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From 2006 until 2010, the HIV/AIDS Monitor focused on the performance of three HIV/AIDS donor programs—the U.S. government's President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund for AIDS, Tuberculosis and Malaria (The Global Fund), and the World Bank's Multi-Country AIDS Program (MAP). The Center for Global Development’s HIV/AIDS Monitor team, led by Nandini Oomman examined key issues in the design, delivery and management of these donor programs, and provided timely analyses to improve the efficiency and effectiveness of each initiative.
Global Level and Country-based reports on the HIV/AIDS programs, produced in collaboration with partners on the ground in Mozambique, Uganda and Zambia, provided evidence-based policy recommendations to the top donors. Over the course of the initiative, with ongoing research and active outreach of its findings, the Monitor team accomplished the following at the global and country level:
Influenced PEPFAR and other donor policies and practices
CGD played an important role in informing and shaping the policies of the three donors on an ongoing basis over the last four years. The HIV/AIDS Monitor's recommendations are now reflected in donor current strategies and actions. For example:
The World Bank's Agenda for Action subsequently incorporated a focus on building governments' financial management capacity based on the recommendation that the World Bank Multi-Country AIDS Program (MAP) should focus on improving health information systems
The Global Fund changed its reporting requirements for recipients from every 3 months to every 6 months following this recommendation from the HIV/AIDS Monitor report on performance-based funding
Increased PEPFAR’s Transparency and Release of Data
An ongoing push throughout the Monitor research recommendations has been the importance of accurate, transparent and readily available data to inform programming at the donor and country level. Our 2008 report, Numbers Behind the Stories, which analyzed newly available PEPFAR data not otherwise public, stressed the importance of making funding data widely available. Our report argues that knowledge of official data on obligations to recipients of the funds improves transparency and allows for accurate analyses of its cost-effectiveness. Knowledge from this report, as well as our other reports that looked more specifically at issues surrounding the availability of programmatic data, informed Nandini Oomman’s memo to President Obama encouraging him to allow for the more public release of PEPFAR data. Evidence from updated PEPFAR policies shows that the U.S. government is heeding this advice—more data on financial obligations by the U.S. Government to specific countries are being released on the website (they were previously redacted) and PEPFAR’s Five-Year Strategy 2009-2014 cites "working to expand publicly available data" as a key initiative in its next five years, though types of data (financial, programmatic, etc.) have yet to be specified.
Informed Congressional Oversight of PEPFAR’s bilateral and multilateral global AIDS Funding
The HIV/AIDS Monitor team provided senior Congressional staff (Democrat and Republican) with study findings and recommendations to inform the creation of new policies (such as reauthorization of PEPFAR), new strategies (PEPFAR II) and new U.S.G global health initiatives (U.S. Global Health Initiative), and monitor the progress of current policies as legislated. In addition, the Government Accountability Office (GAO) team tasked by Congress with oversight of PEPFAR routinely consulted CGD experts on Monitor findings to frame questions for their studies and to use our research results as additional evidence in their reports. In the words of a GAO staff person, “The HIV/AIDS Monitor publications helped us understand the issues surrounding PEPFAR implementation…which in turn helped us define the scope of our research” The Institute of Medicine (IOM) team charged by Congress with the evaluation of PEPFAR II also consulted with the HIV/AIDS Monitor team in preparing background information for the Committee that will plan and implement the evaluation.
Increased the visibility of AIDS funding and global health as a key aid effectiveness issue at the global and country level
The HIV/AIDS Monitor built a brand on the topic of aid effectiveness for AIDS and Global Health funding at the global and country level. By documenting donor policies and practices and sharing these widely with different audiences in the U.S. and globally, the HIV/AIDS Monitor has raised the importance of this topic through several different channels such as publications, events, and extensive use of the World Wide Web. For example, at the global level, a CGD background report shed light on the workings of, and challenges to, antiretroviral supply chains for developing countries—and triggered supply-chain stakeholders to increase the efficiency of the Global Supply Chain and another CGD background report contributed to the debate about increasing aid effectiveness by describing how the three donors take program performance into consideration when making final decisions about funding . At the country level, such as in Zambia, CGD’s report, Following the Funding for HIV/AIDS, was reported (by a donor official) to have influenced the design and process of tracking the HIV/AIDS funds within the National Health Accounts in the Ministry of Health and in the drafting of the International Health Partnership position paper of MOH. In Uganda, the results of the gender theme were presented in parliament and at the health sector review meeting at the invitation of the Director General. A senior official in the MOH reported that lessons learnt from the HIV/AIDS Monitor have influenced their dialogues with donors.
Today, following many of the HIV/AIDS Monitor's recommendations, bilateral and multilateral donors continue to support the HIV/AIDS response in the developing world, moving away from a vertical disease approach to one that focuses on strengthening a country’s capacity to respond to HIV/AIDS as part of a broader set of global health priorities.
The Center for Global Development continues to track ongoing policy changes related to the HIV/AIDS Monitor team's findings and follows the effectiveness of global health development assistance through its research, blogs and global health policy newsletter that is published monthly.
On World AIDS Day in 2003, WHO and UNAIDS launched a campaign called the “3 by 5 initiative,” with the objective to “treat three million people with HIV by 2005.” At that time, AIDS treatment was still prohibitively expensive for poor countries, where only a few thousand people had access to treatment. Thanks to President Bush’s creation of the President's Emergency Plan for AIDS Relief (PEPFAR) program that same year, the number of people on antiretroviral therapy (ART) began to rise dramatically. While the total number of people on ART reached only one million in 2005, the objective to reach three million people was attained in 2007, and the numbers have continued to climb. The numbers have now surpassed 11 million in low- and middle-income countries and 13 million worldwide. (See bottom trend line in figure 1.)
Figure 1. Impressive growth in the number of people on antiretroviral treatment has not yet led to a decrease in the total number of people living with HIV/AIDS
Because treatment extends lives and new infections have persistently outpaced AIDS-related deaths, the number of people living with HIV/AIDS has consequently continued to grow (top line in figure 1). I argued in my 2011 book, Achieving an AIDS Transition, that a unique focus on expanding access to treatment would make recipient countries increasingly dependent on rich ones and would generate unsustainably growing demands for donor resources. The alternative, I proposed, was to focus even more attention and effort on reducing the rate of new infections to below the mortality rate so that the number of people living with AIDS, and eventually the number needing treatment, would begin to decline.
This year, in their annual World AIDS Day plea for more resources, UNAIDS is for the first time focusing more on the need to reduce new infections than on treatment expansion. In figure 2 below, we have assembled into one chart the projections UNAIDS shows in figures 6a and 6b of their new “Fast Track” report. Under their “constant coverage” scenario, new HIV infections will exceed AIDS-related deaths by about half a million persons a year through 2030, causing the number of people living with HIV/AIDS to increase by about 8 million, or to a total of about 43 million (not shown; imagine the top line in figure 1 continuing to climb).
But UNAIDS is urging the world to make one last push. Instead of hoping only for constant coverage, or perhaps failing to sustain even that modest goal, UNAIDS is proposing instead that the world adopt “ambitious targets” by aiming for “zero,” which they define as reducing new HIV infections and AIDS deaths by at least 90 percent by 2030. As figure 2 shows, the ambitious targets would bend both the new infections and the annual deaths dramatically downwards. The “AIDS transition,” a key milestone defined in my book, is passed in 2019 when new infections will for the first time be fewer than deaths and the total number of persons living with HIV/AIDS will begin to decline.
Figure 2. With UNAIDS ambitious targets, the world will reach an AIDS transition after 2019
Of course, it’s one thing to find a set of assumptions that predict new infections and deaths to go down instead of up (the Futures Institute helped UNAIDS with this meticulous and heroic task). It’s another thing to achieve these ambitious targets. UNAIDS is depending on increased funding of existing interventions to get us to the AIDS transition and beyond. Suppressing mortality to this degree requires greatly expanding treatment to 81 percent of all infected people, and suppressing new infections requires that 90 percent of people on treatment have suppressed viral load. So increased funding will certainly be necessary to reach the AIDS transition. However, as I argue in my book, countries that have been receiving aid to finance their AIDS epidemic will also have to dramatically change their attitudes towards HIV prevention. In addition to deploying the array of available preventive medical technology, including treatment-as-prevention, male circumcision, and needle sharing, affected countries must find new ways to incentivize their citizens to assiduously adhere to AIDS treatment guidelines and to adopt safer sexual practices. Cash transfers to schoolgirls and their families show promise but have not yet been widely adopted. More important might be regional and district-level cash-on-delivery rewards for verified evidence of reductions in new HIV infections.
Bravo to UNAIDS for setting a course towards a future when it will no longer be needed—a future without AIDS. Now it must convince donors and recipient countries that this future is realistic and attainable. And that allocating resources towards achieving the AIDS transition is consistent with other sustainable development goals, like universal health coverage and protection from Ebola and other disease outbreaks. The hard work is still ahead.
For the past decade, global AIDS donors have responded to HIV/AIDS in sub-Saharan Africa as an emergency and have mobilized health workers from weak and understaffed workforces. They must begin to address the long-term problems underlying the shortages and the effects of their efforts on the health workforce more broadly.
This report focuses on the workforce strengthening strategies of three of the major HIV/AIDS donors—the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), and the World Bank’s Africa Multi-country HIV/AIDS Program (the MAP)—and identifies six tasks for donors, national governments, and country stakeholders to undertake to reverse the severe shortage of skilled, motivated, and productive health workers.
The concept of country ownership has become increasingly visible in donor policy and strategy, yet definitions vary and there is little clarity and great diversity in how this concept is articulated and practiced by donor and recipient countries. Health experts from Ethiopia, Mozambique, Uganda and Zambia will discuss why and how the U.S. government and host country actors--governments and civil society--are redefining their relationship. Our panelists will reflect on PEPFAR and other global AIDS programs in the last decade to suggest how the U.S. Global Health Initiative's key principle of country ownership may be applied to achieve specific donor and host country objectives. Our panel will attempt to answer some key questions: What is the U.S government's definition of country ownership and does this resonate with that of host country governments'? What are the objectives of country ownership? And what are the challenges to getting to a more shared definition and practice of this concept?
How can we stem the tide of the HIV epidemic? The impressive scale up of international spending on HIV treatment has led to significant declines in morbidity and mortality from HIV/AIDS. However, as these impressive gains have gone unmatched by corresponding decreases in the incidence of new cases of HIV, the number of people on treatment threatens to explode. In order to combat the burden HIV/AIDS places on developing countries, great steps must be taken in order to make prevention the forefront of the global HIV/AIDS strategy. Mead Over will discuss how to incentivize prevention opportunities, and Susan Allen and Gordon Streeb will present in detail the effectiveness and costs of one of the most promising prevention interventions, voluntary counseling and testing for couples.