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2008 PEPFAR Country Profile Updates: Mozambique


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 Mozambique.  Click Here to Read Mozambique'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. 
Mozambique borders some of the countries that have been hardest hit by the HIV/AIDS epidemic in Africa including South Africa, Malawi, and Swaziland, the latter having the highest HIV prevalence in the world at 26.1 percent.[1] It is along the borders between Mozambique and these countries where there is the highest concentration of HIV-positive persons.[2] With a life expectancy of only 47 years, many in Mozambique have become desensitized to the epidemic. In the face of such tremendous fatality and an ominous air of inevitable infection, many neglect effective HIV-prevention measures.[3] 
The first known case of AIDS in Mozambique was detected in 1986.[4]  Since that time the prevalence of HIV has risen steadily, from 4 percent in 1994 to 8 percent in 1998 to 12 percent in 2006 where it currently remains. Mozambique has the fourth highest number of people living with HIV in the world at 1.5 million people of all ages in 2007 (third is India at 2.4 million, second is Nigeria at 2.6 million, and first is South Africa at 5.7 million.)[5] It is estimated that 81,000 adults and children died from AIDS-related causes in 2007.[6] 
Women in Mozambique continue to bear a disproportionate burden of the epidemic; young women ages 15–24 are nearly four times more likely than young men to contract HIV and women ages 15 and over make up more than half of all the HIV cases in the country.[7] While antiretroviral therapy (ART) coverage of HIV-positive pregnant women has gone up substantially in just a few years (from less than 1 percent in 2004 to roughly 50 percent in 2007), less than half of all pregnant women receive antenatal care that includes prevention of mother-to-child transmission (PMTCT) services— leaving many missed opportunities to prevent pediatric HIV infections and treat undiagnosed women.[8]   Children have also been severely affected by the epidemic: estimates show roughly 400,000 children (low estimate 280,000 – high estimate 590,000) ages 0–17 have lost one or both parents due to AIDS.[9] Most children who contract HIV in the peri-natal period die before they are five years old, and few survive to their 10th birthday.[10]
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Mozambique. The stories behind the statistics are fleshed out in greater detail following the chart.
Total population (2006)[11]
Percentage of the population under the age of 24
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005)[12]
Per capita total expenditure on health (Int’l$, 2005)[13]
Secondary school enrollment rate (19992007)[14]
11% Females
16% Males
Estimated number of people ages 15 and over living with HIV (2007)[15]
HIV prevalence in people ages 1549 (2007)[16]
HIV prevalence in people ages 1524 (2007)[17]
11.1% Female upper estimate
4.2% Male upper estimate
5.9% Female lower estimate
1.2% Male lower estimate
Median age of first intercourse
Median age of first marriage
Young people ages 1524 who have had sex before age 15 (2004)[18]
28% Females
26% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2004)[19]
24% Females
52% 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)[20]
14% Females
19% Males
Contraceptive prevalence rate (2004)[21]
Any method: 17%
Modern: 12%
Percentage of couples using condoms for family planning (2005)[22]
Number of births per 1,000 women ages 1519(2005–2010)[23]
Percentage of females ages 2024 who have given birth (2005)[24]
Young people ages 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (2004)[25]
25% Females
39% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[26]
HIV in Mozambique is primarily transmitted through heterosexual sexual contact and from mother-to-child, creating a disparate impact on women and children. In addition, the majority of the country’s population resides in rural areas making it more difficult to access prevention services, as well as HIV testing, treatment, and care services.[27]
The government of Mozambique failed to address the HIV/AIDS epidemic until the late 1990s, largely due to a 17-year civil war that ended in 1992. The national response began with greater earnest in 1998 when the Ministry of Health created the National Programme to Combat AIDS. Two years later, the National AIDS Council (NAC) was set up to provide a comprehensive and multisectoral response to HIV/AIDS. That same year, the NAC developed the National Strategic Plan to Combat STD and HIV/AIDS 2000–2002 (NSP) which sought to slow the spread of HIV infections and to mitigate the effects of the epidemic; notably, antiretroviral therapy was not envisioned at the time because of the high cost. The NSP 2000–2002 also emphasized that special attention be paid to high-risk populations, including, but not limited to, youth, long-distance truck drivers, migrant workers, sex workers, the military, and people living with HIV/AIDS (PLWHA).[28]
The second generation NSP 2005–2009 was developed in 2004 and is the current strategy in place. The main objectives, broad in scope, are the, “promotion of interventions to reduce the level of new infections and increase the care and treatment of people living with HIV and finally engage all stakeholders in [the] mitigation process that will ensure that people living with HIV are treated humanely and their rights are protected.”[29] In addition to the current NSP, other national plans by the Mozambican government, including the Reduction of Absolute Poverty 2006–2009 and the National Strategic Plan for STI/HIV/AIDS 2004–2008, also incorporate issue related to HIV/AIDS. 

20052009 National Strategic Plan Main Objectives
  1. Reduce the level of new infections
  2. Increase care and treatment of people living with HIV
  3. Ensure people living with HIV are treated humanely and their rights are protected


In 2001, Mozambique participated in the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, a landmark meeting which resulted in the Declaration of Commitment on HIV/AIDS. In January 2008, the Republic of Mozambique released a 2006–2007 report detailing its progress in meeting the UNGASS targets. The report notes that Mozambique had several key achievements during this reporting period: a clear expression of political commitment at the highest level as seen in the Presidential Initiative on HIV and AIDS led by President Armando Guebuza, an increase in availability of male condoms, an increase in treatment and care, and increases in data collection.[30] However, the 2008 report also cited numerous barriers that stand in the way of Mozambique’s progress: there is no coherent national prevention strategy based on evidence about the drivers of the epidemic, the linkages between condom distribution and prevention are limited leading to low use of condoms, integration of HIV/AIDS services with treatment and care of other diseases like malaria and tuberculosis is weak, and there is no comprehensive monitoring and evaluation operational plan.[31] 

It is estimated that only 25 percent of pregnant women took advantage of antenatal care services in 2006, and of those women, 14 percent were found to be HIV positive.[32] In addition, only half of all pregnant women living with HIV receive antiretroviral therapy (ART).[33] Clearly there remains an enormous need to improve the nation’s overall health system including a greater integration of services so that all pregnant women receive the care they need all HIV-positive pregnant women are treated in Mozambique.
The number of young people who have knowledge regarding HIV remains low. In 2003, a Demographic and Health Survey (DHS) was carried out in which participants, ages 15–49, were asked five questions to assess their overall knowledge of HIV including: if they thought a healthy looking person could have HIV, if they could get HIV from mosquito bites or sharing food with an infected person, and if using a condom reduced their risk of getting HIV. The percentage of people who gave correct answers to all the questions was shocking given the country’s epidemic—33 percent of males and 20 percent of females.[34] Unfortunately, very little has changed. In the most recent survey only 39 percent of young males and 25 percent of young females answered all five questions correctly.[35] These numbers show that a majority of the Mozambican population still has insufficient knowledge about how HIV is transmitted and how to prevent infection. 
Further proof of this is shown by looking at statistics on sexual behavior. Despite the widespread epidemic, 82 percent of people ages 15–49 reported having sex with a non-marital, non-cohabitating partner in the last 12 months without the use of a condom.[36] In addition, roughly 30 percent of young people have already experienced their sexual debut by the time they are 15 years old.[37] It is clear that Mozambique’s information, education, and communication techniques emphasized by the current NSP have not translated into positive behavior change. 
It is clear that there is much work that can be done to lower the prevalence and impact of HIV in Mozambique, however, the national government can not do it alone. In order to meet its goals, Mozambique receives funds from various organizations and countries, including, the Global Fund, World Bank, the Clinton Foundation, and the Presidents Emergency Plan for AIDS Relief (PEPFAR). The most recent data reported in 2008 shows that external financing sources accounted for 85 percent of all HIV-related expenditures in the country.[38]
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 programs in Mozambique in 2004 with an initial grant of $37,388,347. These funds go toward services in the areas of prevention, treatment, and care. Funds have been continually increased each year, and in 2008 overall funding is more than five times its initial grant at $196,000,944.
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.
In 2005, prevention programming received the larger share of funding over treatment and care. However since then it has become the least funded area of the three despite being listed as the top priority in the country NSP 2005–2009. In 2008, just 24.9 percent of funding was allocated to prevention, 26.6 percent to care, and 48.5 percent to treatment. Prevention funds can further be broken down into program area: Prevention of Mother-to-Child Transmission (PMTCT), Abstinence/Be-Faithful (AB) programs, Blood and Injection Safety, and Other Prevention (OP) programs. Within prevention funding, AB programs have always received the bulk of the funds, comprising nearly 30 percent of the prevention budget in 2008 while OP programs only comprised 20 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. 
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 Mozambique. 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.[44]
Organizations that received AB funding only:

  • EngenderHealth
  • Food for the Hungry
  • Samaritan’s Purse
  • U.S. Agency for International Development
  • World Relief Corporation

Organizations that received AB and OP funding:

  • Academy for Educational Development
  • Foundation for Community Development, Mozambique
  • International Broadcasting Bureau, Voice of America
  • Johns Hopkins University Center for Communication Programs
  • Population Services International
  • U.S. Department of State
  • U.S. Peace Corps
  • World Vision International

Organizations that received OP funding only:

  • Chemonics International
  • The Futures Group International
  • Jhpiego
  • Ministry of Health, Mozambique

AB programs received $11,282,818 in funding and were projected to reach 1,563,799 people through community outreach in 2007.[45] Food for the Hungry received the most AB funding in 2007 with a total of $1,113,480.[46] Food for the Hungry implements the faith-based AB programs “Healthy Choices” and “Choose Life” with youth and adults. The program discusses making choices about education and sexual life within the AB framework of abstinence-only-until-marriage, secondary abstinence, and faithfulness in committed relationships. Recently it has focused its “be faithful” prevention activities on individuals engaged in “transactional sex, cross generational sex and…multiple and concurrent sexual partnerships.”[47] While these programs seek to combat gender-based violence and coercive sex, the moralistic framework used does not meet the needs of the 82 percent of adults who report casual sex without use of a condom.
The top 2007 grantee of AB and OP programs was Population Services International (PSI) at $4,473,500 ($4,273,500 OP funds and $200,000 AB funds).[48] PSI’s AB work was set to reach 5,000 people and OP work set to reach 570,000. PSI has created a widespread condom social marketing project in the Health Policy and Planning Journal that distributes it “JeitO” condom (meaning “style” or “flair” in Portuguese) to more than 5,000 outlets. These outlets may offer condoms free of charge, such as in a clinic, or for sale in a store, market, or gas station. A peer-reviewed assessment of the JeitO condom social marketing campaign that was published in the Health Policy and Planning Journal showed increased knowledge and increased use of condoms with non-regular partners in both men and women ages 15–49.[49] 
PSI’s AB program is directed at changing attitudes and values of uniformed personnel, specifically military and police recruits ($150,000 will support activities for military recruits and $50,000 will support activities for police recruits). The organization delivers behavior change communication messages on the radio and in clinical settings, military bases, and schools. The behavior change program encourages “abstinence, delayed sexual activity for youth, partner reduction among adults, and promotion of faithfulness.”[50] PSI considers it important to not only provide information but change beliefs about sexual behavior because “young recruits will be the agents of… change since they are particularly important in view of their potential role as future leaders and decision-makers, and as peacekeepers in their own countries and elsewhere.”[51] In addition, military and police officers may be increasingly exposed to alcohol and drugs, and engage in behavior that places them at higher risk for contracting the virus. 
In 2007, OP programs in Mozambique received $8,038,000 in funding and were projected to reach 582,745 people through community outreach.[52] OP programs deliver an ABC message, complementary to the AB message, to reduce risk of HIV infection. Futures Group International received the most OP funding in 2007 at $400,000 and was set to reach 3,000 individuals through community outreach.[53] This OP program provides accessibility to condoms and implements prevention programs in various workplaces in the country (mostly to the Dunavant Cotton Company which can reach thousands of rural cotton farmers in the Zambezia province). The program addresses “male norms and behaviors and gender based violence and coercion, shifting norms in the workplace and in the communities towards gender equity and healthy sexual and reproductive health practices.”[54] It is not known how many condoms are distributed but Futures Group International targeted 15 workplaces to ensure condoms were available to workers and staff. It is important to note, however, that while the organization made condoms available to workers, it did not promote correct and consistent condom use.
Only one organization, International Broadcasting Bureau, Voice of America, an AB and OP provider that received $114,167 in AB funding and $85,833 in OP funding, promoted correct and consistent condom use in 2007.[55] The Voice of America funds a radio broadcast and a 30 minute show called Your Health, Your Future to provide education about HIV prevention for young Mozambicans, including correct and consistent condom use. The show covers topics such as drug avoidance, safe sexual behavior, treatment and care, testing, mother-to-child transmission, and social and political implications of HIV/AIDS in Mozambique.
Items of Note: Healthcare Crisis
Underlying these prevention, treatment, and care efforts is the inability of Mozambique’s healthcare system to respond to the needs of those affected and infected by HIV/AIDS. The United States government estimates that Mozambique has a total of about 650 physicians, which amounts to only one physician per 60,000 people.[56] Médecins Sans Frontières (MSF) reports that patients are forced to wait for up to two months to start treatment because of the lack of doctors and nurses; many have even died during the wait.[57] In addition to the shortage of physicians, there are insufficient numbers of other healthcare providers: MSF estimates that there are currently 20 nurses and 34 health providers per 100,000 Mozambicans, well below the World Health Organization minimum of 100 nurses and 228 health providers per 100,000 persons. Approximately half of Mozambique’s physicians work in the capital city, Maputo, which leaves a widespread lack of medical coverage for  individuals living in rural areas.[58]
Doctors and nurses in Mozambique do not make enough money to support themselves. Healthcare workers engaged in public health work for wages as low as $115 per month and it is common for them to leave their jobs at a public health clinic mid-day to supplement salaries by working in private practices.[59] The difficulty of earning a steady income in healthcare has led to incredibly high attrition rates as healthcare workers leave Mozambique in search of more competitive salaries and better working conditions . Almost one in five nurses trained in sub-Saharan Africa are now working in countries like the United States, United Kingdom, and Canada.[60]
However, the problem is not simply one of wages.  MSF reports that the main cause of health worker attrition is death, mostly due to complications from HIV/AIDS.[61] According to a 2002 survey performed by the Mozambican Ministry of Health, 17 percent of health professionals are infected with HIV/AIDS themselves.[62] IRIN, the humanitarian news and analysis service of the UN Office for the Coordination of Humanitarian Affairs, reports that despite having access to services, many doctors and nurses are still afraid to be tested for HIV or seek treatment.[63] The extreme shortage of healthcare workers, combined with the high prevalence is exacerbating already strained resources. It is estimated that as many as 280,000 people are in need of ART, but there is often no one available to administer the drugs.[64] 
Mozambique hopes to recruit as many as 8,000 doctors from nearby countries within the next ten years.[65] It is important that PEPFAR allow its funds to be used to help Mozambique reach this goal, as it is not possible to effectively treat and address the needs of people living with HIV/AIDS without a strong healthcare system in place. Prevention, treatment, and care efforts are lost without an adequate health care workforce in place to provide them. 
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 19 August 2008, 215
[2] Epidemiological Country Profile on HIV and AIDS, UNAIDS, (New York, NY), accessed 19 August 2008,
[3] National Human Development Report 2007 – Mozambique, January 2008, United Nations Development Programme (UNDP), (Maputo, Mozambique) accessed 19 August 2008, 16
[4] Ibid., 15
[5] 2008 Report on the Global AIDS Epidemic Annex 1, 214-219
[6] Epidemiological Country Profile on HIV and AIDS
[7] 2008 Report on the Global AIDS Epidemic Annex 1, 214, 215, 217
[8] Universal Declaration of Commitment on HIV and AIDS: Mozambique Progress Report for the United Nations General Assembly Special Session on HIV and AIDS, January 2008, (Mozambique), accessed 19 August 2008, 30
[9] 2008 Report on the Global AIDS Epidemic Annex 1, 218
[10] National Human Development Report 2007, 22
[11] 2006 UNAIDS Report: Country profiles annex 1, UNAIDS, (New York, NY), accessed 19 August 2008,
[12] Ibid., 16
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.”
[13] Ibid., 16
[14] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 19 August 2008, 86
[15] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[16] Ibid., 215
[17] Ibid., 217
[18] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 19 August 2008,http://data.unaids.org301
Most accurate data available; Country reported value for 2007
[19] Ibid., 307
Most accurate data available; Country reported value for 2007
[20] Ibid., 313
Most accurate data available; Country reported value for 2007
[21] 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.” 
[22] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 19 August 2008,
[23] Monitoring ICPD Goals – Selected Indicators
[24] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC), accessed 5 August 2008, 13
[25] 2008 Report on the Global AIDS Epidemic Annex 2, 296
Most accurate data available; Country reported value for 2007
[26] Ibid., 292
[27] National Human Development Report
[28] Mozambique: The Challenge of HIV/AIDS Treatment and Care. Commission on HIV/AIDS and Governance in Africa, Economic Commission for Africa, accessed 18 June 2008,
[29] Universal Declaration of Commitment on HIV and AIDS, 22
[30] Ibid., 22-24
[31] Ibid., 22-24
[32] Ibid., 31
[33] Ibid., 30
[34] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[35] Ibid., 296
Most accurate data available; Country reported value for 2007
[36] Ibid., 313
[37] Ibid., 301
[38] Latest AIDS Funding Matrix available, 2008, UNAIDS, (New York, NY), accessed 22 August 2008, 3
[39] Mozambique 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,
[40] Total Dollars Planned for FY 2005 by Program Area, U.S. State Department. (Washington, DC), accessed 19 August 2008, 
[41] Approved Funding by Program Area: Mozambique: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department (Washington, DC), accessed 19 August 2008,
[42] Approved Funding by Program Area: Mozambique: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department (Washington, DC), accessed 19 August 2008,
[43] Approved Funding by Program Area: Mozambique: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department (Washington, DC), accessed 19 August 2008,
[44] Mozambique 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 19 August 2008,
[45] Ibid., 80-81
[46] Ibid., 82, 127
[47] Ibid., 128
[48] Ibid., 116, 177
[49] Sohail Agha1, Andrew Karlyn and Dominique Meekers “The promotion of condom use in non-regular sexual partnerships in urban Mozambique” Health Policy and Planning; 16(2): 144-151 Oxford University Press 2001
[50] Mozambique FY 2007 Country Operational Plan, 177
[51] Ibid., 117
[52] Ibid., 167-168
[53] Ibid., 179
[54] Ibid., 179
[55] Ibid., 97, 193
[56] Project Title: Mozambique Fiscal Year 2007 Country Operational Plan, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 19 August 2008,  
[57] Help Wanted: Confronting the health care worker crisis to expand access to HIV/AIDS treatment, MSF experience in southern Africa (Johannesburg, Médecins Sans Frontières, May 2007), accessed 21 August 2008, 9
[58] Ibid., 14
[59] Ibid., 23
[60] Ibid., 23
[61] Ibid., 24
[62] “Mozambqiue: Health worker shortage hinders AIDS response,” IRIN PlusNews, 6 April 2007, accessed 21 August 2008,
[63] “Mozambique: AIDS epidemic overwhelms health facilities,” IRIN PlusNews, 15 June 2007, accessed 18 June 2008
[64] Help Wanted: Confronting the health care worker crisis to expand access to HIV/AIDS treatment, 13
[65] Mangwiro, Charles, “AIDS-ravaged Mozambique to recruit African doctors,” Reuters, 25 June 2007, accessed 18 June 2008,
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