U.S. President George W. Bush’s plan to relieve the AIDS pandemic in Africa has been praised for saving the lives of many people infected with HIV, mainly through its mass provision of drug therapy. But the President’s Emergency Plan for AIDS Relief – known as PEPFAR – has also been heavily criticized. AIDS activists have slammed it as “unrealistic” – mainly because of its reliance on abstinence and fidelity as primary methods to prevent the spread of HIV. Critics say these elements of PEPFAR aren’t feasible in Africa, where women are often forced into sex for economic and cultural reasons, where youngsters begin to have sex at very early ages, and where people who are faithful are at risk of infection from their partners who aren’t. President Bush’s recent request to the US Congress to approve an extension of his Plan resulted in fresh upsurges of criticism against it. In the second part of a series analyzing PEPFAR, VOA’s Darren Taylor focuses on the Plan’s controversial “Abstinence” and “Be Faithful” components – its so-called “AB principles.”
“Make no mistake, Africans are grateful to PEPFAR for supplying life-saving medicines,” says Fatima Hassan, a lawyer at Wits University’s AIDS Law Project in South Africa.
“But many also see it as a sinister attempt by the Bush administration to impose a sort of puritan, kind of Christian ideology, upon Africa,” she adds.
Indeed, all over Africa and the world, AIDS activists criticize PEPFAR for being less about preventing HIV infections, and more about what they refer to as “ideology.”
Dr. Tom Kenyon, chief medical officer at the US State Department’s Office of the Global Coordinator on HIV/AIDS, is quick to point out that not all “so-called ideology” is bad.
“Common sense is also an ideology!” he exclaims. “When we don’t have science, we also have to use common sense, and one of them, having myself raised two teenagers, is that young people need to wait before they become sexually active – not just because of HIV, but just (because of) the devastating effect that simple teenage pregnancy can have on a girl’s education and her future.”
Science, says Kenyon, also recognizes that abstention from sex is the best way of preventing HIV infection, and that being faithful to as few sexual partners as possible significantly reduces a person’s chances of contracting the virus.
But activists - such as Uganda’s Beatrice Were – also use the “common sense” argument. And they say it’s taught them that PEPFAR’s AB approach is unlikely to succeed, especially in a developing world context.
“PEPFAR ignores reality; it is caught up in fantasy. It runs against human nature,” she asserts. “Most people are not religious fundamentalists - they’re going to have sex; they’re not going to abstain. In poor countries, sex equals most people’s only form of recreation, and often only form of income. Better to teach these people to use condoms, rather than waste billions of dollars on a useless campaign that is actually going to result in more infections,” Were states emphatically.
Kenyon says the “whole point” of the “Abstinence” element is “to help empower young people to wait before they are sexually active. They are more susceptible to HIV at a young age, and they need to get an education and to grow up to be responsible young adults.”
He adds that the “Be Faithful message is primarily to reduce partners…. Having multiple concurrent partners is a major contributing factor to transmission.”
AIDS activists don’t dispute that abstinence and fidelity are the best ways to prevent infections - but maintain that they’re “idealistic” responses to the pandemic – “not part of the real world” as Were puts it -and that condoms are a far better, more scientific and sensible response.
PEPFAR officials, however, insist that the Plan promotes extensive condom use – especially amongst “high risk” groups such as sex workers and truck drivers – although rules essentially prevent implementers from giving condom education to people younger than 14 years of age.
The “Being Faithful” part of PEPFAR, Were asserts, is “doomed to failure…. Let me tell you that there are not many people in the world – let alone in Africa – who are are faithful to their partners. I was faithful to my husband, and I still became HIV-positive.”
Hassan cites two reasons why a focus on abstention isn’t an effective strategy to prevent HIV infections in Africa: “One, because many women are in situations where they have no choice and no autonomy, and very little agency to actually refrain from having sex – either because they’re sexually assaulted or abused at a very young age or consistently throughout their marriage, or secondly, because culturally or religiously they have to get married and they have to have sexual relations. And the proof of their worth is how many children can they actually produce throughout the marriage. So abstaining is simply an unrealistic option for many women who find themselves in varied socioeconomic situations as well as in varied cultural and religious settings.”
Hassan also opposes PEPFAR’s focus on fidelity as an effective response to the HIV epidemic. She points out that “in countries where people have polygamous relationships in marriages, being faithful is understood to mean: Be faithful to all four of your partners at the same time - which then obviously increases the risk of HIV infection.”
The dialogue between Were, Kenyon and Hassan is indicative of a tit-for-tat battle of wills that has been raging between PEPFAR’s proponents and opponents ever since the Plan arrived in late 2003.
In late May of this year, President Bush asked the US Congress to approve what he presented as another $15 billion for PEPFAR. This is expected to extend the strategy to 2013, and much of the additional money will be spent on abstinence and fidelity programs: PEPFAR rules require that up to a third of all HIV prevention funding be spent on the A and B components of the Plan.
Critics say groups that receive PEPFAR money sometimes feel compelled to divert funds from life-saving programs, such as those dedicated to preventing mother-to-child HIV transmission, in order to redirect money toward abstinence projects so that they can abide by PEPFAR’s strict requirements.
“The major problem has been the prevention policies that PEPFAR has been promulgating. They’ve been focused on advancing abstinence programming. That has created a collapse of science-based comprehensive programming in many countries. That is a big setback to the prevention initiative,” says Dr. Paul Zeitz, the executive director of the Global AIDS Alliance in Washington.
“We think that young people need to be given full information about how to stay abstinent, to delay the onset of sexual debut. They also need to learn about being faithful. Serial, one person relationships are the best way to stay safe. But, if they do become sexually active, they need to be aware and fully informed about the use of condoms,” says Zeitz. “And this isn’t happening under PEPFAR.”
Activists say PEPFAR dangerously deemphasizes the condom as a primary means of preventing HIV infection, and has, in effect, encouraged elements in Africa to launch anti-condom campaigns.
“The hyperconservative, ideological forces have been reawakened in many African countries, and reempowered, because of the Bush (PEPFAR) approach. And, unfortunately, that is affecting the willingness of African governments to implement comprehensive prevention, to deliver reproductive health services, to make sure that family planning services are widely available. It’s had a whole chilling effect on a wide range of programs. And that effect is going to take years to reverse,” Zeitz laments.
Were, in turn, unequivocally blames PEPFAR for “destroying” Uganda’s past gains against the HIV pandemic.
“In Uganda, people have stopped using condoms, because the groups who are funded by PEPFAR say that people who use condoms are evil,” she says. “Now people are not abstaining, they are not being faithful and they also are not using condoms. Infection rates are going up. There’s a new wave of stigma against HIV-positive people. It’s a terrible situation.”
PEPFAR officials say criticism such as this isn’t valid, and that it’s unfair to blame the Plan for policies implemented by leaders in Africa.
In the 1990’s, the global AIDS sector lauded Uganda for being the first African country to witness a significant drop in its infection rate. It substantially reduced HIV prevalence from 15 percent amongst its adult population in 1990, to six per cent in 2002 – mainly, say activists, because of an emphasis on condom usage. But, since Uganda shifted its focus to comply with PEPFAR’s “Abstinence” and “Be Faithful” components, the incidence - the rate of new infections - of the virus has nearly doubled - from 70,000 in 2003 to 130,000 in 2005, according to Avert, an international AIDS NGO well respected in the international health domain for its research and analysis.
“What Uganda has invested in communities over the last 22 years,” says Were, “is being watered down by PEPFAR.”
“Before the Bush administration’s initiative, the US policy was promulgating a balanced approach between abstinence, faithfulness and condoms. And that had a positive effect on the environments in Africa. It empowered people who believed in the scientific governance of public policy,” Zeitz explains.
PEPFAR’s stressing of fidelity and abstinence, he says, is far more of a “faith-based” approach than a scientific strategy – a criticism vehemently denied by the Plan’s administrators.
“We are all scientists here (at PEPFAR),” Kenyon retorts.
Marina Guevara, an investigative journalist at the Center for Public Integrity in Washington, has completed a year-long investigation into PEPFAR and its efficacy in Africa. She coordinated a team of reporters who conducted in-depth interviews with clinicians and organizations involved in implementing PEPFAR programs. Guevara herself investigated PEPFAR in Ethiopia.
“I have to tell you that nobody I spoke with told me that AB doesn’t work, or that ‘we shouldn’t be doing AB.’ They all supported AB. But they were concerned that there was no equal emphasis on the condom part, on teaching girls how to fight violence and sex violence, etcetera,” she explains.
“One project manager in Ethiopia told me: “We are giving the people this limited message, this limited education about HIV prevention, and this is going to come back to haunt us in the years to come.’ And I thought that this was pretty telling, and scary….”
But Prof. Salim Karim, a world-renowned HIV researcher who implements projects with PEPFAR funds in South Africa, says he’s never felt pressured by the Plan’s officials into emphasizing the “Abstinence” and “Be Faithful” components “over and above” condoms.
“We generally, in our treatment programs, provide the full spectrum of all prevention options. We do not emphasize abstention or condom use in any different way in our PEPFAR programs, than we do in our general prevention programs – and we run several large prevention programs,” Karim maintains.
However, other groups being funded by PEPFAR clearly stress “Abstinence” first, “Being Faithful” second and, as a last resort, “Condoms”, in their approaches.
Job Akuno, of Hope Worldwide, an international Christian NGO, says organizations that get funded by PEPFAR often decide for themselves to emphasize the A and B components ahead of condoms, rather than being directly pressured by the Plan’s officials to follow a certain line.
“In Kenya, we work with learning institutions and faith-based organizations to provide peer education training, to build the capacity of young people to either delay sex, or those that are already having (sexual) relationships, to maintain faithfulness in those relationships. And where they are already sexually active, then we promote the use of condoms as a way of ensuring that they do not engage in dangerous sexual practices,” Akuno says.
Kenyon maintains that PEPFAR’s AB strategy is a success.
“We’re seeing major behavioral changes in countries where PEPFAR is operating. Number one is that young people decide to wait before engaging in sexual activity. The other behavioral change parameter that’s been very prominent is reduction in multiple sexual partners – especially concurrent partners, which seems to be a very powerful driver of the epidemic.”
Warren Buckingham, PEPFAR Country Coordinator in Kenya, insists that condoms are, and have always been, “central” to the Plan’s strategy.
“What the Emergency Plan has allowed us to do is to maintain and even expand everything that we have historically being doing in condoms and other aspects of preventing sexual transmission of the disease, but also to significantly expand our emphasis – particularly for young people - on the Abstinence and Be Faithful parts of the ABC continuum.”
In defending PEPFAR’s AB approach, Kenyon asks its detractors to take note of what he terms a “certain reality”:
“You can only prevent HIV in two ways: You can have no exposure, or you can have limited exposure. And you have no exposure through abstinence, or you have unprotected sex with an HIV-negative partner.”
PEPFAR officials also maintain that condoms only limit exposure to HIV/AIDS; they aren’t one hundred per cent effective. And activists such as South Africa’s Nathan Geffen agree, but maintain that condoms are far more effective weapons against the spread of HIV than a “morality-based” approach.
In the war of wills between PEPFAR administrators and the AIDS activists, Kenyon is willing to make a few concessions. He acknowledges, for example, that one of the Plan’s greatest present challenges to preventing the expansion of HIV is the “evidence emerging that people in seemingly safe relationships are a major source – if not the major source – of HIV transmission, simply because they don’t know one another’s HIV status. There’s this false sense of security created in this context.”
Were accords “great credit” to Kenyon for his “frank admission,” but maintains that the senior PEPFAR official’s remarks should be regarded as “more proof” that the Plan’s emphasis on fidelity to prevent HIV infections is failing.
Kenyon further clarifies his position as follows: “If you’re faithful to an HIV-infected partner, and there isn’t protection, HIV is going to be transmitted within that relationship. So there needs to be a push to empower couples, partners, to know one another’s HIV status and to bring that into the relationships and discussions around their sexual partnership.”
“And to teach them to use condoms,” Were adds.
When reflecting on PEPFAR’s AB strategy, Kenyon further concedes: “I fully agree that not everybody can do this. That’s why we’re not getting prevalence (of HIV infections) down to lower and lower levels. It takes working at the societal level to empower the society to be able to make these behavioral change modifications. And the fact that it doesn’t work for everyone doesn’t mean that we shouldn’t apply it to those who can make these behavioral choices.”
To justify PEPFAR’s implementation of “Abstinence” and “Be Faithful” programs in Africa, the Plan’s administrators frequently argue that the principles originated not in America but on the continent itself, and that they’re merely cooperating with African governments to “give Africa what it wants.”
“(The AB approach) was developed in Africa, by Africans. PEPFAR has simply picked that up, because that’s the strategy that’s recognized by global experts in this area, and Africans, as to be the approach of choice,” says Kenyon.
“It originated in Uganda,” Buckingham adds.
To affirm this position, Kenyon cites his experience in the 1990’s in Botswana, where he served as a health official.
“The very first billboard that I saw as I drove into Gaborone was an ABC poster. That strategy has been around (in Africa) for a long, long time,” he says.
Having experience in Ethiopia, Guevara concurs. She says Ethiopians in particular have been instructed to abstain from sex and to be faithful to their partners for a very long time – yet HIV prevalence rates continue to increase.
“The AB message in a place like Ethiopia has been in the country for a long time, because it’s a very religious country, and the Orthodox Church and the Catholic Church and the Muslim community – they all stress abstinence. That’s when the question comes: Does the US government (not) need to be a little bit broader than what Ethiopians (and many Africans) already have, and already have heard for a long time, from their churches?” Guevara poses.
Many activists say PEPFAR’s assertion that the emphasis on abstinence and fidelity has been around for a long time in Africa is evidence of its failure – not its success - as a means of preventing sexually transmitted diseases, because HIV infection rates continue to rise throughout Africa.
Kenyon responds that PEPFAR has “formalized” the AB approach, and has translated the talk into action.
“Before, (Africans and ourselves) were just talking about (abstinence and faithfulness); we weren’t empowering young people, we weren’t empowering couples and we weren’t empowering people in high-risk settings to take appropriate measures. Now we are, and it’s working. Less young people are having sex,” he insists.
Hassan characterizes the debate about where the AB principles originated as “quite inappropriate.”
“There’s a lot of principles that may or may not be homegrown in Africa, but the US and its administration doesn’t adopt them just because they’re homegrown in Africa. This (AB strategy) happens to be a policy that the White House approves of, and wants to actually push, and it’s linked to funding. So I think it’s quite disingenuous to say, ‘Oh, it’s an African approach and therefore we’re supporting that.’ There are a lot of African countries where they’re saying: ‘Use traditional methods as a cure for HIV/AIDS.’ But PEPFAR doesn’t support that particular approach,” she quips.
Geffen, though, says there’s “some truth” in PEPFAR’s contention that an emphasis on abstinence and faithfulness as key ways to prevent the spread of HIV originated in Africa.
“African governments have to take some responsibility as well for HIV programs, and if their HIV programs are implemented poorly, then they need to be held accountable for that,” he states.
But, leaving aside all the arguments, Hassan says the “simple fact” is that no strategy yet implemented “by anyone” to battle the expansion of the epidemic has been effective for a sustained period of time.
“Scientifically, empirically, ABC is shown not to have worked in Africa. Abstaining, Being Faithful and Condomizing are not the methods that are working. We’ve got higher rates of infection; we’ve got higher levels of new infections so the incidence is quite high, and AIDS-related mortality is quite high. So obviously the programs that we’ve been using and the messages we’ve been using are not making a dent in the epidemic.”
But the longer PEPFAR continues a stressing of the AB principles, says Were, the longer the bitter in-fighting in the global AIDS arena will continue.
Stephen Lewis, former UN Special Envoy for HIV/AIDS in Africa, added more fuel to the fire recently when asked to comment about PEPFAR. He stated: “The overemphasis on abstinence has probably resulted in an unnecessary number of additional infections.”
“I’d love to know the evidence on which Ambassador Lewis based his comment,” Kenyon responds.
In the next part of the series focusing on PEPFAR, VOA will examine the impact the Plan has had on condom use in Africa.