Less diversion. One clearly good choice PEPFAR made was to work through MAUL instead of through the system the Ugandan government uses, the National Medical Stores (NMS). Previous programs haven't been as lucky: In 2002, fluconazole pills donated by Pfizer to the government of Uganda—and intended for distribution through NMS to health facilities—were diverted and ended up for sale on pharmacy shelves. And in 2003, NMS tried to sell GSK-supplied Combivir to a local company, Eris, which was a buyer for Landmark Pharmaceuticals, which was then free to sell the products at profit to other markets. MAUL, to date, has had no similar problems.

It's working. Finally, PEPFAR proponents say, although the system isn't perfect, it is already operational—unlike the Global Fund grants that were promised in 2002 but have not yet been dispersed. "It is not bogged down by bureaucracy," says Emmanuel Luyirika, the medical director of Mildmay Centre, a specialist outpatient referral center set up by international donors for people with HIV/AIDS. "The system PEPFAR uses is much faster than the government system. In fact, the PEPFAR program is the one that has made the biggest impact in our city here, in terms of free care. Within six months, we already have 700 patients on ARVs. We hope by the end of March 2005, we will have about 1,400 receiving free care through PEPFAR. That is our only source of free ARVs."

On the negative side:

"Bilateral plans are turning into a slush fund for Big Pharma," says Asia Russel, coordinator for international policy at HealthGAP, a US-based activist organization.

Parallel systems. PEPFAR's separate and specialized distribution system doesn't support most countries' national scale-up strategies and works outside the Ugandan healthcare system. That's causing confusion inside clinics among physicians and other providers, who must keep funding sources, patients, and pills separate.

"In Rwanda, where we have both MPTCT Plus programs and PEPFAR-funded programs at the same clinic, there's stress that the two different sources look different," says David Hoos, MD, assistant professor at the Columbia University Mailman School of Public Health, and chair of the Global Fund's procurement advisory panel. "They have to keep the stock in separate places so that the parallel system causes distress at the clinical level and it confuses patients. Because they don't know that there are different funding sources and different products, they are asking: 'Why does my drug look different than this person's drug?'"

Not uplifting general system. Nsubuga, who uses NMS to distribute the World Bank's ARVs, says PEPFAR grants also do nothing to uplift, strengthen, and expand the general medical care system, which is collapsing under the weight of the epidemic. Although PEPFAR money is only awarded to programs focused specifically on HIV, the prevalence of AIDS in Uganda (estimates peg it anywhere from 4.1-17 percent) is such that the disease affects all aspects of healthcare—from general practitioners to TB wards. In addition, PEPFAR-funded programs attract the country's skilled manpower with high salaries, which further detracts from the Ugandan system and will have implications when PEPFAR disappears in 2008.

From Infrastructure to Price The pharma industry has been a moving target in the AIDS epidemic. "The debate has gone from being one of patents that kill to prices that kill, to where it is now, which is much more about the whole area of lack of healthcare infrastructure," says Jon Pender, director of external relations, global access issues for GlaxoSmithKline.