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PEPFAR Implementation: Progress and Promise
Develop prevention strategies for people who are HIV-positive. Programs tailored to the needs of people living with HIV/AIDS should be developed and implemented. These programs should involve people living with HIV/AIDS and combat stigma with enforceable laws.
Adapt prevention for people who are HIV-negative. New strategies must emphasize the continued importance of risk reduction and stress that ART is not a cure.
Monitor impact. Surveillance systems should closely monitor the behavioral impact of ART.
Integrated HIV/AIDS programs have been shown to improve the effectiveness of national programs in decreasing rates of HIV infection and death from AIDS. A UNAIDS (2005a) study projects numbers of new HIV infections and AIDS deaths through 2019 based on models for treatment-centered, prevention-centered, and joint prevention/treatment global responses. The latter model results in the largest number of infections averted and the lowest number of AIDS deaths over a 15-year projection. Similarly, an optimistic model developed by Mathers and Loncar (2006), which assumes increased prevention activity, projects a decline in HIV/AIDS deaths as of 2030 from an estimated baseline of 6.5 million to 3.7 million. Likewise, a conference of Christian Aid HIV partners underscored the need to shift the focus of HIV interventions from a prevention-specific ABC approach to a comprehensive approach developed by the African Network of Religious Leaders Living with or Personally Affected by HIV/AIDS called SAVE (Safer practices, Available medications, Voluntary counseling and testing, and Empowerment).
In most of the focus countries, HIV infection is hyperendemic, with transmission occurring from those unaware of their infection status to others unaware of the risk (often spouses of either gender). Counseling and testing are therefore essential to achieving a long-term, sustainable impact on reducing HIV transmission, as well as meeting treatment and care goals. Given its placement in the care category, it appears that PEPFAR views counseling and testing primarily as a means of identifying HIV/AIDS cases eligible for treatment and care. In addition to case finding, however, counseling and testing represents an opportunity to provide HIV education, including prevention messages to people testing both positive and negative for HIV.
PEPFAR continues to struggle with how to integrate prevention, treatment, and care activities and how to measure the level of integration both among PEPFAR-funded services and between those services and the broader health care system in each focus country. For example, OGAC has endeavored to afford Country Teams greater flexibility in planning and budgeting their fiscal year 2007 ABC programs. Country Teams will