This section reviews the progress of PEPFAR’s activities to prevent HIV infection according to the primary routes of transmission of HIV: sexual, through injecting drug use, from mother-to-child, and medical. Also discussed is PEPFAR’s progress in the crucial area of removing gender barriers to prevention.

Prevention of Sexual Transmission of HIV
Promotion of Behavior Change

Sexual transmission accounts for more than 80 percent of all HIV infections worldwide (Piot et al., 1988). Behavioral interventions designed to reduce the risk of sexual transmission of HIV are tailored to specific groups and to be effective require a current understanding of HIV epidemiology, in particular those people at highest risk of infection. These interventions include providing counseling and testing; encouraging risk reduction in people who are both HIV-positive and HIV-negative; and reducing HIV risk cofactors, such as the presence of another sexually transmitted infection (JHU AIDS Service, 2006).

The Leadership Act describes activities to be supported by the U.S. Global AIDS Initiative to prevent HIV transmission. These activities focus on “delay of sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual violence and coercion, including child marriage, widow inheritance, and polygamy, and where appropriate, use of condoms” (P.L. 108-25, p. 729).

As described in the strategy for the program, PEPFAR’s primary approach to preventing sexual transmission of HIV is aimed at changing ABC behaviors. Largely in response to the Leadership Act’s requirement that 33 percent of funding for prevention of sexual transmission go to support abstinence-until-marriage (A) programs, PEPFAR divides activities related to preventing sexual transmission into two funding and reporting subcategories: abstinence/be faithful and condoms and other prevention (GAO, 2006).

Abstinence/Be Faithful

Operational plans for the 15 focus countries incorporate a variety of activities funded under the abstinence/be faithful subcategory, including school-based, community, and media interventions aimed at delaying sexual activity among youths; promoting fidelity and reduction of the number of partners among sexually active adults; addressing gender norms and HIV-

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