Order Code IB10050
CRS Issue Brief for Congress
Received through the CRS Web
AIDS in Africa
Updated January 30, 2006
Nicolas Cook
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
Transmission
Women
Prevalence Trends
Highest Rates
Children
Orphans
Explaining the African Epidemic
Leadership Reaction in South Africa and Elsewhere
Social and Economic Consequences
Rural Livelihoods
Workforce Depletion
Security
Responses to the AIDS Epidemic
Effectiveness of the Response
AIDS Antiretroviral Treatment Issues
U.S. Policy
Bush Administration
Treatment
Spending
Legislative Action, 2000-2004
Legislation in the 109th Congress

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AIDS in Africa
SUMMARY
Sub-Saharan Africa has been more se-
Donor governments, non-governmental
verely affected by AIDS than any other part of
organizations, and African governments have
the world. In 2005, the United Nations reports,
responded by supporting programs intended to
there were about 25.8 million HIV-positive
prevent and reduce the number of new infec-
adults and children in the region, which has
tions and by trying to abate the damage done
about 11.15% of the world’s population but
by AIDS to families, societies, and economies.
over 64% of the worldwide total of infected
The adequacy of this response is the subject of
people. The overall rate of infection among
much debate.
adults in sub-Saharan Africa is 7.4%, com-
pared with 1.1% worldwide. Nine southern
An estimated 500,000 Africa AIDS
Africa countries have infection rates above
patients were being treated with antiretroviral
10%, and the ten African countries with the
drugs in June 2005, up from 150,000 a year
largest infected populations account for over
earlier, but an estimated 4 million remain in
50% of infected adults worldwide. By late
need of such therapy. U.S. and other initia-
2005, an estimated 27.7 million Africans will
tives are expected to sharply expand the avail-
have died of AIDS, including a 2005 estimate
ability of treatment in the near future. Advo-
of 3.1 million deaths. AIDS has surpassed
cates see expanded treatment as an affordable
malaria as the leading cause of death in Af-
means of reducing the impact of the pan-
rica, and it kills many times more Africans
demic. Skeptics question whether treatment
than war. In Africa, 57% of those infected are
can be widely provided without costly im-
women.
provements in health infrastructure.
Experts attribute the severity of Africa’s
U.S. concern over AIDS in Africa grew
AIDS epidemic to the region’s poverty,
during the 1980s, as the epidemic’s severity
women’s relative lack of empowerment, high
became apparent. Legislation enacted in the
rates of male worker migration, and other
106th and the 107th Congresses increased
factors. Health systems are ill-equipped for
funding for worldwide AIDS programs. P.L.
prevention, diagnosis, and treatment.
108-25, signed into law on May 27, 2003,
authorized $15 billion over five years for
AIDS’ severe social and economic conse-
international AIDS programs. President Bush
quences are depriving Africa of skilled work-
announced his Emergency Plan for AIDS
ers and teachers, and reducing life expectancy
Relief (PEPFAR) in his 2003 State of the
by decades in some countries. There are an
Union message. Twelve of 15 PEPFAR
estimated 12.3 million AIDS orphans in Af-
“focus countries” are in sub-Saharan Africa.
rica. They face increased risk of malnutrition
Under the FY2006 budget request, they would
and reduced prospects for education. AIDS is
receive a 54% boost in aid, to $1.2 billion,
also blamed for declines in agricultural pro-
through the State Department’s Global
duction in some countries and is seen as a
HIV/AIDS Initiative. Nonetheless, activists
major contributor to hunger and famine.
and others urge that more be done, given the
scale of the African pandemic.
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MOST RECENT DEVELOPMENTS
In late January 2006, the New England Journal of Medicine reported that multinational
drug firms Gilead and Bristol-Myers Squibb had jointly developed once-daily AIDS
treatments, seen as likely to increase access to and adherence to treatment, notably in
poverty-stricken environments such as Africa. On January 12, 2006, former President Bill
Clinton announced that his Clinton Foundation HIV/AIDS Initiative (CHAI) had negotiated
new agreements to lower prices of WHO-evaluated HIV tests by 50% and for two
antiretroviral drugs by 30%. These will be made available to the CHAI Procurement
Consortium, a group of countries eligible to make purchases under CHAI agreements. It
includes 50 developing countries. The Global Steering Committee, a new international effort
to provide universal AIDS treatment access by 2010, was launched in Washington on
January 10, 2006. The effort, spurred by recent U.N. General Assembly requests and G8
commitments, is intended as an attempt to overcome key challenges to global AIDS
responses, such as sustainable financing and health care delivery system constraints, the need
for development and distribution of low-cost drugs and tests, and AIDS-related stigma and
social discrimination.
Events marking World AIDS Day, originated by the World Health Organization in 1988
to increase awareness about AIDS, were held on December 1, 2005. President Bush marked
it by launching a new component of his President’s Emergency Plan for AIDS Relief, the
New Partners Initiative, described as an effort to identify and provide U.S. competitive
grant-based support to “new partners,” including faith-based and community health care
organizations that are active in the developing world but lack experience in working with the
U.S. government. At the 14th International Conference on AIDS and Sexually Transmitted
Infections in Africa (ICASA), held in Nigeria in early December, UNAIDS director Dr. Peter
Piot said that AIDS remains an uncontained, “acute threat to future generations” and called
for “urgent and sustained action” to increase access to HIV prevention and treatment services
in Africa. At ICASA, World Health Organization (WHO) head Jim Yong Kim praised the
use of public health approaches in scaling-up access to AIDS drugs. He endorsed the use of
simple, uniform fixed-dose drug regimens; drug distribution and use monitoring by nurses
and community workers using simple clinical tools; and the participation of HIV-affected
individuals and communities in program AIDS design and delivery. The Assistance for
Orphans and Other Vulnerable Children in Developing Countries Act of 2005 (P.L. 109-95)
was signed into law on November 8, 2005. On September 6, 2005, at a pledging conference
in London, governments promised $3.7 billion to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria in 2006 and 2007. This amount would adequately fund renewals
of existing Global Fund grants but not new grants. The U.S. pledged $600 million for the
two years. For further information on AIDS, see CRS Report RS21181, HIV/AIDS
International Programs: Appropriations, FY2003-FY2006 and CRS Report RL31712, The
Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background and Current Issues.
BACKGROUND AND ANALYSIS
Sub-Saharan Africa (“Africa” hereafter) has been far more severely affected by AIDS
than any other world region. In December 2005, UNAIDS (Joint United Nations Program on
HIV/AIDS) reported that in 2005, 25.8 million adults and children were living with HIV and
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AIDS in Africa, including 3.2 million newly infected during the year. Africa has about 1.15%
of the world’s population but approximately 64% of the global HIV-positive population. The
infection rate among adults averages an estimated 7.2% in Africa, compared with 1.1%
worldwide. According to UNAIDS estimates, about 27.7 million Africans will have died of
AIDS since the beginning of the epidemic, including an estimated 3.1 million expected to
die by the end of 2005. UNAIDS has projected that between 2000 and 2020, 55 million
Africans will likely lose their lives to AIDS. AIDS has surpassed malaria as the leading cause
of death in Africa, and kills many times more people than Africa’s armed conflicts.
Table 1. African 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
Burkina Faso
4.2
Benin
1.9
Zimbabwe
24.6
Cameroon
6.9
Dem. Rep. of Congo
4.2
Mali
1.9
South Africa
21.5
Kenya
6.7
Togo
4.1
Madagascar
1.7
Namibia
21.3
Burundi
6
Uganda
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
0.8
Cent. Afr. Rep.
13.5
Rwanda
5.1
Ghana
3.1
Mauritania
0.6
Mozambique
12.2
Congo
4.9
Djibouti
2.9
Source: UNAIDS, Report on the Global AIDS Epidemic, July 2004 [biannual country-specific HIV prevalence report].
Data were lacking for Cape Verde, Comoros, Equatorial Guinea, Guinea-Bissau, Mauritania, Sierra Leone, or Somalia.
Characteristics of the African Epidemic
Transmission. HIV, the human immunodeficiency virus that causes AIDS, is spread
in Africa primarily by heterosexual contact, though some believe that the influence of unsafe
medical practices in the spread of HIV may have been underestimated. Others, however,
believe that sexual transmission remains the major mode of spread in Africa. Despite such
debates, many experts believe that a range of blood exposure infections other than through
sex are important factors in HIV infection in Africa. The prevention of the medical HIV
transmission is a component of the President’s Emergency Plan for AIDS Relief (PEPFAR).
Women. About 13.5 million HIV-positive women live in Africa. They comprise an
estimated 57% of infected adults in Africa, compared with 46% globally. Young women are
notably at risk. In 2005, an estimated 4.6% of African women aged 15 to 24 were HIV-
positive, compared with 1.7% of young men. These figures had dropped from 6.9% and
2.2%, respectively, in 2004 (UNAIDS, AIDS Epidemic Updates, December 2005/ 2004).
Prevalence Trends. UNAIDS reports that Africa’s adult HIV infection rate, or
prevalence, has stabilized in recent years, as both the total adult and infected populations
increase. Stabilization means that numbers dying approximate the numbers of newly
infected. HIV has become endemic in many countries and at a minimum will affect several
future generations. Prevalence is still increasing in Madagascar, Swaziland, and a few other
countries, while there have been declines in Uganda and localized areas in certain countries.
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Highest Rates. Southern Africa, where nine countries have adult infection rates above
10% (Table 1), is the most severely affected region. With 1.68% of the world’s population,
these countries account for nearly 30% of infected people worldwide and 45% of those in
Africa. However, populous Nigeria in West Africa, with an estimated 5.4% adult infection
rate, has an estimated 3.6 million infected people — the largest number in Africa apart from
South Africa, where UNAIDS estimates that 5.3 million are infected. South Africa has the
largest infected population in the world. In January 2006, while visiting Nigeria, First Lady
Laura Bush announced that in 2006 the United States would commit to Nigeria $163 million
in PEPFAR funds for AIDS treatment and prevention.
Children. Africa’s AIDS epidemic has a proportionally much greater effect on children
than is the case in other world regions. According to UNAIDS, over 600,000 African infants
become infected yearly with HIV through mother-to-child transmission, either at birth or
through breast-feeding. Most die before the age of two. Nonetheless, an estimated 1.9 million
African children under age 14 were living with AIDS in late 2003.
Orphans. In 2003, there were about 12.3 million AIDS orphans (children 17 and under
who had lost one or both parents to HIV) in Africa. They made up 28.3% of all orphans. By
2010, t heir number is forecast to rise to 18.4 million, or 36.8% of all orphans.1 Because of
stigma attached to AIDS, HIV-positive orphans are at high risk for malnourishment, abuse,
and denial of education. UNICEF has recommended that the capacity of families and
communities to protect and care for orphans be strengthened, that social and state protection
services be provided for orphans and vulnerable children (OVCs), and that public education
about HIV-affected children be increased. In October 2005, Human Rights Watch alleged
in a report that African governments have largely not addressed the myriad barriers to
education faced by AIDS- affected OVCs. The Assistance for Orphans and Other Vulnerable
Children in Developing Countries Act of 2005 (P.L. 109-95) became law in November 2005.
It authorizes U.S. assistance for basic care for orphans and vulnerable children in developing
countries, including aid for community-based care, school food programs, education and
employment training, psycho-social support, protection of inheritance rights, and AIDS care.
Explaining the African Epidemic
AIDS experts attribute Africa’s AIDS epidemic to a variety of economic and social
factors, but place 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 often have limited
capabilities for AIDS prevention work, and HIV counseling and testing are difficult for many
Africans to obtain. Until very recently, AIDS treatment was generally available only to elites.
1 UNAIDS/UNICEF/U.S. Agency for International Development, Children on the Brink, July 2004.
Estimates vary; in November 2003, UNICEF predicted that 20 million children would be orphaned
by AIDS by 2010 and that in a dozen countries orphans from all causes would make up 15% to over
25% of children under 15; see Africa’s Orphaned Generations.
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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 also
seen as key agents in spreading HIV. Meanwhile, poverty forces many women to turn to
“transactional sex” in order to survive, greatly increasing their chance of contracting AIDS.
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 of UNAIDS, has commented that “the unavoidable conclusion is that girls are
getting infected not by boys but by older men,” who are more likely than young men to carry
the disease (UNAIDS press release, September 14, 1999). UNAIDS notes that “with the
downward trend of many African economies ... relationships with (older) men can serve as
vital opportunities for financial and social security, or for satisfying material aspirations”
(AIDS Epidemic Update, 2002). Many believe that the infection rate among women generally
would be far lower if women’s rights were more widely respected in Africa, if women
exercised more political and socio-economic power, 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). An August 2003 Human Rights Watch
study 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 at 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 South African
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, in April 2004, the government began offering
treatment at 5 hospitals in populous and highly urbanized Gauteng province. TAC reported
in February 2005 that about 70,000 South Africans were receiving treatment, but of these
only 27,000 were being treated through the public program; the remainder were under private
care. An estimated 500,000 South Africans are in need of treatment.
The delays in South Africa’s response to the pandemic have been costly, many experts
believe. Survey data released in September 2004 by South Africa’s Health Department
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indicated that HIV infection rates were continuing to increase, though at a slightly 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 Health Department estimated that
5.6 million South Africans were infected. A September 2004 report by the Bureau of Market
Research at the University of South Africa predicted that AIDS-related deaths would exceed
500,000 yearly from 2007 to 2011. Nonetheless, South Africa’s Health Minister Manto
Tshabalala Msimang continues to question the effectiveness of antiretroviral drugs and to
insist that healthy diets and special foods, such as raw garlic and lemon peel, can offer
protection from the disease (Mail and Guardian Online, May 5, 2005). Former President
Nelson Mandela, seeking to combat the stigma associated with AIDS, announced in January
2005, that his son, Makgatho, had died of AIDS. The lower rate of growth in infections
reported may be continuing; a November 2005 South African Human Sciences Research
Council survey data release stated that South Africa’s AIDS epidemic may be “levelling off.”
In the rest of Africa, many heads of state, including the presidents of Uganda, Botswana,
Nigeria, and several other countries, are taking major roles in fighting the epidemic. 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. The New Partnership For
Africa’s Development (NEPAD), in partnership with the African Union, UNAIDS, and other
multinational entities, has formulated a range of strategies for countering AIDS, though the
products of these efforts appear to be limited at present.
Uganda’s president, Yoweri Museveni, has long been recognized for leading a
successful prevention campaign against AIDS in Uganda, where the ABC (Abstinence, Be
Faithful, or Use Condoms) transmission prevention program has won wide praise. A Senate
Foreign Relations Africa Subcommittee hearing in May 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 prevalence declines. Sophia Mukasa Monico, a member of the Global Health
Council and a former AIDS worker in Uganda, testified that all three program elements are
necessary for prevention to work but noted that the Ugandan epidemic was still “raging”and
that much work to counter it remained to be done.
In February 2005, Johns Hopkins and Columbia University researchers released a study
of Rakai, Uganda reporting that a local HIV prevalence decline was due to condom use and
the deaths of infected people (see Maria Wawer, R. Gray, et al., “Declines in HIV Prevalence
in Uganda: Not as Simple as ABC,” 12th Conference on Retroviruses and Opportunistic
Infections, Boston). Abstinence and monogamy appeared not to be increasing. Some saw this
as evidence that sexual behavior change programs were less important than expected. Others
argued that behavior had likely changed substantially prior to the study. In July 2005, First
Lady Laura Bush, speaking in South Africa during a trip to Africa that included visits with
AIDS patients and orphans, said that the Uganda-developed ABC model was “successful”
and added that “ABC stands for Abstinence, Be faithful, and correct and consistent use of
Condoms.” Conflicting reports appeared in late summer 2005 regarding a shortage of
condoms in Uganda for preventing HIV. Some AIDS activists and others blamed the alleged
shortage on an emphasis on abstinence in U.S.-funded AIDS prevention programs and a
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change in policy by Ugandan government officials, who denied a shortage existed. A U.S.
official attributed the problem to a shipment of defective condoms.2
Social and Economic Consequences
AIDS is having severe negative social and economic consequences in Africa, and these
effects are expected to continue for many years, as suggested by a January 2000 Central
Intelligence Agency National Intelligence Estimate on the infectious disease threats:
At least some of the hardest-hit countries, initially in 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.cia.gov/]).
The estimate predicted that AIDS would generate increased political instability and slow
democratic development. The World Bank (Intensifying Action Against HIV/AIDS in Africa,
September 1999 ) has reached similar conclusions with respect to Africa’s economic future:
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.
In the most severely affected countries, sharp drops in life expectancy are occurring,
reversing major gains achieved in recent decades. According to UNAIDS, average life
expectancy in Africa is now 47 years due to AIDS, whereas it would have been 62 years in
its absence. A March 2004 U.S. Census Bureau report predicted absolute population declines
by 2010 in South Africa, Botswana, and three other African countries due to AIDS.
Rural Livelihoods. Studies show that AIDS has devastating effects on rural families.
The father is often the first to fall ill, and when this occurs, farm tools and animals may be
sold to pay for his care, frequently leading to rapid impoverishment of often already poor
families. Should the mother also become ill, children may be forced to shoulder
responsibility for the full time care of their parents, farmsteads, and often of themselves,
despite their frequently limited knowledge about how to carry out farm and domestic work.
Many also become orphans. The U.N. Food and Agriculture Organization reported that since
1985, about 7 million agricultural workers have died in the 25 hardest-hit countries in Africa
and could kill 16 million more before 2020, or about 18.9%, and as much as 26% of their
agricultural workforces (FAO, HIV/AIDS, Food Security, and Rural Livelihoods, 2001).
2 “Condom Demand Rises,” New Vision (Uganda), Sept. 6, 2005; “The Missing Condoms,” New
York Times, Sept. 4, 2005; “U.S. Denies Driving Uganda from Condom Use,” The Monitor
(Uganda), Sept. 1, 2005.
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Some experts attribute serious food shortages in southern Africa in 2002 and 2003 to AIDS-
related production losses (e.g., see FAO, HIV/AIDS and the Food Crisis in Sub-Saharan
Africa, ARC/04/INF/8, March 2004). In February 2003, in separate testimony before the
Senate Foreign Relations Committee and the House International Relations Committee,
World Food Program (WFP) Executive Director James Morris said that AIDS was a central
cause of the famine. In June 2004, Morris said that southern Africa was in a “death spiral”
due to the effects 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). The FAO supports many programs to alleviate the diverse threats that AIDS poses
to agricultural production and food security; see [http://www.fao.org/hivaids].
Workforce Depletion. AIDS is blamed, in part, for increasing shortages of skilled
workers and teachers in several countries and is claiming many African lives at middle and
upper levels of public and private sector management. Although unemployment is generally
high in Africa, trained personnel are not readily replaced. Dr. Peter Piot, UNAIDS Executive
Director, told a June 2, 2005, special U.N. General Assembly meeting on AIDS that by 2006,
11 sub-Saharan countries will have lost 10% of their workforce to the disease. A May 2002
World Bank study, Education and HIV/AIDS: A Window of Hope, reported that over 30%
of teachers are HIV positive in parts of Malawi and Uganda, 20% in Zambia, and 12% in
South Africa. Reports from diverse sources have since continued to mirror such findings.
Security. AIDS may have serious security consequences for much of Africa, since
HIV infection rates in many militaries are reportedly 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, because South African soldiers are
expected to play an important peacekeeping role in Africa in the years ahead. The infection
rate in South Africa has been estimated at 23%, with higher rates reported for units based in
heavily infected KwaZulu-Natal province (for a recent study, see Laurie Garrett, HIV and
National Security: Where are the Links, Council on Foreign Relations, 2005).
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 (ARVs) 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).
Anti-AIDS programs and projects 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 youth to delay the age of “sexual debut” and
to remain faithful to a single partner. The Bush Administration advocates an expansion of
prevention programs focusing on abstinence until marriage and marital faithfulness as
effective means of slowing the spread of HIV, although some critics maintain that this may
be unrealistic in social environments characterized by poverty and lack of education. Some
also question whether such approaches can benefit poor married women in Africa, who have
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little power to refuse the sexual demands of their husbands, whether infected or not — or,
in some cases, to control their extra-marital activities. They are also often unable to refuse
spousal decisions to take more than one wife, given that polygamous marriage is common
and deeply embedded in many African societies. In January 2006, First Lady Laura Bush
defended abstinence approaches, saying that she had “always been a little bit irritated by
criticism of abstinence, because abstinence is absolutely, 100 percent effective in fighting a
sexually transmittable disease.” She added that “In many countries where girls feel obligated
to comply with the wishes of men, girls need to know that abstinence is a choice”(Deborah
Orin, “Laura Defends Sex Abstinence,” New York Post, January 16, 2006).
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 medical visits, and many experts are urging that this be done
continent-wide. AIDS awareness programs are found in many African schools and,
increasingly, in the workplace, where employers are recognizing their interest in reducing
infection rates among their employees. Many projects seek to make condoms readily
available and to provide 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 during infant 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.
In December 2004, the Associated Press reported that several flaws had been found in
a study of the nevirapine conducted in Uganda under U.S. National Institutes of Health (NIH)
sponsorship. According to the report, researchers acknowledged that thousands of bad
reactions were not disclosed. The allegations sparked 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 a statement affirming that “single-dose nevirapine is a safe and
effective drug for preventing mother to infant transmission of HIV.” It termed as “absolutely
false” any implication of thousands of adverse reactions in the Uganda study. AIDS activists
and others worried that the controversy would discourage use of the drug, often the only
available means of preventing mother to child transmission (MTCT) of HIV. The National
Academies’ Institute of Medicine, after investigating the Uganda study, reported that it was
valid and that nevirapine should continue to be used for MTCT.
Church groups and humanitarian organizations have helped Africa deal with the
consequences of AIDS by setting up care and education programs for 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 AIDS
vaccine research and diverse AIDS programs pursued 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 fund Uganda’s AIDS Support Organization and the Infectious Diseases
Institute. It has trained 250 AIDS specialists annually, many slated to work in rural areas. In
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January, the Swiss drug firm Roche said it plans to help African firms produce generic
versions of its WHO-endorsed ARV, Saquinavir, under its Technology Transfer Initiative.
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. Despite these
responses, UNAIDS maintains that significant AIDS funding gaps remain. According to a
recent study, $14.9 billion will be needed in 2006 to fight HIV/AIDS in low- and middle-
income countries globally in 2006, whereas $8.9 billion is likely to be provided. The funding
gap is projected to rise in future years (UNAIDS, Resource Needs for an Expanded Response
to AIDS in Low and Middle Income Countries, June 2005).
Further information on the response to AIDS in Africa and elsewhere may be found
under AIDS Treatment Issues, below, and at the following websites:
— Centers for Disease Control (CDC): [http://www.cdc.gov/nchstp/od/nchstp.html]
— Global Fund to Fight AIDS, Tuberculosis & 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 Network: [http://www.kaisernetwork.org]; click “HIV Daily Reports”
— UNAIDS: [http://www.unaids.org/en/default.asp]
— USAID: [http://www.usaid.gov/our_work/global_health/aids/index.html]
— World Bank: [http://www.worldbank.org]; click “Topics >> AIDS”
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; 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 sexual behavior patterns among young urbanites in some other
countries may be changing in ways that combat the spread of HIV, although increases among
populations continue in many African cities. 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 contend that there are multiple social 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 public education and outreach efforts as essential components of the response
to the epidemic. Indeed, there is strong support for an intensification of such efforts, as well
as adaptations to make them 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 often accompany AIDS. Millions of Africans suffer dual infections of HIV
and tuberculosis (TB), and their combined effects dramatically shorten life. TB can be cured
by combined drug treatments over several months, even in HIV-infected patients. However,
according to the World Health Organization (WHO), Africans often delay seeking treatment
for TB or do not complete their drug regimens (Global Tuberculosis Control: WHO Report
1999, Key Findings), contributing to high death rates among those with dual infections.
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. The Pfizer Corporation
donates the anti-fungal Diflucan (fluconazole), used to treat AIDS-related opportunistic
infections, such as cryptococcal meningitis, a dangerous brain inflammation, to patients in
18 African countries through the Pfizer Diflucan Partnership Program (DPP). DPP is a
public-private effort in collaboration with health ministries, local clinics, and
non-governmental organizations. In partnership with the International Association for
Physicians in AIDS Care, Pfizer also supports education and training for health care
providers in diagnosis and management of opportunistic infections.
AIDS Antiretroviral Treatment Issues
Access for poor Africans to antiretroviral drugs (ARVs) has been perhaps the most
contentious issue surrounding the response to the African epidemic. Administered in a
treatment regimen known as HAART (highly active antiretroviral therapy ), ARVs can
enable AIDS victims to live relatively normal lives and permit long-term survival rather than
early death. ARV treatment has proven highly effective in developed countries, including the
United States, where AIDS, the eighth leading cause of death in 1996, was no longer ranked
among the 15 leading causes by 1998 (U.S. Health and Human Services Department, Press
Release, October 5, 1999).
The high cost of HAART treatments has been the principal obstacle to a large scaling-
up of access to therapy 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 pharmaceutical firms 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 Global
Fund and President’s Emergency Plan for AIDS Relief (PEPFAR; see below) programs. In
December 2003, the WHO formally launched its $5.5 billion “3 by 5” plan to treat 3 million
AIDS patients in poor countries by 2005, with resources to come from the Global Fund and
donors. Leaders of the G8, concluding their summit in Scotland on July 8, 2005, promised
“a package for HIV prevention, treatment, and care, with the aim as close as possible to
universal access to treatment for all those who need it by 2010.”
In October 2003, former President Bill Clinton announced that his Clinton Foundation
had organized a program to provide generic three-drug ARV treatment for AIDS patients in
Africa and the Caribbean for about $.38 per day. Generic drug manufacturers in India and
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South Africa would make the drugs, and funding would come from private donors, some
donor governments, and other sources. 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 ARV scaling up efforts, an
estimated 500,000 sub-Saharan patients were receiving HAART in June 2005, up from
150,000 one year earlier (World Health Organization, “3 by 5” Progress Report, December
2004, and Progress on Global Access to HIV Antiretroviral Therapy, an Update on “3 by
5,” June 2005). However, an estimated 4 million Africans remain in need of HAART. On
April 11, 2005, former President Clinton announced a Clinton Foundation pediatric AIDS
program intended to put 10,000 HIV-positive children on ARV therapy in at least 10
countries in 2005, thus doubling the number of children in treatment. In addition to its drug
buying agreements, CHAI helps countries to implement large-scale, integrated care,
treatment, and prevention programs. Partner governments take the lead, and CHAI provides
technical aid, mobilizes human and financial resources, and promotes sharing of best
practices.
Dr. Jim Yong Kim, head of the WHO AIDS programs, said in February 2005 that the
3 by 5 campaign was struggling to attain its goal (“Global AIDS Effort Still Short of Goal,”
Boston Globe, February 23, 2005). In Africa, Botswana and Uganda would likely meet their
targets, but South Africa and Nigeria were lagging. South Africa’s Health Minister,
Tshabalala-Msimang, said in May that some were trying to “scapegoat” South Africa for the
failure of 3 by 5 and that South Africa could not do a blanket rollout of ARV drugs because
patients had to be closely monitored due to side effects produced by ARVs. She added that
she would continue to inform patients that they had three options: improve their nutrition,
take micronutrients, or enroll in an ARV program (Mail and Guardian Online, May 5, 2005).
Whether African countries are ready to “absorb” (effectively use) 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 Africa. 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 African patients
reportedly follow their AIDS therapy regimens equally or more consistently than many
American patients (“Africans Outdo U.S. Patients In Following AIDS Therapy,” New York
Times, September 3, 2003). For some, the correct response to weaknesses in Africa’s basic
health care systems is to devote resources to strengthening those systems (Holly Burkhalter,
“Misplaced Help in the AIDS Fight,” Washington Post op-ed, May 25, 2004).
Botswana’s President Mogae told a November 2003 meeting, held 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, or the general draw of developed
country job markets. The health minister of Mozambique, which has launched a pilot ARV
drug 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
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in November 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. In
December 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 copies of patented AIDS drugs
(“generic drugs”). 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) 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 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. Some in the pharmaceutical industry, on the other hand,
expressed concern that the declaration was too permissive and might reduce profits that, they
argued, fund medical research. Others, however, maintained that the declaration would have
little practical impact; in their view, poverty, rather than patents, is the key 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). In August 2003, the WTO reached agreement on a plan to
allow poor countries to import generic copies of essential drugs, but the debate over access
to ARVs in Africa seems likely to continue. In March 2005, India’s parliament passed patent
legislation expected to sharply raise prices in Africa and elsewhere for Indian-manufactured
generic copies of newly discovered AIDS medications. Cheap generic copies of existing
drugs can still be sold, although sellers will have to pay licensing fees to patent holders.
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 (see Barton Gellman, “The Global Response to AIDS in Africa: World Shunned Signs
of Coming Plague,” Washington Post, July 5, 2000, and 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
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for a global LIFE (Leadership and Investment in Fighting an Epidemic) AIDS initiative, 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 asserted in 2001
that its support of multilateral efforts and direct sponsorship of regional and bilateral
programs had made it the global leader in the international response to AIDS since 1986,
when it initiated AIDS prevention programs in developing countries (USAID, Leading the
Way: USAID Responds to HIV/AIDS, September 2001). USAID had sponsored AIDS
education programs; trained AIDS educators, counselors, and clinicians; supported condom
distribution; and sponsored AIDS research. USAID claimed several successes in Africa.
These included helping to reduce HIV prevalence among young Ugandans; preventing 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 having spent a total of $51
million on fighting AIDS in Africa in FY1998 and $63 million in FY1999 (Leading the Way,
p. 121). In addition, some spending by the Health and Human Services Department supported
HIV surveillance and other AIDS-related efforts in Africa.
Bush Administration
Combating the AIDS pandemic in Africa has been an important Bush Administration
foreign assistance program goal. In May 2001, President Bush made the “founding pledge”
of $200 million to the Global Fund, and in June 2002, he announced a $500 million
International Mother and Child HIV Prevention Initiative to support efforts to prevent
mother-to-child AIDS transmission. Eight African countries were named as beneficiaries.
In his January 2003 State of the Union address, President Bush announced the launching of
the President’s Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion for fiscal
years 2004 through 2008, including $10 billion in “new money,” that is, spending in addition
to then current levels. In February 2004, the State Department issued a report
[http://www.state.gov/s/gac/rl/or/c11652.htm] providing details on the PEPFAR initiative,
as well as plans to release initial PEPFAR funds for several “public-private partnership”
treatment programs. PEPFAR aims to prevent 7 million new infections globally, provide
ARV drugs for 2 million infected people, and provide care for 10 million infected people,
including orphans. PEPFAR is resulting in major spending increases for HIV/AIDS
prevention, care, and treatment in 15 “focus countries,” 12 in Africa (Botswana, Cote
d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania,
Uganda, and Zambia). The new funds are being provided through the Global HIV/AIDS
Initiative (GHAI), headquartered at the State Department. The GHAI is headed by the U.S.
Global AIDS Coordinator, Randall Tobias, who coordinates not only the GHAI programs in
focus countries but also the international AIDS programs of USAID and other agencies.
President Bush made AIDS a special focus of his five-day trip to Africa in July 2003.
On July 8, in Senegal, the President told Africans, “we will join with you in turning the tide
against AIDS in Africa.” 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.” In
September 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.
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Many AIDS activists and others have praised the President’s initiatives, but critics
maintain that PEPFAR started slowly 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, especially the Global Fund. Some
question whether PEPFAR will do enough to strengthen African health care institutions and
capabilities for coping with AIDS over the long term, or whether the funds will go 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 U.S. contributions of $1 billion
annually for the Global Fund. U.S. Global AIDS Coordinator Randall Tobias responded by
stating that “It’s not going to happen” (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.”
Senator Frist introduced a bill (S. 850) on April 19, 2005, to authorize a Global Health
Corps that would send U.S. health volunteers abroad and expand the availability of health
care personnel, items, and related services. That same day, the National Academies’ Institute
of Medicine (IOM) released a report calling for a U.S. Global Health Service to mobilize
health personnel to work in the 15 PEPFAR focus countries. An initial deployment of 150
key professionals would be paid full salary; others would receive $35,000 fellowships and
student loan repayments up to $25,000. Some suggested that funds might better be spent
training and retaining indigenous health personnel, particularly in Africa; others noted that
training was a key part of the IOM proposal, which they praised as a dynamic response to the
AIDS crisis.
Treatment. The Financial Times reported in April 2004 that the United States was
withholding support from a program intended to treat 140,000 AIDS patients in Kenya with
antiretrovirals because it would rely on a generic three-drug combination (FDC) pill. Many
favor approval of FDCs, including copies of drugs made 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 later wrote to President Bush asking that the United States join an international
consensus that generics are safe and essential for AIDS treatment. In May 2004, then-Health
and Human Services Secretary Tommy Thompson announced that the U.S. Food and Drug
Administration (FDA) was instituting an expedited process that could lead to the approval
of the use of FDCs in PEPFAR-funded programs . Many hailed the news 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. By June 2005, the FDA had reportedly
cleared seven generic anti-retrovirals manufactured in South Africa and India. However, the
Boston Globe reported on June 20 that four African countries, Nigeria, Uganda, Ethiopia, and
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Tanzania, were refusing to accept generic FDA-approved drugs for use in U.S.-funded
treatment programs. Instead, the countries sought approval of the drugs by WHO.
In March 2005, the Department of State released Engendering Bold Leadership: The
President’s Emergency Plan for AIDS Relief, the first annual report to Congress on the
initiative. In an introductory letter to the report, Randall Tobias called PEPFAR
“coordinated, accountable, and powerful.” The report stated that 152,000 African patients
were receiving AIDS treatment due to PEPFAR and that 119 million had been reached with
mass media campaigns promoting abstinence and faithfulness, while 71 million had been
reached with messages promoting other prevention measures, including the use of condoms.
Critics have charged that funding for PEPFAR abstinence programs, notably in Africa, have
increasingly replaced other HIV prevention measures and that the United States is today
sending fewer condoms abroad than in 1990 (Center for Health and Gender Equity,
Prevention Funding Under [PEPFAR]: Law, Policy and Interpretation, December 2005).
Spending. Table 2 reports available information on recent U.S. spending levels on
AIDS programs in Africa. Under the FY2006 request, GHAI assistance to the 12 focus
countries in Africa would grow by 54% to just over $1.2 billion, or 61% or the total GHAI
request. Prior to the launching of PEPFAR, the principal channels for HIV/AIDS assistance
to Africa were USAID and the Global AIDS Program (GAP) of the Centers for Disease
Control (CDC) in the Health and Human Services Department. The drop in USAID funding
in Table 2 from FY2004 to FY2005 results from the shift in funds in the 12 GHAI focus
countries in Africa to the Office of the Global AIDS Coordinator at the State Department.
This was done to simplify the budget, enhance transparency, and stress the President’s
interest in fighting AIDS. Most USAID spending on AIDS in Africa is through the Child
Survival and Health Programs Fund, but limited amounts are provided through the Economic
Support Fund. Information on GAP spending in Africa for FY2004 and subsequent years is
not yet available (NA) due to a change in budget structure at the Department of Health and
Human Services. The Department of Defense (DOD) has undertaken an HIV/AIDS
education program primarily with African armed forces. As in other recent years, the
Administration has not requested funding for this program in FY2006, but in FY2005
Congress continued to support it by appropriating $7.5 million. Funds from the Foreign
Military Financing (FMF) program are also used to support this initiative. A Department of
Labor (DOL) program supports AIDS education in the workplace in four sub-Saharan
countries. (For details, see CRS Report RS21181, HIV/AIDS International Programs:
Appropriations, FY2003-FY2006). Additional U.S. funds reach Africa indirectly through the
AIDS programs of the United Nations (U.N.), the World Bank, and the Global Fund.
The scale of the response to the pandemic in Africa by the United States and other
donors remains a subject of intense debate. The U.N. Special Envoy for HIV/AIDS in Africa,
Stephen Lewis, has been a persistent critic, telling a September 2003 conference on AIDS
in Africa that he was “enraged by the behavior of the rich powers” with respect to the
epidemic. Many activist groups have made similar critiques. The singer Bono said he had
a “good old row” with President Bush in a September 2003 meeting on the level of U.S.
funding for fighting the international AIDS epidemic. Nonetheless, as noted above, others
have argued that Africa’s ability to absorb increased AIDS funding is limited and that health
infrastructure will have to be expanded before new funds can be spent effectively.
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Table 2. U.S. Bilateral Spending on Fighting AIDS in Africa
($ millions)
FY2004 FY2005
FY2006
FY2000
FY2001
FY2002
FY2003
Est.
Est.
Request*
USAID
109
144
183
320
234.0
82.3
82.4
CDC (GAP)
30
77
84
107
15.0
14.8
14.8 est.
GHAI (State)
-
-
-
-
263.8
781.5
1,206.3
DOD
0
5
14
7
4.2
7.5
0
FMF
0
0
0
2
1.5
2.0
2.0
DOL
0
3
6
5
2.1
0
0
Total
139
229
287
441
520.6
888.1
1,303.5
* The Administration is currently making AIDS funding allocation decisions following enactment into law of P.L.
109-102, the FY2006 Foreign Operations FY2006 Appropriation.
Legislative Action, 2000-2004
In August 2000, the Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264)
became law. It authorized funding for FY2001 and FY2002 for a comprehensive,
coordinated, worldwide HIV/AIDS effort under USAID. In the 107th Congress, several 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 PEPFAR 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,
FY2003-FY2006.
Legislation in the 109th Congress
H.R. 1409 (Lee), the Assistance for Orphans and Other Vulnerable Children in
Developing Countries Act of 2005, which was related to S. 350 (Lugar), was signed into law
as P.L. 109-95. H.R. 3057 (Kolbe), the FY2006 Foreign Operations FY2006 Appropriation,
contains significant AIDS funding. It was signed into law as P.L. 109-102. H.R. 3010, the
Health and Human Services FY2006 Appropriations bill, which also contains substantial
funding for international HIV/AIDS, was signed into law as P.L. 109-149. 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; and S. 850 (Frist), Global Health Corps Act of 2005.
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