Prostitution Puts U.S. and Brazil at Odds on AIDS Policy - New York Times
July 24, 2005
Prostitution Puts U.S. and Brazil at Odds on AIDS Policy
By LARRY ROHTER
RIO DE JANEIRO, July 23 - In their baseball caps and T-shirts adorned with a rose in the shape of a heart, they are a familiar and welcome presence in the red-light district on the outskirts of downtown here. For years now, they have been distributing condoms to the prostitutes who work the streets, part of the Brazilian government's larger effort to hold AIDS in check.
Until recently, the condom campaign of the group called Fio da Alma had been partly financed through the United States Agency for International Development. But no longer: rather than comply with an American demand that all foreign recipients of AIDS assistance must explicitly condemn prostitution, Brazil has decided to forgo up to $40 million in American support.
"Our feeling was that the manner in which the Usaid funds were consigned would bring harm to our program from the point of view of its scientific credibility, its ethical values and its social commitment," Pedro Chequer, director of the Brazilian government's AIDS program, said in an interview in Brasilía. "We must remain faithful to the established principles of the scientific method and not allow theological beliefs and dogma to interfere."
Experts here and abroad say the disagreement over how to deal with prostitution is symptomatic of a larger conflict between Brazil and the United States over AIDS policy. Brazil, which spends more than $400 million annually on what is regarded as the most successful AIDS program in the developing world, is taking a pragmatic approach in combating the global epidemic, the experts say, while the United States, increasingly, is not.
"It's not as if you're choosing between two neutral policy programs," said Chris Beyrer of the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health. "Brazil has good data to show that their approach works, and to ask them to change that, even if they get the additional money, to one for which there is no evidence, just because of moral squeamishness in the United States, is an extraordinary position to take."
Dr. Beyrer is one of several thousand AIDS specialists from all over the world who have gathered here for an annual conference of the International AIDS Society that begins Monday. Mark Dybul, deputy coordinator and chief medical officer for the Bush administration's global AIDS initiative, is also taking part, and says the prostitution controversy is not only overblown, but is also an example of the many misconceptions about American policy.
"On the ground, this isn't an issue," Dr. Dybul said in an interview here on Friday. "Part of a compassionate response involves meeting people where they are and working with them."
He added, "Each country has a sovereign right to make decisions for themselves, and we respect that." But in order to receive American aid, he said, "it does require an acknowledgment that prostitution is not a good thing and to be opposed to it."
One gauge of Brazil's success in confronting AIDS is to compare the situation here with that of other developing countries, many of which have sent delegations to study the Brazilian program. In 1990, for example, Brazil and South Africa had roughly the same rate of prevalence of H.I.V. among their adult populations, just over 1 percent.
Today, some studies indicate that 20 percent or more of South African adults of reproductive age are infected with H.I.V. or have AIDS, an estimated total of more than 5 million of the country's 44 million people. In Brazil, in contrast, the rate has dropped nearly by half, and the number of patients being treated has held steady, at about 600,000 out of a total population of 180 million.
"The Brazilian program very early on attempted to recognize that this is a pandemic that could travel through the population if there weren't programs to provide education and give special attention to vulnerable groups," said Mark Schneider, who was the Agency for International Development's director for Latin America in the Clinton administration and has worked at the Pan-American Health Organization.
"They attempted to take out the stigma and practice safe sex so as to prevent the epidemic from expanding, and in that way they were well ahead of other countries, particularly in the developing world."
But the Brazilian approach is anathema to many conservatives in the United States because it makes use of methods seen as morally objectionable. Brazil not only operates a needle and syringe exchange program for drug addicts but also rejects the Bush administration's emphasis on abstinence, being faithful and the controlled use of condoms, the so-called ABC approach, in favor of a pragmatism that recognizes that sexual desire can sometimes overwhelm reason.
"Obviously abstinence is the safest way to avoid AIDS," Dr. Chequer said. "But it's not viable in an operational sense unless you are proposing that mankind be castrated or genetically altered, and then you would end up with something that is not human but something else altogether."
"If we increasingly focus the prevention of AIDS along these lines, we are generating carnage, a slaughter," he said. "It's not a realistic vision, and the epidemic is going to grow larger and larger."
Brazil, of course, is not the only country to have been affected by the American policy. Senegal has one of the lowest H.I.V. prevalence rates in Africa, but has been cut off from the Bush administration initiative, public health experts said, because prostitution has been legal there since 1969. And in Central American countries like Guatemala, religious groups supported by American financing have distributed fliers to prostitutes urging them to adopt the ABC approach.
Fio da Alma, which means Thread of the Soul in Portuguese, is one of about 30 AIDS groups across Brazil that works with prostitutes in cooperation with an organization called Da Vida, or For Life. As many as one million condoms a month are distributed through that program, one of several that were initially financed in part through the American aid agency and were expected to continue as part of a grant that would last through 2008.
The United States wanted to remain involved because the White House in 2003 announced a five-year $15 billion program known as the President's Emergency Plan for AIDS Relief. Congress has authorized financing, but also required that all groups getting American money make an explicit statement of policy opposing prostitution and sex trafficking.
Brazilian AIDS groups that work with prostitutes argue that they are not endorsing the sex trade. Because many of those involved in the Brazilian program are prostitutes themselves, they know the risks involved.
"With what we do, we are definitely not encouraging the sexual exploitation of women and girls," said Ivanilda Lima, 64, the director of Fio da Alma, who said she had been a prostitute herself since age 13. "We just want women who are already on the streets to be able to protect their health."
Brazil and the Bush administration have differed on other AIDS-related issues in the past, including what Dr. Chequer described as a recent effort to get Brazil to endorse the ABC approach. But in each case, he said, the two sides managed to find a middle ground without violating their own principles.
Over the prostitution issue, however, a compromise does not appear possible. Even if the Bush administration were willing to offend the conservative religious groups that are one of its main constituencies, its hands would be tied by the Congressional legislation.
"We follow the law," Dr. Dybul said. "The law says that groups must oppose prostitution, and we will enforce that. We believe that prostitution is a bad thing, both for H.I.V. infection and for the individual. But we are opposed to the activity, not to the person."
Brazilian AIDS workers, on the other hand, argue that even if the Ministry of Health here were willing to accept the American demand, it could not do so legally. Under Brazilian law, two people having sex in exchange for money is neither a felony nor a misdemeanor, but an infraction much like a traffic violation (although procurement is a crime).
"Prostitution in Brazil isn't legalized, but it's not illegal either," Dr. Chequer explained.
In addition, Brazilian labor law recognizes "sex worker" as a profession. That entitles prostitutes, call girls and street hustlers to contribute to the official government pension fund and to receive benefits when they retire.
"We view prostitutes as partners in this effort, partners who are efficient and competent" in getting Brazilians to give up dangerous sexual behavior, Dr. Chequer said. "Prostitution exists everywhere in the world, including the United States, and we have a commitment to work with this group and respect them."