Boston — Summary

Physicians for Human Rights (PHR) commends the President's Emergency Plan for AIDS Relief (PEPFAR), recently released by Ambassador Randall Tobias, for outlining some important strategies, but believes the plan requires more funding, is weak on prevention and is short on details, especially on using generic drugs and recruiting and retaining health workers.

Plan misses key preventions for general population

PHR's chief concern is that the Plan fails to emphasize several of the most important prevention strategies for the general population, in particular comprehensive sex education and condom distribution. PEPFAR instead gives disproportionate focus to abstinence-until-marriage programs. The Plan does, however, recognize the need for targeted interventions for vulnerable populations including commercial sex workers, men who have sex with men and injecting drug users. To improve the chances of success, these interventions must be strengthened to create a non-punitive and non-judgmental atmosphere so that members of these groups are not driven completely underground.

Increase overall spending and Global Fund contributions

PEPFAR fails to respond adequately to the overall funding needs for the AIDS, tuberculosis and malaria pandemics. The Administration has proposed $2.8 billion for global AIDS, tuberculosis and malaria, compared to a global need of $5.4 billion for these three diseases. Furthermore, the Plan does not alter the Administration's initial position to send only a small portion of international AIDS funds through the Global Fund to Fight AIDS, Tuberculosis and Malaria - $200 million in fiscal year 2005, rather than the $1.2 billion the Fund needs in FY 2005. The Plan is correct that other countries must also significantly increase their contributions to the Fund. The United States would help encourage larger pledges by other donors, however, by making significantly higher pledges, not through pledging far less than its fair share.

Plan should fund WHO-approved generic medications

The Plan correctly recognizes that the United States should provide high quality medications at the lowest possible cost. However, the Plan fails to address whether the United States will consider generic anti-retroviral medications that have been pre-approved by the World Health Organization (WHO) to be quality drugs that qualify for US funding. PHR believes that the United States should fund WHO pre-qualified generic medications.

PEPFAR sound on women's and children's rights, but must ensure basic needs met, legal protections secured

Commendably, PEPFAR recognizes the need to promote children's and women's rights, though it is short on details. The Plan does include several key approaches. It covers access to education and eliminating gender inequalities in the civil and criminal legal codes. It seeks the provision of legal assistance to children and families to protect them from abuse and secure their property rights. But in promoting women's and children's rights, the United States must support efforts for women and children to meet their basic needs, including nutrition and shelter. Women and children are often placed in situations where they engage in unsafe behavior precisely because they cannot meet those needs any other way. Where sufficient resources for these activities are not available through PEPFAR, Ambassador Tobias should coordinate with other US and multilateral agencies and programs to provide the necessary resources.

PHR is pleased that the Plan also includes interventions to reduce sexual violence, which contributes to HIV transmission. These interventions include changing public attitudes towards sexual violence to make it less acceptable. In addition, the initiative supports a law enforcement strategy against perpetrators of sexual violence where children are victimized. The United States should add to its five-year plan more ways to reduce sexual violence and coercion, including micro-credit and income-generating projects for women that provide them with the financial independence necessary to leave abusive or coercive relationships. The Plan must also provide support for domestic abuse shelters while promoting and assisting legal reform, including marital rape laws.

Distribute AIDS treatment equitably and invest in local facilities and staff

PEPFAR places a clear and refreshing emphasis on rapidly scaling up access to anti-retroviral therapy (ART) to treat HIV/AIDS. PHR is concerned, however, that the Plan does not recognize the need to develop and implement ways to ensure equity in treatment scale-up. Strategies are needed to ensure treatment for rural population, the poor, women and others who traditionally have had reduced access to health services.

Ambassador Tobias acknowledges the importance of building local capacity to treat HIV/AIDS, which is necessary for a sustainable treatment strategy. But building local capacity cannot be successfully accomplished without sufficient numbers of qualified health personnel. The Plan correctly recognizes the personnel shortages that focus countries face, as well as the urgency of increasing recruitment and retention of health workers. Though the Plan includes several important ways to increase the capacity and effectiveness of the existing workforce, it offers no specifics for recruiting and retaining health workers.

PEPFAR's plan for routine testing bold, should remain confidential and voluntary

Other significant elements of the Plan's prevention component include vastly increased access to confidential HIV testing and the elimination of stigma and denial. PHR welcomes the emphasis on confidential testing, and urges that even as every effort is made to increase access to and acceptance of testing, it remains voluntary because of the continued risk of stigma and discrimination against people with HIV/AIDS. The Plan correctly recognizes the need to integrate testing into other health services, which will require investment in primary health care to draw people into the health system, and hence testing and counseling services.

Plan's inclusion of safe health care welcome

PHR also welcomes the Plan's inclusion of safe health care, including blood safety, injection safety, universal precaution and increased availability of post-exposure prophylaxis.

ANALYSIS:

Overall funding and Global Fund support dangerously low

The Administration's proposed spending for PEPFAR in fiscal year 2005 of about $2.8 billion for global AIDS, tuberculosis, and malaria is far too low, only about one-half of the spending to meet the fair US share of the global need for AIDS, tuberculosis, and malaria. The global need for these three diseases is about $15.3 billion in 2005. The fair US contribution to the global AIDS, tuberculosis, and malaria pandemics is $5.4 billion in fiscal year 2005. This is based on the size of the US economy, about one-third of the global economy, and includes the approximately $300 million that the United States spends annually on international HIV/AIDS research.

Meanwhile, the Bush Administration continues to insist that the United States will provide only $1 billion to the Global Fund to Fight AIDS, Tuberculosis and Malaria over PEPFAR's five years, including $200 million in fiscal year 2005. If the Administration follows this plan, it will cause tremendous damage to the Global Fund and the millions of people who depend on the programs that it supports. The Global Fund expects that it will require $3.58 billion in new contributions in fiscal year 2005. One-third of this total, which is what Congress has recognized as a fair share of US contributions to the Fund, is about $1.2 billion for FY 2005 alone. By underfunding the Fund, the United States (and other donors) risk leaving sound proposals unfunded, discouraging applications to the Fund, and even forcing existing programs to be terminated. Just to keep existing programs operational, the Fund will require about $1.58 billion in FY 2005, the fair US share of which is about $525 million.

The Administration is correct that other countries must also significantly increase their contributions to the Fund, and any US activities to promote this goal will be welcome. The United States undermines this goal, however, by asserting that it will pledge only $200 million in FY 2005, rather than the $1.2 billion needed. The United States would help encourage larger pledges by other donors by making significant pledges itself, not through pledging far less than its fair share.

Prevention

Strategy Fails to Promote Comprehensive Sex Education and Condom Distribution for General Population

The Plan has a welcome stated emphasis on "evidence-based best practices." In fact, however, the prevention plan sharply contradicts best practices by apparently ignoring comprehensive sexual education and condom distribution to the general population, both of which are crucial HIV prevention interventions. Comprehensive sexual education programs promote abstinence, but acknowledge the fact that teens may be sexually active, and so also teach contraception. PHR strongly backs comprehensive education. Such education has been proven to delay the onset of sexual activity, reduce the number of sexual partners and increase condom use. Comprehensive sexual education is supported by leading medical institutions, including the American Medical Association.

PHR urges Ambassador Randall Tobias, the US Global AIDS Coordinator, to ensure that youth education programs, as well as norm promotion for youth and adults, are pragmatic and comprehensive. If not, the Plan will fail to offer the tools and skills people need to protect themselves. Congress did express that one-third of prevention funds should be spent on promoting abstinence-until-marriage, but it did not ban funding for comprehensive sexual education or condom promotion.

It appears that this one-third provision was intended to modify funding for sexual transmission prevention programs, and to assure funding for the "A" portion of "ABC" (Abstain, Be faithful, use Condoms) prevention strategies. In keeping with that spirit, PHR urges that the one-third provision apply only to sexual transmission prevention programs, and that abstinence programs not be funded with resources from other prevention accounts, such as voluntary counseling and testing, safe health care initiatives, programs to prevent mother-to-child transmission, and harm reduction programs for injecting drug users. The funding for abstinence-until-marriage should be used for the abstinence component of comprehensive sexual education programs, as well as for activities that protect girls and young women from forced sex, including activities that combat sexual trafficking and sexual violence and that assist survivors of sexual violence.

The Plan distorts the ABC model by qualifying the "C," use condoms, with the term "as appropriate." Evidently, the Administration believes that correct and consistent condom use is "appropriate" only for certain high-risk groups, falsely implying that this intervention is unimportant for the general population. The five-year plan fails to include condom distribution to the general population through social-marketing and other strategies, instead limiting condom distribution to groups traditionally considered as high-risk groups - "those who are infected or who are unable to avoid high-risk behaviors." These groups include discordant couples (those in which one partner is HIV-positive and the other partner is HIV-negative).

In Africa, fewer than one in three people have access to contraceptive promotion programs. Yet as an analysis of Uganda demonstrates, condoms - along with faithfulness and delayed sexual activity - have played an important role in reducing HIV prevalence. Those who engage in sexual activity at any stage of their life must have the information to protect themselves and their partners and the ability to act on that information. The Plan does recognize that program partners "should not disseminate incorrect information about any health intervention or device," a welcome inclusion in an otherwise very disappointing approach to condoms, as this will prevent funding from going to organizations that, beyond not talking about condoms, provide false information about them.

Strategy Reaches Out to Marginalized Groups but Should Include Needle Exchange

The Plan recognizes the need for targeted interventions to groups at high risk of contracting HIV, including commercial sex workers, men who have sex with men, injecting drug users (and substance abusers more generally), and mobile male populations, including migrant workers, truck drivers, and military personnel. The Plan also recognizes the need for special efforts to ensure that women, the poor and the disabled receive HIV/AIDS information. The United States should also work to create the legal, political, and social conditions where these groups and their advocates will not be subject to harassment or arrest and will not be driven underground because of stigma or fear. Without these conditions, interventions for marginalized populations risk failing.

The Administration should be sure that the goal of eradicating prostitution does not interfere with prevention efforts for commercial sex workers and their clients. These essential life-saving, cost-effective interventions should not be limited by the legislative prohibition of funds to groups without an explicit policy opposing prostitution. PHR urges that the United States approach the eradication of prostitution constructively, through support for economic empowerment of women and education of girls, not through prosecuting women.

Despite several general statements about eliminating sexual trafficking, the Plan does not delve into specifics. The Plan calls for special programs to be "developed for child victims of sexual exploitation and children working in prostitution." PHR urges coordination with the US Office to Monitor and Combat Trafficking in Persons, including a focus on countries such as Thailand and India. Both of those countries have large numbers of trafficking victims and high HIV prevalence.

The Plan commendably includes several specific interventions for injecting drug users. It calls for improving referral systems between substance abuse treatment services and HIV testing and counseling, and promotes services for substance abuse and prevention. The five-year plan does not refer to the importance of clean needle-exchange for injecting drug users, an omission that PHR urges be corrected in the future, including in-country plans. This is particularly important because the 15th focus country will likely be in Asia or Eastern Europe, where injecting drug use is a major factor in HIV transmission. Needle-exchange programs reduce HIV prevalence without increasing drug use. A global review from 1988 to 1993 of 29 cities with needle-exchange programs found no increase in the number of injecting drug users; HIV prevalence fell by 5.8% per year.

Plan confronts stigma and discrimination

PHR appreciates the Plan's approach to stigma and discrimination. PEPFAR proposes to, in its own words, "act boldly to address stigma and denial." This is exactly the type of response needed. PEPFAR includes three main approaches for addressing stigma: 1) working with local and national leaders "to speak out boldly against HIV/AIDS-related stigma and violence against women" and to promote gender equality; 2) engaging in capacity-building activities with organizations that will address stigma, and; 3) "[p]romot[ing] hope by highlighting the many important contributions of people living with HIV/AIDS, by providing ARV [anti-retroviral] treatment to those who are medically eligible."

The United States will also involve HIV-positive people "in meaningful roles in all aspects of HIV/AIDS programming," a critical element of PEPFAR that must be pursued. The Plan also recognizes that stigma is an obstacle to treatment, and proposes several general ways to address this. It puts forth the need to "support implementation of good policies and effective legislation," including to protect "against stigma and discrimination, particularly within key settings such as workplaces, schools, and the military." PHR encourages the Administration to also support policies that address discrimination in the health sector, including by addressing stigma and discrimination in the health worker training that the United States supports.

Even more must be done. The United States should encourage and support innovative ways of addressing discrimination, such as "post-test clubs." These groups, open to anyone who has been tested for HIV, promote acceptance of and can help empower people with HIV/AIDS. The United States should also be cognizant of issues of stigma and discrimination in all aspects of its HIV/AIDS strategy.

PEPFAR outlines women's and children's rights but needs more specifics

PEPFAR recognizes the need to promote children's and women's rights but offers few details. It comments on the need to address inheritance as well as access to education and school-related expenses. The Plan also states that the United States will work with communities, donors and others to promote gender equality and will encourage local leaders, including community, religious, and entertainment figures, to speak out about gender equality.

The United States will support eliminating gender inequalities in civil and criminal legal codes. The Plan includes support for programs that will "provide children and families with legal assistance to protect property rights and ensure protection from abuse." PHR especially welcomes the inclusion of this legal assistance. Even when rights are provided for by law, those rights are frequently disregarded in practice, particularly in areas of law such as marriage, property ownership, and inheritance, for which customary law is often applied. Customary law is mainly unwritten law incorporating traditional norms and values, as they have been applied and interpreted by the courts and social practices. Customary law frequently subordinates women to men.

The United States will also support community-based organizations, "especially faith-based groups, for early outreach and intervention to prevent transactional and survival sex among these extremely vulnerable young people. These local groups will be supported to reach these young people early with HIV education, counseling, and social support to encourage abstinence and other safer behaviors."

Survival sex involves sex in exchange for money or goods that the children need to survive, so is not a matter of meaningful choice. Since encouraging these children to abstain from sexual activities will therefore fail in many cases, organizations that the United States supports to provide HIV information to children at high risk for engaging in transactional and survival sex should include information on and provision of condoms. Both to protect the children from HIV/AIDS - they might not even be in a position to negotiate condom use - and to help protect children's human rights, the United States should fund organizations that will help meet the children's basic needs, such as nutrition, shelter, and education, so that they do not have to engage in transactional and survival sex. These groups should be careful to avoid creating further stigma for these children by labeling them "AIDS orphans," or creating resentment by enabling children whose parents have died of HIV/AIDS to receive support, while children whose parents died of or became disabled by other causes do not receive assistance.

Along with developing strategies to end the discrimination against women and children, the plan should include ways to meet their basic needs, including through micro-credit and income-generating projects, nutritional support, educational support, and shelter. PHR welcomes the Plan's explicit recognition of the need to support children's access to education. Where resources for these activities are not available to the extent necessary through PEPFAR, Ambassador Tobias should coordinate with other US and multilateral agencies and donors to provide the necessary resources.

PEPFAR strong on sexual violence education, less so on economic, legal concerns

The Plan provides several ways to address the significant role of sexual violence and coercion in HIV transmission. These include strengthening community norms against sexual violence; using workplace and school-based programs to educate men and boys about preventing sexual violence; training health providers and teachers to identify cases of sexual abuse, and; supporting "the review, revision, and enforcement of laws relating to sexual violence against minors, including strategies to more effectively protect young victims and punish perpetrators." PHR urges that the training of teachers also include mechanisms to reduce the incidence of sexual abuse by the educators themselves. The plan should also assist confidential reporting and how such abuse is addressed.

In addition, the United States should encourage eradication of sexual exploitation and violence through other measures, including micro-credit and income-generating projects for women, and training for the police and judiciary. The plan should support domestic abuse shelters, assist legal reform such as marital-rape laws, and back women who bring claims of sexual abuse to court. The United States should provide direct support to the women subject to abuse and to groups seeking to end domestic violence, to provide shelter to domestic abuse survivors, and otherwise help end domestic abuse and sexual violence and assist survivors. Financial assistance and reforms in such areas as property law are necessary to provide women the economic independence that they need to enable them to resist coercion and leave abusive partners.

PEPFAR solid on safe health care PHR commends Ambassador Tobias for recognizing safe health care as one of the important elements in an HIV prevention strategy. The document describes both the problem of unsafe health care and the planned US response. The Plan focuses on technical assistance, training, developing policies and protocols, and logistical support in the areas of strengthening blood transfusion services, supporting safe injection practices and universal precautions, and increasing the availability of post-exposure prophylaxis.

Routine testing approach bold but should remain voluntary

The Plan correctly recognizes people's ignorance of their own HIV status as a significant obstacle to HIV prevention and treatment activities. Accordingly, PEPFAR includes HIV testing as one of the pillars of the US prevention plan. The Plan promotes numerous ways to increase confidential testing, including integrating testing with other health services and making confidential testing available in other settings, such as marriage registration, school enrollment and military enlistment. The United States will also support training of health workers, counselors, laboratory workers, and other support people; test kit availability; strengthening links between counseling, testing, and post-test services, and; other interventions that will make greatly increased testing possible. In an important recognition of the special obstacles women face to testing, the Plan includes "[p]roviding support to women to mitigate potential violence or other negative outcomes of disclosing HIV-positive status to male partners."

PHR commends the Plan for recognizing the need to integrate testing into other health services. This will require investment in primary health care to draw people into the health system, in particular at the primary level where most people access health services. Confidential testing and counseling will then be available to people when they access these services.

PEPFAR's goal is to make confidential testing routine. PHR supports this goal, which could have a significant, positive effect on both prevention and treatment. However, the Plan is unclear whether the routine testing it promotes is meant to be voluntary or mandatory. PHR urges that the plan does not eliminate the voluntary aspect of testing, even as every effort is made to increase the availability and acceptability of testing. Because of the continued risk of stigma and discrimination against people with HIV/AIDS, including the risk of violence against women if their husbands learn their status, testing must continue to be voluntary.

Treatment

Plan's use of generics vs. brand medication unclear, PHR urges using WHO-approved generics

The use of the lowest-cost drugs, including generics, is important because this will allow more people to be treated with the same amount of funding. Before the release of the Plan, questions existed about whether PEPFAR would purchase generic anti-retroviral drugs (ARVs) or more expensive branded ARVs. The questions remain. According to the Plan, "Emergency Plan funds used to purchase products will be directed to obtaining high-quality goods at the lowest possible price. This could mean bioequivalent versions of branded ARV and other medications." "[B]ioequivalent versions of branded ARV" are also referred to as generic drugs. In other words, whether generic drugs are purchased hinges on whether they qualify as "high-quality." PHR supports the use of medications that have been pre-qualified by the World Health Organization, and believes that these drugs are, and should be considered by the United States to be, "high-quality."

The questions over generic drugs have been especially focused on their use in fixed-dose combination ARVs, which combine multiple drugs in a single tablet, thus facilitating adherence to treatment. These questions are also unanswered. The Plan states that "[t]he development of safe and effective fixed-dose combination (FDC) antiretroviral medications is a goal the Administration supports, and" that the United States will co-sponsor a conference this spring "to produce an international consensus document that will set out principles that need to be taken into account when considering FDC drug products."

Rollout should be speedy but still equitable

PEPFAR places a clear and welcome emphasis on meeting the tremendous needs of populations where the overwhelming majority of people in need of anti-retroviral therapy (ART) to treat HIV/AIDS are unable to access treatment. To meet this goal, the Plan is directing funds first to existing treatment programs that can be expanded, and then to facilities that can, with targeted technical assistance and training, introduce ART.

PHR is concerned, however, that PEPFAR fails to acknowledge the need to develop and implement strategies that will help ensure equity in treatment scale-up. In most or all of the focus countries, existing health infrastructure is unevenly distributed, favoring urban populations over rural populations. The Plan's emphasis on building treatment capacity in existing facilities therefore risks entrenching these inequities in AIDS treatment. In addition, factors such as the power dynamics within many families and communities place women at risk of receiving less access to treatment than men unless attention is given to designing a treatment plan that will ensure women equal access to treatment. The United States must also pay special attention to ensuring that the poor, including those unable to contribute to the cost of the medications, receive equal access to treatment. PHR welcomes the Plan's recognition that children must be included in treatment programs.

PHR urges Ambassador Tobias and his team to develop strategies to address equity issues, possibly using forthcoming World Health Organization guidelines as a guide. Approaches could include special emphasis on scaling up treatment at facilities where women are likely to receive care (such as antenatal and reproductive health clinics), as well as on public sector and other facilities that provide treatment and no cost or almost no cost, and support to rural clinics to enhance their infrastructure to prepare them to deliver ART. While rapid scale-up now is indeed necessary, discussions at the countries level on equity in scale-up should begin immediately, with broad civil society participation.

PEPFAR aware of need for funding local institutions, integrated health services

PEPFAR correctly recognizes that building local capacity to treat HIV/AIDS and strengthening health infrastructure are necessary for sustainability, and that AIDS treatment should be integrated into other health service delivery.

To the Administration's credit, it appears that treatment funds will largely be directed to local institutions, rather than foreign NGOs or workers. Initial funds will go to existing programs in the interest of moving the funds out and getting treatment started very quickly. This would appear to correspond to the first request for proposals on ART, through which grants are now beginning to be made to US partners. The next phase of scaling up will focus on health facilities that, with some additional training and technical assistance, would be able to provide treatment. Since these phases can occur simultaneously, the second phase should begin immediately. The United States should also quickly begin to invest in health facilities that do not presently provide quality health services, but are important to ensuring the broadest possible coverage of ART, including in rural areas. The sooner the services of these facilities are improved, the sooner treatment will be available to underserved populations.

PEPFAR will target a wide range of facilities in the second phase of treatment scale-up, including public health clinics, private faith-based and community-based organizations (including mission hospitals and health center), and private commercial facilities, as well as existing tuberculosis and malaria treatment sites. Funding local health facilities means that the funds will not go towards developing a parallel infrastructure of AIDS treatment. Integrating treatment with other health services will increase accessibility of treatment, which will also make it more accessible to the poor, and hence more equitable; reduce the degree to which stigma is an obstacle to treatment; facilitate treatment of co-morbid infections (infections such as tuberculosis that are common in people with HIV/AIDS); help ensure sustainability; avoid duplication, and; strengthen health systems overall.

PEPFAR focuses on training local health personnel

The strategy for meeting short-term training needs is "rapidly expanding the training of existing health workers and supplementing their capacity with foreign volunteer health professionals." Given that the foreign health professionals are to be volunteers, and training of existing health workers is an emphasis from the very beginning of the AIDS Initiative, it appears both that PEPFAR is aimed at building local capacity and that the United States will not spend much money on US or other foreign health workers, which would unnecessarily consume significant funds - though because of travel and other costs, even "volunteers" can be significantly more expensive than local personnel. The report calls using volunteer US and other foreign health professionals in the short-term an "important strategy" to meet the human resource needs. It is important that the United States ensure that the use of volunteers is limited, and that the focus of PEPFAR be on developing local capacity. The United States will also assist focus countries with immigration reform to make it easier for health workers from countries with health professional surpluses to provide short-term services in focus countries.

Among activities to support local health personnel are using telecommunications technologies and distance learning for training. Through a twinning mechanism, in which US-based institutions are paired with African or Caribbean institutions, "centers of excellence" will be created, "from which training, research, and talent can be diffused throughout the impacted regions." These should be used to train trainers who can provide on-the-job training in outlying facilities.

To maximize the capacity of existing health personnel, the United States will support several important strategies, including increasing the responsibilities of nurses and other health workers for patient care, treatment, and support, and working to involve traditional healers, birth attendants, family members, and other lay people in HIV services, including for treatment adherence and referral to the appropriate health services. The Plan also recognizes the need to develop a workforce that, over the long-term, will be able to provide ART. To that end, the United States will promote incorporating HIV/AIDS management into pre-service training curricula for health professionals, provide technical assistance for long-term human resource planning, and help develop training program that focus on mentoring health workers in HIV management in clinical settings. PHR commends this plan for focusing on training health workers on-site, rather than on classroom training which requires removing health workers the clinical settings. US training plan should include follow-up to ensure the success and lasting impact of the training and a commitment to facilitating continuing HIV education as needed. Limited rapid human resource assessments will be conducted to determine which facilities are ready to rapidly scale-up treatment, though these are not the nationwide, comprehensive assessments that are also necessary.

PEPFAR needs to develop plan to recruit and retain health workers

An aspect of developing a sustainable treatment program that the Plan only beings to address is the need to ensure that the health personnel who are trained in HIV/AIDS management remain in the health sector to provide those services, including a sufficient number in the public sector. The public health sector typically provides care to half or more of the population of African countries, and is the main source of health care for the poor. Furthermore, enough new health personnel must enter the workforce to meet the growing needs for health services and to compensate for health worker attrition.

The Plan encourages policies to counteract the brain drain - a significant source of health professional attrition in many of the focus countries - and increase job satisfaction. An appendix on human resource capacity concludes: "Clearly, Africa's human resources crisis in health care has a global dimension and an international inquiry and response is needed. The emigration of its health professionals needs to be urgently addressed to help stabilize its health care systems and institutions."

The Plan does not, however, define what these policies will be to counter the brain drain and to recruit and retain health professionals, other than supporting regional policies to address cross-border migration. Given the need to support health workers and to overcome their shortage, it is critical that country strategies include specific policies to recruit and retain health care workers. Such interventions might include additional support for universal precautions, increased compensation for health workers, human resources management capacity-building, support for health training institutions, support for strategies to increase availability of medicines and other key items, and more. While not in the context of recruitment and retention, the Plan does provide for some of this support, including for improving supply chain/distribution systems, as well as for equipping facilities that provide ARVs, upgrading health information management systems, strengthening research and surveillance capacities, improving fiscal and management systems, and increasing laboratory capacity.

The document includes the seeds for many recruitment and retention strategies in the appendix on human resource capacity, but in the context of describing the human resource situation, not the US response to it. In listing "push" and "pull" factors fueling the brain drain, the appendix touches upon many of the issues that must be addressed. The appendix provides some detail on recruitment and retention strategies not provided in the body of the report, such as increased compensation, but these are described as possible host government actions, not planned US actions.

Go to www.phrusa.org for more information.