Shelf Life: Bush, the AIDS President?

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We are anxious to confer upon George W. Bush a legacy. It’s no easy task–world peace is off the table, of course–and the media are still scrambling to single one out. No one wants to believe that the past eight years have been entirely destructive, but come on: Are we really going to let this president, champion of abstinence-only sex education, claim HIV/AIDS work as his legacy?

The New York Times, the Washington Post, and the Boston Globe have suggested as much, assigning legacy-level success to Bush’s $15 billion global HIV/AIDS initiative, the President’s Emergency Plan for AIDS Relief (PEPFAR). Even human-rights purist Nicholas Kristof is a fan: Starting PEPFAR is “the best single thing [Bush] has done in his life,” he wrote in his New York Times column last year.

Setting aside the question of how high a compliment that is, it’s true that PEPFAR has done a great deal to treat HIV/AIDS by distributing antiretroviral drugs to more than a million people who need them. But on the prevention side, PEPFAR is incompatible with most countries’ needs, hardwired with concessions to the conservative religious groups that put Bush in the White House. And here in the United States, eight years spent chipping away at health funding and comprehensive sex education have facilitated growth of the epidemic, particularly among minorities.


Congress is looking into reauthorizing PEPFAR, which will present an opportunity to address some of the problems. Currently, one-third of the funds marked for prevention must go toward promoting abstinence until marriage; PEPFAR grantees must sign a pledge stating that they oppose prostitution; and PEPFAR dollars cannot be used to run needle exchange programs, even in areas where needles are the primary method of HIV transmission.

These stipulations make evaluating PEPFAR “a moral conundrum,” writes Michelle Goldberg for the American Prospect online (July 10, 2007). “How do you weigh lives saved by treatment against lives lost through policies that sabotage prevention?”

And make no mistake, lives will be lost, considering who is left out of PEPFAR’s prevention equation. The “prostitution pledge” ensures that some organizations will opt against working with prostitutes in order to up their chances of snagging PEPFAR funding. In Zambia, writes William Smith for the RH Reality Check blog (March 11, 2008), the prostitution pledge is interpreted “as an explicit direction from the U.S. government that prevention with sex workers is a risky business if you want grant money.” In the truck-stop town of Kafue, where impoverished women and girls sell sex to drivers passing through on one of Zambia’s major highways, there’s only one group handing out condoms–and it’s not PEPFAR-funded.

Regan Hofmann, editor in chief of POZ, one of the few print magazines on the HIV/AIDS beat, urges the administration to broaden its perspective. “If PEPFAR dollars cannot be used to teach safer sex, or to develop programs to unionize sex workers, or to enforce condom usage . . . perhaps the money could be used to help feed, clothe, and house these women (and men),” she writes (May 2008). Such a broad-minded approach–with added focus on education, poverty reduction, and other locally determined priorities that might not scream “AIDS prevention” on a PEPFAR grant application–would also serve other vulnerable groups, particularly women, girls, and drug addicts.

In her book The Invisible Cure: Africa, the West, and the Fight Against AIDS (Farrar, Straus, and Giroux, 2007), Helen Epstein notes that one program in Uganda–Zero Grazing, which focused on partner reduction–was very successful in the 1990s, showing a decline in HIV infection rates concurrent with a drop in the proportion of people having casual sexual encounters. Unfortunately, though fidelity is one part of the American-export ABC mandate (“Abstain, Be faithful, or use Condoms”), Epstein writes that “PEPFAR-funded programs on the ground in Africa overwhelmingly emphasized abstinence for unmarried youths; very few addressed adults or multiple partnerships directly.” As it turns out, many of the nongovernmental organizations that are carrying out PEPFAR’s work abroad are dead-set on employing the same prevention techniques that have failed in the United States.

The Epidemic at Home

No one is lauding Bush’s domestic AIDS efforts–he hasn’t put forth any–but no one’s taking him to task on the issue, either; the epidemic is gradually growing quiet. For one thing, advances in antiretroviral drugs have meant that for those who can afford them, a positive test is no longer a death sentence. The cynic in me thinks there’s something else keeping AIDS out of American headlines and off politicians’ agendas: It’s who’s getting infected these days, namely, minorities, particularly in the South. In 2005, 49 percent of new HIV/AIDS diagnoses were among African Americans; among newly infected women in the United States, 60 percent were African American.

The South sees 45 percent of new HIV infections, reports POZ (Nov. 2007), and half of the country’s AIDS deaths. “The South faces unique problems: deep and widespread poverty, a comparative dearth of federal dollars, its intrinsically rural nature, no national media close at hand, and the Bible Belt mentality once so forcefully advocated by former senator Jesse Helms,” writes Steven Petrow for the Independent Weekly (Nov. 28, 2007). To boot, one AIDS services organization hipped Petrow to a disturbing new trend: In North Carolina, large numbers of people are simultaneously testing positive for HIV and being diagnosed with AIDS, an indication that people are waiting far too long to get tested.

Some precautions that seem like no-brainers–testing prisoners for HIV, for example–aren’t as widely implemented as one might think. Prison Legal News (Aug. 2007) reports that just 10 states have mandatory HIV screening. What’s worse, 95 percent of prisons don’t provide condoms, or make available clean needles or bleach for safer tattooing. Since approximately 25 percent of people with HIV will be incarcerated at least once, and prisons are well-known “incubators and spreaders of disease,” as Prison Legal News puts it, someone ought to be investigating these outdated, prudish policies.

Among them is the preponderance of abstinence-only education in our schools, which continues to expand despite scientific (and commonsense) consensus dictating that it doesn’t work. A study published in the British Medical Journal (July 26, 2007) determined that of 13 different abstinence-only programs for U.S. youth, none reduced the rate of HIV infection.

We’ll be dealing with the fallout from this administration’s HIV/AIDS policies for years to come. Perhaps we should just let Bush’s “legacy” speak for itself.

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