How to win the fight against HIV/AIDS
Since its inception in 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been the dominant development and humanitarian assistance program for the global HIV/AIDS response. Its goal then was to provide an emergency response to the global AIDS epidemic that was wiping out a generation of individuals and reversing important health and development gains in Africa. Its goal now is to ensure that the results realized over the past decade are protected and expanded.
Scientific advances and their successful implementation have brought the world to a tipping point in the fight against AIDS. By expanding coverage of core HIV prevention and treatment services while maintaining the quality of those services, we will continue to drive down new HIV infections and sustain the lives of those already infected. By making smart investments based on sound science and shared global responsibility, millions of lives can yet be saved and an AIDS-free generation achieved.
Protecting results also means sustained action over time, for which “country ownership” is vital – meaning the countries who are the at the front lines of the epidemic lead the response. Capitalizing on its mission-driven focus and strong disease-specific funding, PEPFAR is uniquely positioned to be an effective catalyst for country ownership by supporting local leaders as they work to treat existing infections and prevent new ones in their own countries.
Ten years ago, hospitals were completely overwhelmed by the massive volume of dying people. In the absence of antiretroviral treatment, very little could be done to save them. HIV affected the core of societies. It created millions of orphans, disproportionately affected women and girls, and threatened economic development. The founders of PEPFAR believed that with sharp focus, speed, and significant disease-specific funding, the instability in Southern Africa caused by HIV/AIDS could subside.
HIV treatment was clearly central to the emergency-response equation, although many argued that it was impossible to deliver complex HIV treatment regimes safely in countries with inadequate public health systems. PEPFAR was launched as a proof-of-concept global health effort to show that comprehensive HIV prevention, care, and treatment could be achieved in disease-burdened countries with limited healthcare delivery options. We established treatment sites, set up supply chains, supported testing and counseling, and began to prevent mother-to-child transmission of HIV. Along with many other activities, these steps have saved millions of lives in the 60-plus countries where PEPFAR works.
The foundations of a response are now in place, and the pace of the HIV epidemic has slowed. PEPFAR has evolved to a natural next phase of helping countries build long-term, sustainable HIV responses. Investments in public health systems have created improvements in clinic infrastructure, healthcare worker training and formal education, laboratory capacity and quality, supply-chain management, and health policies that allow for smart service delivery. These important investments have been prioritized for funding along with direct support for HIV prevention and treatment services.
From PEPFAR’s perspective, country ownership requires a fundamental transition from aid to coinvestment. This involves a purposeful shift from a PEPFAR-led and funded program to an integrated program led by the host country. It requires a smooth transfer of the program’s management, implementation, and ownership to the intended host-country recipient. The goal is to achieve a mutually beneficial technical partnership between PEPFAR and the partner country. It means relying more on host-country systems and organizations, emphasizing mutual accountability and transparency; improving coordination with other donors, nongovernmental organization, and the private sector; and making sure that PEPFAR investments are predictable and sustainable.
We conceptualize country ownership along four dimensions: political leadership, institutional and community ownership, technical capabilities, and mutual accountability, including finance. Country ownership is best advanced by progress along all four dimensions.
Strong political leadership allows sound, science-based health policies and strategic plans to be developed. Institutional and community ownership of an HIV response becomes the foundation for implementing HIV programs with significant impact. Technical capacity enables the delivery of effective, high-quality programs.
Finally, principles of mutual accountability and joint financing ensure that decisions are jointly owned, problems jointly solved, and successes jointly shared. If we advance in these four core areas, we can broaden the coverage of HIV prevention and treatment service, protect the quality of services, and sustain service delivery over time. Coverage without quality and coverage without durability will not lead to an AIDS-free generation. The combination of all three can.
Successful country ownership requires governments, communities, civil-society organizations, and businesses that can lead, prioritize, implement and be accountable for a country’s health response. Success can be achieved with the support of donors, including PEPFAR. Our global efforts to foster country-owned and country-led HIV responses demonstrate a fundamental shift in orientation toward achieving sustainable health outcomes by leveraging the country’s ability to achieve better health and security for its own people. PEPFAR will continue to foster country ownership by investing in high-impact, evidence-based programs led by our partner countries. We will also maintain technical cooperation with all countries involved in the fight against HIV/AIDS.
Ultimately, a well-coordinated, country-led health response enhances efficient use of resources and contributes to the long-term sustainability of global health programming. Scientific innovation, combined with improvements in the delivery of effective services, have put the promise of an AIDS-free generation within our collective grasp. PEPFAR remains firmly committed to helping make an AIDS-free generation a reality. Reaching this goal, however, is a shared responsibility, requiring the commitment and leadership of partner countries and reinforced with support from donors, civil society, foundations, the private sector, and people living with HIV.