The United States administration’s strategy to relieve the AIDS pandemic in Africa has saved the lives of many people infected with HIV, mainly through its provision of essential medicines. But the President’s Emergency Plan for AIDS Relief – PEPFAR – has also been roundly criticized by AIDS activists – chiefly for what they see as the Plan’s “purposeful” and “dangerous” negation of the condom as a major means to prevent HIV infections. Although PEPFAR emphasizes abstaining from sex and being faithful to as few sexual partners as possible as key prevention methods, its officials insist that condoms are equally important in the battle against HIV/AIDS. In the third part of a series about PEPFAR, VOA’s Darren Taylor examines the Plan’s approach to condom use in Africa.
AIDS activists say PEPFAR’s strategy to prevent the spread of HIV places a disproportionate and “unrealistic” emphasis on its “Abstinence” and “Be Faithful” – the so-called A and B – components, and significantly less on its C aspect – Condoms.
“PEPFAR looks at A and B only, and the C in the PEPFAR approach is the last thing that you can ever think about,” says Uganda’s Beatrice Were, who’s HIV-positive herself.
“The United States government has certainly promoted views which one could argue come from a religious point of view instead of a scientific point of view, around the prevention of HIV,” comments Nathan Geffen, of South Africa’s Treatment Action Campaign.
Warren Buckingham, who heads the PEPFAR program in Kenya, says many activists accuse the Plan’s administrators of being “out of touch” with what’s happening “on the ground” - but often, he claims, it’s the other way around.
“I think the deliberate misinformation about what can and cannot be done in terms of prevention (by PEPFAR) has been a real challenge for us. And most of that has unfortunately come from the activist community. Four years on, I regularly work with community groups who have been told (by activists): ‘You know, if you accept PEPFAR programs, you can’t talk about condoms; you can only talk about abstinence.’ And that is absolutely false information and it is not coming from us.”
Buckingham alleges “intentional and unfortunate distortion” about PEPFAR’s policy on condoms.
“It has never been A or B or C. It has always been A and B and C,” he stresses.
This isn’t what’s happening “on the ground” in Africa, says Dr. Paul Zeitz, of the Global Aids Alliance in Washington.
“I was in Zambia a few weeks ago, and I visited a (PEPFAR) counseling and testing program, where a person comes in who is obviously sexually active, is trying to get their (HIV) status – whether they’re positive or negative – and is given no information about condoms or sexual prevention. That’s outrageous. That’s bad public health, and that should no longer be acceptable to people in those countries,” he states.
Marina Guevara, a journalist who’s participated in an extensive investigation into PEPFAR in Africa on behalf of the Washington-based Center for Public Integrity, says her research reveals that condom education is an area “not as well covered in many PEPFAR programs as the AB message” is.
But Dr. Tom Kenyon, a senior PEPFAR official in the US State Department’s Office of the Global Coordinator on HIV/AIDS in Washington, insists: “We don’t ever say: Abstinence instead of condoms.”
Were isn’t convinced: “PEPFAR is compromising scientific approaches to AIDS, which show that condoms are far better tools in preventing HIV/AIDS than instructing people not to have sex, or to be faithful. PEPFAR is wasting money on A and B projects that don’t work. That money could be better used - to buy medicine, for example, and to tell young people about condoms,” she says.
Kenyon says PEPFAR officers are “all scientists” and are therefore in a better position to judge the efficacy of health programs than most AIDS activists are. And although condoms offer “very good” protection against HIV, he says, science has also shown that they aren’t one hundred per cent effective. Nevertheless, Kenyon argues that PEPFAR places a “high premium” on condom use in Africa.
“We’re major supporters of condom utilization. Over the past three and a half years, we’ve purchased and distributed over half-a-billion condoms for the countries that we’re supporting.”
But what particularly angers activists about PEPFAR is the Plan’s regulation that essentially prevents organizations that receive its money from giving condom education to people younger than 14 years of age.
“We are expected to focus with children under the age of 14 on A and B. But we have every bit of permission…. to talk with anyone over the age of 14 about correct and consistent use of condoms,” Buckingham clarifies.
“Not good enough,” says Were. “What about all the little girls all over Africa who, because they don’t have anything to eat, sell their bodies for food? Shouldn’t they also be taught that condoms protect them against infection?”
“It’s absolutely essential that children in Africa are taught at primary school level about condoms, so that they’re best able to protect themselves from HIV if and when they become sexually active,” Zeitz says.
Guevara says her research indicates that the Plan’s “rigid rules” are impacting “very negatively” on the continent’s response to the AIDS pandemic.
“In countries like Ethiopia, girls are getting married really, really young – sometimes as young as 12 years old, or 11…. Or girls going into prostitution – forced by their economic situation – at age 12 or 13. So those people really need to have information about condoms.”
Fatima Hassan, of South Africa’s AIDS Law Project, says the latest UNAIDS statistics reveal an increase of HIV infections amongst teenagers in Africa.
“That should scream out to tell you that you really need to do a lot more sustained prevention work with young people and with youth groups, and particularly, young women. These people need to be told about condoms before they become sexually active, to minimize their chances of getting HIV,” she maintains.
“But if you’re not allowed to provide sex education to young girls, if you’re not allowed to advise them on termination of pregnancy, if you’re not allowed to promote condom use amongst young people, or to make condoms available to them, then I’m not sure how useful any of our interventions are going to be in terms of reducing the numbers of infections….” Hassan says.
However, a member of an NGO who’s been implementing HIV prevention projects in various parts of Africa with PEPFAR money since the outset of the Plan, and who requested anonymity, says activists tend to accord “too much rigidity” to PEPFAR.
“We live in the real world, not in Washington,” the NGO worker quips. “PEPFAR people are generally presented by activists as Bush’s bulldogs who are intent on forcing Christian fundamentalism upon the globe, but I can assure you that we teach condom use to any group that we know to be at risk of getting HIV – and this includes kids younger than 14. We don’t beat the drums about it, but we do it. And PEPFAR officials know we do it. And they don’t wave a stick at us, because they’re also human beings. They won’t officially tell you this, but that’s the truth of what’s happening.”
Kenyon does indeed stick to the official line. But he also says PEPFAR implementers are permitted to provide condom education to “anyone who is having sex with a partner of unknown HIV status; you’re putting yourself at risk and condom usage would be the correct intervention in such an instance.”
But the confusion surrounding PEPFAR’s policies on condoms remains. Activists and people involved in PEPFAR projects throughout Africa say organizations that receive funding from the Plan often feel compelled to transcend its rules, especially the limit which prevents them from telling primary school children about condoms – even at risk of losing their funding.
“I’m aware of some organizations that have said…. that they are using the (PEPFAR) funds to carry on with whatever programs they had and they’re not going to let the conditions or the requirements undermine their program,” Hassan says.
According to Were, some groups in Africa that get PEPFAR money are refusing to promote abstinence and fidelity ahead of condom use.
“When they go to do community work and to sensitize the people, they use the original USAID manual - the one that came out before PEPFAR, the one that promotes condom use and instructs sex workers, for example, on how to convince their clients to use condoms,” Were explains.
But she adds that the NGO’s “always make sure that they are in possession as well of the PEPFAR manual, the one that stresses Abstinence and Be Faithful because they know that this is the one that keeps the donor happy.”
And when PEPFAR officials visit the projects, says Were, then the people who accept the Plan’s funding “pretend. They act as if most of their work is focused on A and B, so that they can continue to receive the American money…. People continue to do what is right, but what they do is they don’t speak out about it, because they know that they will lose their funding if they do.”
Guevara’s experience during her investigation into PEPFAR is that “many groups in the field try to – I wouldn’t say go around the rules – but while they respect the rules, they try to be as comprehensive and realistic as possible.”
During her work, Guevara says she met the manager of a PEPFAR program who “gave the AB part of the prevention message in school, and then she set up another workshop outside of the school. And those same kids could go to that workshop to get the condom information. It’s not the most efficient way to deal with it, but it also speaks well of the organizations getting the (PEPFAR) money and the people in the field trying to act with a good conscience.”
These kinds of “nuances” are happening all over Africa, she adds.
But Zeitz says people who are trying to do the “right thing” shouldn’t have to resort to “cloak-and-dagger scenarios” in order to evade possible punishment from PEPFAR administrators.
“People shouldn’t have to be hiding to do science-based, evidence-based programming. The whole framework should be oriented towards optimizing, empowering and supporting people who are doing the right thing, rather than people having to bend the rules or twist the rules in order to do the right thing. That’s insane!” he exclaims.
But PEPFAR’s Buckingham responds that there’s “no reason” for organizations that receive money from the Plan to have to “play hide-and-seek” with PEPFAR officials.
“I think we have guidelines that are in fact very inclusive. And if people think critically and creatively around them, there’s almost nothing that an organization might want to do in response to HIV/AIDS, that couldn’t be properly and effectively supported with PEPFAR funding,” he maintains.
In Uganda, Were says an element with often “fatal consequences” has been added to the debate surrounding PEPFAR and condoms.
“Conservative church fundamentalists are using PEPFAR to justify their views that condoms – and anyone who uses, sells or promotes them – are evil, because, in their minds, condoms promote promiscuity, and sex leads to Satan,” she explains.
“That problem has happened not only in Uganda, but also in Zambia, Tanzania, Mozambique, Nigeria – basically all the places where the US government is active,” Paul Zeitz says.
“All over Africa, people have stopped using condoms, and infection rates are increasing,” Were says.
She claims that PEPFAR has “twisted” Uganda’s previously successful anti-AIDS strategy, which encouraged youngsters to wait as long as possible before having sex – “which PEPFAR has perverted to mean abstinence” – and advocated for people to have as few sexual partners as possible. But central to the strategy’s success, say activists, was the Ugandan authorities emphasis on extensive condom usage as the country’s primary means of preventing HIV.
AIDS activists and many scientists credit the strategy with reducing HIV prevalence amongst Uganda’s adult population from 15 percent in 1990, to six per cent in 2002. But now, infection rates in the country are once again on the rise. According to Avert, an international AIDS NGO, there were 70,000 new infections in Uganda in 2003, compared with 130,000 in 2005.
Were says PEPFAR should bear a large part of the responsibility for this, because of its emphasis on abstinence and faithfulness as the most important ways to prevent HIV. But the Plan’s administrators are adamant that they’re not to blame.
“To suggest that HIV infections were boosted purely because of PEPFAR is absurd,” says Kenyon. “There are other factors at play here. The Ugandan situation is complicated.”
Says Buckingham: “The difficulty that Uganda is facing has largely come from deemphasizing all three parts of the (ABC) continuum as equally important, and focusing more on abstinence. Part of that has come from Ugandan leadership, not from the US government.”
But activists aren’t willing to absolve PEPFAR. Were maintains that the Plan has “inspired” and “motivated” Ugandan politicians and religious leaders to launch anti-condom drives.
At the same time as PEPFAR programs began to be implemented in Uganda, the country’s President, Yoweri Museveni, made a remarkable about-turn: He rapidly went from being an enthusiastic supporter of the prophylactic – at one point going so far as to instruct government officials to consistently mention it in their public speeches – to condemning the condom as “unsafe”. His wife, Janet, has consistently branded it “immoral”. Free condoms are no longer available at most Ugandan clinics. There’ve been condom shortages in the country. Prices of condoms have increased dramatically, making them unaffordable to most Ugandans.
Some AIDS activists acknowledge that a number of factors have conspired against condom usage in Uganda, including the political leadership’s position against it, as well as the influx into the country of a batch of condoms the government described as “faulty” shortly after PEPFAR began.
Kenyon says PEPFAR never “discourages condom use amongst groups deemed to be at risk” of HIV infection, and Buckingham emphasizes that PEPFAR programs should never brand condoms “unsafe.”
But Nathan Geffen says the controversy around PEPFAR will “never end,” unless the Plan allows people who receive its funding to “officially” provide “responsible” instruction about condoms to children younger than 14 years of age, and to "vociferously" promote the condom ahead of the "Abstinence" and "Be faithful" strategies.
“In this way,” he says, “PEPFAR will be able to claim credit for many more lives saved.”