Congress last year passed legislation more than tripling the budget to $48 billion over the next five years, with Republicans and Democrats alike hailing the program as a remarkable success.

But the task remains enormous. More than 1.5 million Africans died in 2007 (the U.S. death toll is under 15,000), fewer than one-third had access to treatment, and new infections continued to outstrip those receiving life-prolonging drugs.

In most African countries, life expectancy has dropped dramatically, and only a few, like Botswana, have started to turn the corner again.

And with no end in sight to the global financial crisis, there are fears about whether all the funding approved by Congress will be delivered.

There continue to be detractors who say the U.S. administration should have channeled the money through the U.N.; that it has placed too much emphasis on faith-based groups and abstinence; that it has trampled on women's health by shunning anything associated with abortions; that it has concentrated on AIDS treatment at the expense of prevention; and that it has diverted attention away from bigger killers like pneumonia and diarrhea.

Helen Epstein, an AIDS expert who has consulted for the U.N. and the World Bank, says both the U.N. and PEPFAR have failed disastrously on prevention by preaching abstinence until marriage and failing to recognize that in some African cultures it is the norm to have several simultaneous long-term relationships.

Critics say money could be better spent
She says the money would be better spent on strengthening African health care systems rather than focusing on a single disease.

Johanna Hanefeld at the London School of Hygiene and Tropical Medicine says her research in Zambia indicated that the U.N. Global Fund to Fight AIDS, TB and Malaria was more effective in using HIV programs as a lever to improve health care and staff training, rather than scattering cash among many non-governmental groups, faith-based or other.

PEPFAR ambassador Mark Dybul dismisses criticism that the funding is too narrowly focused.