Abstinence under attack

Lawmakers returning from a two-week recess face calls for action over a controversial report from the General Accountability Office (GAO) released earlier this month and perhaps waiting among stacks of backlogged congressional mail. The 87-page summation concludes that the Bush administration's support for abstinence programs in the treatment of AIDS is undermining other prevention strategies in AIDS crisis zones in Africa and elsewhere.

The report is a startling wake-up to faith-based organizations and others who have long pushed the so-called ABC approach (Abstinence, Be faithful, use Condoms) as a way to lower the spread of AIDS. It is a potential blow to one of the largest spending initiatives put forward by President George Bush. The audit itself is a surprise, coming barely two years into the program and with funding levels for abstinence programs still below the minimum level required by law.

Three years ago President Bush tripled the rate of federal funding to combat AIDS abroad-from $5 billion to $15 billion over five years-and reordered spending priorities to focus on prevention, including training high-risk groups in abstinence before marriage and faithfulness to one partner (AB of ABC). Although passed by Congress, the approach angered critics within the AIDS establishment, whose chief prevention strategy has been condom distribution (C of ABC) and early sex education. By moving money toward community-based groups and churches, the plan became a benchmark for how well the president's compassionate conservatism can fare overseas.

Now the president's own auditing agency suggests that the plan isn't working. "Support for abstinence programs in the treatment of AIDS is undermining other AIDS-prevention strategies," the GAO concluded. It went further to suggest that laws governing the program be modified by Congress to allow more discretion in whether government and private humanitarian groups actually implement AB programs at all.

That conclusion elicited steady calls for change from newspapers around the country. The Minneapolis Star Tribune said Congress and the Bush administration "should not insist that abstinence and fidelity be such high priorities everywhere." The Salt Lake Tribune called the report "long overdue" and said, "The current policy stubbornly promotes conservative Christian attitudes. . . . Preaching abstinence can do little to halt the spread of HIV in Africa when many people there don't understand the dangers of unprotected sex." And the Seattle Post-Intelligencer, calling for an end to the administration's "abstinence obsession," said a U.S. AIDS-fighting strategy ought to focus "more clearly on saving lives, not reshaping morality to fit a red-states political agenda."

But big print editorial boards, along with lawmakers, may need to look more closely at the report's fine print. While the GAO claims to focus on all 15 countries eligible for funding under the President's Emergency Plan for AIDS Relief (PEPFAR), auditors conducted site visits to only four of those countries (Botswana, Ethiopia, South Africa, and Zambia). The GAO sent requests for information to foreign teams in five countries but received data back from only two.

Elsewhere the GAO conducted "structured interviews" by phone with government officers based in U.S. embassies and nongovernmental agencies, or NGOs, large enough to have Washington offices. According to an appendix, GAO researchers surveyed six leading NGOs out of the hundreds that contract under the plan. And they granted anonymity to those who responded, a detail noted only in its finest print, a footnote attached to the appendix. Asked by WORLD to name those NGOs, the report's author, David Gootnick, declined. The general information contained in the appendix, he said, "is the publicly available information that is pertinent to your request."

The methods behind such methodology may be significant. The GAO report comes at a time when federal agencies supervising the AIDS plan are cutting back on grants to longtime social-service contractors-those the report hints provided information to the GAO-in favor of grassroots and faith-based organizations.

In the past year the Bush administration has cut funding to CORE, a leading AIDS-fighting consortium. It also reduced grants to Family Health International (FHI) and Population Services International (PSI), both leading condom distributors who reluctantly shifted program focus under the Bush plan two years ago in order to qualify for abstinence-based funding ("Hooked on failure," Nov. 6, 2004).

PSI staff in Uganda complained after they were forced to remove posters, billboards, and radio ads promoting condom use in 2004, with public-service messages urging youth to delay sex until marriage going up around Kampala in their place. PSI deputy director Susan Mukasa told the Associated Press that the portion of the group's U.S. prevention funding this year was not renewed, dropping its PEPFAR level from $600,000 to $100,000.

"The notion that because people have always received aid money that they'll get money needs to end," Deputy U.S. global AIDS coordinator Mark Dybul told the Associated Press. "The only way to have sustainable programs is to have programs that are wholly owned in terms of management personnel at the local level."

That's good news for faith-based charities and church groups in Africa that once could only qualify for federal AIDS-fighting money as subcontractors to the larger NGOs like PSI and FHI. Now, under the plan's New Partnership Initiative, those who qualify on their own include Samaritan's Purse, Catholic Relief Services, World Vision, HOPE (a relief organization founded by the International Churches of Christ), World Relief, and others.

The emphasis on the ABC approach as a prerequisite to funding, according to Debbie Dortzbach, director of international HIV/AIDS programs for World Relief, "has focused the priorities-bringing all prevention efforts out into the open for application. For too long the AB part of prevention was given little focus and certainly almost no funding."

Last July Mrs. Dortzbach hosted first lady Laura Bush and U.S. global AIDS coordinator Randall Tobias at a secondary school in Rwanda where World Relief runs one of the U.S.-funded abstinence programs. At that time, federal officials and members of Congress were more concerned about not spending enough on abstinence. The president's plan in 2004 allocated only 27 percent of the 33 percent of prevention funds required by law to AB programs, and in 2005 only 25 percent. Meanwhile, condom procurement under PEPFAR has increased by nearly 50 percent-from 115 million condoms in 2001 to 240 million in 2005.

Mrs. Dortzbach said she is "disappointed" by recent negative reaction to abstinence-based programs-particularly given that the required level of funding is not fully into the pipeline. But "we are not thwarted," she said. "We know abstinence and faithfulness work. We also know faithful women are particularly vulnerable in Africa, due to their unfaithful husbands. We have a lot of work still to do." Data on the success of ABC programs, she said, "will be much more concrete than the words flying around from both sides of the political divide."

Recent studies do suggest that the shift in U.S. funding priorities is having an effect in Africa even before all the money gets there. In Kenya and Zimbabwe, two countries not highlighted in the GAO report, abstinence is up while HIV prevalence is down. The journal Science reported in February that sexual activity among men age 17 to 19 in Zimbabwe dropped from 45 percent in 1998 to 27 percent in 2003. Among women age 15 to 17 over the same time period it fell from 21 percent to 9 percent. Overall HIV prevalence in Zimbabwe has dropped by 23 percent among young men and by 49 percent among young women.

Kenya's Ministry of Health has reported similar statistics, with an overall decline in HIV prevalence from 10 percent in 1998 to 7 percent in 2003. Young Kenyan men reporting more than one sexual partner dropped from 35 percent in 1998 to less than 18 percent in 2003. UNAIDS director Peter Piot admitted that the declines in HIV rates in Zimbabwe and Kenya "have been due to changes in behavior, including increased use of condoms, people delaying the first time they have sexual intercourse, and people having few sexual partners." Such implicit endorsement of the ABC approach may suggest to government auditors and other critics that the ABC success story is only beginning.