The Limits of Moral Ideology in Foreign HIV/AIDS Intervention

BY AKIELLY HU

From the first cases reported in the early 1980s up until today, the HIV/AIDS pandemic has emerged as one of the world’s foremost public health crises. In 2014, there were 36.9 million people living with HIV – an increase of 6.9 million from 29.8 million in 2001.¹ Such a drastic global issue has understandably garnered a large amount of foreign intervention. Although international bodies such as the World Health Organization, the Global Fund, and UNAIDS have made many large-scale efforts to combat HIV/AIDS, the United States has been and is still by far the largest single national donor for global HIV/AIDS intervention, committing over $4 billion in approved funding in 2010 alone.¹ This funding comes primarily through the President’s Emergency Plan for AIDS Relief (PEPFAR), created in 2003 under George W. Bush’s administration. Ample evidence has shown the positive effects of such mass funding; PEPFAR funding has provided anti-retroviral treatment for over 3.9 million people and testing and counseling for over 40 million people in 2011 alone.¹

Although PEPFAR has contributed significantly to the reduction of new HIV infections and HIV-related mortality, its policies and funding have also resulted in harmful consequences due to the inclusion of an anti-prostitution clause in the Global AIDS Act of 2003 that authorized PEPFAR. The anti-prostitution clause states: “no [PEPFAR] funds … may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution.”² This pledge to actively oppose prostitution was introduced and ratified by conservative policy-makers, many of whom were motivated by the traditional Christian view that prostitution is immoral. According to policy researchers, “the pledge has received strong support from activists and politicians in the United States who take a philosophical or religious stance against prostitution.”² Although the Supreme Court ruled this clause unconstitutional in 2013 due to its violation of the First Amendment, the PEPFAR anti-prostitution pledge clearly illustrates the persistent focus on HIV/AIDS in moral terms. Rather than effectively reducing HIV transmission, the dominant approach of focusing on individual moral actions stigmatizes the very people who need the most help. Policymakers should instead shift to a more accurate view of the HIV pandemic as a collective, systemic issue that can be addressed through a community-based, holistic approach.

The ideological stance against prostitution views the HIV pandemic, especially among people in prostitution, as an accumulation of individual moral choices: individuals make the immoral decision to enter the sex trade or pay for sex, effectively choosing to put themselves at risk. With this mindset, PEPFAR and other ideological HIV intervention schemes actively oppose and work to eradicate prostitution as a means of reducing HIV transmission. Viewing the issue of prostitution through this moral lens, however, fails to recognize the factors outside of individual control, such as widespread poverty and lack of employment opportunities. A study by the World Health Organization on prostitution in Asia emphasizes these outside pressures through its findings that “[m]ost of the people who sell sex in Asia do so because they are compelled by economic and social inequality and by terribly restricted life chances. Especially in the poorer countries of the region, they have no other realistic option.”³

Contrary to the PEPFAR and traditional HIV/AIDS policy perspective, these collective issues—not the immoral decisions of individuals—result in the extensive sex trade that drives HIV transmission. Elizabeth Pisani, an HIV/AIDS epidemiologist working in Indonesia, reiterates the need to remove moral judgment in relation to HIV/AIDS. She argues that in many instances, the lucrative nature of the sex trade makes prostitution financially the best option for poor women: “In the factory, you earn 19 cents an hour. In the brothel, your take-home pay averages about US $3.15 an hour. Two horrid jobs; one pays sixteen times more than the other.”⁴ Geetha Das, a woman in prostitution in Sonagachi, a red-light district in India, echoes the significant role of systemic factors such as poverty in driving the sex trade: “Would I have been able to pay for [my children’s] studies if I had stayed at home? Society should first look at itself before condemning us… Did anyone give us a good job? Society has failed people like me.”⁵

The experiences of Das and others like her illustrate the responsibility of the entire society, rather than individual decisions, in driving the issue of commercial sex trade and HIV transmission. The huge disparity between the wages of the limited employment opportunities (namely, factory work or prostitution) for women in impoverished communities further demonstrates that most people enter the sex trade out of economic necessity, rather than their own lack of morality. Rather than effectively reducing HIV transmission, the dominant approach of focusing on individual moral actions stigmatizes the very people who need the most help.

Viewing HIV transmission as an individual moral choice not only is inaccurate, but can also lead to disastrous consequences in policy implementation. Because of the anti-prostitution clause, many foreign HIV/AIDS intervention projects previously funded by PEPFAR were forced to discontinue their efforts due to “lack of compliance.” Such was the case with the Lotus Project, a non-governmental HIV/AIDS program in Svay Pak, a brothel district close to Phnom Penh, Cambodia. Located above and serving in conjunction with a Médecins Sans Frontières clinic, the Lotus Club offered workshops on health, social, and economic issues as well as other topics suggested by people in prostitution themselves. These included instruction on how to use the female condom, individual counseling, English lessons, and basic computing lessons.⁶ Facilitation of community participation and empowerment provided numerous qualitative benefits, such as strengthened relationships and increased support through workshops and discussions.⁷ This collective approach to combatting HIV proved extremely successful in increasing measures to prevent HIV transmission.

Despite its effectiveness, the Lotus Club was brought before the House Committee on International Relations in 2002 as a ‘Foreign Government Complicit in Human Trafficking’ due to failure to “comply” with the anti-prostitution pledge.⁶ The denunciation and eventual discontinuation of the Lotus Club is a clear example of the failure of the current approach to HIV/AIDS intervention. The most telling example of the ignorance of systemic factors occurred when ideological U.S. policymakers condemned the Lotus Club staff for never having called the police. They viewed this inaction as support of prostitution, when in reality, corrupt Cambodian police often cracked down on brothels and demanded bribes in order to supplement their incomes.⁶ The lack of understanding of the corrupt police shows how focusing singularly on the moral ideology of prostitution fails to address actual systemic factors, such as corruption, that perpetuate prostitution.

Right or wrong, viewing prostitution through a moral lens also leads to ineffective HIV reduction. If people in prostitution are condemned and therefore unable to receive support from non-governmental organizations (NGOs), they lose access to tools such as counseling and condoms that can actually reduce HIV transmission. After the implementation of the anti-prostitution pledge, the Lotus Club struggled to maintain an effective relationship with the Svay Pak community. Out of fear of losing further funding, the Lotus Club was unable to provide its previous services that had benefitted the people in prostitution and prevented HIV transmission, and these difficulties eventually dismantled the entire project. The Lotus Club case study shows how imposing a moral ideology on the NGO stifled its prior efforts to address the realities of the local systemic issues and the complex on-the-ground realities of HIV transmission.

Because the HIV pandemic results from of a web of systemic factors including poverty, lack of employment opportunities, and corruption, it requires a community-level, holistic intervention. One successful example of this approach is the Sonagachi Project, an empowerment HIV/AIDS intervention project in the red-light district of Calcutta, India. Along with promotion of condom usage and the establishment of free STD and healthcare clinics, Peer Outreach Workers gave free medication, cared for an assigned caseload of people in prostitution, and provided social and physical support. As the project continued, the Sonagachi workers and Peer Outreach workers provided literacy classes, HIV awareness education, child-care, a micro-loan service, and even created a condom sales business.⁸ All evidence points towards the effectiveness of this systematic, community-based approach to combatting HIV/AIDS. While other cities in India such as Bombay, Delhi and Chennai had HIV rates of 50% to 90%, in Calcutta the rate dropped to about 11% despite the tens of thousands of people in prostitution in its red-light district.⁹ Condom use also rose as a result of Sonagachi, from 3% in 1992 to 90% in 1999.⁹ The Sonagachi Project focused on the facts of the issue of HIV in Calcutta: namely, the lack of STD treatment and testing services, the lack of education and child-care, the need for economic support and the need for measures for occupational safety and support. By addressing these systemic changes in the Calcutta community rather than focusing on attacking the “immoral” choices of individuals, the Sonagachi Project achieved significant, quantifiable outcomes in reducing HIV transmission.

Another systemic change the Sonagachi Project addressed was the need to engage and mobilize the people in prostitution themselves to combat HIV transmission. Though they are at the highest risk of contracting HIV, people in prostitution are often stigmatized and therefore too disempowered to take action against this shared issue of HIV transmission. The extreme success of the Sonagachi Project was due in part to its recognition of this disempowerment and its policies to instead empower and engage people in prostitution in the fight against HIV. The leaders of the Sonagachi Project began doing so by reframing prostitution in their official policies as a means of survival and not as an immoral state of being. These policies empowered people in prostitution by recognizing that the stigma that people in prostitution are immoral and “seeking personal gain” is false. Instead, they recognized the fact that people enter this “employment” as a desperate means of surviving. The Sonagachi workers asserted that like most other people who desire marriage and family, people in prostitution are humans who require income to survive and deserve to be protected against HIV. When they realized the legitimacy of their needs and their ability to take action such as promoting negotiation of condom use, people in prostitution were able to overcome the issue of disempowerment and instead enact systemic change in order to reduce HIV transmission.

Solving the global HIV/AIDS pandemic requires not only continued funding of research and policy implementation, but also a concerted effort to shift our attention from the morality of the pandemic to the fact-based community-level approaches that can be taken to most effectively address these issues. The HIV/AIDS pandemic in particular can often be a morally contentious issue, as high-risk groups include men who have sex with men (MSM), those who engage in unprotected sex, and people in prostitution. However, as the Lotus Club Project and other case studies have shown, focusing too narrowly on the inherent morality of individual actions ignores the more relevant and pressing systemic factors that cause these issues, such as the inevitability of people entering the sex trade and the subsequent need for occupational safety such as increased condom usage. Effective reduction of HIV/AIDS therefore requires the recognition of the pandemic as a collective issue and a community-based, holistic approach to intervention.

Akielly Hu is a sophomore in Berkeley College and a prospective Global Affairs major from Seattle, Washington. Akielly is especially interested in issues surrounding global health and the regions of Southeast and East Asia. She can be contacted at akielly.hu@yale.edu.

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References:

1. The Global HIV/AIDS Epidemic. (n.d.). Retrieved February 13, 2016.
2. Allman, D., & Ditmore, M. (n.d.). An analysis of the implementation of PEPFAR’s anti-prostitution pledge and its implications for successful HIV prevention among organizations working with sex worker. Retrieved February 13, 2016.
3. STI/HIV: Sex Work in Asia. (n.d.). Retrieved February 13, 2016.
4. Pisani, E. (2008). The Wisdom of Whores. New York, NY: W.W. Norton & Company.
5. Inside Sonagachi, Asia’s Largest Red-light District. (n.d.). Retrieved February 13, 2016.
6. Busza, J. (n.d.). Having the rug pulled from under your feet: One project’s experience of the US policy reversal on sex work. Retrieved February 13, 2016.
7. Boesten, J. (2009). Gender and HIV/AIDS Critical Perspectives from the Developing World. Farnham, England.
8. Jana, S., Basu, I., Rotheram-Borus, M., & Newman, P. (2004). The Sonagachi Project: A Sustainable Community Intervention Progra. AIDS Education and Prevention, 16(5), 405-414. Retrieved February 13, 2016.
9. Arora, P., Cyriac, A., & Jha, P. (n.d.). India’s HIV-1 Epidemic. Retrieved February 13, 2016.