Last week, the President’s Emergency Plan for AIDS Relief (PEPFAR) released its annual Country Operational Plan (COP) Guidance.  Although the fiscal year 2012 guidance clearly states that “voluntary family planning should be part of comprehensive quality care for persons living with HIV,” this COP does little to improve upon the previous 2011 guidance. It also fails to follow the Office of the Global AIDS Coordinator’s (OGAC) own rhetoric by prohibiting PEPFAR from funding contraceptives.
The COP Guidance does contain some positive language on the need for family planning among both HIV-positive and negative women and the importance of comprehensive “combination prevention” approaches. Nevertheless, it is disappointing that OGAC refuses to fund contraceptives despite the fact that there is no statutory prohibition preventing them from doing so. This also undermines their plans to simultaneously prioritize prevention of mother-to-child transmission (PMTCT).

FY12 COP Guidance: The Good, the Bad and the Ugly

The Good

OGAC used the FY12 COP to provide long-awaited guidance on family planning (page 34 under “Other guidance”).  This section rightly recognizes the large unmet need for family planning worldwide, among both HIV-positive and HIV-negative women, and focuses on areas where HIV infection rates are high and disproportionately impact women. The COP also spells out the unique family planning needs of HIV-positive women who often face higher rates of unintended pregnancies and greater risk of morbidity and mortality.

The COP guidance details a list of principles that apply to all U.S. government supported family planning/reproductive health (FP/RH) and HIV/AIDS programs.  These principles provide important safeguards on the rights of individuals to determine their reproductive future and are consistent with longstanding informed consent requirements governing USAID’s family planning programs.

Finally, the COP articulates the need to use a comprehensive range of prevention interventions in order to maximize health impacts:

“CP [combination prevention] approaches HIV prevention using a suite of mutually reinforcing interventions to address transmission risk as thoroughly and strategically as possible. It is predicated on the idea that no single intervention is efficacious enough to bring an HIV epidemic under control, but that the optimal set of interventions implemented with quality and to scale can significantly reduce HIV incidence.”(COP page 13)

The Bad

While the COP does provide a list of “opportunities that should be actively pursued” for FP-HIV integration (COP page 35-36), OGAC continues to require that family planning services are funded out of non-PEPFAR accounts.The 2008 PEPFAR Reauthorization law is silent on the integration of FP/RH and HIV/AIDS services. Therefore, OGAC could allow 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.  By continuing to prohibit PEPFAR funds from being used for contraceptives, OGAC undermines the Global Health Initiative’s goal of delivering health care services that are integrated, country-driven, and centered on woman, girls and gender equality.  It also ignores the evidence that supports the role of contraception in HIV prevention, including resources contained in PEPFAR’s own “Technical Considerations.”

The FY12 COP calls on countries to prioritize prevention programs that are: (1) scientifically proven to reduce HIV infection and/or increase access to care; (2) able to demonstrate sustained and long-standing outcomes that contribute to goals; (3) scalable to produce outcomes at the community level; and (4) cost-effective (COP page 13). Based on this criterion, contraception qualifies as an important and effective HIV prevention tool that should be supported—and paid for—as part of PEPFAR’s combination prevention approach.

The Ugly

The failure to address the funding of contraceptives in the COP Guidance is especially egregious because PEPFAR’s first strategic focus listed for FY12 is to “increase PMTCT coverage and effectiveness.” The World Health Organization has long identified family planning as one of four essential components of PMTCT programs, known as “prong 2” —preventing unintended pregnancies among HIV-positive women

OGAC joined the global community in calling for the virtual elimination of mother to child transmission and recently pledged an additional $75 million for PMTCT at the 2011 High Level Meeting on AIDS.  Yet OGAC falls short by preventing these dollars from supporting the full package of PMTCT interventions.

PEPFAR’s own guidance on “PMTCT, MNCH [Maternal, Newborn, and Child Health] and Pediatric HIV Integration” lists “Voluntary family planning for HIV-positive and negative women” as one of three components of an integrated care package that should be made available to all HIV-positive and negative women (page 7). Despite these strong statements, OGAC takes no responsibility to ensure that these essential services are available for women in developing countries by prohibiting PEPFAR funds from paying for contraceptives.

The FY12 COP guidance endorses linkages and referrals for family planning services. While this approach may be sufficient in some areas where the U.S. government, other donors, the host country government, or the private sector supports family planning programs, this is insufficient in some areas that PEPFAR works. OGAC’s own documents acknowledge that “if family planning programs are not further scaled up or falter, the PMTCT burden will increase accordingly” (COP Technical Considerations, page 19). Instead of waiting to see if family planning programs continue to be cut by Congress as a part of their “war on women,” OGAC should embrace PEPFAR’s large platform (see below) to ensure women can access services they want and need as a part of a comprehensive response to HIV/AIDS – including contraception.


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