2008 PEPFAR Country Profile Update: Uganda
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 Uganda. Click Here to Read Uganda's 2005 Original Country Profile)
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries. PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action. At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying. Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20 percent of the funds could be spent on prevention efforts. Moreover, 33 percent of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs. Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings.
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time.
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds.
In addition to this data, each update also offers further analysis on particular items of note in the country. And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries. While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective.
Uganda has one of the highest rates of population growth in the world at over 3 percent annually with a current population of fewer than 30 million people. HIV was first reported in Uganda in the 1980s on the shores of Lake Victoria and spread across the country to large cities and areas along the major road highway network. HIV prevalence has been declining since the early 1990s after peaking around 14 percent in 1991, and is currently estimated to be about 5 percent. Prevalence differs among localities, with urban areas likely to have twice (10.1 percent) the HIV prevalence as rural areas (5.7 percent). Unlike other PEPFAR focus countries, the number of Ugandans living with HIV is decreasing rather than increasing from 1.3 million in the early 1990s to roughly 800,000 in 2007. This is no small matter given Uganda’s population growth and suggests that prevention continues to have a greater impact in Uganda than in many other countries.
Still, AIDS-related illnesses are the leading cause of death among Ugandan adults and the main cause of the falling life expectancy in the country. Roughly 77,000 adults and children died from AIDS-related illnesses in 2007 alone, although this marks a significant decrease from the estimated 120,000 deaths in 2001. These trends are projected to continue, but even with fewer deaths, the HIV/AIDS epidemic continues to have an enormous impact in Ugandan families. By 2007, it is estimated that 1.2 million children lost one or both parents to AIDS.
Women in Uganda are disproportionately affected by the HIV/AIDS epidemic; the prevalence among women is at least twice that of men. Women face gender-based inequality and violence which heightens their vulnerability to contracting the virus. As an example, nearly one in five adolescent females (ages 15–19) report that their first sexual experience was by force or coercion. This widespread sexual violence against women fosters an increased risk of transmission.
Uganda’s healthcare system cannot provide adequate resources and treatment to all people living with HIV/AIDS (PLWHA) in the country. For example, there are only an estimated 8 physicians, 61 nurses, and 4 health workers for every 1,000 Ugandans. According to Uganda’s Ministry of Health, there are still many constraints like low salaries and poor motivation of staff that prevent the health sector from fully curbing the impact of the epidemic.
The coverage afforded by treatment services is astonishingly inadequate. It is estimated that only a little over 30 percent of all Ugandans in need of ART are receiving it, up from about 10 percent in 2004. In addition, only 34 percent of pregnant women who are HIV-positive received ART in 2007 to prevent transmission to their child. This figure represents a significant increase over the previous year during which only 6 percent of pregnant women who needed ART received it.
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Uganda. The stories behind the data are fleshed out in greater detail following the chart.
PORTRAIT OF UGANDA IN NUMBERS
The government of Uganda and the public response to HIV/AIDS was slow in the 1980s. In 1986, the National Resistance Movement political party (which is the current ruling party and the current President of Uganda, Yoweri Museveni) established the first “AIDS control programme” in its Ministry of Health and made “substantial progress in the areas of epidemiology, surveillance, health and AIDS education, and blood transfusion services.” However, the health sector’s exclusive responsibility in coordinating Uganda’s national HIV/AIDS response did not adequately address various drivers of the epidemic such as gender-based stigma and discrimination, populations with heightened vulnerability to HIV transmission, and prevention of mother-to-child transmission (PMTCT). The government responded to this deficiency by appointing a national Task Force on AIDS which culminated in the establishment of the Uganda AIDS Commission (UAC) in 1992.
The UAC provides “overall leadership and oversight in the coordination of HIV/AIDS programs and activities in Uganda with the aim of preventing and controlling the spread of HIV/AIDS and mitigating its impact.”National Operational Plan for STI/HIV/AIDS Activities 1994–1998 which was then succeeded by the National Strategic Framework (NSF) for HIV/AIDS Activities 1998–2000 and the NSF 2000/1–2005/6. A midterm review of the NSF 2000/1–2005/6 conducted by the UAC found many gaps in the policy that were revised into the NSF 2004–2006. The main goal of the NSF 2004–2006 was to reduce HIV infections by 25 percent and it was intended to go hand in hand with another policy set by the Ugandan government, the Poverty Eradication Action Plan (PEAP). PEAP sets out to reduce the incidence of poverty in the country. Both the NSF of 2004–2006 and the current NSF recognize that HIV poses a serious threat to reducing poverty and is an obstacle to PEAP’s ongoing realization.  The UAC spearheaded the development of the Multisectoral Approach to the Control of HIV/AIDS (MACA) in its first year of operation. MACA was the first national policy on HIV/AIDS and served as the basis for developing the
The NSF 2004–2006 came to an end in June 2006 and the UAC initiated the new 5-year planning framework in December 2005. The comprehensive consultation process was concluded in November 2007 and the NSF was succeeded by the current National Strategic Plan (NSP) for HIV/AIDS Activities 2007/8–2011/12. The overall goal of the new strategy is to eventually achieve universal access to prevention, care, treatment, and social support services. The new NSP calls for reducing new HIV infections by 40 percent, reaching 80 percent of those in need of care and treatment, and expanding social support services to 54 percent of the population by the year 2012.
While HIV prevalence rates in Uganda continue a downward trends and ART and PMTCT coverage have been scaled up, the current situation in Uganda is far from meeting its NSP goals. Sites that provide ART have increased dramatically from 175 in 2005 to 286 in 2007 and 94 percent of the population has access to antenatal care that may provide ART; however only 34 percent of HIV-positive pregnant women received ART to prevent HIV transmission to their children and only 33 percent of the larger population who are in need of ART received it. This is far from the NSP target of reaching 80 percent of those in need of treatment and care which is set to be reached in just four years.
In addition, it is unclear how successful the NSP will be at attaining its main goal of reducing the number of new infections of HIV by 40 percent when many drivers of the epidemic, such as lack of knowledge of HIV/AIDS among Ugandans, are not being addressed. For instance, only 32 percent of young women and 38 percent of young men ages 15–24 can properly identify ways of preventing sexual transmission of HIV and reject misconceptions about HIV such as that it can be transmitted by mosquito bites and sharing food with an infected person. Remedying this lack of knowledge is impeded by a lack of information about what is already being done. For example, it is unknown how many schools provide life-skills-based HIV/AIDS education in Uganda. The majority of Ugandans (70 percent of males and 65 percent of females) do attend primary schools and this is an important venue where an HIV-prevention educational program could reach most of them.
The NSP is not the only effort on the part of Uganda’s government to provide leadership in the fight against HIV/AIDS. It held the first conference on the Global Health Workforce Alliance in the capital city Kampala in March 2008. The conference brought in more than 1,000 participants from 57 countries and established the Kampala Declaration, which urges increased international funding to address the African health infrastructure systems and calls on higher-income countries to pay a fee to lower-income countries when recruiting their health workers. In addition, the UAC is pioneering PMTCT research and ongoing HIV vaccine trials in a government-sponsored initiative to accelerate the development and testing of vaccines to prevent HIV transmission.
The financing of Uganda’s battle against HIV/AIDS goes beyond the fiscal resources of the country alone, and like most of the PEPFAR-focus countries, Uganda relies primarily on international funding to cover its HIV/AIDS expenditures. The most comprehensive data on HIV/AIDS expenditures taken from the Joint United Nations Programme on HIV/AIDS (UNAIDS) from 2005 shows that international sources of financing accounted for 94 percent of all HIV/AIDS spending in Uganda with the majority of funds coming from PEPFAR.
President’s Emergency Plan for AIDS Relief (PEPFAR)
PEPFAR began funding HIV/AIDS prevention, care, and treatment services in Uganda in 2004 with an initial allocation of over $90 million, a substantially large allocation compared to other PEPFAR focus countries. This amount has nearly tripled by 2008 and the country was most recent allocated nearly a quarter of a billion dollars.
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*
* 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.
*** Total field and central program funding allocated in 2004
Similar to other PEPFAR-funded countries, the majority of funding is allocated toward treatment and care services, with prevention services as the area that is not only least funded overall but has also seen the smallest funding increases over the years. While the total prevention funds set at over $54 million currently make up 22.5 percent of the total budget, treatment funds at over $100 million make up 43.8 percent, and care funds at over $80 million make up 33.6 percent.
Total prevention funding is further broken down into program areas: PMTCT, Abstinence/Be-Faithful (AB), Blood Safety, Injection Safety, and Other Prevention (OP) that includes condoms. AB programs are set to receive the most funding of all prevention program areas in 2008 at over $17 million or nearly one-third of the prevention budget. OP programs have consistently received less than AB programs including the current fiscal year allocation of $13 million or only one-quarter of the total prevention budget.
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 Operation Plan, within the area of prevention PEPFAR funded a total of eight organizations to implement only AB programs, 14 organizations to implement both AB and OP programs, and five organizations to implement only OP programs. Only six organizations promoted the correct and consistent use of a condom.
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 Uganda. 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.
Organizations that received AB funding only:
Organizations that received AB and OP funding:
Organizations that received OP funding only:
Organizations working in Uganda received a total of $14,012,126 in funding for AB programs in 2007 and were estimated to deliver AB messages to over 8 million individuals. The organization that received the most funding for AB-only programs was Catholic Relief Services (CRS) at a total of $965,621 in 2007 (two AB grants of $744,881 and $220,740). CRS is the lead agency among a consortium of five organizations that implement a program called AIDSRelief which is “a comprehensive HIV CARE program, providing ARV drugs, preventive, curative, palliative, social and ARV services to HIV positive people their families & communities.” In strict adherence to PEPFAR’s guidelines of AB-only messaging, CRS does not finance, distribute, or promote the distribution of condoms in the program. In addition to operating AIDSRelief, CRS uses the life-skills curricula Education for Life, PAPAS/In-Charge, and Faithful House to conduct trainings and workshops to deliver AB messages to “youth both in and out of school and adults particularly the parents, clergy and other religious leaders, community leaders and teachers.”
Faithful House is a weeklong 40-hour program carried out by parishes and dioceses using a faith-based approach with the exclusive goal to boost fidelity. The program teaches couples to improve their marriage through “joint financial planning, and better communication and parenting” in addition to building “healthy decision-making practices, and HIV awareness. Faithful House also encourages couples who are living together to get married.” CRS advertises the program as part of a fundraising scheme. The organization tells of how the program was a “life-changing and lifesaving experience” for one Ugandan couple in a troublesome marriage: “Now, [they] pray together, and Waswa [the husband] understands the importance of putting Christ at the center of their marriage.” Then CRS explains that anyone can help build “strong family structures” by purchasing a gift from its gift catalogue or contributing financially to the organization as part of a “project share.”
The organization that received the most funding for both AB and OP programs in 2007 was John Snow, Inc. at a total of $5,618,000 (four AB grants totaling $3,648,319 and four OP grants totaling $1,969,681). John Snow is part of the Uganda Program for Human and Holistic Development (UPHOLD), a five-year bilateral program primarily funded by the United States Agency on International Development (USAID) through PEPFAR. UPHOLD implements a variety of programs including radio shows and drama productions for school youth that deliver AB messages which are conducted as part of its AB activity. As part of its OP activities, the organization also conducts programs to distribute and promote condoms to groups identified as high-risk. In addition, UPHOLD delivers comprehensive HIV- prevention, care, and treatment services throughout Uganda.
One of the more widely disseminated behavior change campaigns in Uganda was conducted by Johns Hopkins University Center for Communication Programs and received the second highest AB and OP funding in 2007 at a total of $4,350,000 from PEPFAR (three AB grants totaling $1,700,000 and two OP grants totaling $2,650,000). In partnership with Young Empowered and Healthy (Y.E.A.H.), Johns Hopkins helped launch the Be A Man campaign that targets “youth’s ability to be responsible and to protect themselves against becoming infected with HIV.” Be A Man focuses on young men adopting more positive attitudes and behaviors to protect both their health and women’s health. The campaign has been launched through a variety of media including a television spot during the World Cup, a highly popular sports event that reaches millions of young Ugandans. One television ad features three young Ugandan men watching the World Cup at bar while an attractive women walks by catching their attention. The three men decide to instead focus on the sports match and a voiceover then says “A real man focuses on the important things in life: ‘Be A Man’.”
Uganda received a total of $10,644,812 in funding for OP programs in 2007 and was estimated to deliver OP activities including education about condoms to 2.5 million Ugandans. The organization that received the most OP-only funding was Commodity Security Logistics at $1.5 million in 2007. This organization procures condoms at the lowest possible price and distributes them in locations known for having at-risk residents or clientele such as “military and refugee camps, lodges and bars, prisons, sea ports and docks, Truck drivers’ stop points and homes for discordant couples.” An estimated 24 to 60 million condoms were procured with the potential of reaching 200,000 to 500,000 people. In addition, Commodity Security Logistics conducts, “quality assurance and pre-shipment testing for product compliance” of condoms.
Items of Note: War on Condoms
Uganda has been considered a success story because of its declining HIV prevalence. In the late 1980s, the government in Uganda began promoting a combination strategy of abstinence, “be faithful” (or partner reduction), and condom use, which has become known as the “ABC” approach and is credited with a dramatic impact in lowering transmission of HIV into the early 1990s. The ABC message was successful due in large part to the widespread mobilization taking place at all levels of society, from the exceptional volunteerism of community leaders and members, to the political leadership of President Yoweri Museveni. While it is difficult to extract direct correlations between each component of the overall ABC strategy and behavior changes in the various sectors of the population, some key HIV indicators have been observed. These indicators included a decrease of multiple, concurrent partnerships and an increase of condom use among unmarried men and women.
Despite the apparent success of this seemingly even-handed and broad-sweeping approach to prevention, President Yoweri Museveni and First Lady Janet Museveni made a sudden change of strategy in 2004. Despite previously championing condom use, the Musevenis became the most vocal critics of this approach. President Museveni openly attacked condoms, warning that he would “open war on the condom sellers” who were “promoting promiscuity among young people.” In other public statements he charged promiscuity as the major cause driving the epidemic.
Some advocates partially attribute this about-face regarding condoms to the influence of the first lady who has been heavily involved in pro-abstinence and anti-condom advocacy. She has stated that condoms are “pushing [young people] to go into sex” and “it is not the law that our children must have sex.” In addition to sending the message that condoms should be used as a last resort for prevention, President Museveni also had publicly declared that condoms break and therefore “kill people.” In 2004, President Museveni issued a nationwide recall of condoms due to concerns about their quality. Millions of free condoms that were available in health clinics were incinerated and by mid-2005 there was a shortage of condoms in the country. The recall in turn helped fuel more skepticism of the efficacy of condoms and President Museveni placed new taxes on condoms making the few that remained too expensive to afford.
This denigration of condoms and stigmatization of their use seems to coincide with the arrival of U.S. funding and program guidelines which strongly favor abstinence-only-until-marriage and be-faithful frameworks. Research conducted by Human Rights Watch has demonstrated the concerted effort by the Ugandan government to remove condoms from the overall HIV-prevention framework by emphasizing an AB approach only. The organization discovered that teachers were being discouraged from talking about condoms and that misinformation, such as condoms have microscopic holes, was being disseminated to students. Human Rights Watch concluded that despite the endorsement “by some powerful religious and political leaders in Uganda, this policy and programmatic shift is nonetheless orchestrated and funded by the U.S. government."
Despite the evidence that condoms are one of the many tools necessary to combat the spread of HIV, a culture of fear and mistrust has been well cultivated in Uganda. The leadership in Uganda has taken action to impede the free access to accurate information and counseling on condom use, supported by PEPFAR-backed programs and guidelines. Since this war against condoms was initiated in 2004, HIV prevalence has increased at an alarming rate, giving valid cause for alarm. Uganda has been touted as the model of ABC success, but the ABC model is no longer promoted and implemented in the same, balanced method as before. While no single strategy offers a panacea to the HIV/AIDS epidemic, if Uganda is to once again bring the epidemic back into check, it will need to draw on all available resources, including condoms.
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.
 Ibid, 7
 Uganda Epidemiological Country Profile on HIV and AIDS, WHO/UNAIDS, (New York, NY), accessed 9 September 2008,
 WHO Country Cooperation Strategy Uganda, World Health Organization (Geneva, Switzerland), accessed 11 September 2008,
 Uganda Epidemiological Country Profile on HIV and AIDS
 2008 Report on the Global AIDS Epidemic Annex 1, 218
 2008 Report on the Global AIDS Epidemic Annex 1, 214-215
 Country Health System Fact Sheet 2006, Uganda, WHO/UNAIDS, (New York, NY) accessed 9 September 2008, http://www.afro.who.int/home/countries/fact_sheets/uganda.pdf 5
 Uganda Epidemiological Country Profile on HIV and AIDS
 2006 UNAIDS Report: Country profiles annex 1, 1
 Ibid., 1
† 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.”
 Ibid., 1
 Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY), accessed 9 September 2008, http://www.unfpa.org/swp/2007/english/notes/indicators/e_indicator1.pdf 86
 2008 Report on the Global AIDS Epidemic Annex 1,214
 Ibid., 215
 Ibid., 217
 Uganda: 2006 Demographic and Health Survey Key Findings, Uganda Bureau of Statistics (Kampala, Uganda), accessed 10 September 2008, http://www.measuredhs.com/pubs/pdf/SR126/SR126.pdf 6
 Ibid., 6
 2008 Report on the Global AIDS Epidemic Annex 2,302
 Ibid., 309
 Ibid., 315
 Monitoring ICPD Goals – Selected Indicators, 86
† According to UNFPA, “Modern or clinic and supply methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.”
 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 9 September 2008,
 Monitoring ICPD Goals – Selected Indicators, 86
 The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 9 September 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 14
 2008 Report on the Global AIDS Epidemic Annex 2, 297
 Ibid., 292
 The Multi-Sectoral Approach to AIDS Control in Uganda: Executive Summary, Uganda AIDS Commission, February 1993, (Kampala, Uganda), accessed 11 September 2008, http://www.aidsuganda.org/pdf/maca_executive_summary.pdf 2
 2008 Report on the Global AIDS Epidemic Annex 2, 297
 Uganda: 2006 Demographic and Health Survey Key Findings, 4
 Expenditures by Finance Source and Spending Category, Uganda, 2005, UNAIDS, (New York, NY) accessed 9 September 2008, http://data.unaids.org/pub/Report/2008/rt08_uga_en.pdf
 Total Dollars Planned for FY 2005 by Program Area, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 9 September 2008, http://www.state.gov/s/gac/progress/other/data/program/59806.htm
 Uganda Country Operational Plan 2007, U.S. State Department, (Washington, DC), accessed 9 September 2008, http://www.pepfar.gov/documents/organization/103943.pdf 259, 262, 267, 276, 300, 311
 Ibid., 121-122
 Ibid., 123, 150
 Ibid., 124
 Ibid., 124; The President’s Emergency Plan for AIDS Relief Indicators, Reporting Requirements, and Guidelines, July 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 13 September 2008, http://www.pepfar.gov/documents/organization/81097.pdf 40
 Ibid., 151
 Uganda Country Operational Plan, 142, 166, 180, 204, 259, 270, 280, 284
 Ibid., 212, 216, 222, 275, 309
 Ibid., 204
 Y.E.A.H. Launches “Be a Man” Campaign in Uganda during World Cup, June 21 , 2006 (Kampala, Uganda), The Johns Hopkins University, accessed 13 September 2008, http://www.jhuccp.org/pressroom/2006/06-21.shtml See http://www.hcpartnership.org/Programs/Africa/uganda/BeMan1.wmv ; http://www.hcpartnership.org/Programs/Africa/uganda/BeMan2.wmv
 Uganda Country Operational Plan., 242
 Ibid., 264
 Ibid., 264
 Ibid., 264
 What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response, September 2002, U.S. Agency for International Development, (Washington, DC), accessed 13 September 2008, http://www.usaid.gov/our_work/global_health/aids/Countries/africa/uganda_report.pdf 12-14
 The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda, March 2005 Vol. 17, No. 4 (A), Human Rights Watch (New York, NY) accessed 13 September 2008, http://hrw.org/reports/2005/uganda0305/uganda0305.pdf 46-47
 “Museveni Condemns Condom Distribution to Pupils”
 The history of AIDS in Uganda
 Ugandans Resist Anti-Condom Agenda, September 2005, Human Rights Watch (New York, NY) accessed 13 September 2008, http://www.hrw.org/english/docs/2005/09/14/uganda11744.htm
 Uganda Resists Anti-Condom Agenda