Looking back: harnessing RWHAP expertise to rapidly establish and scale-up PEPFAR

When PEPFAR was authorised in 2003,12 millions of people in LMICs were dying annually due to little or no access to life-saving antiretroviral medications. Building on experience administering equitable healthcare to the highest-need communities in the USA, HRSA rapidly established emergency HIV services in 15 countries (table 1, row 1).12 13 Known as the Track 1.0 Care and Treatment Programme, the foundational elements of the RWHAP played a key role in the establishment of PEPFAR initiatives to ameliorate HIV-related morbidity and mortality and the accompanying burden on individuals, families and health systems. Treatment algorithms, best practices and lessons learnt from the RWHAP were used to accelerate development of tailored national treatment guidelines and clinical standards of care while US training materials were modified to rapidly build capacity of health workers. Human resources supporting the RWHAP, transitioned to apply their expertise globally and RWHAP continuous quality improvement techniques were used to increase the effectiveness of PEPFAR programmes. Additionally, the technical assistance framework used to strengthen RWHAP service organisations was adapted to bolster capacity of host governments and local partners, laying the path for transitioning PEPFAR programmes to sustainable, country-led programmes (table 1, row 2).13 14

Given the emergency nature of the PEPFAR programme, the initial focus was on rapidly developing the systems and infrastructures to deliver life-saving treatment. There were, however, byproducts that were positive outcomes to US domestic HIV services. For example, the Medical and Nursing Education Partnership Initiatives (MEPI/NEPI), developed to address health workers shortages in LMICs, created a robust community of practice among 60 medical schools in sub-Saharan Africa and 26 in the USA and Europe which strengthened health education and research in HICs simultaneously (table 1, row 3) as international consortia implemented pioneering, multicountries studies, and US tertiary education institutions for global health programmes.15–18 Additionally, the US Food and Drug Administration pathway of approval for the use of highly efficacious combination HIV antiretroviral medication in the US took into consideration international guidance and the robust portfolio of evidence from PEPFAR-supported countries. Further, the PEPFAR Capacity Building and Strengthening Framework19 was adapted to articulate the RWHAP health systems strengthening efforts from a public health perspective, demonstrating community-level benefits and impacts on direct patient outcomes to successfully ensure continued funding. As an additional example, the Friendship Bench, a problem-based psychological intervention to address common mental health disorders developed in Zimbabwe, has been scaled-up across sub-Saharan Africa and the USA (refer to box 1 for additional examples.)

Reflecting on today: beginning to leverage bidirectional relationships

As PEPFAR programmes matured, lessons learnt from LMICs gradually began impacting health services in the USA with more intentionality. One example is the HRSA Skill Sharing Programme, a bilateral expert exchange programme designed not only to translate clinical successes in the USA to PEPFAR-supported facilities, but also to enable RWHAP providers to apply global best practices to the US healthcare landscape.20 (table 1, row 4). Another example is the HRSA-funded Strengthening Interprofessional Education to Improve HIV Care Across Africa (STRIPE HIV) which supports multidirectional learning networks across sub-Saharan Africa to implement GHRI (table 1, row 5).21 22 A hallmark of STRIPE-HIV is the robust platform for sharing innovation and lessons learnt through the African Forum for Research and Education in Health.23 SSP, STRIPE-HIV and multiple other GHRI have used the Extension for Community Healthcare Outcomes (ECHO) video conference platform developed at the University of New Mexico for teaching community providers to deliver best-practice medical services to underserved populations.24 Used by HRSA to support US health workforce training,25–28 ECHO allows for large-scale bidirectional telementoring and virtual sharing of lessons learnt, facilitating development of peer-to-peer interactions among national, regional and global experts for real-time virtual collaboration, engagement and experience-sharing among geographically dispersed, multidisciplinary teams.

The way forward: optimising GHRI to end the HIV epidemic

As multiple PEPFAR-supported countries begin to reach and exceed the UNAIDS HIV epidemic control targets,29 30 other countries, including the USA, have considerable progress to make. To help close these gaps, HRSA developed a white paper in 2018 exploring areas for GHRI between RWHAP and PEPFAR.31 This laid the groundwork for increasing the frequency, depth and intentionality of bidirectional, mutually beneficial collaboration and coordination between global and US domestic initiatives through forums for sharing and collaboration, the use of implementation science (IS) and by optimising strategic health initiatives.

Learning from the past

HRSA is committed to advancing and integrating bidirectional learning and international collaboration towards ending the US HIV epidemic and the global AIDS pandemic as a public health threat by 2030. An integral part of these initiates is documenting and sharing the lessons learnt, best practices and effective models of care in the global HIV/AIDS response in a timely manner. These include building on what works, harnessing technology and innovation, and inculcating the spirt of multidirectional learning into global health.

Building on what works

When the PEPFAR programme was initiated, the foundational elements of the RWHAP were critical in rapidly developing life-saving HIV programmes in international settings. US treatment algorithms, guidelines, frameworks, models of care and training materials accelerated the establishment of the emergency response. While it was quickly apparent that a ‘plug and play’ approach was inadequate, tailoring elements of the US HIV response to the specific local context within PEPFAR-supported countries was successful in reducing the time, resources and burden required to scale up successful life-saving programmes.

Given the emergency nature of the response when PEPFAR commenced, the leveraging of lessons learnt from on-the-ground implementation was limited. However, as PEPFAR matured, sharing of lessons learnt and best practices increased, with the MEPI/NEPI programmes laying the groundwork for developing communities of practices. By building on the success of the MEPI/NEPI programmes, STRIPE-HIV and the African Forum for Research and Education in Health (AFREhealth) created a robust model for collaborative, evidence-informed sharing of best practices and lessons learnt that emphasised multidisciplinary, team-based learning and continuous quality improvement.22 23 While international communities of practice are now common within PEPFAR programmes, these critical initiatives were built incrementally from the success achieved and challenges overcome by the MEPI/NEPI programmes, the STRIPE-HIV initiative and AFREhealth, which demonstrates the importance and impact of building up on what works.

Harnessing innovation and technology

Innovation is a key ingredient in the promotion of GHRI with in the fight against HIV. The HRSA Skill Sharing Programme took a unique approach to bidirectional learning through international peer-to-peer collaborative problem-solving. By leveraging technological advances in communication, HRSA developed a programme in which remote mentoring successfully supplemented in-person site visits as an add-on approach to create synergies with existing on-the-ground programmes. During the pilot in Uganda, not only did health service delivery improve at the supported PEPFAR-supported sites, but also the RWHAP providers witnessed first-hand the effectiveness of various task shifting, peer support, community support and tailored service delivery models for reaching vulnerable members of their own communities in the USA.

The importance of harnessing innovation and technology is further exemplified by the unique opportunities presented by the COVID-19 pandemic to rapidly scale new training modalities and maximise the use of online learning platforms. As health professionals around the world struggled to address the challenges posed by COVID-19, virtual platforms were integral in leveraging lessons learnt from PEPFAR HIV service delivery in LMICs to support the US domestic response to the COVID-19 pandemic. The PEPFAR-supported efforts to fight HIV in LMICs were critical in the development of COVID-related contact tracing protocols, community outreach programmes and service delivery models to decongest clinics. For example, Jhpiego, a PEPFAR implementing partner specialising in global health, used decades of experience delivering community-based services in LMICs to support the development of the Baltimore Health Corps Project to pilot an innovative community-health worker project during the height of the COVID-19 epidemic.34 The innovative approaches used in the global fight against HIV hold promise for not only helping end the HIV epidemic in the USA and other HICs, but also for bolstering preparedness for outbreak response to future epidemics and health emergencies.

Inculcating the spirt of multidirectional learning into global health

Intentionality is critical in maximising GHRI. Over the past 20 years, there has been an evolution in the focus placed on bidirectional learning within the global-domestic US HIV/AIDS response. While there has been an increased shift towards these important initiatives, the utilisation of these efforts needs to be explored with more intentionality to advance GHRI. While efforts are underway, there is a clear need to expand the breadth and depth of tailored GHRI to fully optimise synergies between RWHAP and PEPFAR. GHRI must be deliberately incorporated into global health programmes to accelerate achievement of HIV epidemic control; ensure country-led, sustained responses to public health threats; and achieve WHO Sustainable Development Goals.

HRSA will continue to explore opportunities for programme and policy innovations that are applicable across borders, linking innovation with impact worldwide. Guided by lessons learnt and best practices from over 30 years of experience administering RWHAP and 20 years supporting PEPFAR implementation, HRSA will continue building on intentional efforts to promote GHRI in domestic and international HIV programming through documenting, sharing and implementing strategies, lessons learnt, best practices and effective models of care in the global HIV/AIDS response.