How Bush's AIDS Program is Failing Africans

NAIROBI, Kenya -- On July 5, Beatrice Were, the founder of Uganda's National Community of Women Living with HIV and AIDS, stood before hundreds of other HIV-positive women in Nairobi's vaulted city hall and denounced the Bush administration's AIDS policies.

Like many in attendance, Were contracted HIV from her husband, a common occurrence in a region where women make up the majority of new infections and marriage is a primary risk factor. For those like her, the White House's AIDS prevention mantra -- which prescribes abstinence and marital fidelity, with condoms only for "high risk" groups like prostitutes and truck drivers -- is a sick joke.

"We are now seeing a shift in recent years to abstinence only," she said. "We are expected to abstain when we are young girls and to be faithful when we are married to men who rape us, who are not necessarily faithful to us, who batter us." The women in the audience, several waiting to share their own stories of marital rape, applauded.

Were exhorted her audience to "denounce programs that are not evidence-based, that view AIDS as a moral issue, that undermine the issues that affect us, women's rights. I want to be very clear -- the abstinence-only business, women must say no!" Again, there were hollers and applause.

There were lots of voices like Were's in Nairobi last week, where the YWCA sponsored a massive international conference on women and HIV. Yet they rarely seem to break through in the United States, where the conventional wisdom holds that the President's Emergency Plan for AIDS Relief (PEPFAR) is a bright spot in an otherwise execrable presidency, one that only the ideologically blinkered refuse to credit. Nick Kristof seems to repeat this notion in The New York Times every other week, and Bono affirmed it when he insisted on putting Bush on one of the 20 different covers that graced Vanity Fair's special Africa issue. "USA TODAY's Susan Page just got off the telephone with Bono. She says President Bush can count the rock star as a fan today," the newspaper's blog reported in late May. "The Grammy winner was singing the praises of the American president for his announcement today that he would propose spending an additional $30 billion over five years to fight AIDS in Africa, doubling the U.S. commitment."

For many toiling in the trenches of the pandemic, though, opinions about PEPFAR are far more ambivalent. It's a moral conundrum: how do you weigh lives saved by treatment against lives lost through policies that sabotage prevention?

It's important to be clear: PEPFAR has done some good. Thanks in part to the program, upwards of 800,000 people are now getting anti-retrovirals that can turned AIDS from a death sentence into a chronic condition. There are remarkable stories of those once wasted and desiccated now restored to life. It may very well be true to say that PEPFAR is the best thing that George W. Bush has ever done. But that's not saying very much at all.

In late May, the White House made the announcement that so pleased Bono, promising to double spending on AIDS from $15 to $30 billion. Like most of the administration's financial figures, the numbers were misleading. The $30 billion was to continue funding PEPFAR for five more years essentially at current levels.

As Health GAP, a U.S.-based NGO, pointed out, "Given that the White House requested $5.4 billion on global AIDS this year (expected to be increased to fulfill U.S. obligations to the Global Fund to fight AIDS, Tuberculosis and Malaria), the $6 billion annual request effectively represents flat funding into the next decade." What the administration is trying to spin as a staggering new burst of generosity is basically the maintenance of the status quo.

Nevertheless, $6 billion a year is a significant amount of money. It remains to be seen, though, how much of it will be spent in ways that worsen the epidemic instead of making it better. Under the current policy, one third of the money allocated to HIV prevention goes to abstinence-only campaigns, often run by evangelical allies of the administration.

But this figure is also deceptive, because the prevention budget includes things like fighting mother-to-child transmission. In fact, a full two-thirds of the money for the prevention of the sexual spread of HIV goes to abstinence. What's left is targeted to groups considered high-risk. HIV-activists have spent the last two decades trying to show that condoms aren't just for prostitutes and the promiscuous; Bush has undone much of their work.

Officially, the abstinence-only money was a Congressional earmark, but it was the White House's doing. "I found the argument about the earmark not coming from the administration to be disingenuous," says Scott Evertz, Bush's first AIDS czar. "The White House had a legislative office that was on the Hill pushing this! Sure, you can say it's [Sam] Brownback and [Dave] Weldon and the likely suspects, but they were up there on the Hill arguing for it." (Last month, senators Diane Feinstein (D-CA) and Olympia Snowe (R-ME) introduced the HIV Prevention Act of 2007, which would repeal the abstinence-only earmark. It remains to be seen whether it will pass, and if it does, whether Bush will veto it.)

Evertz was a Log Cabin Republican who trusted in the administration's good faith, and thus was quite shocked to see how HIV prevention funding turned into a patronage system for the religious right. "The ideologues in and around the administration are not scientists, and they're not even people in many cases who are concerned about data when it comes to proving the abstinence works," he says.

In her brilliant new book, The Invisible Cure: Africa, The West, And The Fight Against AIDS, Helen Epstein shows what some of the ideologues' policies have meant on the ground. Much of her reporting is from Uganda, a country whose history with the disease is hotly contested. In the 1990s, following a concerted campaign by both grassroots organizations and president Yoweri Museveni, Uganda became the first African country to see a significant drop in its infection rate. This wasn't the result of an abstinence campaign, but abstinence crusaders in the west claimed the country's success as their own, and it became a principal justification for Bush's PEPFAR policies.

Indeed, religious conservatives worldwide now tout Uganda's example. Last year in Nicaragua, I asked Monsignor Miguel Mantica, spokesman for the Archdiocese of Managua, why he thought abstinence education is appropriate in a country like his, where men rarely stick to one partner at a time. He replied that Uganda has proven that it works.

Epstein, who has a background in biology and public health, argues that people in East Africa, where the spread of AIDS has been especially catastrophic, don't have more partners over a lifetime than people in other regions, but they are more likely to have simultaneous long-term relationships. Citing the work of the sociologist and statistician Martina Morris, she writes that concurrent liaisons "are far more dangerous than serial monogamy, because they link people up in a giant web of sexual relationships that creates ideal conditions for the rapid spread of HIV."

Uganda's initial response to AIDS addressed this, and urged partner reduction, or "zero grazing," which was not the same as abstinence. Condoms played a role as well. "HIV infection rates fell most rapidly during the early 1990s, mainly because people had fewer casual sexual partners," Epstein writes. "However, since 1995, the proportion of men with multiple partners had increased, but condom use increased at the same time, and this must be why the HIV infection rate remained low."

Yet in a grotesque irony, PEPFAR funding has refashioned Uganda's anti-HIV campaign to fit the distorted notions of American conservatives (and their allies among Uganda's evangelical revivalists, who include First Lady Janet Museveni). "The policy is making people fearful to talk comprehensively about HIV, because they think if they do, they will miss funding," says Canon Gideon, an HIV-positive Anglican minister from Uganda who has been a leader in the clerical response to the epidemic. "Although they know the right things to say, they don't say them, because they fear that if you talk about condoms and other safe practices, you might not get access to this money."

Today, Uganda's infection rate is once again rising.

A few weeks before I came to Kenya, I spoke with Stephen Lewis, who until last year was the United Nations Secretary General's Special Envoy for HIV/AIDS in Africa. I asked how he understood the balance between the harmful and the helpful aspects of Bush's AIDS initiative. "It really is difficult to quantify," he said. "The only thing one can categorically say is that the overemphasis on abstinence probably resulted in an unnecessary number of additional infections." That this policy is celebrated as Bush's greatest moral achievement shouldn't be understood as praise.