Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief
Published: 2006-09-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 authorizes the President's Emergency Plan for AIDS Relief (PEPFAR). It promotes the ABC model (Abstain, be faithful, or use Condoms); recommends that 20 percent of funds appropriated pursuant to the act be spent on prevention; and requires that, starting in fiscal year 2006, 33 percent of prevention funds appropriated pursuant to the act be spent on abstinence-until-marriage activities. The Office of the U.S. Global AIDS Coordinator (OGAC) oversees PEPFAR and administers the Global HIV/AIDS Initiative (GHAI) account, the main repository for PEPFAR funds. For our April 2006 report, GAO reviewed PEPFAR prevention funding trends; described the PEPFAR strategy to prevent sexual transmission of HIV; and examined related challenges. The report recommended that the Coordinator collect and report information on the effects of the abstinence-until-marriage spending requirement and use it to, among other things, assess whether the requirement should apply only to the GHAI account. OGAC agreed to collect information but disagreed with applying the requirement only to certain funds; GAO modified the recommendation. GAO also suggested 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.
section_title: What GAO Found
paragraphs: As GAO reported in April 2006, PEPFAR prevention funding in 15 focus countries increased by 55 percent between fiscal years 2004 and 2006, rising from about $207 million to $322 million. During this time, the prevention share of PEPFAR funding in these countries fell by about one-third, in accordance with the Leadership Act's recommendation that 20 percent of funds appropriated pursuant to the act support prevention. The PEPFAR strategy for preventing sexual transmission of HIV/AIDS is largely shaped by three elements--the ABC model, the abstinence-until-marriage spending requirement, and local prevention needs. In addition to adopting the ABC model, OGAC developed guidance for applying it--for instance, that prevention interventions should be integrated and responsive to local needs and cultural norms. To meet the 33 percent spending requirement, OGAC mandated that country teams (PEPFAR officials in the field) spend at least half of prevention funds on sexual prevention and two-thirds of those funds on abstinence/faithfulness (AB) activities. OGAC permitted certain country teams to seek exemptions from this policy. 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. GAO also reported in April 2006 that OGAC's ABC guidance and the abstinence-until-marriage spending requirement, while valued by country teams, have presented challenges to most teams. First, two-thirds of focus country teams told us that ambiguities in some parts of the guidance led to uncertainty about implementing the model; OGAC officials commented they were clarifying the guidance for country teams. Second, although several teams indicated that they value the ABC model and noted the importance of AB messages, some teams also reported that the spending requirement can limit their ability to design programs that are integrated and responsive to local prevention needs. Most country teams reported, either in structured interviews or exemption requests, that fulfilling the spending requirement, including OGAC's policies implementing it, presents challenges to their ability to respond to local needs. Seven focus country 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 are spending more than 33 percent of prevention funds on AB activities, and OGAC should just meet the overall spending requirement for fiscal year 2006. However, to meet the abstinence-until-marriage spending requirement, teams have in some cases reduced or cut funding for certain prevention programs, such as those to deliver comprehensive messages to certain populations. OGAC's decision to apply the spending requirement to all PEPFAR prevention funds may further challenge country teams' ability to address local prevention needs.

section_title: Letter
paragraphs: I am pleased to be here today to discuss HIV prevention efforts funded  under the President’s Emergency Plan for AIDS Relief (PEPFAR).
In January 2003, citing the need “to meet a severe and urgent crisis  abroad,” President Bush announced PEPFAR, a $15 billion, 5-year  initiative to combat the global HIV/AIDS epidemic through prevention,  treatment, and care interventions. The U.S. Leadership Against HIV/AIDS,  Tuberculosis, and Malaria Act of 2003 (Leadership Act), which authorizes  PEPFAR, endorses using the “ABC model” (Abstain, Be faithful, or use  Condoms) to prevent the sexual transmission of HIV. The act also provides  for the establishment of an HIV/AIDS coordinator within the Department  of State (State) to lead the U.S. response to the HIVAIDS epidemic and  oversee all U.S. efforts to combat HIV/AIDS abroad, including  administering an account—known as the Global HIV/AIDS Initiative  (GHAI) account—containing funds appropriated pursuant to the act. The  act recommends that 20 percent of the appropriated funds be dedicated to  HIV/AIDS prevention and requires that, beginning in fiscal year 2006, at  least 33 percent of these prevention funds be spent on abstinence-until- marriage programs. 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 safety— and defined abstinence-until-marriage programs as AB activities.
My remarks will focus on three areas, as discussed in our report issued on  April 4, 2006: (1) trends and allocation of PEPFAR prevention funding, (2)  the PEPFAR strategy for preventing the sexual transmission of HIV, and  (3) key challenges associated with applying this strategy.
My observations are based on the work of our GAO team over the previous  year. For this project, our team conducted structured interviews with U.S.  agency officials responsible for managing PEPFAR in all 15 PEPFAR focus  countries (focus country teams). This structured interview tool was  designed, tested, and reviewed in consultation with our methodologist to  ensure the validity and reliability of our analysis. Our team also reviewed  key PEPFAR documents, such as country teams’ operational plans, and  interviewed U.S. based officials from the key agencies responsible for  implementing PEPFAR—State, the U.S. Agency for International  Development (USAID), and the Centers for Disease Control and  Prevention (CDC)—as well as representatives of several nongovernmental  organizations based in Washington, D.C. In July 2005, the team visited four  PEPFAR focus countries—Botswana, Ethiopia, South Africa, and  Zambia—that it had selected using a set of objective criteria, such as level  and focus of PEPFAR funding. Finally, the team reviewed information  from five additional PEPFAR country teams that receive at least $10  million in U.S. government funding for HIV/AIDS. We conducted this work  in accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: 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 through pregnancy, childbirth, or breastfeeding). The  majority of HIV infections worldwide are transmitted sexually. About two- thirds of the estimated 40 million people currently living with HIV/AIDS  are in sub-Saharan Africa where, according to the Joint United Nations  Programme on HIV/AIDS, adult HIV prevalence averaged 7.4 percent in  2004.
As the entity responsible for developing the U.S. global HIV/AIDS strategy  and administering PEPFAR, OGAC has defined five prevention program  areas—abstinence/faithfulness (AB), “other prevention,” prevention of  mother-to-child transmission (PMTCT), blood safety, and safe medical  injections. These areas are divided into two groups: those aimed at  preventing sexual transmission—AB and “other prevention”—and those  aimed at preventing nonsexual transmission—PMTCT, blood safety, and  safe medical injections. (See fig. 1.)
AB activities encourage abstinence until marriage, delay of first sexual  activity, secondary abstinence, 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.
In fiscal year 2004, the U.S. Congress appropriated $2.4 billion for global  HIV/AIDS efforts, directing $865 million of this amount to four accounts:  (1) the GHAI account, which received most of the funding; (2) the Child  Survival and Health account; (3) the Prevention of Mother to Child  Transmission account; and (4) CDC’s Global AIDS Program. In our April  2006 report, PEPFAR funding refers to funds appropriated to these four  accounts for the 15 focus countries, as well as bilateral HIV/AIDS funding  for the five additional countries that receive at least $10 million in U.S.  government HIV/AIDS funding. 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). These plans are subject to  OGAC’s review and approval. Focus country teams also receive central  funding—multicountry awards that are managed by U.S. agency  headquarters in Washington, D.C. For fiscal years 2004 and 2005, PEPFAR  funding figures are central and country-level appropriations allocated by  OGAC. For fiscal year 2006, PEPFAR funding consists of planned  allocations of central and country-level appropriations.
The Leadership Act specifies the percentage of PEPFAR funds to be  allocated for HIV/AIDS prevention, treatment, and care for fiscal years  2006-2008. The act recommends that 20 percent of funds appropriated  pursuant to the act be spent on prevention and 15 percent on palliative  care for those living with the disease. The act also requires that, beginning  in fiscal year 2006, at least 55 percent of funds appropriated pursuant to  the act be spent on treatment and at least 10 percent on orphans and  vulnerable children. (See fig. 2).
The Leadership Act further requires that at least one-third of prevention  funding appropriated pursuant to the act be spent on abstinence-until- marriage programs, starting in fiscal year 2006. (The act also  recommended this spending distribution for fiscal years 2004 and 2005.) In  June 2004, OGAC notified Congress that it defines abstinence-until- marriage activities as programs that address both abstinence and  faithfulness.
The Leadership Act states that “behavior change, through the use of the  ABC model, is a very successful way to prevent the spread of HIV.” The  model, which the Leadership Act defines as “‘Abstain, Be faithful, and use  Condoms,’ in order of priority,” is based in part on the experience of  Uganda, which implemented an ABC campaign in the 1980s and observed  a decline in HIV/AIDS prevalence by 2001. Although substantial debate  exists about the extent to which each component of the model is  responsible for reducing HIV prevalence in individual countries, there is  general consensus that using the ABC model can have a positive impact in  combating HIV/AIDS. In November 2004, a key consensus statement  authored by leading public health experts and endorsed by more than 125  prominent figures and world leaders observed that “all three elements of   are essential to reducing HIV incidence, although the  emphasis placed on individual elements needs to vary according to the  target population.”
The PEPFAR prevention goal is to avert 7 million infections in the 15 focus  countries by the year 2010. This 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 host  nations. OGAC plans, over time, to estimate progress toward this goal by  using a statistical model of epidemiological trends developed by the U.S.  Census Bureau. This analysis will compare “expected” HIV incidence rates  in particular countries with “actual” incidence rates, using those  comparisons to estimate the number of infections that have been averted  through PEPFAR and other prevention programs. However, it cannot  attribute this change to any specific intervention or to the success of  particular types of programs. The approach involves substantial challenges  and the reliability of the estimates is not known, according to Census  officials. Key challenges include a lack of data on prevalence rates in many  developing countries and the fact that impacts of behavioral change  programs can occur over a period of time. OGAC initially considered using  a different methodology—the Goals model—that links estimates of  infections averted to specific types of prevention programs carried out  under PEPFAR and their spending levels. However, OGAC concluded that  this model could yield misleading results and was not the best method to  adopt. To acquire information about the effectiveness of specific PEPFAR  prevention programs, especially in the AB area, OGAC plans to fund  targeted evaluations on a very limited scale.
section_title: PEPFAR Prevention Funding in the Focus Countries Grew Significantly during First 3 Years
paragraphs: PEPFAR prevention funding increased significantly between fiscal years  2004 and 2006, while the proportion of total PEPFAR funding dedicated to  prevention declined. Country teams reported varying allocations among  the five prevention program areas. We found that challenges and  inconsistencies in country teams’ categorization of funding for certain  ABC programs and broad sexual transmission prevention activities  resulted in some limitations in the reliability of reported allocations for  sexual transmission prevention.
PEPFAR prevention funding in the 15 focus countries increased by more  than 40 percent, from $207 million in fiscal year 2004 to $294 million in  fiscal year 2005. It further increased by about 10 percent, to $322 million,  in fiscal year 2006. (See fig. 3.)
At the same time, the proportion of PEPFAR funding dedicated to  prevention in the 15 focus countries 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. 4.) 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.
The total proportion of PEPFAR prevention funding that the 15 focus  country teams reported allocating to each of the five prevention programs  varied to some extent across fiscal years 2004-2006. (See fig. 5.)
Challenges and inconsistencies in country teams’ categorization of funding  for certain integrated ABC activities and some broad sexual transmission  prevention activities cause some limitations in the reliability of the  allocations reported for AB and “other prevention.” For example, in their  country operational plans, some teams categorized integrated ABC  programs entirely as “other prevention,” while others divided some or all  of these programs between the AB and “other prevention” categories. In  addition, certain broader components of sexual transmission prevention  programs that are not clearly defined as AB or “other prevention,” such as  activities to prevent substance abuse, may appear in either program area  in the teams’ operational plans. 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.
section_title: PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC Approach, Abstinence-Until- Marriage Spending Requirement, and Local Prevention Needs
paragraphs: The PEPFAR strategy for preventing sexual transmission of HIV is shaped  largely by three components: the ABC model, the abstinence-until- marriage spending requirement, and local prevention needs.
The model should be applied in accordance with local prevention needs.
Prevention activities should be integrated.
Prevention activities should be coordinated with the HIV/AIDS strategies of host  governments.
Prevention interventions should be driven by best practices.
OGAC’s guidance to the field 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.” The ABC guidance also specifies the components of the ABC  model that should be targeted to certain populations and sets parameters  on the prevention messages that may be delivered to youths. For example,  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 give  integrated ABC information to youths older than 14. Other rules include  the following:    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. At-risk groups include, among others, sexually  active discordant couples and those who have sex with one whose HIV  status is unknown.
To meet the 33 percent abstinence-until-marriage spending requirement,  OGAC issued policies in late August 2005 instructing each of the 15 focus  country teams and 5 additional teams to spend at least 50 percent of their  prevention funding on sexual transmission prevention and at least 66  percent of that amount on AB activities. To show compliance with the  spending requirement, country teams’ operational plans must isolate the  amount of funding dedicated to AB activities. OGAC allows country teams  to request exemption from its 50 percent and 66 percent policies.  However, the guidance cautions that, in a generalized epidemic, a very  strong justification is required for not meeting the 66 percent policy and  adds that OGAC expects all focus country teams, particularly those with  total PEPFAR funding exceeding $75 million, to adhere to the policies.  Finally, OGAC directed country teams to apply the spending requirement  to all PEPFAR prevention funding (about $357 million in fiscal year 2006),  although it determined that, as a matter of law, the requirement applies  only to funds appropriated to the GHAI account (about $322 million in  fiscal year 2006).
section_title: ABC Guidance and Abstinence-Until- Marriage Spending Requirement Present Challenges for Country Teams
paragraphs: As our April 2006 report discusses, country teams face challenges related  to both the ABC guidance and the Leadership Act’s abstinence-until- marriage spending requirement. Two-thirds of focus country teams  reported that a lack of clarity in aspects of the ABC guidance has led to  interpretation and implementation challenges. About half of the country  teams indicated that adherence to the spending requirement can  undermine the integrated nature of HIV/AIDS prevention programs. In  addition, most country teams required to meet the requirement, absent  exemptions, reported either in structured interviews or exemption  requests that the requirement challenges their ability to allocate  prevention resources in accordance with local HIV/AIDS prevention needs.  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.
subsections: section_title: Challenges Related to ABC Guidance
paragraphs: We reported in April 2006 that, although many focus country teams told us  that they generally found the ABC guidance to be clear and several said  that it did not present implementation challenges, 10 of the 15 focus teams  cited instances where components of the guidance were ambiguous and  caused confusion. First, 6 focus country teams expressed uncertainty  regarding the populations that should be considered at-risk in accordance  with the guidance, and 5 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.  Second, teams reported that the ABC guidance does not clearly delineate  permissible condom-related activities, causing confusion about proper use  of PEPFAR funds. For example, 5 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. Third, the ABC  guidance does not discuss how the age cutoff for providing condom  information should be applied to groups that include youths younger and  older than 15. We reported in April that OGAC officials told us they were  working to clarify confusing components of the guidance, including  distributing to country teams a document with some additional  clarification on how to apply the ABC guidance.
section_title: Challenges Related to Abstinence-until-Marriage Spending Requirement
paragraphs: 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, because of the country’s high HIV/AIDS prevalence rate,  abstinence is an appropriate message for both youths and adults.
However, the abstinence-until-marriage spending requirement presented  challenges to country teams’ ability to implement integrated prevention  programs. Because the abstinence-until-marriage spending requirement  requires them to segregate AB funding from funding for “other  prevention,” 8 of the 15 focus country teams reported that the spending  requirement can undermine their ability to design and implement  programs that integrated the components of the ABC model. For example,  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 activities that should be integrated and  potentially lowers effectiveness.
In addition, 17 of the 20 PEPFAR country teams required to meet the  abstinence-until-marriage spending requirement, absent exemptions,  reported that the requirement presents challenges to their efforts to  respond to local prevention needs. Ten of these 17 teams requested  exemptions, citing a variety of concerns, such as reduced spending for  PMTCT, limited funding to deliver appropriate prevention messaging to  high-risk groups, lack of responsiveness to cultural and social norms, cuts  in medical and blood safety activities, and elimination of care programs.  The remaining 7 teams, which did not meet OGAC’s proposed criteria for  requesting exemptions, also identified a variety of constraints related to  meeting the requirement, including difficulty in reaching certain  populations with comprehensive ABC messages, limited or reduced  funding for programs targeted at high-risk groups, reduced funding for  PMTCT services, and difficulty in funding programs for condom  procurement and condom social marketing.
The analysis in our April 2006 report showed that, with the approval of all  10 exemption requests, OGAC should just meet the overall 33 percent  target for AB activities for fiscal year 2006 by effectively allowing  exempted teams to spend less than 33 percent on AB programs and  requiring nonexempted teams to spend more than 33 percent. Our report  found that all but one of the exempted teams planned to dedicate less than  33 percent of funds to AB activities—about 23 percent on average—while,  on average, each of the nonexempted country teams planned to spend  around 37 percent.
In allocating funds to meet the spending requirement, country teams are  primarily limited to shifting resources among three prevention program  areas—AB, “other prevention,” and PMTCT. (This limitation occurs  because the overwhelming majority of funds spent on safe medical  injections and blood safety are centrally awarded funds, over which the  country teams have no budgetary control.) If, for example, a country  team’s planned funding has less than a 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.
Our analysis found that nonexempted country teams’ allocations for “other  prevention” funding declined between fiscal year 2005 and fiscal year  2006. 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 6 shows the allocation of prevention  funds by nonexempted and exempted focus country teams for fiscal years  2005 (actual funds) and 2006 (planned funds).
As figure 6 shows, 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.
Finally, OGAC’s decision to apply the spending requirement to all PEPFAR  prevention funding—although OGAC had determined that, as a matter of  law, the requirement applies only to funds appropriated to the GHAI  account—may further challenge some teams’ ability to address HIV  prevention needs at the local level. For fiscal year 2006, non-GHAI  prevention funds amounted 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, some country teams are  constrained from allocating non-GHAI funding to meet local needs if the  allocations do not comply with the spending requirement.
section_title: Concluding Observations
paragraphs: In conclusion, our analysis of HIV/AIDS prevention efforts funded under  PEPFAR reported in our April 2006 report showed that, although country  teams consistently value the ABC model as a useful tool for preventing  HIV, the Leadership Act’s 33 percent abstinence-until-marriage spending  requirement has presented challenges to their ability to adhere to the  PEPFAR sexual transmission prevention strategy. In particular, it has  challenged their ability to integrate the components of the ABC model and  respond to local needs, local epidemiology, and distinctive social and  cultural patterns. OGAC’s application of the spending requirement to $35  million in funds not appropriated to the GHAI account may further hamper  some country teams’ ability to develop locally responsive prevention  programs. OGAC may be able to address some of the constraints country  teams face by reconsidering this policy, but the amount of non-GHAI  funding is relatively small and the underlying challenges that country  teams face in having to reserve a specific percentage of their prevention  funds for abstinence-until-marriage programs would remain.
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, our April 2006 report recommended that the Secretary  of State direct the U.S. Global AIDS Coordinator to take the following  actions:    Collect information from the country teams each fiscal year on the  spending requirement’s effects on their HIV sexual transmission  prevention programming. This information should include, for example,  the justifications submitted by country teams requesting exemption from  the spending requirement.
Provide this information in an annual report to Congress.
Use the information collected to, among other things, assess whether the  spending requirement should be applied solely to funds appropriated to  the Global HIV/AIDS Initiative account, in line with OGAC’s legal  determination that the requirement applies only to these funds.
In commenting jointly on a draft of our April 2006 report, the Department  of State/OGAC, HHS, and USAID reiterated their strong commitment to  fight HIV/AIDS and also noted the importance of the ABC model in  preventing sexual transmission of HIV. The agencies agreed with our  recommendation to collect information regarding the effects of the  Leadership Act’s abstinence-until-marriage spending requirement. They  disagreed with a draft recommendation regarding applying the abstinence- until-marriage spending requirement only to funds appropriated to the  GHAI account, citing concerns about the effect on a unified budget  approach and noting the small amount of non-GHAI funding that the focus  countries receive. We modified our recommendation to recommend that  they consider this policy change after collecting information on the effect  of the spending requirement. However, we noted that the five additional  countries required, absent exemptions, to meet the spending requirement  received more than 80 percent of their funds through non-GHAI accounts.
section_title: Matters for Congressional Consideration
paragraphs: 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, our April 2006  report also suggested that Congress, in its ongoing oversight of PEFAR,  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.
Mr. Chairman and members of the committee, this concludes my prepared  statement. I will be happy to answer any questions you may have at this  time.
section_title: Contacts and Acknowledgments
paragraphs: For information on this statement, please contact David Gootnick,  Director, International Affairs and Trade, at (202) 512-3149. You may also  reach him by email at gootnickd@gao.gov. Other individuals who made  key contributions to this testimony include Celia Thomas (Assistant  Director), Elizabeth Singer, Chad Davenport, and Reid Lowe.
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