Nine program areas characterized U.S.-funded international AIDS activities in 1998. These categories were based on program descriptions and other sources of information. While necessarily somewhat artificial and overlapping, these categories represented the clearest and most relevant classifications we could create. This section describes each program area and its projects.
|Table 3: U.S. International AIDS Funding by Program Area, FY 1998|
|Health systems support||$57,125,000||31%|
|Prevention projects/program evaluation||$36,501,000||20%|
|UNAIDS program support||$23,000,000||12%|
|Surveillance & epidemiology||$14,663,036||8%|
|Training foreign clinicians/researchers||$ 9,704,399||5%|
|Developing government/community leadership||$ 5,749,000||3%|
|Supporting reference labs/animal facilities||$ 4,905,498||3%|
HIV prevention in this context requires a broader definition that used domestically in the United States, including, for example, STD control, family planning, maternal health, orphan care programs, etc.
The largest prevention initiative was the IMPACT Project. Operated by Family Health International, an NGO located in Virginia, and funded by a USAID contract, IMPACT is a multifaceted program operating in 21 countries. In 1998, USAID spent $15 million on the IMPACT project. The annual contract report for the program lists 105 HIV prevention projects, ranging from technical assistance with governments and private groups to the direct operation of prevention programs. IMPACT primarily focuses on the operation, planning, management, and evaluation of interventions that reduce transmission of HIV through sex, including the treatment and prevention of other sexually transmitted infections that enhance HIV's spread. IMPACT also helps care for AIDS orphans, assists with epidemiological surveillance, organizes systems of HIV care for infected people, and provides assistance with HIV testing and blood supply safety. IMPACT is the largest of all USAID's contracts, and one of that agency's most important programs. The IMPACT contract is up for renewal in 2002.
USAID funds a $13 million contract with the Population Council, a New York-based NGO, called the Horizons program. Horizons is a multifaceted program operating in 23 countries. Horizons identifies components of effective HIV/AIDS programs and policies, tests potential solutions to problems in prevention, care, support, and service delivery, and disseminates these findings with a view toward replication and scaling-up of successful interventions. Horizons develops "best practices guidelines" for STD treatment and diagnostic programs, HIV testing sites, and other prevention activities in developing countries. The Horizons contract expires in 2002.
The AIDSMark program is another key HIV prevention initiative of USAID. Operated by Population Services International, an NGO located in Washington D.C., AIDSMark operates in at least seven countries, primarily in Africa and heavily in West Africa. In 1998, USAID spent $8 million on AIDSMark. AIDSMark is a social marketing program that promotes condom use, safer sex, and abstinence. It also subsidizes and distributes condoms and educational materials through community organizations and health clinics. This contract is up for renewal in 2002 as well.
The Peace Corps received $236,000 from USAID for HIV prevention in 1998. The Peace Corps program trains volunteers to conduct prevention workshops and provides them with HIV prevention materials. The Peace Corps contract describes 17 prevention projects in 12 countries.www.unaids.org. Vaccine Infrastructure and Training Foreign Clinicians & Researchers below.) While most academic research was investigator initiated, NIH solicited grant applications for three major programs that play an important international role.
The remaining 43 academic grants were more traditional investigator awards, and they represented the bulk of the international HIV academic research grant portfolio (approximately $18 million in 1998). These awards included such projects as evaluations of school-based behavioral interventions in Indonesia, interventions in Kenya to prevent mother-to-infant HIV transmission in utero or through breast-feeding, basic studies of HIV strains found in developing countries, and analyses of Kaposi's sarcoma-related herpes virus (KSHV/HHV-8), which is endemic in parts of Africa. The NIH funded the HIVNET 012 study, which documented the ability of a single dose of nevirapine given intra partum to an HIV-infected woman, and a single dose given post partum to her newborn, to reduce perinatal transmission of HIV by 47% compared with AZT (Guay 1999).
The NIH codes all its research into "functional categories" for budgetary reporting and strategic planning purposes. In 1998, these international HIV research grants were coded in five functional categories: $8 million for natural history and epidemiology studies (primarily studies of HIV-2 and other HIV-1 strains); $4.7 million for therapeutic research studies (primarily mother-to-infant interventions); $2.8 for pathogenesis research; $1.4 million for behavioral research; and $1 million for vaccine-related research, such as assessing the feasibility of conducting vaccine trials in certain populations.
USAID supported epidemiological work carried out by the U.S. Bureau of the Census ($1.35 million), which maintains a global database of worldwide HIV infection trends and provides technical assistance to other governments. The contract report for the Bureau of the Census did not describe the countries that received technical assistance in 1998, so the number of countries that are described as having epidemiology projects in this analysis is probably an underestimate of the true number.
CDC spent $9 million in 1998 on epidemiology projects in eight countries. Most international HIV work at CDC is organized by the National Center for HIV, STD, and TB Prevention (NCHSTP). That center's largest program is Project RETRO-CI, a collaborative research program with the Ministry of Health of Côte d'Ivoire. The $3.7 million program's primary purpose is to define the magnitude and characteristics of the HIV-1 and HIV-2 epidemics in that west African nation. RETRO-CI sponsored an important study which showed that TMP/SMX, when given to HIV-infected tuberculosis patients in Abidjan, reduced mortality by 46% (Wiktor 1999).
The NCHSTP also had a $2.5 million collaboration with the Thai Ministry of Public Health to help improve understanding of AIDS and the dynamics of its spread, providing a scientific basis for intervention programs. The center had a collaborative relationship with the Ugandan Ministry of Health. The $400,000 Ugandan program provided technical assistance to the government and supported a resident virologist in Entebbe. The center also had an $800,000 technical and computer assistance program to the U.N., South Africa, Malawi, India, and Vietnam.
CDC's National Center for Infectious Disease (NCID) supported a $1.5 million research program in Kenya, supporting a hospital-based cohort study to examine the relationship between HIV infection and several tropical diseases, particularly in pregnant women.Other U.S. Agencies Involved in Developing Countries), which is not analyzed in this report.
Two NIH-funded contracts formed the core of the international vaccine effort. In 1998, the major contract was HIVNET, a $10 million program from NIAID administered by Family Health International (FHI). HIVNET has since been restructured into the Vaccine Trials Network (VTN) and the Prevention Trials Network (PTN). FHI was responsible for administering the international component of HIVNET, which also had a domestic component. FHI contracted with nine universities that ran twelve international field sites in ten countries.3 HIVNET's main purpose was the creation of an international infrastructure for the evaluation of an HIV vaccine. HIVNET was also involved in the search for topical microbicides, STD treatments, prophylaxis to prevent mother- to-infant transmission, behavioral risk-reduction strategies, and baseline seroincidence data. The other major NIH international vaccine contract was a $3 million award to the Fred Hutchison Cancer Center in Seattle, which provided statistical analysis and support for the international vaccine program.