AIDS activists say the United States administration?s plan to relieve HIV/AIDS is failing, because it?s ignoring the reality of violence against women and girls, especially in Africa. The President?s Emergency Plan for AIDS Relief ? PEPFAR ? has since its introduction in late 2003 saved the lives of many HIV-positive people, particularly by providing them with essential medicines. But activists allege that PEPFAR is largely failing to prevent new infections, because it focuses on ?unrealistically? instructing people to Abstain from sex and to Be Faithful to as few sexual partners as possible. It also stresses Condom use amongst groups it considers to be at risk of infection. According to activists, PEPFAR?s so-called ?ABC approach? fails to take into account that these options ? abstaining, being faithful and using condoms - aren?t open to many women and girls in poor countries, where they?re forced to have sex. In the fourth part of a series on the US?s AIDS Plan, VOA?s Darren Taylor reports on the gender aspect of the controversy.       

The gist of the AIDS activist community?s argument against PEPFAR is that, rather than spending billions of dollars on ?unworkable, unrealistic and unnatural? projects that discourage people from having sex, the money would best be spent on combating what the activists consider to be the main ?drivers? of the epidemic, namely poverty, lack of education and - especially - violence against women and girls.

President Bush in late May asked the United States Congress to approve what he presented as another $15 billion for PEPFAR, which would extend the plan to 2013. Most of the money is expected to contribute to the Plan?s controversial ABC strategy.

Beatrice Were, a prominent Ugandan AIDS activist, says PEPFAR programs aren?t ?evidence-based? and view AIDS in ?moral? rather than scientific terms, and that, she maintains, ?undermines women?s rights.?

?PEPFAR ignores the gender aspects of the epidemic. It assumes that women always have control over having sex ? which they most definitely do not. In Africa, many women and girls can?t abstain from sex, because sex is the only way they can get income. There is also rape and forced early marriages. There is polygamy. Also, even if they are faithful to their husbands, women still get HIV from their promiscuous husbands ? that?s what happened to me,? she says. 

According to Were, 60 per cent of all new infections in Uganda right now are ?happening among married women. PEPFAR ignores all of this evidence.? 

Dr. Tom Kenyon, a senior PEPFAR official at the US State Department?s Office of the Global AIDS Coordinator, acknowledges that one of the Plan?s biggest challenges in preventing the spread of HIV is the evidence that people in ?seemingly safe relationships are?. the major source of HIV transmission? because they?re more often than not unaware that they?re HIV-positive, and so unwittingly pass the virus to their sexual partners.

Kenyon says PEPFAR is dedicated to spending more money to combat this phenomenon.     

Were hopes that the Plan?s administrators will live up to this pledge, but she maintains that a ?lot of (PEPFAR) money has been spent on what does not work, what is not realistic, what does not address the human rights issues of the epidemic, the gender dimensions of the epidemic, the issues of poverty and the issues of conflict, which are actually the drivers of this epidemic in Africa?. In this context, I fail to see how PEPFAR?s approach can work.?  

Dr. Paul Zeitz, of the Global AIDS Alliance in Washington, says ?one third of women in Africa are subjected to physical and sexual abuse. Many times young girls are violated in school or on their way to school. They don?t have the opportunity to use?.a female condom, or to tell their partner to put on a condom. And they can?t say: ?I abstain;? they?re being forced into sex.?

Were continues that there are many ?better things for PEPFAR to spend its money on than ABC. We know that education ? getting girls and boys in school, will have a huge effect on reducing HIV-transmission. There?s good data showing that kids who complete primary school and secondary school have much lower rates of HIV-infection when they?re adults. And, of course, violence against women is a major factor in spreading HIV in Africa. PEPFAR must spend some of the money on educating men to treat women better.? 

Warren Buckingham, PEPFAR Country Coordinator for Kenya, acknowledges that the AIDS activists make some ?legitimate observations,? especially with regard to their point of PEPFAR?s ABC strategy not taking into account situations of sexual violence against women. But he qualifies his concession by adding: ?If one assumes that the only emphasis on prevention work (by PEPFAR programs) is on women, then I think that, again, people are missing the point, or misrepresenting the full complexity and depth of the program.?

PEPFAR officials say they?re doing their best, within the parameters of the Plan, to address gender-based violence in Africa, and that they aren?t ignoring it as a primary driver of the HIV pandemic.  

?In Kenya, we have significant investment in programs called ?Men As Partners?. We are doing a lot, aggressively, to try to change male behavior so that women don?t find themselves in situations where they?re trying to negotiate something (like condom use) that men are unwilling to comply with,? Buckingham says.

Job Akuno, of Hope Worldwide, an NGO in Kenya, is receiving PEPFAR funds to implement HIV-prevention projects in various parts of the country.

?In terms of addressing how gender issues and stereotypes and such practices affect men and women, we are implementing a program called ?Men As Partners, he explains. ?We target young people and the adult population in terms of creating an enabling environment to be protected against some of the gender-based practices, while at the same time allowing men to develop healthy relationships with women, in terms of preventing some of the gender-based violence and (sexual) infections ? HIV infections included.?

Kenyon says PEPFAR ?totally shares the view that gender is a critical factor? in the battle against the spread of HIV.

?We have actually within our myriad of working groups here at the headquarters level, a specific gender working group that ensures that gender issues are integrated into our guidance. In fact, all of our country plans are reviewed by a gender working group to ensure that plans take this into account,? he says.

But he agrees that ?it?s no good having all sorts of programs against gender violence? within the offices of Washington, if these don?t ?filter down? to Africa.

?The place where this needs to happen is obviously at the country level. And we have accelerated programs on gender in several countries, trying to take various approaches around gender-based violence, engaging men further in their response to the epidemic,? he says. 

Prof. Salim Karim, a South African scientist world-renowned for his groundbreaking research in the sphere of HIV, commends PEPFAR for providing him with funding to implement strategies to prevent infections.

?We run a fairly large program that deals with a range of gender issues ? including close partner violence. And PEPFAR has been very supportive of that, so I?m not aware of any restriction on that account. Gender-based violence is very much a part of what we have to deal with in the HIV epidemic. Our task has been quite a difficult one to try to support patients who are victims of gender-based violence. We do so through our PEPFAR programs - you can?t not deal with it, because it?s a daily problem,? Karim explains. 

But Zeitz contends that PEPFAR programs designed to prevent, and respond to, gender-based violence are ?not well funded as separate programs? and that a ?lack of transparency makes it nearly impossible to determine their efficacy and impact.?

Akuno disagrees.

?All I know is I have funds to try to stop violence against women. It?s true that it?s not a separate program, but why does something need to be separate in order to succeed

Kenyon denies that PEPFAR gender programs are opaque.  

?We?re about the only project I can think of that actually collects gender data on our care and treatment services. We care very much that there?s equity in care and treatment services. Gender crosses all of our prevention, care and treatment programs. And that data is there for everyone to see, at any time,? he says.         

Zeitz also says that PEPFAR programs that are supposed to address ?socio-cultural norms that put women at risk of HIV? - such as those aimed at gaining stronger legal rights and economic independence for women ? ?remain small-scale, under-funded, and inconsistent? because of the Plan?s continued emphasis on its ABC continuum.

?We?d love to have more money so that we could implement as many projects as possible,? Kenyon responds. ?But, again, I?ll say that we?re doing our best with what we have, but I agree that as much work as possible needs to be done to help empower women so that they?re at decreased risk of HIV infection.?

AIDS activists also allege that PEPFAR discriminates against women by placing restrictions on organizations that accept the Plan?s money that prevent them from giving counseling to women who are considering termination of pregnancy.

Buckingham acknowledges confusion in the AIDS community about PEPFAR?s stance regarding abortion. He explains: ?The Bush administration, early on, reinstituted something called the Mexico City Policy (the so-called Global Gag Rule), which required that US-government funded family planning programs provide limited information or referral to abortion services. But when PEPFAR was passed by Congress, the President explicitly exempted it from the Mexico City provisions.?

A long-standing US law prevents PEPFAR from funding abortions, but organizations that receive its money are permitted to discuss ? but neither promote nor denigrate - termination of pregnancy with women, in country?s where abortion is legal.

According to Population Action International, an international advocacy group working to strengthen support for individual rights to certain health services, NGO?s won?t jeopardize their US funding if they provide legal abortion services, counsel women about and refer women to such services, or lobby to legalize abortion in countries where it remains unlawful ? as long as such activities aren?t paid for with US funds.