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January 01, 2008

The Politicization of HIV Prevention: The Cynicism of U.S. Assistance to Africa

by William A. Smith

Over the past several months, the Democratically led Congress has been acquiescing to ongoing hypermoralism from right-wing politicians and pressure groups, and the White House itself, by conceding to a reauthorization of the President’s Emergency Plan for AIDS Relief, or PEPFAR. To listen to the mainstream media coverage, this process has been an unprecedented practice in hand-holding as a chorus champions the success of PEPFAR and the utter necessity of reauthorizing it. However, the reauthorization of this program to date has, in essence, occurred without serious debate and without a full airing of the significant problems PEPFAR has generated. These problems not only suggest the deepest and most deplorable cynicism toward the greatest challenge of our time, but also strike at the very core of fundamental human rights, such as a right to the highest attainable standard of health.

A Brief History

In his State of the Union Address in 2003, President Bush announced that the United States government would make the largest investment ever in curbing the HIV/AIDS pandemic by calling for the creation of a five-year, $15 billion program to assist some of the world’s most severely affected countries. Even fiscal conservatives in the president’s own party were hard pressed to object, and Congress approved legislation to fund PEPFAR four months later. The legislation encompasses fifteen focus countries—twelve of which were in sub-Saharan Africa, with the remaining three being Vietnam, Haiti, and Guyana.

Congress’s hand in crafting the legislation provided a first glimpse into the trouble that lay ahead as a number of items were included in the law that seemed to go against prevailing wisdom. For example, Congress attached a provision requiring that one-third of all prevention funding be spent on abstinence-until-marriage programs. Another provision required that every grantee sign a pledge saying they oppose prostitution. This prostitution pledge even applied to those programs working with commercial sex workers to prevent HIV infection.

Suddenly, a bold and compassionate step toward dealing with HIV/AIDS in the places most in need of help became an opportunity to advance an extreme social conservative agenda. The Bush White House took things still further by forbidding funds to be used for the distribution of condoms to in-school youth and forbidding youth under the age of 14 from receiving any information about condoms in a school setting. Moreover, it became clear that PEPFAR would operate in its own silo, outside of the many multilateral agencies doing this work.

PEPFAR in Practice

To be clear, on issues of care and treatment of HIV/AIDS, PEPFAR has truly been a success. Yes, there are issues about the pace by which lifesaving anti-retroviral drugs become approved and protectionism for brand-name pharmaceuticals over less expensive generics, but PEPFAR has delivered lifesaving treatment to almost 1.4 million people in the fifteen focus countries as of September 2007. PEPFAR has also shown significant progress in preventing the transmission of HIV from pregnant HIV-positive women to their infants. Where PEPFAR has succeeded, it should be applauded and supported.

When it comes to prevention, however, PEPFAR has utterly destroyed a comprehensive approach in many of the focus countries. Again, it was apparent early on that PEPFAR would promote abstinence until marriage, an idea that the Bush administration had made a major cornerstone of its social conservative agenda domestically since day one. In the United States, Bush will have actively supported and secured spending more than $1.5 billion on abstinence-until-marriage before he leaves office. These funds disproportionately go to right-wing organizations in the United States and have been used over the years to finance the grassroots social conservative movement. Not incidentally, these grantees are also are prohibited from discussing the effectiveness of condoms and contraception even for sexually active youth. To that extent, the core anti-contraception tenor of these right-wing groups is given consent in law.

This domestic approach has been utilized to create a full-fledged industry of abstinence-only-until-marriage providers who have supplanted the more comprehensive providers across the country and fundamentally changed the landscape of sex education in the United States. The Bush administration simply incorporated this strategy into PEPFAR to similarly change the landscape of HIV/AIDS prevention work to be carried out in the focus countries.

The most immediate problem for PEPFAR’s prevention paradigm, however, is that it runs headlong into the foundation of human rights on which most countries base their efforts to combat HIV/AIDS. Many of the PEPFAR focus countries, for example, previously called for a multifaceted approach to prevent HIV, not just because condoms work exceedingly well, but because human rights commitments dictate that condoms not be deliberately withheld.

PEPFAR’s structure was an initial attempt to help isolate it from the pressure of human rights frameworks and, more generally, give it unfettered independence from all external constraints. For example, PEPFAR’s approach to funding is a bilateral one in which the U.S. government creates a contract directly with a grantee to carry out prevention activities. This approach runs counter to the prevailing mechanism, which is a multilateral approach in funding an intermediary party, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, where resources are pooled to ensure efficiency and a higher level of coordination among all parties. In pursuing a bilateral approach, PEPFAR can partner with whomever it wants to do whatever it chooses.

Of course, any individual government could object to PEPFAR’s presence, but reality dictates otherwise. For example, in 2000, the government of Mozambique, one of the fifteen focus countries, spent the equivalent of $9 on health expenditures for each of its citizens—this in a country where more than 16 percent of the adult population has HIV. In four years’ time, PEPFAR funding in Mozambique exceeded $350 million. The hard reality is that Mozambique, and the rest of the focus countries, cannot afford to turn down the financial largesse that is PEPFAR. The need is simply too great.

In addition to PEPFAR’s bilateral structuring of assistance, a mechanism was set into place to make it appear that focus countries accepted the distorted prevention paradigm. While all the focus countries have a national HIV/AIDS strategy of one sort or another, the countries’ own priorities are not sufficient for PEPFAR. Instead, PEPFAR requires focus countries to create, and submit for approval, a separate country operational plan (COP) that fits into PEPFAR’s priorities. This process smacks of a neocolonialism that parallels the Bush administration’s transformational diplomacy scheme—namely, do as we wish and much will come to you. And, of course, the converse is true.

Consequently, on a recent research trip to Zambia, one of the African focus countries, several individuals described their own COP creation process as something written by the United States and accepted by their own government as the avenue to receiving PEPFAR funds. Again, this manner of determining the use and appropriateness of development aid is at best neocolonialist and at worst a fundamental violation of country sovereignty that plays on the need for resources to set the terms of the contract.

As mentioned previously, however, PEPFAR’s most substantive harm comes in its destruction of the comprehensive prevention approach to HIV/AIDS in many of the focus countries, where development aid encounters real people living their lives.

Take something as seemingly harm­less to the average person as asking someone to sign the anti-prostitution pledge. One could argue: Simply sign it and go about your work. After all, the pledge merely says that you do not actively support prostitution and have a policy against it. What harm could such a mere piece of paper stemming from a policy written in Washington, D.C. have on the life of African women?

A Town Named Kafue

The small town of Kafue is just 50 kilometers outside of the Zambian capital of Lusaka. Kafue’s exact unemployment rate is unknown; Zambia is one of the poorest countries in the world and collecting unemployment statistics is far down on the list of priorities. However, the country has an unemployment rate of about 50 percent and Kafue threatens to drive that rate higher. Once booming, Kafue has seen several major plants close, and the compounds, or neighborhoods, that make up Kafue are evidence of life lived on the edge. In one compound, open sewage runs down the same street where the major outdoor market operates. In another, a teacher describes HIV/AIDS as a major problem, but more immediate problems include a food shortage and nutritional deficiencies among all his students.

The real desperation of Kafue, however, becomes apparent as the sun sets. In Zambia, truckers crisscrossing the country as they transport goods throughout sub-Saharan Africa are required by law to cease driving at 8 P.M. The roads are ill-maintained and unlit, and trucks on such roads at dark present not only a danger to other drivers, but to the hundreds of people walking on the side of Zambia’s roads at all hours. Even bicycles are a luxury here. The truck drivers can begin again at 6 A.M.

Kafue sits at a major checkpoint on the main road that runs to Zimbabwe. Each night, truckers pull over in droves, parking anywhere a large enough space can be found. Kafue’s women come—young and old, single and married, beautiful and plain—to engage in sex for money. To call these women prostitutes—as PEPFAR insists—doesn’t quite fit. These women engage in sex to procure life’s basic necessities when nothing else around them can provide it. And their sex work is sporadic. Some women work only to secure enough money to pay the rent that month or buy enough food for their children; they may not work for some time after that.

One group—not funded by PEPFAR—is out in Kafue’s bars and streets each night, encouraging these women to use condoms. They stock jars with condoms, but the jars are emptied faster than they can be filled. Zambia’s most successful condom—the Success® brand from the Planned Parenthood Association of Zambia (PPAZ)—has disappeared. It was the victim of another U.S. policy called the “Global Gag Rule,” also known as the Mexico City Policy, reinstated by President George Bush on his first day in office. The Global Gag Rule prohibits U.S. funding from going to organizations who refer or perform abortions. PPAZ refused to comply and, as a result, the development assistance it once received from the U.S. government vanished overnight, as did the Success condom.

Now, condoms are in scarce supply. More frightening is that the difference between using a condom or not for Kafue’s women is about the equivalent of $25. But $25 means food for the children for several days and one more night home with them or a spouse—living their lives, in short. A heartbreaking reality passes for the nightly scene in Kafue, and only one non-governmental organization (NGO) is there to help educate Kafue’s women about the necessity of condom use.

Working with commercial sex workers in Zambia has become a risky activity for NGOs who want to continue their work. PEPFAR’s anti-prostitution pledge has served to scare nearly everyone away from helping to educate sex workers because of the fear of losing funding. This silly policy has left Kafue’s women and girls underserved and unprotected. The explicit direction from the U.S. government that abstinence until marriage is the priority in HIV/AIDS prevention has had a chilling effect on condom education and distribution. One PEPFAR grantee described it as “A, B, and Silent C”—referring to the tired triad of “ABC” for “Abstinence, Be faithful, and Condoms” that has come to epitomize U.S. prevention activities.

International Human Rights Considerations

If PEPFAR leaves significant populations unprotected, it also leaves them wholly violated when it comes to their human rights. As mentioned previously, PEPFAR seems to have been deliberately designed to stand outside of human rights frameworks that are fundamental to preventing the spread of HIV/AIDS and promoting health more generally in the developing world. Whereas nearly every focus country takes these obligations seriously and has pledged to uphold them, the United States’s more parochial understanding of rights sees them as an obstacle; PEPFAR has served only to reverse the significant human rights progress made in many of the focus countries.

For example, many of the countries are party to the International Convention on Civil and Political Rights. This convention guarantees the right to have access to information, including comprehensive health information and, more specifically, information related to sexuality and reproduction. PEPFAR deliberately hinders this access, thereby violating the rights of citizens in these countries.

Every African focus country has also ratified The African Charter on Human and People’s Rights, which recognizes the right to the highest attainable standard of health. PEPFAR interferes with this right by censoring and denying information about key health technologies such as condoms.

Going Forward

The desire for Congress to reauthorize PEPFAR this year is significant. The bill now being entertained removes the one-third earmark for abstinence-until-marriage programs but replaces it with an equally chilling admonition that focus countries not fall below spending 50 percent on abstinence and faithfulness programs. The anti-prostitution pledge remains, and it is quite possible that the Global Gag Rule language will also find its way into law. The democrats in the House have agreed to all three of these provisions without much hand-wringing—rather hand in hand with the same right-wing elements that crafted the initial law.

If there were any political courage and leadership left on Capital Hill, someone would call an immediate end to reauthorizing PEPFAR and its ideological policies that not only fail the health and rights tests, but the smell test as well. Regardless, America has made a commitment here, and any new administration, or even Congress, failing to allocate the money is unthinkable.

But that is the immediate issue. The longer-term issue is how we fix the mess that has been created by destroying faith in a comprehensive approach to HIV/AIDS prevention. It will most certainly take a new American Emergency Plan for AIDS Relief—one that reflects basic American values and respects human rights standards. The current president’s plan is not that plan. Congress should consider and allocate funding each year moving forward, work long-term toward better policy changes, and restore our standing in countries where our HIV/AIDS prevention policies have betrayed our promise and the very people whose lives we seek to protect and prolong.

William A. Smith

William A. Smith is vice president for Public Policy for SIECUS. He advocates on issues related to reproductive and sexual health including sexuality education, teen sexual health, HIV/AIDS, and sexual orientation.