Solving the Sustainability Challenge in PEPFAR
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The Need for a Sustainable Response in PEPFAR
In the next phase of the President’s Emergency Plan for AIDS Relief (PEPFAR), policy and program strategies must be adjusted to develop a more effective and sustainable response to the epidemic. Ultimately, PEPFAR funding should support strategies that promote: host country ownership of healthcare infrastructures: HIV prevention at a high enough rate to enable the scaling-up of treatment and care services to those already infected; and a response to the HIV/AIDS crisis centered both on evidence and human rights. While increased funding from the U.S. government for the response to global AIDS remains an ever-present necessity, the need for an emphasis on improved policies and programs is equally vital.
Investments in Youth as the Key to Sustainability
At the heart of developing a sustainable response to global HIV/AIDS is the world’s largest generation of young people in history, three billion under the age of 25.I Over the next five years, PEPFAR has the opportunity to chart a new path in the global pandemic by investing in the next generation. Stemming the epidemic is dependent on slowing the rate of new infections among youth and young adults. Youth access to comprehensive HIV prevention education and quality sexual and reproductive health care services are essential to meeting this challenge.
According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2008 Report on the Epidemic, 45 percent of new HIV infections continue to occur among young people aged 15-24 years.II Moreover, thanks to the life saving interventions of the first five years of PEPFAR, many young people living with HIV are now of reproductive age. A sustainable global response facilitated through PEPFAR cannot be achieved without significant adjustments to the youth-related strategies PEPFAR has supported to date.
Young People in PEPFAR Recipient Countries are Part of the Solution
While young people’s sexuality is frequently considered a culturally sensitive issue, society has the responsibility to provide young people with the tools and information necessary to make responsible and informed decisions. Young people’s sexuality is not at odds with culture. Cultural evolution is a constant, “cultures adapt to change, and they also contribute to it.”III All of PEPFAR’s programs have a cultural impact in the countries in which they are implemented because they interact with tradition while introducing new systems, rituals, concepts, and processes. As such, comprehensive prevention education should not be singled out as a “culturally sensitive” intervention when its effectiveness in reducing risky behavior and delaying sexual debut has been proven.IV
One way to improve the effectiveness of PEPFAR is to mandate that young people participate in design, implementation, and evaluation of youth-targeted PEPFAR policies and programs. This strategy has been endorsed by both the International Conference on Population and Development (1994) Programme of Action and the United Nations Declaration of Commitment on HIV/AIDS. By promoting meaningful youth participation, PEPFAR can gain a youth perspective that ensures policies and programs are culturally relevant and resonate with young people.VVI
Improving U.S. Global AIDS Policy for Young People
Improving PEPFAR funding to support strategies that promote host country ownership, increased HIV prevention rates, and rights and evidenced-based policies and programs for young people (both those living with and without HIV and AIDS) can be done. In fact, the Office of the Global AIDS Coordinator (OGAC) can take action in numerous ways. The following recommendations outline specific policy adjustments that would dramatically improve PEPFAR for young people.
Recommendations for the Office of the Global AIDS Coordinator
I. Revise the ABC Guidance to strengthen comprehensive ABC programming for young people.
Count comprehensive prevention programs inclusive of Abstinence and Be Faithful education towards the 50 percent reporting requirement included in PEPFAR law.
Current PEPFAR legislation stipulates that in those countries with generalized epidemics, the Office of the Global AIDS Coordinator (OGAC) must develop a strategy for prevention of sexual transmission ensuring that at least half of such funding supports “activities promoting abstinence, delay of sexual debut, monogamy, fidelity and partner reduction.” The Coordinator must report back to Congress on any country plans that do not meet these criteria.
To fund the most effective prevention programs for youth, OGAC should withdraw the 2005 “ABC Guidance #1” and subsequent related guidance documents and issue updated prevention guidance that outlines objectives for programs seeking to prevent the sexual transmission of HIV. Any program that promotes or achieves the designated outcomes of abstinence, be faithful, delay of sexual debut, fidelity and partner reduction (AB), should be included in calculating the required 50 percent threshold, even if they are part of a comprehensive program that also includes education on and access to condoms. This approach to tallying the 50 percent threshold will ensure the most effective use of taxpayer dollars by preventing the greatest number of new infections possible while ensuring that individuals receive the full range of information and services to protect themselves.I
Eliminate segmentation of components of ABC model based on age.
Current ABC Guidance requires that young people receive information limited to abstinence and being faithful (AB), however, evidence shows that young people who receive a comprehensive prevention education are more likely to delay sexual debut and to reduce risky behavior during sex when they become sexually active.
II. Integrate family planning into HIV prevention education and services
Ensure that sexual and reproductive health services and counseling are strong components of, or well-linked to, any and all U.S.-funded HIV prevention programs.
To ensure linkages with reproductive health programs, OGAC must develop clear guidance on the benefits and mechanisms of integration of HIV prevention with other reproductive and sexual health services and with treatment and care programs (e.g. prevention of mother to child transmission programs). Recommendations developed by US government agencies should be used as the basis for such guidance.
III. Guarantee meaningful youth participation in PEPFAR partnerships
Ensure that youth participation is structurally integrated into any and all U.S.-funded HIV prevention programs. The PEPFAR Partnerships model is focused on engendering a sustainable response to national AIDS epidemics in recipient countries. Youth participation is crucial to long-term success and sustainability.
Young people consistently demonstrate their ability to meaningfully participate in the design, implementation, monitoring and evaluation of global health policies and programming. Partnering with youth can help policy makers and program planners insure that these health strategies are culturally relevant and resonate with youth. The President’s Global Health Initiative can make substantial use of its funds by meaningfully involving young people in the process of policy creation and programming. The benefits include not only more effective policy and program strategies, but additional dividends for the youth who participate in the process. Benefits for these youth often include those relevant to other development indicators, including increased recognition of gender equality, greater motivation for academic success, an expanded understanding of career and life options and/or increased earning potential, among others.
Case Studies: Youth as Full Partners
The following case studies document youth activities in countries that receive PEPFAR funding. The organizations that coordinate this advocacy work are demanding more youth access to sexual and reproductive health information and services, while also seeking to work with government entities and broader civil society to facilitate healthier views on youth sexual and reproductive health and rights in their respective cultures and governments.
Nigeria - Education as a Vaccine against AIDS (EVA)
EVA is a youth-led non-governmental organization (NGO) based in Abuja, Nigeria. It was founded in 2000 by two young women who set out to establish systems and structures for young people to make responsible decisions about their development. The organization was founded on the premise that young people can play a significant role in reversing the tide of the AIDS epidemic if given the necessary resources.
The organization utilizes several approaches for reaching young people, including peer education; financing of youth-led outreach activities; provision of information through a toll-free telephone hotline; development and dissemination of youth-friendly information education, communication (IEC) materials and outreach through mobile HIV counseling and testing.
Advocating for Youth Sexual and Reproductive Health through Government Partnership
EVA also works with a group of youth advocates who form a Youth Council. With the goal of developing a partnership with the government, Youth Council members have reached out to a number of government agencies. As a result, they have held meetings with the Director of HIV/AIDS at the Ministry of Education, the National Coordinator on Reproductive and Sexual Health in the Ministry of Health, the Deputy Directors of both the Ministry of Youth and Development and the Ministry of Education to discuss the progress made towards the construction of youth-friendly centers. Council members also discussed the National Youth Policy and provided suggestions for change and improvement. .
In support of the Council’s advocacy efforts, members produced an advocacy portfolio that examines Nigeria’s response to youth reproductive and sexual health, current gaps in the response, priority recommendations, and the Council’s campaign and objectives. The portfolio has been presented to government stakeholders, youth activists, adult allies, and the media.
Jamaica - Jamaica Youth Advocacy Network (J-YAN)
The Jamaica Youth Advocacy Network (JYAN) is a newly formed youth-led NGO created during a previous USAID-funded project. In 2009, the JYAN formed a council of youth advocates to advance youth sexual and reproductive health policy in Jamaica. The objectives of the Council include: 1) institutionalizing youth participation in decision making bodies that inform youth reproductive and sexual health policy formulation and implementation and 2) promoting policies to facilitate the integration of family planning and HIV programs for youth, given the lack of family planning funding and persistent adolescent pregnancy.
Partnering with the Government and Community to Improve Young People’s Access
The Council partnered with the Youth Interventions Officer from the National HIV/STI Control Programme of the Ministry of Health and Environment to meet with key players from the Ministry and present a list of recommendations for implementing youth leadership programs and mainstreaming family planning and HIV programs. The Council also met with the Director of HIV/AIDS in the Ministry of Education to discuss recommendations for youth-friendly policies reflecting HIV/AIDS prevention efforts.
To engage both the community and government, the Council facilitated a youth forum on sexuality and young people at the Ministry of Education on World AIDS Day. The forum attracted 250 students from 20 high schools and various other key stakeholders, including the Director for HIV Prevention unit at the Ministry of Health and Environment; the HIV/AIDS Coordinator from the Ministry of Education; the Director of the NGO Children First; and Dahlia Harris, a famous actress and radio and TV personality. In a similar effort, the Council also hosted a mass high school sex education campaign and a radio show tour for Safer Sex Week in February 2009.
Ethiopia - Talent Youth Association (TaYA)
The Talent Youth Association (TaYA) is the largest youth-led development organization principally engaged in improving youth reproductive health issues in Ethiopia. Established in 2003, TaYA works with youth to implement a budget tracking system to monitor how key players (government, international NGOs, and bilateral and multi-lateral donors) plan and implement youth reproductive and sexual health programs in Ethiopia. TaYA conducts advocacy and hosts a coalition of 11 colleague organizations working on similar issues as well as a Youth Council.
The objectives of the Council include advocating for the Ethiopian government to: 1) increase access to modern contraceptives for young women between the ages of 15 to 29; and 2) secure youth representation in the decision making process regarding national policies, program implementation, and evaluation on adolescent reproductive and sexual health.
Advocating for Youth Sexual and Reproductive Health through Government Partnership
Recently, the Council met with the Prime Minister for a half-day to discuss the establishment of a National Youth Federation, a legal institution run by young people seated under the Federal Ministry. The Federation would potentially be broken down into different development areas, and the council members plan to support one specific to reproductive and sexual health. In addition, the council met with the Secretariat of the HIV/AIDS Prevention and Control Office to discuss conducting a needs assessment and budget tracking of HIV/AIDS prevention programming specific to youth. To date, lack of data has hindered the assessment from moving forward; however, the Council successfully advocated for a public forum to discuss the need for improved data collection.
To support their advocacy efforts, the Council has produced a 30-minute documentary with personal testimonies from young people, service providers, and peer educators on reproductive and sexual health issues, particularly on unintended pregnancy and unsafe abortion. The Council is also in the process of writing a policy brief with recommendations to improve youth access to sexual and reproductive health services and information in Ethiopia.
Young people around the world are actively working with all levels of their countries’ governments to incorporate HIV prevention, treatment and care education and services that address their needs into their county plans. Because of the limitations in the way PEPFAR addressed the needs of young people in the past, many of these extraordinary efforts are not proactively supported by PEPFAR funding.
As the case studies above demonstrate, young people in countries that receive PEPFAR funding understand that comprehensive prevention education and access to quality sexual and reproductive health care services are essential to stemming the epidemic among their peers. Further, they are demonstrating that they can be meaningful participants in the design, implementation, and monitoring and evaluation of global health policies and programs.
The time is now for PEPFAR to take advantage of the knowledge available about HIV and AIDS among young people and alter its policies and programs to support young people’s health and empowerment.
I UNAIDS 2008 Report on the Epidemic
II UNFPA State of the World Population 2008- Reaching Common Ground: Culture, Gender, and Human Rights. http://www.unfpa.org/swp/
III UNFPA, Cultural Lens http://www.unfpa.org/culture/culture.htm
IV Science and Success in Developing Countries
V ICPD Programme of Action
VI UN Declaration of Commitment on HIV/AIDS
VII National 4-H Council. Creating Youth/Adult Partnerships: the Training Curricula for Youth, Adults, and Youth/Adult Teams. Chevy Chase, MD: The Council, 1997.