related to AIDS prevention and control in Africa. In 1985, it established a Special Programme on AIDS, later renamed the Global Programme on AIDS (WHO/GPA), and began to work with ministries of health in African countries to develop their short-and medium-term plans to fight the epidemic. Furthermore, WHO/GPA offered extensive technical assistance to newly created national AIDS control programs in Africa. It provided as many as four resident expatriate advisers to some programs, all of whom were directly involved in the day-to-day implementation of HIV/AIDS-prevention efforts. Now, five additional United Nations organizations—the United Nations Children's Fund (UNICEF), the United Nations Development Program (UNDP), the United Nations Population Fund (UNFPA), the United Nations Educational, Scientific and Cultural Organization (UNESCO), and the World Bank—have made firm commitments to AIDS activities. As a result, the executive board of WHO recently recommended the creation of a joint United Nations Programme on AIDS (UNAIDS) to improve coordination among the various organizations and to boost the global response.

Fourth, for a number of reasons, current AIDS-prevention efforts may be reaching a plateau. Some donor agencies and governments in developed countries are beginning to suffer from "donor fatigue," induced partly by the realization that the epidemic is unlikely to affect the developed world as badly as was first feared, and partly by an inability to see how the money and effort expended on prevention thus far have affected the course of the epidemic. Many international donors do not want to commit themselves to providing care for the growing number of AIDS patients in countries where expenditures on health averaged less than US $15 per capita in 1990.

The most visible consequence of donor fatigue in Africa is the withdrawal of resident WHO/GPA advisers from national AIDS control programs. Because of financial constraints, WHO/GPA has been unable to sustain its initial level of support, and has been forced to reduce the number of personnel in virtually every country (see also Chapter 7). This reduction in assistance has had enormous costs, in both human and economic terms. It also increases the urgency for action by Africans and their governments. All national AIDS control programs are struggling to recover from the major withdrawal of WHO/GPA technical advisers and the concomitant reduction in funds and guidance, which have left an enormous gap in their ability to implement successful prevention programs. Instead of building on ten years of prevention experience, many programs are being forced to undergo a second infancy, and are repeating mistakes and relearning lessons (see Appendix A).

A fifth reason underscoring the need for immediate action is that AIDS is believed to be an especially costly disease, although the point has proved difficult to document. The economic consequences of AIDS stem from the direct and indirect costs to individuals, aggregated to the macro level. The direct cost of the disease is defined as the lifetime cost per patient for medical care. Estimates of this cost in Africa vary widely, from US $64 to $11,800 (see Chapter 6). The



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