# Presentation: 868114

## Slide 1

## Announcement of PEPFAR

- “ And to meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief -- a work of mercy beyond all current international efforts to help the people of Africa.”
- 			               -President George W. Bush, January 28, 2003

## Adults and Children Estimated to Be Living with HIV in 2006

**Adults and Children Estimated to Be Living with HIV in 2006**

- Source: UNAIDS, 2006

**Notes:**
4.3 million new infections in 2006 compared with 3.9 million new infections in 2004
2.9 million deaths in 2006 compared with 2.7 million in 2004

## The Transformational Power of Partnerships

- The Emergency Plan is part of a broader renaissance in partnerships for international development.
- The United States is changing the paradigm for development, rejecting the flawed “donor-recipient” mentality and replacing it with an ethic of true partnership.
- There is a growing consensus that the world’s response to global HIV/AIDS has undergone a transformation in recent years—and the new U.S. partnerships with hard-hit nations have been the catalyst.

**Notes:**
Trade not aid, need both trade and aid

## Recent USG Spending on Global HIV/AIDS

## International HIV/AIDS Commitments, by Donor, 2005*

- *Source: http://www.state.gov/documents/organization/70482.pdf

## PEPFAR Worldwide Activities

## The Focus Countries

- PEPFAR works predominately in 15 focus countries.  These countries are home to approximately half of all the world’s HIV infections**.**
- These countries were picked because, with U.S. support, they should be able to achieve national scale-up of HIV/AIDS prevention, treatment and care by 2009.
- PEPFAR’s 2-7-10 goals are to support:

-  Prevention of _7 million_ new HIV infections
-  Treatment of _2 million_ HIV-infected people
-  Care for _10 million_ infected with and affected by HIV/AIDS, including   orphans/vulnerable children

## Integrating Prevention, Treatment and Care

- 	When the history of global public health is written, it will highlight two main advances of PEPFAR:
- Massive commitment of resources tied to the accomplishment of clear numerical goals
- Integration of prevention, treatment and care to provide comprehensive programs

## The Power of Partnerships: Impact of Prevention

- The most recent UNAIDS report indicates that there were approximately 4.3 million new HIV infections in 2006.
- If this number continues to rise, it will soon overwhelm the world’s ability to respond and sustain that response.
- The Emergency Plan supports the most comprehensive, evidence-based prevention program in the world, targeting interventions based on the epidemiology of HIV infection in each country.

## Program Area Distribution using Standard International Divisions

## Prevention of Sexual Transmission

- PEPFAR supports the “ABC” approach to behavior change (Abstain, Be faithful, and the correct and consistent use of Condoms where appropriate).
- New data, from time periods that pre-date PEPFAR scale-up, link adoption of all three of the ABC behaviors to reductions in prevalence.
- In addition to earlier dramatic declines in HIV infection in Uganda, there is growing evidence of similar trends in other nations, including Botswana, Ethiopia, Haiti, Kenya, Tanzania, Zambia, and Zimbabwe.

## Prevention of Sexual Transmission

- In focus countries during fiscal year 2006, approximately 61.5 million people were reached by community outreach programs promoting ABC and other related prevention strategies.
- The U.S. Government has supplied 1.67 billion condoms worldwide from 2004 to 2006, lending support to comprehensive ABC approaches based on the epidemiology of each country.
- We have rapidly rolled out programs supporting new prevention strategies as they are identified, such as male circumcision. As other mechanisms are identified by normative agencies as effective prevention interventions, PEPFAR will support them as part of a comprehensive prevention strategy.

## Slide 14

**Notes:**
In Kenya a decline in HIV prevalence has been accompanied by changes in A and B indicators with little change in condom use for men but a substantial increase for women.

## Slide 15

**Notes:**
In a paper published this January in Science, Gregson et al showed improvements in A and B indicators for men accompanied that a significant decline in HIV prevalence.  There was no significant change in condom use.

## Prevention for Positives

**PEPFAR Supports Prevention for People Living with HIV/AIDS by:**
**Giving HIV-positive individuals information about protecting their own health**
**Encouraging and counseling all HIV-positive persons to prevent transmission of HIV **
**Promoting and providing condoms to all sexually active HIV-positive individuals**
**Integrating prevention interventions as a part of all HIV treatment and care services**

## HIV prevalence by age and sex

**Kenya**

**Cameroon**

**Lesotho**

**Malawi**

- Cross Generational Sex

**Notes:**
Turning to problems with Abstinence:  These are illustrative age and sex distributions of HIV prevalence for four African countries.  This is the classic distribution of HIV by gender and age seen throughout Africa.  Young women are infected at much greater rates than young men.  The assumption is that this is best explained by an age differential between the young women and their male partners who tend to be older.

There are many reasons for young women to engage in sex with older men.  Some of them are economic necessity; family and social pressures; coercion; and desire for material goods. 

## Addressing Gender Issues

- PEPFAR recognizes the critical need to address the inequalities between women and men that influence sexual behavior and put women at higher risk of infection.
- Many HIV prevention programs also address issues related to gender.
- Five priority gender strategies are monitored annually during the Country Operational Plan review process.
- In fiscal year 2006, a total of $442 million supported over 830 interventions that included one or more of these gender activities.

**Number of Activities per Gender Strategic Focus **
**Area in FY2006***

- *Source: PEPFAR Third Annual Report to Congress, 2007 (Page 15)

## Relationship between men’s lifetime sexual partners and HIV prevalence

**Notes:**
Now comes the wrinkle.  The number of lifetime sexual partners appears to be a pretty good predictor of individual risk but not population risk.   

These are data compiled by Dr. Martina Morris of the University of Washington. These are graphs of lifetime sexual partners by number of partner for three different countries in 1994.  One would have expected to see HIV prevalence trending up as the proportion of men reporting 10 or more lifetime sexual partners rose.   In fact there is little or no association one way or another.  

As you can see at that time, Uganda reported HIV prevalence of 18% prevalence while 20% of men reported 10 or more lifetime sexual partners. Contrast this with Thailand with a 2% epidemic showing and over 60% of men reporting 10 or more partners.  The united states with the lowest prevalence of the three had a distribution of life time sexual partners very similar to Uganda’s.  

## Low degree networks create a transmission core

- Bicomponents
- in red

- Source: Martina Morris, Univ. of Washington, used with permission from a presentation given at a
- meeting on concurrent sexual partnerships and sexually transmitted infections at Princeton University, 6 May 2006.

- Modeling Sexual Networks

**41%**
**  ****5%**

**64%**
**15%**

**10%**
**  ****1%**

**Notes:**
10,000 node network
These are 4 different iterations of a model of 10,000 sexually active persons demonstrating the resultant networks with different mean number of concurrent sexual partners.

## Condom use in regular partnerships

**Condom use in regular partnerships**

**Notes:**
This is not a blank slide.  This represents the extent to which we have been able to achieve any sort of condom use in regular partnerships.  These are data from Uganda Zimbabwe, Cameroon, Kenya, and Zimbabwe from the early to the late 1990s.  As you can see 3.5% of couples using condoms was the highest we could achieve.

## Prevention of Mother-to-Child Transmission

- As of September 30, 2006, PEPFAR has supported antiretroviral prophylaxis for HIV-positive women during 533,700 pregnancies.
- This has prevented an estimated 101,500 infant infections.
- In total, since the program’s inception, PEPFAR has supported PMTCT services for women during more than 6 million pregnancies.
- By promoting the routine, voluntary offer of HIV testing—so that women receive testing unless they elect not to receive it—host nations have increased the rate of uptake among pregnant women from low levels to around 90 percent at many sites.

## Estimated Coverage of PMTCT with USG Support in FY2004 and FY2006*

- *Source: PEPFAR Third Annual Report to Congress, 2007 (Page 14)

## Slide 24

## The Power of Partnerships: Impact of Treatment

- As of March 31, 2007, the Emergency Plan has supported antiretroviral treatment for  approximately **1,101,000** people in the 15 focus countries.
- When we compare this to the number of people estimated to be on treatment pre-PEPFAR — only 50,000 in sub-Saharan Africa — the benefits of our partnerships are clear.

## Number of Individuals Receiving Antiretroviral Treatment in the 15 Focus Countries

**Number of Individuals Receiving Antiretroviral Treatment**
**Total of both upstream and downstream USG-supported interventions**

**As of March 31, 2007**

## Life-Years Saved through Antiretroviral Treatment Programs

## National Treatment Coverage Supported by All Sources*

- *Source: PEPFAR Third Annual Report to Congress, 2007 (Page 18)

## Progress in PEPFAR Support for Treatment Coverage in Select Focus Countries, FY2004

## Progress in PEPFAR Support for Treatment Coverage in Select Focus Countries, FY2006

**Progress in PEPFAR Support for Treatment Coverage in Select Focus Countries, FY2006**

## Change in Median CD4 Count After 6 Months of ART

- Data presented by EGPAF Track 1.0 program, September 2007

## Access to Generic Antiretroviral Drugs

-  First process to approve a 3-in-1 combination for pediatrics
-  Through this process, 3 generic ARVs are now available in the US
-  As of September 2007, 51 generic ARV formulations have been approved or tentatively approved by the HHS/FDA.

- *Chart reflects generic ARV approvals as of September 2007

**Cumulative HHS/FDA Approvals/Tentative**
**Approvals of Generic ARVs***

## The Power of Partnerships: Impact of Care

- HIV/AIDS and associated opportunistic infections cause severe pain and debilitating symptoms in advanced stages.  Millions of orphans growing up without the support of their parents face increased vulnerability to violence and coercion — and to HIV.

## Number of Individuals Receiving Care in the 15 Focus Countries*

- *Source: PEPFAR Third Annual Report to Congress, 2007 (Page 22)

## The Power of Partnerships: Building Capacity

- PEPFAR estimates its investment in network development, human resources and local organizational capacity development and training in FY 2007 is roughly **$640 million**.
- In FY 2006, **83 percent** of partners were local organizations, which supported more than **15,000 project sites** for prevention, treatment and care.
- Through FY 2006, PEPFAR supported nearly **1.7 million training or retraining encounters**, as well as more than **25,000 service deliver sites**.
- The U.S. Government and other international partners can play a vital role, but outside resources for HIV/AIDS and other development efforts must be focused on transformational initiatives that are owned by host nations.

## The Power of Partnerships: Strengthening Systems

**In a study of 33 PEPFAR-supported sites providing antiretroviral treatment and associated care in 4 countries, PEPFAR supported 92% of the systems strengthening investments at a typical facility. **

## Impact of Basic HIV Care on the Broader Health System

| Non-HIV Health Indicators | Before intro of basic HIV Care | After intro of basic HIV Care | p value | Independent effects
 |
| --- | --- | --- | --- | --- |
| New family planning users | 9 | 13 | .012 | HIV exp
(p <.001) |
| Returning family planning users | 91 | 141 | .002 | HIV exp
(p <.001) |
| Total family planning users | 100 | 155 | .001 | HIV exp
(p <.001) |
| 1st trimester ANC visit | 5 | 10 | .001 | HIV exp (p=.010) |
| 2nd trimester ANC visit | 36 | 52 | <.001 | HIV exp
(p=.004) |
| ANC Coverage rate (all 4 visits) | 3.0% | 4.7% | .016 | HIV exp (p=.020) |
| Syphilis screening | 1 | 79 | <.001 | HIV (<.001) |

**A study by Family Health International at 30 primary health centers in Rwanda examined 22 non-HIV health indicators before and after the introduction of basic HIV care. Only 1 indicator declined, while 15 improved.**

## The Power of Partnerships: Strengthening Systems

**In the 7 sites included in the FHI Rwanda study that had been offering ART for more than 2 months, the average number of new hospitalizations decreased by 20.9 percent. **

## PEPFAR Support for Renovation of Existing PHCs

**PEPFAR Support for Renovation of Existing PHCs**

- Before HIV renovation work, October 2006

- After HIV renovation work, April 2007

**Rutobwe Primary Health Center Lab**

## PEPFAR Support for Renovation of Existing PHCs

- Mukoma Health Center Patient Waiting Area

- After Renovations, May 2007

**PEPFAR Support for Renovation of Existing PHCs**

## PEPFAR also Supports Construction of New Facilities

**Mwananyamla Hospital Care and Treatment Center - Tanzania**

## “That clinic we visited in Durban was made possible by an American program: PEPFAR, the President's Emergency Plan for AIDS Relief. Those lifesaving drugs, the salaries for the staff—even the prefab building—were all financed with American tax dollars.”  
			- Bill Gates, Opinion piece in the October 1, 				2007 edition of Newsweek

- 			- Bill Gates, Opinion piece in the October 1, 				2007 edition of *Newsweek*

**The Power of Partnerships: Building Capacity**

## The Power of Partnerships: Creating a Culture of Accountability

- PEPFAR’s support for capacity-building has important spillover effects that support nations’ broader efforts for sustainable development.
- Expanded health system capacity improves responses for diseases other than HIV/AIDS.
- Supply chain management capacity-building improves procurement for general health commodities.
- Improving the capacity to report on results fosters quality/systems improvement, and the resulting accountability helps to develop good governance and democracy.
- A growing number of nations are investing in fighting HIV/AIDS on a scale commensurate with their financial capacity.

## Next Generation of PEPFAR Indicators 

## Beyond 2008: The Next Phase of PEPFAR

- The American people must and will continue to stand with our global sisters and brothers as they take control of the pandemic and their lives and restore hope to individuals, families, communities and nations.
- Assuming Congress meets the President’s request for Fiscal Year 2008, and with the new $30 billion proposal, the American people have committed more than $48 billion across 10 years to fight HIV/AIDS.
- The next phase of PEPFAR will continue to expand life-saving treatment, comprehensive prevention programs and care for those in need, including orphans and vulnerable children, to support:

-  Treatment for 2.5 million people
-  Prevention of more than 12 million new infections
-  Care for more than 12 million people, including 5  million orphans and vulnerable children.** **

## Beyond 2008: The Next Phase of PEPFAR

_**The New Plan Emphasizes Continuation And Expansion**_
***Continuation*** – HIV/AIDS treatment, prevention and care are life-long needs, and the American people will continue to support those served during PEPFAR’s first 5 years.

***     ******Expansion*** – PEPFAR will further         	expand efforts to strengthen health 	systems, and to leverage programs 	that address malaria, tuberculosis, 	child and maternal health, clean water, 	food and nutrition, education and other 	needs. The Plan will emphasize 	transitioning from an emergency to a 	sustainable response for treatment,   	prevention and care.