PEPFAR and the Power of Partnerships: Doing Good or Causing Harm?


Elisha Dunn-Georgiou is the International Policy Associate at the Sexuality Information and Education Council of the United States (SIECUS).

Last week, the Office of the Global AIDS Coordinator (OGAC) released its 3rd annual report to Congress, The Power of Partnerships: The President's Emergency Plan for AIDS Relief (PEPFAR). According to the report, "Partnership is rooted in hope for and faith in people. Partnerships mean honest relationships between equals based on mutual respect, understanding and trust, with obligations and responsibilities for each partner." While this is a lovely sentiment—and hope and faith do have a place in fighting disease—OGAC should instead be talking about the power of partnerships as being rooted in collaborations that deliver the best, most effective, evidence-based public health program. This includes partnerships with institutions that have technical expertise in evidence-based HIV/AIDS prevention, treatment, and care, or expertise in poverty reduction, capacity building, reducing gender inequalities, reducing stigma and discrimination, and strengthening health systems. Truthfully, it could include forming partnerships with organizations that have expertise in any of the confounding issues that perpetuate high morbidity and mortality rates for HIV/AIDS in the 15 PEPFAR focus countries.

OGAC, however, can't start the report that way, because it is not selecting all of its partners based on these criteria. Instead, some of these partnerships are rooted in a desire to implement an anti-sexual and reproductive health and rights (SRHR) perspective that has become one of the hallmark ideologies of the Bush Administration. This is abundantly clear in the section on the New Partners Initiative.

Announced by President Bush in 2005, the initiative seeks to "increase the Emergency Plan's ability to reach people with needed services," and "build capacity in host nations by developing indigenous capacity to address HIV/AIDS to promote the sustainability of host nation's efforts." Theoretically, of course, this is a wonderful idea. But, a closer look at the list of new partners shows that this is not necessarily happening in practice. Fully 15 of the 22 new partners are faith-based organizations. Two of these new partners, the Natural Family Planning Center of Washington, D.C. and Geneva Global based in Pennsylvania, stand out as being particularly bad choices that meet neither goal of the initiative.

The Natural Family Planning Center received a grant to use its hallmark abstinence-until-marriage program for HIV prevention in Nigeria and Ethiopia. The program, TeenSTAR, developed by Sister Hanna Klaus, M.D., claims to teach girls about their fertility to promote chastity. In actuality, the program, which contains separate lessons for boys and girls, reinforces gender stereotypes and preaches an anti-contraception message. In Klaus's review of the program, titled "Undergirding Abstinence within a Sexuality Education Program," she says, "contraception dichotomizes sex and procreation, thus facilitating fragmented, often solely or largely genital relationships, which do not lead to growth." Moreover, she states that understanding fertility enables girls to develop a "healthy feminine identity" and to understand the "psychosexual differences" between men and women—a key lesson of the curriculum. Klaus, a member of Physicians for Life, is a proponent of allowing medical personnel to refuse to present medical information they find morally objectionable—including information about contraception, condoms, and other sexual and reproductive health services.

Geneva Global, grounds its HIV/AIDS prevention programs in collaborations with faith-based organizations because of the "moral authority" such groups bring to combating the epidemic. Mark Forshaw, manager of Global's HIV/AIDS programming, has a long history of connecting Christian missionary work with HIV/AIDS prevention and of promoting abstinence-until-marriage and be-faithful programs to the detriment of condom promotion. Global praises Forshaw's contribution to an on-line book, The Truth About AIDS by Patrick Dixon. Dixon's chapter, "Condoms are Unsafe," explains, "The condom is the least reliable contraceptive in wide use" and "Over the next few years there will be a growing number of angry men and women who have become infected, despite their using a condom, having thought they were safe."

Ironically, the Power in Partnerships report is replete with rhetoric about the evidenced-based, country-driven focus of the program's efforts, including a whole chapter on PEPFAR's progress in responding to the critical issue of gender and HIV/AIDS. Unfortunately, OGAC's rhetoric is totally disconnected from its recruitment of new partners. How one is supposed to challenge gender norms with programs, like TeenSTAR, that teach girls that their "feminine identity" is rooted in their fertility is inconceivable. Also inconceivable is how PEPFAR can claim a balanced ABC approach while funding partners whose staff has contributed to books containing such medically inaccurate information about condoms.

Partnerships can indeed be powerful in the fight against HIV/AIDS, but only if they use evidence-based, comprehensive prevention strategies that truly address the real needs of people battling this epidemic. Otherwise, the power of these partnerships lies not in the good that they do, but only in the harm.

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  • togden

    Dear Ms. Dunn-Georgiou

     

    I commend your goal of analyzing the effectiveness of PEPFAR. We at Geneva Global believe that a commitment to effectiveness, rather than simply spending more money, is sorely lacking in international relief and development work. Given that we share the same goal of making aid more effective, I hope you’ll give me the opportunity to explain why we believe your analysis of Geneva Global as a “poor choice” for the PEPFAR New Partners Initiative is incorrect.

     

    As you note, the twin goals of the New Partners Initiative are to reach more people with needed services and to develop “indigenous capacity to address HIV/AIDS.” Our model – which involves brokering funding to community organizations with a track record of success – is an excellent way to meet both of these goals. Please note that we do not implement programs. Instead, we find grass-roots organizations that are already working effectively in their communities (whether in HIV/AIDS, community health, microfinance, conflict recovery or any of the other sectors in which we are active). We then broker grants to expand those organizations’ existing programs, and monitor and evaluate their efforts. By supporting these local programs, many of which serve people in need well beyond the reach of most international organizations or government programs, we enable international aid to reach more people and build indigenous capacity.

     

    In terms of our approach, we do work with faith-based organizations as you note in your piece. We do so for many reasons:

    • Our commitment to recommending effective programs regardless of faith perspective. After seven years and $55 million of grants brokered we have seen over and over again that, judged objectively, faith-based organizations are often the most effective at delivering humanitarian services at the lowest cost.

    • Simple logistics. As the WHO has recently noted (http://www.who.int/hiv/mediacentre/news66/en/), somewhere between 30% and 70% of health care services in sub-Saharan Africa are delivered by faith-based organizations. As such, no one serious about being effective in health in Africa can avoid working with faith-based groups. To quote Kevin De Cock, director of the WHO’s Department of HIV/AIDS, “Since they provide a substantial proportion of care in developing countries, often reaching vulnerable populations living under adverse conditions, FBOs must be recognized as essential contributors towards universal access efforts."

    • Culture. We cannot and should not pretend that faith does not play an integral role in the daily lives of and, most importantly from an HIV perspective, the sexual choices of people in Africa (more than 90% of whom claim some faith, Christian, Muslim, animist or other). Again, the real role that faith plays in the social and cultural lives of Africans makes it vital to work with local faith-based organizations, as the authority and influence of faith-leaders allows them to speak to people in their community about their sexual choices and encourage them to make safer ones. (Incidentally, I presume that you meant the “moral authority” link to point to our site, rather than Patrick Dixon’s book site).

    • Fighting stigma. This may seem counterintuitive, as it is sadly true that leaders of Christian and Muslim organizations have contributed to the stigma associated with AIDS that continues to impede progress. But it is for that very reason that we believe it is vital to encourage and support those faith-based organizations that are doing the majority of care for people living with HIV in sub-Saharan Africa. The more faith-based organizations are caring for people infected and affected by HIV, the less faith-based stigma can continue to thrive.

     

    You also say that our Health Sector Manager, Mark Forshaw, has “a long history of connecting Christian missionary work with HIV/AIDS prevention.” If you mean that Mr. Forshaw has spent 15 years working to deploy every available resource, including Christian missionaries, to fight the global AIDS epidemic, then you are absolutely correct. In fact, his dedication to convincing people the world over to devote their time, talent and energy to effective action against AIDS is exactly why we hired him. If by your comments you mean that Mr. Forshaw has a history of encouraging or supporting coercive or discriminatory programs, however, than your statement is absolutely false. As a policy, Geneva Global does not recommend any project that includes evangelism or proselytizing nor will we recommend any project run by an organization that does not support full religious freedom for all people. We have never and will never recommend a project for funding that discriminates against beneficiaries based on faith.

     

    You also criticize Mr. Forshaw for promoting abstinence and “be faithful programs.” At Geneva Global, we are very proud of our commitment to the real ABCs. This is not abstinence-only masquerading as ABC, nor is it solely condom-promotion with a veneer to make it acceptable to certain political views. We strongly believe that every person should hear and understand the full range of risks of contracting HIV and the behavioral choices available to them to mitigate those risks. It is increasingly evident that partner reduction, the B of ABC, is the most critical factor in slowing infection rates in southern Africa. This is acknowledged for instance by the Southern African Development Community, an international coordinating group for the governments of 14 African countries (see: http://www.sadc.int/news/news_details.php?news_id=749). Where reductions of prevalence rates have been found, they are tied at least as strongly to partner reduction as to increases in condom use or age of first sex (for instance see an article on Zimbabwe in Science, http://www.sciencemag.org/cgi/content/abstract/311/5761/664, an article from Sexually Transmitted Infections on Kenya, http://sti.bmj.com/cgi/content/abstract/82/suppl_1/i21, an article from aidsmap on several papers presented at the 16th International AIDS Conference, http://www.aidsmap.com/en/news/0EF80C17-D3E9-4AC4-84F4-FEBA7DB6226F.asp, and the transcript of one of those sessions, available at http://www.kaisernetwork.org/health_cast/uploaded_files/081506_ias_sat_models_transcript.pdf ). Another excellent example of why we believe in ABC so strongly can be seen in Craig Timberg’s recent article in The Washington Post on the epidemic in Botswana and the role that multiple concurrent partners and the failure of condom promotion alone have played there (http://www.washingtonpost.com/wp-dyn/content/article/2007/03/01/AR2007030101607.html).

     

    Finally, you critique Mr. Forshaw’s contribution to Patrick Dixon’s book, The Truth about AIDS, specifically by citing the author’s statement that condoms are the least-effective form of contraception in wide use. Keeping in mind the qualifier “wide use,” the lesser effectiveness of condoms is a scientific fact. According to the WHO and Johns Hopkins Bloomberg School of Public Health, condoms as commonly used are between 86% and 90% effective (“commonly used” distinguishes between how condoms are supposed to be used – i.e. correctly and every time – and how they are actually used – i.e. incorrectly and inconsistently). In contrast, the organizations calculate that the next closest method, Birth Control Pills as commonly used, as between 92% and 94% effective. All others methods in common use (e.g. IUDs) are between 97% and 99.9% effective (http://www.who.int/reproductive-health/publications/Abstracts/contraceptive_technology.html).

     

    As I’ve said, we are quite proud to have been selected to be a New Partner. We are even more proud to work with incredible local community organizations in Ethiopia and Cote D’Ivoire and throughout the developing world (many of which are faith-based) on the front lines of the fight against HIV/AIDS. Ultimately, though we hope to be judged on the results of our work, as measured specifically against the goals of the program: more cases prevented and more people cared for, within the structure of building indigenous capacity to carry on that fight. Since we do monitor, evaluate and report on the effectiveness of every grant we recommend (to date, 79% of projects we recommend meet or exceed their goals), PEPFAR and others will be able to judge exactly that.

     

    Yours sincerely,

    Timothy N. Ogden

    Chief Knowledge Officer

    Geneva Global, Inc.