The Future of PEPFAR: What Zambia Teaches Us

Earlier this month, Population Action International (PAI) and the Sexuality Information and Education Council of the United States (SIECUS) teamed up to conduct a joint policy research trip to Zambia. Zambia is one of the 15 focus countries prioritized to receive global U.S. HIV/AIDS assistance. Zambia was also one of the first countries where PAI documented, in 2003, the destructive impact of the Global Gag Rule (also known as the Mexico City policy) on family planning and reproductive health care services.

Other criteria, however, also made Zambia an ideal country through which to answer many questions about the effects of U.S. policy and funding. Long before PEFPAR's arrival, a conservative religious environment defined Zambian society, within which the promotion of abstinence and marriage were already strong currents in everyday life. First, what would the effect be after four years of the U.S. putting nearly $577 million into the country under policies that disproportionately emphasize these strategies over a more comprehensive HIV- prevention approach that included condom education and distribution? Second, how are PEPFAR policies interpreted and implemented in this environment? And have they exacerbated the dire sexual and reproductive health and rights situation in Zambia, where rural family planning and reproductive health outreach collapsed after the country's leading SRHR provider refused the terms of the Global Gag Rule? Third, has U.S. assistance harmonized with other donors and what has the Zambian government's role been in the midst of this? And finally, and perhaps most importantly, what are the needs of the health care workers on the ground and the Zambian people themselves in attempting to stem the generalized HIV epidemic in the country?

Having returned from the research trip to Zambia, PAI and SIECUS will be answering these key questions over the next several weeks and reporting on our findings and educating Members of Congress and their staff about how U.S. policy and assistance really plays out in the field. We'll also be collaborating with and supporting Zambian NGO colleagues to increase SRHR advocacy with their own policymakers.

Immediately, however, we wanted to share some disturbing observations from our research interviews that both advocates and lawmakers should consider long and hard during Congressional recess and in preparation for floor consideration of PEPFAR reauthorization in a few weeks.

1) By all appearances, reproductive health seems to have vanished from Zambia both conceptually and as a health service. At the policy level, there is no official framework for SRHR. At the program level, sexual and reproductive health (SRH) services are thin and fall far short of demand. Rates of maternal death, unplanned pregnancy and unsafe abortion–especially among young women–are persistently high. Contraceptive stockouts have become more frequent and community-based SRH outreach throughout rural Zambia is non-existent, thanks to the Global Gag Rule. While the U.S. is one of a handful of donors providing FP/RH assistance and donated contraceptives to Zambia (about $6 million in FY07, compared with $216 million in PEPFAR funding), this small amount of U.S. assistance is hamstrung by Global Gag Rule restrictions and consequently is narrowly focused on providing technical assistance to the public sector.

2) While we observed and documented some impressive prevention programming funded with PEPFAR, it is as far from a comprehensive approach as one can imagine. Higher risk groups, such as sex workers, seem mostly neglected by PEPFAR and rarely talked about in a country with major trucking routes and new copper mines drawing migrant workers from the region. Condoms, as well, are not as actively promoted or distributed as they were pre-PEPFAR in Zambia–where prevalence is around 17% and rises to 30% or more in some parts of the country. And based on our conversations with Zambian and U.S. NGO staff, there is a lot of confusion about what you can and can't say about condoms under PEPFAR. The notion that other donors – miniscule in comparison to PEPFAR – will step in to meet needs specifically jettisoned by PEPFAR in practice has not been borne out in Zambia.

3) Sexuality education is the missing foundation for effective prevention of the sexual transmission of HIV/AIDS. In one classroom, we observed a group of students being told that certain body fluids can transmit HIV. The students looked utterly bewildered and the skilled educators realized that it was because these students had a deficit in the basics of how their bodies work. The educators stepped in to describe what these body fluids were, but no patchwork quilt of HIV/AIDS prevention is going to maintain a long-term curbing of the epidemic if the education system does not play its part and begin providing comprehensive sexuality education as a foundation for other efforts.

4) PEPFAR in Zambia operates largely in isolation. This has been observed in other PEPFAR focus countries and is endemic to the U.S. approach to foreign policy in other settings. This has profound implications for harmonizing with the Zambian government and its priorities for tackling the epidemic, as well as for coordinating with other donors to minimize duplication and maximize comparative advantages. For example, while it is true that the Zambian government works with the PEPFAR team there to develop an annual "country operational plan," it is a bit akin to a borrower setting the entirety of the terms for a bank loan–it just doesn't work that way. Zambian providers and advocates repeatedly told us that U.S. political priorities drive PEPFAR planning and programming, not the reality of HIV/AIDS on the ground.

5) Again, as seen in other focus countries, PEPFAR has created a discernible break between local NGOs and international and U.S.-based groups working in the country. The experience of many Zambian NGOs is that PEPFAR has not benefited from the development and capacity building of indigenous groups doing this work, but rather has led to the growth of U.S.-based NGOs, especially faith-based groups, who are the major recipients of PEPFAR's largesse. That said, international and U.S. NGOs are clearly doing impressive work in the areas of treatment and care under PEPFAR, but at present the relatively tiny investment in home-grown, Zambian NGO efforts on the prevention side speaks to concerns about the sustainability of current activities and the development of Zambian professionals to lead this work in the future.

Reauthorization of PEPFAR's prevention components needs to move beyond the persistence of the destructive political and ideological shenanigans of the bill's first iteration. To this end, our field research in Zambia highlights key areas that must be addressed if PEPFAR's promise is to be truly realized, and new infections averted.

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  • 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

  • invalid-0

    No mention of “the pledge” in this atrocious piece of dishonesty, because this has nothing to do with “the pledge” and you are too dishonest to admit it. Again, there are deep problems with PEPFAR. But refusing to directly fund pimps and brothels is not one of them.
    Food for thought: