Promises, Promises

At the June 2003 G8 summit in Evian, France, President George W. Bush met with the other heads of state at a private dinner. There, according to sources close to two dinner guests, he promised the Europeans that if they gave $1 billion to a new joint AIDS fund, he would match it. But by July, Bush was urging Congress to supply no more than $200 million for the Global Fund to Fight AIDS, Tuberculosis and Malaria. “I think everybody felt fooled,” says a Global Fund official.

Ultimately, Congress rebelled, increasing the U.S. contribution to the Global Fund to $547 million, but Bush has again budgeted only $200 million for the Global Fund in 2005. The president fails to mention these skirmishes when he claims that his administration is leading the world in the war on AIDS.

While it's true that the United States is contributing more than any other single country, the president has repeatedly overstated the U.S. financial commitment. Moreover, he has damaged the U.S. alliance with international agencies fighting AIDS. Rather than join the world's AIDS battle plan -- with the Global Fund as financier and monitor, the World Health Organization as technical adviser, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) as coordinator -- Bush has created his own controversial strategy with a separate set of rules for his 15 recipient countries. “At this point, the Bush plan is hurting more than it's helping,” says Paul Zeitz, director of the Global AIDS Alliance, an advocacy group.

Bush announced that program, known as the President's Emergency Plan for AIDS Relief (PEPFAR), in his 2003 State of the Union address, when he promised a $15 billion, five-year mission to combat AIDS in Africa and the Caribbean. In a May 2003 ceremony with African ambassadors at the U.S. State Department, Bush signed a bill authorizing $3 billion in spending for the first year; during his July 2003 trip to Africa, the president spoke of the coming “$15 billion.” His African audiences assumed that $3 billion would be sent in the first year, but the 2004 budget to fight global AIDS amounted to only $2 billion. With the price of AIDS drugs dropping, the billion-dollar shortfall translates into thousands of untreated AIDS patients.

The first round of PEPFAR funding wasn't distributed until February of this year; recipients included Save the Children and Harvard and Columbia universities. The plan covers 12 countries in Africa, two in the Caribbean, and Vietnam. AIDS experts applaud Randall Tobias, who was confirmed last fall in the new State Department post of global AIDS coordinator, for sending U.S. money out quickly after he got it. But they question whether PEPFAR will meet even its first-year goal of putting 201,000 people on anti-retroviral drugs.

“Many [African] health ministers are worried,” says Celina Schocken, adviser to the HIV/AIDS minister of Rwanda, “that the first assessments will show very little progress in getting people on treatment.” In May, the Council on Foreign Relations, a nonpartisan group, and the Milbank Memorial Fund, a nonpartisan health-policy foundation, published a report warning that PEPFAR is underfunded and doesn't emphasize local public-health systems, so that “five years from now … PEPFAR investment into programs directed to HIV/AIDS may fail to achieve its goals.”

Bush's unwillingness to contribute fully both to his own program and to international efforts is consistent with his record: According to a 1999 Salon story, while in Texas, Bush was the only governor who did not participate in a campaign by the nonprofit organization Children Uniting Nations, which seeks to help Africans suffering from AIDS. Then, in March 2002, retiring Senator Jesse Helms of North Carolina called for $500 million to be disbursed that summer for drugs to help HIV–positive pregnant women in Africa avoid transmitting the virus to their babies. That summer, while Helms was in and out of the hospital, the White House negotiated the emergency AIDS funding from $500 million down to $200 million, which Congress approved. But Bush declined to release that money, announcing that he would instead request funding -- in future fiscal years -- for the prevention of HIV transmission from mother to child. As of this March, the United States had contracted out only $134 million for that program.

In January 2003, Bush finally called the AIDS epidemic an emergency, but it would be 13 months until $350 million was released. “Four and a half million people have died since Bush's announcement, and 10 million have died since he became president,” says Paul Zeitz. “And in that time the U.S. has gotten about 1,000 people on treatment.”

But the funding shortcomings and slow response are only part of the problem: Another obstacle, as with nearly every other global effort, is the Bush administration's insistence on working alone. In the case of AIDS, Bush has kept his distance from the Global Fund and leading AIDS agencies because they promote a “bottom-up” approach, meaning local stakeholders -- including government, businesses, and community groups -- meet and develop a plan to scale up their country's public-health system. The White House, on the other hand, is trying to create an AIDS program that is managed from inside the Beltway. And the reason for that is almost entirely ideological. When it comes to how to prevent and treat AIDS, Bush's positions are driven by the “pro-family” agenda of the American right, putting the White House and the global AIDS community into open debate.

To begin with, international agencies and the U.S. government can't even agree on whether condoms are essential to preventing the spread of AIDS. Speaking at a recent dinner in Berlin sponsored by the Global Business Coalition on HIV/AIDS, Tobias reflected the White House view when he said, “Statistics show that condoms really have not been very effective,” adding that “it's been the principal prevention device for the last 20 years, and I think one needs only to look at what's happening with the infection rates in the world to recognize that has not been working.” Under PEPFAR, condoms will be distributed only to unspecified “high-risk” groups.

But public-health experts counter that the rise of HIV is not a consequence of the focus on condoms, but rather of inadequate government attention to HIV prevention more generally. In the 1990s, Uganda was able to limit the spread of HIV through an intensive “ABC” campaign asking people to “Abstain, Be faithful, or use Condoms.” While Bush officials point to Uganda's “A” as a model for other African programs, studies of Uganda's success -- most recently in the April 30 issue of Science magazine -- have shown that increased condom use in Uganda, in conjunction with a measured reduction in sexual partners, or “zero-grazing,” as it was called, helped reduce the number of infections there.

Dr. Philippe Talavera, head of Obetja Yehinga, a public-health education campaign in Namibia, expects to see his group's U.S. funding (which had begun before PEPFAR) cut or eliminated because it brings up condom use with young people. “We were told that the money was to be subject to conditions,” he wrote in an e-mail in response to questions for this article. “Condoms were to be promoted only with the high-risk groups (military, truck drivers, sex workers, drug addicts). This definition might work in the [United] States, but in a country where the prevalence is 22.5 [percent], everybody engaging in sexual activities has to be considered at risk.”

Jodi Jacobson, executive director of the Center for Health and Gender Equity, a reproductive- and sexual-health group, says that U.S. officials and grant recipients “have told us that in three separate U.S. missions [in Africa], people are being told not to include any requests for condoms in their … operational strategies.”

Another issue that splits the White House from the AIDS–relief community is abortion. Soon after his inauguration, Bush reinstated the “Mexico City Policy,” also known as the global gag rule, which had been in effect under Presidents Ronald Reagan and George Bush Senior. Under these restrictions, foreign nongovernmental organizations receiving U.S. government funding must agree not to provide counseling or referral for abortion or perform abortions except in cases of rape, incest, or life-threatening illness. This policy has impeded the fight against AIDS by forcing the closure of many clinics. For example, the Kenya affiliate of Marie Stopes International, a reproductive-health-services group, had to shut down several clinics, including one that served 400 women a month in the province with the highest HIV prevalence rate in the country. In Ghana, the Planned Parenthood Association was forced to reduce not only family-planning services but also voluntary HIV testing and counseling for nearly 700,000 clients.

Bush's “pro-family” agenda is clear in his approach to grant giving as well. The United States is expected to invest about $180 million in abstinence-only-until-marriage programs -- which don't discuss condoms or other forms of contraception -- through PEPFAR in 2005. What's more, the Bush administration appears to be encouraging evangelical groups with no Africa experience to seek grants. In a conference with applicants, Dr. Anne Peterson, an administrator at the U.S. Agency for International Development, said that a “new partners' fund” has been set aside “for groups who've not ever worked with the U.S. government.” According to a source close to the White House, this fund is intended to help American faith-based organizations seeking PEPFAR money. Bush has met with religious leaders at the White House about the HIV–prevention campaign in Africa, and Tobias was the keynote speaker at a conference in November on PEPFAR and faith-based initiatives. At an earlier, similar meeting of Christian groups, Senator Rick Santorum said in a speech, “I, again, want to call on you to take advantage of this funding opportunity.”

This emphasis on faith-based organizations has resulted in the exclusion of nonsectarian groups like the African Services Committee, which runs an HIV–testing center in Addis Ababa, Ethiopia, and sends outreach workers to urban outdoor markets. U.S. officials have praised the project, but when the committee tried to get U.S. financial help, the same officials were unresponsive. Kim Nichols, co-executive director of the African Services Committee, says, “[Faith-based organizations] seem to be getting all the attention.”

The final point of tension between the administration and international public-health agencies is generic AIDS drugs. For three years, AIDS doctors in India and Africa have prescribed a single pill that contains three generic versions of brand-name anti-retroviral drugs. This allows AIDS patients to take two pills a day instead of six. “We know that patient convenience is one of the key factors in HIV/AIDS management,” notes Dr. Jaideep Gogtay, chief medical adviser of the Indian company Cipla, one of two firms that produces these pills. (Cipla supplies the United States with a variety of generic drugs, but not anti-retrovirals, which are still under patent here.)

The generic, two-pill-a-day regime has proven to be as successful as brand-name drugs in clinical outcomes in current programs; the World Health Organization has sanctioned the drugs through a formal prequalification process; the Global Fund permits the purchase of World Health Organization–approved drugs; and they are licensed by the regulatory authorities of many countries in Africa that are already using them. They cost between $140 and $270 per patient per year, as compared with a discounted brand-name triple-combination course of treatment, which costs more than $500 per year, according to Doctors Without Borders.

But one of Tobias' first actions was to begin questioning the safety of the generic drugs. Then he made clear that PEPFAR funds could not be used to purchase them. “Maybe these drugs are safe and effective,” he told a group of African journalists. “Maybe they aren't. Nobody really knows.” PEPFAR grantees have thus been delayed in buying the generics. Faced with global outcry, including protest letters from African health ministers and bipartisan pressure from Congress, Tobias -- a former CEO of the drug company Eli Lilly -- announced in May that the Food and Drug Administration would institute an expedited drug-review process for the drugs in question. But it's still unclear how much time these reviews will take.

“If [the Bush administration] were operating in good faith, they would try to strengthen the [World Health Organization] process and engage in technical discussions with [the World Health Organization] on developing the combinations we so desperately need, like pediatric formulations,” says Rachel Cohen, U.S. director of Doctors Without Borders' Campaign for Essential Medicines. Instead, she says, they're seeking “to deny that these drugs meet international standards, because they don't want to set a precedent of using U.S. government money to finance medicines that are still on patent in the U.S.” In addition, the U.S. trade representative's office is negotiating trade deals with poor countries that would impede them from quickly dispensing generic AIDS drugs.

There's one other step bush could take if he was serious about fighting AIDS in Africa: Press for debt relief. Even Africa's creditors agree that debtor governments spend more money on hospitals and schools when offered debt cancellation: An International Monetary Fund fact sheet issued in April about 27 countries that have received partial debt relief reports that they “have increased markedly their expenditures on health, education and other social services.”

In the case of Iraq, Bush has dispatched former Secretary of State James Baker as a special envoy on debt, and Baker is negotiating with foreign governments to waive 90 percent of Iraq's debt. But Bush has not even implemented the provision in his own AIDS law that would provide partial debt relief to African nations.

And so the situation remains bleak for AIDS workers in Africa, where an estimated 25 million people -- out of a total of 38 million worldwide -- are infected with HIV. Dr. Peter Mugyenyi was prominently seated next to first lady Laura Bush at last year's State of the Union address to applaud the president's stunning $15 billion announcement. Mugyenyi is now using a PEPFAR grant to the Joint Clinical Research Center of Uganda to provide free treatment to HIV–positive AIDS orphans. “We are very happy that we have sufficient money to be able to treat all of these kids without having to choose among them,” says Mugyenyi.

But, as in the other PEPFAR countries, the vast majority of people in immediate need of AIDS drugs will go untreated. In Uganda, 150,000 to 200,000 people will not have access to the medicine they need, Mugyenyi says. “The expectation is very high that the drugs are coming,” he notes carefully, “and we are hopeful that we are not going to disappoint them when they eventually find out that the drugs are not enough to go around.”

Erika Casriel has reported on Bush-administration policies for Rolling Stone and Out.