Order Code IB10050
CRS Issue Brief for Congress
Received through the CRS Web
AIDS in Africa
Updated February 1, 2005
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
Treatment
Spending
Legislative Action, 2000-2004
Legislative Action in the 109th Congresses

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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 through prevention programs in-
the world. The United Nations reports that
tended to reduce the number of new infections
25.4 million adults and children are infected
and by trying to ameliorate the damage done
with the HIV virus in the region, which has
by AIDS to families, societies, and economies.
about 10% of the world’s population but
The adequacy of this response is the subject of
nearly 64% of the worldwide total of infected
much debate. U.N. experts estimate Africa’s
people. The overall rate of infection among
resource needs for fighting AIDS in 2004 at
adults in sub-Saharan Africa is 7.4%, com-
$8 billion, but project expenditures of $6
pared with 1.1% worldwide. Nine countries
billion from all sources, including households.
in southern Africa have infection rates above
10% and account for 30% of infected adults
An estimated 310,000 Africa AIDS
worldwide. By the end of 2004, an estimated
patients were being treated with antiretroviral
25.3 million Africans will have died of AIDS,
drugs at the end of 2004, up from 150,000 six
including a 2004 estimate of 2.3 million
months earlier. However, an estimated 4
deaths. AIDS has surpassed malaria as the
million are in need of the therapy. U.S. and
leading cause of death in Africa, and it kills
other initiatives are expected to sharply
many times more Africans than war. In Af-
expand the availability of treatment in the near
rica, 57% of those infected are women.
future. Advocates see expanded treatment as
an affordable means of reducing the impact of
Experts relate the severity of the African
the pandemic. Skeptics question whether
AIDS epidemic to the region’s poverty, the
treatment can be widely provided without
relative lack of empowerment among women,
costly improvements in health infrastructure.
high numbers of men living as migrant
workers, and other factors. Health systems are
U.S. concern over AIDS in Africa grew
ill-equipped for prevention, diagnosis, and
during the 1980s, as the severity of the
treatment.
epidemic became apparent. Legislation en-
acted in the 106th and the 107th Congresses
AIDS’ severe social and economic conse-
increased funding for worldwide HIV/AIDS
quences are depriving Africa of skilled work-
programs. H.R. 1298, signed into law (P.L.
ers and teachers while reducing life expec-
108-25) on May 27, 2003, authorized $15
tancy by decades in some countries. An
billion over five years for international AIDS
estimated 12.3 million AIDS orphans are
programs. President Bush announced his
currently living in Africa, facing increased
Emergency Plan for AIDS Relief (PEPFAR)
risk of malnutrition and reduced prospects for
in the 2003 State of the Union message.
education. AIDS is being blamed for declines
Twelve of the 15 focus countries are in sub-
in agricultural production in some countries,
Saharan Africa, and are slated for substantial
and is regarded as a major contributor to
aid increases through the State Department’s
hunger and famine.
Global AIDS Initiative. Nonetheless, activists
and others urge that more be done in view of
Donor governments, non-governmental
the scale of the African pandemic.
Congressional Research Service ˜ The Library of Congress

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MOST RECENT DEVELOPMENTS
On January 28, 2004, the U.S. Government Accountability Office (GAO) issued a report
(GAO-05-133) finding that regimen of antiretroviral drugs (ARVs) offered under the
President’s Emergency Plan for AIDS Relief (PEPFAR) is narrower and more costly than
regimens offered by other programs. The World Health Organization (WHO) reported on
January 26 that by December 2004, 310,000 AIDS patients in sub-Saharan Africa were
receiving antiretroviral therapy, up from 150,000 six months earlier. The organization
estimated that 4 million HIV-infected people in the region are in need of ARVs. On January
25, the U.S. Food and Drug Administration (FDA) issued its first approval of a fixed-dose
combination (FDC) pill containing generic versions of three ARVs for use in the PEPFAR
program. The cost of treatment with the South African-manufactured FDC was expected to
be $20-$30 per patient per month, compared with $55 for the brand-name drugs. On January
12, Gordon Brown, Britain’s Chancellor of the Exchequer, proposed a $10 billion per year
program to revitalize the struggle against AIDS. Many AIDS activists welcomed the
proposal, but some said it would focus too heavily on vaccine research, which they regard
as problematic. Nelson Mandela, seeking to combat the stigma and secrecy associated with
AIDS, announced on January 6 that his son, Makgatho, had died of the disease.
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 December 2004, UNAIDS (the Joint United Nations Program on
HIV/AIDS) reported that in 2004, 25.4 million adults and children were living with HIV and
AIDS in the region, including 3.1 million newly infected during the year. Africa has about
10% of the world’s population but approximately 64% of the worldwide total of infected
people. The infection rate among adults aged 15-49 averages an estimated 7.4% in Africa,
compared with 1.1% worldwide. According to cumulative UNAIDS estimates,
approximately 25.3 million Africans will have died of AIDS since the beginning of the
epidemic through the end of 2004, including an estimated 2.3 million expected to die in that
year. UNAIDS projects that between 2000 and 2020, 55 million Africans can be expected
to lose their lives to the epidemic. (Report on the Global HIV/AIDS Epidemic, 2002, p. 46.)
AIDS has surpassed malaria as the leading cause of death in sub-Saharan Africa, and it kills
many times more people than Africa’s armed conflicts.
Characteristics of the African Epidemic
! HIV, the human immunodeficiency virus that causes AIDS, is spread in
Africa primarily by heterosexual contact. (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
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the spread of HIV may have been underestimated. A February 2004 article
in The Lancet rejected this hypothesis, and affirmed that sexual transmission
“continues to be the major mode of spread” of HIV.1)
! Women make up an estimated 57% of the HIV-positive adult population in
sub-Saharan Africa, as compared with 47% worldwide, according to
UNAIDS. Young women are particularly at risk. In 2004, an estimated
6.9% of African women aged 15 to 24 were HIV positive, compared with
2.2% of young men. (UNAIDS, AIDS Epidemic Update, December 2004).
! According to UNAIDS, the adult infection rate or prevalence has stabilized
in sub-Saharan Africa in recent years, as both the total adult population and
the number of infected people increase. Stabilization does not ease the
burden of the epidemic but simply means that numbers dying approximately
equal the numbers of newly infected. The disease has become endemic in
many countries and will affect their people for generations to come.
Prevalence is still increasing in Madagascar, Swaziland, and a few other
countries, while Uganda and localized areas in some other countries have
experienced declines.
! Southern Africa, where nine countries have an adult infection rate above
10% (Table 1), is the most severely affected region. With 2% of the
world’s population, these countries account for nearly 30% of infected
people worldwide. However, populous Nigeria in West Africa, where an
estimated 5.4% of adults are infected, has an estimated 3.6 million infected
people — the largest number in the region apart from South Africa, where
UNAIDS estimates that 5.3 million are infected. South Africa’s is the
largest infected population in the world.
! 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. Most
die before their second birthday. Nonetheless, an estimated 1.9 million
African children under 14 were living with AIDS at the end of 2003. In
South Africa, a sample survey reported by the Human Sciences Research
Council in May 2004 showed that 6.7% of children between the ages of 2
and 9 were HIV positive.
! In 2003, there were an estimated 12.3 million AIDS orphans in Africa —
that is, children 17 and under who had lost one or both parents to the
disease.2 Because of the stigma attached to the AIDS disease, AIDS orphans
are at high risk for being malnourished, abused, and denied an education.
1 George P. Schmid and others, “Transmission of HIV-1 Infection in Sub-Saharan Africa and Effect
of Elimination of Unsafe Injections,” The Lancet, February 7, 2004.
2 UNAIDS, UNICEF, and U.S. Agency for International Development, Children on the Brink, July
2004.
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UNICEF released a report, Africa’s Orphaned Generations, on November
26, 2003, predicting that there would be 20 million AIDS orphans in Africa
by 2010 and that in a dozen countries they would account for 15% to 25%
of children under 15. Among other measures, the report recommended
efforts to strengthen the capacity of families to protect and care for orphans.
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. Until very recently, AIDS treatment has been generally available only to
the elite.
Table 1. Adult HIV Infection Rates (%), end of 2003
Swaziland
38.8
Tanzania
8.8
Chad
4.8
Eritrea
2.7
Botswana
37.3
Gabon
8.1
Ethiopia
4.4
Sudan
2.3
Lesotho
28.9
Cote d’Ivoire
7.0
Burkina Faso
4.2
Mali
1.9
Zimbabwe
24.6
Cameroon
6.9
Congo Kinshasa
4.2
Benin
1.9
South Africa
21.5
Kenya
6.7
Uganda
4.1
Madagascar
1.7
Namibia
21.3
Burundi
6.0
Togo
4.1
Gambia
1.2
Zambia
16.5
Liberia
5.9
Angola
3.9
Niger
1.2
Malawi
14.2
Nigeria
5.4
Guinea
3.2
Senegal
.8
Central Af. Rep.
13.5
Rwanda
5.1
Ghana
3.1
Mozambique
12.2
Congo Brazzaville
4.9
Djibouti
2.9
Source: UNAIDS, Report on the Global HIV/AIDS Epidemic, July 2002. The Zimbabwe estimate represents
a technical correction issued in 2003. Updated estimates are expected in July 2004.
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. Meanwhile, poverty forces many women to turn to
“transactional sex” in order to survive.
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
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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, if
women exercised more power in political and economic affairs, and if donors and
governments would support fidelity campaigns primarily aimed at African men. (For more
on these issues, see Helen Epstein, “AIDS: the Lesson of Uganda,” New York Review of
Books, July 5, 2001; “The Hidden Cause of AIDS,” New York Review of Books, May 9,
2002; and “The Fidelity Fix,” New York Times Magazine, June 13, 2004.) A Human Rights
Watch study released on August 13, 2003, 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.
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.
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.
Under mounting domestic and international pressure, the South African government
seemed to modify its position significantly when the government announced after an April
2002 cabinet meeting that it would triple the national AIDS budget. When a treatment
program had not been launched by March 2003, however, the Treatment Action Campaign
(TAC) launched a civil disobedience campaign. In August 2003, the South African cabinet
instructed the health ministry to develop a plan to provide antiretroviral therapy nationwide,
but by March 2004, TAC was threatening a lawsuit unless the program was actually begun.
Finally, on April 1, 2004, the government began offering treatment at 5 hospitals in Gauteng
province, centered on Johannesburg. Officials said they expected 50,000 patients to be on
antiretrovirals by the end of the year, but the Washington Post reported on November 30,
2004, that about 11,000 were receiving drugs. Overall, about one in fifty South Africans in
need of therapy was receiving it, according to the Post.
The delays in South Africa’s response to the pandemic have been costly, many experts
believe. On September 22, 2004, South Africa’s Department of Health reported survey
results indicating that HIV infection was continuing to spread, though at a somewhat slower
rate than in previous years. Approximately 27.9% of pregnant women in South Africa were
found to be HIV positive in 2003, up from 26.5% in 2002. The Department estimated that
5.6 million South Africans were infected. A report released by the Bureau of Market
Research at the University of South Africa on September 20 predicted that AIDS-related
deaths would exceed 500,000 per year from 2007 through 2011.
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
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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, 2003, 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.”

The presidents of Botswana, Nigeria, and several other countries are widely seen today
as in the forefront of the AIDS struggle as well. Several regional AIDS initiatives have been
launched. For example, in August 2003, the Southern African Development Community
(SADC) agreed to an AIDS strategic framework, including the creation of a regional fund
to fight the disease.
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
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of AIDS, average life expectancy in sub-Saharan Africa is now 47 years, whereas it would
have been 62 years without the epidemic. A U.S. Bureau of the Census report
[http://www.census.gov/prod/2004pubs/wp02-2.pdf], released on March 23, 2004, predicted
population declines by 2010 in South Africa, Botswana, and three other African countries
due to AIDS.
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. On June 22, 2004, Morris said that
southern Africa was in a “death spiral” due to the consequences of the AIDS pandemic,
including the loss of human capacity and the devastation of rural areas, with resulting
negative consequences for food security (WFP press release).
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.
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 through prevention programs, and to some degree,
by trying to ameliorate the damage done by AIDS to families, societies, and economies. A
third response, treatment of AIDS sufferers with antiretroviral drugs that can result in long-
term survival, has not been widely used in Africa until recently; but treatment programs are
expanding. (See below, AIDS Treatment Issues).
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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. Some success has been claimed for these efforts in persuading young people to delay
the age of “sexual debut” and to remain faithful to a single partner. The United States is now
advocating an expansion of prevention programs focusing on abstinence until marriage as
an effective means of slowing the spread of HIV, although some critics maintain that this
may be unrealistic in a social environment destabilized by poverty. Some also question
whether approaches stressing abstinence and faithfulness can benefit poor married women
in Africa, who have little power to deny their husbands, whether infected or not.
Donor-sponsored voluntary counseling and testing (VCT) programs, where available,
enable African men and women to learn their HIV status. In Botswana, HIV tests are now
offered as a routine part of any medical visit, and many experts are urging that this be done
continent-wide. 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. Several projects have had success in
reducing mother-to-child transmission by administering the anti-HIV drug AZT or
nevirapine, before and during birth, and while the mother is nursing. Many AIDS activists
argue that it would be far better to put all infected pregnant women into long-term treatment
programs, which would reduce the likelihood that their children would be orphaned.
On December 13, 2004, the Associated Press (AP) reported that a number of flaws had
been found in a study of the nevirapine conducted in Uganda under the sponsorship of the
National Institutes of Health (NIH). According to the AP report, researchers acknowledged
that thousands of bad reactions were not disclosed. The allegations provoked criticism in
Africa, including a furious response from the South Africa’s ruling Africa National Congress
(ANC). In a December 17 statement, the ANC charged that top U.S. officials had “entered
into a conspiracy with a pharmaceutical company to tell lies and promote the sales of
nevirapine in Africa ...” That same day, NIH issued its own statement affirming that “single-
dose nevirapine is a safe and effective drug for preventing mother to infant transmission of
HIV.” The statement termed as “absolutely false” any implication of thousands of adverse
reactions in the Uganda study. AIDS activists and others were concerned that the
controversy would discourage use of the drug, often the only available means of preventing
mother to child transmission (MTCT) of HIV. Others sought an investigation of NIH
conduct.
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.
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. In Uganda, Pfizer and
the Pfizer Foundation are funding the Infectious Diseases Institute (IDI), expected to train
250 AIDS treatment specialists annually, many of whom will work in rural areas.
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The Global Fund to Fight AIDS, Tuberculosis, and Malaria, created in January 2002,
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.
Nonetheless, UNAIDS maintains that a significant funding gap remains. In September
2003, the organization issued a report entitled Accelerating Action Against AIDS in Africa,
which estimated that $8 billion was required to fight the African AIDS epidemic in 2004,
whereas $6 billion was likely to be provided from all sources, including donors, the Global
Fund, African governments, and African households. UNAIDS expects the resource gap to
widen further in 2005.
Further information on the response to AIDS in Africa may be found below under AIDS
Treatment Issues and at the following websites:
CDC: [http://www.cdc.gov/nchstp/od/nchstp.html]
Global Fund to Fight AIDS, Tuberculosis, and Malaria: [http://www.theglobalfund.org/en/]
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://www.kaisernetwork.org/daily_reports/rep_hiv.cfm/]
UNAIDS: [http://www.unaids.org/en/default.asp]
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). The infection rate has
continued to drop, and in 2003, adult prevalence nationwide was 4.1%, compared with 5.1%
in 2001. 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, the number of infected people in Africa continues to grow.
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.
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
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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 have recommended 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 antiretrovirals (ARVs) has been 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 permit 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.)
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. In May 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.
Initiatives to expand the availability of HAART continued, and treatment became a
major focus of the programs of the Global Fund and of the President’s Emergency Plan for
AIDS Relief (PEPFAR, see below). In October 2003, former President Bill Clinton
announced that his foundation had organized a program to provide generic three-drug
antiretroviral treatment for AIDS patients in Africa and the Caribbean for about $.38 per
day. Generic pharmaceutical manufacturers in India and South Africa would make the drugs,
and funding would come from private donors, some donor governments, and other sources.
On December 1, 2003, World AIDS Day, the World Health Organization formally launched
its $5.5 billion “three by five” plan to treat 3 million AIDS patients in poor countries by
2005, with resources to come from the Global Fund and donors. In April 2004, the Clinton
Foundation announced an agreement with UNICEF, the World Bank, and the Global Fund
to expand the program to more than 100 developing countries worldwide. As a result of the
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impending increased availability of treatment, an estimated 310,000 sub-Saharan patients
were receiving HAART at the end of 2004, up from 150,000 six months earlier.3 However,
an estimated 4 million Africans are in need of HAART.
Whether African countries are ready to “absorb” dramatically increased funding for
treatment has been another issue. 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; although a September 2003 report
indicated that African patients follow their AIDS therapy regimens more consistently than
American patients.4 For some, the correct response to weaknesses in Africa’s basic health
care systems is to devote resources to strengthening those systems.5
Botswana’s President Mogae told a November 12, 2003 meeting, convened in
Washington by the Center for Strategic and International Studies, that the widely-praised
treatment program in his country is being hampered by a “brain drain” of health personnel.
Physicians, nurses, technicians, and other are often hired away by foreign governments,
international organizations, and non-governmental organizations. The health minister of
Mozambique, which has launched a pilot antiretroviral treatment program, said in May 2004
that the country was unable to launch a nationwide program because of serious shortages of
staff and equipment. The Harvard-based Joint Learning Initiative on Human Resources for
Health and Development issued a report on November 27, 2004 finding that Africa had the
lowest ratio of health workers to population of any region. At least one million new workers
are needed, according to the report, which called on developed countries to reduce their
dependence on immigrant health workers trained at the expense of poor countries. On
December 3, 2004, Britain announced that it would provide $100 million to boost salaries
of health workers in Malawi and increase the number of medical staff being trained.
AIDS activists have urged that African governments issue “compulsory licenses” to
allow the manufacture or importation of inexpensive generic copies of patented AIDS
medications. In November 2001, a ministerial-level meeting of the World Trade
Organization(WTO) in Doha, Qatar, approved a declaration stating that the Agreement on
Trade-Related Aspects of Intellectual Property Rights (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.
3 World Health Organization, “3 by 5" Progress Report, December 2004.
4 “Africans Outdo Americans in Following AIDS Therapy,” New York Times, September 3, 2003.
5 Holly Burkhalter, “Misplaced Help in the AIDS Fight,” Washington Post op-ed, May 25, 2004.
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Although the Doha declaration drew broad praise, some AIDS activists criticized it for
not permitting imports of generics. Some in the pharmaceutical industry, on the other hand,
expressed concern that the declaration was too permissive and might reduce profits that, they
argued, were used to fund research. Others, however, maintained that the declaration would
have little practical impact, because in their view, 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.) On August 30, 2003, the WTO reached
agreement on a plan to allow poor countries to import generic copies of essential
medications, but the debate over access to antiretrovirals in Africa seems likely to continue.
For more information, see CRS Report RS21609, The WTO, Intellectual Property Rights,
and the Access to Medicines Controversy.
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. See also Greg Behrman, The Invisible
People: How the U.S. Has Slept Through the Global AIDS Pandemic, the Greatest
Humanitarian Catastrophe of Our Time (New York: Free Press, 2004).
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, then Vice President Al 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.
USAID reported in 2001 that it had 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 had
sponsored AIDS education programs; trained AIDS educators, counselors, and clinicians;
supported condom distribution; and sponsored AIDS research. USAID claimed 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 reported that
it spent a total of $51 million on fighting AIDS in Africa in FY1998 and $63 million in
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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.
Bush Administration
Combating the AIDS pandemic in sub-Saharan Africa has been an important focus for
the Bush Administration’s foreign assistance program. In May 2001, President Bush made
the “founding pledge” of $200 million to the Global Fund, and on June 19, 2002, he
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.
The President’s Emergency Plan for AIDS Relief (PEPFAR) is resulting in major
spending increases for HIV/AIDS prevention, care, and treatment in 12 focus countries in
Africa: Botswana, Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda,
South Africa, Tanzania, Uganda, and Zambia. (The other focus countries are Guyana, Haiti,
and Vietnam.) President Bush announced the launching of PEPFAR in his January 2003
State of the Union address, pledging $15 billion for fiscal years 2004 through 2008, including
$10 billion in “new money,” that is, spending in addition to then current levels. The
program aims to prevent 7 million new infections worldwide, provide anti-retroviral drugs
for 2 million infected people, and provide care for 10 million infected people, including
orphans. The new funds are coming through the Global AIDS Initiative (GAI), headquartered
at the Department of State. The GAI is headed by the United States Global AIDS
Coordinator, Randall Tobias, who coordinates not only the GAI programs in the focus
countries, but also the HIV/AIDS programs of USAID and other agencies in both focus and
non-focus countries.
President Bush made AIDS a special focus of his five-day trip to Africa in July 2003.
On July 10, speaking in Botswana, the President said that, “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.”
On September 22, 2003, then Secretary of State Colin Powell told a U.N. General Assembly
special session on AIDS that the epidemic was “more devastating than any terrorist attack”
and that the United States would “remain at the forefront” of efforts to combat the epidemic.
On February 23, 2004, the Department of State issued a report [http://www.state.gov/s/
gac/rl/or/c11652.htm] providing details on the PEPFAR initiative. At the same time, the
Administration announced plans to release PEPFAR funds for treatment programs conducted
by the Elizabeth Glaser Pediatric AIDS Foundation, Harvard’s School of Public Health,
Colombia’s Mailman School of Public Health, and Catholic Relief Services.
Many AIDS activists and others have praised the President’s initiatives, but critics
maintain that PEPFAR in particular is getting off to a slow start and have urged increased
appropriations. Some also see the program as too strongly unilateral and would like the
United States to be acting in closer cooperation with other countries and donors, particularly
the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Some observers are also
questioning whether PEPFAR will do enough to strengthen African health care institutions
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and capabilities for coping with AIDS over the long term; or whether the funds will flow
primarily to U.S.-based organizations.
U.N. Secretary General Kofi Annan, during an interview at the July 2004 international
AIDS conference in Bangkok, urged the United States to contribute $1 billion annually to
the Global Fund to Fight AIDS, Tuberculosis, and Malaria; but U.S. Global AIDS
Coordinator Randall Tobias said “It’s not going to happen.” (For further information, see
CRS Report RL31712, The Global Fund to Fight AIDS, Tuberculosis, and Malaria:
Background and Current Issues.) Annan asked the United States to show the same
leadership in the AIDS struggle that it had shown in the war on terrorism. U.S. State
Department spokesman Richard Boucher rejected the implied criticism, saying that the Bush
Administration had taken the AIDS crisis very seriously and that the $15 billion pledged to
fight the epidemic over five years was an “enormous and significant amount.” In a speech
interrupted by protestors, Tobias told the conference that “At this point, perhaps the most
critical mistake we can make is to allow this pandemic to divide us.”
Treatment. The Financial Times reported on April 6, 2004, that the United States
was withholding support from a program intended to treat 140,000 AIDS patients in Kenya
with antiretrovirals because the program would rely on a generic 3-drug combination (FDC)
pill. Many favor approval of FDCs, including copies of drugs manufactured by different
companies, on grounds that they are simpler to prescribe and need to be taken just once or
twice a day. U.S. officials had expressed concerns that further study was needed to assure
that their widespread or improper distribution did not contribute to the emergence of resistant
HIV strains. The issue was submitted to a panel of experts instructed to report by mid-May
2004. Several members of Congress subsequently wrote to President Bush asking that the
United States join an international consensus that generics are safe and essential for the
treatment of AIDS. On May 16, 2004, Health and Human Services Secretary Tommy
Thompson announced that the United States Food and Drug Administration (FDA) was
instituting an expedited process that could lead to the approval of the use of FDCs in
programs funded by PEPFAR. Many hailed the announcement as a step forward in making
cheaper and more reliable antiretroviral therapy available in Africa, but critics said it placed
an unnecessary hurdle in the way of distributing such pills. They maintained that the United
States should have relied on the approval process of the World Health organization, which
had already cleared such pills. In January 2005, the FDA cleared the first generic FDC for
use in the PEPFAR program. Manufactured by Aspen Pharmacare of South Africa, the three-
drug FDC will is expected to make treatment available for $20-$30 per patient per month,
compared with $55 for the three brand-name drugs.
On September 14, 2004, the Office of the Global AIDS Coordinator at the Department
of State issued an interim report stating that as of July 31, 24,900 AIDS patients were
receiving antiretroviral therapy (ART) either directly through PEPFAR or indirectly through
programs supported by the program. The report stated that PEPFAR would be providing
ART to 200,000 by June 2005 and that by meeting this goal it would double the number of
patients receiving ART in sub-Saharan Africa. In response, the Global AIDS Alliance, an
activist group, issued a statement maintaining that PEPFAR was moving too slowly toward
its 2008 goal of treating 2 million. The Alliance also criticized the program for using more
costly patented drugs rather than generics.
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Spending. Table 2 reports available information on recent U.S. spending levels on
AIDS programs in Africa. Where information is not available, “NA” has been entered into
the table. Under the FY2005 request, GAI assistance to the 12 focus countries in sub-
Saharan Africa will total just over $1 billion, or 72% or the total requested for the GAI. An
estimated $264.2 million is being spent in bilateral programs with the Africa focus countries
in FY2004, and these countries will also benefit from centrally funded GAI mechanisms,
including Antiretroviral Therapy, Safe Injections, and Abstinence/Faithfulness. Prior to the
launching of PEPFAR, USAID, and the Global AIDS Program (GAP) of the Centers for
Disease Control (CDC) in the Department of Health and Human Services were the principal
channels for HIV/AIDS assistance to Africa. In addition, the Defense Department (DOD)
has undertaken an HIV/AIDS education program with African armed forces. Funds from the
Foreign Military Financing (FMF) program are also used to support this initiative.
Meanwhile, a Department of Labor (DOL) program supports AIDS education in the African
workplace. (For more information, see CRS Report RS21181, HIV/AIDS International
Programs: Appropriations, FY2002-FY2004.) Additional U.S. funds reach Africa indirectly
through the AIDS programs of the United Nations, including the World Bank, and the Global
Fund to Fight AIDS, Tuberculosis, and Malaria.
Table 2. U.S. Bilateral Spending on Fighting AIDS in Africa
($ millions)
FY2004
FY2005
FY2000
FY2001
FY2002 FY2003
Est.
Request
USAID
109
144
183
320
231.0
231.0
CDC (GAP)
30
77
84
107
NA
NA
GAI (State)
-
-
-
-
533.4
1,041.4
DOD
0
5
14
7
4.2
0
FMF
0
0
0
2
1.5
2.0
DOL
0
3
6
5
NA
0
Total
139
229
287
441
Nonetheless, the scale of the response to the pandemic in Africa by the United States
and others remains a subject of intense debate. The U.N. Special Envoy for HIV/AIDS in
Africa, Stephen Lewis, has been a persistent critic, telling a September 2003 conference on
AIDS in Africa that he was “enraged by the behavior of the rich powers” with respect to the
epidemic. The singer Bono said he had a “good old row” with President Bush in a
September 16, 2003 meeting on the level of U.S. funding for fighting the international AIDS
epidemic. Nonetheless, as noted above, others argued that Africa’s ability to absorb
increased AIDS funding is limited and that health infrastructure will have to be expanded
before new funds can be spent effectively.
Legislative Action, 2000-2004
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
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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.)
In May 2003, 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. Appropriations measures have
supported a variety of programs helping Africa fight the pandemic; for further information,
see CRS Report RS21181, HIV/AIDS International Programs: Appropriations, FY2002-
FY2004.
Legislative Action in the 109th Congresses
Bills introduced in the 109th Congress, with provisions related to the African AIDS
pandemic, include the following.
H.R. 155 (Millender-McDonald), Mother to Child Plus Appropriations Act for Fiscal
Year 2005.
H.R. 164 (Millender McDonald), International Pediatric HIV/AIDS Network Act of
2005.
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