In February 2004 Ambassador Randall Tobias, the global AIDS coordinator for the United States, released the nation’s $15 billion, five-year global HIV/AIDS strategy. The new U.S. AIDS initiative, commonly referred to as the President’s Emergency Plan for AIDS Relief (PEPFAR), has three goals: (1) to treat two million HIV-infected people with antiretroviral therapy; (2) to care for ten million people already infected with and affected by HIV/AIDS, including children and orphans; and (3) to prevent seven million new HIV infections. Although it also funds programs elsewhere, the initiative focuses on fifteen countries—twelve in Africa, two in the Caribbean, and one in Asia.
To its credit, PEPFAR’s focus on treatment represents a dramatic shift in U.S. international AIDS policy. It will significantly prolong the lives of many people by fulfilling their right to essential medicines. The program nevertheless has conceptual and programmatic flaws, among them a bilateral structure that provides scant resources for the accepted multilateral funding structure, the Global Fund to Fight AIDS, Tuberculosis and Malaria; a lack of adequate mechanisms to secure the participation of local constituencies; and a funding strategy that back-loads rather than front-loads resources. The level of funding, while representing a very significant increase over previous years, is still insufficient to meet the need. The $15 billion proposed by the Bush administration, which includes funding for tuberculosis and malaria, is only about half of a fair U.S. share for combating these three diseases, based on U.S. economic strength.
The PEPFAR prevention strategy includes welcome attention to vulnerable and marginalized populations. It supports targeted interventions—such as education and condom distribution—for marginalized groups, including sex workers, injecting drug users, and men who have sex with men. PEPFAR also recognizes the need to promote children’s and women’s rights, including eliminating gender inequalities in the civil and criminal legal codes, confronting stigma and discrimination in communities, and providing legal assistance to children and families to protect them from abuse and secure their property rights. By funding medical injection safety and blood safety programs, PEPFAR repudiates a double standard of healthcare that has pervaded the international system, where people in wealthy countries have access to safe healthcare but residents of poor countries do not.
PEPFAR nevertheless raises serious human rights concerns. These fall into three areas: (1) whether the Bush administration is sufficiently committed to human rights policies in the plan, (2) whether the program’s legislative requirements and administrative policies violate human rights, and (3) whether the plan inadequately addresses crucial concerns about the pandemic.
Current Concerns
Let us first review the strength of the administration’s commitment to HIV/AIDS policies that involve human rights issues. Some disturbing signs have already surfaced. In Uganda, for example, PEPFAR administrators have overlooked their mandate to address domestic violence, in large part due to the perceived difficulty in connecting domestic violence programs to PEPFAR’s numerical targets, which require coordinators to identify specific numbers of people treated or cared for, or infections prevented. This stance contradicts the PEPFAR strategy document, which recognizes the need to confront domestic violence as part of a successful prevention effort. Even if PEPFAR lacks the funds to initiate full-fledged programs against domestic violence, it must support some level of intervention and coordinate with other organizations to secure the resources required for a broader effort against domestic violence.
Questions also remain about the program’s level of support for women’s and children’s rights, and its ability to combat stigma and discrimination. Further; while PEPFAR appropriately includes confidential HIV testing as one pillar of prevention, it does not address the dangerous possibility that such a policy could contribute to violence against women if their husbands learn their status. It likewise does not address discrimination in other realms of life resulting from breaches in confidentiality.
Even more disturbing, the PEPFAR strategy, following the authorizing legislation and other aspects of U.S. law and policy on AIDS, contains elements that undermine human rights. The legislation compels groups who receive PEPFAR grants to explicitly oppose prostitution, a requirement that could disqualify some organizations providing important HIV prevention and health services to sex workers from receiving funds. In addition, since U.S. law prohibits federal funding for needle exchange programs, PEPFAR does not include any such programs for injecting drug users, even though the approach is a proven and essential intervention for reducing HIV prevalence (without increasing drug use). Although this law predates PEPFAR, it has taken on added significance now that Vietnam, where injecting drug use is a major form of HIV transmission, has become the fifteenth focus country.
The Bush administration has also insisted that generic antiretroviral drugs, including those that the World Health Organization has deemed safe and effective, pass review by the U.S. Food and Drug Administration using a new, expedited review process. Unless this process is indeed efficient and inexpensive, it will unnecessarily divert funding to more expensive medications. This will force PEPFAR administrators either to purchase fewer drugs, depriving AIDS patients who would otherwise receive life-saving medication, or to reduce spending in other key areas, such as building the infrastructure required to support treatment.
Finally, following an ideological approach on condom use, the PEPFAR strategy provides condom funding only for select, so-called high-risk populations. Yet condom distribution to the general population in addition to specific groups is widely recognized as one of the basic elements of an effective HIV prevention strategy.
Missing Elements
Another source of concern is PEPFAR’s silence on human rights strategies that are critical to effective AIDS prevention and treatment. For example, targeted prevention efforts risk failure if PEPFAR does not promote and support legal, political, and social conditions to protect vulnerable groups and their advocates from harassment or arrest, which could drive them underground, beyond the reach of prevention efforts. Similarly, the treatment section of the PEPFAR strategy does not include special outreach to ensure that vulnerable and stigmatized groups are included in treatment programs.
The danger that the proposed treatment strategies will fail to reach marginalized populations also applies to poor and rural populations generally. For example, the PEPFAR strategy understandably focuses on incorporating treatment programs into existing health infrastructure. This is the fastest way to ramp up treatment, and it deserves support. Yet it must occur simultaneously with other efforts that will enable rural populations and other people who lack access to decent health facilities—or any formal healthcare at all—to receive AIDS treatment. This will require a significant infusion of resources to develop health systems in underserved areas.
Another unresolved aspect of PEPFAR will also affect treatment for marginalized populations, as human rights principles require. So far, PEPFAR’s implementation has not given due attention to an element of the strategy that promotes “policies to support the recruitment and retention of qualified health care professionals.” Countries in Africa, especially many of those hardest hit by AIDS, are suffering severe shortages of trained health personnel. This is proving to be one of the most significant obstacles to improving treatment. The shortages are most severe in rural areas, jeopardizing efforts to bring treatment to inhabitants of those regions, who are often the majority of their country’s entire population. Health professionals who do deliver antiretroviral therapy will have less time to devote to other health services, which in the context of severe personnel shortages will likely mean that those services will go undelivered. Addressing this shortage will facilitate people’s right to the highest attainable standard of health in numerous ways.
A commitment to AIDS treatment and prevention is justifiably a source of hope. Congress and the administration should act now to bring PEPFAR fully in line with human rights.
As published in Human Rights, Fall 2004, Vol. 31, No. 4, p.4-5.