Time to Deliver a More Effective PEPFAR

Susan A. Cohen is Director of Government Affairs at the Guttmacher Institute, where she is responsible for facilitating and coordinating issue analysis and strategy development within the Washington, DC office.

The theme of the Toronto International AIDS Conference in August was "time to deliver." Indeed, while the U.S. deserves credit for ramping up the amount that it has been spending on the global AIDS effort, it is time-past time-to look more closely at how the U.S. is spending its money in addition to talking about how much it is spending overall. Luckily, a rare opportunity to ask just these questions of the person in charge of U.S. AIDS efforts will come on Wednesday, September 6, at 1 p.m. Under the chairmanship of Rep. Christopher Shays (R-CT), a Government Reform Committee subcommittee will hold a hearing examining the impact of the requirement that at least 1/3 of all U.S. global HIV/AIDS funding must be reserved for "abstinence until marriage" programs.

This hearing will be significant because it will be the first opportunity since Toronto for U.S. Global AIDS Coordinator Mark Dybul to testify specifically on what kind of prevention programs the U.S. is delivering. It will also be the first and no doubt the only time there will be a congressional hearing on the role of the abstinence program within the President's Emergency Plan for AIDS Relief (PEPFAR). Certainly it will be the only such hearing in this Republican-controlled Congress that will be organized and chaired by someone who has called for the repeal of the earmark. Shays and other subcommittee members will question Dybul about how this requirement is impeding the availability of resources for other key interventions such as the prevention of mother-to-child transmission. As those following the issue closely are well aware, the Government Accountability Office reported to Congress in April that the abstinence earmark has undermined the ability of the majority of PEPFAR country teams to respond to local epidemiology when it comes to funding decisions on the ground.

The motivation for establishing the 1/3 earmark is purely ideological. When Congress added this mandate to PEPFAR in 2003, the only rationale I could discern from its proponents for siphoning off such a huge chunk of prevention funds for abstinence promotion seemed to be that "A" comprises 1/3 of the letters ABC-shorthand for the comprehensive approach to prevention involving abstaining, being faithful and using condoms correctly and consistently.

PEPFAR however, as its name denotes, is an emergency program. Public health professionals in the field, therefore, need to have the flexibility to respond to the ever-changing demands of the HIV/AIDS epidemic. The "abstinence until marriage" earmark runs counter to this imperative. Of course, programs that encourage young people to delay becoming sexually active are an important component of any prevention effort. So are efforts that help people change their behavior to have fewer concurrent sexual partners and to increase their correct and consistent use of condoms if they are sexually active. But segmenting out prevention interventions according to an arbitrary formula and assigning these interventions, as the U.S. strategy does, to particular groups of people (abstinence for youth, fidelity for married people, condoms for "high risk" groups, which translates to sex workers, truck drivers, men who have sex with men, etc.) is cumbersome and does not derive from the public health evidence or common sense. Youth who are already sexually active, for example, do not fit neatly in the U.S. construct, even though they comprise large numbers of people who could be considered high risk in high HIV prevalence countries.

It is time to repeal or at least mitigate the harm of the abstinence until marriage earmark in PEPFAR. The "Protection Against Transmission of HIV For Women and Youth Act", introduced by Reps. Barbara Lee (D-CA) and Chris Shays, would repeal the earmark and the "HIV Prevention for Youth Act", introduced by Sens. Dianne Feinstein (D-CA) and Olympia Snowe (R-ME), would go a long way towards mitigating its harm. I look forward to the Shays hearing, which holds out the promise of being the first fair and open discussion since PEPFAR was created for looking beyond the politics and at the evidence-or lack thereof- for why the U.S. has made promoting "abstinence until marriage" its single most important U.S. HIV/AIDS prevention intervention.

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