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.

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.

Background

Mozambique is a large country situated on the southeastern coast of Africa. To the north lie Tanzania and Malawi; Zambia lies to the northwest; Zimbabwe lies to the west; and Swaziland and South Africa lie to the south. Mozambique has a 1500 mile shoreline on the Indian Ocean.

This country of just under 20 million people is divided into 10 provinces. Maputo, the capital, lies on the southern coast. The majority of the population lives below the poverty level, and foreign aid comprises much of the country's budget.

A former colony of Portugal — which controlled of the country for nearly five centuries — Mozambique won independence in 1975, a decade after most other European colonies in Africa had gained autonomy. Portuguese is the official language.

From 1977 to 1992, nearly 1 million Mozambicans died from famine and fighting in conflicts between the ruling Front for the Liberation of Mozambique and the Mozambique National Resistance, a group of rebels funded by South Africa. Though a U.N.-negotiated ceasefire formally ended the fighting in 1992, the countryside remains riddled with landmines.

The face of HIV

AIDS is the leading cause of death for adult Mozambicans and fifth for children under 5. The country has the 10th-highest HIV rate in the world. The first case of AIDS in Mozambique was a Haitian doctor who was diagnosed in 1986 and died three days later.

According to the U.S. Centers for Disease Control and Prevention, the epidemic in Mozambique mainly strikes in areas where there is poverty and limited health care services and in corridors through which large numbers of people pass.

Measuring the success of World Vision's efforts might require little more than turning on a TV. The Christian relief organization has capitalized on direct funding appeals since 1950, most notably commercials featuring hungry children in impoverished countries that encourage child sponsorship.

The result? Almost $650 million in annual direct giving in fiscal 2005, supplying the bulk of World Vision's $900 million revenue that year.

World Vision has spread its wealth over nearly 100 countries in which its 22,000 employees work to improve the lives of Third World children and families. The organization is known for providing access to clean water, food and education for sponsored children, and more recently has tackled natural disaster and HIV/AIDS relief.

Child and family sponsors, whom World Vision calls "stewards of God's resources," are the nonprofit's primary funders, but a fair share of the budget is also supported by the U.S. government.

In fiscal 2005, World Vision received more than $240 million in federal funding, continuing a 30-year financial relationship. Although direct sponsorship can be used to provide "spiritual nurture" and all employees must assent to a statement of Christian faith, World Vision said its government funds are not used for religious purposes.

In HIV/AIDS relief specifically, World Vision's prevention, care and advocacy work has been largely financed through U.S. Agency for International Development (USAID) grants.

Its work has carried over into the President's Emergency Fund for AIDS Relief (PEPFAR), the Bush administration's five-year, $15 billion initiative to fight HIV/AIDS in the world. Through PEPFAR, World Vision administered more than $11.7 million for programs in Haiti, Kenya, Mozambique, Tanzania, Uganda and Zambia in 2005.

Background

Located on the southwestern coast of Africa, Namibia borders four countries: Angola and Zambia to the north, Botswana to the east and South Africa to the southeast. Except for Angola, all are designated "focus countries" by PEPFAR, the President's Emergency Plan for AIDS Relief, the five-year, $15 billion U.S. initiative to combat AIDS abroad. Namibia was part of Germany's holdings in Africa until World War I, after which the League of Nations transferred control to South Africa. In 1990, after decades of war and international pressure, South Africa released its claim and Namibia attained independence.

The second most sparsely populated country in the world, Namibia is divided into 13 regions that are further divided into 102 constituencies. Windhoek is the capital.

Namibia's economy is very dependent on mining. Twenty percent of its gross domestic product comes from the extractive industries, including uranium and diamond mining. Subsistence farming accounts for the livelihoods of nearly half of Namibia's population.

While Namibia's gross national income per capita is several times that of sub-Saharan Africa's poorest countries, rampant unemployment means most of the population lives below the poverty level.

Like many southern African countries, Namibia has a diverse population. More than 87 percent is black African, with about half of the nation belonging to the Ovambo tribe. Whites and mixed-race groups each comprise about 6 percent of the population.

Afrikaans is the most widely used common language in Namibia, spoken by nearly all blacks and 60 percent of whites. English, the official language, is widely understood among the younger generation. But both languages are generally second tongues, reserved for the public sphere, while indigenous languages are spoken at home. About half of all Namibians speak Oshiwambo, the Ovambo tribe's language.

Clara Barton founded the American Red Cross (ARC) in 1881, out of a desire to offer neutral humanitarian care to Americans "in peace and in war, during times of disaster and national calamity," according to the organization's Web site. Over the years, it has extended its services at home and abroad.

The American Red Cross is one of 66 organizations that have directly received funding from the U.S. government to implement abstinence-until-marriage and fidelity programs overseas. Those are two components of a wider prevention plan implemented by the Bush administration to fight HIV/AIDS, called "ABC" — which is short for "Abstinence, Be faithful and correct and consistent use of Condoms." The $15 billion President's Emergency Plan for Aids Relief (PEPFAR) is a five-year program focusing in the 15 countries with some of the highest HIV prevalence rates in the world, the majority of which are located in Africa. Besides prevention, PEPFAR also includes funding for treatment and care programs.

Funded by a $7 million award since February 2004, ARC has worked in HIV prevention, implementing the "Together We Can" (TWC) program in partnership with national Red Cross societies and Ministries of Health in Guyana, Haiti and Tanzania.

Together for a decade

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.