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2008 PEPFAR Country Profile Updates: Botswana


 
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 the 15 focus countries of Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

 
(The following is a 2008 update to the status of PEPFAR funding and related issues in Botswana.
 
 
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. 
 
Overview
 
Botswana is a landlocked country with one of the smallest populations in Africa—less than 2 million—making the impact of the HIV/AIDS epidemic especially magnified among those living in the country. Its first AIDS case was reported in 1985 and since that time the prevalence of HIV has risen drastically from 5 percent in 1990 to 25 percent in 2000.[1] Botswana has the highest HIV prevalence of all of the PEPFAR focus countries and the second highest HIV prevalence in the world at 23.9 percent (only Swaziland is higher at 26.1 percent).[2] While data show that HIV prevalence is slowly decreasing this is a result of an increasing population.  In fact, the actual number of people living with HIV is gradually increasing.[3]  
 
Life expectancy in Botswana is currently 52 years of age.[4] It is estimated that 280,000 adults and 20,000 children were living with HIV in 2007.[5] The number of people dying from AIDS-related illnesses peaked in 2002–2003 at 18,000 and has dropped substantially to 11,000 this past year.[6] In addition, there are currently 95,000 children who have lost one or both parents to the disease.[7] 
 
Women in Botswana are three times more likely to be living with HIV than men. According to data derived from HIV surveillance, which is conducted at regular intervals among select sub-population groups, as recently as 2006 pregnant women have a median HIV prevalence of 38.9 percent in urban areas and 32.6 percent in rural areas.[8] This means that more than one out of four pregnant women have HIV which can contribute to both mother-to-child transmission of HIV and the number of orphaned and vulnerable children impacted by the epidemic in Botswana. 
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Botswana. The stories behind these statistics are fleshed out in greater detail following the chart.
 
 
A PORTRAIT OF BOTSWANA IN NUMBERS
 
Total population (2005)[9]
1,765,000
Percentage of the population under the age of 24
59%
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005) [10]
$8,920
Per capita total expenditure on health (Int’l$, 2005) [11]
$218
Secondary school enrollment rate (1999–2005)[12]
77% Females
73% Males
Estimated number of people ages 15 and over living with HIV (2007)[13]
280,000
HIV prevalence in people ages 15–49 (2007)[14]
23.9%
HIV prevalence in people ages 15–24 (2007)[15]
20.8% Female upper estimate
7.9% Male upper estimate
 
10% Female lower estimate
2.1% Male lower estimates
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 (2007)[16]
N/A
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2007)[17]
N/A
Percentage of women and men ages 15–49 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse (2007)[18]
N/A
Contraceptive prevalence rate (2004)[19]
40% Any method
39% Modern methods
Percentage of couples using condoms for family planning (2005)[20]
11.2%
Number of births per 1,000 women ages 15–19 (2005–2010)[21]
71
Females (20 – 24) who have given birth by age 18 (2005)[22]
N/A
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 (2003)[23]
28% Females
N/A Males
Schools with teachers trained in life-skills-based HIV/AIDS education who taught this during the last academic year (2007)[24]
100%
 
The continued high prevalence of HIV in Botswana is alarming, particularly since Botswana was one of the first African countries to make a concerted effort—both in programming and in funding allocation—to address the epidemic. Early on Botswana focused most of its HIV/AIDS resources on screening blood products to eliminate risk of transmission through transfusion. However, as it became clear that the main risk of transmission in Botswana was through heterosexual sexual contact, Botswana shifted its focus to education and behavior change communication programs and eventually to the provision of comprehensive treatment and care for its population.
 
The country also reports a large stockpile of condoms and has improved accessibility to condoms over the years more than many other PEPFAR-funded countries. In 2007, the Central Medical Stores (CMS), a department of the Ministry of Health, had over 18 million male and over 180,000 female condoms in stock.  It had distributed over 7 million male and 86,000 female condoms in one quarter in Fiscal Year 2005, mostly to hospitals and clinics; over 50 percent were distributed for free.[25]  The United States government reported shipping roughly 11.4 million condoms from 2004–2007 to Botswana, although did not provide data on numbers distributed.[26]  
 
Botswana has one of the highest levels of access to healthcare: 100 percent of antenatal clinics provide HIV testing and counseling, over 90 percent of children receive the full complement of immunizations including DPT and Measles vaccines by their first birthday, and 94 percent of birth deliveries are done by skilled attendants.  Compared to other PEPFAR focus countries, Botswana has a relatively high contraceptive rate use, at 40 percent for any method.[27] 
 
Healthcare services specifically for people living with HIV/AIDS have improved in recent years. Botswana was the first African country that explicitly sought to provide anti-retroviral drugs to those in need. The number of sites that provide antiretroviral therapy (ART) quadrupled between 2005 and 2007, now totaling 99 and covering nearly 80 percent of those in need of ART.[28] 
 
Great strides have also been made to increase availability of prevention of mother-to-child transmission (PMTCT) services and reduce the number of pediatric HIV infections. Nearly all pregnant women in Botswana reportedly receive antenatal care and over 95 percent of HIV-positive pregnant women receive ART to prevent mother-to-child transmission.[29] This increase in coverage of PMTCT services has resulted in a dramatic decrease in numbers of infants born with HIV, from 20.7 percent in 2003 to less than 5 percent in 2007.[30] 
 
In addition to having made remarkable strides in the health care systems, Botswana has one of the highest levels of education retention and access compared to most other African nations. Over three-quarters of children are enrolled in secondary schools and 100 percent of schools provide life-skills-based HIV/AIDS education.[31] Despite these educational successes, the high HIV prevalence in the country has impacted the education system. High prevalence of HIV/AIDS among teachers impacts both the quality of education and the numbers of hours taught.  And, school enrollment is expected to fall as children drop out to “care for sick family members, to contribute to household income, or become too sick to attend school.”[32]
 
In 2001, Botswana participated in the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, a landmark meeting that created the Declaration of Commitment on HIV/AIDS. In 2003, the government began implementing the National Strategic Framework for HIV/AIDS 2003–2009 (NSF) which contains a multi-sectoral approach to addressing the epidemic. According to the NSF, prevention is the first priority of Botswana’s response to the epidemic.[33]
 
 

Key Goals of the National Strategic Framework 2003–2009
  1. Prevention of HIV Infection
  2. Provision of Care and Support
  3. Strengthened Management of the National Response to HIV and AIDS
  4. Psycho-social and Economic Impact Mitigation
  5. Provision of a Strengthened Legal System

 

Botswana has made remarkable progress towards achieving the second and third goals of the NSF. It is one of the few African countries to have instituted a national routine HIV testing policy. Routine HIV testing was introduced in all health facilities in Botswana in January 2004. While it is not mandatory, routine HIV testing was accepted by nearly 93 percent of those to whom it was offered.[34] In conjunction with this service, Tebelopele, a prominent NGO that offers free voluntary counseling and testing services (VCT), runs a national campaign Zebras for Life, Test for Life which uses the popularity of Botswana’s football team “The Zebras” to encourage HIV testing.
 
The government of Botswana recently implemented a multi–media campaign, called Make an Impression, to increase correct and consistent condom use among young people ages 15–24.[35] The campaign promotes “safe sex in every sex act” through the use of television, radio, print and outdoor advertising to convey “consistent condom” messages. The government explicitly promotes a correct and consistent condom use message because it recognizes that one of the failures to prevent HIV transmission in Botswana has been “incorrect and inconsistent condom use.”  It also promotes abstinence but acknowledges a “low acceptability of abstinence” in prevention programs.[36] In fact, the government reports that “there is still a degree of skepticism [sic] among sections of the population about the feasibility and acceptability of the abstinence agenda for sexually active adults.”[37] 
 
Though strides have been made in prevention, knowledge about HIV transmission and prevention among the general population remains low and has been slow to change.  According to the 2004 Botswana AIDS Impact Survey, the most recent nationally representative behavioral survey available, only 37.6 percent of people ages 15–24 could correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about the disease. [38]
 
Botswana has one of the stronger economies among sub-Saharan African countries and is unique in that most funding for HIV/AIDS programs comes from the National government. Despite this, the resources needed to address the epidemic far outstrip those within the country. In 2007, Botswana’s government and other domestic agencies funded roughly 88 percent of all HIV/AIDS-related expenditures.[39] International donors supplemented the remaining 12 percent including the United Nations Development Program, the World Bank, the African Comprehensive HIV/AIDS Partnership, and the United States through the President’s Emergency Plan for AIDS Relief.[40]
 
 
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
 
Botswana first received PEPFAR funding in 2004 with an initial grant of $24 million dollars. PEPFAR funding doubled in 2005 for a total allocation of slightly over $45 million and increased slightly in 2006 to just under $47 million. The funding allocation increased significantly in 2007, followed by a smaller increase the next year to reach a total allocation of $69,346,747 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 2004–2008*
 
2004[41]
2005[42]
2006[43]
2007[44]
2008[45]
Total Funds Allocated**
$24,377,740
$45,231,942
$46,951,346
$63,242,743
$69,346,747
Total Prevention Funds Allocated
N/A
$17,040,134
$15,187,416
$15,738,834
$20,141,785
Total AB Funds Allocated
N/A
$3,399,468
$5,626,043
$6,929,620
$8,415,000
Total Other Prevention Funds Allocated (includes condom funding)
N/A
$3,902,361
$2,528,695
$2,763,695
$4,028,000
Total Treatment Funds Allocated
N/A
$15,902,916
$18,527,499
$25,532,018
$23,994,962
Total Care Funds Allocated
N/A
$12,288,892
$15,236,466
$21,971,891
$25,210,000
* 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.
 
In 2008, 29 percent of PEPFAR funds in Botswana were allocated to prevention programming, 34.6 percent to treatment, and 36.4 percent to care. Although Botswana’s NSF prioritized prevention, this area receives the smallest share of the total funding allocation. Within the breakdown of the prevention funding allocation, there was an increase in both Abstinence-only/Be-faithful (AB) and Other Prevention (OP) programs, with funds for AB programs double that allocated to OP. Despite the epidemiological needs of the country and ineffectiveness of the abstinence-only message in Botswana, as acknowledged by the government of Botswana, the funding allocations prioritizing AB over OP programs remain.[46] 
 
While most countries receiving PEPFAR funds have witnessed a progressive increase in treatment funds, in 2008 Botswana was the first country to have the allocation of treatment funding decreased.  The reason behind this funding decision is not known. However, both prevention and care funds were increased. 
 
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. Programs addressing correct and consistent condom use are 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 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 the 2007 Country Operation Plan, PEPFAR funded a total of 15 organizations to implement only AB programs and 10 organizations to implement both AB and OP programs. There were no organizations funded to implement only OP activities. 
 
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 Botswana. 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.[47]
 
Organizations that received AB funding only:

  • African Methodist Episcopal Services Trust
  • Botswana Christian AIDS Intervention Program
  • Botswana Network of People Living with AIDS
  • Flying Mission
  • Hope Worldwide
  • Humana People to People Botswana
  • Kgothatso AIDS Care and Prevention Programme
  • Ministry of Education, Botswana
  • Ministry of Labor and Home Affairs, Botswana
  • Ministry of Local Government, Botswana
  • National Association of State and Territorial AIDS Directors
  • Nkaikela Youth Group
  • True Love Waits
  • Young Women’s Friendly Centre
  • Youth Health Organization of Botswana

 
Organizations that received AB and OP funding:

  • Academy for Educational Development
  • Botswana Defense Force
  • Family Health International
  • Makgabaneng
  • Ministry of Health, Botswana
  • Pathfinder International
  • Population Services International
  • The Futures Group International
  • U.S. Centers for Disease Control and Prevention
  • U.S. Peace Corps

 
Organizations that received OP funding only:
  • None
 
AB programs received $6,929,620 and targeted 122,619 individuals through community outreach.[48] The largest grantee of AB-only funds was the Ministry of Education, Botswana at $900,000 in 2007.[49] The objective of its AB program is to impart life skills that will enhance the prevention of sexually transmitted infections (STI) and HIV/AIDS among all students in primary and secondary schools in Botswana. The program developed materials that prioritize “abstinence, delayed sexual debut, and when appropriate faithfulness and partner reduction.”[50]
 
One AB grantee, True Love Waits, adopted a faith-based abstinence-only-until-marriage program from the United States for use in schools, churches, and non-governmental organizations in Botswana to “provide tailored programs for focused outreach, education, and training for youth ages 13–29 years.”[51] The program received $40,093 and was set to reach 4,006 individuals through outreach. In addition to forming abstinence-only clubs with youth and having youth make abstinence pledges, its objective is “to promote abstinence as the best and 100 percent safe prevention against HIV/AIDS, STIs, teenage pregnancy, etc. and equip young people (13–29 years) to make sound and informed decisions, concerning sexual behavior, i.e. to choose abstinence (primary or secondary virginity) until marriage.”[52] 
 
The information provided on the True Love Waits affiliated African website includes startlingly inaccurate and ideologically based statements about sexual health. For instance, True Love Waits says that there are three main reasons why safe sex is wrong: “First: the physical results - can be unwanted pregnancies, STDs and AIDS. Second: the emotional result. These often include depression, anxiety, insecurity, fear of commitment and abandonment. Third: the social problems that result from unwanted pregnancies and STDs.”[53] The following are a few examples of the answers they provide to sexual health questions:
 
What are 'safe sex' and 'safer sex'?
 
These two terms mean using condoms and spermicide. This is supposed to give some protection from pregnancy and STDs, but offers no protection from the emotional problems that result from premature sexual activity.
 
Are 'safe sex' and 'safer sex' safe?
 
AIDS/HIV transmission is possible with condoms as they are sometimes not completely safe. There are defects in some condoms.
 
What about masturbation – that’s not intercourse?
 
All sexual activity involves the mucus membranes. This means that all sexual activity may transmit the AIDS virus. With mutual masturbation which some people recommend - once you start, you become stimulated very quickly and it takes will power to stop short of actually having intercourse … Masturbation is addictive…[54]
 
The True Love Waits program, exported from the United States, continues to provide false and misleading information on sexual health to adolescents even though Botswana has the second highest HIV prevalence rate in the world paired with low levels of accurate knowledge about the HIV/AIDS epidemic.
 
OP programs received $2,763,695 and targeted 59,052 individuals through community outreach and 920 outlets to distribute condoms.[55] The largest AB and OP provider was Family Health International (FHI) at a total of $1,350,000 ($1,150,000 AB funds and $200,000 OP funds) in 2007.[56] FHI’s program, Youth are the Light, receives 80 percent AB funds and 20 percent OP funds to “address the full HIV and pregnancy prevention needs of sexually-active youth, or those who intend to be sexually-active soon.”[57] The program focuses on abstinence, partner reduction, fidelity, and related life skills. It targets adolescents ages 10–17 in selected districts all over the country.
 
Correct and consistent condom use is mentioned by only two organizations: the Botswana Defense Force and Pathfinders International.  The Botswana Defense Force’s AB and OP activity (which received $115,000 in AB funds and $85,000 in OP funds) targeted soldiers at deployment locations on a routine basis in order to emphasis correct and consistent condom use.[58] Pathfinder’s program (which received a total of $650,000: $450,000 in AB funding and $200,000 in OP funding) is split between 70 percent AB and 30 percent OP.  The OP component addresses correct and consistent condom use and holds discussions about STIs and other HIV-related services, including ART and PMTCT, with youth in peer education programs.[59]
 
 
Items of Note: HIV/AIDS and the Future Economy of Botswana
 
The direct costs involved in providing prevention, treatment, and care services for people living with HIV/AIDS is only one part of the overall economic picture.  In Botswana, the HIV/AIDS epidemic has caused a reduction in productivity as workers take time off due to illness or to care for someone living with HIV/AIDS.  Increased expenditures on health care and reduced personal savings resulting from a decrease or total loss of income takes a toll at the family level and ultimately ripples out to affect the larger community and society. 
 
Unemployment, and the subsequent need to train new members of the workforce, contributes to overall economic uncertainty. HIV prevalence differs across professions: students and officer-related professionals have a lower prevalence rate than domestic workers, laborers, store workers and farmers.[60] The construction industry has been the most adversely impacted by the epidemic: in the past five years roughly 2 percent of all skilled construction workers and 9 percent of all unskilled construction workers died from AIDS.[61]   
 
Botswana’s average real economic (GDP) growth will be reduced by up to 2.0 percent a year over the period 2001–2021, as a direct result of the HIV/AIDS epidemic. This will result in an economy that is 25 to 35 percent smaller than it would have been otherwise.[62] In addition, it is important to note that the affects of HIV epidemic on the labor force is likely to work against efforts to reduce poverty, increase economic output of the country, and increase development of industry and infrastructure.
 
With the government funding nearly 90 percent of all HIV/AIDS expenditures, the epidemic is becoming more and more costly. Routine HIV testing is now practiced in public health facilities and is paid for by the government. Since 2002, the government provides antiretroviral therapy (ART) free of charge through the public health service. It is estimated that ART and hospital admissions are the most costly; together the two will make up $125 million or 50 percent of all HIV/AIDS-related costs to the government by 2020.[63] It is projected that total costs on HIV/AIDS will increase in real terms by some 60 percent by 2021 and spending on HIV/AIDS is expected to account for nearly 8 percent of Botswana’s GDP in the next couple of years.[64] 
 
In order to maintain fiscal balance, the costs of HIV/AIDS spending will have to be met by cutting back spending in other areas unless international donors like PEPFAR increase funding to Botswana and allow those fund to be spent on the country’s own priorities.
 
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. Lawmakers 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] Epidemiological Fact Sheet on HIV and AIDS 2008 Update, UNAIDS/WHO, (New York, NY; Geneva, Switzerland), accessed 27 August 2008, http://www.who.int
[2] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY) accessed 19 August 2008, http://data.unaids.org 215
[3] Epidemiological Fact Sheet on HIV and AIDS: Botswana, 2008 Update, UNAIDS/WHO, Working Group on Global HIV/AIDS and STI Surveillance (Geneva, Switzerland), accessed 27 August 2008, http://www.who.int 5
[4] Ibid., 4
[5] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[6] Epidemiological Fact Sheet on HIV and AIDS: Botswana, 6
[7] 2008 Report on the Global AIDS Epidemic Annex 1, 218
[8] Ibid., 8
[9] 2006 UNAIDS Report: Country profiles annex 1, UNAIDS, (New York, NY), accessed 20 June 2008,
[10] Ibid., 25
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.”
[11] Ibid., 25
[12] Monitoring ICPD Goals – Selected Indicators, 84
[13] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[14]Ibid., 215
[15] Ibid., 217
[16] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 19 August 2008,http://data.unaids.org 300
[17] Ibid., 304
[18] Ibid., 310
[19] Monitoring ICPD Goals – Selected Indicators, 87
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.” 
[20] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY) accessed 19 August 2008,
[21] Monitoring ICPD Goals – Selected Indicators, 87
[22] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC), accessed 5 August 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 13
[23] 2008 Report on the Global AIDS Epidemic Annex 2, 296
Most Recent Data Available
[24]  Ibid., 292
[25] Botswana HIV/AIDS Response Information Management System (BHRIMS), National AIDS Coordinating Agency (NACA), January to March Report, May 2005 (Republic of Botswana), accessed 27 August 2008, http://www.naca.gov.bw 15-17
[26] 2008 Country Profile: Botswana, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC), accessed 27 August 2008, http://www.pepfar.gov/documents/organization/81656.pdf
[27] Botswana HIV/AIDS Response Information Management System, 11
[28] Epidemiological Fact Sheet on HIV and AIDS: Botswana, 11-12
[29] Ibid., 15
[30] 2008 Progress Report of the National Response to the UNGASS Declaration of Commitment on HIV/AIDS, December 2007 (Republic of Botswana), accessed 27 August 2008, http://data.unaids.org 9
[31] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 19 August 2008, http://www.unfpa.org 87; 2008 Report on the Global AIDS Epidemic Annex 1, 292
[32] 2008 Country Profile: Botswana
[33] “Botswana National Strategic Framework for HIV/AIDS 2003-2009,” National AIDS Co-ordinating Agency, (Republic of Botswana), accessed 20 June 2008, http://www.achap.org/downloads/NSF%20final2.pdf
[34] 2008 Progress Report of the National Response to the UNGASS Declaration of Commitment on HIV/AIDS , 20
[35] Ibid., 27-25
[36] Ibid., 33
[37] Ibid., 33
[38] Ibid., 8  
[39] Latest AIDS Funding Matrix available, 2008, UNAIDS (New York, NY) accessed 26 August 2008, http://data.unaids.org/pub/report/2008/rt08_BOT_en.pdf 3
[40] Ibid., 48
[41] Botswana 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,
[42] Total Dollars Planned for FY 2005 by Program Area, U.S. State Department. (Washington, DC), accessed 19 August 2008, accessed 23 June 2008, http://www.state.gov/s/gac/progress/other/data/program/59684.htm
[43] Approved Funding by Program Area: Botswana: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 23 June 2008, http://www.pepfar.gov/about/77672.htm
[44] Approved Funding by Program Area: Botswana: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 23 June 2008, http://www.pepfar.gov/about/82469.htm
[45] Approved Funding by Program Area: Botswana: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 26 August 2008, http://www.pepfar.gov/about/opplan08/102037.htm
[46] 2008 Progress Report of the National Response to the UNGASS Declaration of Commitment on HIV/AIDS, 33
[47] Botswana 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 8 August 2008,
[48] Ibid., 55-56
[49] Ibid., 77
[50] Ibid., 78
[51] Ibid., 97
[52] Ibid., 97
[53] Frequently Asked Questions. True Love Waits SA 2004. Accessed 27 August 2008, http://www.truelovewaits.org.za/page_faq.html
[54] Ibid
[55] Botswana FY 2007 Country Operational Plan, 142-143
[56] Ibid., 68, 157
[57] Ibid., 69
[58] Ibid., 108, 147
[59] Ibid., 155
[60] Final Report: The Economic Impact of HIV/AIDS in Botswana (econsult Botswana) October 2006, National AIDS Coordinating Agency (NACA) and United Nations Development Programme (UNDP), accessed 28 August 28, 2008, http://www.unbotswana.org 29
[61] Ibid., 66
[62] Ibid., 23, 27, 28; Executive Summary: The Economic Impact of HIV/AIDS in Botswana, National AIDS Coordinating Agency (NACA) and United Nations Development Programme (UNDP), accessed 28 August 2008,http://www.unbotswana.org.bw 3
[63] Final Report: The Economic Impact of HIV/AIDS in Botswana, 89
[64] Ibid., 99
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