Next President Must Change Course on PEPFAR

India does not make the list of the fifteen focus countries targeted by the President's Emergency Plan for AIDS Relief (PEPFAR), with Vietnam being the only representative from the continent. And yet the traditional make-up of the country, the emphasis on cultural mores and rituals and the contesting contexts and sub-contexts within the country, could easily act as an example for many parts of the world.

Here, like in many other countries, change is welcome as long as it does not disturb the traditional set-up of communities. Dislodging cultural practices, many of which might be gender imbalanced, continues to meet with opposition in the pursuit of preservation of this cultural ethos. And marriage is at the heart of most of the traditions guiding Indian society. A good marriage is where the woman redeems herself and a bad marriage is a curse she brings upon herself.

Therein lies the problem with the prostitution pledge PEPFAR grantees are obligated to sign. Fathers of girl(s), even today, in many parts of the country carry the "burden" of the girl until the time he finds a suitable groom only to shift that burden on to him. Hence, one of the easiest and oldest ways of luring unsuspecting girls and women into the sex trade is the promise of matrimony. Brought up amidst strong representations of virtue and honor, these are women who even when rescued from the labyrinthine network of the industry hesitate to return to their communities for fear of ostracism or the "shame" that they bring to the family. Thus, they are often compelled to return to the very life they long fight to leave. So are these young lives condemned to a life of stigma and discrimination and to be deprived of medical care and attention simply because they reconciled to sex work as their only means of survival. In a society where these women suffer a near pariah status the availability or non-availability of aid hinged on the prostitution pledge, in effect, is institutionalizing their vulnerability by covertly stating that these women do not deserve care and support because of the work they do.

Given the prevalence of HIV among sex workers, migrant workers, and the wives migrant workers return to, groups working within these communities are bound to find the prostitution pledge a major hindrance while attempting to provide legal, social and health services or in aiding in whatever way possible these sex workers. The prostitution pledge undermines the very programs that so far have proved the most successful in reversing the spread of the virus. It in effect excludes from its group of beneficiaries a substantial portion of the high risk populations in the country and also keeps out groups that do not fit into the high risk category.

So while a sex worker is denied care because the mode of transmission (sex work), the man transmits HIV to his spouse or to other partners due to decreased funding for condom provision or the lack of ability among sex workers to negotiate for condom use. What the "most-at-risk" group clause in PEPFAR does, then, is to keep HIV education, counseling and care out of the reach of these women who contract it from their husbands -- since they are not considered within the vortex of these high risk groups.

Married women form a substantial component of the HIV infected population mainly because of early marriages to much older and often already sexually active men. In the absence of information on the subject -- since sex itself is a taboo subject -- they very rarely are equipped to protect themselves from infections. Pregnancy is the entry point to discuss other issues like reproductive and sexual health, HIV/AIDS and even abortion.

This is significant in many cultural contexts in which contraception is socially and morally criminalized, leaving women with very few options of birth control. While a miniscule minority might be able to exercise their choice of timing the pregnancies and the use of contraceptives, by and large this choice is not available to most. For a long time midwives are the closest pregnant women have come to any kind of structured health care during and after their childbirths. In the absence of access to information on family planning, it is very often midwives who also act as the carriers of information on various issues like contraception and HIV. Public health experts in countries like India and even the Indian government recognized the role of family planning providers in also disseminating HIV prevention education and services, including testing, allowing this information to reach more people at risk of HIV.

What are the implications of the global gag rule (GGR) here? The GGR in effect is snatching from women their only access to information and help on the subject, especially since these family planning workers are often better positioned to prevent new infections among women and youth - also the more vulnerable groups.

The problem with clauses such as the global gag rule and prostitution pledge is that they give little maneuvering space to groups and organizations implementing the programs. These groups and organizations must ensure that the aid reaches those most in need yet, ironically, the aid ties the programs down by their embedded conditionalities, ultimately making them ineffective as they reach the least number in more time instead of the most in the least time.

The fight against the virus is not simply a matter of a successful morality lecture. Whom are we attempting to impact ultimately? All those who require this care or simply those who have made "morally correct" choices? Sustainable development in countries like India is hinged on family planning policies and a rights-based approach to HIV/AIDS. Can the implementation of any program towards controlling the virus be guided by a set of "dos and don'ts" or of disciplining certain groups (by denying them aid) for not leading a moral life, according to some?

A more significant danger of bills like PEPFAR is that they do find support amidst the more conservative pressure groups and policy planners in the country. So the focus could very easily be shifted from universal access to medical care, to practices similar to abstinence only, the prostitution pledge or abortion relegating more controversial measures to the background. The $50 billion effort of PEPFAR should ensure wider information and access to HIV/AIDS treatment as the immediate need and any denial of either funds or treatment to certain groups is an infringement on basic human rights.

There are critical choices that the new government has to make; choices that might reverse not just trends in the developing world with relation to maternal health but also as a consequence impact the health of the families they form, the communities they inhabit and the society they build.