The act recommends that 20 percent of funds appropriated  pursuant to the act be spent on prevention and 15 percent on palliative  care for those living with the disease. The Leadership Act further requires that at least one-third of prevention  funding appropriated pursuant to the act be spent on abstinence-until- marriage programs, starting in fiscal year 2006. PEPFAR Prevention Funding in the Focus Countries Grew Significantly during First 3 Years

PEPFAR prevention funding increased significantly between fiscal years  2004 and 2006, while the proportion of total PEPFAR funding dedicated to  prevention declined. At the same time, the proportion of PEPFAR funding dedicated to  prevention in the 15 focus countries declined from 33 percent in fiscal year  2004 to 20 percent in fiscal year 2006, consistent with the Leadership Act’s  recommendation that one-fifth of funds appropriated pursuant to the act  be spent on prevention. PEPFAR Sexual Transmission Prevention Strategy Is Driven by ABC Approach, Abstinence-Until- Marriage Spending Requirement, and Local Prevention Needs

The PEPFAR strategy for preventing sexual transmission of HIV is shaped  largely by three components: the ABC model, the abstinence-until- marriage spending requirement, and local prevention needs. Finally, OGAC directed country teams to apply the spending requirement  to all PEPFAR prevention funding (about $357 million in fiscal year 2006),  although it determined that, as a matter of law, the requirement applies  only to funds appropriated to the GHAI account (about $322 million in  fiscal year 2006). In  addition, most country teams required to meet the requirement, absent  exemptions, reported either in structured interviews or exemption  requests that the requirement challenges their ability to allocate  prevention resources in accordance with local HIV/AIDS prevention needs. Challenges Related to ABC Guidance

We reported in April 2006 that, although many focus country teams told us  that they generally found the ABC guidance to be clear and several said  that it did not present implementation challenges, 10 of the 15 focus teams  cited instances where components of the guidance were ambiguous and  caused confusion. Challenges Related to Abstinence-until-Marriage Spending Requirement

In several of our structured interviews, focus country teams endorsed the  ABC model and noted the importance of AB messages. Because the abstinence-until-marriage spending requirement  requires them to segregate AB funding from funding for “other  prevention,” 8 of the 15 focus country teams reported that the spending  requirement can undermine their ability to design and implement  programs that integrated the components of the ABC model. The analysis in our April 2006 report showed that, with the approval of all  10 exemption requests, OGAC should just meet the overall 33 percent  target for AB activities for fiscal year 2006 by effectively allowing  exempted teams to spend less than 33 percent on AB programs and  requiring nonexempted teams to spend more than 33 percent. Finally, OGAC’s decision to apply the spending requirement to all PEPFAR  prevention funding—although OGAC had determined that, as a matter of  law, the requirement applies only to funds appropriated to the GHAI  account—may further challenge some teams’ ability to address HIV  prevention needs at the local level. Use the information collected 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. We modified our recommendation to recommend that  they consider this policy change after collecting information on the effect  of the spending requirement. Matters for Congressional Consideration

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, our April 2006  report also suggested that Congress, in its ongoing oversight of PEFAR,  should 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 and use this information 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.
Why GAO Did This Study

The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 authorizes the President's Emergency Plan for AIDS Relief (PEPFAR). It promotes the ABC model (Abstain, be faithful, or use Condoms); 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 activities. The Office of the U.S. Global AIDS Coordinator (OGAC) oversees PEPFAR and administers the Global HIV/AIDS Initiative (GHAI) account, the main repository for PEPFAR funds. For our April 2006 report, GAO reviewed PEPFAR prevention funding trends; described the PEPFAR strategy to prevent sexual transmission of HIV; and examined related challenges. The report recommended that the Coordinator collect and report information on the effects of the abstinence-until-marriage spending requirement and use it to, among other things, assess whether the requirement should apply only to the GHAI account. OGAC agreed to collect information but disagreed with applying the requirement only to certain funds; GAO modified the recommendation. GAO also suggested Congress use the information to assess how well the requirement supports the Leadership Act's endorsement of both the ABC model and strong abstinence programs.

What GAO Found

As GAO reported in April 2006, PEPFAR prevention funding in 15 focus countries increased by 55 percent between fiscal years 2004 and 2006, rising from about $207 million to $322 million. During this time, the prevention share of PEPFAR funding in these countries fell by about one-third, in accordance with the Leadership Act's recommendation that 20 percent of funds appropriated pursuant to the act support prevention. The PEPFAR strategy for preventing sexual transmission of HIV/AIDS is largely shaped by three elements--the ABC model, the abstinence-until-marriage spending requirement, and local prevention needs. In addition to adopting the ABC model, OGAC developed guidance for applying it--for instance, that prevention interventions should be integrated and responsive to local needs and cultural norms. To meet the 33 percent spending requirement, OGAC mandated that country teams (PEPFAR officials in the field) spend at least half of prevention funds on sexual prevention and two-thirds of those funds on abstinence/faithfulness (AB) activities. OGAC permitted certain country teams to seek exemptions from this policy. 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. GAO also reported in April 2006 that OGAC's ABC guidance and the abstinence-until-marriage spending requirement, while valued by country teams, have presented challenges to most teams. First, two-thirds of focus country teams told us that ambiguities in some parts of the guidance led to uncertainty about implementing the model; OGAC officials commented they were clarifying the guidance for country teams. Second, although several teams indicated that they value the ABC model and noted the importance of AB messages, some teams also reported that the spending requirement can limit their ability to design programs that are integrated and responsive to local prevention needs. Most country teams reported, either in structured interviews or exemption requests, that fulfilling the spending requirement, including OGAC's policies implementing it, presents challenges to their ability to respond to local needs. Seven focus country 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 are spending more than 33 percent of prevention funds on AB activities, and OGAC should just meet the overall spending requirement for fiscal year 2006. However, to meet the abstinence-until-marriage spending requirement, teams have in some cases reduced or cut funding for certain prevention programs, such as those to deliver comprehensive messages to certain populations. OGAC's decision to apply the spending requirement to all PEPFAR prevention funds may further challenge country teams' ability to address local prevention needs.