    Global Health: Spending Requirement Presents Challenges for
    Allocating Prevention Funding under the President's Emergency
    Plan for AIDS Relief (04-APR-06, GAO-06-395).

    The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria
    Act of 2003 authorizes the President's Emergency Plan for AIDS
    Relief (PEPFAR) and promotes the ABC model (Abstain, Be faithful,
    or use Condoms). It 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. The Office of the U.S. Global AIDS
    Coordinator (OGAC) is responsible for administering PEPFAR. GAO
    reviewed PEPFAR prevention funds, described PEPFAR's strategy to
    prevent sexual HIV transmission, and examined related challenges.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-06-395
        ACCNO:   A50798
      TITLE:     Global Health: Spending Requirement Presents Challenges
    for Allocating Prevention Funding under the President's Emergency
    Plan for AIDS Relief
         DATE:   04/04/2006
      SUBJECT:   Acquired immunodeficiency syndrome
    	     Appropriated funds
    	     Budget outlays
    	     Developing countries
    	     Financial analysis
    	     Health care programs
    	     International organizations
    	     National policies
    	     Policy evaluation
    	     Sexually transmitted diseases
    	     Strategic planning
    	     AIDS
    	     Global Fund to Fight AIDS, Tuberculosis,
    	     and Malaria

    	     President's Emergency Plan for AIDS
    	     Relief

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    GAO-06-395

         * Report to Congressional Committees
              * April 2006
         * GLOBAL HEALTH
              * Spending Requirement Presents Challenges for Allocating
                Prevention Funding under the President's Emergency Plan for AIDS
                Relief
         * Contents
              * Results in Brief
              * Background
                   * Nature of AIDS Epidemic in PEPFAR Countries
                   * PEPFAR Funding and Requirements
                   * ABC Model and Abstinence- Until-Marriage Spending
                     Requirement
                   * PEPFAR Prevention Program Areas
                   * Office of the Global AIDS Coordinator
                   * OGAC's Key Strategic Principles
                   * OGAC's Prevention Target for PEPFAR
                   * PEPFAR Awards Process
              * PEPFAR Prevention Funding in the 15 Focus Countries Grew
                Significantly during First 3 Years
                   * PEPFAR Prevention Funding in the 15 Focus Countries
                     Increased in Fiscal Years 2004-2006
                   * Proportion of Focus Countries' PEPFAR Funding Dedicated to
                     Prevention Has Declined
                   * Proportion of Focus Countries' PEPFAR Prevention Funding
                     Allocated to Each Prevention Program Area Varied in Fiscal
                     Years 2004- 2006, but Data Reliability Has Limitations
              * PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC
                Approach, Abstinence- Until-Marriage Spending Requirement, and
                Local Prevention Needs
                   * PEPFAR Sexual Transmission Prevention Strategy Is Based
                     Primarily on ABC Model and OGAC's ABC Guidance
                   * PEPFAR Strategy Is Shaped by Abstinence-Until- Marriage
                     Spending Requirement and OGAC's Implementation of the
                     Requirement
                   * PEPFAR Strategy Also Includes Country Teams' Responses to
                     Local Needs
              * ABC Guidance and Abstinence-Until- Marriage Spending Requirement
                Present Challenges for Country Teams
                   * Unclear ABC Guidance Creates Challenges for Many Focus
                     Country Teams
                   * Meeting Abstinence-Until- Marriage Spending Requirement
                     Presents Challenges for Majority of Country Teams
                        * Country Teams Value the ABC Model
                        * Spending Requirement Can Undermine Integration of
                          Prevention Programs
                        * Country Teams Report That Meeting Spending Requirement
                          Challenges Their Ability to Respond to Local Prevention
                          Needs
                        * OGAC's Policies Allow It to Meet the Overall 33 Percent
                          Target
                        * OGAC's Policies Give Some Country Teams Greater
                          Flexibility but Further Constrain Others
                        * OGAC's Application of Spending Requirement to All U.S.
                          Prevention Funding May Further Challenge Country Teams
              * Conclusions
              * Recommendation for Executive Action
              * Matters for Congressional Consideration
              * Agency Comments and Our Evaluation
         * Scope and Methodology
         * AB and "Other Prevention" Programs in Four Focus Countries
              * Botswana
              * Ethiopia
              * South Africa
              * Zambia
         * Prevention Program Indicators and Methods of Measuring PEPFAR
           Prevention Program Results
              * OGAC Tracks the Number of Individuals Reached by Prevention
                Programs as a Performance Indicator
              * OGAC Will Estimate Progress Toward Infections Averted Goal Using
                Statistical Model
              * OGAC Considered Alternative Method of Measuring Infections
                Averted
              * OGAC Is Planning Some Limited Targeted Evaluations of Prevention
                Programs
         * PEPFAR Planning and Reporting Process
         * Methods for Reporting Allocations among PEPFAR Prevention Program
           Areas
         * Joint Comments from State, USAID, and HHS
              * GAO Comments
         * GAO Contact and Staff Acknowledgments

    Report to Congressional Committees

    April 2006

    GLOBAL HEALTH

    Spending Requirement Presents Challenges for Allocating Prevention Funding
    under the President's Emergency Plan for AIDS Relief

    Contents

    Figures

    April 4, 2006Letter

    Congressional Committees

    In January 2003, citing the need "to meet a severe and urgent crisis
    abroad," President Bush announced his Emergency Plan for AIDS Relief
    (PEPFAR), a $15 billion, 5-year initiative to combat the global HIV/AIDS
    epidemic through prevention, treatment, and care interventions. This
    initiative represented a significant increase in U.S. funding for
    HIV/AIDS. Prior to PEPFAR, the United States had committed to provide $5
    billion to bilateral HIV/AIDS initiatives; under PEPFAR, the total
    financial U.S. commitment increased by nearly $10 billion, with $9
    billion1 targeted to HIV/AIDS initiatives in 15 focus countries.2 PEPFAR's
    primary prevention goal is to avert 7 million HIV infections in these
    countries-where heterosexual intercourse is generally the primary mode of
    transmission-by the year 2010. The U.S. Leadership Against HIV/AIDS,
    Tuberculosis, and Malaria Act of 20033 (Leadership Act), which authorizes
    PEPFAR, endorses using the "ABC model" (Abstain, Be faithful, or use
    Condoms) to prevent the sexual transmission of HIV and establishes the
    Global HIV/AIDS Initiative (GHAI) account. The act also recommends that 20
    percent of funds appropriated pursuant to the act be dedicated to HIV/AIDS
    prevention and requires that, beginning in fiscal year 2006, at least 33
    percent of prevention funds appropriated pursuant to the act be spent on
    abstinence-until-marriage programs. Finally, the act provides for the
    establishment of an HIV/AIDS Coordinator within the Department of State
    (State) to lead the U.S. response to the HIV/AIDS epidemic and oversee all
    U.S. efforts to

    combat HIV/AIDS abroad.4 Since its establishment in January 2004, 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 safety5-and defined
    abstinence-until-marriage programs as AB activities.

    Responding to broad-based congressional interest in HIV/AIDS prevention
    efforts under PEPFAR, in this report we (1) review trends and allocation
    of PEPFAR prevention funding, (2) describe the PEPFAR strategy for
    preventing the sexual transmission of HIV, and (3) examine key challenges
    associated with applying the PEPFAR sexual transmission prevention
    strategy. We conducted this review under the Comptroller General's
    authority.

    To address these objectives, we reviewed documents such as the PEPFAR
    5-year strategy,6 first annual report to Congress, and fiscal year 2004
    operational plan; operational plans and annual and midyear progress
    reports provided by U.S. agency officials responsible for managing PEPFAR
    in the focus countries (focus country teams); PEPFAR guidance to the
    field;  and budget documents provided by OGAC. In addition, we interviewed
    U.S.-based officials from OGAC, USAID, and the Department of Health and
    Human Services-Centers for Disease Control and Prevention (HHS/CDC), as
    well as several Washington, D.C.-based nongovernmental organizations
    (NGOs). We also conducted structured interviews between June 2005 and
    January 2006 with key State, USAID, HHS/CDC, and other U.S. agency staff
    in the 15 focus countries.7 We conducted 11 of these structured interviews
    over the telephone and 4 during site visits. We visited Botswana,
    Ethiopia, South Africa, and Zambia in July 2005, selecting this targeted
    sample of focus countries based on criteria such as level of PEPFAR
    funding, HIV prevalence rate,8 and prevention focus. In the countries that
    we visited, we interviewed key U.S. government officials, host country
    government officials, NGOs, faith-based organizations, local
    community-based organizations, and program beneficiaries. We also
    requested information from five additional PEPFAR country teams9 regarding
    their PEPFAR funding, the process of developing country operational plans,
    and the effects, if any, of the abstinence-until-marriage spending
    requirement on their prevention programming; we received responses from
    two of the five country teams. (See app. I for a detailed description of
    our scope and methodology.) In general, we found the data on PEPFAR
    prevention funding, with the exception of data on spending allocations
    among certain prevention program areas, sufficiently reliable for the
    purposes of our engagement. We conducted our work from February 2005 to
    February 2006 in accordance with generally accepted government auditing
    standards.

    Results in Brief

    PEPFAR prevention funding10 in the 15 focus countries grew by more than 40
    percent between fiscal years 2004 and 2005 and by an additional 10 percent
    between 2005 and 2006, rising from $207 million in fiscal year 2004 to
    $322 million in fiscal year 2006. At the same time, consistent with the
    Leadership Act's recommendation that 20 percent of funds appropriated
    pursuant to the act be spent on prevention, the prevention portion of
    total PEPFAR funding in the 15 focus countries declined from 33 to 20
    percent. The proportion of focus countries' total PEPFAR prevention
    funding allocated to each of the five nonsexual and sexual transmission
    prevention program areas varied during fiscal years 2004-2006, and focus
    country teams reported allocating varying amounts for sexual transmission
    prevention programs in fiscal year 2005. However, there are limitations in
    the reliability of these reported allocations because of challenges and
    inconsistencies in country teams' categorization of funding for certain
    ABC programs and some broad sexual transmission prevention activities.

    The PEPFAR strategy for preventing sexual transmission of HIV is largely
    shaped by three elements: the ABC model, the Leadership Act's
    abstinence-until-marriage spending requirement, and local prevention needs
    in the PEPFAR countries.

    o In developing the PEPFAR sexual transmission prevention strategy, OGAC
    adopted the ABC model, endorsed by the Leadership Act, as an effective
    method for preventing HIV/AIDS. In addition, to guide country teams'
    application of the ABC model, OGAC identified general principles for the
    teams to consider in developing and implementing PEPFAR ABC
    programs-stating, for example, that prevention interventions should be
    responsive to characteristics of the epidemic in their country and
    integrated, so that prevention messages are harmonized at the community
    level. OGAC's guidance regarding the ABC model (ABC guidance) 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 The PEPFAR sexual transmission prevention strategy reflects the
    Leadership Act's requirement that, beginning in fiscal year 2006, at least
    33 percent of prevention funds appropriated pursuant to the act support
    abstinence-until-marriage programs.11 To ensure compliance with the
    spending requirement, OGAC established policies in August 2005
    implementing the requirement. These policies directed 20 country teams12
    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) starting in fiscal year
    2006. OGAC also instructed the teams to isolate AB spending in their
    annual reports to demonstrate adherence to the spending requirement. In
    addition, OGAC allowed certain country teams to submit justifications
    requesting exemption from its policies implementing the spending
    requirement. Finally, OGAC applied the spending requirement to all PEPFAR
    prevention funding13 (about $357 million in fiscal year 2006) 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 (about
    $322 million for prevention in fiscal year 2006).

    o 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. For
    example, country teams reserve funding for AB activities to comply with
    the spending requirement and take steps to allocate their prevention funds
    according to factors such as the average age when sexual activity begins
    in their respective countries.

    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 the teams told us
    that they found the guidance clear or easy to implement, 10 of the 15
    focus country teams cited instances where elements of the guidance were
    ambiguous and confusing, leading to difficulties in its interpretation and
    implementation. For example, although the guidance restricts activities
    promoting condom use, it does not clearly delineate the difference between
    condom education and condom promotion, causing uncertainty over whether
    certain condom-related activities are permissible. OGAC officials
    acknowledged that certain components of the guidance can be confusing and
    told us that they are working to clarify them. They also provided a
    document-distributed to country teams in August 2005-that aims to address
    some of the concerns that country teams identified. OGAC plans to update
    this document each fiscal year, based on country teams' feedback about
    implementing the ABC guidance.

    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 by forcing them to isolate funding for AB activities.
    Further, 17 of the 20 PEPFAR teams required to meet the spending
    requirement unless they obtain exemptions from it reported that the
    spending requirement presents challenges to their ability to respond to
    local epidemiology and cultural and social norms. As permitted under
    OGAC's policies, 10 of these 17 teams requested exemption from the
    spending requirement, citing a variety of constraints related to meeting
    it, such as reduced spending for PMTCT and limited funding for prevention
    messages to high-risk groups. Although the remaining 7 country teams did
    not request exemptions (they did not meet OGAC's proposed criteria for
    submitting requests), they also identified specific program constraints
    related to meeting the spending requirement, such as cuts in PMTCT
    services or reduced funding for prevention programs aimed at HIV-positive
    individuals.14 Despite approving the 10 exemption requests, OGAC should
    just meet the overall spending requirement specified by the Leadership Act
    for fiscal year 2006 by effectively requiring teams that do not request
    exemptions to, in most cases, spend more than the 33 percent of prevention
    funds on AB activities. Although exempted country teams avoid, to some
    degree, the challenges they identified related to meeting the spending
    requirement, teams that are not exempted from the requirement must
    sometimes reduce or cut funding for certain prevention programs. For
    example, one country team told us that, to meet the spending requirement,
    it had to limit funding for comprehensive ABC messages to populations at
    risk of contracting HIV. Our analysis shows that for exempted country
    teams, total planned prevention funds dedicated 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. For nonexempted country teams, total planned prevention funds
    dedicated to "other prevention" declined by approximately $5 million-from
    about 23 percent of overall planned prevention funds in fiscal year 2005
    to about 18 percent in fiscal year 2006. Finally, OGAC's decision to apply
    the spending requirement to all PEPFAR prevention funding may further
    constrain some country teams' ability to respond to local prevention
    needs. For example, this policy prevents one country team from funding
    certain condom social marketing programs with $1.5 million in non-GHAI
    funding, despite its having reduced funding for those programs to comply
    with the abstinence-until-marriage spending requirement.

    In light of reported challenges presented by the abstinence-until-marriage
    spending requirement, we are recommending 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
    Global HIV/AIDS Initiative account. We are also suggesting 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.

    We provided a draft of this report to the Department of State/OGAC, HHS,
    and USAID. In commenting jointly on our report, the agencies reiterated
    their strong commitment to fight HIV/AIDS, stating that "only a vigorous
    and comprehensive prevention approach will turn the tide against the
    global HIV/AIDS pandemic." Consistent with our report's discussion, they
    also noted the importance of the ABC model in preventing sexual
    transmission of HIV. Regarding our finding that interpreting and
    implementing the ABC guidance has created challenges for most of the focus
    country teams, the agencies commented that they are committed to
    continually improving efforts to communicate policy to the field. The
    agencies expressed appreciation for our report's findings regarding
    difficult trade-offs that country teams have had to make with respect to
    funding for prevention activities and agreed with our recommendation to
    collect information regarding the effects of the Leadership Act's
    abstinence-until-marriage spending requirement. They disagreed with our
    recommendation regarding applying the abstinence-until-marriage spending
    requirement only to funds appropriated to the GHAI account, stating that
    doing so would limit their ability to use a unified budget approach and
    would have little impact, given the small amount of non-GHAI funding that
    the focus country teams receive. We recognize that allowing country teams
    to apply the spending requirement solely to GHAI funds entails some
    trade-offs. Given the agencies' concerns about maintaining a unified
    budget approach, we have modified our recommendation to recommend that
    they consider this policy change after collecting information on the
    effect of the spending requirement. With respect to the non-GHAI funding
    amounts, we would note that the five additional countries required, absent
    exemptions, to meet the spending requirement receive more than 80 percent
    of their funds through non-GHAI accounts. Thus, we believe that our
    modified recommendation is warranted. Finally, OGAC and USAID also
    provided technical comments on the draft, which we have incorporated as
    appropriate.

    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 during pregnancy, childbirth, or breastfeeding).
    However, the majority of HIV infections worldwide are transmitted
    sexually.15 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 (UNAIDS), adult HIV prevalence
    averaged 7.4 percent in 2004.

    Nature of AIDS Epidemic in PEPFAR Countries

    HIV/AIDS is an urgent and growing health problem, driven by complex
    factors that present challenges to HIV prevention. The nature of the AIDS
    epidemic varies among the 15 PEPFAR focus countries, 12 of which are in
    sub-Saharan Africa (see fig. 1). In addition, the groups most vulnerable
    to HIV infection vary among the focus countries. For example, while girls
    and young women are most vulnerable in some countries, populations
    typically considered high-risk groups, such as intravenous drug-users or
    commercial sex workers, are most vulnerable in others.16 Figure 1 shows
    that although the epidemic in some focus countries is concentrated in
    certain populations, in other focus countries it has spread among the
    general population.

    Figure 1: Stage of the AIDS Epidemic in PEPFAR Focus Countries

    Note: According to UNAIDS and the World Health Organization, a
    concentrated epidemic is defined as one in which HIV has infected at least
    5 percent of individuals in defined subpopulations but is not
    well-established in the general population. In a generalized epidemic, HIV
    has spread among the general population, infecting at least 1 percent.

    PEPFAR Funding and Requirements

    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.17 In this
    report, the term PEPFAR funding describes funds appropriated to these four
    accounts18 in the 15 focus countries, as well as bilateral HIV/AIDS
    funding in five additional countries.19 For fiscal years 2004 and 2005,
    total PEPFAR funding consists of central and country-level actual
    appropriations allocated by OGAC for prevention, care, and treatment
    activities. Similarly, PEPFAR prevention funding for these fiscal years
    consists of central and country-level actual appropriations allocated by
    OGAC for prevention activities (AB, blood safety, PMTCT, safe medical
    injections, and "other prevention"). For fiscal year 2006, total PEPFAR
    funding consists of planned central and country-level PEPFAR funding for
    prevention, care, and treatment activities that have not yet been approved
    by OGAC.20 PEPFAR prevention funding for fiscal year 2006 consists of
    planned central and country-level PEPFAR funding for prevention activities
    that have not yet been approved by OGAC.

    The Leadership Act specifies the percentages of PEPFAR funds to be
    allocated for HIV/AIDS prevention, treatment, and care for fiscal years
    2006-2008. For example, 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.21 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.) See page 14 for
    information on additional spending recommendations and requirements
    specifically related to prevention funds.

    Figure 2: Selected Spending Recommendations and Requirements for Fiscal
    Years 2006-2008 Contained in the 2003 Leadership Act

    ABC Model and Abstinence-Until-Marriage Spending Requirement

    The Leadership Act finds that "behavior change, through the use of the ABC
    model, is a very successful way to prevent the spread of HIV" and requires
    that prevention funding be set aside for abstinence-until-marriage
    programs. It defines the model as "`Abstain, Be faithful, use Condoms,' in
    order of priority." The ABC model 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 2001.22 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 eight leading public health experts23 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." For example, it noted that "for those who have not
    started sexual activity the first priority should be to encourage
    abstinence or delay of sexual onset" and, "when targeting sexually active
    adults, the first priority should be to promote mutual fidelity with an
    uninfected partner as the best way to assure avoidance of HIV infection."
    Finally, according to the document, "all people should have accurate and
    complete information about different prevention options, including all
    three elements of the ABC approach." The statement was signed by more than
    125 prominent figures, including the President of Uganda; the Archbishop
    of the Anglican Church of South Africa; officials from UNAIDS, the World
    Health Organization, and the World Bank; and dozens of other academics,
    representatives of faith-based groups, and public health advocates. In
    promoting the ABC model, the Leadership Act authorizes prevention
    activities that provide information on delaying sexual debut; abstinence;
    fidelity and monogamy; reduction of casual sexual partnering; reducing
    sexual violence and coercion, including child marriage, widow inheritance,
    and polygamy; and where appropriate, use of condoms.

    The act also requires that at least one-third of prevention funding
    appropriated pursuant to the act be spent on abstinence-until-marriage
    programs. The act recommended this spending distribution for fiscal years
    2004-2005 and made it mandatory for fiscal years 2006-2008. In June 2004,
    OGAC notified Congress  that it defines abstinence-until-marriage
    activities as programs that address both abstinence and faithfulness.
    Specifically, OGAC stated that abstinence-until-marriage programs would
    focus on achieving two goals: (1) encouraging individuals to be abstinent
    from sexual activity outside of marriage to protect themselves from
    exposure to HIV and other sexually transmitted infections and (2)
    encouraging individuals to practice fidelity in sexual relationships,
    including marriage, to reduce their risk of exposure to HIV.24

    PEPFAR Prevention Program Areas

    The five PEPFAR prevention program areas-abstinence/faithfulness (AB),
    blood safety, prevention of mother-to-child transmission (PMTCT), safe
    medical injections, and other prevention-are divided into two groups:
    those aimed at preventing sexual transmission and those aimed at
    preventing nonsexual transmission of the disease. (See fig. 3.)

    Figure 3: PEPFAR Prevention Program Areas

    The sexual transmission prevention program areas are focused as follows.

    o AB activities encourage

    o abstinence until marriage,

    o delay of first sexual activity,

    o secondary abstinence,25

    o faithfulness in marriage and monogamous relationships,

    o reduction of sexual partners among sexually active unmarried persons,
    and

    o social and community norms related to the above practices.

    "Other prevention" activities include the

    o purchase and promotion of condoms,

    o management of sexually transmitted infections (if not in a palliative
    care setting), and

    o messages or programs to reduce injection drug use and related risks.26

    (See app. II for examples of AB and "other prevention" programs that are
    being implemented under PEPFAR. For information on the organizations that
    have implemented sexual transmission prevention programs under PEPFAR, see
    http://www.state.gov/s/gac/. )

    Office of the Global AIDS Coordinator

    The Leadership Act provided for the establishment of an HIV/AIDS
    Coordinator, within the Department of State, to lead the U.S. response to
    HIV/AIDS abroad. The Coordinator's authorities and duties include carrying
    out international prevention, care, treatment, and other HIV/AIDS-related
    activities through NGOs and U.S. executive branch agencies and
    coordinating their efforts. The agencies primarily responsible for
    implementing PEPFAR are the Department of State, USAID, and HHS. OGAC,
    established within the Department of State in January 2004, has been
    responsible for developing a global HIV/AIDS strategy and administering
    PEPFAR.

    OGAC's Key Strategic Principles

    OGAC's overall strategic cornerstones and principles, laid out in its
    5-year global HIV/AIDS strategy for PEPFAR, include commitments to

    o respond with urgency to the crisis;

    o make policy decisions that are evidence based;

    o demand accountability for results;

    o implement programs that are suited to local needs and host government
    policies;

    o develop and strengthen integrated HIV/AIDS prevention, treatment, and
    care services; and

    o focus on rapid service delivery.27

    OGAC's Prevention Target for PEPFAR

    OGAC's 5-year strategy states the PEPFAR prevention goal-announced by the
    President and repeated in the Leadership Act-of averting 7 million
    infections in the 15 focus countries.28 Although PEPFAR is authorized
    through fiscal year 2008, OGAC plans to reach its prevention goal by the
    year 2010.29 This prevention 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
    the host nations. (See app. III for a discussion of OGAC's indicators,
    models, and method for measuring infections averted, including the
    challenges that OGAC faces in measuring infections averted and, thus, in
    assessing the success of its prevention activities.)

    PEPFAR Awards Process

    PEPFAR funding for the 15 focus countries is allocated both centrally and
    at the country level.30 Central awards are multicountry awards that are
    managed by U.S. agency headquarters in Washington, D.C. These one-time,
    5-year awards are intended to increase funding for program activities with
    high levels of congressional interest and minimal existing activities in
    the field.31 Country-level awards are managed by the focus country teams.

    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). The plans are subject to OGAC's review and
    approval. (See app. IV for a description of OGAC's review process and a
    time line of the PEPFAR awards process.) Country teams consider a variety
    of criteria when selecting implementing partners, such as the applicant
    organizations' ability to scale up rapidly, sustain programs, and function
    in-country; the strength of their administrative and financial controls;
    and the extent to which their priorities mirror those of the host
    government and the U.S. government. Teams also often place a priority on
    working with local, indigenous organizations rather than large,
    international organizations. In addition, many country teams take steps to
    encourage faith-based organizations to apply for funding, although none of
    the teams reserves a specific percentage or amount of funding for
    faith-based organizations. For example, they may write grants specifically
    designed for organizations that use a faith-based approach or instruct
    prime implementing partners to work with small faith-based organizations
    that lack the capacity or experience to handle large amounts of funding.32

    PEPFAR Prevention Funding in the 15 Focus Countries Grew Significantly
    during First 3 Years

    PEPFAR prevention funding in the 15 focus countries increased by more than
    40 percent between fiscal years 2004-2005 and by an additional 10 percent
    between fiscal years 2005 and 2006.33 At the same time, the proportion of
    total PEPFAR funding in the 15 focus countries dedicated to prevention
    declined from 33 to 20 percent. The proportion of total focus country
    PEPFAR prevention funding that was allocated to each of the five
    prevention program areas varied from fiscal year 2004 to fiscal year 2006,
    and individual country teams reported varying allocations among AB and
    "other prevention." However, there are limitations in the reliability of
    the reported figures.

    PEPFAR Prevention Funding in the 15 Focus Countries Increased in Fiscal
    Years 2004-2006

    PEPFAR prevention funding in the 15 focus countries increased from $207
    million in fiscal year 200434 to $294 million in fiscal year 2005, or by
    more than 40 percent. It further increased to $322 million-about 10
    percent-in fiscal year 2006. (See fig. 4.)

    Figure 4: Total PEPFAR Prevention Funding in the 15 Focus Countries,
    Fiscal Years 2004-2006

    Note: Fiscal year 2006 funding is planned.

    For each of fiscal years 2004 through 2006, about 30 percent of the 15
    focus countries' total PEPFAR prevention funding was awarded centrally.
    Although the majority of funding for blood safety (91 percent) and safe
    medical injection (91 percent) activities was awarded centrally, only 21
    percent of AB funding was awarded centrally. None of the "other
    prevention" funding was awarded centrally.

    In addition, PEPFAR prevention funding for the individual focus country
    teams generally increased between fiscal years 2004 and 2005 and, for most
    of the countries, increased again slightly in 2006. The amount of PEPFAR
    prevention funding for each focus country team varies. (See fig. 5.)

    Figure 5: PEPFAR Prevention Funding, by Focus Country, Fiscal Years
    2004-2006

    Note: Fiscal year 2006 funding is planned.

    Proportion of Focus Countries' PEPFAR Funding Dedicated to Prevention Has
    Declined

    The proportion of PEPFAR funding in the 15 focus countries dedicated to
    prevention 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. 6.) 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. OGAC expected the proportion
    allocated to care and treatment to increase over time because (1) previous
    U.S. global HIV/AIDS efforts had focused on prevention and (2) factors
    such as limited infrastructure and a lack of adequately trained staff in
    the focus countries lengthen the time required to develop and expand
    treatment and care programs.

    Figure 6: Proportion of PEPFAR Funding Dedicated to Prevention in the 15
    Focus Countries, Fiscal Years 2004-2006

    Note: Fiscal year 2006 funding is planned.

    For most of the focus country teams, the proportion of PEPFAR funding
    dedicated to prevention also declined in fiscal years 2004-2006. (See fig.
    7.)

    Figure 7: Proportion of PEPFAR Funding Dedicated to Prevention, by Focus
    Country, Fiscal Years 2004-2006

    Note: Fiscal year 2006 funding is planned.

    Proportion of Focus Countries' PEPFAR Prevention Funding Allocated to Each
    Prevention Program Area Varied in Fiscal Years 2004-2006, but Data
    Reliability Has Limitations

    The proportion of total PEPFAR prevention funding that the 15 focus
    country teams reported allocating to each of the five prevention program
    areas varied to some extent during fiscal years 2004-2006. (See fig. 8.)35
    However, there are limitations in the reliability of these data because of
    challenges and inconsistencies in country teams' categorization of funding
    for certain integrated ABC programs and some broad sexual transmission
    prevention activities. 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. (See app. V for a description of
    country teams' varying methods for categorizing sexual transmission
    prevention funding and the effect of this variation on the reported
    allocations' reliability.)

    Figure 8: Reported Allocation of Focus Countries' Total PEPFAR Prevention
    Funding by Each Prevention Program Area, Fiscal Years 2004-2006

    Note: Fiscal year 2006 funding is planned. Because of data reliability
    issues discussed in appendix V, these figures should be used only to
    understand general trends in data, rather than precise percentage
    differences between program areas and fiscal years. Due to rounding, the
    percentages may not add up to 100.

    We analyzed country teams' reported allocations for AB and "other
    prevention" for fiscal year 2005 and found that these allocations also
    varied. For example, 11 country teams reported allocating between 40 and
    60 percent of their sexual transmission prevention funding to AB, 3 teams
    reported allocating somewhat over 60 percent, and 1 reported allocating
    slightly less than 40 percent to AB. (See fig. 9.)36

    Figure 9: Percentage of Reported Fiscal Year 2005 PEPFAR Sexual
    Transmission Prevention Funding Allocated to Abstinence/Faithfulness and
    "Other Prevention" by Each Focus Country Team

    Note: Individual country teams use different methods for categorizing
    funding in the AB and "other prevention" program areas (see app. V). These
    data should not be used to make direct comparisons between individual
    country teams but rather to understand the overall pattern of funding
    across country teams.

    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 has three
    primary components: (1) the ABC model and OGAC guidance for implementing
    it, (2) the abstinence-until-marriage spending requirement and OGAC's
    interpretation of it, and (3) country teams' strategies for responding to
    local prevention needs. OGAC adopted the ABC model as its primary sexual
    transmission prevention strategy and, in August 2005, provided guidance
    for country teams to use in applying the model. To guide the teams'
    application of the requirement that at least 33 percent of prevention
    funding appropriated pursuant to the Leadership Act fund
    abstinence-until-marriage programs, OGAC directed the teams to spend at
    least 50 percent of their prevention funds on sexual transmission
    prevention and 66 percent of those funds on AB activities. Finally, in
    designing their sexual transmission prevention strategies, country teams
    respond to local factors, such as the host government's capacity to expand
    activities in sexual transmission prevention program areas, as well as to
    the ABC model and the spending requirement.

    PEPFAR Sexual Transmission Prevention Strategy Is Based Primarily on ABC
    Model and OGAC's ABC Guidance

    OGAC adopted the ABC model, endorsed by the Leadership Act, as the primary
    PEPFAR strategy for preventing sexual transmission of HIV. The PEPFAR
    5-year strategy states that evidence from Uganda and other countries
    "demonstrates the effectiveness of a balanced approach to behavior change
    that encourages the adoption of `ABC' behaviors."

    In January 2005, OGAC released guidance to country teams to shape their
    incorporation of the ABC model into their sexual transmission prevention
    strategies.37 The guidance identifies 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.
    The guidance states that one of PEPFAR's commitments is to ensure "that
    interventions be informed by, and responsive to, local needs, local
    epidemiology, and distinctive social and cultural patterns."

    o Prevention activities should be integrated. The guidance notes that "all
    implementing partners must harmonize [prevention messages] at the
    community level."

    o Prevention activities should be coordinated with the HIV/AIDS strategies
    of host governments.

    o Prevention interventions should be driven by best practices.

    Taking these principles into account, the guidance 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."

    In addition, OGAC's ABC guidance contains rules for country teams to
    follow in developing and implementing their sexual transmission prevention
    strategies. First, the guidance specifies the components of the ABC model
    that should be targeted to certain populations. For example, messages
    about abstinence-until-marriage and delay of first sexual activity should
    be targeted to youths; fidelity should be emphasized for married couples
    and those in monogamous relationships; and condom use should be promoted
    to those who practice risky sexual behaviors, such as commercial sex
    workers and individuals who have sex with someone of unknown HIV status.
    Second, the guidance sets parameters on the prevention messages that may
    be delivered to youths. Specifically, 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
    provide integrated ABC information to youths older than 14.

    OGAC also released the following guidance regarding the use of PEPFAR
    funds for ABC programs:

    o Any PEPFAR-funded program that provides information about condoms must
    also provide information about abstinence and faithfulness.

    o PEPFAR funds may not be used to physically distribute or provide condoms
    in school settings.

    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. The guidance defines at-risk groups as

    o commercial sex workers and their clients,

    o sexually active discordant couples or couples with unknown HIV status,

    o substance abusers,

    o mobile male populations,

    o men who have sex with men,

    o people living with HIV/AIDS, and

    o those who have sex with an HIV-positive partner or one whose status is
    unknown.

    PEPFAR Strategy Is Shaped by Abstinence-Until-Marriage Spending
    Requirement and OGAC's Implementation of the Requirement

    The PEPFAR strategy reflects the Leadership Act's
    abstinence-until-marriage spending requirement, as well as OGAC's recent
    policies implementing this requirement. Having defined
    abstinence-until-marriage activities as AB programs, in late August 2005,
    OGAC issued policies to help ensure that the 33 percent spending
    requirement is met. These policies directed each of the 15 focus country
    teams and 5 additional country teams38 to spend at least 50 percent of
    their prevention funding39 on sexual transmission prevention and at least
    66 percent of that amount on AB activities. In other words, OGAC requires
    country teams to spend $2.00 on AB activities for every $1.00 they spend
    on "other prevention" activities-a 2-to-1 ratio. To show compliance with
    the spending requirement, country teams' operational plans must isolate
    the amount of funding spent on AB activities. OGAC's policies relate to
    the Leadership Act's requirement in the sense that, if a country spends
    exactly half of its prevention funding on sexual transmission prevention
    and two-thirds of that funding on AB activities, it will then spend
    one-third of its total prevention funding on AB. Figure 10 provides an
    illustrative example of a country team's prevention funding strictly
    allocated according to OGAC's policies.

    Figure 10: Illustration of a Country Team's Prevention Funding Allocated
    According to OGAC's Policies Implementing the Abstinence-Until-Marriage
    Spending Requirement

    Note: Percentages do not add up to 100, due to rounding.

    In certain cases, OGAC allows country teams to submit justifications
    requesting exemptions to the spending requirement, as defined by the 50
    percent and 66 percent policies. For example, OGAC guidance to the country
    teams states that if 80 percent of a country's epidemic is among
    prostitutes, a team can submit a justification for spending a higher
    proportion of sexual transmission prevention funds on correct and
    consistent condom use. However, the guidance also cautions that, in a
    generalized epidemic, a very strong justification is required for not
    meeting the 66 percent policy. The guidance adds that OGAC expects all
    focus country teams, in particular those with total PEPFAR funding
    exceeding $75 million, to adhere to the policies implementing the spending
    requirement.40

    OGAC also directed country teams to apply the spending requirement to all
    PEPFAR prevention funding (about $357 million in fiscal year 2006).41 OGAC
    adopted this policy although it determined that, as a matter of law, the
    requirement applies only to funds appropriated to the GHAI account (about
    $322 million for prevention in fiscal year 2006). Under OGAC's policy, the
    abstinence-until-marriage spending requirement applies to prevention
    funding from the CDC's Global AIDS Program, the Child Survival and Health
    account, the Freedom Support Act account,  and the GHAI account. However,
    when reporting to Congress on compliance with the spending requirement,
    OGAC reports only the allocation of funds under the GHAI account.

    PEPFAR Strategy Also Includes Country Teams' Responses to Local Needs

    Country teams' sexual transmission prevention strategies are shaped both
    by high-level requirements and local context. In each PEPFAR country,
    country teams design their sexual transmission prevention strategies in
    response to the ABC model and the abstinence-until-marriage spending
    requirement. At the same time, in accordance with OGAC's ABC guidance, the
    strategies take into account local factors such as the host nation's
    capacity to expand activities in the prevention program areas, the nature
    of the HIV/AIDS epidemic in the country, the average age when sexual
    activity begins, and the prevalence of certain social norms. For example,
    in a country where new HIV infections are largely occurring among
    high-risk groups, such as intravenous drug users or sex workers, the team
    determines how to effectively promote condom use to these populations
    while reserving the required percentage of prevention funding for AB
    activities. Likewise, in a country where sexual activity typically begins
    at a relatively low average age, the team decides how best to provide
    effective prevention messages to youths while taking into account the
    parameters that OGAC has established for delivering ABC messages to youths
    of different ages.

    ABC Guidance and Abstinence-Until-Marriage Spending Requirement Present
    Challenges for Country Teams

    Country teams face challenges related to two key drivers of the PEPFAR
    sexual transmission prevention strategy-OGAC's guidance for applying the
    ABC model to country-level programs and the Leadership Act's
    abstinence-until-marriage spending requirement. Although many country
    teams reported that they have found OGAC's ABC guidance to be clear and
    several said that it did not present implementation challenges, two-thirds
    of focus country teams also reported that a lack of clarity in aspects of
    the guidance has led to interpretation and implementation challenges. OGAC
    officials told us that they are aware of these issues and plan to clarify
    the guidance. About half of the focus country teams indicated that
    adherence to the spending requirement can undermine the integrated nature
    of HIV/AIDS prevention programs. In addition, 17 of the 20 country teams
    required to meet the abstinence-until-marriage spending requirement,
    absent exemptions, reported that the requirement would prevent them from
    allocating prevention resources in accordance with local HIV/AIDS
    prevention needs. OGAC's August 2005 policies implementing the spending
    requirement have allowed some of these country teams to address these
    concerns but have further constrained other teams from designing locally
    responsive HIV/AIDS prevention programs. 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.

    Unclear ABC Guidance Creates Challenges for Many Focus Country Teams

    Interpreting and implementing OGAC's ABC guidance has created challenges
    for most of the focus country teams. Although many teams told us that they
    generally found the guidance to be clear, and several said that it did not
    present implementation challenges, 10 of the 15 focus country teams we
    interviewed cited instances where components of the guidance were
    ambiguous and caused confusion.

    o The guidance's definition of at-risk groups is open to varying
    interpretations, causing confusion about which groups may be targeted.42
    Six focus country teams and some implementing partners expressed
    uncertainty regarding the populations that should be considered at-risk in
    accordance with the ABC guidance. Five 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. For example, one team noted that the majority of HIV infections
    in its country are transmitted from one partner to another in either
    married or stable, cohabitating relationships. However, this team told us
    that they understood the ABC guidance on high-risk groups to be relevant
    only to a "limited epidemic" (unlike the generalized epidemic in which
    they were working) and that married couples do not count as high-risk
    under PEPFAR. As a result, they believed that a program designed to reach
    these individuals through ABC messages to a broad population would not be
    allowed. In addition, three teams questioned how to apply the definition
    of at-risk in a generalized epidemic.

    o The guidance does not clearly delineate permissible C activities,
    causing confusion about proper use of PEPFAR funds.  OGAC's ABC guidance
    places restrictions on activities promoting condom use, but it does not
    clearly distinguish permissible and nonpermissible activities. For
    example, the guidance states that condom use programs should provide full
    and accurate information about correct and consistent condom use,
    including how to obtain them. The guidance also places restrictions on
    promoting or marketing condoms to youths;43 however, it does not explain
    how providing condom information differs from condom promotion or
    marketing. Several NGOs that receive PEPFAR funding expressed concern to
    us about crossing the line between providing information about condoms and
    promoting or marketing condoms. For example, representatives of a
    PEPFAR-supported organization that runs a youth camp for students (aged
    15-17) told us that condom use is addressed during camp sessions only when
    youths ask specific questions. However, staff said that they feel
    "constrained" when they hear these questions, because they do not want to
    say more than is allowed under PEPFAR guidelines. Another implementing
    partner representative said that although the organization views condom
    demonstrations as appropriate in some settings, it believes that condom
    demonstrations, even to adults, are prohibited under PEPFAR. OGAC's
    guidance also does not explain whether ABC approaches for broader
    audiences in a generalized epidemic may include condom social marketing.
    Although a senior OGAC official told us that broad condom social marketing
    is appropriate in certain situations, five 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.

    o Guidance regarding mixed-age groups is absent, causing confusion about
    who may receive the ABC message. The ABC guidance prohibits PEPFAR-funded
    programs in schools from providing condom information to youths younger
    than 15, but the guidance does not discuss the application of this age
    cutoff to groups that include youths younger and older than 15. Four focus
    country teams noted that the age cutoff for providing condom information
    to youths presents challenges because classrooms and out-of-school
    programs often include mixed-age groups. Two teams told us that, in these
    situations, only AB messages are typically provided to the entire group
    and, as a result, some older youths who need ABC messages may not receive
    them.

    OGAC officials informed us that they were aware that certain components of
    the ABC guidance could be difficult to interpret. For example, they noted
    that they understood that it may be confusing for the definition of
    at-risk groups to include individuals who have sex with someone of unknown
    status. They explained that, although they had intended the guidance not
    to be overly prescriptive and looked to the country teams to determine how
    to apply rules in different situations, they planned to clarify certain
    parts of the guidance. In December 2005, OGAC officials provided us a
    document that gives country teams some additional clarification on how to
    apply the ABC guidance.44 For example, the document addresses issues such
    as preventing transmission among discordant couples and working within the
    context of a generalized epidemic. According to OGAC officials, they will
    update this document each year to respond to country teams' requests for
    additional clarification and to provide technical assistance as the teams
    prepare their operational plans. Country teams can provide feedback to
    OGAC on the ABC guidance and other issues through Washington-based
    interagency teams (core teams) specifically assigned to support them.

    Meeting Abstinence-Until-Marriage Spending Requirement Presents Challenges
    for Majority of Country Teams

    Satisfying the Leadership Act's abstinence-until-marriage spending
    requirement challenges many country teams' efforts to adhere to two
    principles of the PEPFAR sexual transmission prevention strategy. Country
    teams consistently told us that they value the ABC model, and several
    noted the importance of AB messages. At the same time, about half of the
    15 focus country teams reported that meeting the abstinence-until-marriage
    spending requirement undermines their ability to integrate ABC programs as
    required by the guidance. In addition, most of the 20 PEPFAR teams
    required to meet the spending requirement or receive exemptions reported
    that fulfilling the requirement, including OGAC's 50 percent and 66
    percent policies implementing it, presents challenges to their ability to
    respond to local epidemiology and cultural and social norms. Our analysis
    shows that OGAC should just reach the overall 33 percent target by
    granting exemptions to some country teams and requiring other teams to
    dedicate more than 33 percent of prevention funds to AB activities.
    Exempted teams are, to some degree, able to address the challenges they
    identified related to the spending requirement; however, country teams
    that are not exempted from the requirement face additional challenges,
    such as reduced funding for certain prevention programs. Our analysis
    suggests that "other prevention" allocations declined noticeably in
    country teams that were not exempted from the spending requirement but
    stayed constant in those that were. Finally, OGAC's policy of applying the
    spending requirement to all PEPFAR prevention funds-although it determined
    that, as a matter of law, the requirement applies only to funds
    appropriated to the GHAI account-may further constrain country teams'
    ability to address local prevention needs.

    Country Teams Value the ABC Model

    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 a balanced ABC approach was well within the host country's
    prevention approach, and another stated that each component of the model
    has a role to play. Another country team noted that, because of the
    country's high HIV/AIDS prevalence rate, abstinence is an appropriate
    message for both youths and adults. Several teams also emphasized the
    importance of AB messages. For example, one team told us that it has
    integrated AB messages throughout all prevention activities. Other teams
    noted the particular importance of AB messages for certain populations,
    consistent with the ABC guidance. One country team told us that, because
    it is focused on preventing HIV transmission among youths, its prevention
    programming focuses on AB activities. Similarly, another explained that
    youths in its country almost always receive exclusively AB messages.
    Finally, a U.S. government official in one of the focus countries we
    visited told us that abstinence is an important message for young girls in
    that country because of their lack of negotiating power in relationships.

    Spending Requirement Can Undermine Integration of Prevention Programs

    Because it requires country teams to segregate AB funding 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 PEPFAR sexual transmission prevention strategy. Eight of the 15 focus
    country teams indicated that segregating AB from "other prevention"
    funding compromises the integration of their programs. Examples of the
    problems they cited include the following:

    o Segregating program funding compromises the integration of ABC
    activities, especially for at-risk groups that need comprehensive
    messages. 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 what should be integrated
    and potentially lowers  effectiveness. This team noted that there are
    clear links between programming and implementation. In other words, the
    way that a program is reported on paper affects the way that it is put
    into practice.

    o Segregating program funding limits some country teams' ability to shift
    program focus to meet changing prevention needs. One focus country team
    indicated that segregating program funding reduces the team's ability to
    respond flexibly as program beneficiaries' needs change over time.
    According to OGAC officials, once funds are designated as AB, they can be
    used only for AB purposes. This effectively locks teams into allocation
    decisions made when their operational plans were approved.45 A team that
    funds a prevention program for people living with HIV/AIDS stated that,
    although the program includes faithfulness messages, the team does not
    classify any funding for the program as AB, because it cannot predict the
    portion of the project that should be dedicated to the faithfulness
    component and does not want to lose its flexibility to "do what is
    appropriate."46 Another country team explained that its work with
    commercial sex workers will focus on correct and consistent condom use but
    will also include income-generation activities. Once the sex workers find
    an alternative means of income, AB messages become more relevant for them.
    This team stated that segregating program funding undermines the
    continuity inherent in integrated programs.

    Country Teams Report That Meeting Spending Requirement Challenges Their
    Ability to Respond to Local Prevention Needs

    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 presents challenges to their efforts to
    respond to local prevention needs.47 Seventeen of these teams
    reported-either through documents submitted to OGAC or through structured
    interviews-that meeting the spending requirement, including OGAC's 50
    percent and 66 percent policies implementing it, challenges their ability
    to develop interventions that are responsive to local epidemiology and
    social norms.48

    Between September 2005 and January 2006, 10 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:

    o Reduced spending for PMTCT. Three country teams identified cuts in PMTCT
    as a constraint that they would face if required to meet the spending
    requirement. For example, one country team wrote that "reaching the sexual
    prevention and AB [spending requirements] would have required drastically
    reducing the PMTCT budget [from] $1.4 million to $350,000."

    o Limited funding to deliver appropriate prevention messaging to high-risk
    groups. Several teams noted that AB messages are not well-suited for
    high-risk groups. According to one country team, "it is very important to
    direct a certain amount of prevention funding to high-risk groups located
    along transport corridors, and AB messaging is not always appropriate."

    o Lack of responsiveness to cultural and social norms. Country teams
    identified specific characteristics about the epidemics in their countries
    that require a different allocation of funding than would be allowed under
    the spending requirement. For example, a team explained that dedicating a
    large portion of prevention funds to AB would be inappropriate, given
    conservative social norms-youths in their country "are not sexually active
    at an early age; the age of marriage and the age of first sexual
    experience were both estimated at 20 years."

    o Cuts in medical and blood safety activities. One country team
    highlighted these cuts as a potential consequence of meeting the spending
    requirement.

    o Elimination of care programs. One country team wrote that care and
    "other policy programs" would be cut if it were held to the spending
    requirement.

    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 exemptions49- identified, in structured
    interviews, specific program constraints related to meeting the
    abstinence-until-marriage spending requirement. (While some of these teams
    commented specifically on the original 33 percent requirement, as written
    in the 2003 Leadership Act, others commented on OGAC's 50 percent and 66
    percent policies implementing the Leadership Act's requirement.)

    These constraints included the following:

    o Difficulty reaching certain populations with comprehensive ABC messages.
    One country team stated that, because of the abstinence-until-marriage
    spending requirement, it had limited funding for comprehensive ABC
    messages to the general public. In this focus country, the AIDS epidemic
    is generalized but is largely fueled by populations determined to be most
    at risk of contracting HIV, such as commercial sex workers and truck
    drivers. Most of this country's "other prevention" funding is reserved for
    its most-at-risk populations. However, because one-third of prevention
    funding must be reserved for AB programs, the team had little sexual
    transmission prevention funding to deliver integrated ABC messages to
    those in the general population who, although at risk for contracting HIV,
    are not among the most-at-risk populations.

    o Limited or reduced funding for programs targeted at high-risk groups.

    o A focus country team told us that, to meet the spending requirement, it
    had to cut "other prevention" funding by 50 percent. Team members
    explained that, as a result, services for married discordant couples,
    sexually active youths, and commercial sex workers were reduced. In
    general, this team noted that allocating funding in accordance with the
    spending requirement is not appropriate for the country's epidemic and has
    reduced the quality of the team's prevention programming.

    o In a focus country with one of the world's highest national HIV/AIDS
    prevalence rates, a team member told us that meeting the spending
    requirement had forced the team to substantially reduce planned funding
    for a prevention program for people living with HIV/AIDS.

    o Reduced funding for PMTCT services.

    o In fiscal year 2005, the spending requirement led one country team to
    reduce planned funding for its PMTCT program, thereby limiting services
    for pregnant women and their children. (Although the Leadership Act did
    not make the spending requirement mandatory until fiscal year 2006, OGAC
    encouraged country teams to spend 33 percent of prevention funds on AB
    activities prior to that year, consistent with the act's
    recommendation.50) This focus country lacks a health care system for
    providing PMTCT services and, as a result, the team has had significant
    trouble reaching its target for preventing infections through PMTCT
    activities.51 However, at the start of fiscal year 2005, OGAC directed the
    country team to reduce planned funding for PMTCT and dedicate more funding
    to AB activities, because the team's allocation of prevention funds to AB
    fell short of 33 percent.

    o In another country, where the U.S. government has been the largest
    supporter of the PMTCT program, the team told us that complying with the
    spending requirement would likely force it to shift resources away from
    PMTCT and thus reduce needed PMTCT commodities and services.52

    o Difficulty funding programs for condom procurement and condom social
    marketing.

    o One focus country team told us that the spending requirement had
    complicated its efforts to address a condom shortage in the country. To
    reserve funding to procure condoms, the team was required to cut funding
    for other programs in the "other prevention" program area and to shift
    funds from the care category.

    o Another focus country team stated that, because of the spending
    requirement, it would likely have to reduce funding for condom social
    marketing. In this country, the U.S. government has traditionally paid to
    market condoms socially, and a non-U.S. donor has paid to procure them.53

    OGAC's Policies Allow It to Meet the Overall 33 Percent Target

    Our analysis shows that OGAC's policies implementing the 33 percent
    spending requirement should allow it to just fulfill the Leadership Act's
    spending requirement for fiscal year 2006, with the 20 country teams
    dedicating, in total, slightly more than 33 percent of reported planned
    prevention funds to AB activities.54 OGAC officially approved exemptions
    for the 10 country teams that requested them. As a result, all but one55
    of these teams dedicated less than 33 percent of planned fiscal year 2006
    prevention funds for AB activities-about 23 percent on average. At the
    same time, the 10 country teams that did not submit requests for exemption
    were generally required to spend more than 33 percent of planned
    prevention funds on AB activities; fiscal year 2006 data for these teams
    indicate that, on average, they will each spend around 37 percent of total
    reported planned prevention funding on AB activities. Under OGAC's
    policies implementing the spending requirement, any country team that
    spends more than half of prevention funding on sexual transmission
    prevention will have to spend more than 33 percent of its total prevention
    funding on AB. For example, a team that plans to spend 60 percent of
    prevention funding on sexual transmission prevention to meet local needs
    will have to spend at least 40 percent of total prevention funding on AB
    activities to comply with OGAC's 66 percent policy. For fiscal year 2006,
    all but two of the country teams that did not request exemptions planned
    to spend more than half of total prevention funds on sexual transmission

    prevention-about 57 percent on average. As a result, these country teams
    also must spend more than 33 percent of prevention funds on AB.56
    According to an OGAC official, OGAC would have been unable to meet the 33
    percent target if it had allowed many of the country teams with the
    largest amounts of PEPFAR funding to submit exemptions to the spending
    requirement. For fiscal year 2006, only one of the five top-funded focus
    country teams submitted an exemption request.

    OGAC's Policies Give Some Country Teams Greater Flexibility but Further
    Constrain Others

    OGAC's policies implementing the abstinence-until-marriage spending
    requirement allow it to respond to the concerns of teams that received
    exemptions but prevent it from addressing the remaining country teams'
    concerns. Teams that received exemptions were, to some degree, able to
    avoid the challenges related to meeting the spending requirement that they
    had identified in requesting exemption. For example, a country team that
    requested exemption because "the epidemic in [this country] is still
    concentrated primarily among injection drug users and sex workers" planned
    to dedicate 89 percent of total prevention funds to "other prevention" and
    only 4 percent to AB. Another team whose exemption request noted that the
    epidemic in their country "requires that resources be directed towards
    high-risk populations, and populations likely to engage in risky sexual
    behaviors" received approval to limit AB funding to 28 percent of its
    total planned prevention funds and reserved 22 percent of planned
    prevention funds for "other prevention."

    Under OGAC's policies, however, some nonexempted country teams are unable
    to avoid challenges presented by the spending requirement. As noted above,
    7 of the 10 country teams that did not submit requests for exemption
    identified specific concerns about cutting or reducing funding for certain
    prevention programs. In allocating funds to meet the spending requirement,
    country teams are primarily limited to shifting resources among three
    prevention program areas-"other prevention," PMTCT, and AB. (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 a less than 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.

    Data on total actual and planned spending allocations for the focus
    country teams that did not request exemption from the spending
    requirement57 suggest a noticeable decline in "other prevention" funding
    between fiscal year 2005, when the spending requirement was not mandatory,
    and fiscal year 2006.58 Although some of this shift may be due to varying
    methods of categorizing sexual transmission prevention programs and some
    changes in categorization methods across fiscal years (see app. V), the
    data demonstrate a common trend across these teams. 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 11 shows the allocation of prevention funds by nonexempted and
    exempted focus country teams for fiscal years 2005 (actual funds) and 2006
    (planned funds).

    Figure 11: Prevention Allocations for Nonexempted and Exempted Focus
    Country Teams, Fiscal Years 2005 and 2006

    Note: Fiscal year 2006 funding is planned. Because of data reliability
    issues discussed previously and in appendix V, these figures should be
    used only to understand general trends in data, rather than as precise
    percentage differences between program areas and fiscal years. Because of
    rounding, the percentages may not sum to 100.

    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.

    OGAC's Application of Spending Requirement to All U.S. Prevention Funding
    May Further Challenge Country Teams

    OGAC's decision to apply the abstinence-until-marriage spending
    requirement to all PEPFAR prevention funding-although it determined that,
    as a matter of law, the requirement applies only to funds in the GHAI
    account-may further challenge some country teams' ability to address HIV
    prevention needs at the local level. According to OGAC officials, they
    have chosen to apply the spending requirement to all PEPFAR prevention
    funding in response to a PEPFAR principle that HIV/AIDS programs should be
    integrated within and across agencies. These officials expressed the
    opinion that allowing country teams to apply the spending requirement to
    only a portion of prevention funding would compromise this integration.
    The officials added that the amount of PEPFAR funding not appropriated to
    the GHAI account59 is relatively small. For fiscal year 2006, non-GHAI
    prevention funds amount 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 decision, country teams are constrained from
    allocating non-GHAI funding to meet local needs if the allocations do not
    comply with the spending requirement. For example, for fiscal year 2006,
    one focus country team received about $1.5 million in prevention funding
    that was not covered by the GHAI account. As a country with a generalized
    epidemic and total PEPFAR funding exceeding $75 million, this team did not
    submit a justification requesting exemption from the spending requirement,
    but it identified constraints resulting from meeting the
    requirement-specifically, that it would likely have to reduce funding for
    condom social marketing.60 Because of OGAC's policy regarding non-GHAI
    prevention funding, this country team will be unable to apply the $1.5
    million to the condom social marketing programs for which funding was
    likely reduced.

    Conclusions

    Responding to the severity and urgency of the global HIV/AIDS crisis,
    PEPFAR and its authorizing legislation, the U.S. Leadership Against
    HIV/AIDS, Tuberculosis and Malaria Act of 2003, significantly increased
    the United States' commitment to fight the epidemic. Country teams
    consistently indicated that the ABC model is a useful tool for preventing
    sexual transmission of HIV, and many expressed the importance of AB
    messages for certain populations. However, the Leadership Act's
    requirement that country teams spend at least 33 percent of prevention
    funding appropriated pursuant to the act on abstinence-until-marriage
    programs has presented challenges to country teams' 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 has established policies implementing the
    requirement that respond to these concerns while allowing it to meet the
    overall 33 percent spending target. Under these policies, some country
    teams have, to some degree, been able to avoid problems-such as limited
    funding to deliver appropriate prevention messages to high-risk
    groups-that would have occurred had they been subject to the spending
    requirement. However, other country teams, especially those with large
    amounts of PEPFAR funding and those facing generalized epidemics, have
    faced further constraints that have affected their ability to respond to
    local prevention needs. Finally, OGAC's application of the spending
    requirement to $35 million in funds not appropriated to the GHAI account
    may also hamper country teams' ability to develop locally responsive
    prevention programs. OGAC may be able to address some of these constraints
    by reconsidering its policy of applying the spending requirement to all
    PEPFAR prevention funding; however, the amount of funding not covered by
    the GHAI account is relatively small. Reversing this policy would not
    enable OGAC to fully address the underlying challenges that country teams
    face in having to reserve a specific percentage of their prevention funds
    for abstinence-until-marriage programs.

    Recommendation for Executive Action

    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, we recommend that the Secretary of State direct the
    U.S. Global AIDS Coordinator to take the following action:

    o collect information from the country teams each fiscal year on the
    spending requirement's effect on their HIV sexual transmission prevention
    programming and provide this information in an annual report to Congress.

    o This information should include, for example, the justifications
    submitted by country teams requesting exemption from the spending
    requirement.

    o The information collected should be used by the U.S. Global AIDS
    Coordinator 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.

    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, Congress, in its
    ongoing oversight of PEPFAR, should

    o 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

    o 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.

    Agency Comments and Our Evaluation

    The Department of State/OGAC, HHS, and USAID provided combined written
    comments on a draft of this report. (See app. VI for a reprint of their
    comments and our response.) In their letter, they highlighted the value of
    a comprehensive ABC approach in preventing sexual transmission of HIV and
    cited recent data from Kenya and Zimbabwe showing that where sexual
    behaviors have changed-as evidenced by increased primary and secondary
    abstinence, fidelity, and condom use-HIV prevalence has declined.
    Consistent with our report's discussion, they also stated that more work
    is needed to understand these data and to identify which interventions may
    have influenced them. In response to our finding that interpreting and
    implementing the ABC guidance has created challenges for most of the focus
    country teams, they stated that they are working to improve efforts to
    communicate policy to country teams through various methods, such as
    weekly e-mails and constant contact between the core team leaders and the
    field.

    The agencies stated that the Leadership Act's emphasis on AB activities
    has helped move them toward a balanced ABC strategy. They also accepted
    our recommendation that, given challenges country teams face in allocating
    prevention resources, they should collect information from the country
    teams each fiscal year regarding the spending requirement's effect on
    their HIV sexual transmission prevention programming. The agencies
    disagreed with our recommendation to consider whether the Leadership Act's
    spending requirement should be applied solely to funds appropriated to the
    GHAI account, in line with OGAC's legal determination that the requirement
    applies only to these funds. First, they stated that applying the spending
    requirement to only one part of the budget would harm their efforts to use
    a unified budget approach. Second, they stated that the issue is becoming
    less salient over time because non-GHAI funds have declined in the focus
    countries. As a result of the agencies' comments, we have clarified our
    recommendation to ask that they consider making this policy change after
    reviewing the information they collect on the effects of the spending
    requirement. We believe that this recommendation may be particularly
    relevant for the five additional country teams required, absent
    exemptions, to meet the spending requirement because non-GHAI funds
    represent over 80 percent of their total PEPFAR prevention funding. OGAC
    and USAID also provided technical comments, which we have incorporated
    where appropriate.

    We are sending copies of this report to interested congressional
    committees. We also will make copies available to others on request. In
    addition, the report will be available at no charge on the GAO Web site at
    h  ttp://www.gao.gov. If you or your staff have any questions, please
    contact me at (202) 512-3149 or g  ootnickd@gao.gov. Contact points for
    our Offices of Congressional Relations and Public Affairs may be found on
    the last page of this report. Key contributors to this report are listed
    in appendix VII.

    David Gootnick Director, International Affairs and Trade

    List of Congressional Committees

    The Honorable Arlen Specter Chairman Subcommittee on Labor, Health and
    Human Services,      Education, and Related Agencies Committee on
    Appropriations United States Senate

    The Honorable Richard G. Lugar Chairman The Honorable Joseph R. Biden, Jr.
    Ranking Minority Member Committee on Foreign Relations United States
    Senate

    The Honorable Edward M. Kennedy, Jr. Ranking Minority Member Committee on
    Health, Education, Labor, and Pensions United States Senate

    The Honorable Jim Kolbe Chairman The Honorable Nita M. Lowey Ranking
    Minority Member Subcommittee on Foreign Operations,     Export Financing,
    and Related Programs Committee on Appropriations House of Representatives

    The Honorable Joe Barton Chairman The Honorable John D. Dingell Ranking
    Minority Member Committee on Energy and Commerce House of Representatives

    The Honorable Henry A. Waxman Ranking Minority Member Committee on
    Government Reform House of Representatives

    The Honorable Christopher Shays Subcommittee on National Security,
    Emerging Threats     and International Relations Committee on Government
    Reform House of Representatives

    The Honorable Tom Lantos Ranking Minority Member Committee on
    International Relations House of Representatives

    Scope and Methodology Appendix I

    Under the Comptroller General's authority, in this report we (1) review
    trends and allocation of the President's Emergency Plan for AIDS Relief
    (PEPFAR) prevention funding, (2) describe the PEPFAR strategy for
    preventing the sexual transmission of HIV, and (3) identify key challenges
    associated with applying the PEPFAR sexual prevention strategy. Our work
    focuses primarily on the 15 PEPFAR focus countries: Botswana, Cote
    d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria,
    Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia.

    As part of our efforts to collect information on all three objectives, we
    conducted structured interviews between June 2005 and January 2006 with
    key Department of State, U.S. Agency for International Development
    (USAID), Department of Health and Human Service-Centers for Disease
    Control and Prevention (HHS/CDC), and other U.S. agency staff responsible
    for implementing HIV/AIDS programs in the 15 focus countries.1 We
    conducted 11 of these structured interviews over the telephone and 4
    during site visits to Botswana, Ethiopia, South Africa, and Zambia in July
    2005.

    Our structured interview document contained open-ended questions related
    to each of our three objectives. To develop questions for the structured
    interview, we reviewed key documents from the Office of the U.S. Global
    AIDS Coordinator (OGAC) and other U.S. government agencies, as well as
    country teams' operational plans. We also interviewed key U.S.-based
    officials from OGAC, USAID, and HHS/CDC. We pretested our questions with
    four of our initial respondents and refined our questions based on their
    input. We conducted follow-up interviews with our respondents to obtain
    supplementary information.

    To summarize the open-ended responses and develop categories for the
    analysis, we first grouped open-ended qualitative interview responses into
    a set of overarching issue areas and then, within each of those issue
    areas, we grouped the interview data into subcategories. To ensure the
    validity and reliability of our analysis, these subcategories were
    reviewed by a methodologist, who proposed modifications. After discussion
    of these suggestions, we determined a final set of subcategories. We then
    tallied the number of respondents providing information in each
    subcategory.

    We also requested information from the five additional PEPFAR country
    teams that receive at least $10 million in PEPFAR funding. In October
    2005, we sent standardized questions to these teams on three areas: (1)
    their PEPFAR funding (particularly how their prevention funding was broken
    down by spending account); (2) their experiences developing country
    operational plans; and (3) the effects, if any, of the
    abstinence-until-marriage spending requirement on their prevention
    programming. We received responses from two of these country teams.

    To examine trends and allocation of PEPFAR prevention funding, we reviewed
    budget data provided to us by OGAC on fiscal year 2004 planned and
    approved country-level funding; OGAC's Country Operational Plan and
    Reporting System (COPRS), a central U.S. government data system developed
    to support the collection and analysis of data related to Emergency Plan
    planning and reporting requirements;2 and data provided to us by OGAC on
    centrally awarded funding. To determine how country teams categorize
    funding for integrated programs that include AB and "other prevention"
    components in their country operational plans, we reviewed the President's
    Emergency Plan for AIDS Relief FY06 Country Operational Plan Final
    Guidance (revised Aug. 22, 2005), as well as country teams' operational
    plans. We determined that these data were sufficiently reliable for some
    purposes. (See app. V for a discussion of specific data limitations.)
    Finally, we interviewed U.S.-based officials from OGAC.

    To describe the PEPFAR strategy for preventing the sexual transmission of
    HIV, we reviewed the 2003 Leadership Act; The President's Emergency Plan
    for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (February 2004);3
    OGAC guidance to country teams, including its ABC Guidance #1 For United
    States Government 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 (March 2005); and each focus
    country team's 5-year HIV/AIDS strategy for PEPFAR. We also interviewed
    key U.S.-based officials from OGAC, USAID, and HHS/CDC.

    To identify challenges associated with implementing the PEPFAR sexual
    transmission prevention strategy, we (1) interviewed nongovernmental
    organizations (NGOs) that receive PEPFAR prevention funding; (2) conducted
    site visits to Botswana, Ethiopia, South Africa, and Zambia in July 2005;
    and (3) reviewed country teams' requests for exemption from the spending
    requirement. Prior to conducting our fieldwork, we selected the top five
    NGO recipients of fiscal year 2005 PEPFAR funding for AB activities and
    the top five NGO recipients of fiscal year 2005 PEPFAR funding for "other
    prevention" activities to interview. Because two of these organizations
    were on both lists, we selected a total of eight organizations, of which
    we interviewed six, but were unable to meet with the remaining two.4 For
    our July 2005 fieldwork, we selected a targeted sample of PEPFAR focus
    countries to visit based on six criteria: (1) the amount of the country's
    fiscal year 2004 PEPFAR funding dedicated to HIV prevention; (2) the
    percentage of the country's fiscal year 2004 PEPFAR funding dedicated to
    HIV prevention; (3) the amount of the country's fiscal year 2004 PEPFAR
    funding dedicated to preventing the sexual transmission of HIV; (4) the
    percentage of the focus country's fiscal year 2004 PEPFAR funding for
    preventing sexual transmission of HIV dedicated to
    abstinence/faithfulness; (5) the percentage of the focus country's fiscal
    year 2004 PEPFAR funding for preventing sexual transmission of HIV
    dedicated to "other" prevention methods, such as condom promotion; and (6)
    HIV/AIDS prevalence. In the countries that we visited, we interviewed key
    U.S. government officials, host country government officials,
    nongovernmental organizations (NGOs), faith-based organizations, local
    community-based organizations, and program beneficiaries, and we observed
    programs in all five prevention program areas being implemented. The
    information we obtained during these site visits related primarily to
    challenges associated with interpreting and implementing the ABC guidance.
    Last, we reviewed excerpts of documents that country teams submitted
    requesting exemption from OGAC's policies implementing the
    abstinence-until-marriage spending requirement. These documents were
    submitted by both focus country teams and some of the additional teams
    required to meet the requirement.

    Finally, to further develop our understanding of challenges associated in
    general with preventing HIV/AIDS, we attended prevention conferences in
    Washington, D.C., and reviewed reports prepared by NGOs, private AIDS
    foundations, UNAIDS, and other multilateral and international
    institutions. We also interviewed representatives of some of these
    organizations.

    We conducted our work from February 2005 to February 2006 in accordance
    with generally accepted government auditing standards.

    AB and "Other Prevention" Programs in Four Focus Countries Appendix II

    Fiscal year 2005 program descriptions1 of abstinence/faithfulness (AB) and
    "other prevention" programs in the four focus countries that we visited
    demonstrate the diversity of approaches that the President's Emergency
    Plan for AIDS Relief (PEPFAR) country teams use to prevent HIV/AIDS.
    Country teams employ a host of methods to reach communities, such as mass
    media interventions, one-on-one communication, and capacity building for
    local organizations. The degree to which they emphasize these methods
    varies. For example, the Botswana team dedicates its largest single pot of
    AB funding to a capacity-building program, while the South Africa team
    dedicates its highest funded AB award to a mass media program. Because the
    congressional abstinence-until-marriage requirement and the Office of the
    U.S. Global AIDS Coordinator's (OGAC) policies interpreting it were not in
    effect in fiscal year 2005, the funding amounts for each of the four
    country teams do not show a 2-to-1 ratio of AB to "other prevention"
    funding.

    Botswana

    For fiscal year 2005, the following four programs accounted for about 70
    percent of the Botswana team's total country-level AB funding:

    o $800,000 to strengthen Botswana-based, nongovernmental organizations
    through a central Botswana HIV/AIDS umbrella organization that will become
    a leading partner in the HIV/AIDS response and expand services provided by
    the sector. This umbrella organization works with local faith-based
    organizations, community-based organizations, and nongovernmental
    organizations (NGOs) to fund, among other programs, AB prevention
    activities.

    o $550,000 to fund a radio drama  that models positive behaviors and
    provides information on various issues related to HIV/AIDS, such as
    abstinence, faithfulness, partner reduction, healthy relationships, and
    basic HIV information. The drama is reinforced with activities such as
    road shows, discussion groups, and contests. This program also receives
    funding under "other prevention."

    o $400,000 to conduct a social marketing campaign promoting the "be
    faithful" message. This project also builds capacity of local partners to
    develop behavior change community messages and promote AB messages.

    o $350,000 to support a nationwide door-to-door community HIV education
    program, which trains field officers to inform, educate, and mobilize the
    community on topics such as abstinence and faithfulness. This program also
    receives funding under "other prevention."

    For the same fiscal year, the following five programs accounted for about
    70 percent of the Botswana team's total country-level "other prevention"
    funding:

    o $1,095,000 to fund a radio drama  that promotes counseling and testing,
    information on antiretroviral treatment and adherence, prevention of
    mother-to-child transmission (PMTCT), stigma reduction, disclosure of HIV
    status, and alcohol and domestic abuse. This program also receives funding
    under AB, as noted above.

    o $375,000 to reduce HIV transmission among individuals with
    sexually-transmitted infections. This program works with health care
    professionals and their clients to improve management of sexually
    transmitted infections, with the goal of better identifying populations at
    high risk for transmitting HIV and quickly linking them with HIV treatment
    and related services.

    o $350,000 to support a nationwide door-to-door community HIV education
    program, which trains field officers to inform, educate, and mobilize the
    community on topics such as condom use, voluntary counseling and testing,
    PMTCT, stigma reduction, and related life skills. This program also
    receives funding under AB, as noted above.

    o $349,000 to fund technical assistance.  This program covers salaries for
    three staff members, travel, printing of technical materials to support
    "other prevention" projects, participation in domestic and international
    conferences, and temporary duty visits by colleagues based in the United
    States.

    o $325,000 to lay the groundwork for potential implementation of four
    prevention programs areas: provision of the antiretroviral treatment
    Tenofovir prior to exposure to HIV infection, male circumcision,
    commercial sex work, and gender and HIV/AIDS. For the first two program
    areas, the program works with key stakeholders to determine how each
    service, if proven effective as a prevention strategy, would be introduced
    to the health care community and general population. For the second two
    program areas, the program gathers implementing partners and stakeholders
    to discuss some of the gender issues that inhibit HIV prevention efforts,
    to share best practices on these issues, and to outline research and
    programmatic needs and priorities.

    Ethiopia

    For fiscal year 2005, the following four programs accounted for about 70
    percent of the Ethiopia team's total country-level AB funding:

    o $1,170,000 to continue and expand HIV/AIDS behavior change programs
    targeting youths with AB messages. This program uses a youth action
    toolkit and a sports-related program to model and reinforce AB behaviors
    for primary school students aged 11-14, as well as in-school and
    out-of-school youths aged 15-20.

    o $900,000 to reach high-risk groups and youths, teachers, and community
    leaders with behavior change communication messages. This program targets
    three high-risk groups: short-distance minibus drivers, taxi drivers, and
    their assistants; commercial sex workers; and a regional police force. AB
    is the primary prevention message for these groups. However, this program
    also receives funding under "other prevention" to provide non-AB messages
    for commercial sex workers.

    o $420,000 to provide comprehensive prevention services along a transport
    corridor. This program targets communities along the transport corridor
    between Addis Ababa and Djibouti with community prevention education
    programs promoting AB and reduction of stigma and discrimination. For
    example, the program targets 30,000 in-school youths living along the
    corridor with an abstinence-only education program called Lessons for
    Life. This program also receives funding under "other prevention."

    o $400,000 to promote AB messages through the media. This program trains
    journalists to increase accurate knowledge of HIV/AIDS and reduce stigma
    and discrimination, focusing on the promotion of abstinence and
    faithfulness prevention messages.

    For the same year, one program accounted for about 70 percent of
    Ethiopia's total country-level "other prevention" funding.

    o $2,900,000 to procure, distribute, and market condoms to population
    groups at risk of transmitting HIV. This program will promote 100 percent
    condom use in targeted locations where high-risk groups congregate, such
    as bars and hotels, and will be supported by behavior change and social
    marketing campaigns. This program will also assure condom supplies at
    health facilities, such as hospitals and PMTCT centers, and supply condoms
    to kiosks and marketing outlets in urban settings.

    South Africa

    For fiscal year 2005, the following seven programs accounted for about 70
    percent of the South Africa team's total country-level AB funding:

    o $3,100,000 to produce and broadcast HIV AB messages via television. This
    program broadcasts AB messages to 350 waiting rooms in public health
    facilities, which are complemented by discussions facilitated by trained
    health care workers. It also produces a popular television drama series
    exploring the challenges and life experiences of young people living in a
    rural community, especially their struggles with HIV/AIDS and associated
    social problems. This program includes significant AB messaging. Themes in
    the television drama are linked with targeted community mobilization, such
    as discussion groups.

    o $900,000 to promote and strengthen AB messages through churches,
    schools, community-based organizations, and NGOs. This program conducts
    peer education activities, trains teachers in an AB-based curriculum, and
    holds community meetings and workshops to promote innovative HIV
    prevention programs that incorporate strong AB messages.

    o $400,000 to implement three AB activities: a school-based AB program, a
    program promoting mutual monogamy, and a program targeting AB preventative
    behaviors among orphans and vulnerable children. The school-based program
    integrates AB messages into "Life Skills" education in six schools. The
    monogamy program targets members of faith-based groups with an AB
    curriculum and peer support for abstinence and faithfulness, among other
    activities. The program for orphans and vulnerable children trains youth
    caregivers in prevention; developing, disseminating, and advocating AB
    messages; and promoting dialogue. This program also receives other funding
    through the prevention, care, and treatment program areas.

    o $400,000 to implement AB-focused prevention programs through faith-based
    organizations and traditional leaders and to focus attention on the need
    for AB programs for men who have sex with men. This program develops
    national HIV/AIDS strategies for five faith-based groups and aims to
    improve leadership among traditional leaders in the areas of HIV/AIDS
    advocacy and human rights. It also develops a national strategy to
    stimulate a programmatic and policy focus on providing AB prevention
    messages to men who have sex with men and holds a sensitization workshop
    to increase stakeholders' capacity to implement successful programs that
    target these men.

    o $400,000 to implement a door-to-door HIV prevention campaign. This
    program recruits and trains 400 community members as peer educators and
    counselors to provide information to households on HIV/AIDS prevention and
    preventative behaviors. These educators and counselors promote voluntary
    counseling and testing services and PMTCT services, as well as teach
    proper condom use, when appropriate. These volunteers also mobilize
    communities to address stigma and discrimination associated with HIV/AIDS.

    o $400,000 to produce mass media interventions with AB components. The
    program supports development of a television program for the family
    audience that covers issues such as HIV/AIDS and all aspects of treatment;
    messages on prevention and stigma, such as abstinence/faithfulness and
    voluntary counseling and testing; and masculinity and gender as they
    relate to HIV/AIDS. It also supports development of television and radio
    programs and related materials for children and their parents. These
    programs and materials cover HIV/AIDS from a child's perspective, focusing
    on the impact of HIV/AIDS on children's lives and on the school system and
    promoting prevention messages, particularly abstinence/faithfulness. They
    also cover other topics such as nutrition, lifestyle, gender, and
    masculinity. These youth-focused programs are complemented by community
    mobilization interventions, such as youth clubs to discuss the issues
    presented in different episodes. This program also receives funding under
    the treatment program area.

    o $350,000 to work with teachers' unions on a prevention peer education
    and AIDS management prevention program. This program uses trained school
    union representatives to facilitate weekly discussion groups among
    teachers on issues such as self-awareness, an understanding of one's own
    sexuality, and decision-making skills as they relate to abstinence,
    faithfulness, and sex. The program also receives other funding through the
    prevention, care, and treatment program areas.

    For the same year, the following five programs accounted for about 70
    percent of the South Africa team's total country-level "other prevention"
    funding:

    o $2,800,000 to produce and broadcast AB and other prevention messages via
    television. See program description above under the AB program area.

    o $1,400,000 to train "Master Trainers" from public and private health
    sector unions. Master trainers will conduct HIV and AIDS prevention
    education programs for union membership, senior union leadership, and
    others. This program will also implement a young workers' campaign
    involving life skills-based education to help young workers embrace a
    healthy lifestyle, including adoption of safe sexual practices.

    o $500,000 to support the sexually transmitted infections and HIV
    prevention unit of the National Department of Health. Support includes
    providing logistics, management, and technical assistance in the
    procurement, warehousing, distribution, and teaching of the national male
    and female condom programs.

    o $449,259 to provide technical assistance to government health programs,
    support the distribution of condoms, and operate programs targeting
    high-risk groups. The program provides support and technical advice on the
    development and rollout of government programs, including comprehensive
    HIV management services, such as HIV prevention services and sexually
    transmitted infection prevention and treatment services. The program also
    supports a commercial sex workers project, which provides condoms,
    sexually transmitted infection treatment, and support for leaving sex
    work.

    o $365,000 to address the HIV/AIDS prevention needs of youths and
    underserved groups, such as drug users. This program conducts an
    assessment in three cities to better understand and respond to populations
    that are vulnerable to HIV infection. The program also funds a specialist
    to develop a youth prevention strategy for the National Department of
    Health and to build the capacity of local youth-serving organizations to
    provide skill-building and youth specific interventions.

    Zambia

    For fiscal year 2005, the following two programs accounted for about 65
    percent of the Zambia team's total country-level AB funding:

    o $2,000,000 to strengthen the capacity of local community organizations
    to implement AB programs  that target youths with comprehensive
    skills-based AB prevention activities. This program provides training for
    teachers on HIV/AIDS prevention, with an AB emphasis. It also reviews
    existing AB prevention curricula and programs and assists the Zambian
    Ministry of Education in introducing new modules on preventing
    gender-based sexual violence. In addition, the program establishes a
    school-managed student-driven grants program to implement AB prevention
    activities for youths and involve parents. Finally, the program
    distributes leaflets and life skills booklets in support of an AB message.

    o $1,480,000 for a consortium of faith-based and community-based
    organizations to implement abstinence promotion activities. The focus of
    this program is a small grants program for organizations to work with
    youths. These organizations combine abstinence messaging with business
    management and vocational training in order to decrease economic
    vulnerability among youths. The organizations also use sports camps and
    "coming of age" ceremonies to reach youths. Finally, the program promotes
    fidelity and partner reduction among adults through extensive home-based
    care programs and district-level training sessions.

    For the same year, two programs accounted for about 75 percent of the
    Zambia team's total country-level "other prevention" funding.

    o $3,379,574 for prevention interventions for at-risk groups living and
    working at border and high transit sites. This program targets sex workers
    and their clients, truck drivers, mini bus drivers, and uniformed
    personnel at border and high-transit sites with services including
    sexually transmitted infection management, counseling and testing,
    referrals for antiretroviral treatment, behavior change interventions that
    promote partner reduction and condom use, and condom social marketing.
    Communication methods used include peer education, outreach work, drama,
    one-on-one counseling, group discussion, mass media, and local-based
    promotional activities. This program also receives funding under the AB
    program area.

    o $2,600,000 to provide HIV prevention messages to adults and youths. This
    program will provide support to discordant couples through faithfulness
    and condom-use messages. It will also expand activities targeting at-risk
    groups with messages on healthy practices and correct and consistent
    condom use. For example, the program will use community outreach
    activities such as education sessions with transport workers, uniformed
    personnel, and police on personal risk-assessment skills and
    condom-negotiation skills. In addition, this program supports in-school
    anti-AIDS clubs and a youth radio program that provides A, B, and C
    messages. This program also receives funding under the AB program area.

    Prevention Program Indicators and Methods of Measuring PEPFAR Prevention
    Program Results Appendix III

    The Office of the U.S. Global AIDS Coordinator (OGAC) requires country
    teams to report the number of individuals reached through specific
    prevention programs, but assessing overall progress toward reaching
    prevention goals presents major challenges. OGAC requires that country
    teams report on indicators such as the number of individuals reached by
    the program. OGAC plans, over time, to estimate progress toward the
    President's Emergency Plan for AIDS Relief (PEPFAR) prevention goal by
    using U.S. Census Bureau statistical modeling of countries' HIV/AIDS
    prevalence trends, but these estimates may not be available for several
    years and will not link averted infections to specific types of prevention
    programs. OGAC had initially planned to use an alternative modeling
    approach that linked results to types of programs within the countries,
    but it dropped that approach because of limited research data on the
    effectiveness of particular prevention activities.

    OGAC Tracks the Number of Individuals Reached by Prevention Programs as a
    Performance Indicator

    OGAC requires country teams to report several performance indicators,
    which generally capture the number of individuals reached or trained for
    each prevention program aimed at sexual transmission. Specifically, for
    abstinence/faithfulness (AB) activities they report on the

    o number of individuals reached through community outreach that promotes
    HIV/AIDS prevention through abstinence and/or being faithful,

    o number of individuals reached through community outreach that promotes
    HIV/AIDS prevention through abstinence, and

    o number of individuals trained to promote HIV/AIDS prevention programs
    through abstinence and/or being faifthful.

    For "other prevention" activities, they report on the

    o number of targeted condom service outlets,

    o number of individuals reached through community outreach that promotes
    HIV/AIDS prevention through other behavior change beyond abstinence and/or
    being faithful, and

    o number of individuals trained to promote HIV/AIDS prevention through
    other behavior change beyond abstinence and/or being faithful.

    OGAC tracks similar indicators for prevention programs outside the sexual
    transmission area. These include four indicators for prevention of
    mother-to-child transmission (PMTCT), two for blood safety, and one for
    safe injections.1

    OGAC Will Estimate Progress Toward Infections Averted Goal Using
    Statistical Model

    OGAC plans, over time, to estimate progress toward the PEPFAR goal of
    averting 7 million infections by 2010 by using a statistical model of
    epidemiological trends developed by the U.S. Census Bureau. The model will
    compare "expected" HIV incidence rates in particular countries with
    "actual" incidence rates and use those comparisons to estimate the number
    of infections that have been averted through PEPFAR and related prevention
    programs. This model attempts to estimate the number of infections averted
    over time, but it cannot attribute this change to any specific
    intervention or to the success of particular types of programs.

    Specifically, the model estimates entail the following elements for each
    country:

    o Establish "baseline" projections of HIV incidence for future years,
    using country data on prevalence rates through 2003 to make projections.
    This baseline prevalence is what would theoretically occur in the country
    in the absence of interventions such as PEPFAR. The prevalence data used
    to make these projections are obtained primarily from surveys in prenatal
    clinics.2 The projections are made using assumptions about the rate of
    transmission of the virus in different segments of the population and
    about other factors such as death rates.

    o Estimate actual HIV prevalence trends in countries in future years,
    using country survey data from the prenatal clinics, beginning with data
    collected in 2004.

    o Calculate the number of infections averted in each country as the
    difference between (1) the number of new infections each year that would
    be associated with the baseline prevalence rates and (2) the number of new
    infections each year that would be associated with the prevalence rates
    observed after implementation of PEPFAR and other prevention efforts.

    Thus, if the Census model projected, for example, that based on trends in
    place prior to the initiation of PEPFAR programs, there would be 300,000
    new HIV infections in Kenya between 2005 and 2008, and actual survey data
    in future years indicated there were 200,000,  then PEPFAR would be
    assumed to have contributed to averting 100,000 infections in Kenya during
    that period.

    Estimating infections averted over time using OGAC's modeling approach
    involves substantial challenges and the reliability of the estimates is
    not known, according to Census officials. A key challenge is the lack of
    data on prevalence rates in many developing countries. Because of that
    lack of data, a single long-term study of prevalence trends in Musaka,
    Uganda, serves as the basis for several assumptions that underlie Census
    projections on baseline prevalence rates. These assumptions include, for
    example, the average age when individuals begin to be sexually active and
    infection rates among migrant populations. In addition, estimating changes
    in prevalence rates over time, and thus, infections averted, is
    complicated by the fact that impacts of behavioral change programs can
    occur over a period of time. For example, the impact on prevalence rates
    of providing life skills programs targeted at younger students who are not
    sexually active might not be observed for some period of time. Thus,
    prevalence data gathered in 2008, for example, may not show the full
    impact of PEPFAR prevention programs over the previous year or two.

    OGAC Considered Alternative Method of Measuring Infections Averted

    In March 2004, OGAC convened a technical modeling group to determine a
    methodology for measuring infections averted under PEPFAR.3 The group
    assessed alternative modeling approaches and initially considered the
    Goals Model (developed by the Futures Group)4 as an appropriate tool. The
    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.5 In contrast to the Census model described in the
    previous section, the GOALS model links estimates of infections averted to
    specific types of prevention programs carried out under PEPFAR and their
    spending levels.

    In September 2004, the Futures Group presented estimates of infections
    that would be averted during PEPFAR's first year to the Technical Modeling
    Group. The Futures Group estimated, based on country operational plans,
    that between 550,000 and 580,000 infections would be averted in the
    initial 14 focus countries in fiscal year 2004 and that condom promotion
    and voluntary counseling and testing programs were more likely to avert
    infections than other prevention interventions.

    There was debate within the Modeling Group about the merits of applying
    the Goals Model. Of particular concern were limitations in the research
    underlying the model on the effectiveness of different types of programs
    in preventing HIV transmission. For example, the research included very
    few studies that assessed the effectiveness of abstinence programs in
    limiting

    HIV transmission.6 Although some working group members believed that the
    Goals Model, despite being an imperfect tool, could provide needed
    insights regarding prevention programs' progress in averting infections,
    OGAC concluded that the model could yield misleading results and was not
    the best method to adopt.

    OGAC Is Planning Some Limited Targeted Evaluations of Prevention Programs

    To acquire information about the effectiveness of specific PEPFAR
    prevention programs, especially in the AB area, OGAC plans to carry out
    and fund targeted evaluations on a very limited scale. According to OGAC,
    targeted evaluations are rapid studies that can provide evidence-based
    information to improve prevention programming in the near term. In the
    sexual transmission prevention area, these evaluations will be done on a
    small sample of AB programs. The bulk of the funding for targeted
    evaluations comes through central PEPFAR funds. In 2004, OGAC invested
    about $2 million in targeted evaluations of AB programs to be carried out
    over 2 years. Some country teams are also doing some limited targeted
    evaluations of AB programs through their country operational plans.
    According to an OGAC official, the targeted evaluations will have limited
    use because of their small scale and the amount of time before results are
    available.

    PEPFAR Planning and Reporting Process Appendix IV

    The operational plans that the President's Emergency Plan for AIDS Relief
    (PEPFAR) country teams submit to the Office of the U.S. Global AIDS
    Coordinator (OGAC) each year identify, among other things, the
    organizations that will implement the proposed activities and program
    descriptions. When OGAC receives the operational plans, it implements a
    three-part review process, including a technical review, a programmatic
    review, and a principals' review.1 At the conclusion of the reviews, OGAC
    submits a notification to the relevant congressional committees,2
    informing them of the activities it plans to implement under PEPFAR in the
    current fiscal year.3 Once Congress approves the notification, funds can
    be transferred to the field for obligation. The process for transferring
    and obligating funds and the length of time it takes to complete this
    process varies by agency,4 but all implementing partners are instructed to
    expend their funds within 12 months of receiving them.

    In addition to submitting operational plans, country teams are required to
    submit semiannual and annual progress reports to OGAC each fiscal year.
    These reports identify obligations that have occurred in the past fiscal
    year, as well as results of the various activities. Figure 12 provides a
    time line of OGAC's planning and reporting requirements and the PEPFAR
    funding cycle.

    Figure 12: OGAC Planning and Reporting Requirements for Fiscal Years 2005
    and 2006

    Note: Dates for midyear progress report preparation and operational plan
    preparation are approximate.

    Methods for Reporting Allocations among PEPFAR Prevention Program
    Areas Appendix V

    Country teams have used varying methods to categorize funding for certain
    integrated abstinence/faithfulness/condom use (ABC) programs1 and to
    categorize funding for broader sexual transmission prevention components
    that are not clearly defined as abstinence/faithfulness (AB) or "other
    prevention," owing to challenges they face in categorizing these programs.
    Because of the teams' varying methods for categorizing this funding, the
    reported allocations for the AB and "other prevention" program areas are
    of limited reliability.

    In our structured interviews, 10 of the 15 focus country teams noted the
    difficulty of categorizing funding for certain integrated ABC programs.
    For example, some officials told us that, although they do the best they
    can to estimate the portion of funding for an integrated ABC program that
    will be used for AB versus "other prevention" activities, it can be
    difficult to predict in advance how much funding will be used for AB or
    "other prevention" activities when a program provides a variety of HIV
    prevention messages that may vary based on the needs of program
    participants.

    A review of fiscal year 2006 country operational plans indicates that,
    within the sexual transmission prevention program area,2 country teams use
    different methods for categorizing integrated programs that have ABC
    components in their plans. Some country teams have categorized integrated
    ABC programs entirely as "other prevention,"3 while others have divided
    some or all of these programs between AB and "other prevention" (with the
    C component categorized under "other prevention" and the AB component
    categorized as AB). For example, one country team's fiscal year 2006
    operational plan shows one of its integrated ABC programs split between
    the AB and "other prevention" program areas but two of its integrated ABC
    programs placed entirely in the "other prevention" program area. Another
    country team placed all of its integrated ABC programs entirely in the
    "other prevention" program area rather than split these programs between
    the AB and "other prevention" areas.

    Our structured interviews also showed that country teams have used
    different methods for categorizing funding for integrated ABC programs for
    planning and reporting.4 Following are methods used by country teams we
    interviewed:

    o Twelve of the 15 country teams told us that they split at least some of
    their integrated ABC programs into the AB and "other prevention" program
    areas. Most of these teams told us that they do not split all of their
    integrated programs into the different prevention program. Instead, some
    of these teams told us that they categorize some integrated programs
    entirely in the "other prevention" program area, while some also said that
    they had placed entirely in the AB program area some programs that
    primarily focus on AB but may provide limited information on condoms.5

    o The other three country teams told us that, in general, they do not
    split any of their integrated ABC programs; instead, they categorize these
    programs entirely in the "other prevention" program area. These three
    teams said that, in general, they categorize only programs that include AB
    components, but no C component, in the AB program area.

    o Three country teams reported that they categorize some integrated ABC
    programs based on the target group; for example, integrated programs for
    youths may be categorized entirely in the AB program area, while
    integrated programs for most-at-risk groups may be categorized entirely in
    the "other prevention" program area.

    In addition, we found that certain broader components of sexual
    transmission prevention programs that are not clearly defined as AB or
    "other prevention" may appear in either program area. For example,
    activities addressing issues such as stigma reduction, peer pressure, and
    child, spouse, or substance abuse may be categorized as either AB or
    "other prevention," depending on the country team's judgment and factors
    such as a program's focus or target population. Although these activities
    could be considered AB because they address social and community norms
    related to abstinence and faithfulness, they could also arguably be
    considered "other prevention." One country team's proposed fiscal year
    2006 operational plan illustrates how the same types of broad prevention
    activities may fall under AB or "other prevention," depending on the
    specific program. This operational plan contains one program categorized
    entirely as AB that aims to strengthen the capacity of military chaplains
    to provide counseling on issues including child, spouse, and substance
    abuse; management of family crisis, illness, death, and trauma; and
    alcohol addiction. This program also plans to develop abstinence-based
    literature and toolkits for the chaplains to disseminate to military
    personnel and their families and to support anti-AIDS youth clubs that
    provide HIV/AIDS education on abstinence and antidiscrimination against
    people living with HIV/AIDS. This country team's operational plan also
    contains a program categorized entirely as "other prevention" that
    supports drama groups to provide messages to the country's defense forces
    on topics including abstinence and faithfulness; HIV counseling and
    testing; stigma reduction; child and spousal abuse; and alcohol-related
    issues, as well as correct and consistent use of condoms.

    Because of the varying methods used by country teams to categorize
    integrated ABC prevention programs and because of the inclusion of certain
    broad prevention activities (such as stigma reduction) in both AB and
    "other prevention," a country team's reported AB spending may not truly
    reflect the amount of funding actually supporting AB activities. Likewise,
    a country team's "other prevention" spending may not be a clear indicator
    of how much funding is going to non-AB sexual prevention activities. Some
    AB activities are occurring in the "other prevention" program area,
    suggesting that country teams may be implementing more AB activities than
    first appear in their operational plans. At the same time, however,
    activities that can be categorized as AB or "other prevention," depending
    on a country team's judgment, are also occurring in the AB program area.
    Overall, we consider these data to be sufficiently reliable for the
    purposes of this engagement. In particular, while there are some
    limitations in the reliability of these reported data, they are useful for
    identifying general trends and patterns across fiscal years and program
    areas.

    Joint Comments from State, USAID, and HHS Appendix VI

    The following are GAO's comments on the joint letter from the Department
    of State, the U.S. Agency for International Development, and the
    Department of Health and Human Services, dated March 21, 2006.

    GAO Comments

    1.In their letter, the agencies stated that "financing for all methods of
    prevention have increased under PEPFAR" and that, "even as the amount of
    funding dedicated to a program area rises, the percentage of overall
    funding dedicated to it may decline." Although PEPFAR funding in the 15
    focus countries increased substantially in all five prevention program
    areas between fiscal years 2004 and 2005, figure 8 of our report shows
    that funding dropped in two prevention program areas between fiscal years
    2005 and 2006. Specifically, PEPFAR funding for "other prevention" in the
    15 focus countries declined from $65.8 million to $61.6 million, and blood
    safety funding declined from $53.3 million to $50 million. In addition,
    funding for prevention of mother-to-child transmission stayed relatively
    constant, with $66.3 million in fiscal year 2005 and $67.5 million in
    fiscal year 2006.

    2.The agencies commented that our report reflects misunderstanding of the
    relationship between PEPFAR programming and reporting mechanisms, noting
    that "it is not the case that each program must be only AB, or only C."
    Our report acknowledges that country teams have funded integrated ABC
    programs through PEPFAR. We explain that these programs are often split
    between the AB and "other prevention" program areas for reporting
    purposes, but we do not suggest that each program must be AB only or C
    only. Rather, we note, for example, that once funds are designated as AB,
    they can be used only for AB purposes, effectively locking teams into
    allocation decisions made when their operational plans were approved. In
    other words, the ratio of AB to "other prevention" funding within an
    integrated ABC program cannot change over the course of a funding year.
    Eight of the 15 focus country teams indicated that segregating AB funding
    from "other prevention" program areas compromises the integration of their
    programs. For example, it can limit their ability to shift program focus
    to meet changing prevention needs. Because of this potential, one country
    team chose not to split funding between AB and "other prevention" for a
    prevention program for persons living with HIV/AIDS that includes
    faithfulness messages because it could not predict the portion of the
    project that should be dedicated to the faithfulness component and did not
    want to lose flexibility to "do what is appropriate."

    3.The agencies stated in their letter that "the ABC guidance had been
    issued approximately 2 to 5 months prior to country teams' interviews." As
    we note in our report, country teams first received the draft ABC guidance
    in January 2005. The final guidance, distributed to country teams in March
    2005, differed from the draft guidance only in its discussion of human
    papilloma virus. We conducted an initial round of structured interviews
    with the focus country teams in June and July 2005. We conducted a
    follow-up round of structured interviews with the focus country teams
    between August 2005 and January 2006.

    4.The agencies commented that "it is important to note that certain
    examples provided in the report to demonstrate confusion regarding the ABC
    guidance are in fact clearly spelled out in the guidance. In these cases,
    the issues are actually related to implementation, not the guidance
    document." Our report states that both interpreting and implementing
    OGAC's ABC guidance has created challenges for country teams. For example,
    while the guidance clearly states that "discordant couples should be
    encouraged to use condoms consistently and correctly," it does not
    stipulate whether broad condom social marketing programs are therefore
    appropriate when much of a country's population consists of discordant
    couples. Similarly, while the guidance clearly states that in-school
    youths 14 and younger should not receive condom-related information, it
    does not address the issue of how youth groups that cross this age divide
    should be handled. We recognize that guidance on a subject as complex as
    prevention of sexual HIV transmission will naturally lead to questions and
    believe that the agencies' commitment to continually improve their efforts
    to communicate policy to the field should help resolve these questions.

    5.The agencies' letter stated that they have "been able to approve the
    allocations of countries that submitted justifications without requiring
    other countries to make offsetting adjustments to their proposed
    prevention allocations." However, in our structured interviews, seven
    country teams that were not exempted from the abstinence-until-marriage
    spending requirement identified specific program constraints related to
    the requirement. As we note in our report, some of these teams commented
    specifically on OGAC's 50 percent and 66 percent policies implementing the
    Leadership Act's requirement. For example, one country team told us that,
    because of OGAC's policies, it was required to cut funding for programs in
    the "other prevention" program area and to shift funding from the care
    category in order to address a condom shortage in that country. Another
    country team told us that, because of OGAC's policies, it had been
    required to substantially reduce the amount of funding it had planned to
    dedicate to a prevention program for people living with HIV/AIDS. These
    examples illustrate the adjustments to prevention programming that some
    country teams have had to make to offset the effects of programming
    decisions made by teams exempted from the spending requirement. Further,
    OGAC could not meet the Leadership Act's overall 33 percent target without
    requiring that, overall, more than 33 percent of prevention funds in
    nonexempted countries be spent on AB activities.

    6.The agencies commented that they had asked some of the country teams
    that did not submit justifications if they wanted to do so and that they
    said no. We also did not ask all country teams that did not submit
    justifications whether they had wanted to do so. However, one country team
    told us that, although it was struggling to meet the spending requirement,
    OGAC officials had made it clear that submitting a justification was not
    an option.

    7.The agencies stated that applying the spending requirement only to funds
    appropriated to the Global HIV/AIDS Initiative (GHAI) account would signal
    a step backward in the integration of U.S. government agencies'
    activities. We recognize that exercising this option may entail some
    trade-offs and, as a result, have modified our recommendation to ask that
    the agencies consider this change after reviewing information collected on
    the effects of the spending requirement.

    8.The agencies also stated that applying the spending requirement solely
    to funds appropriated to the GHAI account would have little impact because
    non-GHAI funds account for between 1 and 2 percent of focus country teams'
    budgets. We acknowledge in our conclusions that the amount of overall
    PEPFAR funding not appropriated to the Global HIV/AIDS Initiative account
    is relatively small. We also acknowledge that reversing this policy would
    not enable OGAC to fully address the underlying challenges that the
    country teams face in having to reserve a specific percentage of their
    prevention funds for abstinence-until-marriage programs. However, unlike
    the focus country teams, which receive very limited funding not
    appropriated to the GHAI account, the five additional country teams that
    OGAC requires to meet the spending requirement-unless they receive
    exemptions-receive more than 80 percent of their PEPFAR prevention funds
    in non-GHAI funding.

    GAO Contact and Staff Acknowledgments Appendix VII

    David Gootnick (202) 512-3149

    In addition to the individual named above, Celia Thomas (Assistant
    Director), Elizabeth Singer, Elisabeth Helmer, David Dornisch, Mary
    Moutsos, Reid Lowe, Kay Halpern, and Etana Finkler made key contributions
    to this report.

    (320334)

    transparent illustrator graphic

    www.gao.gov/cgi-bin/getrpt? GAO-06-395 .

    To view the full product, including the scope

    and methodology, click on the link above.

    For more information, contact David Gootnick at (202) 512-3149 or
    gootnickd@gao.gov.

    Highlights of GAO-06-395 , a report to congressional committees

    April 2006

    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)
    and promotes the ABC model (Abstain, Be faithful, or use Condoms). It
    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. The Office of the U.S. Global AIDS Coordinator
    (OGAC) is responsible for administering PEPFAR. GAO reviewed PEPFAR
    prevention funds, described PEPFAR's strategy to prevent sexual HIV
    transmission, and examined related challenges.

    What GAO Recommends

    GAO recommends that the Secretary of State direct the Global AIDS
    Coordinator to collect and report information on the
    abstinence-until-marriage spending requirement's effects and use it to
    assess whether the requirement should apply only to the Global HIV/AIDS
    Initiative account. GAO also suggests that 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. OGAC agreed
    regarding collecting information but disagreed with applying the
    requirement only to certain funds. We modified our recommendation in light
    of this concern.

    In fiscal years 2004-2006, the PEPFAR prevention budget increased by
    almost 55 percent, from $207 million to $322 million. During this time,
    the prevention share of the total PEPFAR budget fell from 33 to 20
    percent, consistent with the Leadership Act's recommendation that 20
    percent of funds appropriated pursuant to the act should support
    prevention.

    The PEPFAR strategy for preventing sexual transmission of HIV is largely
    shaped by the ABC model and the abstinence-until-marriage spending
    requirement. In addition to adopting the ABC model, OGAC developed
    guidance for applying it-stating, for instance, that prevention
    interventions should be integrated and respond to local epidemiology and
    cultural norms. OGAC also established policies for applying the spending
    requirement for fiscal year 2006. To meet the 33 percent spending
    requirement, it mandated that country teams-PEPFAR officials in the
    field-spend half of prevention funds on sexual transmission prevention and
    two-thirds of those funds on abstinence/faithfulness (AB) activities. At
    the same time, OGAC permitted certain teams, especially those with
    relatively small budgets, to seek waivers from this policy to help them
    respond to local prevention needs. 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.

    OGAC's ABC guidance and the abstinence-until-marriage spending
    requirement, including OGAC's policies for implementing it, have presented
    challenges for country teams. First, although most teams found the ABC
    guidance generally clear, two-thirds reported that ambiguities in some
    parts of the guidance led to uncertainty about implementing the model.
    OGAC officials told GAO that they plan to clarify the guidance. Second,
    although several teams told GAO that they value the ABC model and
    emphasize AB messages for certain populations, teams also reported that
    the spending requirement can limit their efforts to design prevention
    programs that are integrated and responsive to local prevention needs.
    Seventeen of 20 country teams reported that fulfilling the spending
    requirement, including OGAC's policies implementing it, presents
    challenges to their ability to respond to local prevention needs. Ten of
    these 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 were effectively required to spend more than 33 percent of
    prevention funds on AB activities; as a result, OGAC should just meet the
    overall 33 percent spending requirement for fiscal year 2006. However, to
    meet the requirement, nonexempted country teams have, in some cases,
    reduced or cut funding for certain prevention programs, such as programs
    to deliver comprehensive ABC messages to populations at risk of
    contracting HIV. Finally, OGAC's decision to apply the spending
    requirement to all PEPFAR prevention funds may further challenge teams'
    ability to address local prevention needs.
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