America Giveth, America Taketh Away


The New York Times

In the battle against AIDS, the Bush administration is both savior and scoundrel. Washington is the single largest financier of AIDS programs in poor countries. But the administration uses its muscle to extinguish necessary and successful programs it finds politically objectionable, and to carry out ineffective ideological crusades.

First the good news. Washington's financing for AIDS treatment does not go as far as it could because American programs have been buying only expensive brand-name drugs, a sop to the pharmaceutical lobby. Administration officials have said that without approval from the Food and Drug Administration, they can't be sure that generics are safe and effective, even though the World Health Organization has endorsed many of them and AIDS programs around the world use them with excellent results. It's not a question of science: the drugs cannot be used in the United States because they would violate patents, so the F.D.A. never examined them.

Until now. Last week, the F.D.A. approved for overseas use two Indian-made generic versions of nevirapine, a standard ingredient in the triple cocktail, and a generic version of efavirenz, another widely used antiretroviral. That brings the number of approved generic antiretrovirals to seven. While none are yet in use in Washington's overseas programs, the approvals will eventually allow four times as many lives to be saved for the same amount of money.

Also last week, however, the administration was on a moral crusade that could lead to a significant rise in AIDS cases in Russia, China, elsewhere in Asia and in the former East bloc. In these places, drug users who inject are a prime risk group for AIDS, and the gateway through which the epidemic will spread into the general population. As many as a third of new AIDS infections outside sub-Saharan Africa are in drug users; in Russia, UNAIDS estimates that injecting drug users are 80 percent of the infected. Needle exchange programs can help control this part of the epidemic.

But at a UNAIDS policy meeting this month, a Bush administration official asked that all references to needle exchange be dropped from the group's governing policy paper.

UNAIDS doesn't control much money, but it sets world policy on how to fight AIDS, and usually operates by consensus to give its recommendations more force. Although America is virtually alone in its opposition to needle exchange, its clout as the largest UNAIDS donor means it might be able to win a vote this week in the group's program coordination board. If UNAIDS could no longer work on needle exchange, nations would lose a valuable source of technical help. And a lack of consensus could keep countries from starting needle exchanges.

American law already forbids United States money from financing needle exchange programs. For Washington to decide that it wants to stop everyone else from doing that as well is a breathtakingly dangerous step.