Rep. Chris Shays held a hearing Wednesday to learn more about how the PEPFAR requirement that at least one third of prevention funding be directed to abstinence-only-until-marriage affects the ability of countries to effectively implement prevention initiatives and what steps can be taken to address concerns about limitations presented by the funding requirement.

Everyone agreed abstinence promotion – or more accurately delaying when people start to engage in sexual activity – should be part of prevention programming. The question at hand is whether there should be a requirement for a specific amount of money to be spent on this one aspect of programming.

No one could articulate how the earmark benefits HIV prevention programs. So, will Congress change the requirement? That remains to be seen.

The following are some highlights and lowlights from the hearing –

Highlights: Rep. Henry Waxman said that no formula written in Congress can be right for each country's situation – and flexibility needs to be provided to ensure that they can respond to the specific needs, not US politics.

Rep. Chris Shays asked government officials if there is any evidence about which ‘A' programs work better than others. For example, are programs that educate people about the health benefits of delaying sexual activity more or less effective than ones that tell people they will go to hell if they have sex. There was no answer because there is no data one way or the other.

Dr. Lucy Nkya – a member of the Tanzanian Parliament, medical chair of the medical board of St. Mary's Hospital Morogoro and Director of the Faraja Trust Fund – spoke eloquently about how the earmark and other PEPFAR funding restrictions have undermined successful prevention efforts in her country (worth the read). She also said in Tanzania "free access to condoms is no longer possible, however, due to shortage of funds." In responding to a question, Dr. Nkya emphasized that people's sexual and reproductive health and rights need to be protected if we are going to confront HIV/AIDS.

More noteworthy than a highlight, both government representatives – Amb. Mark Dybul, MD from State and Kent Hill from USAID – discussed the need to address gender inequality if we are to successfully combat HIV. I agree with them that HIV prevention programs need the flexibility to promote gender equality. But it's interesting that they don't recognize that the earmark limits their flexibility to do the work they think needs to be done.

Lowlights: Rep. John Duncan (R-TN) seemed to miss the purpose of the hearing – focusing instead on wanting to make sure Americans knew how much the United States was giving to these programs. Guess he didn't want to actually think about the issue before the committee.

Dybul continually cited the data and evidence about why ABC is the best prevention approach. That's fine. He couldn't, however, cite evidence about why at least one third of funding should be spent on ‘A' programs – though continued to defend it as an evidence-based approach.

Dybul also repeatedly said it was ok for the United States to provide less support to C, because so many other donors focus heavily on condoms. Tell that to Dr. Nkya (but unfortunately, Dr. Dybul left before he could hear from her).

While trying to investigate the impact of the abstinence-only-until-marriage earmark, part of the hearing degraded into a debate of A v. C. Ab-only proponents resorted to arguing on behalf of abstinence programming because they do not have a good reason for why one-third of prevention funding needs to be directed to such efforts.

We need to critically evaluate the programming that is undertaken to prevent the spread of HIV to ensure that we get every bit of value from the tax dollars we are investing. We also need to do it to save people's lives. This hearing was one step in taking a look at what needs to be done to see that we achieve both goals.