Chapter 9 - Strengthening Bilateral Programs Worldwide


Dr. Skripka, right, practices counseling skills in the Mykolayiv region of Ukraine

�The President�s Emergency Plan for AIDS Relief is a key example of effective foreign assistance and transformational diplomacy in action. Our approach is to empower every nation to take ownership of its own fight against HIV/AIDS through prevention, treatment, and care.�

Secretary of State Condoleezza Rice
Remarks at the Release of the
Second Annual PEPFAR Report to Congress
February 8, 2006

The President�s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) is the single umbrella program for all existing and new U.S. Government (USG) international HIV/AIDS activities, including:

  • Existing HIV/AIDS programs of all USG agencies and departments in 114 countries;
  • Enhanced bilateral programs of all USG agencies and departments in the 15 nations designated as focus countries;
  • USG-funded international HIV/AIDS research activities;
  • USG policies and oversight pertaining to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund);
  • USG relationships with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the HIV/AIDS-related activities of all other multilateral organizations;
  • USG bilateral relationships with HIV/AIDS international partner governments; and
  • All other USG international HIV/AIDS activities and partnerships, including regional platforms.

PEPFAR Worldwide Bilateral Programs Summary

Progress Achieved Through September 30, 2006

  • Supported 12.8 million counseling and testing sessions worldwide in fiscal year 2006, through prevention of mother-to-child HIV transmission (PMTCT) and other counseling and testing activities.
  • Supported antiretroviral prophylaxis for 316,600 HIV-positive pregnant women worldwide, averting an estimated 60,154 infant HIV infections.
  • Supported ART for approximately 987,100 people worldwide.

The Emergency Plan targets $10 billion over five years to dramatically scale up HIV/AIDS services in the 15 focus countries that account for approximately one-half of the world�s HIV infections. The Emergency Plan also targets $5 billion over five years to support HIV/AIDS programs in additional countries, international research, international partnerships (including the Global Fund), and other activities. In fiscal year 2006, PEPFAR directed approximately $428 million to HIV/AIDS program activities in nations outside the focus countries.

Beyond financial resources, the Emergency Plan represents an important change in how USG global HIV/AIDS support is planned, managed, and implemented. Priorities include coordinating all of the USG agencies working in HIV/AIDS, to create one unified USG response at the headquarters and country levels; a focus on accountability and achievement of results; and the strengthening of indigenous responses, organizations, and systems to combat the pandemic and ensure sustainability.

In 2004, PEPFAR established a Five-Year Global AIDS Strategy for achieving the President�s goals; since then, programs, systems, and structures have operationalized the strategy in the focus countries. Fiscal year 2006 was an important year for formally rolling out communications, coordinated strategic planning, resource allocation, and evaluation mechanisms to bilateral HIV/AIDS programs beyond the focus countries.

These mechanisms are helping to ensure that PEPFAR programs worldwide are in keeping with, and contributing to, the goals identified in the Five-Year Global Strategy. The Emergency Plan is working to develop lessons learned from the rapid scale-up of national-level integrated prevention, treatment, and care programs in the focus countries in order to strengthen interventions worldwide.

Even as PEPFAR works to ensure areas of consistency among programs in all nations with bilateral USG programs, it recognizes that every host nation faces a unique HIV/AIDS epidemic. In all nations, the Emergency Plan works with national strategies to support interventions tailored to local circumstances.

Bolivia: Using Data to Fight HIV/AIDS

High-quality, real-time data are helping Bolivian health officials carry out more effective HIV/AIDS prevention education, including HIV counseling and testing services. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the HIV/AIDS prevalence rates in Bolivia�s general population have remained under 0.1 percent, which is a remarkable success compared to some neighboring countries. One study in Santa Cruz, however, detected a prevalence rate of 22 percent among high-risk groups. Tracking these groups remains a high priority for the government, but effective public health programming depends on access to reliable information.

In 2005, an epidemiologist and a data manager began working with Bolivia�s nine regional HIV/AIDS clinics to revise and complete existing data, automate and standardize clinical records, and improve notification forms. The work was conducted in partnership with PEPFAR.

Dr. Percy Calderon, an HIV/AIDS epidemiologist at Bolivia�s Health Ministry, said that PEPFAR �has provided essential support to the Bolivian HIV/AIDS program to achieve an important breakthrough in advanced data management and epidemiological surveillance. This allows decision-makers and health workers to improve the prevention and control of HIV/AIDS.�

  In Bolivia, Dr. Percy Calderon (left), assists a health worker in analyzing HIV/AIDS trends using a new, PEPFAR-supported automated reporting system.

Strengthening Coordination, Management, and Accountability: Ensuring Consistency with Emergency Plan Principles
After an interagency development process during fiscal year 2005, the Emergency Plan issued �General Policy Guidance for All Bilateral Programs� in October 2005. Seeking to ensure consistency of all bilateral programs with PEPFAR principles, the guidance sets forth the basic requirements for programs in all nations receiving bilateral USG resources. In 2006, guidance on Modified Country Operational Plans (mini-COPs), shorter versions of the Country Operational Plans (COPs) used in the focus countries, was developed and disseminated for the 2007 fiscal year planning cycle to 16 other bilateral countries receiving more than $5 million of PEPFAR support. To support efforts for a more consistent approach to policy and reporting across all USG programs, regionally-targeted trainings took place in Latin America and the Caribbean, East/West Africa, Eastern Europe/Eurasia, and Asia, providing a comprehensive explanation of PEPFAR policies, program planning, and reporting requirements. Countries receiving more than $1 million in annual funding through PEPFAR also took part in these trainings.

Adherence to Emergency Plan Policy
All HIV/AIDS programs, regardless of program size or funding account source, must follow PEPFAR policies as outlined in the Global Strategy and associated policy documents, such as the Orphans and Vulnerable Children (OVC) or Food and Nutrition program guidance (described in the chapter on Care), although the determination of how certain elements of the Emergency Plan structure and priorities are implemented varies, based upon the country context.

Coordinated Programming Across USG Agencies
Coordination and collaborative programming of HIV/AIDS activities across USG agencies is an Emergency Plan essential standard of practice. In countries with small programs and few USG agencies physically present, this practice may translate, for example, into coordination meetings several times a year, to include the embassy, USG agencies, and implementing partners. In larger country programs, programming is to assume the model of the focus countries, in which interagency teams working under Chiefs of Mission meet regularly, coordinate annual programming and reporting, and have single USG representation for communication with the Office of the U.S. Global AIDS Coordinator (OGAC) and host country government counterparts. 2006 marked an important year for building these new working relationships among the other bilateral program countries, ensuring more strategic investments with USG dollars, so that maximum impact can be achieved.

Collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria
All USG bilateral programs must coordinate with and facilitate implementation of Global Fund resources, which in general are significantly larger than bilateral resources in countries outside of the focus countries. The USG is the largest contributor to the Global Fund, providing approximately 30 percent of all Global Fund resources. Investing in the Global Fund is a crucial element of the Emergency Plan strategy, and PEPFAR implementation to date has demonstrated the interdependence of these two approaches on the ground.

Given the magnitude of the USG investment in the Global Fund and the commitment of the USG to working collaboratively with other international partners and multilateral institutions, bilateral programs provide support to Global Fund grantees; help to leverage Global Fund resources, when necessary; and bring successful programs to scale. One example of support is the provision of targeted technical assistance, in order to improve Global Fund grant effectiveness. This assistance often includes strengthening the capacity of Country Coordination Mechanisms (CCMs), placing time-limited logistics advisors in Ministries of Health to strengthen logistics systems, create unified procurement approaches, and offer management training. USG health teams around the world also play a regular role in reviewing Global Fund grants as members of CCMs, supporting the review of grant progress, and advising Global Fund management staff on implementation issues. These cooperative efforts and resources contribute to making Global Fund money flow more quickly and efficiently. Please see the chapter on Strengthening Multilateral Action for more information regarding coordination between the bilateral and multilateral components of PEPFAR, including support for the Global Fund.

Relationship to Host Country HIV/AIDS Strategies
The USG is committed to implementing the principles of the �Three Ones� (one agreed-upon action framework; one national HIV/AIDS coordinating authority; one agreed upon country-level monitoring and evaluation system) across all of its international HIV/AIDS activities. All USG bilateral HIV/AIDS programs, therefore, are developed and implemented within the context of multi-sectoral national HIV/AIDS strategies, under the host country�s national authority. Programming is designed to reflect the comparative advantage of the USG within the national strategy, and it also leverages other resources, including both other international partner and private-sector resources. As noted, given the USG investment in the Global Fund, coordination with and provision of support to the Global Fund are of paramount importance in all countries.

Comprehensive HIV/AIDS Technical Interventions
PEPFAR programs are tailored to respond to how HIV/AIDS manifests within each country context, addressing gaps in the existing response, and utilizing the comparative advantage of the USG agencies working in country. Not all countries are required to support all key elements of the Emergency Plan Five-Year Global Strategy (i.e., prevention, treatment, and care, including people living with HIV/AIDS (PLWHA) and OVCs). However, USG programs in all countries are expected to adhere to the general goals of the Global Strategy, including strengthening leadership in the fight against the epidemic; capacity-building for indigenous organizations; and diversifying in-country partners, including faith- and community-based organizations.

Programs receiving greater than $10 million in USG funding are expected to reflect a comprehensive approach to the epidemic, in order to ensure that all key technical areas are addressed, if not directly by the USG, then by other partners who may or may not receive support from the USG. For example, a country may be supporting AIDS treatment using Global Fund resources. It would not then be expected that USG bilateral resources would be used in this area, although the USG team may choose to provide technical assistance to Global Fund grantees to promote the success of treatment efforts.

Accountability and Focus on Results
Regardless of levels of funding, all Emergency Plan programs are results-oriented, with clearly-established targets. Budget reporting and program reporting against standard indicators in the relevant programming areas will be required.

Reporting and Documentation
As the Department of State reforms and streamlines the Foreign Assistance process, OGAC will work to align planning and reporting requirements for the other bilateral program countries covered by the Emergency Plan. For fiscal year 2007, the regional platforms and those countries receiving less than $5 million in HIV/AIDS funding will be incorporated into the Foreign Assistance planning and reporting process. For fiscal year 2008, focus countries receiving more than $10 million will continue to plan and report primarily through the Emergency Plan structures, while countries receiving less than $10 million will be fully incorporated into the Foreign Assistance Operational Plans. OGAC has worked closely with the Office of the Director of Foreign Assistance, to ensure that HIV/AIDS indicators and measures included in the Foreign Assistance Operational Plans match what is requested by the Emergency Plan through the Country Operational Plans. The information for all countries will be coordinated and shared with the Emergency Plan and Office of the Director of Foreign Assistance in a systematic manner.

In fiscal year 2006, among the 99 programs receiving bilateral HIV/AIDS resources outside of the 15 focus countries, five received more than $10 million, 15 received between $5 and $10 million, 23 received between $1 million and $5 million, and the remainder received less than $1 million. A list of PEPFAR countries that received $1 million or more is provided at the end of this chapter. Requirements for reporting and documentation are dependent upon fiscal year 2005 HIV/AIDS funding levels, as follows.

Countries with Funding Under $1 Million

  • USG missions in these countries are expected to report to implementing agencies according to existing reporting requirements.
  • No additional documents (e.g., Country Operational Plan, Joint USG Strategy, or report of indicator data to OGAC) are required.

Countries with Funding Between $1 Million and $5 Million

  • In 2006, USG missions were expected to report annually to their agency headquarters, using standard indicators that measure results of funded program areas. The information is then harmonized among agencies and transmitted to OGAC. Reporting applies only to those indicators (of the 29 total) for which countries have programs, and only downstream results are included.
  • For 2007, these countries will be expected to report annually to their agency headquarters using the full set of indicators.
  • No additional documents (e.g., Country Operational Plan or Joint USG strategy) are required.

Countries with Funding Between $5 Million and $10 Million

  • In 2006, U.S. missions in these countries were required to submit a Five-Year Country Strategy, prepared according to �Country-Specific HIV/AIDS Five- Year Strategy Guidance for Other Bilateral Country Programs,� issued in October 2005. These country strategies were reviewed by an interagency team and the appropriate USG home agency leadership, and approved by the U.S. Global AIDS Coordinator.
  • In 2006, these countries were expected to report annually to their agency headquarters, using standard indicators that measure results of funded program areas. The information was then harmonized among agencies and transmitted to OGAC. Reporting applied only to those indicators (of the 29 total) for which countries have programs, and only downstream results were included.
  • For 2007, Modified Annual Country Operational Plans, known as �Mini-COPs,� will be required for 11 of these countries. The Mini-COP is a simplified COP � a single interagency USG operational plan which outlines key activities, targets, funding requests, and implementation partners for the limited number of program service areas that are funded by a country. For 2007, in these 11 countries, interagency teams under the leadership of the Ambassador in each of these nations will be expected to report results regarding funded programs, using standard PEPFAR indictors. Reporting will be conducted through the agencies and apply only to those indicators (of the 41 total) for which countries have programs; only downstream results will be included.

Countries with Funding Over $10 Million

  • The significant programming levels in these countries have generated a need for greater accountability in terms of programming and results. While these country programs are not expected to support activities across the full range of HIV/AIDS initiatives, it is anticipated that they reflect a comprehensive mix of prevention, treatment, and care interventions.
  • As noted above, if resources for a central component of a comprehensive strategy are being supported by another partner, in particular the Global Fund, then USG resources may be directed to facilitate those programs. Even in countries receiving more than $10 million in bilateral USG resources, it is likely that the greatest investment of USG resources will be through the Global Fund. It is unlikely that sufficient bilateral resources will be available to bring successful USG-supported pilots to scale; instead, there is an expectation that the USG will work to ensure that information from successful pilots and other best practices is widely available and expanded through other resource avenues, such as the Global Fund.
  • In 2006, USG missions in the five other bilateral countries receiving more than $10 million completed five-year country strategies and Mini-COPs. Starting in 2007, these countries will complete mini-COPS on an annual basis.
  • Annual reporting directly to OGAC using the standard Emergency Plan indicators is required. Reporting applies only to those indicators (of the 41 total) for which countries have programs; downstream results are reported for all indicators, and upstream results also are reported for the seven country-level indicators.

Regional Platforms
In addition to the guidance issued to countries receiving bilateral funding, in 2006 Emergency Plan �Guidelines for Regional Programs� were developed and disseminated to the 11 regional USG offices conducting HIV/AIDS work.

These platforms perform three basic types of work as part of the Emergency Plan. Their most important role is to budget for, plan, implement, and monitor HIV/AIDS programs in countries with no dedicated, resident USG HIV/AIDS staff. This role includes providing technical assistance, particularly in strategic information, to these �non-presence� countries, and providing management and administrative support for HIV/AIDS programs.

In addition to their primary role supporting non-presence countries, regional platforms provide technical and management support to Emergency Plan programs in �presence� countries. They also conduct cross-country activities to address regional needs and build the capacity of regional networks. Technical support to presence countries consists of technical assistance, training, and the exchange of information and experiences among countries in the region. The regional platforms foster close collaboration and coordination among the different USG bilateral programs working in the region and facilitate periodic meetings of USG HIV/AIDS staff and other key stakeholders. They also conduct cross-country activities, such as cross-border prevention and care programs that serve mobile populations.

Communication and Support Strategy
OGAC and implementing agencies are working to ensure that USG missions are fully informed of their roles relative to the Emergency Plan, including the associated requirements for planning, reporting, and coordination. Particular support is offered to enable countries to complete the documentation requirements, especially for those countries that complete COPs and mini-COPS. Key efforts include:

  • Ensuring the online accessibility of all relevant documents that provide information on the Global Strategy and its key policies, along with guidance thereon.
  • Using multi-country meetings as venues to disseminate information.
  • Engaging OGAC regional coordinators and host-agency country backstops, including State Department regional bureaus and country desk officers, to serve as key communication channels.
  • Identifying partners from agencies and OGAC regional coordinators to provide technical assistance and support in the development of documents.
  • Engaging in interagency field visits to further disseminate information and expectations on the ground.
  • Conducting quarterly conference calls between the Global AIDS Coordinator and Chiefs of Mission (COMs) in the focus and other bilateral countries to update the COMs on implementation, management, and budget issues. For more information, see the Implementation and Management chapter.
  • Organizing phone-based, distance-based, and regional COP development training.

In fiscal year 2006, all countries with funding over $1 million reported results for programs implemented, using the standard Emergency Plan indicators (see table 9.1 for a complete listing). Countries with funding between $1 million and $10 million reported only downstream results for relevant indicators (i.e., those linked to specific programs areas), while countries with funding greater than $10 million followed a similar practice and also reported upstream results for the seven country-level indicators. Results for select country-level indicators for all of these countries are reviewed in this chapter. The five countries with funding greater than $10 million are described individually, while the remaining countries are clustered according to geographic region. All of these results are added to the focus country totals in order to determine worldwide PEPFAR-supported totals.

Table 9.1: Other Bilateral: FY2006 Country Funding Levels

Emergency Plan bilateral programs support prevention activities and build prevention capacity in host countries. As discussed in the chapter on Prevention, specific activities reflect whether the national HIV epidemic is generalized or concentrated. Generalized epidemics are those in which some subgroups have higher HIV prevalence than others and HIV affects a broad cross-section of society; the primary mode of transmission is sexual activity. Concentrated epidemics are those in which HIV prevalence is heavily concentrated within recognized risk groups, such as people in prostitution, injecting drug users, and men who have sex with men. Potential prevention activities include ABC behavior change to address sexual transmission of HIV, targeted according to the country�s epidemic; PMTCT; safe medical injection and blood safety activities; and efforts to help injecting drug users.

Prevention data for the seven country-level indicators are limited to the PMTCT programs. Both downstream and upstream data are reported for the five countries with more than $10 million in PEPFAR support, while only downstream data are reported for the remaining 38 countries.

Egypt: Clinics Help Prevent HIV/AIDS

The social taboos surrounding sexually transmitted infections (STIs) in countries such as Egypt make it difficult to hold open discussions on prevention and treatment. As a result, HIV-positive people are reluctant to seek medical care, infected partners are not treated, and doctors are hesitant to offer advice about HIV/AIDS prevention and treatment.

To address this challenge, Egypt�s Ministry of Health, in partnership with PEPFAR, has embarked upon a comprehensive program to prevent the spread of STIs, including HIV. The program created national guidelines for STI management, training manuals for frontline service providers, and a chart that details common infections and nationally-available treatments. It also has put in place educational programs addressing high-risk behaviors and prevention and providing information about voluntary counseling and testing services, including a confidential hotline. The program established pilot clinics to offer these services.

  In a renovated clinic in Cairo, Egypt, patients can receive information about STIs and HIV/AIDS.

Greater Mekong Sub-Region: Purple Sky Network Coordinates Regional MSM Activities

In order to address the rise in HIV prevalence among men who have sex with men (MSM) in Asia, a collaborative initiative has been developed involving PEPFAR partner organizations and in-country government representatives from throughout the Greater Mekong sub-region.* This regional network has come to be known as the Purple Sky Network.

In 2005, when the first meetings were held, none of the countries in the Greater Mekong sub-region were addressing MSM issues in their national AIDS plans. Participants agreed on a two-year action plan, including 20 specific targets for improving peer education and outreach, coverage of prevention programs, surveillance, and advocacy. Each country developed specific plans for accomplishing these targets. An MSM Regional Coordination Secretariat was established that was responsible for moving the plan forward.

By late 2006, all of the countries in the sub-region addressed MSM in their national AIDS plans. Many also had established MSM working groups that included representatives from government bodies, international organizations, and national and local nongovernmental organizations, who are working to address HIV/AIDS issues that are MSM-related.

* Greater Mekong sub-region countries include Thailand, Cambodia, Vietnam, Burma, Laos, and the two southwestern Chinese provinces of Yunnan and Guangxi.

Uzbekistan: Preventing HIV/AIDS in Women�s Prison

With PEPFAR support, Tatyana Nikitina, the director of a community organization that works to prevent the spread of HIV/AIDS in Uzbekistan, has developed a training course on HIV/AIDS for prisoners. Four prison officials and 22 female prisoners participated in the program, where they learned about prevention techniques and gained skills and materials for disseminating HIV/AIDS awareness information to other prisoners. Participants learned about antiretroviral treatment, stigma reduction techniques, and methods for supporting people living with HIV/AIDS.

�I saw that the training helped women prisoners believe that life continues and that they can help prevent others from being infected with HIV/AIDS,� said Tatyana Nikitina.

Ms. Nikitina continues to work on HIV/AIDS prevention activities and now is developing a series of training sessions on HIV/AIDS prevention for male prisoners in Uzbekistan.

  At a women�s prison in Uzbekistan, Tatyana Nikitina is leading a PEPFAR-funded HIV/AIDS training session which she developed for inmates and prison employees.

Table 9.2: Other Bilateral: FY2006 Prevention of Mother-to-Child Transmission Results

In addition to the 15 focus nations, the Emergency Plan now partners with 19 host nations to support treatment for approximately 165,100 people. While the USG programs in these nations provide some downstream support, they largely provide critical upstream support, through system-strengthening and capacity-building, including technical assistance to international partners that support treatment. Additionally, many of these countries are working with PEPFAR and other international partners to start pediatric treatment.

Country-level treatment results are limited to the number of persons receiving antiretroviral treatment. Each of the five countries receiving greater than $10 million has PEPFAR- supported treatment programs, while 14 of the remaining 38 countries receive PEPFAR treatment support. Downstream data are available for all countries, and only the five countries with greater than $10 million report upstream results.

Zimbabwe: Standardizing National Antiretroviral Treatment Monitoring Tools

In 2004, the government of Zimbabwe began a national program to provide antiretroviral treatment (ART) to people living with HIV/AIDS. With an expanding program, it became clear that there was an urgent need to develop standardized tools to strengthen program management at all levels. In response, Zimbabwe�s Ministry of Health and Child Welfare, in partnership with PEPFAR, developed paper-based national monitoring tools for the ART program.

The goals of this effort are to standardize indicators for service providers, strengthen national data collection and analysis, improve reporting systems, monitor scale-up of ART services delivery, and improve logistics planning for HIV/AIDS commodities. The standardized, easy-to-use monitoring tools represent a major step forward in the scale-up of ART.

Table 9.3: Other Bilateral: FY2006 Treatment Results

OVC care received USG support in many nations beyond the focus countries in fiscal year 2006, strengthening the capacity of families and communities to care for children in their midst. The Emergency Plan also supports programs to care for PLWHA and to provide HIV counseling and testing in a growing number of countries. These countries are building downstream care services coordinated and linked with counseling and testing services. In addition, many countries, such as Cambodia, are beginning to introduce successful �continuum of care� models.

Reporting of care indicators is limited to counseling and testing results. Both downstream and upstream data are reported for five countries with more than $10 million, while only downstream data are reported for the remaining 38 countries.

Suriname: Rapid Testing Implementation a Tremendous Success

In Suriname, a same-visit rapid testing program employs a multi-sectoral approach to HIV counseling and testing, bringing together the country�s Ministry of Health, the private sector, the community, and U.S. Government staff. PEPFAR supports the program by providing laboratory technical assistance during implementation.

Program activities include a media campaign to increase awareness that resulted in a significant increase in HIV testing between December 2005 and August 2006. According to counseling and testing staff, client satisfaction has improved and staff workload decreased since the implementation of same-visit testing. This program is a regional success story and can serve as a model for other Caribbean countries.

Table 9.4: Other Bilateral: FY2--6 Care - Counseling and Testing Services Results (in settings other than PMTCT)

The Emergency Plan works with national strategies to improve HIV/AIDS responses worldwide. It supports system- strengthening (including laboratories and surveillance and information systems), capitalizing on USG expertise in technical assistance and capacity-building for quality improvement and sustainability of programs. PEPFAR also provides technical assistance to public-and private-sector institutions in policy development, including policies aimed at reducing stigma and discrimination, and other institutional capacity-building activities.

PEPFAR continues to support host nations� efforts to build human capacity, train people to prevent the medical transmission of HIV, provide PMTCT services to pregnant women and their infants, deliver HIV-related palliative care, conduct HIV counseling and testing, and perform necessary laboratory tests. In addition, PEPFAR supports programs to train country staff in monitoring and evaluation, surveillance, and health management information systems, as well as policy, capacity-building, and stigma and discrimination reduction programs.

Russia: Twinning Partnership Builds Capacity

In Russia, PEPFAR is supporting efforts to improve the quality and scope of health care and related services available to people living with HIV/AIDS (PLWHA) through a twinning partnership between Russia and the United States.

The Emergency Plan-supported twinning partnership pairs new Russian HIV/AIDS case managers with experienced case managers from Minnesota and New York. Russian case managers attend courses in which they learn about case management from their American counterparts.

Olga Fyodorova and Vladimir Dementyev, two case managers, are pioneering the new system of health care service delivery for PLWHA in the Saratov Oblast city of Engels. Thanks to the training they received through the PEPFAR-supported twinning partnership, Olga and Vladimir now provide comprehensive care and support services to their HIV-positive clients.

The case workers now refer clients to resources for antiretroviral and tuberculosis treatment, HIV-discordant couples counseling, and employment and legal services. They also provide assistance with disability pension applications. The new case management system has significantly improved services for PLWHA in Engels and throughout Russia.

  Olga Fyodorova and Vladimir Dementyev are pioneering the new system of health care service delivery for people living with HIV/AIDS in Engels, Russia.

Increased Financial Commitments
As the PEPFAR program continues to evolve, closer attention is being paid to resource allocations in countries with significant HIV/AIDS epidemics and where opportunities to leverage other international and host country partner resources are present. For example, support for India � the largest Emergency Plan program outside the focus nations � was over $29 million in fiscal year 2006, up from approximately $17 million in fiscal year 2003. In Russia, PEPFAR funding in fiscal year 2006 was almost $14 million � an increase of approximately 100 percent since fiscal year 2003. Funding for the Democratic Republic of the Congo in fiscal year 2006 totaled $9.3 million, an increase of $3.5 million over fiscal year 2003. Emergency Plan coordination with China continues to grow, as the Chinese government has continued to seek active partnerships with PEPFAR to improve its national health care infrastructure and human capacity.

Similarly, the USG has continued to remain the largest contributor to the Global Fund, having provided approximately 30 percent of the Global Fund�s $4.8 billion in funding commitments through fiscal year 2006. Thus, of the $476 million the Global Fund has committed to projects in China, India, and Russia, approximately $143 million is attributable to USG contributions. For more information, see the chapter on Strengthening Multilateral Action.

India: A Brighter Future for Sunita

Sunita is one of many migrant workers who came to Mumbai, India, in search of work. She found work as a day laborer in one of the city�s 200 nakas or open labor markets. While employed at the naka, Sunita was sexually exploited by the contractor and managers at the construction site where she was working. Degraded by her employers� treatment and unable to earn sufficient wages through the naka, Sunita turned to prostitution to support her disabled husband and five teenage children.

During an information session on HIV/AIDS prevention, Sunita met an outreach worker from NIRMAN, a PEPFAR-supported non-governmental organization that promotes HIV/AIDS awareness among women working in construction. The outreach worker provided Sunita with counseling, which empowered her to share her experiences of sexual exploitation and take action to escape exploitation and prostitution.

Sunita continues to work as a day laborer, but she is no longer involved in prostitution, nor is she being sexually exploited. With the knowledge she gained from NIRMAN, Sunita was inspired to become a peer educator and now helps other female workers at the nakas. She addressed participants at a state-level discussion on sexual harassment in the workplace organized by the Women�s Commission and the India Center for Human Rights and Law. She says, �I am determined to share my experience with other women like me, so that they can safeguard their lives and support their families with dignity.�

  A NIRMAN counselor discusses information about women�s issues in the workplace. Charu Dadlaney

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