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Policy & Politics
OGAC's Abstinence, Faithfulness Requirements for PEPFAR Confusing, Undercutting Other HIV-Prevention Efforts, GAO Report Says

April 5, 2006

The Office of the U.S. Global AIDS Coordinator's mandates for how much President's Emergency Plan for AIDS Relief-funded programs must spend promoting abstinence and faithfulness have caused confusion among many countries and undercut some other HIV-prevention programs, according to a report released on Tuesday by the Government Accountability Office, the Washington Post reports (Brown, Washington Post, 4/5). PEPFAR is a five-year, $15 billion program that directs funding for HIV/AIDS, tuberculosis and malaria to 15 focus countries. The law (HR 1298) authorizing PEPFAR endorses the "ABC" HIV prevention model, which stands for abstinence, be faithful and use condoms. The measure also specifies that one-third of PEPFAR's HIV/AIDS-prevention funding should be used for abstinence-until-marriage and faithfulness programs (Kaiser Daily HIV/AIDS Report, 5/08/03). To meet the one-third requirement, OGAC for fiscal year 2006 established a policy that requires countries to spend half of all HIV-prevention funds received through PEPFAR on preventing the sexual transmission of the virus and that two-thirds of the amount spent on preventing sexual transmission must be spent on abstinence and faithfulness programs. OGAC allowed countries to apply for exceptions to the policy to meet local prevention needs (GAO report highlights, April 2006). The law suggests that 20% of PEPFAR funding be spent on HIV-prevention programs (Stecklow, Wall Street Journal, 4/5).

Findings, Reaction
GAO surveyed U.S. teams in the 15 target countries and five others that receive at least $10 million in PEPFAR funding to fight HIV/AIDS (Beamish, AP/Sacramento Bee, 4/4). U.S. officials responding to the survey were guaranteed anonymity to promote frank answers, the New York Times reports (Dugger, New York Times, 4/5). The report finds that 17 of the 20 country teams said OGAC's requirements for abstinence and faithfulness spending "presen[t] challenges to their ability to respond to local prevention needs" (Allen, Reuters, 4/4). Nine of the 15 focus countries reduced the amount they were planning to spend on preventing mother-to-child HIV transmission in order to meet the requirements, the Post reports. One country reduced from $8 million to $4 million spending on prevention services for couples with one HIV-positive partner and one HIV-negative partner. Ten of the countries surveyed received waivers from OGAC on meeting the requirements (Washington Post, 4/5). Nonexempted countries effectively had to spend more than 33% of prevention funding on abstinence and faithfulness programs for FY 2006, according to the report (GAO report highlights, April 2006). "The GAO report confirms what we have learned from our direct field experience in Africa, that the current PEPFAR funding structure sometimes limits funds at the local level for programs that aim to prevent infant infections," Richard Marlink, scientific director for the Elizabeth Glaser Pediatric AIDS Foundation, said, adding, "We have been concerned for some time that the requirement to spend 33% of PEPFAR prevention funds on abstinence programs is limiting the ability of communities to respond to their most pressing needs -- including prevention of mother-to-child transmission of HIV" (Elizabeth Glaser Foundation release, 4/4). "Messages promoting abstinence and fidelity have a place in a comprehensive strategy, and condoms are not the only solution to AIDS," Paul Zeitz, Executive Director of the Global AIDS Alliance, said in a release, adding, "But the US approach is far from the 'balanced, effective' policy we were promised by President Bush" (Global AIDS Alliance release, 4/4).

Bush Administration, Congressional Reaction
The State Department told GAO that it will work to clarify the OGAC regulations for prevention spending (AP/Sacramento Bee, 4/4). Deputy U.S. Global AIDS Coordinator Mark Dybul said the office has balanced the ABC model with its HIV-prevention requirements for PEPFAR, adding that condoms have not been neglected. Condom distribution worldwide has increased from 348 million in 2001 to 429 million in 2005, according to federal figures. Rep. Henry Hyde (R-Ill.), chair of the House International Relations Committee, said that no report is needed "to uncover the fact that country teams may be resistant to change, and that some adjustment time would be needed to implement new requirements" (New York Times, 4/5). Rep. Chris Smith (R-N.J.), chair of the House subcommittee on Africa, Global Human Rights and International Operations, in a release said, "The timing, methodology and substance of the GAO report all call into question GAO's objectivity," adding, "The most important question is whether the PEPFAR strategy that has proven to be successful in the past is continuing to provide effective results. GAO not only fails to answer that question, it doesn't even bother to address it" (Smith release, 4/4). However, Rep. Barbara Lee (D-Calif.) said in a release that the report "demonstrates the Bush administration's willingness to make [HIV]AIDS-prevention policy a political plaything in their ongoing effort to appease the radical right," adding, "Our global [HIV]AIDS-prevention policy should be based on proven, evidence-based science" (Lee release, 4/4). Rep. Henry Waxman (D-Calif.), the ranking member on the House Government Reform Committee, on Tuesday sent a letter to Secretary of State Condoleezza Rice saying that abstinence messages do not always work in some countries, writing, "The effect may well be to misallocate funds in countries with fast-growing HIV epidemics driven primarily by [injection] drug use or commercial sex, such as Russia and India" (AP/Sacramento Bee, 4/4). Sen. Dianne Feinstein (D-Calif.) in a release said she plans to introduce legislation that would ensure that countries given PEPFAR funding would have more flexibility in spending their funds (Sternberg, USA Today, 4/5).

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