Originally published in the Fall 2006 issue of Ms. magazine.
Beatrice Were is a small woman with delicate features, but don't let that fool you. The Ugandan mother of three has a large presence when it comes to HIV/AIDS, the cause to which she's devoted herself since 1993.
Were, who began her AIDS work as a Red Cross volunteer and now works with ActionAid International, is highly critical of current U.S.-funded AIDS-prevention programs. Those prevention programs aren't just inadequate—they're actually harming women, she says.
"Treatment [for HIV/AIDS must be] complemented by an effective prevention program," says Were. "[But] five years from now we'll need more money [for treatment] because we're bound to have more people who will need [it]."
Her conviction is held by many AIDS workers and experts in countries that receive assistance through PEPFAR, which began distributing funding in February 2004. Although Were praises PEPFAR-funded programs that treat those with AIDS—which involves about half of all PEPFAR funding—she believes the sexual-prevention arm, which strongly favors abstinence and fidelity over other methods, seriously shortchanges the needs of women.
"The gender dimensions of the epidemic are completely ignored," says Were. "We know very well that women don't [always] have control [over sexual decisions]. There is rape in marriage. [There is] the fact that many women can't make a decision on whether to have protected sex or not, even whether to have sex or not, because it's their husbands [who] make the decision."
In Uganda, she says, polygamy and promiscuity among men is both significant and socially acceptable. "This [PEPFAR] approach places a huge burden on a woman to abstain and, when she's married, be faithful," she says. "Personally, I did all of that, but I still got infected, too. It just doesn't work."
Were's situation is not uncommon. More than 80 percent of new HIV infections in women result from sex with their husband or primary partner. Another study, conducted in Zimbabwe and South Africa, showed that even though 66 percent of women reported having but one lifetime sex partner, 40 percent of them had been infected with HIV.
Nonetheless, the ABC plan—Abstinence, Be faithful and use Condoms—continues to be the preferred U.S. strategy for preventing sexually transmitted HIV infections. PEPFAR requires that 33 percent of all prevention monies (which also fund programs for nonsexual transmissions of the virus)—and two-thirds of sexual-transmission funds—be spent on abstinence and fidelity programs. Indeed, service providers often have to reduce other programs focused on effective intervention—such as those to prevent mother-to-child HIV transmission—in order to redirect dollars toward abstinence and thus meet the 33 percent requirement.
But an abstinence-only approach has not proven effective in preventing AIDS transmission; in fact, it may have an opposite effect. Take Uganda, one of the PEPFAR focus countries, which successfully promoted a comprehensive program before PEPFAR, substantially reducing HIV in the country from 15 percent in 1990 to 6 percent in 2002. Since it shifted focus to comply with PEPFAR's A and B guidelines, the incidence of the virus has nearly doubled, from 70,000 new infections in 2003 to 130,000 in 2005. "What Uganda has invested in communities over the last 22 years," says Beatrice Were, "is being watered down."
By failing to recognize that women don't have the same power as men to control their lives and sexual practices, U.S. programs have left women vulnerable. And that's critical, because the new face of the AIDS pandemic is no longer a man's: It's that of a woman.
When it was first recognized in the early 1980s, many considered AIDS to be a primarily male, homosexual, Haitian or intravenous-drug-user's disease. But over the years, HIV has increasingly infected women who are married, have children, are nonwhite and poor. Today, 17.3 million women in the world live with HIV/AIDS, and of the 16,000 new HIV infections daily, as many as 55 percent occur among women. The proportion of women among the total infected population has risen at a steady and frightening rate: from 35 percent in 1990 to 41 percent in 1997, to 48 percent in 2004. The women of sub-Saharan Africa are particularly hard-hit: They comprise 54 percent of all HIV/AIDS cases in the region, and three of four newly infected young people (15 to 24 years old) are women.
Why those escalating numbers? To begin with, women are more biologically susceptible to the disease. A number of studies have found that male-to-female transmission of HIV during sex is about twice as likely to occur as female-to-male transmission, because the HIV virus can more easily penetrate vaginal mucus during intercourse. The risk runs even higher if intercourse is violent, as abrasions caused by forced penetration facilitate entry of the virus—which puts adolescent girls at increased risk. As Stephen Lewis, U.N. Special Envoy for HIV/AIDS in Africa, pointed out at the 2006 International AIDS Conference in Toronto, "In Africa… the violence and the virus go together."
The risk of sexual violence and rape should therefore be a crucial component considered in HIV-prevention policies, says the Rev. Mpho Tutu, the daughter of South African Archbishop Desmond Tutu and an Episcopal priest in Alexandria, Va. "One of the reasons for the feminization of the pandemic is the instability of war and displacement," she explains. "Refugee women are vulnerable because rape and sexual exploitation are weapons of war, and so girls and women are the most vulnerable. And as communities are destabilized, more and more often you'll see women trading sexual favors for economic support."
Tutu describes this sex-for-survival as a Hobson's choice: "It's a choice that's no choice at all. When the choice is between survival and death, then you make the choices that will allow for survival for yourself and for the children you have responsibility for."
Sex-for-survival can also occur in the home, especially when women are poor, as they are in great swatches of the PEPFAR countries. Solange Joseph, a young Haitian rape victim at a Port-au-Prince nonprofit for victims of sexual violence, explains how Haitian women might typically get infected: "You might have a man with you in the house, and he might go to find money, but he will stay out two or three days. When he comes back, since he brings you money, you will talk to him, and if he asks for sex you will do it. You will get the disease from him because there is no other way."
In other words, because of economics and their partners' behavior, among other factors, abstinence and faithfulness are hard for women to achieve in these AIDS-afflicted countries and communities. As for using condoms, studies in Haiti, another PEPFAR focus country, show that more than 60 percent of Haitian women feel that the decision about whether to use condoms is exclusively the man's right.
Discussion of safe sex, as suggested by the ABC plan, requires a discussion of sex itself. Yet the PEPFAR policy is to restrict comprehensive sexual-education programs to only certain sectors of the population. Children up to age 14, for example, are not to be introduced to condoms in any PEPFAR- funded school programs. Unmarried youth are often taught only about abstinence and being faithful. This policy does not reflect the reality of Haitians' sex lives: Recent surveys show that 60 percent of young males and 36 percent of young females reported having their first sexual contact before 15 years of age.
Even when condoms are offered, U.S. requirements stipulate that they must always be accompanied by a notice of their failure rates. Says David Veazey, an HIV/AIDS consultant who worked in the former Soviet Union, "This is not something you would put in a campaign slogan to promote condoms. It would be the same as a seat-belt commercial saying, 'Buckle Up! But there is a 10 percent chance that the seat belt won't save you in an accident.' Not only would people continue to drive—because they have to—but they probably wouldn't see the point in wearing a seat belt either."
The U.S. office that administers PEPFAR insists that the program does recognize the great impact the disease has on women globally. "We are working to strengthen and expand the more than 300 programs with gender issues under PEPFAR," said Mark Dybul, U.S. Global AIDS Coordinator, at an event last July. But other activists and experts claim that the U.S. government's approach, even if supplemented by programs that work specifically with women, contributes to the growth of the epidemic among women.
The U.S. has also recognized that the ABC policy isn't always appropriate, so it has allowed some of the PEPFAR "teams" within the focus countries to direct less of their programs to abstinence and fidelity. But then the rest of the countries' provider teams have to spend more on A and B, which means cutting back on other programs.
"We continue to act as if poor people are stupid people," says Rev. Tutu. "They aren't stupid, they're just poor. They are entitled to make full decisions. [If you provide ABC] and [say] that's all that's available, it's dishonest and it infantilizes those to whom we provide the message."
PEPFAR isn't the only source for distributing significant global funding on AIDS—just the biggest. But its prevention guidelines are quite different from those of another significant player, the Global Fund to Fight AIDS, Tuberculosis and Malaria. The internationally supported Fund, started in 2002, is not required to follow the ABC policy, although its resources are fewer than those of PEPFAR.
"[Abstinence] is one point of disagreement between PEPFAR and the Global Fund," says Dr. Émile Charles, head of a Fund-sponsored health program in Haiti. Haitians didn't want to hear anything about condoms 20 years ago, he says, but after 15 years of organizations marketing condoms in the country, Haitian men are beginning to use them in higher numbers. Charles is concerned, however, about PEPFAR putting more focus on A and B and less on comprehensive sex education.
"I think the position of PEPFAR is guided by some religious aspect," says Charles. "But it's important … for a country like Haiti … to continue to focus on condoms. I think that promoting abstinence is an error, a scientific error."
Restrictive U.S. guidelines have caused some countries and providers to refuse its funding. Brazil turned down $40 million in U.S. AIDS funding in 2005 because it refuses to take a required pledge against "the legalization or the practice of prostitution" (which is already decriminalized in Brazil). The country's AIDS program, considered among the world's most progressive, counts its commercial sex workers among its most determined AIDS activists. Other AIDS providers are reluctant to sign the pledge because they don't want to increase the stigma and isolation of sex workers, which would thus raise further barriers to getting them needed HIV services.
In Uganda, Beatrice Were says that policy makers need to do a better job of listening to women in the field and of addressing the root causes of the epidemic. "The promoters of abstinence-only tend to think that we don't respect the fact that A works," she says. "I believe that A works, but A only doesn't work. And faithfulness, as long as you don't address women's powerlessness, will not work." Without changes, Were says, the $15 billion PEPFAR plan will not achieve its stated goal of preventing 7 million new infections by 2010.
The U.S. Government Accountability Office (GAO) seems to agree. In an April 2006 report requested by a bipartisan group of Congress members, the GAO said that PEPFAR was unable to successfully respond to local needs around prevention. For example, the report showed that some PEPFAR teams had to cut back on funding mother-to-child transmission prevention programs in order to comply with the A and B earmark, thus putting newborns at risk of contracting HIV.
The State Department's office for global AIDS posted an unapologetic response to the GAO's critique on its website, defending its emphasis on A and B. Since the U.S. executive branch doesn't seem to recognize the need to rethink aspects of PEPFAR, Congress has begun to weigh in. The bipartisan Protection Against Transmission of HIV for Women and Youth Act of 2006, also known as PATHWAY, was announced in June, cosponsored by Rep. Barbara Lee (D-Calif.), Christopher Shays (R-Conn.) and dozens of others. PATHWAY would require the administrators of PEPFAR to establish a prevention strategy that specifically addresses the vulnerabilities of women and girls to HIV, eliminate the funding earmark for abstinence, increase access to male and female condoms and address gender violence as a cause of HIV/AIDS.
"A growing number of Congress members agree that this bill is important, as it continues to attract new cosponsors from both parties every month," says Jodi Jacobson, director of the Center for Health and Gender Equity, a nonprofit that advocates accountability for U.S. health policies abroad. "PATHWAY…forces the hand of the administration … to do the right thing when constructing a truly comprehensive approach to prevention.
"We should pass it tomorrow."
For more on this issue, please visit www.msmagazine.com.