Millions mis-spent on HIV prevention in Africa, gays ignored

Source: British Medical Journal

Ideology not science drove the prevention side of PEPFAR, the US international HIV/AIDS programme, during the Bush administration, an insider with personal knowledge of the situation said last week. The charge is not new but the source and the details are. They came at a forum at the liberal think tank The Center for American Progress.

They are contained in a new report and recommendations, "How Ideology Trumped Science: Why PEPFAR has failed to meet its potential," written by Scott Evertz, which is to be published shortly. He was the domestic "AIDS Czar" appointed by President George Bush in 2001. He lasted only 15 months before being shifted to a position in the department of health dealing with AIDS internationally.

Speaking at the forum, Mr Evertz called PEPFAR (President's Emergency Program for AIDS Relief ) "a heroic programme of monumental consequences" in terms of testing, treatment, prevention of mother to child transmission, and care for orphans. "However, from the very early discussions about the PEPFAR programme it became patently clear to me that we weren't going to discuss certain harm reduction strategies in relation to either our domestic or international programming."

Bush "did indicate to me rather strongly that needle exchange and condom distribution were out of the realm of discussion...It was very clear to me that our prevention efforts were going to be somewhat challenging, because there was an ideology that existed from the beginning as we approached prevention," Evertz said.

A disdain for science "led to de-gaying of HIV/AIDS, de-IDUing [injection drug users] [of HIV/AIDS]...Vulnerable populations quickly became set off to the side as a result of ideologies that drove opinions about how we would do prevention in the administration."

Mr Evertz said that such an approach made no sense when estimates of the prevalence of HIV among men who have sex with men (MSM) are 30% in Ghana and 43% in coastal Kenya. Among the first $3bn (1.8bn; {euro}2bn) that PEPFAR spent on prevention, a mere $100 000 went to a single programme targeting that risk group.

He recounted how one potential candidate for the Presidential Advisory Council on HIV/AIDS, who had run an AIDS services group for decades and had the support of his Republican governor, "was summarily axed from consideration because he was supportive of needle exchange and condom distribution."

Many of the advisers to the administration on global AIDS issues were drawn from the abstinence movement within the religious right in the United States. Mr Evertz quoted one spokesman for an evangelist group as saying, "AIDS has created an evangelism opportunity for the body of Christ unlike any other in history."

Mr Evertz said the conservative US group the Children's AIDS Fund applied for a $10m grant to promote abstinence education in Uganda. A technical review committee said it was not appropriate, but Andrew Natsios, then the administrator for the US Agency for International Development (USAID), over-rode that advice and awarded the grant. Protests from Democrats in Congress did not succeed in reversing the award.

"By funding programmes such as this and usurping a strategy by which grants are approved by technical experts paid by the American taxpayers, we were sending a message to some of our partners on the ground ...we want a programme that is centered on abstinence," Mr Evertz said.

The administration used PEPFAR as an opportunity "to excite the (political) base" of support for it among religious conservatives. They were comfortable working with "the innocent victims of AIDS, namely women and children living in Africa," he said.

Mr Evertz said the draconian anti-gay legislation being considered by the Ugandan parliament is "absolutely, positively inexcusable. We need to use PEPFAR funds to discourage such behavior and to encourage work" with gay groups. However, when pressed later, he said funds should not be withdrawn from treatment programmes; once antiretroviral treatment is begun, it must be sustained.

"When homophobic groups are funded...they help to legitimate the stigmatisation, the discrimination," said Ronald Johnson from the lobbying group AIDS Action Council. "That is the environment we need to change by not funding those programmes and making clear that the human rights approach" is the best way to address the AIDS pandemic.

Kent Klindera works for the US charity amfAR to try to strengthen the capacity of groups doing prevention work in Africa among gay men. He said that some people worry that if PEPFAR money is withdrawn from a country, then gays will be blamed for that and made a scapegoat. Others compared the situation to apartheid and called on the US and Europe to apply the equivalent of sanctions, which helped to bring down apartheid.

Mr Klindera called the PEPFAR five year strategic plan, released on 30 November, "wonderful rhetoric." He was encouraged by the programme's "rights based approach." But "one problem is that MSM is not clearly defined."

Mr Klindera cited a programme in Kenya where the focus is preventing the infection of "innocent" women whose husbands are having sex with other men. He said, "The growing openly gay community is not being served at all."

Mr Johnson also found the five year plan "a breath of fresh air," but at the same time, "I kept looking for that next sentence that wasn't there," when it came to implementation.

Paul Zeitz, from the Global AIDS Alliance, criticised the Obama administration for being slow to respond to the Ugandan situation. "I find it very disturbing," he said. He and others urged the administration to conduct "a top to bottom review" of all ties with Uganda-grants for PEPFAR, HIV research, military and trade relations-if the legislation to outlaw homosexuality is passed.

Mr Evertz's report initially was supposed to be released at the 15 December forum but it is being held for last minute revisions to reflect release of the PEPFAR five year strategic plan and congressional action this past weekend that lifted the ban on funding syringe exchange programmes and the requirement for abstinence programmes.

• Read the complete report here (PDF)