The Center for Public Integrity

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.

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."

Background

Rwanda is a tiny country that lies in the Great Lakes region of eastern Africa. It borders two other "focus countries" receiving funds from PEPFAR, the President's Emergency Plan for AIDS Relief: Uganda to the north and Tanzania to the east. It also lies next to the Democratic Republic of the Congo to the west and Burundi to the south.

Rwanda is situated in a particularly war-torn region of Africa. Ongoing civil violence plagues the Democratic Republic of the Congo; the Lord's Resistance Army has been fighting with government troops in northern Uganda for two decades; Rwanda itself suffered a bloody civil war in the mid-1990s. Violence is always a looming threat, with rebel Hutu Rwandan groups living in the Democratic Republic of the Congo determined to overthrow the Tutsi-run Rwandan government.

The majority Hutus and minority Tutsis are Rwanda's two main tribal groups. Relations had always been tense between them, but in 1994, extremist Hutu militia groups massacred 800,000 Tutsis and moderate Hutus in just over 100 days. Ignored by the international community as it unfolded, it is one of the worst acts of genocide on record in modern history.

It is estimated that at least 250,000 women were raped during the genocide, and, as a result, hundreds of thousands of women and girls were infected with HIV. Many of them and others were widowed and left with few resources. Only recently have steps been taken to ensure that the women receive the care and treatment they need.

The face of HIV

Rwanda is the most densely populated country in Africa. Though urban areas have higher HIV prevalence rates, new infection rates have stabilized there, while they are still increasing in rural areas, where more than 90 percent of the population lives.

Background

Côte d'Ivoire is one of only two "focus countries" in West Africa (the other being Nigeria) selected by the President's Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion U.S. initiative to fight AIDS abroad. It is bordered by Burkina Faso, Ghana, Guinea, Liberia and Mali, with its southern coast on the Atlantic Ocean.

A former French colony, Côte d'Ivoire gained its independence in 1960. At one time a prosperous tropical country, today it is torn by a civil war that began in September 2002 after an attempted coup. The northern part of the country is held by rebels, the south is controlled by the government and the middle is a buffer zone controlled by the United Nations.

The country is divided into 19 regions with Yamoussoukro as the official capital since 1983. Abidjan, the largest city and former capital, remains the commercial and administrative hub where the U.S. maintains its embassy.

There are about 60 ethnic groups in Côte d'Ivoire, the largest of which is the Akan people. French is the official national language, but each ethnic group has its own dialect and most Ivorians are multilingual. According to the U.S. Embassy Web site, almost one-third of the population is comprised of immigrants from nearby countries.

Côte d'Ivoire is the leading producer of cocoa beans in the world, with 68 percent of its labor force working in agriculture. It also has a large business sector.

The face of HIV

Côte d'Ivoire has the highest HIV infection rate in West Africa, and its worst impact is in the western part of the country. Jyoti Schlesinger, the country's PEPFAR coordinator, said that the overall rate is about 4.7 percent, according to a new demographic and health survey.

ABC: Abstinence, Be Faithful, and correct and consistent use of Condoms. ABC is part of PEPFAR's prevention program that emphasizes abstinence for youth and unmarried persons, which includes delay of sexual initiation; mutual faithfulness in a sexual relationship and reducing the number of partners for sexually active adults; and correct and consistent use of condoms for individuals engaging in high-risk sex.

Abstinence: The "A" in ABC. Abstinence programs encourage unmarried individuals to abstain from sexual activity as the best and only certain way to protect themselves from exposure to HIV and other sexually transmitted infections.

ABY: Abstinence and behavior change in youth. Interventions targeting youth that promote sexual abstinence.

AIDS: Acquired immune deficiency syndrome. An immune disorder that renders the body more susceptible to opportunistic infections such as certain types of cancers. AIDS is caused by HIV and spread primarily through body fluids, especially blood and semen.

Anti-prostitution loyalty oath: The anti-prostitution loyalty oath is a restriction applied to all HIV/AIDS funding. The amendment that legalized the oath was proposed by Rep. Todd Akin, a Missouri Republican, in July 2004. It mandates that no money designated for HIV/AIDS programs "may be used to promote or advocate the legalization or practice of prostitution or sex trafficking." It also requires that any organization that receives U.S. government funds to combat HIV/AIDS must explicitly state that it opposes prostitution and sex trafficking in order to receive federal funding.

Background

Tanzania is the largest country in eastern Africa. It lies between Mozambique and Kenya and has a coastline on the Indian Ocean. It also borders Malawi, Zambia, Democratic Republic of the Congo, Uganda, Rwanda and Burundi. The country is divided into 26 regions, 21 of which are on the mainland (formerly Tanganyika) and five on the island of Zanzibar.

Tanganyika was a German colony — part of German East Africa — from the late 19th century until the end of World War I, when a League of Nations mandate ceded control of most of the territory to the United Kingdom. The island of Zanzibar was an early Arab and Persian trading port that was made a British protectorate in 1890 as part of an Anglo-German agreement. In the early 1960s, both the mainland and island gained independence from Britain, soon merging to form the United Republic of Tanzania. The country remains comprised of those two semiautonomous states, and political tensions persist between the island and the mainland.

Tanzania has been ruled by the same party, Chama Cha Mapinduzi (CCM), since its independence. In 1995, the first multiparty elections were held, but CCM, led by Benjamin Mkapa, retained control. In December 2005, Jakaya Mrisho Kikwete, previously the foreign minister, was elected to a five-year term as president, the fourth since the country's independence from the U.K. in 1961.

The face of HIV

The first case of AIDS in Tanzania was diagnosed in 1983. Four years later, there were cases in every Tanzanian district. AIDS is the leading cause of death in Tanzania, responsible for about 30 percent of all fatalities.

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.