Washington Watch: Title X notice reflects new program priorities
By Cynthia Dailard
Senior Public Policy Associate
The Alan Guttmacher Institute
In July 2003, the Office of Population Affairs (OPA) at the U.S. Department of Health and Human Services formally requested applications for $49 million for family planning service delivery under the Title X program for FY 2004. The request for applications was in some respects routine and affected the 24 competitive grants supporting service delivery that are up for renewal that year. (The rest of the FY 2004 appropriation will support the remaining 64 grants, which are not open to competition in FY 2004.)
However, the announcement contains a number of new program priorities (affecting the 24 grants this year and, presumably, the remaining grants in subsequent years) that will affect the delivery of subsidized family planning services for millions of low-income women and teens in the years to come.
While continuing to acknowledge Title X’s statutory mission of assuring access to a broad package of high-quality family planning and related preventive health services, the OPA announcement identifies several new overarching goals for the program that reflect the Bush administration’s broader social agenda but do not appear in statute.
Specifically, it stresses that the broad range of services includes "extramarital abstinence education and counseling" designed to "encourage abstinence outside a mutually monogamous marriage or union." Building on the long-standing requirement to encourage family participation in the decision of minors to seek family planning services, funded programs now also will be required to include activities that promote positive family relationships. Finally, emphasis is placed on partnering with faith-based organizations, which, the announcement also notes, are eligible to apply for Title X grants in their own right.
Perhaps most striking, however, is the new language spelling out requirements for the integration of family planning and HIV prevention services. Achieving such integration has been a priority for many family planning providers for several years. While noting that "HIV/AIDS education, counseling, and testing either on site or by referral should be provided in all Title X-funded programs," the announcement states that HIV/AIDS education "should incorporate the ABC’ message" and explains further that:
- for adolescents and unmarried individuals, the message is "A" for abstinence;
- for married or individuals in committed relationships, the message is "B" for being faithful;
- for individuals who engage in behavior that puts them at risk for HIV, the message is "C" for condom use.
The ABC approach is drawn from the experience of Uganda, which saw its HIV infection rates plummet between the late 1980s and mid-1990s. Experts agree that the nation’s extraordinary decline in HIV prevalence, unique among African nations, was due to some combination of fewer Ugandans initiating sex at young ages, people having fewer sexual partners, and increased condom use.1 It also is widely believed among Ugandans and outside analysts alike that the government’s commitment to a comprehensive HIV prevention message — delivered in different ways through a multiplicity of approaches, programs, and types of organizations — was responsible for producing these results.1
The ABC approach now guides U.S. policy for HIV prevention overseas, as reflected by the "United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act," signed into law by President Bush in May. The OPA announcement, however, represents the first time that the administration has imported the ABC approach to a domestic public health program. Rather than requiring the provision of comprehensive messages, similar to the Ugandan experience, the announcement emphasizes a segmented approach that targets different messages to different groups of people. It also represents the first time that the ABC message will shape counseling provided to individuals within the context of a medical family planning visit, rather than public education messages designed to respond to high rates of HIV.
Putting the ABC requirement into practice will pose key challenges for Title X providers, largely because the grant announcement leaves many questions unanswered.
While it spells out different HIV prevention messages to be provided to different subgroups, to what extent are these populations actually separate and distinct? Specifically, should "adolescents and unmarried individuals" who also are sexually active and, therefore, "engag[ing] in behavior that puts then at risk for HIV" be given messages about abstinence, condom use, or both? And if HIV prevention and pregnancy prevention services are to be integrated within a family planning visit, does the ABC approach also become the primary strategy for pregnancy prevention? In other words, how are Title X providers expected to reconcile the new requirement to provide abstinence messages to all unmarried individuals for HIV prevention with the program’s historic mandate to provide contraceptive methods and services to sexually active individuals, including teens?
These are only a few of the questions confronting Title X providers that will be further explicated over time as the administration seeks to implement its new Title X program priorities.
1. Cohen S. Beyond slogans: Lessons from Uganda’s experience with ABC and HIV/AIDS. Guttmacher Report on Public Policy 2003; 6:1-3.