Is AIDS still an emergency?

How you answer that question probably says a lot about whether you think U.S. President Barack Obama's approach to fighting HIV/AIDS abroad is a good idea or a dangerous detour.

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In recent weeks, a growing number of organizations have stepped forward to criticize the Obama administration for allegedly backtracking on a global health battle the world was starting to win. Groups as diverse as Médecins Sans Frontières and the Congress of South African Trade Unions argue that Obama is flat-lining funding for lifesaving anti-retroviral (ARV) treatments, just as the financial crisis is biting hard at other international funding too. They worry that the world could start to lose momentum, failing to keep up with the epidemic's alarming advance.

The U.S. administration counters that more money than ever is going into global health -- it's just no longer myopically focused on HIV/AIDS. The United States responded to the HIV/AIDS emergency a decade ago, the policy's defenders say; now it's time to take a broader, more sustainable approach that can eventually move patients away from their reliance on the United States. As congressional appropriations come up for 2011, battle lines are being drawn.

The fact that this debate is even taking place is a credit to the unsung legacy of a man global AIDS campaigners never expected would be their biggest ally: George W. Bush.

Bush's plan for combating the disease, called the President's Emergency Plan for AIDS Relief (PEPFAR) was an astounding success, exceeding all hopes. When his administration launched the program in 2003, HIV/AIDS was ravaging the developing world, taking the harshest toll on Africa. In some countries in southern Africa, as many as one in four were infected. Public awareness about infection and prevention was minimal, and ARV treatments, which help suppress HIV in infected patients, were scarcely available outside the West. The death rates were staggering -- 8,000 a day worldwide -- picking off adults in the prime of their economic lives and robbing countries of able-bodied workers.

PEPFAR was nothing less than a breakthrough. Bush offered $2.4 billion in its first year alone, pumping funds into preventing the disease through an ABC approach (Abstinence, Be faithful, use Condoms), testing patients for HIV infections before they spread, and treating patients with ARV drugs. Today, about 2.5 million people receive ARV treatment through PEPFAR -- more than half of the global total of patients on ARV treatment.

It was also a breakthrough politically. By focusing heavily on treatment, liberal and conservative members of Congress dodged the political flashpoints of abortion and condom use and forged an overwhelming consensus of support. "The United States is doing far more for Africa today than a decade ago largely because evangelicals became a strong constituency for the Pepfar AIDS program and the PMI malaria program," New York Times columnist Nicholas Kristof explained in February. With the Bush's firm backing, PEPFAR also avoided the kind of slow, cumbersome bureaucracy that has long held back the U.S. Agency for International Development, for example, and became one of the single most efficient aid efforts of the last half-century.

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