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.
Years of mechanism: 2008 2009
N/A
New/Continuing Activity: Continuing Activity
Continuing Activity: 18310
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
18310 6039.08 HHS/Centers for University of 8045 3906.08 CDC/CoAg/HAQ $200,000
Disease Control & Zimbabwe, OCI
Prevention HIV/AIDS Quality
of Care Initiative
11636 6039.07 HHS/Centers for To Be Determined 5835 3906.07 Co Ag TBA
Disease Control &
Prevention
6039 6039.06 HHS/Centers for University of 3906 3906.06 Co Ag $200,000
Disease Control & Zimbabwe, Clinical #CCU020910
Prevention Epidemiol
Table 3.3.08:
Continuing Activity: 18312
18312 6066.08 HHS/Centers for University of 8045 3906.08 CDC/CoAg/HAQ $50,000
11638 6066.07 HHS/Centers for To Be Determined 5835 3906.07 Co Ag TBA
6066 6066.06 HHS/Centers for University of 3906 3906.06 Co Ag $50,000
Table 3.3.09:
New/Continuing Activity: New Activity
Continuing Activity:
18311 6049.08 HHS/Centers for University of 8045 3906.08 CDC/CoAg/HAQ $50,000
11637 6049.07 HHS/Centers for To Be Determined 5835 3906.07 Co Ag TBA
6049 6049.06 HHS/Centers for University of 3906 3906.06 Co Ag $50,000
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $92,233
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Zimbabwe is ranked 20/22 among the high tuberculosis (TB) burden countries and a massive increase in the case load has been
experienced since the 1990's, primarily due to the HIV epidemic. The reported incidence rates of all and sputum smear positive
TB cases were 557/100,000 population and 227/100,000 population in 2006, respectively. TB is the most common cause of
death, particularly in age groups with high HIV prevalence (15-49 years).
In 2005, a total of 57,117 TB cases were notified, although the absolute number of cases registered annually is reported to be
declining in recent years. This is thought to be due to operational rather than epidemiological reasons. Only approximately one-
third of pulmonary TB cases are diagnosed on sputum smear microscopy. The proportion of unproven or clinically diagnosed TB
cases is unacceptably high. An analysis of TB treatment outcomes of smear-positive cases registered between 1996 and 2001
showed that treatment success increased steadily from 62% in 1996 to 71% in 2001, while the proportion of treatment interruption
decreased from 12% to 6% during the same period, with 10% to 12% of patients dying. More than 15% of registered patients were
transferred out during the course of treatment and this is due to the fact that intra-district movement of TB patients while on
treatment are recorded as transfers out and the ‘real' outcomes are not elicited. This unhelpful practice increases the rate of
unfavorable outcomes. It is unlikely that treatment outcomes have improved since 2001.
The last external program review was carried out by WHO in 2003, and rapid assessment with emphasis on laboratory services
was done in 2005. Most of the recommendations made by these missions have not been implemented, and the findings are likely
to be still largely valid.
The most recent drug resistance survey was performed in 1995, and showed less than 3% MDR-TB among new cases and less
than 6% among retreatment patients. There is no systematic monitoring of drug resistance, nor is there available treatment. The
National Tuberculosis Reference Laboratory (NTRL) in Bulawayo has suffered from frequent severe staffing shortages rendering it
non-functional and unable to perform culture and DST. With USG and other donor support, NTRL services are being rebuilt and
are increasingly more available, but sufficient reagent supplies still remain an obstacle. While the number of drug-resistant TB
cases is unknown, multi-drug resistant (MDR)-TB is generally not thought to be a major problem in the country. However, in the
past month two confirmed MDR patients were deported from Botswana, neither of which had access to adequate medication.
USG in collaboration with other partners worked with the NTRL to fill this gap and make the required treatment and care
accessible to these patients. If the quality of DOTS, access and adherence to treatment continue to degrade, while DR-TB
remains unmonitored, the emergence of MDR-TB in this environment would be exceedingly difficult to address.
The NTRL continues to try to do culture and drug susceptibility testing (DST) for first line drugs, and in principle receives sputum
from all re-treatment cases for this purpose. However, as of mid-2007 the NTRL had no reagents to carry out this testing. The
number of drug-resistant TB cases is unknown though multi-drug resistant (MDR)-TB is not generally thought to be a major
problem in the country.
It has been estimated that less than one-third of TB patients are presently tested for HIV even though various research findings
indicate a substantial (approximately 80%) co-infection prevalence. In this context, TB patients experience a high mortality rate.
This presents a considerable missed opportunity. Uptake of HIV testing is higher (up to 80%) in certain clinics in Harare and
Bulawayo where Health Services Departments collaborate with The International Union Against Tuberculosis and Lung Disease
(The Union) in operational research to strengthen joint TB/HIV services and ensure that co-infected TB patients and their
household contacts, as appropriate, access HIV care.
There is no information on the proportion of PLHA who attend various OI/ART units and are screened for TB. TB symptoms
screening is, however, done routinely at client-initiated HIV counseling and testing sites supported by the USG-supported
Partnership Project, which has found that up to 14% of PLHA are found to be TB suspects. This is a second missed opportunity,
and if attended to, could increase TB case detection and strengthen TB control efforts. Isoniazid preventive therapy (IPT) is
presently recommended for under-five contacts of smear-positive TB patients. This practice is not implemented widely and
opportunities to initiate the provision of IPT for PLHA warrant further attention.
The M&E system for TB/HIV needs to be revised for the data collected by NTP, because the current system collects data on HIV
status only. TB/HIV data on the "three I's" (intensified TB case finding, isoniazid preventive therapy, and infection control for TB
within HIV care services) is currently not being collected by the National AIDS Council.
A national level TB/HIV coordinating committee is in place and met in July 2008. Its meetings may be too infrequent (quarterly)
and no minutes have been circulated up to date. There are no mechanisms for TB/HIV collaboration at the provincial or district
level.
In the 1990's the Dutch government supported the NTP financially, and also seconded medical officers who worked both at the
national and provincial levels. The Dutch also financed procurement of TB drugs and laboratory reagents. Presently, the NTP is
supported by the Global Fund Rounds 1 and 5 (GF1, GF5) and the European Commission (EC) provides most TB drugs through
its Vital Health Services Support Program. Recently, a grant application to the Global Drug Facility (GDF) has been made. In
FY05-08, the USG has supported laboratory services and provided laboratory consumables and microscopes to support the
National TB Program.
Implementation of the GF5 for TB ($12 million) has been delayed for several years until recently when some activities have
started. Phases 1 and 2 are to end in August 2009 and August 2010, respectively. The Principal Recipient is the Zimbabwe
Association of Church-Related Hospitals (ZACH). The program is explicitly designed to focus on the same 22 districts covered by
Zimbabwe's GF5 HIV/AIDS award, in order to strengthen TB/HIV linkages. In addition, the GF5 TB award is expected to: improve
treatment outcomes by improving case management of TB patients; strengthen community TB directly observed therapy, short
course (DOTS); support conduct of drug-resistance surveys; introduce fixed-dose combination therapy and train community
DOTS workers in its use; and enable health facilities to offer all TB patients HIV testing and, for those who test positive, offer
Cotrimoxazole prophylaxis and referral for consideration of ART. In addition, it will help to ensure that all HIV-infected individuals
who present for HIV testing are offered TB screening as well. The TB and HIV/AIDS awards taken together are explicitly intended
to improve significantly Zimbabwe's co-management of TB and HIV/AIDS at the national, provincial and district levels.
Zimbabwe's GF8 proposal for TB, for $58.3 million, was recently approved by the technical review committee. Its priorities remain
the same as those of GF5. Given problems in funds management found by a recent GF Inspector General audit in Zimbabwe, it is
not clear when the funding will become available.
In summary, TB control in Zimbabwe has lost its former strength, and the country is challenged to respond to the increased case
load driven by HIV infection. The global Stop TB targets of a case detection rate of 70% and a cure rate of 85% were not achieved
by 2005, and their achievement in 2008 is highly unlikely. Without external support and a greatly strengthened robust national TB
program, TB-related morbidity and mortality will continue unabated, and Zimbabwe's capacity to achieve the 2015 target of
reducing prevalence of and deaths due to TB by 50% is at great risk.
USG Wraparound Program
In September 2008 the USG provided $1.3 million in earmarked TB Initiative funding (non-GHCS) to the central TB Control
Assistance Program (TB CAP) mechanism to support improved TB control in Zimbabwe. The International Union Against
Tuberculosis and Lung Disease (The Union), which already had an in-country presence, is the coordinating partner. The goal of
TB CAP support is to decrease TB-related morbidity and mortality through strengthening TB control activities in Zimbabwe, in line
with the global Stop-TB Strategy and the Zimbabwe Health Sector Strategic Plan.
The long-term strategic approach of TB CAP in Zimbabwe is: (1) To provide technical and financial assistance to the NTP central
unit to strengthen its leadership and management capacity in critical areas of TB control in the country; (2) To provide technical
and financial assistance to the NTP provincial, city, district, and health facility level, ensuring re-establishment of standard basic
DOTS program management through capacity building and assurance of essential inputs; with FY08 funds, in first quarter FY09
the project will start in one province and municipal health authority. Budget permitting based on lessons learned in the initial
demonstration sites, the project will roll out programmatic and operational support to other provinces and cities in subsequent
years. (3) To build NTP support on existing structures, teams and systems of the HIV/AIDS/STI/TB unit and MOHCW, and with
other national and international partners to avoid duplication and overlap, and ensure efficient collaboration with all stakeholders.
The Union is in the process of staffing up, and will develop project targets and indicators within the next few months.
USG PEPFAR Program and Prospects
In FY05-FY06 USG PEPFAR funds for TB/HIV contributed to development of two model programs at large urban clinics, (1) the
Beatrice Road Hospital OI Clinic, which services 10,000 TB patients annually; and (2) the Bulawayo Municipal ARV program
which receives priority referrals from TB clinics. By the end of FY07, both of these programs were providing clinical prophylaxis
and/or treatment for TB for co-infected individuals on a high quality, routine basis.
In FY07-08, the USG-funded program lost focus, and HVTB funds were used primarily to support comprehensive OI/TB/ART
training of health care providers. As part of the USG PEPFAR Zimbabwe team's Joint Portfolio Review in May 2008, the USG
team concluded that although the USG has a strong comparative advantage in TB programs worldwide, its TB-HIV program in
Zimbabwe is not achieving results.
Given the availability of significant new non-PEPFAR USG funds for TB and the involvement of The Union in their use, the USG
PEPFAR Zimbabwe team decided to pursue development of a new strategic complementary TB-HIV program, in which TB CAP
would provide TA and services at the national level and in 1-2 provinces, subject to availability of non-PEPFAR TB funds, and
USG PEPFAR would focus on strengthening the national TB reference lab and TB surveillance with PEPFAR funds.
The FY09 COP follows that decision and will provide modest PEPFAR funding to the MOHCW, and direct USG technical support,
to maintain the USG PEPFAR team's "place at the table" as the TB CAP and GF5 (and possibly GF8) programs move forward.
With FY09 funding, in collaboration with TB CAP and other technical advisors, the MOHCW will be able to support the finalization
of a five year TB strategic plan and the development of a standard TB/HIV course; introduce this new TB/HIV course through a
national training-of-trainers (90 individuals trained); and support supervisory visits to each province three times a year.
With funding from other PEPFAR program areas, USG will also: build capacity for quality TB/HIV diagnostic services including
culture for sputum-negative patients with the NTRL (HLAB funding); develop projections for TB/HIV diagnostic and treatment
requirements (HLAB, HTXD funding); and support efavirenz-based ART nationally for co-infected patients during TB treatment
(HTXD and HTXS funding). USG will also assist in the updating of the current laboratory standard operation procedures (HLAB
funding).
As part of its general collaboration in National AIDS and TB Program implementation, the USG will also provide technical support
in program design, planning, and evaluation to the MOHCW and ZACH on GF5 programs to scale up and improve integrated
TB/HIV care delivery. On a policy level, USG will encourage the MOHCW, with GF5 and other donor funding, to establish
separate, well-ventilated isolation wards for TB patients nationwide. Currently TB patients in district hospitals are housed in
cubicles in the general wards.
In addition to funding for the MOHCW, FY09 funding is also provided for direct USG technical expertise and staffing, and to the
management firm Ernst and Young for select technical assistance and audit requirements.
Wraparounds/Leveraging
Other USG TB funding of $1.3 million in FY08 and $1.5 million in FY09 provide an important wraparound to the modest PEPFAR
funding. The combined USG PEPFAR and TB resources contribute to a larger effort including MOHCW, GF5, European Union
(EU), and WHO. EU supports essential drug procurement for TB drugs. WHO has contributed to technical consultations and
staffing for the National TB Program. GF5 monies of up to $12 million over 3 years will provide a critical infusion of resources for
human capacity development and the procurement of essential equipment and commodities.
Table 3.3.12:
Continuing Activity: 18313
18313 6085.08 HHS/Centers for University of 8045 3906.08 CDC/CoAg/HAQ $50,000
11639 6085.07 HHS/Centers for To Be Determined 5835 3906.07 Co Ag TBA
6085 6085.06 HHS/Centers for University of 3906 3906.06 Co Ag $50,000
Table 3.3.18:
