Scaling-up for Success: PEPFAR’s Prevention Challenge

This is a joint post with Christina Droggitis.Since its release in December 2009, specific pieces of PEPFAR’s new strategy have triggered much discussion both in Washington, D.C. and abroad. In the spirit of sharing-while-doing, Ambassador Goosby spoke at a Center for Strategic and International Studies (CSIS) event on Tuesday on “Confronting the Tough Challenges in HIV Prevention,” focusing his remarks on HIV prevention in the strategy.As outlined in the strategy and stressed in Goosby’s comments, PEPFAR’s main goal towards prevention is to match as aggressive of a response as was launched for treatment in its first phase. This includes working with governments to map the prevention needs of a country, using high-impact, evidence-based approaches—including biomedical, behavioral and structural interventions—that are also linked to care and treatment programs. The strategy lays out the steps for countries to develop a basic package of prevention, but Goosby’s remarks did not hide the fact that there is still much more to learn. Questions raised by Goosby and the audience centered on PEPFAR’s efforts to ensure that prevention interventions are effective and geared towards the right populations, actually work to reduce incidence rates, and are cost-effective in their scale-up.This administration’s plan for a more sustainable and effective resource allocation for treatment, care and prevention is promising. To be successful PEPFAR must work with countries to tackle the challenges to prevention as they launch an aggressive prevention response. Three big challenges for the U.S. administration to think about as it enters the implementation phase of the new strategy:1) Scale-up: How do you scale-up prevention efforts? What does a scale-up plan look like for a given country?While the strategy is good in defining the approach to prevention, it does little in the way of defining the operational features needed to actually expand prevention efforts (i.e., roll-out, monitoring and evaluation, etc.). For example, many prevention interventions are initiated at the community level, especially to tackle risks related to individual behavior, so what is the process for expanding these interventions and approaches across a region or country in a way that will result in the reduction of new infections? Perhaps the evolving guidance and country operational plans (COPS) will be more specific about prevention scale-up by country?2) Metrics: How to measure prevention success? There has been a general lack of information on prevention metrics, both in PEPFAR’s past, as well as in this new strategy. However, if prevention is truly going to be a defining feature of the Obama administration’s approach towards global HIV, there need to be measures in place to identify and show—both to Congress and to its beneficiaries,—PEPFAR’s progress in averting infection.I asked this question at Tuesday’s event, and Dr. Goosby realistically noted that measuring effects on incidence takes time. Given that it’s hard to measure something that does not happen, it was encouraging to learn that PEPFAR is developing “surrogate markers of incidence” with experts both at home and abroad on this topic. Dr. Goosby did not elaborate what these surrogate markers might be except for a quick reference to indicators from ante-natal care, but committed to vetting these more publicly once developed. Clearly, this is something to look out for in the near future.3) Incentives to scale up prevention for success: What incentives, if any, will PEPFAR provide to countries to prioritize prevention?Creating incentives for national governments to focus on prevention efforts is a must for them to succeed. In a forthcoming CGD working paper, CGD colleague Mead Over translates CGD’s concept of “Cash on Delivery”, to HIV prevention. In COD aid, donors commit to pay a specific amount of money for a specific measure of progress, in this case, infections averted. Incentivizing prevention in creative ways is an important step in scaling up efforts and should be a critical component of PEPFAR’s new approach with governments and other country stakeholders.