U.S. policy guides global AIDS prevention: deconstructing PEPFAR and its ‘ABC’s
Katherine Lee writes on how U.S. foreign aid policy, in particular PEPFAR, impacts on teaching about HIV/AIDS.
“(It is t)he largest commitment by any nation to combat a single disease in human history.”(1) PEPFAR, the President’s Emergency Plan for AIDS Relief, was initiated by United States President Bush in early 2003 and reauthorized this year. The Emergency plan supports fifteen focus nations in addition to the AIDS relief given by the United States government to one hundred and fourteen countries. PEPFAR aims for a 2-7-10 goal; two million AIDS patients receive antiretroviral treatment, seven million contractions of the disease are prevented and ten million patients are given supported care. (1)
PEPFAR claims it “employs the most diverse prevention, treatment and care strategy in the world.”(1) Diverse, but not comprehensive- particularly in the area of disease prevention. Most striking is the concerted repression of condom usage. The program teaches the ‘ABC’s of AIDS prevention; ‘A’ is for abstinence, ‘B’ is for being faithful, and ‘C’ is for convoluted. Theoretically ‘C’ stands for correct and consistent condom use however this last letter of the acronym could be easily forgotten. In PEPFAR, as in school, ‘A’ is best.
According to ABC Guidance #1 (2) published on pepfar.gov, “every country program must include all three elements of the “ABCs”‘ and “(T)he A, B, and C components must not undermine or compete with each other.” However this is clearly contradicted and all letters are not created equal, as stated in the next paragraph of Guidance #1 which allows for funding of stand alone abstinence programs. This explicit allocation of funding to exclusively abstinent education has become one of the most contested aspects of PEPFAR and paramount among its many criticisms. As allowed by the budget approved in January of this year, 7.3% of the 22% of total funding allocated towards AIDS prevention through PEPFAR was dedicated to ‘A/B’ or abstinence/be faithful training. This is the single greatest allocation within the prevention program’s financial allowance, seconded only by funding towards Prevention of Mother-to-Child Transmission (PMTCT) at 6.8%. Blood Safety and Injection Safety weigh in at 1.6% and 1.0% respectively, while a miscellaneous “Other Prevention” category rounds out the total at 5.3%. (3) Clearly ‘C’ didn’t make the grade. Exactly what percent of the “Other Prevention” funding was available for safer sex practice education and information on the correct use of a condom was not stated.
Abstinence efficacy rates are generally and historically markedly low; a behavioral study spanning nearly fifty years found that almost all people in the United States have premarital sex. (4) Favoring abstinence as the morally right or only choice is naive, irresponsible, wasteful and dangerous. Abstinence and faithfulness have a place within an individual’s personal set of beliefs and within their own cultural and religious guidelines. These are not behaviors to be mandated by an outside government, let alone any government and certainly not imposed as a requisite for aid funding in a health crisis. While PEPFAR maintains it will tailor the use of the ‘ABC’s to accommodate the need of each individual country, stringent rules govern the administration of the ‘ABC’s and hold no real promise of adaptability. According to Guidance #1 youth aged ten to fourteen will be exposed to ‘A/B’ programs only, while youth aged fourteen and older will be fully alphabetized. Even within the section of literature allegedly dedicated to correct and consistent condom use, the primary importance of abstinence is persistently reiterated. Outlined for the fourteen and older ‘ABC’ youth program are eight steps of prevention, the very last of which is condom usage tagged with the conditional that condoms are for those who “engage in risky behaviors”. (2)
PEPFAR recognizes that some youth may become or be at risk for becoming sexually active before they are introduced to the ‘C’ element of prevention. Action taken in such cases is to target those at risk youth and incorporate them into an integrated ‘ABC’ program outside of school. Guidance #1 stipulates that no funding shall be provided for condom distribution or promotion towards youth within schools. PEPFAR shall only support condom availability outside of school for youths deemed “at risk” or engaging in “risky behavior”. This approach is doubly faulted and flawed. How are “at risk” youth identified and distinguished from their peers? Are they counseled with supportive concern conducive to promoting trust or is the real “risk” ostracizing and alienating through policing and presumption? Secondly, this method of segregating at risk youth for early “comprehensive” sex education disallows for the needs of “at risk” youth that may not have been identified. It also neglects the benefit that all young people would receive from complete and unbiased knowledge. According to a recent review of U.S. sexual education policy performed by Columbia University’s School of Public Health, “(A)bstinence-only programs threaten fundamental human rights to health, information, and life.”(5) Even eclipsing the egregiousness of imposing the conservative views of the current US administration is the denial of access to education free from stigmatism and prejudice. Easily the most toxic aspect of this program is the negative association inherently attached to condom usage; condoms and condom education are only for at risk youth or those engaging in risky behavior, condoms should not be “marketed to broad groups of young people”. (2) Condoms are not for everyone. Condoms are for ANYONE who is sexually active. The issue is not one of morality or cultural invasion- it is the ethical facilitation of empowerment of the people of nations most in need of AIDS prevention to make an educated choice.
Filtering aide funding through impartial world organizations would alleviate the impact of political power in dictating or corrupting expenditure and allow for open delegation between the sponsoring and receiving nations. Ideally this mediation would work to counteract a somewhat forced blind acceptance of conditionals by the receiving nation due to the extreme degree of need.
No doubt with a goal of two million antiretroviral treatments, and 1.73 million patients already reached, (1) PEPFAR has done good work and will continue to into the future. We must ask though, is the force of political power in determining prevention practice ethical? Consider that prevention spending accounts for only twenty two percent of a total budget of forty-eight billion dollars across a ten year period. (1,2) The dollar amount is so great it almost halts debate by virtue of numerical value alone. So don’t say the United States doesn’t care about AIDS prevention- just say we did it our way.
Katherine Lee, studying science journalism. Graduated with a degree in molecular, cellular and developmental biology from the University of California at Santa Cruz and studied as a PhD student in biomedical sciences at the University of Massachusetts Medical School, U.S.A.
References
(1) http://www.pepfar.gov/. Accessed on 31st July 2008.
(2) ABC Guidance #1
http://www.state.gov/documents/organization/57241.pdf
(3) PEPFAR Program Summary Budget 2008 http://www.pepfar.gov/about/opplan08/102042.htm
(4) Filner, LB. “Trends in Premarital Sex in the United States.” Public Health Reports ” 122(1) (Jan-Feb 2007): 73-8.
(5) Santelli, J, et al. “Abstinence and Abstinence-only Education: A Review of U.S. Policies and Programs.” The Journal of Adolescent Health 38(1) (Jan. 2006): 72-81
Suggested Reading
Boler, Tania and David Archer. The Politics of Prevention: A Global Crisis in AIDS and Education