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.
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.
Venter said the infusion of money from PEPFAR enabled two clinics he helps oversee to offer more drugs to more people by improving the training of nurses, providing medical tests and paying some staff salaries. One of the clinics, Venter said, used to add about 10 people a month to its roster of patients on antiretroviral drugs; now that number exceeds 150.
"That's happened with a lot of effort, and that's largely on account of the PEPFAR program," Venter said.
On prevention, the officials who implement PEPFAR have largely abandoned its most audacious and specific claims. Instead they tabulate how many people, for example, may have heard a radio show on AIDS, without attempting to estimate how many avoided contracting HIV as a result.
They do claim, however, to have helped prevent 157,000 cases of pediatric HIV by assisting programs that have provided antiretroviral drugs to pregnant women. Administration officials rarely mention, however, that they have resisted calls to provide women with contraceptives.
Studies have shown that family planning could avert far more infections than antiretroviral drugs because many women, especially those with HIV, want fewer children. Critics say the restriction, along with PEPFAR's emphasis on untested abstinence programs, exists mainly to win support from conservative congressional Republicans, undermining the full potential of a program that the White House bills as one of the biggest humanitarian ventures in history.
"The same money spent in more evidence-based ways would bring more health and happiness," said Malcolm Potts, former head of Family Health International, a research group that receives significant PEPFAR funding.
But PEPFAR officials have adapted. After initial reluctance, they have begun supporting efforts to offer circumcision services for men, which three major experiments in Africa have shown could slow infection rates by more than 60 percent.
The program has also branched out beyond AIDS, which in most African nations kills fewer people than does malaria, malnutrition or contaminated water. In Rwanda, the 3 percent HIV rate is far lower than in southern African nations. PEPFAR money increasingly is used to improve basic medical services.
Yet the past five years have also shown that the AIDS epidemic can be contained by forces other than U.S. money and political will. Africa's biggest declines in HIV rates during Bush's AIDS initiative have come in Zimbabwe, where economic collapse has coincided with fundamental social change, including a shift toward monogamy and away from more-costly multiple relationships, research there shows.
The changes have come as President Robert Mugabe's ruinous rule has driven away foreign funding. Each of its neighbors -- which all lag behind Zimbabwe in slowing HIV -- are PEPFAR focus countries. Zimbabwe is not.