WASHINGTON – A five-year, $15 billion effort to combat AIDS in Africa and other areas — arguably the most important and popular international program of the Bush presidency — may become a political battleground as it comes up for renewal.
President Bush wants to double and House Democrats want to triple spending on a program that is now treating 1.4 million people, most of them in sub-Saharan Africa, where he will visit in two weeks.
Democrats also want to slash spending on a multimillion-dollar component that emphasizes sexual abstinence. And that has conservative groups furious.
The president used his State of the Union address this week to repeat a request he first made last May that Congress double global AIDS money to $30 billion over the next five years.
"We can bring healing and hope to many more," he said.
Bush, who will visit Africa in mid-February, gets no argument on that point from advocacy groups or lawmakers in both parties. They've been hailing the program since he first promoted it and Congress passed it in 2003.
"There is no nation on the planet which would have made a remotely comparable effort," House Foreign Relations Committee Chairman Tom Lantos, D-Calif., said at one of several hearings on how to expand the program.
The President's Emergency Plan for AIDS Relief — or PEPFAR for short — focuses on 15 mostly sub-Saharan African nations. Lantos' committee plans to vote this month on a bill to triple spending on it to $50 billion over five years, a sum that AIDS groups say is closer to the needs of meeting the continuing health crisis.
Democrats have angered conservative groups with plans to remove a provision, inserted by the then-GOP controlled Congress five years ago, requiring that one-third of HIV/AIDS prevention money go to abstinence programs.
That's about 7 percent of all spending. Another controversial provision that could come out forbids grants to groups that provide medical care to prostitutes.
With Bush's problems in Iraq and elsewhere around the world, the AIDS program "is something that could very much be his legacy internationally," said Tom McClusky, vice president of government affairs at the socially conservative Family Research Council.
McClusky accuses Democrats of trying to change the program into a bill that would promote sex trafficking and fund family planning programs that are involved in abortion. "I don't think that's the legacy the president wants."
Sen. Dianne Feinstein, D-Calif., said the current rigid funding requirements "have placed politics above science." She said that "the administration's abstinence-before-marriage earmark shortchanges the prevention programs that are most effective," citing findings of a Government Accountability Office report.
"We have a tremendous fight on our hands," said David Bryden, spokesman for the Global AIDS Alliance.
Bryden also has a different perspective on Bush's assertions about doubling spending. In this fiscal year 2008, the last of the $15 billion program, Congress approved $6 billion for bilateral AIDS work and the international Global Fund to Fight AIDS, Tuberculosis and Malaria. He said the White House will be locking in that $6 billion a year figure in order to reach $30 billion over the next five years.
The Alliance says that a better funding level over five years would be $59 billion, including $9 billion set aside for malaria and tuberculosis programs.
There were 155,000 people in the 15 focus countries of the program receiving antiretroviral treatment in 2004, a number that reached nearly 1.4 million people by September last year.
But with more than 40 million people around the world infected with HIV or living with AIDS, the crisis has hardly abated. The White House says $30 billion in spending will extend treatment to 2.5 million people and prevent 12 million new infections.
Some experts also worry that high-profile AIDS programs will soak up too big a share of scarce health care dollars. "I'm hard pressed to think of anything in recorded history on the scale of it," Laurie Garrett, senior fellow for global health at the Council on Foreign Relations, said of the AIDS initiative.
"How do you target one disease without it being at the expense of other diseases?" she said, citing the pressing needs in Africa for maternal and child health care programs, clean water and sanitation efforts, and more health care training and infrastructure improvements.
U.S. Global AIDS Coordinator Mark Dybul told the House Foreign Relations Committee last year that the AIDS money contributes, directly or indirectly, to a wide range of nutrition, TB, malaria, women's health, clean water and education programs.
"HIV/AIDS does not exist in a vacuum," he said. "It is inextricably tied to other threats to public health, and it has ramifications for a wide range of development-related issues."
The Global AIDS Alliance's Bryden agreed that the AIDS grants from the U.S. have led to broad improvements in general health care delivery. The real need, he said, is to "enlarge the pie" to ensure that every health issue gets the proper attention.