Order Code IB10050
CRS Issue Brief for Congress
Received through the CRS Web
AIDS in Africa
Updated July 10, 2003
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
Leadership Reaction in South Africa and Elsewhere
Social and Economic Consequences
Responses to the AIDS Epidemic
Effectiveness of the Response
AIDS Treatment Issues
U.S. Policy
Bush Administration
Legislative Action, 2000-2002
Legislative Action in the 108th Congress
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
29.4 million adults and children are infected
the number of new HIV infections and by
with the HIV virus in the region, which has
trying to ameliorate the damage done by AIDS
about 10% of the world’s population but more
to families, societies, and economies. The
than 70% of the worldwide total of infected
adequacy of this response is the subject of
people. The overall rate of infection among
much debate. U.N. experts estimate 2003
adults in sub-Saharan Africa is 8.8%; com-
spending from all sources on HIV/AIDS in
pared with 1.2% worldwide. Twelve coun-
low- and middle-income countries worldwide
tries, mostly in east and southern Africa, have
at $4.7 billion, compared with an estimated
HIV infection rates of more than 10%, and the
need of $10.5 billion by 2005.
rate has reached 38.8% in Botswana. As of
2001, an estimated 21.5 million Africans had
Treatment of AIDS sufferers with medi-
died of AIDS, including 2.2 million who died
cines that can result in long-term survival is
in that year. AIDS has surpassed malaria as
reportedly available to fewer than 30,000
the leading cause of death in Africa, and it
Africans. Advocates of expanded treatment
kills many times more Africans than war. In
argue that in view of recent drug price reduc-
Africa, 58% of those infected are women.
tions, treatment is an affordable means of
reducing AIDS damage to African econo-
Experts relate the severity of the African
mies, reinforcing prevention programs, and
AIDS epidemic to the region’s poverty.
keeping parents alive. Skeptics argue that
Health systems are ill-equipped for
treatment is still too expensive to be an option
prevention, diagnosis, and treatment. Poverty
for most Africans and would require costly
forces many men to become migrant workers
improvements in health infrastructure.
in urban areas, where they may have multiple
sex partners. Poverty leads many women to
U.S. concern over AIDS in Africa grew
become commercial sex workers, vastly in-
during the 1980s, as the severity of the epi-
creasing their risk of infection.
demic became apparent. Legislation enacted
in the 106th and the 107th Congresses increased
AIDS’ severe social and economic conse-
funding for worldwide HIV/AIDS programs.
quences are depriving Africa of skilled work-
H.R. 1298, which was signed into law (P.L.
ers and teachers while reducing life expec-
108-25) on May 27, 2003, would authorize
tancy by decades in some countries. An
$15 billion over five years for international
estimated 11 million AIDS orphans are
AIDS programs. President Bush has launched
currently living in Africa, facing increased
an International Mother and Child HIV Trans-
risk of malnutrition and reduced prospects for
mission Initiative that will benefit 8 African
education. AIDS is being blamed for declines
countries, and 12 are slated for added support
in agricultural production in some countries,
under the global aids initiative announced in
and is regarded as a major contributor to the
the January 28, 2003 State of the Union mes-
famine threatening southern Africa.
sage. Nonetheless, activists and others urge
that more be done in view of the scale of the
African pandemic.
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MOST RECENT DEVELOPMENTS
On July 10, 2003, speaking in Botswana, the third stop on a 5-day trip to Africa,
President Bush said with respect to AIDS, “This is the deadliest enemy Africa has ever faced,
and you will not face this epidemic alone.” On July 8, in Senegal, the President told Africans
“we will join with you in turning the tide against AIDS in Africa.” The President also spoke
on the epidemic in South Africa on July 9. According to a Financial Times report that same
day, a representative of the United Nations Development Program (UNDP) said that South
Africa had fallen 28 places on the UNDP Human Development Index since 1990 — to 111th
place out of 175 countries — primarily due to AIDS. As of July 9, the South African
government had not made public a report completed in April on the feasibility of providing
universal treatment to patients needing antiretroviral therapy.
President Bush, on July 2, nominated Randall Tobias, former chairman and chief
executive officer of Eli Lilly and Company, to be Global AIDS Coordinator, a position at the
Department of State carrying the rank of Ambassador. Many praised the appointment on
grounds that Tobias has the management experience needed for a quick launch of the
President’s Global AIDS Initiative, but skeptics noted that the nominee has little experience
with Africa or with AIDS generally. The United Nations Joint Program on AIDS (UNAIDS)
reported on June 26 that about $4.7 billion would be spent combating AIDS in low- and
middle-income countries worldwide in 2003, as compared with the $10.5 million estimated
to be needed annually by 2005. On June 10, President Bush welcomed President Yoweri
Museveni of Uganda to the White House with praise for the Ugandan leader’s “extraordinary
leadership on HIV/AIDS in your country.” On May 27, 2003, President Bush signed into law
H.R. 1298 (P.L. 108-25), the United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003, authorizing $15 billion over 5 years for international AIDS,
tuberculosis, and malaria activities. For details, see CRS Report RS21181, HIV/AIDS
International Programs: Appropriations, FY2002-FY2004; and CRS Report RL31712, The
Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background and Current Issues.
BACKGROUND AND ANALYSIS
Sub-Saharan Africa has been far more severely affected by AIDS than any other part
of the world. In November 2002, UNAIDS (the Joint United Nations Program on
HIV/AIDS) reported that in 2002, 29.4 million people were living with HIV and AIDS in
sub-Saharan Africa, up from 28.5 million in 2001. Africa, where an estimated 3.5 million
people were newly infected in 2002, 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
8.8% in Africa, compared with 1.2% worldwide. Through 2001, an estimated 21.5 million
Africans had lost their lives to AIDS, including an estimated 2.2 million who died in that
year(UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002). UNAIDS estimates that
by 2020, an additional 55 million Africans will loose their lives to the epidemic. 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.
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Reports by scientists at the XIV International AIDS Conference, held in Barcelona in
July 2002, noted that the HIV virus probably could not be eliminated by drug treatment, due
to its newly discovered ability to “hide” in cells of the immune system for decades. Thus,
drug therapy, once begun, would have to be provided throughout a patient’s lifetime. Some
progress was reported in vaccine research, but most reports suggested that an effective
vaccine was still years in the future. The limited availability of AIDS treatment in Africa
was another focus of the meeting, but success was reported in small-scale treatment
programs. Some successes in prevention were also noted, and many speakers urged sharply
increased spending both for treatment and prevention.
Characteristics of the African Epidemic
! HIV, the human immunodeficiency virus that causes AIDS, is spread in
Africa, most experts believe, primarily by heterosexual contact. (A February
2003 article published by David Gisselquist and others in the International
Journal of STD and AIDS asserted that the importance of unsafe medical
practices in the spread of HIV may have been underestimated and called for
further research. The article has caused some controversy, and the Senate
Health, Education, Labor, and Pensions Committee held a hearing on March
27 to examine the issue.)
! Women make up an estimated 58% of the HIV-positive adult population in
sub-Saharan Africa, as compared with 50% worldwide — according to
UNAIDS. Young women are particularly at risk. In 2001, an estimated 6%
to 11% of African women aged 15 to 24 were HIV positive, compared with
3% to 6% of young men. (UNAIDS, AIDS Epidemic Update, December
2002).
! 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 Nigerian states have reached levels seen in
neighboring Cameroon. The U.S. National Intelligence Council, in a
September 2002 report on the “next wave of HIV/AIDS,” predicted that by
2010, 10 to 15 million Nigerians, or 18% to 26% of adults, would be
infected by HIV.
! 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.
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! 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 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
drivers, and drivers of “taxis,” who transport Africans long distances by car, are probably
also key agents in spreading HIV.
Some behavior patterns in Africa may also be affecting the epidemic. In explaining the
fact that young women are infected at a higher rate than young men, Peter Piot, the Executive
Director UNAIDS, has commented that “the 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.) UNAIDS notes that “”with the
downward trend of many African economies ... relationships with (older) men can serve as
vital opportunities for financial and social security, or for satisfying material aspirations.”
(AIDS Epidemic Update, 2002). 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
Adult HIV Infection Rates (%), end of 2001
norms caused by armed conflict is also
contributing to the African epidemic. Conflict is
Botswana
38.8
Swaziland
33.4
typically accompanied by numerous incidents of
Zimbabwe
33.7
violence against women, including rape, carried
Lesotho
31.0
out by soldiers and guerrillas. Such men are also
Namibia
22.5
Zambia
21.5
more likely to resort to commercial sex workers
South Africa
20.1
than those living in a settled environment.
Malawi
15.0
Kenya
15.0
Mozambique
13.0
Leadership Reaction in South
Cent. Af. Republic
12.9
Cameroon
11.8
Africa and Elsewhere
Cote d’Ivoire
9.7
Rwanda
8.9
Many observers believe that the spread of
Burundi
8.3
Tanzania
7.8
AIDS in Africa could have been slowed if
Congo Brazzaville
7.2
African leaders had been more engaged and
Sierra Leone
7.0
outspoken in earlier stages of the epidemic.
Burkina Faso
6.5
Ethiopia
6.4
President Thabo Mbeki of South Africa has come
Togo
6.0
in for particular criticism on this score. In April
Nigeria
5.8
Angola
5.5
2000, President Mbeki wrote then President
Uganda

5.0
Clinton and other heads of state defending
Congo Kinshasa

4.9
dissident scientists who maintain that AIDS is not
Benin
3.6
Chad

3.6
caused by the HIV virus. In March 2001, Mbeki
Equatorial Guinea
3.4
rejected appeals that the national assembly
Ghana
3.0
declare the AIDS pandemic a national emergency,
Eritrea
2.8
Guinea Bissau
2.8
and in September of that year, the South African
Sudan
2.6
government attempted to delay publication of a
Mali

1.7
South African Medical Research Council report,
Somalia
1.0
Senegal
.5
which found AIDS to be the leading cause of
Madagascar
.3
death, accounting for 40% of mortality among
Mauritius
.1
South Africans aged 15 to 49. The Council
Source: UNAIDS, Report on the Global
predicted that South Africa’s death toll from
HIV/AIDS Epidemic, July 2002. Data not
AIDS would reach a cumulative total of between
available for the following countries:
Comoros, Djibouti, Gabon, Gambia, Guinea,
5 and 7 million by 2010, when 780,000 people
Liberia, Mauritania, Niger.
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
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nationwide to reduce the transmission of HIV from pregnant mothers to their newborns. The
South African Treatment Action Campaign (TAC) had 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.
The April 2002 cabinet pledges and the court decision eased tensions in South Africa
over AIDS policy for some months, but activists undertook a new civil disobedience
campaign in March and April 2003, charging two government ministers with “manslaughter”
for failing to provide treatment to those suffering with AIDS. Government officials
responded that the cost of providing universal treatment was still being determined, and the
ruling African National Congress accused TAC of “bully boy tactics.” (South African Press
Association, March 26, 2003.) On April 11, 2003, South Africa failed to sign an agreement
with the Global Fund to Fight AIDS, Tuberculosis, and Malaria on a grant approved in 2002
for HIV/AIDS projects in AIDS-stricken KwaZulu-Natal Province. Global Fund Director
Richard Feachem had been in South Africa for the signing, which South African officials
said had to be postponed for technical and financial reasons.
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 prevention campaign against AIDS in his country, and
Uganda’s ABC (Abstinence, Be Faithful, or Use Condoms) transmission prevention program
has won wide praise. (“Uganda Leads by Example on AIDS,” Washington Times, March 13,
2003.) A Senate Foreign Relations Africa Subcommittee hearing on May 19, 2003, focused
on “Fighting AIDS in Uganda: What Went Right.” Dr. Anne Peterson, Assistant
Administrator for Global Health at the U.S. Agency for International Development (USAID),
testified that the “Uganda success story is about prevention.” She said that successes had
been recorded in promoting abstinence and faithfulness to partners, while increased condom
use in recent years had also contributed to the decline in prevalence. Sophia Mukasa Monico
of the Global Health Council, also a former AIDS worker in Uganda, testified that all three
program elements need to be in place for prevention to work. Mukasa Monico noted that
“the epidemic is still raging in Uganda, and we have much to do before we can claim
victory....”
Meanwhile, the presidents of Botswana, Nigeria, and several other countries are widely
seen today as in the forefront of the AIDS struggle as well. Kenya’s new president, Mwai
Kibaki, elected in December 2002, has declared “total war on AIDS” and committed his
government to treating 40,000 AIDS patients. (“In Another Break with Past, Kenyans See
Hope on AIDS,” Washington Post, May 21, 2003.) Several regional AIDS initiatives have
been launched.
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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. 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), and
a number of experts are relating the current famine in southern Africa to production losses
caused by AIDS. (See “Cursed Twice Over — AIDS and Famine in Southern Africa,” The
Economist, February 15, 2003.) World Food Program Executive Director James Morris,
testifying before the Senate Foreign Relations Committee on February 25, 2003, and the
House International Relations Committee on February 27, said that HIV/AIDS was a central
cause of the famine.
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
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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
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. (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,
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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 and providing AIDS treatment to all who need it. (See “A Small
Nation’s Big Effort Against AIDS,” Washington Post, December 2, 2002.)
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 launched its Multi-Country HIV/AIDS Program (MAP) for Africa in
September 2000, and a Bank official said in October 2002 that to date, $1 billion had been
committed. Since July 2002, such funding is being provided exclusively as grants.
The MAP, designed to be both flexible and rapidly disbursing, according to the Bank,
helps fund AIDS prevention, care, and treatment programs in countries that have developed
a strategic approach. (According to some reports, however, MAP recipients have had
difficulty in disbursing funds in a timely way. Sebastian Mallaby, “An AIDS Policy that
Makes Sense,” Washington Post, December 2, 2002.) 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.)
The Global Fund to Fight AIDS, Tuberculosis, and Malaria was created in January
2002, and to date more than $3 billion has been pledged to the organization. The first grants
were announced in April 2002, and of the $616 million to be awarded over two years
worldwide, Africa is to receive 60%. However, the disbursement of funds for these grants
has been delayed while monitoring and other procedures are put in place. On November 22,
the Global Fund announced that it had signed agreements to provide $6.5 million to Ghana,
including $4.2 million for HIV/AIDS prevention and treatment. The agreements were the
first to be concluded by the Fund. A grant announced on February 27, 2003, will benefit an
AIDS program in Uganda. The Global Fund’s website is at [http://www.globalfundatm.org].
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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 Uganda,
where the rate of infection among pregnant women in urban areas fell from 29.5% in 1992
to 5% in 2001 (UNAIDS, AIDS Epidemic Update, December 2002). HIV prevalence among
young urban women in Zambia has also reportedly fallen, and UNAIDS indicates that urban
sexual behavior patterns among young people in cities in other countries may be changing
in ways that combat the spread of HIV. However, increases in infection rates continue in
cities in several other countries. South Africa has recorded a drop in infections among
pregnant women under 20, and Senegal 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
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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 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. Others, 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. On April 28, 2003,
GlaxoSmith-Kline, the largest manufacturer of AIDS pharmaceuticals, announced further
price reductions for poor countries, including all of sub-Saharan Africa.
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
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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.) Anglo American, the South African mining firm,
announced on August 6, 2002, that it would provide antiretroviral drug therapy to employees
requiring it. Other mining companies subsequently made similar announcements. 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.
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
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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 countries manufacturing generic copies of patented drugs, such as India
or Thailand, should be permitted to export to poor countries was left for further negotiation
through a committee known as the Council for TRIPS.
Although the Doha declaration drew broad praise, some AIDS activists criticized it for
not permitting imports of generics — 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 Council for TRIPS failed to reach agreement by December 2002, the deadline set
by the Doha meeting, on allowing poor countries to import generic copies of essential
patented medications. Reportedly, an accord was stalled by U.S. objections to the number
of diseases and countries that some delegations wanted to include. Nonetheless, on
December 20, the U.S. Trade Representative announced that the United States was pledging
“not to challenge any WTO member that breaks WTO rules to export drugs produced under
compulsory license to a country in need.”
The United Nations convened a General Assembly Special Session (UNGASS) on
HIV/AIDS on June 25-27, 2001 in New York. Much of the debate at the session centered
on the issue of whether large-scale treatment with antiretroviral 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:
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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.
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” to the Global Fund. On June
19, 2002, President Bush announced a $500 million International Mother and Child HIV
Prevention Initiative (IMCPI) to support programs to prevent mother to child transmission
of the virus. Eight African countries were named as beneficiaries. Secretary of State Colin
Powell, speaking on November 13, 2002, at a dinner honoring U.N. Secretary General Kofi
Annan, said that the HIV/AIDS pandemic is “the biggest problem we have on the face of the
earth today.” Nonetheless, editorials, AIDS activist organizations, and others continued to
criticize the Administration’s response to AIDS in Africa. On December 18, 2002, the
Congressional Black Caucus wrote to President Bush seeking sharply increased spending for
AIDS programs in Africa and worldwide.
In his January 28, 2003 State of the Union message, President Bush announced a new
Emergency Plan for AIDS Relief to channel $10 billion in “new money” over five years to
fighting the pandemic in 12 African countries as well as Haiti and Guyana. Budget
documents released at the beginning of February indicated that $450 million was being
requested in FY2004 for a new Global AIDS Initiative (GAI), the principal component of the
Emergency Plan, to be headquartered at the State Department. The objectives of this
initiative include preventing 7 million new infections, providing anti-retroviral drugs for 2
million infected people, and providing care for 10 million infected people, including orphans.
Many AIDS activists and others hailed the President’s initiative, while critics said that the
amount requested for FY2004 showed that it was getting off to a “slow start.”
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Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa
($ millions)
FY2003
FY2004
FY2000
FY2001
FY2002
Projected
Request
USAID
109
144
183
250.4
325
IMCPI
-
-
-
?
?
CDC
34
78
79
?
?
IMCPI
-
-
-
?
?
GAI (State)
-
-
-
-
?
DOD
0
5
14
7
0
FMF
0
0
0
2
1.5
DOL
0
3
6
0
0
Total
143
230
282
Table 1 indicates recent U.S. spending levels on AIDS programs in Africa. USAID and
the Centers for Disease Control (CDC) of the Department of Health and Human Services are
the principal channels for assistance. In addition, the Defense Department (DOD) has
undertaken an HIV/AIDS education program with African armed forces. Funds from the
Foreign Military Financing (FMF) program are also used to support this initiative.
Meanwhile the Department of Labor (DOL) has undertaken a program that supports AIDS
education in the African workplace. Determining the amount to be spent in FY2003 is not
yet possible, since the amounts to be committed under the International Mother and Child
HIV Prevention Initiative (IMCPI) are not yet available. The Omnibus Appropriations
measure for FY2003 (H.J.Res. 2/P.L. 108-7) made funds available for this initiative, but their
allocation is not yet known. As noted above, the FY2004 budget proposal includes
additional funds for the initiative and for the new Global AIDS Initiative (GAI). Again,
information is not yet available on allocation plans for these funds. (For more information,
see CRS Report RS21181, HIV/AIDS International Programs: Appropriations, FY2002-
FY2004.)
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. In July 2002, USAID announced that it had
launched pilot antiretroviral treatment projects in Ghana, Kenya, and Rwanda. 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.
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Legislative Action, 2000-2002
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. In the 107th
Congress, a number of bills were introduced with international or Africa-related HIV/AIDS
related provisions. A major international AIDS authorization bill, H.R. 2069, passed both
the House and Senate during the 107th Congress but did not go to conference. (For
information on appropriations for HIV/AIDS programs, see CRS Report RS21114,
HIV/AIDS: Appropriations for Worldwide Programs in FY2001 and FY2002.)
Legislative Action in the 108th Congress
The FY2003 Omnibus Appropriations measure (H.J.Res. 2/P.L. 108-7), signed into law
on February 20, 2003, funded a number of programs and initiatives that will support the
struggle against AIDS in Africa. In May, Congress approved and President Bush signed into
law H.R. 1298/P.L. 108-25, the United States Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Act of 2003. This bill backs the President’s Emergency Plan for AIDS Relief
by authorizing $3 billion per year for FY2004 through FY2008 (a total of $15 billion) and
creating the office of the Global AIDS Coordinator at the Department of State. (For details,
see Legislation). The amounts to be appropriated for international AIDS programs,
however, remain to be seen. For further information, see CRS Report RS21181, HIV/AIDS
International Programs: Appropriations, FY2002-FY2004. Several bills with provisions
related to the African AIDS pandemic have been introduced in the 108th Congress and
referred to committee, including:
H.R. 390 (Waters)/S. 185 (Daschle), African Famine Relief Act of 2003
H.R. 643 (Waters), Debt Cancellation for the New Millennium Act
H.R. 1145 (Millender McDonald) Peace Corps HIV/AIDS Training Enhancement
Appropriations Act of Fiscal Year 2003
H.R. 1857 (Hastings) Humanitarian Assistance to Combat HIV/AIDS in sub-Saharan Africa
and the Caribbean And National Security Act of 2003
H.R. 2470 (Waters), Medicines to Eliminate Diseases in Developing States Act or the
“MEDDS Act”
S. 250 (Durbin), Global Coordination of HIV/AIDS Response Act (Global CARE Act)
S. 859 (Corzine), Microbicide Development Act of 2003
S. 1067 (Alexander), AIDS Corps Act of 2003
LEGISLATION
P.L. 108-25, H.R. 1298
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.
Authorizes $3 billion for each of the fiscal years 2004 through 2008 for international AIDS,
tuberculosis, and malaria activities. Requires the President to establish a comprehensive,
integrated, 5-year strategy to combat global HIV/AIDS; establishes at the Department of
State a Coordinator of United States Government Activities to Combat HIV/AIDS globally;
establishes a central account to be administered by the Coordinator for all HIV/AIDS funds,
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except for contributions to the Global Fund, appropriated pursuant to the Act; states sense
of Congress that 55% of funding should be spent for treatment (to become mandatory for
FY2006-FY2008) and 20% for prevention, of which 33% should promote abstinence until
marriage programs; mandates that 33% of prevention funds should promote abstinence until
marriage in FY2006-FY2008; authorizes up to $1 billion of the $3 billion authorized for
FY2004 for the Global Fund to Fight AIDS, Tuberculosis, and Malaria for FY2004 and such
funds as shall be necessary through 2008, but U.S. contribution to the Fund not to exceed
33% of total funds contributed by other sources unless the President determines an
international health emergency threatens national security; establishes a U.S. technical
review panel to provide guidance to U.S. representatives to the Global Fund; requires the
Comptroller General to monitor and evaluate projects supported by the Global Fund; amends
the Foreign Assistance Act of 1961 to authorize the President to furnish assistance to
prevent, treat, and monitor HIV/AIDS in countries of sub-Saharan Africa and other countries;
authorizes a pilot program to place health care professionals in overseas areas affected by
AIDS, tuberculosis, and malaria; authorizes the procurement of HIV/AIDS pharmaceuticals;
authorizes such sums as may be necessary for a pilot program of assistance for children and
families affected by HIV/AIDS, and for a pilot program on family survival partnerships; calls
for 10% of funding to be used to help children whose parents have died of AIDS. H.R. 1298
was introduced in the House on March 17, 2003; referred to the Committee on International
Relations; marked up and reported (H.Rept. 108-60) April 2. Passed House (375-41),
amended, May 1, 2003. (For text of amendments, see H.Rept. 108-80.) Passed Senate,
amended, by voice vote, May 16, 2003. House agreed to Senate-passed version by voice
vote, May 21. Signed into law May 27, 2003.
S.Con.Res. 23 (Nickles)
Congressional Budget Resolution. Amendment by Senator Kerry to increase
international AIDS funding by $800 million to match levels in a proposed authorization
measure defeated (47-51), March 26, 2003.
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