At this rate, by 2020, the total death toll from AIDS will reach 70 million — more than double that of the Black Death in Europe in the 14th century.
"We're still losing the war on AIDS," says Richard Holbrooke, chairman of the Global Business Coalition on H.I.V./AIDS. "We're just losing it at a slower rate than we used to."

By Nicholas D. Kristof – New York Times

At this rate, by 2020, the total death toll from AIDS will reach 70 million — more than double that of the Black Death in Europe in the 14th century.

"We're still losing the war on AIDS," says Richard Holbrooke, chairman of the Global Business Coalition on H.I.V./AIDS. "We're just losing it at a slower rate than we used to."

President Bush, to his credit, has taken AIDS more seriously than any of his predecessors or almost any other world leader. His huge increases for AIDS funding (quadruple the spending by President Bill Clinton and the Republican Congress at the time) are expected to save about nine million lives.

My sense is that Mr. Bush's program runs very well in some places, but in others it "is not in touch with the epidemic in southern Africa," in the words of Marlin McKay, an AIDS doctor in South Africa. In Kenya, St. Mary's Mission Hospital says it is pulling out of the U.S. program in disgust at all the money that is going to bureaucrats rather than patients. Father William Fryda, a veteran missionary doctor who runs the hospital, says the U.S. program "struggles for relevance within Africa."

A central problem is that the U.S. program is sometimes squeamish about condoms for young people and obsesses about abstinence. Christina Lem, a friend working on an AIDS orphan project, saw a U.S.-funded aid worker in Zambia warning kids away from condoms because they break.

The Bush administration is right to promote abstinence, but condoms must be part of the message. Pontificating against promiscuity only goes so far, because often what kills African women isn't flings but marriage.

"For a woman, the greatest risk factor is getting married," notes Dan Mullins, a CARE official who showed me some of the group's terrific operations in Swaziland (www.care.org).

Fortunately, over time Mr. Bush's aides have adjusted the AIDS program to meet on-the-ground realities — using cheap generics, for example, rather than just branded medicines. And implementation depends hugely on local officials: here in Namibia, AIDS workers say they have seen no hostility to condoms. All in all, what I see in Africa reassures me about the U.S. program. Its prudishness is a problem in some places, but over all the U.S. still hands out far more condoms than any other country.

Looking ahead, one of the biggest needs is for increased testing — and a challenge there has been resistance from AIDS activists. They worry that people who test positive may be stigmatized and driven from their villages. That's a genuine concern, and confidentiality of test results is important. But the biggest threat to Africans isn't that H.I.V. will stigmatize them, but that it will kill them.

So far the mantra in the field has been VCT — voluntary counseling and testing — but this has been a colossal failure. Today 90 percent of people with the virus don't know it.

We need to move to widespread testing, while still allowing people to opt out. For example, in southern Africa there should be routine testing of pregnant women, people who are to be married and tuberculosis patients.

That way a pregnant woman who is H.I.V.-positive can get drugs to prevent transmission to the child. Young people can find out if a marriage may kill them. (Already young Namibians are often demanding evidence that a partner is H.I.V.-negative before going ahead with a marriage.) And doctors should know about the status of TB patients, because that will help determine the treatment.

We should also promise that if someone tests positive, we will try hard to get antiretrovirals to keep them alive.

So what is to be done? We need to continue developing AIDS vaccines, as well as microbicide gels that women can use to protect themselves from straying boyfriends or husbands. We need to ensure that Mr. Bush's AIDS program is renewed. And all countries need to chip in more to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

After my column about desperate AIDS orphans in Swaziland, a reader named Loryn wrote: "Please offer us some way, short of slitting our wrists, to respond." So, Loryn, open your checkbook: I've seen the great work done in Africa by CARE, Africare, the Cabrini Mission Foundation and Population Services International, and many other private groups do terrific work as well.

Unless we get moving, over the next 14 years some 45 million additional lives may be claimed by AIDS — far more than by either Stalin or Hitler. The fates of those human beings are in our hands.