A Government Accountability Office (GAO) report to Congress dated April 4 details the negative effects of the legal requirement that at least one-third of all prevention funds appropriated under the President's Emergency Plan for AIDS Relief (PEPFAR) be reserved for "abstinence-until-marriage" programs. The report concludes that siphoning off funds for these activities has forced some PEPFAR country teams to reduce the funding they otherwise would have provided to other key prevention interventions. Negatively affected programs include those to prevent the transmission of HIV/AIDS during pregnancy and childbirth, to promote comprehensive messages aimed at preventing the sexual transmission of HIV/AIDS, and to support prevention programs aimed at HIV-positive people and high-risk groups such as sexually active youth, which could involve the distribution of condoms.
In fall 2005, the State Department's Office of the U.S. Global AIDS Coordinator devised a formula implementing the abstinence-until-marriage requirement. The guidelines specify that PEPFAR country teams must reserve half of their prevention funds for programs to prevent the sexual transmission of HIV/AIDS; the remainder must cover all other kinds of prevention interventions, such as mother-to-child and blood-safety programs. In each country, at least two-thirds of the funds to prevent the sexual transmission of HIV/AIDS must be used to promote abstinence and "faithfulness," which the administration deems to be the two goals of the abstinence-until-marriage program. Thus, two-thirds of one-half of all the prevention funds are reserved to promote abstinence and faithfulness—or one-third of the total prevention allocation to each country.
The report sheds important new light on the impact of making the abstinence-until-marriage program the single most important U.S. global HIV/AIDS prevention strategy.
Numerous members of Congress on both sides of the "abstinence-only" debate had asked the GAO—Congress' audit, evaluation and investigative arm—to conduct a review of the effects of the statutory earmark, including how the administration has chosen to implement it. GAO investigators spent the last year interviewing officials—both in the United States and in selected PEPFAR focus countries—from key government agencies, faith-based and other nongovernmental organizations and host country governments themselves. "Satisfying [the law's] abstinence-until-marriage spending requirement presents challenges to most country teams," the GAO reported. Meeting the earmark, GAO investigators were told, presents country teams with a conflict in staying true to the other directive under PEPFAR, also stipulated by law, that they promote a comprehensive ABC approach (abstain, be faithful, use condoms) to preventing the sexual transmission of HIV/AIDS.
Recognizing the problems inherent in imposing a strict formula on countries ranging from Vietnam to Zambia to Haiti, which differ widely in terms of the nature of their HIV/AIDS epidemics as well as social and cultural norms, the administration has established a "waiver" system whereby country teams may be released from the formula based on the local epidemiology and specific country needs. GAO notes, however, that although this may have alleviated the problem in those countries that have won waivers, the remaining country teams must compensate by spending even more than one-third of their total prevention funds on abstinence and faithfulness programs to meet the statutory requirement at the global level.
Assessing the content or effectiveness of the abstinence and faithfulness programs that the United States is funding was beyond the scope of this particular report; that could be a project for the future. Still, the report sheds important new light on the impact of making the abstinence-until-marriage program the single most important U.S. global HIV/AIDS prevention strategy. It reveals that as long as resources are not infinite, the mandated high level of funding in this area is coming at the expense of other, proven interventions, which in many cases have been deemed higher priority by the public health professionals on the ground.
Upon the release of the GAO report, Sen. Dianne Feinstein (D-CA) immediately denounced the abstinence-until-marriage earmark in the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 as "the wrong approach" and declared that she would soon be introducing legislation aimed at mitigating the harm it is causing. "The GAO report…clearly demonstrates that we are not doing everything we can to protect high-risk populations around the world from the transmission of HIV/AIDS," said Feinstein, a key member of the Appropriations Committee. Although Congress is not required to reconsider these and many other issues relating to PEPFAR until 2008, when the law must be renewed, ameliorative action could be taken between now and then in the course of approving an annual appropriation for the program.—Susan A. Cohen