Some Good News about PEPFAR, But Challenges Remain
In late July the House voted 303-115 to approve a measure (HR 5501) that would reauthorize the President's Emergency Plan for AIDS Relief at $48 billion through 2013 and sent the bill to President Bush, who signed it on July 31.
- The measure modifies a requirement that one-third of PEPFAR funds for HIV prevention be spent on abstinence-only education—now, PEPFAR will be required merely to report to Congress if less than half of HIV prevention funds in a particular country are spent on abstinence and fidelity programs.
- The bill also increases attention on women and girls and stresses the prevention of sexual violence. In addition, the final bill aims to reach 80 percent of HIV-positive pregnant women with services to prevent mother to child transmission of the virus.
- The measure also would remove the policy, in place since 1987, which bars HIV-positive foreigners from entering the U.S. (PEPFAR removes the legislative ban, but an administrative mandate from the Department of Health and Human Services which predates the legislation, remains in place – so there is still a significant hurdle to overcome before HIV-positive foreigners may enter the country.)
Advocates welcomes these steps. But prevention policy for young people and other vulnerable populations in the Senate version of the bill still remains unacceptable for a number of reasons.
- Reporting Requirement: The U.S. Global AIDS Coordinator is required to report to Congress any time the decision is made to expend less than 50 percent of funds allotted for prevention of sexual transmission on “activities promoting” abstinence and being faithful. While not a “hard earmark” determining the allocation of funding, this reporting requirement places an emphasis on just two parts of prevention education, even though the Institute of Medicine has clearly stated that segmented prevention programs are not as effective as comprehensive prevention education.
- Refusal clause (the so-called “conscience clause.”): The Global AIDS Act of 2003 includes a refusal clause or so-called “conscience clause” allowing organizations to receive public funding to carry out prevention programs that are based on their own philosophy, even if it is in conflict with evidence-based interventions. The bill passed in the Senate yesterday enables organizations that receive U.S. funds to choose among those groups and individuals to whom they are “morally” comfortable providing care, thereby permitting the denial of services to those whose behavior, identity, religion or other attributes the organization deems unacceptable. This provision actually codifies stigmatization and discrimination into law and allows the use of U.S. taxpayer funds to perpetuate such discrimination.
- The Prostitution Pledge: Current law requires groups fighting HIV/AIDS overseas to pledge their opposition to prostitution and sex trafficking before receiving U.S. money. Some assert that requiring organizations to sign such a pledge will help contribute to ending prostitution, but in reality the opposite may be true. According to numerous reports, the pledge has led to further alienation of already-stigmatized groups, given free rein to police who abuse or extort money from sex workers, and has resulted in further violence and discrimination against women in sex work. Instead of reducing dependence on sex work, the policy is driving sex workers underground and away from the NGOs and health workers best poised to provide them with health and alternate-livelihood services.
- No linkages between family planning and HIV/AIDS services: The omission of these linkages is misguided in that HIV is a reproductive and sexual health issue and sexual transmission is the single greatest cause of new infections. By failing to require strong linkages among these global heath interventions, the legislation purposefully accepts the fact that countless opportunities will be lost to improve the health and save the lives of countless women, their children, and their families as the largest U.S. investment ever in a single disease is spent on what is most politically viable instead of the real-life needs of these women and their families. H.R. 5501, the House version of the bill, which passed in April, includes these linkages, but applies the Global Gag Rule (Mexico City Policy) to family planning implementers that would be linked with PEPFAR funding. Both options place political expediency before public health best practices and the lives and well-being of young people.
- Absence of policy support for young people living with HIV and AIDS (YPLWHA): S. 2731 does not adequately support the needs of the rapidly growing cohort of young people reaching reproductive age while infected with HIV. PEPFAR legislation should both recognize this cohort and foster the development of innovative policy that will support prevention, treatment, and care programming unique to their psychosocial needs. Young people living with HIV and AIDS, just like all young people, have the right to knowledge about their sexuality and how to protect themselves and others from unwanted pregnancy and STIs, including HIV, through access to comprehensive prevention education.
Advocates will continue to work for policies that support culturally appropriate comprehensive, science-based prevention efforts in developing countries.
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