The Center for Public Integrity

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."

Background

Once referred to as the "Pearl of Africa" by Winston Churchill, Uganda lies in East Africa, bordered by Rwanda, the Democratic Republic of the Congo, Sudan, Tanzania and Kenya. The landlocked country is divided into 78 districts that are spread across four administrative regions — Northern, Eastern, Central and Western. The capital is Kampala.

There are myriad ethnic groups in Uganda, none of which is large enough to constitute a majority. Dozens of languages are spoken. While the official languages are Swahili and English, Swahili is not widely spoken.

The country gained independence from the United Kingdom in 1962. In 1971, Idi Amin took over in a military coup and ruled the country for the rest of the decade. Under his reign, nearly 300,000 Ugandans lost their lives and the economy plummeted when Amin forcibly removed minority Indian entrepreneurs from the country.

Amin was overthrown in 1979 by Tanzanian forces and Ugandan rebels. Milton Obote, who had preceded Amin as president, took over and ruled until 1985, when he was overthrown and replaced by a general who ruled for six months. The general was overthrown by the current president, Yoweri Museveni, who has been in power since 1986.

The face of HIV

According to the U.S. State Department's Office of the U.S. Global AIDS Coordinator, the infection rate is 10.7 percent in urban populations and 6.4 percent in rural areas.

In 2006, the government banned HIV-positive recruits from joining the military, a move it called a "humanitarian" measure. The defense force has suffered from losing soldiers to AIDS.

Management Sciences for Health (MSH), a private nonprofit organization that works to strengthen health systems worldwide, was founded in 1971 by Dr. Ronald O'Connor, who wanted to provide technical assistance in public health management to the developing world.

MSH is based in Cambridge, Mass., and receives the vast majority of its funding from the federal government — $155,826,790 for fiscal 2005. MSH is involved in multiple health policy and service areas, including leadership development, financial management, pharmaceutical procurement and inventory management.

Partly as a result of its international work in treatment and supply chain management, MSH is one of the largest recipients of President's Emergency Plan for AIDS Relief (PEPFAR) grants over the last three years, receiving more than $44 million in fiscal 2005 alone. MSH has been receiving funding from the U.S. Agency for International Development (USAID) for 35 years, said Dr. Malcolm Bryant, MSH's director for the Center of Health Outcomes.

MSH programs

In September 2005, the Partnership for Supply Chain Management (PSCM), a nonprofit group created by John Snow Inc. and Management Sciences for Health, was awarded a USAID contract that totals up to $7 billion. The contract was for providing pharmaceuticals and related supplies in PEPFAR countries. MSH and JSI are joined by 15 subcontractors, which include universities, defense companies and international health organizations.

MSH's role in PSCM is multifaceted. It assists in the coordination of country support for HIV/AIDS commodity policy; provides training, guidance, management and technical expertise as well as quality insurance.

MSH has previous experience in supply chain systems and has a program called Rational Pharmaceutical Management Plus Cooperative Agreement, which predates PEPFAR. The program aims to improve access to drugs, vaccines, supplies and equipment. 

Background

The Indian subcontinent is bordered on the west and south by the Indian Ocean and the Arabian Sea, on the east by the Bay of Bengal, and on the north by Pakistan, Nepal, China and Bangladesh. Just over 1 million square miles are home to 1.1 billion people — one-sixth of the world's population, with more than 60 percent living in rural areas.

Once a colony of the British Empire, the country gained independence in 1947. Now a federal union, the Republic of India has 28 states and seven union territories that are self-governing and a prime minister who is the elected head of the country.

The country is characterized by its diversity in language, culture, landscape and heritage. Fertile lands and river valleys support agriculture, which employs about 60 percent of the labor force.

The face of HIV

Migrant laborers and truck drivers, who spend days to months on the road, are among the most vulnerable groups for HIV/AIDS infection. According to the National AIDS Control Organization (NACO), India's central HIV/AIDS agency, there have been 124,995 officially reported cases of AIDS from 1986 to August 2006, though that number may be grossly underestimated because many people do not report their cases. Of those who have reported being infected, 58 percent live in rural areas and about 39 percent are women.

Just over half of all reported cases of HIV/AIDS are in two southern states: 52,036 in Tamil Nadu and 15,099 in Andhra Pradesh. In fact, those two states, along with the southern state of Karnataka and the western state of Maharashtra, which together make up 30 percent of India's population, account for about 75 percent of HIV cases.

Migrant workers and truck drivers who reside in southern India and engage in sex with commercial sex workers or with other men account for the high prevalence rate there.

Background

Bordered by China to the north, Laos and Cambodia to the west and the South China Sea to the east, Vietnam lies in a culturally diverse and politically volatile region of the world. After being ruled by Chinese dynasties, Vietnam achieved independence in the 10th century. In the mid-19th century France colonized Vietnam and remained in power until World War II, when Japan occupied Vietnam. After that war, France unsuccessfully attempted to regain control during an eight-year war that ended in 1954 when Vietnam was temporarily split in two by the Geneva Accords, which called for national elections in 1956 to unify the country.

But the elections didn't happen, and instead, Vietnam was entrenched for two decades in a civil war, with the U.S. sending combat support for South Vietnam. Millions of Vietnamese died in the conflict which ended in 1973 when U.S. troops withdrew. In 1975, the North captured Saigon — renaming it Ho Chi Minh City — and extended the communist regime to the South. In the mid-1980s the Communist Party started to ease its control over the economic market and slowly adopted capitalist practices. Since then, the Vietnamese economy has grown robustly, and political repression has declined.

Vietnam had no formal diplomatic ties with the United States until 1995, when it opened an embassy in Washington. Over the past decade, diplomatic relations between the two nations have developed rapidly.

The country is one of the few remaining with a Communist government and despite its political gains over the past decades, maintains a highly centralized one-party system.

In the aftermath of World War I, British activist Eglantyne Jebb, determined to aid the young survivors in neighboring war-torn Vienna, Austria, founded the Save the Children Fund in England in 1919.

The new organization immediately began pressing for the safeguards of children to be internationally recognized. In 1923, Jebb wrote the Children's Charter, which eventually served as the foundation for an international treaty called the United Nations Convention on the Rights of the Child in 1989. It has been ratified by all but two countries, the United States and Somalia.

The British Save the Children initiative was mimicked in 1932 by American philanthropists to aid children suffering the consequences of the Great Depression. John Voris established Save the Children U.S. in New York.

World War II further spread the work of Save the Children overseas to aid youngsters in England, France, Germany, Italy, Austria and Finland.

In the 1980s, a new crisis emerged that gradually started to affect millions of children around the world. This time, it was not a world war or a stock market crash, but HIV, the virus that causes AIDS.

Besides responding to emergencies and developing a variety of education, health and entrepreneurship programs, Save the Children entered the AIDS battle overseas to promote the care and support of those affected and to address prevention, particularly among high-risk youth.

Background

Haiti, or Ayiti in Creole, the first independent country borne of slave rebellion in 1804, is populated primarily by descendents of slaves taken from Africa by the Europeans. Haiti is slightly smaller than Maryland and encompasses the western third of the island of Hispaniola.

Less than two hours by plane from Miami, Haiti has the highest number of HIV/AIDS cases in the Caribbean. Ten percent of those living with HIV in Haiti are children, and in 2005 there were an estimated 400,000 orphans, many of whose parents died of AIDS.

Traditional medicine continues to play an important role in Haiti. Voodoo priests and priestesses are considered to be traditional healers. Catholicism is the official religion, but it is said by many that voodoo is the national religion.

Haiti shares an island with the Dominican Republic, but the two countries differ greatly. The HIV rate in Haiti is three times that of the Dominican Republic. Socially and economically, the Dominican Republic is also more stable, with a higher life expectancy and a gross national income per capita that is five times as high as Haiti's.

The face of HIV

In 1982, the Centers for Disease Control and Prevention put Haitian-born U.S. residents on the list of "groups at highest risk of acquiring AIDS" along with intravenous drug users, hemophiliacs and homosexual and bisexual men. The stigma attached to the disease at that time affected immigrant Haitians in their searches for employment, citizenship and more. Years later, just being Haitian was no longer considered to be a risk factor in itself, but the damage had been done. Discrimination against Haitians, along with other high-risk groups, and ignorance about the transmission of HIV/AIDS had spread.

ICIJ Director: Wendell Rawls
Editor: Diane Brozek Fancher
Editorial Projects Coordinator: Leah Rush

Writers: Sheetal Doshi, Prangtip Daorueng, Alejandra Fernández Morera, Sarah Fort, M. Asif Ismail, Daniel Kalinaki, Patrick Kiger, Adri Kotze, Victoria Kreha, Anna-Maria Lombard, Arthur Okwemba, Olayinka Oyegbile, Devin Varsalona, Marina Walker Guevara

Translators: Kaleyesus Bekele (Ethiopia), Guy-Claude Jean-Baptiste Jr. (Haiti)

Researchers: Susanna Hamblin, Rakesh Kalshian, Rachel Leven, Sarah Laskow

Associate Editor: Tom Stites
Copy Editors: Marcia Kramer, Tonia E. Moore
Research Editors: Michelle R. Harris, Elizabeth Levine, Peter Newbatt Smith
Database Editor: Helena Bengtsson
Graphic Designer: Jyoti Sauna

Network Administrator: Chatchai Sae-Tung
Web Site Architect: Han Nguyen

Background

Located in southeastern Africa, Zambia is a landlocked country bordered by the Democratic Republic of the Congo, Tanzania, Malawi, Mozambique, Zimbabwe, Botswana, Namibia and Angola.

For centuries, Zambia remained largely unexplored by Western powers. In the mid-19th century, famed British explorer David Livingstone was the first European to reach the Zambezi River's majestic waterfalls, which he later renamed Victoria Falls. Thirty years later, in 1888, Northern and Southern Rhodesia — named for their colonizer Cecil Rhodes — became part of the British sphere of influence.

Zambia is split into nine provinces. Lusaka is the capital city. The country is 35 percent urban and has more than 70 ethnic groups. Many of the groups speak Bantu, an African language, but the official language is English.

Formerly known as Northern Rhodesia, Zambia was renamed for the Zambezi River after gaining independence from Great Britain in 1964. For its first years of independence, Zambia was one of the most prosperous countries in Africa, mainly due to its copper exports. But the copper market crashed in the mid-1970s, and as a result, Zambia is now one of the poorest countries in the world.

The current president is Levy Mwanawasa, who was reelected to a second term in September 2006, despite his opponent's accusations of corruption.

The face of HIV

The first AIDS case in Zambia was diagnosed in 1984. Urban areas have infection rates two to four times as high as in rural areas. According to a study by the University of California, San Francisco, the disease is primarily transmitted by heterosexual intercourse, but mother-to-child transmission accounts for 30,000 new infections a year.

The study estimates that AIDS will reduce the life expectancy of a Zambian by 26 to 39 percent through 2050. By the same year, a cumulative 6.2 million people in Zambia will have died of AIDS-related deaths.

The government program is funded entirely with public money. It has nothing to do with national security. And it appears to spotlight the Bush administration's "compassionate conservative" profile.

It would seem, in other words, to be just the kind of program officials would gladly share with journalists.

But it took about two dozen Freedom of Information Act requests; lawsuits against the State Department, Department of Health and Human Services and U.S. Agency for International Development (USAID); and a yearlong investigation by the International Consortium of Investigative Journalists (ICIJ) to get access to information about the President's Emergency Plan for AIDS Relief (PEPFAR), President Bush's five-year, $15 billion initiative to fight AIDS abroad. PEPFAR is managed through the newly created Office of the Global AIDS Coordinator (OGAC) at the State Department.

During the investigation, reporters encountered PEPFAR officials who couldn't answer basic questions about the program they oversee, recipients of PEPFAR money who were reluctant to criticize their donor out of fear of losing funding and Freedom of Information Act requests that were stalled for months.

In general, U.S. government officials in the field overseas were more knowledgeable and readily available to answer questions than Washington bureaucrats and press officers. Requests for interviews and information from OGAC's Washington office were often ignored; dozens of phone calls and emails were never returned.

About a dozen ICIJ reporters and researchers, working from Uganda, Kenya, South Africa, Ethiopia, Nigeria, Haiti, Thailand and India, investigated the impact of the U.S. government's HIV policies and programs. Additional reporting was done in Washington by ICIJ staff.