Despite the fact that abstinence-only-until-marriage programs have not proven successful here in the U.S., the Bush Administration is exporting these programs to other countries. Abstinence-until-marriage programs are at the core of the Administration's plan for U.S. involvement in HIV/AIDS prevention globally. The President's Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (PEPFAR) guides all foreign assistance related to HIV/AIDS, although it was primarily created to direct the spending of a $15 billion initiative in 15 focus countries; 12 in Africa, two in the Caribbean, and Viet Nam.1

Not Quite the ABC's

The Bush Administration argues that PEPFAR applies the "ABC" model of HIV/AIDS prevention that has shown some evidence of success. "ABC" stands for abstain, be faithful, and use condoms. Although this appears to be a comprehensive approach, the PEPFAR policy does not provide the "ABC"s for every individual. Instead, it restricts condom education and distribution by supporting such programs only "where appropriate," then narrowly defining "appropriate" as only for "high-risk" groups, such as "prostitutes" and "sero-discordant couples," couples in which one partner is HIV-positive and the other is HIV-negative.2 This isolation of "high risk" groups further marginalizes these already vulnerable people and misrepresents the level of risk in the focus countries. Given the high HIV-prevalence rates among the general population in these countries, the reality is that everyone is "high risk" and stopping the spread of HIV requires educating people before they are at risk for infection.

PEPFAR provides no policy support for comprehensive prevention programming that reaches young people or adults. Instead, PEPFAR emphasizes abstinence-until-marriage and fidelity within marriage as its primary prevention strategy. In its most recent report to Congress, the Office of the Global AIDS Coordinator (OGAC) explains, "the PEPFAR-supported ABC approach employs population-specific interventions that emphasize abstinence for youth and other unmarried persons, including delay of sexual debut; mutual faithfulness and partner reduction for sexually active adults; and correct and consistent use of condoms by those whose behavior places them at risk for transmitting or becoming infected with HIV."3 More simply put, "marketing campaigns that target youth and encourage condom use as the primary intervention are not appropriate for youth, and the Emergency Plan will not fund them."4

Strict Control Over Purse Strings

The funding mechanisms for PEPFAR further ensure that abstinence-until-marriage is promoted at the expense of other interventions. The Global AIDS Bill5, the legal mandate for the U.S. Strategy, limits prevention spending to a maximum of 20 percent of all U.S. funds allocated for global AIDS (the rest is spent on treatment and care). The bill requires that at least 33 percent of those prevention funds be spent on abstinence-until-marriage programs.

The most recent guidance document from the OGAC requires United States Agency for International Development (USAID) country teams to spend half of their prevention monies on preventing sexual transmission of the virus that causes AIDS and 66 percent of those funds on abstinence and faithfulness promotion. Countries can apply for a waiver that allows them to reapportion their funds to reflect the nature of the local epidemic, but so far only 10 countries have requested such waivers. In order to meet the congressional mandate, when waivers are granted OGAC must then require other countries to spend more on abstinence and be faithful promotion funding.

Moreover, all prevention monies are available to faith-based organizations, which are allowed to exclude information about contraceptive methods, including condoms, if such information is inconsistent with their religious teachings.6 Under PEPFAR, abstinence-until-marriage programs will likely receive more than $665 million over five years to operate in the 15 focus countries.

More and More People Receiving Less and Less Information

In 2004 and 2005, OGAC claims to have reached nearly 50 million people with prevention activities that promote abstinence and/or being faithful and nearly 20 million people with activities that have abstinence as their primary behavioral objective.7

By touting abstinence-until-marriage programs, the U.S. government is misrepresenting an overwhelming body of available scientific evidence. Evidence from the United States and elsewhere shows that such programs have not worked to prevent either sexually transmitted diseases or pregnancy. In fact, several studies show that while teens who participate in virginity pledges, a common component of abstinence-only-until-marriage programs, may delay sexual debut, they are far less likely to use condoms or contraceptives when they do have intercourse, exposing them to increased risk of unintended pregnancy and STDs, including HIV.

These programs also mistakenly assume that marriage is a protective factor against HIV.8 In the focus countries, married monogamous women are, in fact, among the most vulnerable for HIV infection. Evidence increasingly demonstrates that because women often have few rights within marriage, marriage itself may be a key risk factor for HIV.

Moving Forward

Inside the U.S., advocates at all levels have been working to reveal the foolhardiness of sinking money into unproven programming that is ultimately driven by the ideological agenda of extreme social conservatives. Most recently, the United States Government Accountability Office, the independent and nonpartisan government agency that investigates government programs at the request of members of Congress, released a report showing the ways in which funding for abstinence and be faithful promotion is undermining efforts to be responsive to local needs. The report explains that the programs restrict integrated programming that is critical to young people. In particular, the report concluded that condoms are being increasingly marginalized due to the concentration on abstinence and be faithful promotion and confusion about what activities are permissible.9

In many countries, health care providers, educators, and advocates are speaking out against the U.S.-backed abstinence-until-marriage approach to HIV prevention. Of course, in low-income countries where resources are scarce, many organizations and programs are dependent on U.S. funds to operate and are therefore reluctant to complain. Nevertheless, many brave people have come forward.

In response to the lack of U.S. support for comprehensive prevention and education, on World AIDS Day in 2005, the European Union, under the presidency of the United Kingdom, committed "to address the HIV prevention gap, which left unchecked will undermine the whole AIDS response." Its statement called on world governments to "utilize all approaches known to be effective" rather than "implementing one or a few selective actions in isolation." The statement highlighted the importance of "universal access to education and provision of life-skills and sexuality education."10

References

  1. The 15 focus countries are: Botswana, Cote d'Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia, Haiti, Guyana, and Viet Nam. For information on each of these countries, please see SIECUS PEPFAR Country Profiles: Focusing in on Prevention and Youth, (Washington, DC: the Sexuality Information and Education Council of the United States, 2005) available on-line at http://www.siecus.org/inter/pepfar/.
  2. President's Emergency Plan for AIDS Relief: The U.S. Five-Year Strategy to Fight Global HIV/AIDS, (Washington, DC: Office of the Global AIDS Coordinator, February 2004), 28-29, accessed 10 April 2006, <http://www.state.gov/documents/organization/29831.pdf>.
  3. Action Today, A Foundation for Tomorrow: The President's Emergency Plan for AIDS Relief, (Washington , DC : Office of the Global AIDS Coordinator, February 2006), 25-26, accessed 10 April 2006, <http://www.state.gov/documents/organization/60841.pdf>.
  4. Ibid.
  5. HR 1298, US Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.
  6. President's Emergency Plan for AIDS Relief.
  7. OGAC reports 48,903,800 people were reached with AB programming in 2004/05 and 19,530,400 people reached with abstinence programming alone. Engendering Bold Leadership: The President's Emergency Plan for AIDS Relief, First Annual Report to Congress, (Washington, DC: Office of the Global AIDS Coordinator, March 2005), and Action Today, A Foundation for Tomorrow.
  8. For more information on PEPFAR's failure to adequately address the needs of women, please see Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis, (Takoma, MD: Center for Health and Gender Equity, March 2004) available on-line at <http://www.genderhealth.org/pubs/AIDS5-YearStratAnalysisMar-04.pdf>.
  9. Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief, (Washington, DC: United States Government Accountability Office, April 2006), accessed 10 April 2006, <http://www.gao.gov/new.items/d06395.pdf>.
  10. The European Union, World AIDS Day?EU Statement on HIV Prevention for an AIDS Free Generation, (London: European Union, 24 November 2005 ), 14925/05.