Seeing is Believing: Questions about Faith-Based Organizations Involved in HIV/AIDS Prevention and Treatment

For many years, faith-based health providers have received enormous sums of money from both state-based and private entities to provide healthcare services. More recently, that healthcare has included treatment for people living with HIV and AIDS. Unfortunately, many of these providers do not provide a full range of preventative care, especially advice on the use of and access to condoms to prevent the spread of HIV. Too few people have questioned whether the faith-based groups’ use of those funds is as effective as it might be. This report, sponsored by Catholics for Choice, raises some of those questions and provides some proposals for how we might move forward towards more transparency.

At the end of this report is a series of recommendations that we will be sending to public and private funders of HIV/AIDS care around the world.

In the early years of the AIDS epidemic, recalls Calle Almedal, a longtime HIV/AIDS advocate, Catholic hospitals and other institutions which were mainly staffed by nuns were the only ones that would treat patients dying of AIDS. From New York City to Uganda, as AIDS victims were shunned by hospitals and left to die at home, often the only facilities that would take them in were Catholic.

It reminds Almedal, a gay man and a Catholic who has worked at the intersection of faith-based organizations and AIDS for more than a decade, of an encounter in 1986 with an Irish nun who worked in a Catholic hospital. "She looked at me with her very blue eyes and said, ‘Mr. Almedal, do you think that condoms are the only solution?' I said no, and she looked at me and said, ‘Nor do I.' The nun and her staff were distributing condoms. And they were talking about abstinence."

This disconnect between talk and action that stands out in Almedal's mind has long characterized faith-based work on HIV/AIDS, as religious groups working in the field part ways with the strictures of their traditions and hierarchies, and in recent years the mandates of conservative American funders, in order to deliver potentially life-saving resources to populations most vulnerable to the disease.

"The doctrine is there, but then you have the pastoral care, which is about the reality that people live in," Almedal says. "And that's where those nuns were – out there in reality, and they gave realistic advice to people."

But the principled duplicity of these private acts of resistance seems, in recent years, to have hardened into a new status quo when it comes to partnerships between US and even international funding organizations – meant to be part of the "evidence-based community" – and the conservative FBOs that proudly are not. After six years of billions of dollars of conditional HIV/AIDS funding from the US PEPFAR program, the landscape for FBOs and HIV is incontrovertibly altered, and not all for the good. With rising HIV rates – thanks to abstinence-only education in Africa – and an apparent (and possibly related) spike in anti-gay campaigns across the continent, the global AIDS community might be witnessing a new phase of the old equation: that silence, even silent dissent, can equal death.

Faith-Based Aid

This July, before the 18th International AIDS Conference, a biannual confab hosted by a roster of international bodies, including the United Nations Program on HIV/AIDS (UNAIDS), a coalition of religious groups and representatives gathered to discuss the role of faith-based groups in confronting the epidemic. If the meeting resembled its last iteration, what that role is remains a very fraught question.

In 2008, nearly 500 faith-based delegates, mostly from Christian nonprofits, gathered in Mexico City for a faith-based pre-meeting to AIDS 2008. The pre-conference, "Faith in Action Now!," organized by the international Christian group Ecumenical Advocacy Alliance, featured a number of heavyweights in Christian AIDS work, including Saddleback Church, the Vatican-based UNAIDS partner CARITAS Internationalis, and the massive US evangelical charity World Vision. Besides the star power of Saddleback pastor Rick Warren and his wife, Kay, who led American evangelicals in embracing AIDS activism, the meeting exposed several divides in today's faith-based HIV movement: between mainline Christians and evangelicals, between Christians and the underrepresented non-Christians, but mostly, between the abiding camps of the culture wars.

"It was probably the biggest conference we've had," says the Rev. Jape Mokgethi-Heath, an Anglican priest in South Africa, "but a number of cracks were beginning to emerge in showing how the faith-based sector doesn't necessarily come from the same background. There were groups that felt if we spoke about prevention, as faith-based organizations, we have to give prevention messages for everybody. And there were people very uncomfortable talking about providing prevention for sex workers, men who have sex with men and injecting drug users."

"No one wanted to talk about prevention. ‘That's not what we're here for,' they said," recalls Catholics for Choice president Jon O'Brien. Much of the opposition centered, predictably, around objections to condoms, which religious conservatives view as condoning and enabling lifestyles they disapprove of. Indeed, the Alliance's official faith-based advocacy activities during the main conference, which drew tens of thousands, focused on travel restrictions, workplace discrimination, children's access to treatment and generic anti-retroviral drugs. Noticeably absent from this list was anything concerning prevention.

Subsequent faith-based meetings in Istanbul and New York, as the UN Population Fund sought opinions on how best to partner with FBOs, revealed the same quiet struggle, as many groups refused to discuss issues like condoms, prevention and vulnerable populations like sex workers. In the end, UNFPA declared the topics of collaboration would be the relatively uncontroversial goals of ending violence against women and lowering maternal mortality.

These debates are familiar to anyone who's paid attention to the evolution of the President's Emergency Provision for AIDS Relief, or PEPFAR, since former president George W. Bush launched the $15 billion plan in 2003. Key to the massive outlay of government funds was the administration's insistence that one-third of all prevention funds be used for abstinence-only education, and their practice of privileging startup conservative evangelical nonprofits that had the correct ideology but often little or no experience in development or AIDS work. What's less clear is the effect had by international bodies like UNAIDS or UNFPA doing outreach to faith-based groups, including groups pushing a conservative sexual agenda, and how much the UN may have reinforced PEPFAR's problematic restrictions. The problems that have been identified at the UN level point back to the manner in which US funds influences the UN agenda.

PEPFAR

Although religiously-affiliated medical institutions and other organizations were among the first to work with HIV/AIDS patients, the Jubilee 2000 movement for global debt relief, tied to the Catholic celebration of the millennium, started the popular drive for a faith-based response to HIV/AIDS. While the early movement was dominated by progressive faith groups, they sought the broad support of a big tent, and pushed the Bush administration to address AIDS. Paul Zeitz, the co-founder and executive director of the Global AIDS Alliance, says that when they did, Bush's existing efforts to fund conservative faith-based initiatives influenced how PEPFAR money would be spent.

"As PEPFAR was being designed, there was a premeditated plan to make sure that faith groups sharing the administration's ideological perspective would benefit. It was a well thought-out plan," Zeitz says. One year in, Bush launched the New Partners Initiative, which called for applications from groups with scant experience working with government grants.

"What it meant was the old partners, the public health people who distributed condoms, were disdained," explains Jodi Jacobson, the founder and former executive director of the Center for Health and Gender Equality. "The new partners, many of whom had never stepped foot in Africa, were suddenly getting millions of dollars to go there. As far as we were concerned, it was a slush fund for the far right."

As reports of PEPFAR spending came in, programmatic horror stories abounded: evangelical grantees who counseled women to stay with abusive husbands, or avoid domestic violence by dressing differently; a Ugandan pastor famously praying over a box of burning condoms; a Cameroonian peer education project that required HIV-positive female volunteers to not have any more children; and a Nigerian abstinence-only project targeted at sex workers. More broadly, partners like World Vision, which received more than $750 million between 2006 and 2008 alone, have been blunt in faith-based hiring preferences, stating, "There's no encouragement for a career here if you're not a Christian." And an investigation conducted by the Center for Public Integrity found that evangelical agencies independently determined unfit for funding nonetheless received support thanks to their ties to the Bush White House.

Ellen Marshall, a public policy consultant for the International Women's Health Coalition, says that such stories pale beside the overarching reality that PEPFAR grantees are allowed to refuse certain services within US law. "They're not horror stories when we just know point-blank that people are not getting all the services and information that they need to protect themselves against HIV. That is the horror story that is square on the shoulders of Congress."

Additional PEPFAR conditions prohibited needle exchange programs, banned family planning services in Prevention of Mother-to-Child Transmission Clinics, required grantees to sign an anti-prostitution loyalty pledge, even if they served sex workers, and allowed broad refusal clauses that could permit grantees to refuse service to anyone based on moral objections.

Although there has been hope that the Obama administration will correct PEPFAR's ideologically-driven culture to again promote evidence-based work, just this February the ACLU filed a lawsuit against the US Agency for International Development (USAID), the agency responsible for distributing most PEPFAR funds, for refusing to comply with two Freedom of Information Act requests pertaining to a 2009 audit by the US Inspector General. The audit revealed that USAID had directly funded religious training materials that included Bible stories and proselytism through its "Abstinence and Behavior Change for Youth" program, and that the agency faces "recurring questions about the applicability of the Establishment Clause overseas."

"What the [Inspector General's] report didn't indicate is what happened next," says ACLU Senior Staff Attorney Brigitte Amiri, and whether the curriculum has since been withdrawn. "We're concerned that they haven't issued that mandate, because they seem to be unconcerned with these violations of church and state."

Paul Zeitz says the conflict seems to be an inevitable consequence of progressive AIDS activists partnering with politically powerful conservative evangelicals, who were able to help PEPFAR bring about a sea change in the global AIDS field, but who brought their own demands to the table. At the time, Zeitz says, the conflicting camps agreed that, beyond all ideological differences, they wanted more money spent on AIDS, and quickly. "Our view is that we want to see billions spent on health equity and to advance human rights," Zeitz says. "We'd rather have a huge battle about where the money should be going rather than have a huge battle without any money."

The huge battle came, and conservative titans like Focus on the Family countered progressive criticism by attacking groups that promoted condoms, and successfully pushing to defund two major AIDS coalitions.

There were individual casualties as well. The Rev. Mokgethi-Heath's organization INERELA+, a network for clergy affected by HIV/AIDS, was denied PEPFAR funding because part of its program included needle exchange, and PEPFAR didn't allow selective funding for groups that transgressed any of its regulations. In lobbying PEPFAR's authors in the US Congress, Mokgethi-Heath found that there were baffling systemic cultural problems built into the program that conflicted with all previous standards for effective HIV/AIDS work. "I remember going to various staffers in Washington," he says, "trying to advocate for a greater response in terms of openness and to show how some of the policies around PEPFAR were increasing stigma instead of overcoming it. On one occasion when we walked into the office of a staffer for a Republican senator, this lady said to me, ‘Why would you want to do away with stigma? I think stigma is a very good thing. I think stigma helps to moderate people's behavior.'"

The UN and PEPFAR

While Zeitz saw pragmatic reasons to secure PEPFAR funding quickly before beginning the long debate over how it would be spent, he was troubled by the silence of international groups like UNAIDS on the flaws of PEPFAR. "For those of us in the beltway fighting the PEPFAR policy voraciously, we were troubled that the international normative agencies were pretty mute about the flaws of the policy they were promulgating. Of course, the World Health Organization (WHO) got US money. And UNAIDS – a third of their money came from the [US] government."

From the early years of PEPFAR, Zeitz and others charged that PEPFAR's restrictions were tying the hands of local advocates. But they found many expected allies missing from the fight. Then-UNAIDS Executive Director Peter Piot, "never spoke out about PEPFAR prevention policies," says Zeitz. "And he was a scientist and knew better. They left it to a few small organizations to fight back, and I think we failed. They argued that we were the outside voice and they were doing inside/outside, and trying to mitigate the negative impact [from within the system]. Did we strike the right balance? I don't know."

Piot, who says he no longer talks to the press about his UNAIDS work since leaving the agency, has come under criticism from other progressive HIV/AIDS advocates as well. Jodi Jacobson says that under Piot's leadership, UNAIDS had close ties with PEPFAR authorities, in part because the US was putting such large funds into global AIDS and the money pressured UNAIDS and WHO to "be in line with the US ideological agenda." In 2004, Piot co-authored an op-ed with PEPFAR head Ambassador Randall Tobias, a conservative abstinence promoter who said condoms "really have not been very effective" and who campaigned against prostitution until his involvement in a 2007 prostitution scandal forced his resignation. (Prior to leaving, Tobias, together with US Global AIDS Coordinator Mark Dybul, hosted a cocktail reception for Piot to celebrate his leadership on AIDS.) And in 2007, Piot appeared at Saddleback Church's Global AIDS Summit to praise the work of religious leaders on HIV/AIDS and the US for its PEPFAR funding.

The result of these friendly relations, Jacobson says, was that partnering more indiscriminately with FBOs became a hallmark of the global AIDS movement. "There's a tendency towards fads in the UN agencies, and the faith-based groups became the fad then, and everybody had to work with them."

"My feeling is that international agencies like UNAIDS rushed, like the Bush administration" to partner with faith-based groups, says Jacobson, "because they pandered all the time to what the Bush administration wanted to do and lost their objectivity about who should be getting money, and didn't ask who and what for. It's not that we hadn't worked with [FBOs] before, but they had had to work on human rights and effectiveness standards. When the Bush administration came in, they didn't have to anymore."

Jacobson, whose criticisms of the close ties she saw between PEPFAR and international groups like UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria, resulted in her being uninvited to various discussion lists, recalls that groups like the Global Coalition on Women and AIDS, a UNAIDS partner, would tour the US and never speak a word of criticism about the controversial PEPFAR program, leading to an impression in the HIV advocacy community that "UNAIDS was pretty much in the pocket of the Bush administration."

"If the US holds the purse strings for UNAIDS, then you need someone to stand up. And we had a wet noodle in Peter Piot," says Jacobson.

The UN and Religion

Azza Karam, senior culture adviser at the UNFPA, which supports HIV/AIDS work related to the sexual health agenda, explained the shift at the organization in recent years, following the vision of executive director Thoraya Ahmed Obaid, to focus more on cultural components of the disease. While under the complicated division of labor between UN agencies, "culture" has long been the province of the UN Educational, Scientific and Cultural Organization (UNESCO) alone, the host of taboo topics like sexuality that swirl around HIV/AIDS necessitated more engagement with cultural questions. "HIV/AIDS has been the domain where all the issues we couldn't touch in development communities we had to touch," says Karam.

"The mandate was, we can talk about cultural mandates to change and identify them," says Karam, "but there are so many agents of change and perhaps the strongest are in the faith-based sector." Part of the UNFPA decision to emphasize culture meant mapping out the variety of faith-based actors and confronting problems like the opposition of local leaders to condom access through culturally sensitive solutions, like devising means for condom distribution through traditional authorities and religious institutions. An agency-wide UNFPA survey revealed that the clear majority of its 112 worldwide offices already had strong relationships with faith-based groups, and with good reason, as FBOs are often the longest-serving and most trusted organizations on the ground in developing nations.

"We'd been making partnerships over the years, but suddenly it became mainstream," says Karam. "What that translated into was two things: active outreach to groups who wouldn't have been traditional development partners – transsexuals, MSM, sex workers: the groups you need to target to spread awareness and medicine – but then you realize that you have to reach out to groups that are marginalizing HIV/AIDS sufferers and stigmatizing them. The ones saying ‘don't do condoms, don't do family planning.' A culturally sensitive approach means you have to see [the first] group, and the group that is marginalizing that group. It's prioritizing human capital above all."

The outreach to those doing the marginalizing was intended, Karam says, to bring multiple groups together: existing faith-based partners that either publicly or privately supported the UN's human-rights agenda as well as FBOs opposed to that agenda, so that UNFPA's friends in religious communities could be mobilized to take on opponents. "The UN cannot do the religious preaching," says Karam. "What we can do is facilitate. We can convene them, identify the ones who believe and behave along human rights lines, and get them to understand their power. Then they can be the front lines with the detractors. About what God intended, how the prophet lived.

"We're not doing outreach to the tough guys – at least not directly. The people who work with us, who are our partners, are having themselves to confront some of that traditionalism."

Talk Versus Action

Part of the identification process Karam described in finding out which FBOs are "friends" included separating religious rhetoric from FBOs' actions on the ground. The Achilles heel of the development world, according to Karam, is their consistent self-marginalization by dismissing opponents as fundamentalists. Rather, development workers should listen to religious rhetoric – such as the pope's recent statements that condoms exacerbate the spread of HIV/AIDS – and then look at who's on the ground, at the Catholic nuns providing condoms or referring people to places where they can obtain them. "You realize this community is there and they've been there for ages, and we've dismissed them because of what some of their leaders tell us."

A recent New York Times op-ed by Nicholas Kristof sounded a similar note, praising FBOs like World Vision for expanding the evangelical agenda and deflecting criticism about their enduring sexual concerns by noting the quiet resistance of Catholic nuns and priests who distribute condoms to AIDS patients. It's a common refrain, and not without merit. Many international HIV/AIDS advocates share the impression that FBO workers privately dissent, either to official church doctrines or funding conditionalities, through their actions in the field.

"In some ways," says Kevin Osborne, Senior HIV Advisor for International Planned Parenthood, the disconnect between talk and action is "a good thing, because people on the ground are responding to realities. The bad thing is that it allows dogma to continue, and it allows people to think that everybody is bad. All people get tarnished with a brush that [FBOs are] all bad. And that's too bad, because there are a lot of good – Catholic in particular – groups doing amazing work in a very progressive manner. At the coalface, people are saying we have to provide condoms, not moralize, and treat everyone who comes in – gay men, people using drugs – because that's what our role is."

Among the groups Osborne mentions is Catholic Relief Services, which he says has done amazing work not just around orphans and vulnerable children, but also under-the-radar sexuality education. "I think that these groups are more prevalent than you think they are. But on the international level, nobody tackles the bigger issue, because everyone thinks they are toeing the line."

What it also leads to, says the Rev. Kapya Kaoma, a Zambian Anglican priest and a researcher for progressive think tank Political Research Associates, is the incidence of nonprofits shaping their proposals to the strictures of funders, even when they know that abstinence education is ineffective. As one Ugandan doctor memorably told Kaoma, abstinence education works in one regard alone: to raise funds from international organizations.

Zeitz describes a sense in Africa in the 1990s that hyper-conservative groups were being reined in by evidence-based policies. Among FBOs, there was a culture of open dissent to some aspects of religious dogma, with Catholic groups in Zambia secretly but widely distributing condoms. But this ethos was reversed by the influx of Bush-era American money. When Zeitz returned in 2006 with a representative from World Vision, his inquiries about condoms were met with incredulity. "They looked at me like I was speaking Chinese," he says. Part of the response might be understandable local wariness that the abstinence-promoting World Vision is checking up on FBOs' regulatory compliance, but part of it, Zeitz suspects, is a cultural shift. "When Bush came and brought PEPFAR, they channeled money to those hyper-conservative groups and reawakened them. I think it will take years and years until the chilling and reawakening forces will be done."

FBOs and African Homophobia

The effect of tailoring programs to funding isn't necessarily limited to small organizations. Uganda's President Museveni, who championed condom distribution during the early days of the country's "ABC" prevention program, later disavowed them, and his wife, Janet, became an abstinence crusader. "People all over Africa thought his shift in policy to promoting abstinence, which led to an increase in HIV, was part of a political strategy to get him a third term with US help," says Zeitz.

The turnaround in Uganda's approach to HIV/AIDS, and its possible motivation in US coffers, had another effect as well. In late 2009, much of the world was outraged by news of Uganda's anti-homosexuality bill, which called for the death penalty for some acts of gay sex, and created a pogrom-like atmosphere with a provision to punish people who don't inform on citizens they know to be gay.

The Rev. Kaoma conducted a yearlong investigation into the relationship between conservative clergy in Africa and the US. Focusing on Uganda, Nigeria and Kenya, Kaoma documented a clear trend of the US Christian conservatives fighting a proxy culture war in African countries, helping exacerbate anti-gay hysteria and leaving the fate of African sexual minorities as collateral damage in their effort to shore up global south support against mainline US denominations.

While US conservatives' ultimate goals may be domestic, the result they've had in Africa has been dramatic, reviving a culture of vicious repression of gay rights through the involvement of evangelical figures ranging from the powerful Rick Warren to fringe homophobes like Scott Lively, who testified to the Ugandan parliament in the months before Uganda's anti-gay bill was written that homosexuality was tied to the Holocaust and the Rwandan genocide.

Part of the effectiveness of American missionaries-cum-political advisors stirring African homophobia has been their savvy appeal to postcolonial pride, declaring homosexuality a decadent Western imposition. Similar sentiments have been on display from Catholic officials as well. This October, the African Synod at the Vatican – representing 300 bishops and cardinals from dioceses that have received tens of millions of dollars in PEPFAR funding – declared that progressive Western nonprofits were engaged in a deliberate neo-colonial "anti-family" campaign to corrupt African values through the promotion of condoms and moral relativism. Ghanaian Archbishop Charles Palmer-Buckle went so far as to suggest that Western NGO workers "hang around boys in order to introduce them to homosexual relationships" through condom education.

The irony of the charges of colonialism, notes the Rev. Mokgethi-Heath is that African rhetoric about "throwing off the shackles of colonialism" ignores the colonial origins of conservative evangelicalism in Africa. The Rev. Kaoma agrees, incredulous that Africa's historical acceptance of sexualities counter to conservative mores, including homosexuality, premarital sex and polygamy, has been dismissed.

"The same argument against homosexuality is used against condoms: that this is Africa, and we have to defend our morals," says Kaoma. "There's nothing African about abstinence." But Kaoma says that the outsized credibility visiting white pastors receive in Africa is to blame, with even renegades like Lively, shunned by US evangelicals, ranking an audience with Uganda's leadership.

The results, even before last fall's anti-gay bill, have been horrific. Pastor Martin Ssempa of Uganda's Makarere University Community Church, a PEPFAR fundee and early ally of both Rick Warren and the Musevenis – he was named "special representative of the First Lady's Task Force on AIDS in Uganda" – went beyond burning condoms to help lead the country's anti-gay movement, declaring that homosexuals should have no rights and no place in the country's HIV/AIDS framework; publishing the names and addresses of LGBT rights activists and, most recently, screening gay pornography to his Kampala congregation and asking, "Is this what Obama wants to bring to Africa?"

Although Ssempa may have lost some powerful friends – the Warrens distanced themselves in 2007 after negative publicity about Ssempa – he is not alone. In 2007, the International Gay and Lesbian Human Rights Commission discovered that the Uganda Muslim Tabliqh Women's Desk, another PEPFAR grantee, was likely connected to a planned "Anti-Gay Squad," which Tabliqh Organization senior cleric Sheikh Multah Bukenya said would "wipe out all abnormal practices like homosexuality in our society."

Compounding the rhetoric of American interlopers like Scott Lively, Emmanuel Kolini, Archbishop of the Anglican Church of Rwanda, also a PEPFAR grantee in a country considering its own anti-gay bill, and a partner with Warren in making Rwanda the first "Purpose-Driven Nation," has dealt in similar insinuations, calling homosexuality a form of "moral genocide" – a deadly accusation in a country with Rwanda's history. And the Church of Uganda, a PEPFAR-recipient under the leadership of the virulently anti-gay Archbishop Henry Luke Orombi, has made equivocating statements about the anti-gay bill – suggesting that life imprisonment is a better sentence than death – that demonstrate how reactionary discourse about gay rights, and its inherent links to HIV/AIDS work, has become in the country.

Victor Mukasa, a research and policy associate for the International Gay and Lesbian Human Rights Commission (IGLHRC), describes the sanctions against media outlets and development officials who have spoken about HIV and homosexuality, which included a public warning, published in a newspaper, to a UNAIDS representative who met with LGBT groups, asking him to leave the country. "It shows what power these people have, and how horribly they have affected the fight against HIV/AIDS in Uganda," he says, noting the increase in infection rates in recent years. With options for prevention information or care often limited to groups like Ssempa's church or even the Church of Uganda, Mukasa asks, "Who wants to go there for an HIV test or treatment? Who wants to go and die there or get arrested there? Who wants to go to Makerere church if they're gay? No one! People are going to remain in their closets and continue having high-risk sex activities with each other without a condom, without protection or education because nobody will educate them about what to use. And what will be the end? It will be devastating." Mukasa, who is from Uganda, says IGLHRC has noted similar welcomes for US conservative evangelicals in Nigeria, Rwanda and Ethiopia.

"There's a neo-colonialist attitude that's driving our conservative class," says Kaoma, referring to the importation of American-born solutions to AIDS like the Warrens' Purpose-Driven plans in Rwanda and Uganda. "What pains me most is that they're using Africa as a testing board, a guinea pig for these ideologies. And when they backfire," he says, noting that HIV rates are on the rise again in Africa, "they'll jump out again."

Division of Labor

Part of the solution to rifts in the HIV movement could be dividing funding and work into appropriate sectors. For Catholic groups that traditionally cared for the dying, mitigating the impact of AIDS on sufferers, Mokgethi-Heath says, a continued focus on treatment is an uncontroversial choice. And indeed, South African bishops created a celebrated large-scale treatment program that delivers huge amounts of ARV medications to poor patients.

A guiding compromise at the level of groups like the Global AIDS Alliance has been partnering with conservative faith-based groups where they're willing to work – on care, with orphans – and leaving prevention and condom distribution to groups that embrace comprehensive sex ed. "Our approach is to create strategic alignments based on the policy content that we're trying to advance," says Zeitz, "so when we're working on prevention, we work with the evidence-based crowd, and when we work with orphans, we work with Rick Warren and Kay."

Ellen Marshall hopes that the Office of the US Global AIDS Coordinator will slowly try to formalize this approach and find a way out of some of the abuses of the early PEPFAR years – developing a "graceful and legal way" to shift faith-based groups opposed to prevention to work solely on treatment. "Undoing this takes forever, and it takes a different reason to undo it than, ‘you're not providing the full range of services,' because they're legally protected in doing that."

However, says Kevin Osborne, sectorizing HIV work in this way is no longer simple in the age of life-extending treatments that allow HIV positive people to continue having active sexual lives. "I think there has been a push for them to do that, to get [conservative FBOs] away on principle from the trickiness of prevention, i.e. abstinence. But now what we've learned about HIV is that the dividing line isn't that simple anymore. That's going to be another challenge for faith communities – because they don't have to worry too much about them dying, because people are getting well – but how do I deal with people's vibrant sexuality? As we've acknowledged globally, prevention and care are not even two sides of the same coin, but [part of] a continuum and it's seamless. And it's [on] that seamless continuum that a lot of battles have to be fought."

Part of those battles will concern criminalization of HIV transmission: a trend Osborne sees as in keeping with the current anti-gay movements in Africa, or campaigns against sex workers elsewhere – all related responses to HIV that eschew the human rights orientation that development work should support. "The fight against gays, that's the topic of the moment, but tomorrow it will be something else," Osborne says. "It's just the culture of selective human rights."

Real Dissent

Not all FBOs practice dissent silently, either against PEPFAR conditionality or the broader prohibitions of their faiths. In the ongoing debate over abstinence and condoms, Bishop Kevin Dowling of the Catholic Diocese of Rustenberg, South Africa, is the preeminent example of principled disobedience against the Vatican and doctrine. Dowling, who has worked on HIV/AIDS in South Africa for nearly 20 years, starting community-level home healthcare projects in townships and mining settlements, has received PEPFAR money in recent years to participate in South Africa's highly successful ARV program, which has treated approximately 70,000 people through 17 Catholic hospitals and clinics since 2004. However, the work Dowling became famous for, and for which he has been sharply censured by his church and colleagues, is publicly distributing condoms throughout South Africa's shack settlements.

Dowling, who began his prevention work with women performing survival sex work on the outskirts of South African mining camps, says promotion of condoms is an issue of being fully prolife. "The fact is that we are dealing with 99.9 percent recurring people who are not Catholics. I think it's a matter of conscience for me that we don't offload on them the restrictions required by official Catholic teachings. I can't understand the argument that goes, ‘If you are going to have sex anyway and you're HIV positive, and you've decided not to abstain or be faithful, then in terms of Catholic teaching you're breaking the Sixth Commandment: thou shall not commit adultery.' Now it makes no sense to me to say, ‘Go ahead now and break the Fifth – thou shall not kill – because it's illicit to use a condom to prevent the transmission of a death-giving virus.'"

Dowling is often alone in his stance though, isolated from his colleagues and accused of sowing confusion in the church body. Next to this example, the fact that UNAIDS has a memorandum of understanding with Caritas Internationalis, a mammoth Catholic coalition working in more than 200 countries that upholds Catholic doctrine on prevention issues, reinforces fears that UN efforts to bring religious leaders to the table have outweighed guiding principles on human rights and evidence-based work.

"The price we paid at the ecumenical meeting [before the 2008 AIDS meeting]," says Jon O'Brien, "is that there was no discussion of prevention, or the difficulty of working with men who have sex with men if you see it as a sin."

In a 2003 interview with Vatican Radio, marking the reauthorization of a partnership agreement between Caritas Internationalis and UNAIDS, Calle Almedal, who conducted faith-based outreach for UNAIDS and now consults on the issue for the World Council of Churches, noted the stark differences between the groups over condom use. He said that UNAIDS recognized it has been "a bit too simplistic in our approach to condoms," and had not been "sensitive enough to the issue of abstinence and being faithful," envisioning a technical solution to the disease. (However, while Almedal says that faith-based organizations should become more involved in fighting AIDS, he takes the unorthodox position for an FBO outreach advisor that they shouldn't do so with public money, but should finance themselves by tapping considerable church assets.)

Almedal says, "I got snapped over my head when I brought [comprehensive sexuality education] up in UNAIDS." But he qualifies this by saying not just FBOs, but "the world has taken prevention off the table."

Some FBOs are doing more than quiet resistance, but are leading the way towards better AIDS care, as African Anglican churches declared AIDS stigma a sin, South African congregations declare themselves "AIDS-friendly," and some Malawian FBOs have led secular organizations in breaking taboos on discussing sexuality.

But, as the Rev. Mokgethi-Heath says, not enough do. "I think the difficult thing to do, but the important thing to do, is to operate from the integrity of your position," he says. "If we have identified certain challenges in dealing with HIV, we can't change our message to suit a funder. And that will mean, from time to time, that organizations doing really good work will go under because their messages aren't very popular. If enough people do it, it absolutely will change the funders. But not enough do."

Asked whether private dissent is enough, Bishop Kevin Dowling pauses.
"I can't demand of people to take the road I did. It's very difficult and you feel great isolation and stress and you just feel alone in a very threatening world.

"I take the passage from the Gospel where Jesus was talking to the Pharisees as the heart of the issue here: ‘You're the one who places impossible burdens on the shoulders of your people, but will you lift a finger to help them carry them?' I think all of us as church leaders need to take those words very seriously. We have to do advocacy with both PEPFAR and church leadership all over sub-Saharan Africa. We need to sit down and very honestly look at the total situation of the human person in this epidemic and unpack that fully, and ask ourselves, do we as FBOs and our partners contribute to the solution, or are we continuing to be part of the problem?"

Kathryn Joyce is the author of Quiverfull: Inside the Christian Patriarchy Movement, a study of conservative Christian women's movements (Beacon Press, March 2009). Her articles have appeared in The Nation, Mother Jones, Newsweek and other publications.

Recommendations

We believe that there should be complete transparency about the funding that faith-based organizations receive from local, state, national and transnational institutions. At present, it is unreasonably difficult to find out how much taxpayer money goes to fund organizations working on HIV and AIDS. It is also very difficult to review the criteria by which public funders judge whether any organization may or may not receive funds for their HIV/AIDS work and whether there are special criteria for FBOs.

We believe that public funds going towards preventing the spread of HIV/AIDS and treating those living with HIV/AIDS should be subject to the same strictures as are public funds in other spheres.

All public funding agencies should publish annually a list of the organizations they have funded and how much money each received.

All funding agencies should develop and publish a list of criteria by which they judge whether to fund an organization. If there are special criteria for FBOs, the reason for their existence needs to be made clear, along with the differences from the general criteria.

Finally, funding agencies must ensure that public funding is not used to allow any organization to discriminate in hiring, to refuse to provide or find reasonable alternatives for the provision of basic treatment or prevention options, or for the use of proselytizing.

In publishing those criteria, the following questions should be answered:

• Do funders require evidence-based interventions from their applicants/recipients?
• Do funders require disclosure of which evidence-based interventions applicants will not undertake? (e.g., for those seeking funding for prevention, are condoms and comprehensive sexuality education provided?)
• Do the applicants provide services to all groups in a non-discriminatory manner (e.g. sex workers, men who have sex with men, etc.)?
• For those working on treatment, do applicants provide all services to all those who need them (e.g. ARVs, family planning to prevent unintended pregnancies, needles for intravenous drug users, etc.)?
• In cases where funders give money despite gaps in treatment or prevention options (and we acknowledge that there may be reasons to do so), what are acceptable reasons?
• When there are gaps in treatment or prevention options, what allowances or alternative schemes are set up to ensure that those gaps are filled by other organizations? Do funders design arrangements for the coordination of comprehensive care? Do funders allow recipients to handle pass-through money, trusting that they will find and pay another organization to provide the missing services?