A quarterly international newsletter on sexuality, sexual health, and sexuality education.
Volume 3, Issue 1 - Spring/Summer 2004
The U.S. Five-Year Global HIV/AIDS Strategy: A Vehicle for Conservative Ideology
In the 2003 State of the Union Address, President Bush announced that the government would form a "comprehensive plan [that] will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS."1 Congress then passed the Global AIDS Bill, which required the newly formed Office of the U.S. Global AIDS Coordinator to formulate a comprehensive plan for U.S. interventions in the global AIDS pandemic.2 In late February, the Office of the U.S. Global AIDS Coordinator (at the U.S. Department of State) released The President's Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (the U.S. Strategy, also known as PEPFAR).
The Bush Administration has garnered significant international attention for the U.S. Strategy which will provide grants to support HIV/AIDS prevention, treatment, and care in 14 countries in Africa and the Caribbean, called "focus countries." (A fifteenth country may be added in the near future.)
Although, the initiative proposes spending $15 billion over the next five years, only $9 billion is new money.3 The remainder represents reallocated funds previously spent on various health programs and foreign aid. Nonetheless, the U.S. Strategy is already being under-funded. Originally, the President requested $2 billion for Fiscal Year 2004 that would be increased over time to $4 billion in Fiscal Year 2008, but Congress authorized a constant funding level of $3 billion per year and gave the initiative only $2.4 billion in the first year. Congress has yet to decide Fiscal Year 2005 funding, but the President has requested only $2.8 billion.
While securing adequate funding remains a problem, the U.S. Strategy also raises critical concerns about intervention methods. In the area of prevention, for example, the U.S. Strategy claims to support "evidencebased" approaches, but seems to promote ideology over science by restricting prevention efforts almost exclusively to abstinence-until-marriage programs.
The U.S. Strategy Limits Prevention Education
The Global AIDS Bill, the law behind the U.S. Strategy, limits prevention spending to a maximum of only 20 percent of all U.S. funds allocated for global AIDS.This is further limited because the U.S. Strategy categorizes programs that provide drugs to stop mother-to-child transmissions as prevention rather than treatment.
The bill also requires that at least 33 percent of those prevention funds be spent on abstinence-until-marriage programs: approximately $133 million annually over the next five years. In addition, all prevention monies are available to faith-based organizations (FBOs), which are allowed to exclude information about contraceptive methods, including condoms, if such information is inconsistent with their religious teachings.4
The "ABC" Model
The U.S. Strategy purports to apply the "ABC" model of HIV/AIDS prevention that has shown some evidence of success."ABC" stands for abstain, be faithful, and use condoms.The U.S. Strategy, however, presents these three equally important risk reduction strategies as a hierarchy with abstinenceuntil- marriage programs as the principal method of prevention for all people.
In contrast, the U.S. Strategy marginalizes condom education and distribution by supporting such programs only "where appropriate," and narrowly defining "appropriate" as limited to "high-risk" groups, i.e. "prostitutes" and "sero-discordant couples," couples in which one partner is HIV-positive and the other is HIV-negative.5
This isolation of "high risk" groups misrepresents the level of risk in the focus countries. Given the high HIV prevalence rates among the general population in these countries, the unfortunate truth is that everyone is "high risk."
Nonetheless, the U.S. Strategy emphasizes abstinence-until-marriage as the paramount prevention strategy. It states, "interventions will deliver messages that promote abstinence until marriage…," and "every effort will be made to deliver a consistent 'ABC' message' so that the general population receives a clear message that the best means of preventing HIV/AIDS is to avoid risk all together."6
By promoting unproven and potentially harmful abstinence-until-marriage programs, the U.S. government is misrepresenting an overwhelming body of available scientific evidence. Evidence from the United States and elsewhere shows that such programs have not been proven to prevent either sexually transmitted diseases or pregnancy. In fact, several studies show that while teens who participate in Virginity Pledges, a common component of abstinence-only-until-marriage programs, are likely to delay sexual debut, they are far less likely to use condoms or contraceptives when they do have intercourse.7
Marriage Not A Protective Factor
Abstinence-until-marriage programs also erroneously assume that marriage is a protective factor against HIV. In the focus countries, married monogamous women, despite engaging in "low risk" behavior, are among the most vulnerable for HIV infection. Evidence increasingly demonstrates that because women often have few rights within marriage, marriage itself may be a key risk factor for HIV. For example, in South Africa, studies suggest that "marital partnerships are mainly responsible for adolescent female [HIV] infection."8 Studies in Kenya and Zambia show that adolescent girls have an increased risk of HIV infection when they marry significantly older men.9 Furthermore, in a study of Zambian women, fewer than 25% of the participants believed that a married woman could refuse to have sex with her husband, even if she knew he had been unfaithful or was HIV-positive. Only 11% of participants believed that a woman could ask her husband to use a condom in these circumstances.10
By promoting abstinence-untilmarriage, downplaying correct and consistent condom use and impeding comprehensive medically accurate education about sexuality, the U.S. Strategy puts lives at risk. Evidence from throughout the world shows that culturally appropriate, comprehensive health education that offer access to a wide range of information, education, strategies, and technologies are most effective in reducing both infection and unintended pregnancies. Such programs lead to significant public health gains. According to the United Nations Joint Programme on AIDS (UNAIDS),"the basic elements of successful prevention are communication (including sexual health education) and behavior change, the creation of an environment that enables people to protect themselves against the virus, condom promotion, HIV counseling and testing, and the treatment of sexually transmitted infections." Moreover, UNAIDS asserts "irrespective of their risk, all people must be provided with basic information and the means to protect themselves." 11
The abstinence-until-marriage approach of the U.S. Strategy undermines existing international prevention efforts, individual country HIV/AIDS prevention plans, and international treaties on health and human rights. Additionally, advocates argue that programs that focus exclusively on abstinence violate international law by infringing on freedom of speech and freedom of access to information, and by jeopardizing the right to health.
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