PEPFAR funds not being used efficiently to prevent HIV epidemic, say critics

Money has too many political stipulations

The, United States has spent hundreds of millions of dollars on HIV prevention around the world, but the rules surrounding the money have made the prevention efforts far less efficient than desirable, critics say.

The US President's Emergency Plan for AIDS Relief (PEPFAR), which was first authorized in 2004, is due to be reauthorized by Congress this year. But before it is, many changes should be made, says Serra Sippel, acting executive director of the Center for Health and Gender Equities (CHANGE) in Tacoma Park, MD.

First, Congress should eliminate the abstinence earmark in the bill, Sippel says.

"Congress imposed a requirement that one-third of prevention funding has to go to abstinence, and that earmark should be eliminated in the new law," Sippel says.

"The earmark doesn't mean that no US money can ever be used for distributing condoms, but what Congress did was say that one-third of prevention funding has to be for abstinence until marriage programs," Sippel explains.

Such funding stipulations are rhetoric, not truth about the epidemic, says the Rev. William G. Sinkford, president of the Unitarian Universalist Association of Congregations in the United States. Sinkford spoke at a World AIDS Day event media conference about PEPFAR.

"The truth is that HIV/AIDS is most often spread through sexual contact, and because sex is involved, we have been unwilling to share life-saving information, truthful information about effective prevention," Sinkford says.

"According to UNAIDS, prevention efforts are reaching fewer than 20 percent of the people in dire need," Sinkford says.

"The highest rates of infection are found among young people between the ages of 15 and 24 and married women in their 20s and 30s," he adds. "If we truly want to save lives, we must get serious about delivering effective prevention."

One way to do this is to expand access to HIV prevention programs and reproductive health services, Sinkford suggests.

Congress needs to ensure that PEPFAR funds will be used to integrate family planning and reproductive health in HIV prevention programs, Sippel says.

"How it works now is PEPFAR funding cannot be used for family planning, which hinders the whole integration component of this," Sippel explains. "It causes confusion on the ground about what the money is being used for."

A gag rule, instituted on President George W. Bush's first day of office, prohibits any US funds from going to overseas programs that provide counseling or information about abortion, she notes.

"That is not supposed to apply to PEPFAR funding, but in the field, it causes confusion," Sippel says.

A third needed change is the elimination of the requirement that organizations taking US money sign a pledge that they object to prostitution, she adds.

From a public health perspective, this means that non-government organizations (NGOs) that do outreach work with sex workers have difficulty developing trust with the very population they are targeting for prevention work, Sippel says.

Also, some NGOs have effective programs that use sex workers as peer counselors, and their work is jeopardized by this requirement.

Global HIV prevention experts say that PEPFAR misses the mark in its aim to stop the HIV epidemic because of these political stipulations and requirements.

"The United States government has, unfortunately, put ideologies before evidence-based best medical practices at the expense of lives of young people," says Krystie Corpuz of the International Youth Leadership Council, Advocates for Youth. Corpuz spoke at a World AIDS Day event media conference about PEPFAR funding.

The abstinence until marriage programs are harmful to youths, Corpuz says.

"Not giving youths access to information about the full range of HIV prevention tools at their disposal — such as abstinence, being faithful, and correct and consistent condom usage — means that the very lives programs like PEPFAR are trying to protect are being lost unnecessarily because of ideologically-based public policy," Corpuz says.

The abstinence until marriage programs do not work for African women, says Bernice Heloo, president of the Society for Women and AIDS in Africa in Ghana. Heloo also spoke at a World AIDS Day event media conference on PEPFAR.

"We as African women are concerned about the fact that for a very long time HIV prevention and management have been seen from very narrow perspectives, devoid of the context in which we live and also in which the pandemic thrives in Africa," Heloo says. "It is this parochial approach that has resulted in the apparent narrow focus and emphasis on abstinence until marriage and faithfulness."

What's needed are fully-funded programs that are comprehensive, holistic, nonprescriptive, and provide access to female condoms, Heloo says.

One such program would target women in violent and other difficult situations, she says.

For instance, African women often suffer from gender-based violence, including rape and abuse, which can cause the HIV epidemic to spread, Heloo says.

"Additionally, funds are required to rescue women from harmful social, cultural, and religious practices that predispose them to HIV infection," Heloo says.

"We add our voice to demand the removal of the one-third abstinence earmark and also ask for a track out of the anti-prostitution pledge, which is really discriminatory," Heloo adds.

PEPFAR makes the HIV prevention message a moral one, which is harmful to the goal of eliminating the spread of the virus, says the Rev. J. P. Heath, co-founder and director of the International Programs at the African Network of Religious Leaders Living With or Affected by HIV and AIDS (ANERELA) in South Africa. Heath also spoke at the recent PEPFAR media conference.

"The common strategy that we all know, in terms of HIV prevention is ABC: abstain, be faithful, use a condom," Heath says. "The challenge with this is that the only thing we're talking about is sex."

Once an epidemic's prevention focus turns to sex, it makes the disease a moral issue, Heath explains.

"HIV is a virus — it's not a moral condition," Heath says. "And the way in which we deal with HIV has to reflect that."

Heath offers this example of how destructive the focus on morality can be from a public health perspective: "Yesterday, I was speaking at a gathering in a northwest province of South Africa, and Dr. Kizito from Uganda was there and he related to us a story of a young girl who found out, in Uganda, that one of her previous boyfriends had died of AIDS-related illnesses," he says.

"So what she did was she went out and solicited 10 young men and slept with them and then committed suicide," Heath explains. "She had posted their names on her door and said, 'These people are dying with me.'"

But a post-mortem exam found that the woman was not infected with HIV, he adds.

"Because of the focus on sex, her knowledge that she had a sexual relationship with this man who had died clouded her mind," Heath says. "She didn't know she had to go for a test, and she didn't know that not every time you have unprotected sex the virus is transmitted."

This provides a tragic illustration of why the PEPFAR funding should go toward programs that focus on HIV prevention through the best strategies available, rather than be used as a tool to promote a certain type of morality, he adds.

"You cannot stress enough the need for people to know their HIV status," Heath says. "We have to move to a place that not 10 percent, but 100 percent of humanity knows their HIV status."