JHPIEGO (its name is not an acronym), a nonprofit health organization affiliated with The Johns Hopkins University, works worldwide to "train trainers" — whether they are hospital employees or African village laymen.
JHPIEGO draws on resources from Johns Hopkins' schools of Public Health, Medicine and Nursing, but doesn't offer medical treatment or family services. The organization trains people overseas to do that instead, and mainly uses local medical practitioners and trainers to run its programs.
"Our focus is on establishing the system," said Sam Dowding, acting director of JHPIEGO's Center of Excellence on HIV/AIDS. "We work in institutions where we train the trainers, so in 5 years, 10 years, it continues to be self-sustained."
The organization's funding largely comes from the federal government, which has backed the organization since its first day in operation.
In 2005, the Presidents Emergency Plan for AIDS Relief, a five-year, $15 billion initiative to fight AIDS abroad, granted the organization $8.2 million for its efforts in Côte d'Ivoire, Ethiopia, Mozambique, South Africa, Tanzania and Zambia. The funding accounted for more than a fifth of JHPIEGO's $37.5 million program expenditures and built on its work in more than 90 countries worldwide.
But at least one of JHPIEGO's programs has been debated in international circles and was not supported by PEPFAR.
Working history with U.S. government
For more than 30 years, JHPIEGO has been working with the U.S. Agency for International Development to improve health care services for women and families in developing countries.
It was founded in 1973 to implement a five-year USAID grant to train obstetricians and gynecologists. After the grant's extension, JHPIEGO expanded its global presence through partnerships with USAID, then with private foundations and other international health organizations.
About 25 years after its inception, JHPIEGO made its first inroads into HIV/AIDS relief as part of a consortium of organizations working in West Africa. By 2002, it had entered a five-year partnership with the U.S. Centers for Disease Control and Prevention called the University Technical Assistance Project.
The project, now fully funded by PEPFAR, includes nine other U.S. research universities and provides the CDC with country-specific assistance for HIV/AIDS relief programs. Infection prevention, antiretroviral treatment, counseling and testing services are among the needs addressed through the program.
Through their partnership, the CDC funds 70 percent of expenditures for JHPIEGO's Center of Excellence on HIV/AIDS, established in 2004. That commitment was worth more than $10 million in fiscal 2005 across several countries, including the six of PEPFAR's 15 focus countries in which JHPIEGO operates.
According to Dowding, JHPIEGO implements a step-by-step learning method in its field training programs.
Local health care providers become "qualified clinical trainers" upon completing one or two courses and after conducting their own sessions under review. Through additional coursework, they move on to "advanced trainer," and then may be selected to complete coursework for "master trainer" status. At the peak levels, they help instruct those under them.
While much of its work is carried out through established institutions, such as hospitals, health centers and ministries of health, the organization also has addressed culturally specific needs. In Mozambique, for example, JHPIEGO was awarded PEPFAR funds in 2005 to provide training for a community-based method of HIV testing.
"The Mozambique government recently agreed to an initiative to try to come up with a way of testing every person in the country," Dowding said. "They asked us how we'd do it. We said we'd train lay counselors to go from home to home instead of relying on individuals to come into health centers."
Federal documents obtained by the Center for Public Integrity through a Freedom of Information Act request show that JHPIEGO has worked largely in institutional settings. It has implemented programs in Zambian military hospitals to prevent mother-to-child disease transmission, educated injection and bio-safety trainers in Mozambique and has worked closely with various Ministries of Health to develop training guidelines, like Ethiopia's National Infection Prevention Guidelines.
Yet the tallies of people involved in JHPIEGO's endeavors are sometimes relatively small for PEPFAR, which measures success by the numbers.
In his 2003 State of the Union address in which he introduced PEPFAR, President George W. Bush called it a "work of mercy beyond all current international efforts to help the people of Africa" that would prevent seven million new infections, treat at least 2 million infected individuals and provide care for millions of people affected by HIV/AIDS.
Since then, those target numbers have been calculated through the combined efforts implemented by all contractors, including JHPIEGO. Although JHPIEGO and USAID collaborate on their goals, Dowding shared concern with other organizations over a pressure to produce numbers.
"We've had to change training methodology considerably," Dowding said, referring to a program in South Africa. "We're not one to do training programs with 60 people in a room over two days of lectures. That's not what JHPIEGO prefers, but that's how we have to [work] because of the challenges and resources available."
In at least one case, Dowding said he felt that reported numbers didn't accurately reflect the quality of JHPIEGO's program.
In 2005, JHPIEGO and Family Health International — which Dowding called a "major competitor" — both worked on an effort to train HIV counselors and testers in Ethiopia. While JHPIEGO trained 181 individuals in military and civilian hospitals, FHI educated 1,170 people in health centers and communities.
"We report on the numbers of hospitals [in Ethiopia], which doesn't really reflect our work," Dowding said. "You're not going to be satisfied in doing it in a fairly shallow way; we want to make sure we're doing a quality job."
Debate over male circumcision
Another issue JHPIEGO has raised with PEPFAR remains controversial in international health circles.
In the late 1980s, researchers in Africa began to notice that HIV infection rates were much higher in areas where male circumcisions were not performed due to tribal or regional culture, according to a San Francisco Chronicle report on the practice. Circumcision removes the foreskin, which is filled with white blood cells that AIDS researchers say allow HIV additional access to the bloodstream.
JHPIEGO has had success with a program advocating male circumcision in Zambia under separate USAID funding. It has tried pushing for PEPFAR to support a similar initiative, but to no avail. "We continue to try to get policymakers to see that HIV relief … [involves] a wide range of issues," Dowding said.
Along with JHPIEGO, other international health organizations have issued a call to make inexpensive male circumcisions safe and widely available, saying that doing so would help the infection rate to fall. At the 2006 International AIDS Conference, former President Bill Clinton suggested that he would endorse the practice if studies prove it to be effective.
Yet at the same conference, where JHPIEGO presented its results from Zambia, others pointed out religious and cultural stigmas against male circumcision, as well as noting that there could be a backlash.
The Canadian Press reported that Catherine Hankins, chief scientific adviser for the United Nations AIDS program, noted there that circumcised men are looked down upon in some African cultures. Other men might think that circumcision would take the place of wearing a condom, others argued.
PEPFAR hasn't yet included the practice in its prevention strategy, but it may be moving towards funding the practice. Its second annual report to Congress, released in February 2006, mentions the convening of a Scientific Advisory Board to review data and draft recommendations about male circumcision. The report also says that 2006 funding in Kenya has been appropriated to explore the acceptability and feasibility of male circumcision in the future.