It appears that, after months of behind the scenes wrangling, the President’s Emergency Plan for AIDS Relief in Africa (PEPFAR) is moving. Unfortunately, because some AIDS advocates have allowed social conservatives to disctate the terms of the debate despite a Democratic majority in Congress, the movement is mostly backwards.

With just four short months before a new President and Congress are elected, anyone truly interested in HIV treatment and prevention should support delaying any action to prevent social conservatives from doing more harm to this important international public health program.

Continuing PEPFAR at current levels to get a vastly improved bill in the new Congress, and forcing social conservatives to defend their positions against proven public health prevention methods, will do far less harm than amendments currently being promoted. Senators Tom Coburn (R-OK), Sam Brownback (R-KS) are leading a final charge for social conservative amendments that will undermine the bill’s effectiveness — and these amendments are being tacitly approved by some complicit Democrats to avoid confrontation. Depending upon the insider you talk to, either these are Coburn’s last minute efforts at grandstanding to save face with his more righteous-wing supporters, or deft political gamesmanship. If it is the latter, we won’t know until it is too late to do anything about it. Not the most comfortable negotiating position.

Abstinence-Only — Here we go again …

Congress has been slow to realize what 18 states and American voters already do: abstinence-only is a failure and a waste of tax dollars. Sen. Coburn wants to stipulate that 50 percent (not a typo) of any money spent on prevention of sexual transmission be spent exclusively on abstinence and fidelity programs. Not comprehensive prevention that includes abstinence, fidelity and contraception information, but abstinence and fidelity exclusively. That would increase the share of abstinence dollars from 33 percent during the first five years of PEPFAR, and change language (albeit confusing) that the current version has dictating funding for more general "behavioral modification programs."

While there are rumors that this is Coburn’s last stand and that the language will not be supported in the final version, Congress has yet to show real spine when confronting abstinence-only legislation of any kind. The Democratic majority has played along with social conservatives because they didn’t want to have to deal with social issues in an election year. As comforting as the rumors might be to some, actions speak louder than rumors, and this Congress does not breed confidence on abstinence-only issues.

The corner AIDS advocates may find themselves painted into on this provision can be traced directly to the weak negotiating stance from which they started. Who could blame Sen. Coburn for taking advantage of that to score points? No surprise, the abstinence-only language was written for Sen. Coburn by the US Conference of Catholic Bishops, who remain out of step from rank-and-file Catholics in the pews.

The Stigmatizing Conscience Clause

Like any so-called "conscience clause," PEPFAR, if Coburn and others get their way, will allow people who have dedicated their lives to helping others in need determine which kind of needy people they will help. In other words, unlike Jesus, Christians who don’t want to help sex workers, men having sex with men, or intra-veneous drug users (the populations most vulnerable to contracting and spreading HIV) won’t have to. And they will be able to sleep at night confident their judgment and stigmatization of sex workers and others is exactly as Sen. Coburn ordained it.

In addition to allowing people to justify their personal judgment of others, Sen. Coburn proposes removing provisions allowing for clean needle exchange for drug users. He evidently prefers that people share dirty needles to continue the spread of HIV instead of its prevention. Up is down, down is up; in Sen. Coburn’s world, dirty needles are prevention.

Again, it is worth noting, negotiators that start from positions of strength don’t usually find themselves dealing with ludicrous fringe issues at this late hour. But then again, political negotiations that start from a position of strength are usually handled by people who know what they are doing, not those known for simply marketing colors.

Abortion – A "Red" Letter Word

There never has been, in five years of PEPFAR nor in the draft reauthorization currently before Congress, one word in the legislation that can be construed as allowing for, let alone promoting, abortion. But leave it to Sen. Coburn to read the lemon juice between the lines and insist on removing that non-existent language. (Note that if the non-existent language did exist, it would be illegal because the US government already prohibits foreign assistance dollars from being spent on abortions.)

Sen. Coburn is using the red-hot issue of abortion to undermine family planning and contraception access for women and girls in Africa, ensuring that it will be more difficult to get contraception, prevention and treatment for HIV and family planning services in the same location. Public health experts around the world advocate integrating these services to better help women and girls in Africa who often have little power over their relationships or sexual lives. The word "abortion" is what had some AIDS advocates seeing "red" from the start of this process, running for cover under the banner of bipartisanship and compromise — working against the interests of women and girls — and that’s why Sen. Coburn can still grandstand these issues at this late date.

If Coburn and other social conservatives that claim to support HIV prevention really did, they would not continue to throw these false obstacles in the way of proven public health policies.

Fighting AIDS Is About More Than Money

Because AIDS advocates focused almost exclusively on getting more money, $50 billion up from $33 billion, and didn’t press for sound public health policies to prevent the spread of HIV, who can blame social conservatives from also focusing on the money? Some conservatives want to reduce PEPFAR spending to $30 billion. The White House views this as a "legacy" bill so will fight for the full amount, but that gives Sen. Coburn negotiating leverage on the draconian policies outlined above — and given the track record of these negotiations so far, no one expects Democrats or AIDS advocates to stand firm for women and youth now. Tragic.

Missed Opportunity

Rather than negotiating from weakness and refusing to allow myths around abstinence-only, abortion, and stigmatization to masquerade as good conscience, AIDS advocates could have helped Congress and American voters understand sound public health policies and practices that could truly help women, youth and many others in Africa.

Instead they played politics, and now, might just get played by Sen. Coburn. Rather than risk that, PEPFAR reauthorization should be scrapped and revived when a new Congress and new President can do the right thing, in the name of common sense prevention, treatment and public health policy. If Congress doesn’t have the spine to stand up for public health and HIV prevention during an election year, they have the perfect out. Wait until 2009. Not exactly a profile in courage, but neither is caving to people who claim to support HIV prevention but continue working to undermine it.