There is no doubt that PEPFAR provides assistance for care and treatment in countries most devastated by the HIV/AIDS pandemic. But that admission does not require us to turn a blind eye toward its destruction of a comprehensive prevention agenda - the third part of the emergency response - in the focus countries.
When PEPFAR was reauthorized
earlier this year, the popular press and advocates of a "more money
whatever the cost" approach failed to recognize what our new updates
continue to show: the ideological underpinnings in PEPFAR's prevention
portfolio stand in the way of a good program from being a great program.
The various restrictions and
limitations in PEPFAR's prevention portfolio are well known to many,
and include the disproportionate emphasis on Abstinence-only and "Be-faithful"
programs (AB) while downplaying the importance of correct and consistent
condom use (C). The original law also required 1/3 of prevention
funding to go to AB programs while the reauthorized law strongly suggests
focus countries not to fall below a 50% threshold for AB.
The impact of this particular silliness is entirely serious on the ground.
Tanzania is a disturbing example. Just over 6% of people ages 15- 49 in Tanzania are HIV-positive and about 80% of infections occur through heterosexual sex. The country's own strategy, laid out in what is known as their National Multi-Sectoral Strategic Framework, embraces a comprehensive approach to prevention and recognizes the key role of condoms. (And, just so it's clear that they have their work cut out for them, only about 40% of males and 45% of females in Tanzania could correctly indentify ways to prevent HIV transmission and reject misconceptions about how the virus is spread.)
Nonetheless, in responding to Tanzania's epidemic, PEPFAR prevention funding misses the mark. According to the country's operational plan for 2007, a total of 25 programs received funding, but only three of these were reported to be promoting correct and consistent condom use. Making matters still worse, one of these reported that it only reached 70 people (in a country of more than 38 million people).
A similar disconnectedness
can be observed in Botswana. Botswana is, a country with an HIV prevalence
of nearly 24% (the second highest in the world), and while 25 organizations
received PEPFAR funding to prevent sexual transmission of HIV in 2007,
only two promoted correct and consistent condom use.
Botswana also exemplifies the open-door policy of PEPFAR to faith-based organizations that allows them to withhold any information they deem contrary to faith teachings. So who is getting PEPFAR funding in Botswana? True Love Waits - a program whose central pillar is a virginity pledge that has been disproved as an effective intervention. Moreover, this particular program instructs people that safe sex is wrong and that condoms have defects in them. This, in a country where nearly one in four people carry the virus. True Love Waits also received PEPFAR funding in Kenya and in South Africa.
There is additional, disturbing
evidence about what certain faith-based grantees are doing with
U.S. tax-payer money. For example, in South Africa, a country with about 18% HIV prevalence,
one grantee, called Scripture Union, describes its vision "to introduce
young people to Jesus" and ensure a "commitment to Jesus and also
to abstinence, whichever comes first." To be sure, this is a
missionary organization that uses PEPFAR funding to proselytize and,
in 2007, they received nearly $1 million of U.S. money to do that.
These are just a few of the issues that surfaced in our extensive research and lead us to offer seven policy recommendations. We call for: 1) an end to disproportionate emphasis for ineffective abstinence-only programs; 2) increased transparency of how funds are actually being used; 3) increased oversight to combat proselytizing, to prevent faith-based organizations from exempting themselves from discussing information on condoms/contraception, and to review the influence of the U.S. government in the development of country plans on prevention; 4) an end to the war on prevention efforts for sex workers; 5) increased focus on integration of HIV/AIDS and reproductive health care services; 6) increased investment in indigenous prevention program providers; and 7) an end to legalized discrimination in the program that allows grantees to deny care, treatment and prevention services to whomever they choose based on moral beliefs.
The
2008 Updates contain much useful information, but what was so striking
to us at SIECUS was one consistent theme that emerged in nearly every
country: the way in which the HIV epidemic targets the most vulnerable
members of society. In country after country, young women, commercial
sex workers, injecting drug users, and men who have sex with men disproportionately
suffer from the HIV/AIDS. These are the people who are most in
need of help and medical interventions, but who often slip through the
cracks. As we face the challenges of reaching out to traditionally
underserved communities, we need PEPFAR to be more open and less blindly
moralistic in the way it distributes its resources.
SIECUS has developed updates for all 15 of the focus countries: Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Viet Nam, and Zambia.
]]>To see both the 2008 PEPFAR Country Profile Updates and the 2005 PEPFAR Country Profiles, go to www.siecus.org/countryprofiles.
Julia Kim, from the School of Public Health at the University of Witwatersrand, discussed HIV prevention oriented towards structural determinants, such as gender-based violence, and how to measure an intervention's impact. Inherent in this model is a shift away from the individual level to that of the population. Her research focused on women who received training in gender inequalities and HIV while also participating in a microfinance program. This allowed for prolonged and consistent contact with the research group, more so than in a clinical setting. The research demonstrated that change in a factor such as gender-based violence, which is often deemed to be "too culturally entrenched and resistant to change," is not only possible but measurable.
The widespread impact of such interventions occurs through scale-up to a broader base of people. Ashokh Alexander, Director of Avahan India AIDS Initiative, added how the integration of business models aided in crafting research to scale from the outset, and she emphasized the importance of designing, managing, and evaluating to scale. Building research into program implementation allows for service users to be data gatherers as well, which panelist Jeffrey O'Malley of United Nations Development Programme echoed, and allows for more immediate assessment of program impact to identify areas in need of modification.
Tom Coates, Associate Director of the UCLA AIDS Institute, cautioned that not all forms of information are equally useful, and that we can neither rely exclusively on randomized controlled testing nor on self-reported data to measure the impact of prevention technologies and interventions.
Such HIV research has long posed unique challenges since the data is often difficult to quantify. The panelists briefly reviewed the evolution in the framing and conceptualization of that research which has led to better planning and design of interventions.
]]>This caucus was convened by the Catholic Family and Human Rights Institute (C-FAM), Family Watch International (FWI), National Association for Research and Therapy of Homosexuality (NARTH) and Jews Offering New Alternatives to Homosexuality (JONAH). Lynn Allred, Communications Director for Family Watch International, framed the purpose of the discussion in her opening statements: to uphold religious freedom and parental rights and to defend the beliefs that marriage can only exist between a man and a woman and that "the family is the foundational unit of society." After Allred's introduction, we knew what was in store: good old-fashioned right wing propaganda. But the Right has learned a thing or two in recent years that has greatly influenced their advocacy approach. Old-fashioned propaganda comes with a very new spin.
First, the Right has learned the importance of tailoring messages to a specific audience. Sensationalized defamation and name-calling may play well when preaching to supporters, but doing so in a setting such as the High Level Meeting undermines their legitimacy. Using human rights language and creating arguments which can stand up to some logical inquiry, however, is less likely to alienate those who find sensational rhetoric offensive or unreasonable. When Sharon Slater, President of Family Watch International asked, "Is stigmatizing high risk behavior the same as stigmatizing an individual with HIV?" this was not an innocent question, but a careful calculation on how to undermine sexual rights while seeming to appear fair-minded.
Later in the discussion, Slater told the audience that she has a very good friend who smokes and that she frequently talks to this friend about how she can get help. She stressed that in these conversations, she addressed the behavior not the individual. This is classic homosexual conversion rhetoric, which came as no surprise given the presence of Arthur A. Goldberg, Board member of NARTH, Co-Director of JONAH, and President of Positive Alternatives to Homosexuality (PATH). He argued that many people experience unwanted same-sex attraction for which treatment is available, stressing that the focus is on the rooting out the behavior and not attacking the person. I was unconvinced. He followed this statement with a discussion of a scientific study conducted by homosexual researchers (he made sure we took note of this fact) that demonstrated that no homosexual relationship is 100% monogamous. Goldberg argued that the conclusion to take away from this study was that all homosexual relationships were promiscuous and high risk. He emphasized the fact that these researchers were homosexuals who conducted this study of their own people so they had no ulterior motive. He concluded that "we're not promoting religious values -- we're staying in the secular, scientific and evidence based." Can those of us advocating for sexual and reproductive health and rights can count that as a win -- that the "evidence-based" argument has been so successful that it has been co-opted by the right? It's a bittersweet victory.
Another key lesson learned by right-wing advocates is to have a seat at the table, or at least close to the table. The mandates of organizations like C-FAM and Family Watch International include participating in proceedings and meetings at the international level. C-FAM’s mission is “[t]o defend life and family at international institutions and to publicize the debate,” carried out through their vision, which is “[t]he preservation of international law by discrediting socially radical policies at the United Nations and other international institutions.”
Austin Ruse, President and Founder of C-FAM had this to say at the 1999 World Congress of Families meeting in Geneva:
We have arrived at a perilous moment in the life of the family. Long under attack by her enemies, the family seems now to be disintegrating all around us. In every country of the developed world, families are breaking up under a plethora of pernicious pathologies. The roots of the attack, and their result are easily enumerated by most of the current social science data. But I will focus on one institution with which I am most familiar, the United Nations, an institution that is increasingly at the forefront of the attack on the family.
Piero A. Tozzi, Executive Vice President and General Counsel of C-FAM, stated in the caucus meeting that organizations like C-FAM are present to support countries who believe that families play an important role in society. They do so by convening small, closed meetings with country delegates as well as calling open meetings such as the Family Rights Caucus which can draw anyone present. In the June 25 edition of the Family Watch International newsletter, Slater reported that "caucus meeting allowed [them] to identify new allies in several countries, including an official UN delegate representing Kenya, who pleaded with [them] to come to Kenya as soon as possible to launch an African movement for the family." Their successes come not only in influencing language and content of negotiated documents, but in the relationships forged to further spread their messages. The organizations represented in this caucus meeting are increasingly committed to their mission of engaging in international advocacy. It will serve us well to continue to keep watch on where they go and how they get there.
]]>In recent years there has been a proliferation of organizations—both in the United States and around the globe—that exist to limit individuals' access to sexual and reproductive health information, education, and services. SIECUS believes that it is vital for advocates of sexual health and reproductive rights (SRHR) to stay up-to-date on the goals, thoughts, and activities of these organizations. To help advocates around the world, we monitor right-wing organizations and news sources and compile a digest of their articles on topics such as abortion, family planning, sexuality education, and sexual orientation each month. If you are interested in subscribing to our International Right Wing Watch please fill out this form.
This absence of sexuality education from the battery of information needed to equip individuals is precisely why the High Level Meeting on AIDS side event, Overcoming Barriers to Educating Young People about Sex and HIV, was so important. The Joint United Nations Programme on AIDS (UNAIDS) Secretariat, the United Nations Educational Scientific and Cultural Organization (UNESCO), the United Nations Population Fund (UNFPA), and the International Planned Parenthood Federation (IPPF) organized this luncheon on the first official day of the High Level Meeting on AIDS in New York. They assembled ministers of health, ambassadors to the UN and members of civil society. The session started off with a panel presentation featuring Sanyiyoko Hoilett, a peer educator from Jamaica; Dr. Jose Angel Cordova-Villalobos, Minister of Health from Mexico; and Michel Sidibe, UNAIDS Deputy Executive Director, Programme.
Then there was a shift, and
we, the invited guests, got down to work. No free lunch here!
The seating assignments at each table were strategic, much like the
breakdown of the panel: high level government officials and representatives,
youth leaders and other members of civil society. Each table set
out to answer two important questions: "What are the barriers to educating
young people about sex and HIV in your countries?" and "What promising
approaches or solutions can you recommend to overcome these barriers?"
Some of the barriers that my table identified were religious opposition, "moral panic," cultural taboos around talking about sexuality, inadequate training for teachers, no available curriculum for youth in school, and lack of access to youth who are not in school. Some of the successful approaches that we identified were advocating for change at local levels of governance, using evidence on effectiveness of sexuality education and HIV prevention to compel policy makers to make changes, educating religious leaders to garner their support, and creating demand among the target populations. Such a rich discussion and interaction in the land of formal statements, declarations and negotiated texts!
Do we know whether this discussion
will influence the Ministers of Health and ambassadors to the UN in
attendance? We have no explicit way to measure this outcome.
I do, however, think that the organizers of this event were on to something:
bringing key stakeholders, who normally do not all sit at the same table,
literally and figuratively, together to talk shop.
On the first day, I attended a session entitled "Full Enjoyment of Human Rights by All: Vulnerable Groups Social Exclusion and Progress towards Universal Access." This was co-organized by amFAR, the Global Forum on MSM and HIV, UNDP, and the UNAIDS Secretariat.
The title made me think about the word "all". Obviously, we want human rights for all, for everyone - and it seems like we use this word as a euphemism at times to express that inclusivity. Like those progressive religious congregations that use it to subtly let LGBT individuals know they are welcome. While it's a far cry from the loud rallying of the early LGBT movement's "We're here. We're queer. Get used to it," it can be necessary to open doors, start conversations, and reach those individuals such as those who identify as MSM (men who have sex with men) who may not identify as LGBT.
The problem is that in many countries around the world, these groups get swept up into the all, becoming invisible in and of themselves, and we end up not knowing nearly enough about them.
And so, visibility of men who have sex with men and other LGBT individuals emerged as the central and reverberating theme of the session. Despite the astounding prevalence rates of HIV among MSM, gay men, and transgender individuals as compared to general adult populations around the world, they remain glaringly invisible. Invisible in the epidemiological data, in government gathered national HIV/AIDS surveillance data, in the country progress reports to the U.N. high level meeting, and in so many countries, cultures, towns, and families.
The end result is that we don't know enough about how many individuals need prevention, care, and treatment services. We don't know how many have been reached by these services. We don't know what types of programs and services work best.
We just don't know enough.
Stigma fuels this invisibility, allowing these individuals to be easily dismissed or forgotten. At the same time, the invisibility fuels the stigma because solid policies and programs must be based on evidence. In the absence of evidence the response can never be as robust or effective as it must be, and policies and programs are more vulnerable to influence from ideology and hypermoralism.
Surveillance data must be disaggregated, epidemiological studies of MSM, gay and transgender populations must be conducted with the same rigor as any other populations, and governments must include surveillance criteria regarding percentages of MSM, gay, and transgender populations reached.
When we say all, we should mean it, and we should have the data to back it up.