Last Friday, the Institute of Medicine (IOM) published their long awaited congressionally mandated report evaluating the implementation of the President's Emergency Plan for AIDS Relief (PEPFAR). For weeks, advocates have been anticipating the findings of the report with little rumor of its outcomes. We were not disappointed. The 314 page report, PEPFAR Implementation: Progress and Promise, was well worth the $37.50 download fee. The IOM found:
The Committee has been 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.
There is, however, little evidence to show that ABC when separated out into its components is as effective as the comprehensive approach.
The New York Times quotes one of the IOM committee members, "Ruth Macklin, a bio-ethicist at the Albert Einstein College of Medicine in the Bronx and a panel member, called the restrictions "hamstrings or shackles," though Dr. Macklin said the report diplomatically referred to them as "earmarks or budget allocations."
In case Congress needed more proof that the 33 percent earmark for abstinence-until-marriage programs was a dumb idea, the premier medical institution of the country has stated that it makes no scientific sense. The IOM believes that, "by requiring the Country Teams to isolate funding for these [abstinence and be faithful programs] activities, this budget allocation has undermined the teams' ability to integrate prevention programming" (emphasis mine).
The IOM's research confirmed last year's GAO report findings that the abstinence-until-marriage funding requirement created major challenges for PEPFAR implementers. According to the report, "Confusion and frustration in the field caused by the abstinence-until-marriage allocation have persisted … staff indicated that the allocation did not allow them sufficient flexibility to create the appropriate prevention portfolio based on the available data."
The IOM additionally found that PEPFAR's rigid congressionally mandated budget allocations (earmarks) have resulted in an inability to respond to the local epidemic and that a one-size-fits-all approach does not make sense. The IOM recommends that Congress remove all earmarks. That's right—the IOM is recommending that Congress repeal every single PEPFAR earmark. The report states, "The lack of an evidence base for the budget allocations (earmark) and a rationale linking the allocations to performance targets and goals has adversely affected implementation."
The report made a number of recommendations geared towards moving PEPFAR from an emergency plan to a sustainable initiative. To achieve sustainability, the IOM advises that a stronger emphasis on women and girls is needed. The IOM recommends, "The U.S. Global AIDS Initiative should continue to increase its focus on the factors that put women at greater risk of HIV/AIDS and to support improvements in the legal, economic, educational, and social status of women and girls."
Unfortunately, not everyone was pleased with the report outcomes. The Boston Globe reports, "But Shepherd Smith, president of the Institute for Youth Development, which runs several abstinence programs in Africa, said the report's conclusions on abstinence and fidelity spending ‘make no sense.'" Sorry Shepherd, your days of seeing PEPFAR as a slush fund to spread ideology are coming to a close.
Earlier last week, Representatives Barbara Lee (D-CA) and Christopher Shays (R-CT) introduced the Protection Against Transmission of HIV for Women and Youth (PATHWAY) Act of 2007 (H.R. 1713), a bill that would remove the abstinence-until-marriage funding earmark from PEPFAR and request the President to develop a strategy to respond to the vulnerabilities of women and girls. The findings of the IOM report confirm the urgency of this critical piece of legislation.
The 110th Congress has the power to repeal the abstinence-until-marriage earmark. It's our responsibility to hold their feet to the fire. If your organization has not already endorsed the PATHWAY Act, please do so immediately by clicking here and join the movement to ensure that ideology does not continue to trump science in HIV prevention policy.