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PEPFAR Implementation: Progress and Promise
improvements in survival and reversal of the epidemic—it will be necessary to eliminate the fragmentation introduced by the PEPFAR categories and budget allocations and better capitalize on the synergy that results from effective integration.
The suballocations and corresponding subcategories that OGAC has developed to manage them have also been problematic within categories. According to many of the Country Teams, the abstinence-until-marriage allocation within the prevention category has been the most difficult to manage. The adverse effect of this budget allocation on prevention programming that is responsive to and harmonized with host country plans was also found in a recent Government Accountability Office study (GAO, 2006) that examined countries in addition to the focus countries. By requiring the Country Teams to isolate funding for these activities, this budget allocation has undermined the teams’ ability to integrate prevention programming.
The abstinence-until-marriage budget allocation in particular has fueled a divisive U.S. debate over the ABC concept. It is important to understand that ABC represents neither a program nor a strategy, but a goal of changing key behaviors. There is good evidence that behavior changes such as delaying sexual activity (A), reducing the number of sexual partners (B), and using condoms correctly and consistently (C), reduce the risk of transmitting HIV/AIDS (Stanton et al., 1998; Furguson et al., 2004; Bunnell et al., 2006; Riedner et al., 2006). While no one argued during the Committee’s visits that funding for ABC should exclude activities focused on changing abstinence behaviors, the Committee has been unable to find evidence for the position that abstinence can stand alone or that 33 percent is the appropriate allocation for such activities even within integrated programs.
The ABC debate has also served to obscure the importance of other behaviors that put people at high risk of contracting HIV/AIDS, such as alcohol use and violence toward women. Since programs aimed at reducing alcohol dependence or empowering women are not officially ABC activities, they are less likely to be funded.
Finally, the budget allocations do not allow program implementers sufficient flexibility to respond to change. Moreover, the Leadership Act stipulated that the budget allocations were recommended for the first 2 years of the program and many would be required beginning in 2006. Thus the allocations were set to become more, rather than less, restrictive as the program evolved and attempted to adapt to changes in science, country epidemics, and circumstances. OGAC’s management of the allocations for the first 3 years of funding are shown later in the chapter in Table 3-3.
The difficulties posed by budget allocations will become more pronounced as the HIV/AIDS pandemic and the science of controlling it evolve. For example, several new approaches to prevention are currently being