Twenty years into one of the worst health disasters in human history, the AIDS pandemic continues to grow exponentially, outstripping prevention efforts and treatment programs; every day it kills 8,000 people and infects 13,700 more. Although the United States provides fully half the foreign aid aimed at the pandemic, the total has been woefully inadequate to check its spread or stop the deaths -- until now.
Thanks to recent activism by conservative political and religious groups, AIDS has finally started to gain foreign policy attention commensurate with its substantive importance. Prodded by its conservative evangelical base, the Bush administration has pushed AIDS to the forefront of its international agenda, backing record increases in US assistance for AIDS treatment abroad and beginning to address issues such as sex trafficking and the dangers of HIV transmission from unsafe injections and blood transfusions.
The future of US global AIDS policy will be complicated, however, because the conservative groups interested in the issue have different tactical priorities than their liberal counterparts and the broader medical establishment. They have traditionally been hostile to some important AIDS prevention strategies such as comprehensive sex education and condom distribution, and they are much more enthusiastic than others about policies such as the promotion of abstinence.
Now that the United States is finally stepping up its efforts to tackle the crisis, it would be tragic if their impact were dissipated because of ideological differences between constituencies that are vital to the struggle against AIDS. The time has come, therefore, for all interested in AIDS policy to unite behind a comprehensive strategy to combat the pandemic, one based on the most effective practices in both prevention and treatment. The tens, possibly hundreds, of millions at risk deserve no less.
A Duty to Treat
Until recently, almost all foreign-funded global AIDS programs have been directed toward prevention. Whatever justifications there might be for a prevention-only approach to the pandemic, the strategy has proved neither morally nor medically sustainable.
Ignoring AIDS treatment is tantamount to condemning to death the more than 30 million Africans who have the disease -- most of whom are in the prime of their lives.
Moreover, an estimated 95 percent of Africans do not know their HIV status, partly because the stigma associated with AIDS discourages them from participating in counseling and testing programs. A better-informed population could move more effectively to control the spread of the disease, but absent the possibility of treatment, people have little incentive to learn whether they have the virus or not.
Jim Kim, a senior official at the World Health Organization (WHO) and one of the world's leading AIDS experts, has noted that making treatment available would actually help prevention. He testified before the US Senate that even in Uganda, where prevention efforts have been among the most successful in Africa, prevalence seems resistant to reduction below 8 percent when preventive approaches are used alone. Along with most other infectious disease experts, therefore, he advocates comprehensive programs that integrate prevention and treatment into a mutually supporting package.
Yet seven years after the development of the "cocktail" of drugs now widely used to treat AIDS in the West, fewer than 1 percent of sub-Saharan Africans and 5 percent of Asians who need it have access to it. The single most important impediment to universal treatment is the exorbitantly high cost of the medication. Pressure from AIDS activists has driven down the price of treatment from thousands to hundreds of dollars annually. Yet even at these prices generic drugs remain well out of reach for the poor in the developing world; extensive foreign aid for treatment programs is therefore essential.
In 2001, accordingly, United Nations (UN) Secretary-General Kofi Annan announced the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and asked wealthy donor nations for US$7 billion to US$10 billion a year. In June 2001, the UN General Assembly met in special session and endorsed a comprehensive approach to disease management, including integrated prevention, care, and treatment. US President George W. Bush pledged US$200 million to Annan's fund and boosted bilateral assistance efforts, but US funding for foreign AIDS programs still hovered at less than a fifth of what activists considered an appropriate share of the global burden. After that, support for treatment for people with AIDS in the world's poorest countries gradually increased in the US Congress and among nongovernmental organizations (NGOs). But the real turning point in US AIDS policy came when conservative Christians made the cause their own.
Enter the Evangelists
In February 2002, Franklin Graham, son of acclaimed evangelist Billy Graham and founder of Samaritan's Purse, an evangelical charity based in South Carolina, convened the first "international Christian conference on HIV/AIDS." More than 800 evangelical Protestant and Catholic leaders and overseas missionaries from AIDS-stricken countries gathered in Washington, DC, for the meeting, titled "Prescription for Hope," and demanded treatment for the sick and the dying. Graham's superstar status among evangelicals and the conference's state-of-the-art visuals, gospel choruses, and heartbreaking testimony from African ministers and health workers convinced American religious conservatives that it was their moral duty to do something about the pandemic.
The highlight of the conference came when 81-year-old US Sen. Jesse Helms stated, "I'm so ashamed that I have done so little" to help the victims of AIDS in Africa. Within days, Helms published an op-ed in The Washington Post promising to secure US$500 million to prevent mother-to-child transmission of HIV. By focusing on the "innocent victims" of AIDS, Helms publicized the fact that in Africa the disease was usually transmitted heterosexually, reaching audiences who had previously disregarded its spread among homosexuals or considered it a God-sent punishment.
Bush went on to make a dramatic commitment to tackling the pandemic in his 2003 State of the Union address. In a speech designed to prepare the world for war in Iraq, he announced an "Emergency Plan for AIDS Relief," and committed US$15 billion over five years to the cause. The plan promised to provide treatment for two million people and enough support to prevent seven million new HIV transmissions in Africa and the Caribbean. Although scale-up of this program has been slow, the conservatives' endorsement of the US president's intention to put millions of people on antiretroviral therapy has settled the controversy over treatment once and for all.
Conservatives have also provided welcome leadership in helping reduce the transmission of HIV/AIDS through unsafe needles and blood transfusions. According to the WHO, unsafe healthcare accounts for at least 500,000 new HIV transmissions every year and possibly many more. Yet reducing this number has not been a priority for the international health establishment, which considers such numbers trivial compared to the number of people infected through heterosexual intercourse. But a leading conservative, US Senator Jeff Sessions, has taken this issue to heart.
When a new study was published in early 2003 suggesting that transmissions from unsafe healthcare could represent far more than 7 to 10 percent of new cases, as the WHO estimates, The Washington Times covered the story, conservative groups picked it up, and Sessions held two hearings on the topic. Some AIDS activists feared that religious conservatives would use the issue to discredit and undermine prevention efforts and justify diverting funds from condom distribution and reproductive health programs. But Sessions' safe healthcare initiative proved them wrong. While calling for new studies to clarify the source of HIV transmission, Sessions neither refuted the role of sexual transmission in the pandemic nor criticized safe-sex programs. By the end of 2003 he had built bipartisan support for mainstreaming the issue of injection and blood safety into US-funded prevention strategies, reversing decades of neglect and offering considerable support for building proper health infrastructure in the poorest countries in Africa.
Conservatives in the US House of Representatives, meanwhile, have highlighted another neglected but significant source of HIV transmission: the violent sexual exploitation of trafficked women and children. The issue is hardly minor: the US State Department estimates that India alone has 2.3 million women and underage girls forced into its sex industry, and, in Africa, AIDS is fueling an epidemic of sexual predation against ever-younger girls as older men seek safe sexual partners. The pandemic is also generating millions of orphans and street children throughout the developing world who are especially vulnerable to rape and to being forced into the commercial sex industry.
Forcibly prostituted women and sexually exploited children are not "sex workers" but victims of crimes, including multiple rapes daily. They are particularly vulnerable to HIV transmission, but their needs are not addressed by conventional prevention programs, which are designed for voluntary sex workers and stress empowerment, healthcare, and access to condoms. Reducing harm for trafficking victims involves not encouraging safer sex but removing them from the sex industry and providing them with shelter, rehabilitation, counseling, and healthcare. The predators who sustain the forced-sex trade and child rape industry, meanwhile -- the traffickers, brothel owners, and complicit police and other authorities -- should be punished severely, with significant jail time. Yet this almost never occurs, and most trafficked women and children languish in sexual servitude with no hope of release. Many who provide health services to sex workers acquiesce in the forced exploitation of children and women in the brothels where they work because they are unwilling to jeopardize their access by reporting pimps and brothel owners. Several of the most prominent service providers in Thailand, for example, actively oppose rescue and rehabilitation, and some rehabilitation facilities in India refuse to accept child prostitutes who have been rescued.
Hoping to discourage trafficking, US Representative Chris Smith, a conservative Catholic and an anti-trafficking leader in the US House of Representatives, offered a provision to Bush's AIDS bill that prohibited funding to any organization that did not oppose trafficking and prostitution more generally. According to one of Smith's aides, the measure was aimed at service provider groups who were "a little too casual about Sway Pak" -- a notorious redlight district in the Cambodian capital of Phnom Penh that offers very young Vietnamese girls to Western customers. Smith and like-minded religious conservatives are appalled by trafficking and child prostitution and by the notion that prostitution can be a voluntary choice. Their view -- which is hardly limited to the extreme right -- is that prostitution is always a compelled choice, through either violence or destitution, and that glamorizing it as "work" trivializes the harm it does to the women in it.
It is certainly the case that many in the commercial sex industry, whether trafficked or not, wish to leave it and would do so if alternative employment were available. A 1998 survey of sex workers in South Africa, Thailand, Turkey, the United States, and Zambia, for example, indicated that a large majority of them suffered physical and sexual violence and post-traumatic stress disorder and that almost all wished to leave the business. Sexually exploited Ethiopian street children interviewed by Save the Children overwhelmingly disliked prostitution and wished to escape it. All sex workers are at very high risk of AIDS exposure, but children and trafficked women are especially vulnerable, as their ability to negotiate condom use with clients is virtually nonexistent.
Rather than pitting the interests of victims of forced prostitution against those of voluntary sex workers, two distinct strategies to fight HIV transmission should be developed. Rescue initiatives, shelters, and alternative job opportunities, as well as reform of the police and the judiciary, should be funded to help those who wish to leave brothels. Healthcare, protection from violence, and freedom to organize should be promoted for those who wish to stay in the trade. Documenting and exposing sexual exploitation is essential, but an ombudsman or specially trained anti-trafficking unit is better suited to the task than health workers attempting to disseminate condoms in brothels.
To date, the programs that have most successfully addressed the right of sex workers to healthcare have been empowerment projects that help sex workers organize around their own needs, such as the Sonagachi program in Calcutta. Sonagachi is credited with raising condom use in neighborhoods with organized brothels from less than 1 percent to more than 80 percent, reducing police violence toward prostitutes, and providing services for prostitutes' children. It is true that Sonagachi and similar programs are unabashedly "pro-prostitution" in that they aim to empower women within the sex trade rather than urge them to leave it, but Sonagachi's adult women sex workers are also reported to be vigilant in opposing the presence of children in their brothels. Despite what people on both sides of the controversy might think, there is no reason why this sort of effort cannot coexist and complement well-designed anti-trafficking campaigns.
The involvement of conservative groups in shaping AIDS policy has been most problematic in the area of general AIDS prevention strategies, where their distinct sexual mores have led them to dissent from what most others consider medical best practice. For example, since condoms, if used properly and consistently, are at least 90 percent effective in preventing HIV transmission, the US Agency for International Development (USAID) has quietly provided millions of them annually to AIDS-stricken countries. Now that religious conservatives have taken up the AIDS cause, however, such programs have come under attack. Thus the Family Research Council has insisted that the Bush administration's AIDS plan not become "an airlift for condoms," while conservative religious groups convened by US Senator Sam Brownback have taken aim at various prevention programs that the plan had considered funding.
By the time legislation implementing Bush's vision -- the US Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 -- was completed, conservatives in the US House of Representatives had succeeded in redirecting one third of its AIDS prevention funding toward programs urging abstinence before marriage. The conservatives are inspired by Uganda's "ABC" (Abstinence, Be Faithful, and Use Condoms) program, which has helped lower prevalence dramatically, and are particular fans of its A and B components, which, if faithfully adopted, might offer nearly total AIDS protection. As Chuck Colson and William Bennett of Empower America argued in a recent essay, "African nations that promoted condom use alone, and which have the highest condom user rates on the continent ... also suffer the highest HIV prevalence rates. Clearly, condoms must no longer be considered the first line of defense against HIV."
Unfortunately, however, scientific evaluation and medical surveillance paint a different picture. Studies of Ugandan AIDS prevalence that try to assess the relative contributions of abstinence, multiple-partner reduction, and condom use in lowering infection rates have found that abstinence actually made the smallest contribution, while condoms and partner reduction had the largest impact. David Serwadda, a Ugandan physician who chairs the Global HIV Prevention Working Group, has stated, "As a physician who has been involved in Uganda's response to AIDS for 20 years, I fear that one small part of what led to Uganda's success -- promoting sexual abstinence -- is being overemphasized in policy debates."
At home, meanwhile, the US government currently provides US$100 million per year for abstinence education, making the aid conditional on schools' commitment to neither endorse condoms nor provide instruction on their use. Kenneth L. Connor of the Family Research Council has suggested extending such policies to Africa, on the grounds that "responsible moral behavior is the first and best line of defense against AIDS, and is the only message we should send young people worldwide."
But here again, researchers who have compared abstinence-only and comprehensive sex education programs in the United States have found little evidence that the former had any effect on sexual behavior or contraceptive use among sexually active teenagers. And, sexually inactive teens who received comprehensive sex education were more likely both to delay sexual initiation and to use condoms once they did start having sex than their peers who received abstinence-only instruction.
Another problem with the abstinence approach is that it fails to single out certain marginalized groups who are especially at risk of HIV infection. Outside southern Africa, for example, AIDS prevalence is highest among sex workers, intravenous drug users, and homosexuals. Since these groups suffer discrimination and persecution within their own countries and are often denied access to government health and prevention programs, experts concerned with stopping the spread of the pandemic believe those groups should be singled out for special attention. Yet USAID is reportedly now under heavy pressure to scale back or eliminate outreach, peer counseling, and condom distribution to at-risk groups. The US National Institutes of Health (NIH) and the US Centers for Disease Control and Prevention (CDC), moreover, are reportedly screening out research proposals containing the words "homosexual," "prostitute," and "drug user" in their titles, and whistle blowers within the agencies have reported pressure to approve scientifically unsound HIV projects.
On Common Ground
The AIDS pandemic is almost incomprehensible in its enormity, and in most of the developing world it is still in its early stages. As the world's richest, most powerful, and most scientifically advanced nation, the United States can and should play a uniquely active role in combating this scourge.
The entry of religious conservatives into the struggle has helped galvanize US AIDS policy and has given the issue a welcome hearing in the US Congress and the White House. They have put treatment on the political map, and have focused attention on certain unjustly neglected issues such as sex trafficking and transmission through unsafe healthcare practices. The challenge now is for all those concerned about AIDS to fight the pandemic on all fronts, preventing transmission where it occurs and treating all those in need.
Whatever their views on other issues, conservatives, liberals, and the medical community should be able to reach at least a rough consensus on the most effective practices in both prevention and treatment. The AIDS pandemic will not wait while one successful prevention program is traded for another or scarce resources are squandered on unsound approaches. If a common front can be matched with some common sense, the results could be truly impressive.
Holly Burkhalter is Director of US Policy and of the Health Action AIDS campaign at Physicians for Human Rights.
Editor's Note: This article is reprinted with permission from Foreign Affairs, where it was first published in the January/February 2004 issue.