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entitled 'Global Health: Spending Requirement Presents Challenges for 
Allocating Prevention Funding under the President's Emergency Plan for 
AIDS Relief' which was released on April 4, 2006. 

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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: 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-395]: 

GAO Highlights: 

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

Why GAO Did This Study: 

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 Found: 

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. 

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. 

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

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact David Gootnick at (202) 
512-3149 or gootnickd@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

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

PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC 
Approach, Abstinence-Until-Marriage Spending Requirement, and Local 
Prevention Needs: 

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

Conclusions: 

Recommendation for Executive Action: 

Matters for Congressional Consideration: 

Agency Comments and Our Evaluation: 

Appendixes: 

Appendix I: Scope and Methodology: 

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

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

Appendix IV: PEPFAR Planning and Reporting Process: 

Appendix V: Methods for Reporting Allocations among PEPFAR Prevention 
Program Areas: 

Appendix VI: Joint Comments from the Department of State, the U.S. 
Agency for International Development, and the Department of Health: 

GAO Comments: 

Appendix VII: GAO Contact and Staff Acknowledgments: 

Figures: 

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

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

Figure 3: PEPFAR Prevention Program Areas: 

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

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

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

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

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

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: 

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

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

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

Abbreviations: 

AB: abstinence/faithfulness: 

ABC: Abstain, Be faithful, or use Condoms: 

COPRS: Country Operational Plan and Reporting System: 

GHAI: Global HIV/AIDS Initiative: 

HHS/CDC: Department of Health and Human Services--Centers for Disease 
Control and Prevention: 

NGO: nongovernmental organization: 

OGAC: Office of the U.S. Global AIDS Coordinator: 

PEPFAR: President's Emergency Plan for AIDS Relief: 

PMTCT: prevention of mother-to-child transmission: 

UNAIDS: Joint United Nations Programme for HIV/AIDS: 

USAID: U.S. Agency for International Development: 

Letter April 4, 2006: 

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 billion[Footnote 1] targeted to HIV/AIDS 
initiatives in 15 focus countries.[Footnote 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 2003[Footnote 3] (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.[Footnote 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 safety[Footnote 5]--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,[Footnote 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.[Footnote 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,[Footnote 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 teams[Footnote 9] 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 funding[Footnote 10] 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. 

* 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. 

* 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.[Footnote 11] To ensure 
compliance with the spending requirement, OGAC established policies in 
August 2005 implementing the requirement. These policies directed 20 
country teams[Footnote 12] 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 
funding[Footnote 13] (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). 

* 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. 

* 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. 

* 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.[Footnote 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.[Footnote 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.[Footnote 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: 

[See PDF for image] 

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. 

[End of figure] 

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.[Footnote 
17] In this report, the term PEPFAR funding describes funds 
appropriated to these four accounts[Footnote 18] in the 15 focus 
countries, as well as bilateral HIV/AIDS funding in five additional 
countries.[Footnote 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.[Footnote 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.[Footnote 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: 

[See PDF for image] 

[End of figure] 

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.[Footnote 
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 
experts[Footnote 23] 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.[Footnote 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: 

[See PDF for image] 

[End of figure] 

The sexual transmission prevention program areas are focused as 
follows. 

* AB activities encourage: 

* abstinence until marriage, 

* delay of first sexual activity, 

* secondary abstinence,[Footnote 25] 

* faithfulness in marriage and monogamous relationships, 

* reduction of sexual partners among sexually active unmarried persons, 
and: 

* social and community norms related to the above practices. 

"Other prevention" activities include the: 

* purchase and promotion of condoms, 

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

* messages or programs to reduce injection drug use and related 
risks.[Footnote 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 [Hyperlink, 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: 

* respond with urgency to the crisis; 

* make policy decisions that are evidence based; 

* demand accountability for results; 

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

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

* focus on rapid service delivery.[Footnote 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.[Footnote 28] Although PEPFAR is 
authorized through fiscal year 2008, OGAC plans to reach its prevention 
goal by the year 2010.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 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 2004[Footnote 34] 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: 

[See PDF for image] 

Note: Fiscal year 2006 funding is planned. 

[End of figure] 

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: 

[See PDF for image] 

Note: Fiscal year 2006 funding is planned. 

[End of figure] 

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: 

[See PDF for image] 

Note: Fiscal year 2006 funding is planned. 

[End of figure] 

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: 

[See PDF for image] 

Note: Fiscal year 2006 funding is planned. 

[End of figure] 

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.)[Footnote 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: 

[See PDF for image] 

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. 

[End of figure] 

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.)[Footnote 
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: 

[See PDF for image] 

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. 

[End of figure] 

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.[Footnote 37] The guidance identifies key 
principles that country teams should consider in developing and 
implementing ABC programs. 

* 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." 

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

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

* 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: 

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

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

* PEPFAR funds may not be used in schools for marketing efforts to 
promote condoms to youths. 

* 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. 

* 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: 

* commercial sex workers and their clients, 

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

* substance abusers, 

* mobile male populations, 

* men who have sex with men, 

* people living with HIV/AIDS, and: 

* 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 teams[Footnote 38] to spend at least 50 percent of 
their prevention funding[Footnote 39] 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: 

[See PDF for image] 

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

[End of figure] 

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.[Footnote 40] 

OGAC also directed country teams to apply the spending requirement to 
all PEPFAR prevention funding (about $357 million in fiscal year 
2006).[Footnote 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. 

* The guidance's definition of at-risk groups is open to varying 
interpretations, causing confusion about which groups may be 
targeted.[Footnote 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. 

* 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;[Footnote 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. 

* 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.[Footnote 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: 

* 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. 

* 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.[Footnote 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."[Footnote 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.[Footnote 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.[Footnote 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: 

* 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." 

* 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." 

* 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." 

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

* 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 exemptions[Footnote 49]--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: 

* 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. 

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

* 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. 

* 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. 

* Reduced funding for PMTCT services. 

* 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.[Footnote 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.[Footnote 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. 

* 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.[Footnote 52] 

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

* 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. 

* 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.[Footnote 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.[Footnote 54] OGAC officially 
approved exemptions for the 10 country teams that requested them. As a 
result, all but one[Footnote 55] 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.[Footnote 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 
requirement[Footnote 57] suggest a noticeable decline in "other 
prevention" funding between fiscal year 2005, when the spending 
requirement was not mandatory, and fiscal year 2006.[Footnote 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: 

[See PDF for image] 

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. 

[End of figure] 

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 account[Footnote 59] 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.[Footnote 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: 

* 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. 

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

* 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: 

* 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: 

* 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 [Hyperlink, http://www.gao.gov]. If you or your staff have any 
questions, please contact me at (202) 512-3149 or [Hyperlink, 
gootnickd@gao.gov]. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. Key contributors to this report are listed in appendix VII. 

Signed by: 

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: 

[End of section] 

Appendixes: 

Appendix I: Scope and Methodology: 

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.[Footnote 61] 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;[Footnote 62] 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);[Footnote 63] 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.[Footnote 64] 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. 

[End of section] 

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

Fiscal year 2005 program descriptions[Footnote 65] 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: 

* $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. 

* $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." 

* $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. 

* $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: 

* $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. 

* $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. 

* $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. 

* $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. 

* $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: 

* $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. 

* $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. 

* $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." 

* $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. 

* $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: 

* $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. 

* $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. 

* $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. 

* $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. 

* $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. 

* $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. 

* $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: 

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

* $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. 

* $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. 

* $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. 

* $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: 

* $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. 

* $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. 

* $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. 

* $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. 

[End of section] 

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

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: 

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

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

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

For "other prevention" activities, they report on the: 

* number of targeted condom service outlets, 

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

* 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.[Footnote 66] 

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: 

* 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.[Footnote 67] 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. 

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

* 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.[Footnote 68] 
The group assessed alternative modeling approaches and initially 
considered the Goals Model (developed by the Futures Group)[Footnote 
69] 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.[Footnote 
70] 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.[Footnote 71] 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. 

[End of section] 

Appendix IV: PEPFAR Planning and Reporting Process: 

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.[Footnote 72] At the conclusion of the 
reviews, OGAC submits a notification to the relevant congressional 
committees,[Footnote 73] informing them of the activities it plans to 
implement under PEPFAR in the current fiscal year.[Footnote 74] 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,[Footnote 75] 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: 

[See PDF for image] 

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

[End of figure] 

[End of section] 

Appendix V: Methods for Reporting Allocations among PEPFAR Prevention 
Program Areas: 

Country teams have used varying methods to categorize funding for 
certain integrated abstinence/faithfulness/condom use (ABC) 
programs[Footnote 76] 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,[Footnote 77] 
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,"[Footnote 78] 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.[Footnote 79] Following are methods used by 
country teams we interviewed: 

* 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.[Footnote 80] 

* 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. 

* 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. 

[End of section] 

Appendix VI: Joint Comments from the Department of State, the U.S. 
Agency for International Development, and the Department of Health: 

United States Department of State: 
Assistant Secretary and Chief Financial Officer: 
Washington, D. C. 20520: 

Ms. Jacquelyn Williams-Bridgers: 
Managing Director: 
International Affairs and Trade: 
Government Accountability Office: 
441 G Street, N.W. 
Washington, D.C. 20548-0001: 

MAR 2l 2006: 

Dear Ms. Williams-Bridgers: 

We appreciate the opportunity to review your draft report, "GLOBAL 
HEALTH: Spending Requirement Presents Challenges to HIV/AIDS Prevention 
Programs Funded under the President's Emergency Plan for AIDS Relief," 
GAO Job Code 320334. 

The enclosed Department of State comments are provided for 
incorporation with this letter as an appendix to the final report. 

If you have any questions concerning this response, please contact 
Elisa Catalano, Legislative Compliance Officer, Office of Global AIDS 
Coordinator, at (202) 663-2420. 

Sincerely, 

Signed by: 

Bradford R. Higgins: 

cc: GAO - Elizabeth Singer; 
OGAC - Randall Tobais; 
State/OIG - Mark Duda: 

Department of State, Health and Human Services, and USAID Comments (GAO-
06-395, GAO Code 320334): 

On behalf of the Departments of State and Health and Human Services 
(HHS) and the United States Agency for International Development 
(USAID), the Office of the U.S. Global AIDS Coordinator (OGAC) 
appreciates the opportunity to comment on the draft General Accounting 
Office (GAO) report, Global Health: Spending Requirement Presents 
Challenges to HIV/AIDS Relief (GAO-06-395) (the Report). 

Effective prevention is central to the President's Emergency Plan for 
AIDS Relief (PEPFAR): 

Only a vigorous and comprehensive prevention approach will turn the 
tide against the global HIV/AIDS pandemic - the mission of the 
Emergency Plan. Effective prevention is the only way to stop the human 
suffering caused by HIV infection and limit the number of people who 
will require treatment in the future. Ultimately, it is the only way to 
achieve the elusive goal of an HIV/AIDS-free generation. 

In the three years since President Bush's announcement of the Emergency 
Plan, the United States has demonstrated historic leadership in 
implementing the most diverse HIV/AIDS prevention strategy of any 
international partner, with programs linked to treatment and care for a 
holistic response. The lessons learned from the intensive application 
of the Emergency Plan in the 15 focus countries are now being extended 
to over 120 countries, helping to fuel transformation of HIV/AIDS 
responses in nations around the world. 

This unprecedented initiative dwarfs the pre-PEPFAR baseline levels of 
prevention spending and has allowed for a wide-ranging portfolio of 
high quality, sustainable, evidence-based prevention programs. The 
President's budget request of approximately $4 billion in HIV/AIDS 
funding for fiscal year 2007 will provide the necessary support to keep 
these prevention programs on track to reach the Emergency Plan's five- 
year goal of supporting prevention of 7 million new infections, as well 
as for it to achieve the goals of support for treatment for 2 million 
HIV-infected people and care for 10 million individuals. 

Reflecting the importance of prevention, the Emergency Plan supports 
programs that address a broad range of HIV transmission mechanisms. In 
addition to programs to prevent mother to child transmission, ensure a 
safe blood supply, and prevent infections through unsafe injections, 
PEPFAR supports the ABC approach to prevent the sexual transmission of 
HIV. 

ABC - Abstinence, Be Faithful and Correct and Consistent Condom Use - 
is the most effective, evidence-based approach to sexual transmission 
of HIV infection: 

Recent data from Zimbabwe and Kenya, not discussed in the Report, 
mirror the earlier success of Uganda's ABC approach to preventing HIV. 
These three countries with generalized epidemics (epidemics where HIV 
has spread beyond concentrated groups, such as prostitutes) have 
demonstrated reductions in HIV prevalence, and in each country the data 
point to significant AB behavior change and modest but important 
changes in C. Where sexual behaviors have changed, as evidenced by 
increased primary and secondary abstinence, fidelity, and condom use, 
HIV prevalence has declined. 

In Zimbabwe, Science reported in February 2006 that among men aged 17 
to 29 years in eastern Zimbabwe, HIV prevalence fell by 23% from 1998 
to 2003. Even more impressively, the prevalence among women aged 15 to 
24 dropped by a remarkable 49%. 

* Abstinence (delay in sexual debut): Among men aged 17 to 19, the 
percentage who had begun sexual activity dropped from 45% to 27%, and 
among women aged 15 to 17, it dropped from 21 % to 9%. 

* Being faithful: Among those men who were sexually experienced, the 
proportion reporting a recent casual partner fell by 49%. 

* Condoms: The proportion of women reporting an increase in condom use 
with casual partners rose from 26% to 36%. The proportion of men 
reporting condom use with casual partners remained essentially 
unchanged, as did the proportion among both sexes reporting condom use 
with regular partners. 

In Kenya, the Ministry of Health estimates that HIV prevalence dropped 
from approximately 10% in 1998 to approximately 7% in 2003. This 
decline correlates with a broad reduction in sexual risk behavior. 
Among the findings: 

* Abstinence: There was a delay in average sexual debut among young 
women (with median age of sexual debut rising from 16.7 to 17.8. Among 
both teenage boys and girls, there were high levels of both primary 
abstinence (with a minority of boys and girls in the 15-17 age group, 
and a minority of girls in the 18-19 age group, reporting any prior 
sexual activity) and secondary abstinence (in both age groups, a 
minority of those who reported prior sexual activity reported any 
sexual activity in the last year). 

* Being faithful: Male faithfulness, as measured by the percentage of 
men who report more than one sexual partner in the preceding year, 
increased. In the key 20-24 age group, the percentage dropped from over 
35% to less than 18%. 

Condoms: Condom use among women who engage in risky activity grew, as 
the number of women who reported condom use in their last higher-risk 
sexual encounter rose from 16% to 24%. 

As Dr. Peter Piot of UNAIDS remarked with respect to these two 
countries, "[T]he declines in HIV rates have been due to changes in 
behaviour, including increased use of condoms, people delaying the 
first time they have sexual intercourse, and people having fewer sexual 
partners." More work is needed to understand these data, and to 
identify which interventions may have influenced them. Fundamentally, 
however, it is clear that people in some countries have begun to change 
their sexual behavior in ways that reduce their risk of infection. It 
is thus urgent to identify and scale up initiatives to help even more 
people choose healthy behaviors. 

The national strategies of many host nations included the ABC approach, 
delivered in culturally-sensitive ways, even before the advent of the 
Emergency Plan. The new evidence is highly relevant to PEPFAR's work 
with these nations: most of Sub-Saharan Africa, and 13 of the 15 focus 
countries, are experiencing generalized epidemics. Host nations are 
moving to balance campaigns to promote awareness of HIV with a broader 
public health approach that provides people with comprehensive 
information, services, and support that will enable them to make 
healthy decisions about how to protect themselves. Indeed, providing 
people with this level of information, support and services is not 
merely good public health practice - it can help promote the democratic 
value of personal responsibility that leads to healthy behaviors. 

Congressional directives have helped focus U.S. Government (USG) 
prevention strategies to be evidence-based: 

Because of the data, ABC is now recognized as the most effective 
strategy to prevent HIV in generalized epidemics. One of the most 
striking findings of the Report is the consensus among USG field 
personnel that ABC is the right approach to prevention. 

The authorizing legislation directs that, for fiscal years 2006-2008, 
33% of prevention funding be allocated to abstinence-until-marriage 
programs. In 2004, PEPFAR notified Congress that it counts programs 
that focus on abstinence and faithfulness for this purpose, as A and B 
messages should always be delivered together except in programming for 
young children. 

The legislation's emphasis on AB activities has been an important 
factor in the fundamental and needed shift in USG prevention strategy 
from a primarily C approach prior to PEPFAR to the balanced A13C 
strategy. The Emergency Plan has developed a more holistic and 
equitable strategy, one that reflects the growing body of data that 
validate ABC behavior change. PEPFAR has followed Congress' mandate 
that it is possible and necessary to strongly emphasize A, B, and C, 
while also seeking to support prevention of mother to child 
transmission and other critical prevention interventions. 

Financing for all methods of prevention have increased under PEPFAR: 

PEPFAR's unparalleled financial commitment has permitted the USG to 
support a balanced, multi-dimensional approach - one that was not 
possible with pre-PEPFAR spending levels. The total annual spending in 
the areas of HIV/AIDS prevention, as well as treatment and care, has 
continually increased since the passage of the Leadership Act. If 
Congress enacts the President's request for $4 billion in HIV/AIDS 
funding for fiscal year 2007, that will represent a total increase of 
$740 million from that appropriated in fiscal year 2006 ($3.2 billion) 
and almost $1.2 billion from that appropriated in fiscal year 2005 
($2.8 billion). In addition, these levels of funding represent a 
quantum leap over the pre-PEPFAR baseline levels of funding for global 
HIV/AIDS (U.S. funding totaled $3.87 billion for fiscal years 2000-
2003). 

PEPFAR prevention funding increased from $213 million in FY 2004, to 
approximately $294 million in FY 2005, to over $350 million planned for 
FY 2006. With the vast increase in funding represented by PEPFAR, of 
course, even as the amount of funding dedicated to a program area 
rises, the percentage of overall funding dedicated to it may decline. 
An important consideration in this regard is that before the advent of 
PEPFAR, the USG was supporting very few programs in care and treatment. 
With the massive and highly successful scale-up of these services, 
which PEPFAR now supports, the percentage of resources dedicated to 
prevention has necessarily declined. Yet the USG commitment to global 
HIV/AIDS prevention is now clearly stronger than it has ever been. 

Full funding for focus country budgets will limit the need for trade- 
offs: 

Perhaps the most important contribution the Report will make is to 
highlight the effect of budget issues on prevention funding. The 
President's FY 2007 budget request for the focus countries is, in part, 
an attempt to recover from the effects on focus country programs of the 
redirection of almost $527 million from focus country programs to the 
Global Fund and other components of the Emergency Plan over PEPFAR's 
first three years. The effect of this trend has been to force country 
teams to make difficult trade-offs among prevention, treatment, and 
care (and within prevention, among sexual transmission, mother-to-child 
transmission, and medical transmission programs). 

We appreciate the report's candor about the seemingly impossible 
decisions these budget constraints have forced upon country teams. In 
FY 2007 and beyond, full funding for focus country activities is 
essential if PEPFAR is to meet the 2-7-10 goals, including the 
prevention goal. 

"Counting" ABC allocations does not affect programming: 

The report reflects misunderstanding of the relationship between PEPFAR 
programming and reporting mechanisms. PEPFAR is required to count the 
amounts it allocates to different types of prevention programming for 
purposes of accountability to Congress. But it is not the case that 
each program must be only AB, or only C. Many PEPFAR-supported programs 
integrate all of the ABC strategies, and these programs are encouraged 
to report on the different pieces to the extent possible, because 
accountability is key component of the success of PEPFAR. For a program 
to be a truly integrated ABC program, of course, it must genuinely 
include all three elements, rather than overwhelmingly emphasize only 
one or two elements. PEPFAR is currently working to strengthen its 
reporting conventions in this area through its Technical Working Groups 
and through the programmatic review. 

Guidance on ABC is strong - it addresses most key issues and is being 
clarified as needed: 

OGAC is quoted in the report as saying that further clarification of 
the ABC Guidance will be provided as needed, and we welcome this 
Report's contribution to the ongoing dialogue between PEPFAR 
headquarters and the field. The ABC Guidance had been issued 
approximately two to five months prior to the country teams' interviews 
for this report. It may be expected that adjusting to newly-distributed 
guidance may generate questions and a need for more clarity in the 
short term. The Emergency Plan has since refined the Guidance to 
clarify issues and will continue to do so, updating it on an ongoing 
basis to meet the needs of the country teams. Even as it is updated, 
however, the Guidance will continue to represent the USG's unwavering 
support for ABC as the key evidence-based approach to prevent HIV 
infection in generalized epidemics. 

PEPFAR is committed to continually improving its efforts to communicate 
policy to the field via numerous channels, including weekly emails, 
constant contact between the core team leaders and the field, the 
annual Implementers' Meeting, and others. In addition, each Country 
Operational Plan is developed with significant assistance from 
headquarters, providing another venue for issues to be communicated & 
worked through. 

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 to the Guidance document. One important 
area, which the Guidance addresses at length, is the need to focus on 
"high-risk activity" rather than "high-risk groups," because in a 
generalized epidemic, much of the population can be at risk. 

-On page 29, one country team is quoted as referring to lack of clarity 
regarding support under PEPFAR for programs to address discordant 
couples. Yet on page 28 of the Report, the authors directly quote from 
the Guidance which spells out (in bullet number two) that it is 
appropriate to target discordant couples with prevention activity: 
"Discordant couples should be encouraged to use condoms consistently 
and correctly so as to protect the HIV-negative partner from becoming 
infected. Likewise, prevention messages should strongly support 
preventative behaviors such as eliminating extra partners and 
maintaining a faithful relationship." 

-On page 27, the Report references concern that anyone engaging in 
sexual activity is not considered a "high-risk group." Yet again, on 
page 28, the Report references the Guidance, which says that "to 
achieve the Emergency Plan prevention goal, we must introduce 
combinations of interventions and adapt them to reach, engage, and 
provide the means to enable at-risk populations to reduce their risk- 
taking behaviors in a range of settings (community and facility- 
based)." 

-On page 28, the Report references apparent confusion regarding 
messages that can be delivered to mixed groups of students (including 
youth from age 10 to older than 14) in a single classroom. The Guidance 
is very clear (see Report pages 28 and Guidance pages 6-7) that 
students aged 14 and under may receive certain messages and that only 
students 15 and older can receive additional messages. This is not an 
issue of the ABC Guidance, but of implementation --how best to separate 
students of different ages when prevention is taught. Our interagency 
Prevention Working Group will work with the field on this 
implementation issue. 

PEPFAR has ensured compliance with the Congressional directive while 
tailoring implementation to country circumstances: 

As noted above, the Emergency Plan recognizes the importance of 
tailoring prevention efforts to the particular epidemic of each 
country, consistent with the requirement that 33% of prevention funding 
support AB activities. This requirement is applied across all the focus 
countries collectively. 

As the Report notes, PEPFAR offers each focus country team the 
opportunity to propose, and provide justification for, a different 
prevention funding allocation based on the circumstances in that 
country. In fiscal year 2005, all countries that proposed such 
allocations received PEPFAR approval for them. These countries included 
Cote D'Ivoire, Guyana, Haiti, Mozambique, Rwanda, Tanzania, and 
Vietnam. PEPFAR was able to approve these while continuing to ensure 
that the focus countries as a whole continue to comply with the 
Congressional directive. (Contrary to the report's suggestion, PEPFAR 
has been able to approve the allocations of countries that submitted 
justifications without requiring other countries to make offsetting 
adjustments to their proposed prevention allocations.) 

It is important to remember that most focus countries have generalized 
epidemics, for which the ABC approach is the most effective, data-based 
strategy. Every country has the opportunity to submit a justification, 
but in those with generalized epidemics for which ABC has been proven 
to be so effective, the justification for a different allocation must 
be particularly strong. It is also important to remember that the USG 
is not the only source of funding in-country, and that partners can 
seek funding from other sources for to balance their mix of prevention 
interventions if they find that necessary. 

The ABC approach has clearly represented a change in USG practice, and 
change always involves a period of transition. Yet we have asked some 
of the, country teams that did not submit justifications if they wanted 
to do so and the answer was, emphatically, no. As country teams have 
become more experienced in the ABC approach and familiar with the data 
that supports it, they have become more comfortable implementing it. 

The Emergency Plan accepts the report's recommendation to collect 
information on the effects of the Congressional directive, and the 
information gathered .will inform our adjustments to guidance. As in 
all areas, the Emergency Plan will continue to refine implementation as 
issues are identified, through such mechanisms as the fiscal year 2007 
Country Operational Plan guidance. 

The Congressional directive is appropriately applied to all accounts: 

The Emergency Plan does not agree with the Report's recommendation that 
the Congressional directive should be applied only to funds 
appropriated through the Global HIV/AIDS Initiative Account (GHAI). 

First, one of the principal objectives of the Emergency Plan 
legislation was to integrate the activities of all USG agencies with 
respect to HIV/AIDS programming. One of the Coordinator's tools to 
achieve this has been a unified budget approach, irrespective of the 
source of funding, in planning and approving country activities. 
Applying the spending requirement to only a part of the budget would 
signal a step backward in the integration of USG agencies' activities. 

Second, the issue is becoming less salient over time. With respect to 
focus country budgets, as the Report states, non-GHAI funds have fallen 
to "slightly more than $5 million (2 percent) of the focus country 
teams' planned PEPFAR prevention funds," and only 1 percent if central 
program dollars spent in focus countries is included. The suggested 
change would thus have little impact. 

Conclusion: 

Effective prevention is at the heart of the Emergency Plan, and in 
generalized epidemics, the evidence-based ABC approach is at the heart 
of effective prevention. Among the most encouraging developments in 
many years in the global fight against HIV/AIDS is the growing body of 
evidence demonstrating that ABC behavior change is possible - and that 
it can reduce HIV prevalence on a large scale. 

This report reflects another very encouraging development - the 
consensus support for the ABC strategies on the part of USG personnel 
in the field. The Congressional directive, which itself reflects an 
understanding of the importance of ABC, has helped to support PEPFAR's 
field personnel in appropriately broadening the range of prevention 
efforts. Solid policy guidance from PEPFAR on prevention has helped to 
address many issues of concern, and in implementing ABC consistently 
with the legislative provision, PEPFAR will continue to be responsive 
to the needs of personnel as they respond to circumstances in-country. 

The first two years of the Emergency Plan have demonstrated that high- 
quality prevention programs can work - and are working - in many of the 
world's most difficult places. Through PEPFAR, the American people have 
become true leaders in the world's effort to turn the tide against 
HIV/AIDS. 

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. 

[End of section] 

Appendix VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

David Gootnick (202) 512-3149: 

Staff Acknowledgments: 

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): 

FOOTNOTES 

[1] The remaining $1 billion was intended for the Global Fund to Fight 
HIV/AIDS, Tuberculosis, and Malaria (the Global Fund). 

[2] The President named the following 14 focus countries in 2003: 
Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, 
Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. 
Vietnam was added as the fifteenth focus country in June 2004. 

[3] Pub. L. No. 108-25. 

[4] The U.S. agencies primarily responsible for implementing PEPFAR are 
the Department of State; the U.S. Agency for International Development 
(USAID); and the Department of Health and Human Services (HHS). Other 
agencies involved in PEPFAR are the Department of Defense, the Peace 
Corps, and the Departments of Labor and Commerce. 

[5] Abstinence/faithfulness and "other prevention" funds generally are 
aimed at preventing the sexual transmission of HIV, while funds in the 
other three categories are aimed at preventing nonsexual transmission. 
"Other prevention" includes activities such as programs for high-risk 
groups to increase their awareness of HIV/AIDS prevention behaviors and 
their access to HIV prevention services, such as condom promotion and 
distribution; condom social marketing; substance abuse prevention 
programs; management and treatment of sexually transmitted infections; 
and messages or programs to reduce injection drug use and related 
risks. In its Second Annual Report to Congress, released February 2006, 
OGAC began referring to these activities as "condoms and related 
prevention activities." 

[6] "The President's Emergency Plan for AIDS Relief U.S. Five-Year 
Global HIV/AIDS Strategy," Feb. 23, 2004. 

[7] These officials spoke with us with the understanding that 
individual respondents and the countries where they serve would not be 
named in our discussion of the structured interviews. 

[8] HIV prevalence represents the percentage of the population that is 
estimated to be HIV positive. Estimates of HIV prevalence are often 
based on surveillance of pregnant women in prenatal clinics or 
population-based surveys. In contrast, HIV incidence refers to the 
number of new infections over a period of time (usually 1 year). 

[9] These countries are Cambodia, India, Malawi, Russia, and Zimbabwe. 
Each of these country teams receives at least $10 million in U.S. 
government funding for HIV/AIDS and is therefore required to submit an 
operational plan to OGAC each fiscal year, starting in fiscal year 
2006. 

[10] As discussed on page 11, PEPFAR prevention funding is defined for 
the purposes of this report as funding appropriated to four accounts in 
the 15 PEPFAR focus countries, as well as bilateral HIV/AIDS funding in 
the five additional PEPFAR countries. Funding data for fiscal years 
2004 and 2005 are actual, while funding data for fiscal year 2006 are 
planned funding for activities that have not yet been approved by OGAC. 

[11] Although the spending requirement did not take effect until fiscal 
year 2006, OGAC encouraged country teams to dedicate 33 percent of 
total prevention funds to AB activities in fiscal years 2004 and 2005, 
consistent with the Leadership Act's recommendation to do so. 

[12] These 20 country teams are the 15 focus country teams and the 5 
additional teams that receive at least $10 million in PEPFAR funding. 

[13] As shown on page 11, PEPFAR prevention funding is defined for the 
purposes of this report as funding appropriated to four accounts in the 
15 PEPFAR focus countries, as well as bilateral HIV/AIDS funding in the 
five additional PEPFAR countries. 

[14] These programs aim to prevent transmission of HIV from infected 
individuals to uninfected individuals. 

[15] According to the World Bank, more than three-quarters of HIV 
infections in developing countries are transmitted through sexual 
intercourse. Heterosexual intercourse is the primary mode of 
transmission in 14 of the 15 PEPFAR focus countries. Intravenous drug- 
use is the primary mode of transmission in Vietnam. World Bank 
estimates show that about 15 to 20 percent of all HIV infections in 
Africa occur through mother-to-child transmission. In developing 
countries, on average, blood transfusions account for less than 10 
percent of HIV infections, and medical injections with dirty needles 
are thought to account for about 5 percent of all HIV infections. 

[16] According to the World Health Organization, girls and young women 
in Kenya are particularly vulnerable to HIV infection. In that country, 
women aged 15-24 are more than twice as likely to be infected as men in 
this age group. In Rwanda, however, the groups with evidence of the 
highest infection rates include sex workers, as well as men attending 
clinics that offer treatment for sexually transmitted infections. 

[17] The remaining $1.5 billion was appropriated for, among other 
initiatives, the Global Fund to Fight HIV/AIDS, Tuberculosis and 
Malaria (the Global Fund) and international HIV/AIDS research through 
the National Institutes of Health. The Global Fund is a multilateral, 
nonprofit, public-private mechanism to rapidly disburse grants to 
augment existing spending on the prevention and treatment of HIV/AIDS, 
tuberculosis, and malaria while maintaining sufficient oversight of 
financial transactions and program effectiveness. (See GAO, Global 
Health: Global Fund to Fight AIDS, TB and Malaria Has Advanced in Key 
Areas, but Difficult Challenges Remain, GAO-03-601 [Washington, D.C.: 
May 7, 2003]). 

[18] The PMTCT account expired at the end of fiscal year 2004, but some 
country teams carried over PMTCT funds from fiscal year 2004 to fiscal 
year 2005. Therefore, for fiscal year 2006, this report defines PEPFAR 
funding as funds appropriated to the remaining three accounts. Although 
the PMTCT account expired, OGAC continues to fund PMTCT activities 
through the other funding accounts. 

[19] Others have used PEPFAR funding to describe all U.S. government 
funds dedicated to combating HIV/AIDS worldwide, including funds such 
as U.S. contributions to the Global Fund. 

[20] According to OGAC officials, focus country teams received an 
additional $150 million in fiscal year 2006 "plus-up" funding for 
prevention, treatment, and care activities in January 2006. Fiscal year 
2006 funding figures are likely to change slightly throughout the 
fiscal year, as country teams make adjustments to their funding 
allocations. Data on fiscal year 2006 planned PEPFAR prevention funding 
are current as of March 15, 2006. 

[21] According to the PEFPAR 5-year HIV/AIDS strategy, palliative care 
includes routine clinical care to evaluate the need for symptom relief 
(e.g., from diarrhea or headache); treatment for HIV/AIDS related 
diseases such as tuberculosis and opportunistic infections; preparing 
people for antiretroviral therapy, where possible; and, when treatment 
is not available or has failed, compassionate end-of-life care. 

[22] In 1986, the Ugandan government launched a nationwide information, 
education, and communication tour to encourage Ugandans to abstain from 
sex until marriage, remain faithful to one partner (termed "zero- 
grazing"), and use condoms when necessary. According to the U.S. Census 
Bureau and UNAIDS, national HIV/AIDS prevalence in Uganda fell from 
about 15 percent in the early 1990s to 5 percent in 2001. 

[23] Cates, Willard; Cassell, Michael M; Gayle, Helene D; Green, Edward 
C; Halperin, Daniel T; Hearst, Norman; Kirby, Douglas; and Steiner, 
Markus J. "The Time Has Come for Common Ground on Preventing Sexual 
Transmission of HIV," Lancet: Vol. 364, Nov. 27, 2004. 

[24] Office of the U.S. Global AIDS Coordinator, Appendix 2: The 
Emergency Plan for AIDS Relief: Fiscal Year 2004 Prevention 
Expenditures and Program Classification Criteria (Washington, D.C.: 
U.S. Department of State, 2004). 

[25] According to OGAC, secondary abstinence is for unmarried youths 
who have already engaged in sexual intercourse. 

[26] According to OGAC, "[intravenous drug use] prevention was included 
under sexual prevention because it falls within [PEPFAR's] category of 
"other prevention," i.e. other prevention that is not abstinence and be 
faithful (e.g., women in prostitution, truckers, men who have sex with 
men, etc)." 

[27] The field of HIV/AIDS prevention also involves longer-term, 
research-oriented initiatives, such as research for vaccines and 
microbicides. 

[28] President Bush also established goals of treating at least 2 
million people with life-extending drugs and providing humane care for 
millions of people suffering from AIDS and for children orphaned by 
AIDS. OGAC has stated that its goal is to provide care for 10 million 
people in the 15 focus countries. 

[29] In contrast, OGAC aims to reach the PEPFAR care and treatment 
goals by 2008. 

[30] Until recently, OGAC referred to central awards as "track 1" and 
to country-level awards as "track 1.5" and "track 2." According to 
OGAC, the first round of funding managed by the focus country teams was 
awarded as track 1.5 funding, whereas subsequent rounds were awarded as 
track 2 funding. 

[31] OGAC's target areas for central awards for prevention include AB, 
blood safety, PMTCT, and safe medical injection activities. According 
to OGAC, it has chosen organizations with the capacity to rapidly 
expand activities, a proven track record, and existing operations in 
the focus countries for central awards. Central awards were made in two 
rounds: the first for blood safety, safe medical injections, and 
antiretroviral treatment; the second for orphans and vulnerable 
children and AB activities. Central awards were made for every focus 
country except Vietnam. 

[32] In December 2005, President Bush announced the New Partners 
Initiative, under which $200 million in grants will be awarded to 
nongovernmental organizations with little or no experience working with 
the U.S. government to provide HIV/AIDS prevention and care services in 
the 15 focus countries. 

[33] OGAC officials were unable to provide data on PMTCT central 
funding for prevention. While they estimated that $6.5 million in 
central PMTCT funding went to prevention in fiscal years 2004 and 2005, 
we have not included these rough estimates in our funding figures. 

[34] In fiscal year 2004, the focus countries obligated about $200 
million in country-level and centrally awarded funds for prevention 
activities. Obligations represent a binding financial commitment (such 
as an order placed, contract awarded, or service received) that will 
result in immediate or future outlays. 

[35] These figures also include central funding. 

[36] The reported allocations shown in figure 9 include both central 
and country-level funding. 

[37] Office of the U.S. Global AIDS Coordinator, Guidance to 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 (Washington, D.C.: U.S. Department of State, March 
2005). This guidance was released in its final form in March 2005. 
According to OGAC, the only difference between the draft guidance 
provided to country teams in January and the final guidance was the 
language regarding human papilloma virus. 

[38] These countries are Cambodia, India, Malawi, Russia, and Zimbabwe. 
OGAC officials said they chose to apply the 66 percent requirement to 
these countries because each country receives more than $10 million in 
U.S. government funding for HIV/AIDS activities. 

[39] The sum of funding for all five prevention program areas. 

[40] As shown in figure 1, 11 of the 15 focus countries are 
experiencing generalized epidemics. In fiscal year 2006, 7 of the 15 
focus countries had planned PEPFAR funding over $75 million. 

[41] See page 11 for a definition of PEPFAR prevention funding. 

[42] According to the ABC guidance, at-risk groups include sex workers 
and their clients; sexually active discordant couples or couples with 
unknown HIV status; substance abusers; mobile male populations; men who 
have sex with men; people living with HIV/AIDS; and those who have sex 
with an HIV-positive partner or one whose HIV status is unknown. 

[43] The ABC guidance states that PEPFAR funds may not be used to 
physically distribute or provide condoms in school settings; for 
marketing efforts to promote condoms to youths in school settings; or 
for marketing campaigns that target youths and encourage condom use as 
the primary intervention for HIV prevention in any setting. 

[44] Country teams received this document in August 2005. Although we 
conducted a follow-up round of structured interviews with the country 
teams after this date, we did not specifically ask each country team 
about this document. 

[45] Country teams can submit requests to OGAC to reprogram funds from 
one program to another. 

[46] Under direction from OGAC, this country team categorized the 
program entirely as palliative care. 

[47] The 20 PEPFAR teams discussed in this section comprise the 15 
focus country teams and the 5 additional country teams required to meet 
the spending requirement because they receive at least $10 million in 
PEPFAR funding. 

[48] Of the remaining three country teams, one reported that the 
spending requirement was in line with its prevention strategy; one 
indicated that, although it had some concerns about the prevention 
spending requirement, it had more concerns about the Leadership Act's 
requirement that at least 55 percent of funds appropriated pursuant to 
the act be spent on treatment; and one did not respond to our request 
for information. 

[49] Each of these seven teams has PEPFAR funding over $75 million, is 
working in a country with a generalized HIV/AIDS epidemic, or both. As 
noted on page 30, OGAC discourages these teams from submitting 
documents requesting exemption from the spending requirement. 

[50] In fiscal year 2004, OGAC encouraged country teams to dedicate 7 
percent of total PEPFAR funds on AB activities. This figure reflected 
the Leadership Act's recommendation that 20 percent of total funds 
appropriated pursuant to the act be spent on prevention (7 percent is 
33 percent of 20 percent). 

[51] A 2005 USAID IG report found that this country's reported number 
of PMTCT-prevented infections fell significantly short of the target of 
3,500. 

[52] In this case, we communicated with the country team before it had 
made its final prevention allocations for the upcoming fiscal year. 

[53] In this case, we communicated with the country team before it had 
made its final prevention allocations for the upcoming fiscal year. 

[54] Because of challenges and inconsistencies in country teams' 
categorization of funding for certain integrated ABC programs and some 
broad sexual transmission prevention activities, data on prevention 
allocations may reflect the variation in categorization methods, rather 
than actual differences. (See app. V.) 

[55] Unlike the other teams that submitted requests for exemption, one 
country team plans to spend over 90 percent of total prevention funds 
on sexual transmission prevention. Therefore, even though AB funds do 
not account for 66 percent of this country team's funds to prevent 
sexual transmission of HIV, the team still reserves at least 33 percent 
of prevention funds for AB activities. 

[56] This is not the case for one of the 10 country teams, which 
reported that it would dedicate 32 percent of planned prevention funds 
to AB for fiscal year 2006. Although this team planned to dedicate more 
than 50 percent of total prevention funds on sexual transmission 
prevention funds, it missed the 66 percent policy requirement, 
dedicating about 60 percent of sexual transmission funds to AB 
activities. Prior to receiving plus-up funds at the end of January and 
subsequently reallocating its prevention funds, this team met both the 
50 percent and 66 percent policy requirements and therefore did not 
request exemption. 

[57] We do not have fiscal year 2005 data from the five additional 
country teams that were required to meet the spending requirement in 
fiscal year 2006. Therefore, we are unable to compare the prevention 
allocations in fiscal year 2005 with those in fiscal year 2006 for 
these teams. 

[58] Fiscal year 2005 data represent actual funding. Fiscal year 2006 
data represent planned funding, which has not yet been approved by 
OGAC. For both fiscal years, central and country-level funds are 
included. 

[59] This includes funds appropriated to CDC's Global AIDS Program, the 
Child Survival and Health Account, and the Freedom Support Act. See 
page 30. 

[60] See page 40. 

[61] These officials spoke with us with the understanding that 
individual respondents and the countries where they serve would not be 
named in our discussion of the structured interviews. 

[62] U.S. missions enter planning and reporting requirements, including 
the country operational plans, semiannual and annual progress reports, 
into the COPRS data system. The COPRS data system does not contain 
information on central (track 1) funding or on planned and approved 
funding for fiscal year 2004. 

[63] The Office of the U.S. Global AIDS Coordinator prepared this 
report in collaboration with the Departments of State (including the 
U.S. Agency for International Development), Defense, Commerce, Labor, 
Health and Human Services (including the Centers for Disease Control 
and Prevention, the Food and Drug Administration, the Health Resources 
and Services Administration, the National Institutes of Health, and the 
Office of Global Health Affairs); and the Peace Corps. 

[64] One of these organizations did not respond to our requests for an 
interview; the other agreed to meet with us but later cancelled the 
appointment. 

[65] Fiscal year 2005 program descriptions based on focus country 
teams' country operational plans, dated Mar. 16, 2005. 

[66] The indicators for PMTCT are number of service outlets providing 
the minimum package of PMTCT services according to national and 
international standards; number of pregnant women who received HIV 
counseling and testing for PMTCT and received their test results; 
number of pregnant women provided with a complete course of 
antiretroviral prophylaxis in a PMTCT setting; and number of health 
workers trained in the provision of PMTCT services according to 
national and international standards. For blood safety, the indicators 
are number of service outlets carrying out blood safety activities and 
number of individuals trained in blood safety. The safe medical 
injections indicator is the number of individuals trained in medical 
injection safety. 

[67] The prevalence data used in the Census projection are derived from 
a statistical database (the estimates and projections package) that in 
turn incorporates the country prenatal clinic survey data. Use of these 
data to estimate countrywide incidence assumes that the prevalence rate 
among pregnant women is highly correlated with the prevalence rate in 
the general population. Other organizations such as the Joint United 
Nations Programme for HIV/AIDS also use these data in their prevalence 
estimates. 

[68] The modeling group, chaired by the U.S. Census Bureau, included 
representatives from U.S. agencies, such as the U.S. Agency for 
International Development, the Centers for Disease Control and 
Prevention, and OGAC, as well as independent think tanks and the United 
Nation's Children's Fund. 

[69] The Futures Group is a privately held company that designs and 
implements public health and social programs for developing countries. 

[70] The Goals Model assesses the impact of 13 specific interventions 
including, in part, mass media, community outreach, school-based 
programs, condom social marketing, and outreach to injection drug 
users. For each of these interventions, the model estimates the effects 
of these interventions in changing behaviors. Separate estimates of 
behavior change are made for high-risk, medium-risk, and low-risk 
populations. The model then estimates the reductions in new infections 
that result from the specific changes in behaviors in each of the 
groups. The numerical effects of the 13 interventions on behavior 
change, and of behavior change on the number of new infections, derive 
from peer-reviewed studies. 

[71] The Goals Model incorporates a limited amount of information about 
the impacts of certain interventions on behaviors and infection rates 
because of a lack of evidence from studies. In addition, some of the 
numerical effects specified in the model are based on only one or two 
studies. Because of this lack of evidence, researchers disagree about 
the numerical effects that should be used in the model. 

[72] According to OGAC, the principals are the Global AIDS Coordinator 
and his deputy, the director of the Office of Global Health Affairs and 
Special Assistant to the Secretary for International Affairs at the 
Department of Health and Human Services/Centers for Disease Control and 
Prevention, the acting Assistant Administrator for the Bureau of Global 
Health at the U.S. Agency for International Development, the Deputy 
Assistant Secretary of Defense, the Special Assistant to the Secretary 
for International Affairs, and the Peace Corps AIDS Relief Coordinator. 

[73] The committees are the Senate Committee on Foreign Relations, the 
House Committee on International Relations, and the Senate and House 
Committees on Appropriations. 

[74] OGAC may submit more than one congressional notification. For 
example, for fiscal year 2006, OGAC plans to submit a congressional 
notification before completing the operational plan review process to 
fund programs for which the country teams have requested early funding. 

[75] Each U.S. agency operating under PEPFAR processes grants, 
contracts, and cooperative agreements differently. Procurements may 
occur centrally by agency headquarters, by country U.S. government 
offices, or by regional U.S. government offices. In addition, the type 
of grant, contract, or cooperative agreement affects how it is 
processed. 

[76] An integrated ABC program often addresses a range of issues, 
including abstinence; faithfulness; nutrition; sexually-transmitted 
infections; peer pressure; stigma reduction; child, spouse, and 
substance abuse; alcohol addiction; condom negotiation; and correct and 
consistent condom use. 

[77] Programs outside of the sexual transmission prevention program 
area, such as prevention of mother-to-child transmission or voluntary 
counseling and testing programs, may also include ABC components. 

[78] In fiscal year 2006, no country teams have categorized integrated 
ABC programs entirely in the AB program area. 

[79] Some structured interviews took place prior to submission of the 
fiscal year 2006 operational plans; discussions, therefore, revolved 
around categorization methods used in fiscal year 2005 operational 
plans. Based on these structured interviews and our review of fiscal 
year 2006 operational plans, it appears that there was some change in 
country teams' categorization methods between the fiscal years. 

[80] Office of the U.S. Global AIDS Coordinator (OGAC) officials told 
us that, in reviewing fiscal year 2005 proposed operational plans, they 
found that some countries mistakenly categorized programs with C 
components entirely in the AB program area. However, OGAC will not 
approve this categorization and has instructed country teams that they 
should split the entire C component of any ABC programs into the "other 
prevention" program area. 

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