Order Code IB10050
CRS Issue Brief for Congress
Received through the CRS Web
AIDS in Africa
Updated August 28, 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 more se-
organizations, and African governments have
verely affected by AIDS than any other part of
responded primarily by attempting to reduce
the world. The United Nations reports that
the number of new HIV infections and by
29.4 million adults and children are infected
trying to ameliorate the damage done by AIDS
with the HIV virus in the region, which has
to families, societies, and economies. The
about 10% of the world’s population but more
adequacy of this response is the subject of
than 70% of the worldwide total of infected
much debate. U.N. experts estimate 2003
people. The overall rate of infection among
spending from all sources on HIV/AIDS in
adults in sub-Saharan Africa is 8.8%, com-
low- and middle-income countries worldwide
pared with 1.2% worldwide. Twelve coun-
at $4.7 billion, compared with an estimated
tries, mostly in east and southern Africa, have
need of $10.5 billion by 2005.
HIV infection rates of more than 10%; the rate
has reached 38.8% in Botswana. As of 2001,
Treatment of AIDS sufferers with medi-
an estimated 21.5 million Africans had died of
cines that can result in long-term survival is
AIDS, including 2.2 million who died in that
reportedly available to just 50,000 Africans at
year. AIDS has surpassed malaria as the
present. Advocates of expanded treatment
leading cause of death in Africa, and it kills
argue that in view of recent drug price reduc-
many times more Africans than war. In
tions, treatment is an affordable means of
Africa, 58% of those infected are women.
reducing AIDS damage to African econo-
mies, reinforcing prevention programs, and
Experts relate the severity of the African
keeping parents alive. Skeptics argue that
AIDS epidemic to the region’s poverty.
treatment is still too expensive to be an option
Health systems are ill-equipped for
for most Africans and would require costly
prevention, diagnosis, and treatment. Poverty
improvements in health 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. Legislation enacted
creasing their risk of infection.
in the 106th and the 107th Congresses increased
funding for worldwide HIV/AIDS programs.
AIDS’ severe social and economic conse-
H.R. 1298, signed into law (P.L. 108-25) on
quences are depriving Africa of skilled work-
May 27, 2003, would authorize $15 billion
ers and teachers while reducing life expec-
over five years for international AIDS pro-
tancy by decades in some countries. An
grams. President Bush has launched an Inter-
estimated 11 million AIDS orphans are
national Mother and Child HIV Transmission
currently living in Africa, facing increased
Initiative that will benefit 8 African countries,
risk of malnutrition and reduced prospects for
and 12 are slated for added support under the
education. AIDS is being blamed for declines
global aids initiative announced in the January
in agricultural production in some countries,
28, 2003, State of the Union message. Presi-
and is regarded as a major contributor to the
dent Bush made AIDS a special focus of his 5-
famine threatening southern Africa.
day trip to Africa in July 2003. Nonetheless,
activists and others urge that more be done in
Donor governments, non-governmental
view of the scale of the African pandemic.
Congressional Research Service ˜ The Library of Congress

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MOST RECENT DEVELOPMENTS
The Southern African Development Community (SADC) concluded a two-day meeting
in Tanzania on August 26, 2003, after agreeing to an AIDS strategic framework, including
the creation of a $10.5 million regional fund to fight the disease. Also on August 26,
Senator Bill Frist said in Botswana that the country’s AIDS program should serve as a model
for other African countries. The Senator praised the political will Botswana had shown in
combating the epidemic, and the six-member Senate delegation visited a clinic where 5,000
AIDS patients were receiving treatment. On August 22, South African Trade Minister Alec
Erwin reportedly told the Senate visitors that the epidemic in South Africa was being well-
managed and would have little effect on the country’s economy. 1 Senator Norm Coleman
told reporters that he found Erwin’s words “rather shocking” since the impact of the
epidemic was “overwhelming.”2 On August 8, the South African cabinet instructed the
health ministry to develop a plan by the end of September to provide antiretroviral treatment
nationwide. AIDS activists and others welcomed the decision, but some expressed concern
that implementation of such a program might still be far in the future. On July 31, the South
African Medicines Control Council announced that it was re-opening an inquiry into the
safety of Nevirapine, leading to fears that the antiretroviral would be de-registered for use
in preventing mother-to-child transmission (MTCT) of HIV. In 2002, a South African court
had ordered the government to launch a nationwide Nevirapine MTCT program.
A Human Rights Watch study released on August 13 reported that domestic violence
made women in Uganda more vulnerable to HIV infection — for example by depriving them
of the power to negotiate condom use. A World Bank research report released on July 23
said that the long-term economic impact of AIDS in South Africa and elsewhere could be
much greater than anticipated since, by killing parents, the disease inhibits the transmission
of knowledge and skills from generation to generation. South African officials discounted
the study, citing South African studies suggesting the economic impact of AIDS will be
minor.3 For further information, 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
1 Chicago Tribune, August 22, 2003.
2 Associated Press, August 23, 2003.
3 South African Broadcasting Corporation report, July 28, 2003.
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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. 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, 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 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.
! 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
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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
Adult HIV Infection Rates (%), end of 2001
and social factors in explaining Africa’s AIDS
Botswana
38.8
epidemic, placing primary blame on the region’s
Swaziland
33.4
poverty. Poverty has deprived Africa of effective
Zimbabwe
33.7
systems of health information, health education, and
Lesotho
31.0
Namibia
22.5
health care. Thus, Africans suffer from a high rate
Zambia
21.5
of untreated sexually-transmitted infections (STIs)
South Africa
20.1
other than AIDS, and these increase susceptibility to
Malawi
15.0
Kenya
15.0
HIV. African health systems typically have limited
Mozambique
13.0
capabilities for AIDS prevention work, and HIV
Cent. Af. Republic
12.9
Cameroon
11.8
counseling and testing are difficult for many
Cote d’Ivoire
9.7
Africans to obtain. AIDS treatment is generally
Rwanda
8.9
available only to the elite.
Burundi
8.3
Tanzania
7.8
Congo Brazzaville
7.2
Poverty forces large numbers of African men to
Sierra Leone
7.0
migrate long distances in search of work, and while
Burkina Faso
6.5
Ethiopia
6.4
away from home they may have multiple sex
Togo
6.0
partners, increasing their risk of infection. Some of
Nigeria
5.8
these partners may be women who have become
Angola
5.5
Uganda

5.0
commercial sex workers because of poverty, and
Congo Kinshasa

4.9
they too are highly vulnerable to infection. Migrant
Benin
3.6
Chad

3.6
workers may carry the infection back to their wives
Equatorial Guinea
3.4
when they return home. Long distance truck
Ghana
3.0
drivers, and drivers of “taxis,” who transport
Eritrea
2.8
Guinea Bissau
2.8
Africans long distances by car, are probably also key
Sudan
2.6
agents in spreading HIV.
Mali

1.7
Somalia
1.0
Senegal
.5
Some behavior patterns in Africa may also be
Madagascar
.3
affecting the epidemic. In explaining the fact that
Mauritius
.1
young women are infected at a higher rate than
Source: UNAIDS, Report on the Global
young men, Peter Piot, the Executive Director
HIV/AIDS Epidemic, July 2002. Data not
UNAIDS, has commented that “the unavoidable
available for the following countries:
Comoros, Djibouti, Gabon, Gambia, Guinea,
conclusion is that girls are getting infected not by
Liberia, Mauritania, Niger.
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
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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.)
The breakdown in social order and social norms caused by armed conflict is also
contributing to the African epidemic. Conflict is typically accompanied by numerous
incidents of violence against women, including rape, carried out by soldiers and guerrillas.
Such men are also more likely to resort to commercial sex workers than those living in a
settled environment.
Leadership Reaction in South Africa and Elsewhere
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.
Concern over the consequences of AIDS in South Africa is high, since the number of
infected people there — 4.7 million at the end of 2001 — is larger than in any other country.
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
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) 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.
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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.) According to a Financial Times report on July 9, 2003, 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. The South African government has not made
public a report completed in April 2003 on the feasibility of providing universal treatment
to patients needing antiretroviral therapy.
In the rest of Africa, 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, a member
of the Global Health Council and 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....” On June 10, during a meeting with President Museveni at the White House,
President Bush praised the Ugandan leader’s “extraordinary leadership on HIV/AIDS in your
country.”
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.
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
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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 serious food shortages in southern Africa in 2002 and 2003
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
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 are expected to play an
important peacekeeping role in Africa in the years ahead, but this could be threatened.
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.
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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 to 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,
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.)
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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.
In December 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.) UNAIDS reported on June 26, 2003, that about $4.7 billion would be spent
combating AIDS in low- and middle-income countries worldwide in 2003, as compared to
a total resource need of $10.5 billion by 2005.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria was created in January 2002
and plans to disburse $1.5 billion to fight the three diseases worldwide in 2003 and 2004.
The Fund commits about 60% of its grant funds to Africa, and about 60% of its grants
worldwide go toward fighting AIDS. For further information, see CRS Report RL31712,
The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background and Current
Issues.
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.
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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, 1999.) There is also support for a stronger focus on
treatment of non-HIV sexually-transmitted infections, which studies show can dramatically
lower the rate of HIV transmission.
The lives of infected people could be significantly prolonged and improved, some
maintain, if more were done to identify and treat the opportunistic infections, particularly
tuberculosis, that typically accompany AIDS. Millions of Africans suffer dual infections of
HIV and TB, and the combined infection dramatically shortens life. Tuberculosis can be
cured by treatment with a combination of medications over several months, even in HIV-
infected patients. However, according to the World Health Organization, Africans often
delay seeking treatment for TB or do not complete the course of medication (Global
Tuberculosis Control: WHO Report 1999, Key Findings), contributing to the high incidence
of death among those with dual infections. Pfizer Corporation has signed an agreement with
South Africa to donate the anti-fungal Diflucan (fluconazole) for treating AIDS-related
opportunistic infections, including cryptococcal meningitis, a dangerous brain inflammation.
On December 1, 2001, Pfizer announced that it would sign memoranda of understanding on
donating fluconazole with six other African countries. UNAIDS and the World Health
organization recommended on April 5, 2000, that Africans infected with HIV be treated with
an antibiotic/sulfa drug combination known by the trade name Bactrim in order to prevent
opportunistic infections. Studies indicate that the drug could reduce AIDS death rates at a
cost of between $8 and $17 per year per patient.
AIDS Treatment Issues
Access for poor Africans to 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
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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, according to current estimates, only about 50,000 Africans are
receiving treatment. (White House Fact Sheet on the President’s Emergency Plan for AIDS
Relief, January 29, 2003.) 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.) 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 launch four treatment sites in Africa 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
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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 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.” According to reports appearing in late August
2003, a compromise on this issue may be near. (Washington Times, “WTO Nears Pact on
Generic Pharmaceuticals,” August 28, 2003.)
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U.S. Policy
U.S. concern over AIDS in Africa began 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. Nevertheless, a widely discussed 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).
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.
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
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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 two Caribbean countries. Budget
documents released at the beginning of February indicated that $450 million was being
requested in FY2004 for a new Global AIDS Initiative (GAI), the principal component of the
Emergency Plan, to be headquartered at the State Department. The objectives of this
initiative include preventing 7 million new infections, providing anti-retroviral drugs for 2
million infected people, and providing care for 10 million infected people, including orphans.
Many AIDS activists and others hailed the President’s initiative, while critics said that the
amount requested for FY2004 showed that it was getting off to a “slow start.” President
Bush made AIDS a special focus of his 5-day trip to Africa in July 2003. On July 10,
speaking in Botswana, the President said “This is the deadliest enemy Africa has ever faced,
and you will not face this epidemic alone.” On July 8, in Senegal, the President told Africans
“we will join with you in turning the tide against AIDS in Africa.” The President also spoke
on the epidemic in South Africa on July 9.
Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa
($ 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
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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.
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
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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,
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.
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