General Articles

2008 PEPFAR Country Updates: Haiti


Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.


In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).  
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries.  PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action.  Advocates were hopeful that this large funding stream could offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying.  Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.  
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20% of the funds could be spent on prevention efforts.  Moreover, 33% of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs.  Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs). While these organizations often had vast social service networks already in place in many countries around the world, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings. 
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time. 
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2007 and 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds. 
In addition to this data, each update also offers further analysis on particular items of note in the country. And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries.  While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective. 
The Republic of Haiti has been disproportionately impacted by the HIV/AIDS epidemic compared to its neighbors in Latin America and the Caribbean. Various economic, social, and political conditions have made it difficult for Haiti to successfully fight the disease. The first known case of HIV infection in Haiti was in 1981. Now, almost 30 years later, there are at least 190,000 people living with HIV/AIDS, and an estimated 16,000 people die each year from the disease.[1] Despite these harrowing estimates, the national prevalence rate of HIV/AIDS has gone down from as high as 5.6% in 2003 to as low as 2% in 2007, a 3% drop within four years.[2]  Although these estimates are promising, the decline does not mean preventative behavior has gone up. And, AIDS remains the leading cause of death in the country.[3]  In addition, Haiti has witnessed a disturbing trend of the epidemic disproportionately impacting more women and girls than ever before.[4]
Haiti’s economy continues to be a major factor in the current state of the epidemic.  Haiti is one of the poorest countries in the Western hemisphere with two-thirds of its population living below the United Nations Development Programme (UNDP) established poverty line.[5]  In addition, it has the highest illiteracy rate (44%) and the highest unemployment rate (70%) of any country in the Caribbean.[6]  Poverty has been a main force behind the HIV epidemic and, coupled with other factors like continued political unrest, has also prevented the Haitian government from implementing a multi-sectoral, comprehensive HIV-prevention plan.
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Haiti. These statistics are pulled out in greater detail in the following chart.
Total population (2005)[7]
Percentage of the population under the age of 24
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005)[8]
Per capita total expenditure on health (Int’l$, 2005)[9]
Secondary school enrollment rate (1997–2000)[10]
20% female
21% male
Estimated number of people ages 15 and over living with HIV/AIDS (2005)[11]
HIV prevalence in people ages 15–49 (2005)[12]
HIV prevalence in people ages 15–24 (2003)[13]
4.20% female
1.98% male
Median age of first intercourse
Median age of first marriage
Young people ages 15–24 who have had sex before age 15 (2005)[14]
Young people ages 15–24 reporting sex with a casual partner in the past 12 months (2000)[15]
38.2% female
66.7% male
Young people ages 15–24 reporting using a condom the last time they had sex with a casual partner (2000)[16]
20.0% female
30.0% male
Contraceptive prevalence rate (2004)[17]
Any method: 28%
Modern: 22%
Percentage of couples using condoms for family planning (2005)[18]
Number of births per 1,000 women ages 15–19(2005–2010)[19]
Percentage of females (20–24) who have given birth by age 18 (2005)[20]
Young people ages 15–24 who can correctly identify ways to prevent HIV (2005)[21]
40.7% female
55.9% male
Schools with teachers trained in life-skills-based HIV/AIDS education who taught this during the last academic year
Haiti first attempted to respond to the epidemic in 1987 by establishing a National AIDS Council (NAC). The NAC, however, was largely ineffective and became non-operational during the civil unrest that lasted into the late 1990s. In 1996, the Haitian government made another attempt at providing some national leadership by drafting a National Strategic Plan (NSP) for 1996–2000. Like the NAC however, the NSP 1996–2000 was never implemented due to ongoing economic issues and civil unrest.
However, in 2002, renewed political commitment to fighting the HIV/AIDS epidemic led to the creation of a second National Strategic Plan for the years 2002–2006. This NSP identified six priority areas within prevention to reduce the risk of infection: promoting behaviors that reduce risk, encouraging responsibility for STIs, promoting and distributing condoms, providing a safe blood supply, reducing mother-to-child transmission, and preventing transmission in cases of accidental exposure to blood and in cases of violence.[22]
Key Goals of the NSP 20022006
1.                  Prevent New Infections
2.                  Improve Quality of Life for People Living With AIDS
3.                  Develop Multi-Sectoral Interventions

This plan, while a great improvement to previous government attempts and the first NSP, currently remains only partly implemented. Funding restrictions are largely responsible for the limited implementation of this plan. Specifically, an influx of money from donors like the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR) has led to a prioritization of specific elements of the NSP rather than supporting the plan in its entirety.[23]
In fact, as of 2005, Haiti had made little progress in meeting its NSP goals or in addressing the six priority areas to reduce risk of infection. Haiti has had some form of health education, family life education, or HIV-prevention education in primary and secondary schools since the late 1990s, and the majority of parents think education about condoms should be provided to children 12 and older. Nonetheless, Haiti’s youth are still uninformed about the risks of HIV/AIDS.  Only half of young people ages 15–24 could correctly identify ways of preventing sexual transmission of HIV and reject major myths about the disease.[24] Even fewer young people (28% of females and 42% of males ages 15–24) report using condoms with non-regular partners.[25]  This is particularly troubling given the early age of sexual debut among youth; approximately 62% of youth ages 15–24 report having had sex before age 15.[26] In addition, young people frequently have multiple partners; 67% of young men ages 15–24 indicated having multiple partners.[27]
Haiti’s performance in other areas of prevention has been equally troubling. For example, as of 2005, only 19% of pregnant women received a full course of antiretroviral therapy (ART) to reduce mother-to-child transmission (MTCT).[28] Distribution of ART outside of efforts to prevent MTCT has been a serious problem in Haiti due to lack of funds and infrastructure to support a treatment supply chain. In 2007, only 39% of people in need of ART were receiving them.[29]
The influx of money from PEPFAR and the Global Fund has certainly helped to increase access to prevention, treatment, and care services and programs. However, the immense poverty and ongoing political instability in Haiti, coupled with a lack of human resource capacity, has made implementation of these programs extremely challenging.
President’s Emergency Plan for AIDS Relief (PEPFAR)
Key Terms to Understanding PEPFAR Prevention Programs and Funds
ABC: ABC stands for “Abstain, Be-Faithful, and Correct and Consistent Condom Use.” ABC is PEPFAR’s guiding principal for HIV-prevention programs. PEPFAR requires that a minimum of one-third of all prevention funds be spent on abstinence programs and it limits the promotion and marketing of condoms to specific groups outlined in PEPFAR’s ABC guidance. No discussion or promotion of condoms is permitted with youth under the age of 14 using PEPFAR funds.
Country Operation Plan (COP): A yearly program and budget plan developed for each PEPFAR focus country. The COP is developed by U.S. staff in conjunction with country governments.  It divides programs into three main categories of prevention, care, and treatment:  Abstinence-Be-Faithful (AB), Other Prevention (OP), and Prevention of Mother-to-Child Transmission (PMTCT). A country’s COP is not the same as its National Strategic Plan/Framework (NSP/F). Unlike a NSP/F, a COP is specific to PEPFAR programs and funds, and is developed annually. In comparison, the NSP/F is a multi-year, country-wide strategy on HIV/AIDS that is developed by each country’s government. Although the NSP/F may make reference to PEPFAR and other international donors, it is not limited to a description of activities funded by international donors, and an NSP/F may or may not be developed with input from the United States or other donors. 
Abstinence-Be-Faithful (AB): One category of prevention programs and funding under PEPFAR. Grantees that provide AB programs focus on education and promotion of abstinence-until-marriage and be-faithful messages. Grantees that receive OP funds, such as those to promote condom use, are listed in both sections of the COP.
Other Prevention (OP): One category of prevention programs and funding under PEPFAR.  The OP category includes any prevention program that is not an AB program or a PMTCT program. This category includes surveillance programs, programs aimed at reducing stigma and discrimination, training for healthcare workers, and the promotion and marketing of correct and consistent condom use. Grantees that receive funds for OP programs in addition to AB funds are listed in both sections of the COP.
Prevention of Mother-to-Child Transmission (PMTCT): One category of prevention programs and funding under PEPFAR. The PMTCT category includes routine rapid HIV-testing in antenatal and maternity settings, counseling and support for infant feeding, and linking to care, treatment, and support services.

PEPFAR began allocating funds to Haiti in 2004 with an initial investment of $28 million dollars.  That funding was increased to nearly $44 million for 2005 and saw a slight increase in 2006 to just under $49 million. Funding has been increased again in 2007 to nearly $75 million, with the most significant increases going to treatment and care programs.
PEPFAR promotes an ABC prevention message, which means: Abstain, Be-Faithful, and Correct and Consistent Condom Use. Abstain/Be-Faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC). The following chart details the allocated funds from PEPFAR to the different programs.
Allocated PEPFAR Funds, Haiti, 2004–2007*
Total Funds Allocated**
$ 28,053,144
$ 43,834,021
$ 48,954,947
$ 75,062,732
Total Prevention Funds Allocated
$ 13,834,690
$ 11,311,457
$ 13,121,983
Total AB Funds Allocated
$ 3,619,052
$ 3,895,017
$ 4,046,983
Total Other Prevention Funds Allocated (includes condom programming)
$ 2,301,000
$ 2,625,000
Total Treatment Funds Allocated
$ 19,747,679
$ 26,209,002
$ 35,421,679
Total Care Funds Allocated
$ 10,251,652
$ 11,434,488
$ 27,859,454
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.  
** Total funding allocated to Field Programs only, excludes Agency costs.
As the chart indicates, of the $43 million allocated in 2005, just under $14 million (31%) was allocated for prevention programs.  In 2006, the percentage of prevention funds decreased to 23% of allocated PEPFAR funds, and it dropped even further to 17% in 2007.
Over $3 million (26%) of total PEPFAR prevention funds were allocated in 2005 to AB programs.  This jumped to 34% in 2006 and, in 2007, there was a slight increase in funding for AB programs.     
For OP funding, over $2 million (17%) of total PEPFAR funds were allocated in 2005. OP funds slightly increased the following year to over $2.5 million (23%) of total PEPFAR prevention funds and has remained constant in 2007 ever since.
Prevention Programming
The ABC approach under PEFPAR emphasizes behavioral change, “including delay of sexual debut; mutual faithfulness and partner reduction for sexually active adults; and correct and consistent use of condoms by those whose behavior places them at risk.”[34] General populations receive an AB-based approach, while only high-risk populations receive a fully integrated ABC message that addresses condom use as well as abstinence.
Haiti’s 2007 PEPFAR Country Operation Plan (COP) indicates that there were 12 funded AB programs. These programs were intended to reach an audience of 568,650 people. According to the COP, there were nine OP programs funded in 2007, six of which included either education or distribution of condoms. The other three programs focused on additional prevention initiatives such as post-test counseling, training of healthcare workers and traditional healers, and oversight and/or grant management.  These programs are carried out by organizations ranging from U.S.-based government agencies, community-based organizations, and academic institutions.
Data provided by the Office of Global AIDS Coordinator (OGAC) on the funding of grantees makes it difficult to tell how much each grantee is allocating towards AB or OP programs. In 2007, however, the following grantees and sub-grantees were providing either AB or OP programming in Haiti. A full list of grantees is available at
  • Academy for Educational Development                        
  • Foundation for Reproductive Health and Family Education
  • Johns Hopkins University Center Communications Programs
  • Management Sciences for Health
  • PLAN International     
  • Population Services International
  • U.S. Agency for International Development      
  • World Relief Corporation
  • World Vision International
The main provider of OP programs in 2007 was the U.S. Age