that include condom provision in out-of-school programs for youths identified as engaging in or at high risk of engaging in risky sexual behaviors.

  • PEPFAR funds may not be used to distribute or otherwise provide condoms in school settings.

  • PEPFAR funds may not be used in schools for marketing efforts to promote the use of condoms to youths.

  • PEPFAR funds may not be used in any setting for marketing campaigns that target youths and encourage condom use as the primary intervention for HIV prevention.

These guidelines are reinforced in the draft work plans of the Technical Working Groups, which promote life skills and AIDS education programs delivered in school settings because these interventions have been shown to be effective, and which encourage programs targeting youth aged 10–14 to emphasize abstinence and the delay of sexual initiation. Given the reported early average age of sexual debut (and sometimes marriage) in many countries, however, PEPFAR may wish to re-examine its exclusive AB focus for younger adolescents.

A number of potential challenges to meeting the needs of orphans and other vulnerable children are associated with these funding restrictions and program considerations, in terms of both the location of programs (e.g., in versus out of school) and ages targeted. As discussed previously, the deteriorating health or death of parents or adult guardians forces many orphans and other vulnerable children to drop out of or interrupt school attendance because funds for tuition are lacking, or other obligations become the child’s priority. Prevention programs in the school environment often will not reach this critical population. A number of out-of-school prevention programs exist in many of the focus countries, including community mobilization efforts that often include outreach to peers, adults, and out-of-school youths to expand access to prevention (OGAC, 2005d, 2006g). However, it is not possible to determine how many children are reached with prevention messages through these programs.

The age focus of prevention programs can also be limiting. Being orphaned and otherwise affected by HIV/AIDS can put children in situations in which they are vulnerable to becoming exposed to HIV. Prevention programs must also target these vulnerabilities, including sexual coercion by adults in exchange for food, money, housing, and educational/school opportunities. Such sexually predatory behavior can be committed by extended family members who may be caregivers, employers using an orphaned or vulnerable child’s labor for domestic help, or school teachers promising better grades. Thus the risk of HIV exposure and infection may extend beyond the scope of age-specific interventions or school programs communicating abstinence and be faithful messages. While there are some

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