Order Code RL30883
Report for Congress
Received through the CRS Web
Africa: Scaling Up the Response
To the HIV/AIDS Pandemic
Updated May 29, 2002
Specialist in International Relations
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress
Africa: Scaling Up the Response
To the HIV/AIDS Pandemic
Sub-Saharan Africa’s AIDS pandemic continues to spread – an estimated 3.4
million people were newly infected by HIV in 2001. International resources for
combating the pandemic are increasing, and there is continuing interest in proposals
for a further “scaling-up.” In December 2001, the House passed the Global Access
to HIV/AIDS Prevention, Awareness, and Treatment Act (H.R. 2069), finding that
the African pandemic has become a national security and development crisis and
authorizing increased funding.
AIDS experts see three dimensions to the effort to curb the spread of HIV/AIDS
and reduce the death toll: prevention, care, and treatment. They estimate that by
2005, Africa could effectively absorb about $4.6 billion in the struggle against the
pandemic and that about $3 billion would have to be provided by donors. Donor
contributions were estimated at several hundred million dollars in 2001, and whether
they will be providing $3 billion annually by 2005 remains to be seen.
Nonetheless, HIV/AIDS assistance from the United States and other donors has
been increasing. U.S. bilateral spending on African AIDS programs is expected to
rise from $238 million in FY2001 to $292 million in FY2002. The United States has
pledged $500 million to the Global Fund to Fight AIDS, Tuberculosis, and Malaria,
which announced its first grants in April 2002. About 52% of the $378 million to be
initially disbursed will go to Africa. The scale of future increases in U.S. spending
is unclear; but several bills that would boost the U.S. contribution are currently
The focus in the struggle against AIDS in Africa to date has been on prevention
– only an estimated 25,000 to 30,000 African AIDS patients are currently receiving
treatment with the antiretroviral drugs that have sharply reduced the AIDS death toll
in developed countries. AIDS experts favor a continued scaling up of prevention
measures, including media campaigns, school-based programs, and condom
distribution. At the same time, there is strong support for expanding the availability
of antiretrovirals to prevent mother to child transmission of HIV during birth.
Beyond prevention, many advocates want to enhance home-based care for AIDS
patients and their families and sharply expand programs to care for Africa’s
burgeoning population of orphans. Many also believe that antiretroviral treatment
must be made much more widely available, both on moral grounds and because it can
stem the loss of adults in their most productive years.
In addition to governments, non-governmental organizations, foundations, and
the private sector are expanding their involvement in the campaign against AIDS in
Africa. Community and faith-based organizations are playing key roles in caring for
those affected by AIDS, including orphans and vulnerable children. U.S. government
agencies, meanwhile, have undertaken steps to enhance their policy making and
coordination capabilities, although some observers would like to see additional
efforts in this area.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Objectives of Scaling Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Cost Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Antiretroviral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Costs in 2005 and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Recent Scaling Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Multilateral Programs and the Global Fund . . . . . . . . . . . . . . . . . . . . . . . . . 6
Funding Gap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Scaling Up Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Home Based Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Orphans and Vulnerable Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Participants in an Enhanced Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Non-Governmental Organizations and the Private Sector . . . . . . . . . . . . . . 16
Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Technical Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
U.S. AIDS Policy Making and Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
List of Tables
Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa . . . . . . . . . . . . . . . 5
Africa: Scaling Up the Response to the
In Africa, more than 28 million people are infected by the HIV virus, and 19
million have already lost their lives to the AIDS disease. An estimated 2.3 million
died of AIDS in 2001, and 3.4 million were newly infected.2 Sub-Saharan Africa
has about 10% of the world’s population, but about 70% of the worldwide total of
HIV-infected people live in the region. The HIV infection rate among adults exceeds
10% in 16 countries, reaching 25% in South Africa and 38% in Botswana. Life
expectancy is plunging in these countries, and the social and economic consequences
of widespread illness and death are expected to be severe. Botswana’s President
Festus Mogae, told the June 2001 United Nations General Assembly Special Session
on HIV/AIDS (UNGASS) that “We are threatened with extinction.”3
To date, progress in curbing the HIV/AIDS pandemic has been very limited, and
Uganda and Senegal are the only countries cited by experts as clear-cut “success
stories” in the fight against the disease. Uganda has sharply reduced HIV prevalence
among adults through an intensive AIDS prevention campaign, and Senegal has
evidently avoided a major AIDS epidemic through safe sex education in the schools,
the promotion of condom use, and other measures.4 In both cases, “outspoken and
frank” leadership from the highest levels of government is credited with much of the
success in the struggle against AIDS.5 UNAIDS, the Joint United Nations Program
on HIV/AIDS, also reports some evidence that young people in Zambia and South
Africa are modifying their behavior to avoid HIV infection.6
In view of the continuing threat posed by AIDS to Africa’s people, and to the
region’s future, interest in expanding or “scaling up” the response to the pandemic
For background on AIDS in Africa, and for current legislation, see CRS Issue Brief
IB10050, AIDS in Africa.
United Nations Joint Project on HIV/AIDS (UNAIDS), AIDS Epidemic Update, December
Maggie Farley, “At AIDS Disaster’s Epicenter, Botswana is a Model of Action,” Los
Angeles Times, June 27, 2001.
UNAIDS, Acting Early to Prevent AIDS, the Case of Senegal, June 1999.
World Health Organization, Macroeconomics and Health: Investing in Health for
Economic Development. Report of the Commission on Macroeconomics and Health,
chaired by Jeffrey D. Sachs. Geneva, December 20, 2001: 52.
is strong. It was at an April 2001 Organization of African Unity (OAU) summit on
HIV/AIDS that U.N. Secretary General Kofi Annan called for the creation of a global
trust fund that would spend $7 billion to $10 billion annually to combat the pandemic
worldwide.7 Negotiations on the creation of this fund, named the Global Fund to
Fight AIDS, Tuberculosis, and Malaria (GFATM or Global Fund) were completed
in December 2001, and to date, $1.9 billion has been pledged for combating the three
diseases worldwide. The United States has pledged $500 million.8
The final declaration of the UNGASS meeting noted that HIV/AIDS threatened
social cohesion and political stability in Africa and required urgent national, regional,
and international attention. The declaration set ambitious targets for reducing HIV
prevalence among young men and women, expanding access to information about
AIDS, reducing mother to child transmission (MTCT) of HIV, and enhancing AIDS
care and treatment.
In Congress, the House passed the Global Access to HIV/AIDS Prevention,
Awareness, and Treatment Act (H.R. 2069) in December 2001. This bill finds that
“the HIV/AIDS pandemic in sub-Saharan Africa has grown beyond an international
public health issue to become a humanitarian, national security, and developmental
crisis.” It authorizes increased funding both for bilateral HIV/AIDS programs and
for a U.S. contribution to a global health fund. Other bills currently before
committees in both the House and Senate would increase spending, launch new
initiatives, and strengthen AIDS policy coordination in order to intensify the struggle
against HIV/AIDS in Africa and worldwide.9
The purpose of this paper is to summarize the objectives for scaling up the
response to the AIDS pandemic in Africa, review the estimated costs of scaling up,
and describe the measures against the pandemic that AIDS experts seek to expand.
In addition, the report discusses the types of organizations, including faith-based and
private sector organizations, that will likely play important roles in an enhanced
response, and reviews issues surrounding AIDS policy making and coordination in
U.S. agencies as the U.S. role increases.
Objectives of Scaling Up
Two U.S. authorities on the African pandemic, Helene Gayle of the Bill and
Melinda Gates Foundation, and Peter Lamptey of Family Health International, an
Arlington-based non-profit focusing on reproductive health, have recently called for
“an expanded and comprehensive HIV/AIDS response.” They argue that such a
The Global AIDS and Tuberculosis Relief Act of 2001 (P.L. 106-264) had directed the
Secretary of the Treasury to seek the creation of such a fund.
Testimony of Secretary of Health and Human Services Tommy Thompson before the
Senate Foreign Relations Committee, February 13, 2002.
See CRS Issue Brief IB10050, AIDS in Africa, for a listing.
response would “effectively and rapidly deliver large-scale, comprehensive, and
sustained HIV/AIDS programs”10 in order to meet five objectives:
A substantial reduction in new HIV infections; a substantial reduction in AIDSrelated morbidity (illness) and mortality; improved quality of life for people
infected and affected by HIV/AIDS; reduced HIV/AIDS stigma and
discrimination; (and) reduced impact of the epidemic, especially on children and
During his speech at Abuja, Nigeria, in April 2001, UN Secretary General
Annan laid out a broadly similar set of objectives for scaling up, but specifically
mentioned expanded access to treatment as a goal. According to the Secretary
General, scaling up should aim at
(1) preventing the further spread of the epidemic, particularly by giving young
people the knowledge and power to protect themselves
(2) preventing mother to child transmission of HIV, which Annan called “the
cruellest, most unjust infections of all”
(3) putting care and treatment, including treatment with advanced AIDS
medications, “within everyone’s reach”
(4) delivering scientific breakthroughs by giving a higher priority to finding a
cure and a vaccine
(5) protecting those made most vulnerable by the disease, particularly orphans
who “are growing up malnourished, under-educated, marginalized, and at
risk of being infected themselves.”11
AIDS experts generally argue that these objectives can be achieved by a
substantial expansion in programs aimed at preventing the spread of HIV, and in
programs that provide care and treatment to those affected by the pandemic. These
approaches are discussed in greater detail below.
In December 2001, Peter Piot, executive director of the Joint United Nations
Program on HIV/AIDS (UNAIDS), told an international AIDS conference in Burkina
Faso that assistance to fight HIV/AIDS in Africa should be increased “many-fold,”
and that the region required $4.6 billion per year to confront the pandemic. This
estimate reflected detailed work done by Bernhard Schwartlander of the World
Health Organization and UNAIDS, with others, and published in Science magazine
Peter R. Lamptey and Helene D. Gayle, eds., HIV/AIDS Prevention and Care in ResourceConstrained Settings, A Handbook for the Design and Management of Programs (Arlington,
Virginia: Family Health International, 2001): 685. This publication was funded by the
United States Agency for International Development.
Secretary General Proposes Global Fund for Fight Against HIV/AIDS and Other Infectious
Diseases at African Leaders Summit. UN Document SG/SM/7779/Rev.1 (April 26, 2001).
in June 2001.12 The Schwartlander article looked at “feasible and necessary”
increases in prevention programs on a country by country basis and concluded that
by 2005, Africa could effectively absorb about $1.56 billion in increased
expenditures on prevention. With respect to care and treatment, including treatment
with antiretroviral drugs, the article found that $3.07 billion per year could be used
effectively in Africa by 2005, yielding a total cost for prevention, care, and treatment
of $4.63 billion.
A large part of the cost of enhanced treatment and care in the Schwartlander
estimates is accounted for by antiretroviral (ARV) treatment – the drug therapy that
has done so much to reduce AIDS-related illness and death in the United States and
other developed countries. According to the relief organization Medecins sans
Frontieres (MSF, or Doctors Without Borders) ARV treatment, also known as highly
active antiretroviral therapy (HAART), is currently available to only 25,000 to
30,000 AIDS patients in sub-Saharan Africa,13 and some of this treatment is probably
ineffective, because many patients can afford the antiretrovirals only sporadically.14
An estimated 4 million Africans are in the advanced stages of the disease and most
likely to benefit from antiretroviral therapy. Schwartlander estimates that 2.2 million
people could be treated by 2005, at an estimated cost of $450 per patient for
antiretroviral drugs.15 This degree of coverage would cost nearly $1 billion per year.
Costs in 2005 and Beyond
Schwartlander estimates that of the total of $4.63 billion per year needed for a
scaled up response including prevention, care, and treatment by 2005, $3 billion
would need to be provided by donors. He sees the remainder coming from increased
spending in the health sector by African countries themselves, resources available
from the World Bank/International Monetary Fund Highly Indebted Poor Country
Initiative (HIPC), and the private sector.
Beyond 2005, experts see the cost of a scaled up response increasing.16 This
is because Africa’s capacity to absorb increased resources for dealing with AIDS is
currently quite limited. For example, under current practice, antiretrovirals for
preventing mother to child transmission (MTCT) of HIV are only administered to
pregnant women who have been tested for HIV and are delivering in a health facility.
This number is believed to be only a fraction of the total number of African women
B. Schwartlander and others, “AIDS Resource Needs for HIV/AIDS,” Science, June 29,
MSF spokesperson quoted in “AIDS Drug Access Still Poor in Africa,” Chicago SunTimes, March 29, 2002.
Macroeconomics and Health: 51.
Schwartlander assumes that this would be the cost of the drugs in low income countries.
In view of continuing reductions in drug costs, some reports estimate lower costs.
For an in-depth analysis, see Macroeconomics and Health.
at risk of passing HIV on to their babies. At present, it is estimated that fewer than
half of all births in Africa are attended by health professionals.17 Scaling up,
however, will strengthen Africa’s health infrastructure and make it possible to offer
HIV testing and delivery in health facilities to larger numbers of women, leading to
higher costs for providing MTCT prevention. The capacity to deliver long-term
antiretroviral therapy will also increase over time, making it possible to treat larger
Recent Scaling Up
U.S. and other donor support for HIV/AIDS programs in Africa has increased
significantly in recent years. Table 1 indicates that U.S. spending through bilateral
programs has more than doubled since FY2000. The largest bilateral programs are
those of the U.S. Agency for International Development (USAID) and the Centers
for Disease Control and Prevention (CDC) of the Department of Health and Human
Service. USAID has undertaken an “expanded response” to the global AIDS
pandemic “designed to enhance the capacity of developing countries to prevent an
increase in HIV/AIDS and provide services to those who are either infected and/or
otherwise affected by the epidemic (orphans, vulnerable children, and other family
members.)”18 USAID has identified three African “rapid scale-up” countries –
Kenya, Uganda, and Zambia – to receive significantly increased resources with the
goal of achieving measurable impact “within one to two years.”19 Ten more African
countries and the West African region have been designated for “intensive focus”
and will also receive added resources to combat the disease.
Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa
CDC’s Global AIDS Program (GAP) provides assistance to 17 African countries in
infrastructure and capacity development; primary prevention, including voluntary
USAID, Leading the Way: USAID Responds to HIV/AIDS (Washington, 2001): 21.
USAID, “USAID’s Expanded Response to the Global HIV/AIDS Pandemic” (undated).
counseling and testing for HIV infection; and care and treatment, including treatment
of tuberculosis and other opportunistic infections associated with AIDS.
Meanwhile the Department of Defense (DOD) has launched an AIDS education
program with African armed forces, and the Department of Labor (DOL) has begun
an International HIV/AIDS Workplace Education Program. This program aims at
strengthening prevention education in the workplace, reducing stigma and
discrimination, and helping labor unions, employers, and governments to build
capacity to fight the epidemic.
The degree to which HIV/AIDS spending will increase in FY2003 is not yet
clear. Under the Administration’s FY2003 budget request, USAID spending for
HIV/AIDS in Africa would increase to $250.4 million. It seems unlikely that CDC
spending in Africa could increase significantly under the budget request, however,
since the Administration is proposing to fund the worldwide GAP program at the
same level as in FY2002. No new funds have been requested for the DOL or DOD
programs, although $2 million has been requested under the Foreign Military
Financing program to support the DOD effort.20 The Administration’s budget request
for a $200 million U.S. contribution to the Global Fund in FY2003 is the same
amount pledged for FY2002.
Multilateral Programs and the Global Fund
United Nations agencies, including the World Bank, are expanding their
commitments to the struggle against AIDS. In September 2000, the World Bank
announced that it was making an initial commitment of $500 million to a new MultiCountry HIV/AIDS Program (MAP) to assist African countries in scaling up their
response to the AIDS pandemic. By October 2001, $155 million in loans had been
approved under the MAP program and $15 million had been disbursed. In 2002, the
Bank is programming an additional $500 million for MAP.21
On April 25, 2002, the Global Fund announced its first grants, approving $378
million worldwide over two years, of which 60% is going to fight AIDS and 52% is
for African projects.22 Actual spending will probably be larger than this, since the
Fund board agreed to a fast track process to approve additional loan requests once
certain conditions are met. Moreover, the Fund expects to solicit a second round of
proposals in 2002.
According to Schwartlander, of the $3 billion required from donors for scaling
up the response to AIDS in Africa, only a “few hundred million dollars” was
For more information, see CRS Report RS21181, HIV/AIDS International Programs:
FY2003 Request and FY2002 Spending.
World Bank Intensifies Action Against HIV/AIDS, World Bank Issue Brief available at
Press release available at [http://www.globalfundatm.org].
provided in 2001.23 In view of the scaling up that is occurring in 2002, it seems
likely that considerably more, perhaps several hundred million dollars, is currently
being spent. Thus, a gap of well over $2 billion per year remains to be filled if
Schwartlander/UNAIDS target of $4.6 billion is to be met by 2005.
Whether donors will contribute these sums remains to be seen. Many regard
scaling up as both a moral and security imperative in view of the massive loss of life,
economic difficulties, and political instability that could result if the African
pandemic is not curbed. Harvard economist Jeffrey Sachs wrote in a February 10,
2001 Op-Ed article that the amount required for scaling up is “tiny compared with
the great annual wealth of the well-off nations,” adding that “to turn our back on
Africa over this small sum would constitute one of the greatest moral failings in our
history.”24 On March 25, 2002, twenty eight U.S. religious leaders urged a major
increase in AIDS spending worldwide, writing that “AIDS has become the worst
infectious disease crisis to confront the world since the bubonic plague of the 14th
century halved the population of Europe within five years.”25
Others may contend, however, that the African HIV/AIDS pandemic does not
affect the core economic and security interests of the United States and other donors
sufficiently to justify expenditures at the levels suggested by scaling-up proposals,
particularly those including ARV therapy. There may also be skeptics who will
question whether expanded resources for combating AIDS can be spent effectively
or achieve results in view of the difficult political, economic, and social conditions
prevailing in many African countries. Moreover, some may maintain that the need
to fund AIDS programs in the former Soviet Union and Asia, where epidemics are
worsening, will limit the capacity of donors to increase funding for HIV/AIDS
programs in Africa.
Scaling Up Strategies
Most HIV/AIDS experts see three dimensions to the effort to curb the spread of
HIV/AIDS in Africa, as in other regions, and to reduce the AIDS death toll:
prevention, care, and treatment. To date, the focus in Africa has been on preventing
the spread of the HIV virus, and some argue that prevention is still the most costeffective means of dealing with the pandemic in view of the limited resources
available.26 But others strongly maintain that all three dimensions must be scaled up
quickly if headway is to be made against the pandemic. This is partly because the
availability of care and treatment is seen as essential to persuading people to
“The Best Possible Investment,” New York Times, February 10, 2001. Sachs has since
accepted a new position at Columbia University.
This letter, an appeal to Congress for $2.5 billion in budget authority for AIDS efforts
worldwide, may be found at the website of the Global AIDS Alliance
[http://www.globalaidsalliance.org/]. Click on “News.”
Elliot Marseille, Paul B. Hoffman, and James G. Kahn, “HIV Prevention Before HAART
in Sub-Saharan Africa,” The Lancet, May 25, 2002.
volunteer to be tested for HIV infection, and testing is regarded as a key step in
persuading both the infected and the uninfected to modify their behavior in ways that
will prevent the spread of the virus. At present, only an estimated 5% of Africans
know their HIV status.27
More broadly, it is argued that expanded care and treatment are essential to
keeping alive parents, teachers, health workers, and others playing vital social and
economic roles; and to protecting and educating children orphaned by AIDS or made
vulnerable when their parents fall ill. If these needs are not met, many argue,
widespread social disruption and economic devastation will result.28 Finally, many
believe that since ARV treatment reduces the “viral load” in AIDS patients, it likely
reduces the risk that these patients will pass the disease on to others. This hypothesis
is not yet proven, however.29 Schwartlander maintains that in sub-Saharan Africa,
where so many are infected by HIV and ill with AIDS, 66% of HIV/AIDS resources
should be devoted to care and treatment.30
An effective vaccine against HIV would be the ideal preventive measure for
stopping the African AIDS pandemic. Although one potential vaccine is showing
some promise in human tests, experts believe that a broadly effective AIDS vaccine
will not be available for general use for at least a decade.31 Many who are concerned
about the African pandemic favor increased spending on vaccine development,
emphasizing vaccines that work against the varieties of HIV found in Africa. The
International AIDS Vaccine Initiative (IAVI), which seeks to accelerate vaccine
development with the support of numerous foundations and development agencies,
estimates that $430 million to $470 million is currently being spent per year on HIV
vaccine research and development worldwide,32 and has appealed for an additional
$1.1 billion.33 The World Health Organization has endorsed the creation of a Global
Health Research Fund to support research of all types in order to assure that medical
advances now taking place in the developed countries also benefit the developing
countries, including those in Africa.34
Marcoeconomics and Health: 52.
Lamptey and Gayle in HIV/AIDS Prevention and Care: 688-689.
In Asia, by contrast, where the epidemic is still emerging, 32% of resources should go
toward care and treatment and 68% toward prevention. Schwartlander, 2434.
Associated Press, “AIDS Vaccine Likely Still a Decade Off, Doctor Says,” March 16,
2002. This article cited Dr. Anthony Fauci, director of the National Institute of Allergy and
Infectious Diseases at the National Institutes of Health.
International AIDS Vaccine Initiative, “Delivering an AIDS Vaccine,” briefing document
prepared for the World Economic Forum, January 2002. Available at [http://www.iavi.org].
IAVI briefing paper, July 21, 2001.
WHO press release, April 30, 2002, at [http://www.who.org].
A microbicide gel or cream that would kill the HIV virus is another means of
prevention long sought by those fighting the African AIDS pandemic. Women in
Africa, many experts argue, often lack the power to negotiate the use of condoms
with their partners, even though condoms are highly effective in preventing HIV
infection. A microbicide, experts maintain, would be more under a woman’s control,
and could afford African women the means of protecting themselves against the
virus. Several microbicides are currently being studied and advocates maintain that
with increased spending by governments and foundations a microbicide product
could be ready by 2007. Advocates seek $100 million annually in U.S. government
support, as compared to the $49 million they estimate is currently being spent.35
In the absence of a vaccine or microbicide, a number of other strategies have
been used in an effort to prevent the spread of HIV in Africa, and advocates of
scaling up hope to see them all expanded. The importance of voluntary counseling
and testing (VCT) in achieving behavior change has already been noted. Those
testing positive for HIV in VCT programs are counseled on how they can prevent
spreading the infection, and the majority, who test negative, are advised on the means
of avoiding infection. Uganda reports considerable success with a behavior
modification program known as “ABC” (Abstain, Be faithful, or wear a Condom),
which focuses on sexual abstinence before marriage and fidelity within marriage.36
Other prevention “interventions,” as they are known to health experts, include mass
media campaigns, AIDS education in schools, making condoms widely available,
treatment of sexually transmitted infections that increase susceptibility to HIV
infection, the screening of blood used for transfusions, and peer counseling among
There is also growing support for scaling up the MTCT prevention of HIV by
providing ARVs to pregnant mothers. It is estimated that in 2000, approximately
486,000 African babies were born infected through mother to child transmission,38
but treatment of mothers with antiretrovirals could reduce MTCT by one-third to
one-half.39 In July 2000, the German pharmaceutical manufacturer Boehringer
Ingelheim announced that it would offer the ARV Nevirapine free of charge for five
years in developing countries for the prevention of MTCT. However, as noted above,
experts believe that scaling up MTCT prevention will require substantial
improvements in health care services in many countries. The Global AIDS and
Tuberculosis Relief Act of 2000, in Section 111, requires that not less than 8.3% of
the funds it authorizes be devoted to MTCT prevention strategies.
News report at the IAVI website, [http://www.iavi.org], February 28, 2002.
New Republic, May 27, 2002.
For an in-depth review of prevention strategies, see USAID’s HIV/AIDS Prevention and
Care in Resource Poor Settings.
Based on data appearing in “Transmission de VIH de la Mère à l’Enfant,” UNAIDS fact
sheet at [http://www.unaids.org].
HIV/AIDS Prevention and Care in Resource-Constrained Settings: 437.
The care dimension of an expanded response to AIDS in Africa includes an
expansion of resources to care for those who are HIV positive or have developed the
AIDS disease, and for those, such as AIDS orphans, who are affected by the epidemic
even though they are not themselves infected. Those found to be HIV positive
through VCT programs need continuous psychosocial and medical support, AIDS
experts maintain, if they are to maintain risk reduction behavior changes and cope
with the stigma associated with infection. Post test support groups made up of
people living with HIV/AIDS exist in several countries and can be helpful,40 but they
have limited capabilities in dealing with employment discrimination or the social
stigma often inflicted upon those known to be HIV positive.
The limitations of Africa’s health care systems mean that HIV-infected people
have limited or no access to treatment for the chronic diarrhea, wasting syndrome,
and opportunistic infections, including tuberculosis, that occur as HIV inflicts
mounting damage on their immune systems. Since July 1998, the World Health
Organization and UNAIDS have recommended prescribing the drug isoniazid,
effective against tuberculosis, to every HIV-positive person in areas where TB is
prevalent.41 The drug Bactrim42 is effective against the most common pneumonia
among HIV/AIDS victims,43 and against bacterial and parasitic infections associated
with HIV infection. Studies indicate that given as a prophylactic, Bactrim can
significantly reduce illness and death in HIV outpatients generally.44 These drugs are
inexpensive by western standards. In 1998, it was estimated that isoniazid as a TB
preventive would costs less than $6 per patient per year,45 while long term treatment
of pneumonia with Bactrim would cost less than $12.46 Nonetheless, such costs are
high in the African context, and such drugs are not widely available.
Pfizer Inc. is making its anti-fungal drug Diflucan (fluconazole) available for
free in the 50 least developed countries most heavily affected by AIDS – countries
that are primarily in Africa. Diflucan can be used to treat cryptococcal meningitis,
a dangerous fungal inflammation that swells the lining of the brain and spinal column
and occurs in 10% of AIDS patients in late stages of the disease. The drug is also
effective against esophageal candidiasis, a painful opportunistic infection reported
See Rachel Baggaley, Ignatius Hawaye, and David Miller, “Counseling, Testing, and
Psychosocial Support,” in HIV/AIDS Prevention and Care in Resource-Constrained
Elizabeth Marum et al., Assessment of Home Based Care Services in Malawi, Umoyo
Network (March 2000).
Trimethoprim-sulfamethoxazole, also known as TMP/SMZ, cotrimoxazole, and Septra.
Pneumocystis carinii (PCP).
CDC Global AIDS Activity: 77.
UNAIDS, Best Practice Materials, Technical update (October 1998).
in 20% to 40% of HIV/AIDS patients. This disease can prevent swallowing in some
patients, leading to physical deterioration.47
Home Based Care. In Africa’s resource-poor environment, home based care
(HBC) rather than care at a health facility is often the only option for meeting the
needs of patients ill with AIDS. Two experts have described the ideal home based
At its best, patients can remain in familiar surroundings with loving family
members during repeated illnesses and die with peace and dignity. Competent
home care staff make regular visits to assess patient needs and ensure appropriate
nursing, medical, psychological and spiritual support – not just for the patient,
but for the entire family. Staff help plan for future needs of children and other
dependents, and the home care visits provide an opportunity for HIV education
and prevention efforts with the family and wider community.
In Africa, however, HBC programs typically lack the means of meeting this standard.
Reports indicate that care-givers, where available, often lack soap, rubber gloves,
simple medications, or other basic elements of nursing; and do not have the training
required to combat depression in their clients or provide advice on preventing the
spread of HIV. HBC programs may not be able to offer supplementary food to the
ill and their families, at a time when household income may have fallen sharply due
to the illness of a parent.48 At its worst, some argue, “home care is a euphemism for
home neglect.”49 A Malawi-based study partly funded by USAID recommends that
donor agencies help HBC programs provide all home-based patients, volunteers, and
health workers, with standardized kits including basic medications and other items
needed for effective HBC.50
Orphans and Vulnerable Children. A report issued in 2000 by the U.S.
Agency for International Development (USAID) put the number of maternal or
double AIDS orphans under 15 years of age and then living in 26 African countries
at 6.5 million.51 The report projected that by 2010, there will be 15 million maternal
and double AIDS orphans in Africa; in southern African countries, where HIV adult
Pfizer Inc. press release, June 6, 2001, at [http://www.pfizer.com].
Marum, Assessment of Home Based Care Services in Malawi. At the time of writing, Dr.
Marum was a technical advisor in the U.S. Centers for Disease Control and Prevention and
USAID, Malawi. The Assessment was funded by USAID and others.
Jackson and Anderson, “Home Care for People with AIDS:” 585.
Marum, Assessment of Home Based Care Services. This report lists the recommended
contents of such kits
USAID, Children on the Brink, 2000 update. Data on paternal orphans due to AIDS were
not available for this study. According to UNAIDS, by 1999, a cumulative total of 12.1
million African children had been orphaned by AIDS. Over time, many of these had grown
to adulthood or died.
infection rates are near or above 20%, 30% of all children will be orphans.52
Maternal, paternal, and double orphans due to all causes will total 40 million in 2010,
according to the report. Orphans face severe disadvantages in securing access to
adequate nutrition, health care, and education, and large numbers become “street
children” in Africa’s cities, where they are highly vulnerable to HIV infection. But
children who are not orphans, or not yet orphans, are also made vulnerable by HIV
when one or both parents become infected. They may be forced to drop out of
school, for example, because school fees can no longer be paid and because they are
needed at home as care givers.
In view of the scale of Africa’s orphan crisis, and the speed with which it is
intensifying, many argue that attempting to respond by expanding institutional care
would be impractical.53 Most advocates of scaling up seem to emphasize programs
to strengthen the capacity of extended families to support orphaned children of
relatives, as well as programs to support community-based organizations helping
orphans.54 With the help of families and the community, it is hoped, orphaned
children will be able to attend school and receive adequate nutrition. Some may even
be able to stay in their homes, with an older child serving as head of the household
supported by relatives or community aides.
An alternative view, however, is that it is unreasonable to expect impoverished
African families and communities to care for large numbers of orphans, particularly
since, in the most heavily affected countries, families and communities are
themselves being shattered by AIDS. Father Angelo D’Agostino, founder of the
Nyumbani Orphanage for HIV positive orphans in Kenya, has testified that the
children in that orphanage attend school and receive necessary medical care and
psychosocial support. This does not occur in a community foster care program, also
sponsored by the orphanage, because the community, in Fr. D’Agostino’s words “is
overstretched in its ability to survive, and soon will be reduced to a level of existence
we cannot imagine.”55
The degree to which an expanded response to Africa’s orphan crisis should
include support for institutions is thus an issue in debate. In congressional testimony,
E. Anne Peterson, USAID’s Assistant Administrator for Global Health, has noted the
high cost of institutional care and the benefits to a child of remaining in a family and
community. According to Peterson, where “circumstances prevent immediate care
within a family, care in an orphanage is best used as a temporary measure until more
Susan Hunter and Susan Parry, “Orphans and Other Vulnerable Children: Approaches to
Care and Protection Programs,” in HIV/AIDS Prevention and Care in Resource-Constrained
UNAIDS, AIDS Epidemic Update, December 2000; “Children and AIDS,” Harvard AIDS
Review (Spring-Summer 2000). Both sources also argue that orphanages create various
problems for children and societies, but others maintain that such institutions can provide
Children on the Brink: 7-9.
Testimony before the House International Relations Committee, April 17, 2002.
appropriate placement or fostering within a family can be arranged.”56 Father
D’Agostino, meanwhile, is launching a “Village of Hope,” where 600 orphans will
live together with 400 elderly people who have lost the adult children they had
expected to support them in their old age. The two generations can mutually support
one another, and the presence of elders is expected to help assure the transmission
of cultural values and traditions. The village, which is to be a self sustaining farm,
has received a pledge of $1 million in support from the U.S. charity Samaritan’s
The Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264) made
orphans a significant priority in the U.S. HIV/AIDS program. According to Section
111 of the Act, not less than 20% of the $300 million in Development Assistance
authorized for HIV/AIDS programs in both FY2001 and FY2002 is to be available
“as part of a multi-donor strategy to address the support and education of orphans in
sub-Saharan Africa, including AIDS orphans.” Section 113 states that the President
shall coordinate the development of the multi-donor orphan strategy.
Cost estimates and the rationale for providing expanded access to treatment of
AIDS with antiretroviral drugs have already been discussed. Cost is less an issue in
providing antiretroviral therapy than two years ago, when a standard triple drug
regimen cost an estimated $10,000. In May 2000, five major pharmaceutical
manufacturers announced their willingness to reduce prices on their patented ARVs
in order to boost treatment access in Africa. Their AIDS medications are now
available in Africa at a fraction of their U.S. prices, and a three-drug combination can
reportedly be prescribed for several hundred dollars per year or somewhat more.57
The Indian pharmaceutical CIPLA, which manufactures generic copies of
patented medications, offers a three drug combination for $350 per year – a cost that
still exceeds per capita income in many African countries, but would sharply reduce
the cost of scaling up. In March 2002, the World Health Organization listed CIPLA
products among the drugs that meet its quality standards for AIDS treatment,
although the move drew criticism from the International Federation of
Pharmaceutical Manufacturers, which questions the quality and service CIPLA can
provide. The Federation maintains that an alleged lack of after sales service by
generic manufacturers could lead to misuse of the drugs and the emergence of drugresistant strains of HIV.58 WHO, however, defends its decision, saying it was made
in accordance with a process approved by international experts.
The need for testing and monitoring of AIDS patients undergoing ARV
treatment also complicates efforts to expand access to the therapy in Africa. AIDS
Michael Waldholz and Rachel Zimmerman, “Bristol-Myers Slashes AIDS Drug Prices –
Company Will Sell Below Cost in Africa,” Asian Wall Street Journal, March 16, 2001.
“Generic AIDS Medicines Win Approval from U.N. Agency – Pharmaceuticals Giants
Criticize Decision,” Wall Street Journal, Europe edition, March 22, 2002.
medications can cause a variety of side effects, and over time, the effectiveness of a
particular combination of drugs against HIV is likely to wane. Thus, patients in
developed countries are continuously monitored through tests requiring laboratories
and equipment that are not widely available in Africa. Some fear that in the absence
of such testing, patient safety may be jeopardized and that treatment failure will go
undetected, allowing drug resistant HIV strains to spread. Advocates of scaling up
hope to see advanced laboratory testing become more widely available in Africa, and
at the same time, they are urging the development of less expensive testing
procedures and equipment. In April 2002, the World Health Organization released
guidelines for treatment that listed a number of alternative approaches to testing and
monitoring in poor countries. For example, white blood cell counts and examination
for the clinical signs of AIDS, rather than more costly tests used in developed
countries, could be substituted to monitor the effectiveness of therapy,59 according
U.S. efforts in support of providing antiretroviral therapy have been limited to
date. Small-scale test projects in Uganda and Cote d’Ivoire, conducted in
cooperation with pharmaceutical manufacturers, are receiving technical support from
the CDC.60 USAID has announced that it will launch four treatment sites in Africa
in 2002, partly in order to explore how treatment can best be provided in the face of
many “challenges,” such as the cost of ARVs and the lack of sufficient laboratories
or trained personnel.61 However, support for treatment is building, and several of the
grants announced in April 2002 by the Global Fund to Fight AIDS, Tuberculosis,
and Malaria, are aimed at strengthening treatment programs. Some of the funds will
be used to purchase drugs. Jim Yong Kim, of Harvard Medical School and an AIDS
advocate, said the Fund grants mark “the first time there has been a commitment that
we shouldn’t let people in Africa die when we had the drugs available to keep them
alive.” Jeffrey Sachs, who recently coordinated a major World Health Organization
study on investing in health care to promote economic development, called the grants
a possible “meaningful startup,” but still “grossly inadequate” in view of the scale of
Donald G. McNeil, Jr., “WHO Moves to Make AIDS Drugs More Accessible to Poor
Worldwide,” New York Times, April 23, 2002.
Uganda Ministry of Health, Preliminary Report, UNAIDS HIV/AIDS Drug Access
Initiative, August 1998-2000; Cote d’Ivoire Ministry of Health, HIV/AIDS Drug Access
Initiative, Preliminary Report Covering the Period August 1998-March 2000.
Testimony of E. Anne Peterson, Assistant Administrator for Global Health, before the
Senate Foreign Relations Committee, February 14, 2002.
Both were quoted in John Donnelly, “World Health Fund Designates $1.6b,” Boston
Globe, April 26, 2002.
Participants in an Enhanced Response
Governments and government agencies in both the donor and recipient countries
seem certain to play a major role in an expanded response to the African AIDS
pandemic. USAID, CDC, and the World Bank, a multilateral organization made up
of governments, are major actors in the struggle against AIDS, and African
governments are increasingly engaged. African heads of state, at their April 2001
meeting in Abuja, Nigeria, issued a Declaration on HIV/AIDS, committing their
governments to allocating at least 15% of government spending to the improvement
of the health sector. Whether this goal will soon be met remains to be seen – most
are currently spending between 4% and 9%;63 but African health ministries, with
donor support, are deepening their involvement in the struggle against AIDS.
The Global Fund is also expected to play a growing role in responding to the
pandemic in the years ahead. To date, nearly $1.9 billion has been contributed to the
Fund, primarily from governments, but also by private organizations. Formally
chartered as a non-governmental organization headquartered in Geneva, Switzerland,
the Fund’s governing board consists of representatives of seven donor nations and
seven developing countries, as well as one each from a “southern” non-governmental
organization (NGO), a “northern” NGO, a foundation, and the private sector. The
Fund accepts proposals from “Country Coordination Mechanisms” (CCMs) that also
have a mixed government, NGO, and private sector makeup. The Fund plans to
keep its staff small, and it has established a simplified grants process designed to
speed funds to organizations that are already at work fighting the pandemic.
Some observers worry that the Fund may be too “lean” as an organization to
effectively monitor the projects it supports.64 These observers fear that contributions
to the Fund may dry up if a number of its projects fail and it comes to be seen as an
organization that wastes resources. Supporters of the Fund’s approach note that each
CCM, as part of the application process, is required to develop comprehensive
monitoring plans, making use as much as possible of existing, in-country monitoring
capabilities. Moreover, the work of the Fund is closely integrated with the work of
other donors and international agencies that have a long-established presence in the
countries where grants are being made. These donors and agencies are themselves
monitoring the performance of HIV/AIDS programs and projects, as well as the
performance of the health sector generally in African countries. Thus, many believe
that parallel Global Fund monitoring procedures would be duplicative, and likely to
impose burdensome new reporting requirements on African agencies that are already
weighed down with such requirements.
Based on 1998 data, the most recent available, reported in World Health Organization,
World Health Report, 2001: 160-167. U.S. Government health spending was 16.9% of total
expenditures, according to this source.
“The AIDS Fund Gets Going,” Washington Post editorial, April 29, 2002.
Non-Governmental Organizations and the Private Sector
Non-governmental organizations, including community organizations, faithbased-groups, and the private sector, including U.S.-based non-profits, are also
heavily engaged in efforts to scale up the response to the African AIDS pandemic.
These organizations are valued for their capabilities in delivering assistance to those
in need, providing technical assistance and leadership, developing innovative
responses to the pandemic, and mobilizing resources.
Delivery. Community and faith-based groups in Africa are typically on the
front line in delivering assistance to those affected by HIV/AIDS. They are regarded
as particularly well qualified to do so because of their close and regular contact with
their communities, and their knowledge of community needs.65 Speaking of faithbased organizations, Dr. Paul De Lay, Acting Director of USAID’s Office of
HIV/AIDS, has said that “We have increasingly recognized how important religion
is, not only in the care and support of people who are affected by AIDS, but also in
our ability to prevent new infections.” USAID has launched a program known as the
CORE (Communities Responding to the HIV/AIDS Epidemic) Initiative to make
small grants to faith-based and community-based organizations on the front lines of
the AIDS struggle.
Community and faith-based groups have taken on major responsibilities for
AIDS orphan care and for caring for children infected by HIV. In Johannesburg,
South Africa, for example, Sparrow Ministries, an inter-denominational organization,
has been providing hospice care for small numbers of HIV-infected adults and
children for some years, and is building a new facility that will accommodate 450 in
a village-like environment. Many other faith-based and volunteer groups are
assisting orphans in South Africa.
In Kenya, the Nyumbani orphanage, mentioned previously, shelters abandoned
children until their HIV status can be determined. Those found not to be infected are
placed in appropriate settings outside the orphanage, while the HIV positive children
remain and receive care.66 The home, where 70 to 79 children live, has begun to
provide antiretroviral treatment, using drugs donated by Brazil. Meanwhile, faithbased groups have created numerous orphan-care projects in Uganda as well.
Faith-based and community groups are providing home based care in several
African countries. In Zimbabwe, for example, the Mashambanzou (“dawn of a new
day”) organization, headed by medical missionary Sister Margaret McAllen, employs
60 staff and 450 volunteers. In 2001, Mashambanzou reportedly cared for nearly
9,000 patients in their homes and 12,000 in community centers.67 In Uganda, TASO
(The AIDS Support Organization), founded by people living with HIV and AIDS,
Peter Okaalet, “The Role of Faith-based Organizations in the Fight Against HIV and
AIDS,” testimony before the Senate Foreign Relations Committee, February 13, 2002.
See the website [http://www.nyumbani.org].
Isabelle Ligner, “Finding Hope in Harare for People with AIDS.” Agence France Presse,
March 28, 2002.
reports that it has provided care to 60,000 people since the epidemic began. TASO
is also known for its prevention services, and for its AIDS advocacy, both in Uganda
and at the international level. Groups with experience in providing care could
become major actors in future efforts to provide antiretroviral drugs on a large scale
in Africa, since patients will need to be monitored for adverse reactions and to assure
that they are taking their medications as prescribed. Church-run clinics and hospitals,
which reportedly account for 30% or more of the hospital beds in some countries,68
will likely also be heavily involved in efforts to scale up care and treatment in Africa.
Technical Assistance. U.S. based contractors, including non-profits, are
heavily involved in the struggle against AIDS in Africa, where they are providing
technical assistance to health ministries, training, and management support. In April
2002, USAID announced that it was awarding $162 million over five years to Family
Health International, the reproductive health non-profit mentioned above.69 This
award marked the continuation of a relationship that began in 1997, when USAID
funded FHI’s Implementing AIDS Prevention and Care (IMPACT) project, which
according to FHI, “builds the capacity of local governments and non-governmental
organizations to design, manage, and evaluate HIV/AIDS prevention and care
projects in more than 30 countries worldwide.”70 The international division of John
Snow, Inc., a research and health care consulting firm, is helping to manage and
implement the USAID-funded Zambia Integrated Health Package (ZIHP), which
involves working with communities, the private sector, and health workers to
strengthen the quality and availability of health services. The Johns Hopkins
University and Population Services International (PSI) are also participating in this
project. PSI is known for its work in promoting “condom social marketing,” which
makes condoms widely available through local markets and other key outlets,
including bars, at prices low income buyers can afford.71 PSI is also helping several
African countries implement voluntary counseling and testing programs.
Leadership. Africa’s churches have sometimes been criticized for moving
too slowly in response to the AIDS threat,72 but today, some churches and church
leaders are increasingly outspoken as leaders on AIDS issues. Anglican Archbishop
Njongonkulu Ndungane, who chaired a four-day conference of Anglican leaders on
HIV/AIDS in August 2001, has urged African governments to declare an AIDS state
of emergency.73 Ndungane has asked Anglican clergy and lay leaders to be tested
for HIV as a model to others, and demanded in strongest terms that the South African
government provide MTCT prevention therapy to impoverished pregnant women.
Meanwhile, the ecumenical “Religious Coalition for Reproductive Choice” is
Okaalet testimony, cited above.
USAID press release, April 3, 2002.
IMPACT project description at [http://www.fhi.org].
More information is available at [http://www.psi.org].
Zambia’s former president, Kenneth Kaunda, recently told a major ecumenical meeting
in Lusaka that the church response to date had been “inadequate.” The Post (Zambia),
March 15, 2002.
Anglican Journal, October 2001.
assisting South African churches in efforts to reduce teenage pregnancy.74 In
Uganda, Muslim, Catholic, and Anglican organizations and volunteers have been
credited with helping to lead Ugandans toward the behavior changes that have
sharply cut HIV infection rates.75
Many churches and faith-based organizations beyond Africa are taking lead
roles in responding to the pandemic. MAP (Medical Assistance Programs)
International, a Georgia-based Christian organization dedicated to promoting health,
has worked with African churches, clergy, and seminarians to help them show
leadership in responding to AIDS.76 In February 2002, Samaritan’s Purse, which
describes itself as a non-denominational, evangelical Christian assistance
organization, held a week-long conference in Washington intended to inspire
Christians to do more in response to the pandemic worldwide. Entitled “Prescription
for Hope,” the conference focused heavily on the AIDS situation in Africa. The Rev.
Franklin Graham, who heads Samaritan’s Purse, told the meeting that “We need a
new army of men and women who are prepared to go around the world to help in this
Other non-governmental groups exercising leadership roles in responding to the
pandemic include Doctors Without Borders which is a key advocate for expanding
access to AIDS treatment in Africa, and the Global Business Council on HIV/AIDS,
headed by the former U.S. Ambassador to the United Nations, Richard Holbrooke.
The Council seeks to increase business involvement in fighting HIV/AIDS.
Foundations have also been leaders in organizing the response to the pandemic.
The Bill and Melinda Gates Foundation has given grants in support of AIDS
prevention, assistance to orphans, and care that directly benefit Africa; and the
foundation backs vaccine development and microbicide development as well. The
Rockefeller Foundation is a major backer of microbicide development, and in April
2001, sponsored a major conference in Uganda on enhancing AIDS care in Africa.
Innovation. Non-governmental organizations have been responsible for many
innovations in HIV/AIDS prevention and care, and some are developing new
approaches to treatment. The Clinique Bon Sauveur project, though located in
Cange, Haiti, is thought by some experts to have particular relevance to Africa’s
treatment needs. The project operates under the direction of Dr. Paul Farmer of the
Harvard Medical School, and his medical charity, Partners in Health. It provides
antiretrovirals to about 44 patients using diagnostic and monitoring techniques that
do not require expensive laboratory tests. Local workers are trained in a strategy
known as “directly observed therapy,” long used in tuberculosis treatment, and
maintain continuous contact with patients to be sure the “cocktail” of AIDS drugs is
taken as prescribed. Some experts see the Clinique Bon Sauveur approach as a
The Christian Century, February 13, 2002.
Okaalet testimony, cited above.
Okaalet testimony. See also [http://www.map.org].
Caryle Murphy, “‘Army’ of Christians Needed in AIDS Fight, Evangelist Says.” The
Washington Post, February 19, 2002.
means of quickly scaling up treatment in Africa, though others worry about the risks
of treating large numbers of patients without regular laboratory testing.
Some private companies operating in Africa have developed innovative
approaches to AIDS prevention and treatment. Debswana, the diamond mining
company in Botswana, has developed a comprehensive program of AIDS prevention
education for its employees and provides antiretroviral therapy for those infected
with HIV – about 29% of its 6,000 person workforce.78 Debswana also requires that
all companies doing business with it also have comprehensive AIDS in the workplace
programs. In South Africa, Daimler Chrysler has launched a comprehensive AIDS
program for its employees and will also provide antiretroviral therapy. While these
innovative AIDS in the workplace programs could serve as models to other
employers in Africa, many might require assistance in order to create something
comparable. Such assistance, some might argue, could be part of a scaled up
international response to the pandemic.
Botswana is the site of a “public-private” partnership that has drawn
considerable attention. Merck and Company and the Bill and Melinda Gates
Foundation, each of which has contributed $50 million, have joined with the
Botswana government in a five-year effort to strengthen Botswana’s primary health
care system, and eventually provide universal treatment for AIDS patients needing
antiretroviral therapy. Replicating the Botswana model elsewhere, however, would
be problematic unless substantial new resources become available for fighting AIDS.
Botswana is a resource-rich country with a population of just 1.6 million. Other
heavily affected countries are poorer and must deal with an AIDS threat to much
larger vulnerable populations.
The pharmaceutical firm Bristol Myers Squibb has committed $115 million to
its own AIDS initiative, “Secure the Future.” According to Bristol Myers, it works
with African governments and communities under this initiative to develop
“innovative ways to prevent and treat HIV/AIDS among women and children, and
to help communities deal with the crisis.”79 More than fifty grants have been made
under this program, including a recent one to the University of Natal in South Africa
for research on protecting HIV positive mothers and children from opportunistic
infections, such as pneumonia.80
U.S. AIDS Policy Making and Coordination
As the U.S. response to the global AIDS pandemic has expanded, efforts have
been made to enhance policy making capabilities in the AIDS issue area, and to
enhance coordination among the agencies involved. President Bush has named
Secretary of State Colin Powell and Tommy Thompson, Secretary of Health and
Ed Susman, “Diamond Company Battles AIDS in Botswana,” UPI Science News, July 9,
Press release, March 14, 2001.
Africa New Service, February 17, 2002.
Human Services, as co-chairs of a Cabinet-level task force on the global HIV/AIDS
threat. This cabinet-level task force is backed up by an interagency policy
coordinating committee (PCC), chaired by Scott Evertz, who heads the White House
Office of National AIDS Policy (ONAP), and Jendayi Frazer, Senior Director for
African Affairs at the National Security Council.
Within the PCC, an interagency working group has focused on the negotiations
surrounding the launching of the Global Fund. This group is chaired by Dr. Jack C.
Chow, Deputy Assistant Secretary of State for Health and Science, and William R.
Steiger, Special Assistant to the HHS Secretary for International Affairs. Dr. Chow
serves in the Bureau of Oceans and International Environmental and Scientific
Affairs, which falls under the authority of Paula Dobriansky, Under Secretary of State
for Global Affairs. In addition, he has been named Special Representative of the
Secretary of State for HIV/AIDS with the rank of Ambassador, subject to Senate
Meanwhile, USAID and HHS are re-organizing internally with the goal of
dealing more effectively with the HIV/AIDS epidemic. USAID’s HIV/AIDS
Division is becoming the HIV/AIDS Office in a new USAID Global Health Bureau.
Technical staff who have been involved in implementing HIV/AIDS programs in
USAID’s regional bureaus are being moved into the HIV/AIDS Office. At HHS,
Steiger has been named Director of a new Office of Global Health Affairs. In this
position, his current responsibilities with respect to the PCC continue. At the same
time, what had been known as the Office of International and Refugee Health
(OIRH), based in Rockville, Maryland, has been subsumed by the new office and
brought under Steiger’s authority. Like OIRH, the new office offers technical
assistance and policy advice in fighting global HIV/AIDS within HHS and to other
agencies, including USAID, the Office of the U.S. Trade Representative, and the
Departments of State, Labor, and Defense.
Despite these changes, concerns over HIV/AIDS policy making and
coordination continue. Some worry that there is no single point person responsible
for leading the U.S. response to the global epidemic, a role that, in their view, was
filled during the Clinton Administration by Sandra Thurman, who directed ONAP
and helped develop that Administration’s enhanced response to the international
epidemic in 1999. While many welcome the involvement of Secretary Powell and
Secretary Thompson in the cabinet-level task force, there is concern that neither
official can focus fully on the AIDS pandemic, particularly in view of new
responsibilities arising from the September 11, 2001 terrorist attacks. Moreover,
Secretary Powell is bearing additional burdens as a result of the Israel-Palestinian
With respect to the reforms within USAID, some worry that Africa could be
affected as AIDS experts with long experience in the Bureau of African Affairs are
transferred to the Global Health Bureau. The reforms at HHS, some argue, fall short
in that they do not integrate the Health Resources and Services Administration
(HRSA) into the making of international AIDS policy. From their perspective,
HRSA, which has long experience in developing and implementing health initiatives
in poor settings in the United States, ought to be more engaged in the U.S. response
to AIDS in poor countries overseas.81 Some also question whether the activities of
the National Institutes of Health (NIH), including its Office of AIDS Research
(OAR), are adequately integrated with the overall U.S. response to AIDS. OAR
supports more than 175 overseas research projects, and are seen by NIH as
strengthening health infrastructure in developing countries.
Supporters of the Bush Administration’s approach to policy making and
coordination maintain that the Cabinet-level task force, backed up by the PCC,
creates a stronger policy coordination mechanism than in the Clinton Administration.
Moreover, the re-organizations at USAID and HHS, supporters argue, are raising the
priority given HIV/AIDS and other international health issues, while at the same time
bringing together health experts in ways that will promote a more effective and better
coordinated global AIDS response.
Funds for fighting the HIV/AIDS pandemic in Africa through bilateral and
multilateral assistance programs are increasing; and a new international institution,
the Global Fund to Fight AIDS, Tuberculosis, and Malaria has been created to
channel new resources to the struggle. AIDS experts have identified ways of
expanding prevention, care, and treatment programs better to combat the disease, and
governmental agencies, as well as NGOs and faith-based organizations, are
enhancing their capabilities for responding. Nonetheless, the degree to which the
international response to AIDS in Africa will be scaled up remains in question.
Donors face competing demands on their resources, and may be cautious in making
contributions sufficient to fill the funding gap until existing AIDS programs more
clearly demonstrate that they can achieve sustainable results. AIDS activists and
many experts, however, would argue that until the complex array of programs and
projects required to fight AIDS in Africa is significantly enhanced, it will be
impossible to slow the pandemic. In their view, this requires that the funding gap
soon be closed.
In FY2001, HRSA received $3 million from the CDC budget in exchange for technical
Abstain, Be faithful, or wear a Condom. A Ugandan prevention
Acquired immuno-deficiency syndrome, the AIDS disease.
A Country Coordination Mechanism, eligible to apply to the
Centers for Disease Control and Prevention of HHS.
Communities Responding to the HIV/AIDS Epidemic Initiative,
A USAID program.
Department of Defense.
Department of Labor.
Expanded and Comprehensive HIV/AIDS Response.
Directly Observed Treatment Short Course for TB.
Group of Seven leading industrial nations plus Russia.
Global AIDS Program of the CDC.
Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Highly-active anti-retroviral therapy, usually consisting of three
Department of Health and Human Services.
Heavily-indebted poor country; also the initiative aimed at reducing
the debt of these countries.
Human immuno-deficiency virus, the cause of AIDS.
International AIDS Vaccine Initiative.
Income Generating Activity.
World Bank’s Multi-Country HIV/AIDS Program for Africa.
Mother to child transmission of HIV.
Organization for Economic Cooperation and Development, an
international organization of developed countries.
Office of National AIDS Policy at the White House.
Policy Coordinating Committee.
People Living with AIDS, sometimes PLWHA: People Living with
Private and voluntary organizations.
Joint United Nations Project on HIV/AIDS, consisting of seven U.N.
United Nations Economic Commission for Africa, headquartered in
Addis Ababa, Ethiopia.
United Nations General Assembly Special Session on HIV/AIDS
U.S. Agency for International Development.
World Health Organization.
Voluntary counseling and testing for HIV infection.
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