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2008 PEPFAR Country Profile Updates: Ethiopia


 
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 Ethiopia.  Click Here to Read Ethiopia's 2005 Original 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
 
Ethiopia is one of the countries hardest hit by HIV/AIDS. The first AIDS cases were reported in 1986. Overall prevalence has remained relatively low around 2 percent; prevalence in urban areas has stabilized around 8 percent while rural areas are around 1 percent.[1] Fewer than one million people are living with HIV in Ethiopia, including 90,000 children under the age of 15.  It is estimated that 67,000 adults and children died from AIDS-related illnesses in 2007. In addition, there are 650,000 children who have been orphaned by the epidemic.[2]  
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Ethiopia.  These statistics are pulled out in greater detail following the chart.
 
 
A PORTRAIT OF ETHIOPIA IN NUMBERS
 
Total population (2006)[3]
77,431,000
Percentage of the population under the age of 24
N/A
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2006)[4]
$810
Per capita total expenditure on health (Int’l$, 2004)[5]
$12
Secondary school enrollment rate (2007)[6]
24% Females
38% Males
Estimated number of people ages 15 and over living with HIV (2007)[7]
890,000
HIV prevalence in people ages 1549 (2007)[8]
2.1%
HIV prevalence in people ages 1524 (2007)[9]
1.9% Female upper estimate
0.7% Male upper estimate
 
1.1% 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 1524 who have had sex before age 15 (2005)[10]
16% Females
2% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2005)[11]
<1% Females
3% 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 (2005)[12]
24% Females
52% Males
Contraceptive prevalence rate (2004)[13]
Any method: 8%
Modern: 6%
Percentage of couples using condoms for family planning (2005)[14]
0.3%
Number of births per 1,000 women ages 1519(20052010)[15]
82
Percentage of females (20–24) who have given birth by age 18 (2005)[16]
24%
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 (2005)[17]
21% Females
33% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[18]
70%
 
Heterosexual transmission accounts for nearly 87 percent of all HIV infections in Ethiopia.[19] This underscores the disproportionate impact the disease has on women as women are at a higher risk of contracting HIV/AIDS due to biological, socio-economic, and cultural reasons.  In Ethiopia today, women account for over half of all people infected with HIV.
 
It is estimated that by 2005, as many as 130,000 Ethiopians had died from HIV/AIDS, and the U.S. Centers for Disease Control and Prevention (CDC) reports that that if trends continue, as many as 1.8 million people in Ethiopia will have died from HIV/AIDS complications by the end of 2008.[20] Underlying the HIV/AIDS epidemic in Ethiopia are factors such as poverty, illiteracy, stigma, and discrimination of people living with HIV/AIDS (PLWHA), widespread commercial sex work, gender disparities, and harmful cultural and traditional practices.[21] 
 
The Ethiopian government began responding to the HIV/AIDS epidemic in 1985 by establishing a National Task Force on HIV in the Ministry of Health. Subsequently, two Medium Term Prevention and Control plans were created between 1987 and 1996; however they had little impact on the epidemic. The National AIDS Prevention and Control Council was established in 2000 and eventually evolved into the HIV/AIDS Prevention and Control Office (HAPCO). Since then HAPCO has been responsible for the coordination and implementation of the government’s activities, including the National Strategic Framework, (NSF 2001–2005), the Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response (2004–2008), and the National Universal Access process that set national targets for non-health sectors for 2007–2010.[22]  Together these plans guide the current Ethiopian response to the HIV/AIDS epidemic.
 
Current efforts are framed around the mission, “To prevent and control the spread of HIV/AIDS and reduce its impact through intensified, result-oriented large-scale comprehensive programs with active participation or all partners and with special focus on social mobilization and community empowerment.”[23] This is drawn from the 2004–2008 Response, and is based on guiding principles such as multi-sectoralism, gender sensitivity, and involvement of people living with HIV/AIDS (PLWHA).
 

Key Objectives of NSF 20042008
 
1. Increase primary health service coverage from 60% to 80% and enable the facilities to provide HIV/AIDS related preventive, care and treatment services
2. Staff 80% of health institutions as per the national standard
3. Integrate HIV/AIDS education into the curriculum of all levels of schools
4. Ensure execution capacity of communities and association leaders in effectively managing grassroots response
5. Protect the legal and human rights of individuals infected and affected by HIV/AIDS

 
In 2001, Ethiopia participated in the United Nations General Assembly special session on HIV/AIDS (UNGASS) and signed the declaration of commitment to fight the epidemic. In 2006, HAPCO evaluated Ethiopia’s response under the UNGASS commitment up to that point. HAPCO reported that, “In conclusion it can be stated that the national HIV incidence rate in Ethiopia is leveling off…and the epidemic appears to be stabilizing particularly in urban areas, indicating some behavioral change in the population.”[24] However, according to the 2005 UNGASS Report, there is still a lot of work to be done in order to effectively combat HIV/AIDS in Ethiopia.
 
For example, while 97 percent of Ethiopians are aware of HIV/AIDS, only 24.8 percent answered questions about HIV-prevention methods correctly.[25] Among individuals who stated they had had sex in the last 12 months with a non-marital, non-cohabitating partner, only 23.6 percent of women and 51.9 percent of men aged 15–24 stated they used a condom.[26] Unfortunately, this rate is higher than the most recent data provided by the Joint United Nations Programme on HIV/AIDS (UNAIDS) which notes that only 14.6 percent of women and 36.1 percent of men reported using a condom the last time they had sex with a casual partner.  Overall, UNGASS reports that Ethiopia’s information, education, and communication prevention programs, which focus on positive behavior change, have not been properly coordinated.
 
Prevention of mother-to-child transmission (PMTCT) services have been increased from 12 centers in 2002/3 to 184 centers by the end of 2007. However, PMTCT has also been constrained by lack of access to voluntary counseling and testing (VCT) programs and lack of adequate care and support services for mothers and families living with the virus. In 2008, only 6.5 percent of HIV-positive pregnant women received antiretroviral therapy (ART) to reduce mother-to-child transmission.[27] Further, it is estimated that over 250,000 people who are currently living with HIV/AIDS are in need of ART.[28] According to UNGASS, VCT and PMTCT programs have also had challenges linking their recipients to care and support programs. 
 
Thus, while efforts to respond to the HIV/AIDS epidemic have resulted in a lower prevalence rate, there is still much work to do. Ethiopia’s multi-sectorial plan for 2004–2008 will cost around 6 Billion Birr, over $650 million to implement.[29] The Ethiopian government currently devotes 17 percent of its national budget to the expense. However, there is still a gap in funding. In order to bridge this gap, Ethiopia receives funds from the World Bank, Global Fund, and the President’s Emergency Fund for AIDS Relief (PEPFAR) as well as other bilateral and unilateral partners.[30]
 
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
 
Ethiopia is one of the more well-funded countries under PEPFAR. Since its initial allocation of just under $48 million, funds have been substantially increased each year.  Ethiopia’s 2008 allocation under PEPFAR is over $275 million, nearly six times what it was in 2004.

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 2004–2008*
 
 
2004[31]
2005[32]
2006[33]
2007[34]
2008[35]
Total Funds Allocated**
$47,986,420
$72,639,823
$108,955,747
$214,280,459
$277,521,051
Total Prevention Funds Allocated
N/A
$18,799,607
$22,609,238
$39,579,535
$61,710,684
Total AB Funds Allocated
N/A
$4,554,341
$7,408,381
$12,306,339
$16,861,598
Total Other Prevention Funds Allocated (includes condom programming)
N/A
$4,107,400
$6,241,000
$13,929,000
$19,409,822
Total Treatment Funds Allocated
N/A
$39,084,549
$54,382,700
$112,144,160
$138,803,760
Total Care Funds Allocated
N/A
$14,755,667
$31,963,809
$62,556,764
$77,006,607
* 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.
 
While care was initially the least funded area, prevention now holds this unfortunate position. In 2006, prevention funding received just over 20 percent of overall funding and then went down to just 19 percent in 2007.  It now consists of 22.2 percent of the total budget in 2008. Treatment receives by far the most funding, about 50 percent of overall funds in 2008. 
 
Prevention funds in Ethiopia support programs which focus on maintaining no/low risk behavior among the general population.  The programs are intended to reduce risk behaviors among those populations most at risk in order to reduce sexual transmission of HIV, mother-to-child transmission, and medical transmission through unsafe injections or blood supplies.[36] 
 
PEPFAR promotes an ABC prevention message, which means: Abstain, Be-Faithful, and Correct and Consistent Condom Use. Abstain/Be-Faithful (AB) programming utilizes an AB message, while Other Prevention (OP) programs includes AB messages as well as those that address correct and consistent condom use (ABC).  The following chart details the allocated funds from PEPFAR to the different programs.
 
In 2006, AB programs received the majority of the PEPFAR prevention funds. However, in 2007 and 2008, OP programs were allocated the most prevention funding, making Ethiopia, along with Vietnam, one of only two countries out of the fifteen PEPFAR-focus countries where OP is the most funded prevention area. 
 
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.”[37] General populations receive an AB 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.

According to PEPFAR’s 2007 Country Operational Plan for Ethiopia, there were a total of 21 AB programs, targeting 15,920,395 people.[38] In contrast, there were a total of 22 OP programs, targeting 4,169,339 people, about one-fourth the amount of people targeted by AB programs. The ability to reach more individuals with AB programs with less money, despite the overwhelming evidence demonstrating that abstinence-until-marriage programs are not effective, is an argument often employed by AB promoters.
 
The 2006 COP for Ethiopia set a target of reaching 8,300,000 people (or roughly 11 percent of the entire population) through activities that promote condoms and related prevention services. Unfortunately, this target number was slashed in half for 2007.  In contrast, the target audience for isolated messages of abstinence in 2007 was nearly 12,000,000 or 15 percent of the population.
 
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 Ethiopia. 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.
 
Organizations that received AB funding:

  • Catholic Relief Services
  • Federal Ministry of Health, Ethiopia
  • Food for the Hungry
  • International Orthodox Christian Charities
  • Samaritan’s Purse
  • World Learning

 
Organizations that received AB and OP funding:

  • ABT Associates
  • Addis Ababa University
  • EngenderHealth
  • Family Health International
  • Federal Police
  • Ministry of National Defense, Ethiopia
  • International Rescue Committee
  • Johns Hopkins University Center for Communication Programs
  • Save the Children US
  • Management Sciences for Health
  • Pact, Inc.
  • Population Council
  • United Nations High Commissioner for Refugees
  • US Agency for International Development
  • Young Men Christian Association

 
 
Organizations that received OP funding:

  • Columbia University 
  • Johns Hopkins University Bloomberg School of Public Health
  • Ethiopian Public Health Association
  • Population Services International
  • University of California at San Diego
  • University of Washington
  • USAID Central Commodity Fund

 
 
The main provider of AB-only programs in 2007 was International Orthodox Christian Charities (IOCC) at $635,000 and set to reach 7 million people.[39] According to the IOCC, there are 40 million members of the Ethiopian Orthodox Church or about half of the population; the IOCC delivered AB messages throughout 100 districts in 20 Dioceses to millions of people. The IOCC primarily focuses on “care for those affected or living with HIV/AIDS, promote abstinence and faithfulness and reduce stigma and discrimination” through peer education and Sunday school programs, and public rallies.[40]
 
The main provider of both AB and OP programs in 2007 was Johns Hopkins University Center for Communication Programs at $2,475,000. Johns Hopkins received a total of $1,612,500 in AB funding and $862,500 in OP funding.[41] Within AB programming, Johns Hopkins implemented strategies to promote abstinence and being faithful in addition to promoting people to care for others living with HIV/AIDS (PLWHA), care for children orphaned by the epidemic, to reduce stigma against PLWHA, and lastly adopt HIV prevention behaviors. Some programs use drama, sports, and storytelling in youth-oriented programs such as in the Youth Action Kit (YAK), Sports for Life (SFL), and Beacon Schools (BCS) programs.[42] 
 
Save the Children U.S. was another provider receiving both AB and OP funding and in 2007 they received $300,000 for AB programs and another $300,000 for OP programs. The AB programs specifically targeted high-risk groups such as in/out of school youth, transportation workers, and bar/hotel based commercial sex workers with AB-only messaging.[43] In 2006, in-school counseling services run by Save the Children were able to provide AB-only counseling to 54,933 girls and an additional 12,000 girls were given abstinence-only counseling. Save the Children’s most recent AB program engages youth ages 14–19 in school-based abstinence-only programs. These school-based programs refer young people who report having engaged in sexual intercourse to AIDS Information Centers that Save the Children operates and has previously established. Furthermore, Save the Children does Be Faithful-only outreach to males residing in targeted communities within the high-risk corridor.  The high-risk corridor refers to a busy transportation corridor originating in Addis Ababa all the way to the border with Djibouti. Along the corridor 24 peri-urban and urban areas have AIDS Information Centers and additional HIV prevention outreach activities to transport workers, commercial sex workers, and in/out of school youth. In 2007, Save the Children planned to continue these existing counseling services that they provided for schoolgirls in this high-risk corridor area. Save the Children planned on conducting ABC counseling services and programs that make condoms accessible in commercial sex trafficking areas in 2007.[44] While in theory the practice of referral appears to cover the need regarding access to and information on condoms, it is unclear how successful the referrals have been. In the same vein, targeting condom distribution to a select population means that other populations are left without adequate accessibility. 
 
 
The main provider of OP programs in 2007 was the University of Washington at $450,000.[45] The University of Washington operated at 31 public and private hospitals in the Amhar, Tigrai, and Afar regions. The University provided mainly treatment and care in their OP work, including facilitating and coordinating linkages between STI and HIV/AIDS services, and providing condoms and education on usage. In 2007, 31 outlets were targeted to distribute condoms and 200 counselors were trained to promote HIV/AIDS prevention beyond abstinence and/or being faithful.[46]
 
 
 
In 2007, only two AB and two OP programs addressed correct and consistent condom use. It is not typical for an AB provider to deliver AB messages that include correct and consistent condom use, although the ABC Guidance provided by OGAC does permit it. Management Sciences for Health received $700,000 in AB funding and supported HIV prevention efforts of local government agencies in Ethiopia to provide accurate correct and consistent condom information.[47]   Family Health International, received $200,000 in AB funding and $350,000 in OP funding, to distribute and promote condoms, including providing education on correct and consistent condom use.[48] Finally, the International Rescue Committee received $30,000 in OP funding to deliver correct and consistent condom use messages in refugee camps.[49] 
 
 
Items of Note: Child Marriage
 
A particular area of concern in the HIV/AIDS epidemic fight in Ethiopia is child marriage.  Child marriage is commonly defined as any marriage that occurs before the age of 18.[50] The Universal Declaration of Human Rights (1948), the United Nations (UN) Convention on the Elimination of All Forms of Discrimination Against Women (1979), the UN Convention of the Rights of the Child (1989) and the African Charter on the Rights and Welfare of the Child (1990) all provide for protections against child marriage.[51] However, despite these measures, child marriage is still a prevalent practice. Population Council reports that if continued at its current rate, over 100 million girls worldwide will be married before the age of 18 within the next ten years.[52] 
 
Ethiopia has one of the highest rates of child marriage in the world. While the legal age of marriage is 18 for both males and females, statistics show that this is often ignored. Nationwide, 19 percent of girls are married by age 15, and about 50 percent are married by age 18.[53] In regions where the practice is extremely prevalent, such as the Amhara region, as many as 50 percent of girls are married by age 15 and 80 percent by age 18.[54] In addition, there are many other harmful cultural practices in Ethiopia, including marriage by abduction, forced unions between cousins, and female genital circumcision. [55]
 
Child marriage can have many negative effects, most significantly on the young girls who are forced to marry. For example, child brides are often less educated. In fact, in Ethiopia, just 3 percent of married girls ages 15–19 are in school, compared with 34 percent of unmarried girls.[56] In addition, a husband is often much older than his bride. In Ethiopia the mean age difference between spouses is just over ten years if the wife marries before age 15.[57] Marrying an older man can carry health consequences including physical and psychological harm. For example, the younger the bride the more likely it is that she has never engaged in sexual intercourse. For most of these girls sexual initiation may be unwanted and traumatic; 69 percent of married girls (age range unknown) report having sex before receiving their period and 81 percent of married girls state that it was forced.[58]  
 
In addition, differences in age, as well as socioeconomic status, can have an effect on condom use. There is often no way for these girls to negotiate condom use. Interviews with married girls in Ethiopia revealed that 86 percent were not able to refuse sex with their husbands and at least 12 percent were afraid of contracting HIV as a result.[59] The Amhara region, where child marriage is extremely common, is also reported as having the highest rates of HIV among pregnant women in the entire country.[60]
 
As many as 94 percent of sexually active Ethiopian girls are married.[61] It is also important to note that it is in marriage where these women often face an increased risk of contracting HIV/AIDS, and offering young women and girls a message telling them to Abstain and/or Be-Faithful may be of little realistic value.  Child marriage has other reproductive health consequences as well. For example, young brides often bear children at young ages which can carry long-lasting health consequences such as those associated with obstetric fistula.[62] Finally, many women attempt to avoid child marriage by leaving their families and villages,   and often end up taking exploitative jobs, such as commercial sex work, in order to survive.[63]
 
Child marriage is a problem worldwide, and Population Council reports that it is prevalent in South Asia, Latin America, and many sub-Saharan African countries—many of the same areas which currently receive PEPFAR funds. The negative consequences that the practice can have on young women are numerous and include an increased risk for contacting HIV. In order to adequately prevent future transmission of HIV/AIDS, the Office of the Global AIDS Coordinator (OGAC), which is responsible for implementing PEPFAR, must also work to combat the prevalence of child marriage. Moreover, because marriage itself can present a risk for HIV transmission, an AB message for youth is simply not enough. Instead, it is vital that all people are also taught how to effectively use and negotiate condom use in order to best protect themselves from HIV/AIDS.
 
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 (COPs). A great deal of evidence has emerged from individual countries that suggests that the COPs are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, COPs 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 UNAIDS Report: Report on Progress towards Implementation of the UN Declaration of Commitment on HIV/AIDS, National HIV/AIDS Prevention and Control Office (HAPCO), (Addis Ababa, Ethiopia), accessed 23 June 2008, http://data.unaids.org/pub/Report/21
[2] 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,
[3] 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles, UNAIDS, (New York, NY), accessed 19 May 2008,
[4] Ibid., 33
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.”
[5] Ibid., 33
[6] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 5 August 2008, http://www.unfpa.org/swp/ 86
[7] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[8] Ibid., 215
[9] Ibid., 217
[10] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 5 August 2008
[11] Ibid., 305
[12] Ibid., 311
[13] Monitoring ICPD Goals – Selected Indicators, 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.” 
[14] Condoms Count 2006 Update, Population Action International, accessed 23 June 2008, http://www.populationaction.org/ 2
[15] Monitoring ICPD Goals – Selected Indicators, 86
[16] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 5 August 2008, http://www.prb.org/pdf06/ 13
[17] 2008 Report on the Global AIDS Epidemic Annex 2, 295
[18] Ibid., 292
[19] Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response (2004-2008), Addis Ababa, Ethiopia, December 2004, 10, accessed 23 June 2008,
[20] “The Emergency Plan in Ethiopia,” Centers for Disease Control (CDC), http://www.cdc.gov/nchstp/od/gap/countries/ethiopia.htm.
[21] 2008 UNAIDS Report: Report on Progress towards Implementation of the UN Declaration of Commitment on HIV/AIDS, 54
[22] Ibid., 33
[23] Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response
[24] 2008 UNAIDS Report: Report on Progress towards Implementation of the UN Declaration of Commitment on HIV/AIDS, 92
[25] Ibid., 17
[26] Ibid., 27
[27] Ibid., 17
[28] Ibid., 45
[29] Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response 44
[30] “Summary Profile for HIV/AIDS Treatment Scale-Up: Ethiopia,” World Health Organization, accessed 13 August 2008, http://www.who.int/3by5/support/june2005_eth.pdf.
[31] Ethiopia 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/ethiopia04.pdf  
[32] Ethiopia 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/ethiopia05.pdf  
[33] Approved Funding by Program Area: Ethiopia: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 8 August 2008, http://www.pepfar.gov/about/77677.htm
[34] Approved Funding by Program Area: Ethiopia: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 8 August 2008, http://www.pepfar.gov/about/82466.htm 
[35] Approved Funding by Program Area: Ethiopia: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 8 August 2008, http://www.pepfar.gov/about/opplan08/102034.htm
[36] Ethiopia 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 11 August 2008, http://www.pepfar.gov/documents/organization/103931.pdf
[37] 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 19 May 2008,
[38] Ethiopia FY 2007 Country Operational Plan (COP), 92
[39] Ibid., 123-125
[40] Ibid., 123
[41] Ibid., 212, 216, 283 (in order)
[42] Ibid., 143
[43] Ibid., 111
[44] Ibid., 224
[45] Ibid., 271, 282
[46] Ibid., 272-273
[47] Ibid., 115-116
[48] Ibid., 163, 260
[49] Ibid., 269
[50] Nicole Haberland, Supporting married girls: Young wives and young mothers, (New York: Population Council, May 2005).
[51] Erica Chong and Nicole Haberland, Child Marriage: A cause for global action, (New York: Population Council, October 2005).
[52] Child Marriage Briefing: Ethiopia, (New York: Population Council, July 2004).
[53] Ibid.
[54] Ibid.
[55] Ibid.
[56] Ibid.
[57] Ibid.
[58] Annabel Erulkar and Tekle-Ab Mekbib, Reaching vulnerable youth in Ethiopia, (New York: Population Council, May 2005) accessed 26 June 2008,
[59] Ibid.
[60] Child Marriage Briefing: Ethiopia.
[61] Ibid.
[62] Ibid.
[63] Erulkar and Mekbib, “Reaching vulnerable youth.”
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