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\title{Sustainability of HIV/AIDS Care \& Support Programmes}
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             \author[1]{Mr. Berhanu  Abebe}

             \affil[1]{  Hawassa University and Addis Continental Institute of Public Health}

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\date{\small \em Received: 5 June 2012 Accepted: 30 June 2012 Published: 14 July 2012}

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\begin{abstract}
        


Igratefully acknowledge Prof. Yemane Berhane, program and theory review course instructor as well as advisor, for his professional support and advice in the whole process of developing this review. At this junction, it is a must for me to give special thanks to all my MPH course instructors for their support, motivation, and regular follow up during my stay at ACIPH. Finally, I own a debt of gratitude to all my family members for their unreserved support and encouragement to make a difference in my life.

\end{abstract}


\keywords{instructors, support, motivation, program.}

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\let\tabcellsep& 	 	 		 \par
its advent, the question of sustainability is always a challenge for health care organization particularly in developing countries. Understanding the essence of sustainability requires analyzing its four elements: technical, programmatic, social and financial sustainability. Sustainability measurement relies on the intended targeted/intervention change that happened at individual level, organization level or both. Implementing change at one level while taking into consideration the context of the others (e.g., individual versus group, facility, or system), will produce the most long-lasting impact.\par
Addressing the sustainability issue of an HIV care and support intervention is a dilemma. Some approaches such as community based prevention and rehabilitation, community based investment, participation at grass root level, providing resources, and trainings are helpful in establishing and formalizing long-term sustainability. Provision of necessary care and supports to the expectation level of the needy in an equitable manner are good characteristics of public healthcare and risk reduction. But there are times, where by the technical (ideologies, knowledge etc) and nontechnical (funds, infrastructure etc) determinants gets impaired by the global, national and regional factors from maintaining the equity. 
\section[{III. Background}]{III. Background}\par
For the past three decades, the human immunodeficiency virus (HIV) infection has spread to every corner of the world. It has killed more than 25 million people since 1981 and more than 30 million people (22 million in sub-Saharan Africa alone) are now infected with HIV, which causes AIDS \hyperref[b0]{(1)}. Although the overall percentage of HIV prevalence has stabilized, the number of people with the infection has gradually increased for the fact that new infection cases are occurring every year and the treatments give additional life for the HIV infected people \hyperref[b1]{(2)}.\par
In response to the occurrence control of HIV/AIDS with the view of making a sustainable change \hyperref[b2]{(3)}. Care and support is one of the focus areas that call attention of these interest groups. 
\section[{Global Journal of Medical Research Volume XII Issue VII Version I ear 2012 Y}]{Global Journal of Medical Research Volume XII Issue VII Version I ear 2012 Y}\par
The provision of proper care and support for PLWHA and for their families can contribute in prolonging I. Acknowledgement gratefully acknowledge Prof. Yemane Berhane, program and theory review course instructor as well as advisor, for his professional support and advice in the whole process of developing this review.\par
At this junction, it is a must for me to give special thanks to all my MPH course instructors for their support, motivation, and regular follow up during my stay at ACIPH.\par
Finally, I own a debt of gratitude to all my family members for their unreserved support and encouragement to make a difference in my life. 
\section[{II. Summary}]{II. Summary}\par
For the past three decades, the human immunodeficiency virus (HIV) infection has spread to every corner of the world. It has killed more than 25 million people since 1981 and more than 30 million people (22 million in sub-Saharan Africa alone) are now infected with HIV, which causes AIDS. Such impact alert international donor agencies to increase resources tremendously to reach significant proportion of people by creating access to basic care and prevention programs in countries worst hammered by the epidemic. Universal access to prevention and treatment for all is an integral part of the global agenda to mitigate the HIV pandemic. However, major challenges exist in combating the current HIV infection with regard to access to treatment, efficiency, quality, and sustainability of existing programs.\par
Sustainability of health programmes and services can be defined as the capacity to maintain programme services at a level that will provide ongoing prevention and treatment for a health problem after Author : Joint Hawassa University and Addis Continental Institute of Public Health MPH program. E-mail : bcchange@gmail.com termination of major financial, managerial and technological assistance from an external donor. I of HIV, various local and international organizations are exerting efforts through different systems and approaches towards the prevention and healthy lives(4). However, the implementation of those programs is hindered by challenges at one time or another and at different level. Many of the innovations which demonstrated success during project launch are eventually end up in failing to show achievements for the targets as well as for the implementers. Achieving Success on some projects while others are failing is a question for investigators \hyperref[b3]{(4)}. Besides success, the question of sustainability is always a challenge for health care organization particularly in developing countries \hyperref[b4]{(5)}\hyperref[b5]{(6)}\hyperref[b6]{(7)}\hyperref[b7]{(8)}.\par
Sustainability of health programmes and services can be defined as the capacity to maintain programme services at a level that will provide ongoing prevention and treatment for a health problem after termination of major financial, managerial and technological assistance from an external donor. To ensure the sustainability of HIV care and support programmes, strategies must be built into project design and implementation to enable HIV efforts to continue long after donor-supported projects are completed \hyperref[b8]{(9)}. This is particularly important in developing countries which are highly dependent on external funding sources \hyperref[b8]{(9)}. .Hence, it is worthy to plan and implement the donor-funded programs to the highest level to ensure sustainability \hyperref[b9]{(10)}. communitybased and integrated approaches help to foster the best use of resources in the provision of care and support for PLWHA \hyperref[b9]{(10)}. However, due consideration has not been given to the sustainability aspect \hyperref[b4]{(5)}. This literature review explores sustainability of HIV/AIDS care and support programs with emphasis in developing countries. 
\section[{IV. Objectives of The Review}]{IV. Objectives of The Review} 
\section[{General objective:}]{General objective:}\par
? to understand and explain the sustainability of HIV/AIDS care and support programs. 
\section[{Specific objectives:}]{Specific objectives:}\par
? to figure out basic and associated determinants that are affecting sustainability of HIV/AIDS care and support programmes in developing countries. ? to develop and recommend a frame work that can be used to sustain health projects. 
\section[{V. Methods}]{V. Methods} 
\section[{Sustainability of HIV/AIDS Care \& Support Programmes}]{Sustainability of HIV/AIDS Care \& Support Programmes}\par
Total \# of articles used as key references = 34.  
\section[{Search criteria's :}]{Search criteria's :}\par
articles published with English language.\par
articles published in the last 10 years.\par
various combinations of key words within specific searching engine.\par
repeated articles are dropped. 
\section[{Global Journal of}]{Global Journal of} 
\section[{Medical Research}]{Medical Research}\par
Volume XII Issue VII Version I ear 2012 Y 
\section[{VI. Synthesis}]{VI. Synthesis}\par
Over the past three decades HIV/AIDS is affecting the world human development, Africa is taking the lion share of the burden. The shocking impacts are indicated on the health and demographic indicators (life expectancy at birth e.g. life expectancy at birth in Botswana fell from 65 years in 1990 to less than 40 years by 2005 \hyperref[b10]{(11)}, healthcare assistance, age and sex distribution), economic indicators (income, work force, and economic growth), Social indicators (education and knowledge), and other indicators (governance, gender inequality and human rights) \hyperref[b11]{(12)}. Such impact alert international donor agencies to increase resources tremendously to reach significant proportion of people by creating access to basic care and prevention programs in countries worst hammered by the epidemic \hyperref[b5]{(6)}. Universal access to prevention and treatment for all is also an integral part of the global agenda to mitigate the HIV pandemic(13) However, major challenges exist in combating the current HIV infection with regard to access to treatment, efficiency, quality, and sustainability of existing programs(6, 7). 
\section[{a) Overview of sustainability}]{a) Overview of sustainability}\par
The issue of sustainability gets an international agenda since its advent in the 1980s \hyperref[b13]{(14)}. Understanding the essence of sustainability requires analyzing its four elements: technical, programmatic, social and financial sustainability. The Technical sustainability refers the continuous availability of highquality, facility-based HIV clinical services aligned with national standards (Skilled professionals, adequate laboratory, pharmacy infrastructure, sufficient equipment and commodities). Programmatic sustainability refers effective management, coordination and implementation of facility-based HIV services (robust logistics; commodity and supply management systems; functional communications). Social sustainability refers to sustained HIV activities, which rely on continued demand for HIV services by communities (acceptability, accessibility, affordability and culturally sensitive). Financial sustainability refers the presence of adequate and continuous funding to achieve HIV service targets and objectives. This is a major challenge in resourcelimited countries \hyperref[b12]{(13,}\hyperref[b14]{15)}.\par
Usually, sustainability measurement relies on the intended targeted/intervention change that happened at individual level, organization level or both. Implementing change at one level while taking into consideration the context of the others (e.g., individual versus group, facility, or system), will produce the most long-lasting impact \hyperref[b15]{(16)}. These factors are likely also to be important in work aimed at sustaining organizational innovations that have been successfully introduced. Some factors (e.g., a supportive organizational culture) are likely to come into play earlier on in the introduction of an organizational innovation, whereas others are likely to be more important in sustaining, maintaining, and routinising change \hyperref[b16]{(17)}. Bringing desirable change in individual vise-a-vise organizational performance are two different tasks that require not only different instruments for measuring changes, but acquisition of in-depth knowledge of the processes that control adoption or assimilation of the innovation at either level \hyperref[b15]{(16)}. b) Challenges of PLWHA People living with HIV/AIDS face tremendous challenges, including mental health, lack of care and support, stigma-a dynamic process of devaluation that 'significantly discredits' an individual in the eyes of others \hyperref[b17]{(18)}, and depression \hyperref[b18]{(19)}. Though projects and interventions like HIV therapy and care programs are designed and remains working in the fight against HIV in developing countries, it is not touching the ground as per the wishes. Without adequate treatment, care or support, mortality rates would continue to rise \hyperref[b19]{(20)}. PLWHA as well as family members are not only struggling with sickness, but also facing impaired productivity, declining income, and increasingly difficult choices among essentials but competing expenses 
\section[{Global Journal of Medical Research Volume XII Issue VII Version I ear 2012 Y}]{Global Journal of Medical Research Volume XII Issue VII Version I ear 2012 Y}\par
Sustainability of HIV/AIDS Care \& Support Programmes such as food versus healthcare or schooling versus rent \hyperref[b20]{(21,}\hyperref[b22]{22)} c) Determinants of sustainability HIV/AIDS care and support programs usually require two major categories of support -formal and informal. The formal social supports are those supports provided from health care and social service facilities which are established for the same or related purposes. Whereas the informal social supports are those supports originated from family, friends, and other community organizations (like churches) \hyperref[b23]{(23)}\hyperref[b24]{(24)}\hyperref[b25]{(25)} that are highly recommended in managing most chronic diseases including HIV. The presence and provision of close support from family members for PLWHA promote their odds of entry into medical care \hyperref[b23]{(23)}.\par
In a comparative study to know the relevance of care and support among children who were placed in three domains of outcome measures (group homes, orphanages, and in kinship) those children's who were attached to the group homes performed best in almost all psychosocial variables. Consequently, children's in group homes who were receiving the necessary collaboration, care and support has demonstrated lowest level of anxiety, depression, anger, posttraumatic symptoms, disassociation and sexual concerns \hyperref[b26]{(26)}. Collaboration was found to be the basis for sustainability \hyperref[b27]{(27)}.\par
Provision of necessary care and supports to the expectation level of the needy in an equitable manner are good characteristics of public healthcare and risk reduction. But there are times, where by the technical (ideologies, knowledge etc) and non-technical (funds, infrastructure etc) determinants gets impaired by the global, national and regional factors from maintaining the equity \hyperref[b28]{(28)}.\par
Though aggressive and multidimensional strategies are designed (by foundations, donors, policy makers, and advocates) to stop the HIV infections and sustain impacts, they did not escaped from the increasing criticism for their failures to achieve the 2008 goals(29) (mid point for MDG). On contrary, counter arguments recognize that the relevance and contributions of global health sectors in mobilizing significant amount/kind of resources which was not achieved prior to HIV. The question here is how far the huge resources are contributing for the HIV/AIDS care and support program sustainably in developing world? The other critic is the global fund for HIV is the most extravagant in consuming the majority human and financial resources as compared to the measurable outcomes. Due to this, less resource is being allocated for tuberculosis (TB), malaria, and malnutrition. This leads the vulnerable groups in to further complication and public health problems. Most often, small rural, African villages are the most vulnerable from such negligence. In situations where by the HIV/AIDS case is rampant vise-a-vise low service coverage for the care and support interventions, the poor PLWHA are still challenged with the HIV infection consequences. In order to address these challenges horizontal integration, family wellness, evidence based prevention, and applications of highly active and vibrant systems are advised \hyperref[b29]{(29,}\hyperref[b30]{30)} In a research conducted to identify the decision making process for HIV/AIDS resource allocation including for care and support in sustainable ways, it was revealed that the resource allocation begins with the selection of HIV/AIDS programmes and with available data. This is followed by the funding level and the level of experiences they acquired for each programmes \hyperref[b32]{(31)}. In the process of allocating the resources, external individuals, other organizations, and other intangible factors have an important influence either in supporting or refusing the ultimate decision. This by itself either benefits or hinders the HIV/AIDS care and support programs in developing countries. On a similar research, the type of tools or frameworks that are used by decision makers in allocating resources for HIV/AIDS were analyzed and figured out that for small organization or local level decisions the use of such formal techniques is not common. However, for a national level organization, they use rational economic models to analyze the epidemiological and the costeffectiveness. However, the use of other operations research techniques or framework is not common \hyperref[b32]{(31)}.\par
On the same token in another study the private sector resources mobilization, efficiency in disbursing the funds, and assurances are not satisfying the expectations of the people living with HIV/AIDS, the participating stakeholders, and other multilateral organizations in sub-Saharan Africa \hyperref[b33]{(32)}, a challenge for the sustainability of HIV projects. 
\section[{d) Sustainability strategies}]{d) Sustainability strategies}\par
Due to the escalating number of HIV/AIDS infection in developing countries, there is a high demand for system-level interventions. This is a promising approach aims at improving the proper functioning of the organization as well as the delivery of services to the community in coordinated manner. System-level interventions are a promising approach to HIV/AIDS prevention because they focus on (a) evidence based HIV prevention and care programs (b) develop and establish policies and procedures that maximize the sustainability of on-going prevention and care efforts (c) improve the decision making processes such as incorporating the needs of communities into their tailored services \hyperref[b34]{(33)}.\par
Addressing the sustainability issue of an HIV care and support intervention is a dilemma. Some approaches such as CBPR, community based investment, participation at grass root level, providing resources, and trainings are helpful in establishing and formalizing long-term sustainability \hyperref[b7]{(8)}. But, most of the organization in developing countries, rather than focusing on the mentioned approaches, they were just concentrating on the provision of food aid within their HIV/AIDS care and support programmes with a rationale that PLWHA are not food secured. Food supplementation, however, was quickly recognized as an unsustainable and incomplete intervention \hyperref[b35]{(34)}. A growing body of research suggests that community readiness to adopt and implement evidence-based interventions is essential for sustainability \hyperref[b14]{(15)}. 
\section[{Global}]{Global}\par
Even though the expected outcome towards care and support program is to the minimum level due to the mentioned reasons, it was argued that 'care agenda' needs top priority and urgency by the international health policy in its framework, strategies and actions. Furthermore, it stresses that other non health sector should support and strengthen the policy as well as the community home-based care to the broader sense to ensure sustainability \hyperref[b9]{(10)}.\par
Caring for a person with HIV/AIDS requires considerable time and other resources, which is compounded in many developing countries \hyperref[b9]{(10)}. In response to the growing need for a more programmatic approach to care for persons living with HIV/AIDS, the World Health Organization (WHO), in consultation with a wide group of experts, developed a framework for 'Comprehensive Care across a Continuum' later known simply as the 'Care Continuum' (WHO 2000b). The intent of the model was to promote, create and sustain a 'holistic' approach to care and support for persons living with HIV/AIDS \hyperref[b9]{(10)}. This approach is believed to be an important advance for the fact that it illustrate in creating linkage among care domains. Though this is appreciated, the 'care continuum' is criticized for poor mechanism of linking individuals with home care and peer support across the continuum. Thus the application of the model might be challenged for its intent i.e. promoting and sustaining holistic approaches to care and support for PLWHA. 
\section[{VII. Limitation of The Review}]{VII. Limitation of The Review}\par
The major limitation of this literature review is: ? Majority of the published articles done on sustainability are focusing about overall HIV/AIDS interventions. And identifying only the care and support from the available articles is difficult for the fact that a number of confounding factors are affecting the sustainability aspect. 
\section[{VIII. Conclusions And Recommendations}]{VIII. Conclusions And Recommendations}\par
HIV is still a major public health problem in developing countries. Various local and international organizations are exerting efforts through different systems and approaches towards the prevention and control of HIV/AIDS with the view of making a sustainable change. Care and support is one of the focus areas that call attention of these interest groups. However, the question of sustainability is always a challenge for health care organization.\par
Major factors that determine the sustainability of HIV care and support at the global, national and regional levels are; type of care and support provided, technical (ideologies, knowledge etc) and non-technical (funds, infrastructure etc). In order to address these challenges horizontal integration, family wellness, evidence based prevention, and applications of highly active and vibrant systems are advised. The following framework is also recommended based on the existing sustainability gaps,  ? There has to be aggressive system integration with the existing government structure, supported with evidence based intervention. ? Community members should bear ownership and provide required support to PLWHA as well as the organizations. 
\section[{Global}]{Global}\begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-3.png}
\caption{\label{fig_1}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-4.png}
\caption{\label{fig_2}}\end{figure}
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\end{bibitemlist}
 			 		 	 
\end{document}
