PEPFAR Bill Fails to Promote Proven Strategies

Last week, the House Committee on Foreign Affairs approved HR 5501, the global AIDS reauthorization act. This bill will soon reach the House floor for a final vote. House action took place just days after I returned from Uganda, where I spent nearly two weeks talking to people on the front lines of the global struggle against AIDS. My experience in Uganda and feedback from many of my organization's 375 grantees in 36 countries tells me that the House committee deserves the praise it has received for authorizing $50 billion to continue funding global AIDS programs over the next five years. However, these experiences also tell me that the bill still falls far short in eliminating onerous program restrictions under existing law and in reflecting lessons learned in trying to end this pandemic. The Senate must act to correct these weaknesses.

Over the past five years, funding from the President's Emergency Plan for AIDS Relief (PEPFAR) has provided access to anti-retroviral drugs (ARVs) to 1.4 million people in need of treatment and support for millions of families living with or affected by HIV and AIDS. We should be proud of these achievements, but we cannot let success in one area make us complacent. This year 2.1 million people worldwide will die of AIDS, and another 2.5 million men, women and children will become newly infected–nearly twice the number we have put on treatment after 5 years and 19 billion in U.S. dollars spent

Given these realities, it is impossible to overstate the need for effective prevention programs. In my discussions with Ugandan mothers living with HIV, doctors, Ugandan and U.S. government officials, and representatives of community-based groups working on the ground, there were two consistent themes: We need more help and we need to tackle this epidemic in the best ways we know how.

What Kind of Behavior Change Education?

The original PEPFAR legislation required that one-third of all funds for prevention be directed towards abstinence-until-marriage programs and that organizations receiving PEPFAR funding adopt a policy opposing prostitution. Two highly-regarded studies, one by the Institutes of Medicine and another by the Government Accountability Office (GAO), found that the one-third earmark for abstinence programs undermines successful prevention efforts, in part by limiting flexibility on the ground. Both organizations called on Congress to strike the earmark. The House did so in theory, but replaced it with a new requirement that a minimum of 50 percent of funds for prevention of sexual transmission be allocated to "behavior change" as defined by Congress. Observers have called this a breakthrough.

We all agree that increases in abstinence, faithfulness and delay of sexual debut are critical components of comprehensive HIV prevention, as is promotion of safer sex practices–another critical aspect of "behavior change." But feedback from our partners in Uganda and in other countries suggests it is exactly these seemingly innocuous provisions now found in the House bill that cause the most trouble on the ground. For example, everyone I met credited Uganda's President Museveni for his early work on AIDS. The comprehensive approach to behavior change and safer sex in his country has led to dramatic declines in HIV prevalence since the early nineties. But since the advent of PEPFAR's ABC approach (abstain, be faithful, use condoms) in 2003, the emphasis in practice has moved almost exclusively to abstinence-only programs. According to officials who spoke to me on condition of anonymity, discussion of safer sex practices and condom use has largely disappeared from public rhetoric and funding restrictions have created "silos" between programs that should be integrated.

Reports now indicate that the rate of HIV infections in Uganda is on the upswing. In this context, the new language is not such a win after all. While organizations have the option of not complying, those that deviate from this formula must justify their decision to Congressional committees rife with ideological concerns. The vagueness of these requirements will not only have a chilling effect on programs, but will drain resources from the critical work at hand. We should instead be focused on providing funding to those groups most able to show success in achieving higher abstinence rates, delay of sexual debut and safer sex practices through whatever means they determine are best suited to their communities.

Given the negative effects of such requirements and the persistent pressure by ideologues seeking to hamstring comprehensive prevention here and abroad, this new language could cause just enough anxiety to force mission directors and public health officials to do what they think Congress wants rather than what is needed in the field. With seven new infections for every person put on treatment, this is a bad time for Washington to dictate confusing messages to public health professionals in disparate settings throughout the world.

Pledging Opposition to Prostitution Does Little to Help Sex Workers

The House also completely failed to strike the existing requirement that organizations receiving PEPFAR funds must adopt a policy "opposing prostitution." The prostitution pledge has led to de-funding of several of our key program partners, some of which have received international awards for their work. Other partners have refused funding. Indeed, my organization has refused PEPFAR funding under the faith-based initiative due to the requirements of this policy.

While I was in Uganda, I visited the Ladies Mermaid Bureau (LMB), a civic group that provides care, support and advocacy services for sex workers. These women, many of whom have been infected with HIV and face persistent stigma and discrimination, have found that sex work is the only economically viable way to feed their families. Because the young women I met implicitly trust LMB, the organization is in a unique position to provide prevention and testing services to their clients. The pledge, however, prevents LMB from receiving increased funding and support for its work–they cannot build essential trust among marginalized communities if they condemn their very existence at the same time.

Congress seems to think that forcing organizations to sign such a pledge will help contribute to ending prostitution. In reality the opposite may be true. According to one of our grantees, Ly Pisey of Women's Agenda for Change in Cambodia, these policies have led to the further alienation of already-stigmatized groups and have given free rein to police officials and others to rape, extort money from and otherwise discriminate against women in sex work. Instead of reducing dependence on sex work, the policy is driving sex workers underground and away from the NGOs and health workers best poised to help them.

The Global Gag Rule Should Not Apply to PEPFAR

Vague language in the new House bill may allow the next Administration to prohibit family planning programs from remaining or becoming partners in preventing the spread of HIV. Under current law and policy, eligibility for PEPFAR funds is not subject to other restrictions in US law, such as the global gag rule, which prohibits funding to any organization that so much as collects data on rates of unsafe abortion in places like Uganda, where, mind you, abortion is illegal unless a woman's life is endangered and complications of unsafe abortion are a leading cause of maternal death. The freedom to access PEPFAR funds has enabled groups like the Family Planning Association of Ethiopia, which provides critical pre- and post-natal care, maternal and infant care and family planning information and supplies to also offer women HIV education, counseling and testing. These programs, critical to stopping the spread of AIDS, have been a persistent target for a small group of legislators whose objective is to fully de-fund family planning altogether. Perhaps tellingly, while insisting the language is meaningless, the House minority and White House have refused to remove it.

Family Planning Funding Eliminated

Finally, in a particularly baffling decision, language supporting the purchase by PEPFAR of contraceptive supplies for HIV positive women was eliminated from the original draft House bill. In sub-Saharan Africa, hundreds of thousands of babies are born with HIV each year. While PEPFAR funding has increased access to drug treatment for pregnant women intended to prevent transmission of HIV to their newborn infants, it still remains grossly limited. In Uganda, for instance, only 20 percent of all pregnant women with AIDS can access these treatments. In one study in Uganda, 93 percent of HIV-positive women said their pregnancies were unintended. Access to voluntary services not only enables women to make informed choices about the number and timing of pregnancies, but also dramatically improves infant and child survival, and when reducing unintended pregnancies also reduces the number of new infections.

I can only conclude that when it comes to the poor and marginalized, ideology consistently wins over evidence-based policy. My faith instructs that saving lives should trump ideology in all instances. If our government is going to authorize a $50 billion AIDS package that will save some lives at the cost of others otherwise easily saved, I cannot stand by idly while my neighbor bleeds. This is why the Jewish community is calling on the Senate to take the bold steps necessary to put evidence before ideology.

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  • invalid-0

    There’s a lot here to think about and you make a lot of important points, so thanks for this posting.

    This is not a comment in response to your main points, but, just for the sake of accuracy: it would be better, I think, to say that the bill authorizes $37 billion to continue funding global AIDS programs over the next five years, not $50 billion.

    This is because $13 billion in the bill would go to TB and malaria programs via bilateral agencies and via the US contribution to the Global Fund. (Of course, the bill itself provides zero actual money, since that would be done by the appropriators in Congress.)

  • invalid-0

    Because of the devastating effects of the anti-prostitution pledge, my collegues and I formed a condom-donation outreach project to Santiago, Chile and two sex worker-support organizations there. They were affected by the USAID anti-prostitution pledge (many other organizations in the area folded).

    I say this not just to highlight our small efforts in one part of the world, but because if these short-sighted policies continue to persist, the only solution will be what help citizens can give each other. Which will always be less than what a governement can do.

    This is a terrific summation of the problems — one I hope every member of the House reads.

  • invalid-0

    Thank you for your very insightful and complete analysis of the new PEPFAR bill. Like David (above), I wanted to comment mainly for the sake of accuracy.

    Organizations can collect data on rates of unsafe abortion under the Global Gag Rule. In fact, research on unsafe abortion can and has been conducted using US government funds. But organizations (and this means only organizations outside of the US since the Gag Rule does not- and CAN NOT- be applied to US organizations since it is, essentially, unconstitutional) can not provide abortion services (except in the case of saving a woman’s life, rape or incest, if those indications are already legal in the country), information about abortion option or refer women to services, EVEN IN COUNTRIES where abortion is legal, or legal under certain indications. If organizations receive any US family planning assistance funds, they can not lobby to make abortion legal in their country, even if they use other funds to do that work.

    For more information about the Gag Rule, go to

  • scott-swenson

    Thanks Deborah, I’m curious what your thoughts are on applying the Global Gag Rule to PEPFAR. Since it has not been applied in the first five years, and most people agree it is bad policy where it is applied, what are your thoughts on adding it PEPFAR?

    Be the change you seek,

    Scott Swenson, Editor

  • invalid-0

    I’d love to hear more about, Amanda.

    It is certainly good news that the President has increased funding to fight this epidemic in Africa. But if the funding is tied to ideological mandates that end up harming the very people we are supposed to be helping, what is the point?

    And to institute restrictions that will actually reduce the number of people who can be helped (HIV positive women, sex workers, etc. ) is not only damaging – it’s disastrous. Sex workers can help slow the spread of AIDS in Africa so why set up MORE obstacles to prevention and treatment programs for this group?

    To force organizations to make public declarations on a moral position in order to receive funding can be for no other purpose than to appease certain lobbying forces – a political dance on the backs of vulnerable Africans if you ask me.

    Thank you for your work on this, Amanda. It’s too bad that it’s needed but it definitely is!

  • jodi-jacobson


    thanks for your clarification; much appreciated. however, i wanted to ask if the letter of the law is in fact being followed in the case of the GGR–and if people even know what the letter of the law actually says in the field per se–then i would ask why the following has consistently happened under this Administration?

    1) In settings where discussions about abortion takes place even as a research issue, groups have been widely attacked. In Peru, for example, a couple of years ago, attendees at a conference asked panelists discussing the level of maternal mortality in Peru what contributions were made from unsafe abortion. Persons present in this conference taped the exchange where the issue of abortion was discussed. an international incident erupted over the *discussion* of abortion as a cause of maternal morbidity and mortality.

    2) many organizations here and abroad have scrubbed their websites of material on abortion and related activities.

    3) Organizations throughout Latin America were attacked and projects threatened with de-funding when they sought to provide emergency contraception, which USAID itself technically supports as a method of contraception.

    4) thought the global gag rule restrictions have never applied to FP programs under PEPFAR, what was in my mind deliberate confusion on this issue continued to lead to groups on the ground telling me in 3 months of travel in PEPFAR countries in 2005 and 2006 that they were not able to access funds because they were told by embassies and by some cooperating agencies that the global gag rule would not permit this… was not true, but it was used in the field as either an obstacle or as a political tool to keep them from accessing funds. now that they are, we are faced with new restrictions in the PEPFAR reauth bill itself.

    I agree knowing the letter of the law is important. However, I think we often forget that these polices are used in completely insidious ways to undermine programs which is why so many of us strenuously object to the insertion of vague language that applies to family planning programs and not to any others.

    Thanks a bunch, Jodi Jacobson



    Jodi L. Jacobson

    Director of Advocacy

    American Jewish World Service

    1413 K Street, NW

    Washington, DC


    202 408-1380

    301 257 7897

  • jodi-jacobson

    Hi David,


    Yes the House bill includes language on TB and Malaria.

    We feel strongly that no amount of money will suffice to end an epidemic unless the policies and programs adhere to the evidence.

    Over the 5 year period from 2003 to 2008 PEPFAR funding added 1.4 million people to those with access to ARV treatment. Roughly 27 percent of those in need today have access to treatment according to WHO.

    Over that same 5 year period, some 12.5 million people became newly infected. Even if we double treatment access over 5 years under the reauthorized program we are not even beginning to scratch the surface as indications are in some places like Uganda infections are now on the upswing due to "compromises" that have consistently gutted prevention programs. So a best-case scenario is that between 2008 and 2013 we will see at least another 12.5 million new infections unless we get serious about effective prevention of sexual transmission.

    During the same period under PEPFAR basic family planning programs have been flat-funded at best by the US (in real dollar terms funding for FP has declined). The new bill puts new restrictions in the way of FP programs as partners in prevention efforts despite the fact they are unquestionably best-poised to prevent new infections among women and youth–the two groups experiencing the greatest number of new infections.

    I think many of us have gotten seduced by the very fact of the amounts of money we have gotten out of Congress irrespective of how this money is spent or whether it actually is making a dent in the epidemic. Moreover, we may in some cases be saving a life through access to ARV access one week and losing it to malaria or diarrhea or other conditions the next. Therefore i see the $50 billion whether for AIDS, TB or malaria as hopefully–IF well spent saving lives per se and can't really bring myself to the "only $37 billion for AIDS" concern.

    Finally having shared a panel presentation with someone recently who, from the US, African American, HIV positive, told such a harrowing story of having to get access to treatment here in this country and simultaneously keep herself and her son afloat, I wonder how we can justify even a dollar of this funding going to ineffective programs for the sake of political compromises based on the ideological coercion of a few groups who have tapped into PEPFAR funding.

    In this regard, and others, I think it is i think it is tim we ask some hard questions about our own strategies, tactics, and willingness to compromise principle and evidence for money. i don't think it will end the epidemic and may create problems for funding in the future.


    Jodi Jacobson





    Jodi L. Jacobson

    Director of Advocacy

    American Jewish World Service

    1413 K Street, NW

    Washington, DC


    202 408-1380

    301 257 7897