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In 1975, a family planning research program opened its doors in North Carolina, funded by a grant from the U.S. Agency for International Development (USAID). Its study narrowly focused on contraceptives and fertility, but within a decade, the nonprofit had expanded its mission beyond research, reproductive health and the borders of the United States. In 1986, it started addressing a pandemic that was jolting the world: HIV/AIDS.

Thirty years later, the once-small outfit is a giant in federally funded HIV/AIDS work. Family Health International (FHI) ranks as one of the U.S. government’s top contractors through the President’s Emergency Plan for AIDS Relief (PEPFAR), the five-year, $15 billion initiative to fight HIV/AIDS in 15 “focus countries” (12 in Africa, plus Guyana, Haiti and Vietnam) and more than 100 other countries worldwide.

In fiscal 2005, FHI was granted more than $100 million through PEPFAR, eclipsing most competitors’ contracts by $20 million or more. It has responded to PEPFAR’s emphasis on improving indigenous relief efforts by building many of the emergency fund’s largest networks of overseas and grass-roots partnerships. In nearly every PEPFAR focus country, FHI has worked with hundreds of governments, community organizations, faith-based groups, medical centers and schools.

But a tight, longstanding relationship with Washington hasn’t shielded FHI from criticism within the government. During 2005, the organization faced lashings from congressional conservatives over the nature of its programs. Early in 2006, USAID decided to discontinue its largest joint HIV/AIDS program with FHI — a $441 million undertaking with a eight-year track record — but denied that the move was politically motivated.

FHI has weathered the political spats and still retains firm federal ties. In fiscal 2005, it reported $224 million in revenue, $206 million of which came from U.S. government grants. With its weighty PEPFAR funds, the organization is operating in 14 PEPFAR focus countries — all but Botswana, where it had no prior presence.

FHI background

Touting itself as one of the “largest and most established nonprofit organizations active in international public health,” FHI has 37 offices worldwide and has addressed infectious disease and reproductive health in 70 countries.

The organization is divided into the Institute for Family Health and the Institute for HIV/AIDS. Its 1,600 employees worldwide — most of whom are host country or regional natives — work through the institutes to prevent the spread of infectious disease, provide care for people with HIV/AIDS, build safe and affordable family planning services and improve family and reproductive health, especially in impoverished areas.

Experts in medical, scientific, nursing, social work and public policy make up FHI’s team, known for what Margaret Diebel, a registered nurse and FHI’s vice president for program support, called its “pioneering work” in the early years of the HIV/AIDS epidemic. In the mid-1980s, FHI began addressing the virus in Asia, Diebel said. There, the organization quickly learned that the disease’s impact reached far beyond infected individuals and was expanding beyond Asia. As HIV/AIDS spread throughout the world, FHI followed, working hand in hand with the U.S. government to manage the largest crises.

While the government has the primary stake in FHI’s budget, FHI is also supported by dozens of sources, from pharmaceutical giants such as Pfizer to United Nations agencies and other nongovernmental organizations.

Yet its recent federal ties have been controversial. PEPFAR has been criticized from all sides, especially over a divisive clause tying abstinence advocacy to prevention efforts.

PEPFAR AB vs. C controversy

In 2003, Congress authorized PEPFAR and its multifaceted prevention, care and treatment structure. In doing so, it also endorsed the so-called ABC approach to prevention, through “Abstinence,” “Be Faithful” to one partner, and the correct and consistent use of Condoms.

Under the ABC strategy, one-third of all PEPFAR funding for prevention programs and two-thirds of sexual transmission prevention funding must be spent on programs that encourage the “A” and “B” components. The spending requirements, in turn, have trickled down into efforts implemented by contractors such as FHI.

For many international health organizations, Diebel said, abstinence education is nothing new. FHI in particular sees it as “an important part of the toolbox” in HIV/AIDS prevention, she said, along with endorsing condom use and speaking about the importance of limiting sexual partners.

Special emphasis has been placed on youth abstinence programs, because half of new infections afflict the 15- to 24-year-old age group. Since 2001, FHI has piloted a prevention program called YouthNet for 10- to 24-year-olds. One aspect of the program stresses abstinence as “the most effective means of preventing HIV infection, pregnancy and sexually transmitted infections.”

Youth, however, aren’t the only people being targeted with AB messages through PEPFAR.

According to PEPFAR guidelines, AB education is recommended for all unmarried people, while condom use is to be emphasized mainly among “at-risk” populations such as sex workers and their clients, men who have sex with other men and couples in which one partner is infected. In schools, condoms cannot be distributed or promoted as a prevention strategy for children younger than 14. Furthermore, condom programs must include a discussion of AB alternatives, but not vice versa.

Outside critics and some within the government argue that such a policy distorts the emphasis on prevention techniques in favor of AB, curbs condom distribution and ironically leaves those not in at-risk populations at greater risk of contracting the virus.

In 2006, the Government Accountability Office joined the chorus of critics. The office investigated the policy and concluded that the AB spending requirement challenges PEPFAR’s abilities to meet specified, local prevention needs.

FHI says it promotes the full spectrum of ABC prevention, as is evident in 2005 PEPFAR documents obtained by the Center for Public Integrity through a Freedom of Information Act request. The documents show that FHI promotes condom use in nearly every country where it also runs AB programs.

But in some cases, the official plans also show that more emphasis may have been placed on abstinence.

According to the documents, abstinence and faithfulness were FHI’s primary prevention messages in Ethiopia for at-risk individuals, excluding sex workers and their clients. There, 10.8 million individuals were to be reached with AB messages.

By comparison, 34,000 people, especially those with multiple sexual partners, were to be educated on condom use and limiting sexual partners.

Another program, the Global HIV/AIDS Initiative in Nigeria (GHAIN), also stressed abstinence. GHAIN, fully funded by PEPFAR, was allocated $29 million for fiscal 2005, one of the largest grants of the year.

According to FHI, GHAIN is “the largest and most comprehensive HIV/AIDS project ever implemented in a single developing country” at $193 million over five years. It is a wide-ranging prevention, care and treatment program that seeks to help government, faith-based and community organizations address community challenges arising from Nigeria’s rapid rate of new infections.

Large target goals characterize GHAIN’s approach, but far outnumbering any other target was the emphasis on spreading AB prevention messages. Government documents from fiscal 2005 detail FHI’s plans to work with several faith-based organizations and educate 2.7 million Nigerians on abstinence and fidelity.

In comparison, initiatives focused on at-risk groups with a transport workers union, a teachers union, an employers association and a business coalition planned to target 10,000 people with risk reduction programs “not focused on abstinence and/or being faithful.” (Other programs included supporting 35 health clinics and establishing 40 new ones to counsel and test more than 300,000 people for HIV; establishing “get tested” campaigns; and testing 26,500 pregnant women for HIV and providing them with medical services if infected.)

FHI reported that, through September 2005, GHAIN had reached almost 850,000 people with AB messages. It did not report the number of people reached specifically with condom education, but it said nearly 21,000 people were provided “HIV prevention information.”

Diebel said FHI creates its prevention approach by what it deems appropriate for different groups. “Part of our communication strategy is to understand the receivers of messages,” she said. “With any audience you need to make a rule that the message you’re sending is appropriate, given age, behaviors, et cetera.”

Congressional lashings

The U.S. government reported that in 2005 FHI ran AB programs in 11 out of 14 countries where it received PEPFAR funding. Yet that same year, FHI and other large grant recipients came under fire by several conservatives in Congress who questioned the organizations’ dedication to PEPFAR’s abstinence programming.

According to the Associated Press, several House Republicans, including Rep. Christopher H. Smith of New Jersey, chairman of an International Relations subcommittee on Africa, human rights and international operations, wrote letters to President Bush and USAID accusing the organizations of promoting prostitution and abortion while lacking commitment to abstinence programs.

In response, California’s Rep. Henry Waxman and five other Democratic members of Congress wrote to Secretary of State Condoleezza Rice condemning conservatives who, they said, were undermining “evidence-based approaches to preventing the sexual transmission of HIV.”

Later, FHI was told that funding for its largest joint project with USAID — the $441 million IMPACT project — would not continue past 2006. Ambassador Mark Dybul, now the U.S. State Department’s global AIDS coordinator, told the AP that the discontinuation had nothing to do with the political debates, saying it was only in line with PEPFAR’s emphasis on increased partnerships with indigenous organizations to build their capacity in dealing with the epidemic.

IMPACT has been a major component of FHI’s PEPFAR record and the organization’s leadership in fighting the epidemic around the world. The project includes five other international teams and enlisted hundreds of indigenous community and faith-based groups in several focus countries.

IMPACT has addressed nearly all aspects of PEPFAR’s prevention, care and treatment programs. “With additional funds [through PEPFAR], we’ve been able to expand our programs tremendously,” Diebel said. As described in government documents, in 2005 IMPACT aimed to transfer to the Rwandan Ministry of Health management of some of FHI’s 28 health centers and counsel and test more than 120,000 people; care for 25,000 orphans and other vulnerable children in Namibia and train an additional 1,375 volunteers, many from faith-based organizations; and help organizations in Ethiopia treat nearly 26,000 people diagnosed with or presumed to have HIV.

In fact, indigenous partnerships are what define FHI’s work, Diebel said. Although IMPACT will be eliminated, PEPFAR has allowed FHI to expand its programs in other countries. For example, its $13 million PEPFAR grant for fiscal 2005 allowed it to work with 33 partners in Kenya; in Rwanda, $7.7 million supported work with 59 partners; and in Nigeria, GHAIN’s $29 million involved nearly 100 partners.

The partnerships have furthered FHI’s commitment to strengthen community-specific responses, Diebel said. Through PEPFAR, FHI is largely focused on care and treatment programs, she said, and partnerships have allowed FHI to reach 10 percent of PEPFAR’s treatment goals.

“Part of it was simply necessity,” Diebel said of FHI’s partnerships. “We have to work with local organizations. They’re the ones that know the communities and environment. If we use our own staff — just do our work and leave — that’s just not the right recipe for any kind of sustainable development work.

“An emergency situation, like with PEPFAR, means you can still provide an emergency response while building local capacity with local entities in the community.”

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