Integration has the potential to improve overall health outcomes, create synergies across health and development programs, and promote sustainability with increased efficiency of service delivery. The structural conditions that contribute to HIV infection must be addressed through integrated efforts of multiple sectors that incorporate social, economic, gender, education, and legal interventions. PEPFAR is working at the headquarters level to promote greater integration and synergies in all its programming. However, the practical integration of programs must happen at the country level, based upon country priorities, country opportunities, and the realities of the epidemic at the ground level. Many field programs have provided important lessons learned in program integration to better serve populations. The following are examples of areas where PEPFAR is working over its next phase:
TB is the leading cause of death among individuals with HIV/AIDS in Africa.6 Of the more than 9.2 million new TB cases reported by WHO in 2007, an estimated 1.37 million are related to HIV.7 The prevalence of HIV infection among patients in TB clinical settings is extremely high. In addition, the emergence of multi-drug-resistant (MDR) and extensively drug-resistant (XDR) TB creates additional challenges in expanding HIV care and treatment. Given the overlap in patient populations and the susceptibility of PLWHA to TB infection, PEPFAR is expanding coordination with USG TB programming in the following ways:
Reducing the burden of TB in PLWHA through provision of routine screening, diagnosis, treatment, and prevention of TB among PLWHA
PLWHA have multiple interactions with the health care system, creating opportunities to monitor the progression of HIV-related illness and prevent, identify, and treat opportunistic infections like TB. To avoid additional morbidity and mortality, each person identified as HIV-positive through a PEPFAR-supported testing and counseling program should be screened for TB. Individuals already in HIV treatment or care programs should also receive routine TB screening. Coinfected clients will receive cotrimoxazole, ART, and TB treatment (including isoniazid prophylaxis in patients without active TB and, as applicable, treatment with anti-mycobacterial drugs). As effective successor TB treatments and improved diagnostics become available, PEPFAR will work with countries to incorporate them as appropriate. PEPFAR is also supporting efforts to prevent nosocomial transmission among highly susceptible individuals and health care workers.
Reducing the burden of HIV in persons with TB through provision of routine HIV testing and counseling and ensuring appropriate referrals to care
As HIV testing and counseling is the entry point for HIV care and treatment, PEPFAR supports scaling up provider- initiated testing and counseling in TB clinical settings. Although a large number of TB patients are identified as HIV-positive after being tested in TB clinic settings, many of these individuals do not receive HIV care and treatment. The referral and follow-up of patients from TB sites to HIV care and treatment sites will be strengthened. Doing so improves access and use of both HIV/TB services and broader health care services integrated as part of the GHI. These efforts will be tied to more aggressive efforts to identify and refer partners of PLWHA to testing and counseling.
Engaging in health systems strengthening through HIV/TB
The lack of an adequate and well-trained cadre of health care workers is a constant challenge in the effort to identify and serve coinfected populations. Innovative approaches that strengthen health systems overall can ameliorate this situation. For examples, task-shifting can increase capacity to provide needed services for HIV and TB testing and counseling. The foundation of successful TB diagnosis and treatment programs for PLWHA is a strong laboratory system that includes microscopy, TB culture, and drug-susceptibility testing (DST) capacity. As PEPFAR works with countries to engage in clinic renovation and reconstruction, it will support designs that allow for better infection control. With international partners, PEPFAR is also introducing new laboratory methodologies able to rapidly identify susceptible and resistant TB that are adaptable to low-resource settings.
Supporting coordination between HIV and TB programs
Technical assistance and capacity-building are essential to expand the ability of national HIV and TB programs to plan, implement, monitor and sustain collaborative activities. PEPFAR is supporting development of international and national policies, guidelines and operational tools, providing technical assistance to governments, and performing program evaluations. Key platform-strengthening approaches include a focus on monitoring and evaluation systems and laboratory and program surveillance, including for drug-resistant TB.
Many of the countries in the President's Malaria Initiative (PMI) - Angola, Ethiopia, Ghana, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, and Zambia - are countries in which PEPFAR is currently operating. Given the significant USG investments in both of these initiatives, PEPFAR is integrating and coordinating its services with PMI where feasible. Doing so leverages the expertise of both programs, allows for a broader reach to specific populations, and maximizes the impact of USG investments.
In its next phase, PEPFAR is collaborating with PMI to achieve the following:
Ensuring that families impacted by HIV are able to access malaria prevention and treatment
In countries with high prevalence of both HIV and malaria, country teams are linking services to improve malaria prevention for families with HIV by establishing basic care packages, co-locating services, and ensuring that linkages to referrals are accessible. In addition, community health workers providing basic malaria commodities also provide education and information about HIV.
Increasing integration of health systems functions
Certain functions of both PEPFAR and PMI contribute not only to overall health systems strengthening, but to better functioning of both programs. For example, laboratory strengthening helps labs perform both HIV testing and malaria diagnostics. As part of the GHI, both PEPFAR and PMI will explore additional ways to integrate activities to support health systems at the country level. PEPFAR and PMI should also support co-location of clinical services in the same facility, in order to reduce administrative redundancies and contribute to more efficient procurement and human resources.
According to the WHO, AIDS is the leading cause of death among women aged 15-44 worldwide8, and nearly 60% of those living with HIV in sub-Saharan Africa are women9. As a result, it is essential that PEPFAR ensure that the services it provides for women are linked to and expand access for their primary and specialty health care needs. An ultimate goal of PEPFAR, working as part of the GHI, is to provide women and their providers with the ability to address multiple health care needs at a single visit. PEPFAR can contribute to this goal through efforts to ensure that women living with HIV have access to necessary antenatal and reproductive health care. In addition, women seeking antenatal, reproductive health, or sexually transmitted infection care should have expanded access to HIV prevention, including testing and counseling.
The WHO recommends access to a comprehensive package of services, including services for HIV, maternal and child health, sexually transmitted infections, reproductive health, and family planning. Yet in many PEPFAR countries, platforms for these services are underdeveloped or underutilized. As part of GHI, PEPFAR will focus on increasing the linkages between HIV/AIDS and reproductive health services. These linkages will offer opportunities to identify and refer women in need of HIV-related services.
PMTCT is an important focal point for the GHI effort to expand women's health services. The strength of PMTCT services is reliant upon the strength of national antenatal care programming. As part of PMTCT expansion, PEPFAR is working with countries to provide these services at existing or new sites for maternal, child, family planning, and sexually transmitted infection, and reproductive health care.
Existing family planning programs provide an excellent platform for work on HIV prevention. Women and men in these programs are already receiving information about a range of reproductive health issues. Unfortunately, in many places, family planning programs and systems are not robust and levels of unmet need for family planning are often high. In areas with high HIV prevalence and strong family planning and reproductive health services, PEPFAR has traditionally supported the provision of HIV testing and counseling within existing family planning and reproductive health sites. This co-location links women with HIV education, care, medical treatment and PMTCT as needed. Many women living with HIV, like many other women across the developing world, still experience significant unmet need for contraception. Adequate education and planning for HIV-positive women who desire future pregnancies is lacking.
As part of GHI, PEPFAR will work with countries to create comprehensive access to health services for HIV-positive women, including the following:
Nutrition and Food Security
Food and nutrition support is a critical component of comprehensive HIV/AIDS care and treatment as well as effective TB treatment. For many PLWHA, the infection causes or aggravates malnutrition through reduced food intake, increased energy needs and impaired nutrient absorption. Malnutrition hastens the progression of HIV by further weakening the immune system, increasing susceptibility to opportunistic infections and reducing the effectiveness of treatment. Food and nutrition support breaks this vicious cycle by improving management of symptoms, nutritional status, response to treatment, and quality of life and productivity.
Food and nutrition services are essential as part of a comprehensive response to the epidemic. With the recent G8 and G20 commitments to improve food security at L'Aquila, as well as the USG Global Hunger and Food Security initiative, opportunities exist to increase coordination of nutrition, food security, and PEPFAR programs. Possible linkages include activities around nutrition surveillance at the household level, development of specialized food products to combat undernutrition, and livelihood assistance support.
In PEPFAR programs, food and nutrition care and support is designed to be an integral component of clinical and community services. The primary program approach for integrating nutritional care and support with care and treatment services has been Food by Prescription (FBP). Components of FBP are:
FBP, home-based care and other PEPFAR-supported programs provide entry points and platforms to link food-insecure PLWHA and their families, including OVC, to additional food security and livelihood assistance through partners like the UN's World Food Program, United States Agency for International Development (USAID) Title II programs, and country governments.
In addition to FBP, PEPFAR is working to reach women and children in PMTCT programming. Low-resource settings may lack access to clean water for formula. PEPFAR engages in interventions to reduce postnatal mother-to-child HIV transmission and increase HIV-free survival, and supports activities that adhere to WHO guidelines around breastfeeding. Services include regular post-weaning assessment, nutrition support, early and ongoing infant feeding support and counseling, and provision of basic child survival interventions to at least 24 months of age.
With increased harmonization of PEPFAR and USG food security programming in its next phase, PEPFAR is working with countries to focus on the following areas:
Expanding Nutrition Care and Support for PLWHA
PEPFAR plans to roll out FBP in additional PEPFAR country care and treatment programs. The expansion will increase quality and expand integration with clinical services and home-based care and community programs. In addition, PEPFAR is expanding local industry capacity to manufacture and package safe, quality-assured products for FBP.
Increasing Postnatal PMTCT/HIV-Free Survival of Children
PEPFAR promotes HIV-free survival as a key goal of PMTCT programs. It is increasing linkages between PMTCT and the postnatal continuum of care with FBP, PMTCT and maternal and child health programming.
Food Security and Economic Strengthening
PEPFAR is working to integrate household food security and livelihood assessments within FBP programs. It is establishing referral systems for food commodity assistance and food security and livelihood assistance support. Through these programs, PEPFAR can identify models for livelihood assistance and longer-term food security support. By linking these models to comprehensive food security strategies, countries can reduce poverty and improve nutrition, particularly for those who are most vulnerable.
Education and Economic SupportBasic education provides a forum through which to provide important prevention messages. In addition, schooling has a protective effect in terms of reducing risk behaviors. "Life skills" or "skill-based" programming provides students with the ability to deal effectively with the demands and challenges of everyday life. Life skills curricula include not only HIV information, but also age- and culture- appropriate sex education, and negotiation and decision-making skills. For example, through this programming, students learn about the ways in which HIV is transmitted, how to negotiate delay of sexual debut, and reduce their risk for HIV.
In carrying out this work, PEPFAR collaborates with USAID's basic education programs. Through the GHI, PEPFAR is working with countries to help educational programs deliver coordinated prevention messages. It will also train teachers to deliver quality HIV and life skills curricula. Through Partnership Frameworks, PEPFAR will also work with partner governments to ensure that Ministries of Education are involved in government-wide, multisectoral responses to HIV.
PEPFAR recognizes that a lack of economic assets increases vulnerability to infection, particularly for women, girls and OVC. In addition, extreme poverty can interfere with treatment adherence for PLWHA, leading to worse health outcomes. PEPFAR supports efforts to expand economic opportunities to PLWHA, OVC, and populations at risk for infection. These opportunities help them to avoid high-risk behaviors, to seek and receive health care services, and to care for their families. Such efforts include:
In its next phase, PEPFAR is expanding partnerships in these areas, in order to leverage both expertise and funds from these areas to achieve mutual objectives. A particular focus is working to assist orphans and vulnerable children in accessing vocational training or job opportunities, enabling them to support themselves and their families.
Increasing Government Leadership Capacity
Governance is one of the WHO's six building blocks of a well-functioning health system, and is often a focus of larger development efforts. Financing, budgeting, planning, and prioritization are essential skills for governments that are establishing or expanding HIV and other health services. When corruption exists, wasted money limits the impact of investments in health services. Corruption can also constrain donor engagement, and ultimately hurt the individuals who are in need of care.
With its successes in service delivery, PEPFAR's first five years helped to dispel concerns that corruption would limit the effectiveness of USG foreign assistance programs. PEPFAR's new emphasis on building country-level capacity creates additional opportunity to support accountable and competent leadership in low-resource nations. Country ownership cannot be complete without adequate accountability and financial management systems through which governments can track and report on funding. By working to develop technical expertise with civil service employees at partner ministries across sectors, PEPFAR supports a government culture that emphasizes knowledge and technical skills.
PEPFAR's efforts to build management in the health sector will contribute to and reinforce messages that support competent and honest governance. This message must also be put forward by other donors, including the Global Fund and USG programs like the Millennium Challenge Corporation.
In its next phase, PEPFAR is promoting country leadership capacity with the following activities:
Supporting Development of Country Plans
PEPFAR has always supported countries in the development of country-level plans for a national HIV response, an approach enhanced through the Partnership Framework process. To develop these plans, countries must justify distribution of resources based upon epidemiology, as well as meet the standards of multiple donors. Developing and overseeing national plans also provides countries with an opportunity to coordinate among donors to maximize impact. The act of engaging in needs assessment, planning, and coordination is in and of itself an exercise in capable governance.
Promoting Accountability and Transparency
The Partnership Framework process involves working with countries to jointly establish targets for HIV/AIDS programming. As the process of implementation unfolds, country teams work with partner governments to ensure that they are able to meet and report out on these targets. By supporting stronger linkages between civil society and governments, PEPFAR is helping citizens assist and hold governments accountable in meeting the HIV/AIDS and health needs.
Strengthening financial management
Transitioning management of programs to countries requires strong country financial capacity to oversee programs. Through PEPFAR's plans to support managerial capacities within the civil service of partner countries, it will expand the ability of Ministry of Finance employees to manage donor and national funding in a transparent way. It is important to note that civil society plays a strong role in reinforcing government accountability and ensuring that funding is used in an efficient and effective manner.
Strengthening and Leveraging Key Multilateral Institutions
Strategic integration and coordination requires engagement with multilateral partners at both the country and international level. Through work with multilateral partners, PEPFAR is able to leverage its investments, mobilize resources, support service delivery, and ensure a broad-based multisectoral response. In its next phase, PEPFAR is expanding its work with multilateral partners such as the Global Fund, UNAIDS, WHO and multilateral development banks. More information on PEPFAR's plans for increased multilateral engagement can be found in additional annex documents available at www.pepfar. gov/strategy/.
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