Halting the Global Spread of HIV/AIDS: The Future of U.S. Bilateral and Multilateral Responses
Testimony to the Hearing of the Committee on Foreign Relations of the United States Senate
February 13, 2002
Mr. Chairman, distinguished members of the committee, ladies and gentlemen, I thank you for the opportunity to testify this morning, and I applaud you for your focus on the global AIDS epidemic.
I am here today on behalf of the UN System organizations responding to the global epidemic, and in particular the eight UN agencies whose collective efforts on AIDS make up UNAIDS, namely UNICEF, UNESCO, ILO, the United Nations Development Programme, UNFPA, UNDCP, the World Health Organization and the World Bank.
AIDS Is DifferentAnd Mr. Chairman, I am here today to tell you that the AIDS epidemic is different from any other epidemic the world has faced, and as such, requires a response from the global community that is broader and deeper than has ever before been mobilized against a disease.
Twenty years since the world first became aware of AIDS three things have become clear:
The first twenty years in the history of an epidemic is only the blink of an eye. The other communicable diseases that ravage many parts of the world have been known for many centuries. Their patterns of spread have become well-established and predictable.
Mr. Chairman, committee members, AIDS is unlike any other epidemic that we have faced:
This silent spread and slow impact of AIDS have meant that the threat it poses has been consistently underestimated. For a moment, let us compare it to the much-feared Ebola, a virus I have had first-hand experience with, dating back to when I was a member of the team that investigated the first known epidemic of Ebola virus infection in 1976 in then-Zaire.
Ebola spreads rapidly and causes illness instantly, so there is never any doubt about the need for a rapid and comprehensive response. Today, when Ebola breaks out anywhere, action teams are dispatched without delay. The immediate and present danger it represents is readily recognized and the international community immediately mounts an appropriate response to halt the new epidemic -- and Ebola has caused probably no more than 1,000 deaths in total.
Now, let us imagine a much smarter virus than Ebola. A virus just as deadly, but one capable of creeping silently through whole populations before it revealed itself. A virus whose casualties from its local epidemics are not measured in the hundreds, but in the hundreds of thousands. A virus that kills slowly, and painfully, and generally only after stigmatizing and pauperizing the entire family of an infected person.
It is difficult to imagine a smarter, more devastating virus than the subject of this hearing, the virus that causes AIDS. And it is equally difficult to imagine a world unwilling to mobilize to slow the spread and eventually contain this virus. All the more so, given what we know about it, how long we have seen it coming, and where we can now see it going.
The State of the Global EpidemicMore than 60 million people worldwide have been infected with the virus -- nearly double the population of California. Since the epidemic's start, twenty million of the sixty million people infected with HIV have died -- a number equivalent to the populations of Texas or New York State.
HIV/AIDS is now by a large margin the leading cause of death in sub-Saharan Africa and the fourth-biggest global killer. Life expectancy in sub-Saharan Africa is now 47 years, when it would have been 62 years without AIDS. In 2001 alone, an estimated 5 million people became infected with HIV, and half of them were young people between the ages of 15 and 24. There were an estimated 800,000 children under 15 -- mainly infants -- infected with HIV in 2001, and 580,000 child deaths as a result of AIDS.
Sub-Saharan Africa is the region of the world where the epidemic has been worst and where its impact increasingly threatens the stability of whole societies.
Average prevalence in sub-Saharan Africa is 8.8 percent in the adult population (15-49 years old). There are seven countries, all in the southern cone of Africa, where more than twenty percent of adults are infected with HIV, and a further nine countries where infection rates exceed ten percent.
We still do not know what is the upper limit for the extent of HIV spread in a population. Botswana is the country with the highest HIV rate to date with 36 percent of adults infected. It is followed by Swaziland, Zimbabwe and Lesotho all between 24 and 25 percent.
While the scale and impact of AIDS in sub-Saharan Africa is the worst in the world, HIV is a rapidly expanding problem in other regions.
HIV/AIDS is growing fastest in the countries of the former Soviet Union. There are a million cases in the region, and at least 250,000 new HIV infections in the past year -- most of them in the Russian Federation. Ukraine has the highest prevalence with nearly 1% of the adult population living with HIV.
In Asia, China and India currently have relatively small overall prevalence, but given their huge populations, within each there are large numbers of people and locally high proportions that are infected with HIV. For example, the Indian states of Maharashtra, Andhra Pradesh and Tamil Nadu, each with over fifty million people, have HIV rates measured in pregnant women above three percent, over four times the national average. In China, we have estimated that concerted action taken now will be able to avert ten million new HIV infections over the coming decade.
Adjacent to the U.S. mainland, the Caribbean is, next to Africa, the second-most affected region in the world. In a number of countries in the Caribbean and Central America more than two percent of the population is HIV infected and adult HIV prevalence has risen to over 4% in Haiti and the Bahamas.
Nor can we declare HIV a problem that is over in the U.S., western European, and other wealthy countries -- the rate of new infections in the U.S. and Western Europe has not been significantly reduced in the last decade. In the course of 2001, an estimated 30,000 adults and children became infected with HIV in Western Europe and 45,000 in North America, taking the total numbers living with HIV in these regions combined to 1.5 million. In these countries the face of the epidemic has changed, and it is among the poorer, ethnic minority and immigrant populations that the numbers infected with HIV are growing fastest. Ironically, access to more effective HIV treatment may also be associated with rises in unsafe sex among some of the populations that historically have shown the greatest level of behaviour change, such as gay men.
The Impact of AIDS: Every Sector Is AffectedMr. Chairman, distinguished committee members, AIDS is currently one of the greatest threats to global development and stability. It is a long-term humanitarian crisis of unprecedented proportions -- the death and misery it has caused in the past twenty years dwarfs all of the natural disasters that have occurred in that time combined. The HIV epidemic has not only disrupted many millions of individual and family lives, it has threatened the stability of entire societies.
Economic ImpactIn the worst affected countries, AIDS has a major impact on business productivity, on livelihoods and the supply of food, and on professionals: from doctors through to police forces. For example, in Kenya, AIDS accounts for 75 percent of all deaths in the police force over the past two years. AIDS not only affects the poor, but also the educated and skilled. In South Africa, for example, ING Barings Bank projects that one-third of the semi-skilled and unskilled workforce will be HIV positive by 2005, 23 percent of the skilled workforce and 13 percent of the highly skilled workforce. In the mining industry throughout Africa there is now an acute problem in replacing skilled mine workers lost to AIDS. And in Zambia, nearly two thirds of deaths among managers have been found to be attributable to AIDS, a higher proportion than among middle-ranking workers.
Consequently, AIDS has a direct impact on rates of economic growth in the most affected developing countries. There is a direct relationship between the extent of HIV prevalence and the severity of negative growth in GDP. When the rate of HIV in a population reaches 5 percent, per capita GDP can be expected to decline by 0.4 percent a year. And when HIV reaches 15 percent, a country can expect a one percentage annual drop in GDP.
The cumulative impact of HIV on the total size of economies is even greater. By the beginning of the next decade, South Africa, which represents 40 percent of the region's economic output, is facing a real gross domestic product 17 percent lower than it would have been without AIDS. Similar studies in the Caribbean suggest Jamaica and Trinidad and Tobago face a five percent loss in GDP by 2005 as a result of AIDS.
In settings where subsistence agriculture predominates, measured economic productivity only scratches the surface of the total impact of HIV on livelihoods. For example, AIDS hits the long term capacity for agricultural production, as livestock is often sold to pay funeral expenses, or orphaned children lack the skills to look after livestock in their care.
Armies are among those most affected by HIV. HIV rates in the armed services are in many cases two or three times higher than those in the respective civilian populations. When armies are deployed they spread HIV in the populations where they are stationed, and when they are demobilized they spread HIV in the towns and villages to which they return.
Human ImpactBut measures of per capita GDP in fact underestimate the human impact of AIDS, as AIDS kills people, not just economic activity. We should reflect on what it means for a society when 10, 20 or 30 percent of the population is HIV infected:
The immediate impact of AIDS is felt most acutely in families where one or more members are HIV infected. In South Africa, households will on average have 13 percent less to spend per person by 2010 than they would if there were no HIV epidemic. In Côte d'Ivoire in West Africa, the household impact of HIV/AIDS has been shown not only to reverse the capacity to accumulate savings, but also to reduce household consumption. AIDS not only affects income, with lower earning capacity and productivity, it also generates greater medical, funeral and legal costs, and has long term impact on the capacity of households to stay together.
This is most manifest in the number of children orphaned by AIDS, which now totals nearly 14 million. In developing countries, before AIDS, around 2 percent of children were orphaned, but now in many countries, 10 percent or more of children are orphans. The war in Sierra Leone left 12,000 children without families. AIDS in Sierra Leone has already orphaned five times that number.
A fundamental part of our response to the epidemic must address how families and communities will cope.
Progress in the Global ResponseMr. Chairman, distinguished committee members, for too long we have been transfixed by the toll of the increasing HIV epidemic, unfolding before our eyes. Now we are shifting our gaze: Success is squarely in our sights.
I believe that for the first time in the short history of this epidemic, the world is in a position to translate local and national examples of success into a truly global movement against the HIV epidemic. This is a great leap forward from where we were even a few years ago.
Five major elements define what today gives us the ability to seriously and successfully approach this epidemic on a global scale.
First: there is manifestly greater political momentum dedicated to addressing AIDS. We have learned that political leadership is required at all levels to marshal the necessary commitment and resources for the social mobilization on which the response must be built.
The second major element is that we can now point to increasing success in countries. In the developing world there are a number of familiar examples. In Uganda, surveys in urban areas in the early 1990s found 30 percent of pregnant women were infected with HIV, but there have been sustained drops since then to less than 10 percent. In Thailand comprehensive prevention efforts mean that the number of new HIV infections today is less than a quarter of the number a decade ago. And Senegal is a prime example of a country where the HIV epidemic has been kept small. But today I would also like to draw attention to less familiar examples of success. For example:
The third major element is that there are now widely accepted strategic approaches which are derived from these successful country experiences. The Global Strategy Framework for AIDS which has been endorsed by all the members of the UNAIDS Programme Coordinating Board -- including, of course, the U.S. -- sets out a common understanding of the dynamics of the epidemic and the leadership commitments that are required to reverse it. As a consequence within the UN system, 29 different UN system bodies share a common strategic plan.
The global response to AIDS has moved beyond the stage of trying small scale experiments to see what might or might not have an effect. We are now at the stage of translating proven approaches to full scale national responses. These approaches include:
The fourth major element, is that there is now a clear set of global priorities in the fight against AIDS.
The fifth major advance is in the new realism about the resources required to tackle AIDS.
Additional Resources Required to Address the AIDS EpidemicBefore I come to the total requirements, I will first try to put into perspective how additional resources could make a real difference to the epidemic. Let me take the example of a modest annual investment of $10,000.
If we spent that money on voluntary counseling and testing in India, there are non-government organizations that would provide good quality HIV counseling and testing services to 10,000 people. Or in Gujarat, a hundred buses that could carry AIDS messages for a year, reaching many thousand town and village dwellers.
$10,000 would allow the Brazilian Girl Guide and Scout movement to reach another ten thousand young Brazilians with an AIDS education kit. It would support 80 peer educators to reach hundreds of street children in every part of Brazil. It would allow the Living Positively project in the central Goiás state to reach more women with HIV, helping them to avoid transmission to their babies and training them as peer educators.
In Zambia, with $10,000 there are 1,000 orphans who could receive bursaries so they can stay in school. $10,000 would let the Catholic church in Zambia train another 100 rural caregivers a year in providing community home-based care. There are six more health workers who could be trained and supported to provide antenatal care and antiretroviral drugs to help prevent mother-to-child transmission.
What Does This Add Up To?There is wide global recognition, including from the UN General Assembly, that AIDS spending in low- and middle-income countries needs to rise to $7 to $10 billion annually for a comprehensive AIDS response. The task we face today is to strategically multiply the number of these $10,000 investments until they reach the scale of the epidemic itself. It is no small undertaking -- a million such investments make up the ten billion dollar target. But there are tens of thousands of communities that stand ready to take action and are desperate to do so, and there are hundreds of thousands more to which success could be spread.
A more detailed breakdown of the estimated total spending need has been made by an international group convened by UNAIDS and published last year in Science magazine. It shows there are major differences between regions in the balance of spending needed to respond to the HIV epidemic. In Africa, where 28 million people are already living with HIV, roughly two out of every three dollars would be needed for care and support. In Asia and other regions where the greatest opportunity still exists to prevent massive spread of HIV, the majority of funding would be directed toward prevention programs.
Almost one-quarter of the estimated need in prevention expenditure is for education, counseling and mass media communications aimed at youth to help them avoid becoming infected. We need to provide good information and support to youth before they become sexually active and provide better services and a safer environment once they do become sexually active.
Also included in the estimates are the costs to achieve the global goal to reduce mother-to-child transmission of HIV and thereby reduce the proportion of children infected with HIV by 20% by 2005 and by 50% by 2010. We can achieve this with known technologies that are appropriate in developing country settings. Our challenge is to build up the infrastructure and enhance human capacity to implement these programs for the largest possible number of women. Achieving this goal will save over 100,000 infant lives in 2005 and by 2010 the cumulative number of babies saved would be more than 1.3 million.
Assistance to communities and for school fees could require $700 million in 2005. By 2005 there may be as many as 19 million children orphaned by AIDS. This number is so large that even extended families will find it hard to cope. We must assist the communities where these children live to provide care and support and provide special assistance to ensure that these children have educational opportunities and do not end up in the street.
The business sector has an important role to play in funding the expanded response. Approximately 7% of the total resource need is for workplace prevention programs that can be funded by private enterprises. Many employers are also funding advanced treatment for their employees. Business involvement is crucial, not only because bottom lines are being hurt by AIDS, but also because business is often in the best position to reach its staff and the communities they live in. This is especially the case where there are mobile workforces, and men especially are removed from their families to find work -- in this context, our definition of risk group needs to expand beyond the obvious examples, like miners, to include others, for example trainee bank managers.
Roughly a quarter of the total resource need is for anti-retroviral drugs. Negotiations with the pharmaceutical industry have resulted in significant price reductions that are beginning to make it feasible to deliver these life saving drugs to those who need them. But progress in delivering treatment needs advances on three fronts simultaneously:
Can Extra Resources Be Spent Wisely and Effectively?Countries do have the capacity to programme substantially increased levels of new AIDS funds. UNAIDS has just finished an assessment of the current state of programme readiness which has shown that the majority of countries assessed have already completed much of the planning and programme development work required to be confident of success in expanding their responses to AIDS. There are still some gaps in programme preparedness, especially in the monitoring and costing of plans. However, it is clear that developing countries are seriously engaged in detailed strategic planning on AIDS.
AIDS planning was well developed in 93 out of the 114 countries assessed -- though there remain major challenges in roughly a third of the countries assessed -- particularly in Africa. There are five core components to AIDS readiness: national AIDS plans, the capacity to operationalize the plan, costings, a monitoring and evaluation strategy and mechanisms that can achieve coordination among governments, non-government actors, the UN system and bilateral donors. Across the globe, there are 24 countries assessed where all the elements of comprehensive AIDS programming are already in place. At the other extreme, there are 8 countries which are yet to develop any of the elements of readiness.
One of the ironic benefits of a well-advanced epidemic in much of Africa is that there are good estimates both of the scale of the epidemic and of the resources needed to mount a response. The sea change among African leaders and communities to deal frankly and firmly with the challenge of AIDS is now apparent. Most governments have shown themselves willing to channel public resources to community and civil society organizations. But the systems to support the renewed commitment in most areas of prevention, treatment, care and impact mitigation remains weak. An important positive development has been the more effective and transparent use of resources. There are twelve African countries that have established a management capacity to deal with big increases in funding through the World Bank's Multi-country AIDS Programme for Africa and another 15 are establishing the fiduciary infrastructure required.
Our assessments of AIDS programming around the world also indicate that there is a compelling need for more intensive planning and programme development for effective responses in the education, social welfare, agriculture, and other sectors. Programme development in these sectors has lagged considerably behind the health sector.
The Resources GapMr. Chairman, committee members, we are currently far from having secured the $10 billion required for a comprehensive AIDS response in the world's low- and middle-income countries.
In these countries in 2002, somewhat over $2 billion will be spent on AIDS, including the $1.7 billion made available by the international community. International spending is joined by significant national government expenditures on AIDS, which in middle income countries like South Africa, Brazil or India run to the hundreds of millions, but elsewhere are much smaller.
The gap between current expenditure and total needs is so large, that moving to $10 billion of expenditure immediately is impracticable. Instead, we need to envisage a route to a comprehensive response where the available funds progressively increase over the next four years.
If today's expenditure on AIDS were to be maintained only, next year's funding gap will be greater than $2 billion growing to at least $7 billion by 2005. The implications are quite clear and represent a major challenge for the development of vigorous resource mobilization strategies.
To achieve our objective of scaling resource availability to keep pace with programming capacities, we need to see a roughly 50 percent increase in funding each year, in each of the next four years.
The funding required neither could nor should come from a single source. Only when funds are maximized from all sources can we claim a comprehensive AIDS response.
There are five distinct groups of actors involved in responding to AIDS. Each of them has their own advantages in supporting a comprehensive AIDS response, both in relations to the resources the can mobilize but also in the tasks and responsibilities they perform best.
The Global Fund to Fight AIDS, Tuberculosis and MalariaThe establishment of the Global Fund to fight AIDS, Tuberculosis and Malaria has signaled the new decisiveness in global AIDS efforts. It was only April of last year that UN Secretary-General Kofi Annan declared at the Organisation of African Unity's Special Summit in Abuja that the world needed a new "war chest" in the fight against AIDS. The Fund will approve its first proposals this April -- less than a year after the Secretary-General's call to action.
In 2002 the Global Fund has around $800 million available to it to disburse, and the sources of these funds are largely G-7 pledges. Of course, the Fund will be considering TB and malaria as well as AIDS, although AIDS clearly has the greatest proportion of the needs. The presentation I and Dr. Brundtland, Director-General of the World Health Organization, made to the first meeting of the Board of the Global Fund estimated that AIDS accounts for 76 percent of total global needs, tuberculosis 19 percent and malaria 5 percent.
The Fund has been constituted as a financing instrument to complement the work and responsibilities of existing organizations. Its efforts will therefore be concentrated where they are most needed: on generating and making available additional resources. The Fund is there to support what is happening at community and country level -- proposals have to be owned in the places where the money is going to.
The Fund is a public-private partnership -- its Board includes business representation, as well as non-government organizations and representatives of the communities directly affected. The UNAIDS Secretariat, together with our cosponsors the World Health Organization and the World Bank, sit on the Board. Part of our role will be to help countries in the development and preparation of proposals and to make available our expertise and networks available to the Fund to ensure it has the best possible advice about where its money will make a key difference.
Already, regional planning has taken place -- earlier this month a meeting for the Asia-Pacific region demonstrated the enormous interest in the Fund from countries, and their preparedness to put forward the best possible proposals.
In calling for proposals, the Fund has declared its intention to promote partnerships among all relevant players within countries and across all sectors of society. It will build on existing coordination mechanisms, and promote new and innovative partnerships where none exist. Proposals will be considered through country coordination mechanisms, but eligibility for funding is not restricted to governments: Public, private and nongovernmental programmes can be funded.
The Fund will support programmes both within and outside the health sector if they are technically sound, cost-effective and focus on performance by linking resources to the achievement of clear, measurable and sustainable results.
The support for the Fund in the U.S. Congress was a crucial factor in meeting the rapid timetable for its establishment. The two tranches of $200 million so far allocated to the Fund by the U.S. government have also set the pace for pledges from the rest of the world: Total pledges to the Fund now stand at just under $2 billion.
A very wide international coalition has come together in the Fund, and in spite of the range of interests represented, it is notable that key considerations set by the U.S. Congress have been met including that:
Mr. Chairman, committee members, pledges to the Global Fund already represent a 50 percent increase on the international funds available to fight AIDS. This is progress!
The challenge now is to build on this progress: to make the Fund work well by demonstrating that it can spend wisely, spend rapidly, and show results. If it does this, it is our hope that it will be an increasingly attractive proposition for donors, and the Fund will grow.
Moving ForwardMr. Chairman, committee members, AIDS is a massive global problem, but it is a problem with a solution.
The tools for effective responses exist. In the vast majority of countries around the world, there are detailed plans for dealing with AIDS. There are countless communities ready to take action. And in order to build success, increased financial investment needs to be equally matched with investment in human resource and institutional capacities.
If we are to achieve success, we need to know how our progress is going. Critical U.S. support in monitoring the epidemic and in evaluating the success of AIDS programs has put us in a better position than a few years ago. The cooperative framework for monitoring and evaluation that the UNAIDS Secretariat has been able to deliver has resulted in a level of consensus and influence at country level which has far surpassed what any one agency alone could have achieved.
Of course, for AIDS spending to be worthwhile, it needs to be able to flow efficiently to the levels it is needed. Improving both governance and the efficiency of resource transfer mechanisms remains a core priority for UNAIDS, including our cosponsors, particularly UNDP.
Mr. Chairman, committee members, the fight against AIDS is a race, and so far, it is the virus that has been winning. But we are now in a position to make a leap forward -- a leap that will for the first time put us ahead of HIV. I would be kidding myself as well as all of you if I said the task was an easy one. There are huge challenges:
First, the challenge of scale. There are perhaps a few thousand really effective AIDS programmes and activities around the world today. Unless we can rapidly escalate this number to a few hundred thousand, we will fall behind in the race.
Second, the challenge of coordination. Funding for AIDS has increased. The number of players has increased. Different parts of government are now substantively involved. International and national non-governmental players are increasingly important. But while we must celebrate this renewed level of activity, unless there is a corresponding increase in coordination, we will still fall behind in the race.
Third, the challenge of resources flow. There are still far too many blockages between resource availability at the global level and resource needs at the local, village and neighborhood level. Unless we can unblock the resources pipeline, we will fall behind in the race.
Fourth, the challenge to be led by science. A pragmatic response to evidence must be our guide in the AIDS response. Already too much effort has been diverted by those wishing to turn AIDS into their own private bandwagon. Responding to AIDS will always touch raw nerves around sexuality, drug use, relations between men and women, and the limits of personal confidentiality. But unless we can find the ways to agree to be guided by evidence and reason, then we will fall behind in the race.
Meeting these challenges requires us to marshal all we know about moving forward against the HIV epidemic. We know what to do. We know how to do it. We know it needs to be done at the right scale. We know what it costs. We are clearer than ever before about the ways in which increased spending would make a real difference to the course of the epidemic.
All these elements must now be put together. Success against the epidemic will be achieved when all the players involved play to their strengths. Mr. Chairman, committee members, U.S. support for the global AIDS effort is directed in three areas:
The United States government has long supported global AIDS programs and underwritten a research effort that remains a beacon of hope for people affected by the disease. It remains to the enormous credit of the U.S. Department of Health and Human Services through its Centers for Disease Control and Prevention that its expertise in identifying disease outbreaks was applied rapidly and effectively in the case of AIDS, and its continuing role both internationally and domestically has contributed enormously to the effectiveness of AIDS responses. More recently, initiatives have expanded -- the U.S. Department of Defense, through the LIFE project, has been a key player in responding to AIDS awareness among the uniformed services, working with UNAIDS together with the contribution of one of our cosponsors, UNFPA.
The U.S. is the first developed country to publish its 2003 budget. Most others will be following suit in the next few months -- and I hope they will be able to take note that U.S. proposals for international HIV/AIDS assistance for 2003 are on an upward trend. The U.S., like every other donor, will need to do more if the world is to respond effectively to AIDS. American bilateral efforts on HIV/AIDS -- at USAID, Health and Human Services including CDC, and the Departments of Labor, Agriculture and Defense -- and critically now the Department of State -- will also require further strengthening to keep up with country needs. Unparalleled American know-how in such vital fields as medical training, core public health functions, and service delivery are needed more than ever to assist developing countries.
The U.S. has already proved itself willing to take its leadership role in making the required leaps forward. We would strongly encourage you to continue in that leadership role, and look forward to our continued partnership with you in meeting this great challenge.
Thank you for your attention.
This article was provided by UNAIDS. Visit UNAIDS' website to find out more about their activities, publications and services.