By any measure, syringe exchange works. It dramatically reduces HIV infection without increasing drug use. Do you want to get drug users into treatment for addiction? Syringe exchange helps. Do you want to ensure that police officers aren't stuck with dirty needles in pat downs? Syringe exchange helps. Do you want to reduce the number of people on costly lifetime treatment for AIDS? Syringe exchange helps. Do you want to remove dirty needles from parks and playgrounds? Syringe exchange helps.

There is absolutely no dispute about the scientific evidence on any of these fronts. Eight federally funded reviews found that syringe exchange reduces HIV without increasing drug use. It is endorsed by every major medical association, including the American Medical Association, the American Academy of Pediatrics, and the American Nurses Association. In 2008, the CDC concluded that the incidence of HIV among injection drug users had decreased by 80 percent in the U.S. over a 20-year period in part due to syringe exchange programs.  Two years ago Congress lifted the ban, giving states the option to use federal funds for syringe exchange.

Unfortunately, the reinstatement of the funding ban deals a lethal blow to HIV programs that are proven to work. State health departments with firsthand experience responding to injection drug use understand that peer-driven needle and syringe programs make their communities safer and healthier. In the midst of the fiscal crisis, many of these programs are being cut or scaled back, making federal funds all the more important. But sadly, once again politics trump public health.

Twelve percent of all new HIV infections in the U.S. are among injection drug users. We could bring that number to zero—and help people access treatment for addiction at the same time. But the Congress chooses not to.

At the heart of the speech was a pitch for “combination prevention” that will include prevention of mother-to-child transmission, voluntary medical male circumcision, and treatment for HIV infection. All three have been proven to dramatically reduce the spread of AIDS. Clinton played up the cost effectiveness angle. I’d point out that all three also hit the sweet spot of left-right political support. Under the Bush Administration, Republicans led the call for an historic and dramatic expansion of treatment. Will they do it again?

Three items of note:

• Hello, Ellen. Ellen DeGeneres will be the new Special Envoy for Global AIDS Awareness. Presumably her job is to help the American people understand why we spend more than $6 billion a year on global HIV/AIDS – and why they should feel good about it.

• Clear support for the Global Fund.  The U.S. is the single largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria and made its first multi-year commitment under Obama’s watch. This year the Fund has come under fire for corruption that its own auditors discovered and addressed. On this front, Clinton got it right: “Let’s remember, uncovering problems is exactly what transparency is supposed to do. It means the process is working. So let’s not put the Global Fund into some kind of catch-22. Go be transparent, go be accountable, and when you find problems, we’re going to take money away from you. Now, from day one, the United States Congress has insisted that our contributions to the Global Fund support accountable programs that produce measurable outcomes. And it’s been my experience that the American people are happy to support lifesaving programs if they know they really work. And this is how we show them.”

• Uganda, take note. Clinton notes that the U.S. will work to repeal “laws that make people criminals simply because of their sexual orientation.” This is good news. And lest we think “combination prevention” is too narrow, Clinton was careful to note that the three main interventions work in concert with an array of services, such as condom use and addressing gender-based violence.

What was missing?

• No new money and no new targets. It’s not surprising that Clinton wasn’t in a position to promise new money as the future of foreign aid is under active debate by the congressional “Super Committee” and others. While Clinton spoke of an expansion of those on treatment, it as yet unclear how much the U.S. will take on and how much it will ask of others.

• Only passing recognition of marginalized, at-risk populations. Sex workers, injection drug users (IDUs) and men who have sex with men (MSM) are disproportionately at risk of contracting HIV and far less likely to have access to prevention services and treatment. The promise of “treatment as prevention” is particularly hollow for members of these groups, as criminal laws and discrimination drive them into prison instead of clinics. Under Clinton, the State Department issued excellent guidance for programs addressing both MSM and IDUs but much more needs to be done to implement these policies. The U.S., for example, supports syringe exchange on paper, but has yet to fund a single syringe abroad to help a drug user avoid HIV infection.

• No mention of the International AIDS Conference.  Washington, DC will host more than 25,000 people from around the world in July 2012 for the world’s largest public health conference on HIV/AIDS. It’s the first time the conference has been in the U.S. in 20 years and it falls a few months before the next Presidential election. The U.S. has a lot to be proud of on HIV/AIDS, but the potential for contracting budgets could turn a love-fest into a protest.

The Administration says that Clinton’s speech was the first in a series by high-level Administration officials. Let’s hope they keep pushing for the programs people deserve and a plan for an “AIDS-free generation” we can all embrace.

Read the full text of Clinton's speech: http://www.state.gov/secretary/rm/2011/11/176810.htm

Since the beginning of the AIDS epidemic more than 30 years ago, families, communities, and government have been forced to have difficult conversations about messy topics.  Those most in need of HIV treatment and prevention are also people deemed criminals around the world: sex workers, drug users, and men who have sex with men.   The U.S. global AIDS program, unhelpfully, asks funding recipients to take a pledge to “oppose prostitution” as a condition of getting funding.  While it is unclear what this means—must you send them to jail or simply speak ill of them?—it has prevented debate and discussion where it is most needed.

The Court of Appeals agrees.  Yesterday, an appellate court affirmed that the U.S. Constitution protects the right to free speech, including the right to debate, have opinions, or have no opinion at all on the subject of prostitution.  In making this decision, they took into account that the debate about prostitution is integral to fighting HIV/AIDS.  There are differences of opinion and we need to discuss them.  Putting a muzzle on funding recipients violates the U.S. Constitution and undermines our global health programs. Unfortunately, the decision only provides protection to U.S. groups.  Foreign NGOs don’t have first amendment protections and are still gagged.

Here are excerpts from the opinion:

The right to communicate freely on such matters of public concern lies at the heart of the First Amendment.  The Policy Requirement offends that principle, mandating that Plaintiffs affirmatively espouse the government’s position on a contested public issue where the differences are both real and substantive.  For example, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recognized advocating for the reduction of penalties for prostitution—to prevent such penalties from interfering with outreach efforts—as among the best practices for HIV/AIDS prevention.

The government has, by compelling NGOs to affirmatively pledge their opposition to prostitution, stepped beyond what might have been appropriate to ensure that its anti-prostitution message would not be "garbled" or "distorted."

We do not mean to imply that the government may never require affirmative, viewpoint-specific speech as a condition of participating in a federal program.  To use an example supplied by Defendants, if the government were to fund a campaign urging children to "Just Say No" to drugs, we do not doubt that it could require grantees to state that they oppose drug use by children.  But in that scenario, the government’s program is, in effect, its message.  That is not so here.  The stated purpose of the Leadership Act is to fight HIV/AIDS, as well as tuberculosis, and malaria.  Defendants cannot now recast the Leadership Act’s global HIV/AIDS-prevention program as an anti-prostitution messaging campaign.

The very excellent attorneys at the Brennan Center who successfully argued the case have much more information on their website.  But be warned, your new ability to talk about sex won’t necessarily make it sexy.

The requirement, originally included in the law authorizing the President’s Emergency Plan for AIDS Relief (PEPFAR), states that any organization that receives U.S. money must have a policy “opposing prostitution” – a term that has never been defined.  Because an organization must adopt an organizational policy, the pledge controls all funds, not just those from the U.S. government.

Under the Bush Administration, the pledge was not enforced against U.S. NGOs for the first two years after it was adopted because the Department of Justice (DOJ) warned that it was constitutionally suspect.  DOJ also advised Congress that a similar provision of the Trafficking Victims Protection Act “raises serious First Amendment concerns and may not withstand judicial scrutiny.”   In an undoubtedly political maneuver, however, they reversed that opinion and began to enforce the pledge against U.S. NGOs in 2005.  The Obama Administration had the opportunity to set things right by again declaring the requirement unconstitutional.  Instead, they have now embraced bad policy, and bad public health.

Numerous organizations have spoken out against the pledge, including InterAction and the Global Health Council.  The organizations, along with an Alliance for an Open Society and Pathfinder, are challenging the requirement in court.  Represented by the Brennan Center, they argue that it undermines urgently needed HIV prevention programs and violates the free speech guarantees of the U.S. Constitution. The U.S. district court has twice ruled that the pledge is unconstitutional and violates the First Amendment.  A preliminary injunction prohibits USAID and HHS from enforcing the pledge requirement against the plaintiff organizations and protects U.S.-based members of the Global Health Council and InterAction.

The new regulation is a step in the wrong direction.  A growing body of research finds that sex workers’ high risk of HIV infection is due in part to their marginalized and illegal status which thwarts access to health care services and government benefits, and makes them vulnerable to police abuse and exploitation.  Nongovernmental organizations report that almost half of countries surveyed have laws that impede delivery of HIV/AIDS services to sex workers. Scarce resources exacerbate the poor attention to their health needs.  UNAIDS estimates that less than one percent of the global funding on HIV/AIDS prevention is spent on HIV and sex work.

The new regulations were intended to provide groups with the ability to keep government funding controlled by the pledge separate from their own funds.  But the Obama Administration’s proposed “solution” set forth in the new regulations literally requires groups to create, incorporate and manage entirely new organizations -- separate facilities, staff, management, equipment, and board members.  Much less burdensome regulations have been used in similar cases but the Obama Administration has rejected them in favor of these draconian rules with no explanation whatsoever.  Finally, the guidelines still utterly fail to clear up any of the widespread confusion regarding which privately funded speech and activities are prohibited.

For further analysis, see the Brennan Center’s recent memo.