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						 
                                                                 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
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  [email protected]. 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
[email protected].

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.
*** End of document. ***