PEPFAR—Progress on Water,
Sanitation, and Hygiene
(WASH) for People Living with
HIV/AIDS
Charles B. Holmes, M.D., MPH
Chief Medical Officer, Office of the U.S. Global AIDS Coordinator
AIDS 2012 - Turning the Tide Together
Importance of Water, Sanitation, and
Hygiene
“We shall not finally defeat AIDS, tuberculosis,
malaria, or any other infectious diseases that
plague the developing world until we have
won the battle for safe drinking water,
sanitation and basic health care.”
- Kofi Annan, former UN Secretary-General
Why WASH Matters for PLHIV
• Diarrhea is a leading cause of morbidity and
mortality in people living with HIV (PLHIV) in the
developing world
• Diarrhea rates among PLHIV in Africa are 2-6
times higher than those in the general population
• Diarrhea may reduce absorption of nutrients and
medications
• In PLHIV, diarrheal episodes can lead to increased
viral load, decreased CD4 counts, and worse
clinical outcomes
Critical WASH Behaviors
Integrating WASH into PEPFAR Programs
• Within PEPFAR programs, there are multiple approaches to
providing WASH services:
– WASH commodities and services often included in the Basic
Preventive Care Package provided to PLHIV, including adults,
children and pregnant women
– WASH services integrated within nutrition programming
– WASH services provided through home-based and community
care
– WASH programming for orphans and vulnerable children (OVC)
– Implementation of WASH in clinical facilities
– Public-private partnerships to increase access to safe water
– Wrap-around programming – leveraging partner resources
PEPFAR Guidance on WASH—Key Elements
“PEPFAR programs are encouraged to ensure PLHIV have access to safe drinking
water in facility-based care settings and to support PLHIV with home-based
drinking water treatment methods and safe storage in communities without a
reliable source of safe water.
“PEPFAR programs should support improvements in hygiene and sanitation,
which are essential to reduce the infectious disease burden experienced by
PLHIV…. Hand washing at critical times, with soap and with proper hand
washing technique, is the most important hygiene measure to be integrated
across all care and support programs.
- Care and Treatment Section, 2012 Technical Considerations
PEPFAR Guidance on WASH—Key
Elements
• “Counseling on safe food preparation and storage, point-of-use water
purification treatment and other hygiene and sanitation practices are an
integral component of nutrition assessment and counseling and support
(NACS) within care and treatment services”
- Food and Nutrition Section, 2012 Technical Considerations
• “Programs are also encouraged to consider adopting integrated strategies
for preventing MTCT …integrating or linking to ..safe water and hygiene,
and food supplementation/food by prescription programs.
- PMTCT Section, 2012 Technical Considerations
PEPFAR Basic Preventive Care Package
• Basic preventive care package (BCP): package of commodities and
services offered to PLHIV to reduce HIV-related morbidity and
mortality
– Package is country-specific, and components may differ
– BCP may include cotrimoxazole prophylaxis, insecticide-treated
bed nets, safe water interventions, TB interventions, condoms,
and other associated services
• PEPFAR funds can support the following as part of a BCP:
– home-based safe drinking water interventions for PLHIV
– soap and promotion/training on hand washing
– latrine promotion; consider construction with “wrap-around,”
non-PEPFAR funding
Providing WASH Services through
Basic Preventive Care Package in Uganda
• Uganda initiated BCP
program in 2005
• BCP includes safe water
intervention (safe water
vessel, WaterGuard, and
cloth filter)
• Specific programs children
and pregnant women and
others
Integrating WASH with Nutrition
Programs
• PEPFAR guidance highlights integration of WASH into
nutrition assessment, counseling and support
(NACS):
• Counseling on safe food preparation and storage
• Counseling on household water treatment and storage
• Counseling on use of treated water to prepare
complementary foods and formula for infants following
weaning
Incorporation of WASH Into Guidelines, Development of
National Training Manuals and Job Aids (Facility- and
Community-based Providers)
National nutrition
and HIV guidelines
Training manuals
Job aids
Cote d’Ivoire
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Ethiopia
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Ghana
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Haiti
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Kenya
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Mozambique
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Namibia
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Tanzania
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Vietnam
Zambia
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WASH Integration in Nutrition Programs: FANTA-2
Project – NACS Job Aids
Addressing WASH in Home-Based Care:
Hygiene Improvement Project
• PEPFAR-funded Hygiene Improvement Project (through
USAID) worked to integrate WASH into home-based care
(HBC) in Ethiopia and Uganda
• Conducted participatory research with PLHIV to identify best
practices for WASH in HBC – what can actually be
implemented
• Identified feasible, “small doable actions” - may not be ideal
behavior, but a feasible and effective alternative
• Developed HBC kit with programming guidance, curricula,
tools and training materials
• Implementation in Ethiopia and Uganda
– Developed community of practice, to share information,
resources and approaches
Addressing WASH in Facility-Based Care
• PEPFAR-funded Aidstar-one Project developed a training
curriculum on integration of WASH into facility-based care for
clinic personnel
• Objective: build capacity of health providers to counsel
patients on WASH practices, create a WASH-friendly facility
with access to safe drinking water for staff and patients, a
hygienic latrine, and water for handwashing.
• Field tested in Ethiopia and Kenya in collaboration with
government
• Guidelines and training package will be institutionalized by
both governments and disseminated to other countries
Community WASH Interventions: Safe Water
and AIDS Project (SWAP) in Kenya
• SWAP – PEPFAR-supported NGO in western Kenya; since 2005,
SWAP has supported safe water and HIV programming, using
social marketing approach; also promotes socio-economic
empowerment of PLHIV and others in community
• SWAP now has a network of over 871 HIV support and selfhelp groups, comprising over 6,000 active vendors
• Groups promote and sell water treatment and other health
products as income-generating activity (microfinance and
business training) that also increases access to safe water and
supports disease prevention
Extent of PEPFAR WASH Programming
• In 2010 – 20 of 30 PEPFAR Country Operational Plans
(COPs) reviewed included WASH programming
• Uganda 2010 COP – At least 14 partners included WASH
programming; WASH included in national basic preventive
care package
• Nigeria 2010 COP – At least 16 partners included WASH
programming; WASH included in adult and pediatric BCP
• Kenya – At least 14 partners included WASH programming
in 2010 COP. Of note, USG staff participated in a review of
Kenya’s national HIV policies, recommending specific WASH
activities, resulting in modifications to policies on sanitation
and food and nutrition, among others
Future Directions
• Improved M&E and support for implementation
science (e.g., examining impact and efficiency of scaleup strategies, methods of stimulating uptake and
sustained WASH adherence, etc)
• Strengthened collaboration with host countries to
scale-up regional and national programs to gain greater
impact.
• Greater multi-sectoral programming for sustainable
clean water solutions, including key actors such as MCC
• Enhanced engagement with private sector partners,
including occupational health programs and
technology/commodity manufacturers
Acknowledgements
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Carol Langley – OGAC
Merri Weinger – USAID
Rob Quick – CDC
Tim Quick – USAID
Barb Marston – CDC
Thank You
For further information, please visit:
www.PEPFAR.gov
www.facebook.com/PEPFAR
http://twitter.com/USPEPFAR