Diary Prequel Package — page 153

Awareness Day in the USA. Day was sunny, hot and muggy. I was given a reserved seat in the second row. Had major and important conversations during the reception with Randy Tobias, Mike Gerson and Josh Bolten. Apparently, at a meeting with the POTUS yesterday on PEPFAR funding, there was some opposition to maintaining the funding level. Likely the major mover of this restricted funding was Karl Rove. Condi Rice is out of the country, but will be supportive of expanded funding. Josh Bolten is supportive also. Josh asked me what I thought and I came on strong. Josh pointed out that this was supposed to be a $15 billion program with $3 billion per year for 5 years. Josh said that at the time that I developed the program, I said that we could not absorb the entire $3 billion in the first years and so we would do more in the later years. Now the program is at $5 billion per year, which means that just to sustain it without increases would cost $5 billion per year for 5 years or $25 billion. Many conservatives would oppose this as a bottomless pit. I also argued that we should get rid of the mandated 33% for abstinence of the 20% prevention money. I am attaching an e-mail that I sent to Josh after getting back to my office in which I clarify my position: Josh: It was good to see you at the Malaria event today and I appreciate your listening to Randy, Mike and me. I know that you are very much supportive of the full funding and even increase of the initiative and I know that this view is not shared by all. However, just to reiterate what I said to you and what you already know, this is one of the most important things that this administration has done and is doing. The people of Africa look upon us with great admiration and gratitude because of PEPFAR. We just cannot let it slip. True, we cannot commit to treating every infected person in the target countries, particularly since there are 4.3 million new infections worldwide each year, mostly in developing countries. However, we are making significant progress in prevention. I know that you are aware of how impressive the circumcision data are. In addition, although we are still years away from a vaccine, the most recent candidate has entered a phase 2 trial internationally (including Africa). Even if it does not totally prevent HIVinfection, there is a reasonable chance that it will slow the progression of disease if people do get infected, and this will result in lower levels of virus in their bodies, which in turn makes transmission to others less likely. I tell you this because I believe that we are on the cusp of a slowing down of transmission, which would dampen the possibility of a "bottomless pit" of infection in target countries for which we would feel obligated to treat. Finally, with regard to prevention, I am sorry that I was at first not clear about my position on abstinence being mandated as one third of the 20% prevention piece of the pie. We get enormous bad press (that often overshadows the enormous good that we are doing) because we mandate a specific number for abstinence. The faith-based organizations are going to push abstinence with the prevention money that we give them anyway. Therefore, abstinence will indeed be pursued through PEPFAR. By mandating it, those who do not think that this is the way to go will only drop out of the funding stream and declare the program dysfunctional when it really is a breath-taking success. On balance, it is my opinion that if we remove mandated categories of prevention, abstinence programs will still go on in Africa and PEPFAR will be praised by everyone, deservedly so. I am sorry if I came on somewhat strong at the White House with you, but I feel deeply that PEPFAR is such an historically great program (that would not exist if it were not for you) and I want it to function optimally. As always, if you need me to pitch in on this and articulate my views to anyone, please call upon me. I would jump at the chance. Thank you and best personal regards, Tony During the Rose garden ceremony, the POTUS actually got up and played the drums with a troop of Senegalese/American dancers who provided entertainment on the stage in the