Washington Watch

Global AIDS program: A new push for prevention

By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC

The richer nations of the world have stepped up their collective response to the global AIDS pandemic, with the number of HIV-positive people in low- and middle-income countries receiving treatment increasing from 400,000 to 2 million between 2003 and 2006.1 The U.S. response, through the President's Emergency Plan for AIDS Relief (PEPFAR), deserves a good measure of credit for this progress, both for its rapid implementation of treatment programs and for setting an example for other donors.

Despite this progress, however, HIV infections still are outpacing treatment efforts, and the AIDS community is looking to refocus the world's response onto a sustainable, long-term strategy that emphasizes prevention. One of the first tests of this shift in thinking will come next year, as Congress works to reauthorize a PEPFAR program slated to expire in September 2008. Because of the politics surrounding sexuality, this test may be a difficult one.

The reluctance of many leaders to openly discuss and confront HIV as a sexually transmitted infection leaves two groups — women and young people — at particularly high risk. Half of the world's HIV-positive population is female, up from one-third in the mid-1980s, and women have higher infection rates than men.2 Key to treating these women is overcoming and overturning traditional gender norms that make it difficult for women to protect themselves. These norms include male promiscuity and risk-taking and female subservience — sexually, legally, and economically. The United States and other donors have taken some small steps to counter these norms through targeted programs and encouraging systemic changes, but greater steps are possible and needed.

Perhaps more difficult politically will be the efforts needed to address the pandemic among young people, who account for four in 10 new HIV cases. Contrary to conventional wisdom, females and males in developing as well as industrialized countries are likely to first have sex during their teenage years and often before marriage.3 In countries with high rates of HIV prevalence, anyone who is sexually active is at substantial risk of infection. Thus, the challenge is twofold: help teens delay having sex and provide them with the information and skills they will need when they become sexually active. The best evidence, including a 2007 review of 80 studies worldwide, demonstrates that success on both fronts can be obtained through comprehensive sex education that urges abstinence while also promoting protective behaviors such as condom use.4

Problems with PEPFAR

U.S. policy under PEPFAR works against a comprehensive strategy. First, the program limits comprehensive messages to a narrow range of groups defined as being at high risk, such as commercial sex workers and men who have sex with men. For the rest of the population, including sexually active youth, PEPFAR focuses on abstinence outside of marriage and monogamy within marriage. To avoid a "conflicting message" that may "encourage sexual activity," groups that receive U.S. HIV money cannot use these funds to promote condom use among young people or to provide them with condoms; they may not provide young teens with any school-based education about condoms.5

Second, the PEPFAR law requires that at least one-third of all HIV prevention funds be used for abstinence-until-marriage programs. A 2006 report by the Government Accountability Office found that this requirement has resulted in cuts to proven programs, including those aimed at preventing mother-to-infant transmission,6 and a 2007 report by the Institute of Medicine calls for its elimination.7 Also in 2007, a broad review of HIV-prevention programs in developed countries by University of Oxford researchers found abstinence-only programs "ineffective for preventing or decreasing sexually activity among most participants,"8 and a nine-year, $8 million, congressionally mandated evaluation of U.S.-based abstinence-only programs found that them to have no beneficial impact.9

During the reauthorization of PEPFAR next year, Congress will have an opportunity to rectify these problems. As a first step toward that goal, the House and the Senate voted earlier this year to nullify for FY 2008 the abstinence-until-marriage spending requirement. It remains to be seen whether Congress will take the additional steps needed to once and for all put U.S. global AIDS policy in line with the strategies that the best research says will be most effective.

A related question is whether Congress will muster the political will next year to bring a similar level of evidence-based policy-making to PEPFAR's domestic counterparts. During the past decade, Congress has directed more than $1 billion toward the promotion of abstinence outside of marriage among Americans. Congress has funded programs that are required to ignore or denigrate the effectiveness of contraceptives and safer-sex behaviors. Reversing this strategy remains the highest priority for proponents of an evidence-based approach in the United States.


  1. World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS) and United Nations Children's Fund. Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: Progress Report, April 2007. Geneva: WHO; 2007.
  2. UNAIDS, United Nations Population Fund (UNFPA) and United Nations Development Fund for Women, Women and HIV/AIDS: Confronting the Crisis. Geneva: UNAIDS, 2006.
  3. Lloyd CB, ed. Growing Up Global: The Changing Transitions to Adulthood in Developing Countries. Washington, DC: National Academies Press; 2005.
  4. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world. J Adolesc Health 2007; 40:206-217.
  5. Boonstra HB. PEPFAR reauthorization and the promise of HIV prevention. Guttmacher Policy Review 2007; 10:6-10.
  6. Government Accountability Office. Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief. April 2006. GAO-06-395.
  7. Institute of Medicine. PEPFAR Implementation: Progress and Promise. Washington, DC: National Academies Press; 2007.
  8. Underhill K, Montgomery P, Operario D. Sexual abstinence-only programmes to prevent HIV infection in high-income countries: Systematic review. Br Med J 2007; 335:248.
  9. Trenholm C, Devaney B, Fortson K, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs: Final Report. Princeton, NJ: Mathematica Policy Research; 2007.