Time to Rethink PEPFAR in Vietnam


Editor’s Note: In the coming weeks, RH Reality Check’s Global Perspectives writers will examine the impact the outcome of the US presidential election could have on women’s health and rights in their regions. This piece is the first in that series.

With
PEPFAR
(President’s Emergency Plan for AIDS Relief)
reauthorized until 2013, the upcoming US election presents a vital opportunity to reflect
upon the program’s shortcomings. Vietnam was, controversially, the only country
in Asia selected to be one of 15 focus countries, (the
remaining from Africa and the Caribbean), beating other Asian countries like India
in its designation as one of the worlds most severely affected nations. Since its inception,
many of the requirements of PEPFAR have proved to be similarly controversial in
hindering efforts to combat the spread of HIV/AIDS in Vietnam.

Given the prevalence of
HIV in Vietnam among sex workers, a major flaw with PEPFAR is the requirement
that grantees pledge opposition to prostitution. In Vietnam, pledging
opposition to commercial sex exacerbates the already prevalent marginalization
of women and men in prostitution, some of whom have been trafficked. The
requirement has proved to be a major
obstacle
to those groups trying to provide legal, social and
health services to those Vietnamese engaged in commercial sex. Whether one
supports or opposes the commercial sex industry, the prostitution pledge requirement
has so far undermined services ranging from aiding Vietnamese to move out of
commercial sex altogether, to inhibiting programs designed to empower sex
workers in their demands for universal condom use. Given the pressing need to
reach one of the groups must vulnerable to HIV infection, their marginalization
through PEPFAR’s prostitution pledge reflects a fundamental shortcoming. It is
in fact very telling that in 2005 Brazil
rejected $40 million in U.S. Global AIDS funding
, the Brazilian
Government recognizing that the anti-prostitution requirement would undermine
the very programs that have proved the most successful amongst Brazil’s efforts
to reduce the spread of HIV.

A second major flaw
with the implementation of PEPFAR in Vietnam has been the classification of
"most-at-risk" populations, a classification that has not only ignored the
reproductive health reality facing Vietnamese
youth
,
but also that of  women in general. One recent study shows that whilst a
significant proportion of HIV positive Vietnamese women are infected through
sharing needles and syringes with infected drug users or by having unsafe sex
with clients, the majority of new infections result from pre-marital sex with
young male injecting drug users. Despite studies like these, a perception persists that the
epidemic predominantly exists amongst young Vietnamese males.

According to Vietnam’s
Ministry of Health
, about 263,000 people are living with HIV/AIDS in Vietnam, though only
103,000 cases have been reported. How many of those unreported cases are women
who should otherwise be a central target group for curbing the spread of
HIV/AIDS? Since the majority of PEPFAR’s prevention funding for condom
promotion in Vietnam is reserved for most-at-risk populations, the failure to
perceive women who engage in pre-marital sex in the most-at-risk category
reflects misdirected funding. In light of the abstinece-until-marriage focus,
if PEPFAR remains narrow-minded and ideological in its approach, Vietnamese
women engaging in pre-marital sex will continue to be ignored by
awareness-raising efforts and HIV prevention programs. Clearly, the very likely
continued support of abstinence-until-marriage spending requirements by
Republican candidates McCain
and Palin
will continue to impede access to family planning information and
services for these at-risk women and girls.

Obviously, a further
failing is the approach of targeting HIV alone, without coordinating with
family planning programs, despite the fact that unintended pregnancy and the
need for family planning remains
high

in PEPFAR focus countries. Population
Action International
reports that funding for HIV programs in these countries completely
dwarfs the amount allocated for family planning and reproductive health.  In
Vietnam, funding for HIV/AIDS from international donors, including PEPFAR, has significantly
exceeded

government funding. Yet the opposite
situation
exists for family
planning, with government funding always higher than international funding
since the mid-1990s.

Health advocates can
only hope that candidates for the upcoming US election commit to
rectifying  PEPFAR’s flaws evidenced over
the last 5 years. If we hope to enhance sustainable development and encourage
rights-based approaches to HIV/AIDS and family planning policies in focus
countries like Vietnam, we cannot suffer another 5 years of similarly narrow
and restrictive PEPFAR funding.

Policies designed to
target the HIV pandemic obviously must work to combat stigma and to ensure
health care exists to address the needs of those infected and all men and women
vulnerable to infection, including those engaged in sex work and women having
pre-marital sex. Instead, the shortcomings of PEPFAR wastes funds that could
otherwise be successful in reducing the spread of HIV amongst the general
population of Vietnam. Moreover, support by candidates of such ideological and
restrictive policies reflects a willingness to jeopardize reproductive health,
the empowerment of women and girls and sustainable development in general in
PEPFAR’s focus countries.

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