"After I've taken the pills, my appetite becomes bigger, and I don't have the food," Moleko said, hoisting her niece's baby on her back in a colorful blanket. It is the way women in the mountains of Lesotho carry their children and stay warm.
After a recent trip to the clinic, Moleko walked home from the bus stop through steep, rugged pastures. In parts of Lesotho and Rwanda, patients must walk for as long as nine hours to reach the nearest clinics. Sometimes, Moleko said, she barely makes it. Many don't make it at all.
On most days Moleko's family eats only pappa, cornmeal mush. When possible, she adds a few wild greens from the rocky soil. Pellagra, a nutritional disease that can lead to dementia and death, is common here.
The Global Fund has used Gates Foundation money and other support to finance AIDS treatment for 1.1 million people and TB treatment for 2.8 million, mostly in sub-Saharan Africa.
"The clinics," Moleko said, "don't have what we need: food."
Eyes brimming with tears of frustration, Majubilee Mathibeli, the nurse at Queen II hospital who gives Moleko her pills, said four out of five of her patients ate fewer than three meals a day.
"Most of them," she said, "are dying of hunger."
In recent interviews in Lesotho and Rwanda, many patients described hunger so brutal that nausea prevented them from keeping their anti-AIDS pills down.
Mathibeli is grateful to the Global Fund for its AIDS grants but said the fund was out of touch. "They have their computers in nice offices and are comfortable," she said, nervous about speaking bluntly. But "they are not coming down to our level. We've got to tell the truth so something will be done."
The Global Fund provides food for AIDS patients and their families, but only for a few months. When the food runs out, the hunger returns.
At that point, said Epiphanie Nizane, a lay counselor in Rwinkwavu, a village in eastern Rwanda, many women with AIDS turn to prostitution.
"The Haitians have a saying: Giving a patient medicine without food is like washing your hands and drying them in the dirt," said Dr. Jennifer Furin, the Lesotho director for Partners in Health, a Boston-based NGO. "You're consigning that person to death because they are poor."
Partners in Health gives 10 months' worth of food to AIDS patients, their families and others who need it. The practice has put the group at odds with government officials who fear an endless cycle of dependence.
The imbalance between needs and Global Fund priorities is even more pronounced in Rwanda, where the AIDS problem is far less severe than in Lesotho or Botswana.
In Rwanda, only about 3% of adults are infected. But Dr. Innocent Nyaruhirira, minister of state for HIV/AIDS, said more than 50% of Rwanda's health budget, mostly from the Global Fund and other international sources, was designated for AIDS.
From 2000 to 2005, Rwanda's health budget increased dramatically due to foreign donations -- and deaths from AIDS and AIDS-linked TB dropped.
But despite the aid and strong national leadership, measures of health most dependent on the strength of the nation's overall system of clinics, hospitals and clinicians showed less encouraging results.
TB overall, and TB deaths among patients without HIV, rose dramatically. Child mortality -- mostly from diarrhea, sepsis and other killers rather than from AIDS, stalled at about one death in every five or six live births. Maternal mortality fell slightly, but remained at one of the highest rates in the world.