PEPFAR MythBusters: Episode Two

Healy Thompson

Yesterday, I blogged about how PEPFAR's Third Annual Report to Congress reveals that the United States is not doing as much on treatment in the 15 focus countries as many believed it was. I combated the myth that PEPFAR (the President's Emergency Plan for AIDS Relief) is providing treatment for 822,000 people.

Today, I combat another treatment myth—that generics account for 70% of PEPFAR's expenditure on anti-retroviral AIDS drugs. And I take issue with the argument that since the abstinence-until-marriage spending requirement is "only one-third of the prevention budget, it really isn't that big of a problem."

Yesterday, I blogged about how PEPFAR's Third Annual Report to Congress reveals that the United States is not doing as much on treatment in the 15 focus countries as many believed it was. I combated the myth that PEPFAR (the President's Emergency Plan for AIDS Relief) is providing treatment for 822,000 people.

Today, I combat another treatment myth—that generics account for 70% of PEPFAR's expenditure on anti-retroviral AIDS drugs. And I take issue with the argument that since the abstinence-until-marriage spending requirement is "only one-third of the prevention budget, it really isn't that big of a problem."

Myth: Generic drugs now make up 70% of the PEPFAR expenditure of ARVs (antiretroviral drugs).

Reality Check: In FY2006, generics accounted for 27% of the money spent by PEPFAR in the 15 focus countries on antiretroviral drugs.

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Where did the myth come from? From unclear charts in a PEPFAR report in May of 2006.

In May 2006, PEPFAR released a report entitled Bringing Hope: Supplying Antiretroviral Drugs for HIV/AIDS Treatment. Figures on pages 9 and 10 indicate the percentage of "FDA-approved generic products" of total procurement in the focus countries. The figures show this number to be 70%. A footnote for the chart on page 9 says that "FY06 data represents a limited sample of four respondents." The larger chart on page 10 includes no such footnote, so anyone looking only at that chart (which is also easier to read for many people because it's a pie chart instead of a line graph) would not know that the 70% figure represented only four "respondents."

(It's not clear from the footnote or the surrounding text whether "respondents" means countries or programs in countries. However, a chart on page 10 of Bringing Hope, shows generic drugs percentages for three countries—Haiti, Nigeria, and Zambia—and these are the three countries that a November 2006 Boston Globe article reported as having 70% generics.)

Poorly footnoted figures aren't the only thing to blame for the confusion on generics numbers. There is also the issue of what the numbers are a percentage of. That is, what "total procurement" are we talking about? And that's a question I can't figure out the answer to based on the information in the reports. The figure that included 70% was based on a "total procurement" of the ARVs pot that was expected to be $279 million for FY06 (see page 1 of Bringing Hope). However, the numbers in the annual report (where the 27% generics number came from) indicate that PEPFAR spent $109.8 million in FY06 (fiscal year 2006) to procure ARVs.

While there are certainly questions to be answered about what that 70% figure really referred to, the fact of the matter is that for more than half a year advocates and the media praised PEPFAR for its major scaling up of generic drugs in the programs it is funding. The 2007 annual report to Congress shows that the "major scale-up" has not been very major. The U.S. is only spending 27% of its spending on antiretroviral drugs on generic drugs.

Myth: "Abstinence-until-marriage is only a third of the prevention budget so it's not that big of a problem."

Reality Check: As CHANGE (Center for Health and Gender Equity) has said for some time now, the question shouldn't be what percentage of the total prevention budget is going to abstinence-until-marriage programs but what percentage of the budget for the prevention of the sexual transmission of HIV is going to abstinence-until-marriage programs. Since 40% of the prevention budget in FY2006 went to preventing the non-sexual transmission of HIV (prevention of mother-to-child transmission and preventing the medical transmission of HIV), this is a crucial distinction.

In FY2006, one-third of the total prevention budget went to meeting the abstinence-until-marriage earmark and those programs represented 56% of the prevention of sexual transmission budget. Other programs to prevent the sexual transmission of HIV accounted for just 44% of the budget for the prevention of sexual transmission of HIV and just 27% of the total prevention budget.

PEPFAR refers to this other prevention of sexual transmission money as "Condoms and Related Prevention Activities," however this is a misnomer intended to mislead Congress, the media and members of the advocacy community. Footnote number 2 on page 38 of the annual report explains briefly what that category includes:

"Examples include mass media and community outreach programs to promote avoidance of or reduction of HIV risk behavior, community mobilization for HIV testing, and the social marketing or promotion of condoms, including work with high-risk groups such as injecting drug users, men who have sex with men, people in prostitution and their clients, and people living with HIV or AIDS."

So, the category "Condoms and Related Prevention Activities" actually includes a lot of programs that aren't condom education and distribution or even necessarily related to condoms. Also, the U.S. requires that …

"… [f]or programs that include a ‘C' component, information about the correct and consistent use of condoms must be coupled with information about abstinence as the only 100 percent effective method of eliminating risk of HIV infection; and the importance of HIV counseling and testing, partner reduction, and mutual faithfulness as methods of risk reduction."

(That's from the PEPFAR ABC Guidance.)

So, whereas it has been argued that the earmark is only one-third of prevention money, we see that when taken as a share of prevention of the sexual transmission of HIV (which is all abstinence-until-marriage is used for), abstinence-until-marriage programs (which are really abstinence-only-until-marriage programs) account for 56% of funding. Only 44% of the budget for prevention of the sexual transmission and 27% of the total prevention budget goes to non-abstinence-only-until-marriage responses to the sexual transmission of HIV even though sexual transmission accounts for 80% of all new HIV infections.

Intrigued by my reporting on the PEPFAR report to Congress? Check out www.pepfarwatch.org for more information about PEPFAR. You can also visit www.pepfar.gov/progress for more of PEPFAR's public reports.

News Health Systems

Texas Anti-Choice Group Gets $1.6 Million Windfall From State

Teddy Wilson

“Healthy Texas Women funding should be going directly to medical providers who have experience providing family planning and preventive care services, not anti-abortion organizations that have never provided those services," Heather Busby, executive director of NARAL Pro-Choice Texas, said in a statement.

A Texas anti-choice organization will receive more than $1.6 million in state funds from a reproductive health-care program designed by legislators to exclude Planned Parenthood

The Heidi Group was awarded the second largest grant ever provided for services through the Healthy Texas Women program, according to the Associated Press.

Carol Everett, the founder and CEO of the group and a prominent anti-choice activist and speaker, told the AP her organization’s contract with the state “is about filling gaps, not about ideology.”

“I did not see quality health care offered to women in rural areas,” Everett said.

Heather Busby, executive director of NARAL Pro-Choice Texas, said in a statement that it was “inappropriate” for the state to award a contract to an organization for services that it has never performed.

“The Heidi Group is an anti-abortion organization, it is not a healthcare provider,” Busby said.

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State lawmakers in 2011 sought to exclude Planned Parenthood from the Texas Women’s Health Program, which was jointly funded through federal and state dollars. Texas launched a state-funded version in 2013, and this year lawmakers announced the Healthy Texas Women program.

Healthy Texas Women is designed help women between the ages of 18 and 44 with a household income at or below 200 percent of the federal poverty level, and includes $285 million in funding and 5,000 providers across the state.

Bubsy said the contract to the Heidi Group was “especially troubling” in light of claims made by Everett in response to a recent policy requiring abortion providers to cremate or bury fetal remains. Everett has argued that methods of disposal of fetal remains could contaminate the water supply.

“There’s several health concerns. What if the woman had HIV? What if she had a sexually transmitted disease? What if those germs went through and got into our water supply,” Everett told an Austin Fox News affiliate.

The transmission of HIV or other sexually transmitted infections through water systems or similar means is not supported by scientific evidence.

“The state has no business contracting with an entity, or an individual, that perpetuates such absurd, inaccurate claims,” Busby said. “Healthy Texas Women funding should be going directly to medical providers who have experience providing family planning and preventive care services, not anti-abortion organizations that have never provided those services.”

According to a previous iteration of the Heidi Group’s website, the organization worked to help “girls and women in unplanned pregnancies make positive, life-affirming choices.”

Texas Health and Human Services Commission spokesperson Bryan Black told the Texas Tribune that the Heidi Group had “changed its focus.”

The Heidi Group “will now be providing women’s health and family planning services required by Healthy Texas Women, including birth control, STI screening and treatment, plus cancer screenings to women across Texas,” Black said in an email to the Tribune.

Its current site reads: “The Heidi Group exists to ensure that all Texas women have access to quality health care by coordinating services in a statewide network of full-service medical providers.”

Everett told the American-Statesman the organization will distribute the state funds to 25 clinics and physicians across the state, but she has yet to disclose which clinics or physicians will receive the funds or what its selection process will entail.

She also disputed the criticism that her opposition to abortion would affect how her organization would distribute the state funds.

“As a woman, I am never going to tell another woman what to tell to do,” Everett said. “Our goal is to find out what she wants to do. We want her to have fully informed decision on what she wants to do.”

“I want to find health care for that woman who can’t afford it. She is the one in my thoughts,” she continued.

The address listed on the Heidi Group’s award is the same as an anti-choice clinic, commonly referred to as a crisis pregnancy center, in San Antonio, the Texas Observer reported.

Life Choices Medical Clinic offers services including pregnancy testing, ultrasounds, and well-woman exams. However, the clinic does not provide abortion referrals or any contraception, birth control, or family planning services.

The organization’s mission is to “save the lives of unborn children, minister to women and men facing decisions involving pregnancy and sexual health, and touch each life with the love of Christ.”

News Law and Policy

Texas’ ‘Fetal Remains’ Rule Could Draw Legal Action

Teddy Wilson

The Center for Reproductive Rights cited statements made by Gov. Greg Abbott (R) soliciting campaign contributions to support his efforts to “establish higher standards that reflect our respect for the sanctity of life.”

Proposed rules requiring cremation or burial of fetal remains may result in “costly litigation for Texas—litigation state taxpayers can scarcely afford,” the Center for Reproductive Rights (CRR) said in comments submitted to the Texas Department of State Health Services (DSHS).

Stephanie Toti, senior counsel at CRR, said in a statement that if Texas lawmakers continue to interfere with reproductive health care, the organization will take legal action. 

The DSHS quietly proposed new rules that would prohibit abortion providers from disposing of fetal remains in sanitary landfills, and would require that fetal remains be buried or cremated. 

The rules were published July 1 without notice or announcement in the Texas Register.

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The new regulations would apply to all fetal remains regardless of the period of gestation. Under the proposed rules, any other tissue, “including placenta, umbilical cord and gestational sac,” could still be disposed of through “grinding and discharging to a sanitary sewer system; incineration followed by deposition of the residue in a sanitary landfill.”

Health commission spokesperson Bryan Black told the Texas Tribune that the rules were developed to ensure high sanitation standards. “The Health and Human Services Commission developed new rules to ensure Texas law maintains the highest standards of human dignity,” Black said. 

The rules would require approval from the Republican-held state legislature.

Gov. Greg Abbott’s (R) spokesperson Ciara Matthews said in a statement that the governor is hopeful the legislature will approve the rules. “Governor Abbott believes human and fetal remains should not be treated like medical waste, and the proposed rule changes affirms the value and dignity of all life,” Matthews aid.

CRR cited statements made by Abbott in a fundraising email in which the governor solicited campaign contributions to support his efforts to “establish higher standards that reflect our respect for the sanctity of life.”  

CRR contends that Abbott’s statements undercut “the state’s claims that these regulations have anything to do with protecting women’s health and safety.”

Blake Rocap, legislative counsel for NARAL Pro-Choice Texas, told Public News Service that the regulations will increase the cost of abortion care and the amount of people involved in the process.

“The rule creates ambiguity and involves other licensed professionals, like funeral service directors and cemeteries that are not involved in medical care, and shouldn’t be involved, and don’t want to be involved in it,” Rocap said.

Carol Everett, an anti-choice activist and supporter of the proposed rules, made dubious claims that methods of disposal of fetal remains could contaminate the water supply.

“There’s several health concerns. What if the woman had HIV? What if she had a sexually transmitted disease? What if those germs went through and got into our water supply,” Everett told the Austin Fox News affiliate

The transmission of HIV or other sexually transmitted infections through water systems or similar means is not supported by any scientific evidence.

The new rules could have unintended consequences for medication abortion care. The proposed rules state that “products of spontaneous or induced human abortion” are subject to the law “regardless of the period of gestation.”

Under Food and Drug Administration regulations, the second part of the medication abortion regime can be taken at home. The new Texas rules could effectively ban medication abortion because an embryo miscarried at home through medication abortion cannot in practice be buried or cremated.

The Texas Alliance for Life supports the new GOP-backed rules. However, Texas Alliance for Life executive director Joe Pojman told Rewire that he was unsure what effect the new rules might have on medication abortions. “We’re going to have to study that further,” Pojman said.

Rocap told Public News Service that proposed rules are part of a “pattern of overreach” by Texas lawmakers targeting abortion providers. “This rule was proposed in the dark of night without any openness, which lets you know that they know they’re doing it the wrong way.”  

DSHS has announced a public hearing on the proposed regulations Thursday at 9 a.m. central time.  

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