How best to spend new AIDS money

To a continent ravaged by one of the worst plagues in history, President Bush's pledge of $15 billion to battle AIDS over the next five years was an unexpected balm.

Or as Mr. Bush himself put it, "a work of mercy."

Thirty million of the world's 42 million people diagnosed with HIV/AIDS live in Africa and a generation of children is growing up without their parents. In light of the enormity of the problem, how to use the money effectively is the challenge facing healthcare officials in the 12 African and two Caribbean nations targeted by the proposal.

"Fifteen billion might sound like a lot, but spread over the course of five years and across the continent, it's actually not much," says Najib Balala, Kenya's minister of social services. "It has to be channeled very wisely."

Bush's plan, which has been widely praised, adds $10 billion to the $5 billion he had already allocated for antiretroviral drugs for 2 million Africans, prevention and education programs, and care for children who have lost parents to the disease. In a departure from this administration's policies, the plan also includes money for generic drugs and condoms.

For many AIDS workers in Africa, access to more-affordable drugs is the No. 1 priority. The vast majority of those with HIV/AIDS here don't have access to the sort of advanced medication available in the West. And while the use of some drugs is increasing - such as those that fight HIV-related infections like tuberculosis and pneumonia, and those that prevent mother-to-child transmission - antiretroviral drugs that combat HIV directly are still scarce. (While antiretroviral drugs do not cure AIDS, they have been found to prolong life when taken consistently).

To increase African access to AIDS medication, activists have long advocated the sale of less-expensive generic drugs.

The US has been "an impediment to the fostering and distribution of generic drugs in Africa," says Bettina Schunter, Kenya director of the aid agency Doctors Without Borders (MSF). "The US typically wants to protect big businesses and patent rights.... But we believe in the cheapest drugs available."

Drug companies have opposed the sale of generic drugs. They say they violate companies' patents, and that generic companies are at an advantage because they don't incur the high costs of developing the drugs.

As recently as November, the Bush administration had argued against countries exporting generic drugs. But Anthony Fauci, a senior US government physician who helped formulate the Bush plan, now says that generic AIDS drugs manufactured by Cipla, an Indian company, will be among those recommended under the proposal.

Beyond the need for cheaper drugs, observers say that prevention and education programs, as well as incentives to retain health professionals in Africa, are terribly underfunded. In a letter to Bush last week calling for increased funding, the Boston-based group Physicians for Human Rights said that if prevention programs - including AIDS education in schools, counseling, and access to condoms - were amply expanded, the annual incidence of new HIV infections in adults could be reduced to 1.5 million within five years, from about 4 million now.

Dr. Fauci said that condom distribution would be part of the prevention component, in addition to the message of abstinence. Bush's Christian constituency has long opposed the promotion of condoms, saying they promote promiscuity.

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