PEPFAR Funding Research Articles

Human immunodeficiency virus funding and access to treatment in sub-Saharan Africa.

Human immunodeficiency virus (HIV) treatment prevents illness, death, and transmission. The 90-90-90 disease control target is only 73% of people living with HIV virally suppressed. For 2010 to 2019, we abstracted HIV funding data for 40 countries in sub-Saharan Africa (70% of global HIV burden and >99% of HIV burden in the region in 2018). During 2010-2019, there was ∼$52 billion funding for 40 countries (99% Africa HIV burden). Domestic funding ranged from $0 to $3.2 billion. PEPFAR funding was $32 billion (average $1.4 billion; range $0.089-4.3 billion) among 22 countries. Global Fund averaged $306 million ($1.9 million to $1.1 billion) for 40 countries. Among PLHIV, known HIV status averaged 80% (11% to 94%). ART coverage averaged 64% (9% to 90%). Viral suppression among PLHIV ranged from 8% to 87%. Of the 40 countries, 21 reported under 60% of PLHIV to be on treatment and 13 did not report viral suppression for 2018. Achieving 90-90-90 is feasible in challenging settings if resources are used efficiently. Despite the significant investment in the HIV response, many countries have not reached the 90-90-90 target. Greater attention to efficiency and prioritizing important targets will be required to end AIDS in Africa.

Global Cash Flows for Sustainable Development: A Case Study of Accountability and Health Systems Strengthening in Lesotho.

Despite high health expenditures, Lesotho had some of the world's worst health indicators between 2000 and 2014. Official development assistance tripled from $37 to $107 million. PEPFAR funding rose from $3.8 to $32.4 million. Yet, deaths from TB, HIV, infant mortality, and maternal mortality remained unchanged. Lesotho had declining health outcomes amidst increased disease-focused financing and several large infrastructure projects. A World Bank loan financed the state-of-the-art Mamohato Hospital, and the U.S.-supported $362.5 million Millennium Challenge Corporation Project supported primary and secondary health infrastructure. This analysis uses the WHO Health Systems Framework to explore the unintended consequences of health financing on Lesotho's health outcomes. The WHO Health Systems Framework can be used to optimize health financing through investments in health service delivery, health workforce, health information, essential medicines, leadership, and equitable financial strategies. This approach can support governments to achieve universal health coverage and develop comprehensive health systems.

Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria.

The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543–3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR’s policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.

The effectiveness of PEPFAR's funding for women and children with HIV/AIDS.

Has President's Emergency Plan for AIDS Relief's (PEPFAR) funding been effective in reducing the rate of HIV new infections and AIDS-related deaths among women and children? While previous studies have found HIV/AIDS aid to be ineffective and PEPFAR funding to produce negative externalities, there is lack of empirical examination of the impact of PEPFAR on women and children despite the emphasis on prevention of mother-to-child transmission of HIV during the Bush and Obama administrations. Using descriptive analysis and difference-in-differences (DID) regression, this study finds that PEPFAR's funding has reduced the HIV new infections and AIDS-related death rates of women and children for both focus countries and recipient countries, which are those that were added in a second phase. These findings show that PEPFAR's strategy for women and children has been effective and that it should be continued. However, while PEPFAR has contributed to the fight against HIV/AIDS, the effects of its work have been underestimated.

S01.5 The architecture for prevention and the role of targets and indicators

<h3></h3> There are effective means to prevent every mode of transmission; political commitment on HIV continues to be strong; and financing for HIV programs in low- and middle-income countries increased has surpassed US$17 billion. However, amidst recurring calls for a comprehensive, integrated and sustained AIDS response, funding, targets and delivery are focusing disproportionately on treatment. This presentation will describe the financing, leadership and implementation/delivery architecture for HIV prevention as it exists today, and as it needs to be developed in order to fully realise the potential of existing, emerging and on-the-horizon HIV prevention options. Beginning with an exploration of the current architecture of HIV prevention financing, the presentation will highlighting current gaps, such as the recent scale back of PEPFAR funding for VMMC and shortfalls in funding and planning for PrEP product introduction, citing these examples to highlight broader issues in the architecture as it exists (e.g. the gap between positive research results and substantive, strategic planning to move to implementation), individual interventions (e.g. VMMC) being “owned” by single donors, and then in jeopardy when funding fluctuates. The presentation will also explore the leadership, describing the actors that influence policy, programming and messaging at global, regional and national levels. Finally, this presentation will examine the gaps and strengths in current implementation and delivery architecture, focusing on what is available and/or needed to deliver prevention and on the targets that need to be set to help drive implementation and financing; how targets need to be tailored to each specific intervention; and highlight the potential for conceiving and building a comprehensive prevention delivery platform that maximises the use of existing interventions and supports the rapid and effective integration of new options as they become available.

Building local human resources to implement SLMTA with limited donor funding: The Ghana experience

BackgroundIn 2009, Ghana adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme in order to improve laboratory quality. The programme was implemented successfully with limited donor funding and local human resources.ObjectivesTo demonstrate how Ghana, which received very limited PEPFAR funding, was able to achieve marked quality improvement using local human resources.MethodLocal partners led the SLMTA implementation and local mentors were embedded in each laboratory. An in-country training-of-trainers workshop was conducted in order to increase the pool of local SLMTA implementers. Three laboratory cohorts were enrolled in SLMTA in 2011, 2012 and 2013. Participants from each cohort attended in a series of three workshops interspersed with improvement projects and mentorship. Supplemental training on internal audit was provided. Baseline, exit and follow-up audits were conducted using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. In November 2013, four laboratories underwent official SLIPTA audits by the African Society for Laboratory Medicine (ASLM).ResultsThe local SLMTA team successfully implemented three cohorts of SLMTA in 15 laboratories. Seven out of the nine laboratories that underwent follow-up audits have reached at least one star. Three out of the four laboratories that underwent official ASLM audits were awarded four stars. Patient satisfaction increased from 25% to 70% and sample rejection rates decreased from 32% to 10%. On average, $40 000 was spent per laboratory to cover mentors’ salaries, SLMTA training and improvement project support.ConclusionBuilding in-country capacity through local partners is a sustainable model for improving service quality in resource-constrained countries such as Ghana. Such models promote country ownership, capacity building and the use of local human resources for the expansion of SLMTA.

Response to 'PEPFAR Program Expenditures (Form Number: DS-4213, OMB Control Number: 1405-0208) Third Revision

This response document will briefly address concerns about the ethical, legal and methodological flaws with past research informing aspects of present PEPFAR program areas; concerns about adverse consequences of PEPFAR program areas; and concerns about the absence of oversight of the activities of PEPFAR funding recipients.

Response to 'PEPFAR Program Expenditures' - [Form Number: DS-4213, OMB Control Number: 1405-0208

This response document will briefly address concerns about the ethical, legal and methodological flaws with past research informing aspects of present PEPFAR program areas; concerns about adverse consequences of PEPFAR program areas; and concerns about the absence of oversight of the activities of PEPFAR funding recipients.

Did PEPFAR funding affect non-HIV health indicators? Longitudinal study of facility-based baby deliveries in Uganda, 2005–10

BackgroundWhile PEPFAR investments were associated with HIV-related survival, it has been less clear what the effects of this investment in HIV care have been for health-care use generally, especially in maternal care. Understanding of these effects could have implications for how to organise future global health initiatives for major health problems. Maternal mortality in Uganda remains high (310 per 100 000 livebirths in 2010) and could be reduced by increasing deliveries at health facilities. MethodsWe visited all of Uganda's 56 districts to collect maternity care data from Health Management Information System records, between the years 2005 and 2010, including monthly reports from all public and most private facilities. Our unit of analysis was district-month. We fitted a negative binomial mixed effects model, with number of infants delivered in health facilities per district-month as outcome, and three categories (tertiles) of population-adjusted annual number of PEPFAR-supported patients on antiretroviral therapy (ART) as input. We adjusted for regional HIV prevalence and proportion of elementary school-aged children attending school. To adjust for secular and seasonal effects, we included control variables for year and month. Random effects for district and an offset for district population were included in the model. FindingsPeople on ART per district-month per 1000 population grew from 1079 in 2005, to 6485 in 2010. Facility deliveries averaged 709 per district-month, growing from 561 in 2005 to 830 in 2010. The average rate of health facility deliveries increased by 4% (incidence rate ratio [IRR] 1·04, 95% CI 1·008–1·068, p=0·012) in districts with medium-level PEPFAR investment in ART care, compared with lowest PEPFAR investment districts. In higher-level investment districts, deliveries increased by 8% (IRR 1·08, 95% CI 1·037–1·126, p=0·0001), relative to low-investment districts. InterpretationPEPFAR investments in ART scale-up in Uganda appear to be associated with small increases in health facility deliveries. FundingThis research was funded by the US Centers for Disease Control, Division of Public Health Systems and Workforce Development through a cooperative agreement with the University of Washington and through subcontracts with Makerere University and the Uganda Ministry of Health.

ART treatment costs and retention in care in Kenya: a cohort study in three rural outpatient clinics.

IntroductionAfter almost 10 years of PEPFAR funding for antiretroviral therapy (ART) treatment programmes in Kenya, little is known about the cost of care provided to HIV-positive patients receiving ART. With some 430,000 ART patients, understanding and managing costs is essential to treatment programme sustainability.MethodsUsing patient-level data from medical records (n=120/site), we estimated the cost of providing ART at three treatment sites in the Rift Valley Province of Kenya (a clinic at a government hospital, a hospital run by a large agricultural company and a mission hospital). Costs included ARV and non-ARV drugs, laboratory tests, salaries to personnel providing patient care, and infrastructure and other fixed costs. We report the average cost per patient during the first 12 months after ART initiation, stratified by site, and the average cost per patient achieving the primary outcome, retention in care 12 months after treatment initiation.ResultsThe cost per patient initiated on ART was $206, $252 and $213 at Sites 1, 2 and 3, respectively. The proportion of patients remaining in care at 12 months was similar across all sites (0.82, 0.80 and 0.84). Average costs for the subset of patients who remained in care at 12 months was also similar (Site 1, $229; Site 2, $287; Site 3, $237). Patients not retained in care cost substantially less (Site 1, $104; Site 2, $113; Site 3, $88). For the subset of patients who remained in care at 12 months, ART medications accounted for 51%, 44% and 50% of the costs, with the remaining costs split between non-ART medications (15%, 11%, 10%), laboratory tests (14%, 15%, 15%), salaries to personnel providing patient care (9%, 11%, 12%) and fixed costs (11%, 18%, 13%).ConclusionsAt all three sites, 12-month retention in care compared favourably to retention rates reported in the literature from other low-income African countries. The cost of providing treatment was very low, averaging $224 in the first year, less than $20/month. The cost of antiretroviral medications, roughly $120 per year, accounted for approximately half of the total costs per patient retained in care after 12 months.

Protecting HIV information in countries scaling up HIV services: a baseline study

BackgroundIndividual-level data are needed to optimize clinical care and monitor and evaluate HIV services. Confidentiality and security of such data must be safeguarded to avoid stigmatization and discrimination of people living with HIV. We set out to assess the extent that countries scaling up HIV services have developed and implemented guidelines to protect the confidentiality and security of HIV information.MethodsQuestionnaires were sent to UNAIDS field staff in 98 middle- and lower-income countries, some reportedly with guidelines (G-countries) and others intending to develop them (NG-countries). Responses were scored, aggregated and weighted to produce standard scores for six categories: information governance, country policies, data collection, data storage, data transfer and data access. Responses were analyzed using regression analyses for associations with national HIV prevalence, gross national income per capita, OECD income, receiving US PEPFAR funding, and being a G- or NG-country. Differences between G- and NG-countries were investigated using non-parametric methods.ResultsHigher information governance scores were observed for G-countries compared with NG-countries; no differences were observed between country policies or data collection categories. However, for data storage, data transfer and data access, G-countries had lower scores compared with NG-countries. No significant associations were observed between country score and HIV prevalence, per capita gross national income, OECD economic category, and whether countries had received PEPFAR funding.ConclusionsFew countries, including G-countries, had developed comprehensive guidelines on protecting the confidentiality and security of HIV information. Countries must develop their own guidelines, using established frameworks to guide their efforts, and may require assistance in adapting, adopting and implementing them.

Buprenorphine May Boost HIV Treatment

creases in PEPFAR funding during the program’s early years helped create “a huge amount of enthusiasm for having 6 to 10 million on treatment by 2014 or 2013.” Now, she said, level funding and economic woes have blunted that enthusiasm. At the same time, however, Walensky credits PEPFAR with essentially creating a health care infrastructure in many developing countries and focusing global attention on the need for stronger health care systems in resource-limited regions. “How we prioritize what funds go into what places is going to be our global challenge for years to come.”

Tackling HIV and gender-based violence in South Africa: how has PEPFAR responded and what are the implications for implementing organizations?

South Africa has some of the highest levels of both HIV and gender-based violence (GBV) worldwide. The international literature has highlighted the importance of tackling GBV in the fight against AIDS. Although the link between these epidemics is acknowledged by South Africa's medical and NGO communities, government response has largely dealt with them separately. PEPFAR is South Africa's largest HIV/AIDS donor, representing significant funding potential for programmes seeking to tackle these twin epidemics. Using a combination of policy document analysis and key informant interviews at national and provincial level (Western Cape), we examined PEPFAR's response to the GBV-HIV link, the extent to which PEPFAR is aligned to national policies and the extent to which implementing agencies have felt able to work with PEPFAR funding. A number of PEPFAR-South Africa's positions (e.g. on condoms and abortion) stand in contradiction to South Africa's own laws. While PEPFAR-South Africa officials are adamant that PEPFAR addresses the GBV-HIV link, it does not form an explicit strategic goal and there are no indicators for this work. Although some agencies receiving PEPFAR funding do address the links between GBV and HIV, this appeared incidental rather than the reason for their receipt of PEPFAR funding. Not one implementing agency interviewed agreed with PEPFAR's ideological stance, perceiving it unhelpful and inappropriate in a social context defined by violence and HIV. Nevertheless, many organizations were prepared to apply for funding. Those awarded it found creative ways to work with-or around-PEPFAR's restrictions to ensure delivery of an appropriate range of much needed services to those facing the twin epidemics of HIV and GBV. The recent change in the US administration offers an important opportunity for broader links between HIV and GBV to be supported through PEPFAR. This paper makes recommendations for building a more systematic approach on the current ad hoc experience of PEPFAR in South Africa.

US Health Aid Beyond PEPFAR

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Lost to follow up: contributing factors and challenges in South African patients on antiretroviral therapy.

Patients who do not return for follow-up at clinics providing comprehensive HIV/AIDS care require special attention. This is particularly true where resources are limited and clinic loads are high. Themba Lethu Clinic at Helen Joseph Hospital in Johannesburg is a facility supported by PEPFAR funding through Right to Care (Grant CA-574-A-00-02-00018); more than 800 HIV/AIDS patients are seen there each week. Data on a sample of patients who failed to return for follow-up were analysed to identify the causes and to plan strategies to overcome the problem. A group of 182 patients who missed follow-up appointments at the clinic were identified. Their files were examined to identify possible contributing factors. The patients were then contacted telephonically and asked their reasons for non-attendance. Results show that the leading cause of failure to follow up was financial (34% of patients). Patients cited transport costs and having to pay to open a file at each visit as the biggest monetary obstacles to obtaining treatment. Fifty-five per cent of patients lost to follow-up showed an improvement in CD4 count on treatment. Death accounted for 27% of the patients lost to follow-up and the mean ( +/- standard deviation (SD)) duration of treatment in this group was only 8 ( +/- 6) weeks. Of the patients in this group who had been seen at 4 months, 60% had failed to respond to treatment. The mean duration of ARV treatment before being lost to follow-up was 21 ( +/- 28) weeks. The mean CD4+ count was 92 ( +/- 74.5) cells/ microl and the mean number of visits was 3.33 ( +/- 2.17). Seventy-four per cent of the patients were on regimen 1A, and only 1 cited side-effects of medication as a reason for not returning. This study highlighted financial difficulty as the major obstacle to obtaining treatment. There is evidence in support of providing ARV treatment free of charge to HIVpositive patients who qualify, as occurs in other provinces in South Africa. It is also suggested that providing ARV therapy at more local clinics in the community would make treatment more accessible. Provision of several months' supply of medicines per visit would help to reduce transport costs and minimise patient expenditure. These interventions may reduce the incidence of patients lost to follow-up in this community.