US AIDS fight should refocus on prevention, study suggests

WASHINGTON -- The multibillion-dollar US effort to fight AIDS around the world has placed too little emphasis on stopping the transmission of the deadly virus and has been hampered by funding restrictions imposed by Congress, according to a two-year Institute of Medicine study released yesterday .

A committee of independent health scholars, however, praised the president's Emergency Plan for AIDS Relief 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 in its fourth year, must work on making sure its programs can be sustained over a long period. It also needs to refocus on stopping 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 Sepúlveda, committee chairman and visiting professor at the University of California at San Francisco.

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 39 million people 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 , more than a five-fold increase in six years. By the end of 2008, according to US officials, the administration's program probably will have invested more than $18 billion on fighting AIDS globally -- roughly $3 billion more than Bush's original request in his State of the Union address in 2003.

US officials said the program has supported antiretroviral treatment for more than 800,000 adults and children; given HIV testing and counsel ing to nearly 19 million; and provided services to more than 6 million women to prevent the transmission of HIV from mother to child.

Those numbers show that the United States has made a "strong start," the committee said. But the new numbers of HIV infections globally show the United States needs more prevention programs, Sepúlveda said in an interview.

Harvard University runs major US AIDS programs in Nigeria, Tanzania, and Botswana.

The US AIDS effort, which is focused on 15 countries but serves 120, allocated 19 percent of its budget to prevention last year. But Congress has mandated that one-third be spent on programs that support a message of abstinence before marriage and faithfulness to one partner -- a requirement the panel said hampered prevention efforts in some countries.

Congress also requires that 55 percent of the overall spending go to AIDS treatment; 15 percent to palliative or hospice care ; and 10 percent to assist orphans and other vulnerable children.

The report said 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 R. Dybul , coordinator of the US global AIDS office, said those requirements have helped build up programs. "At a certain point, we probably won't need directives, but we are not there yet," he said.

In particular, he praised both the requirements on spending for orphans and on teaching abstinence and fidelity. Dybul said he has waived Congress's requirements more than a dozen times in the past two years because it was clear that the money would be better spent in other programs in certain countries.

Dybul also defended the program's overall spending priorities, saying treatment programs needed a large 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 said he favors eliminating the 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 fidelity 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.

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 United States has set up a parallel system in which the US Food and 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, received roughly $1,800 per infected person, while South Africa, with 5.5 million people with HIV or AIDS, received about $40 per person.

John Donnelly can be reached at donnelly@globe.com.