Order Code IB10050
Issue Brief for Congress
Received through the CRS Web
AIDS in Africa
Updated May 30, 2002
Raymond W. Copson
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress

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CONTENTS
SUMMARY
MOST RECENT DEVELOPMENTS
BACKGROUND AND ANALYSIS
Characteristics of the African Epidemic
Explaining the African Epidemic
Social and Economic Consequences
Responses to the AIDS Epidemic
Global Fund
Effectiveness of the Response
AIDS Treatment Issues
U.S. Policy
Bush Administration
Legislative Action
LEGISLATION

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AIDS in Africa
SUMMARY
Sub-Saharan Africa has been far more
Donor governments, non-governmental
severely affected by AIDS than any other part
organizations, and African governments have
of the world. The United Nations reports that
responded primarily by attempting to reduce
28.1 million adults and children are infected
the number of new HIV infections, and by
with the HIV virus in the region, which has
trying ameliorate the damage done by AIDS to
about 10% of the world’s population but more
families, societies, and economies. The ade-
than 70% of the worldwide total of infected
quacy of this response is the subject of much
people. The overall rate of infection among
debate. Spending from all sources on HIV/-
adults in sub-Saharan Africa is about 8.4%; it
AIDS in sub-Saharan Africa was estimated at
is 1.2% worldwide. Sixteen countries, mostly
$500 million for FY2000, while U.N. experts
in east and southern Africa, have HIV infec-
believe the region could effectively absorb
tion rates of more than 10%, and the rate has
$4.6 billion to combat the pandemic.
reached 35.8% in Botswana. An estimated
19.3 million Africans have died of AIDS,
Treatment of AIDS sufferers with medi-
including 2.3 million who died in 2001. AIDS
cines that can result in long-term survival has
has surpassed malaria as the leading cause of
not been widely used in Africa. Advocates of
death in Africa, and it kills many times more
treatment argue that in view of recent drug
Africans than war. In Africa, HIV is spread
price reductions, treatment is an affordable
primarily by heterosexual contact, and sub-
means of reducing AIDS damage to African
Saharan Africa is the only region where
economies, reinforcing prevention programs,
women are infected at a higher rate than men.
and keeping parents alive. Skeptics argue that
treatment is still too expensive to be an option
Experts relate the severity of the African
for most Africans and would require donors to
AIDS epidemic to the region’s poverty.
fund costly improvements in Africa’s health
Health systems are ill-equipped for
infrastructure.
prevention, diagnosis, and treatment. Poverty
forces many men to become migrant workers
U.S. concern over AIDS in Africa grew
in urban areas, where they may have multiple
during the 1980s, as the severity of the epi-
sex partners. Poverty leads many women to
demic became apparent. According to the
become commercial sex workers, vastly in-
U.S. Agency for International Development,
creasing their risk of infection.
the United States has been the global leader in
the international response to AIDS since 1986.
AIDS’ severe social and economic conse-
Legislation enacted in the 106th and the 107th
quences are depriving Africa of skilled work-
Congresses increased funding for worldwide
ers and teachers while reducing life expec-
HIV/AIDS programs, and the Administration
tancy by decades in some countries. The
has requested a further increase for FY2003.
cumulative total of African children orphaned
The United States has also pledged $500
by AIDS since the epidemic began is 12.1
million to the new Global Fund to Fight
million. Currently 6.5 million AIDS orphans
AIDS, Tuberculosis, and Malaria. Nonethe-
are living in Africa, facing increased risk of
less, critics find the U.S. response inadequate
malnutrition and reduced prospects for educa-
in view of the scale of the African pandemic.
tion. AIDS is being blamed for declines in
agricultural production in some countries.
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MOST RECENT DEVELOPMENTS
On May 27, 2002, Treasury Secretary Paul O’Neill endorsed a broadening of
antiretroviral therapy for AIDS patients in Africa. The endorsement came after O’Neill
visited a hospital in Soweto, South Africa, with Irish rock star Bono and talked with HIV-
positive mothers whose babies were being treated to prevent mother to child transmission.
At a press conference, O’Neill refused to back proposals to sharply boost U.S. contributions
to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, arguing that before doing so
“we need to understand ... what we are doing with what we have got.” On May 24, 2002,
the House passed its version of the FY2002 Supplemental Appropriations (H.R. 4775),
including $200 million in additional worldwide spending for AIDS, tuberculosis, and
malaria. The Senate version (S. 2551), reported to the floor on May 22, includes an
additional $100 million. S. 2525, introduced by Senator Kerry and others on May 15, would,
among other provisions, require the President to establish a comprehensive 5-year strategy
to combat global HIV/AIDS and authorize an FY2003 contribution of $1 billion to the
Global Fund. The Fund announced its first grants on April 25, 2002. Of the $378 million
awarded worldwide, Africa is to receive 52%.
BACKGROUND AND ANALYSIS
Sub-Saharan Africa has been far more severely affected by AIDS than any other part
of the world. According to a December 1, 2001 report issued by the Joint United Nations
Program on HIV/AIDS (UNAIDS), some 28.1 million adults and children are infected with
the HIV virus in the region, which has about 10% of the world’s population but 70% of the
worldwide total of infected people. The overall rate of infection among adults is about 8.4%,
compared with 1.2% worldwide. UNAIDS projects that half or more of all 15 year-olds will
eventually die of AIDS in some of the worst-affected countries, such as Zambia, South
Africa, and Botswana, unless the risk of contracting the disease is sharply reduced. An
estimated 19.3 million Africans have lost their lives to AIDS, including an estimated 2.3
million who died in 2001. UNAIDS estimates that 3.4 million new HIV infections occurred
in 2001, down from the estimated 3.8 million new infections in 2000. Experts are cautious
in suggesting that this decline might represent some success in prevention efforts,
particularly since the adult infection rates continue to increase in a number of countries,
including Nigeria, Africa’s most populous nation. Moreover, they point out that 3.4 million
new infections still represent a very fast and highly destructive rate of spread. AIDS has
surpassed malaria as the leading cause of death in sub-Saharan Africa, and it kills many times
more people than Africa’s armed conflicts.
Characteristics of the African Epidemic
In addition to its severity, the sub-Saharan AIDS epidemic is defined by a number of
other unusual characteristics.
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! HIV, the human immunodeficiency virus that causes AIDS, is spread in
Africa primarily by heterosexual contact.
! Sub-Saharan Africa is the only region in which women are infected with
HIV at a higher rate than men. According to UNAIDS, women make up an
estimated 55% of the HIV-positive adult population in sub-Saharan Africa,
as compared with 47% worldwide.
! Young women are particularly at risk. A U.N. study found girls aged 15-19
to be infected at a rate of 15% to 23%, while infection rates among boys of
the same age were 3% to 4%.
! Eastern and southern Africa have been far more severely affected than West
Africa, but infection rates in a number of West African countries are starting
to escalate. In some southern African countries, 20% or more of the adult
population is infected with HIV, and the rate has reached 35.8% in
Botswana. On March 20, 2001, the South African government released
statistics showing that 4.7 million South Africans, including 24.5% of
adults, were infected in 2000 – up from 22.4% in 1999. In West Africa,
Senegal, with an active AIDS policy, had an adult infection rate below 2%
in 1999, but the infection rate exceeds 10% in nearby Ivory Coast. Adult
infection rates in four other West African countries, including Nigeria, have
passed the 5% mark.
! The African AIDS epidemic is having a much greater impact on children
than is the case in other parts of the world. An estimated 600,000 African
infants become infected with HIV each year through mother-to-child
transmission, either at birth or through breast-feeding. (White House, Report
on the Presidential Mission on Children Orphaned by AIDS in Sub-Saharan
Africa: Findings and Plan of Action. Washington, July 19, 1999, p. 14.)
These children have a short life expectancy, and the number of infected
children currently alive in Africa is estimated at 1 million (UNAIDS).
! Through 1999, a cumulative total of 12.1 million African orphans had lost
either their mother or both parents to AIDS since the epidemic began,
according to UNAIDS. Of these, many have grown to adulthood or
themselves died. A report issued in 2000 by the U.S. Agency for
International Development (USAID) put the number of maternal or double
AIDS orphans under 15 years of age and then living in 26 African countries
at 6.5 million. (Children on the Brink, 2000 update. Data on paternal
orphans due to AIDS were not available for this study.) The report projects
that by 2010, there will be 15 million maternal and double AIDS orphans in
Africa, including 2.7 million in Nigeria, 2.5 million in Ethiopia, and 1.8
million in South Africa. Maternal, paternal, and double orphans due to all
causes will total 40 million in 2010, according to the report. Because of the
stigma attached to the AIDS disease, AIDS orphans are believed to be at
high risk for being malnourished, abused, and denied an education.
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Explaining the African Epidemic
AIDS experts emphasize a variety of
Adult HIV Infection Rates, end of 1999 (%)
economic and social factors in explaining
Africa’s AIDS epidemic, placing primary blame
Botswana
35.80
on the region’s poverty. Poverty has deprived
Swaziland
25.25
Africa, for example, of effective systems of health
Zimbabwe
25.06
Lesotho
23.57
information, health education, and health care.
South Africa
19.94
Thus, Africans suffer from a high rate of
Namibia
19.54
untreated sexually-transmitted infections (STIs)
Zambia
19.95
Malawi
15.96
other than AIDS, and these increase susceptibility
Kenya
13.95
to HIV. African health care systems are typically
Cent. Af. Republic
13.84
Mozambique
13.22
unable to provide AIDS counseling, which could
Djibouti
11.75
help slow the spread of the disease, and even
Burundi
11.32
HIV testing is difficult for many Africans to
Rwanda
11.21
Cote d’Ivoire
10.76
obtain. AIDS treatment is generally available
Ethiopia
10.63
only to the elite.
Uganda
8.30
Tanzania
8.09
Cameroon
7.73
Poverty forces large numbers of African men
Burkina Faso
6.44
to migrate long distances in search of work, and
Congo Brazzaville
6.43
while away from home they may have multiple
Togo
5.98
Congo Kinshasa

5.07
sex partners, increasing their risk of infection.
Nigeria
5.06
Some of these partners may be women who have
Gabon
4.16
Ghana
3.60
become commercial sex workers because of
Sierra Leone
2.99
poverty, and they too are highly vulnerable to
Eritrea
2.87
infection. Migrant workers may carry the
Liberia
2.80
Angola
2.78
infection back to their wives when they return
Chad

2.69
home. Long distance truck drivers, and drivers of
Guinea Bissau
2.50
“taxis,” who transport Africans long distances by
Benin
2.45
Mali

2.03
car, are probably also key agents in spreading
Gambia
1.95
HIV.
Senegal
1.77
Guinea
1.54
Sudan
.99
Some behavior patterns in Africa may also
Mauritania
.52
be affecting the epidemic. In explaining the fact
Equatorial Guinea
.51
Somalia
NA
that young women are infected at a higher rate
Madagascar
.15
than young men, Peter Piot, the Executive
Director UNAIDS, has commented that “the
Source: UNAIDS, Report on the Global
HIV/AIDS Epidemic, June 2000
unavoidable conclusion is that girls are getting
infected not by boys but by older men,” who are
more likely than young men to carry the disease.
(UNAIDS press release, September 14, 1999.) A
researcher in a UNAIDS project studying the differential rate of infection added that “Young
(women’s) lives are being cut short through sex which is all too often forced, coerced, or
‘bought’ with sugar-daddy gifts.” Many believe that the infection rate among women
generally would be far lower if women’s rights were more widely respected in Africa and if
women exercised more power in political and economic affairs. (For more on these issues,
see Helen Epstein, “AIDS: the Lesson of Uganda,” New York Review of Books, July 5, 2001;
and “The Hidden Cause of AIDS,” New York Review of Books, May 9, 2002.)
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The breakdown in social order and social norms caused by armed conflict could also
be contributing to the African epidemic. Conflict, which has afflicted many sub-Saharan
countries for years, is typically accompanied by numerous incidents of violence against
women, including rape, carried out by soldiers and guerrillas. Such men are also more likely
to resort to commercial sex workers than those living in a settled environment.
Some observers believe that the spread of AIDS in Africa could have been slowed if
African leaders had been more engaged and outspoken in the struggle against the disease.
President Yoweri Museveni of Uganda, in particular, has won wide recognition for leading
a successful campaign against AIDS in his country. But many other African leaders have
said or done comparatively little about the epidemic.
President Daniel arap Moi of Kenya, where 13.9% of adults are infected and nearly a
million people have died from AIDS, did not endorse the use of condoms as a preventive
until December 1999. (Africa News Service, December 23, 1999.) In South Africa, many
critics have maintained that President Thabo Mbeki and his government are not treating the
disease with sufficient urgency. In April 2000, President Mbeki wrote President Clinton and
other heads of state defending dissident scientists who maintain that AIDS is not caused by
the HIV virus. In March 2001, Mbeki rejected appeals that the national assembly declare the
AIDS pandemic a national emergency, and in September, the South African government
attempted to delay publication of a South African Medical Research Council report, which
found AIDS to be the leading cause of death, accounting for 40% of mortality among South
Africans aged 15 to 49. The Council predicted that South Africa’s death toll from AIDS
would reach a cumulative total of between 5 and 7 million by 2010, when 780,000 people
would be dying annually from the disease. Life expectancy would fall from 54 years at
present to 41 by the end of the decade, according to the Council.
In August 2001, the South African Treatment Action Campaign (TAC) launched a suit
against the South African government, demanding a comprehensive program to prevent
mother-to-child transmission (MTCT) of HIV. TAC maintains that current MTCT trials
involving 18 pilot projects providing the antiretroviral drug Nevirapine to HIV-positive
pregnant women are inadequate and that 20,000 babies could be saved by a nationwide
program. The German firm Boerhringer-Ingelheim offers Nevirapine drug free in Africa for
MTCT programs. South African officials maintain that safety precautions require testing of
Nevirapine and MTCT prevention procedures before launching a nationwide program. South
African courts have ruled in favor of TAC, although the case has remained under appeal.
Nonetheless, under mounting domestic and international pressure, the South African
government seemed to modify its position significantly after an April 17, 2002 cabinet
meeting on the AIDS crisis. The cabinet announced that it would triple the national AIDS
budget, end official opposition to the provision of antiretrovirals for rape victims, and launch
a program for universal access to drugs to prevent mother to child transmission, possibly by
December. AIDS activists welcomed the policy changes, but some expressed concerns about
implementation or pointed out that South Africa was still far from providing access to
treatment for all those in need.
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Social and Economic Consequences
AIDS is having severe social and economic consequences in Africa, and these negative
effects are expected to continue for many years. A January 2000 Central Intelligence Agency
National Intelligence Estimate on the infectious disease threat, made public in an unclassified
version, forecasts grave problems over the next 20 years.
At least some of the hardest-hit countries, initially in sub-Saharan Africa and later in
other regions, will face a demographic catastrophe as HIV/AIDS and associated diseases
reduce human life expectancy dramatically and kill up to a quarter of their populations
over the period of this Estimate. This will further impoverish the poor, and often the
middle class, and produce a huge and impoverished orphan cohort unable to cope and
vulnerable to exploitation and radicalization. (CIA, The Global Infectious Disease Threat
and Its Implications for the United States [http://www.odci.gov], “Publications and
Reports”.)
The estimate predicted increased political instability and slower democratic development as
a result of AIDS. According to the World Bank,
The illness and impending death of up to 25% of all adults in some countries will have
an enormous impact on national productivity and earnings. Labor productivity is likely
to drop, the benefits of education will be lost, and resources that would have been used
for investments will be used for health care, orphan care, and funerals. Savings rates will
decline, and the loss of human capital will affect production and the quality of life for
years to come. (World Bank, Intensifying Action Against HIV/AIDS in Africa.)
In the most severely affected countries, sharp drops in life expectancy are occurring, and
these will reverse major gains achieved in recent decades. At AIDS2000, the July 2000
international AIDS conference held in Durban, South Africa, Karen Stanecki of the U.S.
Census Bureau reported that AIDS had cut life expectancy in Botswana from 71 years to 39
and in Zimbabwe from 70 years to 38. Stanecki predicted that South Africa, Zimbabwe, and
Botswana will begin to experience negative population growth in 2003, and that by 2010, life
expectancy at birth will have fallen to about 30 years throughout southern Africa.
According to many reports, AIDS has devastating effects on rural families. The father
is typically the first to fall ill, and when this occurs, farm tools and animals may be sold to
pay for his care. As he grows weaker, he will become unable to farm at all; nor will his wife
be able to farm, since she will be devoting her time to nursing him. The family will be
unable to pay school fees, and in any event, children will likely be kept out of school to
perform added chores at home. Should the mother also become ill, children may be forced
to shoulder responsibility for the full time care of their parents. The economic consequences
of the disruption of rural life can be severe, and reduced food production in some areas due
to AIDS has been reported.
AIDS is also being blamed for shortages of skilled workers and teachers in several
countries. A May 2002 World Bank study, Education and HIV/AIDS: A Window of Hope,
reported that more than 30% of teachers are HIV positive in parts of Malawi and Uganda,
20% in Zambia, and 12% in South Africa. Although unemployment is generally high in
Africa, trained personnel are not readily replaced. AIDS is claiming many lives at middle
and upper levels of management in both business and government.
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AIDS may have serious security consequences for much of Africa, since HIV infection
rates in many armies are extremely high. Domestic political stability could also be
threatened in African countries if the security forces become unable to perform their duties
due to AIDS. Peacekeeping is also at risk. South African soldiers have been widely
expected to play an important peacekeeping role in the Democratic Republic of the Congo
(DRC, formerly Zaire) and perhaps other countries in coming months and years, but
estimates of the infection rate in the South Africa army run from 17% to 40%, with higher
rates reported for units based in heavily infected KwaZulu-Natal province. A December
2001 General Accounting Office (GAO) report raised questions about the ability of the
United Nations to promote AIDS awareness and reduce risky behaviors in U.N.
peacekeeping forces. (GAO Report GAO-02-194, U.N. Peacekeeping: United Nations Faces
Challenges in Responding to the Impact of HIV/AIDS on Peacekeeping Operations.) The
report also noted that the U.N. faced difficulties in providing HIV/AIDS assistance to
civilians affected by conflict.
Responses to the AIDS Epidemic
Donor governments, non-governmental organizations (NGOs) working in Africa, and
African governments have responded to the AIDS epidemic primarily by attempting to
reduce the number of new HIV infections, and to some degree, by trying ameliorate the
damage done by AIDS to families, societies, and economies. A third possible response –
treatment of AIDS sufferers with medicines that can result in long-term survival – has not
been widely used in Africa, largely due to cost, although some treatment is now being offered
at private clinics or through programs offered by a few large employers. Demands for large-
scale treatment are mounting in Africa, and are drawing support from outside the continent
among AIDS activists and others concerned for the region’s future. An effective vaccine
could offer a permanent solution to the African AIDS crisis, but progress in vaccine
development has been slow. (For more information on the international response to the
epidemic, see CRS Report RL30883, Africa: Scaling Up the Response to the HIV/AIDS
Pandemic.)
Efforts to reduce the number of AIDS infections have focused on increasing AIDS
awareness among Africans. Programs and projects aimed at combating the disease typically
provide information on how the disease is spread – and on how it can be avoided – through
the media, posters, lectures, and skits. Donor-sponsored voluntary counseling and testing
(VCT) programs, where available, enable African men and women to learn their HIV status.
Those testing positive are typically referred to support groups and advised on ways to protect
others from contracting the disease; while the majority testing negative are counseled on
behavior changes that will keep them HIV-free. USAID is currently supporting VCT centers
in 10 African countries. AIDS awareness programs can be found in many African schools
and increasingly in the workplace, where employers are recognizing their interest in reducing
the infection rate among their employees. Many projects aim at making condoms readily
available and on providing instruction in condom use. USAID is a major provider of
condoms in Africa. Pilot projects have had success in reducing mother-to-child transmission
by administering the anti-HIV drug AZT or Nevirapine, during birth and early childhood.
Church groups and humanitarian organizations have helped Africa deal with the
consequences of AIDS by setting up programs to provide care and education to orphans. The
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Farm Orphan Support Trust in Zimbabwe tries to keep sibling orphans together and in a
family living situation; the Salvation Army sponsors a pilot, community-based, orphan
support program in Zambia, providing education and health care to vulnerable children.
(Report on the Presidential Mission on Children Orphaned by AIDS.) A United Nations
study has found that community-based organizations, sometimes with the support of NGOs,
have emerged to supply additional labor, home care for the sick, house repair, and other
services to AIDS-afflicted families. (UNAIDS, A Review of Household and Community
Responses to the HIV/AIDS Epidemic in Rural Areas of Sub-Saharan Africa, 1999.)
Public-private partnerships have also become an important vehicle for responding to the
African AIDS pandemic. The Bill and Melinda Gates Foundation has been a major supporter
of vaccine research and a variety of AIDS programs undertaken in cooperation with African
governments and donors. The Rockefeller Foundation, working with UNAIDS and others,
has sponsored programs to improve AIDS care in Africa, and both Bristol-Myers Squibb and
Merck and Company, together with the Gates Foundation and the Harvard AIDS Institute,
have undertaken programs with the Botswana government aimed at improving the country’s
health infrastructure.
USAID estimates that in FY2000, all donors and lending agencies, together with
African governments, spent approximately $500 million in combating AIDS, but donors have
committed to scaling up the response. On July 23, 2000, leaders at the G-8 world economic
summit in Okinawa pledged to reduce the number of young people infected by the HIV virus
by 25%. The World Health Organization estimated that this pledge, and G-8 pledges to
attack malaria and tuberculosis as well, would cost at least $5 billion per year for 5 years.
The World Bank, on September 12, 2000, made an initial commitment of $500 million to a
Multi-Country HIV/AIDS Program (MAP) for Africa. The MAP, designed to be both
flexible and rapidly disbursing, according to the Bank, will help fund HIV/AIDS prevention,
care, and treatment programs in countries that have developed a strategic approach to
combating the epidemic and that met certain other conditions. Nonetheless, on December
9, 2001, Peter Piot, executive director of the Joint United Nations Program on HIV/AIDS
(UNAIDS), told an international AIDS conference in Burkina Faso that assistance to fight
HIV/AIDS in sub-Saharan Africa should be increased “many-fold,” and that the region
requires $4.6 billion per year to confront the pandemic. (For more information, see CRS
Report RL30883, Africa: Scaling Up the Response to the HIV/AIDS Pandemic.)
Global Fund
African heads of state, meeting in Abuja, Nigeria, issued a statement on April 27, 2001,
declaring AIDS a continental emergency, pledging to spend 15% of their annual budgets on
health and urging donors to create a $5 billion to $10 billion Global AIDS Fund. U.N.
Secretary General Kofi Annan subsequently asked for the creation of an international “war
chest” of $7 billion to $10 billion per year, primarily to fight HIV/AIDS but also to combat
tuberculosis and malaria.
On May 11, 2001, President Bush, speaking at the White House in an appearance with
Annan and Nigeria’s President Olusegun Obasanjo, announced that the United States would
make a “founding contribution” of $200 million. The G-8 summit of industrialized nations,
held in Genoa, July 20-22, endorsed the proposed fund and affirmed that members were
committed to making it operational by the end of 2001. Secretary General Annan appointed
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Dr. Chrispus Kiyonga, former Minister of Health in Uganda, to chair a transitional working
group charged with negotiating the terms for establishing the Fund. The transitional working
group included over 40 representatives of governments, non-governmental organizations,
U.N. agencies, foundations, and the private sector.
The Global Fund, which describes itself as an “independent, public-private partnership,”
convened its first Board of Directors meeting in Geneva, Switzerland, where the Fund is
headquartered, on January 28-29. The Board solicited the first round of grant proposals from
“country partners,” which are to be teams made up of government, non-governmental
organizations, and the private sector; the first grants are expected to announced on April 25,
2002. Pledges to the Fund from all donors total $1.9 billion.
The United States has pledged $500 million to the Fund, and to date, Congress has
made available a total of $300 million of this pledge. The Administration has requested that
the additional $200 million be appropriated in the FY2003 appropriations bill. The funds
would come equally from the Foreign Operations Appropriations and from the appropriations
funding the Department of Health and Human Services. (See CRS Report RS21181,
HIV/AIDS International Programs: FY2003 Request and FY2002 Spending.)
Further information on the response to AIDS in Africa may be found at the following
web sites:
CDC: [http://www.cdc.gov/nchstp/od/nchstp.html]
European Union: [http://europa.eu.int/comm/development/aids/]
The Global Fund to Fight AIDS, Tuberculosis, and Malaria:
[http://www.globalfundatm.org]
International AIDS Vaccine Initiative: [http://www.iavi.org]
International Association of Physicians in AIDS Care: [http://www.iapac.org/]
Kaiser Daily HIV/AIDS Report: [http://report.kff.org/aidshiv/]
UNAIDS: [http://www.unaids.org/]
USAID: [http://www.usaid.gov/], click on “Health.”
World Bank: [http://www.worldbank.org/], click on “Topics.”
Effectiveness of the Response
The response to AIDS in Africa has had some successes, most notably in Senegal,
mentioned above, and in Uganda, where the rate of infection among pregnant women in
urban areas fell from 29.5% in 1992 to 11.25% in 2000 (UNAIDS, AIDS Epidemic Update,
December 2001). The Uganda government sponsors an active AIDS awareness program that
openly advocates the use of condoms. HIV prevalence among young urban women in
Zambia has also reportedly fallen, and UNAIDS indicates that urban sexual behavior
patterns may be changing in ways that combat the spread of HIV. Despite some success
stories, however, available evidence indicates that the epidemic is deepening in most of
Africa.
Experts point out that there are a number of barriers to a more effective AIDS response
in Africa, such as cultural norms that make it difficult for many government, religious, and
community leaders to acknowledge or discuss sexual matters, including sex practices,
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prostitution, and the use of condoms. However, experts continue to advocate AIDS
awareness and AIDS amelioration as essential components of the response to the epidemic.
Indeed, there is strong support for an intensification of awareness and amelioration efforts,
as well as adaptations to make such efforts more effective. With respect to amelioration,
UNAIDS has recommended that donors find ways to strengthen those indigenous support
institutions that are already helping AIDS victims and their families. (A Review of
Household and Community Responses.) There is also support for a stronger focus on
treatment of non-HIV sexually-transmitted infections, which studies show can dramatically
lower the rate of HIV transmission.
The lives of infected people could be significantly prolonged and improved, some
maintain, if more were done to identify and treat the opportunistic infections, particularly
tuberculosis, that typically accompany AIDS. Millions of Africans suffer dual infections of
HIV and TB, and the combined infection dramatically shortens life. Tuberculosis can be
cured by treatment with a combination of medications over several months, even in HIV-
infected patients. However, according to the World Health Organization, Africans often
delay seeking treatment for TB or do not complete the course of medication (Global
Tuberculosis Control: WHO Report 1999, Key Findings), contributing to the high incidence
of death among those with dual infections. Pfizer Corporation has signed an agreement with
South Africa to donate the anti-fungal Diflucan (fluconazole) for treating AIDS-related
opportunistic infections, including cryptococcal meningitis, a dangerous brain inflammation.
On December 1, 2001, Pfizer announced that it would sign memoranda of understanding on
donating fluconazole with six other African countries. UNAIDS and the World Health
organization recommended on April 5, 2000, that Africans infected with HIV be treated with
an antibiotic/sulfa drug combination known by the trade name Bactrim in order to prevent
opportunistic infections. Studies indicate that the drug could reduce AIDS death rates at a
cost of between $8 and $17 per year per patient.
AIDS Treatment Issues
Access for poor Africans to costly combinations of AIDS medications or
“antiretrovirals” (ARVs) is perhaps the most contentious issue surrounding the response to
the African epidemic today. Administered in a treatment regimen known as HAART –
highly active antiretroviral therapy – these drugs can return AIDS victims to normal life and
lead to long-term survival rather than early death. Such treatment has proven highly effective
in developed countries, including the United States, where AIDS, which had been the eighth
leading cause of death in 1996 no longer ranked among the 15 leading causes by 1998.
(U.S. Department of Health and Human Services Press Release, October 5, 1999.)
Advocates of making HAART widely available in Africa argue that the therapy would
keep parents alive, slowing the growth in the number of AIDS orphans; and keep workers,
teachers, civil servants, and managers alive as well, thus reducing the economic impact of
the epidemic. Moreover, proponents argue, treatment will strengthen prevention efforts,
since the possibility of treatment will create strong incentives for participation in VCT
programs. Someone who enters treatment and is receiving regular medical attention, many
believe, will be more likely to behave in ways that minimize the risk of spreading HIV.
Some also see a moral obligation to try to save lives when the medications for doing so exist.
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Other, however, argue that as long as resources for combating AIDS are limited, the focus
should continue to be on prevention, which, they maintain, is more cost effective in saving
lives.
The high cost of HAART treatments has been the principal obstacle to offering the
therapy on a large scale in Africa, where most victims are poor and lack health insurance.
The cost of administering HAART was once estimated at between $10,000 and $15,000 per
person per year. On May 11, 2000, five major pharmaceutical companies announced that
they were willing to negotiate sharp reductions in the price of AIDS drugs sold in Africa.
UNAIDS launched a program in cooperation with the pharmaceutical companies to boost
treatment access and, in June 2001, reported that 10 African countries had reached agreement
with manufacturers. The agreements significantly reduced prices in exchange for health
infrastructure improvements to assure that ARVs are administered safely. Patented AIDS
medications are now reportedly becoming available in several African countries, at prices
ranging from a few hundred dollars to just over $1000 per patient per year, for a three-drug
treatment comparable to that available in developed countries. Private clinics in some
African cities are now offering HAART, and Uganda as well as Cote d’Ivoire are providing
treatment in publicly-funded programs to several hundred patients. Nonetheless, Harvard
expert Dr. Howard Hiatt estimated in December 2001 that no more than 25,000 Africans
were receiving treatment. (“Learn from Haiti,” New York Times, December 6, 2001). A
Nigerian program to treat 15,000 AIDS patients with generic antiretrovirals imported from
India was launched in December 2001, but has encountered organizational problems and
difficulties in drug distribution. (Africa News, April 5, 2002; Agence France Presse, May 21,
2002.) In Kenya, a law came into force on May 1, 2002 permitting the importation or
manufacture of generic copies of more expensive patented AIDS drugs, but even such
medications would likely cost more than most Kenyan AIDS patients can afford. (BBC, May
1, 2002.)
Harvard University faculty released a “consensus statement” on April 4, 2001,
maintaining that objections to widespread treatment of HIV-infected people in low-income
countries with antiretroviral drugs were not valid. The statement called for an initial effort
to treat at least one million AIDS patients in Africa within 3 years.
The degree to which Africa’s poorly developed health infrastructure prevents the wider
availability of HAART is controversial. AIDS activists believe that millions of Africans
could quickly be given access to AIDS drugs. Others maintain that African supply channels
cannot make the drugs consistently available to millions of patients and that regular
monitoring of patients by medical personnel is not possible in much of the continent.
Monitoring is necessary, they maintain, to deal with side effects and to adjust medications
if drug resistance emerges. Many fear that if the drugs are taken irregularly, resistant HIV
strains will emerge that could cause untreatable infections worldwide.
AIDS activists also advocate “parallel imports” of drugs and “compulsory licensing”
by African governments to lower the price of patented medications. Through parallel
importing, patented pharmaceuticals could be purchased from the cheapest source, rather
than from the manufacturer; while under “compulsory licensing,” an African government
could order a local firm to produce a drug and pay a negotiated royalty to the patent holder.
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Although both parallel imports and compulsory licensing are permitted under
Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS agreement) of
the World Trade Organization agreement for countries facing national emergencies, U.S.
officials once strongly opposed such measures on grounds that they could lead to
infringements of intellectual property rights. Advocates for the pharmaceutical companies
argued that parallel importing and compulsory licensing could reduce profits, and that this
would hinder the ability of manufacturers to conduct research on new drugs, including drugs
that might be even more effective against HIV. A third view has been that some combination
of subsidization, price reduction, and local manufacturing might be found that would make
the drugs much more widely available while maintaining drug company revenues through
the sheer volume of African sales.
On May 10, 2000, then President Clinton issued an executive order stating that the
United States would not seek to prevent sub-Saharan countries from promoting access to
HIV/AIDS pharmaceuticals or medical technologies consistent with the World Trade
Organization’s TRIPS agreement. On February 22, 2001, an official of the U.S. Trade
Representative’s office said the Bush Administration was not considering any change in
current “flexible policy” on this issue. On November 14, 2001, a ministerial level meeting
of the World Trade Organization in Doha, Qatar, approved a declaration stating that the
TRIPS agreement should be implemented in a manner supportive of promoting access to
medicines for all. The declaration affirmed the right of countries to issue compulsory
licenses and gave the least developed countries until 2016 to implement TRIPS. The
question of whether poor countries should be permitted to import generic copies of patented
drugs was left for further study.
Although the Doha declaration drew broad praise, some AIDS activists criticized it for
not permitting generic imports – cheap copies of patented medications. Some in the
pharmaceutical industry, on the other hand, expressed concern that the declaration was too
permissive and might eventually open the way to such imports. Others, however, argued that
the declaration would have little practical impact, since most AIDS drugs are not actually
patented in many of the countries most heavily affected by the epidemic. From this
perspective, poverty rather than patents is the principal obstacle to drug access in Africa.
(See Amir Attaran and Lee Gillespie-White, “Do Patents for Anti-retroviral Drugs Constrain
Access to AIDS Treatment in Africa?” Journal of the American Medical Association,
October 17, 2001.)
The United Nations convened a General Assembly Special Session (UNGASS) on
HIV/AIDS on June 25-27 in New York. Much of the debate at the session centered on the
issue of whether large-scale treatment with anti-retroviral drugs could be provided in Africa.
The Special Session concluded with passage of a resolution emphasizing the need for
“widespread and effective prevention,” but “recognizing that care, support, and treatment can
contribute to effective prevention.”
U.S. Policy
A July 2000 Washington Post article called into question the adequacy and timeliness
of the early U.S. response to the HIV/AIDS threat in Africa. (Barton Gellman, “The Global
Response to AIDS in Africa: World Shunned Signs of Coming Plague.” Washington Post,
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July 5, 2000). Nonetheless, U.S. concern did begin to mount during the 1980s, as the
severity of the epidemic became apparent. In 1987, in acting on the FY1988 foreign
operations appropriations, Congress earmarked funds for fighting AIDS worldwide, and
House appropriators noted that in Africa, AIDS had the potential for “undermining all
development efforts” to date (H.Rept. 100-283). In subsequent years, Congress supported
AIDS spending at or above levels requested by the executive branch, either through earmarks
or report language.
USAID states that it has been the global leader in the international response to AIDS
since 1986, not only by supporting multilateral efforts but also by directly sponsoring
regional and bilateral programs aimed at combating the disease. (USAID, Leading the Way:
USAID Responds to HIV/AIDS, September 2001). The Agency has sponsored AIDS
education programs; trained AIDS educators, counselors, and clinicians; supported condom
distribution; and sponsored AIDS research. USAID claims several successes in Africa, such
as helping to reduce HIV prevalence among young Ugandans and to prevent an outbreak of
the epidemic in Senegal; reducing the frequency of sexually transmitted infections in several
African countries; sharply increasing condom availability in Kenya and elsewhere; assisting
children orphaned by AIDS; and sponsoring the development of useful new technologies,
including the female condom. USAID reports that it spent a total of $51 million on fighting
AIDS in Africa in FY1998 and $63 million in FY1999 (Leading the Way, 121). In addition,
some spending by the Department of Health and Human Services was going toward HIV
surveillance in Africa and other Africa AIDS-related efforts.
As the severity of the epidemic continued to deepen, many of those concerned for
Africa’s future, both inside and outside government, came to feel that more should be done.
On July 19, 1999, Vice President Gore proposed $100 million in additional spending for a
global LIFE (Leadership and Investment in Fighting an Epidemic) AIDS initiative to begin
in FY2000, with a heavy focus on Africa. Funds approved during the FY2000 appropriations
process supported most of this initiative.
On June 27, 2000, the Peace Corps announced that all volunteers serving in Africa
would be trained as AIDS educators and that 200 former volunteers would be sent to Africa
through the Crisis Corps to work in AIDS care and prevention. Fifty new volunteers would
work exclusively on AIDS-related projects in eastern and southern Africa.
Bush Administration
The Bush Administration has continued to support increases in HIV/AIDS spending for
Africa, and the President has appointed a cabinet level task force, co-chaired by Secretary of
State Colin Powell and Secretary of Health and Human Services Tommy Thompson, to
develop and coordinate HIV/AIDS policy. An interagency policy coordinating committee
headquartered at the White House has been established to back up the task force. Moreover,
as noted above, President Bush made the “founding pledge” of $200 million to the global
Fund, and U.S. pledges to the Fund now total $500 million.
Many support a larger U.S. contribution to the Global Fund, and bills currently before
Congress would provide considerably more than has been pledged. (See for example, H.R.
2069, described in the Legislation section, or S. 1936 listed under Legislative Action.)
Others argue, however, that the Administration has taken only the first steps in what could
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turn out to be a major long-term commitment. At the same time, some concern has been
expressed about the Administration’s focus on the Global Fund, as some observers worry
that the Fund may be diverting attention and support from the bilateral programs of USAID
and the CDC. Many regard these programs as more effective than those of other
organizations and agencies in coping with the African pandemic. In response, others argue
that by supporting the Fund, the United States sets an example that helps to “leverage”
contributions from other donors, thus attracting new resources to the fight against AIDS.
On June 25, 2001, Secretary of State Powell told the United Nations General Assembly
Special Session on HIV/AIDS, that the global response to the pandemic had been “woefully
inadequate” to date. Noting the U.S. support for the Global Fund, however, Powell affirmed
that “more will come from the United States as we learn where our support can be most
effective.” The Secretary of State, also noting U.S. bilateral HIV/AIDS programs and
vaccine research, called for an integrated approach to the pandemic, emphasizing prevention
but also including treatment, orphan care, affordable drugs, and health infrastructure.
Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa
($ millions)
FY2000
FY2001
FY2002
FY2003
estimate
request
USAID
109
144
183
250.4
CDC
34
86
89
89 est.
DOD
0
5
14
0
FMF
0
0
0
2
DOL
0
3
6
0
Total
143
238
292
341.4
est
Table 1, which reviews AIDS spending in Africa since FY2000, as well as estimated
FY2002 spending and the Administration’s FY2003 request, indicates significant increases
in spending through programs of USAID and the Centers for Disease Control (CDC) of the
Department of Health and Human Services. In addition, the Defense Department (DOD) has
undertaken an HIV/AIDS education program with African armed forces. (See CRS Report
RL30761, HIV-1/AIDS and Military Manpower Policy. The amount reported in Table 1 for
this program in FY2002 is the appropriated amount.) Meanwhile the Department of Labor
(DOL) has launched a program that supports AIDS education in the African workplace.
USAID is targeting three heavily affected African countries – Kenya, Uganda, and
Zambia – for a rapid scale up in HIV/AIDS activities intended to show measurable results
in one to two years. Ten African countries have been identified for “intensive focus” to
reduce prevalence rates as well as mother-to-child transmission and to increase support
services for people living with or affected by AIDS within 3 to 5 years. USAID will
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maintain basic programs, including technical assistance, training, and provision of
commodities in eight other African countries. Additional U.S. funds reach Africa indirectly
through the AIDS programs of the United Nations, including the World Bank, and the Global
Fund to Fight AIDS, Tuberculosis, and Malaria.
The Bush Administration’s proposed FY2003 budget seeks $500 million in
Development Assistance for HIV/AIDS programs worldwide, and of this amount, $250.4
million would be spent in Africa. In addition, the Administration is requesting $2 million
in Foreign Military Financing to complement the Defense Department’s AIDS prevention
education program for African armed forces. However, funds have not been requested for
the Defense Department program itself. Africa-specific funding levels for other programs
have not yet been determined, but substantial increases seem unlikely. For CDC HIV/AIDS
activities worldwide, the Administration is requesting $143.8 million, the same level as
appropriated for FY2002. This suggests that CDC spending in Africa will reflect the
FY2002 level of $89 million. The $200 million FY2003 request for the Global Fund is also
the same as the FY2002 level – although FY2002 spending for the Global Fund could
increase under the supplemental appropriations bills currently before Congress. (See
Legislation section.) No funds have been requested for the Department of Labor’s AIDS in
the Workplace program.
The General Accounting Office released a report in March 2001 calling on USAID to
develop better measures for evaluating the effectiveness of its HIV/AIDS programs in Africa.
(GAO Report GAO-01-449, U.S. Agency for International Development Fights AIDS in
Africa, but Better Data Needed to Measure Impact.) In its response, USAID indicated that
it had improved monitoring and evaluation and was using standardized indicators that it had
published in a handbook for use in the field.
The Africa Subcommittee of the Senate Foreign Relations Committee held a hearing
on HIV/AIDS on February 14, 2002. Dr. E. Anne Peterson, Assistant Administrator for
Global Health at the U.S. Agency for International Development, testified that preventing
new infections remained the most urgent priority. Peterson added that USAID would be
launching four treatment sites in Africa in 2002 to provide “critically needed answers” to the
challenges of providing antiretroviral therapy. Harvard Professor Jeffrey Sachs, coordinator
of a recent World Health Organization study on macroeconomics and health, argued that with
“concerted financial support” treatment could be provided on “a greatly enlarged scale.”
Legislative Action
In August 2000, the Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264)
became law. This legislation authorized funding for fiscal years 2001 and 2002 for a
comprehensive, coordinated, worldwide HIV/AIDS effort under USAID, not less than 65%
to be available through non-governmental organizations, including religious-affiliated
organizations, not less than 20% to be available for a multi-donor strategy to address the
support and education of orphans in sub-Saharan Africa, and not less than 8.3% for the
prevention of mother to child transmission. In the 107th Congress, a number of bills have
been introduced with international or Africa-related HIV/AIDS related provisions. These
include:
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H.R. 684 (Millender-McDonald), to authorize assistance for mother-to-child HIV/AIDS
transmission prevention efforts.
H.R. 933 (Waters), Affordable HIV/AIDS Medicines for Poor Countries Act.
H.R. 1185 (Lee), Global Access to HIV/AIDS Medicines Act of 2001.
H.R. 1269 (Crowley), Global Health Act of 2001.
H.R. 1567 (Lee), to encourage the provision of multilateral debt cancellation for countries
eligible to be considered for assistance under the Heavily Indebted Poor Countries
(HIPC) Initiative or heavily affected by HIV/AIDS, and for other purposes.
H.R. 1642 (Waters), Debt Cancellation for the New Millennium Act.
H.R. 1690 (Waters), Export-Import Bank HIV/AIDS Medicine Access Promotion Act.
H.R. 2104 (Eddie Bernice Johnson), to amend the Foreign Assistance Act of 1961 to
authorize the provision of education and related services to law enforcement and
military personnel of foreign countries to prevent and control HIV/AIDS and
tuberculosis.
H.R. 2209 (Bereuter), World Bank AIDS Trust Fund Amendments Act of 2001.
H.R. 2839 (Millender-McDonald), Peace Corps HIV/AIDS Training Enhancement
Appropriations Act for Fiscal Year 2002.
H.R. 3975 (Leach), To provide for the donation of IMF Special Drawing Rights to the
Global Fund, and for negotiations with other countries to induce them to do the same.
S. 463 (Feinstein), Global Access to AIDS Treatment Act of 2001.
S. 895 (Kerry), Vaccines for the New Millennium Act of 2001.
S. 1032 (Frist), International Infectious Diseases Control Act of 2001.
S. 1120 (Boxer), Global AIDS Research and Relief Act of 2001.
S. 1230 (Frist/Clinton), Global Leadership in Developing the Expanded Response Act, or the
“GLIDER Act.”
S. 1752 (Corzine), Microbicide Development Act of 2001.
S. 1936 (Durbin), Global Coordination of HIV/AIDS Response Act
S. 2525 (Kerry), United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Act of 2002
Bills that have been reported out of committee or received floor action are detailed
below, under Legislation. For information on appropriations for HIV/AIDS programs in
FY2002, see CRS Report RS21114, HIV/AIDS: Appropriations for Worldwide Programs
in FY2001 and FY2002.
LEGISLATION
H.Con.Res. 102 (Leach)
Hunger to Harvest: A Decade of Support for Africa. States sense of Congress that
within 90 days the President should submit a report setting forth a five-year strategy, and a
ten year strategy, to reverse hunger and poverty in Africa; emphasis should be on health,
among other objectives, including HIV/AIDS. Introduced in the House on April 4, 2001, and
referred to the Committee on International Relations. Marked up on November 1 and passed
under a suspension of the rules (400-9), December 5. Received in the Senate, December 6.
Passed the Senate by unanimous consent, March 8, 2002.
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H.R. 1646 (Hyde)
Department of State Authorization. Authorizes up to $1 million for HIV/AIDS research
and mitigation strategies in a Border-Less World academic program of the Fulbright
Academic exchange program; states the sense of Congress that U.S. officials should urge the
United Nations to adopt an HIV/AIDS mitigation strategy as a component of U.N.
peacekeeping operations; and that the Secretary of State should establish an international
HIV/AIDS intervention, mitigation, and coordination task force. Introduced on May 4, 2001;
referred to the Committee on International Relations. Marked up and ordered reported, May
2, 2001; report filed (H.Rept. 107-57). Passed the House, May 16, 2001. Received in the
Senate and referred to the Committee on Foreign Relations, May 17, 2001.
H.R. 2069 (Hyde)
Global Access to HIV/AIDS Prevention, Awareness, Education, and Treatment Act of
2001. States the sense of Congress that the United States should provide additional funds
for multilateral programs and efforts to combat HIV/AIDS, including programs that make
available pharmaceuticals and diagnostics for HIV/AIDS therapy in sub-Saharan Africa; and
that programs to help AIDS orphans as well as micro-enterprise programs for HIV/AIDS
affected families should be expanded; amends the Foreign Assistance Act of 1961 (P.L. 87-
195) to state that HIV/AIDS assistance should include prevention (including assistance
through faith-based organizations), treatment, monitoring, and related activities; requires an
annual report on USAID HIV/AIDS activities; authorizes $560 million for these activities
in each of fiscal years 2002 and 2003; requires USAID to assist sub-Saharan and other
developing countries to procure and distribute HIV/AIDS pharmaceuticals, including
antiretrovirals, and authorizes $50 million for this purpose; states that the President shall
establish an inter-agency task force to coordinate international HIV/AIDS activities;
establishes a permanent Global Health Advisory Board to assist in the development and
implementation of international health programs; authorizes $750 million in FY2002 for
contributions to a global health fund or other multilateral efforts to prevent and treat
HIV/AIDS. Introduced on June 6, 2001; referred to the Committee on International
Relations. Amendment in the nature of a substitute marked up and approved by the House
International Relations Committee, June 27, 2001. Reported (H.Rept. 107-137) July 12.
Passed the House by a voice vote under a suspension or the rules, December 11. Received
in the Senate and referred to the Committee on Foreign Relations, December 12, 2001.
H.R. 4775/S. 2551
Supplemental Appropriations for FY2002. House version appropriates an additional
$200 million for emergency expenses related to combating AIDS, tuberculosis, and malaria;
specifies that U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and
Malaria in FY2002 shall not exceed 40% of contributions by all donors. Passed the House
(280-138), May 24, 2002. Senate version provides an additional $100 million for
HIV/AIDS, tuberculosis, and malaria programs, which may be made available to the Global
Fund. Ordered to be reported by the Committee on Appropriations, May 22, 2002.
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