Since President Bushs inauguration in January 2001, the United Statess international and domestic aid policy has changed significantly. In a trend that echoes some of the impulses behind its post-9/11 war on terror, US aid allocation is becoming greatly influenced by homegrown religious fundamentalism.
The impact of this shift is being felt by non-governmental organisations (NGOs) across the world. Those NGOs who depend on money from the US, but who also engage with groups (such as sex workers) perceived by religious conservatives as immoral, see their funding increasingly conditional, or cut altogether. There is also growing evidence that developing or transitional nations with a high prevalence of HIV are being increasingly pressured to alter their domestic health-promotion programmes to give a much stronger emphasis on abstinence.
Also in openDemocracy on the global challenge of HIV/Aids:
Bill Bowtell, HIV/Aids: global policy after Bangkok (August 2005)
Jeremiah Norris, Misleading the poor isnt a policy: a response to Bill Bowtell (August 2004)
Donna M Hughes, The ABC approach to global HIV/Aids: good for women and girls (August 2004)
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The long-term implications of this moral hegemony cannot be underestimated. They deserve to be registered far beyond 2005s World Aids Day, for current trends suggest that US aid policy on HIV/Aids is actively seeking a position on the world stage that is increasingly solitary and out of step with majority international opinion. Whilst such a desire for isolation is not surprising or especially new, it is the nature of the position bolstered as it is by an unfettered evangelical fervour that must cause concern.
In November 2005, Unaids - the United Nations agency coordinating the fight against HIV published statistics confirming that the total number of infected people is now the highest ever. Around 40 million people live with the virus, and during 2005 an estimated 5 million people were newly infected. Ironically, HIV is quite difficult to catch aside from specific routes of transmission, and one of the tricks in its armoury is to lie dormant for years. The person is infectious, but may have no idea that he or she is infected. Another trick is less a matter of pathology and more of cultural mores: it involves sex, and it is this single fact that creates the bulk of the growing controversy around how best to control HIV.
ABC: the model of choice
For sub-Saharan Africa, the behavioural intervention most heavily promoted to reduce HIV transmission is the ABC approach (Abstinence, Be faithful, otherwise use a Condom). Rather than a purely linear model, it is more a toolbox offering a series of choices: and it is the selection of one or more of these that has had the most significant positive impact.
In Uganda, ABC has arguably reduced the incidence of HIV from 16% in 1992 to 6% in 2002, boosted by three developments: international aid was forthcoming; condoms were available; the government was on board.
The ABC model does have its problems it tends to gloss over gender inequality but it is from a moral perspective that ABC is currently attracting the ire of the US, which takes the firm view that abstinence should be the only option for unmarried couples.
Herein lies the root of growing dissension between the US and NGOs in the field, understandably perplexed at how such a moralistic agenda has crept into mainstream US aid policy. The chief US aid agency, Usaid, is adopting increasingly pro-abstinence language (euphemistically known as delayed sex) and developing partnerships with faith-based organisations happy to align with a moralistic agenda.
Uganda itself is a case in point: according to Human Rights Watch, increasing emphasis on abstinence, partnered by a decreasing emphasis on condom use, has been bolted on to large-scale Usaid-funded education programmes across the country. Critics allege that the apparent seizure of stocks of condoms by the Kampala government earlier in 2005 was part of this policy. Meanwhile, the US has threatened to cut funding for condom provision, stirring Stephen Lewis, the highly vocal (and Canadian) UN special envoy for HIV/Aids to Africa, to proclaim this is a dogma-driven policy that is fundamentally flawed (and is) doing damage to Africa.
There are further problems. Brazil refused $40m of US aid in May 2005 because it refused to agree to a declaration condemning sex work. The American Civil Liberties Union expressed deep concern in November 2005 about US government policy limiting funds to NGOs not explicitly opposing sex work: a policy known as the global gag.
The problem of moral hegemony
The conflation of disease and morality is as old as disease itself, and many people are not surprised at the extreme moral stance of some groups in the US, but the mainstreaming of this opinion suggests that a fortress US mentality is becoming more entrenched than ever. It was evident too at the G8 summit in Scotland in July 2005; there, the US was reluctant to align itself with proposals to address world poverty, including the 0.7% target for overseas development aid (which the US had previously committed to) and an international finance facility (IFF) to support debt relief.
The US prefers its own mechanisms the millennium challenge account instead of the IFF, and the presidents emergency plan for Aids relief (Pepfar, launched in 2003), worth a total of $15 billion. Its funds are allocated by the US congress for overseas projects, thus circumventing another major funding stream not entirely under its control, the Global Fund to Fight AIDS, TB and Malaria (a UN initiative). A third of the Pepfar funds are to be used for abstinence until marriage programmes.
So, why is this a bad thing? Why shouldnt the US which as a donor gives more in total aid than any other country demand certain conditions? After all, the notion of calling for aid recipients to be more accountable has been part of development discourse for a number of years: the idea that there must be better ways of managing aid than simply parachuting it into needy countries is certainly not a uniquely US position.
Moreover, the US approach wont prevent HIV transmission. For example, shifting the focus onto abstinence or delayed sexual activity alone as a method of preventing sexually-transmitted infections is at best unproven and at worst egregious. ABC has limitations, but its strength is its choice. Promoting abstinence does not prevent the spread of sexually-transmitted diseases: people will have sex, and trying to prevent this through policy initiatives usually fails as the Catholic church has found to its chagrin. The US, because it is keen to pursue an agenda that provides clear delineations between us and them, is forcing country-level programmes to turn their backs on what has been the only successful single intervention so far to reduce the number of new HIV infections.
The United Statess isolation
It is often said that it is a mistake to attempt to legislate morality. It could also be a mistake to moralise development. Morality is essentially a standard or benchmark, predicated on an assumption that some even many will fail. Founding HIV prevention on this is fundamentally wrong. Pursuing such an intellectually barren course is simply one example, however, of an increasingly isolated superpower attempting to mould the world into its own image.
It is encouraging that US hegemony on morality is not universal. On World Aids Day 2005, the British prime minister Tony Blair speaking on behalf of the European Union is expected to support a broad range of interventions to prevent HIV transmission, including access to condoms and support for NGOs working with at-risk groups. It is unlikely that Washington will be listening: for the United States of George W Bush is now on the road to being a lone state both politically and morally.
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