Policy Alert: Protesting PEPFAR


The President’s Emergency Plan for AIDS Relief (PEPFAR), signed into law in 2003, is a U.S. $15 billion initiative, spread out over five years, which funds all HIV/AIDS expenditure and activities that the U.S government provides globally. It is designed to be a ‘one-stop shop’ for all funding and activities related to HIV/AIDS. 

The initiative initially identified fourteen countries (termed focus countries) that would receive PEPFAR funding directly: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia. Vietnam was added as the fifteenth focus country in June 2004. However, while PEPFAR designates specific countries to receive funding, all spending and activities that the U.S. provides outside its domestic sphere fall under PEPFAR; therefore countries outside of the fifteen focus countries can also receive PEPFAR funding. India, over the past year and a half, has become one of these non-focus countries to receive PEPFAR funding, and in March 2005, legislation was introduced into the U.S. Congress to appoint India as a sixteenth PEPFAR focus country.

What are the main strategies of PEPFAR and their implications?

Abstinence-only funding

80% of funding in PEPFAR is allocated towards care and treatment efforts. Only 20% is committed to prevention programmes, out of which one-third is set aside for ‘abstinence- until-marriage’ programmes. 

Funding eligibility includes (and places a great emphasis on) faith-based organizations, who are known to propagate conservative, ‘abstinence-only’ ideologies.

It has been shown that ‘abstinence-only programmes’ are not effective without an equal or greater emphasis on the use of condoms. Abstinence-only emphases could have particular implications for countries like India and Vietnam, where proliferations of abstinence-until-marriage programmes will perpetuate common misconceptions about the virus and people who become infected that motivate fear, stigma, and discrimination. Moreover, the Indian government’s national HIV/AIDS prevention plan prioritizes interventions that reach the general population and young people, including sexuality education programmes and the choice of condom use in addition to abstinence and monogamy, which directly contrasts with the guidelines set out by PEPFAR.

FDA Approved Drugs

PEPFAR requires the drugs used for treatment be approved by the U.S. Food and Drug Administration (FDA) and other designated regulatory bodies. However, it specifically excludes those drugs which only have the World Health Organization (WHO) approval, whose quality control standards are already high.

This requirement in conjunction with other policies and laws in South and Southeast Asia concerning patents, local drug manufacturing processes, etc., will create additional barriers for people getting timely, low-cost, effective treatment.  

‘High-risk’ groups

HIV/AIDS prevention strategies under PEPFAR restrict provision and promotion of condom use except to specifically identified ‘high-risk’ groups that include: sex workers and their clients, intravenous drug users, mobile male populations, sexually active couples in which one partner is HIV-positive or in which one or both partners’ HIV-status is unknown, men who have sex with men and sexually active people living with HIV/AIDS.

Targeting these ‘high-risk’ groups places the responsibility of controlling the epidemic on them, as opposed to sending the message that everyone is at risk for HIV/AIDS, and that condoms are for people who want to protect themselves or each other. Consequently, the general population, including the large numbers of people who are sexually active, young and unmarried, receive a narrower range of interventions which denies and stigmatizes their sexuality, severely impacting their ability to negotiate their sexual rights and health. In India and Vietnam, where there are already low levels of literacy and knowledge about HIV/AIDS, further stigmatizing ‘high-risk’ groups sends a false message that HIV/AIDS affects only those who are identified in the ‘high risk’ categories. 

Anti-Prostitution Clause

The PEPFAR policies strongly restrict funds or any type of assistance to groups or organizations that do not have explicit policies opposing prostitution and sex trafficking. The PEPFAR guidelines make it clear that none of the funds made available under this agreement may be used to promote or advocate the legalization or practice of prostitution or sex trafficking.  

The argument regarding prostitution and sex trafficking as laid out by PEPFAR offers a narrow, simplistic view of these issues. To begin with, it conflates sex work and sex trafficking. Under this clause, organizations and groups leading several of the most effective prevention programmes with sex workers would be excluded from receiving PEPFAR funds by refusing to sign this clause that directly compromises their rights-based approach to empower sex workers. Plus, under the policy, even groups whose HIV/AIDS work has nothing to do with sex workers must sign a written pledge opposing sex work and trafficking, or risk losing funding. Such funding guidelines dismiss the fact that a range of interventions is necessary to reduce sex workers’ vulnerability. This will have a particular impact on programmes in countries like India, that have models for HIV prevention in sex worker communities based on recognizing the multiple realities of sex work.

Needle exchange programmes

Needle exchange programmes are prohibited under PEPFAR funds.

Needle exchange programmes have been shown to be effective means to prevent the spread of HIV/AIDS by providing clean and sterilized needles to injecting drug users. Refusal of funds to programmes that support this type of intervention, denies countries and populations the opportunity to identify appropriate interventions to reduce transmission of HIV according to their needs. This restriction stands in stark contrast with the Vietnamese government’s national HIV/AIDS prevention plans, whose strategies include harm reduction programmes for sex workers and injecting drug users.

Unclear Guidelines

What may be most difficult in the assessment of PEPFAR and its implications for South and Southeast Asia are the lack of clear and consistent guidelines for interpreting PEPFAR restrictions in various cultural and community contexts. Although USAID has stated that the purpose of PEPFAR isn’t to undermine ongoing national efforts for HIV/AIDS prevention in other countries and manipulate how different governments prioritize their strategies and interventions among target groups, PEPFAR guidelines are not implemented the same way across the board for all organizations. Additionally, while Vietnam may be a designated PEPFAR country, India is not; therefore, interpreting PEPFAR guidelines in India is even more ambiguous.

PEPFAR funding will not only affect those people living with HIV/AIDS; it has a host of implications for those working in rights and health. The examples of Vietnam and India highlight the potential that PEPFAR has to reverse much of the progress that has been made in HIV/AIDS prevention initiatives, reproductive and sexual health programmes and policies. PEPFAR restricts the manner in which service providers, state mechanisms and governments, and civic society render support to millions of people and their ability to access, afford, and negotiate their health.