Zambia: PEPFAR prevention approach too narrow - report

JOHANNESBURG, 30 June 2009 (PlusNews) - The United States President's Emergency Plan for AIDS Relief (PEPFAR) has taken a damagingly narrow approach to HIV prevention in Zambia, ignoring realities on the ground and neglecting the most at-risk populations, says a new report.

Researchers from the Sexuality Information and Education Council of the United States (SIECUS), a non-governmental organization that advocates sexual and reproductive health education and services, travelled to Zambia to determine what nearly US$577 million in PEPFAR funding between 2004 and 2008 had achieved.

Their findings are based on interviews with HIV/AIDS organizations, activists, medical professionals, community leaders, policymakers and programme participants.

PEPFAR followed the "ABC" ("abstinence, be faithful, condomise") approach to HIV prevention in Zambia, but according to the SIECUS report, in 2008 $20.5 million was channelled to programmes focused on abstinence and being faithful, compared to $12.4 million allocated to programmes promoting other approaches, including the use of condoms; only four organizations received funding to promote condom use.

"We noticed that social marketing of condoms was non-existent in the Zambian capital [Lusaka], where approximately 10 percent of the population lives," commented William Smith, vice-president for public policy at SIECUS.

In the report, Making Prevention Work: Lessons from Zambia on Reshaping the US Response to the Global HIV/AIDS Epidemic, condoms are dubbed "the silent 'C'".

PEPFAR policy emphasized condom promotion and distribution only for specific populations, such as discordant couples - in which one partner is HIV positive and the other negative - sex workers, and men who have sex with men. "The disproportionate emphasis on abstinence-until-marriage ... has created a distinctly anti-condom atmosphere," the authors noted.

President Barack Obama has overturned a policy banning funds for organizations performing or promoting abortion, like the Planned Parenthood Association of Zambia, which had also run successful condom promotion campaigns until their funding dried up. However, the anti-prostitution loyalty oath that requires all recipients of PEPFAR funds to denounce commercial sex work is still in place.

Researchers visited one of Zambia's major trucking routes, where high rates of poverty have caused the commercial sex trade to flourish, and found that only one of three organizations distributing condoms to sex workers received PEPFAR funding, and that the supply of condoms constantly ran out. PEPFAR has also failed to prioritize comprehensive sex education as a foundation for effective HIV prevention.

Many organizations receiving funding were confused by PEPFAR requirements, such as that 33 percent of prevention funds be spent on abstinence-until-marriage programmes. Although this stipulation was removed in 2008, the researchers worried that communicating this change to implementers on the ground would take time.

Most PEPFAR funding goes to international or US-based NGOs, and the failure to adequately involve and capacitate local NGOs is viewed as another shortcoming. "The relatively tiny investment in the efforts of Zambian NGOs on the prevention side raises concerns about sustainability and the further development of Zambian professionals to lead this work in the future," wrote the authors.

Among other recommendations, the report called on PEPFAR to develop the capacity of local NGOs to make more substantial contributions to HIV prevention in their country, provide greater transparency about how PEPFAR funds were spent, shift away from the ideological emphasis on abstinence-until-marriage, and invest more in comprehensive sex education.

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