World AIDS Day is a time for somber commemoration of those lost to the pandemic, but this December 1 is also a moment for celebration and hope. The death toll from HIV is falling worldwide, according to new figures from UNAIDS. The pace of new infections has slowed by 21 percent since 1997. Half of those in need of treatment now receive drug combinations that can suppress the virus indefinitely. And science has delivered potent new strategies to slow the spread of the virus. The U.S. government now seriously embraces the prospect of an "AIDS-free generation." In a recent address at the National Institutes of Health, Secretary of State Hillary Clinton described three critical steps for achieving it. They include halting transmission from mothers to infants during childbirth, facilitating voluntary circumcision for men, and rapidly expanding access to treatment -- a feat that not only helps HIV-positive people but greatly lowers the risk of infecting their partners.
All three efforts are critical, and we must ensure that Congress doesn't cut the funding needed to sustain and expand them. But what Secretary Clinton calls "combination prevention" has a fourth vital element that has long been neglected and must now be brought to the fore: integration. In many parts of the world, the key to making HIV prevention work is to combine it more fully with family planning and reproductive health care. Experts have long agreed on the need to weave these overlapping efforts into a coherent whole, but our own country's culture wars have pushed family planning and the AIDS response down separate paths, causing fragmentation, duplication, and waste. As we mark this World AIDS Day, the time has come to set aside ideology, reintegrate our global initiatives, and focus on what works.
President George W. Bush energized the nation's global AIDS response in 2003 by launching the President's Emergency Plan for AIDS Relief, or PEPFAR. Bush's five-year, $15 billion commitment dramatically expanded treatment in countries where people were still dying from the lack of access. Unfortunately, it prioritized treatment over prevention, and a third of the funds allocated for prevention were earmarked for abstinence-only programs not shown to reduce the risk of HIV infection. While pumping billions into AIDS relief, the Bush administration also actively undercut related efforts to improve sexual and reproductive health. Between 2003 and 2008, it gutted the federal government's global family planning program, blocked U.S. support for UNFPA, the United Nations Population Fund, and re-imposed the Reagan-era "global gag rule," which barred U.S. assistance to any foreign health organization that advocated safe, legal abortion or provided referrals to women who needed them. When Congress was reauthorizing PEPFAR in 2008, the administration demanded that all references to "family planning" and "reproductive health" be purged from the bill.
Yet the need for integration was becoming ever clearer. Studies were showing that HIV initiatives accomplished more when they were linked to other sexual health programs -- and Planned Parenthood was putting that insight to work in its global work with community-based health care providers. One of these partner organizations was Nongu u Kristu u ken Sudan hen Tiv (NKST), a Christian Reformed group that provides health services through small outposts in the war-torn, AIDS-ravaged states of northern Nigeria. Before NKST and Planned Parenthood joined forces in 2003, NKST offered HIV treatment but steered clear of reproductive health care. The reasons were understandable -- the group's donors were focused on AIDS care, and NKST's clerical leaders opposed birth control -- but the consequences were as grim as they were obvious. Despite better access to testing and treatment for HIV, women were still dying needlessly from complications of pregnancy, childbirth, and unsafe abortion. So NKST set aside doctrine to embrace a more comprehensive model of care. Today, the group's health workers distribute condoms to help prevent unintended pregnancy as well as HIV. They offer HIV services to patients seeking family planning help and vice versa. Besides making health care more efficient and effective, this two-way integration helps reduce infections among newborns.
Since taking office in 2009, President Obama has embraced this integrated approach. Besides restoring support for UNFPA, lifting the gag rule, and starting to rehabilitate threadbare family planning programs run by the U.S. Agency for International Development, the administration has updated PEPFAR's guidelines in potentially transformative ways. The guidelines now call on providers to ensure that people seeking HIV-related care receive comprehensive sexual and reproductive health care. Obama has also folded PEPFAR into the broader Global Health Initiative, which is designed to foster synergy among programs that have long worked in silos.
The strides we have made are worth celebrating. Family planning clinics can now use PEPFAR funds to provide HIV counseling and referrals, and PEPFAR now urges HIV clinics to provide counseling and referrals for family planning. Yet even today, U.S. policy bars the use of PEPFAR funds to pay for contraceptives -- even in the many settings where patients have no other means of access. On the political front, congressional conservatives and several presidential candidates are campaigning to defund the Global Health Initiative, reinstate Bush-era bans on reproductive health care, or cut foreign assistance altogether. Any one of these moves could cost lives and cripple the global response to HIV. Moving forward will take steadfast commitment and a lot of political courage. If our leaders can tap those resources, we may yet live to see a generation without AIDS.
Mapp Frett is the vice president for global initiatives at Planned Parenthood Federation of America.
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