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. 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. 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.

		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. In this report,  the term PEPFAR funding describes funds appropriated to these four  accounts in the 15 focus countries, as well as bilateral HIV/AIDS funding  in five additional countries. 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.   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. 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.

		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. 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 observed that “all three  elements of  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.

		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.)
The sexual transmission prevention program areas are focused as follows.  delay of first sexual activity,   secondary abstinence,   faithfulness in marriage and monogamous relationships,   reduction of sexual partners among sexually active unmarried   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.   (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 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   develop and strengthen integrated HIV/AIDS prevention, treatment, and   focus on rapid service delivery.

		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. Although PEPFAR is authorized  through fiscal year 2008, OGAC plans to reach its prevention goal by the  year 2010. 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. 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. 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.

	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. 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 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.)
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.)

		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.
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.)

		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.)   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.)
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.)

	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. 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  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   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 to spend at least 50 percent of their prevention funding 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.
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.
OGAC also directed country teams to apply the spending requirement to all  PEPFAR prevention funding (about $357 million in fiscal year 2006).  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. 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; 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. 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. 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.” 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. 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.
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  would  have required drastically reducing the PMTCT budget  $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— 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.)  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. 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.
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.

			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. OGAC officially approved exemptions  for the 10 country teams that requested them. As a result, all but one 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.   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  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  suggest a noticeable decline in “other prevention” funding between fiscal  year 2005, when the spending requirement was not mandatory, and fiscal  year 2006. 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).
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 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. 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  http://www.gao.gov. If you or your staff have any questions, please contact  me at (202) 512-3149 or 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.

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. 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; 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); 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.  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.

AB and “Other Prevention” Programs in Four Focus Countries

Fiscal year 2005 program descriptions 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.

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 faifthful.
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.

	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. 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. The group  assessed alternative modeling approaches and initially considered the  Goals Model (developed by the Futures Group) 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. 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. 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.

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. At the conclusion of the reviews, OGAC  submits a notification to the relevant congressional committees, informing  them of the activities it plans to implement under PEPFAR in the current  fiscal year. 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, 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.

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 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, 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,” 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. 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.
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.

Joint Comments from State, USAID, and HHS

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.

GAO Contact and Staff Acknowledgments

	GAO Contact

	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.

Summary:
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.