The PEPFAR pledge: Goosby’s sex work dissembling

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Eric Goosby, the head of the USA’s global HIV and AIDS programme PEPFAR, gave an interview during the recent International AIDS Conference in Vienna.  He was asked a question about the “prostitution pledge”, a legal requirement that all recipients of PEPFAR funding (and all subsequent recipients to whom funding is passed) have a policy explicitly opposing prostitution.  Here’s the question and the answer in full:

Q: Why has PEPFAR maintained the so-called “anti-prostitution pledge” that effectively leaves sex workers – a high risk group for HIV – out of PEPFAR’s programmes?

A: What the clause really was focused on was to ensure that PEPFAR did not fund organizations involved in trying to legalize prostitution and traffic women into prostitution. We have changed it so an organization doesn’t have to sign [a separate document pledging to oppose sex work and sex-trafficking]; we have folded in an agreement that the [beneficiary] organization will not traffic women into prostitution – there is no separate document.

PEPFAR has not de-funded any programme on the planet for these reasons. We want to care for every sex worker out there. If a sex worker comes into any of our facilities, that person will be embraced and followed for the duration of their life on antiretrovirals.

If there are examples of anybody being turned away [for being a sex worker], if someone feels that they were excluded from or dropped out of care for those reasons, we would get on that like a laser. 

Source: PlusNews: http://www.plusnews.org/Report.aspx?ReportId=89965 

 There is one fair point in his answer.  PEPFAR rules never said “don’t work with sex workers”.  His use of the term “sex worker” is also progress, since “prostitute” has been PEPFAR’s preferred terminology for some years.  However, everything else Goosby said at best fails to grasp the issues caused by the policy and is at worst disingenuous.  Such as:

  • The first point of contact for this policy was international non-governmental organisations and consultancy companies, which receive the lion’s share of PEPFAR money, to be used to manage deliver services and to fund smaller service delivery organisations.  Many of these organisations scaled back their work with sex workers, not because the US government told them to, but because they felt it was too great a risk to be seen to be doing anything that jeopardised the rest of their US funding.  It doesn’t matter that PEPFAR didn’t defund any programmes.  What matters is that organisations censored themselves in terms of what they did, how they did it, and how they talked about it.  A small number of organisations, like SANGRAM in India, turned down US funding on principle rather than develop such a policy – meaning that their efforts were also scaled back.  One can imagine that other projects quietly disappeared.  The reason no organisation has been defunded as an official sanction, is because no organisation has allowed itself to get into the position where it would be.
  • Delivering good AIDS programmes for sex workers means working with sex workers on the ground.  In many countries, sex workers have organised in various ways, for instance by forming unions, associations, and co-operatives.  Understandably, many of these movements have an interest, among other things, in reducing fundamental issues such as stigma, marginalisation, violence and extortion faced by their members – all things that contribute to increased risk of HIV, and all things that are worth fighting for in their own right.  Addressing these issues requires a degree of openness to challenging the power that the police have over sex workers, and by extension to decriminalisation.  These organisations were required to develop a policy that stated that they explicitly opposed prostitution – in other words that they explicitly opposed their own members.  So they had a choice: either work on HIV using very limited strategies (basically, giving out condoms and getting sex workers to get HIV tests), or lose their funding.  Neither of these is good for sex workers.
  • By requiring that funded organisations have a policy, and that all their partners have a policy, the PEPFAR pledge made sure that this provision was applied not just to the programmes US money was going to fund, but that it impacted all the activities of organisations being funded, however small the share of PEPFAR funding was.  This is very similar to the “gag-rule” which various US administrations have introduced to stop funding going to any organisation endorsing abortion.  One of the first things Obama did when he became president was to repeal the abortion gag – but no such move was made on the prostitution pledge.
  • Finally, Goosby says that “if a sex worker comes into any of our facilities, that person will be embraced”.  If this is true, it’s a miracle.  One of the biggest challenges that sex workers face is getting non-stigmatizing access to health services.  Finding the right health care workers, and/or training them (with the help of sex workers) to serve and treat sex workers respectfully and in accordance with their needs, is a crucial job.  Given how reluctant PEPFAR programmes have been to talk about rights-based approaches in the context of sex work, I find it hard to believe that they’ve done the training and preparation needed to make sure sex workers are treated the same as everyone else.  Many health facilities – including many of those funded by PEPFAR – are run by faith-based organizations.  Despite being of generally high quality, they often aren’t the most accepting of groups like sex workers.  Sometimes the situation for sex workers is so bad that they ask for different types of clinical service delivery – such as outreach services, special opening hours, or even special facilities.  It’s not just about walking into the nearest friendly service. 

Surely the impact of the Pledge should be measured in terms of the impact it has had on trafficking.  Another reason they didn’t defund any organisation is probably that global health NGOs don’t on the whole, do human trafficking.  Do “pro-trafficking” health organisations exist, and if they do did they fail to get money? What impact did it have?  Human trafficking is illegal pretty much all over the world, and certainly in the USA.  You’d think it would deserve greater sanction than the withdrawal from organisations involved in trafficking of the opportunity to get HIV/AIDS money.  But maybe, as many of us have long suspected, what this is really about is an opposition to prostitution, wilfully conflated with trafficking in the pledge.  PEPFAR policy called for programmes to provide alternatives to prostitution.  Let’s hear what impact the Pledge had on levels of commercial sex, then.

Ultimately, one of the major tragedies about the Pledge is the absence of the US government’s leadership on one of the most important areas of HIV and AIDS policy and programming.  US government leadership is incredibly important.  PEPFAR has saved millions of lives through providing treatment, and as a result has had a major impact on reducing HIV-related stigma.  In many regions US HIV programmes are playing a leading role in fighting homophobia.  On the other hand sex work (and, by the way, injecting drug use), have suffered from a complete failure of leadership.  And that’s why prevention programmes with sex workers and drug users are in such poor shape today.

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