PEPFAR-3.0-–-Controlling-the-Epidemic-Delivering-on-the-Promise-of-an-AIDS-free-Generation.pdf

Controlling the epidemiC:

delivering on the promise of an aids-free generation pepfar 3.0

Cover Photo Credit: Elizabeth Glaser Pediatric AIDS Foundation

Controlling the epidemiC:

delivering on the promise of an aids-free generation

6 Introduction

9 Impact Action Agenda

14 Efficiency Action Agenda

17 Sustainability Action Agenda

20 Partnership Action Agenda

24 Human Rights Action Agenda

28 PEPFAR 3.0

29 Glossary

Photo Credit: Elizabeth Glaser Pediatric AIDS Foundation

Contents 6 Introduction

9 Impact Action Agenda

14 Efficiency Action Agenda

17 Sustainability Action Agenda

20 Partnership Action Agenda

24 Human Rights Action Agenda

28 PEPFAR 3.0

29 Glossary eleven years ago when the U.s. president’s emergency plan for aids relief (pepfar) was announced by president george W. Bush, and passed with a bipartisan majority in Congress, few thought this massive undertaking would be such a remarkable success.

When PEPFAR was launched in 2003, the word “emergency” in its name actually understated the problem. The world was facing a crisis, particularly in Africa where people were dying by the thousands because the antiretroviral therapy (ART) that was being used in the United States (U.S.) was not available in Africa. At the time, it was estimated that nearly one-third of the population of some sub-Saharan countries were infected with the virus and, over 20 million mothers, fathers, teachers, doctors, nurses and children had died in sub-Saharan Africa. AIDS had already wiped out an entire generation, producing 14 million orphans and vulnerable children. Moreover, much of Africa did not have the infrastructure to prevent, treat and care for people even if ART was available.

But in five short years, the U.S., with tremendous help from countless organizations, governments and individuals, transformed the impossible to the possible. Prevention and treatment became the rallying cry. Hospitals and clinics were built or renovated, doctors and nurses were trained and people were urged to get and stay on treatment. Men and women were given condoms and programs were launched to encourage their use. Pregnant women were educated about preventing HIV transmission to their unborn children by actively receiving treatment. Babies were born HIV-free and children who were infected were treated.

Increasingly, countries were driving their own programs and governments were able to carry out their HIV strategies, which had been developed but lacked the resources for implementation. Prevention, treatment and care became a shared responsibility between the country and its partners, including the U.S. and other donor nations, civil society, faith-based organizations, the private sector, foundations, multilateral organizations and people living with HIV/AIDS.

While Phase I of PEPFAR focused on building an Emergency Response, Phase II, continued under the Obama Administration, emphasized Sustainability. PEPFAR established Partnership Frameworks—joint strategic roadmaps developed, agreed to and signed by the U.S. and partner governments, promoting mutual accountability and sustainability. PEPFAR signed 22 Partnership Frameworks from 2009 through 2012, launching a new era of collaborative planning and health systems strengthening activities with our partner governments.

An emphasis was also placed on increasing the impact of PEPFAR’s investments by scaling up access to ART, preventing mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) for impact.

This led to the landmark announcement in June 2013 by Secretary of State John Kerry that one million babies had been born HIV-free thanks to PEPFAR support.

Now, PEPFAR is heading into what may be its most challenging, but exciting, phase yet—Phase III focusing on Sustainable Control of the Epidemic. To reach the Joint United Nations Programme on HIV/AIDS’ (UNAIDS) ambitious 90-90-90 global goals: 90 percent of people with HIV diagnosed, 90 percent of them on ART and 90 percent of them virally suppressed by 2020—we have to shift the way we do business. We can best control the introduction epidemic by pivoting to a data-driven approach that strategically targets geographic areas and populations where we can achieve the most impact for our investments. As stated in the 2012 PEPFAR Blueprint for Creating an AIDS-free Generation, we need to go where the virus is—targeting evidence-based interventions for populations at greatest risk in areas of greatest HIV incidence.1

As we have done since the creation of the program, we will work to leave no population at greatest risk behind.

Children, adolescents, young women and other key populations, such as men who have sex with men, people who inject drugs, and sex workers will remain a priority. We will accelerate efforts to prevent HIV infections and ensure treatment among those who need it most. Our work will be data-driven from the national level down to the most granular site level to best guide programmatic decision-making and solidify sustainability and quality. Access to viral load testing will be essential so everyone can ensure they have effective treatment. Transparency with data will allow for mutual accountability and innovation, so that PEPFAR investments can have the greatest impact, as quickly as possible, to ensure each dollar is spent effectively.

Partnerships will also continue to be of great importance in ultimately achieving an AIDS-free generation. As President Obama, Secretary Kerry and former Secretary Clinton have made clear, we cannot do this alone. We need partnerships with organizations, other donor nations, civil society and multilateral institutions, and we need on-the-ground partners and governments who are vital to controlling the epidemic in their countries. Greater, deeper, and broader engagement of those most impacted by this epidemic will be launched and monitored.

In just eleven years, PEPFAR has moved from an emergency program to one squarely focused on controlling the epidemic. The remainder of this report presents PEPFAR’s plan to control the epidemic based on five action agendas:

› Impact Action Agenda

› Efficiency Action Agenda

› Sustainability Action Agenda

› Partnership Action Agenda

› Human Rights Action Agenda

It is our plan for America to continue to play a leadership role in ending this devastating pandemic. And it is our plan to help achieve an AIDS-free generation. Compassion and impact demands that all people have access to services that allow them to survive, thrive and fulfill their dreams.

1 The Office of the U.S. Global AIDS Coordinator. (2012). PEPFAR Blueprint: Creating an AIDS-free Generation. Washington, DC.

Photo Credit: Anna Gieselman

Globally there are 40,385 new HIV infections weekly. Over 4,600 babies and 7,000 young women are infected each week.

as is true with any program whose mission is as large as pepfar’s, there are shifts in the way business is done to reflect the reality of the times, and with pepfar, the situations on the ground. pepfar 3.0 reflects the need to undergo a realignment of geographic and programmatic focus and reinvestment in high hiv prevalence areas and populations to more efficiently and effectively reduce transmission and incidence.

our five action agendas—impact, efficiency, sustainability, partnership, and human rights—will direct our work and catalyze the goal of controlling the epidemic and achieving an aids-free generation. These five agendas will also advance the following principles outlined in the PEPFAR Blueprint:

› make strategic, scientifically sound investments to rapidly scale-up core hiv prevention, treatment and care interventions and maximize impact: impaCt and sUstainaBilitY agendas

› Work with partner countries, donor nations, civil society, people living with hiv, faith-based organizations, the private sector, foundations and multilateral institutions to effectively mobilize, coordinate, and efficiently utilize resources to expand high-impact strategies, saving more lives sooner:

partnership agenda

› set benchmarks for outcomes and programmatic efficiencies through regularly assessed planning and reporting processes to ensure goals are being met:

effiCienCY agenda

› focus on women and girls to increase gender equality in hiv services. end stigma and discrimination against people living with hiv and key populations improving their access to, and uptake of, comprehensive hiv services: hUman rights agenda

Epidemic Control:

The point at which new HIV infections have decreased and fall below the number of AIDS-related deaths

PEPFAR 3.0

ContRolling thE EPidEmiC:

dElivERing on thE PRomisE oF An Aids-free gEnERAtion

Photo Credit: UNICEF impact action agenda

PEPFAR’s Impact Action Agenda focuses resources and leverages finances to address the most vulnerable populations. It is driven by the need to do the right things in the right places at the right time.

The Right Things Doing the right things means improving our site monitoring, strengthening our program quality, and scaling-up our core interventions—ART, PMTCT, VMMC and condoms. Scaling-up the core interventions for maximum impact on the epidemic, with substantial declines in HIV incidence, is the only way to reach a truly sustainable response and the final pathway to ending AIDS one country at a time.

The right things also means targeting children, adolescent girls and key populations to increase their access to these core interventions, strengthen children’s resilience, and decrease gender-based violence, discrimination and other barriers to HIV prevention, treatment and care.

Great progress is being made in preventing mother-to-child transmission of HIV. The number of babies born with HIV has been cut in half each year since the launch of PEPFAR. Still, in 2013, one new pediatric HIV infection occurred approximately every two minutes.

Overall, in 2013, 3.2 million children under 15 years of age were living with HIV/AIDS.2

According to UNAIDS, the rate of new HIV infections among girls continues to be disproportionately high, year after year, as compared to their male counterparts.3 In 2013, among the hardest-hit countries in sub- Saharan Africa, nearly 80 percent of all new infections among adolescents occurred among girls.4

PEPFAR is working with U.S. government implementing agencies, partner countries, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other multilateral institutions, including UNAIDS and all its co-sponsors, the World Health Organization (WHO), and civil society to address gender-based violence and HIV prevention for adolescent girls in a comprehensive manner. This means bringing together many relevant approaches from multiple sectors—education, health, community, economic and psychosocial—to establish a core package of evidence-based interventions.

To achieve an AIDS-free generation, strengthening the resilience of orphans and vulnerable children— especially adolescent girls—their families, and communities is a core priority for action.

Overcoming the barriers that prevent key populations from receiving treatment and care is more than a challenge, it is a necessity. In many settings, key populations are at higher risk for acquiring HIV, but are often the least likely to obtain HIV services. Now more than ever, people who inject drugs, sex workers, and men who have sex with men face stigma and discrimination. Human rights among lesbian, gay, bisexual and transgender (LGBT) people in certain parts of the world are increasingly under threat, creating additional barriers to key populations accessing services. If any one of our populations is left behind, we are all left behind and we will not control the epidemic.

Addressing Tuberculosis (TB)/HIV co-infection is also an essential aspect of effective control of the HIV epidemic. In 2013, there were 370,000 deaths from HIV-associated TB, equivalent to 25 percent of all TB deaths last year and 25 percent of the estimated

1.5 million deaths from HIV/AIDS.5 Ending HIV-associated TB among people living with HIV (PLHIV) is possible through high impact interventions such as intensified scale-up of TB prevention, diagnosis and treatment interventions and initiation of ART among TB patients. WHO reports, that in 2013, the global

2 UNAIDS. (2014, September). The Gap Report. Geneva, Switzerland: Author.

3 UNAIDS. (2014, September). The Gap Report. Geneva, Switzerland: Author.

4 United Nations Children’s Fund. (2013). UNICEF Analysis of UNAIDS 2012 HIV and AIDS Estimates. New York, NY: Author.

5 World Health Organization. (2014). Global Tuberculosis Report 2014. Geneva, Switzerland: Author.

6 World Health Organization. (2014). Global Tuberculosis Report 2014. Geneva, Switzerland: Author.

coverage of ART for HIV-positive TB patients rose to 70 percent.6 This is encouraging, but represents only a third of the estimated number of PLHIV who developed TB in 2013. PEPFAR is working to stop TB/ HIV co-infection through expansion of collaborative TB/HIV activities, including closing the unacceptable coverage gaps in ART for PLHIV diagnosed with TB.

The Right Places The right places mean we will focus our efforts on pinpointing the geographic areas at sub-national levels with the highest disease burden in every country.

To maximize resources and reach epidemic control, we should be focusing on geographic areas with the greatest need for treatment and prevention. Simply put, we must become even more efficient and strategic with our efforts to achieve the greatest impact, save the most lives, prevent the most infections and change the course of the epidemic.

As UNAIDS states in a recent report: “the AIDS epidemic is about locations and populations.”7 While global and regional data are important to provide an overview of the epidemic, they do not provide the in-depth picture that is needed to truly address the epidemic. There is national, sub-national and local diversity of the AIDS epidemic. And within the epidemic, different populations are affected. “Many countries now focus on local epidemics using the data available from household surveys combined with other epidemiological data to sharpen the focus on delivering high-quality HIV services,” according to the report.

7 UNAIDS. (2014, September). The Gap Report. Geneva, Switzerland: Author.

As part of its efforts to reach children, adolescents and young women to strengthen children’s resiliency, PEPFAR, in partnership with the Children’s Investment Fund Foundation (CIFF) announced during President Obama’s African Leadership Summit in August 2014, the Accelerating Children’s HIV/AIDS Treatment Initiative (ACT). This two-year $200 million effort will double the number of children receiving life-saving ART in 10 sub-Saharan African countries. ACT will enable 300,000 more children living with HIV to receive ART. Moreover, PEPFAR is creating the DREAMS Partnership to improve and save the lives of adolescent girls and young women in the hardest-hit countries by ensuring they are supported to become:

Determined, Resilient, Empowered, AIDS-free, Mentored and Safe.

What does it look like to double the number of children on ART in Accelerating Children’s HIV/AIDS Treatment (ACT) initiative countries?

The Right Time The right time reflects the fact that addressing an expanding HIV epidemic is not financially sustainable.

As a global community, we cannot have this epidemic continue to expand in countries. It is not affordable and never will be. We are outstripping our ability to treat those in need and, tragically, even control the pandemic if we do not focus together in partnership.

Now is the time to scale-up core interventions. Scaling-up these services is affordable and the key to achieving an AIDS-free generation. As seen in the chart below, investments needed to scale-up core interventions do not result in ever-increasing costs. In fact, upfront investments lead to a decline and, then, flattening out of out-year costs as fewer new services are required and the number of newly infected individuals falls substantially. We also need to ensure earlier treatment initiation and expanded eligibility for testing and treating all pregnant and breastfeeding women.

Defining Progress The world will not control the AIDS epidemic overnight.

So, how do we define progress? Global progress is achieving 90-90-90 by 2020. For PEPFAR, short-term progress means efficient and effective control of the HIV/AIDS epidemic in 5 to 10 countries by 2016, ensuring 90-90-90 in all geographic areas with highest HIV prevalence. The focus will be on making sure that those at the greatest risk and those with the greatest need are supported.

Progress will mean achievement of 90-90-90 in long-term strategy countries (Burundi, Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Rwanda, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe) with direct PEPFAR support of prevention, care and treatment services. Supporting achievement of 90- 90-90 in high burden countries through ongoing partnerships and increasing financial collaboration and direct technical assistance to Botswana, Namibia, Nigeria, South Africa, and Vietnam recognizing their direct and ongoing investment of internal resources to save lives and change the course of the HIV/AIDS epidemic in their countries.

Key to the Impact Action Agenda will be expanding measurement to ensure we are progressing in our achievements and demonstrating control of the epidemic. Central to this effort are HIV/AIDS Impact Assessments. The Impact Assessments will provide the epidemiologic and programmatic data that will quantify our progress to date.

Specifically, our Impact Action Agenda aims are:

» Validate model of core intervention impact through country-level HIV Impact Assessments (HIA) (Launch in two countries)

» Ensure maximal programmatic focus on evidence-based interventions in the geographic areas of highest disease burden and need, ensuring maximal lives saved and greatest impact on the epidemic

» Demonstrate clear progress towards the creation of an AIDS-free generation in two countries and analyze critical elements of success

» Demonstrate clear progress towards the creation of an AIDS-free generation in three additional countries and utilize analysis to accelerate additional countries towards success

» Perform HIA in five additional countries allowing the triangulation of programs and impact on HIV incidence and prevalence as well as community-level viral loads

» Use the HIA data to improve program focus across all countries

» Analyze progress towards an AIDS-free generation in all high investment countries using the HIA program data as surrogates for HIV incidence and ensure refocusing in all countries to make certain of success

» Implement HIA in five additional countries

» Demonstrate clear progress towards an AIDS-free generation in four additional countries

» Demonstrate two-year impact of the ACT initiative in sub-Saharan countries—Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Kenya, Lesotho, Malawi, Mozambique, Tanzania, Zambia and Zimbabwe

» Demonstrate two-year impact of the DREAMS Partnership

» Conduct HIA in specific countries identified in 2016 to ensure progress towards AIDS-free generation

» Demonstrate impact of “Global Pediatric Antiretroviral Commitment-to-Action”

» Demonstrate epidemiologic control in a minimum of 50 percent of high burden countries

Photo Credit: PEPFAR Mozambique

The Efficiency Action Agenda’s goal is to increase transparency, oversight and accountability across PEPFAR and its interagency partners to ensure every taxpayer dollar is optimally invested and tracked. In 2014, PEPFAR increased data access in an unprecedented way, making data accessible and actionable for impact.

PEPFAR Dashboards

In July 2014, Ambassador Deborah L. Birx, M.D., U.S. Global AIDS Coordinator, launched the PEPFAR Dashboards on www.PEPFAR.gov. These Dashboards enable all external stakeholders, including researchers, media, civil society organizations, U.S. government agencies, donors, and partner-country governments to view and utilize PEPFAR planned budgets, program results and expenditure analysis data to independently analyze PEPFAR program effectiveness and efficiency and help improve overall accountability.

In addition to making publicly accessible all of the annual PEPFAR Country and Regional Operational Plans since 2003, there are currently three dashboards available:

› planned funding dashboard – consists of interactive maps and graphs that illustrate the planned budget levels approved each year in the PEPFAR Country Operational Plans (COP) and Regional Operation Plans (ROP).

COPs/ROPs are vehicles for documenting U.S.

government annual investments and program activities in HIV/AIDS for each PEPFAR country or region. They are the basis for approval of annual U.S. government bilateral HIV/AIDS funding in most countries.

› program impact dashboard – provides the planned targets and realized achievements described in the annual COPs/ROPs and Annual Program Results for each of the PEPFAR indicators related to core interventions. The interactive charts and maps can be filtered by country, fiscal year and indicator. The goal of this dashboard is to provide the indicator targets and results in a consolidated format that enables users to examine and track PEPFAR achievements in a standard and easy-to-use format.

› expenditure analysis dashboard – shares the results from PEPFAR’s growing expenditure analysis data collection program, which began in nine PEPFAR countries in 2012 and has expanded to all PEPFAR countries in 2014.

Total PEPFAR expenditures can be viewed by country, program area and cost category.

Interagency Collaborative for Program Improvement

The Interagency Collaborative for Program Improvement (ICPI) was announced by Secretary Kerry during PEPFAR’s Annual Meeting in Durban, South Africa in June 2014. The ICPI has brought together staff from PEPFAR’s interagency partners under one roof—including the United States Agency for International Development (USAID), Department of Health and Human Services (HHS) and its agencies, Peace Corps, Department of Defense (DOD) and Millennium Challenge Corporation (MCC)—to analyze data, improve quality of services and save more lives. Specifically, the Interagency Collaborative will improve partner-and site-level quality and results; ensure quality improvement; and use results and expenditure analyses to significantly increase the impact of every PEPFAR dollar. A series of HIV Impact Assessments will begin measuring the impact of programming on HIV prevalence, incidence and viral load at the community-level throughout countries.

efficiency action agenda

2014 Aid Transparency Index Score PEPFAR is dedicated to using quality data—budget data and results data—to focus our resources geographically and programmatically to ensure that we are saving lives and preventing the spread of HIV. Data transparency is key to enable all stakeholders, including the public, civil society, U.S. government agencies, donors, and importantly—countries themselves—to view and utilize PEPFAR planned budgets, program results and expenditure analysis data in an accessible and easy-to-use format.

PEPFAR has significantly expanded posting its data on-line. As a result of this public display of data, PEPFAR was recognized for the biggest improvement (16.1% to 40.7%) in the U.S. by the 2014 International Aid Transparency Initiative (IATI)—a global campaign to create transparency to ensure that aid money reaches its intended recipients.8

Increasing transparency, oversight and mutual accountability will remain a PEPFAR priority as we work to achieve an AIDS-free generation. In 2015, PEPFAR is looking to establish agency accountability metrics and quality improvement services that demonstrate efficiencies. The ambitious goal for 2016 is to demonstrate domestic and global programmatic synergies with clear cost savings.

Our efficiency goals are both technical and allocative.

With respect to technical efficiency, our goal is to continue to increase the coverage and quality of services and support in a budget-constrained environment. We will do this by triangulating more granular data on cost, performance and quality to identify outliers, improve partner management and replicate best practices and most efficient models/service packages. In addition, as we standardize and increase the routine generation and use of cost and performance data with key stakeholders (e.g., partner governments and the Global Fund), we will enhance our understanding of the full cost, full services and cost drivers to achieve targets for epidemic control and where efficiency gains can be realized.

With respect to allocative efficiency, we will strengthen our focus on geographic areas (down to the lowest sub-national unit with available data) and key and priority populations to most efficiently stem HIV transmission and reduce future costs of care and treatment and productivity losses resulting from HIV. We will also increase investment in the mix of core interventions that have been proven to be most effective in preventing HIV transmission.

8 Publish What You Fund. (2014). Aid Transparency Index 2014 - U.S. President’s Emergency Plan for AIDS Relief. Retrieved from http://ati.

publishwhatyoufund.org/donor/uspepfar/

So first, we need to continue to make strategic and creative investments that are based on the latest science and best practices. In a tight budget environment – and everybody faces that – every dollar, yen, and euro counts. And that’s why we need to focus on data, on mutual accountability, transparency for impact, and put our weight behind HIV prevention, treatment, and care interventions that work.

– Secretary of State John Kerry, United Nations General Assembly, September 25, 2014

Photo Credit: USAID

Specifically, our Efficiency Action Agenda aims are:

» Phase in all PEPFAR operating units to routinely collect results-linked expenditure data

» Disseminate standard, analytic tools using Expenditure Analysis (EA) and program performance data to enhance strategic planning and program management

» Institutionalize use of empirical data and resource projections to build data-driven budgets to maximize impact within current budget envelope

» Publish expenditure data on PEPFAR dashboard by supported countries, program area and cost category

» Develop tools and methodologies to link expenditures to site level results

» Phase in central initiative EA

» Increase capacitation of at least five country teams to independently manage the EA collection and use

» Coordinate with two government partners and the Global Fund to track partner country government expenditures linked to results and use data to inform joint strategic planning

» Demonstrate reduction and variance in the U.S. government cost of providing services due to improvements in program management using EA data

» Establish a process for sharing results linked expenditure data and joint planning with the Global Fund and two partner country governments

» Phase in headquarters’ EA

» Establish process and format for routinely sharing PEPFAR expenditures in a standard format with partner country governments in all PEPFAR supported countries

» Provide technical assistance to two partner country governments to develop and institutionalize routine tracking of national HIV expenditures congruent with international standards to improve joint planning.

» Demonstrate reduction in total cost of delivery of proven effective interventions through funded economic studies

» Full harmonization of results-linked expenditure tracking for HIV/ AIDS for all funding sources in five countries to promote efficient and effective joint strategic planning sustainability action agenda

Chart reflects data on 29 PEPFAR countries:

Angola, Botswana, Burundi, Cambodia, Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Dominican Republic, Ethiopia, Ghana, Guyana, Haiti, India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Thailand, Uganda, Vietnam, Zambia, and Zimbabwe.

Our Sustainability Action Agenda is focused squarely on ensuring that when we and partner countries have scaled up interventions and reached epidemic control, the services, systems, financing and policies required to maintain that control are readily available to PEPFAR beneficiaries and countries. Experience has taught us that we cannot wait for epidemic control to be established to start thinking about sustainability. As we see progress across key areas, and identify gaps that threaten hard fought gains, we must focus on the actions necessary to sustain momentum against HIV/ AIDS into the future.

This is the right time to put our focus on sustainable control of the epidemic. PEPFAR’s contributions to significantly increasing ART coverage have helped drive major progress in reducing AIDS-related morbidity and mortality. Many countries are now positioned to advance domestic HIV/AIDS investments and assume greater partner country responsibilities for increased financing, management, and implementation—but the seeds for this evolution must be sown early.

Sowing these seeds means PEPFAR must be dedicated to the following paths to sustainability:

› implement the sustainability index in pepfar Country programs – This index is designed to measure the sustainability of national HIV responses, with the results used annually to inform PEPFAR investments and steadily advance sustainability across critical areas.

Photo Credit: Julie Mwabe, Centers for Disease Control and Prevention, Kenya

› expand Country health partnerships (Chps) – Establish four new Country Health Partnerships in 2015. The keys to success for CHPs are instituting governance, accountability and transparency models;

data for decision-making; and co-investment.

› Build on health system strengthening (hss) and human resources for health (hrh) programs – Work to ensure countries have the health care infrastructure, workforce and internal resources they need to take on services as we move towards epidemic control.

› engage with multilateral institutions and Civil society – The U.S. cannot do it alone. Achieving sustainability, and ultimately epidemic control, requires enhanced engagement with multilateral agencies and civil society partners both on the international and national level. On the international level, we must aim for greater coordination on sustainability through participation in joint working groups with the Global Fund, UNAIDS, UNICEF, UNITAID, the Medicines Patents Pool, WHO and other multilateral organizations. Ensuring ongoing and increased coordination with the Global Fund both at the headquarters and country level is critical.

Joint meetings with Ministries of Health, country implementers and civil society will need to expand.

› hardwire sustainability within pepfar Business processes – Strengthen internal systems so that PEPFAR investments and programs are taking into account the need for sustainability measures to be built into all planning and implementation processes at the outset.

› Build Business Cases – Show effectiveness of HIV epidemic control in increasing productivity, economic development and overall growth.

Expanding interaction with Ministries of Finance, the World Bank and the Regional Development Banks will be a core element of this approach.

Together, these paths aim to establish affordable, locally-led and driven HIV/AIDS prevention, treatment and care services for sustainable epidemic control. A Sustainability Index will assist PEPFAR teams to diagnose, measure and track a country’s progress in core domains required for a sustainable national HIV/AIDS response and help guide PEPFAR teams in determining where further investments may be required.

» Launch comprehensible, integrated strategy addressing HRH to include Medical Education Partnership Initiative (MEPI); Nursing Education Partnership Initiative (NEPI); Field Epidemiology Training Program (FETP); National Public Health Institute (NPHI); Seed Global Health

» Develop Sustainability Index as a means to monitor country investments and progress

» Launch innovative health financing strategy

» Establish first three CHP countries with full analytics and impact defined

» Define metrics for Health Systems Strengthening

» Increase in-country financing by 10 percent

» Implement Sustainability Index and establish baselines for all countries

» Ensure next four countries advanced against core CHP milestones

» Achieve milestone in health financing strategy in five countries

» Increase in-country financing by 25 percent

» Establish CHPs in all long-term strategy countries

» Achieve milestones for HRH, health financing and HSS in all U.S.

government investment countries receiving >$50 million a year

» Ensure use of Sustainability Index as a diplomatic tool and for strategic investments

» Increase in-country financing by 50 percent

» Establish CHPs in all long-term strategy and Technical Assistance/ Technical Collaboration countries

» Achieve continuous sustainability for epidemic control in Botswana, Democratic Republic of the Congo, Kenya and Swaziland

» Achieve milestones for HRH, health financing and HSS in all U.S.

government investment countries

» Institutionalize sustainability monitoring and reporting for all PEPFAR countries

» Ensure increase in in-country financing

» Achieve continuous sustainability for epidemic control in Zambia with five additional countries (Lesotho, Namibia, Mozambique, Tanzania and South Africa) within reach of achieving this milestone

» Ensure increase in in-country financing

Specifically, our Sustainability Action Agenda aims are:

partnership

Partnerships are the cornerstone of PEPFAR’s work to control the HIV/AIDS epidemic. As outlined in the PEPFAR Blueprint, achieving greater impact through deeper collaboration and focused investment is a core PEPFAR priority. We share responsibility with our partners—including the private sector, civil society, faith-based organizations, multilaterals and bilaterals— to achieve an AIDS-free generation.

Public-Private Partnerships (PPPs) We are building meaningful and wide-ranging public-private partnerships whose impact will be greater than the sum of our investments. The potential to scale-up interventions and control the epidemic is much greater with the support and collaboration of the private sector.

Specifically, PEPFAR is working to identify critical gaps in our program and strategically target investments from the private sector to help fill these gaps. One of our goals is to have our partners leverage the PEPFAR platform to integrate other areas of health, as we have done to improve maternal and child health with the Saving Mothers, Giving Life partnership and to combat cervical cancer with the Pink Ribbon Red Ribbon partnership.

PEPFAR is currently working to partner with the private sector to target key populations, including children and adolescent girls. One of our largest partnerships which will expand access to life-saving antiretrovirals (ARVs) for children was launched in August 2014 at the U.S.-African Leaders Summit. The Accelerating Children’s HIV/AIDS Treatment (ACT) Initiative is a partnership between PEPFAR and the Children’s Investment Fund Foundation (CIFF) to provide 300,000 more children access to pediatric ARVs across 10 sub-Saharan countries—Cameroon, Cote d’Ivoire, Democratic Republic of Congo, Kenya, Lesotho, Malawi, Mozambique, Tanzania, Zambia, and Zimbabwe.

On October 24, 2014, Secretary Kerry and Sir Elton John unveiled a new public-private partnership between PEPFAR, USAID and the Elton John AIDS Foundation to expand access to non-discriminatory HIV-related services for men who have sex with men and transgender individuals. The partnership has an initial focus on South Africa and the potential for future expansion to additional sub-Saharan African countries. The partnership will launch with support for a new program—Health4Men—and its delivery partners, the South African Department of Health and the ANOVA Health Institute, which receives PEPFAR support through USAID.

In total, private sector partners have contributed approximately $264 million in 2014 alone to increase the scale and impact of PEPFAR’s work. The partners contribute not only funding, but also technical assistance.

In addition to contributing funding and technical assistance, these partnerships have the added benefit of strengthening sustainability. The work that these private sector partners do in-country often leads them to begin to build markets or look for opportunities to work with governments to invest in the communities in which they are likely to establish roots.

Multilateral Partnerships Multilateral partnerships are critical to ensuring that all HIV investments are complementary, and that our work is strategically coordinated in the field. The PEPFAR program, the Global Fund and UNAIDS represent three important “legs” of support to global and national HIV responses. Strong partnerships, with intentional and deliberate coordination and mutual accountability, are needed at the country, regional and global levels to leverage and ensure synergistic investment of available HIV/AIDS resources.

The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) The Global Fund offers a multilateral vehicle for a broad range of donors to contribute to the global response to AIDS, malaria and TB. The U.S. government made the

9 The 11 UN co-sponsoring agencies are WHO, UNICEF, World Bank, UNDP, UN Women, UNFPA, UNODC, ILO, UNESCO, UNHCR, and WFP.

10 UNAIDS. (2014, October). 90-90-90 An ambitious treatment target to help end the AIDS epidemic. Geneva, Switzerland: Author.

6%

31%

63%

USA

Total Contributions to the Global Fund (January 2002-October 2014)

Total of all contributions (from all sources):

$32,507,338,699

Source: The Global Fund to Fight AIDS, Tuberculosis, and Malaria

Photo Credit: State Department first donation to the Global Fund and is still the largest donor. Since the establishment of the Global Fund, PEPFAR and the Global Fund have worked hand-in-hand to maximize their joint investment. Increased collaboration between PEPFAR and the Global Fund serves to improve:

› Investment impact through more strategic use of PEPFAR and Global Fund resources;

› Programmatic impact through joint work toward better, more efficient and evidence-based use of funds; and

› Technical and programmatic quality to maximize outcomes.

Joint United Nations Program on HIV and AIDS

(UNAIDS)

The Secretariat and the 11 UN co-sponsoring agencies9 of UNAIDS play a vital role in the HIV response and remain an important partner for the PEPFAR program. As a member of the UNAIDS Programme Coordination Board (PCB), the U.S. government helps to guide the UNAIDS’ work. Recently, the U.S. joined other member states to call on UNAIDS to support efforts to establish new targets for HIV treatment scale-up to end the AIDS epidemic, now known as the 90-90-90 targets.10 On September 25, 2014, Secretary Kerry announced support for achieving the new 90- 90-90 targets, in the high-burden geographical areas in which PEPFAR is working.

UNAIDS continues to play a leadership role as a convener of national governments, civil society and other key stakeholders to support countries to apply a strategic investment approach to guide domestic and international funding for HIV/AIDS in high-burden countries. PEPFAR closely coordinates with UNAIDS’ efforts to support countries to implement the investment approach in national planning processes. The investment approach closely aligns with PEPFAR planning approaches and is designed to use epidemiological and other relevant data to optimize resource allocation by intervention and geography and, ultimately, to accelerate progress toward achieving an AIDS-free generation.

PEPFAR draws on its technical resources and capacity to support the vital role UNAIDS plays as the international standard-bearer in global HIV guidance and guidelines, including treatment protocols, advocacy and data. PEPFAR also partners with UNAIDS to support countries in overcoming key policy, programming and implementation challenges.

Partner Countries PEPFAR and its partner countries have a unique working relationship. PEPFAR supports partner countries in their HIV/AIDS response efforts while also promoting sustainability recognizing that sustainability leads to epidemic control. As highlighted in the Sustainability Action Agenda, our goal is to work in lock step with partner countries as they assume greater responsibility for controlling their own country’s epidemic. We do not believe in a “cut and run” strategy. We are providing countries with the financial and management tools along with the services they need to succeed.

All Other Public Donors All Private Donors

» Work in coordination with partner country governments and multilateral partners, continue to work to fill data gaps and strengthen the availability, quality, and use of strategic information required to support a robust investment approach to national strategic planning

» Enhance strategic engagement with U.S. government field teams, the Global Fund, UNAIDS and others to support epidemic control in-country

» Implement ACT Initiative and begin to deliver on the goal of doubling pediatric treatment across ten countries in two years

» Launch DREAMS Partnership focusing on adolescent girls and young women

» Work in coordination with partner country governments and multilateral partners to support country-led investment approaches to national strategic planning to resource high-impact interventions in high-burden settings under a single national strategic plan

» Work in partnership with national governments, the Global Fund, UNAIDS and other stakeholders to support the goal of 90-90-90 in the high-burden geographical areas where PEPFAR is working

» Build upon new and existing work to address challenging human rights situations with multilateral partners

» Support country teams to demonstrate clarity and complementarity in Global Fund, PEPFAR and partner country contributions

» Align PEPFAR public-private partnerships at all levels to complement PEPFAR strategic priorities including targeted outreach to support key populations, including men who have sex with men

Specifically, our Partnership Action Agenda aims are:

» Continue in-country strategic engagement with the Global Fund, UNAIDS and others to work towards the goal of epidemic control

» Further increase the impact of Global Fund resources by working “hand in glove” to coordinate PEPFAR programming and the Global Fund

» Support the Global Fund Replenishment Cycle

» Increase commitments for new and existing partners focused on innovation

» Maximize impact of full domestic resource mobilization through PEPFAR and other multilateral partners’ contributions, ensuring complementarity as countries move towards greater sustainability in their HIV/AIDS responses

» Focus on capacity building for country- level partnerships to achieve sustainability

» Sustain progress made towards full domestic resource mobilization

» Strengthen monitoring and evaluation best practices in public-private partnerships reporting, evaluation and documentation of results to measure impact

» Evaluate and disseminate lessons learned for current partnerships at all levels human rights

Addressing the HIV/AIDS epidemic cannot be done through medical interventions alone; it also requires protecting human rights and addressing the human rights challenges of those affected by the disease.

Various forms of stigma and discrimination as well as harmful laws and policies reduce access to essential health services, and undermine efforts toward effective responses to HIV/AIDS. Today’s discriminatory actions against people living with HIV and the most affected populations harken back to the early days of the fight against AIDS. It is tragic that we have come so far in this fight and, yet, there are people still being persecuted and prevented from getting the life-saving care they need.

PEPFAR’s dedication to addressing HIV/AIDS through access to prevention, care and treatment means removing barriers to health services for all people, but in particular those most vulnerable who often disproportionately suffer from cultural and structural obstacles to care.

This requires working with our multilateral partners and partner country governments, as well as working with and building the capacity of civil society organizations, to build supportive environments where care is possible.

In these partnerships, and throughout all of our programs, we are committed to ensuring that partners receiving PEPFAR funds implement their programs in a way that is respectful to all the populations they serve. It is imperative that everyone dedicated to reaching an

AIDS-free generation unites to address the human rights issues that plague far too many people.

Success in our Human Rights Action Agenda is defined as: 1) expanded access to non-discriminatory HIV prevention, treatment and care for all people, including LGBT persons; 2) increased civil society capacity to advocate for and create enabling environments; and

3) increased gender equality in HIV services and decreased gender-based violence (GBV).

Access to Non-Discriminatory Prevention and Care

Access to HIV/AIDS prevention, treatment and care remains one of the greatest challenges to responding to the global HIV/ AIDS epidemic. Laws, regulations and policies that relate to HIV can negatively or positively impact the lives and rights of those living with and affected by HIV.

Barriers to prevention and care are particularly acute for people who are marginalized by hostile laws or policies or cultural norms of discrimination. For these reasons, the creation of social and legal environments that encourage people to take up and use HIV services is a necessary part of access. This also requires educating people about their rights as well as, in the case of HIV related discrimination, to have access to justice and redress.

The principles of good public health demand that we strive to reach all affected populations with core HIV services even when facing difficult cultural contexts, severe stigma and discrimination, or challenging security environments.

”– Ambassador Deborah L. Birx, M.D.

May 2014

Photo Credit: White House

In addition to the legal and policy environment, stigma and discrimination on the part of healthcare workers, or those in healthcare settings, often deter people, particularly members of vulnerable groups, including men who have sex with men, sex workers, and people who inject drugs from seeking and accessing health services. PEPFAR programs support the creation of non-stigmatizing environments that enable all persons receiving services, to have consistent safe access to both clinical and community-based care and support.

Recognizing that gender and sexual minorities are disproportionately affected by HIV in many countries and commonly have less access to basic care, Gender and Sexual Diversity Training is required for PEPFAR staff. The training covers the U.S. government non-discrimination policies and the concepts of responsible engagement, which are important in the context of gender and sexual orientation. How service providers engage with these marginalized groups matters greatly, especially in challenging contexts where engagement may inadvertently place individuals at risk.

While anecdotally we know discrimination is often acute, PEPFAR recently partnered with the Global Equality Fund to document how stigma and discrimination as well as discriminatory laws and policies run counter to our efforts to address HIV by creating barriers to safe, effective and confidential health care services. This information will help the PEPFAR program as well as other organizations work to make real change in affected countries.

Civil Society Capacity & the Enabling Environment

The PEPFAR Blueprint outlined PEPFAR’s commitment to work to: 1) End stigma and discrimination against people living with HIV/AIDS and key populations and 2) Increase access to and uptake of HIV services by key populations. At the International AIDS Society Conference in 2012, former Secretary of State Clinton announced three key populations-focused initiatives:

› $15 million in implementation research to identify the specific interventions that are most effective for key populations

› A $20 million challenge fund to support country-led plans to expand services for key populations

› A $2 million annual investment in the Robert Carr Civil Society Network Fund to bolster the efforts of civil society groups to reach key populations.

Since 2012, 19 PEPFAR regional and country programs have benefited from the first two initiatives, and an additional $13 million has been leveraged, bringing the total funding to nearly $50 million. Since its launch in 2012, the Robert Carr Fund has committed $17.4 million over three years to more than 35 civil society networks and consortia.

In addition PEPFAR is investing $31 million in the Local Capacity Initiative (LCI). The LCI supports local nongovernmental organizations in 14 PEPFAR countries in building their capacity to address the HIV/ AIDS epidemic through legal and policy advocacy, stigma and discrimination reduction and planning and implementation of country programs. The further developing of local capacity (organizational and technical) will allow PEPFAR to address HIV/AIDS in a sustainable manner and ensure coordination, direct linkages and supports for local government entities engaged in the HIV/AIDS response.

11 Centers for Disease Control and Prevention, & United Nations Children’s Fund, Swaziland. (2007). Findings from a National Survey on Violence Against Children in Swaziland. Retrieved from http://www.unicef.org/swaziland/sz_publications_2007violenceagainstchildren.pdf

12 United Nations Children’s Fund, Centers for Disease Control and Prevention, & Muhimbili University of Health and Allied Sciences. (2011).