The Global AIDS Program: Philosophy  
 

Introduction | Background | Global Response | U.S. Response | CDC Response | CDC Contribution | Program Goals | CDC Approach | Program Management

Strategy for Intensifying Action Against AIDS

Introduction

In FY 2000 the U.S. Government  joined the International Partnership Against HIV/AIDS in Africa (IPAA) and other international partners in Asia and South America to expand and intensify response to the growing AIDS pandemic and its serious impact. In fiscal year 2000, the U.S. government launched the Leadership and Investment in Fighting an Epidemic (LIFE) initiative with a $100 million dollar increase in U.S. support to 14 countries in Africa and India. Congress approved the 2001 Labor/Health and Human Services Appropriations bill as part of a larger spending bill that included $104.5 million for global HIV/AIDS programs.  In 2002, the total to CDC was $143.7 million for global HIV/AIDS programs.  CDC is working closely with USAID, the Department of Defense, HRSA, NGOs and other international institutions to halt the spread of the epidemic.  Within the total for international activities, $3 million was provided through CDC to support HRSA activities aimed at improving professional education and training.  In addition, CDC works with the International AIDS Vaccine Initiative.

The agreement includes $10,000,000 for the Global HIV-AIDS Workplace Initiative.

This overview outlines CDC's strategy for collaborating with USAID, other USG agencies and the many international partners to strategically address the critical needs of the countries, based on CDC's strong core of expertise and experience. This overarching strategy is only one component of a master plan that is supported by a set of CDC technical strategies and country plans that reflect joint planning at the national level.

Background

Epidemic Growth

Globally more than 16 million people have died of AIDS and more than 16,000 people become newly infected each day¹. The epidemic continues to spread at ferocious speed in many parts of the world and we are only beginning to feel the true impact it will have on the people, communities and nations affected. Developing countries are hardest hit, particularly those in Sub-Saharan Africa where AIDS has surpassed malaria as the number one killer. Although the epidemic is at an earlier stage in Asia, it is growing rapidly in some countries and the sheer number of vulnerable people is cause for alarm.

The region of the world most affected has been Sub-Saharan Africa, where over 23 million adults and children are currently living with HIV/AIDS and more than 13 million have died, accounting for more than 80 percent of the world's deaths due to AIDS. In Africa alone, 10,000 people become infected each day, according to UNAIDS¹

In Southeast Asia, India faces the devastation that Africa has already seen. Although the HIV prevalence rate in India is relatively low, with 0.82 percent of the adults infected, more than 4 million adults were estimated to be living with AIDS at the end of 1997 and more than 350,000 have died since the epidemic first hit India². With a total population of almost one billion, the potential impact is overwhelming.

Impact of the Epidemic

HIV/AIDS has not only become the most important public health problem of the decade but is undermining vital economic and social development as it cuts deep into all sectors of society. The response to this epidemic is ravaging scarce resources and placing huge demands on already frail infrastructures, making it difficult for governments to deal with the problem alone.

Because HIV/AIDS strikes young people in their most productive years, it seriously impacts families as well as overall productivity. It results in decreased earnings, increased expenditures on health, and results in a growing number of orphans, widows and widowers who become increasingly dependent on society.

Vulnerable populations globally include women and children. GAP addresses prevention of transmission through creative, innovative and culturally sensitive strategies.

As the epidemic progresses and more people become ill with AIDS-related illnesses, the impact on health care systems and social safety nets increases dramatically. Many of the poorest countries already struggling with health care reforms are finding it impossible to cope with AIDS. Not only are drugs and supplies scarce, but doctors and nurses are dying, depleting the pool of skilled health care workers that are needed to help cope with this epidemic.

Child survival rates are declining and life expectancy is dropping in some countries to levels not seen since the 1960s, reversing decades of development. AIDS has become one of the greatest threats to social and economic development in the hard-hit countries.

Countries and their development partners have been responding to this epidemic since the early 1980s, but the response has simply not been enough in most countries to slow the spread of the epidemic and avoid the serious impact it brings. Countries need more data not only to track the trends in the epidemic but also to help raise the awareness of leaders, make informed decisions and identify effective programs. They need to expand the scale of many effective pilot type prevention and care projects to reach all those in need throughout the country and identify new models for caring as more and more people fall ill. Governments are facing many competing challenges, suffering from insufficient funding and inadequate capacity and simply cannot mount the level of response needed without outside assistance.

Global Response

The crisis is very real, but there is room for hope and there are examples of success to build upon. Despite the high prevalence rates in many countries there are still more than 200 million adults in Africa and 900 million in India who are not yet infected. Expanding prevention programs will not only protect these people from infection and disease but will greatly reduce the future impact on those societies. Those who are already infected can greatly benefit from improved medical care and social support. Developing new models of care and support and expanding the scale will help those infected and affected to cope with the disease and its impact. A combined and intensified response now can have a huge impact on the future course of the epidemic and the impact on future development in these countries, but urgent action is needed to ensure that the level of response to the AIDS epidemic catches up with the growth of the epidemic itself. UNAIDS reports that the current resources to combat this epidemic are grossly inadequate and AIDS is spreading three times faster than is the funding to control it is allocated.

Recognizing this need for urgent and intensified action, UNAIDS and its development partners created an International Partnership against AIDS in Africa (IPAA) to fight the HIV/AIDS epidemic through stronger national programs backed by four main lines of action:

• Encouraging visible and sustained political support
• Helping to develop nationally-negotiated joint plans of action
• Increasing financial resources
• Strengthening national and regional technical capacity

This partnership has invited nations and development partners to join together to initiate and ensure effective support for the countries hardest hit by the epidemic. It envisions that within the next decade African nations will be implementing larger-scale, sustained and more effective national responses to HIV/AIDS.

The U.S. Response

The U.S. government has now joined this international partnership and strengthened its support for the fight against HIV/AIDS in Africa as well as India. The U.S. government has consistently been a major donor in the global fight against HIV/AIDS and has collaborated with countries throughout the world since the beginning of the epidemic to provide funding and technical assistance, support programs, increase understanding of HIV and to evaluate interventions that can be effective. In July 1999, the US federal government announced a new emergency initiative to address the global AIDS pandemic - the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative. This initiative was supported by a $100 million increase in U.S. funding in FY2000 and an additional $104 million in FY2001 in direct support of this international urgent call to action. The LIFE initiative contained a framework of interventions to prevent further spread of HIV and to care for those affected and is contributing to the goals articulated by UNAIDS for the International Partnership Against AIDS in Africa.

The LIFE initiative addressed four key program elements critical to fighting the HIV/AIDS pandemic: primary prevention, improving community and home-based care and treatment, caring for children affected by AIDS and capacity and infrastructure development. These elements are coordinated and integrated within an overall comprehensive response in each country in response to the needs of the country. USAID missions have the lead responsibility for facilitating inter-agency communication and ensuring a unified U.S. response to host nations, as well as for caring for children affected by HIV/AIDS.

The U.S. agencies participating in the LIFE initiative apply the following principles to the design and implementation of programs:

• Country ownership of the activities is essential.
• Initiative funding must complement existing programs and activities of the agencies as well as work within the context of national HIV/AIDS strategic plans.
• Leverage of, and coordination with, other donors and organizations is critical.
• The number of collaborating U.S. government agencies and other partners in the fight against AIDS must be increased.
• Support for indigenous expertise and institutions in implementing program elements must be emphasized.
• Information sharing must be two-way so as to enhance opportunities to learn about new models.

CDC Response

The CDC Global AIDS Program

CDC is has been an active partner and played a key role in the LIFE initiative. Based on CDC's organizational strengths and skilled resources described in the section below, CDC has initiated the CDC Global AIDS Program (GAP) to implement the following LIFE program elements:

• Primary Prevention - through programs focusing on prevention of sexual transmission through voluntary counseling and testing (VCT), sexually transmitted infection (STI) management, behavioral interventions with youth and other vulnerable groups, national mobilization campaigns and public-private partnerships. It also focuses on reduction of mother to child transmission (MTCT) and reduction of HIV transmission through blood. The primary focus of these interventions is on behavior change to reduce the risks of sexual transmission and to reduce stigma associated with HIV infection.
• Surveillance and Infrastructure Development - through programs focusing on HIV/STI/TB surveillance, laboratory support, monitoring and evaluation, training and information management.
• Care, Support and Treatment  - through programs focusing on tuberculosis (TB) prevention and care, prevention and care of other opportunistic infection, palliative care for AIDS cases and the use of antiretroviral treatments. These interventions, in partnership with HRSA, focus on mitigating the impact of HIV and reducing the associated stigma.

International collaboration

As a leading public health institution, the U.S. Centers for Disease Control and Prevention plays a vital role in preventing and controlling epidemics in the U.S. as well as across the globe. CDC has been a valued international partner with organizations such as WHO, USAID, HRSA, PAHO, UNICEF, the World Bank and UNAIDS in important global public health initiatives including poliomyelitis eradication, child survival, reproductive health, malaria control, tuberculosis programs, emerging infectious diseases and HIV/AIDS. With seconded staff in many of these organizations, CDC not only has close working relationships with these organizations, but a wide and strong network on which to build. Over the years CDC has worked in more than 145 countries throughout the world providing technical assistance, training and conducting research.

CDC's Contribution - Experience, Skills, Resources

CDC has a long history and extensive network of international collaboration for disease prevention and control, experience working in partnership with USAID on critical health initiatives, considerable skill and experience in addressing HIV/AIDS and related infections both domestically and internationally as well as valuable domestic experience that may benefit other countries.

USAID Partnership

CDC has worked in partnership with USAID in programs such as Combating Childhood Communicable Diseases (CCCD) and the Technical Advisors in AIDS and Child Survival (TAACS). These programs both involved a significant combined US presence to support national programs in developing countries and expanded CDC's international experience and networks.

HRSA Partnership

The Health Resources and Services Administration (HRSA) HIV/AIDS Bureau conducts programs in the U.S. domestically that provide primary care and support services to low-income, uninsured and underinsured individuals and families affected by HIV/AIDS, specifically:

• Models of HIV care for the hardest to reach through the Special Project of National Significance Program (SPNS)
• AIDS Educational and Training Centers (AETC)
• Pharmaceutical treatments through an AIDS Drug Assistance Program (ADAP)
• Home and community-based health care and support services
• Comprehensive, community-based and family-centered services to children, youth and women living with HIV and their families.

International HIV/AIDS

Since the beginning of the HIV/AIDS epidemic, CDC has collaborated with international organizations and countries within Africa and Asia to increase understanding of the HIV epidemic and to evaluate intervention methodologies in host countries as well as the U.S. Through its resident programs, CDC has worked closely with governments to increase the training capacity within partner countries and has expanded access to training within the regions. In addition to short-term assistance and research in many countries, CDC currently has resident staff working on HIV/AIDS in 25 countries in Africa, Asia, Latin America and the Caribbean. Some of these staff are based in established field stations where CDC and host country scientists collaborate on research and program activities, whereas in others, CDC staff are assigned to host country agencies to serve as long-term technical advisors to national HIV/AIDS programs. These staff are well placed to immediately begin working with their host countries to determine the needs of the country and rapidly implement activities. Their established presence not only facilitates rapid design and implementation of the programs but also serves as a model for activities in other countries.

Lessons and experience to share

CDC has led the U.S. response to the HIV/AIDS epidemic since 1981, learning along the way what works and does not work. Much of what has been learned may be useful to other governments as they expand and intensify their response to the epidemic. CDC's experience in engaging communities and the private sector in responding to the epidemic and in building the capacity throughout the U.S. may help other countries with these same issues.

• CDC has demonstrated how a federal government agency can successfully engage a wide spectrum of community including faith leaders, educators, NGOs, and people living with HIV and AIDS in its national response through the community planning process, direct funding of community organizations, dialogue at multiple levels, and intensive consultation with technical specialists and communities.
• Because the U.S. response to HIV/AIDS is highly decentralized, important lessons have been learned in building the capacity to respond at the community level. CDC has built upon this experience and developed the Linkages program in collaboration with USAID to link U.S.-based community-based organizations with those in developing countries to respond to their communities' needs.
• CDC has been a leader in engaging the private sector in the fight against AIDS through its flagship programs "Business Responds to AIDS" and "Labor Responds to AIDS." CDC has already begun to enlist the help of large multinational firms to expand their response beyond the U.S. and join the international response.

Skilled resources

CDC has developed a dedicated team of experienced and skilled staff from across the organization to implement the initiative. This team comprises epidemiologists, public health advisors, behavioral scientists, laboratory specialists, training experts, evaluation specialists, clinicians, and information managers. These staff bring their expertise and experience in HIV/AIDS, sexually transmitted infections (STIs), tuberculosis, and other related opportunistic infections as well as relevant experience with broader issues such as disease surveillance systems, laboratory quality assessment, monitoring and evaluation, information management and logistical support of international programs.

Program Goals

The IPAA has created a series of international goals to achieve over the next five years(to 2005). These goals represent the result of total worldwide contribution of resources and efforts. CDC's Global AIDS Program will contribute toward achieving these goals:

• The incidence of HIV infection will be reduced by 25 percent among 15-24 year olds by 2005. (Currently, 2 million young adults are infected each year in sub-Saharan Africa)
• At least 75 percent of HIV-infected persons will have access to basic care and support services at the home and community levels, including drugs for common opportunistic infections. (Currently, less than 1 percent of HIV-infected persons has such access.)
• By 2002, domestic and external resources available for HIV/AIDS efforts in Africa will have doubled to $300 million per year.
• By 2005, 50 percent of HIV-infected pregnant women will have access to interventions to reduce mother-to-child HIV transmission. (Currently, less than 1 percent of HIV infected pregnant women have access to such services in sub-Saharan Africa.

CDC's overall objectives:

• Reduce HIV transmission through primary prevention of sexual, mother-to child, and blood transmission.
• Improve community- and home-based care and treatment of HIV/STI and opportunistic infections.
• Strengthen the capacity of countries to collect and use surveillance data and to manage national HIV/AIDS programs.

CDC Approach

Principles

CDC has adopted the following as guiding principles for implementing the LIFE initiative through GAP:

1. Teamwork and respect. Numerous players are involved besides CDC, many with a longer track record than CDC. Most prominently, these are African governments and communities, but also USAID, HRSA, UNAIDS, WHO, other UN agencies, and other multilateral and bilateral agencies and non-governmental organizations. GAP will consistently collaborate with all other contributors under the umbrella of the National AIDS Strategic Plan in each country. An especially seamless teamwork relationship exists with USAID and HRSA, fortified by strategies in the U.S. and in each country where CDC GAP is implemented.
2. Adaptation to country need. Apart from these principles and the concepts of good public health practice, no strict constraints are planned on the nature of GAP's engagement. In some countries or program areas with good human resources and infrastructure, a technical assistance role alone is optimal. In others, in accordance with NACP intent, a GAP project plays an implementing role at a national level or in a restricted geographic area. Diversity in programmatic implementation is expected, because countries' needs vary so greatly.
3. Focus on prevention impact. GAP is primarily a program, and not a research, initiative. The overriding goal is demonstrable, broad-scale impact from activities that are part of National AIDS Control Programs. However, programs should be designed based on best scientific evidence and should be carefully monitored and evaluated. In addition, GAP resources may support carefully selected and justified operational research that is necessary and sufficient to support broader prevention program implementation and to evaluate models of prevention and care.
4. Strengthening human and institutional capacity for the long-term. We want to contribute actively to building human and institutional capacity within governments, national institutions such as universities, regional institutions such as WHO/AFRO, and multilateral institutions through GAP. A major part of this is helping to build national ownership and human resources.
5. Sustainability. CDC strives to assist countries to sustain their AIDS prevention and care efforts through strengthening the human and institutional capacity to bring the epidemic response to a national scale; however, due to the urgency of the AIDS crisis, GAP also responds to the urgent short-term needs of the countries, whether meeting these needs is sustainable or not. CDC employs and procures local resources where available but does not hesitate to seek and provide external assistance when needed.
6. Innovation and mobilization. GAP presents a special opportunity to assist partner countries in their war against AIDS while helping mobilize diverse communities in the U.S. to appreciate the magnitude of the epidemic in those countries. Broad-ranging opportunities to mobilize new partners, sponsors and relationships in U.S.-African cooperation against AIDS are being pursued.
7. Efficiency and catalytic role. GAP core staff are kept to a minimum, but must suffice to lead and manage core program areas and to provide for cross-cutting accountability for GAP and other resources. Program design and technical assistance are undertaken principally by staff from the relevant divisions, not by GAP core staff.

Geographic Focus

This initiative focuses on 25 target countries with additional regional activities in Africa. The countries were selected based on the magnitude of the epidemic, history of commitment to fighting the epidemic, anticipated receptivity to U.S. assistance and presence of existing U.S. implementation mechanisms---in 2002 they are Angola, Botswana, Brazil, Cambodia, China, Côte d'Ivoire, Democratic Republic of Congo, Ethiopia, Guyana, Haiti, India, Kenya, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Senegal, South Africa, Tanzania, Thailand, Uganda, Vietnam, Zambia and Zimbabwe.

Based on the need to initiate activities rapidly, CDC began by building upon its existing programs in Botswana, Cote d'Ivoire, Kenya, South Africa, Uganda, Malawi and India. Concurrently, CDC began working with USAID to initiate collaborative planning with the remaining countries.

Program Design and Planning

In addition to the overarching strategy described in this document, CDC has developed a set of CDC technical strategies that will be used to design programs of assistance with each of the LIFE countries. The technical strategies identify existing 'best practices," provide an inventory of resources and build upon these and CDC's core competencies to develop a strategic approach that can be refined over time in each country to develop a customized program of support and collaboration.

CDC works with each of the participating countries to design a program of assistance based on:

• The specific needs identified by the country
• The contribution of other partners
• GAP technical strategies

Each country plan is customized to help the country bring its HIV/AIDS programs to sufficient scale to slow the spread of the epidemic and mitigate its impact. CDC's goal is to maximize program impact by focusing on helping countries implement large-scale, national level programs, where feasible, rather than multiple small-scale or pilot type activities. Each country plan identifies one to three technical areas as "major program areas." These are the programmatic domains in which resources and attention are concentrated, and are supported by technical assistance, operations research or pilot projects in additional technical areas.

CDC develops country plans based on the following process:

1. Understand the national HIV/AIDS situation based on existing plans and assessments.
2. Consider the country's need in context of the CDC GAP strategy and the CDC technical strategy.
3. Meet with key partners in country to determine provisional major program areas and other technical assistance needs.
4. Seek consensus within GAP on major program areas and funding levels.
5. Finalize country program design with country partners.
6. Develop country implementation plans and sign agreements.
7. Deploy CDC resident advisor and staff.
8. Implement and monitor program.

Due to the urgency of the situation, the need for rapid response and the opportunity to build upon multiple assessment visits by other partners, many of these steps are concurrent, and  build upon work that has already been done and upon the existing mechanisms and relationships in the country. CDC intends to be highly flexible, operating in a "learn on the run" mode and willing to abandon planned but unproductive activities while reprogramming resources constantly to pursue projects and approaches in country that appear to be yielding the greatest impact.

Program Management

Model for CDC program management and assistance

Most of the GAP countries are not only struggling with a serious epidemic but also need support to build their public health infrastructure and technical capacity for generating and using surveillance data and for delivering prevention and care services. Many of these countries simply cannot absorb the influx of resources that will result from the increased focus of the IPAA. To prevent bottlenecks and to ensure a long-term impact from this initiative, CDC places resident advisors in most countries and helps build human capacity and effective technical systems.

CDC resident advisors work closely with their national counterparts to design and implement a program and build the indigenous technical and managerial capacity to carry out activities independently in the future. The CDC resident advisor serves as the responsible agent of the CDC Global AIDS Program and chief steward of CDC resources in the country.

CDC resources are used to hire local staff, fund the government or local NGOs to hire staff and/or otherwise support local staff to implement the CDC country program. Support through diverse mechanisms according to county needs, preferences and opportunities are focused on strengthening in-country institutions and technical capacity to implement effective public health activities as well as directly funding programs through governments or NGOs.

Generally, CDC focuses its efforts and resources on program implementation, technical assistance, capacity-building and strengthening institutions. In most cases, CDC seeks partnerships for purchasing such commodities as drugs, test kits and condoms. However, CDC, if needed, directly procures certain diagnostic reagents and drugs. In these cases, CDC seeks partnerships for purchasing these commodities and works to build the systems within the country to sustain these efforts.

Monitoring and Evaluation

Monitoring and evaluation are key components to the CDC GAP program to track what is being done and whether the program is making a difference. Monitoring and evaluation systems allow program managers to calculate how to allocate resources to achieve the best overall result.

Monitoring and evaluation of the CDC GAP program occurs at three levels:

• The global GAP program
• The GAP program at the national level
• Specific program areas or activities

Various methodologies are used to collect program-based data to monitor input, process and output whereas population-based biological and behavioral data are used to monitor the intermediate effect or outcome.

Introduction | Background | Global Response | U.S. Response | CDC Response | CDC Contribution | Program Goals | CDC Approach | Program Management