For example, 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. Proportion of Focus Countries’ PEPFAR Funding Dedicated to Prevention Has Declined

The proportion of PEPFAR funding in the 15 focus countries dedicated to  prevention 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 has three  primary components: (1) the ABC model and OGAC guidance for  implementing it, (2) the abstinence-until-marriage spending requirement  and OGAC’s interpretation of it, and (3) country teams’ strategies for  responding to local prevention needs. To guide  the teams’ application of the requirement that at least 33 percent of  prevention funding appropriated pursuant to the Leadership Act fund  abstinence-until-marriage programs, OGAC directed the teams to spend at  least 50 percent of their prevention funds on sexual transmission  prevention and 66 percent of those funds on AB activities. The model should be applied in accordance with local prevention  needs. OGAC adopted this policy although it determined that, as a matter of law,  the requirement applies only to funds appropriated to the GHAI account  (about $322 million for prevention in fiscal year 2006). OGAC  officials told us that they are aware of these issues and plan to clarify the  guidance. Country  teams consistently told us that they value the ABC model, and several  noted the importance of AB messages. In addition, most of the 20 PEPFAR teams  required to meet the spending requirement or receive exemptions reported  that fulfilling the requirement, including OGAC’s 50 percent and 66 percent  policies implementing it, presents challenges to their ability to respond to  local epidemiology and cultural and social norms. These constraints included the following:    Difficulty reaching certain populations with comprehensive ABC  messages. OGAC’s Policies Allow It to Meet the Overall 33 Percent Target

Our analysis shows that OGAC’s policies implementing the 33 percent  spending requirement should allow it to just fulfill the Leadership Act’s  spending requirement for fiscal year 2006, with the 20 country teams  dedicating, in total, slightly more than 33 percent of reported planned  prevention funds to AB activities. As a result, all but one of  these teams dedicated less than 33 percent of planned fiscal year 2006  prevention funds for AB activities—about 23 percent on average. OGAC’s Application of Spending Requirement to All U.S. Prevention Funding May Further Challenge Country Teams

OGAC’s decision to apply the abstinence-until-marriage spending  requirement to all PEPFAR prevention funding—although it determined  that, as a matter of law, the requirement applies only to funds in the GHAI  account—may further challenge some country teams’ ability to address  HIV prevention needs at the local level. According to OGAC officials, they  have chosen to apply the spending requirement to all PEPFAR prevention  funding in response to a PEPFAR principle that HIV/AIDS programs should  be integrated within and across agencies. Leadership Against  HIV/AIDS, Tuberculosis and Malaria Act of 2003, significantly increased the  United States’ commitment to fight the epidemic. 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, Congress, in its  ongoing oversight of PEPFAR, 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. PEPFAR Planning and Reporting Process

The operational plans that the President’s Emergency Plan for AIDS Relief  (PEPFAR) country teams submit to the Office of the U.S.
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) 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.

What GAO Found

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.