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2008 PEPFAR Country Profile Updates: Cote D'Ivoire

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 document is a 2008 update to the status of PEPFAR funding and related issues in Cote D'Ivoire.  Click Here to read the Original 2005 PEPFAR Country Profile).
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% of the funds could be spent on prevention efforts.  Moreover, 33% 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, which 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. 
The first AIDS cases were reported in Côte d’Ivoire in 1987. Twenty-one years later, the country has the highest HIV prevalence in Western Africa— estimated to be as high as 4 percent. Upper estimates of the number of people living with HIV put the total at 550,000.[1] Women are more than twice as likely to be infected with HIV as men. In 2007, the virus was responsible for the deaths of over 38,000 people.[2]
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Côte d’Ivoire. The stories behind these statistics are fleshed out in greater detail following the chart.
Total population (2005)[3]
Percentage of the population under the age of 24
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005)[4]
Per capita total expenditure on health (Int’l$, 2005)[5]
Secondary school enrollment rate (19992005)[6]
18% female
32% male
Estimated number of people ages 15 and over living with HIV (2007)[7]
HIV prevalence in people ages 1549 (2007)[8]
HIV prevalence in people ages 1524 (2007)[9]
3.4% Female upper estimate
1.3% Male upper estimate
1% Female lower estimate
0.3% Male lower estimate
Median age of first intercourse (2004)[10]
16.2 Females
N/A Males
Median age of first marriage
Young people ages 1524 who have had sex before age 15 (2007)[11]
19% Females
15% 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)[12]
4% Females
31% 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)[13]
41% Females
38% Males
Contraceptive prevalence rate (2005)[14]
Any method: 15%
Modern: 7%
Percentage of couples using condoms for family planning (2005)[15]
Number of births per 1,000 women ages 1519(2005–2010)[16]
Percentage of females (20–24) who have given birth by age 18 (2005)[17]
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)[18]
18% Females
28% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[19]
The political and military crisis in Côte d’Ivoire has overshadowed the AIDS epidemic, allowing the epidemic to go largely unchecked during the last few years. Côte d’Ivoire has been unstable for nearly a decade due to a military coup in 1999 which ousted then-President Henri Konan Bédíe. The next year Laurent Gbagbo won the presidency in a much-disputed election.[20] A failed coup attempt in 2002 has left the country divided, with the south controlled by the government and the north held by an armed opposition group, commonly known as the New Forces.[21] Elections failed to be held in October 2006 and Gbagbo’s term was extended by the United Nations for another year. In March 2007, President Gbagbo and former New Force rebel leader Guillaume Soro signed the Ouagadougou Political Agreement; Soro became Gbagbo’s Prime Minister and the zone separating the North from the South was dismantled. Several thousand French and UN troops remain in Cote d'Ivoire to help the parties implement their commitments, especially integrating New Force elements into the country’s political process, and to support the peace process by maintaining elections.
Despite this instability, officials within the national government have made repeated efforts to create a strategy to fight the AIDS epidemic. In 1987, the National Committee for the Fight against AIDS was created, and a five-year plan was implemented to guide the strategy. As part of the government’s commitment to combating the HIV/AIDS epidemic in its country, Côte d’Ivoire participated in the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in 2001, a landmark meeting which resulted in the Declaration of Commitment on HIV/AIDS.  The 189 United Nation members present, including Côte d’Ivoire, signed the Declaration which set national targets for moving towards universal access of HIV/AIDS prevention, treatment, and care services. A series of successive five-year plans followed including the National Strategic Plan (NSP) 2002–2004, and an interim plan for 2005.[22] The Ministry of HIV/AIDS and the HIV Care and Treatment Unit of the Ministry of Health provide leadership in planning and coordinating the national response to the epidemic, the National AIDS Control Programme is responsible for implementation. 
Both the NSP 2002–2004 and the 2005 plan focus on prevention efforts aimed at reducing the prevalence of HIV as well as the rates of sexually transmitted infections overall. Specific emphasis was placed on high-risk and vulnerable groups such as youth, women, sex workers and their partners, mobile populations, police officers and fighters, orphans and vulnerable children, and people living with HIV/AIDS (PLWHA).[23] The 2005 Interim Plan also called for efforts at social reforms, including attempts to alleviate poverty and reduce the negative effect that many traditional practices, including female circumcision/genital mutilation, have on women. Côte d’Ivoire seeks to prevent transmission of HIV primarily through behavioral change with messages stressing abstinence and fidelity as well as through increasing access to condoms.[24]
The 2005 Interim Plan and NSP 2002-2004 sought to achieve these goals through raising awareness of the disease in urban and rural areas. Consequently, the national government has increased its intervention by strengthening prevention and allowing more people access to treatment.[25]
The steps have led to improvement in a number of areas.  For example, nearly 83 percent of people ages 15 to 24 years in Côte d’Ivoire have knowledge on how to avoid sexual transmission of HIV compared with only 40.5 percent in 2002.[26] Nearly 70 percent of this age group also report knowing how to use a condom.[27] The percentage of HIV-infected pregnant women receiving ART to reduce the risk of pregnant mother-to-child transmission (PMTCT) has also increased, from 0.98 percent in 2003 to 4.36 percent in 2005.[28] And, the U.S. government predicts that 46,000 people in Côte d’Ivoire will have accessed antiretroviral therapy (ART) through PEPFAR funds as of the fourth quarter in 2007.[29] It is important to note, however, that the progress achieved has largely been in those areas under government control. Regions in the North and West have, “experienced a complete and prolonged disruption of public sector services and an exodus of skilled professionals.”[30]
The NSP 2006–2010, which is currently in use, contains clear targets for continuing to fight the AIDS epidemic as well as scale up access to HIV prevention, treatment, care, and support.[31] The total cost of this plan is $577 million.[32]   In addition to domestic funding, Côte d’Ivoire relies on the President’s Emergency Fund for AIDS Relief (PEPFAR), the Global Fund, the World Bank, and the UN system.

National Strategy Plan Côte d’Ivoire 2006–2010 Goals
1.      Reduce the prevalence of HIV/AIDS in youth, women and mobile populations.
2.      Promote the utilization of condoms
3.      Protect PLWHA and those affected from stigmatization.
4.      Reduce the prevalence of HIV/AIDS/STI transmitted through sex work.
5.      Reduce the negative effects of traditional practices.
6.      Promote favorable social conditions to reduce the economic impact of HIV/AIDS.
7.      Provide HIV/AIDS services to war-torn regions
8.      Preventing new infections
9.      Treating those already living with HIV
10. Offering care for orphans and vulnerable children affected by the epidemic
11. Increase HIV testing
Original version in French

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.

Since PEPFAR’s inception, Côte d’Ivoire has remained one of the least funded countries. The country received an initial grant of $24,323,367 in 2004 and has now quadrupled that amount to over $100 million in 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*
Total Funds Allocated**
Total Prevention Funds Allocated
Total AB Funds Allocated
$ 3,201,562
Total Other Prevention Funds Allocated (includes condom programming)
$ 2,298,470
$ 2,525,000
Total Treatment Funds Allocated
Total Care Funds Allocated
$ 6,828,031
$ 9,298,000
* 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.
As the above table indicates, the areas of treatment and care receive the most funding.  Each received funding increases in excess of $10 million in 2007, and treatment received a large increase of over $17 million in 2008. Total prevention funds were cut in 2006, however, the prevention subsets of AB and OP received a slight increase in funding form the previous year.
Funding for AB programming was increased by $2,480,935 from 2007 to 2008, and funding for Other prevention (OP), which includes AB programming as well as messages that address correct and consistent condom use, was increased by a little over one million dollars. AB funding made up 7.8 percent of the prevention funding budget while OP funding made up 4 percent. Prevention funds remain the smallest of the three funds in PEPFAR’s budget; it made up 23.4 percent of the 2008 budget, while care made up 24 percent and treatment made up 52.7 percent. 
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, within the area of prevention, PEPFAR funded a total of two AB-only programs, seven AB/OP, and two OP-only programs.  Only five organizations promoted the correct and consistent use of a condom.[38]
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 Côte d'Ivoire. 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.[39]
Organizations that received only AB funding:

  • Hope Worldwide
  • Ministry of AIDS, Côte d'Ivoire

Organizations that received both AB and OP funding:

  • Alliance Nationale Contre le SIDA
  • CARE International
  • Jhpiego International HIV/AIDS Alliance
  • Ministry of National Education, Côte d'Ivoire
  • National Agency of Rural Development
  • Population Services International
  • U.S. Centers for Disease Control and Prevention (CDC)

Organizations that received only OP funding:

  • Central Contraceptive Procurement
  • Family Health International

In 2007, the top AB-only grantee, Hope Worldwide (HWW), received $500,000 in funding and planned to reach 20,000 individuals through AB-only community outreach.[40] Hope Worldwide’s AB prevention program is aimed at promoting abstinence and faithfulness and reducing risky behaviors among youth (ages 10–14), parents, and monogamous couples.  In addition, HWW addresses social norms with men through behavior change communication (BCC) activities carried out in partnership with academic and religious organizations.  BCC is a vague model of behavior change that neither specifies how it modifies behavior nor includes risk reduction. No further details of its activities are given in the Country Operational Plan.
The CDC’s HIV-prevention work is conducted with a primary emphasis on, “…efforts to promote abstinence, fidelity, delay of sexual debut, partner reduction, and related social norms.”[41] In 2007, the CDC received the two largest AB and OP grants; one for of $700,000 in partnership with the Health and Human Services (HHS) and one for $1,350,000 with the Ministry of National Education.[42]  The CDC uses behavior change communication strategies to convey the aforementioned values.  Unfortunately, while much of this funding is directed towards young people, no funding goes towards comprehensive sexuality education that would guide them on best practices for protecting themselves against HIV if/when they become sexually active.  
In contrast, the top 2007 OP grantee, Family Health International (FHI), received $1,440,000 in funding and partnered with the CDC to reach 40,000 people. FHI planned to establish multiple sites for clinic-based prevention outreach, including at least 18 sites that were intended to supply condoms. [43] FHI also trained healthcare providers to do community-based prevention outreach by providing, “HIV/STI prevention and care services for sex workers, transgendered people, MSM, and other at-risk and/or marginalized populations.”[44] 
Items of Note: AIDS, Crisis in Conflict
The current political climate in Côte d’Ivoire has had many negative implications for the country’s fight against HIV/AIDS. The conflict has fostered the deterioration of the healthcare system overall, and the lack of qualified physicians and nurses has hampered efforts to administer HIV treatment and care services. Meanwhile, the northern and western parts of the country, which have experienced increased cases of physical and sexual violence, have been victims of widespread termination of care and services for people living with HIV.[45] 
The government is currently operating under a power-sharing agreement between President Laurent Gbagbo and Prime Minister Guillaume Soro which is mandated by international mediators. The government dissolved the zone that separated the North and South so that both now have equal access to governmental services, including HIV prevention, treatment, and care services. Unfortunately, the benefits of these plans remain largely concentrated in the southern part of the country. Moreover, many financial contributions given to the Côte d’Ivoire focus solely on refugee or military efforts, and do not necessarily take the AIDS epidemic into account.[46] 
Amnesty International reports that hundreds of thousands of internally displaced persons have fled to the south or neighboring countries.[47] Refugees are especially vulnerable to violence, sexual exploitation, disease, malnutrition, and death.[48] In addition, “it is estimated that hundreds, possibly thousands of women in Côte d’Ivoire [have been] victims of sexual violence as a result of the armed conflict,” and it is reported that despite a treaty being signed in 2003, women continue to suffer sexual assault committed by parties on all sides of the crisis.[49] It is also estimated that one million primary schoolchildren and 250,000 secondary schoolchildren have had their education interrupted since the conflict began.[50] Four years after parties signed the Linas-Marcoussis Agreement to end the conflict; these results are still felt throughout the country.
Often, the needs of displaced persons are addressed only in the context of their refugee status, despite the fact that being a refugee also increases their risk of contracting HIV. Although some PEPFAR grantees like Population Services International and Family Health International state that they are providing safer sex education to “mobile populations” including trucker drivers, sex workers, customs and uniformed officials and “migrant populations”, they do not directly target internally displaced persons or refugees.
According to UNICEF, the conflict fosters increased rates of HIV and other sexually transmitted infections.[51] The high rates of sexual assault also put women at higher risk for contracting HIV and increase the risk of transmission to their partners and children.  The lack of a strong health system continues to make it extremely difficult for the country to respond to the AIDS epidemic. Further, the lack of governmental control in the northern and western areas of the country prevents government programs from reaching at-risk populations. As the largest funder of HIV/AIDS programs within Côte d’Ivoire, it is imperative that PEPFAR ensure that all populations, particularly those whose vulnerability to HIV/AIDS is heightened due to this conflict, have access to and are adequately served by its prevention, treatment, and care programs.[52]
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] 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, 214
[2] Ibid., 217
[3] 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles, UNAIDS, (New York, NY), accessed 6 June 2008, 13
[4] Ibid., 13
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., 13
[6] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 10 July 2008, 86
[7] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[8] Ibid., 215
[9] Ibid., 217
[10] Follow-Up on the Undertaking Declaration on HIV/AIDS: Ivory Coast National Report, 2006, (Ministry of Fight Against AIDS, December 2006), UNAIDS, (New York, NY), accessed 10 July 2008, 8
[11] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 5 August 2008, 300
[12] Ibid., 305
[13] Ibid., 310
[14] State of World Populations: Selected Indicators.
According to UNFPA, “These data are derived from sample survey reports and estimate the proportion of married women (including women in consensual unions) currently using, respectively, any method or modern methods of contraception. Modern or clinic and supply ­methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.” 
[15] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY) accessed 6 June 2006, 2
[16] State of World Populations: Selected Indicators.
[17] World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) 12
[18] 2008 Report on the Global AIDS Epidemic Annex 2, 295
[19] Ibid., 292
[20] Côte d’Ivoire Voices of Women and Girls, Forgotten Victims of the Conflict, Amnesty International, 15 March 2007, (New York, NY), accessed 10 July 2008,
[21] Ibid
[22] Côte d’Ivoire: Summary Country Profile for HIV/AIDS Treatment Scale-Up (2005), World Health Organization (New York, NY) accessed 10 July 2008,
[23] Follow-Up on the Undertaking Declaration on HIV/AIDS, 312
[24] Ibid., 9-10
[25] Ibid., 9
[26] Ibid., 11
[27] Ibid.,11
[28] Ibid, 24
[29] 2008 Country Profile: Côte d’Ivoire, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 10 July 2008,
[30] Ibid
[31] Rapport National de la Côte d’Ivoire 2008, UNAIDS, Janvier 2008, (Côte d’Ivoire), accessed 8 August 2008, 38
[32] Drive for AIDS Funding in Côte d’Ivoire, UNAIDS, 9 May 2007, (New York, NY,) accessed 10 July 2008,
[33] Côte d’Ivoire 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 10 July 2008,
[34] Côte d’Ivoire 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 10 July 2008,
[35] Côte d’Ivoire FY 2006 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 10 July 2008,
[36] Approved Funding by Program Area: Côte d’Ivoire: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 10 July 2008,
[37] Approved Funding by Program Area: Côte d’Ivoire: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 10 July 2008,
[38] Côte d’Ivoire FY 2007 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 10 July 2008,
[39] Ibid.
[40] Ibid., 85
[41] Ibid., 86
[42] Ibid., 59, 63, 68, 73, 77, 86, 88, 93
[43] Ibid., 130
[44] Ibid., 131
[45] Follow-Up on the Undertaking Declaration on HIV/AIDS, 28
[46] Ibid., 28
[47] Côte d’Ivoire Voices of Women and Girls, Forgotten Victims of the Conflict
[48] The Impact of Conflict on Women and Girls in West and Central Africa and the UNICEF response, UNICEF, (New York: February 2005), accessed 22 September 2008, 4
[49] Côte d’Ivoire Voices of Women and Girls, Forgotten Victims of the Conflict
[50] The Impact of Conflict on Women and Girls in West and Central Africa and the UNICEF response, 26
[51] Ibid., 22
[52] PEPFAR budget grows again – to record $84 million – to expand fight against HIV/AIDS in Cote d’Ivoire, PEPFAR: Côte d’IvoireEmbassy of the United States, (Côte d’Ivoire),accessed 23 May 2008,
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