IN THE SENATE OF THE UNITED STATES
December 5, 2007
Mr. Reid (for Mrs. Clinton) introduced the following bill; which was read twice and referred to the Committee on Foreign Relations
To require the President and the Office of the Global AIDS Coordinator to establish a comprehensive and integrated HIV prevention strategy to address the vulnerabilities of women and girls in countries for which the United States provides assistance to combat HIV/AIDS, and for other purposes.
This Act may be cited as the
Protection Against Transmission of HIV
for Women and Youth Act of 2007.
Congress finds the following:
The United Nations
Joint Program on AIDS (referred to in this Act as
estimates that more than 33,000,000 people were infected with HIV/AIDS at the
end of 2007, the vast majority of whom are living in the developing
According to the World Health Organization, unprotected heterosexual sex is a major factor in the spread of HIV infections worldwide.
According to UNAIDS, women and adolescent girls account for about 50 percent of all HIV infections worldwide. In sub-Saharan Africa, women and girls make up about 60 percent of all infections and 76 percent of infections among those who are between 15 and 24 years of age.
Women and girls are biologically, socially, and economically more vulnerable to HIV infection. Gender disparities in the rate of HIV infection are the result of a number of factors, including—
cross generational sex with older men who are more likely to be infected with HIV, a lack of choice regarding when and whom to marry, leading to early marriages and high rates of child marriages with older men, and the fact, according to UNICEF, that about 42 percent of all adolescent females in Africa and about 48 percent of adolescent females in South Asia are married by age 18;
high rates of infection within marriage because married girls are more likely to have unprotected sex and have far more frequent sex than their unmarried peers, indicating that marriage cannot be considered a protective factor against HIV infection;
an inability to negotiate safe sex in marriage or with regular partners, the fact that married women and married and unmarried adolescent females often are unable to negotiate the frequency and timing of sexual intercourse, ensure their partner’s faithfulness, or insist on condom use, and the fact that women often run the risk of being infected by husbands or male partners in societies in which it is common or accepted for men to have more than 1 partner;
social and economic inequalities based largely on gender which limit access for women and girls to education and employment opportunities and which prevent them from asserting their inheritance and property rights, including, for many women, a lack of independent economic means sustains their fear of abandonment, eviction, or ostracism from their homes and communities, and can leave many more of them trapped within relationships where they are vulnerable to HIV infection;
a lack of educational opportunities for women and girls, since access to education is linked to delayed intercourse, increased age-at-marriage, delayed childbearing, increased child survival, improved nutrition, and reduced risk of HIV infection, among other positive outcomes;
high rates of gender-based violence, rape, and sexual coercion within and outside of marriage, including, according to the World Health Organization, between 1/6 and 3/4 of women in various countries and settings have experienced some form of physical or sexual violence since age 15;
fear of domestic violence and the continuing stigma and discrimination associated with HIV/AIDS prevents many women from accessing information about HIV/AIDS, getting tested, disclosing their HIV status, accessing services to prevent mother-to-child transmission, or receiving treatment and counseling even when they already know they have been infected with HIV;
an increase in commercial sex for survival, due to pervasive poverty, social dislocation, war and internal conflicts, and other factors, including, according to UNAIDS, the vulnerability of sex workers to HIV infection is heightened by stigmatization and marginalization, limited economic options, limited access to health, social, and legal services, limited access to information and prevention means, gender-related differences and inequalities, sexual exploitation and trafficking, harmful or nonprotective legislation and policies, and exposure to risks associated with commercial sex such as violence, substance use, and increased mobility;
lack of access to basic HIV prevention information, education, and services, and lack of coordination with existing reproductive health services to reduce stigma and maximize coverage;
lack of access to currently available female-controlled HIV prevention methods, such as the female condom, and lack of training on proper use of either male or female condoms;
high rates of other sexually transmitted infections, unintended pregnancy, and complications during pregnancy and childbirth; and
an absence of legal frameworks designed to protect the rights of women and girls and the lack of accountable and effective enforcement of such frameworks, where they exist.
Efforts to increase women’s access to comprehensive prevention information and services, address gender violence, increase women’s economic and social status, and foster equitable partnerships between women and men are all central to reducing the spread of HIV/AIDS worldwide and to enhancing the success of effective treatment and care programs supported by the United States.
integrated, 5-year strategy to combat global HIV/AIDS submitted to Congress on
February 23, 2004 (as required by section 101 of the United States Leadership
Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108–25;
7611)), does not adequately focus or provide sufficient details
on how the United States Government plans to address the factors that lead to
gender disparities in the rate of HIV infection in order to successfully
prevent HIV infection among both married and unmarried women and girls. The
March 2007 Institute of Medicine report, entitled
Progress and Promise, affirms that additional programming is required
to address the factors that put women and girls at risk of contracting
Strategy to prevent HIV infections among married and unmarried women and girls
Statement of policy
In order to meet the stated goal of preventing 7,000,000 new HIV infections worldwide, as announced by President George W. Bush in his address to Congress on January 28, 2003, it is the policy of the United States to pursue a global HIV prevention strategy that emphasizes the immediate and ongoing needs of married and unmarried women and girls and addresses the factors that lead to gender disparities in the rate of HIV infection.
later than 180 days after the date of the enactment of this Act, the President
shall formulate, submit to the appropriate congressional committees, and make
available to the public, a comprehensive, integrated, and culturally relevant
global HIV prevention strategy that addresses the vulnerabilities of married
and unmarried women and girls to HIV infection and seeks to reduce the factors
that lead to gender disparities in the rate of HIV infection. The strategy
shall encompass comprehensive health and HIV prevention education at the
individual and population level beyond the ABC model (
faithful, use Condoms) as a means to reduce HIV infections and shall
include the following strategies:
Empowering women and girls to avoid cross-generational sex and to decide when and whom to marry in order to reduce the incidence of early- or child-marriage.
Dramatically increasing access to currently available female-controlled prevention methods and including investments in training to increase the effective and consistent use of both male and female condoms.
Accelerating the destigmatization of HIV/AIDS, as women are generally at a disadvantage in combating stigma.
Addressing and preventing the consequences of gender based violence and rape against women and girls.
Promoting male attitudes and behavior that respect the human rights of women and girls and that support and foster gender equality.
Supporting the development of micro-enterprise initiatives, job training programs, and other such efforts to assist women in developing and retaining independent economic means.
Supporting expanded educational opportunities for women and girls.
Protecting the property and inheritance rights of women.
Coordinating HIV prevention information and education services and programs for all people, including people living with HIV/AIDS, with existing health care services targeted to women and girls, such as family planning, comprehensive reproductive health services, and programs to reduce the transmission of HIV between parents and children, and expanding the reach of such health services.
Promoting gender equality by supporting the development of civil society organizations focused on the needs of women and utilizing such organizations that are already empowering women and girls at the community level.
Encouraging the creation and effective enforcement of legal frameworks that guarantee women equal rights and equal protection under the law.
Encouraging the participation and involvement of women in drafting, coordinating, and implementing the national HIV/AIDS strategic plans of their countries.
Responding to other economic and social factors that increase the vulnerability of women and girls to HIV infection.
In formulating and implementing the global HIV prevention strategy pursuant to subsection (b), the President shall ensure that the United States coordinates its overall HIV/AIDS policy and programs with the national governments of the countries for which the United States provides assistance to combat HIV/AIDS and with international organizations, other donor countries, and indigenous organizations, including—
organizations focused on or providing services to expanding and enforcing women’s rights, improving women’s health, and expanding education for women and girls; and
organizations providing services to, and advocating on behalf of, individuals living with and affected by HIV/AIDS.
The President shall—
provide clear guidance to field missions of the United States Government in countries for which the United States provides assistance to combat HIV/AIDS, based on the strategies specified under subsection (b); and
submit the guidance described in paragraph (1) to the appropriate congressional committees and make the guidance available to the public.
Country operational plans
In formulating and implementing the global HIV prevention strategy required under subsection (b), the President, acting through the Office of the Global AIDS Coordinator and field missions of the Federal Government in countries for which the United States provides assistance to combat HIV/AIDS, shall consult with appropriate local and national organizations regarding the vulnerability of women and girls at risk of, or living or affected by, HIV and AIDS as part of the development of country operational plans.
Not later than 1 year after the date of the enactment of this Act, and annually thereafter as part of the annual report required under section 104A(e) of the Foreign Assistance Act of 1961 (22 U.S.C. 2151b–2(e)), the President shall—
submit a report on the implementation of this Act during the prior fiscal year to the appropriate congressional committees; and
make the report described in paragraph (1) available to the public.
The report prepared under paragraph (1) shall include—
a description of the prevention programs designed to address the vulnerabilities to HIV/AIDS of married and unmarried women and youth; and
a list of all nongovernmental organizations in each country that receive assistance from the United States to carry out HIV prevention activities, including the amount and the source of funding received.
Balancing funding for HIV prevention methods
Congress finds the following:
evidence-based and measurable strategies for delaying sexual debut are critical
components of comprehensive HIV prevention programs, current United States
funded HIV prevention programs based on the ABC model of
faithful, use Condoms are too narrow in scope and do not respond to the
circumstances that put women and girls at risk of contracting HIV.
In order to maximize the impact of United States foreign assistance to combat HIV/AIDS, all sexually active persons in each country should be equipped with all the skills and tools necessary to avoid infection, including information and training on delay of sexual debut and the practice of safer sex, whether sexual activity begins within or outside of marriage.
Under section 403(a) of the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108–25; 22 U.S.C. 7673), 33 percent of all United States foreign assistance provided for preventing the spread of HIV must be spent on abstinence-until-marriage programs. Based on operational guidance to field missions of the United States Government, in order to meet this requirement, 50 percent of all United States foreign assistance provided for preventing the spread of HIV at the country level must be spent on prevention of sexual transmission and 66 percent of all such funding for sexual transmission must be spent on the Abstinence and Be faithful components of the ABC model.
A recent report by the Government Accountability Office, entitled Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief (GAO–06–395, April 4, 2006) found the following:
Because it requires
country teams to segregate the Abstinence and Be faithful components of the ABC
model from funding for
other prevention, the
abstinence-until-marriage spending requirement can undermine the team’s ability
to design and implement programs that integrate the components of the ABC
model, 1 of the guiding principles of the President’s Emergency Plan for AIDS
Relief sexual transmission prevention strategy. Eight of the 15 focus country
teams indicated that segregating the Abstinence and Be faithful components of
the ABC model from
other prevention funding compromised the
integration of their programs. Examples of the problems they cited include the
Segregating program funding compromises the integration of ABC activities, especially for at-risk groups that need comprehensive messages.
Segregating program funding limits some country teams’ ability to shift program focuses to meet changing prevention needs.
A large majority
of the 20 country teams required to meet the abstinence-until-marriage spending
requirement or obtain exemptions reported that the requirement presented
challenges to their efforts to respond to local prevention needs. Seventeen of
these teams reported, either through documents submitted to the Office of the
Global AIDS Coordinator (referred to in this section as
through structured interviews, that meeting the spending requirement, including
OGAC’s 50 percent and 66 percent policies implementing it, challenged their
ability to develop interventions that are responsive to local epidemiology and
Between September 2005 and January 2006, 10 of these teams submitted documents to OGAC requesting exemption from the spending requirement as it was defined in OGAC’s August 2005 guidance. These documents highlight various challenges that the country teams associated with meeting the spending requirement, including the following:
Reduced spending for Prevention of Mother to Child Transmission.
Limited funding to deliver appropriate prevention messaging to high-risk groups.
Lack of responsiveness to cultural and social norms.
Cuts in medical and blood safety activities.
Elimination of care programs.
In addition, 7 teams that did not submit documents requesting exemption from the spending requirement (they did not meet OGAC’s proposed criteria for requesting exemptions) identified, in structured interviews, specific program constraints related to meeting the abstinence-until-marriage spending requirement, including the following:
Difficulty reaching certain populations with comprehensive ABC messages.
Limited or reduced funding for programs targeted at high-risk groups.
Reduced funding for services to prevent mother to child transmission.
Difficulty funding programs for condom procurement and condom social marketing.
Statement of Policy
In carrying out the activities required by the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108–25; 22 U.S.C. 7601 et seq.) and the amendments made by that Act, it is the policy of the United States—
to provide flexibility to support the implementation of culturally relevant HIV prevention programs that are carried out in accordance with the global HIV prevention strategy established pursuant to section 3;
to ensure that onerous requirements are not imposed with respect to how funds made available for such programs can be obligated and expended; and
to prevent the unnecessary reduction in funding for effective HIV programs in order to meet any such onerous requirements.
Amendments to funding provisions of the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003
Sense of Congress
Section 402(b)(3) of the United States Leadership
Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (22 U.S.C.
7672(b)(3)) is amended by striking
, of which such
amount at least 33 percent should be expended for abstinence-until-marriage
Allocation of funds
Section 403(a) of such Act (22 U.S.C. 7673(a)) is amended by striking the second sentence.
In this Act:
The term AIDS means the acquired immune deficiency syndrome.
Appropriate congressional committees
The term appropriate congressional committees means the Committee on Foreign Affairs of the House of Representatives and the Committee on Foreign Relations of the Senate.
The term HIV means the human immunodeficiency virus, the pathogen that causes AIDS.
The term HIV/AIDS means, with respect to an individual, an individual who is infected with HIV or living with AIDS.