AIDS in Africa

AIDS in Africa
Updated February 2, 2008
Nicolas Cook
Specialist in Foreign Affairs
Foreign Affairs, Defense, and Trade Division

AIDS in Africa
Sub-Saharan Africa (“Africa” hereafter) has been more severely affected by
AIDS than any other world region. In 2007, the United Nations reports, there were
about 22.5 million HIV-positive persons in Africa, which has nearly 12% of the
world’s population but about 68% of the global total of infected persons. The adult
rate of infection in Africa in late 2005 was 6.1%, compared with 1% worldwide, but
had dropped to 5% by 2007, compared to .8% worldwide. Nine southern African
countries have infection rates above 10%. In 2007, 35% of all people living globally
with HIV lived in Southern Africa, where 32% of all global new HIV infections and
AIDS deaths occurred. About 90% of infected children globally live in Africa, where
about 61% of infected adults are women. As many as 30 million Africans may have
died of AIDS since 1982, including 1.6 million who died in 2007, accounting for
about 76% of global AIDS deaths in 2007. AIDS has surpassed malaria as the leading
cause of death in Africa. It kills many more Africans than does war.
Experts attribute the severity of Africa’s AIDS epidemic to poverty, lack of
female empowerment, high rates of male worker migration, and other factors. Many
national health systems are ill-equipped for prevention, diagnosis, and treatment.
AIDS causes severe socioeconomic consequences, e.g., declines in economic
productivity due to sharp drops in life expectancy and the loss of skilled workers. It
also devastates family structures. There are about 11.4 million African AIDS
orphans, many of whom lack access to adequate nutrition and social services.
Private organizations and the governments of donor and African nations have
responded by supporting diverse efforts to prevent and reduce the rate of new
infections and by trying to abate damage done by AIDS to families, societies, and
economies. The adequacy of this response is much debated. An estimated 1.3
million Africa AIDS patients receiving antiretroviral (ARV) drug treatment in late-
2005, up from 150,000 in mid-2004. An estimated 4.8 million Africans needed such
therapy in late 2005. U.S. and other initiatives are reportedly sharply expanding
access to treatment. Advocates see this goal as an affordable means of reducing the
impact of the pandemic. Skeptics question whether drug access can continue to be
rapidly scaled up in the absence of costly general health infrastructure improvements.
U.S. concern over AIDS in Africa grew in the 1980s, as the epidemic’s severity
became apparent. Congress has steadily increased funding for global AIDS programs.
P.L. 108-25, signed into law on May 27, 2003, authorized $15 billion over five years
for international AIDS programs under the President’s Emergency Plan for AIDS
Relief (PEPFAR). Twelve of 15 PEPFAR “focus countries” are in Africa. Under the
FY2008 budget request, these 12 countries would receive $3.421 billion under the
State Department’s Global HIV/AIDS Initiative. Many activists have praised the
extent of such aid, but some urge that more funding or different programs be
provided. Congress is likely to re-authorize PEPFAR, which expires after FY2008,
or create a successor program. Other bills in the 110th Congress that focus on AIDS
in Africa include S. 805 (Durbin), H.R. 3812 (Lee), H.R. 1713 (Lee), S. 2415
(Clinton), and S.Con.Res.31. Global AIDS appropriations are discussed in other CRS
reports cited within this report, which will be updated periodically.

Recent Key Developments...........................................1
Characteristics of the African Epidemic................................2
Overview ................................................2
Prevalence ...............................................2
Prevalence Trends.........................................3
Highest Rates.............................................4
Transmission .............................................4
Women ..................................................4
Children .................................................5
Orphans .................................................6
Explaining the African Epidemic......................................7
Social and Economic Consequences...................................8
Rural Livelihoods..........................................9
Workforce Depletion.......................................9
Security ................................................10
Responses to the AIDS Epidemic....................................10
Leadership Reaction in South Africa and Elsewhere..................12
AIDS Antiretroviral Treatment Issues.............................14
Effectiveness of the Response...................................17
U.S. Policy......................................................18
Clinton Administration........................................18
Bush Administration..........................................19
Treatment ...............................................21
U.S. Assistance..........................................22
Legislative Action, 2000-2004...................................26th
Legislation in the 109 Congress.................................26
Legislation in the 110th Congress.................................26
List of Tables
Table 1. African Adult HIV Infection Prevalence Rates (%), End of 2005 or
Later ........................................................3
Table 2. Ten African Countries with the Largest Populations
of HIV-Positive Women as of late 2005............................5
Table 3. Ten African Countries with the Largest Populations
of HIV-Positive Children as of late 2005...........................6
Table 4. Ten African Countries with the Largest Populations
of AIDS-Orphaned Children as of late 2005.........................7
Table 5. U.S. Bilateral Assistance to Counter AIDS in Africa by Account,
FY2004 - FY2008............................................23
Table 6. African Focus Countries: U.S. Bilateral Assistance to Counter AIDS,
FY2004 - FY2008............................................25

AIDS in Africa
Recent Key Developments
On January 31, 2008, the House Committee on Foreign Affairs announced
that a markup hearing would be held on February 7, 2008 which would consider a
House bill entitled The Global HIV/AIDS, Tuberculosis and Malaria Reauthorization
Act of 2008, for which no text or bill number was immediately available.
On January 25, 2008, the White House announced that President Bush and Mrs.
Bush would travel to five African countries from February 15-21, 2008, in part to
enable the President “to review firsthand the significant progress since his last visit
in 2003 in efforts to [...] fight HIV/AIDS, malaria, and other treatable diseases, as a
result of the United States robust programs in these areas.” President Bush had first
stated his intention to visit Africa in 2008 during a November 2007 speech marking
World AIDS Day, 2007. In the speech, he also called on the Congress to support his
May 2007 call to double U.S. international funding for AIDS, to $30 billion over five1
years, starting in 2009.
International AIDS issues are further covered in CRS Report RL33485, U.S.
International HIV/AIDS, Tuberculosis, and Malaria Spending: FY2004-FY2008;
CRS Report RL34192, PEPFAR: From Emergency to Sustainability; CRS Report
RL33396, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Progress
Report and Issues for Congress; and CRS Report RL31712, The Global Fund to
Fight AIDS, Tuberculosis, and Malaria: Background. All four reports are by Tiaji
Salaam -Blyther.

1 The five countries are Liberia, Benin, Tanzania, Rwanda, and Ghana. See White House
Press Secretary, “President and Mrs. Bush to Visit Africa,” January 25, 2008, and “President
Bush Discusses World AIDS Day,” November 30, 2007.

Characteristics of the African Epidemic2
Overview. Sub-Saharan Africa (“Africa” hereafter) has been far more severely
affected by HIV/AIDS3 than any other world region. In December 2007, the Joint
United Nations (U.N.) Program on HIV/AIDS (UNAIDS)4 released an update on the
global AIDS epidemic. It reported that in 2007, there were between 20.9 million and
24.3 million HIV-positive adults and children in Africa, including 1.7 million newly
infected during the year. Africa has nearly 12% of the world’s population but about
68% of the global total of infected persons. In 2007, about 1.6 million adults and
children were estimated to have died of AIDS, comprising about 76% of global AIDS
deaths in 2007, down from a 2006 estimate of about 2.1 million deaths, when African
AIDS deaths made up about 72% of global AIDS deaths. Aggregate estimates of
deaths caused by AIDS suggest that many as 30 million Africans may have died of
AIDS since 1982, at the start of the epidemic, including those who perished in 2007.5
UNAIDS has projected that between 2000 and 2020, 55 million Africans will likely
have lost their lives to AIDS, which is the primary cause of death in Africa. It causes
more deaths than malaria in African adults, and kills many times more people than
Africa’s armed conflicts.
Prevalence. Multiple health survey data show that the countries with the
highest HIV/AIDS prevalence or infection rates globally are in Africa. The adult rate
of infection in Africa in late 2005 was 6.1%, compared with 1% worldwide, but had
dropped to 5% by 2007, compared to .8% worldwide. National prevalence rates for
individual African countries are shown in Table 1 . The relative accuracy of such
estimates may vary; see “Note,” Table 1.

2 The following data are primarily drawn from an Joint United Nations Program on
HIV/AIDS report AIDS Epidemic Update (December 2007) and UNAIDS, 2006 Report on
the Global AIDS Epidemic (May 2006), supplemented by other published UNAIDS and
other U.N. agency data. Every two years UNAIDS publishes a comprehensive report AIDS-
related demographic trends, the impact of AIDS on people and societies, the status of
prevention, treatment, and care, and other issues concerning national and international
response to AIDS. It publishes one or more updates in intervening years.
3 AIDS is an acronym for Acquired Immunodeficiency Syndrome, a disease that typically
destroys or impairs the immune system and is acquired through infection by strains of the
human immunodeficiency virus, commonly known as HIV. The two acronyms are often
joined to form the compound term HIV/AIDS.
4 UNAIDS, the Joint United Nations Program on HIV/AIDS, helps coordinate the
AIDS-related efforts of ten U.N. and multilateral program and donor agencies in over 80
countries worldwide. The UNAIDS Secretariat is headquartered in Geneva, Switzerland.
5 These totals reflect rough estimates of total numbers of deaths and were compiled by
aggregating the total numbers of deaths reported for all years since 1982, based on data
reported in various published UNAIDS and World Health Organization (WHO) sources (list
available from the author). This method may not be statistically or methodologically sound,
in part because statistical and data collection methods have changed over time or varied
from study to study. Many statisticians harbor doubts about the reliability of death and
infection rate data collected during the early years of the epidemic. UNAIDS does not
regularly publish aggregate historical regional mortality figures for Africa for similar
reasons, and because not all countries have authorized the release of data covering all years.

Table 1. African Adult HIV Infection
Prevalence Rates (%), End of 2005 or Later
More Than 10%5%to 10%Less than 0.1%to 5%
Swaziland*25.9Gabon7.9Nigeria3.9Burkina Faso*2
Bo tswana 24.1 Uganda* 7 .1 Gu inea-Bissau 3 .8 Sudan 1 .6
Lesotho23.2Tanzania6.5Angola3.7Sierra Leone*1.5
Namibia19.6Cent. African Rep.*6.2Chad*3.3Guinea*1.5
Zimb ab we* 18.1 Ken ya 6.1 Burundi 3.3 Liberia* 1 .5
Zambia17.0Cameroon5.4Congo, Dem. Rep.3.2Ethiopia*1.4
South Africa*16.2Congo5.3Equat. Guinea3.2Mali*1.3
Mozambique16.1Côte d’Ivoire*4.7Togo3.2Benin1.2
Malawi 14.1 Djibouti 3 .1 Niger* 0.7
Rwanda* 3 .0 Senegal* 0.7
Eritrea 2.4 S omalia 0.9
Gamb ia 2.4 M au ritania 0 .7
Gh an a 2 .3 Mauritius 0 .6
Madagascar 0.5
Co mo ro s <0 . 1
Source: UNAIDS, 2006 Report on the Global AIDS Epidemic, May 2006; and UNAIDS, AIDS Epidemic
Update, December 2007.
Note: Data are from the 2006 report except in cases denoted by an asterisk, which are from the 2007 update.
Data drawn from the 2007 update are listed in cases where a population-based survey was conducted in 2005 or
later. Data for Liberia, from a 2007 survey, are preliminary. No prevalence rates were reported in either report
for Cape Verde, Sao Tome, or Seychelles. UNAIDS is a key source of national AIDS data in Africa, and is the
most widely cited uniform source of demographic HIV statistics. UNAIDS regularly factors new research
assumptions and modeling methodologies into its estimates, which are largely based on national data. These data
vary in quality due to countries' disparate data collection capacities and the availability of resources to conduct
surveys. As a result of such factors, UNAIDS has periodically revised some of its prevalence estimates. In recent
years, some researchers have asserted that improved data collection and statistical models have shown that
UNAIDS may have overestimated infection rates in a number of countries. UNAIDS appears to have concurred
with such concerns in some instances. In 2007 UNAIDS published revised regional and global AIDS
demographic data, which included downward revisions of some prevalence estimates. These revisions were
attributable to the availability of data from an increasing number of national population-based surveys and
improved sentinel surveillance (use of a representational population sub-groups, like pregnant women, as a
surrogate for projections among the general population), and other methodological factors. For some African
countries, it also provided information on national HIV prevalence rates derived from the most recent
population-based health survey in countries that have conducted them since 2002. In some cases, these rates were
lower than the previous UNAIDS national prevalence rate estimates, published in May 2006 (UNAIDS, 2006
Report on the Global AIDS Epidemic). UNAIDS is expected to release new comprehensive country estimates
in 2008. See Craig Timberg, "How AIDS in Africa was Overstated," Washington Post, April 6, 2006, inter alia,
and UNAIDS, AIDS Epidemic Update, December 2007 and UNAIDS, “Q&A on HIV/AIDS Estimates,”
November 2007.
Prevalence Trends. UNAIDS has reported that Africa’s adult HIV infection
rate, or prevalence, has begun to stabilize or decline moderately in recent years,
having peaked around year 2000, as both the total adult and infected populations
have increased. Stabilization means that numbers dying approximate the numbers
of newly infected, and that net infections are thus halted or nearly curbed. HIV has
become endemic in many countries; at a minimum, it will affect several future
generations. There have been declines in Kenya, Zimbabwe, and urban areas in some
countries. Prevalence had been increasing in southern Africa in recent years, apart
from Zimbabwe and Angola. The 2007 UNAIDS update, however, found that apart
from Mozambique — where prevalence was increasing — the epidemic had
“reached” or was “approaching a plateau.” It found that in Zimbabwe there was a
“significant decline” in national prevalence rates, and that adult prevalence in East

Africa was stable or beginning to decline. In West and Central Africa, adult
prevalence was either generally stable or there were prevalence declines, as in Côte
d’Ivoire, Mali, Benin, and parts of Burkina Faso. Recent prevalence declines are
attributable to a combination of deaths of infected persons; declines in new infections
due to behavioral change and increased access to testing; the scaling up of access to
drug therapy; and, in some cases, improved social services and access to better
Highest Rates. Southern Africa, where nine countries have adult infection
rates above 10% (Table 1), is the most severely affected region. However, populous
Nigeria in West Africa, with an estimated 3.9% adult infection rate (end-2005), had
an estimated 2.9 million infected people,6 the largest number in Africa apart from
South Africa. There, between 5.5 million and 6.1 million [UNAIDS average and
South African government estimates] are infected — the largest such population in
the world.
Transmission. Since the 1980s, HIV in Africa has been viewed by many
researchers as being spread primarily by heterosexual contact, though some believe
that the role of unsafe medical practices in the spread of HIV may have been7
underestimated. Both sexual and medical HIV transmission prevention are
components of the President’s Emergency Plan for AIDS Relief (PEPFAR).
Women. There were roughly 13.73 million women HIV-positive women in
Africa in 2007, up from about 13.2 million HIV-positive women in Africa in 2005.8
They comprised about 59% of infected adults in Africa and about 76% of HIV-
positive females globally in late 2005; women comprised a slightly higher proportion
of all AIDS infections in Africa, 61%, by 2007. Young women are notably at risk. In
2005, about 4.3% of African women aged 15 to 24 were HIV-positive, compared
with 1.5% of young men. Figures for these groups had dropped from 6.9% for
women and 2.2% for men in 2004.

6 UNAIDS estimates for Nigeria vary widely, however, from 1.7 million to 4.2 million.
7 John C. Caldwell et al., “The Social Context of AIDS in sub-Saharan Africa,” Population
and Development Review, (15:2,), June 1989, and John C. Caldwell and Pat Caldwell, “The
African AIDS Epidemic,” Scientific American, (274:3), March 1996, inter alia. Some argue
that researchers tracking the African AIDS epidemic may be significantly underestimating
the role of medical and other non-heterosexual sexual modes of HIV transmission. Such
views are contested, however, as several articles by proponents of this claim (e.g., David
Gisselquist et al.) and responses of their critics in the International Journal of STD & AIDS
in 2003/2004 demonstrate.
8 CRS calculation using UNAIDS data on total regional AIDS population figures and female
proportions thereof.

Table 2. Ten African Countries with the Largest Populations
of HIV-Positive Women as of late 2005
CountryEstimated Number of
HIV-Positive Women
South Africa3,100,000
Nige ria 1,600,000
Moza mbique 960,000
Congo, Democratic Republic of520,000
Source: UNAIDS, 2006 Report..., Annex 2: HIV/AIDS Estimates and Data, 2005 and
2003, Table 1, Estimated Number of People Living with HIV.
Children. Africa’s AIDS epidemic has a proportionally much greater effect
on children in Africa than in other world regions. According to UNAIDS, over
600,000 African infants become infected yearly with HIV through mother-to-child
transmission (see “Maternal Transmission,” below), during pregnancy, at birth, or
through breast-feeding. Most die before the age of two. Nonetheless, roughly 2.24
million African children under age 15 were living with AIDS in 2007,9 down slightly
from an estimated 2.3 million in late 2005. Nearly 90% of HIV-positive children
worldwide live in Africa. Less than 10% of these African children receive basic
support services. An estimated 12 million children less than 17 years of age, slightly
less than 10% of all African children, are believed to have lost one or both parents
to AIDS in recent years.

9 CRS calculation based on UNAIDS global child total and African proportion thereof.

Table 3. Ten African Countries with the Largest Populations
of HIV-Positive Children as of late 2005
CountryEstimated Number of
HIV-Positive Children
South Africa240,000
Moza mbique 140,000
Congo, Democratic Republic of120,000
Source: UNAIDS, 2006 Report..., Annex 2: HIV/AIDS Estimates and Data, 2005 and
2003, Table 1, Estimated Number of People Living with HIV.
Orphans. The number of orphans in Africa is large but appears to be
decreasing slightly. There were an estimated 11.4 million orphans due to AIDS in
Africa in 2007. In late 2005, according to UNAIDS, there were about 12 million
AIDS orphans (children 17 and under who had lost one or both parents to HIV) in
Africa, up from about 10.2 million in late 2003, when AIDS orphans comprised in
the range of 28% of all orphans in the region. The apparent decrease raises the
possibility that a 2004 U.N. study that projected that by 2010 their number would rise
to 18.4 million, or 36.8% of all orphans on the continent, may have underestimated10
the impact of factors leading to a slight decline in HIV prevalence trends.
Because of AIDS-related social stigma, HIV-positive orphans are at high risk
for malnourishment, abuse, and denial of education.11 UNICEF has recommended
that the capacity of families and communities to protect and care for orphans be
strengthened, that social and state protection services be provided for orphans and
vulnerable children (OVCs), and that public education about HIV-affected children
HIV-affected12 be increased. In October 2005, Human Rights Watch alleged in a
report that African governments have largely not addressed the myriad barriers to

10 UNAIDS/UNICEF/U.S. Agency for International Development, Children on the Brink,
July 2004. Estimates vary. Some earlier estimates had put the number as high as 12.3
million. In November 2003, UNICEF predicted that 20 million children would be orphaned
by AIDS by 2010 and that in a dozen countries orphans from all causes would make up 15%
to over 25% of children under 15; see UNICEF, Africa’s Orphaned and Vulnerable
Generations: Children Affected by AIDS, 2006..
11 J. Cohen, “Human Rights Implications of AIDS-affected Children’s Unequal Access to
Education,” presentation at XVI Int. AIDS Conf., August 2006.
12 In this report, the term “AIDS-affected” is used to refer to persons or families who are
HIV-positive themselves or who directly experience the effects of being related to,
dependent on, or responsible for one or more HIV-affected family members or guardians.

education faced by AIDS-affected OVCs. P.L. 108-25 included sense of Congress
language recommending that 10% of U.S. HIV/AIDS international assistance should
fund services for orphans and vulnerable children.
The Assistance for Orphans and Other Vulnerable Children in Developing
Countries Act of 2005 (P.L. 109-95) became law in November 2005. It authorizes
U.S. assistance for basic care for orphans and vulnerable children in developing
countries, including aid for community-based care, school food programs, education
and employment training, psycho-social support, protection of inheritance rights, and
AIDS care.
Table 4. Ten African Countries with the Largest Populations
of AIDS-Orphaned Children as of late 2005
CountryEstimated Number of
AIDS-Orphaned Children
South Africa1,200,000
T a nzania 1,100,000
Zi mb abwe 1,100,000
Congo, Democratic Republic of 680,000
Moza mbique 510,000
Source: UNAIDS, 2006 Report..., Annex 2: HIV/AIDS Estimates and Data, 2005 and
2003, Table 1, Estimated Number of People Living with HIV.
Explaining the African Epidemic
AIDS experts attribute Africa’s AIDS epidemic to a variety of economic and
social factors, but place primary blame on the region’s poverty, which has deprived
Africa of effective systems of health information, health education, and health care.
As a result, Africans suffer from high rates of untreated sexually-transmitted
infections other than AIDS, increasing their susceptibility to HIV. African health
systems often have limited capabilities for AIDS prevention work, and HIV
counseling and testing are difficult for many Africans to obtain. Until very recently,
AIDS treatment was generally available only to elites.
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 engage in
commercial or “transactional” sex because of poverty, which makes them highly
vulnerable to infection. Migrant workers may carry the infection back to their wives

when they return home. Long-distance truck and public transport drivers are also
seen as key agents in the spread of HIV.
Women and girls are disproportionately affected by AIDS in Africa. According
to UNAIDS officials and publications, among other sources, contraction of HIV by
girls from older men is a significant factor contributing to higher rates of infection
among young women than in young men. While older men are more likely than
young men to be HIV-positive, girls in impoverished contexts often view
relationships with older men as vital opportunities for achieving financial, material,
and social security. According to surveys, in many African countries, large numbers
of young women lack comprehensive knowledge of HIV transmission.
Many believe that female infection rates would be lower if women’s rights were
more widely respected in Africa, and if women exercised more political and socio-
economic power. Human Rights Watch (HRW) and other organizations have
reported that domestic violence targeting women in some African countries has made
these women more vulnerable to HIV infection, in part by depriving them of the
power to negotiate condom use.13 For this reason, some policy advocates see a need
for greater support for fidelity campaigns primarily aimed at African men. Women
also lack or have weak property rights in many African countries, making their
homes or property vulnerable to seizure by relatives when women suffer the loss of
their spouses due to AIDS.
Social and Economic Consequences
AIDS is having severe negative social and economic consequences in Africa,
and these effects are expected to continue for many years, as suggested by a January
2000 Central Intelligence Agency National Intelligence Estimate on the infectious
disease threats:
At least some of the hardest-hit countries, initially in Africa and later in other
regions, will face a demographic catastrophe as HIV/AIDS and associated
diseases reduce human life expectancy dramatically and kill up to a quarter of14
their populations over the period of this Estimate. This will further impoverish
the poor, and often the middle class, and produce a huge and impoverished
orphan cohort unable to cope and vulnerable to exploitation and radicalization
(CIA, The Global Infectious Disease Threat and Its Implications for the United
States, []).
The estimate predicted that AIDS would generate increased political instability and
slow democratic development. The World Bank (Intensifying Action Against
HIV/AIDS in Africa, September 1999 ) has reached similar conclusions with respect
to Africa’s economic future:

13 See, e.g., Human Rights Watch (HRW), A Dose of Reality Women’s Rights in the Fight
against HIV/AIDS, March 2005, among other HRW statements and reports.
14 A period of 20 years, i.e., 2000 to 2020.

The illness and impending death of up to 25% of all adults in some countries will
have an enormous impact on national productivity and earnings. Labor
productivity is likely to drop, the benefits of education will be lost, and resources
that would have been used for investments will be used for health care, orphan
care, and funerals. Savings rates will decline, and the loss of human capital will
affect production and the quality of life for years to come.
In the most severely affected countries, sharp drops in life expectancy are
occurring, reversing major gains achieved in recent decades. According to UNAIDS,
average life expectancy in Africa is now 47 years due to AIDS, whereas it would
have been 62 years in its absence. A March 2004 U.S. Census Bureau report
predicted absolute population declines by 2010 in South Africa, Botswana, and three
other African countries due to AIDS.15
Rural Livelihoods. Studies show that AIDS has devastating effects on rural
families. The father is often the first to fall ill, and when this occurs, farm tools and
animals may be sold to pay for his care, frequently leading to rapid impoverishment
of often already poor families. Should the mother also become ill, children may be
forced to shoulder responsibility for the full time care of their parents, farmsteads,
and often of themselves, despite their frequently limited knowledge about how to
carry out farm and domestic work. Many also become orphans. In 2001, the U.N.
Food and Agriculture Organization reported that AIDS had killed about 7 million
agricultural workers in 25 hard-hit countries in Africa and would likely cause 16
million more to die by 2020. In 10 of the most affected countries, labor force losses
of between 10% to 26% were forecast. (FAO, HIV/AIDS, Food Security, and Rural
Livelihoods, 2001). Some experts attribute serious food shortages in southern Africa
in 2002 and 2003 to AIDS-related production losses.16 In February 2003, in separate
testimony before the Senate Foreign Relations Committee and the House
International Relations Committee, World Food Program (WFP) Executive Director
James Morris said that AIDS was a central cause of the famine. In June 2004, Morris
said that southern Africa was in a “death spiral” due to the effects of the AIDS
pandemic, including the loss of human capacity and the devastation of rural areas,
with resulting negative consequences for food security (WFP press release). The
FAO supports many programs to alleviate the diverse threats that AIDS poses to
agricultural production and food security.17
Workforce Depletion. AIDS is blamed, in part, for increasing shortages of
skilled workers and teachers in several countries and is claiming many African lives
at middle and upper levels of public and private sector management. Although
unemployment is generally high in Africa, trained personnel are not readily replaced.
Dr. Peter Piot, UNAIDS Executive Director, told a June 2, 2005, special U.N.
General Assembly meeting on AIDS that by 2006, 11 African countries will have lost

10% of their workforce to the disease. A May 2002 World Bank study, Education

15 Karen A. Stanecki, The AIDS Pandemic in the 21st Century, U.S. Census Bureau, March


16 For example, see FAO, HIV/AIDS and the Food Crisis in Sub-Saharan Africa,
ARC/04/INF/8, March 2004.
17 See [].

and HIV/AIDS: A Window of Hope, reported that over 30% of teachers were HIV
positive in parts of Malawi and Uganda, 20% in Zambia, and 12% in South Africa.
Reports from diverse sources have since continued to mirror such findings.
Security. AIDS may have serious security consequences for much of Africa,
since HIV infection rates in many militaries are reportedly high. Domestic political
stability could also be threatened in African countries if the security forces become
unable to perform their duties due to AIDS. Peacekeeping is also at risk, because
African soldiers are expected to play an important peacekeeping role in Africa in the
years ahead. The infection rate in South Africa has been estimated at 23%, with
higher rates reported for units based in heavily infected KwaZulu-Natal province.
Some Southern African militaries, however, are pursuing efforts to treat and counter18
an increase in AIDS infections.
Responses to the AIDS Epidemic
Donor governments, non-governmental organizations (NGOs) working in
Africa, and African governments have responded to the AIDS epidemic primarily by
attempting to reduce the number of new HIV infections through prevention programs,
and to some degree, by trying to ameliorate the damage done by AIDS to families,
societies, and economies. A third response, treatment of AIDS sufferers with
antiretroviral drugs (ARVs) that can result in long-term survival, is increasing rapidly
in some African contexts, as treatment and drug distribution efforts expand, but
ARVs remain inaccessible to the vast majority of those in need of them in Africa
(See below, “AIDS Treatment Issues”).
Anti-AIDS programs and projects typically provide information on how HIV is
spread and on how it can be avoided through the media, posters, lectures, and skits.
Some success has been claimed for these efforts in persuading youth to delay the age
of “sexual debut” and to remain faithful to a single partner. The Bush Administration
advocates an expansion of prevention programs focusing on abstinence until
marriage and marital faithfulness as effective means of slowing the spread of HIV,
although some critics maintain that this may be unrealistic in social environments
characterized by poverty and lack of education. Some also question whether such
approaches can benefit poor married women in Africa, who have little power to
refuse the sexual demands of their husbands, whether infected or not — or, in some
cases, to control their extra-marital activities. They are also often unable to refuse
spousal decisions to take more than one wife, given that polygamous marriage is
common and deeply embedded in many African societies. In January 2006, First
Lady Laura Bush defended abstinence approaches, saying that she had “always been
a little bit irritated by criticism of abstinence, because abstinence is absolutely, 100
percent effective in fighting a sexually transmittable disease.” She added that “In

18 UN Integrated Regional Information Networks (IRIN), “Southern Africa: Military Taking
Control of Aids,” March 10, 2006.

many countries where girls feel obligated to comply with the wishes of men, girls
need to know that abstinence is a choice.”19
Donor-sponsored voluntary counseling and testing (VCT) programs, where
available, enable African men and women to learn their HIV status. In Botswana,
HIV tests are now offered as a routine part of medical visits, and many experts are
urging that this be done continent-wide. AIDS awareness programs are found in
many African schools and, increasingly, in the workplace, where employers are
recognizing their interest in reducing infection rates among their employees. Many
projects seek to make condoms readily available and to provide instruction in
condom use. Several projects have had success in reducing mother-to-child
transmission by administering the anti-HIV drug AZT or Nevirapine, before and
during birth, and during infant nursing. Nevirapine, however, has been the subject of
controversy. In December 2004, the Associated Press reported that important
reporting flaws, including non-disclosure of bad drug reactions, had been found in
a study of Nevirapine conducted in Uganda under U.S. National Institutes of Health
(NIH) sponsorship. The allegations sparked criticism in Africa, including from the
South Africa’s ruling Africa National Congress, which in December 2004 charged
that top U.S. officials had “entered into a conspiracy with a pharmaceutical company
to tell lies and promote the sales of Nevirapine in Africa...” In response, NIH asserted
in a statement that “single-dose Nevirapine is a safe and effective drug for preventing
mother to infant transmission of HIV.” It termed as “absolutely false” any
implication of thousands of adverse reactions in the Uganda study. AIDS activists
and others worried that the controversy would discourage use of the drug, often the
only available means of preventing mother to child transmission (MTCT) of HIV.
A later National Academies’ Institute of Medicine assessment found that the Uganda
study was valid and that Nevirapine should continue to be used for MTCT.
Church groups and humanitarian organizations have helped Africa deal with the
consequences of AIDS by setting up care and education programs for orphans.
Public-private partnerships have also become an important vehicle for responding to
the African AIDS pandemic. The Bill and Melinda Gates Foundation has been a
major supporter of AIDS vaccine research and diverse AIDS programs pursued in
cooperation with African governments and donors. The Rockefeller Foundation,
working with UNAIDS and others, has sponsored programs to improve AIDS care
in Africa, and both Bristol-Myers Squibb and Merck and Company, together with the
Gates Foundation and the Harvard AIDS Institute, have undertaken programs with
the Botswana government aimed at improving the country’s health infrastructure and
providing AIDS treatment to all who need it. In Uganda, Pfizer and the Pfizer
Foundation fund Uganda’s AIDS Support Organization and the Infectious Diseases
Institute. It has trained 250 AIDS specialists annually, many slated to work in rural
areas. In January 2006, the Swiss drug firm Roche said it plans to help African firms
produce generic versions of its World Health Organization (WHO)-endorsed ARV,
Saquinavir, under its Technology Transfer Initiative.20

19 Deborah Orin, “Laura Defends Sex Abstinence,” New York Post, January 16, 2006.
20 Roche, “Roche offers help to local manufacturers to produce HIV medicine for
sub-Saharan Africa and Least Developed Countries,” January 12, 2006.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria, created in January
2002, commits about 60% of its grant funds to Africa, and about 60% of its grants
worldwide go toward fighting AIDS.21 UNAIDS maintains that significant AIDS
funding gaps remain. According to one study, $14.9 billion was needed in 2006 to
fight HIV/AIDS in low- and middle-income countries globally in 2006, whereas $8.9
billion was likely to be provided. The funding gap is projected to rise in future years,
according to a June 2005 UNAIDS report.
Leadership Reaction in South Africa and Elsewhere
Many observers believe that the spread of AIDS in Africa could have been
slowed if African leaders had been more engaged and outspoken at earlier stages of
the epidemic. President Thabo Mbeki of South Africa has come in for particular
criticism on this score. In April 2000, he wrote to then-President Clinton and other
heads of state defending dissident scientists who maintain that AIDS is not caused
by the HIV virus. In March 2001, Mbeki rejected appeals that the national assembly
declare the AIDS pandemic a national emergency. Under mounting domestic and
international pressure, the South African government seemed to modify its position
significantly when the government announced after an April 2002 cabinet meeting
that it would triple the national AIDS budget. When an ARV drug treatment program
had not been launched by March 2003, however, the South African Treatment Action
Campaign (TAC) launched a civil disobedience campaign. In August 2003, the
South African cabinet instructed the health ministry to develop a plan to provide
antiretroviral therapy nationwide, but by March 2004, TAC was threatening a lawsuit
unless the program was actually begun. Finally, in April 2004, the government began
offering treatment at five hospitals in populous, highly urban Gauteng province. In
its 2006 National Budget Review, the government reported that 112,000 patients
were “enrolled” for ARV therapy by December 2005 but did not specify the number
in publicly funded programs. Estimates of total numbers in treatment and
proportions under public and private care vary widely. In February 2005, TAC
estimated that about 38% of 70,000 patients under ARV therapy were in public
programs; the remainder were receiving private care. Another activist group, the
International Treatment Preparedness Coalition, reported in November 2005 that of
150,000 persons receiving treatment in August 2005, 50%-53% were in public
programs. In May 2006, UNAIDS reported that about 190,000 South Africans were
receiving ARV treatment, but that nearly 1 million, or more than 80% of those in
need of ARV therapy, were not receiving it in 2005.
The delays in South Africa’s response to the pandemic have been costly, many
experts believe. South African Health Department data have shown HIV infection
rates continuing to rise, though according to UNAIDS figures, rates were similar
between 2003 and 2005, though they rose among pregnant women. About 29.5% of
pregnant women in South Africa were found to be HIV positive in 2004, up from
27.9% in 2003 and 26.5% in 2002. The Health Department estimates that there were
5.6 million HIV-positive South Africans in 2004. A September 2004 report by the
Bureau of Market Research at the University of South Africa predicted that AIDS-

21 For further information, see CRS Report RL31712, The Global Fund to Fight AIDS,
Tuberculosis, and Malaria: Background and Current Issues, by Tiaji Salaam-Blyther.

related deaths would exceed 500,000 yearly from 2007 to 2011. A lower rate of
growth in infections reportedly may be under way; a November 2005 South African
Human Sciences Research Council data release stated that South Africa’s AIDS
epidemic may be “leveling off.” Some critics of the government have accused
government leaders of being “AIDS denialists” and of curtailing the rate of scaling
up access to ARVs because of some officials’ reported doubts about ARV use. South
Africa’s Health Minister Manto Tshabalala Msimang has reportedly repeatedly
questioned the effectiveness of ARV drugs and has asserted that healthy diets and
special foods, such as raw garlic and lemon peel, can offer protection from the
disease (Mail and Guardian Online, May 5, 2005). Former President Nelson
Mandela, seeking to combat the stigma associated with AIDS, announced in January

2005, that his son, Makgatho, had died of AIDS.

In the rest of Africa, many heads of state, including the presidents of Uganda,
Botswana, Nigeria, and several other countries, are taking major roles in fighting the
epidemic. Several regional AIDS initiatives have been launched. For example, in
August 2003, the Southern African Development Community (SADC) agreed to an
AIDS strategic framework, including the creation of a regional fund to fight the
disease. The New Partnership for Africa’s Development (NEPAD), in partnership
with the African Union, UNAIDS, and other multinational entities, has formulated
a range of strategies for countering AIDS, though the products of these efforts appear
to be limited at present.
Uganda’s president, Yoweri Museveni, has long been recognized for leading a
successful prevention campaign against AIDS in Uganda, where the ABC
(Abstinence, Be Faithful, or Use Condoms) transmission prevention program has
won wide praise. A Senate Foreign Relations Africa Subcommittee hearing in May

2003, focused on “Fighting AIDS in Uganda: What Went Right.” Dr. Anne Peterson,

Assistant Administrator for Global Health at the U.S. Agency for International
Development (USAID), testified that the “Uganda success story is about prevention.”
She said that successes had been recorded in promoting abstinence and faithfulness
to partners, while increased condom use in recent years had also contributed to
prevalence declines. Sophia Mukasa Monico, a member of the Global Health
Council and a former AIDS worker in Uganda, testified that all three program
elements are necessary for prevention to work but noted that the Ugandan epidemic
was still “raging”and that much work to counter it remained to be done.
In February 2005, Johns Hopkins and Columbia University researchers released
a study of Rakai District, Uganda reporting that a local HIV prevalence decline was
due to condom use and the deaths of infected people.22 Abstinence and monogamy
appeared not to be increasing. Some saw this as evidence that sexual behavior change
programs were less important than expected. Others argued that behavior had likely
changed substantially prior to the study. In July 2005, First Lady Laura Bush,
speaking in South Africa during a trip to Africa that included visits with AIDS
patients and orphans, said that the Uganda-developed ABC model was “successful”
and added that “ABC stands for Abstinence, Be faithful, and correct and consistent

22 See Maria Wawer, R. Gray et al., “Declines in HIV Prevalence in Uganda: Not as Simple
as ABC,” 12th Conference on Retroviruses and Opportunistic Infections, Boston.

use of Condoms.” Conflicting reports appeared in late summer 2005 regarding a
shortage of condoms in Uganda for preventing HIV. Some AIDS activists and others
blamed the alleged shortage on an emphasis on abstinence in U.S.-funded AIDS
prevention programs and a change in policy by Ugandan government officials, who
denied a shortage existed. A U.S. official attributed the problem to a shipment of
defective condoms.
AIDS Antiretroviral Treatment Issues
Access by the poor to antiretroviral drugs (ARVs) has been perhaps the most
contentious issue surrounding the response to Africa’s AIDS epidemic. ARVs are
used in a treatment regime generally dubbed Antiretroviral Therapy (ART). Three
or more ARVs are often used in combination to halt the genetic replication of the
HIV virus at different stages in its life cycle; this treatment regime is known as
Highly Active ART (HAART). ART can enable AIDS victims to live relatively
normal lives and permit long-term survival rather than early death. ARVs have
proven highly effective in developed countries, including the United States, where
AIDS, the eighth-ranked cause of death in 1996, was no longer among the top 15
causes by 1998, according to the U.S. Health and Human Services Department.
The high cost of ARVs has proved a key obstacle to large scaling-up of access
to ART in Africa, where most patients are poor and lack health insurance. Once
estimated at between $10,000 and $15,000 per person per year, ART costs have
dropped dramatically in recent years. In May 2000, five major pharmaceutical
companies agreed to negotiate sharp reductions in the price of AIDS drugs sold in
Africa. UNAIDS launched a program in cooperation with pharmaceutical firms to
boost treatment access. In June 2001, it reported that 10 African countries had
reached agreement with drug makers that would significantly reduce prices in
exchange for health infrastructure improvements to assure that ARVs are
administered safely. Initiatives to expand ARV availability continued, and treatment
became a major focus of Global Fund and the President’s Emergency Plan for AIDS
Relief (PEPFAR) programs (see below). In December 2003, the WHO formally
launched its “3 by 5” campaign to treat 3 million AIDS patients in poor countries by

2005, with resources from the Global Fund and donors. Leaders of the G8,

concluding their summit in Scotland in July 2005, promised “a package for HIV
prevention, treatment, and care,” with the goal of providing “universal access to
treatment for all those who need it by 2010.”
In October 2003, former President Bill Clinton announced that his Clinton
Foundation HIV/AIDS Initiative (CHAI) had organized a program to provide generic
three-drug ARV treatment in Africa and the Caribbean for about $.38 per day per
AIDS patient using drugs manufactured in India and South Africa with backing from
private donors and some donor governments, among other sources. In April 2004,
the Clinton Foundation announced an agreement with UNICEF, the World Bank, and
the Global Fund to expand the program to more than 100 developing countries. In
April 2005, CHAI announced a pediatric AIDS program intended to put 10,000 HIV-
positive children on ARV therapy in at least 10 countries in 2005, doubling the
number of children in treatment. On January 12, 2006, former President Bill Clinton
announced that CHAI had negotiated new agreements to lower prices of
WHO-evaluated HIV tests by 50% and those of two antiretroviral drugs by 30%.

These will be made available to the CHAI Procurement Consortium, a group of
countries eligible to make purchases under CHAI agreements. It includes 50
developing countries. CHAI also helps countries to implement large-scale, integrated
care, treatment, and prevention programs. Partner governments take the lead; CHAI
provides technical aid, mobilizes human and financial resources, and promotes
sharing of best practices.
As a result of ARV scaling up efforts, UNAIDS reported in May 2006 an
estimated 810,000 or about 17% of a total of about 4.7 million Africans in need of
ART (72% of those in need worldwide) were receiving it by late 2005.23 This
number was up from about 500,000 in June 2005 and up from about 150,000 a year
earlier.24 Despite such successes, UNAIDS and WHO had reported in December
2005 that progress in expanding treatment and care in Africa was uneven across the
region and within countries. In general, according to a report by UNAIDS in
December 2005, there was “extensive unmet need” in most of Africa. By late 2005,
UNAIDS reported, coverage levels of 45% or greater had been achieved in countries
such as Botswana, Senegal, Uganda, and Namibia. In slightly under a third of
African countries, coverage rates ranged between 10% and 31%, while in 18
countries, rates were below 10%. About 23.5% of all those receiving ART resided
in South Africa.25 ART access in rural areas, where the majority of the population
in many African countries — and the bulk of AIDS patients — live, is generally
much poorer than in urban areas.
Whether African countries are ready to “absorb” (effectively use) sharp
increases in treatment funding has been another issue. AIDS activists believe that
millions of Africans could quickly be given access to AIDS drugs. Others maintain
that African supply channels cannot make the drugs consistently available to millions
of patients and that regular monitoring of patients by medical personnel is not
possible in much of Africa. Monitoring is necessary, they maintain, to deal with side
effects and to adjust medications if drug resistance emerges. Many fear that if the
drugs are taken irregularly, resistant HIV strains will emerge that could cause
untreatable infections globally. It has been reported, however, that many African
patients follow their AIDS therapy regimens equally or more consistently than many
American patients. The creation of once-daily combined ARV tablets is widely seen
as a likely way to facilitate access to and adherence to ARV therapy, notably in
impoverished settings. In January 2006, the multinational drug firms Gilead and
Bristol-Myers Squibb announced that they had jointly developed such a tablet for
certain drugs. For some, the correct response to weaknesses in Africa’s basic health
care systems is to devote resources to strengthening those systems. News reports
indicate that scaling up of treatment is often stymied by African government
administrative inefficiencies and by donor limitations on what their funds may be
used to purchase.

23 UNAIDS, 2006 Report on the Global AIDS Epidemic.
24 UNAIDS/WHO, AIDS Epidemic Update, December 2005.
25 In late 2005, 190,000 of a total of 810,000 ART patients were South African; see
UNAIDS, 2006 Report.

Botswana’s President Festus Mogae told a November 2003 meeting, held in
Washington by the Center for Strategic and International Studies, that the widely-
praised treatment program in his country is being hampered by a “brain drain” of
health personnel. African physicians, nurses, and technicians are often hired by
foreign governments, international organizations, and non-governmental
organizations outside of Africa, or migrate to developed countries to take advantage
of generally better job opportunities in such countries. The health minister of
Mozambique, which has launched a pilot ARV drug treatment program, said in May
2004 that the country was unable to launch a nationwide program because of serious
shortages of staff and equipment. WHO and other organizations have reported that
Africa has the lowest ratio of health workers to population of any region. WHO
reported that in 2005, there were 2.3 health workers (of all kinds) per 1,000 persons
on average across Africa. It also reported that 36 of 46 (78%) African countries
surveyed had critical shortages of doctors, nurses and midwives, and would have to
increase such professionals by 139% in order to adequately meet current needs.26
AIDS activists have urged that African governments issue “compulsory
licenses” to allow the manufacture or importation of inexpensive copies of patented
AIDS drugs (“generic drugs”). In November 2001, a ministerial-level meeting of the
World Trade Organization (WTO) in Doha, Qatar, approved a declaration stating that
the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)
should be implemented in a manner supportive of promoting access to medicines for
all. The declaration affirmed the right of countries to issue compulsory licenses and
gave the least-developed countries until 2016 to implement TRIPS. The question of
whether countries manufacturing generic drugs, such as India or Thailand, should be
permitted to export to poor countries was left for further negotiation through a
committee known as the Council for TRIPS.
Although the Doha declaration drew broad praise, some AIDS activists
criticized it for not permitting imports of generics. Some in the pharmaceutical
industry, on the other hand, expressed concern that the declaration was too
permissive and might reduce profits that, they argued, fund medical research. Others,
however, maintained that the declaration would have little practical impact; in their
view, poverty, rather than patents, is the key obstacle to drug access in Africa.27 In
August 2003, the WTO reached agreement on a plan to allow poor countries to
import generic copies of essential drugs, but the debate over access to ARVs in
Africa seems likely to continue. This agreement was ratified in December 2005 at
the Hong Kong WTO ministerial meeting. In March 2005, India’s parliament passed
patent legislation expected to sharply raise prices in Africa and elsewhere for Indian-

26 WHO, “Chapter 1: Health Workers: A Global Profile,” The World Health Report 2006 -
Working Together for Health, 2006. The study reflects findings from a number of other
studies by other organizations on healthcare capacity in Africa. See, for instance, papers
published by the now defunct Harvard-based Joint Learning Initiative on Human Resources
for Health and Development on human resources for health in Africa: [ P ublication.htm#wg4].
27 See Amir Attaran and Lee Gillespie-White, “Do Patents for Anti-retroviral Drugs
Constrain Access to AIDS Treatment in Africa?,” Journal of the American Medical
Association, October 17, 2001.

manufactured generic copies of newly discovered AIDS medications. Cheap generic
copies of existing drugs can still be sold, although sellers will have to pay licensing
fees to patent holders.
Effectiveness of the Response
The response to AIDS in Africa has had some successes, most notably in
Uganda, where the rate of infection among pregnant women in urban areas fell from

29.5% in 1992 to 5% in 2001 (UNAIDS, AIDS Epidemic Update, December 2002).28

In most African countries, prevalence rates in 2005 were roughly similar to those in
2003, with only marginal increases or decreases. UNAIDS findings have indicated
that sexual behavior patterns among young urbanites in some other countries may be
changing in ways that combat the spread of HIV, although increases among
populations continue in many African cities. Despite some success stories, however,
the number of infected people in Africa continues to grow, in part due to general
population increases. The estimated number of HIV-positive persons in Africa
increased from 21.6 million in 2003 to 22.5 million in 2007.
Experts contend that there are multiple social barriers to a more effective AIDS
response in Africa, such as cultural norms that make it difficult for many
government, religious, and community leaders to acknowledge or discuss sexual
matters, including sex practices, prostitution, and the use of condoms. However,
experts continue to advocate AIDS awareness and public education and outreach
efforts as essential components of the response to the epidemic. Indeed, there is
strong support for an intensification of such efforts, as well as adaptations to make
them more effective.
The lives of HIV patients could be significantly prolonged and improved, some
maintain, if more were done to identify and treat the opportunistic infections, notably
tuberculosis (TB), that often accompany AIDS. Millions of Africans suffer dual HIV-
TB infections, and their combined effects dramatically shorten life. TB can be cured
by multi-month, combined drug treatments, even in HIV-infected patients. However,
according to the WHO, Africans often delay seeking treatment for TB or do not
complete their drug regimens, contributing to high death rates among those with dual
infections. UNAIDS and the WHO have recommended that Africans infected with
HIV be treated with an antibiotic/sulfa drug combination known as cotrimoxazole in
order to prevent opportunistic infections. Studies indicate that the drug could reduce
AIDS death rates at a cost of between $8 and $17 per year per patient. The Pfizer
Corporation donates the anti-fungal Diflucan (fluconazole), used to treat AIDS-
related opportunistic infections (such as cryptococcal meningitis, a dangerous brain
inflammation) to patients in 18 African countries through the Pfizer Diflucan

28 However, while Uganda’s adult prevalence nationwide had been reported as having
dropped to 4.1% in 2003, compared with 5.1% in 2001, recent statistical reassessments
indicate that Uganda’s actual 2003 prevalence rate was 6.8%, and that its late 2005 rate was

6.7%. This finding appears to indicate that Uganda’s infection rate has generally stabilized,

but not declined quite as much as experts had previously believed. See UNAIDS, 2006
Report ..., pp. 10-11, op. cit.

Partnership Program (DPP). DPP is a public-private effort in collaboration with
health ministries, local clinics, and non-governmental organizations.
Further information on the response to AIDS in Africa and elsewhere may be
found at the following websites.
— Centers for Disease Control (CDC): []
— Global Fund to Fight AIDS, Tuberculosis & Malaria: [http://www.theglobalfund.
— International AIDS Vaccine Initiative: []
— International Association of Physicians in AIDS Care: []
— Kaiser Network: []; click “HIV Daily Reports”
— UNAIDS: []
— USAID: []
— World Bank: []; click “Topics >> AIDS”
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, Congress earmarked FY1988
funds for fighting AIDS worldwide, and House appropriators noted that in Africa,
AIDS had the potential for “undermining all development efforts” to date (H.Rept.
100-283). In subsequent years, Congress supported AIDS spending at or above
levels requested by the executive branch, either through earmarks or report language.
Nevertheless, a widely discussed July 2000 Washington Post article called into
question the adequacy and timeliness of the early U.S. response to the HIV/AIDS
threat in Africa (Barton Gellman, “The Global Response to AIDS in Africa: World
Shunned Signs of Coming Plague,” Washington Post, July 5, 2000).
Clinton Administration
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. In July 1999, the Clinton Administration proposed $100 million in
additional spending for a global LIFE (Leadership and Investment in Fighting an
Epidemic) AIDS initiative, with a heavy focus on Africa.29 Funds approved during
the FY2000 appropriations process supported most of this initiative, and funded the
engagement of the Department of Health and Human Services (HHS), the
Departments of Labor (DoL), and the Department of Defense (DoD), in addition to
USAID, in the global fight against HIV/AIDS. On June 27, 2000, the Peace Corps
announced that all volunteers serving in Africa would be trained as AIDS educators.
USAID asserted in 2001 that its support of multilateral efforts and direct sponsorship
of regional and bilateral programs had made it the global leader in the international
response to AIDS since 1986, when it initiated AIDS prevention programs in
developing countries (USAID, Leading the Way: USAID Responds to HIV/AIDS,

29 Leadership and Investment in Fighting an Epidemic (LIFE), A Global AIDS Initiative,

September 2001). USAID had sponsored AIDS education programs; trained AIDS
educators, counselors, and clinicians; supported condom distribution; and sponsored
AIDS research. USAID claimed several successes in Africa. These included helping
to reduce HIV prevalence among young Ugandans; preventing an outbreak of the
epidemic in Senegal; reducing the frequency of sexually transmitted infections in
several African countries; sharply increasing condom availability in Kenya and
elsewhere; assisting children orphaned by AIDS; and sponsoring the development of
useful new technologies, including the female condom.
Bush Administration
Combating the AIDS pandemic in Africa has been an important Bush
Administration foreign assistance program goal. In May 2001, President Bush made
the “founding pledge” of $200 million to the Global Fund, and in June 2002, he
announced a $500 million International Mother and Child HIV Prevention Initiative
to support efforts to prevent mother-to-child AIDS transmission. Eight African
countries were named as beneficiaries. In his January 2003 State of the Union
address, President Bush announced the launching of the President’s Emergency Plan
for AIDS Relief (PEPFAR), pledging $15 billion for fiscal years 2004 through 2008,
including $10 billion in “new money,” that is, spending in addition to then current
levels. In July 2003, President Bush made AIDS a special focus during a five-day trip
to Africa. On July 8, in Senegal, the President told Africans, “we will join with you
in turning the tide against AIDS in Africa.” On July 10, speaking in Botswana, the
President said that, “this is the deadliest enemy Africa has ever faced, and you will
not face this epidemic alone.” In September 2003, then Secretary of State Colin
Powell told a U.N. General Assembly special session on AIDS that the epidemic was
“more devastating than any terrorist attack” and that the United States would “remain
at the forefront” of efforts to combat the epidemic.
PEPFAR was authorized by P.L. 108-25, the United States Leadership Against
Global HIV/AIDS, Tuberculosis, and Malaria Act of 2003, signed into law by
President Bush on May 27, 2003. Its implementation has resulted in major spending
increases for HIV/AIDS prevention, care, and treatment in 15 “focus countries,” 12
in Africa (Botswana, Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia,
Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia). PEPFAR funds are
provided through the Global HIV/AIDS Initiative (GHAI), headquartered at the State
Department. The GHAI is headed by a U.S. Global AIDS Coordinator, who
coordinates GHAI programs in focus countries and other international AIDS
programs implemented by USAID and other agencies. Permanent incumbents in the
Global AIDS Coordinator position are nominated by the President and confirmed by
the Senate. The first Global AIDS Coordinator was Randall Tobias, the former
Administrator of USAID and the Director of U.S. Foreign Assistance. Ambassador
Mark Dybul is now the U.S. Global AIDS Coordinator.
In February 2004, the State Department issued a report [
gac/rl/or/c11652.htm] which provided details on how PEPFAR would be
implemented, and proposed to use initial PEPFAR funds to support several
“public-private partnership” treatment programs. PEPFAR aims to prevent 7 million
new infections globally, provide ARV drugs for 2 million infected people, and
provide care for 10 million infected people, including orphans. The Administration

has submitted to Congress two subsequent annual PEPFAR reports that describe the
status of PEPFAR program policy and program administration, as well as a number
of other related reports.30
The Office of the Global AIDS Coordinator (OGAC) at the State Department
administers the bulk of U.S. AIDS assistance to Africa. PEPFAR was enacted, in
part, to simplify the international AIDS budget, enhance transparency, and stress the
President’s interest in fighting AIDS and his backing for what the State Department
reports is “the largest commitment ever by a single nation for an international health
initiative.”31 Prior to PEPFAR, the principal channels for HIV/AIDS assistance to
Africa were USAID and the Global AIDS Program (GAP) of the Centers for Disease
Control (CDC) in the Health and Human Services Department. Most USAID
spending on AIDS in Africa is through the Child Survival and Health Programs
Fund. Limited amounts are provided through other accounts, such as multi-
functional Economic Support Fund, Peace Corps, and Migration and Refugee
Assistance. The Department of Defense (DoD) has undertaken an HIV/AIDS
Prevention Program, primarily with African armed forces and administered by the
Naval Health Research Center in San Diego. It also focuses on education and
creation of policy responses. As in other recent years, the Administration did not
request funding for the program in FY2007. In FY2006, Congress continued to
support it by appropriating $5.5 million (of which $3.2 million went to Africa).
Foreign Military Financing (FMF) funds are also used to support this initiative. A
Department of Labor (DOL) program in the past supported AIDS education in the
workplace in several African countries, but was not funded in FY2006. Funds for
these DOL efforts were not requested in FY2007.32 Additional U.S. funds reach
Africa indirectly through the AIDS programs of the United Nations (U.N.), the World
Bank, and the Global Fund.
The scale of the response to the pandemic in Africa by the United States and
other donors remains a subject of intense debate. The U.N. Special Envoy for
HIV/AIDS in Africa, Stephen Lewis, has been a persistent critic, telling a September
2003 conference on AIDS in Africa that he was “enraged by the behavior of the rich
powers” with respect to the epidemic. Many activist groups have made similar
critiques. The singer Bono said he had a “good old row” with President Bush in a
September 2003 meeting on the level of U.S. funding for fighting the international
AIDS epidemic. Nonetheless, as noted above, others have argued that Africa’s
ability to absorb increased AIDS funding is limited and that health infrastructure will
have to be expanded before new funds can be spent effectively.
Many AIDS activists and others have praised the President’s initiatives, notably
the large levels of funding with which they have been supported. During the initial
stages of its implementation, however, some critics maintained that PEPFAR was
starting too slowly. Some have also characterized the program as too strongly

30 These reports are published online. See [].
31 See Emergency Plan Basics, [].
32 For details, see CRS Report RL33485, U.S. International HIV/AIDS, Tuberculosis, and
Malaria Spending: FY2004-FY2007, by Tiaji Salaam-Blyther.

unilateral and would like the United States to act in closer cooperation with other
countries and donors, especially the Global Fund. Some have questioned whether
PEPFAR will do enough to directly strengthen African health care institutions and
capabilities for coping with AIDS over the long term, or whether the funds will go
primarily to U.S.-based organizations. Some also urged increased appropriations, as
some have continued to do. U.N. Secretary General Kofi Annan, during an interview
at the July 2004 international AIDS conference in Bangkok, urged U.S. contributions
of $1 billion annually for the Global Fund. Then-U.S. Global AIDS Coordinator
Randall Tobias responded by stating that “It’s not going to happen.”33 Annan asked
the United States to show the same leadership in the AIDS struggle that it had shown
in the war on terrorism. Then-U.S. State Department spokesman Richard Boucher
rejected the implied criticism, saying that the Bush Administration had taken the
AIDS crisis very seriously and that the $15 billion pledged to fight the epidemic over
five years was an “enormous and significant amount.”
More recently, some healthcare advocates have criticized what they see as a
programmatic over-emphasis on efforts to promote the use of abstinence in the
prevention of HIV, as opposed to the distribution and promotion of condoms for this
purpose. Critics have charged that funding for PEPFAR abstinence programs,
notably in Africa, has increasingly replaced other HIV prevention measures and that
the United States is today sending fewer condoms abroad than in 1990 (Center for
Health and Gender Equity, Prevention Funding Under [PEPFAR]: Law, Policy and
Interpretation, December 2005). Some have cited as evidence for this contention,
an April 2006 Government Accountability Office (GAO) report entitled Global
Health: Spending Requirement Presents Challenges for Allocating Prevention
Funding under the President’s Emergency Plan for AIDS Relief.34 The GAO found
that guidance requiring that 33% of PEPFAR HIV prevention funds be spent on
abstinence and faithfulness-focused programs had, in some cases, led to decreases in
funding for certain other types of HIV prevention efforts. It also suggested that the
guidance contained ambiguities that had created uncertainties among some country
field teams about how to implement PEPFAR programs.
In March 2005, the Department of State released Engendering Bold Leadership:
The President’s Emergency Plan for AIDS Relief, the first annual report to Congress
on the initiative. In an introductory letter to the report, Randall Tobias called
PEPFAR “coordinated, accountable, and powerful.” The report stated that 152,000
African patients were receiving AIDS treatment due to PEPFAR and that 119 million
had been reached with mass media campaigns promoting abstinence and faithfulness,
while 71 million had been reached with messages promoting other prevention
measures, including the use of condoms. The President’s second annual report to
Congress stated that while 115.23 million condoms had been shipped to Focus
Countries in 2001, 198.4 million had been shipped in 2005 — a 72% increase.
Treatment. The Financial Times reported in April 2004 that the United States
was withholding support from a program intended to treat 140,000 AIDS patients in

33 See CRS Report RL31712, The Global Fund to Fight AIDS, Tuberculosis, and Malaria:
Background and Current Issues, by Tiaji Salaam-Blyther.
34 The report is online: [].

Kenya with antiretrovirals because it would rely on a generic three-drug Fixed Dose
Combination (FDC) pill. Many favor approval of FDCs, including copies of drugs
made by different companies, on grounds that they are simpler to prescribe and need
to be taken just once or twice a day. U.S. officials had expressed concerns that further
study was needed to assure that their widespread or improper distribution did not
contribute to the emergence of resistant HIV strains. The issue was submitted to a
panel of experts instructed to report by mid-May 2004. Several Members of
Congress later wrote to President Bush asking that the United States join an
international consensus that generics are safe and essential for AIDS treatment. In
May 2004, then-Health and Human Services Secretary Tommy Thompson announced
that the U.S. Food and Drug Administration (FDA) was instituting an expedited
process that could lead to the approval of the use of FDCs in PEPFAR-funded
programs. Many hailed the news as a step forward in making cheaper and more
reliable antiretroviral therapy available in Africa, but critics said it placed an
unnecessary hurdle in the way of distributing such pills. They maintained that the
United States should have relied on the approval process of the World Health
Organization, which had already cleared such pills. By June 2005, the FDA had
reportedly cleared seven generic antiretrovirals manufactured in South Africa and
India. However, the Boston Globe reported on June 20 that four African countries,
Nigeria, Uganda, Ethiopia, and Tanzania, were refusing to accept generic FDA-
approved drugs for use in U.S.-funded treatment programs. Instead, the countries
sought approval of the drugs by WHO.
U.S. Assistance. Under the President’s FY2008 budget request, the 12 focus
countries in Africa would receive $3.421 billion under the GHAI account. Table 5
reports available information on recent U.S. spending levels on AIDS programs in

Table 5. U.S. Bilateral Assistance to Counter AIDS in Africa
by Account, FY2004 - FY2008
($ millions)
AccountFY2004FY2005FY2006 FY2007 jFY2008 k
Actual Actual EstimatePlannedRequest
CSHa 242.34 81.44 78.48 81.30 na
DHAPP/ DODb 1.87 3.18 2.34 na na
ESFc 3.00 0.08 0.08 0.08 na
FMFd 1.49 1.98 1.98 1.60 1.60
GAPe 68.42 68.42 68.40 69.69 na
GHAIf 441.04 1,089.87 1,462.86 2,191.02 3,421.00
IDFAg 1.50 0 0 0 0
IM ET h 0 0 0 0.01 na
PMT CT i 40.48 3.92 0 0 na
Totals 800.14 1,248.90 1,614.14 2,343.69 3422.60
Note: Totals may differ slightly from sum of individual account entries due to rounding. Table omits
data on HIV-related food aid, for which available official data is irregular and incomplete, and
National Institutes of Health (NIH) Africa-related AIDS research.
a. CSH: Child Survival and Health Programs Fund. Administered by USAID. Data Source: State
Department data sheets on PEPFAR Africa funding by account provided to CRS on April 9,
2007 (“PEPFAR Datasheets hereafter.)
b. DOD/DHAPP: Department of Defense HIV/AIDS Prevention Program administered by the Naval
Health Research Center (NHRC) in San Diego. Provides technical assistance in the development
and implementation of programs to counter HIV/AIDS, primarily in support of diagnosis,
prevention education, counseling, behavior change communication, and treatment. Data Source:
PEPFAR Datasheets and DHAPP-CRS communication, April 11, 2006. DOD/DHAPP
provided CRS with figures that differed slightly from those reported by PEPFAR: $1.767
million in FY2004; $3.046 million in FY2005; and $2.493 million in FY2006. These minor
differences are believed to be attributable to reprogramming of some country budgets during the
24 months for which a given year’s funding is available.
c. ESF: Economic Support Fund (ESF). State Department strategic state stability and security-support
account; programs implemented primarily by State Department and USAID. Data Source:
PEPFAR Datasheets and USAID,Country and Sector Detail,” FY2007.
d. FMF: Foreign Military Financing, Military Health Affairs. State Department account; primarily
used to provide goods in support of DHAPP programs. Data Source: State Department,
Congressional Budget Justification - Foreign Operations, FY2008 and FY2007; and State
Department, Political Military Affairs-CRS communication, April 11, 2007 with reference to
planned FY2007 level.
e. GAP: Global AIDS Program. Implemented by the Centers for Disease Control and Prevention of
the Department of Health and Human Services (HHS). Seeks to prevent HIV infection, improve
care and support, and build capacity to counter HIV/AIDS internationally. Data Source:
PEPFAR Datasheets.
f. GHAI: Global HIV/AIDS Initiative. State Department account used to fund diverse functional
programs administered by multiple agencies, including USAID, HHS, DOD, the State
Department, the Peace Corps, and the Labor Department. For examples, see State Department,
Table 3,” The U.S. Presidents Emergency Plan for AIDS Relief Fiscal Year 2006:
Operational Plan (August 2006 Update). Data Source: PEPFAR Datasheets and State
Department, Congressional Budget Justification - Foreign Operations, FY2008.
g. IDFA: International Disaster and Famine Assistance. USAID-administered multi-purpose
emergency assistance account. Data Source: USAID,Country and Sector Detail,” FY2004.

h. IMET: International Military Education and Training. State Department account used to fund
professionalization and capacity-building of foreign militaries. Data Source: PEPFAR
Da ta she e t s.
I. PMTCT: Prevention of Mother-to-Child Transmission of HIV (PMTCT). HHS account used to
fund PMTCT programs; administered primarily by USAID and HHS agencies. In some past
years, the account included USAID funds. Data Source: PEPFAR Datasheets.
j. Data reflect planned allocations. Levels subject to change following Administration consultation
with Appropriations Committees on final authorized country and regional program levels.
k. Specific AIDS/Africa-related funding levels will not be set until final country and regional program
levels are enacted into law following passage of general account level appropriations. The GHAI
entry for FY2008 reflects the total requested funding level for Focus Countries only.

Table 6. African Focus Countries: U.S. Bilateral Assistance to Counter AIDS, FY2004 - FY2008
(by Agency/Account in $ millions)
YearAgency & AccountBotswanaCote d’Ivoire EthiopiaKenya Mozam-bique NamibiaNigeria RwandaSouth Africa TanzaniaUgandaZambiaCountryTotals
FY2004 USAID/CSH 0 0 16.5 22.28 10.55 3.97 18.95 8.5 25.7 12.5 2 3 22.5 164.44
USAID &1.520.263.466.331.561.578.071.963.124.384.943.3140.48
HHS/GAP 7.55 5.25 5.8 8 .12 2 .34 1 .5 3.06 1.13 4.82 3.88 8.04 2.91 54.4
STATE/GHAI 15.28 18.85 22.33 55.75 23.02 17.46 40.86 27.65 55.64 49.98 54.79 52.94 434.54
FY2004 ACTUAL 24.34 24.36 48.09 92.47 37.47 24.5 70.93 39.24 89.27 70.75 90.77 81.66 693.86
iki/CRS-RL33584FY2005USAID & HHSPMTCT0.240000001.30.8801.503.92
s.orHHS/GAP 7.55 5.25 5.8 8 .12 2 .34 1 .5 3.06 1.13 4.82 3.88 8.04 2.91 54.4
leakSTATE/GHAI 44.05 39.12 77.93 134.82 57.88 41.02 107.19 54.47 142.49 104.9 138.9 127.17 1,069.95
://wikiFY2005TOTAL ACTUAL 51.84 44.38 83.73 142.94 60.22 42.52 110.25 56.91 148.19 108.78 148.44 130.09 1,128.27
httpFY2006 HHS/GAP 7.55 5.25 5.8 8 .12 2 .34 1 .5 3.06 1.14 4.82 3.88 8.04 2.91 54.4
STATE/GHAI 47.38 41.36 117.16 200.15 92.08 55.79 160.55 70.97 216.72 126.08 161.84 146.11 1436.18
FY2006 PLANNED54.9346.61122.96208.2794.4257.29163.6172.1221.54129.97169.88149.021,490.58
FY2007 HHS/GAP 7.55 5.25 5.8 8 .12 2 .34 1 .5 3.06 1.14 4.82 3.88 8.04 2.91 54.4
STATE/GHAI 63.67 60.16 210.97 315.01 144.15 81.56 266.8 91.31 357.91 178.6 206.39 189.1 2165.62
FY2007 PLANNED71.2165.41216.77323.13146.4983.06269.8592.44362.73182.48214.43192.012,220.02
urce: State Department data sheets on PEPFAR Africa funding by account provided to CRS on April 9, 2007.
te: For account titles, see Table 5.

Legislative Action, 2000-2004
The Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264), enacted
in August 2000, authorized funding for FY2001 and FY2002 for a comprehensive,
coordinated, worldwide HIV/AIDS effort under USAID. In the 107th Congress,
several bills were introduced with international or Africa-related AIDS-related
provisions. A major international AIDS authorization bill, H.R. 2069, passed both
chambers during the 107th Congress but did not go to conference.35 In May 2003,
Congress approved and President Bush signed into law H.R. 1298/ P.L. 108-25, the
U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. It
authorized th establishment of PEPFAR and the allocation of $3 billion per year for
the program from FY2004 through FY2008 (a total of $15 billion), and created the
office of the Global AIDS Coordinator at the State Department. Appropriations
measures have supported a variety of programs helping Africa fight the pandemic.36
Legislation in the 109th Congress
P.L. 109-95 (formerly H.R. 1409, Lee), the Assistance for Orphans and Other
Vulnerable Children in Developing Countries Act of 2005, was signed into law in
November 2005. P.L. 109-102 (formerly H.R. 3057, Kolbe), the Foreign Operations,
Export Financing, and Related Programs Appropriations Act, 2006 and P.L. 109-149
(formerly H.R. 3010, Regula), the Departments of Labor, Health and Human
Services, and Education, and Related Agencies Appropriations Act, 2006, provided
the bulk of U.S. international AIDS funding in FY2006. Bills introduced in the
109th Congress, with provisions related to the African AIDS pandemic, included the
following: H.R. 155 (Millender-McDonald), Mother to Child Plus Appropriations
Act for Fiscal Year 2005; H.R. 164 (Millender-McDonald), International Pediatric
HIV/AIDS Network Act of 2005; H.R. 2601 (Smith), Foreign Relations
Authorization Act, Fiscal Years 2006 and 2007; S. 600 (Lugar), Foreign Affairs
Authorization Act, Fiscal Years 2006 and 2007; S. 850 (Frist), Global Health Corps
Act of 2005; and S. 2125 (Obama), Democratic Republic of the Congo Relief,
Security, and Democracy Promotion Act of 2005.
Legislation in the 110th Congress
Apart from appropriations legislation that would fund global HIV/AIDSth
assistance programs, legislation introduced in the 110 Congress that focus on AIDS
in Africa include:
!S. 805 (Durbin) and H.R. 3812 (Lee), both entitled African Health
Capacity Investment Act of 2007, would have authorized the
President to provide assistance, including through international or

35 For information on appropriations for HIV/AIDS programs, see CRS Report RS21114,
HIV/AIDS: Appropriations for Worldwide Programs in FY2001 and FY2002, by Raymond
W. Copson.
36 For further information, see CRS Report RL33485, U.S. International HIV/AIDS,
Tuberculosis, and Malaria Spending: FY2004-FY2007, by Tiaji Salaam-Blyther.

nongovernmental organizations, for programs to improve human
health care capacity in sub-Saharan Africa. They would direct the
President to develop and transmit to Congress a strategy for
coordinating, implementing, and monitoring assistance programs for
human health care capacity in sub-Saharan Africa.
!H.R. 1713 (Lee) and S.2415 (Clinton), both entitled Protection
Against Transmission of HIV for Women and Youth Act of 2007.
The bills would have directed the President to: (1) formulate and
submit to the appropriate congressional committees, and make
available to the public, a comprehensive and culturally appropriate
global HIV prevention strategy that addresses the HIV vulnerability
of married and unmarried women and girls and seeks to reduce the
factors that lead to gender disparities in HIV infection rates; (2)
ensure that the United States coordinates its overall HIV/AIDS
policy and programs with foreign governments, international
organizations, other donor countries, and indigenous organizations;
and (3) provide clear guidance to U.S. field missions.
!S.Con.Res.31 (Feingold), entitled A concurrent resolution
expressing support for advancing vital United States interests
through increased engagement in health programs that alleviate
disease and reduce premature death in developing nations, especially
through programs that combat high levels of infectious disease
improve children's and women's health, decrease malnutrition,
reduce unintended pregnancies, fight the spread of HIV/AIDS,
encourage healthy behaviors, and strengthen health care capacity.
During the first session of the 110th Congress, the Senate Foreign Relations
Committee held the following two hearings on HIV/AIDS:
!Perspectives on the next Phase of the Global Fight Against Aids,
Tuberculosis, and Malaria, December 13, 2007; and
!The Next Phase of the Global Fight Against HIV/AIDS, October 24,


During the first session of the 110th Congress, the Subcommittee on Africa and
Global Health of the House Committee on Foreign Affairs held the following hearing
!The President’s Emergency Plan for AIDS Relief: Is It Fulfilling the
Nutrition and Food Security Needs of People Living with
HIV/AIDS?, October 9, 2007.