HIV prevention policy needs an urgent cure

Abstract

In January, 2003, President George W Bush announced a new fund to combat HIV/AIDS in some of the poorest parts of the world—The President's Emergency Plan for AIDS Relief. PEPFAR hopes to secure US$15 billion in funding between 2004 and 2008. 15 countries that are especially badly affected by HIV will receive $9 billion between them: 12 countries from Africa, plus Guyana, Haiti, and Vietnam. PEPFAR will also spend $5 billion on ongoing bilateral programmes in 105 other countries and will donate $1 billion to the Global Fund to fight AIDS, Tuberculosis and Malaria. The Plan aims to provide treatment to 2 million people with HIV infection and to provide care for a further 10 million people affected by AIDS. In addition, it intends to prevent 7 million new HIV infections by 2010. The cornerstone of PEPFAR's prevention strategy is the ABC approach—Abstain, Be faithful, use Condoms—with a strong emphasis on A and B, over C, in most settings. This approach has been heavily criticised by some observers, including The Lancet. Last week, a report by the US Government Accountability Office (GAO) suggested that the legal requirement to promote abstinence and faithfulness means that funds for other initiatives, especially prevention of mother-to-child transmission of HIV, have had to be cut. The GAO report is the first analysis to show that workers on the ground are struggling to implement PEPFAR's idealogically driven prevention strategy. The legislation that underpins PEPFAR recommends that 20% of the funds be spent on prevention programmes and requires that a third of this money be spent promoting abstinence and faithfulness: $108 million of $322 million in 2006. The ABC approach may be appropriate in some settings, but in others the funding rules hamper prevention efforts. For example, in areas where HIV prevalence among pregnant women is high—such as Swaziland, Mozambique, and rural South Africa—prevention of mother-to-child transmission needs more funding than is allowed by the 33% rule. Although individual country teams can request to be excused from the 33% rule, because of local population needs, the total budget for abstinence and faithfulness programmes has to add up to $108 million, which means that other programmes need to spend more than a third of their prevention funding on abstinence and faithfulness programmes. This lack of flexibility is clearly causing problems on the ground. The Office of the Global AIDS Coordinator (OGAC), which oversees the PEPFAR programme, has produced guidelines for the country teams to help them meet their legal requirements. For example, the OGAC says that PEPFAR funds cannot be used to provide information on condoms to children younger than 14 years old or to provide condoms in schools. Condom use should only be promoted to adults who engage in risky behaviour, the OGAC says, such as commercial sex workers or people who have sex with someone of unknown HIV status. However, these guidelines are often ambiguous and some of the OGAC's implementing partners are confused about which population groups can be targeted with information about condoms. This has led to ridiculous situations, outlined in the GAO report, where workers are unsure whether they will lose funding if they answer young people's legitimate questions about condom use. The OGAC is trying to clarify matters, but what is really needed is a complete reversal of policy. Rigorous implementation of the “C” part of ABC is crucial if PEPFAR is to reach its target of preventing 7 million new infections by 2010. Judging the success or failure of PEPFAR's prevention programme will be impossible, however. The OGAC plans to use a statistical model of epidemiological trends, developed by the US Census Bureau, that will be unable to assess accurately how many HIV infections have been prevented by the Plan. The model will also be unable to determine which prevention programmes are most, or least, effective—convenient given the lack of evidence underpinning the abstinence strategy. PEPFAR is supposed to be an “emergency” plan. It should be executed as such. Health workers who have seen their patients, friends, and family die from this disease should not have to tip-toe around this ill-informed and ideologically driven policy. The GAO report should prompt Congress to ask whether the $600 million ear-marked for prevention programmes based on abstinence and faithfulness is an effective use of US tax-payers' money. Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful.