Political Ideology, HIV Infection, and PEPFAR

Article Outline

• The Good
• The Bad and the Ugly
  • The ABCs
  • Reproductive Health
  • Sex Workers
  • Homosexuality
  • Faith-Based Funding
• For a Few Dollars More
• References
• Copyright

Look at the world as it really is, not through the rose-colored, corrupt glasses of ideology.

—Ben Stein, September 21, 2008 CBS Sunday Morning

Have you read the recent evaluation of the President's Emergency Plan for AIDS Relief (PEPFAR; Evertz, 2010)? It provides an interesting analysis of successes and problems with PEPFAR as well as an agenda to improve this global initiative to stem the tide of the HIV epidemic. Evertz, the first openly gay appointee of a Republican president, served in two different HIV-related positions in the Bush White House. His analysis of PEPFAR comes from an insider's perspective, but his comments are tempered by a pragmatism that was not often applied to HIV during the previous administration.

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The Good 

In 2003, President George W. Bush supported the United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act, which authorized and funded PEPFAR. The Act was reauthorized in 2008 when, in an extremely supportive move, funding levels were doubled. These legislative activities provided a significant boost to international efforts to address HIV and other global epidemics. They brought appropriate accolades to the United States as it entered the fray. PEPFAR signaled a commitment to communities around the world that said: We know this is the right thing to do. We know that people are suffering and that we need to send them support from the United States to bear their problems.

The following benefits have definitely been seen: through global partnerships, PEPFAR has made a difference in the lives of an estimated four million people who now have access to antiretroviral therapy, to 10 million HIV-infected people who have received health care services, and to 240,000 infants who were protected from HIV through proper treatment for their mothers (Ambassador Goosby highlights accomplishments, outlines vision for the future of PEPFAR, 2009). A lot has been accomplished, and PEPFAR has been—rightfully—lauded as the best legacy of the Bush administration.

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The Bad and the Ugly 

However, as with most things, PEPFAR is often not all that it is cracked up to be. The really bad and ugly components of PEPFAR have been swept under the rug and even I (yes, even liberal I), have been guilty of saying, “But look at all of the good it has done. I know it is not perfect, but all those people have benefited—many are alive today because of PEPFAR. How can you argue with that?” The time has come to look at reality and to account for the problems as well as the successes. Fortunately, Evertz (2010) has provided the overview needed for this exercise.

The overarching problem area for PEPFAR was its base in a political ideology that could be boiled down to the following statement: “If we don't approve of it, we aren't going to fund it.” This is perhaps a simplistic take on the issue, but it is also clearly the way things emerged with PEPFAR.

The ABCs 

The Bush administration did not approve of sexual activity outside of a monogamous, committed, married, and heterosexual relationship. This ideal led to the adoption of an edited version of the ABCs (abstain, be faithful, use condoms), known as the more directive “population specific interventions” (Evertz, 2010, p. 9), which focused on abstinence and fidelity, with a nod to condoms as a final alternative. But even this intervention deteriorated over time until we were left with only A (abstain until marriage) and B (be faithful within the context of marriage).

What happened to the C in the ABC formula? Condom use was denigrated as unimportant—after all if you were abstinent until marriage and then faithfully monogamous, why would you need condoms? Condoms were only for sex workers, homosexuals, drug users, and other stigmatized individuals, but—because of purposive disruptions to condom supplies in many PEPFAR countries, including Uganda—even those individuals had a hard time getting access to condoms.

Evertz (2010) also commented on domestic efforts to discredit condom use. In 2002, the Centers for Disease Control and Prevention replaced a fact sheet on effective use of condoms on their Web site with a version that did not give information on how to properly use condoms. The Centers for Disease Control and Prevention also removed information about five scientifically validated studies on the effective use of condoms to prevent disease transmission. Even the U.S. Agency for International Development removed information related to condom effectiveness from their Web site (p. 8).

Reproductive Health 

Because the Bush administration also refused to support comprehensive reproductive health care (fearing the issue of abortion), birth control information was severely limited at PEPFAR-funded sites, even if funds were received from sources other than PEPFAR. The U.S. “global gag rule” on abortion services (which has been lifted by the current administration) effectively eliminated access to comprehensive reproductive health education and contraception information (including condoms) for millions of women and infants at risk for HIV infection in one-sided monogamous relationships over which they had no control.

Sex Workers 

Because the Bush administration did not approve of sex workers, it insisted on a “prostitution pledge.” This policy required that all potential PEPFAR grantees explicitly state their opposition to prostitution, which, once again, applied even if funds were received from sources other than PEPFAR. Although most reasonable people understand the personal and public health risks related to sexual relationships with sex workers, preaching abstinence to sex workers and making them feel unwelcome are sure ways to keep them out of health care services, a condition that is an obvious barrier to public health concerns.

Homosexuality 

Because the Bush administration was opposed to homosexual activity (a case of loving the sinner but not the sin), gay, lesbian, bisexual, and transgender (GLBT) concerns were largely ignored in PEPFAR programs. The uncontested disregard for the basic human rights of GLBT individuals further entrenched the stigma, discrimination, and violence directed toward these communities and drove them further into the closet without access to health care and prevention education. However, it is hard to tell how much of an effect HIV has had on GLBT populations in developing countries that have essentially ignored and stigmatized this vulnerable group of individuals.

Faith-Based Funding 

Because the Bush administration actively promoted faith-based approaches for a broad spectrum of issues, funding to faith-based organizations increased rapidly between the years 2000 and 2008, and many of those grants were for PEPFAR programs. To encourage faith-based applications, the Bush administration drastically changed longstanding rules that maintained the separation of church and state. These grantees have been allowed to co-mingle HIV-service delivery and religious services in the same space (as long as they did not happen simultaneously), to require their employees to take oaths of loyalty to specific religious tenets, and to display religious symbols in areas where health care services were being delivered. Faith-based funding was a win-win situation for the Bush administration. As a group, these grantees were happy to encourage abstinence and fidelity in marriage, downplay reproductive health concerns, ignore GBLT health care needs, and take the anti-prostitution pledge. Suffice it to say that faith-based organizations were more likely than others to follow the ideological base set forth by the administration.

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For a Few Dollars More 

Evertz (2010) provides a list of eight recommendations to redirect future PEPFAR programming on the basis of scientific studies rather than religious and partisan ideology. They include considering the human rights, culture, and context of the individuals to whom services are directed. They also propose increasing the focus on legitimate prevention methods.

The major focus of PEPFAR has been the distribution of antiretroviral medications and improved HIV-care services. This is a worthy concern, which has accounted for 55% of all PEPFAR funds. It is hard to argue against providing services to HIV-infected people, but when palliative care and support for orphans (both important needs) are introduced into the mix, this leaves only 20% of PEPFAR funds for prevention. In 2006, that 20% was further stressed by a requirement that 66% of the allotted prevention money be dedicated to abstinence and fidelity measures (Evertz, 2010, p. 11), despite the lack of evidence that these programs work to prevent HIV transmission. Although this rule was rescinded in the 2008 PEPFAR reauthorization, it was replaced with a reporting requirement that the U.S. global AIDS coordinator provide justifications in cases where prevention funds dedicated to abstinence and fidelity fall to less than 50% of total allotments (Evertz, 2010, p. 31).

In my opinion, it is time to do the things that can truly change the face of the HIV epidemic, and those measures must be applied to domestic as well as global funding programs. Money needs to be spent on evidence-based, pragmatic, and culturally appropriate programs that have been shown to make a difference in risk behaviors.

I am reminded of a young man I met in South Africa. He was probably 16 or 17 years of age, incredibly cute, and cockily sure of himself. One of the women in my group told him that he really did not need to be having sex. His response was, “Yes, I do.” She continued to push him and it got into a “no, you don't/yes, I do” match until he said, “I have to have sex because if I don't have sex I'm not a man.” This kid taught us all an important lesson that day. We do not know what people have to contend with in their social and cultural contexts and we cannot know all of those issues, even if we visit them in their communities. Sexual issues are complex, and a simple “No, you don't,” is an inappropriate, incredibly insensitive, and ultimately futile approach. As my friend, Tom Donohoe says, “Culture eats strategy for lunch.”

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References 

1. Ambassador Goosby highlights accomplishments, outlines vision for the future of PEPFAR. Retrieved from http://www.pepfar.gov/press/docs/132021.htm2009, November;
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2. Evertz SH. How ideology trumped science: Why PEPFAR has failed to meet its potential. The Center for American Progress and the Council for Global Equality. Retrieved from http://www.americanprogress.org/issues/2010/01/pepfar.html2010, January;
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