Integration - HIV/AIDS, U.S. Foreign Assistance

U.S. HIV/AIDS and Family Planning/Reproductive Health Assistance: A Growing Disparity Within PEPFAR Focus Countries

HIV Prevalence Rates and Unmet Need
for Family Planning and Reproductive Health Care

Since the
implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in
2004, U.S. foreign assistance
to fight HIV/AIDS has laudably increased in the program’s fifteen focus
countries in Africa, the Caribbean and Asia.1
This commitment to the prevention, care and treatment of HIV/AIDS is welcome, as
over 33 million individuals are currently living with the disease worldwide, and
2.5 million more are infected each year.2
People living with and affected by HIV face many economic, social and
psychological needs that are not met directly through PEPFAR.  Women face the risk of unintended
pregnancy and the need for access to family planning remains high in most PEPFAR

PEPFAR Acknowledges the Need for
Family Planning and Reproductive Health Care

In their
most recent report to Congress, the Office of the Global AIDS Coordinator (OGAC)
espouses the importance of voluntary family planning and reproductive health
(FP/RH) programs in preventing HIV among vulnerable populations; supporting
people living with HIV/AIDS; preventing mother-to-child transmission of HIV; and
preventing HIV transmission within discordant couples (couples in which one
partner is HIV-positive, while the other remains HIV-negative).3
This policy support acknowledges that FP/RH services provide opportunities to
educate women about HIV prevention, including the correct use of male and female
condoms – the only technologies currently available to prevent HIV.  Further, many women living with HIV want
to limit or space their childbearing. Providing these women with FP/RH care and
contraceptive supplies improves their health and lowers the risk of
mother-to-child HIV transmission.  OGAC expects that important
programs like FP/RH to be funded through “wrap around” funding – in other words,
funding for programs that are beneficial for people living with an affected by
HIV and AIDS, such as nutrition and family planning/reproductive health, but
which cannot be funded directly by PEPFAR. 

Funding for HIV/AIDS Grows while
Funding for FP/RH Falls

A common
misperception about “wrap around” programs is that as funding for PEPFAR has
grown, so too has funding for these programs.   In reality, support for FP and RH
programs – wrap around programs acknowledged by OGAC as critical to ensure their
own health and the health of their families, as well as to the success of HIV
programs – has stagnated.    

As seen in
Figure 1, the President’s funding request for HIV programs in the 15 focus
countries increased 125 percent in just two years over the 2006 allocated level.
However, the funding request for family planning and reproductive health fell by
11 percent. Further, the sheer scale of HIV funding in the focus countries ($3.6
billion requested for 2008), dwarfs FP/RH funding ($67.5 million
requested for 2008, less than 2 percent the amount requested for HIV

Figure 1: U.S. FP/RH and
HIV Funding for Focus Countries, Allocated 2003-2006, Requested



U.S. HIV/AIDS and FP/RH Policies and
Funding Constraints

U.S. funding for both FP/RH and HIV/AIDS
come with distinct restrictions that limit each programs’ effectiveness. With
regards to FP/RH, the Mexico City
Policy/Global Gag Rule (GGR)
denies foreign organizations receiving U.S. FP/RH assistance the right to use
their own non-U.S. funds to provide legal abortion, counsel or refer for
abortion, or lobby for the legalization of abortion in their country. The GGR
does not apply to PEPFAR funds. 
With regards to HIV/AIDS funding, the “abstinence-until-marriage” earmark in
PEPFAR requires one third of all prevention funding (just 20% of all U.S.
HIV/AIDS funding) to promote abstinence as the lead HIV prevention strategy.
 The “Loyalty Oath/Prostitution Pledge”
requires all groups receiving PEPFAR funds sign a pledge opposing prostitution.
Combining FP/RH and HIV/AIDS funding for programs on the ground risks extending
all of the restrictions to both areas, further reducing effectiveness.4
PEPFAR can only support condom use for individuals most at risk of transmitting
or becoming infected with HIV, and cannot support other forms of contraception
despite their role in reducing HIV-infected births.5
Despite these policy constraints, PEPFAR supports addressing the FP/RH needs of
individuals through “wrap-around” programs, or linking to other services.6
However, a successful wrap-around program is difficult when FP/RH programs are
significantly overburdened and underfunded.


Nearly all
of the 15 focus countries are experiencing a persistent need for but a steady
decline in U.S.  FP/RH assistance. The President has requested a decrease
in FP/RH assistance in 10 of the 15 focus countries and a minimal increase in
only one focus country – Rwanda.   Four focus countries receive no
FP/RH assistance. The 2008 Congressional Budget
Justification stated that the reductions in FP/RH funding were due to low
requests from the USAID country missions, citing the 40 year decline in
fertility rates around the world. However, all 11 focus countries receiving
FP/RH assistance have high fertility rates, and many also have high unmet need
for contraception.

Ethiopia saw a 24 percent drop in FP/RH
funding between the 2006 allocation and 2008 request. Yet, the average Ethiopian woman will
give birth 5.4 times in her lifetime, and 33.4 percent of married women have an
unmet need for contraception – they wish to limit or space childbearing, but
are not using contraception (see Figure 2).7
 The 2008 request for FP/RH funding
in Ethiopia is $15 million. In contrast,
the 2008 request for HIV/AIDS is $409 million to address Ethiopia’s
epidemic, estimated at 1.4 % prevalence.8

While the
number of women living with HIV is high in Ethiopia, the
number of women with unmet need is significantly higher, although these groups
are not mutually exclusive (evidence shows that unmet need for contraception is
common among women living with HIV/AIDS).9 
Far more FP/RH funding is needed to help women meet their reproductive
intensions in order to promote the wellbeing and rigpopact of Ethiopian women,
regardless of HIV status.

Figure 2: Married women with unmet
need for FP and women living with HIV/AIDS in Ethiopia10

Figure 3:
U.S. FP/RH and HIV Funding for
Ethiopia, Allocated 2003-2006,
Requested 2007-2008

Kenya has also experienced a decline in
FP/RH funding and currently has an unmet need for contraception of 24.5
While the Kenyan fertility rate has fallen significantly from 6.7 in 1989,12
it recently increased from 4.7 in 1998 to 4.9 in 2003, a seemingly small but
significant setback.13
Had Kenya’s fertility rate continued its
downward trajectory, the country’s population would have been 44 million in
2050, instead of 83 million currently projected, even assuming future declines
in fertility.14
The 2008 funding request to meet FP/RH demand in Kenya is $7.7
million. In stark contrast, $481 million has been requested to combat
Kenya’s 5% prevalence HIV/AIDS
– a sum that exceeds the entire annual U.S. FP/RH budget

Figure 4:
Married women with unmet need for FP in Kenya, and women living with HIV/AIDS in

Figure 5:
U.S. FP/RH and HIV Funding for
Kenya, Allocated 2003-2006, Requested


Voluntary FP/RH
programs, a proven successful intervention long supported by the U.S.
government, is critical to the health and well being of women, children and
families around the world, and is an acknowledged key component to the success
of HIV prevention, care and treatment programs. Dangerously low and declining
 support for family planning,
compounded by restrictive policies, jeopardizes gains in women’s health, poverty
reduction, and undermines the major investments attempting to curb the spread
and impact of HIV/AIDS.  To enhance
PEPFAR’s successes to date and ensure its sustainability in the future ,  improved funding for and coordination
with FP/RH programs are paramount. 


  • Substantially
    increase U.S. funding for international family
    planning and reproductive health to improve HIV prevent efforts for women and
    their children, and to reduce unintended pregnancies, especially among
    HIV-positive women.

  • Remove policy
    restrictions including the Global Gag Rule, the “abstinence earmark” and the
    “loyalty oath” which greatly limit access to the best available HIV/AIDS and
    FP/RH services for women and their families.

Notes on

Funding amounts
for fiscal years 2003 through the FY 2008 request are not completely comparable
but do provide information on country funding trends over the time period. FY
2003-2004 data for FP/RH are expenditure levels derived from the USAID document
Agency-Wide Expenditures in Global Health, FY 2004 published in August 2005– the
latest version available, and is also the source for HIV/AIDS funding levels for
2003. FY2005-2006 data for FP/RH are expenditure levels derived from USAID’s
Congressional Budget Justification (CBJ) documents—FY 2005 figures are drawn
from the FY 2007 CBJ; FY 2006 figures from the FY 2008 CBJ. FY 2004-2006 data
for HIV/AIDS are expenditure levels derived from OGAC’s The Power of
Partnerships: Third Annual Report to Congress on PEPFAR (2007). FY 2007-2008
data for both HIV/AIDS and FP/RH are request levels derived from the 2007 and
2008 USAID CBJs.

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