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.

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.

The major U.S. government program engaged in the worldwide war on the HIV/AIDS epidemic requires those in the field to tell at-risk communities that latex condoms aren't very reliable in preventing transmission of the disease, and instead to emphasize abstinence and fidelity programs.

But several key government agencies and the condom industry disagree with that approach, saying the message is wrong. They maintain that condoms are a vital weapon in fighting the spread of the disease and that they are more effective than the government program acknowledges.

The report, summarizing a workshop in 2000 co-sponsored by the U.S. Agency for International Development (USAID), the Federal Drug Administration, the National Institutes of Health and the Centers for Disease Control and Prevention, found that condoms are "essentially impermeable to particles the size of [sexually transmitted disease] pathogens."

In 2004, the Joint United Nations Program on HIV/AIDS (UNAIDS), the World Health Organization and the United Nations Population Fund released a joint position statement supporting the availability of condoms universally, not only to the parts of the population that are at high risk for contracting HIV, as the President's Emergency Plan for AIDS Relief (PEPFAR) provides, but also to the general population.

Despite those findings, the $15 billion PEPFAR program has been saying that condoms are only 80 to 90 percent effective. The study cited by PEPFAR giving this low range of effectiveness was not exclusively a latex condom study and could have included natural membrane or lambskin condoms which are not recommended by the CDC for disease prevention.

According to the CDC, "only latex or polyurethane condoms provide a highly effective mechanical barrier." USAID refused to comment on this issue but did confirm that it distributes only 100 percent natural latex condoms.

Background

One of only two West Africa "focus countries" under the President's Emergency Plan for AIDS Relief (PEPFAR), Nigeria borders Benin, Niger, Chad and Cameroon and has a coast on the Gulf of Guinea.

Nigeria is the most populous country in Africa, comprising one-sixth of the continent's population, and ninth in the world. In its 36 states, Nigeria has more than 250 ethnic groups. Since 1991, the capital has been Abuja. Previously it was Lagos, which remains the country's largest city.

Nigeria declared its independence from Great Britain in 1960. For decades, Nigeria was controlled by a series of dictators, except for the period from 1979 to 1983 that was known as the second republic. In 1999, Olusegun Obasanjo became the first democratically elected president in decades. He remains in office to this day.

Nigeria has the largest Muslim population of any PEPFAR focus country: about 66 million people, or 50 percent of its population. Twelve of Nigeria's states follow Sharia, or Islamic, law.

The face of HIV

Nigeria has the third-highest number of people living with HIV/AIDS in the world, behind India and South Africa. The first case of AIDS in Nigeria was diagnosed in 1986. HIV rates tend to be higher in urban areas than rural areas, but more research needs to be done to understand the variations found within the country.

About a third of Nigeria's 36 states have HIV infection rates of over 5 percent. Estimates place 60 percent of new infections in the age group of 15 to 25.

In 1975, a family planning research program opened its doors in North Carolina, funded by a grant from the U.S. Agency for International Development (USAID). Its study narrowly focused on contraceptives and fertility, but within a decade, the nonprofit had expanded its mission beyond research, reproductive health and the borders of the United States. In 1986, it started addressing a pandemic that was jolting the world: HIV/AIDS.

Thirty years later, the once-small outfit is a giant in federally funded HIV/AIDS work. Family Health International (FHI) ranks as one of the U.S. government's top contractors through the President's Emergency Plan for AIDS Relief (PEPFAR), the five-year, $15 billion initiative to fight HIV/AIDS in 15 "focus countries" (12 in Africa, plus Guyana, Haiti and Vietnam) and more than 100 other countries worldwide.

In fiscal 2005, FHI was granted more than $100 million through PEPFAR, eclipsing most competitors' contracts by $20 million or more. It has responded to PEPFAR's emphasis on improving indigenous relief efforts by building many of the emergency fund's largest networks of overseas and grass-roots partnerships. In nearly every PEPFAR focus country, FHI has worked with hundreds of governments, community organizations, faith-based groups, medical centers and schools.

Background

Botswana lies in a region of Africa heavily burdened by HIV. It is among six countries in southern Africa that are the President's Emergency Plan for AIDS Relief (PEPFAR) "focus countries" (others include South Africa to the south and Namibia to the north and west). Along the Zambezi River to the north, it shares a border of only a few hundred yards with Zambia, another focus country. Zimbabwe, which is not a PEPFAR focus country, borders Botswana to the northeast.

Diamond, copper and nickel mining and beef exports are the country's main industries, though efforts are being made to diversify and expand the economy. Botswana supplies beef to the European Union, and its diamonds are shipped around the world.

A former British protectorate, the country gained its independence in 1966. Since then, it has experienced the most rapid growth in per capita income in the world. Unlike most African nations, Botswana has experienced almost continuous peace since its independence, which is key to implementing HIV/AIDS programs, according to Mary Kay Larson, deputy director of BOTUSA, a collaboration between the Botswana government and the U.S. Centers for Disease Control and Prevention (CDC).

"If you don't have security, you can't do much" Larson said. "Peace and stability are major, major factors of success."

The face of HIV

Almost all of Botswana's 1.7 million people are affected by HIV in some way. They are themselves infected, caring for someone who is or paying their last respects to AIDS victims. "People are always attending funerals," said Larson. In 2005 alone, about 18,000 people died from AIDS-related illnesses in the country.

While still in medical school at Harvard University in 1987, Drs. Paul Farmer and Jim Yong Kim helped found Partners in Health (PIH) with real estate developer Thomas J. White, friend Todd McCormack, and current organization head Ophelia Dahl.

Kim and Farmer are well-known names in public health: They were independently awarded MacArthur Foundation Fellowships, nicknamed "genius grants." Kim recently returned to PIH after a stint as the director of the World Health Organization's HIV/AIDS Division.

PIH is based in Boston and has sister organizations in Haiti, Latin America, Russia and Africa. In addition to running programs, its Boston headquarters also raises money to support programs around the world. The organization has maintained longstanding alliances with Harvard Medical School and Brigham and Women's Hospital, one of the university's teaching hospitals.

Zanmi Lasante (Creole for "Partners in Health"), PIH's sister organization in Haiti, partners with other nongovernmental organizations (NGOs) and the Haitian Ministry of Health. Zanmi Lasante is the only provider of comprehensive primary health care for the Haiti's Central Plateau, an impoverished and largely rural state located a few hours from the capital city of Port-au-Prince.

According to Ted Constan, PIH vice president for program management, focusing on HIV and other infectious diseases such as tuberculosis, is the organization's way of addressing public health care for the poor.

"Health is just health, and then infectious disease is just our way into that fight," said Constan. "We will ride that battle horse into the fight against poverty, but our goal is poverty reduction and to bring communities out of despair into what we often call a virtuous social cycle where they can lift themselves up and take care of themselves."