Shelf Life: Bush, the AIDS President?

We are anxious to confer upon George W. Bush a legacy. It’s no easy task—world peace is off the table, of course—and the media are still scrambling to single one out. No one wants to believe that the past eight years have been entirely destructive, but come on: Are we really going to let this president, champion of abstinence-only sex education, claim HIV/AIDS work as his legacy?

The New York Times, the Washington Post, and the Boston Globe have suggested as much, assigning legacy-level success to Bush’s $15 billion global HIV/AIDS initiative, the President’s Emergency Plan for AIDS Relief (PEPFAR). Even human-rights purist Nicholas Kristof is a fan: Starting PEPFAR is “the best single thing [Bush] has done in his life,” he wrote in his New York Times column last year.

Setting aside the question of how high a compliment that is, it’s true that PEPFAR has done a great deal to treat HIV/AIDS by distributing antiretroviral drugs to more than a million people who need them. But on the prevention side, PEPFAR is incompatible with most countries’ needs, hardwired with concessions to the conservative religious groups that put Bush in the White House. And here in the United States, eight years spent chipping away at health funding and comprehensive sex education have facilitated growth of the epidemic, particularly among minorities.

HIV/AIDS Abroad

Congress is looking into reauthorizing PEPFAR, which will present an opportunity to address some of the problems. Currently, one-third of the funds marked for prevention must go toward promoting abstinence until marriage; PEPFAR grantees must sign a pledge stating that they oppose prostitution; and PEPFAR dollars cannot be used to run needle exchange programs, even in areas where needles are the primary method of HIV transmission.

These stipulations make evaluating PEPFAR “a moral conundrum,” writes Michelle Goldberg for the American Prospect online (July 10, 2007). “How do you weigh lives saved by treatment against lives lost through policies that sabotage prevention?”

And make no mistake, lives will be lost, considering who is left out of PEPFAR’s prevention equation. The “prostitution pledge” ensures that some organizations will opt against working with prostitutes in order to up their chances of snagging PEPFAR funding. In Zambia, writes William Smith for the RH Reality Check blog (March 11, 2008), the prostitution pledge is interpreted “as an explicit direction from the U.S. government that prevention with sex workers is a risky business if you want grant money.” In the truck-stop town of Kafue, where impoverished women and girls sell sex to drivers passing through on one of Zambia’s major highways, there’s only one group handing out condoms—and it’s not PEPFAR-funded.