Internal criticism voiced on US plan for AIDS relief

DURBAN, South Africa -- The US campaign against AIDS receives praise in many quarters, especially in Africa, the epicenter of the pandemic. But during a five-day conference last week on the President's Emergency Plan for AIDS Relief, it took some unusual criticism -- from the people running the programs.

In two sessions featuring US ambassadors called ``Good Ideas That Worked and Good Ideas That Didn't ," one ambassador said the program needed to pay more attention to preventing infections among men who have sex with men.

Another reported on a worrying unintended consequence of AIDS treatment for HIV-positive women.

And a third ambassador, June Carter Perry in Lesotho, said her staff learned their expectations were too high for local groups: After receiving 118 applications for a contract bid, they spent hours sifting through the piles only to find just one group it could hire.

Dr. Mark Dybul , acting US program coordinator, said one reason for the gathering of more than 1,000 US officials and AIDS specialists involved in the US anti-AIDS campaign was to hear such criticism and correct the problems.

``If we don't face challenges square-on, we're never going to get to national coverage" against AIDS, he said in an interview. ``If you can't improve on what you've done, you can't save as many lives."

The US AIDS program, just three years old, has paid for or supported antiretroviral treatment for 560,000 people, HIV testing and counseling to 13.6 million, prevention of mother-to-child HIV treatment for 4 million women, and care to 3 million orphans and people living with HIV and AIDS. US-supported treatment programs in several countries are considered by many specialists to be among the best in the developing world.

Dybul told the assembled US officials that their accomplishments were ``breathtaking," and noted that other US overseas funding initiatives, such as one battling malaria, are being modeled on the AIDS program approach.

Two signature aspects of the AIDS program are its results-driven strategy and creating teams of people with widely different areas of expertise from several agencies -- a form of collaboration rarely done before in US aid work.

But the AIDS program still has huge challenges, as outlined in some of the presentations last week.

In Ghana, which has a national HIV prevalence rate of 2.7 percent, US Ambassador Pamela Bridgewater said men having sex with men was a large factor in the virus's spread, but almost no groups were addressing the problem.

``Many of these men are married and could be a bridge to spreading HIV to the general population," she said.

Bridgewater said these men ``are stigmatized even by health workers." The embassy recently started a program that brought in gay and bisexual men to sensitize health workers about their needs, which she said appears to be working: Ghana health workers referred 250 men for various services in the last month, compared with 50 four months ago.

In Uganda, US Ambassador Steven Browning said family planning programs for HIV-positive women do not yet appear to be cutting back on fertility rates. Women in Uganda bear an average of almost seven babies each, one of the highest fertility rates in the world.

One of the benefits in taking antiretroviral drugs is that the risk of transmitting HIV during sex in many cases is dramatically lowered. But another consequence of taking the drugs is that women become fertile again -- to the surprise of the women themselves, most of whom had stopped menstruating.

A study in Uganda found that 90 percent of the HIV-positive women who became pregnant did not want to have the child. Browning said the US program now must develop better communication strategies to encourage use of contraception to prevent unwanted pregnancies.

Other issues included frosty relations between the South African Health Ministry and the US Embassy in Pretoria, which were said by US and South African officials to be slightly improving in recent weeks; the Nigerian government's troubles with a Global Fund to Fight AIDS, Tuberculosis, and Malaria grant that recently resulted in the Fund withdrawing $81 million; and an outbreak of diarrhea in Botswana that killed about 200 infants several months ago in part, officials believe, because HIV-positive mothers were counseled not to breast-feed . Mothers run a risk of passing HIV to their children through breast-feeding, but feeding powdered milk formula poses another risk because it does not contain the protective antibodies found in breast milk.

Among the programs touted by ambassadors were the rapid expansion of treatment programs in the Ivory Coast, from 2,000 people in 2004 to 20,000 today, in spite of conflict or widespread insecurity in several regions; the almost-routine HIV testing of tuberculosis patients in Rwanda; a sophisticated drug distribution system in Kenya that can supply medicines countrywide within three to five days of an order; and building up local nongovernmental organizations in Cambodia to improve chances of making the programs sustainable in the future.

``It's great to hear good ideas that work, but sometimes what appears to be the greatest idea since sliced bread on the ground turns out not to be so great," said William R. Steiger , the US Health and Human Services' special assistant to the secretary for international affairs. ``I found those reports to be quite refreshing."

John Donnelly can be reached at donnelly@globe.com