Bush proposes near tripling of U.S. commitment on global HIV epidemic.

In what is widely seen as a groundbreaking advance, President Bush proposed additional U.S. funding of almost $10,000,000,000 over the next five years for fighting the global HIV epidemic. The president made this unexpectedly major announcement in the State of the Union speech on January 29, 2003. If appropriated by Congress, the money would bring the total spending over five years to about to about $15,000,000,000. The measure will have strong bipartisan support, but passage is not assured.

The proposed U.S. initiative is for 14 countries, 12 of them in Africa, that together have about half of the HIV-infected people in the world. Over five years, it aims to prevent 7,000,000 new HIV infections (60% of the number projected for those countries), treat 2,000,000 people with HIV, and care for 10,000,000 HIV-infected individuals and AIDS orphans. (The countries are Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia; for initial ideas on how the program may work within these countries, see the January 29, "Fact Sheet; the President's Emergency Plan for AIDS Relief" at http://www.whitehouse.gov/news/releases/2003/01/20030129-1.html -- check later information if available). The program will start in fiscal year 2004 (the U.S. government fiscal year 2004 begins October 1, 2003), with funding expected to begin slowly and ramp up in later years. This proposal is not finished, and much is being worked out now in discussi ons among the White House, Congress, and global AIDS and health organizations.

The announcement came as a surprise even to members of Congress, and European and other governments -- apparently because President Bush and his administration were weighing many factors and were not sure what HIV program (if any) would be announced until shortly before the speech. It was known that administration officials and AIDS experts had been working quietly for months to develop an initiative to address the global epidemic. We have heard that President Bush was given several proposals, and chose one (the one, incidentally, with the largest total funding). This plan includes a comprehensive prevention program (including abstinence and condoms), and an equal emphasis on prevention and treatment, including antiretrovirals.

This high-profile announcement is already changing the tone of the discussion, with talk in Washington shifting from whether there should be a larger U.S. program to how to make it work. A key issue is getting European and other donor nations to also increase their commitment to fighting an epidemic that could kill a third of the entire population of many countries, and is spreading rapidly today in huge populations in Asia and Eastern Europe.

Some Widespread Criticisms

While the announcement was universally welcomed and the plan is considered credible, there have also been some widespread concerns:

* Even if Congress acts favorably, this plan will not formally start until October, and then will build slowly as the U.S. negotiates and develops new management and oversight structures in the 14 countries instead of using what is already available. Meanwhile, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, started by United Nations Secretary-General Kofi Annan (and now to be headed by U.S. Secretary of Health and Human Services Tommy Thompson), is running today and has excellent proposals ready to go, delayed only by lack of money. But the president's initiative de-emphasizes the Global Fund, and we have heard that administration officials are lobbying Congress not to provide more money. Either they want to see a track record first, with statistical proof of results like number of infections prevented, or they want to control the geopolitical impact of the funding. In either case the result is more delay. Yet in an epidemic, the best time to act is now.

Activists have, however, noted one advantage of the president's initiative over the Global Fund. The new U.S. program is likely to provide antiretroviral treatment to more people than the Global Fund, which developed earlier when treatment was more controversial. Today it is more widely recognized that treatment must be included to make prevention work, since otherwise people have no incentive to come forward for testing, or to help organize prevention and care programs in their communities.

* Health and development experts are concerned that the president's proposal is heavily weighted toward bilateral agreements between the U.S. and each of the 14 countries, instead of multilateral institutions like the Global Fund. Multilateral approaches can better leverage contributions from other donor countries, and coordinate the worldwide fight. Separate donor programs could increase bureaucracy (including multiple application and reporting requirements for the recipient countries) and reduce effectiveness.

Instead of using the Global Fund or other international agencies, the president's initiative calls for oversight by a Special Coordinator for International HIV/AIDS Assistance, to be confirmed by the Senate with a rank of ambassador, and report directly to the Secretary of State. It includes some support for the Global Fund, but only about ten percent of the total. Development experts hope that this small support for multilateral programs can be increased.

* The president's initiative proposed $10,000,000,000 in new money and $5,000,000,000 being spent already, both over five years. Where will the billion dollars a year in "old" money come from? "Mr. Bush in his State of the Union speech proposed new spending to fight AIDS and HIV in Africa and the Caribbean. But his budget for 2004 would reduce by about the same amount the funding that aides had said would be sought for a separate development-aid initiative for poor nations," ("Budget for Hard Times Offers New Plans but Many Cutbacks, by John D. McKinnon and Greg Hitt, The Wall Street Journal, February 4.)

The president's budget request, released February 3, includes major cuts in child health and survival programs, which include routine vaccination, according to the Boston Globe ("U.S. Seeks Cuts in Health Programs Abroad," by John Donnelly, Feb. 5). "The bottom line is with 10.5 million children dying around the world each year from easily preventable causes -- things that could be stopped at very low costs -- this is an area where the world community has really dropped the ball over the last decade. When you recognize that you have dropped the ball, you don't drop it even further." (Nils Daulaire, Global Health Council, quoted in the Boston Globe, February 5.)

Civil society and the public will have to watch these and other issues closely. Certainly funding for AIDS must not come at the cost of programs like child survival.

Community Support Needed

The president's proposal will need public support to make sure that it is implemented and works as well as possible:

* Congress must decide whether or not to spend the money. Members of Congress must hear from their constituents back home that they care about the global epidemic. AIDS and health organizations have generally been effective in working with experts and the media, educating the public on the seriousness of the epidemic and building consensus that this country must help in the solution. They can and must do better in giving non-experts practical ways to express their values and concerns -- to their political representatives, in their social circles, and otherwise. (See "Building Grassroots Support for AIDS" in this issue.)

* How can people get involved in helping? So far, much of the non-government work in pushing government to make sure that President Bush would have well-developed options if he decided to have an AIDS initiative was done by the Advocacy Network for Africa (ADNA), a group of 231 member organizations (as of January 19, 2003; the list is at http://www.africaaction.org/adna/adnalist.htm). Readers can look over this list to find organizations they might like to work with, and see if there is a program where they could help.

Also important is that evangelical Christians are becoming more interested in AIDS in Africa, especially in the last year, and more inclined to see the epidemic there as a health problem instead of a moral one (see "Unlikely Allies Influenced Bush to Shift Course on AIDS Relief," by Mike Allen and Paul Blustein, Washington Post, Jan. 30). It is likely this change is happening now because conservative Christianity is spreading rapidly in Africa, and religious organizations see their members die -- often for reasons beyond their control, as when a faithful wife is infected by her husband. Also, in February 2002, arch-conservative Senator Jesse Helms told conservative Christians that "I have been too lax too long in doing something really significant about AIDS," and was going to keep AIDS in Africa on his agenda for his remaining months in office. This new involvement of evangelical Christians may have been key to a national consensus that made the Bush proposal possible.

Comment: Is the Cup Half Full or Half Empty?

After the State of the Union speech, most AIDS experts and activists saw the president's initiative as a major breakthrough. Two weeks later they still see it that way, although concerns like those above are widely stated. We see this proposal as a big step forward, but one that needs public involvement to help make it work.

One of the problems facing national leaders who want to work on AIDS is their fear that they will be attacked no matter what they do. This fear is realistic, because in fact most governments and their leaders around the world have done appallingly badly on AIDS. But if this is going to change, we must have workable paths forward.

For these reasons we have chosen to emphasize the positive--without denying that, as with any major new proposal, problems exist and changes will be needed as the work goes forward.