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September 26, 2007
In January 2003, President George W. Bush called for the United States to
commit $15 billion over five years to address the international AIDS epidemic.
More recently, in May, 2007, President Bush called for the reauthorization of
the President’s Emergency Plan for AIDS Relief (PEPFAR) with a doubling of
funding, asking Congress to authorize an additional $30 billion over the
following five years. With such a large figure now before the Congress, the
issue of U.S. leadership in the fight against the AIDS pandemic has taken on
unprecedented—and very public—proportions.
The president's initial announcement in 2003 caught many people by surprise
both for its unparalleled commitment of resources and for its timing, given how
much of the administration's attention was focused on the impending war in Iraq
at that time. The surprise was followed by excitement, tempered by skepticism.
Excitement stemmed from the hope that the tragic scope of the AIDS epidemic and
its potential impact on U.S. and global interests were finally being fully
acknowledged. Some observers also felt that the initiative was in line with a
broader definition of "security." Others interpreted the plan as a case of a
major power moving beyond strict national interests to cooperatively address
global humanitarian challenges. Furthermore, since the initiative enjoyed
support from both parties in Congress and an unusual coalition of liberal and
conservative NGOs, PEPFAR suggested a stronger domestic alliance supporting
future U.S. humanitarian initiatives.
Skepticism came from a worry that the announcement was simply a short-term
rhetorical effort to enhance America's image at a time that its use of military
power was opposed by much of the international community. Many also questioned
whether Congress would ever appropriate such a large sum, given other spending
priorities and mounting budget deficits. Most crucially, some observers worried
that program choices would be shaped more by economic calculations and moral
agendas than best-practice medical guidelines.
Four years after PEPFAR's creation, both some excitement and some skepticism
appear warranted, although not for all the same reasons that either the
optimists or pessimists predicted. On the plus side, the initiative has enjoyed
sustained political and fiscal support from both the administration and Congress
and is starting to show impressive results in prevention and treatment. On the
other hand, the optimists' hopes of redefining security and seeing the United
States act multilaterally to address global issues have receded. In addition,
skeptics' fears that U.S. economic interests and conservative Christian views
would heavily influence administration programs have been borne out. Thus, the
optimists won the war but lost most of the battles.
An interim assessment of PEPFAR shows that major humanitarian initiatives can
be developed in today's political environment, but that actual programs will be
more influenced by international and domestic calculations than by pure
humanitarian considerations. With such disputes over details, establishing a
long-term liberal-conservative coalition broadly supporting humanitarian
objectives appears unlikely.
AN OVERVIEW OF PEPFAR'S ORIGINS AND ACTIONS
Although unprecedented in its scale and scope, President Bush's 2003
announcement was not the first U.S., or even the first Bush administration,
action on the international AIDS pandemic. The magnitude of the AIDS crisis
became apparent to U.S. officials in the 1980s, and small amounts of funding
were soon allocated to efforts to address it. In 1996, the United States
supported the creation of a UN program to coordinate global AIDS efforts. In
subsequent years, Clinton administration officials gave the need to combat AIDS
increased rhetorical prominence. U.S. programs increased, but overall funding
remained low. For example, a 2000 bill signed by President Clinton authorized
only $150 million to be administered by the World Bank and $300 million for
bilateral programs.
In the spring of 2001, UN secretary-general Kofi Annan put new pressure on
world governments by proposing the creation of a Global Fund to Fight AIDS,
Tuberculosis, and Malaria. On May 27, 2001, President Bush announced that the
United States would make a founding contribution of $200 million to the fund and
pledged to add more if the programs proved effective. At the time,
administration officials pressed the UN to spend most of its money on prevention
rather than treatment. In one extreme attempt to justify this focus, the United
States Agency for International Development (USAID) administrator Andrew Natsios
argued that sending antiretrovirals to African countries would be ineffective
due to their lack of trained doctors, limited infrastructure, and the inability
of Africans to follow a complicated treatment regimen because of their
insufficient knowledge of clocks. The U.S. focus on prevention continued with
Bush's June 2002 announcement of a new $500 million U.S. initiative aimed at the
reduction of mother-to-child transmission of HIV. This initiative was an
impressive increase over past U.S. funding levels, but it avoided addressing the
crucial, and controversial, issue of prevention of sexual transmission.
Within the administration, support for increased funding of AIDS programs
came from a number of cabinet members, top aides, and President Bush himself,
who came to see it as a moral matter but feared that the money would not be
effectively spent. Congress saw mounting support from both liberal Democrats,
who had long pushed for greater action, and key Republicans. Senate Majority
Leader Bill Frist, a doctor who had been on medical missions to Africa, and
Senator Jesse Helms, a former sharp critic of most U.S. foreign aid programs,
were particularly crucial players. The liberal-conservative alliance in Congress
was mirrored by the mix of NGOs active on the issue. These ran the gamut from
traditionally liberal humanitarian and medically focused groups to conservative
religious groups that argued that Christians had a responsibility to assist the
sick. Claiming that Bush moved forward on AIDS funding only to placate his
Christian conservative base would be an overstatement; encouraging data on
Uganda's prevention programs and sharp decreases in antiretroviral prices were
certainly at least as important. Still, in the words of the rock star and AIDS
activist Bono, "The administration isn’t afraid of rock stars and student
activists—they are used to us. But they are nervous of soccer moms and church
folk. Now when soccer moms and church folk start hanging around with rock stars
and activists, then they really start paying attention."1
The stage was therefore set for President Bush's January 2003 announcement:
The Emergency Plan for AIDS Relief—a work of mercy beyond all current
international efforts to help the people of Africa. This comprehensive plan 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. I ask the Congress to commit $15
billion over the next five years, including nearly $10 billion in new money, to
turn the tide against AIDS in the most afflicted nations of Africa and the
Caribbean. This nation can lead the world in sparing innocent people from a
plague of nature.2
The $15 billion commitment included $5 billion for existing bilateral
programs throughout the world, $1 billion for the UN fund ($200 million per
year), and $9 billion for new programs in fourteen target countries in Africa
and the Caribbean. The announcement contained several noteworthy points. First,
Bush established specific numeric targets for prevention, treatment, and care
before any of the program's details were established. Second, prevention would
now be expanded to programs addressing sexual transmission, following the model
of Uganda's highly regarded ABC program: Abstinence, Be faithful to your
partner, use a Condom. Finally, the biggest change was in the administration's
position on funding treatment. Ultimately, treatment would come to represent
roughly half of all PEPFAR spending.
In May 2003, Congress passed the necessary authorizing legislation. The
legislation largely followed President Bush's original outline, but added three
important provisions. On the House floor an amendment passed, supported by
considerable administration lobbying, requiring that at least a third of all
prevention funds be spent to promote sexual abstinence. A second amendment
allowed faith-based groups to reject strategies they considered objectionable,
such as condom distribution. Third, the law authorized, but did not require, up
to $1 billion per year for the Global Fund, five times what the president had
favored. The legislation stipulated that the exact amount of U.S. contributions
could not comprise more than a third of the total contributions to the fund for
any given year.
Little funding was dispersed in the first year of the plan as a new
bureaucracy and ties to groups in Africa were developed. By the spring of 2007,
however, the administration was able to provide impressive numbers in its third
annual report. Overall U.S. budget authorizations to combat international AIDS
were $2.3 billion in FY2004, $2.6 billion in FY2005, $3.2 billion in FY2006,
$4.5 billion in FY2007, and are projected to be $5.4 billion in FY2008. Thus,
the administration, with some prodding from Congress, which increased early
funding levels, appears on track to exceed its goal of $15 billion in five years
by roughly $3 billion.
Prevention funding has supported outreach activities to over 60 million
people. An estimated 100,000 infant HIV infections have been prevented by mother
to-child-transmission programs. The true efficacy of programs focused on sexual
transmission is harder to assess, since the programs are more diffuse, but the
administration argues they can achieve the goal of preventing 7 million
infections.
Antiretroviral treatment has been provided to 822,000 people in the targeted
countries, and another 165,000 people worldwide. There is, however, controversy
over how the United States reached these figures. Almost half of the recipients
included in U.S. figures were actually receiving treatment through the Global
Fund, and thus were only indirectly funded by the United States. The figures
also include both patients directly receiving U.S.-funded medication and those
receiving treatment after countries received funds for general "system
strengthening." The manager of Botswana's treatment program called the U.S.
figures "a gross misrepresentation of the facts," and several Botswanan
officials have said that not a single Botswanan is receiving treatment as a
direct result of U.S. funding.3
Even using administration figures, the program is behind in reaching its target
of 2 million recipients, in part because of the slow approval of using PEPFAR
funding to buy generic drugs and in part because of significant logistical
barriers to care in some countries.
Overall, PEPFAR's first years have far exceeded the expectations of its
critics: funding has been sustained, programs are rapidly expanding, and
prevention and treatment figures show huge increases over pre-2003 numbers. On
the other hand, PEPFAR has not reached all of its bold goals, and disputes on
several policy issues have generated much controversy.
AIDS AS A SECURITY ISSUE
In the first years of the epidemic, AIDS was largely thought of as a medical
problem. As the scope and impact of the disease became more clear, discussions
centered on AIDS as a social and economic challenge for certain countries.
Beginning in the late 1990s, the terms of discussion shifted once more, notably
in the academic literature and within government circles, and some began to
describe the epidemic as a security issue.
By 1999, key members of the Clinton administration were committed to putting
AIDS on the security agenda. Their efforts led to an unprecedented discussion of
the issue in the UN Security Council in January 2000. There and elsewhere
supporters made the case that the epidemic's impact on social systems,
economies, governing capacities, militaries, and peacekeeping operations meant
that it posed a real threat to both citizens and institutions. Some also used
the emerging idea of "human security" to argue that because AIDS would affect
the core individual right of life, it should be seen as a security concern. In
July 2000, the Security Council passed Resolution 1308, which declared that
action was necessary before the AIDS pandemic could further threaten world
security, and President Clinton announced that AIDS would now be treated as a
threat to U.S. national security.
Intriguingly, as AIDS gained prominence on the U.S. agenda, President Bush
moved away from the formula of AIDS as a security problem. China, India, and
Russia—three strategically important countries that analysts suggest might be
shaken by the second wave of the pandemic—were not included among the countries
targeted for the most U.S. aid. AIDS received only passing mention in Bush's
landmark 2002 National Security Strategy of the United States of
America. More importantly, none of his major speeches on the issue include
the word "security." Instead, his justifications for action repeated themes
enunciated in January 2003:
We have a chance to achieve a more compassionate world for every citizen.
America believes deeply that everybody has worth, everybody matters, everybody
was created by the Almighty, and we're going to act on that belief and we'll act
on that passion.4
In Bush's eyes, AIDS relief is tied to a religious obligation to help the
suffering because all humans are God's creations. He also frequently ties AIDS
relief to a legacy of compassionate U.S. policies, such as the Marshall Plan,
the Berlin Airlift, and the Peace Corps.
Bush's move away from security arguments is in line with the fact that few
Americans ever fully accepted their validity. As long as the epidemic remains
centered in Africa, the average American considers the economic and security
risks too small and too remote to be of concern. The broader concept of human
security also is not widely accepted outside of academic or UN circles. In
coming years, the U.S. government is unlikely to revive the security argument,
and any attempt to do so may be seen as politicizing a moral issue.
The president's reframing of AIDS relief as a non-security, and thus more
optional, issue may have significant future implications. Positioning PEPFAR as
part of a U.S. moral tradition is likely to have rhetorical appeal to future
administrations, but that does not guarantee continued funding and attention. It
is less certain whether the religious arguments will be utilized by others in
the future. So far, AIDS funding has withstood competition from the war on
terrorism and the need to aid tsunami and Hurricane Katrina victims, but future
funding is far from guaranteed under presidents who might stake less of their
personal political capital and moral commitment on the issue.
BILATERAL VERSUS GLOBAL ACTION
Almost as soon as President Bush announced the major U.S. initiative,
observers began to question what relationship the bilateral program would have
with the recently created UN Global Fund. Bush was careful to announce plans for
ongoing donations to the fund, and he also noted that U.S. Secretary of Health
and Human Services Tommy Thompson would chair the fund's board. Similarly, UN
officials expressed the view that the programs were complementary, not
adversarial.
Despite the surface accord, clear signs of friction quickly emerged. On the
very day of the president's program announcement, Anil Soni, an adviser to the
fund's executive director, commented that the United States' "taking a
unilateral approach" could hamper care for victims.5
Subsequently, Ambassador Stephen Lewis, the UN secretary-general's special envoy
for HIV/AIDS in Africa, became a frequent and blunt critic of U.S. funding
priorities and prevention strategies. While top UN officials pressed for large
increases in U.S. support for the fund, Bush administration officials questioned
the fund's management and effectiveness. Questions in these areas were even
included in PEPFAR's formal reports to Congress. Bush's budget requests
repeatedly targeted only $200 million annually for the fund, and despite the
fact that in several years Congress more than doubled the president’s request,
U.S. contributions to the fund were still less than 10 percent of total U.S.
spending on AIDS.
Among those interested in AIDS policy, a fierce debate has raged over whether
UN or U.S. programs are preferable. Some support for the UN arises out of
baseline anti-U.S. and pro-multilateral sentiments, but fund supporters raise
several other points. In a world with finite resources to combat the surging
epidemic, they argue that pooling funds and knowledge is critical. Also, the UN
has existing institutional ties and a decent reputation in most countries.
Working through a multilateral forum also decreases the chance that the
political interests or moral preferences of any one country will dominate
decisions. Finally, the fund's money is disbursed through grants to local
groups, so more of the money goes directly to citizens of targeted countries,
rather than to large international NGOs. Supporters of working through the fund
also suggest that the United States would benefit from both the perception that
it is the leader of a multilateral effort and from sharing the financial burden
of AIDS activism.
Those who favor channeling most or all of the money through bilateral
programs counter that UN agencies are not the right vehicle for a major health
program. There are also long-standing questions about the UN's financial
practices and supervision of those receiving grants. Conversely, U.S. programs
could be guided by professionals with years of experience in health management.
They also would have a single central bureaucracy facilitating tight monitoring
of dispersed funds. Furthermore, a U.S. program could be fully guided by U.S.
interests and perspectives, better enabling it to hold together a supportive
domestic coalition.
Of course, decisions between multilateral and bilateral programs are not made
entirely based on theoretical benefits and pitfalls. In this case, the fund's
performance to date has borne out many of the worries expressed by its critics,
and therefore has decreased the likelihood of multilateral efforts in the
future. Even those generally in favor of the fund have been sharply critical of
its slow disbursement of money. The fund also suffered problems of financial
accountability, and had to suspend grants in Ukraine in January 2004 and Uganda
in August 2005 due to reports of mismanagement. The fund has also been unable to
rally major international financial support. Although the United States has
committed the vast majority of its money to bilateral efforts, it has provided
close to 30 percent of the fund's contributions in most years. The fund is so
short of money that it has only provisionally accepted certain grant
applications, with the hope that new funds will become available. The
combination of slow disbursements, suspended programs, and limited funding of
new grants has left the UN far behind its goal of treating 3 million patients by
2005.
Even had the fund not stumbled, the United States was unlikely to funnel the
majority of its money through the UN. Although it has historically been a global
leader of human rights and humanitarian action, the United States often has been
hesitant to commit to multilateral initiatives. America's tendency toward
unilateralism was reinforced by President Bush's worldview, but it was not
created by this administration and will surely not end with it. Therefore, while
some observers may prefer that U.S. humanitarian actions, and AIDS programs
specifically, be channeled through the UN, they are likely wasting their efforts
and possibly missing any chance they might have to shape U.S. bilateral
programs.
FACTORING IN ECONOMIC INTERESTS
While international AIDS programs are generally described in humanitarian
terms, they are also big business. The contract to oversee the distribution of
U.S. assistance is worth hundreds of millions of dollars. Increased spending on
prevention means major new orders for condom producers. Most important, Bush's
new emphasis on treatment has huge implications for the pharmaceutical industry.
One early indicator of the issue's importance was the creation of two lobby
groups, the Corporate Council on Africa's Task Force on AIDS and the Coalition
for AIDS Relief in Africa, which brought together major pharmaceutical
companies, such as Bristol-Myers Squibb, Abbott Laboratories, Pfizer, and
others, to lobby Congress in support of PEPFAR funding.
At PEPFAR's start, the administration held that its funds could only be spent
on name-brand drugs, to protect patent rights and assure quality. President Bush
did maintain a Clinton-era policy that allowed companies in such countries as
India and Brazil to make generic versions of U.S.-patented drugs, but stipulated
that these companies were not to export those drugs. He also sent an interesting
signal on the issue by appointing the former chairman of Eli Lilly and Company,
Randall Tobias, who had no specific experience on AIDS or African politics, as
U.S. Global AIDS Coordinator. While traveling in South Africa in 2004, Tobias
commented about generics: "Maybe these drugs are safe and effective. Maybe these
drugs are, in fact, exact duplicates of research-based drugs. Maybe they aren’t.
Nobody really knows."6
Others, however, argued strongly that these generics were indeed safe, given
that they had been approved by the World Health Organization’s (WHO)
prequalification program and were being distributed by several governments,
international NGOs, and groups financed by the UN fund. They also argued that
generics should be a crucial part of any major treatment strategy because their
cost was only a third or less of U.S. brands. Furthermore, patient compliance
with drug regimens could be increased by using three-in-one combination pills
that were not available from any U.S. manufacturer at the time.
Pressure to change U.S. policy came from a host of players. AIDS activists
argued that the president's comments on human dignity would ring hollow if the
United States did not take every action possible to increase treatment numbers.
Representatives of the European Union’s drug regulatory authority refused to
attend a U.S.-led conference on generic medications as a symbolic protest
against administration policy. U.S.-based service providers, who hoped to buy
drugs at the lowest available price, also pushed for policy change. In May 2004,
the administration altered its policy to permit PEPFAR funding of generics, but
only once they had U.S. Food and Drug Administration (FDA) approval through an
expedited review process.
Even the revised policy came under fire. Critics argued that requiring FDA
approval was redundant, since the drugs had WHO prequalification, and would only
serve to slow delivery of drugs. They believed the requirement was a political
move designed to reassert U.S. independence and to maintain profits for U.S.
companies. The administration maintained that careful approval procedures would
guarantee medical quality. Ultimately, no generics completed the FDA process
until January 2005, so PEPFAR funds were not used to purchase a significant
number of generics until the end of 2005. By 2007, thirty—four generics had been
approved, but only 27 percent of PEPFAR-funded purchases in 2006 were of
generics.
Overall, the generic drug issue is one of the few examples of a U.S.
administration partly reversing policy in a way that put humanitarian objectives
above U.S economic gains. This issue was unusual for having a particularly
strong coalition of actors pushing for change, directly comparable U.S. and
foreign products, and a situation in which lives potentially hung in the
balance. In most cases, one or more of those conditions will not exist.
Therefore, future humanitarian policies are more likely to resemble President
Bush's original plan, which would have quietly pumped billions of dollars into
U.S. corporations.
IDEOLOGICAL DISPUTES OVER IMPLEMENTATION
On several fronts, the conservative lean of PEPFAR programs threatens both
programmatic success and America's global image. There are both smaller issues
in dispute and larger controversies over the roles of abstinence, condom
distribution, and faith-based programs.
Among the smaller issues is that of AIDS prevention through needle exchange.
By law, the U.S. government does not fund programs that exchange used needles
for clean ones. The argument against needle exchanges is that they support or
encourage drug use. Others argue that drug use would occur in any case, so
needle exchanges simply prevent further HIV transmissions. To date, this policy
has not been a major factor in U.S. international AIDS programs because drug use
is not a major source of infections in Africa; however, it could grow in
importance as the epidemic moves to such places as Russia and China, where
needles are a significant source of infection.
A second issue is restrictive U.S. rules regarding abortion. The Mexico City
Policy announced by President Reagan in 1984 required nongovernmental
organizations to agree as a condition of their receipt of federal funds that
they would neither perform nor actively promote abortion as a method of family
planning in other nations. This policy was rescinded by the Clinton
administration, but Bush restored the policy in a memorandum dated January 21,
2001. As PEPFAR legislation was moving through Congress, he announced that this
rule would be relaxed for groups fighting AIDS, as long as they kept AIDS funds
separate from other funds. Still, in August 2003 the administration terminated
funding for a well-regarded AIDS program run by a consortium of seven groups
because one group had worked with the UN Population Fund, which in turn had
worked with the Chinese government, which allegedly promotes abortion.
A third policy that has triggered debate is a legislative requirement
prohibiting funding of any group that does not have an explicit written policy
opposing prostitution and sex trafficking. Three U.S.-based NGOs filed lawsuits
against USAID, arguing that compelling the pledge was a violation of free
speech. In June 2006, two district courts ruled in favor of the NGOs, but the
rulings have been challenged at the appellate level, and would not apply to
groups based outside the United States. International opposition to the policy
was highlighted by the UN fund's refusal to enact a pledge and by the Brazilian
government's refusal of $40 million in U.S. assistance because it felt that the
requirement would further stigmatize sex workers and make it difficult to
provide AIDS information to an important target group. Since most countries
cannot afford such a loss of U.S. dollars, however, they are forced to pledge or
to scale back certain programs.
Much greater controversy has surrounded U.S. implementation of the
Abstinence, Be faithful, use Condoms prevention strategy. There is a broad
consensus among public health officials that all three elements are essential to
reducing HIV incidence, but the U.S. weighting of programs toward those
promoting A and B over C is sharply contested. PEPFAR requires that at least 33
percent of all funds spent on prevention from 2006 forward go to abstinence and
fidelity programs. This number is somewhat deceptive because mother-to-child
transmission, blood safety, and safe medical use programs are also included
under prevention, so programs to stop sexual transmission receive only just over
50 percent of all prevention funds. Therefore, the Office of the U.S. Global
AIDS Coordinator (OGAC) in March 2005 directed country teams to spend 66 percent
of their prevention funds for the interruption of sexual transmission on A and B
activities. The remaining sexual transmission funds cover testing programs,
condom distribution, and other activities. Country teams can apply for an
exemption to the 33 percent rule, but overall funding across PEPFAR's focus
countries must meet the target, so a waiver for one country requires
compensatory increases by others. Additionally, all programs that discuss condom
use must discuss abstinence, but abstinence programs are not required to discuss
condoms. Therefore, of the 61 million people reached in PEPFAR-supported
outreach programs, over 40 million were in programs promoting only abstinence
and/or being faithful.
PEPFAR strategy documents and administration officials defend the A and B
focus with the argument that abstinence is the only guaranteed way to prevent
sexual infection. They point to evidence from Uganda and elsewhere that sexual
practices were altered and infection rates fell once the government began
promoting the A and B parts of the ABC strategy. Critics, on the other hand,
suggest that such a large focus on abstinence and fidelity is unwise. Data from
a study conducted by Ugandan scientists in collaboration with Columbia and Johns
Hopkins universities shows that the effect of educational messages in Uganda
seems to have peaked. More broadly, the Center for Health and Gender Equity
reports that a survey of the available literature suggests that "abstinence-only
programs have high rates of failure in terms of both infection and other adverse
outcomes, such as unintended pregnancy."7
Additionally, fears that the 33 percent rule makes it difficult to tailor
programs to local circumstances and that the money going to abstinence programs
crowds out funding for other programs have been confirmed by recent studies. In
a 2006 U.S. Government Accountability Office (GAO) study, seventeen of the
twenty country teams required to meet the A and B spending requirements reported
that meeting the requirement "challenges their ability to develop interventions
that are responsive to local epidemiology and social norms."8
In 2005 ten of these countries were granted exemptions. The remaining seven had
to reduce such programs as condom distribution and services for commercial sex
workers in order to meet the requirements. A legislatively required 2007
Institute of Medicine report similarly noted problems caused by the abstinence
requirement. A second area of controversy involves condom distribution. PEPFAR
has increased both funding for condoms and the number of condoms distributed per
year but targets only specific high-risk populations, such as commercial sex
workers and their clients, sero-discordant couples, men who have sex with men,
substance abusers, and mobile male populations. Distribution outlets are placed
near areas where high-risk behavior takes place, so that the general population
receives a clear message that avoiding risk is the best means of preventing
infection. Additionally, specific rules prohibit using funds to discuss condom
use with in-school youth under fourteen, to distribute condoms in school
settings, or to establish marketing campaigns that target youth and encourage
condom use as a primary preventive strategy.
The problem with targeting only high-risk populations is twofold. First,
reports from targeted countries indicate that condom users are now becoming
stigmatized as promiscuous and irresponsibly pro-sex. In societies that have
long avoided open discussions of sexual topics, policies that encourage negative
views of those who take steps to protect themselves could lead to more
misinformation, unsafe sexual practices, and more infections. Second, in
countries whose adult infection rates run as high as 20 or 30 percent, the
argument that any sexually active person is not at high risk lacks credibility.
More specifically, programs that focus condoms only on high-risk groups miss
others, such as sexually active single youth and married women, who remain at
significant risk if their husbands have other sexual partners.
A third major point of debate has been the role of faith-based organizations.
In 2006, 23 percent of all PEPFAR partners were faith-based. The administration
argues that these organizations are the only established institutions providing
aid in many rural areas. President Bush also feels that, in both domestic and
international settings, faith-based groups should not be discriminated against
based on their organizing principles. Administration critics point out that
there now appears to be reverse discrimination, with faith-based groups favored
over secular ones. Country teams do not reserve specific funding for faith-based
groups, but they do write grants specifically designed for groups with a
faith-based approach. Additionally, the administration has set aside $200
million for grants under the New Partners Initiative, and many of the new
partners are faith-based. In several cases, major funds have gone to religious
groups with little or no experience in either AIDS programs or Africa more
broadly.
A fall 2004 grant to the Children's AIDS Fund, a Washington-based group that
promotes abstinence education, serves as a good example of the controversy. The
expert committee that reviewed the request judged that it was "not suitable for
funding."9
Despite this recommendation, USAID's Natsios approved the project, in part
because the Children's AIDS Fund has ties with the Uganda Youth Forum, which is
led by Janet Museveni, the first lady of Uganda and an evangelical Christian.
This relationship suggests that the United States is not simply pushing its
religious and moral values on the rest of the world. In fact, there has been a
major rise of local evangelical Christian groups in many parts of Africa. Even
in Uganda, though, there is some sharp opposition to faith-based groups, because
many groups openly acknowledge that they push their religious beliefs while they
distribute education and assistance.
The exact impact of PEPFAR's choices on abstinence, condoms, faith-based
agencies, and other issues is difficult to measure, but shaping programs to hit
funding targets and ideological goals is not a recipe for maximal medical
success. In politics, though, perceptions often matter as much as hard facts.
Many observers view U.S. programs as employing leverage to spread conservative
moral and religious views. In PEPFAR's early days, tense meetings occurred
between U.S. officials and leaders in Mozambique, who perceived U.S. policies as
arrogant and neocolonial. Stephen Lewis and other UN officials blamed U.S.
policy for a shortfall of condoms in Uganda. Top U.S. officials are aggressively
booed and heckled at international AIDS conferences. Administration policy
choices have reconfirmed global views of the United States as a unilateral power
imposing its views on others. If the administration saw AIDS programs as a way
to improve the country's world image, they have failed miserably.
INTO THE FUTURE
Overall, PEPFAR remains a historically unparalleled effort. Now that programs
are established and generic drugs can be purchased with PEPFAR funds, its
practical impact should continue to grow. The way that PEPFAR has been justified
and implemented allows certain conclusions to be drawn about its future and the
future of other humanitarian aid programs. First, President Bush's shift in
rhetoric away from security and toward humanitarian justifications for AIDS
relief is likely to be applied to future AIDS and other humanitarian programs,
increasing the chance that they will be cut in the future if other interests
become more pressing. Second, the United States will preferentially fund
bilateral rather than multilateral efforts for the foreseeable future. Third,
economic interests remain a prime factor in U.S. aid programs, but can
occasionally be superseded by humanitarian goals. Finally, the conservative
Christian influence on AIDS policy will continue to make U.S. programs a target
for international criticism.
Collectively these lessons also explain why the hope of building a long-term
liberal-conservative coalition supporting future humanitarian objectives has
been dashed. When the conservatives became interested in what previously had
been a liberal issue, they took programmatic control. This left liberals in the
awkward position of being on the outside of decisions but unable to be too
critical because President Bush was providing far more funding and attention to
the AIDS issue than any previous president. Whether liberal groups and
legislators would have been so supportive of PEPFAR in 2003 had they known what
policies would be implemented by 2007 is an interesting question.
Bush's call for the extension of PEPFAR beyond 2008 was again met with
bipartisan and NGO praise, but many supportive statements now included sharp
follow-up comments on the need to change contentious program details. Even
before his announcement, members of the House of Representatives had fired the
first shot of this battle by submitting legislation to end the AB funding
requirements. PEPFAR will likely be reauthorized since it has proven successful
and retains possible political benefits in helping America's global image and
giving President Bush a humanitarian legacy to point to, but political disputes
over implementation will intensify. PEPFAR is a public health program, but it is
also a political program. International and domestic political pressures will
continue to mix with, and at times outweigh, best practice standards of care in
shaping PEPFAR programs and other U.S. global health and humanitarian
initiatives.
1. Bono, as quoted in Sheryl Gay Stolberg,
"The World: A Calling to Heal; Getting Religion on AIDS," New York Times,
February 2, 2003.
2. "State of the Union, 2003"; available
at www.whitehouse.gov/news/releases/2003/01/20030128-19.html.
3. Segolame Ramotlhwa, as quoted in Craig
Timberg, "Botswana's Gains Against AIDS Put U.S. Claims to Test," Washington
Post, July 1, 2005.
4. "President Discusses the Fight Against
Global and Domestic HIV/AIDS," January 31, 2003; available at www.whitehouse.gov/news/releases/2003/01/20030131-4.html.
5. Anil Soni, as quoted in Mike Allen and
Paul Blustein, "Unlikely Allies Influenced Bush to Shift Course on AIDS Relief,"
Washington Post, January 30, 2003.
6. Randall Tobias, as quoted in Nina
Siegal, "No Experience Necessary: A Profile of Bush's AIDS Czar,"
Progressive 68, no. 11 (November 2004), p. 33.
7. Center for Health and Gender Equity,
Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based
Analysis, March 2004, p. 8.
8. United States Government Accountability
Office (GAO), Global Health Spending Requirement Presents Challenges for
Allocating Prevention Funding under the President's Plan for AIDS Relief,
April 2006, GAO-06-395, p. 36.
9. David Brown, "Group Awarded AIDS Grant
Despite Negative Appraisal," Washington Post, February 16,
2005
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