However, along with PEPFAR’s great accomplishments came massive stipulations for how the funds should be used. There are three tiers to the PEPFAR program: prevention, treatment and care. Within prevention, PEPFAR endorses the ABC approach — abstinence, be faithful and condomize. In 2003, when it was signed into law, conservatives inserted an abstinence earmark in the prevention section which required that one-third of the 20 percent recommended for prevention was to be spent on abstinence-until-marriage programs. This earmark not only imposes American values upon AIDS victims benefitting from PEPFAR, but also completely fails women, the largest victims of the pandemic.
To put this into context, in sub-Saharan Africa, the epicenter of the disease, 60 percent of adults living with HIV are female. Most of these women are married and sexually active. Furthermore, given complex gender dynamics, women are often unable to negotiate sexual relations with men, including their own husbands. Therefore, abstinence, the first part of the ABC approach, and the one allocated the most funds, completely fails married women. The second section, faithfulness, also fails women, given their inability to control the sexual relations of their husband in societies where polygamy and extramarital sex is considered socially acceptable. Last, condom use is often impossible, given male domination in sexual relations and the stigma associated with condoms. By including these restrictions, which impose our American values, we are hurting the very victims that PEPFAR seeks to help.
Given the failure of the ABC approach, the 2008 reauthorization of PEPFAR eliminated both the 20 percent requirement for prevention efforts and the 33 percent abstinence-only earmark. However, before Bush left office, he made sure to leave a lasting legacy. Upon reauthorization, PEPFAR retained the “anti-prostitution oath.” This anti-prostitution pledge requires that non-governmental organizations (NGOs) that receive federal anti-HIV/AIDS funds adopt an organization-wide policy opposing prostitution and sex trafficking. This means that organizations that provide counseling to prostitutes or provide services to keep prostitutes healthy are stripped of their PEPFAR funding. President Bush justified the anti-prostitution oath in 2002: “The United States opposes prostitution and any related activities, including pimping, pandering, or maintaining brothels as contributing to the phenomenon of trafficking in persons. These activities are inherently harmful and dehumanizing. The United States Government position is that these activities should not be regulated as a legitimate form of work for any human being.”
Across the world and in sub-Saharan Africa in particular, women are often forced into sex-trafficking work to forge a living and these women are at an acutely high risk for HIV infection. Banning PEPFAR support for male and female prostitutes stigmatizes and demonizes them and prevents them from gaining access to the resources they need to maintain and improve their health. In May, 2005, the Brazilian government refused $40 million in anti-HIV/AIDS funding from the U.S. government because of the anti-prostitution oath. The pledge has been criticized as counterproductive, given the fact that projects that work with and support prostitutes have proven instrumental in the fight against HIV/AIDS. In fact, the United Nations considers the Brazilian anti-AIDS program, which employs prostitutes to distribute information and free condoms, the most successful program in the developing world.
The anti-prostitution pledge, although controversial, is not as controversial as the Mexico City Policy. Also known as the Global Gag Rule, the Mexico City Policy was a United States government policy that forbade any NGO that received federal funding from performing or promoting abortion services. Since it was instituted in 1984 by President Reagan, it has been rescinded and reinstated with every change of Presidential party (Clinton ended it, Bush reinstituted it, Obama ended it). The ban reduced overall funding provided to NGOs and closed off their access to USAID-supplied condoms and other forms of contraception. In effect, it negatively impacted the ability of these NGOs to distribute birth control, increasing the rates of unintended pregnancies and abortions. Without access to a safe abortion, those desperate enough will resort to alternative measures that threaten their health and well-being. The ban was also criticized for its restrictions on free speech. Obama, in his wisdom, saw the error of this policy and rescinded it on his third day in office.
PEPFAR is a massive, generous and necessary source of funding and support for developing countries to fight the AIDS epidemic, and one that we cannot live without. However it is being unfairly constrained and hampered by “American values” that fail to consider the cultural complexities which surround the disease at the community level. Accepting the generosity of the American people in order to eliminate human devastation should not necessitate the adoption of conservative American values. For PEPFAR to be a true legacy, it must completely transcend national and ideological boundaries.