President's Emergency Plan For AIDS Relief Research Articles

Social support seeking and self-efficacy-building strategies in enhancing the emotional well-being of informal HIV/AIDS caregivers in Ibadan, Oyo state, Nigeria

This study examined the relative efficacy of social support seeking (SSS) and self-efficacy building (SEB) in the management of emotional well-being of caregivers of people suffering from HIV/AIDS. It was based at the United States President's Emergency Plan for AIDS Relief (PEPFAR) center in the University College Hospital, Ibadan, Oyo state, being the first and the largest teaching hospital in Nigeria. A 3 × 2 factorial design consisting of treatment and a control group was used. The columns have two levels of gender being male and female caregivers. One-hundred and sixty-five (165) caregivers who were taking care of people that are suffering from HIV/AIDS were purposively selected and randomly assigned to the treatment groups and control. The treatment was carried out for a period of eight weeks. Two null hypotheses were tested, both at .05 levels of significance. Data were collected with the use of standardized intruments rating scale; social support scale, general self-efficacy scale and emotional well-being scale. ANCOVA was used to establish significant treatment effects with the pretest as covariate. Even though SSS and SEB were both found to be effective in enhancing the emotional well-being of informal caregivers in this study when compared to the controls, SSS was significantly more effective than SEB in achieving this goal. Since the HIV/AIDS patients cannot be adequately cared for in the hospital settings due to severe shortages of material, personnel and time, serious efforts should be made by the three levels of the health care system viz: the primary, secondary and tertiary health care systems, to encourage the employment of the psychological management of caregivers of people suffering from HIV/AIDS. Also, the psychologists, clinical psychologists and the significant others should be encouraged to employ this psychological management in the care of HIV/AIDS informal caregivers.

Prevalence of Sickle Cell Trait and Reliability of Self-Reported Status among Expectant Parents in Nigeria: Implications for Targeted Newborn Screening

Background/Aims: Sickle cell disease (SCD) is a life-threatening, autosomal recessive blood disorder prevalent in sub-Saharan Africa. We identified the prevalence of sickle cell trait (SCT) among pregnant women and their male partners in Enugu State, Nigeria, and determined the accuracy of self-reported sickle cell status and its reliability for identifying high-risk newborns for targeted screening. Methods: We conducted a nested cohort study of expectant parents enrolled in the Healthy Beginning Initiative (HBI). The HBI is a cluster-randomized trial of a congregation-based approach designed to increase HIV testing. Participants completed a survey regarding self-awareness of their sickle cell genotype and consented to genotype screening by cellulose acetate electrophoresis. Results: SCT prevalence (HbAS) was 22% (746/3,371). Only 50% of participants provided an accurate self-report. Self-report accuracy was significantly different (p < 0.0001) between individuals who reported having SCT or SCD (61% accuracy) versus those who reported not having SCT or SCD (86% accuracy). Demographic variables including gender, age, household size, employment, education, and home location were significantly associated with providing an accurate self-report. Conclusions: Low numbers of accurate parental self-reports, coupled with a high SCT prevalence in Nigeria, could limit the efficacy of targeted newborn screening. However, our data indicate that it is feasible to integrate sickle cell screening for pregnant women with existing, community-based health care programs developed by the President's Emergency Plan for AIDS Relief (PEPFAR), such as the HBI. Expanding screening programs could enable the development of targeted newborn screening based on maternal genotype that could identify all newborns with SCD in resource-limited settings.

ASCP Leads International Coalition to Accelerate Fight Against Cancer in Africa

![Graphic][1] For the past decade, ASCP members have been delivering health care on a global scale through our involvement in the President's Emergency Plan For AIDS Relief (PEPFAR). These efforts have helped 25 million people living with HIV in Sub-Saharan Africa stay alive. ASCP joined this effort in partnership with the Centers for Disease Control and Prevention to treat and prevent AIDS and tuberculosis in Sub-Saharan Africa and alleviate suffering from other infectious and chronic diseases. This partnership was crucial, since the laboratory plays a vital role in improving healthcare delivery by providing important information for diagnosis and treatment of diseases such as HIV. Our initial involvement was in response to the public health crisis in Sub-Saharan Africa. In resource-limited countries, building laboratory capacity is essential for reliable diagnostic testing, effective treatment, and reducing mortality. ASCP has been assessing laboratory needs, bridging gaps in knowledge and skills, and leaving a sustainable infrastructure. The success of our initiatives is evidenced by the fact that, last year alone, ASCP consultants took part in 70 training activities in 17 countries and provided educational training to 908 participants in PEPFAR activities. Now, we face a new challenge: People are living longer with HIV/AIDS and are now encountering complex health problems like non-communicable diseases, or NCDs, including cancer, cardiovascular disease, and respiratory disease. Roughly 650,000 people in Africa develop cancer annually. Due to limited treatment, about 510,000 cancer deaths occur annually. This is an 80 percent mortality rate. By 2030, those figures are expected to increase to 1.28 million new cancer cases and 970,000 deaths, due to the aging and growth of the population. The potential could be even higher because of behaviors and lifestyles associated with increasing economic development in some countries. ![Graphic][2] More than one-third … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif

Effect of a clinical decision support system on early action on immunological treatment failure in patients with HIV in Kenya: a cluster randomised controlled trial

A clinical decision support system (CDSS) is a computer program that applies a set of rules to data stored in electronic health records to offer actionable recommendations. We aimed to establish whether a CDSS that supports detection of immunological treatment failure among patients with HIV taking antiretroviral therapy (ART) would improve appropriate and timely action. We did this prospective, cluster randomised controlled trial in adults and children (aged ≥18 months) who were eligible for, and receiving, ART at HIV clinics in Siaya County, western Kenya. Health facilities were randomly assigned (1:1), via block randomisation (block size of two) with a computer-generated random number sequence, to use electronic health records either alone (control) or with CDSS (intervention). Facilities were matched by type and by number of patients enrolled in HIV care. The primary outcome measure was the difference between groups in the proportion of patients who experienced immunological treatment failure and had a documented clinical action. We used generalised linear mixed models with random effects to analyse clustered data. This trial is registered with ClinicalTrials.gov, number NCT01634802. Between Sept 1, 2012, and Jan 31, 2014, 13 clinics, comprising 41,062 patients, were randomly assigned to the control group (n=6) or the intervention group (n=7). Data collection at each site took 12 months. Among patients eligible for ART, 10,358 (99%) of 10,478 patients were receiving ART at control sites and 10,991 (99%) of 11,028 patients were receiving ART at intervention sites. Of these patients, 1125 (11%) in the control group and 1342 (12%) in the intervention group had immunological treatment failure, of whom 332 (30%) and 727 (54%), respectively, received appropriate action. The likelihood of clinicians taking appropriate action on treatment failure was higher with CDSS alerts than with no decision support system (adjusted odds ratio 3·18, 95% CI 1·02-9·87). CDSS significantly improved the likelihood of appropriate and timely action on immunological treatment failure. We expect our findings will be generalisable to virological monitoring of patients with HIV receiving ART once countries implement the 2015 WHO recommendation to scale up viral load monitoring. US President's Emergency Plan for AIDS Relief (PEPFAR), through the US Centers for Disease Control and Prevention.

From emergency to sustainability: shifting objectives in the US Government's HIV response in Tanzania

ABSTRACTThe US President's Emergency Plan for AIDS Relief (PEPFAR) was originally designed as an emergency initiative, operating with considerable funds, immediate roll-out, fast scale-up, and top-down technocratic administration. In a more recent iteration, PEPFAR shifted its focus from an emergency response to more closely account for healthcare sustainability. This transition came on the heels of the 2008 financial crisis, which threatened to stall the ‘marvellous momentum’ of the 2000's boom in donor aid for global health overall. Now many programmes are having to do more with less as funding flattens or decreases. This paper examines how this transition took shape in Tanzania in 2011–2012, and the successes and challenges associated with it, using participant observation and interview data from 20 months of fieldwork in rural and urban healthcare settings. In particular, I discuss (1) efforts to increase sustainability and country ownership of HIV programmes in Tanzania, focusing on the shift from PEPFAR-funded American non-governmental organisations to Tanzanian partner organisations; (2) principal challenges stakeholders encountered during the transition, including fragmented systems of healthcare delivery and a weakened healthcare workforce; and (3) strategies informants identified to better integrate services in order to build a stronger, more equitable, and sustainable health system in Tanzania.

Tuberculosis Incidence and Risk Factors Among Human Immunodeficiency Virus (HIV)-Infected Adults Receiving Antiretroviral Therapy in a Large HIV Program in Nigeria.

Background. Despite the benefits of antiretroviral therapy (ART), tuberculosis (TB) is the leading cause of mortality among human immunodeficiency virus (HIV)-infected persons in Africa. Nigeria bears the highest TB burden in Africa and second highest HIV burden globally. This long-term multicenter study aimed to determine the incidence rate and predictors of TB in adults in the Harvard/AIDS Prevention Initiative in Nigeria (APIN) and President's Emergency Plan for AIDS Relief (PEPFAR) Nigeria ART program.Methods. This retrospective evaluation used data collected from 2004 to 2012 through the Harvard/APIN PEPFAR program. Risk factors for incident TB were determined using multivariate Cox proportional hazards regression with time-dependent covariates.Results. Of 50 320 adults enrolled from 2005 to 2010, 11 092 (22%) had laboratory-confirmed active TB disease at ART initiation, and 2021 (4%) developed active TB after commencing ART. During 78 228 total person-years (PY) of follow-up, the TB incidence rate was 25.8 cases per 1000 PY (95% confidence interval [CI], 24.7–27.0) overall, and it decreased significantly both with duration on ART and calendar year. Risk factors at ART initiation for incident TB included the following: earlier ART enrollment year, tenofovir-containing initial ART regimen, and World Health Organization clinical stage above 1. Time-updated risk factors included the following: low body mass index, low CD4+ cell count, unsuppressed viral load, anemia, and ART adherence below 80%.Conclusions. The rate of incident TB decreased with longer duration on ART and over the program years. The strongest TB risk factors were time-updated clinical markers, reinforcing the importance of consistent clinical and laboratory monitoring of ART patients in prompt diagnosis and treatment of TB and other coinfections.

A multidisciplinary approach to increase the pediatric HIV/AIDS treatment rates in Tanzania

Background Tanzania has the second largest burden of children yet to be started on treatment when applying the 2010 World Health Organization (WHO) eligibility criteria. In partnership with the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund, Tanzania has 34,524 children on antiretroviral treatment at the end of FY2013, representing 26.5% coverage based on a UNAIDS estimate. Pediatric antiretroviral treatment coverage in Tanzania …

Dual indices for prioritizing investment in decentralized HIV services at Nigerian primary health care facilities.

Decentralizing health services, including those for HIV prevention and treatment, is one strategy for maximizing the use of limited resources and expanding treatment options; yet few methods exist for systematically identifying where investments for service expansion might be most effective, in terms of meeting needs and rapid availability of improved services. The Nigerian Government, the United States Government under the President's Emergency Plan for AIDS Relief (PEPFAR) program and other donors are expanding services for prevention of mother-to-child transmission (PMTCT) of HIV to primary health care facilities in Nigeria. Nigerian primary care facilities vary greatly in their readiness to deliver HIV/AIDS services. In 2012, MEASURE Evaluation assessed 268 PEPFAR-supported primary health care facilities in Nigeria and developed a systematic method for prioritizing these facilities for expansion of PMTCT services. Each assessed facility was scored based on two indices with multiple, weighted variables: one measured facility readiness to provide PMTCT services, the other measured local need for the services and feasibility of expansion. These two scores were compiled and the summary score used as the basis for prioritizing facilities for PMTCT service expansion. The rationale was that using need and readiness to identify where to expand PMTCT services would result in more efficient allocation of resources. A review of the results showed that the indices achieved the desired effect—that is prioritizing facilities with high need even when readiness was problematic and also prioritizing facilities where rapid scale-up was feasible. This article describes the development of the two-part index and discusses advantages of using this approach when planning service expansion. The authors' objective is to contribute to development of methodologies for prioritizing investments in HIV, as well as other public health arenas, that should improve cost-effectiveness and strengthen services and systems in resource-limited countries.

Strengthening public health supply chains in Ethiopia: PEPFAR-supported expansion of access and availability

When the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported Supply Chain Management System (SCMS) programme began working in Ethiopia in 2006, the estimated population of people living with HIV exceeded one million, while only 24,000 were on treatment and only 50 treatment sites were in operation. SCMS and other key partners entered into this context to support the Ethiopian government in significantly strengthening the public health supply chain system, with the aim of increasing the availability and accessibility of pharmaceutical products. The country now has 1,047 treatment sites and is nearing complete treatment coverage. This article discusses how priorities were set among many competing challenges from 2006 until 2014, and how the four-step strategy of build, operate, transfer, and optimise has resulted in a successful partnership.

P14.14 Intersecting stigmas: a framework for data collection and analysis of stigmas faced by people living with hiv and key populations

Introduction Stigma can impede the implementation of HIV prevention and treatment programmes. Many measurement scales have been developed, though few have addressed intersecting stigmas: that is to say, multiple stigmas faced by people living with HIV, and key populations at high risk of HIV. Methods We developed an approach to measure intersecting stigmas nested within the HPTN 071 (PopART) trial, conducted in South Africa and Zambia. We adopted best-practice wording to assess key domains of stigma, building on a process of global consultative indicator harmonisation. We designed nested data collection items in surveys for parallel use among the general population, health workers and people living with HIV (PLHIV) - including health workers living with HIV - to assess the same phenomena from multiple perspectives. We also designed “parallel” assessments of key population stigma within the health care worker survey to compare the attitudes and perceptions of health care workers towards PLHIV, and those at increased risk of HIV infection, such as migrants, sex workers, MSM, young women, and people with disabilities. A core set of seven questions was included in the HPTN071 (PopART) surveys conducted among the general population (over 10,000 individuals), PLHIV (about 4000 individuals) and health care workers (over 1000 individuals). These items assessed two key domains of HIV stigma: drivers of stigma and manifestations of stigma. In the health care worker survey, questions specific to key populations were also included, to assess health care worker attitudes, experiences and perceptions about those at increased risk of HIV as listed above. We developed an approach to visually represent the complex data set using methods based on social-network analysis. We developed an approach to assess intersecting HIV-related stigmas, incorporating data collected from different population groups. Data collection is ongoing. Disclosure of interest statement HPTN 071 is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) under Cooperative Agreements UM1-AI068619, UM1-AI068617, and UM1-AI068613, with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). Additional funding is provided by the International Initiative for Impact Evaluation (3ie) with support from the Bill and Melinda Gates Foundation, as well as by NIAID, the National Institute on Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH), all part of NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAID, NIMH, NIDA, PEPFAR, 3ie, or the Bill and Melinda Gates Foundation. We have no conflicts of interest to declare.

P14.13 Hiv-related stigma and universal testing and treatment for hiv prevention and care: design of an implementation science evaluation nested in the hptn 071 (popart) cluster-randomised trial in zambia and south africa

Background Stigma and discrimination related to HIV and populations at high risk of HIV have the potential to impede the implementation of effective HIV prevention and treatment programmes. We will conduct an implementation science study of HIV-related stigma in communities and health settings within a large, pragmatic cluster-randomised trial of a universal testing and treatment intervention for HIV prevention in Zambia and South Africa and assess how stigma affects, and is affected by, implementation of this intervention. Methods A mixed-method evaluation will be nested within HPTN071/PopART (Clinical Trials registration number NCT01900977), a three-arm trial comparing universal door-to-door delivery of HIV testing and referral to prevention and treatment services, accompanied by either an immediate offer of antiretroviral treatment to people living with HIV (PLHIV) regardless of clinical status, or an offer of treatment in-line with national guidelines, with a standard-of-care control arm. The primary outcome of HPTN071/PopART is HIV incidence measured among a cohort of 52,500 individuals in 21 study clusters. Our evaluation will include integrated quantitative and qualitative data collection and analysis in all sites. We will collect quantitative data on indicators of HIV-related stigma over three years from large probability samples of community members, health workers, and PLHIV, and qualitative data, including in-depth interviews and observations from members of these same groups sampled purposively. In analysis we will: (i) compare HIV-related stigma measures between study arms, (ii) link data on stigma to measures of the success of implementation of the intervention, (iii) explore changes in the drivers and manifestations of stigma in study communities and the health system. Discussion Using a novel study-design nested within a large, pragmatic trial we will evaluate the extent to which HIV-related stigma affects and is affected by the implementation of a comprehensive combination HIV prevention intervention including a universal test and treatment approach. Disclosure of interest statement HPTN 071 is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) under Cooperative Agreements UM1-AI068619, UM1-AI068617, and UM1-AI068613, with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). Additional funding is provided by the International Initiative for Impact Evaluation (3ie) with support from the Bill and Melinda Gates Foundation, as well as by NIAID, the National Institute on Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH), all part of NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAID, NIMH, NIDA, PEPFAR, 3ie, or the Bill and Melinda Gates Foundation. We have no conflicts of interest to declare.

O12.2 Understanding the relationship dynamics between female sex workers and their intimate partners in kumasi, ghana

Introduction Intimate partners (IP) of female sex workers (FSW) are a population of growing interest in Ghana. The study objectives were to: explore the emotional, financial, and power dynamics within these relationships; describe the sexual behaviours and HIV knowledge and vulnerabilities of both partners; and document the perceived availability and accessibility of social support and health services. Methods In-depth interviews (IDIs) were conducted with 24 male IP of FSW. Two focus group discussions were conducted with 13 male IPs and three with 20 FSWs. The age range of IPs was from 20–60 years and FSWs from 18–50. Results The IPs met their FSWs through introductions by close friends, patronising FSW’s services and/or by FSWs going after the IPs. The nature of relationships ranged from the IP offering protection for financial support (transactional), meeting emotional needs (intimate) to consensual reciprocal relationships. Forty percent of IPs were monogamous with their FSW partner, and about 50% of IPs and FSW couples used condoms. Lack of condom use was considered a sign of intimacy. The majority of respondents had some knowledge of HIV transmission and consequences. All respondents understood that condoms offer protection against HIV infection, but many FSW respondents reported difficulty in convincing regular clients to use condoms. Over half of the men who participated in the IDIs had recently tested for HIV, and half the men knew their FSW partner’s HIV status. Respondents showed varying levels of awareness of HIV testing options and pricing, and had suggestions for how to improve services. Conclusion Study results show a nuanced picture of IP of FSW relationships, and these dynamics are important in the context of HIV and STI transmission prevention. Expanded community-based services for FSW and IP and initiatives that increase availability and acceptability of condom use should be pursued. Disclosure of interest statement This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the US Agency for International Development under Project SEARCH Task Order No. GHH-I-00- 07–00023–00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the US Government.

Understanding HIV-infected patients’ experiences with PEPFAR-associated transitions at a Centre of Excellence in KwaZulu Natal, South Africa: a qualitative study

South Africa was the largest recipient of funding from the President's Emergency Plan for AIDS Relief (PEPFAR) for antiretroviral therapy (ART) programs from 2004 to 2012. Funding decreases have led to transfers from hospital and non-governmental organization-based care to government-funded, community-based clinics. We conducted semi-structured interviews with 36 participants to assess patient experiences related to transfer of care from a PEPFAR-funded, hospital-based clinic in Durban to either primary care clinics or hospital-based clinics. Participant narratives revealed the importance of connectedness between patients and the PEPFAR-funded clinic program staff, who were described as respectful and conscientious. Participants reported that transfer clinics were largely focused on dispensing medication and on throughput, rather than holistic care. Although participants appreciated the free treatment at transfer sites, they expressed frustration with long waiting times and low perceived quality of patient–provider communication, and felt that they were treated disrespectfully. These factors eroded confidence in the quality of the care. The transfer was described by participants as hurried with an apparent lack of preparation at transfer clinics for new patient influx. Formal (e.g., counseling) and informal (e.g., family) social supports, both within and beyond the PEPFAR-funded clinic, provided a buffer to challenges faced during and after the transition in care. These data support the importance of social support, adequate preparation for transfer, and improving the quality of care in receiving clinics, in order to optimize retention in care and long-term adherence to treatment.

Improving the Quality of Voluntary Medical Male Circumcision through Use of the Continuous Quality Improvement Approach: A Pilot in 30 PEPFAR-Supported Sites in Uganda.

BackgroundUganda adopted voluntary medical male circumcision (VMMC) (also called Safe Male Circumcision in Uganda), as part of its HIV prevention strategy in 2010. Since then, the Ministry of Health (MOH) has implemented VMMC mostly with support from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through its partners. In 2012, two PEPFAR-led external quality assessments evaluated compliance of service delivery sites with minimum quality standards. Quality gaps were identified, including lack of standardized forms or registers, lack of documentation of client consent, poor preparedness for emergencies and use of untrained service providers. In response, PEPFAR, through a USAID-supported technical assistance project, provided support in quality improvement to the MOH and implementing partners to improve quality and safety in VMMC services and build capacity of MOH staff to continuously improve VMMC service quality.Methods and FindingsSites were supported to identify barriers in achieving national standards, identify possible solutions to overcome the barriers and carry out improvement plans to test these changes, while collecting performance data to objectively measure whether they had bridged gaps. A 53-indicator quality assessment tool was used by teams as a management tool to measure progress; teams also measured client-level indicators through self-assessment of client records. At baseline (February-March 2013), less than 20 percent of sites scored in the “good” range (>80%) for supplies and equipment, patient counseling and surgical procedure; by November 2013, the proportion of sites scoring “good” rose to 67 percent, 93 percent and 90 percent, respectively. Significant improvement was noted in post-operative follow-up at 48 hours, sexually transmitted infection assessment, informed consent and use of local anesthesia but not rate of adverse events.ConclusionPublic sector providers can be engaged to address the quality of VMMC using a continuous quality improvement approach.

Training for Better Management: Avante Zambézia, PEPFAR and Improving the Quality of Administrative Services Comment on "Implementation of a Health Management Mentoring Program: Year-1 Evaluation of Its Impact on Health System Strengthening in Zambézia Province, Mozambique".

The United States President's Emergency Plan for AIDS Relief (PEPFAR) emphasizes health systems strengthening as a cornerstone of programmatic success. Health systems strengthening, among other things, includes effective capacity building for clinical care, administrative management and public health practice. Avante Zambézia is a district-level in-service training program for administrative staff. It is associated with improved accounting practices and human resources and transportation management but not monitoring and evaluation. We discuss other examples of successful administrative training programs that vary in the proportion of time that is spent learning on the job and the proportion of time spent in classrooms. We suggest that these programs be more rigorously evaluated so that lessons learned can be generalized to other countries and regions.

The critical condition of rhetorical choices

HIV/AIDS is an epidemic that is still pervasive globally. Through effective health communication campaigns, the disease may be contained. This paper is a rhetorical visual analysis of the President’s Emergency Plan for AIDS Relief (PEPFAR) and its online presence. Global policy initiatives such as PEPFAR have wide reaching ramifications. Thus, the rhetoric of the George W. Bush administration as reflected in the PEPFAR initiative bears scrutiny. Both visual and discursive tropes reflected in the PEPFAR initiative offer an interesting contradiction. While the Bush administration's rhetoric purported to offer succor to those stricken with HIV/AIDS, the actual content and substance of PEPFAR belied its surface appearances by undercutting support for those in danger of being infected and those already ill with HIV/AIDS.

Financing the response to HIV among gay men and other men who have sex with men: Case studies from eight diverse countries

Despite reductions in the number of new HIV infections globally, the HIV epidemic among men who have sex with men (MSM) is expanding. This study characterises financing of HIV programmes for MSM and the impact of criminalisation on levels of funding, using data from five countries that criminalise same-sex sexual practices (Ethiopia, Mozambique, Guyana, India and Nigeria) and three that do not (China, Ukraine and Vietnam). For each country, all publicly available documents from the Global Fund to Fight AIDS, Tuberculosis and Malaria for approved HIV/AIDS grants in Rounds 5–9 and Country Operational Plans detailing investments made through the President's Emergency Plan for AIDS Relief (PEPFAR) from US fiscal year (FY) 2007–2009 were examined. Eleven of 20 HIV proposals to the Global Fund contained programmes for MSM totalling approximately $40 million or 6% of proposed budgets. In six countries providing activity-level data on MSM programming, PEPFAR funding that served this population and others ranged from $23.3 million in FY2007 to $35.4 million in FY2009, representing 0.5–25.9% of overall, non-treatment funding over this period. Countries that criminalise same-sex sexual practices spend fewer resources on HIV programmes serving MSM. However, they also show consistent underfunding of programmes serving MSM regardless of context or geography.

Creating a national culture of quality: the Tanzania experience.

Although quality improvement has been a priority for Tanzania's health sector since the 1970s, few effective quality improvement initiatives were implemented, due to limited expertise, political commitment and resources. More recently, as the HIV epidemic gained momentum within the country, an influx of funding and of international organizations with quality improvement expertise accelerated the implementation of quality improvement projects, as well as efforts to institutionalize quality improvement at the national level. The support of US President's Emergency Plan for AIDS Relief (PEPFAR) and other donors, and the increasing numbers of HIV-implementing partners focused on quality management, and quality improvement strategies catalysed the development of HIV-specific quality improvement initiatives first, and then of national quality improvement frameworks. The diversity of quality improvement approaches championed by various donors and partners also presented important challenges to harmonization and institutionalization of quality improvement programmes.

Monitoring quality at scale: implementing quality assurance in a diverse, multicountry HIV program.

The centrality of quality as a strategy to achieve impact within the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has been widely recognized. However, monitoring program quality remains a challenge for many HIV programs, particularly those in resource-limited settings, where human resource constraints and weaker health systems can pose formidable barriers to data collection and interpretation. We describe the practicalities of monitoring quality at scale within a very large multicountry PEPFAR-funded program, based largely at health facilities. The key elements include the following: supporting national programs and strategies; developing a conceptual framework and programmatic model to define quality and guide the provision of high-quality services; attending to program context, as well as program outcomes; leveraging existing and routinely collected data whenever possible; developing additional indicators for judicious use in targeted, in-depth assessments; providing hands-on support for data collection and use at the facility, sub-national, and national levels; utilizing web-based databases for data entry, analysis, and dissemination; and multidisciplinary support from a large team of clinical and strategic information advisors.

Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa

BackgroundSince 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the...