Madame Speaker, Make a Difference for Women on HIV

Scott Swenson

When it comes to PEPFAR, is Speaker Nancy Pelosi better for women and girls, or is President Bush's Global AIDS Coordinator, Dr. Mark Dybul? The Democratic Majority seems to be ignoring the pleas of public health experts.

This presidential primary season is serving as a national teach-in on race and gender issues as America confronts, once again, its history of struggling with the notion that all of us are created equal. The hope of many progressives is that by electing more women and people of color to higher offices, our government will better reflect the sensibilities of the diverse nation we are.

So it is disappointing when a staff member of Speaker Nancy Pelosi, discussing the President's Emergency Plan for AIDS Relief (PEPFAR), compares the bill now before Congress to the recently passed economic stimulus package. PEPFAR has the potential to save millions of lives, the economic stimulus package is intended for American consumers to go buy new gadgets. Public health experts and economists have their doubts about both efforts, due to politics as usual.

The comparison intended by the Pelosi staffer is that PEPFAR, like the stimulus package, will be marked-up, compromised, voted on and passed before any real debate occurs. According to sexual and reproductive health advocates who heard the comment, the comparison indicated that while their concerns about the bill had been noted, nothing would change.

Assuming the staff member reflects the Speaker's views on PEPFAR, it appears she is more interested in passing a bill quickly than making sure PEPFAR achieves its goals. Recent action in the House Foreign Affairs Committee, which compromised vital aspects of the bill before mark-up, is more evidence of the Speaker's plan to rush PEPFAR. This is particularly upsetting given changes to early drafts of PEPFAR that have been compromised by the Democrats, jeopardizing the lives of millions of women and girls.

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Compare the attitude of the Speaker's office to that of Ambassador Mark Dybul, M.D., U.S. Global AIDS Coordinator, as expressed in a letter to the International Planned Parenthood Federation in 2006. The letter clarified PEPFAR's complex ideological restrictions (three years after it first passed):

President Bush has stated that the conditions of the Mexico City Policy "shall not apply to foreign assistance furnished pursuant to [PEPFAR]." Accordingly, all U.S. Government funding solely for HIV/AIDS activities is exempt from the Mexico City Policy.

But the new Democratic Majority's compromise plan, implemented by the staff of the House Foreign Affairs Committee, applies the Mexico City Policy, also known as the Global Gag Rule, to PEPFAR. PEPFAR has nothing to do with abortion, which is what the Global Gag Rule deals with. Democrats did not remove onerous ideological restrictions, they added another one, and on abstinence-only shifted one set of confusing rules to another, just to placate social conservatives.

Amb. Dybul's 2006 letter continues,

… there are numerous reasons why the linkages between voluntary family-planning and HIV prevention and care are important, particularly as we reach out to women who are vulnerable and can face tremendous stigma and barriers in accessing care. Programs supported by the U.S. Government to prevent mother-to-child transmission include linkages with voluntary family planning to ensure quality care, with goals that include prevention of unintended pregnancy among HIV-positive women, in keeping with the World Health Organization guidelines. Evidence also shows that, particularly in high-HIV prevalence settings, voluntary family planning and antenatal care clinics can be important venues for reaching women with HIV prevention, treatment, counseling and testing, and other interventions or referrals. We have made our staff aware that voluntary family-planning clinics and programs are an important HIV/AIDS care delivery point, and play a key role in reducing morbidity and mortality from HIV/AIDS.

But the Democratic Majority's plan, being marked up in the Senate next week and scheduled for a House vote soon, missed the opportunity to apply World Health Organization guidelines with respect to women and girls. Their plan to pass the bill quickly, just like the economic stimulus package, ignored the advice of the Institute of Medicine, Government Accounting Office and Center for Public Integrity that suggested PEPFAR should be streamlined, its ideological restrictions removed, to help more people.

Letters now in circulation from researchers, sexual and reproductive health advocates, public health experts and people who have been on the ground working to implement PEPFAR with its existing ideological restrictions, urge Congress to take a different path. From one letter,

… 75 percent of persons living with HIV still lack access to anti-retroviral therapies (ARVs) needed to ensure they can live long and productive lives. However, there are also seven new infections for every person accessing treatment. Today, we have the benefit of five years of lessons learned and of a strong and growing body of evidence that underscores an immutable fact: We cannot end the global AIDS epidemic without concurrent and dramatically increased support for robust, evidence-based prevention strategies. To achieve our goals, the US must put evidence ahead of ideology in its effort to reauthorize PEPFAR, ensuring the maximum benefit from the resources invested.

Political expediency — avoiding a fight with a dwindling minority of social conservatives — seems more important to Democrats than making sure PEPFAR works. Political expediency seems more important than efficiently distributing the generous $50 billion to NGO's working in Africa, with less bureaucracy so they can focus on their life-saving work.

From another letter signed by experts and advocates urging the Democratic Majority to change course,

… mis-characterizations and untruths were used to remove from the draft, language supporting expanded access to contraceptives for HIV positive women receiving prevention of maternal-to-child transmission (PMTCT) services. We are simply mystified at the failure to support the World Health Organization’s (WHO) standards for these programs. WHO recommends that family planning services be provided to women in PMTCT services should they choose to prevent another pregnancy. Sound health practice appears to have fallen prey to those program implementers who simply do not believe in contraception – putting their own wishes above the health and well being of those they are charged with serving.

The 2003 legislation created barriers to sound health programming and HIV prevention work with sex workers. These men and women are often disenfranchised and without social and health support systems – and US law has put additional barriers in place, rather than paving the way for undertaking more health care interventions with them. Because this community is deeply affected by HIV/AIDS, now is the time to remove these barriers and promote best practices in working with these communities

To President Bush's credit, PEPFAR has helped prevent mother-to-child transmission in Africa in more than three million cases. PEPFAR provided counseling and testing to more than nine million people, 69 percent of whom were women. Sixty percent of the people getting treatment for AIDS from PEPFAR are women. But the reality is that this year, 2.5 million more men, women and children will become infected with HIV. Some of those women and girls will be infected by husbands who have visited sex workers. Sex workers forced into this work because of poverty, many trying to support children of their own. Sex workers made more vulnerable by President Bush's requirement effectively restricting public health outreach to them. The Democratic Majority is now complicit in this failure of leadership, by compromising the Global Gag Rule and the Anti-Prostitution Pledge, thus making this program more complex.

We cannot hope to catch up to, let alone get ahead of, infection rates, if we continue to compromise sound public health strategies for the sake of political expedience. Do people supporting the compromised bill really think we'll have a different conversation five years from now without more courageous leadership?

Senator Barbara Boxer (D-CA) has a chance to help improve the bill, as do other concerned Representatives and Senators. But it appears they will have to do it over the objection of Speaker Pelosi. The question is, will they, or will Congress once again prove how tone deaf it can be to voters demanding more accountability, more solutions, more reality and less ideology.

If ever there was a moment for women and men to demonstrate leadership in Congress and stand up for women and girls in Africa, this is that moment.

If ever there was a moment to ignore the far-right ideologues and make a principled stand for sound public health strategies, literally the difference between life and death for many women and girls, this is that moment.

If ever there was a moment to prove that electing and elevating more women and people of color really can change our politics, and not just on the surface, this, Madame Speaker, is that moment.

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