A poster about stigma in a HIV testing lab in Uganda. Credit: Lyndal Rowlands / IPS.

By Lyndal Rowlands
UNITED NATIONS, Dec 1 2016 (IPS)

Eighteen million people, just slightly under half of the people living with HIV and AIDS globally, are now taking life-saving medication, but global efforts to end the disease still largely depend on prevention.

While efforts to expand antiretroviral treatment have been relatively successfully, prevention efforts have been more mixed.

With the help of treatment, mother to baby transmission has dropped significantly. Transmission between adults aged 30 and over has also dropped.

However, transmission rates among adolescents have risen, causing concern, particularly about the high number of new cases among young women between the ages of 15 to 24.

According to UNAIDS, a new report published last week, “shows that the ages between 15 and 24 years are an incredibly dangerous time for young women.”

The report included data from six studies in Southern Africa, which showed that “southern Africa girls aged between 15 and 19 years accounted for 90% of all new HIV infections among 10 to 19-year-olds.”

“Young women are facing a triple threat,” said UNAIDS Executive Director, Michel Sidibé. “They are at high risk of HIV infection, have low rates of HIV testing, and have poor adherence to treatment. The world is failing young women and we urgently need to do more.”

The report also noted the countries that have increased their domestic funding for HIV prevention, “including Namibia, which has committed to investing 30% of its HIV budget in preventing HIV among adults and children.”

Ensuring the continued and renewed domestic and international funding for both treatment and prevention was the subject of discussion at the Center for Global Development in Washington D.C. on Monday.

The event, held ahead of World AIDS Day on 1 December, focused on a U.S. government initiative aimed at involving government finance departments, as well as health departments, in the HIV response.

Currently over 55 percent of the HIV response in low and middle-income countries comes from the governments of low and middle income countries.

However a significant amount of international support, roughly one third overall funding, comes from the U.S. government, which has made tackling HIV and AIDS a priority through the President’s Emergency Plan for AIDS Relief (PEPFAR).

However while U.S. funding for the HIV and AIDS response is considered bipartisan HIV and AIDS support, like any U.S. government program may change under Presidency of Donald Trump.

IPS spoke to Amanda Glassman, Vice President for Programs and Director of Global Health Policy at the Center for Global Development after the event:

“Of course we all hope that this is a bi-partisan consensus but the fact that we, the U.S. government, continue to pay directly for service delivery in some countries is a huge risk,” she said. “On the one hand I think maybe it makes it harder to cut, but on the other hand if it does get cut it’s a disaster.”

Of the 18 million people currently on antiretroviral treatment globally, “4.5 million are receiving direct support,” from the U.S. while an additional 3.2 million are receiving indirect support through partner countries.

While there remains broad consensus over treatment, prevention efforts are considered more politically contentious.

Previous Republican administrations have supported abstinence programs, which studies have shown to be ineffective at preventing HIV transmission.

Glassman noted that while there is more political consensus over treatment programs “you need prevention really to finish this.”

However she noted one positive example from incoming Vice-President Mike Pence’s home state of Indiana.

“(Pence) actually eliminated (needle exchange) programs and then saw HIV / AIDS go up and so he reversed his position, so I think that sounds good, he listens to evidence and action,” said Glassman.

However Pence’s record on women’s reproductive rights and his reported comments that in 2002 that condoms are too “modern” and “liberal”, may not bode well for overall prevention efforts, especially considering that addressing higher transmission rates among adolescent girls also requires addressing gender inequality and sexual violence. Update: In 2000, Pence’s campaign website also said that a US government HIV/AIDS program should direct resources “toward those institutions which provide assistance to those seeking to change their sexual behavior,” a statement many have interpreted as support for gay-conversion therapy.

Reducing the high rates of transmission among adolescent girls will not be easy. It involves increasing girls economic independence as well as helping them to stay in school longer.

“It’s a discussion of investment in secondary school … so the discussion is bigger than health,” said U.S. Global AIDS Coordinator, Deborah Birx at the event.

This is one of the reasons why involving government finance departments is important.

However finding additional funds for both education and health in the “hardest hit countries” will not be easy, said Glassman.

“(These countries) are coming in with growth projections that are much lower, they have pretty low tax yields meaning that the amount that they get from their tax base is pretty low.”

Monica Wambui, 37, who is deaf, receives HIV/AIDS information in sign language. Wambui was among more than 40 people with disabilities who attended a workshop organised by the USAID-funded APHIAplus Nuru ya Bonde project in Nakuru, Kenya. Credit: USAID/George Obanyi

By Rashmi Chopra
NEW YORK, Nov 28 2014 (IPS)

Jane is a young Zambian mother with a physical disability in Lusaka, who uses a wheelchair to get around. She does not let clinics without ramps or without wheelchair accessible toilets and equipment stop her from claiming her right to health care, including HIV prevention services.

“You have to go the clinic to test yourself, to know your status – you have to force yourself, even crawling, so that the government can see that the clinics are not user-friendly,” she told Human Rights Watch.Faith, 25, a deaf, HIV-positive woman in Zambia, lost her hearing when she contracted cerebral malaria at the age of five. Faith did not know about HIV prevention until she tested positive in 2012.

In local communities, legislatures and at the United Nations, people with disabilities like Jane are demanding their right to equal access to HIV services. Not only on Dec. 1, World AIDS Day, but every day.

This week we also observe the international day of persons with disabilities. This coincidence of the calendar is not a coincidence for millions of people with disabilities around the globe who may have never received any information on HIV and are unable to access HIV prevention, treatment and care services.

Yet they are at increased risk of HIV infection because of discrimination in schooling, poverty and greater risk of physical and sexual violence.

Faith, 25, a deaf, HIV-positive woman in Zambia, lost her hearing when she contracted cerebral malaria at the age of five. She dropped out of school after only a few years because her family could not afford the transportation costs to send her there, and in any case did not believe she would benefit from schooling.

Today, Faith cannot read and communicates through a mix of formal sign language and informal signs that are understood and translated by her brother.

Faith did not know about HIV prevention until she tested positive in 2012. HIV prevention meetings in her local community are not conducted in sign language. And even if Faith had been able to continue her schooling, she likely would not have learned about HIV because of the lack of accessible materials and peer-based HIV prevention programmes for children with disabilities.

Faith found out that she was HIV-positive after giving birth to her daughter, who is also HIV-positive. Her husband is abusive and often absent. Faith relies on her mother to accompany her to appointments for antiretroviral medication and to help her understand information about care and treatment for her and her baby. There is usually no sign language interpreter at the clinic she visits.

A healthcare worker at her clinic told Faith and her mother that someone like Faith should not be allowed to have any more children.

But these barriers, and stigmatising attitudes, are starting to change.

In its 2014 ‘Gap Report’, UNAIDS recognised people with disabilities as one of the 12 vulnerable populations left behind by the AIDS response.

In Zambia, where more than one in 10 adults are living with HIV, and a similar number of people are estimated to have a disability, the government could recognise people with disabilities as a key population within the national HIV response, who should be prioritised for targeted action.

A disability-inclusive approach to HIV policies and national strategic plans is critical for countries in eastern and southern Africa, which remain the epicentre of the HIV pandemic.

Disabled persons’ organisations (DPOs) as well as other disability and health organisations in the region are also working hard to promote and develop inclusive and targeted HIV and sexual and reproductive health services.

Zambia Deaf Youth and Women (ZDYW), a local organisation from the Copperbelt province for example, has been supporting training of deaf counselors to provide peer-based HIV testing services in the region.

This year the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in Zambia will recognise a number of ‘PEPFAR Champions’ who are promoting equal access to HIV services for people with disabilities.

This is a good start, but more needs to be done, and quicker, to draw broader attention to the needs of individuals with disabilities in HIV services and to integrate HIV issues within all disability work. This requires resources, specific budgetary provisions, donor funding allocations and data collection on disability.

The Zambian HIV/TB activist and advocate for disability rights, Winstone Zulu, would have turned 50 this year that marks half a centenary of Zambia’s independence. In this week that recognises both the global AIDS pandemic and the more than one billion people worldwide who have a disability, Zambia should honor his and others’ struggle for equal access to HIV services, and implement inclusive HIV services as a priority, to ensure that people with disabilities such as Jane and Faith no longer remain invisible in the fight against HIV.

Edited by Kitty Stapp

Excerpt:

COUNTDOWN SNAPSHOT: HOW MOZAMBIQUE IS COPING WITH AIDS

By Mercedes Sayagues
MAPUTO, Aug 12 2014 (IPS)

Mozambique struggles to contain the HIV epidemic with one in ten among its 24 million people infected. Helping them is not easy when only 60 percent of people have access to health services.

There are five doctors and 25 nurses per 100,000 people. In neighbouring South Africa, the ratio is 55 doctors and 383 nurses.

Recently, the United Nations ranked Mozambique 178 among 187 countries in human development. Quick stats:

• 50 years: life expectancy
• 3: mean years of schooling
• 70 percent: number of people living in poverty
• 40 percent: number of women who give birth at home
• 56 000: number of women infected with HIV annually

Excessive dependence on donors is another problem, with 90 percent of the health ministry’s HIV/AIDS budget paid by theUnited States President’s Emergency Plan for AIDS Relief (PEPFAR). The overall health budget is just eight percent of the total state budget, far from reaching the 2001 Abuja commitment to allocate 15 percent to health.

Nonetheless, Mozambique is doing quite well in preventing mother to child HIV transmission. Infection rates among children have plummeted, but remain too high at 12,000 in 2013. The good news is that this number is half of what it was five years ago.

Sources: UNAIDS, UNICEF

Rwandan children orphaned by AIDS in Muhanga village. Credit: Aimable Twahirwa/IPS

By Julia Hotz
WASHINGTON, Aug 9 2014 (IPS)

Though West Africa’s massive Ebola outbreak may be dominating the spotlight within the global health community, HIV/AIDS remains an enormous issue for Africa as a whole – a sentiment that Washington officials made clear this week in their discussions of legislative and technological setbacks plaguing progress in fighting the epidemic.

Despite the World Health Organisation’s announcement Friday that Ebola is now an “international public health emergency,” doctors, academics and policymakers met Thursday at the Washington office of Kaiser Family Foundation (KFF), a health-policy non-profit, to discuss the similarly urgent threat posed by HIV/AIDS, the subject of last month’s 2014 International AIDS Conference in Melbourne, Australia.Uganda’s anti-LGBT environment may explain the nation’s distinct increase in the number of new HIV infections, a trend that - with the exception of Angola - has been reversed in surrounding African nations.

Ambassador Deborah Birx, the global AIDS coordinator for the U.S President’s Emergency Plan for AIDS Relief (PEPFAR), echoed the threat’s urgency, explaining that “the AIDS pandemic in southern Africa is the primary cause of death for adolescents, and the primary killer of young women.”

President Barack Obama announced Wednesday at the end of his three-day leaders’ summit with Africa that PEPFAR and the Children’s Investment Fund Foundation (CIFF) will pledge 200 million dollars to work with 10 African countries to help them double the number of children on lifesaving anti-retroviral drugs.

But Ambassador Birx, along with other prominent HIV/AIDS activists in Washington, seemed to suggest that distributing anti-retroviral drugs to children would only address a fraction of the issue.

Fear of HIV/AIDS stigma

While making note of PEPFAR’s unprecedented  progress in moving towards an “AIDS-free generation,” a commitment that President Obama deemed possible in a 2013 national address, Birx suggested that countries with anti-LGBT laws may have disproportionately high rates of new HIV infections.

“People are afraid to be stigmatised,” Birx told IPS, explaining that gay people may refuse to seek diagnosis and treatment for HIV/AIDS if they are legally and culturally persecuted by their homeland.

Identifying nearly 80 countries with such discriminatory environments, Birx’s PEPFAR report highlights Uganda, where the recent passage of anti-LGBT legislation and discriminatory comments of Ugandan President Museveni has attracted substantial condemnation from the international community.

“This is a human rights question,” Birx told IPS, calling specifically on the community of faith- one she describes as “there to wrap its embracing arms in need”- to respond to such LGBT persecution.

Yet beyond humanitarian concerns, PEPFAR’s report notes how Uganda’s anti-LGBT environment may explain the nation’s distinct increase in the number of new HIV infections, a trend that – with the exception of Angola – has been reversed in surrounding African nations.

Birx stressed that the majority of HIV infections are transmitted through heterosexual sex, despite the common misperception that homosexual activity is the cause of HIV/AIDS.

It is perhaps this association, Birx reasoned, that incites fear of seeking diagnosis, and explains why approximately half of all people with HIV are still unaware that they are infected, despite the tremendous increase in HIV testing capacity.

“Incredibly powerful” potential of tech innovation

Panelists at Thursday’s conference spoke about the tremendous expansion of testing capacity, an noted how technological innovation is a leading force not only in HIV/AIDS diagnosis, but also in treatment, prevention and education.

“I think there’s actually a lot going on in innovations in technology,” Chris Beyrer, president of the International AIDS Society, told IPS. “And it’s not only internet technology and mobile technology, but it’s also in other domains, like self-testing and home-testing.”

Beyrer added how “getting testing out of the clinics and getting them directly to people” reduces the strain on medical personnel and funding, two areas in which panellists agree there are great shortages.

“Technology is moving to a place where there are much more local kinds of facilities that can actually do staging,” Beyrer explained to IPS.

“You don’t have these kinds of problems with people waiting forever to get a CD4, and then being told to go somewhere else with their CD4 result.”

“One size does not fit all”

Birx, who also participated in Thursday’s panel, added that technology can potentially be used to disseminate information about HIV/AIDS, and can potentially even correct some of the misconceptions about what causes HIV/AIDS.

She referenced the “incredible work” coming out of Cambodia, which utilises different internet strategies to cater not only to people of different ages, but also to people of different sexual practices, in an attempt to distribute key medical information.

The technique, she says, allows everybody to “click on the site and find the voice that resonates with them and gives them different knowledge [about HIV/AIDS] that they need.”

“I found that so incredibly powerful, and if we can figure out how to do that and get broadband throughout sub-Saharan Africa, it would be terrific.”

Beyrer reiterated the need for technology to offer individualised options for the transmission of knowledge about HIV/AIDS, telling IPS that “one size doesn’t fit all in these innovations.”

“It turns out, for example, from looking at interactive supports for treatment, there are very age-dependent differences even among population,” he said.

“Men under 25,” Beyrer explained, “really like SMS interactive messages, and want to be notified at all times, while older men [tend to say] no thank you, leave me alone…it’s very specific so we’re going to have to get that right.”

Yet despite Beyrer’s enthusiasm for more individually-tailored solutions to those seeking knowledge about HIV/AIDS, he also urges that there be more awareness-building for those not expressly seeking knowledge about HIV/AIDS.

“One sector that hasn’t engaged very much in HIV is social media,” he said, calling specifically on Facebook, Google, and others in Silicon Valley to engage more thoroughly.

“We need that, and we would love them to be way more engaged than they are.”

Edited by: Kitty Stapp

The writer can be contacted at hotzj@union.edu

A CD4 testing machine. Research by the University of Zimbabwe shows that female patients with high CD4 counts have developed a nevirapine toxicity. Credit: Jennifer Mckellar/IPS

By Miriam Gathigah
NAIROBI, May 19 2014 (IPS)

As Africa scales up lifesaving antiretroviral therapy for HIV positive people, concerns are rife that the absence of mass routine viral load testing will hamper extending treatment to the millions who need it.

“Routine viral load testing helps catch people who are failing on treatment before they generate resistance to antiretrovirals and helps keep them less infectious,” explains Teri Roberts, diagnostics adviser at Médecins Sans Frontières (MSF).

Viral load testing, the gold standard in antiretroviral therapy (ART) monitoring, measures HIV levels in the blood, an indicator of the drugs’ success.

The World Health Organisation recommends viral load monitoring six months after starting ART, at 12 months, and every 12 months thereafter.

But a viral load test, although routine in wealthy countries, is scarce and expensive in Africa.

“A viral load test in Kenya is 25 dollars at the National Programme on AIDS, while a similar test in a clinic in Asia costs about 11 dollars,” says Roberts.

In Africa, viral load tests are scarce and expensive. A breakdown of the average cost per viral load test. Courtesy: Médecins Sans Frontières (MSF)

An MSF study on world prices of viral load testing found “a dramatic gap” between the manufacturing cost and the market price African countries pay.

Point of care viral load testing remains largely unavailable in Africa, says the study. Instead, collected blood samples are sent for testing at a central laboratory.

Point of care testing is essential to decentralise care in remote rural Africa, bringing diagnostics closer to the patient and speeding clinical decisions. Though point of care tests are twice as expensive as tests in central laboratories, MSF recommends a mix-and-match combination of solutions that work in a big urban context or in a poor rural district.

HIV experts worry that many women on ARV treatment have never had a viral load test, or it came too late.

“We may have highly infectious mothers on ARVs because they have acquired resistance but are not picked up for lack of proper monitoring,“ says Roberts.

Dr. Dave Muthama, from the Elizabeth Glaser Paediatric AIDS Foundation, tells IPS that “CD4 count does not drop immediately when drugs fail; the CD4 count may remain high for a while and by the time treatment failure is detected, a lot of harm will have been done.”

The World Health Organisation recommends viral load monitoring six months after starting ART, at 12 months, and every 12 months thereafter. Credit: Miriam Gathigah/IPS

Creative solutions

HIV experts are calling on African governments to overcome these challenges.

“While Asia manufactures its own machines and reagents, Africa imports everything,” says Dr. John Ong’ech, assistant director at Kenyatta National Hospital. “We need to explore the option of having locally manufactured viral load testing reagents and machines.”

He warns that the cost of viral load machines could be even higher in Kenya due to the value added tax on imports.

Locally manufactured products will also encounter pitfalls in the form of royalty payments for intellectual property which, according to MSF, can account for up to 65 percent of the manufacturing cost of the tests.

Dorothy Mbori–Ngacha,  senior HIV specialist for East and Southern Africa at the United Nations Children’s Fund (UNICEF), tells IPS that UNITAID, a global health initiative, and UNICEF are trying “to eliminate market monopoly in order to create a competitive market” and make viral load testing technology affordable.

An MSF study on viral load testing in seven African countries assessed options to reduce costs and improve access, such as pooled testing at district level in Malawi and Zimbabwe.

In pooled testing, blood samples from five people are mixed together and only one test is conducted on all five. If it shows a high viral load, individual testing follows.

In Malawi, sample pooling using dried-blood spots collected through easy finger-pricking reduced by 30 percent the number of tests required in a rural district with over 30,000 patients on treatment, saving 207,000 dollars per year.

For quicker and cheaper relaying of results, MSF recommends using mobile phones and electronic health technologies.

Pooling efforts

Roberts stresses the need to push the biggest buyers – the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria purchase nine out of 10 tests – to adopt pooled procurement and get even cheaper prices for all.

But Ong’ech says this may be difficult, because procurement laws differ across countries and even within countries.

“Swaziland uses a generic open platform for procurement of viral load tests, which leads to competition and achieves cheaper prices. Malawi uses a closed platform, which leads to higher prices,” Roberts explains.

A test costs 35 dollars in Swaziland and 25 dollars in Malawi.

In a generic open platform, the elements for viral load testing are sourced from different manufacturers, while in a closed platform, from a single manufacturer.

Nonetheless, as African countries scale up viral load testing, they will gain leverage to negotiate lower prices.

Pushing for transparency with prices among and within countries will help. Roberts tells IPS that in Kenya the same component can cost 24 or 11 dollars depending on who imports it.

Test costs also hinge on the efficient use of viral load machines. According to MSF, the closer to maximal capacity the machine is used, the price per test decreases between 25 and 50 percent.

Viral load testing helps keep people on first line ARVs, which cost a fraction of second and third line.

“The drugs could be failing due to social issues such as stigma and that can be dealt with without changing treatment regime,” Mbori-Ngacha explains.

The MSF study found that in Shiselweni, Swaziland, half of people diagnosed with high viral load improved with adherence counselling and their viral load dropped.

“Mass routine viral load testing is not feasible today due to its cost and complexity,” concludes Roberts.”Complexity has reduced greatly and will reduce more. We must develop strategies to reduce costs.”

A scene from the award-winning documentary "Call Me Kuchu", which follows the fight of courageous LGBT rights activist David Kato and his friends against the rampant homophobia in Uganda. Credit: Katherine Fairfax Wright

By Bryant Harris
WASHINGTON, Feb 26 2014 (IPS)

Ugandan President Yoweri Museveni’s authorisation of the Parliament’s so-called “kill the gays” bill has led Washington officials to announce a review of U.S. aid to the African country.

While the new law no longer provides the death penalty for LGBT people, as it did when parliament first introduced it, it escalates existing penalties on homosexuality, allowing the state to imprison people for life if they engage in “aggravated homosexuality,” defined as repeated instances of gay sex between consenting adults or acts involving minors, disabled, or HIV-positive people.Lively claimed that gays were responsible for the Holocaust and the Rwandan genocide, and asserted that they were now targeting Uganda by trying to “convert” Ugandan children.

The European Union, the United Nations and the Catholic Church have all strongly condemned the new law, which escalates existing penalties for homosexuality.

“Now that this law has been enacted, we are beginning an internal review of our relationship with the Government of Uganda to ensure that all dimensions of our engagement, including assistance programmes, uphold our anti-discrimination policies and principles and reflect our values,” U.S. Secretary of State John Kerry announced Monday.

Some European countries, including Norway, Denmark and the Netherlands, have already halted financial aid to Uganda in protest, while others, like Austria and Sweden, are similarly reviewing their aid commitments. Prominent U.S. policymakers are calling on the United States to temporarily cut off the 456.3 million dollars in aid to Uganda that Congress has appropriated for the coming fiscal year.

“We need to closely review all U.S. assistance to Uganda, including through the World Bank and other multilateral organisations,” U.S. Senator Patrick Leahy said Tuesday. “I cannot support providing further funding to the Government of Uganda until the United States has undergone a review of our relationship.”

Ugandan health and sanitation programmes in particular rely on foreign aid support, especially when it comes to combating HIV/AIDS. Uganda has an HIV prevalence rate of 7.2 percent, a rate that is roughly doubled for men who have sex with men.

“We are also deeply concerned about the law’s potential to set back public health efforts in Uganda,” Kerry said, “including those to address HIV/AIDS, which must be conducted in a non-discriminatory manner in order to be effective.”

As the new Ugandan law prosecutes organisations aiding LGBT individuals, a high-risk group for HIV transmission, Uganda’s actions could have an adverse affect on Ugandan organisations that partner with and receive funding from PEPFAR, the United States’ flagship anti-AIDS programme.

“From a purely operation standpoint … we know that the law itself has specific ramifications for PEPFAR assistance,” Timi Gerson, the director of advocacy for American Jewish World Service (AJWS), a development organisation with operations in Uganda, told IPS. “They’re going to have to look at how this law is going to impact its ability to run those programmes.”

Gerson is hesitant about freezing all aid to Uganda, however.

“AJWS doesn’t support the cutting of fundamental aid to those countries. We don’t support stopping aid to ordinary Ugandans,” she said.

“I wouldn’t talk about cutting aid, I would talk about shifting aid. I think the real question is how you would do that on the ground in light of the situation, so that has to be first and foremost in the [U.S.] review.”

U.S. evangelical influence

Some pro-LGBT advocates are more ambivalent about U.S. aid funding in Uganda, however. They point to an unacceptable trend of U.S. funding being administered by socially conservative Christian groups that have long espoused an anti-LGBT agenda, creating an environment where anti-LGBT legislation enjoys widespread support.

U.S. funding often ends up in the hands of conservative religious groups via a complex system of grants, sub-grants and further sub-grants awarded by sub-grantees.

“[The conservatives] are doing a lot of excellent work when it comes to services like orphanages and very good, well-funded schools,” Rev. Kapya Kaoma of Political Research Associates, a social justice advocacy group, told IPS.

“The conservative schools have very good libraries, unlike other schools, but have books that present a conservative angle regarding Ugandan politics. That is an advantage for them.”

Kaoma noted that organisations headed by people like Martin Ssempa, a vehemently anti-LGBT Ugandan pastor, have received 60,000 dollars in sub-grants from organisations receiving U.S. PEPFAR funds. (Ssempa also opposes the use of condoms.)

“I hear these calls to suspend aid and I am conflicted about that,” said Kaoma. “I don’t think that’s the best way to go, as suspending aid only hurts the poor and not the rich. Museveni won’t lose a single thing.”

Instead, he advocates sanctions on Ugandan individuals responsible for the law – and on U.S. evangelicals who he says have fuelled Uganda’s anti-LGBT movement.

“The alternative is selective sanctioning targeting the people who are responsible, all the anti-gay speakers,” he said.

“If they can be sanctioned, there can be a law that says no money can move from any U.S. organisation to an [anti-LGBT] group in Uganda – then they will start feeling the pinch. If they cut aid, it could just increase hatred against LGBT people as retaliation.”

Kaoma said that he is particularly eager to prevent certain individuals from entering Uganda. He lists prominent U.S. evangelicals such as Scott Lively, Caleb Lee Brundidge, Don Schmierer and Lou Engle as having directly influenced Uganda’s anti-LGBT law.

In March 2009, Lively held a conference for Ugandan political, clerical and civic elites, where he spoke to them about the “gay agenda”. Lively claimed that gays were responsible for the Holocaust and the Rwandan genocide, and asserted that they were now targeting Uganda by trying to “convert” Ugandan children.

Kaoma attended and filmed the 2009 conference, featuring Lively, Brundidge and Schmierer. A week later, Ugandan parliamentarians circulated the first draft of recently enacted law.

“The original bill reads like Scott Lively speaking again,” Kaoma said.

The Centre for Constitutional Rights, a U.S.-based watchdog, is currently representing Sexual Minorities Uganda, a Ugandan LGBT advocacy group, as it sues Lively in a U.S. court for his alleged influence on the legislation.

Lively has conducted similar anti-LGBT activism throughout Africa as well as in Ukraine and Russia.

The Supreme Court overturned a mandate that certain organisations receiving HIV/AIDS funding state their opposition to prostitution. Credit: Bigstock

By Carey L. Biron
WASHINGTON, Jun 20 2013 (IPS)

The U.S. Supreme Court on Thursday overturned a decade-long practise under which the government linked global HIV/AIDS funding to a controversial requirement that organisations explicitly state their opposition to prostitution.

The court’s decision to overturn the mandate surprised many observers, with the 6-2 ruling now being lauded as a major victory by a broad coalition of global health, women’s rights and free speech advocacy groups.

“We are surprised but very happy to hear how the decision came down,” Crystal DeBoise, co-director of the Sex Workers Project at the Urban Justice Centre, a New York advocacy group, told IPS.

“This is a very good progression for the human rights of sex workers and will be a positive development for organisations that are best situated to meet the needs of sex workers and other people who have social and health risks,” DeBoise said.

“Hopefully this indicates that we’re moving in the direction of serving the most vulnerable members of our societies better and more efficiently.”

The anti-prostitution mandate has been part of U.S. policy since 2003, enacted as part of the President’s Emergency Plan for AIDS Relief (PEPFAR). That programme, focused particularly on Africa, offered the largest ever commitments to fight HIV and AIDS.

In the decade since it was enacted, PEPFAR has made available almost 46 billion dollars for HIV/AIDS programmes, according to official figures, directly providing antiretroviral medicines to more than five million people. For this and next year, President Barack Obama has requested another 13 billion dollars.

Yet from the start, Congress wrote the legislation in such a way that any organisation receiving PEPFAR funding would need to explicitly state its opposition to prostitution. Since then, experts from the health community have warned that such a policy runs counter to the aim of wiping out the HIV/AIDS epidemic.

“This policy didn’t emerge from within the public health field, but rather arose when some U.S. legislators saw an opportunity, through PEPFAR, to insert and enforce an ideological purity about sex work,” Serra Sippel, president of the Centre for Health and Gender Equity (CHANGE), a Washington advocacy group, told IPS.

“That was disturbing in part because it’s not a public health intervention to silence people or require organisations to adopt a specific viewpoint of some legislators.”

Building trust

The U.S. government has always explained the anti-prostitution oath by stating that stamping out sex work is a central component of the country’s broader anti-HIV policy. Civil society has also been split on this issue, with some groups – particularly anti-trafficking organisations – supporting the pledge in some way (several such groups contacted by IPS were unable to respond by deadline).

Still, many critics on the ground have for years warned that the oath stood in the way of the independent thinking necessary to find an end to the HIV epidemic. In particular, it distanced health workers from sex workers.

“It’s considered a best practise in public health to build trust among sex workers and to work to end the stigma and discrimination that fuel the epidemic,” Sippel said.

She noted that forcing an organisation like Pathfinder International – a sexual health advocacy and implementing group, and one of the lead plaintiffs in the Supreme Court case – to sign the pledge essentially pushed the organisation to adopt policy stating that it opposed the very people it was supposed to serve."We signed the pledge, knowing that we would wilfully ignore it."
-- Kevin Frost

“There’s no question that the programmatic goal of ending prostitution comes into conflict with the programmatic goal of trying to end HIV infection,” Kevin Frost, CEO of amfAR, the Foundation for AIDS Research, told IPS. “You end up making it exponentially more difficult to reach and built trust with the kind of individuals who are on the front lines of this issue.”

Such contortions led Frost’s organisation to sign the pledge and then continue to do what it thought best.

“Like many, our hand was forced into signing the prostitution pledge, even though we felt from the beginning that this was bad both policy-wise and programmatically and would have a negative impact on our ability to reach the population that needed the kind of services we offer the most – commercial sex workers,” Frost noted.

“So we signed the pledge, knowing that we would wilfully ignore it. We discussed the policy at the board level and signed on, but did so with objection.”

Still law

Thursday’s court decision hinges on a view of the anti-prostitution oath as infringing on free speech, as guaranteed by the U.S. Constitution’s first amendment.

“The [oath] requirement mandates that recipients of federal funds explicitly agree with the Government’s policy to oppose prostitution,” Chief Justice John Roberts wrote for the majority. “The First Amendment, however, ‘prohibits the government from telling people what they must say.'”

Given the polarised nature of sex work in the United States, the case before the court had been specifically tailored to deal solely with this free speech context. As such, the court did not weigh in on the merits of arguments or policies regarding sex work more generally.

Nor did the decision actually strike down the prostitution oath. Rather, it found that the oath infringed on the free speech of the organisations that were directly party to the court case.

More broadly, the case’s interpretation will affect only U.S., rather than international, groups receiving PEPFAR funding. Yet amfAR’s Frost noted that the majority of groups that receive PEPFAR funding are based in the United States and that the programme’s ability to enforce diktat for international organisations is limited.

Still, with the oath still on the books even after Thursday’s decision, the impetus will now come down to how President Obama’s administration proceeds. To date, administration officials have refused to discuss their view of the oath, given that it has been the subject of legal proceedings since Obama took office.

“This is not over – it’s an important milestone in defeating this policy, but the work needs to continue to make sure it’s not applied in a negative way to groups on the ground,” CHANGE’s Sippel said.

“This decision now gives us an opportunity to look at specific instances where U.S. funding can engage sex workers on a more critical agenda,” Sippel added. “Globally, we’re making a lot of progress on HIV/AIDS, particularly in looking at this from a public health and human rights perspective.

“This case now helps us continue to move the conversation in that direction.”

A major audit of the United States’ flagship global anti-HIV/AIDS programme, prepared for the U.S. Congress, notes “remarkable progress” over the past decade. However, it is also warning of insufficient monitoring and urging a stepped-up process of handing over greater control to partner countries.

Known as the President’s Emergency Plan for AIDS Relief (PEPFAR), the initiative is the largest such programme in the world, credited with saving millions of lives, particularly in Africa. Since its authorisation in 2003, at the behest of then-president George W. Bush, PEPFAR has disbursed more than 30 billion dollars through bilateral agreements in over 100 countries.

The legislation that created PEPFAR requires Congressional re-authorisation this year, however. As part of that process, Congress required the national Institute of Medicine (IOM) to conduct an audit on the efficacy of the programme’s first decade.When you start taking [anti-HIV drugs], you have to do so for the rest of your life... It’s much harder to pull funding that will directly cause people to die.

In many regards, the findings of PEPFAR’s impact over the past decade are extremely positive. IOM committee chair Robert Black, an international health expert, notes that his team “repeatedly heard PEPFAR described as a lifeline” during visits to partner countries.

“PEPFAR has achieved – and in some cases surpassed – its initial ambitious aims,” the IOM committee’s 700-page report, released Wednesday, states.

“These efforts have saved and improved the lives of millions of people around the world. That success has in effect ‘reset’ the baseline and shifted global expectations for what can be achieved in partner countries.”

Yet the report also notes that much work remains to be done, particularly to safeguard “hard-fought gains”.

The reporting committee is calling on PEPFAR to increase emphasis on funding for the far more difficult task of HIV prevention, rather than treatment. It is also pushing the agency to focus more on the ultimate impact of its funding on the ground.

“The report does a good job of being explicit about these data gaps and the need for better information on spending,” Victoria Fan, an international health specialist with the Center for Global Development (CGD), a Washington think tank, told IPS. “As PEPFAR wants to shift from measuring funding-related activities to measuring actual outcomes, they are going to need better data-monitoring systems.”

Collective ownership

Of particular prominence in the IOM evaluation is the move towards strengthening “ownership” of PEPFAR programming by partner countries, both in finances and programmatic approach.

“Today, the ability of many countries to respond to HIV relies heavily, and sometimes exclusively, on external funding,” the report states, noting later: “PEPFAR will gradually cede control, as partner countries take on more central roles in accountability and setting strategic priorities for investment in their HIV response … such an evolution in PEPFAR’s mission is vital.”

In part, this process relates to the willingness of the U.S. government to continue these investments over the long term.

“The United States may be thinking that it’s already been engaged in these programmes for the past 10 years, and in that time the epidemic has changed,” CGD’s Fan says. “So, maybe it’s time to let other countries take more ownership and invest more financially in these programmes – that’s a reasonable assertion.”

At the same time, HIV-positive people around the world are today able to live far longer due to new treatment innovations, while a generation of children that would have otherwise risked exposure is being born without HIV. Fan notes that this creates a “moral entitlement” that may have caught some U.S. legislators by surprise.

“Remember, when you start taking [anti-HIV drugs], you have to do so for the rest of your life,” she says. “That’s a long-term commitment that U.S. policymakers may not have been thinking about when they started investing in HIV/AIDS. It’s much harder to pull funding that will directly cause people to die.”

Others have stressed that as PEPFAR moves into a new phase of post-emergency funding, particularly as the U.S. government wrestles with concerns over debt and austerity, it will be increasingly important to determine where exactly that money is going.

“Country ownership doesn’t necessarily mean governments taking control, but rather is about partnerships between national governments, international donors and civil society,” Serra Sippel, the president of the Center for Health and Gender Equality (CHANGE), a Washington advocacy group, told IPS.

“Civil society engagement is particularly important when you look at countries that are not that friendly towards women’s rights or LGBT rights. It’s very important that PEPFAR continue to support and work with civil society to make sure no one is left out of HIV/AIDS-related access to care.”

Ultimately, country ownership today may mean ensuring that the money that has already been spent has a longstanding impact and sustainability.

Keeping Congress out

President Barack Obama is set to indicate his own vision for new PEPFAR funding when he unveils his national budget proposal for 2014, slated to take place in March.

CHANGE’s Sippel points out that funding for PEPFAR won’t actually halt if legislative re-authorisation does not take place, and she is urging that the president simply circumvent the politically fractious Congress.

“Given the climate with Congress right now, we don’t think we have a positive political climate in which to pass effective legislation,” she says.

Certain PEPFAR policies required in the past by the Congress have angered some advocates, and in 2007 a previous IOM report criticised Congress for too tightly controlling how PEPFAR programmes functioned. Yet the new report now vindicates stripping these out, particularly supporting moving away from a previous focus on sexual abstinence and fidelity within marriage.

More problematic is a continued requirement that groups receiving PEPFAR funding must declare their opposition to sex work. While the IOM cautions it didn’t have a mandate to work on this issue, it does note that sex-worker groups are best positioned to deal with prostitution-related HIV/AIDS issues – and warns that their efforts are currently being hampered by this requirement.

The report also shows that PEPFAR still hasn’t figured out how to comprehensively address gender, Sippel says, with the committee researchers noting that responses to women are still “ad hoc”.

“That tells us women are still a blind spot in the global AIDS fight, despite being half of the population living with HIV,” she says. “Until PEPFAR develops a gender strategy with clear objectives and outcomes, we can’t get ahead of HIV.”