Letter to U.S. House of Representatives Expressing Concern for Provision in President’s Emergency Plan for AIDS Relief (PEPFAR), February 6, 2008

February 6, 2008

Dear Representative,

We are writing on behalf of the United States Conference of Catholic Bishops (USCCB) and Catholic Relief Services (CRS) to express our strong support for continuing and strengthening the President’s Emergency Plan for AIDS Relief (PEPFAR), but also to express our profound concern regarding certain provisions in the January 18, 2008 draft of the House Foreign Affairs Committee bill to reauthorize the program. The proposed draft abandons important elements of a critical life-saving program with a proven record of success.

We understand that certain changes may have been made in the January 18 draft and that others may be under consideration. However, since we do not know the content of the bill that will be presented for full Committee approval, our comments in this letter refer to the central issues raised by the January 18 draft.

USCCB and CRS have been deeply committed to the success of the PEPFAR initiative since its overwhelming bipartisan approval by Congress in 2003. Domestically, we have been actively engaged in education and advocacy to support continued major investments in the U.S. effort to fight the global pandemic. Around the world, the Church has long been deeply involved in offering life-saving help to people threatened by HIV and AIDS, regardless of race, creed or social status. The activities of Catholic health institutions extend from major urban centers to the most remote rural villages and deliver approximately 25% of all HIV and AIDS care worldwide.

Based on the valuable experience of those most deeply involved in responding to this deadly disease, the original legislation authorizing PEPFAR was carefully negotiated, and reflects a consensus on what works in combating HIV and AIDS and how best to respond. Any reauthorizing legislation must build on that consensus and maintain PEPFAR’s strong focus on programs of proven effectiveness in prevention, care and treatment of HIV and AIDS.

Turning to the proposed reauthorization, we welcome its proposal for a major increase in funding. We also support its strengthening of PEPFAR programs to address two other seriously debilitating, often deadly, diseases that affect primarily poor people in developing countries: tuberculosis and malaria.

We appreciate two other important new provisions. The bill provides strong support for strengthening the healthcare workforce in program countries. The ever–growing demand for more healthcare professionals in HIV and AIDS is exhausting the limited pool of health care personnel that must also provide for all other health care services. The legislation also calls for strengthening food and nutrition programs—vital components of treatment and care for HIV/AIDS patients and for the support of orphans and vulnerable children.

However, the bill would also make changes in the existing program that are extremely troubling. Our concerns are spelled out in more detail in the attached note. It is especially critical that programs for HIV and AIDS prevention, care and treatment remain sharply focused on their core objective of saving human lives.

In this regard, we are deeply troubled by provisions calling for the integration and coordination of HIV and AIDS prevention, care and treatment services with “reproductive health” and “family planning” services and the possible diversion of much-needed attention and resources into the provision of family planning services. Radically shifting the program’s focus, to make it address what the draft bill calls the “dual threat” of HIV/AIDS and pregnancy, could undermine the effectiveness of the ABC prevention program, endanger the acceptance of PEPFAR’s life-saving programs in host countries, and marginalize the vital role of CRS and other faith-based and community organizations that cannot “integrate” with comprehensive family planning, “reproductive health” and abortion providers.

At the same time, the bill would eliminate any designated funding for effective, values-based prevention programs focusing on behavioral change. Based on historical experience this means that little funding is likely to be available for these purposes.

Either of these actions will jeopardize Catholic participation in PEPFAR. HIV and AIDS-affected women, men and children served through Catholic networks, especially in the poorest, most remote areas of the globe, could lose their access to life-saving prevention and treatment programs. We also have concerns about aspects of the management and operations of the Global Fund for HIV/AIDS, Tuberculosis and Malaria, and about the elimination of the “Prostitution Pledge.”

We believe that it is critically important that the PEPFAR program be authorized this fiscal year. Programming of HIV and AIDS activities by local institutions in sub-Saharan Africa and elsewhere requires advance planning, e.g., to assure timely delivery of drugs that local institutions must purchase abroad. Most of these institutions have limited independent resources and are reluctant to make programming decisions until they have a firm funding commitment. The risk of a hiatus in assured funding, however brief, could disrupt treatment regimens, undermine the credibility of healthcare institutions providing HIV services, and endanger lives. Turning this essential program into a vehicle for other agendas on family planning and abortion is a serious threat to the consensus needed to enact strong and compassionate legislation this year.

We speak on this matter from long experience. CRS, working in partnership with Catholic institutions as well as other faith-based, non-governmental and community organizations, is engaged in HIV/AIDS activities in over 50 poor countries. Since 2003, PEPFAR grants to CRS have enabled it to intensify efforts to provide prevention, care and treatment in 12 of the 15 PEPFAR focus countries and many others, principally in Africa. The Church’s commitment is not about ideology; it is about saving lives. We hope and trust that Congress will not inject other ideologies into a program that in a few short years has already saved millions of lives in the 15 focus countries and beyond, and could save millions more in the years ahead. 

PEPFAR shows the great promise of being one of the most important and successful foreign aid programs that our country has ever mounted. This view is held widely not only in the U.S. but also around the world. It would be tragic if the U.S. were to abandon or dilute features that are essential to its success, including its sharp focus on the primary objectives of reducing HIV transmission, treating and providing care for people living with HIV and AIDS, and providing care and support to orphans and vulnerable children affected by HIV and AIDS. Changing what is already working creates needless risks for millions of people in poor countries around the world, depriving them of our Creator’s most precious gift, human life.

With appreciation for your continued support for addressing the critical health needs of the poor around the world, we remain,

Sincerely yours,

Most Reverend Thomas G. Wenski
Bishop of Orlando
Chairman, Committee on International Justice and Peace 

Ken Hackett
President
Catholic Relief Services

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Concerns of USCCB and CRS on House Foreign Affairs Committee Bill on PEPFAR
(Based on Bill Draft of Jan. 18, 2008)
February 6, 2008

1. Focus of the Program: “Integration” with family planning and reproductive health

We are deeply troubled by the frequent references in the bill to “integration” and “coordination” of HIV and AIDS prevention, care and treatment strategies with “reproductive health” and “family planning” services. Either term could include abortion services, incorporating agendas into PEPFAR that are inconsistent with saving lives. The bill even authorizes “initial funding” for family planning services. The Helms amendment to the Foreign Assistance Act precludes direct U.S. funding of abortion as a method of family planning, but does not address terms like “reproductive health” or this bill’s focus on “integration and coordination” with abortion services.

The bill is not precise as to what such “integration” will entail in terms of the design of PEPFAR-supported programs. It is critically important that the meaning of “integration” not be left to interpretation, as it could lead PEPFAR to support and facilitate “reproductive” services that run counter to the cultures and value systems prevalent in much of sub-Saharan Africa and other parts of the developing world. This would endanger acceptance of life-saving PEPFAR programs in these developing nations, particularly among many women at risk.

Equally troubling, the emphasis on integration may lead to a reduction of PEPFAR funding for, and even marginalization of, Catholic and other faith-based organizations that cannot associate their HIV and AIDS activities in any manner with organizations providing contraception and abortion services. HIV and AIDS affected women, men and children served through Catholic networks, especially in the poorest, most remote areas of the globe, could lose their access to life-saving prevention and treatment programs.

We strongly urge that the draft bill’s focus on integration with reproductive health and family planning services be eliminated. The best way to ensure this is to delete all references to “reproductive health” and family planning services from the bill. This would in no way prevent organizations providing such services from continuing to participate in the program, but would prevent the new bill from creating any mandate that other programs must work with and through them.

2. Conscience Clause and Designated Funding

We appreciate that the new bill does not rescind PEPFAR’s “conscience clause,” which prevents PEPFAR from requiring, as a condition of assistance to an organization, the utilization of prevention methods (or treatment programs) to which the organization has a religious or moral objection. We are also pleased that the bill calls for the incorporation within prevention strategies of behavioral change programs focused on the delay of the initiation of sexual activity and partner reduction (A and B of the “ABC” prevention approach). 

We are greatly concerned, however, that the new bill eliminates the requirement under current law that 33% of prevention funding be allocated to A/B programs. This concern is heightened by the language in the bill, discussed above, attaching considerable importance to “integration” of PEPFAR activities with family planning and reproductive health activities. While the conscience clause is important, it does not by itself ensure that PEPFAR will continue to fund AB programs; nor does it protect these programs from being defunded or marginalized if the overall program begins emphasizing guaranteed access to contraceptive and “reproductive health” measures that have little to do with either preventing or treating HIV/AIDS. In any case the current conscience language protects only moral objections to HIV prevention or treatment methods, not objections to abortion, contraception or “reproductive health” methods.

The inclusion of the designated funding provision for AB programming is critical. Before PEPFAR was enacted virtually no funding was available from the U.S. or any other donor for values-based behavior change programs. Since the advent of PEPFAR in 2003, CRS has been a major partner in PEPFAR prevention programs. The promotion of abstinence-until-marriage and mutual fidelity within marriage has long been the cornerstone of CRS’s HIV prevention programming. Abstinence and fidelity reinforce the precise values and norms necessary for mobilizing people to avoid risk, and for reversing the epidemic. Educating youth on the risks they may face and providing them with good “life skills” so they can make good, sound decisions saves lives.

CRS’s experience has been confirmed by recent scientific studies. According to UNAIDS, at least seven African countries have experienced a reduction in HIV prevalence in recent years. Public health experts examining the evidence conclude that in all these countries, delay in the initiation of sexual activity and partner reduction are the main factors leading to this decline. They further conclude that no generalized HIV/AIDS epidemic has ever been rolled back by a prevention strategy based primarily on condoms.

Despite the findings of the public health experts, few providers of prevention services, other than CRS and other faith-based organizations, give priority to AB services. Even PEPFAR recently rejected CRS funding applications in several African countries because the programs did not include condom promotion (Kenya and Zambia) or family planning services (Rwanda). Thus, there is a grave concern that if the designated funding requirement is removed, the U.S. will revert to earlier patterns and limit its funding for the prevention of sexual transmission largely, or even exclusively, to programs that include condom promotion and/or family planning.

If PEPFAR funding for groups like CRS is cut—because without the designated funding administrators are likely to revert to a condom focused strategy even against the best evidence— it would eliminate almost the only source of funding available for prevention programs that provide AB activities of proven effectiveness. The Catholic Church’s high-quality and extensive health care network would be sidelined in the battle against the transmission of the HIV/AIDS virus. The losers will be thousands of persons in sub-Saharan Africa and elsewhere who will lose their lives because of the scourge of a terrible but preventable disease.

We therefore urge retention of designated funding to ensure that a major share of PEPFAR funding for the prevention of sexual transmission of HIV/AIDS will be allocated to behavior change through abstinence and fidelity programs. Now is the time for intensifying ongoing life-saving programs that work, not refighting old battles or radically changing direction. 

3. The Global Fund for HIV/AIDS, TB and Malaria

To date less than 15% of total funding channeled through contractors and sub-contractors of the Global Fund are faith-based organizations. Religious health care providers account for 30 to 50 percent of health care services in many developing countries, and up to 70% in some countries. Many religious health care providers report that they do not have access to the Global Fund’s country coordinating mechanism (CCM) to help plan and achieve the national objectives for combating HIV/AIDS, TB and malaria. Since the U.S. government is providing up to one-third of the resources for the Global Fund (and we support retaining the one-third limitation), we urge that the bill include provisions to ensure that local religious health care providers are meaningfully engaged in their countries’ CCM and adequately resourced to participate in carrying out their countries’ plan. This will ensure the most productive allocation of scarce resources to achieve the maximum impact in terms of lives saved and protected.

In response to concerns expressed in various quarters, the FY08 omnibus appropriations legislation incorporated provisions to address accountability and transparency issues with the Global Fund. The new January 18 draft bill does not contain such provisions. We believe the reauthorizing legislation should provide for implementing, and, where advisable, building on these appropriations provisions to ensure that U.S. contributions to the Global Fund are clearly and effectively used for the purpose for which they are given.

4. Prostitution Pledge

The existing PEPFAR program prohibits HIV/AIDS funding for groups or organizations that do not have a policy explicitly opposing prostitution and sex trafficking. To implement this provision, the PEPFAR management (OGAC) requires organizations receiving funds to sign the so-called “Prostitution Pledge.” The draft bill reauthorizing PEPFAR would remove the language requiring the Pledge. The Catholic Church’s stance on prostitution and sex trafficking is clear. At the same time, the Church has extensive experience in empowering women who have become involved in prostitution to develop healthier livelihoods that respect their human dignity. OGAC has issued directives making clear that support for women involved in prostitution, and upholding their dignity and rights, is in no way precluded by the pledge, which is directed against prostitution as an institution which demeans women and threatens men’s and women’s health.

The issue at stake is not whether we care for prostitutes. What is at stake is the fact that prostitution is one of the highest risk factors in the transmission of HIV/AIDS. As a recent decision of the U.S. Court of Appeals for the District of Columbia said so well: “It would make little sense for the Government to provide billions of dollars to encourage reduction of HIV/AIDS behavorial risks, including prostitution and sex trafficking, and yet to engage as partners in this effort organizations that are neutral toward or even actively promote the same practices sought to be eradicated.”

We urge retention of the prostitution pledge as an important part of the overriding objective of PEPFAR: saving men’s and women’s lives.

letter-to-house-from-bishop-wenski-and-crs-on-pepfar-reauthorization-2008-02-06.pdf