I 

110TH CONGRESS 

1ST SESSION H. R. 1713 

To require the President and the Office of the Global AIDS Coordinator 

to establish a comprehensive and integrated HIV prevention strategy 

to address the vulnerabilities of women and girls in countries for which 

the United States provides assistance to combat HIV/AIDS, and for 

other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 27, 2007 

Ms. LEE (for herself and Mr. SHAYS) introduced the following bill; which was 

referred to the Committee on Foreign Affairs 

A BILL 

To require the President and the Office of the Global AIDS 

Coordinator to establish a comprehensive and integrated 

HIV prevention strategy to address the vulnerabilities 

of women and girls in countries for which the United 

States provides assistance to combat HIV/AIDS, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Protection Against 

5 Transmission of HIV for Women and Youth Act of 2007’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) Globally, the United Nations Joint Program 

4 on AIDS (UNAIDS) estimates that at the end of 

5 2006 there were more than 39,500,000 people in6 fected with HIV/AIDS, the vast majority of whom 

7 are living in the developing world. 

8 (2) According to the World Health Organiza9 tion (WHO) unprotected heterosexual sex is now the 

10 single most important factor in the spread of HIV 

11 infections worldwide, representing 80 percent of new 

12 infections in sub-Saharan Africa. 

13 (3) According to UNAIDS, women and adoles14 cent girls account for about half of all HIV infec15 tions worldwide. In sub-Saharan Africa, women and 

16 girls make up 60 percent of all infections and 76 

17 percent of infections among those aged 15–24. 

18 (4) Women and girls are biologically, socially, 

19 and economically more vulnerable to HIV infection. 

20 Gender disparities in the rate of HIV infection are 

21 the result of a number of factors, including the fol22 lowing: 

23 (A) Cross generational sex with older men 

24 who are more likely to be infected with HIV, 

25 and a lack of choice regarding when and whom 

26 to marry, leading to early marriages and high 


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1 rates of child marriages with older men. About 

2 half of all adolescent females in Africa and two3 thirds of adolescent females in Asia are married 

4 by age 18. 

5 (B) High rates of infection within mar6 riage. Research shows that married girls are 

7 more likely to have unprotected sex and have 

8 far more frequent sex than their unmarried 

9 peers, indicating that marriage cannot be con10 sidered a protective factor against HIV infec11 tion. 

12 (C) An inability to negotiate safe sex in 

13 marriage or with regular partners. Studies show 

14 that married women and married and unmar15 ried adolescent females often are unable to ne16 gotiate the frequency and timing of sexual 

17 intercourse, ensure their partner’s faithfulness, 

18 or insist on condom use. Women often run the 

19 risk of being infected by husbands or male part20 ners in societies where it is common or accepted 

21 for men to have more than one partner. 

22 (D) Social and economic inequalities based 

23 largely on gender which limit access for women 

24 and girls to education and employment opportu25 nities and which prevent them from asserting 


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1 their inheritance and property rights. For many 

2 women, a lack of independent economic means 

3 sustains their fear of abandonment, eviction, or 

4 ostracism from their homes and communities, 

5 and can leave many more of them trapped with6 in relationships where they are vulnerable to 

7 HIV infection. 

8 (E) A lack of educational opportunities for 

9 women and girls which are linked to delayed 

10 intercourse, increased age-at-marriage, delayed 

11 childbearing, increased child survival, improved 

12 nutrition, and reduced risk of HIV infection, 

13 among other positive outcomes. 

14 (F) High rates of gender-based violence, 

15 rape, and sexual coercion within and outside of 

16 marriage. According to the WHO, between one17 sixth and three-quarters of women in various 

18 countries and settings have experienced some 

19 form of physical or sexual violence since age 15. 

20 (G) Fear of domestic violence and the con21 tinuing stigma and discrimination associated 

22 with HIV/AIDS prevents many women from ac23 cessing information about HIV/AIDS, getting 

24 tested, disclosing their HIV status, accessing 

25 services to prevent mother-to-child transVerDate Aug 31 2005 03:31 Mar 30, 2007 Jkt 059200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1713.IH H1713

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1 mission, or receiving treatment and counseling 

2 even when they already know they have been in3 fected with HIV. 

4 (H) An increase in commercial sex for sur5 vival, due to pervasive poverty, social disloca6 tion, war and internal conflicts, and other fac7 tors. According to UNAIDS, the vulnerability 

8 of sex workers to HIV infection is heightened 

9 by stigmatization and marginalization, limited 

10 economic options, limited access to health, so11 cial, and legal services, limited access to infor12 mation and prevention means, gender-related 

13 differences and inequalities, sexual exploitation 

14 and trafficking, harmful or nonprotective legis15 lation and policies, and exposure to risks associ16 ated with commercial sex such as violence, sub17 stance use, and increased mobility. 

18 (I) Lack of access to basic HIV prevention 

19 information, education, and services, and lack 

20 of coordination with existing reproductive 

21 health services to reduce stigma and maximize 

22 coverage. 

23 (J) Lack of access to currently available 

24 female-controlled HIV prevention methods, such 


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1 as the female condom, and lack of training on 

2 proper use of either male or female condoms. 

3 (K) High rates of other sexually trans4 mitted infections, unintended pregnancy, and 

5 complications during pregnancy and childbirth. 

6 (L) An absence of legal frameworks de7 signed to protect the rights of women and girls 

8 and the lack of accountable and effective en9 forcement of such frameworks, where they exist. 

10 (5) Efforts to increase women’s access to com11 prehensive prevention information and services, ad12 dress gender violence, increase women’s economic 

13 and social status, and foster equitable partnerships 

14 between women and men are all central to reducing 

15 the spread of HIV/AIDS worldwide and to enhanc16 ing the success of effective treatment and care pro17 grams supported by the United States. 

18 (6) The comprehensive, integrated, five-year 

19 strategy to combat global HIV/AIDS submitted to 

20 Congress on February 23, 2004, as required by sec21 tion 101 of the United States Leadership Against 

22 HIV/AIDS, Tuberculosis, and Malaria Act of 2003 

23 (Public Law 108–25; 22 U.S.C. 7611), does not 

24 adequately focus or provide sufficient details on how 

25 the United States Government plans to address the 


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1 factors that lead to gender disparities in the rate of 

2 HIV infection in order to successfully prevent HIV 

3 infection among both married and unmarried women 

4 and girls. 

5 SEC. 3. STRATEGY TO PREVENT HIV INFECTIONS AMONG 

6 MARRIED AND UNMARRIED WOMEN AND 

7 GIRLS. 

8 (a) STATEMENT OF POLICY.—In order to meet the 

9 stated goal of preventing 7,000,000 new HIV infections 

10 worldwide, as announced by President George W. Bush 

11 in his address to Congress on January 28, 2003, it shall 

12 be the policy of the United States to pursue a global HIV 

13 prevention strategy that emphasizes the immediate and 

14 ongoing needs of married and unmarried women and girls 

15 and addresses the factors that lead to gender disparities 

16 in the rate of HIV infection. 

17 (b) STRATEGY.—Not later than 180 days after the 

18 date of the enactment of this Act, the President shall for19 mulate and submit to the appropriate congressional com20 mittees, and make available to the public, a comprehen21 sive, integrated, and culturally relevant global HIV pre22 vention strategy that addresses the vulnerabilities of mar23 ried and unmarried women and girls to HIV infection and 

24 seeks to reduce the factors that lead to gender disparities 

25 in the rate of HIV infection. The strategy shall encompass 


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1 comprehensive health and HIV prevention education at 

2 the individual and population level beyond the ABC model 

3 (‘‘Abstain, Be faithful, use Condoms’’) as a means to re4 duce HIV infections and shall include the following strate5 gies: 

6 (1) Empowering women and girls to avoid 

7 cross-generational sex and to decide when and whom 

8 to marry in order to reduce the incidence of early9 or child-marriage. 

10 (2) Dramatically increasing access to currently 

11 available female-controlled prevention methods and 

12 including investments in training to increase the ef13 fective and consistent use of both male and female 

14 condoms. 

15 (3) Accelerating the destigmatization of HIV/ 

16 AIDS, as women are generally at a disadvantage in 

17 combating stigma. 

18 (4) Addressing and preventing the consequences 

19 of gender based violence and rape against women 

20 and girls. 

21 (5) Promoting male attitudes and behavior that 

22 respect the human rights of women and girls and 

23 that support and foster gender equality. 

24 (6) Supporting the development of micro-enter25 prise initiatives, job training programs, and other 


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1 such efforts to assist women in developing and re2 taining independent economic means. 

3 (7) Supporting expanded educational opportuni4 ties for women and girls. 

5 (8) Protecting the property and inheritance 

6 rights of women. 

7 (9) Coordinating HIV prevention information 

8 and education services and programs for people liv9 ing with HIV/AIDS with existing health care serv10 ices targeted to women and girls, such as family 

11 planning, comprehensive reproductive health serv12 ices, and programs to reduce the transmission of 

13 HIV between parents and children, and expanding 

14 the reach of such health services. 

15 (10) Promoting gender equality by supporting 

16 the development of civil society organizations focused 

17 on the needs of women and utilizing such organiza18 tions that are already empowering women and girls 

19 at the community level. 

20 (11) Encouraging the creation and effective en21 forcement of legal frameworks that guarantee 

22 women equal rights and equal protection under the 

23 law. 

24 (12) Encouraging the participation and involve25 ment of women in drafting, coordinating, and impleVerDate Aug 31 2005 03:31 Mar 30, 2007 Jkt 059200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H1713.IH H1713

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1 menting the national HIV/AIDS strategic plans of 

2 their countries. 

3 (13) Responding to other economic and social 

4 factors that increase the vulnerability of women and 

5 girls to HIV infection. 

6 (c) COORDINATION.—In formulating and imple7 menting the global HIV prevention strategy pursuant to 

8 subsection (b), the President shall ensure that the United 

9 States coordinates its overall HIV/AIDS policy and pro10 grams with the national governments of the countries for 

11 which the United States provides assistance to combat 

12 HIV/AIDS and with international organizations, other 

13 donor countries, and indigenous organizations, including, 

14 specifically, organizations focused on or providing services 

15 to expanding and enforcing women’s rights, improving 

16 women’s health, and expanding education for women and 

17 girls, and organizations providing services to and advo18 cating on behalf of individuals living with and affected by 

19 HIV/AIDS. 

20 (d) GUIDANCE.—The President shall provide clear 

21 guidance to field missions of the United States Govern22 ment in countries for which the United States provides 

23 assistance to combat HIV/AIDS, based on the strategies 

24 specified under subsection (b), and shall submit to the apVerDate Aug 31 2005 03:31 Mar 30, 2007 Jkt 059200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H1713.IH H1713

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1 propriate congressional committees and make available to 

2 the public such guidance. 

3 (e) REPORT.—Not later than one year after the date 

4 of the enactment of this Act and annually thereafter as 

5 part of the annual report required under section 104A(e) 

6 of the Foreign Assistance Act of 1961 (22 U.S.C. 2151b– 

7 2(e)), the President shall submit to the appropriate con8 gressional committees and make available to the public a 

9 report on the implementation of this Act for the prior fis10 cal year. The report shall include the following informa11 tion: 

12 (1) A description of the prevention programs 

13 designed to address the vulnerabilities to HIV/AIDS 

14 of married and unmarried women and girls. 

15 (2) A list of all nongovernmental organizations 

16 in each country that receive assistance from the 

17 United States to carry out HIV prevention activities, 

18 including the amount and the source of funding re19 ceived. 

20 SEC. 4. BALANCING FUNDING FOR HIV PREVENTION METH21 ODS. 

22 (a) FINDINGS.—Congress finds the following: 

23 (1) While effective evidence-based and measur24 able strategies for delaying sexual debut are critical 

25 components of comprehensive HIV prevention proVerDate Aug 31 2005 03:31 Mar 30, 2007 Jkt 059200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H1713.IH H1713

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1 grams, current United States funded HIV preven2 tion programs based on the ABC model of ‘‘Abstain, 

3 Be faithful, use Condoms’’ are too narrow in scope 

4 and do not respond to the specific vulnerabilities of 

5 women and girls. 

6 (2) In order to maximize the impact of United 

7 States foreign assistance to combat HIV/AIDS, all 

8 sexually active persons in each country must be 

9 equipped with all the skills and tools necessary to 

10 avoid infection, including information and training 

11 on delay of sexual debut and the practice of safer 

12 sex, whether sexual activity begins within or outside 

13 of marriage. 

14 (3) Under section 403(a) of the United States 

15 Leadership Against HIV/AIDS, Tuberculosis, and 

16 Malaria Act of 2003 (Public Law 108–25; 22 U.S.C. 

17 7673), 33 percent of all United States foreign assist18 ance provided for preventing the spread of HIV 

19 must be spent on abstinence-until-marriage pro20 grams. Based on operational guidance to field mis21 sions of the United States Government, in order to 

22 meet this requirement, 50 percent of all United 

23 States foreign assistance provided for preventing the 

24 spread of HIV at the country level must be spent on 

25 prevention of sexual transmission and 66 percent of 


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1 all such funding for sexual transmission must be 

2 spent on the Abstinence and Be faithful components 

3 of the ABC model. 

4 (4) A recent report by the Government Ac5 countability Office (Global Health: Spending Re6 quirement Presents Challenges for Allocating Pre7 vention Funding under the President’s Emergency 

8 Plan for AIDS Relief, GAO–06–395, April 4, 2006) 

9 found the following: 

10 (A) Because it requires country teams to 

11 segregate the Abstinence and Be faithful com12 ponents of the ABC model from funding for 

13 ‘‘other prevention’’, the abstinence-until-mar14 riage spending requirement can undermine the 

15 team’s ability to design and implement pro16 grams that integrate the components of the 

17 ABC model, one of the guiding principles of the 

18 President’s Emergency Plan for AIDS Relief 

19 (PEPFAR) sexual transmission prevention 

20 strategy. Eight of the 15 focus country teams 

21 indicated that segregating the Abstinence and 

22 Be faithful components of the ABC model from 

23 ‘‘other prevention’’ funding compromised the in24 tegration of their programs. Examples of the 

25 problems they cited include the following: 


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1 (i) Segregating program funding com2 promises the integration of ABC activities, 

3 especially for at-risk groups that need com4 prehensive messages. 

5 (ii) Segregating program funding lim6 its some country teams’ ability to shift pro7 gram focuses to meet changing prevention 

8 needs. 

9 (B) A large majority of the 20 PEPFAR 

10 country teams required to meet the abstinence11 until-marriage spending requirement or obtain 

12 exemptions reported that the requirement pre13 sented challenges to their efforts to respond to 

14 local prevention needs. Seventeen of these 

15 teams reported, either through documents sub16 mitted to the Office of the Global AIDS Coordi17 nator (OGAC) or through structured interviews, 

18 that meeting the spending requirement, includ19 ing OGAC’s 50 percent and 66 percent policies 

20 implementing it, challenged their ability to de21 velop interventions that are responsive to local 

22 epidemiology and social norms. 

23 (C) Between September 2005 and January 

24 2006, ten of these teams submitted documents 

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1 ing requirement as it was defined in OGAC’s 

2 August 2005 guidance. These documents high3 light various challenges that the country teams 

4 associated with meeting the spending require5 ment, including the following: 

6 (i) Reduced spending for Prevention 

7 of Mother to Child Transmission 

8 (PMTCT). 

9 (ii) Limited funding to deliver appro10 priate prevention messaging to high-risk 

11 groups. 

12 (iii) Lack of responsiveness to cultural 

13 and social norms. 

14 (iv) Cuts in medical and blood safety 

15 activities. 

16 (v) Elimination of care programs. 

17 (D) In addition, seven teams that did not 

18 submit documents requesting exemption from 

19 the spending requirement (they did not meet 

20 OGAC’s proposed criteria for requesting exemp21 tions) identified, in structured interviews, spe22 cific program constraints related to meeting the 

23 abstinence-until-marriage spending requirement. 

24 These constraints included the following: 


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1 (i) Difficulty reaching certain popu2 lations with comprehensive ABC messages. 

3 (ii) Limited or reduced funding for 

4 programs targeted at high-risk groups. 

5 (iii) Reduced funding for PMTCT 

6 services. 

7 (iv) Difficulty funding programs for 

8 condom procurement and condom social 

9 marketing. 

10 (b) STATEMENT OF POLICY.—In carrying out the ac11 tivities required by the United States Leadership Against 

12 HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public 

13 Law 108–25; 22 U.S.C. 7601 et seq.) and the amend14 ments made by that Act, it shall be the policy of the 

15 United States— 

16 (1) to provide flexibility to support the imple17 mentation of culturally relevant HIV prevention pro18 grams that are carried out in accordance with the 

19 global HIV prevention strategy established pursuant 

20 to section 3 of this Act; 

21 (2) to ensure that onerous requirements are not 

22 imposed with respect to how funds made available 

23 for such programs can be obligated and expended; 

24 and 


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1 (3) to prevent the unnecessary reduction in 

2 funding for effective HIV programs in order to meet 

3 any such onerous requirements. 

4 (c) AMENDMENTS TO FUNDING PROVISIONS OF THE

5 UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TU6 BERCULOSIS, AND MALARIA ACT OF 2003.— 

7 (1) SENSE OF CONGRESS.—Section 402(b)(3) 

8 of the United States Leadership Against HIV/AIDS, 

9 Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 

10 7672(b)(3)) is amended by striking ‘‘, of which such 

11 amount at least 33 percent should be expended for 

12 abstinence-until-marriage programs’’. 

13 (2) ALLOCATION OF FUNDS.—Section 403(a) of 

14 such Act (22 U.S.C. 7673(a)) is amended by strik15 ing the second sentence. 

16 SEC. 5. DEFINITIONS. 

17 In this Act: 

18 (1) AIDS.—The term ‘‘AIDS’’ means the ac19 quired immune deficiency syndrome. 

20 (2) APPROPRIATE CONGRESSIONAL COMMIT21 TEES.—The term ‘‘appropriate congressional com22 mittees’’ means the Committee on Foreign Affairs of 

23 the House of Representatives and the Committee on 

24 Foreign Relations of the Senate. 


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1 (3) HIV.—The term ‘‘HIV’’ means the human 

2 immunodeficiency virus, the pathogen that causes 

3 AIDS. 

4 (4) HIV/AIDS.—The term ‘‘HIV/AIDS’’ 

5 means, with respect to an individual, an individual 

6 who is infected with HIV or living with AIDS. 

Æ 


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