Guest Editorial: Poverty, development, and PEPFAR: A US strategy for combating the global HIV/AIDS epidemic

Holzemer, William L.; Marefat, Simin

doi:10.1016/j.outlook.2007.07.008

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Volume 55, Issue 5 , Pages 215-217, September 2007

Guest Editorial: Poverty, development, and PEPFAR: A US strategy for combating the global HIV/AIDS epidemic

Special note: Science Journals, Poverty and Human Development: October, 2007IN 2005, the Council of Science Editors appointed a task force to engage science journals of all disciplines in the effort to combat world-wide poverty and disease and to establish sustainable paths for human development.⁴ That group believed that the science community has a great deal to offer in terms of anti-poverty strategies, such as resources, training, advocacy, information access, fostering of research cultures and building capacity- all in service of supporting sustainable development. Among the many activities spearheaded by this task force the Global Theme Issue on Poverty and Human Development was implemented and will come to fruition this month.⁵ Over 200 journals have agreed to publish editorials, original research, review articles, and/or perspectives related to poverty and human development- all with a common publication or release date of October 22, 2007. The intent is to raise awareness and stimulate interest and research into poverty and human development among scientists in both developing and developed countries. The board of Nursing Outlook chose to participate in this amazing initiative and have chosen the following guest editorial and submitted manuscripts that focus on issues of poverty-both internationally and in the U.S. In each of these 3 papers one can hear the voice as well as actual and potential contributions of nurses to this very challenging problem that affects communities world-wide. Marion E. Broome

In 2003, the US government passed the $15 billion President’s Emergency Plan for AIDS Relief (PEPFAR) into public policy. In the midst of global poverty and the United States’ inconsistent history of development funding, PEPFAR was a much-needed response to the ever-escalating HIV/AIDS global epidemic. Conservative estimates suggest that 25 million people have died of AIDS since 1981, there are 12 million children orphaned by AIDS in Africa, and 40 million adults worldwide are currently living with HIV infection.¹ As respected members of their communities, nurses have been at the forefront of HIV prevention, treatment, and care efforts around the world since the beginning.

Perhaps the most important word in the title of this legislation was “emergency,” which influenced both the goals of the program and the way in which it was implemented. Within 5 years, PEPFAR planned to prevent 7 million new HIV infections, place 2 million people on antiretroviral therapy, and provide care services for 10 million adults and orphans living with or affected by HIV/AIDS. Under the coordination of the US Ambassador in each of the 15 PEPFAR focus countries, the program brought together the US Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the Peace Corps, the Department of Defense, and others. The program was operated with an “emergency” philosophy of vertical implementation and only modest attention to harmonizing its work with other HIV and development programs in the country.

Today, the US Congress faces a request from President Bush to double PEPFAR’s funding to $30 billion to continue this global attack on HIV infection and to provide treatment and care for millions of people. To structure the new legislation, lawmakers are using data and recommendations from The Institute of Medicine’s recent interim report, PEPFAR Implementation: Progress and Promise.² Three relevant IOM recommendations stated that PEPFAR should:

1.Transition from its focus on emergency relief to an emphasis on long-term strategic planning and capacity building for a sustainable response.

2.Address long-term factors underlying the epidemics in each country (i.e., accumulate better public health data, emphasize prevention, empower women and girls, address food shortages and poverty, and build workforce capacity).

3.Improve coordination with partner governments and other donors and support the World Health Organization prequalification process (i.e., a faster process than approval through the US Food and Drug Administration) for medications purchased with PEPFAR funds.

Underlying all of these recommendations is the need for a more integrated and horizontal approach to global HIV prevention, treatment, and care. Seven years after it was founded, UNICEF dropped its “emergency” response upon realizing the need to broaden its mandate. The President’s Emergency Plan for AIDS Relief should follow suit and start looking more carefully at the broad context within which HIV/AIDS exists.

One of the major contextual issues facing PEPFAR is global poverty. Poverty not only facilitates the spread of the disease (e.g., poor women being forced into commercial sex work as their only means of supporting their families), but it also hampers the response at both an individual and national level. The 15 PEPFAR focus countries are among the poorest in the world, and program implementers must face fragile health care systems, inadequate numbers of qualified health care workers, unsafe blood supplies, inadequate injection safety programs, inadequate laboratory systems to conduct HIV-related tests, lack of supply chains to deliver antiretrovirals, and communities of people living with and affected by HIV infection in extreme poverty. Providing food supplements to people on antiretroviral (ARV) medications was originally not part of PEPFAR’s mandate, but it has become apparent that people cannot take and adhere to their medications without sufficient and safe food and water. Providers cannot count on the availability of medications without adequate supply chain systems. In order to more fully respond to the HIV/AIDS epidemic, PEPFAR must take into consideration individual and national poverty.

A second major contextual issue facing PEPFAR is the lack of qualified health care workers and the inability of many of the PEPFAR countries to absorb the influx of funds now available to them. The PEPFAR funds have enabled the creation of tens of thousands of new health care jobs necessary to respond to prevention, treatment, and care needs, but few countries have actually been able to fill those positions. Most are experiencing extreme shortages of qualified health workers. In South Africa alone, 29 000 health care positions in the public sector are vacant, and the national HIV/AIDS treatment plan estimates that only 12 000 will be filled.³ In the past, PEPFAR has funded many in-service training programs for health care professionals that are important for improving care, but the IOM report emphasizes that this does not address the basic need for more workers to care for people living with and affected by the disease.

Although there is clearly a need to train new health care workers, there is also a strong feeling within the World Health Organization and some donor organizations that it takes too long and that trained health workers often leave the country to improve their lives. Because of this, much of the effort in workforce capacity-building today is focused on task-shifting, which moves technical skills to the lowest possible level of provider. Nursing has benefited from this philosophy as physician skills have been shifted to advanced practice nurses and midwives. The next step, then, is to shift tasks from enrolled and registered nurses to community health workers. Some policy planners believe that this can be done with short-term training, but it is unclear whether they understand the potential consequences of having marginally trained health workers visiting homes, counseling patients on ARV adherence, and monitoring disease progression.

The challenge is to ensure that the tasks of enrolled and registered nurses are shifted to skilled workers. Rather than providing short-term training to community health workers, community health workers should be re-conceptualized as nursing assistants and should be taught at a more formal level, in the existing nurse training programs within the country. The PEPFAR funds should be used to upgrade nurse training programs in order to create a qualified teaching and supervision pool, and then to integrate community health workers into nursing assistant programs. By doing this, a qualified teacher pool would be available to train these needed nursing assistants, and a supervision system of enrolled and registered nurses can be developed to supervise their practice. These steps would strengthen training, improve care, and help fill the many thousands of empty health care professional positions created through PEPFAR funding. It may take too many years to train physicians, but there are many examples of successfully shortened nurse training programs at the Nursing Assistant, Enrolled Nurse, Registered Nurse, and Advanced/Specialist Nurse levels, often with very few resources.

United States organizations with a demonstrated commitment to global health, such as the American Academy of Nursing (AAN), can play an important role in this work. The Academy’s Expert Panel on Global Nursing and Health could develop a position statement on the need for resourced countries to become self-sufficient in preparing their health work forces, thus removing the extreme pull that currently draws nurses from low-resource countries to resource rich countries (brain drain). The Academy’s position statement would necessarily focus upon the United States, but such a position could provide leadership for other countries to consider similar steps. The Academy should also join the calls for the creation of a new United Nations agency for women that has sufficient resources and authority to address gender inequality in health around the world. Finally, the Academy should develop strategies to support the new PEPFAR legislation to continue the global commitment to people living with and affected by HIV infection.

The President’s Emergency Plan for AIDS Relief is challenged to broaden its view of HIV/AIDS response and to consider the contextual issues within which the disease exists. By collaborating with non-governmental organizations such as the AAN and other donor organizations to address issues such as poverty and workforce capacity-building, PEPFAR can build upon the successes of its first 5 years to ensure the sustainability of its future efforts.

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References

UNAIDS (2006). AIDS Epidemic Update, December 2006. www.unaids.org.
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Institute of Medicine (2007). PEPFAR Implementation: Progress and Promise. Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation. Available at: http://www.nap.edu/catalog/11905.html. Accessed on April 25, 2007.
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