IB10050: AIDS in Africa

Raymond W. Copson

Foreign Affairs, Defense, and Trade Division

May 14, 2001

CONTENTS

• SUMMARY
• MOST RECENT DEVELOPMENTS
• BACKGROUND AND ANALYSIS
• Characteristics of the African Epidemic
• Explaining the African Epidemic
• Social and Economic Consequences
• Responses to the AIDS Epidemic
• Effectiveness of the Response
• AIDS Treatment Issues
• U.S. Policy
• Bush Administration
• Legislative Action in 2000
• LEGISLATION

SUMMARY

Sub-Saharan Africa has been far more severely affected by AIDS than any other part of the world. The United Nations reports that 25.3 million adults and children are infected with the HIV virus in the region, which has about 10% of the world's population but more than 70% of the worldwide total of infected people. The overall rate of infection among adults in sub-Saharan Africa is about 8.8%, compared with a 1.1% infection rate worldwide. Sixteen countries, mostly in eastern and southern Africa, have HIV infection rates of more than 10%, and the rate has reached 35.8% in Botswana. An estimated 17 million Africans have lost their lives to AIDS, including 2.4 million who died in 2000. AIDS has surpassed malaria as the leading cause of death in Africa, and it kills many times more Africans than war. In Africa, HIV is spread primarily by heterosexual contact, and sub-Saharan Africa is the only region of the world where women are infected at a higher rate than men.

Experts relate the severity of the African AIDS epidemic to the region's poverty. Health systems are ill-equipped for prevention, diagnosis, and treatment. Poverty forces many men to become migrant workers in urban areas, where they may have multiple sex partners; and poverty leads many women to become commercial sex workers, vastly increasing their risk of infection. Cultural and behavior patterns, such as low rates of male circumcision in some countries, may also play a role.

AIDS is having severe social and economic consequences, depriving Africa of skilled workers and teachers, while reducing life expectancy by decades in some countries. There are currently an estimated 6.5 million "AIDS orphans," who face increased risk of malnutrition and reduced prospects for education. AIDS orphans are expected to number more than 15 million by 2010. AIDS is being blamed for declines in agricultural output in some countries.

Donor governments, non-governmental organizations, and African governments have responded primarily by attempting to reduce the number of new HIV infections, and by trying ameliorate the damage done by AIDS to families, societies, and economies. The adequacy of this response is the subject of much debate. Spending from all sources on HIV/AIDS in sub-Saharan Africa was estimated at $500 million for FY2000.

Treatment of AIDS sufferers with medicines that can result in long-term survival - has not been widely used in Africa. Advocates of treatment argue that in view of recent drug price reductions, treatment is an affordable means of reducing AIDS damage to African economies and of keeping parents alive. Skeptics argue that treatment is still too expensive to be an option for most Africans and would require costly improvements in Africa's health infrastructure.

U.S. concern over AIDS in Africa grew during the 1980s, as the severity of the epidemic became apparent. According to the U.S. Agency for International Development, the United States has been the global leader in the international response to AIDS since 1986.

Legislation enacted during the 106^th Congress increased HIV/AIDS funding worldwide and supported several Africa AIDS initiatives. On May 11, 2001, President Bush pledged $200 million to a new global AIDS, malaria, and tuberculosis fund.

MOST RECENT DEVELOPMENTS

On May 11, 2001, President Bush announced that the United States would make a "founding contribution" of $200 million to a new Global Fund dedicated to fighting HIV/AIDS , malaria, and tuberculosis. Additional funding would follow, the President said, "as we learn where our support can be most effective." The Global Fund would be open to contributions by the private sector, including faith-based organizations, and would respect intellectual property rights, according to the President. U.N. Secretary General Kofi Annan and Nigerian President Olusegun Obasanjo, who attended the announcement, praised the U.S. pledge as the first step toward a multi-billion dollar international fund and urged the creation of what Annan called a "war chest" of $7 billion to $10 billion to fight AIDS. African heads of state, meeting in Abuja, Nigeria, issued a statement on April 27 declaring AIDS a continental emergency, pledging to spend 15% of their annual budgets on health and urging donors to create a $5 billion to $10 billion Global AIDS Fund.

BACKGROUND AND ANALYSIS

Sub-Saharan Africa has been far more severely affected by AIDS than any other part of the world. According to a December 1, 2000 report issued by the Joint United Nations Program on HIV/AIDS (UNAIDS), some 25.3 million adults and children are infected with the HIV virus in the region, which has about 10% of the world's population but more than 70% of the worldwide total of infected people. The overall rate of infection among adults in sub-Saharan Africa is about 8.8%, compared with 1.1% worldwide. UNAIDS projects that half or more of all 15 year-olds will eventually die of AIDS in some of the worst-affected countries, such as Zambia, South Africa, and Botswana, unless the risk of contracting the disease is sharply reduced. An estimated 17 million Africans have lost their lives to AIDS, and mortality is rising - 2.4 million Africans died of AIDS in 2000, compared with 2.2 million in 1999. AIDS has surpassed malaria as the leading cause of death in sub-Saharan Africa, and it kills many times more people than Africa's armed conflicts.

Characteristics of the African Epidemic

In addition to its severity, the sub-Saharan AIDS epidemic is defined by a number of other unusual characteristics.

• HIV, the human immunodeficiency virus that causes AIDS, is spread in Africa primarily by heterosexual contact, although intravenous drug use is becoming a significant means of transmission in some urban areas.

• Sub-Saharan Africa is the only region in which women are infected with HIV at a higher rate than men. According to UNAIDS, women make up an estimated 53% of the HIV-positive adult population in sub-Saharan Africa, as compared with 37% in the Caribbean, the next highest-ranking region, and 20% in North America.

• Young women are particularly at risk. A U.N. study found girls aged 15-19 to be infected at a rate of 15% to 23%, while infection rates among boys of the same age were 3% to 4%.

• To date, eastern and southern Africa have been far more severely affected than West Africa, but infection rates in a number of West African countries are starting to escalate. In some southern African countries, 20% or more of the adult population is infected with HIV, and the rate has reached 35.8% in Botswana. On March 20, 2001, the South African government released statistics showing that 4.7 million South Africans, including 24.5% of adults, were infected with HIV/AIDS in 2000 - up from 22.4% in 1999. In West Africa, Senegal, with an active AIDS policy, had an adult infection rate below 2% in 1999, but the infection rate now exceeds 10% in Ivory Coast and is increasing in populous Nigeria as well.

• The African AIDS epidemic is having a much greater impact on children than is the case in other parts of the world. An estimated 600,000 African infants become infected with HIV each year through mother-to-child transmission, either at birth or through breast-feeding. (White House, Report on the Presidential Mission on Children Orphaned by AIDS in Sub-Saharan Africa: Findings and Plan of Action. Washington, July 19, 1999, p. 14.) These children have a short life expectancy, and the number of HIV-infected children currently alive in the region is currently estimated at 1 million (UNAIDS).

• A cumulative total of 12.1 million African children have lost either their mother or both parents to AIDS, according to UNAIDS, and thus are regarded as "AIDS orphans." A recent report by the U.S. Agency for International Development (USAID) puts the number of such orphans currently living in 26 African countries at 6.5 million, and projects that by 2010, there will be 15 million African AIDS orphans, including 2.7 million in Nigeria, 2.5 million in Ethiopia, and 1.8 million in South Africa. (Children on the Brink, 2000 update.) Because of the stigma attached to the AIDS disease, AIDS orphans generally run a greater risk of being malnourished and abused and of being denied an education.

Explaining the African Epidemic

AIDS experts emphasize a variety of economic and social factors in explaining Africa's AIDS epidemic, placing primary blame on the region's poverty. Poverty has deprived Africa, for example, 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 are believed to open the way to infection by HIV. African health care systems are typically unable to provide AIDS counseling, which could help slow the spread of the disease, and even HIV testing is difficult for many Africans to obtain. AIDS treatment is generally available only to the elite.

Poverty forces large numbers of African men to migrate long distances in search of work, and while away from home they may have multiple sex partners, increasing their risk of infection. Some of these partners may be women who have become commercial sex workers because of poverty, and they too are highly vulnerable to infection. Migrant workers can become a conduit for spreading the disease from urban to rural areas; when they return home, they commonly infect their wives. Long distance truck drivers and drivers of "taxis," who transport Africans long distances by car, are also believed to be key agents in spreading 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 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.) A researcher in a UNAIDS project studying the differential rate of infection added that "Young (women's) lives are being cut short through sex which is all too often forced, coerced, or 'bought' with sugar-daddy gifts." Many believe that the infection rate among women generally would be far lower if women's rights were more widely respected in Africa and if women exercised more power in political and economic affairs. (For more on these issues, see Carol Ezzell, "Care for a Dying Continent," Scientific American, May 2000.) Other cultural factors may also be playing a role in the African epidemic. Male circumcision, for example, is reportedly more common in West Africa than in eastern and southern Africa, and some scientists are beginning to suspect that this helps to explain the comparatively lower rate of infection in West Africa. (Boston Globe, November 5, 1999; Sunday Times, London, March 26, 2000).

The breakdown in social order and social norms caused by armed conflict could also be contributing to the African epidemic. Conflict, which has afflicted many sub-Saharan countries for years, is typically accompanied by numerous incidents of violence against women, including rape, carried out by soldiers and guerrillas. Such men are also more likely to resort to commercial sex workers than those living in a settled environment.

Some observers believe that the spread of AIDS in Africa could have been slowed if African leaders had been more engaged and outspoken in the struggle against the disease. President Yoweri Museveni of Uganda, in particular, has won wide recognition for leading a successful campaign against AIDS in his country. But many other African leaders have said or done comparatively little about the epidemic. In September 1999, the United Nations convened a major conference on AIDS in Africa in Lusaka, the capital of Zambia, but none of the 15 invited African heads of state attended. Even the host-country president, Frederick Chiluba, claimed a conflict and sent his vice president to read his opening remarks.

President Daniel arap Moi of Kenya, where 13.9% of adults are infected and nearly a million people have died from AIDS, did not endorse the use of condoms as a preventive until December 1999. (Africa News Service, December 23, 1999.) South Africa has a large AIDS program launched by the former president, Nelson Mandela, who continues to speak out in support of preventive measures, but many critics doubt that the current president, Thabo Mbeki, is treating the disease with sufficient urgency. On April 19, 2000, the press reported that he had sent a letter to President Clinton and other heads of state asserting that Africa would not copy foreign approaches to dealing with AIDS and defending dissident scientists who maintain that AIDS is not caused by the HIV virus. Many health experts feared that Mbeki's assertions that poverty was the underlying cause of AIDS, while in some sense partly true, would confuse South Africans, including poor South Africans, and keep them from taking measures that could prevent infection.

On October 15, 2000, Mbeki reportedly told top leaders of the ruling African National Congress that he would withdraw from the debate over HIV/AIDS. But whether the South African government is treating the epidemic with sufficient urgency remains the subject of much debate. On March 14, 2001, President Mbeki rejected appeals in the national assembly that he declare the HIV/AIDS epidemic a national emergency. Such a declaration would have given the government expanded rights to obtain AIDS medications at lower prices under the World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights. (See below, AIDS Treatment Issues.) Meanwhile, South Africa has yet to launch a promised program to treat HIV-positive pregnant women in public hospitals with the drug Nevirapine, which would be provided free by the German firm Boehringer-Ingelheim. Nevirapine is highly effective in preventing mother to child transmission of HIV.

Social and Economic Consequences

AIDS is having severe social and economic consequences in Africa, and these negative effects are expected to continue for many years. A January 2000 Central Intelligence Agency National Intelligence Estimate report on the infectious disease threat, made public in an unclassified version, forecasts grave problems over the next 20 years.

At least some of the hardest-hit countries, initially in sub-Saharan Africa and later in other regions, will face a demographic catastrophe as HIV/AIDS and associated diseases reduce human life expectancy dramatically and kill up to a quarter of their populations over the period of this Estimate. This will further impoverish the poor, and often the middle class, and produce a huge and impoverished orphan cohort unable to cope and vulnerable to exploitation and radicalization. (CIA, The Global Infectious Disease Threat and Its Implications for the United States [ http://www.odci.gov ], "Publications and Reports".)

The estimate predicted increased political instability and slower democratic development as a result of AIDS. According to the World Bank,

The illness and impending death of up to 25% of all adults in some countries will have an enormous impact on national productivity and earnings. Labor productivity is likely to drop, the benefits of education will be lost, and resources that would have been used for investments will be used for health care, orphan care, and funerals. Savings rates will decline, and the loss of human capital will affect production and the quality of life for years to come. (World Bank, Intensifying Action Against HIV/AIDS in Africa.)

USAID estimates that Kenya's GNP will be 14.4% smaller in 2005 than it would have been without AIDS. The disease is expected to hinder growth prospects in South Africa, Tanzania, Namibia, and other countries in eastern and southern Africa as well. (Report on the Presidential Mission on Children Orphaned by AIDS.)

In the most severely affected countries, sharp drops in life expectancy are occurring, and these will reverse major gains achieved in recent decades. At AIDS2000, the July 2000 international AIDS conference held in Durban, South Africa, Karen Stanecki of the U.S. Census Bureau reported that AIDS had cut life expectancy in Botswana from 71 years to 39 and in Zimbabwe from 70 years to 38. Stanecki predicted that South Africa, Zimbabwe, and Botswana will begin to experience negative population growth in 2003, and that by 2010, life expectancy at birth will have fallen to about 30 years throughout southern Africa due to AIDS.

According to many reports, AIDS has devastating effects on rural families. The father is typically the first to fall ill, and when this occurs, farm tools and animals may be sold to pay for his care. As he grows weaker, he will become unable to farm at all; nor will his wife be able to farm, since she will be devoting her time to nursing him. The family will be unable to pay school fees, and in any event, children will likely be kept out of school to perform added chores at home. Should the mother also become ill, children may be forced to shoulder responsibility for the full time care of their parents, particularly since rural clinics in some countries are reportedly short-staffed because of AIDS.

The economic consequences of the disruption of rural life can be severe. For example, sharp declines in the production of maize, cotton, and other crops in Zimbabwe have been blamed on widespread illness and death from AIDS among peasant farmers and among workers at small commercial farms. (Washington Post, December 12, 1999). A decline in agricultural activity in Kenya has also been attributed to AIDS.

AIDS is also being blamed for shortages of skilled workers and teachers in several countries. Although unemployment is generally high in Africa, such trained personnel are not readily replaced. Teachers are reportedly dying more rapidly than replacements can be found in parts of western Kenya. In Ivory Coast, five teachers reportedly die from AIDS during each week of the school year. According to USAID, the Ministry of Education in Zambia found that 1,300 teachers had died in 1999, mostly from AIDS, and that only 700 new teachers were trained. AIDS is believed responsible for high rates of absenteeism and labor turnover in eastern and southern Africa, and the resulting increased costs are believed to be discouraging new investment. The disease is also claiming many lives at middle and upper levels of management in both business and government.

AIDS may have serious security consequences for much of Africa, since HIV infection rates in many armies are extremely high. South African soldiers have been widely expected to play an important peacekeeping role in the Democratic Republic of the Congo (DRC, formerly Zaire) and perhaps other countries in coming months and years, but the infection rate in the South Africa army is 40% according to one insurance company survey (Mail and Guardian (Johannesburg), October 19, 1999), and other estimates are higher. Infection rates among the seven armies currently embroiled in the conflict in the DRC have been estimated at 50% to 80%. (Report on the Presidential Mission on Children Orphaned by AIDS.) The ability of such armies to conduct effective operations and behave professionally is a source of concern to analysts. Domestic political stability could also be threatened in African countries if the security forces become unable to perform their duties due to AIDS. (For more on this issue, see the CIA Estimate, noted above.)

Responses to the AIDS Epidemic

Donor governments, non-governmental organizations (NGOs) working in Africa, and African governments have responded to the AIDS epidemic primarily by attempting to reduce the number of new HIV infections, and to some degree, by trying ameliorate the damage done by AIDS to families, societies, and economies. A third possible response - treatment of AIDS sufferers with medicines that can result in long-term survival - has not been widely used in Africa, largely due to cost and the lack of effective health care infrastructure. However, demands for large-scale treatment are mounting in Africa, and are drawing support from outside the continent among AIDS activists and others concerned for the region's future. There is also growing support for expanded programs to treat opportunistic infections (OIs), such as tuberculosis, which can shorten the lives of HIV victims by years but can be treated or prevented by comparatively inexpensive drugs. An effective vaccine could offer a permanent solution to the African AIDS crisis, but progress in vaccine development has been slow. (For more information on the international response to the epidcmic, see CRS Report RL30883 (pdf), Africa: Scaling Up the Response to the HIV/AIDS Pandemic.)

Efforts to reduce the number of AIDS infections have focused on increasing AIDS awareness among Africans. Programs and projects aimed at combating the disease typically provide information on how the disease is spread - and on how it can be avoided - through the media, posters, lectures, and skits. Donor-sponsored voluntary counseling and testing (VCT) programs, where available, enable African men and women to learn their HIV status. Those testing positive are typically referred to support groups and advised on ways to protect others from contracting the disease; while the majority testing negative are counseled on behavior changes that will keep them HIV-free. USAID is currently supporting VCT centers in 10 African countries. AIDS awareness programs can be found in many African schools and increasingly in the workplace, where employers are recognizing their interest in reducing the infection rate among their employees. Many projects aim at making condoms readily available - USAID reports that it has shipped more than 2 billion condoms to Africa since 1986 - and on providing instruction in condom use. Some recent pilot projects have had success in reducing mother-to-child transmission by administering the anti-HIV drug AZT, or a less expensive medicine, nevirapine, during birth and early childhood.

Church groups and humanitarian organizations have helped Africa deal with the consequences of AIDS by setting up programs to provide care and education to orphans. The Farm Orphan Support Trust in Zimbabwe tries to keep sibling orphans together and in a family living situation; the Salvation Army sponsors a pilot, community-based, orphan support program in Zambia, providing education and health care to vulnerable children. (Report on the Presidential Mission on Children Orphaned by AIDS.) A United Nations study has found that community-based organizations, sometimes with the support of NGOs, have emerged to supply additional labor, home care for the sick, house repair, and other services to AIDS-afflicted families. (UNAIDS, A Review of Household and Community Responses to the HIV/AIDS Epidemic in Rural Areas of Sub-Saharan Africa, 1999.)

Public-private partnerships have also become an important vehicle for responding to the African AIDS pandemic. The Bill and Melinda Gates Foundation has been a major supporter of vaccine research and a variety of AIDS programs undertaken in cooperation with African governments and donors. The Rockefeller Foundation, working with UNAIDS and others, has sponsored programs to improve AIDS care in Africa, and both Bristol-Myers Squibb and Merck and Company have undertaken programs with the Botswana government aimed at improving the country's health infrastructure.

Donors have made several recent pledges to scale up the international response to the AIDS epidemic. On July 23, 2000, leaders at the G-8 world economic summit in Okinawa pledged to reduce the number of young people infected by the HIV virus by 25%. The World Health Organization estimated that this pledge, and G-8 pledges to attack malaria and tuberculosis as well, would cost at least $5 billion per year for 5 years. On July 20, Peter Piot, executive director of the Joint United Nations Project on HIV/AIDS (UNAIDS) had told the G-8 that a minimum of $3 billion per year was needed to combat AIDS in Africa, while a tenth of that amount was currently being spent. The World Bank, on September 12, 2000, made an initial commitment of $500 million to a Multi-Country HIV/AIDS Program (MAP) for Africa. The MAP, designed to be both flexible and rapidly disbursing, according to the Bank, will help fund HIV/AIDS prevention, care, and treatment programs in countries that have developed a strategic approach to combating the epidemic and that met certain other conditions.

U.N. Secretary General Kofi Annan officially launched the International Partnership Against AIDS on December 7, 2000, at a meeting of the U.N.-convened African Development Forum in Addis Ababa, Ethiopia. The Partnership, which is to bring together African governments with donors, community organizations, and the private sector, will focus on reducing the number of new infections and promoting care for AIDS victims.

Further information on the response to AIDS in Africa may be found at the following web sites:

CDC: [ http://www.cdc.gov/nchstp/od/nchstp.html   ]

European Union: [ http://europa.eu.int/comm/development/aids/ ]

International AIDS Vaccine Initiative: [ http://www.iavi.org ]

International Association of Physicians in AIDS Care: [ http://www.iapac.org/  ]

Journal of the American Medical Association HIV/AIDS Information Center:

[ http://www.ama-assn.org/special/hiv/ ]

Kaiser Daily HIV/AIDS Report: [ http://report.kff.org/aidshiv/ ]

UNAIDS: [ http://www.unaids.org/   ]

USAID: [ http://www.info.usaid.gov/pop_health/aids/aidshome.htm   ]

World Bank: [ http://www.worldbank.org/html/extdr/thematic.htm ].

Effectiveness of the Response

The response to AIDS in Africa has had some successes, most notably in Senegal, mentioned above, and in Uganda, where the rate of infection has been cut in half - to approximately 9.5% - by an active AIDS awareness program that openly advocates the use of condoms. Despite these success stories, however, available evidence indicates that the epidemic is deepening in most of the region. Even the head of the Ugandan AIDS program is worried that Ugandans may let down their guard with respect to the disease, (Africa News Service, December 10, 1999). In the West African nation of Nigeria, Africa's most populous country with 111 million people, the rate of adult HIV infection increased from 4.5% in 1995 to 5.4% in 1999, adding to a large pool of infected people who could be a source of a much more rapid increase in coming years.

A United Nations update on the AIDS epidemic, issued on December 1, 2000, estimated that there had been 3.8 million new HIV infections in Africa in 2000 as compared to 4 million in 1999 and suggested that the decrease could in part reflect the success of prevention programs in some countries. The report also noted, however, that the decline in new infections could have resulted partly from the fact that many of the most vulnerable, sexually active people had already been infected in prior years. In any event, citing Nigeria, the report warned that the epidemic could still take off in countries with comparatively low infection rates.

Experts note that there are a number of barriers to a more effective AIDS response in Africa, such as cultural norms that make it difficult for many government, religious, and community leaders to acknowledge or discuss sexual matters, including sex practices, prostitution, and the use of condoms. However, experts continue to advocate AIDS awareness and AIDS amelioration as essential components of the response to the epidemic. Indeed, there is strong support for an intensification of awareness and amelioration efforts, as well as adaptations to make such efforts more effective.

A World Bank report, among other proposals, recommends that the Bank create teams of well-known African elders, former statesmen, friends of Africa, and celebrities who would visit afflicted countries to help mobilize civil society against the epidemic. (Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis.) With respect to amelioration, UNAIDS has recommended that donors find ways to strengthen those indigenous support institutions that are already helping AIDS victims and their families. (A Review of Household and Community Responses.) There is also support for a stronger focus on treatment of non-HIV sexually-transmitted infections, which can dramatically lower the rate of HIV transmission.

The lives of infected people could be significantly prolonged and improved, some maintain, if more were done to identify and treat the opportunistic infections, particularly tuberculosis, that typically accompany AIDS. Millions of Africans suffer dual infections of HIV and TB, and the combined infection dramatically shortens life. Tuberculosis can be cured by treatment with a combination of medications over several months, even in HIV-infected patients. However, according to the World Health Organization, Africans often delay seeking treatment for TB or do not complete the course of medication (Global Tuberculosis Control: WHO Report 1999, Key Findings), contributing to the high incidence of death among those with dual infections. Pfizer Corporation announced on December 1, 2000, that it had signed an agreement with South Africa to donate the anti-fungal Diflucan (fluconazole) for treating AIDS-related opportunistic infections, including cryptococcal meningitis, a dangerous brain inflammation. UNAIDS and the World Health organization recommended on April 5, 2000, that Africans infected with HIV be treated with an antibiotic/sulfa drug combination known by the trade name Bactrim in order to prevent opportunistic infections. Studies indicate that the drug could reduce AIDS death rates at a cost of between $8 and $17 per year per patient.

USAID estimates that in FY2000, all donors and lending agencies, together with African governments, spent approximately $500 million in combating AIDS. UNAIDS estimates, however, that African countries require about $1.5 billion for HIV/AIDS prevention programs, and another $1.5 billion for HIV/AIDS care, including orphan care. These estimates do not include any funding for AIDS treatment with antiretroviral drugs. (See below, AIDS Treatment Issues.) The funding issue is covered in detail in CRS Report RL30883 (pdf), Africa: Scaling Up the Response to the HIV/AIDS Pandemic.

AIDS Treatment Issues

Access for poor Africans to costly combinations of AIDS medications or "anti-retrovirals" (ARVs) is perhaps the most contentious issue surrounding the response to the African epidemic today. Administered in a treatment regimen known as HAART - highly active antiretroviral therapy - these drugs can return AIDS victims to normal life and lead to long-term survival rather than early death. Such treatment has proven highly effective in developed countries, including the United States, where AIDS, which had been the eighth leading cause of death in 1996 no longer ranked among the 15 leading causes by 1998. (U.S. Department of Health and Human Services Press Release, October 5, 1999.)

Advocates of making HAART widely available in Africa argue that the therapy would keep parents alive, slowing the growth in the number of AIDS orphans; and keep workers, teachers, civil servants, and managers alive as well, thus reducing the economic impact of the epidemic. Some also see a moral obligation to try to save lives when the medications for doing so exist.

The high cost of HAART treatments, however, has been regarded as the principal obstacle to offering the therapy on a large scale in Africa, where most victims are poor and lack health insurance. The cost of administering HAART was once estimated at between $10,000 and $15,000 per person per year. On May 11, 2000, five major pharmaceutical companies announced that they were willing to negotiate sharp reductions in the price of AIDS drugs sold in Africa. Although this offer was widely welcomed, many pointed out that even if the cost could be brought down to $2,000 or $3,000, treatment would still be beyond the means of most Africans. Moreover, experts maintain that providing HAART to large numbers of people in Africa will require major improvements to the region's health infrastructure. Effective HAART requires supply channels that can make the drugs constantly available and regular monitoring of patients, both to deal with side effects and to adjust medications if drug resistance emerges. Many fear that if the drugs are taken irregularly, resistant strains will emerge that could cause untreatable infections worldwide.

By April 2001, pharmaceutical manufacturers had reached agreements with Senegal, Uganda, Rwanda, Cameroon, and Mali for discounts of 60% to 90% in the cost of anti-retroviral drugs in exchange for health infrastructure improvements to assure that ARVs are administered safely. Infrastructure improvements are likely to come slowly, however, and the numbers receiving the drugs are expected to remain small, at least initially. Price reductions offered by pharmaceutical manufacturers in the first months of 2001 for any purchaser in Africa set off speculation on an AIDS drug "price war," particularly since two companies from India are offering copies of patented medications at even lower prices. Analysts again cautioned, however, that HAART will likely remain available to a relatively small number of HIV-infected people who have access to modern health services.

Many also advocate "parallel imports" of drugs and "compulsory licensing" by African governments to lower the price of patented medications. Through parallel importing, patented pharmaceuticals could be purchased from the cheapest source, rather than from the manufacturer; while under "compulsory licensing," an African government could order a local firm to produce a drug and pay a negotiated royalty to the patent holder.

Although both parallel imports and compulsory licensing are permitted under Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS agreement) of the World Trade Organization agreement for countries facing national emergencies, U.S. officials once strongly opposed such measures on grounds that they could lead to infringements of intellectual property rights. Advocates for the pharmaceutical companies argued that parallel importing and compulsory licensing could reduce profits, and that this would hinder the ability of manufacturers to conduct research on new drugs, including drugs that might be even more effective against HIV. A third view has been that some combination of subsidization, price reduction, and local manufacturing might be found that would make the drugs much more widely available while maintaining drug company revenues through the sheer volume of African sales.

On May 10, 2000, President Clinton issued an executive order stating that the United States would not seek to prevent sub-Saharan countries from promoting access to HIV/AIDS pharmaceuticals or medical technologies consistent with the World Trade Organization's TRIPS agreement. On February 22, 2001, an official of the U.S. Trade Representative's office said the Bush Administration was not considering any change in current "flexible policy" on this issue.

In South Africa, a suit by a consortium of pharmaceutical manufacturers against the South African government became a focal point for the debate over the price of AIDS medications in poor countries in the first months of 2001. The suit was directed against the South African Medicines Act, which would allow the health minister to authorize importation of generic copies of patented medications -- a provision the drug companies argued violated South Africa's own constitution and patent laws. The stance of the companies drew widespread protests, and on April 19, 2001, all 39 plaintiffs agreed to drop their suit. The South African government did not immediately move to import generic AIDS medications, however, and is cooperating with manufacturers in drafting regulations to implement contentious portions of the Medicines Act.

Economist Jeffrey Sachs and other faculty members from Harvard University released a "consensus statement" on April 4, 2001, maintaining that objections to widespread treatment of HIV-infected people in low-income countries with antiretroviral drugs were not valid. The statement, available online at http://www.cid.harvard.edu called for an initial effort to treat at least one million AIDS patients in Africa within three years.

U.S. Policy

A July 2000 Washington Post article called into question the adequacy and timeliness of the early U.S. response to the HIV/AIDS threat in Africa. (Barton Gellman, "The Global Response to AIDS in Africa: World Shunned Signs of Coming Plague." Washington Post, July 5, 2000). Nonetheless, U.S. concern did begin to mount during the 1980s, as the severity of the epidemic became apparent. In 1987, in acting on the FY1998 foreign operations appropriations legislation, 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.

Appropriators in 1987 also commended USAID, together with the World Health Organization, for "timely efforts to begin an international attack on the AIDS pandemic." And indeed, USAID states that it has been the global leader in the international response to AIDS since 1986, not only by supporting multilateral efforts but also by directly sponsoring regional and bilateral programs aimed at combating the disease. (See various documents available on the Internet at the USAID world wide web site, particularly http://www.info.usaid.gov/pop_health/aids/aidsaccomplish.htm.) The Agency has sponsored AIDS education programs; trained AIDS educators, counselors, and clinicians; supported condom distribution; and sponsored AIDS research. USAID claims several successes in Africa, such as helping to reduce HIV prevalence among young Ugandans and to prevent an outbreak of the epidemic in Senegal; reducing the frequency of sexually transmitted infections in several African countries; sharply increasing condom availability in Kenya and elsewhere; assisting children orphaned by AIDS; and sponsoring the development of useful new technologies, including the female condom. USAID reports that it spent a total of $67 million on fighting AIDS in Africa in FY1998 and $81 million in FY1999. USAID's spending on the epidemic worldwide, including Africa, was $121 million in FY1998 and $135 million in FY1999. In addition, some spending by the Department of Health and Human Services was going toward HIV surveillance in Africa and other Africa AIDS-related efforts.

As the severity of the epidemic continued to deepen in recent years, many of those concerned for Africa's future, both inside and outside government, came to feel that more should be done. On July 19, 1999, Vice President Gore proposed $100 million in additional spending for a global LIFE (Leadership and Investment in Fighting an Epidemic) AIDS initiative to begin in FY2000, with a heavy focus on Africa. Funds approved during the FY2000 appropriations process supported most of this initiative.

On June 27, 2000, the Peace Corps announced that all volunteers serving in Africa would be trained as AIDS educators and that 200 former volunteers would be sent to Africa through the Crisis Corps to work in AIDS care and prevention. Fifty new volunteers will work exclusively on AIDS-related projects in eastern and southern Africa.

The U.S. Export-Import Bank announced on July 19, 2000, that it would make available $1 billion in loans per year to finance the purchase in sub-Saharan African countries of HIV/AIDS medications, as well as related equipment and services, from U.S. firms. The 5-year loans would be at commercial interest rates, although some small pieces of financing costs might include an element of concessionality, according to the agency. There was some criticism of this offer on grounds that it would burden African countries with added debt and divert scarce resources to the purchase of costly anti-retroviral drugs. Several African governments reportedly rejected the loans. Nonetheless, the Bank has reported some recent interest in such loans, which can be used to build health infrastructure and not just to buy medicines.

Table 1, which compares HIV/AIDS spending in FY2000 with projected spending in FY2001, indicates that spending through the prevention programs of the Centers for Disease Control (CDC) of the Department of Health and Human Services will increase significantly. In addition, the Defense Department is launching a new HIV/AIDS education program with African armed forces (see CRS Report RL30761 (pdf), HIV-1/AIDS and Military Manpower Policy), while the Department of Labor (DoL) is undertaking a program to support AIDS education in the African workplace. Additional amounts may be available through the food aid appropriation (see below), and the Health Resources and Services Administration (HRSA) of HHS. HRSA works primarily to provide medical services for under-served populations in the United States, but will spend $3 million worldwide for HIV/AIDS projects in FY2001.

Table 1. U.S. Spending on Fighting AIDS in Africa
($ millions)

In FY2001, USAID is targeting three heavily affected African countries - Kenya, Uganda, and Zambia - for a rapid scale up in HIV/AIDS activities intended to show measurable results in one to two years. Ten African countries have been identified for "intensive focus" to reduce prevalence rates as well as mother-to-child transmission and to increase support services for people living with or affected by AIDS within 3 to 5 years. USAID will maintain basic programs, including technical assistance, training, and provision of commodities in eight other African countries. The General Accounting Office released a report in March 2001 calling on USAID to develop better measures for evaluating the effectiveness of its HIV/AIDS programs in Africa. (GAO Report GAO-01-449, U.S. Agency for International Development Fights AIDS in Africa, but Better Data Needed to Measure Impact.)

Bush Administration

Prior to the May 11, 2001 announcement of a $200 million U.S. contribution to a global HIV/AIDS, malaria, and tuberculosis fund, the Bush Administration had proposed $480 million in FY2002 for worldwide AIDS spending through existing programs, an 8% increase over FY2001. Proposed allocations of this FY2002 AIDS spending for Africa as a whole, and for particular countries, have not yet been released.

Indications of a new initiative outside existing programs appeared early in the Administration. Secretary of State Colin Powell, in a February 4, 2001 interview, said that "AIDS is a national security problem. It's an economic problem. It is a devastating problem, especially in Africa...." Powell added that Congress had been generous in responding and affirmed that "I think we all need to do more." Vice President Dick Cheney, speaking about AIDS in Africa during an April 8, 2001 appearance on NBC's Meet the Press, said that "I think we're going to have a major initiative in this area..... General Powell is now working with Tommy Thompson (Secretary of the Department of Health and Human Services) over at HHS to put together a package."

After President Bush's May 11 announcement, some AIDS activists and others criticized the pledge as too small to make a significant difference in the African HIV/AIDS pandemic, but others argued that the Administration was taking a first step in what could turn out to be a major long-term commitment. Some also expressed concern that the $200 million U.S. pledge will mean cuts in FY2002 funding for development assistance and other programs funded under the Foreign Operations appropriation and in programs of the Department of Health and Human Services. The budget resolution (H.Con.Res. 83, see Legislation section) does not include "new money" for a contribution to the fund. As noted below, Congress has already appropriated $20 million for an international HIV/AIDS fund, and this might be used as part of the U.S. contribution.

Detailed information on the structure of the new Global Fund is not yet available, but President Bush said on May 11 that he expected the idea to be turned into reality at the United Nations Special Session on HIV/AIDS to be held in New York on June 24-27 and at the G-8 summit to be held in Genoa, Italy, July 20-22. There is some concern among HIV/AIDS experts and activists about using $200 million to provide resources to a new international organization, as yet to be established, rather than to augment the HIV/AIDS resources of USAID and CDC, which many regard as more effective than other organizations and agencies in coping with the African pandemic. Others argue that despite the experience and capabilities of USAID and CDC, it is important to establish an overarching international body that may eventually be able to coordinate and integrate the activities of all donors.

Legislative Action in 2000

In August 2000, the Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264) became law. This legislation authorizes $300 million for each of fiscal years 2001 and 2002 for a comprehensive, coordinated, worldwide HIV/AIDS effort under USAID, not less than 65% to be available through non-governmental organizations, including religious-affiliated organizations, and not less than 20% to be available for a multi-donor strategy to address the support and education of orphans in sub-Saharan Africa. The Act also authorizes contributions to a yet to be created World Bank-administered AIDS trust fund and to the International AIDS Vaccine Initiative.

The Foreign Operations appropriations legislation (P.L. 106-429) provides $300 million - somewhat more than initially requested by the Clinton Administration - for HIV/AIDS programs worldwide in FY2001. The appropriation also provides $10 million for the International AIDS Vaccine Initiative, and language was included stating that $20 million may be available for a U.S. contribution to an international HIV/AIDS fund. The Department of Defense (DoD) appropriations (P.L. 106-259) earmarks the $10 million requested by the Clinton Administration for HIV/AIDS education programs with African armed forces. In addition, the Agriculture appropriation (P.L. 106-387) provides $25 million in food aid to assist foreign countries in mitigating the effects of the epidemic.

LEGISLATION

H.Con.Res. 83 (Nussle)
Budget Resolution FY2002. Senate adopted Frist amendment April 5, 2001, stating sense of the Senate that spending levels on HIV/AIDS prevention, care, and treatment for the neediest countries be increased by $200 million in FY2002 and by $500 million in FY2003, and adjusting budget amounts to provide "new money" for this purpose; conference report (H.Rept. 107-60, Sec. 302) repeated the sense of the Senate language, but did not include the budget adjustments. (Final funding levels for international AIDS programs are not set by this resolution but by appropriations legislation, particularly the Foreign Operations Appropriations and the Departments of Labor, Health and Human Services, and Education Appropriations.) Reported to the House, March 23; passed the House, March 28; passed the Senate with amendment, April 6. Conference report filed, May 8; conference report passed House May 9; passed Senate May 10.

H.Con.Res. 102 (Leach)
Hunger to Harvest Resolution: A Decade of Concern for Africa. States the sense of Congress that Congress should undertake a multi-year commitment with other donors to cut hunger by one-half in sub-Saharan Africa, with funding directed, among other purposes, toward efforts to prevent, treat, and control HIV/AIDS. Introduced on April 4, 2001, and referred to the House Committee on International Relations.

H.R. 684 (Millender-McDonald)
Authorizes $5 million for FY2002 through 2004 for pilot programs for sub-Saharan Africa and India to prevent mother-to-child transmission of HIV/AIDS. The programs are to be established and carried out by the Director of the Centers for Disease Control and Prevention. Introduced on February 14, 2001; referred to the House Committee on International Relations.

H.R. 933 (Waters)
Affordable HIV/AIDS Medicines for Poor Countries Act. States that the Secretary of the Treasury, the USAID Administrator, and the U.S. Trade Representative (USTR) shall encourage developing countries, including African countries, to make available affordable HIV/AIDS pharmaceuticals and medical technologies to their populations; and that, with the Administrator of the Food and Drug Administration, they shall encourage pharmaceutical companies to make such pharmaceuticals and technologies available in such countries at affordable prices. Prohibits use of funds by any department or agency to seek revocation or revision of any laws and policies in any developing countries that promote access to HIV/AIDS pharmaceuticals and technologies; prohibits the USTR from challenging such laws and technologies; requires the President to direct the USTR to seek exemptions for developing countries from any provisions of the TRIPS agreement or any other international agreement on intellectual property rights that restricts access to HIV/AIDS pharmaceuticals and technologies. Introduced on March 7, 2001; referred to the House Committee on Ways and Means and International Relations; referred to the Ways and Means Subcommittee on Trade on March 14.

H.R. 1185 (Lee)
Global Access to HIV/AIDS Medicines Act of 2001. In countries in which 5% or more of the population is HIV positive, or in which the government has declared a national AIDS emergency, prohibits the use of funds by any department or agency to seek the revocation or revision of any intellectual property law or policy that promotes access to HIV/AIDS pharmaceuticals or medical technologies and provides adequate intellectual property protections consistent with the TRIPS Agreement. States that the President shall encourage developing countries to implement policies designed to address the underlying causes of the HIV/AIDS crisis. Introduced on March 22, 2001; referred to the House Committee on International Relations.

H.R. 1269 (Crowley)
Global Health Act of 2001. In addition to amounts made available in FY2001 for international health programs, authorizes $1 billion; of which $275 million shall be available for combating HIV/AIDS and $225 million for the health and survival of children. Introduced on March 28, 2001; referred to the House Committee on International Relations.

H.R. 1567 (Lee)
Requires U.S. officials to call for a vote at the World Bank and IMF on negotiating a strategy for cancelling debts owed by heavily indebted poor countries or countries heavily affected by HIV/AIDS, which strategy should encourage each country and civil society stakeholders to ensure that a national HIV/AIDS strategic plan is fully funded; requires U.S. officials to oppose any World Bank or IMF program that would include user fees for primary health care, including treatment efforts for HIV/AIDS; requires a report on progress by the Secretary of the Treasury within one year. Introduced on April 24, 2001; referred to the House Committee on Financial Services.

H.R. 1642 (Waters)
Debt Cancellation for the New Millennium Act. Finds that the full cancellation of poor country debt, among other objectives, will enable such countries to invest in HIV/AIDS treatment and prevention; urges the President to immediately begin efforts aimed at full debt cancellation. Introduced on April 26, 2001; referred to the House Committee on Financial Services.

H.R. 1646 (Hyde)
Department of State Authorization. As reported, Sec. 103 authorizes up to $1 million for HIV/AIDS research and mitigation strategies in a Border-Less World academic program of the Fulbright Academic exchange program; Sec. 731 states the sense of Congress that U.S. officials should urge the United Nations to adopt an HIV/AIDS mitigation strategy as a component of U.N. peacekeeping operations; states the sense of Congress that the Secretary of State should establish an international HIV/AIDS intervention, mitigation, and coordination task force. Introduced on May 4, 2001; referred to the Committee on International Relations; marked up and ordered reported May 2; report filed (H.Rept. 107-57) and placed on the calendar, May 4.

H.R. 1690 (Waters)
Export-Import Bank HIV/AIDS Medicine Access Promotion Act. Prohibits the U.S. Export-Import Bank from guaranteeing, insuring, or extending credit in connection with any export by a company that is challenging the validity of a qualified HIV/AIDS access law. Introduced on May 2, 2001; referred to the Committee on Financial Services.

S. 463 (Feinstein)
Global Access to AIDS Treatment Act of 2001. Declares as U.S. policy that the United States will not seek the revocation or revision of intellectual property laws or policies in any foreign country undergoing an HIV/AIDS related crisis if they promote access to HIV/AIDS pharmaceuticals or medical technologies and are consistent with the TRIPS agreement. Introduced March 6, 2001; referred to Committee on Health, Education, Labor, and Pensions.

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