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."

The risk of sexual violence and rape should therefore be a crucial component in HIV-prevention policies, says the Rev. Mpho Tutu, daughter of South African Archbishop Desmond Tutu and an Episcopal priest in Alexandria, Va. "One of the reasons for the feminization of the pandemic is the instability of war and displacement," she explains. "Refugee women are vulnerable because rape and sexual exploitation are weapons of war.... And as communities are destabilized, more and more often you'll see women trading sexual favors for economic support."

Sex-for-survival can also occur in the home, especially when women are poor, as they are in great swatches of the PEPFAR countries. As for using condoms, studies in Haiti, another PEPFAR focus country, show that more than 60 percent of Haitian women feel that the decision about whether to use condoms is exclusively the man's right. Discussion of safe sex, as suggested by the ABC plan, requires a discussion of sex itself. Yet the PEPFAR policy is to restrict comprehensive sexual-education programs to only certain sectors of the population. Children up to age 14, for example, are not to be introduced to condoms in any PEPFAR- funded school programs. Unmarried youth are often taught only about abstinence and being faithful. This policy does not reflect the reality of Haitians' sex lives, of course: Recent surveys show that 60 percent of young males and 36 percent of young females reported having their first sexual contact before 15 years of age.

Even when condoms are offered by health providers, U.S. requirements stipulate that they must always be accompanied by a notice of their failure rates. Says HIV/AIDS consultant David Veazey, "This is not something you would put in a campaign slogan to promote condoms. It would be the same as a seat-belt commercial saying, 'Buckle Up! But there is a 10 percent chance that the seat belt won't save you in an accident.' Not only would people continue to drive -- because they have to -- but they probably wouldn't see the point in wearing a seat belt either."

The U.S. has recognized that the ABC policy isn't always appropriate, so it has allowed some of the PEPFAR "teams" within the focus countries to direct less of their programs to abstinence and fidelity. But then the rest of the countries' provider teams have to spend more on A and B, which means cutting back on other programs.

"We continue to act as if poor people are stupid people," says Rev. Tutu. "They aren't stupid, they're just poor. They are entitled to make full decisions. [If you provide ABC] and [say] that's all that's available, it's dishonest and it infantilizes those to whom we provide the message."

PEPFAR isn't the only source of significant global funding on AIDS, just the biggest. But its prevention guidelines are quite different from those of another significant player, the Global Fund to Fight AIDS, Tuberculosis and Malaria. The internationally supported Fund, started in 2002, is not required to follow the ABC policy, although its resources are fewer than those of PEPFAR.

"I think the position of PEPFAR is guided by some religious aspect," says Dr. Émile Charles, head of a Global fund-sponsored health program in Haiti. "But it's important ... for a country like Haiti ... to continue to focus on condoms. I think that promoting abstinence is an error, a scientific error."

Restrictive U.S. guidelines have caused some countries and providers to refuse its funding. Brazil turned down $40 million in U.S. AIDS funding in 2005 because it refuses to take a required pledge against "the legalization or the practice of prostitution" (which is already decriminalized in Brazil). The country's AIDS program, considered among the world's most progressive, counts its commercial sex workers among its most determined AIDS activists. Other AIDS providers are reluctant to sign the pledge because they don't want to increase the stigma and isolation of sex workers, which would thus raise further barriers to getting them needed HIV services.

Congress has recently begun to weigh in on PEPFAR: The bipartisan Protection Against Transmission of HIV for Women and Youth Act of 2006 (PATHWAY), announced in June, would require the program's administrators to establish a prevention strategy that addresses the vulnerabilities of women and girls to HIV, eliminates the funding earmark for abstinence, increases access to male and female condoms and addresses gender violence as a cause of HIV/AIDS.

"A growing number of Congress members agree that this bill is important, as it continues to attract new cosponsors from both parties every month," says Jodi Jacobson, director of the Center for Health and Gender Equity, a nonprofit that advocates accountability for U.S. health policies abroad. "PATHWAY...forces the hand of the administration ... to do the right thing when constructing a truly comprehensive approach to prevention.

"We should pass it tomorrow."

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