Bush's AIDS Program Draws Mixed Reviews

Jon is a staff writer for Science.

A detailed, independent evaluation of President Bush's program to combat AIDS worldwide gives the effort high marks for its aggressive attempts to battle the epidemic in poor countries. But the report, released today, also criticizes the initiative for allowing politics to dictate how the aid is dispensed.

Bush first announced his President's Emergency Plan for AIDS Relief (PEPFAR) in 2003. The 5-year, $15 billion initiative seeks to limit HIV infection around the world and ensure the best care for those who have developed AIDS.

In many respects, the plan has been a success, says the report, authored by a committee of the Institute of Medicine (IOM). For example, the program helped provide anti-HIV drugs to more than 800,000 infected people. It has also funded efforts to prevent transmission from infected mothers to their babies, training for healthcare workers, and community education. "PEPFAR has made a promising start," says committee chair Jaime Sepulveda, a visiting professor in the global health program at the University of California, San Francisco.

But there have been problems with how PEPFAR has been implemented, Sepulveda says. When the U.S. Congress authorized PEPFAR, it made several controversial stipulations about how the money could be spent, including detailing the percentage of funding that should go to abstinence-only education, limiting who can receive condoms, and banning support for needle-exchange programs. The IOM report recommends that Congress remove these stipulations, stating that "rigid budgetary allocations" have "limited PEPFAR's ability to tailor its activities in each country to the local epidemic." Sepulveda, for example, noted that Vietnam--one of 15 "focus countries" that PEPFAR funds the most heavily--has an epidemic driven primarily by injecting drug use, which might benefit from needle-exchange efforts.

The committee also recommended that PEPFAR "should work to support" a World Health Organization (WHO) program that tests and "pre-qualifies" low-cost anti-HIV drugs. PEPFAR has angered countries by requiring that they only use drugs approved by the U.S. Food and Drug Administration, which the report noted cost up to three times as much as generic drugs WHO has prequalified.

U.S. Ambassador Mark Dybul, who oversees PEPFAR, welcomes the report. He says the recommendations regarding the budgetary allocations start "an important conversation to have," but insisted that PEPFAR does tailor programs for each country. He also took exception to the idea that FDA-approved drugs are more expensive. That issue, he said, has "evaporated" because FDA now has approved 41 generic versions of anti-HIV drugs. He said there's also a misunderstanding about limits on condom promotion and abstinence-only programs, which largely are limited to 10- to 14-year-olds.

Chris Beyrer, an epidemiologist at Johns Hopkins University in Baltimore, Maryland, who works in many developing countries and has been critical of PEPFAR in the past, also welcomes the report. "This is an opportunity to really get things right with this program and particularly fix what hasn't been working," he says.

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