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2008 PEPFAR Country Profile Updates: Kenya


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 Kenya.  Click Here to read Kenya's 2005 Original 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 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. 
Kenya declared the HIV/AIDS epidemic a national disaster in 1999, fifteen years after its first AIDS case was reported in 1984. In 2007, the number of adults and children of all ages estimated to be HIV-positive in Kenya was as high as 2,000,000, with an overall prevalence of 7.1–8.5 percent.[1] HIV prevalence has varied among different populations over the years. The current estimate of prevalence of men who have sex with men (MSM) is 43 percent and of injecting drug users (IDUs) is 50 percent in 2007, or at least 8 times higher than the national rate.[2] It is also estimated that up to 1.8 million Kenyans over the age of 15 are living with HIV and that as many as 1.5 million Kenyans have died from AIDS-related illnesses, with roughly 115,000 deaths each year since 2003.[3] In addition, the epidemic has left up to 1.4 million children who have lost one or both parents.[4] 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Kenya. The stories behind these statistics are fleshed out in greater detail following the chart.
Total population (2006)[5]
Percentage of the population under the age of 24
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2006)[6]
Per capita total expenditure on health (Int’l$, 2006)[7]
Secondary school enrollment rate (2007)[8]
48% Females
50% Males
Estimated number of people ages 15 and over living with HIV (2007)[9]
1,400,000 – 1,800,000
HIV prevalence in people ages 15–49 (2007)[10]
7.1% – 8.5%
HIV prevalence in people ages 15–24 (2007)[11]
8.4% Female upper estimate
2.5% Male upper estimate
4.6% Female lower estimate
0.8% Male lower estimate
Median age of first intercourse
Median age of first marriage
Young people ages 15–24 who have had sex before age 15 (2003)[12]
14% Females
29% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2003)[13]
2% Females
12% Males
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 (2003)[14]
12% Females
33% Males
Contraceptive prevalence rate (2007)[15]
Any method: 39%
Modern: 32%
Percentage of couples using condoms for family planning (2005)[16]
Number of births per 1,000 women ages 15–19(2005–2010)[17]
Percentage of females (20–24) who have given birth by age 18 (2005)[18]
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)[19]
58% Females
80% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[20]
The face of the epidemic has drastically changed since HIV/AIDS first appeared in Kenya in the early 1980s, and there are several signs of progress. HIV prevalence in Kenya has remained stable at approximately 8 percent since 2005 after being as high as 25 percent in 2000.[21] In addition, AIDS-related deaths have been reduced by 15 percent from 2001–2007.[22]
In Kenya, the epidemic has been a contributing factor in the dramatic drop in development across all economic sectors. Families affected by HIV/AIDS experience a drop in household income and businesses lose money due to absent employees. Agriculture and educational services, among other sectors, have been increasingly burdened by the social impact and direct cost associated with the epidemic. It is estimated that 10 percent of agricultural laborers in Kenya are infected with HIV, and retirement, illness, health care needs, and death due to AIDS costs the agribusiness industry 1 percent of its annual profit.[23] Labor losses have also resulted in delays in agricultural production and land being left fallow which impacts the entire population.[24]
The epidemic has also hit educational services particularly hard. Children from affected households are more likely to drop out of school (36 percent) because of education-related costs than children from unaffected households (25 percent).[25] In addition to the epidemic’s effect on enrollment, the increase in morbidity and mortality among teachers and education officials has also caused a decline in the quality of education. 
There are major differences in the risk of infection faced by different population groups. As mentioned, HIV prevalence among the MSM and IDU populations is 8 times that of the national average. In addition, women ages 15–24 years are 5.5 times more likely than men of the same age range to be infected with HIV. Two-thirds of HIV-infected couples are sero-discordant (couples in which one partner is HIV-positive and the other is HIV-negative), heightening the latter partner’s risk of contracting the virus if proper precautions, such as correct and consistent condom use, are not taken.
While the Government of Kenya began addressing the epidemic in 1985, it was not until 1999 that President Daniel arap Moi declared the epidemic a national disaster and created the National AIDS Control Council (NACC) to lead the national response and coordinate the government’s efforts.[26] The following year, Kenya unveiled its National HIV/AIDS Strategic Plan 2000–2005 (KNASP). The overarching theme of the plan was to implement social change which would ultimately reduce the spread of HIV and mitigate the effects of HIV/AIDS and poverty.  An additional step was taken in 2002 when the government proclaimed a “Total War on AIDS.”
The current strategy in the fight against HIV/AIDS was released in 2005 and runs through 2010.   Its stated goal is to “Reduce the spread of HIV, improve the quality of life of those infected and affected and mitigate the socio-economic impact of the epidemic in Kenya.”[27] The current KNASP calls for a multi-sectoral approach to enhance advocacy, build strategic partnerships, and mainstream HIV/AIDS within key sectors as well as to focus on gender, youth, and evidence-based interventions.

Key Goals of KNASP 2005/62009/10
  1. Preventing new infections
  2. Improving the quality of life for infected and affected people (care, treatment and human rights)
  3. Mitigating the socio-economic impact of HIV and AIDS with monitoring and evaluation, and other support services.

The framework also adopted the “Three Ones” approach which was laid out in the International Conference on AIDS and Sexually Transmitted Diseases in Africa (ICASA) in 2003. These are:
  1. One national AIDS coordinating authority with a broad-based multi-sectoral mandate;
  2. One AIDS action framework to coordinate the work of all partners;
  3. One national monitoring and evaluation system
The United Nations General Assembly Special Session country report on Kenya highlights some of the strides that have been made in the fight against HIV/AIDS in Kenya since the implementation of KNASP 2000–2005 and the current KNASP 2005/6–2009/10. As mentioned, the overall prevalence is falling. In addition, voluntary counseling and testing (VCT) is more widely available and a greater proportion of Kenyans know their status.  For example, there was an increase in the number of VCT sites, from only 3 locations in the year 2000 to almost 1,000 VCT sites in 2007.[28] The KNASP target for 2010 is at least 2 million people tested annually; 500,000 at VCT sites and 1.5 million in clinical testing which will include pregnant women. Access to antiretroviral therapy (ART) was also scaled up between 2004 when it was provided to approximately 6 percent of Kenyans with advanced HIV infection and 2007 when 38 percent received it. This is credited with saving approximately 15,000 lives each year.  Condom use with casual partners has increased from 38 percent among young people ages 15–24 in 1998 to 47.5 percent in 2003 (the most current data available).[29] In addition, the percentage of young women and men ages 15–24 who reported having sexual intercourse before age 15 and having more than one sexual partner has decreased.[30]
Despite these successes, there is still much to do.  The current KNASP calls for an increased focus on the youth-specific issues.  In Kenya, there are more children ages 0–14 living with HIV than ever before, up from 135,000 in 2001 to 155,000 in 2007.[31] Most of these children contracted the virus through mother-to-child transmission. The epidemic has also resulted in high numbers of orphaned and vulnerable children. These children are at risk on many levels, as they are less likely to receive adequate healthcare and education. 
The KNASP also seeks to address the gendered dimensions of the epidemic. As previously stated, women ages 15–24 are 5.5 times more likely than men of the same age range to contract HIV. The reported knowledge gap between the sexes is also significant, showing that 80 percent of males and only 58 percent of females 15–24 years of age can correctly identify ways of preventing HIV transmission and reject major misconceptions like mosquitoes can transmit the virus.[32]  UNAIDS data has shown that in Kenya, girls’ sexual debut occurs earlier in their lives than it does in the lives of boys, that they tend to have more sexual partners, and that they are victim to higher incidences of violent sexual contact.[33] 
Deep-rooted gender inequalities are often expressed in violence, coercion, or physical or emotional intimidation which heightens their vulnerability for transmission of HIV. According to the 2003 Kenya Demographic Survey, nearly half of Kenyan women (49 percent) reported experiencing violence in the past 12 months. Further, 25 percent of women ages 12–24 experienced their first sexual intercourse by force.[34] Discriminatory laws and practices also leave women at a disadvantage in negotiating condom use within a monogamous relationship or marriage as well prevent them from leaving an infected partner. Women are also more likely to be labeled promiscuous and viewed as responsible for introducing the virus into the family. In order to avoid this stigma, many women refuse HIV tests altogether.
It is estimated that KNASP 2005/6–2009/10 will require up to $605 million dollars per year to implement.  External funds comprise the majority of KNASP’s expenditures while the government of Kenya actually contributes very little to the funding of KNASP.[35] The majority of external funds come from the World Bank, the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund. 
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.

PEPFAR began implementing its HIV/AIDS prevention, care, and treatment programs in Kenya in 2004. At the time, Kenya received more funding than any other focus country. Funding has continued to increase and as of 2008, Kenya received $483,406,512 or more than five times its 2004 grant. 
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
Total Other Prevention Funds Allocated (includes condom funding)
Total Treatment Funds Allocated
Total Care Funds Allocated
* 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.
Kenya’s funding has seen major increases over all four years. This increase in funds has been accompanied by a shift in the distribution; the percentages of overall funds for treatment increased from 46 to 49.9 percent and funds for care increased from 26 to 28 percent between 2005 and 2008. In contrast, the percentage of funds allocated for prevention decreased from 28 to 22 percent during the same time period. Abstinence-only/Be-faithful (AB) funding currently makes up 8.2 percent of the total budget while Other Prevention (OP) funding makes up 5.6 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, 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 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. 
Kenya’s high level of funding has translated into a multitude of prevention programs. According to PEPFAR’s 2007 Country Operation Plan (COP), there were nine organizations that received AB funds, 20 organizations that received both AB and OP funds, and two organizations that received OP funds. In 2007, AB programs were intended to reach 2.57 million individuals through community outreach, 260,000 individuals through abstinence-only programs, and 32,000 individuals trained to promote AB-only messages. [41] That same year, OP programs were intended to reach 3.29 million individuals through community outreach and train 16,300 individuals to promote HIV/AIDS prevention. OP programming also went to support 38,400 targeted condom outlets which ranged from pharmacies, clinics, and hospitals to non-traditional venues like trucking rest stops and other high-transit areas.[42] Out of all the AB and OP programs, only five promoted the correct and consistent use of condoms. 
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 Kenya. 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.[43]
Organizations that received AB funding:

  • Adventist Development and Relief Agency
  • American International Health Alliance
  • Impact Research and Development Organization
  • Live With Hope Centre
  • U.S. Agency for International Development
  • Samaritan's Purse
  • U.S. Peace Corps
  • World Relief Corporation
  • World Vision International

Organizations that received AB and OP funding:

  • Academy for Educational Development
  • CARE International
  • Centre for British Teachers
  • Community Housing Foundation
  • EngenderHealth
  • Family Health International
  • Hope Worldwide
  • Institute of Tropical Medicine
  • International Rescue Committee
  • Jhpiego
  • Kenya AIDS NGO Consortium
  • Kenya Medical Research Institute
  • Kenya Medical Research Institute
  • National AIDS & STD Control Program
  • Pathfinder International
  • Population Council
  • Program for Appropriate Technology in Health
  • Population Services International
  • United Nations High Commissioner for Refugees
  • U.S. Centers for Disease Control and Prevention

Organizations that received OP funding:

  • International Medical Corps
  • University of Manitoba

The U.S. Peace Corps received the most AB funds at $1,205,700. The Peace Corps used sporting activities to, “promote safe sexual practices especially among sexually active youth and young adults with particular emphasis on mutual fidelity.”[44] The activities target youth and adults affected and infected with HIV/AIDS, and include caregivers. 
Family Health International (FHI) received the largest amount of funding ($9,056,000) for both AB and OP programming in 2007. FHI implements several AB programs, including one called ROADS that delivers, “abstinence activities … to primary and secondary school students as well as out-of-school youth and to people living with HIV and AIDS,” in areas designated as high-risk such as along cross-border areas and transportation corridors.[45] Another AB program, called “360-degree Model of Protection” seeks to delay first sexual encounter and increase secondary abstinence among young people ages 10–24, as well as increase safer sexual practices, especially mutual fidelity, among sexually active youth.[46]   FHI implements this program in schools as well as in faith communities.  
Population Services International (PSI), another grantee that receives both AB and OP funds, runs the “Nimechill” (“I have abstained” in Swahili) media campaign with AB funding, claiming the broadest reach of young adolescents through television, radio, and print.[47] It has started hundreds of “Chill Clubs” throughout schools, and the campaign recently partnered with Coca-Cola. PSI conducted a study evaluating the impact of “Nimechill” on urban youth ages 10–14. The evaluation found that while there is a temporary change in the attitudes of youth exposed to the campaign, there is no significant change in behavior.[48] 
The Community Housing Foundation (CHF) received $1,250,000 in AB funds and planned to reach 250,000 individuals through community outreach. CHF works with community and faith-based organizations to help them strengthen implementation of abstinence curricula in their church-sponsored schools. These curricula are used in programs such as the African Inland Church Ministries’ “Why Wait” program, the Baptist AIDS Response Agency (BARA) “True Love Waits,” and a fidelity program of the Kenya Episcopal Conference called “True Love Stays.”[49] 
One of the mainstays of the True Love Waits program is a virginity pledge that youth sign promising that they will abstain from sex until marriage. Virginity pledges have been shown to be ineffective in delaying sexual initiation or protecting youth from sexually transmitted diseases or unintended pregnancy.[50] BARA Kenya’s contains this startling passage:
Those who know will agree that sex in a marriage set up is quite different from that outside marriage. In the former’s case, it is softer and coordinated while in the latter’s case it is the opposite. This is one reason a condom is more likely to slip or burst in the latter’s case thereby reducing its potential to protect to only 60–70 percent. The defect percentage (even if it were 1 percent) is actually DEATH. Nobody is advising you to use a Condom. Everybody is advising you on A and B. They hold the condom as the last words for those who finally declare themselves too weak. Ready for death. But before you reach the stage, we remind you that He who defeated death can defeat your weaknesses. Your creator watches over you. Psalms 121:4 [51]

Given the ongoing stigma attached to AIDS in Kenya and the difficulty that people living with HIV/AIDS have in accessing services, it is unconscionable that U.S. funding is going to agencies that promote such inaccurate, fear-based, and stigmatizing messages.  
The International Medical Corps received the largest grant for OP programming at $175,000. The organization established 250 condom outlets and provides voluntary counseling and testing (VCT) services to a number of islands in Lake Victoria with high concentrations of commercial sex workers and young male fishermen. Outreach VCT to these islands has been well accepted, with as many as one in five of the population on some islands getting tested. HIV rates in VCT clients are very high; on some islands, over 40 percent of the women and over 20 percent of the men tested are HIV positive.[52]  
Items of Note: Institutional Deficiencies
While PEPFAR primarily addresses the issues of prevention, treatment, and care, there are many more complications associated with HIV/AIDS that must be remedied. In Kenya, as well as many other countries around the world, groups that are made most vulnerable to HIV/AIDS are also those that are often marginalized.
Women, children, people living with HIV/AIDS (PLWHA), men who have sex with men (MSM), and the elderly, often face difficulties in seeking legal remedies to human rights issues caused or exacerbated by the epidemic. Kenya has now enacted an anti-discrimination law, the HIV and AIDS Prevention and Control Act; however the date for the legislation to commence has not yet been set.[53] A 2005 UNAIDS report highlighted that healthcare workers have limited knowledge on human and reproductive rights and that the link between HIV/AIDS programs to legal services is weak.[54] One survey found that 72 percent of all organizations interviewed reported at least one case of a human rights violation.[55] In addition, violations ranging from domestic violence to unlawful employment termination have been found by the Kenya AIDS Network Consortium (KANCO).
Throughout the country there are extremely high rates of domestic violence; in some areas up to 94 percent of women reported experiencing domestic violence at least once.[56]   Further, the government of Kenya reports that over 60 percent of the women and children who are abused failed to report the event to the police.[57] While there are laws imposing penalties for rape and sexual violence, marital rape is still not considered a crime. As their partners and/or parents die, women and children are often left without legal claim to their family property, and it is often taken by other family members, leaving them with little on which to survive.[58] 
The elderly also face discrimination and have special needs that general treatment and care programs may not provide. In addition, the elderly often become the primary caregivers of their own grandchildren, or of other children who have been left without other caregivers. They face the difficulty of caring for these children who may also be HIV positive or have AIDS, while also attending to their own declining health and economic security.[59]
Further, while Kenya does have many laws protecting people from discrimination based on actual or perceived HIV status there are many other ways that vulnerable groups are disenfranchised. Kenyan law criminalizes homosexuality, commercial sex work, and injecting drug abuse, thus presenting obstacles to effective HIV prevention and care for the most-at-risk populations. Laws that impose penalties on the knowing transmission of the virus also hinder people from getting tested in the first place. 
Underlying these laws is a legal system that does not sufficiently address the needs of people affected by HIV/AIDS. People seeking a redress of their rights are often limited by the expense and distance to court. Moreover, it is estimated that Kenya has less than 5,000 lawyers and there is no national legal aid program.[60] 
Therefore funding must reach farther than treatment, care, and prevention. PEPFAR seeks to ease the plight of the epidemic through focusing on these areas, but it cannot be truly fixed without attempting some remedy at the underlying institutional deficiencies that plague the country. 
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] 2008 Report on the Status of the global HIV epidemic, UNAIDS, (New York, NY), accessed 4 August 2008, 41
[3] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report – Kenya
Reporting period: January 2006 – December 2007 (National AIDS Control Council, Republic of Kenya, 2008), accessed 23 July 2008,
[4] 2008 Report on the Global AIDS Epidemic Annex 1, 218
[5] 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles, UNAIDS, (New York, NY), accessed 23 July 2008, 27
[6] Ibid., 27
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.”
[7] Ibid., 27
[8] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 5 August 2008, 86
[9] 2008 Report on the Global AIDS Epidemic Annex 1, 214
At the time of production of the current report, analyses incorporating new data from a population based survey with data from other sources were ongoing. This is why only ranges are published based on preliminary analysis. As soon as updated final estimates are available, they will be published on the UNAIDS website.
[10] Ibid., 215
[11] Ibid., 217
[12] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 5 August 2008, 301
Most Recent Data Available
[13] Ibid., 307
Most Recent Data Available
[14] Ibid., 313
Most Recent Data Available
[15] 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.” 
[16] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY) accessed 5 August 2008,
[17]  Monitoring ICPD Goals – Selected Indicators, 86
[18] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 5 August 2008,
[19] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[20] Ibid., 292
[21] 2008 Report on the Status of the global HIV epidemic, 34
[22] 2008 Report on the Global AIDS Epidemic Annex 1, 217
[23] 2008 Report on Mitigating the epidemic’s impact on households, communities, and societies, UNAIDS, (New York, NY), accessed 4 August 2008, 171
[24] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report, 21
[25] Ibid., 21
[26] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report, 22
[27] Ibid., 22
[28] Ibid., 27-28
[29] Ibid., 312-313
[30] Ibid., 306-307
[31] 2008 Report on the Global AIDS Epidemic Annex 1, 216
[32] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[33] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report, 40
[34] Ibid., 41
[35] Scaling Up the Response to HIV and AIDS in Kenya: Mainstreaming through the Government Budget Process, International Development, August 2006, accessed 8 August 2008,  
[36] Kenya 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,
[37] Kenya 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,  
[38] Kenya FY 2006 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008,
[39] Approved Funding by Program Area: Kenya: 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,
[40] The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Fiscal Year Kenya 2008: PEPFAR Operational Plan June 2008, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008, 60
[41]  Kenya 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, 180
[42] Ibid., 372
[43] Kenya FY 2007 Country Operational Plan (COP)
[44] Ibid., 310
[45] Ibid., 281
[46] Ibid., 291
[47] Ibid., 267
[48] Kenya: Evaluation of the Nimechill Campaign to Promote Abstinence among Urban Youth 10-14, The PSI Dashboard, March 2006, (Nairobi, Kenya), accessed 11 August 2008,
[49] Ibid., 201
[50] Peter Bearman and Hannah Brückner, “Promising the Future: Virginity Pledges and the Transition to First Intercourse,” American Journal of Sociology 106.4 (2001): 859-912; Peter Bearman and Hannah Brückner, “After the Promise: The STD Consequences of Adolescent Virginity Pledges,” Journal of Adolescent Health 36.4 (2005): 271-278
[51] FAQS, Kenya Baptist AIDS Response Agency, accessed 11 August 2008,
[52] Kenya FY 2007 Country Operational Plan (COP), 400
[53] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report, 36; ACT NO. 14 of 2006 - HIV and AIDS Prevention and Control Act, Kenya AIDS Network Consortium, accessed 11 August 2008,
[54] Ibid., 36 Source: Report on the Joint AIDS Programme Review, NACC 2005(b)
[55] Kalla and Cohen, Ensuring Justice for Vulnerable Communities in Kenya (New York: Open Society Institute, 2007), 16
[56] Ibid., 16
[57] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report, 41
[58] Kalla and Cohen, Ensuring Justice for Vulnerable Communities in Kenya (New York: Open Society Institute, 2007), 16.
[59] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report, 76
[60] Ibid., 41
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