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More HIV funds to promote abstinence

Researchers call policy misguided

By David Kohn, Baltimore Sun, December 10, 2005

In a decision that has alarmed many public health researchers and AIDS advocates, the Bush administration is increasing the amount of HIV money that must be used to promote abstinence, while at the same time limiting funds for condoms. Opponents see the move as the latest attempt by the White House and religious conservatives to expand what they view as an unscientific and ineffective HIV prevention strategy. Critics say the approach could cost lives in the developing world.

"It's outrageous and stupid," said Duff Gillespie, a professor at the Johns Hopkins University Bloomberg School of Public Health. "From a public health point of view, it's irresponsible." Until 2002, Gillespie was in charge of AIDS programs at the United States Agency for International Development (USAID), which distributes most federal money targeting the disease.

Supporters of the abstinence approach praised the decision. "It is encouraging that the Bush administration is willing to consider alternatives to the increasingly ineffective condoms-only policy," said Indiana Rep. Mark E. Souder, a Republican.

The directive, which took effect Oct. 1, applies to only international HIV prevention. In fiscal year 2005, the U.S. spent $295 million on such programs. The budget is likely to increase in 2006.

The guideline decrees that two-thirds of funding devoted to preventing sexual transmission of AIDS must be spent on programs that encourage abstinence and fidelity.

It is described in a document from the Office of the Global AIDS Coordinator, which oversees the administration's AIDS effort. Under the heading "Key Policy Changes for Fiscal Year '06 Country Operational Plans," the document reads in part: "66 percent of resources dedicated to prevention of HIV from sexual transmission must be used for activities that promote abstinence before marriage and fidelity."

A copy of the document was given to The Sun by a federal AIDS official who was concerned that the policy would weaken the U.S. international HIV prevention effort. Fearing retribution, he asked to remain anonymous.

Dr. Mark Dybul, the deputy U.S. global AIDS coordinator, acknowledged the change but said it was based on good science and would rectify a strategic disparity. "For years, the approach was condoms only," he said. "That needs to change."

He portrayed the shift as an attempt to better adhere to legal requirements. President Bush's $15 billion AIDS bill, passed in 2003, calls for at least a third of prevention funding to be spent on "abstinence-until-marriage programs." This year, these programs accounted for about a quarter of prevention funding.

According to AIDS coordinator office rules, sexual transmission programs must make up at least half of prevention funding. The rest is used to prevent nonsexual HIV transmission, through programs that improve the safety of the blood supply and decrease the incidence of mother-to-child infection.

Dybul said that devoting two-thirds of the sexual transmission money to abstinence will simply ensure that the agency meets the law's original one-third requirement.

In many countries, however, sexual transmission programs account for much more than half of the prevention budget. The result: Abstinence-only programs will likely get an increased share of the prevention pie, often more than a third of the total.

The change implicitly sets tighter limits on spending for condoms. Previously, such programs could theoretically account for up to two-thirds of a country's prevention budget. Now, however, each country's prevention plan must allocate twice as much to abstinence and fidelity as it does to condoms.

Dybul said the change was not an inflexible imperative but a "guidance" designed to highlight a goal.

But the official who provided the guideline document, a senior HIV adviser who has worked on U.S. government AIDS programs for years, said officials at his agency are treating the change as an inflexible order.

The official said that in the region for which he is responsible, U.S. administrators have been working to adjust program funding by increasing the amount spent on abstinence while decreasing the amount spent on condom education.

"This is no longer about preventing HIV; it's about the Office of the Global AIDS Coordinator responding to a conservative social agenda," he said. "And it will absolutely cost lives, in Africa and beyond."

Abstinence-only proponents counter that encouraging virginity and monogamy can reduce HIV rates.

The new rule is the latest round in a fierce debate over how best to prevent HIV, which afflicts 40 million people around the world, according to the United Nations. Three million people died from the disease in 2004, and 5 million were infected.

On one side are most public health researchers and AIDS activists, who argue that the most effective programs promote a combination of abstinence, reduction in sexual partners and condom use.

This approach is known as ABC, for abstinence, being faithful and condom use.

"Why limit yourself arbitrarily to only certain techniques? If your goal is to stop infection, why not use everything you have available to you?" said University of California, Los Angeles public health researcher Thomas Coates, who studies HIV prevention in Africa and Asia.

On the other side are religious conservatives, who argue that "A" and "B" are much more vital than "C". Condom use, they say, encourages promiscuity and helps spread AIDS.

"'C' is an asterisk, limited to couples in which one partner is already infected," said Pia de Solenni, director of life and women's issues for the Family Research Council, a conservative activist group. "We really want emphasis on the 'A' and the 'B' part."

Most public health scientists who study HIV prevention dispute this view. "There's very little evidence that abstinence promotion works," says Bloomberg professor Chris Beyrer, a prevention expert who does research in Asia, Eastern Europe and Russia. "The 'be faithful' message is in the same category."

In contrast, encouraging condom use has been shown to reduce HIV rates, Beyrer and other researchers say.

Some observers suspect that the rule may be a response to demands from conservative Republicans on Capitol Hill.

Representative Souder, a leading congressional proponent of the abstinence approach, said his office has been "very active" in scrutinizing government prevention funding. "We will continue to monitor all HIV prevention programs, including those that emphasize condoms and abstinence, for effectiveness and cost effectiveness," he wrote in an e-mail.

Dybul heatedly denied that congressional pressure had played any role in the decision.

This is not the first time the Bush administration has been accused of making AIDS policy on ideological grounds. In February, USAID awarded $9 million to the Children's AIDS Fund to promote abstinence in Uganda, even though the group had been deemed "not suitable for funding" by the agency's expert committee.

This summer, the agency withdrew funding from an approved prevention program for Central American sex workers after conservative lawmakers complained that the project encouraged prostitution.

This year, the White House decreed that U.S. AIDS groups receiving government funding must sign a pledge opposing prostitution. More than 200 groups protested, saying the vow infringes on free speech and makes it harder to work with prostitutes, who are viewed as a key constituency in stopping the spread of AIDS.

Gillespie, of Hopkins, sees the moves as part of a pattern. "None of this thinking is encumbered by facts. We're talking ideology," he said. "There's a fundamental hostility toward the idea of policies that are driven by evidence."

A 30-year veteran of the agency, he says the current White House takes a far more ideological stance toward public health than did the Reagan or first Bush administrations.

Many researchers say the new rule could do the most harm where the epidemic is not widespread. In these countries, the disease is typically restricted to prostitutes, injecting drug users and gay men.

Programs that emphasize abstinence and fidelity generally have little success with these groups, experts say. Drug users, for example, are typically infected through shared needles; if they don't use condoms, they are likely to pass the virus to partners even if they are monogamous.

And by definition, prostitutes are engaged in risky sexual behavior. "In that context," says Coates, the UCLA researcher, "the whole notion of abstinence and fidelity doesn't make a lot of sense."

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