PEPFAR IMPLEMENTATION

PROGRESS AND PROMISE

Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation

Board on Global Health

Board on Children, Youth, and Families

Jaime Sepúlveda, Charles Carpenter, James Curran, William Holzemer, Helen Smits, Kimberly Scott, and Michele Orza, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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PEPFAR Implementation: Progress and Promise PEPFAR IMPLEMENTATION PROGRESS AND PROMISE Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation Board on Global Health Board on Children, Youth, and Families Jaime Sepúlveda, Charles Carpenter, James Curran, William Holzemer, Helen Smits, Kimberly Scott, and Michele Orza, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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PEPFAR Implementation: Progress and Promise THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by Contract No.SAQMPD05D1147 between the National Academy of Sciences and the U.S. Department of State. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the agency that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation. PEPFAR implementation : progress and promise / Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation, Board on Global Health, Board on Children, Youth, and Families ; Jaime Sepúlveda … [et al.] editors. p. ; cm. Includes bibliographical references. ISBN-13: 978-0-309-10982-6 (hardback : alk. paper) ISBN-10: 0-309-10982-5 (hardback : alk. paper) 1. AIDS (Disease)—Prevention—Government policy—United States. 2. HIV infections—Prevention—Government policy—United States. 3. AIDS (Disease)—Prevention—International cooperation. [DNLM: 1. Government Programs—organization & administration—United States. 2. HIV Infections—prevention & control—United States. 3. Disease Outbreaks—prevention & control—United States. 4. Emergencies—United States. 5. International Cooperation—United States. 6. World Health—United States. WC 503.6 I585p 2007] I. Sepúlveda Amor, Jaime. II. Title. RA643.83.I57 2007 362.196′9792—dc22 2007023493 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. COVER: The flags of the 15 PEPFAR focus countries are overlaying the global symbol of the red ribbon for HIV/AIDS awareness arranged in alphabetical order by country. Suggested citation: IOM (Institute of Medicine). 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press.

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PEPFAR Implementation: Progress and Promise “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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PEPFAR Implementation: Progress and Promise THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PEPFAR Implementation: Progress and Promise COMMITTEE FOR THE EVALUATION OF PEPFAR IMPLEMENTATION Jaime Sepúlveda (Chair), 2007 University of California, San Francisco Presidential Chair and Visiting Professor Helen Smits (Vice Chair), Former Faculty of Medicine, Eduardo Mondlane University, Mozambique Charles Carpenter (Treatment Subcommittee Chair), Professor of Medicine, Director of the Brown University AIDS Center, Brown University, Providence, Rhode Island James Curran (Prevention Subcommittee Chair), Dean, Professor of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia William L. Holzemer (Care Subcommittee Chair), Professor of Nursing and Associate Dean, International Programs, School of Nursing, University of California, San Francisco Stefano M. Bertozzi, Director of Health Economics, National Institutes of Health, Mexico Geoff Garnett, Professor of Microparasite Epidemiology, Faculty of Medicine, Imperial College, London, United Kingdom Ruth Macklin, Head, Division of Bioethics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York Affette McCaw-Binns, Professor, Reproductive Health Epidemiology, Section of Community Health, University of the West Indies, Jamaica A. David Paltiel, Professor, Yale School of Medicine, Yale School of Management, New Haven, Connecticut Priscilla Reddy, Director, Health Promotion Research and Development Unit, Medical Research Council of South Africa David Ross, Director, Public Health Informatics Institute, Decatur, Georgia Heather Weiss, Director, Harvard Family Research Project, Harvard University, Boston, Massachusetts Subcommittee Members, Liaisons, and Study Consultants Maureen Black, John A. Scholl Professor of Pediatrics, University of Maryland School of Medicine, Baltimore Hoosen Coovadia, Victor Daitz Professor of HIV/AIDS Research, Centre for HIV/AIDS Networking, Doris Duke Medical Research Institute, University of Kwazulu/Natal, Durban, South Africa Henry Fomundam, Regional Director, Howard University/PACE Centre, Washington DC/South Africa Paul Gertler, Professor of Economics, Haas School of Business, Professor of Health Services Finance, School of Public Health, University of California, Berkley

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PEPFAR Implementation: Progress and Promise Carl A. Latkin, Professor, Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland James Ntozi, Professor, Department of Population Studies, Makerere University, Uganda James Sherry, Professor of Global Health, School of Public Health and Health Services, The George Washington University, Washington, D.C. Olaitan Soyannwo, Professor of Anesthesia and Consultant Anesthetist, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria Burton Wilcke, Jr., Chair and Associate Professor, Department of Medical Laboratory and Radiation Sciences, University of Vermont, Burlington Michael Merson (Board on Global Health Liaison), Founding Director, Global Health Institute, Duke University, North Carolina Elena O. Nightingale (Board on Children, Youth, and Families Liaison), Scholar-in-Residence, Institute of Medicine, The National Academies, Washington, D.C. Julia Coffman (Consultant), Independent Evaluation Consultant, Alexandria, Virginia Thomas Denny (Consultant), Research Associate Professor, Chief Operating Officer, Duke Human Vaccine Institute and Center for HIV/AIDS Vaccine Immunology, Duke University Medical Center, Durham, North Carolina Florencia Zulberti (Consultant), Assistant Director for Global Health, National Institutes of Health, Mexico Study Staff Patrick Kelley, Board Director, Global Health Rosemary Chalk, Board Director, Children, Youth and Families Michele Orza, Study Director Kimberly Scott, Senior Program Officer Lucía Fort, Program Officer (through November 2006) J. Alice Nixon, Program Officer (through November 2006) Angela Mensah, Senior Program Assistant Kimberly Weingarten, Senior Program Assistant (through September 2006) Sheyi Lawoyin, Senior Program Assistant (May 2006 through July 2006) Jessica Manning, Mirzayan Science and Technology Policy Fellow (May 2006 through August 2006) Keren Ladin, Mirzayan Science and Technology Policy Fellow (June 2006 through August 2006)

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PEPFAR Implementation: Progress and Promise Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s (NRC) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Roberto Arduino, Division of Infectious Diseases, The University of Texas Health Science Center at Houston Solomon R. Benatar, Department of Medicine, University of Cape Town, South Africa Alan Berkman, Mailman School of Public Health, Columbia University, New York Jo Ivey Boufford, Robert F. Wagner Graduate School of Public Service, New York University Fred Carden, International Development Research Centre, Ottawa, Canada Ambassador Johnnie Carson, National Intelligence Council of the Office of the National Director of Intelligence, Washington, District of Columbia Thomas J. Coates, David Geffen School of Medicine, University of California, Los Angeles

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PEPFAR Implementation: Progress and Promise Susan A. Cohen, Guttmacher Institute, Washington, District of Columbia Carlos del Rio, Emory AIDS International Training and Research, Rollins School of Public Health of Emory University and Grady Memorial Hospital, Atlanta, Georgia Christopher J. Elias, PATH, Seattle, Washington Helene Gayle, CARE, Atlanta, Georgia Geeta Rao Gupta, International Center for Research on Women, Washington, District of Columbia Grace John-Stewart, Department of Medicine, International AIDS Research and Training Program, University of Washington, Seattle, Washington James W. Kazura, Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio Mary Anne Koda-Kimble, School of Pharmacy, University of California, San Francisco Adel A. F. Mahmoud, Merck Vaccines, Merck & Co., Inc., Whitehouse Station, New Jersey Anne Mills, London School of Hygiene & Tropical Medicine, London Roeland Monasch, United Nations Children’s Fund, Harare, Zimbabwe J. Stephen Morrison, HIV/AIDS Task Force, Center for Strategic & International Studies, Washington, District of Columbia Anne Peterson, World Vision International, Washington, District of Columbia Robert Redfield, Institute of Human Virology/Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland Catherine M. Wilfert, Duke University Medical Center, Duke University, Chapel Hill, North Carolina; The Elizabeth Glaser Pediatric AIDS Foundation Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Bernard Guyer, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, and Charles E. Phelps, University of Rochester, New York. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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PEPFAR Implementation: Progress and Promise Preface Only a quarter of a century after first reported, HIV/AIDS has become one of the largest global health scourges of all times. This preventable viral disease caused the death of almost 3 million people last year alone, while over 4 million others became infected. The majority of this disease burden occurs in the developing world, with sub-Saharan Africa carrying the largest burden. As a result, life expectancy in that region has decreased, causing enormous human suffering and long-lasting demographic, social, and economic consequences. The very rapid scientific discoveries on the etiology and modes of transmission, and later the development of effective treatment against HIV/AIDS are a tribute to human ingenuity. Our collective social response, however, has taken longer to get organized. Although still far from adequate, the global response to the epidemic is finally growing and progress is evident on a number of fronts. Hope has been restored based on a broad awakening of international commitment and strong evidence that the technical challenges can be met on a large scale. A major factor in the increasing global response is “The President’s Emergency Plan for AIDS Relief,” or PEPFAR. This plan derives from novel legislation, passed by the U.S. Congress in 2003, which also mandated an evaluation of progress on this initiative. It has been the challenge and privilege of our Institute of Medicine to be charged with the conduct of this independent evaluation. The Emergency Plan set ambitious goals. It seeks to support the prevention of 7 million HIV infections, the treatment of 2 million people with

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PEPFAR Implementation: Progress and Promise AIDS, and the care of 10 million orphans and others affected by this epidemic. PEPFAR has focused on 15 countries, which collectively represent around 50 percent of the HIV infections worldwide (12 countries of Africa plus Vietnam, Haiti, and Guyana). Our IOM committee has found its work to evaluate such a multidimensional plan to be a unique challenge. Not only are the programs focused on different activities of prevention, treatment, and care, but within the 15 countries they are also conducted by a variety of public- and private-sector organizations, with various degrees of expertise. Some programs were started shortly after the first funds started to flow in 2004 and others more recently. Few, if any, of the programs observed could be described as mature. Yet, the Committee found evidence to guide future planning and policy. The bulk of this report communicates that evidence and presents the Committee’s conclusions and recommendations. It is in our human nature to better respond to emergencies than to sustain efforts over time. HIV/AIDS, however, is a chronic infection that requires life-long treatment. The continuity of the support is a medical and moral imperative, and therefore PEPFAR will need to make the transition from an emergency plan to a sustained effort that invests in building the capacity within countries to eventually take full responsibility for responding to their epidemics. Constant learning should be at the center of such a transition considering the need to economically and effectively replicate these programs in so many places. The energy, empathy, perseverance, and technical competence of those implementing PEPFAR will be needed for many years into the future. The number of newly infected people with HIV vastly outpaces the capacity to treat patients with AIDS. Treatment of patients is not only a humanitarian imperative; it is also an indivisible component of prevention. But let us make no mistakes here: the only way to eventually control this pandemic is by preventing new cases. The epidemiologic facts are clear. The past occurrence of still largely invisible HIV infections will generate a deluge of new AIDS cases needing treatment over the next decade. Even more sobering is the fact that the rate of new HIV infections continues to grow. Proud as we should be of PEPFAR’s success in providing medication to many of those already ill, it needs to urgently put the accent on preventive measures of proven efficacy on a much larger scale. Nothing is as persuasive as success. A proof of concept is required to make a case; to the usual skeptics, PEPFAR has successfully demonstrated that programs of quality can be implemented, even in resource-thin settings. The many heroic professionals working in suboptimal conditions in the field have proven that large-scale HIV/AIDS prevention services, care, and treatment are feasible. However, many more like them will need to be trained and supported if quality care is to be continued, as it needs to be, over the decades to come.

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PEPFAR Implementation: Progress and Promise Indeed, one area of special concern for sustainability of efforts in affected countries is the local health workforce. Human resource capacity is projected to be a critical rate-limiting factor for all future HIV prevention and treatment initiatives. These capacities take time to build. Health infrastructures are being impaired as worker death and worker morbidity from AIDS, migration to more favorable and high-paying work environments (i.e., the brain drain), and retirements deplete the already thin workforce. The epidemic also has many negative collateral impacts on other health initiatives—such as maternal and reproductive health, vaccination, or malaria—as human, laboratory, and financial resources become overwhelmed by HIV/AIDS-specific needs and resources are diverted to AIDS from other health programs. Building human capacity will need to be an even more essential element of future global AIDS initiatives. “Learning by doing” is a necessary corollary to this unprecedented scale-up of a complex global public health initiative. The Office of the Global AIDS Coordinator has increasingly been making investments into monitoring, evaluation, and various forms of operational research to this end. The IOM committee would like to see its work as part of this evaluative continuum and encourages transparency and wide dissemination of the findings from the ongoing program evaluations of the U.S. Global AIDS Initiative. Creative and accountable action needs to continue unabated, and quality must always be at the forefront. The citizens of the United States expect this, those in need deserve it, and our call to be humanitarians demands no less. The United States has taken a critical leadership role in responding to the HIV/AIDS pandemic but since it can not provide all the necessary resources, the lessons learned from PEPFAR will be critical leverage to motivate other donor nations to follow its lead with deeper investments. The IOM evaluation of the implementation of PEPFAR reflects many months of work not only by 22 uncompensated committee and subcommittee members, but also dozens of consultants, staff members, editors, board liaisons, and reviewers. The committee members enjoyed and were honored by the professionalism of hundreds of individuals who gave candid testimony about how PEPFAR is working in the field and at the management level in Washington, DC. While opinions varied about specific scientific and management approaches and priorities, it became clear that PEPFAR represents a notable achievement not only in its conceptualization but also in its implementation. Global security is profoundly influenced by our increasing health interdependence. No one is safe from the international transfer of risks, and no one should be left out of the international transfer of opportunities, in the form of knowledge, resources and technology. The PEPFAR initiative should be seen not only as an important investment in the lives of many individuals and their families, but also as an investment in global security.

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PEPFAR Implementation: Progress and Promise This is a good example of the kind of health diplomacy needed on a global scale. PEPFAR is a vertical program. Much debate has existed in the past around the relative merits of vertical versus horizontal approaches to health care. To me, this is a false dilemma and an unnecessary dichotomy, for we should aim to have the best of both. A diagonal approach is one in which explicit intervention priorities—such as HIV/AIDS—is used to drive the desired improvements into the health system. AIDS is certainly not the only health problem in sub-Saharan Africa, nor can we tackle all problems at once. PEPFAR is laying the grounds for a unique opportunity—by contributing to the necessary capacity building—to incrementally incorporate other selected health priorities in the different countries’ agendas. While the Committee approached its task to conduct the evaluation in a dispassionate manner, it feels passionate about the problem and the potential solutions. It could not be otherwise; after all, the progress of PEPFAR is measured in real people—men, women, and children supported with vital HIV/AIDS services; health care workers trained to provide HIV/AIDS care; people enabled to change themselves, their communities, and their nations to better respond to the epidemic. Though the programs evaluated are still young, it was clear that millions of people are being served and life-saving medical care is being delivered on a large scale in some of the world’s most challenging settings. As a Foreign Associate member of the Institute of Medicine who had the distinct privilege of leading this evaluation, I strongly believe that the American people, acting through PEPFAR, are to be complimented for supporting this remarkable humanitarian undertaking. I would like to express my deep appreciation to the Institute of Medicine’s authorities for the trust deposited in us, and to the heroic staff for all their hard work; and my perennial gratitude to all our Committee members, from whom I learned so much. The Committee hopes that the recommendations presented herein will be a constructive contribution to the current and future U.S. Global AIDS Initiatives. Jaime Sepúlveda, M.D., Dr.Sc. Chair

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PEPFAR Implementation: Progress and Promise Acknowledgments The Committee is deeply appreciative of the valuable contributions to this project of many knowledgeable and experienced people. Appendix A lists the many people and organizations who generously assisted the Committee with its study. The Committee would like to thank the Office of the U.S. Global AIDS Coordinator—in particular Ambassador Mark Dybul, Dr. Kathy Marconi, and Dr. Nadine Rogers for their assistance throughout the project. The Committee expresses its admiration for and gratitude to its dedicated, hard-working staff, ably led by Dr. Michele Orza—particulary Kimberly Scott and Angela Mensah who saw this book through to completion. Thanks also to the many IOM staff not listed in the following pages including Bronwyn Schrecker, Janice Mehler, Lara Andersen, Allison Brantley, Elizabeth Sharp, Bethany Hardy, and Tyjen Tsai. Special thanks to Hellen Gelband for assistance in drafting background chapters of the report and to Rona Briere and Alisa Decatur for editorial assistance.

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PEPFAR Implementation: Progress and Promise Contents Abstract   1 Summary   3     Introduction,   3     The Progress of PEPFAR,   5     The Promise of PEPFAR,   7     References,   18 PART I:  THE U.S. GLOBAL AIDS INITIATIVE     1   Introduction   23      Background,   24      Study Goals and Approach,   26      Conduct of the Evaluation,   29      Evaluating the Success of PEPFAR,   31      Organization of the Report,   32      References,   33 2   The U.S. Global AIDS Initiative: Context and Background   35      The HIV/AIDS Pandemic,   37      The Global Response to HIV/AIDS in the Developing World,   40      Harmonization in the Global Response to HIV/AIDS,   44      Challenges to HIV/AIDS Programs,   49      The PEPFAR Focus Countries,   58

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PEPFAR Implementation: Progress and Promise      PEPFAR’s Authorizing Legislation: The Leadership Act,   62      The 5-Year Strategy: The President’s Emergency Plan for AIDS Relief,   67      References,   73 PART II:  PROGRESS ON THE FIRST 5-YEAR STRATEGY—PEPFAR     3   PEPFAR’s Management   81      Coordination,   83      Harmonization,   87      Policy Guidance,   92      Planning and Reporting,   93      Technical Working Groups,   94      Functioning as a Learning Organization,   94      Budget Allocations,   98      Targets,   101      Resource Allocation,   102      Conclusion,   109      References,   109 4   PEPFAR’s Prevention Category   113      Category, Target, and Results,   115      Review of Progress to Date,   120      Issues and Opportunities for Improvement,   131      Conclusion,   137      References,   137 5   PEPFAR’s Treatment Category   141      Category, Target, and Results,   143      Review of Progress to Date,   146      Issues and Opportunities for Improvement,   153      Conclusion,   164      References,   164 6   PEPFAR’s Care Category   169      Category, Target, and Results,   171      Background: Models of Care,   176      Review of Progress to Date,   181      Issues and Opportunities for Improvement,   190      Conclusion,   200      References,   202

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PEPFAR Implementation: Progress and Promise 7   PEPFAR’s Orphans and Other Vulnerable Children Category   205      Category, Target, and Results,   207      Background,   210      Review of Progress to Date,   217      Issues and Opportunities for Improvement,   231      Conclusion,   237      References,   237 PART III:  LOOKING TO THE FUTURE     8   Toward Sustainability   243      Common Themes,   245      Conclusion,   267      References,   268 APPENDIXES     A  Acknowledgments   271 B  Methods   287 C  Plan for a Short-term Evaluation of PEPFAR Implementation   301 D  Selected Bibliography for 25-Year Overview of Global HIV/AIDS   333 E  Abbreviations and Acronyms   335 F  Committee and Staff Biographies   337 G  Information-Gathering Meeting Agendas   355 Index   363

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PEPFAR Implementation: Progress and Promise Tables, Figures, and Boxes TABLES 2-1   Classification of Country-Level AIDS Epidemics,   40 2-2   Total U.S. Funding for Global HIV/AIDS for Fiscal Years 2001–2007 (in millions of U.S. dollars),   41 2-3   Density of Selected Health Care Workers in the PEPFAR Focus Countries,   59 2-4   Selected Economic and Health-Related Indicators of the PEPFAR Focus Countries,   61 2-5   Structure for Coordination and Support Within the Office of the U.S. Global AIDS Coordinator,   72 3-1   Focus Country–Implemented Funding by Agency for Fiscal Years 2004–2006 (in millions of U.S. dollars),   104 3-2   PEPFAR Focus Country–Implemented and Central-Implemented Funding for Fiscal Years 2004–2006 (in billions of U.S. dollars),   105 3-3   PEPFAR Funding by Program Category for Fiscal Years 2004–2006 (in billions of U.S. dollars),   107 3-4   PEPFAR Funding by Program Category for Fiscal Years 2004–2006 (in billions of U.S. dollars) with Distribution of Other Costs by OGAC Method,   107 3-5   PEPFAR Funding by Focus Country for Fiscal Years 2004–2006 (in millions of U.S. dollars),   108 4-1   PEPFAR Prevention Funding (in millions of U.S. dollars) and Percent by Subcategory for Fiscal Years 2004–2006,   116 4-2   PEPFAR Activities Corresponding to Funding and Reporting Subcategories,   116

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PEPFAR Implementation: Progress and Promise 4-3   PEPFAR Prevention Results by Fiscal Year, 2004–2006,   119 5-1   PEPFAR Treatment Results by Fiscal Year, 2004–2006,   146 6-1   Comparison of WHO and PEPFAR Definitions of Comprehensive Care for Adults and Children Affected by HIV/AIDS,   174 6-2   PEPFAR Care Results by Fiscal Year, 2004–2006,   176 7-1   PEPFAR Orphans and Other Vulnerable Children Results by Fiscal Year, 2004–2006,   210 7-2   Estimates of Living Children Orphaned as a Result of HIV/AIDS in the PEPFAR Focus Countries and Country Population Totals, 2005–2006,   211 8-1   Summary of PEPFAR Activities Responsive to Legislative Imperatives Concerning Women and Girls,   250 8-2   Summary of Access to PEPFAR-Supported Services for Women and Girls,   251 8-3   Summary of PEPFAR Targeted Evaluations,   264 FIGURES 1-1   Short-term PEPFAR evaluation plan,   28 2-1   Global view of the prevalence of HIV/AIDS,   39 2-2   Percent of adults living with HIV who are female, 1990–2006,   52 2-3   PEPFAR’s network model,   70 6-1   Stages of illness and appropriate HIV/AIDS care services,   181 B-1   Nexus of evidence base and harmonization,   290 B-2   Showing examples of “triangulation” at two levels,   297 BOXES 1-1   Report Structure,   33 2-1   Multilateral Organizations Contributing to Responses to Global HIV/AIDS,   42 2-2   The Three Ones Principles for the Harmonization of National HIV/AIDS Responses,   44 2-3   UNAIDS Guidelines on Major Steps of Strategic Planning at the Country Level,   47 2-4   Major Elements of HIV/AIDS Programs Identified by UNAIDS,   48 2-5   Central Objectives of P.L. 108-25 for Strategy Development,   65 2-6   HIV/AIDS Activities of U.S. Government Agencies Implementing PEPFAR,   69 4-1   Selected Examples of PEPFAR-Supported Abstinence/Be Faithful Activities,   121 4-2   Selected Examples of PEPFAR-Supported Condoms and Other Prevention Activities,   124

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PEPFAR Implementation: Progress and Promise 4-3   Selected Examples of PEPFAR-Supported Activities Aimed at Preventing Mother-to-Child Transmission,   127 4-4   Selected Examples of PEPFAR-Supported Blood Safety Activities,   129 4-5   Selected Examples of PEPFAR-Supported Medical Injection Safety Activities,   130 4-6   Selected Examples of PEPFAR-Supported Prevention Activities That Include Gender Components,   132 5-1   Selected Examples of PEPFAR-Supported Resistance Monitoring Activities,   151 5-2   Selected Examples of PEPFAR-Supported Pediatric Treatment Activities,   152 5-3   Selected Examples of PEPFAR-Supported Nutritional Support Activities,   158 5-4   The WHO Prequalification of Medicines Project,   159 5-5   Institutions Comprising the Partnership for Supply Chain Management,   163 6-1   PEPFAR’s Definition of Palliative Care,   172 6-2   Training Specifications for Introducing Comprehensive Care into PEPFAR Home-Based Programs,   191 7-1   Selected Events Leading to the Development of The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS,   213 7-2   Key Strategies of UNICEF’s The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS,   216 7-3   Selected Examples of PEPFAR-Supported Activities Intended to Strengthen the Capacity of Families for Care and Support of Orphans and Other Vulnerable Children,   219 7-4   Selected Examples of PEPFAR-Supported Activities Intended to Mobilize and Support Community-Based Responses for Orphans and Other Vulnerable Children,   221 7-5   Selected Examples of PEPFAR-Supported Activities Intended to Ensure Access to Essential Services for Orphans and Other Vulnerable Children,   223 7-6   Selected Examples of PEPFAR-Supported Activities Intended to Ensure That Governments Protect the Most Vulnerable Children,   226 7-7   Selected Examples of PEPFAR-Supported Activities Intended to Create a Supportive Environment for Children and Families Affected by HIV/AIDS,   227 7-8   Selected Examples of PEPFAR-Supported Prevention Activities Targeting Orphans and Other Vulnerable Children,   228 8-1   Objectives of the Gender Technical Working Group,   251 B-1   Generic Agenda for Focus Country Visits,   294

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