Senate Passage of Landmark HIV/AIDS Bill; Failure to Maximize Prevention Efforts

Washington, DC … The Senate passage of legislation to extend and expand the U.S. commitment to addressing the HIV/AIDS crisis – the largest single commitment by any government -- deserves recognition for the life-saving impact it has, and will continue to have, on the lives of millions in need.  Population Action International applauds this level of commitment to fighting this pandemic.  But as an organization that works to improve the health of men, women and children in the developing world, PAI is profoundly disappointed in the failure of Congress to use the reauthorization process to make the President’s Emergency Plan for AIDS Relief (PEPFAR) even more effective and successful in preventing the transmission of this deadly disease. 

One of the greatest achievements of PEPFAR’s first five years is its ability to reach millions with lifesaving treatment.  However, for every one person put on treatment, three more people become infected with HIV.  With demand for adequate funding for universal treatment running up against fiscal constraints that will only grow tighter over time – keeping treatment out of reach for so many --  preventing infection must be the foundation of any U.S. program dedicated to stemming the impact of HIV/AIDS globally.  Without enhanced and evidence-based prevention programs, PEPFAR will be fundamentally handicapped in meeting its all-important objectives.

Unfortunately, when given the opportunity to improve the law, Congress chose to sacrifice family planning (FP) integration and real improvements in the prevention provisions in exchange for increases in overall funding levels.  While nothing in the bill expressly precludes integration of FP and HIV/AIDS services, Congress failed to use the reauthorization of PEPFAR to endorse greater integration in the field and fully repeal abstinence earmarks – something that numerous experts and practitioners in the field have recommended.

"While no bill is ever perfect and increased funding is important, this bill is a far cry from what it could -- and should -- be in terms of preventing HIV,” said Tod Preston, PAI’s Vice President for U.S. Government Relations. “By failing to embrace family planning and preserving elements of abstinence funding mandates, Congress is handicapping the effectiveness of these programs. The partnership between family planning and HIV prevention services is paramount to stemming the tide of new infections and using U.S. taxpayer dollars wisely.  Family planning for the prevention of HIV should be supported in PEPFAR."

Despite the fact that 80 percent of new HIV infections come from sexual intercourse, Congress shunned the role of family planning providers in reaching men and women with HIV prevention messages.  Despite the fact that U.S.-supported family planning clinics have been the trusted source of health care for women and their families for more than forty years, their partnership in reducing HIV infections was overlooked.  Despite the fact that HIV-positive women deserve the same access to reproductive health care as women who are not infected, supporting their access to family planning services and contraceptives was ignored.

Background:

Integration of Family Planning and HIV Prevention

Fighting HIV requires that the United States work with the most effective nongovernmental organizations on the ground.  For over forty years, the United States has supported international family planning providers as a trusted and sought-after source of health care for men, women and their children.  According to PEPFAR’s own reports*, family planning is critical to leveraging a more expansive and effective prevention program, especially when it comes to counseling and testing.  Despite universal support for stronger integration between family planning and HIV/AIDS providers in order to prevent the most HIV infections, the bill which passed the Senate fails to enhance these linkages.

Example of family planning/HIV integration:

Many people living with HIV want contraception: Those living with HIV are often motivated to prevent pregnancy because of the risk of transmitting the virus to their newborn or because of concerns that they will leave children behind, whether HIV-positive or not, as orphans.  Providing contraception to HIV-positive women who want to have a child or another child or want to prevent a pregnancy, allows them to time and space their childbearing or to avoid it entirely.

Unmet need for contraception: High rates of unintended pregnancy occur throughout Sub-Saharan Africa, including among women living with HIV. The Centers for Disease Control and Prevention (CDC) reported in 2006 that among pregnant women receiving antiretroviral treatment in Uganda, 92 percent said their pregnancies were unintended. Other studies report that 84 percent of pregnancies among women in three Prevention of Mother-to-Child Transmission (PMTCT) programs in South Africa were unintended.

Contraception as HIV prevention: Research suggests that in the absence of contraceptive use in Sub-Saharan Africa, the number of HIV-positive births would be 31 percent higher than it is now. There would be an additional 153,000 infants born HIV-positive each year—and all of these births would be unplanned.

Contraception enhances PMTCT programs: USAID has projected that adding contraceptive services to PMTCT programs to make it easier for women to avoid an unintended pregnancy can prevent almost twice the number of child HIV infections and three times the number of child deaths as can PMTCT programs alone.

Linking HIV and contraceptive services is cost-effective: Family Health International, a public health nonprofit organization, calculated in 2006 that for the same cost, contraceptive services can avert nearly 30 percent more HIV-positive births (by preventing unwanted pregnancies) than identifying HIV-positive women during pregnancy and administering nevirapine (an antiretroviral drug).

*Excerpt from 2008 PEPFAR Fourth Annual Report to Congress:

“PEPFAR also supports linkages between HIV/AIDS and voluntary family planning programs, including those supported through USAID’s Office of Population and Reproductive Health (PRH). Along with providing linkages to family planning programs for women in HIV/AIDS treatment and care programs, PEPFAR also works to link family planning clients with HIV prevention, particularly in areas with high HIV prevalence and strong voluntary family planning systems. Voluntary family planning programs provide a key venue in which to reach women who may be at high risk for HIV infection. PEPFAR supports the provision of confidential HIV counseling and testing within family planning sites, as well as linkages with HIV care and treatment for women who test HIV-positive. Ensuring that family planning clients have an opportunity to learn their HIV status also facilitates early up-take and access to PMTCT services for those women who test HIV-positive. PEPFAR’s efforts remain focused on HIV/ AIDS prevention, treatment and care, complementing the efforts of USAID/PRH programs and other partners.”

Prevention Earmark

The original PEPFAR legislation contained an earmark requiring 33 percent of all funding for prevention activities to be allocated to abstinence-only-until-marriage programs.  Thus, of the 20 percent of total PEPFAR funding focused on prevention activities, a minimum of one-third has been restricted to abstinence programs.  According to two congressionally mandated reviews from the Government Accountability Office (GAO) and the Institute of Medicine (IOM), and countless experts in the field, this abstinence restriction is detrimental to the overall effort and should be eliminated. 

From the IOM:

“The earmark has greatly limited the ability of Country Teams to develop and implement comprehensive prevention programs that are well integrated with each other and with counseling and testing, care and treatment programs and that target those populations at greatest risk." 

The earmark has “limited PEPFAR’s ability to tailor its activities in each country to the local epidemic and to coordinate with … the countries’ national plans.”

The IOM was “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.”

From the GAO:

The abstinence-until-marriage requirement “can undermine the integration of prevention programs by forcing [country teams] to isolate funding for AB activities.”  This “limited some country teams’ ability to shift program focus to meet changing prevention needs.”

“17 of 20 PEPFAR teams … reported that the spending requirement presents challenges [in responding] to local epidemiology and cultural and social norms.”

Rather than following the advice of either expert body, the series of hearing and briefings held on Capitol Hill, or the recommendations developed by a raft of HIV/AIDS implementers and advocates, the newest compromise contains language that will act as a de facto abstinence earmark.  The reauthorization bill requires countries to report to Congress if less than 50 percent of their prevention-of-sexual- transmission funds are spent on Abstinence and Be-faithful programs (AB).*  Rather than grant countries and experts in the field greater flexibility to develop prevention programs that best meet the needs of their people, Congress is mandating that countries explain in writing if less than 50 percent of their prevention funds are spent on AB programs.

• Within PEPFAR, prevention includes efforts that address the sexual and non-sexual transmission of HIV.  While these prevention efforts receive only about 20 percent of all PEPFAR funding, only a fraction of that 20 percent is spent on comprehensive prevention programs that give people all the tools they need to help them prevent the sexual transmission of HIV.  An alarming fact considering roughly 80% of all new infections are transmitted sexually.

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Population Action International (PAI) works to ensure a world in which humanity and the natural environment exist in balance, fewer people live in poverty, and every person has the right and access to sexual and reproductive health.