George Bush: a Good Man in Africa

They may not be George Bush's natural constituency but Rwanda's prostitutes have good things to say about him. So do poor South Africans abandoned by their quixotic government, and doctors across Africa who otherwise regard the American president as a walking crime against humanity.

As Bush arrives in Africa today at the start of a five-country tour he will be welcomed chiefly for an initiative which has gone largely unnoticed outside the continent but which has saved the lives of more than a million people with HIV.

The $15bn (£7.6bn) President's Emergency Plan for Aids Relief (Pepfar) is in its fifth year and has been hailed as a "revolution" that is transforming healthcare in Africa and has been praised as the most significant aid program since the end of colonialism.

Bill Clinton's legacy in Africa was the debacle of Somalia and the abandonment of Rwanda's Tutsis to the 1994 genocide. But with Pepfar, Bush's primary contribution will be greatly extending millions of lives even though the program has been criticized for emphasizing abstinence in Aids education and using religious organizations to deliver care.

"This is the best thing that ever happened to the poor people I work with," said Edward Phillips, a Catholic priest overseeing the distribution of life-saving antiretroviral drugs (ARVs) in Nairobi, Kenya. "It's one of the few times I've seen US government money really reach down to the poorest of the poor. It's kept a hell of a lot of people alive."

Dr Francois Venter, head of the HIV Clinicians Society in South Africa, where Pepfar is providing 200,000 people with ARVs, is one of a number of Aids doctors almost disbelieving in praise of Bush. "I look at all the blood this man has on his hands in Iraq and I can't quite believe myself but I would say it's a bold experiment from the last people in the world I would expect to do it, and it is saving a lot of lives. To intervene on such a scale and make such a difference is huge," he said.

Pepfar was launched in 2004 with the ultimate goal of providing treatment and care to 19 million people with HIV, mainly in Africa and the Caribbean. It is already supplying ARVs to about 1.4 million people and that number is likely to rise significantly if, as expected, Congress doubles Pepfar's budget later this year.

Those at the coalface of confronting Aids say that while other organizations, such as the Global Fund to fight Aids and the World Bank also fund ARVs, the US program owes its success to combining large amounts of money to fund drugs with broadening assistance beyond the individual with HIV. Pepfar is supplying medical equipment and training large numbers of healthcare staff. It is also reaching into households hit by Aids with programs to put children through school and help those with HIV to carry on working.

Bush confronted the pandemic under pressure from his then secretary of state, Colin Powell, who warned that Aids threatened to wipe out a large part of the working-age population of some African countries. He saw that as a national security issue. So did the CIA. Bush was also lobbied by American Christian evangelicals with strong and expanding ties to Africa, and conservative Republican senators usually instinctively hostile to foreign aid.

In Rwanda - on Bush's tour and one of Pepfar's 15 priority countries - Dr Agnes Binagwaho, the head of the national Aids council, says the US program is the major contributor to a tenfold increase over the past four years in the numbers of Rwandans on ARVs to nearly 50,000 people. Today about 70% of Rwandans who need the drugs receive them. "The impact is huge. The average life expectancy of Rwandans has improved by four years because of Pepfar," she said. "The impact is also really big in the health sector because of the equipment and training. It is putting children through school."

An American group, CHF International, is using Pepfar money to pay for 39,000 children to go to school in Rwanda in part because Aids orphans and other young people left without support are more likely to fall back on casual prostitution to survive.

Anne Smith, the head of CHF in Kigali - who says she is personally keen on a change in the White House - says the unprecedented amount of money provided by Pepfar has changed how Rwanda deals with Aids.

"The scale of the money coming in has really changed everything. If someone in a household has HIV it used to be we only focused on them. Now we look at the health of everyone in the household because if a parent has HIV that has implications for their ability to provide and care for their children. We can now treat the children for other diseases because that is a consequence of HIV in the household," she said.

But Pepfar has come in for strong criticism because its Aids education program, ABC - Abstinence, Be faithful, Condomise - pushes the first two over the third.

Democrats in Congress want to scrap the emphasis on abstinence when Pepfar legislation comes up for renewal later this year. Many Aids workers in Africa think the Bush administration's obsession with the issue is misplaced but say its impact is minimal because government programs in most countries emphasize the use of condoms.

Democrats have also criticized the large numbers of "faith-based" organizations funded by Pepfar, such as Phillips' Eastern Deanery Aids Relief Program, which distributes ARVs to 7,000 people in the poorest parts of Nairobi. Its $3.3m slice of Pepfar's $386m budget in Kenya last year has funded expansion from a few dozen staff and church volunteers to a network of 11 clinics and 300 staff including nurses, social workers, clinicians and nutritionists.

Phillips says that, in accordance with church policy, his program does not distribute condoms - but neither does it teach against the Kenyan government's emphasis on condoms. "The prevalence of Aids has dropped significantly in Kenya. It's down to the various education campaigns by the government, by communities and that people saw that people were dying. You can draw your own conclusions," said Phillips.

John Dunlop, who heads the Pepfar health team in Rwanda, said the relationship with religious organizations had less to do with evangelicals in Washington than with practicalities in Africa. "These are very pious communities; the church runs through every component of life. So if you ignore these church networks as a means of pushing out messages of change you're ignoring a huge resource," he said.

Pepfar's budget in Kenya rises to $535m this year. It already pays for 90,000 people to receive ARVs - nearly half of all those taking them in the country - as well as home care for those with HIV, including food and micro finance so they can still make a living.

Warren Buckingham, the head of the Pepfar program in Nairobi, said he found himself pressing the Kenyan government on behalf of the very people the American Christian right most despised. "If there is resistance it is not in Washington. The people we have to push are the public health officials here to recognize neglected populations and highly stigmatized groups - men who have sex with men, intravenous drug users, sex workers," he said.

In a busy Kigali bar, Linda, a 24-year-old HIV-positive prostitute, explained that she had been afraid to be tested because she didn't want to know that she might soon die. "Then they said they could make us well, they have these drugs. So I got tested and I have the drugs," she said.

So whom does she thank? "The Americans. George Bush has helped us live."

The countries

Pepfar's 15 priority nations Kenya, Botswana, Ivory Coast, Ethiopia, Guyana, Haiti, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, Zambia

Bush's Africa tour Benin, Tanzania, Rwanda, Ghana, Liberia