PEPFAR Guidance Blueprint: Creating an AIDS Free Generation Supplement to presentation by Ambassador Deborah Birx for ClASS Consultants November, 2014

Session Topics Main foundational points from PEPFAR Durban Meeting (outlined in Townhall Forum with Ambassador Birx presentation ClASS website) PEPFAR Quality Strategy (PQS) Monitoring, Evaluation and Reporting (MER) guidance Site Improvement through Monitoring System (SIMS) Expenditure Analysis (EA) Care and Treatment Earmark guidance Integrated PEPFAR Site List (iPSL) Data for Accountability, Transparency and Impact (DATIM) Durban conference for USG personnel; Town Hall Forum discusses similar themes.

PEPFAR Durban Meeting “Delivering Sustainable Results with Accountability, Transparency, and Impact” Five Key Agendas supporting the Blueprint Impact Efficiency Sustainability Partnership: Working Together towards an AIDS-Free Generation Human Rights: Securing, Protecting, & Promoting Human Rights Each agenda item has metrics for success as well as timelines/deliverables.

PEPFAR Durban Meeting – 3 Guiding Pillars Accountability Demonstrate cost-effective programming that maximizes the impact of every dollar invested Transparency Demonstrate increased transparency with validation and sharing of all levels of program data Impact Demonstrate sustained control of the epidemic – save lives and avert new infections

Blueprint: Creating an AIDS Free Generation Four Road Maps supporting the Blueprint Saving Lives: Impact Smart Investments: Efficiency Shared Responsibility: Sustainability Driving Results with Science

Road Map for Saving Lives: Impact Work toward the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Increase coverage of HIV treatment both to reduce AIDS-related mortality and to enhance HIV prevention. Increase the number of males who are circumcised for HIV prevention. Increase access to, and uptake of, HIV testing and counseling, condoms and other evidence-based, appropriately-targeted prevention interventions.

Road Map for Smart Investments: Efficiency Target HIV-associated tuberculosis (TB) and reduce co-morbidity and mortality. Increase access to, and uptake of, HIV services by key populations. Partner with people living with HIV to design, manage and implement HIV programs to ensure that they are responsive to, and respectful of, their needs. Strengthen PEPFAR’s continued focus on women, girls and gender equality. Reach orphans and vulnerable children (OVC) affected by AIDS, and support programs that help them develop to their full potential. Strengthen programmatic commitment to and emphasis on reaching and supporting young people with HIV services. Strengthen PEPFAR supply chains and business processes to increase the efficiency of our investments. Increase efficiencies through innovation and greater integration of services with other U.S., bilateral and multilateral global health investments

Road Map for Shared Responsibilities: Sustainability Partner with countries in a joint move toward country-led, managed, and implemented responses. Increase support for civil society as a partner in the global AIDS response. Expand collaboration with multilateral and bilateral partners. Increase private sector mobilization toward an AIDS-free generation.

Road Map for Driving Results with Science Leverage greatest impact by continuing to invest in implementation science. Support implementation research. Evaluate the efficacy of optimized combination prevention. Support innovative research to develop new technologies for prevention (e.g., microbicides, vaccines) and care e.g., new treatments or treatment regimens). Develop evidence-based approaches to reaching people early enough in their disease progression to help maintain a strong immune system, stave off opportunistic infections, particularly TB, and reduce new HIV infections. Support the deployment of suitable technology for measurement of viral load, both through tiered laboratory networks and ‘point-of-care’ tests as they become available. Assist countries in adopting breakthrough new technologies with proven impact, such as new, molecular-based TB tests that have dramatically reduced diagnosis and treatment time for people living with TB and HIV.

New Directions Restructuring of State/Office of Global AIDS Coordinator A substantially revised COP More USG oversight in the field Secretary Kerry: Call for Interagency Collaborative for Program Improvement “…share data and share best practices in order to deliver better quality services at a better cost.” “Triangulate impact, expenditure, and quality analyses to significantly increase the impact per dollar of PEPFAR programs”

Interagency Collaborative for Program Improvement Goal: Support PEPFAR teams to conduct site & above site level monitoring and real-time reporting, aggregation and analysis Use the data to improve quality Triangulate impact, expenditure, and quality analyses to significantly increase the impact per dollar of PEPFAR programs Allocate resources based on performance and validated data

Budget Realities  Focus on Critical Activities Combination Prevention (PMTCT, ART, Condoms, VMMC) Prevention (effective/targeted) OVC – holistic services for families Neglected & Hard to Reach Populations Pediatrics Adolescent girls Key populations – MSM & Transgender, Female Sex Worker, People who inject drugs Health Systems, especially human resources for health, supply chain, lab, and strategic information that will specifically required to support above activities

Hot Topic Areas Accelerating PMTCT Close Gaps in ART Coverage for TB/HIV Patients Laboratory Quality assurance for rapid HIV testing Develop country-specific strategies for scale-up of viral load testing and development of viral load networks Prevention High impact interventions VMMC, Condoms, HTC and demand creation for clinical services High need populations Key Populations, fishing communities, adolescent girls High impact locations

Care and Treatment Earmark Guidance In PEPFAR’s original authorization, Congress recommended 55% of funds spent on treatment, 15% on palliative care, 20% on prevention, of which at least 33% be spent on abstinence-until- marriage programs, and 10% on OVCs. For FY 2006-08, 55% to be spent on treatment, 10% on OVCs, and 33% of prevention funding on abstinence-until-marriage. FY 2009-13 guidance relaxed some requirements: 10% to be spent on OVCs and at least half on treatment and care, the 33% abstinence-until-marriage directive was removed and replaced by a requirement of “balanced funding” for prevention.   The PEPFAR Stewardship and Oversight Act (2014-18) continues spending directives for OVCs and requires at least 50% of bilateral HIV assistance to be spent on treatment and care. Source: http://kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for/

Expenditure Analysis (EA) Initiative EA data show what PEFPAR funds were used for in each country/region according to major and detailed cost categories. Began in 9 PEFPAR countries in 2012 and will expand to all PEFPAR operating units in 2014. EA Dashboard uses interactive graphs and maps to share the results from PEPFAR’s growing expenditure analysis data collection program. Graphs and maps can be downloaded and viewed by country/region, program area, major cost category, detailed cost category. Link to EA Guidance FY 2014 on class website

PQS will support high-impact efforts that are country-owned-that is, owned by government, civil society, the private sector, and other stakeholders in the partner country. “…striving to help achieve high-impact national HIV responses that are country-owned—that is, owned by government, civil society, the private sector, and other stakeholders in the partner country.”

PQS Priorities 1 1. Compliance for HIV clinical services with guidelines, protocols, and standards in support of optimal patient outcomes 2. Costs and efficiencies gained through institutionalizing countries’ ability to improve HIV programs 3. Sustainability of improvement methods

PQS Priorities 2 4. Rapid scaling of lessons from successful quality improvement initiatives 5. Institutionalization of the ability of the host country to improve HIV programs 6. National capacity in collecting and using high quality improvement related data 7. Learning agendas to support activities specifically designed to expand knowledge about a wide range of improvement issues

Supporting PEPFAR III pillars with Data Accountability Transparency Impact Demonstrate cost-effective programming that maximizes the impact of each dollar invested Demonstrate transparency with validation and sharing of all levels of program data Demonstrate sustained control of the epidemic – save lives and avert new infections AIDS-free Generation

PEPFAR’s Evolving Data Needs Setting site-level targets and results Epi and geospatial data overlays for volume, yield, performance analysis New and emerging data streams addressing accountability, transparency, impact, quality Tighter feedback loops for course correction, continuous analysis

Monitoring, Evaluation and Reporting (MER) Goal: Improve and strengthen collection and use of data Articulates evaluation standards that should improve the quality of evaluations and their contribution to decision-making Provides consistency for evaluation implementation standards across PEPFAR Represents interagency consensus of standards deemed most relevant to conducting quality evaluations within PEPFAR As part of the broader PEPFAR Monitoring, Evaluation, and Reporting (MER) initiative to improve and strengthen the collection and use of data, the purpose of this document is to articulate evaluation standards that should improve the quality of evaluations and their contribution to decision-making. Simultaneously, this document responds to recommendations by the Government Accountability Office (GAO) and the Institute of Medicine (IOM), and stipulations within congressional reauthorization to expand the utility of evaluation processes and data across PEPFAR programming for greater accountability and transparency. Source: http://www.pepfar.gov/documents/organization/221324.pdf

Site Improvement through Monitoring System (SIMS) 1 Goal: Standardize site monitoring of key program area elements and quality of care to increase the impact of PEPFAR programs on the epidemic Primary Objectives: Monitor capacity at sites, community and above- site to provide high-quality HIV/AIDS services in all program areas Facilitate use of these data and quality outcomes to improve services Provide foundational data for regional, national, and global programmatic decision making Source: Joseph Amann SIMS Presentation for QI Course Cape Town November 2014

Site Improvement through Monitoring System (SIMS) 2 Secondary Objectives Demonstrate PEPFAR and its implementing agencies’ accountability for funded activities Emphasize in-country technical staff role in accountability, monitoring, and improvement Improve capacity building by: Providing guidance to assess the content of services through standards-based monitoring Recognizing successes to improve morale and accountability of staff

PEPFAR’s New Information System Data for Accountability, Transparency & Impact (DATIM): PEPFAR’s new information system Starting October 2014, used to enter all PEPFAR Evaluation Standards of Practice adherence data Integrates data entry for all PEPFAR sites: integrated PEPFAR Site List (iPSL) iPSL is the critical backbone for any data entry in DATIM (including SIMS)

PEPFAR Dashboards Goal: Enable all stakeholders, including US citizens, civil society organizations, USG agencies, donors, and host-country governments, to view and utilize PEPFAR planned budgets, program results, and expenditure analysis data in an accessible and easy- to-use format. Supporting PEPFAR’s priority of Transparency 3 Dashboards: Planned Funding Dashboard Program Impact Dashboard Expenditure Analysis Dashboard

It always seems impossible until it’s done. - Nelson Mandela