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Flexibility Not Earmarks are Needed for AIDS Prevention

Ed Scholl helps manage a global AIDS prevention program targeting young people in developing countries.

Congressional earmarks are nothing new and not necessarily bad, especially when used to champion unpopular but worthy causes, or to assure accountability by executive agencies. However, earmarks* can also be used to fund parochial projects in congressional home districts and gain political favors - as the current Jack Abramoff lobbying scandal has brought to the nation's attention.

In the field of international public health, Congress has wisely refrained from imposing too many earmarks on the funds it appropriates, leaving technical experts at the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention, and other agencies free, for the most part, to design the type of programs - such as those for child survival - they feel will best address global health priorities. Unfortunately, U.S. funding to address the global AIDS pandemic is not without multiple earmarks that complicate efforts to implement effective programs.

Prior to 2003, USAID personnel and the private contractors and grantees implementing AIDS prevention programs used their discretion in responding to the AIDS pandemic in ways that were most logical in their respective country settings. This changed, however, in 2003 with the passage of the President's Emergency Plan for AIDS Relief (PEPFAR). Though it provided $15 billion for AIDS relief, PEPFAR includes a number of earmarks. It specifies, for example, the percentage of funds that may be spent on each of its component parts: AIDS treatment, prevention, palliative care, and assistance to orphans and vulnerable children. The same legislation, furthermore, decrees that at least a third of prevention funding be spent on "abstinence until marriage programs."

So what is wrong with an earmark for abstinence (or for that matter, an earmark for condoms or any other specific intervention)? For one, Congress should not be the one to decide how much money is spent on prevention strategies. If anybody should decide that, it should be technical experts in the countries affected, in consultation with epidemiologists, host country governments, NGOs, community groups, and people living with and affected by HIV/AIDS. Local stakeholders, experts and epidemiological data should determine on what and whom scarce AIDS funds are spent.

Second, such hard earmarks, which become the basis for government contracts and grants, are antithetical to the spirit of performance-based contracting. The U.S. government has, since the 1990s, operated under a policy that gives preference to performance-based contracting methods, i.e. specifying the results to be achieved rather than the input required to achieve them. Indeed, candidate George Bush said in 2000, "...Over the next five years, a majority of the service contracts offered throughout the federal government will be performance-based. In other words, rather than micromanaging the details of how contractors operate, the government must set the standards, set the results, and give the contractor the freedom to achieve it in the best way."

This very spirit is lacking today in U.S. government contracts and grants for AIDS prevention. Project design documents should specify not the amount of money to be allocated to specific interventions, but rather the results to be achieved in terms of changing the behaviors that we know influence the sexual transmission of HIV: increasing the age of sexual initiation among young people, decreasing the number of concurrent sexual partners, and increasing the use of condoms among non-regular sexual partners, for example. Contractors and grantees should be able to pursue the strategies they feel will most likely help them achieve these kinds of results and new awards should be based on past performance.

Third, earmarking AIDS prevention activities should be avoided because if ever a public health problem needed an integrated and comprehensive approach, it is AIDS. No one approach works in every country, in every population group within a country, or even in one individual over time. A(abstinence)-B(be faithful)-C(condom) messages should be presented together, as mutually reinforcing components. Though emphasizing different parts of the ABC paradigm makes sense for specific audiences, the determination of emphasis should be made by program personnel who know the audience - not predetermined at the country level, much less at the global level as the PEPFAR program has done. Earmarking funds for AIDS prevention discourages integrated approaches and encourages activities done in isolation of others.

If the existing PEPFAR prevention earmark for abstinence weren't problematic enough, yet another funding allocation formula that further diminishes the flexibility to respond to local needs came into effect in October 2005. According to PEPFAR FY 2006 Country Operational Plan Guidance, each country should strive to dedicate at least 50 percent of total prevention funds to sexual transmission, and out of that, to allocate at least 66 percent to activities that promote abstinence before marriage and fidelity. This additional earmark adds another layer of control over AIDS prevention implementing agencies and could potentially result in much more than a third of all funds being spent on abstinence programs because sexual-transmission programs make up the lion's share of prevention initiatives in many PEPFAR countries.

The President's AIDS program deserves praise for many wonderful things it is sponsoring in the 15 focus countries where it concentrates its resources, especially in expanding treatment and care and support services. Yet it could do more in the area of prevention without unnecessary and unhelpful earmarks. Nor do we need a substitution of condom or sexually transmitted infection treatment earmarks, should Democrats ever gain control of Congress. Flexibility, empowerment of local actors, and offering a range of risk avoidance and reduction options are key elements of a successful AIDS prevention strategy that need to accompany the provision of adequate resources. Recipients of such resources should be held accountable and rewarded for the results they achieve - not for how they allocate their budget to meet earmarks.

*"Earmark," as herein described, refers to any directive that specifies how funds should be spent on behalf of a publicly supported initiative.

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