As we near the end of a long presidential race in the United States, there are still many policy issues to discuss.   Those working on the many aspects of sexual reproductive health and rights (SRHR) are following the campaign carefully and discussing positions passionately.

This post is not about who to vote for in the presidential race or to weigh in on candidates' policy positions related to SRHR - it is to comment on an aspect of the race that is central to our work that I think has been lost in the dialogue.  I am commenting on this based on more than 20 years working on and writing about gender issues related to SRHR.

Gender-based violence (GBV) is one of the most insidious outcomes of gender inequity and while men and boys can be subject to GBV, by and large it is perpetuated on women and girls.  The roots of gender-based violence include gender norms that can result in women being valued less in society than men and turn them into  sexual objects to be controlled by men.  When we think of GBV, physical violence first comes to mind, particularly violence inflicted by intimate partners. A multi-country study by the World Health Organization (WHO) found that about one in three women experience some form of violence in their lifetime.

“Yes we did make a change in POPLINE. We recently made all abortion terms stop terms. As a federally funded project, we decided this was best for now. In addition to the terms you’re already using, you could try using ‘Fertility Control, Postconception.’ This is the broader term to our ‘abortion’ terms and most records have both in the keyword fields…”

This had to be a misguided attempt at an April Fools joke! POPLINE (POPulation information onLINE), is “the world’s largest database on reproductive health, containing citations with abstracts to scientific articles, reports, books, and unpublished reports in the field of population, family planning and related health issues.” It’s maintained by the INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs and is funded by USAID.

I subsequently discovered that the timing was pure coincidence, and this was no joke. Apparently, the POPLINE database includes a number of articles on abortion law reform. Years ago a decision had been made by USAID to strongly encourage its grantees to scrub their websites and publications of material offensive to the delicate sensibilities of Bush political appointees. Now the repercussions of that decision are clear; USAID has been compelled to enforce this policy of censorship. And POPLINE is feeling the long arm of the federal government reaching into its academic research collections.

Johns Hopkins is a university that openly prides itself on “securing more federal research funding than any other university.” Understandable, in the day—not so long ago—when scholarship, libraries, and federally-funded research aligned harmoniously behind the principles of free and open access to information, and of commitment to learning built on the sum of human knowledge. This setback at POPLINE represents more chipping away at these foundational principles, and—even more alarming—turns a fundamental principle of democratic governance on its head: Whereas there has always been the possibility that private sources of funding carry the risk of private bias or censorship, slant or “spin”, public funding has always presupposed protection of the free flow of information and ideas. This is fundamental to a democratic society.

Such an Orwellian act runs counter to everything I learned in history class and in my graduate library programs. How is it possible for “the world’s largest database on reproductive health” to remove the word “abortion” as a search term? What does it say about our government’s lack of respect for freedom of speech and for scientific and academic integrity? What are they afraid of, and why are users of this database not trusted to have access to comprehensive information on abortion?

Not only is Big Brother watching you, but he is afraid to let scientists, researchers, students—and even librarians—have access to honest and evidence-based information. As a librarian, I am outraged that I am being asked to sacrifice everything I learned to the altar of the Bush Administration’s ideology. Censorship is always the antithesis of freedom. Please join me in alerting the world to this latest breach of trust with the American people.

—Mary Panke, Director of Knowledge Resourcing, PAI

HIV Prevalence Rates and Unmet Need for Family Planning and Reproductive Health Care

Since the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2004, U.S. foreign assistance to fight HIV/AIDS has laudably increased in the program’s fifteen focus countries in Africa, the Caribbean and Asia.¹ This commitment to the prevention, care and treatment of HIV/AIDS is welcome, as over 33 million individuals are currently living with the disease worldwide, and 2.5 million more are infected each year.² People living with and affected by HIV face many economic, social and psychological needs that are not met directly through PEPFAR.  Women face the risk of unintended pregnancy and the need for access to family planning remains high in most PEPFAR countries.   

PEPFAR Acknowledges the Need for Family Planning and Reproductive Health Care

In their most recent report to Congress, the Office of the Global AIDS Coordinator (OGAC) espouses the importance of voluntary family planning and reproductive health (FP/RH) programs in preventing HIV among vulnerable populations; supporting people living with HIV/AIDS; preventing mother-to-child transmission of HIV; and preventing HIV transmission within discordant couples (couples in which one partner is HIV-positive, while the other remains HIV-negative).³ This policy support acknowledges that FP/RH services provide opportunities to educate women about HIV prevention, including the correct use of male and female condoms – the only technologies currently available to prevent HIV.  Further, many women living with HIV want to limit or space their childbearing. Providing these women with FP/RH care and contraceptive supplies improves their health and lowers the risk of mother-to-child HIV transmission.  OGAC expects that important programs like FP/RH to be funded through “wrap around” funding – in other words, funding for programs that are beneficial for people living with an affected by HIV and AIDS, such as nutrition and family planning/reproductive health, but which cannot be funded directly by PEPFAR. 

Funding for HIV/AIDS Grows while Funding for FP/RH Falls

A common misperception about “wrap around” programs is that as funding for PEPFAR has grown, so too has funding for these programs.   In reality, support for FP and RH programs – wrap around programs acknowledged by OGAC as critical to ensure their own health and the health of their families, as well as to the success of HIV programs – has stagnated.    

As seen in Figure 1, the President’s funding request for HIV programs in the 15 focus countries increased 125 percent in just two years over the 2006 allocated level. However, the funding request for family planning and reproductive health fell by 11 percent. Further, the sheer scale of HIV funding in the focus countries ($3.6 billion requested for 2008), dwarfs FP/RH funding ($67.5 million requested for 2008, less than 2 percent the amount requested for HIV programming).

Figure 1: U.S. FP/RH and HIV Funding for Focus Countries, Allocated 2003-2006, Requested 2007-2008

U.S. HIV/AIDS and FP/RH Policies and Funding Constraints

U.S. funding for both FP/RH and HIV/AIDS come with distinct restrictions that limit each programs’ effectiveness. With regards to FP/RH, the Mexico City Policy/Global Gag Rule (GGR) denies foreign organizations receiving U.S. FP/RH assistance the right to use their own non-U.S. funds to provide legal abortion, counsel or refer for abortion, or lobby for the legalization of abortion in their country. The GGR does not apply to PEPFAR funds.  With regards to HIV/AIDS funding, the “abstinence-until-marriage” earmark in PEPFAR requires one third of all prevention funding (just 20% of all U.S. HIV/AIDS funding) to promote abstinence as the lead HIV prevention strategy.  The “Loyalty Oath/Prostitution Pledge” requires all groups receiving PEPFAR funds sign a pledge opposing prostitution. Combining FP/RH and HIV/AIDS funding for programs on the ground risks extending all of the restrictions to both areas, further reducing effectiveness.⁴ PEPFAR can only support condom use for individuals most at risk of transmitting or becoming infected with HIV, and cannot support other forms of contraception despite their role in reducing HIV-infected births.⁵ Despite these policy constraints, PEPFAR supports addressing the FP/RH needs of individuals through “wrap-around” programs, or linking to other services.⁶ However, a successful wrap-around program is difficult when FP/RH programs are significantly overburdened and underfunded.

Country-Level Perspectives

Nearly all of the 15 focus countries are experiencing a persistent need for but a steady decline in U.S.  FP/RH assistance. The President has requested a decrease in FP/RH assistance in 10 of the 15 focus countries and a minimal increase in only one focus country – Rwanda.   Four focus countries receive no FP/RH assistance. The 2008 Congressional Budget Justification stated that the reductions in FP/RH funding were due to low requests from the USAID country missions, citing the 40 year decline in fertility rates around the world. However, all 11 focus countries receiving FP/RH assistance have high fertility rates, and many also have high unmet need for contraception.

Ethiopia saw a 24 percent drop in FP/RH funding between the 2006 allocation and 2008 request. Yet, the average Ethiopian woman will give birth 5.4 times in her lifetime, and 33.4 percent of married women have an unmet need for contraception – they wish to limit or space childbearing, but are not using contraception (see Figure 2).⁷  The 2008 request for FP/RH funding in Ethiopia is $15 million. In contrast, the 2008 request for HIV/AIDS is $409 million to address Ethiopia’s epidemic, estimated at 1.4 % prevalence.⁸    

While the number of women living with HIV is high in Ethiopia, the number of women with unmet need is significantly higher, although these groups are not mutually exclusive (evidence shows that unmet need for contraception is common among women living with HIV/AIDS).⁹  Far more FP/RH funding is needed to help women meet their reproductive intensions in order to promote the wellbeing and rigpopact of Ethiopian women, regardless of HIV status.

Figure 2: Married women with unmet need for FP and women living with HIV/AIDS in Ethiopia¹⁰

Figure 3: U.S. FP/RH and HIV Funding for Ethiopia, Allocated 2003-2006, Requested 2007-2008

Kenya has also experienced a decline in FP/RH funding and currently has an unmet need for contraception of 24.5 percent.¹¹ While the Kenyan fertility rate has fallen significantly from 6.7 in 1989,¹² it recently increased from 4.7 in 1998 to 4.9 in 2003, a seemingly small but significant setback.¹³ Had Kenya’s fertility rate continued its downward trajectory, the country’s population would have been 44 million in 2050, instead of 83 million currently projected, even assuming future declines in fertility.¹⁴ The 2008 funding request to meet FP/RH demand in Kenya is $7.7 million. In stark contrast, $481 million has been requested to combat Kenya’s 5% prevalence HIV/AIDS epidemic¹⁵ – a sum that exceeds the entire annual U.S. FP/RH budget globally.

Figure 4: Married women with unmet need for FP in Kenya, and women living with HIV/AIDS in Kenya¹⁶

Figure 5: U.S. FP/RH and HIV Funding for Kenya, Allocated 2003-2006, Requested 2007-2008

Summary

Voluntary FP/RH programs, a proven successful intervention long supported by the U.S. government, is critical to the health and well being of women, children and families around the world, and is an acknowledged key component to the success of HIV prevention, care and treatment programs. Dangerously low and declining  support for family planning, compounded by restrictive policies, jeopardizes gains in women’s health, poverty reduction, and undermines the major investments attempting to curb the spread and impact of HIV/AIDS.  To enhance PEPFAR’s successes to date and ensure its sustainability in the future ,  improved funding for and coordination with FP/RH programs are paramount. 

Key Actions

• Substantially increase U.S. funding for international family planning and reproductive health to improve HIV prevent efforts for women and their children, and to reduce unintended pregnancies, especially among HIV-positive women.

• Remove policy restrictions including the Global Gag Rule, the “abstinence earmark” and the “loyalty oath” which greatly limit access to the best available HIV/AIDS and FP/RH services for women and their families.

Notes on methodology:

Funding amounts for fiscal years 2003 through the FY 2008 request are not completely comparable but do provide information on country funding trends over the time period. FY 2003-2004 data for FP/RH are expenditure levels derived from the USAID document Agency-Wide Expenditures in Global Health, FY 2004 published in August 2005– the latest version available, and is also the source for HIV/AIDS funding levels for 2003. FY2005-2006 data for FP/RH are expenditure levels derived from USAID’s Congressional Budget Justification (CBJ) documents—FY 2005 figures are drawn from the FY 2007 CBJ; FY 2006 figures from the FY 2008 CBJ. FY 2004-2006 data for HIV/AIDS are expenditure levels derived from OGAC’s The Power of Partnerships: Third Annual Report to Congress on PEPFAR (2007). FY 2007-2008 data for both HIV/AIDS and FP/RH are request levels derived from the 2007 and 2008 USAID CBJs.

Funding—The omnibus spending bill includes $461 million for U.S. international FP/RH programs. This is the higher level that was contained in the Senate bill and represents an increase of $21 million above current levels and a more than 25 percent increase above the amount requested by the President.

Global Gag Rule—Disappointingly, the measure approved by both the House and Senate to provide an exemption from the Global Gag Rule—enabling foreign family planning organizations otherwise ineligible for U.S. FP/RH assistance to continue to receive U.S.-donated contraceptives—was dropped by congressional negotiators in the face of an unwavering veto threat from the President. Regrettably, the Senate-passed amendment to fully overturn the Gag Rule also suffered the same fate.

PAI President and CEO Amy Coen had this to say upon hearing the news:

"We commend members of Congress—on both sides of the abortion debate—for finding common ground to improve the lives of women and their children, thus reducing unintended pregnancies, abortion, and HIV infection through greater access to contraceptives. It is tragic that President Bush was unable to follow their lead. His persistent threat to veto the foreign assistance bill doomed this life-saving measure. It is unconscionable for a president to ignore the majority of the members of Congress, the majority of Americans and the best interests of millions of human beings because he is blinded by his own narrow beliefs. Today the shadow of one man darkens the lives of so many."

UNFPA—The omnibus spending bill provides a U.S. contribution to the UN Population Fund of $40 million. The overall contribution level reflects a $6 million increase about the $34 million approved by Congress in FY 2007. The UNFPA contribution still remains subject to the existing "Kemp-Kasten" restriction, which has been interpreted by the Bush administration to deny more than $150 million in funding to UNFPA for the last six years. However, the spending bill includes House-passed language requiring a Kemp-Kasten determination with six months of enactment of the bill and stipulating that the decision must be accompanied by a comprehensive analysis and the evidence used in making the determination. In addition, the bill includes a requirement that any amount withheld from UNFPA under Kemp-Kasten be reprogrammed to USAID for bilateral "family planning, maternal, and reproductive health activities."

Abstinence Earmark—Lastly, and on a very positive note, the omnibus spending bill also contains a provision approved by both the House and Senate nullifying the "abstinence-until-marriage" earmark of bilateral HIV/AIDS prevention funding. By waiving this destructive restriction mandating at least one-third of all HIV/AIDS prevention funding be limited to abstinence-until-marriage programs, this measure will provide much-needed flexibility to the federal Office of the Global AIDS Coordinator (OGAC) in programming prevention funding in developing countries.

This World AIDS Day—and every day after—we need to talk openly and honestly about how to stop the spread of HIV.  We need to ensure that all women have the ability to make choices about their own sexual and reproductive health.  Both men and women need to have access to the contraceptive supplies they need to protect themselves.  Men, women and couples of all ages must be educated about how HIV is transmitted and how to best protect themselves: reducing the number of sexual partners, using a condom every time they have sex, and being aware of their HIV status.  We need to encourage men to be involved in their own sexual health and that of their partners.  And, HIV positive women need to have access to the tools they need to be sexually healthy and make choices about if and when to have children.

When a deadly disease such as HIV/AIDS is transmitted largely through sex, we can't afford to be shy.  We have let ideology and fear curb a global conversation about the reality of how this epidemic continues to spread, and history will judge us harshly for it.   Let’s stop this deadly trend and make sex safer for men and women around the world.  It’s World AIDS Day; let’s talk about sex.

Question: What do you do with a $100 million U.S. government program that isn’t working?  The answer; you fix it.  Abstinence and be-faithful programs for youth in the President’s Emergency Plan for AIDS Relief (PEPFAR) are not meeting the needs of sexually active and at-risk youth, according to a government-commissioned evaluation that took place in March.  Eight months later, no plan has been put into place to address these flaws—endangering the millions of young people these programs are supposed to help protect. 

In July, the Chairman of the House Oversight and Government Reform Committee, Henry Waxman; Chairman of the House Foreign Affairs Committee, Tom Lantos; and member of the exclusive House Appropriations Committee, Congresswoman Barbara Lee—all champions of evidence-based HIV prevention—sent a letter to Mark Dybul, US Global AIDS Coordinator at the Department of State, asking how PEPFAR planned to respond to the serious concerns raised in this report.  Dybul’s response gave no indication of a plan to address the gaps the evaluation found and offered no evidence of the effectiveness of these abstinence and be-faithful programs.  Last month, Reps. Waxman, Lantos and Lee wrote to Mark Dybul again, reiterating the need for a plan to address the shortfalls in PEPFAR’s youth programming. How many letters have to be written when people's lives and wellbeing are at stake? 

For every person who gains access to HIV treatment, six more become infected with this deadly disease. PEPFAR cannot afford to support anything less than sound, evidence-based prevention programs if we truly intend  to stop this epidemic.  There simply isn’t enough funding to spend $100 million on a program with harmful flaws.  While PEPFAR’s administrators write letters, young people are at risk of contracting HIV because they don’t have access to the education and supplies that they can use to protect themselves.

Through programs funded by PEPFAR, the U.S. has made a historic commitment to the prevention, care and treatment of HIV/AIDS.  But this financial commitment is dwarfed in size by the global need for these services.  PEPFAR has a responsibility to ensure that all their programs, including abstinence/be-faithful programs, are addressing the needs of their target audience— youth, including those who are sexually active.  If programs cannot meet this basic requirement, it’s time to find a more effective investment for U.S. dollars.

Women are dying from preventable causes and the U.S. is contributing to the problem. This was the grave truth repeated at last Wednesday’s hearing before the House Committee on Foreign Affairs on the Global Gag Rule (Mexico City policy)—the first hearing of its kind in the last decade. Women are dying because the U.S. Global Gag Rule is preventing them from getting the reproductive health care and supplies they desperately need to prevent unwanted pregnancies. For the first time since President Bush took office, both houses of Congress have passed legislation to right this wrong.

This hearing was a long-overdue opportunity for Congress to better understand the real-life, destructive consequences of the Gag Rule on women and children. Members of the committee heard first-hand how this restriction's cut-off of family planning services is increasing unwanted pregnancies, abortions and maternal mortality. Witnesses testifying at the heavily attended hearing included Duff Gillespie, PhD,former Senior Deputy Assistant Administrator for the Global Health Bureau at USAID and current PAI Board member; Ejike Oji, MD, Country Director for Ipas-Nigeria; and Joana Nerquaye-Tetteh, PhD,former Executive Director, Planned Parenthood Association of Ghana.

“The Global Gag Rule exacerbates the situation in Nigeria whereby women have no choice about how to manage their own lives. That is what makes me so angry, because at the end of the day it is our women—our wives, daughters, and sisters—who are dying,” Dr. Oji testified. The Global Gag Rule prevents USAID from working with organizations that can most effectively increase the use of family planning—largely through rural distribution. This is an incredibly dangerous gamble in Nigeria where nearly one-third of women say they have had an unwanted pregnancy and half of those have attempted an abortion.

Ghana has also been hit hard by the Global Gag Rule. According to Dr. Nerquaye-Tetteh, as a result of this U.S. policy, access to family planning was significantly reduced and the number of unintended pregnancies and new sexually transmitted infections both increased. Immediately following the imposition of the Gag Rule, and PPAG’s refusal to sign the policy, they saw a 50% increase in the number of women seeking post-abortion services.

While some supporters of the policy tried to make the case that family planning is not harmed by the Global Gag Rule, this is simply false. As Chairman Lantos stated in his opening remarks, “While the Global Gag Rule is being promoted as anti-abortion, it remains at its core anti-family planning.” By preventing funding from going to the organizations where they can be most effective on the ground, the Gag Rule is the roadblock keeping life-saving reproductive health care and supplies from women in need.

"It is clear that the Mexico City Policy is in fact thwarting our efforts to prevent unintended pregnancies, abortions and the spread of HIV/AIDS," said Representative Nita Lowey, chair of the House Appropriations Committee on State-Foreign Operations. The Global Gag Rule "is unconstitutional, immoral, unsubstantiated and dangerous."

The hearing was especially well-timed as President Bush threatens to make good on his promise to veto the entire Fiscal Year 2008 foreign assistance spending bill over a provision that exempts contraceptives from the Gag Rule's restrictions. We urge the President to stop playing politics with women’s lives and repeal the Gag Rule.

Last week, experts from around the globe traveled to Washington to discuss an issue critical to the health of millions around the world—access to reproductive health supplies, notably contraceptives and condoms.  At the invitation of USAID, the Reproductive Health Supplies Coalition (RHSC) gathered to strategize how to build support for reproductive health supplies in a time when the development agenda of donors and country governments continues to expand.              

The RHSC is a global partnership dedicated to making essential reproductive health supplies universally available. PAI, a founding member, currently chairs the Coalition’s Resource Mobilization and Awareness Working Group, which is dedicated to achieving political support and increased funding for reproductive health supplies at the global, regional and country levels. In addition, two other working groups focus on strengthening the logistics systems for delivery of reproductive health supplies and on addressing the diverse contributors to the market for reproductive health supplies, especially the private sector.

Last week’s RHSC meeting brought together dozens of representatives of the Coalition’s partners among bilateral and multilateral donor agencies, international institutions and non-governmental organizations. During the meeting, the Coalition welcomed a group of representatives from countries across the Latin America and Caribbean (LAC) region, who shared their experiences with the transition toward national support for reproductive health supplies. Many of the LAC country representatives spoke of how non-governmental organizations (NGOs) had “paved the road for contraceptive access” in their countries by helping create demand, disseminating information, providing technical assistance to governments and ensuring political commitment through strong advocacy.

Access to reproductive health supplies—including condoms and contraceptives—can alleviate unnecessary hardship among so many in the developing world.  When men and women have access to modern contraceptives and condoms, they reduce their risk of HIV infection, unintended pregnancies, abortions and maternal mortality.  The RHSC is helping to make these life-saving supplies more readily accessible.  But the coalition cannot act alone.  While USAID is the world’s largest bilateral donor of contraceptives and condoms, the support of the U.S. government for reproductive health and contraceptives has waned.  Funding for family planning has declined by a staggering 41% (adjusted for inflation) since 1995. As Congress makes the final determinations for the FY2008 budget, including the annual appropriation for international family planning, it must support robust funding for the programs that save so many lives overseas.  Thanks to the work of partnerships such as the RHSC, we are reminded of the critical need for ongoing advocacy for the programs and supplies that make women’s lives safer and are a fundamental human right.

Over half a million women worldwide die every year in pregnancy or childbirth—largely from preventable causes.  In the developing world, pregnancy remains the leading killer of women in their reproductive years.  And for young girls between the age of 15 and 19, their chance of dying in childbirth is twice that of their peers in their 20’s.  In order for countries and donors to address global priorities like poverty eradication, HIV cessation, and economic growth, strong political will to improve the sexual and reproductive health of women is paramount.   

PAI’s new report, A Measure of Survival: Calculating Women’s Sexual and Reproductive Risk, ranks 130 developing and developed countries according to sexual and reproductive risk.  The report, released last week during the Women Deliver conference in London, illustrates the harsh reality of being a poor woman in a poor country.

A Measure of Survival documents the continuing stark disparities in reproductive risk between wealthy countries and poor ones.  Niger, Chad, Mali, Yemen and Ethiopia are among the countries where women are at the highest sexual and reproductive health risk. For many, a skilled attendant at childbirth can make the difference between life and death.  In Ethiopia, which has the lowest rate of births attended by a skilled health personnel, 90 to 95 percent of women deliver at home and are two or more hours away from a health facility.  Unsurprisingly, maternal death and infant mortality rates in Ethiopia are both needlessly high.

Overall, the number of women who die from pregnancy-related causes is over 250 times higher in developing countries than in developed countries.  Even more astonishing, these deaths are largely preventable.  In fact, voluntary family planning programs can reduce the number of maternal deaths by reducing unwanted pregnancies and preventing women from seeking often-unsafe abortion.

Ten years after publishing these rankings for the first time, the story still has the same grim ending: Women are dying needlessly.  We should be long past the point of measuring the well-being of women in 18th century terms—by their chance of survival.  By investing in women and their health now, we can help save lives.  Only then will we begin to measure women’s well-being in terms of the number of girls in school, the number of women in the workforce, and the number of women and children who are healthy.

“The impact [of the Global Gag Rule in Ghana] was immediate, deep and damaging,” — Matilda Owusu-Ansah of the Planned Parenthood Association of Ghana (PPAG).

At a heavily attended briefing in Congress last week, renowned experts Dr. Joachim Osur, of the Ipas African Alliance, and Matilda Owusu-Ansah, formally of the Planned Parenthood Association of Ghana (PPAG), addressed the damaging effects of the Global Gag Rule—highlighting the real, direct, and, more often than not, deadly impact of this policy in their respective countries.

According to Ms. Owusu-Ansah, PPAG, the largest provider of family planning services before imposition of the Global Gag Rule, lost all USAID family planning funding.  Within one year, their condom distribution fell by 40%.  With limited access to reproductive health supplies and services, the number of unintended pregnancies increased dramatically, as well as the number of new sexually transmitted infections. 

In Kenya, the effects of the Global Gag Rule have been equally detrimental. When the policy was reinstated, Dr. Osur was working for the Family Planning Association of Kenya (FPAK).  When FPAK refused to sign, they immediately lost 58% of its annual budget.  These budget cuts forced the closure of eight of FPAK’s 16 clinics, leaving 100,000 women without access to reproductive health services—including the contraceptives that would help them avoid unintended pregnancies, abortion and STIs.

According to the Bush administration, the Global Gag Rule was reinstated in 2001 to prevent abortions worldwide.  In reality, the effect has been quite the opposite.  In addition to creating contraceptive shortfalls and closing reproductive health clinics, Ms. Owusu-Ansah reported that PPAG saw at 50% increase in the number of women who came to their clinics for post-abortion care.  By denying access to reproductive health services and contraceptives, the number of unintended pregnancies grew, often leading to abortion.

Our African colleagues gave this Congressional audience a sobering wake-up call:  Women are dying from causes that, with the use of contraceptives and other family planning services, are preventable.  While Congress voted to repeal this deadly policy in the State-Foreign Operations Appropriations bill, the President is threatening to veto it, perpetuating the Russian roulette these women play with their lives each day they are denied access to family planning. Mr. President, we urge you to sign this bill.  It’s time to give reproductive health back to the hundreds of millions of women whose lives literally depend on it.

PAI’s recent study, The Shape of Things to Come: Why Age Structure Matters to a Safer, More Equitable World, was a hot topic in Washington last week when it drew a panel of experts to the Woodrow Wilson International Center for Scholars. The experts, including a Member of Congress and the heads of the Henry Stimson Center and the Population Reference Bureau, agreed: Demography can often be a powerful indicator for international development.

The Shape of Things to Come offers compelling evidence that a country’s age structure—the size of specific age groups relative to the population as a whole—has a significant impact on its stability, governance and economic development.  While young people are a tremendous asset for any society, countries with very young or youthful age structures have historically faced the greatest challenges in terms of development and stability.  Currently about sixty countries have a “very young” age structure, including Afghanistan, Ethiopia, Haiti, and nearly all of sub-Saharan Africa.  The findings of PAI’s report reaffirm that investments in education, health care and economic opportunities for young people in these countries is critical to these nations’ development.

Congressman Russ Carnahan (D-MO), a member of the House Foreign Affairs Committee who spoke at the Wilson Center event, described The Shape of Things to Come as a valuable resource for policymakers because it provides compelling information on how age structure and population dynamics affect development.  Congressman Carnahan urged other policymakers to use the findings of PAI’s study to highlight approaches through which developing countries with very young age structures can meet the challenges they face and help their citizens live longer and healthier lives.

Today, a critical opportunity to make a difference in the lives of millions of women and young people around the world exists in the annual foreign assistance (State-Foreign Operations Appropriations) bill pending before Congress and President Bush.  As passed by Congress, this bill overturns the Global Gag Rule and expands access to contraceptives in poor nations.  Such a policy shift would greatly benefit the hundreds of millions of women in developing countries who lack access to contraceptives and other basic reproductive health care. Unfortunately, President Bush has threatened to veto the entire foreign assistance bill over the life-saving, anti-Global Gag Rule provisions

As The Shape of Things to Come makes clear, age structure matters to development. And the good news is that demography is not destiny. More balanced age structures can be achieved through popular and effective policies backed by sufficient funding and political commitment. Most importantly, these investments in the health, education and well-being of women and young people are time-tested, cost-effective, and grounded in human rigpopact—and they can truly impact the shape of things to come around the world.

For the first time in recent history, the House and Senate have united in support of the pragmatic "prevention first" policy that is favored by most Americans and backed by strong evidence. Both the House and the Senate have voted in favor of provisions that exempt contraceptives from the Global Gag Rule. Democrat and Republican Members of Congress on both sides of the abortion issue endorsed this common-sense measure, recognizing that it will save the lives of women and children and help reduce unintended pregnancies. The Senate went a step further and repealed the Gag Rule entirely.

Since the Global Gag Rule was reinstated by President Bush in 2001, shipments of U.S.-donated contraceptives have been stopped to 20 developing countries in Africa, Asia and the Middle East. In addition to this devastating impact, dozens of family planning providers in poor, developing nations have lost U.S. funding and technical assistance, forcing them to scale back services, lay off staff, and even close their clinics altogether.

The anti-Gag Rule provisions passed by Congress will bring relief to the tens of millions of poor women overseas who have been victimized by these draconian policies and who lack basic reproductive health care, including contraceptives. The President should sign these provisions into law rather than reward a small but influential group of anti-birth control extremists in his own party and jeopardize such an important bill. Mr. President, the choice is clear.

Peter Piot, head of UNAIDS, made the rounds in DC last week discussing how the global community can achieve the internationally agreed upon target of universal access to HIV prevention, treatment, care and support by 2010.   His message has been clear: Without a massive scale-up of prevention programs, we will fall far short of addressing the growing feminization of this disease.  PAI welcomes Dr. Piot and his salient message.  Now consider the future of this epidemic in countries where men and women desire to protect themselves and plan the size of their families but do not have access to services and supplies—especially condoms and contraceptives—which would make that desire a reality.

Take Kenya, for instance.  In a country where HIV/AIDS funding is strong and steadily growing (U.S. funding increased from $2 million to $74 million, 1995-2005), funding for family planning has fallen off (decreasing from $12 million to $9 million, 1995-2005).  With fewer financial resources for family planning services, unintended pregnancies have risen—nearly doubling in the years 1998 to 2003—and contraceptive use has declined.

If we’re serious about reaching universal access to HIV/AIDS prevention, we cannot turn a blind eye to the demand for voluntary family planning services and supplies—including condoms. Access to these supplies and services gives men and women the tools they need to determine the size and spacing of their families and to protect themselves from sexually transmitted infections.   Through robust voluntary family planning programs and their integration with HIV prevention programs, we can achieve universal access to HIV prevention and treatment programs. 

Tragically, just the opposite is happening.  Since 1995, U.S. funding for international family planning programs has fallen more than $100 million—a whopping 41% reduction when adjusted for inflation—despite the fact that the number of women of reproductive age in the developing world alone has increased by approximately 275 million women since 1995. (In Kenya, the number of women of reproductive age increased 35.9% between 1995 and 2005.)  This family planning funding shortfall is very apparent in PEPFAR's 15 focus countries, where the vast majority have seen a decrease in family planning funds in recent years. 

PAI urges the U.S. and the rest of the world to scale up funding for both HIV prevention and family planning/reproductive health programs.  This is the only way we can ever hope to defeat this deadly disease.

Many men and women already actively seek reproductive health services, whether for family planning, contraceptives, or treatment for sexually transmitted infections, including HIV. Linking these services to HIV/AIDS prevention and treatment—as well as malaria and tuberculosis programs—provides another avenue for men and women to get the supplies and services they need to prevent these deadly diseases, helping the Global Fund to reach its targets: men, women, young people, children and other vulnerable groups.

As the Global Fund’s Replenishment Conference convenes later this month in Berlin, it is critical that SRHR, through strong involvement of key civil society representation, receives the recognition of its significant role in the Global Fund’s mission: preventing HIV and meeting the health needs of those already infected. To date, the process by which the Global Fund invites proposals, the in-country work to develop these proposals, and the process by which they are approved does not adequately support the role of SRHR or sexual and reproductive health providers.

After just a few short years, the Global Fund has saved over 1.8 million lives worldwide. Just think what can be accomplished—how many more lives saved—if the Global Fund partnered with the life-saving work of sexual and reproductive health providers.

Last week, despite President Bush's veto threat, the Senate passed the FY 2008 State-Foreign Operations Appropriations bill (by a vote of 81-12) that includes significant provisions overturning destructive policies on family planning and HIV/AIDS. Thanks to the leadership and commitment of Senators Patrick Leahy (D-VT) and Barbara Boxer (D-CA), the Senate bill not only includes the identical measures in the House-passed bill (H.R. 2764)—exempting contraceptives from the Global Gag Rule and repealing the abstinence-only funding restrictions for HIV prevention programs—it goes even further by repealing the Gag Rule entirely.

This repudiation of some of the most egregious and harmful aspects of U.S. international family planning and reproductive health policy marks a major—and long overdue—victory for sound public health. And to put it in historical perspective, this Senate vote is the first time since the Gag Rule has been in force—from 1984 to 1993 and again since 2001—that both the House and the Senate have passed legislation to repeal or modify the restriction. This is significant in light of the all-important showdown that looms with the White House over President Bush's threatened veto of the entire $34 billion foreign assistance bill over the Gag Rule provisions.

The Senate 53-41 vote in favor of an amendment to repeal the Gag Rule, sponsored by Senators Boxer (D-CA) and Snowe (R-ME), is a victory for the tens of millions of poor women overseas who have been victimized by the Gag Rule and lack basic reproductive health care such as contraceptives. It's a powerful recognition of the Gag Rule's devastating impact on family planning programs.

Because of the Gag Rule, dozens of family planning providers in poor, developing nations have lost U.S. funding and technical assistance, forcing them to scale back services, lay off staff, and even close their clinics altogether. Adding to this harm, contraceptive donations from the U.S. government have been stopped to 20 countries in Africa, Asia, and the Middle East since the Global Gag Rule was reinstated in 2001. Leading indigenous family planning providers in several other countries have also stopped receiving contraceptives from the U.S. Watch PAI's compelling documentary "Access Denied: U.S. Family Planning Restrictions in Zambia" for an example of the immense harm caused by the Gag Rule.

These draconian impacts come on top of major reductions in funding for international family planning and reproductive health in recent years. Since 1995, U.S. funding for these programs has fallen more than $100 million—a whopping 41 percent reduction when adjusted for inflation—despite a growing demand for reproductive health care in the developing world. It's worth noting that the number of women of reproductive age in the developing world alone has increased by approximately 275 million women since 1995. By voting to repeal the Gag Rule and rigid, ineffective abstinence HIV funding mandates, Congress has restored some desperately needed common sense to U.S. FP/RH programs. Not incidentally, they're programs that the vast majority of the American people overwhelmingly support.

So, Mr. President, let's talk about that veto threat of yours.....

The United States gives a tremendous amount of funding to U.S.-based organizations best equipped to provide aid – including food, health care and education – to people in developing countries. Like CARE, these organizations often have the best understanding of the situation on the ground and the infrastructure in place to help the most people.

But federal funding comes with a price: a laundry list of rules and regulations outlining how organizations must spend that money. While these rules and regulations are often an effective way to monitor U.S. spending, the need for U.S. funding often trumps an organization’s desire to challenge – let alone reject – funding because of flawed policies. When NGOs find that U.S. policies don’t support the work they are trying to accomplish – in this case, alleviating chronic hunger in the developing world – it’s time to speak up. In turn, the U.S. government must support an environment in which challenge is supported, rather than stifling dissent.

Sometimes the most powerful decision an organization can make is the courageous decision to say no to U.S. funding. Many family planning and reproductive health providers in the developing world have made similar decisions in recent years, declining much-needed U.S. family planning funding because of destructive restrictions such as the Global Gag Rule (Mexico City Policy). In so doing, organizations like these and CARE help draw attention to flawed and ineffective U.S. policies and lay the groundwork for urgently needed reforms. 

Keeping this language in the 2008 foreign assistance budget is critical - and much will need to happen in the coming months. First, the U.S. Senate, which is expected to vote on their own version of the foreign spending bill when they return to Washington, must take a stand for women’s lives and keep this language in the bill. After that, the House and Senate must gear up to overturn the promised Presidential veto.

We at PAI wonder if anyone in the Bush Administration has really even read this language carefully. It’s hard to fathom that the President would veto the entire foreign operations budget in order to prevent these supplies from reaching the women and couples around the world who desperately want and need them. Since the Global Gag Rule was reinstated by President Bush in 2001, shipments of U.S.-donated contraceptives have been stopped to 20 developing countries in Africa, Asia and the Middle East. Filling the unmet need for contraceptives would avert 52 million unwanted pregnancies each year, preventing an estimated 29 million abortions, 142,000 pregnancy-related deaths and 505,000 children from losing their mothers. How could the President possibly disagree with provisions that have the potential to save so many lives?

Just because Congress isn’t in session this month doesn’t mean that they take a break from their responsibilities on the Hill. While your Senators and Representatives are in your district, ask them to support this bill and vote to overturn a Presidential veto.

In the meantime, we have a little homework assignment for the Bush administration: Take a moment to read this language. We think you’ll realize that all it does is save lives.

“For every person who began antiretroviral therapy in 2006, six people were newly infected,” according to a new report from the Global HIV Prevention Working Group.Without a major scale-up of HIV prevention programs, using existing prevention tools, 60 million more HIV infections are projected to occur by 2015.  The best of the best have confirmed what many knew to be true: Only by significantly ramping up HIV prevention programs can we curb the scourge of HIV/AIDS. If the world does not listen, and new HIV infections continue to grow as they are, we'll have no one to blame but ourselves.  The members of this group  are the most knowledgeable experts on HIV prevention in the world and they have rung an alarm bell that world leaders must heed in order to put an end to the HIV/AIDS epidemic. 

Countries such as Haiti and Kenya have seen early success from a scale up of their HIV prevention programs, as reported by the Prevention Working Group. Haiti has seen a drop in HIV prevalence among pregnant women (from 6% to 3.4% between 1998 and 2004). In Kenya, HIV prevalence among adults fell dramatically, from 10% in the late 1990s to 6.1% in 2005.  But, with the populations of Haiti and Kenya projected to double in 43 and 27 years, respectively, how can this progress possibly continue?

HIV prevention and family planning should go hand in hand. Voluntary, non-coercive family planning programs, including access to contraceptives, help HIV positive women avert unintended pregnancies, while programs that promote condom use not only reduce unintended pregnancies, they also prevent the spread of HIV and other sexually transmitted infections between sexual partners.

Tragically, however, family planning has played a diminishing role in the U.S. response to this epidemic. President Bush’s fiscal year 2008 budget request slashed international family planning assistance to Kenya and Haiti (as well as to six other PEPFAR focus countries) in half.  Meanwhile, populations are growing rapidly, HIV/AIDS continues to spread, and demand for family planning and HIV prevention and treatment programs continues to rise.

Ultimately, the success of our global effort to eradicate HIV/AIDS is two fold: we must scale-up prevention programs while simultaneously increasing access to family planning programs. While a stronger commitment to preventing new infections is paramount —and PAI joins the Prevention Working Group in calling for this—we will never get ahead of the race to end this deadly disease if people don’t have the tools to determine their own fertility.

PAI urges the U.S. and other nations to rapidly step up funding for HIV prevention and family planning programs. Ideology must be set aside in favor of heeding the warnings and advice from the experts.

Too often, it is women who make—and disproportionately bear the brunt of— reproductive health decisions on behalf of a couple.  Women are the ones who risk dying from complications in pregnancy and childbirth.  And if a mother dies, her daughters—not her sons—tend to be the ones who leave school to care for their families. Sadly, men more often hold the power in decision making, both at a personal and at a political level. PAI urges men to be the strongest allies in improving the health and well-being of women— whether as partners or politicians—by engaging in the fight to save the lives of their wives, sisters, daughters, mothers and other women in their community.

This year, World Population Day focused on the role of men in maternal health—emphasizing reproductive health as a goal that both men and women want and need. The role of men is crucial according to Amy Coen, President and CEO of PAI, who stated, “Women cannot win this war—a war in which they suffer poor health at the hands of inequality— without the help of their partners, husbands, and fathers.”

By promoting sound policy, increasing funding for reproductive health programs and making sure that these programs address the needs of both men and women, policymakers have the ability to save tens of thousands of lives and improve the quality of life for countless more women and children—and in turn, the men in their lives.

The involvement of men at all levels of society is critical to saving women’s lives and achieving gender equity.  Reproductive health programs must reach out to men, as well as women, if they are to be effective.  In addition, these programs must be made accessible and attractive to men and be combined with strong programs that engage men in broader issues, like preventing gender-based violence and eliminating the practice of female genital mutilation.  Reproductive health isn’t just a “woman’s issue.”  It affects the health and prosperity of every man, woman and child in the world. 

Next year, for the first time in history, over half of the world’s population will live in urban areas, according to the U.N. report, State of World Population 2007. It is imperative that we not allow this increase in urbanization – most of which will occur in developing countries – to result in a dramatic increase in urban slums and the number of people living in poverty.

Since most of the growth in urban population is due to increased fertility, it is essential to better provide reproductive health services and to empower women through education and economic opportunity.  Janice Banaag, an eighteen-year-old mother who lives with her husband and newborn under a bridge in Manila, doesn't want to have another child until she and her husband can save more money. Tragically, planning one’s family is extremely difficult to do in Manila, where the mayor has banned contraceptives in public hospitals and health centers – making it nearly impossible for women like Janice to protect themselves from HIV/AIDS and to plan the timing of their children.

Currently, over 200 million women in the developing world wish to prevent or delay pregnancy, but lack access to modern contraceptives. If these women – many of whom live in urban slums – had the access they desire and need, they could prevent unwanted pregnancy, curb child and maternal mortality and remain free from sexually transmitted infections like HIV/AIDS, leading to longer, healthier lives. 

Passage of the Senate appropriations bill can help provide access to these life-saving supplies by exempting donated contraceptives from the Global Gag Rule. Since the reinstatement of the Global Gag Rule in 2001, shipments of contraceptives have been stopped to over 20 developing countries in Asia, Africa and the Middle East – the same areas that are now facing this increased urbanization.

Access to reproductive health programs and services is not only a fundamental right, it is key to eradicating poverty. PAI urges the Senate to pass the appropriations bill in its current form, providing the tools necessary for millions to rise out of poverty.

These are the words of Skytt Nzambu, a Kenyan woman who was infected with HIV by her unfaithful husband.  Tragically, Skytt is only one of an increasing number of HIV infections that are occurring within married couples, according to information reported at last week’s HIV/AIDS Implementers’ Meeting  in Rwanda.  This information highligpopact yet again the urgent need to continuously re-evaluate prevention programs as new evidence emerges in order to accurately address the needs of a constantly evolving epidemic. PEPFAR’s (the President’s Emergency Plan for AIDS Relief) ABC model, which emphasizes abstinence and provides condoms only for those “who practice high-risk behaviors,” doesn’t do a good enough job with “B” (Be faithful) to provide protection for what is increasingly becoming a “high-risk behavior” for women: sex between a husband and wife.

Dr. David Apuuli, director-general of the Uganda AIDS Commission, indicated that marital sex accounts for 42% of new infections in Uganda. According to Apuuli, “Studies show that a significant number of new infections through marital sex are because, over the past four years, men have increased their number of sexual partners, be it wives or girlfriends.” Sadly, it is these wives and girlfriends who are paying the ultimate price: HIV infection.

Vinod Mishra, director of research at Macro International, warned the attendees not to ignore these findings, saying, “It’s not about laying blame, it’s about saving lives; it’s about preventing future infections within marriage, and marriage is… the primary route of the epidemic, and the primary source of new infections in many of these countries now.” It is clear that prevention strategies that focus on abstinence and faithfulness in lieu of comprehensive, evidence-based prevention programs are not adequate to protect a woman whose husband is unfaithful.

The House of Representatives has taken the first step toward eradicating these flawed prevention strategies by passing H.R. 2764 , the appropriations bill that provides greater effectiveness and flexibility in the fight against HIV/AIDS by allowing the President to waive the restriction under PEPFAR that mandates at least one-third of U.S. HIV/AIDS prevention funding be limited to abstinence-until-marriage programs.  During House debate of this bill, Congressman Walberg (R-MI) mentioned that he'd met a young woman "with three children who has HIV as a result of behavior issues related specifically to a husband who was unfaithful in many, many ways.” Congresswoman McCollum (D-MN) followed up on that point and said:  "I thought it was very compelling to hear the story that was just shared on the floor by my Republican colleague about how a wife had become infected, not because of her behavior, but because of her husband's behavior."

Now, the Senate has their opportunity to support responsible, evidence-based HIV/AIDS prevention as they debate their own version of the appropriations bill. The language passed by the Senate Appropriations Committee contains a similar provision, which we urge the Senate to maintain to show their commitment to preventing the spread of HIV/AIDS. In addition, it also contains the provision exempting contraceptive donations from the Global Gag Rule . These two provisions will help reduce HIV infections and unintended pregnancies, including among HIV-positive women, strengthening U.S. foreign assistance and improving its ability to save the lives of women and men around the world who don’t currently have the services and supplies they need to protect themselves.

Population Action International celebrated an important victory for women and their families last week, as Congress passed a Foreign Operations Appropriations bill (H.R. 2764 ) that contained language correcting some of the most egregious aspects of U.S. international sexual and reproductive health policy.

Despite attacks by family planning and reproductive health opponents, two important provisions survived:

• An amendment put forth by Foreign Operations Chairwoman Nita Lowey (D-NY) that exempts overseas NGO family planning providers from the restrictions of the Global Gag Rule (Mexico City Policy) that cuts off the flow of U.S.-donated contraceptives and condoms.

• A provision that repeals the abstinence-only funding restrictions under PEPFAR (the President’s Emergency Plan for AIDS Relief) that require at least one-third of all U.S. HIV/AIDS prevention funding be limited to abstinence programs.

Three amendments that came up on the House floor were vigorously debated: the aforementioned Lowey Amendment,  the Smith-Stupak Amendment that would have nullified the Lowey Amendment, and the Pitts Amendment that would have preserved the abstinence funding restriction.

Some of the most powerful statements on the House floor came from Members who identify themselves as anti-abortion but understand that these changes in U.S. policy would help prevent abortion and the transmission of sexually transmitted infections, including HIV/AIDS. Both provisions were upheld with support from both Democrats and Republicans, including some Members who in the past have not been as supportive.

President Bush has vowed to veto the entire $34.2 billion foreign assistance spending bill over the new contraceptives language. This week, the Senate is expected to begin work on its version of the appropriations bill.  Indications are that they will include similar provisions on the Gag Rule and HIV/AIDS. Once the Senate completes its work on the bill in July, the bill will then go to a conference committee.  There, the House and Senate versions will be reconciled and sent to the President for his approval or veto.

So while there are still hurdles to overcome before these provisions can become law, we are celebrating this victory for women and their families around the world. It is a long overdue and much needed dose of common sense when it comes to U.S. assistance on family planning and HIV/AIDS.