1. A Case Story Analysis of the Implementation of PEPFAR's Anti-Prostitution Pledge and Its Implications for Successful HIV Prevention among Organizations Working with Sex Workers Melissa Ditmore 1 and Dan Allman 2 1 www.melissaditmore.com 2 Dalla Lana School of Public Health University of Toronto XVIII International AIDS Conference Vienna 22 July 2010

2. Background

3. Background (1) US funding Restrictions Since 2003, US government funding to address the HIV/AIDS pandemic has been subject to an anti- prostitution clause forbidding the ‘promotion of prostitution’ by grant recipients. This has compromised the efficacy of US-funded HIV prevention efforts, particularly with regard to most-at-risk populations including sex workers and transgender people. As of 2010, grant recipients are required to oppose prostitution and sex trafficking “because of the psychological and physical risks they pose.”

4. Background (2) Purpose To provide information from the field about how funding restrictions have been implemented. To highlight how guidance has not been clear about what is and is not permitted. To reflect how many organizations are interpreting the restrictions on their own, with varying results.

5. Background (3) Timeline 2003 U. S. Congress passes Global AIDS Act. 2004 US President's Emergency Plan for AIDS Relief is authorized 2008 U.S. Congress reauthorizes of PEPFAR and its anti-prostitution pledge with a significant increase in funding. 2010 U.S. Department of Health and Human Services releases new guidance on implementation of anti- prostitution pledge. 2005 USAID issues a directive that only organizations with an explicit policy against prostitution and sex trafficking should be funded.

6. Background (4) Genesis 2003 U.S. Global AIDS Act is passed. It states : “No funds… may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking.” “No funds … may be used to promote, support, or advocate the legalization or practice of prostitution.” 2004 President’s Emergency Plan for AIDS (PEPFAR) states: "[A]ny foreign recipient [grantee] must have a policy explicitly opposing, in its activities outside the United States, prostitution and sex trafficking..."

7. Background (5) Genesis (Cont.) 2008 PEPFAR guidelines require grantees to: “certify” their “objective integrity and independence from any organization that engages in activities inconsistent with a policy opposing prostitution and sex trafficking.” 2010 PEPFAR regulation requires grantees to: “agree” that “they are opposed to the practices of prostitution and sex trafficking because of the psychological and physical risks they pose for women, men and children.”

8. Method

9. Method (1) The Case Story Approach This analysis utilizes a Case Story approach (Flyvbjerg, 2004) to build a narrative of defining features of organizations in receipt of PEPFAR funding. The case story approach is ideal for working with data that are highly sensitive and vulnerable to breach of anonymity because it limits the potential to betray confidences and sources (Smith, 2003), and in this context, limits the potential to jeopardize funding. For this analysis, multiple cases are compiled within a single composite narrative in order to reflect  restrictions imposed by the anti- prostitution clause,  lack of clarity of guidelines for implementation,  the ways some agencies contend with these restrictions.

10. Method (2) Narrative Features Information comes from published accounts and directly from sex workers, NGO staff, and USAID representatives, working on five continents. The single narrative reflects representative experiences as reported by organizations and people. The case story presented here is a fictionalized composite, however, all narrative elements of the case story are based on information reported to the researchers.

11. Method (3) Sample Reports from  over 25 organizations and projects,  in 14 nations,  in Africa, the Asia-Pacific region, the Americas, and Europe.

12. Results

13. Results (1) Composite Narrative Setting The fictional West Lannadesh, is a poor country with limited manufacturing and a growing population. Sex work is carried out in a wide variety of venues including streets, bars, hotels and brothels. HIV prevalence is around 1%, with a concentrated epidemic of HIV among sex workers and drug users, of around 15%. Prior to PEPFAR, only people who can afford to pay for HIV-treatment receive treatment. PEPFAR has made it possible for approximately a quarter of the people who need HIV medications to receive them. HQ, a fictional agency, provides direct services in West Lannadesh. HQ is affiliated with a large international NGO in the US.

14. Results (2) Case Story HQ works in partnership with smaller organizations, some of them subsidiaries. HQ operates in an extremely violent post-conflict setting with histories of civil war and natural disasters. HQ operates a series of clinics in a large urban area. Although the organization does not condone prostitution, it does not condemn the individuals involved in it. Only a few of HQ staff are in favour of the pledge. For example, some see the pledge as an opportunity to withhold services from prostitutes who they were not comfortable working with in the first place.

15. Results (3) Case Story (Cont.) The Director of HQ consults with the local USAID Country officer who clarifies that drop-in centers for sex workers are definitely not permitted under the PEPFAR restriction. At the same time, the USAID Country officer confides to HQ’s Director that this is one of the few areas that is specific and clear regarding this policy. The outcome is that rather than police who can and cannot use the HQ drop-in centers, the centres are simply closed, and any clinic attendees who are known or suspected to be involved in prostitution are informed that they will no longer be provided services. With no drop-in centre access, sex workers have no place to get off the street. As a result, homeless sex workers have no access to basic bathing and toilet facilities.

16. Results (4) Case Story (Cont.) In response to the pledge, local sex workers organize a meeting with the staff of an international human rights organization to try to exert pressure on HQ. Under the increased pressure from sex workers, local communities and human rights organizations, the board of HQ decides to stop seeking HIV funding, and instead concentrate on school-based sex education. UR is an outreach organization with links to HQ. It is also in receipt of PEPFAR funds. Realizing the health and human rights implications of the anti-prostitution pledge, staff at UR agree to allow sex workers to meet and to organize at one of its satellite offices, provided that the sex workers do not make the information regarding their meetings public.

17. Results (5) Case Story (Cont.) When asked how UR can be sure they won’t be punished under the PEPFAR policy, an employee of UR indicates, in confidence, that the NGO is a small part of a much bigger project, and that if USAID officials visit, they will not be told about the sex worker group. At an International Conference on HIV and AIDS, others share the same sentiments: “I understand the decision not to report the provision of these services. My organization has adopted a similar policy. I only wish we could do more.”

18. Discussion

19. Discussion (1) Effects of funding restrictions Within the compiled case, guidance on the implementation of the anti- prostitution pledge has been unclear and enforcement has been unpredictable.  Drop-in centers closed.  Sex workers denied clinic services.  Sex workers have less access to condoms and lubricant, and other critical HIV prevention tools.  Peer education for sex workers about safer sex techniques ends.  Campaigns against violence against sex workers cease.

20. Discussion (2) Effects of funding restrictions at NGOs Some NGO staff using restrictions to promote their prejudices. Some NGOs no longer serve sex workers—among the least-served and most-at-risk people. Some NGOs limit discussing their programming to ensure that they remain within PEPFAR guidelines.

21. Conclusion

22. Conclusion (1) Implications of PEPFAR PEPFAR’s anti prostitution pledge has unintended consequences for agencies seeking to provide services to sex workers and clients. Outreach staff indicate that HIV prevention has been less successful since the inclusion of the pledge, and local HIV incidence rates may reflect this. PEPFAR should reconsider this funding restriction in the light of diminished effectiveness.

23. Conclusion (2) Additional Consequences of PEPFAR The PEPFAR restrictions influence programs indirectly also, even those not directly funded by USAID. The restriction’s wide scope inhibits the sharing of information. A lack of information sharing is a direct result of the chilling effect of the restrictions. The lack of information-sharing prevents the development, implementation, evaluation and diffusion of effective programming for sex workers.

24. Conclusion (3) PEPFAR Works Counter to HIV Prevention Best practices for HIV prevention emphasize combating stigma and discrimination and the involvement of target populations in designing programming for effectiveness (Ban Ki Moon, 2010). While PEPFAR has made life- saving medicines accessible to many, this research documents that it also has—and continues to—promote the stigmatization of sex workers and discrimination against sex workers.

25. Acknowledgements Our sincere appreciation to those who have shared their experiences and assisted in this project’s development. These individuals and organizations are not identified for the reasons stated above. Thank you! Melissa Ditmore mhd-PEPFAR at taumail.com Dan Allman dan.allman at utoronto.ca