|PEPFAR: Priorities for Prevention|
The President's Emergency Plan for AIDS Relief (PEPFAR) is the largest commitment ever made by any nation to an international health initiative dedicated to a single disease. The law authorizing these global HIV/AIDS programs first passed in 2003 with a five-year timeframe. The effort was reauthorized in 2008, and despite containing some improvements to the first phase of PEPFAR, many of the needed fixes for prevention programs went unattended.
Enhanced HIV prevention efforts are needed to ensure program sustainability, good global health, and achievement of the PEPFAR target to prevent at least 12 million new infections by 2013. In response to this need, a coalition of organizations developed recommendations for 12 key areas to enhance the impact of these programs. The recommendations are based on a human rights approach, and they encompass evidence effective programming, data collection on who is vulnerable, and respect for the local conditions in which programs are implemented.
Goal 1: Revise and Provide Effective "ABC" Programming
Currently, PEPFAR calls for spending at least 50 percent of prevention funds designed to halt the sexual transmission of HIV, in countries with generalized epidemics, on the "ABC" approach-Abstinence, Be faithful, Correct and Consistent Use of Condoms. PEPFAR recipients that do not meet this requirement must justify their programmatic decisions through an onerous reporting requirement to Congress and potentially face defunding.
Every individual needs a range of information and services to protect him or herself against HIV, and public health experts on the ground must be able to determine the best mix of prevention programming for their own communities. New prevention guidance should be issued to enable all individuals to have all training, information and service to protect themselves against HIV. Funds spent on comprehensive prevention programs that include ABC programming should count toward the 50 percent reporting requirement.
Goal 2: Integrate HIV Prevention with other Reproductive and Sexual Health Services
In most regions, the number of new infections is growing most rapidly among women and adolescents, primarily through sexual transmission. These two groups are more likely to use family planning and other reproductive health services than any other segment of the population, and would be better equipped to protect themselves from HIV if their access to reproductive health services and education was expanded.
The Office of the Global AIDS Coordinator (OGAC), the agency charged with administering PEPFAR funding, must update guidance and ensure that sexual and reproductive health services and counseling are strong components of, or well-linked to, any and all U.S.-funded HIV prevention programs, including prevention of mother-to-child transmission (PMTCT). PEPFAR program funds should allow the purchase of contraceptives in addition to male and female condoms.
Goal 3: Increase Access to and Effective Use of both Male and Female Condoms
PEPFAR should focus on increasing procurement and distribution of condoms, particularly female condoms, to countries in need. At the same time, PEPFAR should commit to a dramatic expansion of programs to train people in the consistent and effective use of condoms, create demand for them, dispel myths about condoms, and to address the social dynamics that undermine effective condom use.
Goal 4: Provide Voluntary, Medically Safe Adult Male Circumcision as Part of
Comprehensive Prevention Strategies
PEPFAR should scale up adult male circumcision as an informed and voluntary option within the context of comprehensive HIV prevention. Male circumcision programs must reflect international guidelines and recommendations, with particular attention to the consequences for women. When provided by a trained health provider in a clinical setting, male circumcision is a very safe procedure, and complications are rare, but achieving these high standards in countries with weak health systems requires special attention. Further, changes in men's behavior that can or should come as a result of circumcision (including waiting for the surgical wound to heal, post-operative use of condoms, and number of sexual partners) must be addressed to ensure positive health outcomes.
Goal 5: Prevent and Mitigate Gender-Based Violence and Violence against Women
A standard tool for screening for violence, sexual coercion, and rape should be developed based on pilot research funded by the U.S. government. Screening for violence must also be integrated as a core component of HIV prevention, treatment and care programs. Programs to address social norms that perpetuate violence, especially with men and boys, need to be expanded.
Goal 6: Strengthen Prevention Strategies for Children, including Adolescents and Orphans and Vulnerable Children and Youth (OVCY)
PEPFAR programs for youth must be based on local epidemiology and assessments of norms that leave youth vulnerable, and must reflect the fact that young people in many cases comprise parts of other vulnerable populations (i.e., sex workers, child brides, injection drug users, and men who have sex with men). PEPFAR programs must provide young people access to: comprehensive sexuality education programs that include information on HIV prevention, sexuality, sexual diversity, and gender equality; youth-friendly health services; psychosocial support; and access to primary education. The term OVC should be broadened to OVCY to ensure programs include youth.
Goal 7: Expand Programs and Services Reaching Men who Have Sex with Men (MSM)
PEPFAR must ensure access to high-quality prevention, treatment and care services for MSM free from discrimination and the threat of criminal penalties. Strengthened epidemiological surveillance and research on factors driving HIV among MSM is essential to an effective response. OGAC should establish an MSM Coordinator, provide resources proportional to the scale of the epidemic among MSM, and create a budget code assigned to track MSM program spending.
Goal 8: Promote Evidence-Based Prevention Programs with and for Sex Workers
Currently, PEPFAR law requires groups fighting HIV/AIDS overseas to pledge their opposition to prostitution and sex trafficking before receiving U.S. funding. This so-called "anti-prostitution pledge" must be eliminated for all NGOs. Programming for sex workers should reflect international guidelines and agreements on HIV/AIDS and human rights. PEPFAR should support comprehensive and quality health care that does not discriminate against sex workers, and in some instances, encourage legal reform to guarantee that sex workers are able to claim the benefits to which all citizens are entitled. PEPFAR should support community-organized HIV prevention programs and sex worker organizations that provide HIV prevention, care and treatment.
Goal 9: Preventing Mother-to-Child Transmission (PMTCT)
PEPFAR's PMTCT programs should be guided by the World Health Organization's technical guidance. At a minimum, these programs should ensure primary prevention of HIV infection, preventing unintended pregnancies among HIV-infected women, preventing HIV transmission from HIV-infected women to their children, and providing care for HIV-infected mothers and their infants. Once the Congressionally mandated PMTCT expert panel issues its report to Congress, OGAC should implement the panel recommendations expeditiously.
Goal 10: Support Evidence-Based Prevention Strategies for Injection Drug Users (IDUs)
OGAC should scale up prevention initiatives for people who inject drugs, particularly in countries where it is the primary driver of the epidemic. OGAC should change current policy to permit PEPFAR funding for needle and syringe exchange services. Additionally, it should scale up medication-assisted drug treatment regardless of HIV status.
Goal 11: Mitigate Negative Consequences of the Conscience Clause (also known as the Refusal Clause)
PEPFAR contains a provision that enables organizations receiving U.S. funding to pick and choose the prevention, treatment, care, and support services they wish to provide to individuals based on their own moral choices rather than best public health practice. As a result, millions of dollars go to organizations to provide prevention services, even though they refuse to discuss the potential of condoms or other contraceptives in preventing the spread of HIV. The PEPFAR refusal clause must be clarified to require that its invocation cannot result in delay, disruption, or diminished quality of care in the provision of services for HIV/AIDS prevention, treatment, and care. While diverse religious views should be accommodated to the extent possible in the provision of global HIV/AIDS funding, recipients should not be able to reject or ignore objective evidence of what works in provision of programs or services or choose to whom they are willing to provide those programs or services.
Goal 12: Enhance Research, Monitoring, and Evaluation Systems
OGAC should encourage and fund programs integrating formative and operations research, as well as monitoring and evaluation systems with outcome measures. OGAC should engage project implementation partners and national public sector counterparts in setting and negotiating targets in an open, transparent and participatory process. OGAC should propose global data collection tools and guidance on their use and adaptation, and require programs to collect and report age-disaggregated data by sex.