How best to spend new AIDS money

To a continent ravaged by one of the worst plagues in history, President Bush's pledge of $15 billion to battle AIDS over the next five years was an unexpected balm.

Or as Mr. Bush himself put it, "a work of mercy."

Thirty million of the world's 42 million people diagnosed with HIV/AIDS live in Africa and a generation of children is growing up without their parents. In light of the enormity of the problem, how to use the money effectively is the challenge facing healthcare officials in the 12 African and two Caribbean nations targeted by the proposal.

"Fifteen billion might sound like a lot, but spread over the course of five years and across the continent, it's actually not much," says Najib Balala, Kenya's minister of social services. "It has to be channeled very wisely."

Bush's plan, which has been widely praised, adds $10 billion to the $5 billion he had already allocated for antiretroviral drugs for 2 million Africans, prevention and education programs, and care for children who have lost parents to the disease. In a departure from this administration's policies, the plan also includes money for generic drugs and condoms.

For many AIDS workers in Africa, access to more-affordable drugs is the No. 1 priority. The vast majority of those with HIV/AIDS here don't have access to the sort of advanced medication available in the West. And while the use of some drugs is increasing - such as those that fight HIV-related infections like tuberculosis and pneumonia, and those that prevent mother-to-child transmission - antiretroviral drugs that combat HIV directly are still scarce. (While antiretroviral drugs do not cure AIDS, they have been found to prolong life when taken consistently).

To increase African access to AIDS medication, activists have long advocated the sale of less-expensive generic drugs.

The US has been "an impediment to the fostering and distribution of generic drugs in Africa," says Bettina Schunter, Kenya director of the aid agency Doctors Without Borders (MSF). "The US typically wants to protect big businesses and patent rights.... But we believe in the cheapest drugs available."

Drug companies have opposed the sale of generic drugs. They say they violate companies' patents, and that generic companies are at an advantage because they don't incur the high costs of developing the drugs.

As recently as November, the Bush administration had argued against countries exporting generic drugs. But Anthony Fauci, a senior US government physician who helped formulate the Bush plan, now says that generic AIDS drugs manufactured by Cipla, an Indian company, will be among those recommended under the proposal.

Beyond the need for cheaper drugs, observers say that prevention and education programs, as well as incentives to retain health professionals in Africa, are terribly underfunded. In a letter to Bush last week calling for increased funding, the Boston-based group Physicians for Human Rights said that if prevention programs - including AIDS education in schools, counseling, and access to condoms - were amply expanded, the annual incidence of new HIV infections in adults could be reduced to 1.5 million within five years, from about 4 million now.

Dr. Fauci said that condom distribution would be part of the prevention component, in addition to the message of abstinence. Bush's Christian constituency has long opposed the promotion of condoms, saying they promote promiscuity.

According to the United Nations, Uganda is the only country in Africa to have subdued the pandemic. Uganda has mounted a significant prevention campaign, which includes increasing awareness and destigmatizing of the disease. The adult HIV-prevalence rate in the country continues to drop - from 8.3 percent at the end of 1999 to 5 percent at the end of 2001. Peter Mugyenyi, a Ugandan scientist at the forefront of the AIDS battle, was present at Bush's State of the Union address as the guest of First Lady Laura Bush.

The growing number of AIDS orphans in Africa is another area of concern. More than 11 million children have lost parents to the disease. Morris Ringani, who was diagnosed with AIDS, worries about his three children. "As someone who is already sick, I do not need the money very much," says Mr. Ringani, a Kenyan civil servant. "Maybe it could be channeled to an institutions that will take care of the orphans ... my children."

It is still unclear where exactly the money in Bush's proposal would go - whether to governments or nongovernmental organizations (NGOs).

Some is earmarked for the UN Global Fund. Bush proposed $1 billion over the next five years for the fund, which has been struggling financially.

The fund gives grants and works to build up countries' healthcare systems, increase prevention efforts, and expand access to drugs. Most observers say it is the strongest vehicle for carrying out large-scale treatment and prevention projects.

"As a mechanism, the fund is already in place," says Louise Robinson, the HIV/AIDS coordinator for the NGO Care International in Southern Africa. "So it should be used, instead of setting up more parallel structures."

The 12 African nations targeted by the Bush plan are Botswana, Ethiopia, Ivory Coast, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia, as well as Haiti and Guyana, two countries in the Caribbean hardest hit by HIV/AIDS. The plan still has to be approved by Congress and a fight could ensue over the condom-distribution issue.

By and large, observers have been pleasantly surprised by Bush's proposal. "This [initiative] is a signal that the US has decided to respond to the pandemic much more seriously than it has before," said Stephen Lewis, the UN's special envoy on HIV/AIDS in Africa, in a press release. "It is a signal that will alert the world to do the same," he said, voicing his hope that more developed nations will now donate to the global fund.

Experts estimate that rich nations need to spend at least $10 billion a year to fight HIV in the developing world, but spent only $2.8 billion last year.

"The whole purpose of the last year has been a drum roll of desperation to get money from Western donors," said Lewis. "This at least opens the door."

Ethiopia, a country with 3 million people infected with HIV/AIDS, has one of the fastest growing rates on the continent. According to the UN, the number of AIDS orphans in Ethiopia could rise 150 percent in the coming 10 years.

"It is very bad to lose your mother and father," says Hassana, a young girl propped up on some colorful pillows in a rickety bed in a health clinic in the Afar district. She laughs, and then coughs. "That's obvious," she says, "because it's lonely."

In the last stages of AIDS, Hassana spends her days looking out the broken window or talking, slowly, with Tsedala, a girl in the adjacent bed who has just given birth.

So where does Hassana think some of the money should go? "Maybe for my friend," she suggests. "And for her newborn. That they both should grow strong."

Material from the Associated Press was used in this report.