Rethinking the AIDS Emergency and the U.S. Response


In July, I spent two long days with Kenyan health professionals working to hold back the tide of HIV/AIDS in their country. They were encouraging couples to be tested and counseling them about how to care for one another when only one has tested positive for HIV. They were training new nurses to provide family planning counseling in programs designed to prevent HIV transmission from pregnant women to their newborn children. They were providing comprehensive care from medication to prenatal care to family planning. I think often of the waiting rooms in Kenya and the hundreds of women, frequently with children in tow, who had traveled some distance to seek help in managing their lives with a measure of health and dignity that HIV too often takes away.

Wednesday, the House took a big step toward increasing the United States' commitment to ending the suffering caused by AIDS in Africa. It reauthorized the President's Emergency Plan for AIDS Relief (PEPFAR), which will provide $50 billion over the next five years-the largest aid package from any country directed at a cluster of diseases -- HIV/AIDS, tuberculosis, and malaria.

PEPFAR is a landmark initiative. But like all major investments, it is time to reassess the portfolio so we spend U.S. tax dollars as wisely as possible to end the HIV pandemic. I am angry with those who compromise without a single thought to what it is like for those waiting women facing the truths of sex, reproduction, and HIV. I insist that, with courage and vision, $50 billion can stretch much farther and truly restore U.S. leadership in responding to HIV/AIDS.

By the end of the five years, at the 10-year anniversary of PEPFAR, Americans will have provided $80 billion to this "emergency." Fast forward to 2013. If current trends continue, what will we have accomplished with the legislation currently under consideration?

  1. Greater access to anti-retroviral medication. Millions of lives will be extended and improved, but we will still fall far short of meeting the demand.

  2. Greater numbers of people living with HIV. Those newly infected with HIV will continue to outnumber those on treatment, and most new infections will occur in women and young people.

  3. A dark age of "behavior change" propaganda. The promotion of abstinence as a viable HIV prevention strategy continues to deny the risks and realities of people's sex lives. It also ignores the U.S. government's own evidence that this approach has not been successful in delaying sexual debut or preventing the spread of HIV or other sexually transmitted infections. By obliging U.S. aid recipients to publicly denounce sex work and some of the very people they intend to serve, we drive sex work further underground and sex workers further from the services they need to keep themselves safe and healthy.

  4. Inefficiency and cruelty. By failing to invest in the sexual and reproductive health services that women and girls are already using, we weaken rather than strengthen countries' abilities to provide HIV prevention and care for women-the majority of those living with HIV in PEPFAR countries. If you are living with HIV and reliant on PEPFAR funds, family planning services-a tried and true public health advance-are nowhere to be found. If you are a family planning provider, and do not deny women abortion information and services (and therefore do not comply with the U.S. Global Gag Rule), you are ineligible for HIV/AIDS funding and unable to help your clients.

Why does the future look so grim? Our country's standing in the world is so diminished, that lawmakers refuse to look too closely at one of the only bright spots in recent U.S. foreign policy. Plus, history tells us that seeking the lowest common denominator in our global health programs compromises women's rights and health -- especially women living far, far away. Lawmakers have perpetuated the Global Gag Rule, have funneled hundreds of millions of dollars to abstinence-only education abroad, and have eroded the capacity of countries to provide sexual and reproductive health care.

It doesn't have to be this way. In reauthorizing PEPFAR, lawmakers had a golden opportunity to salvage President George Bush's "legacy," and respond to the current state of affairs in Africa and other parts of the world where HIV/AIDS cuts a deadly swath through daily life. The original bill encouraged abstinence in a continuum of ways to protect oneself against HIV, but got rid of the requirement that one-third of prevention funding be spent on abstinence-only. It supported "one-stop" care for pregnant women living with HIV, providing them with the means to prevent another pregnancy if they so desired and protect their health. It took the moral (and public health) high ground, recognizing that the women and men who engage in sex work also have the right to protect themselves, their clients, and their clients' sexual partners from HIV. But so far, these provisions have sadly been compromised by politics rather than shaped by evidence.

Soon the Senate will have a chance to make its imprint on how this $50 billion program should operate. Its actions will set the stage for whether the next administration and Congress will inherit a "legacy" impervious to quick fixes or even grand redesign or apply the lessons learned in the first five years to become more effective in the second five. So far the bill's leadership in the Senate -- Joe Biden (D-DE) and Richard Lugar (R-IN) -- seems inclined to stay the course, hoping that others won't ask for changes for fear of breaking some delicate political deal. But there's time to encourage them to make the changes that will make the difference in millions of lives. If they do, the accomplishments of PEPFAR in 2013 can look much different than where we're headed now.

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