Global Health: Spending Requirement Presents Challenges for
Allocating Prevention Funding under the President's Emergency
Plan for AIDS Relief (06-SEP-06, GAO-06-1089T).
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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-1089T
ACCNO: A60333
TITLE: Global Health: Spending Requirement Presents Challenges
for Allocating Prevention Funding under the President's Emergency
Plan for AIDS Relief
DATE: 09/06/2006
SUBJECT: Accountability
Acquired immunodeficiency syndrome
Appropriated funds
Disease control
Disease detection or diagnosis
Funds management
Health care programs
Program evaluation
Risk management
Sexually transmitted diseases
Strategic planning
Global HIV/AIDS Initiative
President's Emergency Plan for AIDS
Relief
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GAO-06-1089T
* Summary
* Background
* PEPFAR Prevention Funding in the Focus Countries Grew Signif
* PEPFAR Sexual Transmission Prevention Strategy Is Driven by
* ABC Guidance and Abstinence-Until-Marriage Spending Requirem
* Challenges Related to ABC Guidance
* Challenges Related to Abstinence-until-Marriage Spending Req
* Concluding Observations
* Matters for Congressional Consideration
* Contacts and Acknowledgments
* GAO's Mission
* Obtaining Copies of GAO Reports and Testimony
* Order by Mail or Phone
* To Report Fraud, Waste, and Abuse in Federal Programs
* Congressional Relations
* Public Affairs
Testimony
Before the Subcommittee on National Security, Emerging Threats, and
International Relations, Committee on Government Reform, House of
Representatives
United States Government Accountability Office
GAO
For Release on Delivery Expected at 1 p.m. EDT/EST
September 6, 2006
GLOBAL HEALTH
Spending Requirement Presents Challenges for Allocating Prevention Funding
under the President's Emergency Plan for AIDS Relief
Statement of David Gootnick, Director International Affairs and Trade
GAO-06-1089T
Mr. Chairman and Members of the Subcommittee:
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 20031 (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, 2006:2 (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
countries3 (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.4 We conducted this work in accordance
with generally accepted government auditing standards.
1Pub. L. No. 108-25.
2GAO, Global Health: Spending Requirement Presents Challenges for
Allocating Prevention Funding under the President's Emergency Plan for
AIDS Relief, GAO-06-395 (Washington, D.C.: April 4, 2006).
Summary
As we reported in April 2006, PEPFAR prevention funding5 in the 15 focus
countries rose significantly between fiscal years 2004 and 2006, while the
proportion of total PEPFAR funding dedicated to prevention declined.
PEPFAR funding in these 15 countries rose from $207 million in fiscal year
2004 to $322 million fiscal year 2006.6 At the same time, prevention
funding as a share of total PEPFAR funding in the 15 focus countries
declined from 33 to 20 percent, consistent with the Leadership Act's
recommendation that 20 percent of funds appropriated pursuant to the act
be spent on prevention. For fiscal year 2005, focus country teams reported
allocating varying amounts for prevention programs, including those
designed to prevent sexual transmission of HIV-AB and "other prevention."
We found that challenges and inconsistencies in country teams'
categorization of funding for certain ABC programs and some broad sexual
transmission prevention activities, such as programs aimed at reducing
stigma associated with HIV, result in some limitations in the reliability
of reported allocations for sexual transmission prevention.
3The 15 PEPFAR focus countries are Botswana, Cote d'Ivoire, Ethiopia,
Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa,
Tanzania, Uganda, Vietnam, and Zambia. Officials in these countries 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.
4These countries are Cambodia, India, Malawi, Russia, and Zimbabwe. Each
of these teams is required to submit an operational plan to OGAC each
fiscal year, starting in fiscal year 2006.
5For the purposes of this testimony, and in our April 2006 report, PEPFAR
prevention funding is defined 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 as of March 15, 2006.
6Data that OGAC reported to Congress in April 2006 regarding fiscal year
2006 planned PEPFAR prevention funding differ from these figures,
primarily because OGAC's reported prevention funding included costs not
reported in previous fiscal years as program area funds. These costs
include, in part, certain strategic information and management and
staffing costs.
The PEPFAR strategy for preventing sexual transmission of HIV is largely
shaped by three elements-the ABC model, endorsed by the Leadership Act;
the Leadership Act's abstinence-until-marriage spending requirement; and
local prevention needs in the PEPFAR countries.
o ABC model. OGAC adopted the model and identified key principles
to guide country teams' implementation of it-stating, for example,
that prevention interventions should be responsive to
characteristics of the epidemic of the country. OGAC's guidance
regarding the ABC model 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.
o Abstinence-until-marriage spending requirement. The PEPFAR
sexual transmission prevention strategy reflects the Leadership
Act's requirement to reserve at least 33 percent of prevention
funds appropriated pursuant to the act-starting in fiscal year
2006-for abstinence-until-marriage programs. To ensure compliance,
OGAC established policies in August 2005 directing 20 PEPFAR
country teams7 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). OGAC also allowed country teams, especially those with
smaller budgets or more concentrated epidemics, to request
exemption from these policies. Finally, OGAC applied the spending
requirement to all PEPFAR prevention funding 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.
o Local prevention needs. Working within the parameters of the
ABC model and the abstinence-until-marriage spending requirement,
country teams design prevention programs that respond to the
countries' prevention needs.
OGAC's ABC guidance and the Leadership Act's
abstinence-until-marriage spending requirement have presented
several challenges to country teams.
o Lack of clarity in the ABC guidance has created challenges for
a majority of focus country teams. Although a number of teams told
us that they found the guidance clear or easy to implement, 10 of
the 15 focus teams cited instances where elements of the guidance
were ambiguous and confusing, leading to difficulties in its
interpretation and implementation. 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 to address concerns teams had identified.
o 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.
Further, 17 of the 20 PEPFAR teams required to meet the
requirement, absent exemptions, reported either in structured
interviews or exemption requests that it presents challenges to
their ability to respond to local epidemiology and cultural and
social norms. Ten of these 17 teams (including 7 focus country
teams) requested and received exemptions, citing a variety of
constraints related to meeting the requirement, such as reduced
PMTCT spending and limited funding for prevention messages to
high-risk groups. The remaining 7 teams, which did not meet OGAC's
proposed criteria for submitting exemption requests, also
identified specific program constraints related to meeting the
requirement, such as reduced funding for prevention programs aimed
at HIV-positive individuals. Having approved 10 requests for
exemption, OGAC should just meet the Leadership Act's 33 percent
requirement for fiscal year 2006 by effectively requiring teams
that do not request exemptions to, in most cases, spend more than
33 percent of prevention funds on AB activities. However, these
teams must sometimes reduce or cut funding for certain prevention
programs, such as programs to deliver comprehensive ABC messages
to populations at risk of contracting HIV. The analysis in our
April report showed that nonexempted country teams' allocations of
planned prevention funds to "other prevention" declined by
approximately $5 million-from about 23 percent in fiscal year 2005
to about 18 percent in fiscal year 2006. At the same time,
exempted country teams' allocations of planned prevention funds to
"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. Finally, OGAC's
decision to apply the spending requirement to all PEPFAR
prevention funding, rather than only to prevention funding in the
GHAI account, may further constrain some country teams' ability to
respond to local prevention needs.
In our April 2006 report, we recommended 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-until-marriage spending requirement
should be applied only to funds appropriated to the GHAI account.
We also suggested 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. In responding
jointly to a draft of our report, State, USAID, and the Department
of Health and Human Services accepted our recommendation to
collect information from the country teams regarding the spending
requirement's effects on their HIV sexual transmission prevention
programming. They disagreed with our draft recommendation to
consider whether the Leadership Act's spending requirement should
be applied solely to funds appropriated to the GHAI account. We
modified the second recommendation to recommend that they consider
this policy change after collecting information on the effect of
the spending requirement.
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 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 2004.8
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"9-and those aimed at preventing nonsexual
transmission-PMTCT, blood safety, and safe medical injections.
(See fig. 1.)
Figure 1: PEPFAR Prevention Program Areas
AB activities encourage abstinence until marriage, delay of first
sexual activity, secondary abstinence,10 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.11 In our April 2006 report, PEPFAR funding
refers to funds appropriated to these four accounts12 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.13
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).
Figure 2: Selected Spending Requirements and Recommendations for
Fiscal Years 2006-2008 Contained in the 2003 Leadership Act
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.14
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 2001.15 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 [the ABC model] are essential to reducing HIV
incidence, although the emphasis placed on individual elements
needs to vary according to the target population."16
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 model17-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.
PEPFAR Prevention Funding in the Focus Countries Grew Significantly
during First 3 Years
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 funding18 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.)
Figure 3: Total PEPFAR Prevention Funding in the 15 Focus
Countries, Fiscal Years 2004-2006
Note: Fiscal year 2006 funding is planned funding as of March 15,
2006. Data that OGAC reported to Congress in April 2006 regarding
fiscal year 2006 planned PEPFAR prevention funding differ from
these figures, primarily because OGAC's reported prevention
funding included costs not reported in previous fiscal years as
program area funds.
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.
Figure 4: Share of PEPFAR Funding Dedicated to Prevention in the
15 Focus Countries, Fiscal Years 2004-2006
Note: Fiscal year 2006 funding is planned funding as of March 15,
2006. Data that OGAC reported to Congress in April 2006 regarding
fiscal year 2006 planned PEPFAR prevention funding differ from
these figures, primarily because OGAC's reported prevention
funding included costs not reported in previous fiscal years as
program area funds.
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.)
Figure 5: Reported PEPFAR Prevention Funding in Focus Countries,
by Program Area, Fiscal Years 2004-2006
Note: Fiscal year 2006 funding is planned funding as of March 15,
2006. Data that OGAC reported to Congress in April 2006 regarding
fiscal year 2006 planned PEPFAR prevention funding differ from
these figures, primarily because OGAC's reported prevention
funding included costs not reported in previous fiscal years as
program area funds.
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.
PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC
Approach, Abstinence-Until-Marriage Spending Requirement, and Local
Prevention Needs
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.
In adopting the ABC model, OGAC identified the following key
principles that country teams should consider in developing and
implementing ABC programs:
o The model should be applied in accordance with
local prevention needs.
o Prevention activities should be integrated.
o Prevention activities should be coordinated with
the HIV/AIDS strategies of host governments.
o 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."19 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:
o PEPFAR funds may not be used in schools for marketing efforts
to promote condoms to youths.
o 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.
o 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.20 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).
ABC Guidance and Abstinence-Until-Marriage Spending Requirement
Present Challenges for Country Teams
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.
Challenges Related to ABC Guidance
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.
Challenges Related to Abstinence-until-Marriage Spending Requirement
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.21
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 2006.22 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).
Figure 6: Prevention Allocations for Nonexempted and Exempted
Focus Country Teams, Fiscal Years 2005 and 2006
Note: Fiscal year 2006 funding is planned funding as of March 15,
2006. Data that OGAC reported to Congress in April 2006 regarding
fiscal year 2006 planned PEPFAR prevention funding differ from
these figures, primarily because OGAC's reported prevention
funding included costs not reported in previous fiscal years as
program area funds. These percentages are reliable for
understanding general trends in data rather than for precise
percentage differences in program areas, because of potential
differences in categorization methods.
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.
Concluding Observations
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:
o 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.
o Provide this information in an annual report to Congress.
o 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.
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, 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.
Contacts and Acknowledgments
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 [email protected] . 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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7These 20 teams are the 15 focus country teams and the 5 additional teams
that receive at least $10 million annually in U.S. government HIV/AIDS
funding.
8HIV prevalence represents the percentage of the adult 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.
9In its Second Annual Report, released to Congress in February 2006, OGAC
began referring to these activities as "condoms and related prevention
activities."
10According to OGAC, secondary abstinence activities encourage abstinence
for youths who have already engaged in sexual intercourse.
11The remaining $1.5 billion was appropriated for, among other
initiatives, the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria-a
multilateral public-private mechanism-and international HIV/AIDS research
through the National Institutes of Health.
12The Prevention of Mother to Child Transmission account expired at the
end of fiscal year 2004, but some country teams carried over funds from
this account from fiscal year 2004 to fiscal year 2005. Therefore, for
fiscal year 2006, PEPFAR funding is defined as funds appropriated to the
remaining three accounts.
13Fiscal year 2006 funding figures change slightly throughout the fiscal
year, as country teams make adjustments to their funding allocations.
14Office 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).
15In 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.
16Cates, Willard,et.al. "The Time Has Come for Common Ground on Preventing
Sexual Transmission of HIV," Lancet, vol. 364 (Nov. 27, 2004).
17The 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. The model was developed by the Futures
Group-a privately held company that designs and implements public health
and social programs for developing countries.
18OGAC 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, these rough
estimates are not included in our funding figures.
19Office 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).
20In its fiscal year 2007 Country Operational Plan Guidance, OGAC dropped
the language regarding focus teams, particularly those with total PEPFAR
funding exceeding $75 million.
21Because 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.
22Some of the decline in "other prevention" funding may be due to varying
methods of categorizing sexual transmission prevention programs and
changes in categorization methods across fiscal years. However, the data
demonstrate a common trend across the nonexempted country teams.
(320448)
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Highlights of GAO-06-1089T, testimony before the Subcommittee on National
Security, Emerging Threats, and International Relations, House Committee
on Government Reform
GLOBAL HEALTH
Spending Requirement Presents Challenges for Allocating Prevention Funding
under the President's Emergency Plan for AIDS Relief
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.
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.
*** End of document. ***