BioEd Online

The big US programme is the President's Emergency Plan for AIDS Relief (PEPFAR). What are PEPFAR's accomplishments?

We've supported care for 3 million people so far 1.2 million of them are vulnerable children and orphans. For prevention of mother-to-child transmission, we've supported services for 4.2 million women. Of those, 340,000 received short-term prophylaxis, averting approximately 65,000 infant infections.

The work isn't being done by international organizations. It's being done by people at the local level, providing services at ground zero.

Is the balance of prevention and treatment now right?

Three-and-a-half years ago, President Bush had the vision to say prevention, treatment and care need to go together. PEPFAR started that wave. So we're delighted to hear people now saying prevention should be on equal footing with treatment.

Some say that PEPFAR is hiring so many local people that it is undermining the country's own infrastructure for aid. Are you remedying that?

I've heard some of those anecdotes, but we've got more anecdotes about how we're supporting massively programmes in the public sector. Thirty per cent of our resources go for health workers.

There's a lot of shifting back and forth. UN agencies also hire people, and the public sector gets people from [non-governmental organizations]. But what we've seen is an expansion of the total number of people available.

What can you say about the reports from Uganda alleging that PEPFAR's strategy of focusing on abstinence has reduced condom use and resulted in a greater spread of HIV?

It would be nice to look at facts. In 2001 we supported 7 million condoms for Uganda. In 2005 it was 45 million. It's tough to argue we are shying away from condoms in Uganda.

What we try to do is support the local programme, which is the ABC [Abstinence, Be faithful, use Condoms] programme. It's simply untrue that we don't support full ABC programmes in Uganda all you have to do is look at the numbers. We don't do abstinence-only, except in very young kids.

Is there more that can be done, beyond ABC?

We support gender-equality programmes. We're looking at alcohol in a number of countries because alcohol is driving the epidemic. We're doing a lot of cross-generational sex education to try to reduce cross-generational sex, because the one place where stigma is good is stigmatizing older men who prey on younger women.

President Bush made a five-year commitment to the PEPFAR programme, until 2008. What happens next?

By 2008 there will be countries where PEPFAR is supporting AIDS programmes of over half a billion dollars. We can't expect countries to absorb that. We understand there is going to need to be financial support for quite a while in many of these countries. No one is talking about walking away from the support the American people have provided.

What should be the proper mix between bilateral aid (direct from the US) and multilateral aid (through organizations like the Global Fund)? Right now it should be heavily bilateral because that's where we move fastest. That doesn't mean that should be the case indefinitely and we need to look at that.

The question is what will come after, and there will be a lot of work over the next year trying to look at what that should be. Using the evidence we've accumulated through PEPFAR we'll have a sense of what should come next.

Will the PEPFAR strategy be expanded?

If we have microbicides available, if male circumcision is proven effective, these will be things we need to look at.

We need to build infrastructure, not only for implementing new technologies but also for behaviour change. We're going to need to look at that as we move forward.