Prostitution Pledge or Zambia’s Women and Girls

As Congress continues to move forward with PEPFAR reauthorization, there are a number of things that seem to have been unofficially declared "off the table." Perhaps foremost among these is the so-called "prostitution pledge." This pledge, which every PEPFAR prevention grantee is required to sign, is a declaration of the group's condemnation of prostitution. Even – or especially – groups working with women engaged in commercial sex work are required to sign the pledge as a condition of doing their work.

I've spent the past week in Zambia, attempting to understand the implications of our country's HIV assistance policy for actual implementation here in one of the world's poorest countries. Last night, I spent the evening doing what every Washington ideologue who supports the "prostitution pledge" should be required to do–I walked through the main street area and hung out in the bars in a community called Kafue, just 50 kilometers outside of the Zambian capital of Lusaka.

Zambia's unemployment rate hovers around 50%, with nearly 70% of the population living in poverty. HIV prevalence is about 17% but rises to nearly 30% in some communities. Rates of secondary education enrollment are less than a quarter of the eligible population. Worse still, is that the average age of life expectancy in Zambia is 37 years old. AIDS has shaved 15 years off the average age of life expectancy since the pandemic took its grim grip on the country a quarter century ago. It is a sobering portrait to be sure.

In Kafue, the portrait in numbers becomes a real-life picture of people living on the edge. Tourists do not venture to Kafue. One guidebook declares "there is little of interest here." However, Kafue lies on a major highway running through Zambia, connecting it directly to Zimbabwe and serving as a major artery in the trucking route in sub-Saharan Africa. As a result, the thousands of truckers that are fueling the spread of HIV across Africa, visit Kafue. Each night, trucks on the highways are required to stop driving at 8pm and not drive again until 6am because the roads are unlit, not very well maintained and trucks contribute regularly to accidents. They pull over in Kafue every night in a disturbing ritualistic act that sets the stage for Kafue's struggling women and girls to support themselves and their families at any cost.

It is here, at nighttime, that the folly of the United State's hypermorality becomes not just embarrassing, but complicit in shutting down the comprehensive approach to combating the epidemic that is so desperately needed. Women selling sex for money in Kafue are not trying to get a leg up or buy the latest styles. Most are unskilled as Zambia's school system is designed to filter out those deemed less promising, and even those with an education cannot find employment not because of sloth, but because the jobs do not exist. Others engage in sex work sporadically, often because they simply had no money for food that month. This is sex for the purposes of attaining life's basic necessities when nothing else around can provide it.

A single group is doing the outreach in Kafue to both schools and to the sex workers. It does so on a relative shoe-string and outside of the PEPFAR-funded prevention efforts in Zambia. This small NGO's workers are out each evening in Kafue's bars and on the streets where truckers are openly negotiating with women.

Finding a condom in Kafue is often an exercise in futility. They can be purchased in some of the bars, but purchasing condoms for a girl or women who is engaging in sex work in the first place to buy food is a stretch in logic that is the reality of life in Kafue. This single organization is the only presence on the streets, each night, doing a yeoman's job of trying to meet demand with free condoms and urging people to go for testing and counseling. Since the collapse of Planned Parenthood of Zambia's Success condom brand – a collapse facilitated in large part by that group's principled refusal to sign the U.S. global gag rule – free condoms are tough to come by in Kafue. This organization stocks designated boxes with free condoms in some of Kafue's bars but they simply cannot meet demand. Supplies fully stocked the day prior were empty by the time we got there.

Save this one group and a couple of brave others, "condom flight" is pervasive among NGO's doing HIV prevention work in Zambia. One PEPFAR grantee described the country situation as "AB Silent-C." In Kafue, the "Silent C" reality, coupled with the prostitution pledge, has left Kafue's women and girls vulnerable to infection.

PEPFAR's onerous policies have created an important, but politically safe and insufficient portfolio for preventing the sexual transmission of HIV in Zambia. Good prevention work is happening here with PEPFAR funding, but it is as far from a comprehensive approach as one can imagine.

The PEPFAR reauthorization proposals in the House and Senate have some language that might hold out hope for Kafue's women and girls. That hope, however, hinges on an election and an incoming administration that is more concerned with evidence than ideology. But both proposals maintain the prostitution pledge which, like it or not, is interpreted here on the ground as an explicit direction from the United States government that prevention with sex workers is a risky business if you want grant money. Safer to stick to the A and B which is exactly how it has played out here in practice.

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  • invalid-0

    I hadn’t heard AB Silent-C. But when I worked for a US-funded prevention programme and my colleagues and I wrestled with the prostitution pledge while we tried to figure out how to tell people who sell sex for a living that their first choice for HIV prevention should be starvation, we thought ABC stood for: Anything But Condoms.

  • invalid-0

    Hello! Have you not heard that for YEARS we have known that condoms do not protect against STDs?

  • scott-swenson

    You didn't cite any actual evidence for your opinion, but the following is quoted from the Centers for Disease Control.

    Latex condoms, when used consistently and correctly, are highly effective in preventing heterosexual sexual transmission of HIV, the virus that causes AIDS. Research on the effectiveness of latex condoms in preventing heterosexual transmission is both comprehensive and conclusive. The ability of latex condoms to prevent transmission has been scientifically established in laboratory studies as well as in epidemiologic studies of uninfected persons at very high risk of infection because they were involved in sexual relationships with HIV-infected partners. The most recent meta-analysis of epidemiologic studies of condom effectiveness was published by Weller and Davis in 2004. This analysis refines and updates their previous report published in 1999. The analysis demonstrates that the consistent use of latex condoms provides a high degree of protection against heterosexual transmission of HIV. It should be noted that condom use cannot provide absolute protection against HIV. The surest way to avoid transmission of HIV is to abstain from sexual intercourse or to be in a long-term mutually monogamous relationship with a partner who has been tested and you know is uninfected.

    Be the change you seek,

    Scott Swenson, Editor

  • invalid-0

    The “prostitution pledge” is NOT a gag rule. It is a requirement that government funds not be used to fund pimps and prostitution directly. NGOS that sign on to the pledge can still provide condoms, education and ofher assitance to sex workers. Many in fact do. I could provide links to document this, but I know you will delete this comment, just as you deleted previous comments that sought to provide the truth to your readers. PEPFAR is deeply problematic, but there is no reason to lie about what it does, and doesn’t do.

    The only NGO refused funds because it refused to sign the pledge is run by a pornographer, Philip Harvey, who SELLS (rather than gives) condoms to people in poor countries via DKT International. He was involved in promoting in brothels abroad, and therefore could not sign the pledge. Though I imagine you will delete this comment because you do not like the truth, you can read about this here:

    and here

  • scott-swenson

    Dear Anonymous,


    First, the only time we delete comments is when they are outside the bounds of propriety and/or stigmatizing to marginalized populations. Many of our readers actually encourage us to delete far more comments than we do. Unlike many web sites, we encourage respectful dialog on these sensitive issues. If your comments have been deleted, there was good reason, not because we disagreed.

    As to the anti-prostitution pledge, the reality of the US government's policy has been a sharp reduction in outreach efforts through PEPFAR funded programs to this most vulnerable population. This report says it best,

    How has the pledge requirement actually affected programs? While we found few published studies, several cases do suggest possible implications. In our view, the pledge has the potential to restrict programs for those it seeks to protect. Changes in policy have forced some non-US-based projects, such as the Médecins Sans Frontières–run Lotus Project in Svay Pak, Cambodia, to close [24]. Interviews with some 100 women in Svay Pak revealed that only a small number felt they had been forced into sex work, and a significant percentage sought to improve working conditions and safety. The Lotus Project began by offering a range of services to sex workers, from primary health care to English and computer lessons, while receiving funds from USAID for operations research. Within two years after the project's launch, Médecins Sans Frontières handed it over to a local organization, whose funding came primarily from USAID, in an effort to ensure sustainability. Around the same time, the Lotus Project had come on the radar of US activists working on human trafficking issues. After a number of raids on brothels in the area by US-funded anti-trafficking groups, sex workers experienced severely restricted mobility, resulting in limited access to health care and a reduced ability to earn a livelihood. The project's ability to respond effectively to the new situation was hindered by fear of being seen as promoting prostitution. Their freedom to deliver services based on best practices was limited. Eventually, funding from USAID diminished and the Lotus Project closed [24]. The experience of the Lotus Project contradicts a principal argument used in a friend of the court brief in support of USAID. This argument stated that “Organizations can oppose the prostitution industry without stigmatizing the individuals bought and sold in it‥Helping victims while opposing the industry that exploits them is the best way to prevent HIV/AIDS, the best way to advance human rights, and the best way to fulfill the intent of the Act” [25]. We agree. Yet we would argue that the evidence suggests that as long as prostitution and sex trafficking remain conflated, women and men who voluntarily sell sex may be at risk of further marginalization and may, as witnessed by the Lotus Project, be less likely to receive the health, social, and education services they need to eventually move out of the industry. In this polarized debate, neither side has been ready to surrender what it believes to be the best approach to HIV prevention among sex workers. Public health professionals have an obligation to demand that funding be driven by evidence-based strategies for addressing health and social problems, but evidence does not function in a political vacuum. The history of HIV prevention is all too full of programs that have proven to be politically unfeasible in the US despite overwhelming scientific evidence in their favor, such as the efficacy of needle and syringe exchange programs as HIV prevention tools for injecting drug users. The Federal Government continues its ban on federal funding for this intervention, despite endorsements from the Institute of Medicine, the US Surgeon General, and all of the major health professional associations [26]. These political realities have complicated responses to HIV prevention for sex work as well as for injection drug use. While sex work may be seen by some as inherently degrading, it is nevertheless the case that in many settings sex workers choose to continue to work and to demand preventive and other health services. The provision of support, goods, and services to sex workers who want and need them is a compelling ethical and public health priority. Building trust and showing care by providing sex workers with the tools necessary to stay alive, whether they be condoms, counseling, or a safe place to receive medical attention, is our duty as health professionals and as human beings. Whether these goals can be met if we must “oppose prostitution” is actively being argued in the courts, and perhaps more vitally, in the many settings where sex workers provide services societies continue to disdain and demand.



    Be the change you seek,

    Scott Swenson, Editor

  • william-smith

    There are profound differences between policy and practice. My piece was a reflection on the impact of the prostitution pledge in practice, on the ground — between official records and real life impacts. This was entirely lost on the reader. I'd suggest the reader walk a mile in the shoes of many of Kafue's women whose resources to protect their lives, their children and their spouses has been short circuited by the policy and the thinking evidenced by the reader in his/her comment.