Aids in africa

Order Code IB10050 CRS Issue Brief for Congress Received through the CRS Web AIDS in Africa
Updated August 28, 2003
Raymond W. Copson Foreign Affairs, Defense, and Trade Division Congressional Research Service ˜ The Library of Congress
MOST RECENT DEVELOPMENTS BACKGROUND AND ANALYSIS Characteristics of the African Epidemic Explaining the African Epidemic Leadership Reaction in South Africa and Elsewhere Social and Economic Consequences Responses to the AIDS Epidemic Effectiveness of the ResponseAIDS Treatment Issues Bush AdministrationLegislative Action, 2000-2002 Legislative Action in the 108th Congress Sub-Saharan Africa has been more se- organizations, and African governments have verely affected by AIDS than any other part of responded primarily by attempting to reduce the world. The United Nations reports that the number of new HIV infections and by 29.4 million adults and children are infected trying to ameliorate the damage done by AIDS with the HIV virus in the region, which has to families, societies, and economies. The about 10% of the world's population but more adequacy of this response is the subject of than 70% of the worldwide total of infected much debate. U.N. experts estimate 2003 people. The overall rate of infection among spending from all sources on HIV/AIDS in adults in sub-Saharan Africa is 8.8%, com- low- and middle-income countries worldwide pared with 1.2% worldwide. Twelve coun- at $4.7 billion, compared with an estimated tries, mostly in east and southern Africa, have need of $10.5 billion by 2005.
HIV infection rates of more than 10%; the ratehas reached 38.8% in Botswana. As of 2001, Treatment of AIDS sufferers with medi- an estimated 21.5 million Africans had died of cines that can result in long-term survival is AIDS, including 2.2 million who died in that reportedly available to just 50,000 Africans at year. AIDS has surpassed malaria as the present. Advocates of expanded treatment leading cause of death in Africa, and it kills argue that in view of recent drug price reduc- many times more Africans than war. In tions, treatment is an affordable means of Africa, 58% of those infected are women.
reducing AIDS damage to African econo-mies, reinforcing prevention programs, and Experts relate the severity of the African keeping parents alive. Skeptics argue that AIDS epidemic to the region's poverty.
treatment is still too expensive to be an option Health systems are ill-equipped for for most Africans and would require costly prevention, diagnosis, and treatment. Poverty improvements in health infrastructure. forces many men to become migrant workersin urban areas, where they may have multiple U.S. concern over AIDS in Africa grew sex partners. Poverty leads many women to during the 1980s, as the severity of the epi- become commercial sex workers, vastly in- demic became apparent. Legislation enacted creasing their risk of infection. in the 106th and the 107th Congresses increasedfunding for worldwide HIV/AIDS programs.
AIDS' severe social and economic conse- H.R. 1298, signed into law (P.L. 108-25) on quences are depriving Africa of skilled work- May 27, 2003, would authorize $15 billion ers and teachers while reducing life expec- over five years for international AIDS pro- tancy by decades in some countries. An grams. President Bush has launched an Inter- estimated 11 million AIDS orphans are national Mother and Child HIV Transmission currently living in Africa, facing increased Initiative that will benefit 8 African countries, risk of malnutrition and reduced prospects for and 12 are slated for added support under the education. AIDS is being blamed for declines global aids initiative announced in the January in agricultural production in some countries, 28, 2003, State of the Union message. Presi- and is regarded as a major contributor to the dent Bush made AIDS a special focus of his 5- famine threatening southern Africa.
day trip to Africa in July 2003. Nonetheless,activists and others urge that more be done in Donor governments, non-governmental view of the scale of the African pandemic.
Congressional Research Service ˜ The Library of Congress
MOST RECENT DEVELOPMENTS The Southern African Development Community (SADC) concluded a two-day meeting in Tanzania on August 26, 2003, after agreeing to an AIDS strategic framework, includingthe creation of a $10.5 million regional fund to fight the disease. Also on August 26,Senator Bill Frist said in Botswana that the country's AIDS program should serve as a modelfor other African countries. The Senator praised the political will Botswana had shown incombating the epidemic, and the six-member Senate delegation visited a clinic where 5,000AIDS patients were receiving treatment. On August 22, South African Trade Minister AlecErwin reportedly told the Senate visitors that the epidemic in South Africa was being well-managed and would have little effect on the country's economy. 1 Senator Norm Colemantold reporters that he found Erwin's words "rather shocking" since the impact of theepidemic was "overwhelming."2 On August 8, the South African cabinet instructed thehealth ministry to develop a plan by the end of September to provide antiretroviral treatmentnationwide. AIDS activists and others welcomed the decision, but some expressed concernthat implementation of such a program might still be far in the future. On July 31, the SouthAfrican Medicines Control Council announced that it was re-opening an inquiry into thesafety of Nevirapine, leading to fears that the antiretroviral would be de-registered for usein preventing mother-to-child transmission (MTCT) of HIV. In 2002, a South African courthad ordered the government to launch a nationwide Nevirapine MTCT program. A Human Rights Watch study released on August 13 reported that domestic violence made women in Uganda more vulnerable to HIV infection — for example by depriving themof the power to negotiate condom use. A World Bank research report released on July 23said that the long-term economic impact of AIDS in South Africa and elsewhere could bemuch greater than anticipated since, by killing parents, the disease inhibits the transmissionof knowledge and skills from generation to generation. South African officials discountedthe study, citing South African studies suggesting the economic impact of AIDS will beminor.3 For further information, see CRS Report RS21181, HIV/AIDS InternationalPrograms: Appropriations, FY2002-FY2004 and CRS Report RL31712, The Global Fundto Fight AIDS, Tuberculosis, and Malaria: Background and Current Issues.
BACKGROUND AND ANALYSIS Sub-Saharan Africa has been far more severely affected by AIDS than any other part of the world. In November 2002, UNAIDS (the Joint United Nations Program onHIV/AIDS) reported that in 2002, 29.4 million people were living with HIV and AIDS insub-Saharan Africa, up from 28.5 million in 2001. Africa, where an estimated 3.5 millionpeople were newly infected in 2002, has about 10% of the world's population but more than70% of the worldwide total of infected people. The infection rate among adults is about8.8% in Africa, compared with 1.2% worldwide. Through 2001, an estimated 21.5 million 1 Chicago Tribune, August 22, 2003.
2 Associated Press, August 23, 2003.
3 South African Broadcasting Corporation report, July 28, 2003.
Africans had lost their lives to AIDS, including an estimated 2.2 million who died in thatyear(UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002). UNAIDS estimates thatby 2020, an additional 55 million Africans will loose their lives to the epidemic. AIDS hassurpassed malaria as the leading cause of death in sub-Saharan Africa, and it kills many timesmore people than Africa's armed conflicts.
Characteristics of the African Epidemic
! HIV, the human immunodeficiency virus that causes AIDS, is spread in Africa, most experts believe, primarily by heterosexual contact. (A February2003 article published by David Gisselquist and others in the InternationalJournal of STD and AIDS asserted that the importance of unsafe medicalpractices in the spread of HIV may have been underestimated and called forfurther research. The article caused some controversy, and the SenateHealth, Education, Labor, and Pensions Committee held a hearing on March27 to examine the issue.) ! Women make up an estimated 58% of the HIV-positive adult population in sub-Saharan Africa, as compared with 50% worldwide — according toUNAIDS. Young women are particularly at risk. In 2001, an estimated 6%to 11% of African women aged 15 to 24 were HIV positive, compared with3% to 6% of young men. (UNAIDS, AIDS Epidemic Update, December2002). ! Southern and eastern Africa have been far more severely affected than West Africa, but infection rates in a number of West African countries are rising.
In seven southern African countries, 20% or more of the adult population isinfected with HIV, and the rate has reached 38.8% in Botswana. InCameroon, a West African country, the adult infection rate has jumped from4.7% in 1996 to 11.8% in 2001. In Nigeria, with a population that exceeds125 million, an estimated 5.8% of adults were HIV positive in 2001, andinfection rates in some Nigerian states have reached levels seen inneighboring Cameroon. The U.S. National Intelligence Council, in aSeptember 2002 report on the "next wave of HIV/AIDS," predicted that by2010, 10 to 15 million Nigerians, or 18% to 26% of adults, would beinfected by HIV. ! The African AIDS epidemic is having a much greater impact on children than is the case in other parts of the world. According to UNAIDS, morethan 600,000 African infants become infected with HIV each year throughmother-to-child transmission, either at birth or through breast-feeding.
These children have short life expectancies, and the number currently alivemay be about 1 million.
! In 2001, an estimated 11 million children orphaned by AIDS were living in Africa, and an authoritative report estimates that by 2010, 20.1 millionchildren will have lost one or both parents to AIDS. Because of the stigmaattached to the AIDS disease, AIDS orphans are at high risk for being malnourished, abused, and denied an education. The number of orphans dueto all causes is expected to total 42 million in 2010, including 6.7 million inNigeria, 5 million in Ethiopia, and 2.3 million in South Africa. (UNAIDS,UNICEF, and U.S. Agency for International Development, Children on theBrink, 2002, a Joint Report on Orphan Estimates and Program Strategies,p. 28.) Explaining the African Epidemic
AIDS experts emphasize a variety of economic Adult HIV Infection Rates (%), end of 2001
and social factors in explaining Africa's AIDS epidemic, placing primary blame on the region's poverty. Poverty has deprived Africa of effective systems of health information, health education, and health care. Thus, Africans suffer from a high rate of untreated sexually-transmitted infections (STIs) other than AIDS, and these increase susceptibility to HIV. African health systems typically have limited capabilities for AIDS prevention work, and HIV Cent. Af. Republic counseling and testing are difficult for many Africans to obtain. AIDS treatment is generally available only to the elite.
Congo Brazzaville Poverty forces large numbers of African men to migrate long distances in search of work, and while away from home they may have multiple sex partners, increasing their risk of infection. Some of these partners may be women who have become commercial sex workers because of poverty, and they too are highly vulnerable to infection. Migrant workers may carry the infection back to their wives Equatorial Guinea when they return home. Long distance truck drivers, and drivers of "taxis," who transport Africans long distances by car, are probably also key agents in spreading HIV.
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 Source: UNAIDS, Report on the Global young men, Peter Piot, the Executive Director HIV/AIDS Epidemic, July 2002. Data not UNAIDS, has commented that "the unavoidable available for the following countries:Comoros, Djibouti, Gabon, Gambia, Guinea, conclusion is that girls are getting infected not by Liberia, Mauritania, Niger. boys but by older men," who are more likely thanyoung men to carry the disease. (UNAIDS pressrelease, September 14, 1999.) UNAIDS notes that"with the downward trend of many African economies . relationships with (older) men canserve as vital opportunities for financial and social security, or for satisfying materialaspirations." (AIDS Epidemic Update, 2002). Many believe that the infection rate among women generally would be far lower if women's rights were more widely respected in Africaand if women exercised more power in political and economic affairs. (For more on theseissues, see Helen Epstein, "AIDS: the Lesson of Uganda," New York Review of Books, July5, 2001; and "The Hidden Cause of AIDS," New York Review of Books, May 9, 2002.) The breakdown in social order and social norms caused by armed conflict is also contributing to the African epidemic. Conflict is typically accompanied by numerousincidents 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 asettled environment.
Leadership Reaction in South Africa and Elsewhere
Many observers believe that the spread of AIDS in Africa could have been slowed if African leaders had been more engaged and outspoken in earlier stages of the epidemic.
President Thabo Mbeki of South Africa has come in for particular criticism on this score.
Concern over the consequences of AIDS in South Africa is high, since the number ofinfected people there — 4.7 million at the end of 2001 — is larger than in any other country.
In April 2000, President Mbeki wrote then President Clinton and other heads of statedefending dissident scientists who maintain that AIDS is not caused by the HIV virus. InMarch 2001, Mbeki rejected appeals that the national assembly declare the AIDS pandemica national emergency, and in September of that year, the South African governmentattempted to delay publication of a South African Medical Research Council report, whichfound AIDS to be the leading cause of death, accounting for 40% of mortality among SouthAfricans aged 15 to 49. The Council predicted that South Africa's death toll from AIDSwould reach a cumulative total of between 5 and 7 million by 2010, when 780,000 peoplewould be dying annually from the disease. Life expectancy would fall from 54 years atpresent to 41 by the end of the decade, according to the Council. Under mounting domestic and international pressure, the South African government seemed to modify its position significantly after an April 17, 2002 cabinet meeting on theAIDS crisis. The cabinet announced that it would triple the national AIDS budget, endofficial opposition to the provision of antiretrovirals for rape victims, and launch a programfor universal access to drugs to prevent mother-to-child transmission, possibly by December.
AIDS activists welcomed the policy changes, but some expressed concerns aboutimplementation or pointed out that South Africa was still far from providing access totreatment for all those in need.
On July 5, 2002, South Africa's Constitutional Court denied the government's appeal against lower court decisions ordering it to begin providing the antiretroviral drug Nevirapinenationwide to reduce the transmission of HIV from pregnant mothers to their newborns. TheSouth African Treatment Action Campaign (TAC) had launched the suit in August 2001,demanding a comprehensive program to prevent mother-to-child transmission (MTCT).
TAC maintained that MTCT trials involving 18 pilot projects providing Nevirapine to HIV-positive pregnant women were inadequate and that 20,000 babies could be saved by anationwide program. The German firm Boerhringer-Ingelheim offers the Nevirapine drugfree in Africa for MTCT programs. South African officials maintained that safetyprecautions required further testing of Nevirapine but accepted the Constitutional Court'sdecision.
The April 2002 cabinet pledges and the court decision eased tensions in South Africa over AIDS policy for some months, but activists undertook a new civil disobediencecampaign in March and April 2003, charging two government ministers with "manslaughter"for failing to provide treatment to those suffering with AIDS. Government officialsresponded that the cost of providing universal treatment was still being determined, and theruling African National Congress accused TAC of "bully boy tactics." (South African PressAssociation, March 26, 2003.) According to a Financial Times report on July 9, 2003, arepresentative of the United Nations Development Program (UNDP) said that South Africahad fallen 28 places on the UNDP Human Development Index since 1990 — to 111th placeout of 175 countries — primarily due to AIDS. The South African government has not madepublic a report completed in April 2003 on the feasibility of providing universal treatmentto patients needing antiretroviral therapy. In the rest of Africa, many heads of state and other leaders are now taking major roles in fighting the epidemic. President Yoweri Museveni of Uganda has long been recognizedfor leading a successful prevention campaign against AIDS in his country, and Uganda'sABC (Abstinence, Be Faithful, or Use Condoms) transmission prevention program has wonwide praise. ("Uganda Leads by Example on AIDS," Washington Times, March 13, 2003.) A Senate Foreign Relations Africa Subcommittee hearing on May 19, 2003, focused on"Fighting AIDS in Uganda: What Went Right." Dr. Anne Peterson, Assistant Administratorfor Global Health at the U.S. Agency for International Development (USAID), testified thatthe "Uganda success story is about prevention." She said that successes had been recordedin promoting abstinence and faithfulness to partners, while increased condom use in recentyears had also contributed to the decline in prevalence. Sophia Mukasa Monico, a memberof the Global Health Council and a former AIDS worker in Uganda, testified that all threeprogram elements need to be in place for prevention to work. Mukasa Monico noted that"the epidemic is still raging in Uganda, and we have much to do before we can claimvictory." On June 10, during a meeting with President Museveni at the White House,President Bush praised the Ugandan leader's "extraordinary leadership on HIV/AIDS in yourcountry." Meanwhile, the presidents of Botswana, Nigeria, and several other countries are widely seen today as in the forefront of the AIDS struggle as well. Kenya's new president, MwaiKibaki, elected in December 2002, has declared "total war on AIDS" and committed hisgovernment to treating 40,000 AIDS patients. ("In Another Break with Past, Kenyans SeeHope on AIDS," Washington Post, May 21, 2003.) Several regional AIDS initiatives havebeen launched. Social and Economic Consequences
AIDS is having severe social and economic consequences in Africa, and these negative effects are expected to continue for many years. A January 2000 Central Intelligence AgencyNational Intelligence Estimate on the infectious disease threat, made public in an unclassifiedversion, forecasts grave problems over the next 20 years.
At least some of the hardest-hit countries, initially in sub-Saharan Africa and later inother regions, will face a demographic catastrophe as HIV/AIDS and associated diseasesreduce 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 themiddle class, and produce a huge and impoverished orphan cohort unable to cope andvulnerable to exploitation and radicalization. (CIA, The Global Infectious Disease Threatand Its Implications for the United States [], "Publications andReports".) The estimate predicted increased political instability and slower democratic development asa result of AIDS. According to the World Bank, The illness and impending death of up to 25% of all adults in some countries will havean enormous impact on national productivity and earnings. Labor productivity is likelyto drop, the benefits of education will be lost, and resources that would have been usedfor investments will be used for health care, orphan care, and funerals. Savings rates willdecline, and the loss of human capital will affect production and the quality of life foryears to come. (World Bank, Intensifying Action Against HIV/AIDS in Africa.) In the most severely affected countries, sharp drops in life expectancy are occurring, and these will reverse major gains achieved in recent decades. According to UNAIDS, as a resultof AIDS, average life expectancy in sub-Saharan Africa is now 47 years, whereas it wouldhave been 62 years without the epidemic. South Africa and some other countries in southernAfrica could face population declines by the end of the decade, according to experts.
According to many reports, AIDS has devastating effects on rural families. The father is typically the first to fall ill, and when this occurs, farm tools and animals may be sold topay for his care. Should the mother also become ill, children may be forced to shoulderresponsibility for the full time care of their parents. The Food and Agriculture Organizationof the United Nations reports that since the epidemic began, 7 million agricultural workershave been killed in Africa. The agricultural workforce has been reduced by more than 20%in five countries (FAO, HIV/AIDS, Food Security, and Rural Livelihoods, May 2002), anda number of experts are relating serious food shortages in southern Africa in 2002 and 2003to production losses caused by AIDS. (See "Cursed Twice Over — AIDS and Famine inSouthern Africa," The Economist, February 15, 2003.) World Food Program ExecutiveDirector James Morris, testifying before the Senate Foreign Relations Committee onFebruary 25, 2003, and the House International Relations Committee on February 27, saidthat HIV/AIDS was a central cause of the famine.
AIDS is being blamed for shortages of skilled workers and teachers in several countries.
A May 2002 World Bank study, Education and HIV/AIDS: A Window of Hope, reported thatmore than 30% of teachers are HIV positive in parts of Malawi and Uganda, 20% in Zambia,and 12% in South Africa. AIDS is also claiming many lives at middle and upper levels ofmanagement in both business and government. Although unemployment is generally highin Africa, trained personnel are not readily replaced.
AIDS may have serious security consequences for much of Africa, since HIV infection rates in many armies are extremely high. Domestic political stability could also bethreatened in African countries if the security forces become unable to perform their dutiesdue to AIDS. Peacekeeping is also at risk. South African soldiers are expected to play animportant peacekeeping role in Africa in the years ahead, but this could be threatened.
Estimates of the infection rate in the South Africa army run from 17% to 40%, with higherrates reported for units based in heavily infected KwaZulu-Natal province.
Responses to the AIDS Epidemic
Donor governments, non-governmental organizations (NGOs) working in Africa, and African governments have responded to the AIDS epidemic primarily by attempting toreduce the number of new HIV infections, and to some degree, by trying to ameliorate thedamage 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 notbeen widely used in Africa, largely due to cost, although some treatment is now being offeredat private clinics or through programs offered by a few large employers. Demands for large-scale treatment are mounting in Africa, and are drawing support from outside the continentamong AIDS activists and others concerned for the region's future. (For more informationon the international response to the epidemic, see CRS Report RL30883, Africa: Scaling Upthe Response to the HIV/AIDS Pandemic.) Programs and projects aimed at combating the epidemic typically provide information on how HIV is spread and on how it can be avoided through the media, posters, lectures, andskits. Donor-sponsored voluntary counseling and testing (VCT) programs, where available,enable African men and women to learn their HIV status. Those testing positive are typicallyreferred to support groups and advised on ways to protect others from contracting thedisease; while the majority testing negative are counseled on behavior changes that will keepthem HIV-free. The U.S. Agency for International Development (USAID) is currentlysupporting VCT centers in 10 African countries. AIDS awareness programs can be foundin many African schools and increasingly in the workplace, where employers are recognizingtheir interest in reducing the infection rate among their employees. Many projects aim atmaking condoms readily available and on providing instruction in condom use. USAID isa major provider of condoms in Africa. Pilot projects have had success in reducing mother-to-child transmission by administering the anti-HIV drug AZT or Nevirapine, during birthand 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. TheFarm Orphan Support Trust in Zimbabwe tries to keep sibling orphans together and in afamily living situation; the Salvation Army sponsors a pilot, community-based, orphansupport program in Zambia, providing education and health care to vulnerable children.
(Report on the Presidential Mission on Children Orphaned by AIDS.) A United Nationsstudy 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 otherservices to AIDS-afflicted families. (UNAIDS, A Review of Household and CommunityResponses 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 supporterof vaccine research and a variety of AIDS programs undertaken in cooperation with Africangovernments and donors. The Rockefeller Foundation, working with UNAIDS and others,has sponsored programs to improve AIDS care in Africa, and both Bristol-Myers Squibb andMerck and Company, together with the Gates Foundation and the Harvard AIDS Institute,have undertaken programs with the Botswana government aimed at improving the country'shealth infrastructure and providing AIDS treatment to all who need it. (See "A SmallNation's Big Effort Against AIDS," Washington Post, December 2, 2002.) 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 HealthOrganization estimated that this pledge, and G-8 pledges to attack malaria and tuberculosisas well, would cost at least $5 billion per year for 5 years. The World Bank launched itsMulti-Country HIV/AIDS Program (MAP) for Africa in September 2000.
In December 2001, Peter Piot, executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS), told an international AIDS conference in Burkina Faso thatassistance to fight HIV/AIDS in sub-Saharan Africa should be increased "many-fold," andthat the region requires $4.6 billion per year to confront the pandemic. (For moreinformation, see CRS Report RL30883, Africa: Scaling Up the Response to the HIV/AIDSPandemic.) UNAIDS reported on June 26, 2003, that about $4.7 billion would be spentcombating AIDS in low- and middle-income countries worldwide in 2003, as compared toa total resource need of $10.5 billion by 2005.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria was created in January 2002 and plans to disburse $1.5 billion to fight the three diseases worldwide in 2003 and 2004.
The Fund commits about 60% of its grant funds to Africa, and about 60% of its grantsworldwide go toward fighting AIDS. For further information, see CRS Report RL31712,The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background and CurrentIssues.
Further information on the response to AIDS in Africa may be found at the following CDC: []European Union: []The Global Fund to Fight AIDS, Tuberculosis, and Malaria: []International AIDS Vaccine Initiative: []International Association of Physicians in AIDS Care: []Kaiser Daily HIV/AIDS Report: []UNAIDS: []USAID: [], click on "Health."World Bank: [], click on "Topics." Effectiveness of the Response
The response to AIDS in Africa has had some successes, most notably in Uganda, where the rate of infection among pregnant women in urban areas fell from 29.5% in 1992to 5% in 2001 (UNAIDS, AIDS Epidemic Update, December 2002). HIV prevalence amongyoung urban women in Zambia has also reportedly fallen, and UNAIDS indicates that urbansexual behavior patterns among young people in cities in other countries may be changingin ways that combat the spread of HIV. However, increases in infection rates continue incities in several other countries. South Africa has recorded a drop in infections amongpregnant women under 20, and Senegal is credited with preventing an AIDS epidemicthrough an active, government-sponsored prevention program. Despite some success stories,however, available evidence indicates that the epidemic is deepening in most of Africa.
Experts point out that there are a number of barriers to a more effective AIDS response in Africa, such as cultural norms that make it difficult for many government, religious, andcommunity leaders to acknowledge or discuss sexual matters, including sex practices,prostitution, and the use of condoms. However, experts continue to advocate AIDSawareness and AIDS amelioration as essential components of the response to the epidemic.
Indeed, there is strong support for an intensification of awareness and amelioration efforts,as well as adaptations to make such efforts more effective. With respect to amelioration,UNAIDS has recommended that donors find ways to strengthen those indigenous supportinstitutions that are already helping AIDS victims and their families. (A Review ofHousehold and Community Responses, 1999.) There is also support for a stronger focus ontreatment of non-HIV sexually-transmitted infections, which studies show can dramaticallylower 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, particularlytuberculosis, that typically accompany AIDS. Millions of Africans suffer dual infections ofHIV and TB, and the combined infection dramatically shortens life. Tuberculosis can becured by treatment with a combination of medications over several months, even in HIV-infected patients. However, according to the World Health Organization, Africans oftendelay seeking treatment for TB or do not complete the course of medication (GlobalTuberculosis Control: WHO Report 1999, Key Findings), contributing to the high incidenceof death among those with dual infections. Pfizer Corporation has signed an agreement withSouth Africa to donate the anti-fungal Diflucan (fluconazole) for treating AIDS-relatedopportunistic infections, including cryptococcal meningitis, a dangerous brain inflammation.
On December 1, 2001, Pfizer announced that it would sign memoranda of understanding ondonating fluconazole with six other African countries. UNAIDS and the World Healthorganization recommended on April 5, 2000, that Africans infected with HIV be treated withan antibiotic/sulfa drug combination known by the trade name Bactrim in order to preventopportunistic infections. Studies indicate that the drug could reduce AIDS death rates at acost of between $8 and $17 per year per patient.
AIDS Treatment Issues
Access for poor Africans to combinations of AIDS medications or "antiretrovirals" (ARVs) is perhaps the most contentious issue surrounding the response to the Africanepidemic today. Administered in a treatment regimen known as HAART (highly activeantiretroviral 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 indeveloped countries, including the United States, where AIDS, which had been the eighthleading 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 ofthe epidemic. Moreover, proponents argue, treatment will strengthen prevention efforts,since the possibility of treatment will create strong incentives for participation in VCTprograms. Some also see a moral obligation to try to save lives when the medications fordoing so exist. Others, however, argue that as long as resources for combating AIDS are limited, the focus should continue to be on prevention, which, they maintain, is more costeffective in saving lives. The high cost of HAART treatments has been the principal obstacle to offering the therapy on a large scale in Africa, where most victims are poor and lack health insurance.
The cost of administering HAART was once estimated at between $10,000 and $15,000 perperson per year. On May 11, 2000, five major pharmaceutical companies announced thatthey were willing to negotiate sharp reductions in the price of AIDS drugs sold in Africa.
UNAIDS launched a program in cooperation with the pharmaceutical companies to boosttreatment access and, in June 2001, reported that 10 African countries had reached agreementwith manufacturers. The agreements significantly reduced prices in exchange for healthinfrastructure improvements to assure that ARVs are administered safely. Patented AIDSmedications are now reportedly becoming available in several African countries, at pricesranging from a few hundred dollars to just over $1000 per patient per year, for a three-drugtreatment comparable to that available in developed countries. On April 28, 2003,GlaxoSmith-Kline, the largest manufacturer of AIDS pharmaceuticals, announced furtherprice reductions for poor countries, including all of sub-Saharan Africa. Private clinics in some African cities are now offering HAART, and Uganda as well as Cote d'Ivoire are providing treatment in publicly-funded programs to several hundredpatients. Nonetheless, according to current estimates, only about 50,000 Africans arereceiving treatment. (White House Fact Sheet on the President's Emergency Plan for AIDSRelief, January 29, 2003.) A Nigerian program to treat 15,000 AIDS patients with genericantiretrovirals imported from India was launched in December 2001, but has encounteredorganizational problems and difficulties in drug distribution. (Africa News, April 5, 2002;Agence France Presse, May 21, 2002.) In Kenya, a law came into force on May 1, 2002permitting the importation or manufacture of generic copies of more expensive patentedAIDS drugs, although even these medications would likely cost more than most KenyanAIDS patients can afford. (BBC, May 1, 2002.) Anglo American, the South African miningfirm, announced on August 6, 2002, that it would provide antiretroviral drug therapy toemployees requiring it. Other mining companies subsequently made similar announcements.
The Global Fund maintains that its initial round of grants will make possible a six-foldincrease in the numbers being treated in Africa over five years. The degree to which Africa's poorly developed health infrastructure prevents the wider availability of HAART is controversial. AIDS activists believe that millions of Africanscould quickly be given access to AIDS drugs. Others maintain that African supply channelscannot make the drugs consistently available to millions of patients and that regularmonitoring of patients by medical personnel is not possible in much of the continent.
Monitoring is necessary, they maintain, to deal with side effects and to adjust medicationsif drug resistance emerges. Many fear that if the drugs are taken irregularly, resistant HIVstrains will emerge that could cause untreatable infections worldwide. In February 2002Senate testimony, Dr. E. Anne Peterson, Assistant Administrator for Global Health atUSAID stated that USAID would launch four treatment sites in Africa to provide "criticallyneeded answers" to the challenges of providing antiretroviral therapy.
AIDS activists also advocate "parallel imports" of drugs and "compulsory licensing" by African governments to lower the price of patented medications. Through parallelimporting, patented pharmaceuticals could be purchased from the cheapest source, rather than from the manufacturer; while under "compulsory licensing," an African governmentcould 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) ofthe World Trade Organization agreement for countries facing national emergencies, U.S.
officials once strongly opposed such measures on grounds that they could lead toinfringements of intellectual property rights. Advocates for the pharmaceutical companiesargued that parallel importing and compulsory licensing could reduce profits, and that thiswould hinder the ability of manufacturers to conduct research on new drugs, including drugsthat might be even more effective against HIV. A third view has been that some combinationof subsidization, price reduction, and local manufacturing might be found that would makethe drugs much more widely available while maintaining drug company revenues throughthe sheer volume of African sales. On May 10, 2000, then President Clinton issued an executive order stating that the United States would not seek to prevent sub-Saharan countries from promoting access toHIV/AIDS pharmaceuticals or medical technologies consistent with the World TradeOrganization's TRIPS agreement. On February 22, 2001, an official of the U.S. TradeRepresentative's office said the Bush Administration was not considering any change incurrent "flexible policy" on this issue. On November 14, 2001, a ministerial level meetingof the World Trade Organization in Doha, Qatar, approved a declaration stating that theTRIPS agreement should be implemented in a manner supportive of promoting access tomedicines for all. The declaration affirmed the right of countries to issue compulsorylicenses and gave the least developed countries until 2016 to implement TRIPS. Thequestion of whether countries manufacturing generic copies of patented drugs, such as Indiaor Thailand, should be permitted to export to poor countries was left for further negotiationthrough a committee known as the Council for TRIPS. Although the Doha declaration drew broad praise, some AIDS activists criticized it for not permitting imports of generics, cheap copies of patented medications. Some in thepharmaceutical industry, on the other hand, expressed concern that the declaration was toopermissive and might eventually open the way to such imports. Others, however, argued thatthe declaration would have little practical impact, since most AIDS drugs are not actuallypatented in many of the countries most heavily affected by the epidemic. From thisperspective, poverty rather than patents is the principal obstacle to drug access in Africa.
(See Amir Attaran and Lee Gillespie-White, "Do Patents for Anti-retroviral Drugs ConstrainAccess to AIDS Treatment in Africa?" Journal of the American Medical Association,October 17, 2001.) The Council for TRIPS failed to reach agreement by December 2002, the deadline set by the Doha meeting, on allowing poor countries to import generic copies of essentialpatented medications. Reportedly, an accord was stalled by U.S. objections to the numberof diseases and countries that some delegations wanted to include. Nonetheless, onDecember 20, the U.S. Trade Representative announced that the United States was pledging"not to challenge any WTO member that breaks WTO rules to export drugs produced undercompulsory license to a country in need." According to reports appearing in late August2003, a compromise on this issue may be near. (Washington Times, "WTO Nears Pact onGeneric Pharmaceuticals," August 28, 2003.) U.S. Policy
U.S. concern over AIDS in Africa began to mount during the 1980s, as the severity of the epidemic became apparent. In 1987, in acting on the FY1988 foreign operationsappropriations, Congress earmarked funds for fighting AIDS worldwide, and Houseappropriators noted that in Africa, AIDS had the potential for "undermining all developmentefforts" to date (H.Rept. 100-283). In subsequent years, Congress supported AIDS spendingat or above levels requested by the executive branch, either through earmarks or reportlanguage. Nevertheless, a widely discussed July 2000 Washington Post article called intoquestion the adequacy and timeliness of the early U.S. response to the HIV/AIDS threat inAfrica. (Barton Gellman, "The Global Response to AIDS in Africa: World Shunned Signsof Coming Plague." Washington Post, July 5, 2000). USAID states that it has been the global leader in the international response to AIDS since 1986, not only by supporting multilateral efforts but also by directly sponsoringregional and bilateral programs aimed at combating the disease. (USAID, Leading the Way:USAID Responds to HIV/AIDS, September 2001). The Agency has sponsored AIDSeducation programs; trained AIDS educators, counselors, and clinicians; supported condomdistribution; and sponsored AIDS research. USAID claims several successes in Africa, suchas helping to reduce HIV prevalence among young Ugandans and to prevent an outbreak ofthe epidemic in Senegal; reducing the frequency of sexually transmitted infections in severalAfrican countries; sharply increasing condom availability in Kenya and elsewhere; assistingchildren orphaned by AIDS; and sponsoring the development of useful new technologies,including the female condom. USAID reports that it spent a total of $51 million on fightingAIDS in Africa in FY1998 and $63 million in FY1999 (Leading the Way, 121). In addition,some spending by the Department of Health and Human Services was going toward HIVsurveillance in Africa and other Africa AIDS-related efforts.
As the severity of the epidemic continued to deepen, many of those concerned for Africa's future, both inside and outside government, came to feel that more should be done.
On July 19, 1999, Vice President Gore proposed $100 million in additional spending for aglobal LIFE (Leadership and Investment in Fighting an Epidemic) AIDS initiative to beginin FY2000, with a heavy focus on Africa. Funds approved during the FY2000 appropriationsprocess supported most of this initiative. On June 27, 2000, the Peace Corps announced thatall volunteers serving in Africa would be trained as AIDS educators.
The Bush Administration has continued to support increases in HIV/AIDS spending for Africa, and the President has appointed a cabinet level task force, co-chaired by Secretary ofState Colin Powell and Secretary of Health and Human Services Tommy Thompson, todevelop and coordinate HIV/AIDS policy. An interagency policy coordinating committeeheadquartered at the White House has been established to back up the task force. Moreover,as noted above, President Bush made the "founding pledge" to the Global Fund. On June19, 2002, President Bush announced a $500 million International Mother and Child HIVPrevention Initiative (IMCPI) to support programs to prevent mother- to-child transmissionof the virus. Eight African countries were named as beneficiaries. Secretary of State ColinPowell, speaking on November 13, 2002, at a dinner honoring U.N. Secretary General Kofi Annan, said that the HIV/AIDS pandemic is "the biggest problem we have on the face of theearth today." Nonetheless, editorials, AIDS activist organizations, and others continued tocriticize the Administration's response to AIDS in Africa. On December 18, 2002, theCongressional Black Caucus wrote to President Bush seeking sharply increased spending forAIDS programs in Africa and worldwide.
In his January 28, 2003 State of the Union message, President Bush announced a new Emergency Plan for AIDS Relief to channel $10 billion in "new money" over five years tofighting the pandemic in 12 African countries as well as two Caribbean countries. Budgetdocuments released at the beginning of February indicated that $450 million was beingrequested in FY2004 for a new Global AIDS Initiative (GAI), the principal component of theEmergency Plan, to be headquartered at the State Department. The objectives of thisinitiative include preventing 7 million new infections, providing anti-retroviral drugs for 2million infected people, and providing care for 10 million infected people, including orphans.
Many AIDS activists and others hailed the President's initiative, while critics said that theamount requested for FY2004 showed that it was getting off to a "slow start." PresidentBush made AIDS a special focus of his 5-day trip to Africa in July 2003. On July 10,speaking in Botswana, the President said "This is the deadliest enemy Africa has ever faced,and you will not face this epidemic alone." On July 8, in Senegal, the President told Africans"we will join with you in turning the tide against AIDS in Africa." The President also spokeon the epidemic in South Africa on July 9. Table 1. U.S. Bilateral Spending on Fighting AIDS in Africa
Table 1 indicates recent U.S. spending levels on AIDS programs in Africa. USAID and
the Centers for Disease Control (CDC) of the Department of Health and Human Services arethe principal channels for assistance. In addition, the Defense Department (DOD) hasundertaken an HIV/AIDS education program with African armed forces. Funds from theForeign Military Financing (FMF) program are also used to support this initiative.
Meanwhile the Department of Labor (DOL) has undertaken a program that supports AIDSeducation in the African workplace. Determining the amount to be spent in FY2003 is notyet possible, since the amounts to be committed under the International Mother and ChildHIV Prevention Initiative (IMCPI) are not yet available. The Omnibus Appropriations measure for FY2003 (H.J.Res. 2/P.L. 108-7) made funds available for this initiative, but theirallocation is not yet known. As noted above, the FY2004 budget proposal includesadditional funds for the initiative and for the new Global AIDS Initiative (GAI). Again,information is not yet available on allocation plans for these funds. (For more information,see CRS Report RS21181, HIV/AIDS International Programs: Appropriations, FY2002-FY2004.) USAID is targeting three heavily affected African countries — Kenya, Uganda, and Zambia — for a rapid scale-up in HIV/AIDS activities intended to show measurable resultsin one to two years. Ten African countries have been identified for "intensive focus" toreduce prevalence rates as well as mother-to-child transmission and to increase supportservices for people living with or affected by AIDS within 3 to 5 years. USAID willmaintain basic programs, including technical assistance, training, and provision ofcommodities in eight other African countries. In July 2002, USAID announced that it hadlaunched pilot antiretroviral treatment projects in Ghana, Kenya, and Rwanda. AdditionalU.S. funds reach Africa indirectly through the AIDS programs of the United Nations,including the World Bank, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Legislative Action, 2000-2002
In August 2000, the Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264) became law. This legislation authorized funding for fiscal years 2001 and 2002 for acomprehensive, coordinated, worldwide HIV/AIDS effort under USAID. In the 107thCongress, a number of bills were introduced with international or Africa-related HIV/AIDSrelated provisions. A major international AIDS authorization bill, H.R. 2069, passed boththe House and Senate during the 107th Congress but did not go to conference. (Forinformation on appropriations for HIV/AIDS programs, see CRS Report RS21114,HIV/AIDS: Appropriations for Worldwide Programs in FY2001 and FY2002.) Legislative Action in the 108th Congress
The FY2003 Omnibus Appropriations measure (H.J.Res. 2/P.L. 108-7), signed into law on February 20, 2003, funded a number of programs and initiatives that will support the
struggle against AIDS in Africa. In May, Congress approved and President Bush signed into
law H.R. 1298/P.L. 108-25, the United States Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Act of 2003. This bill backs the President's Emergency Plan for AIDS Relief
by authorizing $3 billion per year for FY2004 through FY2008 (a total of $15 billion) and
creating the office of the Global AIDS Coordinator at the Department of State. (For details,
see Legislation). The amounts to be appropriated for international AIDS programs,
however, remain to be seen. For further information, see CRS Report RS21181, HIV/AIDS
International Programs: Appropriations, FY2002-FY2004.
Several bills with provisions
related to the African AIDS pandemic have been introduced in the 108th Congress and
referred to committee, including:
H.R. 390 (Waters)/S. 185 (Daschle), African Famine Relief Act of 2003H.R. 643 (Waters), Debt Cancellation for the New Millennium ActH.R. 1145 (Millender McDonald) Peace Corps HIV/AIDS Training Enhancement Appropriations Act of Fiscal Year 2003 H.R. 1857 (Hastings) Humanitarian Assistance to Combat HIV/AIDS in sub-Saharan Africa and the Caribbean And National Security Act of 2003 H.R. 2470 (Waters), Medicines to Eliminate Diseases in Developing States Act or the S. 250 (Durbin), Global Coordination of HIV/AIDS Response Act (Global CARE Act)S. 859 (Corzine), Microbicide Development Act of 2003S. 1067 (Alexander), AIDS Corps Act of 2003 P.L. 108-25, H.R. 1298
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.
Authorizes $3 billion for each of the fiscal years 2004 through 2008 for international AIDS,tuberculosis, and malaria activities. Requires the President to establish a comprehensive,integrated, 5-year strategy to combat global HIV/AIDS; establishes at the Department ofState a Coordinator of United States Government Activities to Combat HIV/AIDS globally;establishes a central account to be administered by the Coordinator for all HIV/AIDS funds,except for contributions to the Global Fund, appropriated pursuant to the Act; states senseof Congress that 55% of funding should be spent for treatment (to become mandatory forFY2006-FY2008) and 20% for prevention, of which 33% should promote abstinence untilmarriage programs; mandates that 33% of prevention funds should promote abstinence untilmarriage in FY2006-FY2008; authorizes up to $1 billion of the $3 billion authorized forFY2004 for the Global Fund to Fight AIDS, Tuberculosis, and Malaria for FY2004 and suchfunds as shall be necessary through 2008, but U.S. contribution to the Fund not to exceed33% of total funds contributed by other sources unless the President determines aninternational health emergency threatens national security; establishes a U.S. technicalreview panel to provide guidance to U.S. representatives to the Global Fund; requires theComptroller General to monitor and evaluate projects supported by the Global Fund; amendsthe Foreign Assistance Act of 1961 to authorize the President to furnish assistance toprevent, treat, and monitor HIV/AIDS in countries of sub-Saharan Africa and other countries;authorizes a pilot program to place health care professionals in overseas areas affected byAIDS, tuberculosis, and malaria; authorizes the procurement of HIV/AIDS pharmaceuticals;authorizes such sums as may be necessary for a pilot program of assistance for children andfamilies affected by HIV/AIDS, and for a pilot program on family survival partnerships; callsfor 10% of funding to be used to help children whose parents have died of AIDS. H.R. 1298was introduced in the House on March 17, 2003; referred to the Committee on InternationalRelations; marked up and reported (H.Rept. 108-60) April 2. Passed House (375-41),amended, May 1, 2003. (For text of amendments, see H.Rept. 108-80.) Passed Senate,amended, by voice vote, May 16, 2003. House agreed to Senate-passed version by voicevote, May 21. Signed into law May 27, 2003.


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Table 1. By type of infection, microorganisms to be suspected in relation to the presence or not of risk factors for multidrug resistance and suggested empirical treatments [VAP: ventilador-associated pneumonia; MDR: multidrug resistance; ESBL: extended-spectrum β-lactamase; ESCPM group (Enterobacter cloacae, Enterobacter aerogenes, Serratia marcescens, Citrobacter freundii, Providencia rettgeri and Morganella morganii); MRSA: methicillin-resistant S. aureus; HACEK (Haemophilus spp., Aggregatibacter -formerly Actinobacillus- actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp)] INFECTION TYPE