HIV/AIDS and Sexual and Reproductive Health and Rights: how has funding fuelled the divide?

For a pandemic that thrives in poverty and enhances poverty, nothing could be more awash in money than HIV/ AIDS. Even though the Global Fund for AIDS, Tuberculosis and Malaria has not yet met its goal of raising US$10 billion, there is still US$7 billion more than there was in 2001 when the Fund was just formed. In addition, Bush's President's Emergency Plan for AIDS Relief (PEPFAR) promises US$15 billion for HIV/AIDS programmes around the world.

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But, as the saying goes, be careful what you wish for, in case you get it. For the first two decades of the global AIDS pandemic, activists, scientists and doctors lamented the lack of funds for effective HIV/AIDS prevention, treatment and care programmes. Millions died who could have been saved through better funded treatment and support. Millions more could have avoided infection if governments and community organisations had the finances to organise better and more effective prevention programmes. But now that money is available by the bucketful, people are still becoming infected or dying from a lack of knowledge and care. According to UNAIDS estimates, at the end of 2005, 38.6 million people worldwide were living with HIV and an estimated 2.8 million lost their lives to AIDS. (1)

Much of this has to do with money becoming available with strings attached. In particular, US funding comes with conditions that are completely at odds with empirically proven prevention programmes. PEPFAR money may not go to any programme that prefers condom promotion over abstinence. Abstinence-only programmes can be assured of receiving American funding, a fact that makes even successful condom-based programmes make 180 degree about-turns, as has happened in Uganda. Once, Uganda was a country best known for its successful HIV prevention efforts, but recently, as the US ramped up financing for abstinence-only approaches, condoms remained impounded in government warehouses. (2) In addition, programmes promoting harm reduction strategies, including needle exchange programmes, which are sorely needed in Asia and Eastern Europe, have no chance of receiving US funds.

Ideology seems to be the main obstacle to obtaining funding these days. As with the US global 'gag rule' against organisations working on sexual and reproductive health and rights, US funding now seems to be driven by right-wing religious dictates rather than scientific data. NGOs around the world have found themselves suddenly bankrupt because of the reversal of funding criteria, with those working on women's health suffering the most. At the 2004 ICPD Countdown to 2015 Roundtable in London, delegates contended that US policies concerning international sex education and reproductive health are contributing to childbirth- and abortion-related deaths as well as the spread of HIV among women around the world. Similarly, policies against harm reduction programmes for drug users also indirectly harm the women who are the partners of drug users left vulnerable to HIV infection.

Compared to PEPFAR, the Global Fund is less subject to US policy, but the Fund has been criticised for its unwieldy bureaucracy, despite good intentions. Applications for funding have to go through a country coordinating mechanism (CCM). In theory, the CCM includes representatives from governments, multilateral or bilateral agencies, NGOs, CBOs, academic institutions, and people living with HIV and AIDS, who are supposed to work together to develop and submit grant proposals. (3) In reality, this does not happen evenly across the board, or even at all, in some countries. While the Fund has tried to circumvent this to some extent by funding NGOs, such as the Thai Drug Users Coalition, directly, in most cases applications have had to go through the complicated CCM process, with varying degrees of success. Even when the Fund has disbursed money, more country-level bureaucracy has prevented funds from reaching those who need it most. For example, the Fund approved US$ 122 million to provide antiretroviral (ARV) treatment to 700,000 Indians with HIV/AIDS, yet no more 47,000 people are actually receiving ARVs. (4) Bureaucratic snags have held up the money for a year, during which time thousands of poor HIV-positive Indians have died. It is an unspeakably tragic irony.

Also problematic is the fact that major bilateral and multilateral donors exacerbate the divide between HIV/ AIDS and SRHR, as they maintain distinct departments for HIV/AIDS and SRHR, and typically fund projects and services in these areas separately. In addition, the verticality of AIDS funding has been intensified by the narrow remit of the Global Fund, which in its initial conception failed to make linkages with SRHR. (5)

Where in all this do women fit in? The short answer is nowhere. Not only is women's health threatened by ideologically-based funding policies, but the whole question of sexual and reproductive rights is slowly becoming marginalised. (6) Not because money is being diverted towards HIV/AIDS rather than SRHR programmes, but precisely because the HIV/AIDS programmes being funded are those which do not consider sexual and reproductive rights as necessary issues at all.

The reduction of women's vulnerability to HIV depends upon empowering women to make sexual and reproductive choices of their own, but these are exactly the sort of programmes that are not receiving funding. Instead, funding is being made available for abstinence-only programmes, a concept that is irrelevant particularly for married women and those who are victims of sexual violence. Indeed, most women who have become infected are married to one partner. Nor are other so-called prevention programmes meant to empower women to take control of their sexual and reproductive lives. While antenatal testing programmes meant to save babies from infection have been effective, their effects on the babies' mothers in terms of maintaining their quality of life are still unknown. With stigma prevalent in many countries, HIV-positive women are reluctant to seek treatment for themselves, especially for gynaecological and sexual health concerns.

In addition, prevention for women has largely taken the form of mandatory testing, especially for couples intending to marry. Although touted as a means to protect women, in reality this disempowers women by taking away any element of choice or decision-making. Testing without counselling does nothing to prevent women from becoming infected later in life, precisely because it does not deal with the existing power differentials between the sexes, between husband and wife.

Donors, governments, policymakers, programme managers, health services providers, and other stakeholders must recognise that to protect women against HIV infection, we need holistic approaches that address gender issues and sexual and reproductive rights issues. The reduction of women's vulnerability to HIV is contingent upon issues of education, empowerment, access, and equality. While seismic shifts in societal attitudes are needed, small steps must be encouraged. Indeed, there are small programmes in countries like Mozambique and Mali where social clubs for young girls are set up to empower them through activities and discussions on sexual health. Positively, there have even been high-level discussions calling for the advancement of the relationship between SRHR and HIV/AIDS, namely the 2004 Glion Consultation on Strengthening Linkages between Reproductive Health and HIV/AIDS convened by the World Health Organization (WHO) and the United Nations Population Fund (UNFPA). (7) Funding, however, remains the tail that wags the dog--when so many countries depend on a few ideologically-driven donors, the dog seems certain to lie down and die.

Governments would do well to remember their commitments to the ICPD Programme of Action, which clearly articulates in Chapter 7 (7.32) that "Information, education and counselling for responsible sexual behaviour and effective prevention of STIs, including HIV, should become integral components of all reproductive and sexual health services." HIV/AIDS programmes must move beyond a model focused on individual behaviour change to consider issues of violence, discrimination and power that play into women's risk of infection and inability to access treatment and support, and simultaneously work towards erasing such vulnerabilities and barriers.

Endnotes

(1) UNAIDS. 2006. 2006 Report on the Global AIDS Epidemic. http://www.unaids.org/en/HIV_data2006GlobalReport/default.asp

(2) Health GAP. August 26 2005. Media Advisory: "10 months and C and Counting: The Condom Crisis in Uganda." http://www.healthgap.org/press_releases/05/ 082605_HGAP_PA_Uganda_teleconference.html

(3) The Global Fund to Fight AIDS, Tuberculosis and Malaria. 2006. Country Coordinating Mechanisms. http://80.80.227.97/en/apply/mechanisms/

(4) Nair, Rupam Jain. 28 November 2006. "Lacking free AIDS drugs, 18 die in Indian town." Reuters. http://today.reuters.com/news/articlenews.aspx?type=healthNews& storyid=2006-11-28T124704Z_01_B87804_RTRUKOC_0_US-AIDS-INDIA-DEATHS.xml

(5) Berer, Marge. 2003. "HIV/AIDS, Sexual and Reproductive Health: Intimately Related." Reproductive Health Matters.11(22):6-11.

(6) Kaufman, Joan; Messersmith, Lisa. 2005. "Integrating the Fields of Sexual and Reproductive Health and HIV/AIDS." [unpublished] http://paa2006.princeton.edu/download.aspx? submissionId=60226

(7) WHO; UNFPA. 2006. Glion Consultation on Strengthening the Linkages between Reproductive Health and HIV/AIDS: Family Planning and HIV/AIDS in Women and Children. WHO HIV/2006.02

By Marina Mahathir, Member, International Steering Committee, Asia Pacific Leadership Forum on HIV and Development