Global HIV/AIDS: The Politics of Prevention Issue Brief

Summary

Effective global action for HIV/AIDS prevention and care means the difference between life and death for millions of people around the world. As a result of the introduction of relatively effective antiretroviral therapies to prolong the lives of those living with HIV/AIDS, treatment has become a major focus of efforts to check the spread of the virus. Yet, with the number of people acquiring HIV growing every year — an estimated 4.9 million in the year 2005 alone — prevention programs must be expanded as well in order to curb the global pandemic (UNAIDS, 2005).

The United States has contributed an unprecedented level of funding to address the HIV/AIDS pandemic. However, U.S. funds are increasingly tied to ideologically based restrictions that make abstinence the centerpiece of HIV prevention and which are undermining critical prevention strategies. Addressing HIV/AIDS demands comprehensive, epidemiologically and programmatically sound strategies. Justice and fairness demand that we must marshal our resources in the most effective way.

The Global Situation

The global HIV/AIDS pandemic has taken the lives of more than 25 million people and today there are an estimated 40.3 million people living with HIV/AIDS (UNAIDS, 2005a). With the advent of effective antiretroviral drugs, the lives of those living with HIV and AIDS are being prolonged. (These drugs do not cure AIDS.) Yet, the rate of new infections continues to rise every year. In 2005, an estimated 4.9 million people were infected (UNAIDS, 2005a).

The majority of those infected - 95 percent - live in low- and middle-income countries, where the virus is not only costing lives, but also disrupting economic development and demographic structures and taxing health care infrastructure (KFF, 2005).

Young people and women are at the center of the pandemic (KFF, 2005). Women ages 15-49 are increasingly vulnerable to infection, rising from 41 percent of adult infections in 1997 to 47 percent in 2004 (KFF, 2005). Approximately half of new adult HIV infections are young people ages 15-24; the majority of these young people are women (KFF, 2005). In sub-Saharan Africa, the region most heavily affected by HIV/AIDS, approximately 76 percent of all young people living with HIV/AIDS are women (UNAIDS, 2005b).

Feminization of HIV/AIDS

The disproportionate infection of women in sub-Saharan Africa may predict a global trend of women becoming increasingly affected by HIV/AIDS, which is also being observed in Asia, Latin America, and parts of Eastern Europe (Engender Health 2005).

In fact, marriage is becoming a risk factor, particularly for young women (Feuer, 2004; Sinding, 2005). In most sub-Saharan African countries young women usually get married in their teens to older men who are more likely to have had more sexual partners (The Guttmacher Institute, 2004a). Marriage and women's own fidelity do not insure against HIV infection; in fact, in growing numbers these women are becoming infected by their partners (The Global Fund, 2004a). In Colombia, for example, 72 percent of the women who tested HIV positive at an antenatal clinic were in stable relationships (UNAIDS 2005a). "The face of AIDS is changing, and it is quickly becoming the face of a young, married woman" (Engender Health, 2005).

For a variety of biological, cultural, and social reasons, the disease is affecting and infecting women in markedly different ways than men (WHO, 2004). These factors contribute to the spread and impact of the disease, and need to be considered when developing appropriate strategies to address it.

Girls and women are more biologically vulnerable to sexual transmission of HIV. For example, the area of mucous membranes exposed during sex is greater in women than in men and is subject to microtears; the amount of fluids transmitted from men to women is greater as is the viral content of those fluids (WHO, 2004; The Global Fund, 2004a).

Girls and women are also at greater risk of infection due to economic and social inequities that limit their choices or force them into transactional sex (Engender Health, 2005; UNAIDS, 2005b). Gender norms may allow men to have more sexual partners than women or encourage older men to have sex with much younger women. Even if women want their partners to use condoms or to abstain from sex altogether, they often lack the power to make their partners do so or fear violence or other repercussions (WHO, 2004; UNAIDS, 2005b). At the root of these and other factors is gender inequality and the poverty that often accompanies it (UNAIDS, 2005b; WHO, 2004; Engender Health 2005).

HIV/AIDS Prevention, Treatment and Care Prevention:  Strategies to prevent sexual transmission of HIV focus on providing information and education aimed at changing behaviors that contributes to the spread of HIV and AIDS.  Strategies include efforts to increase access to and use of male and female condoms, access to voluntary counseling and testing, drugs and strategies to prevent mother-to-child transmission, training in partner communication and negotiation, and programs to address sexual violence and coercion, among other things (AIDSNET, 2005, Change 2004a; Family Health International, 2005). Treatment and Care:  Though there is no cure for HIV and AIDS, comprehensive treatment and care can improve the quality of life of people living with AIDS and help prevent the spread of the disease.  Treatment and care involves providing information and counseling, clinical treatment and care, home-based care, and family counseling. Antiretroviral treatment is currently the only life-prolonging drug treatment for people living with AIDS, although it is not available to many (AIDSNET, 2005).  Antiretroviral drugs do not cure AIDS.

Effective Prevention Strategies

The causes of HIV infection indicate logical points of intervention: throughout the world today, about 75 percent of HIV cases are transmitted sexually (AIDSNET, 2005). Family planning services have demonstrated effectiveness in preventing transmission of HIV and other sexually transmitted infections (Engender Health, 2004). Effective strategies include comprehensive efforts to increase access to and use of male and female condoms, access to voluntary counseling and testing, drugs and strategies to prevent mother-to-child transmission, training in partner communication and negotiation, and programs to address sexual violence and coercion, among other things (AIDSNET, 2005; UNAIDS, 2005d).

The World Health Organization's Global Health Sector Strategy for HIV/AIDS recognizes that existing reproductive health services are a clear entry point for delivering HIV/AIDS prevention interventions (WHO, 2002). This is particularly critical as women and girls — the same clients who access reproductive health programs — are among the fastest growing infected populations. Existing reproductive health services — many of which have been providing services for decades — offer clients confidential outlets for prevention services free from the stigma of stand-alone HIV/AIDS clinics. In short, it may be easier for a woman to walk into a reproductive health center than it is to enter a stand-alone HIV/AIDS center. As such, integrating HIV and family planning services may be one of the most effective HIV prevention approaches and a smart investment (CHANGE 2004b; Engender Health, 2004; Chikamata, 2002).

While resources have increased over time, globally less than one of five people at risk of HIV infection have access to proven HIV prevention interventions (AIDSNET, 2005). Access to treatment is also low: only about 700,000 of the estimated six million people in need of antiretroviral therapy in low- and middle-income countries have access to it (AIDSNET, 2005). In 2006, UNAIDS projects that $14.9 billion will be needed from all sources to address the HIV/AIDS pandemic in low- and middle-income countries. By 2008 the need is projected to rise to $22 billion (UNAIDS, 2005c), underscoring the urgent need for effective prevention strategies supported by sufficient funding.

International Strategies to Address Prevention of HIV/AIDS

"There is abundant evidence that science-based HIV prevention is effective, especially when backed by high-level political leadership, a national AIDS programme, adequate funding, and strong community involvement."
(Global Fund, 2004c)

In the past few years, governments, the United Nations, and nongovernmental organizations have sought to identify the most effective strategies for the prevention and treatment of HIV/AIDS and make significant, coordinated investments to stem the pandemic. The attention has resulted in several significant global initiatives, including the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. "President's Emergency Plan for AIDS Relief" (PEPFAR). These and other initiatives reflect the principle that the response to HIV/AIDS must contain comprehensive prevention and treatment strategies in order to prevent new infections while providing care and treatment to those already living with HIV (AIDSNET, 2005).

The Global Fund to Fight AIDS, Tuberculosis and Malaria

In 2002 wealthy nations established the Global Fund to Fight AIDS, Tuberculosis and Malaria to finance a dramatic turnaround in some of the world's most devastating diseases. Spearheaded by the United Nations, the fund was envisaged as a necessary and even morally required step to provide interventions to prevent new infections and provide lifesaving drugs to HIV-infected people who simply cannot afford them (GAO, 2002; The Global Fund, 2004b). The Global Fund raises contributions from governments, private donors and philanthropic foundations, corporations, and nongovernmental organizations (The Global Fund, 2005). This diverse funding base serves to ensure that the fund is not influenced by the political purposes of any one donor.

The United States contributes up to $1 billion per year to the Global Fund (P.L. 108-025). However, the U.S. makes its contribution contingent on matching donations from other countries and is limited to 33 percent of the total amount given to the fund (P.L. 108-025). Despite the fact that the United States is the single largest contributor to the Global Fund, it holds no greater say on the activities of the Global Fund than any other donor — a fact that raises the hackles of many U.S. social conservatives (The Guttmacher Institute, 2003).

The Global Fund attracts, manages, and disburses resources, relying on local partners to implement programs in 93 countries (The Global Fund 2004b). Through coordination with governments and organizations involved in health and development, the Global Fund works to ensure that the new programs it funds are coordinated with existing international and national efforts (The Global Fund, 2004b). Over five years, the Global Fund projects to use its resources to provide 52 million people with HIV prevention services, including voluntary testing and counseling (The Global Fund, 2004c).

The US Response to Global HIV/AIDS

"After more than two decades of HIV/AIDS, we have learned a great deal about how it is transmitted, care and treatment options, its global impact... and what prevention measures are most feasible and effective. Yet it sometimes seems as if these science-based lessons are lost in the cacophony of ideological, religious and political rhetoric that surrounds discussion of HIV/AIDS today."
    — Dr. Steven Sinding, Director-General, International Planned Parenthood Federation (Sinding, 2005)

The Bush administration has made global HIV/AIDS a significant focus of foreign policy and development assistance efforts. However, at the behest of President Bush's social conservative base, U.S. global HIV/AIDS funding is attached to an increasing number of criteria and restrictions. These restrictions and criteria are not based in sound epidemiological practice and are being demonstrated to undercut the administration's own work to support developing countries as they struggle to prevent the spread of HIV infections and to care for those who are infected.

In 2003, the Bush administration announced a major new initiative to amplify the U.S. response to the global HIV/AIDS pandemic by tying together existing efforts and investing new resources. The United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 established a comprehensive U.S. policy toward the global HIV/AIDS pandemic. Dubbed PEPFAR - The President's Emergency Plan for AIDS Relief - the plan defines a strategy to address HIV/AIDS through support to the Global Fund and also a significant direct investment in HIV/AIDS prevention, treatment, and support programs. PEPFAR calls for $15 billion to be spent over five years to fight AIDS overseas, with specific focus on 15 countries that account for approximately half of the world's infections (The White House, 2005a; United States Department of State, 2004). PEPFAR's goal is to prevent seven million new HIV infections, provide antiretrovirals to at least 2 million people with HIV, and care for the sick and orphaned (The White House, 2005a).

Public Health through an Ideological Lens

On the surface, this investment implies an operationalization of "compassionate conservatism". However, PEPFAR has come under widespread criticism from HIV/AIDS health experts, advocates, and policymakers from around the world for undercutting prevention programs through under-funding and politically motivated policies. Specifically, despite claiming to emphasize prevention as a core strategy to combat HIV/AIDS, PEPFAR limits spending on prevention programs to 20 percent and requires that one-third of these funds must be used for "abstinence until marriage" programs (P.L. 108-025). (See box "PEPFAR and Prevention.")

PEPFAR and Prevention
What PEPFAR Says about Prevention	What it Does
"Prevention remains the primary strategy to combat HIV/AIDS. Despite two decades of focused attention on prevention, however, we have yet to achieve widespread success? President Bush's Emergency Plan is specifically designed to address these challenges by using evidence-based prevention programs, such as the "ABC" approach of Abstinence, Be faithful and as appropriate, the correct and consistent use of condoms." "Rapid scale-up of existing prevention services is an urgent priority of President Bush's Emergency Plan." "[T]he Emergency Plan will target prevention funds to methodologies that are effective in helping people avoid behaviors that place them at risk of contracting HIV." (United States Department of State, 2004)	The United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 requires the following HIV/AIDS spending: Not less than 55 percent of the funds are to be spent on treatment activities, with 15 percent allocated to palliative care. Recommends 10 percent of funds be allocated for care of orphans and vulnerable children. Prevention — The remaining funds, about 20 percent or $600 million per year, may be spent on prevention activities. (P.L. 108-025)

In addition to under-funding prevention, a diverse range of health experts, advocates, and policymakers also argue that the strategy is essentially flawed in its approach and fails to ensure that all individuals and groups at risk of infection will have access to complete HIV prevention information, education, and training (CHANGE, 2004a). For example, it offers separate strategies for the programs two target populations — "youth" and "high risk" — when in reality these groups are not mutually exclusive. (Individuals considered high risk include couples where one partner is HIV positive or whose status is unknown, sex workers, men who have sex with men, and intravenous drug users (United State Department of State, 2004; The White House, 2005a). According to the strategy, efforts to prevent sexual transmission of HIV among youth will focus on "abstinence until marriage", on "secondary abstinence" (those who are already sexually active abstain from sexual activity), and on messages about "being faithful within marriage" (CHANGE, 2004a). Among other shortcomings, the strategy assumes that most adolescents are not married and that marriage is in itself a protective factor against HIV infection (CHANGE, 2004a). In fact, as outlined earlier in this issue brief, HIV/AIDS experts are identifying marriage as a risk factor for HIV infection. And in countries where HIV infection is widespread, everyone is at high risk of infection.

The potential of PEPFAR's critical investment in life-saving global health strategies is further distorted by politically motivated implementation that serves the interests of U.S. social conservatives but not those of people most at risk of HIV. These policies and practices favor awarding PEPFAR funds to faith-based organizations, including those with little or no relevant international development experience, require emphasis on abstinence-focused programming, require grant recipients to make "anti-prostitution" pledges, and underplay the use of condoms as an effective prevention strategy. These policies and practices directly conflict with evidence-based HIV/AIDS prevention strategies and serve to short-circuit the U.S. investment in programs that are already hard-pressed to serve the needs of those at risk of HIV infection.

A New Role for Faith-Based Organizations

"Instead of getting on with the basics of treating and preventing AIDS, these religious conservatives have gone in with a very aggressive ideological agenda."
    — Paul Zeitz, Director of the Global AIDS Alliance (Kohn, 2005)

Traditionally, funding through government global health initiatives such as PEPFAR goes to nongovernmental and private organizations experienced at fighting HIV and AIDS. Under PEPFAR, organizations that support the president's socially conservative agenda are receiving the funds as well; some without a track record of international and/or HIV/AIDS experience (Sealey, 2005). In fiscal year 2004, over 20 percent of the organizations the U.S. government funded through PEPFAR were faith-based organizations (United States Department of State, 2005). One group, the Children's AIDS Fund, was reported by the Washington Post as having received PEPFAR funds to promote abstinence only programs in other countries despite the citation of an expert panel reviewing requests for government money determining that the group was "not suitable for funding" (Brown, 2005). Another organization, the Florida-based Fresh Ministries, received $10 million from the fund. Despite having little experience with AIDS, the group will run a project called Siyafundisa, which will teach abstinence until marriage to children and young adults in South Africa, Mozambique, and Namibia (Avert, 2005; Sealy, 2005). According to a New York Times editorial, included in organizations receiving PEPFAR funds to work on HIV/AIDS prevention are groups that argue, incorrectly, that the AIDS virus can pass right through a condom (New York Times, 2005).

A-B-C

"While the U.S. government holds up Uganda as a model [of successful use of A-B-C to decrease HIV infection rates].... U.S. rhetoric — and, more importantly, U.S.-funded programs — consistently disparage or undermine the effectiveness of condoms."
— The Guttmacher Institute, 2004b

The A-B-C approach to HIV/AIDS prevention exemplifies the distortion of sound prevention strategies when viewed through a moralizing lens. "Abstain, Be Faithful, Use a Condom" has become synonymous with Uganda's success in slowing the rate of HIV infections in the 1980s and 1990s (The Guttmacher Institute, 2005). A broad A-B-C-centered approach to HIV prevention would encourage people to avoid infection by delaying or abstaining from sex, being faithful to one partner, and using condoms. A-B-C is a "tiered" approach that is "calibrated to levels of risk" and is "epidemiologically and programmatically sound" when appropriately implemented (Sinding, 2005). That this approach is broadly supported is evidenced by a letter making this point which was signed by over 140 leaders of governments, churches, research institutions, and relief organizations around the world and published in the November 27, 2004, issue of the international medical journal The Lancet (The Lancet, 2004).

Despite the prevailing opinion of public health experts, the U.S. interpretation of A-B-C is focused on promoting abstinence. Most explicitly is the requirement that at least one-third of all U.S. global HIV/AIDS prevention assistance be used for "abstinence until marriage" programs (P.L. 108-025). Social conservatives in the United States applaud the approach, but health professionals working on the ground have strongly criticized the U.S. government's narrow interpretation of A-B-C as undermining the global response to HIV/AIDS (The Guttmacher Institute, 2005; Sinding, 2005; CHANGE, 2004a). According to the U.N. secretary general's special envoy for HIV/AIDS in Africa, PEPFAR is being driven by Christian ideology "with disastrous results," including a shortage of condoms in Uganda and new HIV infections which should never have occurred (Reuters, 2005).

Abstinence-only HIV prevention programs simply ignore the realities of people's lives. While women are being told they should abstain from sex until they are married and then remain faithful to their husbands, the strategy only works if their husbands are uninfected and remain faithful as well, and if women have control over whether and when to have sex. As noted in a New York Times editorial on the subject "Abstinence-only teaching does not work in the United States, and there is no reason to think it will work in Uganda" (New York Times, 2005). In practical terms, this unbalanced approach of "A-B-and then maybe C" is paving the way for the marginalization of condoms, the only available technology to prevent HIV transmission, and does so at the peril of people's lives.

Undermining Condoms

"The male latex condom is the single most efficient available technology to reduce the sexual transmission of HIV and other sexually transmitted infections. ... Condoms will remain the key prevention tool for many, many years to come."
— World Health Organization, UNAIDS and United Nations Population Fund Statement on condoms and HIV prevention, 2004

At first glance, PEPFAR reflects the evidence-based strategy of promoting correct and consistent use of condoms to prevent new HIV infections. However, in practice PEPFAR is directly and indirectly undermining condom use as an effective prevention strategy (The Guttmacher Institute, 2003; Sealey, 2005).

The PEPFAR Strategy calls for provision of condoms only to narrowly defined "high-risk" groups, which include, according to PEPFAR, "prostitutes, sexually active discordant couples, substance abusers and others" (United States Department of State, 2004) In January 2005, Ambassador Randall Tobias, President Bush's global AIDS czar, issued guidelines to organizations receiving PEPFAR funds stating that groups working to prevent HIV infections among young people should not present abstinence and condoms as "equally viable, alternative choices" (Sealey, 2005).

This message translates overseas as discouraging education and supply of condoms as a prevention strategy. According to Susan Cohen of the Guttmacher Institute, "Reports from the field indicate that many believe the United States only will support programs that exclude or deemphasize information about condom use even for unmarried young people who are already sexually active" (Cohen, 2005). Another indirect effect of the narrow interpretation of A-B-C to focus on — and fund — abstinence-only programs is that it has actually affected the availability of condoms in countries like Uganda. (See Case Study: Uganda).

Social conservatives in Congress have systematically pursued an agenda that seeks to marginalize the effectiveness of condoms. They inserted a provision in United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 — the bill that created PEPFAR — to "protect" faith-based organizations against distributing condoms. Led by the House Pro-Life Caucus, members of Congress successfully included a condition bill stating that no organization to receive PEPFAR funds to implement HIV/AIDS prevention and care and treatment programs may be required to "endorse, utilize or participate in a prevention method or treatment program" to which the organization has religious or moral objection (P.L. 108-025). Members have also ordered studies of the effectiveness of condoms, which implies problems with condoms and eroding confidence in their use (The Guttmacher Institute, 2003).

By restricting condom education and promotion as a critical HIV prevention strategy, the Bush administration has created a platform for social conservatives to directly attack condom use — through policies that allow HIV/AIDS prevention activities to ignore condoms, through studies that are aimed at undermining confidence in the ability of condoms to protect from STIs, and through public statements by Bush administration representatives such as that from Ambassador Tobias.

Anti-Prostitution Pledge

"The U.S. government's 'anti-prostitution' pledge not only undermines its global efforts against HIV/AIDS, it also undermines the fundamental right of sex workers and trafficking victims to receive life-saving information about HIV/AIDS."
— Rebecca Schleifer, Human Rights Watch (CHANGE, 2005b)

In passing the Bush global AIDS initiative, Congress included a provision requiring that all organizations receiving federal AIDS funds to have a policy "explicitly opposing" prostitution and sex trafficking in order to be eligible for U.S. funds (The Guttmacher Institute, 2003). The policy was originally applied to foreign organizations and was later broadened to a requirement of U.S. organizations receiving federal AIDS funds (Kohn, 2005). As with other ideology-based policies examined here, the implementation of the anti-prostitution pledge has resulted in a distorted environment that sacrifices lifesaving services and places ideology over people's lives.

As a result of the policy, groups such as Population Services International (PSI), which runs HIV prevention programs targeting sex workers in bars and brothels in Central America, appear to be losing federal support (Kohn, 2005). Last year PSI's program made contact with 422,000 people in high-risk groups and has demonstrated a significant decrease in HIV infections among sex workers. An official with the UNAIDS office cites the program as one of the best in the region. Other organizations, such as DKT International, refused to sign the clause on free speech grounds and as a result lost funding (Kohn, 2005; Phillips, 2005). DKT International has subsequently filed a lawsuit against the U.S. government. And the country of Brazil has refused $40 million in U.S. HIV/AIDS grants because they are conditioned on the pledge requirement (Phillips, 2005).

The pledge also is having a chilling effect, as groups wary of losing precious funds cut activities that are aimed at assisting sex workers. The ambiguity of the policy, which, for example, does not clearly define what it means by "prostitution," exacerbates the problem. As a result, for fear of losing funding, nongovernmental organizations in Cambodia discontinued plans to provide English language classes to sex workers — classes which would potentially open opportunities for alternative income generation (CHANGE, 2005b). By forcing service providers to take a position condemning the very people they are seeking to help, the anti-prostitution pledge is yet another example of the Bush administration's fervent commitment to serving the demands of its social conservative base. And it does so at the cost of the lives of those it purports to help through its HIV/AIDS funding and programs.

Conclusion

The Bush administration recognizes the moral imperative of the world's wealthiest country to take significant action against the HIV/AIDS pandemic. Despite the pledges of support, the need for funding and effective programs is far from being met. The global AIDS pandemic is cutting short lives, devastating families, and disrupting communities. Yet, the United States is using its funds to promote a religious agenda that ignores science, promotes abstinence and monogamy over comprehensive education about health and sexuality that includes condoms, and marginalizes the very same "high-risk" groups the funds are supposed to help. If the United States is truly serious about using all the resources at our disposal to undertake "a work of mercy beyond all current international efforts," as President Bush declared in his 2003 State of the Union Address, then U.S.-funded efforts must be based in sound, proven strategies free of political and ideological motivations (White House, 2003).

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Lead Author — Rhonda Schlangen, International Division, Planned Parenthood^® Federation of America

Published: 03.13.06 | Updated: 09.29.06

Published by International Division, Planned Parenthood^® Federation of America

©2007 Planned Parenthood^® Federation of America, Inc.
All rights reserved.


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