The extent to which NGOs can be proactive in scaling up, with sufficient time for reflection and planning in order to maximise impact and safeguard their organisational mission is critical. Not all NGOs should scale up and nor should NGOs scale up all of their activities simultaneously, and thus choices as to which aspects of NGOs work to scale up with maximum impact have to be considered carefully. To the extent that it is possible, organisations need to prepare their own structures and staff for the scaling up process. If they are merely responding to donor demands or the evolution of the epidemic, they will command little control over the scaling up process and ultimately perhaps have less effect. At the same time, however, NGOs may need to sacrifice some elements of the quality of the programmes they run for the sake of broader coverage. This in turn points to the need for more information on the quality and impact of NGO programmes.

While definitions of scaling up vary according to the perspective of the individual and organisation, consensus exists over the need to define objectives in terms of impact on either preventing the epidemic or mitigating its effects. A narrow understanding of impact, however, based only on reducing the number of new infections, without looking at the synergies between prevention, care and support and the broader social change needed to address HIV/AIDS, is misleading. NGOs - based on the many successful but often undocumented experiences of scaling up - need to express their own notions of the impact of their efforts, and to communicate these to a broader audience.

In both effectiveness and efficiency terms, integrating HIV/AIDS efforts into development processes and institutions more broadly is desirable to address the structural and social determinants of the epidemic and take advantage of existing infrastructure. Yet such efforts should not lose sight of the experience accumulated by specialised AIDS-service organisations (O’Malley et al 1996).

Scaling up the programmes of NGOs in HIV/AIDS entails much more, however, than finding avenues for reaching wider coverage. If scaling up is seen as a process, as described here, the dynamic relationships between impact, coverage and quality of programmes mean that at different stages of the process, different objectives become paramount. Moreover, scaling up that is sustainable in social, as well as financial and programmatic terms necessitates understanding, strengthening and catalysing the existing response of individuals and communities to the complexities of the epidemic.