From 2004 to 2009, the USG has contributed an unprecedented amount to global HIV/AIDS programs. Despite the significant gains in health outcomes that have resulted from these investments, there is still unmet need that outstrips the ability of any single donor to meet it.
According to the World Health Organization (WHO), while more than 4 million people are receiving antiretroviral therapy in low- and middle-income countries, more than 5 million people in these countries are currently in need of treatment.1 The WHO recently released clinical guidelines that recommend treatment initiation at a CD4 cell count of 350/mm3, rather than 200/mm3. These guidelines are expected to roughly double the number of people in need of treatment. In addition, the impact of treatment on transmission and future incidence is currently under active debate at the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS).
UNAIDS has done significant work in establishing estimates for long-term funding needs. These estimates inform efforts to meet the Millennium Development Goal of halting and reversing the spread of HIV by 2015. According to UNAIDS, the needs for 2010, based upon country-defined targets in low- and middle-income countries, will be $25.1 billion. This figure encompasses at least $11.6 billion needed for prevention, $7 billion needed for treatment and care, and $2.5 billion for programs serving orphans and vulnerable children.2 In 2008, according to UNAIDS, $13.7 billion was available for HIV programming in low- and middle-income countries.3 Given the scope and enormity of need, a coordinated global effort is necessary to mount an effective and sustainable response to the epidemic. To contribute to this type of response, PEPFAR is focusing on the following:
Efficiencies in Programming and Systems
Efforts to combat global HIV/AIDS have benefited from significant funding over the past decade, allowing for the establishment and rapid scale-up of services. As PEPFAR transitions to a sustainable response, it is working to identify and implement efficiencies at both field and headquarters levels. Since PEPFAR was created, investments from the USG, partner countries, and governments have created conditions that reduce the overall costs associated with programming, particularly the provision of antiretroviral drugs (ARVs). These conditions include:
Investing in equipment, infrastructure, training
Overall, per-patient financial costs of treatment have dropped as global AIDS efforts have matured. Much of the infrastructure and equipment required for a site to function was established before patients were enrolled, and any expansion in patient numbers was preceded by expansions in clinic capacity. As PEPFAR works with the Global Health Initiative (GHI) to expand and build health systems, it will build upon the country infrastructure platform to continue to reduce costs for increased coverage of care.
Improving personnel response
PEPFAR programs benefited from economies of scale as patient cohorts expanded. Increasing numbers of patients are often treated by the same number of health workers as a result of several factors, such as improved worker efficiency after the start-up period. More recently, there is some early indication of the effects of task-shifting upon improving efficiencies. Over the next phase, PEPFAR is identifying additional efficiencies to assist health workers to care for patients. Through the GHI, it will also explore mechanisms like appropriate co-location of services to reduce recurring personnel and facility costs.
Decreasing commodity costs
Licensing, approval, and competitive manufacture of generic formulations of ARVs has resulted in an environment of rapidly declining pricing for these commodities. PEPFAR, utilizing bulk-purchasing mechanisms, has been aggressive in taking advantage of these lower ARV prices to extend treatment to additional patients. PEPFAR is working with partner countries and existing multilateral and foundation efforts to encourage the policy changes needed to continue this downward trajectory of drug prices. As part of the GHI, PEPFAR will also explore possible efficiencies in supply chain management.
Marshaling resources for need
The USG is the major funder of global HIV/AIDS programming. As of 2007, it contributed at least 51% of international donor government assistance to HIV/AIDS.4 The majority of this funding is directed through PEPFAR's bilateral programs. USG contributions also account for roughly 29% of Global Fund resources directed to AIDS.5 Because of the scope of the epidemic, an effective response to global AIDS requires funding from multiple sources, including country governments, bilateral donors, regional actors, multilateral partners, private foundations, and nongovernmental organizations. To support a diverse funding base, PEPFAR is building the capacity of country governments to serve as the conveners and coordinators of these diverse funding sources.
An immediate priority of PEPFAR is to support countries in reassessing and identifying the scale of their national HIV/AIDS epidemic, to ensure interventions respond to existing and emerging realities. Governments should convene or expand inclusive processes in which demographic data is used to define and prioritize unmet need. Once the government has defined need and set priorities for action, PEPFAR will support the country in efforts to coordinate donors and investments. PEPFAR is encouraging its multilateral partners, including the Global Fund and UNAIDS, to join similar coordinated assessments and processes at the national and international level.
Through the GHI, PEPFAR will explore possible financing and leveraging opportunities beyond those traditionally utilized in USG development assistance, including those involving public-private partnerships. PEPFAR will also expand its cooperation with multilateral partners to explore possible cooperation around internationally-supported financing mechanisms.
Country and Regional Overview
When PEPFAR was created, investments were focused in 15 focus countries, although program funding was utilized to support efforts to combat HIV/AIDS in areas beyond these 15 countries. In the next phase of PEPFAR, the program will work to reduce the distinction between "focus" and "other" countries. While the former focus countries account for a significant amount of program funding, PEPFAR has made significant investments in over 30 countries and regions. These countries include both those where the epidemic is concentrated among specific populations, and those where HIV occurs among the general population. In many countries where HIV prevalence rates are above 1% - the widely defined threshold for generalized epidemics - prevalence is often much higher among sub-populations, such as men who have sex with men (MSM) and sex workers. PEPFAR's regional approaches provide an ability to review and apply best practices among similar countries. Whether the countries and regions where PEPFAR works have generalized or concentrated epidemics, all these places have unmet need in HIV prevention, care, and treatment.
Given the dynamic nature of the epidemic, PEPFAR will ensure that its programs are flexible and tailored to the country context. This context includes not only epidemiologic data, but the need to coordinate and reduce duplication with multilateral and country partners and build upon existing health systems. It is important to note that PEPFAR's response is likely to vary based upon the level of investments that exist from PEPFAR and other donor sources within a country. For example, in a country with a concentrated epidemic, PEPFAR's work may focus on providing technical assistance to governments and working to coordinate with mechanisms of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). Alternately, in a low-resource hyperendemic country, PEPFAR's work may focus on ensuring quality service delivery and strengthening country capacity to deliver care.
A brief summary of the epidemic profile in the countries and regions where PEPFAR works follows. Country-level prevalence estimates are from the 2008 UNAIDS Report on the global AIDS epidemic:6
Southern Africa, the epicenter of the pandemic, has countries with the highest HIV prevalence rates in the world, including Swaziland (26%), Botswana (24%), and Lesotho (23%). In these "hyperendemic" countries, HIV has spread widely across the population. The region also has the largest number of PLWHA. Infection rates vary substantially within countries, and there are significant gender disparities in prevalence in the 15-24 age cohort.
HIV infection rates appear to be stabilizing in many countries in Southern Africa, but are still at high levels.7 Declines and plateaus likely reflect the natural course of the epidemic as well as the contribution of program interventions. The potential impact of treatment roll-out on prevention also remains unclear. More analysis is needed to better understand the factors contributing to evolving epidemic trends.
In West Africa, HIV prevalence is notably lower than in southern Africa. High-prevalence West African countries include Côte d'Ivoire (4%) and Nigeria (3%). This lower regional prevalence is likely attributable to numerous factors, especially much higher prevalence of male circumcision.
HIV prevalence in East Africa falls between the levels in West and Southern Africa. Trends in prevalence vary, but there is evidence that prevalence has stabilized.8 Urban prevalence tends to be higher than rural, but access to services is still needed in rural areas.
Caribbean and Latin America
In the Caribbean, many low-level generalized epidemics have stabilized, with evidence of slight declines among some sub-populations. However, prevalence rates remain high in certain countries, including Haiti (2.2%). In Latin America, most countries are experiencing concentrated epidemics, although some countries like Guyana (2.5%) have higher prevalence rates. In these areas, the main mode of HIV transmission is heterosexual sex, often tied to transactional sex, although emerging evidence indicates that substantial transmission is also occurring among men who have sex with men.9
Southeast and East Asia
PEPFAR is operating in several countries throughout Southeast and East Asia. Thailand has the highest prevalence rate in Asia (1.4%). However, the large populations of many countries within Asia mean that a low prevalence rate may translate into a large number of people living with the virus. Approximately 4.7 million people in this region are living with HIV, the second highest number outside of sub-Saharan Africa.10 PEPFAR will continue to support treatment in low-income countries in this region, while also working with governments and civil society to address barriers to services among marginalized populations. In emerging economies like India, where prevalence rates are still low but the number of people living with HIV is substantial, PEPFAR will expand technical assistance and work to leverage investments of multilateral mechanisms like the Global Fund.
Eastern Europe and Central Asia
In Eastern Europe and Central Asia, there is a significant need to address concentrated epidemics, with high rates of HIV occurring among injecting drug users and sex workers. Countries in this area with higher prevalence rates include Ukraine (1.6%) and the Russian Federation (1.1%). PEPFAR will continue to work with countries to support technical assistance and policy reform to address the needs of these often-marginalized populations. PEPFAR will also work to leverage existing investments of these countries and multilateral mechanisms like the Global Fund.
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