Global Health
Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief Gao ID: GAO-06-395 April 4, 2006The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 authorizes the President's Emergency Plan for AIDS Relief (PEPFAR) and promotes the ABC model (Abstain, Be faithful, or use Condoms). It recommends that 20 percent of funds appropriated pursuant to the act be spent on prevention and requires that, starting in fiscal year 2006, 33 percent of prevention funds appropriated pursuant to the act be spent on abstinence-until-marriage. The Office of the U.S. Global AIDS Coordinator (OGAC) is responsible for administering PEPFAR. GAO reviewed PEPFAR prevention funds, described PEPFAR's strategy to prevent sexual HIV transmission, and examined related challenges.
In fiscal years 2004-2006, the PEPFAR prevention budget increased by almost 55 percent, from $207 million to $322 million. During this time, the prevention share of the total PEPFAR budget fell from 33 to 20 percent, consistent with the Leadership Act's recommendation that 20 percent of funds appropriated pursuant to the act should support prevention. The PEPFAR strategy for preventing sexual transmission of HIV is largely shaped by the ABC model and the abstinence-until-marriage spending requirement. In addition to adopting the ABC model, OGAC developed guidance for applying it--stating, for instance, that prevention interventions should be integrated and respond to local epidemiology and cultural norms. OGAC also established policies for applying the spending requirement for fiscal year 2006. To meet the 33 percent spending requirement, it mandated that country teams--PEPFAR officials in the field--spend half of prevention funds on sexual transmission prevention and two-thirds of those funds on abstinence/faithfulness (AB) activities. At the same time, OGAC permitted certain teams, especially those with relatively small budgets, to seek waivers from this policy to help them respond to local prevention needs. OGAC also applied the spending requirement to all PEPFAR prevention funding as a matter of policy, although it determined that, as a matter of law, it applies only to funds appropriated to the Global HIV/AIDS Initiative account. OGAC's ABC guidance and the abstinence-until-marriage spending requirement, including OGAC's policies for implementing it, have presented challenges for country teams. First, although most teams found the ABC guidance generally clear, two-thirds reported that ambiguities in some parts of the guidance led to uncertainty about implementing the model. OGAC officials told GAO that they plan to clarify the guidance. Second, although several teams told GAO that they value the ABC model and emphasize AB messages for certain populations, teams also reported that the spending requirement can limit their efforts to design prevention programs that are integrated and responsive to local prevention needs. Seventeen of 20 country teams reported that fulfilling the spending requirement, including OGAC's policies implementing it, presents challenges to their ability to respond to local prevention needs. Ten of these teams (primarily those with smaller PEPFAR budgets) received exemptions from the requirement, allowing them to dedicate less than 33 percent of prevention funds to AB activities. In general, the nonexempted teams were effectively required to spend more than 33 percent of prevention funds on AB activities; as a result, OGAC should just meet the overall 33 percent spending requirement for fiscal year 2006. However, to meet the requirement, nonexempted country teams have, in some cases, reduced or cut funding for certain prevention programs, such as programs to deliver comprehensive ABC messages to populations at risk of contracting HIV. Finally, OGAC's decision to apply the spending requirement to all PEPFAR prevention funds may further challenge teams' ability to address local prevention needs.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-06-395, Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief
This is the accessible text file for GAO report number GAO-06-395
entitled 'Global Health: Spending Requirement Presents Challenges for
Allocating Prevention Funding under the President's Emergency Plan for
AIDS Relief' which was released on April 4, 2006.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Committees:
April 2006:
Global Health:
Spending Requirement Presents Challenges for Allocating Prevention
Funding under the President's Emergency Plan for AIDS Relief:
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-395]:
GAO Highlights:
Highlights of GAO-06-395, a report to congressional committees:
Why GAO Did This Study:
The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of
2003 authorizes the President‘s Emergency Plan for AIDS Relief (PEPFAR)
and promotes the ABC model (Abstain, Be faithful, or use Condoms). It
recommends that 20 percent of funds appropriated pursuant to the act be
spent on prevention and requires that, starting in fiscal year 2006, 33
percent of prevention funds appropriated pursuant to the act be spent
on abstinence-until-marriage. The Office of the U.S. Global AIDS
Coordinator (OGAC) is responsible for administering PEPFAR. GAO
reviewed PEPFAR prevention funds, described PEPFAR‘s strategy to
prevent sexual HIV transmission, and examined related challenges.
What GAO Found:
In fiscal years 2004-2006, the PEPFAR prevention budget increased by
almost 55 percent, from $207 million to $322 million. During this time,
the prevention share of the total PEPFAR budget fell from 33 to 20
percent, consistent with the Leadership Act‘s recommendation that 20
percent of funds appropriated pursuant to the act should support
prevention.
The PEPFAR strategy for preventing sexual transmission of HIV is
largely shaped by the ABC model and the abstinence-until-marriage
spending requirement. In addition to adopting the ABC model, OGAC
developed guidance for applying it”stating, for instance, that
prevention interventions should be integrated and respond to local
epidemiology and cultural norms. OGAC also established policies for
applying the spending requirement for fiscal year 2006. To meet the 33
percent spending requirement, it mandated that country teams”PEPFAR
officials in the field”spend half of prevention funds on sexual
transmission prevention and two-thirds of those funds on
abstinence/faithfulness (AB) activities. At the same time, OGAC
permitted certain teams, especially those with relatively small
budgets, to seek waivers from this policy to help them respond to local
prevention needs. OGAC also applied the spending requirement to all
PEPFAR prevention funding as a matter of policy, although it determined
that, as a matter of law, it applies only to funds appropriated to the
Global HIV/AIDS Initiative account.
OGAC‘s ABC guidance and the abstinence-until-marriage spending
requirement, including OGAC‘s policies for implementing it, have
presented challenges for country teams. First, although most teams
found the ABC guidance generally clear, two-thirds reported that
ambiguities in some parts of the guidance led to uncertainty about
implementing the model. OGAC officials told GAO that they plan to
clarify the guidance. Second, although several teams told GAO that they
value the ABC model and emphasize AB messages for certain populations,
teams also reported that the spending requirement can limit their
efforts to design prevention programs that are integrated and
responsive to local prevention needs. Seventeen of 20 country teams
reported that fulfilling the spending requirement, including OGAC‘s
policies implementing it, presents challenges to their ability to
respond to local prevention needs. Ten of these teams (primarily those
with smaller PEPFAR budgets) received exemptions from the requirement,
allowing them to dedicate less than 33 percent of prevention funds to
AB activities. In general, the nonexempted teams were effectively
required to spend more than 33 percent of prevention funds on AB
activities; as a result, OGAC should just meet the overall 33 percent
spending requirement for fiscal year 2006. However, to meet the
requirement, nonexempted country teams have, in some cases, reduced or
cut funding for certain prevention programs, such as programs to
deliver comprehensive ABC messages to populations at risk of
contracting HIV. Finally, OGAC‘s decision to apply the spending
requirement to all PEPFAR prevention funds may further challenge teams‘
ability to address local prevention needs.
What GAO Recommends:
GAO recommends that the Secretary of State direct the Global AIDS
Coordinator to collect and report information on the abstinence-until-
marriage spending requirement‘s effects and use it to assess whether
the requirement should apply only to the Global HIV/AIDS Initiative
account. GAO also suggests that Congress use the information to assess
how well the requirement supports the Leadership Act‘s endorsement of
both the ABC model and strong abstinence programs. OGAC agreed
regarding collecting information but disagreed with applying the
requirement only to certain funds. We modified our recommendation in
light of this concern.
www.gao.gov/cgi-bin/getrpt?GAO-06-395.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact David Gootnick at (202)
512-3149 or gootnickd@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
PEPFAR Prevention Funding in the 15 Focus Countries Grew Significantly
during First 3 Years:
PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC
Approach, Abstinence-Until-Marriage Spending Requirement, and Local
Prevention Needs:
ABC Guidance and Abstinence-Until-Marriage Spending Requirement Present
Challenges for Country Teams:
Conclusions:
Recommendation for Executive Action:
Matters for Congressional Consideration:
Agency Comments and Our Evaluation:
Appendixes:
Appendix I: Scope and Methodology:
Appendix II: AB and "Other Prevention" Programs in Four Focus
Countries:
Appendix III: Prevention Program Indicators and Methods of Measuring
PEPFAR Prevention Program Results:
Appendix IV: PEPFAR Planning and Reporting Process:
Appendix V: Methods for Reporting Allocations among PEPFAR Prevention
Program Areas:
Appendix VI: Joint Comments from the Department of State, the U.S.
Agency for International Development, and the Department of Health:
GAO Comments:
Appendix VII: GAO Contact and Staff Acknowledgments:
Figures:
Figure 1: Stage of the AIDS Epidemic in PEPFAR Focus Countries:
Figure 2: Selected Spending Recommendations and Requirements for Fiscal
Years 2006-2008 Contained in the 2003 Leadership Act:
Figure 3: PEPFAR Prevention Program Areas:
Figure 4: Total PEPFAR Prevention Funding in the 15 Focus Countries,
Fiscal Years 2004-2006:
Figure 5: PEPFAR Prevention Funding, by Focus Country, Fiscal Years
2004-2006:
Figure 6: Proportion of PEPFAR Funding Dedicated to Prevention in the
15 Focus Countries, Fiscal Years 2004-2006:
Figure 7: Proportion of PEPFAR Funding Dedicated to Prevention, by
Focus Country, Fiscal Years 2004-2006:
Figure 8: Reported Allocation of Focus Countries' Total PEPFAR
Prevention Funding by Each Prevention Program Area, Fiscal Years 2004-
2006:
Figure 9: Percentage of Reported Fiscal Year 2005 PEPFAR Sexual
Transmission Prevention Funding Allocated to Abstinence/Faithfulness
and "Other Prevention" by Each Focus Country Team:
Figure 10: Illustration of a Country Team's Prevention Funding
Allocated According to OGAC's Policies Implementing the Abstinence-
Until- Marriage Spending Requirement:
Figure 11: Prevention Allocations for Nonexempted and Exempted Focus
Country Teams, Fiscal Years 2005 and 2006:
Figure 12: OGAC Planning and Reporting Requirements for Fiscal Years
2005 and 2006:
Abbreviations:
AB: abstinence/faithfulness:
ABC: Abstain, Be faithful, or use Condoms:
COPRS: Country Operational Plan and Reporting System:
GHAI: Global HIV/AIDS Initiative:
HHS/CDC: Department of Health and Human Services--Centers for Disease
Control and Prevention:
NGO: nongovernmental organization:
OGAC: Office of the U.S. Global AIDS Coordinator:
PEPFAR: President's Emergency Plan for AIDS Relief:
PMTCT: prevention of mother-to-child transmission:
UNAIDS: Joint United Nations Programme for HIV/AIDS:
USAID: U.S. Agency for International Development:
Letter April 4, 2006:
Congressional Committees:
In January 2003, citing the need "to meet a severe and urgent crisis
abroad," President Bush announced his Emergency Plan for AIDS Relief
(PEPFAR), a $15 billion, 5-year initiative to combat the global
HIV/AIDS epidemic through prevention, treatment, and care
interventions. This initiative represented a significant increase in
U.S. funding for HIV/AIDS. Prior to PEPFAR, the United States had
committed to provide $5 billion to bilateral HIV/AIDS initiatives;
under PEPFAR, the total financial U.S. commitment increased by nearly
$10 billion, with $9 billion[Footnote 1] targeted to HIV/AIDS
initiatives in 15 focus countries.[Footnote 2] PEPFAR's primary
prevention goal is to avert 7 million HIV infections in these
countries--where heterosexual intercourse is generally the primary mode
of transmission--by the year 2010. The U.S. Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Act of 2003[Footnote 3] (Leadership
Act), which authorizes PEPFAR, endorses using the "ABC model" (Abstain,
Be faithful, or use Condoms) to prevent the sexual transmission of HIV
and establishes the Global HIV/AIDS Initiative (GHAI) account. The act
also recommends that 20 percent of funds appropriated pursuant to the
act be dedicated to HIV/AIDS prevention and requires that, beginning in
fiscal year 2006, at least 33 percent of prevention funds appropriated
pursuant to the act be spent on abstinence-until-marriage programs.
Finally, the act provides for the establishment of an HIV/AIDS
Coordinator within the Department of State (State) to lead the U.S.
response to the HIV/AIDS epidemic and oversee all U.S. efforts to
combat HIV/AIDS abroad.[Footnote 4] Since its establishment in January
2004, State's Office of the U.S. Global AIDS Coordinator (OGAC) has
defined five HIV/AIDS prevention program areas--abstinence/faithfulness
(AB), "other prevention," prevention of mother-to-child transmission
(PMTCT), safe medical injections, and blood safety[Footnote 5]--and
defined abstinence-until-marriage programs as AB activities.
Responding to broad-based congressional interest in HIV/AIDS prevention
efforts under PEPFAR, in this report we (1) review trends and
allocation of PEPFAR prevention funding, (2) describe the PEPFAR
strategy for preventing the sexual transmission of HIV, and (3) examine
key challenges associated with applying the PEPFAR sexual transmission
prevention strategy. We conducted this review under the Comptroller
General's authority.
To address these objectives, we reviewed documents such as the PEPFAR 5-
year strategy,[Footnote 6] first annual report to Congress, and fiscal
year 2004 operational plan; operational plans and annual and midyear
progress reports provided by U.S. agency officials responsible for
managing PEPFAR in the focus countries (focus country teams); PEPFAR
guidance to the field; and budget documents provided by OGAC. In
addition, we interviewed U.S.-based officials from OGAC, USAID, and the
Department of Health and Human Services-Centers for Disease Control and
Prevention (HHS/CDC), as well as several Washington, D.C.-based
nongovernmental organizations (NGOs). We also conducted structured
interviews between June 2005 and January 2006 with key State, USAID,
HHS/CDC, and other U.S. agency staff in the 15 focus
countries.[Footnote 7] We conducted 11 of these structured interviews
over the telephone and 4 during site visits. We visited Botswana,
Ethiopia, South Africa, and Zambia in July 2005, selecting this
targeted sample of focus countries based on criteria such as level of
PEPFAR funding, HIV prevalence rate,[Footnote 8] and prevention focus.
In the countries that we visited, we interviewed key U.S. government
officials, host country government officials, NGOs, faith-based
organizations, local community-based organizations, and program
beneficiaries. We also requested information from five additional
PEPFAR country teams[Footnote 9] regarding their PEPFAR funding, the
process of developing country operational plans, and the effects, if
any, of the abstinence-until-marriage spending requirement on their
prevention programming; we received responses from two of the five
country teams. (See app. I for a detailed description of our scope and
methodology.) In general, we found the data on PEPFAR prevention
funding, with the exception of data on spending allocations among
certain prevention program areas, sufficiently reliable for the
purposes of our engagement. We conducted our work from February 2005 to
February 2006 in accordance with generally accepted government auditing
standards.
Results in Brief:
PEPFAR prevention funding[Footnote 10] in the 15 focus countries grew
by more than 40 percent between fiscal years 2004 and 2005 and by an
additional 10 percent between 2005 and 2006, rising from $207 million
in fiscal year 2004 to $322 million in fiscal year 2006. At the same
time, consistent with the Leadership Act's recommendation that 20
percent of funds appropriated pursuant to the act be spent on
prevention, the prevention portion of total PEPFAR funding in the 15
focus countries declined from 33 to 20 percent. The proportion of focus
countries' total PEPFAR prevention funding allocated to each of the
five nonsexual and sexual transmission prevention program areas varied
during fiscal years 2004-2006, and focus country teams reported
allocating varying amounts for sexual transmission prevention programs
in fiscal year 2005. However, there are limitations in the reliability
of these reported allocations because of challenges and inconsistencies
in country teams' categorization of funding for certain ABC programs
and some broad sexual transmission prevention activities.
The PEPFAR strategy for preventing sexual transmission of HIV is
largely shaped by three elements: the ABC model, the Leadership Act's
abstinence-until-marriage spending requirement, and local prevention
needs in the PEPFAR countries.
* In developing the PEPFAR sexual transmission prevention strategy,
OGAC adopted the ABC model, endorsed by the Leadership Act, as an
effective method for preventing HIV/AIDS. In addition, to guide country
teams' application of the ABC model, OGAC identified general principles
for the teams to consider in developing and implementing PEPFAR ABC
programs--stating, for example, that prevention interventions should be
responsive to characteristics of the epidemic in their country and
integrated, so that prevention messages are harmonized at the community
level. OGAC's guidance regarding the ABC model (ABC guidance) also
outlined the types of activities that can be funded through PEPFAR and
directed country teams to emphasize different components of the ABC
model for various target populations.
* The PEPFAR sexual transmission prevention strategy reflects the
Leadership Act's requirement that, beginning in fiscal year 2006, at
least 33 percent of prevention funds appropriated pursuant to the act
support abstinence-until-marriage programs.[Footnote 11] To ensure
compliance with the spending requirement, OGAC established policies in
August 2005 implementing the requirement. These policies directed 20
country teams[Footnote 12] to dedicate at least 50 percent of
prevention funding to sexual transmission prevention activities (50
percent policy) and 66 percent of that amount to AB activities (66
percent policy) starting in fiscal year 2006. OGAC also instructed the
teams to isolate AB spending in their annual reports to demonstrate
adherence to the spending requirement. In addition, OGAC allowed
certain country teams to submit justifications requesting exemption
from its policies implementing the spending requirement. Finally, OGAC
applied the spending requirement to all PEPFAR prevention
funding[Footnote 13] (about $357 million in fiscal year 2006) as a
matter of policy, although it determined that, as a matter of law, the
requirement applies only to funds appropriated to the GHAI account
(about $322 million for prevention in fiscal year 2006).
* Working within the parameters of the ABC model and the abstinence-
until-marriage spending requirement, country teams design prevention
programs that respond to the countries' prevention needs. For example,
country teams reserve funding for AB activities to comply with the
spending requirement and take steps to allocate their prevention funds
according to factors such as the average age when sexual activity
begins in their respective countries.
OGAC's ABC guidance and the Leadership Act's abstinence-until-marriage
spending requirement have presented several challenges to country
teams.
* Lack of clarity in the ABC guidance has created challenges for a
majority of focus country teams. Although a number of the teams told us
that they found the guidance clear or easy to implement, 10 of the 15
focus country teams cited instances where elements of the guidance were
ambiguous and confusing, leading to difficulties in its interpretation
and implementation. For example, although the guidance restricts
activities promoting condom use, it does not clearly delineate the
difference between condom education and condom promotion, causing
uncertainty over whether certain condom-related activities are
permissible. OGAC officials acknowledged that certain components of the
guidance can be confusing and told us that they are working to clarify
them. They also provided a document--distributed to country teams in
August 2005--that aims to address some of the concerns that country
teams identified. OGAC plans to update this document each fiscal year,
based on country teams' feedback about implementing the ABC guidance.
* Satisfying the Leadership Act's abstinence-until-marriage spending
requirement presents challenges to most country teams. Several focus
country teams indicated that they value the ABC model as an HIV/AIDS
prevention tool and noted the importance of AB messages, particularly
for certain populations. However, about half of the focus country teams
told us that meeting the spending requirement can undermine the
integration of prevention programs by forcing them to isolate funding
for AB activities. Further, 17 of the 20 PEPFAR teams required to meet
the spending requirement unless they obtain exemptions from it reported
that the spending requirement presents challenges to their ability to
respond to local epidemiology and cultural and social norms. As
permitted under OGAC's policies, 10 of these 17 teams requested
exemption from the spending requirement, citing a variety of
constraints related to meeting it, such as reduced spending for PMTCT
and limited funding for prevention messages to high-risk groups.
Although the remaining 7 country teams did not request exemptions (they
did not meet OGAC's proposed criteria for submitting requests), they
also identified specific program constraints related to meeting the
spending requirement, such as cuts in PMTCT services or reduced funding
for prevention programs aimed at HIV-positive individuals.[Footnote 14]
Despite approving the 10 exemption requests, OGAC should just meet the
overall spending requirement specified by the Leadership Act for fiscal
year 2006 by effectively requiring teams that do not request exemptions
to, in most cases, spend more than the 33 percent of prevention funds
on AB activities. Although exempted country teams avoid, to some
degree, the challenges they identified related to meeting the spending
requirement, teams that are not exempted from the requirement must
sometimes reduce or cut funding for certain prevention programs. For
example, one country team told us that, to meet the spending
requirement, it had to limit funding for comprehensive ABC messages to
populations at risk of contracting HIV. Our analysis shows that for
exempted country teams, total planned prevention funds dedicated to
"other prevention" increased by approximately $700,000 between fiscal
years 2005 and 2006, remaining at about 21 percent of their total
prevention funding in each fiscal year. For nonexempted country teams,
total planned prevention funds dedicated to "other prevention" declined
by approximately $5 million--from about 23 percent of overall planned
prevention funds in fiscal year 2005 to about 18 percent in fiscal year
2006. Finally, OGAC's decision to apply the spending requirement to all
PEPFAR prevention funding may further constrain some country teams'
ability to respond to local prevention needs. For example, this policy
prevents one country team from funding certain condom social marketing
programs with $1.5 million in non-GHAI funding, despite its having
reduced funding for those programs to comply with the abstinence-until-
marriage spending requirement.
In light of reported challenges presented by the abstinence-until-
marriage spending requirement, we are recommending that the Secretary
of State direct the U.S. Global AIDS Coordinator to collect and report
to Congress information from the country teams about the spending
requirement's effect on their prevention programming and use that
information to, among other things, consider whether the Leadership
Act's abstinence-until-marriage spending requirement should be applied
only to funds appropriated to the Global HIV/AIDS Initiative account.
We are also suggesting that, in light of this information, Congress
should assess the extent to which the spending requirement supports the
Leadership Act's endorsement of both the ABC model and strong
abstinence-until-marriage programs.
We provided a draft of this report to the Department of State/OGAC,
HHS, and USAID. In commenting jointly on our report, the agencies
reiterated their strong commitment to fight HIV/AIDS, stating that
"only a vigorous and comprehensive prevention approach will turn the
tide against the global HIV/AIDS pandemic." Consistent with our
report's discussion, they also noted the importance of the ABC model in
preventing sexual transmission of HIV. Regarding our finding that
interpreting and implementing the ABC guidance has created challenges
for most of the focus country teams, the agencies commented that they
are committed to continually improving efforts to communicate policy to
the field. The agencies expressed appreciation for our report's
findings regarding difficult trade-offs that country teams have had to
make with respect to funding for prevention activities and agreed with
our recommendation to collect information regarding the effects of the
Leadership Act's abstinence-until-marriage spending requirement. They
disagreed with our recommendation regarding applying the abstinence-
until-marriage spending requirement only to funds appropriated to the
GHAI account, stating that doing so would limit their ability to use a
unified budget approach and would have little impact, given the small
amount of non-GHAI funding that the focus country teams receive. We
recognize that allowing country teams to apply the spending requirement
solely to GHAI funds entails some trade-offs. Given the agencies'
concerns about maintaining a unified budget approach, we have modified
our recommendation to recommend that they consider this policy change
after collecting information on the effect of the spending requirement.
With respect to the non-GHAI funding amounts, we would note that the
five additional countries required, absent exemptions, to meet the
spending requirement receive more than 80 percent of their funds
through non-GHAI accounts. Thus, we believe that our modified
recommendation is warranted. Finally, OGAC and USAID also provided
technical comments on the draft, which we have incorporated as
appropriate.
Background:
Each day, an estimated 13,400 people worldwide are newly infected with
HIV; more than 20 million have died from AIDS since 1981. HIV is
transmitted both sexually (through sexual intercourse with an infected
person) and nonsexually (through the sharing of needles or syringes
with an infected person; unsafe blood transfusions; or the passing of
the virus from mother to child during pregnancy, childbirth, or
breastfeeding). However, the majority of HIV infections worldwide are
transmitted sexually.[Footnote 15] About two-thirds of the estimated 40
million people currently living with HIV/AIDS are in sub-Saharan Africa
where, according to the Joint United Nations Programme on HIV/AIDS
(UNAIDS), adult HIV prevalence averaged 7.4 percent in 2004.
Nature of AIDS Epidemic in PEPFAR Countries:
HIV/AIDS is an urgent and growing health problem, driven by complex
factors that present challenges to HIV prevention. The nature of the
AIDS epidemic varies among the 15 PEPFAR focus countries, 12 of which
are in sub-Saharan Africa (see fig. 1). In addition, the groups most
vulnerable to HIV infection vary among the focus countries. For
example, while girls and young women are most vulnerable in some
countries, populations typically considered high-risk groups, such as
intravenous drug-users or commercial sex workers, are most vulnerable
in others.[Footnote 16] Figure 1 shows that although the epidemic in
some focus countries is concentrated in certain populations, in other
focus countries it has spread among the general population.
Figure 1: Stage of the AIDS Epidemic in PEPFAR Focus Countries:
[See PDF for image]
Note: According to UNAIDS and the World Health Organization, a
concentrated epidemic is defined as one in which HIV has infected at
least 5 percent of individuals in defined subpopulations but is not
well-established in the general population. In a generalized epidemic,
HIV has spread among the general population, infecting at least 1
percent.
[End of figure]
PEPFAR Funding and Requirements:
In fiscal year 2004, the U.S. Congress appropriated $2.4 billion for
global HIV/AIDS efforts, directing $865 million of this amount to four
accounts: (1) the GHAI account, which received most of the funding; (2)
the Child Survival and Health account; (3) the Prevention of Mother to
Child Transmission account; and (4) CDC's Global AIDS Program.[Footnote
17] In this report, the term PEPFAR funding describes funds
appropriated to these four accounts[Footnote 18] in the 15 focus
countries, as well as bilateral HIV/AIDS funding in five additional
countries.[Footnote 19] For fiscal years 2004 and 2005, total PEPFAR
funding consists of central and country-level actual appropriations
allocated by OGAC for prevention, care, and treatment activities.
Similarly, PEPFAR prevention funding for these fiscal years consists of
central and country-level actual appropriations allocated by OGAC for
prevention activities (AB, blood safety, PMTCT, safe medical
injections, and "other prevention"). For fiscal year 2006, total PEPFAR
funding consists of planned central and country-level PEPFAR funding
for prevention, care, and treatment activities that have not yet been
approved by OGAC.[Footnote 20] PEPFAR prevention funding for fiscal
year 2006 consists of planned central and country-level PEPFAR funding
for prevention activities that have not yet been approved by OGAC.
The Leadership Act specifies the percentages of PEPFAR funds to be
allocated for HIV/AIDS prevention, treatment, and care for fiscal years
2006-2008. For example, the act recommends that 20 percent of funds
appropriated pursuant to the act be spent on prevention and 15 percent
on palliative care for those living with the disease.[Footnote 21] The
act also requires that, beginning in fiscal year 2006, at least 55
percent of funds appropriated pursuant to the act be spent on treatment
and at least 10 percent on orphans and vulnerable children. (See fig.
2.) See page 14 for information on additional spending recommendations
and requirements specifically related to prevention funds.
Figure 2: Selected Spending Recommendations and Requirements for Fiscal
Years 2006-2008 Contained in the 2003 Leadership Act:
[See PDF for image]
[End of figure]
ABC Model and Abstinence-Until-Marriage Spending Requirement:
The Leadership Act finds that "behavior change, through the use of the
ABC model, is a very successful way to prevent the spread of HIV" and
requires that prevention funding be set aside for abstinence-until-
marriage programs. It defines the model as "'Abstain, Be faithful, use
Condoms,' in order of priority." The ABC model is based, in part, on
the experience of Uganda, which implemented an ABC campaign in the
1980s and observed a decline in HIV/AIDS prevalence by 2001.[Footnote
22] Although substantial debate exists about the extent to which each
component of the model is responsible for reducing HIV prevalence in
individual countries, there is general consensus that using the ABC
model can have a positive impact in combating HIV/AIDS. In November
2004, a key consensus statement authored by eight leading public health
experts[Footnote 23] observed that "all three elements of [the ABC
model] are essential to reducing HIV incidence, although the emphasis
placed on individual elements needs to vary according to the target
population." For example, it noted that "for those who have not started
sexual activity the first priority should be to encourage abstinence or
delay of sexual onset" and, "when targeting sexually active adults, the
first priority should be to promote mutual fidelity with an uninfected
partner as the best way to assure avoidance of HIV infection." Finally,
according to the document, "all people should have accurate and
complete information about different prevention options, including all
three elements of the ABC approach." The statement was signed by more
than 125 prominent figures, including the President of Uganda; the
Archbishop of the Anglican Church of South Africa; officials from
UNAIDS, the World Health Organization, and the World Bank; and dozens
of other academics, representatives of faith-based groups, and public
health advocates. In promoting the ABC model, the Leadership Act
authorizes prevention activities that provide information on delaying
sexual debut; abstinence; fidelity and monogamy; reduction of casual
sexual partnering; reducing sexual violence and coercion, including
child marriage, widow inheritance, and polygamy; and where appropriate,
use of condoms.
The act also requires that at least one-third of prevention funding
appropriated pursuant to the act be spent on abstinence-until-marriage
programs. The act recommended this spending distribution for fiscal
years 2004-2005 and made it mandatory for fiscal years 2006-2008. In
June 2004, OGAC notified Congress that it defines abstinence-until-
marriage activities as programs that address both abstinence and
faithfulness. Specifically, OGAC stated that abstinence-until-marriage
programs would focus on achieving two goals: (1) encouraging
individuals to be abstinent from sexual activity outside of marriage to
protect themselves from exposure to HIV and other sexually transmitted
infections and (2) encouraging individuals to practice fidelity in
sexual relationships, including marriage, to reduce their risk of
exposure to HIV.[Footnote 24]
PEPFAR Prevention Program Areas:
The five PEPFAR prevention program areas--abstinence/faithfulness (AB),
blood safety, prevention of mother-to-child transmission (PMTCT), safe
medical injections, and other prevention--are divided into two groups:
those aimed at preventing sexual transmission and those aimed at
preventing nonsexual transmission of the disease. (See fig. 3.)
Figure 3: PEPFAR Prevention Program Areas:
[See PDF for image]
[End of figure]
The sexual transmission prevention program areas are focused as
follows.
* AB activities encourage:
* abstinence until marriage,
* delay of first sexual activity,
* secondary abstinence,[Footnote 25]
* faithfulness in marriage and monogamous relationships,
* reduction of sexual partners among sexually active unmarried persons,
and:
* social and community norms related to the above practices.
"Other prevention" activities include the:
* purchase and promotion of condoms,
* management of sexually transmitted infections (if not in a palliative
care setting), and:
* messages or programs to reduce injection drug use and related
risks.[Footnote 26]
(See app. II for examples of AB and "other prevention" programs that
are being implemented under PEPFAR. For information on the
organizations that have implemented sexual transmission prevention
programs under PEPFAR, see [Hyperlink, http://www.state.gov/s/gac/].
Office of the Global AIDS Coordinator:
The Leadership Act provided for the establishment of an HIV/AIDS
Coordinator, within the Department of State, to lead the U.S. response
to HIV/AIDS abroad. The Coordinator's authorities and duties include
carrying out international prevention, care, treatment, and other
HIV/AIDS-related activities through NGOs and U.S. executive branch
agencies and coordinating their efforts. The agencies primarily
responsible for implementing PEPFAR are the Department of State, USAID,
and HHS. OGAC, established within the Department of State in January
2004, has been responsible for developing a global HIV/AIDS strategy
and administering PEPFAR.
OGAC's Key Strategic Principles:
OGAC's overall strategic cornerstones and principles, laid out in its 5-
year global HIV/AIDS strategy for PEPFAR, include commitments to:
* respond with urgency to the crisis;
* make policy decisions that are evidence based;
* demand accountability for results;
* implement programs that are suited to local needs and host government
policies;
* develop and strengthen integrated HIV/AIDS prevention, treatment, and
care services; and:
* focus on rapid service delivery.[Footnote 27]
OGAC's Prevention Target for PEPFAR:
OGAC's 5-year strategy states the PEPFAR prevention goal--announced by
the President and repeated in the Leadership Act--of averting 7 million
infections in the 15 focus countries.[Footnote 28] Although PEPFAR is
authorized through fiscal year 2008, OGAC plans to reach its prevention
goal by the year 2010.[Footnote 29] This prevention goal is cumulative;
that is, infections averted in 2004 through 2009 will count toward the
final total of infections averted by 2010. In addition, this goal is to
be reached both through PEPFAR activities and through interventions by
other donors and the host nations. (See app. III for a discussion of
OGAC's indicators, models, and method for measuring infections averted,
including the challenges that OGAC faces in measuring infections
averted and, thus, in assessing the success of its prevention
activities.)
PEPFAR Awards Process:
PEPFAR funding for the 15 focus countries is allocated both centrally
and at the country level.[Footnote 30] Central awards are multicountry
awards that are managed by U.S. agency headquarters in Washington, D.C.
These one-time, 5-year awards are intended to increase funding for
program activities with high levels of congressional interest and
minimal existing activities in the field.[Footnote 31] Country-level
awards are managed by the focus country teams.
Each year, to receive country-level funding for the coming fiscal year,
country teams submit budgets, or "operational plans," to OGAC outlining
planned activities and the organizations that will implement them
(implementing partners). The plans are subject to OGAC's review and
approval. (See app. IV for a description of OGAC's review process and a
time line of the PEPFAR awards process.) Country teams consider a
variety of criteria when selecting implementing partners, such as the
applicant organizations' ability to scale up rapidly, sustain programs,
and function in-country; the strength of their administrative and
financial controls; and the extent to which their priorities mirror
those of the host government and the U.S. government. Teams also often
place a priority on working with local, indigenous organizations rather
than large, international organizations. In addition, many country
teams take steps to encourage faith-based organizations to apply for
funding, although none of the teams reserves a specific percentage or
amount of funding for faith-based organizations. For example, they may
write grants specifically designed for organizations that use a faith-
based approach or instruct prime implementing partners to work with
small faith-based organizations that lack the capacity or experience to
handle large amounts of funding.[Footnote 32]
PEPFAR Prevention Funding in the 15 Focus Countries Grew Significantly
during First 3 Years:
PEPFAR prevention funding in the 15 focus countries increased by more
than 40 percent between fiscal years 2004-2005 and by an additional 10
percent between fiscal years 2005 and 2006.[Footnote 33] At the same
time, the proportion of total PEPFAR funding in the 15 focus countries
dedicated to prevention declined from 33 to 20 percent. The proportion
of total focus country PEPFAR prevention funding that was allocated to
each of the five prevention program areas varied from fiscal year 2004
to fiscal year 2006, and individual country teams reported varying
allocations among AB and "other prevention." However, there are
limitations in the reliability of the reported figures.
PEPFAR Prevention Funding in the 15 Focus Countries Increased in Fiscal
Years 2004-2006:
PEPFAR prevention funding in the 15 focus countries increased from $207
million in fiscal year 2004[Footnote 34] to $294 million in fiscal year
2005, or by more than 40 percent. It further increased to $322 million-
-about 10 percent--in fiscal year 2006. (See fig. 4.)
Figure 4: Total PEPFAR Prevention Funding in the 15 Focus Countries,
Fiscal Years 2004-2006:
[See PDF for image]
Note: Fiscal year 2006 funding is planned.
[End of figure]
For each of fiscal years 2004 through 2006, about 30 percent of the 15
focus countries' total PEPFAR prevention funding was awarded centrally.
Although the majority of funding for blood safety (91 percent) and safe
medical injection (91 percent) activities was awarded centrally, only
21 percent of AB funding was awarded centrally. None of the "other
prevention" funding was awarded centrally.
In addition, PEPFAR prevention funding for the individual focus country
teams generally increased between fiscal years 2004 and 2005 and, for
most of the countries, increased again slightly in 2006. The amount of
PEPFAR prevention funding for each focus country team varies. (See fig.
5.)
Figure 5: PEPFAR Prevention Funding, by Focus Country, Fiscal Years
2004-2006:
[See PDF for image]
Note: Fiscal year 2006 funding is planned.
[End of figure]
Proportion of Focus Countries' PEPFAR Funding Dedicated to Prevention
Has Declined:
The proportion of PEPFAR funding in the 15 focus countries dedicated to
prevention declined from 33 percent in fiscal year 2004 to 20 percent
in fiscal year 2006, consistent with the Leadership Act's
recommendation that one-fifth of funds appropriated pursuant to the act
be spent on prevention. (See fig. 6.) OGAC's fiscal year 2004
operational plan predicted this decline, noting that the proportion of
total PEPFAR funding allocated to prevention would likely begin to
decrease relative to the proportion allocated to care and treatment.
OGAC expected the proportion allocated to care and treatment to
increase over time because (1) previous U.S. global HIV/AIDS efforts
had focused on prevention and (2) factors such as limited
infrastructure and a lack of adequately trained staff in the focus
countries lengthen the time required to develop and expand treatment
and care programs.
Figure 6: Proportion of PEPFAR Funding Dedicated to Prevention in the
15 Focus Countries, Fiscal Years 2004-2006:
[See PDF for image]
Note: Fiscal year 2006 funding is planned.
[End of figure]
For most of the focus country teams, the proportion of PEPFAR funding
dedicated to prevention also declined in fiscal years 2004-2006. (See
fig. 7.)
Figure 7: Proportion of PEPFAR Funding Dedicated to Prevention, by
Focus Country, Fiscal Years 2004-2006:
[See PDF for image]
Note: Fiscal year 2006 funding is planned.
[End of figure]
Proportion of Focus Countries' PEPFAR Prevention Funding Allocated to
Each Prevention Program Area Varied in Fiscal Years 2004-2006, but Data
Reliability Has Limitations:
The proportion of total PEPFAR prevention funding that the 15 focus
country teams reported allocating to each of the five prevention
program areas varied to some extent during fiscal years 2004-2006. (See
fig. 8.)[Footnote 35] However, there are limitations in the reliability
of these data because of challenges and inconsistencies in country
teams' categorization of funding for certain integrated ABC programs
and some broad sexual transmission prevention activities. The lack of a
standardized method for categorizing these programs means that, to some
extent, the varied numbers of funding reported across fiscal years may
reflect the variations in categorization methods rather than actual
differences. (See app. V for a description of country teams' varying
methods for categorizing sexual transmission prevention funding and the
effect of this variation on the reported allocations' reliability.)
Figure 8: Reported Allocation of Focus Countries' Total PEPFAR
Prevention Funding by Each Prevention Program Area, Fiscal Years 2004-
2006:
[See PDF for image]
Note: Fiscal year 2006 funding is planned. Because of data reliability
issues discussed in appendix V, these figures should be used only to
understand general trends in data, rather than precise percentage
differences between program areas and fiscal years. Due to rounding,
the percentages may not add up to 100.
[End of figure]
We analyzed country teams' reported allocations for AB and "other
prevention" for fiscal year 2005 and found that these allocations also
varied. For example, 11 country teams reported allocating between 40
and 60 percent of their sexual transmission prevention funding to AB, 3
teams reported allocating somewhat over 60 percent, and 1 reported
allocating slightly less than 40 percent to AB. (See fig. 9.)[Footnote
36]
Figure 9: Percentage of Reported Fiscal Year 2005 PEPFAR Sexual
Transmission Prevention Funding Allocated to Abstinence/Faithfulness
and "Other Prevention" by Each Focus Country Team:
[See PDF for image]
Note: Individual country teams use different methods for categorizing
funding in the AB and "other prevention" program areas (see app. V).
These data should not be used to make direct comparisons between
individual country teams but rather to understand the overall pattern
of funding across country teams.
[End of figure]
PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC
Approach, Abstinence-Until-Marriage Spending Requirement, and Local
Prevention Needs:
The PEPFAR strategy for preventing sexual transmission of HIV has three
primary components: (1) the ABC model and OGAC guidance for
implementing it, (2) the abstinence-until-marriage spending requirement
and OGAC's interpretation of it, and (3) country teams' strategies for
responding to local prevention needs. OGAC adopted the ABC model as its
primary sexual transmission prevention strategy and, in August 2005,
provided guidance for country teams to use in applying the model. To
guide the teams' application of the requirement that at least 33
percent of prevention funding appropriated pursuant to the Leadership
Act fund abstinence-until-marriage programs, OGAC directed the teams to
spend at least 50 percent of their prevention funds on sexual
transmission prevention and 66 percent of those funds on AB activities.
Finally, in designing their sexual transmission prevention strategies,
country teams respond to local factors, such as the host government's
capacity to expand activities in sexual transmission prevention program
areas, as well as to the ABC model and the spending requirement.
PEPFAR Sexual Transmission Prevention Strategy Is Based Primarily on
ABC Model and OGAC's ABC Guidance:
OGAC adopted the ABC model, endorsed by the Leadership Act, as the
primary PEPFAR strategy for preventing sexual transmission of HIV. The
PEPFAR 5-year strategy states that evidence from Uganda and other
countries "demonstrates the effectiveness of a balanced approach to
behavior change that encourages the adoption of 'ABC' behaviors."
In January 2005, OGAC released guidance to country teams to shape their
incorporation of the ABC model into their sexual transmission
prevention strategies.[Footnote 37] The guidance identifies key
principles that country teams should consider in developing and
implementing ABC programs.
* The model should be applied in accordance with local prevention
needs. The guidance states that one of PEPFAR's commitments is to
ensure "that interventions be informed by, and responsive to, local
needs, local epidemiology, and distinctive social and cultural
patterns."
* Prevention activities should be integrated. The guidance notes that
"all implementing partners must harmonize [prevention messages] at the
community level."
* Prevention activities should be coordinated with the HIV/AIDS
strategies of host governments.
* Prevention interventions should be driven by best practices.
Taking these principles into account, the guidance states that "the
optimal balance of ABC activities will vary across countries according
to the patterns of disease transmission, the identification of core
transmitters (i.e., those at highest risk of transmitting HIV),
cultural and social norms, and other contextual factors."
In addition, OGAC's ABC guidance contains rules for country teams to
follow in developing and implementing their sexual transmission
prevention strategies. First, the guidance specifies the components of
the ABC model that should be targeted to certain populations. For
example, messages about abstinence-until-marriage and delay of first
sexual activity should be targeted to youths; fidelity should be
emphasized for married couples and those in monogamous relationships;
and condom use should be promoted to those who practice risky sexual
behaviors, such as commercial sex workers and individuals who have sex
with someone of unknown HIV status. Second, the guidance sets
parameters on the prevention messages that may be delivered to youths.
Specifically, although PEPFAR funds may be used to deliver age-
appropriate AB information to in-school youths aged 10 to 14 years, the
funds may not be used to provide information on condoms to these
youths. When students are identified as being at risk, they may be
referred to out-of-school programs that provide integrated ABC
information and that provide condoms. Under these rules, PEPFAR funds
may be used to provide integrated ABC information to youths older than
14.
OGAC also released the following guidance regarding the use of PEPFAR
funds for ABC programs:
* Any PEPFAR-funded program that provides information about condoms
must also provide information about abstinence and faithfulness.
* PEPFAR funds may not be used to physically distribute or provide
condoms in school settings.
* PEPFAR funds may not be used in schools for marketing efforts to
promote condoms to youths.
* PEPFAR funds may not be used in any setting for marketing campaigns
that target youths and encourage condom use as the primary intervention
for HIV prevention.
* PEPFAR funds may be used to target at-risk populations with specific
outreach, services, comprehensive prevention messages, and condom
information and provision. The guidance defines at-risk groups as:
* commercial sex workers and their clients,
* sexually active discordant couples or couples with unknown HIV
status,
* substance abusers,
* mobile male populations,
* men who have sex with men,
* people living with HIV/AIDS, and:
* those who have sex with an HIV-positive partner or one whose status
is unknown.
PEPFAR Strategy Is Shaped by Abstinence-Until-Marriage Spending
Requirement and OGAC's Implementation of the Requirement:
The PEPFAR strategy reflects the Leadership Act's abstinence-until-
marriage spending requirement, as well as OGAC's recent policies
implementing this requirement. Having defined abstinence-until-
marriage activities as AB programs, in late August 2005, OGAC issued
policies to help ensure that the 33 percent spending requirement is
met. These policies directed each of the 15 focus country teams and 5
additional country teams[Footnote 38] to spend at least 50 percent of
their prevention funding[Footnote 39] on sexual transmission prevention
and at least 66 percent of that amount on AB activities. In other
words, OGAC requires country teams to spend $2.00 on AB activities for
every $1.00 they spend on "other prevention" activities--a 2-to-1
ratio. To show compliance with the spending requirement, country teams'
operational plans must isolate the amount of funding spent on AB
activities. OGAC's policies relate to the Leadership Act's requirement
in the sense that, if a country spends exactly half of its prevention
funding on sexual transmission prevention and two-thirds of that
funding on AB activities, it will then spend one-third of its total
prevention funding on AB. Figure 10 provides an illustrative example of
a country team's prevention funding strictly allocated according to
OGAC's policies.
Figure 10: Illustration of a Country Team's Prevention Funding
Allocated According to OGAC's Policies Implementing the Abstinence-
Until-Marriage Spending Requirement:
[See PDF for image]
Note: Percentages do not add up to 100, due to rounding.
[End of figure]
In certain cases, OGAC allows country teams to submit justifications
requesting exemptions to the spending requirement, as defined by the 50
percent and 66 percent policies. For example, OGAC guidance to the
country teams states that if 80 percent of a country's epidemic is
among prostitutes, a team can submit a justification for spending a
higher proportion of sexual transmission prevention funds on correct
and consistent condom use. However, the guidance also cautions that, in
a generalized epidemic, a very strong justification is required for not
meeting the 66 percent policy. The guidance adds that OGAC expects all
focus country teams, in particular those with total PEPFAR funding
exceeding $75 million, to adhere to the policies implementing the
spending requirement.[Footnote 40]
OGAC also directed country teams to apply the spending requirement to
all PEPFAR prevention funding (about $357 million in fiscal year
2006).[Footnote 41] OGAC adopted this policy although it determined
that, as a matter of law, the requirement applies only to funds
appropriated to the GHAI account (about $322 million for prevention in
fiscal year 2006). Under OGAC's policy, the abstinence-until-marriage
spending requirement applies to prevention funding from the CDC's
Global AIDS Program, the Child Survival and Health account, the Freedom
Support Act account, and the GHAI account. However, when reporting to
Congress on compliance with the spending requirement, OGAC reports only
the allocation of funds under the GHAI account.
PEPFAR Strategy Also Includes Country Teams' Responses to Local Needs:
Country teams' sexual transmission prevention strategies are shaped
both by high-level requirements and local context. In each PEPFAR
country, country teams design their sexual transmission prevention
strategies in response to the ABC model and the abstinence-until-
marriage spending requirement. At the same time, in accordance with
OGAC's ABC guidance, the strategies take into account local factors
such as the host nation's capacity to expand activities in the
prevention program areas, the nature of the HIV/AIDS epidemic in the
country, the average age when sexual activity begins, and the
prevalence of certain social norms. For example, in a country where new
HIV infections are largely occurring among high-risk groups, such as
intravenous drug users or sex workers, the team determines how to
effectively promote condom use to these populations while reserving the
required percentage of prevention funding for AB activities. Likewise,
in a country where sexual activity typically begins at a relatively low
average age, the team decides how best to provide effective prevention
messages to youths while taking into account the parameters that OGAC
has established for delivering ABC messages to youths of different
ages.
ABC Guidance and Abstinence-Until-Marriage Spending Requirement Present
Challenges for Country Teams:
Country teams face challenges related to two key drivers of the PEPFAR
sexual transmission prevention strategy--OGAC's guidance for applying
the ABC model to country-level programs and the Leadership Act's
abstinence-until-marriage spending requirement. Although many country
teams reported that they have found OGAC's ABC guidance to be clear and
several said that it did not present implementation challenges, two-
thirds of focus country teams also reported that a lack of clarity in
aspects of the guidance has led to interpretation and implementation
challenges. OGAC officials told us that they are aware of these issues
and plan to clarify the guidance. About half of the focus country teams
indicated that adherence to the spending requirement can undermine the
integrated nature of HIV/AIDS prevention programs. In addition, 17 of
the 20 country teams required to meet the abstinence-until-marriage
spending requirement, absent exemptions, reported that the requirement
would prevent them from allocating prevention resources in accordance
with local HIV/AIDS prevention needs. OGAC's August 2005 policies
implementing the spending requirement have allowed some of these
country teams to address these concerns but have further constrained
other teams from designing locally responsive HIV/AIDS prevention
programs. Finally, OGAC's policy of applying the spending requirement
to all PEPFAR prevention funding, including funds not appropriated to
the GHAI account, may further constrain country teams' ability to
address local prevention needs.
Unclear ABC Guidance Creates Challenges for Many Focus Country Teams:
Interpreting and implementing OGAC's ABC guidance has created
challenges for most of the focus country teams. Although many teams
told us that they generally found the guidance to be clear, and several
said that it did not present implementation challenges, 10 of the 15
focus country teams we interviewed cited instances where components of
the guidance were ambiguous and caused confusion.
* The guidance's definition of at-risk groups is open to varying
interpretations, causing confusion about which groups may be
targeted.[Footnote 42] Six focus country teams and some implementing
partners expressed uncertainty regarding the populations that should be
considered at-risk in accordance with the ABC guidance. Five of these
teams expressed concern that certain populations that need ABC messages
in their countries might not receive them because they do not fit the
ABC guidance definition of at-risk. For example, one team noted that
the majority of HIV infections in its country are transmitted from one
partner to another in either married or stable, cohabitating
relationships. However, this team told us that they understood the ABC
guidance on high-risk groups to be relevant only to a "limited
epidemic" (unlike the generalized epidemic in which they were working)
and that married couples do not count as high-risk under PEPFAR. As a
result, they believed that a program designed to reach these
individuals through ABC messages to a broad population would not be
allowed. In addition, three teams questioned how to apply the
definition of at-risk in a generalized epidemic.
* The guidance does not clearly delineate permissible C activities,
causing confusion about proper use of PEPFAR funds. OGAC's ABC guidance
places restrictions on activities promoting condom use, but it does not
clearly distinguish permissible and nonpermissible activities. For
example, the guidance states that condom use programs should provide
full and accurate information about correct and consistent condom use,
including how to obtain them. The guidance also places restrictions on
promoting or marketing condoms to youths;[Footnote 43] however, it does
not explain how providing condom information differs from condom
promotion or marketing. Several NGOs that receive PEPFAR funding
expressed concern to us about crossing the line between providing
information about condoms and promoting or marketing condoms. For
example, representatives of a PEPFAR-supported organization that runs a
youth camp for students (aged 15-17) told us that condom use is
addressed during camp sessions only when youths ask specific questions.
However, staff said that they feel "constrained" when they hear these
questions, because they do not want to say more than is allowed under
PEPFAR guidelines. Another implementing partner representative said
that although the organization views condom demonstrations as
appropriate in some settings, it believes that condom demonstrations,
even to adults, are prohibited under PEPFAR. OGAC's guidance also does
not explain whether ABC approaches for broader audiences in a
generalized epidemic may include condom social marketing. Although a
senior OGAC official told us that broad condom social marketing is
appropriate in certain situations, five focus country teams reported
that, in their understanding, PEPFAR funds may not be used for broad
condom social marketing, even to adults in a generalized epidemic.
* Guidance regarding mixed-age groups is absent, causing confusion
about who may receive the ABC message. The ABC guidance prohibits
PEPFAR-funded programs in schools from providing condom information to
youths younger than 15, but the guidance does not discuss the
application of this age cutoff to groups that include youths younger
and older than 15. Four focus country teams noted that the age cutoff
for providing condom information to youths presents challenges because
classrooms and out-of-school programs often include mixed-age groups.
Two teams told us that, in these situations, only AB messages are
typically provided to the entire group and, as a result, some older
youths who need ABC messages may not receive them.
OGAC officials informed us that they were aware that certain components
of the ABC guidance could be difficult to interpret. For example, they
noted that they understood that it may be confusing for the definition
of at-risk groups to include individuals who have sex with someone of
unknown status. They explained that, although they had intended the
guidance not to be overly prescriptive and looked to the country teams
to determine how to apply rules in different situations, they planned
to clarify certain parts of the guidance. In December 2005, OGAC
officials provided us a document that gives country teams some
additional clarification on how to apply the ABC guidance.[Footnote 44]
For example, the document addresses issues such as preventing
transmission among discordant couples and working within the context of
a generalized epidemic. According to OGAC officials, they will update
this document each year to respond to country teams' requests for
additional clarification and to provide technical assistance as the
teams prepare their operational plans. Country teams can provide
feedback to OGAC on the ABC guidance and other issues through
Washington-based interagency teams (core teams) specifically assigned
to support them.
Meeting Abstinence-Until-Marriage Spending Requirement Presents
Challenges for Majority of Country Teams:
Satisfying the Leadership Act's abstinence-until-marriage spending
requirement challenges many country teams' efforts to adhere to two
principles of the PEPFAR sexual transmission prevention strategy.
Country teams consistently told us that they value the ABC model, and
several noted the importance of AB messages. At the same time, about
half of the 15 focus country teams reported that meeting the abstinence-
until-marriage spending requirement undermines their ability to
integrate ABC programs as required by the guidance. In addition, most
of the 20 PEPFAR teams required to meet the spending requirement or
receive exemptions reported that fulfilling the requirement, including
OGAC's 50 percent and 66 percent policies implementing it, presents
challenges to their ability to respond to local epidemiology and
cultural and social norms. Our analysis shows that OGAC should just
reach the overall 33 percent target by granting exemptions to some
country teams and requiring other teams to dedicate more than 33
percent of prevention funds to AB activities. Exempted teams are, to
some degree, able to address the challenges they identified related to
the spending requirement; however, country teams that are not exempted
from the requirement face additional challenges, such as reduced
funding for certain prevention programs. Our analysis suggests that
"other prevention" allocations declined noticeably in country teams
that were not exempted from the spending requirement but stayed
constant in those that were. Finally, OGAC's policy of applying the
spending requirement to all PEPFAR prevention funds--although it
determined that, as a matter of law, the requirement applies only to
funds appropriated to the GHAI account--may further constrain country
teams' ability to address local prevention needs.
Country Teams Value the ABC Model:
In several of our structured interviews, focus country teams endorsed
the ABC model and noted the importance of AB messages. For example, one
team told us that a balanced ABC approach was well within the host
country's prevention approach, and another stated that each component
of the model has a role to play. Another country team noted that,
because of the country's high HIV/AIDS prevalence rate, abstinence is
an appropriate message for both youths and adults. Several teams also
emphasized the importance of AB messages. For example, one team told us
that it has integrated AB messages throughout all prevention
activities. Other teams noted the particular importance of AB messages
for certain populations, consistent with the ABC guidance. One country
team told us that, because it is focused on preventing HIV transmission
among youths, its prevention programming focuses on AB activities.
Similarly, another explained that youths in its country almost always
receive exclusively AB messages. Finally, a U.S. government official in
one of the focus countries we visited told us that abstinence is an
important message for young girls in that country because of their lack
of negotiating power in relationships.
Spending Requirement Can Undermine Integration of Prevention Programs:
Because it requires country teams to segregate AB funding from funding
for "other prevention," the abstinence-until-marriage spending
requirement can undermine the teams' ability to design and implement
programs that integrate the components of the ABC model--one of the
guiding principles of the PEPFAR sexual transmission prevention
strategy. Eight of the 15 focus country teams indicated that
segregating AB from "other prevention" funding compromises the
integration of their programs. Examples of the problems they cited
include the following:
* Segregating program funding compromises the integration of ABC
activities, especially for at-risk groups that need comprehensive
messages. One focus country team told us that artificially splitting
programs for the military (traditionally considered an at-risk group)
between AB and "other prevention" disaggregates what should be
integrated and potentially lowers effectiveness. This team noted that
there are clear links between programming and implementation. In other
words, the way that a program is reported on paper affects the way that
it is put into practice.
* Segregating program funding limits some country teams' ability to
shift program focus to meet changing prevention needs. One focus
country team indicated that segregating program funding reduces the
team's ability to respond flexibly as program beneficiaries' needs
change over time. According to OGAC officials, once funds are
designated as AB, they can be used only for AB purposes. This
effectively locks teams into allocation decisions made when their
operational plans were approved.[Footnote 45] A team that funds a
prevention program for people living with HIV/AIDS stated that,
although the program includes faithfulness messages, the team does not
classify any funding for the program as AB, because it cannot predict
the portion of the project that should be dedicated to the faithfulness
component and does not want to lose its flexibility to "do what is
appropriate."[Footnote 46] Another country team explained that its work
with commercial sex workers will focus on correct and consistent condom
use but will also include income-generation activities. Once the sex
workers find an alternative means of income, AB messages become more
relevant for them. This team stated that segregating program funding
undermines the continuity inherent in integrated programs.
Country Teams Report That Meeting Spending Requirement Challenges Their
Ability to Respond to Local Prevention Needs:
A large majority of the 20 PEPFAR country teams required to meet the
abstinence-until-marriage spending requirement or obtain exemptions
reported that the requirement presents challenges to their efforts to
respond to local prevention needs.[Footnote 47] Seventeen of these
teams reported--either through documents submitted to OGAC or through
structured interviews--that meeting the spending requirement, including
OGAC's 50 percent and 66 percent policies implementing it, challenges
their ability to develop interventions that are responsive to local
epidemiology and social norms.[Footnote 48]
Between September 2005 and January 2006, 10 of these teams submitted
documents to OGAC requesting exemption from the spending requirement as
it was defined in OGAC's August 2005 guidance. These documents
highlight various challenges that the country teams associated with
meeting the spending requirement, including the following:
* Reduced spending for PMTCT. Three country teams identified cuts in
PMTCT as a constraint that they would face if required to meet the
spending requirement. For example, one country team wrote that
"reaching the sexual prevention and AB [spending requirements] would
have required drastically reducing the PMTCT budget [from] $1.4 million
to $350,000."
* Limited funding to deliver appropriate prevention messaging to high-
risk groups. Several teams noted that AB messages are not well-suited
for high-risk groups. According to one country team, "it is very
important to direct a certain amount of prevention funding to high-risk
groups located along transport corridors, and AB messaging is not
always appropriate."
* Lack of responsiveness to cultural and social norms. Country teams
identified specific characteristics about the epidemics in their
countries that require a different allocation of funding than would be
allowed under the spending requirement. For example, a team explained
that dedicating a large portion of prevention funds to AB would be
inappropriate, given conservative social norms--youths in their country
"are not sexually active at an early age; the age of marriage and the
age of first sexual experience were both estimated at 20 years."
* Cuts in medical and blood safety activities. One country team
highlighted these cuts as a potential consequence of meeting the
spending requirement.
* Elimination of care programs. One country team wrote that care and
"other policy programs" would be cut if it were held to the spending
requirement.
In addition, seven teams that did not submit documents requesting
exemption from the spending requirement--they did not meet OGAC's
proposed criteria for requesting exemptions[Footnote 49]--identified,
in structured interviews, specific program constraints related to
meeting the abstinence-until-marriage spending requirement. (While some
of these teams commented specifically on the original 33 percent
requirement, as written in the 2003 Leadership Act, others commented on
OGAC's 50 percent and 66 percent policies implementing the Leadership
Act's requirement.)
These constraints included the following:
* Difficulty reaching certain populations with comprehensive ABC
messages. One country team stated that, because of the abstinence-
until-marriage spending requirement, it had limited funding for
comprehensive ABC messages to the general public. In this focus
country, the AIDS epidemic is generalized but is largely fueled by
populations determined to be most at risk of contracting HIV, such as
commercial sex workers and truck drivers. Most of this country's "other
prevention" funding is reserved for its most-at-risk populations.
However, because one-third of prevention funding must be reserved for
AB programs, the team had little sexual transmission prevention funding
to deliver integrated ABC messages to those in the general population
who, although at risk for contracting HIV, are not among the most-at-
risk populations.
* Limited or reduced funding for programs targeted at high-risk groups.
* A focus country team told us that, to meet the spending requirement,
it had to cut "other prevention" funding by 50 percent. Team members
explained that, as a result, services for married discordant couples,
sexually active youths, and commercial sex workers were reduced. In
general, this team noted that allocating funding in accordance with the
spending requirement is not appropriate for the country's epidemic and
has reduced the quality of the team's prevention programming.
* In a focus country with one of the world's highest national HIV/AIDS
prevalence rates, a team member told us that meeting the spending
requirement had forced the team to substantially reduce planned funding
for a prevention program for people living with HIV/AIDS.
* Reduced funding for PMTCT services.
* In fiscal year 2005, the spending requirement led one country team to
reduce planned funding for its PMTCT program, thereby limiting services
for pregnant women and their children. (Although the Leadership Act did
not make the spending requirement mandatory until fiscal year 2006,
OGAC encouraged country teams to spend 33 percent of prevention funds
on AB activities prior to that year, consistent with the act's
recommendation.[Footnote 50]) This focus country lacks a health care
system for providing PMTCT services and, as a result, the team has had
significant trouble reaching its target for preventing infections
through PMTCT activities.[Footnote 51] However, at the start of fiscal
year 2005, OGAC directed the country team to reduce planned funding for
PMTCT and dedicate more funding to AB activities, because the team's
allocation of prevention funds to AB fell short of 33 percent.
* In another country, where the U.S. government has been the largest
supporter of the PMTCT program, the team told us that complying with
the spending requirement would likely force it to shift resources away
from PMTCT and thus reduce needed PMTCT commodities and
services.[Footnote 52]
* Difficulty funding programs for condom procurement and condom social
marketing.
* One focus country team told us that the spending requirement had
complicated its efforts to address a condom shortage in the country. To
reserve funding to procure condoms, the team was required to cut
funding for other programs in the "other prevention" program area and
to shift funds from the care category.
* Another focus country team stated that, because of the spending
requirement, it would likely have to reduce funding for condom social
marketing. In this country, the U.S. government has traditionally paid
to market condoms socially, and a non-U.S. donor has paid to procure
them.[Footnote 53]
OGAC's Policies Allow It to Meet the Overall 33 Percent Target:
Our analysis shows that OGAC's policies implementing the 33 percent
spending requirement should allow it to just fulfill the Leadership
Act's spending requirement for fiscal year 2006, with the 20 country
teams dedicating, in total, slightly more than 33 percent of reported
planned prevention funds to AB activities.[Footnote 54] OGAC officially
approved exemptions for the 10 country teams that requested them. As a
result, all but one[Footnote 55] of these teams dedicated less than 33
percent of planned fiscal year 2006 prevention funds for AB activities-
-about 23 percent on average. At the same time, the 10 country teams
that did not submit requests for exemption were generally required to
spend more than 33 percent of planned prevention funds on AB
activities; fiscal year 2006 data for these teams indicate that, on
average, they will each spend around 37 percent of total reported
planned prevention funding on AB activities. Under OGAC's policies
implementing the spending requirement, any country team that spends
more than half of prevention funding on sexual transmission prevention
will have to spend more than 33 percent of its total prevention funding
on AB. For example, a team that plans to spend 60 percent of prevention
funding on sexual transmission prevention to meet local needs will have
to spend at least 40 percent of total prevention funding on AB
activities to comply with OGAC's 66 percent policy. For fiscal year
2006, all but two of the country teams that did not request exemptions
planned to spend more than half of total prevention funds on sexual
transmission prevention--about 57 percent on average. As a result,
these country teams also must spend more than 33 percent of prevention
funds on AB.[Footnote 56] According to an OGAC official, OGAC would
have been unable to meet the 33 percent target if it had allowed many
of the country teams with the largest amounts of PEPFAR funding to
submit exemptions to the spending requirement. For fiscal year 2006,
only one of the five top-funded focus country teams submitted an
exemption request.
OGAC's Policies Give Some Country Teams Greater Flexibility but Further
Constrain Others:
OGAC's policies implementing the abstinence-until-marriage spending
requirement allow it to respond to the concerns of teams that received
exemptions but prevent it from addressing the remaining country teams'
concerns. Teams that received exemptions were, to some degree, able to
avoid the challenges related to meeting the spending requirement that
they had identified in requesting exemption. For example, a country
team that requested exemption because "the epidemic in [this country]
is still concentrated primarily among injection drug users and sex
workers" planned to dedicate 89 percent of total prevention funds to
"other prevention" and only 4 percent to AB. Another team whose
exemption request noted that the epidemic in their country "requires
that resources be directed towards high-risk populations, and
populations likely to engage in risky sexual behaviors" received
approval to limit AB funding to 28 percent of its total planned
prevention funds and reserved 22 percent of planned prevention funds
for "other prevention."
Under OGAC's policies, however, some nonexempted country teams are
unable to avoid challenges presented by the spending requirement. As
noted above, 7 of the 10 country teams that did not submit requests for
exemption identified specific concerns about cutting or reducing
funding for certain prevention programs. In allocating funds to meet
the spending requirement, country teams are primarily limited to
shifting resources among three prevention program areas--"other
prevention," PMTCT, and AB. (This limitation occurs because the
overwhelming majority of funds spent on safe medical injections and
blood safety are centrally awarded funds, over which the country teams
have no budgetary control.) If, for example, a country team's planned
funding has a less than 2-to-1 ratio of AB funds to "other prevention"
funds, the team can increase AB funding to reach the required ratio by
reducing funds in "other prevention," PMTCT, or a combination of the
two. The team can also consider taking funds from the treatment and
care program areas and placing them in the AB category.
Data on total actual and planned spending allocations for the focus
country teams that did not request exemption from the spending
requirement[Footnote 57] suggest a noticeable decline in "other
prevention" funding between fiscal year 2005, when the spending
requirement was not mandatory, and fiscal year 2006.[Footnote 58]
Although some of this shift may be due to varying methods of
categorizing sexual transmission prevention programs and some changes
in categorization methods across fiscal years (see app. V), the data
demonstrate a common trend across these teams. For the nonexempted
focus country teams, total funding for "other prevention" declined by
about $5 million from fiscal year 2005 to fiscal year 2006, falling
from about 23 percent to about 18 percent of total prevention funding,
while total funding for AB activities increased by about $25 million,
rising from about 27 percent to about 36 percent of total prevention
funding. By contrast, in the focus country teams that received
exemptions, total prevention funding for "other prevention" increased
slightly by about $700,000, remaining at around 21 percent of total
prevention funding, and total prevention funding for AB activities
increased by about $7 million, from about 23 percent to about 28
percent of total prevention funding. Figure 11 shows the allocation of
prevention funds by nonexempted and exempted focus country teams for
fiscal years 2005 (actual funds) and 2006 (planned funds).
Figure 11: Prevention Allocations for Nonexempted and Exempted Focus
Country Teams, Fiscal Years 2005 and 2006:
[See PDF for image]
Note: Fiscal year 2006 funding is planned. Because of data reliability
issues discussed previously and in appendix V, these figures should be
used only to understand general trends in data, rather than as precise
percentage differences between program areas and fiscal years. Because
of rounding, the percentages may not sum to 100.
[End of figure]
Overall levels of PMTCT funding stayed relatively constant for both
nonexempted and exempted focus country teams. Overall, the proportion
of funding dedicated to PMTCT in the focus countries was about 23
percent in fiscal year 2005 and about 22 percent in fiscal year 2006.
Focus countries' total PMTCT funding was $66.3 million in fiscal year
2005 and $67.5 million in fiscal year 2006.
OGAC's Application of Spending Requirement to All U.S. Prevention
Funding May Further Challenge Country Teams:
OGAC's decision to apply the abstinence-until-marriage spending
requirement to all PEPFAR prevention funding--although it determined
that, as a matter of law, the requirement applies only to funds in the
GHAI account--may further challenge some country teams' ability to
address HIV prevention needs at the local level. According to OGAC
officials, they have chosen to apply the spending requirement to all
PEPFAR prevention funding in response to a PEPFAR principle that
HIV/AIDS programs should be integrated within and across agencies.
These officials expressed the opinion that allowing country teams to
apply the spending requirement to only a portion of prevention funding
would compromise this integration. The officials added that the amount
of PEPFAR funding not appropriated to the GHAI account[Footnote 59] is
relatively small. For fiscal year 2006, non-GHAI prevention funds
amount to about $35 million (10 percent) of PEPFAR prevention funding-
-that is, about $6 million (2 percent) of the focus country teams'
planned PEPFAR prevention funds and about $29 million (82 percent) of
the five additional country teams' planned PEPFAR prevention funds.
Because of OGAC's policy decision, country teams are constrained from
allocating non-GHAI funding to meet local needs if the allocations do
not comply with the spending requirement. For example, for fiscal year
2006, one focus country team received about $1.5 million in prevention
funding that was not covered by the GHAI account. As a country with a
generalized epidemic and total PEPFAR funding exceeding $75 million,
this team did not submit a justification requesting exemption from the
spending requirement, but it identified constraints resulting from
meeting the requirement--specifically, that it would likely have to
reduce funding for condom social marketing.[Footnote 60] Because of
OGAC's policy regarding non-GHAI prevention funding, this country team
will be unable to apply the $1.5 million to the condom social marketing
programs for which funding was likely reduced.
Conclusions:
Responding to the severity and urgency of the global HIV/AIDS crisis,
PEPFAR and its authorizing legislation, the U.S. Leadership Against
HIV/AIDS, Tuberculosis and Malaria Act of 2003, significantly increased
the United States' commitment to fight the epidemic. Country teams
consistently indicated that the ABC model is a useful tool for
preventing sexual transmission of HIV, and many expressed the
importance of AB messages for certain populations. However, the
Leadership Act's requirement that country teams spend at least 33
percent of prevention funding appropriated pursuant to the act on
abstinence-until-marriage programs has presented challenges to country
teams' ability to adhere to the PEPFAR sexual transmission prevention
strategy. In particular, it has challenged their ability to integrate
the components of the ABC model and respond to local needs, local
epidemiology, and distinctive social and cultural patterns. OGAC has
established policies implementing the requirement that respond to these
concerns while allowing it to meet the overall 33 percent spending
target. Under these policies, some country teams have, to some degree,
been able to avoid problems--such as limited funding to deliver
appropriate prevention messages to high-risk groups--that would have
occurred had they been subject to the spending requirement. However,
other country teams, especially those with large amounts of PEPFAR
funding and those facing generalized epidemics, have faced further
constraints that have affected their ability to respond to local
prevention needs. Finally, OGAC's application of the spending
requirement to $35 million in funds not appropriated to the GHAI
account may also hamper country teams' ability to develop locally
responsive prevention programs. OGAC may be able to address some of
these constraints by reconsidering its policy of applying the spending
requirement to all PEPFAR prevention funding; however, the amount of
funding not covered by the GHAI account is relatively small. Reversing
this policy would not enable OGAC to fully address the underlying
challenges that country teams face in having to reserve a specific
percentage of their prevention funds for abstinence-until-marriage
programs.
Recommendation for Executive Action:
Because meeting the 33 percent abstinence-until-marriage spending
requirement can challenge country teams' ability to allocate prevention
resources in a manner consistent with the PEPFAR sexual transmission
prevention strategy, we recommend that the Secretary of State direct
the U.S. Global AIDS Coordinator to take the following action:
* collect information from the country teams each fiscal year on the
spending requirement's effect on their HIV sexual transmission
prevention programming and provide this information in an annual report
to Congress.
* This information should include, for example, the justifications
submitted by country teams requesting exemption from the spending
requirement.
* The information collected should be used by the U.S. Global AIDS
Coordinator to, among other things, assess whether the spending
requirement should be applied solely to funds appropriated to the
Global HIV/AIDS Initiative account, in line with OGAC's legal
determination that the requirement applies only to these funds.
Matters for Congressional Consideration:
Given the challenges that meeting the abstinence-until-marriage
spending requirement presents to country teams attempting to implement
locally responsive and integrated HIV/AIDS prevention programs,
Congress, in its ongoing oversight of PEPFAR, should:
* review and consider the information provided by OGAC regarding the
spending requirement's effect on country teams' efforts to prevent the
sexual transmission of HIV and:
* use this information to assess the extent to which the spending
requirement supports the Leadership Act's endorsement of both the ABC
model and strong abstinence-until-marriage programs.
Agency Comments and Our Evaluation:
The Department of State/OGAC, HHS, and USAID provided combined written
comments on a draft of this report. (See app. VI for a reprint of their
comments and our response.) In their letter, they highlighted the value
of a comprehensive ABC approach in preventing sexual transmission of
HIV and cited recent data from Kenya and Zimbabwe showing that where
sexual behaviors have changed--as evidenced by increased primary and
secondary abstinence, fidelity, and condom use--HIV prevalence has
declined. Consistent with our report's discussion, they also stated
that more work is needed to understand these data and to identify which
interventions may have influenced them. In response to our finding that
interpreting and implementing the ABC guidance has created challenges
for most of the focus country teams, they stated that they are working
to improve efforts to communicate policy to country teams through
various methods, such as weekly e-mails and constant contact between
the core team leaders and the field.
The agencies stated that the Leadership Act's emphasis on AB activities
has helped move them toward a balanced ABC strategy. They also accepted
our recommendation that, given challenges country teams face in
allocating prevention resources, they should collect information from
the country teams each fiscal year regarding the spending requirement's
effect on their HIV sexual transmission prevention programming. The
agencies disagreed with our recommendation to consider whether the
Leadership Act's spending requirement should be applied solely to funds
appropriated to the GHAI account, in line with OGAC's legal
determination that the requirement applies only to these funds. First,
they stated that applying the spending requirement to only one part of
the budget would harm their efforts to use a unified budget approach.
Second, they stated that the issue is becoming less salient over time
because non-GHAI funds have declined in the focus countries. As a
result of the agencies' comments, we have clarified our recommendation
to ask that they consider making this policy change after reviewing the
information they collect on the effects of the spending requirement. We
believe that this recommendation may be particularly relevant for the
five additional country teams required, absent exemptions, to meet the
spending requirement because non-GHAI funds represent over 80 percent
of their total PEPFAR prevention funding. OGAC and USAID also provided
technical comments, which we have incorporated where appropriate.
We are sending copies of this report to interested congressional
committees. We also will make copies available to others on request. In
addition, the report will be available at no charge on the GAO Web site
at [Hyperlink, http://www.gao.gov]. If you or your staff have any
questions, please contact me at (202) 512-3149 or [Hyperlink,
gootnickd@gao.gov]. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
report. Key contributors to this report are listed in appendix VII.
Signed by:
David Gootnick:
Director, International Affairs and Trade:
List of Congressional Committees:
The Honorable Arlen Specter:
Chairman:
Subcommittee on Labor, Health and Human Services, Education, and
Related Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Richard G. Lugar:
Chairman:
The Honorable Joseph R. Biden, Jr.:
Ranking Minority Member:
Committee on Foreign Relations:
United States Senate:
The Honorable Edward M. Kennedy, Jr.:
Ranking Minority Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Jim Kolbe:
Chairman:
The Honorable Nita M. Lowey:
Ranking Minority Member:
Subcommittee on Foreign Operations, Export Financing, and Related
Programs:
Committee on Appropriations:
House of Representatives:
The Honorable Joe Barton:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Henry A. Waxman:
Ranking Minority Member:
Committee on Government Reform:
House of Representatives:
The Honorable Christopher Shays:
Subcommittee on National Security, Emerging Threats and International
Relations:
Committee on Government Reform:
House of Representatives:
The Honorable Tom Lantos:
Ranking Minority Member:
Committee on International Relations:
House of Representatives:
[End of section]
Appendixes:
Appendix I: Scope and Methodology:
Under the Comptroller General's authority, in this report we (1) review
trends and allocation of the President's Emergency Plan for AIDS Relief
(PEPFAR) prevention funding, (2) describe the PEPFAR strategy for
preventing the sexual transmission of HIV, and (3) identify key
challenges associated with applying the PEPFAR sexual prevention
strategy. Our work focuses primarily on the 15 PEPFAR focus countries:
Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique,
Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and
Zambia.
As part of our efforts to collect information on all three objectives,
we conducted structured interviews between June 2005 and January 2006
with key Department of State, U.S. Agency for International Development
(USAID), Department of Health and Human Service-Centers for Disease
Control and Prevention (HHS/CDC), and other U.S. agency staff
responsible for implementing HIV/AIDS programs in the 15 focus
countries.[Footnote 61] We conducted 11 of these structured interviews
over the telephone and 4 during site visits to Botswana, Ethiopia,
South Africa, and Zambia in July 2005.
Our structured interview document contained open-ended questions
related to each of our three objectives. To develop questions for the
structured interview, we reviewed key documents from the Office of the
U.S. Global AIDS Coordinator (OGAC) and other U.S. government agencies,
as well as country teams' operational plans. We also interviewed key
U.S.-based officials from OGAC, USAID, and HHS/CDC. We pretested our
questions with four of our initial respondents and refined our
questions based on their input. We conducted follow-up interviews with
our respondents to obtain supplementary information.
To summarize the open-ended responses and develop categories for the
analysis, we first grouped open-ended qualitative interview responses
into a set of overarching issue areas and then, within each of those
issue areas, we grouped the interview data into subcategories. To
ensure the validity and reliability of our analysis, these
subcategories were reviewed by a methodologist, who proposed
modifications. After discussion of these suggestions, we determined a
final set of subcategories. We then tallied the number of respondents
providing information in each subcategory.
We also requested information from the five additional PEPFAR country
teams that receive at least $10 million in PEPFAR funding. In October
2005, we sent standardized questions to these teams on three areas: (1)
their PEPFAR funding (particularly how their prevention funding was
broken down by spending account); (2) their experiences developing
country operational plans; and (3) the effects, if any, of the
abstinence-until-marriage spending requirement on their prevention
programming. We received responses from two of these country teams.
To examine trends and allocation of PEPFAR prevention funding, we
reviewed budget data provided to us by OGAC on fiscal year 2004 planned
and approved country-level funding; OGAC's Country Operational Plan and
Reporting System (COPRS), a central U.S. government data system
developed to support the collection and analysis of data related to
Emergency Plan planning and reporting requirements;[Footnote 62] and
data provided to us by OGAC on centrally awarded funding. To determine
how country teams categorize funding for integrated programs that
include AB and "other prevention" components in their country
operational plans, we reviewed the President's Emergency Plan for AIDS
Relief FY06 Country Operational Plan Final Guidance (revised Aug. 22,
2005), as well as country teams' operational plans. We determined that
these data were sufficiently reliable for some purposes. (See app. V
for a discussion of specific data limitations.) Finally, we interviewed
U.S.-based officials from OGAC.
To describe the PEPFAR strategy for preventing the sexual transmission
of HIV, we reviewed the 2003 Leadership Act; The President's Emergency
Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (February
2004);[Footnote 63] OGAC guidance to country teams, including its ABC
Guidance #1 For United States Government In-Country Staff and
Implementing Partners Applying the ABC Approach to Preventing Sexually-
Transmitted HIV Infections within the President's Emergency Plan for
AIDS Relief (March 2005); and each focus country team's 5-year HIV/AIDS
strategy for PEPFAR. We also interviewed key U.S.-based officials from
OGAC, USAID, and HHS/CDC.
To identify challenges associated with implementing the PEPFAR sexual
transmission prevention strategy, we (1) interviewed nongovernmental
organizations (NGOs) that receive PEPFAR prevention funding; (2)
conducted site visits to Botswana, Ethiopia, South Africa, and Zambia
in July 2005; and (3) reviewed country teams' requests for exemption
from the spending requirement. Prior to conducting our fieldwork, we
selected the top five NGO recipients of fiscal year 2005 PEPFAR funding
for AB activities and the top five NGO recipients of fiscal year 2005
PEPFAR funding for "other prevention" activities to interview. Because
two of these organizations were on both lists, we selected a total of
eight organizations, of which we interviewed six, but were unable to
meet with the remaining two.[Footnote 64] For our July 2005 fieldwork,
we selected a targeted sample of PEPFAR focus countries to visit based
on six criteria: (1) the amount of the country's fiscal year 2004
PEPFAR funding dedicated to HIV prevention; (2) the percentage of the
country's fiscal year 2004 PEPFAR funding dedicated to HIV prevention;
(3) the amount of the country's fiscal year 2004 PEPFAR funding
dedicated to preventing the sexual transmission of HIV; (4) the
percentage of the focus country's fiscal year 2004 PEPFAR funding for
preventing sexual transmission of HIV dedicated to
abstinence/faithfulness; (5) the percentage of the focus country's
fiscal year 2004 PEPFAR funding for preventing sexual transmission of
HIV dedicated to "other" prevention methods, such as condom promotion;
and (6) HIV/AIDS prevalence. In the countries that we visited, we
interviewed key U.S. government officials, host country government
officials, nongovernmental organizations (NGOs), faith-based
organizations, local community-based organizations, and program
beneficiaries, and we observed programs in all five prevention program
areas being implemented. The information we obtained during these site
visits related primarily to challenges associated with interpreting and
implementing the ABC guidance. Last, we reviewed excerpts of documents
that country teams submitted requesting exemption from OGAC's policies
implementing the abstinence-until-marriage spending requirement. These
documents were submitted by both focus country teams and some of the
additional teams required to meet the requirement.
Finally, to further develop our understanding of challenges associated
in general with preventing HIV/AIDS, we attended prevention conferences
in Washington, D.C., and reviewed reports prepared by NGOs, private
AIDS foundations, UNAIDS, and other multilateral and international
institutions. We also interviewed representatives of some of these
organizations.
We conducted our work from February 2005 to February 2006 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: AB and "Other Prevention" Programs in Four Focus
Countries:
Fiscal year 2005 program descriptions[Footnote 65] of
abstinence/faithfulness (AB) and "other prevention" programs in the
four focus countries that we visited demonstrate the diversity of
approaches that the President's Emergency Plan for AIDS Relief (PEPFAR)
country teams use to prevent HIV/AIDS. Country teams employ a host of
methods to reach communities, such as mass media interventions, one-on-
one communication, and capacity building for local organizations. The
degree to which they emphasize these methods varies. For example, the
Botswana team dedicates its largest single pot of AB funding to a
capacity-building program, while the South Africa team dedicates its
highest funded AB award to a mass media program. Because the
congressional abstinence-until-marriage requirement and the Office of
the U.S. Global AIDS Coordinator's (OGAC) policies interpreting it were
not in effect in fiscal year 2005, the funding amounts for each of the
four country teams do not show a 2-to-1 ratio of AB to "other
prevention" funding.
Botswana:
For fiscal year 2005, the following four programs accounted for about
70 percent of the Botswana team's total country-level AB funding:
* $800,000 to strengthen Botswana-based, nongovernmental organizations
through a central Botswana HIV/AIDS umbrella organization that will
become a leading partner in the HIV/AIDS response and expand services
provided by the sector. This umbrella organization works with local
faith-based organizations, community-based organizations, and
nongovernmental organizations (NGOs) to fund, among other programs, AB
prevention activities.
* $550,000 to fund a radio drama that models positive behaviors and
provides information on various issues related to HIV/AIDS, such as
abstinence, faithfulness, partner reduction, healthy relationships, and
basic HIV information. The drama is reinforced with activities such as
road shows, discussion groups, and contests. This program also receives
funding under "other prevention."
* $400,000 to conduct a social marketing campaign promoting the "be
faithful" message. This project also builds capacity of local partners
to develop behavior change community messages and promote AB messages.
* $350,000 to support a nationwide door-to-door community HIV education
program, which trains field officers to inform, educate, and mobilize
the community on topics such as abstinence and faithfulness. This
program also receives funding under "other prevention."
For the same fiscal year, the following five programs accounted for
about 70 percent of the Botswana team's total country-level "other
prevention" funding:
* $1,095,000 to fund a radio drama that promotes counseling and
testing, information on antiretroviral treatment and adherence,
prevention of mother-to-child transmission (PMTCT), stigma reduction,
disclosure of HIV status, and alcohol and domestic abuse. This program
also receives funding under AB, as noted above.
* $375,000 to reduce HIV transmission among individuals with sexually-
transmitted infections. This program works with health care
professionals and their clients to improve management of sexually
transmitted infections, with the goal of better identifying populations
at high risk for transmitting HIV and quickly linking them with HIV
treatment and related services.
* $350,000 to support a nationwide door-to-door community HIV education
program, which trains field officers to inform, educate, and mobilize
the community on topics such as condom use, voluntary counseling and
testing, PMTCT, stigma reduction, and related life skills. This program
also receives funding under AB, as noted above.
* $349,000 to fund technical assistance. This program covers salaries
for three staff members, travel, printing of technical materials to
support "other prevention" projects, participation in domestic and
international conferences, and temporary duty visits by colleagues
based in the United States.
* $325,000 to lay the groundwork for potential implementation of four
prevention programs areas: provision of the antiretroviral treatment
Tenofovir prior to exposure to HIV infection, male circumcision,
commercial sex work, and gender and HIV/AIDS. For the first two program
areas, the program works with key stakeholders to determine how each
service, if proven effective as a prevention strategy, would be
introduced to the health care community and general population. For the
second two program areas, the program gathers implementing partners and
stakeholders to discuss some of the gender issues that inhibit HIV
prevention efforts, to share best practices on these issues, and to
outline research and programmatic needs and priorities.
Ethiopia:
For fiscal year 2005, the following four programs accounted for about
70 percent of the Ethiopia team's total country-level AB funding:
* $1,170,000 to continue and expand HIV/AIDS behavior change programs
targeting youths with AB messages. This program uses a youth action
toolkit and a sports-related program to model and reinforce AB
behaviors for primary school students aged 11-14, as well as in-school
and out-of-school youths aged 15-20.
* $900,000 to reach high-risk groups and youths, teachers, and
community leaders with behavior change communication messages. This
program targets three high-risk groups: short-distance minibus drivers,
taxi drivers, and their assistants; commercial sex workers; and a
regional police force. AB is the primary prevention message for these
groups. However, this program also receives funding under "other
prevention" to provide non-AB messages for commercial sex workers.
* $420,000 to provide comprehensive prevention services along a
transport corridor. This program targets communities along the
transport corridor between Addis Ababa and Djibouti with community
prevention education programs promoting AB and reduction of stigma and
discrimination. For example, the program targets 30,000 in-school
youths living along the corridor with an abstinence-only education
program called Lessons for Life. This program also receives funding
under "other prevention."
* $400,000 to promote AB messages through the media. This program
trains journalists to increase accurate knowledge of HIV/AIDS and
reduce stigma and discrimination, focusing on the promotion of
abstinence and faithfulness prevention messages.
For the same year, one program accounted for about 70 percent of
Ethiopia's total country-level "other prevention" funding.
* $2,900,000 to procure, distribute, and market condoms to population
groups at risk of transmitting HIV. This program will promote 100
percent condom use in targeted locations where high-risk groups
congregate, such as bars and hotels, and will be supported by behavior
change and social marketing campaigns. This program will also assure
condom supplies at health facilities, such as hospitals and PMTCT
centers, and supply condoms to kiosks and marketing outlets in urban
settings.
South Africa:
For fiscal year 2005, the following seven programs accounted for about
70 percent of the South Africa team's total country-level AB funding:
* $3,100,000 to produce and broadcast HIV AB messages via television.
This program broadcasts AB messages to 350 waiting rooms in public
health facilities, which are complemented by discussions facilitated by
trained health care workers. It also produces a popular television
drama series exploring the challenges and life experiences of young
people living in a rural community, especially their struggles with
HIV/AIDS and associated social problems. This program includes
significant AB messaging. Themes in the television drama are linked
with targeted community mobilization, such as discussion groups.
* $900,000 to promote and strengthen AB messages through churches,
schools, community-based organizations, and NGOs. This program conducts
peer education activities, trains teachers in an AB-based curriculum,
and holds community meetings and workshops to promote innovative HIV
prevention programs that incorporate strong AB messages.
* $400,000 to implement three AB activities: a school-based AB program,
a program promoting mutual monogamy, and a program targeting AB
preventative behaviors among orphans and vulnerable children. The
school-based program integrates AB messages into "Life Skills"
education in six schools. The monogamy program targets members of faith-
based groups with an AB curriculum and peer support for abstinence and
faithfulness, among other activities. The program for orphans and
vulnerable children trains youth caregivers in prevention; developing,
disseminating, and advocating AB messages; and promoting dialogue. This
program also receives other funding through the prevention, care, and
treatment program areas.
* $400,000 to implement AB-focused prevention programs through faith-
based organizations and traditional leaders and to focus attention on
the need for AB programs for men who have sex with men. This program
develops national HIV/AIDS strategies for five faith-based groups and
aims to improve leadership among traditional leaders in the areas of
HIV/AIDS advocacy and human rights. It also develops a national
strategy to stimulate a programmatic and policy focus on providing AB
prevention messages to men who have sex with men and holds a
sensitization workshop to increase stakeholders' capacity to implement
successful programs that target these men.
* $400,000 to implement a door-to-door HIV prevention campaign. This
program recruits and trains 400 community members as peer educators and
counselors to provide information to households on HIV/AIDS prevention
and preventative behaviors. These educators and counselors promote
voluntary counseling and testing services and PMTCT services, as well
as teach proper condom use, when appropriate. These volunteers also
mobilize communities to address stigma and discrimination associated
with HIV/AIDS.
* $400,000 to produce mass media interventions with AB components. The
program supports development of a television program for the family
audience that covers issues such as HIV/AIDS and all aspects of
treatment; messages on prevention and stigma, such as
abstinence/faithfulness and voluntary counseling and testing; and
masculinity and gender as they relate to HIV/AIDS. It also supports
development of television and radio programs and related materials for
children and their parents. These programs and materials cover HIV/AIDS
from a child's perspective, focusing on the impact of HIV/AIDS on
children's lives and on the school system and promoting prevention
messages, particularly abstinence/faithfulness. They also cover other
topics such as nutrition, lifestyle, gender, and masculinity. These
youth-focused programs are complemented by community mobilization
interventions, such as youth clubs to discuss the issues presented in
different episodes. This program also receives funding under the
treatment program area.
* $350,000 to work with teachers' unions on a prevention peer education
and AIDS management prevention program. This program uses trained
school union representatives to facilitate weekly discussion groups
among teachers on issues such as self-awareness, an understanding of
one's own sexuality, and decision-making skills as they relate to
abstinence, faithfulness, and sex. The program also receives other
funding through the prevention, care, and treatment program areas.
For the same year, the following five programs accounted for about 70
percent of the South Africa team's total country-level "other
prevention" funding:
* $2,800,000 to produce and broadcast AB and other prevention messages
via television. See program description above under the AB program
area.
* $1,400,000 to train "Master Trainers" from public and private health
sector unions. Master trainers will conduct HIV and AIDS prevention
education programs for union membership, senior union leadership, and
others. This program will also implement a young workers' campaign
involving life skills-based education to help young workers embrace a
healthy lifestyle, including adoption of safe sexual practices.
* $500,000 to support the sexually transmitted infections and HIV
prevention unit of the National Department of Health. Support includes
providing logistics, management, and technical assistance in the
procurement, warehousing, distribution, and teaching of the national
male and female condom programs.
* $449,259 to provide technical assistance to government health
programs, support the distribution of condoms, and operate programs
targeting high-risk groups. The program provides support and technical
advice on the development and rollout of government programs, including
comprehensive HIV management services, such as HIV prevention services
and sexually transmitted infection prevention and treatment services.
The program also supports a commercial sex workers project, which
provides condoms, sexually transmitted infection treatment, and support
for leaving sex work.
* $365,000 to address the HIV/AIDS prevention needs of youths and
underserved groups, such as drug users. This program conducts an
assessment in three cities to better understand and respond to
populations that are vulnerable to HIV infection. The program also
funds a specialist to develop a youth prevention strategy for the
National Department of Health and to build the capacity of local youth-
serving organizations to provide skill-building and youth specific
interventions.
Zambia:
For fiscal year 2005, the following two programs accounted for about 65
percent of the Zambia team's total country-level AB funding:
* $2,000,000 to strengthen the capacity of local community
organizations to implement AB programs that target youths with
comprehensive skills-based AB prevention activities. This program
provides training for teachers on HIV/AIDS prevention, with an AB
emphasis. It also reviews existing AB prevention curricula and programs
and assists the Zambian Ministry of Education in introducing new
modules on preventing gender-based sexual violence. In addition, the
program establishes a school-managed student-driven grants program to
implement AB prevention activities for youths and involve parents.
Finally, the program distributes leaflets and life skills booklets in
support of an AB message.
* $1,480,000 for a consortium of faith-based and community-based
organizations to implement abstinence promotion activities. The focus
of this program is a small grants program for organizations to work
with youths. These organizations combine abstinence messaging with
business management and vocational training in order to decrease
economic vulnerability among youths. The organizations also use sports
camps and "coming of age" ceremonies to reach youths. Finally, the
program promotes fidelity and partner reduction among adults through
extensive home-based care programs and district-level training
sessions.
For the same year, two programs accounted for about 75 percent of the
Zambia team's total country-level "other prevention" funding.
* $3,379,574 for prevention interventions for at-risk groups living and
working at border and high transit sites. This program targets sex
workers and their clients, truck drivers, mini bus drivers, and
uniformed personnel at border and high-transit sites with services
including sexually transmitted infection management, counseling and
testing, referrals for antiretroviral treatment, behavior change
interventions that promote partner reduction and condom use, and condom
social marketing. Communication methods used include peer education,
outreach work, drama, one-on-one counseling, group discussion, mass
media, and local-based promotional activities. This program also
receives funding under the AB program area.
* $2,600,000 to provide HIV prevention messages to adults and youths.
This program will provide support to discordant couples through
faithfulness and condom-use messages. It will also expand activities
targeting at-risk groups with messages on healthy practices and correct
and consistent condom use. For example, the program will use community
outreach activities such as education sessions with transport workers,
uniformed personnel, and police on personal risk-assessment skills and
condom-negotiation skills. In addition, this program supports in-school
anti-AIDS clubs and a youth radio program that provides A, B, and C
messages. This program also receives funding under the AB program area.
[End of section]
Appendix III: Prevention Program Indicators and Methods of Measuring
PEPFAR Prevention Program Results:
The Office of the U.S. Global AIDS Coordinator (OGAC) requires country
teams to report the number of individuals reached through specific
prevention programs, but assessing overall progress toward reaching
prevention goals presents major challenges. OGAC requires that country
teams report on indicators such as the number of individuals reached by
the program. OGAC plans, over time, to estimate progress toward the
President's Emergency Plan for AIDS Relief (PEPFAR) prevention goal by
using U.S. Census Bureau statistical modeling of countries' HIV/AIDS
prevalence trends, but these estimates may not be available for several
years and will not link averted infections to specific types of
prevention programs. OGAC had initially planned to use an alternative
modeling approach that linked results to types of programs within the
countries, but it dropped that approach because of limited research
data on the effectiveness of particular prevention activities.
OGAC Tracks the Number of Individuals Reached by Prevention Programs as
a Performance Indicator:
OGAC requires country teams to report several performance indicators,
which generally capture the number of individuals reached or trained
for each prevention program aimed at sexual transmission. Specifically,
for abstinence/faithfulness (AB) activities they report on the:
* number of individuals reached through community outreach that
promotes HIV/AIDS prevention through abstinence and/or being faithful,
* number of individuals reached through community outreach that
promotes HIV/AIDS prevention through abstinence, and:
* number of individuals trained to promote HIV/AIDS prevention programs
through abstinence and/or being faithful.
For "other prevention" activities, they report on the:
* number of targeted condom service outlets,
* number of individuals reached through community outreach that
promotes HIV/AIDS prevention through other behavior change beyond
abstinence and/or being faithful, and:
* number of individuals trained to promote HIV/AIDS prevention through
other behavior change beyond abstinence and/or being faithful.
OGAC tracks similar indicators for prevention programs outside the
sexual transmission area. These include four indicators for prevention
of mother-to-child transmission (PMTCT), two for blood safety, and one
for safe injections.[Footnote 66]
OGAC Will Estimate Progress Toward Infections Averted Goal Using
Statistical Model:
OGAC plans, over time, to estimate progress toward the PEPFAR goal of
averting 7 million infections by 2010 by using a statistical model of
epidemiological trends developed by the U.S. Census Bureau. The model
will compare "expected" HIV incidence rates in particular countries
with "actual" incidence rates and use those comparisons to estimate the
number of infections that have been averted through PEPFAR and related
prevention programs. This model attempts to estimate the number of
infections averted over time, but it cannot attribute this change to
any specific intervention or to the success of particular types of
programs.
Specifically, the model estimates entail the following elements for
each country:
* Establish "baseline" projections of HIV incidence for future years,
using country data on prevalence rates through 2003 to make
projections. This baseline prevalence is what would theoretically occur
in the country in the absence of interventions such as PEPFAR. The
prevalence data used to make these projections are obtained primarily
from surveys in prenatal clinics.[Footnote 67] The projections are made
using assumptions about the rate of transmission of the virus in
different segments of the population and about other factors such as
death rates.
* Estimate actual HIV prevalence trends in countries in future years,
using country survey data from the prenatal clinics, beginning with
data collected in 2004.
* Calculate the number of infections averted in each country as the
difference between (1) the number of new infections each year that
would be associated with the baseline prevalence rates and (2) the
number of new infections each year that would be associated with the
prevalence rates observed after implementation of PEPFAR and other
prevention efforts.
Thus, if the Census model projected, for example, that based on trends
in place prior to the initiation of PEPFAR programs, there would be
300,000 new HIV infections in Kenya between 2005 and 2008, and actual
survey data in future years indicated there were 200,000, then PEPFAR
would be assumed to have contributed to averting 100,000 infections in
Kenya during that period.
Estimating infections averted over time using OGAC's modeling approach
involves substantial challenges and the reliability of the estimates is
not known, according to Census officials. A key challenge is the lack
of data on prevalence rates in many developing countries. Because of
that lack of data, a single long-term study of prevalence trends in
Musaka, Uganda, serves as the basis for several assumptions that
underlie Census projections on baseline prevalence rates. These
assumptions include, for example, the average age when individuals
begin to be sexually active and infection rates among migrant
populations. In addition, estimating changes in prevalence rates over
time, and thus, infections averted, is complicated by the fact that
impacts of behavioral change programs can occur over a period of time.
For example, the impact on prevalence rates of providing life skills
programs targeted at younger students who are not sexually active might
not be observed for some period of time. Thus, prevalence data gathered
in 2008, for example, may not show the full impact of PEPFAR prevention
programs over the previous year or two.
OGAC Considered Alternative Method of Measuring Infections Averted:
In March 2004, OGAC convened a technical modeling group to determine a
methodology for measuring infections averted under PEPFAR.[Footnote 68]
The group assessed alternative modeling approaches and initially
considered the Goals Model (developed by the Futures Group)[Footnote
69] as an appropriate tool. The Goals Model is based on published
research studies of the effectiveness of various prevention strategies
and on conversion factors that translate dollars spent on a given
prevention intervention into the number of infections averted.[Footnote
70] In contrast to the Census model described in the previous section,
the GOALS model links estimates of infections averted to specific types
of prevention programs carried out under PEPFAR and their spending
levels.
In September 2004, the Futures Group presented estimates of infections
that would be averted during PEPFAR's first year to the Technical
Modeling Group. The Futures Group estimated, based on country
operational plans, that between 550,000 and 580,000 infections would be
averted in the initial 14 focus countries in fiscal year 2004 and that
condom promotion and voluntary counseling and testing programs were
more likely to avert infections than other prevention interventions.
There was debate within the Modeling Group about the merits of applying
the Goals Model. Of particular concern were limitations in the research
underlying the model on the effectiveness of different types of
programs in preventing HIV transmission. For example, the research
included very few studies that assessed the effectiveness of abstinence
programs in limiting HIV transmission.[Footnote 71] Although some
working group members believed that the Goals Model, despite being an
imperfect tool, could provide needed insights regarding prevention
programs' progress in averting infections, OGAC concluded that the
model could yield misleading results and was not the best method to
adopt.
OGAC Is Planning Some Limited Targeted Evaluations of Prevention
Programs:
To acquire information about the effectiveness of specific PEPFAR
prevention programs, especially in the AB area, OGAC plans to carry out
and fund targeted evaluations on a very limited scale. According to
OGAC, targeted evaluations are rapid studies that can provide evidence-
based information to improve prevention programming in the near term.
In the sexual transmission prevention area, these evaluations will be
done on a small sample of AB programs. The bulk of the funding for
targeted evaluations comes through central PEPFAR funds. In 2004, OGAC
invested about $2 million in targeted evaluations of AB programs to be
carried out over 2 years. Some country teams are also doing some
limited targeted evaluations of AB programs through their country
operational plans. According to an OGAC official, the targeted
evaluations will have limited use because of their small scale and the
amount of time before results are available.
[End of section]
Appendix IV: PEPFAR Planning and Reporting Process:
The operational plans that the President's Emergency Plan for AIDS
Relief (PEPFAR) country teams submit to the Office of the U.S. Global
AIDS Coordinator (OGAC) each year identify, among other things, the
organizations that will implement the proposed activities and program
descriptions. When OGAC receives the operational plans, it implements a
three-part review process, including a technical review, a programmatic
review, and a principals' review.[Footnote 72] At the conclusion of the
reviews, OGAC submits a notification to the relevant congressional
committees,[Footnote 73] informing them of the activities it plans to
implement under PEPFAR in the current fiscal year.[Footnote 74] Once
Congress approves the notification, funds can be transferred to the
field for obligation. The process for transferring and obligating funds
and the length of time it takes to complete this process varies by
agency,[Footnote 75] but all implementing partners are instructed to
expend their funds within 12 months of receiving them.
In addition to submitting operational plans, country teams are required
to submit semiannual and annual progress reports to OGAC each fiscal
year. These reports identify obligations that have occurred in the past
fiscal year, as well as results of the various activities. Figure 12
provides a time line of OGAC's planning and reporting requirements and
the PEPFAR funding cycle.
Figure 12: OGAC Planning and Reporting Requirements for Fiscal Years
2005 and 2006:
[See PDF for image]
Note: Dates for midyear progress report preparation and operational
plan preparation are approximate.
[End of figure]
[End of section]
Appendix V: Methods for Reporting Allocations among PEPFAR Prevention
Program Areas:
Country teams have used varying methods to categorize funding for
certain integrated abstinence/faithfulness/condom use (ABC)
programs[Footnote 76] and to categorize funding for broader sexual
transmission prevention components that are not clearly defined as
abstinence/faithfulness (AB) or "other prevention," owing to challenges
they face in categorizing these programs. Because of the teams' varying
methods for categorizing this funding, the reported allocations for the
AB and "other prevention" program areas are of limited reliability.
In our structured interviews, 10 of the 15 focus country teams noted
the difficulty of categorizing funding for certain integrated ABC
programs. For example, some officials told us that, although they do
the best they can to estimate the portion of funding for an integrated
ABC program that will be used for AB versus "other prevention"
activities, it can be difficult to predict in advance how much funding
will be used for AB or "other prevention" activities when a program
provides a variety of HIV prevention messages that may vary based on
the needs of program participants.
A review of fiscal year 2006 country operational plans indicates that,
within the sexual transmission prevention program area,[Footnote 77]
country teams use different methods for categorizing integrated
programs that have ABC components in their plans. Some country teams
have categorized integrated ABC programs entirely as "other
prevention,"[Footnote 78] while others have divided some or all of
these programs between AB and "other prevention" (with the C component
categorized under "other prevention" and the AB component categorized
as AB). For example, one country team's fiscal year 2006 operational
plan shows one of its integrated ABC programs split between the AB and
"other prevention" program areas but two of its integrated ABC programs
placed entirely in the "other prevention" program area. Another country
team placed all of its integrated ABC programs entirely in the "other
prevention" program area rather than split these programs between the
AB and "other prevention" areas.
Our structured interviews also showed that country teams have used
different methods for categorizing funding for integrated ABC programs
for planning and reporting.[Footnote 79] Following are methods used by
country teams we interviewed:
* Twelve of the 15 country teams told us that they split at least some
of their integrated ABC programs into the AB and "other prevention"
program areas. Most of these teams told us that they do not split all
of their integrated programs into the different prevention program.
Instead, some of these teams told us that they categorize some
integrated programs entirely in the "other prevention" program area,
while some also said that they had placed entirely in the AB program
area some programs that primarily focus on AB but may provide limited
information on condoms.[Footnote 80]
* The other three country teams told us that, in general, they do not
split any of their integrated ABC programs; instead, they categorize
these programs entirely in the "other prevention" program area. These
three teams said that, in general, they categorize only programs that
include AB components, but no C component, in the AB program area.
* Three country teams reported that they categorize some integrated ABC
programs based on the target group; for example, integrated programs
for youths may be categorized entirely in the AB program area, while
integrated programs for most-at-risk groups may be categorized entirely
in the "other prevention" program area.
In addition, we found that certain broader components of sexual
transmission prevention programs that are not clearly defined as AB or
"other prevention" may appear in either program area. For example,
activities addressing issues such as stigma reduction, peer pressure,
and child, spouse, or substance abuse may be categorized as either AB
or "other prevention," depending on the country team's judgment and
factors such as a program's focus or target population. Although these
activities could be considered AB because they address social and
community norms related to abstinence and faithfulness, they could also
arguably be considered "other prevention." One country team's proposed
fiscal year 2006 operational plan illustrates how the same types of
broad prevention activities may fall under AB or "other prevention,"
depending on the specific program. This operational plan contains one
program categorized entirely as AB that aims to strengthen the capacity
of military chaplains to provide counseling on issues including child,
spouse, and substance abuse; management of family crisis, illness,
death, and trauma; and alcohol addiction. This program also plans to
develop abstinence-based literature and toolkits for the chaplains to
disseminate to military personnel and their families and to support
anti-AIDS youth clubs that provide HIV/AIDS education on abstinence and
antidiscrimination against people living with HIV/AIDS. This country
team's operational plan also contains a program categorized entirely as
"other prevention" that supports drama groups to provide messages to
the country's defense forces on topics including abstinence and
faithfulness; HIV counseling and testing; stigma reduction; child and
spousal abuse; and alcohol-related issues, as well as correct and
consistent use of condoms.
Because of the varying methods used by country teams to categorize
integrated ABC prevention programs and because of the inclusion of
certain broad prevention activities (such as stigma reduction) in both
AB and "other prevention," a country team's reported AB spending may
not truly reflect the amount of funding actually supporting AB
activities. Likewise, a country team's "other prevention" spending may
not be a clear indicator of how much funding is going to non-AB sexual
prevention activities. Some AB activities are occurring in the "other
prevention" program area, suggesting that country teams may be
implementing more AB activities than first appear in their operational
plans. At the same time, however, activities that can be categorized as
AB or "other prevention," depending on a country team's judgment, are
also occurring in the AB program area. Overall, we consider these data
to be sufficiently reliable for the purposes of this engagement. In
particular, while there are some limitations in the reliability of
these reported data, they are useful for identifying general trends and
patterns across fiscal years and program areas.
[End of section]
Appendix VI: Joint Comments from the Department of State, the U.S.
Agency for International Development, and the Department of Health:
United States Department of State:
Assistant Secretary and Chief Financial Officer:
Washington, D. C. 20520:
Ms. Jacquelyn Williams-Bridgers:
Managing Director:
International Affairs and Trade:
Government Accountability Office:
441 G Street, N.W.
Washington, D.C. 20548-0001:
MAR 2l 2006:
Dear Ms. Williams-Bridgers:
We appreciate the opportunity to review your draft report, "GLOBAL
HEALTH: Spending Requirement Presents Challenges to HIV/AIDS Prevention
Programs Funded under the President's Emergency Plan for AIDS Relief,"
GAO Job Code 320334.
The enclosed Department of State comments are provided for
incorporation with this letter as an appendix to the final report.
If you have any questions concerning this response, please contact
Elisa Catalano, Legislative Compliance Officer, Office of Global AIDS
Coordinator, at (202) 663-2420.
Sincerely,
Signed by:
Bradford R. Higgins:
cc: GAO - Elizabeth Singer;
OGAC - Randall Tobais;
State/OIG - Mark Duda:
Department of State, Health and Human Services, and USAID Comments (GAO-
06-395, GAO Code 320334):
On behalf of the Departments of State and Health and Human Services
(HHS) and the United States Agency for International Development
(USAID), the Office of the U.S. Global AIDS Coordinator (OGAC)
appreciates the opportunity to comment on the draft General Accounting
Office (GAO) report, Global Health: Spending Requirement Presents
Challenges to HIV/AIDS Relief (GAO-06-395) (the Report).
Effective prevention is central to the President's Emergency Plan for
AIDS Relief (PEPFAR):
Only a vigorous and comprehensive prevention approach will turn the
tide against the global HIV/AIDS pandemic - the mission of the
Emergency Plan. Effective prevention is the only way to stop the human
suffering caused by HIV infection and limit the number of people who
will require treatment in the future. Ultimately, it is the only way to
achieve the elusive goal of an HIV/AIDS-free generation.
In the three years since President Bush's announcement of the Emergency
Plan, the United States has demonstrated historic leadership in
implementing the most diverse HIV/AIDS prevention strategy of any
international partner, with programs linked to treatment and care for a
holistic response. The lessons learned from the intensive application
of the Emergency Plan in the 15 focus countries are now being extended
to over 120 countries, helping to fuel transformation of HIV/AIDS
responses in nations around the world.
This unprecedented initiative dwarfs the pre-PEPFAR baseline levels of
prevention spending and has allowed for a wide-ranging portfolio of
high quality, sustainable, evidence-based prevention programs. The
President's budget request of approximately $4 billion in HIV/AIDS
funding for fiscal year 2007 will provide the necessary support to keep
these prevention programs on track to reach the Emergency Plan's five-
year goal of supporting prevention of 7 million new infections, as well
as for it to achieve the goals of support for treatment for 2 million
HIV-infected people and care for 10 million individuals.
Reflecting the importance of prevention, the Emergency Plan supports
programs that address a broad range of HIV transmission mechanisms. In
addition to programs to prevent mother to child transmission, ensure a
safe blood supply, and prevent infections through unsafe injections,
PEPFAR supports the ABC approach to prevent the sexual transmission of
HIV.
ABC - Abstinence, Be Faithful and Correct and Consistent Condom Use -
is the most effective, evidence-based approach to sexual transmission
of HIV infection:
Recent data from Zimbabwe and Kenya, not discussed in the Report,
mirror the earlier success of Uganda's ABC approach to preventing HIV.
These three countries with generalized epidemics (epidemics where HIV
has spread beyond concentrated groups, such as prostitutes) have
demonstrated reductions in HIV prevalence, and in each country the data
point to significant AB behavior change and modest but important
changes in C. Where sexual behaviors have changed, as evidenced by
increased primary and secondary abstinence, fidelity, and condom use,
HIV prevalence has declined.
In Zimbabwe, Science reported in February 2006 that among men aged 17
to 29 years in eastern Zimbabwe, HIV prevalence fell by 23% from 1998
to 2003. Even more impressively, the prevalence among women aged 15 to
24 dropped by a remarkable 49%.
* Abstinence (delay in sexual debut): Among men aged 17 to 19, the
percentage who had begun sexual activity dropped from 45% to 27%, and
among women aged 15 to 17, it dropped from 21 % to 9%.
* Being faithful: Among those men who were sexually experienced, the
proportion reporting a recent casual partner fell by 49%.
* Condoms: The proportion of women reporting an increase in condom use
with casual partners rose from 26% to 36%. The proportion of men
reporting condom use with casual partners remained essentially
unchanged, as did the proportion among both sexes reporting condom use
with regular partners.
In Kenya, the Ministry of Health estimates that HIV prevalence dropped
from approximately 10% in 1998 to approximately 7% in 2003. This
decline correlates with a broad reduction in sexual risk behavior.
Among the findings:
* Abstinence: There was a delay in average sexual debut among young
women (with median age of sexual debut rising from 16.7 to 17.8. Among
both teenage boys and girls, there were high levels of both primary
abstinence (with a minority of boys and girls in the 15-17 age group,
and a minority of girls in the 18-19 age group, reporting any prior
sexual activity) and secondary abstinence (in both age groups, a
minority of those who reported prior sexual activity reported any
sexual activity in the last year).
* Being faithful: Male faithfulness, as measured by the percentage of
men who report more than one sexual partner in the preceding year,
increased. In the key 20-24 age group, the percentage dropped from over
35% to less than 18%.
Condoms: Condom use among women who engage in risky activity grew, as
the number of women who reported condom use in their last higher-risk
sexual encounter rose from 16% to 24%.
As Dr. Peter Piot of UNAIDS remarked with respect to these two
countries, "[T]he declines in HIV rates have been due to changes in
behaviour, including increased use of condoms, people delaying the
first time they have sexual intercourse, and people having fewer sexual
partners." More work is needed to understand these data, and to
identify which interventions may have influenced them. Fundamentally,
however, it is clear that people in some countries have begun to change
their sexual behavior in ways that reduce their risk of infection. It
is thus urgent to identify and scale up initiatives to help even more
people choose healthy behaviors.
The national strategies of many host nations included the ABC approach,
delivered in culturally-sensitive ways, even before the advent of the
Emergency Plan. The new evidence is highly relevant to PEPFAR's work
with these nations: most of Sub-Saharan Africa, and 13 of the 15 focus
countries, are experiencing generalized epidemics. Host nations are
moving to balance campaigns to promote awareness of HIV with a broader
public health approach that provides people with comprehensive
information, services, and support that will enable them to make
healthy decisions about how to protect themselves. Indeed, providing
people with this level of information, support and services is not
merely good public health practice - it can help promote the democratic
value of personal responsibility that leads to healthy behaviors.
Congressional directives have helped focus U.S. Government (USG)
prevention strategies to be evidence-based:
Because of the data, ABC is now recognized as the most effective
strategy to prevent HIV in generalized epidemics. One of the most
striking findings of the Report is the consensus among USG field
personnel that ABC is the right approach to prevention.
The authorizing legislation directs that, for fiscal years 2006-2008,
33% of prevention funding be allocated to abstinence-until-marriage
programs. In 2004, PEPFAR notified Congress that it counts programs
that focus on abstinence and faithfulness for this purpose, as A and B
messages should always be delivered together except in programming for
young children.
The legislation's emphasis on AB activities has been an important
factor in the fundamental and needed shift in USG prevention strategy
from a primarily C approach prior to PEPFAR to the balanced A13C
strategy. The Emergency Plan has developed a more holistic and
equitable strategy, one that reflects the growing body of data that
validate ABC behavior change. PEPFAR has followed Congress' mandate
that it is possible and necessary to strongly emphasize A, B, and C,
while also seeking to support prevention of mother to child
transmission and other critical prevention interventions.
Financing for all methods of prevention have increased under PEPFAR:
PEPFAR's unparalleled financial commitment has permitted the USG to
support a balanced, multi-dimensional approach - one that was not
possible with pre-PEPFAR spending levels. The total annual spending in
the areas of HIV/AIDS prevention, as well as treatment and care, has
continually increased since the passage of the Leadership Act. If
Congress enacts the President's request for $4 billion in HIV/AIDS
funding for fiscal year 2007, that will represent a total increase of
$740 million from that appropriated in fiscal year 2006 ($3.2 billion)
and almost $1.2 billion from that appropriated in fiscal year 2005
($2.8 billion). In addition, these levels of funding represent a
quantum leap over the pre-PEPFAR baseline levels of funding for global
HIV/AIDS (U.S. funding totaled $3.87 billion for fiscal years 2000-
2003).
PEPFAR prevention funding increased from $213 million in FY 2004, to
approximately $294 million in FY 2005, to over $350 million planned for
FY 2006. With the vast increase in funding represented by PEPFAR, of
course, even as the amount of funding dedicated to a program area
rises, the percentage of overall funding dedicated to it may decline.
An important consideration in this regard is that before the advent of
PEPFAR, the USG was supporting very few programs in care and treatment.
With the massive and highly successful scale-up of these services,
which PEPFAR now supports, the percentage of resources dedicated to
prevention has necessarily declined. Yet the USG commitment to global
HIV/AIDS prevention is now clearly stronger than it has ever been.
Full funding for focus country budgets will limit the need for trade-
offs:
Perhaps the most important contribution the Report will make is to
highlight the effect of budget issues on prevention funding. The
President's FY 2007 budget request for the focus countries is, in part,
an attempt to recover from the effects on focus country programs of the
redirection of almost $527 million from focus country programs to the
Global Fund and other components of the Emergency Plan over PEPFAR's
first three years. The effect of this trend has been to force country
teams to make difficult trade-offs among prevention, treatment, and
care (and within prevention, among sexual transmission, mother-to-child
transmission, and medical transmission programs).
We appreciate the report's candor about the seemingly impossible
decisions these budget constraints have forced upon country teams. In
FY 2007 and beyond, full funding for focus country activities is
essential if PEPFAR is to meet the 2-7-10 goals, including the
prevention goal.
"Counting" ABC allocations does not affect programming:
The report reflects misunderstanding of the relationship between PEPFAR
programming and reporting mechanisms. PEPFAR is required to count the
amounts it allocates to different types of prevention programming for
purposes of accountability to Congress. But it is not the case that
each program must be only AB, or only C. Many PEPFAR-supported programs
integrate all of the ABC strategies, and these programs are encouraged
to report on the different pieces to the extent possible, because
accountability is key component of the success of PEPFAR. For a program
to be a truly integrated ABC program, of course, it must genuinely
include all three elements, rather than overwhelmingly emphasize only
one or two elements. PEPFAR is currently working to strengthen its
reporting conventions in this area through its Technical Working Groups
and through the programmatic review.
Guidance on ABC is strong - it addresses most key issues and is being
clarified as needed:
OGAC is quoted in the report as saying that further clarification of
the ABC Guidance will be provided as needed, and we welcome this
Report's contribution to the ongoing dialogue between PEPFAR
headquarters and the field. The ABC Guidance had been issued
approximately two to five months prior to the country teams' interviews
for this report. It may be expected that adjusting to newly-distributed
guidance may generate questions and a need for more clarity in the
short term. The Emergency Plan has since refined the Guidance to
clarify issues and will continue to do so, updating it on an ongoing
basis to meet the needs of the country teams. Even as it is updated,
however, the Guidance will continue to represent the USG's unwavering
support for ABC as the key evidence-based approach to prevent HIV
infection in generalized epidemics.
PEPFAR is committed to continually improving its efforts to communicate
policy to the field via numerous channels, including weekly emails,
constant contact between the core team leaders and the field, the
annual Implementers' Meeting, and others. In addition, each Country
Operational Plan is developed with significant assistance from
headquarters, providing another venue for issues to be communicated &
worked through.
It is important to note that certain examples provided in the report to
demonstrate confusion regarding the ABC Guidance are in fact clearly
spelled out in the Guidance. In these cases, the issues are actually
related to implementation, not to the Guidance document. One important
area, which the Guidance addresses at length, is the need to focus on
"high-risk activity" rather than "high-risk groups," because in a
generalized epidemic, much of the population can be at risk.
-On page 29, one country team is quoted as referring to lack of clarity
regarding support under PEPFAR for programs to address discordant
couples. Yet on page 28 of the Report, the authors directly quote from
the Guidance which spells out (in bullet number two) that it is
appropriate to target discordant couples with prevention activity:
"Discordant couples should be encouraged to use condoms consistently
and correctly so as to protect the HIV-negative partner from becoming
infected. Likewise, prevention messages should strongly support
preventative behaviors such as eliminating extra partners and
maintaining a faithful relationship."
-On page 27, the Report references concern that anyone engaging in
sexual activity is not considered a "high-risk group." Yet again, on
page 28, the Report references the Guidance, which says that "to
achieve the Emergency Plan prevention goal, we must introduce
combinations of interventions and adapt them to reach, engage, and
provide the means to enable at-risk populations to reduce their risk-
taking behaviors in a range of settings (community and facility-
based)."
-On page 28, the Report references apparent confusion regarding
messages that can be delivered to mixed groups of students (including
youth from age 10 to older than 14) in a single classroom. The Guidance
is very clear (see Report pages 28 and Guidance pages 6-7) that
students aged 14 and under may receive certain messages and that only
students 15 and older can receive additional messages. This is not an
issue of the ABC Guidance, but of implementation --how best to separate
students of different ages when prevention is taught. Our interagency
Prevention Working Group will work with the field on this
implementation issue.
PEPFAR has ensured compliance with the Congressional directive while
tailoring implementation to country circumstances:
As noted above, the Emergency Plan recognizes the importance of
tailoring prevention efforts to the particular epidemic of each
country, consistent with the requirement that 33% of prevention funding
support AB activities. This requirement is applied across all the focus
countries collectively.
As the Report notes, PEPFAR offers each focus country team the
opportunity to propose, and provide justification for, a different
prevention funding allocation based on the circumstances in that
country. In fiscal year 2005, all countries that proposed such
allocations received PEPFAR approval for them. These countries included
Cote D'Ivoire, Guyana, Haiti, Mozambique, Rwanda, Tanzania, and
Vietnam. PEPFAR was able to approve these while continuing to ensure
that the focus countries as a whole continue to comply with the
Congressional directive. (Contrary to the report's suggestion, PEPFAR
has been able to approve the allocations of countries that submitted
justifications without requiring other countries to make offsetting
adjustments to their proposed prevention allocations.)
It is important to remember that most focus countries have generalized
epidemics, for which the ABC approach is the most effective, data-based
strategy. Every country has the opportunity to submit a justification,
but in those with generalized epidemics for which ABC has been proven
to be so effective, the justification for a different allocation must
be particularly strong. It is also important to remember that the USG
is not the only source of funding in-country, and that partners can
seek funding from other sources for to balance their mix of prevention
interventions if they find that necessary.
The ABC approach has clearly represented a change in USG practice, and
change always involves a period of transition. Yet we have asked some
of the, country teams that did not submit justifications if they wanted
to do so and the answer was, emphatically, no. As country teams have
become more experienced in the ABC approach and familiar with the data
that supports it, they have become more comfortable implementing it.
The Emergency Plan accepts the report's recommendation to collect
information on the effects of the Congressional directive, and the
information gathered .will inform our adjustments to guidance. As in
all areas, the Emergency Plan will continue to refine implementation as
issues are identified, through such mechanisms as the fiscal year 2007
Country Operational Plan guidance.
The Congressional directive is appropriately applied to all accounts:
The Emergency Plan does not agree with the Report's recommendation that
the Congressional directive should be applied only to funds
appropriated through the Global HIV/AIDS Initiative Account (GHAI).
First, one of the principal objectives of the Emergency Plan
legislation was to integrate the activities of all USG agencies with
respect to HIV/AIDS programming. One of the Coordinator's tools to
achieve this has been a unified budget approach, irrespective of the
source of funding, in planning and approving country activities.
Applying the spending requirement to only a part of the budget would
signal a step backward in the integration of USG agencies' activities.
Second, the issue is becoming less salient over time. With respect to
focus country budgets, as the Report states, non-GHAI funds have fallen
to "slightly more than $5 million (2 percent) of the focus country
teams' planned PEPFAR prevention funds," and only 1 percent if central
program dollars spent in focus countries is included. The suggested
change would thus have little impact.
Conclusion:
Effective prevention is at the heart of the Emergency Plan, and in
generalized epidemics, the evidence-based ABC approach is at the heart
of effective prevention. Among the most encouraging developments in
many years in the global fight against HIV/AIDS is the growing body of
evidence demonstrating that ABC behavior change is possible - and that
it can reduce HIV prevalence on a large scale.
This report reflects another very encouraging development - the
consensus support for the ABC strategies on the part of USG personnel
in the field. The Congressional directive, which itself reflects an
understanding of the importance of ABC, has helped to support PEPFAR's
field personnel in appropriately broadening the range of prevention
efforts. Solid policy guidance from PEPFAR on prevention has helped to
address many issues of concern, and in implementing ABC consistently
with the legislative provision, PEPFAR will continue to be responsive
to the needs of personnel as they respond to circumstances in-country.
The first two years of the Emergency Plan have demonstrated that high-
quality prevention programs can work - and are working - in many of the
world's most difficult places. Through PEPFAR, the American people have
become true leaders in the world's effort to turn the tide against
HIV/AIDS.
The following are GAO's comments on the joint letter from the
Department of State, the U.S. Agency for International Development, and
the Department of Health and Human Services, dated March 21, 2006.
GAO Comments:
1. In their letter, the agencies stated that "financing for all methods
of prevention have increased under PEPFAR" and that, "even as the
amount of funding dedicated to a program area rises, the percentage of
overall funding dedicated to it may decline." Although PEPFAR funding
in the 15 focus countries increased substantially in all five
prevention program areas between fiscal years 2004 and 2005, figure 8
of our report shows that funding dropped in two prevention program
areas between fiscal years 2005 and 2006. Specifically, PEPFAR funding
for "other prevention" in the 15 focus countries declined from $65.8
million to $61.6 million, and blood safety funding declined from $53.3
million to $50 million. In addition, funding for prevention of mother-
to-child transmission stayed relatively constant, with $66.3 million in
fiscal year 2005 and $67.5 million in fiscal year 2006.
2. The agencies commented that our report reflects misunderstanding of
the relationship between PEPFAR programming and reporting mechanisms,
noting that "it is not the case that each program must be only AB, or
only C." Our report acknowledges that country teams have funded
integrated ABC programs through PEPFAR. We explain that these programs
are often split between the AB and "other prevention" program areas for
reporting purposes, but we do not suggest that each program must be AB
only or C only. Rather, we note, for example, that once funds are
designated as AB, they can be used only for AB purposes, effectively
locking teams into allocation decisions made when their operational
plans were approved. In other words, the ratio of AB to "other
prevention" funding within an integrated ABC program cannot change over
the course of a funding year. Eight of the 15 focus country teams
indicated that segregating AB funding from "other prevention" program
areas compromises the integration of their programs. For example, it
can limit their ability to shift program focus to meet changing
prevention needs. Because of this potential, one country team chose not
to split funding between AB and "other prevention" for a prevention
program for persons living with HIV/AIDS that includes faithfulness
messages because it could not predict the portion of the project that
should be dedicated to the faithfulness component and did not want to
lose flexibility to "do what is appropriate."
3. The agencies stated in their letter that "the ABC guidance had been
issued approximately 2 to 5 months prior to country teams' interviews."
As we note in our report, country teams first received the draft ABC
guidance in January 2005. The final guidance, distributed to country
teams in March 2005, differed from the draft guidance only in its
discussion of human papilloma virus. We conducted an initial round of
structured interviews with the focus country teams in June and July
2005. We conducted a follow-up round of structured interviews with the
focus country teams between August 2005 and January 2006.
4. The agencies commented that "it is important to note that certain
examples provided in the report to demonstrate confusion regarding the
ABC guidance are in fact clearly spelled out in the guidance. In these
cases, the issues are actually related to implementation, not the
guidance document." Our report states that both interpreting and
implementing OGAC's ABC guidance has created challenges for country
teams. For example, while the guidance clearly states that "discordant
couples should be encouraged to use condoms consistently and
correctly," it does not stipulate whether broad condom social marketing
programs are therefore appropriate when much of a country's population
consists of discordant couples. Similarly, while the guidance clearly
states that in-school youths 14 and younger should not receive condom-
related information, it does not address the issue of how youth groups
that cross this age divide should be handled. We recognize that
guidance on a subject as complex as prevention of sexual HIV
transmission will naturally lead to questions and believe that the
agencies' commitment to continually improve their efforts to
communicate policy to the field should help resolve these questions.
5. The agencies' letter stated that they have "been able to approve the
allocations of countries that submitted justifications without
requiring other countries to make offsetting adjustments to their
proposed prevention allocations." However, in our structured
interviews, seven country teams that were not exempted from the
abstinence-until-marriage spending requirement identified specific
program constraints related to the requirement. As we note in our
report, some of these teams commented specifically on OGAC's 50 percent
and 66 percent policies implementing the Leadership Act's requirement.
For example, one country team told us that, because of OGAC's policies,
it was required to cut funding for programs in the "other prevention"
program area and to shift funding from the care category in order to
address a condom shortage in that country. Another country team told us
that, because of OGAC's policies, it had been required to substantially
reduce the amount of funding it had planned to dedicate to a prevention
program for people living with HIV/AIDS. These examples illustrate the
adjustments to prevention programming that some country teams have had
to make to offset the effects of programming decisions made by teams
exempted from the spending requirement. Further, OGAC could not meet
the Leadership Act's overall 33 percent target without requiring that,
overall, more than 33 percent of prevention funds in nonexempted
countries be spent on AB activities.
6. The agencies commented that they had asked some of the country teams
that did not submit justifications if they wanted to do so and that
they said no. We also did not ask all country teams that did not submit
justifications whether they had wanted to do so. However, one country
team told us that, although it was struggling to meet the spending
requirement, OGAC officials had made it clear that submitting a
justification was not an option.
7. The agencies stated that applying the spending requirement only to
funds appropriated to the Global HIV/AIDS Initiative (GHAI) account
would signal a step backward in the integration of U.S. government
agencies' activities. We recognize that exercising this option may
entail some trade-offs and, as a result, have modified our
recommendation to ask that the agencies consider this change after
reviewing information collected on the effects of the spending
requirement.
8. The agencies also stated that applying the spending requirement
solely to funds appropriated to the GHAI account would have little
impact because non-GHAI funds account for between 1 and 2 percent of
focus country teams' budgets. We acknowledge in our conclusions that
the amount of overall PEPFAR funding not appropriated to the Global
HIV/AIDS Initiative account is relatively small. We also acknowledge
that reversing this policy would not enable OGAC to fully address the
underlying challenges that the country teams face in having to reserve
a specific percentage of their prevention funds for abstinence-until-
marriage programs. However, unlike the focus country teams, which
receive very limited funding not appropriated to the GHAI account, the
five additional country teams that OGAC requires to meet the spending
requirement--unless they receive exemptions--receive more than 80
percent of their PEPFAR prevention funds in non-GHAI funding.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
David Gootnick (202) 512-3149:
Staff Acknowledgments:
In addition to the individual named above, Celia Thomas (Assistant
Director), Elizabeth Singer, Elisabeth Helmer, David Dornisch, Mary
Moutsos, Reid Lowe, Kay Halpern, and Etana Finkler made key
contributions to this report.
(320334):
FOOTNOTES
[1] The remaining $1 billion was intended for the Global Fund to Fight
HIV/AIDS, Tuberculosis, and Malaria (the Global Fund).
[2] The President named the following 14 focus countries in 2003:
Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique,
Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia.
Vietnam was added as the fifteenth focus country in June 2004.
[3] Pub. L. No. 108-25.
[4] The U.S. agencies primarily responsible for implementing PEPFAR are
the Department of State; the U.S. Agency for International Development
(USAID); and the Department of Health and Human Services (HHS). Other
agencies involved in PEPFAR are the Department of Defense, the Peace
Corps, and the Departments of Labor and Commerce.
[5] Abstinence/faithfulness and "other prevention" funds generally are
aimed at preventing the sexual transmission of HIV, while funds in the
other three categories are aimed at preventing nonsexual transmission.
"Other prevention" includes activities such as programs for high-risk
groups to increase their awareness of HIV/AIDS prevention behaviors and
their access to HIV prevention services, such as condom promotion and
distribution; condom social marketing; substance abuse prevention
programs; management and treatment of sexually transmitted infections;
and messages or programs to reduce injection drug use and related
risks. In its Second Annual Report to Congress, released February 2006,
OGAC began referring to these activities as "condoms and related
prevention activities."
[6] "The President's Emergency Plan for AIDS Relief U.S. Five-Year
Global HIV/AIDS Strategy," Feb. 23, 2004.
[7] These officials spoke with us with the understanding that
individual respondents and the countries where they serve would not be
named in our discussion of the structured interviews.
[8] HIV prevalence represents the percentage of the population that is
estimated to be HIV positive. Estimates of HIV prevalence are often
based on surveillance of pregnant women in prenatal clinics or
population-based surveys. In contrast, HIV incidence refers to the
number of new infections over a period of time (usually 1 year).
[9] These countries are Cambodia, India, Malawi, Russia, and Zimbabwe.
Each of these country teams receives at least $10 million in U.S.
government funding for HIV/AIDS and is therefore required to submit an
operational plan to OGAC each fiscal year, starting in fiscal year
2006.
[10] As discussed on page 11, PEPFAR prevention funding is defined for
the purposes of this report as funding appropriated to four accounts in
the 15 PEPFAR focus countries, as well as bilateral HIV/AIDS funding in
the five additional PEPFAR countries. Funding data for fiscal years
2004 and 2005 are actual, while funding data for fiscal year 2006 are
planned funding for activities that have not yet been approved by OGAC.
[11] Although the spending requirement did not take effect until fiscal
year 2006, OGAC encouraged country teams to dedicate 33 percent of
total prevention funds to AB activities in fiscal years 2004 and 2005,
consistent with the Leadership Act's recommendation to do so.
[12] These 20 country teams are the 15 focus country teams and the 5
additional teams that receive at least $10 million in PEPFAR funding.
[13] As shown on page 11, PEPFAR prevention funding is defined for the
purposes of this report as funding appropriated to four accounts in the
15 PEPFAR focus countries, as well as bilateral HIV/AIDS funding in the
five additional PEPFAR countries.
[14] These programs aim to prevent transmission of HIV from infected
individuals to uninfected individuals.
[15] According to the World Bank, more than three-quarters of HIV
infections in developing countries are transmitted through sexual
intercourse. Heterosexual intercourse is the primary mode of
transmission in 14 of the 15 PEPFAR focus countries. Intravenous drug-
use is the primary mode of transmission in Vietnam. World Bank
estimates show that about 15 to 20 percent of all HIV infections in
Africa occur through mother-to-child transmission. In developing
countries, on average, blood transfusions account for less than 10
percent of HIV infections, and medical injections with dirty needles
are thought to account for about 5 percent of all HIV infections.
[16] According to the World Health Organization, girls and young women
in Kenya are particularly vulnerable to HIV infection. In that country,
women aged 15-24 are more than twice as likely to be infected as men in
this age group. In Rwanda, however, the groups with evidence of the
highest infection rates include sex workers, as well as men attending
clinics that offer treatment for sexually transmitted infections.
[17] The remaining $1.5 billion was appropriated for, among other
initiatives, the Global Fund to Fight HIV/AIDS, Tuberculosis and
Malaria (the Global Fund) and international HIV/AIDS research through
the National Institutes of Health. The Global Fund is a multilateral,
nonprofit, public-private mechanism to rapidly disburse grants to
augment existing spending on the prevention and treatment of HIV/AIDS,
tuberculosis, and malaria while maintaining sufficient oversight of
financial transactions and program effectiveness. (See GAO, Global
Health: Global Fund to Fight AIDS, TB and Malaria Has Advanced in Key
Areas, but Difficult Challenges Remain, GAO-03-601 [Washington, D.C.:
May 7, 2003]).
[18] The PMTCT account expired at the end of fiscal year 2004, but some
country teams carried over PMTCT funds from fiscal year 2004 to fiscal
year 2005. Therefore, for fiscal year 2006, this report defines PEPFAR
funding as funds appropriated to the remaining three accounts. Although
the PMTCT account expired, OGAC continues to fund PMTCT activities
through the other funding accounts.
[19] Others have used PEPFAR funding to describe all U.S. government
funds dedicated to combating HIV/AIDS worldwide, including funds such
as U.S. contributions to the Global Fund.
[20] According to OGAC officials, focus country teams received an
additional $150 million in fiscal year 2006 "plus-up" funding for
prevention, treatment, and care activities in January 2006. Fiscal year
2006 funding figures are likely to change slightly throughout the
fiscal year, as country teams make adjustments to their funding
allocations. Data on fiscal year 2006 planned PEPFAR prevention funding
are current as of March 15, 2006.
[21] According to the PEFPAR 5-year HIV/AIDS strategy, palliative care
includes routine clinical care to evaluate the need for symptom relief
(e.g., from diarrhea or headache); treatment for HIV/AIDS related
diseases such as tuberculosis and opportunistic infections; preparing
people for antiretroviral therapy, where possible; and, when treatment
is not available or has failed, compassionate end-of-life care.
[22] In 1986, the Ugandan government launched a nationwide information,
education, and communication tour to encourage Ugandans to abstain from
sex until marriage, remain faithful to one partner (termed "zero-
grazing"), and use condoms when necessary. According to the U.S. Census
Bureau and UNAIDS, national HIV/AIDS prevalence in Uganda fell from
about 15 percent in the early 1990s to 5 percent in 2001.
[23] Cates, Willard; Cassell, Michael M; Gayle, Helene D; Green, Edward
C; Halperin, Daniel T; Hearst, Norman; Kirby, Douglas; and Steiner,
Markus J. "The Time Has Come for Common Ground on Preventing Sexual
Transmission of HIV," Lancet: Vol. 364, Nov. 27, 2004.
[24] Office of the U.S. Global AIDS Coordinator, Appendix 2: The
Emergency Plan for AIDS Relief: Fiscal Year 2004 Prevention
Expenditures and Program Classification Criteria (Washington, D.C.:
U.S. Department of State, 2004).
[25] According to OGAC, secondary abstinence is for unmarried youths
who have already engaged in sexual intercourse.
[26] According to OGAC, "[intravenous drug use] prevention was included
under sexual prevention because it falls within [PEPFAR's] category of
"other prevention," i.e. other prevention that is not abstinence and be
faithful (e.g., women in prostitution, truckers, men who have sex with
men, etc)."
[27] The field of HIV/AIDS prevention also involves longer-term,
research-oriented initiatives, such as research for vaccines and
microbicides.
[28] President Bush also established goals of treating at least 2
million people with life-extending drugs and providing humane care for
millions of people suffering from AIDS and for children orphaned by
AIDS. OGAC has stated that its goal is to provide care for 10 million
people in the 15 focus countries.
[29] In contrast, OGAC aims to reach the PEPFAR care and treatment
goals by 2008.
[30] Until recently, OGAC referred to central awards as "track 1" and
to country-level awards as "track 1.5" and "track 2." According to
OGAC, the first round of funding managed by the focus country teams was
awarded as track 1.5 funding, whereas subsequent rounds were awarded as
track 2 funding.
[31] OGAC's target areas for central awards for prevention include AB,
blood safety, PMTCT, and safe medical injection activities. According
to OGAC, it has chosen organizations with the capacity to rapidly
expand activities, a proven track record, and existing operations in
the focus countries for central awards. Central awards were made in two
rounds: the first for blood safety, safe medical injections, and
antiretroviral treatment; the second for orphans and vulnerable
children and AB activities. Central awards were made for every focus
country except Vietnam.
[32] In December 2005, President Bush announced the New Partners
Initiative, under which $200 million in grants will be awarded to
nongovernmental organizations with little or no experience working with
the U.S. government to provide HIV/AIDS prevention and care services in
the 15 focus countries.
[33] OGAC officials were unable to provide data on PMTCT central
funding for prevention. While they estimated that $6.5 million in
central PMTCT funding went to prevention in fiscal years 2004 and 2005,
we have not included these rough estimates in our funding figures.
[34] In fiscal year 2004, the focus countries obligated about $200
million in country-level and centrally awarded funds for prevention
activities. Obligations represent a binding financial commitment (such
as an order placed, contract awarded, or service received) that will
result in immediate or future outlays.
[35] These figures also include central funding.
[36] The reported allocations shown in figure 9 include both central
and country-level funding.
[37] Office of the U.S. Global AIDS Coordinator, Guidance to In-Country
Staff and Implementing Partners Applying the ABC Approach to Preventing
Sexually-Transmitted HIV Infections within the President's Emergency
Plan for AIDS Relief (Washington, D.C.: U.S. Department of State, March
2005). This guidance was released in its final form in March 2005.
According to OGAC, the only difference between the draft guidance
provided to country teams in January and the final guidance was the
language regarding human papilloma virus.
[38] These countries are Cambodia, India, Malawi, Russia, and Zimbabwe.
OGAC officials said they chose to apply the 66 percent requirement to
these countries because each country receives more than $10 million in
U.S. government funding for HIV/AIDS activities.
[39] The sum of funding for all five prevention program areas.
[40] As shown in figure 1, 11 of the 15 focus countries are
experiencing generalized epidemics. In fiscal year 2006, 7 of the 15
focus countries had planned PEPFAR funding over $75 million.
[41] See page 11 for a definition of PEPFAR prevention funding.
[42] According to the ABC guidance, at-risk groups include sex workers
and their clients; sexually active discordant couples or couples with
unknown HIV status; substance abusers; mobile male populations; men who
have sex with men; people living with HIV/AIDS; and those who have sex
with an HIV-positive partner or one whose HIV status is unknown.
[43] The ABC guidance states that PEPFAR funds may not be used to
physically distribute or provide condoms in school settings; for
marketing efforts to promote condoms to youths in school settings; or
for marketing campaigns that target youths and encourage condom use as
the primary intervention for HIV prevention in any setting.
[44] Country teams received this document in August 2005. Although we
conducted a follow-up round of structured interviews with the country
teams after this date, we did not specifically ask each country team
about this document.
[45] Country teams can submit requests to OGAC to reprogram funds from
one program to another.
[46] Under direction from OGAC, this country team categorized the
program entirely as palliative care.
[47] The 20 PEPFAR teams discussed in this section comprise the 15
focus country teams and the 5 additional country teams required to meet
the spending requirement because they receive at least $10 million in
PEPFAR funding.
[48] Of the remaining three country teams, one reported that the
spending requirement was in line with its prevention strategy; one
indicated that, although it had some concerns about the prevention
spending requirement, it had more concerns about the Leadership Act's
requirement that at least 55 percent of funds appropriated pursuant to
the act be spent on treatment; and one did not respond to our request
for information.
[49] Each of these seven teams has PEPFAR funding over $75 million, is
working in a country with a generalized HIV/AIDS epidemic, or both. As
noted on page 30, OGAC discourages these teams from submitting
documents requesting exemption from the spending requirement.
[50] In fiscal year 2004, OGAC encouraged country teams to dedicate 7
percent of total PEPFAR funds on AB activities. This figure reflected
the Leadership Act's recommendation that 20 percent of total funds
appropriated pursuant to the act be spent on prevention (7 percent is
33 percent of 20 percent).
[51] A 2005 USAID IG report found that this country's reported number
of PMTCT-prevented infections fell significantly short of the target of
3,500.
[52] In this case, we communicated with the country team before it had
made its final prevention allocations for the upcoming fiscal year.
[53] In this case, we communicated with the country team before it had
made its final prevention allocations for the upcoming fiscal year.
[54] Because of challenges and inconsistencies in country teams'
categorization of funding for certain integrated ABC programs and some
broad sexual transmission prevention activities, data on prevention
allocations may reflect the variation in categorization methods, rather
than actual differences. (See app. V.)
[55] Unlike the other teams that submitted requests for exemption, one
country team plans to spend over 90 percent of total prevention funds
on sexual transmission prevention. Therefore, even though AB funds do
not account for 66 percent of this country team's funds to prevent
sexual transmission of HIV, the team still reserves at least 33 percent
of prevention funds for AB activities.
[56] This is not the case for one of the 10 country teams, which
reported that it would dedicate 32 percent of planned prevention funds
to AB for fiscal year 2006. Although this team planned to dedicate more
than 50 percent of total prevention funds on sexual transmission
prevention funds, it missed the 66 percent policy requirement,
dedicating about 60 percent of sexual transmission funds to AB
activities. Prior to receiving plus-up funds at the end of January and
subsequently reallocating its prevention funds, this team met both the
50 percent and 66 percent policy requirements and therefore did not
request exemption.
[57] We do not have fiscal year 2005 data from the five additional
country teams that were required to meet the spending requirement in
fiscal year 2006. Therefore, we are unable to compare the prevention
allocations in fiscal year 2005 with those in fiscal year 2006 for
these teams.
[58] Fiscal year 2005 data represent actual funding. Fiscal year 2006
data represent planned funding, which has not yet been approved by
OGAC. For both fiscal years, central and country-level funds are
included.
[59] This includes funds appropriated to CDC's Global AIDS Program, the
Child Survival and Health Account, and the Freedom Support Act. See
page 30.
[60] See page 40.
[61] These officials spoke with us with the understanding that
individual respondents and the countries where they serve would not be
named in our discussion of the structured interviews.
[62] U.S. missions enter planning and reporting requirements, including
the country operational plans, semiannual and annual progress reports,
into the COPRS data system. The COPRS data system does not contain
information on central (track 1) funding or on planned and approved
funding for fiscal year 2004.
[63] The Office of the U.S. Global AIDS Coordinator prepared this
report in collaboration with the Departments of State (including the
U.S. Agency for International Development), Defense, Commerce, Labor,
Health and Human Services (including the Centers for Disease Control
and Prevention, the Food and Drug Administration, the Health Resources
and Services Administration, the National Institutes of Health, and the
Office of Global Health Affairs); and the Peace Corps.
[64] One of these organizations did not respond to our requests for an
interview; the other agreed to meet with us but later cancelled the
appointment.
[65] Fiscal year 2005 program descriptions based on focus country
teams' country operational plans, dated Mar. 16, 2005.
[66] The indicators for PMTCT are number of service outlets providing
the minimum package of PMTCT services according to national and
international standards; number of pregnant women who received HIV
counseling and testing for PMTCT and received their test results;
number of pregnant women provided with a complete course of
antiretroviral prophylaxis in a PMTCT setting; and number of health
workers trained in the provision of PMTCT services according to
national and international standards. For blood safety, the indicators
are number of service outlets carrying out blood safety activities and
number of individuals trained in blood safety. The safe medical
injections indicator is the number of individuals trained in medical
injection safety.
[67] The prevalence data used in the Census projection are derived from
a statistical database (the estimates and projections package) that in
turn incorporates the country prenatal clinic survey data. Use of these
data to estimate countrywide incidence assumes that the prevalence rate
among pregnant women is highly correlated with the prevalence rate in
the general population. Other organizations such as the Joint United
Nations Programme for HIV/AIDS also use these data in their prevalence
estimates.
[68] The modeling group, chaired by the U.S. Census Bureau, included
representatives from U.S. agencies, such as the U.S. Agency for
International Development, the Centers for Disease Control and
Prevention, and OGAC, as well as independent think tanks and the United
Nation's Children's Fund.
[69] The Futures Group is a privately held company that designs and
implements public health and social programs for developing countries.
[70] The Goals Model assesses the impact of 13 specific interventions
including, in part, mass media, community outreach, school-based
programs, condom social marketing, and outreach to injection drug
users. For each of these interventions, the model estimates the effects
of these interventions in changing behaviors. Separate estimates of
behavior change are made for high-risk, medium-risk, and low-risk
populations. The model then estimates the reductions in new infections
that result from the specific changes in behaviors in each of the
groups. The numerical effects of the 13 interventions on behavior
change, and of behavior change on the number of new infections, derive
from peer-reviewed studies.
[71] The Goals Model incorporates a limited amount of information about
the impacts of certain interventions on behaviors and infection rates
because of a lack of evidence from studies. In addition, some of the
numerical effects specified in the model are based on only one or two
studies. Because of this lack of evidence, researchers disagree about
the numerical effects that should be used in the model.
[72] According to OGAC, the principals are the Global AIDS Coordinator
and his deputy, the director of the Office of Global Health Affairs and
Special Assistant to the Secretary for International Affairs at the
Department of Health and Human Services/Centers for Disease Control and
Prevention, the acting Assistant Administrator for the Bureau of Global
Health at the U.S. Agency for International Development, the Deputy
Assistant Secretary of Defense, the Special Assistant to the Secretary
for International Affairs, and the Peace Corps AIDS Relief Coordinator.
[73] The committees are the Senate Committee on Foreign Relations, the
House Committee on International Relations, and the Senate and House
Committees on Appropriations.
[74] OGAC may submit more than one congressional notification. For
example, for fiscal year 2006, OGAC plans to submit a congressional
notification before completing the operational plan review process to
fund programs for which the country teams have requested early funding.
[75] Each U.S. agency operating under PEPFAR processes grants,
contracts, and cooperative agreements differently. Procurements may
occur centrally by agency headquarters, by country U.S. government
offices, or by regional U.S. government offices. In addition, the type
of grant, contract, or cooperative agreement affects how it is
processed.
[76] An integrated ABC program often addresses a range of issues,
including abstinence; faithfulness; nutrition; sexually-transmitted
infections; peer pressure; stigma reduction; child, spouse, and
substance abuse; alcohol addiction; condom negotiation; and correct and
consistent condom use.
[77] Programs outside of the sexual transmission prevention program
area, such as prevention of mother-to-child transmission or voluntary
counseling and testing programs, may also include ABC components.
[78] In fiscal year 2006, no country teams have categorized integrated
ABC programs entirely in the AB program area.
[79] Some structured interviews took place prior to submission of the
fiscal year 2006 operational plans; discussions, therefore, revolved
around categorization methods used in fiscal year 2005 operational
plans. Based on these structured interviews and our review of fiscal
year 2006 operational plans, it appears that there was some change in
country teams' categorization methods between the fiscal years.
[80] Office of the U.S. Global AIDS Coordinator (OGAC) officials told
us that, in reviewing fiscal year 2005 proposed operational plans, they
found that some countries mistakenly categorized programs with C
components entirely in the AB program area. However, OGAC will not
approve this categorization and has instructed country teams that they
should split the entire C component of any ABC programs into the "other
prevention" program area.
GAO's Mission:
The Government Accountability Office, the investigative arm of
Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order
GAO Products" heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office
441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov
(202) 512-4800
U.S. Government Accountability Office,
441 G Street NW, Room 7149
Washington, D.C. 20548:
