The requirement that a large fraction of President Bush's global AIDS plan go to promote abstinence and fidelity is causing confusion in many countries and in a few is eroding other prevention efforts, including ones to reduce mother-to-child transmission of the virus.
Those are among the chief conclusions of an 87-page report by the Government Accountability Office that examined the most controversial aspect of the giant AIDS plan, budgeted at $15 billion over five years.
The survey of U.S.-funded programs in 20 countries -- 15 of them the focus of the President's Emergency Plan for AIDS Relief (PEPFAR) -- found widespread support for the "ABC" strategy that encourages abstinence until marriage, being faithful thereafter and using condoms in high-risk sexual encounters.
At the same time, the document paints a picture of worried program managers trying to juggle the demands of both their local populations and the U.S. Congress, seeking to craft comprehensive prevention messages while simultaneously keeping account books that strictly record spending on the abstinence effort.
The Office of the U.S. Global AIDS Coordinator requires that 20 percent of all AIDS spending go for prevention. Half the prevention budget must be spent to stop sexual transmission of HIV. Two-thirds of that spending, in turn, must be used promoting abstinence and fidelity.
"Most of the 20 PEPFAR teams . . . reported that fulfilling [that requirement] presents challenges to their ability to respond to the local epidemiology and cultural and social norms," the GAO authors wrote. About half a dozen teams said the spending requirement "can undermine the integrated nature of HIV/AIDS prevention programs."
Of the 15 "focus countries" -- 12 African countries, plus Haiti, Guyana and Vietnam -- nine reduced the amount of money for programs to prevent mother-to-child transmission of HIV in their 2006 budgets to meet the spending target for abstinence promotion.
In one, mother-to-child funding was cut from $1.4 million to $1 million, and in another it was reduced by $300,000, said GAO's David Gootnick, who oversaw the report.
In perhaps the largest adjustment, one country cut from $8 million to $4 million its spending on prevention services for couples in which one person has HIV infection and the other does not -- an extremely high-risk group -- as well as on sexually active youths and sex workers.
"This team noted that allocating funding in accordance with the spending requirement is not appropriate for the country's epidemic and has reduced the quality of the team's prevention programming," the authors wrote.
In order to encourage candid answers, GAO agreed to not identify the organizations or countries cited in the report.
But Richard Marlink, a physician who oversees prevention and care programs at the Elizabeth Glaser Pediatric AIDS Foundation, said that the need to spend more on abstinence cut into money available to its mother-to-child prevention programs in Mozambique and Swaziland. Since 2000, the foundation has provided antiviral drugs used to prevent HIV transmission to 136,000 pregnant women.
Several activist organizations said the GAO findings confirm their suspicions.
The abstinence policy "is basically unworkable," said Paul Zeitz, director of the Global AIDS Alliance. "This shows the problem very clearly and starkly."
But the AIDS coordinator's office, which is in the State Department, has shown considerable flexibility in administering the rules.
In June 2004, it notified Congress that it would broaden the definition of "abstinence until marriage" to include programs that also encouraged fidelity in sexual relationships outside marriage.
The office also exempts some countries' programs from meeting the abstinence-spending target as long as the entire overseas AIDS-prevention budget meets it. Ten of the 20 countries surveyed got exemptions.
Mark Dybul, a physician who is the medical director of the Office of the U.S. Global AIDS Coordinator, said condom promotion -- the C in ABC -- has suffered no reduction under the Bush plan.
"What we have done is come into a balance with ABC," he said.
He said the program cutbacks described in the GAO anecdotes would not have been necessary if the administration had receive all the overseas AIDS funding it sought -- $527 million more over the last three budgets.