The Bush administration's $15 billion global AIDS initiative is emphasizing sexual abstinence and fidelity more than Congress intended, and that focus is undermining prevention efforts in poor countries, congressional investigators said Tuesday.
U.S. teams on the ground in Africa and other poor areas told Congress' Government Accountability Office that the requirement that they spend a specific percentage of their money on abstinence is hurting some efforts to tailor prevention programs to countries' needs.
The directives are creating confusion and forcing reduction in some programs deemed necessary for pregnant women, high-risk groups like truck drivers and sex workers, married couples and sexually active youths, the GAO said.
President Bush's five-year plan touts a three-pronged approach to AIDS prevention commonly called "ABC" that combines abstinence, fidelity ("being faithful") and condoms in target countries.
The GAO reported there was "general consensus" among public health experts internationally that the three-pronged prevention approach "can have a positive impact in combating HIV/AIDS."
But it recommended Congress evaluate the effectiveness of the abstinence spending formulas, and the administration consider changing how it implements the law. "Lack of clarity in the ABC guidance has created challenges for a majority of focus country teams," the GAO reported.
"For example, although the guidance restricts activities promoting condom use, it does not clearly delineate the difference between condom education and condom promotion, causing uncertainty over whether certain condom-related activities are permissible," the report said.
The State Department told the GAO it will work to change the regulations to make them clearer.
The GAO also said the administration has gone beyond the abstinence requirement for a major new account Congress created to fight AIDS, mostly in 15 target countries with high rates of the disease. Congress said a third of those prevention funds must go to abstinence and fidelity programs.
The administration, however, extended the same spending formulas to other U.S. funds that fight HIV/AIDS in countries around the world, drawing sharp criticism from some Congress members and activists.
Mark Dybul, the State Department's deputy global AIDS coordinator, said the Bush administration believes all three components need to be emphasized in all 120 countries that get U.S. money for HIV/AIDS, not just the target countries.
"It's important to have guidance that shifted us from where we were, which was not a good situation," he said. "It was too much 'C' (condoms)" prior to Bush's three-year-old program, he added.
As to the GAO's finding that the approach is undermining some anti-AIDS efforts, Dybul said, "There are always challenges when you are changing things." He said U.S. teams in some countries exceeded the minimum required spending for abstinence because they found it was the most effective strategy.
The Associated Press reported earlier this year that the administration has handed out nearly one-quarter of its AIDS grants to religious groups, and has been aggressively pursuing new church partners that often emphasize prevention through abstinence and fidelity over condoms.
Dybul said Congress, which increased Bush's overall AIDS money requests, allocated 12 percent less than Bush asked for the 15 target countries. That extra money could have beefed up all prevention strategies instead of forcing teams on the ground to make tradeoffs, he said.
The report re-ignited debate over how best to fight HIV/AIDS. Rep. Barbara Lee, D-Calif., said it "demonstrates the Bush administration's willingness to make AIDS prevention policy a political plaything in their ongoing effort to appease the radical right."
Rep. Chris Smith, R-N.J., defended the administration's approach, saying the report was "politically biased."
"One of the most underreported international stories is the President's Emergency Plan for AIDS Relief and the ABC approach are working," Smith said.
GAO report author David Gootnick said the nonpartisan agency used standards that were "methodologically rigorous, vetted extensively," including a standard set of questions and evaluations for U.S. field workers.
The GAO surveyed the 15 target countries, plus five others that receive more than $10 million in U.S. help to fight the epidemic.
U.S. teams in 17 countries told the GAO that meeting the spending requirements for abstinence and fidelity "challenges their ability to develop interventions that are responsive to local epidemiology and social norms."
While Bush's AIDS program also includes unprecedented spending for treatment and care, the GAO report focused on prevention.
The administration follows a congressional recommendation that 20 percent of the overall AIDS money be reserved for preventing HIV/AIDS, and mandates a third of prevention money emphasize abstinence until marriage and faithfulness to one partner. The rest goes to condoms and efforts to reduce mother-to-child transmission and intravenous transmission.
The Bush administration refined the mandate to require that half of all prevention money be reserved for programs against sexual transmission of HIV, with two-thirds of that amount for abstinence and fidelity.
Rep. Henry Waxman, D-Calif., in a letter Tuesday to Secretary of State Condoleezza Rice, said those abstinence messages don't always work in countries with high rates of sexual transmission.
"The effect may well be to misallocate funds in countries with fast-growing HIV epidemics driven primarily by intravenous drug use or commercial sex, such as Russia and India," Waxman said.
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