II. Accountability: Report on PEPFAR Partnerships for Prevention, Treatment and Care
Partnerships for Care
PEPFAR supports host nations’ wide-ranging programs to meet the needs of OVCs affected by the pandemic, as well as PLWHA. Figure 24 shows that, as of September 30, 2007, PEPFAR supported care for 6.6 million people, including approximately 2.7 million OVCs and nearly four million PLWHA. In FY2007, PEPFAR provided 30.9 percent of focus country program resources, or $906.5 million, in support of care (including $223 million for counseling and testing programs).
Orphans and Vulnerable Children (OVCs)
Along with the tragedies individual children can experience, the increasing needs of millions of OVCs are severely straining the economic and social resources of families, communities, and entire societies. Inadequate care and protection of children can result in increased social disorder, with profound implications for future political stability. Orphans are especially vulnerable to recruitment by gangs and armed groups, and to exploitation as victims of child labor or human trafficking.
Without education and vocational training, the skills young people need for economic independence can be lost, potentially condemning them — and ultimately their whole society — to continued poverty. One World Bank simulation of the economy of South Africa — a nation with a relatively well-developed economy — found that, without effective intervention to meet the needs of OVCs, by 2020 the average household income will be less than it was in 1960, and will continue to decline thereafter.
OVCs themselves face elevated risk of HIV infection, and PEPFAR supports efforts to expand prevention and HIV counseling and testing, which are an entry point to care and treatment. In addition, meeting the needs of children with HIV also can serve as a way to build relationships with their caregivers, who may themselves be in need of care. Female orphans and vulnerable children face a disproportionate level of risk for exploitation, abuse, and HIV infection. This is especially true for pre-adolescent and adolescent girls who have become heads of households. In economically hard-pressed families, girls are often first to leave school to provide child care, assume extra domestic chores, take on the difficult care of ill parents or relatives, and enter the informal work sector to contribute to family income.
In FY2007, the Emergency Plan provided more than $289.2 million in funding for OVC activities in the focus countries. This represented 10.2 percent of program funding, and supported care for more than 2.7 million OVCs.
As noted, the best way to care for children in countries with a high HIV burden is to provide prevention and treatment to their parents to keep them alive in the first place. Even the best OVC program can never substitute for a parent. Recognizing the central importance of preserving families, PEPFAR focuses on strengthening the capacity of families to protect and care for OVCs by prolonging the lives of parents and caregivers. PEPFAR supports efforts — many by community- and faith-based organizations — to provide both immediate and long-term therapeutic and socio-economic assistance to vulnerable households. Children are often deeply affected by their HIV-infected parents and community members through loss of care, income, nutritional food, and schooling. For those who are orphaned or made vulnerable, care activities emphasize strengthening communities to meet the needs of OVCs, supporting community-based responses, helping children and adolescents meet their own needs, and creating a supportive social environment to ensure a sustainable response. PEPFAR recognizes the urgency of addressing these growing needs by supporting children’s and adolescents’ growth and development, so they become healthy, stable, and productive members of society. Community and faith-based peer support can be crucial for growing children and adolescents who are faced with both the normal challenges of growing up and heavy economic, psychosocial, and stigma burdens.
The Emergency Plan supported training or retraining for approximately 214,900 individuals in caring for OVCs, promoting the use of time- and labor-saving technologies, supporting income-generating activities, and connecting children and families to essential health care and other basic social services, where available.
PEPFAR has partnered with host countries to scale up programs for children affected by HIV/AIDS more significantly than has ever been attempted previously, yet ensuring the quality of these rapidly growing programs is also essential. For the first time in FY2007, PEPFAR sought to improve OVC program quality by requiring partners to track and report on how many of seven key interventions they provide; of those OVCs receiving direct support, nearly half received three or more of the following services:
- Food and Nutritional Support: Besides directly providing needed food and nutrition, programs leverage support from other international or host country partners and work for more sustainable solutions, such as gardens.
- Shelter and Care: The HIV/AIDS epidemic overloads impoverished communities to the point where many children are left without suitable shelter or care. Children who find themselves without a caregiver become highly vulnerable to abuse and stunted development. Given the number of OVCs, particularly in sub-Saharan Africa, and their complex needs, the most effective responses place families, households and communities at the center of interventions.
- Protection: Programs confront the reality of stigma and social neglect faced by OVCs, as well as abuse and exploitation, including trafficking, the taking of inherited property, and land tenure.
- Health Care: There are three areas related to health that are addressed by OVC programs: meeting general health needs of OVCs by providing access to primary health care; health care for HIV-positive children; and guidance for the prevention of HIV.
- Psychosocial Support: Children affected by HIV/ AIDS generally suffer anxiety and fear during the years of parental illness, then grief and trauma with the death of a parent. Cultural taboos surrounding the discussion of HIV/AIDS and death often compound these problems. Programs provide children with support that is appropriate for their age and situation, and recognize that children and adults often respond differently to trauma and loss.
- Education and Vocational Training: Research demonstrates that education can leverage significant improvements in the lives of OVCs. In addition to learning, schools can provide children with a safe, structured environment; the emotional support and supervision of adults; and the opportunity to learn how to interact with other children and develop social networks. Education and vocational training are keys to employability and can also foster a child’s developmentally important sense of competence.
- Economic Opportunity/Strengthening: OVCs and caretakers often experience diminished productive capacity and cash resources necessary for household purchases. Economic strengthening is often needed for the family/caregivers to meet expanding responsibilities for ill family members or to welcome OVCs into the household.
PEPFAR has also worked with its partners to develop a Child Status Index to help the programs ensure that these services result in the improved well-being of the children served.
PEPFAR activities seek to provide OVCs access to other core interventions, beyond traditional health partners and networks, by reaching out to new partners to ensure a coordinated, multi-sectoral approach. Because of the complex array of needs of OVCs, only some of which are directly addressed by prevention, treatment, and care programs, it is essential to coordinate with providers of resources that address the full range of issues. This coordination must take place among international partners and other providers of resources at both the national and community levels. For this reason, as described above, PEPFAR augments its own OVC programs by “wrapping around” those of others that address critical vulnerabilities in the areas of food and nutrition and education. For information on PEPFAR’s activities in the areas of education and nutrition for OVCs, please see the sections on “Linking PEPFAR and Education” and “Linking PEPFAR and Food and Nutrition” above.
Care and Support for People Living With HIV/AIDS
In FY2007, the Emergency Plan committed approximately $702 million for care and support for PLWHA in the focus countries, nearly half the PEPFAR total to date of $1.484 billion. These resources represented 13.9 percent of program funding, supporting care for nearly 4 million people.
Within the network model of care, PEPFAR supports a variety of interventions at different levels (including home-based care programs, as well as health care sites that deliver services). In addition, support is provided to fill specific gaps in national training, laboratory systems, and strategic information systems (e.g., monitoring and evaluation, logistics, and distribution systems) that are essential to the effective roll-out and sustained delivery of quality care.
Care and support for PLWHA helps ensure that they receive treatment at the optimal time, as soon as possible after they become eligible and before serious opportunistic illnesses set in. Regular evaluation for treatment eligibility is thus an important element of success once treatment starts. Second, care programs are a platform for “prevention with positives,” providing PLWHA with information, condoms and other needed support for prevention.
Finally, care helps keep PLWHA healthy and free of OIs, delaying the need for treatment. Care can include pain and symptom management, treatment and prevention of TB and other OIs, social, spiritual and emotional support, and compassionate end-of-life care. PEPFAR supports the development and dissemination of “preventive care packages,” adapted to local circumstances, for children and adults living with HIV. These packages may include a number of interventions, such as cotrimoxazole prophylaxis, water purification systems, and insecticide-treated nets, to keep HIV-positive persons healthy and delay the need for treatment. Like many best practices developed by the Emergency Plan, these advances in the area of care for OVCs and PLWHA have the potential to have a wide impact beyond PEPFAR-supported programs. PEPFAR is working to disseminate them broadly.
Tuberculosis and other opportunistic infections
PEPFAR has scaled up its support for national efforts to provide high-quality care for OIs related to HIV/AIDS. Especially important in this area is care for HIV/TB coinfection, the leading cause of death among HIV-positive people in the developing world. From FY2005 to FY2007, PEPFAR increased funding for HIV/TB from $26 million to $131 million, supporting TB treatment for over 367,000 HIV-infected patients in FY2007. Through its FY2007 contributions and support to the Global Fund, PEPFAR provided an estimated $123 million in additional funding for TB programs around the world.
PEPFAR-supported HIV care and treatment programs are a platform to further HIV/TB collaborative activities. Important interventions supported by PEPFAR include screening for TB among clients in care and treatment, TB infection control and promoting a safe environment in which services are delivered, access to antiretroviral treatment for co-infected clients, and monitoring and evaluation. PEPFAR supports a variety of efforts to co-locate TB and HIV services as an important strategy to increase access to services for co-infected persons.
In collaboration with WHO, PEPFAR supported a program in Rwanda through which more than 88 percent of TB patients are now tested for HIV, 61 percent of co-infected patients receive cotrimoxazole preventive therapy, and 36 percent of TB/HIV patients have accessed antiretroviral treatment. In Kenya, approximately 30,000 TB patients benefited from joint PEPFAR-WHO support, HIV testing increased from 41 percent to 78 percent, uptake of cotrimoxazole increased from 39 percent to 85 percent, and antiretroviral treatment uptake from 19 percent to 33 percent.
The Emergency Plan supports governments and nongovernmental organizations, including community- and faith-based organizations, to conduct intensified TB case-finding among PLWHA at each encounter to ensure early diagnosis and treatment of tuberculosis. PEPFAR also supports host country governments to strengthen their TB lab capacity by implementing an external quality assurance system for sputum smear microscopy and establishing liquid-culture capacity to promote rapid diagnosis of TB, including smear-negative disease among HIV-infected patients.
In 2007, PEPFAR accelerated programming to combat the emerging threat of Extensively Drug-Resistant TB (XDRTB). Activities include systems-strengthening, improving laboratory infrastructure for culture and drug susceptibility testing, TB infection control, and, perhaps most importantly, ongoing efforts to strengthen national TB programs’ capacity to carry out basic DOTS programs to reduce the spread of new drug-resistant TB.
Linkages with care programs
The section above on “Linking PEPFAR and Food and Nutrition” includes a discussion of PEPFAR’s efforts in this area. As noted, in FY2007 PEPFAR supported food and nutritional supplementation for 332,000 through OVC programs, 50,000 through PMTCT programs, and 20,000 through care and treatment. The sections on “Linking PEPFAR and Education” and “Linking PEPFAR with the President’s Malaria Initiative and the Millennium Challenge Corporation” address extensive efforts in those areas.
PEPFAR also supports a variety of economic-strengthening programs to address the prevention, treatment and care needs of PLWHA and OVCs. These programs enable people infected and affected by HIV/AIDS to provide for themselves and their families with dignity; strengthen the ability of communities and families to look after OVCs; give adolescent OVCs the opportunity to support themselves and, in many cases, their younger siblings; and empower women and girls to avoid risky behavior that can lead to HIV infection.
Counseling and Testing
Knowing one’s status provides a gateway for critical prevention, treatment, and care. Millions of people must be tested in order for PEPFAR to meet its ambitious prevention, treatment, and care goals. As noted above, PEPFAR programs have worked to ensure that counseling and testing is targeted to those at increased risk of HIV infection — such as TB patients and women seeking PMTCT services. PEPFAR has estimated that if countries appropriately target counseling and testing and if health care providers offer counseling and testing in routine encounters, at least 30 million people will need to be tested in order for PEPFAR to meet its 2-7-10 goals. To the extent counseling and testing is not well-targeted, the number who must be tested in order for PEPFAR to meet its goals will be correspondingly higher. Table 18 shows achievements in FY2007. PEPFAR invested approximately $223 million in counseling and testing in settings other than PMTCT in FY2007, or about 7.8 percent of program funding in the focus countries.
Table 19 shows cumulative progress achieved to date by PEPFAR-supported programs. These programs have already exceeded the target of 30 million, supporting more than 33 million counseling and testing encounters through FY2007. Among these, nearly 10.1 million encounters were with women seeking PMTCT interventions, a key population to target.
A key barrier to the universal knowledge of serostatus is the lack of routine testing in medical settings, including TB and STI clinics, ANCs, and hospitals. In many focus countries, studies have found that 50 to 80 percent of hospital and TB patients are infected with HIV; many of these patients are in urgent need of treatment. PEPFAR has worked with host nations to build support for the model of routine “opt-out” provider-initiated testing, where, in selected health care settings, all patients are tested for HIV unless they refuse. Most PEPFAR focus countries have now adopted opt-out testing policies, but without successful implementation of opt-out testing, it will be impossible to achieve success in prevention, treatment and care. PEPFAR has also contributed to WHO’s development of guidelines for counseling and testing in health care settings.
Another key policy trend in many nations that PEPFAR has supported is in favor of the use of rapid HIV tests; use of rapid testing improves the likelihood that those who are tested will actually receive their results. All of the focus countries now have policies supporting the use of rapid tests, though opportunities for improvement of implementation remain.
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