Government watchdog criticizes Bush's AIDS plan

The priority given to abstinence-only strategies in President Bush's global HIV/AIDS program may be undermining the overall effectiveness of his administration's multi-billion dollar AIDS prevention efforts, according to a study released on Apr. 4 by Congress' Government Accountability Office (GAO). Based on interviews with 15 country teams in charge of implementing the president's Emergency Plan for AIDS Relief (PEPFAR), the 93-page report found that the plan's requirement that one-third of the funds allocated for prevention activities be devoted to promoting sexual abstinence for unmarried youth and fidelity for married couples made it difficult to meet local needs and, in some cases, resulted in cutbacks to other prevention programs. All but three of the teams "reported that the spending requirement presents challenges to their ability to respond to local epidemiology and cultural and social norms," according to the report. "Teams also reported that the spending requirements can limit their efforts to design prevention programs that are integrated and responsive to local prevention needs," it noted. The report's conclusions were immediately denounced by right-wing lawmakers who support abstinence and fidelity programs. Rep. Chris Smith, the Republican chairman of the House of Representatives Subcommittee on Africa, Global Human Rights and International Operations, charged that it was "politically biased and incomplete." "The timing, methodology and substance of the GAO report all call into question GAO's objectivity and the [GAO director's] motivation for undertaking this project," he said. "The most important question is whether the PEPFAR strategy that has proven successful in the past is continuing to provide effective results. GAO not only fails to answer that question; it doesn't even bother to address it." But critics of the abstinence-only approach claimed that the non-partisan GAO had vindicated their concerns that the administration's prevention strategies were based more on ideology than on proven effectiveness. "Our global AIDS prevention policy should be based on proven, evidence-based science," said Rep. Barbara Lee (D-CA). "Unfortunately, this report demonstrates the Bush administration's willingness to make AIDS prevention policy a political plaything in their ongoing effort to appease the radical right." "This report confirms what we have been saying all along," said Paul Zeitz, director of the Global AIDS Alliance (GAA). "There has been deep concern with this policy–from the European Union, UN officials, African experts, religious organizations and others–and it has been fully justified. Lives are in the balance, and so we need Congress to step in quickly to fix this policy." PEPFAR, the five-year, $15 billion anti-AIDS initiative announced by Bush in January 2003, is a multi-pronged approach to curbing the deadly disease that includes treatment and care, as well as prevention programs for 20 targeted countries in Africa, the Caribbean and Southeast Asia. As passed by Congress, PEPFAR legislation has called for 20 percent of total funding for the program–currently $322 million–to be earmarked for prevention and that half of prevention-related funding be dedicated to preventing sexual transmission of HIV. The other half was to be earmarked for prevention of other ways to transmit the disease, such as mother-to-child transmission or the sharing of unsterilized needles by drug users. In developing PEPFAR's sexual transmission prevention strategy, the US Agency for International Development (USAID) adopted a model based on promoting abstinence until marriage, being faithful in marriage, and using condoms, or the "ABC" approach to prevention, and required that two-thirds of the funding be devoted to abstinence and fidelity (AB)–a ratio that was codified by the Republican-led Congress last year. That requirement has proven extremely controversial among public health professionals and AIDS experts who have argued that, while condom use has a proven track record, the effectiveness of AB programs is not nearly as clear. Indeed, the head of USAID's AIDS programs until 2002 recently complained to the Baltimore Sun that the policy was "outrageous" and "irresponsible." "In effect, we are wasting hundreds of millions of dollars in US taxpayer dollars and precious time that could be better used to prevent the spread of a deadly infection and to save billions of dollars in treatment costs down the line," according to Jodi Jacobson, director of the Washington-based Center for Health and Gender Equity (CHANGE). "The earmark [for AB programs] effectively requires that prevention programs be designed to respond to the ideological agenda of the Bush administration and Congress rather than the local prevention needs of individuals and populations at immediate risk of HIV infection," she added, stressing that the new GAO report "confirms what we have argued for over two years." Among other findings, the report said that most country teams found PEPFAR's directives on prevention are "ambiguous and confusing" and made it difficult to effectively integrate advice about condom usage into programs that emphasized abstinence and fidelity. It noted that some country teams applied for and received exemptions from the AB spending requirements, but that USAID then required that other country teams make up the difference by spending more on AB programs. That practice, according to the report, had led to cuts in funding for condoms and even nonsexual transmission programs. "This report provides more proof that this administration's ideology thwarts proven public-health science," said James Wagoner, president of Advocates for Youth. "The abstinence-only earmark acts like a political straitjacket, hindering on-the-ground efforts to effectively prevent HIV and AIDS." Lee and other Democratic lawmakers said the GAO report would bolster their case for amending the PEPFAR law in order to provide USAID with far more flexibility in spending prevention funds. In 2003, the Senate considered an amendment that would have called for prevention programs to simply place a "priority emphasis" on abstinence and fidelity in order to receive funds. But, under pressure from Bush's Global AIDS Coordinator Randall Tobias, the amendment was narrowly rejected. Tobias was just confirmed as USAID's new administrator.