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2008 PEPFAR Country Profile Update: Namibia


Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

(The following document is a 2008 update to the status of PEPFAR funding and related issues in Namibia.  Click Here to Read Namibia'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% of the funds could be spent on prevention efforts.  Moreover, 33% of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs.  Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, which they believed to be inconsistent with their religious teachings. 
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time. 
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds. 
In addition to this data, each update also offers further analysis on particular items of note in the country.  And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries.  While these updates can be read independently of the original profiles, reading them together affords an even richer perspective. 
The first HIV infection in Namibia was reported in 1986 and the rate of infection progressively increased until leveling off in 2000. The best estimate of HIV prevalence comes from biennial surveys among pregnant women in antenatal clinics that were first conducted in 1992. The most recent survey from 2006 shows that about 20 percent, or one in five pregnant women, are HIV-positive. The data suggest that this rate has remained stable since 2000.[1] Deriving country-wide estimates from antenatal clinics is likely to yield a lower estimate, as such surveys leave out entire segments of the population, including men who have sex with men.
Prevalence estimates taken from antenatal clinics (ANC) also vary based on region. They indicate that different parts of the country are disproportionately affected by the HIV/AIDS epidemic. The highest ANC HIV prevalence (39.4 percent) was reported in Katima Mulilo, a densely populated urban area of more than 100,000 people that is the administrative center and capital of the Caprivi Strip Region that makes up the narrow northeastern strip of Namibia. The lowest (7.9 percent) was reported in both Opuwo and Gobabis; areas made up of rural farmlands that have a population under 15,000 people. Estimates show that by 2007 as many as 200,000 people were living with HIV. This figure is particularly startling in light of the size of Namibia’s overall population which totals just over 2 million.[2] 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Namibia. The stories behind the statistics are fleshed out in greater detail following the chart.
Total population (2006)[3]
Percentage of the population under the age of 24
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2006)[4]
Per capita total expenditure on health (Int’l$, 2006)[5]
Secondary school enrollment rate (2006)[6]
62% Females
54% Males
Estimated number of people ages 15 and over living with HIV (2007)[7]
HIV prevalence in people ages 15–49 (2007)[8]
15. 3%
HIV prevalence in people ages 15–24 (2007)[9]
10.3% Females
3.4% Males
Median age of first intercourse
Median age of first marriage
Young people ages 15–24 who have had sex before age 15 (2007)[10]
7% Females
18% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2007)[11]
3% Females
16% Males
Percentage of women and men ages 1549 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse (2007)[12]
66% Females
74% Males
Contraceptive prevalence rate (2006)[13]
Any method: 44%
Modern: 43%
Percentage of couples using condoms for family planning (2005)[14]
Number of births per 1,000 women ages 15–19(2005–2010)[15]
Percentage of females (20–24) who have given birth by age 18 (2006)[16]
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 (2007)[17]
65% Females
62% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[18]
In 2007, the virus was responsible for the deaths of 5,100 adults and children, and by that year  66,000 children had lost one or both parents to AIDS-related illness or disease.[19] In Namibia, HIV is most commonly spread by heterosexual sexual transmission and mother-to-child transmission. The data suggest women are three times more likely than men to be infected with the virus.[20]
Namibia became independent in 1990, and despite its brief history, Namibia’s government has been working to combat the HIV/AIDS epidemic from the start of its formation. In 1990, President Sam Nujoma launched the National AIDS Control Programme. A National Strategic Plan (NSP) on HIV/AIDS Short-Term Plan for 1990–1992 quickly followed. NSP Medium-Term Plans I, II, and III have been subsequently implemented, covering 1992–1998, 1999–2004, and 2004–2009, respectively. The Namibian government has also worked with United States Agency for International Development (USAID) to create a Country Strategic Plan for 2004–2010. 
While the full text of the  NSP 2004–2009 is not available, the country has released its key strategies.[21] Dr. Norbert Forster, Namibia’s former Under Secretary of Health and Social Welfare Policy of the Namibian Ministry of Health, stated “The objective of the MTP III is to reduce the incidence of HIV infection to below epidemic threshold. In epidemiological terms this implies less than one new infection for every existing person living with HIV/AIDS.”[22] 


Key Strategies of the NSP 2004–2009
1. Creating and strengthening the enabling environment so that people infected and affected with HIV/AIDS can enjoy equal rights in a culture of acceptance, openness and compassion
2. Prevention to reduce new infections of HIV and other sexually transmitted diseases
3. Access to cost effective and high quality treatment care and support services for all people living with, or affected by HIV/AIDS
4. Strengthening and expanding the capacity for local responses to mitigate socio-economic impacts of HIV/AIDS
5. Integrated and coordinated programme management that has effective management structures and systems, optimal capacity skills and high quality programme implementation at all levels of the society

Through its NSP process, Namibia has made HIV/AIDS prevention a major national priority. The stated objective is, “to ensure that each and every Namibian gets accurate, clear, and easy to understand information on HIV/AIDS such that he/she is able to make an informed decision on his/her sexual behavior.”[23] The Namibian government aimed to accomplish these objectives  through three main areas:
1)      Information, education and communication
2)      Condom distribution
3)      Care and support of those affected and infected
In 2006, the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) evaluated Namibia’s success to date. The UNGASS assessment states that although the country had come a long way, “overall the policy environment in Namibia is strong and ready for expanded implementation efforts.”[24] For example, among pregnant women receiving HIV prevention, care, and treatment services during the two years from 2004 to 2006, the percentage of pregnant mothers receiving an HIV test at an antenatal clinic increased from 79 percent to 86 percent. The percentage of those tested who received post-test counseling increased from 38 percent to 58 percent. And the percentage of HIV-positive women who were eligible for antiretroviral therapy increased from 29 percent to 70 percent. These indicators suggest significant improvement a relatively brief period of time.[25] 
Improvements have also been made in safer sex practices. However, UNGASS has reported that females and males continue to have drastically different safer sex practices.[26] According to a 2006 Namibia Demographic Health Survey (DHS), condom use increased. Of those surveyed, 74 percent of females and 81.1 percent of males ages15–24 reported using a condom with a non-regular partner in the past 12 months.[27] This is a large increase compared to the 2000 Namibia DHS with comparable rates of 47.9 percent of females and 69.4 percent of males. These comparisons indicate significant progress in condom use among both sexes but women’s reported usage continues to lag behind men’s. The low condom usage figures among women may be one reason why women are disproportionately affected by HIV. In Namibia, women are three times more likely to contract the virus than men, and one in five pregnant women are HIV-positive.[28] The UNGASS report suggests that there are several key shortcomings in Namibia which lead to this inequality, including inadequate interventions for vulnerable populations, poor legal review of factors affecting gender equality, and insufficient consideration for the factor of gender-based violence.[29] 
Namibia’s government has continually increased funding for programs under its NSP process, but in 2005 the NSP still only funded 41 percent of programs operating in its own country. Namibia bridges the remaining gap with funds from the Global Fund, various United Nations agencies, the European Commission, the Government of Germany, and the United States government, through the President’s Emergency Plan for AIDS Relief (PEPFAR).[30]
President’s Emergency Plan for AIDS Relief (PEPFAR)

Key Terms to Understanding PEPFAR Prevention Programs and Funds
ABC: ABC stands for “Abstain, Be-Faithful, and Correct and Consistent Condom Use.” ABC is PEPFAR’s guiding principal for HIV-prevention programs. PEPFAR requires that a minimum of one-third of all prevention funds be spent on abstinence programs and it limits the promotion and marketing of condoms to specific groups outlined in PEPFAR’s ABC guidance. No discussion or promotion of condoms is permitted with youth under the age of 14 using PEPFAR funds.
Country Operation Plan (COP): A yearly program and budget plan developed for each PEPFAR focus country.  The COP is developed by U.S. staff in conjunction with country governments. It divides programs into three main categories of prevention, care, and treatment: Abstinence-Be-Faithful (AB), Other Prevention (OP), and Prevention of Mother-to-Child Transmission (PMTCT). A country’s COP is not the same as its National Strategic Plan/Framework (NSP/F). Unlike a NSP/F, a COP is specific to PEPFAR programs and funds, and is developed annually. In comparison, the NSP/F is a multi-year, country-wide strategy on HIV/AIDS that is developed by each country’s government. Although the NSP/F may make reference to PEPFAR and other international donors, it is not limited to a description of activities funded by international donors, and an NSP/F may or may not be developed with input from the United States or other donors. 
Abstinence-Be-Faithful (AB): One category of prevention programs and funding under PEPFAR. Grantees that provide AB programs focus on education and promotion of abstinence-until-marriage and be-faithful messages. Grantees that receive OP funds, such as those to promote condom use, are listed in both sections of the COP.
Other Prevention (OP): One category of prevention programs and funding under PEPFAR. The OP category includes any prevention program that is not an AB program or a PMTCT program. This category includes surveillance programs, programs aimed at reducing stigma and discrimination, training for healthcare workers, and the promotion and marketing of correct and consistent condom use. Grantees that receive funds for OP programs in addition to AB funds are listed in both sections of the COP.
Prevention of Mother-to-Child Transmission (PMTCT): One category of prevention programs and funding under PEPFAR. The PMTCT category includes routine rapid HIV-testing in antenatal and maternity settings, counseling and support for infant feeding, and linking to care, treatment, and support services.

Despite the extremely high HIV/AIDS prevalence Namibia falls in the middle of the funding range of PEPFAR-funded countries. Namibia received an initial grant of $24,497,240 in 2004, with steady increases in subsequent years, bring the allocation for 2008 to $88,205,272.
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.
The majority of PEPFAR funding to Namibia goes to programs for treatment and care. The only funding decrease in PEPFAR funds occurred between 2005 and 2006 when funds for Other Prevention (OP) programs were cut nearly in half. Treatment and care funds each received large increases from 2006–2008. In 2008, treatment funds made up 36.7 percent and care funds made up 34.4 percent of the total funds. Prevention funds have received the smallest increases over the years and currently make up only 28.9 percent of the total budget. Abstinence-only/Be-Faithful (AB) funds have nearly doubled each year between 2005–2007 and currently make up a little less than half of the total 2008 prevention budget; making it the fastest growing allocation of funds in Namibia’s PEPFAR budget.
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.
Namibia’s Country Operational Plan for 2007 shows a total of 11 grantees that provided both AB/OP programs, three grantees that provided AB-only programs, and three grantees that provided OP-only programs. AB-only programs received $8,756,505 and were projected to reach 241,784 people through community outreach. In contrast, OP-only programs received $4,974,601 and were projected to reach 406,316 people. This means that OP programming was expected to reach about twice as many people than AB-only programs with approximately half the funds.
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 Namibia. 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.[36]
Organizations that received only AB funding:

  • U.S. Centers for Disease Control and Prevention (CDC)
  • Fresh Ministries
  • Namibia Nature Foundation

Organizations that received both AB and OP funding:

  • Academy for Educational Development
  • Development Aid People to People, Namibia
  • EngenderHealth
  • IntraHealth International, Inc
  • Johns Hopkins University Center for Communication Programs
  • Ministry of Health and Social Services, Namibia
  • Pact, Inc.
  • Project HOPE
  • Public Health Institute
  • Namibian Social Marketing Association
  • Social Marketing Association/Population Services International

Organizations that received only OP funding:

  • Potentia Namibia Recruitment Consultancy
  • University Research Corporation, LLC
  • U.S. Peace Corps

The U.S. Centers for Disease Control and Prevention received $150,000 and was the largest provider of AB-only programs in 2007. According to the Country Operational Plan, AB-only programs are a new activity for the CDC in Namibia and use, “the evidence-based ‘Parents Matter’ or ‘Families Matter’ approach… [in] the Namibia context to create a locally relevant toolkit that willing organizations can put into practice. It is critical that adolescents be taught about responsible sexual behavior by their parents or close relatives taking local cultural practices and norms into account.”[37] “Parents Matter” tries to foster better communication about sex between parents and children between 8 and 12 years of age.
One of the more widespread AB programs in Namibia is implemented by Fresh Ministries which operates a program called “Siyafundisa” or “Teaching Our Children” in Zulu. Fresh Ministries partnered with Episcopalian and Anglican churches throughout Namibia to teach Siyafundisa to youth attending religious services. Youth are taught to abstain from sex until marriage and be faithful once married in order to prevent the transmission of HIV.[38]
The largest provider of AB/OP programs in 2007 was the Ministry of Health and Social Services (MOHSS) at $3,525,000. MOHSS uses an ABC approach to HIV prevention by delivering the AB-only message and distributing condoms to groups that it identifies as high-risk. MOHSS established the Community Counselor cadre which trains individuals to assist doctors and nurses with evidence-based ABC prevention, palliative care, voluntary counseling and testing, and treatment.[39] MOHSS recruits HIV-positive individuals to become counselors in order to reach out to these individuals for treatment and care and to dispel any stigma or myths about the virus; one in four counselors is HIV-positive. MOHSS hopes to reach more than 74 health facilities in Namibia with over 480 community counselors. For its OP programming, MOHSS distributed the highly popular “Smile” brand of condoms free of charge to health facilities for distribution to high-risk clients (HIV-positive patients, STI patients, TB patients, and patients having sex with a person of unknown HIV status), and to NGO/FBO partners for distribution to high-risk individuals (mobile workers, commercial sex workers, PLWHA and their partners, and persons having sex with a partner of unknown HIV status).[40] 
The largest provider of OP programs was the U.S. Peace Corps, which received $566,900. The Peace Corps trained volunteers to help promote healthy lifestyles, HIV/AIDS prevention measures, and life skills development. The Peace Corps projected that 3,000 individuals were reached through its community outreach.[41]
Items of Note: Prevention of Mother-to-Child Transmission
In Namibia, more than one in five pregnant women have HIV and are at risk of transmitting the virus to their children.[42] Mother-to-child transmission of HIV can occur during pregnancy, labor and delivery, or breastfeeding. Approximately 700,000 children under age 15 in sub-Saharan Africa, acquired HIV through mother-to-child-transmission.[43] Though exact figures for Namibia are unknown, mother-to-child-transmission and heterosexual sexual contact are the primary modes of transmission of the virus. 
Under a prevention of mother-to-child transmission (PMTCT) program, women are tested for HIV and, if positive, given a long course of antiretroviral therapy (ART) and instructed to avoid breastfeeding in order to prevent transmission to the child. In countries where ART is well integrated into healthcare protocol, this method has reduced the risk of transmission to below 2 percent.[44] These services are usually part of antenatal care and have the potential to be incredibly successful; the most recent estimate based on the 2006 Demographic and Health Survey preliminary tables shows that 96 percent of pregnant women in Namibia attend antenatal care clinics (ANC) at least once, and 81 percent of deliveries in the last 5 years were conducted by trained health professionals in a health facility. Thus, the potential to reach most pregnant women with PMTCT services in Namibia is high.[45] As many as 90 percent of HIV-positive women, whether they are pregnant or not, receive ART and 85 percent of pregnant women attending an ANC know their HIV status at delivery.[46] 
However, Namibia faces a number of obstacles to successfully providing PMTCT services to all pregnant women. It is estimated that only 43 percent of HIV-positive mothers are actually receiving ART.[47] Training health professionals to effectively implement PMTCT services remains difficult due to inadequate human resource capacity. It is estimated that, as of 2006, the vacancy rate in government positions was 40 percent for doctors, 60 percent for pharmacists, 48 percent for social workers, 25 percent for registered nurses, and 30 percent for enrolled nurses.[48] The shortages are not the only obstacle to PMTCT services. Women in rural areas must travel long distances to access the clinics that offer these services. Since Namibia is a sparsely populated country, it may be hard to ensure that all women have access to these programs.[49] 
PMTCT resources are found at antenatal clinics, while traditional ART is typically given elsewhere. For many women, the difference in the location of care and treatment can inhibit their ability to seek treatment for their own HIV infection after completing the PMTCT program.  Receiving the proper PMTCT care and treatment does not ensure consistent access and use of ART services. Failing to continue treatment leaves these women vulnerable to illness and death due to complications from HIV/AIDS, leaving their children without proper care for extended periods of time or, worse, without a parent.
PMTCT programs have the potential to save thousands of lives. However, the government must still work to ensure that these programs are accessible to rural women and that there are enough qualified healthcare personnel to adequately address their needs.
PEPFAR funding is especially critical in this area. PEPFAR funding for prevention in general continues to remain low compared to funds for treatment and care, and it is hard to effectively allocate enough funds to this area. In 2007, PEPFAR allocated just $3,922,488 to PMTCT services, less than 6 percent of all funding and only 20 percent of prevention funding.[50] For PMTCT to reach its full potential as a life-saving service, it must receive more attention and funding in order to help Namibia overcome the structural barriers which prevent pregnant woman from accessing care.
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] UNGASS Country Progress Report: Namibia, Republic of Namibia Ministry of Health and Social Services, April 2006 – March 2007, (Namibia), accessed 2 July 2008, 9
[2] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY), accessed 4 August 2008, 214; Natural Resource Development: The 2004-2010 Strategy, updated 28 August 2006, UNAIDS, (New York, NY), accessed 2 July 2008,
[3] 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles, UNAIDS, (New York, NY) accessed 5 August 2008, 312
[4] Ibid., 312
According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
[5] Ibid., 312
[6] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 2 July 2008, 94
[7] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[8] Ibid., 215
[9] Ibid., 217
[10] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 31 July 2008, 301
[11] Ibid., 307
[12] Ibid., 313
[13] Monitoring ICPD Goals – Selected Indicators, 94
[14] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 2 July 2008,
[15] Monitoring ICPD Goals – Selected Indicators, 94
[16] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 2 July 2008, 14
[17] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[18] Ibid., 292
[19] 2008 Report on the Global AIDS Epidemic Annex 1, 217, 218
[20] Ibid., 217
[21] Statement by His Excellency, President of the Republic of Namibia: On the Occasion of the Launching of the National Policy on HIV/AIDS, 24 July 2007, (Windhoek, Namibia), accessed 29 July 2008,
[22] Namibia: Namibia rolls out third National AIDS plan, PlusNews (19 April 2004), accessed 2 July 2008,
[23] UNGASS Country Progress Report, 11
[24] Ibid., 18
[25] Ibid., 27-28
[26] Ibid., 42
[27] Ibid., 7
[28] Ibid., 21
[29] Ibid., 43
[30] Ibid., 10
[31] Namibia 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 2 July 2008,
[32] Namibia 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 2 July 2008,
[33] Approved Funding by Program Area: Namibia: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 2 July 2008,
[34] Approved Funding by Program Area: Namibia: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 2 July 2008,
[35] Approved Funding by Program Area: Namibia: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 10 July 2008,
[36] Namibia FY 2007 Country Operational Plan (COP), PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 9 July 2008,
[37] Ibid., 83
[38] Ibid., 62
[39] Ibid., 58
[40] Ibid., 117
[41] Ibid., 155
[42] UNGASS Country Progress Report, 9
[43] Preventing Mother-to-Child transmission of HIV, AVERTing HIV and AIDS (AVERT), Updated May 28, 2008, accessed 9 July 2008,
[44] Preventing Mother-to-Child Transmission in Practice, AVERTing HIV and AIDS (AVERT), Updated May 28, 2008, accessed 9 July 2008,
[45] UNGASS Country Progress Report, 26
[46] Ibid., 28
[47] 2008 Report on the Global AIDS Epidemic Annex 2, 278
[48] Namibia FY 2007 Country Operational Plan, 400
[49] 2008 Country Profile: Namibia, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 9 July 2008, 
[50] Approved Funding by Program Area: Namibia: FY 2007
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