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2008 PEPFAR Country Profile Update: Guyana

 

 
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 Guyana.  Click Here to Read Guyana's 2005 Original Country Profile)
 
 
Introduction
 
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).  
 
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and, to a lesser extent, to over one hundred other countries.  PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV/AIDS and demonstrated the political will to put that concern into action.  At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying.  Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.  
 
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20% 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. 
 
Overview
 
Guyana is a nation of nearly 800,000 people, which sits on the north-east corner of South America along the Atlantic coast.  Due in some part to Guyana’s British colonial heritage, it maintains stronger cultural ties to the Caribbean nations to the north than to its continental neighbors.
 
The first known case of AIDS in Guyana appeared in 1987 and there has been a progressive increase in the number of reported cases ever since. Estimates of the country’s HIV prevalence range from as low as 1 percent to as high as 2.4 percent.[1] Although the epidemic is generalized across all populations, prevalence is higher in specific sub-populations such as sex workers (26.6 percent), men who have sex with men (21.2 percent), and prisoners (5.24 percent).[2]
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Guyana. The stories behind these statistics are fleshed out in greater detail following the chart.  
 
 
 
A PORTRAIT OF GUYANA IN NUMBERS

Total population (2006)[3]
751,000
Percentage of the population under the age of 24
N/A
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2006)[4]
$4,110
Per capita total expenditure on health (Int’l$, 2006)[5]
$233
Secondary school enrollment rate (2000/2004)[6]
97% Females
93% Males
Estimated number of people ages 15 and over living with HIV (2007)[7]
12,000
HIV prevalence in people ages 15–49 (2007)[8]
2.5%
HIV prevalence in people ages 15–24 (2007)[9]
1.7% Females
0.5% Males
Median age of first intercourse
N/A
Median age of first marriage
N/A
Young people ages 15–24 who have had sex before age 15 (2005)[10]
12% Females
30% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2005)[11]
1% Females
9% Males
People 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)[12]
56% Females
53% Males
Contraceptive prevalence rate (2006)[13]
N/A
Percentage of couples using condoms for family planning (2005)[14]
8.8%
Number of births per 1,000 women ages 15–19 (2005–2010)[15]
N/A
Percentage of females (20–24) who have given birth by age 18 (2006)[16]
N/A
Young people ages 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (2005)[17]
44% Females
34% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[18]
N/A
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Guyana first responded to HIV by establishing the National AIDS Program in 1989. This was followed by the establishment of the National AIDS Programme Secretariat in 1992 to coordinate the nation’s response to the epidemic. In 1999, Guyana implemented its first National AIDS Strategic Plan (NSP) covering 1999–2001. Although these initiatives demonstrated a strong political will to combat the epidemic, they were hampered in large part by a lack of sufficient funds and coordination at the national and regional levels. Guyana developed subsequent NSPs focusing on surveillance, care, treatment, support, and risk reduction. The NSP for 2007–2011 retains the same goal as its predecessor to “reduce the social and economic impact of HIV and AIDS on individuals and communities and ultimately the development of the country” but is more extensive than earlier plans such as the 1989 National AIDS Programme. [19] 
 

Relevant Guiding Principles for the 20072011 NSP
 
  1. The response must consider efforts at behaviour change, but must also address the vulnerability factors such as fear, denial, stigma and discrimination, gender equality and power differentials, poverty and livelihood insecurity, internal migration for employment purposes, social-cultural norms, values and practices, and the national legislative and policy environment
  2. People living with HIV/AIDS (PLWHA) are central to the overall response, they need to be empowered to enable them to take effective action themselves and with others
  3. Recognizes the special needs of other vulnerable and disadvantaged groups, such as women, those living in poverty, street children, the disabled, migrants, sex workers, prisoners, men who have sex with men
  4. Ensures 100% access to PMTCT
  5. Ensures that the needs of those caring for PLWHA are taken into account
  6. Empower communities to take effective action themselves and in collaboration with others to prevent HIV transmission and to improve the quality of life of PLWHA
  7. Mobilize and train members of the community, FBOs, CBOs, NGOs and the private sector to provide complementary services to add to those provided by health care providers in counseling and testing and in general awareness programs for HIV/AIDS, TB and STIs
 
 


However, despite this new plan to eradicate HIV/AIDS, Guyana has shown little progress in controlling the spread of the epidemic. Stigma and discrimination still abound in Guyana, hampering efforts to expand voluntary HIV testing and creating obstacles to accurate knowledge of the virus. 
 
Several national surveys, including the most recent 2005 AIDS Indicator Survey (AIS), Behavioural Surveillance Surveys (BSS), and the Biological and Behavioural Surveillance Surveys (BBSS)—conducted among young people, employees of the sugar industry, members of the uniformed services, female sex workers, and MSM—show these populations hold a number of misconceptions regarding HIV transmission. For instance, among out-of-school youths, approximately 30 percent of all respondents believed that HIV can be transmitted via mosquitoes and close to 25 percent thought it could be transmitted through the sharing of a meal with an infected person. In fact, only 39 percent of young people ages 15–24 both correctly identified ways of preventing the sexual transmission of HIV, and rejected major misconceptions about HIV transmission.[20] Approximately 25 percent of respondents said they would not purchase food from an HIV-infected shopkeeper and 33 percent said that if a family member was infected, they would want the person’s status to remain secret.[21]   
 
This lack of knowledge and ongoing bias may translate into a decrease in safer sex practices. According to the AIS, 64 percent of men and 39 percent of women ages 25–49 reported using a condom during their last sexual encounter. Furthermore, survey data from the 2005 BBSS indicates that only 80 percent of men (age range not specified) reported using a condom during anal sex with a non-regular male partner.[22]
 
Guyana is one of the poorer countries in the Caribbean region, ranking 97 out of the 177 countries in the 2007–2008 United Nation’s Human Development Index.[23] Guyana has limited resources to address the HIV epidemic on its own. With only a $233 per capita expenditure on all healthcare needs, Guyana is heavily dependent on external donors for the implementation of its HIV prevention, care, and treatment programs.[24] In addition to PEPFAR funding, Guyana receives assistance from many other organizations: the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), which has provided approximately $27.2 million for the period of 2004–2008, the World Bank, which has provided $10 million over the same period, and various other bodies of the United Nations.[25]
 
President’s Emergency Plan for AIDS Relief (PEPFAR)

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

Funding
 
PEPFAR began implementing its HIV programs in Guyana, one of three non-African nations chosen as a focus country, in 2004 with an initial grant of $12 million dollars. Although total funding for Guyana increased by $4 million from 2004–2005 and by another $4 million from 2006–2007, it has not received the dramatic doubling of funding that some of the sub-Saharan African countries have seen. 
 
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstinence-only, Be faithful, and Correct and Consistent Condom Use. Abstinence-only/Be-faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).
 
 
Allocated PEPFAR Funds 2004–2008*
 
 
2004[26]
2005[27]
2006[28]
2007[29]
2008[30]
Total Funds Allocated**
$12,200,205
$16,145,585
$17,789,116
$21,664,520
$17,985,898
Total Prevention Funds Allocated
N/A
$7,193,958
$6,583,756
$6,468,160
$6,812,993
Total AB Funds Allocated
N/A
$1,415,000
$1,890,754
$1,861,231
$2,267,491
Total Other Prevention Funds Allocated (includes condom funding)
N/A
$1,051,000
$1,423,000
$1,578,000
$1,510,817
Total Treatment Funds Allocated
N/A
$5,313,127
$7,502,360
$10,506,360
$6,793,706
Total Care Funds Allocated
N/A
$3,638,500
$4,185,000
$4,740,000
$4,379,999
* 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.
 
Guyana’s total funds were cut by over $3.5 million in 2008 with no clear justification for the decrease in funding. In addition, target goals of reaching HIV-positive persons with treatment dropped from 2,100 in 2007 to fewer than 2,000 in 2008. This means that Guyana’s goal for the number of people who will receive treatment in 2008 is lower than the actual number of HIV-positive people who were treated in 2007. This is clearly a step in the wrong direction.[31] 
 
The percentage allocated for total prevention funds has increased slightly to 37.9 percent of the total funds. This is the first time since 2005 that the percentage of prevention funds has increased; it had steadily decreased from 45 percent of the total budget in 2005 to 37 percent in 2006, and finally to 29.6 percent in 2007. Much of the decrease over the previous years was due to a substantial decrease in funds for Injection Safety during 2005–2007.  
 
Funding for Other Prevention (OP) programs has slightly decreased, while funding for Abstinence-only/Be-faithful (AB) programs increased by close to half a million dollars from 2007 to 2008. AB program funds now account for 12.6 percent of the total budget; the largest allocation of the total budget to date. Considering that the highest prevalence rates are in most-at-risk-populations, such as sex-workers, for whom abstinence and being faithful are not an option, the funding distribution appears at odds with the country’s current prevention needs.
 
Prevention Programming
 
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population. Programs addressing correct and consistent condom use are most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding. 
 
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP).  The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP.   This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR’s overall impact on prevention programming in the country. 
 
According to the 2007 Country Operational Plan, PEPFAR implemented a total of eleven AB programs that were funded at $1,861,231 and intended to reach 167,850 people[32] In contrast, there were a total of eight OP programs intended to reach 32,175 people and funded at $1,578,000.[33] All of the organizations that received OP funding also received AB funding. In addition, only three of the eight OP programs specifically addressed correct and consistent condom use and increased access to condoms.[34]
 
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 Guyana. 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.[35]
 
Organizations that received only AB funding only:

  • American Red Cross
  • Catholic Relief Services
  • Ministry of Health, Guyana

 
Organizations that received both AB and OP funding:

  • Center for Disaster and Humanitarian Assistance Medicine
  • Comforce
  • Family Health International
  • Manila Consulting, Inc.
  • Maurice Solomon Accounting
  • Public Health Institute
  • U.S. Peace Corps
  • U.S. Centers for Disease Control and Prevention (CDC)

 
Organizations that received only OP funding:
  • None
                                                
The American Red Cross received the most AB funding at $74,231 and Catholic Relief Services (CRS) received the second largest amount at $20,000. CRS has operated AB-only programs in Guyana since it first became a PEPFAR grantee in 2004.  In 2007, it used its AB-only money to expand its program, Guyana Abstinence Program, by training 300 peer educators who promoted what the organization described as “value-based, HIV-prevention activities.” Its description of the program, however, does not further explain the kinds of activities being implemented or what it means by “value-based.” CRS also established a youth club in order to coordinate future initiatives to promote value-based HIV-prevention activities that will reach 5,000 young people through the youth clubs.[36]
 
Family Health International (FHI), Maurice Solomon Accounting, and the U.S. Centers for Disease Control (CDC) received the largest overall AB/OP funding amounts in 2007. FHI received the largest amount at $4,670,000, Maurice Solomon Accounting received $2,763,000, and the CDC received $2,091,511. Of these three grantees, only FHI provided increased access to condoms and advocated for correct and consistent condom use or an ABC approach to HIV prevention.
 
The best measure of how effective FHI’s ABC approach to prevention has been is the USAID’s most recent audit of FHI’s programs in Guyana from 2006. Data from the USAID audit is not available in other PEPFAR focus countries. The audit found that FHI worked with 19 local non-governmental organizations to accomplish all of its prevention, care, and treatment work. Of these NGOs, seven did not provide OP programs and one delivered AB-messages only.[37] FHI was expected to train 400 individuals to carry out OP programming but only half were trained.[38] In addition, only several thousand condoms were actually distributed by FHI’s partners.[39] According to the audit, FHI also contracted with three U.S. based organizations: Cicatelli Associates Inc., Management Sciences for Health, and Howard Delafield International. Howard Delafield International collaborated on a major behavior change campaign that included media messages to reduce stigma and discrimination, increase testing and counseling, and lessen sexual activity in youth. Although the program planned to deliver twenty mass media programs, only three were actually implemented. All of the media programs used abstinence and be-faithful messages— there were no messages containing information on correct and consistent condom use in the media programs.[40] Despite USAID’s audit showing clear evidence that FHI failed to meet its OP programming targets and objectives in 2006, its budget continued to increase, and it remains the largest grantee of PEPFAR aid in AB/OP programming.
 
Items of Note: Sex Workers and the Prostitution Loyalty Oath
 
Guyana is unique among the PEPFAR-funded countries in that it is the only Caribbean nation included as a focus country. As is the case in Vietnam, Guyana’s HIV epidemic is primarily located in a specific population. One particularly hard hit population is female sex workers (FSWs).  HIV prevalence among FSWs has ranged from 25–45 percent in the 1990s to the current prevalence of 26.6 percent. The fluctuation in rates has been accredited to more FSWs being tested throughout the years and does not necessarily reflect a rise or fall in actual incidences of HIV infection.[41] Prevalence among female sex workers is 11 times higher than the national average of roughly 2.4 percent. It is also higher than other subgroups that have high HIV prevalence rates such as men who have sex with men (21.2 percent) and miners (6.9–11 percent).[42]
 
Guyana’s sex work industry is located primarily in the capital city of Georgetown, but has expanded into rural areas as well. This expansion is in part due to the influx of migrant workers flooding into Guyana from Venezuela and Brazil to work in the mining industry. 
 
The original legislation authorizing PEPFAR stipulates that any domestic or international organizations receiving these funds is required to certify that it has an official policy opposing sex work. This policy, informally known as the “prostitution pledge”, prohibits organizations from spending any funds, whether from the U.S. government of not, on activities that, “promote or support the legalization or practice of prostitution.”[43] Even groups working with women engaged in commercial sex work are required to officially oppose sex work as a condition of receiving funds.  
 
Three of the AB/OP PEPFAR grantees in 2007 provided prevention outreach to sex workers. FHI received $400,000 in OP funding and offered as part of its OP program: “skills-building opportunities to increase alternative income generation or employment options, in addition to condom negotiation skills and strategies for avoiding violence (avoiding alcohol and drugs).”[44] Maurice Solomon Accounting received $625,000 in OP funding and offered as part of its OP program: “Interventions including HIV/STI prevention education including information on assessing, reducing and eliminating one’s risk of infection through behavior change. These are conducted through one-on-one interaction by outreach workers and peer-education training.
Outreach workers and peer educators also facilitate access to screening and treatment for HIV and other STI, assistance for care and treatment referrals, as well as access to affordable condoms.”[45] Manila Consulting, Inc received $233,900 in OP funding and had the most targeted program to sex workers: a program called MARCH (Modeling and Reinforcement to Combat HIV/AIDS). MARCH reaches out to sex workers to “specifically address consistent and correct condom use, access to services and reduction of stigma and discrimination through the radio serial drama (RSD), Merundoi.  The 15-minute RSD will be aired twice weekly beginning October 2006 on the popular FM station and repeated on the Voice of Guyana, a channel with a wider reach.”[46]
 
In the field the restrictions brought about by the “prostitution pledge” have hampered some organizations’ efforts to work with these vulnerable populations, prevented some organizations from receiving funds, and made some of the organizations most skilled at understanding the complex social, economic, and cultural needs of sex workers reluctant to continue providing HIV prevention and other services for fear of losing funds. Although some organizations have refused to comply with the “prostitution pledge” and therefore refused PEPFAR funding for their work, many organizations need the financial support to continue their operations within their communities. The “prostitution pledge” not only limits the prevention efforts on the ground but also perpetuates the stigma and discrimination of FSWs by forbidding necessary aid to them. The result is that the population made most vulnerable by this epidemic is the one population barred from receiving any need that could help the most.   
 
Recommendations
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Lawmakers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
 
1.  Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
 
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion.  As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
 
 
2. Increase Transparency of PEPFAR Prevention Funds
           
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement, OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession. 
 
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
 
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
 
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
 
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.  
 
4.  Rescind the Anti-Prostitution Pledge
 
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable.  The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
 
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
 
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease.  However, such segmentation has also led to too narrow a framework/conceptualization.  Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
 
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground. 
 
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
 
6.  On-the-Ground Monitoring of Funded Activities
 
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways.  Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming.  PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs.  We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
 
7. Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
 
 
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 
 
 
 
 
 
 
 


[1] UNGASS Country Progress Report: Republic of Guyana, Government of Guyana/United Nations General Assembly Special Session on HIV/AIDS 2006-2007 Progress Report, (Guyana; New York, NY), accessed 16 July 2008, http://data.unaids.org 16
2 Ibid., 16-17
3 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles, UNAIDS, (New York, NY), accessed 16 July 2008, http://data.unaids.org 11
4 Ibid., 11
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., 11
[6] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC), accessed 16 July 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf9
[7] 2008 Report of the Global AIDS Epidemic Annex 1: HIV and AIDS Estimates and Data, 2007 and 2001, UNAIDS, (New York, NY) accessed 29 July 2008 http://data.unaids.org 229
[8] Ibid., 230
[9] Ibid., 232
[10] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 31 July 2008, http://data.unaids.org 301
[11] Ibid., 305
[12] Ibid., 311
[13] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY), accessed 16 July 2008,http://www.unfpa.org/swp/2006/english/notes/indicators/e_indicator1.pdf 95
[14] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 30 June 2008,
[15] Monitoring ICPD Goals, 95
[16] The World’s Youth 2006 Data Sheet, 15
[17] 2008 Report on the Global AIDS Epidemic Annex 2, 296
[18] Ibid., 292
[19] National Strategic Plan for HIV/AIDS 2002-2006, Republic of Guyana, (Guyana), accessed 16 July 2008, http://siteresources.worldbank.org 5; National Strategic Plan for HIV/AIDS 2007-2012, Republic of Guyana, (Guyana), accessed 15 July 2008, http://www.hiv.gov.gy/docs/moh_sp_nsp_2007_11.pdf 14
[20] UNGASS Country Progress Report, 11
[21] Ibid., 19-20
[22] Ibid., 14
[23] 2007/2008 Report Human and income poverty: developing countries, United Nations Development Programme (UNDP), (New York, NY), accessed 16 July 2008, http://hdrstats.undp.org/indicators/17.html
[24] 2006 Report on the Global AIDS Epidemic Annex 1, 11
[25] Guyana 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 16 July 2008, http://www.pepfar.gov/about/82451.htm
[26] Guyana FY 2004-2006 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 16 July 2008,   http://foia.state.gov/COP/guyana04_06.pdf
[27] Approved Funding by Program Area: Guyana: FY 2005, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 16 July 2008, http://www.state.gov/s/gac/progress/other/data/program/59698.htm
[28] Approved Funding by Program Area: Guyana: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 16 July 2008, http://www.pepfar.gov/about/77678.htm
[29] Approved Funding by Program Area: Guyana: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 16 July 2008, http://www.pepfar.gov/about/82465.htm
[30] Approved Funding by Program Area: Guyana: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 16 July 2008, http://www.pepfar.gov/about/opplan08/102033.htm 
[31] What is PEPFAR? AVERT. Updated 30 June 2008, accessed 16 July 2008, http://www.avert.org/pepfar.htm
[32] Guyana 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 16 July 2008,   http://www.pepfar.gov/documents/organization/103932.pdf 35
[33] Ibid., 79-96
[34] Ibid., 79, 82, 92
[35] Ibid
[36] Ibid., 57
[37] Audit of USAID/Guyana’s Progress in Implementing the President’s Emergency Plan for AIDS Relief, Office Of Inspector General, (San Salvador, El Salvador), accessed 1 July 2008, http://www.usaid.gov 43
[38] Ibid., 7
[39] Ibid., 16
[40] Ibid., 10
[41] Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections (2004 Update, Guyana), accessed 11 July 2008, http://www.hiv.gov.gy/edocs/unaids_st_epigy04.pdf 2
[42] HIV/AIDS in Guyana. Government of Guyana National HIV/AIDS Programme, Ministry of Health, (Brickdam, Georgetown, Guyana) Last Updated: January 25, 2008, accessed 11 July 2008, http://www.hiv.gov.gy/gp_hiv_gy.php
[43] See P.L. 108-25, 23 May 2003, 111 STAT 734(f), accessed 11 July 2008,
[44] Guyana FY 2007 Country Operational Plan (COP), 82
[45] Ibid., 85
[46] Ibid., 92
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