The International Response to HIV/AIDS
(July 2002) With its poverty and underdeveloped health systems and other infrastructures, it is certain that Africa will not be able to bring the HIV/AIDS epidemic under control as rapidly as it needs to if the continent has to rely only on its own resources. Financial support and technical assistance from the international community is key to alleviating the terrible toll that the epidemic is taking on the people of Africa.
During the early years of the epidemic, the World Health Organization (WHO) became a leading organization in the international response to the HIV/AIDS epidemic. WHO played a leading role in helping countries organize national AIDS programs and in developing mid-term, strategic plans. Debate lingers over whether WHO responded as vigorously as necessary to the epidemic, but, in any case, the United Nations system decided by the mid-1990s that it needed a greatly expanded program.
The Role of UNAIDS
In 1996, the UN organized the Joint United Nations Programme on HIV/AIDS (UNAIDS),1 which now has seven cosponsoring bodies: the United Nations Children’s Fund (UNICEF); the United Nations Development Programme (UNDP); the United Nations Population Fund (UNFPA); the United Nations International Drug Control Programme (UNDCP); the United Nations Educational, Scientific and Cultural Organization (UNESCO); WHO; and the World Bank. UNAIDS has a secretariat in Geneva, a professional staff of almost 130, and an annual budget of about US$60 million.
UNAIDS is designed to be the leading advocate for an expanded worldwide response to HIV/AIDS. As such, it is designed to encourage and coordinate action, rather than to function as a direct funding or implementing agency. While this is an important role, African countries often find it easier to work with agencies that have their own implementing budgets.
One of the important recent initiatives undertaken by UNAIDS is the International Partnership Against AIDS in Africa (IPAA). IPAA has its roots in a 1999 dialogue between the Organisation for African Unity (OAU) and UNAIDS. IPAA is a partnership of governments, civil society organizations, and national and international organizations working against AIDS. African governments lead the effort and are responsible for developing broad-based, national responses.
IPAA claims it has had a significant start. For example, IPAA has extended financial, technical, and management support to strengthen national AIDS councils in several countries. It has also assisted in the development of new national strategic plans. When IPAA was organized in late 1999, 14 countries had completed national strategic plans. Now, 30 countries have completed plans and another 14 are underway. IPAA has also been involved in mobilizing political leadership, securing additional funding from national governments, and promoting community involvement and district-level action.
UNAIDS also organized the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), held in New York in June 2001. This was an historic event, marking the first time that a General Assembly meeting was devoted to a health issue. More than 3,000 delegates attended UNGASS, including several heads of state or government and ministers of health. HIV/AIDS activists were also well represented.
The UNGASS delegates adopted a Declaration of Commitment on HIV/AIDS that identifies the HIV/AIDS epidemic as a devastating global emergency, and, in particular, describes the African epidemic as a state of emergency that requires urgent and exceptional national, regional, and international action. The Declaration of Commitment calls for intensified action that would lead to a 25 percent overall reduction in HIV prevalence among people 15 to 24 years old by 2005 in the most affected countries.
As is typical of UN conferences and resolutions, the UNGASS Declaration of Commitment has no funding or enforcement mechanisms, leading some critics to question its ultimate usefulness. Nevertheless, the document serves as a blueprint for intensified action and provides an intellectual and policy framework for greatly intensified action.
With the increasing understanding of the devastating impact that the HIV/AIDS epidemic is having in Africa and the expanding international commitment to do something about it, much recent discussion has focused on funding levels that will be required to support an adequate programmatic response to the African epidemic. A huge difference between estimated needs and actual spending continues to plague efforts to address the problem.
UNAIDS estimates that the region needs US$3 billion to US$4 billion per year for the next decade or even longer to mount an effective response. By contrast, current annual expenditures on HIV/AIDS in Africa are in the US$300 million to US$400 million range, or less than 10 percent of estimated requirements. A major question now facing the international community is how to eliminate this gap by the year 2005.2
African governments may have to carry a larger proportion of the burden themselves. For many years, donor funding dominated HIV/AIDS programs. Now, while the international community may still be providing the preponderant proportion of funds, African governments may be forced to play a much more significant role to help narrow the funding gap.
The declaration adopted at the African Summit on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases in April 2001 calls on African governments to set a target allocation of at least 15 percent of their annual national budgets to strengthen the health sector, a pledge reiterated in the UNGASS Declaration of Commitment. (The target is 15 percent of annual national budgets for the entire health sector, only a portion of which would go directly to HIV/AIDS programs.) UNAIDS estimates that if African countries were able to commit 0.25 percent to 0.50 percent of their gross domestic products to HIV/AIDS programs, the African national contribution could reach US$0.8 billion to US$1.6 billion annually.
Most Heavily Indebted Countries Are Hardest Hit
Debt relief is among the important mechanisms being used to try to help African countries mobilize the funds needed to fight HIV/AIDS across the continent. Many of the African countries most affected by the HIV/AIDS epidemic are also among the world’s most heavily indebted countries. By 2000, the 41 most heavily indebted poor countries had an accumulated debt stock of more than US$200 billion. Zambia was spending more on debt service than it was on public health and education combined. Similarly, in Nigeria, debt payments exceeded health and education expenditures.
The idea behind debt relief is that the lending institutions or countries would forgive or cancel existing debts. In exchange, the countries would use the funds they save for HIV/AIDS and other poverty reduction programs. Probably the most important effort is the Heavily Indebted Poor Country (HIPC) initiative developed by the World Bank and International Monetary Fund. While African countries have not yet exploited all the possibilities of debt relief as a potential way of mobilizing new HIV/AIDS resources, sufficient progress has been made to illustrate that this is a real possibility.
For example, in late 2000, Zambia qualified for sufficient debt relief under the HIPC initiative to save US$52 million annually on debt servicing. About half of this has been designated for social sector programs, including HIV/AIDS. In mid-2000, Burkina Faso qualified for HIPC debt relief on about US$700 million of its debt stock, which translates into about $37 million per annum on debt servicing. Burkina Faso is using at least some of these savings to fund its National Strategic Framework Against HIV/AIDS 2001-2005. Overall, the World Bank reports that debt relief packages are now in place for 26 countries — 22 from Africa — as of May 2002. Another 10 African countries were actively developing HIPC agreements. The World Bank notes that social spending for these countries is projected to rise from an average of 6 percent of gross domestic product in 1999 to 9 percent of GDP in 2002. As a share in government revenue, social spending would increase from 37 percent before HIPC relief to an average of 55 percent following HIPC relief.3 How much debt relief really contributes to HIV/AIDS funding remains to be seen, but it is at least one creative initiative aimed at closing the funding gap with internal resources.4
Even if African countries are able to achieve designated funding targets for HIV/AIDS, external assistance of up to $3.2 billion annually will still be required for many years. The international community is trying to mobilize the needed funds. In April 2000, United Nations Secretary-General Kofi Annan called for the establishment of a global fund to expand rapidly and significantly the resources available to address HIV/AIDS and other global diseases. The initiative, known as the Global Fund to Fight AIDS, Tuberculosis and Malaria, has received commitments from national governments, private foundations, companies, and even individuals amounting to some US$2 billion. At the end of April 2002, the Fund announced its first round of grants to prevent and treat the three diseases in severely affected countries, awarding US$378 million over two years to 40 programs in 31 countries, with some 60 percent of the funds going to HIV/AIDS projects. Overall, some 52 percent of the funds have been devoted to Africa.5
Other international organizations are also intensifying efforts to mobilize additional resources to combat HIV/AIDS in Africa. For instance, in February 2002, the World Bank announced approval of an additional US$500 million in no-interest loans for the second stage of its Multi-Country HIV/AIDS Program (MAP) for Africa. This brings the amount of the Bank’s no-interest HIV/AIDS lending to Africa through this program to $1 billion for the financial year.
Bilateral funding — monies provided directly by national governments to other countries — is also an important source of support for HIV/AIDS efforts. The United States has been the leader in providing bilateral funding to combat the HIV/AIDS epidemic in sub-Saharan Africa and elsewhere, though critics caution that the total amount is still small both relative to world needs and to the country’s national capability to contribute.6 The Department of State reports that the U.S. is the largest bilateral donor of HIV/AIDS assistance, providing nearly half of all international HIV/AIDS funding.7 For FY2001, U.S. bilateral assistance for international HIV/AIDS was programmed at US$466 million, for a range of efforts implemented through the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the Department of Defense, and the Department of Labor. More recently — this June — U.S. President George Bush pledged US$500 million over three years to help prevent HIV-infected mothers in parts of Africa and the Caribbean from transmitting the virus to their infants.
As with much of the response to HIV/AIDS, the U.S. financial commitment has surged in recent years. For example, USAID funding increased gradually from US$119 million in 1997 to US$139 million in 1999, but then leaped to US$200 million in 2000 and US$340 million in 2001. What is also noteworthy is that the U.S. international contribution is still dwarfed by the amount of resources available for domestic programs. For example, the National Institutes of Health’s (NIH) budget for HIV/AIDS research in FY2002 is scheduled to be US$2.5 billion.
In sum, the magnitude of the HIV/AIDS epidemic is such that Africa is financially and technically dependent on the donor community to generate sufficient funds to mount an appropriate response to the epidemic. In recent years, actual spending on HIV/AIDS programs in sub-Saharan Africa has only been a fraction of real annual needs.
Both the international and the internal African responses have intensified over the past few years. UNGASS was a landmark event. U.S. and other bilateral and multilateral funding has surged and the organization of the Global Fund for AIDS, Tuberculosis and Malaria provides a new mechanism for mobilizing and distributing large sums of money to combat the epidemic. Debt relief is proving an effective mechanism to generate new internal resources in many African countries. For all the new initiatives, available resources still fall vastly short of what is needed to fund efforts in the African region. An even greater international response is required. HIV/AIDS activists remain concerned that the focus of the world on the antiterrorism campaign mounts yet a new hurdle to mobilizing sufficient resources to combat the epidemic.
- Much valuable information on UNAIDS, International Partnership Against AIDS in Africa, United Nations General Assembly Special Session on HIV/AIDS, Global Fund for AIDS, Tuberculosis and Malaria, and many other topics can be found at www.unaids.org.
- See, for example, UNAIDS, “Mobilizing Billions to Fight AIDS in Africa: The Way Forward” (Geneva: UNAIDS, 2001). The accompanying PowerPoint presentation with the same name, prepared for the Conference of African Ministers of Finance in Algiers in May 2001, can also be downloaded from the UNAIDS website. See also B. Schwartlander et al., “Resource Needs for HIV/AIDS,” Science 292 (June 29, 2001): 2434-2436.
- World Bank, “Heavily Indebted Poor Countries (HIPC) Initiative: Status of Implementation” (Washington, DC: World Bank: April 14, 2002).
- Countries trying to qualify for debt relief have to prepare an interim Poverty Reduction Strategic Plan (PRSP) and then the involved parties accept a final Poverty Reduction Strategic Plan as part of the debt relief agreement. The PRSPs offer a blueprint on how funds freed for social funding by debt relief are actually going to be used. To date, HIV/AIDS has not been a centerpiece of most PRSPs and therefore it remains to be seen exactly how much debt relief is going to contribute to closing the funding gap.
- The Global Fund to Fight AIDS, Tuberculosis & Malaria, “Global Fund to Fight AIDS, Tuberculosis and Malaria Announces First Grants,” accessed online at www.globalfundatm.org, on June 26, 2002.
- For a review of United States Agency for International Development programs see Leading the Way: USAID Responds to HIV/AIDS (Washington, DC: TvT Associates, Inc., 2001). This document was prepared with USAID funding and is a promotional document. It contains much valuable information on both the epidemic and the USAID response.
- U.S. Department of State reports on international health affairs can be found at www.state.gov.
Thomas Goliber is a senior fellow at The Futures Group International, an international development organization headquartered in Washington, D.C. and Bath, United Kingdom. He is a reproductive health policy specialist with expertise in sub-Saharan Africa, a region where he has been working for more than two decades.