other forms of outreach more effective. Improved data quality to reduce the risk of double-counting, a change in the way that PEPFAR programs count people reached through large group settings, a reduction in the number of condom delivery outlets in Kenya, and delayed implementation in Namibia also contributed to the decline.
	Along with its programs that teach correct and consistent condom use for those who are sexually active, the USG seeks to ensure an adequate supply of condoms. The USG has supplied nearly 1.9 billion condoms worldwide from 2004 through 2007, lending support to comprehensive ABC approaches based on the epidemiology of each country. It is important to note that prevention of sexual transmission is chronic disease management — just as treatment and care are. An individual must be reached at an early age to have maximum impact on behavior as the person grows older, and prevention messages must change in an age-appropriate way as risk behavior changes. Prevention programs span from at least 10 years of age to when a person is beyond risk, i.e. when they are no longer sexually active. Until that time, efforts must continue unabated to reinforce and maintain safe and personally responsible behavior. For this reason, data on the reach of behavior- change messages and condom supply are provided both for FY2007 and cumulatively from FY2004 through FY2007. Elements of ABC interventions ABC programs are more complex than the simple acronym suggests, because changing human behavior is a uniquely difficult undertaking. Achieving ABC requires significant cultural changes. Reaching children at an early age is key if they are to delay sexual debut and limit their number of partners. It is essential to rapidly expand life skills programs for youth because of the generational impact they can have — influencing a 10 year old’s future behavior is far easier than changing a 25 year old’s settled behavior. Behavioral impact from programs for children may not immediately be apparent, because programs must work to influence future behavior rather than immediate behavior. Yet we must be patient and persistent — we are only four years into PEPFAR’s partnerships for a generational approach to prevention. ABC also includes changing gender norms. Partnering with children’s parents and caregivers, supporting their efforts to teach children to respect themselves and each other, is the best way to promote gender equality. In order for the ABC approach to be effective it must address the gender dynamics that affect sexual decision-making and strive to reduce sexual coercion, violence and rape. Through support for delayed sexual debut, secondary abstinence, fidelity to a single partner, partner reduction and correct and consistent condom use, ABC contributes to changing unhealthy cultural gender norms. It is essential to reduce stigma against PLWHA — and also reduce stigma against those who choose healthy lifestyles. On the other hand, we must identify — and even stigmatize — cross-generational sex, including the phenomenon of older men preying on young girls, and sexual violence. We must also intensify our efforts to reduce stigma against women and girls who are victims of sexual violence and strengthen services for them, ensuring that HIV post-exposure prophylaxis (PEP), related medical care and psycho-social support are accessible to all survivors. Recent PEPFAR-supported efforts include a growing number of interventions with PLWHA. The adoption of healthy living and reduction in risk behaviors among HIV-positive people leads to a substantial improvement in quality of life and a reduction in HIV transmission rates. These prevention efforts aim to mitigate the spread of HIV to sex partners, injecting drug use partners, and infants born to HIV-infected mothers, as well as protect the health of infected individuals. For example, in Uganda, a collaborative provider training initiative involving nongovernmental organizations, community groups, and the Uganda Ministry of Health was developed to build capacity of service providers to deliver effective HIV counseling for PLWHA. Organizations and networks of PLWHA worked together to create prevention messages on a variety of topics, including: partner testing, status disclosure, socio-cultural barriers to prevention, HIV discordance, condom use, and managing the “new lease on life” challenges after antiretroviral treatment, including relationships, marriage and child-bearing. Knowing your epidemic While ABC programs must be comprehensive to be effective, they also must be tailored to the contours of the epidemic in its specific time and place. ABC behavior change must undeniably be at the core of prevention programs, but one size does not fit all. This is why PEPFAR takes different approaches, depending on whether a country has a generalized and/or a concentrated epidemic. The existing directive that 33 percent of prevention funding be spent on abstinence and faithfulness programs is applied across the focus countries collectively, not on a country-by-country basis — and certainly not to countries with concentrated epidemics. In countries with concentrated epidemics where, for example, 90 percent of infections are among persons in prostitution and their clients, the epidemiology dictates a response more heavily focused on B and C interventions. For this reason, PEPFAR changed its FY2008 guidance to release countries with concentrated epidemics — defined as a prevalence rate below one percent — from the directive that abstinence and faithfulness programs receive at least one-third of prevention resources. (It was possible to do this because compliance with the directive is assessed for PEPFAR as a whole.) In countries with prevalence above one percent where PEPFAR teams believe meeting the abstinence and faithfulness directive would not make epidemiological sense, programs may also submit a justification explaining why they have chosen not to meet the requirement. PEPFAR has never rejected such a justification, and the number submitted by the focus countries has grown from 8 in FY2006 to 11 each in FYs 2007 and 2008. Illustrating the importance of knowing one’s epidemic and responding accordingly, a story on PBS’ “NewsHour with Jim Lehrer” depicted the varied challenges facing PEPFAR in Tanzania in tailoring prevention interventions to address that country’s situation. The complete story can be found at http://www.pbs.org/newshour/bb/ africa/july-dec07/aids_11-30.html. Addressing multiple concurrent partnerships and discordant couples For older adolescents and adults who are sexually active, ABC includes reducing casual and multiple concurrent partnerships, which can rapidly spread HIV infection through broad networks of people. Multiple concurrent partnerships are common in many countries hardest-hit by HIV, and PEPFAR supports programs that emphasize the importance of partner reduction toward the goal of faithfulness to a single HIV-negative partner.
Discordant couples are another important focus for intensive HIV prevention interventions. Figure 19 contains data presented at the 2007 HIV/AIDS Implementers Meeting. In this sample (in which the overall percentage of infections occurring among married people is comparable to the percentage of the population that is married), half of new HIV infections among married people occurred within HIV-discordant marriages. Given the large number of infections occurring through these discordant partnerships, PEPFAR supports efforts to reach discordant couples through a range of interventions that include: couples HIV testing; behavior change counseling, including on the importance of being faithful and using condoms correctly and consistently; and ensuring that the HIV-infected partner is linked to appropriate care and treatment services, which can lower the likelihood of transmission. Adopting new prevention interventions The Emergency Plan is also ready to support nations that adopt new prevention technologies once clinical trials are complete and guidance from a normative agency, such as WHO or UNAIDS, is available. In 2006, studies showed that medical male circumcision can significantly reduce the risk of HIV transmission for men. Once WHO issued normative guidance on the use of circumcision for HIV prevention in 2007, PEPFAR, working closely with partner countries, has aggressively pursued implementation. In FY2007, PEPFAR allocated approximately $16 million for activities related to male circumcision, up from approximately $600,000 in FY2006. As of December 2007, PEPFAR is supporting male circumcision activities in 11 countries. PEPFAR country teams have supported host country governments in the establishment of training facilities in Zambia and Kenya, where PEPFAR is also partnering with the Gates Foundation. Situational assessments are underway in South Africa, Malawi, and Lesotho; male circumcision service delivery has started or will start shortly in Swaziland, Kenya, Zambia, and Uganda; and planning for service delivery is under way in Mozambique, Rwanda, Namibia and Botswana. Total investments are expected to rise to at least $30 million in FY2008. Roll-out presents significant challenges, including the need for human resources and appropriate counseling as well as the danger of risk compensation (in which men engage in more risky behavior because they believe they are completely protected by circumcision). PEPFAR partners are making it clear that male circumcision is not a silver bullet, but rather one part of a broad prevention arsenal. The USG is initiating male circumcision programs only at the written request of host country governments and incorporating ABC behavior change education into the counseling that men receive along with circumcision. PEPFAR is rolling programs out as rapidly as possible, beginning in areas of high HIV prevalence and with those at greatest risk of becoming infected, such as discordant couples in which the woman is HIV-positive, for largest impact. There is also a need to develop training and quality-assurance programs to ensure that activities are achieving maximum effectiveness. As other new prevention strategies, such as microbicides or pre-exposure prophylaxis, are identified by normative agencies as effective prevention interventions, PEPFAR will support them as part of a comprehensive prevention strategy. Thanks to PEPFAR’s wide network of care and treatment sites, PEPFAR country teams will be able to implement these methods rapidly whenever they become available — demonstrating again the value of integrated programs.
	Addressing gender issues PEPFAR fully integrates gender into its prevention, care, and treatment programs, recognizing the critical need to address the inequalities between women and men that influence sexual behavior and put women at higher risk of infection — as well as those that create barriers to men’s and women’s access to HIV/AIDS services. Additionally, the Emergency Plan supports five key crosscutting gender strategies that are critical to curbing the HIV/AIDS epidemic, ensuring access to quality services, and mitigating the consequences of the epidemic. These strategic focus areas are given below in Table 8. Activities in support of these focus areas are monitored annually during the Country Operational Plan (COP) review process. In FY2007, a total of $906 million was dedicated to 1,091 activities that included interventions to address one or more of these gender focus areas; in FY2008, the total is expected to rise to approximately $1.03 billion. In 2007, three special gender initiatives were launched in nine countries to intensify program efforts in three of these focus areas: scaling up evidence-based programs to address male norms and behaviors; strengthening interventions for victims of sexual violence, including PEP; and reducing inequities that fuel girls’ vulnerability to HIV/AIDS. Gender issues are central to many HIV prevention programs, particularly those focused on youth. As young people are taught through the ABC approach to respect themselves and respect others, they learn about gender equality. While gender equity does not directly reduce HIV transmission, the ABC approach is particularly important for the protection of women and girls. By teaching delayed sexual debut, secondary abstinence, fidelity to a single partner, partner reduction, and correct and consistent condom use, ABC interventions can address unhealthy cultural gender norms among boys, girls, men, and women. A paper published in Science in 2006, for example, showed that the proportion of men reporting a casual sexual partner over the past month dropped by 49 percent between 1998 and 2003 in eastern Zimbabwe. In Kenya, the percentage of men aged 15-49 reporting multiple partners in the last year dropped from 30 percent in 1998 to 17 percent in 2003. These changes are positive developments in the fight against HIV/AIDS, and they also represent increased empowerment of women in controlling their sexual encounters. PEPFAR-supported prevention, treatment and care programs address gender issues in other ways as well. They provide information on the harmful effects of violence against women, cross-generational sex, and transactional sex, as well as the importance of inheritance rights and women’s access to productive resources. For example, PEPFAR supports the Kenya Federation of Women Lawyers, which provides legal advice to PLWHA concerning rape, sexual assault, and property and inheritance rights. In South Africa, PEPFAR supports the Men as Partners project, which tailors behavior change interventions to redefine masculinity and strength in terms of men taking responsible actions to prevent HIV infection and gender-based violence. In Namibia, PEPFAR supports the Village Health Fund Project, a microenterprise program that provides vulnerable populations, such as widows and grandmothers who care for orphaned grandchildren, with start-up capital for income-generating projects. Such gender approaches are not in conflict with ABC — they are integral to it.
PEPFAR also supports linkages between HIV/AIDS and voluntary family planning programs, including those supported through USAID’s Office of Population and Reproductive Health (PRH). Along with providing linkages to family planning programs for women in HIV/AIDS treatment and care programs, PEPFAR also works to link family planning clients with HIV prevention, particularly in areas with high HIV prevalence and strong voluntary family planning systems. Voluntary family planning programs provide a key venue in which to reach women who may be at high risk for HIV infection. PEPFAR supports the provision of confidential HIV counseling and testing within family planning sites, as well as linkages with HIV care and treatment for women who test HIV-positive. Ensuring that family planning clients have an opportunity to learn their HIV status also facilitates early up-take and access to PMTCT services for those women who test HIV-positive. PEPFAR’s efforts remain focused on HIV/ AIDS prevention, treatment and care, complementing the efforts of USAID/PRH programs and other partners. Injecting Drug Users Substance use, including injection drugs, is a major means of spreading HIV in many parts of the world. According to UNAIDS, outside of sub-Saharan Africa injecting drug use comprises just under one-third of global HIV transmission. Injecting drug users (IDUs) everywhere are at great risk for infection with HIV, through contaminated needles and syringes, risky sexual practices, and higher rates of sexually transmitted infections (STIs). In PEPFAR focus countries, all of which but Vietnam have generalized epidemics, substance use plays a much smaller role in HIV transmission. PEPFAR therefore invests the most resources in the primary drivers of the epidemic, which in focus countries other than Vietnam are sexual and mother-to-child transmission. At the same time, PEPFAR has invested in focus country and other bilateral programs to establish the political support, policy frameworks, and programmatic experience to scale up HIV/AIDS prevention, treatment and care for IDUs. In Vietnam, PEPFAR resources — approximately $66 million in FY2007 — are focused primarily on addressing the IDU-driven HIV epidemic. Additional efforts are under way to map IDU communities in other PEPFAR focus countries, such as Mozambique, Kenya, and South Africa, and to explore their role in the HIV epidemics of these countries. PEPFAR supports three primary approaches to HIV prevention among IDUs: 1) tailoring HIV prevention programs to substance abusers; 2) supporting substance abuse therapy programs for HIV-positive individuals — and in certain cases in pilots for HIV-negative individuals — as an HIV prevention measure; and 3) offering HIV-positive drug users a comprehensive HIV/AIDS treatment program to reduce the risk of transmission. An important emerging strategy that PEPFAR supports for HIV prevention is medication-assisted therapy (MAT), also known as substitution therapy, for IDUs. PEPFAR supports the use of MAT for HIV-positive and HIV-negative IDUs, focusing on HIV-positive IDUs because they represent an especially high-risk population. They pose risk for transmission of HIV to HIV-negative individuals — including other IDUs — and for fostering drug resistance if they are not adherent to their antiretroviral treatment. Regardless of their serostatus, capacity for MAT interventions for IDUs is extremely limited in PEPFAR countries, so prioritizing interventions for HIV-positive individuals is critical. However, where capacity allows it, PEPFAR has begun to pilot HIV prevention programs that include preventing and treating injecting drug use in HIV-negative individuals. PEPFAR has supported MAT globally by working first with governments to develop the political acceptance and national policies to permit MAT interventions to take place. However, because the IDU population is heavily stigmatized globally, MAT interventions are controversial, and not all countries have passed enabling legislation. A significant breakthrough occurred in 2006; with strong PEPFAR support, Vietnam changed its five-year national HIV/AIDS strategy and passed HIV legislation to legalize MAT for IDUs. PEPFAR responded by supporting the development of plans for launching pilot MAT centers in rural and urban sites in several provinces, to serve HIVpositive and -negative clients. Prevention of Mother-to-Child Transmission UNAIDS estimates that 420,000 children under the age of 15 became infected with HIV/AIDS in 2007, down from 460,000 in 2001. Approximately 90 percent of these infections were due to mother-to-child transmission. Prevention of mother-to-child transmission (PMTCT) is a key element of the prevention strategies of host nations, and PEPFAR is supporting their efforts. The Emergency Plan has provided support for host nations’ PMTCT interventions for women during approximately 10 million pregnancies to date. Of these, over 827,000 women were determined to be HIV-positive and received preventive antiretroviral drugs (ARVs), preventing an estimated 157,000 infections of newborns to date. As shown in Table 9, PEPFAR provided $195 million in support of PMTCT programs in FY2007, or 6.9 percent of the total program funding in the focus countries.
	As Table 10 indicates, access to vital ANC interventions varies across the focus countries. As a key element of its support for comprehensive programs, the Emergency Plan supports host governments’ and other partners’ efforts to provide PMTCT interventions, including HIV counseling and testing, for all women who attend ANCs. Key obstacles to successful scale-up of PMTCT programs that PEPFAR is working to address include: 1) failure to adopt and fully implement “opt-out” provider-initiated counseling and testing; 2) lack of integration as a basic part of maternal and child health care; 3) difficulties extending coverage to peripheral and rural sites; and 4) challenges in developing effective linkages with HIV care and treatment services. As shown in Table 10, many nations have made significant progress in reaching pregnant women with PMTCT interventions with PEPFAR support in the last four years, often building on programs that pre-dated PEPFAR. In other countries, progress has been slower, and the Emergency Plan is supporting these nations in redoubling efforts to close the gap. When comparing results from the first year of PEPFAR in FY2004 to FY2007, all countries have scaled up, and most have dramatically improved availability of PMTCT interventions to pregnant women. Nations have sought to ensure that all women receive the option of an HIV test through pre-test counseling during pregnancy (or at or after delivery, if they do not seek care before delivery). By promoting the routine, voluntary offer of HIV testing — so that women receive testing unless they opt out — host nations have increased the rate of uptake among pregnant women from low levels to around 90 percent at many sites. Adoption and effective implementation of opt-out testing, rapid testing, and other essential policy changes, is essential for success. For further information on policies relating to HIV testing, please see the section on Counseling and Testing. Prevention of Medical Transmission In FY2007, PEPFAR provided approximately $61 million for medical transmission prevention activities in the focus countries, or 2.1 percent of program funds. This included direct support for 4,589 blood-safety service outlets or programs, as well as broader efforts to strengthen blood service management, commodity procurement, infrastructure, and national policies. With Emergency Plan support, 11 of the PEPFAR focus countries can now meet 50 percent of their annual demand for safe blood — up from just four of the focus countries when PEPFAR started. Seven of these 11 countries are now meeting two-thirds of their annual demand. In order to build capacity for a sustainable response into the future, PEPFAR also supported training or retraining for 7,558 people in blood safety and 78,000 in medical injection safety in 31 countries worldwide, as well as providing commodities for safe medical injections.
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