The Accelerating Children's HIV/AIDS Treatment (ACT) Initiative was a 2-year initiative launched in August 2014 to double the number of children on antiretroviral therapy (ART) in 9 African countries [ACT Initiative countries were Cameroon, Democratic Republic of Congo (DRC), Kenya, Lesotho, Malawi, Mozambique, Tanzania, Zambia, and Zimbabwe]. The US Government's President's Emergency Plan for AIDS Relief (PEPFAR) and the private Children's Investment Fund Foundation (CIFF) jointly funded the $200 million effort. ACT was a unique public–private partnership that set ambitious treatment targets with focused resources for HIV-positive children that improved pediatric ART coverage and reduced disparities with adult coverage.
Between 2014 and 2016, the number of children younger than 15 years receiving treatment with support from PEPFAR and CIFF increased by 44% to 352,076 across the 9 ACT countries.1 Despite the initiative's success in treatment, challenges remain along the HIV clinical cascade. For example, an estimated 160,000 new children continue to be infected every year.2 Work still needs to be done to ensure retention and viral load suppression for children and adolescents, and there are concerns that the health systems are not strong enough to maintain some of the interventions introduced and funded under the ACT initiative.
Although a focus on treatment is critical for pediatric HIV and HIV broadly, a narrow focus on treatment can miss opportunities that support host country ability to maintain the progress gained once donor funds and initiatives transition. This article assesses the status of sustainability in context of the ACT countries after the pediatric treatment surge that occurred primarily between 2014 and 2016. It uses the case of the ACT Initiative to argue that although surge activities are successful in rapidly scaling treatment results, work remains to be done to strengthen the health system's ability to maintain the progress along the full cascade. ACT provides us with important lessons for planning and management of transition to inform future donor initiatives.
WHAT CAN THE ACT INITIATIVE TEACH US ABOUT SUSTAINABILITY?
To assess the capacity of local health systems to take responsibility for maintaining progress on pediatric ART coverage and strengthen the entire clinical cascade for children, this article draws from the PEPFAR Sustainability Index and Dashboard (SID)3 and an independent evaluation of CIFF investments in 4 countries (Kenya, Malawi, Tanzania, and Zimbabwe) completed by Rabin Martin4 to assess sustainability. This sustainability analysis for this article pulls from literature and donor definitions of sustainability, including PEPFAR's Sustainability Position Paper.5–7 Sustainability strengths, weaknesses, and progress are reviewed through a health systems lens across the domains of (1) Policies, (2) Financing and Efficiencies, and (3) Program Capacities of (a) Supply Chain/Commodities, (b) Human Resources for Health (HRH), and (c) Data Systems for pediatric HIV programming in the 9 ACT countries.
The data present a mixed picture: although gains have been made in some areas, countries need additional investment in policy execution, domestic resource mobilization and efficiencies, HRH workforce planning and transition, commodity security, and data system implementation to own the full progress ACT achieved during the surge and to continue to build on it.
ACT CATALYZED POLICY ADOPTION BUT IMPLEMENTATION WAS INCOMPLETE
ACT contributed to the final adoption of Test and Treat policies for children and adolescents and supported the implementation of these policies. In 2015, while most countries (except Mozambique) had Test and Treat policies in place for children, only Lesotho and Malawi had Test and Treat policies in place for adolescents (aged 10–19 years). By 2017, all 9 ACT countries had adopted the policy for all populations.
The CIFF independent evaluation found that, by and large, ACT resulted in significant gains that strengthened national HIV pediatric and adolescent treatment policies now guiding practice. However, there are still gaps in adoption of key national policies related to age of consent for testing, such as in Tanzania, where the policy was held up before adoption due to broader national concerns with minors' rights.
According to PEPFAR SID 2017 data, 5 countries (Lesotho, Malawi, Mozambique, Zambia, and Zimbabwe) allowed for HIV testing without parental consent for adolescents of 15 years of age or older (and in some countries even younger than 15 years). Kenya also has policies in place for consent for testing adolescents 15 years and older.8 Tanzania has a testing consent policy in place for adolescents 18 years and older, with a clause indicating testing earlier if needed for mature minors.9 Only Malawi, Mozambique, Zambia, and Zimbabwe allow for HIV treatment without parental consent for adolescents 15 years or older. Greater advocacy is required in countries without these policies such as Cameroon and DRC to ensure that policies are in place to help facilitate access to testing and treatment among adolescents.
Even when policies are in place, translation of national policy into subnational and facility-level implementation remain a barrier to strong service delivery. This is due to a combination of factors including disconnection between national and subnational priorities, lack of resources available for provider training and mentoring, and competing service delivery priorities. The CIFF independent evaluation found that in Malawi, there was a lack of resources to implement provider trainings for pediatric and adolescent-specific policies, and in Kenya, differentiated care guidelines for pediatric and adolescent patients needed strengthening and there were challenges facing policy implementation at the subnational level. With the end of the ACT initiative, work remains to continue advocating, adopting, and ensuring the proper implementation of policies that increase access to pediatric services and treatment.
ACT GENERATED LIMITED HEALTH FINANCING DATA, DOMESTIC RESOURCE COMMITMENTS, AND EFFICIENCIES
The national HIV/AIDS response in all ACT countries remains primarily donor-funded, with less than 20% of the overall HIV funds provided by host country governments (PEPFAR SID 2.0 and 3.0, 2015 and 2017). Domestic funding levels insufficiently match priorities and CIFF independent evaluation interviewees viewed this as a major threat to programming sustainability and effectiveness. For example, external funding constitutes approximately 80% of the national HIV budget in Kenya and Zimbabwe, 86% in Malawi, and 95% in Tanzania (PEPFAR Country Operational Plans, Kenya, Zimbabwe, Malawi, Tanzania, 2016). No ACT country finances more than 22% of the national HIV response (PEPFAR SIDs 2.0 and 3.0, 2015 and 2017). PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) remain key funders in all countries.
Respondents in the CIFF independent evaluation suggested that given the predominance of external donor funding for HIV, governments tended to allocate their limited resources to health issues other than pediatric HIV. Data are limited for pediatric HIV expenditures and governments often do not collect these data. To gather more data and support specific pediatric HIV financing needs, the United States Agency for International Development (USAID), with PEPFAR, funded the Health Policy Project in 2015 to assess the funding needs for Tanzania to meet pediatric ART national targets by 2020. The analysis identified that from 2015 to 2020, Tanzania had a funding gap of $159 million to reach the national targets. ACT funding was supporting 45% of the country's pediatric ART commodity procurement requirements. Tanzania will likely require additional resources to address recurring or new challenges along the cascade, such as identifying children who are hard to reach.10 This exercise provided the Government of Tanzania with critical finance information to be able to plan and program resources for pediatric HIV programs with the end of ACT. However, this one activity alone could not successfully ensure a pathway for acquiring the funds or finding efficiencies to meet the funding gap.
Although increasing domestic funding is critical for financial sustainability, there is also a need to strengthen financial planning and budgeting and technical and allocative efficiencies to ensure that existing resources are used in the best manner. This can be measured by indicators such as the rate of budget execution for HIV and pediatric HIV funding, or the pathway from an approved budget to the actual spending of the budgeted funding; the use of unit cost data; and integration of services, which are measured in the PEPFAR SID.
Looking at one of these indicators in ACT countries, it is noteworthy that the overall ACT country rate of budget execution for HIV funds was low with most reporting no information on this or less than 50% of HIV-budgeted funds used (5 of 9 countries) from PEPFAR SID 2017 data. Only Zimbabwe had an average budget execution rate of 90%–100% over the past 3 years (PEPFAR SID, Zimbabwe, 2017). These low levels of HIV budget execution demonstrate poor budget planning and this can result in Ministries of Health returning money to Ministries of Finance at the end of the year, with less funds allocated in subsequent years.
Interviewees from the CIFF independent evaluation cited cases of terminating staff at the conclusion of ACT because government, typically at more subnational levels, had not budgeted or committed to absorb staff in annual workplans. Such findings indicate opportunities for donors to provide technical support to countries to improve expenditure tracking, efficiency analysis, and financial transition planning and management at the start of and throughout surge activities. It is also critical to manage and communicate financial and staffing expectations with all partners from start to end of an initiative.
ACT INCREASED THE PEDIATRIC WORKFORCE WITHOUT ADEQUATE PLANS FOR TRANSITION
PEPFAR SID 2017 data showed that at least 50% of HRH costs are funded by national governments in all the 9 ACT countries, which emphasizes the dependency on donors to deliver services. The ACT surge required the rapid hiring of providers to fill critical roles in facilities, laboratories, and other staff positions. However, staffing was cited in the CIFF independent evaluation as a key risk to the ongoing sustainability of the pediatric HIV response. Respondents in the CIFF independent evaluation indicated that key pediatric HIV positions within ministry and subnational leadership were often donor-funded. In addition, clinical staff and auxiliary workers were routinely hired and trained for project-specific work, including for ACT, and then eliminated in large numbers at project conclusion.
ACT countries face significant workforce shortages and challenges due to insufficient domestic funding, limited engagement of community systems, limited pediatric pre-service and in-service training opportunities, and inefficient planning and workforce management. With joint donor and government analysis, some portion of the health workers hired during the surge could have transitioned to facilities or community-based interventions. However, this type of transition requires upfront planning between government and donors, close management during phaseout, clear communication on transition expectations, and sufficient time to ensure success.
COMMODITY SECURITY IMPROVED WITH ACT BUT REMAINS A CONCERN
Commodity security and a strong supply chain system are critical for the sustainability of pediatric HIV treatment results. The CIFF independent evaluation showed that in the 4 countries studied, country-specific commodity stock-outs improved over time, with intermittent stock-outs for pediatric commodities, including test kits, early infant diagnosis reagents, cold-chain–reliant ARVs and cotrimoxazole. However, from PEPFAR SID 2017, only 4 countries (Kenya, Lesotho, Malawi, and Zimbabwe) of the 9 ACT countries had ARV stocked according to plan (above the minimum and below the maximum) in facilities over 90% of the time. This is critical to keeping children and adolescents on treatment and virally suppressed.
Data from the PEPFAR SID 2017 reveal that financing for HIV commodities overall is still highly donor-reliant in all 9 ACT countries. Six of the ACT countries (DRC, Kenya, Malawi, Mozambique, Tanzania, and Zimbabwe) contributed less than 10% of domestic funding for ARVs. Only one country contributed over 50% domestic funding for ARVs (Lesotho). As previously mentioned, Tanzania had 45% of pediatric commodities covered by ACT Initiative funding alone.
PEDIATRIC DATA SYSTEMS ARE IN PLACE BUT REQUIRE SUPPORT TO IMPROVE DATA QUALITY AND USE
According to PEPFAR SID 2015 data, Mozambique was the only ACT country that did not collect HIV/AIDS service delivery data routinely by program and geographic area for pediatric care and support programs. By 2017, all 9 ACT countries had the data capabilities in place (PEPFAR SID 2017). However, stakeholders in countries reported needing further support after ACT to ensure appropriate use of the data systems.
Qualitative data from the CIFF independent evaluation highlighted surveillance and service delivery data quality challenges, primarily related to timeliness and data use. Comprehensive surveillance data are limited or focused on the adult population living with HIV. In addition, countries and donors often rely on estimates to guide programming priorities and set targets. Respondents also reported issues with staff capacity and training for data collection, given the wide range of indicators required by both government and donors. Interviewees suggested that these gaps in training and collection subsequently lead to lower-quality data and lessened the motivation for data use. In some cases, data mishandling or misinterpretation has even lead to a lack of consensus around performance of targets.
ACT SUPPORTED THE CONCEPT OF SUSTAINABILITY IN GUIDANCE BUT LACKED MONITORING AND ACCOUNTABILITY
Sustainability was not forgotten in the design of ACT. The original ACT Initiative Guidance laid out 7 pillars of focus to support the pediatric treatment surge, including 4 that supported sustainability and system strengthening areas: policy reform, community engagement, strategic information, and domestic resource mobilization. Although the initiative provided guidance to support these system interventions, the specific ACT country workplans and budgets either did not allocate sufficient funding to this kind of work or did not have clear, monitored deliverables or targets. Often activities that fell within the domestic resource mobilization pillar had zero dollars associated. When countries did list specific systems or sustainability activities with funds associated, the monitoring of progress was limited and the results of the work were unclear. Example indicators included the number of plans developed or number of assessments conducted and were less meaningful to assess progress toward sustainability. Better indicators for success related to funding mobilized for pediatric treatment or future financial, technical, and human resource commitments from host governments might have supported improved results.
SUSTAINABILITY LESSONS TO TAKE FROM ACT IN LIGHT OF THE GLOBAL TREATMENT SURGE
It is important to note that PEPFAR continues to support and fund pediatric HIV programming, although outside any pediatric initiative. Global Fund also has limited but continuing pediatric programming and other donors also contribute depending on the specific country. None of the ACT countries have truly transitioned from donor support with the end of ACT.
This analysis has several limitations. Sustainability data for pediatric and adolescent programming in the SID tool are limited to a handful of questions. These indicators do not capture all aspects of HIV pediatric programming. The qualitative data from the CIFF independent evaluation were conducted in 4 countries and results are not final until June 2018. This review therefore does not cover all aspects of sustainability or provide the full picture in all ACT countries. However, the data and story of ACT demonstrate that there is a need for stronger health systems that can better maintain or improve on programmatic results after a donor initiative ends. Thus, the following lessons are crucial considering recent focus on scaling up treatment and push to achieve the UNAIDS 90-90-90 targets by 202011 and achieving 95-95-95 targets for epidemic control.
Ensure that Transitions are Planned at the Start of the Surge and Monitored Throughout
Despite the common understanding of the need to plan for transition at the start of programs and examples to draw from, many donor initiatives do not undertake this as well as they could.12 Donors need to plan for staff time and resources to map donor investments, targets, results, and geographic coverage at the start of the initiative and at regular intervals throughout and support integration with national and subnational plans. Planning should be inclusive and involve donors, civil society groups, and government stakeholders from, at a minimum, the Ministries of Health and Finance with regular communication throughout the initiative to assess progress toward transition. Donor engagement with subnational leadership is especially important in countries where county-level leaders drive local health service delivery priorities and in countries with overlapping geographic areas of donor support. The planning should be specific to key areas such as HRH and include strategies for the new positions to be absorbed into government systems as appropriate after the end of funding. Donors need to share multi-year funding trajectories to facilitate in-country planning and mobilize political will for transition. Mechanisms should be put in place to appropriately gradually increase government stewardship and implementation capacity throughout the duration of the donor-funded program. At the end of an investment, donor–donor coordination can also support the transition of successful programming from one donor to another, as was seen in some ACT countries, in cases where governments are unable to take on the programming.
Fund Sustainability Activities With Clear Outcomes That are Monitored Regularly
Systems and sustainability programming requires funding. It cannot be conducted without staff time and resources allocated. But, funding alone will not advance the ultimate objectives. Donors must fund interventions that are the most effective and ensure there are clear targets and outcomes; this is especially true for policy reform and implementation, financing and efficiencies, HRH transition planning, and system implementation for supply chain and data. It is not enough to develop plans; activities should have outcomes that are tailored to the context, realistic, and truly move the sustainability of programs forward.
For example, in settings where analysis shows efficiencies can be gained and would create significant savings, clear goals should be established and closely monitored. It may be possible to free up more funds for core HIV services by improving the overall efficiency of the HIV response—eg, through clear outcomes related to the integration of HIV services into primary care, or by leveraging regional-level negotiating power to reduce drug procurement costs—but even after exploiting all possible gains from technical and allocative efficiency improvements, it is almost certainly still the case that additional funds will be required.13 Although increasing domestic resource contributions to HIV programs may be challenging in countries in the lowest income bracket, the rising middle-income country group does have options to find local funds (public and private) to support HIV programs. In these settings, activities should again be closely monitored for successes with actual domestic resource commitments and budgets allocated as indicators of success.
For HRH programming, donors should establish an HRH transition plan with clear indicators to monitor progress before any hiring surge. Health care staff are the backbone of pediatric and adolescent HIV care, and long-term donor support of core cadres, although effective, will not result in a sustainable response. During implementation, donors should prioritize funding that builds the capacity of in-country personnel in skills required to support the policies, organizations, and processes established by the initiative. Similarly, donors and host country governments should consider translatable technical skills that a surge workforce may acquire to facilitate the transition of workers to other health system or other industry employment. One way to do this is to integrate programming with other child and adolescent health services, such as immunization, sexual and reproductive health, and education to broaden the health worker skill base and closely monitor the process for integration. HRH surge hiring should also be required to hire at comparable pay scales as government. All these activities require funding to ensure success. Where possible, donors should also avoid reliance on international partners to implement.
Commodity Security and Data Systems are Long-Term Investments
Capacity building should extend beyond service delivery to include supply chain and data system management to ensure that adequate monitoring data are available and used to holistically sustain programs and identify potential problems early. Improvements are needed in data collection, quality, and age disaggregation to accurately monitor status and tracking progress for pediatric and adolescent HIV results. As budgets for health system strengthening decline, these areas should still remain in focus for funding and monitoring.
Continue External and Internal Advocacy After Initiative
Although donor resources can end with the close of an initiative, donor presence does not always disappear. External donors can continue to use their position in country to support continued focus on priority populations, enactment and implementation of priority policies, and advocacy for increased financing of critical health and development areas. In addition, civil society groups can advocate for these same areas and monitor progress internally. Together, those advocates can be a powerful voice to sustain progress, monitor implementation, and continue programmatic successes. Plans should be put in place before the close of an initiative to use these internal and external advocates.
ACT demonstrates that 2 years is a short time to both (1) rapidly scale up a treatment program and (2) put in place lasting and functioning systems. With flatlined or, in some cases, declining external funding, donors often pit the 2 against each other and seem to suggest that the 2 priorities are at odds. Not at all. Strengthening host country health systems should multiply the impact of donor-funded treatment programs and thus, should be the focus of continued donor investment and monitoring. As 2018 again marks a focus of aggressive treatment target-setting for epidemic control, investing in health systems and sustainability will ensure that the gains along the cascade are owned by countries for the long haul.
The authors thank Ariel Falconer, Kim Morgan, Holly Gray and Francesca Boldrini from Rabin Martin, Taryn Barker and Joanna Robinson from the Children's Investment Fund Foundation, Kate Harrison from Avert and colleagues from the U.S. President's Emergency Plan for AIDS Relief and USAID for their partnership and review of this manuscript.