In a clear disavowal of Bush-era rules that prevented cooperation between government-funded HIV/AIDS programs and broader sexual health and gender work in developing countries, the Obama administration has signaled to agencies abroad that the walls are coming down and that experts on the spot will have new freedom of action.
Under Bush, people in the field working to implement the United States President’s Emergency Plan for AIDS Relief, known as Pepfar, were subject to micromanagement under ideologically inspired guidance that, among other requirements, demanded that 50 percent of AIDS prevention funds in countries with generalized epidemics be devoted to abstinence and “faithfulness” campaigns. That provision, born of provincial ignorance about the world, would be a joke if it weren’t so cruel to millions.
The old guidelines also barred links between AIDS efforts and family planning, at a time when AIDS was becoming a woman’s disease in many places and women had no power to resist unwanted or risky sex.
In new guidelines for 2010, the Obama Pepfar team opened the way to linking AIDS work with strengthening of health systems generally, taking into account the development of human resources, maternal and child health, family planning and access to it for women, gender equality, malaria and tuberculosis, food and nutrition, education and local economies. While Pepfar money may not be involved directly, the program’s door will be open for cooperation. It is, in short, a holistic and realistic policy. It will matter because the United States is the world’s largest contributor to HIV/AIDS relief, and Bush restrictions have had a deadening effect on many international programs.
“This is a big one,” said Wendy Turnbull, senior policy research analyst at Population Action International in Washington, which acquired a copy of the internal government Country Operational Plan Guidance for 2010 (dated June 29) in July, digested it and sent a heads-up summary to health workers in government and nongovernment agencies abroad. “We all think this is significant.”
The relaxed guidelines, from the office of the recently installed global AIDS coordinator, Eric Goosby, former CEO of Pangaea Global AIDS Foundation and professor of clinical medicine at the University of California, San Francisco, follow a series of steps taken by Obama to increase American support for global family planning and the health of women and children.
The trend began early in the year with the reversal of the global gag rule that banned US aid to any organization dealing in any way with the issue of abortion. Then came the resumption of US contributions to the United Nations Population Fund (UNFPA). Bush had stiffed the agency since 2002, citing ideologically motivated, untrue accusations that the UNFPA abetted abortion in China.
The United Nations, the perennial target of the know-nothing extreme right, has been dogged by hysterical antiabortionists, Catholic and evangelical Protestant, since the 1994 UN conference on population and development in Cairo, which asserted that women had reproductive rights and choices. Perhaps this accounts for the unannounced way the new Pepfar guidance slipped into view when all hands were needed to concentrate on domestic healthcare reform.
Despite the repeated pleas of the UNFPA and other relevant UN bodies, there has been a precipitous international decrease in family planning funds since Cairo. In part, this has been a result of higher priorities and more public campaigning for increased AIDS funding. “There was a schism between the HIV/AIDS community and the sexual-reproductive health community, which is unfortunate because the issues are inseparable,” Turnbull said of the atmosphere in 2008 when the current Pepfar legislation was extended.
Coupled with the Bush administration’s near-total ban on condoms in foreign aid programs and residual criticisms among European liberals of family planning as a Western intrusion into Third World cultures (ask the women in the poorest countries about that theory), grassroots women’s health work has been left desperately short of money and supplies. An estimated tens of millions of women who want contraceptives are unable to get them, or may have no choice beyond crude sterilization or unsafe abortion.
If there are shrieks from the right when the new sexually relaxed direction of Pepfar gets noticed, there will also be those in the feminist reproductive health and rights field who will think that the guidelines do not go far enough. The administration is hobbled, however, by provisions in the legislation creating Pepfar in 2003, revised and renewed for five years in 2008. But there is room for interpretation and discretion, Turnbull said, citing as an example the change from strict annual accounting for full use of abstinence money to a less inflexible requirement to explain why funding may have been below target.
Prevention will get a new look from Goosby, according to sexual health advocates. “Talk about drug use, talk about men who have sex with men, everything,” Turnbull said. Pepfar’s attitude on the issue of prostitution is still unclear, though. The Bush administration had prohibited aiding programs for sex workers, yet these women and men are pivotal in stopping the spread of HIV in many developing societies.
“This is just a start,” Turnbull said of the 2010 guidance. “There is a lot of damage to undo. There is a lot of reinterpretation that needs to happen.” But the message to workers in the field is clear, she said. “Just go for it.”