April 12, 2006, 7:21 a.m.
Condomania
The ABCs of African AIDS prevention need the A and B.

By John S. Gardner

There is an old Washington game locally known as "Washington Monument Syndrome." Suppose Congress decides to "cut" (i.e., reduce the rate of planned increase) funding for the National Park Service. The classic bureaucratic response is not to put a new program on hold or look for more efficient ways of doing things but rather to target the cut where it would be most visible, for instance by closing the Washington Monument. The result? Congress cancels the planned "cut" and spending is increased.

A report last week from the "Government Accountability Office" (previously the General Accounting Office) shows that Washington Monument Syndrome is alive and well. It has even traveled to Africa.

In 2003, Congress passed the Leadership Act, which set up the president's Emergency Plan for AIDS Relief (PEPFAR) and promised to spend $15 billion over five years to fights AIDS. PEPFAR has 15 focus countries, primarily in Africa, and it gave control over spending to a global AIDS coordinator (Randall Tobias, now confirmed as administrator of USAID). Congress endorsed the "ABC" approach ("Abstain, Be faithful, or use Condoms, in order of priority") that has been so successful in reducing Uganda's AIDS epidemic. Knowing that something drastic had to change to reverse the course of the disease, the law also gave specific targets for certain types of interventions. Notably, Congress set a goal that 55 percent of funding should be used for treatment and 20 percent for prevention activities. In August 2005, to comply with the law, the coordinator directed country teams to dedicate at least 50 percent of the prevention funding to sexual-transmission-prevention activities and 66 percent of that amount to A and B activities (for convenience, call these "abstinence-until-marriage" (AUM or AB) programs).

The Left's first response to the law was to try to redefine ABC as "delayed sexual debut, partner reduction, and condoms." Spot the one that didn't change. After the predictable jokes ("But honey, I'm reducing my number of partners!"), the coordinator's office reasserted Congress' definition of ABC. Still, all groups who accepted ABC as a policy were eligible for funding, even if they chose to focus their intervention only on one area. The only requirement was that each country have a balanced ABC approach.

GAO's report tries to show that Congress's desire to spend a small percentage of AIDS-prevention money on abstinence-until-marriage programs is causing difficulties in the field. The report states that "17 of the 20 country teams . . . reported that the requirement would prevent them from allocating prevention resources in accordance with local HIV/AIDS prevention needs." (Of course, this should read: "their interpretation of those needs.") So the country teams respond by proposing to reduce spending for mother-to-child transmission programs and by anonymously criticizing the requirement's supposed "lack of responsiveness to cultural and social norms" (which shows a shocking attitude toward Africans and contradicts the plain evidence from Uganda). Some U.S. officials even spoke to GAO only on the condition that their countries not be identified — not a promising basis for a scientific study, but very convenient to take potshots at a policy one doesn't like.
Put bluntly, the report is nonsense. There is absolutely no reason why the PEPFAR country teams cannot find the money to fund abstinence-until-marriage, mother-to-child Transmission, and other programs that work while still funding the prevention activities they prefer. Thirty-three percent of 20 percent is 6.6 percent of total funding — not much for a program that reflects conviction that AB programs can sharply reduce the number of new infections.

Even though the requirement only came into force for Fiscal Year 2006 (which began in October 2005), GAO visited the field (Botswana, Ethiopia, South Africa, and Zambia) in July 2005 and spoke to other U.S. officials last year. Of course, the appropriations bills did not pass on time, and it takes additional time for the money to arrive in the agencies, so this was effectively a preemptive attack on a requirement that is just now coming into force. Clearly, the PEPFAR country teams haven't been trying very hard to find groups that can implement the requirement. Instead, it seems they would prefer to fund the usual suspects, now busily reinventing themselves as teachers of abstinence and supporters of ABC — or at least their interpretation of it.

The deep anger from the Left on this issue is palpable. When young Simon Onaba, an 18-year-old from Uganda, spoke at the International AIDS Conference in Bangkok in 2004, and said that he was now abstaining from sex after having started at age 15 and that "it is possible for young people to say no to sex, to feel empowered," he was booed and criticized.

The real agenda here comes out in one unidentified official's complaint about "[d]ifficulty funding programs for condom procurement and condom social marketing." Well, so what? This has been tried, and it is continuing. Other donors make it their focus, too. There will always be plenty of money for C. The point of the requirement was precisely to require a balanced approach and to end the lopsided, near-exclusive focus on C. The team could simply have taken money from elsewhere; instead, it chose to complain to GAO and present a false choice between complying with Congress's intent and its desire to promote condom use even more than it already does. Reading the list of programs for the countries GAO visited, one gets the sense that the AB funding is tentative and that the country teams still feel more comfortable and confident funding all those C programs under "other prevention."

Another supposed objection to AB programs is what another official calls the "lack of evidence from studies," which of course becomes a self-fulfilling prophecy. There is no funding for a program, so no one wants to do studies on it, so it all comes back to C. But the report also complains about the requirement for segregation of AUM funding, even though this will enable researchers to evaluate the programs more easily, so that funding decisions can be made on evidence rather than emotion. Or are some afraid that the evidence will show these program work?

And history shows that unless the funds are segregated Congress will have no idea whether money is really being spent for abstinence activities or for "abstinence." In this case, trust must be earned, not assumed. One country that received an exemption to the requirement, for instance, planned to spend only 4 percent of funds on AB.

As the State Department's response to the report declares, "Where sexual behaviors have changed . . . HIV prevalence has declined." Just as PEPFAR will scale up treatment efforts, so too will it increase funding for programs that are useful in reducing risky behaviors. Even so, it is important to remember that total Federal spending on all methods of prevention — including Cis rising. It's hard to avoid the conclusion that the critics just don't want to spend money on abstinence-until-marriage programs.

Near everyone agrees that condoms have an important and appropriate place in AIDS programs. Years of the condom focus, however, still result in a world in which over 13,000 people become infected with HIV every day. Congress got it right in 2003 when it decided to try something new. This attempt to attack the ABC policy under an unscientific cloak of anonymity should be shelved.

— John S. Gardner served as deputy assistant to President George W. Bush and as general counsel of the U.S. Agency for International Development from 2001 to 2005.