Editor's Note: In the coming weeks, RH Reality Check's Global Perspectives writers will examine the impact the outcome of the US presidential election could have on women's health and rights in their regions. This piece is the first in that series.
With PEPFAR (President's Emergency Plan for AIDS Relief) reauthorized until 2013, the upcoming US election presents a vital opportunity to reflect upon the program's shortcomings. Vietnam was, controversially, the only country in Asia selected to be one of 15 focus countries, (the remaining from Africa and the Caribbean), beating other Asian countries like India in its designation as one of the worlds most severely affected nations. Since its inception, many of the requirements of PEPFAR have proved to be similarly controversial in hindering efforts to combat the spread of HIV/AIDS in Vietnam.
Given the prevalence of HIV in Vietnam among sex workers, a major flaw with PEPFAR is the requirement that grantees pledge opposition to prostitution. In Vietnam, pledging opposition to commercial sex exacerbates the already prevalent marginalization of women and men in prostitution, some of whom have been trafficked. The requirement has proved to be a major obstacle to those groups trying to provide legal, social and health services to those Vietnamese engaged in commercial sex. Whether one supports or opposes the commercial sex industry, the prostitution pledge requirement has so far undermined services ranging from aiding Vietnamese to move out of commercial sex altogether, to inhibiting programs designed to empower sex workers in their demands for universal condom use. Given the pressing need to reach one of the groups must vulnerable to HIV infection, their marginalization through PEPFAR's prostitution pledge reflects a fundamental shortcoming. It is in fact very telling that in 2005 Brazil rejected $40 million in U.S. Global AIDS funding, the Brazilian Government recognizing that the anti-prostitution requirement would undermine the very programs that have proved the most successful amongst Brazil's efforts to reduce the spread of HIV.
A second major flaw with the implementation of PEPFAR in Vietnam has been the classification of "most-at-risk" populations, a classification that has not only ignored the reproductive health reality facing Vietnamese youth, but also that of women in general. One recent study shows that whilst a significant proportion of HIV positive Vietnamese women are infected through sharing needles and syringes with infected drug users or by having unsafe sex with clients, the majority of new infections result from pre-marital sex with young male injecting drug users. Despite studies like these, a perception persists that the epidemic predominantly exists amongst young Vietnamese males.
According to Vietnam's Ministry of Health, about 263,000 people are living with HIV/AIDS in Vietnam, though only 103,000 cases have been reported. How many of those unreported cases are women who should otherwise be a central target group for curbing the spread of HIV/AIDS? Since the majority of PEPFAR's prevention funding for condom promotion in Vietnam is reserved for most-at-risk populations, the failure to perceive women who engage in pre-marital sex in the most-at-risk category reflects misdirected funding. In light of the abstinece-until-marriage focus, if PEPFAR remains narrow-minded and ideological in its approach, Vietnamese women engaging in pre-marital sex will continue to be ignored by awareness-raising efforts and HIV prevention programs. Clearly, the very likely continued support of abstinence-until-marriage spending requirements by Republican candidates McCain and Palin will continue to impede access to family planning information and services for these at-risk women and girls.
Obviously, a further failing is the approach of targeting HIV alone, without coordinating with family planning programs, despite the fact that unintended pregnancy and the need for family planning remains high in PEPFAR focus countries. Population Action International reports that funding for HIV programs in these countries completely dwarfs the amount allocated for family planning and reproductive health. In Vietnam, funding for HIV/AIDS from international donors, including PEPFAR, has significantly exceeded government funding. Yet the opposite situation exists for family planning, with government funding always higher than international funding since the mid-1990s.
Health advocates can only hope that candidates for the upcoming US election commit to rectifying PEPFAR's flaws evidenced over the last 5 years. If we hope to enhance sustainable development and encourage rights-based approaches to HIV/AIDS and family planning policies in focus countries like Vietnam, we cannot suffer another 5 years of similarly narrow and restrictive PEPFAR funding.
Policies designed to target the HIV pandemic obviously must work to combat stigma and to ensure health care exists to address the needs of those infected and all men and women vulnerable to infection, including those engaged in sex work and women having pre-marital sex. Instead, the shortcomings of PEPFAR wastes funds that could otherwise be successful in reducing the spread of HIV amongst the general population of Vietnam. Moreover, support by candidates of such ideological and restrictive policies reflects a willingness to jeopardize reproductive health, the empowerment of women and girls and sustainable development in general in PEPFAR's focus countries.
