�The Emergency Plan is the single largest international initiative by any country for any disease, and we�re making progress each step along the way; one more orphan, one more patient is taken care of or treated, and one more person can live with the disease.�

Secretary of State Condoleezza Rice
Remarks at the Swearing-in of the
U.S. Global AIDS Coordinator
October 10, 2006

The President�s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) is committed to supporting societies in developing comprehensive responses that address the many impacts of HIV/AIDS. Only responses that address the full range of HIV/AIDS-related challenges will fully enable nations to move from despair to hope.

The focus nations of the Emergency Plan are places in which this need for care is especially great. Approximately half of the more than 39 million people currently living with HIV/AIDS worldwide live in the 15 focus countries of PEPFAR. Of the more than 15 million children orphaned by HIV/AIDS, at least eight million are estimated to live in the focus countries, and many more children are made vulnerable due to the reduced care-taking abilities of their HIV-positive parents. In most of the focus nations, the limited availability of care for those infected or affected by the virus is placing additional stresses on social bonds that already may be severely frayed. Solutions that are of high quality and can be sustained for the long term may be all that protect these societies from unraveling altogether.

Perhaps the most obvious manifestation of HIV/AIDS in many countries is the large number of orphans and vulnerable children (OVCs). Orphans are defined as children under age 18 who have lost a mother, a father, or both, and vulnerable children are those affected by HIV through the illness of a parent or principal caregiver.

Many communities have traditional, family-based care approaches for children, such as care by grandparents, but even extended family and social structures are being stretched beyond their capacity, overwhelmed by the sheer number of children who are in need of care. Orphans and other vulnerable children are often forced into roles for which they are not yet prepared, and their vulnerability places them at high risk of HIV infection.

Also straining these societies are the large numbers of people living with HIV/AIDS (PLWHA) who are in need of care. Both those not yet in need of antiretroviral treatment (ART) and those receiving it require basic health care, social, spiritual and emotional support, and in some cases, end-of-life care. Again, many communities� current resources for meeting the needs of PLWHA are inadequate for the task.

In many cases, caring for family, friends, and children infected or affected by HIV/AIDS consumes energies and resources needed for survival. Communities may abandon or reject those who need care, creating hopelessness that undermines all efforts to mobilize communities, and even nations, to respond.

A related challenge is increasing the number of people who know their HIV status. In some surveys, only 10 percent of people know their HIV status, yet when asked, most people say that they would like to know. Confidential counseling and testing provide an entry point to treatment and care, as well as a crucial opportunity for prevention education � for those who are infected and their partners, and also for those who are not infected. Unfortunately, counseling and testing remain stigmatized and thus are utilized by far too few people in nations hard-hit by HIV/AIDS.

The Emergency Plan thus works in concert with national strategies in the following areas, which collectively are considered �care� for PEPFAR purposes:

• Support basic needs of OVCs.
• Support care for PLWHA (also known as palliative care).
• Support HIV counseling and testing, especially in settings with people at high risk for having HIV (e.g., tuberculosis clinics).

Orphans and Vulnerable Children
Because HIV/AIDS predominantly affects people of childbearing age, its impact on children, extended families, and communities is devastating. If a parent dies of AIDS, the child is three times more likely to die, even though he or she is HIV-negative. Besides increased risk of death, children whose parents have died of AIDS also face stigmatization and rejection, and often suffer from emotional distress, malnutrition, a lack of health care, poor or no access to education, and a lack of love and care. They are also at high risk for labor exploitation, sex trafficking, homelessness, and exposure to HIV. Extended families and communities in highly affected areas often are hard-pressed to care for all the children.

In communities hard-hit by both HIV/AIDS and poverty, there are many children who are not orphans, but who have been made more vulnerable by HIV/AIDS. For example, children whose parents are infected with HIV might not receive the care and support they require, and may instead become their parents� caregivers, dropping out of school and assuming the responsibilities of the head of the household. Research indicates that these children, caring for sick and dying parents, are among the most vulnerable.

The most fundamental way to meet the needs of vulnerable children is to keep their parents alive and well, thus preventing these children from becoming caretakers or orphans. Treatment and care for PLWHA, supported by the Emergency Plan, often enable parents to resume their role as caregivers, allow children to reclaim their childhood, and protect families. Nonetheless, even with treatment and a reduction in HIV prevalence, the number of orphans will continue to rise in many countries. By 2010, the number of children orphaned by AIDS is projected to exceed 20 million, and the number of other children made vulnerable because of HIV/AIDS is estimated by some to be more than double that number.

The Emergency Plan recognizes the urgency of addressing the growing needs of children orphaned or made vulnerable by HIV/AIDS. PEPFAR is committed to the development of evidence-based policy and the implementation of sound practices in the care and support of orphans and other children made vulnerable by HIV/AIDS. Our goal is to support these children�s and adolescents� growth and development, so they become healthy, stable, and productive members of society.

The Emergency Plan supports varied interventions to enable communities to mobilize their own resources to care for their own children and families affected by HIV/AIDS. Community and faith-based peer support can be crucial for growing children and adolescents who are faced with both the normal challenges of growing up and heavy economic, psychosocial, and stigma burdens.

OVC services include caregiver training, access to education, economic support, targeted food and nutritional support, protection and legal aid, medical care, psychological and emotional care, and other social and material support. Please see accompanying text box and the chapter on Children.

OVCs themselves face elevated risk of HIV infection, and PEPFAR supports efforts to expand prevention and HIV counseling and testing, which are an entry point to care and treatment. In addition, the Emergency Plan recognizes that meeting the needs of children with HIV also can serve as a way to build relationships with their caregivers, who may themselves be in need of services.

Results: Rapid Scale-Up
In fiscal year 2006, Emergency Plan funding for treatment and care services for OVCs totaled more than $213 million in the focus countries (including approximately $63 million for pediatric AIDS) � approximately 12 percent of prevention, treatment, and care resources (approximately nine percent when funding for pediatric AIDS is excluded). PEPFAR-supported activities reached more than two million OVCs during fiscal year 2006. This figure is in addition to OVCs receiving antiretroviral treatment (ART) through USG programs. More than 1,346,00 of the children who received care services were beneficiaries of downstream support at the site of service, while the remainder received upstream support through USG contributions to national, regional, and/or local activities such as training, systems strengthening, and policy and protocol development. Of those receiving downstream support that partners reported by gender, 51 percent were girls and 49 percent were boys.

PEPFAR seeks to support evidence-based, high-quality OVC programs that result in making a measurable difference in the lives of children affected by HIV/AIDS, so that these children can enjoy their childhoods and grow into healthy, productive members of society. In 2006, to increase the effectiveness and expand the reach of PEPFAR- supported OVC programs, PEPFAR�s OVC Technical Working Group (including field staff) developed guidance for OVC programs. The guidance includes principles for program implementation and examples of core services that can be funded by PEPFAR. The guidance emphasizes developmentally based and gender-sensitive programs, along with clear definitions of an OVC and distinctions between OVCs receiving primary and supplemental direct services and those receiving indirect support (please see accompanying text box).

Sustainability: Building Capacity
The Emergency Plan seeks to support communities, families, and OVCs themselves in accessing the full range of supportive resources available to them. These resources include those funded by PEPFAR, but must also include those provided by a range of other sources (including other USG programs).

Among the most important potential sources of long-term support for OVC care are national governments. Strengthening citizens� ability to work with � and, when necessary, demand � effective responses from their governments is a key Emergency Plan strategy for building sustainability in OVC responses.

Further laying the foundation for sustainable responses, the USG supported the training of more than 143,000 community or family caregivers in the focus nations during fiscal year 2006, enabling them to access time- and laborsaving technologies and income-generating activities, and connecting children and families to health and social services, where available.

Key Challenges and Future Directions
Scaling Up Support to Families and Communities The ideal for orphaned children is usually to remain in family settings within their communities. In hard-hit communities, however, families� capabilities are already stretched to the breaking point by poverty and, in many cases, HIV/AIDS within the family itself. Continued stigma against children and caregiving families makes the ideal situation still more difficult to achieve.

The Emergency Plan thus concentrates its efforts on strengthening families and communities, working with community- and faith-based organizations (CBOs and FBOs) to identify promising models and bring them to scale. For example, in Fond des N�gres, Haiti, Bethel Clinic supports a wide range of interventions in health and child protection, including comprehensive services for OVCs (see accompanying story).

Quality of Programs for Orphans and Vulnerable Children
Providing high-quality services that make a measurable difference in the lives of the children is essential in programming for OVCs. One way of supporting quality is by requesting programs to monitor the well-being of a child in six key areas of his or her life and to provide comprehensive services to address the areas of need. In order to facilitate this monitoring and service provision, new service tracking requirements were established in 2006 that will be implemented for reporting in fiscal year 2007. Coordinating activities with government and civil society partners to determine standards of care for delivering effective and efficient services to OVCs also serves to improve quality in line with national plans of action for OVCs. Harmonized care practices paired with continuous quality improvement will enable programs to achieve measurable results in the lives of children.

Addressing the Special Vulnerability of Girls
As noted in the chapters on Prevention and Gender, adolescent girls in the developing world often face special vulnerability to the HIV/AIDS pandemic and its effects. This vulnerability can be greatly compounded for girls who are orphaned, losing their means of economic and social support and protection. They often bear the burdens of care for families impacted by the disease and become primary care providers. Girls are typically the first to lose access to school, as resources are diverted to provide care for persons in households infected with HIV. Such girls are at high risk of abuse and exploitation, violence, and transactional and cross-generational sex � all pathways to HIV/AIDS infection.

Because of this special vulnerability, the Emergency Plan focuses special attention on female OVCs and their distinctive issues. In Mozambique, a PEPFAR partner developed a plan to boost the income of OVCs and single mothers affected by HIV/AIDS by hiring a dressmaker to train older female orphans and single mothers in dressmaking and other handiwork with a local market. When the local school introduced a school uniforms requirement for the new academic year, the existing income-generating activity was incorporated into the on-site manufacture of the school uniforms, with additional skills training provided with USG support.

Working with Other Sectors and Partners for a Multi-Sectoral Approach
The Emergency Plan recognizes the broad array of challenges facing OVCs and supports a coordinated, holistic approach, with linkages to programs that meet key needs of OVCs in such areas as:

• Care & shelter
• Food
• Education
• Vocational training
• Protection
• Health care
• Emotional support
• Substance abuse prevention and treatment

Like the other aspects of the HIV/AIDS emergency in a given nation, the OVC crisis requires more resources than the USG alone can contribute. The Emergency Plan recognizes that the ability and willingness of host governments to marshal all resources available to them � not only those of outside partners � for an effective response must be fostered. The USG, therefore, is working with host governments, while coordinating with other international partners, the private sector, and communities themselves, to ensure development of sustainable systems that fully recognize and meet the needs of children, including those affected by HIV/AIDS. OVC programs and the OVC technical working group work closely with the United Nations Children�s Fund (UNICEF) in particular, on both the country and international levels, to coordinate programs, strategize, and leverage funding.

In many cases, successful programs are those in which the Emergency Plan interventions link or �wrap around� critical support to other sectors. Examples of wraparound programs in the area of education with which the Emergency Plan coordinates support are found in the accompanying text box.

Food insecurity is a critical challenge for children in many countries, and PEPFAR works with other international and USG partners to leverage food and nutrition resources for OVCs. USG high priority target groups for food and nutritional support include OVCs, especially children under the age of two born to HIV-positive mothers. Support to these groups can include nutritional assessment and counseling, therapeutic and supplementary feeding, replacement feeding and support under acceptable, feasible, affordable, sustainable, and safe conditions, and, where indicated, micronutrient supplementation. For the wider group of OVCs, leveraging nutritional support from other sources is a central focus of PEPFAR efforts. PEPFAR provided guidance to the field on food and nutritional support in May 2006 (Use of Emergency Plan Funds to Address Food and Nutrition Needs of People Infected and Affected by HIV/AIDS), and reported to Congress on its activities in this area (Report to Congress: Food and Nutrition for People Living with HIV/AIDS). Both documents can be found at http://www.PEPFAR.gov/progress.

Tanzania: A Local Leader in the Fight Against HIV/AIDS Aisha Ally enjoys her work as a community home-based care supervisor. She has nine clients, whom she visits one to three times per week, depending on their condition. Through her work, Aisha has gained respect and prominence in her community. �People love me because I am saving them,� she said. With support from PEPFAR, the Tutunzane program reaches clients who are unable physically or financially to travel to health facilities. It also serves to ease the burden that HIV/AIDS has placed on the traditional medical infrastructure. Communities ultimately must take ownership of community home-based care activities for them to be sustainable. Aisha found a way to promote community ownership through her job in the local government. She uses her influence in this position to allocate money to help care for PLWHA. If her clients are too sick or otherwise unable to feed themselves, she makes sure they receive assistance from the local government. Local people like Aisha are leading the fight against HIV/AIDS in their own nations and communities, buoyed by the generosity and goodwill of the American people.

Care for People Living with HIV/AIDS
For HIV-positive people, the need for care extends throughout the continuum from diagnosis of infection until death. This entire spectrum of care for PLWHA is known as palliative care, under definitions developed by PEPFAR, based on those of the U.S. Department of Health and Human Services (HHS) and the World Health Organization (WHO). In the United States, palliative care sometimes is used in a much more narrow sense, to refer only to end-of-life care. The broader definition used by the Emergency Plan, however, is the one customarily used in Africa and much of the rest of the world.

An often-overlooked reality of HIV/AIDS care is that many people infected with HIV at a given time do not meet the clinical criteria for antiretroviral treatment. Of the nearly 40 million HIV-positive people living worldwide at present, it is estimated that about 6.8 million currently need ART. Therefore it is critical to establish programs and services for HIV-positive people that address the needs of those not yet on ART. A key aspect of caring for PLWHA who are not yet on ART is ensuring that they receive ART soon after they are eligible. Studies and program reports show that patients who start ART late, often when their immune systems are already severely compromised and they have serious opportunistic illnesses, do not fare as well as those who start on ART soon after being eligible. In fact, Emergency Plan programs are working hard to enroll PLWHA in care programs that include regular evaluations for ART eligibility � programs that do this have experienced fewer early illnesses and death than other programs.

While the basic health care needs of HIV-positive people and people who are HIV-negative are similar, HIV-positive individuals often require additional care for HIV related symptoms. These care services can include pain and symptom management, treatment and prevention of opportunistic infections (OIs) and other diseases, social, spiritual and emotional support, and compassionate end-of-life care.

In fact, some countries are beginning to standardize their approach and are working with implementing partners to ensure that all HIV-positive people who receive care, even if they are not eligible for ART, receive a �basic preventive care package� that provides a number of these lifesaving interventions (see accompanying text box). These interventions benefit all HIV-positive individuals at every stage of the disease. Moreover, when people receive ART without other needed care, they fail to reap the full clinical benefit of ART. Establishing a basic standard of care allows health care providers to benchmark the quality of services and strive to improve, so that all PLWHA receive high-quality care interventions.

The Emergency Plan focuses on integrating care for PLWHA with treatment and prevention. Prevention is a crucial component of PEPFAR and is important regardless of one�s sero-status. Linkages between care for PLWHA and �prevention with positives� programs, further discussed in the chapter on Prevention, support positive living.

For successful implementation of care programs, reliable procurement and distribution of essential commodities are required. In addition to medications for pain and symptom relief and OI management, providers of care need access to items necessary for managing clinical conditions (e.g., drug-dispensing equipment, gloves, wound-care and mouth-care supplies, and HIV-testing kits). The Emergency Plan works closely with governments and their procurement systems to strengthen timely acquisition and usage of these types of commodities and to increase the effectiveness of care.

Furthermore, there is a need to train health providers and peer educators in the prevention of HIV transmission, the prevention and management of OIs, and the use of program data and reporting to inform and improve the delivery of interventions. Experience in Uganda and elsewhere also supports the development and monitoring of program indicators to benchmark and improve program quality and ensure that PLWHA receive the highest possible standard of care. The Emergency Plan provides support for an interdisciplinary, holistic range of palliative care services, listed in the accompanying text box.

Results: Rapid Scale-Up
In fiscal year 2006, the Emergency Plan committed $198 million for care for PLWHA (consisting of funding for palliative care, including basic health care and support and TB/HIV services; funding for OVCs; and counseling and testing as discussed elsewhere in this chapter) in the focus countries. These resources supported care for nearly 4.5 million people. Approximately 11.3 percent of resources for prevention, treatment, and care activities in the focus countries were devoted to care for PLWHA.

Emergency Plan support is provided for a variety of interventions at different levels within the network model (including home-based care programs, as well as health care sites that deliver services). In addition, support is provided to fill specific gaps in national training, laboratory systems, and strategic information systems (e.g., monitoring and evaluation, logistics, and distribution systems) that are essential to the effective roll-out and sustained delivery of quality care.

Tuberculosis and HIV/AIDS
More than 40 percent of HIV-infected people in many areas of the focus nations are co-infected with Mycobacterium tuberculosis � a leading cause of illness and death in PLWHA. Of those co-infected, approximately 10 percent per year develop active TB. It is vital to treat people with TB to prevent illness and death, as well as to prevent its spread to others. The Emergency Plan thus supports activities to serve people living with HIV-TB co-infection.

Cohort analyses of patients on highly active antiretroviral therapy (HAART) reveal high rates of prevalent and incident TB (15-30 percent). TB incidence is especially high during the first six months of HAART and is associated with high mortality in HIV-infected patients. Screening for TB as part of the preventive care package for HIV-infected persons is taking place in many places, and the Emergency Plan is working closely with host country partners to expand these efforts.

Given the serious implications of TB/HIV for PLWHA, the Emergency Plan supports governments and non-governmental organizations, including community- and faith-based organizations, which work at the facility level, including hospital wards, to ensure that health care providers screen HIV-infected patients for TB at each encounter. With USG support, host country programs have developed simple symptom-screening tools and recording-and-reporting forms to document screening for TB. When appropriate, health facilities are responsible for ensuring the proper diagnosis and management of TB according to WHO-recommended Directly Observed Therapy, Short Course (DOTS) strategy and national TB program guidelines. Because TB is so common among PLWHA, the Emergency Plan also supports screening of HIV-infected persons in settings outside of health care facilities, such as in their homes through home-based care programs.

The Emergency Plan is working with host governments and technical partners such as WHO to increase TB patients� access to HIV testing and other HIV/AIDS services. At present, TB patients in many places are referred to voluntary counseling and testing centers that are physically separate from their TB clinics, while elsewhere HIV testing is available in the TB clinic. The percentage of TB patients who undergo HIV testing varies accordingly. For example, in An Giang province in Vietnam 100 percent of TB patients undergo HIV testing, while in Western province of Zambia only about 50 percent of TB patients undergo HIV testing.

In many countries, including Botswana, Ethiopia, Kenya, Rwanda, and Tanzania, the Emergency Plan is thus working with partners to support expansion of provider-initiated HIV counseling and testing among TB patients. The results are impressive. Recent data from Botswana�s National TB program suggest that 68 percent of registered TB patients undergo HIV testing. In districts with provider-initiated HIV counseling and testing in Tanzania, more than 80 percent of TB patients accept testing and learn their HIV status. Other Emergency Plan countries are also moving toward provider-initiated HIV counseling and testing. Emergency Plan support for efforts to increase HIV testing among TB patients translates into increasing numbers of HIV-infected TB patients being linked to prevention programs and HIV treatment and care.

For TB/HIV co-infected patients, there is a critical need to ensure adequate treatment and care for both diseases. Linking suspected TB patients who have been identified through screening to TB diagnosis and treatment, and maintaining HIV-infected TB patients on both TB treatment and HIV treatment and care, are major challenges. Some countries, including Kenya and Mozambique, are exploring ways to provide DOTS TB treatment in HIV clinics or cotrimoxazole at TB sites, to facilitate simultaneous care for TB/HIV co-infected patients. Other countries, such as Tanzania, are initiating provision of ARVs in TB clinics; this requires a strong national TB program. Others, such as C�te d�Ivoire, whose ART programs are decentralizing, are trying to co-locate TB and HIV care in the same facilities. Regardless of the location of care, the Emergency Plan and its partners are increasing support for efforts to control TB infection in health care facilities.

The Emergency Plan supported TB treatment and care for approximately 301,000 co-infected people in focus countries during fiscal year 2006. Given the high prevalence of TB among PLWHA both before and after starting treatment, the priority is support for the diagnosis and treatment of active TB using DOTS principles, with support also provided for diagnosis and treatment of latent TB infection to prevent the development of active disease. Another important priority is ensuring that all TB patients receive confidential HIV counseling and testing and are provided access to HIV prevention and, if necessary, treatment and care. In most focus countries, the Emergency Plan also supports the development of a strong, tiered public health laboratory network for diagnosing and managing OIs such as TB. Laboratories will be especially important as countries increase their efforts to diagnose and manage drug-resistant TB, particularly extensively drug-resistant TB (XDR TB), which is resistant to many of the essential TB medicines. Of all adults and children who received TB treatment and care with PEPFAR support, 139,000 received it at USG-supported delivery sites, while the remainder received support through contributions to national, regional, and local programs.

For example, the Emergency Plan has made a major commitment to support the Government of Rwanda�s (GoR) national efforts to address TB/HIV. The Emergency Plan has provided technical and financial support, assistance with national implementation guidelines, and training of health care workers. In fiscal year 2006, the USG supported central-level coordination through a national TB/HIV technical advisor and program coordinators at the Programme National Int�gr� de lutte contre la L�pre et la Tuberculose (PNILT) and the Treatment and Research AIDS Center (TRAC). The PNILT technical manual has been revised to include a chapter on TB/HIV, and the national TB register and treatment cards have been updated to include HIV-related information. A paper-based HIV register was developed that includes information on screening for active TB disease and will be distributed for use at all HIV treatment and care sites. In fiscal year 2007, the USG plans to support implementation of recently developed national guidelines to achieve the goal of testing all TB patients for HIV as part of routine care and providing referral and access to HIV treatment and care. Priority will be placed on regular evaluation of HIV-infected patients for TB, using a recently developed WHO TB screening tool to quickly identify and ensure appropriate and timely TB treatment. For more information on PEPFAR�s TB/HIV efforts in Rwanda, see the accompanying text box.

South Africa: Good Shepherd Hospice Gives Hope to a Young Family Shadrack Lelani is a 31-year-old husband and father of a three-year-old daughter. Shadrack and his family live in a small, rural community in South Africa�s Eastern Cape province. In 2004, Shadrack contracted tuberculosis and learned that he was HIV-positive. �I did not even feel sick at the time,� he recalled. Thankfully, the PEPFAR-supported Good Shepherd Hospice was able to provide Shadrack with tuberculosis medication. His cough improved, but soon he fell ill and began to lose weight. In May 2006, Shadrack returned to the Hospice for life-saving antiretroviral treatment. Today he reports: �I have picked up some weight. It has really helped me.� Like many people living with HIV/AIDS in the community, Shadrack is visited regularly by Hospice staff and his home-based caregiver, Sylvia. Sylvia lives a couple of streets away and visits Shadrack every week. Shadrack considers the Good Shepherd Hospice staff very supportive: �They are good to me and have helped me a lot.� The hospice also provides Shadrack�s family with a food parcel every two weeks and hospice staff members helped him access a disability grant from the South African government. The antiretroviral medication and care packages � and the community�s love and support � have given Shadrack and his family hope for a brighter future.

Sustainability: Building Capacity
The Emergency Plan focuses on supporting the expansion of networks of health care providers and linking them to home-based care programs, in order to support sustainable care for people living with HIV/AIDS. PEPFAR efforts focus on building the capacity of community- and faith-based groups, which have played a leading role in home-based care in many countries. USG in-country teams have found that even small grants can be very empowering for these grassroots organizations, allowing them to expand their services and advocate for increased community and national commitment to people living with HIV/AIDS.

Building the capacity of networks of PLWHA to provide care and leadership is another key element of PEPFAR�s work in this area. The involvement of these networks in palliative care helps build sustainable systems that respond fully to the challenges PLWHA face.

Recognizing the long-term importance of appropriate national policies in regard to care for people living with HIV/AIDS, the Emergency Plan has supported policy development initiatives. Another focus is strengthening referral systems to medical care for PLWHA.

USG support was provided for training of close to 94,000 palliative care providers in the focus countries in fiscal year 2006, while 8,019 sites received support for personnel, infrastructure development, logistics, strategic information services, and other components of high-quality care.

Key Challenges and Future Directions
Human Capacity. As in other areas of HIV/AIDS response, inadequate human capacity remains a major challenge to ensuring quality of care for PLWHA, with nurses and other health care providers in desperately short supply in many nations.

For lay workers and volunteers who provide palliative care as well as professional health care workers, there is a need to expand and improve training, and strengthened supervision systems and appropriate incentives are essential. With PEPFAR support, South Africa�s Hospice Palliative Care Association was able to strengthen its financial and technical capacity, increasing its ability to provide high-quality outreach and services to people living with HIV/AIDS. To expand this initiative throughout the region, PEPFAR also has supported the African Palliative Care Association.

To ensure quality, the Emergency Plan supports efforts to strengthen supervision of lay workers by health professionals, where possible. Initiatives to provide incentives to volunteers, including remuneration, also receive support, which strengthens the care networks. Key training programs include pre-service training for future health care professionals and in-service training for current health workers.

Addressing Key Policies That Limit Care. National policies in some countries prevent health aides, including nurses, from engaging in key activities for care of PLWHA. Given the centrality of nurses to provision of care in the developing world, it is essential that nurses become HIV experts who may develop capabilities to provide medication. In collaborative efforts with host governments, advanced practice nursing is a priority for Emergency Plan policy development efforts.

Opioids, which may be one element of such care, and can be essential for pain relief, are often not registered by national governments for pain relief for AIDS patients. Working with host governments, PEPFAR continues to offer strong support to efforts to improve end-of-life care policies as well as programs.

Also critical is the dissemination of �basic preventive care packages� developed by the Emergency Plan under National Strategies, offering services such as medications to prevent OIs, insecticide-treated nets to prevent malaria, and clean drinking water. The effort to establish a high standard of care for PLWHA includes support for the development of basic program monitoring indicators, supportive supervision to provide on-site guidance and mentoring, and monitoring and evaluation to measure the impact of the new care services.

Addressing Burden on Women and Girls. The burden of caregiving for PLWHA falls disproportionately on women and girls, exacting an emotional, physical, and financial toll on a group of people who have limited access to resources. The Emergency Plan thus supports efforts to make comprehensive, high-quality care available at the community level, with links to broader health networks. These initiatives augment policy advocacy on behalf of women and community outreach to involve men in caregiving, thus reducing the burdens on women and girls. For example, countries such as Uganda and Zambia have established programs that provide legal protection and education for women and orphans at the community level, focusing on issues such as inheritance rights.

Food and Nutrition. The Emergency Plan�s interagency technical working group on food and nutrition includes OGAC, U.S. Agency for International Development (USAID), HHS, and the U.S. Department of Agriculture (USDA). As discussed above, this interagency group has developed guidance on food and nutrition for incorporation into the care activities of USG teams in the field. The guidance clarifies circumstances under which the Emergency Plan supports appropriate assessment, monitoring, and counseling regarding the nutritional needs of PLWHA.

Emergency Plan teams work to leverage food and nutrition resources from other USG sources, such as USAID�s Title II program and USDA�s Food for Progress program, among others. In addition, the Emergency Plan seeks to leverage food from other sources, including the World Food Program and the private sector. The Emergency Plan will also expand collaboration with host governments as they increase their efforts to provide for their own populations.

Community Support for Care, Including Involvement of People Living with HIV/AIDS. The Emergency Plan strongly supports efforts to include PLWHA in the provision of care, which not only helps to address the human capacity shortfall in developing countries, but also ensures that care activities are conducted in ways that respond to the needs of PLWHA. USG country teams are reaching out to groups of PLWHA, including them in the design and implementation of care programs, and providing funding for a growing number of support groups in all focus country programs. PEPFAR also supports associations that reach out to the most highly stigmatized individuals, such as men who have sex with men and injecting drug users. In Kenya, faith-based organization (FBO) leaders who are living with HIV provide outreach to members of the faith community to help reduce stigma, while providing education and a system of support. In addition, PEPFAR is supporting a variety of efforts to support communities as they confront the challenge of providing care and support. As part of these efforts to engage the community, many countries have pioneered the provision of home-based care. In Uganda, a family-centered approach serves as the foundation for home-based HIV testing for entire families, with linkages to treatment and care services. More than 90 percent of all family members who participate in this program accept confidential testing in the privacy of their home.

Secure and Reliable Supply Chain for Drugs and Commodities. As with antiretroviral drugs, a consistent and secure supply chain for commodities and medications is necessary for high-quality palliative care. The Supply Chain Management System, described in the chapter on Building Capacity: Partnerships for Sustainability, is working to ensure the quality of these items.

HIV Counseling and Testing
The Emergency Plan has led the way in supporting the expansion of access to HIV/AIDS prevention, treatment, and care in the developing world. Knowledge of HIV status is increasingly recognized as essential for all persons living in high-prevalence countries, both for access to treatment and care and so that individuals and couples can make informed decisions and choices about HIV prevention strategies. Technological advances have led to rapid HIV tests that provide results within minutes. In spite of these advances, however, it is estimated that more than 80 percent of all people living in PEPFAR focus countries do not know their HIV status.

Knowing one�s status provides a gateway for critical prevention, treatment, and care services. Millions of persons must be tested for PEPFAR to meet its ambitious treatment and care and goals in the focus countries. It is estimated that a minimum of 30 million people will need to be tested to meet PEPFAR�s 2-7-10 goals � if countries appropriately target counseling and testing to populations at increased risk of HIV infection (such as TB patients and women seeking PMTCT services) and if health care providers offer counseling and testing in health care encounters. To the extent counseling and testing is not well-targeted, the number who must be tested for PEPFAR to meet its goals will be correspondingly higher.

Table 3.6 shows the steep increase in the number of people receiving counseling and testing services with Emergency Plan support. Although many others also receive these services

The Emergency Plan is moving with urgency and innovation, commensurate with this extraordinary challenge. A growing number of best practices have been identified to increase testing in health facilities and to increase access to testing services in rural and remote areas. In addition, the PEPFAR-supported scale-up of PMTCT programs has increased the number of women who have learned their HIV status during pregnancy.

A key barrier to the universal knowledge of serostatus is the lack of routine testing in medical settings, including TB and sexually transmitted infection (STI) clinics and hospitals. In many focus countries, studies have found that 50 to 80 percent of hospital and TB patients are infected with HIV; many of these patients are in urgent need of treatment. As noted in table 3.10, there is increasing international support for this model of �routine� or �opt-out� testing, where in selected health care settings, all patients are tested for HIV unless they refuse; this approach has successfully identified many patients in need of treatment and care. Several studies presented at the HIV/AIDS Implementers� Meeting in Durban demonstrated the impact this policy can have. A pilot project in Zimbabwe showed a 54 percent increase in testing rates at urban ANCs after the introduction of routine testing and a 76 percent increase in rural areas. Another study conducted in the maternity ward of a 200-bed hospital in rural Uganda found that moving to routine testing more than doubled the proportion of women discharged from the ward with a known HIV status, from 39 percent to 88 percent.

In all approaches, the person tested should give consent, be informed of his or her test results, be provided with information on how to prevent HIV transmission or acquisition, and if infected, be referred for treatment and care. Nigeria has made considerable progress in this area, with some partners having a tenfold increase in the number of patients being tested at their clinical sites. Other countries that have made significant progress in the scale-up of HIV counseling and testing in medical settings in 2006 include Botswana, Kenya, Malawi, Rwanda, and Tanzania.

A major challenge associated with this best practice is linking patients who have been identified as seropositive with HIV care, including cotrimoxazole and ART. Other obstacles include the distance of patients from facilities and the inadequate numbers of health care workers and inconsistent test kit supplies at health care facilities.

In addition to HIV testing in medical settings, PEPFAR continues to support the expansion of testing in the community in many countries. Stand-alone centers in urban areas attract many young men and other groups who otherwise do not frequent medical facilities. Some of these centers, often known as voluntary counseling and testing (VCT) sites, also provide services to special groups such as the deaf, rape victims, injecting drug users, and people in prostitution. Couple counseling and testing, both for premarital and married couples, is provided in many sites supported by PEPFAR, including through faith-based organizations that encourage members to know their status. Couples who know they are HIV-discordant (couples in which one partner has HIV and the other does not) can successfully prevent transmission to the negative partner.

The experience of home-based counseling and testing in Uganda demonstrates the value of identifying family members who are at high risk of either having undiagnosed HIV infection or acquiring HIV. Identification of discordant couples through home-based HIV testing was identified as a best practice at the PEPFAR Implementers� Meeting in June 2006.

The Emergency Plan also supports laboratory quality improvement, a key element of effective testing programs, through training of laboratory workers, improving the physical infrastructure of labs, and ensuring consistent supplies of test kits.

Effective programs must overcome these obstacles, while ensuring that counseling and testing services are of high quality. Compounding all these challenges are the fear, stigma, and discrimination against those who are infected with HIV, which remain significant barriers in many nations.

Results: Rapid Scale-Up
To date, the Emergency Plan has provided support for more than 18.6 million confidential HIV counseling and testing sessions in the focus countries. More than 9.2 million of these occurred in fiscal year 2006: more than 2.8 million in PMTCT settings and more than 6.4 million through other counseling and testing activities.

Of the more than 9.2 million counseling and testing sessions in fiscal year 2006, approximately 6.4 million were performed at USG-supported sites, while the remainder were the result of PEPFAR support for countries� capacity to provide services (including assistance for national and regional policies, communications, protocols to ensure high-quality services, laboratory support, and purchase of test kits).

Reflecting the importance of counseling and testing in achieving the goals of the Emergency Plan, $130 million, or approximately seven percent of fiscal year 2006 focus country resources for prevention, treatment, and care, were committed to counseling and testing activities. An additional $92 million, or five percent, were committed to PMTCT activities, which include counseling and testing of pregnant women along with other activities.

Approximately 71 percent of those who received downstream USG-supported counseling and testing services in fiscal year 2006 were female. This figure includes all women tested through PMTCT services. In other, non- PMTCT sites, including VCT centers, medical facilities, and mobile sites, 56 percent were women.

Sustainability: Building Capacity
Emergency Plan teams have worked with host governments and other partners to integrate counseling and testing into routine health care, as well as supporting local, indigenous, and faith-based organizations to provide confidential counseling and testing services to their communities.

In the focus countries in fiscal year 2006, the Emergency Plan provided support for training of approximately 66,100 individuals in counseling and testing (including approximately 32,600 as part of PMTCT training and approximately 33,500 others). PEPFAR also supported more than 11,000 service sites (including 4,800 PMTCT sites and 6,400 other counseling and testing sites).

Key Challenges and Future Directions
Bolstering Sustainable Activities to Increase the Number of People Who Learn their HIV Status.
Given the challenges involved in rolling out counseling and testing on a massive scale, it is critical to focus efforts upon people with a higher likelihood of HIV infection than the general population. Making diagnostic testing a part of health care interactions is among the most efficient and sustainable ways of accomplishing this goal. Accordingly, the Emergency Plan is bolstering its support for routine counseling and testing in clinics that treat TB or STIs, hospitals, and other health care settings.

The Emergency Plan has taken special efforts to ensure that women receive counseling and testing without stigma and discrimination, and that they have full access to treatment and care as needed. Many of the initiatives described have fostered the achievement of these goals, including testing for pregnant women in health care settings, partner testing, and activities to reduce stigma and cultural barriers that inhibit women�s access to services. The USG has collaborated with UNICEF, WHO, and others to produce a PMTCT counseling and testing tool that streamlines and standardizes high-quality counseling and increases the uptake of HIV testing.

At the same time, it is important to ensure access for the population at large, especially in countries with generalized epidemics. Community-based counseling and testing remains an important HIV prevention opportunity. PEPFAR works to ensure that all people who want to know their status have access to testing services, particularly in countries with high HIV prevalence, where all sexually active persons have some risk for HIV infection. This includes innovative

One requisite for high-quality counseling and testing programming is that those who are tested actually receive their test results. Due to long delays in obtaining test results, however, many who are tested have not returned for their results. Finger-prick (whole blood) and oral rapid testing, which do not require cold chain storage or additional equipment or supplies, can be used in a variety of settings by a variety of health care workers, from nurses to lay counselors. Rapid testing is especially important when testing is conducted outside of health facilities. The increasing availability and quality of rapid tests is one of the most encouraging developments in the fight to expand counseling and testing, and PEPFAR continues to strongly support country teams and partners� inclusion of rapid tests in their plans. A number of host nations and partners have moved to rapid testing in recent years, with USG support, and PEPFAR supports efforts to resolve regulatory and policy obstacles to the implementation of rapid tests.

Ensuring Quality in Counseling and Testing. Widely available, high-quality HIV testing requires large numbers of testing kits. The Emergency Plan-supported Supply Chain Management System, described in the chapter on Building Capacity: Partnerships for Sustainability, works with host nations to ensure uninterrupted supplies of high-quality test kits.

High quality in counseling is equally important. A number of countries have developed protocols and systems to assess and improve counseling services. Counseling for those who test negative is an area that has received insufficient attention in the past, wasting critical opportunities for prevention efforts. The Emergency Plan therefore is supporting efforts to expand and improve training of counselors to ensure that they are able to offer appropriate prevention information.

International Counseling and Testing Day. In her remarks to the United Nations General Assembly High Level Meeting on HIV/AIDS in June 2006, First Lady Laura Bush called for the establishment of an International HIV Testing Day. PEPFAR subsequently developed a feasibility analysis for UNAIDS, outlining issues to be addressed for the establishment and success of an International HIV Testing Day. In December 2006, the General Assembly of the United Nations adopted the proposal. This initiative, implemented by each country beginning in 2007 according to its own capacity and needs, will be an important step toward expanding access to confidential HIV counseling and testing and de-stigmatizing learning one�s status; in so doing, it will contribute to meeting PEPFAR�s prevention, treatment, and care goals.

Accountability: Reporting on the Components of Care
As discussed earlier, PEPFAR works closely with countries to maximize both downstream and upstream support wherever partnership limitations or technical, material or financial constraints require it. The Emergency Plan, either alone or in concert with another partner, may support every aspect of the complete package of prevention, treatment, or care services at a specific public or private delivery site, in coordination with the host country�s national strategies. The comprehensive and ongoing nature of providing HIV/AIDS care poses significant challenges for program monitoring and evaluation. The Emergency Plan recognizes this, as well as the importance of accurate program monitoring in establishing high-quality services. Understanding and recording the types of care services that are delivered is the foundation of ensuring that programs maximize scarce resources for as many PLWHA as possible. As part of Emergency Plan capacity-building, country teams are working closely with host governments and partners to build and improve upon information systems for monitoring and evaluating routine program indicators for care. For more information, please see the Improving Accountability and Programming chapter.

Attribution Challenges Due to Country-Level Coordination. The Emergency Plan supports national HIV/AIDS treatment strategies, leveraging resources in coordination with the host countries� multi-sectoral organizations and other partners, to ensure a comprehensive response. For an effective and sustainable response, host nations must lead a multisectoral national strategy for HIV/AIDS. International partners must ensure that interventions are in concert with host government national strategies, responsive to host country needs, and coordinated with both host governments and other partners. Stand-alone service sites managed by individual international partners are not desirable or sustainable. In such an environment, attribution is complex, including both upstream and downstream activities, often with multiple partners supporting the same sites to maximize comparative advantages. PEPFAR is conducting audits of its current reporting system to refine methodologies for the future, and continues to assess attribution and reporting methodologies in collaboration with other partners.

Care Reporting Conventions. During this reporting period, results for PEPFAR care programming were determined by totaling all the programs, services, and activities aimed at optimizing quality of life for OVCs; at caring for patients and their families throughout the continuum of illness; and at diagnosing HIV-infection through counseling and testing, including through PMTCT activities.

Activities aimed at improving the lives of children and families directly affected by AIDS-related morbidity and/or mortality are counted as OVC programs. These may include training caregivers; increasing access to education; economic support; targeted food and nutrition support; legal aid; medical, psychological, and emotional care; and/or other social and material support. Institutional responses are also included.

Given the need to independently account for TB prevention, treatment, and care, palliative care totals are made up of two service categories � basic health care and support, and TB/HIV care and support. Basic health care and support includes all clinic- and home/community-based activities aimed at optimizing quality of life of HIV-infected (diagnosed or presumed) clients and their families by means of symptom diagnosis and relief; clinical monitoring and management (and/or referral for these) of opportunistic infections, including malaria and other HIV/AIDS-related complications; culturally appropriate end-of-life care; social and material support, such as nutrition support, legal aid, and housing; psychological and spiritual support; and training and support for caregivers. TB/HIV care and support activities include examinations, clinical monitoring, treatment, and prevention of tuberculosis in HIV palliative care settings, as well as screening and referral for HIV testing and TB-related clinical care. In-country partners derive these counts from program reports and health management information systems.

In the area of HIV testing, results report on numbers of individuals trained, numbers of sites where HIV testing is supported, and numbers of individuals tested, disaggregated by gender. Equipment and commodities, in particular test kits, are provided through the program and are inventoried and tracked through standard USG reporting and accounting systems by the grantees acquiring the goods.

The Emergency Plan has also funded an evaluation project, discussed in the chapter on Improving Accountability and Programming. This evaluation will provide:

• Data quality audit guidance for program-level indicators;
• Best practices for program-level reporting; and
• Implementation of data standards guidance in select countries.

Back to Report Main Page