PEPFAR Wins Money, Compromises Principle

Americans need look no farther than the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR) to understand why dramatic and fundamental change is needed in Washington. The good intentions of American taxpayers wanting to extend a helping hand to Africans ravaged by the global AIDS pandemic got caught between far-right Republican ideologues and Democrats interested in claiming victory in compromise over producing principled legislation based on sound science.

PEPFAR's mission, to turn back the spread of HIV/AIDS in Africa, a mostly sexually transmitted disease, was compromised because American legislators cannot discuss sexual and reproductive health openly and honestly. Ironically, the major changes to the bill that secured the compromise were those dealing with sexual and reproductive health, thus compromising the integrity of the bill. The compromise reached with the White House was presented by House Foreign Affairs committee staff as a done deal, all efforts seemingly geared toward avoiding any genuine debate on the very issues of sexual and reproductive health experts agree are central to getting the upper hand on HIV/AIDS.

For 25 years social conservatives ignored HIV, using it marginalize people and allowing the disease to run rampant. Now that they've discovered the issue, their ideology prevents them from allowing public health experts to use proven scientific methods to educate, prevent and treat. The Democrats who compromised on evidenced-based principles are politically complicit.

The PEPFAR reauthorization, in some ways, was over before negotiations even began. Too many people signaled a willingness to compromise on issues that have nothing to do with PEPFAR before the gavel called the committee to order. All the far-right had to do was scream abortion and Democrats, along with a few activists who understand the science and public health implications, ran for cover.

Ignoring the Institute of Medicine, General Accounting Office, Center for Public Integrity and other objective organizations working to improve PEPFAR, the compromise that has been spun by some as a success by focusing on increased dollars, fails to apply lessons from the first five years of PEPFAR ensuring those dollars are spent wisely.

The result of compromise based in political fear is more bureaucracy, and a program now so politicized that under GOP administrations one can imagine more insistence on failed abstinence programs, and during Democratic administrations, more emphasis on sound science and public health. Like the Global Gag Rule, which committee Democrats have agreed to extend to PEPFAR, these monies will be subject more to politics than public health.

This flies in the face of every bit of advice given on how to improve PEPFAR in keeping with best practices of other international aid efforts.

There is some good news:

$50 Billion. The White House has agreed to the Congress' demands for a $50 billion, five-year program, up from the $30 billion President Bush requested. More money is good; more money spent more wisely, based on reality, evidence and public health, would have been better.

Women, Girls and Youth. The new bill includes efforts to address some of the unique circumstances that women, girls and youth face, including efforts to confront violence against women, promoting property and inheritance rights, expanding economic opportunity to promote financial independence, and efforts to work with men and boys to reinforce positive attitudes and the human rights of women.

Other positive outcomes include increased training of health care professionals and support for nutrition programs.

Now for the bad news.

Abstinence-only. The 33 percent abstinence-only earmark is being eliminated; that should be good news. But in its place is a requirement that 50 percent of funds for preventing sexual transmission be spent on "behavior change," defined as abstinence, delay of sexual debut, monogamy and fidelity. The bill puts in place a system that requires local public health officials to report if they are not going to comply with the provision. The abstinence earmark is gone, but the tone set by the new requirement is easily misinterpreted by the time these restrictions get to the field level, especially on the heels of the abstinence-only earmark under which these providers have been working.

Instead of learning the lessons from PEPFAR suggesting that program and message consistency and cohesion is important in coordinating international aid with local programs, the White House and the House Foreign Affairs Committee have agreed to a process where public health officials must worry more about remaining eligible for grants than preventing HIV.

One characterization of the language in the bill obtained by RH Reality Check says that these exemptions will be "based on objective epidemiological evidence."

News Flash! The objective epidemiological evidence is in and it suggests, conclusively, we should abandon abstinence-only programs and stop forcing program requirements based on narrow ideologies as they impede PEPFAR's ability to achieve its goals, and work cohesively with other international aid programs that base their decisions on sound science and public health strategies.

One characterization of this provision states,

The PEPFAR administrator is to provide balanced funding for prevention activities for sexual behavior and prevention of HIV/AIDS, funded in a meaningful and equitable way in the strategy for each host country based on objective epidemiological evidence. If this strategy provides less than 50 percent of such sexual transmission funds for behavior change programs, the Coordinator shall report to the appropriate Congressional committees the justification for this decision.

The details of program decisions should be made by qualified public health professionals on the ground in Africa, who understand the culture and the needs. Abstinence-only policies either work or they don't, and all the evidence from five years of PEPFAR indicates they don't. Congressional micro-management only serves to perpetuate the ludicrous notion that failed abstinence-only policies have any place at all in these programs. This goes beyond traditional oversight, and serves to empower a far-right vocal minority that has demonstrated it is more interested in ideological politics than saving lives. That Democrats continue to cave to the minority in this way seems to suggest they prefer to see success in getting more money, than using any amount wisely.

Preventing Mother to Child Transmission. The U.S. Conference of Catholic Bishops lobbied and successfully removed provisions that allowed voluntary contraception services to be offered to participants in programs working to prevent mother to child transmission of HIV. The World Health Organization clearly states that voluntary contraception is one of the most important aspects of preventing mother to child transmission.

About the Bishops role in the negotiations, Jon O'Brien, President of Catholics for Free Choice said,

The approach adopted by the US bishops, in partnership with Catholic Relief Services (CRS), stems from a self-serving perspective that few Catholics share, let alone those of other and no religious preference. Catholics in the United States and elsewhere support aid for international family planning and reject abstinence-only education. Studies show that properly directed funding for international family planning programs saves women's lives and the lives of their children when those women have HIV/AIDS. Many studies, including some sponsored by the US Congress, show that abstinence-only programs do not work. The bishops ignored this evidence to ensure that their own narrow, out-of-the-mainstream beliefs held sway on Capitol Hill.

Global Gag Rule. Only family planning organizations that sign the Global Gag Rule are now eligible for PEPFAR money. This has a direct impact on organizations like the Ethiopia Family Planning Association, which has been getting PEPFAR dollars and effectively integrating HIV education, testing and counseling along side the family planning services paid for with non-PEPFAR monies. Because EFPA has not signed the Global Gag Rule they will lose PEPFAR dollars.

Family planning organizations were not seeking to use PEPFAR money to perform or counsel abortions. They want to help provide contraception and reproductive health services along side HIV services, instead of forcing women to walk miles between various clinics. PEPFAR's first five years demonstrated the importance of integrating these services, but the far-right succeeded in politicizing PEPFAR by raising abortion, and the Democrats and some activists chose compromise over principle.

Prostitution Pledge. The Democrats voluntarily gave up the prostitution pledge without the Republicans asking them to do so. The pledge effectively restricts organizations receiving money from PEPFAR from working with prostitutes, who are one of the most vulnerable populations in terms of contracting HIV, and a primary target group to slow the spread of the disease.

Instead of acknowledging the reality of sex workers and taking a smart public health tact to direct money to fight the problem at its source, again based on mounds of evidence, the Democrats chose to walk away from an issue they did not want hanging over their heads in November. Evidently they are more worried about how they will spend millions of dollars on their re-election than the few dollars it would take to reach out to sex workers with contraception, education and prevention programs geared to slowing the spread of HIV.

Katee Reik of Health Gap wrote on the blog for University Coalition for Global Health,

Experts have argued that this requirement means that local groups have to choose between providing treatment, services and support to individuals who engage in sex work in order to survive and ignoring those at higher risk for HIV infection. Representative Ackerman from New York responded that saving the lives of women who engage in survival sex is in the best interest of public health.

The press releases attempting to cover the tracks of those complicit in compromising sound science are flying through email, spinning the success of new money while bemoaning the failures to reach agreement on family planning and other issues that required more backbone than spin.

The reality is this was a moment missed. A moment to work together to put politics aside and follow the sound advice of people in the field based on science and public health. It was a moment to prove that a Democratic majority could do something differently, better, for the people of Africa.

Will more lives be saved with this bill? Yes. Could we have saved even more? Without doubt. Why didn't we? Some people put politics over public health, and compromise and complicity became more important than principle. Raise your glass in a toast to politics as usual.

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  • invalid-0

    Abstinence is the only scientifically proven way to completely avoid sexually transmitted diseases. You are wrong to think that African children cannot be taught self-control when it comes to sex. Instead of spending so much effort in opposition to abstinence education, you should use all your “scientific” brainpower to figure out how to teach it better in order to make it work. Providing free condoms is not sustainable and neither is it wise. If you give a child a condom he’s going to want to use it, simple as that. You can test it on yourself. Carry a condom around with you and see if it doesn’t burn a hole in your pocket. Now imagine you’re a curious, horny teenager with nothing better to do. So you get all the kids in Africa hooked on sex. Then what? What happens that one time Uncle Sam isn’t there to give him/her a free condom? Do you think he’s going to know how to stop himself? Of course not, because you deprived him of abstinence education. It only takes one lapse to pass an STD. You can give an African kid 1 million free condoms, and he can use them 1 million times. But that 1,000,001th time there is no condom, or there is an urge to feel the euphoria of flesh against flesh, and bam, you’ve got HIV, and your 1 million free condoms were useless. But if you teach a kid pre-marital abstinence and marital faithfulness, you’ve just saved his life and his partner’s life, for their entire lives, and they can pass the behavior on to their children. Think “sustainability”; think “self-reinforcing”; think “long-term solution”; think “let’s change the world and not just put condoms on its penises”. I learned abstinence from my parents, and guess what, it worked! Now the US government doesn’t have to spend a single penny to prevent me from getting an STD, much less treat me for one.

    As for all your scientific studies, “science” is a sausage shop as much as anything is and that you have such faith in science exposes the fact that you must not know much about it.

  • invalid-0

    Why don’t you stop promoting promiscuity and instead devote your energies to figuring out better ways to teach children abstinence? Get a bunch of behavioral psychologists together and figure it out. Maybe you’ll discover a magic educational formula, and then you will really be the saviors of the world. Figure out a way to convince children that it’s better to have only one sexual partner with whom you carry on a lifelong, monogamous relationship. Then all STDs will go away forever and we won’t even have to have this discussion anymore. Don’t let your hatred for George W. Bush get in the way of scientific progress. Just like with the whole embryonic stem cell research debacle, you may discover that the principled way actually produces the best results in the long run because it forces you to think outside your little liberal-tinted “scientific” box and do things like figure out how to create stem cells out of adult skin cells instead of aborting babies. So figure out a way to teach kids not to have sex instead of teaching them to be promiscuous.

  • invalid-0

    Might we apply the logic of these (anonymous) commentators to mother-to-child transmission, also? The reality is that some 15 million women are infected with HIV. Most of them are of childbearing age, and many are married. To use the language of “Anonymous”, the only scientifically proven way to completely avoid passing on HIV from mother to infant is for a woman to avoid pregnancy. And the only scientifically proven way to completely avoid pregnancy is abstinence. So no sex within marriage, please.

    Of course people who live in the “liberal-tinted science box” of your second (anonymous) commentator believe that there is another effective way to prevent pregnancy: contraception. Contraception would be a pretty good way to help those 15 million infected women risk bearing HIV-infected children. But wait, under the PEPFAR bill, we’re not allowed to spend money to help women avoid pregnancy. Perhaps you could explain, anonymously if you wish, the anomaly of this position.

  • brady-swenson

    Dear Anonymous,

    Thank you for your comments, however science is actually in disagreement with your stance. Last year a report filed by a group of scientists showed that abstinence-only education does not lead to people actually abstaining from sexual activity. Consequently when people do engage in sexual activity despite their 'education' they are not prepared to engage in sex safely and thus spread disease and conceive when ill-prepared to care for a baby.

    No one here is saying that we should not talk about abstinence, and even teach that abstinence is the only 100% effective way to avoid diseases and unwanted pregnancies. However, we should also recognize the reality of human sexual behavior as proven by scientific study and craft sex education policies in light of this knowledge. This means providing a comprehensive sex education that includes teaching the benefits of abstinence alongside those of proper contraception use (99.5% effective or better) and other safe sex practices.

    The goal here is to improve the health of our world, to reduce suffering and give people more control over their reproduction so that people conceive when they are ready to care for a child. From where I stand this approach is much more sustainable, self-reinforcing and long-term simply because it is a more encompassing approach based in reality and science.

  • invalid-0

    Scott — a wonderful and cogent contribution to the muddied waters as too many groups fall into rationalizing how bad this bill is and in the process, fall into the deliberate trap that more money would buy acquiescence. It seems to be working. The extension of the principles of the Global Gag rule into this bill is disastrous and should be reason enough to call for an “end game” to reauthorization this year. It will serve only to undermine existing infrastructures in the countries for delivering health care services and prevention education. Additionally, the extension of the focus country framework was never discussed and remains wholly unassessed in terms of just how badly it has affected prevention on the ground in focus countries. Prevention activities in non-focus countries, meanwhile, subsist on a pocket full of quarters as money is diverted to focus countries. And to make matters worse, the bill extends the focus country framework into the Caribbean and Belize where MSM transmission is the dominant means of transmission and where PEPFAR has shown itself incapable of honestly embracing this risk group.

    What no one has answered sufficiently is why the rush to get this done now? Do we really think the future Administration of any party in 2009 will gut this effort? That is ridiculous. The money will still flow and if it doesn’t, cries will come from every corner — including the right wing organizations and missionary groups experiencing the largest windfall in history under this program. It is utterly clear that an extension of current policy for a short period is preferable to swallowing this compromise here and now.

  • invalid-0

    Great post, Scott.

    Sure, abstinence is the only 100% effective way of preventing HIV, but it is only 100% effective for the duration of its use 100% of the time and only when it’s used 100% correctly.

    If you live in a family and community where talking about sex is taboo, then you may not know what sex is. Is it sex if you/your partner pulls out before ejaculation? Is anal sex sex?

    The first anonymous post included this line: “Instead of spending so much effort in opposition to abstinence education, you should use all your ‘scientific’ brainpower to figure out how to teach it better in order to make it work.”
    Scientists, researchers, and public health experts HAVE figured out how to teach it better. And that better way is to include teaching about abstinence in a comprehensive prevention program that actually talks about sex and sexuality and teaches people how to use condoms and negotiate condom use when they do start having sex (whether that’s soon or in 10 years).

    As I mentioned at the beginning of this comment, abstinence only protects someone from HIV for as long as they they are abstinent. The vast majority of people will not be abstinent for their entire life, so what we’re really talking about is delay of sexual debut. If we’re talking about delaying sexual debut, then we should be preparing for having safer sex when they do start having sex (whether in a long term partnership/marriage or at some other time).

    And speaking about sex in partnership, “be faithful” only prevents HIV if both parties enter the relationship HIV negative and remain HIV negative throughout it. Your faithfulness is no guarantee of your partner’s. There is no reason why so-called “be faithful” messages shouldn’t be combined with information about how to use condoms and negotiate condom use and provision of those condoms.

  • invalid-0

    Let’s not rush to judgment on this.

    It is not clear at this point that Scott is correct to say that this bill means that only family planning organizations that sign the Global Gag Rule are now eligible for PEPFAR money. Let’s examine the bill closely before we rush to judgment on this, and then figure out next steps.

    On abstinence funding, it is not clear that Scott is correct to suggest that in this bill “behavior change,” can only be messages about abstinence, delay of sexual debut, monogamy and fidelity. It seems to me an exaggeration for Scott to suggest that Congress “ignored” the conclusions of the IOM and the GAO, and I think that actually all of our collective advocacy bringing the problems with the policy to the fore had significant impact in the end.

    Let’s also keep in mind that secular NGOs are getting a large amount of funding via PEPFAR for HIV/AIDS programs. It looks to me like in Rwanda and Tanzania, where Bush visited recently, it’s the secular NGOs that are getting the bulk of the money.

    We did not get what we wanted in terms of funding for AIDS per se, and that’s a compromise which I find a little hard to accept, especially given the G8 promise of universal access to ALL AIDS services by 2010.

    At most, $37 billion is for AIDS, and you could argue it’s actually $31 billion, once you subtract what it would cost to achieve the health systems strengthening target and also the spending for OVC, which is not supposed to only be for children orphaned by AIDS.

    I hope there is enough money for AIDS authorized by the bill, and I hope all of the money authorized, for all the health programs it covers, actually gets appropriated. That is far from guaranteed. The bill authorizes $10 billion for the Global Fund, which is right now financing evidence-based prevention programs, but I am not sure appropriators are quite ready to provide this level of financing.

    The other concern is whether the budget committees will provide enough in the international affairs portion of the FY 2009 budget to accomodate the level of spending we would need to see to move toward the total amount this bill authorizes. The budget proposal mark up process will start in the House next week.

  • invalid-0

    Scott Swenson’s article reads as though it was written by a field doctor.

    These people usually forget that PEPFAR (and all other acts for that matter) are created by a political process by politicians. That it made it through in its current, pretty good form is an amazing accomplishment given the complexity of the issues. Remember, many Americans don’t want even one dollar being spent overseas for any reason, certainly not 35 billion dollars to provide healthcare to Africans.

    We should count our blessings.

  • scott-swenson


    Thanks, as always, for writing. Five years of experience with PEPFAR demonstrates that more must be done to integrate RH/HIV services. Major foundations working in this space have been advocating this integration as you well know. The public health expertise on the ground says to protect women and girls, integrate these services. But the minute some wingnut yells abortion, some get nervous and start accepting that political compromise requires a compromise of principles. It does not. Political compromise, most often a tool of the majority not the minority, to many people means that the majority’s principles will govern the bill, as it did in PEPFAR One. People in the sexual and reproductive health community, and I’ve heard from many who agree, believe that these issues, most central to curbing the spread of HIV/AIDS, were compromised in the most unprincipled way. If this bill reflects the majority’s beliefs, then the majority is telling us that they want to spend more money without improving the program based on mounds of objective evidence that suggests politicizing PEPFAR as the GOP ideologues did, is impeding the program’s effectiveness. When the GOP was in the majority, the bill did reflect their principles.

    Finally, counseling a wait and see approach after a compromised bill was presented as a done deal, is a bit frustrating. We’ve waited for five years to improve this bill after seeing the problems of its ideological origins. The time for patience passed, the time for action to improve the bill is passing right now, before our very eyes.

    Be the change you seek,

    Scott Swenson, Editor

  • scott-swenson


    Thanks for your comment. I’ve never been a field director, but having spent the last twenty years closely watching and involved in the class of political professionals in Congress, the White House, and various progressive advocacy communities, I think its long past time we listen to field directors. And public health experts. And scientific studies. And the American people, who seem to be saying in this election season that Congress with a Democratic Majority is no different than Congress with a Republican Majority — both held in low regard.

    It is because I understand how politics works that I’m working to change politics. The many Americans who don’t want to spend one dollar overseas may feel that way because there is a perception, in this case reality, that we celebrate the spending of more money without evaluating and improving programs to use that money wisely. There are many MORE Americans who do want to help Africans, especially when it comes to HIV, and I believe the case is made stronger when we go to the American people and say we’re spending money wisely, based on what we’ve learned.

    Finally, to your point of a political process created by politicians, I guess I thought the election of 2006 put different values in control, and that a system with a new majority would reflect the ideals of that majority. But instead it seems, as Jodi Jacobson said in CQ, that a certain “political naivete” has been at play in these negotiations.

    It is because of the complexity of these issues that those who understand how best to deal with difficult public health issues in complex cultures dealing with sensitive issues, should be heard more in the political process, and the ideologues heard less.

    Be the change you seek,

    Scott Swenson, Editor

  • invalid-0

    All this talk about abstinence education in Africa or other nations is ridiculous, since it doesn’t take into account the cultural implications. Women in many other countries have no choice when it comes to intercourse. Men expect them to comply. Non-compliance carries the most dire consequences. You speak about abstinence as though it is what all moral, decent people should do. Western or Judeo/Christian notions of morality mean nothing to people from other cultures and/or religions. We really must not link government programs to our own belief systems. Come to think of it, many American women have no choice either.