HIV/AIDS in Sub-Saharan Africa

• 28.5 million living with HIV/AIDS at end-2001
• 2.2 million deaths in 2001
• 3.5 million new infections in 2001
• 12 countries have infection rates of 10 percent or more among 15-49 year olds
• 11 million AIDS orphans in 2001; UNAIDS predicts 20 million by 2010

Seventy-five percent of those living with HIV/AIDS are in sub-Saharan Africa. The pandemic is changing the demographic structure of Africa and wiping out life expectancy gains. In many African countries, life expectancy is dropping from more than 60 years to around 45 years. In Botswana, it has dropped to 39; without AIDS, it is estimated to have been 72 years.

The estimates of the impact of HIV/AIDS on economic growth rates vary but the trend is clear. A World Bank researcher estimated that the average 0.4% per capita income growth rates Africa achieved in 1990-1997 would have been 1.1% per year without HIV/AIDS. In countries with prevalence rates around 20%, the effect is more dire; GDP growth rates will be about 2.6% less than they would have been without the epidemic.

While the long-term effect of the pandemic is not known, studies to date paint a grim picture. According the to the World Bank, "Labor productivity is likely to drop, the benefits of education will be lost, and resources that would have been used for investments will be used for health care, orphan care, and funerals. Savings rates will decline, and the loss of human capital will affect production and the quality of life for years to come." By 2005, South Africa, for example, is projected to lose 11% of its workforce to AIDS; Zimbabwe nearly 20%.

This crushing HIV burden comes on top of Africa’s significant share of global health problems generally. For example, 80 percent of the world’s tuberculosis cases occur in Africa and respiratory infections, parasitic diseases, diarrheal diseases, and malaria remain major killers of children and adults across the continent.

U.S. Interests

The U.S. has recognized that HIV is not only a threat to the health and economic well-being of Africans but a national security issue as well. As HIV/AIDS strains the economic, social and security fabric of Africa, it affects U.S. policy interests across the board. HIV undermines hard-fought development gains and can destroy communities and destabilize regions. It is also disproportionately affecting African militaries, with prevalence rates in some armed services possibly reaching 50%. The severe ripple effects of HIV/AIDS, if not contained, pose a clear threat to U.S. interests in a peaceful, prosperous and stable Africa.

Early intervention is important. As prevalence rates grow, per capita costs of addressing the epidemic also grow, thereby making a strong case for early intervention. When HIV rates are below 5%, the cost of programs is about $3 per capita. Once the rates hit 15%, the cost becomes $10-$12 per capita (this does not include anti-retroviral treatment).

The U.S. focuses its programs on prevention, care and support through multi-faceted programs that include preventing new infections, reducing risky behavior, social marketing of condoms, preventing mother-to-child transmission, voluntary counseling and testing, treating other sexually transmitted diseases, and programs to address the needs of AIDS orphans and communities caring for them. The U.S. is also supporting programs to strengthen vaccine research and testing and overall health system capacities. USAID and HHS (CDC) administer the bulk of USG resources but DoD and DoL have targeted programs to address HIV/AIDS in the military and workplace, respectively.

The issue of treatment, especially access to anti-retroviral drugs at affordable prices has been at the forefront of the AIDS debate domestically and internationally. With encouragement from the U.S., a number of pharmaceutical companies have responded by agreeing to make their anti-retroviral drugs available in developing countries at greatly reduced cost. While cost is an important issue and even reduced costs pose a challenge for very poor African countries, delivery/monitoring challenges associated with poor health care infrastructure are as important a consideration as cost. WTO Doha Ministerial Declaration on TRIPS and Public Health clarified the flexibility the TRIPS agreement offers in addressing health care emergencies, while retaining the integrity of the agreement and recognizing that TRIPS, and the incentives it offers for innovation and research, is part of the solution to health care crises. At their recent summit in Kananaskis, G-8 leaders reiterated their commitment to continue to promote the availability of an adequate supply of life-saving medicines in an affordable and medically effective manner.

The USG is the single largest donor to international AIDS efforts. The FY 02 budget for the USG’s international HIV/AIDS programs is about $800m, including $200 million of our $500 million pledge to the Global Fund. In FY ’03, the request is about $1.1 billion. Just over half of U.S. support for bilateral HIV/AIDS programs goes to Africa. The US bilateral program to date has focused about 70% of its resources on prevention efforts.

In June, President Bush announced a major new initiative to accelerate and expand U.S. efforts to fight mother and child HIV infection. The $500 million initiative will target 12 countries in sub-Saharan Africa and the Caribbean. Within five years, the goal is to treat one million women and reduced mother-to-child transmission by 40 percent. The initiative includes elements to improve the health care delivery systems by pairing U.S. hospitals with African clinics, facilitating the implementation of prevention, care and treatment programs, and providing AIDS drugs where appropriate. Kenya, South Africa, and Uganda and Nigeria are slated to receive support in FY 2002; Nigeria will be added in FY 2004.

The U.S. is also the major contributor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The U.S. has pledged $500 million to the Fund, which announced its first round of grants in April. The Board approved grants worth $378 million over two years for 40 programs in 31 countries. Another 18 proposals worth $238 million were put on a fast track for approval once some modifications are made to meet Fund criteria. About half of the value of the approved grants are for countries in sub-Saharan Africa. The Fund has issued its second call for proposals and will announce additional grants in January 2003.