In 2006, when Kau Makgosa was diagnosed with HIV, a new US-funded program provided him with free antiretroviral (ARV) treatment. Now he's healthy enough to plan an ascent of Africa's tallest mountain, Mt. Kilamanjaro, to raise awareness about HIV and give hope to others living with the disease.
"Basically, I'm healthy now, and I think it's impossible to say if it will be for five years or 15 years, but I know I will be around for a long time," says Mr. Makgosa, a Johannesburg social worker who now lives openly with HIV and teaches other South Africans about the disease and its treatment.
When President Bush announced the signature $15 billion President Emergency Plan for AIDS Relief (PEPFAR), there were murmurs of disbelief amid the applause. But five years later, PEPFAR is still the largest and most comprehensive program for HIV patients in history, and may have saved millions of lives. By setting targets of putting 2 million HIV patients on medical treatment, preventing 7 million others from contracting HIV through education programs on abstinence, and providing funding for an estimated 10 million children whose parents have died of AIDS, PEPFAR has made a huge impact in Africa, the continent most affected by the disease.
Now, as Mr. Bush visits Africa on a five-country tour, he is hearing plenty of stories similar to Makgosa's. He may also be hearing muted criticism that PEPFAR could do much more if it was not as devoted to its faith-based message of abstinence and marital fidelity.
"There are many good things about PEPFAR, one of which is that it's put a lot of people on ARV treatment, and it's hard to complain about that," says Helen Epstein, a New York-based author of the book "The Invisible Cure: Africa, the West, and the Fight Against AIDS."
But while the treatment side of PEPFAR has saved lives, "the prevention side has been a flop," says Ms. Epstein. "The emphasis on abstinence, when you realize what is at stake in Africa, was a huge mistake."
Critics question focus on abstinence
Nearly a third of PEPFAR's funding for HIV prevention goes to faith-based organizations, who preach a mantra of ABC, "Abstain, Be faithful, and Condomize." While using faith-based organizations makes a lot of sense, since churches are powerful institutions in traditional African communities, experts like Epstein and epidemiologists say there is no evidence that the message of abstinence has had any impact in halting the spread of HIV.
"As far as prevention is concerned, I have not seen any evidence that PEPFAR has made a difference," says Mark Heywood, director of the AIDS Law Project in Johannesburg. "Now it may be that prevention itself is difficult. But when the fundamentalism of Bush and company intrude – with restrictions that programs shouldn't provide encouragement to use condoms or shouldn't provide assistance to sex workers – then the consequences of abstinence-only programs are felt."
AIDS activists say PEPFAR funds could do a lot more if they were directed toward more proven strategies of lowering infection rates through encouraging the use of condoms, rather than on the more difficult goal of promoting abstinence.
"There are many sex workers who get infected with HIV, but the programs say that we can't give them assistance," says Luckyboy Makhondwane, a social worker who teaches adults about HIV in Johannesburg. "These sex workers get marginalized. They are out of the system. So then you have no way to influence them, to help them, to prevent the spread of HIV to their customers."
PEPFAR makes a big difference in Rwanda
Two years ago, Anastasia Uklimana – a housewife in Kigali, Rwanda – was too weak and thin to lift the yellow plastic jerrycans women here use to collect water. Her husband had to do it after a long day of work – along with the cooking, the cleaning, the laundry, and the many duties that go with caring for a newborn baby.
That seemed fair enough, she says, because "he is the one who brought the problem" – the HIV – "into the home."
But thanks to free ARV drugs – provided by PEPFAR – she now has enough energy to raise her three children, as well as volunteer as a community health worker, counseling her neighbors to seek out treatment as well.
Ms. Uklimana is one of 27,800 Rwandans – more than half of the population infected with HIV – receiving free ARVs through PEPFAR. Since Rwanda began receiving the funds in 2005, medical professionals here say the health infrastructure, and the people it can serve, have improved dramatically.
"I think PEPFAR makes a very big difference – not only in the number of people receiving [medication], but also in the quality of care," says Joseph Nyibizi, acting coordinator of care and treatment at the Treatment and Research AIDS Center (TRAC).
A recent TRAC evaluation of care in 2004 and 2005 showed that patients are staying alive longer and coming in for relevant checkups more frequently, and staff are receiving better training in care management, he says.