Smart Investments in AIDS and Global Health: Building on What Works


The response to the HIV/AIDS pandemic has transformed

global health financing and programming, demonstrating the

potential to make substantial progress against diseases in low-

This article is part of a series on global AIDS issues to be published
by Rewire throughout December.  It is drawn from a report
co-produced by amfAR (The Foundation for AIDS Research) and
The Center for Global Health Policy of the Infectious Diseases Society of America.

A full copy of the report including all tables,
graphs and references cited can be found here. Other articles in the series can be found by searching “global AIDS 2009” on Rewire.  

The response to the HIV/AIDS pandemic has transformed global health financing and programming, demonstrating the potential to make substantial progress against diseases in low- and middle-income countries and placing a new emphasis on accountability, public engagement, and the health needs of the most vulnerable populations.

There are indications that the U.S. government is considering a significant slowing in the scale-up of global AIDS programming in 2010 and beyond. Such a slowdown would have serious negative impacts on both the global response to the AIDS epidemic and broader efforts to advance global health.

Instead of pulling back, U.S. policy makers should leverage the achievements of the AIDS response, continue the accelerated scale-up of HIV/AIDS prevention and treatment, and use these efforts as a foundation on which to build broader and more sustainable healthcare capacity in low- and middle-income countries. Such strategies capitalize fully on
global health investments made over the last several years.
Over the last decade the U.S. commitment to global HIV/AIDS initiatives has grown markedly.

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The Response to the AIDS Pandemic to Date

Over the last decade the
U.S. commitment to global HIV/AIDS initiatives has grown
markedly.  Funding for PEPFAR [The President’s Emergency Plan for AIDS Relief), which includes all bilateral funding for HIV and tuberculosis (TB), and U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria], has risen from $2.3 billion in FY 2004 to more than $6.6 billion in FY 2009. Among all sources worldwide, available funding to address the HIV/AIDS pandemic has grown from an estimated $2.1 billion in 2001 to $15.6 billion in 2008.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has documented many positive outcomes from these investments, including dramatically expanded coverage of lifesaving antiretroviral therapy (ART) among children and adults, from 5 percent of those in need in 2003 to 42 percent in 2008.

Many of the investments made in HIV/AIDS programs have also yielded important outcomes well beyond HIV and AIDS. There are preliminary but clear indications that investments in HIV/AIDS programs are demonstrating sustainable positive
results—establishing new healthcare infrastructure and
catalyzing policy change—that hold promise for improving healthcare for millions.
The HIV/AIDS response is beginning to reverse the overall trend in mortality

  • A study of Ugandan adults found a 95% reduction in mortality in HIV-infected
    individuals after 16 weeks of combination treatment with ART and co-trimoxazole, an 81% reduction in mortality in their
    uninfected children younger than 10, and an estimated 93%
    reduction in orphanhood.

  • In Brazil, ART has led to a 40–70 percent decrease in mortality, a 60–80 percent decrease in morbidity, an 85 percent decrease in hospitalization of people living with HIV/AIDS, and savings of $1.2 billion in healthcare costs.

  • Through the implementation of HIV/AIDS programs, in Botswana infant mortality rates have dropped and life expectancy has increased for the first time in many years.
    The AIDS response directly benefits the treatment and prevention of other diseases. 


The AIDS response
directly benefits the treatment and prevention of other

  • ART was associated with a 75 percent decline in the incidence of malaria in a study conducted among HIV-positive patients in Uganda.

  • Distribution of insecticide-treated nets has been incorporated into comprehensive care strategies for HIV-positive people in many malaria-endemic areas. A qualitative study conducted in HIV-affected households in Rakai, Uganda, reports excellent retention and appropriate use of nets distributed as a part of a PEPFAR-supported community-based outpatient HIV care program.

  • HIV program implementers have begun to integrate TB  diagnosis into HIV treatment and
    care. In one Rwanda program, for example,
    HIV-positive patients are
    now routinely screened for TB.
    In Uganda, integrated HIV
    and TB care at nearly 90 clinics helped
    achieve a doubling of the
    TB assessment rate for ART patients
    over two years.

  • In a study of a South African community with high prevalence of HIV and an established TB
    program, there was a significan correlation between the
    rollout of ART and a decline (more than 75 percent) in annual TB
    notifications among people receiving ART.


The AIDS response is
strengthening health
services and primary care
in many settings:

The global response to
HIV/AIDS has helped develop health infrastructure and
general health systems in many settings.
  Nearly one-third (32%) of
PEPFAR investments are directed towards strengthening health
systems through programs to build human ca-
pacity, provide technical
assistance, create laboratory infrastructure, enhance supply chain
management, and strengthen monitoring and evaluation systems.

The Global Fund is also a
major contributor to health system strengthening. Approximately 35% of Global Fund
resources are used to that end,
providing invaluable support for human resources, training, and
infrastructure and equipment. In addition to providing
many health systems benefits, scale-up of AIDS services has also
revealed fragilities in health systems that existed before the
AIDS epidemic.
33 In some cases, expanded financing for HIV/AIDS
services has placed additional burdens on healthcare workers and
health systems struggling to deliver HIV-related and other

Still, AIDS programming
offers a blueprint for advancing primary care in
resource-limited countries. A
chronic disease characterized by periods
of illness and periods of health, HIV/AIDS impacts patients and
their families throughout their lives. 
The response to AIDS has
led to a patient-centered, holistic model of care, with high levels
of patient engagement and a range of supportive services to
promote retention in care and adherence to medications

Delivery of HIV/AIDS treatment has also led to the strengthening of systems to ensure continuity of care that can be replicated to help treat other chronic diseases such as diabetes, cardiovascular disease, and mental illness, and to help tackle problems such as malnutrition and gender and social inequality.

  • A  study in rural Haiti found that delivery of integrated HIV/AIDS treatment and
    prevention helped achieve a number of primary health goals,
    including expanded vaccination, family planning, TB case
    finding and treatment, and health promotion.  The study also showed improved staff
    morale and enhanced confidence
    in public health and medicine.

  • A study of PEPFAR-supported  sites in Rwanda found that offering comprehensive
    HIV services led to fundamental
    improvements at public
    health centers, including training
    laboratory technicians
    and nurses, providing medical
    supplies and equipment,
    and renovating laboratories
    and clinics.

  • Since the start of PEPFAR, improvements in the safety andadequacy of blood
    supplies have been made in 14 countries
    with high prevalence of
    HIV infection.
      By 2007, national policies on blood supply
    safety had been established in
    12 PEPFAR countries and
    were in development in the two
    remaining countries. 

  • In Zambia, Namibia, Malawi, Uganda and Guyana, PEPFAR-funded programs have used
    financial and other incentives
    such as special
    allowances for housing, transportation,
    hardship, and education
    to promote improved distribution
    of health workers in
    rural and remote areas.

  • As HIV treatment programs have been implemented, hospital admissions have
    declined dramatically and hospital
    beds have been freed up
    in many communities hit hard by
    the epidemic.44
    For example, after ART was introduced in
    Botswana, the percentage
    of hospital beds occupied by
    people living with
    HIV/AIDS fell from 93 percent to 52 percent in one


The AIDS response can
help address the global health workforce crisis

The AIDS epidemic has
ravaged the healthcare workforce in the developing world.  For example, in Lesotho and  Malawi, the
single greatest cause of
health worker attrition is death from HIV/AIDS.
  ART roll-out has saved the lives of thousands of healthcare workers,
allowing them to continue providing care. 

The World Health
Organization estimates that more than four million healthcare
workers are needed to fill the deficit of doctors, nurses, and
other professionals who form the backbone of the healthcare system.
The situation is most dire in sub-
Saharan Africa, which has
11% of the world’s population but 24% of the global burden
of disease and only 3% of the world’s health workers.

The AIDS response has had
a mixed impact on the health worker crisis. For
example, global AIDS initiatives have been associated with some
migration of healthcare workers away from the public sector.
But in many instances, HIV programs have helped to strengthen
healthcare workforce retention by providing new training
opportunities, better working conditions, and other support for
many healthcare workers,
such as special
allowances for housing, transportation, hardship, and education
to promote improved distribution of health workers in
rural and remote areas. 

  • In fiscal year 2008, PEPFAR spent approximately $310 million to support training
    activities; from 2004 to 2008, the program supported an estimated
    3.7 million training and retraining encounters for healthcare

  • The AIDS response has inspired “task-shifting” and other innovative solutions to
    the workforce crisis, freeing up doctors and nurses to attend to
    critical patient needs while cultivating a cadre of engaged
    community health workers.
    1  One study in Rwanda demonstrated that
    task-shifting the administration of ART reduced demands on
    doctors’ time by 76% over a two-
    year period.

  • PEPFAR has highlighted the dearth of health professionals in Africa and mounted a
    strong response, from training and
    task-shifting initiatives
    to a new mandate, included in the
    2008 reauthorization of
    PEPFAR, that calls for the training
    of 140,000 new healthcare
    workers in 15 target countries by
    2014. This and other efforts to address the
    workforce crisis
    will only be realized
    with adequate funding.


The AIDS response is
strengthening government
and program

PEPFAR, the Global Fund,
and other HIV/AIDS programs are focused on demonstrating
tangible results based on clear objectives and
accountability measures. This outcomes-driven orientation has been key
to the programs’ success and has helped cultivate similar
performance-based models in other health initiatives.
Indeed the Commission on Smart Global Health Policy at the Center for
Strategic and International Studies has recommended that
PEPFAR-created platforms be the basis for extending more effective
measurement frameworks into other priority health areas.

  • From  its inception,  PEPFAR has set specific targets for delivering AIDS treatment,
    reducing rates of HIV infection, and
    meeting the care needs of
    millions of adults, orphans, and
    vulnerable children.
    PEPFAR’s ambitious targets have helped
    drive planners and
    providers to focus on results and have led to
    the development of new
    monitoring and evaluation systems.

  • Performance-based financing, a founding priniciple of the Global Fund, has created
    a variety of mechanisms to ensure
    accountability, including
    key performance indicators on all
    Grant recipients are held accountable for specific
    targets throughout the
    life of the grant.


Principles for Moving Forward

Identify opportunities
for new areas of investment while
building on achievements
to date, including HIV/AIDS programs.

The intensive response to
HIV/AIDS through PEPFAR has demonstrated the profound
impact that can be achieved when programs have sufficient
resources and are focused on achieving specific outcomes.  The most deadly diseases, such as AIDS, malaria, and TB, will
continue to need dedicated programming even as more funds are
invested in general health systems and other health needs.  Disease-specific programs, including
those for HIV/AIDS, will
continue to play a critical role in strengthening overall health systems
and advancing the response to other diseases.

While increasing efforts
to strengthen overall healthcare
systems, ensure that
these systems meet the health needs
of vulnerable

Women and girls, gay men
and other men who have sex with men, transgender people,
injection drug users, migrant workers, sex workers, and other
socially marginalized groups are often at elevated risk for HIV and
other health concerns.  These
groups are also often
marginalized in their societies, have limited or no access to health
services, and are in some cases not even counted in health statistics.
  Strengthened health systems can only be effective at addressing a
community’s health needs if they are able to serve those who are most vulnerable.


Use PEPFAR programming as
a foundation for broader health service
scale up

PEPFAR is evolving from
an emergency relief effort to a comprehensive system for
implementing health interventions in partnership with
countries.  It has worked with
countries to develop five-year
strategies, partner implementation plans, and effective approaches
to fund management, metrics, and evaluation. These core
processes, already well established in many countries, can be
used as a foundation for addressing a range of health needs.

For example:

  • Expand PEPFAR’s new health system strengthening framework to address the
    other priorities in the President’s Global Health Initiative,
    including child and maternal health.

  • Expand the PEPFAR New Partners Initiative
    that seeks to enhance the capacity
    of NGO, faith-based, and other community efforts to
    improve civil society engagement in addressing health needs.

  • Create incentives for different health service delivery networks, including
    PEPFAR, TB control programs, and Neglected Tropical
    Disease service sites to work collaboratively to
    maximize cost-effective, high-quality delivery of multiple
    health services.

  • Ensure vulnerable populations at highest risk (including MSM, sex workers, and
    injection drug users) receive services that meet their
    needs as PEPFAR moves to build country capacity.

  • Ensure that healthcare professionals trained under PEPFAR also receive clinical
    training and mentorship on other
    relevant infectious
    diseases and primary healthcare delivery, including training that
    addresses stigma, discrimination, and mistreatment of
    marginalized and vulnerable populations.

  • Strengthen and expand laboratory capacity in countries to respond to diagnostic and
    clinical monitoring needs in TB, malaria, maternal and
    child health, and family planning.

  • Ensure the provision of healthcare for women living with or at risk for HIV
    infection by integrating family planning
    services with HIV care
    delivery and scaling up the provision
    of HIV counseling and
    testing at family planning sites.

  • Prioritize  the development of integrated systems of screening and care for
    HIV and TB to reduce morbidity and
    mortality in co-infected


Bring HIV/AIDS and other
global health services to scale

  • Fund PEPFAR at the levels authorized by Congress through the Lantos-Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis and Malaria
    Reauthorization Act of 2008. 

  • Provide significantly increased resources through the Global Fund and other programs
    to ensure the Administration’s Global Health Initiative
    broadens the U.S. approach to global health while
    maintaining the commitment to scale up the response to HIV/AIDS,
    TB, and malaria.

  • Launch a coordinated operations research agenda across federal agencies to identify the best models for integrating HIV/AIDS programs and other health services. 

  • Coordinate efforts across federal agencies to ensure research findings relevant to the Global Health Initiative are implemented in developing country settings as quickly as possible.

  • Support the development of local generic ARV production capacity in Africa and
    craft strategies to drive down the cost of second- and third-line

As the Obama
administration and Congress develop and implement a new Global
Health Initiative, it will be essential to determine the most
strategic approaches and best opportunities for
achieving broad global health goals across a range of diseases and conditions.  Evidence to date
indicates that resources committed
to addressing HIV/AIDS can in many cases be leveraged to
strengthen comprehensive healthcare in low- and middle-income

Commentary Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

Roundups Politics

Campaign Week in Review: Republican National Convention Edition

Ally Boguhn

The Trump family's RNC claims about crime and the presidential candidate's record on gender equality have kept fact-checkers busy.

Republicans came together in Cleveland this week to nominate Donald Trump at the Republican National Convention (RNC), generating days of cringe-inducing falsehoods and misleading statements on crime, the nominee’s positions on gender equality, and LGBTQ people.

Trump’s Acceptance Speech Blasted for Making False Claims on Crime

Trump accepted the Republican nomination in a Thursday night speech at the RNC that drew harsh criticism for many of its misleading and outright false talking points.

Numerous fact-checkers took Trump to task, calling out many of his claims for being “wrong,” and “inflated or misleading.”

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 Among the most hotly contested of Trump’s claims was the assertion that crime has exploded across the country.

“Decades of progress made in bringing down crime are now being reversed by this administration’s rollback of criminal enforcement,” Trump claimed, according to his prepared remarks, which were leaked ahead of his address. “Homicides last year increased by 17 percent in America’s 50 largest cities. That’s the largest increase in 25 years. In our nation’s capital, killings have risen by 50 percent. They are up nearly 60 percent in nearby Baltimore.”

Crime rates overall have been steadily declining for years.

“In 2015, there was an uptick in homicides in 36 of the 50 largest cities compared to the previous years. The rate did, indeed, increase nearly 17 percent, and it was the worst annual change since 1990. The homicide rate was up 54.3 percent in Washington, and 58.5 percent in Baltimore,” explained Washington Post fact checkers Glenn Kessler and Michelle Ye Hee Lee. “But in the first months of 2016, homicide trends were about evenly split in the major cities. Out of 63 agencies reporting to the Major Cities Chiefs Association, 32 cities saw a decrease in homicides in first quarter 2016 and 31 saw an increase.”

Ames Grawert, a counsel in the Brennan Center’s Justice Program, said in a statement posted to the organization’s website that 2016 statistics aren’t sufficient in declaring crime rate trends. 

“Overall, crime rates remain at historic lows. Fear-inducing soundbites are counterproductive, and distract from nuanced, data-driven, and solution-oriented conversations on how to build a smarter criminal justice system in America,” Grawert said. “It’s true that some cities saw an increase in murder rates last year, and that can’t be ignored, but it’s too early to say if that’s part of a national trend.” 

When Paul Manafort, Trump’s campaign chairman, was confronted with the common Republican falsehoods on crime during a Thursday interview with CNN’s Jake Tapper, he claimed that the FBI’s statistics were not to be trusted given that the organization recently advised against charges in connection with Hillary Clinton’s use of a private email server during her tenure as secretary of state.

“According to FBI statistics, crime rates have been going down for decades,” Tapper told Manafort. “How can Republicans make the argument that it’s somehow more dangerous today when the facts don’t back that up?”

“People don’t feel safe in their neighborhoods,” said Manafort, going on to claim that “the FBI is certainly suspect these days after what they did with Hillary Clinton.”

There was at least one notable figure who wholeheartedly embraced Trump’s fearmongering: former KKK Grand Wizard David Duke. “Great Trump Speech,” tweeted Duke on Thursday evening. “Couldn’t have said it better!”

Ben Carson Claims Transgender People Are Proof of “How Absurd We Have Become”

Former Republican presidential candidate Ben Carson criticized the existence of transgender people while speaking at the Florida delegation breakfast on Tuesday in Cleveland.  

“You know, we look at this whole transgender thing, I’ve got to tell you: For thousands of years, mankind has known what a man is and what a woman is. And now, all of a sudden we don’t know anymore,” said Carson, a retired neurosurgeon. “Now, is that the height of absurdity? Because today you feel like a woman, even though everything about you genetically says that you’re a man or vice versa?”

“Wouldn’t that be the same as if you woke up tomorrow morning after seeing a movie about Afghanistan or reading some books and said, ‘You know what? I’m Afghanistan. Look, I know I don’t look that way. My ancestors came from Sweden, or something, I don’t know. But I really am. And if you say I’m not, you’re a racist,’” Carson said. “This is how absurd we have become.”

When confronted with his comments during an interview with Yahoo News’ Katie Couric, Carson doubled down on his claims.“There are biological markers that tell us whether we are a male or a female,” said Carson. “And just because you wake up one day and you say, ‘I think I’m the other one,’ that doesn’t change it. Just, a leopard can’t change its spots.”

“It’s not as if they woke up one day and decided, ‘I’m going to be a male or I’m going to be a female,’” Couric countered, pointing out that transgender people do not suddenly choose to change their gender identities on a whim.

Carson made several similar comments last year while on the campaign trail.

In December, Carson criticized the suggested that allowing transgender people into the military amounted to using the armed services “as a laboratory for social experimentation.”

Carson once suggested that allowing transgender people to use the restroom that aligned with their gender identity amounted to granting them “extra rights.”

Ivanka Trump Claims Her Father Supports Equal Pay, Access to Child Care

Ivanka Trump, the nominee’s daughter, made a pitch during her speech Thursday night at the RNC for why women voters should support her father.

“There have always been men of all background and ethnicities on my father’s job sites. And long before it was commonplace, you also saw women,” Ivanka Trump said. “At my father’s company, there are more female than male executives. Women are paid equally for the work that we do and when a woman becomes a mother, she is supported, not shut out.” 

“As president, my father will change the labor laws that were put into place at a time when women were not a significant portion of the workforce. And he will focus on making quality child care affordable and accessible for all,” she continued before pivoting to address the gender wage gap. 

“Policies that allow women with children to thrive should not be novelties; they should be the norm. Politicians talk about wage equality, but my father has made it a practice at his company throughout his entire career.”

However, Trump’s stated positions on the gender wage gap, pregnancy and mothers in the workplace, and child care don’t quite add up to the picture the Trumps tried to paint at the RNC.

In 2004, Trump called pregnancy an “inconvenience” for employers. When a lawyer asked for a break during a deposition in 2011 to pump breast milk, Trump reportedly called her “disgusting.”

According to a June analysis conducted by the Boston Globe, the Trump campaign found that men who worked on Trump’s campaign “made nearly $6,100, or about 35 percent more [than women during the April payroll]. The disparity is slightly greater than the gender pay gap nationally.”

A former organizer for Trump also filed a discrimination complaint in January, alleging that she was paid less than her male counterparts.

When Trump was questioned about equal pay during a campaign stop last October, he did not outline his support for policies to address the issue. Instead, Trump suggested that, “You’re gonna make the same if you do as good a job.” Though he had previously stated that men and women who do the same job should be paid the same during an August 2015 interview on MSNBC, he also cautioned that determining whether people were doing the same jobs was “tricky.”

Trump has been all but completely silent on child care so far on the campaign trail. In contrast, Clinton released an agenda in May to address the soaring costs of child care in the United States.

Ivanka’s claims were not the only attempt that night by Trump’s inner circle to explain why women voters should turn to the Republican ticket. During an interview with MSNBC’s Chris Matthews, Manafort said that women would vote for the Republican nominee because they “can’t afford their lives anymore.”

“Many women in this country feel they can’t afford their lives, their husbands can’t afford to be paying for the family bills,” claimed Manafort. “Hillary Clinton is guilty of being part of the establishment that created that problem. They’re going to hear the message. And as they hear the message, that’s how we are going to appeal to them.”

What Else We’re Reading

Vox’s Dara Lind explained how “Trump’s RNC speech turned his white supporters’ fear into a weapon.”

Now that Mike Pence is the Republican nominee for vice president, Indiana Republicans have faced “an intense, chaotic, awkward week of brazen lobbying at the breakfast buffet, in the hallways and on the elevators” at the convention as they grapple with who will run to replace the state’s governor, according to the New York Times.

“This is a party and a power structure that feels threatened with extinction, willing to do anything for survival,” wrote Rebecca Traister on Trump and the RNC for New York Magazine. “They may not love Trump, but he is leading them precisely because he embodies their grotesque dreams of the restoration of white, patriarchal power.”

Though Trump spent much of the primary season denouncing big money in politics, while at the RNC, he courted billionaires in hopes of having them donate to supporting super PACs.

Michael Kranish reported for the Washington Post that of the 2,472 delegates at the RNC, it is estimated that only 18 were Black.

Cosmopolitan highlighted nine of the most sexist things that could be found at the convention.

Rep. Steve King (R-IA) asked, “Where are these contributions that have been made” by people of color to civilization?