A day of failed promise

TODAY MARKS THE NEW MOON, the first window on an Advent calendar and the birthday of Woody Allen. More important, Dec. 1 is also World AIDS Day. Founded by the World Health Organization in 1988, World AIDS Day is meant to draw attention to the HIV/AIDS epidemic. It’s not a holiday -- and if it were, there would be precious little to celebrate. Nearly a quarter of a century since the first AIDS case was reported in 1981, the disease is spreading rapidly around the world, and the efforts to fight it have come up woefully short.

The head of the WHO’s HIV/AIDS program, Dr. Jim Yong Kim, took the unusual step of apologizing on Monday for failing to meet one of the organization’s key goals: putting 3 million people on antiretroviral drugs by the end of 2005. The “3 by 5” initiative has missed by at least 1 million people. New infections are coming at a near-record pace. “I think we have to just admit we’ve not done enough and we started way too late,” Kim said.

Yet the failure isn’t just the fault of the WHO; there is more than enough blame to go around. Donor nations -- even generous ones such as the United States -- can get better results by better coordinating their efforts and not being so insistent on direct aid. And recipient nations and groups need to be more candid and open about the disease and how to prevent it.

On paper, the United States is the leader in the global fight against AIDS. It spends far more on the disease than any other country, and the amount is increasing. This year it contributed $2.8 billion, and next year’s budget, if an upcoming bill is approved, includes that much plus $600 million. But what looks good on paper can sometimes be pretty ugly on the ground.

If the proposed $3.4 billion in U.S. spending for next year is approved, slightly more than half of the money -- $1.8 billion -- will go to the President’s Emergency Plan for AIDS Relief, widely known as PEPFAR. Another $550 million will go the Global Fund to Fight AIDS, Tuberculosis and Malaria, with the rest going to various bilateral programs and research.

PEPFAR does good work that has benefited millions. But the money comes with strings attached that have more to do with satisfying narrow political interests in the United States than with meeting the needs of people with AIDS abroad. For instance, PEPFAR requires recipients to adopt policies opposing sex work, hampering them from working effectively with a population that plays a key role in the spread of AIDS. Then there’s its approach to abstinence.

Programs promoting abstinence can be effective in stemming AIDS; the problem is, PEPFAR places far too high a priority on them. Of the money PEPFAR dedicates to preventing (as opposed to treating) the disease, 56% is spent on abstinence programs, while the amount dedicated to supplying condoms is decreasing, according to an analysis by the Maryland-based Center for Health and Gender Equity. The highest rates of new infection in sub-Saharan Africa are among young married women, who for the most part are faithful to their husbands; they need condoms for their husbands and for themselves, not lectures on abstinence.

President Bush should be commended for playing a leadership role on AIDS, pledging $15 billion over five years to fight it. But his fondness for bilateral initiatives such as PEPFAR, as opposed to multilateral ones such as the Global Fund, results in the United States being less effective than it could be. Other big donors such as Britain and Japan also like to create their own bilateral programs, but these initiatives suffer from similar drawbacks: They focus on their own priorities, not those of recipient countries, and they don’t coordinate with each other, leading to confusion and redundancy.

It’s unfair to blame only the donors for the failure to make major inroads against AIDS. A large share of the responsibility belongs to the governments of countries that are hard-hit by the epidemic. Many have failed to create national AIDS programs or plans to fight the disease, so there is no coordination for domestic and international groups.

In many Third World countries, there is a powerful stigma against AIDS patients. Combine this with discrimination against women, ignorance about the disease and its transmission, and the lack of even the roads needed to move patients from far-flung villages to treatment centers, and you have a recipe for a long-lasting epidemic. Leaders in these countries could help solve some of these problems by mounting information campaigns and using their own influence to counter the negative perceptions about people with AIDS. Too few are doing so.

It’s too late to meet the “3 by 5” goal. There are other big milestones on the horizon, notably a commitment by the Group of 8 industrialized nations to provide universal access around the world to AIDS treatment by 2010. That too will be a failed promise unless the G-8 nations decide to fully finance the struggling Global Fund and retool their own bilateral programs, and recipient nations get their own houses in order. The message of the next World AIDS Day needn’t be a story of failure, as it is today.