Very few AIDS advocates, and even fewer members of the press, attended the most recent meeting of the Presidential Advisory Council on HIV/AIDS (PACHA). But for those who did journey last June to a nondescriptWashington, DC, hotel, descending to the dimly lit conference room where the meeting took place was like falling down Alice's rabbit hole -- into a world where AIDS reality has been turned on its head.
The first day began right-side-up enough, with a presentation about rapid HIV testing, and ended with the merely typical absurdity of a flak disingenuously praising his boss: In this case, special assistant on global health and "friend of W" Bill Steiger calling the U.S.'s $200 million pledge to the Global AIDS Fund for next year -- a tenth of what advocates say is needed from the U.S. -- "a sign of the administration's strong commitment."
But sandwiched in-between was something quite odd: an entire afternoon of presentations on HIV prevention without a single expert on IV drug use. Still, if the presenters were loath to address an activity responsible for at least one in four U.S. transmissions, they were eager to talk about sex -- or rather to talk about not talking about sex. The lineup featured one lone presenter on "comprehensive" education, the science-based approach that includes measures from condoms to "just say no" and has long been the public-health standard. She was interrupted repeatedly by PACHA co-chair Tom Coburn -- the former congressman who famously called safer sex a "lie" -- who presided over the affair like a patriarch over Thanksgiving dinner. And she was then outflanked by two speakers promoting abstinence-until-marriage, the favored prevention message among Christian conservatives. One, PACHA member Joe McIlhaney, ominously emphasized that even 100 percent condom use still leaves some "relative risk" and warned against not just fluid-sharing sex but "any contact that creates arousal."
After that, Health and Human Services (HHS) assistant secretary Eve Slater trumpeted her agency's aggressive audit of HIV prevention spending. While earlier speakers had bashed "so-called AIDS activists" as "actually furthering transmission of HIV," Slater ended her talk by dryly complaining that "this field [AIDS] has often been plagued by an over-energetic desire to get things done."
And yet the meeting exploded into complete unreality only on Day Two, when Coburn tossed out the schedule and ceded the floor to PACHA director Pat Ware, who gave an impromptu 20-minute monologue on the importance of marriage. "My goal," said the longtime single mom, "is to bring more black men into homes as loving, caring fathers. A two-parent household stabilizes the family, the community and the nation." When PACHA member Brent Minor, a Clinton holdover, responded, "What about me as a gay man? We have to be included as part of prevention," born-again Christian council member Joseph Jennings exploded: "Is this a gay HIV agenda? Is this a gay thing?" Afterward, Minor told POZ, another council member approached him to say, "Don't take this wrong, but I just don't believe in 'that way.'"
That's very curious, as Alice might say, coming from a member of a council charged with advising the president on an epidemic in which sex between men remains the single-most common mode of transmission. But while Alice woke up from her journey to find herself on the bank of a peaceful stream, the AIDS community seems unable to rouse itself from this AIDS Wonderland. Consider: The administration's May attempt to block UN endorsement of contraception use across the globe; the June firing of AIDS czar Scott Evertz, an openly gay man despised by the religious right; a Congressional investigation, launched in July, into every AIDS group, including veterans like GMHC, that protested HHS secretary Tommy Thompson's speech at the international conference in Barcelona; a new audit of HIV spending at the Centers for Disease Control and Prevention (CDC), piled on top of an audit of San Francisco's longtime gay prevention group Stop AIDS Project and Slater's at HHS. And then there's Bush's 2003 budget request, which denies even a cost-of-living increase for Ryan White, but tens of millions extra for abstinence-only, for a total of $135 million.
"If you put these things together," says longtime activist and HIVer Eric Sawyer, "the faith-based program, the punitive audits, the abstinence-only funding, you come up with the impression that the administration's policy is to totally dismantle the fight against AIDS." So PACHA may be poised to become the Red Guard of this Bush-era Cultural Revolution.
Once a Great Notion
The first presidential AIDS council was established in 1987, and despite all odds, each one to follow offered resounding calls to conscience in the face of presidential complacency. Ronald Reagan's Presidential Commission on AIDS began ignominiously, in controversy over the appointment of members who believed HIV was transmitted by mosquitoes or who called AIDS "the due penalty for [gay men's] perversion." But when retired admiral James Watkins took over as chair, he hired a staff of 30 experienced Capitol Hill operatives and, though deeply Catholic himself, vowed to "keep morals out of this." Within 10 months he had held 43 hearings with hundreds of witnesses and issued a 279-page report that excoriated Reagan for his "sluggish" response to AIDS and called for anti-discrimination legislation, comprehensive K-12 health education and a big jump in federal funds.
Councils since have continued to play this Isaiah-like role. Papa Bush's commission charged that he had "seriously underestimate[d] the scale of the AIDS disaster," and when the administration resisted its call for universal health care, drug treatment on demand and the legalization of hypodermic needles, commissioner Magic Johnson resigned in protest.
Clinton's Presidential Advisory Council was no softer. It expressed "grave concerns" about the government's "overly timid" prevention plan and pushed the administration, in countless memos, reports and editorials, to endorse needle exchange. It was stacked with people who had devoted their lives to AIDS -- from pioneering women-and-AIDS researcher Alexandra Levine, MD, to GMHC deputy director Ronald Johnson -- many of whom also had HIV. According to Levi Strauss rep Stuart Burden, a Clinton appointee retained by Bush, "the council had big-time wonks who knew the entire history of a bill, who was lined up around it, the complete political context."
Bush Jr.'s council does not. Of the nine Clinton-era remainders and 26 Bush appointees, PACHA contains only one scientist, holdover Cynthia Gomez, and only five people with HIV. There isn't a single staffer from a major national AIDS organization. Instead, this council has nine longtime advocates of abstinence-only HIV prevention, a few of whom, such as 26-year-old Dandrick Moton, openly acknowledge that "I'm not an expert on AIDS." "For any other advisory group," says Gomez, a researcher at the Center for AIDS Prevention Studies (CAPS) at the University of California at San Francisco, "you'd be hard-pressed to find someone to suggest that a third to a half of the council should be composed of people who don't know the field."
From its leaders Ware and Coburn on down, what this council does know well is the promotion of virginity until marriage. And a core strategy of their sex-is-scary campaign is to dismiss anything that could enable sex outside of matrimony to come without a cost -- and that means emphasizing, relentlessly, that condoms can fail.
It's been a long, hard road from the first guerrilla prevention pamphlet, 1983's How to Have Sex in an Epidemic, written by gay men for distribution in bathhouses, to the full embrace of safer sex, and condom use, by everyone from former surgeon general C. Everett Koop to Madonna to the 80 percent of Americans who, according to the CDC, would like to see condom information on TV. As Bush Jr. took office, nearly 20 years into the epidemic, the consensus had seemed secure. Even a July 2000 NIH study of condoms, instigated by Coburn in the hope that flaws would be exposed, instead affirmed "strong evidence for the effectiveness of condoms for reducing sexually transmitted HIV." But now the audits by HHS, Congress and the CDC threaten to defund HIV prevention at the very organizations that built up the response to AIDS from the beginning. And the Christian right takeover of the administration and the AIDS council could undermine decades of safer sex education. "By going after condoms as a tool, they are destabilizing the whole structure of HIV prevention as we know it," says Daniel Wolfe, former communications director at GMHC and author of the gay men's health guide Men Like Us. "Their underlying message is that HIV prevention doesn't work and there's no use bothering."
For the record, repeated CDC reviews of the research concluded that that "even with repeated sexual contact, 98 to 100 percent of people [in sero-diverse couples] who used latex condoms correctly and consistently did not become infected." They show that "successful prevention" requires that "individuals use the full array of existing prevention interventions," including condoms and other safer sex practices, and that such practices cut HIV rates among white gay men in half between 1988 and 1993 -- hailed by some as a public-health near-miracle.
Abstinence-only HIV education, on the other hand, has "no evidence of effectiveness," in the words of the federal Institute of Medicine. According to the Sexuality Information and Education Council (SIECUS), a sex-ed research and advocacy group, the government makes evaluation of the 700 programs across the country it has funded since 1998 optional, and so far only 11 of those programs have volunteered to go under the microscope. SEICUS reports that when it sent out its own evaluation survey, the religious right lobby Focus on the Family countered with a memo urging "Do not sign and return." So when McIlhaney tells POZ, "Let's increase funding for abstinence programs and see what they can do," he does so in a context where scientific evaluation is unlikely, on purpose.
Instead, abstinence-only advocates trot out a small handful of non-peer-reviewed studies, such as a 1995 graduate-student thesis evaluating the Best Friends Program in Washington, DC, which found that only four of 600 girls reported pregnancies -- the most prominent citation in congressional testimony by both Ware and McIlhaney. One NIH-funded study of the Southern Baptist-run True Love Waits found that while some participants who pledged virginity did delay sex for 18 months (not till marriage), once "pledged" kids broke their vow, they were a third less likely to use contraceptives than those who never took the pledge in the first place.
Such data trouble longtime CAPS director Thomas Coates, PhD, who says, "Promoting abstinence-only prevention is like a doctor saying, 'I'd rather treat HIV with valerian root.' It's that dangerous. Fine, fund studies of abstinence-only -- but we should not promote it as a public-health policy in the absence of evidence. Especially when we've got so much evidence supporting the comprehensive approach."
Hello, "A Team"
PACHA member Dandrick Moton, director of the Arkansas abstinence-until-marriage group Choosing to Excel, has recruited a group of kids dubbed "The A Team," each of whom has taken a public pledge of abstinence to show other kids that virginity until marriage is "a realistic approach." It seems Bush appointed his own A Team to PACHA -- with Tom Coburn and Pat Ware as captains -- who seek to tear down the safer-sex consensus.
Coburn, an Oklahoma doctor and Baptist deacon, entered Congress in the Gingrich Revolution of 1994 and -- between board meetings of the far-right Family Research Council -- proceeded to make his name around AIDS. While he cosponsored the Ryan White CARE Act, he also pushed for names reporting and called for an investigation into AIDS agencies, which he accused of mismanaging federal dollars (see "New Enemies List..."). Though he told POZ, "Do I agree with the homosexual lifestyle? No. That's a well-known fact," he knows AIDS well, and at times his abstinence argument has subtlety and force. "We've spent billions on prevention," he says, "and yet we're in the middle of a big second wave, with young gay men throwing care to the wind and putting themselves at risk. My question is: Is the libertinism of the gay community worth having a whole generation die?"
Ware, though less well known, has made a career out of hailing abstinence until marriage and two-parent households as the two magic bullets for all that ails the African-American community. She and her message were snapped up by the first Bush White House, where she had a teen-pregnancy post, and by the religious right, in the form of a senior position at the Americans for a Sound AIDS Policy (ASAP), best known for seeking to block HIVers from protection under the Americans With Disabilities Act. She spoke warmly to POZ about "male friends" from her days in the theater who got sick from AIDS, saying that "I promised then that I would do something to help stop this suffering," but insists that her abstinence-until-marriage concept would have applied to them, too. "For young gay men," she told POZ, "it's the same message."
Cornelius Baker, the director of Washington, DC's Whitman-Walker HIV clinic, served with Ware in the first Bush administration and is sympathetic to her message. "We in the African-American community know that to delay sexuality is not a bad thing. That message needs to be heard," he says. "The challenge is: How do you do that and not also create ignorance about how to protect yourself from HIV? It's abstinence only that has the potential to do great harm."
Ware downplays her starring role at PACHA, but according to Beltway insiders, she enjoys strong support from HHS deputy secretary Claude Allen, a fellow Virginian and an abstinence backer since his days heading up that state's health department. Greg Smiley, interim PACHA director for the first year of the Bush administration, says that Ware "drew a line in the sand about a lot of things," setting meeting agendas, choosing speakers and stacking the council with like-minded people she met on her extensive travels as an abstinence missionary. These likely include, Smiley says, most of the A Team, including Moton, who sits on the board of Ware's family-values foundation; Rashida Jolley, a former Miss DC and self-proclaimed 22-year-old virgin; Lisa Shoemaker, who says that she was infected with HIV by her dentist and now tours as a pro-abstinence speaker; and Jennings. It is no coincidence that all (but Shoemaker) are African American.
The A Team's most savvy politickers are Joe McIlhaney and Anita Smith, both white. Smith, prominently positioned as PACHA's Prevention Committee chair, is head of the Children's AIDS Foundation, ASAP's new moniker, while McIlhaney is director of the Texas-based Medical Institute for Sexual Health, which provides condom-debunking information to abstinence educators across the country, as well as the coauthor of a book revealingly entitled The Myth of Safe Sex. He nearly capsized a Texas health curriculum committee by refusing to negotiate on his abstinence message.
According to John Marble, spokesperson for the gay group National Stonewall Democrats, "The abstinence-only message is deeply linked with evangelical Christianity." Marble should know, as a former youth-abstinence educator himself. "You're really hoping everyone will come to Christ and wait till marriage for sex," he says. "It's a mind-frame that it has to be total in order to be acceptable, so no attempts at compromise will be tolerated."
The leading religious-right groups are no doubt pressuring Ware to make sure PACHA upholds their morality-based message, and it seems she is delivering in small ways already. Cynthia Gomez, the prevention researcher who was PACHA's Prevention Committee chair under Clinton, was relegated to the treatment committee, and managed to switch to prevention only after facing off with Ware. Several Clinton holdovers interviewed by POZ say that they received the agenda -- with an already-final speakers' list emphasizing abstinence -- only a few days before the Washington meeting. And several members claim that Ware instructed them not speak to POZ, which she says has an unfair "editorial slant."
All Roads Lead to Rove
Few people with HIV will forget the Bush administration's first "AIDS moment": comments by W's chief of staff that the AIDS czar and PACHA would be axed. After banner headlines and vocal protest, the administration called the statement a "mistake" -- and then waited more than a year to make council appointments. This foot-dragging has led many observers, including leading HIV doctor Scott Hitt, PACHA chair under Clinton, to question the council's relevance. He says that his council met with the president within six weeks of being formed, but "I just don't get the sense that this administration is engaged." Other signs, however, point to a deep synchronicity between the council and the Bush White House -- one in perfect harmony with the vision of W's campaign mastermind-turned-advisor Karl Rove.
According to Fred Barnes of the conservative must-read Weekly Standard, Rove's focus is "keeping the Republican Party's conservative base solidly behind Bush" and adding new minority constituencies to the party; this "political maneuvering," writes Barnes, "propels Bush's agenda." A born-again Christian himself, Bush has demonstrated his comfort with the beliefs of the far right, but courting that sector is also key to the Rove electoral strategy. This means that Rove went to bat to push the president's Faith-Based Initiative through Congress (it doles out social service dollars to congregations) and that, writes Barnes, "every appointment, even the most insignificant, crosses his desk." When seen through this lens, the PACHA appointments and agenda lose their Wonderland aspect and enter the land of Realpolitik. By completely politicizing HIV prevention, Bush can channel millions in pork to the party faithful in abstinence-only dollars while also assisting the progress of a cherished agenda.
Still, some advocates hold out a thin hope that, as National Association of People With AIDS (NAPWA) director Terje Anderson says, precisely because the council is so right wing, it "may be able to have a positive influence on the Bush White House on some [non-prevention] issues, such as ADAP funding or expanding Medicaid coverage." This possibility is bolstered by the seven or so outspoken dissidents among the council's Clinton holdovers, including Gomez and John Perez, the council's only Latinos; HIVers Brent Minor and Caya Lewis; and former congressman Ron Dellums, a strong advocate for global AIDS funding. They are joined by HIV positive Bush appointee Mary Fisher, a connected party loyalist who spoke at the Republican National Convention in 1992 and has worked on the inside ever since to extend her party's AIDS commitment and sanity.
There are a few additional Bush picks who show no signs of having pledged a loyalty oath yet and may prove to be allies of science-based HIV policy. Among them are Tennessee Rev. Edwin Sanders, an advocate of needle exchange; James Driscoll, a gay Republican, former ACT UPer and staunch defender of ADAP; and Maine health-department director Nathan Nickerson, who, when McIlhaney barked in June that condoms require 100 percent adherence to work, snapped back, "And abstinence doesn't?" Finally, there's Katryna Gholston, an HIV positive mother of five from Alabama, who is highly regarded among local African American AIDS advocates and spoke resolutely to POZ in opposition to the A Team's vision. She scoffs at the idea of marriage as a form of HIV prevention, saying "I know so many women who were in committed relationships who were totally blindsided when they found out they had HIV." And she is passionately against basing HIV prevention in faith: "Whenever you bring the church in, it brings up a sense of rebellion in people. You don't need judgmental people to do prevention."
And just as the A Team has its backers in Rove and Allen, these moderates have their own potential allies in the administration, reflecting the political divides in Bush's "compassionate conservativism" coalition. They include veteran HIV doctors and researchers like Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases (NIAID); Julie Gerberding at the CDC; new, openly gay AIDS czar Joe O'Neill; even pro-condom secretary of state Colin Powell (see "...And a Few Allies"). These figures "could have a tremendous influence on policy," says NAPWA's Anderson.
Brave New World
These bright and dark sides of the council were both visible in PACHA's only -- and, to date, unanswered -- official communication with the president. The short letter, sent last March, asks for increased funding for ADAP, now facing crisis shortfalls, and an increased U.S. contribution to the Global Fund -- two items also at the top of most progressive AIDS activists' agendas. But at the same time, it also argues, in a soft allusion to the abstinence-only agenda, that "we should revisit current strategies to determine if they are, indeed, still the most effective methods of prevention education." And it asks that federal dollars "be prioritized to where the disease is specifically accelerating" -- code language used in Coburn's years-long effort to defund gay AIDS groups. And it twice mentions the "responsibility [of people with HIV] to not infect someone else," language that Fisher, in a memo to Ware before the letter was sent, said "strongly infers that evil people are out intentionally infecting innocent folk" and that HIV is "a disease of the guilty."
At presstime, Ware told POZ that Coburn and his co-chair, Louis Sullivan, MD, health secretary under Bush I, were in the process of arranging a meeting with the president "very soon." The shape of that meeting will depend in part on whether council dissidents -- and AIDS advocates -- raise their voices.
So far, says Anderson, most AIDS agency staffers "are scratching our heads and saying what can we do" or meeting for quiet strategy sessions about how to stave off audit-induced budget disasters. Others, such as Scott Hitt, express hope that the threat posed by HIV audits will catalyze some ACT UP-style activism, which, he says, "is badly needed right about now." But it has fallen to other, non-AIDS forces to declare war. In late July, the ACLU won a court case against a Louisiana abstinence-only program for using public money to "further religious objectives," while in late August, SIECUS and Planned Parenthood joined the fray, launching a national campaign, No New Money, to halt additional spending on abstinence-only ed. Then in September, the Human Rights Watch released a scathing report on the dangers of abstinence-only and called on the U.S. government to repeal abstinence legislation and put comprehensive sex ed in its place (see "What Can You Do?" below).
But if Bush hews to Rove's prevention-as-pork course, it could well mean a brave new world of American AIDS -- designed by preachers, not by public-health experts. Between abstinence-only programs and "faith-based grants," Bush could dump up to $285 million into anti-condom programs in the coming year -- more than the entire contribution to the Global AIDS Fund. Most of these programs have a strong "Jesus element," says SEICUS rep Adrienne Verrilli, such as the Louisiana program described by The Washington Post that uses federal abstinence dollars "to distribute Bibles, stage prayer rallies outside clinics that provide abortions and perform skits with characters that preach Christianity."
What could our AIDS future look like? A world in which young African-American men-who-have-sex-with-men, one in six of whom is positive, will have to depend on "Just Say Whoa" messages from "Bible Man" to protect himself from HIV. A world in which a young woman who doesn't know her husband uses heroin is told that a church-sanctioned marriage is all the HIV protection she needs. A world in which a kid who falls off the virginity wagon doesn't bother to use a condom for sex because all she's ever heard is that "condoms fail." You can glimpse this future in the words of Linda P., 16, a Waco, Texas, high school student taught abstinence-only, who told a researcher in May, "I don't know any other way but abstinence to prevent HIV."
"The ascension of these conservatives to places of power in the federal AIDS administration took years of campaigning and pressuring and e-mail trees and Christian voter guides and radio shows," says Daniel Wolfe, "but it's been successful." The real tragedy, Wolfe says, is that just when "we in the AIDS community need to take risks to creatively reinvent HIV prevention," the religious conservatives of PACHA are instead using the spike in young gay men's infections "to promote a strategy that we knew then and know now doesn't address the reality of our lives."
As if on cue, Tom Coburn says to POZ nonchalantly, and in defiance of all the evidence, "We have emphasized condoms, and it hasn't worked. So how about abstinence?"
Research assistance: Danielle Zielinski
What Can You Do?
1. Tell the Truth: Human Rights Watch, a globally respected group that monitors abuses, issued a damning report in September of U.S. abstinence-only ed, complete with recommendations for Bush. Check it out at www.hrw.org/press/2002/09/us0918.htm.
2. Lose the Faith: Go to the website of Americans United for the Separation of Church and State at www.au.org/press/pr12601.htm for a 2001 report on Bush's controversial Faith-Based Initiative. Then click on "Legislative Update" (at left) to send an e-mail to Congress opposing the latest effort to dump public money into programs where social services come with mandatory prayers.
3. Dry Up the Honey Pot: Join the 50-plus organizations that just kicked off a No New Money campaign to cancel virginity-or-bust dollars at www.nonewmoney.org. It just takes a few clicks to e-mail the prez or Congress to tell them to stop funding abstinence-only programs -- and put dollars into real HIV prevention instead.
4. Get Out and Vote: Most of Congress's AIDSphobes are in safe seats. But support two AIDS allies who are in trouble, targeted for defeat by team Bush: Rep. Tammy Baldwin, the openly lesbian Wisconsin Democrat, and Sen. Paul Wellstone, the Minnesota Dem who is a top advocate of national health care. The bottom line? Vote Dem on November 2. If the Senate -- where the Dems have only a one-vote majority -- is lost to the Republicans, Bush's war against safer sex will gain unstoppable force.