On World AIDS Day 2009 (December 1), the Office of the Global AIDS Coordinator (OGAC) released its second 5-year PEPFAR strategy.?Months ago, OGAC officials told NGOs that the strategy was not going to be very detailed—more of a 30,000 feet overview—and they meant it. This strategy is focused on broad directions, which include sustainability, integration, country leadership and ownership, efficiency and more emphasis on health system strengthening.These are generally very positive directions.?Below are a few of my thoughts on this initial strategy, and on where you and PHR can have impact on AIDS policy for the next half decade:A Question of Ownership: Country ownership and local empowerment is critical for AIDS programming to succeed. But the question remains: what qualifies as “the country?" ?Is it only the government, or also civil society?? What are the implications for marginalized populations who might be the subject of official discrimination, such as the case of men who have sex with men in countries that criminalize homosexuality, or the implications for injecting drug users in countries that treat addiction as a crime? PHR works with both government and local civil society, and PEPFAR must think about both levels as they move forward.Health Workforce: One of PHR’s signature issues receives several mentions in the strategy, while the strategy highlights PEPFAR’s new, more deliberate emphasis on health system strengthening. The target of at least 140,000 new health workers is referenced as one of the PEPFAR targets, and training and retaining health workers is included as one of the planned HSS activities, but with virtually no additional detail.? Also on the health worker front, strategy says: “PEPFAR’s prevention, care and treatment activities are planned with consideration of how they may impact the overall health system, particularly human resources for health.” This focus on health workers and health systems more broadly is good news for ensuring the overall right to health is promoted through PEPFAR, but we will have to stay vigilant and support the administration to fill in the details of how to reach this critical goal.Prevention–Women and IDU: Prevention remains paramount in PEPFAR II—but prevention programs this time around are based more firmly in science, and less in ideology. The strategy includes services for IDU as an example of high-impact prevention interventions for which PEPFAR is expanding investments, and the strategy refers to having services responsive to needs of marginalized populations, such as IDU.? It does not say more about these services, however, such as whether they will include syringe exchange.? While federal legislation to end the ban on the use of federal funds for domestic needle exchange is currently stalled in the Senate, we will need your help soon to ensure US laws reflect the best knowledge of science for IDUs.To its credit and very significantly, OGAC is now committed to integration, with a particular focus on integration of HIV services with family planning and reproductive health services. ?The strategy also includes several references to stigma, including as an area that can be addressed in partnership frameworks (though a new PHR analysis of partnership framework agreements has found that the framework agreements developed thus far could do a much better job of addressing stigma and discrimination).? PEPFAR programs will address particular vulnerabilities of women, especially gender-based violence.? The strategy also notes that PEPFAR, as part of the Global Health Initiative, is working to implement women centered-care. ?And in a shift to evidence-based prevention, the strategy includes the target that all youth who are “in PEPFAR prevention programs” should have “comprehensive and correct knowledge of the ways HIV/AIDS is transmitted and ways to protect themselves.” None of this is surprising, but it is all to the good.? The question will be how this plays out in more detailed guidance and, ultimately and most significantly, on the ground.Treatment and timing: Amidst limited detail, a few things did stand out.? One was the treatment goal of 4 million people, an increase from the 3 million target that had been part of PEPFAR’s messaging previously.? While this increase is welcome, it nonetheless represents a slower paced scale up than in the past – adding not much more than 300,000 people per year to treatment over the next five years, building from the 2.4 million people that PEPFAR had on treatment by the end of September 2009.? This compares to an increase of more than 500,000 people from FY’06 to FY’07, and an increase of more than 600,000 people from FY”07 to FY’08.? We have already seen the slowed pace of treatment scale up that has come with flat-funding – the increase from FY’08 to FY”09 fell to about 400,000.? This comes even as WHO has recommended that people receive treatment earlier, which will further add to the number of people who need treatment.? Under the previous guidelines, in the end of 2008 nearly 10 million were in immediate need of treatment, a number that increases each year.Another point of note is timing – targets are for fiscal years 2010-2014, even though PEPFAR was reauthorized for FY’09-FY’13.? The FY’10-FY’14 dates align with the Global Health Initiative and account for the fact that FY’09 is over.? These dates give PEPFAR an extra year to meet its targets, such as the new treatment goal.? This may also explain why the strategy describes the target for new health workers as “more than” 140,000 new health care workers, even as the legislation calls for “at least” this number of new health workers..Coordination and Mission Expansion: While the strategy was quite positive on PEPFAR’s efforts, it was self-critical of some operational aspects with respect to inter-agency coordination, incorporating (or not) field perspectives, and burdensome reporting requirements.? And reflecting the wavering global commitment to AIDS funding, and the growing interest in health system strengthening and other health issues, including maternal and child health, the strategy includes points about the broader positive health impact of PEPFAR and AIDS investments generally, particularly with respect to reducing child mortality overall and from non-HIV causes.Funding: The strategy includes little discussion of future funding – even as global AIDS budgets have been more or less flat-funded in FY’09 and FY10 – and there is a real risk of flat-funding again in FY’11.? In some countries, flat funding is already leading to ARV stock-outs, treatment freezes, and reduced voluntary testing and counseling efforts for fear that if HIV-positive people are identified, money wouldn’t be available to treat them.? Inadequate funding is costing lives.? And it will make goals like training and retaining at least 140,000 new health workers and reaching the treatment target of 4 million people – while also expanding prevention and other efforts – significant challenges.? Securing increased and sufficient funding for global AIDS and other global health needs will clearly remain a major priority for health advocates – and a significant challenge, an uphill struggle – in the years ahead.? We will need your help.Global Responsibility, Local Mentoring: Perhaps because of the funding situation, the strategy includes some emphasis on how fighting AIDS and improving global health is a shared global responsibility, and on collaboration with other donors and partners.? The strategy does say that in its next phase, PEPFAR will work “with countries and international organizations to develop a shared global response to the burden of treatment costs in the developing world, and assisting countries in achieving their defined treatment targets.”? Read one way, this could be quite meaningful – figuring out what the treatment costs are and developing some agreed to formula to ensure that these costs are met.? That would however be too optimistic a reading, probably; more likely, this is simply about getting other non-US government sources to pick up more of the cost of treatment.Interestingly, in several places the strategy references technical assistance and mentoring country governments.? Looking ahead, this could create advocacy opportunities with respect to certain things we would like to see included in such TA and mentoring, such as on policies addressing stigma and discrimination, rights-based policies more generally, and ways to increase domestic health spending.Rights and Responsibilities: Speaking of rights, the last point I will note here is that according to the strategy, PEPFAR is ”facilitating partnerships between governments and a strong civil society, to ensure that citizens can work to provide support to and demand accountability from governments.”? This is a potential entry point increased US government focus – through PEPFAR and perhaps other parts of the Global Health Initiative – to give significant focus on – and make investments in – developing rights-based health systems, for which accountability is a central element.? For more on what the United States could do to help countries develop rights-based health systems, you can have a look at our recommendations on the Global Health Initiative.