Last week, the departure of Mark Dybul as Global AIDS Coordinator caused a ruckus in the press and in some parts of the global AIDS community because, to paraphrase the general sentiment, PEPFAR has been an unmitigated success, and Dybul did a great job steering the ship.
In response, I wrote that: “Prevention is critical to the success of any public health strategy. And PEPFAR under current law and policy fails on prevention. And by failing on prevention, it fails overall.” I also contended that Dybul, who consistently put ideology before evidence, is at least partly responsible for the weakness of prevention strategies under PEPFAR because he ran the program, defended it incessantly and uncritically in Congress and to the press, and even went out of his way to weaken prevention efforts that would have helped women and youth. Of course, blame also goes to President Bush and those members of Congress, the faith community and the advocacy community who formed the PEPFAR cheering squad but failed to insist these policies change before the program was reauthorized for another 5 years. But defenders of this program, particularly those from the far right, asserted that claims of Dybul’s complicity in undermining prevention programs were lies.
Today, I will address just one example of how prevention strategies that help women were perverted by ideology, and how current law and policy must change. In the next installment, we’ll do the same by examining programs aimed at prevention of sexual transmission and PEPFAR’s focus on abstinence-only-until marriage.
Sex. Abortion. Parenthood. Power.
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In February 2008, the State Department Office of the Global AIDS Coordinator (OGAC), run by Ambassador Mark Dybul, sent a letter to the staff of Congressman Tom Lantos (Chair of the House Committee on Foreign Affairs) opposing, among other things, efforts by Congressman Lantos to fulfill a pledge he had made to honor evidence over ideology in reauthorizing the President’s Emergency Plan for AIDS Relief (PEPFAR) at a level of $50 billion over 5 years (2008-2013).
Lantos, who was gravely ill and died just a few days after the letter was stamped, had drafted a bill, then widely supported in the advocacy community, that would have removed restrictions on prevention funding, such as the abstinence-until-marriage earmark in the original PEPFAR legislation. Such restrictions have been found by the Government Accountability Office (GAO) and by the Institutes of Medicine, among many others, to obstruct effective prevention strategies.
“Facts,” he stated while he still had control of the wheel,“ are driving the reauthorization of the Global HIV/AIDS program, not ideology.”
Lantos knew that while the Bush Administration had a stated goal of preventing 7 million infections in the first 5 years of PEPFAR (2003-2008), the Administration had no sound method of measuring success toward this goal. As pointed out in numerous country evaluations conducted by USAID’s Office of the Inspector General (variously 2004-2008), as well as the full GAO report, prevention guidance was found to be confusing to people in the field. Findings also underscored the fact that there is often little-to-no oversight of local program partners conducting prevention activities, and there are no metrics for measuring real outcomes in reaching the 7 million goal.
The one exception is the effort focused on prevention of maternal-to-child transmission (PMTCT), which prevents transmission from an HIV-positive mother to her infant during labor and delivery. In this case, infections averted are relatively easy to track because drugs are delivered in a discrete timeframe and the baby is either infected or not. Measuring “abstinence messages delivered” just didn’t cut it according to the Inspector General.
Lantos knew, and was not afraid to address, the fact that HIV is a sexual health and rights issue, but also a reproductive rights issue. Today, unprotected sex (both heterosexual and among men who have sex with men) is the single most important factor in the spread of HIV and is responsible for an estimated 80 percent of new HIV infections worldwide. Women are both socially and biologically more vulnerable to HIV infection: They are 3 to 4 times more likely to become infected in any single act of unprotected vaginal intercourse with an infected partner than is an uninfected male having sex with an HIV-positive female.
Unprotected sex also leads to pregnancy and pregnancy sometimes is not a desired or intended outcome of sex, not least for women who are HIV-positive, already have reached their desired family size, and may be quite rationally worried about how long they will be around to care for the children they already have.
Women without access to basic sexual and reproductive health services—and particularly those living in societies where women have few rights generally—are therefore at greater risk of both HIV infection and unintended pregnancy in any given act of sexual intercourse. It should be no surprise then that in a country like Uganda, rates of HIV infection among women are high and according to some may be rising once again, but rates of unintended pregnancy, unsafe abortion, and maternal death also are high…indeed among the highest in sub-Saharan Africa.
Lantos was a man of courage and knew that integrating HIV prevention with basic reproductive health and family planning programs made eminent sense and so he fought for it despite the hullaballoo he must have known would erupt.
And as someone interested in facts, Lantos also knew that basic reproductive health services were the first responders for women and girls in such settings (indeed for youth of both sexes), and that when they had access, people would turn to these services for everything from basic information on pregnancy, childbirth, pre-natal care, delivery, breastfeeding, contraception and birth-spacing to HIV prevention, voluntary counseling and testing and other critical needs. These services also enable people to exercise their right to make informed choices about their health. Integration therefore enables people to achieve healthy outcomes of pregnancy and childbirth when those are the chosen outcomes and addresses multiple adverse outcomes of unprotected sex–such as unintended pregnancy and infection. Integration also simultaneously strengthens health systems, saves money, and allows individuals to get their various needs met effectively and efficiently. This makes good use of US taxpayer funds while accomplishing a humanitarian feat.
So apart from simply unshackling prevention programs, Lantos also sought to further strengthen these linkages by including strong language in the bill toward this end. This was good policy aimed at sensible efforts to address adverse public health outcomes of sex and reproduction such as HIV infection and unintended pregnancy. Regarding the legislation, he stated:
With this draft legislation, the Committee has clarified that additional contraceptive services may be provided under the law as long as these services are focused on stopping the transmission of HIV/AIDS…For instance, this provision will ensure contraceptive assistance to HIV-positive women who wish to delay or prevent a subsequent pregnancy.
He was of course attacked. Congressman Chris Smith of New Jersey, Congressman Mike Pence of Indiana, and their good friend Pastor Rick Warren all appeared together at a press conference to decry the draft bill as “$50 billion for the abortion industry.” The media (and I know it will shock readers of this column to learn this) repeated the abortion-connection wholesale and decried the inclusion of family planning in PEPFAR as a “needless distraction.” (I guess so….unless you are HIV-positive, poor, pregnant, and can’t afford to get pregnant again.)
And, in the swirl of ensuing controversy, numerous groups working to pass PEPFAR for as much money as possible as quickly as possible with as large a number of Republican votes as possible joined in the marginalization of this issue by blaming sexual and reproductive health advocates working on HIV for causing a stir. We gals just like to cause trouble.
All this despite the fact that so radical a feminist reproductive rights organization as the Bush Administration itself had earlier recommended greater integration of services. The President’s own 2008 annual report to Congress on the implementation of the global HIV/AIDS program specifically called for linkages between HIV/AIDS and voluntary family planning programs. Just for good measure, I will also note that integration of services wherever it makes sense also is supported by those other radical bodies known as the World Health Organization and UNAIDS.
The gap in integrated services for HIV as part of sexual and reproductive health care overall is huge, but for already-HIV positive women it is particularly stark because they already face higher risks in pregnancy.
Women with "unmet need for family planning" are women of reproductive age who prefer to avoid or postpone childbearing, but are not using any method of contraception. Rates of unmet need for family planning remain high in developing countries. [O]ne in seven married women in these countries has an unmet need for contraception. But in sub-Saharan Africa, the ratio is nearly one in four.
Since 2003, PEPFAR reports having “supported prevention of mother-to-child-transmission services for women during nearly 16 million pregnancies.” Given the evidence, it is difficult to believe that a large share and perhaps the majority of these women (HIV positive, largely poor and with few resources) do not have an unmet for family planning concurrent to their need for PMTCT services. But we would not know because given the climate engendered by PEPFAR we would not ask these individuals how we could best help them. It’s the "don’t ask, don’t know" approach to public health.
This story is emblematic because as the State Department letter underscores, Dybul went out of his way to ignore evidence and human rights and to weaken prevention programs, at the behest of the Catholic Church and evangelical groups with which he worked closely and whose programs he funded. Regarding integration, for example, the letter states:
We strongly oppose introduction and endorsement of family planning as an aspect of PEPFAR and a potential means of prevention or mother-to-child transmission of HIV. Such language does not appear in the current law and wrongly suggests it is necessary to prevent children from being born in order to prevent them from being born with HIV, when in fact PEPFAR currently supports highly effective methods of avoiding mother-to-child transmission. This language is contrary to PEPFAR’s life-saving principles and should be struck from the bill.
Just replace "life-saving" principles with "pro-life principles" (as defined by the Catholic Church) and you can imagine the Bishops using that dictaphone.
“Do the people objecting to this provision want to stand in the way of a sick woman trying to avoid getting pregnant?” Lantos asked before he died. Apparently, in the case of Dybul, Smith, Pence, Warren and President Bush himself the answer is yes.
Dybul lobbied strenuously and successfully after Lantos died to reinstate restrictions on prevention funding (favoring abstinence programs over comprehensive approaches) and the prostitution pledge. He also lobbied successfully to remove the Chairman’s language from the bill supporting integration, and to include in the bill language applying the global gag rule to PEPFAR funds. Doing so would effectively have killed any efforts to promote integration of and greater access to life-saving services for women.
Upon final passage of the bill, both the langauage on family planning and the gag rule had been stripped and the legislation was “silent” on the issue of family planning. To ensure that void could not be filled with rogue public health officials seeking to provide women access to services "on the sly," Dybul then wrote and disseminated guidance forbidding the purchase with PEPFAR funds of any contraceptive commodities for HIV-positive women in PEPFAR-funded programs.
Nothing like a good day at the office.
So now we have a new Administration. And you might rationally think, hey, this is all past history, who cares….but for three things.
First, make no mistake that the legacy of these restrictions lingers in the field and that programs will not proactively move forward without strong signals from the new Administration. Guidance left behind by Dybul prohibiting PEPFAR funding for contraceptives must be immediately revised, if this has not already been done. New guidance should allow field staff to proceed with integration of services to the extent possible and immediately, and to purchase contraceptive supplies, even given any limitations posed by current grant agreements and funding. Full integration of programs wherever feasible and effective should be encouraged in the next round of operational plans and grant agreements. It could not have helped jittery field managers of PEPFAR programs watching the domestic stimulus legislation debate unfold from afar to see that family planning funds were thrown out the window like a hot piece of kryptonite. Messages to the field indicating full support for linking or integrating services however they can manage now must be sent swiftly and clearly. Women need these services. Now.
Second, the mythology of PEPFAR’s unmitigated excellence and success is so widespread that the prevailing view among lawmakers and others is that "we are done." But we should not be "done." We need to go back to the original vision offered by Congressman Lantos and remove the restrictions embedded in PEPFAR as soon as possible. This will take guts and bravery on the part of the new administration, but I want to believe "yes we can."
Any and all efforts to review and correct existing PEPFAR programs must be undertaken with great objectivity by those in charge. We have to ask questions about every part of the program, what works, what does not, and be smart about changes needed. And no longer can we allow the Catholic Church, fundamentalist evangelicals or any other group with an ideological agenda to supercede what is right from a public health perspective, to override the basic human rights of women, or to claim moral stances that simply don’t comport with the realities of real people living with and dying of HIV and AIDS nor be complicit in the moral and ethical dilemmas inherent in denying them servcies. It is time to get real about global AIDS policy. And it is time to be accountable to the US taxpayer for spending their money wisely.
And third, we have to choose a new Global AIDS Coordinator who gets it. S/he does not have to be a medical doctor, though there is nothing wrong with choosing one. The most critical qualifications for the next Administrator include a strong grounding in public health, an equally strong grounding in human rights, and a perspective, like our new President, of saying "Let’s try this and if it does not work we will correct it," rather than protecting failed aspects of a huge program as an homage to their own ego. If we do not take this approach now, in the long run we will not end this epidemic.
As the saying goes, history repeats itself. The arguments made by Dybul and others to just “get a PEPFAR bill with ‘bipartisan support’” as quickly as possible last year are the same or similar arguments made by Congress, the president, the far right and the media in the recent stimulus debate, at least with regard to women’s health. As one colleague said about the stimulus debate: "Feels like PEPFAR all over again." These are or will be the same arguments used by the far right to deny women access to services in the future, or to continue funding of organizations promoting abstinence-only programs that leave people at risk now (more on this in our next installment). We have to take the power out of them by ignoring them, forcefully and proactively providing the evidence, and pushing through to the next step.
We all have a responsibility to reject the policies and strategies of the past. Now is the time to review, reject and rewrite these ideological restrictions that cost untold numbers of lives.