The Complex Battle for PEPFAR: How a successful foreign policy program silently fuels homophobia

With the virtually constant onslaught of national political news, it is incredibly demanding to ask the general public also to be well-versed in our nation’s foreign policy. Those interested in foreign affairs are likely immersed in the issues of Ukraine and/or the Israel-Palestinian conflict. While debate and air time remain primarily dedicated to these noteworthy issues, another foreign affair was heavily debated but rarely centered. 

What was under intense scrutiny? The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The program, popularly known as PEPFAR, once shared immense bi-partisan support and is documented to have saved at least 25 million lives, in over  55 countries. Despite this astounding and historic success, PEPFAR has recently been met with intense apprehension as some claimed the funds were wrongfully used to support abortions globally. Add this controversy to Uganda’s recent anti-homosexual legislation, and the continent of Africa is propelled into the limelight. 

It is irrefutable that PEPFAR has saved millions of lives and altered HIV efforts at the international level, but it is also true that PEPFAR ushered in a wave of beliefs and assumptions that left behind and established the foundation for homophobia, ridicule, stigma, and shame. 

“One of the most significant criticisms of PEPFAR has been its reliance on faith-based initiatives, which frequently subject gay men to religious-based stigma and discrimination. ”

The Promise and Power of PEPFAR

At the beginning of his presidency, President George Bush was juggling a myriad of controversies, including terrorism and war. Still, in 2003, the then-president saw a dire need to fight HIV/AIDS internationally as the number of new HIV cases and AIDS-related deaths hit historic highs. Where others saw a problem, Bush saw an opportunity.

In turn, with astounding bipartisan support, President Bush enacted PEPFAR in 2003, and the program was implemented in 2004.  To this date, with support easily reaching billions of dollars, PEPFAR is still the largest commitment by any nation to combat a single disease. No other nation has invested as much in international HIV efforts as the United States of America. 

PEPFAR employs a united approach to the global HIV crisis. The program works in tandem with several entities, including The U.S. Agency for International Development, The Department of Health and Human Services, The Department of Defense, the Peace Corp, and even the Department of Commerce.

Crucial to PEPFAR's success in Africa is its collaborative approach. By partnering with local governments, NGOs, and community leaders, PEPFAR ensures programs cater to specific regional needs, respect cultural norms, and achieve sustainability.

In countries like Tanzania, this led to a significant increase in clinics offering treatments, from a mere handful in 2004 to hundreds by 2010. In Uganda, PEPFAR implemented a program to prevent vertical HIV transmission, a non-stigmatizing term for mothers to newborns. They managed to reduce transmission rates significantly through medications, counseling, and breastfeeding guidance.

Two of PEPFAR’s biggest success stories can be found in South Africa and Namibia. Because of PEPFAR, by 2018, over 90% of people living with HIV  in South Africa were aware of their status, with 68% on treatment and 87% of those achieving viral suppression. Next, with PEPFAR's assistance, Namibia became an example of controlling the HIV epidemic. Comprehensive approaches, from community engagement to expanding treatment centers, led to vast improvements. By 2019, 95% of HIV-positive Namibians knew their status, with 89% on treatment. It is important to note that almost all of this progress was in the heterosexual community, as the homosexual community continued to be silenced, ridiculed and exploited. 

“Prioritizing heterosexual individuals in PEPFAR’s HIV response efforts while neglecting gay men is like building a dam to stop water, but leaving a significant gap.”

How PEPFAR leaves gay men behind

 To many, PEPFAR  exemplifies the potential of American foreign assistance that is coordinated, compassionate, efficient, and transparent. On the other hand, countless studies and critics have expressed the barriers and problems with the historic program. PEPFAR has undeniably provided treatments and resources to those in need, but a deeper look reveals a side that is worrisome, particularly for queer people living in certain African nations. 

One of the most significant criticisms of PEPFAR has been its reliance on faith-based initiatives, which frequently subject gay men to religious-based stigma and discrimination. 

While playing a crucial role in providing care and resources, these programs often come with a set of conservative beliefs that may not align with broader human rights perspectives. For example, from 2003-2016, PEPFAR initially mandated that one-third of its prevention funds be reserved for abstinence-until-marriage programs. 

The heavy focus on abstinence-only is particularly troublesome for queer men for multiple reasons. Abstinence-only education primarily emphasizes abstaining from sexual activity until heterosexual marriage. This framework fails to address the realities of gay men, many of whom cannot legally marry or openly engage in same-sex relationships in numerous African countries. By promoting an exclusively heterosexual narrative, the educational approach marginalizes the experiences and needs of gay men. At best, it is exclusionary; at worst, it is stigmatizing and fuels toxic beliefs related to sexuality. 

Even if one disagrees with homosexuality, it is a terribly ineffective public health practice not to center this demographic. Prioritizing heterosexual individuals in PEPFAR's HIV response efforts while neglecting gay men is like building a dam to stop water, but leaving a significant gap. No matter how robust the dam is, water will always find its way through that gap, undermining its entire purpose and lessening its success. Or let’s use another analogy- PEPFAR's approach to HIV without adequately addressing the needs of gay men is like a doctor treating a wound but ignoring an underlying ailment; the surface might seem protected, but the real danger remains untreated.

Additionally, gay and bisexual men are at an increased risk of HIV acquisition, mainly through unprotected anal intercourse, which carries a higher risk than vaginal intercourse. By emphasizing abstinence over other preventative measures, such as the use of condoms or pre-exposure prophylaxis (PrEP), the programs neglect the most crucial risk-reduction methods for gay men. These are all compounded by larger issues such as mental health, lack of resources, and social isolation.  PEPFAR also allowed a “conscience clause” for a while, which allowed faith-based partners to opt out of certain services if they conflicted with their religious beliefs. Gay men were frequently left out of programming due to this clause.

Looking ahead

It is possible to applaud the work of PEPFAR while also holding the program and its supporters accountable for its unequal success. Luckily, significant changes have been made.

For example, now, PEPFAR officially supports the inclusion and circulation of PrEP as an effective preventative tool.  

However, according to the Center for Disease Control and Prevention (CDC), from October 2016 to September 2018, in 15 out of 35 programs backed by the U.S. President’s Emergency Plan for AIDS Relief, PrEP coverage tripled among the general population compared to female sex workers, gay men, and transgender women. Simply, gay men still are not being prioritized in the rollout of PrEP in various African countries.

In an evolving global health landscape, the effectiveness of PEPFAR hinges not merely on its medical interventions, but also on its commitment to equity and inclusivity. Gay men, historically marginalized and disproportionately affected by HIV, are a testament to the gaps that still exist in HIV prevention and treatment even after the success of PEPFAR.  Combating homophobia and prioritizing the promotion of PrEP ensures that the program addresses the epidemic holistically, reaching all vulnerable populations. Only by championing inclusivity and dismantling barriers of prejudice can PEPFAR truly fulfill its mission and vision of eradicating HIV.