PEPFAR Technical Leadership and Support Expenses: FY 2010


Project Title: Department of Defense (DoD), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $1,106,750

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

In order to encourage comprehensive prevention efforts, Headquarters (HQ) will provide funding to initiate male circumcision (VMMC) programs in countries where other funding is not available and will provide technical assistance (TA) in support of VMMC activities.

Headquarters strategic information efforts include supporting the attendance of partner-country military staff at monitoring and evaluation trainings and providing TA in program evaluation. Funding will support training on surveillance-related data entry, data quality assurance and quality control, use of geographic information systems, basic data analysis and report writing for militaries conducting seroprevalence surveys, and may be used to sponsor military surveillance meetings. Funding will also support health management information systems (HMIS), country-based eHealth educator, and electronic medical record activities, and HMIS technical working group member costs.

Four country study on the sexual behavior of military personnel, family, and community members will gather data on current sexual behavior, sexual risks of deployment, condom use, alcohol use as it relates to sexual risk, HIV testing and perceived risk of HIV. Data will be used to inform prevention programming targeted to militaries.

DoD will also provide laboratory support for an adult care and support activity aimed at determining the disease burden of specific opportunistic infections in low-resource, high HIV burden settings to inform care and treatment programming.

Public Health Evaluations

Funding will provide continued support to the Public Health Evaluation (PHE) program though DoD, which supports studies that guide PEPFAR in program and policy development, inform the global community, and identify areas where further evaluation and research may be needed.

Project Title: Department of Health and Human Services (HHS): Centers for Disease Control and Prevention (CDC), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $87,825,443

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

Direct government-to-government assistance to Ministries of Health (MOAH) is critical to support sustainable, country-owned programs to ensure quality HIV/AIDS care and treatment services; implement effective HIV/AIDS prevention programs; improve program impact and cost effectiveness; and build sustainable public health information, laboratory, and management systems and local workforce capacity.

Projects planned in FY 2010 support comprehensive prevention programs targeting interventions based on the epidemiology of HIV infection in each country, including: HIV counseling and testing, HIV prevention for pre-sexual youth, reducing sexual transmission with behavioral risk reduction interventions including correct and consistent use of condoms, implementing biomedical interventions including male circumcision, and preventing transmission of HIV through unsafe blood and medical injections. Projects planned in FY 2010 will also support country programs for the delivery of ART to adults and the prevention, diagnosis, and treatment of opportunistic infections (OI) including TB as well as the scale-up of comprehensive, quality prevention of mother-to-child transmission (PMTCT) and pediatric programs. Additionally, funds will support laboratory capacity-building strategies in response to the field program needs including: purchasing test kits and laboratory supplies in order to remain functional in evaluating test kits for the USAID waiver list in support of the Partnership for Supply Chain Management Systems (SCMS); performing post market surveillance for HIV test kits in the field and to remain functional in evaluating test kits currently being used in support of country HIV algorithms; purchasing test kits, equipment, maintenance agreements, and other key supplies for the laboratory; supporting Memorandum of Understandings with the CDC Office of Health and Safety, CDC Division of Laboratory Systems, CDC Division of Sexually Transmitted Diseases, and the CDC National Center for Environmental Health for activities that are complementary to laboratory activities. Projects planned in FY 2010 will also support the development and implementation of surveillance, statistics, data management, and monitoring and evaluation activities to assist countries in developing or enhancing HIV-related surveillance systems and surveys for impact monitoring, program planning, and HIV/AIDS policy making. Finally, activities will support building national capacity to implement and manage sustainable, effective, efficient and accountable HIV/AIDS programs.

The development and implementation of surveillance activities that enable the strategic collection, synthesis, analysis, presentation, and use of information at HQ, by USG country teams, and by national HIV programs is a key component of implementing PEPFAR. CDC, through PEPFAR, works with partners to support a wide range of strategic information activities. Projects planned in FY 2010 to support strategic information activities include: analysis of Annual Program Result (APR) and Country and Regional Operational Plan (COP/ROP) data to develop annual country summary reports for all 15 focus countries; assisting countries to develop protocols and implement national ART outcome evaluations; finalizing and implementing surveillance training materials around the world; assisting countries to do data triangulation and analysis.

FY 2010 GHCS-State funding will support the establishment of critical public health competencies in African medical education and serve as a foundation for institutionalizing interventional epidemiology and public health laboratory management in countries that support the Medical and Nursing Education Partnership Initiative (MEPI). The Field Epidemiology and Laboratory Training Programs (FELTP) infrastructure in Africa will be leveraged to: adapt materials and integrate evidence-based short course curricula and field exercises in surveillance and epidemiology into the coursework of medical students at MEPI-supported institutions, relevant to each country context; establish a one-year fellowship in public health surveillance and response from MEPI-supported institutions; and design and pilot a course in clinical epidemiologic surveillance.

TB/HIV Scale-Up

TB is the leading cause of morbidity and mortality among HIV-infected persons in sub-Saharan Africa. FY 2010 funding will be used to implement critical TB/HIV activities that have long been articulated through WHO normative guidance but for which uptake has lagged, either due to stovepiped programming, resistance to program aspects, incompatible programs’ cultural schisms and vastly different modalities of implementation. Interventions will be included as a “package of care” building on the successful HIV package of care modality. This project will demonstrate a reduction in incidence of TB and a reduction in TB mortality among HIV infected persons by scale-up of implementation of a package of TB/HIV interventions in four sub-Saharan countries. The package of services will include the scale-up of country-wide intensified TB case finding, improved TB infection control best practices, isoniazid preventive therapy, HIV testing and counseling of all TB patients, and ART for all HIV-infected TB patients.

While initially targeting a region or province(s) in a country, these activities are unique in that they will be based on joint planning between PEPFAR, USAID, and Global Fund TB and HIV-supported programs in collaboration with National TB and AIDS Programs. This approach will increase efficiencies and rationalization of programming across major funding sources and will contribute to overall strengthening of national TB and HIV programs. To maximize access to expertise of CDC and USAID staff and partners, the project is a joint USG project with both agencies in the lead roles for designing the protocol, selecting the countries, and implementation of the project at country level. Country-specific selection of partners and mechanisms will be determined by consensus by an interagency TB/HIV working group that will manage implementation, in consultation with field representatives.

Funding will support the implementation of newly-approved rapid TB diagnostics in PEPFAR-supported settings, , including rapid detection of multi drug- resistant (MDR)-TB, and extremely drug-resistant (XDR)-TB, and equipment and commodities, as well as support for policy and strategy, guidelines, and evaluation related to new diagnostics. The Gene XPert diagnostic was endorsed by WHO in late 2010, and will be supported in up to three countries with this additional funding.

Public Health Evaluations

Funding will provide continued support to the Public Health Evaluation (PHE) program, which supports studies that guide PEPFAR in program and policy development, inform the global community, and identify areas where further evaluation and research may be needed. As PEPFAR implements scientific advances on a large-scale through its programs, PHE assesses the effectiveness and impact of PEPFAR programs on those at risk for and those infected or affected by HIV at community and national levels; compares evidence-based program models in complex health, social and economic contexts; and addresses operational questions related to program implementation within existing and developing health systems infrastructures. Emphasis is placed on addressing country-driven priorities and strategic priority questions that can inform and improve PEPFAR programming broadly, that PEPFAR is uniquely poised to address, and that take advantage of central coordination and support where appropriate.

These proposals will help support study effectiveness of HIV-treatment and prevention approaches already proven efficacious and effectiveness of “at scale” interventions. These studies will also support research of relevance to PEPFAR that will focus on the challenges being encountered by programs in resource-limited countries when they attempt to deploy effective prevention, treatment, and integrated interventions against HIV/AIDS.

The reauthorization of PEPFAR included as specific priorities promotion of research/evaluation and partnerships to increase human and institutional capacity to respond to the epidemic. To this end, the PHE program will work collaboratively with USG agencies to support research capacity building and provide technical assistance to strengthen capacity of host country program staff, researchers and institutions to conduct research and evaluation as an integral component of PEPFAR implementation. The intention is to strategically invest in a country-driven, strategic approach to research capacity in a way that leverages existing resources, makes a demonstrable improvement in the availability of data to inform national HIV prevention, care, and treatment programs, and contributes to the advancement and sustainability of broader health systems. This will help facilitate and strengthen core competencies of individuals, institutions, networks, communities, and systems within country to efficiently perform and achieve their objectives.

These funds will contribute support to a larger PEPFAR and international effort to build research capacity within partner countries. This effort will focus on a longer-term strategy to create sustainable country capacity in the research field, ensuring that recipients of this support will make substantive contributions to their countries and to the HIV/AIDS field in the future. PEPFAR will partner with select country programs and individuals, develop tailored strategies for capacity building, and support the training and mentoring of these individuals in the context of appropriately sized research projects.

Finally, funding will support new PHE studies. Approved new PHE concept studies include funds for 11 PHE studies in ten countries. The topics include the following areas: care and treatment; prevention of mother-to-child transmission (PMTCT); integration of care; evidence-based prevention in youth; cost-effectiveness of counseling and testing; point-of-care technologies; and training of community and health care workers. Continuation funding for PHE studies with approved protocols is also included for evaluations in the following areas: care and treatment; PMTCT/pediatrics; alcohol harm reduction; and strengthening HIV testing and treatment uptake.

Combination Prevention

Successful combination prevention entails choosing sets of HIV interventions that complement and strengthen each other. On their own, individual prevention interventions (e.g. condom promotion, partner reduction strategies, male circumcision, PMTCT etc) can have a proven effect on reducing the risk of HIV transmission. However, in recent years, the concept of combining interventions to maximize the potential influence and impact over behaviors and cultural norms has become a more common approach. In order to achieve impact on reducing HIV transmission these interventions must be appropriately targeted to specific populations, scaled for that population, and implemented with quality.

While individual prevention interventions have been well researched for impact on reducing HIV transmission, little data is available on the impact of combination prevention efforts and beyond modeling efforts, virtually no data is available on the impact of combination prevention on population level HIV incidence or which mix of interventions has the greatest impact or the degree of cost effectiveness of this approach. To address these questions, PEPFAR will support the implementation of three evaluation research studies that will evaluate the impact of specific combination prevention programs on population HIV incidence as well as a number of other endpoints related to behaviors and biomarkers. The studies will also include a cost-effectiveness analysis. All studies will be conducted in Africa where the HIV burden is the greatest and where prevention is of the highest priority. The studies will all be carried out in partnership with PEPFAR service delivery partners thereby ensuring ‘real-life’ program evaluation and to fully avoid any parallel research service delivery units from being formed.

Prevention is of critical importance and obtaining this data in order to assure that PEPFAR programs are implement in a cost-effective manner is vital. The funding for the combination prevention evaluation effort will provide rigorous data that will allow for informed decision and will further the field of prevention and evidence-based prevention programming.

Project Title: Department of Health and Human Services (HHS): Health Resources and Services Administration (HRSA), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $12,770,000

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

The American International Health Alliance Twinning Center strengthens the role of institutional relationships and long-term volunteers in supporting capacity development needs for in-country partners. It expands the pool of trained providers, managers, and allied health staff who can deliver quality HIV/AIDS care to patients and their families, and further promotes long-term sustainability through on-going ‘north-to-south’ and ‘south-to-south’ partnerships. FY 2010 funding will also support an evaluation of the Twinning Center.

I-TECH, in partnership with University of Washington, provides technical assistance and builds the capacity of the Caribbean HIV/AIDS Regional Training Network to strengthen the capacity of national healthcare personnel and systems to provide access to quality HIV/AIDS prevention, care, treatment and support services for all Caribbean people through the development of a sustainable training network. I-TECH is also developing an evaluation protocol for training associated with PEPFAR, which will be used at the individual health center level to perform a comprehensive assessment that will include an evaluation of the results of any training that has occurred and will also identify areas where training is needed. Funding will support I-TECH’s close collaboration with HRSA to develop a Training Evaluation Framework to assess linkages between training and health service delivery. The evaluation framework will guide training program and strategy evaluations. The framework and tools will be piloted in two countries.

The Columbia University ICAP Nurse Capacity Building Initiative strengthens the overall capacity of the health care delivery system by cultivating a network to provide in-depth clinical training about HIV/AIDS; mentoring; integrating HIV/AIDS education into nursing curricula; and developing a regional, African association of nurses in HIV/AIDS care.

CAREWare is a comprehensive and customizable electronic health record developed and supported by the HIV/AIDS Bureau in HRSA. CAREWare fills an important health information technology role in select countries (Nigeria, Uganda, and Vietnam).

The International Quality Improvement Center is a capacity-building initiative. A leadership team based at the Ministry of Health in each country provides coaching to clinic sites to strengthen systems of care. The Center, in coordination with other agencies, will develop a strategy for implementing recommended QI/QA interventions associated with integration of nutrition assessment, counseling and support within greater HIV/AIDS care and support services.

FY 2010 funding will provide supplemental program evaluation, staff development activities, and logistic support and support conducting programmatic assessments of partners and sites receiving USG funding for HIV/AIDS care and treatment in PEPFAR countries.

Medical and Nursing Education Partnership Initiative

Finally, HHS/HRSA is partnering with PEPFAR to invest more than $100 million over five years to transform African medical education and dramatically increase the number of health care workers. Through the Medical and Nursing Education Partnership Initiative (MEPI and NEPI, respectively), grants have been awarded directly to African institutions in a dozen countries, working in partnership with U.S. medical schools and universities. The initiative will form a network including about 30 regional partners, country health and education ministries, and more than 20 U.S. collaborators.

The NEPI awards are provided to support government responses (national and institutional) to address the severe shortage of nurses and midwives in the areas of recruitment, training and education, and retention of qualified nurses. Activities proposed for these awards are determined by the Ministries of Health and Social Welfare in collaboration with other government (including the Ministry of Education) and institutional stakeholders (e.g., nursing and midwifery councils and associations) in the country. In September 2010, three countries were selected and awarded NEPI grants, Malawi, Lesotho, and Zambia. These countries have been provided support by HRSA through the Columbia University ICAP Nursing Capacity Project to complete a national survey on nursing and midwifery capacity needs and, based on survey results, to engage in a process to establish a national strategic plan on the use of the awards to strengthen nursing capacity. Once the plans are completed, support will be provided directly from HRSA ICAP projects to support interventions at the institutional level.

Project Title: Department of Health and Human Services (HHS): Office of Global HIV/AIDS (OGHA), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $24,000,000

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

The implementation of HHS-funded “Track 1.0” antiretroviral treatment (ART) programs is being transitioned from international non-governmental organizations to Ministries of Health and other local organizations to ensure indigenous leadership and sustainable support for HIV services that are integrated into host country national systems. To support this transition, HRSA and CDC will work in collaboration to provide technical assistance to maximize the limited resources and harness the comparative advantages. HRSA will continue to fund organizational assessments of local organizations for their ability to take on the management of the programs, using teams of highly qualified consultants, along with in-country experts adding additional perspective and expertise. CDC will provide TA and provide capacity-building support in strategic planning, project management, and financial and grants management, in addition to specific technical program areas, to ensure that MOH and other indigenous partners are capable of managing additional responsibilities and funding through direct USG awards as prime partners.

Medical and Nursing Education Partnership Initiative

FY 2010 funding will also support the Medical Education Partnership Initiative (see above).

The MEPI supports innovative models of medical education which strengthen pre-service training and education of medical students and build clinical and research capacity focused on PEPFAR priority areas and other country specific public health concerns and chronic non-communicable diseases. The MEPI awards were announced in October 2010 and directly support 13 African institutions in 12 countries, creating a network of 30 regional partners and more than 20 U.S. collaborating institutions. In addition to supporting pre-service training to address the HIV/AIDS pandemic in Sub-Saharan Africa, with funding from the NIH, awards also focus on expanding training into other critical areas such as maternal, neonatal, and child health and non-communicable diseases.

Project Title: Department of Health and Human Services (HHS): National Institutes of Health (NIH), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $20,000,000

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

Public Health Evaluations

FY 2010 GHCS-State funding will provide continued support to PHE program through NIH, which supports studies that guide PEPFAR in program and policy development, inform the global community, and identify areas where further evaluation and research may be needed.

In collaboration with OGAC, NIH will solicit applications which will inform PEPFAR on effective and efficient approaches to HIV prevention, care and treatment. These proposals will help support study effectiveness of HIV-treatment and prevention approaches already proven efficacious and effectiveness of “at scale” interventions. These studies will also support research of relevance to PEPFAR that will focus on the challenges being encountered by programs in resource-limited countries when they attempt to deploy effective prevention, treatment, and integrated interventions against HIV/AIDS.

Combination Prevention

To address questions regarding successful combination prevention, PEPFAR will provide in funding for evaluation of implementation of combination prevention, through NIH in collaboration with CDC, USAID, and OGAC.

Project Title: Department of State (DoS): Office of the Global AIDS Coordinator (OGAC), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $196,932,995

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

Headquarters programs fund activities and collaborations that reinforce the aims of country ownership and sustainability in-country, in coordination with the PEPFAR Five-Year Strategy and Global Health Initiative (GHI) goals. FY 2010 GHCS-State funding will support programs and technical assistance in the following areas: strategic information systems; evaluation and research; technical assistance support; PEPFAR data collection and database development; evidence-based prevention; integrated food and nutrition support within HIV/AIDS care and treatment; gender programs driven by a women- and girl-centered approach; multilateral diplomacy and collaboration; and the implementation of country-directed responses to the HIV/AIDS epidemic.

Some of the specific projects and initiatives planned in FY 2010 to support PEPFAR in response to the field program needs include:

Food and Nutrition Programming

FY 2010 GHCS-State funding will support both new and ongoing efforts to integrate food and nutrition (FN) support as a critical component of comprehensive HIV/AIDS care and treatment. Integration will take place within both clinical and community services. The focus will be on ensuring that nutrition assessment, counseling, and support, including specialized food products, micronutrient supplementation and household water treatment, are routinely provided to OVC, pre- and postnatal women in PMTCT programs, and adult and pediatric HIV patients prior to and during ARV treatment. In addition, funding will support the provision of assistance to PLWHA and their families to strengthen household capacity to meet their food and other basic needs. Countries and proposals slated to receive additional FY 2010 funding in support of FN activities will be assessed in relation to factors such as PEPFAR response to target groups, absorptive capacity of ongoing FN programs, size of PEPFAR budget, and food insecurity, in order to identify priority countries for additional FN funding. Dialogue with priority countries will confirm their ability to initiate or expand FN programming and the funding levels required for this expansion.

Scale-Up of Gender Programs

Funding for the scale-up of gender programs will support the Gender Challenge Fund as well as the scale-up of gender-based-violence (GBV) programming in three countries.

The Gender Challenge Fund is structured to leverage country PEPFAR funds to advance key gender-related issues and programs based on pre-established criteria. These funds will enable countries to allocate new funding for gender activities, and OGAC will match these funds based on an interagency review process of proposals. Activities will be aligned with the five strategies to address gender issues within PEPFAR: (1) Increasing gender equity in HIV/AIDS activities and services, including strengthening linkages with reproductive health; (2) addressing male norms and behaviors; (3) reducing violence and coercion; (4) increasing women’s access to education, income and productive resources, and (5) increasing women’s legal rights and protection.

Funding will also be used to support the ongoing work to strengthen gender in PEPFAR programs. Funding will primarily support ongoing efforts to scale-up the response to GBV in three countries: Democratic Republic of Congo, Mozambique, and Tanzania. GBV fosters the spread of HIV/AIDS because it limits women’s and girls’ ability to negotiate sexual practices, to disclose HIV status and to access services due to fear of GBV. Funds will expand access to post-rape care, as well as work to change social norms that enable GBV through policy and legal level changes, communication, and social mobilization. In addition, funding will be used to further strengthen gender programming at HQ, by supporting technical assistance and outreach activities to better coordinate our gender programming both within and outside USG.

Strategic Information Model Country Initiative

FY 2010 funding will provide support to the PEPFAR Strategic Information (SI) Model Country Initiative, a substantial one-time supplement to the SI budgets of two countries to promote the advancement and sustainability of national SI systems to improve HIV prevention, care, and treatment in the receiving countries. The intention is to strategically invest in a country-driven, strategic approach to SI systems and SI capacity in a way that leverages existing resources (especially those from PEPFAR, Global Fund, World Bank, and partner country governments), makes a demonstrable improvement on national HIV prevention, care, and treatment programs, and contributes to the advancement and sustainability of broader health systems.

Selection of the two countries will occur through a request for proposals (RFP) process that will allow for interested country teams to work with all appropriate country stakeholders to develop and present a strategic approach that best aligns with and leverages current activities in country. Critical to this proposal is the demonstration of a strong governmental leadership, political will, and country-ownership philosophy, as well as the inclusion of Global Fund stakeholders and other donors in all appropriate areas. This model also requires a strong, collaborative, and effective in-country USG team willing to help facilitate and support the implementation of the proposed initiative.

Fundamental to this broad approach is building and maintaining structural/environmental, organizational, and individual capacity that includes capacity assessment, implementation of blended capacity building strategies, and monitoring of progress toward sustainable capacity in SI. Countries will submit a proposal with goals, objectives, a collaborative implementation process, methods to measure progress toward the goals, and a general timeline and budget. Countries will also be expected to describe their “baseline” of existing SI systems, and their expectations of innovation and achievement in SI systems and capacity. Initial steps following identification of the two countries will involve a review of all pertinent baseline system data, and if necessary, the actual implementation of a comprehensive national SI assessment. To the extent possible, any assessment should utilize international standards, tools and approaches, and adapt to the local context to provide the basis for a formal implementation plan. This plan, developed by all stakeholders, will detail the relevant activities, with associated targets, benchmarks, timelines, budgets, and identification of responsible parties.

Global Fund Technical Assistance and Staffing for Collaboration

The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is one of the most important partners for the USG in the fight against these three diseases. As a partnership among governments, civil society, the private sector and affected communities, the Global Fund represents an innovative approach to international health financing, which supports country-owned programs according to principles of performance-based funding, represents a key opportunity for supporting country ownership, promoting sustainability, and leveraging additional financing from other donors complements our bilateral programs and is critical to our success in achieving our global health goals. However, the Global Fund model presents new challenges in terms of building capacity for oversight and implementation of grants and collaboration with other donors.

The Global AIDS Coordinator is authorized and has acted on the ability to withhold up to five percent of the USG contribution to the Global Fund for the purpose of technical assistance (TA) programs. Given the importance of this work in contributing to the Global Health Initiative GHI goals and ensuring the mutual success of PEPFAR and Global Fund HIV/AIDS programs, this additional funding will contribute to expanding the scope of support provided to Global Fund programs through PEPFAR headquarters and field teams.

Funding for TA to Global Fund HIV/AIDS grants will be used in approximately five countries to support a range of activities identified through the PEPFAR country teams in conjunction with the Global Fund Country Coordinating Mechanisms (CCMs) and Principle Recipients (PRs). In the short term, these activities may include: technical support needs assessments, TA Planning, building CCM governance and organizational capacity to do grant oversight, and strengthening management and oversight linkages between PRs and Sub-Recipients (SRs). These funds will be used over a two-year period, during which time they may also be used to strengthen the procurement and supply chain management (PSM), monitoring and evaluation (M&E) and financial systems of PRs, build organizational capacity within PRs and SRs, and increase the capacity of the CCM secretariat. The approximately six countries will be chosen through a collaborative interagency process with PEPFAR headquarters and country staff, as well as with the Global Fund.

This funding will also support increasing on-the-ground, USG personnel dedicated to Global Fund issues in 10-12 countries in order to support the Missions in their efforts to manage the USG relationship with the Global Fund, to increase coordination and collaboration between Global Fund grants and USG programming, and to support Global Fund grant management and oversight, including through the provision of technical assistance. Through the existing USG Global Fund TA portfolio, the USG has already placed a number of personnel into these types of positions to support the three diseases, and based on the need expressed by countries, PEPFAR aims to expand the scope. This funding may also support extended contracts for some of the existing personnel where the advent of these positions has been particularly successful.

It is anticipated that comprehensively these activities will contribute to successful grant implementation, improved coordination and collaboration with USG programs, and ensure adequate capacity at the country level to effectively manage Global Fund resources.

Country Ownership Program Implementation

Country ownership represents an important concept in supporting the growing commitment of the donor community and partner countries to promote and operationalize a country-directed response to their HIV/AIDS epidemic. Responding to the policy directives from the end of the first phase of PEPFAR and the PEPFAR II Five-Year Strategy, the Partnership Frameworks (PFs) under development between the USG and partner countries have provided an inroad for discussions on country ownership given the aims of the PFs, such as: strengthening partner country leadership and decision making; promoting engagement with civil society and communities of persons living with HIV/AIDS; and supporting a greater role for government in financial management and accountability. This purposeful shift in approach to engagement with partner countries represents an opportunity to have a transparent dialogues on long-standing issues, including the process for prioritization of health and HIV issues, addressing management and leadership capacity, budget negotiations and financial management, and approaches to technical support that leave real and lasting capacity within a country. Implementation of the Global Health Initiative necessitates levels of collaboration and integration of donor resources and funding streams that will be best realized by continuing to build indigenous capacity and leadership and systems upon which multiple health issues can be addressed.

PEPFAR will engage in processes at country level, beginning work in a small number of countries and then expanding to others, based on this experience. Countries selected will take into consideration: current leadership in addressing HIV/AIDS issues; country vision in alignment with the PEPFAR strategy; country size and ease of demonstrating a change through greater focus on country ownership; capacity for leadership and management have been enhanced by similar approaches of other donors; and selection as a GHI Plus country. With the aim of moving country ownership from the PEPFAR strategy into tangible action, FY 2010 funds will support: the preparation of USG teams for a shift in their approach and/or focus of activity; in-country political negotiations; prioritization of areas of focus, assessments and development of project plans; and implementation of project plans.

As a follow-on to the planning and assessment phase, additional FY 2010 funding will support anticipated country ownership activities in up to four countries. The Global AIDS Coordinator is currently initiating focused discussions and assessments on barriers to full indigenous country ownership of HIV/AIDS policy and program development with Botswana and South Africa, and anticipates engaging with Malawi, Rwanda, and Tanzania in the near term. These discussions and assessments of leadership, management, and health system infrastructure will result in the identification of priorities that will address deficits in systems and/or quality of program delivery and will require subsequent financial inputs. While funding assocated with PFs is ideally suited to support priorities that would enhance country leadership and management of their HIV/AIDS epidemic and donor funding, it is anticipated that due to the timing of country ownership prioritization country budgets will be already fully programmed and new funds will not be available until FY 2012. Thus, this funding will ensure that efforts to enable countries to increase their ownership and leadership of their programs will not be delayed.

Country ownership initiatives will be planned through PEPFAR Operational Plan and PF funding in future years. One of the primary mechanisms through which country programs will work toward accomplishing the goals of country ownership and sustainability will continue to be through the negotiation and implementation of PFs with partner country governments and the development and implementation of GHI strategies.

Public Health Evaluations

Additional FY 2010 GHCS-State funding will provide continued support to the PHE program though OGAC, which supports studies that guide PEPFAR in program and policy development, inform the global community, and identify areas where further evaluation and research may be needed (see above).

Combination Prevention

To address questions regarding successful combination prevention, PEPFAR will provide funding for evaluation of implementation of combination prevention, through NIH in collaboration with CDC, USAID, and OGAC (see above).

Institute of Medicine: Phase II of Evaluation of Programs Implemented under the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008

This Congressionally-mandated task is an assessment of the performance of the United States-assisted global HIV/AIDS programs and an evaluation of the impact on health of prevention, treatment, and care efforts that are supported by United States funding, including multilateral and bilateral programs involving joint operations.

Congress asked that the IOM study include the following as part of its evaluation:

  • An assessment of progress toward prevention, treatment, and care targets
  • An assessment of the effects on health systems, including on the financing and management of health systems and the quality of service delivery and staffing
  • An assessment of efforts to address gender-specific aspects of HIV/AIDS, including gender-related constraints to accessing services and addressing underlying social and economic vulnerabilities of women and men
  • An evaluation of the impact of treatment and care programs on 5-year survival rates, drug adherence, and the emergence of drug resistance
  • An evaluation of the impact of prevention programs on HIV incidence in relevant population groups
  • An evaluation of the impact on child health and welfare interventions authorized under this Act on behalf of orphans and vulnerable children
  • An evaluation of the impact of programs and activities authorized in this Act on child mortality
  • Recommendations for improving the HIV/AIDS programs implemented under the U.S. Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.

In this phase, the evaluation committee will produce one consensus report with its findings and recommendations. This report is targeted for delivery to Congress in late 2012.

Project Title: Department of State (DoS): Africa Bureau (AF), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $105,000

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

Complex public health jobs in support of PEPFAR activities are not widely understood in the DOS Human Resources position classification process. The position classification of the work performed by locally employed staff in support of PEPFAR varies widely between Posts and Agencies. This initiative aims to standardize through framework job descriptions (FJD) the classification of 50 complex PEPFAR position descriptions while correcting misclassified positions impacting recruitment and retention. This interagency initiative requires extensive coordination with technical and programmatic subject matter experts and DOS HR professionals, as well as with experts from USAID and HHS in particular. Interagency FJD implementation training workshops will ensure uniform classification accuracy across the PEPFAR programs. Fourteen FJDs have already been completed at grades 12-13, of which 11 have been cleared and disseminated for use. Additional funding will support the completion of FJDs are grades 9-11.

Project Title: U.S. Agency for International Development (USAID), Technical Leadership and Support Projects

Budget: FY 2010 Approved GHCS-State Funding: $116,324,101

Program Description:

Projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

Technical Leadership and Support programs fund technical assistance and other activities to further PEPFAR policy and programmatic objectives in the field, at headquarters, and internationally. In addition to supporting USG technical assistance, this program utilizes existing contractual and grant mechanisms within USAID. Key activities include:

  • Using standing contracts and grants to facilitate access to technical expertise for program design, strategy development, and general support of field programs and policy development;
  • Directing and providing scientific and technical assistance and monitoring of central cooperative agreements for field programs (e.g., abstinence and be faithful, orphans and vulnerable children, and safe medical injections programs); and
  • Providing technical assistance to country programs (e.g., through direct assistance by USAID program and scientific experts from a variety disciplines including medical officers/physicians, health scientists, epidemiologists, public health advisors, AIDS education and training experts, statisticians and informaticians).

Some of the specific projects planned in FY 2010 to support PEPFAR in response to the field program needs include:

South Africa Antiretroviral (ARV) Procurement

South Africa has the world’s largest population of people living with HIV/AIDS, and also the largest treatment program. There are approximately 950,000 South Africans currently on treatment and a South African Government-projected scale-up of 45,000 new patients each month; however, this current figure on treatment represents just under 50% of those actually needing treatment. The prior South African Government (SAG) administration denial of HIV and of internationally-accepted treatment contributed to a lack of resources and restricted access to HIV/AIDS services – thereby resulting in hundreds of thousands of needless deaths. After years of neglect, the new SAG leadership is now committed to reforming HIV/AIDS policies, and the U.S. Government (USG) has a unique opportunity to support this administration’s efforts. Given drastic increases in demand for ARV services, coupled with the current economic downturn, the SAG faces immediate-term financial challenges. The SAG formally asked the USG, through PEPFAR, to provide additional funding for ARV drugs during a projected two-year financial shortfall. PEPFAR will meet this request with a total of $120 million, to be divided by $60 million each in FY 2009 and FY 2010. FY 2010 funding will continue to support SAG efforts to cover current patients on treatment while assisting the SAG to prepare for a massive scale-up effort for treatment. This support is contingent upon demonstrated progress by the SAG in establishing a financial plan to avoid future shortfalls, and the establishment of national HIV/AIDS/TB/STI oversight roles and functions within the National Department of Health. The SAG is taking immediate measures to build capacity within its National and Provincial Departments of Health to strengthen logistics and forecasting capacities. The NDOH, with PEPFAR-supported technical assistance, is addressing a number of related systematic weaknesses through ARV costing exercises and modifications to tender policies so as to reduce drug procurement costs in the future. In addition, the SAG National Treasury is engaged in this ongoing costing and analysis, with the intent to allow planning for additional resource allocation beyond the current two years, incorporating all additional ARV costs in their budget planning for FYs 2012-2013. Progress is ongoing and the RSA team reports on a regular basis in the rapidly evolving environment in RSA.

Some immediate progress has already been achieved since the provision of the initial $60 million in FY 2009 PEPFAR funding. First, the USG has been given a special exemption from single exit pricing for this ARV support. Also, the SAG is already revising its ARV tender policy to drive down procurement costs of ARVs and the NDOH has reorganized to take on an oversight role of HIV/STIs and empowered SANAC to tackle HIV/AIDS. The president has garnered significant support from high levels of government, including getting the cabinet to "own" the problem and initiate a massive national testing campaign for renewed emphasis on attaining NSP goals. Finally, national ARV treatment guidelines have been revised and updated to initiate children, pregnant women, and HIV/TB co-infected persons to ARVs per the latest WHO guidelines.

TB/HIV Scale-Up

TB is the leading cause of morbidity and mortality among HIV-infected persons in sub-Saharan Africa. FY 2010 funding will be used to implement critical TB/HIV activities that have long been articulated through WHO normative guidance but for which uptake has lagged, either due to stovepiped programming, resistance to program aspects, incompatible programs’ cultural schisms and vastly different modalities of implementation. Interventions will be included as a “package of care” building on the successful HIV package of care modality. This project will demonstrate a reduction in incidence of TB and a reduction in TB mortality among HIV infected persons by scale-up of implementation of a package of TB/HIV interventions in four sub-Saharan countries. The package of services will include the scale-up of country-wide intensified TB case finding, improved TB infection control best practices, isoniazid preventive therapy, HIV testing and counseling of all TB patients, and ART for all HIV-infected TB patients.

While initially targeting a region or province(s) in a country, these activities are unique in that they will be based on joint planning between PEPFAR, USAID, and Global Fund TB and HIV-supported programs in collaboration with National TB and AIDS Programs. This approach will increase efficiencies and rationalization of programming across major funding sources and will contribute to overall strengthening of national TB and HIV programs. To maximize access to expertise of CDC and USAID staff and partners, the project is a joint USG project with both agencies in the lead roles for designing the protocol, selecting the countries, and implementation of the project at country level. Country-specific selection of partners and mechanisms will be determined by consensus by an interagency TB/HIV working group that will manage implementation, in consultation with field representatives.

Funding will support the implementation of newly-approved rapid tuberculosis (TB) diagnostics in PEPFAR-supported settings, including rapid detection of multi drug- resistant (MDR)-TB, and extremely drug-resistant (XDR)-TB, and equipment and commodities, as well as support for policy and strategy, guidelines, and evaluation related to new diagnostics. The Gene XPert diagnostic was endorsed by WHO in late 2010, and will be supported in up to three countries with this additional funding.

Public Health Evaluations

FY 2010 GHCS-State funding will provide continued support to the PHE program through USAID, which supports studies that guide PEPFAR in program and policy development, inform the global community, and identify areas where further evaluation and research may be needed (see above).

Combination Prevention

To address questions regarding successful combination prevention, PEPFAR will provide funding for evaluation of implementation of combination prevention, through USAID in collaboration with CDC, NIH, and OGAC (see above).

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