Four more years of AIDS under George W. Bush doesn't add up to four more years of complacency and denial, as it did when Ronald Reagan won re-election in 1984. That's because midway through his first term Bush did something Reagan never dreamed of: He made AIDS his own. No more tawdry talk of gay men and drug users, condoms and clean needles; by abandoning the domestic for the international, Bush rewrote AIDS as a story about orphans, abstinence and faith. Unilateralism, corporatism--Bush found a home for these first principles, too, in his $15 billion global AIDS initiative, which is US-run and Pharma-friendly.

The Bush Administration's AIDS conservatism has been on vivid display in its attacks on the Global Fund to Fight AIDS, which it has sought to undermine, preferring its own, US-owned and -operated vehicle. In September, several top US AIDS officials, including global health adviser and Bush family friend Bill Steiger, held a briefing on Capitol Hill at which they charged that the fund was descending into chaos. This set the tone for final deliberations by Republican leaders in Congress over the government's 2005 contribution to the fund, slated for a $200 million cut. US diplomats even lobbied the fund's board members to vote against launching a new round of grants in 2005 at its mid-November board meeting. This, just as the UN announced that the number of HIV-infected has reached 39 million worldwide.

These developments are ominous for several reasons, not least that the fund is active in 127 countries, while Bush's global AIDS initiative serves only fifteen. The fund supports country-driven approaches, which depend on generic drugs for treatment and sometimes include needle-exchange programs for drug users, safer sex education for sex workers and condom promotion in the general population, all of which are either discouraged or banned in Bush's plan. Bush's grants favor faith-based programs, and while his first round of grants supported more mainstream religious charities like World Vision, a new $100 million round of international abstinence grants--announced in October--went to such Christian right groups as Samaritan's Purse. That relief organization, headed by the Rev. Franklin Graham (who called Islam an "evil" religion), was censured just three years ago for proselytizing while using a USAID grant to assist Salvadoran earthquake victims. At a Christian AIDS conference in February 2002 (attended by USAID officials), Graham indicated that he'd bring the same approach to HIV prevention, declaring, "Only a massive societal change in behavior can stop the spread of AIDS, and only Jesus Christ can bring about this change."

At home, two leading conservative AIDS ideologues are poised to join the Senate. Jim DeMint of South Carolina is one of a gang of ultraconservatives in Congress who brought intimidation to the AIDS field. A favorite tactic: poison-pen letters, like one demanding a financial investigation into AIDS groups that protested during Health Secretary Tommy Thompson's speech at an international AIDS conference, and another threatening to defund an organization doing international HIV prevention because the group holds the patent on RU-486. Senator-elect Tom Coburn is a former Congressman from Oklahoma who made his name pushing for the criminalization of HIV transmission and for warning labels on condoms. He most recently served as co-chairman of Bush's presidential AIDS council, a platform he used to advocate abstinence education and make antigay remarks. Coburn's council issued nary a peep when some 200 community-based HIV-prevention groups (several serving gay men) were defunded this past June, and when the Ryan White CARE Act was denied a budget increase by Congress.

Meanwhile, Bush's neglect of the domestic epidemic has borne fruit. New data show that the government is set to fail at its 2001 goal to cut new domestic HIV infections in half by 2005. Far from declining, HIV infections plateaued at 40,000 a year during 2002 and 2003; this year, documented HIV diagnoses actually rose. Could we be seeing the impact of Bush's disinvestment in proven approaches to HIV prevention, while hundreds of millions go to abstinence-only programs that can mention condoms only in terms of their failure rates? On the treatment front, in May an Institute of Medicine report calculated that tens of thousands of Americans living with HIV aren't getting needed treatment--the result of state cuts to Medicaid and the chronic flat funding of the Ryan White Act.

A climate of fear now prevails among AIDS service organizations, most of which depend on government grants to offer HIV prevention and care. Many have been the targets of punitive financial investigations under Bush; all now face a censorious new approval process for sexually explicit prevention materials. At the moment, most AIDS lobbyists are hoping only to hold the line in the years ahead: to get Ryan White reauthorized without significant cuts, to keep cash flowing to the Global Fund, to stave off increases to the abstinence-only pot.

Will they shake off their fear and engage in a resurgent AIDS activism? Perhaps. Their hand will certainly be strengthened if African leaders publicly protest the "morality"-based strictures attached to Bush's largesse; if people with AIDS in red states start to raise their voices when they're cut off from care; and if the media pick up on mounting scientific evidence that virginity programs actually put youth at risk for STDs. It will take a series of eruptions like these to rattle the new Republican AIDS machine.

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