Fix PEPFAR Now to Prevent HIV Infections, Save Lives

The President’s Emergency Plan for AIDS Relief (PEPFAR) is moving toward a cloture vote in the Senate, a vote that will determine whether the $50 billion reauthorization lives or dies. That same life or death question applies to millions of people in Africa, and comparing actual life or death in Africa to the political legacy of President Bush, as many people see PEPFAR as his greatest achievement, is appalling. Doubly so when the politicians and mainstream media refuse to demand fixes to PEPFAR’s problems. Like the rest of President Bush’s legacy, PEPFAR, as successful as it has been in part, is a go-it-alone strategy that has alienated much of the rest of the world’s public health community.

The reality is this: as successful as PEPFAR has been getting life-saving treatment to nearly two million people, it has failed to slow the infection rate because it has been hampered by unnecessary ideological restrictions. For every two people who receive treatment, five are newly infected with HIV, according to a letter from leading public health advocates circulating on Capitol Hill.

The current legislation will not change that.

At that rate of infection, fiscal conservatives like Sen. Jon Kyl (R-AZ) are right to question the amount of money being spent and if it makes sense, because unless you stem the infection rate, no matter how many people get treated there will always be more than twice as many who don’t. Unless the bill is fixed to eliminate ideological provisions, touted by Sen. Tom Coburn (R-OK) that have hampered PEPFAR’s prevention efforts in its first five years, and promise more of the same if the current bill passes, PEPFAR will not be as successful in fighting HIV in Africa as it could be.

Unfortunately, that is not the heart of Sen. Kyl’s objections. He and other fiscally-conservative Republicans who’ve been blocking the bill have taken some heat in editorials recently for standing in the way of "the greatest foreign policy achievement since the Marshall Plan," according to PEPFAR supporters quoted in a Wall Street Journal editorial. Given the continued infection rates and failure to address PEPFAR’s flaws to turn the tide, the comparison to the Marshall Plan could only be accurate if Europe were still in shambles.

The Las Vegas Sun writes,

A small group of Republican senators, though, is spoiling the momentum
by arguing that the legislation costs too much and includes money for
unrelated poverty programs.

Poverty is indeed related to the spread of HIV and anyone who doesn’t get that yet isn’t paying attention. Poverty is at the heart of why prevention efforts are so challenging and must be changed, and why putting treatment ahead of prevention is the proverbial cart-before-horse problem. They must work together, and only prevention can ultimatley lessen the burden of treatment.

We should all celebrate the two million lives with us today that otherwise would not be because of PEPFAR treatment. The stark realities of those lives are documented beautifully in a special exhibition, Access to Life, at the Corcoran Gallery in Washington, DC, sponsored by The Global Fund on AIDS. The photos tell the story of people from every imaginable walk of life, mostly women, often young, always on the margins — who because of treatment are alive today, working, raising families, educating others about HIV/AIDS.

Every Member of Congress should be forced to visit this exhibit before voting on PEPFAR, because as much as it speaks to the life-saving power of treatment, the exhibition also speaks truth about the need to set ideology aside in favor of reality-based education and prevention efforts, now. Had ideology not stood in our way for the first 25 years of the AIDS pandemic, many of these people might never have been infected in the first place. Prevention is and always will be the key to fighting HIV.

Christianity Today, yesterday lamenting the delays, wrote this,

Jon Kyl, the junior senator from Arizona, pretty much has sterling
conservative credentials and a "solidly conservative voting record" in
the words of the Almanac of American Politics.

So what is his beef with
the reauthorization of PEPFAR, perhaps the most relatively untarnished
legacy program of the Bush administration?

Certainly, sticker shock and mission creep are legit concerns. But here’s some op-ed commentary, published in the Tuscon Citizen:

Yet despite the program’s widespread support and irrefutable
success, Kyl and a handful of Republicans think the price tag of $50
billion over five years is too high. It would be one thing for legislators thing to balk at expanding a
program that had not delivered its intended results, but quite another
to stop one that works.

The Baltimore Sun said,

Republican leaders must rein in the conservative flank of their party
and put lives before votes. Otherwise, the president’s biggest
achievement abroad may come undone, and millions of children will
suffer the dire consequences

Most of these editorials also referenced that Bush needed PEPFAR to be passed before leaving for the G-8 Summit in Japan last week. That was great, if unsuccessful, spin and most people recognize that the agreements at the G-8 did not hinge on PEPFAR. In fact, as Jill Sheffield notes from the G-8 Summit, once again the world’s wealthiest nations continue to disappoint with regard to HIV:

Related language
in the whole health section of the final G-8 Communiqué is weak and

"G-8 will take concrete steps to work toward improving
the link between HIV/AIDS activities and sexual and reproductive health
and voluntary family planning programs, including preventing mother-to-child
transmission, and to achieve the MDGs by adopting a multi-sectoral approach
and by fostering community involvement and participation." Really,
couldn’t they have done better than "work toward improving"?

While the editorial writers have part of the PEPFAR story right, that there are conservative politicians putting roadblocks in the way of solid public health policy, they have completely missed out on the story of PEPFAR’s well documented problems and the fixes that are necessary. RH Reality Check has been covering those problems extensively since negotiations began, noting that it is not just the fiscally conservative wing of the GOP that is causing delays, but the social conservative wing as well, insisting on ideological provisions like failed abstinence-only requirements, and using completely irrelevant issues like abortion to gain negotiating advantage over squeamish Democrats. These tactics have complicated negotiations and will prevent improvements to prevention efforts. At least the fiscal conservatives aren’t pretending they care about HIV/AIDS as the ideologues try to do, while ignoring public health realities.

But the PEPFAR spin-fest has been a bipartisan affair. The Democratic Majority has shirked its oversight responsibility to learn from the first five years of PEPFAR and improve efforts by applying proven public health strategies. Instead, they have acted more like a minority, allowing the negotiations to be handled between the fiscal and social conservative wings of the GOP in an effort to avoid dealing with social issues during an election year.

But even at this late hour, because of fixes required on the treatment side of the bill, it is possible for Congress to improve PEPFAR in order to slow the infection rate as well, which in the long term, could mean less money required for treatment once the spread of the disease is slowed.

Global public health advocates at the American Jewish World Service, Center for Health and Gender Equity, International Women’s Health Coalition, the National Council of Jewish Women and the Sexuality Information and Education Council of the US clearly articulate these improvements as:

  • Abolish arbitrary funding guidelines. In a 2007 report, The Institute of Medicine (IOM) recommended removing the current PEPFAR requirement that one-third of prevention funds be spent on abstinence-until-marriage programs. The Senate bill ignores the findings of this congressionally-mandated study and findings from the government’s own Accountability Office (GAO) about the ineffectiveness of this approach. The current bill calls for spending at least fifty percent of prevention funds designed to halt the sexual transmission of HIV, in countries with generalized epidemics, only on abstinence and faithfulness programs. PEPFAR recipients that do not meet this requirement must justify their programmatic decisions through an onerous reporting requirement to Congress, potentially facing defunding. Every individual needs a range of information and services to protect him or herself against HIV, and public health experts on the ground must be able to determine the best mix of prevention programming for their own communities. As it stands, their hands are tied by policies from Washington.


  • Support prevention strategies that reach the largest number of people. In most regions, the number of new infections is growing most rapidly among women and adolescents, primarily through sexual transmission. These two groups are more likely to use family planning and other reproductive health services than any other segment of the population, and would be better equipped to protect themselves from HIV if their access to reproductive health services and education was expanded. The U.S. government concluded that integrating family planning with HIV prevention and treatment services could double the effectiveness of programs to prevent transmission of HIV from mother to infants by expanding women’s choices about pregnancy and childbearing. Recent studies suggest that upwards of 90 percent of HIV-positive pregnant women in countries such as Uganda and South Africa have unmet need for integrated family planning and HIV services. However, the current bill before the Senate fails to call for or even acknowledge the need to strengthen critical linkages between family planning and reproductive health services and HIV prevention efforts.


  • Remove the unconscionable “conscience clause.” The 2003 PEPFAR legislation contains a provision that enables organizations receiving U.S. funding to pick and choose the prevention and treatment services they wish to provide. Millions of dollars go to organizations to provide prevention services, even though they refuse to discuss the potential of condoms or other contraceptives in preventing the spread of HIV. As abstinence and partner reduction programs have outpaced programs that enable individuals to have all the information they need to prevent HIV, the law stands in the way of effective use of resources. The Senate bill takes this bad policy and makes it worse by extending the so-called “conscience clause” to organizations that provide care and support to people living with HIV/AIDS, their families and their communities. This provision paves the way for taxpayer-funded discrimination based on “moral” and religious grounds leaving it wide open to refuse care to someone based on their religion, how they got infected or any other basis. The refusal clause is another damaging provision that flies in the face of good public health practice.


  • Eliminate the prostitution pledge. Current law requires groups fighting HIV/AIDS overseas to pledge their opposition to prostitution and sex trafficking before receiving U.S. money. Sex workers are among the most marginalized people in every country and often lack access to social and health support systems. Prevention programs that have reached sex workers through first building trust have yielded dramatic reductions in HIV infections among these populations. Some continue to believe that having organizations sign such a pledge will help end prostitution, but in reality, the opposite may be true. According to numerous reports, the pledge has led to further alienation of already-stigmatized groups and given free rein to police and resulted in further discrimination against women in sex work. Instead of reducing dependence on sex work, the policy is driving sex workers under ground and away from the non-governmental organizations and health workers best poised to help them and to prevent HIV.

This bill will set the policy for the United State’s global HIV/AIDS programs. As the cloture vote approaches, and assuming it passes, there will still be opprotunities to set better policy on how we spend $50 billion over the next five years. There are concerns on both sides of the aisle, and the Senate should take those issues on, vote on them, and pass a bill that has the greatest impact in saving lives.

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  • invalid-0

    Thank you Scott for fitting all this information together in a clearly-written column. I will be forwarding it to my friends outside the international SRHR community to explain what is going on. Cheers!

  • invalid-0

    “According to numerous reports, the pledge has led to further alienation of already-stigmatized groups and given free rein to police and resulted in further discrimination against women in sex work. Instead of reducing dependence on sex work, the policy is driving sex workers under ground and away from the non-governmental organizations and health workers best poised to help them and to prevent HIV.”

    Any documentation whatsoever for any of this?

    Just to note one of the abject lies you are perpetuating here: How could asking NGOs to agree not to advocate for pimps or brothels possibly “give police free reign” in a foreign country. It doesn’t effect the police powers of other countries at all.

  • scott-swenson

    Dear Anonymous,

    I guess if I can prove to you that in fact the threat is not an "abject lie" then your opposition, and that of all opponents, would magically disappear? In fact, the threat as the article clearly states, is that people most vulnerable for contracting and potentially spreading HIV are being driven underground because the NGO’s — often the only people who could/would help them — are not being allowed to.

    As opposed to listing all the articles, I’ll offer to guide you on how to learn on your own — the old "teach a man to fish" model. Simply google "sex workers raped by police" (or click that link) and read about how those brave law enforcement types around the world take advantage of sex workers. Now, let’s imagine that they contract HIV, take it home to a wife who believes her husband is faithful, neither are tested, and he continues having sex with others.

    That’s what I call police power … and policy impotence. We can keep ignoring the realities as the uninformed ideologues want us to, or we can choose — as Jesus did and nearly every faith tradition teaches — to reach out to the most vulnerable among us and offer to educate — teach them how to prevent and take care of themselves.

    Most sex workers are not doing it from choice, but for survival, often supporting families of their own.

    Please, anonymously judge and stigmatize as you will … just don’t call those of us trying to shed light instead of heat liars. Proof is just a google away.

    Be the change you seek,

    Scott Swenson, Editor

  • invalid-0

    Please accept more appreciation for the clarity of your writing as it allows us to comprehend the current PEPFAR situation.

    And now the questions remain… How goes it on the Hill? What strategy are ‘we’ using to whip changes in the bill as you spelled out? Vigilance and tenacity are required.

    Many thanks to all who are doing the needful.

  • invalid-0

    And reiterate the points Scott addressed in the piece. That is how we will get these critical issued addressed.

  • scott-swenson

    Thanks for the kind words, as the commenter below suggests, anyone interested in adding their individual voice should call the Senate switchboard and contact their Senators encouraging common sense changes in the bill. The cloture vote is scheduled for 5:21 p.m. ET and if they do not have the requisite 60 votes, there is a plan to hold it again on Monday.


    Next, look at this post today and see the groups that are working to make these changes — and support them. There are other groups actively working against these changes in the name of "compromise" with an opposition that never has, and never will, know the meaning of the word. People need to be smart with their votes, and invest in causes wisely. There is lots of money sloshing around HIV/AIDS advocacy but if it isn’t spent wisely, who does it really benefit?


    The next thing — talk to people, forward posts from this site, share them with friends on Facebook or other social networking sites, be active commenting on progressive sites that don’t pay enough attention to sexual and reproductive health issues, as well as ours. The silence and misinformation on this issue in the mainstream media, as well as the progressive blogosphere, is telling. I personally think people want so desperately to feel good about doing something, anything, to help AIDS in Africa, they are willing to ignore the facts on the ground, the truth of what works, and will celebrate success with dollars rather than results. When problems feel too big, we often accept less than we should and call it progress.


    As for how it goes on Capitol Hill, the latest rumor is that certain conservative Senators are now trying to apply Kemp Kasten, the legislation that President Bush uses to deny funds to UNFPA, to this bill, meaning that any organization, like the Global Fund for AIDS, working in China, could not receive US dollars. It is ludicrous with respect to UNFPA, and downright shocking when given the realties of HIV/AIDS. But these are the sorts of ideas that gain traction when you negotiate from a position of weakness, undermine progressive colleagues, and believe that anyone on the far-right is interested in finding common ground.


    Lastly, hold your elected officials feet to the fire. Call, write, see them when they are home campaigning and tell them its time for common sense to prevail over ideology when it comes to sexual and reproductive health. The vast majority of Americans support common sense policies on a range of sexual and reproductive health issues, but who can blame the far-right for manipulating issues and scaring moderates and progressives in both parties when it keeps working — even when their numbers are in such drastic decline. Until politicians get a back bone and stand up to the far-right, demonstrating that they are an incredibly shrinking minority, they will continue to hold weaker politicians over a barrel and persuade rock stars who see politics through rosey-red colored glasses that manipulation equals compromise.

    But then again, I don’t really feel strongly about this ;-)

    Be the change you seek,

    Scott Swenson, Editor

  • scott-swenson

    The Senate will start to hear argument on PEPFAR this afternoon, with a few amendments to be argued and votes expected Tuesday. It is possible this goes into Wednesday, but more likely that Majority Leader Harry Reid will keep the pace quick to avoid any discussion of reality about the need to fix PEPFAR’s flaws.

    The Senate Bill, for all intents and purposes at this point, INCREASES the abstinence-only requirement from Zero, where the negotiations started, to 50 percent, a dramatic increase from the requirement of 33 percent during the first five years. I do hope the lead negotiators will write a piece about how they worked so hard to take a clean bill and make it worse (with the exception of dollars allocated) than when they started; it will be a case study for lobbying for years to come. And yes, major AIDS Advocates who know, and in many cases have produced the stats that demonstrate abstinence-only has failed, still work to stifle debate about the facts, preferring just to get the bill slammed through Congress.

    Amendments that will be considered include efforts to reduce overall spending on the bill, to leave the current PEPFAR program in place with no changes, and several intended to junk up the bill with unrelated programs — those are coming from Senators on the right, not the left. In fact, all of the accepted amendments are coming from the right, and most would make the legislation even worse in terms of effectiveness in fighting the spread of HIV than the Senate version already is.

    But, some advocates are preparing to pop champagne corks and celebrate more money that will flow through their coffers, all the while downplaying the reality that for every two people PEPFAR treats, five more will be infected because of the failure in Congress to learn from five years of PEPFAR experience and follow proven public health strategies.

    Democrats in Congress remain silent. Not exactly what Nixon had in mind when he spoke of “a silent majority.”

    Be the change you seek,

    Scott Swenson, Editor

  • invalid-0

    If you are going to make the assertion that “numerous reports” back your claims, at least have the decency to post references to these numerous reports. Google searches are not references nor “numerous reports”.

    The idea that signing an agreement to oppose prostitution and sex trafficking will cause HIV / AIDS infections to increase is ridiculous. An organization can oppose a horrible, illegal activity such as sex trafficking and still support global health issues.

    To extrapolote your argument concerning prostitution and sex trafficking, a similiar argument could be used against housing organizations. Does opposing homelessness preclude these organizations from helping the homeless into affordable housing?