An elusive goal in AIDS battle

PRESIDENT George W. Bush surprised many AIDS advocates in 2003 when he announced a first-ever US-sponsored multi-billion-dollar emergency plan to combat HIV/AIDS in many of the hardest hit countries in sub-Saharan Africa and the Caribbean -- the President's Emergency Plan for AIDS Relief. Three years later, as the White House is planning the next phase of the program, it is clear that it has done significant good, especially in expanding access to lifesaving antiretroviral medicines. The US program is now providing urgently needed treatment and keeping families together for approximately 800,000 people.

The program set out its own important goals, including ensuring access to AIDS treatment for 2 million people by 2008. But, earlier this year, a new goal was set at a June session of the UN General Assembly, attended by first lady Laura Bush. With the support of the United States, the global community has adopted the much broader target of universal access to prevention, treatment, care, and support by 2010. This is a promise made to some of the most vulnerable and suffering people on the globe, and it is one that should be taken with the utmost seriousness.

Unfortunately, the latest reports show we are not on track to reach this level of access. According to the UN report released last week, only about one in five people have access to prevention services and commodities, and access to treatment for those who need it is still at low levels (23 percent in Africa and only 16 percent in Asia). The global HIV epidemic continues to spread, with over 4 million new infections this year and 3 million deaths, mostly in sub-Saharan Africa, and significantly increased infections in Eastern Europe, Southeast Asia, and China.

The United States, while declaring AIDS a global emergency, still has no real strategy for how the world will reach this target, and its efforts, especially in the area of prevention, have mired the global effort in polarization and confusion. The newly elected Democratic Congress will undoubtedly use its new authority to investigate some of the obvious flaws in the US approach. However, the president and Congress need to work together to end ideological approaches to AIDS and leverage better and faster action by the global community.

This is a moment when the president should consider his legacy on AIDS. He should again surprise friends and foes alike by defining a bold new vision that helps put the world on course to reach the universal access goal. Some basic changes to the US approach would help put us on this path and garner broad support among AIDS advocates:

Today 85 percent of all US spending on global AIDS supports unilateral action, often sidelining effective multilateral programs and imposing US-defined programs on affected countries. Instead, the president should invigorate key multilateral partners, such as the World Health Organization and UNICEF, which have been weakened by years of neglect. In particular, the president should end his now yearly ritual of proposing a massive cut in the US contribution to the Global Fund to Fight AIDS, TB, and Malaria. The Global Fund can do much to alleviate the critical shortage of health care workers, which has proved a major obstacle to progress, but only with full US backing.

Violence against women and girls is a key driver of infection in many countries, and it can make it difficult or even impossible for them to seek HIV testing and treatment. There is now clear evidence that successful programs exist that can begin changing norms of male behavior, yet these programs remain scattered and small-scale. The president should consolidate and expand anti violence efforts as part of the US AIDS response. He should also put back on track his Women's Justice and Empowerment Initiative, a program that was supposed to help African countries better protect women and enforce laws against violence but which has been stalled in bureaucratic inertia.

Girls and women who have a basic education are much less likely to become infected with HIV. In Zambia, for instance, infection rates declined by half for educated women but remained the same for uneducated women, yet in most of Africa school fees block access for the poor. Bush should immediately announce a new initiative to ensure universal access to education, starting with the US AIDS program's 15 focus countries. At the same time, to address violence in the schools, he should speed up and expand the scope of the Safe Schools Program, in which the United States is supporting training for teachers and other personnel in how to protect girls from violence.

Tragically, the crisis of orphaned children remains the most orphaned element of the global AIDS response. The UN estimates that there will be 20 million children orphaned and made vulnerable by HIV/AIDS by 2010, and only 3 to 5 percent of these children receive any care and support. Bush should mobilize all sectors of society, including the business and religious leaders, to mount a fully funded, community-driven effort to ensure that these children get the care they need.

Finally -- and this may have to be done by Congress over the president's objection -- the United States should come up with a more flexible approach to HIV prevention. The United States should also abandon its unfounded objection to needle exchange programs for injecting drug users, since these programs are essential in places where AIDS is exploding, particularly in Asia and Eastern Europe.

In addition, the requirement that one-third of funding for sexual prevention programs be reserved for abstinence and fidelity programs, originally imposed by Congress, has proven unworkable and even fostered a stigmatization of condom use in some countries, such as Uganda. Instead, the United States should formulate a policy that is based on a comprehensive and realistic approach, which provides condom access and instruction for everyone at risk, including teenagers, while also urging people to stick to one concurrent sexual partner.

The commitment to ensure universal access to AIDS services made by the United States and rest of the global community at the UN earlier this year is a solemn promises, and we need the United States to redesign its AIDS program with this goal in mind. As the president looks to his legacy on AIDS, he should open the doors, consult widely, and then work with the Democratic Congress to take the global AIDS response into its next phase, to make this commitment a reality.

Paul S. Zeitz is executive director of the Global AIDS Alliance.