A highly anticipated review of the first three years of the President's Emergency Plan for AIDS Relief (PEPFAR) unequivocally recommends greater flexibility in the global fight against HIV/AIDS, including doing away with minimum budget allocations for abstinence-until-marriage education currently required by federal law. Released March 30 by the Institute of Medicine (IOM), PEPFAR Implementation: Progress and Promise says PEPFAR must now transition from a program focused on emergency relief to one focused on sustainability. To this end, the congressionally mandated report calls for a greater emphasis on prevention than the law currently allows and says that "removal of the abstinence-until-marriage" earmark, among other changes, "could enhance the quality, accountability, and flexibility" of prevention efforts.

Indeed, the IOM calls for all of the congressionally mandated budget allocations to be removed to allow for greater responsiveness to the evolution of the epidemic and to the specific epidemiology in each focus country. Currently, at least 55% of all PEPFAR funds each year must go for treatment, 15% for palliative care and 10% for services specific to orphans and vulnerable children. This leaves only 20% for prevention, of which "not less than one-third" is reserved for abstinence-until-marriage programs.

The report notes that Congress included earmarks in the original PEPFAR authorizing legislation at a time when little information existed on how to meet the law's specified five-year performance targets, which include preventing seven million infections, providing antiretroviral therapy to two million people and providing care for 10 million people. It concludes, however, that these "rigid congressional budget allocations among categories, and even more so within categories," have hindered flexibility and responsiveness on the local level. "Contrary to basic principles of good management and accountability," the report says, "the budget allocations have made spending money in a particular way an end in itself rather than a means to an end—in this instance, the vitally important end of saving lives today and in the future." PEPFAR must do better, it says, to harmonize its approach with the individual focus countries and to incorporate lessons learned over time. "Resource allocation that is the consequence of rather than the precursor for adaptive, evidence-based programming would better enable the initiative to have an optimal impact."

In addition to calling for a greater emphasis on prevention in general, the IOM stresses that more attention to improving the status of women and girls is critical to fighting HIV/AIDS over the long term. It recommends that more emphasis be placed on the particular vulnerabilities of women and girls and that a greater effort be made to document services provided to them as the program transitions to sustainability.

The IOM report is in keeping with the conclusions of a report issued last year by the Government Accountability Office (GAO) that also criticized the abstinence-until-marriage spending requirement. At the behest of Congress, the GAO conducted a year-long investigation and determined that meeting the abstinence-until-marriage spending requirement led to cuts in proven programs aimed at preventing mother-to-infant HIV transmission and at promoting comprehensive ABC (abstinence, be faithful, use condoms) messaging. In addition, it found that although certain countries were granted exemptions from the abstinence-until-marriage spending requirement, these "waivers" necessitated increased abstinence funding above and beyond the one-third rate on the part of nonwaiver countries.

Many of the recommendations identified within the GAO and IOM reports dovetail nicely with legislation introduced earlier this year in the House. The Protection Against Transmission of HIV for Women and Youth (PATHWAY) Act, introduced on March 27 by Reps. Barbara Lee (D-CA) and Christopher Shays (R-CT), addresses the particular vulnerability of women and girls within the HIV pandemic. The legislation calls for the creation of a specific strategy to address the prevention needs of women and girls, and to remove the one-third abstinence-until-marriage spending requirement. Although Congress is not expected to begin considering legislation to reauthorize PEPFAR until next year, the debate over its future is already well underway.—Casey Alrich