Slide 1
The President’s Emergency Plan for AIDS Relief:
Defining U.S. Support for National Strategies

Slide 2
The Emergency Plan: Focus Country Goals
Emergency Plan goals in focus nations:

• Support antiretroviral treatment for 2 million people
• Support prevention of 7 million infections
• Support care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children

Slide 3
Support for National Strategies
Monterrey Accord: National ownership is key to sustainability.
The Three Ones Agreement:

• One national strategy
• One national coordinating authority
• One national monitoring and evaluation system

Slide 4
The Biggest Challenges
Resource-poor nations face significant limitations in capacity.

• Physical infrastructure
• Human resources
• Systems
  • Management
  • Financial
  • Supply chain
  • Quality
  • Strategic information

Slide 5
The Capacity-Building Consensus
"We will ensure our actions strengthen health systems at national and local level and across all sectors since this is vital for long-term improvements in overall health, and we will encourage donors to help build
health capacity." G-8 Gleneagles Communique

Slide 6
The President’s Emergency Plan Emphasizes Capacity-Building

"Across Africa, we're working with local health officials to expand AIDS testing facilities, to train and support doctors and nurses and counselors, to upgrade clinics and hospitals, to care for children orphaned by AIDS, and to support pastors and priests and others who are teaching young people the values of respect and responsibility and prevention." President George W. Bush, June 28, 2005

Slide 7
FY 2005 Planned Focus Country Funding for Capacity-Building
(excluding Track 1.0 funds)

Total = $958M

In the graphic below, blocks stacked in two columns show how the total of $958 million is broken down, with dollar amounts and percentages used for "Capacity Building" ( $301 million or 31% and "Other" ($657 million or 69%). Capacity Building is broken down to show dollar amounts and percentages for Local Organization Capacity Development ($66 million or 22%), Workforce ($93 million or 31%) and Training ($142 million or 47%).

The figures given for Capacity Building and Other are for the total country budget excluding management and staffing costs.

Note: All funding amounts are rounded to the nearest million. Funding does not include central money.

Local Organization Capacity Development: strengthening the ability of key local institution to implement HIV/AIDS programs efficiently with diminishing reliance, over time, on external technical assistance

Workforce: refers to innovative approaches to recruitment, retention, deployment and rewarding of quality performance of health care workers and managers, workforce assessments and policy and planning activities.

Training: activities that impart skills, knowledge, and attitudes to individuals, groups or organizations to enhance their ability to provide quality HIV/AIDS services that are
responsive to clients’ needs

Slide 8
Capacity-Building Must Count

• Given fundamental importance of
• capacity-building in building country
• ownership…
• Must acknowledge reality that those who
• support capacity-building contribute to
• prevention/treatment/care of individuals

Slide 9
Implementation and Program Monitoring
A key choice:

• Delay implementation until monitoring systems were ideal?

• Push ahead with implementation and refine monitoring systems while implementing?

Slide 10
What We Will Cover

• Why we report
• How we report
• What we are doing to improve reporting

Slides 11 and 12
Why we report

• To use data to improve programs
• To promote accountability and good governance in country
• Not to take credit for what is being done, given that, as Ambassador Tobias said when we released our latest results:

• Responding to the Washington Post, Botswana Health Minister Tlou said it best:

Slides 13 and 14
How we report
International Collaboration

• U.S., UNAIDS, WHO, Global Fund, DfID, GBC
• Efforts leading to Davos announcement
• Strategic Information and Monitoring and Evaluation Field Officer Regional Meetings in Africa
• Collaboration in defining common sets of indicators and measurement
• Joint work on state of the art methodologies for monitoring and evaluation of the epidemic: surveillance systems; facility based health management information
• systems; population-based and facility surveys
• HMIS meeting in Africa to talk about joint health-HIV reporting databases and transfer of data – plans to define international standards for HIV database storage and database transmission

Slide 15
People in the 15 Focus Nations Receiving ARV Treatment With Support from the President's Emergency Plan for AIDS Relief as of September 30, 2004

Graphic shows the number of people receiving treatment, depicting those receiving treatment with support from U.S. Bilateral Programs (172,000 people), which are 100 % funded by the Emergency Plan and/or those receiving treatment with support from the Global Fund To Fight AIDS, Tuberculosis, and Malaria (130,000 people), which is 33% funded by the Emergency Plan. Of these two figures -- 172,000 and 130,000 -- 63,000 overlap, so the combined total is 239,000 people (172,000+130,000 less 63,000).

Treatment data for Emergency Plan bilateral programs provided by the Office of the U.S. Global AIDS Coordinator.

Treatment data for the Global Fund programs provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Slide 16
Focus on Prevention

• Prevention impact will be assessed by surveys (2-3 per focus country during 5
• year program)
• No partner will be able to specify specific program resulting in specific infections averted
• Important to strengthen host country surveillance
• Currently count numbers reached

Slides 17, 18, and 19
Focus on Treatment
Defining Elements of Quality Treatment (Annual Report, pages 34-37)

• Antiretroviral therapy (ART), as defined by national strategies, includes many elements
• If any of these key elements are absent, not quality ART
  • General clinical support for patients, including other medications and lab tests
  • Training and support for health care personnel
  • Infrastructure, including clinics, counseling rooms, labs, and distribution and logistics systems
  • Monitoring and reporting systems
  • Appropriate referral systems
  • Antiretroviral drugs (ARVs)
• One size does not fit all –
  • Each nation’s needs are unique
  • Each nation in the best position to know its needs

Slide 20
Cost of Antiretroviral Treatment

• Cost of ARVs no longer the main cost of providing quality ART
• Due to the importance of local conditions, cost of providing quality ART varies dramatically from one nation to another, even for the same partner

Slide 21
Definition of Categories of Emergency
Plan ART Support (Annual Report, pages 35-37)

• Complexity of ART created need for more precise definition of categories of support within national programs
• Innovation in reporting: Emergency Plan First Annual Report (February 2005) distinguished between "Upstream" and "Downstream" support

Slide 22
Downstream Support

• "Downstream site-specific support refers to… instances where the Emergency Plan is providing all or part of the necessary components for quality ART at the point at which services are delivered." (Annual Report, page 34)
• Relatively easy to quantify results at service delivery sites where USG directly involved in providing assistance

Slides 23 and 24
Upstream Support

• "Beyond the site-oriented downstream components of treatment, support is required to provide other critical elements of treatment, such as the training of physicians, nurses, laboratory technicians, and other health care providers; laboratory systems; strategic information systems, including surveillance and monitoring and evaluation systems; logistics and distribution systems; and other support that is essential to the effective roll-out of quality ART. This coordination and leveraging of resources optimizes results while limiting duplication of effort among donors, with roles determined within the context of each national strategy." (Annual Report, page 35)

• "Such support, however, often cannot easily be attributed to specific sites because it is national or regional in nature, and, in fact, many sites benefit from these strategic and comprehensive improvements. Therefore, this support is referred to as "upstream" support and is essential to developing network systems for care and treatment." (Annual Report, page 35)

Slide 25
Table 2.1 - Treatment1: FY04 Overall Results Through September 30, 2004 (from Annual Report)

The following table shows the number of people in each country receiving treatment along with the June 2005 target number and the percent of that target reached. The June 05 targets were set by the countries in March 2004 to approximate the overall yearly target for the Emergency Plan. Note that the first disbursement of Emergency Plan funds occurred in late February, 2004. The June 2005 target of at least 200,000 people receiving treatment was set to allow the countries an achievable goal after one full year of programming. This is a year one anomaly.

Treatment includes the provision of antiretroviral drugs and clinical monitoring of ART among those with advanced HIV infection in either an ART or a PMTCT+ setting. PMTCT+ includes a minimum package of services: HIV/AIDS counseling and testing for pregnant women, ARV prophylaxis to prevent mother to child transmission, counseling and testing for safe infant feeding practices, family planning counseling or referral, ARV therapy for HIV+ women, their children and their families.

The number of people receiving treatment is broken down by those receiving upstream and downstream support for treatment. The number reached through upstream systems strengthening includes those supported through contributions to national, regional and local activities such as training, laboratory support, monitoring and evaluation, logistics and distribution systems, protocol and curriculum development. The number reached through downstream site-specific support includes those receiving services at U.S. Government funded service delivery sites.

Table: Results (Numbers are rounded to nearest 100. Numbers may be adjusted as attribution criteria and reporting systems are refined.)

Country	June 2005 Target	Upstream	Down-stream	Total number of people reached	Percentage of year 1 target met
Botswana (The total number of people on treatment in Botswana represents a decline from the 32,000 on treatment at the end of September 2004. This decline is due to a more conservative method for estimating the extent of USG support through systems strengthening. At the end of March 2005, a total of 41,000 people were receiving antiretroviral therapy throughout Botswana.)	29,000	31,900	1,000	32,900	113%
Cote d'Ivoire (Cote D'Ivoire semi-annual reporting does not include results from public sites).	10,000	0	4,500	4,500	45%
Ethiopia (In FY04, Ethiopia did not use USG funds to provide treatment at service delivery sites.)	15,000	9,500	0	9,500	63%
Guyana	300	100	400	500	167%
Haiti	4,000	0	2,800	2,800	70%
Kenya	38,000	9,100	8,000	17,100	45%
Mozambique	8,000	4,800	400	5,200	65%
Namibia	4,000	100	3,900	4,000	100%
Nigeria	16,000	7,800	5,700	13,500	84%
Rwanda	4,000	100	4,200	4,300	108%
South Africa	20,000	7,300	4,900	12,200	61%
Tanzania	11,000	0	1,500	1,500	14%
Uganda	27,000	6,600	26,400	33,000	122%
Vietnam (Vietnam received Emergency Plan funds late in FY04 and is not required to report during this cycle.)	1,000	0	-	-	-
Zambia	15,000	10,200	3,400	13,600	91%
All Countries (This line has been adjusted to match the Emergency Plan target of 200,000 individuals receiving treatment by June 2005 and the Total Number of Individuals Reached for All Countries has been rounded up to the nearest 1,000. As such, totals may not equal the sum of every column.)	200,000	87,500	67,100	155,000	78%

Slide 26
Treatment: Fiscal Year 2005 Semi-Annual Results (as of March 31, 2005)

The following table shows the same set of figures as the previous table, except the figures are through March 31, 2005, and figures are not given for the Percentage of year 1 target met. Notes for the table are the same as above, with exceptions noted in the table.

Country	June 2005 Target	Upstream	Down-stream	Total number of people reached
Botswana	29,000	17,500	2,500	20,900
Cote d'Ivoire (Cote D'Ivoire semi-annual reporting does not include results from public sites).	10,000	0	2,100	2,100
Ethiopia	15,000	0	14,900	14,900
Guyana	300	0	600	600
Haiti	4,000	0	3,900	3,900
Kenya	38,000	1,800	26,500	28,300
Mozambique	8,000	8,300	2,000	10,300
Namibia	4,000	800	8,800	9,600
Nigeria	16,000	5,200	8,300	13,500
Rwanda	4,000	200	10,100	10,300
South Africa	20,000	19,000	25,600	44,600
Tanzania	11,000	500	3,900	4,400
Uganda	27,000	11,400	39,500	50,900
Vietnam	1,000	0	300	300
Zambia	15,000	10,200	11,800	22,000
All Countries	200,000	74,900	160,800	235,700

Slide 27
Counting Conservatively

• In light of evolving nature of reporting, important to count conservatively
• Examples:
  • Cote d’Ivoire
  • Counting patients who receive both downstream and upstream support in downstream total only

Slides 28 and 29
Upstream Support for Sustainable National Systems
"In Botswana, for example, the government has led an aggressive and
highly successful multisectoral response with its own resources and significant
downstream contributions from the private sector through the African Comprehensive HIV/AIDS Partnerships (funded by the Bill & Melinda Gates Foundation and the Merck Company Foundation)…

"As the Emergency Plan began, extensive consultations with the government and
other donors identified the greatest added value to be strengthening national
laboratory and training systems and developing national protocols. This
upstream support contributes to the overall success of Botswana’s national strategy." (Annual Report, page 35)

Slides 30 and 31
Upstream Support for Botswana’s National Program
"The Government of Botswana has used its own resources to lead a highly
successful multisectoral treatment program. Consultations with the
Government and other partners made clear that the appropriate role for the
Emergency Plan in Botswana was to support national laboratory, training and
quality assurance systems, contributing to the overall success of the program…

"The U.S. transparently reported the nature of the partnership in Botswana and the number of persons whose treatment benefits from that
partnership. The Government of Botswana did, and continues to, agree with that report." Letter to Washington Post from Professor Sheila Dinotshe Tlou, Minister of Health, Republic of Botswana and Ambassador Randall Tobias, U.S. Global AIDS Coordinator

Slide 32
Range of Emergency Plan Support

• In contrast to Botswana, U.S. support for ART in Rwanda is predominantly downstream (4200 people served downstream vs. 100 upstream in FY04)
• In Kenya, the ratio is close to even (8000 downstream vs. 9100 upstream)
• Both categories of support are of equal value – key question is what is needed by national response

Slide 33
Cumulative number of patients started on ART,
Namibia, June 2003 - March 2005 

 
Dr. I. Katjitae, Chair, Technical Advisory Committee, ARV Therapy Propand Patient Care, Ministry of Health and Social Services

(Note:Total number of patients is based on reports from sites. Monthly ‘new starts’ based on reports from sites and modeling.)

The bar below chart shows increases in the number of patients started on ART from June 2003 to January 2004 (from zero to about 694), when PEPFAR was begun, and a steady increase from then until March 2005 (ending at 8,805), the end of the chart.

"Right here in our country, the money has already arrived and it's being put to use to assist our victims of this killer disease." President Hifikepunye Pohamba, Republic of Namibia

Slides 34 and 35
What we are doing to improve reporting
Refining While Implementing

• Goal: proactive, continuous improvement of data collection and results reporting
• Major challenges in all program areas – prevention is the most difficult of all

Slide 36
A Data Collection Challenge

• Because upstream support is provided to national programs, Emergency Plan largely depends on national authorities for information on results, including numbers of patients receiving ART
• Emergency Plan working to improve data standards and guidelines for reporting of upstream support

Slide 37
The Road Ahead
Strategic information refinement efforts:

• Revision of Indicators, Reporting Requirements, and Guidelines (July 2005)
• Country Operational Plan & Reporting System guidance
• Interagency Emergency Plan teams train country teams
• Country teams work with partners
• Independent assessment to develop Emergency Plan data quality standards and guidelines
• Further work on prevention and care, both especially challenging

Slide 38
ART Progress by Multi-Country Track 1.0 Partners (FY04)

The following table shows planned and actual expenditures and projected and actual numbers of patients on ART for year 1, broken down by country. Expenditures and actual number of patients on ART are as of March 31, 2005. Totals for each dollar amount and number of patients are given at the bottom of each respective column.

The last row in the table shows that planned spending accounted for 100% of the Total Budget Amount, that 87% of that amount had been expended as of March 31, 2005, and that 91% of the targeted number of patients on ART were on ART as of March 31, 2005.

TOTAL - ALL TRACK 1.0 PARTNERS

Country	Total Budget Amount	Projected number of Patients on ART - year 1 (Downstream)	Expenditures as of March 31, 2005	Number of patients on ART on March 31, 2005 (Downstream)
Botswana	$2,351,855	2,800	$2,351,855	3,026
CoteD'Ivoire	$6,549,367	1,879	$6,339,787	2,050
Guyana	$303,738	50	$303,738	52
Haiti	$1,189,097	900	$1,189,097	199
Kenya	$8,973,119	3,431	$7,014,427	5,908
Mozambique	$5,000,000	9,540	$1,707,515	1,005
Nigeria	$11,131,809	8,600	$11,131,809	6,365
Rwanda	$5,647,188	781	$5,765,482	2,981
SouthAfrica	$16,354,979	5,053	$14,631,768	4,466
Tanzania	$16,182,389	9,014	$12,104,535	2,943
Uganda	$2,898,884	2,700	$2,898,884	4,407
Zambia	$15,417,575	3,584	$15,039,203	10,692
TOTAL	$92,000,000	48,332	$80,478,100	44,094
	100% of Year 1 Budget Obligated		87% of Year 1 Budget Expended	91% of Year 1 target reached

Slide 39
The Road Ahead (continued)
Closer coordination with international partners (meeting in Geneva this week)
Investments (e.g. training) in partner capacity for monitoring and evaluation
Deepening partnership with host nations – As national responses and national ownership mature, majority of U.S. support could become more upstream

Slide 40
A Vision of Partnership
"This effort is succeeding because America is providing resources and
Africans are providing leadership. Local health officials set the strategy and we're
supporting them." President George W. Bush, June 28, 2005