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�The pandemic of HIV/AIDS can be defeated, and the United States is willing to take the lead in that fight. But we can�t do it alone, and so for our international partners, we appreciate what you do.� President George W. Bush The fight against HIV/AIDS must be sustained, and ultimately won, at the national and community levels. At this stage of the fight, the support of international partners is of vital importance in many places, and each must ensure that it supports communities in developing their own capacity to create and sustain their leadership in the fight. The �stove-piping� that often occurs when international partners make contributions poses risks of duplication and waste, while failing to help develop indigenous capacity. The responsibility to avoid this rests on international partners � including the United States Government. In addition to implementing high-quality, sustainable programs that deliver results, all partners must work together to ensure coordinated action in support of host countries� national strategies. | |||||||||||
Increasingly, the President�s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) is seen as a leader in the international fight against HIV/AIDS � not only at the aggregate level of total resources, but also at the country level for its commitment to local capacity-building. PEPFAR is working to ensure that effectiveness and sustainability are core values upheld by all partners in the fight.
Strengthening Multilateral Action at the Country Level The U.S. Government (USG), as a founding member of the Global Fund and its first and largest contributor, continues to play a leadership role in ensuring the success of this essential international effort. The Global Fund is based on a unique model which encourages and relies upon partnerships among governments, civil society (including community- and faith-based organizations), international organizations, bilateral and multilateral contributors, the private sector, and affected communities � all united in the fight against HIV/AIDS, tuberculosis (TB), and malaria. U.S. Financial Support Founded in January 2002, the Global Fund operates as a financing instrument � not an implementing entity � to attract and disburse additional resources to prevent and treat these three deadly diseases. As a partnership among governments, civil society, the private sector, and affected communities, the Global Fund acts as a coordinated, multilateral financing mechanism, which enables a variety of international partners to pool their resources and finance essential programs in resource-limited settings. The USG contribution to the Global Fund is particularly impressive because it is in addition to massive bilateral efforts. As the world�s largest source of financing for combating HIV/AIDS, TB, and malaria internationally, the United States views its contribution to the Global Fund as both an invitation and a call to action to the rest of the international community to join in the commitment to combating these diseases. Many countries have become generous contributors to the Global Fund, and international foundations recently have joined their ranks. While resources mobilized to date have been impressive, more new contributors are needed. For the long-term viability of the Global Fund, the Board of the Fund must seek and engage new public- and private-sector donors and turn them into sustained and committed contributors. As mandated by Congress, the USG contribution to the Global Fund cannot exceed 33 percent of all contributions to the Fund. The United States has made clear to the Global Fund Secretariat, Board, and others that the cap on USG contributions is a maximum limit, not an annual obligation. At the same time, the scale of USG appropriations for the Global Fund in recent years has encouraged the Global Fund Board and Secretariat to vigorously pursue sufficient contributions from others, in order to enable the Global Fund to access the full USG contribution. The 33 percent limit provides others with added incentive to contribute to the Fund. Because of the terrible and immediate effects of HIV/AIDS � 11,000 new infections and 8,000 deaths every day � each country must assess how it can respond most urgently and effectively to the global epidemic. Each nation must make its own decision about how to allocate its contributions, between its bilateral programs and multilateral initiatives such as the Global Fund. Although it is essential that the USG continue to provide resources for the Global Fund, the most effective use of USG resources in the near term is through bilateral programs, and we are not alone in this view. As shown in figure 10.1, other countries with significant bilateral programs have a higher bilateral ratio, as a share of all global HIV/AIDS funding, than the United States, and many other nations have ratios comparable to that of the United States.
The Emergency Plan consistently encourages other developed countries to increase their own financial commitments to the global HIV/AIDS fight. The Global Fund provides a vital mechanism through which they can increase their financial commitment. USG Country-Level Support for Grant Management and Coordination In the PEPFAR focus countries, where the USG has committed resources to bring HIV/AIDS prevention, treatment, and care programs up to national scale, collaboration based on comparative advantages contributes to consistent and comprehensive service provision. In many nations outside the 15 focus countries, Global Fund financing plays a leading role in bringing national programs of prevention, treatment, and care to full national scale. In such countries, through the provision of technical assistance and improved coordination, USG bilateral support is working to ensure that Global Fund dollars are used to maximum advantage through a national-level focus. This will ensure that the Global Fund efforts support and complement our bilateral efforts. Recognizing the importance of technical assistance to the success of the Global Fund, Congress authorized the U.S. Global AIDS Coordinator to use up to five percent of the USG contribution for technical assistance to Global Fund grantees through USG bilateral mechanisms. In fiscal years 2005 and 2006, the USG directed approximately $12 million to provide technical assistance to Global Fund grantees. These funds filled a critical need expressed by many Global Fund grantees and allowed them to expand access to services and support the success of their grants. To ensure that the requests were demand-driven, it was required that they be submitted by Global Fund Country Coordinating Mechanisms (CCMs) or Principal Recipients (PRs). The USG�S technical assistance helped alleviate bottlenecks and resolve major issues that can cause these grants to falter. The funding has been used to:
In view of the close link between TB and HIV/AIDS, the USG also provided technical assistance funding to WHO�s Green Light Committee (GLC), to help country programs improve their capacity to provide treatment for multi-drug resistant TB (MDR-TB). This followed the Global Fund�s decision to require GLC approval for all MDR-TB programs supported by the Global Fund, aimed at preventing the spread of deadly new drug-resistant TB strains. In addition, to improve effectiveness of TB prevention and treatment programs, the USG supported technical assistance for the Advocacy, Communication and Social Mobilization (ACSM) components of country TB programs, through STOP TB. Based on the field response to this initiative to date, the Office of the U.S. Global AIDS Coordinator (OGAC) will continue to provide technical assistance funding into 2007. USG Global Fund financial support, bilateral programs, and technical assistance all provide important opportunities to help Global Fund grants succeed. Also crucial are the unparalleled relationships the United States has in these host nations, thanks to the dedicated USG teams in country. USG field personnel represent the United States on local CCMs, contributing to the development and selection of proposals to recommend for Global Fund Secretariat and Board approval, and playing a role in the oversight of program implementation. During the second Round of grant proposal submission in 2003, USG representatives had seats on just over 26 percent of the Global Fund CCMs around the world. By the sixth Round in 2006, the USG had representatives on 57 CCMs (59 percent) from the 97 countries that submitted Round 6 proposals. To promote coordination, the USG has entered into Memoranda of Understanding (MOUs) in a number of countries. These documents bring together Ministries of Health, PEPFAR, and the Global Fund to clarify collaboration and partnership activities. Such MOUs have been entered into in Tanzania and Ethiopia and will help to ensure a coordinated approach in such areas as antiretroviral treatment (ART) provision. To strengthen coordination, PEPFAR held bilateral meetings with the World Bank and the Global Fund to better understand management practices and priorities at the country level. These discussions in Washington, D.C., in January 2006 strengthened understanding and collaboration among international partners in the field. One of the most innovative partnerships underway in 2006 as a result of the January 2006 meetings involves a cooperative agreement among the Global Fund, World Bank, and Emergency Plan to coordinate efforts in procurement issues through a procurement working group. In a �first� for multilateral organizations in the fight against HIV/AIDS, both the Fund and the Bank have agreed to use the Emergency Plan-funded Partnership for Supply Chain Management System as the Secretariat for the working group. USG Policy and Strategy Support
Dr. William Steiger, Director of the Office of Global Health Affairs at the U.S. Department of Health and Human Services, continues to serve as the United States representative on the Board. In 2006, the Board Chair and Vice Chair confirmed Dr. Steiger as head of the Policy and Strategy Committee (PSC). The PSC is leading the development of a five-year strategy for the Fund, the first phase of which was adopted by the Global Fund Board in November 2006. Ambassador Jimmy Kolker, Deputy U.S. Global AIDS Coordinator, serves as the United States� Alternate Board Member and representative on the PSC. With the assistance of USG field staff and an interagency headquarters core team, the United States actively contributes to discussions on Global Fund policies and procedures in Geneva. The United States continues to work with the Global Fund Secretariat and its Board of Directors to establish a set of performance measures for all grants to maintain the consistent application of the Global Fund�s principle of �performance- based� funding, and continues to encourage the Global Fund to use agreed-upon indicators within the Secretariat to evaluate grant effectiveness. OGAC also has continued to work closely with the Global Fund Secretariat and other international partners to develop a standardized set of progress indicators for each disease. An area of special concern is the Global Fund�s current inability to track the budgets of specific prevention, treatment, and care interventions within each grant. However, the Global Fund Secretariat is working to improve its reporting system in order to capture this breakdown of budgetary data. It has built a spreadsheet for this purpose into the new grant proposal form and currently is seeking the information from existing grantees. The Global Fund has been fully operational since January 2002, and in less than five years, the institution has made remarkable progress. The USG will remain alert to the common need to monitor absorptive capacity in developing countries, as well as fiduciary oversight and accountability. As part of this monitoring effort, PEPFAR teams are working closely with the Global Fund on an ambitious process and impact evaluation of the Fund�s work and that of its partners. The impact study is of special interest because it will review the impact of all international partners in the selected countries. A total of 20 countries will be selected for study, of which eight will be �Comprehensive Analysis� countries and 12 will be �Secondary Analysis� countries. The USG remains deeply committed to ensuring that the Global Fund succeeds in its mission to help in the global fight to combat HIV/AIDS, TB, and malaria. Through its seat on the Board of Directors and its Chairmanship of the critical PSC; through formal and informal discussions with Global Fund Secretariat staff, CCMs, and local fund agents; and through active engagement with both private- and public-sector stakeholders in affected countries, the USG will stay fully engaged with the Global Fund in order to ensure its ultimate success. Cooperation within the UN System, the �Three Ones� and the Global Task Team A visible example of the advantages of working through the UN emerged in 2006 in the area of HIV counseling and testing. Noting that it is not possible to receive life-saving treatment without knowing one�s status, First Lady Laura Bush used the occasion of her remarks to the UN General Assembly High Level Meeting on AIDS in June to call for the establishment of an International Voluntary HIV Counseling and Testing Day. At the request of the United States, UNAIDS followed up this call with a feasibility study on the merits of holding an International Testing Day; the study determined that it could be useful in many circumstances with proper planning and preparation. Heeding this advice, the USG and 24 other governments from Africa, the Americas, and Asia proposed a decision calling on all UN Member States to observe an International Voluntary HIV Counseling and Testing Day in 2007 on December 1, or such other day or days as each country decides. The UN General Assembly adopted this decision by consensus on December 4, 2006. PEPFAR is working with WHO and UNAIDS to support countries in holding successful Testing Day events. A number of disparate UN programs and agencies are engaged in the fight against HIV/AIDS. Their efforts are coordinated by the Joint UN Programme on HIV/AIDS (UNAIDS), which also works to raise awareness and develop and disseminate international policies in the fight against HIV/AIDS. The United States was a driving force behind the creation of UNAIDS and continues to support its work, both financially and politically. The USG is one of the largest contributors to UNAIDS� all-voluntary budget each year. UNAIDS has ten official UN co-sponsors:
All of these organizations have a role to play in supporting national and local leadership in the fight. In one example of cooperation, the United States is working closely with UNAIDS to develop a uniform set of indicators countries can use for monitoring and evaluation of the effectiveness of HIV/AIDS programs. It is expected that such a uniform set of indicators will reduce duplication and improve program effectiveness over time. UNAIDS has also developed a Technical Support Division of Labor that identifies the core competencies of its cosponsors and works to reduce duplication and overlap among their efforts by designating a lead agency and supporting agencies for particular types of activities. In 2004, the United States co-sponsored the �Three Ones� agreement under the auspices of UNAIDS. The Three Ones represent a commitment on the part of the major international HIV/AIDS partners, including PEPFAR, to support one national HIV/AIDS framework, one national coordinating authority, and one country-level monitoring and evaluation system in each nation. This commitment is fully consistent with the principles established at the United Nations International Conference on Financing for Development, held in March 2002 in Monterrey, Mexico (the �Monterrey Consensus�), which asserted that developing countries must take ownership of their development activities in order for these activities to fully succeed. It further complies with commitments the United States made in March 2005 through the Paris Declaration on Aid Effectiveness: Ownership, Harmonization, Alignment, Results, and Accountability. International support for the �Three Ones� principles has significantly improved coordination and the ability of recipient countries to effectively utilize the funds they receive. The Global Task Team on Improving AIDS Coordination Among Multilateral Institutions and International Donors (GTT) was created after a March 2005 UNAIDS conference aimed at identifying strategies to implement the Three Ones. The GTT has made specific recommendations for further coordination, particularly within the multilateral system, to resolve areas of duplication and gaps in the global response to AIDS. As a leader in both the adoption of the Three Ones and the development of the GTT recommendations, the USG commends the GTT recommendations for identifying specific strategies for furthering international collaboration and coordination in the fight against HIV/AIDS. However, the USG emphasizes that implementation of the GTT recommendations must be within the framework of national laws and policies, as well as regulations and policies of the governing bodies of multilateral organizations and international institutions. The GTT recommendations provide a means for partners to work together to ensure that programs reflect the values of accountability and program effectiveness, as well as the realities and priorities of governments and civil society in recipient countries. To promote follow-through by all relevant partners, the USG is supporting the work of UNAIDS to conduct an independent assessment of progress on the implementation of the GTT recommendations in support of national AIDS responses. The assessment will focus on how the UN system has provided and coordinated technical support to countries, and how effectively international partners have rationalized and simplified management of development funding for national partners. Results from the GTT assessment are expected to be made public by May 2007. PEPFAR�s strategic information team has worked intensively with UNAIDS and other international partners to implement the GTT�s recommendations in the monitoring and evaluation area. One result has been the development of a Global Fund assessment tool, discussed further in the chapter on Improving Accountability and Programming. This tool will allow improved accountability for the effectiveness of Fund grants. Finally, the USG has partnered closely with WHO on developing patient monitoring guidelines, which are an important step towards a standardized approach to monitoring patients on ART.
Reform and Accountability within the UN System � UNAIDS Leading the Way World Health Organization As a WHO Member State with considerable expertise in HIV/AIDS, the United States has been intimately involved in formulating HIV/AIDS-related policy and guidelines, actively participating in the World Health Assembly � where Emergency Plan policy often informs the discussion � and partnering with WHO and host countries to adapt and implement such policies. In recognition of WHO�s leadership role in establishing norms and standards in public health and in global TB control, the Emergency Plan is working cooperatively with WHO to fight TB and HIV/AIDS (see accompanying text box). The approximately $2 million joint WHO-Emergency Plan TB/HIV project is an example of the kind of cooperation between bilateral and multilateral programs in support of national goals that must be a priority for international partners.
A second possible collaborative project between the United States and WHO would involve work to expand the health workforce in order to scale up HIV services through �taskshifting� (see accompanying text box).
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PEPFAR and WHO are working together to make essential antiretroviral drugs (ARVs) more rapidly available in countries where they are most urgently needed. In order to hasten the in-country drug regulatory approval process, HHS/FDA and the WHO Prequalification Program have established a confidentiality agreement by which, with company permission, the two organizations share dossier information regarding reviews and inspections. As a result, generic ARVs which have been HHS/FDA approved or tentatively approved can be added rapidly to the WHO prequalification list. The rapid WHO prequalification of these medications facilitates in-country drug regulatory review and thereby hastens the availability of these lower-cost, high-quality ARVs for purchase under the Emergency Plan. The USG also participated in the high-level WHO/UNICEF meeting to enhance and accelerate prevention of mother-to-child HIV transmission and provided funding to WHO for HIV/TB and safe blood programs. Together with UNICEF and WHO, PEPFAR has launched a public-private partnership to promote scientific and technical discussions on solutions for pediatric HIV treatment, formulations, and access. This partnership brings together the resources of innovator and generic pharmaceutical companies, civil society organizations such as the Elizabeth Glaser Pediatric AIDS Foundation and the Clinton Foundation, and the UN system to maximize the utility of currently-available pediatric formulations and to accelerate children�s access to treatment. This partnership will complement other PEPFAR efforts to support programs that expand treatment for adults and children, such as support for health care capacity-building and the expedited regulatory review of drugs. The partnership will offer children and parents hope for a better day � the hope of families staying | |||||||||||
| together, leading healthy lives, and living positively with HIV/AIDS. Please see the chapter on Building Capacity: Partnerships for Sustainability for more information.
Key Challenges and Future Directions Given the importance of the Global Fund to the overall PEPFAR initiative, the USG will continue to work with the Fund, as well as the World Bank, to address grant management and implementation issues, as well as coordination challenges on the ground. Starting in 2004, the USG and the Global Fund jointly announced treatment results, reflecting the large number of sites where programs complement each other directly. Similarly, the PEPFAR partnership with UNAIDS and its co-sponsoring agencies will be vital to building and maintaining momentum in the fight. The Global Fund�s unique approach is working, and is an essential part of the effort to improve the health and lives of millions of people around the world. This is a global epidemic that requires a global response, and the Global Fund and other multilateral entities are critical to achieving sustainability in the international community�s response to HIV/AIDS. | ||||||||||||
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