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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
AIDS. Author manuscript; available in PMC 2013 February 20.
Published in final edited form as:
PMCID: PMC3576840

Transitioning HIV care and treatment programs in southern Africa to full local management

Sten H. Vermund, MD, PhD,1,2,3,4 Mohsin Sidat, MD, PhD,5 Lori F. Weil,1,6 José A. Tique, MD,1,4 Troy D. Moon, MD, MPH,1,2,4 and Philip J. Ciampa, MD, MPH1,3


The global HIV pandemic may be the worst single-agent scourge since the bubonic plague outbreak in 14th century Europe.1,2 Efforts to substantially prevent sexually-acquired HIV infection have been disappointing, despite the fact that effective approaches for preventing spread of this infection are well known.39 UNAIDS estimated that there were 33.3 million [likely range 31.4–35.3 million] persons infected with HIV globally by the end of 2009,10 68% of whom were in sub-Saharan Africa, home for only 13% of the global population.11 In all of sub-Saharan Africa, an estimated 5% of the population aged 15–49 years was infected in 2009.10 In highest prevalence nations of southern Africa, 15–28% of adults are infected.12

Health investments from such sources as the U.S. President’s Emergency Plan For AIDS Relief (PEPFAR;, accessed February 19, 2012), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund;, accessed February 19, 2012), and the World Bank’s Multi-country AIDS Programme (MAP;, accessed February 19, 2012) enabled HIV/AIDS care and combination antiretroviral therapy (cART) treatment to expand markedly in sub-Saharan Africa and other resource-limited nations. Nonetheless by mid-2011, only 6.6 million of the world’s 33.3 HIV-infected persons were on cART and an estimated 9 million people eligible for cART had yet to receive therapy.13 The gap would be fully 26.7 million if all infected persons were to be treated (an increasing common clinical and public health approach in high income countries). Donor nations, particularly the U.S., have taken on the challenge and have invested in this historic effort in partnership with local governments and non-governmental institutions, but the gap in services vs. need is a vast one.


Successes are many in the scale-up of global efforts for HIV infection care, treatment, and prevention, but programmatic gaps pose future peril as PEPFAR, Global Fund, and MAP investments diminish. Terms like “treatment mortgage” and “exit strategy” suggest the current focus of donor nations, shifting from the emergency response to one that will mitigate their future financial burden of global HIV/AIDS care by having the lower income nations take on the care costs themselves.14 Recipient nations are concerned about disproportionately investing health resources in HIV/AIDS when the disease is one of many ills to which they must respond. Foreign donations to tackle HIV/AIDS have invited financial dependence when such funding dominates local governmental budgets. Several countries have actually diverted their own health investments to tackle other non-health issues when a generous flow of funds for HIV/AIDS and tuberculosis presents a perverse disincentive to properly invest in their citizens’ health needs.1517

In representative low income countries (e.g., Zambia and Mozambique), PEPFAR support represents fully 1 of every 3 health care dollars (Table 1). Even in comparatively higher income nations (e.g., Botswana and South Africa), PEPFAR support has been substantial (Table 1). Hence, the impact of a given per capita cut in lowest income nations will be far higher than that same per capita cut in more prosperous nations. Putting this another way, in Mozambique and Zambia, where the contribution of the government to overall health care is low (Table 1), it would take such a disproportionate national investment to make up lost PEPFAR resources that other health needs would likely suffer cuts to make up the HIV care and treatment needs. Given that more prosperous Botswana receives four and one-half times more PEPFAR support per capita than does more resource-constrained Mozambique (Table 1), one presumes the former to be in a much better position to rapidly take on greater national responsibility based on accelerated capacitation.

Table 1
Estimated per capita government expenditures on health and per capita PEPFAR expenditures per year, 2005–2009: Botswana, South Africa, Zambia, and Mozambique

The expansion of HIV/AIDS care and treatment services poses challenges to under-capacitated primary health care infrastructures, even as it has created opportunities for life-saving cART expansion.18,19 Most PEPFAR, Global Fund, and MAP support is through Ministries of Health and care and treatment technical partners (universities, non-governmental organizations). PEPFAR works primarily through USAID and CDC. This split authority has created some very odd field disparities; a good example is that USAID has building authority from the U.S. Congress while CDC does not. Hence, a USAID-supported PEPFAR implementer may build a needed clinic, while a CDC-supported implementer will not be authorized to do the same, regardless of need. Needed clinics have been put into shipping containers so that no building need be involved; this “Alice in Wonderland” illogic is mandated by restrictions that defy logical explanation by national authorities, US government sponsors, and implementers alike. Faith-based institutions, militaries, community-based organizations, orphanages, Peace Corps, malaria and tuberculosis control initiatives, and the National Institutes of Health are among the groups also supported by PEPFAR for projects in their spheres of expertise. Partners deliver HIV/AIDS care and prevention technical support within national programs that are theoretically designed to be sustainable, though few believe that they will be so in the near future in the most resource-limited settings.

Since the beginning of PEPFAR in 2003, many undercapacitated primary care services have been highly stressed to meet their other health care obligations in the face of rapid HIV service expansions.18,19 An opinion backlash against desperately needed HIV spending is possible when other needs are neglected. Improving many programmatic elements, including better integration of services and a major expansion of the health workforce, including task shifting from unavailable to available staff, are essential for eventual sustainability of HIV programs (Table 2).2027

Table 2
Examples of essential elements requiring ongoing donor country investments to nurture successful and complete transition of HIV care and treatment programs to national governments and local organizations.


PEPFAR seeks to transfer authority to local entities to improve sustainability and to fully invest HIV/AIDS care and prevention within national programs and local nongovernmental organizations. This approach will save money by paying local rather than international salaries, for example, and will save on overhead from so-called “indirect cost” payments to American partners. Empowering local health entities and health workers (rather than expatriates) and incentivizing local governments to take on more of the fiscal burden of their own care and prevention are obvious goals for any foreign aid program. However, funders eager to diminish their fiscal exposure face the reality of huge local socioeconomic disparities at many levels: from nation-to-nation, within states/provinces, within districts/communities, and between persons of varying socioeconomic status.

Literacy comparisons from four southern African nations illustrate this development disparity. Adult (>15 years) literacy statistics from 2005–2008 are cited in the 2010 UN Human Development Report: Botswana, 83.3%; South Africa, 89.0%; Zambia, 70.7%; Mozambique, 54.0%.28 Average national statistics mask disparities in rural settings. A provincially representative sample of female heads of households in Mozambique’s Zambézia Province demonstrated that of the Portuguese-speakers (31% of the 3,529 women surveyed) 51.8% were unable to read a single word on a literacy subscale, and of non-Portuguese speakers (69% of the women), fully 93.7% were unable to do so (PJC, unpublished data). Such severe socioeconomic and educational disparities pose additional challenges in delivering HIV care and treatment services without a sustained donor country commitment.


Also telling is just how resource-constrained some of the most heavily afflicted countries really are. In 2010, Mozambique ranked 165 of 169 nations on the World Development Index of the United Nations Development Programme.28 The World Health Organization estimates the gross national income to be US$770 per capita in 2009, with male and female life expectancies of 47 and 51 years, respectively.29 An estimated 142 children under age 5 years will die per 1000 live births. The total expenditure on health per capita in 2009 was only $50 and represented only 5.7% of the national gross domestic product. Mozambique’s health workforce is one of the most under-capacitated in the world and nearly all HIV/AIDS care and treatment services are provided by nurses and técnicos de medicina (analogous to clinical officers in Anglophone Africa) rather than by physicians.2124,27 To meet the needs in HIV care and treatment, effectively implement successful prevention programs, and integrate HIV into improved primary care programs, our experience suggests the need for sustained health workforce training and program support for decades to come.30

In contrast, more prosperous nations like Botswana are making steady and impressive progress towards achieving target metrics for cART coverage by national guidelines. The results indicate the relative maturity of their testing programs, comparative successes in effective linkage to care, and substantial proportions of eligible HIV-infected persons placed on cART. We used a number of sources to contrast Botswana and South Africa (comparatively higher income) and Zambia and Mozambique (low income) nations vis-à-vis cART coverage estimates, in the context of estimated national populations and likely numbers of HIV-infected persons.

Botswana (Figure 1) and Zambia (Figure 2) have succeeded in rapid scale-up with over half of eligible persons now on cART in both nations.26,3137 Both have been more generously supported than have South Africa and Mozambique (Table 1). South Africa seems to have widespread coverage for high-access urban dwellers, but far less coverage for lower-access persons in rural or otherwise underserved communities; South Africa had reached 36.9% of infected persons eligible for cART by national standards in 2009, low, but a substantial increase from the 9.5% estimate in 2005 (Figure 3).3138 At the same time, South Africa has already achieved a high level of independence in managing its own HIV care and treatment programs.38 While the lag in achieving coverage in South Africa is due, in large part, to the AIDS-denialism viewpoint of the Mbeke government (1999–2008), the current South African Zuma administration is accelerating services at every level. Even though there has been consistent government support of cART in Mozambique (i.e, no AIDS denialism), only 29.7% of infected eligible persons were on cART in 2009 (Figure 4).3137 Furthermore, much of Mozambique’s challenge is in its rural regions with exceedingly limited infrastructures, workforce, and systems of drug delivery systems, data management, quality improvement, and transportation.30,3943

Figure 1
Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, Botswana. Data from references 26, 3137.
Figure 2
Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, Zambia. Data from references 3137.
Figure 3
Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, South Africa. Data from references 3138.
Figure 4
Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, Mozambique. Data from references 3137.

Some nations lack even a fraction of the qualified health workers needed. The 2010 Report from the Mozambican Ministry of Health Human Resources Department states that of 1105 physicians working for the government, about 62% were concentrated in Maputo City and urbanized areas of Maputo Province, Beira (Sofala Province) and Nampula City (Nampula Province); these three cities host the nation’s three central hospitals.44 The remaining seven provinces shared 420 public sector physicians to cover two-thirds of Mozambique’s 21 million persons, corresponding to nearly 33,000 persons per doctor, compared to 10,000 persons per doctor in Maputo City, Beira and Nampula City. (Fewer than 1000 persons per doctor is the norm for high and high-middle income nations.) Shortages of nursing and other health staff are similarly serious; neighboring Malawi and Tanzania have similarly dismal population-to-doctor ratios that impede transition of HIV services to local management. Mozambique’s current rural-urban disparity may have actually increased since 2005 when 57% of physicians were found in the city of Maputo and Sofala (including Beira) and Nampula Provinces.45 In the face of this dire healthcare labor scenario in Mozambique, the timetable set for local control of PEPFAR programs is planned aggressively, despite current low treatment coverage rates, high loss to follow up, and poor levels of health infrastructures, health workforce capacitation, and programmatic integration. An excessively rapid timetable for transition to local management will not fit all circumstances and may well compromise those achievements that PEPFAR programs have nurtured in Mozambique and elsewhere to date.14,46,47,48


A measured, staged approach of local capacity-building will depend on key elements of improvement that include sustainable change and program reform (Table 2). Recent insights into strategies for specific community engagement to maximize retention and adherence must be a chance to take hold beyond the limited areas where they have been implemented.49 Low income nations need ongoing technical assistance for decades to come, even as better capacitated nations will take on the lion’s share of managing their own HIV care and treatment programs. The morale imperative today is much the same as it was when PEPFAR was begun in 2003. The promise of earlier treatment as a tool for HIV prevention4,5,7 and the benefits of cART for tuberculosis control50 suggest that continued care and treatment expansion today will save money in the long run through prevention of HIV transmission and prevention of future lost productivity and health care costs.5155 It is essential that donor nations see this reality, even as they address their own economic challenges that may result in political pressures to diminish high income nation commitments to overseas aid.14,5660

Transfer of capabilities to local entities is an important long term goal, but will have perverse consequences if done too quickly or too cheaply.1519,6165 National Ministries of Health are likely to welcome a longer term strategy to better integrate those myriad of HIV services introduced and/or supported by PEPFAR, Global Fund, and MAP programs, many years before marked reductions in international assistance should be implemented. In the emergency response, many HIV care programs, clinical databases, drug procurement systems, laboratories, and clinical infrastructures were established side-by-side with standard Ministry of Health facilities and now require full integration. In regions of greatest need, as with Zambia and Mozambique, where health systems deficits may continue to inhibit HIV-related service expansion, donor nations should stay the course to address gaps in care, partnering with recipient nations to bolster their health system and health worker capacities.66 Premature cuts and hasty “exit strategies” risk millions of lives … once again.


The history of the HIV epidemic in Africa has been changed dramatically by the national and international investments to improve care and treatment coverage for HIV-infected persons, as well as prevention interventions for mother-to-child, blood-borne, and sexual transmission. Our comparisons of data from comparatively higher and lower income PEPFAR-target nations illustrate huge disparities in financing and in-country capacities. Ongoing challenges in program implementation will be most acute in the poorest nations, particularly those in which PEPFAR funding has been lower, as with Mozambique (Table 2). In its efforts to turn over full management responsibility to national authorities, PEPFAR will do well to move huge chronic disease care obligations onto undercapacitated health service programs at a pace commensurate with their abilities to absorb such burdens. Infrastructure, work force, and health systems strengthening will be needed for years to come in building the first chronic disease management system in those nations that have not had prior experience with long-term, sustainable programs, particularly in rural settings.


Dr. Tique supported by the Fogarty AIDS International Training and Research Program, NIH grant # D43TW001035.


1. Olea RA, Christakos G. Duration of urban mortality for the 14th-century Black Death epidemic. Hum Biol. 2005;77:291–303. [PubMed]
2. McEvedy C. The bubonic plague. Sci Am. 1988;258:118–23. [PubMed]
3. Dieffenbach CW, Fauci AS. Thirty years of HIV and AIDS: future challenges and opportunities. Ann Intern Med. 2011;154:766–71. [PubMed]
4. Kurth AE, Celum C, Baeten JM, Vermund SH, Wasserheit JN. Combination HIV prevention: significance, challenges, and opportunities. Curr HIV/AIDS Rep. 2011;8 :62–72. [PMC free article] [PubMed]
5. Burns DN, Dieffenbach CW, Vermund SH. Rethinking prevention of HIV type 1 infection. Clin Infect Dis. 2010;51:725–31. [PMC free article] [PubMed]
6. Cohen MS, Hellmann N, Levy JA, DeCock K, Lange J. The spread, treatment, and prevention of HIV-1: evolution of a global pandemic. J Clin Invest. 2008;118:1244–54. [PMC free article] [PubMed]
7. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. N Engl J Med. 2011;365:493–505. [PMC free article] [PubMed]
8. Padian NS, McCoy SI, Karim SS, Hasen N, Kim J, Bartos M, et al. HIV prevention transformed: the new prevention research agenda. Lancet. 2011;378:269–78. [PMC free article] [PubMed]
9. Buchbinder S. HIV epidemiology, testing strategies, and prevention interventions. Top HIV Med. 2010;18:38–44. [PubMed]
10. Joint United Nations Programme on HIV/AIDS. [accessed July 30, 2011];Global report: UNAIDS report on the global AIDS epidemic 2010. 2010 :20–21. Document UNAIDS/10.11E | JC1958E. Available:
11. Calculated by the authors from the U.S. Census Bureau. [accessed July 30, 2011];US & World Population Clocks mid-year 2011 estimates.
12. Karim QA, Kharsany AB, Frohlich JA, Werner L, Mashego M, Mlotshwa M, et al. Stabilizing HIV prevalence masks high HIV incidence rates amongst rural and urban women in KwaZulu-Natal, South Africa. Int J Epidemiol. 2011;40:922–30. [PMC free article] [PubMed]
13. World Health Organization. News release: HIV treatment reaching 6.6 million people, but majority still in need -- WHO embarks on a new HIV strategy to boost further progress in 2011–2015. Geneva: WHO; Jun 3, 2011. [accessed September 21, 2011]. Online at: [PubMed]
14. Garrett LA. The Future of Foreign Assistance Amid Global Economic and Financial Crisis Advancing Global Health in the US Development Agenda. Washington DC: The Council on Foreign Relations; Jan, 2009. [accessed September 21, 2011]. Online at:
15. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008;23:95–100. [PubMed]
16. Shiffman J, Berlan D, Hafner T. Has aid for AIDS raised all health funding boats? J Acquir Immune Defic Syndr. 2009;52 (Suppl 1):S45–8. [PubMed]
17. Lordan G, Tang KK, Carmignani F. Has HIV/AIDS displaced other health funding priorities? Evidence from a new dataset of development aid for health. Soc Sci Med. 2011;73:351–5. discussion 356–8. [PubMed]
18. Brugha R, Simbaya J, Walsh A, Dicker P, Ndubani P. How HIV/AIDS scale-up has impacted on non- HIV priority services in Zambia. BMC Public Health. 2010;10:540. [PMC free article] [PubMed]
19. Potter D, Goldenberg RL, Chao A, Sinkala M, Degroot A, Stringer JSA, et al. Do targeted HIV programs improve overall care for pregnant women? Antenatal syphilis management in Zambia before and after implementation of prevention of mother-to-child HIV transmission programs. J Acquir Immune Defic Syndr. 2008;47:79–85. [PMC free article] [PubMed]
20. Pfeiffer J, Montoya P, Baptista AJ, Karagianis M, de Pugas MM, Micek M, et al. Integration of HIV/AIDS services into African primary health care: lessons learned for health system strengthening in Mozambique - a case study. J Int AIDS Soc. 2010;13 :3. [PMC free article] [PubMed]
21. Sherr K, Pfeiffer J, Mussa A, Vio F, Gimbel S, Micek M, et al. The role of nonphysician clinicians in the rapid expansion of HIV care in Mozambique. J Acquir Immune Defic Syndr. 2009;52 (Suppl 1):S20–3. [PubMed]
22. Kober K, Van Damme W. Scaling up access to antiretroviral treatment in southern Africa: who will do the job? Lancet. 2004;364:103–7. [PubMed]
23. Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Vujicic M, Soucat A. Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Hum Resour Health. 2011;9:1. [PMC free article] [PubMed]
24. Brentlinger PE, Assan A, Mudender F, Ghee AE, Vallejo Torres J, Martînez Martínez P, et al. Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians’ performance in HIV/AIDS care. Hum Resour Health. 2010;8:23. [PMC free article] [PubMed]
25. Pfeiffer J. International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Soc Sci Med. 2003;56:725–38. [PubMed]
26. Bussmann H, Wester CW, Ndwapi N, Grundmann N, Gaolathe T, Puvimanasinghe J, et al. Five-year outcomes of initial patients treated in Botswana’s National Antiretroviral Treatment Program. AIDS. 2008;22:2303–11. [PMC free article] [PubMed]
27. Moon TD, Burlison JR, Sidat M, Pires P, Silva W, Solis M, et al. Lessons learned while implementing an HIV/AIDS care and treatment program in rural Mozambique. Retrovirology: Research and Treatment. 2010;3:1–14. doi: 10.4137/RRT.S4613. [PMC free article] [PubMed] [Cross Ref]
28. United Nations Development Programme. Human Development Report 2010, 20th Anniversary Edition: The Real Wealth of Nations: Pathways to Human Development. New York: UNDP; [accessed September 21, 2011]. pp. 194–5. Table 13.
29. World Health Organization. [accessed September 21, 2011];Mozambique Health Profile. 2009 Online at:
30. Audet CM, Burlison J, Moon TD, Sidat M, Vergara AE, Vermund SH. Sociocultural and epidemiological aspects of HIV/AIDS in Mozambique. BMC Int Health Hum Rights. 2010;10:15. [PMC free article] [PubMed]
31. The World Bank Group. [Accessed 13 July 2011];Data: Population, total. 2011 Available at:
32. The World Bank Group. [Accessed 29 July 2011];Data: GDP (current US$) 2011 Available at:
33. UNAIDS. HIV estimates with uncertainty bounds 1990–2009. [Accessed 11 July 2011];UNAIDS Report on the Global AIDS Epidemic. 2010 Available at:
34. WHO. [accessed September 21, 2011];HIV in the WHO African region: Progress towards achieving universal access to priority health sector interventions 2011 update. Available at:
35. Office of the United States Global AIDS Coordinator. PEPFAR Second (2006), Third (2007), Fourth (2008), Fifth (2009), and Sixth (2010) [accessed 11 July 2011];Annual Reports to Congress. Available at:
36. Office of the United States Global AIDS Coordinator. [accessed 11 July 2011];PEPFAR First and Third Annual Report to Congress. 2007 Available at:
37. Office of the United States Global AIDS Coordinator. PEPFAR Fiscal Year 2008 (June 2008) and Fiscal Year 2009 (November 2010) [accessed 11 July 2011];Operational Plans. Available at:
38. Klausner JD, Serenata C, O’Bra H, Mattson CL, Brown JW, Wilson M, et al. Scale-up and continuation of antiretroviral therapy in South African treatment programs, 2005–2009. J Acquir Immune Defic Syndr. 2011;56:292–5. [PubMed]
39. Cook RE, Ciampa PJ, Sidat M, Blevins M, Burlison J, Davidson MA, et al. Predictors of successful early infant diagnosis of HIV in a rural district hospital in Zambézia, Mozambique. J Acquir Immune Defic Syndr. 2011;56:e104–9. [PMC free article] [PubMed]
40. Manders EJ, José E, Solis M, Burlison J, Nhampossa JL, Moon T. Implementing OpenMRS for patient monitoring in an HIV/AIDS care and treatment program in rural Mozambique. Stud Health Technol Inform. 2010;160(Pt 1):411–5. [PubMed]
41. Gimbel S, Micek M, Lambdin B, Lara J, Karagianis M, Cuembelo F, et al. An assessment of routine primary care health information system data quality in Sofala Province, Mozambique. Popul Health Metr. 2011;9:12. [PMC free article] [PubMed]
42. Lambdin BH, Micek MA, Koepsell TD, Hughes JP, Sherr K, Pfeiffer J, et al. Patient volume, human resource levels, and attrition from HIV treatment programs in central Mozambique. J Acquir Immune Defic Syndr. 2011;57:e33–9. [PMC free article] [PubMed]
43. Groh K, Audet CM, Baptista A, Sidat M, Vergara A, Vermund SH, et al. Barriers to antiretroviral therapy adherence in rural Mozambique. BMC Public Health. 2011;11:650. [PMC free article] [PubMed]
44. Ministério da Saúde (MISAU), Moçambique. Relatório Anual da DRH (2010) [accessed September 21, 2011];Maputo. 2011 Sep 01; Online at:
45. Ministério da Saúde (MISAU), Moçambique. [accessed September 21, 2011];DRH–Direcçäo de Recursos Humanos: Estatísticas. 2011 Online at:
46. Ciampa PJ, Burlison JR, Blevins M, Sidat M, Moon TD, Rothman RL, et al. Improving Retention in the Early Infant Diagnosis of HIV Program in Rural Mozambique by Better Service Integration. J Acquir Immune Defic Syndr. 2011;58 :115–9. [PubMed]
47. Brentlinger PE, Torres JV, Martínez PM, Ghee A, Lujan J, Bastos R, et al. Clinical staging of HIV-related illness in Mozambique: performance of nonphysician clinicians based on direct observation of clinical care and implications for health worker training. J Acquir Immune Defic Syndr. 2010;55:351–5. [PubMed]
48. Lahuerta M, Lima J, Elul B, Okamura M, Alvim MF, Nuwagaba-Biribonwoha H, et al. Patients enrolled in HIV care in Mozambique: baseline characteristics and follow-up outcomes. J Acquir Immune Defic Syndr. 2011;58:e75–86. [PMC free article] [PubMed]
49. Decroo T, Telfer B, Biot M, Maïkéré J, Dezembro S, Cumba LI, et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. J Acquir Immune Defic Syndr. 2010 Epub ahead of print Nov 13. [PubMed]
50. Coggin WL, Ryan CA, Holmes CB. Role of the US President’s Emergency Plan for AIDS Relief in responding to tuberculosis and HIV coinfection. Clin Infect Dis. 2010;50 (Suppl 3):S255–9. [PubMed]
51. Kahn JG, Marseille EA, Bennett R, Williams BG, Granich R. Cost-effectiveness of antiretroviral therapy for prevention. Curr HIV Res. 2011 Epub ahead of print Oct 14. [PMC free article] [PubMed]
52. Schwartländer B, Stover J, Hallett T, Atun R, Avila C, Gouws E, et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet. 2011;377:2031–41. [PubMed]
53. Shah M, Johns B, Abimiku A, Walker DG. Cost-effectiveness of new WHO recommendations for prevention of mother-to-child transmission of HIV in a resource-limited setting. AIDS. 2011;25:1093–102. [PubMed]
54. Walensky RP, Wood R, Fofana MO, Martinson NA, Losina E, April MD, et al. The clinical impact and cost-effectiveness of routine, voluntary HIV screening in South Africa. J Acquir Immune Defic Syndr. 2011;56:26–35. [PMC free article] [PubMed]
55. Johnston KM, Levy AR, Lima VD, Hogg RS, Tyndall MW, Gustafson P, et al. Expanding access to HAART: a cost-effective approach for treating and preventing HIV. AIDS. 2010;24:1929–35. [PubMed]
56. Leeper SC, Reddi A. United States global health policy: HIV/AIDS, maternal and child health, and The President’s Emergency Plan for AIDS Relief (PEPFAR) AIDS. 2010;24:2145–9. [PubMed]
57. El-Sadr WM, Hoos D. The President’s Emergency Plan for AIDS Relief--is the emergency over? N Engl J Med. 2008;359:553–5. [PubMed]
58. Rennie S, Behets F. AIDS care and treatment in Sub-Saharan Africa: implementation ethics. Hastings Cent Rep. 2006;36:23–31. [PubMed]
59. Zachariah R, Van Damme W, Arendt V, Schmit JC, Harries AD. The HIV/AIDS epidemic in sub-Saharan Africa: thinking ahead on programmatic tasks and related operational research. J Int AIDS Soc. 2011;14 (Suppl 1):S7. [PMC free article] [PubMed]
60. Walensky RP, Kuritzkes DR. The impact of the President’s Emergency Plan for AIDS Relief (PEPfAR) beyond HIV and why it remains essential. Clin Infect Dis. 2010;50:272–5. [PubMed]
61. Duber HC, Coates TJ, Szekeras G, Kaji AH, Lewis RJ. Is there an association between PEPFAR funding and improvement in national health indicators in Africa? A retrospective study. J Int AIDS Soc. 2010;13:21. [PMC free article] [PubMed]
62. Bendavid E, Bhattacharya J. The President’s Emergency Plan for AIDS Relief in Africa: an evaluation of outcomes. Ann Intern Med. 2009;150:688–95. [PMC free article] [PubMed]
63. Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plan. 2009;24(4):239–52. [PMC free article] [PubMed]
64. Hecht R, Stover J, Bollinger L, Muhib F, Case K, de Ferranti D. Financing of HIV/AIDS programme scale-up in low-income and middle-income countries, 2009-31. Lancet. 2010;376:1254–60. [PubMed]
65. Izazola-Licea JA, Wiegelmann J, Arán C, Guthrie T, De Lay P, Avila-Figueroa C. Financing the response to HIV in low-income and middle-income countries. J Acquir Immune Defic Syndr. 2009;52 (Suppl 2):S119–26. [PubMed]
66. Médicins san Frontières. No time to quit: HIV treatment gap widening in Africa. Brussels: Médecins Sans Frontières Brussels operational centre; May, 2010. [accessed February 19, 2012]. pp. 1–32. Available: