The massive surge in spending to combat Africa's HIV/AIDS epidemic is often bottlenecked by disorganized government departments, fledgling community groups and unstable health care systems, aid agency leaders say.

Mozambican officials estimate that only a fraction of the 70,000 children eligible for AIDS drug treatment will receive it this year due to a shortage of trained health care professionals. Health departments in hard-hit South Africa report being unable to spend their AIDS budgets, while in Nigeria, bureaucracy has been blamed for questionable data and missed treatment goals.

"We all need to begin thinking out of the box," UNAIDS Executive Director Peter Piot said during a recent inspection trip to Tanzania, after being asked why cash was not reaching community groups. "Stopping the AIDS epidemic is going to require more than just a medical approach."

In 2005, worldwide AIDS funding reached more than $8 billion, compared to $250 million in 1995. The increased funding has made a major impact in Africa, boosting the number of people getting AIDS treatment -- often for free -- during the past two years. But despite this progress, officials say only 10 percent of Africans who need antiretroviral therapy are receiving it, while services like assistance for AIDS orphans are equally limited.

Piot said there is a growing concern over the disconnect between the structure of AIDS funding and basic needs such as free HIV tests, and bicycles that allow health workers to reach more people with prevention and treatment. "It is hard to make the machine work," he acknowledged. "Donors say you can't buy things like bicycles. They see that as leakage. ... These bottlenecks are everywhere."

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