US President George W. Bush launched the $15 billion plan in 2003 to expand prevention, treatment and support programs in 15 hard-hit countries, 12 of them African – including Rwanda, which account for more than half the world's estimated 33 million AIDS infections.
The initiative tied in with a World Health Organization campaign to put 3 million people on AIDS drugs by 2005 – a goal it says was reached in 2007.
Last year, Mr. Bush asked US lawmakers for expansion of the program- more than tripling the budget to $48 billion over the next five years.
In Rwanda, by the end of 2008, the program – along with the Global Fund to Fight AIDS, Tuberculosis, and Malaria – has put 58,325 people on much needed treatment – receiving free antiretrovirals, up from a few hundreds in 2003.
Government estimates point to about a 3% prevalence of HIV in a population of about 10million, down from about 10% some years back. Other assessments say the average prevalence may be between 3 and 5 percent among the adults.
That is a level far below many of Rwanda’s neighbours and dramatically lower than in countries such as Botswana where 40% of the adult population is infected, according to local campaigners.
In 2007, Rwanda got some $103million from PEPFAR, with more than 70% earmarked for care and treatment alone. Prevention gets just $17.8million going to prevention of mother-to-child transmission (PMTCT), abstinence and faithfulness programs, condom and other prevention strategies.
But the task remains enormous. Although there are no immediate figures on Rwanda, more than 1.5 million Africans died in 2007, fewer than one-third had access to treatment, and new infections continued to outstrip those receiving life-prolonging drugs.
There continue to be detractors who say the U.S. government should have channeled the money through the U.N.; that it has placed too much emphasis on faith-based groups and abstinence; that it has trampled on women's health by shunning anything associated with abortions; that it has concentrated on AIDS treatment at the expense of prevention; and that it has diverted attention away from bigger killers like pneumonia and diarrhea.
“There are health centers where basic infections go untreated and women lack pre-natal care yet AIDS is well treated. That’s not acceptable”, says Dr. Josh Ruxin, Assistant Clinical Professor of Public Health, Columbia University, and has worked in rural Bugesera district for several years.
“The US program should embrace all aspects of basic primary health care, particularly maternal and child health — two areas that have suffered budget cuts during Bush’s tenure”, he points out.
Rwanda government figures suggest infections among married couples are going up – with increasing cases of discoundance – where one of the partners is infected. The findings prompted government to launch a massive nationwide campaign in December to test all couples.
The UN report in July said young people in Rwanda and some other countries could be getting to know about sex, and actually having it at a very early age. This brought to doubt the performance of the ‘Witegereza’ campaign launched by government aimed at encouraging parents to speak openly on sexuality with their children.
The National Aid Commission says it would have to wait for more definitive national data before committing more resources to sexual abstinence efforts. A national survey of youth sexual behavior in the country is ongoing due for completion in 2010.
For Dr. Ruxin, the fact of the matter is that overall, the war against the pandemic is “being lost”, and it “remains a death sentence”, but not in Rwanda.
“Rwanda’s success — largely due to strong leadership and competent execution of programs — shows that even a poor country can potentially bring the disease under control”, he says.
Campaigners say PEPFAR in part manifests one of the Bush administration’s core principles: ideology is more important than science.
In public health, argues Dr. Ruxin, such an approach is invariably disastrous.
In PEPFAR’s programming, abstinence promotion and faithfulness promotion received extraordinary levels of funding in spite of a mixed bag of findings, including studies showing that both could actually increase HIV transmission.
“For example, students enrolled in abstinence promotion programs tend to have sex later in life, but do so without condoms” Dr. Ruxin notes.
Activists say the new Administration of President Barak Obama must make it clear from the start that it seeks results, not the promotion of a particular point of view.
A Modes of HIV Transmission (MoT) study, funded by UNAIDS – concluded last year covering five countries – including Uganda, shows that the epidemic is changing its face with rising infections. The study was done in a bid to understand the new face of the scourge and the possible sub-epidemics that may be causing the rise in cases.