This week, Michael Gerson called me and my colleagues in the prevention and reproductive and sexual health advocacy community liars in the New York Times, and "weasels" in the Washington Post.  (And note that the author of the Times article slipped in the word "abortion," which had basically nothing to do with this discussion to date, but just for good measure and because Gerson can’t maintain an argument on these issues without waving that red flag for the base….).

Whew!  Quite a week.  I think I remember watching a similar argument unfold  on the playground in elementary school.

Why all the vitriol?  Because we ("we" being the weasels) present evidence revealing that while PEPFAR provides life-saving anti-retroviral treatment for an estimated 1.5 to 2 million people (exactly how many additional people PEPFAR *added* to treatment remains unclear), PEPFAR fails on prevention.

Let me be clear: PEPFAR has indeed strengthened treatment access and saved lives.  

I repeat: There are many good things about PEPFAR.

But the program is and has been unsustainable in the long run unless the United States is willing to foot the bill for treating untold numbers of people well into the future even while our own health care system crumbles and an estimated 46 million US citizens lack health care coverage. 

I realize that for many AIDS advocates–myself among them, though of course from the "weasel" genus–these politics are personal in that we know and have friends among the millions who are infected with or affected by HIV and AIDS.  And to forestall comments suggesting otherwise, I think it is
important to address the AIDS epidemic head-on. 

The question is how
and in what context.

Because the realities of the bigger picture also are personal.  This morning, for example, I opened my email to learn of a mother in our own school district who herself is on dialysis and with chronic health problems, whose middle-school son has just died of a congenital heart problem for which she had trouble affording and accessing ongoing basic care for his condition and whose daughter has the same health problem and is now in failing health.  There is no father in the home.  They cannot afford health care in their own country.   She was unable to afford funeral expenses for her son.  These stories abound and will increase as people continue to lose jobs and health insurance in the United States.

And therein lies the dilemma.  

We have huge problems in both prevention and treatment across the board, here and abroad.  We need serious overhauling of our basic health strategies here, and of our international health policy and funding for things like HIV and AIDS, tuberculosis, malaria, reproductive and sexual health, and in other areas.  We need to spend our money better and more sustainably.  And we need someone, anyone, in some legislative exercise to stand up for what is right even when being lobbied by powerful interests like the Catholic Church to spend money in ways that are more about religious ideology than about health and saving lives. 

This is no secret and no great revelation.

But prevention is critical to the success of any public health strategy.

And PEPFAR under current law and policy fails on prevention.

And by failing on prevention, it fails overall.  When you have an epidemic in which:

* new infections far outpace the rate at which you can put more people on treatment;
* becoming infected is most likely still a death sentence because there is no foreseeable way through which everyone suffering from AIDS-related illness can gain access to treatment in a timely manner;
* the costs of preventing a new infection are far lower than treating the next new AIDS case and when the same prevention strategies for HIV bring you multiple other positive outcomes;
* BUT you have loaded your prevention programs with restrictions authored by or at the behest of the Catholic Church and the evangelical right…..

…then you have set yourself up for failure.

And since the myth of PEPFAR’s unmitigated success represents the "grand distraction" from the mess made of the US and the world by eight years of Republican rule under Bush, it is hard for the now out-of-power Republican right PEPFAR cheering squad to take it when the evidence is presented and their myths are exposed.

It became even harder when Mark Dybul was dismissed as Global AIDS Coordinator, because he remained the lifeline for the far right into global AIDS funding.  Dybul had been trying to push through more restrictive guidance interpreting the so-called conscience clause under PEPFAR to accommodate the US Conference of Catholic Bishops before it was "too late."

Moreover, had he stayed even "for a while," he was poised to facilitate funding for the Church and many evangelical groups in the next round of grants now coming due for renewal.  We would then be stuck with "non-prevention" prevention strategies for another 12 to 18 months, continuing to leave people unnecessarily at risk of HIV infection.  I suspect the loss of that possibility is at least in part behind the post-Dybul hysteria, along with the fears incited in the AIDS community by the conversations now going on about less-siloed approaches to health and disease and more integration in our international approaches, which they fear might lead to PEFPAR losing its unique status.

In his screeds, Gerson presents no evidence to refute the problems cited with prevention.  He just calls names.  This is schoolyard politics and my first thought was that I would have expected more of the Post than to hire columnists who throw tantrums based solely on ideology.  But I remind myself that I also would have expected a lot more investigative research by the Post, the New York Times and many others on PEPFAR the past 5 years, and well, let’s just say I stopped holding my breath a long time ago.

Remember….this was the same media that just went along with WMDs.

So, rather than engaging Gerson, we will simply present the evidence, here, again in full view.

See Rewire this week on the myths and facts about PEPFAR prevention strategies.