* Anderson was not yet USAID Administrator during the period of this analysis, nor was Koplan at CDC.
** Varmus is no longer NIH Director; Ruth Kirchstein is acting director.
NOTE: This chart lists only major administrative units with defined programs, humanitarian response, and program coordination bureaus at USAID ($3,575,000 in AIDS funding collectively) and mental health, research resources, and dental institutes at NIH ($1,908,431 in AIDS funding collectively) are omitted because their programs are ancillary.
USAID, the agency with the largest international HIV program, is a primary instrument of American diplomacy with the developing world, dispersing billions in foreign assistance each year for economic, political, and health programs. The $123 million 1998 HIV budget at USAID existed within that agency's broader effort on world population, health, and nutrition. Of that, $23 million went to UNAIDS and $100 million was directly programmed by USAID. Most HIV projects supplemented or operated within existing USAID-funded prenatal, family planning, primary care, and sexually transmitted disease (STD) programs. Through USAID alone, the U.S. contributed more to the developing world for HIV than any other country.
USAID is organized into four regional bureaus that operate missions and programs in selected developing countries around the world. Each regional bureau is further divided into country-level missions. In 1998, 66 USAID missions were involved in USAID's population, health, and nutrition programs, 40 of which received discrete HIV funding. The Africa bureau was at the center of the USAID HIV program. It received more HIV funding than any other bureau, and it maintained 19 country-level missions involved with HIV projects. The global bureau provided support and direction to the overall USAID effort, in particular through the management of seven large, multi- country contracts awarded by the agency to non-governmental organizations. The global bureau played a particularly important role in USAID's HIV program.
USAID's Asia and Near East Bureau had the second largest program, operating health programs in 14 country-level missions, 8 of which received HIV funding. The Latin America and Caribbean bureau operated health programs at 13 country-level missions, 10 of which received HIV funding. The Eurasia bureau operated health programs through country-level missions in 18 countries, 4 of which received HIV funding. Other bureaus at USAID that received HIV funds include the humanitarian response bureau, which operates disaster relief programs, and the policy and program coordination bureau, which plays an administrative role at USAID's Washington headquarters. A full description of USAID mission-level HIV budgets is in Table 9.
NIH is the world's largest funder of biomedical research. Its international HIV/AIDS program is a small part of a much larger $1.8 billion HIV research program. NIH is organized into 26 institutes and centers, including the Office of the Director, which includes the Office of AIDS Research (OAR). Four NIH institutes played a major role in the international HIV program in 1998. The National Institute of Allergy and Infectious Diseases (NIAID) had the largest program, followed by the Fogarty International Center (FIC), the National Cancer Institute (NCI), and the National Institute of Child Health and Human Development (NICHD). Three other NIH institutes, the National Institute of Dental Research (NIDR), the National Institute of Mental Health (NIMH), and National Center for Research Resources (NCRR) used small portions of their HIV budgets to support the international initiatives of the four primary institutes. During 1998, NIH operated HIV programs 51 developing countries at a cost of $52.3 million.
CDC is the U.S.'s domestic health monitoring and disease prevention agency. Two centers at CDC, the National Center for HIV, STD, and TB Prevention (NCHSTP) and the National Center for Infectious Disease (NCID), conduct international HIV programs and provide technical assistance to other governments. During 1998 CDC spent $9.03 million on its international HIV/AIDS programs, operated HIV programs in four countries, and provided technical assistance to four others.
These three agencies are, however, just the starting point for this analysis because most U.S. international HIV funds are given as grants and contracts to non-governmental organizations and universities in the United States. NIH plays a well-known role as a grant-giving institution. Eighty- eight percent of the NIH's international HIV budget is awarded as grants to universities and other academic institutions. USAID is also a grant-making institution. Fifty-three percent of its funds are awarded to NGOs and the UNAIDS program, with the remainder used by USAID missions around the world. CDC does not award grants for international HIV programs. Eighty-seven million of the U.S. international HIV budget is awarded to NGOs and universities, $23 million to UNAIDS, and $74 million to CDC, NIH, and USAID. Table 7 itemizes all contractors and grantees, while Table 8 itemizes all intramural and interagency programs funded by the three agencies.
Figure 2: U.S. International AIDS Funding -- Intramural, Extramural, UNAIDS