3
The Burden of HIV/AIDS: Implications for U.S. Interests

Key Findings

  • The expected growth in the burden of HIV/AIDS in the coming decade portends significant challenges for the United States in sustaining and expanding commitments to combating HIV/AIDS in Africa.

  • The combination of competing health and development demands, the rising cost burden of HIV/AIDS treatment, and continued resource constraints will force difficult choices and trade-offs for U.S. policy makers, made more politically sensitive by heightened expectations around U.S. commitments to HIV/AIDS prevention, treatment, and care services in Africa.

  • The epidemic in Africa is a crisis that requires both an emergency response and the forethought, planning, and sustained commitment of a long-term development intervention. Accordingly, the international community must focus now on preventive measures and human and institutional capacity building.

  • Strategies for addressing the impacts of the epidemic on U.S. interests include moving toward shared responsibility with African partner states, leveraging multilateral assets, and striving for integration and efficiency.



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3 The Burden of HIV/AIDS: Implications for U.S. Interests Key Findings • The expected growth in the burden of HIV/AIDS in the coming decade portends significant challenges for the United States in sus - taining and expanding commitments to combating HIV/AIDS in Africa. • The combination of competing health and development demands, the rising cost burden of HIV/AIDS treatment, and continued resource constraints will force difficult choices and trade-offs for U.S. policy makers, made more politically sensitive by heightened expectations around U.S. commitments to HIV/AIDS prevention, treatment, and care services in Africa. • The epidemic in Africa is a crisis that requires both an emergency response and the forethought, planning, and sustained commitment of a long-term development intervention. Accordingly, the international community must focus now on preventive measures and human and institutional capacity building. • Strategies for addressing the impacts of the epidemic on U.S. inter- ests include moving toward shared responsibility with African partner states, leveraging multilateral assets, and striving for integration and efficiency. 42

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43 IMPLICATIONS FOR U.S. INTERESTS The HIV/AIDS epidemic, first identified in 1981, remains among the greatest threats to global health, with an epicenter in the acutely affected countries of east and southern Africa (Independent Task Force Report No. 56, 2006; UNAIDS and WHO, 2009). Life-saving antiretroviral therapy (ART) was, until 2000, not acces- sible to those most in need because they were poor and lived in developing coun - tries. With the turn of the 21st century, global attitudes on this morally intolerable situation began to shift, and the International AIDS Conference in Durban in July 2000 marked a turning point with a powerful call to the international community to take responsibility for mounting an urgent response. The United States responded and, with the launch of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, established itself as a global leader in the fight against HIV/AIDS. Through PEPFAR and support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States helped galvanize an extraordinary global response to a single disease and mobilize donor and private-sector resources on an unprecedented scale to respond to the costly but critical task of addressing the HIV/AIDS crisis. Perhaps most important, this response demonstrated, in the face of considerable skepticism at the time, that dramatically expanding access to HIV/AIDS treatment was possible even in the world’s most resource-constrained settings (IOM, 2007). The U.S. campaign against HIV/AIDS has had a historic impact and is considered among the most significant and enduring achievements of the George W. Bush administration (Stolberg, 2008). Yet despite its substantial immediate impact, this emergency response has failed to halt or reverse the HIV/AIDS epidemic in Africa. Indeed, as outlined in the previous chapter and Appendix A, the burden of HIV/AIDS in Africa will continue to grow. As a result of continued high HIV incidence rates, the need for lifelong HIV/AIDS treatment has grown more rapidly than the ability to initiate new patients on ART. This growing burden will place ever higher demands on health care services, including an increasing number of ambulatory and hos - pitalized patients requiring HIV/AIDS care, an increasing number of patients requiring ART, a substantial need for additional health care workers, and a con - tinued rise in financial and other resource requirements. In the context of this growing burden, the United States and the global community will face significant challenges in sustaining and expanding com - mitments to combating HIV/AIDS in Africa. In the United States, the effects of a historic global financial crisis and a domestic deficit approaching $2 trillion will likely drive greater congressional scrutiny of spending on foreign assis - tance (Garrett, 2010). Moreover, the success of the U.S. HIV/AIDS effort has, ironically, increased attention to other African health challenges, which may drive competition in resource allocation among disease and health priorities. Beyond health, U.S. interests in Africa have expanded dramatically in the last decade, resulting in growing recognition of new challenges that confront development in such areas as food security, climate change, and unemployment and creating

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44 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA increased competition for scarce development assistance. And as the United States vies for influence in an increasingly competitive international context, it will seek new forms of engagement in Africa that provide greater political and economic leverage than traditional development and humanitarian assistance (Independent Task Force Report No. 56, 2006). As new HIV infections continue to outstrip the world’s willingness to pro - vide ART to those in need, the costs of treatment alone will consume ever larger proportions of available resources. The combination of competing health and development demands, the rising cost burden of HIV/AIDS treatment, and con - tinued resource constraints will force difficult choices and trade-offs for U.S. policy makers, made more politically sensitive by heightened expectations around U.S. commitments. As the largest single contributor to global HIV/AIDS resource flows to date, the United States will need to manage these choices and trade- offs in a way that does not compromise the global achievements in HIV/AIDS; advances U.S. interests; and strengthens current and future global capacities to respond to HIV/AIDS, as well as other global health challenges. One way for the United States to accomplish these goals while addressing its own fiscal concerns is to transition to a model for long-term sustainability. This model would be one of shared responsibility with African partner states and the broader international community. By looking to African partner states to assume increasing responsibility for leadership, management, and investment of resources in HIV/AIDS, the United States would be promoting a future of self-reliance and self-sustainability. Under this shared-responsibility model, the United States would assist African partner states in developing the leadership, academic, medical, research, and other capacities necessary to assume that responsibility effectively. Implementation of this model would necessitate greater accountability and trans- parency in the investments being made by each African partner state. Similarly, the United States would need to take an approach grounded in realism, setting ambi- tious but realistic objectives for the next 10 to 15 years and placing an urgent and consistent focus on prevention of new HIV infections. This chapter begins by describing the U.S. contributions to the global HIV/AIDS response. It next details the implications of the African HIV/AIDS burden for a variety of U.S. interests, including diplomacy, the private sector, research and academia, and foundations. The chapter then assesses the policy challenges that lie ahead for the United States in addressing these impacts and offers recommendations for moving forward in the fight against HIV/AIDS in Africa. U.S. CONTRIBUTIONS TO THE GLOBAL HIV/AIDS RESPONSE While it is important to be cognizant of the policy challenges that lie ahead, it is also important to acknowledge the significant accomplishments that have resulted from U.S. leadership in the global response to HIV/AIDS. In less than a

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45 IMPLICATIONS FOR U.S. INTERESTS decade, U.S. engagement in combating the pandemic has had a dramatic impact, particularly in Africa, the predominant focus of PEPFAR’s initial phase (Inde - pendent Task Force Report No. 56, 2006; UNAIDS and WHO, 2009). Beyond the immediate human impacts, U.S. leadership has stimulated the global community and created new awareness of and support for global health among U.S. domestic actors and institutions. Finally, the U.S. response has built new partnerships in Africa and in the broader international community that ultimately strengthen the nation’s standing in an increasingly competitive, multipolar global political environment (Pew Research Center, 2008; Ray, 2008). The human impact of U.S. investments in HIV/AIDS has been profound. At the end of 2003, the year President Bush announced the PEPFAR initiative, an estimated 100,000 people, or 2 percent of those in need, were receiving ART in Africa (WHO et al., 2009). As of September 2009, more than 2.4 million people, approximately 20 percent of those in need, had access to life-saving ART because of direct bilateral PEPFAR support (PEPFAR, 2009b). Figure 3-1 shows the cumulative years of life gained through 2009 as a result of PEPFAR support for ART. An additional 1.9 million individuals in Africa receive treatment through programs supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund, 2010a), to which the United States is the largest national con- tributor. Figure 3-2 shows that 3.7 million people in low- and middle-income countries had been supported by PEPFAR and the Global Fund as of September fig 3-1.eps FIGURE 3-1 Cumulative years of life gained through 2009 as a result of PEPFAR support for antiretroviral therapy. bitmap SOURCE: PEPFAR, 2009a.

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46 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA FIGURE 3-2 People receiving treatment with U.S. bilateral and multilateral support as fig 3-2.eps of September 2009. bitmap SOURCE: PEPFAR, 2010. 2009. In 2009, 6.4 million pregnant women in Africa received antenatal HIV counseling and testing because of PEPFAR, and 504,800 received antiretroviral (ARV) prophylaxis (PEPFAR, 2010). In 2009, PEPFAR gave direct HIV/AIDS and tuberculosis care and support to 6.9 million people living with HIV/AIDS and supported 3.5 million orphans and vulnerable children in Africa (PEPFAR, 2010). At the same time, U.S. investments in responding to HIV/AIDS have advanced U.S. interests well beyond the pandemic and laid the foundation for a more comprehensive approach to public health and broader global support. U.S. leadership contributed directly to the formation of new international initiatives such as the Global Fund, with the United States providing an early $200 million in seed money, investing considerable attention in the early formation and struc - ture of the fund (Summers, 2002) and remaining the largest single contributor to the fund since its inception. U.S. leadership has challenged other international donors to expand their investments in HIV/AIDS (see Figure 3-3) and led to the creation of numerous new public−private partnerships in the global HIV/AIDS response. Within the United States, the PEPFAR initiative created greater public aware- ness of global HIV/AIDS and support for foreign aid. Beginning with the January 2002 State of the Union Address in which he first outlined the PEPFAR initiative, President Bush made combating HIV/AIDS a signature element of his foreign assistance strategy, brought home to the public through multiple trips by the President and the First Lady to African and non-African PEPFAR countries and numerous public statements and White House ceremonies highlighting the accom- plishments of the initiative. Congressional travel, public speeches, and hearings on the initiative further raised the profile of global HIV/AIDS, and the focus within the U.S. government on HIV/AIDS helped fuel greater media coverage of the pandemic and the U.S. response. PEPFAR, which was the largest component of a near tripling of foreign assistance to Africa during the Bush administration (Fletcher, 2006), also garnered a robust bipartisan consensus within Congress in support of U.S. leadership; instigated a growing interest and activism among U.S.

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47 IMPLICATIONS FOR U.S. INTERESTS $8.7 $8.7 $6.6 $5.6 $4.3 $3.6 $2.0 $1.6 2002 2003 2004 2005 2006 2007 2008 2009 Commitments (Enacted Amounts) $7.7 $7.6 $4.9 $3.9 $3.5 $2.8 $1.6 $1.2 2002 2003 2004 2005 2006 2007 2008 2009 Disbursements FIGURE 3-3 Steady increase in international funding for HIV/AIDS from Group of Eight (G8), European Community (EC), and other donor governments, 2002−2009 (in billions fig 3-3.eps of U.S. dollars). SOURCE: Kaiser Family Foundation, 2010. faith-based communities with respect to development and poverty relief in Africa by opening up new areas of potential funding; and inspired new efforts by, among others, private foundations, public health researchers, political scientists, and development economists. Many of these groups brought to the forefront of U.S. leadership’s attention such potentially contentious issues as how the United States plans to deal with the human, health, security, and economic implications of the

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48 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA projected international trends in HIV/AIDS. These new constituencies could be valuable sources of information for building a long-term strategy to combat HIV/ AIDS, as well as influential bases of support for future efforts in global health. Although the PEPFAR initiative has maintained a singular focus on HIV/ AIDS, it has helped raise the profile of global health more broadly and cata - lyzed greater interest in the complexities of development and public health. As evidenced by adjustments to PEPFAR, new emphases in successive congres- sional authorizations, and the Obama administration’s Global Health Initiative, U.S. interventions in HIV/AIDS through PEPFAR quickly revealed the enduring challenges of gender inequity; health infrastructure deficits; shortages of health professionals; multiple disease threats; and the intersection of public health with education, economic development, and food security. PEPFAR’s early lessons have helped inform U.S. efforts going forward and have piqued the interest and commitment of a younger generation increasingly attracted to international service. Research and university partnerships have expanded, as have innova- tive public−private partnerships in health service delivery, training, and capacity building. These achievements will ultimately strengthen a long-term, comprehen- sive approach to HIV/AIDS, but also bring greater focus to the broader disease burden and structural development challenges faced by African countries. IMPLICATIONS FOR U.S. INTERESTS Implications for Diplomacy PEPFAR funding and programming have engaged U.S. researchers, public health experts, technical experts, military personnel, and others with counterparts in African governments and communities in ways that simply would not have happened absent the PEPFAR platform. These interactions have impacts beyond HIV/AIDS: they build trust, strengthen a sense of shared purpose and responsi - bility, and foster abiding relationships that ultimately redound to U.S. interests in greater global engagement and understanding. African opinion of the United States has remained overwhelmingly positive in the last decade (Pew Research Center, 2008; Ray, 2008). Many observers attribute this goodwill to U.S. lead - ership and engagement in combating HIV/AIDS. While U.S. funding for HIV/ AIDS treatment, which is, of necessity, a substantial long-term commitment, does not necessarily give U.S. policy makers greater leverage over recalcitrant authori- tarian states in Africa (Lyman and Wittels, 2010), the linkages to individuals and communities built today may offer a basis for stronger partnerships in the future. Finally, a less tangible but equally important outcome of U.S. global HIV/ AIDS efforts has been to help rebuild the positive stature and constructive role of the United States in the world—a role that draws on international partnerships, such as those with European governments, United Nations agency heads, and African leaders, to tackle the world’s most vexing transnational problems and is

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49 IMPLICATIONS FOR U.S. INTERESTS based on a core belief in the value of human dignity. Such leadership is all the more strategically important in a global context that is vastly different from that of 10 or 15 years ago, one in which the United States must compete with emerging powers and ideologies for alliance and influence. There is growing consensus, reiterated in the Obama administration’s 2010 National Security Strategy, 1 on the need to rebuild and strengthen the elements of U.S. soft power2 and build a “whole of government” approach—integrating the military, diplomacy, develop- ment, intelligence, and security arenas—to U.S. engagement in the world (The White House, 2010). By sustaining its commitment to the fight against HIV/ AIDS and bringing the multiple elements of U.S. soft power to bear—including capacities in research, education, technology, public health, private enterprise, and philanthropic institutions—the United States has at once had an impact on the pandemic and begun to burnish its credentials as a global force for positive change. Implications for the Private Sector The last decade has seen a dramatic rise in private-sector engagement on HIV/AIDS, involving advocacy, philanthropic contributions, in-country program- ming, in-kind donations, and an array of innovative public−private partnerships (IOM, 2009a). Many companies have recognized the reputational benefits of engagement and advocacy on HIV/AIDS and have found resonance with a U.S. consumer base that is socially conscious and better informed on the scope of the pandemic. Corporations with operations in Africa, particularly those with large employee bases, have recognized the potential impact of HIV/AIDS on their workforce—in absenteeism, productivity declines, health care expenditures, and workforce turnover—and on the broader communities in which they operate. Pro - vision of HIV/AIDS services to employees, their families, and the communities in which they live thus serves the purposes of both corporate social responsibility and good business sense. Through the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC), for example, corporate-sector members (such as Chevron from the United States, South Africa’s Standard Bank, and nearly 200 others) align with a network built for action and achievement in the fight against infectious disease. GBC also manages the private-sector delegation to the Global Fund (GBC, 2010). Similarly, the South African Business Coalition on HIV & AIDS 1 A document released by the Obama administration that lays out a strategic approach for advancing U.S. interests, including the security of the American people, a growing U.S. economy, support for our values, and an international order that can address 21st-century challenges. 2 Soft power denotes the theory that the United States can achieve foreign policy objectives by attracting others through the legitimacy of U.S. policies and the values that underlie them, rather than through coercion with threats or payments (Nye, 2006).

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50 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA (SABCOHA) coordinates a private-sector response to HIV/AIDS by empowering its members to plan for and effectively manage the impact of the epidemic in that nation. Its major projects include BizAIDS—a series of workshops with supportive materials to help micro and small companies reduce their opera- tional risk and make them aware of the burden of HIV/AIDS—and supply chain management projects that aim to broaden the reach of private-sector HIV/AIDS initiatives (SABCOHA, 2010). Corporate social responsibility and corporate philanthropy have brought significant resources to the global effort on HIV/AIDS, but equally important has been the rise in private−public partnerships that bring a company’s core com- petence to bear. Companies engage in public−private partnerships for a variety of reasons, including not only corporate philanthropic objectives but also more business-driven motivations. Such partnerships can improve market access and foster partnerships and goodwill with host country governments. They can also build capacities that, while benefiting partner organizations, may serve corporate interests as well, for example, in research and development; procurement, supply chain, and other logistics management; manufacturing of pharmaceuticals; adap - tation of specific technologies; laboratory building; and development of a trained and knowledgeable workforce. Ultimately, these kinds of partnerships with direct relevance to a company’s business will be the most durable and sustainable, since philanthropic giving alone will be vulnerable to financial and economic fluctua - tions (IFC, 2008). Pharmaceutical companies are vital to the fight against HIV/AIDS in devel- oping new technologies, providing an adequate supply of drugs and technolo - gies, and conducting critically needed research and development. In the early 2000s, pharmaceutical companies were a target of global HIV/AIDS activism, ultimately acquiescing to dramatic price reductions for first-line ARV drugs for the developing world. That experience may better prepare companies for future demands, but may also lead some to disinvest in research and development for products that are perceived as ultimately not serving bottom-line business inter- ests. Already there are signs of a troubling decline in commercial investments in research and development for HIV/AIDS vaccines, microbicides, and prevention (AVAC, 2010). As demand for affordable access to treatment increases in the future, com- panies will face strong downward pressure on prices for second-line therapies; new, more effective drugs; and other medical technologies. The World Trade Organization’s (WTO’s) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) includes a number of limitations and exceptions for developing countries that enable the import and manufacture of generic versions of needed drugs, although both the United States and some pharmaceutical com - panies have been accused at various times of retaliating against countries that choose to exercise these flexibilities (American University Washington College of Law Program on Information Justice and Intellectual Property, 2010). Moreover,

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51 IMPLICATIONS FOR U.S. INTERESTS as some of these exemptions for developing countries expire in 2016, tensions around intellectual property rights may increase. A number of companies have negotiated creative licensing agreements with partner states—for example, Gilead Science’s arrangements with Indian and South African manufacturers to assist them in producing tenofovir while retaining patent rights—arrangements that offer hope of expanded and more sustainable access to drugs in Africa and the rest of the developing world (Bate, 2010). Pharmaceutical companies have been strong proponents of patent protection in their attempts to protect their markets and profit margins. The result has been the perception that they place profit ahead of human welfare, a criticism that the sector has vigorously been trying to shed. Approaches to addressing this challenge include dual pricing (substantially lower prices in developing than in developed countries), voluntary licensing to developing-country generic drug manufacturers, and the creation of low-priced “generic equivalents” for low-income countries. While these approaches have increased access to affordable drugs, they have also enabled pharmaceutical companies to protect their lucrative developed-country markets and their patent provisions. In addition, pressure and support for volun- tary patent pooling are rising. UNITAID, for example, announced its intention to launch a patent pool for HIV/AIDS drugs in mid-2010, an arrangement in which branded pharmaceutical companies will voluntarily waive patent rights in low-income countries in exchange for royalty fees, allowing production by local generic manufacturers while maintaining patent rights in higher-income coun - tries. Some companies have embraced the model, although for others, questions around eligibility persist (UNITAID, 2010). For the global effort against HIV/AIDS, it will be important that private- sector involvement and investment in new drugs and technologies be maintained (see the case example in Box 3-1). But are there adequate market signals and incentives for the development and manufacture of critically important drugs and technologies? Pharmaceutical and health technology manufacturers could help define and advocate for adequate, realistic incentive structures and advance purchasing mechanisms that would ensure investment in those drugs and tech - nologies most relevant to the developing world. Organizations such as the Clinton Foundation and mechanisms such as UNITAID can serve as important interlocu - tors in these discussions. Implications for Research and Academia As noted, the HIV/AIDS pandemic and U.S. global efforts have attracted the attention of a younger generation increasingly interested in international service (Drain et al., 2007; IOM, 2009a,b). The last decade has seen an explosion of public and global health degree programs and multidisciplinary global health institutes at U.S. universities. A recent survey of 37 universities by the Coalition of Universities in Global Health revealed more than a doubling of the numbers

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52 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA BOX 3-1 Building Drug Manufacturing Capacity: A Case Example Public−private partnerships can lend themselves to building not only human resource capacity but also drug manufacturing capacity. In 1989, Merck Pharma- ceuticals, Inc. signed an agreement with the Chinese Ministry of Public Health to share Merck’s recombinant hepatitis B vaccine technology with two Chinese vac- cine manufacturers. At the time, China had one of the highest hepatitis B rates in the world and limited production of plasma-derived hepatitis B vaccines. Through this partnership, Merck provided China with the process design knowledge needed to produce the hepatitis B vaccine and the training needed to operate the new technology. The Chinese ministry constructed the manufacturing facility, purchased the equipment, and managed the production of the vaccine in the newly built facilities. Over a 3-year period, Chinese engineers, quality control scientists, and production supervisors trained at Merck facilities in the United States, learning the design process, assembly, and testing for the manufacturing equipment. The equipment was then shipped and installed in China, with Merck employees assisting in the reassembly. Sixty-five percent of China’s hepatitis B vaccines are now produced in these facilities, preventing more than 30 million chronic hepatitis B infections and related sequelae (Feinberg, 2010). This example of a pharmaceutical company building capacity for drug manufacturing can be applied to Africa and ART for HIV/AIDS. of undergraduate, graduate, and doctoral students in global health studies in just 3 years, from 2006 to 2009. In addition, these 37 universities have a com - bined 302 long-term training and education projects in 97 countries around the world. Beyond the dramatic enrollment figures, the survey found that students had formed 105 global health groups—nearly three per campus (CUGH, 2009). Universities can capitalize on this burgeoning interest and broaden the interdisci - plinary focus on global health and HIV/AIDS, encouraging inter- and intrauniver- sity collaborations and joint degree programs in public health, nursing, business, management, policy, and international affairs. Collaborations with African aca - demic institutions, through faculty and student exchanges, distance learning, and shared curricula, can enrich both U.S. universities and African counterparts (IOM, 2005, 2009b). U.S. academic institutions have played a key role in supporting and col - laborating with African researchers to make substantial contributions to the gen - eration of new knowledge, especially in the areas of clinical and public health research on HIV/AIDS. U.S.−African research partnerships are well established and have a long track record of building local capacity to conduct research. Most notable among these initiatives is the Fogarty AIDS International Training and

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59 IMPLICATIONS FOR U.S. INTERESTS strong incentives for effective and accountable partner-country governance and investment. It would also spell out U.S. obligations and commitments in a more reliable and predictable way that would facilitate future planning by host country governments. This model would resemble the compact model of the U.S. Mil- lennium Challenge Account (MCA), which, based on strong positive indicators in the areas of good governance, economic freedom, and investments in their citizens, gives partner countries far greater control over planning, allocation, and management for large-scale, 5-year grants (MCC, 2010). Because African countries fall along a broad continuum in terms of their capacity to take on “full ownership,” the shared-responsibility paradigm is intended to provide incentives to move toward greater ownership and help give African nations the capacities to do so. As with the MCA, countries with dem - onstrated political will, an emphasis on prevention, and efficient, transparent health management would receive stronger financial commitments with less control, oversight, or intervention from the United States. This approach would move the United States more in the direction of providing direct budget support. If African countries did not maintain their commitment to the binding aspects of the contract, the agreement would require a renegotiation. For the lowest-income, less-capable countries in Africa with weak leadership around HIV/AIDS, the contract model should incorporate incentives to improve their performance in order to receive increased financial support. In their relationship with these less equipped countries, the United States and other donors should play a larger role in the capacity-building aspects of the shared-responsibility paradigm, including leadership and infrastructure development, and should maintain strict oversight of budgetary support. Given the projected burden of HIV/AIDS in the coming decades, support from international donors today can help build the infrastruc - ture, political will, and institutional and human resource capacity that African nations will need to address their own country-specific HIV/AIDS needs and priorities in 2020 and beyond. The following are examples of what the United States and other partner governments might include as essential or “nonnegotiable” elements of such a contract relating to African government responsibilities: • sustained political leadership on HIV/AIDS; • ommitment to human rights and an evidence-based national response to c the epidemic; • a strong focus and voice on HIV/AIDS prevention; and • ransparent, efficient, and accountable procedures for the use of both t country-level and donor resources. Those countries deemed as lacking these essential elements would not qualify for elevated levels of financing or a contract model ceding greater control to the African partner government.

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60 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA The committee acknowledges that the achievement of these contract respon - sibilities may take time. Nevertheless, the United States should immediately make clear that it will become more selective with respect to its development partners. As less restrictive approaches to these types of institutional relation - ships have not succeeded in the past, it is the committee’s best judgment that binding contracts—in which the United States would cut back on funding in those countries that lagged in taking the path toward shared responsibility—are worth trying in the future. Making Prevention a Priority The greatest challenge to U.S. policy is the continued expansion of the epidemic in Africa. Today, incidence rates remain at alarmingly high levels, out - stripping expanded access to treatment by a ratio of 5 to 2—for every two people accessing ART for the first time, an estimated five people are newly infected (see Chapter 2 for a discussion of the treatment gap and associated resource requirements). The many achievements of the U.S. global HIV/AIDS response—and indeed the global community’s remarkable mobilization around the disease—are pro - foundly at risk if this trajectory persists. Yet despite these alarming statistics, sup- port for prevention has been among the more politically divisive issues within the Congress, with ideological sensitivities focusing on condom promotion, sex edu - cation, outreach to commercial sex workers, and injecting drug use. Should new infections in Africa continue to outstrip access to treatment, by 2020 the costs of providing treatment will far exceed the international community’s capacity and will to mobilize adequate resources. This reality must be the central driver of any future strategy on HIV/AIDS. Failure to reduce incidence rates will make the goal of universal access to treatment impossible and will result in increasingly difficult decisions about complex trade-offs and political choices in the coming decade and beyond (see Chapter 2). Chapter 2 underscores the importance of acting now to shape outcomes that will be apparent only in the long term. Failure to act decisively on HIV/AIDS pre- vention now will result in an even bleaker situation in 2020 in terms of the ever- growing need and demand for treatment resources. Prevention works best when interventions are selected on the basis of knowledge of the risks and drivers of the epidemic and when they are implemented appropriately and to scale. To this end, a better balance must be struck in the allocation of effort and resources to preven- tion and treatment (Independent Task Force Report No. 56, 2006; UNAIDS and WHO, 2009). The overlap between the two is significant (see Chapter 2) but not absolute, and in a context of finite resources and the present fiscal situation in the United States, trade-offs in resource allocation will most certainly be necessary. However, attaining the optimum balance between treatment and prevention will

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61 IMPLICATIONS FOR U.S. INTERESTS likely be a politically complex issue, as saving lives through expansion of ART is the highly visible and pressing need. Given this difficult challenge, it is important not to lose sight of the value of treatment efforts already under way while strengthening prevention messages and activities. Evidence of successes in HIV/AIDS prevention is growing; for example, the drop in new HIV infections among children between 2001 and 2009 suggests that the increase in coverage for services to prevent mother-to-child transmission of HIV is saving lives (UNAIDS, 2010). Engaging the World: Leveraging Multilateral Assets In today’s global political context, in which the United States must increase its reliance on global alliances and partnerships, strengthening and working through multilateral mechanisms are of increasing strategic importance, a point underscored in President Obama’s 2010 National Security Strategy (The White House, 2010). Accordingly, the United States will want to ensure continued inter- national engagement on HIV/AIDS and leverage the full range of capabilities and resources that the broader global community can bring to bear. Multilateral forums and institutions have been an important component of U.S. engagement on HIV/AIDS. They have been a strong asset for U.S. leader- ship in building international consensus, mobilizing resources and attention, coor- dinating global efforts, and creating and strengthening international institutions dedicated to global health and the fight against infectious disease. The Clinton administration’s engagement in the 2000 United Nations (UN) Security Council Session on HIV/AIDS in Africa, which declared HIV in Africa a threat to security (Gore, 2000), and participation in the UN General Assembly Special Session on HIV/AIDS in 2001 (UNGASS, 2001), for example, are considered watershed events in bringing greater international attention and urgency to the HIV/AIDS pandemic. Support for UNAIDS has allowed that organization to aggregate and communicate data on the pandemic effectively and to help ensure coordination and complementarity of international efforts at the country level. The U.S. voice at successive G8 summit meetings has helped generate significant resource commitments from G8 members in support of HIV/AIDS endeavors. Mechanisms such as UNITAID, which pursues price reductions for drugs and medical technologies, offer models for innovative financing and market incentives that complement U.S. bilateral funding flows. Today, as the Group of Twenty (G20) gains global traction, the United States should seek to broaden discussions on global health and encourage continued attention to HIV/AIDS. It should make a particular effort to engage emerging economic powers, including China, India, Russia, and Brazil, both in formulating multilateral strategies on HIV/AIDS and in strengthening human resource− and capacity-building collabo- rations within South−South partnerships.

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62 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA Perhaps most important in the multilateral arena, early U.S. support for the Global Fund helped initiate and sustain a new model of international financial support that is driven by country-level plans, priorities, and decision making (Global Fund, 2010b). How best to strike an appropriate balance between U.S. bilateral commitments and commitments channeled through multilateral mecha - nisms such as the Global Fund has been the source of ongoing domestic debate. Both approaches have their merits and shortcomings. Bilateral programming has allowed the United States to channel resources quickly to recipient countries; realize quick returns on short-term investments; and retain close control, oversight, and accountability in U.S. funding flows. The pressure to see quick results led to an early tendency by PEPFAR implementers to seek to bypass weak, inefficient systems in recipient countries. PEPFAR’s deci- sion to initially operate independently of existing mechanisms was key to making things happen quickly in partner organizations (as centralizing and coordinating slows down operations). In this sense, the approach was pragmatic and timely, but it did undermine host countries’ abilities to attain greater coordination. For this reason, bilateral programs have been criticized for creating parallel procurement and service delivery systems, for failing to integrate fully with recipient country priorities, and for tending toward short-term strategies that do not necessarily give priority to capacity building or sustainability. The Global Fund model, on the other hand, ensures that funding flows are more clearly aligned with country priorities as determined by a multisectoral Country Coordinating Mechanism; that recipients enjoy greater flexibility in using resources for long-term approaches and system strengthening; and that more responsibility is placed with host countries for planning, management, and institutional capacity to oversee and account for health resources. This model also has been criticized, however, for such reasons as slow disbursements of funding, reliance on in-country capacities that are overly weak or politicized, and laborious bureaucratic processes. No doubt both U.S. bilateral efforts and the Global Fund will require adjust - ments as the HIV/AIDS pandemic and country capacities evolve. By analyzing these efforts over the coming decade, the United States could capitalize on the positive aspects of both models; the committee calls for drawing on the best of both approaches. For example, as a recipient country’s capacity for delivery, management, and oversight of interventions becomes more robust, the United States may want to shift away from bilateral interventions to multilateral funding mechanisms. The committee does not expect this shift to occur overnight, but sees its progressive realization as a potentially important long-term goal of the pro - posed shared-responsibility model. The U.S. effort can help remedy inadequate infrastructure and systems only if the host country itself has the will to do so.

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63 IMPLICATIONS FOR U.S. INTERESTS Striving for Integration and Efficiency U.S. commitments to combating HIV/AIDS, and in particular the growing costs associated with expanded provision of treatment, may ultimately limit U.S. flexibility and ability to address the health and development priorities articulated by African partner states. Since 2001, HIV/AIDS has dominated U.S. global health funding. Critical investments in family planning, in maternal-child health, and in early childhood diseases have not seen increases commensurate with those in HIV/AIDS services, although they face devastating challenges in virtu - ally every African state. The Obama administration’s expanded Global Health Initiative budget for 2010 includes significant increases in family planning and maternal-child health, but PEPFAR programming is expected to make up some 77 percent of overall funding flows (Kaiser Family Foundation, 2009). Accusations of “AIDS exceptionalism” may intensify, especially if expen - ditures on ARV drugs consume an ever larger proportion of U.S. global health spending. Policy makers may face increasing pressure from U.S domestic inter- ests, donor partners, and African partner governments to address more directly health priorities beyond HIV/AIDS and to support multipurpose investments in health system strengthening.4 In a world of finite financial resources, policy makers must confront difficult trade-offs, including that between focusing on life- prolonging ARV drug purchases and envisioning HIV/AIDS in a broader context of pressing and equally devastating disease challenges. Just as striking the right balance between prevention and treatment efforts will be difficult for governments, striking the appropriate balance between funding for HIV/AIDS and other diseases will be an ongoing and sensitive political challenge. Identifying and strengthening synergies between HIV/AIDS interventions and other health objectives may alleviate some of this difficulty. To this end, implementers on the ground might proactively seek opportunities for integration of HIV/AIDS services and capacities with other disease and develop - ment interventions. Funders could help as well by identifying and developing approaches that better integrate HIV/AIDS interventions with other critical health priorities. For the U.S. government, this might mean better integration of global health efforts and improved alignment with host country priorities. By giving greater priority to those interventions that build enduring health care capacity, the United States can enable African partners to manage the multiple challenges their citizens confront. An even broader challenge will be balancing HIV/AIDS and other health interventions with other forms of U.S. development assistance. In the course of the last decade, Africa has moved more firmly into the mainstream of U.S. policy with an expansion of U.S. interests and investments; a changing notion of what 4 An assessment of positive, negative, or neutral spillover effects of HIV/AIDS-targeted programs on health systems is discussed in Chapter 4.

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64 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA constitutes security; and greater competition for influence and alliance in an increasingly globalized, multipolar international context. Engagement on HIV/ AIDS has been an important component of expanded U.S. relations with Africa, but only one of many strands of additional attention and concern. Support for HIV/AIDS programming represents a growing proportion of U.S. development assistance to Africa overall. In many African countries, HIV/AIDS and other health funding is by far the largest component of U.S. assistance. In Nigeria, HIV/ AIDS constitutes 77 percent of U.S. State Department/U.S. Agency for Interna - tional Development (USAID) assistance, and overall health programming con - stitutes 89 percent of assistance (USAID, 2009b); in Rwanda, the corresponding proportions are 60 percent and 79 percent (USAID, 2009c); in Kenya, 77 percent and 88 percent (USAID, 2009a); and in Uganda, 64 percent and 83 percent (USAID, 2009d).5 Investments in agriculture, in education, and in democracy and governance are dwarfed by HIV/AIDS funding, although each of those areas intersects in significant ways with public health and is viewed by many African governments as an important development priority in its own right. Further, expanded investments in HIV/AIDS and health will ultimately yield diminishing marginal returns if other critical developmental priorities—employment, food security, economic growth, education, and water and sanitation—remain unad - dressed. Domestic critics may argue that U.S. efforts in international development are too heavily skewed toward HIV/AIDS and that areas of pressing international and foreign policy concern are being neglected. HIV/AIDS interventions, some observers argue, may be popular among African partner countries, but they do not necessarily lead to greater leverage or influence (Lyman and Wittels, 2010). U.S. policy makers are understandably reluctant to use support for HIV/AIDS services or other forms of humanitarian assistance as a political bargaining chip. But the domination of HIV/AIDS within U.S. foreign assistance flows means there is little room for other forms of engage - ment that might provide that leverage. The 2010 National Security Strategy promises that “the United States will work to remain an attractive and influential partner by ensuring that African priorities such as infrastructure development, improving reliable access to power, and increased trade and investment remain high on our agenda” (The White House, 2010). Similarly, the administration has announced global food security as a top priority, with President Obama prom - ising $3.5 billion to strengthen food security and enlisting the G8 to give greater priority to assisting poor farmers (Baker and Dugger, 2009; Council on Foreign Relations, 2009). A renewed focus on agricultural development through the Feed the Future initiative was welcomed by development experts and African leaders alike, who have seen investment in agricultural development fall from a high of 18 percent of official development assistance in 1979 to 3.5 percent in 2004 (World Bank, 2008). But unless the overall flow of U.S. assistance increases dra - 5 Percentages calculated using fiscal year 2010 estimates.

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65 IMPLICATIONS FOR U.S. INTERESTS matically, there will be little room for these new initiatives—or for other major initiatives not yet envisioned—given current commitments to PEPFAR and global health. U.S. support for HIV/AIDS assistance to Africa is authorized primarily by the 1961 Foreign Assistance Act as well as the PEPFAR legislation, which was reauthorized in 2008 for an additional 5 years.6 The 1961 Foreign Assistance Act was last reauthorized in 2002, and the Congress is currently designing new legislation to update the act. This overhaul offers an opportunity to incorporate some of the steps toward shared responsibility that are described in this report. RECOMMENDATIONS Recommendation 3-17: Emphasize a new contract approach that incen- tivizes shared responsibility. The Office of the Global AIDS Coordinator should emphasize, develop, and implement a more binding, negotiated con - tract approach at the country level. The contract should incentivize shared responsibility whereby additive donor resources are provided to a large extent as matching funds for partner countries’ investments of their own domestic resources in health. Such matching funds should not be a uniform ratio; rather, the ratio should vary based on each African partner’s ability to contribute. Recommendation 3-2: Develop a U.S. roadmap for HIV/AIDS in 2020. The White House and the Office of the Global AIDS Coordinator should develop a U.S. roadmap for HIV/AIDS in 2020 incorporating a model of U.S.−African shared responsibility that makes prevention a priority and bal- ances bilateral and multilateral funding. The roadmap should: • ive priority to prevention as a central tenet of a sustainable long-term G response to the HIV/AIDS epidemic. To this end, steps should be taken to: − trengthen country-level surveillance and monitoring of the epi- s demic to ensure adequate and reliable data with which to estimate incidence rates (see Recommendation 2-1); − ncourage the UNAIDS-recommended approach of targeted preven- e tion strategies tailored to in-country priority populations, applying evidence-based public health approaches; − ncrease access to and coverage of synergistic combinations of i known effective prevention technologies; and − expand research and investments in new prevention technologies. 6 Tom Lantos and Henry J. Hyde United States Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, Public Law 110-293 (July 30, 2008). 7 See counterpart Recommendation 4-3 directed to African countries (Chapter 4).

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66 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA • trike an optimal balance between bilateral and multilateral mecha- S nisms for HIV/AIDS funding. The United States should seek to capi- talize on the strategic complementarity of bilateral and multilateral funding flows and engagement and work to strengthen multilateral institutions toward that end. U.S. policy makers should encourage greater involvement of emerging economic powers, including Brazil, China, Russia, and India, in international forums and activities on HIV/ AIDS and in strengthening of South−South collaborations addressing the epidemic. Recommendation 3-3: Integrate health and development. Congress should support greater integration of U.S.-funded HIV/AIDS interventions with broader U.S. global health initiatives and African countries’ comprehensive development plans. As Congress contemplates an overhaul of the U.S. For- eign Assistance Act, it should seek to encourage greater flexibility in devel- opment funding to ensure that assistance for both health and development meets recipient country priorities. REFERENCES Accordia Global Health Foundation. 2010. Return on investment: The long-term impact of building healthcare capacity in Africa. Washington, DC: Accordia Global Health Foundation. AHF (AIDS Healthcare Foundation). 2010. AHF to roll out “Who’s better on AIDS?” Obama/Bush comparison ad campaign in DC. http://www.aidshealth.org/news/press-releases/ahf-president- obama-fails.html (accessed May 20, 2010). AIHA (American International Health Alliance). 2005. HIV/AIDS twinning center frequently asked questions. http://www.twinningagainstaids.org/faq.html (accessed November 2, 2009). American University Washington College of Law Program on Information Justice and Intellectual Property. 2010. Complaint to UN special rapporteur on the right to health, July 19, 2010. AVAC: Global Advocacy for HIV Prevention. 2010. AVAC report 2010: Turning the page. New York: AVAC. Baker, B., and C. Dugger. 2009. Obama enlists major powers to aid poor farmers with $15 billion. The New York Times. Bate, R. 2010. Solving an innovator’s dilemma. The American: Journal of the American Enterprise In- stitute. http://www.american.com/archive/2010/may/solving-an-innovators-dilemma (accessed May 20, 2010). The Bill & Melinda Gates Foundation. 2010. Overview: The Gates Foundation’s HIV strategy. http:// www.gatesfoundation.org/hivaids/Documents/hiv-strategy-overview.pdf (accessed September 7, 2010). Clinton Foundation. 2010. Why global health? Our approach. http://www.clintonfoundation.org/ what-we-do/clinton-health-access-initiative/our-approach (accessed September 7, 2010). CUGH (Consortium of Universities for Global Health). 2009. Saving lives: Universities transforming global health. San Francisco, CA: CUGH. Council on Foreign Relations. 2009. Obama’s food security initiative in Africa. http://www.cfr.org/ publication/20020/obamas_food_security_initiative_in_africa.html (accessed October 6, 2010).

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69 IMPLICATIONS FOR U.S. INTERESTS Ward, J. 2007. Bush to visit Africa to see fruit of U.S. AIDS funding. The Washington Times, De- cember 1. Whiteside, A., and A. Whalley. 2007. Reviewing “emergencies” for Swaziland: Shifting the paradigm in a new era. Mbabane and Durban: National Emergency Response Council on HIV/AIDS (NERCHA) and Health Economics & HIV/AIDS Research Division (HEARD). WHO, UNAIDS, and UNICEF. 2009. Towards universal access: Scaling up priority HIV/AIDS inter- ventions in the health sector, progress report 2009. Geneva: WHO. World Bank. 2008. World development report: Agriculture for development. Washington, DC: World Bank. Zakumumpa, H. 2010. Thousands risk early death as AIDS care centres turn away new patients. The Independent.