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.