The outlook in the early 1990s for HIV-positive Kenyans was bleak when Warren W. Buckingham first began working in the eastern African country.

Buckingham, who arrived in Kenya as part of the U.S. Agency for International Development (USAID), tells the story of his Kenyan friend whose brother had been diagnosed with HIV. “I wish he would just hurry up and die,” the man said of his brother. Four close relatives had already succumbed to the virus, and his family had been driven to abject poverty while caring for each sick relative. The man’s view was clear: HIV brought shame, poverty and ultimately death into his family.

Today, the picture is very different. Any Kenyan diagnosed with HIV is eligible to receive comprehensive treatment and care. In Kenya, access to drug therapy has transformed living with the virus from a death sentence to a manageable chronic disease. While many Kenyans who need to be on treatment are not, Buckingham, who is now the country coordinator for the President’s Emergency Plan for AIDS Relief (PEPFAR), has noticed that attitudes toward the disease are changing. There is now hope in a country where 6.1 percent of adults are HIV positive.

Launched in 2004, PEPFAR pledged $15 billion over five years to fight the global HIV/AIDS pandemic. It set the goal of treating 2 million people with anti-retroviral therapy, preventing 7 million new infections and supporting the care of 10 million people in the program’s 15 recipient countries: Botswana, Ethiopia, Haiti, Mozambique, Nigeria, South Africa, Uganda, Zambia, Cote d’Ivoire, Guyana, Kenya, Namibia, Rwanda, Tanzania and Vietnam.

PEPFAR is the largest foreign aid program ever dedicated to a single disease. Along with the Global Fund and the World Bank, it leads the international effort against HIV/AIDS in terms of funding and strategy.

In September 2006, the third year of the program, approximately 822,000 people were on therapy because of PEPFAR support, and 61.5 million people were reached with prevention messages.

“It is unprecedented in U.S. foreign policy to put 2 million people on life sustaining therapy with no cure and no vaccine in sight,” said J. Stephen Morrison, executive director of the HIV/AIDS task force at the Center for Strategic and International Studies. “It is a huge ethical obligation.”

U.S. Global AIDS Coordinator Mark Dybul says the biggest challenge to the global fight against HIV/AIDS is “vision.” “Any time something this visionary gets started, it’s great up front . . . and then you start dealing with the bureaucracies and the politics, and things start breaking down. And then you don’t have that matching vision in the rest of the world,” he said.

Global HIV/AIDS assistance still falls far short of the need, according to UNAIDS, the Joint United Nations Program on HIV/AIDS. In 2006, for example, $8.9 billion was spent globally on HIV/AIDS, but the estimated need was $14.9 billion, according to the organization.

PEPFAR’s vision, according to Dybul, is that it recognized that HIV/AIDS was an epidemic unlike any other that had to be confronted in a completely different way.

As a result, the program shies away from the traditional — and outdated —“donor-recipient” model of development, in which a donor sets standards for countries that receive its aid, and instead works as a partnership between the United States and low- and middle-income countries, Dybul said.

Instead of combating HIV/AIDS by region or continent, PEPFAR has a country-based system in which each country must come up with its own strategic plan tailored to local needs and priorities.

As a result, PEPFAR supports different intervention strategies in each country. For example, Vietnam’s HIV/AIDS prevention program recently began to support substitution therapy — which weans addicts by giving them alternative medications — to help prevent transmission of HIV through intravenous drug use. In Haiti, PEPFAR cooperates with a USAID microfinance program, providing women who receive loans with information on HIV/AIDS.

In April, the House Foreign Affairs Committee held a hearing on PEPFAR’s progress in preparation for the program’s reauthorization, still a year away.

“The battle against HIV/AIDS is a marathon, it is not a sprint,” said Committee Chairman Tom Lantos, D-Calif.

While the program is often regarded as an unprecedented aid approach, there is concern among international development workers that the program’s high visibility siphons attention and resources away from more basic — but highly critical — issues such as poverty and childhood diseases.

“PEPFAR needs to be more in-sync with other health and [poverty reduction] goals,” said Smita Baruah, senior policy associate for government relations at the Global Health Council. One frustration is that PEPFAR money cannot be used for childhood immunizations and that PEPFAR clinics that give medication to prevent mother-to-child-transmission of HIV/AIDS do not offer prenatal care, Baruah said. “To treat HIV patients, you need clean water, nutrition and basic health services,” she said.

In Haiti, the largest obstacles to combating HIV/AIDS are “joblessness, malnutrition and poverty,” according to Judith Timyan, a senior technical adviser to the USAID mission in Haiti. Not only do those factors drive transmission of the infection — for instance, poverty compels young women into prostitution —but they make life difficult even for those on treatment. “We save people from the brink of death [and return them to] a very grim situation,” Timyan says.

A recent report on PEPFAR by the Institute of Medicine found that the program was on the path to meeting its goals, but recommended that PEPFAR should “continue to transition from its focus on emergency relief to an emphasis on the long-term strategic planning and capacity-building.”

The report echoed a common refrain that Dybul frequently discusses. While HIV/AIDS might be an exceptional disease, it cannot be treated in isolation from other conditions, such as malaria, tuberculosis and malnutrition — especially because people who have HIV/AIDS are more susceptible to other life-threatening diseases.

Dybul has said the program has already tapped into ways to combine resources — for instance, PEPFAR-funded laboratories are now used to diagnose tuberculosis.

At the congressional hearing, Dybul said the possibility of using new technologies — such as a vaccine and microbicides — in combating the epidemic are still far off. He noted that PEPFAR is looking at circumcision programs that recent studies have found provides protection for men against HIV/AIDS.

An estimated 39.5 million people worldwide have HIV/AIDS, according to UNAIDS. In 2006, approximately 2.6 million people died from AIDS and 4.3 million people became infected with HIV. Almost two-thirds of all people with HIV/AIDS live in sub-Saharan Africa.