Politics & Policy

This Is Compassion

“Compassionate conservatism” has been justly maligned, but it may yet leave one lasting and worthy legacy.

That would be the President’s Emergency Plan for AIDS Relief (PEPFAR), begun in 2003, which George W. Bush asked Congress last week to extend for another five years. Funding for AIDS prevention and treatment has seen a spectacular rise under PEPFAR. While spending on global AIDS relief hovered just short of $1 billion annually during Bill Clinton’s last years in office, the Bush administration has tripled that amount, spending an average of $3 billion per year since PEPFAR began. Under the proposal announced last Wednesday, that figure would double to $6 billion per year from 2008 to 2012. This is, as the president noted Wednesday, “unprecedented — the largest commitment by any nation to combat a single disease in human history.”

Very rarely does a government program produce such momentous results: 1.1 million people afflicted with HIV have received treatment, and many of them have been saved from a horrible death not widely seen in America since the early ’90s. And, more important for the long run, prevention programs are working. Africa’s rate of HIV infection peaked around 2000, and is now decreasing more quickly than ever before.

PEPFAR signaled, and its second iteration amplifies, the United States’ emergence under the Bush administration as the global leader in the fight against the spread of HIV/AIDS.

At least, it should. The president had not even formally announced the program in the Rose Garden when press releases began to circulate, complaining that it wasn’t enough. No appropriation — even the largest of its kind in history — is ever enough for advocacy groups.

The same groups have made a whipping boy of PEPFAR’s set-aside for abstinence-promotion programs, which equals a mere seven percent of total funding. This, they say, is evidence that the American Right’s dogmatism is seeping into a program where efficacy should be the only consideration.

But PEPFAR’s model is Uganda’s hugely successful “Abstinence, Be Faithful, Always Use a Condom” (ABC) policy. It was an early, prescient, home-grown creation — one that sought to facilitate the role of traditional leaders and faith-based organizations in encouraging restraint in sexual behavior. The public-health community smugly considered the approach naïve, and Africans’ sexual mores were stereotyped as promiscuous and incorrigible. But Uganda proved its critics wrong: From 1991 to 2001, in the wake of the ABC campaign, HIV prevalence in Uganda fell by 66 percent. Only after Western consultants rewrote the country’s AIDS policy, deemphasizing the “A” and “B,” did Uganda see another increase in the infection rate.

Kenya, Ethiopia, Malawi, and Zimbabwe also all recorded changes in sexual behavior in the wake of ABC-style campaigns. And all of these countries have shown a decline in HIV prevalence.

Some AIDS experts, particularly scientists, have come to heed these data. But the public-health lobby remains unthinkingly devoted to dated assumptions forged in the fight against AIDS in the developed world. There, homosexual men and intravenous drug users are disproportionately afflicted by AIDS, and together compose a majority of its sufferers. In such a context, distributing condoms and clean needles to particularly high-risk groups makes sense.

But the African AIDS problem is fundamentally different. There, the disease is a generalized epidemic, and is spread much more evenly throughout society than in the West. This difference has implications for how HIV can be prevented. The ABC approach favored by the Bush administration is incorporative — it reinforces existing norms of abstinence for young Africans and monogamy for their elders, and presents condoms as a less surefire preventative technique for those who are already sexually active. This is a far cry from the mischaracterization of the policy as an “ineffective ‘abstinence only until marriage’ education,” as one indignant press release last Wednesday called it.

Really, it is the public-health lobby that has nurtured a dogma — condom promotion to the exclusion of other techniques — and has thus been blinkered to local conditions. As Edward C. Green of Harvard’s School of Public Health points out, “More condoms have not translated into lower infection rates. People who use condoms take more risks, and they use them inconsistently. Even if they are used consistently, the risk is only reduced by 80 to 85 percent.” The time has come for the public-health lobby to disabuse itself of the notion that condoms are the end-all, be-all of AIDS prevention.

With Democrats in control of Congress, it is unlikely that PEPFAR’s reauthorization will include funds reserved for abstinence promotion. That would be a blow to this outstanding program.


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