April 2007

Also available in [PDF] format.

When Congress authorized the President’s Emergency Plan for AIDS Relief (PEPFAR), it mandated that the Institute of Medicine (IOM) evaluate PEPFAR’s implementation after three years. In fulfilling this mandate, the IOM Committee for the Evaluation of PEPFAR Implementation conducted country visits to PEPFAR focus countries, reviewed official documents from the Office of the Global AIDS Coordinator (OGAC), and conducted interviews with relevant stakeholders. On March 30, 2007, the IOM released, “PEPFAR Implementation: Progress and Promise.” The report includes key findings and recommendations to improve PEPFAR implementation, many of which relate to HIV/AIDS prevention for young people.

Key Findings

• The IOM could find no evidence to justify Congress’ 33 percent budget allocation (earmark) for abstinence-until-marriage programming or OGAC’s implementation of a segmented ABC approach.
• PEPFAR’s rigid budget allocations do not allow country teams the flexibility necessary to respond to the local epidemic.
• Increasing attention on women and girls is critical for the sustainability of PEPFAR.

Advocates for Youth Policy Recommendations

Advocates for Youth urges Members of Congress to:

• Immediately repeal the abstinence-until-marriage earmark from the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108-25)
• Co-sponsor the Protection Against Transmission of HIV for Women and Youth (PATHWAY) Act of 2007 (H.R. 1713), a bill that would require OGAC to develop a strategy to address the vulnerabilities of women and girls to HIV infection and remove the abstinence-until-marriage earmark.

No Evidence Supports the Abstinence-Until-Marriage Earmark as Effective

"The Committee has been unable to find evidence for the position that abstinence can stand alone or that 33 percent is the appropriate allocation for such activities even within integrated programs.” IOM Report, p. 80

"There is, however, little evidence to show that ABC when separated out into its components is as effective as the comprehensive approach.” IOM Report, p.100

The IOM report found no scientific evidence to support the 33 percent abstinence-until-marriage earmark mandated by Congress in the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. Further, the IOM’s research confirmed an April 2006 report by the United States Government Accountability Office (GAO), Spending Requirement Presents Challenges for Allocating Prevention Funding Under the President’s Emergency Plan for AIDS Relief, that found that “meeting the abstinence-until-marriage earmark undermines their [Country Teams] ability to integrate ABC programs as required.”

In confirmation, the IOM report found that “confusion and frustration in the field caused by the abstinence-until-marriage allocation have persisted . . . staff indicated that the allocation did not allow them sufficient flexibility to create the appropriate prevention portfolio based on the available data.” The IOM believes that, “by requiring the Country Teams to isolate funding for these [abstinence and be faithful] activities, this budget allocation has undermined the teams’ ability to integrate prevention programming.”

PEPFAR’s Budget Allocations Are Too Rigid

"To achieve longer term targets and the ultimate goals of the Leadership Act . . . it will be necessary to eliminate the fragmentation introduced by the PEPFAR categories and budget allocations and better capitalize on the synergy that results from effective integration.” IOM Report, p.80

"The difficulties posed by budget allocations will become more pronounced as the HIV/AIDS pandemic and the science of controlling it evolves.” IOM Report, p. 80

The IOM found that all of PEPFAR’s budget allocations, not just the abstinence-until-marriage earmark, have created major challenges for country teams trying to develop programs that are tailored to the local epidemic. The budget allocations lead to a one size fits all approach instead of one that is flexible. Specifically, the IOM found, “the lack of an evidence base for the budget allocations and a rationale linking the allocations to performance targets and goals has adversely affected implementation.” Additionally, “the budget allocations do not allow program implementers sufficient flexibility to respond to change.”

The budget allocations force PEPFAR’s programs to be categorized broadly into prevention, treatment, or care interventions. The IOM found that these categories and the subcategories within them “fragment the natural continuum of needs and services, often in ways that do not correspond to global standards, do not align with an individual focus country’s perspective, and do not permit optimal management of patients and their families.”

On prevention, the IOM report stated, “The proportions of total PEPFAR prevention funding allocated to each subcategory—abstinence/be faithful (30 percent), condoms and other prevention (22 percent), prevention of mother-to-child transmission (22 percent), blood safety (14 percent), and medical injection safety (12 percent)—are not well-aligned with the estimated proportions of new infections from the major routes of transmission.”

More Attention is Needed to Women and Girls

"The U.S. Global AIDS Initiative should continue to increase its focus on the factors that put women at greater risk of HIV/AIDS and to support improvements in the legal, economic, educational, and social status of women and girls.” IOM Report, p. 203

The IOM report made a number of recommendations geared towards moving PEPFAR from an emergency plan to a sustainable, long-term initiative. One such priority was to focus on the vulnerabilities of women and girls. The report said, “In the transition from emergency response to sustainability . . . the U.S. Global AIDS Initiative will need to keep gender issues at the core of its efforts.” In addition, the IOM pays special attention to the need to increase linkages between HIV/AIDS programs and reproductive health and family planning services for women, particularly for those who are HIV positive.