US President's Emergency Plan Research Articles

Progress, Challenges, and New Opportunities for the Prevention of Mother-to-Child Transmission of HIV Under the US President's Emergency Plan for AIDS Relief

In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortality--all by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.

Scale-up of HIV Treatment Through PEPFAR

Since its inception in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.

PEPFAR support for the scaling up of collaborative TB/HIV activities.

The US President's Emergency Plan for AIDS Relief (PEPFAR) has supported a comprehensive package of care in which interventions to address HIV-related tuberculosis (TB) have received increased funding and support in recent years. PEPFAR's TB/HIV programming is based on the World Health Organization's 12-point policy for collaborative TB/HIV activities, which are integrated into PEPFAR annual guidance. PEPFAR implementing partners have provided crucial support to TB/HIV collaboration, and as a result, PEPFAR-supported countries in sub-Saharan Africa have made significant gains in HIV testing and counseling of TB patients and linkages to HIV care and treatment, intensified TB case finding, and TB infection control. PEPFAR's support of TB/HIV integration has also included significant investment in health systems, including improved laboratory services and educating and enlarging the workforce. The scale-up of antiretroviral therapy along with support of programs to increase HIV counseling and testing and improve linkage and retention in HIV care may have considerable impact on TB morbidity and mortality, if used synergistically with isoniazid preventive therapy, intensified case finding, and infection control. Issues to be addressed by future programming include accelerating implementation of isoniazid preventive therapy, increasing access and ensuring appropriate use of new TB diagnostics, supporting early initiation of antiretroviral therapy for HIV-infected TB patients, and strengthening systems to monitor and evaluate program implementation.

Engaging to End the Epidemic

Engaging to End the Epidemic

Transitioning HIV care and treatment programs in southern Africa to full local management

Global AIDS programs such as the US President's Emergency Plan for AIDS Relief (PEPFAR) face a challenging health care management transition. HIV care must evolve from vertically-organized, externally-supported efforts to sustainable, locally controlled components that are integrated into the horizontal primary health care systems of host nations. We compared four southern African nations in AIDS care, financial, literacy, and health worker capacity parameters (2005 to 2009) to contrast in their capacities to absorb the huge HIV care and prevention endeavors that are now managed with international technical and fiscal support. Botswana has a relatively high national income, a small population, and an advanced HIV/AIDS care program; it is well poised to take on management of its HIV/AIDS programs. South Africa has had a slower start, given HIV denialism philosophies of the previous government leadership. Nonetheless, South Africa has the national income, health care management, and health worker capacity to succeed in fully local management. The sheer magnitude of the burden is daunting, however, and South Africa will need continuing fiscal assistance. In contrast, Zambia and Mozambique have comparatively lower per capita incomes, many fewer health care workers per capita, and lower national literacy rates. It is improbable that fully independent management of their HIV programs is feasible on the timetable being contemplated by donors, nor is locally sustainable financing conceivable at present. A tailored nation-by-nation approach is needed for the transition to full local capacitation; donor nation policymakers must ensure that global resources and technical support are not removed prematurely.

The US President's Emergency Plan for AIDS Relief

This article analyses the US response under former President George W. Bush to the global HIV/AIDS epidemic at the intersection of neo-conservatism and neo-liberalism, highlighting the various ways their distinct gender logics collide to reproduce masculine privilege and gender inequalities on a global scale. The President's Emergency Plan for AIDS Relief (PEPFAR) is the United States global HIV/AIDS policy and is the largest commitment made by any single nation for an international health project. My analysis is based on PEPFAR's ‘formal’ policy texts, including its authorizing legislation, five-year strategic framework and specific policy directives for recipient organizations. In addition, I examine more ‘informal’ texts like Congressional reports and Presidential speeches delivered by George W. Bush on various occasions. Drawing on a rich body of feminist ethnographic work in the fields of global governance, international political economy, organizational theory and sexuality and masculinity studies, the following article examines the various ways market-based norms and practices can legitimate the moral imperatives of neo-conservatism to promote ‘traditional’ values and institutions in the global South as leading solutions to global problems and insecurities.

HIV Development Assistance and Adult Mortality in Africa

The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown. To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively. Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics. Adult all-cause mortality. We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively. Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.

The politics and policies of HIV prevention in sex work

Decades into the HIV epidemic, we know surprisingly little about the relative burden of HIV among sex workers. UNAIDS estimates that less than 50% of sex workers have access to HIV prevention programmes worldwide.1 HIV prevalence among sex workers is highly heterogeneous both across and within regions. In addition to individual and biological drivers (eg, the epidemic structure, co-infection with other sexually transmitted infections [STIs], and antiretroviral therapy [ART] coverage), structural features continue to play a crucial part in shaping risk of infection among sex workers and their clients, including work environment, violence, stigma, and the legal, cultural, and political contexts of sex work.2 and 3 In The Lancet Infectious Diseases, Stefan Baral and colleagues4 report a systematic review and meta-analysis of HIV burden among female sex workers in 50 low-income and middle-income countries. Female sex workers had an overall increased odds of HIV infection (odds ratio 13·5, 95% CI 10·0–18·1) relative to the general female population of reproductive age, with the highest odds in Asia (29·2, 95% CI 22·2–38·4) and lowest in Latin America and the Caribbean (12·0, 95% 7·3–19·7). Baral and colleagues show substantially high HIV prevalence levels across geographical regions and epidemic structures, including both concentrated epidemics and mature, generalised epidemics, as in sub-Saharan Africa where the pooled HIV prevalence was 36·9% (95% CI 36·2–37·5). The heavy HIV burden points to the crucial need for urgent scale-up of comprehensive initiatives simultaneously targeting HIV prevention, ART access, and care among female sex workers, especially in view of the established role of treatment as prevention. Of concern, two-thirds of countries have no data on HIV burden in this group. As Baral and colleagues suggest, the dearth of data can be attributed in large part to the same structural conditions that increase risk of HIV and prevent engagement in interventions among female sex workers, including criminalised legal and policy environments, violence, stigma, and restrictive funding policies.5 and 6 All too often moral debates dominate the public health response among sex workers, and science continues to take a backseat to punitive approaches and raid and rescue operations aimed at eliminating sex work. The US antiprostitution pledge enacted in 2003 continues to prevent non-governmental organisations from accessing funds from the US Presidents Emergency Plan for AIDS Relief if they did not oppose sex work. Evidence suggests that in settings where sex work is criminalised or heavily sanctioned (eg, mandatory testing), sex workers are pushed outside the public health system.6 and 7 The common threat of violence towards sex workers by clients and third parties (eg, police, exploitative managers, pimps) are associated with increased risk for HIV infection.8 Enforcement efforts (eg, police crackdowns, raids), punitive sanctions, and the threat of violence can deter sex workers from accessing HIV prevention services, constrain their ability to negotiate condom use, and prevent the roll-out and rigorous assessment of HIV interventions.6 Individual country and programme successes have made important progress regionally, but for the most part have not been met with global backing from international and governmental bodies, and face the same structural barriers to large-scale implementation and rigorous assessment. A systematic review9 of HIV and STI intervention studies among female sex workers in low-resource settings showed significant use of multicomponent and structural interventions (policy change and sex-work collectivisation), with only modest effects reported for behavioural interventions alone. Multipronged HIV-prevention strategies have been adopted in several countries (eg, safer sex-work environments),2 with the most well documented structural HIV interventions being those led by sex workers in India (Songachi and Avahan models).10 and 11 The results stand as an important marker of the sheer scale of the HIV epidemic among female sex workers worldwide, and a call to action, both for investment in science and scale-up of evidence-based HIV-prevention interventions. With efforts to better characterise the epidemic in sex work and the response to it, research and interventions among the male client population and other subpopulations of sex workers (eg, male and transgender sex workers, migrant workers) are also crucial. As the epidemic matures in many settings, with some countries already reporting over 50% of sex workers living with HIV, comprehensive initiatives simultaneously targeting HIV prevention, ART access, and care are increasingly vital. As highlighted in a recent report by the UNAIDS advisory on sex work and HIV,12 removal of structural barriers (eg, criminalised laws and policies, violence) remains a necessary precondition to an effective HIV response in sex work worldwide.

Barriers to antiretroviral initiation in HIV-1-discordant couples.

In Kenya and much of sub-Saharan Africa, nearly half of all couples affected by HIV are discordant. Antiretroviral therapy (ART) slows disease progression in HIV-1-infected individuals and reduces transmission to uninfected partners. We examined time to ART initiation and factors associated with delayed initiation in HIV-1-discordant couples in Nairobi. HIV-1-discordant couples were enrolled and followed quarterly for up to 2 years. Clinical staff administered questionnaires and conducted viral loads and CD4 counts. Participants with a CD4 count meeting ART criteria were referred to a nearby US President's Emergency Plan for AIDS Relief-funded treatment center. Barriers to ART initiation among participants with a CD4 count eligible for ART were assessed by Cox regression. Of 439 HIV-1-infected participants (63.6% females and 36.4% males), 146 met CD4 count criteria for ART during follow-up. Median time from meeting CD4 criteria until ART initiation was 8.9 months, with 42.0% of eligible participants on ART by 6 months and 63.4% on ART by 1 year. The CD4 count at the time of eligibility was inversely associated with time to ART initiation (hazard ratio = 0.49, P < 0.001). Compared with homeowners, those paying higher rents started ART 48% more slowly (P = 0.062) and those paying lower rents started 71% more slowly (P = 0.002). Despite access to regular health care, referrals to treatment centers, and free access to ART, over one-third of participants with an eligible CD4 count had not started ART within 1 year. Factors of lower socioeconomic status may slow ART initiation, and targeted approaches are needed to avoid delays in treatment initiation.

Stuckler et al. Respond

We welcome the effort by Larson et al. to extend our analysis of inequalities in health care provision in South Africa1 to an external disease-specific agency, the US President's Emergency Plan for AIDS Relief (PEPFAR). Although the analysis is interesting, the authors misleadingly suggest that their findings may be more robust because they used district level data. In fact, they are looking at something quite different. There is no a priori reason to expect that the distribution of funds by an international aid agency should be the same as that in the national government's healthcare budget. A larger question that the authors do not address is whether external agencies and private donors substitute for domestic spending on health care.2 PEPFAR has gone to great lengths to avoid such a possibility, for example, by setting up matching initiatives with government finance. Yet one unresolved concern is that when external groups provide health care services to vulnerable groups, they may unintentionally relieve the pressure on those making domestic budgetary decisions to reverse historical inequalities in health care. Independent analysis and scrutiny is needed to understand how external bodies such as PEPFAR have perpetuated or helped alleviate historical infrastructure-inequality traps that we observed. While considerable effort is expended in public health research to assess the determinants of health outcomes and inequalities,3 an equal need exists for rigorous studies to understand how to address deeply embedded causes of institutional inequalities and their influence on the evolution of public health systems.

Using global health initiatives to strengthen health systems: A civil society perspective

Research into the effects of global health initiatives (GHIs) on health systems has largely left out the viewpoints and contributions of civil society. This study details civil society's perspective regarding the effects of two GHIs, the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), on country health systems and the added value of civil society interacting with GHIs to strengthen health systems. The study employed qualitative data collection methods using semi-structured interviews administered during focus groups and key informant interviews. A range of health system stakeholders were interviewed in Kenya, Malawi, Uganda and Zambia. Data were coded and analysed for themes and sub-themes. In total, 2910 civil society participants provided information individually or in focus groups. Respondents reported that GHIs have contributed to dramatic health benefits within and outside of a disease-specific focus, including health systems strengthening efforts. However, opportunities for synergy between GHIs and health systems have been missed, and GHIs have not worked sufficiently to close capacity gaps of grassroots civil society organisations. Despite some governance innovations, civil society's opportunities to participate meaningfully in GHI priority setting efforts are limited. Recommendations are included on how to best use GHIs to strengthen health systems by partnering with civil society.

Characteristics of HIV Care and Treatment in PEPFAR-Supported Sites

The US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the extension of HIV care and treatment to 2.4 million individuals as of September 2009. With increasing resources targeted toward rapid scale-up, it is important to understand the characteristics of current PEPFAR-supported HIV care and treatment sites. Forty-five sites in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam were sampled. Data were collected retrospectively from successive 6-month periods through reviews of facility records and interviews with site personnel between April 2006 and March 2007. Facility size and scale-up rate, patient characteristics, staffing models, clinical and laboratory monitoring, and intervention mix were compared. Sites added a median of 293 patients per quarter. By the evaluation's end, sites supported a median of 1649 HIV patients, 922 of them receiving antiretroviral therapy. Patients were predominantly adult (97.4%), and the majority (96.5%) were receiving regimens based on nonnucleoside reverse transcriptase inhibitors. The ratios of physicians to patients dropped substantially as sites matured. Antiretroviral therapy patients were commonly seen monthly or quarterly for clinical and laboratory monitoring, with CD4 counts being taken at 6-month intervals. One-third of sites provided viral load testing. Cotrimoxazole prophylaxis was the most prevalent supportive service. HIV treatment sites scaled up rapidly with the influx of resources and technical support through PEPFAR, providing complex health services to progressively expanding patient cohorts. Human resources are stretched thin, and delivery models and intervention mix differ widely between sites. Ongoing research is needed to identify best-practice service delivery models.

Implementation Science for the US President's Emergency Plan for AIDS Relief (PEPFAR)

Working with implementing organizations and governments in over 32 countries, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has contributed to the rapid acceleration of HIV treatment access, availability of care and support services, and HIV prevention interventions. In the first phase of PEPFAR, these activities were appropriately carried out in an emergency fashion with the goal of using available interventions to reduce mortality and alleviate suffering from HIV disease as quickly and effectively as possible. Many lessons have been learned through examination of programs, including simple evaluations and operations research. Commensurate with the emergency response, however, state-of-the-art monitoring, evaluation, and research methodologies were not fully integrated or systematically performed. In the second phase of PEPFAR, characterized by an increased emphasis on sustainability, programs must demonstrate value and impact to be prioritized within complex and resource-constrained environments. In this context, there is a greater demand to causally attribute outcomes to programs. Better attribution can be used to inform midcourse corrections in the scale-up of new interventions (eg, male circumcision) or to reevaluate investments in programs for which impact is less clear. To meet these demands, PEPFAR is adopting an implementation science (IS) framework to improve the development and effectiveness of its programs at all levels. IS is the study of methods to improve the uptake, implementation, and translation of research findings into routine and common practices (the ‘‘know-do’’ or ‘‘evidence to program’’ gap). For example, IS was used to evaluate the routine operational effectiveness of the South African National Prevention of Mother-to-Child Transmission Programme. Investigators explored the survival of HIV-free infants across program sites and identified specific sources of variation such as health system factors (eg, limited antenatal visits and lack of syphilis screening) and individual behaviors (eg, breastfeeding practices). By framing the problem through IS, the study revealed opportunities for improving program performance that could be translated into immediate solutions (eg, improving quality of care, infant feeding counseling). In this way, IS proved to be a valuable tool that was used not only to improve program effectiveness, but also to explain what worked, why, and under what circumstances. Although no less rigorous than biomedical research dictated by a static protocol with robust internal validity (ie, ‘‘proof-of-concept’’ research with a precisely defined and narrow objective), an IS approach represents a paradigmatic shift in emphasis to greater external validity. The IS scope is also broader, seeking to improve program effectiveness and optimize efficiency, including the effective transfer of interventions from one setting to another. The methods of IS facilitate making evidence-based choices between competing or combined interventions and improving the delivery of effective and costeffective programs.

Laboratory Systems and Services Are Critical in Global Health

The $63 billion comprehensive global health initiative (GHI) emphasizes health systems strengthening (HSS) to tackle challenges, including child and maternal health, HIV/AIDS, family planning, and neglected tropical diseases. GHI and other initiatives are critical to fighting emerging and reemerging diseases in resource-poor countries. HSS is also an increasing focus of the $49 billion program of the US President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Laboratory systems and services are often neglected in resource-poor settings, but the funding offers an opportunity to end the neglect. To sustainably strengthen national laboratory systems in resource-poor countries, the following approaches are needed: (1) developing integrative national laboratory strategic plans and policies and building systems to address multiple diseases; (2) establishing public-private partnerships; (3) ensuring effective leadership, commitment, and coordination by host governments of efforts of donors and partners; (4) establishing and/or strengthening centers of excellence and field epidemiology and laboratory training programs to meet short- and medium-term training and retention goals; and (5) establishing affordable, scalable, and effective laboratory accreditation schemes to ensure quality of laboratory tests and bridge the gap between clinicians and laboratory experts on the use of test results.

Use of Generic Antiretroviral Agents and Cost Savings in PEPFAR Treatment Programs

One of the biggest hurdles to the rapid scale-up of antiretroviral therapy in the developing world was the price of antiretroviral drugs (ARVs). Modification of an existing US Food and Drug Administration (FDA) process to expedite review and approval of generic ARVs quickly resulted in a large number of FDA-tentatively approved ARVs available for use by the US President's Emergency Plan for AIDS Relief (PEPFAR). To evaluate the uptake of generic ARVs among PEPFAR-supported programs in Guyana, Haiti, Vietnam, and 13 countries in Africa, and changes over time in ARV use and costs. An annual survey from 2005 to 2008 of ARVs purchased in 16 countries by PEPFAR implementing and procurement partners (organizations using PEPFAR funding to purchase ARVs). Drug expenditures, ARV types and volumes (assessed per pack, a 1-month supply), proportion of generic procurement across years and countries, and cost savings from generic procurement. ARV expenditures increased from $116.8 million (2005) to $202.2 million (2008); and procurement increased from 6.2 million to 22.1 million monthly packs. The proportion spent on generic ARVs increased from 9.17% (95% confidence interval [CI], 9.17%-9.18%) in 2005 to 76.41% (95% CI, 76.41%-76.42%) in 2008 (P < .001), and the proportion of generic packs procured increased from 14.8% (95% CI, 14.79%-14.84%) in 2005 to 89.33% (95% CI, 89.32%-89.34%) in 2008 (P < .001). In 2008, there were 8 PEPFAR programs that procured at least 90.0% of ARV packs in generic form; South Africa had the lowest generic procurement (24.7%; 95% CI, 24.6%-24.8%). Procurement of generic fixed-dose combinations increased from 33.3% (95% CI, 33.24%-33.43%) in 2005 to 42.73% (95% CI, 42.71%-42.75%) in 2008. Estimated yearly savings generated through generic ARV use were $8,108,444 in 2005, $24,940,014 in 2006, $75,645,816 in 2007, and $214,648,982 in 2008, a total estimated savings of $323,343,256. Among PEPFAR-supported programs in 16 countries, availability of generic ARVs was associated with increased ARV procurement and substantial estimated cost savings.

Role of the US President's Emergency Plan for AIDS Relief in Responding to Tuberculosis and HIV Coinfection

The intersection of tuberculosis (TB) and human immunodeficiency virus (HIV) infection has eroded gains made in TB control, because previously well-functioning national TB programs have been overwhelmed by the dual challenges posed by TB and HIV coinfection. The US President's Emergency Plan for AIDS Relief (PEPFAR), through its direct support of >2.4 million persons receiving HIV treatment and, in 2009, support of >308,000 HIV-infected persons receiving TB treatment, works closely with national governments and other partners to strengthen the response to TB and HIV coinfection. PEPFAR-supported activities fall within the World Health Organization's 2004 framework for collaborative TB and HIV activities, including critical interventions to (1) develop organizational methods of collaboration across the 2 programs, (2) reduce the burden of HIV infection among patients with TB, and (3) reduce the burden of TB among persons with HIV infection or AIDS. To date, PEPFAR and partners have made important gains in coverage and scope of HIV testing, referral, and antiretroviral therapy for patients with TB. TB screening of HIV-infected patients is also beginning to increase, although greater progress needs to be made in increasing access to isoniazid preventive therapy and strengthening TB infection control. Continued strategic integration of TB and HIV interventions into PEPFAR-supported programs is essential to easing the patient burden of dual infection, improving patient outcomes, and, ultimately, decreasing rates of TB in areas with a high prevalence of TB.

A tale of two-component generalised HIV epidemics

The 5-year strategy from the US President's Emergency Plan for AIDS Relief, released in December, 2009, proposed a laudable goal: the prevention of 12 million HIV infections.1 But success will require resolving a deep gulf dividing the prevention community. One camp sees that multiple sexual partnerships drive infection in generalised epidemics in eastern and southern Africa, dispersed through the broad population.2 The other emphasises the large number of already infected individuals, particularly the many existing discordant couples, and stresses widespread HIV testing.

Learning and doing: operational research and access to HIV treatment in Africa

Learning and doing: operational research and access to HIV treatment in Africa

Is there an association between PEPFAR funding and improvement in national health indicators in Africa? A retrospective study

BackgroundThe US President's Emergency Plan for AIDS Relief (PEPFAR) was reauthorized in June 2008 with a three-fold increase in funds, and a broader, more explicit mandate to improve health in the low- and middle-income countries that it funded. However, the ability of a disease-specific, or vertical, programme to have a spill-over effect and improve health outcomes has been questioned. In this study, we sought to examine associations between being designated as a PEPFAR focus country (and receiving increased PEPFAR funding) and non-HIV-specific health outcomes in the World Health Organization (WHO) Africa Region, the area most affected by the HIV/AIDS epidemic.MethodsA retrospective analysis of publicly available health outcomes data published by the World Health Organization was performed for all countries in the WHO Africa Region. Fractional changes in health indicators between 2000 and 2006 were calculated, and PEPFAR focus and non-focus countries were then compared.ResultsOverall, countries in the WHO Africa Region showed a small worsening in health outcomes status when all indicators were analyzed together and weighted equally. However, more health indicators improved than worsened over this six-year period. A comparison of PEPFAR focus and non-focus countries found no significant difference in the fractional change among 13 of 14 health indicators during the study period.ConclusionsThis study suggests that vertical programmes, even one that is the scale of PEPFAR, may have little or no impact on health outcomes not explicitly targeted.

From project aid to sustainable HIV services: a case study from Zambia

IntroductionSustainable service delivery is a major challenge in the HIV response that is often not adequately addressed in project implementation. Sustainable strategies must be built into project design and implementation to enable HIV efforts to continue long after donor-supported projects are completed.Case descriptionThis paper presents the experiences in operational sustainability of Family Health International's Zambia Prevention, Care and Treatment Partnership in Zambia, which is supported by the US President's Emergency Plan for AIDS Relief through United States Agency for International Development (October 2004 to September 2009). The partnership worked with Zambia's Ministry of Health to scale up HIV clinical services in five of the country's nine provinces, reaching 35 districts and 219 facilities. It provided technical and financial support from within the ministry's systems and structures. By completion of the project, 10 of the 35 districts had graduated beyond receiving ongoing technical support.Discussion and evaluationBy working within the ministry's policies, structures and systems, the partnership was able to increase the ministry's capacity to add a comprehensive HIV service delivery component to its health services. Ministry structures were improved through renovations of health facilities, training of healthcare workers, procurement of essential equipment, and establishment of a quality assurance plan to ensure continued quality of care. The quality assurance tools were implemented by both the ministry and project staff as the foundation for technical graduation. Facilities that met all the quality criteria for more than six months were graduated from project technical support, as were districts where most supported facilities met the criteria. The district health offices then provided ongoing supervision of services. This predetermined "graduation" exit strategy, with buy in of the provincial and district health offices, set the stage for continued delivery of high-quality HIV services.ConclusionsAchieving operational sustainability in a resource-limited setting is feasible. Developing and institutionalizing a quality assurance/quality improvement system is the basis on which facilities and districts can move beyond project support and, therefore, sustain services. Quality assurance/quality improvement tools should be based on national standards, and project implementation should use and improve existing health system structures.