Global Health:

Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief

GAO-06-395: Published: Apr 4, 2006. Publicly Released: Apr 4, 2006.

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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.

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.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Matters for Congressional Consideration

    Matter: 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, may wish to use the information provided by OGAC 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.

    Status: Closed - Implemented

    Comments: The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25) requires that President's Emergency Plan for AIDS Relief (PEPFAR) spend at least 33 percent of funds for the prevention of HIV/AIDS on abstinence-until-marriage programs. In April 2006, GAO reported that this spending requirement presented challenges for country teams that manage PEPFAR in the field (GAO-06-395). GAO suggested that Congress consider information from the Office of the Global AIDS Coordinator (OGAC) on the spending requirement's effect on country teams' efforts to prevent sexual transmission of HIV and use this information to assess the extent to which the spending requirement supports the Leadership Act's endorsement of the ABC model (abstain, be faithful, or use condoms) and strong abstinence-until-marriage programs. In April 2008, GAO reported that HIV/AIDS experts expressed concerns about the effects of the abstinence-until-marriage spending requirement on country-based and evidence-based programming (GAO-08-480). In the event that Congress removed PEPFAR's spending directives, GAO suggested that Congress encourage OGAC to adopt a more country-based and evidence-based approach to allocating funds. In July 2008, the President signed the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act (H.R. 5501) into law. The act reauthorizes PEPFAR for another 5 years. It removes the abstinence-until-marriage spending requirement and calls for the Global AIDS Coordinator to ensure that abstinence and fidelity programs are evidence-based and country-based. After the House of Representatives passed the original version of this bill in April 2008, a press release from the House Committee on Foreign Affairs noted that the bill removed the abstinence-until-marriage spending requirement, citing recent GAO reports about the spending requirement's negative effect on PEPFAR efforts in the field.

    Matter: 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, may wish to 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.

    Status: Closed - Implemented

    Comments: The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25) requires that President's Emergency Plan for AIDS Relief (PEPFAR) spend at least 33 percent of funds for the prevention of HIV/AIDS on abstinence-until-marriage programs. In April 2006, GAO reported that this spending requirement presented challenges for country teams that manage PEPFAR in the field (GAO-06-395). GAO suggested that Congress consider information from the Office of the Global AIDS Coordinator (OGAC) on the spending requirement's effect on country teams' efforts to prevent sexual transmission of HIV and use this information to assess the extent to which the spending requirement supports the Leadership Act's endorsement of the ABC model (abstain, be faithful, or use condoms) and strong abstinence-until-marriage programs. In April 2008, GAO reported that HIV/AIDS experts expressed concerns about the effects of the abstinence-until-marriage spending requirement on country-based and evidence-based programming (GAO-08-480). In the event that Congress removed PEPFAR's spending directives, GAO suggested that Congress encourage OGAC to adopt a more country-based and evidence-based approach to allocating funds. In July 2008, the President signed the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act (H.R. 5501) into law. The act reauthorizes PEPFAR for another 5 years. It removes the abstinence-until-marriage spending requirement and calls for the Global AIDS Coordinator to ensure that abstinence and fidelity programs are evidence-based and country-based. After the House of Representatives passed the original version of this bill in April 2008, a press release from the House Committee on Foreign Affairs noted that the bill removed the abstinence-until-marriage spending requirement, citing recent GAO reports about the spending requirement's negative effect on PEPFAR efforts in the field.

    Recommendation for Executive Action

    Recommendation: 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, the Secretary of State should direct the U.S. Global AIDS Coordinator to 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.

    Agency Affected: Department of State

    Status: Closed - Implemented

    Comments: Congressional action has rendered this recommendation moot. Specifically, in July 2008, the President signed the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act (H.R. 5501) into law, which reauthorizes PEPFAR for another 5 years. It removes the abstinence-until-marriage spending requirement and calls for the Global AIDS Coordinator to ensure that abstinence and fidelity programs are evidence-based and country-based. After the House of Representatives passed the original version of this bill in April 2008, a press release from the House Committee on Foreign Affairs noted that the bill removed the abstinence-until-marriage spending requirement, citing recent GAO reports about the spending requirement's negative effect on PEPFAR efforts in the field.

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