5

Prevention

Making strong global, national, and programmatic commitments to HIV prevention is critical to any balanced attempt to change the course of the HIV epidemic, and PEPFAR has made major investments in activities aimed at reducing HIV transmission. The congressional charge for this evaluation, as laid out in the Lantos-Hyde Act of 2008, requested both “an assessment of progress toward prevention, treatment, and care targets” and “an evaluation of the impact of prevention programs on HIV incidence in relevant population groups.”1 This chapter presents the committee’s assessment of PEPFAR’s prevention activities.

In this chapter a brief overview of the evolution of HIV prevention science is followed by an overview of PEPFAR’s programmatic targets and funding for prevention and then discussions about the prevention of sexual transmission, including prevention for people who engage in sex work and prevention for men who have sex with men; prevention of mother-to-child transmission (PMTCT); prevention for people who inject drugs; and a limited assessment of PEPFAR’s efforts in the areas of blood and medical injection safety. The sections for each prevention area contain relevant historical and contextual framing and an assessment using the program impact pathway framework of inputs, activities, and, to the extent possible, the outcomes and impact of PEPFAR’s prevention efforts. This is followed by a

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1 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008) at img101(c), 22 U.S.C. 7611(c)(2)(B)(i) and (v).



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5 Prevention Making strong global, national, and programmatic commitments to HIV prevention is critical to any balanced attempt to change the course of the HIV epidemic, and PEPFAR has made major investments in activities aimed at reducing HIV transmission. The congressional charge for this evaluation, as laid out in the Lantos-Hyde Act of 2008, requested both “an assessment of progress toward prevention, treatment, and care targets” and “an evaluation of the impact of prevention programs on HIV incidence in relevant population groups.”1 This chapter presents the committee’s assess- ment of PEPFAR’s prevention activities. In this chapter a brief overview of the evolution of HIV prevention science is followed by an overview of PEPFAR’s programmatic targets and funding for prevention and then discussions about the prevention of sexual transmission, including prevention for people who engage in sex work and prevention for men who have sex with men; prevention of mother-to-child transmission (PMTCT); prevention for people who inject drugs; and a limited assessment of PEPFAR’s efforts in the areas of blood and medical injection safety. The sections for each prevention area contain relevant his- torical and contextual framing and an assessment using the program impact pathway framework of inputs, activities, and, to the extent possible, the outcomes and impact of PEPFAR’s prevention efforts. This is followed by a 1  Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tu- berculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008) at §101(c), 22 U.S.C. 7611(c)(2)(B)(i) and (v). 163

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164 EVALUATION OF PEPFAR discussion of the role of counseling and testing within a prevention context, with more in-depth discussion and analysis of this topic in Chapter 6, “Care and Treatment.” Finally, there is a discussion of emerging prevention inter- ventions and the committee’s recommendation for strategically strengthen- ing PEPFAR’s prevention efforts. Further discussion of PEPFAR’s activities related to reducing HIV risk for women and girls and for men who have sex with men can be found in Chapter 8, “Gender.” The IOM committee is mindful that, over the course of its existence, PEPFAR has had dual roles as both a catalyst and a respondent to various developments in global HIV prevention. The committee recognizes both the opportunities and the challenges inherent in these roles, and the results of this evaluation are described in this context. EVOLUTION OF HIV PREVENTION SCIENCE Throughout the history of the HIV epidemic, including the years of PEPFAR implementation, HIV prevention has been evolving, influenced by developments in science, policy, and advocacy in the context of an ever-changing epidemiological, political, and economic landscape. There are multiple, overlapping constructs through which HIV prevention efforts have been envisioned and organized. These include • modes of transmission (sexual, parenteral, perinatal); • populations and HIV-risk exposure behaviors (heterosexual men and women, men who have sex with men, transgender persons, people who inject drugs, HIV serodiscordant couples, pregnant women, young people, sex workers, etc.); • unit- or level-targeted (individual, couple, network, community); and • disciplinary, science-based approaches (biomedical, epidemiologi- cal, behavioral, social/structural). Over time and in different geographic locations, some of these constructs have been emphasized over others, based on current science, epidemiologi- cal trends, or political shifts. Evolution of Interventions to Prevent or Reduce HIV Infection The search for an AIDS vaccine—considered an ultimate goal to pre- vent infection—began as soon as HIV was discovered to be the causative agent of AIDS. Finding an effective vaccine quickly proved to be elusive, and it remains a challenge given the rapidly adaptive nature of the virus (NIAID, 2012). Meanwhile, in the early years of the HIV response most

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PREVENTION 165 prevention efforts were focused on behavioral change strategies that had the potential to be effective in slowing the epidemic. These efforts were supported by observational data from developing countries suggesting that behavioral change made a significant difference in reducing HIV transmis- sion (Gregson et al., 2006; Stoneburner and Low-Beer, 2004). In addition to behavior change efforts, biomedical approaches became a focus of HIV prevention. One of the most exciting developments in bio- medical prevention approaches was the discovery that the administration of antiretroviral (ARV) drugs (initially zidovudine and then nevirapine) to pregnant women and their newborns could significantly reduce HIV trans- mission from mother to child before, during, and after delivery (Connor et al., 1994; Guay et al., 1999; Shaffer et al., 1999; Sperling et al., 1996). This initial finding was followed by research on reducing the risk of transmission through breast feeding (Nduati et al., 2000). The focus on PMTCT added urgency to addressing HIV infection in women; epidemiological data have shown high and often unequal rates of HIV infections among women as compared to men in many regions (WHO, 2011). In addition, the recognition that women do not control male con- dom use, the most widely available method to prevent sexual transmission of HIV (UNAIDS, 2009), highlighted the need for women-focused and women-initiated HIV prevention strategies. Female condoms have become more widely available since 2009, but have several disadvantages, includ- ing cost and difficulty of use based on current designs, which have limited their utilization. The global availability and distribution of female condoms remains less than for male condoms, and the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) are encouraging more widespread access and use to prevent pregnancy and sexually transmitted infections (Avert.org, 2012). Research to develop ef- fective vaginal microbicides began to gain support in the early 1990s, but clinical trials of various compounds proved unsuccessful until 2010, when the Centre for the AIDS Program of Research in South Africa (CAPRISA) trial results were released showing reduced risk of HIV infection with use of an ARV-based gel (Abdool Karim et al., 2010). In the 1990s evidence emerged supporting the effectiveness of harm reduction strategies as a way to prevent HIV transmission among people who inject drugs. Harm reduction efforts seek to minimize negative health outcomes associated with drug use, including reducing the risk of HIV transmission, for people who are unwilling or unable to quit their addiction (IHRA, 2009). These strategies may include sterile needle and syringe ex- change programs, the relaxation of drug paraphernalia and possession laws, and the provision of medication for substitution therapy (Harm Reduction International, 2012). The adoption of harm reduction approaches varied considerably, but in cities with sterile needle and syringe exchange programs

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166 EVALUATION OF PEPFAR in place, significant reductions have been seen in HIV epidemics where transmission was concentrated among people who inject drugs (Hurley et al., 1997). Despite the mounting evidence of its effectiveness, harm reduction has continued to be very politically and culturally controversial and was not widely implemented, even in some countries with ongoing or emergent concentrated HIV epidemics (Auerbach, 2009). Other HIV prevention strategies explored and implemented in the first two decades of the global epidemic included the treatment of other sexually transmitted infections (STIs) to reduce the increased risk of HIV infection that accompanies STIs, and expanded blood donor HIV testing and other efforts to ensure the safety of blood and blood products and infection con- trol practices in hospitals and other health care settings to reduce iatrogenic transmission (Auerbach et al., 2006). By the time PEPFAR was initiated in 2003–2004, global experts had identified several effective, evidence-based prevention strategies and inter- ventions that were recommended for implementation and scale-up to ad- dress HIV epidemics in developing and developed countries alike (Global HIV Prevention Working Group, 2003). These included • behavioral change programs to reduce sexual risk behaviors and be- havioral prevention programs specifically targeted to HIV-positive individuals; • harm reduction services for people who inject drugs; • antiretroviral prophylaxis for PMTCT; • universal safety precautions, blood safety practices, and infection control in health care settings; • identification and treatment of STIs in addition to HIV; • HIV counseling and testing; and • policy reforms (such as those to reduce the vulnerability of women and girls or to expand access to effective prevention strategies). The HIV prevention field has continued to evolve, influenced by on- going research on approaches to address social, economic, political, and environmental factors linked to HIV risk, also referred to as structural interventions for HIV prevention (Gupta et al., 2008). Such interventions aim to create an enabling environment that will allow individuals to act in their own and their partners’ best interests by supporting policy or legal and environmental changes, shifting harmful social norms, catalyz- ing social and political change, and empowering communities and groups (Auerbach, 2009; Gupta et al., 2008). Multiple structural interventions have been effective at achieving HIV prevention outcomes such as reduc- tions in HIV transmission and social and structural risks that contribute to HIV vulnerability (Baird et al., 2012; Gupta et al., 2008; Pronyk et al.,

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PREVENTION 167 2006). Studies in this area are important because they provide evidence that structural interventions can influence the social determinants of HIV risk, reduce sexual and other HIV risk behaviors, and lower the rate of HIV infection. Clinical interventions have also been a part of the evolution of the field of HIV prevention. In 2005 evidence of the efficacy of medical male circumcision for preventing HIV acquisition among men emerged (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). More recently, findings have been reported from clinical trials investigating the effectiveness of interventions such as oral pre-exposure prophylaxis (PrEP), topical micro- bicides, and antiretroviral therapy (ART) for prevention of HIV transmis- sion (Abdool Karim et al., 2010; Cohen et al., 2011; Microbicide Trials Network, 2012a,b). These advances tremendously altered the prevention landscape—shifting from the historic emphasis on behavioral change strate- gies to one focused on biomedical prevention technologies. As HIV prevention has evolved over time to encompass a broad array of strategies and interventions that have been informed by an evolving evidence base, appreciation has grown for a “combination approach” that integrates effective biomedical, behavioral, and structural components of HIV prevention—as appropriate for a given setting or population—for maximum effect (Auerbach and Coates, 2000; Global HIV Prevention Working Group, 2003; Hankins and de Zalduondo, 2010; Kurth et al., 2011; Padian et al., 2011; WHO, 2011). In addition, the adoption and implementation of interventions to pre- vent HIV infection also occur in the context of historical and contemporary stigmatization. Both the ways in which HIV is transmitted—predominantly through sexual intercourse and illicit drug injection—and the social at- titudes about people identified as most vulnerable—including men who have sex with men, sex workers, people who inject drugs, individuals with multiple or concurrent sex partners, young women, and HIV serodiscor- dant couples—have contributed to stigmatization (Avert.org, n.d.). These political and cultural aspects of HIV prevention must be acknowledged when assessing how donors, governments, civil society, communities, and individuals have addressed the epidemic. OVERVIEW OF PEPFAR-SUPPORTED PREVENTION PROGRAMS Programmatic Targets and Goals for HIV Prevention Over Time The key programmatic target for prevention activities during the first phase of PEPFAR was to prevent 7 million new infections worldwide (OGAC, 2004b). In the 2008 reauthorization legislation, this target was increased to preventing 12 million new infections by 2013, and the goal

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168 EVALUATION OF PEPFAR was added of providing “at least 80 percent of the target population with access to counseling, testing, and treatment” for PMTCT.2 History of PEPFAR Funding for Prevention Figure 5-1 depicts the amount of planned/approved funding for PEPFAR’s prevention activities, not including counseling and testing, from fiscal year (FY) 2005 to FY 2011, disaggregated by PMTCT and all other prevention activities combined. Publicly available funding data do not provide any disaggregation of spending within prevention modalities—for example, how much is spent on activities, the procurement of supplies, workforce training, infrastructure, etc. The aggregate dollar amount of funding for these prevention activities has increased each year. The propor- tion of funds spent on prevention relative to total PEPFAR funding was highest in FY 2005 at 30 percent, and then declined for 2 years, followed by a steady increase from 18 percent in FY 2007 to 24 percent in FY 2011. The 2003 authorizing legislation included a prevention funding alloca- tion requirement that required that not less than 33 percent of PEPFAR pre- vention funds be spent on programs promoting abstinence until marriage,3 which PEPFAR interpreted as including programs addressing both absti- nence and being faithful within a monogamous relationship (later com- monly referred to as “AB”) (Ryan et al., 2012). Early in the implementation of PEPFAR, frustration was expressed by PEPFAR headquarters (HQ), mis- sion teams, and other stakeholders about the rigidity of budget allocations that explicitly required a certain proportion of expenditures on abstinence and be faithful activities, which limited PEPFAR’s ability to tailor activities to respond to country epidemiological information and to align with na- tional AIDS plans (GAO, 2006; IOM, 2007a). In 2007 an IOM committee recommended that these not be legislative requirements (IOM, 2007a), and the earmark was removed in the 2008 reauthorization legislation. The re- quirement was amended to state that prevention program portfolios should include a balanced funding approach within their prevention of sexual transmission activities.4 Additionally, in countries with generalized epidem- ics, a justification was required if programs promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction constituted less than 50 percent of funds spent on prevention of sexual transmission.5 2  Supra, note 1 at §301(a)(2), 22 U.S.C. 2151b-2(b)(1)(A)(i) and (iv). 3  United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st sess. (May 27, 2003) §402(b)(3). 4  Supra, note 1 at §403, 22 U.S.C. 7673(a)(1)(A). 5  Supra, note 1 at §403, 22 U.S.C. 7673(a)(2)(B).

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PREVENTION 169 $1,200 35% $1,000 30% Constant 2010 USD Millions 25% $800 20% $600 15% $400 10% $200 5% $0 0% FY05 FY06 FY07 FY08 FY09 FY10 FY11 All Other PrevenƟon $228.6 $224.8 $320.1 $493.3 $635.5 $627.6 $652.6 PMTCT $70.9 $65.6 $147.1 $204.5 $233.0 $313.3 $396.0 PrevenƟon as % of 30% 19% 18% 19% 21% 23% 24% Total PEPFAR Funding FIGURE 5-1 PEPFAR’s planned/approved funding over time for prevention (FY 2005–FY 2011). NOTES: This figure represents funding for all PEPFAR countries as planned/approved through PEPFAR’s budget codes. The budget codes are the only available source of funding information disaggregated by type of activity, and are therefore used in this report as the most reasonable and reliable approximation of PEPFAR investment by programmatic area. (See Chapter 4 for a more detailed discussion of PEPFAR’s budget codes and the available data for tracking PEPFAR funding.) Data are presented in constant 2010 USD for comparison over time. These data represent planned/approved funding for the PMTCT budget code and all other prevention budget codes combined. In this graph, “All Other Prevention” includes funding for abstinence and be faithful, other sexual prevention, blood safety, injection safety, male circumcision, and injecting and non-injecting drug use budget codes. (Male circumcision and injecting and non-injecting drug use were not reported as unique budget codes until FY 2009; prior to FY 2009 they were included in a bud- get code labeled “Other Prevention.”) Funding for counseling and testing is not included in prevention here (which differs from the presentations in Chapter 4). The funding data for the counseling and testing budget code, which was included first in the care technical area and since 2009 in the prevention technical area, are presented independently in Chapter 6. SOURCES: OGAC, 2005b, 2006c, 2007c, 2008b, 2010d, 2011e,f. Evolution of PEPFAR Prevention Programming As HIV prevention science has evolved, PEPFAR’s programming has shifted from an initial focus on a limited number of behavioral and bio- medical interventions to an expanded prevention portfolio that includes new, evidence-based biomedical, behavioral, and structural approaches. When PEPFAR began in 2004, its prevention programs built on existing U.S. government (USG) activities focused on the prevention of PMTCT and expanded to include blood and medical injection safety, as well as behavior change strategies in line with the “Abstinence, Be faithful, and correct and consistent Condom use” approach (also known as “ABC”) (OGAC, 2004b). Although PMTCT remains a central pillar of prevention programming, the PEPFAR portfolio has since broadened to include a more diverse array of strategies for people vulnerable to sexual and drug- use-related HIV transmission. This includes the incorporation of strategies for which evidence emerged or for which evidence existed but had not yet

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170 EVALUATION OF PEPFAR been adopted or scaled up by PEPFAR, such as voluntary medical male circumcision, promoting the use of female condoms, and harm reduction programs (OGAC, 2008b, 2009b, 2010b, 2011c). In line with the global HIV prevention movement, PEPFAR now supports a combination preven- tion strategy, which it defines as HIV prevention using a suite of mutually reinforcing interventions to address the risks of transmission and acquisition as thoroughly and strategically as possible. It is predicated on the idea that no single intervention is efficacious enough to bring an HIV epidemic under control on its own, but that the optimal set of interventions implemented with quality and to scale can significantly reduce HIV incidence. (OGAC, 2011a, p. 7) This process of evolution in PEPFAR’s support for prevention pro- grams, which has been occurring much more slowly than many in the public health community would like, reflects the difficulties of implement- ing these programs which, more than care and treatment, intersect with a particularly sensitive context globally, domestically in the United States, and in partner countries. This affects both general programming for the prevention of sexual transmission and even more so, programming to meet the prevention needs of marginalized populations at elevated risk for HIV infection. As one stakeholder interviewed for this evaluation noted: “I think one of the great challenges for PEPFAR has been on the one hand, professing to be evidence driven and interested in best practice and standards for HIV prevention, treatment, and care and at the same time, being constrained by the very real politi- cal realities of the U.S. where both sex work and injection drug use have been identified as things that the U.S. should not be funding.”6 (NCV-24-USNGO)7 6  Single quotations denote an interviewee’s perspective with wording extracted from transcribed notes written during the interview. Double quotations denote an exact quote from an interviewee either confirmed by listening to the audio-recording of the interview or extracted from a full transcript of the audio-recording. 7  Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-Country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Coun- try) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

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PREVENTION 171 A more in-depth discussion of the evolution of PEPFAR’s activities within specific areas of HIV prevention programming is provided in sub- sequent sections of this chapter. The committee chose to focus on three components of PEPFAR’s prevention programming for its primary analysis: prevention of sexual transmission, including prevention with people who engage in sex work and prevention with men who have sex with men; PMTCT; and prevention of HIV transmission among people who inject drugs. These were selected because they correspond to the greater share of HIV transmission; comprise the majority of PEPFAR’s prevention efforts, accounting for 58 to 70 percent of the program’s prevention spending from FY 2005 to FY 2011 (OGAC, 2005b, 2006c, 2007c, 2008b, 2010d, 2011e,f); and were a reasonable and feasible focus given the time and re- source limitations for this evaluation. Additionally, these three components allowed the committee to evaluate PEPFAR’s prevention activities over time across the broadest possible range of countries, populations, and epidemic types. The remaining PEPFAR prevention program components are also addressed briefly, but because the committee did not conduct an extensive analysis of these activities, no conclusions were drawn in these areas. PREVENTION OF SEXUAL TRANSMISSION Background More than 85 percent of new HIV infections are estimated to be sexu- ally acquired (Abdool Karim et al., 2007; Gouws et al., 2006). As such, the prevention of sexual transmission of HIV infection among both hetero- sexuals and men who have sex with men (MSM) (including sexually active people who inject drugs) is critical to bringing the epidemic under control and has been a primary focus of global prevention efforts. Early in the HIV/AIDS response in the United States, rigorously tested behavioral change intervention models in areas of health that pre-dated HIV/AIDS were adapted to develop HIV interventions (FHI 360, 2004; National Cancer Institute, 2005). These models focused on how an indi- vidual conceptualizes and the acts upon health-related beliefs and behaviors that are relevant to transmissible diseases, such as HIV. Behavior change strategies have continued to be expanded and refined, particularly with re- spect to focusing on specific populations. Predominant strategies that have been used over time to increase male condom use, reduce the number of sex partners, and, for young people, delay onset of sexual activity, include individual and group behavioral change interventions, social marketing techniques, and mass media-based communications campaigns (Global HIV Prevention Working Group, 2008).

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172 EVALUATION OF PEPFAR Today, the modalities available for the prevention of sexual transmis- sion are varied and expanding, and most contain a mixture of biomedical and behavioral elements. The quantity and type of evidence available for each prevention modality varies substantially, ranging from interventions having multiple scientific studies demonstrating efficacy and population- level impact, to interventions based on established theory or observational data only. This was illustrated by a recent review of prevention interven- tions in generalized epidemics conducted as part of a consultation for the World Bank, the United Nations Population Fund (UNFPA), and UNAIDS (Hearst et al., 2012). Hearst et al. found that voluntary medical male cir- cumcision and interventions designed for identifiable sex worker popula- tions have the most robustly documented evidence base within generalized epidemics (Hearst et al., 2012). In the case of behavior change activities designed to reduce multiple concurrent partnerships, observed changes in sexual behavior have been followed by declines in HIV transmission in several countries (Hearst et al., 2012); however, several randomized clini- cal trials of behavior change interventions to reduce sexual risk behaviors have been unable to replicate this effect (Corbett et al., 2007; Cowan et al., 2010; Gregson et al., 2007; Jewkes et al., 2008; Kamali et al., 2003; Pronyk et al., 2006; Ross et al., 2007). The efficacy of correct and consis- tent male and female condom use is well-proven, but the effectiveness of condom promotion and distribution campaigns has yet to be established in a real-world context (Hearst et al., 2012). Finally, for other interventions, especially structural efforts and new biomedical tools such as microbicides and prevention benefits of antiretroviral therapy, evidence for potential effectiveness is emerging, and ongoing data collection is under way. The committee’s analysis of the implication of these gaps in knowledge regard- ing the prevention of sexual transmission and the pressing need to address them is presented in the section on the analysis of prevention impact later in this chapter. In addition to the varying levels of evidence for intervention approaches, there has also been large variation across countries and populations in the extent to which prevention of sexual transmission strategies have been adopted. For example, UNFPA estimated that in 2011 there were nine male condoms purchased with donor support for each male aged 15 to 49 in sub-Saharan Africa, and 2 billion condoms were procured by low- and middle-income countries in 2010; however, this is far short of the 13 bil- lion condoms estimated to be needed by 2015 (UNAIDS, 2012b). There is very little known about the coverage of individual and mass media behav- ior change education programming, but in 26 countries with generalized epidemics reporting to UNAIDS, less than half of young women reported comprehensive knowledge of HIV transmission and prevention (UNAIDS, 2012b). Only 13 countries have established national targets for voluntary

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PREVENTION 173 medical male circumcision; of these, 10 had achieved 20 percent or less of their goal by 2011 (UNAIDS, 2012b). PEPFAR’s Prevention of Sexual Transmission Efforts Initially PEPFAR efforts and activities to prevent sexual transmission focused on the promotion of behavior change interventions. The 2003 PEPFAR authorizing legislation highlighted the “ABC model”—Abstinence, Be faithful, and correct and consistent Condom use—as a successful ap- proach to the prevention of sexual transmission of HIV.8 It instructed PEPFAR to support “programs and efforts that are designed or intended to impart knowledge with the exclusive purpose of helping individuals avoid behaviors that place them at risk of HIV infection,” which included delay of sexual debut, fidelity and monogamy, abstinence, reduction of casual sexual partnering, and condoms.9 The 2008 reauthorization legislation expanded the scope of program activities, incorporating additional approaches, such as health education for serodiscordant couples, and structural interventions to address sexual transmission risk from vulnerabilities related to gender and age.10 In addition to the legislative directives, PEPFAR’s portfolio of HIV prevention activities is also driven by guidance documents—directives speci- fying what can and should be supported with PEPFAR resources—that are fundamental to operationalizing programmatic targets and goals. A gen- eral discussion on the role of Office of the U.S. Global AIDS Coordinator (OGAC) in issuing PEPFAR guidance can be found in Chapter 3. For the purposes of this chapter, the following sections provide a brief review of the guidance for the prevention of sexual transmission issued by OGAC over time and describe how PEPFAR-supported activities have evolved. PEPFAR Guidance for the Prevention of Sexual Transmission In 2005 PEPFAR released ABC Guidance #1 (OGAC, 2005a). With respect to the relative role and incorporation of the different elements of the ABC approach in its prevention program, the guidance stated, “Emergency Plan funds may be used for abstinence and/or be faithful programs that are implemented on a stand-alone basis. For programs that include a “C” component, information about the correct and consistent use of condoms must be coupled with information about abstinence as the only 100 percent effective method of eliminating risk of HIV infection; and the importance of 8  Supra, note 3 at §2(20)(c). 9  Supra, note 3 at §301(a)(2), 22 U.S.C. 2151b(d)(1)(A). 10  Supra, note 1 at §101(a), 22 U.S.C. 7611(a)(12)(A-J).

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