Over the past year, President George W. Bush's Global AIDS Coordinator, Randall Tobias, has accomplished what few activists believed possible: he channeled hundreds of millions of newly appropriated funds to administer treatment programs for tens of thousands of AIDS patients in Africa and the Caribbean.

Yet despite this considerable achievement, certain aspects of the Bush administration's program have been highly controversial at home and abroad: the decision to purchase brand pharmaceuticals instead of generics for U.S.-funded treatment initiatives, for example, and the administration's circumventing the Global Fund to Fight AIDS, Tuberculosis and Malaria, by directing the bulk of its resources to its own initiative.

A third major controversy has surrounded the administration's approach to research and programs on HIV-prevention. The issue has been particularly divisive, because it pits firmly held views about condoms, abstinence, and homosexuality that divide religious conservatives and secular activists such as health professionals. Tobias faced the formidable challenge of keeping faith with the conservative Catholic and evangelical Christians who constitute President Bush's political base -- some of whom oppose essential prevention initiatives -- while funding enough medically sound strategies to meet the president's ambitious goal of preventing seven million AIDS transmissions in five years.

Tobias's job was further complicated by some of the decisions the U.S. Congress made for him in mid-2003, when it enacted the United States Leadership Against HIV, Tuberculosis, and Malaria Act of 2003, which laid the ground rules for the expenditure of billions of dollars worth of foreign aid for the prevention, care, and treatment of HIV/AIDS in sub-Saharan Africa and the Caribbean. Although the legislation represented a high-water mark of cooperation across political, religious, and ideological lines, some of its features made both the left and the right uneasy. Progressives were dismayed by a requirement that the executive branch spend a third of prevention resources on programs promoting abstinence before marriage. Right-of-center lawmakers, meanwhile, had to accept that two-thirds of the funds would be used for activities other than abstinence promotion, including condom dissemination.

Satisfying both constituencies has been an unenviable task, and Tobias has clearly struggled with it. On the eve of a trip to Africa last May, he said that, "Statistics show that condoms really have not been very effective." (To the horror of Ugandan AIDS activists, President Yoweri Museveni then picked up the theme and publicly called condoms "inappropriate for Ugandans," notwithstanding his past leadership in promoting their use.) But two months later, in a speech to the International AIDS Conference, Tobias delivered the opposite message: "Ugandan President Yoweri Museveni has, largely by sheer leadership and will, fought back this disease in his country with an A-B-C prevention focus. We must learn from his leadership in the fight against AIDS. Abstinence works . . . Being Faithful works . . . Condoms work. Each has its place."

Fortunately, in distributing the abstinence-until-marriage funds earmarked by Congress, the U.S. Agency for International Development (USAID) seems to have taken its cues from Tobias's second remark. It has funded programs to prevent sexual coercion, exploitation, and violence, and it has allowed recipients to include information about the correct and consistent use of condoms in their programs. The first round of abstinence grants, which were announced on October 5, were distributed far more fairly than many AIDS activists had expected. Catholic Relief Services, which does not consider condoms to be a "morally appropriate" prevention strategy, did receive a grant, as did Samaritan's Purse, a conservative evangelical humanitarian group. But the bulk of the $100 million was awarded to groups, secular and religious, that earned superb credentials preventing the spread of HIV/AIDS, including by providing condoms and comprehensive sexual education. Condom dissemination by USAID, moreover, has not dropped off during the Bush presidency. In fact, it has expanded from $15 million in 2002 to $24 million in 2003, and it could reach $30 million this year.

Still, some worrisome trends are developing. Anecdotal reports from countries receiving U.S. funding indicate that condoms are available for targeted intervention with high-risk groups, but also that programs that once disseminated condoms to the general public are drying up. In Uganda, for example, two major U.S. contractors that once distributed condoms to sexually active young people are now moving toward abstinence-only programs. A magazine for young people that used to have a broad safe-sex agenda advocating abstinence, faithfulness, and condoms, now deletes references to the latter altogether.

Furthermore, although Tobias has managed to tread a relatively pragmatic middle path between conservatives and progressives, other agents of the Bush administration have adopted a more ideological-and damaging-stance. The Department of Health and Human Services recently announced guidelines that restrict federal funding to educational materials on HIV-prevention that pass a local obscenity test. Since most prevention education in the United States targets high-risk groups such as homosexuals and people in the commercial sex industry, it seems almost certain that most of these materials will not pass the test; indeed, they are likely to offend the sensibility of the "average" citizen, the arbiter of community obscenity standards.

Federal funding for domestic and international HIV/AIDS research by the National Institutes of Health (NIH) and the Center for Disease Control have also been afflicted by conservative ideology, some of it religious. Last year, the conservative Traditional Values Coalition released a "hit list" of researchers and projects, and the Republican leadership in the House of Representatives directed the NIH to subject grants to programs addressing sex outside of marriage to an additional layer of review. Fortunately, NIH director Elias Zerhouni defended the projects targeted by the Traditional Values Coalition, reaffirmed the scientific review process, and committed himself to continued investment in research on human sexuality. But the episode cast a chill among researchers and academics working on HIV/AIDS, particularly those committed to helping patients engaged in high risk activities such as prostitution and intravenous drug use.

Thus, after its first year, the Bush administration's global AIDS initiative looks like a glass both half full and half empty. On the one hand, President Bush's leadership in Congress has secured unprecedented commitment to and funding for AIDS treatment. On the other, the administration's decision to buy high-priced brand drugs and the international perception that ideology has trumped pragmatism have tarnished its record and diminished the international recognition that the United States otherwise deserves as the world's biggest donor on HIV/AIDS.

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  • Holly Burkhalter is Director of U.S. Policy and of the Health Action AIDS campaign at Physicians for Human Rights.
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