Re-Building Distribution Networks to Assure Future Microbicide Access
Publication date: 2005
92 Fall/Winter 2005AIDS & Public Policy Journal ABSTRACT The first candidate topical microbicides — products designed to reduce women’s risk of HIV infection — are now in the final stages of efficacy testing, and, if success- ful, could start to be available by the end of the decade. Advocates in public health and international development are already discussing how to expedite access to this new technology in countries where it could have the largest public health impact. The World Health Organization (WHO), World Bank, and the European Union support the integration of family planning and HIV programs. Such integration is impeded by U.S. policy, funding restrictions, and reluctance to inte- grate family planning and HIV/AIDS funding. This article describes how these policies weaken, rather than strengthen, the capacity of distribution networks to play an urgently needed role in microbicide roll-out when the time comes. THE FEMINIZATION OF HIV/AIDS The HIV/AIDS pandemic has undergone a dramatic demographic shift in the last two decades, with women and girls becoming the majority of newly infected individuals. This impact is most pronounced in sub-Saharan Af- rica.1 Although home to only one-tenth of the world’s population, the region supports rough- ly two-thirds of all people living with HIV/ AIDS.2 In 2005, women made up 57 percent of those living with HIV/AIDS in the region,3 and girls comprised 76 percent of all HIV-posi- tive young people (15 to 24 years old) there.4 Socio-economic, cultural, and physiologi- cal factors place women and girls at greater risk for contracting HIV than men. This vul- nerability heightens the urgency of the need for woman-initiated HIV-prevention methods. Topical microbicides are being developed to meet this need. Designed for insertion into the vagina prior to intercourse as a supposi- tory, gel, or foam, microbicides are being de- veloped in contraceptive and noncontracep- tive forms. Unlike a male or female condom, a microbicide can be used by a woman with- out her partner’s active cooperation at each act of intercourse. Analysts estimate that the Re-Building Distribution Networks to Assure Future Microbicide Access Anna Forbes and Nicole Engle Anna Forbes, MSS, is Deputy Director of the Global Cam- paign for Microbicides, an international advocacy coali- tion, in Washington, D.C., email@example.com. Nicole Engle, MPH, is Program Manager at the Academy for Educational Development Center on AIDS & Commu- nity Health in Washington, D.C., firstname.lastname@example.org. ©2006 by University Publishing Group. All rights reserved. This article was published in March 2007. © Copyright 2006 by University Publishing Group. Used with permission. All rights reserved. Copies may not be made without the express written permission of the publisher. email@example.com Volume 20, Number 3/4 93AIDS & Public Policy Journal first generation of microbicides may only be 50 to 60 percent effective, although effective- ness is expected to increase as the second and third generations of products are refined and improved.5 While far from optimal, a product that is 50 percent effective could give millions of women who are unable to insist on con- doms an opportunity to reduce their risk of infection by half. Research done among women and men on the potential acceptabil- ity of this product reveals a range of reactions to the possibility of microbicides, but the fact that such a product could offer a risk-reduc- tion option that does not interfere with sexual pleasure and spontaneity is generally regarded very positively.6 All too often, new medical technologies take years, even decades, to “trickle down” to developing countries. The first candidate mi- crobicides are now in the final stages of effi- cacy testing and advocates in public health and international development — determined to prevent this delay — are already discuss- ing how to expedite access to this new tech- nology in countries where it may have the larg- est public health impact. Mathematical mod- eling indicates that an estimated 2.5 million new HIV infections could be averted over three years in 73 developing countries if a 60 percent efficacious microbicide were to reach 20 percent of the population with access to healthcare — even if it were used in only half of sexual acts not involving a condom.7 Avert- ing 2.5 million infections would also yield $2.7 billion in direct savings to the healthcare system, not including savings on the costs of antiretroviral therapy (ART) and losses in eco- nomic productivity.8 Collaborative work is beginning to address the access and distribution problems expected to impede the rapid introduction of a safe and effective microbicide. The subsidized price of a first generation microbicide in the develop- ing world is expected to be about $0.35 per dose when purchased in a 20-dose multi- pack.9 As noted, subsequent generations of microbicides are expected to increase in ef- fectiveness and the subsidized cost is expected to decrease to about $0.28 per dose.10 Because of this partial efficacy, introduction of the use of microbicides will necessarily be framed by risk-reduction messages explaining that con- doms are more protective than microbicides, but that, when condom use is impossible, a microbicide used alone will reduce risk bet- ter than using no protection at all.11 When comparing the effectiveness of con- doms and microbicides, it is vital to factor in the realities of condom use. Even in commu- nities that have undergone condom promo- tion programs (including free condom access), the percentage of long-term couples using con- doms consistently rarely exceeds 20 to 30 per- cent, except when both partners know that they differ in HIV sero-status.12 A 2004 report issued by the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the United Na- tions Development Fund for Women Acronyms Used in this Article ABC model Abstinence, Be faithful, or use Condoms ART antiretroviral therapy CSIS Center for Strategic and International Stud- ies GAO General Accounting Office GRHR Harvard University Global Reproductive Health Forum IPPF International Planned Parenthood Federa- tion MTCT maternal-to-child transmission NGO non-governmental organization OGAC Office of the Global AIDS Coordinator PAI Population Action International PEPFAR President’s Emergency Plan for AIDS Relief RH-FP reproductive health/family planning UNAIDS Joint United Nations Programme on HIV/ AIDS UNFPA United Nations Population Fund UNIFEM United Nations Development Fund for Women USAID United States Agency for International De- velopment WHO World Health Organization 94 Fall/Winter 2005AIDS & Public Policy Journal (UNIFEM) noted that, in sub-Saharan Africa, “60 to 80 per cent of HIV-positive women re- port having had sexual relations only with their husbands.” Among married women in India, the report adds, “condom use was ex- tremely rare.”13 In the context of this level of risk, even a partially effective microbicide could make a crucial difference. INTEGRATING FAMILY PLANNING AND HIV/AIDS PROGRAMMING The World Health Organization (WHO), World Bank, and the European Union all sup- port the integration of family planning and HIV programs,14 on the grounds that these pro- grams offer optimal entry points for HIV-pre- vention services and information to women who are at high risk of infection. Jodi L. Jacobson observes, “For women who are al- ready or suspect they may be infected, inte- grated services provide confidential outlets for voluntary counseling and testing, drugs to pre- vent maternal-to-child transmission (MTCT), and accurate information on sensitive issues, such as whether HIV-positive mothers can safely breastfeed infants. They provide a source of care free from the stigma often asso- ciated with stand-alone HIV prevention pro- grams.”15 The WHO further observes, “Integrating HIV/AIDS services and programmes into the existing mainstream health system frequently results in effective, cost-efficient outcomes.”16 Integration of services also allows people to access services through providers they already know and trust. Describing their experience in Zambia, researchers at the Policy Project, which is funded by the U.S. Agency for Inter- national Development (USAID), note that both the clients seeking family planning/antenatal care and HIV- positive women coming for HIV care “said they trusted the service providers to maintain confidentiality.”17 Several international agencies have been urging the global donor community to increase funding for condoms and HIV-related supplies to providers of family planning services, thus taking advantage of well-established systems, where they exist, and strengthening those that are underperforming.18 After recognizing the utility of integrating services, envisioning the potential value of integration in facilitating distribution of the first successful microbicides is a logical next step. Unfortunately, the ability to take this step is impeded by United States policies, specifi- cally the Mexico City Policy, funding restric- tions imposed in the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Bush administration’s apparent reluctance to inte- grate family planning and HIV/AIDS funding. These factors are steadily eroding the public’s access to careproviders who are experienced in women’s health and in family planning — the very entities who are the most logical con- duits for distributing microbicides in the fu- ture. This article describes how these policies weaken, rather than strengthen, the capacity of distribution networks to play an urgently needed role in microbicide roll-out when the time comes. THE MEXICO CITY POLICY Announced in 1984 at the United Nations International Conference on Population held in Mexico City, the Mexico City Policy (also known by its opponents as the Global Gag Rule) prohibits provision of U.S. federal fund- ing to foreign non-governmental organizations (NGOs) that perform or “actively promote abortion as a method of family planning.”19 President Clinton rescinded this policy in 1993, but President Bush reinstated it in 2001.20 The Harvard University Global Repro- ductive Health Forum (GRHF) notes that, un- der the policy, “abortion related activities in- clude information provision, counseling, ad- vocacy and lobbying, as well as clinical ser- vices.”21 The GRHF adds, “Lobbying and ad- vocacy work is restricted under the Mexico City Policy and yet this would be unconstitu- tional if imposed on U.S. soil under the First Amendment of the U.S. Constitution, which protects the freedom of speech.”22 Volume 20, Number 3/4 95AIDS & Public Policy Journal Population Action International (PAI) con- curs with this interpretation. According to PAI, no U.S. family planning assistance dol- lars can be provided to foreign NGOs that use funding from any source whatsoever to do any of the following: • Perform abortions in cases other than a threat to the life of the woman, rape, or incest; • Provide counseling and referral for abor- tion; or • Lobby to make abortion legal or more available in their country.23 The Mexico City Policy forbids foreign NGOs that receive U.S. federal funding to un- dertake these activities, regardless of the sources through which those activities, them- selves, are funded. The direct and indirect impact of the Mexico City Policy is difficult to quantify overall, but some data exist. In 2000, the International Planned Parenthood Federation (IPPF) provided family planning services to 24 million clients in 180 countries through 50,000 outlets.24 Unwilling to jeopar- dize its clients’ health by withholding full medical advice, IPPF chose to decline U.S. funding rather than comply with the Mexico City Policy when it was reinstated. As a re- sult of this decision, an estimated 1.6 million clients lost IPPF services in Ethiopia, Ghana, and Kenya due to immediate clinic closures.25 By 2002, the Mexico City Policy restric- tions had stopped the flow of USAID funding to leading family planning associations in 14 developing countries (sometimes due to de- nial of funding to noncompliant grantees and sometimes due to grantees’ decision to refuse funding rather than comply), and stopped the flow of U.S.-funded contraceptive supplies to 16 more;26 11 clinics in three countries closed, and the closure of three more in Tanzania27 was expected as a direct result of the policy. Other national governments and multilateral agencies have taken action to help compen- sate for the withdrawal of U.S. funding, but critical gaps in service and supply remain. On 29 August 2003, President Bush issued a memo to the U.S. Secretary of State clarify- ing that the Mexico City Policy restrictions apply to all family planning assistance pro- vided by the U.S. to foreign NGOs — whether supplied by USAID or by the U.S. State De- partment.28 The memo went on to note, how- ever, that the Mexico City Policy did not ap- ply to assistance provided by “multilateral organizations that are associations of govern- ments,” and further specified, “This policy shall not apply to foreign assistance furnished pursuant to the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108-25).”29 The decision not to attach the Mexico City Policy to funding for PEPFAR means that con- doms and other family planning supplies can be purchased and counseling provided by PEPFAR-funded programs without applica- tion of the Mexico City Policy restrictions. But, although this has been politically popular, the decision to exempt PEPFAR programs from the ban has further complicated the challenge of integrating family planning and HIV pro- grams. Any project funded with a mix of fam- ily planning and PEPFAR funds is automati- cally subject to the restrictions of the Mexico City Policy. This compromises the provision of care at a number of levels; for example, pro- grams are not able to provide comprehensive counseling to HIV-positive women regarding their options should a contraceptive fail, or to young people who seek advice should a condom break or slip, even in countries where abortion is legal. The Mexico City Policy has not only caused the loss of vital clinic services; it also has impeded the integration of reproductive health and HIV-prevention services. A 2006 report published by the Center for Strategic and International Studies (CSIS) notes, “it of- ten precludes organizations with years of ex- perience in reproductive health from bring- ing their expertise into an integrated program approach. While such groups could work the HIV side of a project, they cannot work on the RH-FP [reproductive health/family planning] piece. Given the important overlap between 96 Fall/Winter 2005AIDS & Public Policy Journal the two fields, there are serious concerns that this policy is contributing to a weakening of reproductive health systems in HIV-affected countries, which are vital avenues to reach- ing women and girls.”30 PEPFAR PEPFAR has significantly increased U.S. capacity to combat the global HIV/AIDS pan- demic. Passed as the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Public Law 108-25), PEPFAR is a five-year, $15 billion plan to provide HIV treat- ment, prevention, care, and support in 15 heavily impacted countries.31 Thus far, the initiative has trained 536,000 local staff in the 15 focus countries and sup- ported 14,960 program sites. Prevention fund- ing for abstinence and fidelity programs stood at $63.3 million in 2004 and $75.6 million in 2005. Funding for condoms and related pre- vention was $45.2 million in 2004 and $65.7 million in 2005. By the end of fiscal year 2005, PEPFAR’s prevention outreach programs reached 42 million people with efforts to pre- vent the sexual transmission of HIV.32 PEPFAR’s stated intention to avert 7 mil- lion new infections in five years is laudable. However, women and girls are falling through the cracks because PEPFAR embraces a behav- ior change approach to HIV prevention based on an “ABC” model (Abstinence, Be faithful, or use Condoms, in that priority order).33 While PEPFAR funding is not subject to the Mexico City Policy, its ABC approach is hier- archical — emphasizing abstinence and mo- nogamy as the “best” approaches to HIV pre- vention, with the use of condoms recom- mended as a last resort.34 The funding restric- tions in Public Law 108-25 reinforce this philosophical orientation by requiring that 20 percent of PEPFAR funding be allocated to HIV- prevention programming, and that one- third of these prevention funds be used for abstinence-until-marriage programs.35 Abstinence programs cannot address the needs of married and partnered women — a serious deficit given that, according to the United National Population Fund, more than 80 percent of new HIV infections among women occur through sex with a husband or long-term partner.36 In early 2006, the U.S. General Accounting Office (GAO) released a report documenting the negative impact of “abstinence-only” prevention funding restric- tions and called for less stringent require- ments.37 PEPFAR’s current approach to prevention substantially reduces its ability either to take full advantage of the healthcare infrastructure created with USAID funding under previous administrations or to work toward fully inte- grating HIV-prevention programs and family planning programs. In the 2006 CSIS report, analysts note, “During a CSIS mission to Zam- bia in 2005, one US embassy official described a ‘firewall’ between HIV and reproductive health, inhibiting important synergies be- tween the two.”38 PLANNING FOR MICROBICIDE DISTRIBUTION Microbicides are being developed to save lives by averting new HIV infections, particu- larly among women and girls. If any of the three candidate microbicides now in the fi- nal stages of testing proves effective, the first microbicides could become available in a handful of countries (probably those hardest hit by the HIV pandemic) by 2010. The ques- tion, then, becomes how to maximize distri- bution of these new products, given the ex- tent to which the Mexico City Policy has di- minished natural distribution networks by causing clinic closures and PEPFAR’s failure to optimize access to existing services by in- tegrating the provision of reproductive health services and HIV/AIDS services. The potential reach of U.S.-funded health- care providers in heavily impacted countries is vast. In fiscal year 2005 alone, PEPFAR al- located $479 million to expanding HIV treat- ment. These resources have created substan- tial new healthcare infrastructures in target countries — infrastructures sufficient to pro- Volume 20, Number 3/4 97AIDS & Public Policy Journal vide or contribute to the provision of ART to approximately 400,000 people in the target countries, as well as HIV-related care and sup- port to nearly 3 million people. A reported 42 million people have been reached by PEPFAR HIV-prevention outreach activities thus far.39 Lifting the policy-imposed “firewall” be- tween HIV and reproductive health services and actively promoting integration of the two would enable the U.S. to build on the distri- bution capacity created first with family plan- ning funding and more recently with PEPFAR dollars. PEPFAR is up for re-authorization in 2008. Even without lifting the Mexico City Policy (which may be politically impossible at present), a reallocation of $15 million (less than 1 percent of overall PEPFAR funding proposed by the President in fiscal year 2007) could build reproductive health services within PEPFAR programs and link them to existing reproductive health services, thus facilitating the distribution of microbicides to PEPFAR service recipients as soon as such products become available. This could potentially provide access to microbicides for approximately 8 million HIV- negative women in the 12 PEPFAR focus coun- tries in sub-Saharan Africa (see table 1), thus potentially averting as many as 862,500 new HIV infections among women annually (see table 2). CONCLUSION Since the 1960s, USAID has played a sig- nificant role in procuring and distributing sup- plies and providing services and/or technical assistance to reproductive health programs in the developing world. As HIV/AIDS began to heavily impact developing countries, USAID responded by generating a substantial U.S.- funded HIV/AIDS prevention effort. USAID-funded sites would be natural out- lets for microbicide access since the agency works in nearly 100 countries through HIV- prevention and family planning clinics.40 Within the imposed restrictions, USAID de- cides how to allocate funding based on de- mand and resources available. In the wake of the GAO report, advocates are calling on PEPFAR to better meet the pre- vention needs of women and girls, stipulat- ing that programs should “Ensure universal access to all existing sexual and reproductive health technologies, including HIV prevention technologies, such as male and female con- doms; contraceptives; and microbicides when these become available.”41 Microbicides are being developed in both contraceptive and noncontraceptive forms, and no overt opposition to them has yet emerged among the political constituencies opposed to condom distribution. There is un- likely to be political opposition to the alloca- tion of either USAID or PEPFAR funds to dis- tribute microbicides if the effectiveness of these products against HIV is well docu- mented and if such distribution is occurring in response to demand for them expressed by the governments, communities, and the in- country providers receiving USAID donated supplies. An optimal scenario for the rapid devel- opment of microbicide distribution networks would be as follows: • The U.S. repeals the Mexico City Policy altogether, and • The U.S. loosens restrictions on PEPFAR to allow local NGOs to allocate resources to the prevention strategies that have been shown to be the most effective in reduc- ing incidence of HIV in their own com- munities. Since these two goals may not be achiev- able in the current political environment, the next best strategy is the one capable of saving the most lives under current constraints. This may be to advocate for the full integration of reproductive health and HIV-prevention pro- grams both in USAID-funded family planning programs and in PEPFAR-funded treatment, care, and prevention services, where appro- priate. 98 Fall/Winter 2005AIDS & Public Policy Journal TABLE 1 The Number of HIV-Negative Women Who Might Gain Access to Microbicides Should They Be Distributed through Existing PEPFAR Programs, Once Microbicides Are Available Due to the overlap of prevention, counseling, and testing programs, it seems reasonable to assume that a portion of the women who receive counseling and testing services are also those who are reached by programs that promote fidelity. Given this, we estimate that as many as 8 million HIV-negative women could have potential access to microbicides through these two PEPFAR programs, if PEPFAR programs provided them. This figure is based on the following data and assumptions: • Approximately 7.3 million HIV-negative women have accessed PEPFAR programs that promote fidelity. This figure was estimated as follows. A total of 17 million people were reached through these fidelity programs in the 12 African PEPFAR countries.1 If one-half of those who use the programs are women, as many as 8.5 million women may be reached by the programs. The weighted average of HIV prevalence rates in the PEPFAR countries in Africa is 13.6 percent.2 This indicates that approximately 86.4 percent, or 7,344,000, of the 8.5 million women reached by the PEPFAR programs were presumably HIV negative. • Approximately 3 million HIV-negative women were reached by PEPFAR-funded counseling and testing programs other than the programs for the prevention of MTCT. This number is estimated from reports that 69 percent of the people reached by the counseling and testing programs were women, as stated in the Annual Report for PEPFAR by the U.S. Office of the Global AIDS Coordinator (OGAC) in 2005.3 (The same weighted average of 13.6 percent was used as above.) NOTES We realize that microbicides may also help prevent re-infection among HIV-positive women and transmission from HIV-positive women to their HIV-negative partners. The potential efficacy of such secondary prevention, however, is very unclear at this point. We have, therefore, to limit these calculations estimating the seroconversions that may be averted among HIV-negative women who access PEPFAR services. 1. The 12 countries are Botswana, Côte d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. U.S. Office of the Global AIDS Coordinator, “Annual Report to the Congress on the President’s Emergency Plan for AIDS Relief,” 8 February 2006, http://www. state.gov/s/gac/rl/c16742.htm. 2. United Nations Population Fund (UNFPA), “State of World Population 2005,” 2006, http://www.unfpa.org/swp/ 2005/english/ch1/index.htm, “Indicators.” 3. Ibid. The CSIS reports that Deputy U.S. Global AIDS Coordinator Mark Dybul wrote the fol- lowing in a letter to IPPF in 2006: “The Emer- gency Plan has communicated to countries and partners the importance of voluntary fam- ily planning as a ‘wraparound’ intervention. We have made our staff aware that voluntary family planning clinics and programs are im- portant HIV/AIDS care-delivery points.”42 Ambassador Dybul’s explicit recognition of the role that family planning clinics and programs can play as venues for HIV/AIDS care is encouraging. For the countries and partners he is addressing to implement his advice, however, they need more explicit guidance on what is meant by a “wraparound intervention” and how comprehensive care can be expanded in these natural venues. Does this guidance, in fact, mean that organizations such as IPPF, which have chosen to refuse U.S. State Department family planning funding rather than comply with the Mexico City Policy, are still eligible to receive HIV/AIDS funding supplied by PEPFAR and/or USAID? It is time for the U.S. Office of the Global AIDS Coordinator (OGAC) to take the follow- ing steps: 1. Clarify for all grantees the differences (if any) between “wraparound” services and integrated services, Volume 20, Number 3/4 99AIDS & Public Policy Journal 2. Identify the policy barriers (if any) to the integration of reproductive health and HIV/AIDS services, and 3. Provide leadership to overcome these bar- riers. Acting now to re-build and expand net- works that are capable of assuring the rapid and targeted distribution of microbicides and other HIV prevention tools has the potential to save women’s lives. If we delay such re- building, the cost will be paid in the same currency. NOTES 1. UNFPA, “State of World Population 2005,” published 2005, available at http:// www.unfpa.org/swp/2005/english/ch4/ chap4_page1.htm. 2. International Partnership for Microbi- cides, “Microbicides: An Essential HIV Pre- vention Strategy for Achieving the Millen- nium Development Goals,” published Sep- tember 2005, available at http://www.ipm- microbicides.net/pdfs/english/ipm_publicati ons/2005/policy_k_092005.pdf (p. 1). 3. UNAIDS, “AIDS Epidemic Update 2005,” published 2005, found in the Interna- tional Women’s Coalition, “Women and HIV/ AIDS: Select Facts,” November 2005, avail- able at http://www.iwhc.org/resources/hivaids factsheet.cfm. 4. UNAIDS, “AIDS Epidemic Update 2004,” published December 2004, found in the International Women’s Coalition, see note 3 above. 5. Pharmaco-Economics Working Group of the Rockefeller Foundation Microbicides Ini- tiative, “The Economics of Microbicide De- TABLE 2 The Number of HIV Infections that May Be Averted Should 8 Million HIV-Negative Women Have Access to Microbicides • Although microbicides do not technically require the cooperation of a male partner, many women indicate that they would most likely discuss the use of a microbicide with their male partner.1 If a woman’s use of a microbicide depends on the cooperation of her partner, this may limit the use of microbicides. Based on available research, we assume that 86 percent of these women may agree to use a microbicide.2 Thus, 86 percent of 8 million women who may be reached through PEPFAR programs — 6.9 million women — may see the use of a microbicide as a viable option. • Of those 6.9 million women, we estimate that half may want to use a microbicide on an ongoing basis, and may use the product in half of the sex acts in which they do not use a condom. Thus, 3.45 million may use a microbicide on an ongoing basis. • We reduced the 3.45 million by half — 1.73 million — to allow for the risk incurred by inconsistent use of a microbi- cide, and halved that number again, because the first-generation microbicides are expected to be 50 percent effec- tive.3 • Given these assumptions, as many as 862,500 women might avoid infection by the use of first-generation microbi- cides. NOTES 1. J. Mantell et al., “Microbicide Acceptability Research: Current Approaches and Future Directions,” Social Science and Medicine 60 (2005): 319-30. 2. G. Ramjee et al., “The Acceptability of a Vaginal Microbicide among South African Men,” International Family Planning Perspectives 27, no. 4 (2001): 164-70. 3. Pharmaco-Economics Working Group of the Rockefeller Foundation Microbicides Initiative, “The Economics of Microbicide Development: A Case for Investment,” http://www.globalcampaign.org/clientfiles/rep3_economics.pdf, p. 3. 100 Fall/Winter 2005AIDS & Public Policy Journal velopment: A Case for Investment,” available at http://www.global-campaign.org/clientfiles /rep3_economics.pdf (p. 3). 6. G. Ramjee et al., “The Acceptability of a Vaginal Microbicide among South African Men,” International Family Planning Perspec- tives 27, no. 4 (2001): 164-70. 7. Public Health Working Group of the Microbicide Initiative, “The Public Health Benefit of Microbicides in Lower-Income Countries: Model Projections,” available at http://www.ipm-microbicides.org/pdfs/ english/microbicide_publications/public_hea lth_benefits.pdf (p. 6). 8. Ibid. 9. See note 5, p. 5. 10. Ibid. 11. J. Mantell et al., “Microbicide Accept- ability Research: Current Approaches and Future Directions,” Social Science and Medi- cine 60 (2005): 319-30. 12. A.M. Foss et al., “Shifts in Condom Use Following Microbicide Introduction: Should We Be Concerned?” AIDS 17, no. 8 (2003): 1227-37. 13. UNFPA, UNAIDS, and UNIFEM, “Women and HIV/AIDS: Confronting the Cri- sis,” 2004, available at http://www.genderand aids.org/modules.php?name=News&file=arti cle&sid=746 (p. 16). 14. J. Jacobson, “Women, HIV, and the Glo- bal Gag Rule: The Dis-Integration of U.S. Glo- bal AIDS Funding,” published 2003, available at http://www.genderhealth.org/pubs/Jacobso nAIDSMexicoCityOpEdFeb2003.pdf. 15. Ibid. 16. World Health Organization, “Global Health-Sector Strategy for HIV/AIDS 2003- 2007: Providing a Framework for Partnership and Action,” published May 2003, available at http://www.who.int/hiv/pub/advocacy/ GHSS_E.pdf (p. 13). 17. H.N. Banda, S. Bradley, and K. Hardee, “Provision and Use of Family Planning in the Context of HIV/AIDS in Zambia: Perspectives of Providers, Family Planning and Antenatal Care Clients, and HIV-Positive Women,” pub- lished by the Policy Project and the Support for Analysis and Research in Africa (SARA) Project, February 2004, available at http:// www.policyproject.com/pubs/countryreports/ Zam_FGD.pdf (p. vii). 18. Supply Initiative, “Access to Condoms and Contraceptives — Vital for the Prevention for HIV,” available at www.rhsupplies.org. 19. U.S. Federal Register, 29 March 2001, vol. 66, no. 61 [Presidential Documents 17301- 17313], available at http://www.usaid.gov/ business/business_opportunities/cib/pdf/cib0 108r.pdf. 20. The White House, “Memorandum for the Administrator of the United States Agency for International Development. Subject: Res- toration of the Mexico City Policy,” posted on 22 January 2001, available at http://www.white house.gov/news/releases/20010123-5.html. 21. Global Reproductive Health Forum, “Bush Administration: Implications for Glo- bal Reproductive Health and Rights: Explor- ing recent FAQs posed to GRHF,” Newsletter 5, April 2001, posted by Global Reproductive Health Forum @ Harvard, a project of the Harvard School of Public Health, available at http://www.grhf.harvard.edu/newsletter 5.html. 22. Ibid. 23. Population Action International, “What You Need to Know about the Global Gag Rule & U.S. HIV/AIDS Assistance: An Unofficial Guide,” published in June 2004, available at http://www.populationaction.org/ resources/publications/globalgagrule/ GagRule_AIDS/GGRandHIV-AIDSbrochure.p df (p. 4). 24. IPPF, “Annual Programme Review,” published in 2000-2001, found in Supplies Initiative, “RHInterchange Partners,” available at www.rhsupplies.org. 25. The Global Gag Rule Impact Project, “Access Denied: Countries Reports,” for Ethio- pia, Kenya, and Ghana, published 2003-2006, available at http://www.globalgagrule.org/. 26. The Global Gag Rule Impact Project (2006), “The Global Gag Rule & Contraceptive Supplies,” fact sheet, available at http:// www.globalgagrule.org/. Volume 20, Number 3/4 101AIDS & Public Policy Journal 27. The Global Gag Rule Impact Project, “Access Denied: Country Report for Tanza- nia,” published 2005, available at http:// www.globalgagrule.org/. 28. U.S. Executive Office of the President, “Assistance for Voluntary Population Plan- ning,” Memorandum for the Secretary of State, 29 August 2003, available at http:// www.whitehouse.gov/news/releases/2003/08/ 20030829-3.html. 29. Ibid. 30. J. Fleischman, “Integrating Reproduc- tive Health and HIV/AIDS Programs: Strate- gic Opportunities for PEPFAR,” a Report of the CSIS Task Force on HIV/AIDS, July 2006, available at http://www.csis.org/index.php?op tion=com_csis_pubs&task=view&id=3340 (p. 25). 31. U.S. Department of State Bureau of Public Affairs, “The United States Emergency Plan for HIV/AIDS Relief,” fact sheet, avail- able at http://www.state.gov/documents/orga- nization/21313.pdf. 32. Office of the Global AIDS Coordina- tor, “Annual Report to the Congress on the President’s Emergency Plan for AIDS Relief,” published 8 February 2006, available at http:/ /www.state.gov/s/gac/rl/c16742.htm (pp. 10- 11). 33. The White House, “Fact Sheet: The President’s Emergency Plan for AIDS Relief,” issued in July 2003, available at http:// www.whitehouse.gov/news/releases/2003/07/ 20030702-4.html. 34. K. Backes, A. Forbes, and C. Polis, “One Choice is no Choice,” Harvard Health Policy Review 6, no. 1 (2005): 19-30, p. 19. 35. For the full text of Public Law 108-25, “United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003,” please see http://frwebgate.access.gpo.gov/cgi-bin/ useftp.cgi?IPaddress=220.127.116.11&filename= publ025.108&directory=/disk2/wais/data/108 _cong_public_laws (p. 117). 36. UNFPA, 2005, “State of World Popu- lation: The Promise of Equality: Gender Eq- uity, Reproductive Health and the MDGs,” http://www.unfpa.org/swp/2005/pdf/ en_swp05.pdf (p. 38). 37. U.S. Government Accountability Of- fice, “Global Health Spending: Spending Re- quirements Presents Challenge for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief,” published April 2006, available at http://www.gao.gov/ new.items/d06395.pdf (p. 6). 38. See note 30 above, p. 23. 39. See note 32 above. 40. United States Agency for International Development website, “Welcome to the U.S. Agency for International Development’s Glo- bal Health Website,” available at http:// www.usaid.gov/our_work/global_health/. 41. PEPFAR Watch, “Prevention” section, available at http://www.pepfarwatch.org/ index.php?option=com_content&task=view &id=20&Itemid=34. 42. See note 30 above, p. 27.