II. The United States War on Condoms
At the July 2004 International AIDS Conference in Bangkok, U.S. Global AIDS Coordinator Randall Tobias attempted to deflect charges from AIDS activists that the United States had substituted abstinence until marriage programs for science-based HIV prevention strategies that included correct and consistent condom use. Tobias stated that the United States HIV prevention message had been and continued to be ABC, which stands for Abstain, Be faithful, use Condoms, in that order. He went on to say, Abstinence works, being faithful works, condoms work. Each has its place.9 Three months earlier, however, Tobias had stated that statistics show that condoms really have not been very effective. He added, It's been the principal prevention device for the last twenty years, and I think one needs only to look at what's happening with the infection rates in the world to recognize that it has not been working.10
Tobias contradictory statements exemplified a trend of U.S. officials concealing or distorting scientific evidence about condoms in order to consolidate support for abstinence until marriage programs.11 In 2000, the U.S. Congress passed legislation requiring studies and educational materials on the effectiveness or lack of effectiveness of condoms in preventing human papillomavirus (HPV), a mandate that was clearly intended to undermine confidence in the use of condoms against HIV.12 In 2002, a fact sheet on the effectiveness of condoms was removed from the website of the U.S. Centers for Disease Control and Prevention (CDC) and replaced by a new fact sheet which, while factually accurate, eliminated instructions on how to use a condom properly and evidence indicating that condom education does not encourage sex in young people.13 Information on condom effectiveness was similarly altered on the website of USAID.14 Supporters of abstinence until marriage provisions, including Ambassador Tobias and the director of HIV/AIDS programs at USAID, Anne Peterson, relied throughout 2003 on a tendentious reading of successful HIV prevention efforts in Uganda, attributing decreases in HIV prevalence there to increased abstinence and fidelity and downplaying the role of condoms.15 Since George W. Bush assumed the presidency in early 2001, the United States has sought to restrict references to condoms and comprehensive sex education in United Nations policy documents.16
While President Bush has at times mentioned condoms in his public speeches, he has demonstrated a clear and consistent commitment to abstinence only programs that censor information about condoms. As governor of Texas and during his 2000 presidential campaign, Bush supported federally-funded abstinence-only programs and vowed to expand them if elected president.17 Soon after taking office in 2001, Bush appointed as high-level HIV/AIDS advisers physicians who denied the effectiveness of condoms, including former U.S. Representative Tom Coburn and Joe S. McIlhaney, Jr., president of the Texas-based Medical Institute for Sexual Health (MISH) and a long-time recipient of federal abstinence-only funds.18 As president, he has continued to support funding for abstinence programs in both his domestic and foreign policy agendas.19
The United States has traditionally been the worlds largest donor of condoms to low and middle-income countries. Throughout the 1990s, however, the number of condoms shipped abroad by the U.S. Agency for International Development (USAID) dropped from a high of approximately 800 million condoms in 1991 to just over 200 million in 1999.20 Condom shipments increased to approximately 480 million condoms in 2003, higher than the approximately 233 million condoms shipped in 2002.21 Yet this was still a fraction of the amount provided in the early 1990s, despite the fact that the number of people living with HIV/AIDS nearly tripled over that same time period.22 Laws requiring that U.S.-donated condoms be purchased from American manufacturers mean that the U.S. does not obtain the lowest possible price for condoms, despite the fact that many non-U.S. brands of condoms on the international market meet stringent quality control standards.23
Enacted in June 2003, the United States Leadership against HIV/AIDS, Tuberculosis and Malaria Act of 2003 stipulates that 33 percent of prevention spending go to abstinence until marriage programs.24 In the fiscal years (FY) 2004 and 2005, the United States spent more than U.S.$20 million on abstinence until marriage programs under PEPFAR25 and continued to issue requests for proposals and grants for these programs.26 While government-issued program guidelines do not forbid recipients from promoting condoms, they make no mention of condom availability as an indication of program outcome or performance and, as required by PEPFAR, state that applicants will not be required . . . to endorse, utilize or participate in a prevention method to which the organization has a religious or moral objection.27 The five-year strategy document released in February 2004 by the U.S. Office of the Global AIDS Coordinator, which administers PEPFAR, states that correct and consistent condom use will be promoted only for those who practice high-risk behaviors, advising only abstinence and fidelity for all others.28 The fact that domestically funded abstinence-only programs in the U.S. censor information about condoms outright, combined with the widespread official anti-condom sentiment that accompanied PEPFARs enactment, suggests that condoms are intended to play at best a minor role in PEPFAR-funded abstinence until marriage programs.
Following the ramping up of U.S.-funded abstinence until marriage programs, leaders of African countries standing to receive PEPFAR funding made numerous public statements in favor of sexual abstinence as a primary HIV prevention strategy. In May 2004, for instance, Ugandan president Yoweri Museveni deviated from his historical support of condoms by stating that condoms should be provided only for sex workers.29 This change in position occurred at approximately the same time that the U.S. announced that Uganda would receive $90 million of PEPFAR funds.30 President Museveni continued to make similar statements in his public speeches, including at the International AIDS Conference in July 2004.31
There are signs of attitudes towards condoms changing elsewhere as well. In Zambia, President Mwanawasa gave a speech in 2004 suggesting that traditional methods to fight HIV/AIDS, including promoting condoms and public awareness campaigns, were not working and that the country needed instead to promote sexual abstinence.32 In March 2004, the Zambian government reportedly banned the distribution of condoms in schools on the grounds that condoms promoted promiscuity among youth.33
In Swaziland, which has one of the highest HIV prevalence rates in the world (between 37 and 40 percent of adults as of 2004), leading government officials and important public figures, including the founder of Swazilands AIDS Support Organization, took public anti-condom stands in 2003. A top traditional leader reportedly ridiculed condoms as ineffective and inconsistent with Swazi manhood.34 In 2001, the Kenyan government discontinued the supply of free condoms to the general population, although it continued to supply highly subsidized condoms. When asked about this change, a health ministry official stated that if the poor cannot afford condoms, they should be faithful.35
Such anti-condom sentiment appears to be affecting programs funded by the U.S. Agency for International Development (USAID), in addition to those funded by PEPFAR. A Peru-based staff member of the Center for Health and Gender Equity (CHANGE), a nongovernmental organization, observed that pressure for abstinence programs in Peru was arising from the fact that USAID had requested funding proposals on abstinence-based HIV prevention, as well as a broader perception that the U.S. prefers abstinence programs.36 A reproductive health expert in Nigeria told Human Rights Watch, I think that USAID is not promoting condoms any longer, but abstinence only.37 This perception may discourage programs from including condom provision and condom information as programmatic elements in their applications for funds from USAID.
 CNN.com, U.S. fights criticism at AIDS conference, online: http://www.cnn.com/2004/HEALTH/conditions/07/14/aids.conference.reut/ (retrieved August 25, 2004).
 Kaiser Family Foundation, U.S. Global AIDS Coordinator Tobias Defends Emphasis on Abstinence, Daily HIV/AIDS Report, April 22, 2004.
 See, e.g., Nicholas D. Kristof, The Secret War on Condoms, The New York Times, January 10, 2003; Marie Cocco, White House Wages Stealth War on Condoms, Newsday, November 14, 2002; Caryl Rivers, In Age of AIDS, Condom Wars Take Deadly Toll, Womens eNews, December 10, 2003, http://womensenews.org/article.cfm/dyn/aid/1633/context/archive (retrieved February 16, 2004); Art Buchwald, The Trojan War, The Washington Post, December 11, 2003.
 42 U.S.C. section 247b-17. The legislation creating PEPFAR similarly required the president to report on the impact that condom usage has upon the spread of HPV in Sub-Saharan Africa. H.R. 1298, s. 101(b)(3)(W); see also, Presidents Emergency Plan for AIDS Relief: Five Year Strategy Document, pp. 79-80. Pro-abstinence advocates have long sought to disparage condoms by speculating about the link between condom usage and HPV, some strains of which cause cervical cancer. Condom use is in fact associated with lower rates of cervical cancer and HPV-associated disease, though the precise effect of condoms in preventing HPV is unknown. CDC, Male Latex Condoms and Sexually Transmitted Diseases (2002).
 Compare CDC, Condoms and Their Use in Preventing HIV Infection and Other STDs (September 1999), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_orig.pdf with CDC, Male Latex Condoms and Sexually Transmitted Diseases (2002), available at http://www.house.gov/reform/min/pdfs/pdf_inves/pdf_admin_hhs_info_condoms_fact_sheet_revis.pdf. See also, A. Clymer, Critics Say Government Deleted Web Site Material to Push Abstinence, The New York Times, November 26, 2002; U.S. House of Representatives, Committee on Government ReformMinority Staff, Special Investigations Division, U.S. Rep. Henry A. Waxman, Politics and Science in the Bush Administration, August 2003, updated Nov. 13, 2003, p. 12.
 Compare USAID, The Effectiveness of Condoms in Preventing Sexually Transmitted Diseases, http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condom_effect.html (retrieved January 28, 2003; no longer available) with USAID, USAID: HIV/AIDS and Condoms, http://www.usaid.gov/pop_health/aids/TechAreas/condoms/condomfactsheet.html (retrieved July 10, 2003).
 See Tina Rosenberg, On Capitol Hill, Ideology Is Distorting an African AIDS Success, The New York Times, April 28, 2003; Emily Wax, Ugandans Say Facts, Not Abstinence, Will Win AIDS War, The Washington Post, July 9, 2003; Tom Carter, Uganda Leads by Example on AIDS, The Washington Times, March 13, 2003. National-level survey data suggest that delays in sexual debut, a reduction in the number of sexual partners, and increases in condom use all played a part in lowering HIV risk in Uganda. See Susheela Singh, Jacqueline E. Darroch, and Akinrinola Bankole, A, B and C in Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline, Occasional Report No. 9, The Alan Guttmacher Institute, December 2003; Susan Cohen, Flexible But Comprehensive: Developing Country HIV Prevention Efforts Show Promise, The Guttmacher Report on Public Policy, October 2002.
 See discussions in Francoise Girard, Global Implications of US Domestic Policy and International Policies on Sexuality, IWGSSP Working Papers, No. 1 (June 2004), p. 8; Esther Kaplan, With God on their Side: How Christian Fundamentalists Trampled Science, Policy, and Democracy in the Bush White House (New York: The New Press, 2004), pp. 235-39; Human Rights Watch, Unprotected: Sex, Condoms and the Human Right to Health in the Philippines (May 2004), vol. 16, no. 6(C); Human Rights Watch, Ignorance Only, p. 12.
 In 1999, speaking about his gubernatorial record, President Bush said, We have an aggressive U.S.$5 million-a-year abstinence program [in Texas] to teach young people that the rewards of abstinence far outweigh the risks of sex. Governor George W. Bush, Speech to Right Choices for Youth Conference, Austin, Texas, March 31, 1999. In the presidential debates, before being elected president, Bush said, I will promote abstinence programs in our school systems. President George W. Bush, final New Hampshire Republican primary debate, Manchester, New Hampshire, January 26, 2000. President Bush also mentioned abstinence in his speech accepting his partys nomination at the 2000 Republican National Convention. President George W. Bush, Presidential nomination acceptance speech, Philadelphia, Pennsylvania, August 3, 2000. Text of all three statements mentioned above as well as others are available from Project Vote Smart at http://www.vote-smart.org/speech.php?can_id=CNIP9043 (retrieved August 25, 2004).
 As a member of Congress, Coburn was instrumental in the passage of 2000 legislation requiring studies of the impact of condom use on HPV transmission and in pushing the National Institutes of Health to convene a series of meetings on condom effectiveness. McIlhaneys Medical Institute for Social Health (MISH) uses discredited science to argue that condoms are safe, and receives federal funding to produce written and video materials for adults and youth explaining why condoms are not a reliable alternative to abstinence. Medical Institute for Social Health, Condoms: Whats Still At Risk; Do Condoms Make Sex Safe Enough?; Sex, Condoms and STDs: What We Know Now (Spring 2003).
 See, e.g., The White House, President Announces Welfare Reform Agenda, February 26, 2002, http://www.whitehouse.gov/news/releases/2002/02/20020226-11.html (retrieved August 2, 2002).
 USAID Bureau for Global Health, Overview of Contraceptive and Condom Shipments, FY 2001 (Washington, D.C.: PHNI Project for USAID, September 2002), pp. 17-18.
 Remarks by Andrew S. Natsios, administrator, United States Agency for International Development (USAID), HIV Prevention Symposium, Academy for Educational Development, January 14, 2004.
 USAID Bureau for Global Health, Overview of Contraceptive and Condom Shipments, FY 2001; UNAIDS, 2004 Report,p. 25, figure 1.
 In 2002, USAID contract negotiations reduced the average procurement price of condoms from U.S.$0.06 to U.S.$0.04. This new price is still higher than the lowest international price, thus limiting the number of condoms procured per U.S. dollar spent. See Consolidated Appropriations Act, 2004, 118 Stat. 3, 147 (2004), Donald McNeil, Global War Against AIDS Runs Short of Vital Weapon: Donated Condoms, The New York Times, October 9, 2002.
 United States Leadership against HIV/AIDS, Tuberculosis and Malaria Act of 2003, P.L. 108-25, 22 U.S.C. sections 7601 et seq. (2003), ss. 402(b)(3), 403(a).
 Jennifer Kates, U.S. Government Funding for Global HIV/AIDS Through FY 2004, HIV/AIDS Policy Brief, Kaiser Family Foundation (June 2004), p. 10.
 In April 2004, USAID announced first round grant awards for abstinence and behavior change programs with youth to two organizations serving six countries, representing $16.7 million. USAID Announces First Round of Grants for President Bush's Emergency Plan for AIDS Relief, USAID press release, April 13, 2004.
 USAID, Annual Program Statement: HIV/AIDS Prevention Through Abstinence and Behavior Change for Youth, November 26, 2003, pp. 7, 13-15. Appropriations legislation for FY2004 requires that information about condoms be medically accurate if it is provided, including public health benefits and failure rates. Consolidated Appropriations Act, 2004, 118 Stat. 3, 147 (2004).
 PEPFAR: Five Year Strategy Document, p. 9.
 Health and Development Networks, Condom U-Turn puts many young Ugandans at Risk, May 26, 2004, online: http://archives.hst.org.za/af-aids/msg01372.html (retrieved August 25, 2004).
 Racheal Rinaldo, Condoms Take a Back Seat to Abstinence with U.S. AIDS Money, Inter Press Service, May 24, 2004, online: http://www.ipsnews.net/interna.asp?idnews=23879 (retrieved August 25, 2004). The article quotes an unnamed U.S. official as saying that prevention funds could be used to purchase condoms, but that condoms would ideally be used only with high risk populations.
 Kaisernetwork.org, Daily Update from the XV International AIDS Conference, July 12, 2004.
 Human Rights Watch internal e-mail communication with Tony Tate, June 19, 2004.
 Z. Geloo, Anger at Move to Declare Schools Condom-Free Zones, Inter Press Service, March 16, 2004.
 U.N. Office for the Coordination of Humanitarian Affairs, Swaziland: Resisting Condom Use as AIDS Deaths Soar, Integrated Regional Information Network (IRIN) News, December 1, 2003.
 No More Free Condoms in Kenya, The East African Standard, November 10, 2001.
 Human Rights Watch telephone interview with Anna-Britt Coe, Center for Health and Gender Equity, Lima, Peru, June 25, 2004.
 Human Rights Watch telephone interview with Dr. Friday Okonofua, editor, African Journal of Reproductive Health and dean, School of Medicine, College of Medical Sciences, University of Benin, Benin City, Nigeria,July 13, 2004.