Order Code IB10050
Issue Brief for Congress
Received through the CRS Web
AIDS in Africa
Updated August 1, 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
28.5 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 9%; it is
AIDS in sub-Saharan Africa was estimated at
1.2% worldwide. Twelve countries, mostly in
$500 million for FY2000, while U.N. experts
east and southern Africa, have HIV infection
believe the region could effectively absorb
rates of more than 10%, and the rate has
$4.6 billion to combat the pandemic.
reached 38.8% in Botswana. An estimated
21.5 million Africans have died of AIDS,
Treatment of AIDS sufferers with medi-
including 2.2 million who died in 2001. AIDS
cines that can result in long-term survival is
has surpassed malaria as the leading cause of
reportedly available to fewer than 30,000
death in Africa, and it kills many times more
Africans. Advocates of expanded treatment
Africans than war. In Africa, HIV is spread
argue that in view of recent drug price reduc-
primarily by heterosexual contact, and sub-
tions, treatment is an affordable means of
Saharan Africa is the only region where
reducing AIDS damage to African econo-
women are infected at a higher rate than men.
mies, reinforcing prevention programs, and
keeping parents alive. Skeptics argue that
Experts relate the severity of the African
treatment is still too expensive to be an option
AIDS epidemic to the region’s poverty.
for most Africans and would require donors to
Health systems are ill-equipped for
fund costly improvements in Africa’s health
prevention, diagnosis, and treatment. Poverty
infrastructure.
forces many men to become migrant workers
in urban areas, where they may have multiple
U.S. concern over AIDS in Africa grew
sex partners. Poverty leads many women to
during the 1980s, as the severity of the epi-
become commercial sex workers, vastly in-
demic became apparent. According to the
creasing their risk of infection.
U.S. Agency for International Development,
the United States has been the global leader in
AIDS’ severe social and economic conse-
the international response to AIDS since 1986.
quences are depriving Africa of skilled work-
Legislation enacted in the 106th and the 107th
ers and teachers while reducing life expec-
Congresses increased funding for worldwide
tancy by decades in some countries. An
HIV/AIDS programs, and the Administration
estimated 11 million AIDS orphans are
has requested a further increase for FY2003.
currently living in Africa, facing increased
The United States has also pledged $500
risk of malnutrition and reduced prospects for
million to the new Global Fund to Fight
education. AIDS is being blamed for declines
AIDS, Tuberculosis, and Malaria. Nonethe-
in agricultural production in some countries.
less, critics find the U.S. response inadequate
in view of the scale of the African pandemic.
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MOST RECENT DEVELOPMENTS
The XIV International AIDS Conference concluded in Barcelona, Spain, on July 12,
2002. A report issued at the conference warned that the pandemic was continuing to
intensify in Africa, where 55 million additional AIDS-caused deaths could occur by 2020.
Some scientific papers focused on the capacity of the HIV virus to mutate and to “hide” in
cells of the immune system for decades, but some progress was reported in vaccine and drug
research. The limited availability of AIDS treatment in Africa was another focus, but
success was reported in small-scale treatment programs. Some successes in prevention were
also noted, but a large number of speakers urged sharply increased spending both for
treatment and prevention. Protestors demanding increased international AIDS funding
disrupted a July 9 speech by Secretary of Health and Human Services Tommy Thompson.
On June 19, President Bush announced a three-year, $500 million initiative to prevent
mother to child transmission of HIV worldwide. More than 600,000 African children are
born with the infection each year, and twelve African countries were proposed as initial
participants in the program. Critics maintained, however, that the proposed spending was
inadequate in view of the scale of the problem.
BACKGROUND AND ANALYSIS
Sub-Saharan Africa has been far more severely affected by AIDS than any other part
of the world. According to a July 2002 report issued by the Joint United Nations Program
on HIV/AIDS (UNAIDS), some 28.5 million adults and children are infected with the HIV
virus in the region, which has about 10% of the world’s population but more than 70% of the
worldwide total of infected people. The infection rate among adults is about 9% in Africa,
compared with 1.2% worldwide. An estimated 21.5 million Africans have lost their lives
to AIDS, including an estimated 2.2 million who died in 2001. UNAIDS estimates that by
2020, an additional 55 million Africans will have died earlier than they would have in the
absence of AIDS. An estimated 3.5 million new infections occurred in 2001, dashing hopes
that the epidemic might be reaching a natural limit and would level off. In Botswana, the
worst-affected country, 55.6% of urban pregnant women aged 25-29 and attending ante-natal
clinics were HIV positive in 2001. Rising infection rates continue to be seen in Zimbabwe,
Namibia, and other countries as well. 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
! 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
58% of the HIV-positive adult population in sub-Saharan Africa, as
compared with 47% worldwide.
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! Young women are particularly at risk. A U.N. study found that in 1998,
girls aged 15-19 were infected at a rate of 15% to 23%, while the rate among
boys of the same age was 3.5%.
! Southern and eastern Africa have been far more severely affected than West
Africa, but infection rates in a number of West African countries are rising.
In seven southern African countries, 20% or more of the adult population is
infected with HIV, and the rate has reached 38.8% in Botswana. In
Cameroon, a West African country, the adult infection rate has jumped from
4.7% in 1996 to 11.8% in 2001. In Nigeria, with a population that exceeds
125 million, an estimated 5.8% of adults were HIV positive in 2001, and
infection rates in some states have reached levels seen in Cameroon.
! The African AIDS epidemic is having a much greater impact on children
than is the case in other parts of the world. According to UNAIDS, more
than 600,000 African infants become infected with HIV each year through
mother-to-child transmission, either at birth or through breast-feeding.
These children have short life expectancies, and the number currently alive
may be about 1 million.
! In 2001, an estimated 11 million children orphaned by AIDS were living in
Africa, and an authoritative report estimates that by 2010, 20.1 million
children will have lost one or both parents to AIDS. 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. The number of
orphans due to all causes is expected to total 42 million in 2010, including
6.7 million in Nigeria, 5 million in Ethiopia, and 2.3 million in South Africa.
(UNAIDS, UNICEF, and U.S. Agency for International Development,
Children on the Brink, 2002, a Joint Report on Orphan Estimates and
Program Strategies, p. 28.)
Explaining the African Epidemic
AIDS experts emphasize a variety of economic and social factors in explaining
Africa’s AIDS epidemic, placing primary blame on the region’s poverty. Poverty has
deprived Africa of effective systems of health information, health education, and health care.
Thus, Africans suffer from a high rate of untreated sexually-transmitted infections (STIs)
other than AIDS, and these increase susceptibility to HIV. African health systems typically
have limited capabilities for AIDS prevention work, and HIV counseling and testing are
difficult for many Africans to obtain. AIDS treatment is generally available only to the elite.
Poverty forces large numbers of African men to migrate long distances in search of
work, and while away from home they may have multiple sex partners, increasing their risk
of infection. Some of these partners may be women who have become commercial sex
workers because of poverty, and they too are highly vulnerable to infection. Migrant workers
may carry the infection back to their wives when they return home. Long distance truck
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drivers, and drivers of “taxis,” who transport
Adult HIV Infection Rates (%), end of 2001
Africans long distances by car, are probably also
key agents in spreading HIV.
Botswana
38.8
Swaziland
33.4

Zimbabwe
33.7
Some behavior patterns in Africa may also
Lesotho
31.0
be affecting the epidemic. In explaining the fact
Namibia
22.5
Zambia
21.5
that young women are infected at a higher rate
South Africa
20.1
than young men, Peter Piot, the Executive
Malawi
15.0
Director UNAIDS, has commented that “the
Kenya
15.0
Mozambique
13.0
unavoidable conclusion is that girls are getting
Cent. Af. Republic
12.9
infected not by boys but by older men,” who are
Cameroon
11.8
Cote d’Ivoire
9.7
more likely than young men to carry the disease.
Rwanda
8.9
(UNAIDS press release, September 14, 1999.) A
Burundi
8.3
researcher in a UNAIDS project studying the
Tanzania
7.8
Congo Brazzaville
7.2
differential rate of infection added that “Young
Sierra Leone
7.0
(women’s) lives are being cut short through sex
Burkina Faso
6.5
which is all too often forced, coerced, or ‘bought’
Ethiopia
6.4
Togo
6.0
with sugar-daddy gifts.” Many believe that the
Nigeria
5.8
infection rate among women generally would be
Angola
5.5
far lower if women’s rights were more widely
Uganda

5.0
Congo Kinshasa

4.9
respected in Africa and if women exercised more
Benin
3.6
power in political and economic affairs. (For
Chad

3.6
Equatorial Guinea
3.4
more on these issues, see Helen Epstein, “AIDS:
Ghana
3.0
the Lesson of Uganda,” New York Review of
Eritrea
2.8
Books, July 5, 2001; and “The Hidden Cause of
Guinea Bissau
2.8
Sudan
2.6
AIDS,” New York Review of Books, May 9,
Mali

1.7
2002.)
Somalia
1.0
Senegal
.5
Madagascar
.3
The breakdown in social order and social
Mauritius
.1
norms caused by armed conflict is also
contributing to the African epidemic. Conflict is
Source: UNAIDS, Report on the Global
HIV/AIDS Epidemic, July 2002. Data not
typically accompanied by numerous incidents of
available for the following countries:
violence against women, including rape, carried
Comoros, Djibouti, Gabon, Gambia, Guinea,
Liberia, Mauritania, Niger.
out by soldiers and guerrillas. Such men are also
more likely to resort to commercial sex workers
than those living in a settled environment.
Many observers believe that the spread of AIDS in Africa could have been slowed if
African leaders had been more engaged and outspoken in earlier stages of the epidemic.
President Thabo Mbeki of South Africa has come in for particular criticism on this score.
In April 2000, President Mbeki wrote then 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 of that year, 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
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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.
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.
On July 5, 2002, South Africa’s Constitutional Court denied the government’s appeal
against lower court decisions ordering it to begin providing the antiretroviral drug Nevirapine
nationwide to reduce the transmission of HIV from pregnant mothers to their newborns. The
South African Treatment Action Campaign (TAC) has launched the suit in August 2001,
demanding a comprehensive program to prevent mother-to-child transmission (MTCT).
TAC maintained that MTCT trials involving 18 pilot projects providing Nevirapine to HIV-
positive pregnant women were inadequate and that 20,000 babies could be saved by a
nationwide program. The German firm Boerhringer-Ingelheim offers the Nevirapine drug
free in Africa for MTCT programs. South African officials maintained that safety
precautions required further testing of Nevirapine but accepted the Constitutional Court’s
decision. However, continuing South African government objections to a grant awarded by
the Global Fund to Fight AIDS, Tuberculosis, and Malaria to KwaZulu-Natal Province,
where infection rates are extremely high, has caused some to question whether official
attitudes on the AIDS epidemic have in fact changed.
In the rest of Africa, meanwhile, many heads of state and other leaders are now taking
major roles in fighting the epidemic. President Yoweri Museveni of Uganda has long been
recognized for leading a successful campaign against AIDS in his country, and the presidents
of Botswana, Nigeria, and several other countries are today in the forefront of the AIDS
struggle as well. Several regional AIDS initiatives have been launched.
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”.)
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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. According to UNAIDS, as a result
of AIDS, average life expectancy in sub-Saharan Africa is now 47 years, whereas it would
have been 62 years without the epidemic. South Africa and some other countries in southern
Africa could face population declines by the end of the decade, according to experts.
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. Should the mother also become ill, children may be forced to shoulder
responsibility for the full time care of their parents. The Food and Agriculture Organization
of the United Nations reports that since the epidemic began, 7 million agricultural workers
have been killed in Africa. The agricultural workforce has been reduced by more than 20%
in five countries. (FAO, HIV/AIDS, Food Security, and Rural Livelihoods, May 2002.)
AIDS is 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. AIDS is also claiming many lives at middle and upper levels of
management in both business and government. Although unemployment is generally high
in Africa, trained personnel are not readily replaced.
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.
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
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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.)
Programs and projects aimed at combating the epidemic typically provide information
on how HIV 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. The U.S. Agency for International Development
(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
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.
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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
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 $2.1 billion. The Fund announced its first
grants on April 25, 2002. Of the $616 million awarded over two years worldwide, Africa
is to receive 60%.
To date, 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. For details and information on
appropriations, 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/]
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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 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. Senegal, meanwhile, is credited with preventing an AIDS
epidemic through an active, government-sponsored prevention program. 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,
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
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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 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. Some also see a moral obligation to try to save lives when the medications for
doing so exist. 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, UNAIDS
estimates that only about 30,000 Africans are receiving treatment. 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, although even these medications would
likely cost more than most Kenyan AIDS patients can afford. (BBC, May 1, 2002.) The
Global Fund maintains that its initial round of grants will make possible a six-fold increase
in the numbers being treated in Africa over five years.
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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. In February 2002
Senate testimony, Dr. E. Anne Peterson, Assistant Administrator for Global Health at
USAID stated that USAID would be launching four treatment sites in Africa in 2002 to
provide “critically needed answers” to the challenges of providing antiretroviral therapy.
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.
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
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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,
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 $100 million in additional spending for a
global LIFE (Leadership and Investment in Fighting an Epidemic) AIDS initiative to begin
in FY2000, with a heavy focus on Africa. Funds approved during the FY2000 appropriations
process supported most of this initiative. On June 27, 2000, the Peace Corps announced that
all volunteers serving in Africa would be trained as AIDS educators.
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Bush Administration
The Bush Administration has continued to support increases in HIV/AIDS spending for
Africa, and the President has appointed a cabinet level task force, co-chaired by Secretary of
State Colin Powell and Secretary of Health and Human Services Tommy Thompson, to
develop and coordinate HIV/AIDS policy. An interagency policy coordinating committee
headquartered at the White House has been established to back up the task force. Moreover,
as noted above, President Bush made the “founding pledge” the Global Fund.
Many support a larger U.S. contribution to the Global Fund, and bills currently before
Congress would provide considerably more than has been pledged. (See below.) Others
argue, however, that the Administration has taken significant first steps in what will likely
be a major long-term commitment. At the same time, some concern has been expressed
about the Administration’s focus on the Global Fund, as some observers worry that the Fund
may be diverting attention and support from the bilateral programs of USAID and the CDC.
Many regard these programs as more effective than those of other organizations and agencies
in coping with the African pandemic. In response, others argue that by supporting the Fund,
the United States sets an example that helps to “leverage” contributions from other donors,
thus attracting new resources to the fight against AIDS.
Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa
($ 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
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, which reviews direct AIDS spending in Africa since FY2000, as well as
estimated FY2002 spending and the Administration’s FY2003 request, indicates significant
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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
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.
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.
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.
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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.
H.R. 4524 (Smith of New Jersey), Debt Relief Enhancement Act of 2002.
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. 2210 (Biden), Debt Relief Enhancement 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.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
Global Access to HIV/AIDS Prevention, Awareness, Education, and Treatment Act of
2001. House version states the sense of Congress that the United States should provide
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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.
Senate-passed version replaces provisions of H.R. 2069 with those of S. 2525 (Kerry),
the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2002, and
S. 2649 (Kennedy). Requires the President to establish a comprehensive, five-year strategy
to combat global HIV/AIDS; requires USAID to develop a comprehensive plan to empower
women to project themselves against the spread of HIV/AIDS; requires the Department of
State to appoint a Coordinator of United States Government Activities to Combat
HIV/AIDS; authorizes $1 billion in FY2003 and $1.2 billion in FY2004 for contributions to
the Global Fund; authorizes $60 million in FY2002 and $70 million in FY2003 as
contributions to the global Vaccine Fund, $12 million and $15 million respectively for
contributions to the International AIDS Vaccine Initiative, and $5 million and $6 million for
the Malaria Vaccine Initiative; authorizes and requests the Secretary of the Treasury to seek
improvements in the Heavily Indebted Poor Countries Initiative (HIPC) to combat AIDS,
tuberculosis, and malaria; authorizes $800 million in FY2003 and $900 million in FY2004
for bilateral HIV/AIDS programs, specifying amounts for microbicide research and the
procurement of pharmaceuticals; authorizes funding to combat tuberculosis and malaria;
requires the President to establish pilot programs to facilitate the service of U.S. health care
professionals in Africa and elsewhere; authorizes $50 million in FY2003 and $55 million in
FY2004 for a required expansion of the Department of Defense AIDS prevention activities
with African armed forces; requires a report on USAID and CDC programs to provide
treatment, as well as annual reports on preventing MTCT; authorizes $15 million in FY2003
and $30 million in FY2004 for a pilot program of assistance for children and families
affected by AIDS; sets out principles for U.S. firms operating in countries affected by the
AIDS pandemic; in Title VI (from S. 2649), provides additional authorities for the
Department of Health and Human Services and the Department of Labor with respect to
international AIDS activities; authorizes $400 million for CDC international activities in
FY2003, $50 million for AIDS care and treatment, and $10 million for the Department of
Labor. H.R. 2069 passed the Senate, as amended, by unanimous consent, July 12, 2002;
message on Senate action sent to the House on July 15.
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H.R. 4546/S. 2515
National Defense Authorization. Amendment to S. 2515 by Sen. Reid (for Kerry, Frist)
authorizes $30 million for an expanded Department of Defense AIDS education program
with African armed forces, adopted June 26, 2002; H.R. 4564 passed the Senate (97-2), with
provisions of S. 2515 substituted, June 27, 2002 (House version, passed on May 10, does not
include a comparable provision); Senate appointed conferees, July 26; House appointed
conferees, July 27.
H.R. 4775/S. 2551
Supplemental Appropriations for FY2002. House version appropriated 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 as introduced provided an additional $100 million
for HIV/AIDS, tuberculosis, and malaria programs, which could be made available to the
Global Fund. Ordered to be reported by the Committee on Appropriations, May 22, 2002.
Amendment by Senator Durbin to increase the amount to $500 million failed when a motion
to overturn a point of order failed (46-49), June 6; amendment by Senator Frist to increase
the amount to $200 million, place special emphasis on mother to child transmission
prevention, and limit contributions to the Global Fund to the amount contributed by other
donors passed (79-14), June 6. Bill passed the Senate (71-22) as an amendment to H.R.
4775, June 7; Senate appointed conferees, June 7. Conference version provides $200
million for emergency expenses related to combating AIDS, tuberculosis, and malaria,
including not less than $100 million for the Global Fund; states that additional assistance
should be provided to prevent MTCT; requires that cumulative amount of U.S. contributions
to the Fund should not exceed resources provided and available for use by other donors as
of December 31, 2002. Appropriation of AIDS funds, with other funds, is contingent upon
a presidential designation within 30 days that all such funds are an emergency requirement.
House agreed (397-32) to conference report (H.Rept. 107-593) July 23; Senate agreed to
conference report, July 24; presented to the President, July 26, 2002.
S. 2766 (Harkin)
Departments of Labor, Health and Human Services, and Education Appropriations,
FY2003. Provides that $100 million may be made available by the National Institute of
Allergy and Infections Diseases of the National Institutes of Health as a contribution to the
Global Fund. Reported to the Senate (S.Rept. 107-216), July 22, 2002.
S. 2779 (Leahy)
Foreign Operations Appropriations, FY2003. Provides $500 million under Child
Survival and Health Programs for global HIV/AIDS programs, of which $18 million is to be
used for microbicide development, as well as $200 million as a contribution to the Global
Fund and $12 million for the International AIDS Vaccine Initiative; provides $50 million for
HIV/AIDS from other assistance programs. Reported to the Senate (S.Rept. 107-219), July
24, 2002.
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