Even rabid Bush-haters will grudgingly grant the president one major foreign policy accomplishment: He has spent money combating global AIDS like no other world leader. Indeed, there was another round of plaudits last month when the Senate finally passed the $48 billion reauthorization for the President's Emergency Plan for AIDS Relief, or PEPFAR. The bill renewed legislation, first passed in 2003, that has allocated many billions for HIV treatment, testing, and prevention efforts in Africa, Asia, and the Caribbean. Senator Joseph Biden has called PEPFAR "the single most significant thing the president has done."
And there's no doubt about the good PEPFAR has accomplished: About 1.7 million people infected with HIV currently receive antiretroviral medication thanks to the program. But, for all the lives PEPFAR has saved, it has done little to halt the spread of HIV among a critical demographic group: men who have sex with men, or MSM in public-health parlance (a clunky but necessary term, since many of these men also have female partners and do not self- identify as gay). The reason for this omission will surprise no one: Social conservatives left their stamp on the legislation at the expense of public health. So, even in its finest moment, the Bush administration allowed ideology to trump good policy.
Information about MSM in developing countries and their HIV rates is difficult to obtain. But epidemiologists at Johns Hopkins recently calculated that MSM in low- and middle- income countries were 19 times more likely to have HIV than the overall adult population. In one study in Senegal, 22 percent of MSM were found to be HIV-positive, compared to just 1 percent of all adults. The Johns Hopkins epidemiologists pooled each country's data and estimated HIV prevalence among MSM to be 12 percent in Peru, 15 percent in India, and 25 percent in Thailand--in all cases, many times higher than in the total population. In some countries, infection rates appear to be rising more quickly among MSM than among other groups. Yet, globally, less than 10 percent of them have access to adequate HIV services and information, according to the Joint United Nations Programme on HIV/AIDS.
Beyond the numbers, epidemiologists are especially alarmed because social and legal mores have made it hard to reach out to the MSM population in Third World countries. For one thing, many of these men don't perceive themselves to be at risk of HIV infection, and so they are less likely to look for help under any circumstances. But, even worse, in much of the developing world, public discussion of sexual orientation--and, most critically, the risk of HIV infection through same-sex contact--is almost impossible due to anti-gay attitudes. Earlier this year in Egypt, for example, nine men, most of them HIV- positive, were convicted of "habitual practices of debauchery" and sentenced to prison. It's hard to imagine that these cases, which were widely publicized by Human Rights Watch and other groups, will encourage gay men in Egypt to seek counseling and treatment. So, even with abundant funding, it would not be easy to craft sensitive and appropriate policies in countries where homosexuality is illegal or taboo.
But PEPFAR has further complicated efforts to reach these groups. Since its inception, PEPFAR has required that a large percentage of its prevention funds be spent promoting abstinence until marriage--a strategy that, by definition, pretty much excludes recognition of same-sex relationships. Pepfar has also mandated that organizations receiving funds denounce prostitution, a stance that makes HIV outreach to male sex workers more difficult. And the PEPFAR legislation included a so-called "conscience clause" that, according to a report published earlier this year by the conservative Heritage Foundation, "ensures that faith-based groups are not required to provide services they don't support"--including for men who have sex with men.
AIDS activists point to an Ugandan evangelical leader, Martin Ssempa, as Exhibit A in their case that PEPFAR 's approach can harm the fight against the disease. Ssempa, the pastor of Makerere Community Church in Kampala, Uganda's capital, and a vigorous supporter of the abstinence approach to HIV prevention, has denounced condom use and condemned homosexuality, yet his church has received PEPFAR funding to promote its faith-based message. Last year, after gay rights activists staged a protest in Kampala, news reports quoted Ssempa as saying that "homosexuals should absolutely not be included in Uganda's HIV/AIDS framework. It is a crime, and when you are trying to stamp out a crime, you don't include it in your programs."
Public health experts have long complained about PEPFAR 's restrictions, and recent reports evaluating the program have echoed those criticisms. Last year, a report by the Institute of Medicine urged PEPFAR to "increas[e] attention to marginalized populations," citing men who have sex with men as a key example. In 2006, the Government Accountability Office found that the abstinence requirements presented a "challenge" to those implementing the program and that "country teams have, in some cases, reduced or cut funding for certain prevention programs, such as programs to deliver comprehensive ... messages to populations at risk of contracting HIV."
The original PEPFAR legislation did not prohibit support for MSM outreach, and some efforts have been funded. But Ellen Marshall, a public policy consultant with the International Women's Health Coalition, says that countries receiving PEPFAR money generally feel they must conform to priorities and directives established in the United States. "Countries where PEPFAR funds are invested are very aware of what U.S. policy is, and they don't want to have policies that are more expansive for fear of potentially losing U.S. dollars," says Marshall.
Some major donor organizations, including the Gates Foundation and amfAR, the Foundation for AIDS Research, have recently started to focus attention on the issue, which was also discussed and debated at the Seventeenth International AIDS Conference held this week in Mexico City. Even the recently approved version of PEPFAR, a compromise between social conservatives and the Democrats who now control Congress, could help. Although the new legislation retains some of the ideological constraints found in PEPFAR's initial iteration, it cites the importance of addressing the epidemic among men who have sex with men. That's certainly an improvement, but it's still not a substitute for adequate education and counseling and outreach--the commonsense solutions that ideology shouldn't be blocking.
David Tuller is a freelance journalist in San Francisco and a lecturer in journalism at the University of California, Berkley.