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African AIDS Crisis Outlives $15 Billion Bush Initiative

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By Craig Timberg
Washington Post Foreign Service
Wednesday, February 20, 2008

JOHANNESBURG, Feb. 19 -- Five years after President Bush vowed to "turn the tide against AIDS" in Africa, he is traveling across a continent where the government's $15 billion investment has extended the lives of hundreds of thousands of people and eased the sense of certain doom once experienced by millions of others.

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But in the worst-hit areas, clustered mainly on Africa's southern tip, the tide has decidedly not turned. The epidemic continues to spread at a torrid pace that shows little sign of easing, with people contracting HIV much faster than sick ones can be put on crucial antiretroviral drugs, research shows.

Bush's initiative, the President's Emergency Program for AIDS Relief, or PEPFAR, has not found a way to prevent a significant number of the estimated 1.7 million new cases of HIV each year in Africa. Nearly half of today's 15-year-olds in South Africa, one of the biggest beneficiaries of the program, will contract the virus in their lifetimes at current infection rates, estimates show.

"They've turned the treatment tide in a fundamental way," said Francois Venter, president of the Southern African HIV Clinicians Society, who works on several programs that receive PEPFAR funding, referring to administration officials. "In terms of prevention, they haven't. . . . It's quite clear that [South Africa's] prevention programs have failed completely."

In southern Africa's increasingly plentiful and well-funded AIDS clinics, patients appear healthy as they get checkups and pick up monthly supplies of antiretroviral drugs. But prevention messages, inside the clinics and beyond, continue to stress condoms, HIV testing and abstinence -- none of which have demonstrated major impacts in slowing the AIDS epidemic in Africa.

Interventions that research shows can slow the epidemic, such as circumcising men, encouraging monogamy and making contraception widely available to infected women, have gained relatively little attention. And new technologies, such as vaccines and vaginal microbicides, have continued to disappoint in research trials despite massive investments.

Bush announced PEPFAR in his 2003 State of the Union address, promising to prevent 7 million new infections while treating at least 2 million people with antiretroviral drugs. "I ask the Congress to commit $15 billion over the next five years, including nearly $10 billion in new money, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean. This nation can lead the world in sparing innocent people from a plague of nature," Bush said.

The money is heavily weighted toward 15 "focus countries," 12 of which are in Africa. As the initial investment nears its end, Bush has called for renewing the program at double the original amount over the next five years. The two leading Democratic candidates are urging even more.

PEPFAR has won over some skeptics, including Paul Farmer, a founder of Partners in Health, a Boston nonprofit that provides medical services in Africa and elsewhere.

"As someone who has been highly critical of this administration's foreign policies, PEPFAR and other investments in health have outstripped that of all other administrations," said Farmer, who works extensively in Rwanda, where Bush was Tuesday.

It also has impressed Eric Goemaere, the top official in South Africa for Doctors Without Borders, which initially criticized Bush for resisting the use of generic drugs and failing to integrate its AIDS effort with national health programs. "Five years down the line, they have been much more promising than many other funders," Goemaere said.

Bush's treatment goal appears on track. The White House says that PEPFAR is supporting the treatment of 1.3 million Africans, though in some cases that support is indirect, such as formulating policies or improving management systems for national health programs that would have been treating their citizens anyway. Also, research suggests that 40 percent of Africans who start on antiretroviral drugs cannot be accounted for two years later because they stopped taking the medicine, transferred to another program or died.


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