Where the U.S. Is Involved in the Developing World
Figure 4: Countries with U.S.-funded AIDS Programs in 1998
African Countries with the Most U.S. Involvement
Asian Countries with the Most U.S. Involvement
Latin American & Caribbean Countries Where the U.S. Is Most Involved
Eastern Europe & the Former Soviet Union
Figure 4: Countries with U.S.-funded AIDS Programs in 1998
red = most U.S. involvement; green = some U.S. involvement; blue = less U.S. involvement (see text).
The U.S. was directly or indirectly involved in 79 developing countries in 1998. To describe the relative level of American involvement in each country, three categories were established.
This section summarizes U.S.-funded HIV activities in the countries where the U.S. was most involved. Organized by region, it includes other available information on overall U.S. development assistance when that information was available.Table 9.
U.S. involvement in Kenya was extensive. The USAID mission budget for Kenya was $51.6 million, $3.5 million of which was designated for HIV. Japan was the largest international donor; the U.S. was fifth. The USAID mission focused on political reform, agricultural reform, and HIV prevention. The mission's HIV program funded both the national health ministry and community organizations. The mission helped improve the delivery of family planning services, trained health workers, organized the supply of condoms and drugs for STD treatment, created public education campaigns on condom use, and developed malaria control programs. The Population Council assessed distribution strategies for male condoms, evaluated HIV testing strategies, particularly for youth and pregnant women, trained health workers to conduct HIV tests, and examined strategies to reach men who use unauthorized pharmacies to self-medicate for STDs. The Futures Group helped government officials develop HIV control strategies. The Peace Corps trained its volunteer in Kenya to conduct HIV prevention workshops. The University of Washington operated a $760,000 research program that examined HIV shedding in infected women and transmission through breast-feeding. The University of Washington trained Kenyan physicians. The University of California-Davis operated a $23,000 FIRCA grant that examined SIV in African green monkeys.
The CDC NCID had a $1.5 million hospital-based cohort study in Kenya that assessed vertical transmission of HIV and the relationship between schistosomiasis and malaria and HIV.
The U.S. was the seventh largest development aid donor to Zambia, providing 2% of total assistance. USAID's total budget for Zambia was $18 million, 16% ($3 million) of which was designated for HIV. Japan and the U.K. were the two largest developmental assistance donors.
Although the U.S. was a small donor to Zambia, it was the largest provider of HIV funds. The USAID mission used its HIV funds to support integrated children's health programs, to subsidize and distribute male and female condoms (averaging 550,000 male condoms a month in 1998, the highest per capita rate in Africa), and to develop programs for AIDS orphans. The Population Council examined the behavioral impact of caring for a sick elder on young people, examined various STD control strategies, examined the practicality of HIV testing during pregnancy, and promulgated best practice guidelines on HIV testing and HIV stigma and discrimination. Zambia had an HIVNET vaccine research site operated by the University of Alabama. Two major academic research programs operated in Zambia. A $2.2 million program at the University of Alabama examined acute HIV infection in an established cohort and examined the factors associated with infection in HIV-discordant heterosexual couples. A $400,000 research program at the University of Nebraska examined the pathogenesis of Kaposi's sarcoma-related herpes virus (KSHV/HHV-8).
Zambian physicians received clinical training at the University of Alabama and the University of Miami.
Ethiopia was the largest recipient of American foreign aid in Africa. USAID's total assistance budget for Ethiopia was $115 million, $4.8 million (4%) of which was designated for HIV programs. American aid and commitment to Ethiopia increased substantially during the period of this analysis, rising from $56 million in 1996 when the U.S. was the third largest bilateral donor. The USAID mission in Ethiopia focused on health, education, and food security. One-third of the total USAID mission expenditure on health programs was for HIV. The HIV program was part of an overall health effort that focused on maternal and child health programs in the southern region of the country, where more than 11 million people have received health care services from USAID-funded programs. The USAID mission supported STD treatment clinics for Ethiopians in urban areas and reported that it served about 30,000 people during the period of this analysis. The USAID mission also subsidized condom distribution through the private sector, with about 24 million condoms distributed in 1998. The Futures Group trained Ethiopian government officials at the national Ministry of Health and in the Oromia region to develop and implement the national AIDS control strategy. Ethiopian physicians received HIV clinical training at Johns Hopkins University.
Through USAID, the U.S. government supplied 4% of Tanzania's development aid. USAID was the largest supporter of family planning activities. Japan, the U.K., and Denmark were the three largest donors to Tanzania. In 1998, the American government devoted $24 million to development projects in Tanzania, focused on health and family planning, environmentally sustainable natural resources management, democratic governance, micro- and small enterprise development, and rural roads improvement. Fifteen percent of U.S. mission-level assistance was designated for HIV. Mission-level activities focused on the establishment and support of 150 community-based agencies that reached approximately 50% of the country. The community-based agencies typically focused on HIV prevention and peer education at work sites. Family Health International provided technical assistance to USAID-funded community groups, particularly to analyze peer education programs. Population Services International subsidized condoms for private and government health facilities. The Population Council conducted research on how to encourage Tanzanians to seek HIV testing. The Futures Group trained national and regional health authorities on AIDS control strategies. The National Cancer Institute's Viral Epidemiology Branch and the Research Triangle Institute, through an NCI contract, conducted epidemiological studies on HIV strains found in Tanzania. Harvard University trained Tanzanian clinicians, and sponsored a $480,000 research study on the impact of vitamin supplementation on HIV progression and perinatal transmission in women at the Muhimbili Medical Centre in Dar-es-Salaam. Tanzania was a site for a Johns Hopkins University research study that examined the cost effectiveness of various HIV prevention strategies in developing countries.
Unlike other African nations where the U.S. was most involved, Côte d'Ivoire had no direct USAID presence. There was no USAID mission in the country, and the regional program that covered Côte d'Ivoire closed in 1998. Nevertheless, Côte d'Ivoire was the location of the largest international project of CDC. The National Center for HIV, STD and TB Prevention of CDC operated Project Retro-CI in Abidjan. Project Retro-CI was a collaborative research project between CDC and the national health ministry. The project defined the magnitude of the national epidemic, described clinical manifestations of HIV-1 and HIV-2 infections, defined causes of death in HIV-infected persons, studied the response to tuberculosis therapy in HIV-infected persons, studied the laboratory diagnosis of HIV-1 and HIV-2, and conducted clinical trials to develop effective interventions that prevent mother-to-child and heterosexual HIV transmission. Family Health International funded community groups to attend a Retro-CI conference. Population Services International subsidized condom distribution. Physicians from Côte d'Ivoire received clinical training at the University of California-Berkeley.
The U.S. HIV program in Mozambique was centered almost entirely on the USAID mission there. The U.S. was the largest donor to Mozambique, and it concentrated primarily on agricultural reform in the country's central provinces. Switzerland was the largest donor in the health sector. Five percent ($3.7 million) of the USAID mission's $67 million budget was designated for HIV projects. The HIV activities focused on improving maternal and child health and STD treatment. USAID purchased STD drugs for government health clinics and helped improve their management. The mission established a condom distribution and subsidy program, with more than 16 million condoms distributed in 1998. Clinicians from Mozambique received training at the University of Washington.
Senegal was the U.S.'s most important ally in francophone Africa, receiving $17 million in aid from USAID, $2.5 million of which was designated for HIV. France was the largest donor nation, although the U.S. was the largest donor to family planning programs. Senegal has the lowest HIV prevalence of any sub-Saharan African nation. USAID's HIV program focused on maternal and child programs, particularly primary and prenatal care, childhood immunizations, and STD treatment. Family Health International supported the participation of local groups and officials in regional conferences. The Population Council evaluated the impact of people with HIV participating in the organization of prevention and care programs. The International AIDS Alliance organized community-based groups in Senegal. The Peace Corps trained its volunteers to conduct HIV prevention workshops. A $160,000 research study at Johns Hopkins University examined resistance profiles of HIV strains found in Senegal. A $1 million research program at the University of Washington examined the natural history of cervical dysplasia in HIV-infected Senegalese women. Harvard-trained Senegalese physicians and operated a $90,000 research project, in which Senegal was one participating nation, examining immunologic responses to HIV strains prevalent in West Africa.
Malawi received substantial U.S. assistance to fight its HIV epidemic. The $36 million USAID mission budget in Malawi was focused on economic reforms, health improvements, and strengthening democracy. The U.S. and U.K. were the largest developmental assistance donors to Malawi. The USAID mission designated $2.4 million of its budget for HIV programs, primarily support for maternal and child health and STD clinics. The Population Council promulgated best practices guidelines on workplace HIV discrimination and stigma, and evaluated a community-based HIV prevention program in the Mangochi district. The Peace Corps provided HIV prevention workshops through its volunteers in the country. The Futures Group trained government officials in the development and implementation of a national AIDS control strategy. An HIVNET vaccine research site was located in the country, administered by Johns Hopkins University. Malawi had two additional major NIH-funded academic research programs, including a $550,000 research program at Johns Hopkins that examined the role of vitamins in HIV progression and perinatal transmission, and a $125,000 program at the University of North Carolina that examined the pathogenesis of Kaposi's sarcoma-related herpes virus (KSHV/HHV-8). NCI funded HIV epidemiology through its Viral Epidemiology Branch and the Research Triangle Institute. Clinicians from Malawi received training at Johns Hopkins University.
The USAID mission in Zimbabwe had an $11.8 million budget, $1.9 million of which was designated for HIV. The U.S. was not a major donor to Zimbabwe (Japan was the largest, with $66 million in annual assistance), but it played an important role in housing assistance, family planning, and natural resources management. The U.S. was the largest donor for family planning services, and thus played an important role in HIV prevention. The USAID mission helped develop the private-sector health care system, including private-sector community groups that focus on HIV. HIV activities included condom subsidies and logistics management, including reforms to the national tax system that heavily taxes contraceptives. Although USAID played a key role in the area of family planning, the agency was planning to cease aid to Zimbabwe in 2003. The Population Council was heavily involved in Zimbabwe. Population Council projects included assessing the practicality of female condom use and appropriate instructions for its use, examining approaches to HIV testing and training nurses and others in counseling and testing, developing prevention strategies for pregnant women, examining STD control strategies, and planning systems of care for AIDS orphans. The Futures Group trained government officials to develop and implement a national AIDS control strategy. Zimbabwe was the site of an HIVNET vaccine research site operated by Stanford University. In addition to vaccine research, a $127,000 research program at Stanford examined vertical transmission in Zimbabwe. Physicians from Zimbabwe were trained at the University of California-Berkeley.
Nigeria received only $7 million from USAID, $1.9 million of which was designated for HIV programs. This small amount reflected a drastic scaling-back of U.S. and all other foreign assistance to Nigeria beginning in 1994 due to the worsening military dictatorship at the time. USAID used its HIV funds to support local, community-based HIV organizations that focused on HIV prevention in 14 Nigerian states. Family Health International supported the work of USAID-funded community organizations in Nigeria by training staff and peer educators, developing materials, distributing condoms, organizing workshops, creating mass media prevention campaigns, and staging music concerts for youth. The Population Council evaluated HIV prevention strategies for young Nigerian women. The Futures Group helped Nigerian officials develop a national AIDS control strategy. Through an NIH grant, the U.S. Army's Walter Reed Research Institute surveyed Nigerian flora as part of an international biodiversity initiative. NCI's Viral Epidemiology Branch conducted surveys of HIV-1 and HIV-2 strains found in Nigeria.
The USAID mission in South Africa spent $1.3 million of its $70 million budget on HIV programs. The U.S. was the third largest donor to South Africa, with the major focus on economic reform and training for black South Africans. The mission's HIV program supported the primary health care system in the Eastern Cape province. The Population Council evaluated HIV prevention programs among South Africa's migrant mine workers, examined HIV testing strategies, and evaluated the impact of rigid gender roles on HIV prevention programs. The Peace Corps provided HIV prevention workshops through its volunteers in the country. South Africa was the site of two HIVNET vaccine research sites, one at the Centre for Epidemiological Research of South Africa in Durban and one at the Chris Hani Baragwanath Hospital in Johannesburg. Two major academic research projects operated in South Africa, a $325,000 program at Columbia University that examined the immunologic characteristics of HIV-infected children and a $25,000 FIRCA collaborative grant that examined perinatal transmission from infected women who also have tuberculosis. South African physicians were trained at Columbia and Johns Hopkins Universities.
Rwanda is a small nation with a big HIV epidemic. The USAID mission in Rwanda designated $500,000 of its $18 million budget for HIV. The mission's goal was increasing democratic governance, rebuilding the health infrastructure, and increasing food supplies. USAID's mission-level HIV funds were used to help reconstruct health clinics that were destroyed in the war and genocide of 1994, primarily in the prefectures of Byumba, Gitarama, Kigali, and Kibungo. USAID stated that it would rebuild 60 health clinics to be used for primary health care and STD treatment. Family Health International was heavily involved in Rwanda. The FHI program was multifaceted, with major efforts in training local health officials on STD diagnosis and treatment, developing HIV monitoring systems, and providing technical assistance for HIV prevention programs. Rwandan physicians received HIV clinical training at Johns Hopkins University.
USAID provided Ghana with $53 million in annual aid in 1998, $1.2 million of which was designated for HIV. The U.S. provided 7% of total international aid to Ghana, which was the largest recipient of U.S. aid in west Africa. The USAID program focused on increasing private-sector development, improving the effectiveness of primary education, improving family planning, HIV/AIDS prevention and child survival interventions, and enhancing civic participation and accountable governance. USAID mission-level HIV funds were used to support family planning clinics, contraceptive availability, and child health programs, particularly immunization programs. Family Health International played an important role in Ghana. FHI trained the Ghanaian police force to implement behavioral interventions and conduct seroprevalence studies, trained staff at government-funded public health clinics and laboratories to diagnose STDs, and convened symposia for workers involved in AIDS prevention. The Population Council evaluated STD interventions among workers at the Ashanta Gold Mines in Obusai. The Futures Group trained government officials to develop and implement a national AIDS control strategy. Through an NIH grant, the Population Council evaluated school-based HIV prevention strategies.
The U.S. was involved, either directly or indirectly, in 20 Asian nations in 1998, five of which met our definition of most involved.
The HIV epidemic in Thailand is one of the most intensively studied in the world. Thailand received no direct development assistance from USAID, but it received substantial indirect assistance from USAID contractors and other forms of direct assistance from CDC and NIH. The Population Council promulgated an HIV prevention curriculum for use in primary and secondary schools as well as management guidelines for opportunistic infections, analyzed STD data, convened workshops on integrating HIV prevention into family planning activities, and evaluated workplace HIV prevention programs. The National Center for HIV, STD and TB Prevention at CDC had a $2.5 million collaboration with the Thai Ministry of Health. The collaboration focused on tracing the dynamics of the HIV epidemic in Thailand. Research projects included evaluating therapies to reduce perinatal transmission, the link between heterosexual HIV and STD transmission, the role of vaginal microbicides in high- and low-risk populations, and HIV transmission among intravenous drug users. Chiang Mai University was an HIVNET vaccine research site, operated by Johns Hopkins University. The Army's Henry M. Jackson Foundation operated a $325,000 NIH-funded research program examining interventions to prevent perinatal transmission. An $863,000 program at Harvard examined AZT's role in blocking perinatal transmission. Thai physicians were trained at Johns Hopkins, University of Washington, Emory University, Harvard, University of California-Berkeley, and University of California-Los Angeles.
U.S. involvement in the HIV epidemic in India was multifaceted and substantial. USAID provided India with $143 million in development assistance, of which $2.7 million was designated for HIV programs. The U.S. was the seventh largest donor to India. The main focus of USAID in India was controlling population growth and alleviating malnutrition. The mission's HIV activities centered on the southern Indian state of Tamil Nadu, which has a large HIV-infected population. The mission funded 102 community-based organizations that focused on truck drivers, prostitutes, and other high-risk groups. These groups used their USAID funds for condom distribution and other prevention initiatives. In addition, the mission helped local commercial facilities produce condoms and helped support STD treatment clinics. In 1998, the USAID mission expanded its HIV program to include the state of Maharashtra, which has the highest rate of HIV infection in the country. The mission's HIV programs also helped support the ongoing polio eradication effort in India. Family Health International helped develop an HIV monitoring system in Maharashtra. The Futures Group trained government officials to develop and implement an AIDS control strategy. The Population Council assessed appropriate STD control strategies for truck drivers, examined how STD treatment can be integrated into reproductive health clinics, examined HIV prevention issues for women, including women and girls who have been "trafficked" for sex, and convened regional conferences on ethical issues and HIV testing. The National AIDS Research Institute in Pune (Maharashta) was an HIVNET vaccine research site, operated by Johns Hopkins University. The Laboratory of Immunoregulation at NIAID operated a $337,000 research program in Pune that examined the natural history of acute HIV infection. Johns Hopkins University operated a $413,000 research program in collaboration with the Laboratory of Immunoregulation that examined acute HIV infection in Pune. The University of North Carolina operated a $25,000 FIRCA grant in collaboration with the Government Medical College in Nagpur that examined the use of gonorrhea screening and treatment as an HIV prevention intervention. The University of Pittsburgh operated a $25,000 FIRCA grant in collaboration with the Chittaranjan National Cancer Institute in Calcutta that examined the immunology of CD8 cells in people infected with Indian strains of HIV. Indian physicians received clinical training at Johns Hopkins University and UCLA.
The U.S.'s long relationship with the Philippines extends to involvement with HIV programs. In 1998, USAID allocated $43.6 million for development assistance, $1.5 million of which was designated for HIV programs. The U.S. was the largest donor to HIV programs in the Philippines. The USAID mission used its HIV funds to help monitor the epidemic and develop prevention strategies for prostitutes and other high-risk groups. Family Health International developed strategies for the control of STDs, including training health clinic staff and local government officials, implementing national monitoring systems, assessing resistance mutations in gonorrhea isolates, and surveying the sexual practices of young men. The Population Council assessed the role of HIV-infected people in the delivery of HIV treatment and prevention services. The Futures Group trained government officials to develop and implement a national AIDS control strategy. The International AIDS Alliance provided technical assistance and evaluation for community-based HIV organizations. A $470,000 research program at UCLA studied prevention strategies among men who visit prostitutes, police, taxi drivers, and industrial workers. The UCLA program included its Center for AIDS Research. Filipino physicians were trained at Brown University.
U.S. law prohibits most direct American assistance to Vietnam. Nevertheless, there was substantial indirect U.S. involvement in Vietnam through USAID contractors and NIH-funded universities. Family Health International operated a major program in three Vietnamese provinces, Tay Ninh, Quang Ninh, and Can Tho. This program surveyed sexual behaviors, assessed treatment clinics for STDs, and developed community-based prevention programs. In addition, FHI trained government officials in male and female condom distribution logistics and encouraged greater private-sector production of condoms. Johns Hopkins University operated a $26,000 FIRCA grant that examined the ability of women in north Vietnam to recognize STD symptoms. UCLA operated a $21,000 FIRCA grant that examined the prevalence of HIV-1 subtype E, a strain common in Southeast Asia, among intravenous drug users in south and central Vietnam. Vietnamese physicians received clinical training at Emory University, Johns Hopkins University, University of California-Berkeley, and UCLA.
The U.S. funded HIV programs, either directly or indirectly, in nineteen Latin American and Caribbean countries, four of which met this report's definition of most involved.
Haiti is the poorest country, and suffers the most intense HIV epidemic, in the western hemisphere. The U.S. was the largest donor to Haiti, supplying $104 million in 1998, of which $1.3 million (1%) was designated for HIV programs. The USAID mission supported health care programs, primarily for women and children, addressed environmental degradation, and attempted to strengthen democracy and train the national police force. USAID HIV/AIDS funds supported family planning and maternal and child health programs in three of Haiti's ten departments, reaching over half the nation's population. Twenty-two Haitian community-based groups received some direct support from the USAID mission for HIV prevention. The Futures Group trained national health officials to develop and implement a national AIDS control strategy. Haiti was the site of an HIVNET vaccine research site operated by Cornell Medical College, which also operated an $851,000 research project examining the natural history of HIV infection in a Port-au-Prince cohort. Johns Hopkins University operated a $324,000 research program that examined tuberculosis prevention in PPD- negative HIV-infected people. Haitian physicians were trained at Cornell, Johns Hopkins, and University of Miami.
The U.S. donated $13.2 million in development assistance to the Dominican Republic in 1998, of which $1.8 million was designated for HIV. The U.S. was the fifth largest donor to the Dominican Republic. USAID focused on economic development, political reform, transitioning to more efficient energy sources, and reconstruction after serious hurricane damage. The USAID mission-level HIV program focused on improving family planning services at ten hospitals, supporting community-based HIV organizations, and increasing access to potable water in rural areas. Family Health International promulgated a training manual on STD treatment, trained health clinic staff in STD treatment, assessed the national AIDS control strategy, helped develop a national AIDS plan, developed an HIV monitoring system, and improved the management of the national AIDS program. The Population Council examined strategies for increasing condom use in brothels. The Peace Corps trained its volunteers to conduct HIV prevention workshops. The Dominican Republic was one site of an international research program operated by Johns Hopkins University that assessed the cost-effectiveness of prevention strategies in developing countries. Dominican physicians were trained at Johns Hopkins and the University of Miami.
U.S. involvement in Trinidad & Tobago was entirely in the form of NIH-funded research programs. (Trinidad does not appear on our map because of the scale.) The National Cancer Institute funded a $315,000 program at the Caribbean Epidemiology Center and a $680,000 program at the University of the West Indies, both in Trinidad, to conduct epidemiological surveys of HTLV, lymphomas, and HIV. NCI's Viral Epidemiology Branch also conducted epidemiological surveys in Trinidad. Research Triangle Institute, with NCI support, analyzed HIV strains found in Trinidad. Trinidad was the site of an HIVNET vaccine research site at the University of the West Indies, operated by the University of Maryland. The Center for AIDS research at Duke University operated a $1.6 million program that conducted immunologic and virologic studies of HIV isolates and patients from Trinidad. Physicians from Trinidad received clinical training at the University of Maryland.
In 1998, USAID donated $10 million to Mexico for development assistance, $400,000 of which was designated for HIV programs. USAID's role in Mexico was primarily focused on environmental protection and drug trafficking. The mission's HIV activities focused on improving STD treatment in the states of Yucatan, Guerrero, Mexico (along with the Federal District), Puebla, Veracruz, Jalisco, and Oaxaca. Family Health International supported the mission's activity by training government officials, public health providers, and community groups in STD control, and improving the national monitoring system for HIV and other STDs. The Population Council developed and promulgated a school-based HIV prevention curriculum for pre-school through secondary school. The Futures Group trained government officials to develop and implement an AIDS control strategy. The International AIDS Alliance developed community-based HIV organizations, primarily in Yucatan. Mexican physicians received clinical training at Emory University and UCLA.
This article was provided by Treatment Action Group. It is a part of the publication Exploring the American Response to the Global AIDS Pandemic.