New Directions

This global epidemic requires a comprehensive, multisectoral approach that expands access to prevention, care and treatment. As PEPFAR works to build upon its successes, it will focus on transitioning from an emergency response to promoting sustainable country programs.

Sustainable programs must be country-owned and country-driven. Given that the AIDS epidemic represents a shared global burden among nations, the next phase of PEPFAR represents an opportunity for the United States to support shared responsibility with partner countries. To seize this opportunity, PEPFAR is supporting countries in taking leadership of the responses to their epidemics. In addition, to support an expanded collective impact at the country level, PEPFAR is increasing collaboration with multilateral organizations.

Sustainable programs must address HIV/AIDS within a broader health and development context. PEPFAR must be responsive to the overall health needs faced by people living with HIV/AIDS (PLWHA), their families, and their communities, linking the HIV response to a diverse array of global health challenges. As a component of the Global Health Initiative, PEPFAR will be carefully and purposefully integrated with other health and development programs.

Integration expands country capacity to address a broader array of health demands and to respond to new and emerging challenges presented by HIV. Strategic coordination furthers the reach of bilateral assistance, leverages the work of multilateral organizations, promotes country ownership, and increases the sustainability of national health programs.

Sustainable programs must build upon our strengths and increase efficiencies. PEPFAR is renewing its emphasis on a "whole of government" response, ensuring that agencies focus on core competencies and better coordination to maximize the effectiveness of U.S. Government (USG) assistance. It is also identifying and implementing efficiencies in its work at both field and headquarters levels to ensure value for money. To build upon the strengths of proven programs, PEPFAR is scaling up effective interventions, particularly in prevention. Finally, it is working to ensure that increased access to coverage is accompanied by an emphasis on quality of services.

PEPFAR's Goals:

1. Transition from an emergency response to promotion of sustainable country programs.
2. Strengthen partner government capacity to lead the response to this epidemic and other health demands.
3. Expand prevention, care, and treatment in both concentrated and generalized epidemics.
4. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems.
5. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.

PEPFAR's Targets from Fiscal Year (FY) 2010- FY 2014:^*

Prevention

• support the prevention of more than 12 million new HIV infections;
• ensure that every partner country with a generalized epidemic has both 80% coverage of testing for pregnant women at the national level, and 85% coverage of antiretroviral drug (ARV) prophylaxis and treatment, as indicated, of women found to be HIV-infected;
• double the number of at-risk babies born HIV-free, from the 240,000 babies of HIV-positive mothers who were born HIV-negative during the first five years of PEPFAR;
• in every partner country with a generalized epidemic, provide 100% of youth in PEPFAR prevention programs with comprehensive and correct knowledge of the ways HIV/AIDS is transmitted and ways to protect themselves, consistent with Millennium Development Goal indicators in this area.

Care and Support and Treatment

• provide direct support for more than 4 million people on treatment, more than doubling the number of people directly supported on treatment during the first five years of PEPFAR;^*
• support care for more than 12 million people, including 5 million orphans and vulnerable children (OVCs); and
• ensure that every partner country with a generalized epidemic reaches a threshold of 65% coverage for early infant diagnosis at the national level, and testing of 80% of older children of HIV-positive mothers, with increased referrals and linkages to care and treatment.

Sustainability

• support training and retention of more than 140,000 new health care workers to strengthen health systems;
• in order to support country ownership, ensure that in each country with a major PEPFAR investment (greater than $5 million), the partner government leads efforts to evaluate and define needs and roles in the national response; and
• ensure that in every partner country with a Partnership Framework, each country will change policies to address the larger structural conditions, such as gender-based violence, stigma, or low male partner involvement, which contribute to the spread of the epidemic.

Programmatic Strategy

In this second phase of PEPFAR, a new program strategy is underway that supports the Administration's overall emphasis on improving health outcomes, increasing program sustainability and integration, and strengthening health systems. Some of these changes are already being implemented with planning and programming for FY 2010. Over the next year, PEPFAR will be working closely with country teams in order to translate, prioritize, and implement this strategy in a manner appropriate to the country context. More information on the broader strategic framework for PEPFAR activities can be found in the strategy annexes which will be made available at www.pepfar.gov/strategy.

Prevention

Prevention remains the paramount challenge of the HIV epidemic, and the major priority for the next five years of PEPFAR. Successful prevention programs require a combination of evidence-based, mutually reinforcing biomedical, behavioral, and structural interventions. PEPFAR is expanding its prevention activities with an emphasis on the following:

• Working with countries to track and reassess the epidemiology of the epidemic, in order to fashion a prevention response based on best available and most recent data;
• Emphasizing prevention strategies that have been proven effective and targeting interventions to most at-risk populations with high incidence rates; and
• Increasing emphasis on supporting and evaluating innovative and promising prevention methods.

Linking HIV/AIDS to Women's and Children's Health

According to the World Health Organization (WHO), AIDS is the leading cause of death among women aged 15-44 worldwide.¹ Nearly 60% of those living with HIV in sub-Saharan Africa are women.² UNICEF estimates that nearly 12 million children in sub-Saharan Africa have lost one or both parents to HIV/AIDS.³ Women and children living with HIV also face other conditions, ranging from inadequate access to family planning to lack of antenatal care to the need for food and nutrition support. As part of its overall prevention, care and support, and treatment efforts, PEPFAR is leveraging and linking HIV services to broader delivery mechanisms that improve health outcomes for women and children. Some of these activities include:

• Increasing investment in prevention of mother-to-child transmission to meet 80% coverage levels in HIV testing and counseling of pregnant women and 85% coverage levels of ARV prophylaxis for those women who test positive;
• Increasing the proportion of HIV-infected infants and children who receive treatment commensurate to their representation in a country's overall epidemic, helping countries to meet national coverage levels of 65% for early infant diagnosis, and doubling the number of at-risk babies born HIV-free;
• Expanding integration of HIV prevention, care and support, and treatment services with family planning and reproductive health services, so that women living with HIV can access necessary care, and so that all women know how to protect themselves from HIV infection;
• Strengthening the ability of families and communities to provide supportive services, such as food, nutrition, education, livelihood and vocational training, to orphans and vulnerable children; and
• Expanding PEPFAR's commitment to cross-cutting integration of gender equity in its programs and policies, with a new focus on addressing and reducing gender-based violence.

Treatment

PEPFAR's treatment programs provide essential medications to more than two million people. PEPFAR also contributes to the strengthening of the health systems needed to deliver these drugs in low-resource settings. In addition, PEPFAR serves populations with special treatment needs, like children. Together, all global efforts support approximately four million people on antiretroviral treatment, but at least five million more are still in need of ARV drugs.⁴ This figure will likely double with the recent revision of WHO recommendations for treatment initiation. As part of its reauthorization, PEPFAR was charged with supporting increased treatment commensurate with increased appropriations and efficiencies realized. PEPFAR's treatment strategy over the next five years emphasizes the following activities:

• Directly supporting more than 4 million people on treatment, more than doubling the number of patients directly supported by PEPFAR in its first five years;
• Scaling up treatment with a particular focus on serving the sickest individuals, pregnant women and those with HIV/TB coinfection;
• Increasing support for country-level treatment capacity by strengthening health systems and expanding the number of trained health workers; and
• Working with countries and international organizations to develop a shared global response to the burden of treatment costs in the developing world, and assisting countries in achieving their defined treatment targets.

Health Systems Strengthening

PEPFAR has had a positive impact on the capacity of country health systems to address the WHO's six building blocks of health systems functions. However, the program to date has not placed a deliberate focus on the strategic strengthening of health systems. In its next phase, PEPFAR is working to enhance the ability of governments to manage their epidemics, respond to broader health needs impacting affected communities, and address new and emerging health concerns. PEPFAR now emphasizes the incorporation of health systems strengthening goals into its prevention, care and treatment portfolios. Doing so will help to reduce the burden of HIV/AIDS on the overall health system. Planned activities include the following:

• Training and retention of health care workers, managers, administrators, health economists, and other civil service employees critical to all functions of a health system;
• Implementing a new health systems framework to assist country teams in targeting and leveraging PEPFAR activities in support of a stronger country health system;
• Supporting efforts to identify and implement harmonized health systems measurement tools; and
• Coordinating USG activities across multilateral partners to leverage and enhance broader health system strengthening activities.

Country Ownership

PEPFAR's commitment to the principles of country ownership highlights a new focus on engaging in true partnership with countries. These partnerships pave the way for new approaches to foreign assistance based upon principles and directions common to partner country plans and USG objectives. Over the next five years, PEPFAR's emphasis on country ownership will include:

• Continuing bilateral engagement through its Partnership Frameworks and other efforts to promote and develop a more sustainable response to the local epidemic, whether concentrated or generalized;
• Ensuring that the services PEPFAR supports are aligned with the national plans of partner governments and integrated with existing health care delivery systems;
• Strengthening engagement with diplomatic efforts at all levels of government to raise the profile and dialogue around the AIDS epidemic and its linkages with broader health and development issues;
• Expanding technical assistance and mentoring to country governments, in order to support a capable cadre of professionals to carry out the tasks necessary for a functioning health system; and
• Partnering with governments through bilateral, regional and multilateral mechanisms to support and facilitate South-to-South technical assistance.

Integration

As the largest component of President Obama's Global Health Initiative, PEPFAR is actively working to enhance the integration of quality interventions with the broader health and development programs of the USG, country partners, multilateral organizations, and other donors. Through activities like co-location of services and expanded training of health care workers, PEPFAR can expand access to overall care and support for infected and affected individuals. As noted earlier, a particular focus of PEPFAR's integration is to expand access to care for women and children. PEPFAR is also emphasizing engagement with broader health and development programs. Some examples include:

• Expanding HIV/TB integration by ensuring that PLWHA are routinely screened and treated for TB, and that people with TB are tested for HIV and referred, with follow up, for appropriate prophylaxis and treatment;
• Linking PEPFAR food and nutrition programs with the new USG Global Hunger and Food Security Initiative;
• Expanding partnerships with education, economic strengthening, microfinance, and vocational training programs; and
• Promoting accountable and responsive governance through increased bilateral engagement and capacity building with partner governments.

Multilateral Engagement

PEPFAR is part of a shared global responsibility to address global health needs. Its success has been closely linked to the success of newer multilateral initiatives such as the Global Fund for AIDS, Tuberculosis and Malaria (Global Fund), and long-standing multilateral organizations including the Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO. PEPFAR is expanding its multilateral engagement with the goal of strengthening these institutions and leveraging their work to maximize the impact of PEPFAR. PEPFAR's multilateral engagement includes a new emphasis on the following:

• Supporting the Global Fund's efforts to improve oversight, grant performance, and its overall grant architecture in order to position it as a key partner for PEPFAR;
• Supporting UNAIDS efforts to mobilize global action and facilitate adoption of country-level changes that allow for rapid scale-up of key interventions;
• Negotiating a strategic framework for greater PEPFAR-WHO engagement; and
• Increasing coordination with multilateral development banks to improve the performance of health systems investments and better integrate with their broader economic development efforts.

Monitoring, Metrics and Research

PEPFAR's work can and should be systematically studied and analyzed to help inform public health and clinical practice. PEPFAR is not a research organization, but is expanding its current partnerships with implementers, researchers, and academic organizations to improve the science that guides this work. As PEPFAR transitions to support sustainable, country-led systems, it will improve efforts to contribute to the evidence base around HIV interventions, as well as broader health systems strengthening and integration. Over its next phase, PEPFAR will support the following new initiatives:

• Building the country capacity necessary to implement and maintain a fully comprehensive data use strategy;
• Reducing the reporting burden on partner countries and supporting transition to a single, streamlined national monitoring and evaluation system; and
• Working to expand publicly available data.

^* For more information on PEPFAR's data collection, please visit: www.pepfar.gov/2009results/.

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