HIV/AIDS in Africa: Bush’s Broken Promise


uring his 2003 State of the Union address, President Bush proposed the
AIDS Leadership Act, claiming that “this comprehensive plan will prevent
seven million new AIDS infections, treat at least two million people with
life-extending drugs, and provide humane care for millions of people suffering
from AIDS and for children orphaned by AIDS.” He touted the success of
this 5-year, $15 billion initiative in his 2007 State of the Union speech
when he said that “the number of people receiving life-saving drugs has
grown from 50,000 to more than 800,000 in three short years.” 

Many are unaware that these efforts were largely spurred by Bush’s “Christian
supporters [who] seldom get the credit they deserve for their role in the
global fight against AIDS” (

LA Times

, November 30, 2006). Also off the
radar screen is one of the most controversial clauses in the AIDS Leadership
Act that states that federal funding is unavailable “to any group or organization
that does not have a policy explicitly opposing prostitution and sex trafficking.”
Stipulations like this one, which is currently the subject of ongoing litigation,
have served to undermine the potential of foreign aid to curb the epidemic
of HIV/AIDS in Africa. (Note: this article is concerned with outreach to
sex workers whose sexual activity is consensual.) 

The manner in which wealthy countries like the United States contribute
foreign aid has drawn disapproval from those saying that the amount is
too little and is “primarily designed to serve the strategic and economic
interests of the donor countries or to benefit powerful domestic interest
groups.” To serve these interests, there are often strings attached, such
as requiring governments to “open up to trade and foreign investors” and
adhere to “enhanced patent protections” that prevent access to affordable
medications. According to Nii Akuetteh, executive director of Africa Action,
“There are conditions that are attached where the emphasis is more on countries
that open up their markets so American companies can go in and privatize
things like water and electrical service or have access to certain resources.”
Some of the most damaging restrictions, though, are the ones reflecting
moral dogma, like the sex worker clause in the AIDS Leadership Act. This
clause, however, is not without precedent. Often, a designated percentage
of U.S. foreign aid for HIV/AIDS prevention must be dedicated to abstinence
programs, although even many mainstream experts assert that there are more
effective methods. 

The politicizing of foreign aid in areas of health has its roots in the
Mexico City Policy initiated by Ronald Reagan in 1984. The policy prohibited
recipients of U.S. international family planning funds from having anything
to do with abortion, including mentioning the procedure in counseling.
This “global gag rule,” retracted by Clinton but resurrected by Bush, is
responsible for the closing of essential health clinics, including five
in Kenya, some of which “were the only affordable reproductive health services
in the area.” The AIDS Leadership Act follows this example, with devastating
effects and questionable legality. 

Many organizations have condemned the Act, resulting in two ongoing lawsuits
brought by the Alliance for Open Society International, Inc. and DKT International,
both of which have been heavily involved in preventing the spread of HIV/AIDS
in Africa. Last year, over 200 charities and organizations signed a letter
to Bush protesting the sex worker rule. Many of these organizations, with
support from the American Civil Liberties Union, have attacked the Act
for violating the First Amendment rights of U.S. organizations. According
to DKT International, the Act constrains the organization’s “speech in
other programs for which it does not receive federal funds and…forces [it]
to convey a message with which it does not necessarily agree” (

DKT International,
Inc v. USAID).

Though two federal courts ruled that the Act’s policy was
in violation of the First Amendment, the Court of Appeals of the District
of Columbia Circuit reversed the decision in the DKT

International case
on February 27.


DKT International, which receives roughly 16 percent of its budget from
the United States Agency for International Development (USAID), refused
to sign the pledge because it would result in “stigmatizing and alienating
many of the people most vulnerable to HIV/AIDS—sex workers.” This concern
was echoed by the 25 organizations that signed the ACLU’s friend-of-the-court
brief, including such varied voices as the American Foundation for AIDS
Research, American Jewish World Service, Physicians for Human Rights, and
Dr. Jim Young Kim, chair of the Harvard Medical School Department of Social
Medicine. According to the ACLU, “Many organizations that work to prevent
the spread of HIV/AIDS often reach out to commercial sex workers to distribute
condoms and offer education on safer-sex measures.” 

This point was emphasized by Chris Beyrer, the director and founder of
the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg
School of Hygiene and Public Health, in a declaration to the court in

for Open Society International, Inc. v. USAID

. Beyrer cites USAID’s own
research to support his claims: “Providing sex workers with access to education,
condoms, and other prevention tools is very effective in curbing the spread
of the disease within this community and the general population. It is
essential to involve members of the target high-risk community, such as
sex workers, in delivering the message of HIV/AIDS prevention.” It was
USAID, in fact, that released valuable information on the ways in which
stigma and discrimination “push people in high-risk groups (e.g., sex workers,
injecting drug users) underground, making them difficult to reach through
prevention programs and thus creating more opportunities for HIV/AIDS to
spread to the general population.” Though the political aspects of this
debate are highly contro- versial, there is a near consensus among health
experts that the pledge in the AIDS Leadership Act is misguided and harmful.     

Most experts agree with Paul Zeitz of the Global AIDS Alliance who says
that the most rapidly growing HIV/AIDS epidemics “are happening among sex
workers in developing countries, yet the Bush administration policy would
create an even bigger crisis.” Organizations like DKT International do
most of their work in these vulnerable nations, such as Sudan and Ethiopia,
which have some of the highest rates of infection. According to Beyrer,
groups including the World Health Organization, UN- AIDS, and the World
Bank have promoted working with commercial sex workers as an effective
strategy to fight the epidemic. Evidence of this effectiveness is clear
in nations like Brazil (which has refused to accept $40 million in American
aid because of the restrictions) and Thailand, the latter having seen rates
of infection in soldiers peak at over 12 percent in 1991 and then fall
to under 1 percent 10 years later, due to programs involving outreach to
sex workers. 

Not only have organizations seen success with these tactics, but sex workers
have formed their own coalitions to battle the virus. Women in the Indian
state of Maharashtra created the organization SAN- GRAM, “a collective
of female sex workers that grew to include thousands of members.” SANGRAM
has worked extensively against the spread of HIV, leading to a number of
international awards for their positive results. Despite these proven strategies,
no organization receiving funding from the AIDS Leadership Act could effectively
work with a group like SAN- GRAM. 

The deleterious effects of attaching politically motivated strings to foreign
aid are evident. The sex worker pledge in the AIDS Leadership Act could
hurt states that were previously on upwards paths, such as Uganda, one
of the few African countries that was reducing infection rates, but that
improvement has recently deteriorated, partly as a result of U.S. policy.
Stephen Lewis, the UN Secretary General’s Special Envoy for HIV/AIDS in
Africa, says that U.S. cuts in funding for condoms and a focus on abstinence
has contributed to a critical shortage of condoms. According to Lewis,
“There is no doubt in my mind that the condom crisis in Uganda is being
driven by [U.S. policies]. To impose a dogma- driven policy that is fundamentally
flawed is doing damage to Africa.” 

The fact that this Administration, despite these harmful restrictions and
opting for political moralizing over saving lives, has done more for victims
of HIV/AIDS in Africa than any previous Administration is a testament to
how poorly the United States, and other wealthy nations, have done in addressing
the problem. That the AIDS Leadership Act rejects the advice of health
experts in order to appease those who morally object to prostitution, though,
is unconscionable, if not unconstitutional. For true progress to be made
against HIV/AIDS and other diseases that plague impoverished populations
in Africa and elsewhere, the United States and other nations must cooperate
with local coalitions and health experts, even  at the expense of political


Activist “die-in” at international AIDS conference in 2004—photo by Paul Jeffrey/GlobalAware



Aaron Sussman is a freelance journalist, activist, and co-founder/editor
of Incite- He is also a radio host, stand-up comedian, and
works for a legal advocacy and civil liberties organization in New York