The Dis-Integration of U.S. Global AIDS Funding

In his proposed “Emergency Plan for AIDS Relief” announced during last month’s State of the Union Address, President Bush promised, among other things, “a comprehensive plan [to] prevent seven million new HIV infections.” International organizations working to prevent the spread of HIV and improve women’s health worldwide met the announcement with a mixture of hope and skepticism. Hope because prevention is critical to reducing the toll of HIV worldwide. Skepticism because sound AIDS prevention depends on effective promotion of safe sex, an obvious area of contention for the Bush administration.

Unprotected heterosexual sex is the leading factor in HIV transmission throughout the world today. Women now represent half of those infected with HIV worldwide, and 58% of those infected in sub-Saharan Africa, the region most severely affected by the AIDS epidemic to date. Moreover, in many countries, including India and other parts of Asia, new infections are rising rapidly among married women and adolescent girls. High rates of sexual violence and coercion by husbands and intimate partners, discriminatory cultural practices such as child marriage and dowry, and economic dependence on men leave even monogamous married women increasingly vulnerable to both unsafe sex and to infection due to the behavior of their husbands.

These same conditions also result in high rates of unintended pregnancy. It is a fundamental reality that women are uniquely at risk of HIV infection and pregnancy in every single act of unprotected intercourse, illustrating the urgent need to simultaneously address the realities of sex, power, and reproduction. Common sense and field experience suggests the best approach is to invest heavily in integrated HIV and family programs that offer a range of services, including efforts to increase access to and use of male and female condoms and other contraceptive methods; training in partner communication and negotiation; access to voluntary counseling and testing; and programs to address sexual violence and coercion, among other things. As noted by the World Health Organization (WHO) Global Sector Strategy for HIV/AIDS, existing family planning programs “provide a clear entry point for the delivery of HIV/AIDS interventions” critical to slowing the spread of HIV, and reducing unintended pregnancies and unsafe abortions worldwide. WHO, the World Bank, the European Union, and until recently, USAID, all strongly support integrated prevention strategies.

Given this reality, the President’s new AIDS plan immediately raised an obvious question. Could an administration reflexively opposed to any kind of reproductive health services embrace a sound public health strategy in response to the inextricably linked problems of unprotected sex, unintended pregnancy, and infection? The answer: Apparently not.

For the past two years, President Bush has been waging what can only be called a religious war on sexual and reproductive health programs both at home and abroad, undercutting the very foundations on which prevention strategies are built. He began this crusade by reneging on the U.S. contribution to the United Nations Population Program. Since then, State Department operatives tried–and failed–to undermine a global consensus on the need for universal access to reproductive health services. The President is slashing funds for sex education and family planning while touting unproven “only-abstinence” strategies domestically and internationally. He is replacing scientific and medical information in the public domain with unsubstantiated findings on condoms and abortion cooked up by the far right. And he regularly panders to groups that define both IUDs and contraceptive pills as “abortifacients” and refer to HIV as a “gay plague.” The list goes on.

In listening to the President’s new religion on HIV, a healthy dose of skepticism therefore seemed warranted. Even so, initial indications were promising. The President’s plan appeared to dramatically increase funding for global AIDS programs, and to acknowledge the need for sound prevention strategies by virtue of inclusion in the ensuing press releases of the word “condoms.” Soon, however, reality set in. The promised $15 billion ($10 billion in new money) for international HIV/AIDS programs evaporated in a cloud of double- and triple-counting of funds already appropriated, and of contributions deferred far into the future. If the President’s plan is adopted, the U.S. will annually contribute less than a third of the amount estimated by the international community to be our fair share in the fight against AIDS, and our contribution to the Global Fund will be all but eliminated.

Now comes the announcement last week by the administration that U.S. funding for global HIV programs will be saddled by ideologically driven restrictions aimed at separating “family planning” from “HIV prevention” in developing countries. The so-called Mexico City policy or “global gag rule” will now be applied to all integrated family planning and HIV prevention programs. This policy denies funding to any international organization that, in addition to routine contraceptive and other essential reproductive health services, performs abortions in countries where they are legal (like, say, the United States), collects data on, provides referrals for abortion services, or advocates for changes in laws regulating abortion (which, thanks to the First Amendment, still includes the United States). Seeing an abortion behind every clinic wall, but clearly just opposed to family planning generally, the administration has now decided to apply these restrictions wholesale to integrated HIV and family planning programs.

The State Department and USAID have been scrambling to write guidance for this convoluted policy. An internal memo, noting that, “comprehensive HIV/AIDS programs usually contain some family planning” indicates that the policy “would apply to foreign NGOs implementing U.S. funded family planning within HIV/AIDS programs.” In other words, programs will be forced to play “this little condom goes to HIV prevention, and this little condom goes to pregnancy prevention (or not).” Never mind that HIV-infected sperm don’t make such distinctions.

This policy is the clearest evidence yet that the administration is against family planning and contraception, period. The draft guidance says that organizations that have signed the Mexico City Policy (MCP) “will still be able to receive HIV/AIDS funding, as long as none of the funds are diverted to family planning [and] NGOs that don’t accept MCP can accept HIV funds, provided they don’t engage in family planning activities or abortion as part of U.S. funded health programs.” This is, in effect, an expansion of the existing policy.

The most immediate victims of this new assault will be women and children for whom integrated services often make the difference between life and death. Hundreds of millions of women in every region of the world rely heavily on family planning programs for a range of services for which there are no alternatives. For women at risk, these programs are the best entry point for information on prevention. For women who are already or suspect they may be infected, integrated services provide confidential outlets for voluntary counseling and testing, drugs to prevent maternal-to-child transmission (MTCT), and accurate information on sensitive issues, such as whether HIV-positive mothers can safely breastfeed infants. They provide a source of care free from the stigma often associated with stand-alone HIV prevention programs. They also offer HIV-infected women access to contraceptive information and supplies, enabling them to exercise their fundamental right to decide whether and when to bear children.

Now, service providers will have to refrain from counseling family planning clients on how to practice safe sex to avoid infection. They won’t be able to help infected women prevent an unintended pregnancy. The President appears unable or unwilling to grasp the fact that women seeking contraceptive information and supplies are sexually active and therefore by definition at risk of infection from unprotected sex, and that HIV-infected women may remain sexually active and at risk of unintended pregnancy. What is more, he clearly has no idea of the realities of women’s lives in settings in which violence, discrimination, and lack of access to the most basic forms of information and care are the norm.

These restrictions are morally and ethically indefensible and contradict basic principles of public health, human rights, and economic efficiency. If the President seriously believes that the U.S. has “a calling to make this world better” he should devise an HIV/AIDS initiative in which actions speak louder than words.