PEPFAR Wins Money, Compromises Principle

Scott Swenson

The moment to improve PEPFAR based on reality and public health passed before the House Foreign Affairs Committee was ever convened. Americans frustrated with political game playing over dedicated problem solving will see this as one more reason Washington must change.

Americans need look no farther than the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR) to understand why dramatic and fundamental change is needed in Washington. The good intentions of American taxpayers wanting to extend a helping hand to Africans ravaged by the global AIDS pandemic got caught between far-right Republican ideologues and Democrats interested in claiming victory in compromise over producing principled legislation based on sound science.

PEPFAR's mission, to turn back the spread of HIV/AIDS in Africa, a mostly sexually transmitted disease, was compromised because American legislators cannot discuss sexual and reproductive health openly and honestly. Ironically, the major changes to the bill that secured the compromise were those dealing with sexual and reproductive health, thus compromising the integrity of the bill. The compromise reached with the White House was presented by House Foreign Affairs committee staff as a done deal, all efforts seemingly geared toward avoiding any genuine debate on the very issues of sexual and reproductive health experts agree are central to getting the upper hand on HIV/AIDS.

For 25 years social conservatives ignored HIV, using it marginalize people and allowing the disease to run rampant. Now that they've discovered the issue, their ideology prevents them from allowing public health experts to use proven scientific methods to educate, prevent and treat. The Democrats who compromised on evidenced-based principles are politically complicit.

The PEPFAR reauthorization, in some ways, was over before negotiations even began. Too many people signaled a willingness to compromise on issues that have nothing to do with PEPFAR before the gavel called the committee to order. All the far-right had to do was scream abortion and Democrats, along with a few activists who understand the science and public health implications, ran for cover.

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Ignoring the Institute of Medicine, General Accounting Office, Center for Public Integrity and other objective organizations working to improve PEPFAR, the compromise that has been spun by some as a success by focusing on increased dollars, fails to apply lessons from the first five years of PEPFAR ensuring those dollars are spent wisely.

The result of compromise based in political fear is more bureaucracy, and a program now so politicized that under GOP administrations one can imagine more insistence on failed abstinence programs, and during Democratic administrations, more emphasis on sound science and public health. Like the Global Gag Rule, which committee Democrats have agreed to extend to PEPFAR, these monies will be subject more to politics than public health.

This flies in the face of every bit of advice given on how to improve PEPFAR in keeping with best practices of other international aid efforts.

There is some good news:

$50 Billion. The White House has agreed to the Congress' demands for a $50 billion, five-year program, up from the $30 billion President Bush requested. More money is good; more money spent more wisely, based on reality, evidence and public health, would have been better.

Women, Girls and Youth. The new bill includes efforts to address some of the unique circumstances that women, girls and youth face, including efforts to confront violence against women, promoting property and inheritance rights, expanding economic opportunity to promote financial independence, and efforts to work with men and boys to reinforce positive attitudes and the human rights of women.

Other positive outcomes include increased training of health care professionals and support for nutrition programs.

Now for the bad news.

Abstinence-only. The 33 percent abstinence-only earmark is being eliminated; that should be good news. But in its place is a requirement that 50 percent of funds for preventing sexual transmission be spent on "behavior change," defined as abstinence, delay of sexual debut, monogamy and fidelity. The bill puts in place a system that requires local public health officials to report if they are not going to comply with the provision. The abstinence earmark is gone, but the tone set by the new requirement is easily misinterpreted by the time these restrictions get to the field level, especially on the heels of the abstinence-only earmark under which these providers have been working.

Instead of learning the lessons from PEPFAR suggesting that program and message consistency and cohesion is important in coordinating international aid with local programs, the White House and the House Foreign Affairs Committee have agreed to a process where public health officials must worry more about remaining eligible for grants than preventing HIV.

One characterization of the language in the bill obtained by Rewire says that these exemptions will be "based on objective epidemiological evidence."

News Flash! The objective epidemiological evidence is in and it suggests, conclusively, we should abandon abstinence-only programs and stop forcing program requirements based on narrow ideologies as they impede PEPFAR's ability to achieve its goals, and work cohesively with other international aid programs that base their decisions on sound science and public health strategies.

One characterization of this provision states,

The PEPFAR administrator is to provide balanced funding for prevention activities for sexual behavior and prevention of HIV/AIDS, funded in a meaningful and equitable way in the strategy for each host country based on objective epidemiological evidence. If this strategy provides less than 50 percent of such sexual transmission funds for behavior change programs, the Coordinator shall report to the appropriate Congressional committees the justification for this decision.

The details of program decisions should be made by qualified public health professionals on the ground in Africa, who understand the culture and the needs. Abstinence-only policies either work or they don't, and all the evidence from five years of PEPFAR indicates they don't. Congressional micro-management only serves to perpetuate the ludicrous notion that failed abstinence-only policies have any place at all in these programs. This goes beyond traditional oversight, and serves to empower a far-right vocal minority that has demonstrated it is more interested in ideological politics than saving lives. That Democrats continue to cave to the minority in this way seems to suggest they prefer to see success in getting more money, than using any amount wisely.

Preventing Mother to Child Transmission. The U.S. Conference of Catholic Bishops lobbied and successfully removed provisions that allowed voluntary contraception services to be offered to participants in programs working to prevent mother to child transmission of HIV. The World Health Organization clearly states that voluntary contraception is one of the most important aspects of preventing mother to child transmission.

About the Bishops role in the negotiations, Jon O'Brien, President of Catholics for Free Choice said,

The approach adopted by the US bishops, in partnership with Catholic Relief Services (CRS), stems from a self-serving perspective that few Catholics share, let alone those of other and no religious preference. Catholics in the United States and elsewhere support aid for international family planning and reject abstinence-only education. Studies show that properly directed funding for international family planning programs saves women's lives and the lives of their children when those women have HIV/AIDS. Many studies, including some sponsored by the US Congress, show that abstinence-only programs do not work. The bishops ignored this evidence to ensure that their own narrow, out-of-the-mainstream beliefs held sway on Capitol Hill.

Global Gag Rule. Only family planning organizations that sign the Global Gag Rule are now eligible for PEPFAR money. This has a direct impact on organizations like the Ethiopia Family Planning Association, which has been getting PEPFAR dollars and effectively integrating HIV education, testing and counseling along side the family planning services paid for with non-PEPFAR monies. Because EFPA has not signed the Global Gag Rule they will lose PEPFAR dollars.

Family planning organizations were not seeking to use PEPFAR money to perform or counsel abortions. They want to help provide contraception and reproductive health services along side HIV services, instead of forcing women to walk miles between various clinics. PEPFAR's first five years demonstrated the importance of integrating these services, but the far-right succeeded in politicizing PEPFAR by raising abortion, and the Democrats and some activists chose compromise over principle.

Prostitution Pledge. The Democrats voluntarily gave up the prostitution pledge without the Republicans asking them to do so. The pledge effectively restricts organizations receiving money from PEPFAR from working with prostitutes, who are one of the most vulnerable populations in terms of contracting HIV, and a primary target group to slow the spread of the disease.

Instead of acknowledging the reality of sex workers and taking a smart public health tact to direct money to fight the problem at its source, again based on mounds of evidence, the Democrats chose to walk away from an issue they did not want hanging over their heads in November. Evidently they are more worried about how they will spend millions of dollars on their re-election than the few dollars it would take to reach out to sex workers with contraception, education and prevention programs geared to slowing the spread of HIV.

Katee Reik of Health Gap wrote on the blog for University Coalition for Global Health,

Experts have argued that this requirement means that local groups have to choose between providing treatment, services and support to individuals who engage in sex work in order to survive and ignoring those at higher risk for HIV infection. Representative Ackerman from New York responded that saving the lives of women who engage in survival sex is in the best interest of public health.

The press releases attempting to cover the tracks of those complicit in compromising sound science are flying through email, spinning the success of new money while bemoaning the failures to reach agreement on family planning and other issues that required more backbone than spin.

The reality is this was a moment missed. A moment to work together to put politics aside and follow the sound advice of people in the field based on science and public health. It was a moment to prove that a Democratic majority could do something differently, better, for the people of Africa.

Will more lives be saved with this bill? Yes. Could we have saved even more? Without doubt. Why didn't we? Some people put politics over public health, and compromise and complicity became more important than principle. Raise your glass in a toast to politics as usual.

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