***Special Report***

Breaking the Promise:
The Politics of Domestic HIV Prevention

Domestic HIV-prevention efforts have, in fact, been largely successful in the United States.  A combined effort of activists sounding the alarm, educators conducting outreach, researchers testing scientifically based prevention methods, and policymakers enacting sound policies and investing needed resources has helped stem the epidemic in this country. Today, we see 40,000 new infections each year, and while this number is too high-even one new infection is too high when dealing with a disease that we know how to prevent-it is a sign of remarkable progress for a country of over 300 million people.

Recent research by David Holtgrave of Emory University paints a very different portrait, arguing that if we had not invested as we have done, we could have likely experienced an additional 1.5 million infections in the United States. Holtgrave also found that by averting new infections and the related costs of treatment, prevention saved taxpayers $11 billion.1

Unfortunately, we have hit a plateau in the prevention of this disease and the number of new infections has remained stagnant rather than continuing to decrease. A different reality might be at hand had HIV prevention been given the necessary political support and adequate funding for evidence-based interventions. Instead, the Bush administration has seized on this plateau and declared our domestic HIV-prevention efforts a failure.

By perpetuating this myth, the administration can justify its own decisions to drastically reduce funding for HIV prevention and to shift focus away from proven prevention strategies based on science toward ideologically driven programs that have never been shown to be effective.

Only a renewed commitment to evidence-based HIV prevention can move us forward as a nation. You cannot starve a program of its lifeblood and then ask why it is not making additional progress, as this administration has done. It is a deceptive slight of hand that has, in just a few short years, had a dramatic impact on our ability to prevent HIV. This report documents this impact and offers seven recommendations for moving forward.

Following the Money

The clearest illustration of the administration's priorities when it comes to HIV prevention can be seen by following the money; and the portrait that emerges from looking at domestic HIV-prevention funding is a sobering one of shrinking funds and misplaced priorities.

The budget requests from the Bush administration for domestic HIV prevention have been woefully out of step with community needs and reality. For example, in Fiscal Years 2005 and 2006, the administration requested level funding for domestic HIV prevention despite rising costs.2 In reality, according to the Kaiser Family Foundation, overall spending for domestic HIV prevention decreased by over $70 million dollars between Fiscal Years 2003 and 2006.3

The percentage of overall domestic HIV/AIDS spending dedicated to prevention has also shrunk drastically. When social conservatives came to power in the Republican congressional wins of 1995, HIV-prevention funding accounted for 10% of overall HIV/AIDS domestic spending. By 2002, this proportion had fallen to 7% and by 2006 to around 4%.4 It is difficult to surpass the success of holding ground at 40,000 new infections each year when the fiscal resources are not made available to invest in prevention. With a shifting epidemic that we are still trying to understand, AIDS-service organizations and other community-based groups are left to meet new and rising demands with fewer resources.

In contrast, abstinence-only-until-marriage programs, the cornerstone of the Bush administration's plan for preventing sexually transmitted diseases (STDs) and HIV, have seen a dramatic boost in funding. Between Fiscal Years 2001 and 2006, domestic abstinence-only-until-marriage programs increased by about $100 million. In 1995, the same conservative Congress passed a law that added $50 million to existing funding for these programs (at the time they received little more than $9 million). In 2001, social conservatives in Congress added another funding stream to these programs to the tune of $30 million. By 2006, annual funding for abstinence-only-until-marriage programs grew to $176 million, despite the lack of evidence that these programs can have favorable long term impacts on individual's behavior, let alone at the population level.

Federal Spending for Abstinence-Only-Until-MarriagePrograms (1982-2007)

An Old Debate

The underlying impetus for this change of course is not entirely new. In fact, in many ways funding for abstinence-only-until-marriage programs usurping funding for traditional HIV- prevention efforts is merely the latest example of the debate between risk reduction and risk elimination.

The early crackdowns on gay bathhouses and sex clubs in the 1980's represent a similar response from the political sphere to what were deemed the undesirable behaviors of gay men. This "father figure" mentality suggested that the government was protecting deviants from themselves and ultimately set the stage for a backlash that has been well documented by historians. This backlash resulted in a massive investment of money-both public and private-in risk reduction activities, such as condom education, safer sex instruction, and partner reduction initiatives, throughout the gay community. This investment has paid off in spades as evidence mentioned earlier corroborates. Though far too many deaths occurred needlessly as politicians fought against-or ignored-the risk-reduction strategies being advocated by public health and rights activists, far more deaths would have occurred had we let politics and the hypermoralism of the religious right insist that risk elimination was the only acceptable avenue to address HIV in the gay community.

A similar debate continues today around HIV-prevention policies and intravenous drug use (IDU). Harm reduction initiatives that aim to reduce needle sharing and other behaviors that increase HIV risk have remained at the fringe of prevention policies and funding despite the evidence that such interventions can play an important role. IDU prevention represents the political sphere's rejection of the science that risk reduction can work with IDU populations and supplants it with a hard-line stance that risk elimination is the only acceptable intervention. In other words, politicians have followed a path that says we are not interested in helping people reduce the types of risky behaviors that they may participate in because we find these behaviors to be at odds with the overall social good. The theory goes that an insistence on eradicating "bad" behavior will, in time, produce good health outcomes.

As a theory, risk elimination is wonderfully simple and powerful. The problem is that it butts up against human nature itself and indeed the entirety of human history. Human beings err and in turn, mistakes happen to them. Risk elimination seeks not to accept and modulate this fact, but to judge it. It suggests that certain behaviors are so repugnant that the government's responsibility extends only to assistance in eradicating the behaviors altogether. Within this framework, there are no such things as innocent victims, but rather, only people complicit in activities that bring upon them what they indeed deserve.

The Politics of Risk Elimination

The ideology of risk elimination once again became increasingly popular and visible under the Bush administration and under the tenure of an extreme socially conservative Congress that saw its ascendancy in 1995 (and its collapse in the most recent 2006 mid-term elections). At a meeting held at the Department of Health and Human Services (HHS) in early 2003, Claude Allen, then Deputy Secretary of HHS, pronounced that HHS was dispensing with risk-reduction interventions for sexually transmitted diseases, including HIV, and would be moving toward a risk-elimination model. Allen, then one of the foremost proponents of abstinence-only-until-marriage programs, saw a panacea in this approach; no need to make sex safer-indeed, its not possible-we must instead eliminate sexual behavior that occurs outside of the context of a heterosexual marriage.

From May 2001 to December 2004, when he left HHS for a high-level post in the White House as a domestic policy advisor (a post he was forced to resign from in early 2006 when he was charged with stealing merchandise from several retail stores), Allen was the second highest official in HHS. He steadfastly worked to advance his and the Bush administration's vision of a systemic shift for the prevailing HIV- and STD-prevention paradigm from risk reduction to risk elimination.

Allen was naively explicit, however, when he explained how HHS was set to toss aside scientific evidence and human nature in pursuit of a more "morally pure" paradigm. In some ways saner heads within HHS prevailed and have continued to do so. However, this shift has had some lasting impacts.

For example, non-marital sexual behaviors suddenly reappeared in official government discourse as yet another human behavior that the government could not tolerate. While this line of thinking was consistent with other areas within HHS-namely abstinence-only-until-marriage programs-it was anathema to two decades of successful efforts to prevent sexual transmission of HIV domestically. In fact, public health experts know that such thinking simply plays into a cycle of stigma and discrimination that serves only to force behaviors underground and beyond the easy reach of public health.

Abstinence-Only-Until-Marriage Programs as Risk Elimination

One of the key risk elimination models championed by Allen and the Bush administration was the expansion of abstinence-only-until-marriage programs. These programs had been in existence since 1982, and by 2001 had become a cornerstone issue for social conservatives and a major priority for the incoming administration. These programs would also prove to be a huge cash boon for right-wing organizations that could clothe themselves in a public health mantel while advancing an extreme social experiment.

All programs that receive abstinence-only-until-marriage funds must adhere to a strict eight-point definition of "abstinence education" which specifies, in part, that "a mutually faithful monogamous relationship in the context of marriage is the expected standard of all human sexual activity" and that "sexual activity outside the context of marriage is likely to have harmful psychological and physical effects." Students must also be taught that "abstinence from sexual activity is the only certain way to avoid.sexually transmitted diseases."5 Because funded programs must have as their "exclusive purpose" promoting abstinence outside of marriage, programs may not in any way advocate contraceptive use or discuss contraceptive methods, including condoms, in positive ways.

The idea that animates these programs is painfully simple-if people just abstained until marriage and then married someone who also had never had sex, then there are no risk behaviors to address-risk has been wholly eliminated.

The concerns about abstinence-only-until-marriage programs have become relatively well known. Issues of medical inaccuracies in many of the most commonly used programs have been well reported. Some of these programs even prey on outdated fears of HIV such as teaching youth that HIV can be caught through contact with sweat and tears.6 In November 2006, the non-partisan Government Accounting Office also concluded that HHS failed to ensure that programs were medically accurate.7 In addition, programs are prohibited from discussing the benefits of condoms and contraception, even for sexually active youth, and many abstinence-only-until-marriage programs actively seek to denigrate condoms, thereby discouraging their use. Other concerns include the discriminatory nature of any program that insists that heterosexual marriage is the only acceptable context for human sexual activity. Such programs are inherently alienating and stigmatizing to individuals who live in other family structures as well as lesbian, gay, and bisexual individuals. Finally, domestic and global scrutiny is increasingly bearing down on abstinence-only-until-marriage programs as a violation of human rights because they deny basic information that can save lives to those who are or will become sexually active.

Perhaps most importantly, however, is that these programs remain entirely unproven. No sound public health study exists to suggest that they have a long term positive impact on young people's sexual behavior. Programs that, among other things, teach teens about abstinence and contraceptive use, can help teens delay the onset of sexual intercourse, reduce the frequency of sexual intercourse, and reduce the number of sexual partners they have. Studies have also found that such programs can increase use of condoms and other contraception among those teens who are sexually active.8

Strategies at Odds

Combating HIV with evidence and compassion is incompatible with the absolutism of abstinence-only-until-marriage programs. Despite this, however, in Fiscal Year 2005, with the exception of California, Maine, and Pennsylvania, every state's health department received both HIV-prevention funding and abstinence-only-until-marriage funding.

More recently, several states have found that not only are abstinence-only-until-marriage programs inconsistent with their public health mission and goals, but that their state laws make teaching abstinence-only-until-marriage programs in schools illegal. In October of 2006, state health officials in New Jersey went one step further in rejecting abstinence-only-until-marriage money, arguing that abstinence-only-until-marriage programs are not cost effective because the state would have to spend even more money to fund programs that would "correct medical inaccuracies" in the programs and "augment" the lack of full and complete instruction they provide.9

States, however, are not the only entities that have been involved in pursuing these incompatible strategies. For example, several non-profit agencies are also "double dipping" in both HIV-prevention funds and abstinence-only-until-marriage money. In Fiscal Year 2005, the Arizona-Mexico Border Health Foundation received a combined total of $900,000, including $632,000 from the strictest account of abstinence-only-until-marriage money. In the same fiscal year, The AIDS Resource Center of Wisconsin, the state's largest AIDS-service organization, received just over a quarter of a million dollars in HIV-prevention money from the Substance Abuse and Mental Health Services Administration (SAMSHA) and almost an additional million dollars in abstinence-only-until-marriage money. Houston-based Families Under Urban and Social Attack received almost $464,000 in CDC HIV- prevention funds in Fiscal Year 2005 and an additional $400,000 of abstinence-only-until-marriage money to their programming budget. Finally, Illinois' Roseland Christian Health Ministries received more than $1.2 million in CDC HIV-prevention funds and received the largest allowable grant, $800,000, from the strictest abstinence-only-until-marriage account in Fiscal Year 2005.

Several county health departments also follow the example of states and non-profit agencies. In Fiscal Year 2005, Florida's Hendry County Health Department received $260,000 in HIV- prevention funds as well as almost $400,000 in money from the strictest abstinence-only-until-marriage account. That same year, Ross County Health District in Chillicothe, Ohio also partook of both types of funding, in fact, it received one of the largest direct abstinence-only-until-marriage grants.

Evidence-based HIV-prevention and abstinence-only-until-marriage programs cannot peacefully coexist in the same entity. In order to follow the tenets of HIV prevention that have been successful in the past, providers must follow a risk-reduction model that includes unapologetic support of condoms. In order to adhere to the laws regarding abstinence-only-until-marriage funding, providers must vilify condoms or pretend they do not exist. While the appeal of abstinence-only-until-marriage funding, especially in light of dwindling HIV-prevention funds, is undeniable, there is, in the end, no responsible use for abstinence-only-until-marriage money within a public health framework.

Vilifying Condoms

The shift away from risk-reduction strategies is perhaps most visible when looking at the government's messages about condoms. Early in the epidemic condoms were hailed as the best protection available for sexually active individuals and they were and remain the lynchpin in successful efforts to decrease HIV prevalence among men who have sex with men. Prevention programs focused on the importance of consistent and correct condom use and a major goal of such programs was to increase the public's confidence in this important prevention tool. Today, proponents of a risk-elimination model frequently attack condoms as ineffective in preventing STDs, including HIV.

In 2000, then-Representative Tom Coburn (R-OK), an outspoken opponent of reproductive and sexual rights, slipped language into the Fiscal Year 2001 Labor, Health and Human Services appropriations act requesting that the CDC issue a report on the effectiveness of condoms in preventing human papillomavirus (HPV). Coburn's goal in requesting this report was not to cull the best public health data but to undermine the public's confidence in condoms by suggesting that they cannot protect against HPV, a virus that can lead to genital warts and cervical cancer.

The report did not yield the results that Coburn had desired. In fact, the CDC explained that "Available studies suggest that condoms reduce the risk of the clinically important outcomes of genital warts and cervical cancer." In addition, the report reiterated what public health professionals have known for years; condoms provide excellent proven protection against HIV.10

Despite this and other evidence suggesting the benefits of condoms, Coburn (now a Senator) and other risk-elimination supporters such as Representatives Mark Souder (R-IN) and Dave Weldon (R-FL), have continued their crusade against condoms. They have called for new "medically accurate" condom labels that specifically note the lack of protection condoms provide against HPV. The Food and Drug Administration's resulting draft of new condom labels was released for public comment in early 2006. Public health advocates fear that the FDA's suggested changes will make the benefits of condoms in preventing STDs less clear and might undermine user's confidence in this prevention method.

These attacks on condoms are predicated on the illogical assumption that if individuals believe that condoms don't work they will abstain from sexual behaviors. Public health advocates realize, however, that this is not the case. Instead, individuals who believe condoms don't work will abstain from using condoms when they are sexually active thereby increasing their risk of contracting HIV.

Pitting Testing Against Prevention

The shift away from the tried and true risk-reduction model also means that prevention receives less emphasis as part of the overall HIV/AIDS portfolio. The Centers for Disease Control and Prevention's (CDC's) new recommendations around HIV testing provide a clear example of prevention being push aside.

For far too long, there have been too many barriers to HIV testing. Some barriers are logistical, such as where tests are provided and who pays for them. Other barriers are more personal, such as issues of confidentiality in testing itself, gender differences, reporting positive results by name, the intractable (though lessening) stigma associated with testing, and, of course, fear.

The CDC had many legitimate rationales for devising new recommendations around testing. Most pointedly, HIV infection has become a much more treatable disease and getting HIV-positive individuals into treatment early provides the best possible hope for long-term health. In addition, testing can bolster prevention efforts as evidence suggests that many HIV-positive individuals unknowingly infect others because they have never been tested and are unaware of their own HIV status.

On September 22, 2006, the CDC released "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings" in the Morbidity and Mortality Weekly Report.11 The recommendations call for routinized testing in public and private health care settings of all adults and adolescents ages 13-64. This means that anyone in this age group will be offered HIV testing whenever they seek healthcare of any kind.

This much-needed scale up of testing was met with praise in much of the public health community. However, when closely scrutinized, the recommendations continue to push us away from a risk-reduction model.

The CDC has recommended that pre-test prevention counseling be done away with as part of the testing process. It argued that such a significant expansion of testing would tax the ability to provide pre-test prevention counseling and suggested that prevention counseling was a barrier to HIV testing. Yet the CDC's solution to dispense with this practice altogether suggests a failure on its part to take into proper account the evolution of the pre-test counseling session into one of the most important prevention opportunities. When HIV was viewed as-and often meant-a death sentence, pre-test counseling was done to prepare the person for the weight of such news. In recent practice, however, pre-test counseling evolved into prevention education and risk-reduction instruction on such topics as partner reduction and safer sex practices.

This is a vital opportunity to reach individuals who are concerned about their HIV status and their health. Individuals seek testing for many reasons-perhaps they have developed physical symptoms, participated in behaviors that put them at risk, know that they were exposed to HIV, or are seeking to take control of their overall health. Whatever the case, why would we willingly do away with such a pivotal opportunity to provide prevention education to the exact population most in need of it?

Moreover, the CDC did not replace this opportunity with any other form of prevention education. The agency could have, for example, required healthcare providers to give some level of basic information and referrals to patients who are tested for HIV. Or, the CDC could have created a pot of funding that would have allowed community-based organizations to partner with healthcare providers in increasing prevention education to meet the increase in testing. Instead, the CDC's action indicates that a scaling up in testing means a scaling down of prevention.

The CDC strategically released its recommendations at the government-funded United States Conference on AIDS, allowing a paramount opportunity for presentation and spin. Perhaps this is why, instead of concern, many in the HIV/AIDS community praised the CDC recommendations and went along with the notion that pre-test prevention counseling was a barrier to testing instead of a challenge to be met in maintaining this strategic prevention intervention.

The reaction to the new recommendations and their affect on prevention underscore not just the assault on HIV prevention generally, but also the lack of assertive, coherent, and coordinated advocacy in the HIV/AIDS community. The seriousness of this situation is exacerbated by the fact that there is no single, large venue for the HIV-prevention community in the U.S. to share information and develop advocacy capacity that is not tied to funding from the very same government that continues to shift the debate and use conferences to monopolize the discourse and stifle discussion.

Ultimately, the new recommendations are consistent with the risk-elimination model in that risk-reduction education with clients seeking testing is no longer part of CDC recommended protocol. Remedying this situation is essential to sustaining HIV prevention and also to maintaining important linkages in the continuum of HIV/AIDS prevention, care, and treatment.

Recommendations

If, as a nation, we want to achieve our government's stated goal of reducing new infections by a half, then we must have a plan that helps guide us out of the current quagmire. This plan must begin with a return to the sound public health policies of risk reduction. Below are seven recommendations that can lead us back to a renewed prevention agenda and the promise that such prevention can bring.

•  FUND PREVENTION. The U.S. Congress should immediately move to restore appropriate funding to domestic HIV prevention. While the Bush administration has proposed an increase in funding for HIV prevention for Fiscal Year 2007, it barely restores levels achieved in 2001. The HIV-prevention community has said that the Fiscal Year 2007 budget must include a minimum of $1 billion for prevention programs in order to address the actual need and reinvigorate prevention efforts. Redirecting existing streams of abstinence-only-until-marriage funds can be a way to achieve these necessary funding levels.

•  FOCUS ON PUBLIC HEALTH NOT POLITICS. The shift away from risk reduction was a political decision based on ideology and not founded in science or sound public health strategies. This is just one of the many examples of the current administration chipping away at the importance of science. The progress we have made, however, in stemming the tide of this epidemic was made as a result of science and not politics. We need to return to policies that elevate evidence-based strategies to their proper place and support the adaptation of existing and promising new programs to help reduce the annual burden of new infections. One way to achieve this would be to pass the Responsible Education About Life Act which would provide $206 million in grants for comprehensive, evidence-based, risk-reduction sexuality education programs, including HIV-prevention interventions, that discuss abstinence, contraception, and other life skills.

•  ABOLISH ABSTINENCE-ONLY-UNTIL-MARRIAGE FUNDING. Congress should abolish funding for abstinence-only-until-marriage programs. These programs have received over $1 billion dollars under the Bush administration, all without any legitimate evidentiary support in their favor. They run counter to science, public health, public opinion, human rights and common sense. It is time for this social experiment to end and for an investment to be redirected toward programs that work.

•  FOLLOW A CONSISTENT APPROACH. In the meantime, public and private agencies at the state and community level that are working to advance evidence-based HIV prevention should cease taking and using abstinence-only-until-marriage funding. Although the pot of money for HIV prevention has been shrinking, abstinence-only-until-marriage programs run against, not with, the grain of HIV prevention. HIV prevention has worked in this country because we have been unabashed in support of condoms for reducing risk. Abstinence-only-until-marriage programs do not seek to reduce risk, they seek to eliminate it, and, in the process, are prohibited from saying anything positive about condoms or recommending their use. It is irresponsible for those organizations and agencies attempting to advance public health and prevent HIV to play a role in disparaging condoms or -as is required by the federal government-withholding information about their effectiveness. In addition, abstinence-only-until-marriage programs seek to stigmatize everything except virginity. HIV prevention requires a more thoughtful, moral and inclusive approach.

•  ACKNOWLEDGE THE IMPORTANT ROLE OF CONDOMS. A return to a risk-reduction model must acknowledge that condoms are our best defense against the spread of HIV for sexually active people. Therefore, HHS should immediately require all programs receiving funds to provide written "non-disparagement" assurances in regard to condoms. Research suggests that using a condom for HIV prevention is 10,000 times safer than not using a condom.12 Instead of vilifying this important prevention method, we must return to a message that consistently explains that condoms are an important strategy for making sex safer.

•  RESTORE THE LINK BETWEEN TESTING AND PREVENTION. The CDC should issue more flexible recommendations that once again explicitly link HIV testing and prevention education. Such recommendations should view prevention education as a compliment to testing, instead of a barrier, and we must collectively take responsibility to seize any and all opportunities to educate individuals. As a start, the CDC can balance the need to expand testing without abandoning prevention education by issuing separate recommendations for settings with routine testing and for settings where an HIV test is specifically requested and sought out by an individual. By re-establishing the link between testing and prevention for those specifically seeking an HIV test, we can reach this important population-one that has already self-identified as at risk or concerned about their health.

•  BRING THE HIV-PREVENTION COMMUNITY TOGETHER IN A NEUTRAL SETTING . The larger national community of HIV-prevention advocates, educators, and providers must establish an independent periodic event to assess the state of prevention and share information about best practices. The administration has deftly used its funding of existing venues and HIV/AIDS agencies to stifle dissent and control the conversation. As such, the marked decline in domestic prevention funding and a startling escalation of abstinence-only-until-marriage funding has been barely touched upon at the major national conferences dealing with prevention. If an independent event is not possible, the domestic community should move to set up satellite or parallel sessions at existing venues to ensure that the important issues of HIV prevention are raised.

References

1. U.S. HIV Prevention Efforts May Have Prevented 1.5 Million Domestic HIV Infections and Saved Billions of Dollars, Study Says (Washington, DC: The Kaiser Family Foundation), accessed 27 November 2006, <http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=14793>.
2. U.S. Federal Funding for HIV/AIDS: The FY 2005 Budget Request (Washington, DC: The Kaiser Family Foundation), accessed 12 November 2006, <http://www.kff.org/hivaids/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=31456>;
3. U.S. Federal Funding for HIV/AIDS: The FY 2006 Budget Request accessed (Washington, DC: The Kaiser Family Foundation), accessed 12 November 2006, <http://www.kff.org/hivaids/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=51641>.
4. Todd Summers and Jennifer Kates, Trends in U.S. Government Funding for HIV/AIDS: Fiscal Years 1981 to 2004 , (Washington, DC: Kaiser Family Foundation, March 2004); Jennifer Kates, "Issues Impacting the CDC's New HIV Strategic Plan," Presentation at CDC/HRSA Advisory Committee on HIV and STD Prevention and Treatment, 13 November 2006.
5. Ibid.
6. Section 510(b) of Title V of the Social Security Act, P.L. 104-193
7. The Content of Federally Funded Abstinence Education Programs, Prepared for Representative Henry Waxman (Washington DC: Committee on Government Reform-Minority Staff, Special Investigations Division, December 2004).
8. Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs, (Washington, DC: United States Government Accountability Office, October 2006), accessed 27 November 2006, <http://www.gao.gov/docsearch/abstract.php?rptno=GAO-07-87>..
9. Doug Kirby, Emerging Answers , (Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2001); Doug Kirby, et al,, Sex and HIV Education Programs for Youth : Their Impact and Important Characteristics (Research Triangle Park, NC: Family Health International, 2006); John Santelli and Mary Ott, "Abstinence-only education policies and programs: A position paper of the Society for Adolescent Medicine," Journal of Adolescent Health 38 (2006): 83-87.
10. Letter from New Jersey Commissioner of Health and Human Services, Fred M. Jacobs, M.D., J.D., and New Jersey Commissioner of Education, Lucille Davy, J.D., to U.S. Secretary of Health, Michael Leavitt. Dated 24 October 2006.
11. Julie Gerberding , Report to Congress: Prevention of Genital Human Papillomavirus Infection (Atlanta, GA: Centers for Disease Control and Prevention, January 2004) 1-35, <www.cdcnpin.org/scripts/std/HPV%20ReportJan%202004.pdf>.
12. Bernard M. Branson, et. al., "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings," Morbidity and Mortality Weekly Report 55(RR14) (September 22, 2006): 1-17, accessed 12 November 2006, <www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm>.
13. Ronald Carey, et al., "Effectiveness of Latex Condoms As a Barrier to Human Immunodeficiency Virus-sized Particles under the Conditions of Simulated Use," Sexually Transmitted Diseases 19.4 (July/August 1992): 230.

A special thanks to the Robert Sterling Clark Foundation for supporting
the development of this report, though its content solely reflects the views of SIECUS.