Obama to Keep Abstinence-Only AIDS Coordinator


Confirming month-old rumors, a high-level source reported last night that President-Elect Obama’s transition team has asked Ambassador Mark Dybul to remain in place as Global AIDS Coordinator, despite strong opposition by treatment access, HIV prevention, and women’s rights advocates across the global HIV and AIDS community, many of whom signed letters calling for a change in PEPFAR leadership at this crucial time.  While keeping Dybul on may be a stopgap measure for a new Administration dealing with huge problems across the board, it is a decision that signals we may not be getting "the change we need" in global AIDS policies.

Dybul, a medical doctor, is strongly associated with the failed policies of the President’s Emergency Plan for AIDS Relief (PEPFAR), including those that flout both evidence and human rights, and that neglect the role of stigma, discrimination and gender equity in the spread of HIV.  Under his tenure and that of his predecessor Ambassador Randall Tobias, for example, the Office of the Global AIDS Coordinator (OGAC) has funded abstinence-only until marriage programs that fail to provide all individuals with the basic information, skills and methods for practicing safer sex, supported policies that prohibit US funding of syringe and needle exchange programs despite evidence that such programs are the best means of preventing the spread of HIV among injecting drug users, and perpetuated restrictions on organizations conducting HIV prevention among sex workers.  All of these policies have been shown ineffective by government agencies, such as the Government Accountability Office and the Institutes of Medicine, as well as by numerous independent studies conducted by non-governmental organizations.

As Global AIDS Coordinator, Dybul obviously works at the pleasure of the current Administration and is responsible for carrying out the law.  However, he also is morally and ethically responsible for speaking out when taxpayer funding is being used to perpetuate ideology over evidence, and is leaving people at risk of new infections, as has been the case with PEPFAR prevention programs since day one.  When given the opportunity in Congressional hearings and other fora, Dybul failed to unequivocally support removal of the abstinence-until-marriage restrictions in the original PEFPAR legislation despite mounting evidence that this restriction was undermining efforts to stop the spread of HIV.  He did not speak out publicly against other restrictions such as that on syringe exchange.  His office failed to use its own leverage in writing guidance that would have supported a comprehensive approach to prevention of sexual transmission of HIV or would have greatly alleviated the adverse effects of the so-called prostitution pledge.  In short, even as a medical doctor he supported ideology over evidence, serving his own interests and the interests of politicians rather than those of people at risk.

Moreover, Dybul is very close to the religious right, including Pastor Rick Warren, and supported the positions of the US Conference of Catholic Bishops and Catholic Relief Services in maintaining restrictions on funding for prevention in the recent reauthorization of PEPFAR.  Lobbying by these groups resulted in the retention of restrictions on funding for prevention of sexual transmission, needle exchange, and sex worker organizations.  It also resulted in an expanded "conscience clause" which unconscionably allows groups to discriminate as to who will receive prevention, treatment, and care under programs funded by the U.S. taxpayer.  Under Dybul’s tenure, tens of millions of dollars have been given to ideologically-driven faith-based organizations under the controversial New Partners Initiative.

And after passage of PEPFAR 2 in 2008, Dybul acted quickly to mollify religious conservatives by writing program guidance not required by law which forbids purchase of contraceptive commodities using PEPFAR funds. This step greatly undermines integration of HIV prevention with reproductive health programs, limiting efforts to slow the rapid spread of new infections among women in sub-Saharan Africa and denying HIV-positive women in prevention of maternal-to-child transmission programs support they need to space or limit births.  The guidance flouts recommendations by global bodies such as the World Health Organization and UNAIDS, and by OGAC itself, that integration of programs is an urgent priority. Dybul also tends to take a very defensive stance in regard to problems with PEPFAR.  He holds grudges against critics and does not welcome vigorous debate on or critique of PEPFAR policies, a problem in a new Administration that has promised transparency and access and for a program which obligates nearly $50 billion in taxpayer funding.

The extension of Dybul’s tenure may well be an interim measure until the new Administration can get its bearings and make decisions about the reorganization of foreign assistance, a process that is in the early stages.  In one scenario, for example, OGAC will become part of a more integrated and revitalized effort to deliver aid abroad while also changing the nature and scope of our assistance policies and strategies.  Dybul has also worked Congress to his advantage, and built political connections that strengthen his hand.  It is quite possible that keeping Dybul until things were more settled represented the course of least resistance.

This decision is nevertheless not likely to make many in the global AIDS community happy.  Appointing a new Global AIDS Administrator, even if only for an interim period, somone with the ability to start a fresh dialogue on global AIDS policy would have signaled the Administration’s intention to make changes more clearly than keeping the old guard in place.  And if Dybul is in for the long haul, this Administration will have failed to do what is necessary to ensure confidence in PEPFAR and to make the changes necessary to replace ideology with evidence in US global AIDS policy.

 

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  • invalid-0

    I’ve been working on a project funded through the New Partners Initiative for a while now, and I hear about all this controversy, but I don’t personally see it.

    You state in your article that “tens of millions of dollars have been given to ideologically-driven faith-based organizations under the controversial New Partners Initiative.”

    Can you point me to your source for this? Like, is this all of the funding for NPI, or part of it? Which organizations that received funding do you feel are “ideologically driven” and do you have evidence that their programs, funded under NPI, are negatively impacting the communities where they are working?

    Do you feel that the NPI program has produced any positive results, or is it wholly negative?

    I have read other blogs in the past that bash this program, and, having had a different experience than is implied by this and other articles, I’m just wondering what your resource is, or if you are just repeating something you heard elsewhere?

  • jodi-jacobson

    Dear Anonymous,

    Thank you for your comments and questions.

    This analysis comes from three sources, one being my own experience on the ground interviewing people about PEPFAR programs, a second being other organizations who have done similar work, and the third being the lists of grantees and their activities themselves.  

    I and several staff of my previous organization spent several years following PEPFAR in-depth at the ground level in several countries and in regular contact with organizations holding cooperating agreements and sub-contracts in Kenya, Namibia, Nigeria, South Africa, Tanzania, and Uganda. As I and my colleagues worked with and interviewed people off the record, we found example after example of faith-based organizations recieving funding under PEPFAR whose program work was grounded in an ideological, rather than a public health and human rights approach to HIV prevention.  It is one thing for a faith-based organization to get money for providing access to treatment, which is relatively non-controversial, easily measured in terms of outcomes (numbers of people receiving drugs), and the science of which is not driven by ideologies regarding sex, reproduction and sexual identity.  It is another thing to give public dollars to organizations whose very operating philosophy precludes them from providing information, services, and methods, such as male and female condoms, that are supported by the wealth of public health evidence on how to stop the spread of HIV.  I encountered organizations funded by PEPFAR whose message included telling teens that if they had premarital sex they would burn in hell, and those vandalizing condoms prior to demonstrations to "prove" they did not work.  I encountered faith-based organizations telling women experiencing domestic violence that they should work a bit harder to make their husbands happy…a case of blaming the victim if ever there was one.  This to me is an ineffective and controversial use of taxpayer dollars.

    The focus of funding of faith-based organizations under PEPFAR has been on organizations that have an ideological bias against providing comprehensive sexuality and sexual health education and who focus on stand-alone "abstinence" and "faithfulness" programs (which are controversial in themselves because they have been shown by numerous multivariate studies not to work) to the exclusion of comprehensive approaches to prevention supported by the global public health community and proven to work.  Comprehensive meaning that all individuals have unfettered access through approaches that provide all choices objectively and without a filter.  The proof that a large if not majority share of funding under NPI went to ideologically driven programs can be found in the list of grantees on the NPI website itself, which lists one after the other organization receiving or having received funding whose ideologies preclude them from providing such comprehensive programming, as per their own descriptions of their work and their activities.

    Finally, I spent considerable time with a group whose work on HIV and AIDs long pre-dated many of the New Partners, a faith-driven organization led by clergy who were themselves HIV positive….and because they believed in comprehensive approaches they were told in no uncertain terms that they were not the "right kind" of faith based partner for PEPFAR.

    I believe the means test for using taxpayer dollars for addressing an epidemic such as HIV and AIDS–or any health care strategy–should rest with whether an organization can do the work that is needed according to objective principles of evidence and human rights, not whether or not it is "faith-based."

    For these and other reasons, this has been a controversial program.

    Thank you again for writing.

    Jodi Jacobson

    • invalid-0

      Thanks, Jodi. Let me tell you that I agree with your premise that public health programs funded with taxpayer dollars must be designed based upon scientific principles of what has been proven to be effective.

      I am a public health professional, and have been working on PEPFAR funded projects for several years. I have seen a lot of issues with PEPFAR, which I have documented in evaluations and other forums.

      However, unlike a lot of people I meet in the public health world, I have no particular love for or bias against faith-based organizations — I just want to see if they achieve results. Similarly, I have no particular love for or bias against international NGOs. The only bias I have is for community based NGOs, which I feel get the short-end of the stick in PEPFAR. But that is another story. But when it comes to any kind of international organizations, faith-based or secular, my bias is simply that programs are effective in providing quality services to people who need them.

      Here is my concern with your blog, and, in particular your calling out of the NPI program. You are basing your judgements on off-the-record conversations, and what some website supposedly says about the ideology of some organizations that were funded under this program. Now, I know this is just a blog, and not supposed to be investigative journalism, but I just feel your statements aren’t based on any real evidence of what is happening on the ground. (Perhaps your off-the-record conversations are, but I have to just take your word on that…)

      I’m not saying NPI-funded programs are or are not effective, but I don’t believe that saying that what some organization says on their website automatically precludes them from being a good service provider on the ground.

      Similarly, I’ve seen some real crap programming from international NGOs that had great vision statements on their websites… I think we can agree that what websites say doesn’t necessarily translate to effective or ineffective programming on the ground in some village in Africa.

      I am all for having big changes at OGAC, in the NPI program, and in PEPFAR in general. No professional in this field doesn’t agree with that, and everyone wants the funding to be used to save lives and mitigate the impacts of HIV in the most vulnerable places on earth. But, I just feel that the discussions that need to take place both formally and in informal blogs needs to be more evidence-based.

      On another note, some time ago, I actually spoke to one of the key people in ANERELA+ about their experience applying for NPI funding. There are always numerous reasons why organizations win or lose funding requests, but I would be shocked to hear that someone from the US Government said to someone at ANERELA+ “in no uncertain terms” that their organization was not the “right kind of faith-based organization.”

      If one stupid individual said this, then call them out. But to imply that the professionals in the US Government who work hard to manage an effective response to the AIDS epidemic would ever say such a thing about ANERELA+ is “in no uncertain terms” completely unfair.

      • jodi-jacobson

        Thanks for bringing up these points, Anonymous.  I welcome the chance to respond.  Let me take this one by one.

        First, we both agree that:

        public health programs funded with taxpayer dollars must be designed
        based upon scientific principles of what has been proven to be
        effective.

        The problem is that this has not been the case either domestically or internationally under the Bush Administration.  We have built ideological bias right into our law and our policy internationally with things like the abstinence-until-marriage earmark, prostitution pledge, so-called "conscience clause" and the de facto restrictions on needle exchange.  Virtually nothing about sexual transmission, or transmission of HIV among vulnerable populations has been governed by evidence under PEPFAR from the get-go.  Programs that existed under PEPFAR doing good work were and are surviving despite not because of these restrictions.  This problem is not a surprise: domestically we continue to fund abstinence-only programs and to give funds to questionable organizations at the state level despite a large number of studies now that disprove the efficacy of these programs.  Many groups have documented this, including Advocates for Youth, SIECUS, Legal Momentum and others.

         

        The same trend is true under PEPFAR internationally.  A large amount of funding has gone to organizations receiving funding because they are faith-based, and/or because they shared the ideology on prevention espoused by PEPFAR, not because they were equipped to do promote public health and human rights, or achieve results.  Technical committees were rigged to ensure funding to these groups; technical guidelines and peer review thrown by the wayside.  There are many examples of this and many reports on this issue.  Just one example:  The Children’s AIDS Fund Received PEPFAR Grant Despite Expert Committee’s Ruling That Request Was ‘Not Suitable for Funding.’  

        Two, we also agree on this:

        I have no particular love for or bias against faith-based organizations — I just want to see if they achieve results.

         

        I do not either have any particular love for or bias against faith-based organizations.  Period.  I have a very big problem with faith-based organizations who bend the law and the policy to suit their own ideological agendas in a manner that flouts public health and human rights principles so that they can get taxpayer money to run programs that do not work by any measure of effectiveness.  I have a problem with a government funded effort to expand funding of prevention of HIV to organizations–whether they call themselves faith-based or not–that can not work according to any acceptable principles of public health or human rights, and whose work is not able to be evaluated according to accepted measurable outcomes.  I have a big problem with religious institutions that see the world through one lens, and not only want everyone to conform to that worldview but want government funding to espouse and promote it. 

         

        And I have a big problem with lack of accountability of billions of dollars of US funding going to such efforts.  As far as I am concerned, if you can not work according to basic public health and human rights principles in carrying out work on prevention of sexual transmission, you should not get funded by the government to do this work.  Anyone can belong to any faith they want, and follow whatever principles they want.  I draw the line when those principles flout the evidence and use government money and policy to do so.  This was the basic problem with a huge share of PEPFAR funding going to FBOs.  

         

        Three, we share a concern about facts and accuracy, so I want to respond to this point:

        Here is my concern with your blog, and, in particular your calling
        out of the NPI program. You are basing your judgements on
        off-the-record conversations, and what some website supposedly says
        about the ideology of some organizations that were funded under this
        program. Now, I know this is just a blog, and not supposed to be
        investigative journalism, but I just feel your statements aren’t based
        on any real evidence of what is happening on the ground. (Perhaps your
        off-the-record conversations are, but I have to just take your word on
        that…)

         

         

        My knowledge of PEPFAR is based on the following: 10 years of work on global AIDS policy, including in-depth accountability work on PEPFAR during which time I and my staff at the time read every single cooperating agreement and contract coming out of OGAC that had anything to do with prevention.  The findings of that work, for which I was originally pilloried by OGAC and others and all of which were later confirmed by the GAO report and the IOM report and the work of numerous other organizations, led to the conclusion that  nearly 60 percent of funding of prevention of sexual transmission was going to abstinence-only programs in FY 2005 and 2006.  My analysis is further informed by a cumulative total of 8 months of field work by my staff and myself in PEPFAR focus countries between 2004 and 2007 during which we sat with officials from US missions, CDC, USAID, cooperating agencies, other donors, Global Fund, UNAIDS, countless NGOS on the ground, public health officials, government officials, regular citizens doing one-on-one interviews, focus groups and the rest.  This is not anecdotal evidence based on a couple of casual conversations nor the product of a short visit to someone’s website…..everything I have reported here has been previously reported, vetted, confirmed, worked on by others…and so on.

         

        This website contains many different forms of articles, based on investigative journalism, reporting of findings, opinion and commentary pieces and so on.   Because it is a website and blog, please do not confuse that with the lack of knowledge of the facts or capacity to conduct in-depth analysis.

         

        Finally, to your point about the work of other "international NGOs" I would agree….there is a great deal of work out there that is questionable, we should be holding everyone accountable to public health and human rights standards with clear measures of accountability, and too many organizations do not speak out about policy because they become so dependent on the US government for the bottom line.  So we agree on that too.  Has nothing to do with what is on a website….but it is a different story.

         

        Best wishes, Jodi

         

         

         

         

  • invalid-0

    Rather than get into a debate about the NPI program, I want to comment on the Obama Administration keeping Mark Dybul as the Gloabl AIDS Coordinator.

    Withholding life-saving information from young people about condoms in order to push an ideological stance against sex outside of marriage goes beyond ethical misconduct for a health care professional and borders on the realm of criminal. Any physician who believes in evidence-based, medically accurate programs should be appalled.

    Yet, this is the basis of the abstinence-until-marriage programs that are the cornerstone of the HIV prevention efforts directed at young people under PEPFAR.

    Mark Dybul was responsible for promoting this policy. As a physician, he had ample opportunity to express his support for science-based prevention strategies. He never did.

    The Global AIDS Coordinator in the Obama administration will be immediately responsible for developing a new five-year global AIDS strategy that will shape our response to the epidemic well into the next decade.

    Young people, worldwide, cannot afford to have Dybul be that person.

  • http://www.reproductiverights.org invalid-0

    Jodi,

    Thank you for this very informative posting. I agree with you wholeheartedly, but I comment only to underscore the point that the decision to keep Dybul is also a huge warning to those of us working to eliminate abstinence-only-until-marriage funding in the U.S. As you say, many reports have revealed that these programs are not only ineffective (and therefore a massive waste of taxpayer money), but also violate adolescents’ fundamental human rights, including the rights to life, health, education, information, and nondiscrimination (see http://www.reproductiverights.org/pdf/BRB_SexEd.pdf and http://www.reproductiverights.org/pdf/pub_fac_sexed_9.08.pdf). Indeed, you may be right that this decision is the most politically expedient one right now and will soon be remedied. But as advocates for sexual and reproductive rights, we need to keep the pressure on the incoming Administration to eliminate funding for abstinence programs domestically as well as internationally.

  • jodi-jacobson

    Obama has been criticized by some for naming people to his cabinet who are from previous administrations.  Generally, I understand the strategy he has taken.  There are those places, however, OGAC being one among them, where change is desperately needed.  It is unacceptable to many in the community that Dybul stay in this post. Without more information, it is as yet unclear if he is there as a placeholder or for the long haul.  An Administration that promises transparency does not need a Global AIDS Coordinator whose office required the filing by many of Freedom Of Information Act requests to find out details about how the US was spending billions of dollars on global AIDS programs.

     

    Irrespective of who replaces Dybul, the guidance and interpretation of law which has been so narrowly construed needs to change dramatically.

     

    These same changes are also urgently needed on the domestic front.  A critical issue in regard to domestic program funding is getting Congress to stop appropriating the funds for these discredited programs.

     

    Thanks, Katrina, for your comment.

     

    Jodi

  • invalid-0

    Thanks, Jodi. I am very, very interested to read more about your work examining the CA’s coming out of OGAC, and the other investigations you’ve done on PEPFAR programs.

    I have read so much noise on various websites with a lot of very general criticisms of PEPFAR, but the writers don’t base their complaints on anythings solid. I am glad to see that your analysis is based on significant research. I’m also very interested to read more about CAF (though your link didn’t work.) I am familiar with this organization, and feel they are one of two examples I have personally seen of organizations that are tainting the reputation of FBOs in general.

    I know there is a lot more funding out there for organizations to do PEPFAR work, than there is to evaluate PEPFAR work. And the funding to evaluate their work usually comes from either the USG or the organization being evaluated. Therefore, the evaluators are not always truly independent — and if anything bad is said, the USG or the organizations don’t have real incentive to publicize this information.

    Thanks for responding to my comments. I look forward to continuing to read your articles in the future.

    • jodi-jacobson

      This is all about the dialogue, debate and discussion.  I appreciate that you took the time to write and raise important issues.

       

      Jodi

  • invalid-0

    Friends sometimes have to disagree. My colleague Jodi Jacobson has written recently of her disappointment at President-elect Obama’s decisions to retain Mark Dybul as US Global AIDS Coordinator. She says Ambassador Dybul represents all that was wrong about the Bush Administration’s AIDS policies and has made a call for a stark break from the past with the appointment of a new person for this key post.
    I have mixed feelings about Dybul’s work. Under a Republican administration we could have done a lot worse than Dr. Dybul–think Bill Steiger or Tom Coburn–and Dybul did preside over a rapid and extensive roll out of AIDS treatment around the world in what is a remarkable achievement. Yes, I agree with Jodi that his association with the Bush Administration’s abstinence-only HIV prevention policies, the ban on needle exchange and the restrictions on groups aiding sex workers, eroded his credibility as a scientist driven by evidence in implementing policy and did great damage to our nation’s response to the epidemic. I’ve told him that in person and in public at at least one AIDS conference now where we’ve shared the stage.
    However, under the Clinton Administration, there were many officials and hangers-ons in Washington, DC, some of whom have expressed keen interest in the OGAC post, who are hardly profiles in courage. Some of those circling around the OGAC job never spoke out in the 90s about needle exchange , presided over an explosion of HIV infections in the African American community, particularly among black, gay men and women, and never argued for access to treatment for the developing world though the potent drugs to treat HIV infection were around for at least the second half of the Clinton reign. If it’s a choice between Clinton era retreads or DC NGO bureaucrats for the OGAC job, I’ll stick with Dr. Dybul please.
    Yes, I would like someone to be appointed to the OGAC post that is a champion of comprehensive HIV prevention and access to treatment free of the ideological baggage that came along with PEPFAR. I want someone who can provide visionary leadership and directly confront those people who have made it a fashionable thing lately to say AIDS gets too much money, or AIDS is hurting health and development overall. These ideologues are as dangerous as the Rick Warrens and Jesse Helmses of the world and may be worse because they claim to speak as progressives or public health experts. In these times, we need someone at OGAC who is a once-in-a-generation leader for a once-in-a-generation crisis.
    Until a candidate for OGAC emerges that rises to the challenges of what we face, throwing Ambassador Dybul out for the crimes of the Bush Administration and putting a craven Clintonista or an AIDS mafioso in his place won’t be doing us much good. Let’s give Ambassador Dybul a chance to work, to perform free of the constraints of the Bush Administration for the next few months and see what he does while we look for someone who can take the office to the next level. If Dr. Dybul represents the past, so do many of the names being circulated for the OGAC and other global health posts right now. Who knows? Dr. Dybul may surprise us or someone may emerge who can offer us a real change for the better, but the other choices right now are far from inspiring. So, Jodi and I will have to agree to disagree. Dybul may be of the ancien regime but I think we can work with him while we wait for something better to come along. He deserves a chance.

    • invalid-0

      Gregg -
      I think you underestimate the extent to which Dybul willingly went along with the Bush agenda on prevention that has all but destroyed a comprehensive prevention approach in many of the PEPFAR focus countries, particularly those where the USG is the source for the vast majority of their funding. It is not just that he worked under ideological restrictions on prevention, it was that he implemented them with vigor and never bothered to issue proper guidance that would not have countries all but abandoning comprehensive prevention. He did not turn a blind eye and hope that countries would continue broader approaches, he and his team worked to cajole countries into the development of Country Operational Plans that reflected the Bush/Coburn agenda. He was an active player in destroying comprehensive prevention efforts, not a bystander….a price has to be paid for that and his removal is a fine start.
      I agree with you that we need bold new leadership – regardless of the existing field of contenders. But any one of the existing field of contenders can begin to restore integrity to the US committment to comprehensive prevention. Dybul has no credibility left on the prevention front and it is hard to accept any conversion at this point given his slavish devotion to the dominance of AB over everything else.
      Why must we accept someone who has had a large hand in ushering in the destruction of a comprehensive approach to prevention? We deserve better…..and frankly, we have given Dybul years to give us a nod that he disagrees with the existing paradigm. He has never done it. That makes him a good civil servant to the right wing nightmare we can now see the other side of but it hardly justifies his staying on beyond January 20. Even Dr. Gerberding did not destroy our domestic HIV/AIDS prevention portfolio to the extent Dybul has done so internationally and she is out. Why? Because new leadership is needed for the about-face that must come….and the same is true for the international portfolio.
      So….my friend….I want to disagree agreeably with you as well.

  • invalid-0

    Jodi,

    You refer in a comment to:

    stand-alone “abstinence” and “faithfulness” programs (which are controversial in themselves because they have been shown by numerous multivariate studies not to work)

    I am a researcher on such behavior change programs, and do not know of any rigorous studies about the efficacy of abstinence or faithfulness programs in any countries in which PEPFAR operates. If you know of any, I would be very interested to know about them.

    I am certainly aware of the US research on abstinence programs, which has shown some abstinence programs to be ineffective. (Many comprehensive sex ed programs have also been shown to be ineffective, although the evidence for them seems to be much stronger. See Doug Kirby’s work.)

    I do know that there have been population-wide trends towards greater faithfulness (and in some cases greater abstinence and condom use) in a number of countries in which HIV prevalence has also declined (Uganda, Kenya, Zimbabwe, and a number of others). This has been well documented in the academic literature.

    My point here is that there is a paucity of data about the effect of actual PROGRAMS, and unless you can point to studies that have rigorously evaluated such programs in PEPFAR countries, the statement you made above does not seem to be evidence-based.

    For the record, nowhere in PEPFAR legislation is the term “abstinence-ONLY” used. I understand that abstinence-until-marriage (what the legislation does say) is equally problematic to many, but in fact many abstinence programs (in my experience including the great majority of faith-based organizations) are also committed to providing correct information on condom use. And as I’m sure you know, PEPFAR does distribute condoms to young people and is the largest distributor of condoms in the world.

    One more question– in your research did you ever speak to young people who had positive feelings about abstinence programs? In my experience there are a lot of them out there, as well as a lot of young people who are abstaining. Certainly young people who are having sex need a certain type of message and information, but the majority of unmarried youth in most if not all PEPFAR countries are actually abstaining at any point in time– and they also need support for the behavior they are choosing.

    • jodi-jacobson

      I did not originally see this comment added.

       

      You raise a range of issues both explicitly and implicitly.  Let me try to answer them.

      You are correct that the term "abstinence-only" does not appear in PEPFAR legislation.  The law say "abstinence-until-marriage."  However, as we both likely well know, laws are only as good as the interpretations brought to them, the implementation according to spirit or letter of the law, and the accountability efforts meant to ensure that laws and policies are based in reality, evidence, human rights and not ideology.  It is what happens in practice, not what the paper says, that is so important.

      From the beginning of PEPFAR, policy guidance was written and programs implemented in such a way to effectively fund abstinence-only-until-marriage programs.  I personally have read virtually all the contracts and agreements between 2004 and 2007; our work at the Center for Health and Gender Equity at that time, supported by the Government Accountability Office, showed that nearly 60 percent of all funds for prevention of sexual transmission in PEPFAR focus countries was going to abstinence-only programs.  You can also read now publicly available materials on the PEPFAR and NPI websites to see description after description of such programs.  I have explained this extensively elsewhere so will not repeat here, but the point is that the law left a huge amount of wiggle room—even for counting efforts within comprehensive programs that resulted in delays in sexual debut toward the earmark–and the Bush Administration and OGAC chose instead to fund stand-alone abstinence programs, later with some "faithfulness" thrown in.  The evidence on this is extensive….there is not room in this comment to present all of it.

       

      I want to point out something in your response that I think is too commonplace….it assumes that someone here–me specifically, RH Reality Check writers writ large—thinks there is something wrong with people "choosing" to abstain from sex, or "choosing" to be faithful. That would be wrong.

       

      I want to state this very clearly.  People have the right not to have sex.  We should encourage delay of sexual debut among adolescents.  I have two children, as I have stated here before, who are without question being taught to respect their bodies and themselves and, both implicitly and explicitly not to be drawn into sexual or other activities before they are ready.  But I also know they will likely engage in sexual activities before they get married—IF they choose to marry–and hopefully they will have long, fulfilling, and healthy lives in which sex will be a part.

       

      If someone chooses never to have sex, that is their choice and I defend it.  If someone chooses to wait until marriage, assuming they can and want to get married…same thing.  If someone decides to have sex before they are married or to have sex and never get married, or is GLBT and can’t get married because of the stupidity of legal constraints, or wants to have serial monogamous or non-mongamous concurrent relationships, I defend that too: I would simply assert that they have both rights and responsibilities….the right to have sex and the responsibility to do so only when it is truly consensual and only acting responsibly…(e.g. protecting themselves and their partners from known risks to the best of their ability).

      In short, people also have the right to have sex.  And I happen to think sex is a great thing.  

      The line gets drawn here between both the terms we use and the assumptions inherent in those terms.  Public health strategies talk about delay of sexual debut among adolescents–the longer they can delay initiating sexual activity the better, as the longer they do, hopefully the more mature and responsible their actions will be.  "Delay of sexual debut" is far different to me than the meaning of "abstinence…" which has come to represent such a loaded term…loaded with negativity about sex, with religious overtones, with scolding.  If someone does not want to wait til they get married–or never wants to get married–they have a right to have accurate information, skills and tools to engage in sexual relationships responsibly.  Equipping people to exercise rights with responsibilty is a lifelong endeavor.  You don’t produce a polite, socially conscious child-turned-adult overnight….it is a long-term project.  Likewise, you don’t turn a healthy, sexually responsible adult out overnight….children and adolescents need accurate information about their bodies, about negotiation, about saying no, and saying yes when they want to do so.  And about being prepared when they do say yes.  This is the part that gets left out in the "abstinence" discussion.  This is my problem with abstinence-only or abstinence-until-marriage….there are too many moralistic and erroneous assumptions inherent in both the terms and the approaches and the expected outcomes, not to mention the hetero-centric mindset.

       

      Same with "faithfulness."  I know many people who have been faithful to a partner and then faithful to their next partner, myself included.  Nothing wrong with this.  "Faithfulness" as a term is loaded with cultural and religious overtones.  The real issue is how do we tell people that at the population level having fewer partners overall and practicing safer sex with any and all partners is imperative without coating all of this with the religious notion of "faithfulness" in heterosexual marriage.  I would like to point out that at least one of the authors of the original legislation –a Republican–waxed terrific about faithfulness and turned out to have out-of-wedlock offspring.  Enough said.

       

      My point is: Let’s start to get real about reality.  Sex is part of being human.  Different people have different levels of sex drive, different sexual identities, different trajectories….changing circumstances throughout their lives.  Let’s equip them to make good choices no matter what path they are on.  Let’s also talk about the realities and joys of sex and recognize for example that teaching masturbation (oh, horrors!) can possibly help teens delay intercourse even longer.  

      This is why ALL comprehensive programs focus on increasing delay of sexual debut among adolescents—successfully so according to the data—as well as equipping them to be safe when engaging in sex.

      And this is why abstinence-only programs, virginity pledges and the rest fail….because they are derived from a fantasy world.

       

      The point here is: our public health efforts and efforts to ensure we fulfill the human right to basic health information should not be confused with religious morality and fear of sex.  This not only is intuitive…it is based on the evidence, of which there is a great deal out there, showing that well-designed comprehensive programs work far better than any other strategy.

       

      And this entire discussion focuses only on adolescents without realizing that the real challenge is how do we equip people to be healthy sexually for their entire lives…including through their senior years?

       

      To your point about evidence in the US versus abroad….why would we export programs found to be ineffective here with no evidence that they work?  To me, the  burden of proof is on the ab-only or ab-til=marriage advocates and I simply see no evidence that these strategies have worked.  Indeed, the fact that now in many countries those most likely to be infected are married women in their twenties and thirties tells me something.

       

      But you have provided a lot of fodder for further discussion.  Thank you.  Jodi

  • invalid-0

    Jodi,

    I think you and I agree on a lot—giving young people (and older people) the skills and information they need to make good choices, understand and take responsibility for their sexuality, etc. Of course. And I know you believe young people also have a right to choose to abstain.
    My point was about PROGRAMS—and the non-evidence based statements you make when attacking programs. In your original blog you referred to “stand-alone ‘abstinence’ and ‘faithfulness’ programs… which have been shown by numerous multivariate studies not to work.” I replied to your blog to say I’m not aware of any such evidence in PEPFAR countries, and you don’t seem to be aware of any such evidence either. So it’s simply not an evidence-based statement.
    .
    I know, I know, you will point to the failure of abstinence programs in the U.S. I have a couple points about this. One is that the situation is a little more complicated than “abstinence programs always fail and comprehensive programs always work.” I’m sure you’re familiar with Doug Kirby’s 2007 report—which I think is widely felt to be very thorough, fair, and evidence-based. He says: “Even though there does not exist strong evidence that any particular abstinence program is effective at delaying sex or reducing sexual behavior, one should not conclude that all abstinence programs are ineffective. After all, programs are diverse, fewer than 10 rigorous studies of these programs have been carried out, and studies of two programs have provided modestly encouraging results.” (He also notes that abstinence programs do not have “negative impact on the use of condoms or other contraceptives.”)
    .
    Of course Kirby argues that there is much greater evidence for comprehensive programs, but of the 48 comprehensive programs he surveys in the 2007 report, two-thirds showed some positive behavioral effects and one-third did not. My point is that programs are different—quality of programming varies, the population varies, certain particulars that we may never capture in evaluations vary. We can’t just make blanket statements.
    .
    My second point about why it’s not evidence-based to say that abstinence programs have been proven to fail (in the context of PEPFAR) is that we don’t yet have any solid evidence for abstinence programs in PEPFAR countries. (I actually know of a PEPFAR-funded abstinence program that has shown positive changes in A, B, and C behaviors, but these data aren’t yet published. I suspect there is more such data out there that hopefully will be published soon.) You say, “why would we export programs found to be ineffective here”? Well, I would say that the abstinence programs that have been evaluated here (primarily school-based programs) are pretty different from many of the programs happening in Africa, to say nothing of the populations and whole socio-cultural environment being pretty different. Things that work here may not work in Africa or other PEPFAR locations, and vice-versa. We simply don’t have the evidence base yet to say what is and isn’t working (in terms of prevention) in PEPFAR countries.
    .
    In the absence of solid evidence about PEPFAR programming, the question is not what you or I would choose for our children. The question is really what African (or other PEPFAR country) parents would choose for their children, and what those children would choose for themselves. It seems to me that in Africa abstinence programs have a huge amount of support among parents and youth themselves. (I realize Africa is a big, complex continent and this is a big generalization—but I think it is fair.) That’s why I asked the question about whether or not in your research you had encountered young people with positive feelings about abstinence programs. I know you don’t hate abstinence/delay of sex per se, but you certainly seem to hate abstinence programs, and I am baffled how you have not run into African youth—many, many African youth—who have very different, very positive feelings about abstinence programs.
    .
    You say: “ ‘Delay of sexual debut’ is far different to me than the meaning of ‘abstinence…’ which has come to represent such a loaded term…loaded with negativity about sex, with religious overtones, with scolding.” That’s fine that you feel that way, but actually I don’t really care how you feel about it. I think the relevant question is how Africans themselves choose to speak about these things. If they want to call it “delay”, fine. If they want to call it “abstinence,” fine. I’m sure there are a hundred other terms out there in a whole bunch of languages and dialects—great! I know there has been some research done on people misunderstanding the term “abstinence”—and that’s a very real concern. Of course programs should be sensitive to what language communicates in their context. If “abstinence” doesn’t work as a term in a certain context, let’s use something else—but my experience is that it is the term used by many English-speaking Africans. If you don’t want to use the term “abstinence”, that’s certainly your right. But why should you blackball it for others who feel it’s just fine?
    .
    Ditto with “faithfulness”. You say “ ‘Faithfulness’ as a term is loaded with cultural and religious overtones.” Okay, for you it is. Maybe it’s not for everyone else. The point should be what communicates to people in the program context, not what is felt by US experts to be too culturally or religiously loaded. And why is a cultural and religious association bad, anyway? To most Africans, religion and/or traditional culture are very important. A culturally and/or religiously-grounded message may be exactly what will reach some people. Others may need something totally different. I’m certainly not arguing that all AIDS programs should be religious or appeal to traditional culture—for some people, that won’t work at all. But for some, it will. People are different! Why would we US experts blackball “faithfulness” or religious/cultural messages just because we have personal problems with them? That makes no sense! The point should be what is appropriate and effective for the cultures in which these programs operate.
    .
    In response to another statement in your post—you claim that “nearly 60 percent of all funds for prevention of sexual transmission in PEPFAR focus countries was going to abstinence-only programs.” In my opinion this is laughable! As you probably know, some of the biggest recipients of abstinence program funds have been very well respected organizations such as FHI and PSI. Are you really accusing these organizations of doing abstinence-only programming?? Faith-based organizations (who everyone seems to believe are the real abstinence-only bad guys) have NOT gotten the majority of abstinence funds, and not even the majority of NPI funds.
    .
    Furthermore, the vast majority of FBO abstinence programs that I am aware of (I might even say every FBO program I know of, not that I know every one) are solid, life-skills based programs that provide accurate information on condoms and if they can’t give out condoms themselves, provide referrals to organizations that can. I understand this is far from ideal as far as you’re concerned. But can’t you be a little more nuanced in your statements, rather than making specious claims about 60 percent of funds going to abstinence-ONLY programs? There is simply no evidence for this.
    .
    One more thing. You say: “the fact that now in many countries those most likely to be infected are married women in their twenties and thirties tells me something.” What specifically does it tell you? There is a lot of discussion now among greater HIV risk among women, and certainly we should be concerned. We need to figure out what is contributing to women’s risk and what is going to reduce that risk. But actually women in their 20s and 30s who are not married (in Africa and probably elsewhere) are far more likely to be HIV infected than women who are married. Check the DHS data if you don’t believe me. The vast majority of women in their 20s or 30s are married—so of course the great majority of HIV-infected women in these age groups are also married. That doesn’t mean there is a causal relationship between the two.
    .
    And as I’m sure you’re aware, some recent research shows that in 30 to 40 percent of discordant couples in Africa it’s the woman and not the man who is infected. Once again, my point is not that we shouldn’t be concerned about very high HIV rates among women. But I’m really not sure what connection you were trying to make between high HIV among women in their 20s and 30s and abstinence programs. Furthermore, the explanations often given for high HIV among women (namely women’s purported powerlessness and men’s infidelity) clearly aren’t the whole story, as the discordancy data tell us.
    .
    Thanks for the continuing discussion.

  • http://floodcontroller.com invalid-0

    And after passage of PEPFAR 2 in 2008, Dybul acted quickly to mollify religious conservatives by writing program guidance not required by law which forbids purchase of contraceptive commodities using PEPFAR funds. This step greatly undermines integration of HIV prevention with reproductive health programs, limiting efforts to slow the rapid spread of new infections among women in sub-Saharan Africa and denying HIV-positive women in prevention of maternal-to-child transmission programs support they need to space or limit births. The guidance flouts recommendations by global bodies such as the World Health Organization and UNAIDS, and by OGAC itself, that integration of programs is an urgent priority. Dybul also tends to take a very defensive stance in regard to problems with PEPFAR. He holds grudges against critics and does not welcome vigorous debate on or critique of PEPFAR policies, a problem in a new Administration that has promised transparency and access and for a program which obligates nearly $50 billion in taxpayer funding.

  • http://aquadry.org/ invalid-0

    Give me a break

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