In May 2003, P.L. 1). Global AIDS Coordinator is based and reports  directly to the Secretary of State; USAID; and the Department of Health and  Human Services (HHS). Leadership Act established the position of the U.S. The U.S. U.S. Government Faces Five Major Challenges to Expanding ARV Treatment in Resource- poor Settings

In our structured interviews, we identified the following major challenges  to U.S. government agencies in expanding ARV treatment in resource-poor  settings:  (1) difficulties coordinating with other groups involved in  combating HIV/AIDS; (2) U.S. government policy constraints; (3) shortages  of qualified health workers; (4) host government constraints; and (5) weak  infrastructure (see fig. These challenges were also highlighted by  numerous government and nongovernment experts whom we interviewed  and in documents we reviewed. Coordinator’s Office Has Taken Steps to Address Challenges, but Continued Effort Is Needed

The Office of the U.S. Global AIDS Coordinator has acknowledged each of  the five challenges to expanding ARV treatment programs and has taken  certain steps to address them, but some of these challenges require  additional effort, longer-term solutions, and the support of others involved  in providing ARV treatment. First, the Coordinator’s Office has devised  means to improve coordination among U.S. agencies and with host  governments and other organizations; however, it is too soon to tell  whether they will be effective and the PEPFAR strategy does not state  whether the means will be monitored. Third, the Coordinator’s Office proposed short-term assistance to address  health worker shortages, including the use of paid workers and volunteers  from the United States and other countries, and the PEPFAR strategy  proposes several longer-term interventions. However, U.S. officials said  that using international volunteers for the short-term activities is not cost  effective. However, this guidance leaves key issues unresolved. Global AIDS Coordinator’s ability to address  challenges in expanding AIDS treatment in PEPFAR focus countries, we  recommend that the Secretary of State direct the Coordinator to  monitor implementing agencies’ efforts to coordinate PEPFAR activities  with stakeholders involved in ARV treatment, including taking adequate  steps to actively solicit the input of host government officials and  respond to their input;  collaborate with the Administrator of USAID and the Secretary of HHS  to address contracting capacity constraints in the field and resolve any  negative effects resulting from the differing laws governing the funds  appropriated to these agencies in the areas of procurement and foreign  taxation of U.S. assistance, as well as differing requirements for auditing  non-U.S. grantees;  specify the activities that PEPFAR can fund and support in national  treatment programs that use ARV drugs not approved for purchase by  the Coordinator’s Office; and   work with national governments and international partners to address  the underlying economic and policy factors creating the crisis in human  resources for health care. Response

To assess the Global AIDS Coordinator’s response to these challenges, we  reviewed The President's Emergency Plan for AIDS Relief: U.S. Five Year  Global HIV/AIDS Strategy (February 2004); administration guidance,  including several communications to the field on ARV procurement; and  information on the emerging structure and initial activities of the  Coordinator’s Office.
Why GAO Did This Study

The President's Emergency Plan for AIDS Relief (PEPFAR), announced January 2003, aims to provide 2 million people with anti-retroviral (ARV) treatment in 14 of the world's most severely affected countries. In May 2003 legislation established the position of the U.S. Global AIDS Coordinator in the State Department. GAO was asked to (1) identify major challenges to U.S. efforts to expand ARV treatment in resource-poor settings and (2) assess the Global AIDS Coordinator's response to these challenges.

What GAO Found

GAO interviewed 28 field staff from the U.S. Agency for International Development (USAID) and the Department of Health and Human Services (HHS), who most frequently cited the following five challenges to implementing and expanding ARV treatment in resource-poor settings: (1) coordination difficulties among both U.S. and non-U.S. entities; (2) U.S. government policy constraints; (3) shortages of qualified host country health workers; (4) host government constraints; and (5) weak infrastructure, including data collection and reporting systems and drug supply systems. These challenges were also highlighted by numerous experts GAO interviewed and in documents GAO reviewed. Although the Global AIDS Coordinator's Office has begun to address these challenges, resolving some challenges requires additional effort, longer-term solutions, and the support of others involved in providing ARV treatment. First, the Office has taken steps to improve U.S. coordination and acknowledged the need to collaborate with others, but it is too soon to tell whether these efforts will be effective. Second, to address policy constraints, U.S. agencies are working to enhance contracting capacity in the field and resolve differences on procurement, foreign taxation of U.S. assistance, and auditing of non-U.S. grantees. However, the Office's guidance did not address key issues related to the use of PEPFAR funds to buy certain ARV drugs. Third, the Office has proposed short-term solutions to the health worker shortage, such as using U.S. and other international volunteers for training and technical assistance; however, agency field officials said that using such volunteers is not cost effective. The Office is discussing with other donors certain longer-term interventions. Fourth, the Office has taken steps to encourage host countries' commitment to fight HIV/AIDS, but it is not addressing systemic challenges outside its authority, such as poor delineation of roles among government bodies. Finally, the Office is taking steps to improve data collection and reporting and better manage drug supplies.