Just two months before ordering the invasion of Iraq, President Bush in his 2003 State of the Union address asked Congress to appropriate $15 billion for care, treatment and prevention of HIV/AIDS in developing countries. The subsequent President's Emergency Plan for AIDS Relief (PEPFAR) served to burnish his "compassionate conservative" credentials even as he took the nation into war.
Congress authorized the money to be spent over five years primarily in 15 "focus countries," although more than 100 other countries receive smaller amounts. The major goals were to treat those infected with HIV/AIDS, care for those dying of or orphaned by AIDS and prevent the spread of the disease.And it has enabled his administration to funnel tens of millions of dollars to Christian faith-based organizations that support his ideology and form his political base.
"This was an unprecedented moment in history," said Dr. Paul Zeitz, executive director of the Global AIDS Alliance, a Washington-based AIDS advocacy group, and a former official with the U.S. Agency for International Development (USAID). "We've never had this opportunity before. We are the first generation in 100,000 years to have such an opportunity to face a global scourge and defeat it.
"We have the information technology, the communication technology, the transportation technology, the developmental and health systems technology, the biological technology, the global wealth and the moral compass to face this pandemic and change the course, change the reality faster than ever before. There's never been a time when we had all these technologies" to work with.
Dr. Mark Dybul, ambassador for the Office of the Global AIDS Coordinator, refused repeated requests for an interview about the PEPFAR program and its restrictions. But Zeitz was not so reluctant to make an assessment.Despite some successes, PEPFAR has not worked out the way it was envisioned.
"In fact," Zeitz said, PEPFAR "is failing to stop the global spread of AIDS and failing to help lead the world to stop this deadly disease." Instead of "empowering local people," he said, "we are restricting them. We have a flawed framework with flawed policies that have kept us from being where we should be by now."
Information accumulated by reporters in the International Consortium of Investigative Journalists (ICIJ) through more than 100 interviews, examination of thousands of pages of documents and reporting on the ground in affected countries indicates that this historic opportunity may be slipping away, because PEPFAR's "flawed framework" has stressed a restrictive use of the funds earmarked to combat HIV/AIDS.
Experts and activists say that attacking one of the most deadly pandemics in history is an extraordinarily complex venture, dealing with abject poverty and starvation; civil wars and rebellions; devastating violence against women; centuries of such cultural mores as male domination and polygamy, political and corporate corruption, and religions.
In the face of all of that, critics say, PEPFAR has proved at times to be too simplistic and narrow to deal with the complexities of the epidemic.
Initially, the program relied heavily on the use of brand-name antiretroviral drugs instead of more affordable generic drugs. Its prevention theories are mostly limited to what is known as ABC — for Abstinence, Be Faithful, and correct and consistent Condoms use — an approach that some experts say is not responsive to situations of violence and gender inequality.
And while the president set a goal of preventing 7 million new AIDS infections, the proportion of money in focus countries going for prevention has fallen by more than a third over the first three years of the program, from 34 percent of the total PEPFAR budget in 2004 to 22 percent this year.
While Dybul would not be interviewed for this article, in testimony at a House subcommittee hearing, he defended the ABC approach in all of its manifestations.In fact, the actual prevention practices stress the "AB" messages — abstinence until marriage and being faithful to one partner. The "C" has moved to a small c, and the use of condoms is lumped into the category of "other preventions" that includes prevention of mother-to-child transmission, blood safety, safe medical injections and control of intravenous drug use.
"To the extent any controversy remains around ABC," he swore, "I believe it stems from misunderstanding. ABC is not a narrow, one-size-fits-all recipe. It encompasses a wide variety of approaches to the myriad of [sic] factors that lead to sexual transmission. The interventions that help people choose to avoid the risk of HIV infection entirely, to reduce their risk, vary according to the circumstances of their lives."
In a speech delivered Nov. 27 at Georgetown University, he acknowledged that, concerning the AB and C programs, "It is all very complicated and we don't have it right everywhere and need to improve still."
A major source of HIV infection is sexual transmission through commercial sex work. But the administration requires organizations receiving PEPFAR funding to take an "anti-prostitution loyalty oath," a signed statement saying they oppose prostitution. As a result, many organizations that have worked on health, safety and rights issues of sex workers can't sign the oath and don't qualify for U.S. funding.
Many of the faith-based groups, nongovernmental organizations, American universities and private companies whose HIV/AIDS programs PEPFAR is funding have accepted the strings attached. But many others interviewed by ICIJ said they devise ways to get around the rules to spread their prevention messages. Some American evangelical groups are revising their own procedures and including condoms information in their abstinence-centered programs.
While some organizations receiving PEPFAR funds have extensive experience running public health programs in developing countries, others, such as Food for the Hungry and the International Orthodox Christian Charities (IOCC) started their first stand-alone HIV programs only when PEPFAR funds became available.
Critics say that some PEPFAR-funded groups lack the know-how to run HIV programs. In one instance, a politically well-connected U.S. faith-based group, Children's AIDS Fund (CAF), was found by an expert panel of reviewers to be "not suitable" for PEPFAR funds, according to published reports. But this finding was overruled by the then head of USAID, and the group was awarded a $10 million grant anyway to run abstinence-centered programs in Uganda, Zambia and South Africa. The president of CAF, Anita Smith, a longtime vigorous promoter of abstinence programs, has been the co-chairwoman of President Bush's Advisory Council on HIV/AIDS.
The president was an early subscriber to Smith's abstinence education views and he pushed them when he was Governor of Texas. But abstinence-only sex education programs in Texas were found to have had no impact in teenagers' sexual behavior, according to a Reuters news service report of a study by researchers at Texas A&M University.
In fact, reflecting statewide trends, teenagers in 29 high schools became increasingly sexually active despite taking courses emphasizing abstinence-only themes, according to the study commissioned by the Texas Department of State Health Services.
The President's and his supporters' focus on abstinence programs provides some perspective on their approach to the global epidemic. Here are some salient facts regarding the U.S. response and the president's global plan and actions:
- How well has PEPFAR worked?About 40 million people in the world are living with HIV/AIDS, two-thirds of them in sub-Saharan Africa.
- More than 20 million people died from AIDS in the quarter-century before PEPFAR was established.
- Of the $15 billion appropriated for PEPFAR, only 60 percent was new federal funding. The remainder includes other, previous international commitments. And $1 billion of the $15 billion went to the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.
- About half of the treatment money is going for antiretroviral drugs, which at the beginning were required to be highly expensive name-brand drugs approved by the Food and Drug Administration and provided largely by major American pharmaceutical companies. More recently, some two dozen generic formulations have been approved for PEPFAR use by the FDA.
- Congress mandated that one-third of the prevention money (about 20 percent of the total appropriated) be earmarked to go to abstinence and fidelity programs. A 2006 Government Accountability Office report concluded that this spending requirement was hurting other programs in the field, such as prevention of mother-to-child transmission.
- The discussion of condoms is routinely discouraged as a primary prevention approach among youth and cannot even be mentioned to those under age 15 in school programs, even if they are already involved in sexual conduct. Condoms can be addressed in out-of-school settings among youth who engage in high-risk behavior.
- In general, at least two-thirds of all foreign aid funds never leaves the United States, according to a Congressional Research Service report. The money buys U.S. products, pays for U.S salaries, overhead, benefits packages, travel, American-made vehicles, office expenses, computers and other equipment. USAID awards 87 percent of its consultant dollars to U.S.-based firms.
A yearlong investigation by ICIJ, a division of the Center for Public Integrity, including in-country reporting from Ethiopia, Kenya, Nigeria, Uganda, South Africa, Haiti, India and Thailand, disclosed that ideology has at times trumped science in the Bush administration's rules, regulations and support of the organizations that have received taxpayer money.
The precise amounts are difficult to discover. While the State Department, through its Office of the Global AIDS Coordinator, claims pride in its "transparency," the agency routinely takes a year or more to provide public documents requested under the Freedom of Information Act. Facing long delays with not even an estimated delivery date, the Center for Public Integrity filed lawsuits to gain access to PEPFAR records. By comparison, USAID was relatively prompt, but the State Department held the bulk of the requested documents.
When the State Department did provide the documents, under a schedule arbitrated by a federal court, it blacked out the significant financial information. Almost none of the public documents were made available except in response to the litigation.
Finally, to settle the Center's lawsuit, the State Department released data that included PEPFAR money flows for 2004 and 2005, but the numbers didn't always add up correctly, and officials admitted that their database contains flaws and errors.
Interviews with scores of activists, people living with HIV/AIDS, physicians, health care workers, government officials and academics, along with examination of thousands of pages of incomplete documents, also show a pattern of contradictory, conflicting and confusing policies. The picture presented is one of an extraordinarily disorganized operation.
More than 3½ years after President Bush's State of the Union address that led to PEPFAR's creation, about $8.3 billion has been spent for PEPFAR activities, according to the State Department. That is the about same amount spent in three weeks of war in Iraq.
Less than $1 billion has actually been spent preventing people from contracting AIDS in the 15 focus countries — about the same amount of money that is spent in three days of war in Iraq.
Meanwhile, the number of people who become infected with HIV continues to rise in some countries, and three-quarters of them are infected through sexual intercourse. More than 450 people contracted HIV each hour last year, constituting more than 4 million new cases.
While the spread of HIV/AIDS has continued and sub-Saharan Africa remains the global center of the pandemic, the people in some countries are faring worse than others.
An exceedingly high percentage of the population is infected in some of those countries, such as Swaziland, Lesotho and Zimbabwe. In Swaziland, infections among pregnant women rose from 4 percent in 1992 to 43 percent in 2004. In Lesotho and Zimbabwe, more than a fifth of the population is infected, although a new UNAIDS report released last week said the national adult HIV rate in Zimbabwe is declining.
But none of the three is included among the 15 PEPFAR focus countries, and no one in the administration could offer an explanation of how the focus countries were selected.
Still, the problems facing those included on the list are extensive.
In Botswana, more than 24 percent of adults are infected.In South Africa, for example, almost one of every three pregnant women attending prenatal clinics in 2004 was infected with AIDS. The 2006 United Nations Report on the Global AIDS Epidemic reported no clear signs of declining HIV/AIDS prevalence throughout southern Africa.
A dynamic epidemic is under way in Mozambique, and infections are spreading particularly fast in areas linked by major transportation corridors to Malawi, South Africa and Zimbabwe, the U.N. reports.
In Uganda, whose programs President Bush touted and used to pattern PEPFAR's ABC prevention approach, success seems to be reversing. In the two years since the new U.S. emphasis on youth abstinence began, the rate of new HIV infections has almost doubled, from 70,000 in 2003 to 130,000 in 2005, according to the director general of the Uganda AIDS Commission.
Since the arrival of PEPFAR money, the student and teacher materials in schools now stress abstinence. One student handbook advises: "Young people do not need condoms; they need skills for abstaining from premarital sex."
According to documents, PEPFAR requires its partners to emphasize condoms' failure rates, which is exaggerated to approach 20 percent, when studies have shown that latex condoms are vigorously tested and, when used properly, have a success rate in excess of 98 percent.
Ethiopia is a nation staggering under the weight of poverty and famine, and rural women and girls move into cities in search of jobs. Many of them are not able to find steady employment and some become commercial sex workers along the main transportation routes. Even university students engage in sex in exchange for money to buy food and books.
A government survey found that 70 percent of the sex workers in the capital city, Addis Ababa, were HIV-positive in 1998. Only $110,000 of PEPFAR funds was allocated in 2006-2007 for condom promotion among sex workers, truck drivers and other high-risk groups along the Djibouti corridor, Ethiopia's main route to the seaports and an area where sex work is widespread. But almost five times that amount was allocated for abstinence and fidelity activities.
Over the entire country, PEPFAR's budget for prevention increased between 2005 and 2006. The funding for abstinence and fidelity activities increased by 63 percent, while condom funding increased 28 percent.
After Thailand went to a "100 percent condom" program in 1991, the rate of HIV infection among female sex workers declined from 30 percent in the mid-1990s to less than 10 percent in 2004. By 1995, the number of men coming to government clinics for treatment of sexually transmitted diseases declined by more than 90 percent.
Thailand has a long history with AIDS and a large HIV-infected population, but it was not selected to be a focus country.When condom use was enforced on sex workers and in the brothels, the number of annual new HIV infections fell from 143,000 in 1991 to about 20,000 by 2003. The condom promotion program was so successful that public health experts urged that it be copied in other developing countries where prostitution was common.
Now the HIV/AIDS epidemic is feared to be resurging. A 2005 World Health Organization report said that new infections are no longer declining as rapidly as they did in the 1990s.
In Thailand between one-third and one-half of newly infected Thais are women in stable relationships, indicating that their male partners are engaging in risky sexual activity with others.
India, also not a PEPFAR focus country, has a relatively low HIV prevalence rate, but because of the country's population, it translates into almost 6 million HIV-infected people — the largest group in the world. About 85 percent of HIV/AIDS cases in India are attributed to heterosexual sexual activity, and commercial sex work is the major contributing factor.
Bharati Dey, a former sex worker who is a program director of a successful HIV/AIDS prevention project, sees commercial sex work not only surviving, but also expanding. "Traditional occupations of women are diminishing, and so the amount of female sex workers has increased over the past decade," she said.
That condition exists for women all over the globe, and the poorer the country, the worse their plight. There are limited opportunities for women in India as well as in Haiti, where fewer jobs, widespread starvation and more desperation to care for themselves and their children have put women at greater risk of contracting such sexually transmitted diseases as HIV/AIDS.
According to U.N. data, women and girls in the Caribbean, 15 to 24 years old, are up to six times as likely as men to contract HIV, often as the result of sexual violence. In rural areas of Haiti, economic dependence on men is one of the primary risk factors for infection.
Haitian women have the highest rate of new AIDS cases in the Americas. But while the World Health Organization says that violence against women is often a cause and a consequence of HIV, the money being spent by the U.S. government on HIV prevention in Haiti has not yet seriously addressed the issue of violence against women.
And the violence feeds on the poverty. In some communities in Haiti, people eat just one meal a day. Along with Afghanistan and Somalia, Haiti has one of worst caloric deficits per inhabitant in the world.
While PEPFAR orchestrates programs for abstinence and fidelity, reality in the developing world moves to different music. In many places, poverty and hunger are constant companions of women and playmates for their children. For some, survival sex is the only way of life.
The bottom line is that, for most women, abstinence is rarely an option. In fact, as Anne Sosin, the head of a rape crisis center in Haiti, says, "Abstinence, Be Faithful and Condom use works in a context where women are able to exercise their sexual rights." That is not the norm in many communities around the world.
More than 80 percent of new HIV infections in women results from sex with their husbands or primary partner. The men usually became infected from extramarital sexual partners.
Beatrice Were is a small, delicate Ugandan woman, mother of three, devoted HIV/AIDS activist and care volunteer.
In Uganda, she says, polygamy and promiscuity among men are both significant and socially acceptable. "This [PEPFAR] approach places a huge burden on a woman to abstain and, when she's married, to be faithful," she said in an interview with ICIJ reporters. "Personally, I did all of that, but I still got infected."
ICIJ members and Sheetal Doshi, Sarah Fort, Victoria Kreha and Marina Walker Guevara contributed to this story.