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

Table 15
Through theater, six young boys, ages eight through 14, are encouraging abstinence, behavior change, and healthy lifestyles in an effort to prevent the spread of HIV/AIDS in Angonia, Mozambique. Drawn to the stage after seeing a group of the district's senior boys perform an interactive PEPFAR-supported production about HIV/AIDS prevention, these young boys formed the 'Junior Theatre Group of Angonia.' So far this youth theatre group, supported by PEPFAR through a faith-based organization, has hosted performances about HIV/AIDS and its effects on issues including gender, children's rights, family relationships, and friendship.

Partnerships for Care

PEPFAR supports host nations' wide-ranging programs to meet the care needs of OVCs affected by the pandemic, as well as people living with or affected by HIV/AIDS. PEPFAR now supports care for over 10 million worldwide as of September 2008, including over 4 million OVCs. Figure 21 and Table 15 show that nearly 9.7 million people were supported in the 15 focus countries through September 2008, including nearly 4 million OVCs. In FY2008, PEPFAR provided 29.5 percent of focus country program resources, or $953 million, in support of care (including $216 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.

Children whose parents are sick or have died from AIDS are often also left without an education or needed vocational training. Thus, 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 entry points 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 need care. Female OVCs face a disproportionate risk for exploitation, abuse, and HIV infection. This is especially true for preadolescent 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.

Table 16 shows that PEPFAR provided $312 million in funding for OVC activities in the focus countries in FY2008. This represented 9.7 percent of program funding.

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. 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 CBOs and FBOs - 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 and family-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 needs by supporting the growth and development of children and adolescents to ensure that they become healthy, stable, and productive members of society. Community and faith-based peer support can be crucial for children and adolescents who are faced with both the normal challenges of growing up and heavy economic, psychosocial, and stigma burdens.

PEPFAR supported training or retraining for approximately 247,000 individuals in caring for OVCs. Training includes 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. PEPFAR requires 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:

1. Food and Nutritional Support: In addition to direct provision of food and nutrition, programs leverage support from other international or host country partners and work for more sustainable solutions, such as improved gardening.

2. 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.

3. 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, and helping children obtain birth certificates to legalize their status.

4. 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; linking HIV-positive children with appropriate health care; and guidance for the prevention of HIV.

5. 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.

6. 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 sense of competence.

7. Economic Opportunity/Strengthening: OVCs and caregivers 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 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 core interventions by reaching out to partners, beyond traditional health agencies and networks, 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, 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 previous sections on Linking PEPFAR and education and Linking PEPFAR and food and nutrition.

Figure 21
Table 16

Mestawot Wase, an Ethiopian mother of three, learned that she and her eldest son were HIV-positive shortly after her estranged husband died of AIDS. Stigmatized and traumatized, she began to attend support meetings through a PEPFAR-supported faith-based organization. Mestawot used the training she received during the support meetings to become an outspoken community leader. She then decided to enter a line of work where she could earn a living and raise HIV/AIDS awareness. With the 500 Birr (US $50) she was lent by the support group, Mestawot opened a barbershop. Her barbershop is now thriving and she has touched many customers with her story of resilience.
Bahati Mwitula received HIV counseling training by a PEPFAR-supported mobile HIV/AIDS counseling and testing program that serves the remote areas of Tanzania. Now a certified trainer, Mwitula travels to Tanzania's rural areas to spread HIV/AIDS awareness. On one of his recent visits, Bahati and his team of trainers identified a 16-year-old female as HIV-positive. The girl explained that she had never engaged in high-risk behavior and questioned if she should inform her mother about her status. With Mwitula's encouragement, she disclosed her status to her mother and learned that she had contracted HIV at birth. Bahati was able to refer the mother and daughter to the nearest care and treatment center for additional services. By bringing mobile counsel�ing and testing services to remote villages, counselors are able to encourage behavior change and risk reduction in rural settings.

Care and Support for People Infected with or Affected by HIV/AIDS

In FY2008 PEPFAR committed nearly $425 million for care and support for people infected with or affected by HIV/AIDS in the focus countries. These resources represented 8.8 percent of program funding, supporting care for over 5.7 million people. Care programs often serve as a critical link between HIV counseling and testing and ARV treatment programs.

Care programs include a wide range of providers and delivery sites within a network model of care. 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, strategic information systems, and health systems strengthening (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 includes regular clinical and laboratory monitoring to ensure that they receive ART promptly once they are eligible. Care programs also provide 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 ART. Care can include pain and symptom management; prevention and treatment of TB and other OIs; social, spiritual and psychological support; and compassionate end-of-life care.

In addition, 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 PEPFAR, these advances in the area of care for PLWHA have the potential to have a wide impact beyond PEPFAR-supported programs, and PEPFAR is working to disseminate them broadly.

In March 2008, a technical consultation was convened to assess whether PEPFAR should support cervical cancer screening in HIV-positive women. HIV-positive women are known to have an increased risk of pre-cancer and cancer of the cervix, compared to women without HIV; thus cervical cancer can be considered an opportunistic process. Based on this consultation and further review by the PEPFAR Scientific Steering Committee, PEPFAR will now support, as part of a comprehensive approach to OIs, pilot programs which provide screening and treatment to prevent cervical cancer in HIV-positive women, using as a model the "see and treat" approach.

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 co-infection, the leading cause of death among HIV-positive people in the developing world. Table 17 shows the results from FY2008. From FY2005 to FY2008, PEPFAR increased bilateral funding for HIV/TB from $26 million to $140 million, supporting TB treatment for over 395,400 HIV-infected patients through September 2008. Through the end of FY2008, the Global Fund reported providing an estimated $2.25 billion 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 ART 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 ART. In Kenya, approximately 30,000 TB patients benefited from joint PEPFAR-WHO support, HIV testing increased from 41 percent to 84 percent, uptake of cotrimoxazole increased from 39 percent to 90 percent, and ART uptake increased from 19 percent to 28 percent.


PEPFAR supports governments and NGOs, including CBOs and FBOs, to conduct intensified TB case-finding among PLWHA at each encounter to ensure early diagnosis and treatment of TB. PEPFAR also supports host country governments to strengthen their TB laboratory 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.

Since 2007, PEPFAR has accelerated programming to combat the emerging threat of XDR-TB. 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

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 previously, 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. Table 18 shows achievements in FY2008. PEPFAR invested approximately $216 million in counseling and testing in settings other than PMTCT in FY2008, or about 6.7 percent of program funding in the focus countries.

Table 19 shows the cumulative progress achieved by PEPFAR-supported programs. These programs have far exceeded the target of 30 million, supporting nearly 57 million counseling and testing encounters through FY2008. Among these, nearly 16 million encounters were with women seeking PMTCT interventions, a key target population.

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 countries, studies have found that 50 percent 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 the use of rapid HIV tests which improve 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 in implementation of these policies remain.


Table 17
Table 18, Table 19

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