In January 2003, President George W. Bush announced his plan to ask Congress for $15 billion to fight the global AIDS pandemic. In contrast to the 1980s and 1990s—when many U.S. conservatives, most notoriously Ronald Reagan, studiously avoided referring to HIV—after the millennium, conservative leaders seized upon HIV, particularly its appalling impact in Africa, as a key issue. Called the President’s Emergency Plan for AIDS Relief (PEPFAR), Bush’s initiative sped through Congress and is now five years old. Thanks to widespread, bipartisan support in 2008, PEPFAR will likely be again funded with $30 billion for the next five years.
The program focuses funds on 15 countries (12 African nations, together with Guyana, Haiti, and Vietnam) although others also receive support. Most of the funds (70%) are expended on care and treatment, while 10% is spent on supporting AIDS orphans and affected children, and 20% on prevention, of which at least one third must be spent on abstinence training (and two thirds on combined abstinence-fidelity education). The program was slow to adopt generic drugs, but in the last few years there has been a dramatic shift, so that generics now account for the majority of the drugs provided.1
Overall, the program has unquestionably helped to increase the number of HIV-positive people who receive medication. It has also cut the rate of mother-to-child transmission, as well as supported people living with HIV and AIDS orphans. The Economist has called PEPFAR the key positive foreign policy of Bush’s presidency; by providing medications to more than 1 million HIV-positive Africans, the magazine suggests, the program has served both humanitarian and propaganda purposes, with the majority of Africans still viewing the United States positively as a result. 2The PEPFAR agency points to its efforts over the last five years to “build partnerships” by strengthening the capacity of more than 2,000 local organizations in Africa.3
Given these achievements, how could the program be controversial? In 2005 I interviewed government and NGO leaders in São Paulo, Brazil, where PEPFAR evoked powerful emotions. At the time the Brazilian government was considering seeking funds from PEPFAR (although Brazil is not a focus country), which would have meant signing an “oath” affirming Brazil’s opposition to prostitution. To the Brazilian leaders—who have had great success in containing HIV, largely by reaching out to marginalized groups like sex workers and drug addicts—this requirement seemed illogical. How, they asked me, can you fight AIDS if you don’t work with prostitutes? They decided against seeking U.S. funds; for many Brazilians, the anti-prostitution requirement reflected the efforts of U.S. religious groups to impose their views on other nations by means of their financial and political power. The sense of anger was perhaps best captured in the words of Pedro Chequer, the director of Brazil’s AIDS program and the chairman of the national commission that turned down the U.S. money: “We can’t control [the disease] with principles that are Manichean, theological, fundamentalist, and Shiite.”4
Critics have also charged that PEPFAR inappropriately requires that HIV/AIDS prevention efforts prioritize abstinence and fidelity training.5 Little research in peer-reviewed journals suggests that such training decreases sexual activity among the young, and the example of Thailand proves what a solid condom-based HIV prevention program can do. But the larger issue that disturbs critics is that neither abstinence nor fidelity is a realistic option for many women becoming infected with the virus. In places like Oaxaca, Mexico, a large proportion of new HIV infections are among housewives, the majority of whom may have had only one sexual partner in their lives. A stress on faithfulness may actually distract these women from the dangers they face.
In São Paulo I visited a support group for people who had difficulty sticking to their regimen of HIV medications. One woman had been living with HIV for years and was now on her own, because her husband had died of AIDS. Her voice shook with anger as she talked about the man who had infected her, who was the same man with whom she had lost her virginity. He had most likely infected her because he cheated on her after their marriage. Because abstinence does not protect married women, who need to learn to protect themselves, workers in the field are often infuriated by the suggestion that abstinence education is the key to AIDS prevention. Furthermore, monogamy and fidelity are not an issue for married women or babies who become infected. Nor do many sex workers face realistic options. For this reason, many public health officials advocate a more pragmatic approach.
In short, critics have charge that politics rather than science drives U.S. AIDS policy, pointing to the program’s favoring of treatment over prevention, which would entail engaging with politically difficult issues like teen sex and homosexuality, condom usage and prostitution. As the Brazilian experience has shown, effective anti-AIDS policy must integrally link prevention and treatment, rather than favor one over the other. If the program, now launching into a second incarnation that is twice its original size, is to be effective, it must be seen in the Global South as building upon best practices and scientific knowledge. The process by which the focus countries are selected should be transparent and based on objective criteria. And the compassion that has shaped the program needs to be matched by a ruthless dedication to results, whether considering policy options in Haiti or Kenya.
Shawn Smallman is the author of The AIDS Pandemic in Latin America (University of North Carolina Press, 2007). He is Vice-Provost for Instruction and Dean of Undergraduate Studies at Portland State University in Oregon.
1. www.avert.org/pepfar.htm
2. “Doing Good, Quietly,” The Economist (February 16, 2006): 5–56.
3. PEPFAR press release, “The U.S. President’s Emergency Plan for AIDS Relief Releases Fourth Annual Report to Congress: the Power of Partnerships,” February 1, 2008.
4. Michael M. Phillipsand Matt Moffett, “Brazil Refuses U.S. AIDS Funds Due to Antiprostitution Pledge,” The Wall Street Journal, May 2, 2005.
5. Wendell Rawls, “Bush’s AIDS Initiative: Too Little Choice, Too Much Ideology,” www.publicintegrity.org/aids/report.aspx?aid=800.
