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Research article
An analysis of the implementation of PEPFAR’s anti-prostitution
pledge and its implications for successful HIV prevention among
organizations working with sex workers
Melissa Hope Ditmore
§,1
and Dan Allman
2,3
§
Corresponding author: Melissa Hope Ditmore, PO Box 20853, New York, NY 10009, USA. (mhd-pep@taumail.com)
Abstract
Introduction: Since 2003, US government funding to address the HIV and AIDS pandemic has been subject to an anti-prostitution
clause. Simultaneously, the efficacy of some HIV prevention efforts for sex work in areas receiving US government funding has
diminished. This article seeks to explain why.
Methods: This analysis utilizes a case story approach to build a narrative of defining features of organizations in receipt of
funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) and other US funding sources. For this analysis, multiple
cases were compiled within a single narrative. This helps show restrictions imposed by the anti-prostitution clause, any lack of
clarity of guidelines for implementation and ways some agencies, decision-making personnel, and staff on the ground contend
with these restrictions.
Results: Responses to PEPFAR’s anti-prostitution clause vary widely and have varied over time. Organizational responses have
included ending services for sex workers, gradual phase-out of services, cessation of seeking US government HIV funds and
increasing isolation of sex workers. Guidance issued in 2010 did not clarify what was permitted. Implementation and
enforcement has been dependent in part on the interpretations of this policy by individuals, including US government
representatives and organizational staff.
Conclusions: Different interpretations of the anti-prostitution clause have led to variations in programming, affecting
the effectiveness of work with sex workers. The case story approach proved ideal for working with information like this that is
highly sensitive and vulnerable to breach of anonymity because the method limits the potential to betray confidences and
sources, and limits the potential to jeopardize funding and thereby jeopardize programming. This method enabled us to use
specific examples without jeopardizing the organizations and individuals involved while demonstrating unintended
consequences of PEPFAR’s anti-prostitution pledge in its provision of services to sex workers and clients.
Keywords: PEPFAR; AIDS; HIV; sex work; prostitution; trafficking; funding; policy.
Received 17 April 2012; Accepted 13 February 2013; Published 28 March 2013
Copyright: – 2013 Ditmore MH and Allman D; licensee International AIDS Society. This is an open access article distributed under the terms of the Creative
Commons Attribution 3.0 Unported (CC BY 3.0) Licence (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Introduction
Funding from the President’s Emergency Plan for AIDS
Relief (PEPFAR) has enabled access to treatment for more
than 3.9 million people living with HIV and AIDS in places
where they would not otherwise have received anti-retroviral
medicines (ARVs). In the fiscal year, 2011, PEPFAR supported
HIV testing and counselling for more than 40 million people,
including 9.8 million pregnant women. However, not all
PEPFAR funding is for treatment and testing. A high number
of HIV prevention programmes around the world receive
PEPFAR funding also [1].
Since 2003, US government funding to address the HIV and
AIDS pandemic has been subject to an anti-prostitution
clause colloquially known as ‘‘pledge’’ that requires aid
recipients to adopt an organizational policy opposing pros-
titution. In essence all who agreed to receive PEPFAR funds
were required to state in writing that any and all activities
supported by PEPFAR would not encourage or condone
prostitution. From its inception, the pledge was accompanied
by a second restriction forbidding the ‘‘promotion of
prostitution’’ by grant recipients. This second restriction has
been presented by the US administration as a mechanism to
prevent the promotion of prostitution and human trafficking
through its donor monies. This article seeks to demonstrate
that despite this intent, the pledge has blossomed into
something altogether different when implemented in the
field [2]. This article first documents the history of the pledge
and then applies a case story method to illustrate the
unintended yet adverse effects of the implementation of the
pledge.
Origin and history of the anti-prostitution policy
The anti-prostitution clause as it presently exists within US
policy has a convoluted and nuanced history (see Table 1)
[3 24]. In December 2002 Colin Powell, the United States
Secretary of State under President George W. Bush issued
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Table 1. PEPFAR anti-prostitution pledge timeline
Date Event Notes
May 2003 Global AIDS Act signed [3].
January 2004 The Global Fund for AIDS, Tuberculosis and Malaria, the World Health Organization, the International
AIDS Vaccine Advocacy Coalition, and all UN agencies are exempt from the pledge [4].
These exemptions are made clearer in language released by the CDC in May 2005,
stipulating that these organisations are not subject but that sub-grantees are
subject to the pledge.
2004 US Office of Legal Counsel opinion about enforcing the pledge upon US-based organisations working
abroad written but not publicly released in its entirety. The Brennan Center filed a FOIA request for
this document [5].
March 2005 Statement appears: ‘‘U.S. law ... prohibits such funds from being used to implement any program
that targets victims of severe forms of trafficking in persons involving sex trafficking by an
organization that has not stated in either a grant application, a grant agreement, or both, that it does
not promote, support, or advocate the legalization or practice of prostitution. It is the responsibility
of the primary grantee to ensure these criteria are met by its sub-grantees’’ [6, see also 7].
June 2005 Department of Justice reverses earlier First Amendment based ruling.
June 2005 USAID issued a directive that only organisations with an explicit policy against prostitution and sex
trafficking should be funding recipients. Guidelines for funding include the right of USG
representatives to investigate activities to enforce the pledge. Guidelines further state that funding
recipients may have partners including subcontractors that do not have policies provided there is
‘‘sufficient’’ separation, reminiscent of the separation required under the Global Gag Rule addressing
abortion, which was not defined but instead was addressed on a case-by-case basis [8,9].
August 2005 DKT files suit against USAID to challenge the anti-prostitution policy requirement, saying.
‘‘DKT has no policy on prostitution and does not wish to adopt one’’ [10].
September 2005 AOSI/Pathfinder lawsuit filed contesting the pledge.
January 2006 BBC rejects US funding with the pledge [11]. ‘‘But six months into the contract, the US government terminated the project after
tightening up on a requirement that organisations receiving US funds had to sign a
pledge ‘‘explicitly opposing prostitution.’’ The BBC project would not have
provided direct services to Tanzanian prostitutes, but some programmes might
have dealt non-judgmentally with their role in the epidemic. A signature on
the anti-prostitution pledge would have entitled US government officials to vet
all the trust’s projects worldwide for compliance with Washington’s ‘‘morality’’
doctrine. The BBC’s Tanzanian project would also have had to join the US campaign
to promote sexual abstinence by stressing the failure rates of condoms.’’
April 2006 US Government Accounting Office (GAO) releases report ‘‘Spending Requirement Presents
Challenges for Allocating Prevention Funding under the President’s Emergency Plan for
AIDS Relief’’ [12].
Report criticizes promotion of ideological (abstinence and monogamy) rather
than evidence-based, proven-effective programming. Report also cites lack of
clarity about what could be done to make condoms accessible and the confusion
created by spending earmarks that diverted money to abstinence programming at
the expense of other programmes.
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Table 1 (Continued )
Date Event Notes
May 2006 District court rules that the anti-prostitution pledge violates First Amendment rights in DKT v. USAID.
May 2006 District court rules that government must stop requiring plaintiff organisations to comply with
anti-prostitution pledge. This applies only to organisations that signed on to the AOSI/Pathfinder
lawsuit. These organisations number over 200.
February 2007 US Circuit Court reverses DKT v. USAID ruling and upholds anti-prostitution pledge.
March 2007 Institute of Medicine releases report, ‘‘PEPFAR Implementation: Progress and Promise,’’ calling for
greater emphasis on prevention of HIV infection generally, improved data on prevalence and at-risk
populations [13].
January 2008 Reauthorization of US anti-trafficking legislation [14].
February 2008 Congress discusses the reauthorization of PEPFAR, and a coalition of NGOS successfully advocated
for the removal of the anti-prostitution pledge in the original drafting of the legislation.
Representative Tom Lantos (D-CA) championed an end to the abstinence earmark and the
anti-prostitution pledge, saying ‘‘It is inconsistent with this goal to place ideologically driven
restrictions on the implementation of efforts to prevent spreading the virus.’’ Lantos died after a long
illness. However, the anti-prostitution pledge was reinstated during closed-door sessions between
right-wing Christian conservative Representative Chris Smith (R-NJ) and some NGOs [15, see also 16].
July 2008 The Lantos-Hyde Act reauthorized PEPFAR [17] with a significant increase in funding but retaining
anti-prostitution pledge signed by then-US President George Bush. The abstinence earmark was
removed but requires reporting justification of spending less than half the funds on abstinence and
be faithful programming (the A and B of ABC).
August 2008 Court grants injunction against anti-prostitution pledge requirement.
December 2008 Guidelines for anti-prostitution pledge require grantees to ‘‘certify’’ their ‘‘objective integrity and
independence from any organization that engages in activities inconsistent with a policy opposing
prostitution and sex trafficking’’ [18].
June 2009 UN Secretary General Ban-Ki Moon states ‘‘In countries without laws to protect sex workers, drug
users, and MSM, only a fraction of the population has access to prevention. Conversely, in countries
with legal protection and the protection of human rights for these people, many more have access to
services. As a result, there are fewer infections, less demand for anti-retroviral treatment, and fewer
deaths. Not only is it unethical not to protect these groups; it makes no sense from a health
perspective. It hurts all of us.’’ in his statement to the International AIDS Conference [19].
May 2009 Court rules in AOSI/Pathfinder suit that the pledge violates the First Amendment rights of the
plaintiffs. This applies only to the organisations signed on to the suit, including members of the
Global Health Council.
January 2009 President Barack Obama takes office and begins appointing members of the administration.
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Table 1 (Continued )
Date Event Notes
July 2009 Eric Goosby, US Global AIDS Coordinator, states that PEPFAR will seek to use human rights based
approaches to sex workers, as well as MSM and drug users, during his address to an International
AIDS Society meeting [20].
November 2009 Eric Goosby, US Global AIDS Coordinator, says ‘‘My role is to be supportive and helpful to the
patients who need services. It is not to tell a country how to put forward legislation. But I will engage
them in conversation around my concern and knowledge of what this is going to do to that
population.’’ in response to uproar over PEPFAR support to Uganda which implements an
actively homophobic agenda. Note the lack of clarification of the word population as used by
Goosby [21].
April 2010 Department of Health and Human Services releases new guidance on implementation of
anti-prostitution pledge. The new regulation requires recipients to ‘‘agree’’ that ‘‘they are opposed
to the practices of prostitution and sex trafficking because of the psychological and physical risks
they pose for women, men and children’’ [2: 45 C.F.R. § 89.1(b), 22].
April 2010 The new guidance also makes some adjustments to what determines adequate separation from a
sub-grantee doing work that may be constrained by the pledge. Legal separation is still a factor, but
physical separation is required ‘‘to the extent practicable in the circumstances.’’ Itemized separation
is no longer stated but consideration of these and other factors remain at the discretion of HHS
[2: 45 C.F.R. § 89.3(b), 22].
July 2010 During the International AIDS Conference in Vienna, Austria, Eric Goosby, US Global AIDS
Coordinator, states that sex workers would be ‘‘embraced’’ at all US funded HIV and AIDS services,
and that if discrimination against sex workers were to occur at any such programme, the US
government would be ‘‘on that like a laser’’ [23].
January 2013 The Supreme Court of the United States announces that it will hear the case challenging the
pledge [24].
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Table 2. Case story
Organization: Agency X Organization: HQ Organization: HOBO
Status Large international NGO based in the US with in-country
office and programmes
Largest non- international NGO
In the nation
Local, small NGO with small staff, and locally driven
programmes
Funding Sources USAID, multilateral donors, other national donors Sub-grantee of Agency X, sometimes a direct recipient
from USAID, including PEPFAR
Partner with NGOs across the country, sometimes a
sub-grantee from USAID and funding from private
foundations
Description of SW project
at the time the pledge
was instituted
Runs a programme for sex workers
Some sex workers are in low paid positions with intention
to train and promote them
Runs extensive programme with drop-in centres for sex
workers, including health services
Conducts social marketing of condoms and personal
lubricant
Supports sex workers’ anti-violence
campaign by offering them space to meet
Has a small, well-respected sex work project, that is
very much community-led aside from medical services
HIV programming, meetings of sex workers, support of
self-organizing of sex workers
Some healthcare is offered on-site. Referrals are made
to other existing services
Introduction of pledge Stops publicizing sex work project
Cancels planned scale-up of successful sex work project
Meets with USAID country officer, who explains that
what they understand is that drop-in centres are not
allowed
Drop-in centres for sex workers close
Other HIV programming continues to provide services
to sex workers, including social marketing of condoms
and lubricant
Staff would like to stop working with sex workers,
because they are stigmatized for working with sex
workers but management does not want to end
programming
Programming does not change. Information sharing
continues
Response to 2006
investigation of sex
work projects at a US
based NGO
Divestment from SW programming becomes a priority
Seeks to spin off SW project, but there are no
organizational takers because of the climate after the
pledge
Stops seeking HIV funding
Ends social marketing of condoms and lubricant
Personal lubricant becomes virtually
unavailable
Discussion of what this means for SW project.
No changes to programming services
Information about project shared
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Table 2 (Continued )
Organization: Agency X Organization: HQ Organization: HOBO
Response to 2006
investigation of sex
work projects at a US
based NGO
Community members employed by project lack
skills necessary to run project. Debate about whether
capacity building among sex workers to run the
project themselves would be considered ‘‘promoting
prostitution’’ prevents training in skills necessary to run
an organization
Funding is secured from another agency for the SW project
SW project is spun off, with one staff person from Agency X
moving to it
End of support for sex workers’ anti-violence
campaigns. Support was in the form of meeting space
2008 Spin-off SW project eventually closes due in part to the lack
of organizational skills among sex worker staff without
capacity building and training
Information about project shared only with local
partners
2009 Seeks HIV funding again. Sex work programming is not
included
2010 IAC Not publicizing work with sex workers, despite strong
programming, in deference to pledge and lack of
guidance about what could be construed as
‘‘promoting prostitution’’
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a directive that organizations in receipt of US government
funding should remove references to condoms from their
websites, and also that ‘‘organizations advocating prostitu-
tion as an employment choice or which advocate or support
the legalization of prostitution are not appropriate partners
for USAID anti-trafficking grants and contracts, or sub-grants
and sub-contracts’’ [25]. This foreshadowed the inclusion of a
clause indicating that ‘‘no funds ... may be used to provide
assistance to any group or organization that does not have a
policy explicitly opposing prostitution and sex trafficking’’ in
the United States Leadership against HIV/AIDS, Tuberculosis,
and Malaria Act [3] (known as the Global AIDS Act), passing,
in May 2003. The text of the act also states that ‘‘no funds
made available to carry out this Act, or any amendment
made by this Act, may be used to promote or advocate the
legalization or practice of prostitution or sex trafficking’’ [3].
A similar restriction was included in the Trafficking Victims
Protection Reauthorization Act of 2003, passed prior to the
Global AIDS Act, stating that, ‘‘No funds made available
to carry out this division, or any amendment made by this
division, may be used to promote, support, or advocate
the legalization or practice of prostitution’’ [26]. Require-
ments of anti-prostitution policies have become standard
in US funding agreements, and two lawsuits have been filed
against these restrictions as applied to HIV prevention
programmes [27]. Nonetheless, the inclusion of such restric-
tions has had a profound impact. For example, in July 2004,
a statement issued by the Centers for Disease Control and
Prevention of the US Department of Health and Human
Services aimed at the expansion of HIV and AIDS activities
for vulnerable populations in Co
ˆ
te d’Ivoire indicated that
any foreign recipient of aid monies needed to have in place a
policy explicitly opposing prostitution and sex trafficking [28].
Funding was authorized in 2004 with a call for proposals,
which stated ‘‘No funds made available ... may be used to
provide assistance to any group or organization that does not
have a policy explicitly opposing prostitution and sex
trafficking’’ [29]. This was reiterated in 2005, when USAID
issued a directive that only organizations with an explicit
policy against prostitution and sex trafficking should be
funding recipients and also when the pledge was first applied
to US-based organizations. At this time, the government of
Brazil declined US$ 40 million of these conditional funds
because they would inhibit HIV prevention programming
[30]. Some organizations also have declined such conditional
funding. For example, the BBC declined this conditional
monetary support [31] for an HIV-oriented programme.
Additionally, the US government made a concerted effort
to fund faith-based organizations, which were typically new
to HIV and AIDS programming and generally less familiar with
evidence-based HIV programming [32]. While all grant
recipients developed organizational policies as required by
the pledge, organizations that were less familiar with
implementing evidence-based programming may have been
less likely to consider the implications of the enactment of
the pledge.
In 2008, efforts to remove the pledge were defeated [33]
and US Congress re-authorized PEPFAR with a significant
increase in funding , but no change in requirements. Grantees
were still requested to ‘‘certify’’ their ‘‘objective integrity and
independence from any organization that engages in activ-
ities inconsistent with a policy opposing prostitution and sex
trafficking’’ [34]. In 2010, under the Obama administration,
the US Department of Health and Human Services released
new guidance on the implementation of the anti-prostitution
pledge, requiring grantees to ‘‘agree,’’ in a phrasing of the
anti-prostitution pledge embedded within PEPFAR contracts,
that the recipient is ‘‘opposed to prostitution and sex
trafficking because of the psychological and physical risks
they pose for women, men and children’’ [11].
This was arguably less difficult to meet than some of
the previous requirements because the policy had been
written into the contract in a form that was more like a
philosophy rather than a policy developed and implemented
by the organization. Nevertheless, organizations are known
to continue to decline funding that includes such a clause.
One example is SANGRAM, an organization for sex workers in
Sangli, India, known for its community empowerment model
that addresses needs identified by the sex workers served
by the organization [2]. Another example is found in
a short item in The New York Times Magazine about an
organization of sex workers in Cambodia that turned down a
substantial grant, asking: ‘‘Do they think we’re worse than
dogs?’’ [35]. For those for whom declining funding is not an
option, the outcome is that organizations struggle to provide
a dignified and effective service to a population that they are
encouraged to ‘‘oppose’’ and as a result may find they are
unable to deliver services without stigmatizing their intended
beneficiaries.
Despite the origin of the anti-prostitution pledge in a
broader policy context, we focus specifically on PEPFAR
because this is the pool of money that most directly affects
the greatest number of sex workers, as members of what
USAID terms a ‘‘most-at-risk population’’ (MARP) [17]. The
United States is the largest national donor for HIV-related
funding, with over US$ 4 billion approved funding in 2010
[25]. US funding for other programmes affecting sex workers,
such as anti-trafficking money, is dwarfed by the funds for
PEPFAR (for example, $16 million for anti-trafficking pro-
gramming abroad in fiscal year 2011 [15]). However, the anti-
prostitution clause is not applied exclusively to PEPFAR
funding only, but to all the organizations’ funding, and
therefore affects education and other programming. In this
way, these funding restrictions affect many more pro-
grammes in addition to HIV-related programming, including
programmes promoting access to clean water, sanitation,
life-saving medicines and medical care. These requirements
and the subtle changes to their contract wording have
far-reaching implications because they affect the distribution
of many millions of aid dollars.
The pledge has received strong support from activists and
politicians in the United States who take a philosophical or
religious stance against prostitution. For example, the chair of
a women’s studies department at a state university gave
a speech attacking individuals and organizations working
with sex workers for addressing the concerns of sex workers
including HIV and AIDS rather than working to eliminate
prostitution [36]. Public support for the anti-prostitution
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clause has led to investigations of projects in receipt of
PEPAR funds by conservative Christian politicians; this is
one example: after the aforementioned speech was given,
a project in Cambodia was closed [37] seemingly in response
to an investigation directly linked to the speech. Once the
Cambodia project was investigated and eventually closed,
an organization of local sex workers that had been part of a
network of HIV and AIDS projects in Cambodia was suddenly
isolated from their contacts within other programmes and
excluded from this network of HIV and AIDS projects [38].
What do these restrictions mean in programming?
Specific activities prohibited by this restriction have never
been defined; rather, guidance has been vague. This vague-
ness has led to arbitrary and unsystematic interpretations of
the pledge, contributing to self-censorship by grant recipi-
ents. This article offers information from the field about how
funding restrictions have been implemented, particularly in
HIV programming. In this article, we offer examples from
actual programmes which have been anonymized using
a case story methodology in order to argue that the policy
has compromised the efficacy of US-funded HIV prevention
efforts, particularly with regard to most-at-risk populations
including sex workers and transgender people.
Methods
This analysis utilizes a case story approach [39] to build
a narrative of defining features of organizations in receipt
of PEPFAR funding. The case story approach is ideal for
working with data that are highly sensitive and vulnerable
to breach of anonymity because it limits the potential to
betray confidences and sources [40], and in this context,
jeopardize funding and programmes. The approach also
allows construction of a narrative that more fully represents
the impact of the funding restrictions within PEPFAR
contracts than a case study of a single organization could.
For this analysis, therefore, multiple cases are compiled
within a single narrative in order to allow identification of
restrictions imposed by the anti-prostitution clause, lack
of clarity of guidelines for implementation and ways some
agencies contend with these restrictions.
Whereas the use of a case study methodology is common
within medical research and other disciplines [41 43], the
application of a case story methodology is much more novel.
A case story differs from the more frequently-used case
study in that typically a case study uses one sole case as an
illustrative and defining example. In contrast, a case story
compiles numerous examples into one narrative. It does so
by selecting various narrative elements from multiple cases
and compiles them into a single case.
Our information has been collected since 2003 and
comes from published accounts and directly from sex
workers, NGO staff and USAID representatives, working on
five continents. These reports come from over 25 organiza-
tions and projects in 14 nations in Africa, the Asia-Pacific
region, the Americas and Europe. As the authors’ interest
in PEPFAR and funding restrictions became known through
publications (e.g. [25,44 46]), some people came forward
without prompting to share information with us.
Case stories use multiple accounts in order to triangulate
events and to identify generative themes or recurring
tensions [47]. We present these scenes in this narrative
because they are representative of the experiences of
organizations and people. Each event presented actually
happened in at least one location, and there was significant
overlap and multiple occurrences of many of the events
presented. However, to the best of our knowledge not all
events in this case story have occurred in any single location.
This case story uses three organizations, each a composite, to
illustrate different strategies and responses to US funding
policy. This case story incorporates examples from the people
and projects that have shared information with the authors
to illustrate the ways these restrictions have affected sex
workers.
Results: the case story
Background
In the context of our case story, set as it is in the fictional
country of West Lannadesh, NGOs do not promote prostitu-
tion or trafficking in persons. Rather, NGOs advocate for the
health and wellbeing of their constituents and work to
prevent social and structural harms (see Table 2). Within this
context many if not most stakeholders are unsure of what
the PEPFAR policy means. This is in part because the guidance
that has accompanied the PEPFAR policy has been unclear
about what exactly ‘‘promotion’’ means. This has resulted in
some NGOs being falsely accused of encouraging sex work
and trafficking, which has been exacerbated by widespread
conflation of human trafficking with sex work. In the case
story reflective as it is of actual events many organiza-
tions have restricted their activities in response to the anti-
prostitution policy requirement. Indeed, this has been the
experience in the fictional country of West Lannadesh.
Setting
West Lannadesh is a poor country with limited manufacturing
and a growing population. Neighbouring countries include a
nation that has signed the US anti-prostitution pledge and a
middle-income nation that has rejected a substantial but not
overwhelming amount of US funding because of the pledge.
Description of sex work environment
Sex work is carried out in a wide variety of venues including
streets, bars, hotels and brothels. The overwhelming majority
of clients are locals. Some bars cater to Western aid workers
and a small number of highly visible tourists. Condoms
are accessible through social marketing programmes, some
of which employ sex workers. The condom sales support
some of the local sex work organization’s staff.
Description of HIV epidemics
HIV prevalence is around 1%, with a concentrated epidemic
of HIV among sex workers and people who use drugs, around
15%. It is suspected that hepatitis C virus (HCV) co-infection
is high but testing is infrequent and treatment for HCV is not
available. Incidence is highest among people under 35 years
of age.
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Description of access to prevention, treatment, care and
support
Only people who can afford to pay for HIV-treatment or other
medical care receive any kind of treatment outside of NGO
settings. The very wealthy leave the country for medical care.
Most people receive no treatment and visit pharmacies for
medical needs only when they absolutely must. However,
PEPFAR has made it possible for approximately a quarter of
the people who need HIV medications to receive them, when
their CD4 counts dip below 200.
Agency X is a large international NGO based in the US.
Agency X has many programmes, most of which focus on
development. Their programmes with sex workers earn high
praise for their innovative, community-based approaches and
success reducing the incidence of HIV among sex workers.
Efforts to scale up these programmes have stalled since
the imposition of PEPFAR’s anti-prostitution policy. In fact,
all plans for scaling up evidence-based programming with
sex workers have been abandoned. Projects with sex workers
remain small ‘‘boutique’’ projects that are sound but not
publicized in reports from Agency X. Agency X seeks to divest
itself from sex work programming in a responsible way and
is therefore trying to ensure that these small, evidence-based
programmes carry on without being associated with Agency
X. This divestment is a priority for Agency X because of
the investigation of a similar organization for work with
sex workers. Congressional staff was physically present in
the offices of this other agency, and their questions about
particular projects demanded so much time that the head-
quarters office was fully occupied in submitting to their
requests. This investigation led to an inability to fulfil
contracts during this three-month period. Agency X is one
of a number of organizations attempting to extricate them-
selves from working with sex workers. Their decision
was directly influenced by this investigation of another
organization.
Agency X tries to encourage and train local organizations
to take over these programmes with sex workers, including
seeking alternative funding for them. Agency X’s efforts to
divest from its work with sex workers are made difficult
because partners hesitate to take on programming that is
itself stigmatized and which may prevent their seeking large
grants from the US government. Many of the people who
benefit from the programme would like to work for it and
ensure its continuity, but most beneficiaries are not literate
and have had little if any formal schooling. Several years of
capacity building would be necessary for the sex workers
themselves to run all aspects of the organization, but
Agency X and others are concerned that this capacity
building would be considered to promote prostitution. In
this situation, these programmes are destined to stay small
and remain marginalized within an organization, possibly
Agency X but possibly not, or be conducted by an organiza-
tion that is itself marginalized by other NGOs, even or
perhaps especially if the sex workers themselves run the
project.
Agency X is one of a number of organizations in
West Lannadesh, many of which are trying to navigate their
way through the anti-prostitution pledge. The largest local
organization, HQ, works in partnership with smaller organiza-
tions, some of which are subsidiaries. It operates in an
extremely violent post-conflict setting with histories of civil
war and natural disasters. It has been in existence for
22 years. HQ operates a series of clinics in a large urban
area, in partnership with international aid agencies and
local and foreign universities. The mandate of HQ is HIV
education, prevention, care and support. This includes an
array of services that individuals can access including a
drop-in centre, bathing and sanitation facilities, and condom
distribution. HQ operates under a variety of funding
arrangements, one which is a multi-year grant provided by
USAID. One condition of this grant is the requirement to
sign PEPFAR’s anti-prostitution pledge. The Director of HQ
is clear that the agency does not support prostitution or sex
trafficking. Although the organization does not condone
prostitution, it does not condemn the individuals involved
in it. The result is the pledge has led to conflict between HQ
management and its staff as sex workers have traditionally
come to HQ to use the drop-in centre, to bathe and to get
condoms. It is not clear to the HQ director or staff how this
would be supporting prostitution.
Despite this, some HQ staff are in favour of the pledge.
For example, there are doctors who work at the HQ
clinics who see the pledge as an opportunity to withhold
services from sex workers. These individuals rationalize this
to colleagues by suggesting that they never wanted to work
with prostitutes and that the pledge will lead to great
personal relief, as they will no longer be required to
experience the stigma of working with these people. Sex
workers are highly stigmatized, so much so that this stigma
affects those providers who work with sex workers, including
in healthcare settings.
The Director of HQ consulted with the local USAID Country
Officer who clarified that drop-in centres for sex workers are
definitely not permitted under this restriction. At the same
time, the Country Officer confides to the Director that this is
one of the few areas that is specific and clear regarding this
policy. Rather than police who can and cannot use the HQ
drop-in centres, HQ simply closed them. In addition, any
clinic attendees who are known or suspected to be involved
in sex work are informed that they will no longer be provided
services. The result is that sex workers are publicly forced to
leave the clinic. This was the only clinic they attended in the
city because others, including public clinics, either barred
them outright or made them so unwelcome that sex workers
did not return. There are no other services dedicated to sex
workers. Therefore, HQ’s denying sex workers services
effectively denies them any healthcare.
With no drop-in centre access, sex workers have no place
to get off the street. Further, homeless sex workers have no
access to basic bathing and sanitation facilities. In response
to the pledge, local sex workers organize a meeting with
the staff of an international human rights organization.
They report that HQ has informed them that in addition to
exclusion from its clinics and the closure of its drop-in
centres, HQ will no longer support sex workers organizing
against violence by offering a space for sex workers to meet
and strategize anti-violence efforts, despite the fact that sex
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9
workers and HQ had worked collaboratively together for
12 years. Local sex workers cannot understand these
developments, as they are sure that all HQ and local partner
staff are against violence. The international human rights
organization makes it clear that it is not violence that is
the issue but rather the new restriction on HQ and partners
imposed by the anti-prostitution pledge and that the
restriction makes HQ leadership worry whether supporting
this anti-violence effort could be construed as promoting
prostitution.
Under increased pressure from sex workers, local commu-
nities and human rights organizations, and worried whether
programming that continued after the closure of the drop-in
centres could be considered promoting prostitution, the
board of HQ decides to stop seeking HIV funding, and instead
to concentrate on school-based sexual education, which
is not affected by the US anti-prostitution pledge, but which
does not reach sex workers. Peer education and social
marketing of condoms and safe sex supplies for sex workers
is halted. Locally, condom sales drop by more than two-
thirds. Personal lubricant becomes almost inaccessible be-
cause the cost is simply prohibitive outside social marketing
schemes.
Realizing that a dangerous situation regarding human
rights and public health seems imminent, HOBO, an alto-
gether different outreach organization, that is also in receipt
of PEPFAR funds agrees to allow sex workers to meet and to
organize at one of their satellite offices, provided that the sex
workers do not make the information regarding their meet-
ings public. When asked how HOBO can be sure that they will
not be punished under the PEPFAR policy, an employee of
HOBO indicates that the NGO is a small part of a much bigger
project and that if USAID officials visit, they will not be told
about the sex worker group. Internally, and in time, HOBO
staff members are praised for the increase in the use of its
services and the improvements in its outcome evaluations.
Unlike the Director of HQ, the Director of HOBO indicates
to its staff that information pertaining to sex workers’ use of
services will not be published and will be made available only
to its staff.
At the 2010 World AIDS Conference, an informal discussion
is held among Directors of outreach organizations similar to
HOBO. There, a colleague from a neighbouring country
indicates to HOBO’s Director that while they were looking
forward to seeing the HOBO annual report, in particular,
to the outcomes of the new and covert services delivered to
sex workers that, not reporting this information was the right
thing to do: ‘‘I understand. My organization has adopted a
similar policy. I only wish we could do more.’’
Discussion
Government and NGO personnel report that the guidance
on the implementation of the anti-prostitution pledge has
been unclear and enforcement has been unpredictable. As
described above, written guidance has not stipulated what
exactly is or is not permitted, and therefore, many organi-
zations have interpreted the restrictions on their own, with
varying results. While some organizations’ personnel, as
at Agency X, advised declining to work with sex workers
altogether for fear of losing the important USAID contract,
others cautioned that in doing so, sex workers would
be discriminated against and denied critical HIV prevention
and health services. The consensus reached by one organiza-
tion, HOBO, was to modify its terminology in order to offer
services to sex workers without compromising their US
funding, and when appropriate, to implement USAID’s non-
discrimination clause that prohibits the denial of services to
anyone, but also to attempt to suppress and withhold
information about their work with sex workers.
In some instances, one of the effects of funding restric-
tions is that programming has been eliminated. Within some
organizations, peer education for sex workers about safer sex
techniques have ended. Campaigns against violence against
sex workers, who are subject to some of the highest rates of
violence among any population have been dropped.
NGO staff have used restrictions to promote their
prejudices. This reinforces stigmatization and discrimination.
Some NGOs no longer serve some of the least-served and
most-at-risk people, sex workers. Those who are homeless,
transgender, or otherwise suffer double stigma are most
adversely affected. A large number of NGOs have limited
their funding and programming and even their discussions
in wide-ranging self-censorship to ensure that they remain
within this limitation. Reports and publications about
successful HIV and AIDS programming with sex workers
have been suppressed.
Conclusions
Breadth
These are restrictions that apply to many programmes,
beyond USAID, as PEPFAR is the largest US foreign aid
programme. The restriction’s wide scope inhibits the sharing
of information in the form of reports, papers, presentations
and other media. The lack of information sharing is a direct
result of the chilling effect of the restrictions. Furthermore,
the lack of information sharing prevents the development,
implementation and replication of effective programming
for sex workers, far beyond PEPFAR.
The anti-prostitution pledge works counter to HIV
prevention
Best practices for HIV prevention emphasize combating
stigma and discrimination [48] and the involvement of target
populations in designing effective programs [19,49]. Sex
workers’ descriptions of the adverse effects of this restriction
have been repeatedly ignored by multiple US administrations.
This is counter to best practices and should be rectified for
evidence-based proven-effective programming.
While PEPFAR has made life-saving medicines accessible to
many, our research documents that it has also promoted the
stigmatization of sex workers and discrimination against sex
workers.
New guidance issued in April 2010 does not clarify what is
permitted or restricted and so cannot rectify this situation
created in part by lack of guidance [22]. The new guidance
further promotes stigma and discrimination by discussing
unproven effects. PEPFAR’s August 2011 HIV prevention
guidance states that ‘‘there is substantial evidence for the
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10
effectiveness of a core set of interventions for populations at
high risk of HIV, including [sex workers]’’. However, there is
no clear guidance for HIV prevention programming with sex
workers, although there is such guidance for other popula-
tions at higher risk of HIV including men who have sex with
men [50] and people who inject drugs [51].
PEPFAR’s anti-prostitution pledge has had unintended
consequences on NGOs, local organizations and primarily,
the provision of services to sex workers and clients. Outreach
staff indicate that HIV prevention has been less successful
since the inclusion of the pledge, and local HIV Incidence
rates reflect this, particularly among sex workers and people
presumed to be sex workers, including some gay men and
transgender people. The funding restrictions have reduced or
eliminated access to services. Drop-in centres have closed; in
some instances sex workers no longer have access to places
to bathe and use a toilet. Sex workers have been denied
clinic services. Sex workers have less access to condoms and
personal lubricant, critical HIV prevention tools and neces-
sary commodities for safe sex. The current US Global AIDS
Coordinator has been quoted as saying that turning away
anyone who should receive services would not be tolerated:
What the clause really was focused on was to ensure
that PEPFAR did not fund organizations involved in
trying to legalize prostitution and traffic women into
prostitution. We have changed it so an organization
doesn’t have to sign [a separate document pledging
to oppose sex work and sex trafficking]; we have
folded in an agreement that the [beneficiary] orga-
nization will not traffic women into prostitution
there is no separate document. PEPFAR has not de-
funded any programme on the planet for these
reasons. We want to care for every sex worker out
there. If a sex worker comes into any of our facilities,
that person will be embraced and followed for the
duration of their life on anti-retrovirals. If there are
examples of anybody being turned away [for being a
sex worker], if someone feels that they were
excluded from or dropped out of care for those
reasons, we would get on that like a laser [23].
This statement implies that the US government wishes to
enforce the anti-discrimination clause that prevents anyone,
including sex workers, from being denied services. However,
this type of clarification does not address or counter the
preceding years’ promotion of discrimination against sex
workers or organizations working with them, which cannot
be undone through popular reportage, particularly consider-
ing the phrasing in US contracts through 2011 and lack of
clear guidance about what exactly is and is not permitted
with US funding. This lack of clarity allows the US adminis-
tration to continue to enforce the pledge as it sees fit,
as the previous administration has and the next administra-
tion could. The provision of life-and-death services should not
be determined by ‘‘political winds’’ [52]. Clear guidance for
HIV programming with sex workers could alleviate this.
Clearly within policy arenas there are mixed perspectives
on the impacts of the PEPFAR restrictions with regards to
sex work. However, real world prevention care and treat-
ment of HIV and AIDS for sex workers does not occur in
policy arenas but rather on the ground, in venues and
avenues far removed from policy discourse. Meanwhile,
although policymakers reflect on the intent or the outcome
of the pledge, on the ground the policy has and may
continue to have consequences. As a result of the pledge, in
many instances information sharing about successful pro-
gramming with sex workers has nearly ceased. Sex work
programming has become a taboo topic; organizations that
receive other funding are likely to be interested in or to
seek US government contracts and funds. Others with
specific missions have reigned in all activities unrelated or
tangentially related to their missions; this has affected many
sex work projects the world over. The anti-prostitution
pledge has prevented the sharing of information about
successful programming and prevented scaling up successful
operations.
The US government should reconsider this funding
restriction in the light of diminished effectiveness, and
instead implement evidence-based interventions in its HIV
programming.
Authors’ affiliations
1
Independent consultant, New York, NY, USA;
2
HIV Social, Behavioural and
Epidemiological Studies Unit;
3
the CIHR Social Research Centre in HIV
Prevention (SRC), Dalla Lana School of Public Health, University of Toronto,
ON, Canada
Competing interests
MHD has worked as a paid consultant for organizations working with sex
workers, some of which receive US government funding and others which
do not. It is anticipated that they will neither gain nor lose from the publication
of this article.
Authors’ contributions
MHD conceived of the study, participated in its design, coordinated the
collection and analysis of data and helped draft the manuscript. DA
participated in the study design and helped draft the manuscript. Both
authors read and approved the final manuscript.
Acknowledgements
Melissa Hope Ditmore was supported as a postdoctoral fellow in the
Behavioral Sciences Training in Drug Abuse Research program sponsored by
Public Health Solutions and the National Development and Research Institutes
(NDRI) with funding from the National Institute on Drug Abuse (5T32
DA07233). The HIV Social Behavioural and Epidemiological Studies Unit is
funded by the Faculty of Medicine, University of Toronto. The CIHR Social
Research Centre in HIV Prevention (SRC) is funded by the Canadian Institutes
of Health Research.
Disclaimer: Points of view, opinions and conclusions in this article do not
necessarily represent the official position of the US Government, Public Health
Solutions or National Development and Research Institutes.
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