Response to the Government Accountability Office Report, Global Health: Spending Requirement Presents Challenges to HIV/AIDS ReliefApril 7, 2006 On behalf of the Departments of State, Health and Human Services (HHS) and the United States Agency for the International Development (USAID) and Office of the Global AIDS Coordinator (OGAC) we appreciate the opportunity to comment on the draft Government Accountability Office (GAO) report, Global Health: Spending Requirement Presents Challenges to HIV/AIDS Relief (GAO-06-395). Effective prevention is central to the Emergency Plan Only a vigorous and comprehensive prevention approach will turn the tide against the global HIV/AIDS pandemic – the mission of the Emergency Plan. Effective prevention is the only way to stop the human suffering caused by HIV infection and limit the number of people who will require treatment in the future. Ultimately, it is the only way to achieve the elusive goal of an HIV/AIDS free generation. In the three years since President Bush’s announcement of the Emergency Plan, the United States has demonstrated historic leadership in implementing the most diverse HIV/AIDS prevention strategy of any international partner, with programs linked to treatment and care for a holistic response. The lessons learned from the intensive application of the Emergency Plan in the 15 focus countries are now being extended to over 120 countries, helping to fuel transformation of HIV/AIDS responses in nations around the world. This unprecedented initiative dwarfs the pre-PEPFAR baseline levels of prevention spending and has allowed for a wide-ranging portfolio of high quality, sustainable, evidence-based prevention programs. The President’s budget request of approximately $4 billion in HIV/AIDS funding for fiscal year 2007 will provide the necessary support to keep these prevention programs on track to reach the Emergency Plan’s five-year goal of supporting prevention of 7 million new infections, as well as for it to achieve the goals of support for treatment for 2 million HIV-infected people and care for 10 million individuals. Reflecting the importance of prevention, the Emergency Plan supports programs that address a broad range of HIV transmission mechanisms. In addition to programs to prevent mother to child transmission, ensure a safe blood supply, and prevent infections through unsafe injections, PEPFAR supports the ABC approach to prevent the sexual transmission of HIV. ABC is the most effective, evidence-based approach to sexual transmission of HIV infection Recent data from Zimbabwe and Kenya, not discussed in the report, mirror the earlier success of Uganda’s ABC approach to preventing HIV. These three countries with generalized epidemics (epidemics where HIV has spread beyond concentrated groups, e.g. prostitutes) have demonstrated reductions in HIV prevalence, and in each country the data point to significant AB behavior change and modest but important changes in C. Where sexual behaviors have changed, as evidenced by increased primary and secondary abstinence, fidelity, and condom use, HIV prevalence has declined. In Zimbabwe, Science reported in February 2006 that among men aged 17 to 29 years in eastern Zimbabwe, HIV prevalence fell by 23% from 1998 to 2003. Even more impressively, the prevalence among women aged 15 to 24 dropped by a remarkable 49%.
In Kenya, the Ministry of Health estimates that HIV prevalence dropped from approximately 10% to approximately 7% from 1998 to 2003. This decline correlates with a broad reduction in sexual risk behavior. Among the findings:
As Dr. Peter Piot of UNAIDS remarked with respect to these two countries, "[T]he declines in HIV rates have been due to changes in behaviour, including increased use of condoms, people delaying the first time they have sexual intercourse, and people having fewer sexual partners." More work is needed to understand these data, and to identify which interventions may have influenced them. Fundamentally, however, it is clear that people in some countries have begun to change their sexual behavior in ways that reduce their risk of infection. It is thus urgent to identify and scale up initiatives to help even more people choose healthy behaviors. The national strategies of many host nations included the ABC approach, delivered in culturally-sensitive ways, even before the advent of the Emergency Plan. This new evidence is highly relevant to PEPFAR’s work with these nations: most of Sub-Saharan Africa, and 13 of the 15 focus countries, are experiencing generalized epidemics. Host nations are moving to balance campaigns to promote awareness of HIV with a broader public health approach that provides people with comprehensive information, services, and support that will enable them to make healthy decisions about how to protect themselves. Indeed, providing people with this level of information, support and services is not merely good public health practice – it can help promote the democratic value of personal responsibility that leads to healthy behaviors. Congressional directives have helped focus USG prevention strategies to be evidence-based Because of the data, ABC is now recognized as the most effective strategy to prevent HIV in generalized epidemics. One of the most striking findings of the report is the consensus among USG personnel that ABC is the right approach to prevention. The authorizing legislation directs that, for fiscal years 2006-2008, 33% of prevention funding be allocated to abstinence-until-marriage programs. In 2004, PEPFAR notified Congress that it interprets such programs as those that focus on abstinence and faithfulness, as the AB messages should not be separated except in programming for young children. Together with the evidence of ABC behavior change, the legislation’s emphasis on AB activities has been an important factor in the fundamental and needed shift in USG prevention strategy from a primarily C approach prior to PEPFAR to the balanced ABC strategy. The Emergency Plan has developed a more holistic and equitable strategy, one that reflects the growing body of data that validate ABC behavior change. PEPFAR has followed Congress’ mandate that it is possible and necessary to strongly emphasize A, B, and C, while also seeking to support prevention of mother to child transmission and other critical prevention interventions. Financing for all methods of prevention have increased under PEPFAR PEPFAR’s unparalleled financial commitment has permitted the USG to support a balanced, multi-dimensional approach – one that was not possible with pre-PEPFAR spending levels. The total annual spending in the areas of HIV/AIDS prevention, as well as treatment and care, has continually increased since the passage of the Leadership Act. If Congress enacts the President’s request for $4 billion in HIV/AIDS funding for fiscal year 2007, that represents a total increase of $740 million from that appropriated in fiscal year 2006 ($3.2 billion) and almost $1.2 billion from that appropriated in fiscal year 2005 ($2.8 billion). In addition, these levels of funding represent a quantum leap over the pre-PEPFAR baseline levels of funding for global HIV/AIDS ( U.S. funding totaled $3.87 billion for years 2000-2003). With the vast increase in funding represented by PEPFAR, of course, reductions in the percentage of funding dedicated to one program area may occur despite an increase in the actual dollar amounts dedicated to that area. This has been true with respect to prevention in PEPFAR. Prevention funding increased from almost $294 million in FY 2005 to over $350 million in FY 2006. Before the advent of PEPFAR, the USG was supporting very few programs in the areas of care and treatment. With the massive and highly successful scale-up of these services which PEPFAR now supports, obviously the percentage of resources dedicated to prevention has declined. Yet the USG commitment to global HIV/AIDS prevention is now clearly stronger than it has ever been. “Counting” ABC allocations does not affect programming The report reflects misunderstanding of the relationship between PEPFAR reporting mechanisms and programming. PEPFAR is required to count the amounts it allocates to different types of prevention programming for purposes of accountability to Congress. But it is not the case that each program must be only AB, or only C. Many PEPFAR-supported programs integrate all of the ABC strategies, and these programs are encouraged to report on the different pieces to the extent possible, because accountability is key component of the success of PEPFAR. For a program to be a truly integrated ABC program, of course, it must genuinely include all three elements, rather than overwhelmingly emphasize only one or two elements. PEPFAR is currently working to strengthen its reporting conventions in this area through its Technical Working Groups and through the programmatic review. Guidance on ABC is strong – it addresses most key issues and is being clarified as needed OGAC is quoted in the report as saying that it will provide further clarification of the ABC Guidance, and we welcome this report's contribution to the ongoing dialogue between PEPFAR headquarters and the field. The ABC Guidance had been issued approximately two to five months prior to the country teams’ interviews for this report. It may be expected that adjusting to newly-distributed guidance may generate questions and a need for more clarity in the short term. OGAC has since refined and adjusted the guidance to clarify issues as needed and will continue to do so. The Guidance is a document which is updated and adjusted on an ongoing basis to meet the needs of the country teams. Even as it is updated, however, the Guidance will continue to represent the USG’s unwavering support for ABC as the key evidence-based approach to prevent HIV infection in generalized epidemics. PEPFAR is committed to continually improving its efforts to communicate policy to the field via numerous channels, including weekly emails, constant contact between the core team leaders and the field, the annual Implementers’ Meeting, and others. In addition, each country’s operating plan is developed with significant assistance from headquarters, providing another venue for issues to be communicated & worked through. It is important to note that certain examples provided in the report to demonstrate confusion regarding the ABC Guidance are in fact clearly spelled out in the Guidance, so the issues are actually related to implementation, not to the Guidance. One important area which the Guidance addresses at length is the need to focus on “high-risk activity” rather than “high-risk groups,” because in a generalized epidemic, much of the population can be at risk.
-On page 27, the Report references concern that anyone engaging in sexual activity is not considered a “high-risk group.” Yet again, on page 28, the Report references the Guidance which says “to achieve the Emergency Plan prevention goal, we must introduce combinations of interventions and adapt them to reach, engage, and provide the means to enable at-risk populations to reduce their risk-taking behaviors in a range of settings (community and facility-based).” -On page 28, the Report references apparent confusion regarding messages that can be delivered to mixed groups of students (includes youth spanning ages 10 to older than 14) in a single classroom. The Guidance is very clear (see Report pages 28 and Guidance pages 6-7) that students aged 14 and under may receive certain messages and that only students 15 and older can receive additional messages. This is not an issue of guidance, but of implementation -- how best to separate students of different ages when prevention is taught. Our interagency Prevention Working Group will work with the field on this implementation issue. PEPFAR has applied the Congressional directives in a flexible way tailored to country circumstances As noted above, the Emergency Plan recognizes the importance of tailoring prevention efforts to the particular epidemic of each country. As the report notes, PEPFAR offers country teams the opportunity to propose, and provide justification for, prevention funding allocations that differ from the Congressional directive. In fiscal year 2005, all countries that proposed such allocations received PEPFAR approval for them. These countries included Cote D’Ivoire, Guyana, Haiti, Mozambique, Rwanda, Tanzania, and Vietnam. (Contrary to the report’s suggestion, it must be noted that when PEPFAR approved the allocations of countries that submitted justifications, it did not require other countries to make offsetting adjustments to their proposed prevention allocations.) It is important to remember that most focus countries have generalized epidemics, for which the ABC approach is the most effective, data-based strategy. Every country has the opportunity to submit a justification, but in those with generalized epidemics for which ABC has been proven to be so effective, the justification for a different allocation must be particularly strong. It is also important to remember that the USG is not the only source of funding in-country, and that partners can seek funding from other sources for to balance their mix of prevention interventions if they find that necessary. We recognize that the ABC approach represents a change in USG practice, and that change always involves a period of transition. Yet we have asked some of the countries that did not submit justifications if they wanted to do so and the answer was, emphatically, no. As country teams have become more experienced in the ABC approach and familiar with the data that supports it, they have become more comfortable with implementing it. The Emergency Plan accepts the report’s recommendation to collect information on the effects of the Congressional directives, and the information gathered will inform our adjustments to guidance. As in all areas, the Emergency Plan will continue to refine implementation as issues are identified, through such mechanisms as the fiscal year 2007 Country Operational Plan guidance. Guidance should apply to all accounts OGAC has considered the report’s recommendation that the Congressional directive should be applied only to funds appropriated through the Global HIV/AIDS Initiative Account (GHAI), but does not believe it to be appropriate. First, one of the principal objectives of the Emergency Plan legislation was to integrate the activities and efforts of all USG agencies with respect to HIV/AIDS programming. One of the Coordinator's tools to achieve this has been a unified budget approach, irrespective of the source of funding, in planning and approving country activities. Applying the spending requirement to only a part of the budget would signal a step backward in the integration of USG agencies’ activities. Second, the issue is becoming less salient over time. With respect to focus country budgets, as the report states, non-GHAI funds represent only "slightly more than $5 million (2 percent) of the focus country teams' planned PEPFAR prevention funds," and only 1 percent if central program dollars spent in focus countries is included. The suggested change would thus have only a modest impact. Full funding for focus country budgets will limit the need for trade-offs Perhaps the most important contribution the report will make is to highlight the effect of budget issues on prevention funding. The President's fiscal year 2007 budget request for the focus countries is, in part, an attempt to recover from the effects on focus country programs of the redirection of almost $527 million from focus country programs to the Global Fund and other components of the Emergency Plan over PEPFAR's first three years. The effect of this trend has been to force country teams to make difficult trade-offs among prevention, treatment, and care (and within prevention, among sexual transmission, mother-to-child transmission, and medical transmission programs). We appreciate the report’s candor about the seemingly impossible decisions these budget constraints have forced upon country teams. In fiscal year 2007 and beyond, full funding for PEPFAR’s focus country activities is essential if PEPFAR is to meet the 2-7-10 goals, including the prevention goal. Conclusion Effective prevention is at the heart of the Emergency Plan, and in generalized epidemics, the evidence-based ABC approach is at the heart of effective prevention. Among the most encouraging developments in many years in the global fight against HIV/AIDS is the growing body of evidence demonstrating that ABC behavior change is possible – and that it can reduce HIV prevalence on a large scale. This report reflects another very encouraging development – the consensus support for the ABC strategies on the part of USG personnel in the field. The Congressional directive, which itself reflects an understanding of the importance of ABC, has helped to support PEPFAR’s field personnel in appropriately broadening their range of prevention efforts. Solid policy guidance from PEPFAR on prevention has helped to address many issues of concern, and in implementing ABC, PEPFAR will continue to be responsive to the needs of personnel as they respond to circumstances in-country. The first two years of the Emergency Plan have demonstrated that high-quality prevention programs can work – and are working – in many of the world’s most difficult places. Through PEPFAR, the American people have become true leaders in the world’s effort to turn the tide against HIV/AIDS. |
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