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2008 PEPFAR Country Profile Updates: Haiti


 
Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.
 

(The following document is a 2008 update to the status of PEPFAR funding and related issues in Haiti. Click Here to View Haiti's Original 2005 Country Profile
 
 
 
Introduction
 
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).  
 
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries.  PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action.  At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying.  Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.  
 
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20 percent of the funds could be spent on prevention efforts.  Moreover, 33 percent of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs.  Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings. 
 
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time. 
 
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds. 
 
In addition to this data, each update also offers further analysis on particular items of note in the country.  And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries.  While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective. 
 
These updates track the impact that the original law has had on the HIV-prevention landscape. The U.S. Congress had the opportunity to remedy many of the shortcomings of the original law when they reauthorized PEPFAR in 2008. The evidence on the successes and failures of the original PEPFAR as gathered and shared with lawmakers by researchers and advocates had limited impact on policymakers as the reauthorization passed in July 2008 embodied many of the same prevention inadequacies as the original law. SIECUS will continue to monitor the impact that PEPFAR has on communities affected by HIV in need of prevention technologies and interventions to ensure that the most sound practices are lifted up, and those which are not are eliminated.
 
 
Overview
 
The Republic of Haiti has been disproportionately impacted by the HIV/AIDS epidemic compared to its neighbors in Latin America and the Caribbean. Various economic, social, and political conditions have made it difficult for Haiti to successfully fight the disease. The first known case of HIV infection was in 1981. Now almost 30 years later, there are at least 120,000 adults and children living with HIV and an estimated 7,500 people died in 2007 from the disease.[1] Despite these harrowing estimates, the national prevalence rate of HIV has been stabilized at 2.2 percent since the 1990s.[2]  Although this prevalence is low, AIDS remains the leading cause of death in the country with approximately 8,000 deaths each year.[3]  In addition, Haiti has witnessed a disturbing trend of the epidemic disproportionately impacting more women and girls than ever before.[4]
 
With at least 120,000 people living with HIV, Haiti bears the largest burden of HIV in the Caribbean. It is estimated that only 39 percent of people in need of treatment in 2006 were actually receiving it. Haiti’s economy continues to be a major factor in the current state of the epidemic.[5]  In addition, poverty has been a main force behind the HIV epidemic and, coupled with other factors like continued political unrest, has also prevented the Haitian government from implementing a multi-sectoral, comprehensive HIV-prevention plan.
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Haiti. The stories behind these statistics are fleshed out in greater detail following the chart.
 
A PORTRAIT OF HAITI IN NUMBERS
 
Total population (2005)[6]
8,528,000
Percentage of the population under the age of 24
N/A
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005)[7]
$1,680
Per capita total expenditure on health (Int’l$, 2005)[8]
$32
Secondary school enrollment rate (1997–2000)[9]
20% Females
21% Males
Estimated number of people ages 15 and over living with HIV (2005)[10]
110,000
HIV prevalence in people ages 15–49 (2007)[11]
2.2%
HIV prevalence in people ages 15–24 (2007)[12]
1.8% Female upper estimate
0.9% Male upper estimate
 
1.0% Female lower estimate
0.2% Male lower estimate
Median age of first intercourse
N/A
Median age of first marriage
N/A
Young people ages 15–24 who have had sex before age 15 (2005)[13]
15% Females
43% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2006)[14]
1% Females
23% Males
Percentage of women and men ages 1549 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse (2006)[15]
21% Females
34% Males
Contraceptive prevalence rate (2004)[16]
Any method: 28%
Modern: 22%
Percentage of couples using condoms for family planning (2005)[17]
2.9%
Number of births per 1,000 women ages 15–19(2007)[18]
58
Percentage of females (20–24) who have given birth by age 18 (2005)[19]
15%
Young people ages 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (2006)[20]
32% Females
40% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[21]
N/A
 
Haiti first attempted to respond to the epidemic in 1987 by establishing a National AIDS Council (NAC). The NAC, however, was largely ineffective and became non-operational during the civil unrest that lasted into the late 1990s. In 1996, the Haitian government made another attempt at providing some national leadership by drafting a National Strategic Plan (NSP) for 1996–2000. Like the NAC however, the NSP 1996–2000 was never implemented due to ongoing economic issues and civil unrest.
 
However, in 2002, renewed political commitment to fighting the HIV/AIDS epidemic led to the creation of a second National Strategic Plan for the years 2002–2006. This NSP identified six priority areas within prevention to reduce the risk of infection: promoting behaviors that reduce risk, encouraging responsibility for STIs, promoting and distributing condoms, providing a safe blood supply, reducing mother-to-child transmission, and preventing transmission in cases of accidental exposure to blood and in cases of violence.[22]
 

Key Goals of the NSP 20022006
1.                  Prevent New Infections
2.                  Improve Quality of Life for People Living With AIDS
3.                  Develop Multi-Sectoral Interventions

 
This plan, while a great improvement to previous government attempts and the first NSP, currently remains only partly implemented. Funding restrictions are largely responsible for the limited implementation of this plan. Specifically, an influx of money from donors like the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR) has led to a prioritization of specific elements of the NSP rather than supporting the plan in its entirety.[23]
 
In fact, as of 2005, Haiti had made little progress in meeting its NSP goals or in addressing the six priority areas to reduce risk of infection. Haiti has had some form of health education, family life education, or HIV-prevention education in primary and secondary schools since the late 1990s, and the majority of parents think education about condoms should be provided to children 12 and older. Nonetheless, Haiti’s youth are still uninformed about the risks of HIV/AIDS.  Less than half of young people aged 15–24 could correctly identify ways of preventing sexual transmission of HIV and reject major myths about the disease.[24] Even fewer people (21 percent of females and 34 percent of males aged 15–49) report using condoms with non-regular partners.[25]  This is particularly troubling given the early age of sexual debut among youth; almost half of males and a quarter of females aged 15–24 report having had sex before age 15.[26] In addition, young people frequently have multiple partners; almost a quarter of young men aged 15–24 indicated having multiple partners.[27]
 
Haiti’s performance in other areas of prevention has been equally troubling. For example, as of 2007, only 22 percent of pregnant women received a full course of antiretroviral therapy (ART) to reduce mother-to-child transmission (MTCT).[28] Distribution of ART outside of efforts to prevent MTCT has been a serious problem in Haiti due to lack of funds and infrastructure to support a treatment supply chain. It is estimated that there are only 46 sites in Haiti providing ART and 15,000 people receiving ART; leaving roughly 36,000 other individuals in need of ART or 59 percent of individuals eligible for treatment without coverage.[29]
 
The influx of money from PEPFAR and the Global Fund has certainly helped to increase access to prevention, treatment, and care services and programs. However, the immense poverty and ongoing political instability in Haiti, coupled with a lack of human resource capacity, has made implementation of these programs extremely challenging.
 
President’s Emergency Plan for AIDS Relief (PEPFAR)
 

Key Terms to Understanding PEPFAR Prevention Programs and Funds
 
ABC: ABC stands for “Abstain, Be-Faithful, and Correct and Consistent Condom Use.” ABC is PEPFAR’s guiding principal for HIV-prevention programs. PEPFAR requires that a minimum of one-third of all prevention funds be spent on abstinence programs and it limits the promotion and marketing of condoms to specific groups outlined in PEPFAR’s ABC guidance. No discussion or promotion of condoms is permitted with youth under the age of 14 using PEPFAR funds.
 
Country Operation Plan (COP): A yearly program and budget plan developed for each PEPFAR focus country. The COP is developed by U.S. staff in conjunction with country governments. It divides programs into three main categories of prevention, care, and treatment:  Abstinence-Be-Faithful (AB), Other Prevention (OP), and Prevention of Mother-to-Child Transmission (PMTCT). A country’s COP is not the same as its National Strategic Plan/Framework (NSP/F). Unlike a NSP/F, a COP is specific to PEPFAR programs and funds, and is developed annually. In comparison, the NSP/F is a multi-year, country-wide strategy on HIV/AIDS that is developed by each country’s government. Although the NSP/F may make reference to PEPFAR and other international donors, it is not limited to a description of activities funded by international donors, and an NSP/F may or may not be developed with input from the United States or other donors. 
 
Abstinence-Be-Faithful (AB): One category of prevention programs and funding under PEPFAR. Grantees that provide AB programs focus on education and promotion of abstinence-until-marriage and be-faithful messages. Grantees that receive OP funds, such as those to promote condom use, are listed in both sections of the COP.
 
Other Prevention (OP): One category of prevention programs and funding under PEPFAR.  The OP category includes any prevention program that is not an AB program or a PMTCT program. This category includes surveillance programs, programs aimed at reducing stigma and discrimination, training for healthcare workers, and the promotion and marketing of correct and consistent condom use. Grantees that receive funds for OP programs in addition to AB funds are listed in both sections of the COP.
 
Prevention of Mother-to-Child Transmission (PMTCT): One category of prevention programs and funding under PEPFAR. The PMTCT category includes routine rapid HIV-testing in antenatal and maternity settings, counseling and support for infant feeding, and linking to care, treatment, and support services.
 

Funding
 
PEPFAR began allocating funds to Haiti in 2004 with an initial investment of $28 million dollars.  That funding was increased to nearly $44 million for 2005 and saw a slight increase in 2006 to just under $49 million. Funding has been increased again in 2007 to nearly $75 million, with the most significant increases going to treatment and care programs.  It is now currently more than triple its initial amount at $85,328,286 in fiscal year 2008.
 
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstinence-only, Be faithful, and Correct and Consistent Condom Use. Abstinence-only/Be-faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).
 
 
Allocated PEPFAR Funds, Haiti, 2004–2008*
 
2004[30]
2005[31]
2006[32]
2007[33]
2008[34]
Total Funds Allocated**
$28,053,144
$43,834,021
$48,954,947
$75,062,732
$85,328,286
Total Prevention Funds Allocated
N/A
$13,834,690
$11,311,457
$13,121,983
$18,037,781
Total AB Funds Allocated
N/A
$3,619,052
$3,895,017
$4,046,983
$5,116,611
Total Other Prevention Funds Allocated (includes condom programming)
N/A
$2,301,000
$2,625,000
$2,640,000
$3,300,000
Total Treatment Funds Allocated
N/A
$19,747,679
$26,209,002
$35,421,679
$39,484,679
Total Care Funds Allocated
N/A
$10,251,652
$11,434,488
$27,859,454
$27,805,826
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.  
** Total funding allocated to Field Programs only, excludes Agency costs.
 
 
As the chart indicates, of the $43 million allocated in 2005, just under $14 million (31 percent) was allocated for prevention programs.  In 2006, the percentage of prevention funds decreased to 23 percent of allocated PEPFAR funds, and it dropped even further to 17 percent in 2007. It currently makes up 21.1 percent of the total budget.
 
Over $3 million (26 percent) of total PEPFAR prevention funds were allocated in 2005 to AB programs.  This jumped to 34 percent in 2006 and in 2007, there was a slight increase in funding for AB programs. It currently makes up 6 percent of the total budget and 28 percent of the prevention budget.     
 
For OP funding, over $2 million (17 percent) of total PEPFAR funds were allocated in 2005. OP funds slightly increased the following year to over $2.5 million (23 percent) of total PEPFAR prevention funds and has remained constant in 2007 ever since.  It currently makes up only 3.9 percent of the total budget and 18 percent of the prevention budget.
 
Prevention Programming
 
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population, and programs addressing correct and consistent condom use most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding.

The ABC approach under PEFPAR emphasizes behavior change, “including delay of sexual debut; mutual faithfulness and partner reduction for sexually active adults; and correct and consistent use of condoms by those whose behavior places them at risk.”[35] General populations receive an AB-based approach, while only high-risk populations receive a fully integrated ABC message that addresses condom use as well as abstinence.
 
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP).  The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP. This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR's overall impact on prevention programming in the country.

Haiti’s 2007 PEPFAR Country Operation Plan indicates that there were five providers that received AB funding, six providers that received AB and OP funding, and three providers that received OP-only funding. AB programs were intended to reach an audience of 568,650 people and OP programs were intended to reach an audience of 2,927 people; less than 1 percent the amount of reach of AB programs. 
 
The following is a list provided of PEPFAR grantees receiving prevention funding as reported by the Office of Global AIDS Coordinator in the 2007 Country Operational Plan for Haiti. This list indicates whether grantees received only Abstinence-only/Be-faithful (AB) funding, only Other Prevention (OP) funding or both. While there is a summary of funding projections available through 2008, the breakdown of funding according to recipient and amount granted in the full Country Operational Plan is only available for 2007.[36]
 
Organizations that received AB funding:
  • American Red Cross
  • Food for the Hungry
  • World Concern
  • World Relief Corporation
  • World Vision International
 
Organizations that received AB and OP funding:
  • Academy for Educational Development
  • Education Development Center
  • Foundation for Reproductive Health and Family Education
  • Johns Hopkins University Center Communications Programs
  • Management Sciences for Health
  • PLAN International
 
Organizations that received OP funding:            
  • Population Services International
  • Promoteurs Objectif Zéro Sida
  • U.S. Agency for International Development      
 
The main provider of AB-only programs in 2007 was World Vision International at $597,006.  Part of World Vision’s abstinence-only activities includes creating clubs of abstaining youth aged 10–24. These youth are encouraged to delay their sexual debut and monitor their sexual behavior. Sexually active youths who are not yet married will be encouraged and motivated to practice secondary abstinence for at least one year. Additional clubs have been created for faithful spouses married under 24 and clubs for parents to, “support and promote positive traditional norms of behavior that will help them traverse the risks they face in their daily lives—reminding youth to keep their promise [of abstinence].”[37]
 
Many AB programs are administered by faith-based organizations (FBO).  In addition, Haitian FBOs collaborated with other U.S. agencies in 2006 to form a faith-based alliance called the “Alliance” to scale up prevention, palliative care, and support to orphans and vulnerable children.  As part of its activities, the Alliance planned to use two curricula, Facing AIDS Together and Choose Life, to promote secondary abstinence among survivors of sexual assault.[38]  In conjunction with other FBOs, the Alliance conducts AB programs called “Abstinence and Be Faithful for Youth (ABY)” in schools, churches, and community centers in conjunction with other FBOs.
 
Johns Hopkins University Center for Communication Programs was the largest grantee that provided both AB and OP programs in 2007 at approximately $750,000 in funding. As part of its OP activity, Johns Hopkins ran a media campaign through 25 community radio stations and 4 TV stations to reinforce ABC messages that are estimated to reach 750,000 people. The details of the media campaign are not listed in the Country Operational Plan. Special targeting of messages to men, youth, and the general population were to be carried out with a focus on protecting girls and young women, given the “feminization” of HIV/AIDS in Haiti.[39]
 
The top OP-only provider in 2007 was Population Services International at $625,000. Population Services International mainly provides condom outlets, distribution, and a condom marketing social campaign.[40]  The targeted goal was to distribute 6 million male condoms and 50,000 female condoms to retail outlets and hopes to reach 50,000 individuals through community outreach.
 
There was one AB program and six OP programs that promoted correct and consistent condom use in 2007. World Concern’s AB program included correct and consistent condom use in its “awareness curriculum, educational methods, counseling techniques and motivational interviewing” in addition to teaching it in its “220 full training sessions each lasting two days, with an average of 25 participants for a total of 5,500 participants.”[41]  The six OP programs that promoted correct and consistent condom use ranged from using mass media to deliver the message in educational shows on TV and radio (Johns Hopkins University) to ensuring that evidence-based prevention incorporated correct and consistent condom use (Academy for Educational Development).[42]
 
Items of Note: Hunger, Poverty and Prevention
 
Haiti is one of the poorest countries in the Western Hemisphere with the average income amounting to less than $3 dollars a day.[43] The situation is even worse in rural areas where poverty and lack of resources is even higher. This extreme poverty, combined with ongoing political and civil unrest, has made food insecurity a real issue for the Haitian population. According to the World Food Program, chronic malnutrition is widespread with food supply meeting only 55 percent of Haitians’ need. While several international aid organizations help to supply food to Haiti’s population, this lack of food security has several implications for implementing PEPFAR’s prevention, care, and treatment strategies. 
 
In 2006, PEPFAR released Policy Guidance on the Use of Emergency Plan Funds to Address Food and Nutrition Needs. The guidance details when PEPFAR funds can and cannot be used to supply food and nutrition to vulnerable populations and people living with HIV/AIDS (PLWHA). The guidance, while acknowledging the need to provide food support to Haiti, focuses mainly on the needs of those in AIDS treatment and care programs. The guidance makes little to no mention of the impact that food insecurity may have on HIV prevention for the larger population, particularly for certain vulnerable groups such as women and girls.
           
A lack of food security has an impact far beyond a lack of nutrition. It works in conjunction with other social and cultural issues that increase risk of HIV infection among women and girls—like lack of education, transactional sex, and lack of property rights.  Once HIV/AIDS strikes a household, women and girls bear the double burden of not only producing food and domestic work but also taking care of the sick. This means that girls are often withdrawn from schools and may even have to engage in transactional sex in order to obtain food and other goods to sustain the family.  Women and girls who are withdrawn from school lack skills that can help them to be financially independent and therefore their only means of survival may be an inequitable marriage in which they cannot negotiate safe sex or the fidelity of their husbands.  Clearly, as we are seeing in Haiti and across the world, the HIV/AIDS epidemic disproportionately impacts women and girls.
           
Beyond prevention, food insecurity has an impact on treatment and care as well. PEPFAR guidance recognizes the biological (i.e. nutritional needs) link between these, but stops short of considering the social and economic impact of food insecurity on people living with HIV/AIDS. Recent reports from PEPFAR focus countries indicate that people are selling their antiretroviral medication to obtain food for themselves and their family.[44] The need for food among people with HIV is critical to staying healthy while on ART.  In fact, HIV-positive individuals require 20–30 percent more calories than HIV-negative individuals of the same age and sex. Unfortunately, PLWHA usually get less food. In Haiti, a study found that HIV-positive patients were 12 times more likely to have gone a day without eating than HIV-negative individuals.[45]
           
Moving forward, PEPFAR needs to reexamine its food and nutrition guidance to include efforts that incorporate reducing food insecurity as a prevention strategy at the country level by loosening its restrictions on the use of food and nutrition funds for HIV-positive and vulnerable individuals. As a Haitian proverb says, “Giving drugs without food is like washing your hands and drying them in the dirt.”  Unless PEPFAR begins to consider the root causes of illness and risk of disease, there is very little chance of reducing the HIV/AIDS epidemic in impoverished countries like Haiti.
 
Recommendations
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Law-makers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
 
 
1.  Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
 
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion.  As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
 
 
2. Increase Transparency of PEPFAR Prevention Funds
           
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data  in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement,  OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession. 
 
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
 
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
 
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
 
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.  
 
4.  Rescind the Anti-Prostitution Pledge
 
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable.  The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
 
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
 
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease.  However, such segmentation has also led to too narrow a framework/conceptualization.  Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the  opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
 
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground. 
 
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
 
6.  On-the-Ground Monitoring of Funded Activities
 
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways.  Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming.  PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs.  We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
 
7.  Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
 
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 
 


[1] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY) accessed 4 August 2008,
[2] Epidemiological Country Profile on HIV and AIDS: Haiti 2008 Update, World Health Organization, UNAIDS (New York, NY), accessed 13 August 2008,
[3] Ibid.
[4] Rapport National de Suivi de la Declaration D’Engagement sur le VIH/SIDA (UNGASS) Haiti 2007, Janvier 2008, Programme National de Lutte contre le VIH/SIDA, Republique D’Haiti, accessed 13 August 2008, http://data.unaids.org/pub/Report/2008/
[5] Caribbean AIDS epidemic update Regional Summary (New York, NY: UNAIDS), accessed 13 August 2008, http://data.unaids.org/pub/Report/2008/5
[6] 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles G-L, (New York, NY: UNAIDS), accessed 6 June 2008,
[7] Ibid.
According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
[8] Ibid.
[9] Fact Sheet: Stats on Haiti, (New York, NY: UNICEF), accessed 6 June 2008, http://www.unicef.org/media/media_19596.html
[10]2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY) accessed 4 August 2008, http://data.unaids.org/pub/GlobalReport/2008/229
[11] Ibid., 230
[12] Ibid., 232
[13] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 5 August 2008
[14] Ibid., 305
[15] Ibid., 311
[16] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 5 August 2008, http://www.unfpa.org/swp/2007/86
According to UNFPA, “Modern or clinic and supply ­methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.” 
[17] Chaya, Nada and Sarah Haddock. Condoms Count: Meeting the Need in the Era of HIV/AIDS, Appendix 1, 2006 Update – Why Condoms Count: Indicators of Vulnerability to HIV/AIDS, Population Action International (2006), Washington DC, accessed on 5 June 2008, http://www.populationaction.org/Publications/Reports/
[18] Monitoring ICPD Goals – Selected Indicators, 89
[19] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 5 August 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 15
[20] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[21] Ibid., 292
[22] Ministère de la Santé Publique et de la Population, Plan Strategique National Pour La Prevention el le Controle des IST et du VIH/SIDA en Haiti 2002-2006, March 2002.
2002-2006
[23] Rapport National de Suivi de la Declaration D’Engagement sur le VIH/SIDA
[24] 2008 Report on the Global AIDS Epidemic Annex 2,296
[25] Ibid., 311
[26] Ibid., 301
[27] Ibid., 304-305
[28] Ibid., 277
[29] Epidemiological Country Profile on HIV and AIDS, 12-13
[30] Haiti FY 2004 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC), accessed 8 August 2008,
http://foia.state.gov/COP/haiti04.pdf 
[31] Haiti FY 2005 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC), accessed 8 August 2008,
http://foia.state.gov/COP/haiti05.pdf 
[32] Haiti FY 2006 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC), accessed 8 August 2008,
http://foia.state.gov/COP/haiti06.pdf 
[33] Approved Funding by Program Area: Haiti: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC), accessed 6 June 2008,
[34] Approved Funding by Program Area: Haiti: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC), accessed 14 August 2008, http://www.pepfar.gov/about/opplan08/102032.htm
[35] Defining the ABC Approach, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 10 July 2008,
[36] Haiti FY 2007 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 10 July 2008, http://www.pepfar.gov/documents/organization/103933.pdf
[37] Ibid., 59
[38] Ibid., 174
[39] Ibid., 136
[40] Ibid., 120
[41] Ibid., 65-66
[42] Ibid., 135, 110-111, 115, 120, 128, 140
[43] Epidemiological Country Profile on HIV and AIDS, 4
[44] Okwemba, Arthur. Black Market Dispenses HIV Drugs and Risk: Treatment’s Cost and Stigma Force Some Kenyans to Take Their Chances, The Center for Public Integrity (30 November 2006), Washington DC, accessed 6 June 2008, http://www.publicintegrity.org/aids/report.aspx?aid=804.
[45] Food, Water and Housing, Partners in Health, Washington DC, accessed 6 June 2008, http://www.pih.org/issues/foodwaterhousing.html.
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