Health GAP Global Access Project

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PEPFAR Promises, Pitfalls and the Need for Change
Health GAP (Global Access Project) XVI
International AIDS Conference
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PEPFAR Basics

• TREATMENT, CARE AND PREVENTION GOALS
• Provide anti-retroviral therapy to 2 million
  individuals
• Provide care to 10 million people infected and
  affected by HIV/AIDS, including orphans and
  vulnerable children through 2008
• Avert 7 million infections by 2010
• PEPFAR FUNDING
• 55 for treatment programs (or which 75 for
  ARVs)
• 20 for prevention (50 for sexual prevention
  two-thirds for AB programs)
• FOCUS COUNTRIES
• Botswana, Ivory Coast, Ethiopia, Kenya,
  Mozambique, Namibia, Nigeria, Rwanda, South
  Africa, Tanzania, Uganda and Zambia, Guyana,
  Haiti, Vietnam

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Political and policy challenges

• Prevention and ideology
• Sexual prevention
• Drug using populations
• Prostitution loyalty oath
• Sustainability and scale up responding to the
  health care workforce crisis
• Sustainability and scale up SCMS
• PEPFARs governance
• Transparency
• Meaningful involvement of people living with
  HIV/AIDS
• New Partner Initiative quality assurance and ME

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Political and policy challenges Sexual
prevention

• The GAO found 10 of the 15 focus country teams
  cited instances where elements of the guidance
  were ambiguous and confusing, leading to
  difficulties in its interpretation and
  implementation.
• About half of the focus country teams interviewed
  reported that the spending requirement can
  undermine the integration of prevention programs
  by forcing them to isolate funding for AB
  activities.

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Political and policy challenges Sexual
prevention

• Although some country teams value the ABC model
  and emphasize AB messages for certain
  populations, others reported that the spending
  requirement can limit their efforts to design
  prevention programs that are integrated and
  responsive to local prevention needs. Seventeen
  of 20 country teams reported that fulfilling the
  spending requirement, including OGACs policies
  implementing it, presents challenges to their
  ability to respond to local prevention needs.
• OGACs principle prevention programs should be
  responsive to the needs of local populations.

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Political and policy challenges Sexual
prevention

• Interventions in the ABC prevention model are
  elements of a comprehensive, evidence-based
  response
• Disaggregated deployment of ABC through the AB
  earmark defies evidence, human rights and common
  sense
• Evidence from some countries distorting medical
  information, increasing stigma of people living
  with HIV, assigning mirage of protection to
  marriage

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Political and policy challenges Drug Users

• PEPFAR requires HIV testing before IDUs attain
  substitution tx may encourage implementers to
  limit to HIV positive IDUs only (J. Auerbach et
  al, April 2006)
• PEPFAR pilots substitution tx for HIV negative
  IDUs in Vietnam
• Persistent negative impact of federal funding ban
  on needle exchange

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Political and policy challenges Prostitution
Loyalty Oath

• PEPFAR requires foreign and U.S. organizations to
  state their opposition to prostitution
• Resulted in cancellation of important prevention
  grants
• U.S. requirement ruled unconstitutional still in
  force

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Political and policy challenges Health workforce

• Health workforce crisis in focus countries

WHO World Health Report 2006
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Political and policy challenges Health workforce

• Ad hoc trainings insufficient to increase
  capacity
• PEPFAR must invest extensively efforts to rapidly
  increase the number and diversity of health care
  workers
• At least 650 million in 2007, increasing over
  time to billions of dollars
• Policy changes required so USG and other donors
  can invest in recurrent costs
• Must focus on increasing the capacity of the
  public sector

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Political and policy challenges Health
workforce

• PEPFAR has the potential to make a difference.
  But to guarantee sustainable programmes and to
  break the yoke of dependence and build national
  dignity, support should ensure full participation
  and capacity building of the local partners and
  the existing health infrastructures. While PEPFAR
  rightly focuses on getting treatment to the
  patients as soon as possible, its vertical
  one-donor approach may collapse the very system
  it needs to strengthen.
• (EPN newsletter)

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Political and policy challenges

• GAO interviewed 28 field staff from the U.S.
  Agency for International Development (USAID) and
  the Department of Health and Human Services
  (HHS), who most frequently cited the following
  five challenges to implementing and expanding ARV
  treatment in resource-poor settings
• coordination difficulties among both U.S. and
  non-U.S. entities
• U.S. government policy constraints
• shortages of qualified host country health
  workers
• host government constraints and
• weak infrastructure, including data collection
  and reporting systems and drug supply systems.
• These challenges were also highlighted by
  numerous experts GAO interviewed and in documents
  GAO reviewed.

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Political and policy challenges Supply Chain
Management System

• Procurement systems in focus countries are
  fragile, weak, and a major barrier to scaling up
  programs
• SCMS launched after three years mandatory
  program turned voluntary
• Concerns
• Destabilization of existing systems
• Tension between SCMS objectives
• Overhead
• Procurement restrictions

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Political and policy challenges Transparency
and Governance

• Country Operating Plans are currently secret
• Global Funds standard of transparency should be
  matched
• New Partners Initiative 200 million for
  organizations will little or no experience
  working with the USG
• Meaningful involvement of PWAs
• PEPFAR programs at country level should actively
  and regularly engage PWAs and their networks in
  consultations to assure accountability and
  relevance of USG supported activities.
• OGAC should issue guidelines outlining minimum
  standards for meaningful involvement of people
  living with HIV and AIDS in PEPFAR program
  planning, implementation and oversight art the
  country level. (L. Francis, June 2006)

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RecommendationsPEPFAR II

• Repeal the AB earmark
• Lift the ban on needle exchange funding
  rationalize guidance on drug users
• Repeal the prostitution loyalty oath
• Monitor PEPFARs involvement with PWAs and the
  quality of all PEPFAR programming, in particular
  the NPI

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RecommendationsPEPFAR II

• Invest 650 million and billions in the coming
  years to dramatically increase the number of
  health care workers
• Cover the costs of PEPFARs impacts on the health
  system
• Rapidly diversify the cadres of health care
  workers paid, supported and trained to do HIV
  care, prevention and treatment
• In particular paid community health workers,
  especially women and people living with HIV

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• It seems that the goal to get 190,000 people
  in treatment by the end of this year will be
  reached. This is very encouraging! But this
  success is possible only because this is a strong
  vertical program. The decisions are being made in
  the US and a very detailed system, managed by
  mainly US organizations, has been introduced
  resulting in minimal bureaucracy at country
  level. This practical and result-oriented way of
  working has allowed for a very quick
  identification of hospitals and an immediate
  supply of the needed drugs. A number of EPN
  members are involved in the system and more are
  likely to join. But what are the pitfalls of this
  system? (EPN Newsletter)

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thank you asia_at_healthgap.org