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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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