Cribsheets
The Legacy of PEPFAR
After speaking on his efforts to fight HIV/AIDS, President Bush hoists 4-year-old Baron Mosima Loyiso Tantoh.
(AP Photo/J. Scott Applewhite)
As President George W. Bush’s tenure draws to a close, it’s still unclear what his enduring legacy will be. It could be the complete fiasco of the Iraq war or the high levels of corruption in the Justice Department. But some point to a more positive effort: Bush’s pledge to fight HIV/AIDS around the world with the President’s Emergency Plan for AIDS Relief (PEPFAR). Congress has approved $19 billion in PEPFAR funding over the past five years, and this summer Congress approved a budget of over $48 billion more for the next five. But although Bush undoubtedly has played a major role in addressing the world’s deadliest sexually transmitted infection (STI), his emphasis on abstinence-only programs in PEPFAR could tarnish his legacy. Abstinence-only programs are at best ineffective and at worst putting millions of people at risk around the world.
What do we mean by abstinence-only programs?
Since their inception through legislation passed by Congress in 1981, abstinence-only programs have taught that abstinence until marriage is the only acceptable means of protection from pregnancy and STIs. Abstinence-only programs intentionally withhold any information that might be of use to those who have sex before marriage, have no control over sex within marriage, or cannot marry. Abstinence-only programs do not include information on how to use any form of contraception, like condoms or the birth control pill. In fact, to receive federal funding, such programs can only mention contraceptives like condoms to discuss their failure rates. This effectively discourages teens from using them. Studies show that preaching abstinence until marriage is unrealistic—more than nine out of ten Americans have sex before marriage.
What’s almost more alarming than the information these programs leave out is what they do include—biased or entirely inaccurate information. A 2004 study prepared for Congressman Henry Waxman (PDF), chair of the House Government Oversight Committee, found mistakes in a number of the most widely used abstinence-only programs funded by the federal government. For example, several curricula cited a bogus study from 1993 which states that condoms only reduce the rate of HIV infection by 69 percent. The study was discredited back in the late 1990s by both the Center for Disease Control and the Food and Drug Administration.
Moreover, a report by the advocacy group Legal Momentum found that many of these programs promote harmful gender stereotypes (PDF). For example, the report found one curriculum that outlined the following stereotype as fact: “Because girls are usually more talkative, make eye contact more often than men, and love to dress in eye-catching ways, they may appear to be coming on to a guy when in reality they are just being friendly.”
What does this have to do with PEPFAR?
Through restrictions on the use of PEPFAR funds, the United States is failing to provide at-risk men and women around the world with the tools they need to prevent HIV infection. In the past, the bulk of PEPFAR money has been spent on HIV/AIDS treatment, while only 20 percent targeted prevention. Of that money, a third had to be spent on programs that promote abstinence until marriage. An audit by the Institute for Medicine told Congress last year that this was one of the main factors keeping PEPFAR from further efficacy, especially since this restriction applies even in countries where HIV is mainly transmitted within marriage or through shared needles, rather than via extramarital sexual behavior.
Do abstinence-only programs work?
A 2007 report from a private research company, commissioned and funded by the federal government, found no differences among students who had participated in abstinence-only programs and those who had not in STI rates, rates of sexual activity, age at first sexual experience, likelihood of being abstinent, or pregnancy rates. In fact, one of the only differences it found was that students from the abstinence-only programs had a poorer understanding of the effectiveness of birth control and of condoms in preventing pregnancy and STIs.
Some policymakers are finally starting to take notice. California, Massachusetts, Ohio, Arizona, and Iowa recently joined the ranks of states rejecting federal funding for abstinence-only programming. Now 25 states (PDF) have abstinence-only funding for the upcoming fiscal year. These states are giving up a lot of money: The federal government matches $4 for every $3 a state spends on abstinence-only programs. This money comes from Title V, one of the major federal sources for such programs.
To qualify for Title V funds, the programs must exclude any information on contraceptives and focus on sex within marriage as the “expected standard for all school-age children.” Now, rather than using state funds to meet the federal match for programs known to be ineffective, policymakers and educators across the country have rejected these stifling restrictions and chosen instead to teach sex education with a more comprehensive definition of sexual health.
What’s next for abstinence-only?
Congress has already approved a large share of next year’s domestic abstinence-only funding. A lot is at stake—in 2008, the federal government allocated about $175 million for all the abstinence-only programs it supports. The money is divided into three major funding streams, including Title V as well as two programs that bypass state governments, channeling money directly to community and faith-based organizations. This money goes through huge appropriations bills for the Department of Health and Human Services (HHS).
The Bush administration, though, is seeking to protect these programs from any attacks or budget cuts they might receive in the years to come. A leaked document from HHS reveals a proposed change that would allow states to retain Title V funding for five years, from 2009 to 2013, waiving the requirement that they reapply each year. Whether or not Bush succeeds at keeping states’ abstinence-only programs immune from losing funding, these efforts represent a dangerous step backwards.
In July 2008, PEPFAR was renewed after much scrutiny and debate. New changes to the legislation attempted to soften the rigid rules dictating that a third of a country’s prevention funding be used for abstinence-only programs. This provision wasn’t included in the renewed PEPFAR funding guidelines, though a program coordinator must provide an explanation if funding for abstinence-only programs falls below half of prevention spending in countries with AIDS epidemics. Ultimately, this rule could increase the amount of abstinence-only programming in a country, even where it might be inappropriate to meet that country’s prevention needs.
Despite the mounting evidence against abstinence-only, its proponents still hold a lot of sway. Earlier this year, the National Abstinence Education Association launched a massive campaign promoting abstinence-only with the help of CRC Public Relations, the same firm that produced the Swift Boat ad campaign. And though Congressman Waxman held a congressional hearing about the effects (or lack thereof) of abstinence-only programs earlier this year, it is still unlikely that these misguided programs will disappear anytime soon.
Stephanie Gross is a Domestic Policy intern in the Women’s Health and Rights Program at the Center for American Progress and a senior at Northwestern University.
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