The Reality of PEPFAR


The Reality of PEPFAR

February 1, 2008

On February 27, the House Committee on Foreign Affairs will take the first step in reauthorizing the President's Emergency Plan for AIDS Relief, or PEPFAR, a 5-year, $15 billion dollar initiative proposed by President Bush in January 2003 and enacted by Congress in May that same year. Among PEPFAR's original goals were to treat two million people infected with HIV, prevent seven million new infections, and provide care and support for 10 million people infected with HIV and/or affected by AIDS. The new bill includes even more ambitious goals, such as preventing 12 million new infections.

In 2007, more than two million people died of AIDS, and 2.5 million people were newly infected with HIV, according to the United Nations Joint Programme on AIDS (UNAIDS). Given the scope of the AIDS epidemic, and the amount of money involved, an effective U.S. strategy on global AIDS has the potential to make vast contributions to ending the AIDS pandemic.

Unfortunately, restrictions on prevention funding under the existing law governing PEPFAR have severely hampered efforts to prevent as many new infections as possible and undermined broader efforts to stop the spread of HIV infections. AJWS and a wide range of others are working hard to ensure such restrictions are removed from the new legislation, which if passed will authorize at least $50 billion for AIDS, tuberculosis and malaria from 2008 through 2013. Among our key concerns are to ensure that programs save the greatest number of lives possible through effective and efficient investment of US taxpayer dollars in programs proven to work.

Today, unprotected sex is the single greatest factor in the spread of HIV worldwide and is responsible for more than 80 percent of new infections in sub-Saharan Africa. Comprehensive prevention strategies—including efforts to simultaneously promote delay of sexual initiation among unmarried teens; partner reduction and fidelity; and correct and consistent use of male and female condoms—have proven most effective in reducing the spread of HIV.

Unfortunately, PEPFAR includes an abstinence-until-marriage earmark requiring that one-third of all funds spent on HIV prevention go to abstinence-until-marriage programs. This policy has been so strictly enforced that many programs receiving US funds are promoting only abstinence even to married women, sex workers and sexually active youth at immediate risk of infection. It has also resulted in reduced access to programs aimed at promoting safer sex practices and the consistent and correct use of condoms. Moreover, the earmark has reduced funding for prevention of mother-to-child transmission of HIV. From 2004 to 2007, nearly 60 percent of all funds for prevention of sexual transmission were spent on abstinence-only programs. Two government reports, one by the Government Accountability Office and the other by the Institute of Medicine concluded that the earmark was undermining effective prevention programs and should be removed. Notwithstanding this and other evidence, social conservatives in Congress are fighting hard to keep these restrictions in place.

The prostitution pledge requires organizations receiving U.S. international assistance to adopt a policy "opposing prostitution," and to ensure that none of their programs "promote the legalization or practice of prostitution." Both the law and the policy are very vague, and many organizations (including AJWS and some of its grantees) have refused to accept funding under these conditions because such policies alienate those at greatest risk of infection, and because requiring such a pledge is considered a violation of the constitutional protection against compelled speech. Others have lost funding due to claims that their work "promotes prostitution" though the basis for such claims has not been made clear. This has been a blow to many groups dependent on international funding, a large number of which are recognized by the international public health community for their cutting edge work.

These restrictions ignore the realities and needs of communities in the developing world. AJWS' grantees in Africa, Asia and the Americas have strongly voiced their concerns that the HIV/AIDS epidemic cannot be successfully addressed by a top-down plan that imposes restrictions with no basis in the realities of people's lives. They argue such programs must simultaneously addresses local needs while promoting basic human rights—such as women's rights to education, economic opportunities and inheritance of property.

As the new Global AIDS Act moves from committee to a full vote in the House, and as the debate moves to the Senate, AJWS is calling on Congress to strike the abstinence-until-marriage earmark and the prostitution pledge. In addition, AJWS is advocating for more funding to be invested in meeting the needs of women, youth and other vulnerable populations (such as youth, sex workers, men who have sex with men, and intravenous drug users); the establishment of monitoring and evaluation systems to ensure effective use of U.S. taxpayer dollars; and increased linkages with basic family planning and reproductive health services. These measures are critical first steps to ensuring that new US global AIDS programs meet their stated goals.