By Robert Wyrod
As the Trump presidency enters its third month, we are beginning to see the implications for the U.S. role in promoting global sexual health. Trump’s reinstatement and expansion of the Mexico City Policy, aka the global gag rule, has rightfully received much attention. By prohibiting U.S. foreign aid from funding any organization providing or promoting abortions, it severely limits America’s ability to improve sexual health in the Global South. For the many health clinics across Africa that rely on U.S. funding for reproductive health and family-planning services, this may likely mean dramatically scaling back services or shuttering clinics.
Efforts are underway to challenge the reinstatement, most prominently the Global Health, Empowerment, and Rights (HER) Act led by Senator Jeanne Shaheen (D-NH). But there is another, less-discussed issue that could have an even greater impact on sexual health worldwide, especially in Africa. Will Trump defund the President’s Emergency Plan for AIDS Relief? The PEPFAR program, launched in 2004 during the George W. Bush administration, is the largest health initiative in history focused on fighting a single disease. To date, over $70 billion has been spent on PEPFAR programs, mostly in sub-Saharan Africa. This makes PEPFAR a tempting target for the current administration, especially given Trump’s deep skepticism of foreign aid. In mid-January, the Trump transition team sent a series of pointed questions to the State Department about U.S. aid to Africa, asking “Is PEPFAR becoming a massive, international entitlement program?”
In a strange twist of fate, however, it seems the PEPFAR program may dodge the budget ax. This is due in part to PEPFAR’s unusual origin story. The program was conceived in an alliance between conservative evangelical Christians and their political allies, including Jesse Helms, who convinced George W. Bush to act decisively to “save” Africans from the scourge of AIDS. This backstory has made PEPFAR a darling of the religious right—a constituency that Trump is eager to keep in his orbit. To date, the Trump administration has said nothing about the fate of PEPFAR but it is a rare program in which an Obama-appointed director, Deborah Birx, has been allowed to stay at her post. And the fact that Birx is a lifelong evangelical Christian may have played a role in her retention.
PEPFAR has been rightfully heralded as a success in addressing AIDS in Africa, in particular the crucial funding it provides for AIDS drugs across the continent. PEPFAR’s HIV prevention programs, however, have had a much more checkered history. The conservative Christian influence strongly shaped the first iteration of prevention programs, notoriously reserving one third of prevention funds for programs promoting abstinence and “being faithful,” relegating condoms to a maligned fall-back strategy for the morally suspect. Recent studies, including one examining 22 African countries, have shown that these prevention programs, and the roughly billion-and-half dollars spent on them, did nothing to prevent new HIV infections.
These controversial prevention programs were largely phased out in the Obama years. But the question remains if they will gain new-found favor under a Trump presidency. This would indeed be a tragedy for the sexual health of millions of Africans. The science of HIV prevention has now firmly moved away from such puritanical approaches to fighting AIDS. The emphasis today is on addressing HIV prevention more holistically, including ameliorating the effects of broader social-structural drivers of infection, from gender-based violence to unemployment. Even more central to current efforts is the emphasis on getting AIDS drugs to people as soon as possible because that dramatically reduces their ability to pass on HIV to their sexual partners.
In my own research on AIDS in Uganda, I’ve seen firsthand the negative impact of prevention strategies focused on abstaining and being faithful. These approaches only serve to make sexual health issues more morally charged, and their simplistic focus on individual behavior change can shame HIV-positive people, fueling AIDS stigma. More crucially, exhortations for a person to “choose” abstinence or monogamy do nothing to address economic inequality and gender inequality, both of which are central to women’s and men’s vulnerability to HIV infection in Africa.
While PEPFAR’s emphasis on abstaining and being faithful has declined, about $50million per year is still being spent promoting abstinence and faithfulness programs. This is hardly a trifling amount and increasing it would squander scarce resources for fighting AIDS. Trump needs to reaffirm the U.S. commitment to PEPFAR but not at the expense of returning to ideologically-driven HIV prevention programs that have been resoundingly discredited.
The fundamental roles the twin axes of economic and gender inequality play in the AIDS crisis were glaringly evident in my decade of fieldwork in one community in the Ugandan capital Kampala. Unemployed men would sometimes try to compensate for being failed family providers by having multiple sexual partners. At the same time, some more-successful men would exhibit their economic status by also having multiple partners. Women, however, were stigmatized if they had multiple partners, even if such partners were economic survival strategies. Monogamous women, in turn, often had little ability to challenge their male partners’ sexual behaviors, making them more vulnerable to HIV infection. Addressing these inequalities is key to a true solution to the AIDS crisis in Africa, something well beyond PEPFAR’s simplistic, puritanical preoccupation with changing an individual’s sexual behavior.
Robert Wyrod is an assistant professor in the Women and Gender Studies Department and the International Affairs Program at the University of Colorado Boulder. His first book, AIDS and Masculinity in the African City: Privilege, Inequality, and Modern Manhood, was recently published by the University of California Press.