Decision Points

collective soul.
    By early 2002, I had concluded that the Global Fund was not a sufficient response to the AIDS crisis. While America had increased our contribution to $500 million, the Fund was short on money and slow to act. Meanwhile, the AIDS epidemic was sending more Africans to their graves. The majority were between ages fifteen and forty-nine, the key demographic for productive nations. Left unchecked, the disease was projected to kill sixty-eight million people by 2020, more than had died in World War II.
    I couldn’t stand the idea of innocent people dying while the international community delayed. I decided it was time for America to launch a global AIDS initiative of our own. We would control the funds. We would move fast. And we would insist on results.
    Josh Bolten assembled a team * to develop recommendations. In June, they came to me with a proposal to focus on one particularly devastating part of the AIDS crisis: its impact on women and children. At the time, 17.6 million women and 2.7 million children were living with HIV/AIDS. Every forty-five seconds, another baby in Africa was born with the virus.
    Recently, scientists had discovered new medicines, particularly a drug called Nevirapine, that could reduce the rate of mother-to-child transmission by 50 percent. But it was not widely available in Africa or other parts of the developing world. The team proposed spending $500 million over five years to purchase medicine and train local health-care workers in the most heavily affected African and Caribbean countries.
    “Let’s get it started right now,” I said. The plan was tailored to a specific part of the crisis in the neediest parts of the world. It put local officials in the lead. And it had an ambitious but realistic goal: to treat one million mothers and save one hundred fifty thousand babies every year after five years.
    On June 19, 2002, I announced the International Mother and ChildHIV Prevention Initiative in the Rose Garden. In seventeen months, we had doubled America’s commitment to fighting global AIDS.

    The morning I unveiled the mother and child program, I called Josh Bolten into the Oval Office. “This is a good start, but it’s not enough,” I told him. “Go back to the drawing board and think even bigger.”
    A few months later, he and the team recommended a large-scale program focused on AIDS treatment, prevention, and care—the strategy that would ultimately become PEPFAR.
    The first part of the proposal, treatment, was the most revolutionary. Across Africa, it was estimated that four million AIDS patients required antiretroviral drugs to stay alive. Fewer than fifty thousand were receiving them. Thanks to advances in drug technology, AIDS treatment regimens that used to require thirty pills a day could be taken as a twice-a-day cocktail drug. Soon, only one pill was required. The new medicine was more potent and less toxic to patients. And the price had declined from $12,000 a year to under $300. For $25 a month, America could extend an AIDS patient’s life for years.
    “We need to take advantage of the breakthrough,” I told the team, “but how will we get the drugs to the people?”
    Tony Fauci described a program in Uganda led by Dr. Peter Mugyenyi , an innovative doctor who operated an advanced clinic and was one of the first people to bring antiretroviral drugs to Africa. At one Oval Office meeting, Tony showed me photos of Ugandan health workers from TASO climbing aboard motorcycles to bring antiretroviral drugs door-to-door to homebound patients. While only partially complete, the Mugyenyi and TASO programs showed what could be possible with more support.
    In addition to treatment, Uganda employed an aggressive prevention campaign known as ABC: Abstinence, Be faithful, or else use a Condom. The approach was successful. According to estimates, Uganda’s infection rate had dropped from 15 percent in 1991 to 5 percent in 2001.
    PEPFAR would include one additional element: caring for victimsof AIDS, especially orphans. It broke my heart that fourteen million children had lost parents to AIDS. It also worried me. A generation of rootless, desperate young people would be vulnerable to recruitment by extremists.
    I pressed for specifics on the plan. “What are our goals?” I asked. “What can we accomplish?”
    We set three objectives: treat two million AIDS patients, prevent seven million new infections, and care for ten million HIV-affected people. We would