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Progress Toward Eliminating Mother to Child Transmission of HIV in Kenya: Review of Treatment Guideline Uptake and Pediatric Transmission at Four Government Hospitals Between 2010 and 2012.
AIDS and Behavior. 2016 Nov; 20(11):2602-2611.We analyzed prevention of mother-to-child transmission (PMTCT) data from a retrospective cohort of n = 1365 HIV+ mothers who enrolled their HIV-exposed infants in early infant diagnosis services in four Kenyan government hospitals from 2010 to 2012. Less than 15 and 20 % of mother-infant pairs were provided with regimens that met WHO Option A and B/B+ guidelines, respectively. Annually, the gestational age at treatment initiation decreased, while uptake of Option B/B+ increased (all p's < 0.001). Pediatric HIV infection was halved (8.6-4.3 %), yet varied significantly by hospital. In multivariable analyses, HIV-exposed infants who received no PMTCT (AOR 4.6 [2.49, 8.62], p < 0.001), mixed foods (AOR 5.0 [2.77, 9.02], p < 0.001), and care at one of the four hospitals (AOR 3.0 [1.51, 5.92], p = 0.002) were more likely to be HIV-infected. While the administration and uptake of WHO PMTCT guidelines is improving, an expanded focus on retention and medication adherence will further reduce pediatric HIV transmission.
Program Implementation of Option B+ at a President's Emergency Plan for AIDS Relief-Supported HIV Clinic Improves Clinical Indicators But Not Retention in Care in Mbarara, Uganda.
AIDS Patient Care and STDs. 2017 Aug; 31(8):335-341.2013 WHO guidelines for prevention of mother to child transmission recommend combination antiretroviral therapy (ART) for all pregnant women, regardless of CD4 count (Option B/B+). We conducted a retrospective analysis of data from a government-operated HIV clinic in Mbarara, Uganda before and after implementation of Option B+ to assess the impact on retention in care. We limited our analysis to women not on ART at the time of their first reported pregnancy with CD4 count >350. We fit regression models to estimate relationships between calendar period (Option A vs. Option B+) and the primary outcome of interest, retention in care. One thousand and sixty-two women were included in the analysis. Women were more likely to start ART within 6 months of pregnancy in the Option B+ period (68% vs. 7%, p < 0.0001) and had significantly greater increases in CD4 count 1 year after pregnancy (+172 vs. -5 cells, p < 0.001). However, there was no difference in the proportion of women retained in care 1 year after pregnancy (73% vs. 70%, p = 0.34). In models adjusted for age, distance to clinic, marital status, and CD4 count, Option B+ was associated with a nonsignificant 30% increased odds of retention in care at 1 year [adjusted odds ratio (AOR) = 1.30, 95% CI 0.98-1.73, p = 0.06]. After transition to an Option B+ program, pregnant women with CD4 count >350 were more likely to initiate combination therapy; however, interventions to mitigate losses from HIV care during pregnancy are needed to improve the health of women, children, and families.
[Washington, D.C.], World Bank, 2008 Jan. 4 p. (en breve No. 114)In 2001, after a long period of recession, Argentina faced the greatest economic, political and institutional crisis in its history. Unemployment reached levels nearing 18% and the poverty rate reached a peak of 58% in 2002, increasing twofold the number of people living below the poverty line and impacting –in a disproportionate manner- the most vulnerable and poverty stricken families. The crisis also had a tremendous impact on Argentina’s middle-class. Increased unemployment and the freezing of wages and bank deposits forced many families to face poverty for the first time, and to seek new survival strategies. The crisis caused the rupture of traditional roles within the household, forcing many women into the workforce, many young people to leave school in search of a job, and many tradtional breadwinners to remain at home. In many cases, these changes challenged not just the economic viability of households but the role of families. Recognizing the potential impact of the situation, the Government of Argentina approached the World Bank for a small loan ($5 million), aimed at promoting gender equity and the development of families through the Family Strengthening and Social Capital Promotion Project (PROFAM). (excerpt)
Washington, D.C., World Bank, 2015 Feb.  p. (From Evidence to Policy)Poor children face barriers to healthy development even before they are born. Their mothers may not have nutritious food or proper prenatal care, which can harm a baby s brain development when it needs it most. Mothers may not deliver in a health facility nor have a skilled birth attendant present, increasing the risk of complications and ultimately putting their life and that of the baby at risk. In Argentina, the World Bank supported a government program, Plan Nacer, to improve maternal-child health outcomes through increased coverage and quality of health services. The program gives provincial authorities financial incentives for enrolling pregnant women and children in the program and for achieving specific primary health care goals. An impact evaluation found that Plan Nacer improved the birth weight of babies and reduced newborn deaths, while improving access to public health facilities and boosting the quality of care. The evidence from this evaluation will equip policy makers in low and middle income countries with additional information when designing health programs aimed at improving specific outcomes. As governments around the world look for ways to create effective programs to help their poorest citizens, the results from this impact evaluation provide an example of how health sector reforms can give children the right start in life.
[International financial cooperation in the fight against AIDS in Latin America and the Caribbean] La cooperacion financiera internacional para la lucha contra el SIDA en America Latina y el Caribe.
Cadernos De Saude Publica. 2014 Jul; 30(7):1571-6.This study analyzed the financial contribution by the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria and its relationship to eligibility criteria for funding in Latin America and the Caribbean in 2002-2010. Descriptive analysis (linear regression) was conducted for the Global Fund financial contributions according to eligibility criteria (income level, burden of disease, governmental co-investment). Financial contributions totaled US$ 705 million. Lower-income countries received higher shares; there was no relationship between Global Fund contributions and burden of disease. The Global Fund's international financing complements governmental expenditure, with equity policies for financial allocation.
Progress in the establishment and strengthening of national immunization technical advisory groups: Analysis from the 2013 WHO/UNICEF joint reporting form, data for 2012.
Vaccine. 2013 Nov 4; 31(46):5314-5320.The majority of industrialized and some developing countries have established National Immunization Technical Advisory Groups (NITAGs). To enable systematic global monitoring of the existence and functionality of NITAGs, in 2011, WHO and UNICEF included related questions in the WHO/UNICEF Joint Reporting Form (JRF) that provides an official means to globally collect indicators of immunization program performance. These questions relate to six basic process indicators. According to the analysis of the 2013 JRF, data for 2012, notable progress was achieved between 2010 and 2012 and by the end of 2012, 99 countries (52%) reported the existence of a NITAG with a formal legislative or administrative basis (with a high of 86% in the Eastern Mediterranean Region - EMR), among the countries that reported data in the NITAG section of the JRF.There were 63 (33%) countries with a NITAG that met six process indicators (47% increase over the 43 reported in 2010) including a total of 38 developing countries. 11% of low income countries reported a NITAG that meets all six process criteria, versus 29% of middle income countries and 57% of the high income ones. Countries with smaller populations reported the existence of a NITAG that meets all six process criteria less frequently than more populated countries (23% for less populated countries versus 43% for more populated ones).However, progress needs to be accelerated to reach the Global Vaccine Action Plan (GVAP) target of ensuring all countries have support from a NITAG. The GVAP represents a major opportunity to boost the institutionalization of NITAGs. A special approach needs to be explored to allow small countries to benefit from sub-regional or other countries advisory groups.
Releve Epidemiologique Hebdomadaire. 2013 Apr 26; 88(17):173-80.Add to my documents.
Engaging informal providers in TB control: what is the potential in the implementation of the WHO stop TB strategy? a discussion paper.
World Health and Population. 2011; 12(4):5-13.The World Health Organization (WHO) Stop TB Strategy calls for involvement of all healthcare providers in tuberculosis (TB) control. There is evidence that many people with TB seek care from informal providers before or after diagnosis, but very little has been done to engage these informal providers. Their involvement is often discussed with regard to DOTS (directly observed treatment - short course), rather than to the implementation of the comprehensive Stop TB Strategy. This paper discusses the potential contribution of informal providers to all components of the WHO Stop TB Strategy, including DOTS, programmatic management of multi-drug-resistant TB (MDR-TB), TB/HIV collaborative activities, health systems strengthening, engaging people with TB and their communities, and enabling research. The conclusion is that with increased stewardship by the national TB program (NTP), informal providers might contribute to implementation of the Stop TB Strategy. NTPs need practical guidelines to set up and scale up initiatives, including tools to assess the implications of these initiatives on complex dimensions like health systems strengthening.
Lancet. 2010 Sep 11; 376(9744):846.This article discusses the lack of palliative care and pain treatment for Kenyan children with diseases such as cancer, HIV/AIDS, and sickle-cell anemia. Although WHO and Kenya consider morphine an essential medicine, only seven of 250 public hospitals stock it and healthcare professionals are rarely trained to treat pain and are unaware of the benefits of morphine. It concludes that the Kenyan Government should immediately improve access to oral morphine and draw up a policy and plan of action on how to scale up palliative care.
Strong ministries for strong health systems. An overview of the study report: Supporting Ministerial Health Leadership: A Strategy for Health Systems Strengthening.
[Kampala], Uganda, African Centre for Global Health and Social Transformation [ACHEST], 2010 Jan.  p.This overview is adapted from the report Supporting Ministerial Health Leadership: A Strategy for Health Systems Strengthening by Dr. Francis Omaswa, executive director and founder of The African Center for Global Health and Social Transformation (ACHEST) and Dr. Jo Ivey Boufford, president of The New York Academy of Medicine (NYAM). The study and report were commissioned by the Rockefeller Foundation to explore the feasibility of establishing a support mechanism for ministers and ministries of health especially in the poorest countries, as part of the Foundation’s Transforming Health Systems initiative, The study was initially designed to assess the potential value of three proposed programs to strengthen the leadership capabilities of ministers of health: a global executive leadership program for new ministers; an ongoing, regional, in-person and virtual leadership support program for sitting ministers; and a virtual global resource center for ministers and high level ministerial officials providing real-time access to information. During the course of the study, it became clear that it was essential to expand the inquiry to better understand the challenges and needs of ministries as a whole, as they and their ministers provide the stewardship function for country health systems.The content of the report was derived from six major activities:a comprehensive literature review of the theory and practice of effective leadership development and organizational capacity building, and an environmental scan to identify any existing or planned leadership development programs for ministers of health or any that have occurred in the recent past globally; a survey of the turnover of ministers of health; targeted interviews with ministers, former ministers, and key stakeholders who interact with them, conducted between October 2008 and September 2009, to better understand the roles of ministers and ministries, the challenges they face, resources at their disposal, and their thoughts on what additional resources might enhance their personal effectiveness and that of their ministries; a consultative meeting of experts and stakeholders held in Bellagio, Italy part way through the project; participation of the project leaders (Omaswa and Boufford) in relevant global and regional meetings, as well as individual meetings about the project with critical leaders in international and donor organizations and potential champions of this effort; and a consultation with African regional health leaders to discuss the final report, held in Kampala, Uganda. (Excerpt).
Geneva, Switzerland, World Health Organization, [WHO], 2009. 48 p. (Analytic Case Studies. Initiatives to Increase the Use of Health Services by Adolescents)This case study describes how the Government of Mozambique scaled up its successful youth HIV prevention and sexual and reproductive health program to a national level. Geared toward developing-country governments and nongovernmental organizations, the case study provides a technical overview of the program and its interventions, a detailed description of the scale-up process and lessons learned, and the program's achievements.
Oxford, United Kingdom, Oxfam International, 2009 Feb. 55 p. (Oxfam Briefing Paper No. 125)'The realization of the right to health for millions of people in poor countries depends upon a massive increase in health services to achieve universal and equitable access. A growing number of international donors are promoting an expansion of private-sector health-care delivery to fulfil this goal. The private sector can play a role in health care. But this paper shows there is an urgent need to reassess the arguments used in favor of scaling-up private-sector provision in poor countries. The evidence shows that prioritizing this approach is extremely unlikely to deliver health for poor people. Governments and rich country donors must strengthen state capacities to regulate and focus on the rapid expansion of free publicly provided health care, a proven way to save millions of lives worldwide. (Excerpt)
Teddington, United Kingdom, Tearfund, 2008 Jul. 44 p.This report provides an overview of PMTCT and is an attempt to explore what is working, and why, in scaling up access. The report captures innovative examples of successful programming and partnerships, while identifying challenges and bottlenecks that must be overcome if these countries are to meet their nationally set universal access targets by 2010. The research methodology used for this report was based on a desk review, interviews with key global informants (see Acknowledgements) and country case studies in Malawi, Nigeria and Zambia in early 2008. The in-country study included semi-structured interviews with representatives of government and nongovernmental organisations as well as focus group discussions with community representatives, participatory and observational methodologies. The main objectives of the research were to: 1) identify and conduct interviews with the key international and national stakeholders and explore the structure, components, implementation, co-ordination, financing, policies, and guidelines and monitoring system of the PMTCT programmes; 2) determine what was working well and why; and 3) identify specific bottlenecks, challenges and recommendations for progress. This report provides an overview of the perceptions of key experts and communities on PMTCT interventions and approaches, current global action and country progress.
New York, New York, United Nations Population Fund, HIV/AIDS Branch, . 8 p. (Guidance Brief)This Brief has been developed by the Inter-Agency Task Team (IATT) on HIV and Young People1 to assist United Nations Country Teams (UNCT) and UN Theme Groups on HIV/AIDS in providing guidance to their staffs, governments, development partners, civil society and other implementing partners on HIV interventions for young people in the education sector. It is part of a series of seven global Guidance Briefs that focus on HIV prevention, treatment, care and support interventions for young people that can be delivered through different settings and for a range of target groups.
New York, New York, United Nations Population Fund, HIV/AIDS Branch, . 8 p. (Guidance Brief)This Brief has been developed by the Inter-Agency Task Team (IATT) on HIV and Young People1 to assist United Nations Country Teams (UNCT) and UN Theme Groups on HIV/AIDS in providing guidance to their staffs, governments, development partners, civil society and other implementing partners on community HIV interventions for young people. It is part of a series of seven global Guidance Briefs that focus on HIV prevention, treatment, care and support interventions for young people that can be delivered through different settings and for a range of target groups.
New York, New York, United Nations Population Fund, HIV/AIDS Branch, . 8 p. (Guidance Brief)This Brief has been developed by the Inter-Agency Task Team (IATT) on HIV and Young People1 to assist United Nations Country Teams (UNCT) and UN Theme Groups on HIV/AIDS in providing guidance to their staffs, governments, development partners, civil society and other implementing partners on effective HIV interventions for young people in humanitarian emergencies. It is part of a series of seven global Guidance Briefs that focus on HIV prevention, treatment, care and support interventions for young people that can be delivered through different settings and for a range of target groups.
New York, New York, United Nations Population Fund, HIV/AIDS Branch, . 8 p. (Guidance Brief)A series of seven Guidance Briefs has been developed by the Inter- Agency Task Team (IATT) on HIV and Young People1 to assist United Nations Country Teams (UNCT) and UN Theme Groups on HIV/AIDS in providing guidance to their staffs, governments, donors and civil society on the specific actions that need to be in place to respond effectively to HIV among young people. This Brief provides a global overview and is complemented by a separate Brief for most-at-risk young people and five others on HIV interventions among young people provided through different settings /sectors: community, education, health, humanitarian emergencies and the workplace.
Indian Journal of Medical Ethics. 2007 Jul-Sep; 4(3):109-10; discussion 111-2.In the last several months, there have been discussions in the media, including in this journal (1), about issues related to how AIDS vaccine trials are conducted in India. The International AIDS Vaccine Initiative (IAVI) has partnered with the ministry of health and family welfare in India through the National AIDS Control Organisation (NACO) and the Indian Council of Medical Research (ICMR) since 2002 to implement the AIDS vaccine research and development programme. With our partners, we strongly support transparency and the highest ethical standards in our joint efforts to find and deliver an AIDS vaccine that the world so desperately needs. In fact, IAVI's intellectual property agreements are also used as a mechanism to avoid any delay in the introduction of vaccines to developing countries (delays of more than 10 years or so in the past) by insisting that any vaccine will be made simultaneously available in developed and developing countries (2). (excerpt)
American Journal of Public Health. 2008 Oct; 98(10):1737.The 1994 Cairo International Conference on Population and Development helped governments, the organs and agencies of the United Nations system, and nongovernmental organizations move beyond the confines of traditional family planning approaches. This watershed event fostered and defined subsequent international and national reproductive and sexual health policies and programs as well as global efforts to realize reproductive and sexual rights. However, moving beyond history, or the "archeology of Cairo" (as a participant at a meeting I recently attended called it), are we now simply using the language of the Cairo conference with little attention to the conceptual and operational implications of its words? Has the politically charged notion of rights with its attendant government responsibility and accountability succumbed to the less controversial notion of health? As the public health community recognized even before the Cairo consensus, barriers to reproductive and sexual health operate on a number of levels-including legal, social, cultural, political, financial, attitudinal, and practical -- and interact in complex ways. What rights add to this mix is a framework for programming and for action and a legal rationale for government responsibility-not only to provide relevant services but also to alter the conditions that create, exacerbate, and perpetuate poverty, deprivation, marginalization, and discrimination as these affect reproductive and sexual health. By fixing attention on the responsibility and accountability of governments to translate their international-level commitments into national and subnational laws, policies, programs, and practices that promote and do not hinder reproductive and sexual health, the actions of governments are open to scrutiny to determine their influences-both positive and negative-on reproductive and sexual health, including barriers that affect the availability, accessibility, acceptability, and quality of reproductive and sexual health services, structures, and goods. Despite the framework that the Cairo conference helped put into place, work falling under the rubric of reproductive and sexual rights now includes everything from the provision of abortion services to the reduction of maternal mortality -- as though simply working on these issues is equal to working on rights. Consequently, one has to ask this: Are reproductive, and even sexual, rights becoming synonymous with reproductive, and sexual, health? Those who understand their work to be in the area of reproductive and sexual rights sorely need to discuss whether their efforts are aligned with the politics that underlie the words of the Cairo conference or whether, bluntly speaking, the politics are a historical artifact and it is simply time to move on. Bringing the political back into reproductive and sexual rights would require going beyond the technical dimensions of addressing reproductive and sexual health issues to the application of the norms and standards that are engaged by a human rights discourse. This includes attention to the basics of reproductive and sexual rights: the efforts that exist to ensure the sustained participation of affected communities; how discrimination that affects both vulnerability to ill health and access and use of services is being tackled; the extent to which any legal, political, and financial constraints are being addressed; how rights considerations are brought into policy and program design, implementation, and evaluation; and the existence of mechanisms that require government as well as intergovernmental and nongovernmental institution accountability. And so yes, in a word, words do matter. And they matter for the actions they inspire. (full-text)
London, United Kingdom, ACF International Network, . 80 p. (Hunger Watch Publication)This report documents the findings of Local Voices, a six month qualitative research project that provided HIV orphans, vulnerable children and their carers with the opportunity to discuss and document the difficulties they face providing food, water and healthcare for their families. Through meetings, detailed interviews and discussions the project initiated and developed an ongoing dialogue with 20 families in four areas of the Kitwe district in the Copperbelt province of Zambia: Chimwemwe, Kwacha, Chipata and Zamtan. The discourse that developed over the course of the project has given Action Against Hunger (ACF-UK) and CINDI insight in two key areas. Firstly, the research has added a household perspective to existing ideas and analysis of food security in an HIV/AIDS context. Secondly, the project highlights the knowledge and learning that can be gained when people living with a positive HIV diagnosis are seen as 'experts' and their experiences are used to help identify and address the problems they face. Through the voices of the project's participants, the testimonies and images that are the core of this document explore the social and economic impact HIV/AIDS has on families affected by the disease. ACF-UK and CINDI pioneered this work because we believe HIV/AIDS can no longer be seen as just a medical issue. Within this report we demonstrate that HIV/AIDS has a direct impact on the economic and social well-being of both households and communities; and as such it must be tackled using an integrated approach where food, livelihoods and social protection are highlighted as solutions alongside access to medical care. This report opens with statistics that outline current rates of HIV/AIDS and poverty in Zambia, focusing specifically on the Copperbelt province and the Kitwe district. The testimonies that form the centrepiece of this report are introduced by a summary of the key social and economic issues that HIV orphans, vulnerable children and their carers face, together with a synopsis of government and community based organisation (CBO) responses. These topics have been selected as they cover the core issues that were raised during the Local Voices project. The document ends with a brief conclusion and the report recommendations.
Introducing WHO's sexual and reproductive health guidelines and tools into national programmes. Principles and processes of adaptation and implementation.
Geneva, Switzerland, World Health Organization [WHO], Department of Reproductive Health and Research, 2007. 25 p. (WHO/RHR/07.4)The Departments of Reproductive Health and Research (RHR) and Making Pregnancy Safer (MPS) at the World Health Organization (WHO) have developed a series of guidelines and tools to promote evidence-based practices in sexual and reproductive health within programs. The guidance developed by WHO/RHR and WHO/MPS includes: norms, standards and protocols designed to inform the development and revision of national policies and standards; programmatic guides to inform the development of sexual and reproductive health programs; tools and clinical guides designed to be used by health-care providers in clinical setting, according to evidence-based norms. The guidance covers a range of themes, including maternal and neonatal health, family planning, prevention and control of reproductive tract infections and sexually transmitted infections (RTIs/STIs) and the prevention of unsafe abortion. The various documents are based on scientific evidence and have been developed by WHO/RHR and WHO/MPS as generic global materials that are not specific to any one national context. (excerpt)
Public-private partnerships: Managing contracting arrangements to strengthen the Reproductive and Child Health Programme in India. Lessons and implications from three case studies.
Geneva, Switzerland, World Health Organization [WHO], 2007.  p.Strengthening management capacity and meeting the need for reproductive and child health (RCH) services is a major challenge for the national RCH program of India. Central and state governments are using multiple options to meet this challenge, responding to the complex issues in RCH, which include social, cultural and economic factors and reflect the immense geographical barriers to access for remote and rural population. Other barriers are also being addressed, including lessening financial burdens and creating public-private partnerships to expand access. For example, the National Rural Health Mission was initiated in order to focus on rural populations, although departments of health face a number of challenges in implementing this initiative. In this document, we focus on a key area: the development of management capacity for working with the private sector. We synthesize the lessons learnt from three case studies of public-private partnerships in RCH: two are state initiatives, in Gujarat and Andhra Pradesh, and the third is the national mother nongovernmental organization scheme. The case studies were conducted to determine how management capacity was developed in these three public-private partnerships in service delivery, by examining the structure and process of partnerships, understanding management capacity and competence in various public-private partnerships in RCH, and identifying the means for developing the management capacity of partners. (author's)
Arlington, Virginia, JSI, DELIVER, .  p. (Policy Brief)Driven by the increasing demand for and popularity of family planning, increasing population size, and changing demographics with more couples entering their fertile years, the financing requirement for contraceptives has become increasingly onerous. Strategies to finance contraceptives include expansion of the donor base; increased use of cost recovery, including revolving drug funds; greater use of the private sector; and direct government financing of contraceptive procurement. None of these is mutually exclusive, and to ensure contraceptive security, most countries are likely to use some or all of these approaches, and many others. Evidence suggests that many governments are beginning to finance contraceptive procurement using national resources, but limited data are publicly available regarding the global extent of this financing. This brief details the findings of a survey of the extent to which national governments of developing countries are using national resources to finance contraceptive procurement. The brief examines the different types of financing used, some of the benefits of this type of financing, and some of the issues it raises. Hopefully, this study can be repeated to track spending and will spur more rigorous efforts to measure this practice. (excerpt)
New York, New York, United Nations, Department of Economic and Social Affairs, Population Division, 2008 Mar.  p. (ST/ESA/SER.A/270)The AIDS epidemic remains one of the greatest challenges confronting the international community. In countries with a large number of people living with HIV, all population and development indicators are affected by the epidemic. Governments often cite HIV/AIDS as their most significant demographic concern. For more than two decades, the rapidly expanding HIV/AIDS epidemic has triggered a wide array of responses at the national, regional and global levels. The goals established by the United Nations General Assembly in the 2000 Millennium Declaration and through the adoption of the 2001 Declaration of Commitment on HIV/AIDS reflect widely-held concerns about the impact of the epidemic on development and human well-being. More recently, at the 2006 High Level Meeting on AIDS, Member States adopted a Political Declaration focusing on how to attain universal access to comprehensive HIV/AIDS prevention programs, treatment, care and support by 2010. (excerpt)
Supporting and sustaining national responses to children orphaned and made vulnerable by HIV and AIDS: Experience from the RAAAP exercise in sub-Saharan Africa.
Vulnerable Children and Youth Studies. 2006 Aug; 1(2):170-179.The growing number of children orphaned and made vulnerable by HIV and AIDS in sub-Saharan Africa presents an enormous socioeconomic and public policy challenge. Despite international commitments to increase resource allocation and scale up services and support for AIDS-affected children, families and communities, the national- and sub-national-level state responses have been inadequate. The rapid assessment, analysis and action planning (RAAAP) process for orphans and vulnerable children, conceived in late 2003, was intended as a multicountry incentive to identify and resource immediate actions that can be taken to scale in 16 heavily affected countries. This review of experiences to date with the RAAAP process highlights some key areas of learning, including: (a) fund mobilization has been slow and has reached approximately only one-third of what is required; (b) ownership and integration into development planning of the issue of orphans and vulnerable children at country level has been undermined by the perception that the response is an 'emergency' and externally (donor) driven exercise; (c) centralized planning has failed to appreciate the complexity of context and responses at the meso- and micro-levels within countries, entailing the need to support a comprehensive decentralization process of planning and implementation; (d) comprehensive multisectoral and interagency collaboration, involving civil society, is an important but overlooked element of the planning process; and (e) definitional variation between countries has led to large variations in budgets and coverage targets. While the RAAAP process has undoubtedly raised awareness at state level of the nature and extent of the 'orphan crisis' and raised vital resources, only full integration of the new planning process for orphans and vulnerable children within the range of macro and national development tools will allow the response to be sustainable in the longer term. (author's)