Effort to fight AIDS lacks emphasis on stopping transmission

WASHINGTON --The multi-billion-dollar US effort to fight AIDS around the world has placed too little emphasis on stopping the transmission of the deadly virus and Congress has handcuffed it by imposing mandates of how the money should be spent, according to a two-year Institute of Medicine study released today.

A committee of independent health scholars, however, praised the President's Emergency Plan for AIDS Relief program and its ``heroic'' workers around the world for demonstrating that ``programs of quality can be implemented, even in resource-thin settings.''

The committee said the US program, now beginning its fourth year, must work on making sure its programs can be sustained over a long period, and that it needed to refocus on finding ways to stop HIV infections.

``It needs to transit from an emergency mode toward a sustained effort that allows countries to go on dealing with their epidemics,'' said Jaime Sepulveda, committee chairman and visiting professor at the University of California-San Francisco's global health sciences and school of nursing.

The AIDS pandemic has killed an estimated 25 million people in the quarter-century since the virus was first recognized among gay men in the United States. The epicenter of the disease is in sub-Saharan Africa, although it has spread to almost all parts of the world. Today, UNAIDS says that 39 million are currently living with the virus, including 4 million who contracted the disease last year alone.

When the Bush administration took office, US spending on HIV and AIDS was $840 million; for 2007, spending will be $4.5 billion, a five-fold increase in six years. By the end of 2008, according to US officials, the administration's program will have likely invested more than $18 billion in AIDS globally _ roughly $3 billion more than Bush's original request in his State of the Union address in 2003.

So far, US officials said the program has supported anti-retroviral treatment for more than 800,000 adults and children, helped give HIV testing and counselling for nearly 19 million, and helped provide services to prevent he tranmission of HIV from mother to child to more than 6 million women.

Those numbers show that the US effort has made a ``strong start,'' the committee said. But the new numbers of HIV infections globally show the US needs ``more prevention (programs), and ... better prevention,'' Sepulveda said in an interview.

The US AIDS effort, which is focused on 15 countries but also funds a total of 120 nations, allocated 19 percent of its budget to prevention last year. Of that money, Congress has mandated that one-third is spent on programs that support a message of abstinence before marriage and faithfulness to one partner. The panel said that requirement and others tied the hands of some countries.

Other requirements from Congress include that 55 percent of the overall spending goes to AIDS treatment; 15 percent to palliative or hospice care for patients; and 10 percent to assist orphans and vulnerable children.

The report said that US officials expressed their ``frustrations with these allocations and have illustrated how they thwart rational and strategic planning,'' according to the report. Such misgivings also were documented in an earlier report on the AIDS program written by the Government Accountability Office, the investigative arm of Congress.

But Ambassador Mark Dybul, coordinator of the US global AIDS office, said those requirements have helped scaling up programs that needed attention. ``At a certain point, we probably won't need directives, but we are not there yet,'' he said in an interview.

In particular, he praised both the requirements on spending for orphans and on teaching abstinence and fidelty messages. Dybul also said more than a dozen occasions in the last two years he has waived Congress' requirements because evidence showed in specific countries that money would be better spent in other programs.

Dybul also defended the program's overall spending priorities, saying that treatment programs needed a big infusion of money early in order to save lives. But he agreed with the committee's overall emphasis on prevention, saying ``it is the benchmark to which we will be measured.''

Paul Zeitz, executive director of the Global AIDS Alliance, a Washington-based advocacy group, said the abstinence-only spending requirement ``really created confusion on how to do effective prevention.'' He favored cutting the spending requirement and allowing countries to decide how to spend money on prevention.

But Shepherd Smith, president of the Institute for Youth Development, which runs several abstinence programs in Africa, said the report's conclusions on abstinence and fidelty spending ``make no sense.''

``I feel it is very short-sighted to discontinue a part of the prevention approach that has the most documented success,'' Smith said, citing studies that showed that faithfulness helped curb Uganda's AIDS epidemic in the 1990s. He also said studies have shown that when HIV prevalence decreases, the average age of ``sexual debut'' -- the first time a a person has sex -- increases.

The committee, which visited 13 of the 15 focus countries from October 2005 to February 2006, also recommended that the US government accept the World Health Organization's system of approving drugs; the US has set up a parallel system in which the US Food & Drug Administration examines all AIDS drugs.

And they pointed out that some countries receive a large amount of money per HIV patient and others receive relatively little.

In 2006, Guyana, with an estimated 12,000 people living with HIV or AIDS, was receiving roughly $1,800 per infected person; South Africa, in contrast, with 5.5 million people with HIV or AIDS, was receiving about $40 per person.

John Donnelly can be reached at donnelly@globe.com