PEPFAR—Progress on Water, Sanitation, and Hygiene (WASH) for People Living with HIV/AIDS Charles B. Holmes, M.D., MPH Chief Medical Officer, Office of the U.S. Global AIDS Coordinator AIDS Turning the Tide Together

Importance of Water, Sanitation, and Hygiene “We shall not finally defeat AIDS, tuberculosis, malaria, or any other infectious diseases that plague the developing world until we have won the battle for safe drinking water, sanitation and basic health care.” - Kofi Annan, former UN Secretary-General

Why WASH Matters for PLHIV Diarrhea is a leading cause of morbidity and mortality in people living with HIV (PLHIV) in the developing world Diarrhea rates among PLHIV in Africa are 2-6 times higher than those in the general population Diarrhea may reduce absorption of nutrients and medications In PLHIV, diarrheal episodes can lead to increased viral load, decreased CD4 counts, and worse clinical outcomes

Critical WASH Behaviors

Integrating WASH into PEPFAR Programs Within PEPFAR programs, there are multiple approaches to providing WASH services: – WASH commodities and services often included in the Basic Preventive Care Package provided to PLHIV, including adults, children and pregnant women – WASH services integrated within nutrition programming – WASH services provided through home-based and community care – WASH programming for orphans and vulnerable children (OVC) – Implementation of WASH in clinical facilities – Public-private partnerships to increase access to safe water – Wrap-around programming – leveraging partner resources

PEPFAR Guidance on WASH—Key Elements “PEPFAR programs are encouraged to ensure PLHIV have access to safe drinking water in facility-based care settings and to support PLHIV with home-based drinking water treatment methods and safe storage in communities without a reliable source of safe water. “PEPFAR programs should support improvements in hygiene and sanitation, which are essential to reduce the infectious disease burden experienced by PLHIV…. Hand washing at critical times, with soap and with proper hand washing technique, is the most important hygiene measure to be integrated across all care and support programs. - Care and Treatment Section, 2012 Technical Considerations

PEPFAR Guidance on WASH—Key Elements “Counseling on safe food preparation and storage, point-of-use water purification treatment and other hygiene and sanitation practices are an integral component of nutrition assessment and counseling and support (NACS) within care and treatment services” - Food and Nutrition Section, 2012 Technical Considerations “Programs are also encouraged to consider adopting integrated strategies for preventing MTCT …integrating or linking to..safe water and hygiene, and food supplementation/food by prescription programs. - PMTCT Section, 2012 Technical Considerations

PEPFAR Basic Preventive Care Package Basic preventive care package (BCP): package of commodities and services offered to PLHIV to reduce HIV-related morbidity and mortality – Package is country-specific, and components may differ – BCP may include cotrimoxazole prophylaxis, insecticide-treated bed nets, safe water interventions, TB interventions, condoms, and other associated services PEPFAR funds can support the following as part of a BCP: – home-based safe drinking water interventions for PLHIV – soap and promotion/training on hand washing – latrine promotion; consider construction with “wrap-around,” non-PEPFAR funding

Providing WASH Services through Basic Preventive Care Package in Uganda Uganda initiated BCP program in 2005 BCP includes safe water intervention (safe water vessel, WaterGuard, and cloth filter) Specific programs children and pregnant women and others

Integrating WASH with Nutrition Programs PEPFAR guidance highlights integration of WASH into nutrition assessment, counseling and support (NACS): Counseling on safe food preparation and storage Counseling on household water treatment and storage Counseling on use of treated water to prepare complementary foods and formula for infants following weaning

Incorporation of WASH Into Guidelines, Development of National Training Manuals and Job Aids (Facility- and Community-based Providers) National nutrition and HIV guidelines Training manualsJob aids Cote d’Ivoire√√√ Ethiopia√√√ Ghana√ Haiti√√ Kenya√√√ Mozambique√√√ Namibia√√√ Tanzania√√√ Vietnam√ Zambia√√√

WASH Integration in Nutrition Programs: FANTA-2 Project – NACS Job Aids

Addressing WASH in Home-Based Care: Hygiene Improvement Project PEPFAR-funded Hygiene Improvement Project (through USAID) worked to integrate WASH into home-based care (HBC) in Ethiopia and Uganda Conducted participatory research with PLHIV to identify best practices for WASH in HBC – what can actually be implemented Identified feasible, “small doable actions” - may not be ideal behavior, but a feasible and effective alternative Developed HBC kit with programming guidance, curricula, tools and training materials Implementation in Ethiopia and Uganda – Developed community of practice, to share information, resources and approaches

Addressing WASH in Facility-Based Care PEPFAR-funded Aidstar-one Project developed a training curriculum on integration of WASH into facility-based care for clinic personnel Objective: build capacity of health providers to counsel patients on WASH practices, create a WASH-friendly facility with access to safe drinking water for staff and patients, a hygienic latrine, and water for handwashing. Field tested in Ethiopia and Kenya in collaboration with government Guidelines and training package will be institutionalized by both governments and disseminated to other countries

Community WASH Interventions: Safe Water and AIDS Project (SWAP) in Kenya SWAP – PEPFAR-supported NGO in western Kenya; since 2005, SWAP has supported safe water and HIV programming, using social marketing approach; also promotes socio-economic empowerment of PLHIV and others in community SWAP now has a network of over 871 HIV support and self- help groups, comprising over 6,000 active vendors Groups promote and sell water treatment and other health products as income-generating activity (microfinance and business training) that also increases access to safe water and supports disease prevention

Extent of PEPFAR WASH Programming In 2010 – 20 of 30 PEPFAR Country Operational Plans (COPs) reviewed included WASH programming Uganda 2010 COP – At least 14 partners included WASH programming; WASH included in national basic preventive care package Nigeria 2010 COP – At least 16 partners included WASH programming; WASH included in adult and pediatric BCP Kenya – At least 14 partners included WASH programming in 2010 COP. Of note, USG staff participated in a review of Kenya’s national HIV policies, recommending specific WASH activities, resulting in modifications to policies on sanitation and food and nutrition, among others

Future Directions Improved M&E and support for implementation science (e.g., examining impact and efficiency of scale- up strategies, methods of stimulating uptake and sustained WASH adherence, etc) Strengthened collaboration with host countries to scale-up regional and national programs to gain greater impact. Greater multi-sectoral programming for sustainable clean water solutions, including key actors such as MCC Enhanced engagement with private sector partners, including occupational health programs and technology/commodity manufacturers

Acknowledgements Carol Langley – OGAC Merri Weinger – USAID Rob Quick – CDC Tim Quick – USAID Barb Marston – CDC

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