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2008 PEPFAR Country Profile Update: Tanzania

 

 
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 Tanzania.  Click Here to Read Tanzania'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
 
The first reported cases of HIV/AIDS in Tanzania were in 1983 in the Kagera Region, a large rural farm area in the northwestern corner of the country well known for its banana, plantain, and coffee produce. It is estimated that AIDS-related mortality is currently the most common cause of death in Tanzania killing as many as 180,000 people each year.[1] It is estimated that as many as 1.3 million people over 15 are currently living with HIV and almost one million children have been orphaned because of the disease.[2] Current life expectancy in Tanzania is 47 years for men and 49 years for women, and life expectancy in the country is estimated to be nearly ten years lower in 2010 than it would have been in the absence of the disease. 
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Tanzania. The stories behind the statistics are fleshed out in greater detail following the chart.
 
 
A PORTRAIT OF TANZANIA IN NUMBERS
 
Total population (2006)[3]
38,329,000
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]
$660
Per capita total expenditure on health (Int’l$, 2006)[5]
$16
Secondary school enrollment rate (1999–2005)[6]
5% female
6% male
Estimated number of people ages 15 and over living with HIV (2007)[7]
1,300,000
 
HIV prevalence in people ages 15–49 (2007)[8]
6.2%
HIV prevalence in people ages 15–24 (2007)[9]
1.3% Female upper estimate
0.7% Male upper estimate
 
0.5% Female lower estimate
0.4% Male lower estimate
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]
13% Females
10% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2006)[11]
5% Females
20% 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 (2005)[12]
38% Females
50% Males
Contraceptive prevalence rate (2004)[13]
26% Any method
20% Modern methods
Percentage of couples using condoms for family planning (2005)[14]
2.7%
Number of births per 1,000 women ages 15–19(2005–2010)[15]
98
Percentage of females (20–24) who have given birth by age 18 (2005)[16]
26%
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)[17]
45% Females
40% Males
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[18]
N/A
 
HIV in Tanzania is predominantly transmitted through heterosexual sexual contact, which accounts for nearly 80 percent of reported cases. It is difficult to determine HIV prevalence in the country as it varies greatly by region. On average, urban inhabitants have considerably higher levels of infection (10.9 percent) than rural inhabitants (5.3 percent). More specifically, the HIV prevalence in densely-urban areas like Iringa (18.2 percent), Mbeya (15.9 percent), and Dar es Salaam (10.9 percent) are high compared to rural areas like Kigoma (3.5 percent) and Kagera (4.7 percent).[19]
 
The prevalence rates among women vary widely based on age, regions, and level of education. A 2005–2006 surveillance report looked at rates of syphilis and HIV among 31,224 women who attended antenatal care clinics. It found that HIV prevalence is highest among women ages 25–34 years (9.9 percent) compared to those ages 15–24 years (6.8 percent) and 35 years or older (8.1 percent). This is much higher than the UNAIDS estimates included in the chart above. The same report shows that single women have slightly higher prevalence rates than married women (8.9 percent versus 8.1 percent). Overall, women with secondary school education or more have the highest HIV prevalence (9.3 percent), while women with no education have the lowest prevalence (5.5 percent). 
 
This trend is true of both men and women; those with secondary or higher education are 50 percent more likely to be infected. Also, men and women with the greatest wealth have a prevalence rate of 9.4 percent and 11.4 percent, respectively, while men and women with the least wealth have a lower prevalence rate of 4.1 percent and 2.8 percent, respectively.[20] This could be attributed to the fact that, as mentioned earlier, urban areas have a higher prevalence rate than rural areas and individuals with a higher level of education and more wealth are more likely to reside in urban areas.[21] 
 
Tanzania began to formally recognize the dangers of the epidemic in the 1980s, starting with the implementation of the National AIDS Control Programme in 1986. However, it was not until 1999 that President William Mkapa declared HIV/AIDS a national disaster. The following year the government established the Tanzania Commission for HIV/AIDS (TACAIDS). Its mission is, “to provide strategic leadership and to coordinate the implementation of a national multi-sectoral response to HIV/AIDS leading to the reduction of further infections associated diseases and the adverse socio-economic effect of the epidemic.”[22]
 
TACAIDS was established by the passage of the Tanzania Commission for AIDS Act in 2001. The Act urges openness and frankness on all levels to address issues related to HIV/AIDS, as well as acknowledges the important impact that the epidemic has had on gender and youth. In addition, TACAIDS established Tanzania’s National Multi-Sectoral Strategic Framework (NMSF) which formulates the country’s national response to the epidemic. The most current NMSF covers the years 2003–2007.  Its goals are listed in the box below.[23]  
 

National Multi-Sectoral Strategic Framework (NMSF) Goals 2003–2007
 
  1. Reduce the spread of HIV in the country
  2. Reduce HIV transmission to infants
  3. Political and government leaders will consistently give high visibility to HIV/AIDS in their proceedings and public appearances
  4. Political leaders, public and private programmes, projects and interventions will address stigma and discrimination and take human rights of persons living with HIV/AIDS into account
  5. HIV/AIDS concerns are fully integrated and prioritized in the National Poverty Reduction Strategy and Tanzania Assistance Strategy
  6. Reduce the prevalence of STIs in the population
  7. Increase the knowledge of HIV transmission in the population
  8. Increase the number of persons living with HIV/AIDS who have access to a continuum of care and support from home/community to hospital levels
  9. Reduce the adverse effects of HIV/AIDS on orphans
 

The progress toward increasing knowledge about HIV prevention among young people has been minimal.  Only 26 percent of females ages 15–24 demonstrated adequate general knowledge about HIV/AIDS according to the UNGASS Country Report in 2003.[24] When the AIDS Indicator Survey (AIS) was conducted two years later among females ages 15–24, it showed that 44 percent had adequate general knowledge about the virus. Though this may indicate some progress, it is unclear whether this is the result of improved prevention efforts or improved survey designs. Moreover, despite major prevention efforts based on creating positive behavioral change, there has been little reported change in risky sexual behavior. According to a 2005 UNAIDS study, over 80 percent of males and over 30 percent of females (ages 15–24) had casual sex, and less than half had used a condom.[25] 
 
Women are at higher risk of contracting the virus, in part because of traditionally male-dominated gender relations and limited economic opportunities which impact the capacities women and girls have to determine their sexual relationships.[26]  TACAIDS has acknowledged this and made an effort to remedy the problem by addressing the cultural, biological, and economic difficulties women face. Nonetheless, prevalence is still reported to be higher in women (7.7 percent versus the 6.3 percent nationwide). Of the 1,300,000 people over 15 years of age living with HIV, at least 710,000 of them are women.
Mother-to-child transmission is the leading cause of HIV infection among children in Tanzania, and its prevention has been steadily improving under TACAIDS. The number of pregnant women reached by antenatal clinics (ANCs) has gone up from 255,913 in 2005 to 608,077 in 2007, and the majority of pregnant women visiting ANCs are tested for HIV.  It is estimated that 8.2 percent of pregnant women who attend ANCs are HIV positive.[27]  However, ANCs only reach 44 percent of all the pregnant women in the country. It is thought that some women may be reluctant to use ANCs because many mothers face discrimination and stigmatization from others if it is discovered that they are HIV-positive.  
 
In addition, coverage of antiretroviral therapy (ART) overall is startlingly low in the country.  As of 2007, only 20 percent or 373,584 of an estimated 1.9 million HIV-positive people in need of ART were receiving it.[28] This means that the majority of HIV-positive individuals are not receiving the proper treatment that they need.
 
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

 
Tanzania receives a substantial amount of PEPFAR funding. Beginning in 2004, Tanzania received over $70 million and its funding has grown each year starting from a large increase of $20 million in 2005 to its largest increase yet, almost $77 million, in 2008. Tanzania is currently one of the PEPFAR focus countries receiving the highest funds of over $250 million in its 2008 budget which more than triples its original funding.
 
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[29]
2005[30]
2006[31]
2007[32]
2008[33]
Total Funds Allocated
$70,628,839
$91,949,620
$113,162,791
$181,310,937
$258,300,191
Total Prevention Funds Allocated
N/A
$28,135,920
$27,871,626
$37,567,685
$60,940,494
Total AB Funds Allocated
N/A
$6,308,129
$9,265,186
$11,908,695
$18,183,501
Total Other Prevention Funds Allocated (includes condom funding)**
N/A
$6,322,468
$6,300,000
$8,655,000
$11,384,616
Total Treatment Funds Allocated
N/A
$44,532,723
$59,663,973
$95,985,401
$126,372,526
Total Care Funds Allocated
N/A
$19,280,977
$28,977,192
$52,449,415
$70,987,171
* 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.
 
All of the program areas, prevention, care, and treatment, in Tanzania have experienced increases in funding over the years.  Currently treatment funds make up almost half of the total PEPFAR budget in Tanzania at 48.9 percent, care funds make up 27.5 percent, and prevention funds make up 23.6 percent. 
 
Similar to funding patterns in other PEPFAR focus countries, more prevention funds are designated for AB programs than OP programs. In fact, while AB funds went up, funds for OP programs slightly decreased between 2005 and 2006.  In 2008, AB funds make up 30 percent of the overall prevention budget while OP funds have decreased to only 19 percent of the overall 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. 
 
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 the United Republic of Tanzania. 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.[34]
 
 
Organizations that received only AB funding:

  • Adventist Development and Relief Agency
  • American Red Cross
  • Balm in Gilead
  • International Youth Foundation
  • Jane Goodall Institute
  • Johns Hopkins University
  • Mbeya HIV Network Tanzania
  • Ministry of Education and Culture, Tanzania
  • Ministry of Health and Social Welfare, Tanzania
  • Resource Oriented Development Initiatives
  • Salesian Mission
  • SONGONET-HIV Ruvuma
  • US Department of Defense
  • World Vision International

 
Organizations that received both AB and OP funding:

  • Academy for Educational Development
  • Family Health International
  • Kikundi Huduma Majumbani
  • National AIDS Control Program Tanzania
  • U.S. Agency for International Development
  • U.S. Centers for Disease Control and Prevention (CDC)
  • U.S. Peace Corps

 
Organizations that received only OP funding:

  • Central Contraceptive Procurement
  • Columbia University
  • The Futures Group International
  • PharmAccess

 
According to the 2007 Country Operational Plan, 14 AB-only programs received a total of $12,353,695 and were targeted to reach 7,384,850 individuals through community outreach. In contrast, 11 OP programs, seven of which received AB funding in addition to OP funding, received a total of $8,210,000 and were targeted to reach 1,978,500 individuals through community outreach. Of the 11 OP programs only 3 (Academy for Educational Development, National AIDS Control Program Tanzania, U.S. Peace Corps) delivered a message that promoted the correct and consistent use of condoms and provided education about condoms. 
 
Tanzania’s National Multi-Sectoral Strategic Framework (NMSF) 2003–2007 recognizes that condoms are one of the most effective and easy-to-use barriers in preventing the sexual transmission of HIV among sexually active populations. It does not support an exclusive AB approach but rather a comprehensive one.[35] Despite this, PEPFAR continues to disproportionately support the AB-only approach over other prevention measures. 
 
The top AB/OP grantee, U.S. Centers for Disease Control and Prevention (CDC), received a total of $5,874,357 in AB and OP funds. The top AB-only grantee, Ministry of Health and Social Welfare, Tanzania, received a total of $1,841,280 in AB funds. The top OP-only grantee, Columbia University, received a total of $7,990,000 in OP funds.
 
A closer look at the three OP programs that included a correct and consistent condom component shows that they all came from organizations that also received AB-only funding. It is unclear how effectively this ABC messaging was executed.  The National AIDS Control Program Tanzania reported that its ABC messaging only reached seventy community young people in a skills building workshop.[36] The Academy for Educational Development conducted a condom social marketing campaign to promote Tanzania’s new Dume brand male condoms in barbershops, bars, and nightclubs.[37] The U.S. Peace Corps reported the best effort in delivering ABC-messaging; it trained 1,450 teachers and peer educators to use an ABC program called “Life Skills” that included the correct and consistent use of condoms in secondary schools.[38] The Peace Corps received $200,000 in OP funding to do ABC messaging and received $240,000 in AB funding to do programs in primary schools that reached 13,000 school youth.[39]
 
Items of Note: Children and AIDS
 
One of the biggest problems facing Tanzania today is the plight of children affected by this epidemic. Children have been and are affected in a myriad of ways, whether directly, through contracting HIV themselves or losing a parent to the disease, or indirectly, through the loss of educational opportunities as more and more teachers fall victim. The number of children orphaned by the epidemic in sub-Saharan Africa is expected to exceed twenty-five million by 2010.[40] Tanzania’s orphan population is second only to South Africa’s.[41] 
 
Tanzania’s government reported that children who are orphaned due to the epidemic often drop out of school to work or take care of other relatives who have contracted the disease.[42] Children may also be pulled out of school by their families either due to lack of money or a need for their help at home. Aside from purely economic consequences, these children are also robbed of their childhood.
 
Young girls in particular are disproportionately affected by the disease. They are increasingly required to care for the sick and must give up educational or social opportunities to do so. Moreover, female children are also more likely to become sex workers, increasing their risk of contracting the virus themselves.
 
Children are also affected by a lack of educational opportunities in general. The HIV/AIDS epidemic has had a devastating effect on teachers. Teachers are more affluent and mobile than the average population, factors that have actually increased their risk of contracting the disease. World Bank projections predict that by 2010, 14,460 teachers will have died from AIDS-related illnesses in Tanzania.[43]  Additionally, like their younger counterparts, female teachers who are HIV-negative also often take on the responsibility of caring for their sick relatives and must leave the profession to do so. The absence of just one teacher has the potential to deprive an entire class of its education. 
 
As PEPFAR and other agencies move forward in assisting Tanzania combat the epidemic, the effects of HIV/AIDS on the young must be made central to an effective strategy ending the spread of HIV in the country.
 
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] Boerma, J. T., et al. “Levels and causes of adult mortality in rural Tanzania with special reference to HIV/AIDS,” Health Transition Review, Supplement 2 to Volume 7, 1997, 63-74, accessed 28 July 2008, http://htc.anu.edu.au/pdfs/Boerma1.pdf 4
[2] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS Estimates and Data, 2007 and 2001,UNAIDS, (New York, NY), accessed 31 July 2008, http://data.unaids.org 214, 218
[3] 2006 Report on the Global AIDS Epidemic Annex 1: Country Profiles, UNAIDS, (New York, NY), accessed 31 July 2008, http://data.unaids.org 5
[4] Ibid
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] 2006 Report on the Global AIDS Epidemic Annex 1, 5
[6] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY), accessed 28 July 2008,http://www.unfpa.org 86
[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, http://data.unaids.org 302
[11] Ibid., 309
[12] Ibid., 315
[13] Monitoring ICPD Goals – Selected Indicators, 86
[14] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 28 July 2008, http://www.populationaction.org 2
[15] Monitoring ICPD Goals – Selected Indicators, 86
[16] World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC), accessed 28 July 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 13
[17] 2008 Report on the Global AIDS Epidemic Annex 2, 297
† Most recent data available
[18] Ibid., 292
[19] UNGASS Country Progress Report Tanzania Mainland: Reporting Period January 2006 – December 2007, (Dar Es Salaam, Tanzania), accessed 15 July 2008, http://data.unaids.org 12-13
[20] Ibid., 13
[21] Ibid., 13
[22] “Tanzania Commission for Aids: Mission and Vision,” The United Republic of Tanzania (2006), accessed 28 July 2008, http://www.tacaids.go.tz/index.php/about-tacaids/vision-a-mission.html
[23] National Multi-Sectoral Strategic Framework on HIV/AIDS (NMSF) 2003-2007, January 2003, Tanzania Commission for HIV/AIDS (Dar es Salaam, Tanzania), accessed 28 July 2008, http://www.tanzania.go.tz/pdf/tacaidsnmf.pdf 11-12
[24] 2006 Report on the Global AIDS Epidemic Annex 3, UNAIDS, (New York, NY), accessed 19 September 2008, http://data.unaids.org/pub/GlobalReport/2006/2006_GR_ANN3_en.pdf 565
[25] Ibid., 570, 565
[26] Tanzania HIV/AIDS Indicator Survey 2003-2004, December 2005, (Dar es Salaam, Tanzania), accessed 28 July 2008, http://www.measuredhs.com/pubs/pdf/AIS1/AIS1-TZ03-04.pdf 73-78
† Most recent data available
[27] UNGASS Country Progress Report Tanzania Mainland, 27
[28] Ibid., 26
[29] Tanzania 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 15 July 2008,   http://foia.state.gov/COP/tanzania04.pdf
[30] Approved Funding by Program Area: Tanzania: FY 2005, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 28 July 2008, http://www.state.gov/s/gac/progress/other/data/program/59804.htm
[31] Approved Funding by Program Area: Tanzania: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 28 July 2008, http://www.pepfar.gov/about/77691.htm
[32] Approved Funding by Program Area: Tanzania: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 28 July 2008, http://www.pepfar.gov/about/82457.htm
[33] Approved Funding by Program Area: Tanzania: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 28 July 2008, http://www.pepfar.gov/about/opplan08/102025.htm
[34] Tanzania 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 28 July 2008, http://www.pepfar.gov/documents/organization/103942.pdf
[35] National Multi-Sectoral Strategic Framework on HIV/AIDS (NMSF) 2003-2007, 11
[36] Tanzania FY 2007 Country Operational Plan, 259
[37] Ibid., 249
[38] Ibid., 268
[39] Ibid., 166-167
[40] Framework for the Protection of Case and Support of Orphans and Vulnerable Children Living in a World with HIV/AIDS (New York: UNICEF, July 2004). 5.
[41] “Number of orphans due to AIDS, alive in 2005,” updated April 21, 2008, AVERT (West Sussex, England), accessed 28 July 2008, http://www.avert.org/aidsorphans.htm
[42] Ibid., See “Impact of the HIV/AIDS epidemic”
[43] Tanzania AIDS Assessment and Planning Study, (Washington: World Bank, 1993), accessed 28 July 2008, http://www.worldbank.org/aids-econ/tanz-report/pt3.pdf
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