On September 6, the House Government Reform Subcommittee on National Security, Emerging Threats and International Relations held a hearing entitled, “HIV Prevention: How Effective is the President’s Emergency Plan for AIDS Relief (PEPFAR)?”
Subcommittee Chair Christopher Shays (R-CT) stated, “The 2003 Leadership Act, which authorized PEPFAR, recommended and now requires 20 percent of total PEPFAR funds to be spent on HIV prevention. The Act endorses HIV sexual transmission prevention through the model for ‘Abstinence, Being faithful, and Correct and Consistent use of Condoms’ — known for short as ABC — and includes a spending requirement that one third of prevention funds go to abstinence-until-marriage initiatives. This spending requirement has come under intense scrutiny as a conservative political vehicle rather than scientifically-based policy.” Asserting the need to ensure that “our funding is responsive and that the money is being used sustainably and wisely,” Rep. Shays said that he, Rep. Barbara Lee (D-CA), and others have introduced the Protection Against Transmission of HIV for Women and Youth (PATHWAY) Act of 2006, “which includes a provision to lift the abstinence-until-marriage funding earmark from PEPFAR.”
Noting that “PEPFAR has made important progress in some areas,” full committee Ranking Member Henry Waxman (D-CA) stated that “it is time that Congress take a serious look at prevention. We need to examine what’s working and what isn’t.” He emphasized that allocating one third of prevention funds to abstinence programs restricts funding for other prevention programs, such as blood supply safety. Stating that “HIV prevention is extremely complicated,” Rep. Waxman said, “No formula that we try to write in Congress will ever be right for the epidemiology and culture of each country.” Rep. Barbara Lee (D-CA) echoed his comments, saying that the U.S. approach should not be “heavy handed,” but flexible, allowing countries to come up with their own solutions to the HIV/AIDS pandemic. “Why can’t we repeal the earmark and let countries make whatever plan makes sense to deal with this?” she asked.
U.S. Global AIDS Coordinator Mark Dybul described the success of PEPFAR, in collaboration with the people it serves, as “breathtaking.” He said that PEPFAR programs have “supported treatment for over 560,000 thousand people — 61 percent of whom are women and 8 percent of whom are children,” as well as “care for three million, including 1.2 million orphans and vulnerable children,” and “counseling and testing for 13.6 million — 69 percent of whom are female.” He warned, however, that “effective prevention is the only way to achieve the elusive goal of an HIV/AIDS-free generation” since “the overwhelming majority of cases of HIV infection are due to sexual activity.”
Addressing the ABC approach, Dr. Dybul explained that this strategy was developed in Africa and used long before PEPFAR. He cited recent data from Kenya and Zimbabwe that reflect decreases in HIV prevalence due to changes in sexual behavior, and quoted Dr. Peter Piot, director of the Joint United Nations Programme on HIV/AIDS, who said, “The 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.” Because of a “growing body of evidence demonstrating that ABC behavior change is possible — and that it can reduce HIV prevalence on a large scale,” Dr. Dybul said, “ABC is now recognized as the most effective strategy to prevent HIV in generalized epidemics.” He clarified that ABC “is not a narrow, one-size-fits-all recipe,” but a combination of many approaches, including addressing gender issues such as violence against women, cross-generational sex and transactional sex. “While gender equity does not directly reduce HIV transmission, ABC is crucial for the protection of women,” he stated.
Dr. Dybul also detailed PEPFAR mother-to-child transmission prevention programs: “Through March 2006, we supported programs that provided women with these services, including voluntary HIV counseling and testing, during more than 4.5 million pregnancies. It is noteworthy, by the way, that the number of women served with activities to prevent mother-to-child transmission grew dramatically from 821,000 in the first half of FY2005 to almost 1.3 million in the first half of FY2006. In over 342,000 pregnancies, the women were identified as HIV-positive and given antiretroviral prophylaxis to prevent infection of their children. Using an internationally-agreed model, we estimate that this intervention averted approximately 65,100 infant infections through March of this year.” He concluded, “The initial 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.”
U.S. Agency for International Development (USAID) Bureau for Global Health Assistant Administrator Kent Hill concurred with Dr. Dybul’s assessment of the ABC model, stating, “The ABC approach is an evidence-based, flexible, and common-sense based strategy which plays a major role in stemming the tide of the HIV/AIDS pandemic.” Highlighting the importance of gender issues in ABC prevention interventions, Dr. Hill said, “Critics of the Emergency Plan argue that ABC does not speak to a women’s ability, or inability, to negotiate within a sexual relationship. But, in fact, central to the ABC strategy are parallel efforts to address the vulnerability of women and girls. In addition, within the ABC strategy there is very specific and growing attention to issues of male behavior, which of course lies at the heart of gender inequality and sexual coercion.” Dr. Hill gave several examples of PEPFAR programs that focus on changing the behavior of men to reduce HIV/AIDS infection, including the South African Soul City program that highlights the role of men in parenting and “challenges social norms around men’s perceived right to sex, sexual violence, and transgenerational sex,” and the Lifeline Childline program in Namibia that “uses age-appropriate messages to teach boys – as well as girls – about HIV/AIDS, sexual abuse, domestic violence, and the resources available to vulnerable children through specialized counseling and other services.”
David Gootnick, director of International Affairs and Trade at the U.S. Government Accountability Office (GAO) discussed the April 2006 GAO report examining PEPFAR prevention funding. He noted that, “although country teams consistently value the ABC model as a useful tool for preventing HIV, the Leadership Act’s 33 percent abstinence-until-marriage spending requirement has presented challenges to their 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.” He added, “Two-thirds of focus country teams reported that a lack of clarity in aspects of ABC guidance has led to interpretation and implementation challenges.” Mr. Gootnick stated the GAO recommendation that the U.S. Global AIDS Coordinator collect data each fiscal year from country teams on the effects of the spending requirements on their HIV sexual transmission prevention programming, and that this information be provided to Congress in an annual report.
Testifying for CARE USA, President and Chief Executive Officer Helene Gayle commended PEPFAR for its leadership and programs in the fight against HIV/AIDS, but raised several areas of concern. “Too often, PEPFAR has emphasized the narrower interpretation of appropriate programming, ignoring meaningful comprehensive programming in favor of a more basic AB [abstinence, be faithful] message. Our country offices express deep concern that messages about abstinence or faithfulness, de-coupled from the broader reality that most individuals in resource-poor countries face every day, are not effective in influencing high-risk behaviors or promoting safer practices over the long term,” she said, adding that “CARE urges Congress to consider modifying or repealing the AB set-aside to substantially increase the ability of PEPFAR country teams and implementing partners to respond to local circumstances.”
Dr. Gayle asserted that “gender inequity still is not a sufficient focus of PEPFAR nor an area that PEPFAR is especially effective at addressing.” Women in sub-Saharan Africa, she noted, “represent 60 percent of those infected with HIV and 75 percent of those infected between the ages of 15 and 24. Young women age 15-24 in South Africa, Zambia and Zimbabwe are three to six times more likely to be infected than are young men. One in four women in South Africa is HIV-infected by the age of 22.” Dr. Gayle explained, “Women and girls in these countries are only meaningfully engaged by the ABC model when they are free to choose to abstain from sex, or to choose to enter or to remain in a relationship where their own faithfulness is reciprocated and thus truly protective, or to avail themselves of condoms where they can negotiate correct and consistent use. In those instances, ABC as a preventive strategy — including AB for appropriate target populations — is an effective intervention. But wherever women cannot control the sexual encounters they engage in, either for reasons of rape or abuse, gender disempowerment, economic dependency, or cultural practices, ABC in its current formulation is significantly more problematic. Worldwide, thousands of women and girls are infected with HIV daily in settings where saying no to sex or insisting on condom use is not an option because of cultural factors, lack of financial independence, and even the threat of violence.”
Tanzanian Member of Parliament and Faraja Trust Fund Director Lucy Nkya summarized the experience of the Faraja with PEPFAR in the Morogoro region of Tanzania. HIV/AIDS education, counseling, legal aid, health, and youth programs were in place when Faraja’s collaboration with PEPFAR began in 2004. The aim of the project was to “promote the youths’ behavioral change, abstinence until marriage, condom promotion, and promotion of voluntary testing.” Dr. Nkya said that this phase of the project was very successful: HIV/AIDS awareness increased as well as condom use. In 2005, the second phase of the project began with similar goals though without condom promotion; sex workers were excluded. Many youth were confused with the “new moralistic approach of encouraging youth to abstain until marriage, no condom use, and family planning,” Dr. Nkya said. Since the government had no free condoms, the youth no longer had any condoms available. Dr. Nkya felt that the AB approach compared to the ABC approach did not address fundamental realities, such as polygamy, local traditions, the role of poverty in spreading HIV/AIDS, and unemployment. “The bottom-line outcome arising from the complexity of HIV/AIDS is that the traditional family support system is rapidly weakening due to rapid urbanization, deaths of parents caused by AIDS, and family breakdown,” she stated.
Harvard Center for Population and Development Studies Senior Research Scientist Edward Green also testified.
