title: From scaling up to sustainability in HIV: potential lessons for moving forward.
abstract: BACKGROUND
  In 30 years of experience in responding to the HIV epidemic, critical decisions and program characteristics for successful scale-up have been studied. Now leaders face a new challenge: sustaining large-scale HIV prevention programs. Implementers, funders, and the communities served need to assess what strategies and practices of scaling up are also relevant for sustaining delivery at scale.
  
  
  METHODS
  We reviewed white and gray literature to identify domains central to scaling-up programs and reviewed HIV case studies to identify how these domains might relate to sustaining delivery at scale.
  
  
  RESULTS
  We found 10 domains identified as important for successfully scaling up programs that have potential relevance for sustaining delivery at scale: fiscal support; political support; community involvement, integration, buy-in, and depth; partnerships; balancing flexibility/adaptability and standardization; supportive policy, regulatory, and legal environment; building and sustaining strong organizational capacity; transferring ownership; decentralization; and ongoing focus on sustainability. We identified one additional potential domain important for programs sustaining delivery at scale: emphasizing equity.
  
  
  CONCLUSIONS
  Today, the public and private sector are examining their ability to generate value for populations. All stakeholders are aiming to stem the tide of the HIV epidemic. Implementers need a framework to guide the evolution of their strategies and management practices. Greater research is needed to refine the domains for policy and program implementers working to sustain HIV program delivery at scale.
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, USA. lrh3@hms.harvard.edu.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
authors.forename: Julie R
authors.initials: JR
authors.lastname: Talbot
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Irwin
authors.forename: Maria A
authors.initials: MA
authors.lastname: May
authors.forename: Nayana
authors.initials: N
authors.lastname: Dhavan
authors.forename: Robert
authors.initials: R
authors.lastname: Shady
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Ellner
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Weintraub
mesh_terms: D003695:Delivery of Health Care; D015658:HIV Infections / Q000517:prevention & control*; D006291:Health Policy; D006301:Health Services Needs and Demand; D006801:Humans