AIDS Alert International

GAO report finds problems with PEPFAR's int'l rules

No funds for teaching youths about condoms

The President's Emergency Plan for AIDS Relief (PEPFAR) basic requirements have created confusion and problems for many countries receiving the funds, according to a recent report by the U.S. Government Accountability Office (GAO).1

The Office of the U.S. Global AIDS Coordinator (OGAC) adopted the ABC (abstinence, be faithful, use condoms) model as an effective method for preventing HIV/AIDS in its PEPFAR sexual transmission prevention strategy. So the PEPFAR strategy contains the ABC model as one of its three elements, and combines this with the Leadership Act's abstinence-until-marriage (AB) spending requirement, and local prevention needs in the PEPFAR countries.1

The Leadership Act requires that beginning in fiscal year 2006 at least 33% of prevention funds be appropriated to abstinence-until-marriage programs.

The GAO report found that ABC guidance lacks clarity and creates problems for a majority of focus country teams.

Ten of the 15 focus country teams cited instances where elements of the guidance were ambiguous and confusing, the report says.

"For example, although the guidance restricts activities promoting condom use, it does not clearly delineate the difference between condom education and condom promotion, causing uncertainty over whether certain condom-related activities are permissible," the report states.

Also, most countries find it challenging to satisfy the Leadership Act's AB spending requirement because it can undermine the integration of prevention programs and it can impede their ability to respond to local epidemiology and cultural and social norms, the report says.

Ten of the 17 teams requested exemptions from the spending requirement, which meant the remaining seven teams had to spend more than 33% of prevention funds on AB activities in order for the entire program to meet the requirement.1

The GAO report recommended that Congress review and consider information provided by OGAC regarding the spending requirement's effect on country teams' efforts to prevent the sexual transmission of HIV.

The OGAC's guidance for using PEPFAR funds for ABC programs is as follows, according to the GAO report:

• Any PEPFAR-funded program that provides information about condoms must also provide information about abstinence and faithfulness.1

• PEPFAR funds may not be used to physically distribute or provide condoms in school settings.1

• PEPFAR funds may not be used in schools for marketing efforts to promote condoms to youths.1

• PEPFAR funds may not be used in any setting for marketing campaigns that target youths and encourage condom use as the primary intervention for HIV prevention.1

• PEPFAR funds may be used to target at-risk populations with specific outreach, services, comprehensive prevention messages, and condom information and provision. The guidance defines at-risk groups as:

— commercial sex workers and their clients;

— sexually active discordant couples or couples with unknown HIV status;

— substance abusers;

— mobile male populations;

— men who have sex with men;

— people living with HIV/AIDS, and

— those who have sex with an HIV-positive partner or one whose status is unknown.


  1. Global Health, spending requirement presents challenges for allocating prevention funding under the president's emergency plan for AIDS relief. United States Government Accountability Office Report to Congressional Committees. April 2006:1-47.