The New York Times - April 28, 2009
Neil Macfarquhar

The President's Emergency Plan For AIDS Relief, known as Pepfar, was championed by President George W. Bush. It is expected to spend $48 billion over the next five years and is credited with markedly reducing the disease's death rate. Its prevention policy has been controversial because of its emphasis on socially conservative methods.

With a new administration and a Democratic majority in the House, organizations seeking prevention choices beyond abstinence and fidelity -- including a renewed commitment to distributing condoms -- are eager to try to rewrite the guidelines.

Dr. Goosby, 56, will probably become the lightning rod for that fight once he is confirmed by the Senate as the State Department's global AIDS coordinator and ambassador at large. The doctor, a medical professor at the University of California, San Francisco, has a long career in public health that includes senior posts in the Clinton administration.

He declined to be interviewed, but in acknowledging the appointment, he hinted at his sympathies. "The Pepfar program has already saved millions of lives in sub-Saharan Africa and other hard-hit areas around the world," Dr. Goosby said in a statement. "But significant challenges relating to the prevention and treatment of H.I.V. remain."

Supporters of loosening the guidelines want to include family planning programs that they say would give women more options in avoiding AIDS.

"What we have found is that the disproportionate emphasis on abstinence and fidelity has led to the destruction of a comprehensive approach," said William A. Smith, the vice president for public policy at Siecus, the Sexuality Information and Education Council of the United States.

Those pushing for change point to a recent study that shows that although Pepfar money has made a significant dent in the death rate, the infection rate has remained steady. The study, published this month in the Annals of Internal Medicine, showed that by 2007, four years after Pepfar was organized, AIDS deaths had dropped by 10.5 percent in countries with the program. But infections climbed in all the countries studied.

In the past, maternal health organizations and AIDS organizations have been divided on how to handle financing with stipulations. In recent months, activists said, the Bill and Melinda Gates Foundation has led an attempt to make peace so both camps could press for the same guidelines.

Some guidelines on spending will come from Dr. Goosby, but some policies were written into the law. These included the stipulation that organizations receiving money be able to opt out of aspects they opposed.

Critics said the ability to opt out meant AIDS prevention programs were unbalanced in places where they were run by faith-based organizations.

If the choice of opting out of the program is removed, then Catholic and missionary programs are likely to be discontinued, and millions will be denied health care, said Bill O'Keefe, the spokesman for Catholic Relief Services, which rejects condoms in its prevention programs.
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