Provide clear information. The U.S. response to the global AIDS pandemic is growing. To ensure that this growth is efficient and effective, the U.S. government should commission an external review of its international AIDS program. It should also release comprehensive periodic updates, with full budget information, about its international AIDS programs. A preferred option would be for the Office of National AIDS Policy (ONAP) to produce an annual report that could serve as a guide to program growth and evaluation.
Be transparent, accountable, and organized. Greater transparency and accountability is needed. After reading thousands of pages of material, we are still left with many questions. All agencies should implement an information system that can be used to evaluate programs, to assure that investments in AIDS programs are targeted, efficient, and effective, and to describe to the American people their government's response to the global AIDS pandemic.
Coordinate the response, with involvement from scientists and NGOs. Three U.S. agencies are involved in the international AIDS programs in a major way. Other agencies, such as the military, the labor department, and the state department also have international programs. We found no evidence these agencies regularly discuss their international programs with each other. Regular interagency meetings should be established to plan and evaluate the American response. Representatives from the universities and NGOs involved in the U.S. international effort should participate in an external planning and evaluation process. The evaluation should include testimony from NGOs, researchers, clinicians, and advocates from the U.S. involved in international activities, and from developing countries.
Evaluate the overall U.S. international AIDS program. The U.S. program needs to have a set of overarching goals. Resources need to be deployed where they are most needed, and where they can achieve the biggest impact. (Why, for instance, did the epidemic in Indonesia receive more U.S. resources than that in Zimbabwe, which has one of the world's direst epidemics?) To accomplish this, a detailed, qualitative analysis of what is being done now, and what should be done, is needed. This evaluation should be carried out in concert by the U.S. agencies involved, with input from scientists, NGOs, and developing countries. It should identify clear priorities and ensure that resources are deployed to accomplish them.
Increase the U.S. international AIDS budget in a big way. As Jeffrey Sachs put it in The Economist, the U.S. is "the meanest donor of all" (6/24/2000). The U.S. gives far less development assistance (HIV related and general) than many other rich countries on a population and GNP adjusted basis. The U.S. should give more because we know resources matter. In Uganda and Senegal, for example, explosive epidemics have been blunted due to effective interventions. They are the only two countries with declining incidence in Africa. More resources can be a part of making this a reality worldwide. We support the administration's current proposal to increase support for international AIDS activities by $100 million in fiscal year 2001 as a minimum acceptable increase; ideally the Congress should increase the USAID budget by $725 million, the NIH AIDS research budget by $301 million, and the CDC budget by $305 million (domestic and international), in accordance with the recommendations of the National Organizations Responding to AIDS (NORA 2000).
Keep the AIDS research program robust. AIDS research is a crucial part of the global AIDS strategy, and one where the U.S. makes the biggest contribution. Political leaders and community advocates need to recognize the importance of AIDS research in fighting the epidemic worldwide. NIH should continue increasing its support for international AIDS research as the overall NIH AIDS research budget rises, along with that of NIH as a whole.
Double U.S. support for the UNAIDS program now. In the short term, the U.S. should at least double its annual contribution to UNAIDS from $23 million to $46 million. The American government should advocate that other developed nations do the same. This move should be a first step in more significant increases for UNAIDS over time.
Don't politicize international AIDS. International AIDS should not become a domestic political football. The American response should be about the health of the world and the ethical obligations of the world's strongest and richest country. The current administration has taken some bold recent steps, and some congressional Republicans have shown leadership as well. Both parties in Congress, and whoever wins the White House this year, should commit to a sustained, bipartisan, and vigorous U.S. international AIDS program.
Do not let U.S. international AIDS funding become domestic pork. When a program area is slated for major increases, as the international AIDS budget is now, the temptation always exists in Washington to "spread the wealth around" among numerous agencies and departments. This is particularly worrisome with international AIDS because so little information exists on the current nature of the American response, no one agency is clearly in charge, and no organized domestic constituency is prepared to monitor the effectiveness of new programs. It would be unethical, short-sighted, and stupid to treat new funds for international AIDS as a fungible windfall. For example, why does the administration propose giving the labor department $10 million in its new international initiative, while NIH, which has a long track record and an important existing program, is slated to receive no new funds? No new money should be allocated to any federal agency for international AIDS unless that agency clearly articulates a public plan for those funds.
Lead. The U.S. government's response to the global AIDS pandemic does not take place in a vacuum. On one hand, the U.S. should lobby other developed democratic nations to increase their support for international AIDS programs. On the other hand, the U.S. should make global AIDS strategy a central part of its diplomacy with poorer countries. Even though some poor countries face AIDS epidemics of staggering proportions, their governments do not always acknowledge the scope or even the existence of the epidemic because of corruption, denial, war, and lack of democracy. As the world's strongest country, the U.S. can thrust AIDS into the center of diplomatic discussion.
Strengthen USAID. USAID conducts and supports vital, front-line work to prevent and manage AIDS epidemics in countries around the world. This work is essential, and should be strengthened and expanded, after undergoing a comprehensive external review.
Clean up the mess in USAID's accounting system. USAID's has the worst budget information system we have ever seen. They provided voluminous material, none of which appeared internally consistent. USAID needs to develop a clear, comprehensive, and complete annual report of its international AIDS programs.
Develop criteria for program evaluation with outside experts, and publish the results. USAID had no clear system for measuring the success of its programs. What are the metrics? Who will generate them, and who will validate them? This is particularly important because several major USAID programs expire in 2002, just as substantial new resources become available. What evaluation is planned or ongoing? Will there be any kind of external peer review? What is the public role? What will the process be for planning the renewal or redirection of the prevention program contracts?
Communicate better. The U.S. response to the global AIDS pandemic suffers because USAID can not describe its work to the American people. Health systems support and prevention programs are the two largest pieces in the USAID international AIDS program, and they are essential elements of a response to the global pandemic. Yet USAID can't explain exactly what was funded, when, where, and whether it worked, so it will not be able to redirect resources or reshape programs when necessary, and it will be harder to sustain public and congressional support. Furthermore, we do not understand how USAID's bureaus relate to each other, how USAID relates to other government agencies, how it relates to other bilateral donor programs, how it relates to other UN/multilateral programs, or precisely how it interacts at the country level with local governments, health systems, and communities. These are the questions USAID needs to answer.
Conduct implementation research. NIH, in conjunction with CDC and USAID, should conduct research on strategies to implement prevention and treatment interventions in developing countries that lack infrastructure and resources. Areas include HIV diagnosis, prevention of mother-to-child-transmission, treatment of opportunistic complications, and treatment strategies such as pulsed therapy or short-course HAART regimens. Which treatment, prevention, and diagnostic strategies are appropriate for impoverished Africa and which are appropriate for middle-class Brazil? NIH should help to address these questions.
Involve international researchers and advocates. NIH has made international research a priority in its strategic plan. It should ensure the involvement of international researchers and treatment advocates, including those from developing countries, in the development and implementation of its international AIDS research programs.
Improve data systems. NIH institute-level definitions of AIDS-related research have greatly improved since the 1996 Levine Committee report. The NIH AIDS Research Information System (ARIS), while not perfect, is a better database than others we reviewed. However, NIH institutes often provide contradictory and incomplete information about their AIDS and international research activities; the NCI intramural program remains particularly problematic in this regard.
Expand epidemiology. Emerging issues in epidemiology and surveillance include HIV-1 and HIV-2 coinfection, the transmission of drug-resistant HIV strains, and coinfection with HIV-1 and other infections such as tuberculosis and hepatitis C virus.
Coordinate natural history cohorts in developing countries. There is a pressing need to identify existing natural history cohorts in developing countries, to coordinate them, and if necessary to expand them, in order to better understand the epidemiology of various opportunistic complications of HIV in countries and regions around the world.
Conduct treatment research relevant to developing countries. NIH should team up with other sponsors of HIV/AIDS treatment research working in developing countries to carry out treatment research relevant to a variety of epidemic, economic, and therapeutic settings. With the exception of interventions to reduce mother-to-infant HIV transmission, and of the CDC's Projet RETRO-CI in Côte d'Ivoire, which conducted a study of trimethoprim/sulfamethoxazole in Abidjan (Wiktor 1999), we found virtually no treatment research being supported by U.S. agencies. It is far past time to figure out how to make the substantial therapeutic advances of the past five years much more broadly available around the world.
Increase support for training programs for researchers and clinicians from developing countries. The Fogarty International Center's excellent training programs for researchers and clinicians from developing countries reach more places than any other U.S. program. They provide essential opportunities for researchers from north and south to work together, learn from each other, and apply science and technology in ways relevant to the places where the epidemic is occurring. These vital programs are small; both the size of the awards and their number should be increased.
CDC has done an excellent job focusing on a few long-term projects. The Centers for Disease Control and Prevention (CDC), with a small investment, has made major contributions to the international AIDS effort, ranging from epidemiology to treatment research (e.g., Bactrim studies in Côte d'Ivoire). Now, as it is slated for major increases ($26 million in FY 2001), the CDC should conduct an external review to ensure that the new resources -- which should not come from badly-needed domestic AIDS programs -- are deployed as effectively as possible.
Tell us more, and coordinate. CDC provided accurate and complete information. They should produce an annual report and budget describing their international AIDS programs on the Internet every year. CDC should coordinate its international AIDS activities with those of other agencies.
Communicate and evaluate. DOD needs to provide more accurate, comprehensive, and detailed information about its role in HIV-related activities, both domestic and international, and this information needs to be made publicly accessible. In addition, the DOD should review its research program to ensure it is focused, non-duplicative, and coordinated with other U.S. agencies and their work.
DOD and Other U.S. Agencies
Collaborate. As the three main agencies develop systems for collaboration, other agencies should participate. We did not identify significant international HIV/AIDS activities carried out in 1998 by other U.S. agencies, with the exception of interagency agreements and contracts carried out by the U.S. Bureau of the Census and the Peace Corps. However, as part of the annual report on U.S. international HIV/AIDS activities mentioned in recommendation #1, ONAP should ensure that all agencies involved internationally are described and budgeted.