WASHINGTON — Dr. Jean W. Pape did not know what to expect when, in early January 2003, he slipped away from his work treating AIDS patients in Haiti and flew to Washington for a secret meeting with President Bush.

Haitian national, Dr. Jean W. Pape, one of several international AIDS experts U.S. President Bush consulted with before considering devoting billions to comat global AIDS, standing in front of his AIDS clinic, Centres Gheskio, in Port-au-Prince, Haiti in an undated photograph. (wehaitians.com photo/archives)

Mr. Bush was considering devoting billions to combat global AIDS, a public health initiative unparalleled in size and scope. The deliberations had been tightly held; even the health secretary was not in the loop. If President Bush was going to shock the world — and skeptical Republicans — with a massive infusion of American cash to send expensive drugs overseas, he wanted the money to be well spent.

“He said, ‘I will hold you accountable, because this is a big move, this is an important thing that I’ve been thinking about for a long time’,’’ recalled Dr. Pape, one of several international AIDS experts Mr. Bush consulted. “We indicated to him that our arms are totally broken as physicians, knowing that there are things we could do if we had the drugs.”

Nearly five years later, the President’s Emergency Plan For AIDS Relief — PEPFAR, for short — may be the most lasting bipartisan accomplishment of the Bush presidency. With a year left in office, Mr. Bush confronts an America bitterly split over the war in Iraq, an uncertain economy and a hostile Congress. His big achievements, the tax cuts and education reform, are not fully embraced by Democrats, and his second term legislative agenda — revamping Social Security and immigration policy — lies in ruins,.

The global AIDS program is a rare exception. So far, roughly 1.4 million AIDS patients have received life-saving medicine paid for with American dollars, up from 50,000 before the initiative. Even Mr. Bush’s most ardent foes, among them Senator John Kerry of Massachusetts, his 2004 Democratic challenger, find it difficult to argue with the numbers.

“It’s a good thing that he wanted to spend the money, and put his administration behind spending the money, absolutely,” said Mr. Kerry, an early proponent of legislation similar to the plan Mr. Bush adopted. “I think it represents a tremendous accomplishment for the country.”

Announced in the 2003 State of the Union address, the plan called for $15 billion for AIDS prevention, treatment and care, concentrating on 15 hard-hit nations in Africa and the Caribbean. An enthusiastic Congress has already approved $19 billion.

Mr. Bush is pressing lawmakers for a new five-year commitment of $30 billion. He will travel to Africa in February to make his case — and, the White House hopes, burnish the compassionate conservative side of his legacy.

Despite the effort, there are still 33 million people living with HIV, and the United Nations estimates that there were 1.7 million new infections in 2007 in sub-Saharan Africa alone. Critics, including Mr. Kerry, are particularly incensed by the requirement that one-third of the prevention funds be spent teaching abstinence, despite a lack of scientific consensus that such programs reduce the spread of the AIDS virus.

When a Ugandan AIDS activist, Beatrice Were, denounced the abstinence-only approach at an international AIDS conference last year, she received a standing ovation. Paul Zeitz, executive director of the Global AIDS Alliance, an advocacy group here, says the Bush program has been hamstrung by “ideologically driven policies.”

That assessment was echoed, in more diplomatic terms, by the independent Institute of Medicine, which evaluated the program in March. It called on Congress to abandon the abstinence requirement and to lift the ban on paying for clean needles for drug addicts, among other changes.

Yet the institute concluded that overall the program has made “a promising start.” And when they step back, even critics like Mr. Zeitz concede Mr. Bush spawned a philosophical revolution. In one dramatic step, he put to rest the notion that because patients were poor or uneducated they did not deserve, or could not be taught to use, medicine that could mean the difference between life and death.

In Haiti, about 13,000 patients are now receiving anti-retroviral drugs. That is only half the estimated 26,000 who need them, but far more than the 100 being treated five years ago. “A huge success story,” Dr. Pape says, “beyond my imagination.”

In Uganda, a country already far along on its own AIDS initiative when Mr. Bush began his, 110,000 people are under treatment and 2 million have HIV tests each year, up from 10,000 treated and 400,000 tested before, according to Dr. Alex Coutinho, a top AIDS expert there. The money comes mostly from PEPFAR, but also from a United Nations fund to which the United States contributes.

Dr. Coutinho said Ugandans are terrified that when Mr. Bush leaves office, “the Bush fund,” as they call it, will go with him.

“When I’ve traveled in the U.S., I’m amazed at how little people know about what PEPFAR stands for,” he said. “I think America should not be shy about what it has achieved. Just because it has been done under Bush, it is not something the country should not be proud of.”

The story of how a conservative Republican president became a crusader for global AIDS is an unlikely one. Mr. Bush ran for the White House in 2000 with what Joshua B. Bolten, his chief of staff, calls “a Republican’s skepticism about the efficacy of foreign aid.” He talked of letting “Africa solve Africa’s problems.” His top priorities were tax cuts and education. But a variety of forces conspired to put the international AIDS epidemic on the new president’s agenda.

General Colin Powell, the new secretary of state, was deeply troubled by demographics showing that in some African nations, the entire child-bearing population had been wiped out — conditions that could create instability, and a climate ripe for terrorism. Just weeks into his new job, he called Tommy Thompson, the new health secretary.

“I said, ‘Tommy, this is not just a health matter, this is a national security matter,’” General Powell recalled. They vowed to work together, and the president, General Powell said, “bought into it immediately.” Yet, little was done at first, infuriating advocates like Mr. Zeitz.

By 2002, though, Christian conservatives, a core component of Mr. Bush’s political base, began adopting the cause. Jesse Helms, the ultra-conservative North Carolina senator, declared himself ashamed he had not done more. Bill Frist, a physician who was then a Republican senator from Tennessee, was bending Mr. Bush’s ear about the epidemic. So was Bono, the rock star. Generic drugs were slashing the costs for treatment.

In the spring of that year, Mr. Bush sent Mr. Thompson and the government’s top AIDS expert, Dr. Anthony S. Fauci, to Africa “to try to scope out anything we could do in a humanitarian way,” Dr. Fauci said.

They came back and proposed $500 million to prevent mother-to-child transmission of the disease. The president approved, Dr. Fauci said, but told them to think bigger.

“He wanted to do something game-changing,” Mr. Bolten said. “Something that, instead of at the margins assuaging everybody’s conscience, might actually change the trajectory of this disease which, from the reports we were getting, was headed to destroy a whole continent.”

Mr. Bolten, Dr. Fauci and a small collection of others spent eight months quietly planning. Inside the White House, Condoleezza Rice, then the national security adviser, favored the program. But, there was resistance from those who thought it “problematic to be announcing a lot of money for foreigners,” said Michael J. Gerson, Mr. Bush’s former speechwriter. Opponents waged a last-ditch attempt to strip the announcement from the address. Mr. Bush overruled them.

With the United States about to invade Iraq, some theorized Mr. Bush was trying to soften the nation’s image. Not so, says Mr. Gerson, who calls the initiative “foreign policy moralism.” But he does see a link: “It fit a broader conception of his view of America’s purpose in the world, which included not just the liberation of other people, but their treatment for disease.”

The goals were ambitious: to treat 2 million people, prevent 7 million new infections and provide care for 10 million, including orphans and vulnerable children, over 5 years, beginning in 2004 when the money became available.

The prevention targets will not be measured until 2010. But Mark Dybul, Mr. Bush’s global AIDS coordinator, says the program is on track to meet its goals. In addition to drugs for 1.4 million, the government says it has provided care for nearly 6.7 million people affected by the disease, including 2.7 million orphans and vulnerable children. Drugs provided to pregnant women have spared an estimated 152,000 infants from infection, the government says.

There is a debate over how efficiently the money has been spent, but going forward the fight is not over whether to reauthorize the program, but how. Much of the money has been channeled through American faith-based organizations, drawing criticism from people like Dr. Coutinho of Uganda who say local control would bring down costs.

Based on the current infection rate, advocates say $50 billion is needed, not $30 billion as Mr. Bush has proposed. Senator Joseph I. Biden Jr., the Democratic chairman of the Senate Foreign Relations Committee, is also calling for $50 billion, as is Dr. Coutinho.

“Unless PEPFAR is reauthorized at a much higher level,” said Dr. Coutinho, “we are going to be in the business of playing God.”

At the White House, AIDS advocacy has become a family affair. Laura Bush made her third trip to Africa this year, and the president’s daughter, Jenna, chronicles the life of a young HIV-positive woman in a new book.

Mr. Bush announced his trip to Africa in conjunction with World AIDS Day in November, with a quote from the Bible: “I have set before you life and death. Therefore, choose life.”

On that day, the North Portico of the White House was festooned with a huge red ribbon, the symbol of the epidemic. Even Mr. Zeitz took it as a promising sign.

Copyright 2008 The New York Times Company. Reprinted from The New York Times, Health, of Saturday, January 5, 2008.

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