|A Letter to the U.S. Senate Urges Reform of the Global AIDS Relief Package|
In anticipation of a cloture vote in the Senate in July 2008, 55 advocacy organizations sent a letter (below) urging Senators to fix the President's Emergency Plan for AIDS Relief (PEPFAR) before it passed. The letter argues that the existing program, while impressive for getting treatment to two million people, fails to address serious flaws documented during PEPFAR's first five years.
July 11, 2008
The undersigned represent organizations committed to promoting effective global health programs. We applaud the historic commitment made by President Bush and the U.S. Congress since 2003 under the President’s Emergency Plan for AIDS Relief (PEPFAR) in providing unprecedented funding for the expansion of programs addressing HIV and AIDS worldwide, including most specifically funds for expanded access to anti-retroviral therapy for those in greatest need. We also recognize the strenuous efforts that have been made over the past several months to reauthorize and expand PEPFAR for the next five years.
We write, however, with deep concern regarding provisions in the proposed substitute PEPFAR reauthorization bill governing prevention activities. The substitute reauthorization bill not only perpetuates but expands restrictions on funding for prevention activities that have been shown by various studies—including those by the Institute of Medicine (IOM) and the Government Accountability Office (GAO)—to undermine efforts to prevent the spread of HIV. Further, the bill deliberately omits for purely political purposes any mention of integration of HIV prevention with family planning despite the fact that such integration is recognized by the U.S. government as critical to strengthening HIV prevention programs for women and youth.
The reauthorization process provides an opportunity to both set and correct policies based on evidence gathered and lessons learned after five years and nearly $20 billion of U.S. funding on global AIDS programs under PEPFAR. In short, this is the time to set policy based on the best available public health evidence. By contrast, passing the current substitute amendment containing provisions discredited by our own government agencies—and in many cases shown to actually undermine our own stated goals – virtually guarantees the failure of our own efforts to end the AIDS pandemic and by extension represents a wasteful use of scarce U.S. taxpayer dollars. At a time when so many U.S. citizens themselves lack health care, we can ill afford to pass legislation aimed at funding programs already widely proven to be ineffective.
It is important to note that the concerns outlined below have been raised repeatedly by many groups throughout the process of reauthorization in both the House and the Senate, and to date have remained unaddressed. In order to effectively combat the spread of HIV, and to ensure full accountability in the use of U.S. taxpayer dollars, we must urge you one last time to fix the following fatal flaws before passing this bill.
Remove all requirements and language governing distribution of funds for prevention of sexual transmission. The original PEPFAR legislation contained an earmark requiring that 33 percent of all funding for prevention activities be allocated to abstinence-only-until-marriage programs despite any evidence supporting this practice.
Both guidance written by the Office of the Global AIDS Coordinator (OGAC) and funding streams allocated for programs ensured that from 2003 through 2007 funding for prevention of sexual transmission under PEPFAR went primarily to abstinence-only-until-marriage programs to the exclusion of ensuring that every individual has all the information needed to protect him or herself against HIV. In fact, from the inception of PEPFAR, well over 50 percent of funding for prevention of sexual transmission was allocated to abstinence-only-until-marriage programs in many focus countries. Both the IOM and the GAO recommended removing the abstinence earmark.
Rather than following the advice of either expert body, the series of hearing and briefings held on Capitol Hill or the recommendations developed by a raft of HIV/AIDS implementers and advocates, the newest compromise contains language that will act as an earmark. And rather than leaving decisions about how to invest in prevention programs to the people in-country who are actually engaged in the day-to-day realities of the epidemic, the substitute bill continues to set formulas in Washington based on political expediency rather than real needs. In these areas, the substitute is even more restrictive than the original Senate bill. In an epidemic in which there were 5 new infections for every 2 people put on treatment in the last year, this is unacceptable. Moreover, we find it ironic that the reauthorization calls for additional IOM reports while blatantly ignoring the recommendations made from the first one.
Remove the refusal clause (the so-called “conscience clause.”) The Global AIDS Act of 2003 includes a refusal clause or so-called “conscience clause” allowing organizations to receive scarce public funding to carry out prevention programs that are based on their own philosophy, even if it is in conflict with evidence-based interventions. Millions of dollars go to organizations to provide prevention services, even though they refuse to discuss the potential of male or female condoms or other contraceptives in preventing the spread of HIV. Stand-alone abstinence and partner reduction programs have outpaced other programs providing individuals with a full range of information needed to prevent sexual transmission of HIV, underscoring that this law stands in the way of effective use of resources. This is neither fiscally nor morally responsible.
The substitute amendment before the Senate now takes it one step further – by enabling organizations that receive U.S. funds to choose among those groups and individuals to whom they are “morally” comfortable providing care, thereby permitting the denial of services to those whose behavior, identity, religion or other attributes may be deemed unacceptable. During the nearly three decades of the HIV and AIDS epidemic, efforts to reduce and eliminate stigmatization of those infected and those at risk have been a critical factor in successful approaches to prevention. Yet, this provision actually codifies stigmatization and discrimination into law and allows the use of U.S. taxpayer funds to perpetuate such discrimination.
We believe evidence, not religion or ideology, should guide the spending of public health funding, and that refusal clauses have no place in the provision of health care funded by taxpayer dollars. If a group or organization can not, due to its own biases, implement programs or provide care based on the best available public health evidence, it should not be eligible for nor be free to seek or accept public funding for such programs.
Remove the “prostitution pledge.” Though to date both the House and Senate have been disinclined to address it, imperatives of both public health and human rights compel us to remind you of the enormous negative impact of the anti-prostitution pledge. Current law requires groups fighting HIV/AIDS overseas to pledge their opposition to prostitution and sex trafficking before receiving U.S. money. Sex workers are among the most marginalized people in every country and often lack access to social and health support systems. Prevention programs that have reached sex workers by first building trust have yielded dramatic reductions in HIV infections among these populations. For example, a 1991 study of 1,000 sex workers in
Some assert that requiring organizations to sign such a pledge will help contribute to ending prostitution, but in reality the opposite may be true. According to numerous reports, the pledge has led to further alienation of already-stigmatized groups, given free rein to police who abuse or extort money from sex workers, and has resulted in further violence and discrimination against women in sex work. Instead of reducing dependence on sex work, the policy is driving sex workers underground and away from the NGOs and health workers best poised to provide them with health and alternate-livelihood services.
Include explicit language strengthening the linkages between reproductive health services and HIV prevention. Despite calls from the World Health Organization (WHO), U.S.-funded operational research, and even OGAC’s own recognition of benefits, so far in the PEPFAR reauthorization process Congress has failed to recognize the benefits of strengthening and linking health services that provide multiple benefits – including reproductive health services and HIV prevention. The WHO recognizes family planning services as an integral component of prevention of mother-to-child transmission services and the linkages between HIV prevention and family planning to be part of best practices. Yet for what can only be presumed as political expediency to accommodate a vocal few, the substitute amendment fails to promote these linkages. At its base, this premise is misguided in that HIV is a reproductive and sexual health issue and sexual transmission is the single greatest cause of new infections. By failing to require strong linkages among these global heath interventions, this legislation purposefully accepts the fact that countless opportunities will be lost to improve the health and save the lives of countless women, their children, and their families as the largest U.S. investment ever in a single disease is spent on what is most politically viable instead of the real-life needs of these women and their families.
The House-passed bill and the first Senate bill were weak on prevention, failing to address the shortcomings identified in the first five years of implementing PEPFAR. Yet the new compromise weakens prevention even further. But what’s the real impact? The fiscal conservatives who are working to dilute prevention activities are cutting off their noses to save their face. In so doing, the long-term costs of providing AIDS treatment and care will grow to unsustainable proportions if more is not done to prevent new infections. Congress must be more focused on serious public health measures for prevention rather than debating morality so that we can prevent more infections and save more lives.
We urge you to strive for the best public health investments that can be made by adopting these changes before passing the final bill. In so doing, the PEPFAR investments will have a greater impact on saving the greatest number of lives and while using scarce U.S. taxpayer funds most wisely.
ActionAid International USA
Advocates for Youth
African Medical and Research Foundation USA
African Services Committee
AIDS and Rights Alliance for Southern Africa
American Civil Liberties Union
American Jewish World Service
American Medical Student Association
Asia Pacific Network of Sex Workers
Association to Fight Violence against Women (ALVF) Antenne Centre - Cameroon
Canadian Treatment Action Council
Caribbean Vulnerable Communities Coalition
Catholics for Choice
Center for Health and Gender Equity
Center for Inquiry
Center for Reproductive Rights
Community HIV/AIDS Mobilization Project
Durbar Mahila Samanwaya Committee – India
Empower Foundation Thailand
Foundation for Integrative AIDS Research
Global Youth Coalition on HIV/AIDS
Health GAP (Global Access Project)
International Committee on the Rights of Sex Workers in Europe
International Council of AIDS Service Organizations (ICASO)
International Planned Parenthood Federation/Western Hemisphere Region
International Women’s Health Coalition
Law Students for Reproductive Justice
National Council of Jewish Women
National Council of Women’s Organizations
National Partnership for Women and Families
Network of Sex Work Projects
New York City AIDS Housing Network
Organization For Life Care – Cameroon
Partners In Health
Physicians for Human Rights
Planned Parenthood Federation of America
Religious Coalition for Reproductive Choice
Secular Coalition for America
Sex Workers Project at the Urban Justice Center
Sex Workers' Rights Advocacy Network - Central and Eastern Europe and Central Asia
Sexuality Information and Education Council of the United States
Society of Women and AIDS in Africa - Cameroon
The Swedish Association for Sexuality Education
Women's Network for Unity – Cambodia
Womyn's Agenda for Change - Cambodia