Progress Varies On Global AIDS Plan

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Controversial Strategy Credited For Improvement

February 13, 2006

In its first two years, the Bush administration's global AIDS plan has spent $5.2 billion to help prevent 47,100 infections in infants, bring drug therapy to 471,000 ill people and care for more than 1.2 million children orphaned by the disease.

Those were among the highlights of a data-heavy report submitted to Congress last week describing early results of the $15 billion five-year project, formally known as the President's Emergency Plan for AIDS Relief (PEPFAR).

The vast majority of the money is being spent in 12 African nations and in Guyana, Haiti and Vietnam, although the program is paying for AIDS work in more than 100 other countries, including Russia and India.

Of the $294 million spent on prevention last year, $76 million, or 26 percent, went toward efforts to encourage sexual abstinence or faithfulness to a single partner. About $66 million was spent on the provision of condoms and prevention messages emphasizing their use.

This "ABC" strategy -- abstinence, be faithful, condoms -- is the program's most controversial aspect. Mark Dybul, a physician who is the program's deputy director, defended it in a State Department news conference.

"There are only three countries with generalized epidemics in Africa that have seen a decrease in [HIV] prevalence. In all three cases, the reason was exactly the same -- A, B and C," he said.

A study published in the journal Science about two weeks ago found that change in sexual behavior accompanied the recent drop in prevalence of HIV infection in Zimbabwe -- and probably helped cause it.

Twelve communities were surveyed in the late 1990s and again three years later. Over that interval, HIV prevalence declined from 23 percent to 21 percent. The steepest declines were in men ages 17 to 29, falling from 11 percent to 8 percent; and in women 15 to 24, it was halved, from 16 percent to 8 percent.

The fraction of older teenage boys who were sexually active declined from 45 percent to 27 percent. Among slightly younger girls, the fraction who were no longer virgins fell from 21 percent to 9 percent. Each sex also reported fewer partners than people the same age who were surveyed three years earlier.

Condom use with recent casual partners remained 42 percent for men in both surveys, but for women it rose from 26 percent to 37 percent.

AIDS-related services funded by the program are being provided through about 14,900 clinics, laboratories, hospitals and counseling sites. About 536,000 people have been trained in such services as prevention counseling for school children and pregnant women, testing blood used for transfusions, and medical care of patients on anti-retroviral drugs, according to the report.

The program's approach "is to empower every nation to take ownership of its own fight against HIV/AIDS," Secretary of State Condoleezza Rice told reporters at a news briefing. She called PEPFAR a key example of "transformational diplomacy in action."

The program provides money to foreign governments, charities, nongovernmental organizations and several U.S. universities running AIDS programs overseas. About 82 percent of the services it finances are provided by local organizations; about 20 percent are government agencies and 20 percent are local and U.S. faith-based groups.

The plan seeks to bring anti-retroviral drugs to 2 million people in the 15 countries by the end of its fifth year. There are 401,000 on treatment now and 70,000 more in other countries receiving grants.

Countries vary greatly in progress toward their goals. In Uganda, 67,500 people are receiving AIDS drugs through PEPFAR-funded programs -- more than the target of 60,000. In Ethiopia, however, 16,200 people are on treatment with U.S. government support -- less than one-tenth of the target. Vietnam is only 3 percent of the way to its target.

Also in the program's first two years, about 250,000 pregnant women with the AIDS virus received anti-retroviral drugs during labor to keep from infecting their babies. Many programs are now targeting those women for long-term treatment.

Some groups criticized aspects of the program.

Jodi Jacobson, director of the Center for Health and Gender Equity, in Takoma Park, said many prevention programs target condom education only to high-risk groups such as commercial sex workers and truck drivers.

"The problem is that the highest rates of new infection in many of these societies is among married women," she said. The husbands of these women often have multiple partners. "What you need to do is provide all people with the complete range of tools and information that they need to make choices that fit their own personal circumstances."

Jacobson also said that some of the U.S. program's faith-based "partners" have little or no experience in health education or care.

"If you are facing a public health crisis, you hire professionals with a proven track record. You don't hire organizations with an ideological agenda," Jacobson said.
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