Experts say the policy will make it difficult for groups to work with sex workers.

The Bush administration in June announced that US-based AIDS groups working in other countries must formally oppose prostitution in order to win federal funds for their programs.

Only foreign organizations acting overseas were previously required to make the antiprostitution pledge, under legislation authorizing the five-year $15 billion President's Emergency Plan for AIDS Relief (PEPFAR) (Nat. Med. 9, 808; 2003). PEPFAR mandates that US funds only go to groups that adopt “a policy explicitly opposing prostitution and sex trafficking.”

The policy shift had been anticipated since September 2004, when the US Department of Justice ruled that applying PEPFAR's pledge conditions to domestic charities did not breach US constitutional rights of free speech. In May, 200 US-based nonprofit groups wrote a letter against the mandate, arguing that ideological arguments should not influence evidence-based public health interventions.

Roslyn Matthews, a spokesperson for the US Agency for International Development (USAID) says the policy does not preclude groups from providing services to high-risk populations, including sex workers.

But an official antiprostitution policy might further alienate a high-risk population already on the fringe. “The credibility that organizations and individuals must cultivate to gain the trust of this population would be dramatically undermined,” says Judith Auerbach, vice president of public policy at the American Foundation for AIDS Research.

It's grossly immoral and goes against human rights and bioethical principles. , Jodi Jacobson, Center for Health and Gender Equity

The pledge erodes ground-level HIV prevention programs, adds Jodi Jacobson, executive director of the Center for Health and Gender Equity, which monitors US health policy around the world. “It's grossly immoral and goes against human rights and bioethical principles.”

Already, a few groups are preemptively pulling the plug on their programs. For instance, the Urban Sector Group in Cambodia decided last November to discontinue English lessons for sex workers. “The English skills enabled [sex workers] to negotiate safer sex and begin moving out of sex work,” says Alice Miller, assistant professor of public health at Columbia University. “But is that the same thing as promoting prostitution?”

Programs that are most likely to lose funding are those that blend public health interventions with human rights work, even though they have been among the most successful in preventing HIV/AIDS, says Jacobson. India's 60,000-member Durbar Mahila Samanay Committee, for instance, simultaneously promotes HIV/AIDS peer education and sex worker advocacy for equal worker rights. More than 3,000 members of the group in May protested the antiprostitution pledge. The Brazilian government also in May refused $40 million from USAID on grounds that the pledge does not stem from scientific evidence.

Nonprofit groups might mount legal action opposing the pledge. But until then, Jacobson says, “my only projection is one of despair.”