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UN Secretary General Kofi Annan has asked Western nations to spend $7 to $10 billion a year to fight AIDS. The request came at a special session of the UN General Assembly on AIDS. The first U.N. session on AIDS four years ago led to the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since then, the fund has helped improve the health of millions of people in developing countries.

But as NPR's Brenda Wilson reports, the global fund now faces questions of whether it can ever thrive under constant pressure to prove to donors that it's working.

BRENDA WILSON reporting:

The Global Fund to fight AIDS, Tuberculosis and Malaria started out as a relatively simple idea, executive director Richard Feachem says.

Mr. RICHARD FEACHEM (Global Fund): It was for a war chest. That was Kofi Annan's expression, a war chest to fight HIV AIDS. And in fact, in some people's minds, it was a war chest to fight HIV AIDS in Africa.

WILSON: AIDS had already killed more than 22 million people, the vast majority in developing countries, where just 240,000 people were on at the AIDS drugs. A good part of Feachem's job has been raising money.

Dr. FEACHEM: Some people early in the life of the Global Fund called for an income of $10 billion per year. I think that is the right number. I call that the cruising altitude, but of course no one ever believed one could jump from zero, which is where we were in early 2002, to $10 billion a year overnight.

WILSON: The fund now has a budget of roughly $2 billion a year and is committed to funding 400 projects for five years. A little less than a third of that money comes from the U.S. At times that has stirred up fears that the fund would become a creature of the U.S., emphasizing abstinence only and prohibiting the purchase of anything but brand name anti-AIDS drugs.

Those fears haven't quite panned out. Paul Zeitz the director of the advocacy group the Global AIDS Alliance, says the Global Fund money freed countries not only to use generics to treat AIDS but to offer new treatments and millions of bed nets to fight malaria.

Mr. PAUL ZEITZ (Global AIDS Alliance): I just came back from Zambia and government officials told me that without the Global Fund, they would not have been able to provide the first line recommended drug for malaria. Also on HIV AIDS, they're playing a key role in supporting the scale up of lifesaving AIDS medicines.

WILSON: More than two-thirds of international support to treat malaria and TB, diseases that also kill millions each year, comes from the Global Fund. And the fund has not flinched in dealing with the major donor concern, accountability. Grants have been terminated or suspended for poor performance or corruption.

Mr. ZEITZ: For example, in Uganda, where there was corruption perceived by the fund, they publicly withheld a grant and created an investigation by the government and they revealed a corruption dynamic that has now been fixed. The World Bank, you don't know where their money goes. US government funds, we never hear about this kind of thing happening although we know it does happen.

WILSON: Global Fund grants will soon be coming up for renewal and a new round of proposals have been called for. But donor contributions will hang on how well the first countries performed.

Mr. BERNARD RIVERS (Global Fund Observer): The Western donor governments gave the Global Fund a bunch of money at the beginning that you can think of as like start up capital for a new company. Here's a bunch of money, get on with it. If you can use it effectively, we'll give you some more.

WILSON: Bernard Rivers of the Global Fund Observer thinks the fund is in something of a bind. It has to raise even more money when the hard work is just beginning.

Mr. RIVERS: Building clinics, training doctors, buying drugs - and so the fund has this challenge of getting more money, increasing amounts of money, when it's only just getting to the point of putting the pills in people's mouths. That's a challenge that any investor in a new company would have foreseen and would've worked out a strategy how to get through.

WILSON: It's a challenge the next director will have to face since Feachem is stepping down after this year. There's a push for someone with corporate skills who can level the financial power of a multi-billion dollar institution, the political skills to stand up to the US and a hands on approach to help poor countries sustain the programs, a tall order that Dr. Feachem says will require an increase in funding to $3.6 billion a year.

Dr. FEACHEM: If the Global Fund does not have a fully funded round six in 2006, the goal of universal access re-enunciated again this week in New York, that goal is complete pie in the sky.

WILSON: If Western donors fail to increase the funding, Feachem says, it raises serious questions about their motivations in promising to support universal treatment for people with AIDS.

Brenda Wilson, NPR News.

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