“[P]eople who know they can be treated are more likely to seek testing... And we’re working with our partners to expand compassionate care - especially for the millions of children made orphans by this cruel disease.”
-- President George W. Bush,
World AIDS Day December 1, 2005

Emergency Plan support is not limited to activities to keep people from being infected with HIV and to keep people who become infected alive. PEPFAR also supports societies in developing comprehensive responses that address the impact of HIV/AIDS. Only responses that address the full range of HIV/AIDS-related challenges will fully enable nations to move from despair to hope.

The focus nations of the Emergency Plan are places in which this need is especially great. Approximately half of the over 40 million people currently living with HIV/AIDS worldwide live in the 15 focus countries of PEPFAR. Of the over 14 million children orphaned or made vulnerable by HIV/AIDS, at least 8 million live in the focus countries. In most of the focus nations, the inadequate availability of care for those infected and affected by the virus is placing additional stresses on social bonds that are already severely frayed. Solutions that are of high quality – and that can be sustained for the long term – may be all that protect these societies from unraveling altogether.

Care Summary Five-Year Goal in the 15 Focus Countries Support care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children Progress Achieved through September 30, 2005 Supported care for nearly 3 million people, including: Care for over 1.2 million orphans and vulnerable children Care for over 1.7 million people living with HIV/AIDS, including over 368,000 who received care and treatment for tuberculosis Supported counseling and testing for over 9.4 million people to date, including over 6.6 million in fiscal year 2005, through prevention of mother-to-child transmission and other counseling and testing activities Supported training or retraining of approximately 75,000 individuals to care for orphans and vulnerable children in fiscal year 2005 Supported training or retraining of over 86,000 individuals to care for people living with HIV/AIDS and approximately 6,800 service sites Supported training or retraining of over 50,000 individuals to provide counseling and testing and over 6,600 service sites through prevention of mother-to-child transmission and other counseling and testing activities Allocation of Resources in Fiscal Year 2005 $274 million to support care for orphans and vulnerable children and people living with HIV/AIDS and for counseling and testing in settings other than prevention of mother-to-child transmission (26 percent of total focus country resources for prevention, treatment, and care)

Perhaps the most obvious manifestation of HIV/AIDS in many countries is the large number of orphans and vulnerable children (OVCs). Orphans are defined as children under age 15 who have lost a mother, a father, or both, and vulnerable children are those affected by HIV through the illness of a parent or principal caretaker.

Many communities have traditional family-based care approaches for children, such as care by grandparents, but even extended family and social structures are being stretched beyond their capacity as they are now overwhelmed by the sheer number of children who are in need of care. Orphans are forced into roles they are not yet prepared for, placing them at high risk of HIV infection.

Also straining these societies are the large numbers of people living with HIV/AIDS (PLWHA) in need of care. Both those not yet in need of antiretroviral treatment (ART) and those who are receiving it require basic health care, social, spiritual and emotional support, and in some cases, end-of-life care. Again, many communities’ current resources for meeting the needs of PLWHA are inadequate to the task.

In many cases, caring for family, friends, and children infected and affected by HIV/AIDS consumes energies and resources needed for survival. Communities may abandon or reject those who need care, creating hopelessness that undermines all efforts to mobilize communities – and nations – to respond.

A related challenge is increasing the number of people who learn their HIV status. In some surveys, only 10% of people know their HIV status – yet when asked, a majority say that they would like to know. Counseling and testing is an entry point to care and treatment, and is also a crucial opportunity for prevention education – for those who are infected and their partners, and also for those who are not infected. Yet counseling and testing remain stigmatized and utilized by far too few people in nations hard-hit by HIV/AIDS.

The Emergency Plan thus works in concert with national strategies in the following areas, which collectively are considered "care" for PEPFAR purposes:

• Support basic needs of orphans and vulnerable children
• Support care for people living with HIV/AIDS (Palliative Care)
• Support counseling and testing for HIV

Orphans and Vulnerable Children
The Emergency Plan supports varied interventions to help communities mobilize to care for their own children and families affected by HIV/AIDS. Community and faith-based peer support can be crucial for growing children and adolescents faced with both the normal challenges for their age and heavy economic, psychosocial and stigma burdens.

OVC services include caregiver training, access to education, economic support, targeted food and nutritional support, legal aid, medical care, psychological and emotional care, and other social and material support. These services are summarized in the text box on the following page, and are described in further detail in the chapter on Children. OVCs themselves face elevated risk of HIV infection, and PEPFAR supports efforts to expand HIV counseling and testing, which are an entry point to care and treatment. In addition, the Emergency Plan recognizes that meeting the needs of children with HIV can also serve as a way to build relationships with their caregivers, who may themselves be in need of services.

Results: Rapid Scale-Up
In fiscal year 2005, Emergency Plan funding for care services for OVCs totaled over $62 million in the focus countries – approximately 6 percent of prevention, treatment, and care resources.

PEPFAR-supported activities reached over 1.2 million OVCs during the reporting period. This figure is in addition to OVCs receiving antiretroviral treatment through USG programs, as described in the chapters on Treatment and Children. Over 815,000 of the children who received care services were beneficiaries of downstream support at the site of service, while the remainder received upstream support through USG contributions to national, regional, and/or local activities such as training, systems strengthening, and policy and protocol development. Definitions for these terms are provided in the Accountability section at the end of this chapter. Of those receiving downstream support whom partners reported by gender, 52 percent were girls and 48 percent were boys.

Sustainability: Building Capacity
The Emergency Plan seeks to support communities, families, and OVCs themselves in accessing the full range of supportive resources available to them. These resources include those funded by PEPFAR, but also include those provided by a range of other sources (including other USG programs).

Among the most important potential long-term sources of support for OVC care are national governments. Strengthening citizens’ ability to work with – and, when necessary, demand – effective responses from their governments is a key Emergency Plan strategy for building sustainability in OVC responses.

Further laying the foundation for sustainable responses, the USG supported the training of over 74,000 community or family caregivers in the focus nations during fiscal year 2005, helping them to access time- and labor-saving technologies and income-generating activities, and connecting children and families to health and social services where available.  

Key Challenges and Future Directions

Scaling up support to families and communities
It is usually ideal for orphaned children to remain in family settings within their communities. In hard-hit communities, however, families’ capabilities are already stretched to the breaking point by poverty and, in many cases, AIDS within the family itself. Continued stigma against children and caregiving families makes the ideal situation still more difficult to achieve.

The Emergency Plan thus continues to concentrate its efforts on strengthening families and communities, working with community- and faith-based organizations to identify promising models and bring them to scale. For example, in Rwanda an Emergency Plan partner started what is known in Kinyarwanda as the Nkundabana (I Love Children) project. The project is specially designed for child-headed households, with assistance provided by volunteers within the community. These volunteers receive training in active listening, nutrition, HIV/AIDS and hygiene, and provide the children with needed support and assistance.

Quality of programs for orphans and vulnerable children
Because OVC services are delivered by organizations working at the family and community levels, quality assessment poses special challenges. The Emergency Plan is contributing to the effort to meet these challenges.

The USG is supporting host government efforts to develop standard packages of OVC services and program monitoring and evaluation. In Kenya, the government and international partners have collaborated to create an OVC quality package that includes six essential services that must be provided in every OVC program (health, education, nutrition, psychosocial support and protection). PEPFAR supports host government initiatives to develop national policies, protocols, and guidelines. USG supports dissemination of these to communities, as well as efforts to inform communities of the rights of their OVCs.

Addressing the special vulnerability of girls
As noted in the chapters on Prevention and Gender, girls in the developing world often face special vulnerability to the HIV/AIDS pandemic and its effects. This vulnerability can be greatly compounded for girls who are orphaned, losing their means of economic and social support and protection. Such girls are at high risk of abuse and exploitation, violence, transactional and cross-generational sex – all pathways to HIV/AIDS infection. In addition, girls often bear the burdens of care for families impacted by the disease as primary care providers. Girls are typically the first to lose access to school, as resources are diverted to provide care for persons in household infected with HIV.

Because of this special vulnerability, the Emergency Plan focuses special attention on female OVCs and their distinctive issues. In Zambia, the PEPFAR-funded RAPIDS project supports community care coalitions that focus on issues such as providing support and supplies for children, especially girls, who have dropped out of school due to the death of a parent. These groups are also helping to end the practice of early marriage, which has grown as young orphaned girls have come to be viewed as a burden by their own families.

Working with other sectors and partners for a multisectoral approach
The Emergency Plan recognizes the broad array of challenges facing OVCs and supports a coordinated, holistic approach, with linkages to programs that meet key needs of OVCs in such areas as:

• Food
• Education
• Vocational training
• Protection
• Emotional support
• Substance abuse prevention and treatment

In many cases successful programs are ones in which the Emergency Plan interventions link or "wrap around" critical support to other sectors. Examples of wraparound programs in the area of education with which the Emergency Plan coordinates support are found in the accompanying text box.

Leveraging partners and resources
Like the other aspects of the HIV/AIDS emergency in a given nation, the OVC crisis requires more resources than the USG alone can contribute. The Emergency Plan recognizes that the ability and willingness of host governments to marshal all resources available to them – not only those of outside partners – for an effective response must be fostered. The USG is thus working with host governments, while coordinating with other international partners, the private sector, and communities themselves, to ensure development of sustainable systems that fully recognize and meet the needs of children, including those affected by HIV/AIDS.

Care for People Living with HIV/AIDS (Palliative Care)
For HIV-positive people, the need for care extends throughout the continuum from diagnosis with HIV infection until death. This entire spectrum of care for PLWHA is known as palliative care, under definitions developed by PEPFAR based on those of the U.S. Department of Health and Human Services and the World Health Organization. In the United States, palliative care is sometimes used in a much more narrow sense, to refer only to end-of-life care. The broader definition used by the Emergency Plan, however, is the one customarily used in Africa and much of the rest of the world.

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. Of the over 40 million HIV-positive people living worldwide at present, it is estimated that about 6.5 million currently need ART.

In any case, the health care needs of the HIV-positive individuals who do not yet need treatment are different from those of people without HIV. While their basic health care needs may be similar, HIV-positive individuals may also require symptom management, treatment or prevention of opportunistic infections, social, spiritual and emotional support, and compassionate end-of-life care.

The Emergency Plan focuses on integrating prevention for PLWHA with care and treatment services. Prevention is a crucial component of PEPFAR and important regardless of one’s sero-status, helping to ensure positive living, including the prevention of new HIV infections. These efforts are further discussed in the chapter on Prevention.

In addition to efforts to work with PLWHA to prevent transmission of HIV, another PEPFAR focus is prevention of opportunistic infections (OIs) and other diseases. The Emergency Plan supports such interventions as cotrimoxazole to prevent diarrhea and other OIs, insecticide- treated bed nets to prevent malaria, clean water vessels, condoms and, where appropriate, isoniazid to prevent tuberculosis (TB).

Basic Palliative Care Services Provided Through the Emergency Plan Palliative care comprises a broad range of services including physical, psychological, spiritual and social support services with the following elements: Routine clinical monitoring and management of HIV/AIDS complications Opportunistic infection prophylaxis and treatment (e.g., cotrimoxasole drug therapy, bed nets for malaria, treatment for Mycobacterium tuberculosis infection) Management of opportunistic cancers Management of neurological and other HIV/AIDS-associated diseases Symptom diagnosis and relief, including pain control End-of-life care, including bereavement support for family members Mental health care and support Social support, including organization of basic necessities such as nutrition, financial assistance, legal aid, housing, and permanency planning Support for caregivers Spiritual care HIV/AIDS prevention services

Some countries are beginning to standardize their approach and are working with implementing partners to ensure that all HIV-positive people receiving services, even if they are not eligible for ART, receive a "basic preventive care package" that provides a number of these lifesaving interventions. These interventions benefit all HIV-positive individuals whether they have begun ART or are not yet in need of it. When people receive ART without other needed care, they fail to reap the full clinical benefit of ART.

The Emergency Plan provides support for an interdisciplinary, holistic range of palliative care services. These services are listed in the accompanying text box.

Results: Rapid Scale-Up
In fiscal year 2005, the Emergency Plan committed $121 million for care for PLWHA in the focus countries. With these resources, palliative care was supported for approximately 1.7 million people. Approximately 12 percent of resources for prevention, care and treatment activities in the focus countries were devoted to palliative care for people living with HIV/AIDS.

Emergency Plan support is provided for a variety of interventions at different levels within the network model (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) essential to the effective roll-out of quality care.

Over 50 percent of HIV-infected people in many areas of the focus nations are co-infected with TB – a deadly airborne disease and a leading cause of death in those living with HIV/AIDS. Of those infected, approximately 10% per year develop active TB. It is vital to treat people with TB to prevent illness and death, as well as to prevent its spread to others. The Emergency Plan thus monitors activities dedicated to people living with HIV/AIDS-TB co-infection.

The Emergency Plan supported TB care and treatment for approximately 369,000 co-infected people in the focus countries during fiscal year 2005. The priority is diagnosis and treatment of active TB (including directly observed therapy, or DOTS), with support also provided for diagnosis and treatment of latent TB infection to prevent the development of active disease, and for general TB-related care. Of all adults and children who received TB care, 179,400 received it at USG-supported delivery sites, while the remainder received support through contributions to national, regional, and local programs.

Best Practices Kenya: Integration of HIV and TB diagnostic testing results in improved ART access HIV and poverty drive the tuberculosis (TB) epidemic in Kenya, with a ten-fold increase in registered TB cases since 1987. In the eastern slums of Nairobi, an epicenter of the dual HIV/TB epidemic, the Eastern Deanery of the Nairobi Catholic Diocese has provided health care through seven clinics since the early 1990s. In 2001, a partnership between the Eastern Deanery AIDS Relief Program (EDARP), the Kenya National Leprosy and TB Program (NLTP) of the Ministry of Health, and HHS/CDC established integrated HIV and TB services in these clinics. Initially, TB patients were referred to freestanding counseling and testing centers; however, only one in eight patients referred for counseling and testing actually sought testing. To improve uptake and better integrate the services, in 2003 physicians assistants began to provide diagnostic counseling and testing at the time of TB diagnosis. Despite this change in procedure, many TB patients were not tested for HIV. With Emergency Plan support, the program began in 2004 to routinely offer HIV counseling and testing to all outpatients believed to have TB. Nurses conducted the testing, using simple HIV rapid tests done in the presence of the patients. Of 1,917 patients offered HIV counseling and testing over 19 months, 85% accepted during their initial clinic visit – and nearly all of those who came for follow-up due to active TB eventually accepted testing. The expansion of testing has accompanied the rapid expansion of care and antiretroviral treatment (ART) in the program, helping to identify patients who are eligible to start ART. Lessons learned from this project have informed national policy and strategy, serving as a model for integrating TB and HIV services. The USG team estimates that offering testing to the 400,000 patients believed to have TB annually in Kenya can be expected to result in 300,000 accepting testing, potentially leading to 100,000 referrals for HIV care per year. The majority of these people would be eligible for ART. Manpower constraints in TB clinics have slowed the application of these lessons throughout the country, but they have informed the Kenya National Guidelines for HIV Testing in Clinical Settings and established a best practice model that is now being duplicated around the country. Offering diagnostic testing for HIV and TB routinely at the first patient contact is more acceptable to patients, more efficient for staff, and results in better management of both diseases. This advance is making a difference for people in the slums of Nairobi. Salome Majuma (name and details changed to protect her identity) is a woman in her early 40’s who was diagnosed with HIV and TB in May 2004. At the time of diagnosis, she began her 8 month course of TB treatment and cotrimoxazole prophylaxis to prevent other opportunistic infections. In February 2005 she began ART and visits the clinic monthly to collect her medications, provided with Emergency Plan support. Her tuberculosis is now cured and her health improved – offering a hopeful future.

Sustainability: Building Capacity
The Emergency Plan focuses on supporting the expansion of networks of health care providers and linking them to home-based care programs in order to support sustainable care for people living with HIV/AIDS. PEPFAR efforts focus on building the capacity of communityand faith-based groups, which have played a leading role in home-based care in many countries. USG in-country teams have found that even small grants can be very empowering for these grassroots organizations, allowing them to expand their services and advocate for increased community and national commitment to people living with HIV/AIDS.

Building the capacity of networks of PLWHA to provide care is another key element of PEPFAR’s work in this area. Their involvement in palliative care helps build sustainable systems that respond fully to the challenges PLWHA face.

Recognizing the long-term importance of appropriate national policies on care for people living with HIV/AIDS, the Emergency Plan has supported policy development initiatives. Another focus is strengthening referral systems to services beyond medical needs for people living with HIV/AIDS.

USG support was provided for training of over 86,000 palliative care providers in the focus countries in fiscal year 2005, while approximately 6,800 sites received support for personnel, infrastructure development, logistics, strategic information services, and other components of quality care.

Key Challenges and Future Directions
Human capacity
As in other areas of HIV/AIDS response, inadequate human capacity remains a major challenge to ensuring quality of care for PLWHA, with nurses and other health care providers in desperately short supply in many nations.

For lay workers and volunteers who provide palliative care as well as professional health care workers, there is a need to expand and improve training, and strengthened supervision systems and appropriate incentives are essential. With PEPFAR support, South Africa’s Hospice Palliative Care Association was able to strengthen its financial and technical capacity, increasing its ability to provide high quality outreach and services to people living with HIV/AIDS. To expand this initiative throughout the region, PEPFAR has also supported the African Palliative Care Association (APCA), as described in the chapter on Building Capacity for Sustainability.

To ensure quality, the Emergency Plan supports efforts to strengthen supervision of lay health workers by professionals where possible. Initiatives to provide incentives to volunteers, including remuneration, also receive support, helping to strengthen care networks. Key training programs include pre-service training for future health care professionals and in-service training for current health workers.

Addressing key policies that limit care
National policies in some countries prevent health aides, including nurses, from engaging in key activities for care of people living with HIV/AIDS. Given the centrality of nurses to care in the developing world, it is essential for quality care that nurses become HIV experts who may develop capabilities to provide medication. In collaborative efforts with host governments, advanced practice nursing is a priority for Emergency Plan policy development efforts.

Holistic physical, psychological, and supportive end-oflife care remains a relatively recent innovation in many nations. Opioids, which may be one element of such care, and can be essential for pain relief, are often not registered for pain relief for AIDS patients by national governments. Working with host governments, PEPFAR continues to offer strong support to efforts to improve end-of-life care policies as well as programs.

Also critical is dissemination of the "basic preventive care packages" developed by the Emergency Plan under national strategies, offering services such as medications to prevent opportunistic infections, bed nets to prevent malaria, and clean drinking water.

Addressing burden on women and girls
The burden of caregiving for PLWHA falls disproportionately on women and girls, exacting an emotional, physical, and financial toll on a group with limited access to resources.

The Emergency Plan thus supports efforts to make comprehensive, high-quality care available at the community level, with links to broader health networks. These initiatives augment policy advocacy on behalf of women and community outreach to involve men in caregiving, thus reducing the burdens on women and girls. For example, countries such as Uganda and Zambia have established programs that provide legal protection and education for women and orphans at the community level, focusing on issues such as inheritance rights.

Food and nutrition
In 2005, the Emergency Plan created an interagency technical working group on food and nutrition that includes the Office of the U.S. Global AIDS Coordinator (OGAC), USAID, HHS, and the U.S. Department of Agriculture (USDA), and developed policy guidance which is now being finalized for incorporation into the care activities of USG teams in the field. The guidance clarifies that the Emergency Plan supports appropriate assessment, monitoring, and counseling on the nutritional needs of people living with HIV/AIDS.

Emergency Plan teams work to leverage food and nutrition resources from other USG sources, such as USAID’s Title II program and USDA’s Food for Progress program, among others. In addition the Emergency Plan seeks to leverage food from other sources, including the World Food Program and the private sector. The Emergency Plan will also expand collaboration with host governments as they increase their own efforts to provide for their populations.

One Woman’s Story Zambia: From HIV-positive to positive about life Mary-Gorretti Banda (known as "MG") is a service provider, outreach worker, and mentor all in one. She can most often be found at Minga Mission Hospital where she is an HIV/AIDS counselor and coordinator of three hospice wards while also leading a massive home-based care outreach effort. Her work is part of SUCCESS, a broad spectrum palliative care program supported by the Emergency Plan. MG’s past has brought her to this work. During her married life, her husband decided to take two more wives. MG, being first wife, was devastated by her husband’s decision but had little choice in the matter, as local tradition allows men to have more than one wife. She decided to remain in her matrimonial home, despite being the least "loved" among the three wives, and rarely had sex with her husband. MG’s husband became sick and eventually died of what seemed to be AIDS, and MG worried that she too could be infected. MG’s two co-wives suffered from health symptoms similar to her late husband’s, and within one year, both died. Would MG be next in line? After the deaths, MG went for an HIV test and learned that she was HIV-positive. Her first reactions were fear, bitterness, depression, and denial. Watching HIV positive patients coming to Minga Hospital for help, however, MG soon wondered how she could assist them and herself. When the hospice program at Minga Hospital was launched, MG decided to take courses in counseling and testing and attend HIV/AIDS workshops, and she began to work in the hospice section of the hospital. Eventually she became Minga Hospital’s home-based care coordinator as well as a counseling and testing advisor and hospice coordinator. MG now spends weeks on end in the field caring for others infected by HIV/AIDS just like herself, and she estimates that her counseling center can test as many as 200 people a month. Mary-Gorretti Banda has truly transformed being HIV-positive into being positive about life. The Emergency Plan has made a difference for MG, who remarked, "Through my participation in the hospice and outreach activities, I have come to accept my status, take care of myself, and better understand the HIV/AIDS pandemic."

Community support for care, including involvement of people living with HIV/AIDS
The Emergency Plan strongly supports efforts to include PLWHA in the provision of care, helping to address the human capacity shortfall in developing countries while ensuring that care activities are conducted in ways that respond to the needs of PLWHA. USG country teams are reaching out to groups of PLWHA, including them in the design and implementation of care programs, and providing funding for a growing number of support groups in all focus country programs. PEPFAR also supports associations that reach out to the most highly stigmatized individuals, for example, men who have sex with men, and injecting drug users in Vietnam. In Kenya, faith-based organization (FBO) leaders who are living with HIV provide outreach to members of the faith community to help reduce stigma, while providing education and a system of support. In addition, PEPFAR is supporting a variety of efforts to help communities confront the challenge of providing care and support.

Secure and reliable supply chain for drugs and commodities
As with antiretroviral drugs, a consistent and secure supply chain for commodities and medications is necessary for quality palliative care. The Partnership for Supply Chain Management established in fiscal year 2005 and described at length in the chapter on Building Capacity for Sustainability will help to ensure the quality of these items.

HIV Counseling and Testing
The Emergency Plan has led the way in supporting the expansion of access to HIV/AIDS prevention, treatment and care in the developing world. Yet one of the key limiting factors is people’s lack of knowledge of their HIV status.

A person unaware of his or her HIV-positive status will not begin life-saving treatment, or care that can prevent opportunistic infections, and may not take all possible prevention steps to avoid spreading infection. Counseling and testing are key gateways to prevention, care and treatment.

Large numbers of people must be tested for PEPFAR to meet its ambitious care and treatment goals in the focus countries. Yet the numbers receiving counseling and testing today remain far short of what is needed, and the consequences of this shortfall affect all other efforts to combat HIV/AIDS.

A key current barrier to counseling and testing is lack of routine availability in health care settings, including TB and sexually transmitted infection (STI) clinics – among the most important venues for testing people who are more likely than the general population to be infected. Other obstacles include distance of patients from facilities, and inadequate access to providers, rapid tests, and laboratory services. Sustainable programs must overcome these obstacles while also ensuring that services provided are of high quality. Compounding all these challenges, stigma and discrimination against those thought to be HIV-positive remain significant in many nations.

The Emergency Plan is moving with the urgency and innovation that are commensurate with this extraordinary challenge. A growing number of best practices for sustainable, quality counseling and testing have been identified. PEPFAR is working with country teams and partners to bring these to scale as quickly as possible, using locally-appropriate approaches that can be sustained in the future.

Best Practices Tanzania and Namibia: U.S. and host nation militaries bring leadership and teamwork to the fight Each August, an estimated 2 million people attend the week-long annual Agriculture and Industry Fair known as "Nane Nane" in the southern Tanzanian town of Mbeya. This year, the U.S. Department of Defense (DoD), using Emergency Plan resources, worked with 11 local partners to staff counseling and testing and educational booths at the fair. About 300,000 people explored the booths, and 700 sought testing. The partner organizations gave educational speeches from a grandstand built specially by the Tanzania People’s Defense Force, and presented dramas, dances, songs, and testimonies throughout the week. They also staffed all-day counseling and testing booths, contributing "runners" to take blood samples to the referral hospital lab. Due to the overwhelming number of clients, one night they were forced to conduct group counseling and take 50 clients to the Regional Hospital to finish the testing. Out of the 700 tested, 9.4% were positive and given referrals to support groups and care and treatment centers. Significantly more males than females were tested, and 85% were between the ages of 19-28. The Tanzania Minister of Transportation and Communication, Professor Mark Mwandosya, hailed the partnership of the American and Tanzanian governments, and encouraged all attendees to work together to control HIV/AIDS. The remarkable range of partners was among the most impressive aspects of the event. The 11 local partners were faith- and community-based organizations providing HIV services in the Southern Highlands. The partners collaborated so well that they decided, with the encouragement of DoD and the Walter Reed HIV/AIDS Foundation, to form a network of local non-governmental organizations in Mbeya region. The network meets on the last day of each month to share information on best practices in the field, while planning, implementing and evaluating programs to address HIV/AIDS in the Southern Highlands of Tanzania. In a number of countries DoD is collaborating with ministries of defense to develop leadership in HIV prevention for military personnel. In Namibia, the DoD-sponsored Military Action and Prevention Program in the Namibian Defense Force sponsored a base commanders’ seminar, which forty-eight senior line officers attended. The seminar encouraged open discussion about the threat of HIV to military readiness and national security, and the responsibility of commanders to provide opportunities and encouragement for participation of soldiers in HIV prevention activities and testing. In Namibia and other Emergency Plan countries, an encouraging sign is the involvement of senior officers in the development of policies regarding HIV-positive troops and their future in military service – a previously taboo subject.

Because prevention of mother-to-child transmission (PMTCT) services include counseling and testing, PMTCT activities are among the most effective ways to increase women’s access to these services. As described further in the chapters on Prevention and Children, PMTCT encounters also serve as an entry point for provision of prevention, treatment, and care services.

In addition to PMTCT efforts, other innovative PEPFAR initiatives include support for expansion of diagnostic counseling and testing in other health care settings in Botswana, Kenya, and Tanzania. A major expansion of rapid testing has been supported in Namibia, while couples counseling is being supported in a number of focus countries. In Uganda and Botswana, door-to-door testing of entire districts is being supported, with promising results.

The Emergency Plan is also supporting laboratory quality improvement, which is a key element of effective testing programs, through training and other efforts. Support is also provided for the expansion of rapid HIV testing. These efforts are described at length in the chapter on Building Capacity for Sustainability.

Results: Rapid Scale-Up
To date, the Emergency Plan has provided support for HIV counseling and testing services for over 9.4 million people in the focus countries. Of these, over 6.6 million received services in fiscal year 2005 – over 1.9 million in PMTCT settings and over 4.6 million through other counseling and testing activities.

Of the over 6.6 million counseled and tested in fiscal year 2005, over 3.7 million received these services with downstream PEPFAR support at USG-supported sites, while the remainder were supported through upstream PEPFAR support for countries’ capacity to provide services (including assistance for national and regional policies, communications, protocols to ensure quality services, laboratory support, and purchase of test kits). Definitions for upstream and downstream support are provided in the Accountability section at the end of this chapter.

Reflecting the importance of counseling and testing to achieving the goals of the Emergency Plan, approximately $64 million, or 6 percent, of focus country prevention, treatment and care resources in fiscal year 2005 were committed to PMTCT services, while $90 million, or about 9 percent, were committed to other counseling and testing activities.

Table 3.7 - Care: Cumulative Counseling and Testing Results, FY04-FY05 Number of women receiving C&T through PMTCT1 FY04: 1,017,000 FY05: 1,957,900 Cumulative C&T to date: 2,974,900 Number of women receiving C&T through PMTCT2 FY04: 1,791,900 FY05: 4,653,200 Cumulative C&T to date: 6,445,100 Total FY04: 2,808,900 FY05: 6,611,100 Cumulative C&T to date: 9,420,000 NOTE: Numbers may be adjusted as attribution criteria and reporting systems are refined. Numbers above 100 are rounded to nearest 100. FOOTNOTES: 1In FY04 only, it was assumed that 80% of women receiving PMTCT services were counseled and tested. 2 In FY05, the PMTCT indicator was clarified, so that women were only counted as receiving PMTCT services if they were counseled, tested, and received their test results.

PEPFAR continues to work to overcome challenges to reach women with much-needed services. Approximately 69 percent of those who received USG-supported counseling and testing services in fiscal year 2005 were female. This figure includes all PMTCT clients, as the PMTCT services indicator for fiscal year 2005 was clarified to ensure that a woman was only counted as receiving PMTCT services if she was counseled and tested and received her test result. For clients receiving non- PMTCT counseling and testing at a downstream USGsupported site and whom implementing partners reported by gender, 53 percent were women. This percentage was then applied to those who received upstream support as well.

Sustainability: Building Capacity
The Emergency Plan has continued to make progress in partnering with host nations to make counseling and testing a centerpiece of efforts to bring national responses to scale – but much more effort is needed. Emergency Plan teams have worked with host governments and other partners to integrate counseling and testing into routine health care, as must be done to reach the large numbers who require testing if the tide is to be turned.

In the focus countries in fiscal year 2005, the Emergency Plan provided support for training of approximately 50,800 individuals in counseling and testing (including 28,600 in PMTCT and approximately 22,200 in other counseling and testing services). PEPFAR also supported approximately 6,700 service sites (including 2,500 PMTCT sites and 4,200 other counseling and testing sites).

Key Challenges and Future Directions
Bolstering sustainable activities to increase the number of people who learn their HIV status
Given the challenge involved in rolling out counseling and testing on the massive scale needed, it is critical to focus efforts on people with a higher likelihood of HIV infection than the general population. This must be done without neglecting efforts to ensure access for the population at large, especially in countries with generalized epidemics.

Table 3.9 - Care: FY05 Total Counseling and Testing Capacity-Building Results

Country	Number of USG-supported PMTCT sites	Number of USGsupported sites other than PMTCT	Total	Number of health workers trained or retrained in PMTCT services	Number of individuals trained or retrained in counseling and testing in settings other than PMTCT	Total
Botswana	12	32	44	100	30	130
Cote d'Ivoire	44	54	98	200	200	400
Ethiopia	100	800	900	4,900	2,200	7,100
Guyana	46	15	61	75	88	200
Haiti	60	74	100	1,900	1,400	3,300
Kenya	900	500	1,400	3,100	2,200	5,300
Mozambique1	51	52	100	500	100	600
Namibia	79	200	300	900	1,200	2,100
Nigeria	42	200	200	800	1,500	2,300
Rwanda	64	72	100	1,600	800	2,400
South Africa	400	1,000	1,400	8,400	3,800	12,200
Tanzania	200	100	300	2,200	700	2,900
Uganda	300	700	1,000	2,700	6,200	8,900
Vietnam	7	61	68	500	400	900
Zambia	200	300	500	700	1,400	2,100
Total	2,500	4,200	6,600	28,600	22,200	50,800
Note: Numbers may be adjusted as attribution criteria and reporting systems are refined. Numbers above 100 are rounded to nearest 100. Footnotes: 1In FY04, voluntary counseling and testing sites in Mozambique received upstream USG support, which was provided to Mozambique’s national voluntary counseling and testing program. This central support included USG-supported procurement of all of the test kits Mozambique used in FY2004 as well as development of protocols, guidelines, training curricula, and a range of related technical support without which the expansion would not have occurred. In FY05 the level of central support in the area of C&T was not as extensive. Therefore, for FY05, Mozambique reported only downstream USG-supported sites.

Making diagnostic testing a part of health care interactions is among the most efficient and sustainable ways of accomplishing this goal. Accordingly, the Emergency Plan has sharply increased its support for routine voluntary counseling and testing in programs for pregnant women, clinics that treat TB or STIs, hospitals, and other health care settings. In addition, as prevention is being integrated into care and treatment services in places such as Kenya and Uganda, clients receiving treatment services are asked about disclosure and partner testing.

As noted above, a variety of other locally-designed initiatives have shown very promising results, including partner testing for couples, home-based testing (including testing of family members), mobile testing, hotlines linking callers to testing sites, and others.

The Emergency Plan has taken special efforts to ensure that women receive counseling and testing without stigma and discrimination, and that they have full access to care and treatment as needed. Many of the initiatives described have helped to achieve these goals, including testing for pregnant women in health care settings, partner testing, and activities to reduce stigma and cultural barriers that inhibit women’s access to services. Integration of counseling and testing into family planning clinics is a priority, and routine testing within PMTCT programs has proven a highly effective means of linking women to needed treatment and care.

One requisite of quality in counseling and testing programming is that those tested actually receive their test results. Long delays in obtaining test results, however, have led many who are tested not to return for their results. The increasing availability and quality of rapid tests is thus one of the most encouraging developments
in the fight to expand counseling and testing, and PEPFAR continues to strongly support country teams and partners’ inclusion of rapid tests in their plans. A number of host nations and partners have moved to rapid testing in recent years with USG support.

Ensuring quality in counseling and testing
Widely available, high-quality testing requires testing kits in very great numbers. The Emergency Plan’s new Partnership for Supply Chain Management, described in detail in the chapter on Building Capacity for Sustainability, will help host nations to ensure uninterrupted supplies of high-quality test kits.

High quality in counseling is perhaps even more difficult to ensure than quality in testing. Counseling for those who test negative is an area that has tended to receive insufficient attention, wasting critical opportunities for prevention efforts. The Emergency Plan is thus supporting efforts to expand and improve training of counselors and to ensure that they are able to offer appropriate prevention information.

 Accountability: Reporting on the Components of Care
The First Annual Report to Congress of the Emergency Plan described the ways in which U.S. support is provided. Where partnership limitations or technical, material or financial constraints require it, the Emergency Plan, or another international partner, may support every aspect of the complete package of prevention, treatment, or care services at a specific public or private delivery site, in coordination with host-country national strategies.

Downstream support
In many areas, the Emergency Plan will coordinate with other partners to leverage resources at a specific site, providing those essential aspects of quality services that others cannot provide due to limited technical and/or financial circumstances. For example, in some settings components of services are provided to specific sites through the host-country government or other international partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, while the Emergency Plan may contribute other essential services, training, commodities, and infrastructure. "Downstream" site-specific support refers to these instances where the Emergency Plan is providing all or part of the necessary components for quality services at the point at which services are delivered.

Upstream support
Beyond the site-oriented downstream components of services, support is required to provide other critical elements, which may include the training of physicians, nurses, laboratory technicians, other health care providers, and counselors or outreach workers; laboratory systems; strategic information systems, including surveillance and monitoring and evaluation systems; logistics and distribution systems; and other support that is essential to the effective roll-out of quality services. This coordination and leveraging of resources optimizes results while limiting duplication of effort among partners, with roles determined within the context of each national strategy. Such support, however, often cannot easily be attributed to specific sites because it is national or regional in nature, and, in fact, many sites benefit from these strategic and comprehensive improvements. Therefore, this support is referred to as "upstream" support and is essential to developing network systems for prevention, treatment, and care.

Attribution challenges due to country-level coordination
The Emergency Plan supports national HIV/AIDS treatment strategies, leveraging resources in coordination with host-country multisectoral organizations and other partners to ensure a comprehensive response. Host nations must lead a multisectoral national strategy for HIV/AIDS for an effective and sustainable response. International partners must ensure that interventions are in concert with host government national strategies, responsive to host country needs, and coordinated with both host governments and other partners. Stand-alone service sites managed by individual international partners are not desirable or sustainable. In such an environment, attribution is complex, including both upstream and downstream activities, often with multiple partners supporting the same sites to maximize comparative advantages. PEPFAR is conducting audits of its current reporting system to refine methodologies for the future, and continues to assess attribution and reporting methodologies in collaboration with other partners.

Care reporting conventions
During this reporting period, results for PEPFAR care programming were determined by totaling all the programs, services, and activities aimed at optimizing quality of life for OVCs; at caring for patients and their families throughout the continuum of illness; and at diagnosing HIV-infection through counseling and testing, including through PMTCT activities.

Activities aimed at improving the lives of children and families directly affected by AIDS-related morbidity and/or mortality are counted as OVC programs. These may include training caregivers; increasing access to education; economic support; targeted food and nutrition support; legal aid; medical, psychological, and emotional care; and/or other social and material support. Institutional responses are also included.

Given the need to independently account for TB prevention, care, and treatment, palliative care totals are made up of two service categories – basic health care and support and TB/HIV care and support. Basic health care and support includes all clinic- and home/community-based activities aimed at optimizing quality of life of HIVinfected (diagnosed or presumed) clients and their families by means of symptom diagnosis and relief; psychological and spiritual support; clinical monitoring and management (and/or referral for these) of opportunistic infections, including malaria and other HIV/AIDS-related complications; culturally appropriate end-of-life care; social and material support, such as nutrition support, legal aid, and housing; and training and support for caregivers. TB/HIV care and support activities include examinations, clinical monitoring, treatment, and prevention of tuberculosis in HIV palliative care settings as well as screening and referral for HIV testing and TB-related clinical care. In-country partners derive these counts from program reports and health management information systems.

In the area of HIV testing, results report on numbers of individuals trained, numbers of sites where HIV testing is supported, and numbers of individuals tested, disaggregated by gender. Equipment and commodities, in particular test kits, are provided through the program and are inventoried and tracked through standard USG reporting and accounting systems by the grantees acquiring the goods.

The Emergency Plan has funded the MEASURE Evaluation Project, discussed in the chapter on Improving Accountability and Programming. This evaluation will provide:

• Data quality audit guidance for program-level indicators
• Best practices for program-level reporting
• Implementation of data standards guidance in select countries