William Smith's blog

States Say 'No Thank You' To Millions in Ab-Only Funds

2008-06-27T08:00:00-04:00

Earlier this week, the Associated Press' Kevin Freking covered the astonishingly high number of states that have withdrawn from the federal government's Title V abstinence-only-until-marriage funding scheme. Freking reported that just 28 states are still participating in the federal funding, meaning that 23 (22 states and the District of Columbia) are out.

The Administration of Children and Families (ACF), which is currently overseeing the collapse of this hallmark initiative of the Gingrich Congress, says that the following states are participating for Fiscal Year 2008: AL, AZ, AR, FL, GA, HI, IL, IN, IA, KS, KY, LA, MD, MI, MS, MO, NE, NV, NH, NC, ND, OK, OR, SC, SD, TX, UT, and WV. ACF has also indicated that it is aware that Arizona and Iowa will not be participating after the end of the current fiscal year.

Thus, at this moment even according to ACF's rosy, "by-the-letter" optimism, half the states have sent the message that they will not be participating by October of this year.

Freking's inquiry was sparked by SIECUS' own research -- to be released in our annual SIECUS State Profiles publication -- which shows that an additional two states, at a minimum, will also reject abstinence-only funding. That brings the number of states opting out to 27. All told, our calculations are showing that nearly $24 million will be turned down by states next year.

As recently as September of 2005, California stood alone in rejecting ab-only funds, until Maine joined in. In those early days, most people thought it impossible that we would end up with more than half the states rebuffing the federal program and its promise of easy money. But, as Freking reports, participation has dropped 40% in just two years. The strong and clear message coming from the states is that this is, at best, a floundering program growing weaker by the minute.

States Opt Out for Both Substantive and Administrative Reasons

The challenge in the present moment, however, is that the reasons for reaching this critical mass of states are complex and diverse. Some are outright rejections; states telling Washington they don't want money for junk programs when they desperately need funds for effective programs, including comprehensive sex education. Others are not participating for administrative reasons. The program has been hobbling along on short term extensions from Congress that make budgeting and implementation at the state level difficult. Others have submitted comprehensive applications that are deliberately non-compliant with the strict definitions of what must be taught such that these applications also send a clear message of what states want and need.

Congress Considers Yet Another Extension

Congress is currently mulling an extension of the Title V abstinence-only-until-marriage program that may prolong the program's life for a year or longer. This would be the longest extension granted by Congress since the original authorization of the program expired in 2002. That seems an odd parting gift for the 111th Congress to give a program in collapse. Further, because the longer extension creates fewer administrative hurdles to using the money, a few states not participating for these reasons are likely to again accept the funds.

This Congress still has time to remedy its record on sex education by abolishing the program in one fell swoop. But if Congress feels the need to extend it (and they do because it seems inextricably linked to another priority piece of legislation), it should do so for a very short period of time and give a new Congress and a new President an opportunity for a fresh look.

States Lead the Way

States are leading the way. They're already making the paradigm shift: they're embracing a more comprehensive approach to sex education. In fact, our research shows that for the first time since 1998, there are a handful of states that are totally free of any federal abstinence-only-until-marriage funding. Coupled with the repudiation of the Title V abstinence-only-until-marriage program from coast to coast, we have more than just a trend on our hands -- we have a virtual watershed.

It is much too early to celebrate. It took a quarter of a century for the abstinence-only-until-marriage industry to reach its zenith and it will not disappear overnight. But we are making enormous progress.

And there is one more new trend that should lend substance to my optimism: the abstinence-only-until-marriage industry itself seems to have tossed in the towel on defending its own programs. The lobbying arm of the industry, the National Abstinence Education Association, now rarely speaks of the benefits of abstinence-only-until-marriage programs at all, focusing instead on demonizing the majority of Americans who support a more comprehensive approach to sex education as condom pushers and purveyors of promiscuity. That is the exact type of dishonest, fear-based, culture war blather that the nation has seen too much of since the ascendancy of the religious right some three decades ago. It's tired and a bit pathetic.

Fortunately, it is also confirmation that we are on the right track.

Hearing Highlights Ab-Only Industry In Peril

2008-04-30T09:42:21-04:00

Last Wednesday, Congress held the first ever oversight hearing on the abstinence-only-until-marriage industry. It's about time. These programs have been around for over a quarter century and consumed nearly $2 billion in federal and state tax dollars. After all the grousing about the bias of the hearing from the right wingers who support the abstinence-only-until-marriage approach, one might ask: If the programs are so great, why did the Republicans never hold similar hearings to champion their success? The answer: It would have been laughable.

And so it was last week when one lone researcher working from his home-based "institute" tried to outwit the major public health institutions of our country. By his own words, Stan Weed, the only witness last week suggested by the Republican minority to scientifically defend the Bush administration's funneling of billions to their favored kin, has spent more than 20 years working on these issues, interviewed more than 500,000 teens, and studied more than 100 abstinence-only programs. Okay, it sounds impressive, right? Until you learn, that after all that bluster, Weed has just one - ONE - peer reviewed and published study in a refereed journal showing abstinence-only-until-marriage programs can have a modest impact among seventh graders in delaying sex. And with that, Weed urged - straight-faced - to continue the gravy train that is the abstinence-only-until-marriage industry.

It should also be noted that Weed's guest on his back-up chair while testifying was not an assistant at his "institute" or some other public health professional. It was the head of the National Abstinence Education Association, the abstinence-only-until-marriage industry's lobbying arm, Valerie Huber. For what purpose did the researcher need the hired gun lobbyist at his side? Her presence stretched the credibility of Weed's objectivity, to say the least.

On the side of public health evidence, however, were the Institute of Medicine, the American Academy of Pediatrics, the American Public Health Association, the Society for Adolescent Medicine and many others. All concurred that more than a decade worth of research demonstrates that abstinence-only-until-marriage programs are not working and a change in course is long overdue.

The clear imbalance left some right-wing Congressional Members scrambling during the hearing.

Representative Mark Souder (R-IN), one of the most extreme right wing lawmakers in the Congress, praised Weed - the man with thread-bare credentials who works out of his home - as the lone voice of sound public health in the room. As for the real luminaries at the witness table with Weed, Souder charged all of them with advancing ideological positions. He might as well have decried the entire thing a vast left wing conspiracy among the protectors of our public health and left the room.

Representative John Duncan, a Republican from Tennessee, said it was "rather elitist" that those with public health degrees thought they knew better than parents what type of sex education works. Well, yes, Mr. Duncan, isn't that why we fund and support public health as a vocation - to assist individuals, parents and families in promoting good health practices? And isn't this why the Congressional Committee on Oversight and Government Reform on which you sit, has jurisdiction over health programs and spending? The entire purpose is to consult those who actually "know" in order to arrive at informed decisions instead of opinions formulated from ignorance. One can reject their findings - as Mr. Duncan did - but it ought to be done honestly and with full confession for a "science-be-damned" mentality.

Duncan and Souder however, were left with little else to rely on. The evidence is in and the programs were finally called to account for the boon they've experienced at the taxpayer's expense. In desperate times, people do desperate things and Duncan and Souder were headed down that sad road.

For those present at the hearing, there was no more desperate a sign of the abstinence-only-until-marriage industry's questionable future than Heritage Foundation's Robert Rector's attempts at spin. Rector, credited as the architect of the state grants through Title V to pay for abstinence-only-until-marriage programs, tried valiantly to stave off the hearing's impact. The day prior, he and another colleague at Heritage, attempted some up-front spin by assembling and regurgitating previous so-called "evidence" to support their position. At the close of the hearing, a crest-fallen and clearly annoyed Rector was observed to be expressing his deep displeasure to Representative Souder for apparently failing to carry the Heritage Foundation's banner. It almost made me feel sorry for Souder. Almost. Perhaps I actually would have if Souder had not earlier told the two youth witnesses on the panel - one of whom acquired HIV due to abstinence-only-until-marriage instruction - that they were irrelevant to the purpose of the hearing. Far from laughable, this was downright appalling.

What was most miraculous at the hearing was just how much had been conceded by the supporters of abstinence-only-until-marriage programs. Next week, I'll be writing about this in terms of the key pieces of good news that emerged from the Congressional hearing and will answer the most consistent question I've gotten since the hearing: So what does this mean? I assure you, it was a lot more than just words that came out of last week.

Combating the Politicization of HIV Prevention

2008-04-14T09:51:21-04:00

In 2006, many of the United State's major organizations leading the fight against HIV/AIDS and their international partners came together to create the Caucus for Evidence-Based Prevention. Originally started in the lead-up to the International AIDS Conference in Toronto in 2006, the Caucus was designed to highlight and defend the importance of evidence and science in determining what works best to prevent HIV infection.

Now, more than 40 members of the Caucus are preparing in earnest for the 2008 International AIDS Conference in Mexico City in early August 2008. Our work is clearly cut out for us. The current politicization of HIV prevention by the US Administration and its favored groups here at home and around the globe, remain the largest single threat to curbing the spread of HIV/AIDS. This is not the first time the US has supported ideology over evidence. Past International AIDS Conferences have revealed the US administration's reluctance to embrace sound science over moral rhetoric. And while advocates continue to press for comprehensive HIV prevention grounded in evidence, the US government ceases to withhold its support of questionable programming.

For example, as we await revised and higher estimates of new infections each year here at home, country successes such as Uganda's success in curbing HIV prevalence appears to be unraveling and the largest donor in the world to HIV/AIDS, the United States government, continues its staunch support for abstinence and marriage promotion over a more comprehensive approach that would include condom and contraception education and distribution. Other effective interventions with evidence behind them, such as harm reduction programs and targeted outreach work with high-risk groups, are also set aside in pursuit of politically safe, feel-good nonsense that only hampers global efforts to turn the tide against HIV. Why does this story continue to repeat itself?

As we gather in Mexico City with colleagues from around the world, we know how the optics of political ideology and moral rhetoric can cast a shadow over the substance of science. Our efforts provide a clear lens in a time when sanity and science are desperately needed to return our country to its evidence-based prevention paradigm.

This year, we ask you to help us change the storyline from one of ideology to evidence-based prevention. We invite you to join list of newsletters recipients by sending your e-mail to sonia.kandthil(AT)yahoo(DOT)com. At the Mexico City conference in August, as we begin to turn the tide on HIV prevention, you'll be getting the same timely coverage from the Caucus that we delivered in Toronto in 2006. If your organization wants to become part of the Caucus, we welcome your participation as well by sending an e-mail to this same address.

In 2006, we provided a united front in the fight to end AIDS and we will do so again in 2008. We will continue to be the voice of sound science where ideology abounds.

The opinions of the author do not necessarily represent those of The Caucus for Evidence-Based Prevention.

Prostitution Pledge or Zambia's Women and Girls

2008-03-11T09:47:00-04:00

As Congress continues to move forward with PEPFAR reauthorization, there are a number of things that seem to have been unofficially declared "off the table." Perhaps foremost among these is the so-called "prostitution pledge." This pledge, which every PEPFAR prevention grantee is required to sign, is a declaration of the group's condemnation of prostitution. Even - or especially - groups working with women engaged in commercial sex work are required to sign the pledge as a condition of doing their work.

I've spent the past week in Zambia, attempting to understand the implications of our country's HIV assistance policy for actual implementation here in one of the world's poorest countries. Last night, I spent the evening doing what every Washington ideologue who supports the "prostitution pledge" should be required to do--I walked through the main street area and hung out in the bars in a community called Kafue, just 50 kilometers outside of the Zambian capital of Lusaka.

Zambia's unemployment rate hovers around 50%, with nearly 70% of the population living in poverty. HIV prevalence is about 17% but rises to nearly 30% in some communities. Rates of secondary education enrollment are less than a quarter of the eligible population. Worse still, is that the average age of life expectancy in Zambia is 37 years old. AIDS has shaved 15 years off the average age of life expectancy since the pandemic took its grim grip on the country a quarter century ago. It is a sobering portrait to be sure.

In Kafue, the portrait in numbers becomes a real-life picture of people living on the edge. Tourists do not venture to Kafue. One guidebook declares "there is little of interest here." However, Kafue lies on a major highway running through Zambia, connecting it directly to Zimbabwe and serving as a major artery in the trucking route in sub-Saharan Africa. As a result, the thousands of truckers that are fueling the spread of HIV across Africa, visit Kafue. Each night, trucks on the highways are required to stop driving at 8pm and not drive again until 6am because the roads are unlit, not very well maintained and trucks contribute regularly to accidents. They pull over in Kafue every night in a disturbing ritualistic act that sets the stage for Kafue's struggling women and girls to support themselves and their families at any cost.

It is here, at nighttime, that the folly of the United State's hypermorality becomes not just embarrassing, but complicit in shutting down the comprehensive approach to combating the epidemic that is so desperately needed. Women selling sex for money in Kafue are not trying to get a leg up or buy the latest styles. Most are unskilled as Zambia's school system is designed to filter out those deemed less promising, and even those with an education cannot find employment not because of sloth, but because the jobs do not exist. Others engage in sex work sporadically, often because they simply had no money for food that month. This is sex for the purposes of attaining life's basic necessities when nothing else around can provide it.

A single group is doing the outreach in Kafue to both schools and to the sex workers. It does so on a relative shoe-string and outside of the PEPFAR-funded prevention efforts in Zambia. This small NGO's workers are out each evening in Kafue's bars and on the streets where truckers are openly negotiating with women.

Finding a condom in Kafue is often an exercise in futility. They can be purchased in some of the bars, but purchasing condoms for a girl or women who is engaging in sex work in the first place to buy food is a stretch in logic that is the reality of life in Kafue. This single organization is the only presence on the streets, each night, doing a yeoman's job of trying to meet demand with free condoms and urging people to go for testing and counseling. Since the collapse of Planned Parenthood of Zambia's Success condom brand - a collapse facilitated in large part by that group's principled refusal to sign the U.S. global gag rule - free condoms are tough to come by in Kafue. This organization stocks designated boxes with free condoms in some of Kafue's bars but they simply cannot meet demand. Supplies fully stocked the day prior were empty by the time we got there.

Save this one group and a couple of brave others, "condom flight" is pervasive among NGO's doing HIV prevention work in Zambia. One PEPFAR grantee described the country situation as "AB Silent-C." In Kafue, the "Silent C" reality, coupled with the prostitution pledge, has left Kafue's women and girls vulnerable to infection.

PEPFAR's onerous policies have created an important, but politically safe and insufficient portfolio for preventing the sexual transmission of HIV in Zambia. Good prevention work is happening here with PEPFAR funding, but it is as far from a comprehensive approach as one can imagine.

The PEPFAR reauthorization proposals in the House and Senate have some language that might hold out hope for Kafue's women and girls. That hope, however, hinges on an election and an incoming administration that is more concerned with evidence than ideology. But both proposals maintain the prostitution pledge which, like it or not, is interpreted here on the ground as an explicit direction from the United States government that prevention with sex workers is a risky business if you want grant money. Safer to stick to the A and B which is exactly how it has played out here in practice.

Back to School Means Back to Work for Congress

2007-09-04T07:52:01-04:00

While parents and children were soaking up the last bits of summer and buying the latest gear for the return to school, the usually quiet August recess for Congress was punctuated by a good old-fashion American political sex scandal. The disgraced and soon to be former Senator Craig's layover prowl in Minneapolis' airport, coupled with Senator Vitter's (R-LA) earlier July admission of marital infidelity in hiring a sex worker, has significantly undermined the Republican "family values" brigade that has held firm sway in Congress since 1995.

Given this, when it comes to sex education, the question now becomes whether Democrats will carry on the social conservatives' agenda by continuing to pour money into abstinence-only-until-marriage programs. That we're posing the question is a real problem. That the answer remains something less than a definitive "no" is even more distressing.

Make no mistake: Congress' actions before the August recess were not all bad news. Let's start with the good news and where that may take us.

Early news reports suggested that House Democrats would not renew one of the largest pots of abstinence-only-until-marriage money, the Title V funding that comes to the states. This set off hopeful and too-certain conclusions that this fight was sewn up. It wasn't. Those reports were premature at best and failed to recognize that action does not always follow intent in Washington.

For the better part of its existence, the Title V abstinence-only-until-marriage program has been legislatively tied to another program called Transitional Medical Assistance (TMA). TMA is important because it provides a health services safety net for those in our country who may have no other recourse for care. Republicans leaders have long taken advantage of this and tied TMA's reauthorization to Title V abstinence-only-until-marriage funding -- a marriage of convenience from which an amicable divorce has been difficult.

Early news reports failed to take this marriage under consideration, even as some Democratic leaders were testing the murky waters of a trial separation. It wasn't possible. This was not because of cowardice on the part of Democratic leaders but based on the reality that the votes simply are not there. Consequently, and as part of the State Children's Health Insurance Program (SCHIP) legislation, House Democrats reauthorized TMA and the Title V abstinence-only-until-marriage program. But I promised you good news and here is where that comes in. The reauthorization of Title V included some very important changes that will, if enacted, minimize the harm of continued abstinence-only-until-marriage programs and create the first federal funding stream to support age-appropriate sex education for America's youth.

The House SCHIP bill expands the existing law to support additional education programs that go beyond the simplistic (not to mentioned failed) abstinence-only-until-marriage approach. There are 11 states currently not participating in the Title V abstinence-only-until-marriage funding scheme and an additional dozen or so that are awaiting federal action to allow flexibility or they too will also likely pull out. This new flexibility provision meets this need and, in the process, supports the efforts of states to implement policies and programs that provide sex education in a more comprehensive way. The feds have never done this before. Some states will likely continue to fund abstinence-only-until-marriage programs; we of course wish that were not the case. But the reality is that it was this outcome or a straightforward reauthorization exactly as the program currently exists. Given the options, this is indeed good news.

The Senate's SCHIP bill is silent on both TMA and Title V abstinence-only-until-marriage which means the House and Senate need to put the pieces together from their respective bills this month before SCHIP expires on September 30. Many of us are working to keep the significant rewrite of the Title V abstinence-only-until-marriage in the final bill. Of course, that may all be for naught should the President come through on his promised veto of the bill due to what he deems excessive spending. If that happens, we may have to revisit this in its entirety.

Now for the bad news, or, if you're a glass half empty kind of person, the worse news. As many know, the House has proposed increasing funding for the worst abstinence-only-until-marriage programs-the Community Based Abstinence Education programs (CBAE)- by nearly $28 million. What's worse, they included abstinence-only-until-marriage programs under the rubric of common ground efforts to reduce the number of abortions. The evidence is clear that these programs don't even affect sexual behaviors. For Democrats to give them credence by suggesting that they can be part of reducing abortions is ridiculous and an affront to the Prevention First agenda that is a hallmark issue of the Democratic Caucus. The increase was a ploy to lure enough Republicans to support the bill and override a Presidential veto. This was optimistic at best and has since devolved into a colossal miscalculation and utter failure.

Fortunately, the House's blunder can be remedied by solidarity and discipline in ceding to what the Senate has done which is to cut these same programs by $28 million. Unfortunately, the appropriations process is a complete mess and the bill that funds the Department of Health and Human Services may get rolled in with something else. Nonetheless, the opportunity to do the right thing will more than likely present itself in one way or another this year and passing these appropriations bills is front and center on Congress' agenda.

With the lame-duck President's approval rating continuing to falter among the public and all of his top advisors fleeing from his collapse, the Congress has an opportunity to reestablish some semblance of balance between the Executive and Congressional powers. This can be accomplished by acting in a way that creates a new and different direction than what we've been force-fed by Bush and the Gingrich and DeLay Congresses of the past decade.

The President has made the promotion of abstinence-only-until-marriage one of the key pillars of his right wing agenda dressed up as compassionate conservatism. But a pig in lipstick is still just a pig. This billion-dollar spending spree by Bush has nothing to show for it but an emboldened and well-financed cadre of right wing groups in communities across the country. And, moreover, resources for efforts that actually work have been siphoned off to finance this nonsense. In channeling Karl Rove, one might add: “Just as intended.”

The new Congressional leadership can support abstinence education by getting on with the process of cutting money to programs that fail to increase rates of abstinence. In turn, a new direction begins with funding sex education programs with a broader focus that actually do a better job of helping young people abstain than do those favored by Bush, Gingrich, DeLay - and yes, Vitter and Craig.

Irish Mobilize Young Decision Makers

2007-07-13T09:00:00-04:00

Last week, the Irish Family Planning Association held that country's first ever Young Decision Makers' (YDM) conference in Dublin. Following a model established in successful YDM meetings in Portugal, Spain, and Finland, the Irish YDM marks a two-front effort to scale up advocacy for sexual and reproductive health and rights (SRHR) in a country that has traditionally been seen as a bit behind on these issues (especially when compared to other countries on the continent).

First, the YDM model serves to mobilize young decision makers—members of political parties, those holding elected positions, and other well-situated advocates—at the country level to advocate for better national policies on a wide array of SRHR issues. Given the age of these advocates, policies affecting youth are naturally prominent, if not paramount, on the agenda.

Second, the YDM meetings are explicitly coordinated to bridge concern about national issues to equal concern with the role of governments as donors in promoting and prioritizing SRHR in developing parts of the world. This is, of course, all the more important in the current global climate as U.S. shenanigans that undermine SRHR at every turn mean we've got to rely on other donor countries to fill the decency gap. Consider the lackluster support by the U.S. for condoms in combating HIV/AIDS in sub-Saharan Africa—that gap becomes a public health nightmare that other donors must repair.

Youth issues are particularly crucial for the Irish as more than 1/3 of their population is under the age of 25 (larger than the European Union average of about 29 percent). And, the time may be right for change. The law currently makes all sex under the age of 17 illegal (of course, it is worth mentioning that most teens in Ireland initiate sex at or before 16 years of age, thus this "crime" is pervasive on the Emerald Isle). A recent Supreme Court decision, however, means that this law must be reconsidered.

Thankfully, along with the fertile ground for a realistic change in outdated laws, Ireland's approach to sex education is more progressive than most might think. In 1995, Ireland instituted a nationwide program called Relationships and Sexuality Education (RSE) which aimed to "promote an understanding of sexuality" and "healthy attitudes and values toward their sexuality in a moral, spiritual and social framework." The language itself is startling, particularly for Americans who cannot even get new, supposedly progressive, Democratic leaders in the U.S. Congress to drop the tired mantra of teen pregnancy prevention as the rationale for why young people need sexuality information. The Irish are light years ahead.

The program is not perfect, however. Research released earlier this year which was presented at the conference, sheds light on the fact that RSE's implementation is falling short of desired outcomes. Problems of oversight on implementation, poor teacher training, and the universal scourge of discomfort in addressing sexuality issues with young people, remain significant obstacles. Yet, Ireland's national program far surpasses anything we have in the United States and makes the Bush administration's promotion of abstinence-only programs look appropriately like 18th century thinking. And, surprise, surprise: participants at the YDM reported that abstinence-only-until-marriage programs are gaining access to Irish schools and providing incorrect and religiously themed programs.

The young decision makers gathered in Dublin last week also spoke about the need for basic reproductive health care services, including legal abortion. Advocates in Ireland continue to battle for the right to choose and a new innovative campaign, Safe and Legal, has been launched to galvanize and magnify these efforts.

One thing that struck me in Ireland and that was raised at the YDM was the issue of access to condoms. It is not that they cannot be found. This American likes a pint of Guinness as much as any Irishman and in each pub I ventured into, condom machines were in each of the restrooms (or the jacks, as they call them). The issue in the urban areas is thus not so much access as it is price (though access and price are issues outside of urban hubs). The price of a condom in the average pub is about 4 Euros—about the same price as an additional pint. That's a problem. Cost is high in pharmacies as well. Part of this problem is that condoms are taxed as a luxury item in Ireland which means they cost 10 to 20 percent more than they should. The YDM shed light on this and a change in the rate of taxation on condoms, at a minimum, is essential.

Going forward, the young decision makers gathered in Ireland will be creating a statement of priorities to move country-level policy. With the creation of an organized group of young decision makers in the country, these priorities have an actualizing element that can make a difference. European countries need these types of groups in this important time of transition and expansion of the European Union. Indeed, other counter forces are at work in countries like Poland and in Brussels to turn back the clock on SRHR. Let's make sure they don't get a free ride.

Senator Coburn’s Very Good and Dishonest Week

2007-06-18T10:30:00-04:00

Senator Tom Coburn must have felt like a champ last week. He released his own missive on the CDC (Centers for Disease Control and Prevention), claiming in the title of the document that the CDC's "wasteful" spending indicated a "CDC Off Center." The 114 pages of that report have consumed more paper and staff time in its creation than it is worth. Until the CDC comes fully into line with Dr. Coburn's vision of fiscal restraint and public health strained through an ideological sieve, such diatribes make for amusing reading. I was pleased to see that yours truly made the cut when Coburn retold the story of how I got booted from a peer-reviewed panel at the national STD conference. I was tossed out because I was actually going to question the public health rationale for abstinence-only-until-marriage programs—of course, that's not exactly how Coburn told the story. Amusingly, the CDC ended up picking up the last minute tab for the goofs brought in to replace me—of course the report didn't mention that.

Yet Coburn must have been particularly pleased with the release of a second report last week to which he was tied. In cahoots with another comrade in the social issue assault on America, former Senator Rick Santorum (R-PA), Coburn managed to have a hatchet job on comprehensive sexuality education programs (PDF) released under the auspices of the U.S. Department of Health and Human Service's Administration for Children and Families (ACF). Not coincidentally, ACF is the entity that is charged with administering federally funded abstinence-only-until-marriage programs and has never funded any type of comprehensive program aimed at sexual behavior change. Perhaps to show some semblance of credibility, ACF farmed out the project to a third party.

Into the picture steps two right-wing organizations well-known as architects of Bush's extreme social agenda. The Sagamore Institute for Public Policy Research was contracted to conduct the Santorum/Coburn report. This group's founder, Jay Hein, was tapped by Bush in 2006 to take over the White House Office of Faith-Based and Community Initiatives. And who, among the luminaries in the public health arena did the Sagamore Institute reach out to? None other than Bush's favored Medical Institute (formerly known as the Medical Institute for Sexual Health or MISH), the Texas-based group that was at Bush's side when he was Texas Governor and has since reaped enormous fiscal rewards and extended national bragging rights for carrying out the administration's agenda.

The problem with the Santorum/Coburn report are numerous and in so many ways not worthy of rebuttal. Yet, they have to be addressed for at least two reasons. First, because the Bush administration has proven, once again, just how willing it is to sacrifice sound public health by slapping official government endorsement on politically motivated nonsense. (Make no mistake, ACF's imprimatur means that officially the report matters more than say the polemics emitting from Coburn's personal office.) Second, the sloppiness of the report disparages several prominent and well-known programs that have been proven to help young people be more responsible in their behaviors. This is of course, wholly intended. To quote the wizard behind the curtain, Robert Rector of the Heritage Foundation, as proof: the best way to defend abstinence-only programs is to attack comprehensive sex education.

To begin, the Santorum/Coburn report claims that a review of comprehensive sex education programs shows evidence of medical inaccuracies and insufficient emphasis on abstinence. On medical inaccuracies, they take issue with the fact that one curriculum refers to a certain latex barrier as a "dental dam" instead of the FDA-approved term "rubber dam." (It doesn't matter that no one in the public health field has ever heard of a rubber dam.) Several also referenced the use of the spermicide Nonoxynol-9 which had been recommended by the CDC prior to 2003 when many of these curricula were last released.

On insufficient emphasis on abstinence, the report follows Rector and Heritage not just in spirit but in practice. Recently, Rector issued his own report (PDF) on the treatment of abstinence in what he characterized as comprehensive sex education programs. What profound methodology did the wizard employ to determine the emphasis on abstinence? A word count. You know, the tool in your word processing program that allows you to search for a word. That is what passes for genuine inquiry at the Heritage Foundation these days and the Santorum/Coburn report follows suit. Now, what these bright folks fail to recognize is that motivating behavior change means you actually have to use terms that young people accept. So, because we all want young people to delay sex, good program developers have employed other words that are either too complicated to search for, or more likely, lack the black/white and abstinent/promiscuous dichotomies that create the ordered mania that passes for logic among the right wingers.

At the end of the day, the report does agree that the programs reviewed actually work. Most of them increased condom use and several helped delay sex. That is volumes more than abstinence-only programs do. The report is also forced to admit that "...the medical accuracy of comprehensive sex education curricula is nearly 100%." But these findings are buried on the underside of a teacup with a tempest inside it. Instead, the reader is led to the conclusion that the semantics over whether to use the word "dental" or "rubber" rise to the same level as previous evidence showing medical inaccuracies in abstinence-only-until-marriage programs such as that HIV can be spread through sweat and tears. Elementary word counts are also passed off as careful reviews of curriculum content.

This is classic public health rationale Bush-style and it is a shameful slip of hand to have our government's seal applied to in agreement. Is this a surprise? Hardly. Yet it comes just days after House Democrats agreed—despite so much evidence against it—to increase funding for one of the federal government's abstinence-only-until-marriage programs. Who would have guessed six months ago that the efforts of Santorum, Coburn, and House Democrats would combine forces to try and save crumbling abstinence-only-until-marriage programs from the public health ash heap? Not even Coburn, I'd say.

Youth in Vietnam Ignored by PEPFAR

2007-06-06T09:00:00-04:00

Bush's announcement last week to double the funding for the President's Emergency Plan for AIDS Relief (PEPFAR) to $30 billion was nothing less than political brilliance on his part. I mean that genuinely. It was a preemptive strike to once again claim empathetic superiority in an area once reserved for well-meaning progressives. Yes, it was also timed to provide cover for Bush's anti-environmentalism in advance of the G8 Summit, but here at home, it had the added utility of once again using an abundance of funding to disguise underlying policy flaws—deliberate and favored—that are hampering a good program from being a great one.

Already, some rumblings suggest that Democrats might be throwing up their hands in the face of Bush's suggestion of fiscal largess. If that happens, prevention policies will continue to undermine attempts to curb HIV transmission via commercial sex work by retaining the anti-prostitution pledge, and countries like Uganda will continue to see early successes unravel as comprehensive programs disappear in favor of abstinence and marriage promotion. But, more importantly, the same Bush ideological kin will continue to reap huge windfalls that in the long run serve only to undermine sexual and reproductive health and rights globally.

The debate on PEPFAR's future, at present on but a slow simmer, is likely to hit the front burner after the summer months. While Bush throws cash to distract, our goal as advocates must be continued vigilance in shining a light on PEPFAR's policies that are undermining prevention.

To this end, today SIECUS has released a special report on PEPFAR prevention policies and how they are affecting efforts in Vietnam (PDF), one of the 15 PEPFAR focus countries and the only one in Asia. In 2006, SIECUS and colleagues from Population Action International (PAI) conducted an investigative research trip to Vietnam. (PAI's own earlier report can be found here.) SIECUS' report is particularly focused on the impact of PEPFAR's prevention efforts on youth in Vietnam.

In 1992, Vietnam had no reported cases of HIV among youth. Less than ten years later, young people under age 19 made up 10% of all cases. Greater emphasis on testing accounts for part of this, but given that more than half of Vietnam's 84 million people are under age 24, this trend nonetheless presents a particular challenge.

PEPFAR is the largest HIV/AIDS donor in Vietnam, providing $17 million in Fiscal Year 2004 and an additional $25 million in Fiscal Year 2005. For Fiscal Year 2006, Vietnam applied for and received a waiver from the requirement that 1/3 of all prevention funding go to abstinence-until-marriage programs. This makes good sense given that commercial sex work and injection drug use are the main culprits behind Vietnam's epidemic. Yet, despite the waiver on paper, the U.S. Office of the Global AIDS Coordinator (OGAC) has continued to ask Vietnam to focus on abstinence and marriage promotion/faithfulness programming. This pressure from Vietnam's largest HIV/AIDS donor continues to result in a ramping up of abstinence-until-marriage programming. The funding for these types of programs has nearly doubled from $1.2 million in 2005 to $2 million allocated for 2006.

Additionally, the majority of PEPFAR's prevention funding for condom promotion in Vietnam is reserved for MARPS, or most-at-risk populations, and exclude youth more generally. To address the inability to use U.S. funds to educate youth about things other than abstinence and marriage promotion, Vietnam has secured two additional donors, the European Union and the Asia Development Bank to fund more comprehensive programs that give youth the full and complete information they need to protect themselves from HIV.

PEPFAR's splintering policies impede collaboration and the resulting lack of coordination with other donors in Vietnam is wasting both human and fiscal resources. This was documented in a 2006 report by the Center for Strategic & International Studies and corroborated in our in-country interviews with key players.

Moving forward, our report views Vietnam as yet another example of why PEPFAR's ideological shenanigans—namely the anti-prostitution pledge and the abstinence-until-marriage earmark—must be abandoned. Our research also shows that the lack of coordination by OGAC continues to be a major flaw. This lack of coordination applies both within the PEPFAR triad of treatment, care, and prevention itself, but also in how it interacts with the many other donors in the country. Bush's press to double funding before the kinks are worked out should give Congress even greater emphasis to force OGAC to solve the coordination conundrum that has become a hallmark of PEPFAR.

Will Congress heed the lessons of PEPFAR before it is reauthorized? We should be hopeful, but at the same time, recognize that it is our additional duty to leave as little wiggle room as possible. Then the Democrats can claim to have made a good program a great one and Bush's cynical support for nonsense can once again occupy the maniacal rantings of Focus on the Family instead of official U.S. international development policy.

Postcard from Down Under

2007-04-23T09:00:00-04:00

Most sexual and reproductive health advocates may not know it, but the 1st World Congress on Sexual Health was held last week in the land Down Under. The Congress was organized by the World Association for Sexual Health (WAS), formerly known as the World Association for Sexology, and, though the group has held 17 previous Congresses, when it changed its name in 2005, it also wanted to usher in a new moniker for the Congresses.

WAS has been around since 1978 and until recently, has been mostly focused on the clinical side of sexuality—things like dysfunction, therapy, and the like. They have also had a strong education emphasis over the years. But with the name change comes an expanded mission that has public policy and advocacy at its heart.

WAS's strategy reminds me of Kevin Costner's hopeful dictum in the film Field of Dreams —"if you build it, they will come." Well, Australia was a far way to go, but this year's Congress featured more sessions on policy and advocacy than any prior WAS meeting. And, with the nearly 1,000 registered attendees from every part of the globe, these sessions had strong presentations that drew significant crowds.

Some of the advocacy highlights this year were an Oxford-style debate on abstinence and adolescence and a presentation on how sexuality education is causing controversy throughout countries in Latin America. There was also much talk of the Millennium Development Goals, something that would have been mostly unheard of among the docs and clinical types just a few shorts years ago. Today though, WAS and its members are committed to opening a space for cross-discipline dialogue that can only serve to benefit us all.

In addition to the ability to draw a crowd—the WAS Congress in Paris in 2001 drew nearly 2,000 people—WAS has a framework ready built for advocacy capacity as it is affiliated with five active regional networks and currently has 124 member organizations representing 53 countries in five continents. The group has also recently created its own scientific, peer-reviewed journal, The International Journal of Sexual Health.

More specifically, however, WAS has embraced and promulgated what it calls Sexual Health for the Millennium (PDF). Based on the Millennium Development Goals and the Cairo Programme of Action, the document puts forward eight points, including one addressing gender equity, another promoting sexual rights, and another addressing the vital, rights-based framework to sexual health information and services. This is coming from a parallel universe of sexual health professionals with whom we in the advocacy community converse but a little. Imagine the potential when we actually engage!

The next World Congress on Sexual Health will be held in Goteberg, Sweden in June of 2009 and the timing could not be better. With Europe under attack from both homegrown and imported radical elements opposed to sexual and reproductive health and rights, the Goteberg Congress will provide an opportunity for advocates from around the globe to take a proactive stand and utilize this network for the advocacy and policy work it wants to undertake. They are building it. And we should definitely be engaging.

The Right Wing on Mathematica’s Reports

2007-04-16T09:01:00-04:00

William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States.

I remember being with several colleagues in 2002 preparing for a hearing in the U.S. House of Representatives. About ten minutes before the hearing was supposed to start, a knock at the door of a small office in which we had huddled brought an interim report from Mathematica Policy Research. Mathematica had been funded by the federal government to conduct an entirely voluntary evaluation of programs receiving funding under Title V. The hearing was centered on the reauthorization of the Title V abstinence-only-until-marriage program which delivers $50 million in federal funds each year to states. Of course, we thought the timing was highly suspect to say the least, but this interim report (PDF) said nothing of import. It reported out on a great deal of process but included no data whatsoever on behavioral impacts.

The lack of findings in this interim report did not stop the Republican majority at that time from declaring that the report showed that this program was working. In fact, Billy Tauzin of Louisiana, who was then Chairman of the committee where the hearing was taking place, literally held up a copy of the report during his opening remarks and said it declared these programs were working and should be reauthorized. It was all blue smoke and mirrors—deliberate misrepresentation of the worst kind—but even by then this had been par for the course for a White House hell-bent on advancing an ideological agenda without respect for scientific integrity.

Then, in 2005, another interim report (PDF) was released by Mathematica. "New HHS Study Confirms Abstinence Education" shouted the headline of the Abstinence Clearinghouse's press release when this report came out. The U.S. Department of Health and Human Services's (HHS) own press release said, "Students who are in these programs are recognizing that abstinence is a positive choice." It went on to say, "Abstinence education programs that help our young people address issues of healthy relationships, self-esteem, decision-making, and effective communications are important to keeping them healthy and safe. We need to build the scientific knowledge base on abstinence education programs, so we know what works and what needs improvement." Again, no actual behaviors were measured.

Now, on Friday the 13th of April, the final report on these programs comes and this time, it actually reports on behavioral impact—or lack there of. After almost ten years of funding approaching three-quarters of a billion dollars in federal and state money and consistent spin from the ideologues, what we have is a colossal waste of taxpayer money.

I suppose it should not come as a surprise that, after embracing previous reports from the exact same group on the exact same programs, every mouthpiece of the abstinence-only-until-marriage industry is now discounting the report, its findings, and in some cases, the researchers themselves.

For example, the Medical Institute (formerly the Medical Institute for Sexual Health) said the findings merely pointed to the need of more funding for programs and more research (PDF). No, really. In defending the indefensible, the Medical Institute says—straight-faced—that this is merely a clarion call to spend more money. Keep in mind, of course, that the Medical Institute was once just Governor Bush's go-to on abstinence-only in Texas and is now a dominant force in the industry. And of course, over the past four fiscal years, the Medical Institute has benefited from more than half a million in Title V abstinence-only-until-marriage money.

The Abstinence Clearinghouse, struggling to maintain some credibility after trumpeting previous findings from Mathematica, did something quite novel in its press release. First, its release came at least two hours before the report was actually even released by HHS. And second, instead of mentioning Mathematica by name, it pulled a shell game. The press release deceptively read "Abstinence Education Programs Proven Effective" and then goes on to list the junk science of 10 programs that the Clearinghouse tries to spin as evidence. Nice try.

Most interestingly, despite weighing in effusively with releases on the two interim reports, HHS did not issue a press release about the final Mathematica report. Instead, Harry Wilson at HHS' Administration for Children and Families, the agency who runs the Title V abstinence-only-until-marriage program, distanced himself from the findings and basically told the Associated Press that what we need are more programs over longer periods of time.

I suppose that, if this were the first study, one could argue that more funding and more research are still called for. But we are not talking about a single study. We are talking about $1.5 billion dollars of taxpayer money over more than 25 years and a complete lack of evidence to show it has made a difference in helping young people behave more responsibly. It hasn't.

The Mathematica final report could not have been more timely as the Title V abstinence-only-until-marriage program expires at the end of June. The evidence is clear comprehensive programs—programs that complement and augment the education that young people are getting at home, programs that a majority Americans support—are the way to go. It is time to pull the plug on abstinence-only-until-marriage programs.

You can help. Go to www.nomoremoney.org.

Spring Awakening: Sexual and Reproductive Health and Rights on Broadway

2007-02-21T08:00:00-05:00

This is a weird blog for me. I usually indulge in the policy wonkiness that folks like me thrive on here in Washington, DC. And while I love the work I get to do on sexual and reproductive health and rights, the theatre has become another of my great loves. My partner opened up this world for me as he is an award winning local actor and musical theatre performer in Washington. We also indulge in frequent New York weekends that are a volleyball match between theaters and restaurants followed by much needed sleep on Amtrak on the trip back home.

Our most recent trip to New York was memorable as work and private life melded into enjoying what critics have hailed as the best new musical to hit Broadway in a long time. For me, I can explain it best as sexual and reproductive health and rights (SRHR) on Broadway, and in particular, the most forthright and unapologetic defense of adolescent sexual health and rights I've ever seen as a form of entertainment.

The musical, Spring Awakening, is one of those rare opportunities that both entertains and speaks our language. Based on a controversial 1891 play by Frank Wedekind, the story is set in the last decade of the 19^th century in an un-named German province. The show opens with a mother, struggling as too many mothers do, to speak with her blossoming daughter about her sexuality. The audience's raucous laughter at this opening suggests that the situation resonates with everyone. Even a stuffy older couple behind us who had earlier chatted about how they thought this show "was about kids and sex and coming of age or something like that" let loose, breaking the ice on America's collective discomfort with the subject matter at hand.

The show unfolds with a cast of good looking and exceptionally talented young actors who are likable because we see ourselves in each of them. A rebellious young woman who flees to the city to escape conformity is paired with a male whose angst is all internalized and consequently, leads to disaster. Another male character deals with his sexual orientation. The lead female, Wendla, finds herself experiencing puberty in ignorance because her mother refuses to speak with her about it. She's attracted to the free-spirited Melchoir, and when these two fumble into sex, the narrative heartbreakingly unfolds.

I don't want to give too much away, but the storyline of this show serves to underscore why our work in SRHR is so important. While it never clunks you over the head with issues—sex education, contraceptive information and services, and access to safe abortion—they are collectively the clear underpinnings of this timely show. In fact, in the time of abstinence-only, marriage promotion as public health, and explicitly denying young people access to information about contraception and related services, this show is helping to educate an audience normally beyond our reach. That it is consistently sold out is even better.

This show is not for young children. It includes simulated masturbation, some nudity and explicit language, including one of my favorite songs from the show called "Totally F#@*ed." Yet even during these moments, the older couple behind me, who had unwittingly become my mini focus group, had clearly reached back into their own experiences and perhaps those of friends, children, grandchildren, to discover a universality in the theme of this musical.

Perhaps more than anything, that is what one is left with after seeing Spring Awakening: the feeling that we fail our kids miserably when we—as individuals and as a society—firmly plant our heads in the sand and deny young people the information they need to make good, responsible decisions. It leaves the cast of this musical screaming for help in the lyrics of the song "The Bitch of Living" and ultimately, leaves an audience weeping for unnecessary losses.

GAO Blasts Ab-Only For A Second Time in a Month

2006-11-17T12:17:31-05:00

William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States.

Things this week at Bush’s Department of Health and Human Services (HHS) have once again exceeded the bounds of credibility. Early in the week, news came that prominent abstinence-only-until-marriage promoter Patricia Sulak had been asked to join the CDC’s Advisory Committee on HIV and STD Prevention. Sulak’s silly and self-congratulatory presentation at this year’s national STD conference, which can be heard here, should have been more than enough to disqualify her from the advisory committee.

Then came news that an anti-contraception champion and “medical director” of a crisis pregnancy center, Eric Keroack, would take over the Title X family planning program at HHS. Keroack currently works for A Woman’s Concern, a Massachusetts-based recipient of major abstinence-only-until-marriage funding. Keroack’s predecessor never advocated for a single additional dollar for Title X family planning during her tenure, but his appointment is a classic example of the fox in the hen house.

Figures like Sulak and Keroack only rise to positions of import in what my colleague James Wagoner has aptly called the “flat earth society.” And, unfortunately, despite the mid-term election we’re still in one.

But on Thursday, for the second time in a month, the non-partisan Government Accountability Office (GAO) brought a bit of reality to the fore and fired off more damning evidence against the administration’s massive expansion of abstinence-only-until-marriage programs.

The GAO report, the result of a Congressional request led by Congressman Henry Waxman (D-CA), concluded that the Administration for Children and Families (ACF), the agency administering the bulk of abstinence-only-until-marriage money, was not screening grantees to make sure that funded materials were medically accurate. GAO also found that HHS was falling far short in sufficiently staying on top of evaluating programs to make sure that the $1 billion-plus of tax money being spent will make a positive difference on adolescent behaviors.

This comes as no big surprise to those of us familiar with these issues, and our noise on the outside has contributed to getting this report from the inside. The inside/outside dynamic matters not just because of the mounting evidence and the affirmation that we are on the right track, but also because ACF has officially responded to the GAO; whereas we are easily ignored, their response is just laughable.

ACF admits—two years after the Waxman report revealed serious medical inaccuracies in the majority of the most popular abstinence-only-until-marriage curricula— that it does not monitor for medical accuracy in programs. But, ACF explains that it does require programs to assure programs are “true and correct.” Is this public health or an honor code in an elementary school? The GAO is clear: “ACF cannot be assured that the materials used in its State and Community-Based Programs are accurate.” ACF is indifferent and seems content to continue shoveling money out the door to folks like Sulak and Keroak with little more than a pinky swear promise that their programs will be accurate.

On the issue of evaluation though, HHS’ response to the GAO’s findings can only be described as either delusional or deliberately deceptive. HHS’ argument is basically that it is trying. Twenty-five years of funding and almost a billion and half dollars put into these programs and the best HHS can come up with is that it’s trying?

As reported in our earlier analysis of the new requirements under the largest pot of abstinence-only-until-marriage money, HHS has gutted, not strengthened, attempts at gathering behavioral measurements and instead, requests that grantees gather very basic process information like the number of youth served in a program and the number of hours of instruction.

It is not by coincidence that the same day the GAO report was released, an announcement appeared in the wonky Federal Register that ACF would be conducting a public opinion survey to support its mission of the no-sex, get married approach. A new Congress, with Waxman as head of oversight in the House, must be a bit frightening for a program that has funneled so much money to social conservatives with so little evidence and accountability.

Lord Acton said “power corrupts and absolute power corrupts absolutely.” And I might add, in the case of ACF, leads to delusional thinking. We’ll be working with the new Congress to keep up the drumbeat against abstinence-only-until-marriage programs and ensure that it exercises the oversight that the repudiated leadership of the last Congress refused to provide. You can help, go to www.nomoremoney.org

The Garden State Rejects Abstinence-Only Funding

2006-10-31T08:40:00-05:00

William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States.

Last week New Jersey became the fourth state to pull itself out of the federal scheme to distribute abstinence-only-until-marriage money. New Jersey, like Maine and California before it, decided that in addition to never having been proven effective as a broad strategy, the federal abstinence-only-until-marriage programs ran contrary to its own state's laws regarding sexuality education. If the state chose to accept the nearly $1 million of federal funds it was entitled to, it would not only have had to follow strict federal rules, it would also have had come up with a match of three state-raised dollars to every federal dollar. New Jersey's decision was therefore not just principled, but fiscally responsible as well.

The rebuke comes as a result of the U.S. Department of Health and Human Services ever increasing restrictions on how the nearly $200 million per year of federal funds for abstinence-only-until-marriage must be spent. For example, grantees of one funding account are required to target individuals ages 12-29. Under stipulations from another account, grantees are required to define sexual activity as "any type of genital contact or sexual stimulation between two persons including, but not limited to, sexual intercourse." Under this lunacy, young people are told to abstain from everything from kissing to handholding to watching TV-anything that generates any type of sexual response. (I suppose this shouldn't surprise us given that this comes from the same crowd that recommends abstinent youth refrain from socializing with sexually active peers for fear of contagion.)

New Jersey Governor Jon Corzine is to be commended for his decision to side with common sense and every major public health entity in the country and, indeed, around the globe. Many of us worked Corzine endlessly about this issue during his Senate tenure. State groups - in particular ANSWER, the group that creates the great teen newsletter Sex, Etc., and the New Jersey ACLU -- worked to help strengthen the environment for sexuality education in New Jersey and get the state government out of the business of peddling this right wing extremism.

Disappointingly, one state that had previously opted out of the federal scheme has reversed course. Perhaps what is most astonishing is that the reversal comes from one of the most liberal and progressive Governors in the country -- Ed Rendell of Pennsylvania. For the past two years, Pennsylvania did not apply for abstinence-only-until-marriage money. This year, reports confirm that it will. In a state where the stalwart conservative Senator, Rick Santorum, may likely go down to defeat and where Rendell seems assured another term, the decision to jump back into the cauldron seems to be either the result of political pandering or thoughtlessness. Either way, advocates should make clear to Rendell that progressives are elected to jettison right-wing extremism, not coddle it and serve as a mechanism to funnel money to its supporters.

The good news is that over the course of the next year, several other states are certain to follow New Jersey's decision. And, Rendell ought to find his bearings again as well.

Editor's note: We misprinted the number of years that Pennsylvania did not apply for abstinence-only-until-marriage funding. The correction has been made above.

US Conference on AIDS Overlooked and Divided

2006-09-29T08:02:00-04:00

William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States.

The US Conference on AIDS (USCA) wrapped up this week on the sun-drenched Southern Florida coast with nary a mention in the press or elsewhere. This is a far cry from the extensive coverage of the "Bill and Bill" show at the international meeting in Toronto in August. There, news coverage documented the re-emergence of prevention and the global push-back against U.S. dogmatism on key issues like abstinence-until-marriage programs, the lack of support for condoms and the prostitution pledge. In Florida, the conversation could not have been more different.

HIV/AIDS looks different in the U.S. so the conversation should be different than in the global context. Yet, other factors were also at play. Part of the divergence can be explained by timing. It may be telling secrets outside of school, but at present, domestic HIV/AIDS advocacy is both justifiably preoccupied and unfortunately, very nearly a house divided against itself.

Last week, the re-authorization of the Ryan White CARE Act, the very backbone of our country's HIV/AIDS care and treatment services, was moving through the House of Representatives. The bill has fueled passions by reallocating money away from areas like New York and California to southern states, many of which argue that they have been woefully under funded for too long and face increasing caseloads as the domestic epidemic changes. That, in and of itself, would be enough to put prevention and everything else on the backburner. And it now looks like this may be a prolonged condition if the CARE Act is extended for just a single year, likely renewing the family struggle in the first session of the new Congress.

Another explanation for the difference between Toronto and USCA can be viewed through the relation of our national meeting to our own government. USCA is and has been a conduit for the federal government to engage the many staff members of community based AIDS service organizations and advocacy agencies. After all, this year, records show more than 3,000 people were registered for USCA. It's a great audience if you can get it and the federal government gets it by footing much of the bill.

This year the feds were strategic in setting the agenda. On the conference's first day, the CDC released long anticipated new guidelines around HIV testing. Of particular interest, was the decision to recommend testing without providing counseling as part of the upfront process. When HIV was viewed as-and often meant-a death sentence, the counseling was done to prepare the person for the weight of such news. More recently and in practice, counseling evolved into prevention education and instruction on how to reduce exposure to risk.

When someone seeks testing, it is likely because they have developed some physical symptoms that are of concern, have participated in behaviors that may have put them at risk, or know they were exposed to HIV. Whatever the case, why would we do away with an opportunity to do provide prevention education?

It is true that broader testing for HIV has been inhibited by many barriers. Unfortunately, instead of formally recognizing the pre-test counseling session as a prevention education session, the federal government has convinced many long-time leaders in HIV/AIDS, whom I respect immensely, that pre-test counseling is one of those barriers. The result: a scale-up for testing means a scale-down for prevention education. At USCA, this was barely discussed as many admirers of the new guidance, and government officials themselves, applauded the new effort and made the hard sell that it was a long-time in coming. I, and many others, remain unpersuaded and thus we have the second issue currently dividing our forces-one against the other.

For those who do evidence-based prevention and those who advocate for it, the situation just got worse. With an Administration that doesn't believe in risk reduction, but touts risk elimination, the new guidelines make good sense and the timing was Machiavellian. It was yet another opportunity to pull back "condom promotion" while at the same time, funnel more money to groups to promote abstinence-only-until-marriage as a means of disease prevention and as "the expected standard of human sexual behavior."

The next USCA is a year out and though our epidemic is different, domestic HIV/AIDS advocates need to come together and engage in the global discussion where prevention has again come to the forefront. After all, our own country, while the source of much goodness, is also the wellspring of much of the mischief on global HIV prevention, including the mischief in our own midst. Here. There. It makes no difference. We owe it to ourselves, but also to those relying on us in lands where 1 in 3 people have HIV.

A Turning Point in the Fight Against HIV/AIDS

2006-08-16T17:14:50-04:00

William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States.

For advocates of evidence-based prevention, the International AIDS Conference in Toronto is likely to be remembered as a turning point in our efforts to eradicate HIV/AIDS. From the high-profile attention given to efforts such as microbicides, pre-exposure prophylaxis, male circumcision and harm reduction, prevention has come back to the fore and taken a seat alongside care and treatment, restoring the necessary balance to the global effort. Perhaps most interesting however, has been the repudiation at this conference of the lop-sided prevention efforts that have been focused on abstinence and marriage promotion.

In part, the repudiation has been made easy because the usual promotional tour for these issues has yet to manifest itself in Toronto. In fact, for those of us in the U.S., the near total absence of our government here in Toronto is startling, considering the bill of goods on prevention that it was forcing on the world at the earlier Barcelona and Bangkok HIV/AIDS conferences. In fact, on Tuesday night at an event hosted by The Lancet, Mark Dybul, head of the Office of the Global AIDS Coordinator, told the audience that he believes the focus of prevention is moving toward a firm foundation in evidence. Really.

That is encouraging news from the world's largest donor, but experience suggests a "wait and see" approach. However, if we had followed a public health approach based on sound evidence, instead of letting ideology lead us astray, PEPFAR's promise would have been even more fully realized. In the United States, we have had a quarter-century of experience (and more than $1 billion spent) that has shown us that abstinence-only-until-marriage programs are not sufficient and in fact, if young people are left to dwell in a vacuum without more comprehensive information, they make poorer decisions about protecting their health. As a result, Ambassador Dybul saying we are moving toward evidence seems to assume that the evidence wasn't there at the outset of PEPFAR. This simply isn't true. It was there, but it was jettisoned in some cases and twisted in others to justify a pre-determined approach that public health had already deemed a failure in our own country.

Some epidemiologists whom I respect immensely have come to regard abstinence and marriage promotion as "overhead" for getting PEPFAR's money where it is needed. That is the wrong diagnosis and all evidence from the US and countries where PEPFAR's more harmful policies are taking hold indicate that it isn't "overhead" - it is a Trojan horse with ominous and long-term implications for undoing the entire framework of preventing the sexual transmission of HIV, including supportive public policies.

Reauthorization of PEPFAR is on the horizon and if the United States continues to believe that it can better distribute funding than coordinated, multi-lateral efforts like the Global Fund, its glaringly obvious problems must be stripped - beginning with the abstinence-until-marriage earmark and the prostitution pledge. Countries need maximum flexibility in crafting and implementing efforts to meet the varied needs of the epidemics in their countries and waivers from silly, ideological hurdles are a cop-out from fessing up to flawed policies.

Enormous work remains to undo the damage that has been done and move forward. Yet, if Toronto is a turning point on this issue, it is because at home and abroad, advocates have sided with evidence - and bolstered their advocacy with a human rights framework and a desire for gender equity - that has restored evidence - not ideology - as the primary guide for prevention.