Addressing the HIV/AIDS Pandemic:
A U.S. Global AIDS Strategy for the Long Term
Council on Foreign
Milbank Memorial Fund
At the dawn of the new
millennium, there are few threats more dangerous to mankind than the global
HIV/AIDS pandemic. Infecting 40 million people and already accounting for 25
million deaths, it could well become the worst health crisis in modern
history. While centered today in sub-Saharan Africa, it is spreading rapidly
in India, China, Central Asia, and Russia.
In January 2003
President George W. Bush announced a $15 billion President's Emergency Plan
for AIDS Relief (PEPFAR), intended to achieve a series of five-year goals:
preventing 7 million new infections, getting 2 million infected people on
treatment, and caring for 10 million people with HIV/AIDS.
This report recognizes
that PEPFAR is a historic and laudable initiative. But the administration's
plan is too near-term in orientation and too narrow in scope to achieve its
long-term objectives. This report recommends that the United States adopt a
longer-term and broader-based strategy, addressing, in particular, the basic
health systems that developing countries need and the critical issues that
go beyond health delivery. While this strategy will require more resources,
it will be more likely to enable the United States to reach its five-year
goals for PEPFAR, and it will enhance the ability of the United States to
effect long-term, sustainable progress against this and other diseases.
The report, a Council
Special Report and Milbank Memorial Fund Report, is the product of a joint
project by the Council on Foreign Relations and the Milbank Memorial Fund,
in conjunction with the Open Society Institute. The project convened
meetings with specialists and representatives of more than 30 government and
private organizations working in this field, with the U.S. Global AIDS
Coordinator and his staff, and with numerous individual researchers.
The Council and the Fund
have each worked for many years to bring the best available information and
ideas to bear on the development and implementation of policy in their
respective fields—the Council in foreign policy and national security
matters, the Fund in health care and population health. This is our second
joint project. In 2001 the Council and the Fund published the report, Why
Health Is Important to U.S. Foreign Policy. Daniel M. Fox, President of
the Fund, proposed that the two organizations collaborate again on the
HIV/AIDS crisis and invited the Open Society Institute to collaborate in
recognition of its path-breaking work in this field.
Princeton N. Lyman,
Ralph Bunche Senior Fellow and Director of Africa Policy Studies at the
Council on Foreign Relations, and Daniel M. Fox directed the project. Greg
Behrman was the coordinator of the project and is the principal drafter of
The Council and the Fund
are grateful to many colleagues who contributed to this report. They are
listed in the Acknowledgments.
Princeton N. Lyman
Director of Africa Policy Studies
Council on Foreign Relations
Daniel M. Fox
Milbank Memorial Fund
The report could not
have been written without the intellectual contributions of an exceptional
group of people from over 30 organizations. They are listed with their
affiliation at the time of their participation.
Kathleen Andersen of the
Milbank Memorial Fund, Kathleen M. Foley of the Memorial Sloan-Kettering
Cancer Center, Zoe Hudson of the Open Society Institute's Washington office,
and Nina R. Schwalbe of the Open Society Institute were involved in the
early stages and provided insights, expertise, and valuable material
throughout the project. Others include Judith D. Auerbach of the American
Foundation for AIDS Research; Holly J. Burkhalter of Physicians for Human
Rights; Craig Calhoun of the Social Science Research Council; Mary Callaway
of the Project on Death in America; Jennifer Cooke of the Center for
Strategic and International Studies; Kathleen Cravero of UNAIDS; Nils
Daulaire of the Global Health Council; Alex de Waal of Justice Africa; Linda
Distlerath of Merck & Co.; Andy Fisher of the Horizons Program at the
Population Council; Janet Fleischman of the Committee on Gender of the
Center for Strategic and International Studies Task Force on HIV/AIDS;
Richard L. Garwin of the Council on Foreign Relations; Adrienne Germain of
the International Women's Health Coalition; Norman Hearst of the University
of California, San Francisco; Michael Iskowitz of UNAIDS; Jennifer Kates of
the Henry J. Kaiser Family Foundation; Patrick W. Kelley of the Institute of
Medicine; Thomas Loftus of the World Health Organization; Ellen Marshall of
Good Works Group; Phillip Nieburg of Project Hope; James C. O'Brien of The
Albright Group; Leonard S. Rubenstein of Physicians for Human Rights; Peter
A. Selwyn of Montefiore Medical Center; Gayle Smith of the Center for
American Progress; Daniel Steinberg of the Allergy and Asthma Center of
Massachusetts; Ann Swidler of the University of California, Berkeley; Sandy
Thurman of the International AIDS Trust; and Marcel van Soest of the
International HIV Treatment Access Coalition. Robin T. Kelley of the
American Psychological Association's Office on AIDS provided an excellent
assessment of the 14 countries early on in the project.
We were especially
fortunate to hear from leaders in the international HIV/AIDS NGO community.
Mr. Modibo Kane of Reseau Africain des Personnes Vivant avec le VIH/SIDA in
Kenya and Mr. Henri Mukumbi Masangu of the African Council of AIDS Service
Organizations (AFRICASO) in the Democratic Republic of Congo enlightened us
with their perspectives. Mr. Ainsley Reid of the Caribbean Conference of
Churches in Jamaica spoke eloquently on the need for a balanced approach to
the HIV/AIDS problem.
Tobias, the U.S. Department of State's Global AIDS Coordinator, met with
members of the group and provided a constructive base for the report. Joseph
F. O'Neill and Ambassador John Lange of Ambassador Tobias's office
contributed their time and insights.
Colleagues at the
Council on Foreign Relations contributed immensely to the report. Laurie
Garrett gave valuable comments, while James M. Lindsay and Richard N. Haass
both provided comments and helped to guide the report to its completion.
Gail Cambridge of the
Milbank Memorial Fund and Odette Boya of the Council on Foreign Relations
were invaluable in organizing meetings and facilitating communication among
members of the group.
The United States has
embarked on a major effort to combat the HIV/AIDS pandemic. The success of
this effort will be critical. Yet as impressive as the U.S. response has
been, more will have to be done on a broader level to achieve the objectives
that have been set forth.
The global HIV/AIDS
pandemic constitutes one of the most pressing threats known to mankind. Over
the past 20 years, more than 65 million people have become infected with
HIV/AIDS. More than 25 million have died.1
Roughly 14 million children have lost one or both parents due to AIDS. By
2010 it is estimated that approximately 100 million people will have been
infected and that there will be 25 million AIDS orphans worldwide. A
humanitarian catastrophe of incomparable proportions, the pandemic is also a
threat to global economic and geopolitical stability and a critical
strategic threat to the United States.
On January 28, 2003,
President George W. Bush announced the President's Emergency Plan for AIDS
Relief (PEPFAR), pledging $15 billion over the next five years to combat the
pandemic, including $10 billion in new monies for 14 targeted countries. The
initiative aims to prevent 7 million new infections, provide treatment for 2
million people, and care for 10 million people. It is the most ambitious
plan ever proposed by any single country to battle the pandemic. Congress
has been strongly supportive, enacting authorization legislation in 2003 and
appropriating $2.4 billion for fiscal year (FY) 2004. The Senate has
confirmed Randall Tobias as Global AIDS Coordinator. His office has been
established at the State Department. In late February 2004 the office
released the administration's five-year strategic plan (or "strategic
statement") for enacting PEPFAR. Congress has suggested guidelines for some
aspects of the program—for example, that 33 percent of prevention funds be
dedicated to promoting abstinence—and instructed the administration to
select a 15th country for the program. Congress also mandated that U.S.
contributions to the recently formed Global Fund to Fight AIDS, Tuberculosis
and Malaria be matched two for one by all other donors.
initiative constitutes a historic recalibration of the U.S. response to this
insidious modern-day plague and places the United States in an excellent
position to lead a comprehensive international effort to combat the
pandemic. As the title of its program indicates, the administration has
chosen to emphasize that the pandemic is an emergency. Fewer than 500,000 of
those infected who need antiretroviral (ARV) treatment, estimated at 6
million, have access to these lifesaving drugs. Thus PEPFAR will focus on
rapid delivery of health services and an emergency effort to treat persons
as quickly as possible. This approach is understandable and justified when
looking at the immediate needs. But the current U.S. strategy is near-term
and too narrowly focused. It must be upgraded and broadened if it is to
reach its near-term goals and achieve long-term success.
The broader and
long-term approach that is required must meet the basic health needs of
affected developing countries. As urgent and necessary as it is to address
the plight of the 20 to 30 percent of a country's population infected by
HIV/AIDS, to overlook the health needs of the other 70 to 80 percent with
other health needs is neither politically nor financially sustainable as
host countries and donors strain to support two separate health systems.
African countries are quick to point out that 1 million people die from
malaria each year, and other diseases take a vast toll in morbidity and lost
productivity. This competition between HIV/AIDS and other health programs
will become particularly intense as the annual cost of treatment grows and
as more infected persons receive treatment.
Moreover, it is now
clear that it will not be possible to reach the vast majority of people who
do not know they are infected by HIV without having basic health facilities
that can make HIV testing a routine part of general health services.2
Thus the United States must build upon the valuable PEPFAR initiative with
an equally strong commitment to leading an international effort to help
build the basic health systems of developing countries. This is an extensive
proposition, but one that has many rewards.
The World Health
Organization (WHO) has estimated that providing basic health services to
developing countries will take financial assistance of $27 billion per year
by 2007, and up to $38 billion annually during the following eight years.
While those figures are high, WHO estimates that such an initiative would
save 8 million lives per year by 2010 and generate $186 billion in new
economic output per year by 2015.
Nevertheless, we do not
recommend that the United States and its international partners commit all
of the funds upfront or even funds at the full annual level right away. Much
of PEPFAR and other international funding for HIV/AIDS can contribute to
this objective if so structured. However, the United States should begin to
mobilize international support for broader health systems in the countries
that PEPFAR focuses on so that such systems are in place in five years.
Otherwise, five years from now, not only will the broader health needs not
have been addressed, but PEPFAR investment into programs directed to
HIV/AIDS may fail to achieve its goals. But if properly planned, the
HIV/AIDS work in these countries can lay the basis, in experience and
improved methods, for the larger program envisaged by WHO.
In this context, the
long-term implications of a commitment to universal access to treatment,
which host countries are urged to adopt, need to be addressed. Contemplating
lifetime treatment for 30 to 40 million people or more represents a
commitment for that intervention alone of at least $9 to $12 billion a year.
Developing countries are deeply concerned about who will bear this cost.
The United States will
also have to broaden its use of PEPFAR funds in the next five years to
address some of the social and economic factors that contribute to the
spread of HIV. The U.S. strategic statement does recognize many of these
factors, including the legal, social, and economic forces that increase the
vulnerability of women and girls to infection and the vulnerability of
children affected by HIV/AIDS. But the statement is ambiguous on how much
PEPFAR funding will be devoted to these factors. While PEPFAR itself cannot
fund such programs like universal primary education, or address alone the
impact of gender factors on HIV/AIDS, it can help build support for such
programs and for legal and policy changes affecting discrimination; PEPFAR-supported
programs can demonstrate that those programs are essential complements to
any health-based effort to combating HIV/AIDS.
The strategic statement
gives insufficient attention to the military. The military in Africa is
particularly hard hit by the disease and is a key source of its spreading.
The U.S. Department of Defense has begun HIV/AIDS programs with many African
military forces, and continuation of these programs is vital for PEPFAR's
success. However, the strategic statement makes no mention of how these
programs will be funded or incorporated into the overall plan.
The strategic statement
commendably highlights the importance of scientific evidence in guiding
policy decisions. It is imperative that decisions about what prevention
programs to implement be buttressed by the strongest scientific evidence
available. This is particularly important because there are strong
ideological and other differences about how to prevent HIV/AIDS. Sexual
abstinence, condom distribution, and programs for sex workers and drug users
are all controversial approaches, each advocated by one or more groups. The
U.S. strategic statement is correct to assert that science must trump
ideology. Ensuring that the United States and its international partners
analyze the effectiveness of various interventions at the outset will help
provide the evidence to make these consequential policy decisions in the
best informed manner possible.
Based on the analysis
above, we propose the following:
Key Recommendations for
U.S. Global AIDS Policy
Even as it hastens to meet the president's five-year targets, the
administration must launch a long-term effort to build politically and
financially sustainable basic health systems. This effort should begin with
the 14 or 15 focus countries under PEPFAR, where HIV/AIDS programs should be
integrated as much as possible with building such systems. Over the next
five years, the United States and other international donors should begin to
build support and financing for the World Health Organization's
recommendation of $27 billion per year by 2007 and $38 billion per year by
2015 to vastly upgrade health infrastructure in the entire developing world.
Affected communities must have this infrastructure to wage a sustainable
battle against HIV/AIDS and other pressing health crises.
The growing commitment of the international community to providing
treatment for as many people in need as possible, which is at the heart of
PEPFAR and a comparable WHO program, is welcome. But it involves major
long-term responsibilities that have not been fully appreciated. The
long-term costs of lifetime antiretroviral treatment for all those who need
it could reach $9 to $10 billion annually for decades to come. This will
have significant implications for development strategies and assistance
programs, especially in sub-Saharan Africa. We recommend that a high-level
international commission be formed to address this long-term issue,
examining the respective roles and responsibilities of host countries,
donors, pharmaceutical companies, and other possible sources of support in
sustaining treatment for as long as necessary.
The United States must pursue a comprehensive approach to HIV/AIDS,
paying particular attention to factors fundamental to the pandemic's spread,
such as the vulnerability of women and girls and the special role of the
military in demobilization and peacekeeping operations. PEPFAR funds should
be allocated to demonstrating the direct relevance to control of the
pandemic of such factors as legal protection and expanded access to
education for women and girls. Department of Defense funding should be
allocated to work with military forces in acutely affected countries.
The best available scientific evidence should guide the
administration's policies. The use of science in decision making must be
ideology-free, and it must be shared with other donors and countries in
which programs are operating. This will be particularly important in
assessing the efficacy of prevention programs where controversy exists. It
is also important in selection of drug regimens, determination of safe drug
sources, and other aspects of the program. From the outset, the
Coordinator's Office should work with local partners to vigorously promote
operational research, or research on the effectiveness of various
interventions, to provide greater scientific insight into which
interventions do and do not work in certain settings.
Monitoring and evaluation must be structured from the start to serve
both short-term and long-term objectives. It is particularly important to
monitor resistance and related outcomes of treatment regimens in order to
measure compliance, assess the costs and benefits of different regimens, and
identify new strains of the virus that may be developing. Because microbial
timelines are different from timelines for operations, funding, and even
individual health, sophisticated monitoring programs should be employed. It
will also be essential to work closely with local program managers,
researchers, and community leaders in establishing monitoring and evaluation
programs and to make the results available and accessible to them. The
Coordinator should work closely with the Institute of Medicine (IOM), which
Congress has charged with evaluating PEPFAR after three years, regarding the
information systems, data, and other inputs IOM will need.
The strategic statement highlights the role of innovation and
flexibility. Embassies must engage local people affected by the pandemic,
NGOs, and community-based programs in planning and reviewing strategies and
in implementing projects. This will not be possible, however, without more
flexible funding mechanisms. The Coordinator should examine the innovative
techniques for reaching and funding small local groups closest to the
problem, which the U.S. Agency for International Development (USAID)
instituted and oversaw in South Africa in the early 1990s and in Nigeria in
The strategic statement places great emphasis on "graduation" plans
by which U.S. support would phase out. However, combating this pandemic will
require decades of international involvement and the funding of programs
well beyond the emergency focus of the next five years. "Graduation" plans
should be honest about this. Even speaking too glibly of "graduation" could
alarm developing countries about the burdens that will fall on them,
underestimate the long-term costs, and undermine the public understanding
and support necessary for this commitment.
Emergency Plan for AIDS Relief
Background, Purpose, and
During his State of the
Union Address on January 28, 2003, President George W. Bush announced to the
world the President's Emergency Plan for AIDS Relief (PEPFAR). Described as
"a work of mercy beyond all current international efforts to help the people
of Africa," the plan targeted the modern-day scourge that has become one of
the most perilous threats known to mankind: human immunodeficiency virus
(HIV) and acquired immune deficiency syndrome (AIDS).
Almost 70 percent of
those infected with the virus now live in sub-Saharan Africa, by far the
world's most acutely afflicted region.3
Estimates predict 100 million or more cumulative global infections by
The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that by
2010 approximately 25 million children will have lost one or both parents to
AIDS, creating a generation of orphans, 20 million of whom are likely to
reside in Africa's subcontinent.
If Africa is the
epicenter of the pandemic, a second wave is projected in Asia and Eastern
Europe. The National Intelligence Council (NIC) has estimated that, at the
current trajectory, China and India are likely to have 10 to 15 million and
20 to 25 million infected people, respectively, by 2010.5
Such levels of infection would reduce economic growth, produce social
pressures in various regions and subgroups of the population, and possibly
engender some measure of political disaffection. These pressures may very
likely render the disease a destabilizing force in the world's two most
populous countries, both of which are nuclear powers and both of which have
critical strategic relationships with the United States. Already mired in a
debilitating demographic crisis elsewhere in Eurasia, Russia is likely to
have 5 to 8 million HIV-infected people by decade's end.6
That will imperil Russia's tenuous democratic transition and breed economic
and political disorder in a nation already struggling to safeguard thousands
of nuclear weapons and vast quantities of nuclear materials.7
At present, the
disease's implications for U.S. and global security are most profound in
sub-Saharan Africa. In the landmark 2002 U.S. National Security Strategy,8
the administration made the "revolutionary"9
assertion that, for the first time in history, weak states pose a greater
threat to the United States than strong states. The disease is eroding state
capacity in sub-Saharan Africa, an increasingly important front in the war
on terror and an increasingly important source of resources and minerals.
(The United States is expected to import as much as 25 percent of its oil
from this region within the next decade.)10
For example, the U.N. World Food Programme reports that AIDS has depleted
the rural work force in southern Africa so thoroughly that it has seriously
eroded the population's capacity to deal with cyclical droughts and food
shortages. The growing number of orphans increases the prospect of child
soldiers being recruited for rebel armies or militias; child soldiers have
already been heavily recruited into nearly all the conflicts on the
continent. Infection rates among African military personnel range as high as
with serious implications for Africa's ability to keep the peace and
maintain law and order. With reduced ability to deal with either economic
development or security, Africa will become increasingly susceptible to
conflict and increasingly attractive as a haven for terrorists and
transnational criminal elements hostile to the United States.12
There is an additional
threat to the United States. As treatment programs are introduced in Africa,
concern over mutations of the virus will heighten, especially if treatment
is not maintained. The spread of a more virulent virus to the United
States—one immune to current treatment—would cause major health problems in
the United States. Thus, stemming the rate of infection and monitoring
treatment programs in Africa are of vital importance to America's own public
It is of paramount
importance, then, that the administration accord this global catastrophe the
urgent priority it deserves. HIV/AIDS is not only an unprecedented
humanitarian catastrophe but a political and security threat to both U.S.
and global interests. Because of the United States' global power and reach,
the U.S. response will—as it has throughout the history of the pandemic—set
the bar and the standard for the global response at large. It is a role that
the United States should not shrink from. American moral and strategic
interests demand engagement at the highest level and with the urgency and
scale of a high-priority U.S. foreign policy issue.
Proposed Funding for
Against the backdrop of
increasing acknowledgment of the magnitude of the crisis and the urgency of
the threat, the president's announced plan was met with wide acclaim and
enthusiasm around the world. The president pledged $15 billion over the next
five years to fight the pandemic. He aimed to prevent 7 million new
infections, treat 2 million people, and care for 10 million infected people.
legislation that Congress passed in May 2003 fleshed out the president's
plan. Congress authorized $3 billion per year for fiscal years 2004–2008,
including $2 billion for bilateral assistance and $1 billion for the Global
Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) that is
contingent on matching funds at a two-for-one ratio from other nations.
While not binding, provisions in the legislation recommended that funds be
apportioned 55 percent for treatment; 20 percent for prevention (one-third
of which was earmarked for "abstinence before marriage"); 15 percent for
palliative care; and 10 percent for orphans and other vulnerable children.
Under the legislation, $750 million—including $300 million, which would be
directed to an initiative aimed at reducing mother-to-child
transmission—would be directed toward 14 countries: the Caribbean nations of
Guyana and Haiti, and the African countries of Botswana, Cote d'Ivoire,
Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa,
Tanzania, Uganda, and Zambia. In addition, the legislation created a new
position at the State Department for a Global AIDS Coordinator, charged with
carrying out the president's plan.13
The Global AIDS Coordinator's mandate is to lead the U.S. response to combat
the worldwide pandemic; the Coordinator's purview is not restricted to the
14 or 15 PEPFAR countries.
After President Bush
requested $2.1 billion for FY2004, Congress appropriated $2.4 billion.
Existing bilateral programs, such as those outside the focus countries,
received $1.258 billion, including $324 million for research by the National
Institutes of Health. For the focus countries, Congress appropriated $637
million, plus $547 million for the Global Fund. The appropriators also
instructed the president to add a 15th country outside of the Caribbean or
The president's budget
request for FY2005 would sharply increase funds for the focus countries to
$1.45 billion, while slightly reducing existing programs elsewhere, and
would reduce the contribution to the Global Fund to $200 million. The
president's total request for HIV/AIDS in FY2005 is $2.7 billion plus $120
million for tuberculosis and malaria.
initiative constitutes a leap forward in funding and priority. It positions
the United States as a global leader on this issue. It should galvanize
leaders in affected countries to improve their national efforts and it
should catalyze the rest of the international community, particularly donors
in the developed world.
Key Elements of the
With the appointment of
a Global AIDS Coordinator and the legislation's enactment, the Coordinator's
Office has spelled out key features of the administration's plan:
The president has provided a clear five-year mandate to the Coordinator's
Office. Over the next five years, it aims to prevent 7 million new
infections, treat 2 million people, and care for 10 million infected people.
Coordinator's Office intends to support each national program, as outlined
by that country. U.S. ambassadors will be the point people in each nation
and will report directly to the Coordinator. They will be charged with
disbursing funds and overseeing each country's national effort. U.S.
efforts, then, will cohere with each country's plans and support its
The initiative is an "Emergency" plan recognizing the urgency of the
catastrophe and the need to plan and act accordingly.
With a global purview, the Coordinator will coordinate U.S. efforts with
those of myriad other international actors including bilateral donors,
various U.N. agencies, UNAIDS, the Global Fund, and NGOs.
Key Strengths of the
In "The President's
Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy"
(the "strategic statement"), released in February 2004, the administration
spelled out the objectives and operational principles of its plan in detail.
The strategic statement's objectives and principles bode well for the
prospects of producing near-term results in the targeted countries. Key
strengths of the U.S. strategy include:
strategic statement emphasizes the importance of scientific evidence as the
foundation for making informed policy decisions. Given the plethora of
interested parties and their distinct agendas and perspectives—some more
ideological than scientific—this is a valuable guiding principle. It will
help policymakers identify the most effective interventions possible.
The strategic statement highlights the importance of clear, open decision
making at every level. The Office of the Global AIDS Coordinator and other
U.S. actors will do their best to make available the criteria for awarding
contracts to grantees, updates on the progress of various programs, and
other important facets of U.S. activities. The use of a highly transparent,
user-friendly Web site will facilitate the sharing of information.
Even though its primary goal is successful health-based actions, the
strategic statement recognizes that changes in socioeconomic factors such as
education, legal frameworks, and social and economic welfare—particularly as
they relate to the vulnerability of women and girls and the plight of
children affected by HIV/AIDS—will be essential to stemming the tide of the
pandemic. Pursuing these aims will have a powerful impact on the
effectiveness of American efforts. Yet the strategic statement is
nevertheless ambiguous about the degree to which PEPFAR funds will be used
for these purposes.
Coordination on Safety
of Drug Regimens.
With a plethora of international actors now providing drug treatment to the
affected countries, and individual countries making national decisions on
regimens and sources of drugs, it is imperative that these entities
establish some degree of coordination to make sure that drug regimens
provided are not only effective, but safe, and to monitor their use
carefully. The strategic statement promises early work with multilateral
institutions and other donors on these issues.
Provision of Palliative
strategic statement refers to the need for community-based palliative care.
This will be essential both for those with access to ARV treatment and for
the many others who are unlikely to have access in the near future.
Palliative care is needed for pain management, psychological distress, and
opportunistic infections. Patients should be provided with essential
medicines, counseling, and caregiving. Such care is also an excellent entrée
for encouraging patients to write wills and to deal with inheritance and
other succession issues.
Coordination with Donors.
The strategic statement stresses the importance of U.S. coordination with
its international partners to standardize paperwork as well as monitoring
and information systems. Administrative capacity in affected countries is
low, and administrators and health care practitioners often find themselves
overwhelmed and exhausted. In addition, disparate monitoring and information
systems from nation to nation make it difficult to analyze the effectiveness
of various interventions. The statement is especially encouraging about U.S.
willingness to adopt some of the systems established by the United Nations
or others, rather than insisting on its own.
Willingness to Purchase
"Safe" Drugs at Lowest Possible Price.
The United States recognizes the importance of pursuing the most effective
approach to treatment methods. The strategic statement implies at least that
if "generic" drugs, or those produced by non-pharmaceutical companies based
on off-patent drugs, are safe and the least expensive, the United States
will buy them. This will allow assisted countries to purchase as many drugs
and treat as many people as possible for the dollars available. However, the
qualifier is that PEPFAR will insist on adherence to the Trade-Related
Aspects of Intellectual Property Rights (TRIPS) agreement, which may limit
purchases to patented drugs in some cases.
Emphasis on Community
Almost every part of the strategic statement stresses the importance of
responding to local conditions. The United States welcomes the chance to
build upon local capacity and to work with local officials and those
affected, including HIV/AIDS patients and children affected by HIV/AIDS, to
ensure that U.S. efforts suit local needs as much as possible. This will
help produce successful results.
Innovative and Flexible
strategic statement recognizes the need to be innovative and flexible in
identifying and supporting the most effective programs available. Most
disbursal decisions will be made "close to the ground" in affected
countries. This, too, will be a key ingredient of success.
Rather than pursuing its own agenda, the United States has specified that it
will serve the national strategy of each affected country. This will foster
coordination and ensure that U.S. efforts meet national and local needs
Recognition of Enormous
Lack of Health Infrastructure.
Throughout the strategic statement, the administration recognizes the
crippling deficit in health care infrastructure as a fundamental impediment
to fighting the pandemic. It highlights the dearth of physical
infrastructure, like health centers, clinics, equipment, and delivery
systems, and the lack of human infrastructure in the form of health care
workers and administrators. The strategic statement explains that the United
States will work to enhance health care systems and capacity, primarily with
respect to delivery systems for HIV/AIDS drug treatment and recruiting and
training health care workers to treat and care for HIV/AIDS patients. These
will certainly be essential elements—though health infrastructure, as
detailed below, must be addressed much more broadly to realize the program's
The strategic statement
is commendable. All of its objectives and guiding principles noted above
will help produce short-term results. The plan in its present form, however,
is too near-term in orientation and too narrow in scope. In order both to
meet the president's five-year targets and to achieve longer-term success in
battling the pandemic, a broader plan of attack is necessary.
To begin with, the
United States should pursue a two-track approach to building improved health
delivery systems. The first track would be a five-year strategy with an
emergency posture and time horizon equal to PEPFAR. Concomitantly, though,
the United States should move just as rapidly and vigorously to enact the
long-term strategy of building health infrastructure in the most affected
regions and in the rest of the developing world. ("Health infrastructure" is
used in the comprehensive sense here to include building health delivery
systems from hospitals to health centers to community-level clinics; support
systems to provide drugs and supplies; and trained health workers at all
levels.) This long-term strategy requires a greater financial commitment.
In addition, both tracks
will require an extensive response beyond health delivery systems if they
are to succeed. The United States and its international and local partners
must tackle pressing social and political issues that are fundamental to the
spread of HIV/AIDS. Finally, within the parameters of the strategy
statement, there are certain principles and practices that require further
emphasis and elaboration.
It should also be noted
that while this report strongly advocates that the United States lead a
global response, some of the specific recommendations below focus on U.S.
policy vis-à-vis the 14 or 15 countries highlighted in the president's
initiative, although most of the recommendations contain principles with
on these points follow.
Infrastructure: The Key to Waging a Long-Term, Sustainable Battle
infrastructure is perhaps the most important part of a successful,
sustainable attack on the pandemic and of improved long-term health in the
affected countries. As the strategic statement recognizes, most of those
countries and many other countries in the developing world have appallingly
weak national health systems. The absence of hospitals, health centers,
clinics, delivery services, and other physical infrastructure has been
crippling and will constitute a major obstacle to progress. The deficit in
human capital—the health care workers necessary to treat, counsel, and care
for patients, and to manage and administer health systems—has been
debilitating, and it continues to worsen. Many sub-Saharan countries and
impoverished countries elsewhere in the world devote only a few dollars per
capita per year to health; Ethiopia, for example, currently spends
The pandemic severely
compounds the infrastructure problem. It weakens economic conditions, which
in turn lower the amount of money available for health systems and services.
In addition, the disease is killing doctors, nurses, and other health care
workers, who are already scarce. This is part of the tragic impact of AIDS:
It has hit people in their most productive stages of life and those who
should be in the forefront of prevention programs. Furthermore, sickness and
death are so prevalent, working conditions so poor, misery so acute, and
resources so scant that many health workers, already insufficiently
compensated, suffer from depression and are unable to cope and perform.
emergency approach is essential. Therein, the United States should be as
aggressive as possible in meeting treatment and care targets. The strategic
statement addresses the deficit in health care infrastructure in three
primary ways. First, it stresses a "network model,"15
whereby the United States would embark on a near-term process of shifting
health systems from the center (i.e., hospitals, clinics, labs, and other
institutions) out to the community level (house visits, volunteers, ad hoc
care in the targeted countries). Second, it highlights the need to build out
delivery services for antiretroviral drugs. Third, it notes the need to
recruit and train health care workers in order to make up for the deficit in
human capital. These measures are sensible and should yield important
But there are five
critical reasons why this approach will fail to yield long-term success in
the battle against the disease.
First, whereas the
five-year U.S. goal aims to get 2 million people on treatment, there are
currently 20 million infected people in the 14 countries selected for PEPFAR.
A much more robust health infrastructure will be necessary to treat tens of
millions of infected people in the years ahead. The same argument holds true
for testing. Ninety-five percent of Africans and 95 percent of people
infected globally do not know their HIV status. Tens of millions of people
will need to be tested in order to get on treatment and to be counseled to
abet prevention. Part of the reason for the lack of testing is the stigma
attached to going to HIV/AIDS–specific centers for this purpose. Vast
increases in health facilities, clinics, and health care workers will be
needed to provide the setting to test, treat, counsel, and care for all who
need to be reached.
Second, a preoccupation
with AIDS threatens to cause other pressing health challenges to be
neglected. The strategic statement's noted intention to build delivery
services for ARV drug treatment, while vital, is a perfect example. Such a
delivery system might provide a robust and sustainable part of the overall
health system, whereby other drugs for other purposes could also be
delivered over time. However, if these services are designed solely to
deliver ARV, they will drain resources from other areas of the health system
and create a parallel structure. In fact, even where the administration
emphasizes integrating HIV/AIDS into every aspect of existing or new
components of health systems, history shows that the net effect will be to
divert more attention and resources within those systems to HIV/AIDS. The
concerted campaign to fight malaria in the 1960s and 1970s drew resources
from the larger health systems and from other vital health problems. For the
smallpox eradication campaign of the 1970s and 1980s, a separate delivery
system was developed and then allowed to dissolve, leaving no infrastructure
for later vaccination campaigns. Fighting HIV/AIDS in the same way would
have a negative effect on health systems' capacity to meet other health
needs, and it would have disastrous consequences for the long-term health
and development of affected countries.
flourishes in conditions in which health is generally poor. When people are
sick—particularly with serious diseases such as TB or malaria—their immune
systems are compromised, and HIV thus hits them hardest. Improving general
health conditions is part and parcel of battling HIV/AIDS.
Fourth, although the
strategic statement laudably recognizes the dearth of health care workers
and other human resource problems, such as the "brain drain"—the flight of
health care workers to other fields or geographic areas—it is unclear how
much impact PEPFAR will have on this enormous problem, given the
administration's extremely long list of objectives and limited funds. To
truly tackle the human capacity problem, the United States will need to
provide a large pool of funds over a long time horizon for wide-scale
recruitment and training efforts, which will take many years to produce
Fifth, it is doubtful
that it will be politically possible for recipient countries to sustain a
health delivery system that is largely geared to the needs of 20 to 30
percent of their populations, however dangerous HIV/AIDS is. There is the
likelihood, therefore, of political backlash against donor insistence on
this priority and a weakening of host countries' commitments.
WHO has developed plans
and funding estimates for a more broad-based basic health system in
developing countries. The costs are significant but also need to be put in
context. Health spending in high-income countries averages more than $2,000
per capita per year.16
WHO estimates that essential health interventions in the developing world
require expenditures of $34 per capita per year. Even at that level,
however, considerable funding must come from the donor community. Most
African countries currently spend less than a third of that amount, many far
WHO estimates that the total additional funding required is $27 billion
annually by 2007 and $38 billion by 2015. If the United States were to
provide one-third of it—i.e., $9 billion per year by 2007—it would be a
significant increase in foreign assistance. However, it would still amount
to less than 0.1 percent of GNP, or less than ten cents per every $100 of
GNP. However, all of this need not come from foreign aid. African countries
today, despite their poor economic condition, pay $11 billion annually in
debt service. Canceling or substantially lowering this debt would allow
these countries to direct those funds to basic health services. The results
of the Highly Indebted Poor Countries (HIPC) debt reduction program
demonstrate this potential (e.g., the rising health and educational
expenditures in Uganda and Mozambique).
The returns from this
investment would be substantial. First, according to WHO, it would save 8
million lives per year by 2010. Second, WHO estimates that these countries'
economic output would grow by $186 billion per year by 2015, making for a
much sounder global economy. Third, while this investment would require a
long-term commitment of up to 20 years, WHO estimates that the gains in
health and economic output will finance ongoing health efforts in a
self-sustaining fashion following that period.
Despite these potential
benefits and the desirability of meeting these important health needs, we
are not recommending that the United States immediately accept the entire
WHO plan. Coming on the heels of the administration's commitment of $15
billion for the campaign against HIV/AIDS, it is not politically feasible to
obtain such funding from Congress. Moreover, much can be done by using
PEPFAR and by beginning such work in the 14 or 15 focus countries in which
these funds are to be spent. Programs in these countries would also provide
the experience and methods that could be later adapted to a broader set of
Recommendations for a
Infrastructure with Overall Health Systems.
Because of the emergency at hand, PEPFAR should pursue immediate and
opportunistic measures to promote testing, treatment, prevention, and care.
However, the long-term ability of affected countries to deal with the
pandemic will depend upon the strength of their overall health systems.
Therefore, the administration should do its best to integrate PEPFAR's
infrastructure-related investments with the overall national health systems.
The same approach should be taken in United States bilateral HIV/AIDS
programs in other countries. This would mean training health workers to deal
with a broad range of health problems; developing delivery systems that can
accommodate drugs other than ARV; enhancing the testing, treatment, and
counseling capacities of existing health centers and clinics as much as
possible before establishing separate ones for HIV/AIDS; providing
incentives to retain health professionals who are leaving for developed
countries; and helping national governments develop comprehensive health
systems, rather than drawing resources from those systems purely for
HIV/AIDS work. The Coordinator should encourage a similar approach by
multilateral and other bilateral donors.
Address the TB/HIV
Co-Pandemic More Broadly.
Of those infected with HIV, 30 percent are estimated to be co-infected with
TB, the leading cause of death among HIV-positive people in the affected
countries. As a result, the incidence of TB among the overall population in
those countries is also at an alarming level. Although the strategic
statement does call for treatment for people with TB, it refers primarily to
those also infected with HIV; this treatment will be critical to keeping
people with HIV/AIDS alive longer and to raising the plummeting life
expectancy rates. Yet a broader approach, in which non-HIV-infected TB
patients are treated, is imperative and responds to the needs of the general
population indirectly affected by the HIV/AIDS pandemic. This is also a
natural way to integrate the HIV/AIDS investments with broader health
responses. The administration should promote successful models such as the
Directly Observed Treatment Short-Course (DOTS), the internationally
recommended TB-control strategy. DOTS combines five elements: political
commitment, microscopy services, drug supplies, surveillance and monitoring
systems, and use of highly efficacious regimens with direct observation of
treatment. All these elements are similar to, and therefore compatible with,
the conditions for a successful ARV treatment program.
Incorporate Malaria into
The strategic statement gives little mention to malaria. Yet this disease
kills more than 1 million Africans per year. It is also one of three
diseases targeted by both the president's initiative and the Global Fund to
Fight AIDS, Tuberculosis and Malaria (Global Fund) that is funded under the
president's program. Focusing on HIV/AIDS, or even on the TB/HIV
co-pandemic, will drain resources from anti-malaria efforts. This would meet
resistance from Africans and would fail to improve their overall health.
Malaria outreach programs—such as provision of treated bed nets—are not as
technically integrated with health delivery systems as TB programs, but they
can be part of a national health system, and counselors and community
workers can be cross-trained to deal with HIV/AIDS, TB, and malaria.
Develop a Broader Health
Program for the Focus Countries for 2006.
The State Department Office of International Health should work with the
Coordinator's Office to develop a program for achieving a longer-term and
broader set of goals with respect to health in the focus countries. This
program should be developed in conjunction with WHO and with other donors
for introduction into a global health strategy for 2006. The administration
should request additional funding for this purpose in its next annual
HIV/AIDS report and in the 2006 budget.
Such an approach would
enlarge general health objectives in countries where the United States will
be most heavily committed to HIV/AIDS programs, and it would lay the
groundwork for international support of the longer-term goals of the WHO
Planning for Lifetime
Provision of Antiretroviral Drugs: The Key to Mobilizing Resources for
Now that the
administration and other authoritative international actors—such as WHO and
UNAIDS—have accepted the principle that treatment is a critical pillar in a
comprehensive long-term effort to battle the pandemic and that it should be
provided for all of those who need it, the international community must
begin to anticipate how to fund that treatment. The international community
has assumed responsibility for people's lives, because once treatment begins
it cannot be stopped without causing death. The cost of lifetime treatment
for all those who will need it could rise to as much as $9 to $12 billion
annually—more than is currently being provided from all sources for all
HIV/AIDS programs. Neither the administration's estimates nor the
international agencies' estimates has addressed this long-term commitment.
It is, however, a major concern of the developing countries that are being
urged to introduce treatment programs. It is imperative that escalating
costs for HIV/AIDS not drive down investments in other health or development
programs. That would be self-defeating for the developing countries.
Interrupting or reducing treatment programs later, because of a lack of
continued funding, on the other hand, would be a death sentence for those
being treated. This is a difficult issue to face now, when so much effort is
going into the introduction of treatment programs. But facing it is morally
imperative. Here is an excellent way to begin:
high-level international commission, the members of which should have wide,
interdisciplinary professional and governmental experience. They should
examine the scientific aspects of and probable trends in treatment regimens;
the likely costs of treatment over time; the variables in epidemiology,
treatment adjustments, etc. that would affect those costs; the ethical
questions surrounding choices that may have to be made among competing
priorities, such as prevention investments versus treatment; the shared
responsibility; and the economic and political issues.
its analysis, the commission should make specific recommendations on how
these long-term costs should be supported, taking into account affected
countries' different economic capacities, the ways, including appropriate
incentives and other measures, to keep drug prices at or below cost levels,
and international mechanisms for assisting the poorer countries. The
commission might consider recommending a long-term fund for this purpose,
perhaps under the Global Fund, to which contributions would be made each
year on a steadily rising scale. Such a fund would help isolate these costs
from other development financing. The commission should also examine ways in
which treatment programs can strengthen prevention programs and ways to
assure that treatment costs do not drive out funding for prevention.
Finally, the commission should examine how ancillary development programs,
such as the longer-term investment in health proposed in this report, would
increase affected countries' own economic and managerial capacity for taking
over prevention and treatment of HIV/AIDS.
commission should make its recommendations to the international community
within two years.
Beyond Health: Issues
that Require Concerted Focus and Engagement
The United States and
its international partners must tackle other issues fundamental to the
spread of this disease. They affect large populations that have been
particularly hard hit by HIV/AIDS and its aftershocks. Because these issues
are critical obstacles to a successful response, a concerted effort to deal
with them must be incorporated into both the administration's near-term and
developing world, girls and women are particularly hard-hit by and
vulnerable to the pandemic. In sub-Saharan Africa, they comprise 58 percent
of those living with HIV/AIDS. In some of the worst affected countries in
southern Africa, HIV is four to seven times more prevalent among girls aged
15 to 19 than among boys their age.18
The strategic statement
does an excellent job of outlining the reasons why women and girls are
vulnerable. It stresses the need to support specific programs directed
toward them, as well as toward some males, to modify behavior that infects
women and girls. But while the strategic statement highlights the
socioeconomic factors—such as education, legal reform, justice, economic
empowerment, and other social services—it is unclear about what PEPFAR will
do to deal with those factors. For example, after discussing these and other
nonhealth issues, the strategic statement says: "The United States will
focus its interventions on health care and human services approaches to
HIV/AIDS prevention, treatment, and care. . . . Many multilateral
organizations have vital expertise in specific [other] areas."19
Here the strategic statement seems to imply that the United States
recognizes the need for these important services and will cooperate with
other actors but will leave the bulk of the burden on their shoulders.
To combat gender
vulnerability, it is imperative that the United States:
Vulnerability through PEPFAR.
Where socioeconomic factors (again, such as education, legal reform,
justice, economic empowerment, etc.) are considered necessary to prevention,
treatment, and care—as the strategic statement suggests they often are—the
United States must make it clear to other countries that PEPFAR will support
such programs financially and/or summon the appropriate international
partners to help.
Improve Access to
The World Bank and other authoritative sources have demonstrated that
keeping girls and children affected by HIV/AIDS in school reduces their
Effective HIV/AIDS prevention messages should be incorporated in school
curricula. Local authorities must then ensure that schools remain safe for
girls. Enhanced access to education should be pursued as a matter of policy.
PEPFAR should fund programs that demonstrate the positive impact on HIV/AIDS
of greater access to education.
Increase Funding for
Improving education—even universal primary education—in the developing
countries demands significant increases in international funding. UNESCO
estimates that an additional $5.6 billion annually is needed to achieve the
goal of universal primary education in the developing nations by 2015. This
report does not try to address the strategy or timing for reaching that
goal. It is already enshrined in the U.N.'s Millennium Development Goals,
which the United States pledged to support in 2000. But given the importance
of education in containing HIV/AIDS, the United States should build on the
data and experiences of programs relating education and HIV/AIDS and within
the next five years lead a large-scale international effort to realize that
objective. It would be extremely helpful if the Coordinator would discuss
the relationship of education to PEPFAR's goals in the annual reports to
strategic statement pays very little attention to the military. The annex
shows that the administration has eliminated separate funding for Department
of Defense (DOD) HIV/AIDS programs in 2004 and 2005. DOD funding outside of
PEPFAR is not described.
Members of the armed
forces, primarily young men away from their families, are at exceptionally
high risk of contracting and transmitting HIV/AIDS. It is difficult to
obtain statistics because national governments put a lid on such information
years ago after realizing the severity of the problem and their consequent
military vulnerability. Experts suggest that in some nations military
incidence may be 50 percent or higher. Military incidence of 30–40 percent
in sub-Saharan Africa is "not unusual," says one expert,21
and infection rates are rapidly growing among militaries in Asia and the
former Soviet Union. The disease also tends to affect a disproportionately
high number of senior officers.
In acutely affected
regions, HIV/AIDS is eviscerating national military forces. It is rendering
acutely affected countries increasingly unable to safeguard their national
interests and to participate in regional peacekeeping. This is especially
important to the United States, which is relying more and more on African
peacekeepers to address regional conflicts, like those in Liberia, Cote
d'Ivoire, the Democratic Republic of Congo, and Burundi. Where highly
infected armies do participate in peacekeeping operations, they spread the
disease; where uninfected soldiers practice high-risk sex, they take the
disease back home. The disease must therefore be recognized as a threat to
regional, global, and U.S. national security.
On the other hand,
because it is often the strongest and most centralized institution in
acutely affected countries, the military is an excellent area to focus on in
combating the disease. Experts in the impact of HIV/AIDS on security assert
that national militaries must assume "command control," so that everyone
from the chief of the army to platoon commanders and in between assumes
responsibility for those directly under their command.22
Most military forces already conduct mandatory testing; all must do so.
Furthermore, testing must be followed up with treatment, counseling, and, if
need be, employment assistance. When test results are negative, the military
should use education, counseling, and other measures to help prevent
infection of health service members. Senegal, for example, has done an
impressive job controlling HIV/AIDS within its military, enabling it to be a
reliable partner in regional peacekeeping.
Very few military forces
have instituted these straightforward and very powerful measures. The United
States is one of them. U.S. strength, breadth, and its own military model
make it a prime candidate to lead on this issue. Exceptional cases, such as
that of Bangladesh, where military infection is near zero, should be
reviewed for programmatic ideas. To help military forces in acutely affected
nations with this critical security issue, the United States should use
Appeal to Affected
Countries through Diplomatic Engagement.
High-level U.S. political and health officials and top-rank military leaders
should highlight the importance of this problem, the feasibility of taking
steps to combat it, and its urgency as a matter of national, regional, and
international security. The United States should lend strong support to the
U.N. effort to assure that countries participating in U.N. peacekeeping
missions test their soldiers before and during deployment and minimize the
danger of peacekeepers spreading the disease.
Provide Technical and
Acting through the Coordinator's Office or the Defense Department, the
administration should ensure that national governments have the resources
necessary to control HIV/AIDS in the military. The U.S. strategic plan
should include technical and financial assistance with testing, treatment,
counseling, and employment assistance, as well as general guidance on
From 2000 to 2004, the Defense Department spent $35 million for
military-to-military advice and training on HIV/AIDS. The DOD has now worked
with 27 countries and made significant progress in helping institute
testing, counseling, and treatment programs. Viable requests for further
U.S. assistance now exceed available funds. Rather than having the DOD
obtain funds from PEPFAR, which already faces nearly overwhelming demands,
Congress should directly fund at least $30 million annually for U.S.
military assistance for HIV/AIDS. This will give the DOD the incentive and
ability to pursue these programs aggressively.
Scientific Evidence as
the Paramount Guide for Policy: The Key to a Sound Approach
With the influx of
funding and the impetus to move quickly to meet the president's five-year
goals, there will be much pressure to devise, initiate, and support
interventions as rapidly as possible. In addition, because of the high
profile of the effort and the strong feelings and viewpoints about it in
many quarters involved, there is likely to be a good deal of pressure on the
Coordinator's Office to support certain interventions and avoid others. This
is especially true regarding the prominent emphasis in the strategic
statement on sexual abstinence and faith-based programs and the statement's
limitations regarding the use of condoms ("when appropriate and correctly
The strategic statement
should be commended for recognizing the critical importance of basing
interventions on the strongest scientific evidence available. Evidence-based
interventions are likely to be the most effective. To ensure that science
guides policy, there are several important principles to which the
administration must adhere:
Put Science before
Ideology has no place in this decision-making process. In devising,
advocating, and implementing various interventions, those best supported by
unbiased scientific evidence should be chosen. Policy should be unhindered
by ideology. Specifically, abstinence programs, which are highlighted in the
strategic statement, as well as those for condom promotion and other
measures, should be judged strictly on their scientific merit. Where good
evidence is still lacking, as may well be the case for several years to
come, the United States should support a variety of well-conceived HIV/AIDS
prevention programs, using different approaches according to the local
Be Sensitive to Local or
Indigenous Faith-Based Groups.
The strategic statement emphasizes the role of faith-based organizations (FBOs)
as critical partners in prevention, treatment, and care interventions. Scant
distinction, however, is made between organizations based in the United
States and other foreign countries and local and indigenous organizations.
While U.S. and foreign FBOs have a widespread and powerful presence in the
targeted countries and elsewhere in the developing world and must indeed
take part in PEPFAR and the greater effort called for in this report, great
care must be taken to ensure that local and indigenous FBOs are enfranchised
as partners. The increased presence and role of the foreign organizations
must not impinge on the integrity of local customs and values. Such
encroachment will produce a backlash that can harm not only U.S. global AIDS
policy but U.S. foreign policy and interests at large. The United States
must be particularly sensitive to local religion, customs, and values in
areas like Muslim-populated Nigeria. The recent rejection by some Nigerian
Muslim leaders of a polio vaccination program, because they feared it was a
plot to render Muslims infertile, is an example of the suspicions that can
Much more operational research—research measuring the effectiveness of
various interventions—is needed. The administration must promote a vigorous
operational research effort from the outset so that much more might be
gathered on what does and does not work.
In an example of
effective operational research, a team of researchers from the Horizons
Program teamed with AIDS workers in eastern and southern Africa, the MTCT
(mother-to-child-transmission) Working Group in Zambia, and UNICEF to do
operations research at UNICEF-sponsored PMTCT pilot sites. The team asked a
series of questions about service delivery in Kenya and Zambia: What type of
staff training would be needed? Would the services be acceptable to clients?
How would the new services affect existing services? What would the programs
cost? What effect would programs have on HIV transmission? Over the course
of four years, the research answered these and many other questions. The
answers have helped to inform UNICEF's PMTCT efforts around the world and
have resulted in practical guidelines that have made programs more
productive and cost-effective.23
Put More Emphasis on
Social Science Research.
The research annex of the strategic statement places a great deal of
emphasis on biomedical research and on measuring process results (e.g.,
number of people reached), but not very much on social science research that
would assess the impact of various messages on behavioral change. The Global
AIDS Coordinator's Office should draw on the Social Science Research Council
and other sources of expertise to develop measures that evaluate impact
under various circumstances and within differing cultural contexts.
Every stage of the research and policymaking with respect to the science
should be transparent. The administration should disclose to donors and the
public the science it is and is not considering. All research results should
be available and disseminated to the broader scientific community. Research
needs to be conducted in cooperation with local researchers, program
managers, and other people directly involved in or affected by the programs.
Use Standard Definitions
Descriptions of various interventions need precise definitions in ways that
permit the scientific community to evaluate them, unimpeded by ideology or
preconceptions. Abstinence, for example, may be an effective tool for
reducing the infection rate. But it is essential to specify the meaning of
"abstinence" in order to understand and evaluate its place in an overall
strategy. The word can mean "delayed onset of sexual activity," which may
not necessarily have long-term effectiveness if U.S. evidence is indicative,
or the term can mean "abstinence until marriage," which may be more
effective than delayed onset but take longer and be harder to trace and
Create an Independent
It would be advantageous to the administration, the international community,
and all the actors with a stake in this issue to organize an independent
body to review the quality and significance of available evidence and
recommend priorities for new research. Such a "council" should be
independent of the administration but should seek to collaborate with it.
Employ Scientific Tools.
The administration should consider using systematic reviews and emerging
Systematic reviews use a scientific, unbiased method to assess and analyze
all available studies on a given question and then determine what the
science says about what does and does not work. Though more primary research
must be done, systematic reviews are a highly effective way to synthesize
existing science and eliminate bias in the research findings that inform
policy decisions. The value of systematic reviews for policymaking will grow
as more primary research data are collected. Excellent sources for
systematic reviews are the Cochrane Collaboration24
—though based mainly on data from the United States and other industrialized
countries; the "Guide to Community Preventive Services" published by the
Centers for Disease Control and Prevention; and the work of the
Evidence-Based Practice Centers designated by the U.S. Agency for Healthcare
Research and Quality. (At the request of the Council on Foreign Relations
and the Milbank Memorial Fund, the Cochrane Collaborative Review Group on
HIV Infection and AIDS summarized the findings from systematic reviews
pertinent to PEPFAR as of December 2003. This document, "Evidence
Assessment: Strategies for HIV/AIDS Prevention, Treatment and Care," is
Emerging Technological Tools.
Models such as Archimedes—a mathematical model capable of simulating
randomized controlled trials and filling some of the gaps in the available
—will become increasingly useful as more studies, operational research, and
randomized controlled trials are completed. Additional mathematical
modeling, social network analyses, rapid assessment techniques, and
geographic information systems will all be valuable technical tools in
applying science to guide policy.
Evaluation: The Key to Improved Performance
The strategic statement
highlights the importance of incorporating monitoring and evaluation from
the outset to help produce results efficiently and serve the
administration's focus on near-term targets. But monitoring and evaluation,
like other aspects of this challenge, must be designed to meet both
short-term and long-term objectives.
Three keys will be:26
The monitoring of resistance and related outcomes of treatment will be very
important. From the standpoint of the immunologist or microbiologist, issues
such as outcomes monitoring, evolving patterns of resistance, and compliance
will significantly affect the cost-benefit analysis of any interventions
under consideration as part of the larger social and political context. The
results will also be critical in being able to promptly identify new strains
of the virus that may be developing. The microbial timelines—such as
mutation or newly developing strains—are different from operational,
funding, and even individual health timelines and extend over decades.
Treatment programs will thus require a sophisticated set of monitoring
programs that respond to different decision points but continue gathering
essential data over long periods of time.27
Work with Local Efforts.
The Coordinator's Office must ensure that monitoring and evaluation are
conducted in concert with local program managers, researchers, and community
leaders. All results must be made available to these local participants so
that every stakeholder in programs and interventions can assess the data and
use lessons learned to improve upon programs and interventions. This will
help overcome rumors, interruptions in local support, and loss of
Work with the Institute
of Medicine from the Outset.
The legislation stipulates that in three years the Institute of Medicine
(IOM) will have to produce a report assessing PEPFAR's success. The
Coordinator should work with IOM on the information systems, data, and other
inputs that IOM will need to make its assessment.
Flexibility: The Key to Effective Interventions
The strategic statement
highlights the importance of innovation and flexibility in each facet of the
U.S. response. This will be particularly significant in identifying and
supporting the best programs and partners available.
Enfranchise Local NGOs
and Community-Based Organizations.
Embassies must engage local people affected by the pandemic, including NGOs
and community-based organizations, in the planning and reviewing of
strategies and programs. All aspects of in-country activity should be open
to members of civil society, ensuring their enfranchisement in decision
making on the ground. Those with local, grassroots experience have much
expertise and must "own" the long-term effort to combat HIV/AIDS.
Examine the South
African and Nigerian Examples.
USAID developed innovative techniques for getting its funds to small, local
NGOs in its anti-apartheid programs in South Africa in the early 1990s and
again in the wake of the restoration of civilian rule in Nigeria in
1999–2000. These administrative innovations should be examined as models, so
that the United States can get HIV/AIDS funds out to community-based NGOs
and civic groups, which are indispensable to a successful program. Without
some of USAID's flexible mechanisms, it will be extremely difficult for U.S.
funds to reach and empower the communities targeted.
The strategic statement
places great emphasis on "graduation" plans, or the plan by which the United
States would phase out its support of various programs. The impulse to want
to achieve the program objectives soon and extricate the United States from
further financial responsibility is understandable. However, containing this
pandemic will require decades of international involvement and funding far
beyond the emergency focus of the next five years.
Even speaking glibly of
"graduation" could undermine public understanding of the costs of this
pandemic and support for the necessary commitment. It could also alarm
developing countries about the burdens that will fall on them once these
programs are introduced. Thus when planning "graduation" dates, the United
States should employ great flexibility to ensure that humane objectives are
not subject to rigid and imprudent deadlines. This also underscores the need
for a thorough assessment of long-term requirements to support universal or
wide-scale access to treatment.
Senator Bill Frist (R.-Tenn.),
majority leader of the U.S. Senate, has said: "History is going to record
what we do when we face the terrible waste of life and hope that is the
global AIDS epidemic today. Our grandchildren will ask us what we did to
Senator Patrick J. Leahy (D.-Vt.) agreed: "When future generations look back
at this time and place, I believe they will judge us, more than anything, on
how we responded to AIDS. It is the most urgent, the most compelling moral
issue of our time."29
It is that and more. Global AIDS is also changing the social, economic, and
geopolitical landscape of our world, threatening to beget dislocation and
instability. It is a humanitarian issue, a social issue, an economic issue,
and a political issue, and it is a threat to global and U.S. national
The PEPFAR initiative is
a landmark attempt to recalibrate the erstwhile meager U.S. and
international response to what the Washington Post has called perhaps
"the most underestimated enemy of all time."30
The essential elements, the objectives, and most of the operational
strategies for effecting the plan are sound and laudable. Yet they mark only
the beginning of what must be a truly comprehensive effort to fight this
The United States must
lead a broad-based, long-term international effort to combat HIV/AIDS. This
report presents seven major recommendations and makes additional
recommendations in the body of the report. The recommendations offered in
the body of the report will be essential to the attainment of the
president's five-year goals. More than that, they will be critical to the
key U.S. strategic priority of waging an effective long-term battle against
Global HIV/AIDS is
undoubtedly one of the greatest contemporary threats to mankind. With a
long-term and broad-based strategy, the United States has a historic
opportunity to save tens of millions of lives and to safeguard the world
from widespread suffering and instability. U.S. moral and strategic
interests are very much at stake. To meet the magnitude of the threat, the
response by the United States must be ambitious, thoughtful, innovative, and
comprehensive from the outset. Much hangs in the balance. We must not fail.
Epidemic Update" (Geneva, Switzerland: UNAIDS and World Health
Organization, Dec. 2003).
Holbrooke and Richard Furman,
"A Global Battle's Missing Weapon," New York Times, Feb. 10, 2004.
"The Next Wave of AIDS: Nigeria, Ethiopia, India, Russia and China"
(prepared under the auspices of David F. Gordon, Washington, D.C., Sept.
2002). The NIC estimates between 50 and 75 million infections for the five
next wave countries and between 30 and 35 million for southern and central
Africa, yielding a total estimated range between 80 and 110 million
collectively by 2010. This does not include Latin America, North America,
most of Southeast Asia, Eastern Europe, Western Europe, the Middle East, and
elsewhere, where there are likely to be millions of additional infections.
This would place 100 million infections at the low end of the NIC range.
Jon Tedstrom, "Russia
Must Tackle AIDS without Delay" (editorial), Financial Times,
Sept. 17, 2003.
Nicholas Eberstadt, "The
Future of AIDS: Grim Toll in Russia, China and India," Foreign
Affairs 81 (Nov.–Dec. 2002): 22–45; Peter Baker, "U.N.:
AIDS a Crisis in Eastern Europe," Washington Post, Feb. 18,
2004. In his "intermediate" and "severe" sc