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U.S. Department of State
July 1995 US International Strategy on HIV/AIDS
Bureau of Oceans, International Scientific and Environmental Affairs






                      U.S. INTERNATIONAL STRATEGY ON HIV/AIDS


July, 1995

Dear Friend,

     Every region of the world has been affected by the devastation 
caused by HIV/AIDS.  As the numbers of new infections continue to rise, 
we face the enormous challenge of developing more effective approaches 
to dealing with this pandemic.

     The U.S. International Strategy on HIV/AIDS is designed to assist 
U.S. government efforts in meeting the challenge. The Strategy is an 
interagency effort led by the Department of State.  Representatives from 
the Departments of Health and Human Services, Defense, Commerce, 
Education, Labor, Justice, as well as USAID, Peace Corps, the 
intelligence community, and the National AIDS Policy Director worked in 
close collaboration in the development of this report.  The result is a 
Strategy which contains a set of priorities for action which all 
relevant U.S. agencies will work to achieve.

     In this effort, I was particularly pleased to have the full 
participation of over twenty non-governmental groups -- including 
representatives from the AIDS activist community, health service 
providers and the business community and people living with HIV/AIDS.

     I look forward to a more comprehensive effort to prevent new HIV 
infections and mitigate the impact of AIDS.  In this Strategy, we now 
have a plan of action.

                                Sincerely,


                                (signed)

                                Timothy E. Wirth





I.  INTRODUCTION
  ABOUT THIS DOCUMENT
  SCOPE OF THE PANDEMIC
  PREVENTING INFECTIONS
  TREATMENT
  U.S. FOREIGN POLICY IN THE GLOBAL COMBAT AGAINST HIV/AIDS

II.  ACTION STRATEGY:  MEETING U.S. INTERNATIONAL HIV/AIDS GOALS
   A.  PREVENT NEW HIV INFECTIONS
1. TAKE DIPLOMATIC INITIATIVES TO PROMOTE MORE ACTIVE INVOLVEMENT ON 
HIV/AIDS ISSUES BY NATIONAL GOVERNMENTS.
2.  DEVELOP BEHAVIORAL PREVENTION STRATEGIES.
3. AUGMENT RESEARCH.
4.  SAFEGUARD THE BLOOD SUPPLY.
5.  PROVIDE ACCESS TO HEALTH SERVICES AND TECHNOLOGIES.
6. ADDRESS THE ADVERSE IMPACT OF POVERTY AND OTHER FACTORS ON PREVENTION 
EFFORTS.
   B.  REDUCE PERSONAL AND SOCIAL IMPACT
1.  PROVIDE CARE AND SUPPORT.
2.  GUARANTEE HUMAN RIGHTS.
3.  PROTECT POLITICO-MILITARY STRUCTURES AT RISK.
4.  PLACE HIV/AIDS ON THE SUSTAINABLE DEVELOPMENT AGENDA.
   C.  MOBILIZE AND UNIFY NATIONAL AND INTERNATIONAL EFFORTS

APPENDIX A:  AN AGENDA FOR ACTION
APPENDIX B:  INTERNATIONAL RESEARCH COOPERATION
APPENDIX C:  PREVENTION
APPENDIX D:  THE IMPACT OF AIDS -- U.S. SECURITY INTERESTS/CONCERNS
APPENDIX E:  DONOR COORDINATION


ACRONYMS
AIDS         Acquired Immune Deficiency Syndrome

CDC          Centers for Disease Control and Prevention
CIA          Central Intelligence Agency

DHHS         Department of Health and Human Services
DOD          Department of Defense

FDA          Food and Drug Administration

HIV          Human Immunodeficiency Virus

NGO          non-governmental organization
NIH          National Institutes of Health

PHS          Public Health Service

STD          sexually transmitted disease

U.N.         United Nations
UNDP         United Nations Development Programme
UNFPA        United Nations Population Fund
UNICEF       United Nations Children's Fund
USAID        United States Agency for International Development

WHO          World Health Organization




I.  INTRODUCTION

     The HIV/AIDS pandemic poses major challenges to all nations.  
HIV/AIDS is, as President Clinton observed, "the health crisis of this 
century."  HIV/AIDS will also have economic, social, political and 
security implications throughout the world.

     While human suffering is the most significant implication of 
HIV/AIDS, the pandemic is affecting a widening spectrum of society both 
in the United States and abroad.  The spread of HIV/AIDS threatens to 
undermine democratic initiatives by destabilizing societies.  HIV/AIDS 
threatens the sustainable economic development of many countries, 
including current and potential trading partners.  U.S.-based 
multinational companies will face difficult challenges in addressing the 
impact of global HIV/AIDS on trade and investment considerations.  
National security interests are affected by the high rate of HIV 
infections among the military of certain countries.  The international 
community is becoming increasingly concerned that some governments use 
HIV/AIDS as a justification for the violation of human rights.  In many 
countries women's lower socio-economic status puts them at higher risk 
of becoming infected.

     The United States must struggle against the HIV/AIDS pandemic.  As 
the major contributor to multilateral and bilateral prevention efforts 
and as the world's standard bearer for biomedical research, the United 
States has been a central player in efforts to stem the spread of global 
HIV/AIDS.  Our strong support for the streamlined newly established 
Joint U.N. Programme on AIDS provides another example of U.S. leadership 
on this issue.  Yet much hard work remains.  Success will require a 
sustained and vigorous commitment by the United States and its 
international partners.


About this document

     This Strategy and action plan seeks to assist U.S. policymakers in 
working more effectively with international partners in the fight 
against global HIV/AIDS.  Even as an early draft, this framework proved 
useful in guiding our preparation for the Paris AIDS Summit in December, 
1994, and will help guide the U.S. planning for the IVth World 
Conference on Women to be held in September, 1995 and other future 
international meetings.

     A USG interagency working group developed the document in 
consultation with non-governmental AIDS activist groups, business and 
trade representatives, and service organizations.  The strategy 
articulates a set of U.S. international objectives for the fight against 
HIV-infection and AIDS and a set of actions aimed at meeting these 
objectives.  The paper is intended mainly for the traditional foreign 
affairs agencies, such as the Department of State and USAID, as well as 
domestic agencies such as the Department of Health and Human Services to 
the extent that their activities promote international HIV/AIDS policy 
objectives.

     Appendices B-E are interagency working group reports which formed 
the basis of the Strategy.  Reports were prepared on Research (chaired 
by NIH), Prevention (chaired by USAID), National Security (chaired by 
CIA) and Donor Coordination (chaired by USAID).  The Strategy itself, 
which has been cleared by all concerned USG agencies, is based on the 
interagency working group reports and State Department input and was 
developed through coordination and synthesis by the State Department.  
The Strategy does not describe all AIDS-related activities of all 
agencies but rather highlights activities that advance foreign policy 
objectives (USAID activities, for example, are described in a separate, 
comprehensive document).

     The interagency working groups made rapid progress in outlining 
the fundamental tenets of the present document.  This permitted the 
United States to support the inclusion of many of the principles 
contained herein in the Paris AIDS Declaration which was signed by 
leaders from 42 countries at the 1994 Paris AIDS Summit.  The document 
is the basis in principle for U.S. support for the establishment of the 
U.N. Joint and Co-Sponsored Programme on HIV/AIDS and for the World 
Health Organization's Global Programme on HIV/AIDS.

     HIV/AIDS is a long-term problem requiring a long-term commitment.  
The present Strategy should therefore be considered a long-term foreign 
policy framework supported by a near-term set of action items.  As the 
present pandemic changes, and as we learn more about successful 
approaches to combat HIV/AIDS, our overall strategy and action plan 
should change accordingly.  The Strategy should be viewed as a dynamic 
and flexible document, to be reviewed and revised as appropriate and at 
least biennially.  The State Department will monitor progress toward 
reaching the goals outlined in the present Strategy.
Scope of the Pandemic

     No region of the world has been spared the steady, silent spread 
of human suffering associated with AIDS.  While the poorest regions of 
the world have been spared the least, industrialized countries will also 
be faced with increasing numbers of AIDS cases well into the foreseeable 
future.  In the United States, HIV/AIDS is now the number one killer of 
Americans in the 25 - 44 year old age group, according to the Centers 
for Disease Control and Prevention.

     Two to three million new HIV infections worldwide are expected 
annually.  By the year 2000, the WHO estimates conservatively that 30-40 
million people will have been infected.  Harvard's Global AIDS Policy 
Coalition estimates that between 40 to 110 million people will have been 
infected by that time.  While a small percentage of HIV-infected 
individuals have lived for twelve years or more with no sign of AIDS, 
the large majority of HIV-infected individuals develop AIDS and die 
within years.

     Unlike other infectious disease epidemics such as cholera or 
plague, AIDS will not likely run its course and subside, at least in the 
foreseeable future.  Without more effective response strategies and 
massive behavioral and societal change, or an effective vaccine, AIDS 
will continue to spread, especially in the Third World, reaching 
staggering levels of infection, death, human suffering, and social 
disorder.  Thus, without human intervention, the number of AIDS cases 
will continue to rise in all regions of the world well into the next 
century.

     Thus HIV/AIDS presents a unique set of health, social, economic 
and political challenges which will affect both developed and developing 
countries.  For the most part, HIV/AIDS affects those in the 25-44 age 
group, arguably the most productive in society.  Developing countries 
and countries in transition will suffer the most from the loss of 
productivity.  The incubation period from initial infection to disease 
onset is usually upward of ten years, during which time the infection 
may be unknowingly spread.  Almost 80% of infections occur through 
sexual transmission;  current prevention strategies rely primarily on 
changes in high-risk sexual behaviors, notoriously difficult to control.  
As governments cope with increasing numbers of cases and already 
weakened health care systems, the economic impact on the most productive 
segments of society, and the impact on their military and political 
forces will become increasingly evident.  

     Some specific examples of the broad impact of HIV/AIDS include:
The World Health Organization (WHO) estimates there will be between 10 
and 15 million orphans worldwide attributable to HIV/AIDS by the turn of 
the century.

The proportion of women infected with HIV is increasing rapidly; by the 
year 2000, the WHO predicts that more than half of newly infected adults 
will be women.

In 1992 in Thailand, multinational firms invested $1.3 billion.  If 
projected rates of HIV infection in Thailand hold, a labor force 
increasingly weakened by AIDS-related illness and reduced by AIDS deaths 
could discourage foreign investors and jeopardize advances in the Thai 
standard of living.  Tourism in Bangkok, a major source of income in the 
Thai economy, is lagging already, in part because of the fear of 
HIV/AIDS.

A World Bank and U.S. Census Bureau modeling exercise found that by 
2015, Africa's total GDP could be reduced by up to 22 percent relative 
to a no-AIDS scenario, which assumed moderate economic growth through 
the period.

Certain militaries may begin to experience the adverse effects of AIDS 
in the next five years as rising HIV infections among young men reduce 
conscript pools and as an increasing number of officers, senior NCOs, 
and trained technicians become ill and die.  HIV/AIDS could begin to 
degrade military manpower pools and readiness within the next ten years.

     In the industrialized countries, HIV/AIDS will raise a number of 
questions that governments and businesses must address:

U.S. and other multinationals will be forced to consider HIV/AIDS in 
foreign investment and trade discussions.

HIV/AIDS is already straining the health care systems in cities that are 
hard-hit.  In some U.S. cities, the majority of beds in some hospitals 
are filled with AIDS patients.

Worldwide peacekeeping operations will become increasingly controversial 
as militaries with high infection rates find it difficult to supply 
healthy contingents.  The United Nations will have to grapple with 
politically sensitive choices, such as refusing HIV-infected troops.

Human rights violations of HIV-infected persons are likely to increase 
and require attention.


Preventing Infections

     Despite enormous progress in understanding the AIDS virus and its 
effects, there is presently no available vaccine that can prevent HIV 
infection or progression to AIDS. 

     At present, however, there are over a dozen vaccine candidates in 
the early phases of clinical trials.  Even if one of these vaccines 
proves effective in preventing infection or progression of illness, it 
will be years before it could be produced and distributed on a global 
basis.

     In addition to the long-range goal of vaccine development, our 
strategies must focus on two broad areas:  the reduction of high-risk 
sexual and drug behaviors and the development of non-vaccine preventive 
technologies, especially those that allow women the option of protecting 
themselves from infection, including vaginal microbicides and the female 
condom.  Improvements in female-controlled preventive technologies are 
promising; these technologies will be the most effective in preventing 
HIV infection in women, at least in the near term.  Further, female-
controlled technologies may be more viable options in the long run for 
developing countries.  Also, biomedical researchers have recently 
demonstrated that use of an antiviral therapy appears to reduce the 
likelihood for HIV-infected mothers to pass the infection to their 
infants.  In addition, preliminary studies indicate that higher levels 
of a particular nutrient in the mother's bloodstream are associated with 
decreased risk of mother-to-fetus transmission, although the nature of 
this relationship needs more study.

     WHO estimates that if all developing countries were to implement a 
basic HIV prevention program about one-half of the 20 million new 
infections expected worldwide between now and 2000 (based on 
conservative estimates) could be averted.  However, such a program 
presupposes a full commitment by national political leaders -- often in 
conflict with strongly held cultural and religious sentiments.  While 
some leaders have made strong commitments to preventing the spread of 
HIV/AIDS, much more needs to be done to implement government policies 
and programs.  The United States respects the sovereign right of each 
nation to make its own policies.  Truly successful strategies should 
draw on multiple sectors of society, including business and labor.  A 
strong commitment to prevention activities could stave off the enormous 
adverse impact of HIV/AIDS that is projected for expanding economies. 
Education is critical, including discussions of abstinence and mutual 
monogamy.  
Treatment

     Although HIV infection cannot be "cured" at present, biomedical 
research in the 1980's and 1990's produced several drugs that prolong 
and improve the quality of life for those infected with HIV.  In 
addition, relatively inexpensive non-drug therapies and other strategies 
are being developed to help slow the progression of HIV disease.  In 
poorer areas these interventions may be more appropriate than more 
costly antiviral drugs.  Further research is needed to determine how 
effective and feasible these interventions may be.  Nevertheless, the 
issue of access to adequate and affordable supplies of drugs for HIV and 
related opportunistic infections will surface increasingly in 
international discussions.

U.S. Foreign Policy in the Global Combat Against HIV/AIDS

     The HIV/AIDS pandemic increasingly threatens economic, social and 
political stability (see Appendix D), and also threatens to undermine 
U.S. foreign policy initiatives including the promotion of 
democratization and sustainable development, conflict resolution and 
peacekeeping, and human rights.  With no effective and affordable long-
term medical treatment or vaccine on the horizon and without more 
aggressive efforts to prevent new infections, the AIDS pandemic will 
have greater and greater impact on developed and developing countries 
well into the next century.

     How can the United States advance the worldwide struggle to 
contain the HIV/AIDS pandemic and to mitigate its effects?  This 
strategy lays out a plan of action for U.S. leadership:

   Increase the political and economic commitment by foreign leaders to 
stem the spread and mitigate the impact of HIV/AIDS;

    Persuade other donor countries to shoulder a greater share of the 
technical assistance burden for HIV/AIDS;
Focus world attention on the special needs of women, children and youth 
and their predisposition to become infected with HIV;

   Support the concept that sustainable development, family stability 
and personal responsibility are inextricably linked to stemming the 
spread of HIV/AIDS;

   Improve international cooperation on AIDS research and vaccine 
development;

   Encourage the efforts of the United Nations on HIV/AIDS, including 
continued support for the Joint U.N. Programme on AIDS;

   Address the human rights implications of HIV/AIDS in all appropriate 
fora; and,

   Foster greater involvement by non-governmental organizations, 
communities, business and labor leaders, and people infected with, and 
affected by, HIV/AIDS in AIDS policy and program formulation.

     The U.S. Strategy is divided along thematic lines that reflect the 
three main objectives of the World Health Organization's "Global 
Strategy for the Prevention and Control of AIDS."  These WHO objectives 
provide a useful framework from which to delineate an action plan to 
meet the U.S. foreign policy goals described above:

   Prevent new infections;
   Reduce personal and social impact; and,
   Mobilize and unify national and international efforts.


II.  ACTION STRATEGY:  Meeting U.S. International HIV/AIDS Goals

A.  PREVENT NEW HIV INFECTIONS

     One focus of U.S. and global efforts is on preventing new 
infections and AIDS cases by more effectively promoting the utilization 
of existing technologies and strategies, including the promotion of 
condom use; by working toward the development of more effective 
biomedical interventions, including vaginal microbicides and female-
controlled barriers; by continuing to support health-promoting 
behaviors; and, by working to address underlying social conditions that 
enhance the transmission of HIV.

1.  Take Diplomatic Initiatives to Promote More Active Involvement on 
HIV/AIDS Issues by National Governments.

     National governments have the primary responsibility for sounding 
the alarm and for instituting programs to prevent the spread of 
HIV/AIDS.  Prevention strategies are boosted by the active involvement 
of political leaders who openly address the HIV/AIDS issue.  The USG 
should work with other governments to increase their recognition of the 
need for strong political and governmental leadership in stemming the 
spread of HIV/AIDS.

The State Department and senior U.S. officials will:

--  urge foreign leaders to openly address the HIV/AIDS pandemic in 
their own countries;

--  urge other governments to consider the adverse economic and social 
impact of HIV/AIDS in their countries;

--  urge other governments to increase spending or to reallocate funds 
to prevent the spread of HIV/AIDS and strengthen AIDS research efforts;

--  emphasize the importance of National AIDS Action Plans which involve 
all relevant governmental agencies, Ministries, NGOs and the private 
sector;

--  encourage foreign leaders to support the Joint U.N. Programme on 
AIDS; and,

--  urge foreign leaders to join the United States and 41 other 
countries in endorsing the Paris AIDS Declaration.

U.S. ambassadors and other embassy representatives will meet with host 
country counterparts to describe the U.S. International Strategy on 
HIV/AIDS and will encourage leaders to expand HIV/AIDS prevention and 
mitigation programs.  Emphasis will also be placed on the important role 
that non-governmental organizations, business groups, people living with 
HIV/AIDS and community organizations should play in an effective 
response to HIV/AIDS.

The State Department will seek to heighten the awareness of the foreign 
policy implications of HIV/AIDS in the foreign service community, 
through all available mechanisms, including training and conferences for 
foreign service officers. 

The State Department will transmit this Strategy in a cable to all 
posts.

2.  Develop Behavioral Prevention Strategies.

     Prevention programs aimed at reducing high-risk behavior are the 
best hope for reducing the numbers of new HIV infections.  The Congress 
will be asked to support increases in the funding for global prevention 
programs that have been shown to reduce high risk behaviors that lead to 
the spread of HIV infection.  The Secretary of State will describe in a 
letter to Congress the implications of the global HIV/AIDS issue for 
U.S. foreign policy and the need for U.S. funding for international 
programs aimed at reducing high-risk behaviors associated with HIV 
infection.  (This letter, to be sent jointly with the Secretary of 
Health and Human Services, will address other AIDS-related issues, as 
described below.)

     Successful prevention strategies can provide cost-effective ways 
to improve both domestic and international prevention efforts.  Low-
cost, effective and culturally relevant programs that are designed and 
implemented in collaboration with affected communities hold great 
promise.  As HIV/AIDS becomes increasingly a disease of the poor in the 
United States, lessons gained from community-based organizations 
overseas become highly relevant.  Similarly, community-based 
organizations in other countries can benefit from the U.S. experience, 
for example, in community planning for HIV/AIDS prevention.  USAID 
combats global HIV/AIDS by identifying successful prevention strategies 
and applying them to appropriate new regions or countries.  Such 
strategies should be publicized to government and community health 
workers.  The Peace Corps incorporates HIV/AIDS education into other 
services, such as the teaching of English.  This model approach for 
successful and integrated intervention should receive continued support.  
Through continued military-to-military educational programs on HIV/AIDS, 
The Department of Defense will collaborate to reduce the rate of 
infection in foreign militaries.

     Governmental groups should seek the expertise of those on the 
front lines of the HIV/AIDS battle, including people living with 
HIV/AIDS and non-governmental experts.  The NGO community, business and 
labor leaders, and people living with HIV/AIDS should be included as 
appropriate in AIDS policy dialogue as well as in designing and 
implementing of prevention strategies aimed at changing high-risk 
behaviors.  The State Department will host a conference with U.S.-based 
international business leaders to discuss a range of HIV/AIDS-related 
issues, including the impact of HIV/AIDS on trade and investment 
decisions and on sustainable economic development.  The State Department 
will work with non-governmental organizations that bring together 
private sector and public health interests to prepare the conference.
The State Department, USAID and the National AIDS Policy Director will 
host a conference for domestic and international non-governmental 
organizations to discuss the U.S. response to global HIV/AIDS and to 
foster the exchange of information and experiences between domestic and 
international groups.  Expected participants include representatives 
from the private sector, the religious community, activist groups and 
service organizations.  USAID, the National AIDS Policy Director and the 
State Department will explore the feasibility of hosting satellite 
meetings at the International AIDS Conferences and regional AIDS 
conferences at which large cohorts of domestic and international NGOs 
are represented in order to foster dialogue between domestic and 
international NGOs.

3.  Augment Research.  

     The U.S. maintains the world's most advanced biomedical and 
behavioral research base on HIV/AIDS.  Advances made domestically will 
have international applications and impact.

     The U.S. research agenda on HIV/AIDS emphasizes the development of 
preventive vaccines and other interventions to reduce the spread of 
HIV/AIDS, including microbicides, and more effective behavioral 
strategies and therapies to suppress opportunistic infections.

The National Institutes of Health (NIH) have primary USG responsibility 
for conducting and funding basic and clinical research on AIDS.

USAID and the Centers for Disease Control and Prevention (CDC) conduct 
international surveillance, behavior research, and prevention 
activities.

The Department of Defense conducts mission relevant biomedical research 
activities toward candidate vaccine development.

     International research collaboration helps:  (a) expand the 
knowledge base for diverse strains of HIV, (b) boost understanding of 
epidemiologic trends and mechanisms of HIV transmission, and  (c) 
identify successful behavioral strategies for prevention.  Such 
collaboration will provide the basis for eventual large-scale testing of 
vaccines, therapies and other interventions.

The Congress should be encouraged to support the substantial U.S. 
research agenda on HIV/AIDS since these activities are most likely to 
produce a vaccine, drugs, technologies or behavioral strategies that 
could be used on a global scale.

In their joint letter to the Congress, The Secretary of State the and 
Secretary of Health and Human Services will describe the important role 
of U.S. biomedical and behavioral research in the global strategy to 
prevent infections.  The letter will explain why Congress should support 
fully the Administration's budget request for biomedical research.  

USG representatives, including embassy personnel, will encourage foreign 
governments to recognize the value of supporting, both financially and 
in principle, HIV-related research.  Where appropriate, embassies will 
assist in gaining approval for HIV/AIDS vaccine trials and other 
research efforts in host countries.

     Through training and education, foreign representatives and health 
professionals will be more able to address the epidemic in their own 
countries.  They will develop more reliable statistics and better train 
more staff to monitor the spread of HIV/AIDS.

The NIH and its Fogarty International Center will establish and 
strengthen international biomedical scientific collaborations and 
training.

NIH's Office of AIDS Research, in collaboration with the Fogarty 
International Center, will develop an inventory of NIH-supported 
research being conducted in both developing and developed countries.

The State Department will assist USG agencies as necessary in 
strengthening or establishing international research and training 
collaborations.

     USG technical agencies will maintain, expand or improve their 
research-related AIDS efforts:

The National Institutes of Health will continue its strong AIDS research 
program with the aim of developing effective behavioral strategies, 
drugs, vaccines, other prevention technologies and approaches, including 
vaginal microbicides, and low-cost diagnostics to reduce the spread and 
impact of HIV/AIDS.  NIH will work with the private sector, as 
appropriate, in this endeavor.

A key element of USAID's strategy on HIV/AIDS is to continue to support 
behavioral research, with the aim of developing culturally appropriate 
prevention strategies, and studies of the economic impact of HIV/AIDS, 
particularly at the household level.

FDA will work with product manufacturers to facilitate the rapid 
development of new agents for the prevention and treatment of HIV-
related conditions as well as medical devices for the prevention of HIV 
transmission.

CDC will continue to support behavioral research that provides 
information on risk behaviors and assists in targeting prevention 
strategies more appropriately.

The Department of Defense will continue mission relevant biomedical 
research efforts toward candidate vaccine development.

NIH's Office for Protection from Research Risks will continue its 
advisory and regulatory role in ensuring that international research is 
conducted in an ethical manner, consistent with agreed principles for 
protecting human subjects.

Recognizing that international health problems portend domestic 
concerns, CDC, in collaboration with other agencies, will work toward 
improved global monitoring of the spread of HIV/AIDS.

The State Department will convene a meeting of the National Science and 
Technology Council's Committee on International Science, Engineering and 
Technology to address the global challenge of emerging and re-emerging 
diseases, including HIV/AIDS.  Enhanced federal efforts to improve 
global surveillance of disease will be one major focus of the meeting.

The U.S. Census Bureau will expand its international HIV/AIDS database 
to include statistics from developed countries and countries where data 
had not been available previously, such as those of the Former Soviet 
Union.

The State Department, in collaboration with the CDC, will organize a 
workshop to examine surveillance and epidemiological issues and related 
policy concerns in the Former Soviet Union.

The Department of Defense will continue its biomedical research efforts 
toward vaccine development and toward improving the understanding of 
strains of HIV which pose potential risks to U.S. troops serving 
overseas.

4.  Safeguard the Blood Supply.

The overall number of HIV infections which is attributed to receiving 
infected blood is relatively small.  Yet technology exists that can 
safeguard the blood supply and effectively prevent these infections.  
Making this technology available to countries in need and reducing the 
number of unnecessary blood transfusions will prevent the majority of 
infections acquired through this mechanism.

The Department of Health and Human Services will work with international 
partners, including NGOs and international development agencies and 
organizations, to assist in safeguarding the world blood supply.
FDA will work with manufacturers to facilitate the development of new 
testing methodologies and other approaches to help assure the safety of 
the blood supply.

5.  Provide Access to Health Services and Technologies.

Access to health services, and particularly those related to 
reproductive health and treatment of sexually transmitted disease, is 
essential in enhancing the efficacy of prevention strategies.  The U.S. 
will give priority to ensuring access to primary health care services, 
and particularly to reproductive health and STD services;

At international meetings the USG will emphasize the importance of 
access to health services as an important component of HIV/AIDS 
prevention and care strategies.

USAID's HIV/AIDS strategy includes programs that underscore the linkage 
between reproductive health services, the treatment of sexually 
transmitted diseases, and reduction in the spread of HIV/AIDS.
The USG will stress the important role that communities play in delivery 
of health services.

     Access to effective prevention and treatment technologies for 
HIV/AIDS remains a major concern for many groups.

The USG will work with international partners to improve access to 
effective and affordable condoms and drugs, critical to effective 
HIV/AIDS prevention.

Concerned USG agencies will consider alternative and innovative ideas, 
including the establishment of an international fund, aimed at improving 
access to prevention and treatment technologies, including condoms and 
vaginal microbiocides once they are developed.

6.  Address the Adverse Impact of Poverty and Other Factors on 
Prevention Efforts.

The epidemic is steadily increasing in poorer populations who have 
limited access to information about HIV and AIDS and/or preventive 
health services and limited ability to act on the information they may 
have.  As societies improve access to information and services for all 
members and promote the rights and dignity for all members, thereby 
reducing discrimination, they will be increasingly successful in 
reducing the social and economic damage caused by AIDS.  

The USG will work with other governments and in every appropriate forum, 
including international conferences and within the U.N. system, toward 
improving conditions which foster HIV/AIDS prevention efforts for groups 
that may be at higher risk for HIV infection, including women, children, 
youth, members of minority groups, the poor, homosexuals, mobile 
populations, and intravenous  drug users.  Illustrative examples of USG 
actions are outlined below.

Women:  Coupled with their biological susceptibility to infections 
through heterosexual transmission, the lower social, educational, and 
economic status of women in some countries puts them at even higher risk 
for becoming infected with HIV.  Their subordinate role in some 
countries prevents them from refusing unsafe sex or from leaving 
marriages in which their partner is engaging in behaviors which places 
him at high risk for becoming HIV-infected.  The improvement of the 
status and self-esteem of women and their role in the family will have 
far-reaching effects in reducing HIV infections in women and in stemming 
the spread of HIV/AIDS.

     Several conditions may directly or indirectly impact the rates of 
HIV infection in women:

--     Human rights abuses, such as the selling of women and girls into 
prostitution and the traditional practice of female genital mutilation;

--     Increasing trend toward early childhood marriage; and,

--     Discriminatory land-tenuring and inheritance laws.

In all appropriate fora, the USG will emphasize the special needs of 
women, including the protection of women's human rights. 

DHHS and the National AIDS Policy Director will establish an interagency 
working group to discuss women's health issues related to HIV/AIDS and 
associated concerns as they relate to key international meetings.
USAID programs to increase the education of girls and women and their 
economic potential will address the socio-economic factors contributing 
to women vulnerable to HIV-infection.

The USG will support global research priorities that emphasize 
protecting women from infection.  Research aimed at development of 
technologies that increase women's ability to protect themselves from 
infection is of global import since such technologies may be the best 
hope to decrease heterosexual spread of AIDS in the near term.

USAID and the PHS will prioritize efforts in the development of 
technologies such as microbicides and the female condom and behavior 
strategies which will provide greater options for women to protect 
themselves from infection.

As a means to provide greater protection for women as well as men, USAID 
and PHS will prioritize efforts to develop new and better male condoms.

Children and Youth:  Cultural and societal attitudes which inhibit frank 
discussions about sex and gender issues and which condone high-risk 
sexual behavior can be counterproductive to HIV/AIDS prevention efforts.  
Successful and long-term HIV/AIDS prevention strategies must include 
age-appropriate education and others which instill a sense that 
individuals are able and have a responsibility to protect themselves 
from infection.  In addition, research aimed at preventing infection of 
infants born to infected mothers should remain a central focus.

In every appropriate forum the USG will recommend adoption of age-
appropriate education on HIV/AIDS.

The NIH will place a high priority on following up initial studies which 
could lead to methods for preventing HIV transmission from mother to 
fetus, including antiviral therapy (AZT) and micronutrient treatment 
(vitamin A) during pregnancy and on further defining the context of 
their use.

The State Department will emphasize to appropriate U.N. agencies, 
including UNICEF, UNDP, WHO, and UNFPA, the importance the USG places on 
prevention of HIV infection of children and youth and will urge U.N. 
bodies to prioritize their efforts for preventing infections and 
mitigating the impact of HIV/AIDS on children and youth.

Mobile Populations:  Millions of people who daily move across national 
borders pose global economic, security and health concerns.  This mobile 
population constitutes one of the world's largest potential transmission 
pools of HIV.  Members of militaries, multinational companies, refugee 
groups, teams on large development projects, farm groups, trucking 
companies, and others in this mobile group may engage in high-risk 
behaviors that would lead to HIV infection.  Members of these groups 
should have access to information and services that would assist in 
preventing infection, either of themselves or of others.  Reducing HIV 
infections in mobile populations would presumably have a secondary 
benefit of decreasing rates of transmission once the worker returned 
home.  The USG will work to improve access to information and services 
for mobile populations.

The State Department will convene an interagency working group to 
discuss cooperation more closely with development banks to reduce the 
spread of HIV/AIDS at development project sites and particularly among 
workers who migrate to work at those sites.

When appropriate and feasible, USAID will incorporate HIV/AIDS 
prevention activities into the overall health strategy for well-
established refugee camps.

B.  REDUCE PERSONAL AND SOCIAL IMPACT

	Medical services and social support are vital for persons with HIV 
and their families.  Nations need long-term treatments for HIV and AIDS 
and for the opportunistic infections which complicate HIV infection, 
such as tuberculosis.

     HIV/AIDS poses problems to infected persons which go beyond the 
medical and health implications, such as the potential for human rights 
abuses and discrimination in the workplace.  Further, the impact of 
HIV/AIDS on society as a whole is manifested in destabilized family 
structures, adverse impact on the economy, and the threat of political 
and military destabilization.  These broader issues must be considered 
in any strategy to mitigate the impact of HIV/AIDS on the individual and 
the society.

1.  Provide Care and Support.

	Most countries aspire to ensure access to health care services for 
all citizens.  In developed and developing countries alike, however, the 
growing numbers of AIDS cases will strain health care systems.  In 
developing countries, health care systems have been inadequate even 
before HIV/AIDS.  The result is less access to service for those in 
need.  The effects are multiplied because governments will be forced to 
buttress weak health care systems by diverting scarce resources from 
national savings or other sources that are critical for national 
economic stability.  While working to boost health care infrastructures, 
governments should work with non-governmental groups and people infected 
and affected by HIV/AIDS to more effectively meet the care and support 
needs of HIV-infected individuals.

o     With the goal of developing effective and affordable long-term 
treatments and strategies to provide care and to assist HIV-infected 
persons and their families, USAID and PHS, with support from the State 
Department as needed, will continue and expand efforts to bolster health 
care infrastructures, including strengthening of tuberculosis control 
programs.

USAID and DHHS agencies will provide technical assistance to countries 
for the identification and development of international procurement and 
distribution mechanisms for drugs, vaccines and other preventive 
technologies.

The USG will support the inclusion of non-governmental organizations and 
people infected with and affected by HIV/AIDS in the design of care 
strategies.

In appropriate international meetings the USG will support a strong role 
for community-based provision of care and support to those affected by 
HIV/AIDS.

Special emphasis on families:  The impact of HIV/AIDS on families is 
cause for alarm.  By the year 2000, it is estimated that 10 - 15 million 
children will have become orphans because of HIV/AIDS.  They may swell 
the ranks of the unemployable, become part of the alienated and 
increasingly criminal class in many cities, and add to the worldwide 
increase in street children.  The impact on women is equally alarming.  
As infected women become sick and die, families will increasingly feel 
the burden of lost economic income, especially in agricultural-based 
societies, as well as the loss of the major caregiver for the family.  
The USG will advance the recognition in every appropriate forum that 
HIV/AIDS can have a devastating and destabilizing impact on families, 
and particularly on women, children and youth.

The State Department will stress the urgent need of addressing the 
impact of HIV/AIDS on families in all appropriate international fora, 
including the IVth World Conference on Women and the Joint U.N. 
Programme on AIDS.

USAID will work with other donors to establish innovative programs, 
including the establishment of trust funds, in order to provide social 
services and support for the burgeoning number of AIDS orphans in 
developing countries.

2.  Guarantee Human Rights.

	Universal recognition of the human rights of HIV-infected persons 
is essential to reducing the personal and social impact of HIV/AIDS.  
The USG will promote non-discriminatory workplace policies, protection 
from punitive or coercive measures with respect to HIV testing, policies 
relating to entry into foreign countries that are based on sound public 
health practice, and non-discriminatory access to education and medical 
treatment as well as the protection of civil and political rights.

In all appropriate international fora the State Department and other 
appropriate USG representatives will promote the safeguarding of equal 
protection under the law for persons living with HIV/AIDS with regard to 
access to health care, employment, education, travel, housing and social 
welfare.

The State Department will continue to include HIV/AIDS-related di 
scrimination and human rights abuses in regular embassy reporting.

3.  Protect Politico-Military Structures at Risk.

     HIV has the potential to affect the stability and readiness of 
militaries, especially those in developing countries with very high HIV 
rates of infection.  The overall impact on military capabilities in most 
instances appears to be slight thus far; however, as key career 
personnel increasingly move past the long HIV latency stage and contract 
AIDS, their loss will have a detrimental effect, particularly in the 
more sophisticated developing-country militaries that depend 
significantly on well trained and experienced technical personnel.

	Militaries are composed largely of young men and women who are 
susceptible to behaviors that carry with them the risk of contracting 
HIV.  Nethertheless educated and disciplined troops can be trained to 
avoid high-risk behaviors by a military establishment that recognizes 
and responds to the threat of HIV/AIDS.  That explains, in part, the 
relatively low HIV prevalence in developed-country militaries.

     World-wide peacekeeping operations may pose a danger of spreading 
HIV, particularly as traditional developing-country suppliers of troops 
find it increasingly difficult to supply units that are free of HIV 
infection.  The risk runs both ways; peacekeepers could both be a source 
of HIV infection to local populations and be infected by them, thus 
becoming a source of the infection when they return home.  In combat 
situations, there may also be increased risk of HIV transmission among 
peacekeepers, and between them and local populations, through contact 
with HIV contaminated blood.

	A more substantial overall risk, however, is the transmission of 
HIV-related secondary infections, such as tuberculosis, which are far 
more contagious and more easily transmitted.  The spread of those 
diseases cannot be largely avoided by controlling high-risk behaviors, 
as is the case with HIV.

All appropriate support should be given to DOD's military-to-military 
educational programs on HIV/AIDS that are geared to improving prevention 
strategies in foreign militaries.

The State Department will convene an interagency meeting to address the 
impact of HIV/AIDS on international peacekeeping operations and 
humanitarian missions.  Issues to be considered include risk of exposure 
of U.S. troops to HIV/AIDS and to HIV-associated and possibly multi-drug 
resistant TB; combat medical conditions, including safety of the blood 
supply and medical personnel and treatment of non-U.S. troops; the 
importance of military training in the U.S. as a democracy promoting 
measure and the impact of restrictive U.S. entry requirements on such 
training, and the degree of spread of various strains of HIV due to 
peacekeeping operations.  Recommendations for action will be made to 
appropriate officials, including those responsible for development of 
U.S. policy on U.N. peacekeeping operations.

The National Intelligence Council will coordinate the preparation of a 
National Intelligence Estimate on the impact of HIV/AIDS on military 
establishments.

4.  Place HIV/AIDS on the Sustainable Development Agenda.  

     The growing AIDS epidemic will complicate ongoing sustainable 
development efforts.  While AIDS has adversely impacted the skilled, 
urban workforce in developing countries, the disease will also have an 
increasingly devastating impact in rural regions over the next several 
years.  Because remittances from urban workers are often critical 
sources of income for family members who remain in the countryside, the 
illness and death of urban workers may mean fewer resources are 
available to rural communities and households.  The loss of trained 
workers and supervisors will reduce the professional and technical and 
skills base, especially in smaller countries, while infection among the 
unskilled will disrupt routine operations even in sectors where 
replacements are readily available.  Losses in the agricultural labor 
pool could lead to decreased production of cash crops as subsistence 
farming consumes all available labor in some communities.

	The credit-worthiness of those seeking loans for low-cost housing, 
farm improvements, or to expand small businesses is weakened if family 
incomes are reduced by illness and death.  Education is vital for 
development, but children are leaving school early to care for ill 
relatives or because falling family incomes do not allow for payment of 
school fees.  Moreover, since infected people die during their most 
productive years, tough decisions will have to be made regarding 
expenditures for training.

The State Department will work with the Departments of Commerce and 
Treasury and USTR to propose AIDS as an agenda item at the G-7 and other 
appropriate international economic meetings.

The State Department, in consultation with business and labor groups, 
other NGOs and appropriate USG agencies, will host a 1-5 day conference 
on a range of HIV/AIDS-related issues, including the impact of HIV/AIDS 
on sustainable development of trading partners.

The intelligence community will produce and update analyses of the 
impact of HIV/AIDS in selected countries and regions, as needed.


C.  MOBILIZE AND UNIFY NATIONAL AND INTERNATIONAL EFFORTS

     Strengthened collaboration within and among countries is an 
essential component to improving efforts to combat global HIV/AIDS.  The 
U.S.G. should use a variety of mechanisms to meet these objectives, 
including the following:

The Interdepartmental Task Force on HIV/AIDS, chaired by the National 
AIDS Policy Director, will develop a national action plan for HIV/AIDS, 
as directed by the President.

--	The State Department will work to ensure that the objectives 
outlined in the present document support and complement those of the 
national action plan.

The Joint U.N. Programme on AIDS is expected to provide an excellent 
framework for the coordination of bilateral and multilateral HIV/AIDS 
efforts.  Continued support for the Programme sends the message that the 
U.S. sees coordination of efforts as a critical element in a successful 
effort to combat global HIV/AIDS.

--     The State Department and senior USG officials will support -- and 
will urge other governments to support -- the speedy establishment of 
the Joint U.N. Programme on AIDS.

The State Department and senior USG officials will urge other 
governments to increase their contributions to the UN's efforts on 
HIV/AIDS to the already high levels being contributed by the USG.

Since the HIV/AIDS issue is taken up in a number of intergovernmental 
fora, both within and without the U.N system, the State Department will 
convene regular interagency meetings to discuss the international agenda 
and to develop common approaches on HIV/AIDS issues.

Using the HIV/AIDS component of the Common Agenda with Japan as a model, 
the State Department and USAID will pursue agreements with other donors 
to work more closely on HIV/AIDS in priority countries.

To the extent possible, U.S. international policy on HIV/AIDS will be 
consistent with other international efforts, and those of the U.N. 
system in particular.

APPENDIX A:  An Agenda for Action

	The following breakdown by agency re-capitulates the action items 
outlined in the body of the document in their order of appearance.  For 
actions in which more than one agency is involved, the action, in most 
cases, is listed according to the agency which will take the lead.

State Department

1a    The State Department will ensure that the major tenets of this 
document are promoted in relevant international meetings of the U.N. and 
other bodies, including the IVth World Conference on Women, as well as 
within U.N. agencies themselves, and particularly in the Joint U.N. 
Programme on AIDS.

1b    The State Department will develop policy guidance materials to 
ensure that U.S. international HIV/AIDS objectives are promoted in 
discussions between senior USG representatives and national leaders from 
key countries.  In addition to encouraging leaders to join the United 
States in endorsing the 1994 Paris AIDS Declaration and the Joint U.N. 
Programme on AIDS, USG representatives will emphasize a range of 
concerns, including the urgent need for leaders to openly address the 
HIV/AIDS pandemic in their own countries, the need for governments to 
consider the adverse economic impact of HIV/AIDS in their countries, the 
need for other governments to increase spending on HIV/AIDS prevention 
and research, and the need to establish or implement National AIDS 
Action Plans.

1c    U.S. ambassadors and other embassy representatives will meet with 
host country counterparts to describe the U.S. International Strategy on 
HIV/AIDS and to encourage leaders to expand HIV/AIDS prevention and 
mitigation programs.  Emphasis will be placed on the important role that 
NGOs, business groups, people living with HIV/AIDS, and community 
organizations should play in an effective response to HIV/AIDS.

1d    The State Department will transmit this Strategy on HIV/AIDS in a 
cable to all posts.

1e    The State Department will seek to heighten the awareness of the 
foreign policy implications of HIV/AIDS to the foreign service community 
through all available mechanisms.

1f    The Secretary of State will join the Secretary of the Department 
of Health and Human Services in sending a joint letter to Congress 
describing the broad impact of HIV/AIDS, including the implications for 
U.S. foreign policy and national security interests.  The letter should 
describe the important role of U.S. biomedical research in the global 
strategy to prevent infections.  The letter should urge Members to 
support fully the Administration's budget request for biomedical 
research and international AIDS prevention.

1g    The State Department will host a 1-5 day conference with U.S.-
based international business leaders to discuss a range of HIV/AIDS-
related issues, including the impact of HIV/AIDS on trade and investment 
decisions and on sustainable economic development of trading partners.

1h    The State Department will assist USG agencies as necessary in 
strengthening or establishing international research and training 
collaborations and will assist, as necessary, in gaining approval for 
HIV/AIDS vaccine trials and other research efforts in host countries.

1i    The State Department will convene a meeting of the National 
Science and Technology Council's Committee on International Science, 
Engineering, and Technology to address the global challenge of emerging 
and re-emerging diseases, including HIV/AIDS.

1j    The State Department, in collaboration with the CDC, will organize 
a workshop to examine surveillance and epidemiological issues and 
related policy concerns in the Former Soviet Union.

1k    The State Department will emphasize to appropriate U.N. agencies, 
including UNICEF, UNDP, WHO and UNFPA, the importance which the USG 
places on prevention of HIV infection of children and youth and will 
urge U.N. bodies to prioritize their efforts for preventing infections 
and mitigating the impact of HIV/AIDS on children and youth.

1l    The State Department will convene an interagency working group to 
discuss mechanisms whereby the USG may work more closely with 
development banks to reduce the spread of HIV/AIDS at development 
project sites.

1m    The State Department and other appropriate USG representatives 
will promote the safeguarding of the protection under the law for 
persons living with HIV/AIDS with regard to access to health care, 
employment, education, travel, housing and social welfare in all 
appropriate fora.

1n    The State Department will continue to include HIV/AIDS-related 
discrimination and human rights abuses in regular embassy reporting.

1o    The State Department will convene an interagency meeting to 
address the impact of HIV/AIDS on international peacekeeping operations 
and humanitarian missions.  Recommendations for action will be made to 
appropriate officials, including those responsible for U.S. policy on 
U.N. peacekeeping operations.

1p    The State Department will work with the Departments of Commerce 
and Treasury and USTR to include AIDS as an agenda item at the G-7 and 
other appropriate international economic meetings. 

1q    The State Department will work to ensure that the objectives 
outlined in the present document support and complement those of the 
national HIV/AIDS action plan, now being developed.

1r    The State Department and senior USG officials will support -- and 
will urge other governments to support -- the speedy establishment of 
the Joint U.N. Programme on AIDS.  They will also urge other governments 
to increase their contributions to the U.N.'s efforts on HIV/AIDS to the 
already high levels being contributed by the USG.

1s    The State Department will convene regular interagency meetings to 
discuss the international calendar and to develop common approaches on 
HIV/AIDS issues.

1t    Using the HIV/AIDS component of the Common Agenda with Japan as a 
model, the State Department and USAID will pursue agreements with other 
donors to work more closely on HIV/AIDS in priority countries.

USAID

     As outlined in the body of the present document, the following are 
some of the key elements of USAID's global HIV/AIDS strategy:

2a    Identify successful prevention strategies and, through USAID 
missions and U.S. embassies, publicize successes to government and 
community health workers so that they may be duplicated elsewhere, 
including in other regions of the same country as well as in other 
countries.

2b    Continue to support behavioral research, with the aim of 
developing culturally appropriate prevention strategies, and studies of 
the economic impact of HIV/AIDS, particularly at the household level.

2c    Continue to develop programs which underscore the linkage between 
provision of reproductive health services, the treatment of sexually 
transmitted diseases, and reduction in the spread of HIV/AIDS.

2d    Address the socio-economic factors which contribute to women's 
vulnerability to HIV infection through programs to increase the level of 
education in girls and women and their economic potential.

2e    Support efforts in the development of technologies such as 
microbicides and the female condom and behavior strategies which will 
provide greater options for women to protect themselves from infection.

2f    Develop new and better male condoms.

2g    When appropriate and feasible, incorporate HIV/AIDS prevention 
activities into the overall health strategy for well-established refugee 
camps.

2h    With the goal of developing long-term treatment and care 
strategies for HIV/AIDS affected persons, USAID, with support from the 
State Department as needed, will continue and expand efforts to bolster 
health care infrastructures in countries in need.

2i    Continue to provide technical assistance to countries for the 
identification and development of international procurement and 
distribution mechanisms for drugs, vaccines and other preventive 
technologies.

2j    Work with other donors to establish innovative programs, including 
the establishment of trust funds, in order to provide social services 
and support for the burgeoning number of AIDS orphans in developing 
countries.


DHHS AGENCIES

3a    NIH's Office of AIDS Research, in collaboration with the Fogarty 
International Center, will develop an inventory of NIH-supported 
research being conducted in both developing and developed countries.

3b    NIH will continue its strong AIDS research program with the aim of 
developing effective behavioral strategies, drugs, vaccines and other 
preventive technologies and approaches, including vaginal microbicides, 
and low-cost diagnostics to reduce the spread and impact of HIV/AIDS.  
NIH will work with the private sector, as appropriate, in this endeavor.

3c    FDA will work with product manufacturers to facilitate the rapid 
development of new agents for the prevention and treatment of HIV-
related conditions as well as medical devices for the prevention of HIV 
transmission.

3d    CDC will continue to support behavioral research which provides 
information on risk behaviors and which assists in targetting prevention 
strategies more appropriately.

3e    NIH's Office for Protection from Research Risks will continue its 
advisory and regulatory role in ensuring that international research is 
conducted in an ethical manner and one that is consistent with agreed 
principles for protecting human subjects.


3f    DHHS will work with international partners, including NGOs and 
international development agencies and organizations, to assist in 
safeguarding the world blood supply.

3g    FDA will work with manufacturers to facilitate the development of 
new testing methodologies and other approaches to help assure the safety 
of the blood supply.

3h    PHS will prioritize efforts in the development of technologies 
such as microbicides and the female condom and behavior strategies which 
will provide greater options for women to protect themselves from 
infection.

3i    PHS will prioritize efforts to develop new and better male 
condoms.

3j    The NIH will place a high priority on following up initial studies 
which could lead to methods for preventing HIV transmission from mother 
to fetus, including antiviral therapy (AZT) and micronutrient treatment 
(vitamin A) during pregnancy and on further defining the context of 
their use.

3k    With the goal of developing effective and affordable long-term 
treatments and strategies to provide care and to assist HIV-infected 
persons and their families, PHS, with support from the State Department 
as needed, will continue and expand efforts to bolster health care 
infrastructures.

3l    DHHS agencies will continue to work toward the identification and 
development of international procurement and distribution mechanisms for 
drugs, vaccines and other preventive technologies.

3m  CDC, in collaboration with other agencies, will work toward improved 
global  monitoring of the spread of HIV/AIDS.  This includes working 
with the U.S. Census Bureau to expand its international HIV/AIDS 
database to include statistics from developed countries and the Former 
Soviet Union.


Peace Corps

4a    The Peace Corps' programs which incorporate HIV/AIDS education 
into other services, such as the teaching of English, should be viewed 
as models for successful and integrated interventions and should receive 
continued support.



Defense Department

5a    The Department of Defense will continue to conduct military-to-
military educational programs on HIV/AIDS, which are expected to 
contribute to changes in high-risk behaviors and overall decreases in 
the rate of infection in foreign militaries.  All appropriate support 
should be given to these programs.

5b    The Department of Defense will continue mission relevant 
biomedical research efforts toward candidate vaccine development.



The Intelligence Community

6a    The National Intelligence Council will coordinate the preparation 
of a National Intelligence Estimate on the impact of HIV/AIDS on 
military establishments.

6b  The intelligence community will produce and update analyses of the 
impact of HIV/AIDS in selected countries and regions, as needed.



Multiple Agency Efforts:

7a    The State Department, USAID and the National AIDS Policy Director 
will host a conference for domestic and international AIDS non-
governmental organizations to discuss the U.S. response to global 
HIV/AIDS and to foster the exchange of information between domestic and 
international groups.

7b    USG representatives, including embassy personnel, will encourage 
foreign governments to recognize the value of supporting, both 
financially and in principle, HIV-related research.

7c    USAID, the National AIDS Policy Director and the State Department 
will explore the feasibility of hosting satellite meetings at the 
International AIDS Conferences and regional AIDS conferences at which 
large cohorts of domestic and international NGOs are represented in 
order to foster dialogue between domestic and international NGOs.

7d    Concerned USG agencies will consider alternative and innovative 
ideas and will work with international partners to improve access to 
essential commodities, including condoms, vaginal microbicides (once 
they are developed and made available) and drugs to treat sexually 
transmitted diseases.

7e    DHHS and the National AIDS Policy Director will establish an 
interagency working group to discuss women's health issues and 
associated concerns as they relate to key meetings on the international 
agenda.

7f    Representatives from the State Department, USAID, the National 
AIDS Policy Director's office, and others will meet on a regular basis 
to discuss key issues of common concern.




APPENDIX B:  International Research Cooperation

INTRODUCTION

	Science is an international enterprise, and international 
scientific dialogue and research are essential in advancing knowledge 
about HIV infection and AIDS.  International HIV-related research 
intersects with other foreign policy issues as it develops information 
to address a fundamental health issue contributing to social and 
economic instability in many countries.  The U.S, has much to gain by 
continued strong international cooperative and collaborative efforts 
with nations with highly advanced biomedical research programs and 
health delivery systems and with nations with less developed research 
and public health capabilities.  Such efforts are a key part of a 
comprehensive U.S. international HIV/AIDS strategy.

     Information from international research benefits U.S. citizens, as 
well as people in the country where research is conducted and people 
world-wide who are affected by HIV.  Some of the most critical 
scientific information on HIV/AIDS has been derived from collaboration 
with colleagues in other countries, with implications for prevention and 
treatment of HIV infection and disease, as well as the impact on 
societies.  These studies provide information on the variation of 
strains of HIV from various geographical regions; risk factors for 
heterosexual and mother to child transmission of HIV; the role of other 
sexually transmitted diseases in HIV transmission; the relationships 
between HIV infection and other diseases; and the demographic and 
socioeconomic impact of HIV/AIDS/  Global monitoring of the epidemic is 
crucial to further understand mutation and evolution of HIV and patterns 
of spread.  The recent explosive epidemic in Asia caused by variants 
differing from that found in the U.S. warrants close attention; HIV 
evolutionary patterns in foreign settings may foreshadow unanticipated 
events in the U.S.

	The development of HIV-related research skills in scientists and 
health professionals is central to an international research strategy.  
Scientist exchanges facilitate the generation of new research ideas.  In 
addition, international training programs increase the expertise of both 
American and foreign scientists in HIV/AIDS research, provide the 
opportunity to develop collaborative relationships between American and 
foreign scientists, and will facilitate the international testing of 
anti-HIV drugs and vaccines.

     Consideration of human rights must be fundamental to the 
philosophy guiding U.S.-sponsored research in foreign countries.  
Ethical and legal issues related to the conduct of international HIV-
related research will be continually examined, including issues such as 
the protection of human participants in research in vastly differing 
cultural contexts and the rights of collaborating researchers and 
institutions.  These principles are well-articulated in recent documents 
(see references 1,2,3).

	A basic ethical responsibility of developed nations is to ensure 
that developing countries receive benefits from research.  Issues 
include the dissemination of research information to researchers, care 
providers, and program managers; dialogue with vaccine and drug 
manufacturers concerning the need to develop products with global 
utility; and the development of scientific and laboratory capabilities 
in developing countries.  Research collaboration and training strengthen 
the scientific foundation and help to establish the knowledge, skills, 
and laboratory capacity upon which countries can further develop public 
health infrastructure to deliver HIV vaccines, when available, and cost 
effective interventions.  Such efforts will have far-reaching effects 
through application to other infectious diseases prevalent or emerging 
in developing countries.

CURRENT INTERNATIONAL HIV-RELATED RESEARCH ACTIVITIES

     Several government agencies conduct international HIV-related 
research efforts, the nature and perspective varying with the mandates 
of the individual agencies.  In addition to U.S. and other countries' 
government agencies, activities related to international research on HIV 
are conducted by multilateral organizations, including U.N. agencies and 
the World Bank, and by private foundations.

National Institutes of Health (NIH) supports over 100 collaborative 
HIV/AIDS research projects, in both developed and less developed 
countries.  These include basic research studies, such as genetics and 
immunology; research related to the development of vaccines and 
therapeutics; population-based research on transmission of HIV and 
progression of HIV disease; the behaviors associated with increased risk 
for HIV infection.  These studies help to develop the infrastructure for 
clinical trials of vaccines by defining potential study populations and 
developing laboratory and research capabilities.  The AIDS International 
Training and Research Program (AITRP) provides research training 
designed to increase the capacity of developing countries to address 
AIDS.  A reagent repository provides access to research reagents world-
wide.  The NIH has developed formal agreements with several foreign 
countries to collaborate on AIDS-related research, including Japan, 
Germany, and Thailand.

Centers for Disease Control and Prevention (CDC) international AIDS 
research activities include two collaborative research projects with CDC 
professional staff posted overseas in Cote d'Ivoire and Thailand, 
transfusion safety research and assessment in Africa, characterization 
of viral isolates, field evaluations of low-technology diagnostics, 
epidemiologic and research training, plus short-term technical 
consultations and long-term assignment of professional staff to U.N. 
agencies.  The principal areas of current and near future activities 
include epidemiologic and intervention research in mother-to-child 
transmission, heterosexual transmission and its interactions with other 
sexually transmitted diseases, TB-HIV interactions, and blood safety.  
Training of international public health professionals in epidemiology 
and research includes courses in Atlanta and overseas, one-on-one 
mentoring in research projects abroad, and longer-term training for 
foreign nationals in the U.S. and Belgium, supported in part by funding 
from the NIH.

U.S. Agency for International Development (USAID) has supported research 
on behavior change, social marketing for condom promotion, and sexually 
transmitted disease (STD) reduction via its AIDSCAP project.  In 
addition, USAID supports several grants to non-governmental 
organizations (or private voluntary organizations, NGO/PVO), as well as 
epidemiological and biomedical research administered by the NIH, CDC, 
and the Global Programme on AIDS of the WHO.  Specific areas of research 
include female-controlled vaginal spermicides and microbicides, female 
condoms, the economic impact of HIV/AIDS, inexpensive STD diagnostics, 
and novel testing and counselling strategies.

Department of Defense (DoD) HIV/AIDS efforts comprise militarily 
relevant, product oriented, applied research aimed at reducing the rate 
of new infections, disease progression, and death of DoD personnel.  A 
key objective is to develop a vaccine(s) offering protection from HIV 
for U.S. military personnel world-wide, including:  isolation and 
characterization of the genetic diversity of HIV from international 
sites; initiation of joint U.S./Thai preventive vaccine field trials in 
late 1994 or 1995.  A collaborative program with other militaries 
through DoD's world-wide network of military research laboratories forms 
the basis for potential HIV/AIDS clinical and research observations, 
especially in the development and pre-clinical testing of vaccines 
corresponding to virus prevalent in developing countries.  A behavioral 
prevention program includes intervention-based prevention research 
directed at reducing high risk behaviors among uninfected military 
personnel.


FUTURE DIRECTIONS IN INTERNATIONAL HIV RESEARCH COOPERATION

	International research collaboration will continue to provide 
unique research opportunities that allow us to obtain useful scientific 
information more rapidly and at less cost, benefitting all concerned.  
The following are critical areas of international HIV-related research 
collaboration to be pursued.

Basic biomedical research in areas such as virology, immunology, and 
molecular biology will provide the basis for the development of AIDS 
vaccines and therapeutic strategies.

Study of the clinical and molecular epidemiology of HIV/AIDS and 
mathematic modelling of individual epidemics is central to an 
international strategy to address AIDS, particularly in areas already 
greatly impacted by the pandemic, such as Africa and Latin America, and 
in areas of escalating epidemics, such as the Far East and Western 
Pacific.

Research on risk behaviors and the factors that motivate and sustain 
behavior change in difference populations and under a variety of social, 
cultural, and economic circumstances will provide the foundation for the 
development, testing, and implementation of behavioral interventions.

Studies of risk factors and mechanisms of HIV transmission will provide 
information critical to the development of biologically-based strategies 
to interrupt transmission, including transmission from mother to infant, 
sexual transmission, and transmission through injection drug use.  In 
particular, studies of the role of treatment of STDs in control of HIV 
transmission will be critical to efforts to link STD programs with HIV 
prevention.

Studies of the progression of HIV-related disease from early infection 
through long-term consequences, including opportunistic infections, will 
provide information central to the clinical management of HIV-infected 
patients.

The development and evaluation of non-vaccine interventions that are 
effective against HIV infection and disease progression, cost effective, 
and useful in a variety of settings are critical to a comprehensive 
approach to aids prevention and an international research strategy.

The development of HIV vaccines that are safe and effective in 
preventing infection in exposed individuals is a major international 
public health priority.  The evaluation of vaccines for efficacy, 
including vaccines for mother to child transmission, will likely involve 
international vaccines trials at international sites.

The development of technologies that are applicable to research and 
patient care in less developed country settings is essential to 
effective research and care infrastructure.

Basic social science research that addresses the impact of social, 
economic, demographic, and cultural factors on AIDS epidemics, as well 
as the consequences of the epidemic for the family, society, culture, 
economic stability, national security, and demographic change, including 
worker migration, the role of poverty, the status of women, and 
political repression, will provide information of use to governments in 
developing broad social and political strategies to combat their 
epidemics.

     Additional activities will include the continued development of 
training programs; expansion of the use of established repositories, 
including encouragement for foreign scientists to submit specimens and 
facilitation of access to repositories by foreign scientists; 
collaboration in the development of a database of international clinical 
trials; and the dissemination of state-of-the-art research information 
to foreign scientists.

	For international research efforts to proceed smoothly, it is 
critical that mechanisms  e developed for coordination and information 
sharing among agency program staff.  Such activities might include 
developing briefing materials applicable across agencies; maintaining a 
database of international research activities; and convening meetings to 
share information and collaborate on program planning, collectively 
identifying opportunities to address problems cost-effectively.

     The U.S. should also coordinate effectively with other 
organizations with roles in international research on HIV, including the 
WHO Global Programme on AIDS, WHO regional offices, other U.N. 
organizations, the World Bank, private foundations, and regional non-
governmental organizations.  The U.S. government should also nurture 
partnerships with private industry and academia to further research with 
international relevance.  Specifically, the U.S. should collaborate with 
industry in developing vaccine candidates with global potential, perhaps 
through joint ventures between the U.S. government and industry.

     To advance the research agenda, it is necessary to consider policy 
issues in the context of research.  In this regard, the research 
community will rely on the efforts and expertise of other branches of 
the Government as noted below.  The U.S. should utilize diplomatic 
channels to encourage foreign governments to recognize the value of 
supporting, both financially and in principle, HIV-related research.  Of 
particular importance is research that will provide information relative 
to the empowerment of women and other disenfranchised segments of 
societies.  Where necessary, U.S. agencies and investigators should 
enlist assistance from Embassies to facilitate the establishment of 
relationships and the development of in-country infrastructure for 
research and dissemination of research findings.  Other efforts that 
would complement the international research agenda related to the 
investigation of mechanisms to remove barriers to infrastructure 
development for HIV-related research in foreign countries, including re-
examining existing authorities in relation to agency programs, 
addressing immigration issues, and initiating international dialogue 
concerning taxes and tariffs on equipment imports.

     Most important, close ties between U.S. and foreign scientists are 
essential for advancement of international collaborative research on 
AIDS.  To this end, a variety of formal and informal relationships 
should be cultivated, including scientist-to-scientist relationships, as 
well as formal agreements between the U.S. and foreign governments and 
institutions.  Where possible, the U.S. should attempt to develop full 
collaborative relationships with foreign investigators and maintain 
long-term institutional and personal relationships, whether through 
funding of projects, exchange of scientific expertise and information, 
or collegial communication.

REFERENCES

1.  U.S. Public Health Service (PHS) consultation on International 
Collaborative HIV Research, Law, Medicine, and Health Care, vol. 19, 
1991.

2.  International Ethical Guidelines for Biomedical Research Involving 
Human Subjects, Council for International Organizations of Medical 
Sciences (CIOMS), 1991.

3.  The Human Immunodeficiency Virus Vaccine Challenge:  Issues in 
Development and International Trials, a report by the Committee on Life 
Sciences and Health, Federal Coordinating  Council on Science, 
Engineering, and Technology, 1993.


APPENDIX C:  Prevention

     There is currently no cure for AIDS nor an effective treatment for 
HIV.  Therefore the main focus of current global efforts must be on 
prevention of new infections in order to break the chain of 
transmission.

     In order to prevent the spread of HIV, it is necessary in each 
country to identify behaviors which place individuals at the highest 
risk for transmission and to target these behaviors for intensive 
intervention efforts.  Active efforts are required to determine 
community needs, perceptions, and the basis for risk behavior, as well 
as assessment of which activities will be most likely to result in lower 
risk behaviors.  In some instances, mitigation of the social effects of 
high rates of AIDS-related illness will contribute to these efforts.

     The prevention strategy which is developed will need to be 
carefully coordinated with other donors and international organizations 
to maximize impact.  Additionally, the success of our national, regional 
and global programs to confront HIV/AIDS effectively requires active of 
participation of people infected and affected by HIV/AIDS and community-
based non-governmental organizations in the design, development, 
implementation and evaluation of policies and programs whose purpose is 
to affect their communities.

ELEMENTS OF AN EFFECTIVE U.S. GLOBAL HIV/AIDS PREVENTION STRATEGY:
Policy Dialogue

U.S. HIV/AIDS efforts should seek to identify and foster policies which 
promote the successful implementation of HIV/AIDS prevention programs.  
Consideration of both public policy and individual human rights should 
be included in the U.S. effort.  U.S. interventions in the policy arena, 
both at the diplomatic and community level, will seek to promote 
policies which enhance HIV/AIDS prevention and address the social, 
political, and economic underpinnings and consequences of the pandemic.  
They should also seek to eliminate policies that undermine successful 
HIV/AIDS prevention interventions.  These policies often include cross-
sectoral and multi-sectoral issues outside the realm of health and will 
require a coordinated U.S. response.

Information, Education and Communication for Behavior Change

Key to the U.S. strategic response to the HIV/AIDS pandemic are 
prevention interventions which lead to behavior change, including the 
establishment of community and individual norms that reinforce safe 
behavior to lower the risk of acquiring sexually transmitted diseases 
and HIV.  Education and information interventions should take into full 
consideration the cultural beliefs of the community and work from within 
the community to alter behaviors which place individuals at risk.

Increase Condom Use

Condoms are a major component of front line interventions in HIV/AIDS 
prevention.  The U.S. response includes interventions to assure the 
availability and affordable pricing of condoms through improved 
logistical systems, condom social marketing and, when appropriate, the 
provision of condoms as well as efforts to facilitate the development of 
more effective and acceptable barrier devices.

HIV Testing and Counselling

HIV testing and counselling can be a useful element in the U.S. response 
as a methods to provide individuals with the knowledge of their personal 
HIV status and as a diagnostic to obtain treatment.  The effectiveness 
of HIV testing and counselling as a behavior change mechanism is still 
uncertain, but the U.S. is currently undertaking research activities to 
assess the efficacy and cost of this intervention as a behavior change 
tool.

Biomedical Interventions

An important correlate to prevention education and behavior change 
interventions is improved STD case management through support to the 
provision of STD diagnostic and treatment services.  Treatment of 
opportunistic and secondary infections associated with HIV and a 
compromised immunological status should also be included in the U.S. 
strategy.  Additionally, the development, testing and dissemination of 
new prevention technologies, including vaginal microbicides and the 
female condom, is a high priority.

Injection Drug Use

There are many adverse consequences of illicit drug injection, including 
the risk of HIV transmission, and so an important U.S. policy goal is to 
reduce the demand for psychoactive drugs.  

Simultaneously, efforts must be carried out to help drug abusers prevent 
sexual transmission of HIV.  Behavioral change research into the 
prevention of bloodborne transmission is also needed.

Blood Screening and Blood Safety

The U.S., when appropriate, provides technical assistance in ensuring 
the safety of national and transnational blood supplies, and in helping 
to develop safe medical practices for health care.

Evaluation and Analysis of Data

The compilation and analysis of data with respect to the 
epidemiological, political, social and economic impact of the HIV/AIDS 
pandemic is essential to U.S. efforts to assist host governments.  It is 
required to assess the effectiveness of ongoing interventions as well as 
inform future program development.  The U.S. assists in improving 
surveillance of HIV infections and monitoring of related indicators.

Research

U.S. research institutions, with their extensive capacity and expertise, 
provide an invaluable contribution to HIV/AIDS prevention.  The 
objective basis for the implementation and evaluation of HIV/AIDS and 
other STD prevention and treatment interventions, as well as a full 
understanding of socio-economic impact, derives from basic and applied 
bio-medical and behavioral research.  Research areas should include 
STD/HIV epidemiological analysis, vaccine development and female-
controlled methods of HIV/SD protection, as well as behavioral and 
social determinants of HIV infection.


U.S. EFFORTS TO ADDRESS THE ELEMENTS OF THIS PREVENTION STRATEGY:

Policy Dialogue:  HIV/AIDS should be introduced to a greater extent in 
the U.S. diplomatic and policy dialogue in order to underscore the 
recognition of HIV/AIDS as an international problem with political, 
social and economic impact which go well beyond the boundaries of the 
traditional health sector.  Nations must address HIV/AIDS as a pandemic 
fueled by socio-economic inequities, human rights issues and questions 
of gender status.  

Discussion and resolution of these and related issues begin at senior 
policy levels.  The State Department should play a central role in 
raising HIV/AIDS in international fora.

Prevention Interventions:  USAID implements HIV/AIDS prevention 
interventions in over 40 countries through NGOs, the private sector and 
governments.  The focus of USAID prevention programs is to engage in 
efforts to change high-risk behaviors, encourage health seeking 
behaviors for individuals with STDs, improve the case management of 
STDs, and to provide individuals with access to affordable condoms.  
USAID also supports efforts in policy analysis and dialogue and the 
incorporation of HIV/AIDS prevention efforts into ongoing development 
assistance programs.  For example, the Peace Corps has developed 
education materials and curricula integrating HIV/AIDS prevention with 
the teaching of English.

CDC provides technical assistance in surveillance, STD case management 
and program development.

Behavior Research:  USAID's behavioral research program includes 
knowledge, attitude and practices surveys, behavior change research and 
the impact of counselling and testing on HIV prevention, as a part of 
its intervention agenda.

Several U.S. agencies carry out behavior research which is designed to 
provide indirect or direct information for HIV efforts in the global 
context.  The DOD Behavioral Prevention research effort focuses on 
behavior change interventions to prevent HIV transmission in military-
associated populations.  This effort places priority on data-derived 
interventions to prevent transmission in various populations, through 
educational interventions for individuals with higher levels of risk-
relevant behaviors for HIV infection, and counselling interventions for 
individuals who are HIV infected.  The approaches developed may be 
applicable in certain military or civilian populations in other areas, 
including some global efforts.

CDC has increased its domestic behavior agenda which may provide insight 
into persistent behavior change issues in other settings.

Biomedical Research:  The research of the National Institutes of Health 
and the Centers for Disease Control and Prevention includes basic 
research and applied retroviral research, vaccine development and drug 
therapy.  The Department of Defense biomedical effort places emphasis on 
applied retroviral research, with a focus on vaccines for prevention of 
HIV infection.  These research efforts are considered to be essential 
contributions to the global HIV/AIDS prevention effort and results of 
these efforts will continue to have an impact on prevention worldwide.




APPENDIX D:  The Impact of AIDS -- U.S. Security Interests/Concerns

     The number of AIDS cases worldwide will rise rapidly during the 
remainder of the 1990s and will increasingly undermine other projects 
intended to foster key US policy goals, including democratization, 
economic development, conflict resolution and peacekeeping, and 
promotion of individual and political rights.  The AIDS pandemic will 
overwhelm underfunded and inadequate health delivery systems in much of 
the developing world and could undo hard-won health, social, and 
economic gains.  Moreover, because AIDS mainly affects adults in their 
most productive years and is virtually always fatal, AIDS will have a 
more severe economic impact than do myriad other diseases.

     The World Health Organization (WHO) estimates there were 14 
million HIV infections by mid-1993.  As many as 30 million to 40 million 
people worldwide will have been infected by the year 2000.  While the 
largest number of infections are in Africa, southeast Asia could soon 
claim that distinction.

--     An average of one in 40 African adults is infected with the virus.  
In some East and Central African cities the rate is one in three.

--     If unchecked, infection could reach African magnitude -- affecting 
5 percent or more of the population -- in several countries, notably 
Brazil, the Dominican Republic, and Haiti over the next decade.  Major 
social and economic disruptions are possible in many others, including 
The Bahamas and Honduras.

--     More than 1 million people in South Asia are infected, with small 
numbers of cases reported in Bangladesh, Sri Lanka, Pakistan, and Nepal.  
Most cases are in India, however, with HIV present in both rural and 
urban populations in every state.  Indian Government neglect of the 
problem has the potential of allowing replication of the African 
experience in 10 or 15 years.

--  The incidence of HIV and AIDS is increasing in almost every country 
in Southeast Asia.  Thailand has one of the world's highest infection 
rates and the epidemic is rapidly spreading to neighboring countries, 
especially Burma.

--  Although China claims to have only 1,100 reported AIDS cases, if 
effective measures to fight the disease are not enacted soon some 10 to 
20 million Chinese could be infected by the year 2000.

--  Little information is available on rates of HIV infection in North 
Africa and the Middle East although measurable levels of infection are 
present in many countries of the region and the problem is believed to 
be understated.

--  The AIDS problem in the former Soviet Union is small but growing, 
and deteriorating health services will make diagnosis and treatment 
difficult.

--  Romania appears to have the greatest AIDS problem in Central Europe, 
although infections have been reported in almost all countries in the 
region.

     The infection pattern found in Africa is similar throughout the 
developing world -- highest rates in urban areas, along major trade 
routes, and in former areas of conflict.  Although homosexual contact 
and intravenous drug use account for most the spread of the disease in 
North America and Europe, most HIV transmission in the developing world 
occurs through heterosexual contact or from mother to child.  Highly 
mobile population groups -- refugees and displaced persons, truck 
drivers and other labor migrants, and demobilizing soldiers -- quicken 
the spread within and across national boundaries.  People at highest 
risk are those with multiple sex partners who do not use condoms, 
prostitutes and their clients, and people with sexually transmitted 
diseases.

--  Intravenous drug use is a significant vector for transmission in the 
Middle East, Asia -- particularly China, Burma and Pakistan -- and in 
some urban areas of Latin America.

--  Contaminated blood products also contribute significantly to the 
epidemic in the former Soviet Union and some developing countries.

Social and Economic Impact

     The epidemic's indirect costs will be enormous.  Such costs will 
be incurred as skill losses, decreased worker output, lost income, and 
increasingly inefficient business and government operations.  Losses of 
trained workders and supervisors will reduce the professional and 
technical and skills base, especially in smaller countries, while 
infection among the unskilled will disrupt routine operations even in 
sectors where replacements are readily available.  Seriously affected 
countries could experience losses in the tourist industry as the extent 
of the epidemic becomes widely known.  Moreover, there is anecdotal 
evidence that businessmen and investors are increasingly reluctant to 
visit and live where there is a major impact.

--  In Thailand, for example, multinational firms spent $1.3 billion in 
1992, but if projected rates of HIV infection hold, a labor force 
increasingly weakened by AIDS-related illness and reduced by AIDS deaths 
could discourage foreign investors and jeopardize advances in the 
standard of living.  Tourism in Bangkok is lagging already, in part 
because of the fear of HIV/AIDS.;

--  A World Bank and US Census Bureau modeling exercise found that by 
2015, Africa's total GDP would be reduced by up to 22 percent relative 
to a no-AIDS scenario, which assumed moderate economic growth through 
the period.

     The growing epidemic threatens to overwhelm fragile health 
delivery systems in many countries.  In many developing countries the 
annual cost of care for patients with HIV and AIDS -- if provided at US 
levels of care -- would exceed the per capita gross national product of 
these nations.  In Brazil, for example, the cost of such care could be 
as high as 838 percent of GNP per capita.  Moreover, both money and 
scarce physical and human health resources are increasingly commandeered 
for AIDS care; AIDS patients fill 80 percent of hospital beds in the 
capital of Ethiopia and 40 percent of available beds in Kenya, for 
example.

     Infectious diseases linked to AIDS are soaring.  Tuberculosis (TB) 
-- the most important HIV-associated disease and already the leading 
cause of death in Africa among HIV-infected and AIDS patients -- has 
again reached epidemic proportions in many countries after decades of 
decline.  TB also is making swift inroads into non-HIV infected 
populations.

     The proportion of women infected with HIV is increasing rapidly; 
by the year 2000, WHO predicts that more than half of newly infected 
adults will be women.  Economic and social realities such as poverty, a 
lower level of education, and subordinate social status put women at 
particular risk of HIV infection.  AIDS-related deaths among women will 
contribute to reduced productivity in Africa and other parts of the 
developing world because of the extensive agricultural role of women.  
Moreover, the loss of women to AIDS will result in decreased home care 
and will further strain beleaguered health care systems.

     WHO estimates there will be between 10 to 15 million orphans 
worldwide by the turn of the century.  Many are abandoned and barely eke 
out a living, are without health care, and frequently do not attend 
school.  They will swell the ranks of the unemployable, could become 
part of the alienated and increasingly criminal class in many cities, 
and are adding to the worldwide increase in street children.

--  Growing numbers of street children in Brazil, Columbia, and other 
countries are particularly vulnerable to infection because they are 
frequent targets of sexual abuse and because they often resort to 
prostitution and drug use.  One-third of street children recently tested 
in Columbia were HIV-positive.

     AIDS also is beginning to reverse the hard-won gains in improved 
child health care in parts of the developing world.  The US Census 
Bureau projects that the infant and child mortality rates will increase 
significantly in Thailand, more than doubling for infants and rising 
nearly fivefold for children.

--  In Uganda by 1991, AIDS had halted improvements in infant mortality 
rates and by 1993 had risen beyond 1986 levels.
Impact on Rural Areas.  While AIDS impacts most visibly on the highly 
skilled, mainly urban workforce, the disease could also have a 
devastating impact on the countryside over the next several years.  The 
UN Food and Agricultural Organization estimates that a quarter of the 
farms in the most affected countries in Africa may fail as the disease 
decimates the rural population.  Moreover, as remittances from urban 
workers are often critical sources of income for family members who 
remain in the countryside, the illness and death of urban workers will 
mean fewer resources are available to rural communities and households.

Impact on Development.  The growing AIDS epidemic will compound the 
difficulty of sustaining development already underway.  Even the methods 
of achieving market-based development are being increasingly undermined 
by the consequences of AIDS.  For example, the credit worthiness of 
those seeking loans for low-cost housing, farm improvements, or to 
expand small businesses is weakened if family incomes are reduced by 
illness and death.  Labor mobility -- including rural-urban, among 
regions, and between countries -- has always promoted access to jobs and 
income, but migrant labor also spreads the infection.  Education is 
vital for development, but children are leaving school early to care for 
ill relatives or because falling family incomes do not allow for payment 
of school fees.  Moreover, since infected people die during their most 
productive years, tough decisions will have to be made regarding 
expenditures for training.  For example, if AIDS reduces school 
graduates' work life by 15 years, then the payoff to investment in 
education is greatly reduced.

Potential Human Rights Problems.  Gains in personal and political 
freedoms could be endangered by the spreading epidemic.  Pushed to 
respond to an increasingly difficult domestic situation, leaders could 
search for scapegoats or advocate repressive or discriminatory policies 
toward unpopular, ethnic, regional, or religious groups, or AIDS victims 
themselves.  Governments could restrict movement across borders, refuse 
refugees from highly-infected countries, or take other legal measures.

--  At least 50 countries have some explicit requirement for HIV testing 
of foreigners.

--  Cuba's aggressive AIDS control program of lifetime quarantine of 
those who test positive is a human rights concern that could increase if 
other countries attempt to emulate such controls.

National Leadership Essential.  Recognition of the problem and promotion 
of AIDS education and prevention programs by high level government 
officials is vital to the success of AIDS prevention.  Many leaders, 
especially in the hardest-hit countries in Africa, have begun speaking 
out but some officials will likely remain on the sidelines, reluctant to 
court controversy for fear of losing foreign investment or domestic 
support.  A few governments, like Thailand, have begun aggressive AIDS 
prevention programs, but those programs tend to be targeted only at 
high-risk groups, particularly sex workers, giving the mistaken 
impression that the bulk of the population is not at risk.

--  Most African leaders have yet to translate words into action by 
putting AIDS at the top of the political agenda.  Moreover, most leaders 
have spoken out more as a result of international donor pressure or a 
bid to gain aid rather than in response to domestic needs.

Prevention Strategies and Cost

     Although anti-AIDS programs are widespread, there is little 
evidence that greater knowledge has changed attitudes and altered sexual 
behavior on a scale needed to slow the epidemic.  While current programs 
may be worthwhile in terms of lives saved per dollar spend, in the 
developing world they are still small in scale.  Condom use, education 
to promote behavior change and treatment for STDs are critical 
components of an effective HIV/AIDS prevention strategy.

--  Many men are unreceptive to condom use, however, despite having 
multiple partners.  Many Ugandans tell researchers that condoms 
stigmatize users as being promiscuous.

Costs of Prevention.  A strategy to stem the AIDS epidemic would require 
enormous resources, but there is no guarantee that even significant 
expenditures could stop the spread of the disease.  However, WHO 
estimates that if all developing countries were to implement a basic HIV 
prevention project -- information on how to avoid infection, promotion 
of condom use, treatment of sexually transmitted diseases, and the 
maintenance of a safe blood supply -- about one-half of the 20 million 
new infections expected worldwide between now and 2000 could be averted.

     Such a program would cost about $1.5 to $2.9 billion a year.  
Currently, worldwide AIDS expenditure on AIDS prevention is about $1.5 
billion a year, but only about $120 million a year is spent in 
developing countries where 85 percent of all infections occur.

--  Thailand spends the most for AIDS prevention, with 1992 spending 
of$45 million.

--  Total AIDS spending on prevention in Africa is only about $90 
million, less than 10 percent from host-nation government funds.

     Developing country leaders are likely to turn to donors with a 
host of increased assistance needs, and international cooperation will 
be needed to set priorities and fund programs in the anti-AIDS effort.  
At least some countries would probably respond positively to suggestions 
that the AIDS epidemic has made imperative more realistic planning of 
future development efforts, a more careful use of human and financial 
resources, and serious AIDS prevention efforts.  In return, however, the 
United States and the West will be expected to underwrite broader and 
more costly assistance programs to cope with the disease.

Impact of AIDS on Military Forces

     In terms of military significance, HIV/AIDS is not a "war-
stopper;" it will not immediately render large numbers of field troops 
unfit for combat.  However, as the HIV/AIDS pandemic erodes economic and 
security bases of affected countries, it may be a potential "war-
starter" or "war-outcome-determinant."

     HIV directly impacts military readiness and manpower, causing loss 
of trained soldiers and military leaders and shrinkage of recruit and 
conscript pools.  Military populations are at heightened risk for 
HIV/AIDS.  Militaries typically comprise large groups of young, sexually 
active men who are conditioned to feelings of invincibility and bravado, 
have money and time to spend on prostitutes and other forms of casual 
sex, and are removed from traditional mores and societal constraints on 
their behavior.

     In addition to their higher risk of contracting hIV/AIDS, military 
forces also are a significant factor in spreading the disease.  
Peacekeeping and demobilization present particular dangers in this 
regard.

     Worldwide peacekeeping operations will become increasingly 
controversial as militaries with high infection rates find it difficult 
to supply healthy contingents.  Infected troops could be a risk to 
populations in host countries, and, given battlefield conditions, a risk 
to the troops with whom they serve.  Moreover, peacekeepers from lower 
incidence countries may contract AIDS during operations in high 
incidence areas and spread it on their return home.  The UN will have to 
grapple with politically sensitive choices, such as refusing HIV-
infected troops, leading to charges of racial bias and meddling in what 
most militaries consider to be national security concerns.

     Growing efforts to demobilize in many regions, including Latin 
America, Southeast Asia, and Africa, in part prodded by economic 
considerations and Western donors, may exacerbate the epidemic, 
particularly if released soldiers take advantage of incentives to return 
to rural areas, which usually have lower infection rates than cities.  
On the other hand, former soldiers who remain in cities probably will 
add to urban health problems. 

     HIV and AIDS impose enormous economic burdens on military health 
care organizations.  The cost of AIDS treatment may divert funds and 
resources from other vital medical services.  As most military medical 
systems are not equipped to deal with long-term care, military AIDS 
patients may be diverted into already overburdened civilian health care 
systems or released without treatment to their homes.

Regional Assessments.  The pandemic's effects on military forces are 
most pronounced in Africa.  South and Southeast Asia and, to a lesser 
degree, Latin America, may follow the African model in five to 15 years.

--  Africa.  AIDS is a significant operational problem for many Sub-
Saharan militaries.  With HIV infection rates in some forces exceeding 
60 percent, a serious degradation of military capabilities may begin 
soon.  Within the next five to 10 years, most militaries in the region 
will experience loss of readiness from decreased force levels.  More 
importantly, HIV infection and AIDS among military leaders and skilled 
technicians will have an impact far greater than in numbers alone as 
hard to replace leadership experience and technical capabilities are 
lost.

--  Asia.  The militaries of India, Burma, and Thailand could begin to 
experience the adverse effects of AIDS in the next five years as rising 
HIV infections among young men decrease conscript pools and as an 
increasing number of officers, senior NCOs, and trained technicians 
become ill and die.  HIV/AIDS could begin to degrade military manpower 
pools and readiness in Vietnam, Cambodia, and Indonesia within the next 
10 years.

--  Latin America.  Haiti's military is already severely impacted and 
will suffer serious personnel and leadership losses in the next five 
years.  In 10 years, HIV/AIDS will play an increasing role in the 
militaries of Brazil, Honduras, and the Dominican Republic.

     On a more positive note..As the world's militaries have common 
features that place them at greater risk of HIV/AIDS, they also share 
characteristics that may favor effective responses to HIV/AIDS.  These 
include command, control, and communications systems that facilitate 
rapid dissemination of policy and directives, higher literacy rates 
among senior personnel who can pass on education materials to 
subordinates, better funded health systems that are often independent of 
civilian systems and less subject to non-medical pressures (funding, 
politics, etc.), less and a leadership that views HIV/AIDS control as 
being in their vital interests.  Militaries are also less likely to have 
reservations about mandatory testing programs (although they may not 
publish results).

Implications for the United States

     The negative effects of HIV/AIDS in AFRICA, Asia, and Latin 
America in the next five to 15 years will have consequences for the 
United States.

--  US military personnel, operating in high-incidence countries, will 
be at increased risk of exposure to HIV/AIDS.

--  Medical cooperation between US and allied or coalition forces will 
be difficult if high HIV incidence exists in non-US troops.  It is 
virtually impossible to employ universal blood precautions under combat 
medicine conditions forward of the first hospital in the evacuation 
chain.  Therefore, US medical personnel may be forced to choose between 
diverting or even refusing foreign patients or placing US health care 
workers at elevated risk.  US military personnel may also be at higher 
risk of exposure to HIV-associated and possibly multi-drug resistant 
tuberculosis.

--  The US could find itself embroiled in the explosive problem of 
devising UN guidelines for the participation of HIV-infected militaries 
in peacekeeping.

     Many otherwise qualified potential students have declined training 
in the West due in part to the requirement of US and other Western 
militaries for students to be free of HIV infection.  The loss of such 
training opportunities, which are viewed as mechanisms to promote 
civilian control over the military, democratic principles, and respect 
for human rights, and slow the transformation of the military into an 
apolitical institution in many countries.

APPENDIX E:  Donor Coordination

Introduction

The United States is the largest contributor to global HIV/AIDS 
activities, providing bilateral support primarily for HIV prevention 
activities, research and training and multilateral support for HIV/AIDS 
program development within the U.N. system.  Along with these financial 
and scientific contributions, the United States plays a lead role in 
working  with other governments and non-governmental organizations to 
improve coordination of the global HIV/AIDS effort.  Because of the 
seriousness of the HIV/AIDS epidemic and the necessity to involve a 
wide, diverse range of people and organizations to mobilize an effective 
response, coordination of national and international efforts is complex 
but critical.  This is especially true given the current worldwide 
economic environment and the need to optimize the use of existing scarce 
resources.

Obstacles and limitations to coordination

While accepting its importance, coordination among organizations and 
governments presents many obstacles and has inherent limitations.   
Within the USG, there are multiple Departments and Agencies involved in 
our response to the HIV/AIDS epidemic.  Each of these organizations has 
its own mandate, set of priorities, and decision-making structures.  The 
same is true for our multilateral, bilateral and host country partners 
and the respective organizations.  In addition, while the host of actors 
involved in this effort have distinct mandates, they are nonetheless 
interrelated.  Setting each group's mandate into operation can lead to 
overlap in activities and perceived areas of responsibility.

The World Health Organization's Global Programme on AIDS (WHO/GPA) Task 
Force on HIV/AIDS Coordination proposed the following definition of 
coordination:  Coordination of HIV/AIDS activities is a process which 
promotes information exchange, builds alliances and facilitates the 
creation of complementary and reinforcing programmes, rather than being 
mechanisms of control.  The process should be based on a partnership 
approach, with mutually respectful pursuit of jointly accepted goals and 
targets of national AIDS strategies and plans.

This definition is supported by the following elements:

Understanding and common acceptance by all participating parties of 
objectives and priorities, e.g., of the WHO/GPA Global AIDS Strategy and 
National AIDS Strategy;

Agreement on the need for consultation and exchange of information;
Joint recognition of the mandates, unique roles and responsibilities, 
and the areas of comparative advantage of each of the parties;

Concerted effort by all participating parties to ensure information 
sharing, harmonious policies and action; and,

Concerted actions for mobilization and optimal use of resources 
according to nationally identified priorities and strategies, with the 
aim of minimizing gaps and overlaps in programme activities and reach.

These are important guidelines for our efforts in coordination within 
our own government and among our international partners.

Past and present coordination efforts

The USG has developed different approaches to coordination of its 
international HIV research and program activities:

The International Subcommittee of the Federal Coordinating Committee on 
AIDS was a subcommittee of the PHS Federal Coordinating Committee on 
AIDS that was convened to coordinate activities of the federal 
government agencies working on  HIV/AIDS internationally.  Participation 
extended beyond PHS to all involved USG organizational units.  Besides 
information exchange, this group had developed a database on USG 
international HIV/AIDS activities.  This group became inactive after 
changes in the parent committee and in anticipation of new coordination 
efforts in this administration.

The International Forum of AIDS Research (IFAR) was established in 1988 
after a group of USG agencies funding international AIDS research saw a 
need for more regular opportunities to exchange information about their 
activities.  The secretariat for IFAR was the Institute of 
Medicine/National Academy of Sciences and membership included government 
and private organizations from the United States and Canada.  This 
served as a useful forum for information exchange and led to some cross-
agency international collaborative activities.  IFAR was discontinued in 
1992 due primarily to lack of continued financial support.

The Office of AIDS Research (OAR), established in 1993, at the National 
Institutes of Health has primary responsibility for planning, 
coordinating and funding all AIDS-related research in the NIH.  The 
mandate of the OAR is to evaluate the entire NIH AIDS research program, 
and to set in place refocused scientific priorities through the 
development of a comprehensive research plan and budget.  It is expected 
that the OAR will improve the effectiveness of the U.S. biomedical 
effort on HIV/AIDS and will ensure that HIV/AIDS research priorities are 
given appropriate attention.  This refocused effort has significant 
international implications, since the USG is the world's standard for 
biomedical research in this area.

The Federal Coordinating Committee on Science, Engineering and 
Technology (FCCSET) Working Group on HIV Vaccine Development and 
International Field Trials was established in 1992 to focus on issues 
related to the development, testing and coordination of multinational 
field trials for candidate HIV vaccines and to help coordinate USG 
Agencies' activities in this area.  The Working Group developed a 
report, "The Human Immunodeficiency Virus Vaccine Challenge:  Issues in 
Development and International Trials," that was issued in July, 1993.  
The group continues to meet under the auspices of the National Science 
and Technology Council to further develop a strategy and plan for 
vaccine development and international trials.

Several structures and initiatives have facilitated and continue to 
facilitate the coordination of HIV/AIDS within the U.N. system:

The WHO/GPA Management Committee (GMC) has provided an opportunity for 
member states of WHO that contribute to GPA and other U.N. organizations 
to discuss overall management of GPA and its progress towards achieving 
its goals.

The GMC Task Force on HIV/AIDS Coordination was set up in 1993 to 
facilitate coordination of the response to the HIV/AIDS pandemic.  The 
Task Force was established by the Management Committee of the WHO/GPA 
with an initial two year term and is now being dissolved.  In the first 
year, the Task Force focused its work on:  (1) developing a 
comprehensive report summarizing HIV/AIDS-related activities of all 
major organizations within the United Nations system, intergovernmental 
organizations, bilateral agencies, and non-governmental organizations;  
(2) preparing an inventory and summary analysis of coordination issues 
and problems; (3) elaboration of a framework for guiding principles for 
HIV/AIDS coordination at country level; and (4) providing input in the 
process towards developing a joint and cosponsored U.N. programme on 
HIV/AIDS, which is now being established.  TheTask Force also served as 
a clearinghouse for exchange of views and coordination of decisions 
relating to HIV/AIDS in different governance fora for other related U.N. 
organizations.  The United States was one of twelve members on the Task 
Force and represented itself, Canada, Australia and Japan.

In response to concerns about the coordination of the United Nations' 
efforts on HIV/AIDS, a resolution was adopted by the World Health 
Assembly to direct WHO to explore with its U.N. partners options for a 
joint and co-sponsored U.N. programme on HIV/AIDS.  The governing bodies 
of WHO, UNICEF, UNDP, UNFPA, UNESCO and the World Bank have endorsed the 
establishment of such a program.  It is anticipated that the program 
will be operational by January 1996.  The program is expected to provide 
a framework for better coordination for all actors in the global 
HIV/AIDS effort, including bilateral agencies and governments, and to 
improve the effectiveness of HIV/AIDS activities in-country.  The United 
States has strongly supported the establishment of this program and 
continues to work toward making it operational by the target date of 
January 1996.


Conclusions and Recommendations

Considerable efforts have begun to improve coordination among the 
multiple international partners involved in the response to the HIV/AIDS 
pandemic.  The USG role has and will continue to be key in this 
evolution.  International initiatives such as Joint U.N. Programme on 
AIDS should assist in coordinating the HIV/AIDS efforts within the U.N. 
system and among governments and non-governmental institutions.

Given the involvement of multiple USG Departments and Agencies in 
international HIV/AIDS activities, exchange of information and 
coordination of activities is critical.  An ongoing process should be 
developed to facilitate this.  Possible mechanisms for increasing 
coordination within the USG include:

The convening of annual or semiannual meetings of high level Department 
and Agency representatives to review ongoing and planned activities 
within the framework of an international HIV/AIDS strategy and 
development of related interagency policies.

Establishment of a regular forum at the working level to exchange 
information among agencies on international HIV/AIDS activities.  This 
forum could involve non-governmental organizations as appropriate based 
on the topics to be discussed.

Collaboration with the National AIDS Policy Director to ensure that 
international activities are incorporated within the framework of a 
national policy and strategy.
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