Dear Senators:

The undersigned organizations, physicians, healthcare workers, and advocates are writing regarding our collective support for the pre-service training, support and retention of 140,000 new health professionals plus additional paraprofessional and community health workers in the U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (S. 2731). Provided adequate training and supervision within functioning referral systems, lay or community health workers and paraprofessionals are an important part of delivering high-quality standards of care. However, they should not come at the expense of the health professionals needed, and should not be counted against the 140,000 new health workers called for in the House and Senate bills.

Developing countries are facing a health workforce shortage crisis, most severely in sub-Saharan Africa where many countries have less than one health worker per thousand residents. Without adequate numbers of nurses, doctors, clinical officers and midwives, the historic U.S. investments being made to fight AIDS will continue to fall far short of their potential. Paraprofessionals and community health workers are crucial to scaling up human resource capacity for health. However, studies [1] have shown that in order for programs involving paraprofessionals and community health workers to be successful, health professionals are needed to provide support, referral services and supervision. Indeed, recent guidelines published by the Office of the Global ADS Coordinator, W.H.O. and UNAIDS have stated clearly that community health workers require additional health professionals in order to be successfully utilized.[2] Fortunately, new PEPFAR legislation soon to come up for vote in the Senate calls for the training and retention of new health professionals in partner countries. Unfortunately, the current language calls for the training of 140,000 “new health professionals, paraprofessionals and community health workers,” and goes on to define “paraprofessionals” to include very low-level basic heath assistants. The inclusion of lower cadres of non-professional health workers provides a dangerous loophole which allows OGAC to continue its harmful current practice of hiring away scarce health professionals from struggling public clinics, or else expensively importing expatriates. This loophole will result in a continuation of ongoing trainings for community health workers and existing health professionals, without ensuring a serious effort to increase the supply and retention of doctors and nurses needed to create sustainable solutions or to successfully utilize lay-health workers. Without the training and retention of additional needed health professionals, HIV/AIDS will continue to devastate families and entire populations in Sub Saharan Africa. We encourage you to support language specifying a commitment to train and retain 140,000 new health professionals plus additional paraprofessionals and community health workers necessary for the success of PEPFAR.

We thank you for your action and your leadership.

Sincerely, [List in formation] National Physicians Alliance The AIDS Institute American Medical Student Association Health GAP NOTES:

1. Lehmann, Uta, Friedman,Irwin, and Sanders, David “Review of the Utilization and Effectiveness of Community-based Health Workers in Africa,” Joint Learning Initiative Working Paper 4-1, February 2004
2. OGAC/WHO/UNAIDS Task shifting guidelines, available at: http://www.who.int/healthsystems/TTR-TaskShifting.pdf