Bush’s Failed Global AIDS Plan

In his January 2003 State of the Union address, President George W. Bush announced a $15 billion initiative to "turn the tide" against AIDS, targeted mainly at 14 of the hardest-hit African and Caribbean countries, plus Vietnam. That would virtually triple the U.S. commitment, offering renewed hope to the nearly 30 million AIDS sufferers in Africa alone.

It all sounded grand.

But very quickly, the strings of the plan -- now known as PEPFAR, the President's Emergency Plan for AIDS Relief -- began to show. Starting in 2004, the United States recommended -- and by 2006 required -- that 33 percent of all prevention funding be earmarked for abstinence and fidelity programs. Condoms could be recommended only for high-risk groups, not for sexually active people in general. No funds would be provided to groups that don't explicitly condemn prostitution. Finally, the Bush administration seemed to be spreading a significant share of AIDS funding through faith-based groups.

Meanwhile, the AIDS pandemic has been rapidly feminized over the past 15 years. But PEPFAR -- underpinned by the political and religious philosophies of the Bush administration -- often doesn't take into account the facts of life for women in the countries it serves.

"The gender dimensions of the epidemic are completely ignored," says Beatrice Were, a Ugandan mother of three who has devoted herself to AIDS activism since 1993. "We know very well that women don't [always] have control [over sexual decisions]. There is rape in marriage. ... Many women can't make a decision on whether to have protected sex or not, even whether to have sex or not, because it's their husbands [who] make the decision."

In Uganda polygamy and promiscuity among men is both significant and socially acceptable. "This [PEPFAR] approach places a huge burden on a woman to abstain and, when she's married, be faithful," says Were. "Personally, I did all of that, but I still got infected, too. It just doesn't work."

Nonetheless, the ABC plan -- Abstinence, Be faithful and use Condoms -- continues to be the preferred U.S. strategy for preventing sexually transmitted HIV infections. Indeed, service providers often have to reduce other programs -- such as those to prevent mother-to-child HIV transmission -- in order to redirect dollars toward abstinence and thus meet the 33 percent requirement.

But an abstinence-only approach has not proven effective in preventing AIDS transmission; in fact, it may have an opposite effect. In Uganda, which successfully promoted a comprehensive program before PEPFAR, the incidence of the virus has nearly doubled since shifting its focus to comply with PEPFAR's A and B guidelines. When first recognized in the early 1980s, AIDS was pegged as a disease affecting primarily men, homosexuals, Haitians or intravenous-drug-users. But over the years, HIV has increasingly infected women who are married, have children and are nonwhite and poor. Today, 17.3 million women in the world live with HIV/AIDS, and of the 16,000 new HIV infections daily, as many as 55 percent occur among women. The proportion of women among the total infected population has risen at a steady and frightening rate: from 35 percent in 1990 to 41 percent in 1997, to 48 percent in 2004.

The women of sub-Saharan Africa are particularly hard-hit. They comprise 54 percent of all HIV/AIDS cases in the region, and three of four newly infected young people (15 to 24 years old) are women.

A number of studies have found that male-to-female transmission of HIV during sex is about twice as likely to occur as female-to-male transmission, because the HIV virus can more easily penetrate vaginal mucus during intercourse. The risk runs even higher if intercourse is violent, as abrasions caused by forced penetration facilitate entry of the virus -- which puts adolescent girls at increased risk. As Stephen Lewis, U.N. Special Envoy for HIV/AIDS in Africa, pointed out at the 2006 International AIDS Conference in Toronto, "In Africa... the violence and the virus go together."