[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5674 Introduced in House (IH)]








109th CONGRESS
  2d Session
                                H. R. 5674

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

                             June 22, 2006

Ms. Lee (for herself, Mr. Leach, Mr. Lantos, Mrs. Maloney, Ms. Corrine 
 Brown of Florida, Ms. Jackson-Lee of Texas, Mr. Jefferson, Mr. Payne, 
 Mr. Gutierrez, Ms. Norton, Mr. Honda, Ms. Schakowsky, Mr. McDermott, 
   Mr. Conyers, Mr. Waxman, Mr. Berman, Ms. Woolsey, Ms. Waters, Mr. 
 McGovern, Mr. Crowley, Mr. Brown of Ohio, Mrs. McCarthy, Mr. Wexler, 
Mrs. Christensen, Mr. Meeks of New York, Ms. McCollum of Minnesota, Mr. 
   Capuano, Mr. Shays, Mr. Pallone, Mrs. Capps, Mr. Blumenauer, Ms. 
 McKinney, Mr. Owens, Mr. Cummings, Mr. Carnahan, Mr. Wynn, Ms. Solis, 
      Mr. Nadler, Mr. Davis of Illinois, Mr. Stark, Mr. Frank of 
   Massachusetts, Mr. Moran of Virginia, Mr. Scott of Virginia, Mr. 
  Clyburn, Mr. Delahunt, Ms. Kilpatrick of Michigan, Mr. Sanders, Ms. 
  Watson, Mr. Rush, Mr. Kucinich, Mr. Grijalva, Mr. Lewis of Georgia, 
  Mrs. Tauscher, Mr. Jackson of Illinois, Mr. Bishop of Georgia, Ms. 
   Carson, and Ms. Harman) introduced the following bill; which was 
          referred to the Committee on International Relations

_______________________________________________________________________

                                 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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Protection Against Transmission of 
HIV for Women and Youth Act of 2006''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Globally, the United Nations Joint Program on AIDS 
        (UNAIDS) estimates that at the end of 2005 there were more than 
        38,600,000 people infected with HIV/AIDS, the vast majority of 
        whom are living in the developing world.
            (2) According to the World Health Organization (WHO) 
        unprotected heterosexual sex is now the single most important 
        factor in the spread of HIV infections worldwide, representing 
        80 percent of new infections in sub-Saharan Africa.
            (3) According to UNAIDS, women and adolescent girls account 
        for about half of all HIV infections worldwide. In sub-Saharan 
        Africa, women and girls make up 60 percent of all infections 
        and 76 percent of infections among those ages 15-24.
            (4) Women and girls are biologically, socially, and 
        economically more vulnerable to HIV infection. Gender 
        disparities in the rate of HIV infection are the result of a 
        number of factors, including the following:
                    (A) Cross generational sex with older men who are 
                more likely to be infected with HIV, and a lack of 
                choice regarding when and whom to marry, leading to 
                early marriages and high rates of child marriages with 
                older men. About half of all adolescent females in 
                Africa and two-thirds of adolescent in Asia are married 
                by age 18.
                    (B) High rates of infection within marriage. 
                Research shows that married girls are more likely to 
                have unprotected sex and have far more frequent sex 
                than their unmarried peers, indicating that marriage 
                cannot be considered a protective factor against HIV 
                infection.
                    (C) An inability to negotiate safe sex in marriage 
                or with regular partners. Studies show that married 
                women and married and unmarried adolescent females 
                often are unable to negotiate the frequency and timing 
                of sexual intercourse, ensure their partner's 
                faithfulness, or insist on condom use. Women often run 
                the risk of being infected by husbands or male partners 
                in societies where it is common or accepted for men to 
                have more than one partner.
                    (D) Social and economic inequalities based largely 
                on gender which limit access for women and girls to 
                education and employment opportunities and which 
                prevent them from asserting their inheritance and 
                property rights. For many women, a lack of independent 
                economic means sustains their fear of abandonment, 
                eviction, or ostracism from their homes and 
                communities, and can leave many more of them trapped 
                within relationships where they are vulnerable to HIV 
                infection.
                    (E) A lack of educational opportunities for women 
                and girls which are linked to delayed intercourse, 
                increased age-at-marriage, delayed childbearing, 
                increased child survival, improved nutrition, and 
                reduced risk of HIV infection, among other positive 
                outcomes.
                    (F) High rates of gender-based violence, rape, and 
                sexual coercion within and outside of marriage. 
                According to the WHO, between one-sixth and three-
                quarters of women in various countries and settings 
                have experienced some form of physical or sexual 
                violence since age 15.
                    (G) Fear of domestic violence and the continuing 
                stigma and discrimination associated with HIV/AIDS 
                prevents many women from accessing information about 
                HIV/AIDS, getting tested, disclosing their HIV status, 
                accessing services to prevent mother-to-child 
                transmission, or receiving treatment and counseling 
                even when they already know they have been infected 
                with HIV.
                    (H) An increase in commercial sex for survival, due 
                to pervasive poverty, social dislocation, war and 
                internal conflicts, and other factors. According to 
                UNAIDS, the vulnerability of sex workers to HIV 
                infection is heightened by stigmatization and 
                marginalization, limited economic options, limited 
                access to health, social, and legal services, limited 
                access to information and prevention means, gender-
                related differences and inequalities, sexual 
                exploitation and trafficking, harmful or nonprotective 
                legislation and policies, and exposure to risks 
                associated with commercial sex such as violence, 
                substance use, and increased mobility.
                    (I) Lack of access to basic HIV prevention 
                information, education, and services, and lack of 
                coordination with existing reproductive health services 
                to reduce stigma and maximize coverage.
                    (J) Lack of access to currently available female-
                controlled HIV prevention methods, such as the female 
                condom, and lack of training on proper use of either 
                male or female condoms.
                    (K) High rates of other sexually transmitted 
                infections, unintended pregnancy, and complications 
                during pregnancy and childbirth.
                    (L) An absence of legal frameworks designed to 
                protect the rights of women and girls and the lack of 
                accountable and effective enforcement of such 
                frameworks, where they exist.
            (5) Efforts to increase women's access to comprehensive 
        prevention information and services, address gender violence, 
        increase women's economic and social status, and foster 
        equitable partnerships between women and men are all central to 
        reducing the spread of HIV/AIDS worldwide and to enhancing the 
        success of effective treatment and care programs supported by 
        the United States.
            (6) The comprehensive, integrated, five-year strategy to 
        combat global HIV/AIDS submitted to Congress on February 23, 
        2004, as required by section 101 of the United States 
        Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 
        2003 (Public Law 108-25; 22 U.S.C. 7611), does not adequately 
        focus or provide sufficient details on how the United States 
        Government plans to address the factors that lead to gender 
        disparities in the rate of HIV infection in order to 
        successfully prevent HIV infection among both married and 
        unmarried women and girls.

SEC. 3. STRATEGY TO PREVENT HIV INFECTIONS AMONG MARRIED AND UNMARRIED 
              WOMEN AND GIRLS.

    (a) Statement of Policy.--In order to meet the stated goal of 
preventing 7,000,000 new HIV infections worldwide, as announced by 
President George W. Bush in his address to Congress on January 28, 
2003, it shall be the policy of the United States to pursue a global 
HIV prevention strategy that emphasizes the immediate and ongoing needs 
of married and unmarried women and girls and addresses the factors that 
lead to gender disparities in the rate of HIV infection.
    (b) Strategy.--Not later than 180 days after the date of the 
enactment of this Act, the President shall formulate and submit to the 
appropriate congressional committees, and make available to the public, 
a comprehensive, integrated, and culturally appropriate global HIV 
prevention strategy that addresses the vulnerabilities of married and 
unmarried women and girls to HIV infection and seeks to reduce the 
factors that lead to gender disparities in the rate of HIV infection. 
The strategy shall encompass comprehensive health and HIV prevention 
education at the individual and population level beyond the ABC model 
(``Abstain, Be faithful, use Condoms'') as a means to reduce HIV 
infections and shall include the following strategies:
            (1) Empowering women and girls to avoid cross-generational 
        sex and to decide when and whom to marry in order to reduce the 
        incidence of early- or child-marriage.
            (2) Dramatically increasing access to currently available 
        female-controlled prevention methods and including investments 
        in training to increase the effective and consistent use of 
        both male and female condoms.
            (3) Accelerating the destigmatization of HIV/AIDS, as women 
        are generally at a disadvantage in combating stigma.
            (4) Addressing gender based violence and rape against women 
        and girls.
            (5) Promoting male attitudes and behavior that respect the 
        human rights of women and girls and that support and foster 
        gender equality.
            (6) Supporting the development of micro-enterprise 
        initiatives, job training programs, and other such efforts to 
        assist women in developing and retaining independent economic 
        means.
            (7) Supporting expanded educational opportunities for women 
        and girls.
            (8) Protecting the property and inheritance rights of 
        women.
            (9) Coordinating HIV prevention information and education 
        services with existing health care services targeted to women 
        and girls, such as family planning, comprehensive reproductive 
        health services, and programs to reduce the transmission of HIV 
        between parents and children, and expanding the reach of such 
        health services.
            (10) Promoting gender equality by supporting the 
        development of civil society organizations focused on the needs 
        of women and utilizing such organizations that are already 
        empowering women and girls at the community level.
            (11) Encouraging the creation and effective enforcement of 
        legal frameworks that guarantee women equal rights and equal 
        protection under the law.
            (12) Responding to other economic and social factors that 
        increase the vulnerability of women and girls to HIV infection.
    (c) Coordination.--In formulating and implementing the global HIV 
prevention strategy pursuant to subsection (b), the President shall 
ensure that the United States coordinates its overall HIV/AIDS policy 
and programs with the national governments of the countries for which 
the United States provides assistance to combat HIV/AIDS and with 
international organizations, other donor countries and indigenous 
organizations, including specifically organizations focused on 
expanding and enforcing women's rights, improving women's health, and 
expanding education for women and girls, and organizations advocating 
on behalf of individuals infected with and affected by HIV/AIDS.
    (d) Guidance.--The President shall provide clear guidance to field 
missions of the United States Government in countries for which the 
United States provides assistance to combat HIV/AIDS, based on the 
strategies specified under subsection (b), and shall submit to the 
appropriate congressional committees and make available to the public 
such guidance. Such guidance shall also include operational definitions 
and a clear articulation of acceptable and prohibited activities 
related to funding limitations for organizations working with 
vulnerable and marginalized populations such as commercial sex workers, 
in accordance with subsections (e) and (f) of section 301 of the United 
States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 
2003 (Public Law 108-25; 22 U.S.C. 7631).
    (e) Monitoring and Evaluation System.--
            (1) In general.--The President shall develop and implement 
        a monitoring and evaluation system in order to measure the 
        effectiveness of United States assistance in preventing HIV 
        infection among women and girls and in addressing the factors 
        that lead to gender disparities in the rate of HIV infection.
            (2) Requirements.--For each of the countries for which the 
        United States provides assistance to combat HIV/AIDS, and in 
        consultation with national governments, international 
        organizations, indigenous organizations, and other donor 
        countries, the monitoring and evaluation system under this 
        subsection shall--
                    (A) establish performance goals for such assistance 
                and express such goals in an objective and quantifiable 
                form, to the maximum extent practicable;
                    (B) establish performance indicators to be used in 
                measuring or assessing the achievement of the 
                performance goals established pursuant to subparagraph 
                (A);
                    (C) measure rates of HIV incidence and prevalence 
                among women and girls by age and marital status;
                    (D) measure rates of marriage for girls under the 
                age of 18;
                    (E) measure rates for children in school;
                    (F) measure access rates to primary health care, 
                including primary reproductive health and HIV 
                prevention programs, services, and technologies;
                    (G) measure utilization rates by married and 
                unmarried women of HIV prevention services and 
                commodities directly funded or supported by the United 
                States;
                    (H) measure rates of reported gender-based violence 
                and sexual coercion; and
                    (I) measure the prevalence of social norms and 
                beliefs supporting gender-based violence among women 
                and men, to the maximum extent practicable.
            (3) Use of scientific surveys.--Where appropriate, the 
        President may utilize any existing scientific surveys to 
        augment the measurements required under subparagraphs (C) 
        through (I) of paragraph (2).
    (f) Report.--Not later than one year after the date of the 
enactment of this Act and annually thereafter as part of the annual 
report required under section 104A(e) of the Foreign Assistance Act of 
1961 (22 U.S.C. 2151b-2(e)) the President shall submit to the 
appropriate congressional committees and make available to the public a 
report on the implementation of this Act for the prior fiscal year. The 
report shall include the following information:
            (1) The results of the monitoring and evaluation system 
        required under subsection (e).
            (2) A description of the prevention programs designed to 
        address the vulnerabilities to HIV/AIDS of married and 
        unmarried women and girls.
            (3) A list of all nongovernmental organizations in each 
        country that receive assistance from the United States to carry 
        out HIV prevention activities, including the amount and the 
        source of funding received.

SEC. 4. BALANCING FUNDING FOR HIV PREVENTION METHODS.

    (a) Findings.--Congress finds the following:
            (1) While effective evidence-based and measurable 
        strategies for delaying sexual debut are critical components of 
        comprehensive HIV prevention programs, current United States 
        funded HIV prevention programs based on the ABC model of 
        ``Abstain, Be faithful, use Condoms'' are too narrow in scope 
        and do not respond to the specific vulnerabilities of women and 
        girls.
            (2) In order to maximize the impact of United States 
        foreign assistance to combat HIV/AIDS, all sexually active 
        persons in each country must be equipped with all the skills 
        and tools necessary to avoid infection, including information 
        and training on delay of sexual debut and the practice of safer 
        sex, whether sexual activity begins within or outside of 
        marriage.
            (3) Under section 403(a) of the United States Leadership 
        Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public 
        Law 108-25; 22 U.S.C. 7673), 33 percent of all United States 
        foreign assistance provided for preventing the spread of HIV 
        must be spent on abstinence-until-marriage programs. Based on 
        operational guidance to field missions of the United States 
        Government, in order to meet this requirement, 50 percent of 
        all United States foreign assistance provided for preventing 
        the spread of HIV at the country level must be spent on 
        prevention of sexual transmission and 66 percent of all such 
        funding for sexual transmission must be spent on the Abstinence 
        and Be faithful components of the ABC model.
            (4) A recent report by the Government Accountability Office 
        (Global Health: Spending Requirement Presents Challenges for 
        Allocating Prevention Funding under the President's Emergency 
        Plan for AIDS Relief, GAO-06-395, April 4, 2006) found the 
        following:
                    (A) Because it requires country teams to segregate 
                the Abstinence and Be faithful components of the ABC 
                model 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 President's 
                Emergency Plan for AIDS Relief (PEPFAR) sexual 
                transmission prevention strategy. Eight of the 15 focus 
                country teams indicated that segregating the Abstinence 
                and Be faithful components of the ABC model from 
                ``other prevention'' funding compromised the 
                integration of their programs. Examples of the problems 
                they cited include the following:
                            (i) Segregating program funding compromises 
                        the integration of ABC activities, especially 
                        for at-risk groups that need comprehensive 
                        messages.
                            (ii) Segregating program funding limits 
                        some country teams' ability to shift program 
                        focuses to meet changing prevention needs.
                    (B) 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 presented challenges to their efforts to 
                respond to local prevention needs. Seventeen of these 
                teams reported, either through documents submitted to 
                Office of the Global AIDS Coordinator (OGAC) or through 
                structured interviews, that meeting the spending 
                requirement, including OGAC's 50 percent and 66 percent 
                policies implementing it, challenged their ability to 
                develop interventions that are responsive to local 
                epidemiology and social norms.
                    (C) Between September 2005 and January 2006, ten 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:
                            (i) Reduced spending for Prevention of 
                        Mother to Child Transmission (PMTCT).
                            (ii) Limited funding to deliver appropriate 
                        prevention messaging to high-risk groups.
                            (iii) Lack of responsiveness to cultural 
                        and social norms.
                            (iv) Cuts in medical and blood safety 
                        activities.
                            (v) Elimination of care programs.
                    (D) In addition, seven teams that did not submit 
                documents requesting exemption from the spending 
                requirement (they did not meet OGAC's proposed criteria 
                for requesting exemptions) identified, in structured 
                interviews, specific program constraints related to 
                meeting the abstinence-until-marriage spending 
                requirement. These constraints included the following:
                            (i) Difficulty reaching certain populations 
                        with comprehensive ABC messages.
                            (ii) Limited or reduced funding for 
                        programs targeted at high-risk groups.
                            (iii) Reduced funding for PMTCT services.
                            (iv) Difficulty funding programs for condom 
                        procurement and condom social marketing.
    (b) Statement of Policy.--In carrying out the activities required 
by the United States Leadership Against HIV/AIDS, Tuberculosis, and 
Malaria Act of 2003 (Public Law 108-25; 22 U.S.C. 7601 et seq.) and the 
amendments made by that Act, it shall be the policy of the United 
States--
            (1) to provide flexibility to support the implementation of 
        culturally appropriate HIV prevention programs that are carried 
        out in accordance with the global HIV prevention strategy 
        established pursuant to section 3 of this Act;
            (2) to ensure that onerous requirements are not imposed 
        with respect to how funds made available for such programs can 
        be obligated and expended; and
            (3) to prevent the unnecessary reduction in funding for 
        effective HIV programs in order to meet such onerous 
        requirements.
    (c) Amendments to Funding Provisions of United States Leadership 
Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.--
            (1) Sense of congress.--Section 402(b)(3) of the United 
        States Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
        Act of 2003 (22 U.S.C. 7672(b)(3)) is amended by striking ``, 
        of which such amount at least 33 percent should be expended for 
        abstinence-until-marriage programs''.
            (2) Allocation of funds.--Section 403(a) of such Act (22 
        U.S.C. 7673(a)) is amended by striking the second sentence.

SEC. 5. DEFINITIONS.

    In this Act:
            (1) AIDS.--The term ``AIDS'' means the acquired immune 
        deficiency syndrome.
            (2) Appropriate congressional committees.--The term 
        ``appropriate congressional committees'' means the Committee on 
        International Relations of the House of Representatives and the 
        Committee on Foreign Relations of the Senate.
            (3) HIV.--The term ``HIV'' means the human immunodeficiency 
        virus, the pathogen that causes AIDS.
            (4) HIV/AIDS.--The term ``HIV/AIDS'' means, with respect to 
        an individual, an individual who is infected with HIV or living 
        with AIDS.
                                 <all>