PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $50,000
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $50,000
Economic Strengthening
Education
Water
Table 3.3.09:
Program Budget Code: 11 - PDTX Treatment: Pediatric Treatment
Total Planned Funding for Program Budget Code: $300,000
Total Planned Funding for Program Budget Code: $0
Table 3.3.11:
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $100,000
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $450,000
Program Area Narrative:
OVERVIEW
TB is responsible for an estimated 11,000 deaths each year in Ghana. Data suggests that 46,000 new cases of active TB (rate of
203/100,000 population) occur in Ghana each year, of which 21,000 (90/100,000) are smear-positive (WHO/MOH 2006-8). Of
these active disease cases, only 14,000 (7,700 of whom are smear-positive) are diagnosed and notified via the National TB
Control Program. Ghana's case detection rate of 30% for all forms of TB and 37% for smear-positive cases is markedly below the
70% globally accepted target. The DOTS strategy has been adopted nationally and the country reports 100% coverage. Of those
who are reported using the DOTS strategy, 68% are considered cured, 5% do not complete treatment, 9% die while on treatment,
2% fail, and 11% default. The overall success rate of 73% is substantially below the 85% global target.
National policy documents cite TB as a major priority and TB has received stable funding in recent years. However, Ghana's low
case detection rate (30% versus the African regional average of 41% for all forms; 37% versus the 46% regional average for
smear positive TB) remains stubbornly low. The low detection and treatment success rates fuel ongoing transmission of the
disease. Low treatment success rates can also foster the development of drug resistant disease, which can be difficult or
impossible to treat, particularly for HIV positive individuals.
A national study of HIV infection in smear positive TB cases is underway. Data will be available in late 2009. It is expected that
the data will support estimations that HIV has been increasingly impacting TB rates and outcomes over the past several years. In
1989, about 14% of TB cases were attributed to HIV/AIDS. By 2009, it is projected that approximately 59% of TB cases will be
attributed to HIV/AIDS. Hospital studies suggest that the prevalence of HIV in TB patients is 25-30% and that as many as 50% of
patients with chronic cough could be HIV-infected. At the Korle-Bu Teaching Hospital in the capital Accra, 30% of HIV patients
present with TB, and TB accounts for 40-50% of HIV deaths. A particular challenge to treating TB/HIV co-infection is that there is
a higher incidence of smear-negative and extra-pulmonary TB (EPTB) in HIV-positive individuals, both of which are more difficult
to diagnose than smear-positive TB.
The national TB and AIDS control program has developed policies to promote collaboration as articulated in the GHS February
2007 TB/HIV Technical Policy and Guidelines. This document was developed using WHO recommendations and USAID support
though SHARP and QHP. Despite this, implementation of collaborative activities is lagging. For example, TB and HIV services
are often co-located but systematic referral between the two services has only begun in some of the larger facilities. In 2008,
about 5,600 TB patients were tested for HIV (1,450, or 26%, were found positive). There is no reliable national statistic estimating
the number of PLHA that are screened for TB.
KEY INTERVENTIONS
The main thrust of USG efforts in HIV care and treatment is to support the provision of a full continuum of care (including ART and
palliation of symptoms) through the High-Impact Package (HIP). HIP concentrated at 25 focus facilities. USAID's TB/HIV
interventions within this care continuum are largely carried out through Quality Assurance activities and includes:
•Dissemination of and support for the implementation of the TB/HIV dual infection guidelines (QHP).
•Strengthening TB screening and treatment of HIV-infected individuals at 25 health facilities (QHP), and train DOTS centers in
testing for HIV.
•Supporting PLHA groups in early diagnosis and referral.
In addition, the USAID Health Program provides $500,000 non-PEPFAR funding for improving the diagnosis and treatment of TB
through technical assistance in the areas of strategic planning, laboratory quality assurance, pharmaceutical management, and
data analysis.
CURRENT USG SUPPORT
After the February 2007 development of the Guidelines, which mandated improved collaboration between the national TB and
AIDS control programs and other partners, QHP continued supporting their roll-out and implementation in 25 facilities offering
comprehensive HIV/AIDS and DOTS services (from 10 in FY07). QHP aims to introduce quality improvement approaches
including the use of standard guidelines and tools through its proven COPE ("Client Oriented, Provider Efficient") methodology.
QHP also trains counseling and testing (CT) providers to use TB screening tools so that they can recognize the disease early
among PLHA and appropriately refer or link them with DOTS services. QHP strengthens referral mechanisms for managing
TB/HIV both within and beyond the health facilities to community-based palliative supportive services. QHP promotes routine HIV
testing for all TB patients and routine screening of HIV-infected individuals for TB at the facilities through integrated services or
strengthened referral networks. Results for FY 08 are modest but reflective of an encouraging trend: in 25 USG-supported
facilities, approximately 850 PLHA received treatment for TB, and 1,700 registered TB patients were tested for HIV and received
their results.
In order to increase the TB detection and cure rates among PLHA, SHARP collaborates with QHP and the national Community
DOTS program to encourage TB screening and treatment referrals by local groups who work closely with the target population,
namely PLHA support groups, PLHA peer educators, and NGOs. Activities to support this objective include training community
health workers on basic care and management of TB and use of the national TB screening checklist. PLHA peer educators and
NGO program staff received training in TB prevention, early case detection and referral for treatment. The peer educators
continued to be supported through SHARP's implementing partners to conduct TB screening and education for 8,500 PLHA in
155 support groups.
USG FY09 SUPPORT
FY09 support will emphasize strengthening M&E systems to provide reliable national statistics including documentation of how
many PLHA are screened for TB.
QHP will roll-out HIP to an additional 15 facilities, for a total of 40. QHP will conduct COPE reviews to ensure that systems and
processes put in place through the quality improvement exercises are maintained and strengthened. In addition, QHP will provide
in-depth updates on clinical management of TB/HIV staff who have not had such training previously. QHP will also train CT
providers to use TB screening tools so that they can recognize the disease early among PLHA and appropriately refer or link them
with DOTS services.
Through a new USAID implementation mechanism that focuses on sub-granting for most-at-risk groups, prevention for positives
will be supported. Amongst others, PLHA groups will be trained to conduct TB screening and education, targeting 3,000 PLHA
referred to TB treatment sites for secondary screening.
LEVERAGING AND COORDINATION
Most TB control activities in Ghana are driven by Global Fund (GF) grants. In 2004-06, $3.3 million in Round 1 Global Fund
support was made available for Public-Private Mix initiatives and an enabler's package to support DOTS implementation in two
regions. In 2005, Ghana was awarded a GF Round 5 grant ($31.5 million for 2006-2010) for national scale-up of these activities,
and new initiatives including community-based DOTS, TB/HIV, the new anti-TB drug regimen, and extension of the TB control
program in prisons. Ghana's GF Round 5 award for HIV/AIDS also provides $2.9 million to the NACP for TB/HIV activities.
USAID, with Child Survival and Health funds, has assisted the National Tuberculosis Program since March 2008. Activities for FY
2009 include support to the NTP in finalizing the strategic plan, the development of an SOP for TB Case detection for use by
health facilities and communities and the development of operational guidelines for national scale up of PPM DOTS. The two
existing operations research studies will be finalized and the results will be used for program improvement. Training of
laboratories in quality control will be carried out nationwide. Improving the quality of monitoring and supervision of TB/HIV
collaborative activities will remain a key focus in FY 2009.
No other development partners finance TB control in Ghana. WHO provides $40,000 in technical assistance to the NTP, while
KNCV (The Royal Netherlands Tuberculosis Foundation) provides technical assistance to the NTP with Canadian and other
funding.
USG activities reinforce the GF HIV and TB grants. Coordination is critical to the grant's success and the USG therefore works to
ensure that managers and service providers responsible for the HIV and the TB program optimize their collaboration to improve
delivery of services to those co-infected. At the national level, USG will support stakeholders meetings to assess progress and
inform all parties.
EXPANSION OF PROGRAM WITH ADDITIONAL COMPACT FUNDING
Building on the successful work of the QHP projects, Quality Assurance (QA) activities to Global Fund supported sites will be
dramatically scaled up to implement TB standard operations procedures that include HIV testing of all TB patients and TB testing
of all HIV patients. Assistance to PLHA groups will be increased to early detect and refer TB cases. A recent laboratory
assessment concluded that safety procedures and quality control measures especially for TB tests are inadequate. There are
presently no activities to address those concerns. With USG leadership through CDC, TB lab safety measures and quality control
procedures will be enhanced nationally.
To address the enormous gap between theoretical national TB prevalence and actual cases, USG Ghana would provide TA for
the national TB prevalence survey. USG Ghana support would leverage the existing GF Round 5 funding for the creation of a
national TB prevalence survey by providing technical assistance.
The Global Fund and the Government of Ghana would support the creation of the survey itself. Finally, USG Ghana would support
the institutionalization of regional training and supervision teams to ensure the sustainability of QA and supervision activities and
alleviate pressure on NTP's national coordination, which is presently unable to carry out such activities with sufficient frequency.
PRODUCTS/OUTPUTS
•40 facilities' ability to provide TB/HIV services strengthened through the COPE method, and SOP training
•3,000 PLHA in 175 support groups provided with TB screening and education
•3,000 PLHA receiving TB treatment
•2,500 TB patients identified as HIV positive
•200 individuals trained to provide treatment for TB to HIV-infected individuals
Table 3.3.12:
