Washington Memo

The recently released Fiscal Year 2013 Country Operational Plan (COP) Guidance  states in no uncertain terms that “PEPFAR funds may not be used to purchase family planning commodities” (page 52).  As they have since the beginning of the program, PEPFAR will continue to pay for male and female condoms, although the COP guidance makes no reference to their dual protection benefits – preventing both HIV and unintended pregnancies. The COP guidance governs the development of annual country plans for the President’s Emergency Plan for AIDS Relief (PEPFAR).

The decision outlined in the FY13 COP is not mandated in the PEPFAR legislation.  The 2008 law contains no prohibition on the use of PEPFAR funds for contraceptive commodities; in fact it is totally silent on the integration of HIV/AIDS and family planning/reproductive health services.  The FY13 COP’s restrictive position goes beyond the legislation and is the third COP (click here for analysis of the FY12 and FY11 COPs) which has failed to provide the flexibility needed to deliver effective programs.

Instead of reflecting the best public health practices of the day, it reflects the worst politics of the day.  The past year saw an unprecedented assault on contraception and women’s access to basic healthcare. Congressional opponents of contraception surely would have spoken out if PEPFAR had made a different decision but some fights are worth fighting.  Standing on the side of science, good public health, and women is the right thing to do.  If we don’t, we undermine our ability to achieve an AIDS-free generation and our credibility as a leader on HIV/AIDS and global health.

This is the first COP guidance released since the U.S. government announced its bold vision for an AIDS- free generation.  When Secretary Clinton provided this vision at July’s International AIDS Conference, she said “Every woman should be able to decide when and whether to have children. This is true whether she is HIV-positive or not.”

Creating an AIDS-free generation is an ambitious and laudable goal.  To achieve it we need to harness all of the effective tools that are available. This is why it is especially disappointing that the Office of the Global AIDS Coordinator has taken the option of paying for contraception off the table for country teams.

Why PEPFAR Should Let Countries Decide

Allowing country teams and program experts to decide to use PEPFAR funds for contraception based on the nature of their country’s epidemic and funding landscape for HIV/AIDS and FP/RH is consistent with the goal of delivering health care services that are integrated, country-driven, and centered on women, girls and gender equality. In the FY13 COPs, country teams are required to report on progress towards meeting these Global Health Initiative (GHI) imperatives (p42) as well as the targets identified in their GHI country strategy (p25), but these unnecessary restrictions hamper their ability to decide how to best do so.

The Science and Evidence is Clear

There is a well-documented evidence base that supports the role of contraception in HIV prevention. World Health Organization (WHO) guidelines identify contraception as one of four essential components of programs that prevent mother-to-child transmission ( PMTCT), known as “prong 2” —preventing unintended pregnancies among HIV-positive women.  The U.S.-supported Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan) also includes contraception as part of the comprehensive package of HIV prevention and treatment interventions and services.  It also reinforces the centrality of “prong 2” and sets the ambitious goal of reducing unmet need for family planning to zero by 2015.

The Demand is Real

The COP Guidance acknowledges that “there is strong evidence to suggest that they [women living with HIV] have less access to family planning and reproductive health services, in the face of great need and often higher vulnerability to morbidity and mortality.”  As cited in PEPFAR’s Technical Considerations, of the 22 high burden countries targeted in the Global Plan, rates of unmet need for family planning vary between 13 percent and 38 percent. Of the 26 countries receiving FY2011 PEPFAR PMTCT funding, 11 reported contraceptive stock-outs of various methods that year (Kenya, DRC, Madagascar, Ethiopia, Mozambique, Malawi, Nigeria, Tanzania, Uganda, Zambia, and Dominican Republic).

Referrals Aren’t Enough

While endorsing linkages between HIV/AIDS and FP/RH services, PEFPAR’s current policy largely relies on referrals or the co-location of services, funded out of separate funding streams. However, of the 31 PEPFAR countries required to submit Country Operational Plans, 10 do not receive annual U.S. assistance for family planning and reproductive health programs.  At least 11 of the 31 countries experienced contraceptive stock-outs in 2011. Because of funding levels, the PEPFAR reach is also significantly larger than the family planning program. As a result, even in countries that receive U.S. funding for both, PEPFAR may work in regions with no family planning support.

Increased coordination with other donors, host country governments, or private-sector supported family planning programs could help alleviate some of the gap. However, a recent report revealed that the Global Fund, which allows funds to be used to pay for contraception if it is tied to the prevention, treatment or care of HIV/AIDS, TB or malaria, estimates that the contribution of its PMTCT grants to prong 2 (i.e. contraception) is 0.13%.  So, while the COP laudably calls on PEPFAR to coordinate with Global Fund-supported efforts in-country (p30), it would be wrong to assume that the Global Fund can cover the need for contraceptives within PMTCT programs – or the broader need for contraceptives among women accessing HIV/AIDS services.    

What’s Next?

When Secretary Clinton announced the plan to create an AIDS-Free Generation Blueprint at the International AIDS Conference, she said, “Women want to protect themselves from HIV and they want access to adequate health care. And we need to answer their call.” The policy position in the COP Guidance clearly fails to answer their call.

Here are a few opportunities to do so in the future:

Blueprint for An AIDS Free Generation: On World AIDS Day 2012 the U.S. will announce a blueprint for an AIDS-Free Generation.  This is an opportunity to reverse the ill-conceived decision and get serious about leveraging all of the tools that will be needed to achieve this important goal.  For example, in the blueprint OGAC could allow countries to submit explanations for why purchasing contraceptives with PEPFAR funds helps advance the goal of an AIDS-free generation and approve that use of funds at the country level on a case-by-case basis.

Funding for the U.S. Family Planning and Reproductive Health Program: If PEPFAR continues to refuse to allow PEPFAR funds to be used to pay for contraceptive commodities where needed to advance HIV prevention and PMTCT goals, then U.S. funding for family planning and reproductive health programs must be significantly increased.  This program is currently – and historically – underfunded. Current funding ($610 million annually), falls far short of what it is needed to address the needs of the 222 million women in the developing world who want to avoid a pregnancy but are not using an effective method of contraception. U.S. advocates have been calling for at least $1 billion annually.

FY13 COP Process:  The FY13 COP Guidance identifies a number of ways that field teams can communicate with staff at the Office of the Global AIDS Coordinator throughout the COP process.  Where this restrictive policy impedes effective programs, PEPFAR country teams and implementing partners should convey that to their Country Support Team Leads and during weekly COP clarification calls (p8).


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