Findings

Congress makes the following findings: (1)The President’s Emergency Plan for AIDS Relief (in this Act referred to as PEPFAR) is an unprecedented effort to combat the global AIDS epidemic, with $9,000,000,000 targeted for initiatives in 15 focus countries. (2)The PEPFAR prevention goal is to avert 7,000,000 HIV infections in the 15 focus countries—most in sub-Saharan Africa where heterosexual intercourse is by far the predominant mode of HIV transmission. (3)The PEPFAR strategy for prevention of sexual transmission of HIV is shaped by 3 elements: the ABC model, defined as Abstain, Be faithful, use Condoms, the promotion of abstinence-until-marriage, and deference to local prevention needs. (4)The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 requires that at least one-third of all prevention funds be reserved for abstinence-until-marriage programs. In implementing this requirement, the U.S. Global AIDS Coordinator has required that 50 percent of prevention funding be dedicated to sexual transmission prevention activities. This requirement severely limits countries from employing strategies for the prevention of sexual transmission other than abstinence, because the other sexual transmission prevention programs under PEPFAR (such as the purchase of condoms and management of sexually transmitted infections) cannot exceed one-sixth of the total prevention funds. (5)The Government Accountability Office (GAO) issued a report in April, 2006, “Spending Requirement Presents Challenges For Allocating Funding under the President’s Emergency Plan for AIDS Relief”, that found significant challenges associated with meeting the earmark for abstinence-until-marriage programs. (6)GAO found that a majority of country teams report that fulfilling the requirement presents challenges to their ability to respond to local epidemiology and cultural and social norms. (7)GAO found that, although some country teams may be exempted from the abstinence-until-marriage spending requirement, country teams that are not exempted have to spend more than the 33 percent of prevention funds on abstinence-until-marriage activities—sometimes at the expense of other programs. (8)Indeed, according to GAO, the proportion of HIV prevention funds dedicated to other prevention activities (i.e. the purchase and promotion of condoms, management of sexually transmitted infections other than HIV, and messages or programs to reduce injection drug use) declined from 23 percent in fiscal year 2005 to 18 percent in fiscal year 2006 for country teams that did not receive exemptions. (9)GAO found that, as a result of the abstinence-until-marriage spending requirement, some countries have had to reduce planned funding for Prevention of Mother-to-Child Transmission programs, thereby limiting services for pregnant women and their children. (10)GAO found that the abstinence-until-marriage spending requirement limited or reduced funding for programs directed to high-risk groups, such as services for married discordant couples, sexually active youth, and commercial sex workers. (11)GAO found that the abstinence-until-marriage spending requirement made it difficult for countries to fund medical and blood safety activities. (12)GAO found that, because of the abstinence-until-marriage spending requirement, some countries would likely have to reduce funding for condom procurement and condom social marketing. (13)In addition, GAO found that two-thirds of focus country teams reported that the policy for implementing the ABC model is unclear and open to varying interpretations, causing confusion about which groups may be targeted and whether youth may receive the ABC message. (14)GAO found that the ABC guidance does not clearly delineate permissible C activities under the ABC model. Program staff reported that they feel constrained by restrictions on promoting or marketing condoms to youth. Other country teams reported confusion about whether PEPFAR funds may be used for broad condom social marketing, even to adults in a generalized epidemic. (15)Each day, an estimated 13,400 people worldwide are newly infected with HIV. (16)Sub-Saharan Africa is home to almost two-thirds of the estimated 40,000,000 people currently living with HIV. (17)In many African countries, the epidemic has spread among the general population. The HIV prevalence rate for the general population is 8 percent across sub-Saharan Africa. Among the United States focus countries in sub-Saharan Africa, the HIV prevalence rate ranges from 4 percent in Uganda to 37 percent in Botswana. (18)According to the Joint United Nations Programme on HIV/AIDS, young people between the ages of 15 and 24 are the most threatened by AIDS and are at the centre of HIV vulnerability. Globally, this age group accounts for half of all new HIV cases each year. More than 7,000 young people contract the virus every day. (19)Most young people in sub-Saharan Africa have sex before marriage during their adolescent years. In many countries, at least half of all women have sex before age 20 and before marriage. Among young men, more than 70 percent have premarital sex before age 20. (20)Many adolescents, who are sexually active and not yet married, have inadequate information on how to protect themselves against HIV. Fewer than half of young people in sub-Saharan Africa mention abstinence, monogamy, or condom use as a way of avoiding HIV. (21)Young people who have sex are at greater risk of acquiring HIV than adults, partly because of their lack of knowledge. They are apt to change partners frequently, have more than 1 partner in the same time period, or engage in unprotected sex. (22)Coercion and sexual violence undercut the ability of young people—women in particular—to prevent HIV and contribute to the vulnerability to infection. In addition, gender inequality makes it much more difficult for young women to negotiate abstinence from sex or to insist that their partners remain faithful or use condoms. (23)Marriage does not protect young women from HIV, even when they are faithful to their husbands. In some settings, it appears marriage actually increases a woman’s HIV risk. In some African countries, married women aged 15–19 have higher HIV infection levels than nonmarried sexually active women of the same age. (24)A recent USAID-funded review found that sex and HIV education programs that encourage abstinence but also discuss the use of condoms do not increase sexual activity as critics of sex education have long alleged. Sex education can help delay the initiation of intercourse, reduce the frequency of sex and the number of sexual partners, and also increase condom use. (25)Young people are our greatest hope for changing the course of the AIDS epidemic. According to the World Health Organization, “Focusing on young people is likely to be the most effective approach to confronting the epidemic, particularly in high prevalence countries.”.