The President’s Emergency Plan for AIDS Relief (PEPFAR) is moving toward a cloture vote in the Senate, a vote that will determine whether the $50 billion reauthorization lives or dies. That same life or death question applies to millions of people in Africa, and comparing actual life or death in Africa to the political legacy of President Bush, as many people see PEPFAR as his greatest achievement, is appalling. Doubly so when the politicians and mainstream media refuse to demand fixes to PEPFAR’s problems. Like the rest of President Bush’s legacy, PEPFAR, as successful as it has been in part, is a go-it-alone strategy that has alienated much of the rest of the world’s public health community.

The reality is this: as successful as PEPFAR has been getting life-saving treatment to nearly two million people, it has failed to slow the infection rate because it has been hampered by unnecessary ideological restrictions. For every two people who receive treatment, five are newly infected with HIV, according to a letter from leading public health advocates circulating on Capitol Hill.

The current legislation will not change that.

At that rate of infection, fiscal conservatives like Sen. Jon Kyl (R-AZ) are right to question the amount of money being spent and if it makes sense, because unless you stem the infection rate, no matter how many people get treated there will always be more than twice as many who don’t. Unless the bill is fixed to eliminate ideological provisions, touted by Sen. Tom Coburn (R-OK) that have hampered PEPFAR’s prevention efforts in its first five years, and promise more of the same if the current bill passes, PEPFAR will not be as successful in fighting HIV in Africa as it could be.

Unfortunately, that is not the heart of Sen. Kyl’s objections. He and other fiscally-conservative Republicans who’ve been blocking the bill have taken some heat in editorials recently for standing in the way of "the greatest foreign policy achievement since the Marshall Plan," according to PEPFAR supporters quoted in a Wall Street Journal editorial. Given the continued infection rates and failure to address PEPFAR’s flaws to turn the tide, the comparison to the Marshall Plan could only be accurate if Europe were still in shambles.

The Las Vegas Sun writes,

A small group of Republican senators, though, is spoiling the momentum
by arguing that the legislation costs too much and includes money for
unrelated poverty programs.

Poverty is indeed related to the spread of HIV and anyone who doesn’t get that yet isn’t paying attention. Poverty is at the heart of why prevention efforts are so challenging and must be changed, and why putting treatment ahead of prevention is the proverbial cart-before-horse problem. They must work together, and only prevention can ultimatley lessen the burden of treatment.

We should all celebrate the two million lives with us today that otherwise would not be because of PEPFAR treatment. The stark realities of those lives are documented beautifully in a special exhibition, Access to Life, at the Corcoran Gallery in Washington, DC, sponsored by The Global Fund on AIDS. The photos tell the story of people from every imaginable walk of life, mostly women, often young, always on the margins — who because of treatment are alive today, working, raising families, educating others about HIV/AIDS.

Every Member of Congress should be forced to visit this exhibit before voting on PEPFAR, because as much as it speaks to the life-saving power of treatment, the exhibition also speaks truth about the need to set ideology aside in favor of reality-based education and prevention efforts, now. Had ideology not stood in our way for the first 25 years of the AIDS pandemic, many of these people might never have been infected in the first place. Prevention is and always will be the key to fighting HIV.

Christianity Today, yesterday lamenting the delays, wrote this,

Jon Kyl, the junior senator from Arizona, pretty much has sterling
conservative credentials and a "solidly conservative voting record" in
the words of the Almanac of American Politics.

So what is his beef with
the reauthorization of PEPFAR, perhaps the most relatively untarnished
legacy program of the Bush administration?

Certainly, sticker shock and mission creep are legit concerns. But here’s some op-ed commentary, published in the Tuscon Citizen:

Yet despite the program’s widespread support and irrefutable
success, Kyl and a handful of Republicans think the price tag of $50
billion over five years is too high. It would be one thing for legislators thing to balk at expanding a
program that had not delivered its intended results, but quite another
to stop one that works.

The Baltimore Sun said,

Republican leaders must rein in the conservative flank of their party
and put lives before votes. Otherwise, the president’s biggest
achievement abroad may come undone, and millions of children will
suffer the dire consequences

Most of these editorials also referenced that Bush needed PEPFAR to be passed before leaving for the G-8 Summit in Japan last week. That was great, if unsuccessful, spin and most people recognize that the agreements at the G-8 did not hinge on PEPFAR. In fact, as Jill Sheffield notes from the G-8 Summit, once again the world’s wealthiest nations continue to disappoint with regard to HIV:

Related language
in the whole health section of the final G-8 Communiqué is weak and
convoluted:

"G-8 will take concrete steps to work toward improving
the link between HIV/AIDS activities and sexual and reproductive health
and voluntary family planning programs, including preventing mother-to-child
transmission, and to achieve the MDGs by adopting a multi-sectoral approach
and by fostering community involvement and participation." Really,
couldn’t they have done better than "work toward improving"?

While the editorial writers have part of the PEPFAR story right, that there are conservative politicians putting roadblocks in the way of solid public health policy, they have completely missed out on the story of PEPFAR’s well documented problems and the fixes that are necessary. Rewire has been covering those problems extensively since negotiations began, noting that it is not just the fiscally conservative wing of the GOP that is causing delays, but the social conservative wing as well, insisting on ideological provisions like failed abstinence-only requirements, and using completely irrelevant issues like abortion to gain negotiating advantage over squeamish Democrats. These tactics have complicated negotiations and will prevent improvements to prevention efforts. At least the fiscal conservatives aren’t pretending they care about HIV/AIDS as the ideologues try to do, while ignoring public health realities.

But the PEPFAR spin-fest has been a bipartisan affair. The Democratic Majority has shirked its oversight responsibility to learn from the first five years of PEPFAR and improve efforts by applying proven public health strategies. Instead, they have acted more like a minority, allowing the negotiations to be handled between the fiscal and social conservative wings of the GOP in an effort to avoid dealing with social issues during an election year.

But even at this late hour, because of fixes required on the treatment side of the bill, it is possible for Congress to improve PEPFAR in order to slow the infection rate as well, which in the long term, could mean less money required for treatment once the spread of the disease is slowed.

Global public health advocates at the American Jewish World Service, Center for Health and Gender Equity, International Women’s Health Coalition, the National Council of Jewish Women and the Sexuality Information and Education Council of the US clearly articulate these improvements as:

• Abolish arbitrary funding guidelines. In a 2007 report, The Institute of Medicine (IOM) recommended removing the current PEPFAR requirement that one-third of prevention funds be spent on abstinence-until-marriage programs. The Senate bill ignores the findings of this congressionally-mandated study and findings from the government’s own Accountability Office (GAO) about the ineffectiveness of this approach. The current bill calls for spending at least fifty percent of prevention funds designed to halt the sexual transmission of HIV, in countries with generalized epidemics, only on abstinence and faithfulness programs. PEPFAR recipients that do not meet this requirement must justify their programmatic decisions through an onerous reporting requirement to Congress, potentially facing defunding. Every individual needs a range of information and services to protect him or herself against HIV, and public health experts on the ground must be able to determine the best mix of prevention programming for their own communities. As it stands, their hands are tied by policies from Washington.

 

• Support prevention strategies that reach the largest number of people. In most regions, the number of new infections is growing most rapidly among women and adolescents, primarily through sexual transmission. These two groups are more likely to use family planning and other reproductive health services than any other segment of the population, and would be better equipped to protect themselves from HIV if their access to reproductive health services and education was expanded. The U.S. government concluded that integrating family planning with HIV prevention and treatment services could double the effectiveness of programs to prevent transmission of HIV from mother to infants by expanding women’s choices about pregnancy and childbearing. Recent studies suggest that upwards of 90 percent of HIV-positive pregnant women in countries such as Uganda and South Africa have unmet need for integrated family planning and HIV services. However, the current bill before the Senate fails to call for or even acknowledge the need to strengthen critical linkages between family planning and reproductive health services and HIV prevention efforts.

 

• Remove the unconscionable “conscience clause.” The 2003 PEPFAR legislation contains a provision that enables organizations receiving U.S. funding to pick and choose the prevention and treatment services they wish to provide. Millions of dollars go to organizations to provide prevention services, even though they refuse to discuss the potential of condoms or other contraceptives in preventing the spread of HIV. As abstinence and partner reduction programs have outpaced programs that enable individuals to have all the information they need to prevent HIV, the law stands in the way of effective use of resources. The Senate bill takes this bad policy and makes it worse by extending the so-called “conscience clause” to organizations that provide care and support to people living with HIV/AIDS, their families and their communities. This provision paves the way for taxpayer-funded discrimination based on “moral” and religious grounds leaving it wide open to refuse care to someone based on their religion, how they got infected or any other basis. The refusal clause is another damaging provision that flies in the face of good public health practice.

 

• Eliminate the 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 through first building trust have yielded dramatic reductions in HIV infections among these populations. Some continue to believe that having organizations sign such a pledge will help end prostitution, but in reality, the opposite may be true. According to numerous reports, the pledge has led to further alienation of already-stigmatized groups and given free rein to police and resulted in further discrimination against women in sex work. Instead of reducing dependence on sex work, the policy is driving sex workers under ground and away from the non-governmental organizations and health workers best poised to help them and to prevent HIV.

This bill will set the policy for the United State’s global HIV/AIDS programs. As the cloture vote approaches, and assuming it passes, there will still be opprotunities to set better policy on how we spend $50 billion over the next five years. There are concerns on both sides of the aisle, and the Senate should take those issues on, vote on them, and pass a bill that has the greatest impact in saving lives.