The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, which became law in May some 17 years after the federal government made its first investments in the fight against HIV/AIDS overseas, is the first comprehensive articulation of U.S. policy toward the global HIV/AIDS epidemic. The new law is the result of a confluence of historic forces and the coming together of a wide and ideologically diverse coalition of key individuals and interest groups, all on behalf of a much expanded U.S. effort to combat the epidemic in the developing world.

In line with President Bush's personal commitment, the act calls for a major increase in U.S. spending on global HIV/AIDS. It also sets out the basic policy parameters for the expenditure of those funds. In a historic shift of priorities, it commits the lion's share not to prevention activities but to services for people living with HIV or AIDS. Moreover—and of particular concern to sexual and reproductive health advocates—the relatively modest funds available for prevention will be constrained by a series of last-minute amendments to the legislation that largely reflect the ideology and interests of religious and social conservatives.

Converging Forces

Each year since 1986, Congress has set aside funds for global AIDS activities during the annual appropriations process. For the bulk of that time, in the absence of effective therapies to prolong the lives of people with AIDS, virtually all U.S. funding supported efforts to prevent new HIV infections, such as protecting the blood supply and providing individuals in developing countries with information and services to protect themselves against transmission of the virus through unprotected sex or intravenous drug use. These efforts largely have been administered by the U.S. Agency for International Development (USAID), although the Centers for Disease Control and Prevention (CDC) has became a significant player in the last few years.

More recently, however, as antiretroviral therapies became more effective and affordable in the United States, AIDS activists began to agitate for increased access to similar treatment overseas. Treatment activists targeted pharmaceutical companies to lower drug prices, and just within the last year, these companies began to offer deeper discounts for their products, enabling poor countries to consider for the first time providing treatment for those living with AIDS.

During the same period, fostered by the lobbying efforts of the Irish rock star Bono and evangelical relief groups such as World Vision and Rev. Franklin Graham's Samaritan's Purse, concern about the disease's impact on families, and children in particular, began to manifest itself among conservative groups and even the most conservative members of Congress. These groups admit to coming late to the AIDS issue but are active today in caring for those affected as a mission of mercy. The idea of reaching out on behalf of the "innocent victims" of AIDS also appeals to President Bush, who grabbed hold of the AIDS issue as part of his "compassionate conservative" agenda in 2002 with the announcement of an effort to prevent pregnant and lactating women from passing the virus to their newborns.

Meanwhile, international pressure was mounting on the world's wealthiest nations to give more in the fight against AIDS. In April 2001, United Nations Secretary-General Kofi Annan called for the creation of a global fund to fight HIV/AIDS "to bring about a quantum leap in the scale of resources available." The Global Fund to Fight AIDS, Tuberculosis and Malaria was formally launched in January 2002 as an independent, multilateral organization designed both to attract new resources and to direct those resources in a coordinated way to where they are needed most.

This confluence of forces created the momentum necessary to finally pass a global AIDS bill. Congress came close to passing such a measure in 2002, but congressional leadership did not deem completing action a high-enough priority in the session's final days. That changed when the president announced his new AIDS initiative in the State of the Union address in January, surprising even members of his own party. The global AIDS bill gained new momentum, and the legislation was enacted in near-record time.

Major Directions

In addition to setting a funding goal of $15 billion over the next five years (FY 2004-2008) for U.S. spending on international AIDS, tuberculosis and malaria activities, the new global AIDS act reorganizes the way the U.S. government will administer its program across multiple agencies, balances U.S. participation in multilateral AIDS efforts with its long-standing bilateral activities and reorients the United States away from prevention-focused activities to a range of services for HIV-positive people.

Global AIDS coordinator. In an action that received relatively little public attention when the measure was being considered but that could have far-reaching implications, the new act establishes within the Department of State a coordinator of U.S. government activities to combat HIV/AIDS globally. Up to now, USAID and CDC (as well as the Departments of Labor and Defense, which run much smaller programs) had direct and independent programming authority over the funds administered by their agencies. The law, however, gives the coordinator broad power and oversight, including final say over how those agencies' resources are allocated. In addition to this substantial oversight authority, the coordinator will have a dedicated budget of his or her own from which to make direct grants to nongovernmental organizations ("including faith- and community-based organizations"). Improved coordination of the increasingly large and multifaceted effort is a laudable goal. All the same, AIDS advocates are concerned that these funds could be subject to even greater political pressures than the programs run under the auspices of USAID and CDC, which have strong public health traditions.

In July, the president nominated Randall Tobias, a Republican activist and donor and former pharmaceutical company CEO, to be the global AIDS coordinator. Tobias's appointment has been greeted generally with cautious optimism by AIDS activists; his nomination must still be confirmed by the Senate before he takes office.

Role of the Global Fund. Agitation for increasing U.S. support to the Global Fund stems both from the international community and from U.S.-based AIDS activists, who have been frustrated with the way the United States traditionally has addressed global AIDS—through bilateral assistance to other nations and nongovernmental organizations. Bilateral programs, say some activists, have large administrative overheads and long lead times for delivering aid to the field and too often reflect U.S. geopolitical concerns. By pooling donor resources and relying on country-level partnerships to submit proposals to a single source of financing, they argue, the Global Fund is better equipped to direct resources quickly and efficiently to where they are needed most.

Critics of the Global Fund are concerned that in a rush to disburse funds quickly, the fund will sacrifice accountability, including its own responsibility to ensure results. And many, especially on the conservative side, bristle at the fact that although the United States is the fund's leading contributor, it holds no greater power than any of the other countries—half donor and half developing—that constitute the fund's board. (This notwithstanding that Department of Health and Human Services Secretary Tommy G. Thompson is the board's chairman.)

The new law authorizes a U.S. contribution of up to $1 billion annually for the Global Fund. However, it places an important condition on these funds, prohibiting the United States from contributing more than 33% of the total amount given to the fund. In other words, the U.S. contribution to the fund has been made contingent on matching donations from other countries.

De-emphasizing prevention. The global AIDS law marks a sharp change in the emphasis of activities undertaken by the U.S. government around the world. To date, prevention efforts have made up the largest proportion of U.S. activities. Only in recent years has the U.S. government funded small-scale treatment programs, providing antiretroviral therapies to those living with AIDS, and supported programs that offer treatment of opportunistic infections, palliative care for people dying from AIDS and care for children orphaned by AIDS.

While not binding until FY 2006, the law requires that "not less than" 55% of the funds administered by the U.S. government be spent on treatment activities, with most of this amount to be used for the purchase and distribution of antiretroviral therapies. The law also "recommends" that 15% of the funds be spent on palliative care and 10% on orphans and vulnerable children. When all is said and done, it is estimated that only about 20% of the funds—$3 billion over the five-year period, or $600 million per year—will be eligible for HIV prevention activities.

Sexual and Reproductive Health Implications

Only after the president unveiled his new AIDS initiative in his State of the Union address in January did social conservatives recognize both the threat and the opportunity of this new effort. Once they did, they quickly turned their energies to two interrelated priorities: advancing their ideological agenda as a matter of policy and fostering the funding of conservative, and especially faith-based, groups. Initially, they lobbied the White House to ensure that, in the words of Austin Ruse of the Catholic Family and Human Rights Institute, "proabortion groups and abortion providers do not get any of this money. Not even a nickel." Indeed, the White House looked for ways to expand the "Mexico City" global gag rule to HIV/AIDS funding, which currently affects only U.S. overseas family planning assistance. (The policy requires that in exchange for family planning funds from USAID, foreign nongovernmental organizations must agree to forego any privately funded abortion-related activities; "Global Gag Rule: Exporting Antiabortion Ideology at the Expense of American Values," TGR, June 2001, page 1.)

In the end, however, the administration apparently was unable to find a way to apply this ideological litmus test without disqualifying groups overseas it felt were necessary to achieve its program goals. Moreover, it did not want abortion politics to get in the way of the bill. In a February letter to the president, more than 130 organizations expressed their concern over any expansion of the global gag rule: "Any such restrictions can only impede progress in the battle against HIV/AIDS and erode the good will generated by the Administration's renewed commitment to funding HIV/AIDS programs." Shortly thereafter, the administration announced it would not be expanding the gag rule to HIV/AIDS funds, and the House leadership was persuaded not to press the point when the bill was considered on the House floor.

Stung by their defeat on the gag rule, social conservatives denounced the pending bill as failing to address their priorities. In March, Rep. Joseph Pitts (R-PA) and the House Pro-Life Caucus released a statement of demands and, as the bill moved through the process, Pitts and his allies were able to secure nearly every one of them.

Near the top of the social conservatives' list was making abstinence promotion a priority in U.S.-funded HIV prevention programs. To make their case, conservative leaders latched on to the example of Uganda, which experienced significantly reduced HIV prevalence rates during the 1990s after adopting the so-called ABC approach— "Abstinence," "Be faithful" and "use Condoms"—to behavior change. Despite evidence that behavior had changed on all three fronts and that condom use had increased significantly ("Flexible But Comprehensive: Developing Country HIV Prevention Efforts Show Promise," TGR, October 2002, page 1), conservative congressional leaders persisted in attributing Uganda's success to increased abstinence.

Writing in the Washington Post, David Serwadda, director of the Institute of Public Health at Makerere University in Kampala, Uganda, commented, "As a physician who has been involved in Uganda's response to AIDS for 20 years, I fear that one small part of what led to Uganda's success—promoting sexual abstinence—is being overemphasized in policy debates. While abstinence has played an important role in Uganda, it has not been a magic bullet." Nonetheless, by a vote of 220-197, the House adopted a Pitts amendment reserving at least one-third of prevention funds for "abstinence-until-marriage" programs. The provision is advisory for FY 2004 and 2005 but mandatory for FY 2006-2008.

Another priority of the Pro-Life Caucus was "protection for faith-based groups against distributing condoms." Even though the bill (as well as preexisting USAID policy) was already explicit that no organization must provide condoms, Pitts and his allies contended that the legislation did not go far enough to ensure that Catholic and other religiously based service agencies would not be discriminated against in applying for funding. As a result of their efforts, the new law states that no organization funded under the act may be required to "endorse, utilize or participate in a prevention method or treatment program" to which it has a religious or moral objection.

Continuing with the anticondom theme, social conservatives succeeded in compelling USAID to analyze the impact of condom use on the spread of human papillomavirus in Sub-Saharan Africa (see related story, page 4). And in a final expression of moralistic opportunism, conservatives slipped in a provision that requires any organization, including even the Global Fund, to have a policy "explicitly opposing" prostitution and sex trafficking, to be eligible for U.S funds.

Challenges Ahead

The speed with which the new law was enacted this year is a reflection of the fact that, for good or ill, the global AIDS issue is now not only at center-stage on the agenda of traditional AIDS and international public health advocates but also firmly on the agenda of the president, Congress and the antiabortion, "profamily" movement as well. The policies contained in the global AIDS act reflect the disparate, often opposing, interests of this broad coalition. Meanwhile, the lofty funding goals set forth in the new law on which there is broad consensus remain just that. During his trip to Africa in July, President Bush convincingly expressed concern for those living with AIDS and reiterated his commitment to spend $15 billion over the next five years to fight the epidemic. Nevertheless, he asked Congress to allocate only $2 billion for the first of those years, and federal budget constraints are only expected to intensify in the years ahead.

In short, on both the policy and the funding fronts, questions abound and future conflicts would appear inevitable. How these questions will be answered and conflicts reconciled over time, as the expanding U.S. program is implemented on the ground, remains to be seen. To be sure, the stakes are high for the millions of people around the world at risk of or living with HIV or AIDS—and for the world around them.