Funding Failures Force South Africans to Decide Between Abstinence and AIDS
By Rita Kreig

Executive Summary

The President’s Emergency Plan for AIDS Relief (PEPFAR) is a $30 billion U.S. development initiative, which was created in 2003 to decrease the scale of the HIV/AIDS pandemic in the fifteen worst-affected countries worldwide. The program provides grants and contracts for the implementation of multilateral HIV/AIDS prevention, treatment, and education programs. While the PEPFAR programs have had great success in implementing short-term treatment solutions, the structure of the PEPFAR program is currently preventing it from realizing its long-term goals. Because PEPFAR funding allocations are decided by U.S. committees without the help of experts from regional and non-medical fields, the allocation of funds to PEPFAR partners reflects a conservative political bias. This bias is reflected in the use of one, uniform funding allocation plan for all fifteen target countries, which prevents PEPFAR from addressing the structural circumstances in target countries. This is particularly problematic in South Africa, where legacies of apartheid make the population especially vulnerable to HIV, and where PEPFAR education programs are having a negligible effect, due to funding and policy restrictions from Washington. I argue that increased transparency, information sharing, and cross-cutting multilateral programming, in combination with major funding reforms, will allow the PEPFAR programs to improve the development of the target countries.

In 2003, President Bush initiated the President’s Emergency Plan for AIDS Relief (PEPFAR), a program aimed at alleviating the diverse effects of HIV and AIDS in the fifteen most hard-hit countries around the globe. PEPFAR works with governments, non-governmental organizations (NGOs), and faith based organizations (FBOs), providing them with funds and technical assistance in order to implement projects for the prevention and treatment of HIV and AIDS. Of the fifteen target countries, South Africa is an especially interesting case, due to the individual political, economic, and social conditions that differentiate it from its Sub-Saharan neighbors. In this paper I will argue that PEPFAR’s programs will realize only short-term successes due to PEPFAR’s implementation of one-size-fits-all funding allocation plans, and its use of morality clauses that further its own political agenda, while subverting the structural needs of South Africa. I will begin by outlining the affects that HIV has on international development, and how PEPFAR has attempted to alleviate these consequences in South Africa. I will then discuss PEPFAR’s shortcomings, and offer some possible methods of overcoming its limitations.

More than just an issue of public health, the current HIV/AIDS crisis threatens the political, social, and economic viability of all states; especially developing ones. While HIV is a universal pandemic, approximately 95% of HIV sufferers live in the developing world, in places where structural conditions prevent adequate management of the health factors of the disease, and where the non-health impacts of HIV threaten to topple the already vulnerable economies (USAID). AIDS-related illness is the leading cause of death in Sub-Saharan Africa, and the fourth leading cause of death internationally (USAID). As the crisis worsens, the infrastructure needed to implement solutions progressively crumbles, making it increasingly difficult to execute new treatment programs. Without these new treatment programs, it becomes more and more difficult to maintain a healthy workforce, causing the infrastructure to continue to fail. This cycle will worsen until programs aimed at fighting HIV are nearly impossible to carry out on the necessary scale. Due to the fact that HIV is a relatively new virus, having been discovered within the last thirty years, and that the 1990s predictions of its magnitude so grossly underestimated the possibilities of its impact, any program aimed at alleviating the current crisis must put aside all other priorities and focus only on the best and most efficient methods of achieving long-term success.

PEPFAR is “the largest commitment ever by any nation for an international health initiative dedicated to a single disease” (PEPFAR). Headed by the U.S. Department of State, the program works with the U.S. Agency for International Development (USAID), the U.S. Agency for International Development, the Peace Corps, and the U.S. Departments of Defense, Commerce, Labor, and Health and Human Services in order to implement multisectoral solutions. PEPFAR began in 2003, when $15 billion was proposed for a five year program aimed at decreasing the severity of the HIV/AIDS pandemic in the fifteen most severely affected countries in the world. On May 30, 2007, President George W. Bush asked Congress to reauthorize PEPFAR and to increase the funding to $30 billion. PEPFAR focuses on providing educational programs that emphasize HIV prevention, expanding the availability of antiretroviral therapy (ART), providing counseling to HIV-affected people, preventing mother-to-child transmission during pregnancy, aiding children affected by HIV/AIDS, and providing treatment/care facilities for HIV/AIDS patients. As of September 30, 2006, President Bush stated that PEPFAR was on track for meeting its goals, and that it had already helped to provide treatment for 1.1 million patients in the fifteen target countries (PEPFAR).

PEPFAR chooses target countries based on many criteria, including the severity, magnitude, and impact of the disease, the availability of alternative funding and support, U.S. political and economic interests, and the strength of pre-existing relationships with the United States (Nelson, p. 26). The fifteen target countries contain over half of the world’s HIV infections, and all have an HIV prevalence rate of greater than five percent (USAID). PEPFAR works with all levels of governments, non-governmental organizations (NGOs), faith based organizations (FBOs), grassroots organizations, academic institutions, the medical research community, the private sector, and other U.S. programs in order to implement its multilateral programs. Of all programs involved in carrying out PEPFAR’s objectives, 80% are indigenous to the target countries (USAID).

One such target country is South Africa. As of 2007, more than 5.5 million South Africans were HIV positive; more than in any other country around the globe (USAID). According to USAID, approximately 1,700 South Africans become infected with HIV every day, and AIDS-related illnesses are the country’s leading cause of death. One study of South Africa predicts that, at the current rates, the HIV crisis will “lead to complete economic collapse within three generations” (Bell). Although South Africa is considered by the United Nations to be a “middle income” country, with modern infrastructure and the most developed economy in Africa, legacies of its colonial past persist and create added challenges for any program attempting to implement change of any sort.

From the 17th to the early 20th century, English and Dutch colonizers controlled South Africa. After independence, the National Party maintained the exploitative practices of the colonial powers and officially structured the country along racial dividing lines. In 1948, the practice of apartheid or “separateness” was officially put into law, dividing the population of South Africa into the categories of “White,” “Black,” and “Colored.” Black and White citizens were forced to work different types of jobs, follow separate laws, utilize separate health services, and live in different parts of the country. Discrimination was rampant, and there were huge discrepancies between Black and White services and institutions. Although they represented the large majority of the population of South Africa, Black citizens were forced to live in “homelands,” or tiny allotments of land within South Africa, which lacked resources, jobs, and space. It wasn’t until the United Nations proposed trade embargoes, cutting off international support for the South African government, that the National Party’s control began to weaken. Apartheid began to fail in 1990, and the first election with universal suffrage took place in 1994, when the African National Congress (ANC) came into power (Crais, pp.721-740).

South Africa still has one of the most unequal income distributions in the world, with most of the wealth and power still held by the country’s minority of White citizens, and large social and institutional inequalities persist. The public health system during apartheid treated different populations separately and unequally, thus excluding a majority of the population from primary healthcare. . Although there have been improvements since 1994, the infant mortality rate in the country is still ten to twenty times higher for Black infants than for White infants (UNAIDS). The “modern infrastructure” in South Africa is extremely localized, and many of the areas that were previously “homelands” lack basic necessities such as trained educators and medical professionals. The poverty that these inequalities reinforce puts many South Africans in an especially vulnerable situation when it comes to HIV, because they are unable to locate and afford even the least effective forms of public healthcare. The loss of work due to illness makes this situation even direr. Because of these conditions, any program aimed at implementing multilateral development programs in South Africa must take into account the structural inequalities that persist, as well as the discrimination that prevents much of the population from receiving even the most basic education and care. Although PEPFAR does work with many local organizations in South Africa, a lot of the basic requirements for PEPFAR programs are outlined in Washington D.C., and have no basis in the specific needs of the target countries in which they are employed. This discrepancy leads to inefficiencies and ineffective practices that may help to treat current cases of HIV, but don’t change the structural inequalities that make HIV so prevalent and difficult to control. This problem is most visible in PEPFAR’s one-size-fits-all funding allocations and continued exclusive usage of the “ABC approach to behavioral change,” the education method at the forefront of PEPFAR’s prevention campaign.

The U.S. Department of State works with universities in the U.S. in order to formulate its PEPFAR plan of action, but it chooses to work with technical experts rather than with regional specialists, thus favoring U.S. initiatives over local needs. The Leadership Act of 2003, under which PEPFAR received its original authorization, requires that 20% of all PEPFAR funding be used to teach the “ABC Model” of HIV prevention, which focuses on “A for abstinence, B for being faithful, and C for correct and consistent condom use” (USAID). Of these funds, one-third must be used for “abstinence-until-marriage initiatives,” which means that any policy that could be construed as supporting pre-marital sexual relationships cannot be undertaken by any PEPFAR-supported program. This often excludes funding to programs that do not comply with conservative, political values, such as those that teach proper birth control methods to unmarried people, and it enforces a view of sex as an activity that should only be undertaken between married, heterosexual couples. These funding requirements do three things: first, they cut funds from vital programs and exclude aid to programs that would otherwise be very beneficial; second, they exclude entire segments of the population while enforcing gender and sexuality stereotypes; and third, they focus on methods of prevention that are morally driven and not completely effective, while withholding lifesaving information.

First, funding for PEPFAR comes directly from the U.S. government, and is coordinated by the Global AIDS Coordinator’s Office before distribution. A majority of the funds are distributed through USAID, which has been actively involved in AIDS prevention and treatment programs since 1986 (Nelson, p. 1). Much of the funding for PEPFAR programs is handled through grants and contracts, which are awarded by the U.S. government to all levels of involved parties, from grassroots NGOs in the target countries to large multinational corporations with strong ties to the U.S. All of the contracts and grants that are associated with PEPFAR contain “morality clauses,” which prevent programs that are contractually associated with the project from taking certain moral stances (GAO). For example, the programs cannot provide sterile needles for intravenous drug users, because this would be construed as supporting drug use, and they cannot actively and aggressively distribute condoms to certain populations of people, because this would be seen as promoting pre-marital and promiscuous sex. Also, the contracts delineate how specific programs are to spend their money, which forces already successful programs to spend less money and energy on programs that already work, and focus more time on programs that are less successful. These clauses prevent many well-functioning and necessary programs from receiving helpful financial and logistical assistance from PEPFAR. Because PEPFAR is the largest worldwide donor program providing funds for HIV-related programs, the forced allocation of funds to abstinence-only programs is no small problem. All programs in the fifteen target countries are influenced by the sheer power of the PEPFAR program, making its inefficiencies and misguided qualifications universally problematic. By strictly controlling PEPFAR funding, the United States pushes its own agenda while ignoring the specific needs of the people of South Africa and of the other target countries.

Secondly, the “morality clauses” that dictate PEPFAR’s spending also prevent PEPFAR programs from reaching the high-risk populations that fall outside of the conservative, moral development framework that the U.S. government operates within. The project’s focus on abstinence-until-marriage programs, which are often carried out by FBOs, is seen by some to promote abstinence to the point that people who contract HIV are stigmatized and believed to be at fault for their own “high-risk” behaviors (GAO). This causes problems for victims of sexual abuse, sex workers, unwed teenagers, homosexuals, and drug users. This is also a problem for people who are faithful to one partner, but are unaware of their HIV status, as well as for non-target populations such as middle-class White citizens who are not receiving the benefits of as many educational aid programs. Because these programs promote heterosexual marriage as the only moral context for sex, all other forms of sexuality are deemed deviant and wrong. People who fall outside of the moral norm are advised to change their behaviors, and are not taught the safe practices that are applicable to their own lives (Santelli).

PEPFAR funding qualifications also create gender stigmas and enforce gender stereotypes. In South Africa, men are the primary providers of the family and women are usually economically dependent. This prevents women from being able to demand condom use or other prevention methods, since their sexual partners have control over their livelihoods (Crais). Women who are HIV positive are frequently shunned by the communities in which they live, and their families often disown them for being “dirty” or “bad” women. Even women who are the victims of sexual abuse, or who are forced to become sex-workers because of extreme poverty, are stigmatized and thus not provided with the support they need in order to receive treatment, care, and the education necessary to prevent further transmission of the virus. The lack of programs aimed at empowering women and the other underrepresented populations of South Africa allows PEPFAR to ignore the structural inequalities that exist in the country, while reproducing stereotypes and decreasing the likelihood that grassroots and other bottom-up forms of development will take place. This helps to maintain an environment in which the government is not held accountable to the people with the least voice.

Third, these funding requirements and “morality clauses” lead PEPFAR programs to teach an HIV-prevention method that is not entirely effective or complete. The promotion of abstinence as the preferred method of prevention is unrealistic when applied to people who usually become sexually active during their teenage years. Because the funding requires that one-third of the education funds go to abstinence-only programs, while another third goes to partner faithfulness programs, and the last third goes to condom provision, it does not provide much room for cross-cutting initiatives. The three parallel programs allow two-thirds of all the education funding to go towards programs that do not mention or provide condoms. While delayed sexual activity and partner reduction are both good methods in decreasing one’s chance of becoming infected with HIV, they are not complete.

The “ABC Model” describes abstinence as a moral commitment, and describes HIV-prevention in terms that are neither scientific nor behavioral. This creates a stigma surrounding those people who have not made a commitment to remaining abstinent, leads to confusion and incomplete information, and ultimately puts people at risk (Santelli). When educational terms are vaguely defined, as they are in the “ABC Model,” people are found to be less likely to use condoms or to get tested for HIV, since they believe that limiting their number of partners and occasionally abstaining from sex makes them immune to the virus. On top of this, the “ABC Model,” which focuses heavily on the “A” and “B” terms, has proven almost entirely ineffective in the United States. While it has been shown to slightly increase the time before sexual debut, and the number of sexual partners that people have, it has not been shown to effectively promote abstinence-until-marriage (Santelli). The “ABC Model” appears to be too heavily weighted towards ill-defined promotions of abstinence, and too little focused on the full disclosure of more effective HIV-prevention methods.

Also, by focusing primarily on abstinence as the preferred method of preventing HIV transmission, PEPFAR’s partner programs withhold what could be lifesaving information from at-risk populations. When this problem is combined with the ambiguous actions of the government, it leads to confusion and misinformation about the infection. Many members of South African society are unwilling to question the government’s insufficient actions in regards to HIV and AIDS because they do not want to criticize the government that freed them from apartheid (CNN). At the same time, the government of South Africa is afraid of dealing with the issue due to the fear of misunderstanding. A telling example of this problem is the manner in which the government of South Africa officially took no position on the issue of HIV/AIDS for a long time and was unwilling to distribute ART to its population, due to the fear that its programs would be mistaken by the international community as a repeat of apartheid’s medical experiments to sterilize Black South Africans (CNN). In South Africa, the culture is one in which much of the population does not trust medical treatments, but prefers traditional remedies as methods of managing and “curing” AIDS. Many people, especially in rural communities, believe that exercise, diet, and other remedies can rid the body of the virus, making them unlikely to attempt to prevent HIV or to accept treatment. Members of the religious and spiritual community are often loath to discuss AIDS, and do not support methods of contraception other than abstinence, which exacerbates the stigma that is associated with HIV and AIDS patients. Because of these specific cultural conditions in South Africa, the amount of incomplete and incorrect information surrounding the issue of HIV and AIDS is enormous, and the only way to combat is by providing complete and correct information on a large-scale.

Educators and health care providers have an ethical obligation to prevent, treat, and control the spread of HIV in the best way possible, but the “morality clauses” and funding restrictions in PEPFAR’s programs actively prevent this from happening. By focusing on abstinence and fidelity as the best methods of prevention, and only focusing some funds on the promotion of condom use, PEPFAR programs exclude alternative methods of prevention from their educational initiatives. Not only are these educational programs incomplete, but they completely omit other precautions, such as proper testing of the blood supply and the use of sterile needles. The focus on the “ABC Model” also distracts funds from programs that prevent mother-to-child transmission, programs that provide inexpensive ART, and programs that treat the AIDS-related illnesses that lead to so many deaths in South Africa.

In order to fix these ineffective practices, certain measures must be undertaken. Most importantly, the U.S. Department of State must create a better method of allocating funds to PEPFAR partners. While certain percentages of funding should be put aside for education on HIV prevention, the U.S. should re-evaluate how these percentages should be allocated. Because the HIV crisis is a problem that affects many levels of international development, the U.S. government should assemble a team of experts that represents all affected fields, including, but not limited to, medicine and public health, and including experts from the United States as well as regional specialists from the target countries. This team could create allocation plans that are unique to each of the fifteen target countries. These plans should be reviewed on a regular basis, as data is collected on their implementation and efficacy, and they should be adjusted every couple of years to allow for improvements. A committee of the U.S. House of Representatives should monitor this team of experts, and should ensure that funding is allocated in a timely and accurate manner.

The interconnected nature of all aspects of development means that PEPFAR programs should work with other U.S. development programs in order to create cross-cutting initiatives that tackle all areas of development that are affected by HIV. For example, decreasing the stigma associated with AIDS means working with religious leaders, counseling centers, and educators in order to spread non-biased, factual information and to create a dialogue about the effects of the virus. Creating better educational facilities and programs for women would empower them to take control of their own health, while simultaneously decreasing gender stereotypes and strengthening the depleted workforce in South Africa. Removing morality clauses and restructuring funding requirements would mean that PEPFAR programs could work hand-in-hand with other aid organizations to tackle non-health aspects of the crisis.

Also vitally important, is the restructuring of the HIV-prevention education programs. The “ABC Model” is too biased and too focused on incomplete information. This model should be completely replaced with one that does not include moral bias or judgment, and applies to all members of the population; regardless of age, gender, occupation, or sexual preference. The new model should explain in behavioral and scientific terms what HIV and AIDS are, how they are contracted, how they are prevented, and how they are treated. The model should focus on condom use, the importance of sanitary needles for injections of all sorts, how to test the blood supply to allow for safe transfusions, and specifically defined methods of abstinence and partner fidelity. Both women and men should be encouraged to ensure their own individual safety, and HIV testing should be made readily available at clinical facilities. Education should also include the knowledge that being HIV positive is not a crime, and that infected people should not be stigmatized or shunned, as they are valuable members of society. By teaching how to prevent and treat the disease, while empowering marginalized populations and decreasing social phobias, the program could be adapted to suit the regional and cultural environments in which it is being practiced, thus allowing for a flexible and effective use of PEPFAR funds.

In finding solutions to these problems, all implementers of the PEPFAR programs would do well to remember Article 12 of the International Covenant on Economic, Social, and Cultural Rights, which “obliges all governments to take all necessary steps for the prevention, treatment, and control of epidemic…diseases” (Santelli). By including morality clauses in all PEPFAR funding packages, and ensuring the exclusive use of the “ABC Method” as the only taught method of HIV prevention, the 2003 Leadership Act favored the conservative moral agenda of Washington over the specific conditions within target countries, such as South Africa. Because these qualifications require PEPFAR programs to function in a way that has proven to be ineffective and inefficient, during a time when efficiency and effectiveness are the only two things that can prevent the AIDS crisis from spiraling further out of control, they prove that the U.S. must take further steps to do all that is necessary to improve the functioning of all PEPFAR programs in South Africa, and around the globe. In order for improvement to occur, old policies must be reviewed and changed. They must address, not the arbitrary desires of Washington policy makers, but the realities of the crisis within target countries. These changes will mean little for U.S. policy, and will effectively improve political relations with the governments of the target countries, because they will better involve the local governments in the policies that so greatly affect their countries and constituents. Economically, change is always costly, but the efficiencies created by more effective policies will ultimately improve the way that U.S. funds are spent. These simple changes will help put PEPFAR on the path to providing long-term development to target countries.


Photo courtesy of hdptcar, mvcorks, rguerra


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