Friday, December 1st, was World AIDS Day, a United Nations-sponsored occasion for global reflection on the threat posed by the HIV-AIDS epidemic. The disease afflicts nearly 40 million people in the world today, most of them women and children who may receive little or no treatment. But government agencies and various private-sector and community organizations are continuing to make headway in fighting the disease, supported by the Global Fund to Fight AIDS, the largest single non-political source of money in the battle against the disease.

The Global Fund is a multi-billion dollar project, supported by a consortium of donor nations, non-governmental organizations, in-country health care providers, educators and others. While the workings of this Geneva-based agency are quite complex, the core idea underlying its work is quite simple. It says that each of the 131 nations that seek AIDS funding is in the best position to know what its own needs are, and how best to spend the money it receives.

"The Global Fund says to each country, in effect, 'what do you want to do to fight AIDS?' says Bernard Rivers, the executive director of AIDSPAN, an independent organization that monitors the Global Fund and publishes The Global Fund Observer, a free online newsletter about its activities.

"And each country can design the program it wants," he continues. "One country might want to set up an anti- retroviral treatment program. That is, they want to buy lots of the modern anti-retroviral drugs to keep people able to function to be able to live a normal life while they have AIDS. Another country might want to focus on prevention through education. Another country may want to focus on prevention through the distribution of condoms."

Here's how the Global Fund works: Donor nations contribute funds to a common reserve, which today totals about 6.3 billion dollars. Nations who apply for funds submit specific proposals, which are evaluated by an independent, technical review panel, then approved by a board made up of international government and private sector representatives.

The proposals are judged according to their merit and the results promised -- never on political considerations. "What's more," Rivers says, "the decision to renew funding is based entirely on results achieved." "This poses an interesting challenge," he adds. "Because if the country sets ridiculously high targets by spending a very small amount of money it claims it will deliver phenomenal results, that may look good in the proposal. But if the grant is approved, the Global Fund says 'where are the results? Are you delivering those results?'"

But if the country "aims low" in its proposal and promises very modest results, the Global Fund may say 'well, we can get better results elsewhere by giving grants to other countries.' "So the countries really have to think what kind of results they commit themselves to," opines Rivers.

One example of this tough "bottom line" approach occurred early in 2006 when the Global Fund cut off 70 million dollars in funding to Nigeria. Nigeria's proposal had promised that 14 thousand of its AIDS-infected citizens would receive antiretroviral drugs by the end of last year. But by the end of the year, no one had been given treatment.

Rivers says that a number of people started to be put on treatment in the second year "but the grant was way behind schedule, and there was a serious lack of desire by the government of Nigeria to make those grants work efficiently."  That is why those programs were deemed, in Global Fund terminology, 'not performing' and they were terminated? because that money could be more efficiently spent by sending it to other countries.

Official denials that there is an AIDS epidemic have often stymied efforts to battle the disease. Rivers says China's leadership once fell squarely into this camp, but in recent years its government has applied for, and received, numerous Global Fund grants.

"Honestly, they don't really need the money, in my view," he says, "but I still think that it is important because China's decision to apply to the Global Fund for money was its way of saying it was going to get with the program, its way of saying it wanted to join the developing world in fighting AIDS."

When asked we stand in the fight against AIDS, on World AIDS Day 2006, Bernard Rivers offers a mixed assessment.

"The good news" he says, is that "there is more money available to fight AIDS, more willingness by governments to acknowledge that AIDS is a crisis which must be fought, more doctors and nurses trained and more anti-retroviral drugs available at a lower price?"

But Rivers is quick to point out the bad news as well. "Individual human beings still deny the possibility that they themselves have HIV and that they themselves might give HIV to someone else, says Rivers. "So you have pigheadedness. You have stupidity. You have denial. And while those personal characteristics persist, the HIV epidemic will continue to advance."