The President’s Emergency Plan for AIDS Relief (PEPFAR) was created to fund HIV/AIDS prevention, treatment and care programs in the countries where women are most at risk of contracting this deadly disease. It is a well-intentioned and well funded initiative launched by President Bush in 2003, but with one major problem: its effectiveness is hampered by the inclusion of an abstinence-until-marriage requirement. Abstinence-only programs have a long history in the United States and in 2003 President Bush took steps to officially promote such programs abroad, again prioritizing conservative ideology above sexual health care.
PEPFAR has many laudable goals, including preventing new HIV infections, treating two million people living with AIDS-related illnesses, and providing care for and support for persons affected by AIDS. Its size, focus on a single disease and emphasis on treatment are noteworthy. However, PEPFAR’s rigid emphasis on abstinence-only programs has dangerous consequences, particularly for women and girls.
After the program was announced during President Bush’s 2003 State of the Union address, Congress authorized $15 billion to PEPFAR over a 5-year period. Funding guidelines require 20% of the total funds to be used for prevention programs, and 33% of that prevention money must be spent solely on abstinence-until-marriage programs (commonly referred to as the “abstinence earmark” and functionally the same as abstinence-only programs). In FY 2006, $108 million of prevention funding went to abstinence-until-marriage programs.
PEPFAR has 15 focus countries -- Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia – that are home to roughly half of all people living with HIV/AIDS, and over one hundred additional countries also receive PEPFAR funding.
PEPFAR is managed by the newly created Office of the Global AIDS Coordinator (OGAC), and the U.S. Ambassador in each country oversees PEPFAR programs. The non-profit Center for Gender Health and Equity (CHANGE) provides even more valuable oversight of the program’s abstinence requirements on its PEPFAR Watch website at www.pepfarwatch.org.
An in-depth review of the first three years of PEPFAR conducted by the Institute of Medicine in 2007 recommended abandoning the abstinence-until-marriage program requirements in order to allow greater flexibility and enhance program effectiveness. Similarly, a report by the Government Accountability Office (GAO) in 2006 criticized PEPFAR’s abstinence earmark, finding the earmark made it difficult for PEPFAR country teams to implement effective, locally relevant programming. Moreover, the majority of countries receiving PEPFAR funds requested an exemption from the abstinence earmark in 2006, citing its detrimental impact on other prevention activities.
The rigid restrictions imposed by PEPFAR force programs to prioritize ideology over locally based needs, and therefore often result in inappropriate and ineffective programming, such as requiring programs that focus a population of sex workers to emphasize both abstinence and faithfulness if they educate about condom use.
The proportion of women diagnosed with HIV/AIDS continues to increase each year, in every region in the world. In addition to physiological factors that make females more susceptible to contracting HIV and other sexually transmitted infections, gender inequality and economic hardships for many women in developing countries put them at greater risk of infection. Their inferior legal status in these nations leaves women and girls vulnerable to economic dependency and diminishes their sexual decision-making power. Other social factors, including cultural practices such as wife inheritance, virginity testing, and female genital mutilation, underscore this gender inequality, and thus exacerbate the risk faced by women and girls in these countries. Women and girls in such situations may lack the ability or the authority to remain abstinent even if they desire to do so.
By promoting abstinence and marriage as guaranteed protection from the virus in cultures where the very structure of marriage is based on gender inequality, PEPFAR programs deprive women and girls of crucial prevention strategies. Teaching only abstinence ignores the reality of many women’s lives, and in so doing puts their health and lives at jeopardy.
Last month Congress added a provision to the 2008 appropriations bill to provide State Department’s U.S. Global AIDS Coordinator (OGAC) which oversees the program, discretion to waive the abstinence earmark. Unfortunately this waiver amounts to nothing more than a symbolic step in the right direction: OGAC has embraced the President’s abstinence-only agenda and states that they will continue to guide funded countries to devote a third of their prevention funds to the abstinence agenda.
When PEPFAR reauthorization comes before Congress this year it must move to entirely strike the abstinence earmark from this program. Similarly, the Protection Against Transmission of HIV for Women and Youth Act (“PATHWAY”) would strike PEPFAR’s abstinence earmark while also requiring the development of a real strategy to address HIV prevention for vulnerable women and girls and increase condom availability.
It is time to ensure that PEPFAR’s resources are not be squandered on ideologically-driven abstinence-only programs that are a proven failure in the United States and abroad.