a

GAO

United States Government Accountability Office

Report to Congressional Committees

April 2006 GLOBAL HEALTH

Spending Requirement 

Presents Challenges 

for Allocating 

Prevention Funding 

under the President’s 

Emergency Plan for 

AIDS Relief

GAO-06-395
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

April 2006

GLOBAL HEALTH

Spending Requirement Presents 

Challenges for Allocating Prevention 

Funding under the President's 

Emergency Plan for AIDS Relief 

Highlights of GAO-06-395, a report to 

congressional committees 

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-untilmarriage. The Office of the U.S.

Global AIDS Coordinator (OGAC)

is responsible for administering

PEPFAR. GAO reviewed PEPFAR 

prevention funds, described 

PEPFAR’s strategy to prevent 

sexual HIV transmission, and 

examined related challenges. 

In fiscal years 2004-2006, the PEPFAR prevention budget increased by 

almost 55 percent, from $207 million to $322 million. During this time, the 

prevention share of the total PEPFAR budget fell from 33 to 20 percent, 

consistent with the Leadership Act’s recommendation that 20 percent of 

funds appropriated pursuant to the act should support prevention. 

The PEPFAR strategy for preventing sexual transmission of HIV is largely 

shaped by the ABC model and the abstinence-until-marriage spending 

requirement. In addition to adopting the ABC model, OGAC developed 

guidance for applying it—stating, for instance, that prevention interventions 

should be integrated and respond to local epidemiology and cultural norms. 

OGAC also established policies for applying the spending requirement for 

fiscal year 2006. To meet the 33 percent spending requirement, it mandated 

that country teams—PEPFAR officials in the field—spend half of prevention 

funds on sexual transmission prevention and two-thirds of those funds on 

abstinence/faithfulness (AB) activities. At the same time, OGAC permitted 

certain teams, especially those with relatively small budgets, to seek waivers 

from this policy to help them respond to local prevention needs. OGAC also 

applied the spending requirement to all PEPFAR prevention funding as a 

matter of policy, although it determined that, as a matter of law, it applies 

only to funds appropriated to the Global HIV/AIDS Initiative account. 

OGAC’s ABC guidance and the abstinence-until-marriage spending 

requirement, including OGAC’s policies for implementing it, have presented 

challenges for country teams. First, although most teams found the ABC 

guidance generally clear, two-thirds reported that ambiguities in some parts 

of the guidance led to uncertainty about implementing the model. OGAC 

officials told GAO that they plan to clarify the guidance. Second, although 

several teams told GAO that they value the ABC model and emphasize AB 

messages for certain populations, teams also reported that the spending 

requirement can limit their efforts to design prevention programs that are

integrated and responsive to local prevention needs. Seventeen of 20 country 

teams reported that fulfilling the spending requirement, including OGAC’s 

policies implementing it, presents challenges to their ability to respond to 

local prevention needs. Ten of these teams (primarily those with smaller 

PEPFAR budgets) received exemptions from the requirement, allowing them 

to dedicate less than 33 percent of prevention funds to AB activities. In 

general, the nonexempted teams were effectively required to spend more 

than 33 percent of prevention funds on AB activities; as a result, OGAC 

should just meet the overall 33 percent spending requirement for fiscal year 

2006. However, to meet the requirement, nonexempted country teams have, 

in some cases, reduced or cut funding for certain prevention programs, such 

as programs to deliver comprehensive ABC messages to populations at risk 

of contracting HIV. Finally, OGAC’s decision to apply the spending 

requirement to all PEPFAR prevention funds may further challenge teams’ 

ability to address local prevention needs. 

What GAO Recommends

GAO recommends that the 

Secretary of State direct the Global

AIDS Coordinator to collect and 

report information on the 

abstinence-until-marriage spending 

requirement’s effects and use it to

assess whether the requirement 

should apply only to the Global 

HIV/AIDS Initiative account. GAO 

also suggests that Congress use the 

information to assess how well the 

requirement supports the 

Leadership Act’s endorsement of

both the ABC model and strong 

abstinence programs. OGAC agreed

regarding collecting information 

but disagreed with applying the 

requirement only to certain funds. 

We modified our recommendation

in light of this concern. 

www.gao.gov/cgi-bin/getrpt?GAO-06-395.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact David Gootnick 

at (202) 512-3149 or gootnickd@gao.gov. 
Page i GAO-06-395 Global HIV/AIDS Prevention

Contents

Letter 1

Results in Brief 3

Background 8

PEPFAR Prevention Funding in the 15 Focus Countries Grew 

Significantly during First 3 Years 19

PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC 

Approach, Abstinence-Until-Marriage Spending Requirement, and 

Local Prevention Needs 26

ABC Guidance and Abstinence-Until-Marriage Spending 

Requirement Present Challenges for Country Teams 31

Conclusions 44

Recommendation for Executive Action 45

Matters for Congressional Consideration 46

Agency Comments and Our Evaluation 46

Appendixes

Appendix I: Scope and Methodology 50

Appendix II: AB and “Other Prevention” Programs in Four Focus 

Countries 54

Appendix III: Prevention Program Indicators and Methods of Measuring 

PEPFAR Prevention Program Results 62

Appendix IV: PEPFAR Planning and Reporting Process 67

Appendix V: Methods for Reporting Allocations among PEPFAR 

Prevention Program Areas 69

Appendix VI: Joint Comments from State, USAID, and HHS 73

GAO Comments 84

Appendix VII: GAO Contact and Staff Acknowledgments 87

Figures Figure 1: Stage of the AIDS Epidemic in PEPFAR Focus 

Countries 10

Figure 2: Selected Spending Recommendations and Requirements 

for Fiscal Years 2006-2008 Contained in the 2003 

Leadership Act 12

Figure 3: PEPFAR Prevention Program Areas 15

Figure 4: Total PEPFAR Prevention Funding in the 15 Focus 

Countries, Fiscal Years 2004-2006 20
Contents

Page ii GAO-06-395 Global HIV/AIDS Prevention

Figure 5: PEPFAR Prevention Funding, by Focus Country, Fiscal 

Years 2004-2006 21

Figure 6: Proportion of PEPFAR Funding Dedicated to Prevention 

in the 15 Focus Countries, Fiscal Years 2004-2006 22

Figure 7: Proportion of PEPFAR Funding Dedicated to Prevention, 

by Focus Country, Fiscal Years 2004-2006 23

Figure 8: Reported Allocation of Focus Countries’ Total PEPFAR 

Prevention Funding by Each Prevention Program Area, 

Fiscal Years 2004-2006 24

Figure 9: Percentage of Reported Fiscal Year 2005 PEPFAR Sexual 

Transmission Prevention Funding Allocated to 

Abstinence/Faithfulness and “Other Prevention” by Each 

Focus Country Team 25

Figure 10: Illustration of a Country Team’s Prevention Funding 

Allocated According to OGAC’s Policies Implementing 

the Abstinence-Until-Marriage Spending Requirement 29

Figure 11: Prevention Allocations for Nonexempted and Exempted 

Focus Country Teams, Fiscal Years 2005 and 2006 43

Figure 12: OGAC Planning and Reporting Requirements for Fiscal 

Years 2005 and 2006 68
Contents

Page iii GAO-06-395 Global HIV/AIDS Prevention

Abbreviations

AB abstinence/faithfulness

ABC Abstain, Be faithful, or use Condoms

COPRS Country Operational Plan and Reporting System

GHAI Global HIV/AIDS Initiative 

HHS/CDC Department of Health and Human Services—Centers for 

Disease Control and Prevention

NGO nongovernmental organization

OGAC Office of the U.S. Global AIDS Coordinator

PEPFAR President’s Emergency Plan for AIDS Relief

PMTCT prevention of mother-to-child transmission

UNAIDS Joint United Nations Programme for HIV/AIDS

USAID U.S. Agency for International Development

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately.
Page 1 GAO-06-395 Global HIV/AIDS Prevention

United States Government Accountability Office

Washington, D.C. 20548

A

April 4, 2006 Letr

Congressional Committees

In January 2003, citing the need “to meet a severe and urgent crisis abroad,” 

President Bush announced his Emergency Plan for AIDS Relief (PEPFAR), 

a $15 billion, 5-year initiative to combat the global HIV/AIDS epidemic 

through prevention, treatment, and care interventions. This initiative 

represented a significant increase in U.S. funding for HIV/AIDS. Prior to 

PEPFAR, the United States had committed to provide $5 billion to bilateral 

HIV/AIDS initiatives; under PEPFAR, the total financial U.S. commitment 

increased by nearly $10 billion, with $9 billion1

 targeted to HIV/AIDS 

initiatives in 15 focus countries.2 PEPFAR’s primary prevention goal is to 

avert 7 million HIV infections in these countries—where heterosexual 

intercourse is generally the primary mode of transmission—by the year 

2010. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act 

of 20033

 (Leadership Act), which authorizes PEPFAR, endorses using the 

“ABC model” (Abstain, Be faithful, or use Condoms) to prevent the sexual 

transmission of HIV and establishes the Global HIV/AIDS Initiative (GHAI) 

account. The act also recommends that 20 percent of funds appropriated 

pursuant to the act be dedicated to HIV/AIDS prevention and requires that, 

beginning in fiscal year 2006, at least 33 percent of prevention funds 

appropriated pursuant to the act be spent on abstinence-until-marriage 

programs. Finally, the act provides for the establishment of an HIV/AIDS 

Coordinator within the Department of State (State) to lead the U.S. 

response to the HIV/AIDS epidemic and oversee all U.S. efforts to

1

The remaining $1 billion was intended for the Global Fund to Fight HIV/AIDS, Tuberculosis, 

and Malaria (the Global Fund).

2

The President named the following 14 focus countries in 2003: Botswana, Cote d’Ivoire, 

Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, 

Tanzania, Uganda, and Zambia. Vietnam was added as the fifteenth focus country in June 

2004. 

3

Pub. L. No. 108-25.
Page 2 GAO-06-395 Global HIV/AIDS Prevention

combat HIV/AIDS abroad.4 Since its establishment in January 2004, State’s 

Office of the U.S. Global AIDS Coordinator (OGAC) has defined five 

HIV/AIDS prevention program areas—abstinence/faithfulness (AB), “other 

prevention,” prevention of mother-to-child transmission (PMTCT), safe 

medical injections, and blood safety5

—and defined abstinence-untilmarriage programs as AB activities. 

Responding to broad-based congressional interest in HIV/AIDS prevention 

efforts under PEPFAR, in this report we (1) review trends and allocation of 

PEPFAR prevention funding, (2) describe the PEPFAR strategy for 

preventing the sexual transmission of HIV, and (3) examine key challenges 

associated with applying the PEPFAR sexual transmission prevention 

strategy. We conducted this review under the Comptroller General’s 

authority.

To address these objectives, we reviewed documents such as the PEPFAR 

5-year strategy,6

 first annual report to Congress, and fiscal year 2004 

operational plan; operational plans and annual and midyear progress 

reports provided by U.S. agency officials responsible for managing 

PEPFAR in the focus countries (focus country teams); PEPFAR guidance 

to the field; and budget documents provided by OGAC. In addition, we 

interviewed U.S.-based officials from OGAC, USAID, and the Department 

of Health and Human Services–Centers for Disease Control and Prevention 

(HHS/CDC), as well as several Washington, D.C.-based nongovernmental 

organizations (NGOs). We also conducted structured interviews between 

June 2005 and January 2006 with key State, USAID, HHS/CDC, and other 

4

The U.S. agencies primarily responsible for implementing PEPFAR are the Department of 

State; the U.S. Agency for International Development (USAID); and the Department of 

Health and Human Services (HHS). Other agencies involved in PEPFAR are the Department 

of Defense, the Peace Corps, and the Departments of Labor and Commerce.

5

Abstinence/faithfulness and “other prevention” funds generally are aimed at preventing the 

sexual transmission of HIV, while funds in the other three categories are aimed at preventing 

nonsexual transmission. “Other prevention” includes activities such as programs for highrisk groups to increase their awareness of HIV/AIDS prevention behaviors and their access 

to HIV prevention services, such as condom promotion and distribution; condom social 

marketing; substance abuse prevention programs; management and treatment of sexually 

transmitted infections; and messages or programs to reduce injection drug use and related 

risks. In its Second Annual Report to Congress, released February 2006, OGAC began 

referring to these activities as “condoms and related prevention activities.” 

6

“The President’s Emergency Plan for AIDS Relief U.S. Five-Year Global HIV/AIDS Strategy,” 

Feb. 23, 2004.
Page 3 GAO-06-395 Global HIV/AIDS Prevention

U.S. agency staff in the 15 focus countries.7 We conducted 11 of these 

structured interviews over the telephone and 4 during site visits. We visited 

Botswana, Ethiopia, South Africa, and Zambia in July 2005, selecting this 

targeted sample of focus countries based on criteria such as level of 

PEPFAR funding, HIV prevalence rate,8

 and prevention focus. In the 

countries that we visited, we interviewed key U.S. government officials, 

host country government officials, NGOs, faith-based organizations, local 

community-based organizations, and program beneficiaries. We also 

requested information from five additional PEPFAR country teams9

regarding their PEPFAR funding, the process of developing country 

operational plans, and the effects, if any, of the abstinence-until-marriage 

spending requirement on their prevention programming; we received 

responses from two of the five country teams. (See app. I for a detailed 

description of our scope and methodology.) In general, we found the data 

on PEPFAR prevention funding, with the exception of data on spending 

allocations among certain prevention program areas, sufficiently reliable 

for the purposes of our engagement. We conducted our work from 

February 2005 to February 2006 in accordance with generally accepted 

government auditing standards. 

Results in Brief PEPFAR prevention funding10 in the 15 focus countries grew by more than 

40 percent between fiscal years 2004 and 2005 and by an additional 10 

percent between 2005 and 2006, rising from $207 million in fiscal year 2004 

7

These officials spoke with us with the understanding that individual respondents and the 

countries where they serve would not be named in our discussion of the structured 

interviews.

8

HIV prevalence represents the percentage of the population that is estimated to be HIV 

positive. Estimates of HIV prevalence are often based on surveillance of pregnant women in 

prenatal clinics or population-based surveys. In contrast, HIV incidence refers to the 

number of new infections over a period of time (usually 1 year). 

9

These countries are Cambodia, India, Malawi, Russia, and Zimbabwe. Each of these 

country teams receives at least $10 million in U.S. government funding for HIV/AIDS and is 

therefore required to submit an operational plan to OGAC each fiscal year, starting in fiscal 

year 2006. 

10As discussed on page 11, PEPFAR prevention funding is defined for the purposes of this 

report as funding appropriated to four accounts in the 15 PEPFAR focus countries, as well 

as bilateral HIV/AIDS funding in the five additional PEPFAR countries. Funding data for 

fiscal years 2004 and 2005 are actual, while funding data for fiscal year 2006 are planned 

funding for activities that have not yet been approved by OGAC. 
Page 4 GAO-06-395 Global HIV/AIDS Prevention

to $322 million in fiscal year 2006. At the same time, consistent with the 

Leadership Act’s recommendation that 20 percent of funds appropriated 

pursuant to the act be spent on prevention, the prevention portion of total 

PEPFAR funding in the 15 focus countries declined from 33 to 20 percent. 

The proportion of focus countries’ total PEPFAR prevention funding 

allocated to each of the five nonsexual and sexual transmission prevention 

program areas varied during fiscal years 2004-2006, and focus country 

teams reported allocating varying amounts for sexual transmission 

prevention programs in fiscal year 2005. However, there are limitations in 

the reliability of these reported allocations because of challenges and 

inconsistencies in country teams’ categorization of funding for certain ABC 

programs and some broad sexual transmission prevention activities. 

The PEPFAR strategy for preventing sexual transmission of HIV is largely 

shaped by three elements: the ABC model, the Leadership Act’s abstinenceuntil-marriage spending requirement, and local prevention needs in the 

PEPFAR countries. 

• In developing the PEPFAR sexual transmission prevention strategy, 

OGAC adopted the ABC model, endorsed by the Leadership Act, as an 

effective method for preventing HIV/AIDS. In addition, to guide country 

teams’ application of the ABC model, OGAC identified general 

principles for the teams to consider in developing and implementing 

PEPFAR ABC programs—stating, for example, that prevention 

interventions should be responsive to characteristics of the epidemic in 

their country and integrated, so that prevention messages are 

harmonized at the community level. OGAC’s guidance regarding the 

ABC model (ABC guidance) also outlined the types of activities that can 

be funded through PEPFAR and directed country teams to emphasize 

different components of the ABC model for various target populations. 

• The PEPFAR sexual transmission prevention strategy reflects the 

Leadership Act’s requirement that, beginning in fiscal year 2006, at least 

33 percent of prevention funds appropriated pursuant to the act support 

abstinence-until-marriage programs.11 To ensure compliance with the 

spending requirement, OGAC established policies in August 2005 

implementing the requirement. These policies directed 20 country 

11Although the spending requirement did not take effect until fiscal year 2006, OGAC 

encouraged country teams to dedicate 33 percent of total prevention funds to AB activities 

in fiscal years 2004 and 2005, consistent with the Leadership Act’s recommendation to do so.
Page 5 GAO-06-395 Global HIV/AIDS Prevention

teams12 to dedicate at least 50 percent of prevention funding to sexual 

transmission prevention activities (50 percent policy) and 66 percent of 

that amount to AB activities (66 percent policy) starting in fiscal year 

2006. OGAC also instructed the teams to isolate AB spending in their 

annual reports to demonstrate adherence to the spending requirement. 

In addition, OGAC allowed certain country teams to submit 

justifications requesting exemption from its policies implementing the 

spending requirement. Finally, OGAC applied the spending requirement 

to all PEPFAR prevention funding13 (about $357 million in fiscal year 

2006) as a matter of policy, although it determined that, as a matter of 

law, the requirement applies only to funds appropriated to the GHAI 

account (about $322 million for prevention in fiscal year 2006). 

• Working within the parameters of the ABC model and the abstinenceuntil-marriage spending requirement, country teams design prevention 

programs that respond to the countries’ prevention needs. For example, 

country teams reserve funding for AB activities to comply with the 

spending requirement and take steps to allocate their prevention funds 

according to factors such as the average age when sexual activity begins 

in their respective countries. 

OGAC’s ABC guidance and the Leadership Act’s abstinence-until-marriage 

spending requirement have presented several challenges to country teams. 

• Lack of clarity in the ABC guidance has created challenges for a 

majority of focus country teams. Although a number of the teams told us 

that they found the guidance clear or easy to implement, 10 of the 15 

focus country teams cited instances where elements of the guidance 

were ambiguous and confusing, leading to difficulties in its 

interpretation and implementation. For example, although the guidance 

restricts activities promoting condom use, it does not clearly delineate 

the difference between condom education and condom promotion, 

causing uncertainty over whether certain condom-related activities are 

permissible. OGAC officials acknowledged that certain components of 

the guidance can be confusing and told us that they are working to 

12These 20 country teams are the 15 focus country teams and the 5 additional teams that 

receive at least $10 million in PEPFAR funding. 

13As shown on page 11, PEPFAR prevention funding is defined for the purposes of this 

report as funding appropriated to four accounts in the 15 PEPFAR focus countries, as well 

as bilateral HIV/AIDS funding in the five additional PEPFAR countries. 
Page 6 GAO-06-395 Global HIV/AIDS Prevention

clarify them. They also provided a document—distributed to country 

teams in August 2005—that aims to address some of the concerns that 

country teams identified. OGAC plans to update this document each 

fiscal year, based on country teams’ feedback about implementing the 

ABC guidance. 

• Satisfying the Leadership Act’s abstinence-until-marriage spending 

requirement presents challenges to most country teams. Several focus 

country teams indicated that they value the ABC model as an HIV/AIDS 

prevention tool and noted the importance of AB messages, particularly 

for certain populations. However, about half of the focus country teams 

told us that meeting the spending requirement can undermine the 

integration of prevention programs by forcing them to isolate funding 

for AB activities. Further, 17 of the 20 PEPFAR teams required to meet 

the spending requirement unless they obtain exemptions from it 

reported that the spending requirement presents challenges to their 

ability to respond to local epidemiology and cultural and social norms. 

As permitted under OGAC’s policies, 10 of these 17 teams requested 

exemption from the spending requirement, citing a variety of constraints 

related to meeting it, such as reduced spending for PMTCT and limited 

funding for prevention messages to high-risk groups. Although the 

remaining 7 country teams did not request exemptions (they did not 

meet OGAC’s proposed criteria for submitting requests), they also 

identified specific program constraints related to meeting the spending 

requirement, such as cuts in PMTCT services or reduced funding for 

prevention programs aimed at HIV-positive individuals.14 Despite 

approving the 10 exemption requests, OGAC should just meet the 

overall spending requirement specified by the Leadership Act for fiscal 

year 2006 by effectively requiring teams that do not request exemptions 

to, in most cases, spend more than the 33 percent of prevention funds on 

AB activities. Although exempted country teams avoid, to some degree, 

the challenges they identified related to meeting the spending 

requirement, teams that are not exempted from the requirement must 

sometimes reduce or cut funding for certain prevention programs. For 

example, one country team told us that, to meet the spending 

requirement, it had to limit funding for comprehensive ABC messages to 

populations at risk of contracting HIV. Our analysis shows that for 

exempted country teams, total planned prevention funds dedicated to 

14These programs aim to prevent transmission of HIV from infected individuals to 

uninfected individuals. 
Page 7 GAO-06-395 Global HIV/AIDS Prevention

“other prevention” increased by approximately $700,000 between fiscal 

years 2005 and 2006, remaining at about 21 percent of their total 

prevention funding in each fiscal year. For nonexempted country teams, 

total planned prevention funds dedicated to “other prevention” declined 

by approximately $5 million—from about 23 percent of overall planned 

prevention funds in fiscal year 2005 to about 18 percent in fiscal year 

2006. Finally, OGAC’s decision to apply the spending requirement to all 

PEPFAR prevention funding may further constrain some country teams’ 

ability to respond to local prevention needs. For example, this policy 

prevents one country team from funding certain condom social 

marketing programs with $1.5 million in non-GHAI funding, despite its 

having reduced funding for those programs to comply with the 

abstinence-until-marriage spending requirement. 

In light of reported challenges presented by the abstinence-until-marriage 

spending requirement, we are recommending that the Secretary of State 

direct the U.S. Global AIDS Coordinator to collect and report to Congress 

information from the country teams about the spending requirement’s 

effect on their prevention programming and use that information to, among 

other things, consider whether the Leadership Act’s abstinence-untilmarriage spending requirement should be applied only to funds 

appropriated to the Global HIV/AIDS Initiative account. We are also 

suggesting that, in light of this information, Congress should assess the 

extent to which the spending requirement supports the Leadership Act’s 

endorsement of both the ABC model and strong abstinence-until-marriage 

programs. 

We provided a draft of this report to the Department of State/OGAC, HHS, 

and USAID. In commenting jointly on our report, the agencies reiterated 

their strong commitment to fight HIV/AIDS, stating that “only a vigorous 

and comprehensive prevention approach will turn the tide against the 

global HIV/AIDS pandemic.” Consistent with our report’s discussion, they 

also noted the importance of the ABC model in preventing sexual 

transmission of HIV. Regarding our finding that interpreting and 

implementing the ABC guidance has created challenges for most of the 

focus country teams, the agencies commented that they are committed to 

continually improving efforts to communicate policy to the field. The 

agencies expressed appreciation for our report’s findings regarding difficult 

trade-offs that country teams have had to make with respect to funding for 

prevention activities and agreed with our recommendation to collect 

information regarding the effects of the Leadership Act’s abstinence-untilmarriage spending requirement. They disagreed with our recommendation 
Page 8 GAO-06-395 Global HIV/AIDS Prevention

regarding applying the abstinence-until-marriage spending requirement 

only to funds appropriated to the GHAI account, stating that doing so 

would limit their ability to use a unified budget approach and would have 

little impact, given the small amount of non-GHAI funding that the focus 

country teams receive. We recognize that allowing country teams to apply 

the spending requirement solely to GHAI funds entails some trade-offs. 

Given the agencies’ concerns about maintaining a unified budget approach, 

we have modified our recommendation to recommend that they consider 

this policy change after collecting information on the effect of the spending 

requirement. With respect to the non-GHAI funding amounts, we would 

note that the five additional countries required, absent exemptions, to meet 

the spending requirement receive more than 80 percent of their funds 

through non-GHAI accounts. Thus, we believe that our modified 

recommendation is warranted. Finally, OGAC and USAID also provided 

technical comments on the draft, which we have incorporated as 

appropriate. 

Background Each day, an estimated 13,400 people worldwide are newly infected with 

HIV; more than 20 million have died from AIDS since 1981. HIV is 

transmitted both sexually (through sexual intercourse with an infected 

person) and nonsexually (through the sharing of needles or syringes with 

an infected person; unsafe blood transfusions; or the passing of the virus 

from mother to child during pregnancy, childbirth, or breastfeeding). 

However, the majority of HIV infections worldwide are transmitted 

sexually.15 About two-thirds of the estimated 40 million people currently 

living with HIV/AIDS are in sub-Saharan Africa where, according to the 

Joint United Nations Programme on HIV/AIDS (UNAIDS), adult HIV 

prevalence averaged 7.4 percent in 2004. 

15According to the World Bank, more than three-quarters of HIV infections in developing 

countries are transmitted through sexual intercourse. Heterosexual intercourse is the 

primary mode of transmission in 14 of the 15 PEPFAR focus countries. Intravenous drug-use 

is the primary mode of transmission in Vietnam. World Bank estimates show that about 15 

to 20 percent of all HIV infections in Africa occur through mother-to-child transmission. In 

developing countries, on average, blood transfusions account for less than 10 percent of HIV 

infections, and medical injections with dirty needles are thought to account for about 5 

percent of all HIV infections.
Page 9 GAO-06-395 Global HIV/AIDS Prevention

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.16 Figure 1 shows that although 

the epidemic in some focus countries is concentrated in certain 

populations, in other focus countries it has spread among the general 

population.

16According to the World Health Organization, girls and young women in Kenya are 

particularly vulnerable to HIV infection. In that country, women aged 15-24 are more than 

twice as likely to be infected as men in this age group. In Rwanda, however, the groups with 

evidence of the highest infection rates include sex workers, as well as men attending clinics 

that offer treatment for sexually transmitted infections. 
Page 10 GAO-06-395 Global HIV/AIDS Prevention

Figure 1: Stage of the AIDS Epidemic in PEPFAR Focus Countries

Note: According to UNAIDS and the World Health Organization, a concentrated epidemic is defined as 

one in which HIV has infected at least 5 percent of individuals in defined subpopulations but is not wellestablished in the general population. In a generalized epidemic, HIV has spread among the general 

population, infecting at least 1 percent. 

Guyana

Cote d’Ivoire

Nigeria

Ethiopia

Kenya

Tanzania

Zambia

Namibia

Botswana

South Africa

Mozambique

Vietnam

Haiti

Rwanda

Uganda

Sources: World Bank (data), supplemented by information provided by OGAC and USAID; MapArt (image).

Concentrated

Generalized
Page 11 GAO-06-395 Global HIV/AIDS Prevention

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.17 In this report, 

the term PEPFAR funding describes funds appropriated to these four 

accounts18 in the 15 focus countries, as well as bilateral HIV/AIDS funding 

in five additional countries.19 For fiscal years 2004 and 2005, total PEPFAR 

funding consists of central and country-level actual appropriations 

allocated by OGAC for prevention, care, and treatment activities. Similarly, 

PEPFAR prevention funding for these fiscal years consists of central and 

country-level actual appropriations allocated by OGAC for prevention 

activities (AB, blood safety, PMTCT, safe medical injections, and “other 

prevention”). For fiscal year 2006, total PEPFAR funding consists of 

planned central and country-level PEPFAR funding for prevention, care, 

and treatment activities that have not yet been approved by OGAC.20 

PEPFAR prevention funding for fiscal year 2006 consists of planned central 

and country-level PEPFAR funding for prevention activities that have not 

yet been approved by OGAC. 

17The remaining $1.5 billion was appropriated for, among other initiatives, the Global Fund 

to Fight HIV/AIDS, Tuberculosis and Malaria (the Global Fund) and international HIV/AIDS 

research through the National Institutes of Health. The Global Fund is a multilateral, 

nonprofit, public-private mechanism to rapidly disburse grants to augment existing 

spending on the prevention and treatment of HIV/AIDS, tuberculosis, and malaria while 

maintaining sufficient oversight of financial transactions and program effectiveness. (See 

GAO, Global Health: Global Fund to Fight AIDS, TB and Malaria Has Advanced in Key 

Areas, but Difficult Challenges Remain, GAO-03-601 [Washington, D.C.: May 7, 2003]).

18The PMTCT account expired at the end of fiscal year 2004, but some country teams carried 

over PMTCT funds from fiscal year 2004 to fiscal year 2005. Therefore, for fiscal year 2006, 

this report defines PEPFAR funding as funds appropriated to the remaining three accounts. 

Although the PMTCT account expired, OGAC continues to fund PMTCT activities through 

the other funding accounts. 

19Others have used PEPFAR funding to describe all U.S. government funds dedicated to 

combating HIV/AIDS worldwide, including funds such as U.S. contributions to the Global 

Fund.

20According to OGAC officials, focus country teams received an additional $150 million in 

fiscal year 2006 “plus-up” funding for prevention, treatment, and care activities in January 

2006. Fiscal year 2006 funding figures are likely to change slightly throughout the fiscal year, 

as country teams make adjustments to their funding allocations. Data on fiscal year 2006 

planned PEPFAR prevention funding are current as of March 15, 2006.
Page 12 GAO-06-395 Global HIV/AIDS Prevention

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.21 The act also requires that, 

beginning in fiscal year 2006, at least 55 percent of funds appropriated 

pursuant to the act be spent on treatment and at least 10 percent on 

orphans and vulnerable children. (See fig. 2.) See page 14 for information 

on additional spending recommendations and requirements specifically 

related to prevention funds. 

Figure 2: Selected Spending Recommendations and Requirements for Fiscal Years 

2006-2008 Contained in the 2003 Leadership Act

21According to the PEFPAR 5-year HIV/AIDS strategy, palliative care includes routine 

clinical care to evaluate the need for symptom relief (e.g., from diarrhea or headache); 

treatment for HIV/AIDS related diseases such as tuberculosis and opportunistic infections; 

preparing people for antiretroviral therapy, where possible; and, when treatment is not 

available or has failed, compassionate end-of-life care.

Treatment

Prevention

Palliative care

Orphans and vulnerable children

10%

15%

20%

55%

Source: GAO analysis of 2003 Leadership Act.

Recommended

Required
Page 13 GAO-06-395 Global HIV/AIDS Prevention

ABC Model and AbstinenceUntil-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 2001.22 Although substantial debate 

exists about the extent to which each component of the model is 

responsible for reducing HIV prevalence in individual countries, there is 

general consensus that using the ABC model can have a positive impact in 

combating HIV/AIDS. In November 2004, a key consensus statement 

authored by eight leading public health experts23 observed that “all three 

elements of [the ABC model] are essential to reducing HIV incidence, 

although the emphasis placed on individual elements needs to vary 

according to the target population.” For example, it noted that “for those 

who have not started sexual activity the first priority should be to 

encourage abstinence or delay of sexual onset” and, “when targeting 

sexually active adults, the first priority should be to promote mutual 

fidelity with an uninfected partner as the best way to assure avoidance of 

HIV infection.” Finally, according to the document, “all people should have 

accurate and complete information about different prevention options, 

including all three elements of the ABC approach.” The statement was 

signed by more than 125 prominent figures, including the President of 

Uganda; the Archbishop of the Anglican Church of South Africa; officials 

from UNAIDS, the World Health Organization, and the World Bank; and 

dozens of other academics, representatives of faith-based groups, and 

public health advocates. In promoting the ABC model, the Leadership Act 

authorizes prevention activities that provide information on delaying 

sexual debut; abstinence; fidelity and monogamy; reduction of casual 

sexual partnering; reducing sexual violence and coercion, including child 

22In 1986, the Ugandan government launched a nationwide information, education, and 

communication tour to encourage Ugandans to abstain from sex until marriage, remain 

faithful to one partner (termed “zero-grazing”), and use condoms when necessary. 

According to the U.S. Census Bureau and UNAIDS, national HIV/AIDS prevalence in Uganda 

fell from about 15 percent in the early 1990s to 5 percent in 2001. 

23Cates, Willard; Cassell, Michael M.; Gayle, Helene D.; Green, Edward C.; Halperin, Daniel 

T.; Hearst, Norman; Kirby, Douglas; and Steiner, Markus J. “The Time Has Come for 

Common Ground on Preventing Sexual Transmission of HIV,” Lancet: Vol. 364, Nov. 27, 

2004. 
Page 14 GAO-06-395 Global HIV/AIDS Prevention

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.24

PEPFAR Prevention 

Program Areas

The five PEPFAR prevention program areas—abstinence/faithfulness (AB), 

blood safety, prevention of mother-to-child transmission (PMTCT), safe 

medical injections, and other prevention—are divided into two groups: 

those aimed at preventing sexual transmission and those aimed at 

preventing nonsexual transmission of the disease. (See fig. 3.)

24Office of the U.S. Global AIDS Coordinator, Appendix 2: The Emergency Plan for AIDS 

Relief: Fiscal Year 2004 Prevention Expenditures and Program Classification Criteria

(Washington, D.C.: U.S. Department of State, 2004). 
Page 15 GAO-06-395 Global HIV/AIDS Prevention

Figure 3: PEPFAR Prevention Program Areas

The sexual transmission prevention program areas are focused as follows.

• AB activities encourage 

• abstinence until marriage, 

• delay of first sexual activity, 

• secondary abstinence,25

25According to OGAC, secondary abstinence is for unmarried youths who have already 

engaged in sexual intercourse.

Sexual transmission prevention programs

Nonsexual transmission prevention programs

Source: GAO analysis of OGAC’s fiscal year 2006 Country Operational Plan Guidance.

AB: activities to 

encourage abstinence 

and fidelity.

Other prevention: 

condom activities, 

management of 

sexually transmitted 

infections, reduction 

of injection drug use.

Blood safety: efforts to 

establish national 

blood collection and 

transfusion services.

Safe medical 

injections: technical 

assistance and 

training to increase 

the use of safe 

injection practices.

PMTCT: activities

to prevent HIV 

transmission from 

mother to child.
Page 16 GAO-06-395 Global HIV/AIDS Prevention

• faithfulness in marriage and monogamous relationships, 

• reduction of sexual partners among sexually active unmarried 

persons, and

• social and community norms related to the above practices. 

“Other prevention” activities include the 

• purchase and promotion of condoms,

• management of sexually transmitted infections (if not in a palliative 

care setting), and

• messages or programs to reduce injection drug use and related 

risks.26 

(See app. II for examples of AB and “other prevention” programs that are 

being implemented under PEPFAR. For information on the organizations 

that have implemented sexual transmission prevention programs under 

PEPFAR, see 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/AIDSrelated 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. 

26According to OGAC, “[intravenous drug use] prevention was included under sexual 

prevention because it falls within [PEPFAR’s] category of "other prevention," i.e. other 

prevention that is not abstinence and be faithful (e.g., women in prostitution, truckers, men 

who have sex with men, etc).”
Page 17 GAO-06-395 Global HIV/AIDS Prevention

OGAC’s Key Strategic 

Principles

OGAC’s overall strategic cornerstones and principles, laid out in its 5-year 

global HIV/AIDS strategy for PEPFAR, include commitments to

• respond with urgency to the crisis; 

• make policy decisions that are evidence based;

• demand accountability for results; 

• implement programs that are suited to local needs and host government 

policies;

• develop and strengthen integrated HIV/AIDS prevention, treatment, and 

care services; and 

• focus on rapid service delivery.27 

OGAC’s Prevention Target 

for PEPFAR

OGAC’s 5-year strategy states the PEPFAR prevention goal—announced by 

the President and repeated in the Leadership Act—of averting 7 million 

infections in the 15 focus countries.28 Although PEPFAR is authorized 

through fiscal year 2008, OGAC plans to reach its prevention goal by the 

year 2010.29 This prevention goal is cumulative; that is, infections averted in 

2004 through 2009 will count toward the final total of infections averted by 

2010. In addition, this goal is to be reached both through PEPFAR activities 

and through interventions by other donors and the host nations. (See app. 

III for a discussion of OGAC’s indicators, models, and method for 

measuring infections averted, including the challenges that OGAC faces in 

measuring infections averted and, thus, in assessing the success of its 

prevention activities.)

27The field of HIV/AIDS prevention also involves longer-term, research-oriented initiatives, 

such as research for vaccines and microbicides. 

28President Bush also established goals of treating at least 2 million people with lifeextending drugs and providing humane care for millions of people suffering from AIDS and 

for children orphaned by AIDS. OGAC has stated that its goal is to provide care for 10 

million people in the 15 focus countries. 

29In contrast, OGAC aims to reach the PEPFAR care and treatment goals by 2008.
Page 18 GAO-06-395 Global HIV/AIDS Prevention

PEPFAR Awards Process PEPFAR funding for the 15 focus countries is allocated both centrally and 

at the country level.30 Central awards are multicountry awards that are 

managed by U.S. agency headquarters in Washington, D.C. These one-time, 

5-year awards are intended to increase funding for program activities with 

high levels of congressional interest and minimal existing activities in the 

field.31 Country-level awards are managed by the focus country teams. 

Each year, to receive country-level funding for the coming fiscal year, 

country teams submit budgets, or “operational plans,” to OGAC outlining 

planned activities and the organizations that will implement them 

(implementing partners). The plans are subject to OGAC’s review and 

approval. (See app. IV for a description of OGAC’s review process and a 

time line of the PEPFAR awards process.) Country teams consider a 

variety of criteria when selecting implementing partners, such as the 

applicant organizations’ ability to scale up rapidly, sustain programs, and 

function in-country; the strength of their administrative and financial 

controls; and the extent to which their priorities mirror those of the host 

government and the U.S. government. Teams also often place a priority on 

working with local, indigenous organizations rather than large, 

international organizations. In addition, many country teams take steps to 

encourage faith-based organizations to apply for funding, although none of 

the teams reserves a specific percentage or amount of funding for faithbased 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.32

30Until recently, OGAC referred to central awards as “track 1” and to country-level awards as 

“track 1.5” and “track 2.” According to OGAC, the first round of funding managed by the 

focus country teams was awarded as track 1.5 funding, whereas subsequent rounds were 

awarded as track 2 funding. 

31OGAC’s target areas for central awards for prevention include AB, blood safety, PMTCT, 

and safe medical injection activities. According to OGAC, it has chosen organizations with 

the capacity to rapidly expand activities, a proven track record, and existing operations in 

the focus countries for central awards. Central awards were made in two rounds: the first 

for blood safety, safe medical injections, and antiretroviral treatment; the second for 

orphans and vulnerable children and AB activities. Central awards were made for every 

focus country except Vietnam. 

32In December 2005, President Bush announced the New Partners Initiative, under which 

$200 million in grants will be awarded to nongovernmental organizations with little or no 

experience working with the U.S. government to provide HIV/AIDS prevention and care 

services in the 15 focus countries.
Page 19 GAO-06-395 Global HIV/AIDS Prevention

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 2006.33 At the same time, the 

proportion of total PEPFAR funding in the 15 focus countries dedicated to 

prevention declined from 33 to 20 percent. The proportion of total focus 

country PEPFAR prevention funding that was allocated to each of the five 

prevention program areas varied from fiscal year 2004 to fiscal year 2006, 

and individual country teams reported varying allocations among AB and 

“other prevention.” However, there are limitations in the reliability of the 

reported figures. 

PEPFAR Prevention 

Funding in the 15 Focus 

Countries Increased in 

Fiscal Years 2004-2006

PEPFAR prevention funding in the 15 focus countries increased from $207 

million in fiscal year 200434 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.) 

33OGAC officials were unable to provide data on PMTCT central funding for prevention. 

While they estimated that $6.5 million in central PMTCT funding went to prevention in fiscal 

years 2004 and 2005, we have not included these rough estimates in our funding figures. 

34In fiscal year 2004, the focus countries obligated about $200 million in country-level and 

centrally awarded funds for prevention activities. Obligations represent a binding financial 

commitment (such as an order placed, contract awarded, or service received) that will 

result in immediate or future outlays. 
Page 20 GAO-06-395 Global HIV/AIDS Prevention

Figure 4: Total PEPFAR Prevention Funding in the 15 Focus Countries, Fiscal Years 

2004-2006

Note: Fiscal year 2006 funding is planned.

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.)

0

50

100

150

200

250

300

350

Country-level funding

Fiscal year

Central funding

Sources: GAO analysis of fiscal year 2004 budget data provided by OGAC; OGAC’s Country Operational Plan and

Reporting System database; and OGAC Central Awards database.

2004 2005 2006

Dollars in millions
Page 21 GAO-06-395 Global HIV/AIDS Prevention

Figure 5: PEPFAR Prevention Funding, by Focus Country, Fiscal Years 2004-2006

Note: Fiscal year 2006 funding is planned.

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 

Focus country

Sources: GAO analysis of fiscal year 2004 budget data provided by OGAC; OGAC’s Country Operational Plan and

Reporting System database; and OGAC Central Awards database.

Dollars in millions

2006

2005

2004

Zambia

Vietnam

Uganda

Tanzania

Sout

Ni

Rwanda

h Africa

geria

Namibia

Mozambique

Kenya

Haiti

Ethiopia

Guyana

Cote d’Ivoire

Botswana

0

10

20

30

40

50
Page 22 GAO-06-395 Global HIV/AIDS Prevention

countries lengthen the time required to develop and expand treatment and 

care programs. 

Figure 6: Proportion of PEPFAR Funding Dedicated to Prevention in the 15 Focus 

Countries, Fiscal Years 2004-2006

Note: Fiscal year 2006 funding is planned.

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.)

Fiscal year

Sources: GAO analysis of fiscal year 2004 budget data provided by OGAC; OGAC’s Country Operational Plan and

Reporting System database; and OGAC Central Awards database.

Percentage

0

5

10

15

20

25

30

35

2004 2005 2006
Page 23 GAO-06-395 Global HIV/AIDS Prevention

Figure 7: Proportion of PEPFAR Funding Dedicated to Prevention, by Focus Country, Fiscal Years 2004-2006

Note: Fiscal year 2006 funding is planned.

Sources: GAO analysis of fiscal year 2004 budget data provided by OGAC; OGAC’s Country Operational Plan and

Reporting System database; and OGAC Central Awards database.

Percentage

Fiscal year 2006

Fiscal year 2005

Fiscal year 2004

Focus country

0

10

20

30

40

50

60

70

80

Zambia

Vietnam

Uganda

Tanzania

South Africa

Rwanda

Nigeria

Namibia

Mozambique

Kenya

Haiti

Ethiopia

Guyana

Cote d'Ivoire

Botswana
Page 24 GAO-06-395 Global HIV/AIDS Prevention

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.)35 

However, there are limitations in the reliability of these data because of 

challenges and inconsistencies in country teams’ categorization of funding 

for certain integrated ABC programs and some broad sexual transmission 

prevention activities. The lack of a standardized method for categorizing 

these programs means that, to some extent, the varied numbers of funding 

reported across fiscal years may reflect the variations in categorization 

methods rather than actual differences. (See app. V for a description of 

country teams’ varying methods for categorizing sexual transmission 

prevention funding and the effect of this variation on the reported 

allocations’ reliability.) 

Figure 8: Reported Allocation of Focus Countries’ Total PEPFAR Prevention 

Funding by Each Prevention Program Area, Fiscal Years 2004-2006

Note: Fiscal year 2006 funding is planned. Because of data reliability issues discussed in appendix V, 

these figures should be used only to understand general trends in data, rather than precise percentage 

35These figures also include central funding.

Sources: GAO analysis of fiscal year 2004 budget data provided by OGAC; OGAC’s Country Operational Plan and

Reporting System database; and OGAC Central Awards database.

Percentage

0 20 40 60 80 100

Safe medical injections

Prevention of mother-to-child transmission

Blood safety

Other prevention

Abstinence/faithfulness

2006

2005

2004

Fiscal year

31%

($63 M)

22%

($45 M)

13%

($27 M)

21%

($44 M)

13%

($27 M)

26%

($76 M)

22%

($66 M)

18%

($53 M)

23%

($66 M)

11%

($33 M)

34%

($108 M)

19%

($62 M)

16%

($50 M)

21%

($68 M)

11%

($34 M)
Page 25 GAO-06-395 Global HIV/AIDS Prevention

differences between program areas and fiscal years. Due to rounding, the percentages may not add up 

to 100. 

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.)36

Figure 9: Percentage of Reported Fiscal Year 2005 PEPFAR Sexual Transmission 

Prevention Funding Allocated to Abstinence/Faithfulness and “Other Prevention” by 

Each Focus Country Team

Note: Individual country teams use different methods for categorizing funding in the AB and “other 

prevention” program areas (see app. V). These data should not be used to make direct comparisons 

between individual country teams but rather to understand the overall pattern of funding across 

country teams.

36The reported allocations shown in figure 9 include both central and country-level funding. 

Source: GAO analysis of OGAC’s Country Operational Plan and Reporting System database. 

Percentage

PEPFAR focus country

0 20 40 60 80 100

Other prevention

Abstinence/faithfulness

Zambia

Vietnam

Uganda

Tanzania

South Africa

Rwanda

Nigeria

Namibia

Mozambique

Kenya

Haiti

Guyana

Ethiopia

Cote d’Ivoire

Botswana
Page 26 GAO-06-395 Global HIV/AIDS Prevention

PEPFAR Sexual 

Transmission 

Prevention Strategy Is 

Driven by ABC 

Approach, AbstinenceUntil-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.37 The guidance identifies key principles that country teams 

should consider in developing and implementing ABC programs. 

• The model should be applied in accordance with local prevention 

needs. The guidance states that one of PEPFAR’s commitments is to 

ensure “that interventions be informed by, and responsive to, local 

needs, local epidemiology, and distinctive social and cultural patterns.” 

37Office of the U.S. Global AIDS Coordinator, Guidance to In-Country Staff and 

Implementing Partners Applying the ABC Approach to Preventing Sexually-Transmitted 

HIV Infections within the President’s Emergency Plan for AIDS Relief (Washington, D.C.: 

U.S. Department of State, March 2005). This guidance was released in its final form in March 

2005. According to OGAC, the only difference between the draft guidance provided to 

country teams in January and the final guidance was the language regarding human 

papilloma virus. 
Page 27 GAO-06-395 Global HIV/AIDS Prevention

• Prevention activities should be integrated. The guidance notes that “all 

implementing partners must harmonize [prevention messages] at the 

community level.” 

• Prevention activities should be coordinated with the HIV/AIDS 

strategies of host governments.

• Prevention interventions should be driven by best practices. 

Taking these principles into account, the guidance states that “the optimal 

balance of ABC activities will vary across countries according to the 

patterns of disease transmission, the identification of core transmitters 

(i.e., those at highest risk of transmitting HIV), cultural and social norms, 

and other contextual factors.” 

In addition, OGAC’s ABC guidance contains rules for country teams to 

follow in developing and implementing their sexual transmission 

prevention strategies. First, the guidance specifies the components of the 

ABC model that should be targeted to certain populations. For example, 

messages about abstinence-until-marriage and delay of first sexual activity 

should be targeted to youths; fidelity should be emphasized for married 

couples and those in monogamous relationships; and condom use should 

be promoted to those who practice risky sexual behaviors, such as 

commercial sex workers and individuals who have sex with someone of 

unknown HIV status. Second, the guidance sets parameters on the 

prevention messages that may be delivered to youths. Specifically, although 

PEPFAR funds may be used to deliver age-appropriate AB information to 

in-school youths aged 10 to 14 years, the funds may not be used to provide 

information on condoms to these youths. When students are identified as 

being at risk, they may be referred to out-of-school programs that provide 

integrated ABC information and that provide condoms. Under these rules, 

PEPFAR funds may be used to provide integrated ABC information to 

youths older than 14. 

OGAC also released the following guidance regarding the use of PEPFAR 

funds for ABC programs:

• Any PEPFAR-funded program that provides information about condoms 

must also provide information about abstinence and faithfulness.

• PEPFAR funds may not be used to physically distribute or provide 

condoms in school settings.
Page 28 GAO-06-395 Global HIV/AIDS Prevention

• PEPFAR funds may not be used in schools for marketing efforts to 

promote condoms to youths. 

• PEPFAR funds may not be used in any setting for marketing campaigns 

that target youths and encourage condom use as the primary 

intervention for HIV prevention. 

• PEPFAR funds may be used to target at-risk populations with specific 

outreach, services, comprehensive prevention messages, and condom 

information and provision. The guidance defines at-risk groups as

• commercial sex workers and their clients, 

• sexually active discordant couples or couples with unknown HIV 

status,

• substance abusers, 

• mobile male populations,

• men who have sex with men, 

• people living with HIV/AIDS, and

• those who have sex with an HIV-positive partner or one whose status 

is unknown.

PEPFAR Strategy Is Shaped 

by Abstinence-UntilMarriage Spending 

Requirement and OGAC’s 

Implementation of the 

Requirement

The PEPFAR strategy reflects the Leadership Act’s abstinence-untilmarriage 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 

teams38 to spend at least 50 percent of their prevention funding39 on sexual 

38These countries are Cambodia, India, Malawi, Russia, and Zimbabwe. OGAC officials said 

they chose to apply the 66 percent requirement to these countries because each country 

receives more than $10 million in U.S. government funding for HIV/AIDS activities. 

39The sum of funding for all five prevention program areas.
Page 29 GAO-06-395 Global HIV/AIDS Prevention

transmission prevention and at least 66 percent of that amount on AB 

activities. In other words, OGAC requires country teams to spend $2.00 on 

AB activities for every $1.00 they spend on “other prevention” activities—a 

2-to-1 ratio. To show compliance with the spending requirement, country 

teams’ operational plans must isolate the amount of funding spent on AB 

activities. OGAC’s policies relate to the Leadership Act’s requirement in the 

sense that, if a country spends exactly half of its prevention funding on 

sexual transmission prevention and two-thirds of that funding on AB 

activities, it will then spend one-third of its total prevention funding on AB. 

Figure 10 provides an illustrative example of a country team’s prevention 

funding strictly allocated according to OGAC’s policies.

Figure 10: Illustration of a Country Team’s Prevention Funding Allocated According 

to OGAC’s Policies Implementing the Abstinence-Until-Marriage Spending 

Requirement

Note: Percentages do not add up to 100, due to rounding.

16.5%

33%

50%

Source: GAO.

Prevention of mother-to-child transmission,

safe medical injections, blood safety

Nonsexual transmission prevention

Sexual transmission prevention

Abstinence/faithfulness

Other prevention
Page 30 GAO-06-395 Global HIV/AIDS Prevention

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.40 

OGAC also directed country teams to apply the spending requirement to all 

PEPFAR prevention funding (about $357 million in fiscal year 2006).41

OGAC adopted this policy although it determined that, as a matter of law, 

the requirement applies only to funds appropriated to the GHAI account 

(about $322 million for prevention in fiscal year 2006). Under OGAC’s 

policy, the abstinence-until-marriage spending requirement applies to 

prevention funding from the CDC’s Global AIDS Program, the Child 

Survival and Health account, the Freedom Support Act account, and the 

GHAI account. However, when reporting to Congress on compliance with 

the spending requirement, OGAC reports only the allocation of funds under 

the GHAI account. 

PEPFAR Strategy Also 

Includes Country Teams’ 

Responses to Local Needs

Country teams’ sexual transmission prevention strategies are shaped both 

by high-level requirements and local context. In each PEPFAR country, 

country teams design their sexual transmission prevention strategies in 

response to the ABC model and the abstinence-until-marriage spending 

requirement. At the same time, in accordance with OGAC’s ABC guidance, 

the strategies take into account local factors such as the host nation’s 

capacity to expand activities in the prevention program areas, the nature of 

the HIV/AIDS epidemic in the country, the average age when sexual activity 

begins, and the prevalence of certain social norms. For example, in a 

40As shown in figure 1, 11 of the 15 focus countries are experiencing generalized epidemics. 

In fiscal year 2006, 7 of the 15 focus countries had planned PEPFAR funding over $75 

million. 

41See page 11 for a definition of PEPFAR prevention funding. 
Page 31 GAO-06-395 Global HIV/AIDS Prevention

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-UntilMarriage 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. 
Page 32 GAO-06-395 Global HIV/AIDS Prevention

• The guidance’s definition of at-risk groups is open to varying 

interpretations, causing confusion about which groups may be 

targeted.42 Six focus country teams and some implementing partners 

expressed uncertainty regarding the populations that should be 

considered at-risk in accordance with the ABC guidance. Five of these 

teams expressed concern that certain populations that need ABC 

messages in their countries might not receive them because they do not 

fit the ABC guidance definition of at-risk. For example, one team noted 

that the majority of HIV infections in its country are transmitted from 

one partner to another in either married or stable, cohabitating 

relationships. However, this team told us that they understood the ABC 

guidance on high-risk groups to be relevant only to a “limited epidemic” 

(unlike the generalized epidemic in which they were working) and that 

married couples do not count as high-risk under PEPFAR. As a result, 

they believed that a program designed to reach these individuals 

through ABC messages to a broad population would not be allowed. In 

addition, three teams questioned how to apply the definition of at-risk in 

a generalized epidemic.

• The guidance does not clearly delineate permissible C activities, 

causing confusion about proper use of PEPFAR funds. OGAC’s ABC 

guidance places restrictions on activities promoting condom use, but it 

does not clearly distinguish permissible and nonpermissible activities. 

For example, the guidance states that condom use programs should 

provide full and accurate information about correct and consistent 

condom use, including how to obtain them. The guidance also places 

restrictions on promoting or marketing condoms to youths;43 however, it 

does not explain how providing condom information differs from 

condom promotion or marketing. Several NGOs that receive PEPFAR 

funding expressed concern to us about crossing the line between 

providing information about condoms and promoting or marketing 

condoms. For example, representatives of a PEPFAR-supported 

organization that runs a youth camp for students (aged 15-17) told us 

42According to the ABC guidance, at-risk groups include sex workers and their clients; 

sexually active discordant couples or couples with unknown HIV status; substance abusers; 

mobile male populations; men who have sex with men; people living with HIV/AIDS; and 

those who have sex with an HIV-positive partner or one whose HIV status is unknown.

43The ABC guidance states that PEPFAR funds may not be used to physically distribute or 

provide condoms in school settings; for marketing efforts to promote condoms to youths in 

school settings; or for marketing campaigns that target youths and encourage condom use 

as the primary intervention for HIV prevention in any setting. 
Page 33 GAO-06-395 Global HIV/AIDS Prevention

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 mixedage 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.44 For example, the document addresses issues such as 

44Country teams received this document in August 2005. Although we conducted a follow-up 

round of structured interviews with the country teams after this date, we did not specifically 

ask each country team about this document. 
Page 34 GAO-06-395 Global HIV/AIDS Prevention

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-UntilMarriage 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 
Page 35 GAO-06-395 Global HIV/AIDS Prevention

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
Page 36 GAO-06-395 Global HIV/AIDS Prevention

approved.45 A team that funds a prevention program for people living 

with HIV/AIDS stated that, although the program includes faithfulness 

messages, the team does not classify any funding for the program as AB, 

because it cannot predict the portion of the project that should be 

dedicated to the faithfulness component and does not want to lose its 

flexibility to “do what is appropriate.”46 Another country team explained 

that its work with commercial sex workers will focus on correct and 

consistent condom use but will also include income-generation 

activities. Once the sex workers find an alternative means of income, AB 

messages become more relevant for them. This team stated that 

segregating program funding undermines the continuity inherent in 

integrated programs. 

Country Teams Report That 

Meeting Spending Requirement 

Challenges Their Ability to 

Respond to Local Prevention 

Needs

A large majority of the 20 PEPFAR country teams required to meet the 

abstinence-until-marriage spending requirement or obtain exemptions 

reported that the requirement presents challenges to their efforts to 

respond to local prevention needs.47 Seventeen of these teams reported—

either through documents submitted to OGAC or through structured 

interviews—that meeting the spending requirement, including OGAC’s 50 

percent and 66 percent policies implementing it, challenges their ability to 

develop interventions that are responsive to local epidemiology and social 

norms.48 

Between September 2005 and January 2006, 10 of these teams submitted 

documents to OGAC requesting exemption from the spending requirement 

as it was defined in OGAC’s August 2005 guidance. These documents 

highlight various challenges that the country teams associated with 

meeting the spending requirement, including the following: 

45Country teams can submit requests to OGAC to reprogram funds from one program to 

another. 

46Under direction from OGAC, this country team categorized the program entirely as 

palliative care.

47The 20 PEPFAR teams discussed in this section comprise the 15 focus country teams and 

the 5 additional country teams required to meet the spending requirement because they 

receive at least $10 million in PEPFAR funding. 

48Of the remaining three country teams, one reported that the spending requirement was in 

line with its prevention strategy; one indicated that, although it had some concerns about 

the prevention spending requirement, it had more concerns about the Leadership Act’s 

requirement that at least 55 percent of funds appropriated pursuant to the act be spent on 

treatment; and one did not respond to our request for information. 
Page 37 GAO-06-395 Global HIV/AIDS Prevention

• Reduced spending for PMTCT. Three country teams identified cuts in 

PMTCT as a constraint that they would face if required to meet the 

spending requirement. For example, one country team wrote that 

“reaching the sexual prevention and AB [spending requirements] would 

have required drastically reducing the PMTCT budget [from] $1.4 million 

to $350,000.”

• Limited funding to deliver appropriate prevention messaging to highrisk 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 exemptions49— identified, in structured 

interviews, specific program constraints related to meeting the abstinenceuntil-marriage spending requirement. (While some of these teams 

49Each of these seven teams has PEPFAR funding over $75 million, is working in a country 

with a generalized HIV/AIDS epidemic, or both. As noted on page 30, OGAC discourages 

these teams from submitting documents requesting exemption from the spending 

requirement. 
Page 38 GAO-06-395 Global HIV/AIDS Prevention

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 abstinenceuntil-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 
Page 39 GAO-06-395 Global HIV/AIDS Prevention

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.50) This focus country 

lacks a health care system for providing PMTCT services and, as a 

result, the team has had significant trouble reaching its target for 

preventing infections through PMTCT activities.51 However, at the 

start of fiscal year 2005, OGAC directed the country team to reduce 

planned funding for PMTCT and dedicate more funding to AB 

activities, because the team’s allocation of prevention funds to AB 

fell short of 33 percent. 

• In another country, where the U.S. government has been the largest 

supporter of the PMTCT program, the team told us that complying 

with the spending requirement would likely force it to shift resources 

away from PMTCT and thus reduce needed PMTCT commodities and 

services.52

• Difficulty funding programs for condom procurement and condom 

social marketing. 

• One focus country team told us that the spending requirement had 

complicated its efforts to address a condom shortage in the country. 

To reserve funding to procure condoms, the team was required to cut 

funding for other programs in the “other prevention” program area 

and to shift funds from the care category. 

50In fiscal year 2004, OGAC encouraged country teams to dedicate 7 percent of total 

PEPFAR funds on AB activities. This figure reflected the Leadership Act’s recommendation 

that 20 percent of total funds appropriated pursuant to the act be spent on prevention (7 

percent is 33 percent of 20 percent).

51A 2005 USAID IG report found that this country’s reported number of PMTCT-prevented 

infections fell significantly short of the target of 3,500. 

52In this case, we communicated with the country team before it had made its final 

prevention allocations for the upcoming fiscal year. 
Page 40 GAO-06-395 Global HIV/AIDS Prevention

• 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.53

OGAC’s Policies Allow It to Meet 

the Overall 33 Percent Target

Our analysis shows that OGAC’s policies implementing the 33 percent 

spending requirement should allow it to just fulfill the Leadership Act’s 

spending requirement for fiscal year 2006, with the 20 country teams 

dedicating, in total, slightly more than 33 percent of reported planned 

prevention funds to AB activities.54 OGAC officially approved exemptions 

for the 10 country teams that requested them. As a result, all but one55 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

53In this case, we communicated with the country team before it had made its final 

prevention allocations for the upcoming fiscal year. 

54Because of challenges and inconsistencies in country teams’ categorization of funding for 

certain integrated ABC programs and some broad sexual transmission prevention activities, 

data on prevention allocations may reflect the variation in categorization methods, rather 

than actual differences. (See app. V.) 

55Unlike the other teams that submitted requests for exemption, one country team plans to 

spend over 90 percent of total prevention funds on sexual transmission prevention. 

Therefore, even though AB funds do not account for 66 percent of this country team’s funds 

to prevent sexual transmission of HIV, the team still reserves at least 33 percent of 

prevention funds for AB activities. 
Page 41 GAO-06-395 Global HIV/AIDS Prevention

prevention—about 57 percent on average. As a result, these country teams 

also must spend more than 33 percent of prevention funds on AB.56 

According to an OGAC official, OGAC would have been unable to meet the 

33 percent target if it had allowed many of the country teams with the 

largest amounts of PEPFAR funding to submit exemptions to the spending 

requirement. For fiscal year 2006, only one of the five top-funded focus 

country teams submitted an exemption request. 

OGAC’s Policies Give Some 

Country Teams Greater 

Flexibility but Further Constrain 

Others 

OGAC’s policies implementing the abstinence-until-marriage spending 

requirement allow it to respond to the concerns of teams that received 

exemptions but prevent it from addressing the remaining country teams’ 

concerns. Teams that received exemptions were, to some degree, able to 

avoid the challenges related to meeting the spending requirement that they 

had identified in requesting exemption. For example, a country team that 

requested exemption because “the epidemic in [this country] is still 

concentrated primarily among injection drug users and sex workers” 

planned to dedicate 89 percent of total prevention funds to “other 

prevention” and only 4 percent to AB. Another team whose exemption 

request noted that the epidemic in their country “requires that resources be 

directed towards high-risk populations, and populations likely to engage in 

risky sexual behaviors” received approval to limit AB funding to 28 percent 

of its total planned prevention funds and reserved 22 percent of planned 

prevention funds for “other prevention.” 

Under OGAC’s policies, however, some nonexempted country teams are 

unable to avoid challenges presented by the spending requirement. As 

noted above, 7 of the 10 country teams that did not submit requests for 

exemption identified specific concerns about cutting or reducing funding 

for certain prevention programs. In allocating funds to meet the spending 

requirement, country teams are primarily limited to shifting resources 

among three prevention program areas—“other prevention,” PMTCT, and 

AB. (This limitation occurs because the overwhelming majority of funds 

spent on safe medical injections and blood safety are centrally awarded 

funds, over which the country teams have no budgetary control.) If, for 

56This is not the case for one of the 10 country teams, which reported that it would dedicate 

32 percent of planned prevention funds to AB for fiscal year 2006. Although this team 

planned to dedicate more than 50 percent of total prevention funds on sexual transmission 

prevention funds, it missed the 66 percent policy requirement, dedicating about 60 percent 

of sexual transmission funds to AB activities. Prior to receiving plus-up funds at the end of 

January and subsequently reallocating its prevention funds, this team met both the 50 

percent and 66 percent policy requirements and therefore did not request exemption. 
Page 42 GAO-06-395 Global HIV/AIDS Prevention

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 requirement57

suggest a noticeable decline in “other prevention” funding between fiscal 

year 2005, when the spending requirement was not mandatory, and fiscal 

year 2006.58 Although some of this shift may be due to varying methods of 

categorizing sexual transmission prevention programs and some changes 

in categorization methods across fiscal years (see app. V), the data 

demonstrate a common trend across these teams. For the nonexempted 

focus country teams, total funding for “other prevention” declined by about 

$5 million from fiscal year 2005 to fiscal year 2006, falling from about 23 

percent to about 18 percent of total prevention funding, while total funding 

for AB activities increased by about $25 million, rising from about 27 

percent to about 36 percent of total prevention funding. By contrast, in the 

focus country teams that received exemptions, total prevention funding for 

“other prevention” increased slightly by about $700,000, remaining at 

around 21 percent of total prevention funding, and total prevention funding 

for AB activities increased by about $7 million, from about 23 percent to 

about 28 percent of total prevention funding. Figure 11 shows the 

allocation of prevention funds by nonexempted and exempted focus 

country teams for fiscal years 2005 (actual funds) and 2006 (planned 

funds). 

57We do not have fiscal year 2005 data from the five additional country teams that were 

required to meet the spending requirement in fiscal year 2006. Therefore, we are unable to 

compare the prevention allocations in fiscal year 2005 with those in fiscal year 2006 for 

these teams.

58Fiscal year 2005 data represent actual funding. Fiscal year 2006 data represent planned 

funding, which has not yet been approved by OGAC. For both fiscal years, central and 

country-level funds are included.
Page 43 GAO-06-395 Global HIV/AIDS Prevention

Figure 11: Prevention Allocations for Nonexempted and Exempted Focus Country 

Teams, Fiscal Years 2005 and 2006

Note: Fiscal year 2006 funding is planned. Because of data reliability issues discussed previously and 

in appendix V, these figures should be used only to understand general trends in data, rather than as 

precise percentage differences between program areas and fiscal years. Because of rounding, the 

percentages may not sum to 100. 

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 

23% 

($23 M)

21% 

($22 M)

22% 

($22 M)

22% 

($22 M)

13% 

($13 M)

28% 

($30 M)

21% 

($23 M)

20% 

($21 M)

19% 

($21 M)

12% 

($13 M)

Exempted country

teams

Sources: GAO analysis of fiscal year 2005 country operational plans and OGAC’s Country Operational

Plan and Reporting System database. 

Percent

Fiscal year

0 20 40 60 80 100

Safe medical injections

Blood safety

Prevention of mother-to-child transmission

Other prevention

Abstinence/faithfulness

2005

2006

2005

2006

27%

($53 M)

23% 

($44 M)

23% 

($44 M)

16% 

($31 M)

10% 

($20 M)

36% 

($78 M)

18% 

($39 M)

22% 

($46 M)

14% 

($29 M)

10% 

($21 M)

Nonexempted country

teams
Page 44 GAO-06-395 Global HIV/AIDS Prevention

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 account59 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.60 Because of OGAC’s policy regarding non-GHAI 

prevention funding, this country team will be unable to apply the $1.5 

million to the condom social marketing programs for which funding was 

likely reduced. 

Conclusions Responding to the severity and urgency of the global HIV/AIDS crisis,

PEPFAR and its authorizing legislation, the U.S. Leadership Against 

HIV/AIDS, Tuberculosis and Malaria Act of 2003, significantly increased the 

United States’ commitment to fight the epidemic. Country teams 

consistently indicated that the ABC model is a useful tool for preventing 

sexual transmission of HIV, and many expressed the importance of AB 

messages for certain populations. However, the Leadership Act’s 

requirement that country teams spend at least 33 percent of prevention 

funding appropriated pursuant to the act on abstinence-until-marriage 

programs has presented challenges to country teams’ ability to adhere to 

the PEPFAR sexual transmission prevention strategy. In particular, it has 

59This includes funds appropriated to CDC’s Global AIDS Program, the Child Survival and 

Health Account, and the Freedom Support Act. See page 30.

60See page 40. 
Page 45 GAO-06-395 Global HIV/AIDS Prevention

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 
Page 46 GAO-06-395 Global HIV/AIDS Prevention

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 
Page 47 GAO-06-395 Global HIV/AIDS Prevention

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. 

David Gootnick

Director, International Affairs and Trade
Page 48 GAO-06-395 Global HIV/AIDS Prevention

List of Congressional Committees

The Honorable Arlen Specter

Chairman

Subcommittee on Labor, Health and Human Services,

Education, and Related Agencies

Committee on Appropriations

United States Senate

The Honorable Richard G. Lugar

Chairman

The Honorable Joseph R. Biden, Jr.

Ranking Minority Member

Committee on Foreign Relations

United States Senate

The Honorable Edward M. Kennedy, Jr.

Ranking Minority Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Jim Kolbe

Chairman

The Honorable Nita M. Lowey

Ranking Minority Member

Subcommittee on Foreign Operations,

Export Financing, and Related Programs

Committee on Appropriations

House of Representatives

The Honorable Joe Barton

Chairman

The Honorable John D. Dingell

Ranking Minority Member

Committee on Energy and Commerce

House of Representatives

The Honorable Henry A. Waxman

Ranking Minority Member

Committee on Government Reform

House of Representatives
Page 49 GAO-06-395 Global HIV/AIDS Prevention

The Honorable Christopher Shays

Subcommittee on National Security, Emerging Threats

and International Relations

Committee on Government Reform

House of Representatives

The Honorable Tom Lantos

Ranking Minority Member

Committee on International Relations

House of Representatives
Page 50 GAO-06-395 Global HIV/AIDS Prevention

Appendix I

Scope and Methodology AAppenednxidexiIs

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.1

 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. 

1

These officials spoke with us with the understanding that individual respondents and the 

countries where they serve would not be named in our discussion of the structured 

interviews.
Appendix I

Scope and Methodology

Page 51 GAO-06-395 Global HIV/AIDS Prevention

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-untilmarriage 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;2

 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);3

 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 Sexually2

U.S. missions enter planning and reporting requirements, including the country operational 

plans, semiannual and annual progress reports, into the COPRS data system. The COPRS 

data system does not contain information on central (track 1) funding or on planned and 

approved funding for fiscal year 2004.

3

The Office of the U.S. Global AIDS Coordinator prepared this report in collaboration with 

the Departments of State (including the U.S. Agency for International Development), 

Defense, Commerce, Labor, Health and Human Services (including the Centers for Disease 

Control and Prevention, the Food and Drug Administration, the Health Resources and 

Services Administration, the National Institutes of Health, and the Office of Global Health 

Affairs); and the Peace Corps.
Appendix I

Scope and Methodology

Page 52 GAO-06-395 Global HIV/AIDS Prevention

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.4

 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 

4

One of these organizations did not respond to our requests for an interview; the other 

agreed to meet with us but later cancelled the appointment. 
Appendix I

Scope and Methodology

Page 53 GAO-06-395 Global HIV/AIDS Prevention

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. 
Page 54 GAO-06-395 Global HIV/AIDS Prevention

Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries ApendxiI

Fiscal year 2005 program descriptions1 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, communitybased 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 

1

Fiscal year 2005 program descriptions based on focus country teams’ country operational 

plans, dated Mar. 16, 2005.
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 55 GAO-06-395 Global HIV/AIDS Prevention

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 
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 56 GAO-06-395 Global HIV/AIDS Prevention

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.
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 57 GAO-06-395 Global HIV/AIDS Prevention

• $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 highrisk 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.
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 58 GAO-06-395 Global HIV/AIDS Prevention

• $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 faithbased 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 
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 59 GAO-06-395 Global HIV/AIDS Prevention

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. 
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 60 GAO-06-395 Global HIV/AIDS Prevention

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 
Appendix II

AB and “Other Prevention” Programs in Four 

Focus Countries

Page 61 GAO-06-395 Global HIV/AIDS Prevention

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 riskassessment 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. 
Page 62 GAO-06-395 Global HIV/AIDS Prevention

Appendix III

Prevention Program Indicators and Methods 

of Measuring PEPFAR Prevention Program 

Results ApendxiI

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. 
Appendix III

Prevention Program Indicators and Methods 

of Measuring PEPFAR Prevention Program 

Results

Page 63 GAO-06-395 Global HIV/AIDS Prevention

OGAC tracks similar indicators for prevention programs outside the sexual 

transmission area. These include four indicators for prevention of motherto-child transmission (PMTCT), two for blood safety, and one for safe 

injections.1

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.2

 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. 

1

The indicators for PMTCT are number of service outlets providing the minimum package of 

PMTCT services according to national and international standards; number of pregnant 

women who received HIV counseling and testing for PMTCT and received their test results; 

number of pregnant women provided with a complete course of antiretroviral prophylaxis 

in a PMTCT setting; and number of health workers trained in the provision of PMTCT 

services according to national and international standards. For blood safety, the indicators 

are number of service outlets carrying out blood safety activities and number of individuals 

trained in blood safety. The safe medical injections indicator is the number of individuals 

trained in medical injection safety. 

2

The prevalence data used in the Census projection are derived from a statistical database 

(the estimates and projections package) that in turn incorporates the country prenatal clinic 

survey data. Use of these data to estimate countrywide incidence assumes that the 

prevalence rate among pregnant women is highly correlated with the prevalence rate in the 

general population. Other organizations such as the Joint United Nations Programme for 

HIV/AIDS also use these data in their prevalence estimates. 
Appendix III

Prevention Program Indicators and Methods 

of Measuring PEPFAR Prevention Program 

Results

Page 64 GAO-06-395 Global HIV/AIDS Prevention

• 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. 
Appendix III

Prevention Program Indicators and Methods 

of Measuring PEPFAR Prevention Program 

Results

Page 65 GAO-06-395 Global HIV/AIDS Prevention

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.3

 The group 

assessed alternative modeling approaches and initially considered the 

Goals Model (developed by the Futures Group)4

 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.5

 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

3

The modeling group, chaired by the U.S. Census Bureau, included representatives from U.S. 

agencies, such as the U.S. Agency for International Development, the Centers for Disease 

Control and Prevention, and OGAC, as well as independent think tanks and the United 

Nation’s Children’s Fund.

4

The Futures Group is a privately held company that designs and implements public health 

and social programs for developing countries.

5

The Goals Model assesses the impact of 13 specific interventions including, in part, mass 

media, community outreach, school-based programs, condom social marketing, and 

outreach to injection drug users. For each of these interventions, the model estimates the 

effects of these interventions in changing behaviors. Separate estimates of behavior change 

are made for high-risk, medium-risk, and low-risk populations. The model then estimates 

the reductions in new infections that result from the specific changes in behaviors in each of 

the groups. The numerical effects of the 13 interventions on behavior change, and of 

behavior change on the number of new infections, derive from peer-reviewed studies.
Appendix III

Prevention Program Indicators and Methods 

of Measuring PEPFAR Prevention Program 

Results

Page 66 GAO-06-395 Global HIV/AIDS Prevention

HIV transmission.6 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. 

6

The Goals Model incorporates a limited amount of information about the impacts of certain 

interventions on behaviors and infection rates because of a lack of evidence from studies. In 

addition, some of the numerical effects specified in the model are based on only one or two 

studies. Because of this lack of evidence, researchers disagree about the numerical effects 

that should be used in the model.
Page 67 GAO-06-395 Global HIV/AIDS Prevention

Appendix IV

PEPFAR Planning and Reporting Process ApendxiIV

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.1

 At the conclusion of the reviews, OGAC 

submits a notification to the relevant congressional committees,2 informing 

them of the activities it plans to implement under PEPFAR in the current 

fiscal year.3

 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,4

 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. 

1

According to OGAC, the principals are the Global AIDS Coordinator and his deputy, the 

director of the Office of Global Health Affairs and Special Assistant to the Secretary for 

International Affairs at the Department of Health and Human Services/Centers for Disease 

Control and Prevention, the acting Assistant Administrator for the Bureau of Global Health 

at the U.S. Agency for International Development, the Deputy Assistant Secretary of 

Defense, the Special Assistant to the Secretary for International Affairs, and the Peace 

Corps AIDS Relief Coordinator.

2

The committees are the Senate Committee on Foreign Relations, the House Committee on 

International Relations, and the Senate and House Committees on Appropriations. 

3

OGAC may submit more than one congressional notification. For example, for fiscal year 

2006, OGAC plans to submit a congressional notification before completing the operational 

plan review process to fund programs for which the country teams have requested early 

funding.

4

Each U.S. agency operating under PEPFAR processes grants, contracts, and cooperative 

agreements differently. Procurements may occur centrally by agency headquarters, by 

country U.S. government offices, or by regional U.S. government offices. In addition, the 

type of grant, contract, or cooperative agreement affects how it is processed.
Appendix IV

PEPFAR Planning and Reporting Process

Page 68 GAO-06-395 Global HIV/AIDS Prevention

Figure 12: OGAC Planning and Reporting Requirements for Fiscal Years 2005 and 

2006

Note: Dates for midyear progress report preparation and operational plan preparation are approximate.

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

Fiscal year 2005

midyear progress

report preparation

Fiscal year 2005

midyear progress

report due May 15

Fiscal year 2005

funds appropriated

by Congress

Fiscal year 2005 funds transferred to focus countries

and obligated; programs start implementation once

funds are received.

Fiscal year 2005

annual progress

report prepared

Fiscal year 2005

annual progress

report due Nov. 15

Fiscal year 2006

operational plan

preparation

Fiscal year 2006

country operational

plan due Sept. 30

Sources: GAO analysis of structured interviews with focus country teams; Fiscal Year 2006 Country Operational Plan Guidance; and

interview with OGAC officials.
Page 69 GAO-06-395 Global HIV/AIDS Prevention

Appendix V

Methods for Reporting Allocations among 

PEPFAR Prevention Program Areas ApendxiV

Country teams have used varying methods to categorize funding for certain 

integrated abstinence/faithfulness/condom use (ABC) programs1

 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,2

 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,”3

 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 

1

An integrated ABC program often addresses a range of issues, including abstinence; 

faithfulness; nutrition; sexually-transmitted infections; peer pressure; stigma reduction; 

child, spouse, and substance abuse; alcohol addiction; condom negotiation; and correct and 

consistent condom use. 

2

Programs outside of the sexual transmission prevention program area, such as prevention 

of mother-to-child transmission or voluntary counseling and testing programs, may also 

include ABC components.

3

In fiscal year 2006, no country teams have categorized integrated ABC programs entirely in 

the AB program area.
Appendix V

Methods for Reporting Allocations among 

PEPFAR Prevention Program Areas

Page 70 GAO-06-395 Global HIV/AIDS Prevention

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.4

 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.5

• 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. 

4

Some structured interviews took place prior to submission of the fiscal year 2006 

operational plans; discussions, therefore, revolved around categorization methods used in 

fiscal year 2005 operational plans. Based on these structured interviews and our review of 

fiscal year 2006 operational plans, it appears that there was some change in country teams’ 

categorization methods between the fiscal years. 

5

Office of the U.S. Global AIDS Coordinator (OGAC) officials told us that, in reviewing fiscal 

year 2005 proposed operational plans, they found that some countries mistakenly 

categorized programs with C components entirely in the AB program area. However, OGAC 

will not approve this categorization and has instructed country teams that they should split 

the entire C component of any ABC programs into the “other prevention” program area. 
Appendix V

Methods for Reporting Allocations among 

PEPFAR Prevention Program Areas

Page 71 GAO-06-395 Global HIV/AIDS Prevention

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 
Appendix V

Methods for Reporting Allocations among 

PEPFAR Prevention Program Areas

Page 72 GAO-06-395 Global HIV/AIDS Prevention

identifying general trends and patterns across fiscal years and program 

areas. 
Page 73 GAO-06-395 Global HIV/AIDS Prevention

Appendix VI

Joint Comments from State, USAID, and HHS ApendxiVI

Note: GAO comments 

supplementing those in 

the report text appear 

at the end of this 

appendix.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 74 GAO-06-395 Global HIV/AIDS Prevention
Appendix VI

Joint Comments from State, USAID, and HHS

Page 75 GAO-06-395 Global HIV/AIDS Prevention
Appendix VI

Joint Comments from State, USAID, and HHS

Page 76 GAO-06-395 Global HIV/AIDS Prevention
Appendix VI

Joint Comments from State, USAID, and HHS

Page 77 GAO-06-395 Global HIV/AIDS Prevention

See comment 1.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 78 GAO-06-395 Global HIV/AIDS Prevention

See comment 2.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 79 GAO-06-395 Global HIV/AIDS Prevention

See comment 3.

See comment 4.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 80 GAO-06-395 Global HIV/AIDS Prevention

Now on p. 32.

Now on p. 32.

Now on p. 33.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 81 GAO-06-395 Global HIV/AIDS Prevention

See comment 5.

See comment 6.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 82 GAO-06-395 Global HIV/AIDS Prevention

See comment 7.

See comment 8.
Appendix VI

Joint Comments from State, USAID, and HHS

Page 83 GAO-06-395 Global HIV/AIDS Prevention
Appendix VI

Joint Comments from State, USAID, and HHS

Page 84 GAO-06-395 Global HIV/AIDS Prevention

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.” 
Appendix VI

Joint Comments from State, USAID, and HHS

Page 85 GAO-06-395 Global HIV/AIDS Prevention

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-untilmarriage 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, 
Appendix VI

Joint Comments from State, USAID, and HHS

Page 86 GAO-06-395 Global HIV/AIDS Prevention

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-untilmarriage 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.
Page 87 GAO-06-395 Global HIV/AIDS Prevention

Appendix VII

GAO Contact and Staff Acknowledgments ApendxiVI

GAO Contact David Gootnick (202) 512-3149

Staff 

Acknowledgments 

In addition to the individual named above, Celia Thomas (Assistant 

Director), Elizabeth Singer, Elisabeth Helmer, David Dornisch, Mary 

Moutsos, Reid Lowe, Kay Halpern, and Etana Finkler made key 

contributions to this report. 

(320334)
GAO’s Mission The Government Accountability Office, the audit, evaluation and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

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