Summary Findings

Table 1

Three U.S. government agencies formed the core of the American response to the global AIDS pandemic in 1998. The U.S. Agency for International Development spent $123.7 million on international AIDS programs in 1998, including a $23 million contribution to the United Nations AIDS program, the single largest component of that international agency's budget. The National Institutes of Health spent $52 million on international AIDS research projects in 1998. The Centers for Disease Control spent $9 million on international AIDS programs in 1998.

The U.S. government supported 463 HIV/AIDS projects in 79 developing nations. The U.S. response reached 28 African countries (36% of the budget). Twenty Asian nations were included in the U.S. response (15% of the budget). Nineteen Latin American and Caribbean were involved ( 12% of the budget). Twelve Eurasian countries (1% of the budget) received AIDS support from the United States government, none at an intensive level. The U.S. also supported 53 projects that were global, multi- region, or undefined in scope, reaching many countries across regions. These global programs accounted for about 34% of U.S. funds.

* Includes North Africa;
** Eastern Europe & former Soviet Union;
*** Includes programs for which specific country-level funding could not be obtained.
**** Includes $23 million to UNAIDS

We describe the U.S. international HIV/AIDS 1998 program activities in nine categories. The largest (31% of the total budget) was the development of health systems infrastructure by the U.S. Agency for International Development (USAID) in 36 countries. USAID supported HIV prevention programs (20% of the budget) in 37 countries. Support for the United Nations AIDS Program took up 12% of the total budget. NIH-funded academic research projects (11% of the budget) in 37 countries. All three agencies funded epidemiology and surveillance projects (8% of the budget) that operated globally and in 12 countries. The National Institutes of Health (NIH) supported a vaccine discovery program (7% of the budget) in ten countries. NIH trained researchers (5% of the budget) from 43 countries. USAID developed community and governmental leadership (3% of the budget) in 29 countries. NIH supported reference labs and other research resources in the U.S. (3% of the total budget) that served global needs.

Other U.S. agencies played a role in the global AIDS response, but that role is small and, in some cases, unclear. The most important example is the Department of Defense (DOD), which maintains an international HIV research program. DOD officials refused to cooperate with this report. Other agencies with an international presence are the departments of state, labor, and commerce. The limited information we could obtain about these programs is summarized in section 8 but is not otherwise included in this analysis.

The U.S. international HIV program is not direct aid to foreign governments or agencies. In 1998, the U.S. international HIV program included the direct overseas programs of twelve divisions of the U.S. government (cf. Table 8), support for the United Nations, and contracts and grants to 48 universities or NGOs, all but three of which are located in the U.S. (cf. Table 7).¹

Most contracts and grants in the U.S. international program were concentrated at seventeen academic or non-governmental organizations (sixteen American and one British). These organizations all received more than $1 million from the U.S. government for international HIV programs, and collectively received 43% ($79.8 million) of the total program. The single largest contractor was Family Health International, a Virginia-based NGO, which alone received $25 million. Johns Hopkins University received $4.4 million, more than any other academic institution (cf. Table 7).

The U.S. international AIDS program is a small part of larger initiatives in global health and research. In 1998, the NIH international AIDS research program was 2% of the $1.8 billion AIDS research program. CDC's international AIDS program was less than 1% of its overall AIDS program. Even at USAID, AIDS was just a fraction of that agency's development agenda. AIDS programs accounted for less than 9% of USAID's entire budget, and less than 22% of its health programs. In countries where USAID operates missions, AIDS funding typically never exceeded 5% of the total mission budget. In those few cases where the relative portion of AIDS funding was higher at a USAID mission, the absolute funding for AIDS and other activities was generally low. As a portion of the U.S. domestic $8.7 billion AIDS budget, the entire U.S. international program barely reached 2%.

While the U.S. is the largest contributor of AIDS-related development assistance in absolute terms, other rich countries spend far more when population and gross national product are taken into account. The Netherlands, Norway, Sweden, Denmark, Australia, Canada, the U.K., and even Belgium contributed more on this adjusted basis (UNAIDS 1999). However, these comparisons do not include funding for AIDS research, an area in which the U.S. clearly spends far more than any other country. These two factors should be considered when comparisons are made.

This year, the U.S. proposed its new Leadership and Investment in Fighting an Epidemic (LIFE) initiative. Funded with $100 million in new or redirected resources (opinions vary), LIFE will reprogram $54 million for international AIDS activities to USAID, $26 million to CDC, and $10 million each to the Departments of Defense and Labor (ONAP 2.8.00) in fiscal year 2001. While supportive of this new initiative, we would support inclusion of new resources for NIH as well, which has a substantial ($53 million) investment in international research, as well as significant expertise and infrastructure. The LIFE initiative represents a minimum acceptable increase in U.S. support for international HIV/AIDS activities and we hope resources continue to increase substantially.

Information from U.S. agencies ranged from clear to chaotic to non-existent. The lack of clear information hampers not only this analysis but any attempt to understand and evaluate the successes and limitations of the U.S. program. If the program cannot be defined, how can anyone know if it succeeded? These findings should be viewed as a first step, an exploration of the U.S. government's emerging response to the global AIDS pandemic, and a call to action for the future.