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CFR - World AIDS Day Tobias Letter

CFR - World AIDS Day Tobias Letter



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Published by: Mrkva2000 account! on Sep 26, 2007
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Ambassador Randall TobiasOffice of the Global AIDS CoordinatorUnited States Department of State2201 C Street, NWWashington, DC 20520December 1, 2003Dear Ambassador Tobias:As physicians, nurses, public health specialists, we write to you on World AIDS Day toseek your assurance that US-funded HIV/AIDS prevention programs will be guided bysound science and human rights principles. We are members of Physicians for HumanRights’ Health Action AIDS campaign, which is committed to best practices for acomprehensive strategy of HIV/AIDS prevention, care, and treatment. We support theABC’s of prevention – abstain, be faithful, use a condom – while insisting that a successfulprevention strategy must go well beyond ABC. Such a strategy requires that activitiesprotect even the hardest to reach – the most vulnerable populations.Those most at risk – such as men who have sex with men, injecting drug users, andcommercial sex workers – are marginalized within their own countries. As you know,USAID has a history of providing AIDS education and condoms to such groups, who inmany countries are not reached by their own governments’ initiatives. It is vitallyimportant that the United States continue to fill this extremely important gap.Expanding access to prevention interventions for general populationTargeted programs for especially high risk for contracting HIV/AIDS is crucial, yetslowing and ultimately reversing the spread of HIV/AIDS also requires making AIDSinterventions readily accessible to the general population. Access to preventioninterventions remains distressingly low in many AIDS-burdened countries. For example,according to the United Nations, globally only one in nine people who are seeking theirHIV status have access to voluntary counseling and testing services. In Africa, fewer thanone in three people have access to contraceptive promotion programs. Thus, access toprevention interventions must be vastly expanded, including voluntary counseling andtesting, management of sexually transmitted infections, risk reduction programs and life-skills education for youth, targeted programs for married couples, and access to condoms.The planned rapid scale-up of US-funded HIV treatment is also crucial to HIV/AIDSprevention, because the possibility of treatment can motivate people to seek voluntarycounseling and testing, anti-retroviral therapy reduces patient viral load, and theavailability of treatment can help reduce the stigma associated with HIV/AIDS. Reducingthe denial, stigma, and discrimination associated with HIV/AIDS is central to HIV/AIDSprevention efforts.Mass marketing of condoms and comprehensive sexual education As part of its HIV prevention strategy, the United States must continue to include massmarketing of condoms and comprehensive sexual education. While abstaining from sex isthe only way to guarantee that a person will not contract HIV through sexual activity,consistent use of condoms will greatly reduce the risk of people who do engage in sexualactivity. Studies demonstrate that condoms are at least 90% effective at preventing HIV
transmission when used correctly and consistently. A recent study by the Guttmacher Institute concludedthat progress on abstinence, reduced numbers of multiple-partners, and increased condom use allcontribute to Uganda’s reduction in HIV prevalence, “although reductions in the number of sexualpartners and increased condom use may be playing a more significant role in reducing HIV risk thansexual abstinence by itself.” A literature review of US sexual education programs by the AIDS ResearchInstitute at the University of California, San Francisco found that abstinence-until-marriage education hasno measurable impact, whereas comprehensive sexual education often delays the onset of sexual activity,reduces the number of sexual partners, and increases condom use.Congress has directed that one-third of money for prevention activities should be used for abstinence-until-marriage programs. If grants are made to NGOs that do not support condom use, USAID mustensure that these NGOs neither discourage condom use nor discredit their effectiveness. Further, thesegrants must be balanced by grants to programs that do provide information on and access to condoms, sothat comprehensive prevention services are available to all. Also, it appears that the one-third provisionwas meant to modify funding for sexual transmission prevention programs, to assure that the “A” portionof “ABC” prevention strategies be funded. In keeping with that spirit, we respectfully urge that the one-third provision apply only to sexual transmission prevention programs, and that abstinence programs notbe funded with resources from other prevention accounts, such as voluntary counseling and testing, safehealth care initiatives, programs to prevent mother-to-child transmission, and harm reduction programsfor injecting drug users.Marginalized populationsWomen at risk of domestic violence and coerced sexPrevention efforts must provide people options that are relevant to their circumstances. Safe sexualbehavior is not an option for many women, as they risk violence, abandonment, and economic destitutionif they contest the sexual demands of their partner. To help provide women the ability to choose theterms of their sexual interactions without risking violence or jeopardizing their ability to meet their basicneeds, the United States should incorporate the protection of women’s rights into its strategy to combatHIV/AIDS. Key elements include: 1) tailor HIV/AIDS prevention, care, and treatment programs toaddress specific needs of women, such as by incorporating partner communication skills in preventionprograms
and ensure women’s access to these programs; 2) integrate voluntary counseling and testingservices into antenatal and other health services used by women; 3) assist law enforcement in preventingand prosecuting violence against women; 4) promote income-generating opportunities for women andeconomic assistance to survivors of domestic violence; 5) establish shelters for survivors of domesticviolence; 6) encourage legal change to provide women equal rights in areas including property,inheritance, and divorce, and ensure women access to legal assistance; 7) support domestic violencesensitization programs for health providers and encourage the establishment of protocols on healthproviders’ interactions with survivors of domestic violence, and; 8) promote widespread education onwomen’s rights.People engaged in sex work Women and men engaged in sex work are especially vulnerable to HIV infection. Many sex workers,most of whom are women, do not choose this form of work. Rather, they enter it as a last resort to earn aliving for themselves and their children. Prevention efforts should include support for girls’ and women’seducation and income-generating projects that will provide sex workers other options, but not to theexclusion of strategies to protect women and men who are engaged in sex work, including condomdissemination, prevention and treatment of sexually transmitted infections, and voluntary counseling andtesting. In Thailand, promoting universal and consistent condom use among commercial sex workers has
been central to Thailand’s success in turning the tide of its epidemic, as new HIV infections have droppedby 80% from peak levels in the early 1990s. UNAIDS reports that in Abidjan, Côte d'Ivoire, targetedprevention efforts for sex workers increased their condom use from about 20% in 1992 to almost 80% in1998, while cutting their HIV prevalence by nearly two-thirds.Men who have sex with menAggressive outreach efforts are needed to provide HIV/AIDS services to men who have sex with men,who are often driven underground by stigma and persecution. Prevention efforts should include targeteddistribution of condoms, promotion of safer sex, and treatment of sexually transmitted infections. Theyshould also offer opportunities for these men to communicate openly on issues they face and to providesupport for one another. Prevention efforts will be most successful when coupled with efforts to defendthe human rights of men who have sex with men. Countries should not punish sex between consentingadults and should make available non-punitive and non-judgmental confidential prevention, care, andtreatment services to men who have sex with men. These services work. In Jamaica, for example, anational AIDS organization sponsors an outreach and risk reduction project for men who have sex withmen. Over eight months in 1996, the project led to a 40% increase in condom use and 30% reduction inreported high-risk behavior among clients. The United States should help build the capacity of organizations that provide these outreach services and endeavor to protect the rights of men who have sexwith men. The US government should also strongly and openly condemn remarks by officials in AIDS-burdened countries that are hostile to the rights of homosexuals, or even deny the very existence of homosexuals in their countries. Such comments are anathema to HIV prevention, and must be addressed.Injecting drug usersIn Eastern Europe, Russia, and much of Central and Southeast Asia, injecting drug use is the major forcedriving the AIDS epidemic. Given the complexity and long-term nature of the problem of drug use, anAIDS prevention strategy for injecting drug users cannot rely solely on efforts to stop injecting drug use.Rather, it should follow a harm reduction approach, which incorporates a spectrum of strategies rangingfrom safer drug use to managed drug use to no drug use. These strategies include ensuring access tocondoms and sterile syringes, as well as education and access to voluntary counseling and testing andHIV care. Needle-exchange programs do not increase drug use. A global review from 1988 to 1993 of 29 cities with needle-exchange programs found no increase in the number of injecting drug users; HIVprevalence fell by 5.8% per year. This finding has been confirmed by numerous studies since. Needleexchange programs have reduced the prevalence of HIV among injecting drug users in New York City,New Haven, and other US cities, and is being implemented in several countries in Asia includingThailand, India, and China. In 1997, the National Institutes of Health credited needle exchange programswith reducing HIV transmission rates in the United States by one-third to two-fifths. The same year, theUS Conference of Mayors endorsed needle exchange as part of a comprehensive harm reduction strategyfor injecting drug users in the United States.These are far from the complete range of interventions needed as part of a comprehensive strategy forHIV/AIDS prevention, care, and treatment. Populations besides those discussed above are at high-risk and require targeted strategies, including street children and other youth, as well as migrant workers.Prevention efforts are also required for the general population. US-funded prevention programs shouldtarget all routes of HIV transmission. Programs to prevent mother-to-child HIV transmission and to endHIV transmission in health care settings, including through blood transfusions and medical injections,should expand dramatically.

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