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GAO Report finds Frustration and Confusion in Countries Receiving U.S. Assistance for HIV/AIDS

On April 4, 2006, the United States Government Accountability Office (GAO) released Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief . Despite claiming to take a comprehensive approach to HIV-prevention, based on “ABC” (Abstain, be Faithful, and use Condoms) messages, law and policy governing U.S. foreign assistance related to HIV/AIDS has required a substantial focus on promoting abstinence-until-marriage. The report, requested by both Democrat and Republican members of Congress, examines how these specific law and policy requirements are hindering HIV-prevention work in 20 low-income countries.

The President’s Emergency Plan for AIDS Relief (PEPFAR) has been the U.S. government’s framework since 2004 for addressing the global AIDS pandemic. It includes substantial, targeted funding for 15 focus countries in Africa and the Caribbean as well as Vietnam . To prepare the report, GAO interviewed in-country teams made-up of U.S. agency officials responsible for managing PEPFAR in the focus countries. The investigators also interviewed U.S.-based officials from the Office of the Global AIDS Coordinator (OGAC), the United States Agency for International Development (USAID), the Department of Health and Human Services—Centers for Disease Control and Prevention, and representatives of U.S.-based NGOs.

Limitations on Prevention Funds

The legislation governing PEPFAR requires that at least one-third (33%) of all prevention funds, which include money for programs designed to prevent mother to child transmission as well as blood safety programs, be reserved for abstinence-until-marriage programs. To reach this one-third for abstinence earmark, OGAC, the U.S. government office responsible for implementing PEPFAR through all international AIDS programs, requires countries to dedicate at least half of total prevention funds to sexual transmission and then spend at least 66% of these funds on abstinence and faithfulness promotion programs (66% of 50% = 33% of 100%).1 As a matter of law, this budgetary restriction applies only to the 15 focus countries, however, OGAC has extended this requirement to all organizations and countries receiving U.S. foreign assistance for HIV/AIDS.2

The majority of PEPFAR country teams on the ground reported that meeting the spending requirement “challenges their ability to develop interventions that are responsive to local epidemiology and social norms.”3 In an attempt to balance the need for responsiveness with the rigid spending framework, OGAC offered country teams the opportunity to apply for a wavier based on local epidemiology. The GAO found that country teams that are exempted from the abstinence-until-marriage spending requirement have increased flexibility to meet local needs. In order for OGAC to meet the required earmark overall, however, country teams that are not exempted have to spend more than the 33% of prevention funds on these activities—sometimes at the expense of other programs such as prevention of mother to child transmission programs, blood safety activities, and condom social marketing.

Ultimately, the report illustrates how the abstinence-until-marriage set aside inherently contradicts the “ABC” (Abstain, Be faithful, and use Condoms) approach and additional directives of the program to be responsive to local epidemics, cultural norms, and general needs. Not surprisingly, this has led to confusion for in-country teams and their partners resulting in programming that is even more limited than Congress may have intended.

Condom Promotion Programs Marginalized

The report also confirmed fears that condoms are being increasingly marginalized due to the set aside and confusion about what activities. PEPFAR purports to apply a comprehensive “ABC” approach, but the policy actually splits-up the three elements to deliver certain messages and education to sub-populations. Information about correct condom use is only sanctioned for so-called “high risk groups.” Despite guidance issued by OGAC, country teams remain confused about who the U.S. government recognizes as “high-risk” and in what circumstances teaching about condoms and supplying them is permitted. Faced with ambiguous policies during a time when abstinence has become a hot button issue for policymakers in Washington , the report found that U.S. missions and contracting organizations are censoring themselves. For example, the GAO report cites that although a senior OGAC official reported broad condom social marketing is appropriate in certain situations, five focus country teams report that, in their understanding, PEPFAR funds may not be used for broad condom social marketing, even to adults in a generalized epidemic.4

In addition to the confusion over when and whether condom programs are appropriate, the requirement that a large portion of prevention funds be dedicated to abstinence-only-until-marriage programming has meant that there is simply less money available for comprehensive programming and condom social marketing. One country team reported limiting funding to provide comprehensive “ABC” messages to the general public, who are at risk for contracting HIV in a generalized epidemic but are not necessarily among the most-at-risk populations.5 In another country, the team reported that the spending requirement has complicated its efforts to address a condom shortage. 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.6 Another country team, in a country where the U.S. government has traditionally paid for the campaigns and a non-U.S. donor has paid to procure condoms, reported that it would likely have to reduce funding for condom social marketing.7

Poor Evaluation Methods

Despite claims of taking an evidence-based approach to prevention and seeking to meet concrete goals, the evaluation methods selected by OGAC fail to accurately measure the impact of U.S.-funded initiatives. In addition to concerns about the reliability of the data that will be used, the method fails to differentiate the effects of PEPFAR-funded programming from all other programming and cannot attribute changes in HIV prevalence rates to any specific intervention or to the success of particular types of programs.8 This means that the USG will get credit for all averted infections regardless of the number and range of programs supported locally or by other donors. It also means that the impact of one type of intervention versus others will go unmeasured. In particular, the true impact of abstinence promotion programs, which remain unproven, will not be revealed.

In the short-term, OGAC currently requires country teams to report the number of people reached with various interventions and the number of people trained to deliver programs and messages. This, of course, is not the same as measuring behavioral outcomes; it merely presents the scope of programming not its depth or success. OGAC is also funding “targeted evaluations on a very limited scale,” and in the sexual transmission prevention area, these evaluations will be carried out on a small sample of Abstinence and Be Faithful programs. An OGAC official admits, however, that these evaluations “will have limited use because of their small scale and the amount of time before results are available.”9

GAO Recommendations

Listening to the frustration of in-country teams of experts, the GAO initially recommended that the Secretary of State and the Global AIDS Coordinator should cease applying the abstinence-until-marriage spending requirement outside of the 15-focus countries but later revised its statement, calling for these officials to collect and report information on the abstinence-only-until-marriage spending requirement’s effects and use it to asses whether the requirement should be more narrowly applied. Further recommendations include that Congress use this information to assess how well the set-aside supports both the “ABC” model and strong abstinence programs.

William Smith , vice president for public policy at SIECUS cautions, “It is clear that OGAC and political operatives put a great deal of pressure on the GAO and provided push back at every turn. The GAO admits as much in the report.” Nevertheless, he calls the report “a good beginning.”

“This is the first and most comprehensive analysis that we have from on the ground sources that there are fundamental problems within PEPFAR and that the source of those problems is the layering of ideology and hyper-moralism over a program designed to address real and diverse human needs to stem HIV/AIDS,” he said.

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  1. Conversation with Heather Boonstra, Senior Public Policy Associate, Guttmacher Institute, 13 April 2006 .
  2. Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief, (Washington , DC : the U.S. Government Accountability Office, April 2006), accessed 20 April 2006 , <>.
  3. Ibid., 36.
  4. Ibid., 33.
  5. Ibid., 38.
  6. Ibid., 39.
  7. Ibid., 40.
  8. Ibid., 63-64.
  9. Ibid., 66.