Ignoring objective analyses and recommendations based on PEPFAR's first five years from the Institute of Medicine, General Accounting Office, Center for Public Integrity and others, the current proposal fails to ensure the increased funds are spent wisely. Congress will spend more without listening to proven public health strategies.
The good news is the White House has agreed to Congress' request for $50 billion, over five years, up from $30 billion President Bush requested. More money is good, but more money spent wisely, based on reality is better.
The new proposal includes efforts to address unique circumstances that women, girls and youth face, including efforts to confront violence against women, promoting property and inheritance rights, expanding economic opportunity to promote financial independence, and efforts to work with men and boys to reinforce positive attitudes and the rights of women. Women in Africa have less ability to negotiate sex, are often married young, and exposed to HIV often through marriage.
Other positive changes include increased training of health care professionals and support for nutrition programs.
Now for the bad news:
- Republicans continue to push abstinence-only policies that major studies on PEPFAR indicate impede program effectiveness. An earmark insisting 33 percent of funds be spent on abstinence is gone. But in its place is a requirement that 50 percent of funds for preventing sexual transmission be spent on "behavior change," defined as abstinence, delay of sexual debut, monogamy and fidelity. The tone of the new requirement suggests that abstinence-only programming is preferred. The proposal requires local public health officials to report noncompliance. Congressional micro-management like this perpetuates failed abstinence-only policies and politicizes a program that should be based on scientific evidence, not ideology.
- The U.S. Conference of Catholic Bishops successfully removed provisions allowing voluntary contraception services to be offered to participants in programs working to prevent mother to child transmission of HIV. The World Health Organization states that voluntary contraception is one of the most important aspects of preventing mother to child transmission.
- Only family planning organizations that sign the Global Gag Rule, prohibiting recipients of U.S. foreign assistance from even discussing abortion, are now eligible for PEPFAR. Family planning organizations are not seeking to use PEPFAR money to perform or counsel abortions, and cannot by existing law. They want to help provide contraception and reproductive health services alongside HIV services, as recommended by public health experts.
- The Democrats voluntarily gave up fighting the anti-prostitution pledge.
The pledge effectively restricts organizations receiving money from PEPFAR from working with sex workers, who are one of the most vulnerable populations in terms of contracting HIV, and a primary target group to slow the spread of the disease. They were more concerned about re-election than attacking HIV/AIDS strategically.
There is no doubt that issues of sexual and reproductive health are difficult to discuss, but in order to address the AIDS pandemic in Africa, Congress must learn from public health experts.
American voters are clamoring for reality-based politics this primary season, looking for solutions to difficult problems, and rejecting politicians who continue to divide.
The reality is this was a moment missed by the House Foreign Affairs Committee. It was a moment to prove that a Democratic majority could do something differently, better, for the people of Africa; that we could rise above polarization and partisanship.
There is still hope the full House will change the proposal based on sound public health strategies.
More lives will be saved with the new proposal, but we can save even more if our elected officials put public health over politics.
Scott Blaine Swenson, the Editor of RH Reality Check.org, an online publication dealing with sexual and reproductive health.
Copyright © 2008 by the American Forum.
