Washington Blade - April 26, 2006
Joshua Lynsen

The United States Government Accountability Office recently concluded U.S. health field teams are less effective than they could be because they must heavily promote abstinence as a primary means to stop the spread of AIDS.

The guidelines-imposed by Congress and enforced by the Bush administration's Global AIDS Coordinator-require that field teams spend 33 percent of their prevention funds on programs that advocate abstinence or monogamy within marriage. AIDS activists have long criticized such messages because marriage is not an option for gays.

Field teams interviewed for the GAO report dated April 4 said the requirement precludes them from using their prevention funds in more effective ways, like delivering comprehensive messages that include information about condom use.

According to the report, 17 of 20 country teams said the spending requirement challenges "their ability to respond to local prevention needs." The requirement also is impeding work in certain "focus countries," where the epidemic is most severe.

Domestic and international AIDS groups said congressional Republicans and the Bush administration are hampering the worldwide fight against the epidemic.

"This report confirms for me that the administration has created an ideologically driven program," said Jodi Jacobson, executive director of the Center for Health & Gender Equity in Maryland. "It's an unethical policy, and it goes against basic human rights principles."

Rob Noble, spokesperson for Avert, an international AIDS charity based in the United Kingdom, said the United States must change its approach to better fight AIDS worldwide.

"The scientific evidence supports a comprehensive approach to HIV prevention, which includes providing full and accurate information about condoms," he said. "This is the approach encouraged by the World Health Organization, the European Union, the Global Fund, and leading experts in public health. There is no robust evidence to support abstinence-only programs."

The abstinence-only spending requirement stems from the president's Emergency Plan for AIDS Relief.

Announced in January 2003, PEPFAR is a $15 billion initiative to combat the global AIDS epidemic through prevention, treatment and care interventions. It aims to avert 7 million HIV infections in 15 focus countries by 2010.

$15 billion initiative

In the focus countries-Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia-heterosexual intercourse is generally the primary mode of transmission.

PEPFAR aims to prevent HIV transmission through three main strategies: promote the "Abstain, Be faithful, or use Condoms" approach, also called the ABC model; through abstinence-only education; and through supporting local prevention efforts.

Abstinence education encourages abstinence until marriage, faithfulness in marriage, and a voluntary "secondary abstinence" for people who have already engaged in sexual intercourse.

The ABC model allows field teams to additionally promote condoms, help manage sexually transmitted infections, and advocate against injected drug use.

Field teams must spend 50 percent of their prevention money on blood safety programs and similar, nonsexual safety issues. Another 33 percent must be spent on abstinence programs, while the remaining 17 percent goes toward ABC programs.

The GAO report says this predetermined budget has caused some field teams to "cut funding for certain prevention programs. For example, one country team told us that, to meet the spending requirement, it had to limit funding for comprehensive ABC messages to populations at risk of contracting HIV."

The GAO report also found the emphasis on abstinence-only education has created confusion in the field, with teachers giving inconsistent messages.

The report cites several cases, including one where teachers working with teenagers felt constrained when teenagers asked about condoms. The report notes educators didn't want "to say more than is allowed under PEPFAR guidelines."

Field teams seek control

Jacobson said these problems show why U.S. field teams need more control over the implementation of localized prevention efforts.

She said people who are supposed to benefit from PEPFAR are instead being hurt by the inadequate, inconsistent and incomplete information it provides.

Noble said U.S. officials would better combat the epidemic by replicating successful campaigns from Uganda and Thailand, where the ABC model was reiterated by relief organizations, religious groups and others.

"An effective HIV prevention program must employ all approaches known to be effective, rather than just implementing one, or a few select actions, in isolation," he said. "Responses to HIV/AIDS should be evidence-based and should be tailored to local conditions. They should not be based on ideology."

Carl Schmid, director of federal affairs for the AIDS Institute in Washington, D.C., said the abstinence-only spending requirement was an arbitrary mandate with no scientific basis.

"It was ideologically driven, completely," he said. "These barriers are impediments to what should be done."

Despite the spending requirement, Schmid said the field teams are providing much-needed relief.

"They could do better if they didn't have the restrictions, but I think they are doing a good job," he said.

However, Noble said the required focus on abstinence-only education is weakening other prevention efforts.

"We think that the spending requirement should be scrapped because it is hampering global HIV prevention efforts," he said.

Earmark unchanged, targeted

In a joint response to the report, the State Department, Global AIDS Coordinator and others reiterated their commitment to fight AIDS.

They wrote, "Only a vigorous and comprehensive prevention approach will turn the tide against the global HIV/AIDS pandemic."

Officials said they would work to clarify confusion among field teams, so consistent messages are being given, but opposed moves to lessen the amount of money dedicated to abstinence-only education.

Rep. Barbara Lee (D-Calif.), who helped write legislation authorizing PEPFAR, said she is planning to introduce a measure to repeal the abstinence-only education earmark.

"Our global AIDS prevention policy should be based on proven, evidence-based science," she said in a statement.

Jacobson said the GAO report-plus other finished and forthcoming reports documenting similar problems-should give earmark opponents a strong argument.

"We are working vigorously to create substantial change," she said.

Noble said that Avert would welcome changes that make PEPFAR stronger and more versatile.

"President Bush has committed to spending around $3 billion per year on combating HIV/AIDS worldwide, which is a lot more than his predecessors spent," he said. "The initiative has already helped tens of thousands of people around the world to access life-saving treatment. What is sad is that PEPFAR could be a lot better than it is."

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