US government watchdog criticises PEPFAR prevention policy

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US legislation which requires Federal-funded prevention programmes to spend at least a third of their prevention budgets on promoting sexual abstinence before marriage is causing serious implementation problems on the ground in the 15 countries receiving aid through the President’s Emergency Plan for AIDS Relief, says a report from the US Congress’s Government Accountability Office published last week.

The Government Accountability Office report shows that the Office of the Global AIDS Coordinator (OGAC), the government department responsible for implementing the President’s Emergency Plan (PEPFAR), has gone even further than the legislation required, by telling country programmes to dedicate at least half of prevention funding to sexual transmission prevention activities in 2006, and two-thirds of that amount to promoting abstinence before marriage and faithfulness in marriage.

However, a number of country PEPFAR programmes questioned by the Government Accountability Office said that these requirements were causing problems, such as:

Glossary

mother-to-child transmission (MTCT)

Transmission of HIV from a mother to her unborn child in the womb or during birth, or to infants via breast milk. Also known as vertical transmission.

  • The need to cut services for prevention of mother to child transmission in order to reach spending targets on abstinence-based prevention.
  • Comprehensive prevention programmes that included condom promotion for the entire at-risk population were sacrificed in some countries to prioritise sexual abstinence before marriage.
  • The application of OGAC rules on abstinence-based education to programmes funded with non-PEPFAR money from the US (such as USAID aid not appropriated within the Global HIV/AIDS Initiative).

In addition, country programmes told the Government Accountability Office that the guidance issued by the OGAC was ambiguous and was causing confusion in the field. For example, one country programme was unable to determine whether it should be spending money on prevention work targeted at married couples, whilst NGOs receiving PEPFAR support said that they were uncertain about the distinction between condom information and condom promotion (the latter is banned by PEPFAR), and felt constrained from discussing condoms with young people despite an obvious demand to do so.

Dr Mark Dybul, deputy head of the PEPFAR programme, pointed out that US condom provision had increased from 248 million in 2001 to 429 million last year.

OGAC has promised to update and clarify its guidance in response to the report, but other government agencies rejected the need for a review of how non-PEPFAR funds are being affected by the rules.

The Government Accountability Office has recommended that Congress should review the spending requirements on abstinence-based education to determine whether they are inhibiting overall prevention activities.

"This report confirms what we have been saying all along," said Paul Zeitz, director of the Global AIDS Alliance (GAA). "There has been deep concern with this policy - from the European Union, U.N. officials, African experts, religious organisations and others - and it has been fully justified. Lives are in the balance, and so we need Congress to step in quickly to fix this policy."