AIDS Relief

U.S. Five-Year Global HIVAIDS Strategy

Emergency Plan for

The President’s
This report was prepared by the Office of the United States Global AIDS Coordinator in collaboration with

the United States Departments of State (including the United States Agency for International Development),

Defense, Commerce, Labor, Health and Human Services (including the Centers for Disease Control and

Prevention, the Food and Drug Administration, the Health Resources and Services Administration, the National

Institutes of Health, and the Office of Global Health Affairs), and the Peace Corps. 
F O F CI E OF THE

UNITED STATES

GLOBAL AIDS C

OORD NI

ATOR

AIDS Relief

U.S. Five-Year Global HIVAIDS Strategy

Emergency Plan for

The President’s

3

February 23, 2004

Dear Senator/Representative:

On behalf of the President of the United States, it is my pleasure to submit to you a comprehensive five-year

global strategy for President Bush’s Emergency Plan for AIDS Relief, as required by Section 101 of P.L. 108-25,

The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.

I am encouraged by the progress achieved in the four and a half months since I assumed the position of U.S.

Global AIDS Coordinator – by those working with me to create and launch the new Office of the U.S. Global

AIDS Coordinator, by my colleagues across the government, many of whom will play key roles in implementing

this plan, and by those across a wide spectrum outside the U.S. Government who have already provided valuable

input and advice, including those in countries in which we are working. This global strategy is an important part

of that progress. It is intended to address key questions raised by the legislation, as well as to define the strategic

direction of our activities – in the focus countries and around the world. 

The foundation for this effort is President Bush’s commitment to provide $15 billion over five years to fund the

Emergency Plan for AIDS Relief. Our strategy takes into account the pragmatic necessity that annual funding

requests within that commitment will ramp up as effective implementation capabilities are put in place and

expanded. It outlines our work through bilateral programs as well as the significant role that will be played by

multilateral partners such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria. And finally, it recognizes that national leadership is one of the critical factors in achieving success in the battle against HIV/AIDS.

Our priorities in carrying out this extraordinary humanitarian effort ultimately draw on that leadership and will

follow closely the strategies and priorities of the host countries we seek to assist. After all, their needs are what

this effort is all about.

This strategy has been carefully, thoughtfully, yet urgently developed with the knowledge that each day, 8,000

lives are lost to AIDS. Clearly, we do not have answers to every question we have identified. Working closely

with host governments, U.S. Government teams in the field, our various partners, and those living with AIDS,

we will continue to learn and to develop new or more comprehensive approaches. Our intent is to move ahead

without delay. At the same time, our strategy will evolve as we engage new partners and respond to innovation,

input, experience, and outcomes. It must be a living document – always a work in progress. We must maintain

flexibility and remain responsive to the ever-changing nature of the HIV/AIDS pandemic.

This plan reflects our current best thinking about what needs to be done and what we believe it is possible to

do. We have not tempered our aspirations with our knowledge of the magnitude of the challenges ahead. Yet we

do not underestimate the implementation difficulties the Emergency Plan will face. Addressing HIV/AIDS in the

developing world requires confronting overstressed and struggling health care systems with limited capacity to

provide treatment and care; social inequalities such as those involving the status of women, girls, and the poor;

and the varied economic and political circumstances (as well as diverse and deeply ingrained cultural patterns)

of each country. In addition, the sheer magnitude of the crisis, and its effect on present and future populations,

brings about consequences that reverberate from the individual to the international community, many of which

we are only beginning to understand. The challenges inherent in combating HIV/AIDS are very real, but if the

battle is not won – if instead citizens, many in their most productive years, die in greater and greater numbers –

opportunities for broad-based economic and social development will be set back for decades. 

In carrying out President Bush’s intent, our strategy is built on four cornerstones: (1) rapidly expanding services

by building on existing successful programs that are consistent with the principles of the Emergency Plan;

United States Department of State

Washington, D.C. 20520
4 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

(2) identifying new partners and building capacity for sustainable, effective, and widespread HIV/AIDS responses; (3) encouraging bold leadership and fostering a sound enabling policy environment for combating HIV/AIDS

and mitigating its consequences; and (4) implementing strong strategic information systems that will contribute

to continued learning and identification of best practices. We will pursue these strategies through collaborative

and coordinated processes that ensure programming that is responsive to local needs, is supportive of and

integrated with national strategies, and enlists the strengths and expertise of the many U.S. agencies and

departments, nongovernmental organizations including faith-based organizations, the private sector, and

multilateral institutions that have made vital contributions to combating HIV/AIDS. This strategy will ensure

that the President’s unprecedented commitment is a success. The Emergency Plan is the single largest up-front

commitment in history for an international public health initiative involving a specific disease.

In the short time I have held this position, I have been privileged to see firsthand the success that can be

achieved in fighting HIV/AIDS, even in some of the most under-resourced communities in the world. This

success is measured in lives saved, families held intact, and nations moving forward with development. I look

forward to working with you as we embark on transforming despair into hope worldwide.

Ambassador Randall L. Tobias

U.S. Global AIDS Coordinator
5

TABLE OF CONTENTS

Letter From Ambassador Randall L. Tobias, U.S. Global AIDS Coordinator . . . . . . . . . . . . . . . . . . . . . . . .3

I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

1. Strategic Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

2. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

II. The Global HIV/AIDS Emergency and the U.S. Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

1. The Global HIV/AIDS Emergency: A Severe and Urgent Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

2. President Bush’s Emergency Plan for AIDS Relief: The Hope of a New Approach . . . . . . . . . . . . . . . .16

3. Structure of the Strategic Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

III. Engendering Bold Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

IV. Critical Interventions in the Focus Countries: Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

V. Critical Interventions in the Focus Countries: Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

VI. Critical Interventions in the Focus Countries: Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

1. Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

2. Care for Orphans and Vulnerable Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

VII. Strengthening Bilateral HIV/AIDS Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

VIII. Strengthening Multilateral Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

IX. Implementation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

X. Supportive Interventions for U.S. Government Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

1. Supply Chain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

2. Evidence-Based Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

3. Public-Private Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

XI. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

A. Human Resource Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

B. Human Papilloma Virus in Sub-Saharan Africa and the Impact of Condom

Use on Its Spread . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79

C. Core Expertise of U.S. Government Agencies With Existing International HIV/AIDS Programs . . . .81

D. The Emergency Plan for AIDS Relief: USG Contributions

to Global HIV/AIDS, TB, and Malaria, FY 2003-2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

E. Focus Country HIV/AIDS Profile Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

F. U.S. Government HIV/AIDS Bilateral Programs of the President’s

Emergency Plan for AIDS Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 

G. The Emergency Plan’s Program-Level Monitoring Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

H. Summary of HHS Research Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89

I. USAID’s HIV/AIDS Research Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

J. Summary of Testimony and Recommendations Received 12/18/03 at the

PACHA Townhall Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

K. Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98

STRATEGIC GUIDANCE & EXECUTIVE SUMMARY 7

1. Strategic Guidance

The President’s Vision Statement describes our aspiration for the future. Our Mission Statement

describes our overarching approach to achieve the

vision. Our Goals identify the actions we will take,

then measuring the results to determine our progress

toward achieving our mission. Our Strategic

Principles describe many, but certainly not all, of the

principles that have driven our deeper thinking.

Our Vision:

President Bush’s Emergency Plan for AIDS Relief will

turn the tide of this global pandemic. 

Our Mission:

To work with leaders throughout the world to combat

HIV/AIDS, promoting integrated prevention, treatment, and care interventions, with an urgent focus on

countries that are among the most afflicted nations of

the world.

Our Goals:

Across the world, we will:

 Encourage bold leadership at every level to fight

HIV/AIDS; 

 Apply best practices within our bilateral

HIV/AIDS prevention, treatment, and care

programs, in concert with the objectives and

policies of host governments’ national HIV/AIDS

strategies; and

 Encourage partners, including multilateral organizations and other host governments, to coordinate

at all levels to strengthen response efforts, to

embrace best practices, to adhere to principles of

sound management, and to harmonize monitoring

and evaluation efforts to ensure the most effective

and efficient use of resources.

In the Emergency Plan’s 15 focus countries,1 we will:

 Provide treatment to 2 million HIV-infected

people;

 Prevent 7 million new HIV infections; and

 Provide care to 10 million people infected and

affected by HIV/AIDS, including orphans and

vulnerable children.

Our Strategic Principles:

We will respond with urgency to the global

HIV/AIDS crisis.

Recognizing that HIV/AIDS is a global emergency, we

will rapidly mobilize resources. We do not underestimate the implementation challenges the Emergency

Plan will face. The task is daunting. Nonetheless, we

are determined to reverse the momentum of increasing HIV/AIDS infections and stem suffering through

“Human dignity has been a part of our history for a long time. We fed the hungry after World War I. This country

carried out the Marshall Plan and the Berlin airlift . . . It’s nothing new for our country. But there’s a pandemic

which we must address now, before it is too late.”

President George W. Bush, January 31, 2003

I. EXECUTIVE SUMMARY

1 Botswana, Côte d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia in Africa; Guyana and

Haiti in the Caribbean; and a 15th country to be determined.

White House Photo Office
prevention, treatment, and care. Our strategic plan

lays the cornerstone of our approach. At the same

time, we must maintain flexibility and remain responsive to the ever-changing nature of the HIV/AIDS

pandemic. Our strategy will evolve as we seek new

partners and respond to innovation, input, experience, and outcomes. 

We will fight HIV/AIDS worldwide.

The United States has been and will continue to be a

world leader in combating HIV/AIDS. The President’s

Emergency Plan reinforces U.S. global leadership in

three key areas:

X Focusing significant new resources in 15 of

the most afflicted countries in the world;

X Consolidating our leadership, renewing our

commitment, and harmonizing our policy in

the more than 100 countries where we currently

have bilateral programs; and

X Amplifying the worldwide response to

HIV/AIDS through international partners,

including the Global Fund to Fight AIDS,

Tuberculosis, and Malaria.

We will actively seek new approaches.

Global HIV/AIDS is an unprecedented crisis

requiring an unprecedented response. The President’s

Emergency Plan for AIDS Relief is the boldest international health initiative ever undertaken by a single

country. It not only brings hope through the commitment of extraordinary resources, but, as important,

the opportunity to find new and more effective ways

to fight the HIV/AIDS pandemic. Our approach will

not be “business as usual.” 

We will use a new leadership model.

The United States Global AIDS Coordinator will

oversee and direct all U.S. Government (USG)

international HIV/AIDS activities in all departments

and all agencies of the Federal Government. This new

approach for the coordination and deployment of

resources from across the U.S. Government will result

in more effective and efficient programs that capitalize

on the skills and expertise of staff from across the U.S.

Government. 

We will make policy decisions that are

evidence-based.

We will build on the best practices established in the

fight against HIV/AIDS and bring the resources of

sound science to bear in selecting and developing

interventions that achieve real results. 

We will demand accountability for results. 

The President’s Emergency Plan will establish

measurable goals for which we will hold ourselves

and our partners accountable. In the focus countries

and throughout the world, effective monitoring and

evaluation systems will identify successful models for

scale-up and poorly performing programs for revision

or termination. 

We will implement programs suited to local needs

and host government policies and strategies.

We will implement programs that are coordinated

with the policies and strategies of host governments

and are responsive to local needs. Countries and communities are at different stages of HIV/AIDS response

and have unique drivers of HIV, distinctive social and

cultural patterns (particularly with regard to the status of women), and different political and economic

conditions. Effective interventions must be informed

by local circumstances and coordinated with local

efforts. The U.S. Global AIDS Coordinator will

provide the strategic direction, the “what” for USG

programs. Each U.S. Chief of Mission will lead a coordinated U.S. Government country team to identify

the “how,” through program implementation that is

directed by a USG country plan, responsive to local

needs and circumstances, and coordinated with the

host government’s national HIV/AIDS strategy. 

We will develop and strengthen integrated

HIV/AIDS prevention, treatment, and care

services.

The President’s Emergency Plan is unmatched in its

commitment to provide prevention and treatment

and care services, with the knowledge that these

efforts are enhanced through their integration. In

the absence of treatment and care, HIV infection is

perceived as a death sentence, hindering prevention

efforts as fear inhibits people from seeking testing

services and internalizing prevention messages. The

availability of treatment and care, in addition to prolonging life and easing the suffering of the infected

and affected, amplifies prevention efforts by offering

incentives to seek HIV/AIDS information, get tested,

and declare HIV status.

We will develop sustainable HIV/AIDS health

care networks.

We recognize the limits of health resources and capacity in many, particularly rural, communities. To more

effectively address that shortfall, we will build on and

strengthen systems of HIV/AIDS health care based on

the “network” model. Prevention, treatment, and care

protocols will be developed, enhanced, and promoted

in concert with local governments and ministries of

health. With interventions emphasizing technical

8 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
STRATEGIC GUIDANCE & EXECUTIVE SUMMARY 9

assistance and training of health care professionals,

health care workers, community-based groups, and

faith-based organizations, we will build local capacity

to provide long-term, widespread, essential HIV/AIDS

services to the maximum number of those in need. 

We will employ the prevention lessons learned from

the “ABC” model.

Uganda’s success has identified the “ABC” model

(Abstinence, Be faithful, and, as appropriate,

correctly and consistently use Condoms) as an

effective HIV/AIDS prevention tool. We will promote

the proper application of the ABC approach, through

population-specific interventions that emphasize

abstinence for youth, including the delay of sexual

debut and abstinence until marriage; HIV/AIDS

testing and fidelity in marriage and monogamous relationships; and correct and consistent use of condoms

for those who practice high-risk behaviors.

We will combat stigma and denial.

Stigma remains a primary barrier to combating

HIV/AIDS. Fear of disease and discrimination inhibits

people from seeking and offering information, testing,

treatment, and care. HIV travels swiftly and surely

under cover of silence and denial. We will take

leadership, and encourage leadership, in promoting

the message that HIV is a virus that knows no borders, discriminates against no race, no gender, and no

class. We will encourage people to fight the disease,

not the people who live with it, and to treat people

infected and affected by AIDS not with cruelty and

discrimination but with dignity and compassion.

We will seek new strategies to encourage

HIV/AIDS testing.

The war against HIV/AIDS begins with prevention.

The disease cannot be conquered unless new infections are eliminated. Forty million people worldwide

are already infected with HIV, and each day 14,000

more are added to their ranks. Alarmingly, the vast

majority do not know they are infected and unknowingly pass the virus to others. People have not wanted

to be tested, in part because a positive result was a

death sentence. Knowledge about the President’s

commitment to antiretroviral treatment and care will

encourage testing. Knowledge of HIV status is a vital

tool for helping individuals avoid behaviors that place

them at risk of HIV infection, leading people to protect themselves and others from HIV infection. We

will seek and promote new strategies to dramatically

increase HIV testing.

We will encourage bold national leadership.

Where national leaders have taken early and effective

action to publicly acknowledge HIV/AIDS as a problem in their countries, raised and devoted appropriate

resources, and demanded broad involvement, the

battle against HIV/AIDS is meeting success. Through

effective diplomacy and communication, we will

engender new leadership at every level – from

national statesmen to village elders – in the fight

against HIV/AIDS.

We will seek the involvement of people infected

with and affected by HIV/AIDS.

People infected with and affected by HIV/AIDS have

unique contributions to make in identifying their

needs, testifying to program effectiveness, advocating

for an improved response, and combating stigma and

discrimination. We will encourage the input of these

individuals so that we respond more effectively to the

needs of these people, who are among those the

Emergency Plan seeks to serve. 

We will encourage and strengthen faith-based and

community-based nongovernmental organizations.

Faith-based and community-based organizations were

among the first responders to HIV/AIDS, caring for

fellow human beings in need. Their reach, authority,

and legitimacy identify them as crucial partners in the

fight against HIV/AIDS. We will encourage their

involvement, and, in particular, we will welcome new

partners with innovative ideas.

We will maintain our own focus while coordinating

with other partners.

Our focus, worldwide, is on achieving targeted goals

within HIV/AIDS prevention, treatment, and care.

Other entities contribute vital efforts to these goals

and to combating the drivers and consequences of

HIV/AIDS. This pandemic is one of the most complex crises the world has encountered, and all of these

efforts are necessary and important. Each of our

efforts is amplified when we work in concert toward

the overarching shared goal of eradicating HIV/AIDS

and the devastation it wreaks. 

2. Summary

The Global HIV/AIDS Emergency and

the U.S. Response

The global HIV/AIDS pandemic is one of the

greatest challenges of our time. Worldwide, over 40

million people are now infected, and each day 14,000

more are added to their ranks. In claiming the lives of

societies’ most productive populations – adults ages

15 to 45 – HIV/AIDS threatens a basic principle of

development, that each generation does better than

the one before. 
Four months after his inauguration, President

George W. Bush began an historic expansion of the

U.S. Government’s commitment to global HIV/AIDS

when he announced the founding donation of $200

million that established the Global Fund to Fight

AIDS, Tuberculosis, and Malaria. Shortly thereafter

he initiated his International Mother and Child HIV

Prevention Initiative and, in his 2003 State of the

Union address, he announced his historic Emergency

Plan for AIDS Relief – the largest and boldest assault

on the global AIDS pandemic in history. Other global

leaders have also taken action against the crisis of

HIV/AIDS, and there are many successes to build

upon. Nonetheless, significant challenges remain.

Treatment remains out of reach for the vast majority

of those who need it. The lack of basic care and

support services leaves millions in daily pain and suffering. The ever-growing orphan population is straining community support mechanisms, with little to fill

the gaps. Inadequate leadership and enduring stigma

keep HIV spreading swiftly and surely under cover

of silence. Combined, these challenges necessitate a

complex response to delivering prevention, treatment,

and care services to the many who are in need. 

President Bush has responded to the challenge of

global HIV/AIDS with his Emergency Plan for AIDS

Relief. The Emergency Plan targets $9 billion in new

funding to dramatically ramp up prevention, treatment, and care services in 15 of the most affected

countries of the world representing at least 50 percent

of HIV infections worldwide. The Emergency Plan

also devotes $5 billion over five years to ongoing

bilateral programs in more than 100 countries and

increases our pledge to the Global Fund to Fight

AIDS, Tuberculosis, and Malaria by $1 billion over

five years. 

President Bush’s Emergency Plan also demands a

new way of doing business that will transform U.S.

Government HIV/AIDS activities worldwide. It

makes a revolutionary commitment to providing integrated prevention, treatment, and care services to

those infected with and affected by HIV/AIDS, and

establishes measurable goals against which progress

will be tracked and evaluated. Policy and program

decisions will be evidence-based and results-driven.

New partners and innovations will be actively sought

and rigorously evaluated. The President’s Emergency

Plan will be implemented under new leadership from

the U.S. Global AIDS Coordinator, coordinating, in

the United States and in the field, the work of all U.S.

agencies fighting HIV/AIDS globally. 

President Bush has demanded that the U.S.

Government’s approach to global HIV/AIDS be

focused, coordinated, and accountable for results. It

capitalizes on specialized expertise and the strengths

of partnerships with host governments, multilateral

institutions, nongovernmental organizations, and the

private sector. 

Engendering Bold Leadership

As President Bush has demonstrated, leadership is

an essential enabler for HIV/AIDS efforts, spurring

action and magnifying its effects. In highly impacted

countries and those experiencing emerging epidemics,

leadership is required from the statehouse to the

village to combat stigma, denial, and misinformation;

influence cultural patterns; and mobilize new partners, action, and resources. For those countries with

the means to be international donors, national leaders

are in a position to increase public and private

international HIV/AIDS assistance. The U.S. Government, under President Bush’s leadership, will use its

position and influence to encourage others to demonstrate similar bold leadership that is necessary to win

the war against AIDS. Through proactive diplomacy

and communications, the United States will engender

greater leadership at every level in the fight against

HIV/AIDS.

Critical Interventions in the Focus Countries 

Within prevention, treatment, and care interventions,

activities will focus on rapidly scaling up existing

successful programs to immediately stem the tide

and halt suffering attributable to HIV/AIDS. They

will also focus on expanding partnerships; building

capacity for effective, innovative, and sustainable

services; creating a supportive and enabling policy

environment for combating HIV/AIDS; implementing

strong monitoring and evaluation systems to identify

best practices; evaluating progress toward goals; and

ensuring compliance with Emergency Plan policies

and strategies. 

Prevention

Prevention remains the primary strategy to combat

HIV/AIDS. Despite two decades of focused attention

on prevention, however, we have yet to achieve

widespread success. Inappropriate and inconsistent

prevention messages, stigma, gender inequality, poor

knowledge of HIV status, limited testing strategies,

medical transmission of HIV through unsafe injections and blood supply, and HIV transmission from

mother to child continue to fuel the spread of HIV.

President Bush’s Emergency Plan is specifically

designed to address these challenges by using evidence-based prevention programs such as the “ABC”

approach of Abstinence, Be faithful, and as appropriate, the correct and consistent use of Condoms.

Other identified best practices to achieve real results

10 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
STRATEGIC GUIDANCE & EXECUTIVE SUMMARY 11

in reducing the number of new infections include

increased testing; appropriately tailored interventions

for specific populations including women, men, and

high-risk groups; the involvement of people living

with HIV/AIDS, parents, and leaders from all sectors

of society; and stigma reduction.

Treatment

Fewer than 8 percent of the 6 million people in

resource-limited settings in immediate need of

antiretroviral treatment currently receive it. A strong

focus on treatment underlies the Emergency Plan.

President Bush’s vision that each human life has

dignity and that the most vulnerable people in the

world living with HIV/AIDS should have access to

antiretroviral treatment guides the U.S. Global AIDS

Coordinator’s implementation activities. Providing

treatment may be our best hope against the disease

and the devastation it wreaks. Availability of treatment provides an incentive to get tested; reduces stigma; and, in restoring health, mitigates consequences

of the disease such as loss of productivity, dramatically

increased poverty, and growing orphan populations.

The Emergency Plan will build on established

clinical programs and develop the necessary infrastructure, staff, and technical capacity to provide

long-term, widespread, high-quality, safe, and

essential HIV/AIDS services to the maximum number

of people in need. In addition, it will contribute to

the development of appropriate treatment protocols

and policies to ensure safe and effective treatment

services, drug supply, and equitable distribution of

health resources.

Care

Care services under President Bush’s Emergency

Plan include both palliative care for people living

with HIV/AIDS and care for orphans and other vulnerable children affected by HIV/AIDS. HIV/AIDS

and associated opportunistic infections cause severe

pain and debilitating symptoms for many with

advanced disease. Poor health contributes to reduced

productivity and diverts meager resources, leading to

myriad consequences including diminished food security. At the same time, millions of orphans growing up

without the support of their parents face increased

vulnerability to HIV, violence, sexual coercion, and

reduced access to essential services such as health

care and education. 

The President’s Emergency Plan seeks to mitigate

these consequences by building the capacity of professional and family- and community-based health care

providers to provide palliative care, by strengthening

health care referral networks, and by ensuring necessary supplies. For orphans and vulnerable children,

the Emergency Plan seeks to strengthen the capacity

of extended families and communities to care for

orphans and to advance policy and legal reforms related to inheritance, access to basic social and protective

services in order to enable supportive environments

for children’s growth and development.

Strengthening Bilateral HIV/AIDS Programs 

President Bush has called upon political leaders

around the world to address the HIV/AIDS crisis

and to partner with the United States under a shared

vision of human dignity and access to treatment, prevention, and care. His Emergency Plan offers a fresh

opportunity to develop and implement consistent

HIV/AIDS policies and programs across our existing

bilateral prevention, treatment, and care programs.

By drawing on the body of evidence collected over 20

years, new evidence-based lessons and insights from

Emergency Plan initiatives in focus countries, and the

U.S. Government’s strong field presence and technical

expertise, the Office of the U.S. Global AIDS

Coordinator will work to harmonize in policy and

management our bilateral programs worldwide.

Strengthening Multilateral Actions

The Bush Administration has recognized the importance of multilateral approaches to fighting the global

HIV/AIDS pandemic. The President’s early and

aggressive support of the Global Fund to Fight AIDS,

Tuberculosis, and Malaria has enabled this important

mechanism of funding HIV/AIDS programs to begin

to fulfill its potential. The contributions of other multilateral institutions and international organizations

working with great dedication to combat HIV/AIDS

provide a vital opportunity for a comprehensive

response. The diverse drivers and consequences of

HIV/AIDS, and its many complicated interactions

with a variety of other social, political, and economic

circumstances, demand an equal number of diverse

actors with varied expertise. The President’s

Emergency Plan commits a significant proportion of

its resources to the Global Fund to Fight AIDS,

Tuberculosis, and Malaria in recognition of the fact

that the Global Fund is a promising global force in

the fight against AIDS, tuberculosis, and malaria, and

offers important opportunities to address needs complementary to other elements of the Emergency Plan.

Other multilateral institutions and international

organizations, such as the Joint United Nations

Program on HIV/AIDS, the World Health

Organization, and the World Bank, have also

provided essential global leadership, expertise, and

resources. The U.S. Government will strengthen its

relationships with multilateral institutions and international organizations to amplify global action against

HIV/AIDS by encouraging coordination, based on
comparative strengths, to fill gaps in current activities,

avoid duplication of efforts, and ensure efficient and

effective use of resources. 

Implementation and Management

Meeting the challenge of the global AIDS crisis is

a monumental task that will require – along with

strong leadership and vision – robust and flexible

administrative structures. President Bush has set

clear goals for his Emergency Plan and has insisted

that the U.S. Global AIDS Coordinator’s response

be rapid, effective, and evidence-based, and make

efficient and focused use of all relevant government

capabilities through coordination, collaboration, and

cooperation across U.S. Government agencies. It must

also reflect administration policy and statute; respond

to the diverse needs of the various communities

around the world in which the U.S. Government

works; and account for progress toward achieving

these goals. Four primary processes underlie this

approach:

 Coordination. President Bush created the position

of the U.S. Global AIDS Coordinator, who shall

have primary responsibility for the oversight and

coordination of all resources and international

activities of the U.S. Government to combat the

HIV/AIDS pandemic. The U.S. Global AIDS

Coordinator is thus responsible for both internal

and external coordination of HIV/AIDS activities.

Internal coordination is carried out by country-specific response teams comprising staff from the

implementing agencies and the Office of the U.S.

Global AIDS Coordinator. In Washington, coordination between various federal agencies is achieved

through multiple methods of communication, joint

project planning, and policy development. External

coordination with non-U.S. Government stakeholders, including host-country governments

and multilateral institutions, is carried out both

through in-country coordination led by field staff

and through proactive liaising on the part of the

U.S. Global AIDS Coordinator.

 Planning. At the core of the implementation

strategy is an ongoing in-country planning effort,

beginning with the focus countries. Chiefs of

Mission in each country will lead a strategic planning process, aided by the Office of the U.S. Global

AIDS Coordinator and involving all relevant U.S.

Government entities, host-country governments,

nongovernmental organizations, the corporate sector, multilateral institutions, and other in-country

stakeholders. This process will result in individualfive-year country strategies and annual operational

plans for strengthening the quality, availability, and

sustainability of prevention, treatment, and care

services. Plans will be submitted to the U.S. Global

AIDS Coordinator for review. Final approval by

the Coordinator will ensure consistency with

Congressional intent, Administration policy, and

the Coordinator’s strategic objectives. 

 Allocation of Funding. The President’s Emergency

Plan relies on a variety of funding allocation mechanisms in order to maximize flexibility and encourage innovation while responding to specific country

needs: 

X Funding levels by country will be allocated on

the basis of the country’s five-year strategic

plan, and funds will be released upon approval

of annual country operational plans by the U.S.

Global AIDS Coordinator. 

X Central funding mechanisms developed and

approved by the Office of the U.S. Global AIDS

Coordinator will fund regional initiatives serving

more than one country, such as professional

training or twinning for which organizations will

provide technical assistance on a regional basis. 

X Funding decisions will be based upon performance in reaching annual prevention, treatment,

and care targets. Strategic information will guide

allocation of resources for maximum impact and

ensure accountability to American taxpayers. 

 Communications. President Bush has insisted

that implementation be transparent and

accountable. The U.S. Global AIDS Coordinator

will ensure that the public is given timely, accurate,

and complete information regarding the President’s

Emergency Plan for AIDS Relief. A variety of

mechanisms, including Web technology, reports

to Congress, and media outreach will serve

this purpose.

Supportive Interventions for U.S. Government

Programs

Interventions that support implementation of the

President’s Emergency Plan include an effective and

accountable supply chain; a strong research program

to provide the evidence base necessary to guide policies and programs, including a coordinated strategic

information system; and enhanced public-private

partnerships.

 Supply chain management is critical to ensure a

secure and sustainable supply of quality essential

drugs, materials, and equipment for HIV/AIDS

programs. Supply chain management systems will

be coordinated with complementary programs and

will reduce and eliminate diversion, counterfeiting,

12 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
STRATEGIC GUIDANCE & EXECUTIVE SUMMARY 13

and the sale of HIV/AIDS products and supplies

on the black market. 

 A strong evidence base will provide new knowledge

and give direction to policy and program decisions.

Strategic information systems will track programs

to ensure they are meeting targets and having

measurable impact. Best practices for HIV/AIDS

treatment, prevention, and care will be identified

through both of these processes. 

 Public-private partnerships will mobilize the

private sector to leverage resources and capabilities

across all sectors, including contributions to building sustainable systems of HIV/AIDS treatment,

prevention, and care. The comparative advantages

of these partnerships will be maximized to

complement services provided by the public and

nongovernmental/faith-based organization sectors.

THE GLOBAL HIV/AIDS EMERGENCY AND THE U.S. RESPONSE 15

1. The Global HIV/AIDS

Emergency: A Severe and

Urgent Crisis

President Bush has recognized that the global

HIV/AIDS pandemic is one of the greatest health

challenges of our time. Worldwide, over 40 million

people are now infected, and each day 14,000 more

are added to their ranks. Over 25 million have lost

their lives to the disease, leaving behind anguished

loved ones, orphaned children, and ravaged communities. The burden of disease, pain, and suffering is

immense and growing every day. More than 13 million children have been orphaned by AIDS, leaving

families and communities to face the challenges of

providing guidance, health care, education, love, and

hope. These children are often vulnerable to the worst

forms of child labor and risk dropping out of school.

The disease has turned back many of the hard-won

development gains of the 20th century, reducing life

expectancy, increasing child mortality, and threatening fragile democracies as nations are overcome by

political, social, and economic instability. AIDS strikes

at the heart of hope, progress, and potential by claiming lives and causing untold suffering. Some of the

most affected are societies’ most productive populations – parents and teachers, police officers and

government workers, farmers and health care

providers. In robbing societies of these individuals,

AIDS threatens a basic principle of development, that

each generation does better than the one before it.

The greatest burdens of disease are concentrated in

developing countries least able to cope. The countries

of sub-Saharan Africa and the Caribbean are home to

nearly 30 million people with HIV/AIDS, nearly 70

percent of the world’s total. HIV/AIDS has deepened

poverty and diverted state resources in regions already

struggling with overburdened health systems and populations living on less than $2 per day. It has fueled a

resurgence of the tuberculosis epidemic, further exacerbating strained health resources and compounding

the suffering of those infected and affected by

HIV/AIDS. 

Emerging epidemics in India, China, and Eastern

Europe threaten to become new epicenters of the disease. Given current infection rates and limited health

services, these regions may compete with central and

southern Africa as home to the greatest number of

HIV-infected individuals by the end of the decade.

Like President Bush, the international community and

many national leaders have taken action against the

crisis of HIV/AIDS, and there are many successes to

build upon. The United Nations General Assembly

Special Session on HIV/AIDS affirmed the international community’s commitment to progress against

HIV/AIDS and provided the foundation for mobilizing

significant resources to fight it. The Global Fund to

Fight AIDS, Tuberculosis, and Malaria and other multilateral institutions, such as the Joint United Nations

Program on HIV/AIDS (UNAIDS) and various other

U.N. agencies, have made vital contributions.

“The legislation [P. L. 108-25] that I sign today launches an emergency effort that will provide $15 billion over

the next five years to fight AIDS abroad. This is the largest single up-front commitment in history for an international public health initiative involving a specific disease. America makes this commitment for a clear reason,

directly rooted in our founding. We believe in the value and dignity of every human life.”

President George W. Bush, May 27, 2003

II. THE GLOBAL HIV/AIDS EMERGENCY

AND THE U.S. RESPONSE

White House Photo Office
We now have proven methods for combating

HIV/AIDS, including effective strategies that highlight abstinence and fidelity, fight stigma and denial,

and partner government with civil society. We know

that leadership is essential and that early and effective

action can contain and even roll back epidemics.

Most importantly, where there used to be a “prevention versus treatment” debate, today few dispute that

we must do both.

However, significant challenges face all nations,

donors, institutions, and individuals attempting to

respond to the global AIDS pandemic. Treatment

continues to be out of reach for the vast majority of

those who need it. The lack of basic care and support

services leaves millions in daily pain and suffering.

Limited infrastructure and human resource capacity

in affected countries constrain their ability to respond

to the HIV/AIDS crisis overtaking their communities.

The ever-growing orphan population is straining community support mechanisms, with little to fill the

gaps. Inadequate leadership and enduring stigma keep

HIV spreading swiftly and surely under cover of

silence. Insufficient coordination and evaluation of

programs contribute to the inefficient use of funds

and ineffective interventions. Combined, these challenges necessitate an extremely complex response to

delivering HIV/AIDS prevention, treatment, and care

services to the many who are in need.

Without intervention, experts predict that over 100

million people will be infected worldwide by 2010,

with a cumulative loss of human life to AIDS totaling

100 million by 2020. We cannot let that happen.

With our partners worldwide, we will turn the tide

against HIV/AIDS and release its stranglehold on

the future.

2. President Bush’s Emergency

Plan for AIDS Relief: The Hope of

a New Approach

President Bush has responded to the challenge of

global HIV/AIDS with his Emergency Plan for AIDS

Relief. The Emergency Plan brings unprecedented

resources to bear against the disease. Committing $15

billion over five years, the President’s initiative is the

largest commitment in history by a single nation for

an international health initiative. The Emergency

Plan makes a revolutionary commitment to providing

resources for treatment for HIV-infected individuals,

a vital intervention that many have thought could

not be offered in developing-country environments.

President Bush has asserted that “in the face of preventable death and suffering, the United States has

the power and moral duty to act,” and the Emergency

Plan will focus on bringing life-extending HIV/AIDS

treatment to some of the most afflicted and underresourced countries in the world. 

The Emergency Plan strongly supports integrated prevention, treatment, and care with the knowledge that

the availability of each enhances the effect of all.

Prior interventions have focused on preventing HIV

transmission, correctly acknowledging that the war

against the disease cannot be won unless new infections are prevented. But prevention efforts have been

hindered by the limited availability of treatment and

care. Lack of treatment has contributed to fear of and

stigma against the disease, discouraging people from

seeking testing and disclosing their status to partners,

a necessary step for preventing HIV transmission.

The priorities defined above – providing treatment in

some of the most afflicted nations, and integrating

prevention, treatment, and care – are reflected in the

breakdown of the initiative’s funding. The Emergency

Plan targets $9 billion in new funding to dramatically

ramp up prevention, treatment, and care services in

15 of the most affected countries of the world,2 representing at least 50 percent of HIV infections worldwide. At the same time, President Bush’s Emergency

Plan devotes $5 billion over five years to existing

bilateral efforts to support HIV/AIDS, tuberculosis,

and malaria programs and research, and pledges $1

billion over five years to the Global Fund to Fight

AIDS, Tuberculosis, and Malaria. Through intensive

intervention in areas with the highest concentration

of disease and strengthened programs worldwide, the

United States and its partners will defeat AIDS.

The Emergency Plan is defined by more than the

unprecedented commitment of resources. Through his

Emergency Plan, President Bush has also demanded a

new way of doing business that will transform our

HIV/AIDS activities worldwide. His Emergency Plan

will demand high levels of accountability and will

establish measurable goals against which progress will

be tracked and evaluated, with funding decisions

based on performance toward these goals. Policy and

program decisions will be evidence-based and results16 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

2Through President Bush’s Emergency Plan for AIDS Relief, the United States will continue to work throughout the world to combat HIV/AIDS, tuberculosis, and malaria through bilateral programs, providing $5 billion in baseline funds over five years. Bilateral programs will also be harmonized to incorporate new best practices. New funding of $9 billion over five years will focus on countries that are among the most afflicted in Africa and the Caribbean:

Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. These

14 countries are also the focus of the President’s International Mother and Child HIV Prevention Initiative. Per the requirement in P.L. 108-199 (FY 2004

Consolidated Appropriations bill), a 15th country will be named shortly as a focus country not located in Africa or the Caribbean region.
THE GLOBAL HIV/AIDS EMERGENCY AND THE U.S. RESPONSE 17

driven. The Emergency Plan will be implemented under

new leadership from the U.S. Global AIDS Coordinator,

reporting directly to the Secretary of State and coordinating, in the United States and in the field, the work

of all U.S. agencies fighting HIV/AIDS globally. With

the core expertise of various U.S. agencies reoriented

and redirected toward a coordinated, focused mission

to achieve measurable goals, our progress against

HIV/AIDS will be greatly amplified. 

The President’s Emergency Plan dramatically expands

upon two decades of the United States’ global leadership in the fight against HIV/AIDS. The United States

has been the primary contributor to HIV/AIDS

research, instrumental to the development of tools

ranging from testing to treatment, as well as projects

that provide hope for the future, such as vaccines and

microbicides. Under President Bush’s leadership, the

United States currently provides over 50 percent of all

bilateral funding to combat global AIDS; was a founding member of the Global Fund to Fight AIDS,

Tuberculosis, and Malaria; and is the Fund’s largest

donor, responsible for over 37 percent of all pledges

to it. The Secretary of Health and Human Services is

lending additional U.S. leadership and support to the

Fund as Chair of its Board through 2005. 

Through their field presence in over 100 countries, U.S.

agencies have provided essential technical assistance

and training to strengthen HIV/AIDS programs worldwide. The President’s International Mother and Child

HIV Prevention Initiative, established in 2002 to reduce

mother-to-child HIV transmission by 40 percent within

five years in the Emergency Plan’s 14 focus countries,

has laid the groundwork for the strategies that the

Emergency Plan will pursue. It has also provided additional evidence and knowledge on the feasibility – and

necessity – of integrated prevention, treatment, and

care programs. 

Following President Bush’s lead, we embark on this new

phase of our global leadership in the fight against

HIV/AIDS with hope and humility, knowing that our

efforts must be grounded in partnership, collaboration,

and compassion. The world is poised to halt and reverse

the devastation wrought by HIV/AIDS, with the historic opportunity to confront the challenges and

achieve dramatic results. With a fundamental belief in

the value and dignity of every human life, as articulated

by President Bush, the United States is capitalizing on

its expertise and the strengths of its partnerships with

host governments, multilateral institutions, nongovernmental organizations, and the private sector to take

bold action against HIV/AIDS. 

3. Structure of the Strategic Plan

Critical interventions to reach the goals of President

Bush’s Emergency Plan are presented in the following

chapters. Chapter III emphasizes the need for bold

leadership from all sectors, and in all nations, and

describes strategies the United States will pursue to

bring voice and additional resources to the fight against

global AIDS. Chapters IV, V, and VI describe strategies

for integrating and strengthening prevention, treatment,

and care activities in the focus countries. Chapter VII

illustrates how the Emergency Plan will direct U.S.

Government HIV/AIDS activities in countries beyond

the focus countries where today we have existing bilateral programs. Chapter VIII identifies methodologies

for engagement with multilateral institutions and joint

The Integrated HIV/AIDS Prevention,

Treatment, and Care Model

President Bush’s Emergency Plan is based on the

established best practice of providing a continuum of care consisting of a full range of integrated HIV/AIDS services. The availability of each

of the continuum’s activities – prevention, treatment, and care – strengthens and reinforces the

effect of each intervention. Prevention activities

such as HIV/AIDS education and awareness,

behavior change, and testing are thus more

effective when combined with treatment and

restorative or curative care, including such services as routine follow-up of HIV-infected individuals prior to receiving antiretroviral therapy,

control of symptoms, end-of-life care, and

bereavement support. All three interventions

are mutually supportive, so that over time, as

the availability of treatment (e.g., antiretroviral

drugs) grows under the Emergency Plan, the

need for palliative care will decrease. 

Care for orphans and vulnerable children is

another critical component of the Emergency

Plan. The strategy emphasizes mitigating the

consequences of disease to this population and

reducing their risk and vulnerability to HIV.

The difficulties faced by children orphaned by

HIV/AIDS represent some of its greatest shortand long-term consequences. In providing

prevention, treatment, care, bereavement,

and other support services to children, orphan

care further reinforces the synergies of integrated service delivery. Wherever appropriate,

services for orphans and vulnerable children

will be linked to the health care and human

services network.
ventures for an amplified global HIV/AIDS response.

Implementation and management strategies are

presented in chapter IX. Interventions that support

strengthened programming and accountability in USG

initiatives, including issues related to supply chain

management and the role of research and strategic

information, are presented in chapter X. Chapter XI

presents special topics of congressional interest and

other appendices. 

18 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
ENGENDERING BOLD LEADERSHIP 19

President Bush’s bold and agressive attack on global

HIV/AIDS has made it clear – leadership is essential

to battling HIV/AIDS. Early and effective action by

high-level political leaders can contain and even roll

back epidemics, as evidenced in Uganda, Thailand,

and Senegal. Where leaders have been silent, inactive, or worse – combative, or propagating incorrect

or stigmatizing messages – HIV continues to spread

despite the best efforts of communities and contributors. Leadership is an essential enabler for HIV/AIDS

efforts, spurring action and magnifying its effects.

Heads of state wield enormous power, authority,

and legitimacy. They can combat stigma, denial, and

misinformation through forthright discussion of the

nature of the disease and thus lead citizens to change

their behavior. They can influence cultural patterns

that contribute to the spread of disease, including

gender inequity. By demonstrating that all sectors of

society must contribute to the battle against AIDS

and applying appropriate levels of human and financial resources to prevention, control, and treatment

activities, they are powerful mobilizers of new partners, action, and resources. It is political leadership

that ensures a multisectoral response, proven crucial

to combating HIV/AIDS effectively.

The need for leadership is not limited to heads of

state. At both the national and community levels,

wide-ranging leadership is needed in civilian government, the military, medical institutions, ethnic and

cultural groups, corporations, labor unions, schools

and universities, religious institutions, nongovernmental organizations (NGOs), and the media. Those who

lead and influence people and organizations have the

capacity, and the duty, to make a dramatic difference

in stemming the spread of the epidemic and supporting the necessary treatment and care for those

infected and affected by AIDS.

The need for leadership is also not limited to highly

impacted countries. Every country has a starting point

for the epidemic. Early leadership can determine the

difference between societies that experience low

incidence of disease and those held hostage by raging

epidemics. In many countries, low overall prevalence

rates often mask firmly entrenched epidemics in highrisk groups, such as injection drug users, sex workers,

and men who have sex with men. Epidemics among

these often disenfranchised communities must be

addressed to conquer the disease. Too often, patterns

of official denial and stigmatization have led to widespread epidemics.

President Bush has called for leadership against AIDS

from every nation. For those countries with the means

to be international donors, national leaders are in a

position to increase public and private international

HIV/AIDS assistance. The United States is continuing to show unprecedented global leadership and

commitment in funding the global AIDS response. In

2002 and 2003, the U.S. Government gave international contributions greater than those of all other

donor governments combined. Assuming level funding by other donors, U.S. international contributions

in 2004 will be approximately twice those of the rest

of the world’s donor governments combined. Given

that HIV/AIDS is a crisis of unprecedented global

“There are only two possible responses to suffering on this scale. We can turn our eyes away in resignation and

despair, or we can take decisive, historic action to turn the tide against this disease and give the hope of life to millions who need our help now. The United States of America chooses the path of action and the path of hope.”

President George W. Bush, April 29, 2003

III. ENGENDERING BOLD LEADERSHIP 

White House Photo Office
proportions, there is a role for every leader to play

in defeating it. 

President Bush has stepped up to this challenge

with his Emergency Plan for AIDS Relief. His

Administration will use its leadership position and

influence to encourage others to demonstrate the bold

leadership that is necessary to win the war against

AIDS. Through proactive diplomacy and communication, the U.S. Government will stimulate greater leadership at every level – from national statesmen to

village elders – in the fight against HIV/AIDS.

Leadership Objective:

Engender bold leadership and additional resources

from other countries for the fight against global AIDS

Leadership Strategies:

1. Engaging heads of state and other government

officials through bilateral diplomatic interventions

and multilateral forums

2. Reaching out to a broad range of community

and religious leaders and private institutions to

generate multisectoral leadership and responses

to HIV/AIDS

3. Using the tools of public diplomacy and communications to inform and engage new partners, including media, in the fight against HIV/AIDS

4. Using diplomatic interventions in bilateral and

multilateral forums with donor nations, and communications tools with the public and private institutions, to raise additional resources for global

AIDS

1. Engaging heads of state and other government officials through bilateral diplomatic

interventions and multilateral forums

Heads of state have a particular role to play, and particular responsibility to bear, in engendering an appropriate response to HIV/AIDS. In countries facing

current or emerging epidemics, leadership from heads

of state can generate early and effective action by

publicly acknowledging HIV/AIDS as a problem in

their country, raising and devoting appropriate

resources, and demanding broad involvement. In

many countries, budgetary resources need to be

focused on prevention, care, and treatment programs

to stem the epidemic. The engagement of heads of

state contributes greatly to a coordinated response,

offering such tools as national HIV/AIDS strategies

and dedicated funding streams through which to allocate and track resource distribution.

HIV/AIDS adversely affects health care systems,

education in schools and universities, economic

development, and, more broadly, peace and security.

All ministries have a role to play in the fight against

the pandemic. Military leaders and other sectoral

leadership such as ministers of education and labor

can strengthen the HIV/AIDS response by capitalizing on their access to specific populations that have

specific needs.

Under President Bush’s leadership in fighting global

HIV/AIDS, the U.S. Government has an opportunity

to encourage leadership from heads of state and other

government officials. The United States will:

 Employ diplomatic interventions by high-level officials based in Washington and American ambassadors abroad to engage directly with and encourage

strong leadership from heads of state and counterparts in government such as ministers of health,

education, defense, and foreign affairs;

 Ensure that American embassy staffs abroad are

informed and engaged on the issue of HIV/AIDS

as it relates to their host countries and raise

HIV/AIDS issues in host-country forums; and

 Advocate for greater leadership through

multilateral forums such as UNAIDS, international

HIV/AIDS events and conferences, and multilateral actions such as the Global Fund to Fight AIDS,

Tuberculosis, and Malaria.

2. Reaching out to a broad range of

community leaders and private institutions

to generate multisectoral leadership and

responses to HIV/AIDS

Some of the most intractable problems in achieving

an effective HIV/AIDS response have been combating

stigma, reaching individuals with HIV/AIDS messages

to bring about behavior change, and addressing issues

of culture and traditional roles that contribute to

increased vulnerability, especially for women and girls.

HIV/AIDS messages need to reach people where they

live, learn, work, and worship. Trusted community

leaders have reach, authority, and legitimacy to carry

forward vital messages about HIV/AIDS and combat

stigma, denial, and negative cultural practices. In

addition, where government has not responded adequately to HIV/AIDS, bottom-up leadership can help

mobilize appropriate responses, including resources,

from government. 

The U.S. Government will use public-private

partnerships at local, national, regional, and world20 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
ENGENDERING BOLD LEADERSHIP 21

wide levels to strengthen global and in-country

responses to HIV/AIDS. These partnerships will

be fostered by the Office of the U.S. Global AIDS

Coordinator and U.S. ambassadors in all regions.

In countries where the United States has existing

HIV/AIDS programs (see appendix F), these efforts

will be closely linked to the programs. In countries

where the U.S. Government has HIV/AIDS activities,

such as public diplomacy efforts, but no assistance

programs, these efforts will serve as a catalyst for

action by local officials. 

The United States will:

 Engage with community leaders such as mayors,

tribal authorities, elders, and traditional healers to

promote correct and consistent information about

HIV/AIDS and combat stigma and harmful cultural practices. Even in an environment of strong

government leadership and good policy, failure to

involve community leaders can undermine efforts

to implement sound policies and programs.

Conversely, community leaders can reinforce messages and engender cultural change that is difficult

to achieve via program or policy means. 

 Engage with faith-based leaders on international,

national, and local levels. Religious leaders have

enormous reach and authority. In many countries,

as many as 80 percent of citizens participate regularly in religious life, and the pulpits of religious

leaders are a powerful platform from which to

promote correct and consistent information,

encourage behavior change, combat stigma, and

strengthen community responses to HIV/AIDS.

The United States will identify, train, and partner

with faith-based leaders.

 Work with national and international business

coalitions and labor organizations to facilitate

their efforts to improve and greatly expand programs in the workplace, particularly at companies

in heavily impacted countries. Through close

collaboration with business and labor, the U.S.

Government will serve as a catalyst for developing

and implementing prevention, treatment, and care

programs for employees and immediate communities. The strategy will take advantage of marketing,

communications, and logistical skills in the business sector to improve the reach and effectiveness

of AIDS programs.

3. Using the tools of communications to inform

and engage new partners, including media, in

the fight against HIV/AIDS

In many countries of the world, there is great unrealized potential in using the media as a positive force

for discussion of AIDS and for overcoming stigma and

denial, promoting information based on best practices,

and expanding the reach of correct and consistent

HIV/AIDS messages. The United States will:

 Inform the public of the extent and nature of the

AIDS epidemic and the need for action through

international media channels and through print

and electronic media in the 162 countries where

the United States is represented, including placement of public service announcements on radio

and television and publication of op-ed pieces by

the American ambassador and others;

 Assist journalists in promoting responsible

reporting on HIV/AIDS; and

 Use exchange programs to provide key people with

participatory involvement in a range of activities

that serve to enhance their skills and knowledge

related to HIV/AIDS. These exchanges will be

customized for specific sub-groups of people who

are in a position to demonstrate leadership in their

home countries, including health care workers,

journalists, and others.

4. Using diplomatic interventions in bilateral

and multilateral forums with donor nations,

and communications tools with the public and

private institutions, to raise additional resources

for global AIDS

Worldwide resources to combat global HIV/AIDS

remain far short of what is necessary to win the war

against the disease. Wealthy nations, corporations

such as the Coca-Cola Company, and private institutions such as the Bill & Melinda Gates Foundation

have made vital contributions to the fight against

HIV/AIDS, and the U.S. Government will continue to

seek their partnership and support. Under President

Bush’s lead, the U.S. Global AIDS Coordinator will

work with the Secretary of State, the Secretary of

Health and Human Services, and others in this

high-level effort to generate greater bilateral and multilateral contributions from donor governments and

private institutions. In addition, the Office of the U.S.

Global AIDS Coordinator will use public communications tools to inform and engage citizens worldwide

in the battle against HIV/AIDS and develop a constituency that will ensure a long-term global response.

CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Prevention 23

The 2003 UNAIDS AIDS Epidemic Update offered a

set of stunning statistics – last year, 3 million people

died of AIDS. At the same time, 5 million more were

infected with HIV. Despite two decades of focused

attention on prevention, we have yet to achieve

widespread success, as evidenced by the 14,000 people who each day join the ranks of those infected.

Clearly, HIV/AIDS cannot be defeated unless the

number of new infections is dramatically reduced

and eventually eliminated. 

It is time, however for new thinking and approaches.

Past and current prevention messages have often

failed to achieve the widespread behavior change

that is necessary to end the pandemic. Prevention

efforts are further hampered by the stigma surrounding HIV/AIDS and gender inequality that increases

the vulnerability of women and girls. 

Of the approximately 40 million people infected with

HIV worldwide, it is estimated that as many as 95 percent do not know their status. Without knowledge of

their status, people continue to spread the disease

unwittingly and do not seek treatment. Given the

sheer numbers of people who do not know their status, this factor alone represents an enormous challenge

to turning the tide against HIV/AIDS. Limited testing

strategies, insufficient testing services, and a lack of

enabling policies have thus far proven inadequate for

making sufficient progress against the disease. 

Overstressed and poorly functioning health care systems also contribute to the spread of disease. Medical

transmission of HIV continues to be a problem,

spread through unsafe injections, unnecessary medical

procedures, and use of unscreened blood supplies.

Rates of sexually transmitted infections (STIs) remain

high, and, when untreated, contribute to the spread

of HIV. Health care systems, understaffed and inadequately supplied, have been unable to close this entry

point for HIV infection.

In 2001, an estimated 720,000 children globally were

infected via mother-to-child HIV transmission. U.S.

Government programs such as the President’s

International Mother and Child HIV Prevention

Initiative, as well as those implemented by other partners, have proven that the administration of a short

course of antiretroviral (ARV) drugs and improved

breastfeeding practices can dramatically reduce the

number of mother-to-child infections and thus the

number of new infections overall. Such programs

also provide a critical link to HIV/AIDS treatment

programs that offer ARV and other treatment to HIVinfected women and their families, thus helping to

preserve the family unit.

Finally, the limited availability of treatment and care,

and its effects of extinguishing hope and fueling fear

and stigma, presents its own barriers to prevention

efforts, as denial continues to bolster inaction.

The President’s Emergency Plan is specifically

designed to address these challenges and capitalize on

the opportunities outlined above in achieving its goal

of preventing 7 million new HIV infections. In its use

of evidence-based prevention programs such as the

“ABC” – Abstinence, Be faithful, and as appropriate,

“We will train doctors and nurses and other health care professionals so they can treat HIV/AIDS patients. Our

efforts will ensure that clinics and laboratories will be built or renovated and then equipped. Child care workers will

be hired and trained to care for AIDS orphans, and people living with AIDS will get home-based care to ease their

suffering . . . And we’re developing a system to monitor and evaluate this entire program, so we can be sure we’re

getting the job done.”

President George W. Bush, July 2, 2003

IV. CRITICAL INTERVENTIONS

IN THE FOCUS COUNTRIES: Prevention

White House Photo Office
correct and consistent use of Condoms – approach,

proven successful in Uganda, Zambia, Senegal, and

elsewhere, the Emergency Plan will target prevention

funds to methodologies that are effective in helping

people avoid behaviors that place them at risk of

contracting HIV. Identified best practices such as

increased testing; appropriately tailored interventions

for specific populations including women, men, and

high-risk groups; the involvement of people living

with HIV/AIDS, parents, and leaders from all sectors

of society; and stigma reduction will be aggressively

promoted to achieve real results in reducing the

number of new infections. At the same time, these

interventions must strengthen existing indigenous

responses to the epidemic, be discerning and responsive to the culture, and build on community structures that influence social and community norms in

order to reduce risk behaviors.

Furthermore, in keeping with the Emergency Plan’s

health care approach, specific interventions to

strengthen health care services to reduce HIV transmission are another cornerstone of prevention activities. The President’s Emergency Plan will help build

the health care infrastructure necessary to strengthen

infection control programs, reduce medical transmission of HIV, and build the capacity of health care

workers to treat STIs and prevent mother-to-child

infection. Last, the fundamental principle of the

President’s Emergency Plan – to integrate prevention,

treatment, and care – is intended to stimulate a cycle

that will reduce stigma and fear, create incentives for

testing, and thus amplify prevention efforts. 

Prevention Objective: 

Prevent 7 million HIV infections in the focus

countries

Prevention Strategies:

1. Rapidly scale up existing prevention services

2. Build capacity for effective long-term prevention

programs

3. Advance policy initiatives that support prevention

of HIV infection

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan policies and strategies 

1. Rapidly scale up existing prevention services

It is estimated that immediate action to implement

comprehensive prevention programs could avert 60

percent of new HIV infections in resource-limited settings by 2010. A delay of only three years could

reduce efficacy by nearly 50 percent. Thus, rapid

scale-up of existing prevention services is an urgent

priority of President Bush’s Emergency Plan. Much

has been learned about effective strategies for prevention over the past two decades. While the President’s

Emergency Plan seeks in the long term to develop

sustainable national programs in each country, in the

short term it will move quickly through the expansion

of current activities. Faith-based and communitybased groups, as well as many ministries of health,

have established excellent prevention programs in

the areas of abstinence promotion, behavior change,

prevention of HIV infection from mother to child,

and technical assistance for improved medical practices. These organizations offer innovative, effective,

and accountable local programs, and have established

relationships with national organizations and local

communities. Such organizations provide the

optimal foundation to build on best practices

toward the development of comprehensive

national prevention programs. 

Organizations are poised to rapidly and accountably

scale up programs in the following priority areas:

 Prevention of HIV infection through abstinence

and behavior change for youth; 

 Prevention of HIV infection through HIV testing,

targeted outreach, and condom distribution to

high-risk populations;

 Prevention of HIV infection from mother to

child; and

 Prevention of HIV infection through safe blood,

improved medical practices, and post-exposure

prophylaxis.

Prevention of HIV infection through abstinence

and behavior change for youth 

In many of the countries hardest hit by HIV/AIDS,

sexual activity begins early and prior to marriage.

Surveys show that, on average, slightly more than 40

percent of women in sub-Saharan Africa have had

premarital sex before age 20; among young men, sex

before marriage is even more common. Moreover, a

significant minority of youth experience first sex

before age 15. Abstinence until marriage programs are

particularly important for young people, as fully half

of all new infections occur in the 15- to 24-year-old

age group. Delaying first sexual intercourse by even a

year can have significant impact on the health and

well-being of adolescents and on the progress of the

epidemic in communities.

24 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Prevention 25

Adolescent girls in high HIV-prevalence countries in

Africa are at significantly higher risk of acquiring HIV.

In some communities, as many as 20 percent of girls

aged 15 to 19 are infected compared to 5 percent of

boys the same age. These age differentials in HIV

prevalence reflect a pattern of older men having

sex with younger women. Young women involved

in exchange relationships with older men are

disadvantaged by gender, age, and economic power.

Moreover, a substantial proportion of girls in Africa

and the Caribbean experience coerced sex, including

forced first sex. 

Youth are subject to a variety of conflicting social

messages and influences related to sex. Although

many traditional social norms emphasize abstinence

for youth, extramarital sexual activity is common

among adults, especially men. While virginity is

emphasized for girls, sexual activity is often seen as

a sign of manhood for young men. Parents, religious

leaders, teachers, and the media may each provide

different information related to HIV/AIDS, adding

to confusion in decision-making.

Comprehensive and effective prevention approaches

reflect the complex influences on young people’s decision-making and the need to address the broader

social factors that shape their behaviors.

Internationally, a number of programs have proven

successful in increasing abstinence until marriage,

delaying first sex, reducing the number of partners,

and even achieving “secondary abstinence” among

sexually experienced youth. 

President Bush’s Emergency Plan recognizes the

diversity of countries and the need to harmonize

prevention messages at the community level. Correct

and consistent information is vital to effective HIV

prevention, and program partners thus should not

disseminate incorrect information about any health

intervention or device. In addition, national governments may appropriately seek to coordinate information or referral links to other services designed for

high-risk populations. 

The Emergency Plan supports the following categories

of activities as part of its rapid scale-up of prevention

programs for youth:

Scale up skills-based HIV education, especially for

younger youth and girls. Young people need to be

reached early, before they begin having sex, with

skills-based HIV education that provides focused messages about the benefits of abstinence until marriage

and other safe behaviors. Activities should help young

people develop the self-esteem to delay sex until marriage, make informed choices, and develop the

communication skills to say “no” to sex (as well as

to alcohol and drugs, which increase vulnerability to

sexual pressure). Best practices suggest that communication skills and the ability to personalize risk can

be achieved through curricula that use interactive

methods to target specific risk factors for early sexual

activity in the local context and help young people

define values. Ideally, programs should go beyond

sexuality to build on young people’s assets and

encourage them to stay in school and plan for their

futures. While these programs are most relevant to

younger adolescents aged 10 to 14 years, especially

girls, they are also appropriate for older adolescents.

Suggested activities include:

X Developing and disseminating age-appropriate

curricula that include clear messages about

abstinence until marriage and other safe

behaviors, and that address risk factors in

the local context;

Risk Elimination, Risk Reduction

Basic public health approaches to disease

prevention rely on both risk elimination and risk

reduction. Risk elimination strategies are those

that reduce exposure to disease, such as abstinence in the case of STIs. Risk reduction

strategies are those that reduce the likelihood of

transmission during any given exposure, such as

the use of condoms or the provision of prophylactic ARV treatment for exposed newborns or

health care workers. 

Risk elimination is a cornerstone of the

President’s Emergency Plan. Approaches that

are directed to behavior change, such as encouraging abstinence, testing, and faithfulness in

sexual relationships, have proven to be successful and will be expanded. Knowledge of HIV

status, fidelity in marriage, and monogamy for

the sexually active are equally important goals

of prevention programs. 

Evidence from Thailand suggests condom use is

an important means of reducing, but not eliminating, risk. Working closely with local governments, nongovernmental organizations, and

prevention experts, condom programs targeted

to at-risk populations will be supported. In doing

this, it will be important to disseminate clear

messages that support, rather than confound, a

core risk elimination approach. 
X Expanding skills-based HIV education through

schools, working both at the national level with

ministries of education and local schools at the

community level;

X Strengthening HIV education delivered through

after-school programs run by youth services networks, including faith-based networks; and

X Strengthening programs in HIV education for

children who are not in school.

Promote healthy norms and behaviors. Communities

need to mobilize to address the norms, attitudes,

values, and behaviors that increase vulnerability to

HIV, including multiple casual sex partners and crossgenerational and transactional sex. To stimulate such

mobilization, there is an urgent need to help communities identify and recognize the ways in which they

contribute to establishing and reinforcing norms that

may contribute to youth risk, vulnerability, and

stigma. President Bush’s Emergency Plan will support

groups that discourage harmful norms through a variety of media and other activities at both the community and national levels. Suggested activities include:

X Training local religious and other traditional

leaders in HIV concerns and supporting them

in publicizing the risks of early sexual activity,

multiple partners, and cross-generational sex;

X Supporting youth-led community media to help

youth, their parents, and the broader community personalize the risks involved in these behaviors; and 

X Supporting media campaigns that reinforce and

make abstinence until marriage, fidelity, partner

reduction, and other safer behaviors legitimate

options and standards of behavior for both

youth and adults.

Reinforce the role of parents and other protective

factors. Parents are potentially the most powerful

protective factors in young people’s lives; they have

great potential to guide youth toward healthy and

responsible decision-making and safer behaviors. In

Emergency Plan countries, where many youth have

lost their parents to AIDS, other adult caregivers and

mentors also have an important role to play in providing guidance to youth. Many adults, however, find it

difficult to communicate with teens, both on broader

issues of regulation and discipline and in discussing

sexuality and their own expectations and values about

sex. The Emergency Plan will support efforts to reach

out to parents and other adult caregivers to educate

and involve them in issues relating to youth and HIV

and to empower them by improving their communication skills in the areas of sexuality as well as broader

limit-setting and mentoring. Suggested activities

include:

X Holding parenting education workshops to

improve parent-child communication on HIV,

sexuality, and broader issues such as limit-setting, through parent-teacher associations, local

social and civic clubs, and faith-based groups; 

X Organizing special school and community events

jointly for parents and teens to promote mutual

communication about HIV and healthy behaviors; and

X Developing and training a cadre of volunteer

mentors for youth who lack sufficient parental

or other adult supervision, including training in

messages for HIV prevention.

Address sexual coercion and exploitation of young

people. Adolescents need a safe environment where

they can grow and develop without fear of forced or

unwanted sex, which often precludes the option of

abstinence. The Emergency Plan supports psychosocial and other assistance for victims of sexual abuse.

Efforts to target men with messages that challenge

norms about masculinity and that emphasize the

need to stop sexual violence and coercion will also

be important. Suggested activities include:

X Organizing campaigns and events to educate

local communities about sexual violence against

youth and strengthen community sanctions

against such behaviors; 

X Implementing workplace programs for older

men and school-based programs for young boys

to provide education about preventing sexual

violence, with a special focus on men who have

a higher propensity to become perpetrators;

X Training health care providers, teachers, and

peer educators to identify, counsel, and refer

young victims of sexual abuse for other health

services; and

X Working with governments and NGOs to

eliminate gender inequalities in the civil and

criminal code.

26 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Prevention 27

Prevention of HIV infection through HIV testing,

targeted outreach, and condom distribution to

high-risk populations

Following the “ABC” model, and recognizing that

condoms are an essential means of HIV prevention

for populations who engage in risky behavior, rapid

scale-up of activities that target specific at-risk populations with outreach, prevention messages, testing,

and condoms will be undertaken. These groups

include prostitutes, sexually active discordant couples,

substance abusers, and others. In doing this, care will

be taken to adhere to local guidelines and standards

and to ensure that the key behavioral messages of

abstinence, faithfulness, and partner reduction are

not confounded.

Prevention of HIV infection from mother to child 

The technology now exists to substantially reduce

mother-to-child transmission (MTCT) using simplified interventions that international clinical trials

have demonstrated can reduce risk of HIV transmission from mother to child by 30 to 50 percent. The

interventions involve providing routine HIV testing

for pregnant women, administering short-course ARV

prophylaxis to HIV-infected mothers in the last weeks

of pregnancy or during labor or delivery, and administering ARV drugs by droplet to infants within 72

hours of birth. The interventions also call for less

invasive medical procedures during childbirth,

improved breastfeeding practices, and prevention

and treatment of malaria.

The President’s Emergency Plan will build on the

significant work already accomplished under the

President’s 2002 International Mother and Child

HIV Prevention Initiative (now integrated into the

Emergency Plan). President Bush’s Emergency Plan

will support rapid expansion of these programs

through the following suggested activities:

X Scaling up existing prevention of mother-tochild transmission (PMTCT) programs by

rapidly mobilizing resources;

X Providing technical assistance and expanded

training for health care providers (including

family planning providers, traditional birth

attendants, and others) on appropriate antenatal

care, safe labor and delivery practices, breastfeeding, malaria prevention and treatment, and

family planning;

X Strengthening the referral links among health

care providers; 

X Ensuring effective supply chain management

of the range of PMTCT-related products and

equipment; and

X Expanding PMTCT programs to include HIV

treatment for HIV-infected mothers and other

members of the child’s immediate family.

Prevention of HIV infection through safe blood,

improved medical practices, and post-exposure

prophylaxis

HIV transmission in medical settings, including

through blood transfusions, is a significant contributor

to the HIV pandemic. Thus, the rapid implementation of safe blood programs and precautions against

medical transmission of HIV is a priority area for the

President’s Emergency Plan. The World Health

Organization (WHO) estimates that 5 to 10 percent

of all HIV transmissions are attributable to unsafe

blood transfusions. Transmission of HIV and other

bloodborne pathogens via blood transfusion is preventable by establishing an adequate supply of safe

blood through a systematized blood transfusion

service and by minimizing unnecessary transfusions.

According to WHO, however, in 2002 only 90 percent of blood donations in Africa were screened for

HIV, only 40 percent for hepatitis C, and 55 percent

for hepatitis B. 

Violence Against Women and HIV/AIDS

Evidence from Rwanda, Uganda, Tanzania, and

Zambia shows that violence against women is

both a cause and consequence of rising rates of

HIV infection – a cause because rape and sexual

violence pose a major risk factor for women and

a consequence because studies have shown that

HIV-positive women are more likely to suffer

violence at the hands of a partner than those

who are not infected. For many women, fear of

sexual coercion and violence often precludes the

option of abstinence or holds them hostage to

their husband’s infidelity. Through President

Bush’s Emergency Plan, the U.S. Government

will work closely with communities, donors, and

other stakeholders to reduce stigma, protect

women from sexual violence related to HIV,

promote gender equality, and build family skills

in conflict resolution. The Emergency Plan will

also support interventions to eradicate prostitution, sexual trafficking, rape, assault, and sexual

exploitation of women and children.
Much can be done to reduce the likelihood of

transmission, improve infection control, and increase

the quality of health care services overall. President

Bush’s Emergency Plan will provide technical assistance and training to prevent medical transmission of

HIV and improve the quality of services through the

network model. Support will be provided to improve

blood safety, increase the use of safe injection practices, ensure the practice of universal precautions, and

increase the availability of post-exposure prophylaxis.

Specifically, expert guidance, support, and assistance

from organizations currently providing training and

technical assistance will be provided to ministries of

health and national transfusion services to develop

and implement comprehensive national safe blood

programs. Suggested activities include:

X Providing technical assistance for developing

effective national, generic, and site-specific policies, protocols, guidelines, and practices related

to blood donation; safe injections; obtaining,

handling, storing, testing, transporting, distributing, and disposing of blood, sharps, other injection equipment, and medical wastes; and

universal precautions for infection control and

prevention and management of occupational

exposure to HIV;

X Training health care staff in the use of protocols

and guidelines – the Emergency Plan will support training, supervision, and other performance improvement measures for health care

professionals in the areas listed above as well

as education about alternatives to injection in

primary care practice;

X Ensuring effective supply chain management of

the range of products and equipment needed to

prevent medical transmission of HIV; and 

X Providing technical assistance, training, and

products for post-exposure prophylaxis in

health care settings and for other types of

potential exposure (such as sexual violence)

once protocols have been established and

trained personnel and supplies are in place.

2. Build capacity for effective long-term

prevention programs

At the same time that President Bush’s Emergency

Plan is mobilizing the rapid scale-up of behavior

change interventions and other prevention services, it

will also be laying the foundation for sustainable and

effective long-term local and national prevention

programs. The President’s initiative will help build,

strengthen, and improve the quality and sustainability

of prevention programs by promoting evidence-based

best practices, encouraging innovation and evaluation

to identify effective new approaches, and improving

program planning, implementation, management, and

monitoring. The development of such comprehensive

and sustainable programming will be accomplished

through the following key operational strategies:

 Promoting the “ABC” model;

 Innovatively expanding HIV testing;

 Supporting interventions for those at high risk

of infection;

 Reaching and engaging mobile male populations;

 Improving diagnosis and treatment of STIs; and 

 Developing and strengthening institutional

capacity of implementing organizations.

Promoting the “ABC” model

Evidence from Uganda, Senegal, and Zambia

demonstrates the effectiveness of a balanced

approach to behavior change that encourages the

adoption of “ABC” behaviors – A for abstinence, B

for being faithful, and C for correct and consistent

use of condoms as appropriate.

The application of A, B, and C interventions will be

balanced and targeted according to the needs and

specific circumstances of different at-risk populations.

Expanding the human resources necessary to implement this bold new prevention strategy will require

engaging a wide range of partners, from women’s

associations to faith-based organizations (FBOs),

sports clubs to workplaces, parents to schools, and

health workers to traditional healers. President Bush’s

28 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

John E. Lange
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Prevention 29

Emergency Plan will support efforts to build the

capacity of local and national partners to strengthen

ABC prevention messages and link them in their

application to ongoing treatment and care programs. 

The application of the ABC model will emphasize:

Abstinence for youth. The strategies for youth

described in detail above encourage abstinence until

marriage for those who have not yet initiated sexual

activity and “secondary abstinence” for unmarried

youth who have already engaged in intercourse. FBOs

are in a strong position to help young people see the

benefits of abstinence until marriage and support

them in choosing to postpone sexual activity.

Programs will help youth develop the knowledge, confidence, and communication skills necessary to make

informed choices and avoid risky behavior. President

Bush’s Emergency Plan will also support programs that

reinforce parental involvement, as parents are the

primary caregivers and have the responsibility of

overseeing the upbringing of their children.

Being faithful. Some of the most significant results

from Uganda resulted from changes in behavior related to fidelity in marriage, monogamous relationships,

and reducing the number of sexual partners among

sexually active unmarried persons. President Bush’s

Emergency Plan will build on this success by supporting counseling, peer education, and community-based

interventions to address social norms that increase

vulnerability to HIV, such as the acceptance of men

having multiple sexual partners outside of marriage,

cross-generational sex, and transactional sex. Working

through the media and community-based and faithbased institutions, interventions will deliver messages

that promote abstinence until marriage and fidelity to

one partner, encourage men to refrain from sexual

promiscuity and to respect women, and encourage

testing. Knowledge of HIV serostatus is especially

important, and counseling and HIV testing of couples

can be an effective strategy. Despite the fact that

sero-discordant couples – couples in which one partner is HIV-positive and the other HIV-negative – may

remain monogamous, the risk still remains high for

the uninfected partner. 

Correct and consistent use of condoms as appropriate.

For those who are infected or who are unable to avoid

high-risk behaviors (such as discordant couples),

condom use is a critical risk-reduction intervention.

The Emergency Plan will make condoms available to

reduce the risk of the spread of HIV infection among

those who engage in high-risk activity by strengthening public and private sector programs to create

demand among those at high risk and by expanding

the number of condom distribution outlets near

areas where high-risk behavior takes place. Improved

condom forecasting and supply chain management

will be necessary to ensure condoms are available in

these high-risk settings. Use of condoms will also be

promoted for sexually active discordant couples. In

doing this, every effort will be made to deliver a consistent “ABC” message so that the general population

receives a clear message that the best means of preventing HIV/AIDS is to avoid risk altogether. 

Innovatively expanding HIV testing 

Estimates indicate that at many as 95 percent of

people living with HIV/AIDS do not know their

status. Without knowing their status, individuals can

neither access appropriate care service for themselves

nor take steps to prevent transmission to others. HIV

testing is a critical intervention that serves as a linchpin connecting prevention to care and treatment.

When combined with counseling, testing can also

be a powerful means of educating individuals and

communities about HIV and preventing infection.

Those who know their HIV-negative status can avoid

future infection and be linked to community prevention activities. Those who know their HIV-positive

status can live positively and start early prevention

and treatment of opportunistic infection or STIs,

begin antiretroviral therapy (ART), seek psychosocial

support, and plan for their futures. A strong testing

and counseling program helps to reduce stigma and

enhance the development of care and support services. In addition, HIV testing programs that target couples can identify sero-discordant couples and create a

critical opportunity for prevention interventions.

While it is anticipated that the hope generated by

access to ART will increase demand for HIV testing,

this is not sufficient. Innovative solutions must be

found to dramatically increase the number of individuals who are tested and know their status. The

Emergency Plan will increase the availability of HIV

testing services through a number of key innovative

strategies:

X Integrating testing with other health services,

such as family planning, antenatal care, STI,

tuberculosis, and malaria programs, and improving the referral links among all of these services; 

X Expanding the range of settings in which

confidential testing and counseling are offered,

including at times of employment, school enrollment, military enlistment, and marriage registration, and ensuring that non-discrimination

policies and practices are in place; 
X Strengthening training of health workers,

professional and lay counselors, laboratory

technicians, and other support people

necessary to rapidly expand services;

X Strengthening linkages between testing and

counseling and post-test services;

X Focusing efforts to make HIV testing available

to those at highest risk of infection;

X Strengthening of counseling and support to

clients to encourage disclosure of status to

others;

X Ensuring adequate supplies of HIV test kits and

other essential products;

X Stimulating demand for services through innovative communications and social marketing

approaches at the community and mass media

levels; 

X Providing support to women to mitigate potential violence or other negative outcomes of disclosing HIV-positive status to male partners; and

X Strengthening national guidelines for HIV testing and counseling, where appropriate; encouraging the adoption of routine testing policies;

and ensuring regulatory support for maintaining

confidentiality, service quality, and adequate

procurement and supply chain management.

Supporting interventions for those at high risk of

infection

Some of the populations most affected by HIV/AIDS

are also the most difficult to reach through conventional health care programs. Prostitutes and their

clients, men who have sex with men, and injecting

drug users are among those who are most marginalized in society and have the least access to basic

health care. Developing and implementing interventions with some of these groups is even more difficult

because of stigma and discrimination. At the same

time, these populations are generally at higher risk of

infection and in greatest need of prevention services.

First and foremost, the Emergency Plan will support

approaches directed at ending risky behavior. In addition, the Emergency Plan supports effective new

approaches to reach groups at high risk through a

combination of:

X Interpersonal approaches to behavior

change, such as counseling, mentoring, and

peer outreach;

30 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

Reducing Stigma and Denial

Stigma against HIV and AIDS, real or perceived, is one of the most difficult barriers to

overcome. It strengthens existing social inequalities and prejudices, especially those related to

gender, sexual orientation, economic status,

and race. Fear of rejection by family, employer,

or community causes many people to fear the

stigma associated with the virus more than the

virus itself. It may encourage people to ignore or

deny their HIV status and make choices that are

not in their own or society’s best interest.

Among health workers, negative perceptions

of people living with HIV/AIDS can affect the

quality of care they provide to patients suspected of HIV and cause those who need services

to avoid them for fear of disclosure. 

Stigma and denial create barriers to prevention,

treatment, and care that must be addressed.

President Bush’s Emergency Plan will act boldly

to address stigma and denial through three operational strategies that:

X Engage local and national political, business,

community, and religious leaders and popular

entertainers to speak out boldly against

HIV/AIDS-related stigma and violence

against women, to promote messages that

address gender inequality, to encourage men

to behave responsibly, to promote HIV testing, and to encourage those found to be HIV

positive to seek treatment;

X Identify and build the capacity of new partners from a variety of sectors to highlight the

harm of stigma and denial and promote the

benefits of greater openness through community- and faith-based organizations, private

sector businesses, the entertainment industry,

the public health system, and the national

government; and

X Promote hope by highlighting the many

important contributions of people living

with HIV/AIDS, by providing ARV treatment to those who are medically eligible, and

by involving those who are HIV-positive in

meaningful roles in all aspects of HIV/AIDS

programming.

Finally, efforts to address stigma and denial will

seek synergies among the prevention, treatment,

and care realms. The hope offered by treatment

is an effective tool to combat irrational fear of

the disease and open up channels of communication within communities. 
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Prevention 31

X Community and workplace interventions to

eliminate or reduce risky behaviors; 

X Initiatives to promote the use of testing and

counseling services;

X Linkages through referral networks with other

health services;

X Diagnosis and treatment of STIs; 

X Promotion of condom use during high-risk

sexual activity; 

X Strengthened referral systems to link substance

abuse treatment services with HIV testing and

counseling; 

X Promotion of substance abuse prevention and

treatment services; and

X Mass media interventions with specially tailored

messages.

Reaching and engaging mobile male populations

Workers engage in risky behavior, such as sexual

relations with non-regular partners, more often when

they are posted away from home or are required to

travel for extended periods of time. Migrant workers,

truck drivers, and members of uniformed services

such as the armed forces and police face serious risks

of HIV and other STIs and can serve as a bridge for

transmitting infection to the general population. The

uniformed services present unique challenges and

opportunities for HIV prevention. The United States

has played a leadership role in pioneering prevention

approaches with the military. President Bush’s

Emergency Plan will build on already initiated U.S.

Government activities to reach the military and

other uniformed services including:

X Peer education, interpersonal and group communication strategies, and local mass media to

promote faithfulness, partner reduction, avoidance of commercial sex, and condom use during

high-risk sexual behavior;

X STI and HIV testing and counseling services,

linked to treatment and care;

X Basic workplace and in-service training on

HIV/AIDS for employees, new recruits, and

existing personnel; and

X Condom promotion and distribution for those

who practice high-risk sexual behavior.

Improving diagnosis and treatment of STIs

An important link exists between STIs and the sexual

transmission of HIV. Untreated, STIs can significantly

increase the likelihood of both acquiring and transmitting HIV. President Bush’s Emergency Plan will

support STI prevention, diagnosis, and treatment

services, and the linking of these services through

referral networks with HIV testing and counseling

and other HIV services, through implementation of

the following strategies: 

X Increasing availability and accessibility of STI

treatment services through the expansion of

STI prevention and treatment services where

appropriate;

X Integrating STI treatment services with

other HIV/AIDS and reproductive health

care services and improving the referral links

between programs; and

X Improving national STI treatment protocols,

training health workers in their use, and where

needed, developing national evidence-based

guidelines, protocols, and training curricula. 

Developing and strengthening institutional capacity

Prevention programs are only as strong as the institutions that support them. Therefore, a strong organizational infrastructure is the foundation upon which the

planning, implementation, and evaluation of effective

behavior change interventions and prevention services are built. Many of the organizations that implement

risk elimination and reduction interventions may need

to enhance of develop the institutional capacity to

support the rapid scale-up of prevention programs

necessary to effectively address the epidemic. 

The President’s Emergency Plan will invest in

strengthening the institutional capability of implementing organizations by providing technical assistance, training, and funding to improve and expand

the organizational capability of key partners – including FBOs, other community-based organizations

(CBOs), and nongovernmental organizations (NGOs)

– as well as public and private facilities that deliver

abstinence-until-marriage programs, HIV testing and

counseling, and PMTCT and STI services. By looking

at the institutional capacity building needs of partners

within a network, and the linkages between them,

support will be provided to:

X Equip health facilities and mobile units to

provide testing and counseling and STI services;
X Strengthen public and private sector

capabilities to design and produce behavior

change materials;

X Upgrade routine health information systems to

improve prevention services data management;

X Strengthen qualitative and quantitative research

capability; 

X Support effective product procurement, storage,

and distribution, particularly for HIV testing

and targeted condom distribution programs; 

X Strengthen NGO/CBO financial and

administrative systems; and 

X Improve laboratory capacity to perform

HIV testing. 

3. Advance policy initiatives that support

prevention of HIV infection

Many of the focus countries have elevated HIV/AIDS

to national priority status. All promote a comprehensive approach integrating prevention, treatment, and

care. Most have clear statements supporting the

human rights of people living with HIV/AIDS and

condemning stigma and discrimination related to

HIV status. Several explicitly state the importance of

greater involvement of people living with HIV/AIDS

in program planning and policy. In an effort to address

underlying factors that promote vulnerability to HIV,

most of the focus countries have established policies

to promote gender equality, improve women’s socioeconomic status, and address violence against women.

Application of these policies is far from complete,

however, especially at the community level.

A key priority of President Bush’s Emergency Plan will

be to support implementation of good policies and

effective legislation, particularly at the community

level. Illustrative examples of policy issues that may be

addressed through Emergency Plan technical assistance include: 

 Protection against stigma and discrimination,

particularly within key settings such as workplaces,

schools, and the military;

 Use of routine testing while applying the principles

of confidentiality;

 Human resources policies, including the broadening of responsibility for HIV testing and counseling

to lower levels of care;

 Access to health information and care, including

for traditionally underserved populations such as

women, the poor, and the disabled;

 Polices to promote gender equality; 

 Support for the review, revision, and enforcement

of laws relating to sexual violence against minors,

including strategies to more effectively protect

young victims and punish perpetrators; and 

 Programs that support abstinence until marriage

and fidelity within marriage. 

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan policies and strategies

Measuring prevention activities and providing useful

feedback to programs for accountability and quality

improvement is a goal of strategic information for

improved HIV prevention activities. Improved HIV

sentinel clinical and population-based surveillance

systems will measure the impact and outcomes of

prevention programs. Program monitoring will enable

the tracking of training, media, and community outreach activities, including interventions to promote

abstinence. Targeted program evaluations will provide

evidence-based information to improve prevention

programs, and information management systems will

facilitate data storage and data flow. Sets of internationally agreed upon prevention indicators developed

by WHO, UNAIDS, and U.S. Government agencies

will guide the Emergency Plan’s strategic

information system. 

The prevention goal of 7 million HIV infections

averted over five years will, by necessity, be based on

mathematical projections. A methodology will be

established that will use estimates of new infections

based on assumptions of rates that would occur without the Emergency Plan, estimates of numbers of new

infections under the new program, measures of program intensity (such as numbers of persons receiving

prevention services, numbers of workers trained, and

numbers of programs supported), and expected levels

of program effectiveness.

32 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Treatment 33

In 2003 alone, AIDS claimed a staggering 3 million

lives. The vast majority of these deaths – 2.4 million

– occurred in developing nations. Access to antiretroviral therapy (ART) and improved treatment of

opportunistic infections have dramatically reduced

AIDS morbidity and mortality in the industrialized

world. But in developing countries, fewer than 8 percent of the 6 million people in immediate need of

treatment receive it.

The United States has been a global leader in

developing the tools – including ART and other

treatment methodologies – that have enabled people

in industrialized nations to live long and productive

lives despite HIV. Driven by the President’s fundamental belief in the value and dignity of every

human life, President Bush’s Emergency Plan for

AIDS Relief expands this leadership role to dramatically increase access to treatment in some of the most

affected and underserved countries in the world. 

In the past, the provision of treatment in the

developing world was considered too costly for

under-resourced nations and too complicated for

developing-country health infrastructures. These

concerns are real but can no longer be barriers to

providing treatment to the millions who need it.

President Bush believes that moral duty alone is

sufficient reason to act quickly to save lives.

Providing treatment may be our best hope

against the disease and its consequences.

In the absence of treatment, HIV is viewed as a death

sentence. With no hope of survival, many refuse to be

tested and thus lack information they need to protect

themselves and others. Lack of hope contributes to

fear of the disease and stigmatization of those who

live with it, further hindering testing efforts. In contrast, the availability of treatment demystifies, and

thus destigmatizes, AIDS and people who have it.

The availability of treatment also provides an incentive to get tested. Treatment, then, can provide links

to prevention efforts. 

In addition, treatment provides a means to address

the devastating consequences of AIDS-related mortality. It is the human toll of the disease that contributes to the loss of productivity, the dramatically

increased poverty, the staggering numbers of orphans,

and the population distortions that threaten not only

the present but also the future. Treatment, in its basic

ability to prolong life and reduce morbidity, allows

parents to continue parenting, teachers to continue

teaching, and civil servants, including health care

workers, to continue serving their nations and fellow

citizens for years to come. The hope for a future again

appears on the horizon.

The President’s Emergency Plan establishes the

aggressive goal of providing treatment over the

next five years to at least 2 million people living

with HIV/AIDS in countries bearing some of the

greatest burdens of disease. Not everyone infected

by HIV needs immediate ART, which starts when a

person begins to experience symptoms or when their

immune system has deteriorated. Once ART has

begun, it continues for life. 

“There are whole countries in Africa where more than one-third of the adult population carries the infection. More

than 4 million require immediate drug treatment. Yet across that continent, only 50,000 AIDS victims – only

50,000 – are receiving the medicine they need.”

President George W. Bush, January 28, 2003

V. CRITICAL INTERVENTIONS

IN THE FOCUS COUNTRIES: Treatment

White House Photo Office
Meeting this goal requires far more than providing a

consistent supply of essential drugs, although this is a

daunting challenge in itself. It requires addressing

complex issues such as the lack of adequate infrastructure, staff, and technical capacity to provide safe,

high-quality treatment programs that reach even rural

communities. Further, many countries have yet to

develop appropriate treatment protocols and policies

to ensure safe and adequate drug supply and the equitable distribution of health resources. Other issues,

such as drug resistance and patient adherence, are

essential challenges that must be addressed.

The President’s Emergency Plan will capitalize on

decades of U.S. Government expertise in biomedical

research, delivery of HIV/AIDS care and treatment,

and development to address these challenges and rapidly expand ARV treatment availability while building

national and local health care capacity to sustain

treatment programs over the long term. Reduced drug

prices, proven treatment methodologies, committed

host governments, and the involvement of FBOs,

CBOs, and other private sector partners have proven

that it is possible to deliver this life-extending intervention in resource-poor settings. 

Priorities for the distribution of resources for treatment will ultimately be based upon the strategies,

needs, and existing resources of the host countries.

Activities funded under the Emergency Plan will collaborate closely with other donors to ensure complementary treatment efforts and the best use of

treatment dollars.

The President’s Emergency Plan is fundamentally oriented to removing barriers to treatment and working

to ensure that geography, gender, ethnicity, risk factors, and income no longer determine who lives and

dies with AIDS. With the knowledge that 8,000 lives

are lost daily to AIDS, there is no time to waste. 

Treatment Objective:

Provide treatment to at least 2 million HIV-infected

individuals in the focus countries

Treatment Strategies:

1. Rapidly scale up treatment availability through

the network model 

2. Build capacity for long-term sustainability of

quality HIV/AIDS treatment programs

3. Advance policy initiatives that support treatment 

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan and national policies and

strategies

1. Rapidly scale up treatment availability

through the network model

The expansion of treatment services in the focus

countries at the scale and scope envisioned by

President Bush’s Emergency Plan is unprecedented.

Pioneering new approaches are required to achieve

the Emergency Plan’s ambitious treatment goal. Four

operational strategies will guide the rapid scale-up of

treatment availability:

 Assessing network capacity for treatment

expansion;

 Building on established clinical programs;

 Rapidly training and mobilizing health care

personnel to provide treatment services; and

 Enhancing the capacity of supply chain management systems to respond to rapid treatment

scale-up.

Assessing network capacity for treatment expansion 

The Emergency Plan will move quickly within each of

the focus countries to help the host government and

other in-country stakeholders assess the current

capacity of the HIV/AIDS network by identifying key

facilities, organizations, and health providers who

deliver treatment at each level of the system. Using

existing data to the greatest degree possible, the rapid

assessment will document:

X Current capacity (human resources, infrastructure) of key units within the network to deliver

and rapidly expand treatment and related services, including public facilities, private NGOs,

FBOs, and private commercial facilities;

X The strengths and weaknesses of the systems

that support the delivery of treatment, such as

referral systems, logistics systems, management

information systems, etc.; 

X Organizations that currently deliver good health

services – especially those with wide networks –

that could be mobilized to expand their range of

services to include HIV/AIDS treatment; and

X Policy issues and cultural practices that either

support or inhibit the capacity to deliver treatment services.

34 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Treatment 35

The strategy to achieve President Bush’s Emergency

Plan’s ambitious goals focuses on improving health

care system capacity to deliver effective and

expanded HIV/AIDS prevention, treatment, and

care services. The focus on health care systems

provides a base from which to rapidly expand

essential services. Health care systems in the target

countries, and indeed in much of the world, are

currently organized around the concept of a “network model” comprising central medical facilities,

district-level

hospitals, and

local health

clinics, supplemented by

private, often

faith-based,

facilities. This

network concept of public

and private

health care

institutions

currently

provides the

backbone

design of

health care

delivery systems, and

many of the

focus countries – Nigeria, Uganda, and Haiti, for example –

have planned their HIV/AIDS strategies with networked health care systems as the foundation. 

The current capacity of these existing health systems to deliver HIV/AIDS prevention, treatment,

and care services is limited, however, particularly in

rural areas. The Emergency Plan, in accordance

with national health and HIV/AIDS strategies and

with the intent to build long-term sustainability,

will strengthen linkages between central facilities

and international and private support to build the

capacity of different network components and

strengthen network-wide linkages in order to more

effectively deliver quality HIV/AIDS services to

those who need them most. 

The Emergency Plan, in support of national

HIV/AIDS strategies, aspires to the goal of wellfunctioning, well-managed health care networks in

which central medical centers and referral hospitals

at the core of the network will have an adequate

number of health care professionals highly trained in

all aspects of HIV/AIDS clinical and program management. These facilities must also have adequate

physical infrastructure and research capabilities. The

central facilities will link through effective referral

networks to a series of smaller regional hospitals and

district facilities down to community-level satellite

clinics, mobile units, and community-based services.

To reach even the most rural areas, and to dramatically scale up

access in the

short term,

communitybased health

care workers

will deliver

essential

supplies,

including

medica- tions,

to patients in

their communities, as currently practiced in

Uganda.

Nurses and

community

health care

workers will

be trained in

routine care, symptom management, and monitoring

for treatment adherence, while highly trained doctors – currently in scarce supply – will use their

expertise in specialized and difficult cases. Doctors,

for example, would periodically visit a community

to evaluate patients identified for advanced care by

nurses and community health care workers.

The network ensures technical support and products flowing out from the center to facilities in the

periphery that provide care. Facilities and health

workers within the network, in turn, identify and

refer patients for higher levels of care as needed.

This might include HIV/AIDS patients exhibiting

greater levels of complexity. Information systems

link all levels of the network with regular feedback

loops, enabling both providers and health policymakers to make decisions based on solid data.

Finally, the system will employ relatively uniform

HIV/AIDS treatment and care protocols that are

consistent with national strategies and guidelines. 

The Network Model
The results of this rapid assessment will be used to

guide Emergency Plan interventions to strengthen

the capacity of the HIV/AIDS network to deliver

treatment within each of the focus countries. Plans

for technical assistance, training, and program interventions will be closely coordinated with host-country

counterparts and will be consistent with their national

AIDS strategies.

Building on established clinical programs

Based on the results of the assessment, the Emergency

Plan will mobilize immediately to scale up programs

that already deliver ART or that have the necessary

medical competence to do so quickly. Using existing

programs (those already supported by the United

States as well as those supported by others) as a platform for scale-up will allow for easier replication of

best practices, more rapid mobilization of resources

through institutions that already have functioning

systems, and increased opportunities for twinning

successful programs with those that show promise.

President Bush’s Emergency Plan will support communication efforts to prepare communities for the introduction of ARV drugs. Such efforts should describe

ARV treatment programs, including the nature of

taking ARVs for life, and include messages to combat

the possible misperception that a cure has arrived.

The second phase of scale-up will focus on those facilities that do not provide ART but do provide good

health or HIV/AIDS prevention and care services and

have networks of sites and personnel that allow for

rapid expansion and mobilization to provide ARV

treatment. Through targeted technical assistance and

training, many public health facilities, private FBOs

and CBOs, and private commercial facilities in the

focus countries will be able to add ART to their services in a relatively short period of time. FBOs will play

an important role, as in some countries in Africa

nearly half of all medical services are provided

through mission hospitals and health centers.

Other programs that offer the possibility for rapid

scale-up and development of program synergies

include:

Tuberculosis control programs. Tuberculosis (TB)

is frequently the first manifestation of HIV/AIDS

disease and the reason many people first present

themselves for medical care. Since both tuberculosis

treatment and HIV/AIDS treatment require longitudinal care and follow-up, successful TB programs may

provide excellent platforms upon which to build

capacity for HIV/AIDS treatment. The Emergency

Plan will support TB treatment for those who are

HIV-infected and develop HIV treatment capacity in

TB programs. In addition, interventions that increase

the number of persons diagnosed and treated for

HIV/AIDS will increase the need for TB treatment

and care services. Therefore, action is required to

build or maintain necessary tuberculosis treatment

capacity. Laboratories, clinical staff, community

networks, and management structures used for TB

control can be upgraded to accommodate HIV/AIDS

treatment. Many of the techniques that have been

found useful for TB control, such as directly observed

therapy, may be applied to monitoring compliance

with HIV/AIDS treatment. Because the prevalence of

HIV infection is high among persons with tuberculosis, TB programs may be an important site for HIV

testing in the focus countries. 

Malaria control programs. Malaria infection during

pregnancy increases the risk of mother-to-child HIV

transmission. Therefore, the Emergency Plan will

strengthen in-country program linkages between

HIV/AIDS and malaria programs and provide technical assistance, training, and support to malaria prevention and control initiatives focusing particularly on

HIV-positive pregnant women through PMTCT interventions. Bednets, an effective antimalarial intervention, will be incorporated into the Emergency Plan’s

coordination strategy with malaria control programs.

Rapidly training and mobilizing health care

personnel to provide treatment services

Expanding the human resources necessary to implement this bold new treatment program will require

both short- and long-term strategies. In the short

term, the immediate need for greater numbers of

trained health workers to manage ARV treatment will

be met by rapidly expanding the training of existing

health workers and supplementing their capacity with

foreign volunteer health professionals. At this stage,

technical assistance and in-service training will be

the primary vehicles for building the skills of current

health workers, including physicians, nurses, community health workers, pharmacists, and laboratory

technicians. Training will focus on building health

worker skills to improve ART case management for

both adults and children, including administering

drugs, monitoring patients for side effects and treatment failure, and promoting treatment adherence. 

In order to facilitate rapid expansion, President Bush’s

Emergency Plan will support local and national efforts

to broaden responsibility for patient treatment, care,

and support to nurses, lay health workers and counselors, and health volunteers. Given the enormous

human resource constraints, it will be critical to give

greater responsibility, through training and supervi36 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Treatment 37

sion, to greater numbers of health workers in order

to achieve treatment goals. 

In addition to strengthening the skills of formally

trained medical professionals, and as a way to extend

services into the community, President Bush’s

Emergency Plan will explore options to involve traditional healers, birth attendants, family members, and

other lay persons in a more substantial way. Building

on previous U.S. Government-funded work in this

area, programs will focus on building skills to recognize HIV complications, provide basic home-based

care, support patients and caregivers, increase

adherence to treatment regimens, and refer patients

to appropriate health care services. The Emergency

Plan will also support efforts to forge relationships

with associations of people living with HIV/AIDS

to train their members to provide patient education,

adherence counseling, and patient follow-up in order

to free clinical staff to perform higher-level tasks.

Recruiting and deploying volunteer doctors, nurses,

pharmacists, laboratory technicians, and other

health professionals from the United States and

other nations is another important strategy to meet

the human capacity needs for HIV/AIDS treatment.

Short-term training and technical assistance by experienced professionals, possibly as part of a twinning

program, will help fill human resource gaps in key

technical areas and provide opportunities for on-thejob training and mentoring of host-country counterparts. The U.S. Global AIDS Coordinator is exploring

various mechanisms and options for facilitating U.S.

professionals in this effort under the President’s

Volunteers for Prosperity Initiative, including the

Peace Corps’ Crisis Corps program, Freedom Corps,

and other programs. Finally, telemedicine and

distance education can be used to build the skills

of health professionals in the focus countries and

strengthen local, national, and international

connections among medical institutions. 

The twinning of U.S.-based institutions with African

or Caribbean institutions (or African with Caribbean

or African) offers an important means of establishing

these types of relationships. The twinning mechanism

that is part of President Bush’s Emergency Plan will

allow the creation and support of “centers of excellence” from which training, research, and talent can

be diffused throughout the impacted regions. It is this

ongoing sustained support for professional excellence

that holds the key to increased capacity for care.

Volunteers for Prosperity 

President Bush’s Emergency Plan for AIDS

Relief and many of its grantees will be participating in Volunteers for Prosperity, President Bush’s

call to international service to engage the people

of the United States as part of U.S. Government

assistance programs that meet global prosperity

needs. The Volunteers for Prosperity initiative is

part of President Bush’s USA Freedom Corps

volunteer service initiative that encourages highly skilled and trained individuals to volunteer

with organizations promoting health and prosperity throughout the world. Volunteer service is

a major component of the President’s ongoing

effort to involve all Americans in sharing compassion and skills with others in their own communities and around the world. 

Monitoring Resistance to Antiretroviral Drugs 

Careful monitoring of ARV treatment is essential to limit the development of resistant strains

of the virus and ensure the long-term durability

of treatment regimens. Currently, only a few

countries have the sophisticated laboratory

infrastructure, highly skilled laboratory staff, and

rigorous health information systems necessary to

support an ARV resistance monitoring program.

President Bush’s Emergency Plan will help build

the capacity of focus countries to monitor resistance to ARVs at the program level by providing

technical assistance and training to upgrade laboratory capacity and strengthen monitoring and

evaluation systems. The Emergency Plan will

work with the U.S. Department of Health and

Human Services and its constituent parts, the

National Institutes of Health and the Centers

for Disease Control and Prevention, and other

research organizations to ensure that surveillance and research are supported to help detect

viral resistance to ARVs and better understand

the determinants of resistance in local settings.

These studies will help inform decisions and

policies related to clinical care, program management, and drug procurement. Clinical and operations research will identify and test appropriate

alternative approaches to sophisticated laboratory monitoring of ARV therapy in resource-limited settings and increase understanding of ways

to increase ARV regimen durability.
Enhancing the capacity of supply chain

management systems to respond to rapid

treatment scale-up

The development and implementation of logistics

systems to manage the increased volume of products

needed for an expanded treatment program will

require both short- and long-term strategies. During

rapid scale-up, the focus will be on procuring and

delivering a continuous and secure supply of highquality products to patients at all levels of the

health system.

In most countries, the sharp increase in the volume of

products provided through the Emergency Plan and

other new sources such as the Global Fund to Fight

AIDS, Tuberculosis, and Malaria will likely challenge

existing national supply systems. To facilitate rapid

implementation of effective procurement and delivery

systems, President Bush’s Emergency Plan will explore

options to enhance the immediate performance of

national logistics systems through: 

X Centralized or pooled procurement mechanisms

at global or regional levels, including collaboration with other donor-funded programs – e.g.,

the Global Fund, the World Bank’s MultiCountry HIV/AIDS Program for Africa (MAP),

and WHO – and direct product donations; 

X Outsourced transportation to secure courier

services or purchase of dedicated vehicles for

ARV drug delivery;

X Design of user-friendly, timely, and accurate

methods of logistics data capture, collection,

analysis, and feedback for resupply and

forecasting; 

X Product selection and packaging for better

adherence;

X Provision of skilled people to perform logistics

management functions;

X Strengthened collaboration between supply

chain managers and program service managers

to ensure coordination of patient enrollment

and supply needs; 

X Improvements in secure storage space and

inventory management; and

X Facilitated development of national coordinating

bodies to schedule donor financial and commodity commitments, develop medium-term procurement plans, and track actual funds and

products received in order to avoid duplication

of investment. 

For more information on supply chain management

issues, see chapter X, Supportive Interventions for U.S.

Government Programs, Supply Chain Management.

2. Build capacity for long-term sustainability of

quality HIV/AIDS treatment programs

While mobilizing rapid scale-up for treatment availability, the Emergency Plan will also lay the foundation for sustainable high-quality treatment programs.

This will be accomplished by:

 Strengthening national human resource capacity

through health care worker recruitment and retention strategies, longer-term training, and technical

assistance;

 Establishing, disseminating, and implementing

treatment protocols; 

 Developing the capacity of new partners; and

 Developing and strengthening health

infrastructure.

Strengthening national human resource capacity

through health care worker recruitment and

retention strategies, longer-term training, and

technical assistance

President Bush’s Emergency Plan will focus on

building long-term human resource capacity through

training and technical assistance that directly supports

national strategic plans for scale-up of HIV/AIDS

programs. Short- and long-term training is the backbone of this strategy, including the incorporation of

PMTCT and ART content into the basic training

programs for doctors, pharmacists, laboratory technologists, nurses, and midwives, including rotational

practice. Activities include:

X Curriculum development to incorporate management of HIV-related illness into the basic

package of care offered thorough routine health

services, including methodologies for promoting

treatment adherence;

X Technical assistance and training to improve

ART case management, including promoting

adherence and monitoring patients for side

effects, treatment failure, toxicity, and contraindications;

38 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Treatment 39

X Technical assistance and training in improved

supervision and quality assurance;

X Technical assistance in long-term planning for

infrastructure and manpower requirements;

X Development of innovative training programs,

including faculty and student exchange programs and a practicum for health workers that

allows trainees to gain experience in HIV/AIDS

management by working under supervision in

health clinics or hospitals providing high-quality

treatment programs;

X Technical assistance to promote and improve

treatment literacy for clients, through patient

education, counseling, and community outreach to inform patients and their families

about the drugs they are receiving, management of side effects, and the importance of

adherence; and

X Promotion of policies to support the

recruitment and retention of qualified

health care professionals.

Establishing, disseminating, and implementing

treatment protocols 

It is important that every country have evidencebased national guidelines and protocols for managing

ART and opportunistic infections. These guidelines

and protocols must be constantly updated to reflect

the nature of the epidemic and “state of the art”

treatment, and they are an important tool for improving the quality of HIV/AIDS care. Thus, President

Bush’s Emergency Plan will:

X Provide technical assistance and training to

health ministries and professional organizations

to strengthen the development, dissemination,

and implementation of national guidelines and

protocols for ART and treatment of opportunistic infections, based on evidence and experience

gained in local settings and incorporating knowledge of the local health infrastructure and epidemiology of the epidemic in each country; and

X Provide technical assistance to develop clinical

care guidelines and ARV regimens for children

(which can significantly differ from those for

adults), including methodologies for addressing

treatment adherence and psychosocial support. 

Developing and strengthening HIV/AIDS-related

health infrastructure

A strong health infrastructure is the foundation that

supports effective planning, delivery, and evaluation

of HIV/AIDS treatment programs. Currently, health

infrastructure within the focus countries is often not

equipped to support the sustainable high-quality

treatment services necessary to effectively address the

epidemic. Thus, the President’s Emergency Plan will

provide targeted technical assistance, training, and

funding to improve and expand the infrastructure

necessary to ensure optimal delivery of HIV/AIDS

treatment services. By looking at the requirements at

each level of care – and the linkages between them –

support will be provided to:

X Equip health facilities and mobile units utilized

for HIV/AIDS treatment services; 

X Upgrade routine health information systems to

improve treatment data management; 

X Strengthen research and surveillance capacity; 

X Develop twinning mechanisms for the broad

engagement of institutions across a full range of

infrastructure-strengthening activities;

X Support effective product procurement, storage,

and distribution; 

X Strengthen financial and management 

systems; and 

X Improve laboratory capacity to diagnose infection and monitor ARV treatment. 

Jimmy Kolker
Developing the capacity of new partners

In order to achieve its ambitious treatment goals,

the Emergency Plan must help focus countries link

communities with treatment services on an enormous

scale. To facilitate this, the President’s initiative seeks

to leverage the comparative strengths of a wide range

of different public and private sector partners to dramatically increase the number and reach of organizations providing treatment services. Activities to

identify and engage new and innovative partners

include outreach to and capacity building of:

Faith-based and community partners currently providing HIV/AIDS prevention and care services to

add treatment support to their slate of services.

Faith-based and other community partners have

extensive reach and legitimacy in local communities

and are among the most experienced organizations in

providing HIV/AIDS prevention and care services.

Expanding their services to treatment support will

require training in both the technical aspects of

treatment support services and building institutional

capacity in program planning, financial and program

management, and evaluation.

Corporate sector partners with resources and innovations to contribute. The corporate sector is a vibrant

force for development worldwide. Partners from the

corporate sector have enormous potential to bring

significant new resources and innovative ideas to the

fight against AIDS. The President’s Emergency Plan

will provide technical assistance to help the corporate

sector identify ways to support and expand treatment

programs through improved workplace policies,

delivery of services, the leveraging of commercial

resources, and the application of new technologies.

Business “champions” who provide effective

HIV/AIDS treatment and care support services will

be identified. President Bush’s Emergency Plan will

also coordinate with private corporations to include

treatment services for community members in their

corporate health facilities.

Private sector networks such as unions and agricultural collectives to strengthen treatment programs

through workplace-based HIV/AIDS programs, with

support to employees and families where appropriate.

3. Advance policy initiatives that

support treatment 

President Bush’s Emergency Plan will provide support

to governments to implement their national

HIV/AIDS strategic plans and develop a comprehensive set of policies to support their implementation

through a collaborative process involving stakeholders

across multiple sectors. Most of the focus countries

have committed to uphold the human rights of people

living with HIV/AIDS and have begun to formulate

policies in alignment with the 2001 United Nations

General Assembly Special Session on HIV/AIDS

(UNGASS) Declaration of Commitment on

HIV/AIDS. Most have begun to consider how to

address a wide range of HIV-related policies. President

Bush’s Emergency Plan will help create a strong

enabling environment that will support the expansion

of high-quality treatment programs by:

 Providing technical assistance in policy

development, and

 Building political commitment.

Providing technical assistance in policy

development

As accessibility to treatment is a relatively new

phenomenon in the focus countries, the policies

and structures needed to support effective planning,

implementation, and evaluation of treatment programs are generally not yet in place. Policy reform to

support HIV/AIDS treatment must begin immediately

to ensure successful expansion of treatment services

under the Emergency Plan. Treatment-related policy

issues that may need to be addressed through technical assistance include: 

X Product registration;

X Development of standard treatment guidelines

and essential drug lists; 

X Drug procurement and financing;

X Compliance with the World Trade Organization

Agreement on Trade-Related Aspects of

Intellectual Property Rights (TRIPS) and other

trade agreements;

X Regulations related to importation and taxation

of drugs and medical supplies/equipment;

X Human resources policies, including broadened

responsibilities for HIV treatment and opportunities for testing and diagnosis, so more nurses

and community health workers can deliver care;

X Appropriate resource allocation and flow of

national resources to HIV/AIDS programs;

X Barriers to treatment caused by stigma and

discrimination;

40 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Treatment 41

X Insurance coverage of ART; and

X Administrative policy relating to health

sector reform.

Building political commitment

A primary strategy of President Bush’s Emergency

Plan is to build political commitment at the highest

levels of government and ensure that a nation’s

policies and infrastructure support this commitment.

Every opportunity will be used to make a persuasive

case to formal and informal leaders of national governments, businesses, and faith-based and nonprofit

organizations to follow President Bush’s lead and take

effective action and make compelling choices in support of treatment as a critical component of an effective HIV/AIDS program. The Emergency Plan will

mobilize all the resources incumbent in the agencies it

coordinates to convey the importance of HIV/AIDS

treatment to national and international programs. It

will support government, NGO, and private sector

leaders to garner public support for effective policies

and adequate resources for treatment programs. Public

diplomacy and communication are essential in assembling the resources, political support, and citizen support needed to make a tangible, sustainable impact. 

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan and national policies and

strategies

President Bush has insisted that his Emergency Plan

place a high priority on maintaining program integrity,

ensuring accountability, and assuring compliance with

U.S. Government polices. A strategic information system to monitor treatment implementation and impact

will be built upon:

 Surveillance information to track HIV incidence,

prevalence, and mortality;

 Program monitoring information to measure

provider capacity to treat clients, including individuals receiving ART and associated supply chain

management and clinical care;

 Targeted evaluations to support evidence-based

decisions regarding clinical programs; and

 Management information systems to increase data

storage and flow.

An appropriate information technology framework

has the potential to revolutionize the health information system supporting clinical care, program management, and international reporting. A strategic

information system provides a vehicle for identifying

those elements of a program that are most successful

and highlighting those that could be more effective. 

The Emergency Plan will help countries effectively

collect and use appropriate data for decision-making

and reporting on progress toward the achievement

of results. A second critical activity is to harmonize

indicators and reporting systems with international

agencies such as UNAIDS and WHO and major

international donors such as the Global Fund and the

World Bank. Balance must be achieved between the

need for immediate reports and results (e.g., timely

demonstration of PMTCT core indicators) and the

long-term objectives of building HIV country reporting capacity and institutionalizing locally useful and

sustainable health information systems. 

CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Care 43

The care activities of President Bush’s Emergency

Plan will comprise palliative care for people with

HIV/AIDS and care for children orphaned by AIDS

and other vulnerable children. Palliative care spans a

continuum of care from the time a person is diagnosed with HIV infection until death. The continuum of palliative care includes routine clinical care to

evaluate the need for symptom relief (from diarrhea

or headache, for example); treatment for HIV/AIDSrelated diseases such as tuberculosis and opportunistic infections; preparing people for antiretroviral

therapy where that is possible; and, when treatment

is not available or has failed, compassionate end-oflife care. 

HIV/AIDS and associated opportunistic infections

cause severe pain, debilitating symptoms and death.

Oral and esophageal infections can make eating and

swallowing painful or impossible. Uncontrolled diarrhea can cause weakness to the point of total disability, and many of the conditions associated with

HIV/AIDS cause severe pain. Pneumonia and other

opportunistic infections can, if left untreated, kill. If

basic HIV/AIDS care, supportive care, and compassionate end-of-life care for people living with AIDS

are not provided, the burden of suffering, morbidity,

and early death will continue on an immense scale.

Added to the millions who live in daily pain and

suffering as a result of HIV/AIDS are the millions of

orphans – over 13 million children under the age of

15 – left to grow up without the love and support of

their parents. Without widespread access to basic

needs such as food and shelter and essential services

such as education and health care, this population of

children is acutely vulnerable to a host of dangers,

including HIV/AIDS, and can themselves become a

high-risk population fueling the pandemic.

Basic medical care, including treatment of opportunistic infections, symptom management, and end-of-life

care and support, is currently out of reach for many

millions of people infected and affected by HIV/AIDS,

including orphans and other vulnerable children.

Little end-of-life care is available to aggressively

address symptoms, pain, and suffering. Basic care and

social support needs are currently being addressed, in

large part, by family members and neighbors, responding in whatever way they can to fellow community

members in crisis. The enormous burdens of care are,

however, stretching communities to the breaking

point. The lack of services to meet basic care needs

not only contributes to daily suffering for those infected and affected by HIV/AIDS. HIV/AIDS-related

morbidity also reduces the productivity of both people

with HIV/AIDS and their care providers. It diverts

scarce family resources as income shifts to health care

needs and affects social stability as people are unable

to work, parent, teach, or carry out other social

responsibilities.

Women bear the greatest burden of care – a load that

negatively affects not only them but also their children and families. In most of the focus countries,

families earn their subsistence through agriculture.

Women are the major contributors to the agricultural

workforce, feeding their families and earning a meager

family income in the marketplace. When women’s

“Fighting AIDS on a global scale is a massive and complicated undertaking. Yet, this cause is rooted in the simplest

of moral duties. When we see this kind of preventable suffering, when we see a plague leaving graves and orphans

across a continent, we must act. When we see the wounded traveler on the road to Jericho, we will not, America

will not pass to the other side of the road.”

President George W. Bush, April 29, 2003

VI. CRITICAL INTERVENTIONS

IN THE FOCUS COUNTRIES: Care

White House Photo Office
health deteriorates, or when they must provide care

to other family and community members, basic needs

such as food security come under threat. Thus, the

lack of consistent care services contributes to many of

the most severe consequences of HIV/AIDS and perpetuates the vicious cycle of poverty and HIV/AIDS. 

The lack of strong care systems also fuels stigma and

denial. As communities come under increasing strain,

individuals who need care are increasingly left to fend

for themselves. Rejection and discrimination feed fear

and hopelessness and keep people from internalizing

prevention messages or seeking testing and treatment.

HIV/AIDS care, then, has an enormous role to play

in reducing AIDS-related morbidity, relieving stress

on families and mitigating consequences of disease.

Many faith- and community-based groups have been

the first organized responders to the demands for care

and have worked to strengthen and support family

and community care strategies. President Bush’s

Emergency Plan will build on these and other opportunities, including national strategies to provide care

for those infected and affected by HIV/AIDS, to

expand, strengthen, and improve the quality and sustainability of programs to meet the needs of those now

suffering, including orphans and vulnerable children.

Care Objective:

Provide care and support to 10 million people living

with and affected by HIV/AIDS including orphans

and vulnerable children in the focus countries

Care Strategies:

1. Rapidly scale up existing palliative care services

(basic health care and support services, including

symptom management, social and emotional support, and end-of-life care, for persons living with

HIV/AIDS); rapidly scale up existing care services

for orphans and vulnerable children

2. Build capacity for long-term sustainability of palliative care (basic health care and support services,

including end-of-life care, for persons living with

HIV/AIDS); build capacity for long-term sustainability of care services for orphans and vulnerable

children

3. Advance policy initiatives that support basic health

care and support, including palliative care, and

care for orphans and vulnerable children

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan policies and strategies

This care goal includes both care for orphans and

vulnerable children as well as basic health care and

support, including symptom management, social and

emotional support and end-of-life care, for persons

living with HIV/AIDS. Because of programmatic

differences these will be discussed separately below.

Additionally, many of the strategies and interventions

that apply to care (such as supply chain management)

are described in detail elsewhere in this document.

1. Palliative Care

1. Rapidly scale up existing palliative care

services

Currently, palliative care needed by those living

with HIV/AIDS is not widely available in the target

countries. Most countries’ ministries of health support

district health centers, clinics, and hospitals but few

of these are adequately staffed or equipped to meet

the basic health care needs of large numbers of

people living with HIV/AIDS. Hospitals and clinics

supported by faith-based and other nongovernmental

organizations also often lack supplies and trained

personnel needed to address non-ARV treatment

for the HIV- infected.

End-of-life care is now provided through some 40 hospice programs. These, by themselves, are inadequate

to meet the need posed by this crisis. The number of

people needing pain and symptom management as

well as social, psychological, and practical support is

simply too large. Home-based care programs have

provided support to large numbers of individuals and

families living with HIV/AIDS but rarely have the

health care capacity or capability to provide minimum

standards of palliative care. Principles of palliative

care must be applied throughout the course of illness

as well as at the end of life.

Operational strategies for rapid scale-up of basic

health care, including palliative and end-of-life care,

include:

 Providing technical assistance and training to build

and expand the capacity of existing care services;

 Providing technical assistance and training to build

and expand the capacity of health care personnel;

 Integrating care services with current prevention

and treatment programs; and

 Using U.S. volunteers.

44 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Care 45

Not all people living with HIV/AIDS need antiretroviral treatment. All do need basic health

care and support, however. When ART is not

available, or it fails, many will require symptom

management, social and emotional support and

compassionate end-of-life care. Basic health care

and support includes routine monitoring of disease

progression, prophylaxis and treatment of opportunistic infections, cancers, and other complications

of immune suppression.

Palliative care and support goes beyond the

medical management of infectious, neurological,

or oncological complications of HIV/AIDS, and

addresses symptoms and suffering directly. Building

upon definitions of palliative care developed by the

U.S. Department of Health and Human Services’

Health Resources and Services Administration

(HRSA) and WHO, President Bush’s Emergency

Plan envisions expansion of an intradisciplinary

approach to palliative care and support making use

of interventions to relieve physical, emotional,

practical, and spiritual suffering.

Palliative care that includes basic health care and

support, symptom management, and end-of-life care

will involve the following elements:

 Routine clinical monitoring and management

of HIV/AIDS complications

X Opportunistic infection prophylaxis and

treatment

X Management of opportunistic cancers

X Management of neurological and other

diseases associated with HIV/AIDS

X Symptom diagnosis and relief

X Social support, including organization

of basic necessities such as nutrition,

financial assistance, legal aid, housing,

and permanency planning

 End-of-life care

X Mental health care and support

X Social support including organization of basic

necessities such as nutrition, financial assistance, legal aid, housing, and permanency

planning

X Support for caregivers

X Bereavement support for family members

Basic Health Care and Support, Including End-of-Life Care
Providing technical assistance and training to build

and expand the capacity of existing care services

Families and communities are already responding to

the needs of those living with HIV/AIDS. Most often

these informal caregivers are not adequately trained

or supported. Building and expanding these networks

by providing targeted technical assistance and education will help to increase their capacity and effectiveness. The Emergency Plan will work with existing

health care delivery sites (public and private),

hospices, home-based care providers, faith-based facilities, and other points of health care delivery to offer

on-site training, technical assistance, and ongoing

education for providers.

Providing technical assistance and training to build

and expand the capacity of health care personnel

Specific medical and nursing training (focusing on

prevention, recognition, and treatment of HIV complications and pain and symptom management) will

be especially important to achieve rapid scale-up of

basic health care services, including palliative and

end-of-life care, for the HIV-infected in target countries. Following local policies, practices, and professional standards, nurses and other health care

personnel may be given expanded training to extend

the reach of basic health care systems into rural or

remote areas. These health care personnel can also

train community volunteers and family members in

skills needed to provide home care.

Integrating care services with current prevention

and treatment programs

Existing prevention and treatment programs offer

another opportunity for expanding care, which in

turn will strengthen prevention and treatment interventions. President Bush’s Emergency Plan will seek

to layer care services onto existing prevention and

treatment programs by providing additional training

for staff. This strategy establishes other important

links between services – many who receive symptom

management may be able to progress to ARV therapy.

Also, palliative and end-of-life care interventions

provide unique opportunities to promote prevention

messages and should help inform messages used in

behavior change programs. For example, involving

at-risk youth as volunteers in care programs can

help overcome stigma and denial and contribute to

behavior change.

Using U.S. Volunteers

U.S. volunteers may provide an additional resource

for rapid scale-up of care. A rapid local assessment of

skills needed must be undertaken in order to ensure

that there is an appropriate and helpful match of talent with need. In the early rapid scale-up phase of

implementation, it is likely specific technical skills in

nursing, medicine, social work, palliative care, and

pharmacy will be in greatest demand.

2. Build capacity for long-term sustainability of

palliative care

As is the case for increasing long-term capacity for

ART, increasing the availability of basic health care

and support, including end-of-life care, will require a

sustained partnership with ministries of health, nongovernmental organizations, professional associations,

and training institutions. The provision of basic

health care and support services, including end-of-life

care, must be based upon an adequate supply of professionals – doctors, nurses, social workers, pharmacists, and others. These individuals must be trained

and provided with ongoing continuing education, in

topics relevant to the care of HIV-infected patients. A

great deal of attention must be given, therefore, to

establishing long-term professional and institutional

relationships so that ongoing professional communications and referrals can be supported.

The twinning of U.S.-based institutions with African

or Caribbean institutions (or African with Caribbean

or African) offers an important means of establishing

these types of relationships. The twinning mechanism

that is part of the Emergency Plan will allow the

creation and support of “centers of excellence” from

which training, research, and talent can be diffused

throughout the impacted regions. It is this ongoing

sustained support for professional excellence that

holds the key to increased capacity for care.

Increasing long-term capacity for end-of-life care

poses some special problems. End-of-life care is a

well-established field in only a few areas of the world.

It is only now gaining stature in the United States,

and in Africa there are only two academically associated training programs in end-of-life care and only

about 40 hospices in all of the focus countries. A

strategy that will advance palliative care will involve,

therefore, capacity building in African and Caribbean

academic training institutions, aggressive in-service

training, and continuing education. Partnerships in

this regard between the United States and other

developed nations where end-of-life care is well

established may be especially useful. Establishment

and support of twinned hospices will also provide

support and opportunities for training and technical

assistance.

Operational strategies for building long-term sustainability for basic health care and support, including

palliative care, include:

46 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Care 47

 Technical assistance for development of

appropriate care protocols;

 Twinning;

 Curriculum change in health professional schools;

 Expansion and integration of hospice services; 

 Identifying new public-private partnership

opportunities; and

 Provision of essential supplies.

3. Advance policy initiatives that support basic

health care and support, including palliative

care 

Policy reform must begin immediately to establish an

environment that is conducive to the implementation

of the basic health care and support and palliative

care interventions and services described in this strategy. A key priority of the Emergency Plan will be to

support implementation of good policies and effective

legislation, in concert with national strategies and

cognizant of local needs, particularly at the community level. 

Strategic approaches will include the following areas: 

 Human resources policy reform and development,

including the broadening of responsibility for

HIV/AIDS clinical care to lower levels of care

providers, and policy reforms to recruit and

encourage retention of care professionals; and

 Policy reforms to increase availability of pain

medications.

Human resources policy reform and development

Focus countries face severe shortages of health care

professionals. Devolving care skills and responsibilities

to lower levels of care providers, such as nurses and

clinic staff, will greatly increase the pool and reach of

care providers. 

In addition, recruiting doctors, nurses, and other

health care professionals from countries with a

surplus may be a short-term strategy for increasing

the number of care providers in a given country. The

Emergency Plan will work with policymakers to support the changes in immigration policy necessary to

implement this strategy in the focus countries. 

Difficulties in retaining trained health professionals

are another common problem in these countries.

Policies to counteract the “brain drain” will be

encouraged, as will programs to increase provider

job satisfaction. Some of this policy work must be

done on a regional basis to counteract cross-border

migration of health professionals. 

Policy reforms to increase availability of pain

medications

People living with HIV/AIDS often need opioids

and other analgesics to treat pain and mitigate other

symptoms. The Emergency Plan will work with local

regulatory authorities to remove barriers to the availability of these medications and to ensure they are

used appropriately and not diverted for illicit use.

Specific areas of activity may include:

X Implementation of policies to expand the use of

oral opioids (through, for example, working with

community leaders to translate national policy

changes into action);

X Liberalization of laws restricting medicinal use

of opioids;

X Expanding the ability of nurses to dispense pain

medication, including opioids, especially in the

home setting; and

X Strengthening of laws to prevent diversion of

opioids for illicit purposes. 

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan policies and strategies 

A strong evidence base will support the Emergency

Plan to provide services to relieve suffering. Palliative

and related care supports both those who receive and

those who do not receive ART. Strategic information

to support care must measure both home- and clinicbased activities. Outcomes will be measured through

surveillance activities, especially population-based surveys. Provider information on care capacity, training,

and services will provide data to monitor the progress

of care programs on an ongoing basis. Targeted evaluations will identify best care practices. A management

information system will provide the backbone for

reporting information.

The goals of providing care to 10 million individuals

(palliative care and care for orphans and vulnerable

children) over the five-year period will be measured

using a variety of service-based statistics, surveys, and

special studies. Indicators for measuring Emergency

Plan progress toward achievement of care goals will

include numbers of individuals served, numbers of
persons trained to deliver care, and number of service

delivery programs supported. 

2. Care for Orphans and

Vulnerable Children

Children affected by HIV/AIDS have the same

basic needs – economic and food security, education,

nutrition, health, and emotional well-being – as other

children, but the pandemic’s impact is eroding family

and community capacity to meet these needs. AIDS

is having a negative impact on the education, nutrition, health, economic and food security, and emotional well-being of children, including orphans and

other children affected by AIDS. A variety of strategies must be used, depending on local context.

Research has shown that resources – financial,

human, public services – vary between and within

countries. In many places, communities are mobilized

and have systems in place to identify, protect, and

provide basic necessities to the most vulnerable children. In other places – even in neighboring communities – the response from the community is minimal.

Therefore, specific interventions must ultimately be

based on identifying and strengthening already existing resources in a manner that does not undermine

them. Areas of particular vulnerability in specific

locations must be identified and interventions developed to strengthen existing community initiatives and

fill the gaps. The exact mix of services provided and

the number of beneficiaries will differ by location,

existing resources, and types of vulnerability faced by

the children in the intervention area. 

Donors, governments, and NGOs should recognize

that families, communities, and children themselves

are the front line of response to HIV/AIDS.

Traditional community mechanisms for orphan care,

in many cases, have been overwhelmed by the sheer

numbers of orphans, yet that number is set to rise as

high as 25 million by 2010. Thus, developing and

strengthening local structures is of primary importance in laying the foundation for future efforts that

will support the growing numbers of children affected

by HIV/AIDS. Funding and activities must support

communities in ways that do not undermine community ownership of interventions or the long-term

capacity of communities to respond. Outside assistance should accordingly focus on engaging in longterm partnerships to support, strengthen, and sustain

ongoing community initiatives through training and

technical assistance, organizational development, and

sustained financial and material support. 

Two other overarching principles apply in President

Bush’s Emergency Plan’s strategic approach to care

for orphans and other vulnerable children. Because

targeting specific categories of children can lead to

increased stigmatization and discrimination, the

Emergency Plan specifically identifies “orphans and

other vulnerable children” as beneficiaries of care.

Directing program efforts exclusively to children with

a parent or parents who have HIV infection or have

died of AIDS is both unrealistic and detrimental to

those children. In addition, efforts should not focus

solely on children whose parent or parents have

already died. Long before they become orphans, children experience severe distress as a result of living

with – and often caring for – a terminally ill parent.

Throughout the world, communities have mobilized

and developed systems to identify, prioritize, and care

for those who are most vulnerable. These systems,

where effective and sustainable, will be supported. 

Finally, President Bush’s Emergency Plan will seek

where possible to support family and community

mechanisms as opposed to institutional care.

Alternatives to traditional orphanages, such as community-based resource centers, continue to evolve in

response to the massive number of orphans left behind

by the AIDS epidemic. These centers help families

continue to support children within the community,

providing support groups, counseling, temporary medical care for HIV-infected children, training in parenting skills, skills training programs for older children,

and daycare for parents or foster parents who need

48 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

Meeting the Needs of Afflicted Families

Families are the cornerstone of a strong society.

Families with children are especially impacted by

HIV/AIDS - when parents and children are

sick, the ability to cope with the impact of

HIV/AIDS is dramatically diminished. President

Bush’s Emergency Plan will particularly focus on

care, treatment, and prevention needs of families with children. Many of these families are, in

fact, headed by children because parents are

dead or sick. Best practices of community support for these households will be identified and

promulgated. Mothers and fathers caring for sick

children are likely to be HIV-infected themselves and will be encouraged to be tested and

enter into life-sustaining treatment. Homebased care and support programs will be especially targeted to such families in order to do all

that is possible to keep them in tact and organizations with particular expertise in family care

will be targeted for funding.
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES: Care 49

relief. They can also prevent children from entering

the worst forms of child labor.

In some cases, however, institution-based activities are

necessary. For abandoned children or children living

on the street, an institution might be the only alternative to death from exposure and starvation. The

challenge is to develop better alternatives, such as

emergency and long-term foster care and local

adoption. In addition, there has been an increase in

facility-based palliative care for children living with

HIV/AIDS. Many of these institutions are also reaching out to provide care in local communities.

The Emergency Plan will help build, strengthen, and

improve the quality and sustainability of programs to

meet the needs of orphans and vulnerable children

through rapid scale-up, capacity building, strengthening the enabling environment, and tracking progress

and establishing best practices.

1. Rapidly scale up care services for orphans

and vulnerable children 

Rapid scale-up of services and support systems for

orphans and other vulnerable children will rely on

improving the quality and expanding the reach of

existing responses. Rapid scale-up will be guided by

the following operational strategies:

 Strengthening the capacity of families to cope with

their problems;

 Mobilizing and strengthening community-based

responses;

 Increasing the capacity of children to become

proactive in meeting their own needs; and

 Integrating care services with existing prevention

and care programs.

Strengthening the capacity of families to cope with

their problems 

Since the first and most important responses to

HIV/AIDS are carried out by affected children, families, and communities, President Bush’s Emergency

Plan will support projects to increase the capacity of

families and communities to provide care and support

to children affected by the epidemic. Activities might

include training caregivers, increasing access to education, promoting the use of time- and labor-saving

technologies, supporting income-generating activities,

and connecting children and families to essential

health and social services where available.

Mobilizing and strengthening community-based

responses

After family, the community is the next safety net for

children affected by HIV/AIDS. The Emergency Plan

will both provide direct support to community efforts

and build the capacity of local NGOs and CBOs to

support a greater number of community initiatives.

Community support includes providing mentors for

emotional support, resources such as food and schoolrelated expenses, household help, child care, and farm

labor. Other programs provide children and families

with legal assistance to protect property rights and

ensure protection from abuse.

Increasing the capacity of children and young people to become proactive in meeting their own needs

Children and adolescents affected by HIV/AIDS are

active participants in mitigating the pandemic’s

impact, moving beyond the role of recipients of

assistance. For example, young people are increasingly

involved in making home visits to orphans and vulnerable children and helping HIV/AIDS-affected

households. Additionally, the Emergency Plan will

support initiatives that ensure that children and adolescents stay in school, are trained in vocational skills,

and receive adequate nutrition and health services.

Integrating care services with existing prevention

and care programs

Programs that focus on care for vulnerable children

within the context of services for the greater population of people living with HIV/AIDS can enhance

both prevention and care services. For example,

adding care components such as access to medicine

and food to prevention programs can draw in new

populations for HIV/AIDS education. Programs that

provide home-based care and support to people living

with HIV/AIDS may be able to add components

addressing the needs of children. Ongoing community

White House Photo Office
support to HIV-positive women and their families,

including their children, could be added to

HIV/AIDS testing at sites offering PMTCT services.

Special programs should also be developed for child

victims of sexual exploitations and children working

in prostitution.

2. Build capacity for long-term sustainability

of care services for orphans and

vulnerable children 

Given the current disease burden in highly impacted

countries, the number of orphans will continue to rise

over the next decade. Thus, President Bush’s

Emergency Plan will pursue the following strategies in

building capacity for sustainable quality care programs: 

 Strengthening the organizational capacity of community- and faith-based organizations to address

the needs of orphans and other vulnerable children;

 Strengthening early interventions with

at-risk youth; 

 Promoting collaboration and coordination among

partners for a long-term response; and 

 Identifying new public-private partnership

opportunities. 

Strengthening the organizational capacity of community- and faith-based organizations to address

the needs of orphans and other vulnerable children

Building the organizational capacity of communityand faith-based groups is essential to ensuring longterm availability of care. The Emergency Plan will

support activities to improve management skills,

including planning, monitoring and evaluation,

resource mobilization, and networking.

Strengthening early interventions with at-risk youth

Special efforts are needed to reach those young people, including orphans, who are most vulnerable to

early sexual activity and other risky behaviors. These

young people who are at highest risk are often hard to

reach because they are not enrolled in school, do not

attend religious institutions, and do not participate in

mainstream youth organizations. Youth who lack

parental support are especially vulnerable. President

Bush’s Emergency Plan will support CBOs, especially

faith-based groups, for early outreach and intervention

to prevent transactional and survival sex among these

extremely vulnerable young people. These local groups

will be supported to reach these young people early

with HIV education, counseling, and social support to

encourage abstinence and other safer behaviors. 

Promoting collaboration and coordination among

partners for a long-term response

The impact of HIV/AIDS around the world is so large

and growing so rapidly that no single government,

international organization, or donor can unilaterally

make a sufficient difference. Collaborative action

is key to mobilizing resources to better address the

overwhelming needs that continue to escalate among

children in AIDS-affected areas. Programs will be

encouraged not only to coordinate their efforts with

other stakeholders but to actively work to build collaborative responses to address the problems at scale

and unify and expand the response to children and

adolescents affected by HIV/AIDS. 

Identifying new public-private partnership

opportunities 

The magnitude of the problems of orphans and vulnerable children will require the active involvement

of a large number of new partners and significant

leveraging of private sector resources. Industry and

labor have long-standing social protection programs

that will be mobilized to provide services to orphans

and vulnerable children. The Emergency Plan will

provide technical assistance to identify and support

AIDS-affected youth and adults as candidates for

jobs and, through partnerships with businesses, will

link candidates to job opportunities with employers

seeking to sustain and grow jobs in vulnerable communities. The President’s initiative will also actively

encourage corporations to provide direct services or

seed-funding for community initiatives to help

orphans and other vulnerable children. Public-private

partnerships will support a number of strategies to

mobilize and coordinate community care initiatives,

including collaborative efforts of employers to address

community problems collectively and industry/labor

support for government efforts to provide care to this

vulnerable population. 

3. Advance policy initiatives that support care

for orphans and vulnerable children

President Bush’s Emergency Plan will work with

government ministries and other organizations in

focus countries to support initiatives to institute

policy, program, and operational reforms, including

reforms to ensure access to basic social services and

to create special protection and care measures for

children outside families and communities. Activities

will promote supportive environments for vulnerable

children and include advocacy for basic legal protections, transformation of public perceptions of

HIV/AIDS, and strengthened school-based HIV

prevention and care programs.

50 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
CRITICAL INTERVENTIONS IN THE FOCUS COUNTRIES 51

To support the Emergency Plan programs that will

meet the needs of millions of orphans and vulnerable

children, some critical policy areas must be addressed.

These policy areas cover issues related to:

 Inheritances and succession;

 Bereavement among children;

 Child-headed households;

 Access to education and school-related

expenses; and 

 Protective services (e.g., against abuse,

trafficking, child prostitution, and other worst

forms of child labor, etc.).

4. Collect strategic information to monitor and

evaluate progress and ensure compliance with

Emergency Plan policies and strategies 

There is a long history of measuring care and support

for orphans and vulnerable children. This history will

form the basis of measuring progress toward achieving

Emergency Plan goals in support of these children.

Measurement will include:

 Population-based surveys of care and support for

orphans and vulnerable children;

 Program monitoring of provider capacity and

training;

 Targeted evaluations of best practices for

outreach to and care for orphans and vulnerable

children; and 

 Management information systems to strengthen

data transmission and storage. 

The goal is to provide strategic information to programs, countries, donors, and the U.S. Government to

strengthen the accountability and improvement of

programs for orphans and vulnerable children. This

strategic information strategy will support evaluation

of programs on a timely basis, making it possible to

discard models that are not working and to identify

the best practices that contribute towards the care

goals of President Bush’s Emergency Plan.

STRENGTHENING BILATERAL HIV/AIDS PROGRAMS 53

In keeping with the United States’ position as

the global leader in the fight against HIV/AIDS,

President Bush’s Administration provides over 50

percent of bilateral international HIV/AIDS assistance. Through various agencies and departments,

the United States has bilateral programs to combat

AIDS in over 100 countries, including the focus

countries, and is active through diplomatic and

public diplomacy channels in dozens more.

Outside of the Emergency Plan’s focus countries, the

profile of HIV/AIDS varies widely among nations.

Some countries have a high disease burden; others

have low incidence of HIV but are witnessing emerging epidemics through rapid increases in infections;

and others have low HIV incidence rates but need to

remain vigilant. Unfortunately, no country is unaffected by the problem.

These countries have diverse drivers of HIV/AIDS,

including epidemics led and compounded by such factors as high-risk sexual behavior, injection drug use,

unsafe medical practices, gender inequality, prostitution, and poverty. All have challenges in implementing integrated and effective prevention, treatment,

and care strategies. Stigma and denial remain widespread challenges, as does the lack of correct and

consistent information about HIV/AIDS. Testing is

underutilized, and appropriate protocols and enabling

policies are often lacking. The U.S. Government has

collected many “lessons learned” over two decades

of worldwide HIV/AIDS activity, and it is on the

strength of best practices that we embark on an intensified effort in our bilateral HIV/AIDS programs to

ensure coordination, effectiveness, and accountability. 

The President’s Emergency Plan offers a fresh

opportunity to develop and implement consistent

HIV/AIDS policies and programs across our bilateral

prevention, treatment, and care initiatives, drawing

on the U.S. Government’s strong field presence and

technical expertise. Our bilateral programs worldwide

will be an integral part of the President’s Emergency

Plan for AIDS Relief and will be harmonized in policy

and management to create the momentum that will

truly turn the tide against HIV/AIDS. 

Bilateral Program Objective: 

Apply best practices in prevention, treatment, and

care, and improve coordination, management, and

accountability across all U.S. Government (USG)

bilateral HIV/AIDS programs

Bilateral Program Strategies: 

1. Strengthen quality and capacity of prevention,

treatment, and care programs

2. Advance policy initiatives that support effective

bilateral programs

3. Strengthen coordination, management, and

accountability of programs, and ensure their consistency with the principles of the Emergency Plan

“By the legislation I will sign today, the United States of America will take the side of individuals and groups and

governments fighting HIV/AIDS in Africa and other parts of the world. We’ll provide unprecedented resources to

the effort. And we will keep our commitment until we have turned the tide against AIDS.”

President George W. Bush, May 27, 2003

VII. STRENGTHENING BILATERAL

HIV/AIDS PROGRAMS

White House Photo Office
1. Strengthen quality and capacity of

prevention, care, and treatment programs

Integrated prevention, care, and treatment programs

are an established best practice. Integrated programs

combat stigma, encourage behavior change and testing, and mitigate the consequences of HIV/AIDS.

Countries are at different stages of HIV/AIDS

response, but all HIV/AIDS programs of the U.S.

Government should be working toward establishing a

continuum of prevention, treatment, and care programs in proportions appropriate for the host country.

Thus, USG efforts will be focused toward increasing

the availability of high-quality, sustainable prevention,

treatment, and care programs by:

Promoting evidence-based risk elimination and

reduction programs

Successful strategies, such as the ABC approach and

tailored interventions for high-risk groups like injection drug users, are helping to prevent new HIV

infections. These strategies will be promoted across all

USG bilateral HIV/AIDS programs.

Promoting strategies to increase testing

Worldwide, it has been estimated that some 95 percent of HIV-infected individuals do not know their

status and thus do not have vital information to

protect themselves and others. Testing is a crucial

behavior change strategy, and new methods for

increasing testing will be explored and promoted,

including routine testing in health care settings.

Promoting strategies to combat stigma and denial

Stigma and denial remain primary barriers to addressing HIV/AIDS effectively. Programs will address

stigma and denial by increasing the involvement of

people living with HIV/AIDS, emphasizing the role

of leadership, and providing consistent and correct

HIV/AIDS information.

Offering technical assistance for the development

of appropriate prevention, treatment, and care

protocols. 

Many countries lack appropriate prevention,

treatment, and care protocols, contributing to

ineffective and inconsistent program implementation.

The U.S. Government will capitalize on its expertise

and established best practices to promote and assist

with the development of comprehensive national

prevention, treatment, and care protocols to guide

program development across all governmental and

nongovernmental sectors.

Offering technical assistance and training of

providers

Limited technical capacity is a barrier to increasing

and strengthening prevention, treatment, and care

interventions, and to ensuring compliance with established protocols. The focus of the U.S. Government’s

HIV/AIDS programs, and a necessary tool for ensuring sustainability, is building the capacity of local

providers to implement effective programs. USG

efforts will have as a priority capacity building of

health care workers and CBOs to strengthen the

quality and expand the reach of effective HIV/AIDS

interventions.

Identifying and developing the capacity of new

partners

Worldwide, efforts against HIV/AIDS are amplified

through approaches that reach individuals where they

live, learn, work, and pray. New partners can expand

the reach of programs, fill gaps in service delivery, and

contribute additional necessary resources to the fight

against HIV/AIDS.

Coordinating with host governments and a wide

range of organizations active in country

To be fully effective, USG programs should be coordinated with and complementary to existing programs

and the host government’s national AIDS strategy.

The U.S. Government will work closely with the host

government, the private sector, NGOs, FBOs, multilateral institutions, other bilateral donors, and others

active in country. 

2. Advance policy initiatives that support

effective bilateral programs 

The ability of programs and populations to address

HIV/AIDS and mitigate its consequences are

enormously impacted by policies related to the

importation, regulation, and registration of essential

medicines and supplies; the provision of basic social

services such as health and education; and the allocation of resources. The President’s Emergency Plan will

promote policies reflecting best practices through:

Active diplomacy to advocate for the adoption of

supportive policies

Through the U.S. Chief of Mission and U.S.

Government representatives in sectors such as education, health, defense, and trade, the U.S. Government

will engage with its leadership counterparts in host

countries to advocate for the adoption of supportive

HIV/AIDS prevention, treatment, and care policies.

54 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
STRENGTHENING BILATERAL HIV/AIDS PROGRAMS 55

Technical assistance for policy development

Drawing on its expertise and worldwide experience,

the U.S. Government, through its representatives in

the field, will provide technical assistance for the

development and application of policies supportive

of effective action against HIV/AIDS and its

consequences.

3. Strengthen coordination, management,

and accountability of programs, and ensure

their consistency with the principles of the

Emergency Plan

President Bush has placed a strong emphasis on

increased accountability for program activities. The

USG programs worldwide are currently implemented

by a multitude of U.S. Government agencies and

departments, each with different management and

accountability processes. Programs can be uncoordinated, both with other U.S. Government agency programs and with host governments and other donors,

leaving gaps in service delivery and needs unmet. The

lack of uniform accountability methods, including

program evaluation methodologies, poses difficulties

in comparing program impact and ensuring effective

and efficient allocation of resources. 

President Bush’s Emergency Plan will:

Coordinate leadership of U.S. Government bilateral

HIV/AIDS programs through the leadership of U.S.

Chiefs of Mission

The benefits of coordinated leadership, as demonstrated by the U.S. Global AIDS Coordinator and the

U.S. Chief of Mission-led in-country USG teams in

the focus countries, should be applied across USG

bilateral programs. Government agencies will work as

a united team under the leadership of the Chief of

Mission, ensuring that programs are working toward

shared goals. 

Coordinate with host governments and other

donors to eliminate duplication and ensure that

needs are met

Coordination with host governments and donors will

be strengthened. This will allow for more effective

communication and evaluation of country-specific

needs and circumstances, facilitate the effective and

efficient use of funds, and determine and fill gaps in

service provision.

Implement uniform standards for strategic information and evaluation

As a unified team implementing a coordinated country plan, all U.S. Government agency activities will be

evaluated on their progress toward meeting established goals according to shared indicators that will

facilitate the comparison of programs. 

Hold U.S. Government programs accountable

for results

U.S. Government programs will be funded according

to their ability to indicate evidence-based success

against specified goals. Improved accountability, in

addition to uniform evaluation standards, will facilitate the identification of successful programs for scaleup and poorly performing programs for elimination.

Assist countries in developing their own strategic

plans

Following from the coordination of leadership

described above, U.S. Government departments and

agencies will work with host-country governments to

develop coordinated country plans that will identify

opportunites to capitalize on the strengths of individual USG agencies and eliminate duplication in program services. 

STRENGTHENING MULTILATERAL ACTIONS 57

The crisis of global AIDS is too great for any one

entity to solve. Turning the tide will require a sustained collaborative effort from a multitude of international, national, and local organizations leveraging

their comparative strengths. Not only are there

extraordinary resource needs, but the diverse drivers

and consequences of the disease, and its many complicated interactions with a variety of other social,

political, and economic circumstances, demand an

equal number of diverse actors with varied expertise. 

President Bush’s Emergency Plan makes an unprecedented commitment of resources and focuses funds

on the U.S. Government’s strengths in providing

technical assistance, training, research, and material

resources to dramatically increase health care infrastructure and capacity to address HIV/AIDS effectively, including providing treatment. The Emergency

Plan recognizes, however, that strengthened health

care systems are but one powerful tool in combating

HIV/AIDS. Many other essential requirements,

including such basic needs as clean water and adequate nutrition, present barriers to a successful

HIV/AIDS response. Conflict, famine, and gender

inequality all make contributions to the spread of HIV

and the devastation of AIDS, and must be addressed. 

The President’s Emergency Plan commits a significant

proportion of its resources to the Global Fund to Fight

AIDS, Tuberculosis, and Malaria in recognition of the

fact that the Fund is a promising global force in the

fight against AIDS and offers important opportunities

to address needs complementary to other elements of

this strategy. Other multilateral institutions and international organizations, such as UNAIDS and its

“Three Ones” principles, WHO and its “3 by 5”

initiative, the World Bank, and the World Bank’s

International Bank for Reconstruction and

Development, have also provided essential global

leadership, expertise, and resources, particularly in the

areas of advocacy, government and civil society collaboration, HIV/AIDS and economic development,

and health sector response (including HIV/AIDS

surveillance, prevention, treatment, and care).

Organizations such as the World Food Program

(WFP), the United Nations Children’s Fund

(UNICEF), the United Nations Development

Program (UNDP), the International Labor

Organization (ILO), United Nations Educational,

Scientific and Cultural Organization (UNESCO),

the United Nations High Commissioner for Refugees

(UNHCR), and the International Committee of the

Red Cross (ICRC) have HIV/AIDS programs focused

on specific needs or populations, such as food security,

mothers and children, workplace issues, refugees,

migrant workers, and youth.

The contributions of these multilateral institutions

and international organizations working with great

dedication to combat HIV/AIDS provide a vital

opportunity for a comprehensive response. The U.S.

Government will strengthen its relationships with

multilateral institutions and international organizations to amplify global action against HIV/AIDS by

encouraging coordination to fill gaps in current activities and ensure efficient use of funds. Effective collaboration, however, requires addressing several of the

“The United States is committed to working with other nations to reduce suffering and to spare lives. And working

together is the key. Only through sustained and focused international cooperation can we address problems so

grave and suffering so great.”

President George W. Bush, May 11, 2001

VIII. STRENGTHENING MULTILATERAL

ACTIONS

White House Photo Office
challenges currently facing the international community in its fight against HIV/AIDS. 

Duplication of program efforts and an uncoordinated

response, especially in the most afflicted nations

where so many have initiated programs, must be

avoided. Harmonized proposal, surveillance, reporting,

and accountability requirements will avoid placing

additional burdens on governments already weighed

down by the disease burdens of HIV/AIDS, malaria,

and tuberculosis. As an international community,

donors should commit to promoting best practices

and evidence-based interventions and adhere to high

standards for resource allocation and management. At

the same time, recognizing that HIV/AIDS is a global

emergency, donors should ensure that funds are

quickly dispersed to organizations effectively serving

those in need, with an eye to building local capacity

for a sustainable long-term response. 

The U.S. Government will use the full range of diplomatic tools to engage international organizations as

partners in the fight against HIV/AIDS. Under

President Bush’s Emergency Plan, efforts will be made

to strengthen U.S. participation on governing boards

and to consult closely and often with both the leadership and working levels of the multilateral and other

international organizations working on HIV/AIDS.

Across the world, the United States will coordinate

programmatic and diplomatic efforts at the local level

in order to enhance the effect of global contributions.

Together with the strength of USG bilateral programs,

effective multilateral engagement and action will win

the war on AIDS.

Multilateral Objective: 

Ensure a comprehensive and amplified response to

global HIV/AIDS through leadership, engagement,

and coordination with multilateral institutions and

international organizations

Multilateral Strategies:

1. Coordinating programs to capitalize on the

comparative advantage offered by each multilateral

organization, including targeting multilateral

strengths to unique challenges

2. Working to harmonize proposal, reporting, and

strategic information systems across all multilateral

and international organizations

3. Promoting evidence-based policies and sound

management strategies

4. Encouraging expanded partnerships that build

local capacity

1. Coordinating programs to capitalize on

the comparative advantage offered by each

multilateral organization, including targeting

multilateral strengths to unique challenges

True progress against HIV/AIDS will require a comprehensive response that addresses the diverse drivers

and consequences of disease. The United States will

focus its interventions on health care and human

services approaches to HIV/AIDS prevention, treatment, and care that capitalize on its expertise in

technical assistance, training, and research. Many

multilateral organizations have vital expertise in specific areas. For instance, WHO addresses the health

sector to HIV/AIDS and works closely with health

ministries. The ILO focuses on HIV/AIDS in the

workplace and the rights of workers living with

HIV/AIDS, while the WFP focuses on food security

and nutritional needs. ICRC and UNHCR are able

to reach refugees and displaced persons, while many

other organizations focus on improving the status of

women. Each of these interventions, and those from

other agencies both in and out of the U.N. system, is

important to a comprehensive and effective response

to global HIV/AIDS, and contributions are amplified

when they are coordinated. 

The U.S. Government will strongly encourage coordination to fill gaps by:

 Engaging, through the U.S. Global AIDS

Coordinator, the leadership of multilateral and

international organizations to identify and then

complement comparative strengths;

 Encouraging the development of one in-country

structure that can facilitate coordination between

donors, host governments, people living with

HIV/AIDS, and NGOs; and

 Ensuring that U.S. missions, through their networks of public affairs, refugee, economic, health,

and development assistance officers and other specialists, are working with their in-country counterparts in the field.

2. Working to harmonize proposal, reporting,

and strategic information systems across all

multilateral and international organizations

Harmonization of proposal, reporting, surveillance,

management, and evaluation procedures across all

multilateral and international organizations is a key to

the success of global HIV/AIDS efforts. Harmonized

procedures both ensure comparability of different programs across countries and decrease the burden on

host organizations and governments. The U.S.

58 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
STRENGTHENING MULTILATERAL ACTIONS 59

On May 11, 2001, President George W. Bush,

flanked by U.N. Secretary-General Kofi Annan and

Nigerian President Olusegun Obasanjo, made the

first pledge to what would become the Global Fund

to Fight AIDS, Tuberculosis, and Malaria. The U.S.

Government was a leader in the creation of the

Global Fund as the embodiment of a new way of

doing business, bringing together diverse partners,

including the public and private sectors, donors and

recipients, and NGOs and affected communities, to

quickly and effectively mobilize resources for combating HIV/AIDS and the other two diseases. The

Fund’s existence is based on strong public-private

partnerships, results-based management, and a

focus on local capacity building. 

The Global Fund is a private nonprofit foundation

based in Switzerland, with a “limited financial

partnership” board model that includes a balance

between donor and recipient nations. In an

arrangement unique among international organizations, the private sector has its own seat and vote,

as do private foundations and “northern” and

“southern” NGOs. The Fund has the potential to

revolutionize the provision of assistance, and the

United States is committed to the fulfillment of this

vision and the Fund’s full potential.

The United States leads the world in donations to

the Fund, with $623 million in contributions to

date and has pledged a total of $1.97 billion from

the inception of the Fund through 2008 (with

cumulative contributions not to exceed one-third of

the total contributions to the Fund from fiscal years

2004 to 2008). The United States accounts for 37

percent of total pledges and 29 percent of contributions to the Fund. Secretary of Health and Human

Services Tommy Thompson was elected Chairman

of the Fund’s Board in January 2003, giving the

U.S. Government a special leadership responsibility

through January 2005. Secretary Thompson has

traveled throughout the world on behalf of the

Fund, enlisting and engaging government, private

sector, and NGO actors to support the Fund’s

efforts to combat global AIDS.

Over the next five years, the United States will

remain deeply engaged in working to ensure the

realization of the Fund’s unique potential as an

effective actor to combat HIV/AIDS, tuberculosis,

and malaria. The United States will:

z Work to ensure the Fund maintains its unique

public-private character, with a strong and active

board and a secretariat accountable to that

board;

z Support projects built on proven best practices

that incorporate the principles of results-based

management and strong mechanisms of accountability for both in-country and Fund project

managers;

z Work to ensure harmonization of reporting, monitoring, and evaluation of projects;

z Work to strengthen mechanisms that increase

coordination of the Fund’s country activities

with those of other donors;

z Continue to strongly support the Fund’s mandate

of local capacity building of governments, NGOs,

and the private sector, with embassy and incountry program support for the Fund to establish such capacity where it does not exist; 

z Continue its strong support for the concept of

“additionality” for Fund projects, so that the

Fund acts in addition to (rather than replaces)

local and bilateral HIV/AIDS efforts; and 

z Srengthen efforts to coordinate with the Global

Fund so that in-country resources are leveraged

to ensure that gaps in service are met and overlaps are minimized or eliminated. 

SPECIAL FOCUS: The Global Fund
Government will actively participate in harmonization

efforts with WHO, UNAIDS, the Global Fund, and

other multilateral organizations, through the participation of U.S. Government representatives to each of

these bodies. Harmonizing multilateral efforts includes

engaging all the partners within a given organization

to follow through on agreed commitments. The

United States will use its bilateral relationships to

further and strengthen the U.S.-supported goals of

multilateral organizations. Activities include:

 Actively working to ensure that all resolutions and

commitments agreed to in the multilateral area are

compatible with our bilateral policies;

 Using our bilateral relationships to come up with

creative ways to work together to further those

goals agreed upon within our common organizations; and

 Working to adopt the same monitoring and evaluation, procurement, and reporting standards to ease

the work of recipients.

3. Promoting evidence-based policies and

sound management strategies

President Bush’s Emergency Plan recognizes that the

nature of the HIV/AIDS crisis urges immediate

action, yet interventions must reflect sound science

and management. The large influx of resources for

combating global HIV/AIDS from both bilateral and

multilateral donors makes best practices and accountability for use of those funds even more important,

particularly to sustain public support for the AIDS

effort. The U.S. Government will strive to ensure

accountability for its contributions, both through

multilateral and bilateral efforts, and will encourage

partners to do the same.

To achieve maximum impact against the disease,

funds must be targeted to effective interventions.

Two decades of HIV/AIDS work have revealed an

evidence base on which to begin building effective

programs. The United States will work closely with

technical organizations such as WHO to determine

the best range of options for treatment, prevention,

and care, and will promote the adoption of such

established best practices across all areas of multilateral action. Specifically, the U.S. Global AIDS

Coordinator will:

 Actively work with the Global Fund Secretariat,

through the U.S. Executive Director’s Office at the

World Bank and elsewhere, to ensure a focus on

results-based management of HIV/AIDS projects;

 Use the “parallel project review” process mandated

by Congress to lead an internal USG review to

ensure that all proposals recommended to the

Global Fund Board for approval are technically and

developmentally sound, demonstrate that added

resources will bring results, and meet high programmatic and financial accountability standards;

 Use the programmatic expertise of the Department

of Health and Human Services and policy experts

at the Department of State, both in the United

States and in countries in which the U.S.

Government has HIV/AIDS program presence and

expertise, to evaluate proposals and their impact

potential on the ground; 

 Provide guidance to U.S. Government representatives to multilateral organizations on the technical

efficacy, need, and management strategies of proposed programming; and

 Collaborate with other donors, including the

Global Fund Secretariat, to encourage other

nations to undertake a similarly detailed review in

countries where they have expertise to ensure the

best possible outcome for recommended projects.

4. Encouraging expanded partnerships that

build local capacity

The U.S. Government will encourage multilateral

organizations to work through local partners and

existing mechanisms within the host country’s

national strategy wherever possible, and, where this is

not possible, to make building local capacity a strong

priority. Multilateral organizations that serve as incountry implementing partners will also be encouraged to have phase-out goals for a country’s

“graduation” from the need to rely on outside sources

for management or implementation of programs.

Governments, NGOs, and the private sector all have

a role to play in this effort. The U.S. Government will

work both within multilateral organizations and

through embassies to identify and support NGO and

private sector providers to participate in partnerships

and build their capacity to manage programs at the

local level. The U.S. Government will:

 Set an example in capacity building by including

“graduation” language in our contracts for bilateral

grants with all non-local organizations;

60 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
STRENGTHENING MULTILATERAL ACTIONS 61

 Continue to support the Global Fund’s commitment to including similar “exit strategies” in its

grant agreements with UNDP and other major

multilaterals serving as temporary principal

recipients and will work to ensure this goal is

achieved; and

 Facilitate the creation of co-investment strategies

with private sector partners and/or local government partners to deliver services that will serve

as models for the rest of the world.

IMPLEMENTATION AND MANAGEMENT 63

Meeting the challenge of the global AIDS crisis is a

monumental task that will require – along with

strong leadership and vision – robust and flexible

administrative structures. This section describes the

Office of the U.S. Global AIDS Coordinator’s organization and implementation strategy for President

Bush’s Emergency Plan for AIDS Relief.

The implementation strategy of President Bush’s

Emergency Plan is designed to meet the goals he set

in his historic State of the Union message of 2003.

The U.S. Global AIDS Coordinator’s response must

be rapid, effective, and evidence-based, and make

efficient and focused use of all relevant government

capabilities through coordination, collaboration, and

cooperation across U.S. Government agencies. It

must also reflect administration policy and statute;

respond to the diverse needs of the various communities around the world in which the U.S. Government

works; and account for progress toward achieving the

President’s goals.

Additionally, as implementation moves forward, a

growing number of public and private entities will

become active partners in the United States’ fight

against global AIDS. This is, in fact, a focus of this

initiative – to bring the breadth and depth of

American public and private talent to the fore to

meet the challenge of global AIDS. Coordination of

these activities will pose an ever-increasing challenge

and will be taken into account as the Emergency Plan

is implemented. 

The Office of the U.S. Global AIDS Coordinator will

lead an integrated U.S. Government global

HIV/AIDS effort; provide a rallying point for private

sector, FBO, and NGO efforts; and make necessary

decisions and take actions to ensure that policies are

harmonious, programs synergistic, and operations efficient and effective. An overarching objective is to

create a single coordinated U.S. Government global

AIDS response. The U.S Global AIDS Coordinator

will lead a unified global projection of U.S. resources

and talent to turn the tide against HIV/AIDS.

It is important that a consistent philosophy permeate

all activities overseen by the U.S. Global AIDS

Coordinator. The strategic guidance outlined at the

beginning of this document applies to all U.S. bilateral

activities. Across all programs, implementation efforts

will follow the President’s vision for the Emergency

Plan. They will focus on the urgency of response and

the desire to seek new approaches and foster bold

leadership. Reliance on evidence-based approaches

and accountability, and the recognition that planning

and implementation must be based on local conditions and follow the lead of local government, will

inform program implementation. Bilateral programs

outside of the focus countries will also experience

dynamic improvements in their programs and activities as they will specifically benefit from strengthened

management, coordination, and best practices identified through focus country activities. 

The following sections describe broad categories of

implementation and management activities that will

drive President Bush’s Emergency Plan. 

“As Global AIDS Coordinator . . . he will coordinate all of our international HIV/AIDS activities for all of our

government departments and agencies. He will oversee all resources of this program. And he will work with the

faith-based and community groups to get the job done. He will report regularly to Congress on the progress and

effectiveness of our efforts.” 

President George W. Bush, July 2, 2003

IX. IMPLEMENTATION AND

MANAGEMENT

White House Photo Office
Coordination

The position of the U.S. Global AIDS Coordinator

was specifically mandated to provide coordination

and oversight across all U.S. international HIV/AIDS

activities, including those run by specific U.S. agencies

or through multilateral organizations. Coordination

with other stakeholders, including national governments and nongovernmental service providers, is key

to the amplified response expected under President

Bush’s Emergency Plan. The U.S. Global AIDS

Coordinator is thus responsible for both internal and

external coordination of HIV/AIDS activities.

Internal Coordination. The Office of the U.S. Global

AIDS Coordinator will undertake an ongoing planning, policy development, and program implementation process that involves all relevant U.S.

Government departments and agencies and draws on

the technical strengths of central and in-country staff.

The U.S. Global AIDS Coordinator’s office will conduct regular intergovernmental program and policy

meetings and will support collaborative planning,

implementation, and objective review processes that

will involve bringing in-country staff to headquarters

for short-term technical exchanges.

Country-specific response teams composed of agency

and U.S. Global AIDS Coordinator staff have been

organized for the focus countries. These teams provide each U.S. Mission with a consistent, competent,

and informed point of contact in the central office

and ensure that central office staff are aware of

specific issues, situations, and factors that influence

implementation in the field.

At the same time, staff will coordinate with U.S.

Government agencies or offices that are not specifically involved in HIV/AIDS efforts but promote initiatives supportive of the fight against HIV/AIDS in

important additional areas, such as food and other

development assistance programs, research activities,

and faith-based initiatives.

External Coordination. Coordination with local

policies, programs, and strategic plans is crucial to

the sustainability of programs and efficient use of

resources. Coordination with other donors and contributors is also crucial to combating HIV/AIDS. In

order to work smoothly in the target countries, the

U.S. Global AIDS Coordinator will task field offices

to ensure that donors with significant equities are

included in the local planning process. On the multilateral level, the U.S. Global AIDS Coordinator will

liaise with representatives in multilateral institutions

to avoid conflicts and duplication of efforts. Again,

coordination with multilateral institutions and

international organizations is intended to mobilize a

comprehensive response to global HIV/AIDS that

capitalizes on the expertise of various groups.

It is also important that the Coordinator learn from

the experiences of others working in this arena. Close

proactive liaison with private sector organizations,

businesses, and faith-based and other organizations

involved in global HIV/AIDS will help to support an

environment that strengthens and fosters innovation.

64 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

The U.S. Global AIDS Coordinator:

A New Leadership Model

The U.S. Global AIDS Coordinator,

Ambassador Randall L. Tobias, was appointed

by President Bush and confirmed by the Senate

to coordinate and oversee the U.S. global

response to HIV/AIDS. Reporting directly to

Secretary of State Colin Powell, the U.S. Global

AIDS Coordinator will:

X Lead the U.S. Government’s international

HIV/AIDS efforts;

X Ensure program and policy coordination

among the relevant USG agencies and

departments and nongovernmental organizations, avoiding duplication of effort;

X Pursue coordination with other countries and

international organizations;

X Resolve policy, program, and funding disputes

among the relevant USG agencies and

departments;

X Directly approve all activities of the United

States relating to combating HIV/AIDS in 15

focus countries; and 

X Promote program accountability and monitor

progress toward meeting the Emergency

Plan’s goals.

The U.S. Global AIDS Coordinator is particularly aware of the need for the Emergency Plan’s

programs to be accountable to both the

President of the United States and the

Congress. Accordingly, the Global AIDS

Coordinator is committed to regular communication and consultation about the Emergency

Plan’s progress and achievements. 
IMPLEMENTATION AND MANAGEMENT 65

Country Planning 

At the core of the implementation strategy is a robust

ongoing in-country planning effort. This will begin in

the focus countries where the U.S. Global AIDS

Coordinator will ask each Chief of Mission to undertake a strategic planning process to develop a fiveyear plan for strengthening the quality, availability,

and sustainability of treatment, prevention, and care

services. The planning process will include all relevant USG entities as well as the host-country government, the NGO sector, people living with AIDS,

other bilateral and multilateral donors, and additional

stakeholders. The plan will identify relevant U.S.

Government agencies, existing resources, needs, gaps,

partners, programs, objectives, performance measures,

staffing, and technical assistance requirements.

Coordination will thus be improved and resources

best matched to local needs and conditions.

The in-country strategic planning process is critical

to the success of the Emergency Plan and will be

strongly supported by technical assistance from the

Office of the U.S. Global AIDS Coordinator and other federal agencies. Plans will be submitted to the

Coordinator for review, in consultation with field

offices, technical experts, and agency officials. Final

approval by the Coordinator will ensure consistency

with congressional intent, administration policy, and

program objectives. 

Planning for services is critical in every U.S. mission

and for every country, be it a focus country or not.

Increasing attention will be directed to non-focus

countries in the months and years ahead. Staff in

non-focus countries will work with local governments

to develop national strategic plans for prevention,

treatment, and care. Best practices in the focus countries will be emphasized and technical assistance from

USG staff and relevant experts in focus countries will

be facilitated by the U.S. Global AIDS Coordinator. 

Allocation of Funding

The President’s Emergency Plan relies on a variety of

funding allocation mechanisms in order to maximize

flexibility and encourage innovation while responding

to specific country needs. 

Allocations by Country. Funding levels for focus

countries will be allocated on the basis of five-year

strategic plans, and funds will be released upon

approval of annual country operational plans by

the U.S. Global AIDS Coordinator. The Coordinator

will not predetermine annual funding levels agency by

agency but will instead consult with the agencies and

Chiefs of Mission to determine the optimal mix of

U.S. Government agency support appropriate for local

conditions, capabilities, and needs. This process will

leverage the comparative advantages of various USG

organizations, ensure coordination, and stimulate

innovation. An annual review will be conducted for

other ongoing HIV/AIDS bilateral programs. 

Central Funding Mechanisms. Some resources will

be disbursed through central office initiatives. Some

NGOs have existing capacity to respond quickly and

effectively in more than one country, making it more

efficient to fund multiple country projects. In other

cases, the U.S. Government will seek out organizations that can provide technical assistance and

support for activities such as professional training or

twinning programs on a regional basis. In both cases,

these organizations will be included in local strategic

plans and subject to approval by the Chiefs of Mission

in the targeted countries so that, if performance is

acceptable, they will receive ongoing support through

field mechanisms. This process will ensure efficiency

as well as policy consistency and coherency.

In the case of central funding mechanisms, the U.S.

Global AIDS Coordinator will assign implementation

Limitation on the Use of Funds

P.L. 108-25 includes certain restrictions on

the use of international HIV/AIDS funds and

requires recipients of those funds to have certain

policies in place. The Office of the Global AIDS

Coordinator is committed to ensuring that the

following provisions are incorporated into program implementation efforts:

SEC. 301, Assistance to Combat HIV/AIDS

(e) Limitation. – No funds made available to

carry out this Act, or any amendment made by

this Act, may be used to promote or advocate

the legalization or practice of prostitution or

sex trafficking. Nothing in the preceding sentence shall be construed to preclude the provision to individuals of palliative care, treatment,

or post-exposure pharmaceutical prophylaxis,

and necessary pharmaceuticals and commodities, including test kits, condoms, and, when

proven effective, microbicides.

(f) Limitation. – No funds made available to

carry out this Act, or any amendment made

by this Act, may be used to provide assistance

to any group or organization that does not have

a policy explicitly opposing prostitution and

sex trafficking.
responsibility to the central office of a U.S.

Government agency. In consultation with the Office

of the U.S. Global AIDS Coordinator, the agency will

solicit proposals, conduct reviews, and award grants,

contracts, or cooperative agreements through a transparent competitive process. 

Evidence-Based Allocations. The U.S. Global AIDS

Coordinator’s funding decisions will be evidencebased. A strong monitoring and evaluation function

will be established (see chapter X) with the goal of

gathering strategic information necessary to allocate

resources for maximum impact and ensure accountability to American taxpayers and their congressional

representatives. Allocations of funds among and within the focus countries will be based upon performance

in reaching treatment, prevention, and care targets.

These targets will be derived from the “2-7-10” goals

set by President Bush in his 2003 State of the Union

address – 2 million people in treatment, 7 million

infections prevented, and 10 million people provided

with care.

Fiscal Controls

Congress has entrusted the U.S. Global AIDS

Coordinator with unprecedented resources to fight

global HIV/AIDS. Utilizing existing capabilities and

processes within U.S. Government agencies, the U.S.

Global AIDS Coordinator has established mechanisms

to track funds accurately and control disbursements

so that resources will be correctly directed to their

intended use and will be deployed rapidly. Careful

attention will be paid to distinguish obligations from

expenditures in order to make realistic budget projections to fund services for those in need as aggressively

as possible.

Communications/Liaison

Transparency in implementation is critical. Over half

of all international assistance donated to fight global

HIV/AIDS comes from U.S. taxpayers, and they, as

well as the people and communities being served,

should be able to readily understand how funds are

allocated, distributed, and used; what impact they

are having; and who is benefiting from them.

66 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

Allocation of Funds

In P.L. 108-25, the “United States Leadership Against

HIV/AIDS, Tuberculosis, and Malaria Act of 2003,”

Congress provided recommendations for an effective

distribution of funds appropriated under the Act and

specified out-year allocations. 

SEC. 402 SENSE OF CONGRESS

(b)Effective Distribution of HIV/AIDS Funds.–It is the

sense of Congress that, of the amounts appropriated

pursuant to the authorization of appropriations under

section 401 for HIV/AIDS assistance, an effective

distribution of such amounts would be–

(1)55 percent of such amounts for treatment of individuals with HIV/AIDS;

(2)15 percent of such amounts for palliative care of

individuals with HIV/AIDS;

(3)20 percent of such amounts for HIV/AIDS prevention

consistent with section 104A(d) of the Foreign

Assistance Act of 1961 (as added by section 301 of

this Act), of which such amount at least 33 percent

should be expended for abstinence-until-marriage

programs; and

(4)10 percent of such amounts for orphans and

vulnerable children.

SEC. 403. ALLOCATION OF FUNDS.

(a)Therapeutic Medical Care.–For fiscal years 2006

through 2008, not less than 55 percent of the

amounts appropriated pursuant to the authorization

of appropriations under section 401 for HIV/AIDS

assistance for each such fiscal year shall be expended

for therapeutic medical care of individuals infected

with HIV, of which such amount at least 75 percent

should be expended for the purchase and distribution

of antiretroviral pharmaceuticals and at least 25 percent should be expended for related care. For fiscal

years 2006 through 2008, not less than 33 percent of

the amounts appropriated pursuant to the authorization of appropriations under section 401 for

HIV/AIDS prevention consistent with section

104A(d) of the Foreign Assistance Act of 1961

(as added by section 301 of this Act) for each such

fiscal year shall be expended for abstinence-untilmarriage programs.

(b)Orphans and Vulnerable Children.–For fiscal years

2006 through 2008, not less than 10 percent of the

amounts appropriated pursuant to the authorization

of appropriations under section 401 for HIV/AIDS

assistance for each such fiscal year shall be expended

for assistance for orphans and vulnerable children

affected by HIV/AIDS, of which such amount at least

50 percent shall be provided through non-profit, nongovernmental organizations, including faith-based

organizations, that implement programs on the community level.
IMPLEMENTATION AND MANAGEMENT 67

Communication is therefore another key element of

implementation. The U.S. Global AIDS Coordinator

will ensure that the public is given timely, accurate,

and complete information regarding the President’s

Emergency Plan for AIDS Relief. A variety of mechanisms, including Web technology, reports to Congress,

and media outreach will serve this purpose.

Office of the U.S. Global AIDS Coordinator

With the authority to act internationally, to transfer

and allocate funding to executive branch agencies,

and to contract with NGOs, including faith- and

community-based programs, the U.S. Global AIDS

Coordinator has been given the necessary tools to

lead a unified, coordinated U.S. Government global

AIDS response. As champion of the vision and strategic direction of the President’s Emergency Plan, the

U.S. Global AIDS Coordinator will also determine

resource allocation and program effectiveness.

In broad terms, the Office of the U.S. Global AIDS

Coordinator will be organized to provide strategic and

policy direction as well as technical and program

management to oversee global HIV/AIDS program

activities. In addition, the Office of the Coordinator

will provide communications, administrative, and

diplomatic resources for managing bilateral and multilateral activities. Recognizing that the implementation

of the Emergency Plan will be carried out largely by

other departments and agencies (centrally and in the

field), the Office will be a small organization focused

on leadership, coordination, learning, and oversight,

and will strive to remain flexible and innovative in its

approaches. 

Functions of the Office of the U.S. Global

AIDS Coordinator 

The Office of the Global AIDS Coordinator is organized and will be staffed to lead the implementation of

President Bush’s Emergency Plan for AIDS Relief.

The Office is organized into units of specialized

function as follows:

X The Leadership of the Office is responsible for

overseeing all activities and ensuring that the

programs and activities of the Emergency Plan

are accountable to the President and the

Congress. 

X The Program Services unit is responsible for

development and compliance monitoring of

implementation plans for each of the Emergency

Plan’s focus countries. This unit will also serve

as a technical and clinical support resource for

the focus countries and all other activities conducted by the U.S. Global AIDS Coordinator. It

will also serve as a technical resource for human

capacity development activities and will develop, implement, and monitor programs that

respond to training needs.

X The Strategic Information and Evaluation unit

will be responsible for gathering the information

necessary to ensure that Emergency Plan goals

are reached and that those goals have the

expected impact. This unit will work with the

international community to harmonize strategic

information collection and will also serve as a

liaison to the research community as well as the

research and information components of implementing agencies. 

X The Management Services unit will provide operational support to the Office and will track the

disbursement of program funds.

X The Diplomatic Liaison unit is responsible for

strategic planning and activities to foster leadership and develop a coordinated international

response on HIV/AIDS by working with international institutions, foreign governments,

NGOs, and others. 

X The Government and Public Liaison unit will

have the responsibilities of responding to congressional requests for data and information and

communicating policy to Congress. It will prepare congressional reports and compliance documents. It serves as the technical resource for the

U.S. Global AIDS Coordinator on budget and

appropriations issues. The unit is also responsible for developing the annual budget and will

serve as the liaison to the White House and to

administration departments and agencies and

their budget offices.

X The Public Affairs and Communications unit

will plan and implement domestic and foreign

communications in support of Emergency Plan

activities and will conduct outreach activities

to promote involvement of various public and

private organizations that could be beneficial

in the fight against HIV/AIDS.

SUPPORTIVE INTERVENTIONS FOR U.S. GOVERNMENT PROGRAMS 69

Interventions that support implementation of

President Bush’s Emergency Plan will include an

effective and accountable supply chain; a strong

research program to provide the evidence base necessary to guide policies and programs, including a coordinated strategic information system; and enhanced

public-private partnerships.

Supply chain management is critical to ensure the

delivery of essential drugs, supplies, and equipment

that make HIV/AIDS programs possible. Under the

Emergency Plan, attention will be focused on supporting a secure and sustainable supply chain management system that is reliable and coordinated with

complementary programs, such as donated ARV

drug programs. Efforts will also be targeted toward

reducing and eliminating diversion, counterfeiting,

and the sale of HIV/AIDS products and supplies on

the black market. 

A robust evidence base is needed to direct the

Emergency Plan’s treatment, prevention, and care

programs. A strong research program will both provide

new knowledge (e.g., more effective ARV therapy or

discovery of effective prevention methodologies) as

well as give direction to policy and program decisions

(operational studies). Moreover, by strengthening

linkages between the research community and the

Emergency Plan, implementation successes and failures can inform future research agendas. A second set

of evidence will be collected through a strategic information system that will track programs to ensure that

they are meeting targets (monitoring) and that activities have measurable impact (evaluation). Best practices for HIV/AIDS treatment, prevention, and care

will be identified through both of these processes. 

Public-private partnerships will mobilize private sector

resources to build sustainable systems of HIV/AIDS

treatment, prevention, and care. The comparative

advantages of these partnerships will be maximized to

complement the services provided by the public and

NGO/FBO sectors. 

1. Supply Chain Management

Comprehensive HIV/AIDS programs require a large

number of products. Effective supply management is

critical to the delivery of these products. To ensure

sustainability of HIV/AIDS programs, essential supply

chain management personnel will be trained and

health logistics systems strengthened. Efforts will need

to be taken to minimize drug diversion, counterfeiting,

and waste, with a special focus on ARVs, given the

high cost of these drugs and the risk of drug resistance

if they are administered inappropriately. Opioids also

need similar strong management to avoid diversion

and misuse. President Bush’s Emergency Plan will

coordinate with other donors so that supply chain

synergies are maximized and gaps in distribution

systems minimized. 

Currently, the U.S. pharmaceutical industry estimates

the cost of distribution from manufacturer to retailer

to be about 20 to 25 percent of the drug’s retail cost.

The Office of the U.S. Global AIDS Coordinator

“It’s more than money we bring, we bring expertise and compassion and love and the desire to develop a

comprehensive system . . .”

President George W. Bush, April 29, 2003

X. SUPPORTIVE INTERVENTIONS FOR

U.S. GOVERNMENT PROGRAMS 

White House Photo Office
anticipates investing a comparable percentage of

product costs for supply chain management.

Supply Chain Management Objective:

Create, enhance, and promote an uninterrupted

supply of high-quality, low-cost products that flow

through an accountable system

Supply Chain Management Strategies:

1. Rapidly scale up supply chain management to support HIV/AIDS treatment, prevention, and care

2. Build capacity for long-term sustainable

procurement and distribution

3. Ensure quality control of drugs, test kits, and

other supplies

4. Focus on intellectual property law at international

and national levels

1. Rapidly scale up supply chain management to support HIV/AIDS treatment, prevention,

and care

The development and implementation of logistics systems to manage the increased volume of products and

supplies for the full continuum of care will require

both short- and long-term strategies. The focus of all

strategies will be on procuring and delivering a continuous and secure supply of high-quality products to

patients who need them at all levels of the health

system. In the short term, the approach will require a

combination of outsourcing some logistics functions to

the private sector, rapidly building a vertical distribution and information management system with external technical assistance, and improving the storage

conditions, distribution networks, and human capacity

skills at sites providing HIV care and treatment. 

In most countries, the sharp increase in the volume

of products provided through President Bush’s

Emergency Plan, and other new sources such as the

Global Fund, will probably challenge existing national

supply systems. To ensure product supply and quality,

the Emergency Plan will explore options to enhance

the immediate performance of national logistics systems, including: 

 Centralizing or pooling procurement mechanisms

at global or regional levels;

 Outsourcing transportation to secure courier

services or purchases of dedicated vehicles for the

delivery of ARVs, other drugs, and other essential

products (e.g., palliative care supplies);

 Designing user-friendly, timely, and accurate methods of logistics data capture, collection, analysis,

and feedback for resupply and forecasting;

 Selecting products and improving packaging to

support patient adherence;

 Providing skilled individuals to perform logistics

management functions; and

 Improving secure storage space and inventory

management systems.

Key to success will be the seamless collaboration

between the supply chain managers and program service managers. Overall program impact will be ensured

through coordination of patient enrollment, product

availability, and service capacity. Collaboration with

other donors and stakeholders is also imperative. For

example, a logistics system that manages products

procured under the Emergency Plan may be able to

take on management of similar products funded

through other sources, such as the Global Fund or the

World Bank’s Multi-Country HIV/AIDS Program for

Africa (MAP), in addition to existing donor basket

funds and direct product donations. President Bush’s

Emergency Plan will work to facilitate the development of national coordinating bodies to manage

donor financial and product/supply commitments,

develop medium-term procurement plans, and track

actual funds and products received. The coordinating

body will promote a synergistic approach to donor

inputs to avoid duplication of investment and waste

of resources. 

2. Build capacity for long-term sustainable

procurement and distribution

President Bush’s Emergency Plan will build on lessons

learned through other public health programs, such as

those that manage essential drug, immunization, family planning, and child survival initiatives. To improve

program effectiveness, procurement and supply management considerations will be built into program

design and implementation. The Emergency Plan will

provide technical assistance and training to strengthen

procurement and distribution systems in the areas of:

 Product selection; and 

 Distribution. 

Product selection

Products identified for procurement must be compatible with national essential drug lists, testing policies,

treatment protocols, and product registration proce70 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
SUPPORTIVE INTERVENTIONS FOR U.S. GOVERNMENT PROGRAMS 71

dures. The development of safe and effective fixeddose combination (FDC) antiretroviral medications is

a goal the Administration supports, and to that end

the U.S. Government is cosponsoring, with WHO,

UNAIDS, and the Southern Africa Development

Community, an international scientific conference in

the spring of 2004 to produce an international consensus document that will set out principles that need

to be taken into account when considering FDC drug

products. The document will contain definitions of

terms and set out principles that relate to the safety,

quality, effectiveness, and ongoing quality assurance

for these products. It will deal with such issues as

bioequivalence, bioavailability, and stability, as well as

how drug regulatory authorities should approach

reviews of these products. The document will not

issue guidelines or regulatory guidance, nor will it deal

with procurement, clinical issues, blister packs, or

compliance – only technical and scientific issues.

Distribution

President Bush’s Emergency Plan will address incountry distribution by focusing on building local

capacity to negotiate, purchase, manage, and supply

goods. This will be accomplished by improving coordination among donors, developing and applying logistics management information systems, building the

local capacity of human resources, strengthening

customs processes, improving storage facilities and

practices, enhancing transportation systems, and

preventing diversion of products into commercial

or black markets.

3. Ensure quality control of drugs, test kits, and

other supplies

Under the Emergency Plan, products of the highest

quality will be purchased at the lowest price. Ensuring

high quality is absolutely essential for HIV/AIDS

drugs, test kits, and other supplies. Therefore, products will be procured from reliable manufacturers to

ensure product safety and efficacy. The Emergency

Plan will enhance in-country capacity to perform

quality-testing procedures and, where appropriate, will

support the development of regional testing facilities

to ensure product quality.

4. Focus on intellectual property law at

international and national levels 

Through President Bush’s Emergency Plan, the Office

of the U.S. Global AIDS Coordinator is eager to work

with all parties who are interested in contributing to

this important effort to combat the global HIV/AIDS

epidemic by ensuring that high-quality affordable

drugs are available to those in need of them.

Within this context, Emergency Plan funds used to

purchase products will be directed to obtaining highquality goods at the lowest possible price. This could

mean bioequivalent versions of branded ARV and

other medications. Voluntary differential pricing

already exists, and there is no evidence that the market is not working or that companies are preparing to

rescind their preferential pricing offers for poor countries. Major research-based companies are responding

to the evolution of a market in the developing world

to bid competitively, even beating per-patient generic

prices in some markets in the developing world, and

these companies are encouraged to compete for tenders that will use Emergency Plan funds. Brand-name

companies have also done an exemplary job of donating their products to roll out treatment and care for

patients with HIV/AIDS. Public-private partnerships

(like the Merck/Gates Foundation/Harvard collaboration in Botswana or the Global Alliance for Vaccines

and Immunization) are providing drugs and vaccines

at no or very low cost in many places in the developing world. Voluntary out-licensing proposals to

encourage market competition in the production of

pharmaceuticals, such as Pharmacia’s arrangement

with the International Dispensary Association in the

Netherlands for manufacturing one of its AIDS drugs

in the developing world, are potential models as well.

Grantees will be expected to follow national laws in

the countries in which they will be operating and to

respect applicable international obligations regarding

intellectual property. All procurement under the

Emergency Plan will have to fit within the parameters

of existing federal and international law for the protection of intellectual property rights.

There is a need for balance between the needs of poor

countries without the resources to produce or pay for

cutting-edge pharmaceuticals and the need to ensure

that the patent rights system, which provides the

incentives for continued development and creation of

new lifesaving and life-extending drugs, is promoted.

Because a high percentage of all new medicines are

invented in the United States, the new medicines

that will solve the health problems both of today and

tomorrow will likely come from U.S. companies. In

this regard, intellectual property rights are not the

problem but a part of the solution – they provide the

incentive for innovation in creating new medicines,

including vaccines, and private enterprises are the

principal entities that bring new health technologies

to market. 

The United States supports the decision of the

General Council of the World Trade Organization

(WTO) on August 30, 2003, regarding the implemen-
tation of Paragraph 6 of the Doha Declaration on the

Agreement on Trade-Related Aspects of Intellectual

Property (TRIPS) and Public Health. This decision

represents an expeditious solution to the difficulties

that developing-country WTO members with insufficient or no manufacturing capacities in the pharmaceutical sector could face in making effective use of

the flexibilities contained in the TRIPS Agreement.

The United States expects that all countries will

cooperate to ensure that the drugs and active ingredients produced under the terms of the Paragraph 6

solution – as well as other drugs sold or donated in

developing countries – are not diverted from countries

in need to wealthier markets. There is also insufficient

government action in many developing countries to

prevent the marketing, sale, and use of substandard

and counterfeit drugs, some of which find their way

back to developed markets. In the last year, police and

drug regulators have discovered crime rings that were

diverting donated or reduced-price AIDS drugs from

developing nations and selling them in Europe.

European nations also are experiencing growing problems with counterfeit or substandard medicines

imported from Africa and Asia, and counterfeit AIDS

medications have begun to circulate in Africa as well.

Tariffs and duties on pharmaceuticals pose another

problem. These are barriers that can be important elements in increasing the cost of drugs in developing

countries and work at cross-purposes with initiatives

that NGOs, governments, and industry are undertaking to improve access to medicines. 

2. Evidence-Based Programs 

Policy and program decisions for the President’s

Emergency Plan will be evidence-based. The evidence

needed includes:

 Research: The U.S. Global AIDS Coordinator’s

Office will bring together publicly and privately

supported projects to inform the evidence base of

President Bush’s Emergency Plan; will work to

ensure the highest scientific and ethical standards

in research; and will communicate scientific findings in transparent and useful ways.

 Strategic information: Strategic information systems will address questions such as: “Are federal

agencies and partners meeting targets?” and “What

is the impact of actions taken?”

Research

Research important to the Emergency Plan can be

broadly divided into two parts: (1) research to produce new knowledge, and (2) targeted research to

support the programs and policies of the initiative. 

Basic, clinical, social science, translational, and operational clinical research will be supported through the

Department of Health and Human Services’ National

Institutes of Health (HHS/NIH) and will follow the

HHS/NIH Office of AIDS Research (OAR) annual

strategic plan for HIV/AIDS research as described in

appendix H. The HHS/NIH annual AIDS research

strategic plan addresses the following research areas:

natural history and epidemiology, etiology and pathogenesis, therapeutics, vaccines, behavioral modification research, microbicides, HIV prevention, women

and girls, training and infrastructure, and information

dissemination, as well as a component devoted to

international AIDS research. Similarly, the U.S.

Agency for International Development (USAID) will

continue to support applied and operational research

as well as focused activities on vaccines and microbicides, as described in appendix I. Although HHS and

USAID research activities will generally not be funded through the Emergency Plan, the U.S. Global

AIDS Coordinator will work closely with both HHS

and USAID leadership to make sure that goals and

needs of the Emergency Plan are supported by these

research priorities. These collaborative efforts will also

work to rapidly translate research into practice in the

initiative’s activities.

The many programs and activities undertaken to

reach the goals of the President’s Emergency Plan

will require a certain amount of targeted evaluation

and research that addresses special circumstances in

the diverse settings of the focus countries. New

approaches to prevention, treatment, and care must

be rigorously analyzed as to their relative merit and

effectiveness. Clinical decision-making will require

studies to determine optimal treatment in diverse settings and conditions. While some of these studies will

fall under the mandate of HHS or other departments,

others may not. In these cases, the Office of the U.S.

Global AIDS Coordinator, in consultation with HHS,

the U.S. Agency for International Development, the

Department of Defense, and other partners and interested parties, may need to fund a program of special

studies. The agenda for these special studies includes

developing clinical guidelines, addressing optimal program and policy formulation, seeking solutions to barriers to care, and conducting other studies to assist

programs in meeting the goals of the President’s

Emergency Plan.

Finally, global research capacity is a key component of

sophisticated health systems development. The NIH

research agenda, by developing research capacity in

72 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
SUPPORTIVE INTERVENTIONS FOR U.S. GOVERNMENT PROGRAMS 73

the focus countries and around the world, will

enhance clinical care in those countries. At the

pinnacle of health systems networks are research

institutions that will be able to work with NIH and

other international research organizations. This

research capacity will, in turn, help support achievement of national HIV/AIDS strategies as well as

programmatic efforts to meet the goals of President

Bush’s Emergency Plan.

Strategic Information

Strategic information for the President’s Emergency

Plan for AIDS Relief is the systematic collection,

analysis, and dissemination of information about

reaching the Emergency Plan’s objectives, as well as

the related programmatic activities funded to reach

these goals. It includes surveillance, monitoring, and

evaluation of HIV programs supported by the U.S.

Government and is essential to meet legislated goals

and program objectives and to inform the public and

their representatives in Congress. 

We plan, through strategic information, to:

 Provide assistance to countries in the collection

of core indicators (some of which rely on facilitybased information) for the timely production of

monitoring and evaluation reports based on these

data. Core indicators will include outcome indicators addressing the Emergency Plan’s “2-7-10” goals

of 2 million people treated, 7 million infections

prevented, and 10 million persons provided with

care. Program progress indicators include numbers

of facilities supported, numbers of practicing professionals and community workers trained, and

numbers of clients reached through prevention,

treatment, and care interventions. 

 Develop and improve capacity to collect client-level

and clinical service and surveillance information

that will assist in daily management of individual

patient care, and to evaluate and routinely report

on the quality and outcomes of that care.

 Develop and improve capacity to collect facilityand district-level information that will assist clinic

and program management, such as targeted prevention activities and HIV testing and counseling.

 Supplement the periodic collection of information

with targeted evaluation studies that address

program effectiveness, the feasibility of different

intervention technologies, and improved surveillance methods. 

 Design country-appropriate HIV management

information systems (MIS) that integrate separate

HIV information systems, including patient care

management, facility and program management,

laboratory reporting, logistics management, and

routine reporting of indicators to the national level

and to the U.S. Government. 

 Integrate HIV/AIDS facility-based MIS into broader regional or national health information systems

to support the provision of holistic and continuous

care and to reduce the duplication and burden of

data collection and reporting within the facilities.

In order to build sustainable management systems

over the long term, the strategic information system

must take into account the broader health care delivery system in which it will be implemented. A facilitybased MIS structure should permit generation of the

necessary strategic information for rational decisionmaking at each level of the health system, from the

facility to national and donor levels. As seen below,

each user requires reliable and timely information to

support its own set of management functions. These

functions include individual patient care management, facility management, and health program management at district, national, and international levels. 

The first step in the long-term development of strategic information for HIV/AIDS facility-based interventions will be to define management functions at each

level, starting with the patient/client level. This

process will ultimately make it easier to identify the

information required at each management level for

decision support. Basic data elements (e.g., the number of new clients served) should not be lost as they

are reported “up.” However, indicators and analysis of

the information may differ at each level. Core indica-
tors focus mainly on program management functions

at district, national, and international levels. Health

facilities require a different set of indicators for

patient and facility management. 

At the level of the U.S. Global AIDS Coordinator’s

Office, USG country offices will report critical

indicators into one U.S. Government reporting system

that is transparent, communicates with other international donors, and provides access for the public to

program information. Initial reporting will be on a

semiannual basis.

This system will need to be built from the ground up.

Existing facility-based health information systems in

most countries are unable to provide the information

support needed to manage a broad range of health

system interventions. Some of the main reasons for

this are inadequate financial and human resources;

irrelevance and consequentially poor data quality collected at the facility level; centralization and/or fragmentation of information system management; and

poor health information system infrastructure.

Experience in several countries in the last two

decades has shown that decentralization of information management is an effective strategy to improve

facility-based management information systems. To

support this approach we will need to adapt information needs to the specific management functions at

each level, produce high-quality information in a

timely fashion, and ensure sufficient health information resources and careful management of the system. 

To measure the “2-7-10” goals of President Bush’s

Emergency Plan, surveillance and program reporting

systems will need to indicate (1) the total number

of clients reached with ART (including through

PMTCT initiatives); (2) the total number of clients

receiving care and support services, including TB/HIV

clinical care and palliative care through home- or

community-based programs; and (3) the total number

of orphans and vulnerable children reached with

care and support. The number of infections prevented

will be determined through modeling techniques using

both antenatal surveillance clinical information and

behavioral surveillance data. Appendix G presents

the Emergency Plan’s program-level monitoring

framework.

The strategic information underlying the President’s

Emergency Plan will not be accomplished by U.S.

Government efforts alone. It will build upon international strategic information efforts to harmonize

informational measures, provide monitoring and

evaluation training in affected countries, and share

gathered data. Both WHO and UNAIDS have

formed donor coordinating groups for strategic

information that address surveillance, monitoring and

evaluation, and MIS. The United States will actively

participate in these groups beginning with adoption of

the WHO and UNAIDS guidelines on the construction of core HIV indicators. In consultation with the

World Bank and the Global Fund, the Emergency

Plan will ensure that informational data collection

by donors is aligned in targeted countries to minimize

the burden of information collection and to maximize

the focus on HIV prevention, treatment, and care. 

The task of health information system reform is both

formidable and complex, particularly in the context of

developing countries. The Office of the U.S. Global

AIDS Coordinator will provide the leadership, consensus building, and commitment at the U.S.

Government level to implement the health information restructuring that is needed to measure progress

under the President’s Emergency Plan. 

3. Public-Private Partnerships 

President Bush believes that public-private partnerships offer a unique and sustainable opportunity for

the provision of quality HIV/AIDS services with wide

reach, as they combine the strengths of government,

business, and civil society. Private sector innovations,

resources, and expertise are essential to the battle

against HIV/AIDS, which has strained government

and civil society responses. 

As one example of the power and reach of public-private partnerships, innovations in the workplace can

have broad impacts on families, communities, and the

entire socioeconomic fabric of a country. An estimated 26 million people – more than 60 percent – of the

40 million living with HIV/AIDS are workers between

the ages of 15 and 49, the most economically active

segment of society and the mainstay of families,

communities, enterprises, and national economies.

UNAIDS projects that high-prevalence countries will

see their workforces decrease by 10 to 34 percent as a

result of AIDS by 2015 and that gross domestic product in the hardest-hit countries may decline by as

much as 8 percent by 2010. 

The primary vehicle for protecting the workforce is

the workplace. Workplaces, ranging from small businesses to multinational corporations, provide regular

access to workers, and by extension, their families and

communities. Experience in Africa and the Caribbean

has shown that workplace-related programs are often

the only source of prevention, treatment, and care

services for workers, their families, and their communities, and that combating stigma and discrimination

74 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
SUPPORTIVE INTERVENTIONS FOR U.S. GOVERNMENT PROGRAMS 75

in the workplace is essential to increasing the

utilization of HIV/AIDS services. In some cases,

multinational companies operating in Africa and the

Caribbean have been the first to introduce HIV/AIDS

programs and policies and have set standards for the

community at large, serving as models for the development of national strategies. President Bush’s

Emergency Plan will coordinate with private corporations to provide HIV/AIDS services to community

members through corporate health facilities.

The capacity of the private sector to reach broad sections of the population through workplaces and information campaigns can promote a supportive culture

throughout the community for defeating HIV/AIDS.

In addition, public-private partnerships such as twinning of private sector technical expertise with groups

developing HIV/AIDS programs can play a crucial

role in rapidly scaling up quality HIV/AIDS services. 

Public-private partners share risks and accomplishments, as well as resources, including finances, infrastructure, information, and people to achieve a

common goal. Private sector initiatives contribute

resources outside of the traditional health infrastructure and are critical for creating the social, cultural,

and political environment that will enable the

achievement of Emergency Plan goals. 

Public-Private Partnerships Objective:

Foster public-private partnerships and provide support

for the development of HIV/AIDS initiatives that

complement the treatment, prevention, and care goals

of the Emergency Plan for AIDS Relief 

Public-Private Partnerships Strategies:

 Encouragement for the establishment and strengthening of public-private partnerships at the international, national, and enterprise levels to strengthen

HIV/AIDS initiatives

 Mobilization of private sector resources for

HIV/AIDS programs, including pooling of

resources to gain economies of scale 

 Creation of an enabling environment for the

private sector to contribute their respective core

competencies to the development of national

AIDS strategies

 Inclusion of private sector representatives (including experts on child labor) on country assessment

and planning teams

 Identification of workplace facilities/resources for

inclusion in clinical capacity building through the

health network model

 Provision of technical assistance to move existing

workplace programs into the community at large,

strengthening the sustainability of public programs

and coverage of women 

 Creation of synergies to meld private sector initiatives with broader national, regional, sectoral, and

civil society efforts already underway

APPENDICES 77

XI. APPENDICES

Appendix A:

Human Resources Capacity

In sub-Saharan Africa, the Caribbean, and many

other parts of the world inadequate human resource

and training policies and weak institutions contribute

to the insufficient supply of health care workers. In

Kenya, for example, the Medical Association has

more than 5,000 registered doctors but only 600 work

in public hospitals, and the government in 2001

received only eight applications for 100 advertised

vacancies. The weak labor supply throughout the

region is further adversely affected by the emigration

of trained and skilled health care personnel (see

“Brain Drain” section below). There is thus an urgent

need to increase health sector human resources, especially skilled health workers such as physicians, nurses, pharmacists, and managers to address HIV/AIDS.

Although not specifically addressed here, efforts must

also be undertaken to remedy the lack of personnel

with clerical, data entry, and adminstrative skills

necessary to run effective programs.

Increasing and developing human resources has both

short-term and long-term strategies. Professional training, especially of physicians, takes years. Investments

in schools made today may, therefore, not have a

measurable impact for some time. In the shorter term,

providing HIV/AIDS specific training to already practicing professionals can be of great benefit.

There is also an immediate for workers to provide

counseling and testing, antiretroviral therapy (ART),

and other treatment and care services. These will be

developed by recruiting and training community

health workers, foreign volunteer health professionals,

and short-term in-country training of medical staffs. 

Volunteer doctors, nurses, pharmacists, and other

health care workers from the United States will be

recruited and deployed as a key component of our

short-term strategy to meet the human capacity needs

for HIV/AIDS treatment. There are a large number

of mechanisms, both public (Peace Corps, Freedom

Corps, Crisis Corps, and various DHHS mechanisms)

and private, by which such volunteers can be identified and supported. The Office of the U.S. Global

AIDS Coordinator will undertake a systematic review

of these options and, in consultation with host countries, ministries of health, nongovernmental organizations, Congress, and others develop an approach to

deployment of volunteers that is effective, efficient,

and driven by the needs and priorities identified in

the field.

The twinning of U.S. with foreign institutions will

allow for multifaceted exchanges of personnel and

volunteers. Curricula can be exchanged and technical

assistance and expertise provided. These activities can

be expected to be of great benefit to the U.S. institutions as well as foreign. Many innovative approaches

to HIV/AIDS care, treatment, and prevention developed in Africa, the Caribbean, and elsewhere in the

world can and should be adapted for use in the

United States.

President Bush’s Emergency Plan will also support

local and national efforts to broaden responsibility for

treatment, care, and support, possibly including nurses, paramedics, lay counselors, and health volunteers.

Community workers have been used to extend the

medical system for successful provision of ART in

some resource-poor settings. Community workers, volunteers, and family members have been trained to dispense drugs, note occurrence of signs and symptoms

of disease, note drug reactions, and refer to higher

levels of care. This strategy is essential in countries

where the number of trained health care workers is

limited. Efforts will focus on determining the tasks

that must be completed in order to deliver quality

ART (e.g., diagnosis, prescribing, counseling, monitoring adherence, follow-up) and identifying and training

the appropriate people to undertake these functions,

with a focus on expanding ART services to the

greatest number possible while maintaining quality

standards. To further extend treatment services into

the community, President Bush’s Emergency Plan will

also explore options to involve traditional healers and

birth attendants, by training them to recognize HIV

complications, provide basic home-based care, communicate key messages, and refer patients to appropriate health care. 

1. Training 

Short-term training of existing health care professionals will build capacity. This can be accomplished

through training exchanges as part of twinning

programs. Training can also be provided by clinical

experts who visit facilities in the focus countries for

days, weeks, or months to provide lectures and clinical oversight. Finally, telemedicine can provide case

management support to clinicians, and distance education can address short-term training needs. Training

must include both didactic as well as clinical experiences. Care must be taken to establish procedures for

supervision of staff and regular monitoring of service

quality. These short-term training exercises will be
focused on skills-building, not diploma- or credentialbuilding. 

Long-term human resource needs must be included in

national strategic planning of each country. Increasing

the quality and number of graduates from health care

professional schools will be necessary. Capacity building in health care training will include curriculum

development, creation of faculty and student

exchange programs, and development of a comprehensive plan for long-term human resource needs.

Training curricula at all medical, nursing, dental,

pharmacy, and public health schools need to be

reviewed and revised to incorporate the latest information on HIV/AIDS prevention, care (including palliative care), and treatment. Developing and adopting

relevant, applicable training programs can help minimize the difficulties and frustrations experienced by

health care professionals working in resource-poor

environments. In-service training and lifelong learning opportunities with emphasis on linkages between

the learner’s practical work experience and primary

health care can help attract and retain workers. 

Programs are also increasingly forging relationships

with associations and groups of people living with

HIV/AIDS to train their members to provide patient

education, adherence counseling, and patient followup in order to free clinical staff to perform higher-level

tasks. Given the enormous human resource constraints, it will be critical to give greater responsibility,

through training and supervision, to greater numbers

of health and human services workers in order to

achieve treatment, prevention, and care goals. 

2. Recruitment and retention

In general, the ratios of health personnel to population in Africa are very low compared to those of other

developing countries. Few African countries meet the

WHO “Health for All” standard of one doctor per

5,000 population. In the late 1990s, the Emergency

Plan focus countries of Côte d’Ivoire, Ethiopia,

Mozambique, Rwanda, Tanzania, Uganda, and Zambia

all had a ratio of one doctor per 10,000 people or

more. The current ratio in Uganda is only one doctor

per 24,700 people. Comparable countries like Bolivia,

Honduras, and India, have one doctor for every 2,000

to 3,000 people. The ratio of nurses to population is

also very low in sub-Saharan Africa - in Uganda, for

example, it is one nurse per 5,000 people.

Labor supply in health sectors is thus a major concern

to program policymakers and planners. The “brain

drain” of medical and health professionals to developed countries is overwhelming and a major contributing factor to the low health care worker-topopulation ratios. Practical strategies are needed

to recruit and retain health professionals, ensure

well-trained workforces, and prevent the brain drain

emigration of health workers. 

Domestic conditions can be improved by providing

incentives and creating policies that reduce workforce

attrition and attract medical professionals to return

from affluent countries. More effective human

resource management may involve going beyond the

narrow issues of salary and training to consider broader incentives and systems for encouraging and managing good performance. For example, Thailand and

Ireland have reversed their brain drain through programs that offer generous research funding and monetary incentives as well as improved benefits and

assistance. Sub-Saharan African countries similarly

need to address structural, political, and economic

problems that lead to brain drain. Host-government

actions might include increasing salaries for health

professionals, permitting health professionals in the

public sector to do some private practice, providing

educational benefits for their children, and providing

house mortgages and car loans at low interest rates.

Practice conditions will improve as infrastructure

and institutional capacity are developed, creating a

stimulating environment for professional growth.

Agreements should be sought with developed countries to ensure that donor-funded programs do not

offer exceptionally high salaries. Bilateral and international agreements about recruiting processes that

minimize adverse effects on health care in exporting

countries are also needed. The Pan American Health

Organization, for example, is developing a program of

managed migration of nurses in the Caribbean, traditionally a major source of employees for foreign

recruiters.

While the focus countries all have health care human

resource shortages, some countries (Uruguay, for

example) have a surplus. Recruitment of health care

professionals from countries with a surplus of human

resources may be a useful strategy for some countries.

This recruitment will require changes in immigration

and licensure policies in some of the countries.

President Bush’s Emergency Plan will address these

issues of policy reform and locating and recruiting

doctors, nurses, pharmacists, and other trained health

care professionals.

3. The “brain drain” of health care human

resources from sub-Saharan Africa and the

Caribbean

The already inadequate supply of health care workers

in sub-Saharan Africa and the Caribbean is further

78 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
APPENDICES 79

affected by the “brain drain” of trained medical and

public health personnel to industrialized countries.

Although “brain drain” emigration is not a new

phenomenon, the growing number of health workers

leaving sub-Saharan African countries exacerbates

the shortage of health care personnel to fight the

HIV/AIDS pandemic. 

The effects of brain drain are abundantly clear. In

Zimbabwe, only 360 of 1,200 doctors trained in the

1990s are practicing domestically. Information from

South African medical schools suggests that one-third

to one-half of their graduates emigrate to developed

countries, mainly Canada, the United Kingdom, and

New Zealand. WHO estimates that Zambia’s health

system needs 1,500 doctors but there are only about

800 doctors registered in the country (only 50 of

whom work in the public sector), while many have

migrated to work in affluent countries. The loss of

nurses to developing countries is also extreme. For

instance, 18,000 of Zimbabwe’s nurses work abroad,

mainly in the United Kingdom. Ghana loses more

nurses annually to foreign employment than its

nursing schools can graduate. 

African health workers who emigrate represent a

serious economic setback to their countries. Many

African governments heavily finance these workers’

training. The U.N. Commission for Trade and

Development has estimated that each migrating

African professional represents a loss of $184,000 to

Africa, while Africa spends $4 billion a year on the

salaries of 100,000 foreign experts.

Factors fueling the brain drain. “Push” factors in

developing countries that motivate health care personnel to migrate include professional dissatisfaction

as a result of low remuneration, poor working conditions, and institutional inadequacies such as lack of

technology and equipment, inadequate structures,

weak internal systems and practices, lack of autonomy

and incentives, and lack of funding for research. In

many countries in Africa, larger social or political

problems such as civil or ethnic strife, poor security,

oppressive political climate, and persecution of or

discrimination against intellectuals are factors. On the

personal level, limited career prospects at home, poor

intellectual stimulation, and the desire to seek a good

education for children are motive for migrating.

Major “pull” factors (deliberate or unintended actions

of the destination countries that attract health care

professionals to recipient countries) include the high

demand for health professionals in developed countries with aging populations who require increasing

amounts of care. For example, the United States had

126,000 unfilled nursing posts in 2002; by 2015, this

shortage will increase to 500,000. Canada currently

needs 16,000 nurses and will need up to 113,000

nurses by 2011. In the United Kingdom, it was estimated that 15,000 foreign nurses were recruited for

positions in 2001, with 35,000 more needed by 2008.

In 2006, Australia expects 31,000 nursing vacancies.

To meet these needs, active recruitment of health

care personnel is ongoing in sub-Saharan African

countries such as Kenya, Ghana, South Africa,

Uganda, and Zambia. According to the U.S.

Immigration and Naturalization Service, immigrants

during fiscal year 2002 with medicine- and healthrelated occupations included 64 from Kenya, 181 from

Nigeria, 212 from South Africa, 15 from Uganda, 11

from Zambia, and 31 from Zimbabwe. 

Impacts of the brain drain. The loss of health workers

to affluent countries is particularly harmful to subSaharan African and Caribbean countries in the era

of HIV/AIDS. Effects of the brain drain include:

 Decline in quality of care;

 Increased workloads for health workers left behind; 

 Adverse effects on leadership and morale;

 Public sector costs for educating and training the

emigrating workers; and

 Less effective and efficient use of other health

infrastructure resources.

Clearly, Africa’s human resources crisis in health care

has a global dimension and an international inquiry

and response is needed. The emigration of its health

professionals needs to be urgently addressed to help

stabilize its health care systems and institutions. 

Appendix B: Human Papilloma

Virus in Sub-Saharan Africa and

the Impact of Condom Use on

Its Spread

Human papilloma virus (HPV) is used to describe

more than 100 different types of related viruses. HPV

can be transmitted through contact with skin surfaces

or genital fluids infected with the virus.1 Genital HPV

infection is usually, though not always, sexually transmitted. While many other sexually transmitted infections (STIs) have been associated with increased risk

of acquiring or transmitting HIV, this association has

not been observed for HPV. However, persons with

HIV/AIDS seem to be at increased risk for HPV
infection and associated sequelae of HPV infections

such as genital warts and dysplasia.2

Cervical and anal/genital cancers, precancerous cervical tissue abnormalities, genital warts and wart-like

lesions, and cervical cell dysplasia have been associated with infection with specific HPV types. Cervical

cancer is the leading cancer among women in Africa.3

The report of a workshop sponsored by the National

Institutes of Health National Institute of Allergy and

Infectious Diseases (NIH/NIAID) within the

Department of Health and Human Services on the

evidence of the effectiveness of condoms to prevent

sexually transmitted diseases (STDs) concludes that

co-infection with HPV and HIV may lead to

increased risk of cervical neoplasia and anal cancers

among persons infected with HIV, as HIV suppresses

the body’s immune system.4

There is little known about the prevalence of HPV in

sub-Saharan Africa.5,6,7 Few studies on the prevalence

of any STI, let alone HPV, have been conducted in

the region. Of the available recent published reports,

HPV research often covers specific populations in

geographically specific areas of a country. For example, a 2001 study of HPV genotypes among 262

women in a rural area of Mozambique found that 40

percent of women in the study tested positive for at

least one type of HPV.8 A 2003 study of 429 female

family planning clinic attendees in urban Nairobi,

Kenya, found an HPV prevalence of 44 percent. In

addition, research sample sizes have been small and

non-representative, making it difficult to generalize to

entire populations, and advanced definitive diagnostic

methods for HPV have only recently been made

available. There have been no national or sentinel

surveillance programs to assess HPV infection in subSaharan Africa. Therefore, it is difficult to accurately

gauge HPV prevalence in the region.

Additional HPV epidemiological research in developing countries is needed to develop more effective

HPV and cervical cancer prevention strategies. The

focus of this research should include the prevalence of

specific HPV strains associated with cervical cancer,

the prevalence of co-factors affecting the progression

to cervical cancer, region-specific risk factors for HPV

infection and cervical cancer, and the association

between HIV infection and HPV epidemiology.

Screening and treatment programs for cervical cancer

are also recommended to prevent cervical cancer

deaths in sub-Saharan Africa. 

Condoms have been shown to be effective in

preventing the transmission of many STIs, including

HIV/AIDS. According to a 2004 report of the

Department of Health and Human Services’ Centers

for Disease Control and Prevention (CDC), condom

use has been associated with lower rates of the HPVassociated diseases of genital warts and cervical

cancer. However, the effect of condoms in preventing

HPV infection is unknown, and the available scientific evidence is not sufficient to recommend them as a

primary prevention strategy for preventing genital

HPV infection.9

The CDC report concluded that because genital HPV

infection is most common in men and women who

have had multiple sex partners, abstaining from sexual

activity (i.e., refraining from any genital contact with

another individual) is the surest way to prevent infection. For those who choose to be sexually active, a

monogamous relationship with an uninfected partner

is the strategy most likely to prevent future genital

HPV infections. For those who choose to be sexually

active but who are not in a monogamous relationship,

reducing the number of sexual partners may reduce

the risk of genital HPV infection.

The CDC also noted that all published epidemiologic

studies of HPV have methodologic limitations that

make the effectiveness of condoms in preventing HPV

infection unknown. While a few studies on genital

HPV infection and condom use showed a protective

80 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

1National Institute of Allergy and Infectious Diseases. 2001. “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted

Disease (STD) Prevention.” June 12-13, 2000. Hyatt Dulles Airport. Herndon, Virginia. 

2Ibid.

3De Vuyst, H. et al. 2003. “Distribution of Human Papillomavirus in a Family Planning Population in Nairobi, Kenya.” Sexually Transmitted Diseases

30(2): 137-42.

4National Institute of Allergy and Infectious Diseases. 2001. “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted

Disease (STD) Prevention.” June 12-13, 2000. Hyatt Dulles Airport. Herndon, Virginia. 

5Castellsague, S. et al. 2001. “Human Papillomavirus Genotypes in Rural Mozambique.” Lancet 358: 1429-30.

6De Vuyst, H. et al. 2003. “Distribution of Human Papillomavirus in a Family Planning Population in Nairobi, Kenya.” Sexually Transmitted Diseases

30(2): 137-42.

7Okobia, M.N. 2003. “Cancer Care in Sub-Saharan Africa – Urgent Need for Population-based Cancer Registries.” Ethiopian Journal of Health and

Development 17(2): 89-98. 

8Castellsague, S. et al. 2001. “Human Papillomavirus Genotypes in Rural Mozambique.” Lancet 358: 1429-30.

9Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 2004. “Report to Congress: Prevention of Genital

Human Papillomavirus Infection.” Appendix B in the Five-Year Strategy for the President's Emergency Plan presented to Congress in February 2004

did not refer to this report, and the final three paragraphs shown above have replaced the concluding paragraph on condoms and HPV in the original

Strategy document.
APPENDICES 81

effect, most did not. Recognizing that the optimal

study design to ensure valid measurements can be

problematic, it remains important to carry out further

research to help determine the efficacy of condoms in

preventing HPV infection.

Appendix C: Core Expertise of

U.S. Government Agencies With

Existing International HIV/AIDS

Programs

The following list provides a brief description of the

U.S. Government agencies and departments that are

currently responding to the international HIV/AIDS

pandemic.

Department of Commerce 

The HIV/AIDS initiative of the Department of

Commerce (DOC) serves as a conduit to the private

sector, particularly to U.S. companies already engaged

in HIV/AIDS activities or those not yet actively

involved but interested in partnering to combat

HIV/AIDS. DOC’s initiative promotes cross-sector

collaboration; provides information on opportunities

to foster partnerships, leverage resources, and transfer

technologies to African countries; and creates a dialogue with African countries to reduce trade barriers

to health care products and delivery systems. 

Department of Defense

The Department of Defense (DOD) currently supports military-to-military HIV/AIDS awareness and

prevention education in Africa and has supported the

development of policies for dealing with HIV/AIDS in

a military setting and the construction of facilities

used for HIV/AIDS activities funded by other U.S.

Government agencies. The Department’s HIV vaccine research program has been transferred to HHS. 

Department of Health and Human Services (HHS)

HHS, through its Centers for Disease Control and

Prevention (CDC), its National Institutes of Health

(NIH), and its Health Resources and Services

Administration (HRSA), supports prevention, care,

and treatment programs in developing countries and

conducts HIV/AIDS research. 

 CDC’s Global AIDS Program provides technical

assistance to countries in the areas of primary

prevention, surveillance and infrastructure development, and care, support, and treatment.

 NIH supports a comprehensive program of basic,

clinical, and behavioral research on HIV infection

and its associated opportunistic infections and

malignancies that will lead to a better understanding of the basic biology of HIV, the development

of effective therapies to treat it, and the design of

better interventions to prevent new infections,

including vaccines and microbicides. NIH supports

an international research portfolio encompassing

more than 50 countries and is the lead agency for

biomedical research on AIDS. 

 HRSA provides training and technical assistance,

including twinning, nurse training, and palliative

care programs in collaboration with CDC in the

HHS Global AIDS Program countries.

 In addition, the Food and Drug Administration

serves as an important advisory resource on drug

quality, safety, and efficacy, and conducts related

HIV/AIDS activities.

Department of Labor

The Department of Labor (DOL) supports projects

that target the workplace for prevention education

and strengthen the response to HIV/AIDS by providing technical assistance to governments, employees,

and labor leaders. DOL also funds an international

assistance program to reduce workplace stigma and

discrimination against people living with HIV/AIDS.

It also has an extensive international technical assistance program focused on child labor that works with

the International Labor Organization, UNICEF,

NGOs, and FBOs to implement programs targeting

HIV-affected children forced to work and children

involved in prostitution.

Department of State

The Office of the U.S. Global AIDS Coordinator

is located within the Department of State. The

Coordinator has primary responsibility for the

oversight and coordination of all resources and

international activities of the U.S. Government to

combat the HIV/AIDS pandemic, including the

President’s Emergency Plan for AIDS Relief. In addition the Department of State supports a wide range

of HIV/AIDS activities and small-scale programs

through its embassies in 162 countries. Most of these

activities and small programs focus on prevention.

Chiefs of Mission and other American officials

engage in policy discussions with leaders to generate

additional attention and resources for the epidemic.

Small projects usually are closely targeted at the

specific needs of the host country, developed in coordination with local nongovernmental organizations

and municipalities, and spearheaded by the U.S.

Ambassador. Embassies also use the tools of public

diplomacy to reach out through print and electronic

media, to facilitate exchange programs, etc. In many
countries, the Ambassador’s Self-Help Program provides small-scale assistance to projects that entail

extensive community involvement. 

Peace Corps

The Peace Corps has more than 3,000 volunteers

working on HIV/AIDS projects, including 1,000

volunteers committed as a result of the Emergency

Plan. The goal of the Peace Corps HIV/AIDS program is to build community-level capacity to address

the pandemic’s social, economic, and health impacts,

particularly in rural areas. All volunteers serving in

Africa, regardless of sector, are trained to serve as

advocates and educators for HIV/AIDS prevention.

In addition, the Peace Corps offers a short-term

program called the Crisis Corps that mobilizes

former Peace Corp Volunteers to help countries

address critical needs, including HIV/AIDS.

U.S. Agency for International Development

(USAID)

USAID has been the lead U.S. Government agency

fighting the global AIDS pandemic since 1986.

Currently, USAID has bilateral programs in 50 countries and reaches an additional 48 countries through

regional programs. USAID provides assistance through

an “expanded response” operational plan, which focuses on countries where the magnitude and severity of

the disease is high with strategies designed to respond

to a particular country’s epidemic. In addition to its

prevention, treatment, and care programs, USAID

also has expertise in the management of pharmaceutical logistics; supports operational and biomedical

research; and strengthens health systems so countries

are better able to respond to HIV/AIDS. USAID’s

HIV/AIDS programs are coordinated with other

development programs, including food aid, housing,

education, rule of law, as well as with health care

activities in tuberculosis, malaria, and maternal health.

82 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
APPENDICES 83

Appendix D

THE EMERGENCY PLAN FOR AIDS RELIEF

USG CONTRIBUTIONS TO GLOBAL HIV/AIDS, TB, & MALARIA FY 2003-2005

(dollars in millions)

2003 2004 2004 2005

EXISTING BILATERAL PROGRAMS Enacted Budget Enacted Budget 

USAID Bilateral Programs: 655 645 750 645 

Child Survival HIV/AIDS 488 500 513 500 

Other Accounts HIV/AIDS 38 40 53 40 

Child Survival TB and Malaria 129 105 184 105 

HHS Bilateral Programs: 421 445 493 524

CDC HIV/AIDS 154 155 154 154 

NIH HIV/AIDS Research 252 275 324 355 

CDC TB and Malaria 15 15 15 15 

State/Foreign Military Finance 2 2 1 2

DOL Bilateral Programs 10 0 10 0

DOD Bilateral Programs 7 0 4 0

Sub-total Existing Bilateral Programs: 1,095 1,092 1,258 1,171 

ADDITIONAL RESOURCES FOR FOCUS COUNTRIES

U.S. Global AIDS Coordinator’s Office 0 450 488 1,450

Mother and Child HIV/AIDS Prevention Initiative:1 139 300 149 0

USAID Child Survival 99 150 0 0 

HHS/CDC 40 150 149 0 

Sub-total Additional Resources for Focus Countries: 139 750 637 1,450

Global Fund to Fight HIV/AIDS, TB and Malaria: 347 200 547 200 

USAID Child Survival 248 100 398 100 

HHS/NIH 99 100 149 100 

TOTAL, GLOBAL HIV/AIDS, TB & MALARIA 1,581 2,042 2,442 2,821 

TOTAL, GLOBAL HIV/AIDS 1,437 1,922 2,243 2,701 

TOTALS BY AGENCY

State 2 452 489 1,452

USAID 1,002 895 1,148 745

HHS 560 695 791 624 

DOL 10 0 10 0

DOD 7 0 4 0

TOTAL, GLOBAL HIV/AIDS, MALARIA & TB 1,581 2,042 2,442 2,821 

State 2 452 489 1,452 

USAID 873 790 964 640 

HHS 545 680 776 609 

DOL 10 0 10 0

DOD 7 0 4 0

TOTAL, GLOBAL HIV/AIDS 1,437 1,922 2,243 2,701 

1 Beginning in FY 2005, these activities will be supported through President Bush’s Emergency Plan for AIDS Relief at the Department

of State. 
84 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

Appendix E: Focus Country HIV/AIDS Profile Information

2001 HIV/AIDS Data for Focus Countries of the President’s Emergency Plan for AIDS Relief

Country Adults (15-49)

With HIV/AIDS

Adult (15-49)

Infection

Rate (%)

Children (0-14)

With HIV/AIDS

Orphans (0-14)

Currently Living

AIDS Deaths

Adults and

Children

Botswana 300,000 38.8 28,000 69,000 26,000

Côte d’Ivoire 690,000 9.7 84,000 420,000 75,000

Ethiopia 1,900,000 6.4 230,000 990,000 160,000

Guyana 17,000 2.7 800 4,200 1,300

Haiti 240,000 6.1 12,000 200,000 30,000

Kenya 2,300,000 15.0 220,000 890,000 190,000

Mozambique 1,000,000 13.0 80,000 420,000 60,000

Namibia 200,000 22.5 30,000 47,000 13,000

Nigeria 3,200,000 5.8 270,000 1,000,000 170,000

Rwanda 430,000 8.9 65,000 260,000 49,000

South Africa 4,700,000 20.1 250,000 660,000 360,000

Tanzania 1,300,000 7.8 170,000 810,000 140,000

Uganda 510,000 5.0 110,000 880,000 84,000

Zambia 1,000,000 21.5 150,000 570,000 120,000

Source: UNAIDS, 2001

Note: Per the requirement in P.L. 108-199 (FY 2004 Consolidated Appropriations bill), a 15th country will be named shortly as a focus country not located

in Africa or the Caribbean region.
APPENDICES 85

Region/Country USAID HHS DOD DOL Peace Corps

Sub-Saharan Africa

1 Angola B B B

2 Benin B B B V

3 Botswana R B B B V

4 Burkina Faso R B V

5 Burundi R B

6 Cameroon R B V

7 Cape Verde R

8 Chad R B V

9 Congo, D.R. of B B B

10 Côte d’Ivoire R B

11 Djibouti R

12 Eritrea B B

13 Ethiopia B B B B

14 Gabon B V

15 Gambia, The R

16 Ghana B B B V

17 Guinea Bissau R

18 Kenya B B B B V

19 Lesotho R B B V

20 Liberia R

21 Madagascar B B V

22 Malawi B B B B V

23 Mali B B V

24 Mauritania B

25 Mozambique B B B B V

26 Namibia B B B B V

27 Niger R V

28 Nigeria B B B B

29 Rwanda B B

30 Senegal B B B V

31 Sierra Leone R B

32 Somalia R

33 South Africa B B B B V

34 Sudan R

35 Swaziland R B B V

36 Tanzania B B B B V

37 Togo R B B V

38 Uganda B B B B V

39 Zambia B B B B V

40 Zimbabwe B B B B

B = bilateral program; R = regional program; V = volunteers, prevention education. In addition, the State Department

has public diplomacy and some smaller-scale HIV/AIDS prevention programs at many of its posts abroad.

Appendix F: U.S. Government HIV/AIDS Bilateral Programs of the

President’s Emergency Plan for AIDS Relief (Focus countries in bold)

The U.S. Government, through USAID and HHS, has substantial programs in 101 countries, including the Emergency Plan

focus countries. In addition, through DOD, DOL, and Peace Corps, the U.S. Government has a number of smaller bilateral

programs in additional countries.
86 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

Appendix F, continued

Region/Country USAID HHS DOD DOL Peace Corps

Asia and Near East:

41 Bangladesh B

42 Burma R

43 Cambodia B B B B

44 China R B

45 East Timor R

46 Egypt B B

47 India B B B B

48 Indonesia B B B

49 Jordan B

50 Laos R B

51 Nepal B B V

52 Papua New Guinea R

53 Philippines B

54 Thailand R B B

55 Vietnam R B B B

56 West Bank/Gaza B

Europe and Eurasia:

57 Albania B V

58 Armenia B

59 Azerbaijan B

60 Belarus B

61 Bosnia R

62 Bulgaria R

63 Croatia R

64 Estonia R 

65 Georgia B B

66 Kazakhstan B B V

67 Kosovo B

68 Kyrgyzstan R B

69 Latvia R

70 Lithuania R

71 Macedonia R

72 Moldova B

73 Romania B B B V

74 Russia B B

75 Serbia R

76 Tajikistan R B

77 Turkmenistan R V

78 Ukraine B B B V

79 Uzbekistan R B V

B = bilateral program; R = regional program; V = volunteers, prevention education. In addition, the State Department

has public diplomacy and some smaller-scale HIV/AIDS prevention programs at many of its posts abroad.
APPENDICES 87

Appendix F, continued

Region/Country USAID HHS DOD DOL Peace Corps

Latin America and the Caribbean

80 Antigua & Barbuda R V

81 Argentina B

82 Bahamas B

83 Barbados R

84 Belize R B B V

85 Bolivia B B V

86 Brazil B B B

87 Chile B

88 Colombia B

89 Costa Rica B B

90 Dominica R V

91 Dominican Republic B B B V

92 Ecuador B V

93 El Salvador B V

94 Grenada V

95 Guatemala B V

96 Guyana B B B V

97 Haiti B B B V

98 Honduras B B B V

99 Jamaica B B V

100 Mexico B

101 Nicaragua B V

102 Panama R B V

103 Paraguay B V

104 Peru B B B V

105 St. Lucia R V

106 St. Kitts and Nevis R V

107 St. Vincent & Grenadines R V

108 Suriname R V

109 Trinidad and Tobago R B

110 Uruguay B

111 Venezuela B

B = bilateral program; R = regional program; V = volunteers, prevention education. In addition, the State Department

has public diplomacy and some smaller-scale HIV/AIDS prevention programs at many of its posts abroad.
* Number of clients to be collected disaggregated by sex

† Number of clients to be collected disaggregated by pregnancy status

88 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

Appendix G: The Emergency Plan’s Program-Level Monitoring

Framework

Number of facilitiesand/or programs

Number of faithbased facilitiesand/or programs1Number of abstinence/faithfulnessfocused programs2

Number of clientsservedNumber of newclients served3

Number of currentclients in continuousservices for morethan 12 months4Number of peopletrained

Prevention x x 

PMTCT x x x 

Risk Avoidance/Reduction

Mass Media x x x x 

Community Outreach x x * x 

Medical Transmission

Blood Safety x x 

Injection Safety x x 

STI Diagnosis and Treatment x * x 

Counseling and Testing x x * x 

Care, Treatment, and/or Support5 x x x x 

Treatment

ART x *✝ *✝ *✝ x 

PMTCT x *✝ *✝ *✝ x 

Clinical Care (non-ART care) x * x 

TB/HIV6 x * 

Palliative Care x * x 

OVC x x * x 

Labs x x 

Strategic Information x 

1 Number of faith-based facilities and/or programs is a subset of the number of facilities and/or programs..

2 Number of abstinence/faithfulness-focused programs is a subset of the number of facilities and/or programs.

3 Number of new clients served is a subset of number of clients served.

4 Number of clients in continuous services for more than 12 months is a subset of number of clients served.

5 Total number of clients is unduplicated at the facility/program level.

6 Number of TB/HIV programs/facilities and clients is a subset of clinical care facilities/programs and clients.
APPENDICES 89

Appendix H: Summary of HHS

Research Strategy

The National Institutes of Health Revitalization

Act of 1993 (Public Law 103-43) provided that the

Director of the Office of AIDS Research (OAR)

“shall plan, coordinate and evaluate research and

other activities conducted or supported” by the NIH.

The Director of OAR “shall act as the primary

Federal official with responsibility for overseeing all

AIDS research conducted or supported by the

National Institutes of Health” and “shall establish a

comprehensive plan for the conduct and support of

all AIDS activities of the agencies of the National

Institutes of Health...; ensure that the Plan establishes

priorities among the AIDS activities that such agencies are authorized to carry out; ensure that the Plan

establishes objectives regarding such activities...; and

ensure that the Plan serves as a broad, binding statement of policies regarding AIDS activities of the

agencies, but does not remove the responsibility of

the heads of the agencies for the approval of specific

programs or projects, or for other details of the daily

administration of such activities, in accordance with

the Plan.” The law further provides that “the Director

of the OAR shall ensure that the Plan provides for

basic research; provides for applied research; provides

for research that is supported and conducted by the

agencies; provides for proposals developed pursuant to

solicitations by the agencies and for proposals developed independently of such solicitations; and provides

for behavioral research and social science research.”

Highlights from the plan are provided below. More

detailed information can be obtained at

http://www.nih.gov/od/oar/public/public.htm#PLAN.

Vaccine development

A safe and effective HIV vaccine would provide a

valuable tool to prevent HIV infection. Despite years

of extensive research, however, a vaccine to prevent

HIV infection remains elusive. Private- and government-sponsored research continues, focusing on

defining necessary vaccine components and the best

means of vaccine delivery to ensure the optimal protective response.

The process of vaccine development will benefit from

a strategic alliance that ensures coordination among

the agencies working to identify a safe and effective

HIV/AIDS vaccine, particularly as activities to evaluate promising candidate vaccines in developing countries progress. The Emergency Plan offers an

unprecedented opportunity to develop interagency

alliances. The Department of Health and Human

Services (HHS) has created a new strategic alliance –

Partners in AIDS Vaccine Evaluation (PAVE) – in

which the National Institute of Allergy and Infectious

Diseases (NIAID/HHS) will be joined by the NIH

Office of AIDS Research, the Centers for Disease

Control and Prevention (CDC), the Department of

Defense (DOD), and the HIV Vaccine Trials

Network. PAVE will invite participation from nongovernmental organizations that are collaborating

directly with government agencies on HIV vaccine

development. PAVE will serve as a forum to achieve

increased efficiencies and cost-effectiveness for all

vaccine evaluations under its auspices. A steering

group comprising the principals from the three governmental agencies and the chair of NIH’s AIDS

Vaccine Research Working Group will serve as

PAVE’s principal advisory group. 

PAVE will focus initially on preparing for phase III

trials, which will involve:

 Developing common immunological, virological,

safety, and other laboratory capabilities worldwide;

 Strengthening clinical trial site capacity in developing countries, including the development and use

of common training modules and site development

priorities and standards; and

 Developing shared, compatible protocols.

Strategies include:

1. Central medical centers: Institutions suitable for

hosting central medical centers to serve as hubs or

referral centers for institutions conducting HIV

vaccine trials will be identified. Logistical, managerial, operational, ethical, and regulatory support

will be provided to ensure adequate capacity for

conducting large-scale trials and to help link existing networks to future central medical centers. 

2. Efficacy trials: Support will be provided to identify

and advance promising candidate vaccines to efficacy trials, including trials in five to seven targeted

countries. These trials will evaluate vaccine safety

and efficacy against locally circulating strains of

HIV. 

3. Phase I/II studies: Phase I/II studies in two to

three targeted countries will be conducted to evaluate the safety and immunogenicity of promising

candidate vaccines; to train research staff in the

conduct of HIV vaccine trials; to establish standard operating procedures for high-quality, ethically sound trials; and to ensure that appropriate

reporting and oversight procedures are in place.

Knowledge from clinical trials will be used to
90 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

improve vaccine design and make vaccines

more effective. 

4. Capacity building: Health care delivery networks

need to be strengthened so they have the components and capacities necessary to conduct trials of

the highest caliber and integrate these activities

into care and prevention programs. These components and capacities include:

X Sufficient numbers of motivated and trained

medical, laboratory, and support personnel;

X Equipment to plan, conduct, and oversee

quality vaccine trials;

X The capacity to follow patients for

prolonged periods;

X The ability to maintain medical records according to international standards; and

X Appropriate reporting and oversight procedures

to ensure the protection of human subjects, data

quality, and study integrity. 

The linkages among federally supported vaccine

development programs need to be strengthened

with emphasis on preparing sites for HIV vaccine

efficacy trials.

5. Public-private partnerships: Expansion of publicprivate partnerships in HIV vaccine development

will help engage the expertise necessary to advance

candidate vaccines through the clinical pipeline.

Partnerships should provide support to companies

for developing manufacturing and testing processes

and producing sufficient doses of the most promising candidate vaccines for efficacy trials.

Microbicide development

In the absence of a safe and effective vaccine, the

options for sexually active women – particularly

those who are coerced or forced to have sex – to

protect themselves from HIV and other sexually

transmitted infections remain minimal. A safe and

effective topical microbicide (i.e., an antimicrobial

product applied topically that inhibits or inactivates

HIV) would offer another means of protection for

women beyond condoms. 

Under the Emergency Plan, HHS will continue to

support a comprehensive program for discovering,

developing, testing, and evaluating microbicides for

HIV prevention.

NIH is the major federal sponsor of microbicide

research and development, supporting microbicide

design research and microbicide development and

production. Under the Emergency Plan, NIH will

expand the HIV Prevention Trials Network, a worldwide network for collaborative multidisciplinary, multisite clinical trials established by NIH to evaluate the

safety and efficacy of non-vaccine HIV prevention

interventions. 

NIH has also spearheaded an effort to develop a U.S.

Government strategic plan for microbicides, which

incorporates the microbicide activities of agencies

within HHS such as NIH, CDC, and the Food and

Drug Administration, as well as USAID. This strategic plan provides a blueprint for a coordinated effort

structured to address each step involved in developing

and testing potential microbicides and their subsequent implementation in prevention activities. 

Strategies include:

1. Basic biological and physiological research related to microbicides: This research will elucidate

the basic mechanisms of HIV transmission (both

virus and host factors) and other sexually transmitted infections at mucosal surfaces. Such research is

important for developing and applying microbicides

in diverse populations.

2. Microbicide development and preclinical

studies: The Emergency Plan will support the

discovery, development, and preclinical evaluation

of topical microbicides alone and in combination.

3. Microbicide formulations and modes of delivery:

Programs will develop and assess acceptable formulations and modes of delivery for microbicides,

bridging knowledge and applications from the

chemical, pharmaceutical, physical, bioengineering,

and social sciences.

4. Clinical trials of microbicide products: Clinical

studies of candidate microbicides will be conducted

to assess their safety, acceptability, and effectiveness in reducing the transmission of HIV and other

sexually transmitted infections in diverse populations in domestic and international settings.

5. Behavioral and social science research related to

microbicides: Basic and applied behavioral and

social science research will be conducted to

enhance microbicide development, testing, acceptability, and use domestically and internationally.
APPENDICES 91

6. Training and infrastructure: Infrastructure and

training needs will be met to permit international

and domestic microbicide research to proceed and

to accelerate access to microbicidal products in

diverse populations.

Therapeutics research

Considerable progress has been made in understanding how HIV attacks the immune system and how to

treat it. Researchers have developed new methods to

detect and measure HIV in blood and tissue and to

test for antiretroviral (ARV) drug resistance.

Therapeutic regimens using combinations of drugs

have extended and improved the quality of life for

many HIV-infected people in developed nations and

have led to declines in AIDS-related mortality. 

There is an urgent need today to extend these

benefits to developing countries hardest hit by the

disease. Research is needed to determine how best to

deliver and monitor antiretroviral therapy (ART)

and to manage the clinical treatment of adults and

children in resource-limited settings. Additionally,

research is needed to determine the spectrum of

opportunistic infections and co-infections in threatened populations and their impact on HIV infection

and disease progression.

Under the President’s Emergency Plan, the United

States will support the expansion of preclinical drug

development resources; feasibility studies and efficacy

trials for ARV and antimicrobial drugs; and the provision of laboratory support for diagnostics, clinical

trials, and expanded treatment delivery. As part of

this effort, NIH is working with France’s Agence

Nationale de Recherche sur le SIDA and the

Antiretroviral Therapy Cohort Collaboration to

develop a database that will collect treatment-related

data from a large number of research sites in developing countries. Systematic analyses of the database may

permit comparisons of the short- and long-term effectiveness of ART in these sites and developed countries. The database also will facilitate studies on other

aspects of treatment-related operational research.

Findings from this project may provide important

models for multisite, multicountry operational

research that will complement traditional clinical

research models in establishing the effectiveness of

antiretroviral strategies in developing countries.

Tuberculosis research

Worldwide, tuberculosis is the leading cause of death

in HIV-infected persons. Research is needed to determine the incidence of TB infection and co-infection,

improve diagnostic capability, and develop and deliver

affordable and effective therapies to adults and children in developing countries. Important research

questions include the effectiveness and tolerance of

different dosing regimens and comparisons of providing concurrent TB/ARV treatment and providing TB

treatment before ART.

Research is needed to: 

 Determine incidence of TB infection and

co-infection;

 Improve diagnostic capability, especially given the

significant lower sensitivity of current methods in

persons infected with HIV;

 Develop and deliver affordable and effective therapies to adults and children in developing countries;

 Determine the effectiveness and tolerance of different dosing regimens and comparisons of providing

concurrent TB/ARV treatment;

 Optimize timing of providing TB treatment

before ART;

 Develop new drugs to combat the problem of

emerging drug resistance;

 Develop and test molecular targets for tuberculosis

vaccines tailored for HIV-infected persons, including those in largely BCG-vaccinated populations;

 Develop models for building community-research

partnerships with local health units in ethnically

diverse communities;

 Focus on the special problems of children

co-infected with tuberculosis and HIV; and 

 Refine cooperative strategies between tuberculosis

and HIV prevention and control activities.

Malaria research

Malaria is a major cause of death and disability in

Africa. The research agenda will include:

 The genome sequencing of the malaria parasite

Plasmodium falciparum and of its mosquito vector

Anopheles gambiae;

 Development of molecular tools to genetically

manipulate the parasite and vector in studies

relevant to drug and vaccine discovery;

 Pathogenesis and vector control;
92 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

 Identification of the genes mediating chloroquine

and insecticide resistance and molecular techniques to characterize drug-resistant parasites from

clinical isolates;

 An accelerated malaria vaccine research and

development program;

 Quantification of the economic impacts of malaria

in endemic countries;

 Discovery and development of new antimalarial

drugs from plants, animals, and microorganisms;

and 

 Development of predictive models of the transmission risk for many infectious diseases, including

malaria, in relation to major environmental disturbance events.

Appendix I: USAID’s HIV/AIDS

Research Strategy

The U.S. Agency for International Development has

been a leader in fighting HIV/AIDS since 1986. One

of the key components of USAID’s HIV/AIDS program has been to conduct biomedical and operational

research to develop and evaluate new tools for providing antiretroviral therapy, preventing HIV transmission, and caring for people living with AIDS. 

The major focus of USAID’s research is to address

needs for program implementation in resource-limited

settings. USAID-funded research is comprehensive,

from identifying a program problem to research and

efficacy verification, to field testing and then finally

full implementation in developing countries. 

Treatment

Antiretroviral Therapy

There are many complex issues related to the

introduction and impact of antiretroviral therapy in

resource-constrained settings. Current research examines methods to improve ease of administration and

adherence to therapy and methods to decrease drug

tolerance and side effects. Antiretroviral therapy

implementation sites also serve as learning sites.

Three USAID introductory sites are models for

antiretroviral treatment.

Preventing Mother-to-Child Transmission

Operations research currently underway includes: 

 Studies to determine the effectiveness of introducing a package of prevention of mother-to-child

transmission services into existing antenatal,

maternal, and child health services; and

 Development and implementation of packaging

options that could create a sustainable supply of

nevirapine in single or small-dose packaging.

Prevention

ABC: Abstinence, Be Faithful, Use Condoms

USAID has carried out pioneering studies in the area

of behavior change for successful HIV prevention,

including a recently funded six-country study on ABC

and has published an important paper analyzing the

success of the ABC approach in Uganda. New studies

are being planned to optimize the implementation of

ABC interventions for youth and at-risk groups. 

Male Circumcision

Clinical trials are currently underway to review

whether male circumcision has a strongly protective

effect on HIV transmission. USAID is supporting

research in Haiti, Zambia, Kenya, and South Africa to

learn more about issues of safety and complications,

acceptability and feasibility, and the logistical issues

involved in developing pilot demonstration services

for safe/affordable male circumcision and male reproductive health. 

Injection Safety

In addition to the transfusion of HIV-infected blood,

transmission of HIV in the health care setting can

occur through unsafe injections and other unsafe

medical practices, including occupational exposure to

blood. USAID is supporting research in this area,

including: 

 Evaluation of health care worker acceptance of

single-use devices;

 Field safety comparisons of new devices; and 

 Pioneering and evaluating the use of bundling an

injectable contraceptive commodity with auto-disable syringes and safety boxes.

Care

Nutrition 

HIV infection affects nutrition through reduction in

dietary intake, nutrient malabsorption, and complex

metabolic alterations that culminate in weight loss

and wasting. USAID is implementing research on: 
APPENDICES 93

 The impact/effectiveness of providing nutrition

supplements on adherence to antiretroviral treatment and return for HIV care; 

 Cost and feasibility of incorporating nutrition

supplements into antiretroviral treatment

programs; and 

 Nutrient and caloric formulation of nutrition

supplements in children and adults living with

HIV/AIDS.

Orphans and Vulnerable Children

USAID-supported projects for orphans and vulnerable children aim to increase a family’s ability to provide care and support to children affected by AIDS.

USAID supports research to identify successful

approaches, including studying:

 Effectiveness of interventions to help parents and

families affected by HIV plan for their children’s

future care;

 Psychosocial issues affecting adolescent orphans

and vulnerable children; and

 Different models to enhance food security and

nutrition in programs assisting orphans and vulnerable children.

Biomedical Research

Microbicides

Because standard prevention strategies are often out

of the control of women, USAID is actively developing microbicides – a female-controlled chemical barrier to the AIDS virus. USAID’s research priorities are

the identification of the best active agents for use in

new microbicidal products, early-stage clinical studies

to establish the safety and acceptability of potential

new microbicides, advanced clinical studies to test the

effectiveness of the most promising microbicide candidates in large-scale trials, and planning the introduction of the most appropriate microbicides in the

context of developing countries. 

Vaccines

Prevention of HIV infection remains a primary strategy in the fight against the worldwide HIV pandemic,

and a safe and effective HIV vaccine would provide

an extremely important tool for this purpose. USAID

funds the International AIDS Vaccine Initiative to

accelerate the development and introduction of new

vaccine candidates and technologies and link vaccine

designers with manufacturers and with developing

country sites suitable for testing promising HIV

vaccine candidates. 

USAID’s Tuberculosis and Malaria Research

Strategies

Tuberculosis

USAID’s investment in global tuberculosis control

includes support for focused research in a number of

critical areas. Of the 40 million HIV-infected people

worldwide, almost one-third are also infected with

TB. USAID’s research in this area includes:

 Development of new and improved diagnostics

appropriate for use in developing and transitional

countries and functional in a variety of settings

(including areas of high HIV-prevalence); 

 Development of new drug treatment regimens and

new drugs which are easier to use, safer, lower in

cost, and less labor-intensive to administer;

 Strengthening of clinical trial capacity for the

evaluation of new diagnostics, drugs, and drug

treatment regimens, and strengthening of operations research capacity at the country level; 

 Improving the management and delivery of care for

multidrug-resistant TB; 

 Research on the impact of antiretroviral therapy on

TB infection;

 Testing model approaches to improve care and

support within general health services to persons

with HIV and TB; and

 Generating evidence on the best mix of TB/HIV

activities according to different levels of HIV

prevalence. 

Malaria

As many as 900 million cases of malaria occur every

year, directly and indirectly causing up to 2.7 million

deaths. Priority research areas include: 

 Malaria vaccine research; 

 Issues on delivery and rapid deployment of the

most promising malaria treatment currently

available; 

 New drug development in collaboration with

the Medicines for Malaria venture;
94 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

 Community approaches to vector management;

and

 Issues related to co-infection of malaria and HIV.

Appendix J: Summary of

Testimony and Recommendations

Received 12/18/03 at the PACHA

Townhall Meeting

The commentary and papers received by the PACHA

International Committee on behalf of Ambassador

Tobias and the President’s Emergency Plan for AIDS

Relief were broadly focused and rich in experience

and passion. Together they provided a number of

consistent messages and subsequent recommendations

that will hopefully enhance the efforts underway and

still being developed to ensure the success of the

Emergency Plan. Below is a brief summary of the

principal issues and themes that arose in the verbal

and written comments received during the Townhall

Meeting based on the three questions disseminated

before the meeting.

1. What lessons can you provide/share regarding

planning, implementation, and outcome measurements strategies that have worked best and

what did not work and why?

2. What are the vital aspects of effective partnerships and with whom? 

3. How have you been able to effectively involve

people living with HIV/AIDS in your work?

HIV treatment/access to antiretroviral drugs:

Nothing should get in the way of the overarching goal

of providing universal access to treatment. Parallel

issues, such as trade agreements on intellectual

property rights and generic medicines, should be

congruent with this goal, as well as decreasing the

costs of medicines.

Access to ARVs is an absolute priority that reduces

stigma, improves health of the individual, the community, the economic viability and social structures of a

nation. ARVs are being done, can be done effectively

and safely and can be scaled up quickly in most of the

Emergency Plan’s focus countries. Such implementation requires a different approach to the “the western

medical model.” Barriers must be reduced to allow the

use of combination pills (generics), new algorithms of

treatment success, and understanding that a perfect

model of implementation does not exist. Many models

must be urgently instituted with failures in some

expected, but with the understanding that the good

outweighs the bad in this approach in lives saved and

children raised by their own parents. 

Access to holistic care includes non-ARV health

interventions that have also been proven effective in

reducing morbidity and mortality. Care needs to be

comprehensive and not just focused on medication

distribution. Many were concerned too much emphasis is currently on ARVs, that other important aspects

may be getting inadequate attention, such as:

 Adequate nutritional supplementation and food

security;

 Clean water; and

 Palliative care (treatment of suffering, and symptom management).

There was an emphasis on paying attention to the

social/family dynamics of the disease:

 The need to attend to the care of orphans;

 Make care family-centered;

 Utilize friends and family members (natural support

systems) as part of the care model; and

 There is a continued need to address the issues of

stigma reduction.

There is a need to accelerate AIDS vaccine

research. It was suggested that this, and the

development of effective microbicides, should have

comparable federal incentives as the research of TBrelated vaccines.

Communication strategies require the development of

sound evidence-based messages that utilize multiple

communications media and technologies that cater to

the learning needs, languages, culture, and access

requirements of specific groups, especially in remote

areas for women, men, youth, and children.

Treatment and care must be simple, adapted to local

conditions and decentralized.

Design of service delivery strategies should include:

A multisectoral response, including a health response

(technical) and social, economic, financial, and political responses. Multifaceted problems require multifaceted solutions.
APPENDICES 95

Community in all aspects from care delivery to leadership and decision-making.

In-country collaboration broadly defined to include

local leadership, public-private partnerships, ministries

of health, faith-based organizations, and health worker collaborations among the various disciplines. Also

necessary is collaboration among the donor agencies

working with specific organizations. The lack of

streamlined and compatible technology was identified

as a potential barrier to effective programming and

collaboration, as many different organizations, each

with different information processing systems, are

involved in combating HIV/AIDS. Logistics, specifically the ability to have consistent access to quality

supplies, was also identified as a barrier to the success

of programs.

Culturally appropriate and relevant solutions, delivery

strategies, and training methodologies that include

respect for the oral traditions of learning and retention of information, the learning style and the proven

strategy of the message being delivered by trusted

members within the group, peer-to-peer learning, and

interventions be instituted at all levels of strategies.

Focus on women and families with key support for

prevention efforts and treatment shifts to reduce the

burden of new infections as well as reduce the number of children becoming orphans.

Local capacity building and use of volunteers is an

important part of any strategy that brings a different

motivation to the rebuilding of communities and

health delivery strategies. While extremely important,

this has to be done with caution as communities are

already overwhelmed with too much emphasis and

reliance on their function. 

Non-physician health workers such as nurses, community health workers, midwives, and traditional healers

who are the main providers of the African health

delivery system. The focus on physician-driven efforts

and training, while valuable in the long term, is not

immediate and is limited in its effect in the field. The

immediate relevant inclusion of non-physician health

workers into decision-making, leadership, resources,

and scale up to sustain work and practice is critical to

the success of the Emergency Plan. The training provided to this group must be developed and delivered

by peers. These training initiatives and linkages to the

ministries of health are new models (in fact the U.S.

health delivery leaders have little experience with

these type of educational and training models) that

have hidden power barriers that can limit the ability

of these workers to be enhanced and will require significant leadership on how to work collaboratively

and truly empower this group to be effective. Nurses

were significantly pointed out in over 10 of the commentaries.

Use of existing infrastructures such as faith-based care

centers that already mandate holistic care and respect

for the community and demonstrate willingness can

ensure effective use of Emergency Plan funds and sustainability over time. A modest investment can go a

long way.

Promoting behavioral change:

Prevention as the primary weapon to combat HIV.

Turning the tide requires dramatically reducing the

number of new infections. A few organizations

emphasized abstinence and fidelity as appropriate,

effective, and necessary preventions strategies.

Participants testified that treatment has a huge role to

play in mitigating the consequences of HIV/AIDS,

but prevention has to remain a primary aim.

Behavior change for sexual transmission is proving

effective on a number of fronts that include each

component of the ABC model. Caution to the use of

a one-size-fits-all approach was repetitious in the

commentary. The emphasis on A and B was welcomed especially by the faith-based groups and

churches that are providing the bulk of health care

delivery and social modeling. Culturally relevant and

community-driven prevention efforts should be the

long-term focus and goal. 

Behavior change in health delivery requires immediate attention and the systems that support the spread

of non-sexual transmission of HIV such as safety for

health workers, equipment in treatment facilities, and

policies that support the reduction of this underreported transmission route. This also impacts the

sustainability of a health workforce. We heard that

two or three nurses are dying monthly in Kenya

from possible occupational exposure. The immediate

treatment of the health workforce must be part of

the Emergency Plan. With examples such as DaimlerChrysler and the Global Business Council using

comprehensive workforce policy and programs, the

President’s Initiative should ensure that this style of

health workforce program be enacted in both the

public (ministries of health) and the private (mission)

sectors. The mission health systems are providing

about 40 to 70 percent of all health delivery in many

of the Emergency Plan focus countries and will

require resources to move forward on this end.

The development of alternatives to condoms must be

enhanced, such as microbicides and gender rights
issues. As women are increasingly infected, the previously heavy reliance on condoms or other male-driven responsibility measures must be attended to. The

development of female-centered technologies should

be prioritized so that other methods of prevention

besides condom use can be promoted specifically with

women. Strategies must be put in place to address

vulnerabilities of women, including social rules that

inhibit their ability to negotiate sex and the use of

condoms. Participants emphasized that a gender strategy intended to empower women must target men

and boys to change attitudes. 

People living with HIV/AIDS are vital contributors

to prevention efforts, fighting stigma, and planning

effective interventions. Their involvement is crucial.

Youth make the greatest proportion of new infections;

participants emphasized strategies that target youth.

Program interventions to assist orphans and vulnerable children must be community-based, building on

community coping mechanisms with an eye to sustainability.

Issues of program effectiveness in HIV/AIDS:

Programs must strike a balance between the urgency

of the pandemic and the long-term investments and

strategies required to develop sustainable services.

Well-conceived and thought-out community planning

processes built on bottom-up approaches have had

greater success in mobilizing community involvement

and ownership. This has led to lower costs in service

delivery and greater access to resources for families.

Programs need to take better advantage of skills and

resources of health professionals at the local level.

We need to develop new kinds of community

involvement to prevent social fatigue, such as patientcentered adherence and programs to de-stigmatize

HIV/AIDS. 

Operations research has not been part of funding

strategies in development work and must be considered as the Emergency Plan is initiated to measure

progress, identify lessons learned, and improve program effectiveness on a continuing and permanent

basis. Developing national capacities for data collection and implementation monitoring will be important

for creating successful programs.

Sustainability:

Another consistent thread was for HIV/AIDS health

services to be addressed in a broader scope of development and poverty reduction that are fueling the

HIV pandemic. Incorporating collaborations that

address nutrition, food security, clean water, reproductive health care, sanitation, and economic/job solutions for ill family members who cannot support the

health of the family is crucial. 

Scaling up successful pilot projects has had dismal

results to date. While outcomes research as the test of

the success of a program is important, they must now

include operations research to ensure that scale-up

can be effective. 

Successful HIV programs are one part ARV and nine

parts development. Programs should be comprehensive and address the multifaceted nature of human

health and welfare as it relates to HIV/AIDS.

Administrative policy in the Emergency Plan for

AIDS Relief:

The structure of the procurement process for grants

from the Emergency Plan should facilitate and

encourage partnership arrangements to the greatest

extent possible.

The Emergency Plan should revisit, on a permanent

basis, the procurement rules to ensure that they are

not too rigid and burdensome.

Local institutions:

Links with local institutions are critical to successful

interventions. However, it is important not only to

view local institutions as a means to achieving program goals, but to recognize them as institutions in

their own right, with their own identity, that form a

part of a social fabric for development.

Work with local churches that are providing HIV

care and treatment as well as education should be

strengthened and expanded. Patient fellowships

with PLWA and local churches are one way to

develop new social networks for prevention,

treatment, and care.

National and global coordination:

Initiatives promoted by the President’s Initiative

should be articulated and integrated into the national

AIDS plans of the countries in which they are implemented, focusing on strengthening national capacities

to facilitate local initiatives.

The Emergency Plan should develop effective

coordination and collaboration mechanisms with

the Global Fund and the World Health Organization’s

“3 by 5” program.

96 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
APPENDICES 97

In addition to the above summary from the public

comments, the PACHA International

Subcommittee would like to make the following

suggestions:

The Emergency Plan should institute a vigorous evaluation component to ensure that desired outcomes

and the mandate from Congress are achieved.

The Initiative’s program strategies should encourage

HIV/AIDS care burden-sharing with recipient’s countries. The countries should be mandated to do their

fair share of providing adequate health care to citizens. The success of any program in Africa requires

firm commitment and active participation of local

governments of the African countries. The political

will and determination of the African governments

are necessary to ensure the success of combating

HIV/AIDS in their countries.

Emergency Plan funding should be used to complement and not serve as a substitute or replacement for

HIV activity work that is currently in place through

various international and local agencies.

In-country community mobilization and capacity

building is a crucial aspect of all programs.

The Request for Proposals (RFPs) process should

be made less cumbersome. It was clear that there

was considerable confusion about the “process” of

the RFPs that had recently been solicited. The time

frame and the nature of it needs to be explained going

forward especially in light of the fact that there will be

“different” RFPs coming down the pike.
Appendix K: ACRONYMS

AIDS Acquired immune deficiency syndrome

ART Antiretroviral therapy

ARV Antiretroviral (drugs, treatment, etc.)

CBO Community-based organization

CDC Centers for Disease Control and Prevention (HHS)

DOC Department of Commerce, U.S.

DOD Department of Defense, U.S.

DOL Department of Labor, U.S.

FBO Faith-based organization

FDC Fixed-dose combination

FY Fiscal year

HHS Health and Human Services (U.S. Department of)

HIV Human immunodeficiency virus

HPV Human papilloma virus

HRSA Health Resources and Services Administration (HHS)

ICRC International Committee of the Red Cross

ILO International Labor Organization

MAP Multi-Country HIV/AIDS Program for Africa (World Bank)

MIS Management information system

MTCT Mother-to-child transmission

NGO Nongovernmental organization

NIAID National Institute of Allergy and Infectious Diseases

NIH National Institutes of Health (HHS)

OAR Office of AIDS Research (HHS/NIH)

PACHA Presidential Advisory Council on HIV and AIDS

PAVE Partners in AIDS Vaccine Evaluation

PLWA Person(s) living with AIDS

PMTCT Prevention of mother-to-child transmission

RFP Request for proposal

STD Sexually transmitted disease

STI Sexually transmitted infection

TB Tuberculosis

TRIPS Trade-Related Aspects of Intellectual Property Rights (Agreement)

98 THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF
APPENDICES 99

UNAIDS Joint United Nations Program on HIV/AIDS

UNDP United Nations Development Program

UNGASS United Nations General Assembly Special Session

UNHCR United Nations High Commissioner for Refugees

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

USG United States Government

WFP World Food Program

WHO World Health Organization

WTO World Trade Organization