AIDS Funding Binds Longevity of Millions to U.S.

He also worries that with such lopsided and personal relationships between countries, providing life-sustaining care may become a "strategic resource that will be used, or will be an implicit bargaining chip, in negotiations." He added that "sovereign countries are likely to feel quite vulnerable if they perceive that the lives of a substantial number of their citizens are dependent on the continued largess of a donor."

Over's solution is to spend much more AIDS assistance on prevention efforts, and to channel money for treatment through international organizations to spread future obligations among as many donors as possible.

Others, including PEPFAR's director, do not see such problems.

"The notion that this is going to have a harmful effect on our relationship with other countries in the long term is exactly the opposite not only of what I believe but of what is being shown," said Mark R. Dybul, a physician and AIDS researcher who also holds the rank of ambassador at the State Department, which administers PEPFAR.

Dybul said the program is sowing goodwill at the same time it is stabilizing AIDS-ravaged countries in a way that will ultimately serve American interests. The fact that AIDS is a disease requiring lifelong treatment may even have an unexpected benefit, he says. The AIDS treatment programs are forcing permanent improvements in medical care -- with spillover benefits for the whole population.

"We are building systems and capacity for country ownership in ways that has never happened before," Dybul said. "That's real development."

What is certain is that the AIDS-treatment lifeline between rich and poor countries is growing rapidly. About 3 million people in low- and middle-income countries are now on the drugs. Five years ago, the number was 250,000.

As of the end of March, Bush's program was directly underwriting the care of 1,383,300 AIDS patients. Most were in 15 "target" countries: Haiti and Guyana in the Americas, Vietnam in Asia, and 12 in sub-Saharan Africa. The care of another 344,700 people is supported indirectly by money going to improve laboratories, information systems, logistics and other improvements of health-care delivery.

The other big funder is the Global Fund to Fight AIDS, Tuberculosis and Malaria, an independent organization in Geneva that gets money from rich countries, foundations and individuals, and awards it to approved programs in low-income ones. As of last December, the fund was underwriting treatment of 1.4 million AIDS patients, more than twice as many as the year before.

The expanded U.S. program aims to have 3 million people on antiretroviral AIDS treatment by 2015. Both the U.N. General Assembly and the Group of Eight industrialized countries are on record as supporting "universal access" to AIDS treatment, defined as providing treatment to 80 percent of those who need it. That would mean 18.6 million people on daily AIDS drugs by 2015, according to an estimate by UNAIDS.

The cost is huge, even considering the recent steep decline in the price of AIDS drugs. By 2015, the price tag for "universal access" to AIDS treatment would be $19 billion a year.

When the full package of prevention services, aid to orphans, and "health systems building" is added in, the global bill for AIDS services in the developing world will be $50 billion a year. Two-thirds of that money will have to come from rich countries. This compares with $110 billion spent last year for all foreign aid by all countries of the world, of which about $10 billion went for AIDS.