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PEPFAR Politics vs. Public Health

Kelly Castagnaro

As expected, the House wrapped itself in a big red bi-partisan bow when discussing PEPFAR, and Rep. Steny Hoyer said the bill shouldn't fall prey to "political sport." Here's hoping this weekend's Final Four is more competitive than the PEPFAR reauthorization ever was.

During the House debate to reauthorize the President's Emergency Plan for AIDS Relief (PEPFAR), Majority Leader Steny Hoyer praised the $50 billion effort saying that global AIDS is too large an issue to “fall prey to political sport.” In sports there are winners and losers, but PEPFAR had win-win potential. Hoyer went on to say the bill “will not make everyone happy.”

The issue here should not be about being happy or providing comfort to politicians to skirt around real life issues that will determine if someone can protect themselves against HIV. Despite all the flowery language about bipartisanship and compromise, key issues that should have been addressed in PEPFAR fell prey to political sport, and people will lose not just a game, but their lives.

This game came at the expense of good public health policies. Why? Because policy makers would rather avoid fundamental issues like human sexual relations, even though they are central to confronting the HIV pandemic. Everyone knows you can't play sports unless you address sound fundamentals first.

The political sport ends up looking like this:

Sex. Abortion. Parenthood. Power.

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In the name of reducing HIV infections, the majority inbounds a consensus bill that includes support for voluntary contraceptive services for HIV positive women, in case a woman decides she doesn’t want to become pregnant again. The GOP ideologues then steal the issue with hyperbolic claims that abortion is being promoted as a way to prevent HIV. They shoot, they score, as Democrats (heavily favored to win due to their majority status) watch helplessly. Democrats tense up and start to play nervous.

From the stands public health experts are shouting that by enabling funds for HIV prevention education and services, including testing, to go to family planning providers, we can reach more people at risk of HIV – helping to slow the spread. Their shouts are backed up by facts that no one on the floor seems to care about.

The GOP takes the ball away from the Democrats and again asserts that providing HIV prevention through family planning services is really about expanding abortion. Like basketball before the shot clock, conservative ideologues just keep tossing the abortion issue back and forth even though it has nothing to do with PEPFAR, leaving Democratic leadership playing defense. Even some of the Democrats' fans, you know the types, the rock stars that always get court side seats, turn around to tell the public health experts from the stands to just be quiet and enjoy the game.

Rep. Betty McCollum (D-MN) gets the ball and moves it up the court, working through the legislative process to enable HIV/AIDS education, counseling and testing activities to be provided by a larger group of health care providers, particularly because part of the mission of the reauthorization is to expand services. Her shot is blocked by those claiming that to maintain the delicate compromise, we cannot talk about the issue on the House floor, and she, and her good efforts, are sidelined. Another last minute shot on the floor comes from Rep. Joe Crowley (D-NY), suggesting we shouldn’t limit access to HIV prevention services by enacting a strangle hold where individuals can receive these services. Again, his shot is blocked by those who say, in the name of compromise, nothing can be changed.

The slam dunk would have been to simply, honestly and straightforwardly acknowledge that HIV is primarily a sexually transmitted infection. To slow the spread of the infection, we need to reach people where we can – to encourage testing and to provide the range of tools to protect themselves from HIV.

The obsessed anti-choice Republicans who are supporting this bill spent a lot of time on the House floor indicating there is a moral obligation for the US to continue leadership in this area. Agreed. The moral obligation they didn’t discuss – and don’t support – is that to be truly pro life is to take every action available to prevent the spread of HIV – not only the ones that fit into their personal definition of morality, but in the public health framework of what works. That includes better access to prevention, education and contraception for women through integrated HIV/family planning services.

No doubt PEPFAR will continue to do good – but the question remains, why add constraints that make it impossible to do more, prevent more infections, and protect more lives with the resources available?

As Rep. Hoyer said, PEPFAR shouldn't have fallen prey to political sport. What he didn't say was that it had before the game even got started. The fix was in. The public health experts in the cheap seats left the stadium hoping the team can do better next time and vowing to keep cheering them on with evidence, stats and real world experience that supports their case. The celebrity fans left unconcerned about the outcome of the game so long as they keep getting those cool front row seats.

Fighting AIDS is About More Than Money … Read RHRealityCheck's extensive PEPFAR coverage.