I. Overview: The Role of America's Partnerships in the Worldwide Fight Against HIV/AIDS

	Introduction: Partnerships Create Hope For more than 25 years, the global community has witnessed the devastating impact of HIV/AIDS. Until recently, many wondered whether prevention, treatment and care could ever make a measurable impact, particularly in resource-limited settings where HIV was a death sentence. Just 5 years ago, only 50,000 people living with HIV in all of sub-Saharan Africa were receiving antiretroviral treatment (ART). Recognizing that HIV/AIDS was and is a global health emergency requiring emergency action, President George W. Bush and a bipartisan, bicameral Congress reflected the compassion and generosity of the American people. Their creation, the U.S. President’s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR), holds a unique place in the history of public health for its size and scope: In size, with an original commitment of $15 billion over 5 years, and a final funding level of $18.8 billion, it is the largest international health initiative in history dedicated to a single disease and also the largest development initiative in the world. The first phase of PEPFAR went beyond a commitment to allocating resources to a commitment to achieving results, with ambitious goals to support prevention of 7 million new infections, treatment of 2 million and care for 10 million, including orphans and vulnerable children (OVCs).   In scope, it is the first large-scale effort to tackle a chronic disease in the developing world. It moves beyond isolated efforts and pendulum swings that led programs to focus on prevention or treatment or care for HIV/AIDS, to sound public health principles - integrated prevention, treatment and care. The results speak for themselves. On World AIDS Day 2008, President Bush announced that, ahead of schedule, the United States has fulfilled its commitment to support life-saving ART for 2 million people. As of September 30, 2008, the American people have supported ART for more than 2.1 million men, women and children living with HIV/AIDS around the world. Of these, over 2 million people were reached through bilateral programs in PEPFAR’s 15 focus countries in sub-Saharan Africa, Asia, and the Caribbean (Figure 1). PEPFAR treatment support is estimated to save 3.28 million adult years of life through September 2009, and many more beyond that time frame. These additional years of life are ones in which people can play their vital roles in society as parents, teachers, or caregivers. As of September 30, 2008, nearly 9.7 million people affected by HIV/AIDS in PEPFAR’s focus countries have received compassionate care, including nearly 4 million OVCs. Using conservative projections, the American people have exceeded the goal of supporting care for 10 million people in PEPFAR’s focus countries as of December 1, 2008 (Figure 2). Worldwide, PEPFAR has supported care for over 10.1 million through September 2008. From fiscal year 2004 (FY2004) through FY2008, PEPFAR has supported prevention of mother-to-child HIV transmission (PMTCT) during nearly 16 million pregnancies. Antiretroviral prophylaxis has been provided to HIV-positive women in over 1.2 million pregnancies, allowing nearly 240,000 babies to be born free of HIV. In FY2008, PEPFAR-supported programs reached 58.3 million people with support for prevention of sexual transmission using the ABC approach (Abstain, Be faithful, correct and consistent use of Condoms). The U.S. Government (USG) has supplied more than 2.2 billion condoms worldwide from 2004 through December 20, 2008 - as Dr. Peter Piot, former Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) has said, more than all other developed countries combined. The American people have supported nearly 57 million counseling and testing encounters cumulatively through FY2008. Over the past 5 years, the 14 countries that received PEPFAR support for safe blood programs have seen a decrease in the prevalence of HIV-infected units and are moving progressively closer to meeting their annual demand for safe blood. The success of PEPFAR is firmly rooted in a commitment to results. Through partnerships between the American people and the people of the countries in which we are privileged to serve - governments, non-governmental organizations (NGOs) including faith-based organizations (FBOs) and community-based organizations (CBOs), and the private sector - we are building sustainable systems and empowering individuals, communities, and nations to battle HIV/AIDS. Together, we have acted quickly. We have obligated 92 percent of the funds appropriated to PEPFAR so far, and expended or outlayed 68 percent of them.1 Figure 3 depicts the allocation of program resources in the 15 PEPFAR focus countries in FY2008. But success is not measured in dollars spent: it is measured in services provided and lives saved. On many fronts, the progress to date has been remarkable; as the Institute of Medicine (IOM) noted,
PEPFAR has already achieved what many thought was impossible. Encouraged by this progress, Congress came together in a bipartisan way to strengthen the program. On July 30, 2008, President Bush signed into law P.L. 110- 293, the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, authorizing up to $48 billion over the next 5 years to combat global HIV/AIDS, tuberculosis (TB), and malaria. Through FY2013, PEPFAR plans to work in partnership with host nations to support treatment for at least 3 million people; prevention of 12 million new infections; and care for 12 million people, including 5 million OVCs. To meet these goals and build sustainable local capacity, PEPFAR will support training of at least 140,000 new health care workers in HIV/AIDS prevention, treatment and care.
	Trends in Health The developing world faces a wide range of health and development issues. Some have questioned whether HIV/AIDS merits the intensive focus that the Emergency Plan has brought to it. PEPFAR’s emphasis on health systems strengthening and local capacity building has benefits that go beyond HIV/AIDS prevention, treatment and care. In the 15 PEPFAR focus countries, home to approximately half of the world’s HIV-infected persons, valuable perspective is gained by examining changes in infant mortality over the past two decades. As seen in Figure 4, infant mortality has declined in 12 of the 15 focus countries since 1988; in most of them, the decline has been very substantial. Yet Figure 5 shows that few of these countries have experienced significant improvements in life expectancy. Tragically, many have seen life expectancy drop, with especially dramatic declines in southern Africa, where HIV prevalence is the highest in the world. Even if nations are having success in improving some health indicators for their people - and many are - the impact of HIV/AIDS is offsetting those improvements. In many regions where PEPFAR works, 50 percent or more of hospitalizations are due to HIV/AIDS. In the hardest-hit countries, decades of public health gains have been erased. For example, in Botswana, HIV/AIDS drove an increase in infant mortality despite significant increases in health resources committed by the Government (Figure 6). Similarly, life expectancy in Botswana dropped by 30 percent during the 1990s and early 2000s (Figure 7). In recent years, the Government of Botswana reports that those trends have turned around, thanks to a major assault on HIV/AIDS funded primarily with its own resources, but also with increased support from international partners. For the first time in more than a decade, infant mortality has decreased and life expectancy has increased there. The correlation between HIV/AIDS programs and improved quality and duration of life for women and children is unmistakable. A study in Uganda shows the expansion of HIV services led to a decrease of 81 percent in non-HIV infant mortality, in part because the number of children orphaned by HIV/AIDS decreased by 93 percent. In other words, parents, including many mothers, are staying alive. The good news is that growing evidence shows that aggressively confronting HIV/AIDS has a broad impact on the overall health of populations. It is clear that an effective response to the unique challenge of HIV/AIDS is necessary for real progress on health in the developing world. The data are increasingly compelling; as countries scale up their HIV/AIDS prevention, treatment and care
programs, they are making progress toward reversing the course of the epidemic. Their efforts are paying off as life expectancy once again begins to rise and infant mortality continues to fall. Trends in HIV/AIDS UNAIDS has revised its estimate of the number of people living with HIV/AIDS worldwide downward to 33 million from a previous estimate of 39.5 million. For the most part, the revision reflects the strengthening of HIV surveillance capacity over the past few years, as countries have implemented population-based surveys (in many cases with PEPFAR support) to supplement the antenatal clinic (ANC) surveillance previously used to estimate prevalence. Even with the new prevalence estimates, however, the number of people living with HIV/AIDS worldwide in 2007 was roughly 4.2 million more than in 2001. Prevention remains the central challenge.
	Prevention Sexual transmission Of the countless recent developments in the global fight against the pandemic, perhaps the most important is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior. According to UNAIDS’ 2008 Report on the Global AIDS Epidemic: “In sub-Saharan Africa, most national epidemics have stabilized or begun to decline.” Zimbabwe, Botswana, Malawi, and Zambia are among those that have seen declines in national prevalence. The report also emphasizes, however, that although most sub-Saharan epidemics have stabilized, they have often done so at high prevalence levels. The report continues: “The rate of new HIV infections has fallen in several countries, although globally these favourable trends are at least partially offset by increases in new infections in other countries.” A key trend in HIV/AIDS prevention is the growing importance of addressing HIV-discordant regular partnerships as a means for transmission. According to Uganda’s 2005 National HIV Survey, approximately 50 percent of new infections there occurred within discordant regular partnerships. Many HIV-discordant couples do not know their HIV status. Several studies in Africa have shown that provision of voluntary counseling and testing for couples reduces HIV transmission by 56 percent and that consistent condom use in discordant couples is associated with an 80 percent reduction in HIV transmission. However, the rate of condom usage in regular partnerships remains low. In Uganda, for example, condom use rose from 0 percent in the early 1990s to 1.9 percent in the late 1990s. Despite massive provision of condoms by the USG and others, increasing usage has proven difficult, even when couples know their HIV status. A promising new prevention approach is safe medical male circumcision, which studies have shown lowers transmission rates where the man is the HIV-negative partner. Discordant couples represent an important opportunity
for prevention, so further innovation is needed to address this vulnerable population. For example, antiretroviral (ARV) medications have the potential to be used either as pre-exposure prophylaxis for the HIV-negative partner, or to reduce the level of HIV in the positive partner, thereby reducing the transmission rate in discordant couples. For all populations, multiple concurrent partnerships remain a significant prevention challenge. On average, an African’s number of life-time partners is comparable to that of an American or a European. However, in some areas multiple concurrent partnerships, which could promote more rapid spread of HIV, are common. The challenges of multiple concurrent partnerships parallel those of discordant couples. Data show that decreases in the number of sexual partners - the “B” in “ABC” - could have a significant impact on HIV transmission. This issue will continue to be a key focus for PEPFAR.
	As the epidemic changes, the global community must constantly adapt and improve its programs. One of the central themes of PEPFAR continues to be “Knowing Your Epidemic” - understanding where, why and in whom infections are occurring, both in terms of geography and in terms of vulnerable populations, and tailoring programs accordingly. An HIV prevention program in Vietnam, where the epidemic is largely concentrated among injecting drug users (IDUs) and people in prostitution and their clients, requires a different approach from a prevention program in Uganda, where most infections occur through sexual partnerships in the general population (and, increasingly, within discordant couples). Regardless of the key factors in transmission, in the continued absence of an effective vaccine or microbicide, behavior change must remain the keystone of HIV prevention success. Even with the recent advances in prevention related to male circumcision, maintaining behavior change is essential. Armed with data from UNAIDS and others showing encouraging trends, PEPFAR is promoting life skills and comprehensive HIV prevention programs beginning with the very young, because it is easier to influence behavior if educational programs begin early. Life skills and HIV prevention programs teach youth to respect themselves, to respect others, including the opposite sex, and to practice personal responsibility. Such programs are being scaled up nationally, both in- and out-of-school, in PEPFAR countries. In many countries, adults continue to face elevated risk of HIV infection, and PEPFAR is supporting the expansion of programs for them as well. PEPFAR prevention programs target different age groups with interventions tailored to the risks they face, recognizing that effective prevention is a life-long matter. Prevention of mother-to-child transmission Mother-to-child transmission remains the leading source of child HIV infections, and providing PMTCT remains an essential challenge. According to UNAIDS, the global number of children who became infected with HIV has dropped slightly, from 460,000 in 2001 to 370,000 in 2007. PEPFAR supports host nations’ efforts to provide PMTCT programs, including HIV counseling and testing for all women who attend ANC, and sharply increased its PMTCT resources in FY2008. PEPFAR has supported PMTCT interventions for women during nearly 16 million pregnancies to date, providing antiretroviral prophylaxis for over 1.2 million HIV-positive pregnancies, and preventing an estimated 237,600 infections of newborns. Despite significant resources from PEPFAR, levels of PMTCT coverage continue to vary from
country to country. While all PEPFAR focus countries have scaled up services significantly in recent years, the results in some countries remain disappointing. A central obstacle in many nations is failure to fully implement policies allowing “opt-out,” provider-initiated counseling and testing, under which all women who visit ANCs routinely receive voluntary HIV testing unless they decline. Nations that have adopted and implemented opt-out testing have dramatically increased the rate of uptake among pregnant women, from low levels to around 90 percent at many sites. Under the highly successful national program in Botswana, where approximately 13,000 HIV-infected women give birth annually, the country has increased the proportion of pregnant women being tested for HIV from 49 percent in FY2002 to 86 percent in FY2008. This type of change can be seen in other countries as well. It reflects a combination of political leadership, and implementation of opt-out and HIV rapid testing. Without these changes in policy and their successful implementation, success similar to that achieved by Botswana is unlikely to occur.
	Treatment AIDS is still among the most deadly infectious diseases in the world. In sub-Saharan Africa, the epicenter of the pandemic, it is the leading cause of death. More than 22 million of those infected - more than two thirds of all people living with HIV/AIDS - live in the region, and approximately 1.7 million people die of AIDS there each year, more than three-quarters of the global total. However, there is new reason for hope. On a global basis, UNAIDS also estimates that the number of people dying of AIDS-related causes has declined in recent years, from 2.2 million in 2005 to 2.1 million in 2007. This is the first time such a decline has occurred, and the change is due largely to the increased availability of ART - though improved prevention and care programs have likely contributed as well. PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) report supporting treatment for a collective total of 2,952,600 persons as of September 2008. In the focus countries, continued scale-up of ART has led to massive improvements in coverage rates since the beginning of the program (Table 1). In 2003, less than 2 percent of the populations in need of ART received treatment. Just 5 years later, the coverage rate has increased to 38 percent (Range: 27 percent–95 percent). (It is important to note that comparisons cannot be made between treatment coverage estimates published in the 2008 Report to Congress and those published in this 2009 report. The differences are largely the result of refinements in the UNAIDS methodology used to estimate the number of HIV-positive people who are eligible for ART, rather than trends in the pandemic itself.2) Data on morbidity and mortality naturally lag behind expansions of treatment. However, in Botswana, where former President Festus Mogae provided early leadership for national treatment scale-up beginning in 1999, a treatment-driven decline in adult mortality has already begun to occur. Lives prolonged through treatment benefit not only those on treatment. The ultimate measure of treatment is the daily impact on individual lives, and therefore on their families, communities and nations. Perhaps the best way to assess the impact of treatment is to estimate its effect on peoples’ life spans. Unlike treatment for malaria or TB, treatment for HIV/AIDS cannot cure people, only extend their lives. To reflect this, PEPFAR measures the impact of its treatment programs through “life-years saved” rather than “lives saved” - a small but important distinction. As Figure 8 shows, PEPFAR support for treatment in the focus countries is estimated to save nearly 3.28 million adult years of life through the end of September 2009 (as many as were saved by treatment in the United States from 1989 through 2006). Undoubtedly, this will provide many additional years in which people can play their vital roles for their loved ones. Along with its bilateral support for treatment programs, PEPFAR is also the largest contributor to the Global Fund, providing approximately 27 percent of all resources to date. The Global Fund has reported support for treatment for 1,986,000 million people globally as of the end of 2008, of whom 1,073,000 were reported in PEPFAR focus countries (Figure 9). Care As the pendulum on HIV/AIDS interventions swings between prevention and treatment, it is often care that is lost. Yet care is a critical element of a truly comprehensive approach to fighting HIV/AIDS. As defined within PEPFAR, there are three key dimensions to care: care for OVCs; care and support (other than ART) for people infected with or affected by HIV/AIDS; and HIV counseling and testing (which has been counted as Care during the first phase of PEPFAR, but will be counted as part of Prevention for future years). Despite significant progress by PEPFAR in all three areas, much more needs to be done. Orphans and vulnerable children Even the best OVC program cannot replace parents. Because HIV/AIDS predominantly affects people of childbearing age, its impact on children, extended families, and communities is devastating. If a child’s parent dies of AIDS, the child is three times more likely to die, even if he or she is HIV-negative. Besides increased risk of death, children whose parents have died of AIDS face stigmatization and rejection, and often suffer from emotional distress, malnutrition, inadequate health care, poor or no access to education, and a lack of love and care. They may also be at high risk for labor exploitation, sex trafficking, homelessness, and exposure to HIV. Extended families and communities in highly affected areas are often hard-pressed to care for all the children in need. In families and communities affected 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 chronically ill with HIV/AIDS may instead become caregivers for parents and younger siblings, dropping out of school and assuming the responsibilities of the head of the household. Research indicates that children who care for sick and dying parents are among the most vulnerable. The best way to support children is to keep parents alive and healthy through effective HIV prevention and treatment. In order to capture the role that treatment programs can play in protecting children from orphanhood, PEPFAR has developed a methodology to estimate the number of orphans averted through treatment programs. Through FY2008, the number is nearly 1.6 million. Through FY2008, in addition to preventing orphanhood, PEPFAR helped to mitigate the negative social and developmental impact of HIV/AIDS for over 4 million OVCs worldwide up from 630,000 in FY2004. Yet the number reached still falls far short of the need. Although there is uncertainty around OVC estimates in light of UNAIDS’ revised HIV prevalence estimates, by 2010, the number of children orphaned by AIDS globally may exceed 20 million, and the number of other children made vulnerable because of HIV/AIDS may be more than double that number. In addition to scaling up HIV/AIDS programs for OVCs on a larger scale than has been attempted previously, PEPFAR has also sought to strengthen the quality of OVC programs. OVC programs must now report not only on how many of seven key services they provide but also must strive to ensure that these services are making a difference in the lives of children served. Among the areas of support for OVCs in PEPFAR programs are support for food and nutrition and for education. PEPFAR has invested in these areas, and linked to other USG programs addressing these needs.
	Care and support for people infected with or affected by HIV/AIDS The term “care and support” refers to the wide range of services other than ART offered to people living with HIV/AIDS (PLWHA) and other affected persons, such as family members. Care and support comprises five categories of services: clinical (including prevention and treatment of opportunistic infections [OI] and AIDS-related malignancies, and pain and symptom management), psychological, social, spiritual, and preventive services. These services may be provided in facility-, community-, or home-based settings. Care and support is vitally important throughout the lifespan of individuals infected with HIV, starting at the time of diagnosis. The change in nomenclature from “palliative care” to “care and support” was designed to better describe the broad scope of services provided by PEPFAR, while allowing a more accurate application of “palliative care,” as defined by the World Health Organization (WHO). The principles of palliative care remain a priority within PEPFAR; as defined by WHO, palliative care focuses on improving the quality of life for patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering with a focus on assessment and treatment of pain and other symptoms. 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 ART. Therefore, it is critical to establish programs and services for HIV-positive people that address the needs of those not yet on treatment. A key aspect of caring for PLWHA is the provision of regular clinical and laboratory monitoring to ensure that patients receive treatment promptly once they are eligible. Studies show that patients who start treatment late,often when their immune systems are already severely compromised and they have serious OIs, do not fare as well as those who start on treatment promptly once they are eligible. Quality care and support services include regular monitoring for treatment eligibility and prompt initiation of
treatment when appropriate, which has been shown to reduce HIV-associated illnesses and deaths. Care and support programs provide a platform for a range of services to allow PLWHA to stay healthy and delay the need for treatment. Services include the five broad categories noted previously; thus care and support may range from supporting income-generating activities to provide economic stability, to providing compassionate end-of-life care. PEPFAR is encouraging countries to work toward providing all HIV-positive individuals with care and support, including provision of a “basic preventive care package” that provides an array of life-saving interventions, such as insecticide-treated bed nets (ITNs), water purification systems and cotrimoxazole prophylaxis. Finally, programs support HIV-positive people - many of whom are in HIV-discordant partnerships - through “prevention with positives” programs which provide them with information and condoms so they can take appropriate steps to avoid infecting others. PEPFAR has scaled up its support for national efforts to provide high-quality care for OIs related to HIV/AIDS. Co-infection with TB is a leading cause of death among HIV-positive people in the developing world and multi-drug- resistant (MDR) and extensively drug-resistant (XDR) TB are growing threats. PEPFAR increased its funding for HIV/TB more than five-fold, from $26 million to over $140 million, from FY2005 to FY2008. Counseling and testing As PEPFAR scales up confidential counseling and testing programs, addressing policy and implementation constraints around testing is essential for success in prevention, treatment, and care. Knowing one’s status provides a gateway to critical prevention, treatment, and care services. Since their inception, PEPFAR programs have supported testing for nearly 57 million people, including nearly 16 million pregnant women in PMTCT settings. Impressive as these results are, continued success depends on widespread testing in medical settings, including TB and sexually transmitted infection (STI) clinics, ANCs, and hospitals. People in these settings are far more likely than the general population to be HIV-positive, and to need care, treatment and personalized prevention messages which can be provided in counseling and testing encounters. PEPFAR has worked with host nations to build support for the “opt-out” model of provider-initiated counseling and testing for patients in these settings. With the addition of the use of rapid HIV tests, providers are able to return test results the same day, improving the likelihood that those tested will actually receive their results. As noted previously, during the first phase of PEPFAR, funding for counseling and testing was counted as part of Care; during the second phase, it will be counted as part of Prevention.
	Social Impact of HIV/AIDS HIV/AIDS is more than just a health issue. It is among the most serious economic development and security threats of our time - one reason why the United States and PEPFAR host nations have made addressing this epidemic a priority. As President Bush said at the 2008 White House Summit on International Development, “America is committed - and America must stay committed - to international development for reasons that remain true regardless of the ebb and flow of the markets. We believe that development is in America’s security interests. We face an enemy that can’t stand freedom. And the only way they can recruit to their hateful ideology is by exploiting despair - and the best way to respond is to spread hope.” Unlike many diseases, HIV/AIDS predominantly affects people between the ages of 15 and 49 years, the most productive and reproductive years. In the hardest-hit countries, the epidemic is taking a heavy toll on parents, teachers, health care workers, breadwinners, and peacekeepers and is rending the social fabric of communities, nations, and a continent. This is a dangerous mix that promotes hopelessness and despair, and is conducive to breeding extremism. Economic impact Businesses in the developing world are faced with absenteeism, declines in skilled workers, high rates of turnover, expenses to train new workers, reduced revenue, and increased health care costs due to HIV/AIDS. The International Labor Organization (ILO) has estimated that 41 percent of worldwide labor force participants (and 43 percent in sub-Saharan Africa) living with HIV are women. Forty-three countries heavily affected by HIV/AIDS lost a yearly average of 0.5 percent in their rate of economic growth between 1992 and 2004 due to the pandemic, and as a result
forfeited 0.3 percent per year in employment growth. Among them, 31 countries in sub-Saharan Africa lost 0.7 percentage points of their average annual rate of economic growth and forfeited 0.5 percentage points in employment growth. The pandemic is not only affecting current growth, but it also threatens the future economic prosperity of countries that are particularly hard-hit by the disease because of its devastating impact on teachers. A study in the late 1990s, for example, reported that in Zambia the equivalent of two-thirds of each year’s newly trained teachers were being lost to HIV/AIDS. Impact on peacekeepers Many nations suffer from high HIV prevalence among defense forces, losing their soldiers - including their leadership - to AIDS. Militaries are fundamental to peacekeeping and protecting civilian populations, but are often unable to keep their own personnel alive and healthy. A study done by a Commandant of the Nigerian Army Medical Command in the late 1990s showed that HIV infection rates among peacekeeping troops deployed in Sierra Leone increased from 7 percent for those deployed for 1 year to 10 percent for those deployed for 2 years and to more than 15 percent for those deployed for more than 3 years. Deaths due to HIV/AIDS are estimated to have reduced the size of Malawi’s armed forces by 40 percent. In South Africa, HIV/AIDS was estimated to account for 70 percent of military deaths, and prevalence in the armed forces has been estimated at between 17 percent and 23 percent, with some battalions tested in 2004 showing prevalence rates near 80 percent. In Uganda, more soldiers are believed to have died from AIDS than from the nation’s 20-year insurgency. Against this background, PEPFAR reflects the recognition of hard-hit nations and the United States that, in this era, confronting HIV/AIDS is fundamental to development and security.
	PEPFAR: One Element of a New Era in Development PEPFAR is the largest international public health initiative aimed at a single disease that any nation has ever undertaken. It represents a bold change from traditional thinking about HIV/AIDS and development, and is part of a new era of partnerships for international development. Under the leadership of President Bush, and with the bipartisan support of Congress, this new era - with a particular focus on Africa - represents both a massive commitment of treasure and a strengthened sense of compassion for those most in need. The United States is changing the paradigm for development, rejecting the flawed “donor-recipient” mentality and replacing it with an ethic of partnership that emphasizes country ownership, good governance, and accountability. Partnership is rooted in hope for and faith in people. Partnership means honest relationships between equals based on mutual respect, understanding and trust, with obligations and responsibilities for each partner. Partnership is the foundation of PEPFAR’s success and of what Secretary of State Condoleezza Rice has called “transformational diplomacy.” In addition to PEPFAR, President Bush has presided over a near tripling of support for development worldwide, and a quadrupling of resources for Africa, through the creation of innovative programs like the Millennium Challenge Corporation (MCC), the President’s Malaria Initiative (PMI), the Women’s Justice and Empowerment Initiative (WJEI) and the African Education Initiative (AEI). The United States has also more than doubled trade with Africa and provided 100 percent debt relief to the poorest countries. The Emergency Plan is central to U.S. efforts to “connect the dots” of international development. PEPFAR programs are increasingly linked to other important programs -including initiatives of other USG agencies and other international partners - that meet the needs of people infected or affected by HIV/AIDS in such areas as nutrition, education and income generation. While PEPFAR is an important part of connecting the development dots, it does not - and could not - replace the United States Agency for International Development (USAID), MCC, PMI, or any of its sister initiatives or agencies. To respond effectively to the many interrelated causes and effects of the epidemic, PEPFAR must integrate with other development programs as part of a comprehensive approach. Nearly every person affected by HIV/AIDS, and also their families and the broader communities in which they live can benefit from additional food support, greater access to education, economic opportunities and clean water. Linking PEPFAR with food and nutrition In FY2008, PEPFAR continued to advance the integration of food and nutrition services, as well as longer-term food security interventions, into its programs. Several countries initiated or made plans to initiate new food and nutrition programs. PEPFAR’s 2007 change in policy guidance regarding parameters for food support to HIV-positive adult patients enabled programs to reach increased numbers of HIV-positive individuals with food and nutrition support. In FY2008, having adapted its data system, PEPFAR was better able to report on beneficiaries as well as dollars planned for actual food purchases with PEPFAR resources. PEPFAR’s interagency, multi-sectoral technical working group on food and nutrition actively guides the incorporation of key components of nutrition into HIV programs. In addition to the primary PEPFAR implementing agencies, the group includes other agencies and offices that work directly with issues of food security and nutrition, including USAID’s Food for Peace (FFP) program and Bureau for Economic Growth, Agriculture, and Trade, as well as the U.S. Department of Agriculture (USDA). In FY2008, the group provided guidance to PEPFAR country teams on integrating food and nutrition activities into HIV/AIDS programs and developed programmatic guidance on procurement and quality assurance of specialized food products for PEPFAR programs. The group also competitively disbursed $7 million in central funds to 11 countries to jump-start programs specifically targeted at post-natal support and food security/livelihoods, two areas that were identified as programming gaps. In terms of its own targeted nutritional support to people infected with and affected by HIV/AIDS, PEPFAR guidance designates three priority populations for food support using PEPFAR resources: 1) OVCs born to an HIV-infected parent, regardless of the child’s HIV or nutritional status; 2) HIV-positive pregnant and lactating women, regardless of nutritional status; and 3) HIV-positive adult patients in treatment and care programs who have evidence of malnutrition, which is defined by WHO as a Body Mass Index (BMI) at or below 18.5 (in earlier years, only those adult patients with a BMI under 16 were eligible for nutritional support under PEPFAR). PEPFAR also supports nutrition
counseling and multivitamin supplementation as part of a preventive care package for adult PLWHA. FY2007 marked the first year that PEPFAR requested specific information regarding food and nutrition programming through the country reporting process. That request for information was further refined in FY2008. According to the data received, in FY2008, PEPFAR supported food and nutritional supplementation in the 15 focus countries for approximately: 48,000 HIV-positive pregnant or lactating women; 814,800 OVCs; and 73,000 people receiving ART (with evidence of severe malnutrition as defined by the guidance). Additional refinements will be undertaken for reporting in FY2009. In addition to the number of people served, the introduction of a new budget code will allow the collection of information on PEPFAR dollars spent and leveraged for food, while next generation indicators will help monitor the impact of food and nutrition support. The number of examples of integration of food and nutrition into PEPFAR programming continues to increase. In partnership with the World Food Programme (WFP) in Ethiopia, PEPFAR partners ensured that OVCs and PLWHA along the transport corridor received nutritional assistance in addition to home-based care services. Through its partners, USAID/FFP provided 7,220 metric tons of food support to PLWHA and OVCs in 12 food-insecure districts in Rwanda. PEPFAR partners leveraged this support to provide food and nutrition to 8,560 OVCs and 2,332 HIV-positive pregnant or lactating women. This support also improved food security for 65,500 people affected by HIV - of whom 13,100 are PLWHA. In Uganda, a USAID/FFP program is focusing on food security issues in conflict-affected Northern, Central, and Eastern Uganda. This 5-year program is working with PEPFAR partners to link services and increase access for PLWHA. In Kenya, the Emergency Plan supports a “food-by-prescription” approach and is working with the Government, private sector, civil society, WFP and others to ensure that broader communities, as well as individuals who may fall outside of PEPFAR guidelines for support, are reached. Linking PEPFAR and education For too many young people, education has been a casualty of the HIV/AIDS pandemic. Partnering with the education sector to ensure that teachers, parents and students have the tools they need to fight the epidemic is a vital component of PEPFAR programming. In FY2008, PEPFAR made significant strides in partnering with the education sector in HIV/AIDS-affected countries, leveraging USG resources with key international partners and the private sector. Early in 2008, PEPFAR collaborated with other USG actors to develop an action plan for interagency work on education issues. This effort has led to a unified USG strategy in which PEPFAR plays a key role. Together with USAID, PEPFAR formed an Interagency Education Steering Committee charged with developing a strategy for education and HIV/AIDS wraparound programs, to ensure promising practices are shared and utilized to their maximum potential. PEPFAR works through OVC programs to ensure children’s attendance at school. PEPFAR has developed a particularly strong partnership with the AEI, implemented through USAID, whose goal is to improve educational opportunities for Africa’s children so they may lead happier, healthier lives, and become productive members of society. The USG is providing $400 million through AEI to train 500,000 teachers and provide scholarships for 300,000 young people, mostly girls. In Zambia, PEPFAR and AEI fund a scholarship program that helps to keep in school nearly 4,000 OVCs in grades 10 to 12 who have lost one or both parents to AIDS or who are HIV-positive. The scholarship also funds pre-school programs and support for OVCs in primary school. Similar partnerships exist in Uganda, where PEPFAR and AEI are working together to strengthen life skills and prevention curricula in schools. This program targeted 4 million children and 5,000 teachers. Schools are important venues for teaching age-appropriate HIV prevention strategies as well as identifying and supporting children who have been orphaned or made vulnerable as a result of AIDS. In addition to providing scholarships for school fees, OVC programs provide school materials and supplies, uniforms, meals, mentoring and even child care programs to enable older siblings to attend school. PEPFAR-supported OVCs programs also provide life skills training and HIV prevention messages. At the primary and secondary school levels, OVC programs support vocational training for older students to prepare them to provide economically for their families. This is especially important given the proliferation of child-headed households brought about by the HIV/AIDS epidemic. In Zambia and Namibia, scholarship programs help girls continue their education beyond primary into secondary school. Also in Zambia, PEPFAR has provided 53 schools with small grants to assist OVCs. In some cases, grants are provided to schools to improve school facilities and materials in exchange for allowing OVCs to attend school for free. In Uganda, through The AIDS Support Organization (TASO), PEPFAR reaches almost 1,000 children with primary and secondary school fees, boarding fees for those in secondary schools, uniforms, and school supplies. Support of in-school feeding programs for OVCs is also a common intervention. In Nigeria, where an estimated one-third of all children do not attend primary school, PEPFAR’s support of nonformal schools, focusing on literacy and numeracy for vulnerable children, plays an important role not only in providing basic education but in assisting children to transition to formal schools when ready. Along with its efforts in primary and secondary school settings, PEPFAR also supports pre-service and in-service training for health care and social workers provided through institutes of higher learning in host countries. Primary and secondary school teacher organizations are also supported as avenues for providing prevention messages and counseling and testing for teachers. PEPFAR support for education illustrates the fact that support to one sector can leverage support to other sectors to achieve broad benefits. One example is block grants given to schools for specific purposes, such as desks, books, lab equipment or school refurbishment, in exchange for the schools admitting an agreed number of HIV-affected OVCs to attend school without paying fees or with reduced fees for a certain period of time. Such block grants are a way of enabling thousands of HIV-affected OVCs to attend school while benefiting the broader school population.
	Other Key Linkages PEPFAR and PMI have worked together to identify countries with joint opportunities for leveraging. Currently, nine PEPFAR countries with significant programs are also PMI focus countries (Ethiopia, Ghana, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, and Zambia). PMI and PEPFAR efforts currently overlap in three major areas: ITN distribution and education to pregnant women through ANCs; ITN distribution and education to PLWHA; and coordination of lab services. Together, PMI and PEPFAR are now working with Malaria No More to add a private sector component to this cooperative effort. In Zambia, by using the PEPFAR-supported distribution infrastructure, the RAPIDS consortium led by World Vision, PMI, PEPFAR and the private sector delivered more than 485,000 bed nets before malaria season at a 75 percent savings - and the USG saved half the remaining cost of nets through a public-private partnership led by the Global Business Coalition on HIV/AIDS, TB and Malaria. The two programs are also coordinating on surveys and surveillance to reduce the cost of monitoring program results. Other examples include: In Uganda, PEPFAR and PMI are providing joint funding of a nationwide health facility survey. Several PEPFAR partners have gained access to free ITNs through PMI support, and PEPFAR and PMI are providing joint support for ANC interventions for malaria and HIV/AIDS (e.g., distribution of ITNs through ANCs, and integrated training linking PMTCT and malaria prevention to maternal and child health curricula).   In Kenya, in addition to PEPFAR-PMI support for ANC interventions, PEPFAR is also supporting partners in the distribution of vouchers for ITNs to PLWHA as part of a basic care package in Nyanza Province.   In Tanzania, PEPFAR and PMI are working together to support the inclusion of a malaria indicator module in the HIV/AIDS indicator survey, and PMI is providing ITNs to PLWHA.
MCC is another key USG partner with which PEPFAR is seeking opportunities for coordinated effort. In Lesotho, PEPFAR has co-located staff with those of MCC to ensure joint support for expansion of health and HIV/AIDS services, with MCC placing a strong focus on infrastructure and PEPFAR on human capacity building. PEPFAR also supports linkages between HIV/AIDS and voluntary family planning programs, including those supported through USAID’s Office of Population and Reproductive Health (PRH). Along with providing linkages to family planning programs for women in HIV/AIDS treatment and care programs, PEPFAR also works to link family planning clients with HIV prevention, particularly in areas with high HIV prevalence and strong voluntary family planning systems. Voluntary family planning programs provide a key avenue to reach women who may be at high risk for HIV infection. PEPFAR supports the provision of confidential HIV counseling and testing within family planning sites, as well as linkages with HIV care and treatment for women who test HIV-positive. Ensuring that family planning clients have an opportunity to learn their HIV status also facilitates early uptake and access to PMTCT services for those women who test HIV-positive. PEPFAR’s efforts remain focused on HIV/AIDS prevention, treatment and care, complementing the efforts of USAID/PRH programs and other partners. Promoting Sustainability and Accountability Central to sustainability is the capacity of host nations to finance HIV/AIDS and other health efforts. At present, their ability to do so on the scale required varies widely. Many developing nations are years from being able to launch comprehensive programs with their own resources. However, it is essential that these countries appropriately prioritize HIV/AIDS and respond to the disease with locally available resources, including financial resources. Many are beginning to make this commitment. Some countries are making progress, and a growing number of nations are investing in fighting HIV/AIDS on a scale commensurate with their financial capacity. In some cases, for example, host nations are procuring all or a portion of their own ARV drugs, while PEPFAR provides support for other aspects of quality treatment. These developments within hard-hit nations build sustainability in each country’s fight against HIV/AIDS. With support from PEPFAR, host countries are developing and expanding a culture of accountability that is rooted in country, community, and individual ownership of and participation in the response to HIV/AIDS. PEPFAR is collaborating with host nations, UNAIDS and the World Bank to estimate the cost of national HIV/AIDS plans, a key step toward accountability. Businesses are increasingly eager to collaborate with PEPFAR, and public-private partnerships are fostering joint prevention, treatment, and care programs. This culture of accountability bodes well not only for sustainable HIV/AIDS programs, but also for an ever-expanding sphere of transparency and accountability that represents transformational diplomacy in action. While HIV/AIDS is unmistakably the focus of PEPFAR, the initiative’s support for technical and organizational capacity-building for local organizations has important spillover effects that support nations’ broader efforts for sustainable development. Organizations whose capacity is expanded in order to meet fiduciary accountability requirements are also in an improved position to apply for funding for other activities or from other sources. Expanded health system capacity improves responses for diseases other than HIV/AIDS. Capacity-building in supply chain management improves procurement for general health commodities. Improving the capacity to report on results fosters quality and systems improvement, and the resulting accountability helps to develop good governance and democracy. As the name of the Emergency Plan frankly acknowledges, HIV/AIDS is a global emergency, and PEPFAR has rapidly sought to save as many lives as possible. At the same time, it is essential to look to the future with a sustainable, effective response. HIV/AIDS is a chronic disease requiring lifelong prevention, treatment and care and so rather than support one-time interventions, PEPFAR supports enduring contributions that build health systems as part of a broader development approach. PEPFAR is working to ensure a sustainable response by building the capacity of public and private institutions in host nations to respond to HIV/AIDS.
	Building health systems Discussions of global HIV/AIDS efforts have sometimes pitted “vertical” disease-specific programs against “horizontal” programs designed to build health systems. This is a false dichotomy. Disease-specific programs, if appropriately designed, can also strengthen overall health systems. PEPFAR and host nations are demonstrating how HIV/AIDS funding strengthens the ability of nations to improve overall health. Preliminary analysis from Rwanda estimates that 60 percent of PEPFAR resources had an impact beyond HIV/AIDS. According to Dr. Jaime Sepulveda, Chairman of the IOM Committee which in 2007 completed a congressionally mandated study of PEPFAR, “PEPFAR is contributing to make health systems stronger… doing good to the health systems overall.” As noted earlier, data from Botswana suggest that HIV/AIDS resources contributed to a decline in infant mortality and increase in life expectancy - significant gains in general health indicators. While much evaluation remains to be done, the only data available clearly indicate that HIV/AIDS resources are having a positive impact on general health care. For this reason, health experts are now talking about “diagonal” programs that have broad effects on the health system even as they focus on a specific disease. PEPFAR is such a program. PEPFAR estimates that approximately $734 million in FY2008 resources were invested in capacity building in the public and private health sectors to support service delivery sites for prevention, treatment and care. A recent study of PEPFAR-supported treatment sites in four countries found that PEPFAR supported a median of 92 percent of the investments in health infrastructure to provide comprehensive HIV treatment and associated care, including building construction and renovation, lab and other equipment, and training (Figure 10). PEPFAR also supported a median of 57 percent of personnel costs (salaries and retention bonuses) at those sites. Discussions of health systems often split over the “vertical” versus “horizontal” debate, but also are often grounded in a belief that the public sector is the only valid “horizontal” system. This is not true for two significant reasons: much of the health care in the developing world is not provided through the public sector, and NGO partners can strengthen the public health system. WHO has estimated that FBOs alone provide 30 percent to 70 percent of health care in sub-Saharan Africa. In Kenya, for example, it is estimated that half of health care is provided by FBOs. However, the public sector is an essential component of health care as well, and data show that PEPFAR support as a percentage of total resources was higher in public sector facilities than it was in private sector ones (Figure 10). This reflects PEPFAR’s commitment to supporting nations’ efforts to expand public sector health infrastructure. In addition, for a variety of reasons, it is often more cost-effective to use NGO partners to strengthen the public sector. In South Africa, a snapshot of non-governmental PEPFAR partners demonstrated that 19 of 22 were supporting services in the public sector across a range of program areas (Figure 11). PEPFAR has been instrumental in building laboratory capacity around the world and is partnering with Ministries of Health (MOHs) to support the development of national strategic laboratory plans. Training, logistics and commodities management, facility and equipment maintenance, and quality assurance are cross-cutting aspects of all disease-specific laboratories, and PEPFAR is providing support to address all of these by helping countries develop national strategic laboratory plans. These plans integrate cross-cutting aspects of all disease-specific laboratories. This helps to reduce parallel disease-specific laboratory systems, and thereby build efficiency and augment countries’ ability to respond effectively to numerous diseases including HIV, TB, malaria, and avian influenza. To address the critical need for a well-trained laboratory workforce, PEPFAR partnered with the South African National Health Laboratory Service and National Institute for Communicable Diseases to establish the African Centre for Integrated Laboratory Training (ACILT) in Johannesburg, South Africa. This center is helping to meet Africa’s need for a competent and motivated workforce trained in TB and HIV diagnostics throughout Africa and will also serve as a reference laboratory for TB, HIV, and other diseases. Impact of HIV/AIDS investment on non-HIV/AIDS health - “diagonal programs” Perhaps the most striking data on the “vertical/horizontal” debate come from a Family Health International (FHI) study in Rwanda showing that the addition of basic HIV services to primary health centers contributed to an increase in the use of maternal and reproductive health, prenatal, pediatric, and general health care (Figure 12). The study collected data from 30 primary health centers that had at least 6 months of experience providing basic HIV care interventions and controlled for possible influences from other health initiatives. It found statistically significant increases in delivery of 17 non-HIV interventions, including a 24 percent increase in outpatient consultations and a rise in syphilis screenings of pregnant women, from one test in the 6 months prior to the introduction of HIV care to 79 tests after HIV programs began. Large jumps were also seen in non-HIV related laboratory testing and provision of family planning. Improving the health sector by reducing burdens on it In the hardest-hit regions, 50 percent or more of hospital admissions are due to HIV/AIDS. As effective HIV programs are implemented, hospital admissions plummet, easing the burden on health care staff throughout the system. In the Rwanda study cited earlier, the average number of new hospitalizations at seven sites that had been offering ART for more than 2 months dropped by 21 percent (Figure 13). Building human resources for health Functioning health systems depend on a workforce that can carry out the many tasks and build the systems that are needed. The lack of sufficient health workforce in many of the countries where PEPFAR is working presents a serious challenge not only to HIV/AIDS programs, but to every area of health care. PEPFAR cannot solve the overall health workforce crisis, but it can contribute by making significant investments in capacity building that, while focused on HIV/AIDS, have a broader impact. As Table 2 shows, from FY2004 through FY2008, PEPFAR supported an estimated 3.7 million training and retraining encounters for health care workers. In FY2008, PEPFAR provided an estimated $310 million to support training activities. PEPFAR focuses on areas that most directly impact HIV/AIDS programs: HIV/AIDS training for existing clinical staff such as physicians, nurses, pharmacists, and laboratory technicians; management and leadership development for health care workers; and building new cadres of health workers. This strategy to support local efforts to build a trained and effective workforce has provided the foundation for the rapid scale-up of prevention, treatment and care that national programs are achieving and provides a solid platform on which other health programs can build.
	A workforce pyramid Recognizing the continued importance of human capacity development, for FY2008 PEPFAR country teams supported 1,133,525 training and retraining encounters. Pre-service training: The expansion of care and treatment requires an expansion in the workforce to provide these services. For FY2008 the amount of funds each PEPFAR country team could use to support long-term pre-service training was increased threefold, to $3 million. Namibia is one country that took advantage of this new allowance. There are no schools of medicine and pharmacy in Namibia. In FY2008, an existing scholarship program for students in these disciplines was expanded to increase the number of students attending training institutions in South Africa, with a requirement to return to Namibia to provide national service. In Kenya, an HIV fellowship program has been developed to train senior HIV program managers. In Vietnam, PEPFAR is working with the Hanoi School of Public Health to increase the number of health professionals receiving advanced degrees in public health and management. There has also been a significant increase in support for expanding HIV curricula in pre-service training programs. These efforts reflect the increase in resources dedicated to training of new doctors, nurses, clinical officers, laboratory technicians, and pharmacists in HIV/AIDS. Task-shifting: While building cadres of new highly trained professionals is a long-term objective of PEPFAR and other development initiatives, it can take years to build a sufficient health care workforce. Unfortunately, we do not have years to wait. As experts from PEPFAR and the WHO argued in an article published in the New England Journal of Medicine, policy change to allow task-shifting from more-specialized to less-specialized health workers is the one strategy that will have the most significant and immediate effect on increasing the pool of health workers in resource-limited settings. Changing national and local policies to support task-shifting can foster dramatic progress in expanding access to HIV prevention, treatment and care, as well as other health programs. PEPFAR supported WHO’s efforts to develop the first-ever set of task-shifting guidelines, released in January 2008. This continues and expands PEPFAR’s support for the leadership of its host country partners in broadening national policies to allow trained members of the community - including PLWHA - to become part of clinical teams as community health workers. Support for salaries: Along with support for training, supporting new highly trained health professionals, and task-shifting, PEPFAR supports the growing number of personnel necessary to provide HIV/AIDS services. To capture this support more comprehensively, in the FY2009 Country Operational Plans (COPs), PEPFAR country teams estimated the number of health care workers whose salaries PEPFAR is supporting. They reported support for more than 127,300 workers (Table 3), illustrating PEPFAR’s commitment to building health workforces that are sustainable for the long term. In Kenya, for example, PEPFAR has reached an agreement with the MoH to incrementally absorb these personnel into the public health system, providing long-term sustainability while also allowing for rapid hiring and deployment. Examples of support for salaries in the focus countries include: Government sector: Namibia: PEPFAR supports the salaries of nearly all clinical staff doing treatment work and counseling and testing in the public sector.   Kenya: PEPFAR supports the Government’s hiring plan to train and deploy retired physicians, nurses, and other health care workers for the public sector; 830 were deployed in 2008.   Ethiopia: PEPFAR supports the Government’s program to train 30,000 health extension workers in order to place two of these community health workers in every rural village; 19,000 have already been trained.   Cote d’Ivoire: PEPFAR supported the development of the Government’s plan to redeploy health workers from the south back to the north and west following the peace agreement. Non-government sector: Uganda: One of the largest HIV/AIDS service providers, TASO, has increased staff from 16 in the early 1980s to several thousands today, and PEPFAR supports salaries for nearly all of them. Building supply systems Procurement capacity is another key element of national health systems. PEPFAR’s Supply Chain Management System (SCMS) project strengthens the capacity of local systems to deliver an uninterrupted supply of high-quality, low-cost products that flow through a transparent and accountable system. SCMS activities include supporting the purchase of life-saving ARVs, including low-cost generic ARVs; capacity-building for quantification of needs, safer storage and distribution systems, and effective stock and inventory control systems to avoid “stock outs”; drugs for care for PLWHA, including drugs for OIs such as TB; laboratory materials, such as rapid test kits; and supplies, including gowns, gloves, injection equipment, and cleaning and sterilization items. By pooling procurement across countries, SCMS is able to stabilize supply, plan for capacity expansion, and achieve economies of scale. In a FY2007 survey, 73 percent of ARVs provided by PEPFAR, and 93 percent delivered through SCMS, were generic formulations (Tables 4 and 5). By using generics, PEPFAR partners were able to save an estimated $64 million - a 46 percent reduction from the cost if they had purchased only innovator drugs. Additionally, by augmenting and improving country supply chains, rather than replacing functioning systems, SCMS strengthens the capacity of health systems to deal with other health and development issues. These country supply chains are strengthened through the use of regional distribution centers, which distribute commodities in quantities that existing infrastructure can handle reliably and safely. Figure 14 shows the locations of these regional distribution centers in sub-Saharan Africa. Supporting strategic information for program accountability and improvement Evidence-based programming depends on strong data. PEPFAR is addressing this need from many directions, and the results will benefit all programs, not just those supported by PEPFAR. Surveillance and mapping PEPFAR is building the capacity of resource-constrained nations to strategically collect and use information for program accountability and improvement. Measuring the burden of HIV is essential for developing effective prevention and care interventions. To gain better understanding of the relationships among populations, HIV prevalence, and existing services, PEPFAR is building the capacity of host countries to design, implement, and evaluate HIV/AIDS-related surveillance systems and surveys. PEPFAR also assists and trains countries to analyze, disseminate, and use HIV/AIDS data. These efforts include development of tools, guidelines, recommendations, and policies to translate research for improved planning and program implementation, in addition to supporting evaluation and implementation of novel approaches for conducting surveillance and surveys. PEPFAR has supported population surveys such as Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) in 27 countries, including Botswana, Cote d’Ivoire, Ethiopia, and Vietnam. This helps to improve prevalence estimates, among other data, as demonstrated by the recent revision of UNAIDS global estimates. This past year in Kenya, PEPFAR supported the groundbreaking Kenya AIDS Indicator Survey (KAIS) that included measurement of diseases that interact with HIV (i.e., syphilis, Herpes Simplex Virus Type 2 [HSV2], and viral hepatitis), estimation of ART need on the basis of CD4 measurements, and returning HIV test results to participants. These population surveys are also improving incidence data that help determine where recent transmission has occurred. This information is essential for planning effective prevention programs and also for measuring the success of programs in achieving PEPFAR’s prevention goals. PEPFAR also supports the use of surveys and surveillance within subpopulations to assist in development of more targeted and effective prevention and care interventions. These behavioral or prevalence surveys are employed to characterize specific subpopulations or communities (e.g., pregnant women, youth, migrants, IDUs) which are recognized as primary drivers of local epidemics. These studies provide more detailed information than population surveys and are increasingly being supported even within generalized-epidemic settings. PEPFAR is working with countries to build local capacity to conduct both types of surveys/surveillance, as a combined approach represents the most robust framework against which to develop, monitor, and evaluate interventions. PEPFAR is also supporting countries to make more effective use of geographic information mapping to assist in data analyses and in program implementation. Increasingly, countries are making use of these technologies to document current efforts and service gaps. For example, Figure 15 shows a sample map that depicts treatment delivery sites in Ethiopia. The technology is also being used to create more dynamic maps tracking the relationships among services and local HIV epidemic patterns. Next generation of indicators Constant evaluation to improve programs must characterize all HIV/AIDS efforts, including those of PEPFAR. PEPFAR is thus working with a wide variety of stakeholders to update the performance measures used to evaluate programmatic progress. The new measures will move PEPFAR toward the challenging goal of measuring program outcomes and impacts. The next generation of PEPFAR indicators will be rolled out for use in planning and reporting in FY2010. The continuum of indicators is depicted in Figure 16.
Sharing lessons learned Public health evaluation Through Public Health Evaluation (PHE) - also called “implementation research” or “operations research” - PEPFAR supports research on strategic priority questions that can inform and change how PEPFAR and others deliver prevention, treatment and care programs. Because of its size and scope, PEPFAR offers unique opportunities to address and resolve issues related to the implementation of scientifically sound, cost-effective programs. In FY2008, PEPFAR heightened its emphasis on priority research questions that can inform PEPFAR programs globally; respond to identified PEPFAR priorities; reflect the diversity of PEPFAR programs and populations served; and take advantage of coordination and multi-country implementation where appropriate. At the same time, PEPFAR PHE continues to support locally focused research activities that address local implementation challenges. In FY2008, $40 million was directed toward PHE. These funds were awarded based on competition and PEPFAR programmatic priorities, and further refinement of PHE is anticipated for FY2009. Though PEPFAR is unmistakably focused on implementation, PHE allows PEPFAR to address the important questions that will change how we and others implement programs to save more lives.
	International HIV/AIDS Implementers’ Meeting The Emergency Plan seeks to build the capacity of local people and organizations to evaluate their work and present their findings to colleagues from around the world. In June 2008, PEPFAR and its partners convened the HIV/AIDS Implementers’ Meeting in Kampala, Uganda. The meeting, which drew more than 1,600 delegates from Uganda and around the world, was hosted by the Government of Uganda and co-sponsored by PEPFAR, the Global Fund, UNAIDS, the United Nations Children’s Fund (UNICEF), the World Bank, WHO, and the Global Network of People Living with HIV/AIDS. The vast majority of presenters was from severely affected nations in Africa, Asia, Eastern Europe, and Latin America, and included representatives from governments and NGOs, including FBOs and CBOs, and the private sector. Building partnerships Expanding the circle of local partners An important part of systems strengthening is PEPFAR’s support for local organizations, including host government institutions, groups of PLWHA, FBOs, and CBOs. Annual COP reviews include evaluation of efforts to increase the number of indigenous organizations partnering with PEPFAR. In FY2008, PEPFAR partnered with 2,667 organizations, up from 1,588 in FY2004, of which 86 percent were local. Reliance on local organizations is sometimes challenging but is essential for PEPFAR to fulfill its promise to partner with host nations to develop sustainable responses to HIV/AIDS.
As another step toward sustainability, PEPFAR country programs may devote a maximum of 8 percent of funding to a single partner (with exceptions made for host government partners, commodity procurement, and “umbrella contractors” for smaller organizations). This requirement is helping to expand and diversify PEPFAR’s base of partners. New partnerships, particularly with local partners, are vital to sustainability. The exception for umbrella contracts is intended to support large organizations in mentoring smaller local organizations, thus supporting capacity building in challenging areas such as management and reporting. PEPFAR has also worked with its international implementing partners in developing strategies for handing over programs as local organizations increase their capacity to work directly with the USG. PEPFAR’s interagency Procurement and Assistance Working Group has also created a new definition of “local partner” that addresses confusion about whether specific organizations qualify for the exemption. New Partners Initiative On World AIDS Day 2005, President Bush launched the New Partners Initiative (NPI), part of PEPFAR’s broader effort to increase the number of local organizations, including FBOs and CBOs, that work with the Emergency Plan. The first 23 NPI grants were awarded on World AIDS Day 2006, followed by 14 grants on World AIDS Day 2007 and 19 additional grants on World AIDS Day 2008. Altogether, 56 new prime partnerships have been awarded through NPI. NPI is enhancing the technical and organizational capacity of local partners and is working to ensure sustainable, high-quality HIV/AIDS programs by building community ownership. More than half of NPI grantees have previously received smaller grants from the USG or received PEPFAR funds working as sub-partners to larger organizations. NPI has allowed these organizations to compete among their peers and graduate to “prime partner” status. Each grantee receives comprehensive technical and organizational support through NPI, including support for financial and reporting capacity, enabling them to compete not only for PEPFAR resources but also for grants and contracts from other sources of funding.
	Public-private partnerships Public-private partnerships (PPPs) are collaborative endeavors that combine public and private sector resources to accomplish HIV/AIDS prevention, care and treatment goals. PPPs help ensure sustainability of PEPFAR programs, facilitate scale up of interventions, and leverage private sector resources to multiply impact. In addition to an array of country-level PPPs and workplace programs with local private-sector entities, PEPFAR supported eight large-scale, multi-country PPPs in 2008. One new initiative was the launch of the Partnership for an HIV-Free Generation, a global PPP to advance youth-focused HIV-prevention. This PPP, initially piloted in Kenya, marries PEPFAR’s technical and programmatic capacities with the skills and 21st century tools of numerous private sector entities. For example, a HIV prevention video game was developed in partnership with Warner Bros. Interactive Entertainment. PEPFAR also expanded its PPP with Becton, Dickinson and Company, joining forces with the International Council of Nurses to create a Wellness Center for health workers in Uganda. The Wellness Center will serve 29,000 health workers in Uganda and their families, protecting the people who are the backbone of PEPFAR programming. This type of initiative complements the expansion of existing partnerships, including the Phones for Health PPP for health management and information systems. Goals for future PPPs include expanding private health insurance options and strengthening health
systems, including improving human resource capacity and expanding information communications and technology offerings. PEPFAR also remains dedicated to expanding workplace programs that provide HIV/AIDS prevention, treatment and care. Working with international partners The United States is not the only international partner of host nations. Other key international partners include: the Global Fund; the World Bank; United Nations agencies, led by UNAIDS; other national governments; and increasingly the businesses and foundations of the private sector. All of these partners have vital contributions to make to the work of saving lives around the world. The Global Fund: The USG is the largest contributor to the Global Fund and has given almost $3.3 billion since 2001, or about 27 percent of total contributions. USG representatives chair the Global Fund Board’s Finance and Audit Committee, and represent the USG on the Board’s Policy and Strategy Committee. Recent Board achievements supported by the USG include the approval of Round 8 grants, which represented the most successful and largest round to date; the adoption of a new and strengthened quality assurance policy for pharmaceutical products; a review of the Global Fund architecture, leading to recommendations for streamlined and strengthened application and implementation processes; the adoption of a gender equality strategy; and the presentation of a report and recommendations on the Partnerships component of the Global Fund Five-Year Evaluation. The USG also provides direct technical assistance to Global Fund grants that are experiencing implementation bottlenecks, using U.S. legislative authority to withhold up to 5 percent of contributions for this purpose. Such funds are used to improve institutional and program management; strengthen governance and transparency; strengthen procurement and supply-chain management; and improve monitoring and evaluation systems. Because of the close link between TB and HIV/AIDS, the USG also provides technical assistance funding to improve treatment for MDR-TB and to enhance the Advocacy, Communication and Social Mobilization (ACSM) components of country TB programs. The USG also provides funds for Global Fund technical assistance through the Roll Back Malaria international partnership and the three UNAIDS Technical Support Facilities in sub-Saharan Africa. PEPFAR country teams work closely with the Global Fund grant programs in host nations. USG representatives sit on Global Fund Country Coordinating Mechanisms (CCMs) in 94 percent of PEPFAR countries, the vast majority of which support Global Fund proposal development. PEPFAR country programs have allocated over $10 million annually to technical assistance for Global Fund grants. To promote deeper coordination, the USG has entered into Memoranda of Understanding (MOU) in several countries. These documents bring together Ministries of Health, PEPFAR, and the Global Fund to clarify collaboration and partnership activities, particularly in the area of drug procurement for ART. UNAIDS: The United States was a driving force behind the creation of UNAIDS’ “Three Ones” principles for support of national HIV/AIDS leadership and continues to support UNAIDS’ work in a variety of ways. The USG is one of the largest contributors to UNAIDS’ all-voluntary budget each year and provided nearly $40 million in FY2008. The United States served as Chair of the UNAIDS Programme Coordinating Board (PCB) in 2008. As PCB Chair, the United States instituted a number of reforms in PCB practice aimed at increasing transparency and effectiveness, particularly in civil society. Other priorities during the U.S. tenure included reforms to maximize UNAIDS’ effectiveness at the country level and guidance for leaders as they convened in June 2008 at the U.N. General Assembly for a High- Level Meeting on HIV/AIDS. The gavel was passed to Ethiopia in December at the same time as Michel Sidibe succeeded Dr. Peter Piot as Executive Director. Among the most important relationships in the multilateral response to HIV/AIDS is that between UNAIDS, which leads a strong in-country United Nations presence, and the Global Fund, which provides funding but no direct technical support to countries. The United States used its term as Chair to promote a stronger Global Fund-UNAIDS relationship, by advocating for adoption of a new MOU between the two and leading discussions on how to cooperate at country level. WHO: WHO provides evidence-based technical leadership, sound management, and norms and standards to guide the international public health response to HIV/AIDS. As a WHO member state with considerable expertise in HIV/AIDS, the USG has been intimately involved in formulating HIV/AIDS-related policy and guidelines and has partnered with WHO and host countries to roll out, adapt, and implement the policies. Support in FY2008 totaled more than $16 million, with the USG providing technical expertise and financial support to WHO in multiple areas including male circumcision, laboratory capacity, PMTCT, TB/HIV, health systems strengthening, and counseling and testing.
1 FY2008 fourth quarter data at the time of drafting was still preliminary. 2 As noted in the 2007 AIDS epidemic update published by UNAIDS, “The major elements of methodological improvements in 2007 included greater understanding of HIV epidemiology through population-based surveys, extension of sentinel surveillance to more sites in relevant countries, and adjustments to mathematical models because of better understanding of the natural history of untreated HIV infection in low- and middle- income countries.” The report continues: “Because estimates of new HIV infections and HIV-associated deaths are derived through mathematical models applied to HIV prevalence estimates, new estimates of HIV incidence and mortality in 2007 also differ substantially from earlier assessments.” Back to Report Main Page