Washington, D.C. – The Senate is poised to consider reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $50 billion initiative to combat HIV/AIDS, tuberculosis and malaria globally. But policymakers must address critical shortfalls in the draft bill to ensure effective use of scarce public funds and adopt a sustainable and effective response to the pandemic. 

 

Many have publicly touted PEPFAR as the Bush Administration’s legacy-building success and called for speedy passage through the Senate following the House vote in April. Today, the Administration estimates that nearly two million more people have access to anti-retroviral medication than five years ago due to U.S. government support. However, for every two people put on treatment five are newly infected with HIV —hardly a far-sighted approach to public health programming. 

 

The failure to stem the tide of new infections is due in part to restrictions contained in the original PEPFAR legislation. Much has been learned since PEPFAR was enacted in 2003. Yet rather than heeding the evidence collected by our own government agencies, the bill now before the Senate continues to compromise sound public health practice for ideology and political expediency. 

 

Under pressure to act quickly to reauthorize PEPFAR, Congress is poised to pass a bill that will lock these restrictions into law for five more years. Doing so threatens scarce public resources, leaves more lives at risk, and impedes the development of a comprehensive approach that would make a difference in the lives of millions. The following changes must be made to the bill before final passage:

 

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.

 

 

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.