There is increasing frustration in development with the failure of many small-scale research, pilot or demonstration projects to get “out of the hothouse” to have a larger influence on policies and programmes (Myers 1992: 370). This frustration is perhaps more pronounced in the area of HIV/AIDS as the epidemic escalates. The World Bank report on Sub-Saharan Africa notes, for example, that among the lessons that have been learned about successful HIV/AIDS prevention efforts is that small pilot programmes with no chance of duplication or replication are not helpful (World Bank 1999). In an article in Science (Binswanger 2000) the director for rural development and environment at the World Bank gives a stark example of limited coverage in the Kagera Region of Tanzania, where 200,000 of the region’s 1.9 million people are children orphaned by AIDS. There, NGO directors stated that they operate mainly in two out of five districts, leaving three with almost no services, and in the two districts where they do work, they serve no more than an estimated 5 per cent of the population.

Elsewhere, as the UNAIDS recent report states: “…action remains sporadic and patchy rather than comprehensive. ‘Boutique’ projects may provide services for one or two communities, while large areas of the countryside have nothing. Many programmes have yet to become comprehensive in either geographical coverage or content.” (UNAIDS 2000). Indeed such is the lack of information about access and coverage that it is not generally known who has access to, let alone uses, HIV/AIDS related services (Paurvi Bhatt, USAID/DC, Horizons/Alliance Seminar). Estimates of current levels of coverage in sub-Saharan Africa for HIV/AIDS prevention interventions suggest that overall coverage is less than 20% of the target populations in most countries