By: Matthew Cordell on March 10, 2008 The pending US legislation to reauthorize the President’s Emergency Plan for AIDS Relief (PEPFAR) needs to be informed by the fact that increasing targets and money alone will not significantly help in responding to AIDS. After more that 25 years of a global fight against AIDS with little progress made, it is important to re-define the values and principles that will guide us to achieve the ideal of combating a disease that has brought much suffering to many individuals, families and communities around the world. In my view, the principle of equity and equality must remain the two key defining elements of local, national and global responses to the AIDS epidemic.First, all human groups, in spite of sexual identity or orientation, must have an un-restricted, user friendly access to appropriate sexual reproductive health services. Second, public health responses cannot be implemented in isolation from the contextual realities. It is therefore critical to take into account historical, traditional, cultural, and economic factors that have marginalized certain groups in society when putting together policies and finances to guide interventions. Money tied with restrictions that exclude many groups and limit access to services will only save to extend the lifeline of the epidemic. In order to make real progress, there has to be a paradigm shift in our perception of sex and sexuality in the context of HIV. Underlying that should be a commitment to principles and ideals of making real progress in the global fight again AIDS. Global health responses should work to ensure that the weaknesses, needs and concerns that put marginalized groups at risk are reflected in policies and programs. In that vein, while US’ financial investment on efforts to fight the AIDS epidemic has indeed positively impacted many communities, households and individual in sub-Saharan Africa, much more could be done. The main problem with the US financial package is that it is not hitched to the ideals that will help individuals, communities and nations to fight the epidemic. Certainly, some progress will be recorded in monitoring and evaluation reports that will end up on cozy shelves but the human damage will be far much more, and difficult to comprehend. As I see it, the ideological trumping of proven public health strategies that reflects the past and current thinking around PEPFAR is a result of the major challenge which is at the heart of HIV: sex and sexuality. In order to save lives and truly make an impact, US policy must engage in a process of self-introspection with the aim of removing culture or religious specific notions of sex and sexual engagement. But honestly, all it takes is to appreciate evidence-based, ground realities, and ensure that they are reflected in public health policies, funding and practices. Perhaps the major shortfall of US’s “strings-attached” foreign public health assistance to an effective HIV response is that it does not project the holistic approaches required to help affected and infected communities fight the epidemic. There is nothing inherently wrong with promoting “abstinence-only” earmarks; the problem comes when that is the sole method regarded above all the others. Abstinence only strategies must be part and parcel of other proven initiatives to fight AIDS, such as condom use, and access to services for all groups. Maintain uncompromising positions on sex and sexuality only means that millions of people will not be reached by services, and intended outcomes of financial investment will remain a pipedream. It is highly unfortunate that in the design of policies, politicians and government leader fail to listen to ground realities from researchers, implementers and scientists working with affected communities, and instead only cater to the interests of minority constituencies that are far flung from the ground reality. In that vein, by ignoring evidence-based research, and promoting morality over reason, the US government is wittingly committing genocide against millions of marginalized people, particularly women, girls, youth and children. The real losers of US straight jacketed overseas public health funding are the weak, voiceless, and highly marginalized groups in already disenfranchised communities. A more progressive approach must ensure that women have access to medical treatment, including access to drugs that can prevent sexually transmitted infections, condoms, psychosocial and legal support and access to abortion services to terminate forced and unwanted pregnancies. In communities where PEPFAR is supposed to have an impact, particularly in sub-Saharan Africa, women have a very small voice in deciding sex and sexuality matters. Many are forced to sex work due to lack of economic opportunities. Denying these women access to services is indeed tantamount to committing genocide, and it’s not due to ignorance but a failure to understand the new thinking required to combat AIDS.