The Senate Foreign Relations Committee met in a small room that didn't allow many stakeholders in the debate about the President's Emergency Plan for AIDS Relief (PEPFAR) to be present. No problem, democracy wasn't there either. All the decisions were made in political deals before the mark-up, more concerned with ideology than facts.

Repeating the path set by the House Foreign Relations Committee, the Senate Committee marked up PEPFAR this morning without considering any amendments, hearing little debate, and refusing to listen to what every other donor nation, the World Health Organization, the Institutes of Medicine, the Center for Public Integrity, and countless other organizations have to say. Instead, Congress is one step closer to spending 50 billion taxpayer dollars without looking at the facts, public health strategies or data gathered from the first five years of PEPFAR. Political ideology and the fear of debate in our democracy will govern.

Rhetorically, when it comes to the issue everyone is fearful of addressing, family planning, it sounds as though there is common ground. Listen to socially conservative Sen. Tom Coburn (R-OK), quoted in a press release:

Perhaps the single, most significant achievement in the battle against HIV/AIDS has been the discovery of medical interventions that make it possible to virtually eliminate baby AIDS at relatively little cost. Yet, despite this promise, thousands of babies continue to be infected with HIV every year. Ending the tragedy of baby AIDS must be the highest priority of the tens of billions of dollars we are committing the U.S. taxpayer to spend.

The only problem is that Sen. Coburn thinks he knows better than every other person working on HIV around the world, and the evidence they've produced suggesting to achieve that goal, we should integrate family planning and HIV services for greater access to voluntary contraception for women and girls. When he speaks of stopping baby AIDS, he means getting treatment to the babies of infected mothers, without much regard or thought about how we might prevent women from getting HIV in the first place, or if they have HIV, prevent unintended pregnancy with contraception.

Sen. Barbra Boxer (D-CA) wanted to offer an amendment inserting family planning into a list of services PEPFAR grantees can refer clients to, helping to reach Sen. Coburn's goal. But Sen. Richard Lugar (R-IN) told Sen. Joe Biden (D-DE) that the Boxer amendment was a "poison pill". Without Chairman Biden's blessing, the Boxer amendment had no hope of passing. Just like the House, without paying any attention to evidence or experience from PEPFAR One, deals were done.

There is still the possibility of a floor fight, with actual debate which neither the House or Senate Foreign Relations Committees have held so far. That will require real leadership, something sorely lacking on this bill.

Even more troubling, continuing reports from Hill staffers that some AIDS advocacy groups are saying all the right things in press releases publicly, participating in coalitions supposedly working to improve PEPFAR, but conveying very different messages privately to Hill staff, especially as regards family planning. As discussed on this site through the PEPFAR process, the money seems more important than the truth; more important than science; more important than doing something the right way and escaping the ideological stranglehold put on PEPFAR five years ago.

When it comes to the prevention of mother-to-child-transmission of HIV, or "baby AIDS" as Sen. Coburn calls it, the vast majority of AIDS experts around the world believe the best way to prevent children from getting AIDS is preventing their mothers from getting it first, or preventing unintended pregnancy. From the Guttmacher report, Hiding in Plain Sight, authored by Susan Cohen,

The vast majority of these [HIV positive] women live in Sub-Saharan Africa, and thus, it is not surprising that 90% of the 2.5 million children younger than 15 living with HIV live there as well. Almost all of these children became infected through their mothers during pregnancy, birth or breastfeeding.

 

Considering the difficulties of delivering services to HIV-positive pregnant women, and the simple fact that most women who are HIV-positive do not know it, it is not entirely surprising that only 11% of all theoretically eligible women in poor countries are benefiting from any PMTCT intervention. And without intervention, about one-third of babies born to HIV-positive women likely will become infected.

 

USAID projected that over a five-year period, adding family planning services to PMTCT programs could prevent almost twice the number of infections to children, and nearly four times the number of deaths to children, as PMTCT alone could prevent

 

Greater access to contraceptive services then — whether among women in HIV treatment programs, PMTCT programs or counseling and testing programs, or among women in traditional family planning programs in high-HIV-prevalence countries—is a “win-win-win situation.” It increases the chances that women living with HIV can prevent future pregnancies they do not want, thereby reducing the incidence of perinatal transmission and the number of potential child deaths, and it achieves these humanitarian ends in a highly cost-effective way.

Only eleven percent of women have access to services to prevent mother-to-child transmission, and with integration of family planning and HIV services that could increase significantly, saving more babies and mothers, yet the Congress of the United States will not even discuss the issue.

The Elizabeth Glaser Pediatric AIDS Foundation, the largest provider of mother-to-child prevention services is one organization that understands both the problem on the ground in Africa, and the politics in Washington. In a letter to the House Foreign Relations Chairs, CEO Pamela Barnes writes,

As the largest provider of prevention of mother-to-child transmission (PMTCT) services under PEPFAR, we are concerned the language proposed by the [US Conference of Catholic Bishops (USCCB)] would undermine PEPFAR's critical efforts to integrate a full range of services into our PMTCT programs.

The Foundation currently works in more than 2,300 sites in 18 countries, with a focus in sub-Saharan Africa. To date we have reached nearly 3.6 million women with services to prevent transmission of HIV from mothers to babies and 226,000 individuals through HIV/AIDS care and support programs.

There is an international consensus that provision of voluntary family planning services is a critical component of HIV prevention activities, particularly PMTCT.

The language supported by the USCCB contradicts what is well known in the HIV community -- forcing patients to go to separate sites for separate services dramatically impacts patient access and uptake. The best way to ensure that patients are receiving the services needed to prevent HIV infection is to integrate, not bifurcate, essential prevention services.

To achieve Sen. Coburn's goal to dramatically reduce mother-to-child transmission of HIV, Congress will have to rise above its ideological battles and understand that voluntary contraceptive services provided through family planning is as essential, if not more so, than treatment. AIDS advocates will have to actually back up their press releases mouthing words of support, with the courage to apply political pressure where it is needed. The Democratic leadership will have to find some backbone and stand on principle to ensure PEPFAR is improved and that the new money being spent actually works to prevent the spread of HIV/AIDS.

In today's Washington, that's a tall order.

Read RH Reality Check's extensive PEPFAR coverage, it's factual!