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Bush's Embattled AIDS Bill. Serious Concerns Raised Over Use of Funds By Sue Ellin Browder
WASHINGTON, D.C., JUNE 30, 2008 (Zenit.org).- Pressing the Senate to rubberstamp $50 billion in global spending on AIDS, malaria and TB, AIDS activists marched on the White House last week bearing signs with slogans like "Now or Never."

But this week, a Anglican priest from Uganda opened more serious dialogue about the bill, saying that "condom promotions have failed in Africa" and AIDS "profiteers" have subverted African fidelity and abstinence programs in order to sell commodities for a profit.

"AIDS is no longer simply a disease; it has become a multibillion-dollar industry," Reverend Sam Ruteikara, co-chair of Uganda's national AIDS-prevention committee, wrote today in the Washington Post.

Stalled for months in the Senate, the reauthorization for the President's Emergency Plan for AIDS Relief (PEPFAR) would more than triple program spending from $15 to $50 billion over five years. But Ruteikara told ZENIT that if the money is misspent, it won't stop the spread of AIDS in sub-Saharan Africa, and it could even raise HIV rates.

President George Bush wants the bill passed before the G-8 summit in Japan next week. But in a March 31 letter to Senate Republican leader Mitch McConnell, seven senators led by Senator Tom Coburn of Oklahoma urged delay, saying the bill has "serious problems."

Among other concerns, the senators said the new initiative costs too much and would fund "morally dubious" activities such as needle-exchange programs for drug addicts.

Further, the letter expressed major concerns about the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. The senators wrote, "The [Global] Fund has serious policy problems, drug quality problems, administrative corruption, and [it] operates programs not bound by U.S. laws on abortion, needle exchange, prostitution/trafficking policy and others."

Over five years, the new PEPFAR bill would give the Global Fund $10 billion -- a quarter of the fund's budget. But the U.S. has only one vote out of 20 on how the money is spent.

The senators also want to reinstate wording from the original PEPFAR bill specifying that 55% of AIDS monies will go for treatment.

Prevention first

An AIDS-prevention authority on the frontlines in Africa, Ruteikara agreed the Global Fund has serious problems that merit more U.S. oversight, but he questioned whether 55% of AIDS monies should be spent on treatment.

"HIV-testing and treatment are good, but they won't stop the pandemic," Ruteikara said. "With six Africans becoming infected for every person who gains access to treatment, we can't treat our way out of this tragedy. Effective prevention must come first."

Coburn, a physician, and others have argued that anti-retroviral treatment will do more than just prolong lives; it will prevent new AIDS cases by making the HIV virus less infectious and, therefore, less likely to be transmitted.

But in The Lancet, a leading British medical journal, James Shelton of USAID called this theory a "myth" unsupported by science. Shelton observed that as people become healthier on anti-retroviral treatment, they're likely to become more sexually active, creating further chances for the virus to spread.

Physician Norman Hearst of the University of California, San Francisco, agreed that "treatment is important, but it's not prevention."

"In sub-Saharan Africa, prevention must be linked to sexual behavior, because that's what fuels the pandemic," Hearst explained. Whereas most Westerners are monogamous -- one sex partner at a time -- many Africans, even when married, have one or two long-term lovers on the side. In a young-adult survey in Botswana, where one-third of the population carries the HIV virus, 43% of men and 17% of women reported having two or more regular lovers.

"The latest evidence shows it's these long-term, overlapping multiple partnerships that drive the pandemic," Hearst said. "This new scientific understanding that the African pandemic is fueled by people having more than one current sex partner explains why public-health campaigns urging sexually active adults to be faithful have worked so well in Africa."

ABC

Between 1991 and 2002, Ugandans lowered the proportion of the population infected with HIV from 21% to 6% with their famous ABC (Abstain, Be faithful, or use a Condom) campaign -- with "B" as the pillar. "We promoted fidelity for sexually active people, abstinence for young people, and condoms only as a last resort," Ruteikara said.

In response to the campaign, the number of Ugandan men embracing monogamy shot up from 59% to 79% -- and the number of faithful women rose from 79% to 91%. Rates of new HIV infections fell by two-thirds.

"Uganda provides the clearest example that HIV is preventable if populations are mobilized to avoid risk," Cambridge University researchers Rand Stoneburner and Daniel Low-Beer wrote in Science magazine. They likened Uganda's plunge in casual sex to the equivalent of an AIDS vaccine that's 80% effective.

What's more, prevention advocates say, sexual behavior change is a bargain. "HIV treatment costs an estimated $1,000-per-patient per added year of life. Uganda's successful prevention campaign cost less than 30 cents per person per year," says Edward Green, head of Harvard's AIDS Prevention Research Project.

"Because we knew what to do in our country, we succeeded," Ruteikara wrote in the Post. But he said that when "international AIDS experts" arrived in Uganda, they came with their own "casual-sex agendas," which they forced on Africans -- even to the point of rewriting Uganda's National Strategic Plan, which guides how PEPFAR money is spent.

Ruteikara reported that he and his fellow Ugandans would repeatedly put abstinence and fidelity into the National Strategic Plan. "Repeatedly, foreign advisors erased our recommendations. When the document draft was published, fidelity and abstinence were missing." Meanwhile, a suspicious statistic blaming most HIV infections on marriage appeared. Repeated requests for the source of the statistic have gone unanswered, the priest said.

"As fidelity and abstinence have been subverted, Uganda's HIV rates have begun to tick back up," Ruteikara wrote. "The Western media have been told this renewed surge of HIV infection is because there are 'not enough condoms in Uganda,' even though we have many more condoms now than we did in the early 1990s, when our HIV rates began to decline."

Off course

Green said that Western "sexual freedom ideologies" have caused successful AIDS-prevention strategies to be derailed in Africa, perhaps costing millions of lives.

"If AIDS prevention is to be based on [scientific] evidence rather than ideology or bias, then fidelity and abstinence programs need to be at the center of programs for general populations. [...] What the churches are inclined to do anyway turns out to be what works best in AIDS prevention," Green and his Harvard colleague Allison Herling Ruark wrote in the April issue of First Things.

In a 2004 "common ground" statement in The Lancet, 150 global AIDS-prevention leaders agreed fidelity should be the first-line prevention strategy for population-wide epidemics like those in sub-Saharan Africa.

The Senate bill mentions fidelity, but not as a central priority. Instead, the initiative, if passed, will fund a wide array of commodities and services to combat AIDS indirectly -- from HIV tests and Chlamydia treatments to female condoms. The latter are more expensive than male condoms -- and so unpopular in Africa that Uganda has stopped importing them.

Only 20% of funds in the new PEPFAR bill would go for prevention. Ruteikara would like to see that percentage doubled until the pandemic is under control.

The only hint of a spending requirement for fidelity in the current bill is a clause stating that in the event a country chooses to spend less than half its prevention funding on fidelity and abstinence programs, a report must be sent to Congress.

The bill also calls for preventing 12 million new HIV infections worldwide, but doesn't specify how.

Calling for HIV/AIDS profiteers to "let [his] people go," Ruteikara wrote, "We understand that casual sex is dear to you, but staying alive is dear to us. Listen to African wisdom, and we will show you how to prevent AIDS."

Green said, "This is a challenging moment for Congress to unite behind objective scientific evidence, and do the right thing. If Congress puts fidelity promotions at the center of our AIDS response, billions of tax dollars will be effectively spent and millions of African lives will be saved."