Advocacy Ethics and Public Health: Ethical Challenges in PEPFAR and Uganda's ABC approach to Prevent HIV

Uganda is a recipient of the President's Emergency Plan for AIDS Relief (PEPFAR) funds initiated by President Bush in 2003. The initially $15 billion was tripled in 2008 to intensify the fight against HIV/AIDS, tuberculosis, and malaria mostly in sub-Saharan African countries. Uganda has successfully utilized the aid to reduce mother-to-child transmission, increase antiretroviral drugs, testing and counseling services. Surprisingly, the HIV prevalence rate which was reduced in the 1990s from 18% to 6.2% using the ABC approach has for the last eight years stagnated at 6.2 %. “A” stands for abstain if unmarried; “B” for be faithful; and, “C” for use condoms if unable to A B. Uganda's ABC strategy pursues epidemiological goals of ameliorating morbidity and mortality in the populations by combining behavior change and risk-reduction approaches. The behavior change strategy informed by family core values is donor-unfriendly for perceived prescriptive moral judgments. Sex reformists prefer risk-reduction which provides prevention tools and information, and enhances sex freedom. Human rights provide the ethical code for enforcing respect for sex orientation and gender identity interests. Faith-based conservatives, supportive of abstinence programs, turn to governments for ordinances protective of family values. The competing interests have stalled Uganda's effort to prevent heterosexual transmission of HIV. Ethicists have long expressed that political advocacy being goal-orientated and populist ethics may compromise ethics standards and science method. Public health needs inclusive ethics to re-focus on epidemiological goals.