With the political landscape in the United States set to change after next year?s election in the country, AIDS activists are hoping too for sweeping changes to America?s AIDS plan, known as PEPFAR. Introduced by President George W. Bush in late 2003, the Emergency Plan for AIDS Relief has saved the lives of many HIV-positive people, especially by providing them with essential medicines. But AIDS activists say PEPFAR?s emphasis on encouraging people not to have sex and to be faithful to as few sexual partners as possible as the most important ways to prevent HIV infections are failing in Africa. They also criticize PEPFAR projects for not giving condom education to children younger than 14. In the final part of our series on PEPFAR, VOA?s Darren Taylor examines the future of the controversial Plan.

Some activists go so far as to call for PEPFAR?s dissolution, but most agree that a sustained effort by the richest country in the world to combat a virus that the United Nations says has infected 65 million people and killed 25 million ? mostly in Africa ? over the past 25 years, is essential. What they want, however, is for certain conditions that govern PEPFAR programs to be scrapped, and the US?s response to the HIV crisis drastically overhauled. 

?Remove all the ideology - the puritan, conservative elements that underpin a lot of PEPFAR?s programs. That?s what I say,? says Fatima Hassan, of South Africa?s AIDS Law Project.  

?PEPFAR money should be used to promote condoms (to children as well as adults), it should be used to promote interventions amongst sex workers, it should be used to promote (abortion) choice ? reproductive choice for women. There should be no ideological barriers to the use of PEPFAR money ? so long as the money is used to help prevent, or treat, HIV,? comments Nathan Geffen, an activist with South Africa?s Treatment Action Campaign.

According to PEPFAR rules, organizations that are funded by the Plan must encourage people to ?Abstain? from sex, to ?Be Faithful? to their sexual partners and to use ?Condoms? as the chief methods of preventing HIV infections. This is PEPFAR?s so-called ?ABC? approach. But the activists argue that expecting people not to have sex ? especially in Africa where it?s the only source of many women?s and girl?s incomes ? and to be faithful in a context where many women indeed are, but are still infected by their promiscuous husbands, is unrealistic and is boosting, rather than decreasing, infection rates.      

They also slam PEPFAR programs for only giving condom education to children older than 14, saying that it?s essential that people are taught to ?condomize? before they become sexually active.                   

?I think in the future the US administration needs to listen to people like us, who are working on the ground to fight this epidemic on a day to day basis. They shouldn?t again try to impose a package on us from Washington. It doesn?t do much good at all to export conservative American values to Africa, and expect it to work here,? says Ugandan AIDS activist, Beatrice Were.

But Warren Buckingham, PEPFAR chief in Kenya, responds that the people who are ?in control of the programs on the ground in Africa are overwhelmingly Africans ? not people based in Washington D.C?. We provide regular reports to Washington, but I have 15 years (experience) with working with federal programs, and I have not felt that this program was any more or less micromanaged from Washington than anything else I?ve been involved with.? 

No matter, says Hassan, it?s time for US officials to acknowledge that PEPFAR?s ABC strategy isn?t working.

?If you look at the high levels of teenage pregnancy as well as of general pregnancy rates in Africa, it shows two things: That people are having a lot of sex, and that they?re not doing it in a safe manner, which means that your ABC (approach) ? scientifically, empirically, factually ? can go to some point in addressing the epidemic, but it?s not going to be the solution. And we?ve always said it?s not that there?s no place for ABC ? obviously there?s a need for ABC ? but you need to carry on with the D to Z. That?s what I want to see happening in the future.?

While activists agree that people must continue to be instructed that abstinence and faithfulness are important, they call on the US to place more emphasis on male circumcision, reducing sexual abuse and violence against women, and poverty relief, as major methods of preventing the spread of the virus.

Job Akuno, an NGO manager who implements PEPFAR-funded projects, says he appreciates the US money, but wishes that he had leeway to implement strategies other than those linked to the Plan?s ABC continuum.

?We are working in communities that are predominantly poor, and one of the most critical challenges is (being compelled by PEPFAR rules) to address behavior in isolation of the social and economic determinants of behavior. Most of the funding and the activities that we implement are geared towards addressing behavioral aspects?. But we would like to also be able to implement job creation programs, for example, because we believe that if people have gainful employment, they are less likely to engage in risky behavior. But under PEPFAR guidelines, we?re not permitted to set up such projects,? Akuno laments.

International AIDS activist, Dr. Paul Zeitz of the Global AIDS Alliance in Washington, is optimistic that political change in the US will lead to PEPFAR ?adapting.?  

?We would like to see a major reform of the way the US government programs its global AIDS funding and we?re hoping that this Democratic Congress and a new president will fix PEPFAR ? or change it dramatically ? so that it can be more effective in its policies, and in the way that it programs its money.?

He calls for PEPFAR to be ?more aligned with African and international strategies? and for it to ?partner? with the international community ? ?like the Global Fund and the UN system ? to make it stronger and more effective. It can be aligned with African AIDS plans.

?Basically, the whole thing has to be rethought. We need to bring together the international community and come up with a strategic plan to achieve universal access (to treatment) by 2010, and halt the epidemic, dramatically.?

Zeitz points out that the US in the past led international efforts to eradicate smallpox and polio and that success was achieved in cooperation with many other countries, and the World Health Organization.

?Right now, in terms of HIV/AIDS, the US is doing it on its own, and it?s not working,? he states.  

PEPFAR?s Buckingham says: ?It?s up to the people in Washington, and particularly members of Congress, to define how they think the program can best be refined (in the future).?

He?s positive that the Plan?s administrators will soon be able to make some strategic changes to PEPFAR.

?Before I worked internationally, I worked on the Ryan White CARE Act, which is the US?s domestic response to HIV/AIDS. Each time that legislation was reauthorized, we were able to make minor adjustments to the program that provided the opportunity to build on lessons learned, and also to respond to how the epidemic is changing and evolving,? Buckingham explains. 

He?s confident that PEPFAR will soon possess the necessary ?resources and programmatic guidelines? that?ll enable it to institute new interventions designed to prevent the spread of HIV, such as male circumcision, and to prepare for ?much more mature treatment programs, where more people are going to need to be on second and third line (drug) regimens.?

A senior PEPFAR administrator in Washington, Dr. Tom Kenyon, acknowledges that the program must ?broaden? in the future. 

?There are major gender inequities that exist (in PEPFAR countries), especially gender-based violence that contributes to transmission. There are economic issues, there are mobility issues; alcohol ? many other factors that need to be addressed in order to create an environment for interventions to work,? he says.

Kenyon agrees that a ?multi-pronged approach? is needed, but also stresses that there will be no backtracking on PEPFAR?s ABC approach, because ?everyone accepts that the best way to not get infected is not to have sex, and to be faithful to one partner, and correct and consistent condom use.?    

Were, though, says the American public should ask their leaders to abandon PEPFAR?s ?blind? focus on ABC.

?I don?t think Americans want to see their money go into what doesn?t work. I don?t think Americans want to see their money being spent on what undermines other cultures, what is not respectful. I have been to the US, and I?ve talked to many Americans, and I know that?s not what they want,? she says.

Kenyon urges activists not to ignore that PEPFAR has provided more than a million people in sub-Saharan Africa with antiretroviral drugs, medicines that allow them to live longer and healthier lives.

Were says activists, in their bid to pressure the US authorities to ?modify? PEPFAR, are willing to ?praise the good parts of the Plan,? but she maintains: ?With all the many billions of dollars that PEPFAR has been pumping into the response to HIV/AIDS, most people still can?t get drugs, they can?t get access to the things they need to save their lives. When you go to most areas of Africa, there are no CD-4 count machines (instruments that measure the white CD-4 cells in the blood, and are crucial to treating HIV-positive individuals). Many people are taking antiretrovirals and they have to pay from their own pockets. Just for the monitoring of their blood, they have to travel miles, and sometimes have to spend two days waiting. Those are critical issues that PEPFAR could have addressed, instead of putting its money into useless programs like abstinence.?

Many activists also allege that PEPFAR has ?dangerously split? the world?s response to the pandemic.   

?PEPFAR has been played up against the Global Fund (to Fight AIDS, Tuberculosis and Malaria). And all of our efforts and energies I believe should have been invested in the Global Fund,? Hassan says.

?We should have had one driving vehicle for implementing prevention, care and treatment programs around the world. On that level, PEPFAR has been quite a problem, because almost all the US funding is now going into PEPFAR, instead of them honoring their commitments to the Global Fund.?

PEPFAR officials say it?s up to the US administration to decide upon the most efficient way of using American taxpayers? money, but Kenyon adds that PEPFAR ?makes major contributions? to the Global Fund.

However, Zeitz says only 15 per cent of US AIDS funding is going to the Global Fund, and the rest to PEPFAR. This scenario is ?out of balance? and his organization is calling for 50 per cent of the money to be channeled to the Global Fund to ?improve? the international response to HIV/AIDS.           

Were says PEPFAR, in its ?unilateral, cowboy? approach, isn?t strengthening African health systems.

?Instead of a united international response to the epidemic, PEPFAR has created a parallel structure. It now goes directly to African communities, and cuts out all other agencies. This lack of cooperation between all the players weakens our health systems in Africa, and does not create sustainability. So if today PEPFAR stopped, it would not leave an impact on our health systems, which can help us to carry on with what PEPFAR has started,? says Were.

In South Africa, says Hassan, PEPFAR officers sometimes establish programs without consulting provincial authorities, and that this results in ?friction? and ?misunderstandings.?

?The PEPFAR people also set up programs without considering the long term consequences of eventually exiting and transferring those patients to the public facilities,? she adds.

Buckingham responds that PEPFAR officials ?work closely with our host governments, but also with local NGO?s and networks of people living with AIDS and others, to define what the country most needs. And then we engage those organizations in implementing the program. Cooperation and respect for local authorities is the name of our game.?

But ?sustainability? isn?t, Hassan alleges: ?What we have currently is patients who have been started on a PEPFAR parallel program or a not-for-profit program and at some point have to be transferred and absorbed by the public facilities, who are then being turned away and told, ?Well, go back to the program where you started; we don?t have the capacity or the ability to take you on?.?

This shouldn?t happen and ?PEPFAR will never just abandon people,? Kenyon rejoins, before adding that activists should remember that the Plan?s projects are often implemented in ?extremely resource-poor settings? and that serious efforts have to be made towards ?big improvements? in local African health systems to enable PEPFAR to work optimally.            

Buckingham says PEPFAR projects always strive to give patients the best care possible, but he also acknowledges that ?sustaining the momentum (of massive drug rollout) is going to be challenging, because we have identified and begun to provide services in most of the sites where it?s reasonable to provide services, and we now need to find ways to take those services to other health facilities, and they?re going to require more support and more intervention. And as a program like this matures, it?s always a challenge to maintain a sense of urgency.?

Prof. Salim Karim, a renowned South African scientist who specializes in the field of HIV/AIDS and receives funding from PEPFAR, is convinced that the flow of US money to fight the pandemic in Africa can?t last forever ? and neither can Africans expect it to. 

?At the end of the day, we?ve got to transition to some kind of long-term, sustainable program that?s got to be funded by the countries themselves. We can?t forever be dependent on external aid. I see aid and the PEPFAR program as one example of something that can help kick start, accelerate and facilitate rapid progress, efficient implementation. But the longer term part of the strategy has to be transitioning to government programs,? Karim states.

Zeitz says it?s not only the US that should be expected to contribute billions of dollars to the effort to decrease the rate of infections on the continent.      

?The responsibility of combating AIDS falls on everyone?s shoulders. So, African governments themselves have to step up to the plate and meet their own commitments,? he says.

In 2001, at a meeting of heads of state in Abuja, Nigeria, that discussed the UN?s Millennium Development Goals, African governments committed to dedicating 15 per cent of their national budgets towards their health sectors.

Yet only two countries in Africa  - Botswana and The Gambia - are presently living up to that pledge.

Zeitz adds that in addition to political leaders committing themselves to the anti-AIDS effort, the continent?s religious leaders also need to ?do the rights things to stop HIV.? 

But at the moment, he says, most are not. Thabo Mbeki, for example, the president of Africa?s most powerful economy, South Africa, is frequently the target of the international AIDS activist community?s scorn for his ?dissidence? with regard to the causes of the epidemic.

In a country where between 5 and 6 million people are HIV-positive, and where international agencies estimate at least 1,000 people die of AIDS-related illnesses every day, Mbeki has been largely silent about the epidemic since he questioned the causal link between HIV and AIDS in 2000. Mbeki?s opinions are in opposition to the dominant scientific view that HIV attacks the body?s immune system, usually leading carriers to develop AIDS. 

And only in 2003 did the SA government begin a program to put masses of HIV-positive citizens on antiretroviral medication. By this time, activists say, millions had already died and the state has since regularly been criticized for failing to adequately respond to the epidemic.    

 In Uganda, President Yoweri Museveni has labeled condom unsafe. His wife, Janet, says they?re ?immoral.? While liberal African religious leaders ? most notably SA?s Anglican Archbishop Desmond Tutu ? have pleaded with people on the continent to use condoms, many leading clergymen in Africa oppose prophylactic use on the basis that it encourages promiscuity.

Zeitz says African societal leaders must share responsibility, along with ?unrealistic? strategies like PEPFAR?s ABC, for the ?dire state? that the continental response to HIV/AIDS is in, and that has seen infection rates increasing rapidly despite the plethora of initiatives in place. 

Hassan says PEPFAR should also put pressure in the future on African leaders to take strong action against HIV/AIDS. 

?I?d like to see PEPFAR taking on the lack of political will or leadership in many African countries on HIV/AIDS. Often I think it?s too much of a buddy-buddy kind of relationship, where PEPFAR keeps quiet because they?re afraid of the repercussions. But they need to realize that a lot of African countries are dependent on their money and that they?re in quite a strong position to influence a more scientific, evidence-based, rational approach to dealing with the epidemic,? she says.

But, when Karim considers the future of PEPFAR, he envisions a global HIV/AIDS sector ?free of bickering? that he says has resulted in ?dangerous disunity and loss of focus.?   

?We just find the task (of preventing and treating HIV) is just so enormous and the challenge is so big, we?ve got to be very focused on getting the job done. Every patient that we put on treatment is a life saved, and that?s what our focus is. For those who want to engage in the politics of it all ? that?s fine. But really, our task is to get on with it and save lives,? Karim says.