IN THE same State of the Union address in which George Bush prepared the world for war in Iraq in 2003, he announced a foreign policy initiative of an altogether different kind 鈥� 鈥渁 work of mercy beyond all current international efforts to help the people of Africa鈥�. This was the President鈥檚 Emergency Plan for AIDS Relief (PEPFAR), a $15 billion commitment that dwarfed all previous efforts to combat the disease.
Along with the Iraq venture, PEPFAR represented the high-water mark of Bush self-confidence. Over five years, a can-do America would give anti-retroviral drugs to 2 million people in poverty, prevent 7 million new HIV infections and provide care for 10 million people affected by the disease, including millions of AIDS orphans. With PEPFAR nearly halfway through, and the AIDS epidemic 25 years old, it is worth asking what kind of an impact Bush鈥檚 programme has had so far.
On the treatment front, the results are remarkable. Some 500,000 HIV-positive people in Africa are now on US-supported drug programmes and living decent lives when they would otherwise be dead. Without this there would be no chance of the world coming even close to meeting the promise made by Tony Blair at last year鈥檚 G8 summit of treatment for all by 2010. Similarly encouraging is progress on providing care, with some 3 million people receiving help. So thank you, America.
Advertisement
There is a problem, however, with PEPFAR鈥檚 work on prevention, and it is a big one. The plan has so far prevented just 47,000 HIV infections out of the target of 7 million 鈥� the result of excellent programmes to stop mother-to-child transmission of HIV. PEPFAR says it is impossible to produce concrete figures for averted infections since they are, by definition, non-events, and that final assessments based on models will be available in 2010. But that is only part of the story.
What is wrong with the prevention strategy? The flaw is the US government鈥檚 commitment to a policy of sexual abstinence and marital fidelity. A report by the US Government Accountability Office says that for every dollar PEPFAR spends on condoms to prevent infection, it is spending two dollars on promoting abstinence and fidelity. Much of the money goes to church groups, or to major advertising campaigns. For example, visitors to Uganda are greeted on the airport road with a huge hoarding, paid for by the US, showing a wholesome young woman and the words, 鈥淪he鈥檚 keeping herself for marriage. What about you?鈥� This is America鈥檚 official ABC policy in action: Abstinence, Be Faithful and Condoms, in that order of priority.
George Bush maintains that 鈥渁bstinence works every time鈥�. He can hardly be contradicted on that, but the important question is this: is campaigning for abstinence and fidelity, to the significant exclusion of condom promotion, the right way to tackle HIV in Africa? The US position is based almost entirely on the Ugandan experience, where HIV prevalence was brought down dramatically in the 1990s. President Yoweri Museveni, then a charismatic ex-guerrilla leader, did better than any other African leader in warning his people about AIDS and urging them to adopt a 鈥渮ero-grazing鈥� approach to their sex lives.
鈥淯S-funded evangelical groups in Uganda are marginalising the use of condoms鈥�
But speak to Uganda鈥檚 senior public health officials and they will tell you that their success had just as much to do with condoms as with 鈥渮ero-grazing鈥�, and that the current situation, where US-funded evangelical groups are marginalising and often condemning the use of condoms, is ruining Uganda鈥檚 chances of sustaining its success. This is not helped by the Bush administration giving priority funding to American and African evangelical groups, which are allowed to conduct AIDS prevention programmes that do not even mention condoms.
The US鈥檚 moralising attitude does not stop at ABC. Agencies taking US money to work on AIDS have to sign an undertaking 鈥渆xplicitly opposing prostitution and sex trafficking鈥�. In other words, they must formally condemn a trade in which many of their most vulnerable clients are forced to work. There鈥檚 no denying the evil of sex trafficking, but prostitution is a dismaying feature of poverty throughout the developing world, and unless Bush is prepared to eradicate poverty first, this policy is counterproductive.
Another counterproductive policy is the Congressional ban on funding needle-exchange programmes for intravenous drug users, which remains in force at a time when some of the world鈥檚 worst AIDS epidemics are being driven by drug use. There is overwhelming evidence that 鈥渉arm-reduction鈥� programmes are effective and do not encourage greater drug use, but for almost 20 years the American 鈥淛ust Say No鈥� camp has continued to hold the line.
In extending their fundamentalist fervour into the area of sexual morality and public health, this lobby has ensured that three years on from that stirring State of the Union speech, George Bush has compromised his often admirable efforts to 鈥渢urn the tide鈥� against AIDS.
