HRSA’s role in ART started out as an emergency response targeting nations hardest hit by the HIV/AIDS epidemic. Nongovernmental organizations with an established presence in these countries helped get medications rapidly disseminated to areas in need. Low-cost antiretroviral therapies and other medications have been provided to millions of people across multiple continents and regions—in Africa the Caribbean, and Asia. Services include delivery of essential antiretroviral therapy for HIV infection; medications to prevent and treat common opportunistic infections such as tuberculosis; supportive care for orphans and vulnerable children; and other critical services. HRSA is the third largest of the U.S. government implementing agencies under which PEPFAR funds these activities.
Today, HRSA is helping host nations take ownership and control of their HIV/AIDS programs by building their capacity to deliver HIV/AIDS medications. HRSA is funding development of systems to deliver medications and more effectively manage laboratories and supplies. Care systems have been strengthened in many ways (e.g., quality improvement methods, various types of training, mentoring, and organizational and professional capacity development).
PEPFAR has funded the delivery of antiretroviral therapy (ART) to over two million individuals (as of 2009). As a central part of these international activities, HRSA has provided antiretroviral therapy to approximately one-fourth of this total. In the first phase of PEPFAR, HRSA delivered antiretroviral therapy to 300,000 people via 250 treatment sites, in most PEPFAR focus countries. Today, well over half a million receive ART under PEPFAR programs coordinated by HRSA at approximately 300 treatment sites in 11 countries.
HRSA also puts medicine to work by funding and supporting the delivery of services like clinical examinations, lab monitoring (clinical chemistry, CD4, and viral load), and pharmacy and drug adherence monitoring. HRSA is directly engaged in ART delivery programs in 11 countries. In Nigeria, for example, 60,000 people are receiving ART (including 9,000 at one hospital alone, the largest in the country if not all of West Africa) as a result of PEPFAR funding administered by HRSA.
HIV test kits and laboratory supplies for critical diagnostic tests and screenings have been provided to multiple facilities. HRSA-funded training and technical support has also helped develop and strengthen systems to assure that supply chains operate efficiently and that pharmaceuticals and supplies are regularly in stock.
HRSA’s Global Program has provided HIV/AIDS care for nearly one million persons. Care services are community-based and involve work with patients and families to build attitudes and skills that target relief of suffering and the best possible quality of life.
Care services take many forms. Examples include nursing care, prophylaxis to prevent opportunistic infections, and social and economic services that support family members—the primary care providers in African countries.
HRSA supports non-medical supportive care such as services for orphans and vulnerable children. HRSA also supports palliative care, which is designed to provide relief from the debilitating conditions that accompany severe disease, which with HIV/AIDS take such forms as pain, diarrhea, nausea, and weakness. Palliative care also involves providing mosquito nets and creating support groups for children and families to help break down anti-AIDS stigma that is so common in PEPFAR countries in Africa and elsewhere.
HRSA has supported updating and tailoring of guidelines on treatment and delivery of antiretrovirals and other services. For example, HRSA supported the development of a national antiretroviral case management model for use in Ethiopia, allowing for some health care clinical tasks to be shifted to case managers and community health workers. Case managers have helped improve adherence to antiretroviral regimens and re-engage people in care when they periodically drop out because of competing life challenges.
In Nigeria, Africa’s largest country and home to 10 percent of the world’s HIV/AIDS cases, HRSA delivers comprehensive ART treatment to adults and children in 66 health facilities located in the country’s eight states.
ART services in Plateau state are illustrative of how care and treatment accommodates local needs. Six satellite sites have been established and can be expanded as more ART services are put in place as these sites are linked to tertiary health facilities and the expertise they offer. HRSA administers over $60 million in PEPFAR funds in Nigeria.
PEPFAR delivers services and builds institutional capacity, with a goal to bring services closer to clients. Such decentralization can increase access to care and treatment and unclog larger health institutions that have served as central service locations. Hundreds of satellite sites have been established under variable structures—from outreach sites that are resupplied by central offices to sites that are primarily staffed by nurses who focus on refilling medications for stable patients.
One PEPFAR approach to delivery of ART is through a network of faith-based institutions. In many areas, faith-based institutions have existed for many years, providing a platform for building sustainable care programs. Activities include strengthening local technical expertise, building capacity of local agencies to deliver ART, developing locally appropriate models of care, and applying evidence-based practices to improve care and treatment. Among the results: