Africa’s path to an AIDS-free future: Sustaining gains through PEPFAR

The U.S. President's Emergency Plan for AIDS Relief, or PEPFAR, aims to end HIV as a public health threat by 2030. As countries achieve that through epidemic control, PEPFAR’s support shifts from direct service delivery to helping host governments sustain and progressively finance their HIV response. In Mozambique, this transition is underway through PEPFAR’s second-largest bilateral HIV program, which the government now oversees.

Denise Namburete is founder and executive director of N’weti Health Communication — a community-based health and HIV/AIDS service provision organization in Mozambique and a key partner on the project. She is concerned that the gains made will be reversed as countries are ill-equipped to maintain established prevention, care, and treatment while simultaneously meeting transition criteria.

PEPFAR was created under former United States President George W. Bush in 2003 to address the global AIDS epidemic. At the time, 2.6 million people were newly infected, and 3 million people were dying of the disease, the majority in sub-Saharan Africa. PEPFAR was a commitment by the U.S. to fund HIV/AIDS prevention, care, and treatment programs in the global south and has largely been seen as a success. Since its inception, $120 billion has been channeled into efforts that are estimated to have prevented 25 million deaths and ended the epidemic in several of the 50 countries it has supported.

The best chance countries have of maintaining the gains made so far, said Namburete, is in integrating HIV programming into primary health care, but this takes time and she is concerned about unrealistic transition timetables.

“The U.S. government will need to continue supporting HIV/AIDS programming for some time to allow local governments to build, to mobilize enough resources, and to continue funding HIV/AIDS programming in countries,” she said. As it stands, PEPFAR provides an annual $400 million to Mozambique, one of the worst affected countries by HIV.

Sitting down with Devex, Namburete explained what integration of HIV services into primary health care systems looks like, why it isn’t already integrated, and what it will take to make that a reality in order to preserve global progress on HIV/AIDS, with AIDS-related deaths down almost 70% since the 2004 peak.

This conversation has been edited for length and clarity.

What key features are in integrated health service delivery that would be missing in stand-alone HIV service delivery?

PEPFAR has been operating as a parallel, as a vertical program, for many years and it has created silos of excellence in HIV/AIDS programming. Those silos of excellence need to be transferred to the local authorities and governments so that they strengthen the national health systems to be able to provide essential services and sustain the gains that PEPFAR had over the years.

The HIV/AIDS stand-alone programming is well-resourced. … That means the monitoring and evaluation component is very strong; the information strategic system is strong; the service delivery is well-designed and implemented; capacity building happens frequently; and the ability to conduct procurement on commodities is very strong. These are all features that have been developed as a standalone program over the years, which are not present in the essential services delivered by the national health system.

There's a lot of stockout of medicines for essential services; essential care capacity building is not done regularly; there are not enough resources; it's not well funded; the monitoring and evaluation is very weak; and the information systems component is also very weak, so procurement has its challenges.

We need to transition the vertical PEPFAR-supported program and integrate it into the country-led essential services, so that we have only one primary health care program with HIV/AIDS integrated into it.

How important is it for integration strategies to be led by local authorities as opposed to central or international bodies?

It is essential because it means strengthening the national health systems. … So far it has not been led by local authorities, although local authorities have experience of leading HIV/AIDS programming through Global Fund programming. With the exception of the commodities component … all the other components of programming have been led by the local authorities, which means that to some extent local authorities are in position to lead HIV/AIDS programming if only they are given enough time to grow their capacity to lead HIV programming; special capacity around procurement; around information systems; and around human resources. All these components need to be strengthened to improve local authorities’ capacity to manage HIV/AIDS programming.

For the next five years, which is the final leg of the transition from PEPFAR-led programs to local authorities, I think we need to focus on strengthening and overseeing local authorities’ management of HIV/AIDS programming so that beyond 2030, local authorities are able to lead with quality, allowing access, and paying attention to equity.

Aside from more time, what other kinds of key considerations need to be made to ensure that HIV services can be integrated in primary care?

The continuation of funding for outside the health system is needed so that demand is generated for people living with HIV/AIDS to access the services. The integrated services prevention work has been discontinued for many, many years and we are seeing that funding for prevention needs to be reinstated in countries.

We need to also strengthen the capacity of the government around procurement, human resources, and their technical capacity to provide services, essential services, and commodities. … Basically, information systems need to be strengthened at the government level and at the local authorities’ level, so that we can sustain the gains from PEPFAR.

How would you characterize Mozambique's readiness in terms of its ability to successfully integrate HIV services into broader health systems?

We need more time for the transition. There are components that the government has established with capacity to manage with quality, for example, the provision of services … I think that the government is able to provide services as long as there is oversight, but we need more time to address weaknesses.

There's a lot of procurement that happens in HIV/AIDS programming and we need to make sure that resources are applied in the best way possible. Because the Mozambique health system is very prone to corruption and rent-seeking, we need to establish very strong oversight systems to oversee their procurement for HIV/AIDS programming.

Another weakness is around monitoring and evaluation, basically information systems, so we need also to continue providing oversight for this component. … Capacity building is a continuous need in HIV programming if we decide to integrate essential services into primary health care.

Another important component is funding. As PEPFAR reduces and moves out from countries, we need to mobilize domestic resources to fund HIV/AIDS programming. That means replacing up to $400 million that PEPFAR invests on an annual basis in Mozambique. HIV/AIDS programming becomes a big burden on the state budget if we talk about integration into primary health care, so efforts to increase resource mobilization to fund HIV/AIDS integration is at the center of the challenges that we have at the moment. Basically, it comes down to the very same issue: We need more time.

Learn more about sustaining HIV progress while leveraging integrated health systems here.