When George W. Bush proposed his five-year, $15 billion initiative to "turn the tide against AIDS" in the developing world in 2003, he said the availability of low-cost drugs to fight the disease "places a tremendous possibility within our grasp."

Bush told Americans in his State of the Union address that the per-patient cost of antiretroviral drugs (ARVs), which improve the health and extend the lives of people who have HIV/AIDS, had dropped "from $12,000 a year to under $300 a year."

That significant decrease was a result of the competition from generic drug manufacturers. Yet Bush's initiative, the President's Emergency Plan for AIDS Relief (PEPFAR), funded by Congress a few months after that speech, has been slow to embrace funding cheaper generic ARVs.

ARV treatment is a major focus of PEPFAR and similar international programs. In addition to providing the drugs, it typically includes things such as HIV testing, counseling, monitoring for side-effects, lab tests and hospitalization.

Estimates released by PEPFAR reveal that in 2004 and 2005, its first two fully funded years, the plan allocated only about 5 percent of its overall ARV drug budget — less than $15 million — for generic drugs. A key reason for that lies in PEPFAR's own rules: only ARVs approved by the U.S. Food and Drug Administration (or given tentative FDA approval through an expedited review process set up in May 2004) can be procured with the program's funds.

While the president's AIDS initiative was still on the drawing board, that proposed stipulation drew fire from some, including Rep. Henry Waxman of California.

JHPIEGO (its name is not an acronym), a nonprofit health organization affiliated with The Johns Hopkins University, works worldwide to "train trainers" — whether they are hospital employees or African village laymen.

JHPIEGO draws on resources from Johns Hopkins' schools of Public Health, Medicine and Nursing, but doesn't offer medical treatment or family services. The organization trains people overseas to do that instead, and mainly uses local medical practitioners and trainers to run its programs.

"Our focus is on establishing the system," said Sam Dowding, acting director of JHPIEGO's Center of Excellence on HIV/AIDS. "We work in institutions where we train the trainers, so in 5 years, 10 years, it continues to be self-sustained."

The organization's funding largely comes from the federal government, which has backed the organization since its first day in operation.

In 2005, the Presidents Emergency Plan for AIDS Relief, a five-year, $15 billion initiative to fight AIDS abroad, granted the organization $8.2 million for its efforts in Côte d'Ivoire, Ethiopia, Mozambique, South Africa, Tanzania and Zambia. The funding accounted for more than a fifth of JHPIEGO's $37.5 million program expenditures and built on its work in more than 90 countries worldwide.

But at least one of JHPIEGO's programs has been debated in international circles and was not supported by PEPFAR.

Working history with U.S. government

For more than 30 years, JHPIEGO has been working with the U.S. Agency for International Development to improve health care services for women and families in developing countries.

It was founded in 1973 to implement a five-year USAID grant to train obstetricians and gynecologists. After the grant's extension, JHPIEGO expanded its global presence through partnerships with USAID, then with private foundations and other international health organizations.

Although its name suggests a scholarly focus, the Academy for Educational Development's reach extends far beyond the classroom. AED is organized into 27 "centers of excellence" and has programs in 167 countries, making it one of the world's largest nonprofits addressing human and social development.

AED has forged partnerships with governments, companies and communities around the world, but perhaps none has been more crucial than its relationship with the U.S. government. In fiscal 2004, AED's federal, state and local grants, combined with its program-related revenues (including government contracts) amounted to nearly 80 percent of the organization's quarter-billion-dollar budget.

Government support is vital to the academy's HIV/AIDS efforts. According to Michael Kaplan, vice president and deputy director of AED's Center on AIDS and Community Health, the U.S. government historically has been AED's largest funder for its HIV/AIDS efforts. In 1987, for example, AED was awarded one of the U.S. Agency for International Development's first global HIV/AIDS relief contracts.

AED's work has carried over into participating in the President's Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion initiative to fight AIDS in 15 focus countries (Vietnam, as well as 14 in Africa and the Caribbean) and more than 100 other nations. Through PEPFAR, AED was allocated $11 million in 2005 for its programs in Botswana, Haiti, Kenya, Namibia, Nigeria, South Africa, Tanzania, Vietnam and Zambia.

Background and PEPFAR programs

AED was founded in 1961 as an initiative to study the higher education system in Kansas. Over the next 40 years the organization expanded domestically and internationally to help build local sustainability. AED now also focuses on environment and energy policy, health, youth initiatives, leadership and democracy and HIV/AIDS relief.

Cooperative for Assistance and Relief Everywhere Inc. (CARE) debuted in the international humanitarian arena in 1945 to aid survivors of World War II. Over two decades, more than 100 million food parcels, the legendary "CARE packages," were delivered in Europe.

In 1966, CARE started phasing out the food packages as the core of its mission while moving on to other projects. Health, children and poverty are now at the center of its work. But the organization also focuses on education, combating HIV/AIDS and emergency disaster relief. Across the board, CARE strives to give poor women resources because, the organization's literature says, "women have the power to help whole families and entire communities escape poverty."

Among the world's largest private international humanitarian organizations, CARE spent more than $514 million in 2005 on its programs around the world. Its tax returns filed with the Internal Revenue Service between the 2000 and 2004 tax years show that, historically, CARE has obtained the bulk of its funds from governmental agencies such as the U.S. Agency for International Development (USAID). For example, 70 percent of its funds in 2003 and 57 percent for fiscal 2004 (the most recent fiscal-year records available) came from the government.

Care for HIV/AIDS

The relief group started addressing HIV/AIDS in 1987 in Thailand. Today, CARE has more than 150 programs tackling the causes and consequences of the virus in nearly 40 countries and reaching more than 7 million people, according to agency spokeswoman Alina Labrada.

The announcement of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion initiative launched in 2003 to fight HIV/AIDS abroad, again infused CARE programs with federal funds.

Hope worldwide is a faith-based global charity founded in 1991 by the International Churches of Christ (ICOC), a denomination that grew out of the Boston Church of Christ established by charismatic preacher Kip McKean in the late 1970s. The relief agency's Web site says that it was created "in response to the Scriptures that call us to have the heart of Jesus by serving the poor and needy throughout the world."

In the early 1990's, ICOC was one of the fastest growing churches in the United States. The church's methods of spreading its religious message, treating its members and recruitment practices were the focus of significant news coverage. In a 1993 ABC News exposé and a 1994 New York Times article, former members of ICOC compared the ministry with a cult and characterized its operations as brainwashing. However, McKean's own rule that church leaders should step down if one of their own children leaves the church forced him to resign as ICOC leader in 2002 after his daughter Olivia left the church.

Hope worldwide's income grew from less than $800,000 in 1991 to $39.9 million by the end of 2004. When launched, 95 percent of Hope worldwide's revenue consisted almost exclusively of ICOC donations. Nowadays, that percentage has dropped to 5 percent as reported in the agency's 2004 annual report, the most recent one available.

The organization's funding sources, besides from churches, are a variety of corporate, federal, state and local government grants, individuals and volunteer fundraisers. The Bill and Melinda Gates Foundation and the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis have been among the group's supporters.

Background

South Africa occupies the entire southern tip of Africa. The 25th-largest country in the world, South Africa borders Namibia, Botswana, Zimbabwe, Mozambique and Swaziland, and it surrounds the kingdom of Lesotho.

South Africa has a diverse population and a rich yet controversial history. It was first colonized by the Dutch; Great Britain took control in 1806. With the discovery of diamonds and gold in the late 19th century, European immigration to the territory greatly increased, as did subjugation of the indigenous peoples. Apartheid — an official policy of racial segregation — was born of this era and continued after South Africa gained independence from Great Britain in 1961. It was ended after the election of 1994 created a black-majority government.

During apartheid, the white minority held the political and economic power. Policies of apartheid South Africa were similar in some ways to the principle of "separate but equal" used during segregation in the United States; facilities and programs designated as "black only" were separate indeed, but rarely — if ever — equal.

Under apartheid, all citizens had to be registered as an ethnic group, e.g., white, black (African), colored (or mixed race), or Asian (mostly Indian). Mixing of the races was strictly forbidden, and ethnic groups were socially and sometimes geographically stratified. Myriad rules and statutes existed to create separate social spheres among the races and maintain white dominance.

Blacks were prohibited from residing in or even visiting all-white towns without special permission. Only blacks who worked in the cities were generally allowed to live in them, and even then, they often couldn't have their immediate families with them, separating spouses from each other and parents from their children. About 13 percent of the country was divided into separate "homelands" for blacks, who comprised about 80 percent of the population.

Independent media, open communication and community empowerment are what the nonprofit Internews Network strives to create — largely with the help of the U.S. government.

Since the early 1990s, Internews has been working to develop autonomous media outlets and fair media laws in more than 70 countries. In 23 countries the organization now has offices, most run by journalists native to the region in which they are working. The organization has given training to tens of thousands of journalists on issues such as diverse news coverage, media production techniques and the importance of government accountability.

Though Internews is an organization that promotes an independent press, its own autonomy is an issue it "wrestles with all the time," said Annette Makino, the organization's senior vice president for communications. The vast majority of Internews' efforts are bankrolled by the U.S. Agency for International Development and other federal sources.

Internews' donors over the years have included foundations, individual contributors, corporations, nongovernmental organizations and foreign governments. However, all but $1.6 million of the $26.7 million in revenue it reported in 2004 came from the federal government.

The group's ties to Washington are more than financial. On its board of directors — consisting mainly of journalists, media analysts and philanthropists — sits U.S. Rep. Jim Leach, R-Iowa, whose 30-year run in Congress will end in January, and Lorne Craner, formerly a high-ranking State Department official under George W. Bush.

Although Internews has a working history with the U.S. government, it seems an unlikely candidate for funding from the President's Emergency fund for AIDS Relief, a five-year, $15 billion initiative to fight AIDS in 15 focus countries (Vietnam, as well as 14 in Africa and the Caribbean) and more than 100 other nations.

Background

Located in the northern part of the South American continent on the Atlantic Ocean, Guyana — an Amerindian word meaning "land of many waters" — is bordered by Brazil to the south and southwest, Suriname to the east and Venezuela to the west. Though located in South America, Guyana is considered, both culturally and economically, to be a Caribbean country. It is a member of the Caribbean Community and Common Market, or CARICOM.

Guyana gained independence from Great Britain in 1966 and became a cooperative republic in 1970. It is the only country in South America where English is the official language.

Guyana, which is divided into 10 administrative regions, is the third smallest independent country in South America after Suriname and Uruguay. The capital is Georgetown, which lies on the coast.

Guyana is a religiously and ethnically diverse country. The largest ethnic group in Guyana is East Indian, or Indo-Guyanese — descendants of East Indian indentured servants brought to Guyana in the early 19th century — followed by Afro-Guyanese, or Guyanese of African descent. Both groups live primarily along the coast. Guyana's rural interior is populated by several groups of Amerindians, comprising about 7 percent of the population. The predominant religions are Christianity, Hinduism and Islam.

Although Guyana is a very poor country, it ranks higher on the U.N. Human Development Index — 103 out of 177 — than any other of the "focus countries" receiving funds from the President's Emergency Plan for AIDS Relief (PEPFAR), the five-year, $15 billion U.S. initiative to combat AIDS abroad.

The face of HIV

The first case of AIDS in Guyana was diagnosed in 1987. That same year, the HIV infection rate was 1.3 per 100,000 inhabitants. By 2003, that number had ballooned to 56.2 cases per 100,000 inhabitants.