We will never turn you away . . . AIDS, Abortion and Effective U.S. Policy

“We have no medicines.

Many hospitals tell people, you’ve got AIDS,

we can’t help you. Go home and die.”

— African doctor quoted by President Bush

State of the Union Address, January 28, 2003

Contents

• Executive Summary
• 1. President Bush’s Emergency Plan for AIDS Relief
• 2. The Current Epidemic
• 3. The Wrong Paradigm
• A. The Conventional Wisdom: HIV in Africa is Transmitted by Heterosexual Sex
• B. AIDS and Ideology
• C. New Evidence: HIV in Africa is Transmitted by Unsafe Injections and Poor Medical Practice
• 4. Ineffective Methods of Prevention
• A. Deadly Combination: USAID AIDS/SRH Integration
• B. Victimization of Women
• C. Dirty Needles, Tainted Vials, and the Spread of HIV/AIDS
• D. Norplant, Sterilizations, and Blood Transfusions
• E. Manual Vacuum Aspirators, Abortion, and the Transmission of HIV/AIDS
• F. Are Condoms Safe Sex? Over Reliance on Condoms—False Sense of Security
• 5. Current Proposals
• A. The Global Fund (Worst Option)
• B. USAID AIDS/SRH Integration (Actually Integrated with Global Fund on the Ground)
• C. Abstinence
• D. Rebuilding Africa’s Health Care System
• 6. Policy Recommendations

Contents

• Executive Summary
• 1. President Bush’s “Emergency Plan for AIDS Relief”
• 2. The Current Epidemic
• 3. The Wrong Paradigm
• A. The Conventional Wisdom: HIV in Africa is Transmitted by Heterosexual Sex
• B. AIDS and Ideology
• C. New Evidence: HIV in Africa is Transmitted by Unsafe Injections and Poor Medical Practice
• 4. Ineffective Methods of Prevention
• A. Deadly Combination: USAID AIDS/SRH Integration
• B. The Victimization of Women
• C. Dirty Needles, Tainted Vials, and the Spread of HIV/AIDS
• D. Norplant, Sterilizations, and Blood Transfusions
• E. Manual Vacuum Aspirators, Abortion, and the Transmission of HIV/AIDS
• F. Condoms and “Safe Sex”
• 5. Current Proposals
• A. The Global Fund
• B. Integrated AIDS/SRH Programs
• C. Abstinence
• D. Rebuilding Africa’s Health Care System
• 6. Policy Recommendations

–>

Executive Summary

1. President Bush’s Emergency Plan for AIDS Relief

2. The Current Epidemic

3. The Wrong Paradigm
A. The Conventional Wisdom: HIV in Africa is Transmitted by Heterosexual Sex
B. AIDS and Ideology
C. New Evidence: HIV in Africa is Transmitted by Unsafe Injections and Poor Medical Practice

4. Ineffective Methods of Prevention
A. Deadly Combination: USAID AIDS/SRH Integration
B. Victimization of Women
C. Dirty Needles, Tainted Vials, and the Spread of HIV/AIDS
D. Norplant, Sterilizations, and Blood Transfusions
E. Manual Vacuum Aspirators, Abortion, and the Transmission of HIV/AIDS
F. Are Condoms Safe Sex? Over Reliance on Condoms—False Sense of Security

5. Current Proposals
A. The Global Fund (Worst Option)
B. USAID AIDS/SRH Integration (Actually Integrated with Global Fund on the Ground)
C. Abstinence
D. Rebuilding Africa’s Health Care System

6. Policy Recommendations
–>

Executive Summary

The need for effective AIDS relief in Africa, as called for by President Bush, is tragically self-evident. Three and a half million people were newly infected with the disease in Africa alone in 2002, out of 5 million worldwide. Millions already die each year, yet transmission rates in many Sub-Saharan African countries are so startlingly high that the HIV/AIDS epidemic continues to spread. Of the estimated 42 million people worldwide who are currently HIV positive, nearly 30 million reside in Africa. One in 11 adults is infected with the disease. According to conservative demographic projections, there will be 300 million fewer Africans in 2050 because of the scourge of AIDS.

Past programs have been ineffective or, what’s worse, have actually contributed to the spread of the disease. They have been based on a false premise—that HIV/AIDS in Africa was transmitted primarily by sex between men and women.

Many influential AIDS experts believe that heterosexual transmission and the sexual behavior of Africans accounts for 90% or more of HIV infections in African adults. But a series of new meta-analyses reveals that the real culprit may be medical transmission. These studies posit that unsafe injections and other medical exposures to contaminated blood may account for two-thirds or more of the new cases of HIV/AIDS. In this new view, heterosexual sex is, at most, responsible for one-third of the spread of HIV in Africa.

The current approach to HIV/AIDS relief as practiced by USAID (United States Agency for International Development) and the United Nations Global Fund (GF) seeks to combine, or “integrate,” HIV/AIDS relief programs with “sexual and reproductive health” (SRH) programs. Such “integrated” programs certainly raise the possibility of increased nonsexual transmission. They bring HIV positive and HIV negative patients together in the same setting, and subject both to invasive medical procedures.

Among the procedures that may have directly contributed to the spread of HIV/AIDS in Africa are the reuse of injection equipment and multidose vials of injectable contraceptives such as Depo-Provera or other medications used for STD (sexual transmitted disease) treatment and antenatal care. Other family planning procedures which may serve as vectors for nonsexual transmission are Norplant implantation and abortion (called “post-abortion care”) by manual vacuum aspirator (MVA).

This problem has been exacerbated by foreign aid programs which emphasize reproductive health procedures (contraception, sterilization, and abortion) to the near exclusion of primary health care. Clinics are well supplied with Depo-Provera, IUDs, and condoms, but lack health care essentials such as needles, syringes, rubber gloves, and disinfectant. Medical equipment, such as syringes and manual vacuum aspirators, cannot be properly disinfected before they are reused. The local blood supply may be tainted, providing yet another vector for HIV transmission.

The over reliance upon condoms that characterizes these programs is not without its drawbacks as well. The accompanying “safe sex” message creates a false sense of security that may encourage promiscuous behavior. New studies show that the condom does not provide absolute protection against HIV.

President Bush has proposed a program based on abstinence before marriage, fidelity within marriage, and condoms for the intemperate. Abstinence stops heterosexual transmission absolutely and should be promoted.

But the safe sex message is insufficient. Millions of married and monogamous couples on the African continent have gotten HIV/AIDS from poor medical procedures. To stop the infection of additional innocents we need to stop funding existing “integrated” AIDS/SRH programs, and shift these resources back into primary health care where they belong. Hundreds of millions of lives are at stake.

Steven W. Mosher

President

Population Research Institute

President Bush’s “Emergency Plan for AIDS Relief”

In the best tradition of compassionate conservatism, President Bush has proposed an “Emergency Plan for AIDS Relief” in Africa and the Caribbean. Bush’s plan, unveiled during his 2003 State of the Union address, is to offer medical treatment to those with the disease as well as prevent its further spread. In his own words:

Today, on the continent of Africa, nearly 30 million people have the AIDS virus—including 3 million children under the age 15. There are whole countries in Africa where more than one-third of the adult population carries the infection. More than 4 million require immediate drug treatment. Yet across that continent, only 50,000 AIDS victims—only 50,000—are receiving the medicine they need.

Because the AIDS diagnosis is considered a death sentence, many do not seek treatment. Almost all who do are turned away. A doctor in rural South Africa describes his frustration. He says, “We have no medicines. Many hospitals tell people, you’ve got AIDS, we can’t help you. Go home and die.” In an age of miraculous medicines, no person should have to hear those words.

AIDS can be prevented. Anti-retroviral drugs can extend life for many years. And the cost of those drugs has dropped from $12,000 a year to under $300 a year—which places a tremendous possibility within our grasp. Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many.

We have confronted, and will continue to confront, HIV/AIDS in our own country. And to meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief—a work of mercy beyond all current international efforts to help the people of Africa. This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS.

I ask the Congress to commit $15 billion over the next five years, including nearly $10 billion in new money, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.

This nation can lead the world in sparing innocent people from a plague of nature.¹

The President’s proposal addresses both the treatment of persons already infected with the disease and the prevention of its further spread. AIDS treatment programs involve drug therapy for persons already infected with HIV and are largely noncontroversial. Few would disagree with the President that anti-retroviral AIDS treatment can “extend life for many years.”

AIDS prevention programs, in contrast, are highly controversial, primarily because they have so spectacularly failed to stop the epidemic. President Bush nevertheless asserted that “AIDS can be prevented,” going on to speak of a “comprehensive plan [that] will prevent 7 million new AIDS infections.” Abstinence programs are what the President had in mind. It was no accident that the President of Uganda was sitting in the Gallery during the President’s address. Alone among the African states, Uganda has dramatically reduced the number of AIDS infections over the past decade. It has done this by stressing abstinence before marriage, and fidelity within marriage, rather than relying solely upon a condom-based approach.

Although the President clearly favors an abstinence-based approach, such an approach is foreign to the thinking of the current crop of HIV/AIDS “experts.” They are lobbying hard for an expansion of current programs, in which HIV/AIDS programs are “integrated” with “sexual and reproductive health” programs. Yet these latter programs, which are more accurately referred to as “family planning” or “population control” programs, have spectacularly failed to check the spread of HIV/AIDS. As spending for these programs has increased over the past decade, HIV/AIDS cases have skyrocketed.

The Current Epidemic

For the first time since the Black Death in the Middle Ages, a disease is sending whole nations into absolute demographic decline. AIDS was first recognized in the late 1970s. In the years since, some 25 million people have died of the disease.² Yet the deadly virus continues to spread with horrifying rapidity in many parts of the world. Today, approximately 42 million people are infected with the AIDS virus worldwide. Millions die each year, yet transmission rates in many of these countries are so startlingly high that the HIV/AIDS epidemic continues to claim millions of new victims. While over 3 million died of HIV/AIDS in 2002, for example, five million more were newly infected that year.³

The chief region affected by the HIV/AIDS crisis is Sub-Saharan Africa. It is home to 70% of the adults infected with the virus, and 80% of the children. In the Republic of South Africa, for example, over 13% of the total population is infected with the virus.⁴ According to conservative demographic projections, there will be 300 million fewer Africans in 2050 because of the scourge of AIDS.

The demographic impact of AIDS, especially in Africa, is so pronounced that in the late 1990s the U.N. Population Division (UNPD) began to factor into global and country population projections the geometrical impact of AIDS mortality. In 1998, the UNPD designated 35 countries as “highly affected.” By 2000, this list of “highly affected” countries had grown to 45.⁵

AIDS shortens life spans, raises the death rate, and may, in “highly affected” countries, reduce the overall population. By 2015, in Africa’s 35 “highly affected” countries, average life expectancy of 48.3 years is projected to be 6.5 years less than it would have been without AIDS. An estimated 42 million people worldwide are currently HIV positive, with most of these residing in Africa and the Caribbean. They will, barring life-extending retroviral treatment, all be dead within a decade. By 2050, because of AIDS mortality, the overall population in these same 35 African countries is projected to be approximately 270 million less than it would have been without AIDS. Speaking of sub-Saharan Africa as a whole, there will be 300 million fewer Africans in 2050 because of deaths from HIV/AIDS.⁶ Even this number, as large as it is, fails to convey the enormous devastation wrought by AIDS, which leaves millions of broken families and orphans in its wake.

These United Nations projections, with their intolerably high levels of mortality and infection, are based on the continuation of current protocols for HIV/AIDS treatment and prevention. In the next section we shall examine AIDS prevention programs in detail, and show why they have proven themselves ineffective at stopping the African epidemic.

The Wrong Paradigm

The need for effective AIDS relief in Africa, as called for by President Bush, is tragically self-evident. But before we throw $15 billion at the problem, we must understand that past HIV/AIDS programs in Africa have failed. Even more importantly, we must understand why they have failed. It is not because they lacked resources, but rather because they were based on a false—and deadly—premise of reckless promiscuity among Africans. Many AIDS experts have long maintained that heterosexual transmission and the sexual behavior of Africans account for 90% or more of HIV infections in African adults. But the series of published studies by Gisselquist, Potterat, and their colleagues, published in three parts in the March 2003 issue of a respected peer-reviewed journal, the International Journal of STD & AIDS, suggests that the chief culprit may be medical transmission.^{7, 8, 9} Infected needles and infected blood, in other words.

This brilliant meta-analysis of African AIDS studies should be read by all concerned about the future of the African peoples. In the first part, the authors propose that “existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic.” In the second, they discuss “how health care transmission of AIDS in Africa was ignored” in previous studies. In the third, and final, article, they estimate the actual percentage of HIV/AIDS cases in Africa that was transmitted heterosexually, as opposed to medically.

These studies empirically demonstrate that unsafe injections and other medical exposures to contaminated blood may account for two-thirds or more of the new cases of HIV/AIDS. In this new view, heterosexual sex is, at most, responsible for one-third of the spread of HIV in Africa.

This mistaken paradigm, driven by a fixation on reducing African populations through failed programs that may spread HIV/AIDS, has cost millions of lives.

The Conventional Wisdom: HIV in Africa is Transmitted by Heterosexual Sex

In the late eighties, influential AIDS experts wrongly concluded that heterosexual sex was playing an exceptional role in the African AIDS epidemic. In a prominent 1988 article in Science, Piot et al wrote that “Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation.”¹⁰ That same year the World Health Organization’s (WHO) Global Program on AIDS circulated estimates that 80% of HIV infections in Africa was due to heterosexual transmission, 10.8% was from mother-to-child transmission, 6% from blood transfusions, 1.6% from contaminated medical injections and other health care procedures, and 1.6% from men who have sex with men (MSM) and injection drug use (IDU).¹¹ Similar estimates emerged from Zaire’s National AIDS Control Program and the United States Centers for Disease Control at that time.¹² By mid-1989, an overview of global HIV epidemiology by leading AIDS experts at the Fifth International Conference on AIDS did not even mention medical injections as a risk for HIV.¹³

Once this paradigm was firmly in place, it tended to be self-perpetuating. Epidemiological evidence of medical transmission of AIDS by unsafe injections and other medical exposures to contaminated blood was ignored or misrepresented. As Gisselquist et al note, “The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in Africa . . . . has suppressed inquiry and dissent. Hence, from 1988 the consensus has been self-reinforcing, as researchers in Africa . . . have often assumed sexual transmission without testing partners, without asking about health care exposures, and when conflicting evidence nevertheless emerges—such as infected adults who deny sexual exposures to HIV—routinely rejecting it.”¹⁴ The predictable result of this stultification of the scientific process has been the acceptance of heterosexual transmission of AIDS in Africa as fact. The World Health Organization now claims that “current estimates suggest that more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex.”¹⁵ 99%! A recent special series in the Lancet on Africa’s HIV/AIDS epidemic averred that most infections are from heterosexual intercourse, while “blood transfusions, injections with infected needles, and scarification are thought to represent only a few infections.”¹⁶

But on what evidence were these sweeping conclusions based? As Gisselquist et al note, “We have been unable to locate any document—from the 1980s or later—that describes a process to estimate a 90% sexual contribution to Africa’s HIV epidemic from empirical studies of risk factors for HIV.”¹⁷

So where did the “consensus” come from?

AIDS and Ideology

Very early on in the African epidemic, AIDS was demographically associated with sexually active populations, principally prostitutes and their clients.^{18, 19} This association seems to have caught the attention of various interest groups which, for diverse ideological, political, and financial reasons, promoted the notion of heterosexual transmission in their publications, proposals, and press releases.

First, many in the foreign aid community shared the conviction that Africa was “overpopulated,” and that both the world and Africa would be a better place if fewer African babies were born.²⁰ In order to drive down the birth rate, ongoing population control programs relied upon the promotion and distribution of condoms and contraceptives. Those who supported or participated in these anti-natal programs would be inclined to emphasize the role of sexual transmission in African HIV/AIDS as an additional argument for condom promotion and distribution.

Second, in 1984 USAID began piggybacking its HIV/AIDS programs onto preexisting family planning programs. Organizations which applied for and received funding for such “integrated” programs—so-called because they brought together HIV prevention and pregnancy prevention under the same roof—may have been inclined to emphasize sexual transmission of HIV in their grant proposals and reports. If “unprotected” sex was driving up both the birth rate and the HIV/AIDS rate, then their integrated AIDS/SRH clinics were the answer to both crises.

Third, HIV/AIDS was identified in the Western mind with homosexuals (also called MSMs, or men who have sex with men) and injection drug users. As Gisselquist et al write, “[I]t was in the interests of AIDS researchers in developed countries—where HIV seem stubbornly confined to MSMs, IUDs, and their partners—to present AIDS in Africa as a heterosexual epidemic.”²¹ Homosexual activist Randy Shilts writes in his account of AIDS in America that “Nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS.”²² And, one might add, the public, the Congress and the grant makers.

Fourth, as Packard and Epstein have documented, “the role of sexual promiscuity in the spread of AIDs in Africa appears to have evolved out of prior assumptions about the sexuality of Africans.”²³ That is to say, Africans were imagined to have too much sex with too many partners in circumstances that were too risky. These assumptions have little basis in reality. As Brewer et al report, “Levels of sexual activity reported in a dozen general population surveys in Africa are comparable to those reported elsewhere, especially in North America and Europe. Perhaps more importantly, there appears to be little correlation with the level of risky sexual behavior shown in these surveys and the epidemic trajectories observed in these countries.”²⁴

Fifth, as Gisselquist et al notes, “health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that “a health message—e.g., to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected.”²⁵

In short, individuals and organizations read into the African situation their own biases (against people in general and Africans in particular), and their own agenda (a heterosexual epidemic and immunizations). The result was what Gisselquist et al call the “ignoring and misinterpreting of epidemiologic evidence.” This is very, very strong language for a scientific journal to publish.

New Evidence: HIV in Africa is Transmitted by Unsafe Injections and Poor Medical Practice

In their second study, Gisselquist, Potterat and their colleagues examined all the evidence on African AIDS transmission available through 1988, before what they call the “premature closure of the debate” led “researchers in Africa . . . [to] often assume sexual transmission without testing partners, without asking about health care exposures, and when conflicting evidence nevertheless emerges—such as infected adults who deny sexual exposures to HIV—routinely rejecting it.”¹ In all, they reviewed 22 separate studies. What they found is startling:

• Injections were more highly associated with HIV than sex. “Published epidemiological evidence from 1984-88 in Africa shows higher average crude PAFs [population attributable fractions, a measure of risk] associated with injections than with measures of sexual exposure.”²⁷
  
  


• Most of those infected with HIV were in a long-term monogamous relationship. “Although some adults may have under-reported numbers of sexual partners, the consistency of the evidence suggests a large majority of HIV infections in non-promiscuous adults, and little concentration in the general population according to sexual activity.”²⁸
  
  


• Those of higher socioeconomic status have higher rates of HIV than those of lower status. “Since STD [sexually transmitted disease] have long been associated with lower socioeconomic and educational attainment, it was at least equally plausible that associations between high status and HIV pointed to differences in health care rather than sexual behavior.”²⁹  That is to say, the more “health care” one was exposed to, the greater one’s risk of developing HIV.


• 
  
  Clinic attendance was associated with HIV. “Comparison of HIV prevalence and incidence in STD clinics with prevalence in general population studies suggests that risk for HIV infection was associated with clinic attendance.”³⁰
  
  


• 
  
  Infants were medically infected with HIV. “High rates of HIV infections in children that could not reasonably be attributed to vertical [that is, mother-to-child] transmission.”³¹

In the third, and final, article, Gisselquist et al estimate the actual percentage of HIV/AIDS cases in Africa that was transmitted sexually. The figure they come up with—25 to 35%—is far below the 90% hypothesis customarily assumed by researchers.³² This rate of sexual transmission is only a third or less of what would be necessary to account for the expanding HIV/AIDS epidemic.

Over the years, various attempts have been made to salvage the theory that HIV/AIDS in Africa is almost entirely the product of heterosexual sex. Many have speculated that sexual transmission is much more efficient in Africa than, say, North America. Auverrt et al speculate that the probability of contracting the disease from a casual partner is 1.³³ This is one thousand times higher than the generally accepted probability of transmission for penile-vaginal sex (about one in 1000³⁴ ), and lacks empirical foundation. Other speculations—higher rates of anal intercourse, lower frequency of circumcision, infection with STD, etc.—are similarly unencumbered by data.³⁵

Gisselquist et al urge a new effort to assess the role of medical transmission: “A growing body of evidence points to unsafe injections and other medical exposures to contaminated blood as pathways that have not yet been adequately addressed.”³⁶ The risk of infection with HIV from a contaminated medical injection has been estimated at one in ³⁰, which is 33 times higher than the risk from heterosexual sex.³⁷

Where do Africans experience such exposures, which take such a toll on African life? To answer this question, we must take a close look at existing HIV/AIDS and family planning (also called “sexual and reproductive health”) programs, and the relationship between the two.

Ineffective Methods of Prevention

Deadly Combination: USAID AIDS/SRH Integration

The belief that HIV/AIDS in Africa was sexually transmitted was freighted with consequence. It led directly to the current approach to HIV/AIDS relief, as practiced by the United States Agency for International Development, the United Nations Global Fund, and other national and international agencies. This is the so-called “integrated” approach, which piggybacks HIV/AIDS programs on existing “sexual and reproductive health” programs, also known as family planning programs. If both HIV and pregnancy are both a result of “unprotected” sex, and you want to reduce the incidence of both, then it makes perfect sense to attack them simultaneously, out of the same clinics, with the same staff, and utilizing the same equipment.

The USAID has been promoting the integrated AIDS/SRH approach since 1984, when the numbers of those infected with HIV in Sub-Saharan Africa could still be counted in thousands, rather than millions. In the years since, USAID reports that it has spent over $2.3 billion in its “fight against the global AIDS pandemic.”³⁸ The lion’s share of this money has gone to Africa, and into integrated programs. The integrated approach received a further boost in 1994, when it was endorsed by the Cairo Conference on Population and Development. Other countries began combining HIV prevention with population control in their own foreign aid programs.

Integrated AIDS/SRH programs are thus the “gold standard” in HIV prevention. Family planning NGOs hoping to be on the receiving end of a USAID grant are well-advised to adopt this paradigm and to testify to its effectiveness. So we find Population Action International (PAI), a USAID-funded population control group, averring that “Prevention efforts need to promote the integration of sexual and reproductive health services, including family planning, maternal health care, and STI/HIV prevention and care, especially for young people. In the absence of a vaccine, preventive measures such as sexual health education and provision of condoms that provide dual protection from both sexually transmitted infections (STIs) and unwanted pregnancies remain the most effective and affordable interventions for slowing the HIV pandemic [italics added].”³⁹

Neither the international consensus on the importance of integrated AIDS/SRH programs, nor the billions of dollars poured into these programs through organizations like PAI, has checked the spread of the disease, however. On the contrary, the number of HIV cases in Sub-Saharan Africa has continued to rise exponentially. Since USAID began its integrated programs, the number of people infected with HIV/AIDS globally has increased more than one-thousand-fold, going from 43,000 in 1987, to over 14 million by 1995, to a total of about 60 million today, with an increasing percentage of these cases in Sub-Saharan Africa.⁴⁰ And the virus continues to infect record numbers each year.

Family Health International, another USAID-funded NGO, is pessimistic about the future prospects of the African people. “[W]ith the HIV-positive population still expanding, the annual number of AIDS deaths can be expected to increase for many years.”⁴¹

The reason why the integrated AIDS/SRH approach hasn’t slowed the spread of HIV in Africa should by now be obvious. It is because most HIV/AIDS cases on that continent are not the result of sexual contact at all. Rather they are the result of contact with the HIV virus through dirty needles and other substandard, invasive medical procedures. More to the point, they are the result of the kinds of procedures—Depo-Provera and other injections, Norplant insertions, IUD implantations, tubal ligations, and MVA abortions—that are a staple of AIDS/SRH clinics. The implications of this are sobering: Could the very programs undertaken to stem the HIV/AIDS pandemic be contributing to its spread?

The first thing that must be said about integrated projects is that they bring both seropositive (HIV positive) and seronegative (HIV negative) patients into the same clinic, and subject both to the same kinds of invasive medical procedures. The possibility of transmission by contaminated instruments in such a setting is obviously an ever-present danger, and one that can only be averted by taking the strictest care. We will discuss the likelihood of transmission by specific procedures below. Suffice to say here that substandard medical practices are not uncommon in Africa’s chronically under-funded, understaffed, and poorly equipped clinics, conditions which the single-minded focus of foreign aid donors on family planning has done little to alleviate.

This is not mere speculation. There is empirical evidence linking HIV/AIDS transmission directly to African clinics that provide sexual and reproductive health care. Gisselquist et al found that those who attended sexually transmitted disease clinics were at greater risk of HIV infection:

Comparison of HIV prevalence and incidence in STD clinics with prevalence in general population studies suggest that risk for HIV infection was associated with clinic attendance. In two STD clinics in Rwanda, HIV prevalence in attendees was four to nine times higher than in controls (general population samples). Among STD outpatients in Zambia in 1985, HIV prevalence in those reporting previous attendance at an STD clinic was 37% compared to 23% for first-time attendees. In another study in Zambia, 15% of HIV-negative STD patients seroconverted within two years. Among men attending an STD clinic in Nairobi in 1986-87 after recent contact with prostitute women, 8% seroconverted within an average of 15 weeks of follow-up.⁴² Brewer et al found an increased risk of HIV infection among women who received reproductive health care at African clinics. As they write: “A higher HIV prevalence has been observed in women seen in prenatal, postpartum, and induced abortion settings than in their community counterparts. In a number of studies, there appears to be a discrepancy between the observed prevalence in women undergoing reproductive medical care, and the prevalence that would be observed in such a group from heterosexual transmission alone.”⁴³ In others words, clinic attendance seems to have condemned some mothers to an untimely death.

The Victimization of Women

An examination of HIV/AIDS statistics by region and by gender reveals a curious anomaly. In areas of the world where the primary means of transmission is assumed to be heterosexual sex, such as sub-Saharan Africa, North Africa and the Middle East, and the Caribbean, the majority of HIV-positive adults are women. The United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization have recently called attention to this disparity in their AIDS Epidemic Update. In sub-Saharan Africa, for example, they report that 58% of those who have HIV/AIDS are women.⁴⁴ In the younger age groups the disparity is even higher: “[O]verall about twice as many young women as men are infected in sub-Saharan Africa. In 2001, an estimated 6-11% of young women aged 15-24 were living with HIV/AIDS, compared to 3-6% of young men.”⁴⁵

These results are surprising because they appear to contradict what we know about human sexual behavior. Cross-culturally, men are more promiscuous than women. They have more sexual partners before marriage and higher rates of marital infidelity. Moreover, some of their numbers patronize prostitutes, who are a prime vector for AIDS transmission. These are all behaviors which expose men to a greater risk of sexually contracting HIV/AIDS.

“Why do young African women appear so prone to HIV infection?” asks UNAIDS and WHO. Their answer (which of course assumes that HIV is sexually transmitted) is that African women are forced by circumstances to have sex with HIV positive men: “Women and girls are commonly discriminated against in terms of access to education, employment, credit, health care, land and inheritance. . . [R]relationships with men (casual or formalized through marriage) can serve as vital opportunities for financial and social security, or for satisfying material aspirations. But, in areas where HIV/AIDS is widespread, they [men] are also more likely to have become infected with HIV. The combination of dependence and subordination can make it very difficult for girls and women to demand safer sex (even from their husbands) or to end relationships that carry the threat of infection.”

This explanation—that African women are infected by rapacious men—may be convincing to the radical feminist mind, but it completely begs the question. Why does HIV in Africa disproportionately strike women?

The answer lies in the medical transmission of HIV/AIDS. The public health sector in many African countries has simply collapsed. African clinics are short of almost everything, from vaccines and malaria tablets to rubber gloves and needles. Little, if any, care is available to African men and women ill with malaria and other tropical diseases. Medical equipment, such as syringes, surgical instruments, and manual vacuum aspirators, cannot be properly disinfected before being reused. The local blood supply is unreliable.

The one exception to the generally dismal state of primary health care in Africa is Western-funded sexual and reproductive health programs which target women. African medical workers are taught (and paid) to emphasize reproductive health procedures (contraception, sterilization, and abortion), often to the near exclusion of primary health care. Otherwise poorly equipped clinics are kept well-stocked with Depo-Provera, IUDs, and condoms. According to Dr. Stephen Karanja, the former Secretary of the Kenyan Medical Association, “Thousands of the Kenyan people will die of malaria whose treatment costs a few cents, in health facilities whose stores are stacked to the roof with millions of dollars worth of pills, IUDs, Norplant, Depo-Provera, most of which are supplied with American money.”⁴⁶

Is it mere coincidence that the same groups that are targeted for invasive procedures are disproportionately afflicted with AIDS? We think not. Women and girls account for such a high percentage of HIV/AIDS victims in Africa because they are infected during procedures designed to disable their reproductive systems and prevent them from conceiving or bearing children. To paraphrase UNAIDS, it is the dependence and subordination of women to clinic personnel—often the only available source of health care for themselves and their families—that makes it very difficult to demand safe medical care, and to end medical relationships that carry the threat of infection.

Dirty Needles, Tainted Vials, and the Spread of HIV/AIDS

Among the sexual and reproductive health procedures that may have directly contributed to the spread of HIV/AIDS in Africa among women are the reuse of injection equipment and multidose vials of injectable contraceptives such as Depo-Provera, or other medications used for STD treatment and antenatal care. Women visiting African clinics are rarely tested for HIV before being given injections, and the likelihood that needles and syringes will be reused is high. Many of these clinics are filthy and drug use is largely unregulated.

The World Health Organization has long recognized that disposable syringes—an all-plastic syringe with a separate steel needle—are not thrown away in the developing world, but reused again and again, with all the risks that this entails.⁴⁷ Warns the WHO: “Reuse of syringes and needles in the absence of sterilization exposes millions of people to infection. Syringes and needles are often just rinsed in a pot of tepid water between injections. In some countries the proportion of injections given with syringes or needles reused without sterilization is as high as 70%.”⁴⁸ Elsewhere, the WHO reports that syringe/needle reuse “is most often reported” in Sub-Saharan Africa and Asia, and speculates that half of all syringes and needles on these continents are reused.⁴⁹ This estimate of 50% reuse for syringes and needles seems unrealistically low, for two reasons. First, as anyone who has been in an African clinic can testify, practically every kind of medical device is in short supply. It is highly unlikely that undertrained personnel would throw away a perfectly serviceable needle and syringe just on the suspicion that it might be contaminated with the HIV virus or hepatitis. Even if they did, these disposable syringes and needles are unlikely to actually find their way into a landfill. WHO admits that “In developing countries, additional hazards occur from scavenging on waste disposal sites and manual sorting of the waste recuperated at the back doors of health-care establishments.”⁵⁰ Those syringes and needles recovered from the trash are then sold on the black market to untrained lay practitioners who reuse them.⁵¹ The percentage of needles and syringes that is reused is likely closer to 100% than to 50%.

This is especially true in light of the overuse of injection in the developing world. According to the WHO, “Each year some 16 thousand million injections are administered in developing and transitional countries. . . . In certain regions of the world, use of injections has completely overtaken the real need, reaching proportions no longer based on rational medical practice. In some situations, as many as nine out of ten patients presenting to a primary healthcare provider receive an injection, of which over 70% are unnecessary. . .”⁵²

Out of the total of 16 billion injections given each year, let us assume that one in four, or 4 billion, are given to Sub-Saharan Africans. This works out to a staggering 10 million injections a day across the continent. Needless to say, the annual number of injections dwarfs the supply of syringes and needles from all sources. The sheer magnitude of the number of injections given suggests that each syringe and needle is not only reused, but that it is reused until it is literally “worn out,” that is, until the plunger no longer seals against the inside of the syringe or the needle breaks off.

Where does the limited supply of needles and syringes come from? In part from the injectable contraceptives, chiefly Depo-Provera, which are a staple of family planning programs. Depo-Provera is an injectable, progesterone-based contraceptive which acts by inhibiting ovulation. Intramuscular injections are required every three months to ensure continued sterility.

From 1994-2000, USAID provided 41,967,200 units of Depo-Provera into the developing world, at a cost of over $40 million.⁵³ But even this number, large though it is, pales in comparison to shipments by the United Nations Population Fund (UNFPA), which boasts of being the largest supplier of contraceptives in the world. The UNFPA provided about 12 million doses in 1992 and 20 million doses in 1994, including shipments for the World Bank.⁵⁴ By way of comparison, USAID delivered only 1 million doses in 1994 between August, when shipments began, and December of that year. Other countries, such as Great Britain, also purchase substantial amounts of Megastron (Depo-Provera).

Perhaps half of all these shipments are bound for Africa. Depo-Provera (or its sister drug, Megastron) is a major component of foreign-funded family planning programs in Africa. Although exact numbers are difficult to come by, the UNFPA spends more money on its African programs than in any other single region. USAID sends more units of Depo-Provera to Africa, to countries such as Mozambique, Tanzania and Nigeria, than to any other part of the world.

According to Dr. Jim Shelton, who has served as USAID’s senior reproductive health advisor since 1977, the U.S. aid agency has only shipped single-dose vials from the inception of its Depo-Provera program.⁵⁵ In a project funded by the European Development Fund, the government of Kenya imported 3 million one-dose vials of injectable contraceptive, along with an equal number of separately packed disposable syringes and needles, in March 2003.⁵⁶ It is unclear whether the UNFPA, International Planned Parenthood Federation (IPPF), or other suppliers also ship only single-dose vials, with an equal number of syringes and needles, or whether they provide the drug to end-users as multi-dose vials, with the associated risk of contamination and HIV transmission that this entails.⁵⁷

USAID-supplied vials come in packages which contain, in the words of the accompanying advertising poster, “complete injection kit for convenience.” An injection kit is a plastic syringe equipped with a steel needle. Both of these devices are reusable and are, in the impoverished African context, probably reused hundreds of times.

In Kenya, PRI (Population Research Institute) investigators recently discovered that Depo-Provera kits are available over-the-counter at a nominal price from dilapidated “pharmacies” for private use in completely unsupervised settings.⁵⁸ These kits were advertised as having been “Manufactured in Belgium by Pharmacia and Upjohn, and distributed by PSI Kenya. PSI stands for Population Services International, one of the principal recipients of USAID family planning/population stabilization funds. Encouraging the self-injection of drugs which, in the United States, can only be administered by a health care professional, raises additional questions. A number of serious warnings are listed by the manufacturer including “delay in spontaneous abortion,” “fetal abnormalities,” “thrombotic disorder” (blood clots), “ocular disorders” (“a sudden partial or complete loss of vision”), and “lactation” (the passing of the drug through breast milk to nursing infants). No reference is made to these dangers in the standard “bilingual patient information leaflet.” The “leaflet”—a single 3½” by 8” sheet—answers the question, “Is Megastron [another brand name for Depo-Provera] Safe?” by saying only: “Yes, it is safe for use. Severe side effects, like heavy bleeding is unusual. Some women may experience missing periods or spotting, but there is no need for undue concern.” No mention here of birth defects, blood clots, or blindness.

Taking Depo-Provera while not under a doctor’s care renders women vulnerable to potentially deadly or disabling side effects. As Dr. Stephen Karanja has commented, “I see women coming to my clinic daily with swollen legs—they cannot climb stairs. They have been injured by Depo-Provera, birth control pills, and Norplant. I look at them and I am filled with sadness. They have been coerced into using these drugs. Nobody tells them about the side effects, and there are no drugs to treat their complications. In Kenya if you injure the mother, you injure the whole family.”⁵⁹ To the extent that follow-up care is received, and involves injections, then these women are put at additional risk of exposure to HIV.

And where do the millions of needles and syringes distributed to the general public wind up? Bear in mind that these are individuals with no medical training whatsoever, who do not understand the germ theory of disease, and who are clueless where the sterilization or disposal of contaminated medical devices is concerned. It is safe to assume that virtually all of these “disposable” syringes and needles remain in circulation long after they have been initially used.

How many Depo-Provera “injection kits” have been shipped to Sub-Saharan Africa over the past decade from all sources? The UNFPA and the World Bank have probably averaged close to 10 million kits a year, the U.S. something less than 2 million, with assorted other organizations and donor-countries adding a few hundred thousand here and there. It is probably safe to assume that more than 100 million Depo-Provera syringes and needles have been put into circulation in Africa since the early nineties.⁶⁰ During this same decade, something like 40 billon injections have been given to Africans. And the AIDS epidemic simply exploded.

This is not the place to attempt a detailed calculation of the number of HIV/AIDS cases that have resulted from unsafe injections. But a rough calculation will suggest the dimensions of the problem. If we assume that each needle and syringe is used 10 times on a population in which 1 in 10 women are seropositive, and further that the injection transmission risk is 1 in 30, then there will be one seroconversion for each six syringes and needles. This would result in 15-20 million new cases of HIV/AIDS over the past decade.

In the past few months, in a belated recognition of the possible role played by tainted needles and syringes in the transmission of AIDS, USAID has modified the injection kits. The first change came late last year and involves the replacement of the previous reusable syringe with an “auto-disable syringe.” The plunger on this type of syringe can only be pulled back once, to aspirate the contents of Depo-Provera vial. Once the plunger is depressed, in injecting the drug intramuscularly into the woman, the plunger cannot be withdrawn a second time. The second change, which was just accomplished in May 2003, was the replacement of the standard needle size with a needle size unique to the Depo-Provera syringe. Because it is a unique size, the new needle cannot be attached to any other syringe than the one to which it is originally attached. These changes constitute a tacit admission of the dangers of providing reusable injection equipment in circumstances where poverty and over-the-counter distribution to all comers makes their reuse not merely likely, but virtually certain.

Norplant, Sterilizations, and Blood Transfusions

Another SRH procedure that may serve as a vector for nonsexual transmission of HIV is Norplant implantation. Norplant consists of six small flexible capsules made of Silastic tubing and filled with a synthetic progesterone, levonorgestrel. The capsules are surgically placed under the skin on the inner side of a woman’s upper arm where they are supposed to remain for five years and then be removed surgically. Norplant was until recently manufactured by Wyeth-Ayerst, a division of American Home Products. Although Wyeth-Ayerst has ceased production, the device is still being manufactured for use in developing countries by a Finnish firm. The Population Council holds the patent for Norplant. It is claimed that extensive clinical trials, involving some 55,000 women from 46 countries, have proven both the safety and the efficacy of Norplant. These trials, however, did not take into account the risk of HIV infection that women are exposed to in both the insertion and removal process, especially in an African setting.

Finally, it should be noted that all progesterone-based approaches to contraception, including birth control pills, entail an increased risk of contracting HIV. A 1996 study conducted by researchers at the Aaron Diamond AIDS Research Center in New York and supported by the World Health Organization found an elevated infection rate among monkeys who were given subdermal progesterone implants and also found that the vaginal epithelia of the monkeys with the implants were “significantly reduced.” The Aaron Diamond Study thus confirms that the presence of progesterone likely thins the vaginal wall and thus makes it far more vulnerable to infection by STDs or HIV during intercourse.

Sterilizations, also encouraged in AIDS/SRH programs, provide an additional vector for infection. Sterilization is relatively uncommon in Africa. Only 1% of the reported 222 million individuals sterilized worldwide reside in Africa.⁶¹ Given the relatively primitive conditions in which these operations have been performed, however, sterilization as a possible vector for HIV transmission cannot be ignored.

Blood transfusions, often required in surgical procedures, are another major, though unquantifiable, risk. The World Health Organization’s Global Program on AIDS circulated estimates in 1988 that 6% of the HIV infections in Africa were due to blood tranfusions. As Dr. Stephen Karanja has commented, “If a woman requires a blood transfusion, I wait until the last possible minute, because a blood transfusion is often a death sentence.”

Still, as Gisselquist and Potterat write, “ Importantly, [the
data] point to injections—not blood transfusions—as the
main health care risk.”⁶²

Manual Vacuum Aspirators, Abortion, and the Transmission of HIV/AIDS

Another sexual and reproductive health procedure that may have directly contributed to the spread of HIV/AIDS in Africa among women is the widespread practice of performing abortions with hand-held suction abortion syringes under the guise of “menstrual regulation” or “post-abortion care.” Since at least 1991 a company known as International Products Assistance Services (IPAS) has been manufacturing and distributing these syringes, generally referred to as manual vacuum aspirators or MVAs, to countries in Africa and elsewhere. An MVA consists of a long plastic tube attached to a large syringe. The model in current use, called the “IPAS Double-Valve Aspirator,” contains a 60cc aspirator, or syringe, to which plastic cannulae [tubes] sized 4-12mm can be attached “for use in uterine evacuation for several clinical indications.” The tube is inserted into the cervix, and the plunger on the syringe is pulled back by hand to suction out the contents of the uterus. “Aspirator holds evacuated tissue for easy examination,” IPAS assures the user.⁶³

This crude and dangerous operation, known in many African clinics as simply “the procedure,” is the most common form of abortion in Africa. It is performed without anesthesia, up to and beyond 16 weeks gestation. A Marie Stopes International (MSI) clinic operator in Kenya told a PRI investigator that the procedure can be performed up to 20 or 24 weeks gestation “if the technician is brave.” But, he warned, “the women tend to cry.”⁶⁴ No doubt. Attempting to extract a second-trimester fetus 12 to 14 inches in length and weighing 1 to 2 pounds using a cannula with a maximum diameter of only 12 millimeters (1/2 inch) must be a daunting—and gruesome—prospect for all concerned.

In the context of the HIV/AIDS epidemic in Africa, MVA abortions hold a significant risk of infection. First, the forcible dilation of the cervix can cause abrasions. Second, despite IPAS’s promise that “The flexible design [of the polyethelene plastic tube] can reduce the risk of uterine perforation, this remains a significant risk, especially as the gestational age of the fetus to be aborted increases. Third, the “whistle cut” or “scoop” opening near the end of the tube can also scrape or nick the uterus.

The MVA and its detachable tubes not only can be reused again and again, like past Depo-Provera syringes and needles, it is intended to be reused. “Reusable aspirator results in very low per-procedure cost,” IPAS advertises. But it goes on to warn that “In the United States, the cannulae are strictly single-use. Where reuse is required and local regulations allow, the cannulae must undergo sterilization or high-level disinfection before reuse.⁶⁵ [italics added]

The cannulae are “strictly single-use” in the United States because plastic is notoriously hard to sterilize. So why would reuse be required in overseas settings like Africa where it is highly unlikely that the requirements laid down by the manufacturer for “sterilization or high-level disinfection” of these plastic tubes could be met? Because IPAS knows that its principal clients, which are USAID grantees and other agencies that purchase this abortion equipment for shipment to Africa, are supplying far too few cannulae for the number of abortions that are being performed.

Women visiting African clinics are rarely tested for HIV before being given an MVA abortion, and the syringes and the tube used for this procedure will almost certainly be reused in the days following. It is difficult to estimate the likelihood of transmitting the HIV virus by means of an infected MVA. Given the trauma and bleeding associated with the procedure, however, the transmission efficiency is probably as high or higher than that of an injection, which is 1 in 30. In 1997 the World Health Organization estimated that in Sub-Saharan Africa there were 4,400,000 unsafe abortions performed each year, leading to 32,800 cases of maternal mortality.⁶⁶ If the number of MVA abortions performed annually is in this range, then these hand-held suction abortion syringes may be a prime vector of HIV/AIDS transmission, infecting hundreds of thousands of women each year.

While some HIV positive women may be aborted by clinic personnel who do not know their HIV status, others may be specifically targeted for this procedure precisely because they have the disease. There is credible evidence that, in some countries, abortion is being used as a means of AIDS prevention. The U.N.’s World Health Organization (WHO) has condoned and promoted this method of preventing the mother-to-child transmission of AIDS, writing that “Access to safe abortion and counseling to ensure informed decision making and consent by the women, should be part of the services [for pregnant HIV positive women].”⁶⁷

The HIV/AIDS epidemic is also being used by some to justify the legalization of abortion, on the grounds that the best way to prevent mother-to-child transmission is to end life in utero. A recent conference in Haiti, entitled “A quest for legislation for protecting public health and the rights of people living with HIV/AIDS,” provided a forum for advocates of aborting HIV victims. As one participant, a Haitian lawyer, asserted, “To deny a woman the right to undergo abortion, when we know that the risks of transmission of the virus to the baby at birth are very high, would be to deny her the freedom of choice.”⁶⁸

But is the risk of mother-to-child transmission (MTCT) as high as this suggests? MTCT can occur during pregnancy, at the time of delivery, and after birth through breastfeeding. According to the World Health Organization, “Based on a compilation of studies, it is estimated that MTCT rates, without any anti-retroviral intervention, range from 15 to 30% in the absence of breastfeeding, to 25 to 35% if there is breastfeeding through 6 months and to 30 to 45% if there is breastfeeding through 18 to 24 months.”⁶⁹ Delivery techniques can further reduce the rate of mother-to-child transmission, as can anti-retroviral therapy. Even without these kinds of special interventions, only one of every four or five babies born to seropositive mothers will be seropositive at birth. Most newborns of HIV/AIDS mothers do not carry the virus. Should all be terminated because some fraction of their number will contract the disease?

MVA abortion as “AIDS prevention” constitutes an absolute betrayal of trust. It is population control masquerading as HIV/AIDS prevention. It harms women, eliminates their unborn children, and further contaminates medical devices that will be used on subsequent, HIV negative patients.

Condoms and “Safe Sex”

The AIDS virus is transmitted from one person to another by contact with an infected person’s body fluids. In Africa, the Caribbean, and many parts of the world heterosexual sex was, until recently, believed to be the primary means of transmission.⁷⁰ This is why barrier methods of birth control, chiefly the condom, were early pressed into service to combat the epidemic.

Over the past 20 years, HIV/AIDS prevention programs have centered on the large-scale distribution of condoms. These have been combined with “safe sex” propaganda campaigns aimed at convincing the public that putting a layer of latex between sexual partners can guarantee protection against infection by the HIV/AIDS virus. Population Services International, a USAID-funded group, uses aggressive and ubiquitous advertising campaigns to flood the media with a pro-condom message. These “safe sex” campaigns involve, to use PSI’s own martial language, a constant “barrage of radio spots and films shown on television, in cinema halls, and on [PSI’s] fleet of mobile film vans” all extolling the perfect protection afforded by condom usage.⁷¹

But the “safe-sex” approach, designed to induce a “behavioral change” (wearing a condom), has not been effective in reducing the incidence of HIV/AIDS. A study published in the Lancet and reported in the AIDS Weekly found that promoting safer-sex made no difference in a Ugandan intervention trial.⁷² Numerous studies, on the other hand, have repeatedly shown that promoting abstinence and being faithful to a single sexual partner resulted in significant declines in HIV incidence in Uganda.

On the macro level as well, there is no evidence that throwing boatloads of condoms at the epidemic has had a significant impact. Over the course of the nineties, USAID shipped approximately 5 billion condoms abroad.⁷³ Billions of others came from the UN Population Fund, the UK’s Overseas Development Agency, and other providers. Yet, despite this flood of condoms into the developing world, the rate of HIV/AIDS infection continued to grow at startling rates. The number of victims increased one thousand-fold, from just over 40,000 in 1990 to over 40 million in 2000. Why is this?

One answer may be suggested by a review of the scientific evidence on condom effectiveness conducted by the National Institutes of Health (NIH).⁷⁴ Citing a study by Davis and Weller, NIH postulated that condoms, if consistently and properly used, provide an 85% reduction in HIV/AIDS transmission risk.⁷⁵ While no one would deny that this reduction in risk is significant, it is far from being the perfect protection promised by the “safe sex” propaganda funded by USAID. Even paved with condoms, the road to promiscuity still leads to death.

The failure of condoms to provide perfect protection against HIV/AIDS is also suggested by studies of condom use for the prevention of pregnancy. Approximately 3% of couples who reported using condoms consistently and correctly (considered “perfect use”) are estimated to experience an unintended pregnancy during the first year of use.⁷⁶ If sperm can find their way around the latex barrier, then so, presumably, can the AIDS virus.

To further complicate matters, the presumed protection resulting from using a condom may lead to behavioral changes that completely negate the protection. For example, an individual who believes that consistent and correct use of condoms provides near-absolute protection against HIV/AIDS may engage in recklessly promiscuous behavior that they would otherwise avoid. Why? Because they have been led to believe that, by practicing “safe sex,” they are immune from contracting the disease. In this way, the rate of HIV/AIDS transmission may not be reduced at all by the “safe sex” message, but actually increase over time.

A recent article in Lancet, the premier British medical journal, suggested that a condom-based approach, by creating a false sense of security on the part of users, had not only failed to stop the spread of AIDS, but had actually exacerbated the problem. The authors drew a parallel with the seat belt law that was projected to dramatically decrease the number of traffic fatalities. Instead, the number of deaths remained roughly the same, as drivers took risks they previously would have avoided because they felt safer. Perhaps this is one of the reasons why, despite massive shipments of condoms overseas, the rate of HIV/AIDS infections continues to grow.

And so we come full circle. Family planning programs instituted to reduce fertility rates have actually contributed, in various ways, to the spread of AIDS. Africans can be forgiven for wondering if this was an intended consequence, for it was surely an avoidable one.

Current Proposals

The Global Fund

The idea for a Global Fund originated with U.N. Secretary General Kofi Annan who, in 2001, called for the establishment of an international organization, modeled on the World Bank, to fund groups working on HIV/AIDS, tuberculosis and malaria.

The Global Fund to date has received pledges exceeding $2 billion from U.S. and foreign governments. Under a current proposal, the Fund would receive an additional $1 billion from the U.S. alone over the next five years. These funds would likely be disbursed from the Department of Health and Human Services (DHHS), a domestic agency with little international experience. The monies would disappear into a secretive bureaucracy, the World Bank, there to be commingled with the contributions of other nations before being disbursed by the World Health Organization to groups around the world.

Critics of the Global Fund warn that its operations are both inefficient and opaque. While billions of dollars have been committed, little has been done to date. Thirteen months after Annan’s call to action, WHO announced it had approved 61 Global Fund proposals for 43 countries, along with three multi-country proposals. At that time, 21 proposals were fast-tracked for approval, despite WHO’s own admission that there “is a need for greater clarity about the roles and responsibilities of the country coordinating mechanisms and, most urgently, the means by which funds can be transferred to the successful applicant.”⁷⁷ Today, two years later, GF projects are underway in only four countries.

Despite the World Health Organization’s demand for “greater clarity,” the Global Fund remains anything but transparent. The Fund has been reluctant to provide information about the international organizations it intends to fund. A number of international organizations, most notably the International Planned Parenthood Federation, have been outspoken in their support for the Fund, however. Collaboration between abortion supporters in Global Fund and IPPF appears imminent. IPPF praised the first Global Fund grants and, in particular, lauded the appointment of Richard Feachem to be the executive director of the Fund.⁷⁸ Feachem reciprocated with praise of his own, saying that “With family planning organizations in over 180 countries worldwide, IPPF provides the ideal outlet for HIV/AIDS education and prevention programs. As Executive Director of the Global Fund to fight AIDS I look forward to working with [newly appointed IPPF Director-General] Dr. Sinding in the future.”⁷⁹

Will Global Fund AIDS projects carry out abortion? Most likely. The World Health Organization promotes “termination of pregnancy” as a method to prevent the spread of AIDS.⁸⁰ Saying that the spread of AIDS can be checked by abortion is no less reprehensible than saying that abortion should be used as a means of population control—an idea that many nations have forcefully rejected as genocidal. Another indication of the Global Fund’s tendencies in regard to abortion is the fact that it has sought the active participation of the UN Population Fund in “country coordinating mechanisms” (CCMs). The UNFPA, of course, has been cited by U.S. Secretary of State Colin Powell for its involvement in coerced abortion in China.

The Global Fund also supports the normalization of prostitution in Africa. Ignoring the views of Ugandans, Kenyans and other Africans who are strongly opposed to prostitution, U.N.-sanctioned “AIDS prevention” programs work to legitimize the prostitution “industry” and emphasize the “rights” of “sex workers.” UNAIDS prevention programs service prostitutes, and their clients, with “reproductive health” supplies—including condoms and abortions—and are silent about the exploitation of women and girls sold or trafficked into sexual slavery.

The so-called Global Fund for AIDS threatens to draw U.S. tax dollars into support for many anti-life causes. Not only is the Global Fund associated with groups that promote and support abortion, prostitution, and homosexuality, it is rife with bureaucratic and regulatory problems. The Global Fund should be zero funded.

Integrated AIDS/SRH Programs

The current approach to HIV/AIDS relief, as practiced by the United States Agency for International Development and other national and international agencies, is to piggyback HIV/AIDS programs on existing “sexual and reproductive health” programs, also known as family planning programs. We have already discussed in Section 4(A) how integrated AIDS/SRH programs have not only failed to check the spread of HIV, they may actually be spreading the disease. They bring both seropositive (HIV positive) and seronegative (HIV negative) patients into the same clinic, and subject both to the same kinds of invasive medical procedures using often-contaminated instruments. They are also a source of contaminated needles and syringes for inappropriate (and often deadly) reuse by others in the community.

Like any well-funded program, the integrated AIDS/SRH approach to AIDS relief has its strident supporters, chiefly USAID’s major “family planning” NGOs like Population Services International, Family Health International (FHI), and Pathfinder International. These have adopted and aggressively promoted the integrated AIDS/SRH model, and in return receive tens of millions of dollars from U.S. taxpayers each year to provide HIV/AIDS services through their existing programs.⁸¹ International Planned Parenthood Federation, which expects to be a major beneficiary of increased international spending on HIV/AIDS, has launched a major public policy campaign to preserve the AIDS/SRH integrated paradigm for AIDS relief.⁸² Such groups concentrate on the social marketing of condoms and “safe sex” behavioral change, and give little thought to both abstinence before marriage and fidelity within marriage. The fact is, such marketing techniques necessarily promote a lifestyle which contributes to the sexual transmission of AIDS. Indeed, the “AIDS awareness” education promoted by these groups often misrepresents abstinence and denigrates natural forms of family planning which rely upon fidelity and periodic abstinence.⁸³ For example, in Kenya, the USAID-funded NGO Family Health International merely touches on abstinence before passing quickly to the marketing and distribution of oral and injectible contraceptives for women and teenagers. Women who say they practice abstinence are nonetheless encouraged to accept contraception, and the risks of contraceptives and the benefits of abstinence are not provided.⁸⁴ International abortion groups such as IPPF, UNFPA and Population Action International explicitly denigrate abstinence and its role in AIDS prevention.

Currently, many USAID-funded groups operate population control programs that supposedly include “abstinence education.” The trouble is that abstinence is often only a fig leaf for the promotion of condoms and abortifacient contraceptives. Family Health International is promoting sex-education to children and teens in schools throughout the developing world,⁸⁵ clean needle exchange programs and condom use among teens and adults—anything and everything, it seems, except abstinence.⁸⁶ Population Action International promotes a condoms-first approach to AIDS relief.⁸⁷

USAID speaks of preventing HIV/AIDS by seeking a “common ground” between faith-based groups that reject abortion, population control and casual sex, and groups that do accept them.⁸⁸ But how can groups which are driven by an ideology that denies the possibility of self-control where sex is concerned possibly take abstinence seriously? Integrated programs are unable to effectively promote abstinence.

Integrated programs also promote MVA abortion. USAID-funded Pathfinder International promotes so-called post-abortion care (PAC) with manual vacuum aspiration, in the Caribbean and South America and elsewhere. With the support of IPPF, Pathfinder has integrated reproductive health programs components involving euphemistic abortion (MVA) into HIV/AIDS projects designed to prevent mother-to-child HIV/AIDS transmission. The International Planned Parenthood Federation performs abortions and promotes AIDS/SRH integration.⁸⁹

Finally, integrated AIDS/SRH programs are also suspect from the point of view of the African peoples. While AIDS is ravaging Africa, and threatens to reduce the populations of many countries, developed world donors, led by USAID, continue to spend hundreds of millions of dollars on thinly veiled “population stabilization” efforts. Is it any wonder that African leaders are beginning to denounce such programs as racist and even genocidal?

Abstinence

The effectiveness of abstinence in HIV/AIDS programs can be demonstrated by Uganda’s approach to the epidemic. Uganda’s HIV-prevalence has decreased from 21.2% in 1991 to only 6.2%. Why?

In the late eighties Ugandan President Yoweri Museveni learned that hundreds of thousands of Ugandans, including a third of his army officers, were HIV-positive. He launched the much-vaunted ABC program, whose initials stand for “Abstain,” “Be Faithful,” and “Use a Condom”—in that order. Museveni, and other Ugandan officials, promoted the message of sexual purity via official speeches, school curricula and billboards.

Under the Bush administration, USAID has praised Uganda’s program, pointing out that from 1989 to 1995, the number of Ugandans who reported having a casual sexual partner declined from 30 to 20%. This drop in recreational sex was coupled with a decline in HIV prevalence, from 15 to 5% between 1991 and 2000.⁹⁰

Many health experts readily admit that Uganda owes its success in combating AIDS to abstinence. “Uganda’s outstanding success really has American heads turning,” said Dr. Milton Amayun, World Vision’s HIV/AIDS international program representative. “Experts in the U.S. are starting to see the value of teaching people to limit their sexual relationships within the context of marriage.”⁹¹ Abortion and family planning groups continue to dispute this obvious point, arguing that condom use, not abstinence, was key to the decline in HIV prevalence in Uganda. Planned Parenthood and its research arm, the Alan Guttmacher Institute (AGI), claim that “Abstinence is not a significant factor” in Uganda’s decreased rate of HIV prevalence. AGI reported that increased condom use in Uganda, between 1995 and 2000, “is likely to be a significant contributing factor” in lowering Uganda’s rate of HIV prevalence.⁹²

The relationship between increasing abstinence and lower rates of HIV prevalence is too striking to be ignored or explained away, however. Abstinence has also resulted in lower levels of STDs and probably, although there is no data on this, fewer clinic visits and injections. Uganda receives relatively less amounts of USAID injectable contraceptives than many other African nations. In fact, Uganda’s falling HIV prevalence may be related not just to lower sexual transmission of the disease, but to lower medical transmission as well.

Abstinence, not condoms, is the key to stopping the AIDS epidemic in Africa.

Rebuilding Africa’s Health Care System

Abstinence works not only because it stops heterosexual transmission absolutely, but because it frees resources to be spent on good medical practice.

By breaking through the AIDS/SRH integrated paradigm, genuine public health services abroad can be strengthened, and AIDS relief will be effective. The medical transmission of HIV by the reuse of dirty needles and syringes can be halted.

Without a strong commitment to effective prevention, untold numbers will die. Stubborn and ideological reliance on failed measures of the past is nothing less than betrayal. Failure to develop new, effective methods of AIDS relief is nothing short of turning away the people whom we purport to help. A new and effective approach to AIDS relief will extend lives, provide hope, and stem the spread of HIV/AIDS.

Policy Recommendations

The United States is committed to AIDS relief. Will we rely on the failed methods of the past, which will perpetuate the spread of HIV/AIDS?

Or will we turn to new, effective methods of AIDS relief in foreign aid?

Here is what must be done:

IDENTIFY ABSTINENCE-ONLY GROUPS TO IMPLEMENT ABSTINENCE PROGRAMS: Since USAID-funded NGOs that implement AIDS/SRH integrated programs publicly advance a pro-condom, anti-abstinence ideology, it is vital that other groups, including faith-based groups, be recruited to implement abstinence programs.

SEPARATE HIV/AIDS PROGRAMS FROM SEXUAL AND REPRODUCTIVE HEALTH (FAMILY PLANNING) PROGRAMS: The incautious “integration” of HIV/AIDS and SRH programs has endangered millions. These programs must be separated. Pathfinder International is already complaining publicly that: “Forcing organizations to create an artificial separation between family planning and HIV/AIDS services will mean thousands of missed opportunities to educate people [in the need for population control] and prevent the spread of the disease.”93 This is exactly backwards. Separating out these two services will save thousands of lives by preventing the spread of the disease in a clinic setting.

SUPPORT DRUG TREATMENT THERAPY: Currently, 4 million AIDS victims require anti-retroviral drug therapy. In Africa, only 50,000 AIDS victims are receiving the drug therapies they need. Anti-retroviral therapy extends life. It is a prescription for hope. The cost of this therapy has been dramatically reduced, from $12,000 per year to under $300. In addition to abstinence, funding for AIDS treatment must be key. Providing the 4 million AIDS victims who currently need drug treatment must be a priority. Preparing to treat the estimated 50 million people currently infected with HIV/AIDS must also be a key priority.

NO ABORTION: Since abortion is not only an ineffective method of AIDS prevention, but a betrayal of trust as well, it is imperative that the Bush Administration execute wide discretion over AIDS policy and funding to expand pro-life protections to AIDS programs. Abortion groups must not receive U.S. funds to run so-called AIDS programs.

NO GLOBAL FUND: All U.S. AIDS relief must be bilateral. The Global Fund, a conduit for abortion promotion, must not be funded.

PERMANENT POLICY: Finally, congressional efforts must be made to secure these policies under future administrations.

The vision of an effective AIDS program in Africa based on abstinence laid out by President Bush is at once far-reaching and compassionate. But the realization of this vision is threatened by groups that promote “sexual and reproductive health.” Driven by an ideology that denies the possibility of self-control where sex is concerned—even in the face of death—that seeks to control population growth, and that promotes abortion on demand, they oppose effective AIDS relief, proposing in its stead a continuation, indeed, an enlargement, of the failed programs of the past.

“Turning the tide against AIDS” in the area of prevention will require more than an expansion of existing programs. Indeed, as the “tide” metaphor suggests, it will mean moving in a completely different direction, away from pornographic sex education in African schools, away from dirty clinics and infected needles, away from the massive distribution of condoms, towards an approach that emphasizes abstinence and self-control.

Only then can we say, in good conscience, to the African people, “We will never betray you, we will never turn you away.”