Advice to the New Global AIDS Coordinator: Report Shows Changes Needed

Last week, the Senate confirmed Dr. Eric Goosby as head of the Office of Global AIDS Coordinator (OGAC). The good doctor could not arrive soon enough. Expectations are high that his leadership will be just the remedy to restore integrity and legitimacy to the President’s Emergency Plan for AIDS Relief (PEPFAR) – a good program whose potential for greatness was compromised by the Bush Administration’s dogged and consistent pursuit of ideologically motivated non-sense. This is the legacy that Dr. Goosby inherits.

This week, SIECUS is offering up some welcoming guidance to Dr. Goosby, his team at OGAC, and colleagues at USAID by releasing the second in our series of reports on how PEPFAR has shaped prevention policy in select countries. This report focuses on Zambia and, while I have previously written on RH Reality Check about the impact of the still-existent anti-prostitution loyalty oath on prevention work in this African nation, our new report focuses on the larger prevention dynamics in the country.

Titled Making Prevention Work: Lessons from Zambia on Reshaping the U.S. Response to the Global HIV/AIDS Epidemic , the report highlights just how severe the impact of recent U.S. HIV/AIDS prevention policy has been on this nation where an estimated 15% of the population is HIV positive and where life expectancy has plummeted to less than 39 years.

Our report highlights what $577 million in U.S. funding has accomplished during the first four years, specifically focusing on prevention. Based on extensive research and on-the-ground interviews with a wide diversity of parties, our report reveals the qualitative impacts of U.S. policy and we highlight six specific areas of concern.

First, the overemphasis on abstinence-until-marriage served to further constrict the range of prevention programs required to meet the diverse needs of a multilayered epidemic. 

Second, our extensive interviews on the ground with a wide array of partners made clear that widespread confusion resulted from U.S policy and that very little direction was offered at the country level to help clarify what types of prevention programs could and could not be funded.

Third, comprehensive sex education is nearly non-existent and, without it, even the best intentioned HIV prevention programs have an uphill battle.

Fourth, even U.S. funded implementers acknowledged a pervasive “Silent C” reality means condoms have virtually disappeared from the prevention paradigm. We ourselves noticed that social marketing of condoms was non-existent in the Zambian capital where approximately 10 percent of the population lives.

Fifth, the chilling factor of the U.S. anti-prostitution loyalty oath has left entire communities with active commercial-sex sectors without sufficient prevention outreach.

And, sixth, local NGO’s have thus far not been adequately brought into solving their own nation’s epidemic raising serious concerns about the sustainability of prevention as U.S. funding is eventually scaled back.

The report covers a great deal more ground on these points than can be provided here, but, taken together, these six areas represent a prevention agenda in the country that needs an immediate course adjustment as the second phase of PEPFAR rolls out. And, we have to remember, this is not just about politics and policies. This is about what we can do to help the Zambian people help themselves and save the next generation from the fate met by approximately one million of their countrymen who have died from AIDS-related illnesses since 1990. Yes, one million – and in a country with only 12 million people.

So what can be done to make prevention work? The report highlights seven recommendations that, with the election of Barack Obama as President, become not a cry into the wind, but rather concrete steps to be undertaken with swiftness.

1) The time has come to shift away from the abstinence-until-marriage nonsense that has been proven ineffective, and has also been disastrous in nearly destroying a more comprehensive approach to prevention in many countries who received the largess of U.S HIV/AIDS assistance, including Zambia. This is a matter wholly solvable by new leadership at OGAC.

2) After years of requests for more transparency around how PEPFAR funds are being spent, little progress has been made. The transparency promised by the Obama Administration must be translated to PEPFAR and, in particular, what types of prevention activities are being carried out, what materials and curriculum are being used, and who exactly are the multitude of sub-grantees receiving funding but not appearing on grantee lists?

3) PEPFAR was originally crafted as an emergency plan and as it now transitions to a greater emphasis on sustainability, it must focus on developing the capacity of local, in-country NGO’s to more substantially contribute to the prevention work in their country. The tired thinking that bemoans that local NGO’s lack absorptive capacity must transition from being an excuse into a challenge to be met. These NGO’s must also increasingly become engaged alongside their governments in developing the operational plans to address their epidemics. We heard many times in Zambia that the country’s plan was written primarily by U.S. mission staff with minimal country input. That has to be flipped on its head by new OGAC leadership.

4) Congress must rescind the anti-prostitution loyalty oath. Yes, it is a long shot that this will happen before another PEPAR reauthorization, but it is the moral and right thing to do. In the meantime, OGAC should work with countries to ensure that prevention activities are re-established to meet the needs of those engaged in commercial sex work.

5) Greater efforts must be made to implement programming and create policy which connects HIV/AIDS to other sexual and reproductive health issues. This can be supported at a number of different levels if OGAC provides explicit leadership to prioritize this at the decision making levels both in Washington and on the ground. It can no longer be just a principle in the ether but must be concretely carried out and models of best practices need to be widely supported.

6) The refusal clause in current law allows any funded provider of prevention, care and treatment to deny services based on moral or religious objections. This is a violation of human rights and its persistence is a troubling reminder of just how far the previous U.S. Administration debased our moral standing in the world. It must be repealed by Congress. OGAC can also do a great service by finally collecting data from grantees about who is taking advantage of the refusal clause. This can help in planning supplemental interventions from other donors until this embarrassing vestige of darker days can be put to rest.

7) Finally, and perhaps most importantly for SIECUS’ own work going forward, is that U.S. HIV/AIDS assistance must prioritize comprehensive sex education as the foundation for HIV prevention. We cannot expect to significantly impact generalized epidemics if we are not reaching the maximum number of people with basic literacy on how to protect their health and to do so before they are sexually active. Comprehensive sex education works and every major public health entity around the world is calling for it to be scaled up. OGAC and US AID should quickly join that consensus. The work that has moved forward in Latin America and the Caribbean and encompassed in the Mexico City Declaration on Sex Education and HIV Prevention provides an excellent model to follow.

New leadership at the helm in Washington creates an opportunity. As advocates, we need to seize that opportunity and need to move from the position of critical observer, outside the mechanisms of decision making to being the civil society partner, alongside our colleagues in government. In other words, we need to take back our rightful place that for the past eight years has been occupied by the likes of extreme organizations like Concerned Women for America.

The end of our isolation is at hand.  But rejoining the effort must be balanced with the thoughtful and often difficult work of making sure that we hold our new leaders accountable for the change that is needed. SIECUS’ new report on lessons from Zambia provides a roadmap to help right prevention. Our cards are on the table – face up – and we look forward to Dr. Goosby’s arrival and working together to realign sane policy with the enormous and compassionate investment of our nation to end the HIV/AIDS pandemic.

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    While your article was interesting, I don’t see any mention of the fundamental problem being faced by PEPFAR right now; the lack of money. After years of growth in spending on international HIV/AIDS programs towards the end of the Clinton administration and throughout the Bush administration, President Obama has turned his back on the international response by proposing a miniscule 2% increase in next years HIV/AIDS budget. In normal circumstances I would say that an increase is still an increase, but in this case the growth in need for treatment plus the increasing need for second line therapy means that President Obama’s proposed budget will literally leave people to die (mostly in Africa). This despite Senator Obama’s praise for PEPFAR and his vote to massively increase HIV/AIDS spending internationally. Had a Republican president proposed what President Obama has just proposed, there would be outrage and there would be accusations of playing politics with an essentially successful program. Instead the left seems committed to letting the president do what he wants without any criticism of a proposal which will force people off treatment. If you have any doubts that this is the case, look at the Free State in South Africa where the government has already made a concerted effort to allow people to die of what is a treatable disease.

    As for prevention, to be fair there is some pretty convincing evidence that countries which have pursued a full ABC approach have done much better than those who have merely pursued condom distribution. Where I believe PEPFAR has failed is in silencing the “C”, as you mention, not in promoting the “AB”.

    What I wonder is if you will criticize PEPFAR under the Obama administration as they fund interventions which have limited evidence of success? For example we are now seeing PEPFAR promoting the MCP approach (multiple concurrent partners). MCP, in my opinion, seems truly unworkable. Who has concurrent partners as opposed to just having multiple partners? How do you identify those people (with the exception of prostitutes)? Where are the studies which show that MCP works? The data is sadly lacking, as is your silence towards the promotion of such unproven approaches.