Politics, Policy and Prevention in the Battle Against HIV/AIDS in Africa

On April 17, 2006, Pangea hosted an education session addressing the intersection of US policy and HIV/AIDS prevention and treatment in Africa.  A brief recap of each presentation is provided below.  If you would like more details, including the speakers’ contact information, please send an email to Pangea at info@pangeagiving.org.       

Politics of US Aid:  The Rapid Scale-Up of HIV Care in Mozambique
James Pfeiffer, MPH, PhD
Associate Professor, University of Washington

HIV/AIDS presents a tremendous challenge to the people of Mozambique.  In 2002, HIV prevalence was 13.6%, with 1.26 million people infected.  Mozambique also has relatively limited domestic resources to address the challenge; roughly US$8/capita on healthcare overall.  Mozambique is, however, working to “scale up” programs to deliver prevention and treatment services to a substantial portion of the population.  This effort provides an interesting case study of some of the problems exacerbated by US HIV/AIDS policy in Africa, as well as possible solutions.

To date, Mozambique’s HIV/AIDS response has focused primarily on prevention, with relatively few resources devoted to HIV care and anti-retroviral drug treatment (ART).  To the extent care has been provided, efforts have been made to integrate it with other programs.  As it tries to scale up its programs and provide substantial HIV care, it needs to secure external funding and wishes to do so in a way that does not undermine other programs.

An early funding source for this undertaking was the Clinton Foundation (CF).  CF aspired to deliver ART to all citizens meeting certain criteria, as part of a comprehensive system of prevention, care and treatment.  CF intended to rely upon Mozambique’s Ministry of Health (MoH) and the national healthcare system for program implementation, strengthening that system.  To achieve the objectives set by Mozambique and CF, roughly US$330 million in funding would be required over a five year period.  The World Bank and European governments joined CF as donors, but the largest prospective donor was the US government, through the US Agency for International Development (USAID) and the President’s Emergency Plan for Aids Relief (PEPFAR).   US government funding was, however, subject to several problematic constraints. 

• The first constraint was that ART funding be used to purchase branded drugs.  In 1999, the cost of branded drugs was roughly US$10,000/person/year.  In contrast, CF was able to negotiate “generic” ART drugs from Indian manufacturers for roughly US$150/person/year.  Clearly a “branded drug” constraint would significantly limit the number of people that could be treated and impair Mozambique’s efforts to scale up its solutions.  Pressure from MoH and other major donors, eventually resulted in some concessions from the US government:  funding can not be used to purchase generic ART drugs, but it can be used for other HIV/AIDS programs.     

• The second constraint related to the administration of funds and programs.  While CF and others wanted to work through MoH, the US government emphasized the role of nongovernmental organizations to administer the funds and programs.   Similarly, the US government wanted separate reporting systems (i.e., parallel to MoH systems) for program administration.  At best, this second constraint would do little to strengthen the MoH and national healthcare system.  The creation of parallel programs also had the potential to create inefficiencies that would limit the ultimate scale of the program.  Again, in response to pressure from MoH and other donors, the US government offered some concessions: US funding would not go to a common fund managed by MoH, but an effort would be made to coordinate programs funded by the US and the common fund.

There are other implications of US policy on HIV/AIDS in Mozambique.  For example, the US imposes a “global gag rule” on funded organizations, prohibiting them from offerings abortion-related services, including counseling.  As a result, reproductive health care services in Mozambique have been limited, impairing efforts at prevention and early treatment.  US policy generally favors the promotion of abstinence over condom usage, despite cultural and other practical conditions limiting the effectiveness of this policy.  Finally, US funding generally requires labeling of resultant products and services as such, potentially creating inefficiencies and impacting US good will. 

Hopefully, with the encouragement of African governments and other donor organizations, the US government will continue to assess its policy on HIV/AIDS funding and make other changes that allow its investments to be more efficient and effective.     

Rights Have No Borders
Megan DeRhonghe, JD
Associate Director, Planned Parenthood Global Partners

 Across Africa, 21 million people have died of HIV/AIDS.  Another 40 million are infected, with 75% of those being women.  Preventing the further spread of HIV/AIDS is critical.  Unfortunately, politics and policy are impeding prevention in important ways. 

A first example is the “global gag rule,” also known as the Mexico City policy.  The rule roughly posits that, if an organization providing reproductive health care services receives funding from the US government, it is precluded from using its own non-U.S. funds to provide abortion-related services, including legal abortions and medical counseling or referrals regarding abortion.  While the global gag rule fosters administration abortion policy, it has had the unintended consequence of dramatically limiting gains that could have been made in preventing the spread of HIV/AIDS.  The rule has limited funding to reproductive health care service providers, a critical vector for achieving increased condom use and decreasing the spread of HIV/AIDS.

A second example involves inefficient and ineffective elements of prevention policy.  While the President’s Emergency Plan for Aids Relief (PEPFAR) admirably commits US$15 billion over a five year period, with the goal of preventing 7 million new HIV infections by 2010, only 20% of the funding is to be used for prevention and one-third of that is to be used to promote abstinence until marriage.  Although these funding constraints foster administration policy regarding abstinence, they have the unintended consequence of significantly limiting the effectiveness of the US investment in preventing the spread of HIV/AIDs.  An “abstinence until marriage” approach simply does not work in the cultural context of Africa, where, for example, HIV transmission to married partners is a significant problem. 

One way for the American public to influence the above policies is to support legislative changes reflected in, for example, draft bills entitled “Global Democracy Promotion Act” (which would revoke the global gag rule) and “Ensuring Access to Contraceptives Act” (which would exempt the supply of condoms from the global gag rule).     

 My Experience with HIV/AIDS Programs in Kenya
Odilliah Sagali, BA
Social and Community Development Officer

Ms. Sagali recently finished 10 years of work in two slums in Nairobi, Kenya.  During that time, she was involved in programs targeting slums and low-income communities and groups at high-risk of contracting HIV/AIDS.  The programs promoted community involvement and developed unique services including child-to-child and peer education regarding HIV prevention.  Involving infected peers in the education process was extremely effective.  She provided first-hand testament to the unintended consequences of US policy on HIV/AIDS prevention and treatment noted by the other speakers. 

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