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Rhetoric versus reality on Obama Administration’s AIDS policies overseas

Jessica Mack

This is a guest post by Jessica Mack

Jessica Mack is a global gender specialist and freelance writer. She is currently based in Bangkok, Thailand where she works on issues of violence against women and girls in the Asia Pacific region. More at You can also follow her on Twitter @fleetwoodjmack

The Obama Administration talks a lot about integrating and coordinating our various global health projects, and also about how important it is to empower women. That’s the rhetoric. Here’s one womens health advocate’s view of the reality.


Preventing the spread of HIV and AIDS has a lot to do with promoting safe sex.

That may sound obvious, but it seems to remain a mystery to those in the U.S. Government who set our AIDS prevention policies overseas. Stemming the spread of HIV has as much to do with family planning and enabling safe sex as it does with ensuring access to affordable drugs, accurate education, or changing norms and mindsets at the community level.

So it would make a hell of a lot of sense if all money for HIV/AIDS prevention efforts also included money for family planning. But alas.

Though the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been touted as one of our nation’s most successful initiatives in global health (and certainly one of President George W. Bush’s most positive legacies) it continues to miss the mark on this important point.

Oddly, PEPFAR will allow funds to be used for condoms — but only if they are promoted for protection against HIV as opposed to pregnancy.

PEPFAR recently released its 2013 country operational plan (COP), the framework for how its funding should be used by developing countries. This included what activities should and should not be supported – with one big bolded addition.

Under the section titled “Family Planning” – which extolls the importance of family planning as an effective means for reducing HIV/AIDS – is added this sentence: “PEPFAR funds may not be used to purchase family planning commodities.”

Um, come again?

This bizarre prohibition has had and will continue to have the effect of systematically cleaving contraceptive services from HIV/AIDS treatment and prevention services, oftentimes quite literally into different clinic sites and distinct service providers.

It doesn’t make sense, and it’s dangerous.

Coordinating, simplifying, health services can be particularly critical for HIV-positive women, whose reproductive health and rights are chronically overlooked. When you have limited time, financial resources, and the pressure of cultural stigma bearing down on you, the fewer clinic visits you need to make to get the care you deserve the better. Right?

When you can’t get birth control information or pills at the same place where you get your anti-retrovirals, or in the same clinic where you’ve just learned you are HIV-positive, those are needless barriers that make your life harder, and could indirectly contribute to the further spread of HIV.

“Condoms for the most part are male-controlled methods of contraception whereas methods like injectables, implants and pills are female-controlled methods,” noted Elisha Dunn-Georgiou, Vice President of Advocacy for Population Action International. The DC-based global reproductive health advocacy group has been tracking this issue for the last few years, and was the only NGO to ‘blow the whistle’ on this move by PEPFAR last week.

Other advocates for women’s and reproductive health (including supporters of good, smart aid) had seen this coming, but that doesn’t dampen our disappointment and outrage.

While earlier PEPFAR rules did not specifically dictate whether or not funding could be used for contraceptive supplies, the language over the last few years has become increasingly restrictive on this point (with many speculating that this has been done to assuage the moral concerns of key US conservative constituents).

What makes this explicit prohibition so outrageous is that the Obama Administration says it is all about integrating and coordinating our nation’s many global health initiatives. This does just the opposite.

The essential role of contraception in preventing the spread of HIV/AIDS is intuitive, obvious, and also well documented. Even PEPFAR itself says this, that it’s one key to preventing the spread of HIV is to link prevention services with women’s reproductive health services It’s not just access to contraception that is important, but access in proximity to HIV/AIDS testing, prevention, and treatment services.

Using the same funds to provide HIV/AIDS services and contraceptive services is smart and, like I said, something strongly supported in principle by the Obama Administration.

So the serious offense here is the gaping chasm between policy and practice.

As a Guttmacher Institute policy review on PEPFAR’s reluctance to fund contraception stated, “The bottom line is that the administration recognizes the critical role of unintended pregnancy prevention in preventing HIV, but does not complete the loop by paying for contraceptives for HIV-positive women who want to prevent pregnancy.”

One might wonder, is there really any point to a global health policy that does not ‘complete the loop?’

The tension between HIV/AIDS programs and sexual and reproductive health programs is not new. For years, the ungraceful verb “siloed” has been used to describe the separation between funding streams for each issue. In 2009, President Obama unveiled the Global Health Initiative, a new approach to global health policy whose key principles include “increase impact through strategic coordination and integration.”

PEPFAR is simply flying directly in the face of the Global Health Initiative’s vision and the stated objectives of the Obama Administration.


About Author

Jessica Mack

Jessica Mack is a writer, blogger and global gender consultant specializing in women's issues, reproductive health and human rights. Her work has appeared in The Guardian, Ms. Magazine, and Foreign Policy in Focus and she was formerly a senior editor for Gender Across Borders. Currently based in Bangkok, Thailand, you can contact her at jessmack[at] or follow Jess on Twitter at @fleetwoodjmack