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News/Event Item
PEPFAR Reauthorization Recommendations from Global AIDS Experts
Sept. 26, 2007
The President’s Emergency Plan for AIDS Relief (PEPFAR) is a five-year, $15 billion, comprehensive approach for combating HIV/AIDS. The program, and the legislation that supported it, will expire in 2008. To prepare for the reauthorization process, a working group of Council member organizations with expertise in implementing global AIDS programs and the Global AIDS Roundtable (GAR) have developed recommendations for Congress. Both groups are convened at the Global Health Council. The GAR is an independent coalition and its recommendations do not necessarily reflect the opinion of the Council.
Council Member Recommendations for Improving the Implementation of PEPFAR Programs and Services
To assure the continuation of PEPFAR and strengthen the U.S. government response to the pandemic, the Global Health Council convenes a group of its members with expertise in implementing HIV programs to offer input and suggestions to policymakers. Under the Council’s leadership, representatives of its member organizations developed the following set of recommendations.
1. HIV/AIDS Prevention Efforts Must be Scaled Up
Council members endorse the Administration's proposal to increase the number of people reached by HIV/AIDS prevention programs from 7 million to 12 million. Members support developing prevention strategies tailored to the needs of specific types of epidemics and populations that are designed at the country level and based on evidence of most effective interventions. In order to provide prevention programs to significantly more people, members recommend eliminating the prostitution pledge and modifying the guidance on harm reduction, which currently only covers prevention interventions among HIV-positive injecting drug users.
2. More flexibility is needed in PEPFAR’s budgetary allocations
Members support modifying budgetary allocations to allow for country-specific and epidemic-specific programming.
3. Increase Ability to Use PEPFAR Resources Between Program Areas and Between HIV and non-HIV Health Services
Create the policy and budgetary environment to support more wrap-around services or linkages between HIV and non-HIV services. This includes allowing the flexibility to use funds for integrated programming such as child immunizations in a PEPFAR pediatric treatment site.
4. Expand Treatment and Care Programs and Improve Quality of Treatment Programs
Members support expanding access to antiretroviral therapy through public-private partnerships; expanding technical support and resources to increase access to palliative care; increasing access for infants and children for diagnosis and care and treatment services; improving patient follow-up practices; and recognizing the World Health Organization (WHO) prequalification process for availability of drugs.
5. Train Additional Health Care Workers and Strengthen Health Systems
Members support using PEPFAR resources to increase the number of health-care workers in HIV-affected communities and to contribute to, not draw down from, the total number of health-care workers. Members recommend training more workers particularly in providing palliative care, pediatric treatment and diagnosis, and other sets of services for HIV patients. Members also support using PEPFAR resources to strengthen health systems in HIV-affected communities.
6. Improve and Expand Operations Research
PEPFAR is a learning organization and as such it should modify and improve its current monitoring and evaluation process and devote more resources to operations research. Members recommend that PEPFAR communicate more with implementing agencies to share best practices and lessons learned in order to better inform policy and budgetary decisions in the future.
For more information on these recommendations, please contact Smita Baruah, senior policy associate, at the Global Health Council (sbaruah@globalhealth.org, 202-833-5900, x3245). The Global Health Council is the world’s largest membership alliance dedicated to saving lives by improving health throughout the world. The Council serves and represents thousands of public health professionals from over 100 countries.
Summary of the Global AIDS Roundtable Recommendations for Improving PEPFAR
Working groups of the Global AIDS Roundtable (GAR), a coalition of HIV/AIDS policy advocates, proposes the following recommendations for Congress to consider during the reauthorization process. The GAR focuses on all aspects of the response to the AIDS pandemic and has formed groups to specifically address the areas of prevention, gender and treatment.
1. Increase Resource and Programmatic Coordination between PEPFAR-supported HIV Prevention, Treatment and Care (PTC) Services and Other Health and Development Services
To effectively address poor health and development conditions in HIV affected communities, PEPFAR programming must be coordinated to provide health and development services. HIV PTC services should include elements such as nutritional needs, ante-natal care, basic education, water and sanitation treatment, and socioeconomic efforts to address vulnerable populations.
2. Strengthen Flexibility in Policies and Programming at the Country Level
PEPFAR should remove its one-size-fits-all budget allocation per country and provide more flexibility to allow countries to meet their individual needs based on their epidemiological data. It should provide direct support for treating at least 33 percent of the people in clinical need worldwide and also set vulnerable population treatment and prevention targets in each focus country.
3. Increase Consultation with Civil Society Organizations in Planning, Policy Development and Implementation, Including Reviewing Final Country Operational Plans
A wide variety of civil society organizations should be consulted when determining how PEPFAR resources are allocated, including those most impacted by the disease. Strengthening the voice of women and girls in national AIDS policy and the agencies that serve them should be part of this effort. Investing in women’s organizations and improving the capacity of these groups to work with international bodies that focus on this issue will help achieve this.
4. Establish Clear Guidance on Country Selection
Additional countries should be chosen as PEPFAR focus countries based on epidemiological studies that look at their rates of prevalence and acceleration. An exit plan should be determined at the time of country selection with allowances to provide for unforeseen circumstances. “Graduation” of focus countries and increasing U.S. investments in multilateral programs should not alter overall U.S. bilateral contributions. Investments should also be made in non-focus countries to effectively stem the spread of HIV/AIDS.
5. Authorize Funding for Critical HIV-related Issues
Funding targets should be set for critical elements that are currently being overlooked. Areas needing funding include: securing health workforces, support for orphans and vulnerable children, nutrition and HIV, pediatric HIV treatment, addressing TB/HIV co-infection, and U.S. support for the Global Fund to Fight AIDS, TB and Malaria.
6. Monitoring and Evaluation Must be Strengthened
A more robust set of program indicators are needed in areas including orphans and vulnerable children, pediatric treatment, impact of programs on women and girls, and human resource capacity. The Office of the Global AIDS Coordinator (OGAC) should be audited independently on a regular basis with transparent benchmarks set for achieving its treatment targets. Focus countries should assess the health system obstacles for scaling up services in HIV, TB and malaria and invest in overcoming these obstacles in a systemwide manner, paying attention to meeting appropriate health workforce density ratios.
7. More Operations Research Needed
PEPFAR or the U.S. Agency for International Development (USAID) should be allowed to use funds to improve the quality and performance of programs by researching issues such as establishing “best practice” models; methods for improving anti-retroviral therapy (ART) adherence; the cost-effectiveness of specific strategies; and the best means for meeting the HIV/AIDS-related needs of adolescent girls and young women.
8. Increase Flexibility in Providing Prevention Services
The abstinence-until-marriage earmark and the prostitution pledge should be withdrawn. A comprehensive prevention approach should be established that includes components of abstinence, faithfulness and condoms as well as prevention efforts for populations at risk because of poverty, conflict, drug use, unsafe medical treatment, and concentrated epidemics. Attention also should be given to prevent mother-to-child transmission through providing these services for pregnant women and providing HIV counseling to all women.
9. Gender Issues Should be More Explicitly Addressed
Women and girls should receive priority in OGAC Operational Policy because gender inequality is a driver of the AIDS epidemic. Requirements should be established for addressing gender across all HIV/AIDS programs. Recipient countries should be encouraged to improve the overall social, economic, education and legal status of women and girls and be issued guidance on how to address their unique needs in all HIV program phases. Linkages between sexual and reproductive health services and HIV/AIDS PTC programs also should be strengthened.
10. Treatment Programs Should be Strengthened
The original PEPFAR legislation should continue and be strengthened. In addition, the United States should: provide financing and support for at least 33 percent of the people in clinical need of treatment worldwide, work with stakeholders to ensure universal access in future focus countries, support ARV therapy for all vulnerable populations, and increase access to pediatric treatment. The costly FDA approval process for medicines should be eliminated and replaced with an internationally accepted program. PEPFAR commodities should be purchased at the lowest available prices through transparent competitive bids.
11. Address Health Systems Capacity and Health Workforce
Country Operational Plans should forecast health workforce gaps and include strategies to address them. OGAC should work with focus country governments to establish minimum health workforce density targets and cover the impact of its own programs. Community health workers should be trained and deployed to the level of 250,000 in focus countries to provide primary care services. Technical assistance is needed to build supply chain capacity in each focus country.
The GAR is convened by the Global Health Council at its offices in Washington, D.C., monthly. For more information, or to receive the full GAR recommendations paper, contact Smita Baruah at the Global Health Council.
Key Contacts for GAR Recommendations:
Prevention: Jodi Jacobson, jjacobson@ajws.org;
Treatment: Paul Davis, pdavis@healthgap.org
Gender: Kathy Selvaggio, kselvaggio@icrw.org.
All else: Smita Baruah, sbaruah@globalhealth.org
category: Global Health Council News : General Health News
contributed by Winnie Mutch on 26 September 2007
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