In Zambia, they microwave condoms and then pour milk through them to show they don’t work. In Nigeria, an organization working with youth can’t get money from the United States because it talks about condoms with school kids. In South Africa, publication of a book for Muslims that contains the headline “Sex is OK” was held up for more than six months. In Tanzania, condom marketing campaigns disappear, and rumors begin that condoms aren’t effective.
At the International AIDS Conference here, activists and non-governmental groups swapped stories like these that all had a common culprit—President George W. Bush’s plan to spend $15 billion to fight AIDS—known by the acronym PEPFAR—and its approach to preventing HIV infections worldwide.
PEPFAR officials beg to differ.
“PEPFAR is increasing the HIV epidemic in some places,” said Anne-Christine D’Adesky, who runs WE-ACTx, a group in Rwanda that provides HIV care and treatment to more than 4,000 people. “It’s an incredibly dangerous policy. The [groups] that we have worked with have found it a very difficult process to fit their programs into something that PEPFAR has set up and they feel it’s not realistic given what’s going on on the ground.”
“There is not a single country in which the United States government is funding HIV work where abstinence-only is being pursued,” countered Warren W. Buckingham III, the head of PEPFAR in Kenya. “No one else has this comprehensive an approach,” said U.S. Global AIDS Coordinator Mark Dybul.
The differences between the activists and U.S. officials are so striking it appears they are working in two different realities. In one, PEPFAR is a White House-driven program insisting on an unsuccessful, ideological approach lacking scientific support. In the other, it is a locally led, comprehensive effort—the broadest in the world with spending of $322 million in fiscal year 2006—that is about to bear fruit.
From top to bottom in Toronto, PEPFAR has been a target for suspicion. Though many credit the half-million people it has put on anti-retroviral drugs, at least some hostility greets most appearances by U.S. officials.
“In the fight against AIDS, condoms save lives,” Melinda Gates said in a subtle dig during her keynote address August 13. “If you oppose the distribution of condoms, something is more important to you than saving lives.”
Bill Clinton said that though PEPFAR has done more good than harm, “An abstinence-only program is going to fail.”
Activists hope to use the conference to build momentum to overturn what they call PEPFAR’s emphasis on abstinence-until-marriage programs and de-emphasis of condom distribution. The PEPFAR law mandates that one-third of prevention money must be spent on abstinence programs. U.S. Representative Barbara Lee, a California Democrat, introduced a bill in June that would strike the one-third earmark. The bill itself may not go far in the Republican-controlled House, but Lee wants to lay the groundwork for the change when PEPFAR must be completely reauthorized in 2007. Lee’s measure has 73 co-sponsors, two of them Republicans, and the support of more than 70 groups such as the National Organization for Women, Gay Men’s Health Crisis, and the Elizabeth Glaser Pediatric AIDS Foundation.
U.N. Special Envoy for HIV/AIDS in Africa Stephen Lewis called the earmark “incipient neocolonialism” for dictating policy to developing countries.
“Policy research shows that U.S. policy on HIV prevention under the Bush administration is tied to an overall agenda to control non-orthodox expressions of sexuality, and by that I mean, everything but the sex that takes place within heterosexual marriage,” Francoise Girard, a senior program officer at the International Women’s Health Coalition, told a roomful of delegates. “It’s to enforce a set of views about sex and morality without regard to context.”
Dybul said the law’s mandate brought U.S. work into balance from a position that favored condom distribution. The rule “served a good purpose to get us into a balanced program. There are many other donors that fund condoms, no one else is funding AB”—the abstinence and faithfulness initiatives, he said.
According to the Center for Health and Gender Equity, in 2006, 60 percent of U.S. sexual prevention money goes to programs supporting abstinence and fidelity, far exceeding the legal requirement, according to CHANGE Executive Director Jodi Jacobson. It’s part of what she sees as a programmatic shift that goes deeper than dollars.
In Tanzania, for example, Jacobson said 95 percent of new money for prevention is going to these programs. Dybul said each country can determine its prevention spending at the local level. “We’re just supporting what they develop,” he said.
That’s a contention Jacobson vigorously disputes. “Tanzania has its own strategy, a comprehensive strategy,” she said. “But [PEPFAR] is 95 percent abstinence and fidelity.” Only two of PEPFAR’s 15 focus countries include condoms in prevention programs in 2006, she said.
An April Government Accountability Report found that the spending requirement can impair development of prevention programs that respond to local needs. “To meet the requirement, [some] country teams have, in some cases, reduced or cut funding for certain prevention programs, such as programs to deliver comprehensive messages to populations at risk for contracting HIV.” The Global AIDS Coordinator directed one country’s team to shift money from programs to reduce mother-to-child transmission to abstinence and fidelity programs to meet the requirement, though the country then fell far short of its goals on providing service to keep newborns free of infection.
PEPFAR guidelines require that condom programs include information on abstinence and fidelity, though U.S. officials in Toronto suggested the situation on the ground may differ from the guidelines. “I’m not aware of any requirement that condom programs must be linked to A and B programs,” said Buckingham. “There are politicians who are saying things and people who are implementing programs to do what needs to be done.”
The rhetorical debate has progressed to the point where both sides say they want the same thing. PEPFAR officials argue for the right to choose abstinence in the same terms that activists argue for the right to choose condoms: “We need to get past this polarization and get to the real issues,” Dybul said.
And Nono Simelela of the International Planned Parenthood Federation told a group of activists that finding effective prevention methods that work would be a better idea: “We can blame Bush. After he leaves we’ll find someone else. Let’s stop doing that and find something else.”