BUSH'S GLOBAL AIDS EFFORT LIMITED BY RESTRICTIONS

President Bush's $15 billion plan to fight AIDS globally is seriously
hampered by restrictions imposed by Congress and the administration,
a panel of medical experts said yesterday.

The country's most prestigious medical advisory panel, the Institute
of Medicine, was asked by Congress to assess the five-year plan at
midway. The 13 members of the panel praised the efforts, saying the
plan had "demonstrated what many doubted could be done." But it needs
to move from an emergency response to a long-term battle plan, the
panel said, and its members listed these three restrictions that they
felt were the most hindering:

- -- The requirement that 33 percent of all money for prevention be
spent teaching chastity and fidelity, even in countries where most
cases are spread by drug injection.

- -- The need for separate Food and Drug Administration approval of
AIDS drugs that the World Health Organization has already approved.

- -- Laws forbidding the use of taxpayer money to give clean needles to
drug addicts.

Ruth Macklin, a bioethicist at the Albert Einstein College of
Medicine in the Bronx and a panel member, called the restrictions
"hamstrings or shackles," though Dr. Macklin said the report
diplomatically referred to them as "earmarks or budget allocations."

"There's a feeling that when reporting to Congress you have to
pussyfoot around a bit and show respect for the legislation," she said.

Dr. Mark R. Dybul, the global AIDS coordinator who oversees the
President's Emergency Plan for AIDS Relief, known as Pepfar, said he
welcomed the report as "quite an endorsement of our program," but
disagreed with the panelists on some aspects.

"I don't think we're hampered too much by the restrictions," Dr. Dybul said.

The $15 billion that Mr. Bush promised in his State of the Union
address in 2003 is far more than any other country has spent fighting
AIDS outside its borders and far more than any previous
administration spent. Though the ambitious plan has not yet helped as
many people as its original goals envisioned, the panel endorsed
financing it beyond its 2009 expiration date.

"Over all, Pepfar is doing quite well, has made a good start, but it
needs to transition from emergency mode to a sustainable effort,"
said Dr. Jaime Sepulveda, director of the National Institutes of
Public Health in Mexico and the panel chairman.

With its limited money, the program has to focus much more on
prevention than treatment. "Otherwise," Dr. Sepulveda said, "the
epidemic will never end."

He added that the plan needed more freedom to tailor its responses to
each of its 15 "focus countries," Guyana, Haiti, Vietnam and 12
African countries.

Congress requires that 55 percent of the budget be spent on
treatment, 15 percent on care for the dying and 10 percent on
children and orphans. Of the 20 percent left for prevention, a third
must be spent on promoting abstinence until marriage.

The law against using taxpayer dollars for needle swaps predates Pepfar.

Critics have said that under pressure from those directives and
conservative Christians, the plan tends to give condoms to
prostitutes and truckers but only abstinence advice to young people
and counseling rather than clean needles to drug addicts, and does
too little for women and girls likely to be infected by rape or by
their husbands.

The rules forbid using the money to distribute condoms in schools,
the panel said, and "returning to abstinence" is a primary message
for youths having sex.

"Given the reported early average age of sexual debut (and sometimes
marriage) in many countries, Pepfar may wish to re-examine its
exclusive AB focus for younger adolescents," the report said.

AB is short for "abstinence/be faithful."

Dr. Dybul has often rejected such criticisms, saying that young
children should be given abstinence messages and that his agency can
still tailor its approach because the mandates apply to overall expenditures.

"A lot of what they suggest is exactly what we're trying to do," he
said. "I'd be worried, for instance, if we didn't have a mandate that
we spend 10 percent on orphans, because without it we wouldn't have
made such progress there."

When the panel visited AIDS treatment programs in Africa, Dr. Charles
C. J. Carpenter, head of AIDS research at the Brown University
medical school and a panel member, said doctors complained that they
could buy three times as much medicine if the program accepted W.H.O.
approvals.

Dr. Dybul should assess the W.H.O. approval process, Dr. Carpenter
said, and, "if it's equally good, we think we should accept it."

Dr. Dybul said he saw little need for that because he felt that the
foreign doctors' complaints were outdated. The F.D.A. has recently
approved more low-priced generic drugs, including three-in-one
antiretroviral cocktails.

He also disagreed that the program should pay for clean needle
programs, saying it paid for methadone for infected addicts.

"Needle exchange just continues the condition," Dr. Dybul said. "If
other countries want to fund it, that's fine with us."

At its halfway point, the program is not halfway toward meeting its
goals, which included treatment for 2 million people, caring for 10
million and preventing 7 million new cases of AIDS by 2010.

As of September, the program was underwriting treatment for 822,000 people.