Special Report - AIDS Prevention Funding At Risk: Are prevention programs falling prey to political pressure?
Are prevention programs falling prey to political pressure?
Administration scrutinizes obscenity, abstinence
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HIV activists and others say that the Bush administration’s HIV/AIDS prevention policy appears to have made a 90-degree right-hand turn between last summer and this year, and the changes could result in failed or stymied prevention measures. Last summer, David Satcher, MD, who was then serving as U.S. Surgeon General, issued a health "call to action" for a mature and thoughtful discussion about sexuality. Satcher’s July 2001 report said it was the responsibility of each community to ensure that the public has access to developmentally and culturally appropriate sexuality education, including sexual and reproductive health care and counseling. At about the same time, the Centers for Disease Control and Prevention in Atlanta launched a five-year prevention campaign that called for a 50% decrease in the number of people at risk of acquiring HIV infection. Helene D. Gayle, MD, MPH, director of the CDC’s National Center for HIV, STD, and TB Prevention, said the CDC would provide $400 million to state prevention programs that target high-risk individuals, including gay men.
The nation appeared to be poised to redouble its HIV prevention efforts with focused, far-reaching public health programs to educate people of color, youths, and men who have sex with men (MSM) about how to prevent HIV infection. However, any optimism that HIV advocacy groups, clinicians, and others had about such a program’s success is evaporating. Since the summer there has been a push for increased funding for abstinence-only-until-marriage education programs in public schools and a call to investigate all CDC-funded prevention programs to determine whether they deliver a message that could be construed as obscene.
"I find it incredibly alarming," says Stephen Goldstone, MD, medical director of GayHealth.com, a New York City-based Web site that provides HIV prevention educational material and clinical answers to questions posed by men and male youths who have sex with other males. "Abstinence is always taught within the context of marriage, which basically dooms it to failure among gays and lesbians, who are not allowed to marry, so it’s infuriating," Goldstone says.
While no one objects to audits of government-funded programs, there is a political agenda involved with this issue that goes beyond merely requiring accountability, critics say. "There is a hostile climate from Congress, where they are asking for audits of all HIV programs for prevention and care," says Tanya Ehrmann, director of public policy for AIDS Action in Washington, DC. "There clearly is an agenda about undercutting programs that talk about sex, and there’s an attempt under way, orchestrated by the religious right, to discredit those programs," Ehrmann says.
The Lambda Legal Defense and Education Fund of New York City has issued a public criticism of Health and Human Services Secretary Tommy Thompson for his call to investigate whether HIV prevention programs encourage sex.
"It’s pretty clear this is politically motivated, and the interest in doing this investigation is coming from the same people who are pushing abstinence-until-marriage programs and restrictions on reproductive rights and are opposing quote-unquote special rights for gay people," says Catherine A. Hanssens, JD, director of the AIDS Project for Lambda Legal Defense.
The controversial initiative by HHS resulted from an October 2001 letter from Inspector General Janet Rehnquist in which she stated that CDC-funded prevention programs implemented by STOP AIDS Project Inc. of San Francisco could be viewed as obscene and encouraging sexual activity.
Although the ongoing $698,000 CDC prevention grant used by the STOP AIDS Project may not be at risk, the government’s investigation of all prevention projects is likely to have a chilling effect on programs that target youths and men who have sex with men, particularly if they use specific sexual terminology and street language to get the message across, says Darlene Weide, MPH, MSW, executive director of STOP AIDS Project.
People’s lives are in danger’
"This investigation can have very serious and dangerous consequences," Weide says. "The biggest consequence is that people’s lives are in danger, and this is not the time to threaten prevention spending."
Repercussions soon were seen after Rehnquist’s report. For example, a month after Thompson called for the investigation, the South Dakota Department of Health in Pierre declined to approve CDC funding for an HIV prevention project proposed by the Sioux Empire (SD) Red Cross. The organization had requested $21,296 to hold two MSM risk reduction seminars.
According to Bob Mercer, press secretary for South Dakota Republican Gov. Bill Janklow, the state’s secretary of health was concerned that the program might not meet with federal approval. "[The state secretary of health] said that HHS is looking at this, and they didn’t see any point in going forward with a program at this point that might be turned down at the federal level," Mercer says. "Once they know what the feds’ policy is on it, they will look at it again, but the money didn’t go unspent; it’ll go through another round of proposals."
The state also had turned down a proposal made by The Center, a gay and lesbian counseling service, which had requested nearly $100,000 to expand and implement an HIV/AIDS peer education system. Mercer said he didn’t know why that program was denied. Mercer says both The Center and the Sioux Empire Red Cross already receive state and federal funding for other HIV prevention programs. "We have a ton of MSM programming," Mercer says. "We use intervention dollars proportionate to the target populations, which basically are MSM, intravenous drug users, and high-risk heterosexuals."
At Thompson’s direction, the CDC has sent letters to all recipients of federal HIV prevention funding, reminding them to adhere to 1992 requirements for content of AIDS-related written materials, pictorials, etc. "The CDC is asking their grantees to adhere to the guidelines and have their materials reviewed by local panels," says Cynthia Glocker Crick, CDC senior press officer.
The examination of HHS-funded HIV/AIDS activities will be handled by Claude Allen, HHS deputy secretary, according to a letter Thompson wrote Nov. 14, 2001. Thompson’s letter, written to U.S. Rep. Mark E. Souder (R-IN), indicates that Thompson first discussed his concerns with Souder about CDC-funded HIV prevention programs on Sept. 12, 2001, one day after the terrorist attacks on the World Trade Center and the Pentagon. After their discussion, Thompson launched an OIG investigation of HIV prevention programs at the Stop AIDS Project. AIDS advocates are equally concerned about the Bush administration’s increased focus on abstinence-only education directed toward youths.
Abstinence-only-until-marriage education funding has existed since the Reagan years, and in 1996 the federal government provided $250 million for five years to fund abstinence-only education in the states. The funding was issued in the form of block grants in which the states had to match three dollars for every four federal dollars, says Marcela Howell, director of public affairs for Advocates for Youth. That Washington, DC-based nonprofit organization creates programs and advocates policies to help youths make informed sexual and reproductive health decisions. All states except California and New Hampshire accepted the abstinence-only grants, Howell says.
"The reason people are concerned now about HIV/AIDS education is because the CDC currently funds states to teach AIDS education, and right now in many school districts the only place young people are getting information about contraceptives is in AIDS education," Howell says. "So groups that are opposed to teaching young people about contraceptives have begun to attach HIV/AIDS programs within their states, and there are incidents where state legislatures are pressured not to take HIV/AIDS money."
Abstinence funding increases
Also, the FY 2002 federal budget includes substantial increases for abstinence-only programs, with a $10 million increase in funding under Special Projects of Regional and National Significance, which is part of the Maternal and Child Health Block Grants. The FY 2001 budget provided for $20 million, and FY 2002 provides for $30 million, Howell says. To receive this money, states must establish abstinence-only programs that meet specific criteria, including teaching youths that all sexual activity outside of marriage can be psychologically and physically harmful, Howell says.
There’s also the danger that schools will select abstinence-only curricula that are medically inaccurate or misleading, such as statements indicating that condoms have such high failure rates that it’s dangerous for youths to use them. This is why it’s important for HIV clinicians to offer to review their local school district’s abstinence-only or sexual education materials to make certain they’re currently and medically accurate, Howell says.
"A doctor can say to the school district, I’m concerned about this high rate of HIV among young people, and I’d like to make sure that what you’re teaching them is medically accurate, so I’d like to offer my services to review the curricula, and I’m willing to talk with teachers about this,’" Howell says.
At present, Ohio and Utah are the only states that have refused HIV education funding from the CDC, although there has been word that other states also are discussing rejecting the funds because they would prefer to promote abstinence-only education, says Jennifer Kates, senior program officer of HIV/AIDS policy for the Kaiser Family Foundation. Kates works in the Washington, DC, office of the Menlo Park, CA-based organization.
Howell notes that Nebraska and Texas have voted to refuse the CDC prevention money unless the programs had a strict abstinence-only education component. "When you think of 50% of new HIV infections occurring to young people under age 25, then clearly HIV/AIDS education is needed, and teaching them how to protect themselves from HIV infection is clearly needed," Howell says.
Before selecting a prevention intervention for a particular community, it’s important to find out what will work in that community, says Larry Peiperl, MD, executive editor of HIV InSite and assistant professor of medicine at the University of California - San Francisco. Peiperl oversees HIV education and prevention material on a Web site directed toward youths (http://whatudo.org). "To make a policy based on fairly narrow moral or even religious teachings can really limit the effectiveness of the prevention efforts," Peiperl says. "It’s a question of how realistic does one want to be in one’s moral reasoning vs. how abstract."
There is a body of research that shows how targeted HIV prevention education helps reduce risky sexual behavior. A series of national surveys of students and their parents, teachers, and principals from the Kaiser Family Foundation on Sex Education in America found that parents, educators, and students would favor expanding sex education courses and curricula, Kates says. "In general, most Americans, about four out of five, support a more comprehensive approach to sexual education," Kates adds.
Satcher’s "call to action" report states that existing research supports the conclusion that teaching students about sexual education does not increase sexual activity. Kates says recent research analyses have found that there is not enough evidence available to assess the effectiveness of abstinence-only education.
Plus, abstinence-only education can be misconstrued by youths to mean that only heterosexual sex is prohibited and that experimental sexual activity between same-gender youths is not an issue, Goldstone says. For example, Goldstone has fielded some troubling questions from boys who write to him via GayHealth.com about their sexual experiences with other boys. In one letter, a 14-year-old boy said he was going to have a sleep-over with his friend next door and the two boys would be "going all the way." In another letter, a teen-age boy wrote Goldstone that the boys at school thought he was effeminate-acting, so they raped him, and now he’s afraid he might have been exposed to HIV.
"I think we need to address these same-sex issues that kids need to hear about, because they certainly won’t ask their parents about it," Goldstone says. "So we need to provide a curriculum that is inclusive, and we need to train doctors to be inclusive in their messages to kids and adolescents."
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