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Excerpts: Presidential Report on Children Orphaned by AIDS in Africa (Says leadership, sustained investment can save millions)


WASHINGTON - "AIDS is the leading cause of death in Africa," but "determined leadership and sustained investment have made, and continue to make, an extraordinary difference and will save millions of lives," says a report issued on July 19 by the White House Office of National Aids Policy.
The report, "A Presidential Mission on Children Orphaned by AIDS in sub-Saharan Africa: Findings and Plan of Action," made plain that besides being a serious health issue, the spread of AIDS across the continent also looms as a trade and investment issue, and poses security, stability, and crime problems.

The report quotes Professor Jeffrey Sachs, director of the Harvard Institute for International Development, who said that "a frontal attack on AIDS in Africa may now be the single most important strategy for economic development."

Citing data from the Southern Africa AIDS Information Dissemination Service, the report estimated that the economies of sub-Saharan Africa will be reduced by 25 percent in the next 20 years if current trends prevail.

"In fact," the report said, "this AIDS-related economic impact has already begun" to be felt.

"According to the Economist," the report added, "a recent study in Namibia estimated that AIDS cost the country almost 8% of GNP in 1996 and by 2005, Kenya's GNP will be 14.5% smaller than it would have been without AIDS. In Tanzania," the report said, "The World Bank predicts that GNP will be 15-25% lower as a result of AIDS. The South African government estimates that AIDS costs the country 2% of GNP each year."

Despite such statistics, however, the report said that "determined leadership and sustained investment have made, and continue to make, an extraordinary difference and will save millions of lives."

"Leadership matters" in fighting the AIDS epidemic, the report continued, but it asserted also that "making a difference in Africa and in other highly impacted areas requires broader political
commitment, enhanced community mobilization, and, most urgently, increased resources."

In 1998, the report noted, spending on AIDS in Africa totaled just $165 million, an amount the report termed "woefully inadequate."

In the year 2000 budget, a Clinton administration initiative is seeking an additional $100 million for the global battle against AIDS, with concentration in four key areas:

  • containing the AIDS pandemic ($48 million);
  • providing home- and community-based care ($23 million);
  • caring for children orphaned by AIDS ($10 million); and
  • strengthening prevention and treatment ($19 million).

Following are excerpts from the report:

(begin excerpts)

Report on the Presidential Mission on Children Orphaned by AIDS in Sub-Saharan Africa: Findings and Plan of Action

The White House
July 19, 1999

Summary

1. AIDS is the leading cause of death in Africa. In the next decade, 40 million children will become orphans -- by losing one or both parents to AIDS.

2. AIDS is wiping out decades of progress on a variety of development fronts, including per capita GNP, infant mortality, and life expectancy.

3. AIDS is not just taking lives, it is threatening economies, stability, and civil society.

4. As goes Africa, so will go India, South-East Asia, and the Newly Independent States of the former Soviet Union, and by 2005, more than 100 million people worldwide will have been infected with HIV.

5. We know what works. Scaling up these proven interventions to meet the magnitude of this crisis is essential.

6. Leadership and resources are desperately needed if we are to turn the tide.

Background

On December 1, 1998, World AIDS Day, President Clinton highlighted the growing global tragedy of children orphaned by AIDS in sub-Saharan Africa. At that time, he directed Sandra Thurman, Director of the Office of National AIDS Policy, to lead a fact-finding mission to the region and to report back to him with recommendations for productive action. From March 27 through April 5, Director Thurman led a Presidential Mission to Zambia, Uganda, and South Africa. Director Thurman was accompanied by Representatives Jackson-Lee, Kilpatrick, and Lee, and senior staff from the offices of Senators Hatch, Helms, and Kennedy, and Representative Pelosi. Also joining the Mission was a group of community leaders from outside of government including Mayor David Dinkins, Bishop Felton May, and William Harris. (Attachment A: Trip Manifest)

The goals of the trip were to:

  • investigate the extent of the AIDS crisis in sub-Saharan Africa particularly as it relates to children orphaned by AIDS;
  • identify proven and promising interventions; and,
  • promote leadership both at home and abroad.

"I believe that if we could reach to the heart of people, we would always do better in dealing with problems, for our mind always conjures a million excuses. We cannot restore to (these children) all they have lost, but we can give them a future -- a foster family, enough food to eat, medical care, a chance to make the most of their lives by helping them to stay in school."

President Clinton, World AIDS Day 1998

Information for this report was gathered from meetings with African presidents, government ministers, donors, experts, providers, children, parents, and community leaders. In addition, site visits were made to a wide variety of community-based programs serving children and families affected by AIDS. Both the meetings and the visits provided an important perspective on the problem regarding actions taken, lessons learned, and further progress needed. (Attachment B: Groups Visited)

Findings

The Problem:

AIDS in sub-Saharan Africa is a plague of biblical proportions.

AIDS in sub-Saharan Africa, notes The United Nations, is the "worst infectious disease catastrophe since the bubonic plague." Deaths due to AIDS in the region will soon surpass the 20 million people in Europe who died in the plague of 1347 and the more than 20 million people worldwide who died in the influenza epidemic of 1917. Over the next decade, AIDS will kill more people in sub-Saharan Africa than the total number of casualties lost in all wars of the 20th century
combined.

While sub-Saharan Africa accounts for only one-tenth of the global population, it currently carries the burden of more than 80% of AIDS deaths worldwide:

  • In the past decade, 12 million people in sub-Saharan Africa have died of AIDS -- one-quarter of them children -- and each day AIDS buries another 5,500 men, women and children.
  • In 1998, AIDS was the largest killer and accounted for 1.8 million deaths in sub-Saharan Africa, nearly double the 1 million deaths from malaria and eight times the 209,000 deaths from tuberculosis.
  • By 2005, the daily death toll will reach 13,000 people with, nearly 5 million AIDS deaths in that year alone.

And yet, the pandemic rages on:
  • In sub-Saharan Africa, more than 22 million adults and 1 million children are currently living with HIV.
  • Every day, 11,000 additional people are infected -- one every 8 seconds.
  • Since the Administration launched this effort on World AIDS Day (December 1, 1998), more than 2.5 million people in sub-Saharan Africa have been infected with HIV, 368,000 in South Africa alone.
  • Half of all new infections in southern Africa, and 10% of new infections worldwide, occur in South Africa, now experiencing the fastest growing AIDS disaster.

Fragile health care systems are already buckling beneath the weight of the rapidly growing number of people with AIDS and the growing loss of health personnel as a result of AIDS. For example, The World Bank estimates that in Zimbabwe, Zambia, and Cote d'Ivoire, people with AIDS already occupy 50-80% of all beds in urban hospitals. In addition, the escalating incidence of tuberculosis (TB), the most common opportunistic infection associated with AIDS, now accounts for between one-third and one-half of all AIDS deaths in Africa.

AIDS in sub-Saharan Africa is stalking women and young people, shattering families, and placing extraordinary burdens on the extended family and village systems that have been the backbone of African child-rearing tradition.

While AIDS in sub-Saharan Africa is an equal opportunity killer, women, children, and young people are increasingly caught in the path of this relentless pandemic.

All too often, cultural norms place women at heightened risk of HIV. In many parts of sub-Saharan Africa, and around the world, discrimination against women begins early and continues throughout
life. Girls are far less likely to have access to education, information, and skill training. And in turn, women are far less likely to have access to essential health care and income generating opportunities. These realities increase their vulnerability to both poverty and HIV.

The low status of women in sub-Saharan Africa severely restricts their power to make informed and safe choices. As a result, more than half of all new HIV infections in sub-Saharan Africa are among women and 80% of the 14 million HIV-positive women of childbearing age worldwide
reside in sub-Saharan Africa.

In many areas throughout the region, pregnant women have astronomically high rates of HIV infection including 73% in Beit Bridge, Zimbabwe and 43% in Francistown, Botswana. Nine out of every ten infants infected with HIV at birth and through breastfeeding live in sub-Saharan Africa -- with nearly 600,000 new infections each year among babies.

There are many places throughout the region where up to one-quarter of all children are already living with an HIV-positive parent. And in nine sub-Saharan African countries, between one-fifth and one-third of all children will be orphaned by AIDS by the end of this year. In human terms, the AIDS orphan emergency is causing unprecedented threats to child welfare. This vulnerability includes decreased access to life-sustaining food, education, health care, housing, and clothing, and increased psychosocial distress brought on by the death of a parent, isolation, and stigma. These children are also at extraordinary risk of physical and sexual abuse as well as child labor
exploitation. And while most of these orphans were born HIV-negative -- this vulnerability leaves them at seriously increased risk of becoming HIV infected themselves.

Tragically, the worst is yet to come. During the next decade, more than 40 million children will be orphaned by AIDS, and this "slow burn disaster" is not expected to peak until at least 2030. According to UNICEF, the AIDS pandemic in sub-Saharan Africa is having and will continue to have a more significant impact on child survival and maternal mortality than all other emergencies on the continent combined. Without a doubt, AIDS has placed an entire generation of Africa's children in jeopardy.

In 9 sub-Saharan African countries, one-fifth to one-third of all children under the age of 15 will be orphaned by the year 2000.

AIDS is wiping out decades of progress on a host of development objectives. After hundreds of millions of dollars of donor investment and well-documented results, AIDS is now turning back the development clock to the 1960s. In the coming decade in many areas of sub-Saharan Africa, infant mortality (those less than one year old) will double and child mortality (those under age five) will triple. In addition, despite steady advances in access to education, a rapidly increasing number of children (particularly girls) are now dropping out of school to act as substitute labor or as caregivers for their dying parents. Far too few are finding their way back to school. Finally, according to the US Census Bureau, AIDS has already reduced life expectancy in Zimbabwe by 25 years and in Zambia from 56 years old to 37. In the next few years, AIDS will reduce life expectancy in South Africa by a third, from 60 years old to 40.

AIDS is not only causing unfathomable human suffering, it is jeopardizing economic growth, political stability, and civil society in many sub-Saharan African nations.

AIDS is a trade and investment issue. The Blueprint for a US/Africa Partnership for the 21st Century, adopted at the US/Africa Ministerial Meeting states: "African-US economic ties continue to grow. For example, US exports to Africa grew more rapidly in 1998 than did US exports to most other regions and are now 45% greater than its exports to all countries of the former Soviet Union combined. As a source of crude oil, Africa is as important to the United States as the Persian
Gulf. On a balance of payment basis, American private investment consistently produces a higher rate of return in Africa than in any other region."

According to Professor Jeffrey Sachs, Director of the Harvard Institute for International Development, "a frontal attack on AIDS in Africa may now be the single most important strategy for economic development." This is true because as the Southern Africa AIDS Information Dissemination Service estimates, over the next 20 years AIDS will reduce by a fourth the economies of sub-Saharan Africa. In fact, this AIDS related economic impact has already begun. According to the Economist, a recent study in Namibia estimated that AIDS costs the country almost 8% of GNP in 1996 and by 2005, Kenya's GNP will be 14.5% smaller than it would have been without AIDS. In Tanzania, The World Bank predicts that GNP will be 15-25% lower as a result of AIDS. The South African government estimates that AIDS costs the country 2%
of GNP each year.

AIDS has hit professionals hard in sub-Saharan Africa, particularly civil servants, engineers, teachers, miners, and military personnel. In Malawi and Zambia, 30% of teachers are HIV-positive, and in Zambia, 1,500 teachers died of AIDS in 1998 alone. In South Africa, 1 in 5 miners is currently infected with HIV. Uganda Railways has already lost 5,600 employees (10% of its workforce) to AIDS and now has an AIDS-related labor turnover rate of 15% annually. And in Zimbabwe, a major transportation company employing 12,000 workers found that by 1996 more than one-third were already HIV positive. According to a World Bank study in Kigali, Rwanda, 34% of people with post-secondary education were HIV positive, compared to 18% of those with primary education, and civil servants were more than three times more likely to be HIV-positive than farmers.

Increased benefits and training costs, and the disruption to regular production due to sick and bereavement leave, are seriously affecting both the private and public sectors. A study in South Africa found that at current levels of benefits per employee, the total cost of benefits would rise from 7% of salaries in 1995 to 19% by 2005 due to AIDS. Companies like British Petroleum and Barclays Bank have stated that they are now hiring two employees for every one skilled job, assuming that one will die of AIDS. The Indeni Petroleum Refinery in Zambia reportedly spent more on AIDS-related costs than it declared in profits.

AIDS is a security and stability issue. According to the Economist, "the estimated HIV prevalence in the seven armies embroiled in the Congo range from 50% to 80%." Recent reports project that the South African military and police are also already heavily infected by HIV. Moreover, as these troops participate in an increasing number of regional interventions and peacekeeping operations, the pace of the epidemic is likely to accelerate. Extremely high levels of HIV infection among senior officers could lead to rapid turnover in those positions. In countries where the military plays a central or strong role in government, such rapid turnover could weaken the central government's authority. For those countries in political transition, instability in the military and security forces could slow or even reverse the transition process. This dynamic merits attention, not only in Africa where the pandemic is already entrenched, but also in India and the Newly Independent States where the pandemic is intensifying its grip.

AIDS is a crime issue. The South African Institute for Security Studies has linked the growing number of children orphaned by AIDS to future increases in crime and civil unrest. The assumption is that as the number of disaffected, troubled, and undereducated young people
increases, many sub-Saharan African countries may face serious threats to their social stability. Without appropriate intervention, many of the two million children projected to be orphaned by AIDS in South Africa alone will raise themselves on the streets, often turning to crime, drugs, commercial sex, and gangs to survive. This seriously affects stability and promotes the spread of HIV among these highly vulnerable young people.

As goes Africa, so will go India, South-East Asia, and the Newly Independent States, and by 2005, more than 100 million people worldwide will be HIV-positive.

According to current projections, by 2005, AIDS deaths in Asia will mirror those in Africa. As the world's most populous continent, Asia will soon come to dominate the HIV picture accounting for one out of every four infections worldwide by the end of the year. Already, trends suggest that Asia may surpass Africa with the highest number of new infections.

India is increasingly at the center of the global epidemic, with more HIV infected people than any other country in the world -- an estimated 5 million. While the current death rate remains low in
comparison to sub-Saharan Africa, infection rates are increasing rapidly and are expected to double every 14 months. Surveillance of the disease is particularly difficult in India as cultural norms, gender inequities, and stigma continue to drive the epidemic, underground. As a result, AIDS cases in India are thought to be under-diagnosed, and therefore, poorly treated. By 2000, AIDS will cost India $11 billion or 5% of GNP.

According to Surgeon General Satcher, "It was only a few years ago that epidemiologists offered projections of disease prevalence for sub-Saharan Africa that were met with disbelief. If the present warnings go unheeded, South Asia, Southeast Asia, and, perhaps, China will follow the disastrous course of sub-Saharan Africa."

The Newly Independent States have also registered astronomical growth in HIV infection rates over the past few years. In the last four years alone, Eastern Europe and Central Asia have seen six-fold increases in HIV infections.

In the Russian Federation, HIV infections have increased 27-fold between 1994-1997. And in the Ukraine, HIV infections have increased 70-fold. Injection drug use now accounts for 80% of new infections in the Russian Federation and the increasing number of new users signals a growing dual epidemic of AIDS and drugs.

Adults & Children
Region Epidemic Adults & Children Newly Infected
Started Living With HIV/AIDS With HIV

Sub-Saharan Late 70's - 22,500,000 4,000,000
Africa Early 80's

South & South- Late 80's 7,260,000 1,400,000
East Asia

Eastern Europe Early 90's 270,000 80,000
& Central Asia

The Response:

Determined leadership and sustained investment have made, and can continue to make, an extraordinary difference and will save millions of lives.

Leadership matters. Amidst the tragedy of AIDS, there is hope. Uganda has shown that even a country with limited resources and a low literacy level can turn the tide on this burgeoning epidemic. President Museveni demonstrated bold leadership early in the epidemic by making every government ministry take the problem seriously, requiring them to develop and implement a plan to reduce AIDS stigma and HIV transmission, and to support those who became sick. In so
doing, Uganda created an "enabling environment" for donors to assist in this effort. Over the past decade, the US has invested $46 million (26% of the donor contributions to AIDS in Uganda) in partnership with the Ugandan government, other donors, and non-governmental organizations (NGOs) to provide HIV prevention, care and support. As a result, HIV rates in urban Uganda have been cut in half.

Effective solutions for children orphaned by AIDS are community-based and multi-sectoral. Families and communities not only bear the brunt of the impact of AIDS, they form the frontline of an effective response. In the long-standing African tradition, communities across the continent are searching for creative ways to support the village in its efforts to raise its children. Unfortunately, the growing number of young deaths and orphaned children is beginning to overwhelm many of these small villages. Nevertheless, when residents are brought together to organize in the face of seemingly insurmountable odds. These community partnerships are making the difference by helping to strengthen the capacity of those on the frontline to cope with this ever unfolding crisis.

Through village banks and micro-finance programs, women are receiving loans, starting small businesses, and with increased household incomes, are taking in children orphaned by AIDS. With support, communities are mobilizing to deal with school fees, food assistance, counseling, material support, immunizations and basic healthcare, and the range of other services orphaned and other vulnerable children desperately need.

These efforts are low cost strategies designed to empower women (many of whom are HIV-positive), protect children, and support extended families and communities in caring for their own. Community mobilization and micro-finance programs are affordable, mutually reinforcing ways to build the capacity of families and communities to cope with the impact of AIDS. This approach is universally preferred to the use of orphanages, a solution that can never keep pace with this burgeoning pandemic. For a small fraction of the cost of one orphanage bed, many more vulnerable, children can receive care in a family setting. The problem is, only a very tiny fraction of those children in need actually receive even this modest level of support.

A focus on children orphaned by AIDS can and should be a catalyst for a more comprehensive fight against AIDS. It is almost impossible to consider the issues surrounding the care and protection of children orphaned by AIDS without also considering HIV prevention and AIDS treatment. It is certainly true that the only way to slow the number of children orphaned by AIDS is to reduce the transmission of HIV infection among parents and prospective parents. Yet today, young people under the age of 25 represent at least 60% of all new infections in sub-Saharan Africa. Until there is an available vaccine, more aggressive prevention efforts, particularly programs targeted to youth, are essential to stem this rising tide of devastation.

Community action to save orphans can help to facilitate effective prevention efforts by reducing stigma, denial, and fatalism in the face of AIDS. Planning for children orphaned by AIDS brings home the very real consequences of HIV -- death and orphanhood. These grim realities are all too often denied due to the "conspiracy of silence" that surrounds this illness and its long latency period. But this is a matter of life and death and more. Once denial fades, community mobilization enables those involved to believe that they can change their circumstances for the better. This sense of possibility is a powerful behavior change tool.

Helping keep parents alive assures a better future for their children. The number of children being orphaned by AIDS in Africa is staggering, and those children orphaned are at greater social, economic and health risk than their non-orphaned peers. Parents, guardians, and extended families are best able to provide the nurturing environment for these children. Basic care and psycho-social support can make a huge difference. The delivery of low cost treatments for opportunistic infections (especially TB), and the provision of psycho-social support, helps people with HIV and AIDS live longer and better lives, and enables them to plan for the future of their children. In addition, the availability of care and support gives increased credibility to prevention efforts by demonstrating the merits of pursuing HIV testing and counseling.

Ultimately, it is important to remember that children and families caught in the crossfire of this epidemic do not segment their lives into pieces that follow programmatic or budgetary line items.
Therefore, the more holistic and integrated the approach to this complex problem -- the more effective the result.

Preventing Mother-to-Child Transmission

Ten percent of all new HIV infections in Africa occur through mother-to-child transmission, with nearly 600,000 infants becoming infected per year. In Africa today, for every ten children born to
HIV-positive mothers, two become infected during delivery and one becomes infected through breastfeeding.

Developing methods to reduce mother-to-child transmission of HIV that are feasible in Africa is a high priority. For the past three years, multiple studies have been initiated to find proven interventions that could be workable in poor countries. In February 1998, data from the first of these studies were released from Thailand, which demonstrated that a short course of AZT (Zidovidene) could reduce mother-to-infant HIV transmission by nearly 40% in non-breastfeeding infants. Even more recently, on July 14, 1999, the National Institutes of Health announced a joint Uganda-US study breakthrough identifying a low cost drug, nevirapine (NVP) that can reduce mother-to-child transmission of HIV at birth by an additional 50% as compared to the short course of AZT regimen. These drug regimens are far simpler and less expensive than the antiretroviral regimens used in the United States, and potentially just as effective. These new interventions will give pregnant women an incentive to seek HIV testing and counseling, and if infected, to receive treatment where it is available.

These new developments are extremely encouraging and provide hope for being able to save the lives of hundreds of thousands of babies a year -- most of whom will live in sub-Saharan Africa. However, a host of additional issues need to be explored and addressed before this knowledge can be effectively translated into productive action. For example, to receive maximum benefit from AZT and perhaps NVP, mothers should not breastfeed. In many areas of sub-Saharan Africa, infant formula is unaffordable and lack of clean water often makes it unworkable. In some cases, babies are as likely to die from diarrhea resulting from incorrect use of formula as they are from AIDS.

The lack of health care infrastructure is also a serious issue. At least 95% of pregnant women do not know they are HIV-positive and currently lack access to the testing and counseling services needed to find out. In many areas, most women deliver their children with the assistance of midwives in their homes, or in makeshift clinics currently unequipped for complex interventions. In the poorest parts of Africa, nearly 80% of women lack access to any kind of health care at all.

Further, the stigma of AIDS is often so great that fear of discrimination, violence and abandonment dramatically restrict the ability of women to make safe choices. In cultures where breastfeeding
is the norm, women who choose not to breastfeed are assumed to be HIV-positive, often with dire consequences. Recently, an HIV-positive woman in South Africa went public with her status and was stoned to death by her neighbors. Countless other women and children have been left destitute after their husbands discovered, or decided, they were HIV-positive.

These technical and ethical challenges deserve our immediate and urgent attention, so that the promise of these exciting new technologies can become a reality for as many women and children as possible.

The Challenge:

It's time to bring effective interventions to scale. We know what works. Unfortunately, these proven interventions currently fail to reach the overwhelming majority of those in need. Successful small scale efforts must be dramatically expanded. While the magnitude of the global AIDS pandemic is far too extensive for any donor, host government, or multilateral institution to ignore, it is also too great for any single entity to address adequately by itself. To make a real difference, an effective response must mobilize and coordinate the commitment and resources of the full range of key stakeholders, including governments, bi-lateral and multi-lateral development bodies, international organizations, religious networks, the private sector, NGOs, families and communities, and people living with HIV/AIDS. AIDS is everyone's problem and everyone must be a part of the solution.

Plan of Action

The Background:

Throughout the Mission's travel in Africa, it was clear that President Clinton's "Partnership with Africa" is making hope a reality, even at the village level. From Kampala to Cape Town, people across Africa know of this historic initiative. Unfortunately, AIDS threatens to decimate the progress of this partnership and everything else in its path. To protect and defend the legacy of growth and opportunity we have built with Africa, and the children and families who depend on
it, an aggressive AIDS initiative, involving concrete action both at home and abroad, is essential.

Given the magnitude of the AIDS pandemic and its devastating impact on child survival, economic development, trade, regional stability, and civil society in Africa today, and in India tomorrow, the President established a Global AIDS Emergency Working Group. Included were the National Security Council, Office of Management and Budget, Office of the Vice President, USAID, and the Departments of Defense, State, Treasury, Commerce, and HHS. The Office of National AIDS Policy coordinated this effort, and together the Working Group and the members of the Presidential Mission made specific recommendations. These recommendations form the basis of the Plan of Action now put forward by the Administration.

The Goals:

UNAIDS, in cooperation with its bi-lateral and multi-lateral partners, has laid out a series of goals for the next five years as described below. The Administration seeks to further these goals through an initiative entitled "Joining Forces for LIFE": Leadership and Investment in Fighting an Epidemic.

  • The incidence of HIV infection will be reduced by 25% among 15-24 year olds by 2005. (Currently 2 million young adults are infected each year in sub-Saharan Africa.)
  • At least 75% of HIV infected persons will have access to basic care and support services at the home and community levels, including drugs for common opportunistic infections (TB, pneumonia, and diarrhea). (Currently, less than 1% of HIV infected persons have such access.)
  • Orphans will have access to education and food on an equal basis with their non-orphaned peers.
  • By 2001, domestic and external resources available for HIV/AIDS efforts in Africa will have doubled to $300 million per year. (Currently, approximately $150 million per year is spent on HIV/AIDS prevention in sub-Saharan Africa.)
  • By 2005, 50% of HIV infected pregnant women will have access to interventions to reduce mother-to-child HIV transmission. (Currently, less than 1% of HIV infected pregnant women have access to such services in sub-Saharan Africa.)


The Initiative:

1. Increasing the US Government investment in the global battle against AIDS to begin to reflect the magnitude of this rapidly escalating pandemic.

Making a difference in Africa and in other highly impacted areas requires broader political commitment, enhanced community mobilization, and, most urgently, increased resources. In 1998,
spending on AIDS in Africa totaled only $165 million. Compared to the ever-escalating need and other health programs, this amount is woefully inadequate. For example, in 1998, over $500 million was spent for basic childhood immunization programs in Africa. Based on our experience in those countries that are starting to demonstrate success, such as Uganda and Senegal, UNAIDS and donors now agree that a minimum of $600 million is needed in sub-Saharan Africa per year for
HIV prevention alone ($2 per adult per year).

While we acknowledge the leadership role that the US plays globally and the urgent need to act, clearly an effort to combat AIDS must be driven by many actors including host countries, multi-lateral organizations, and bi-lateral donors, to be successful. In FY1999, the US Government spent $74 million in USAID prevention and care in Africa and $38 million in HHS research and surveillance/prevention. But more remains to be done in sub-Saharan Africa and in other seriously
affected parts of the world.

The Administration proposes to commit an additional $100 million in FY2000 to the global battle against AIDS. This initiative will enable us to move forward on four critically important and interconnected fronts including:

  • Containing the AIDS Pandemic ($48 million) Implement a variety of prevention and stigma reduction strategies, especially for women and youth, including: HIV education, engagement of political, religious, and other leaders; voluntary counseling and testing; interventions to reduce mother-to-child transmission (MTCT); and enhance training and technical assistance efforts, including Department of Defense efforts with African militaries.
  • Providing Home and Community-Based Care ($23 million) Deliver counseling, support, palliative and basic medical care including treatment for sexually transmitted diseases, opportunistic infections (OIs), and tuberculosis (TB) through community-based clinics and
    home-based care workers. Enhance training and technical assistance efforts.
  • Caring for Children Orphaned by AIDS ($10 million) Assist families, extended families, and communities in caring for their children through nutritional assistance, education, training, health, and counseling support, in coordination with micro-finance programs.
  • Strengthening Prevention and Treatment by Augmenting Planning, Infrastructure, and Capacity Development ($19 million) Strengthen host country ability to plan and implement effective interventions. Strengthen the capacity for effective partnerships and the ability of
    community based organizations to deliver essential services. Strengthen surveillance systems to track the epidemic and target HIV/AIDS programs.

This US Government assistance would be provided through AID ($55 million), HHS ($35 million), and DoD ($10 million). The focus of this funding is HIV prevention, and AIDS care and treatment. In those areas, this initiative represents nearly a doubling of funding in Africa from current levels ($81 million in FY99, which excludes research). The Administration recognizes the fight against AIDS must be sustained to keep pace with this burgeoning epidemic, and is committed to a multi-year effort in this critical area.

II. Building partnerships with other key stakeholders to maximize our impact on the rapidly expanding pandemic.

Increasing US investment in the global baffle against AIDS is critical, but is not sufficient to achieve the outcomes needed. The commitment of in-country political leaders and of various segments of civil society are key to success. Moreover, resources provided by the US Government need to help leverage, and to be coordinated with, those of other donors, the private sector, and national governments to ensure synergy and to maximize impact. Building partnerships with key stakeholders in support of effective action at the community level is our greatest hope for progress.

This initiative will pursue a variety of strategic opportunities for challenging other partners to join in an enhanced effort, including:

  • Leadership Meeting. On September 7, 1999, First Lady Hillary Rodham Clinton will convene a meeting of key US officials, The World Bank, UNAIDS, as well as heads of foundations, corporate CEOs, and others to discuss how best to enhance AIDS prevention and treatment efforts in Africa and around the world. The meeting will focus not only on leveraging additional resources, but also on establishing priorities, identifying effective public/private partnerships, and identifying targets for action to combat the crisis of HIV/AIDS.
  • African Leaders Summit. We propose hosting a high-level meeting with Africa government and community leaders within the next ten months. This meeting will highlight the critical role of leadership in arresting the epidemic and will work to encourage increased leadership efforts. Topics will include the economic impact of HIV/AIDS, examination of models of success in reducing the transmission of HIV, and addressing the need for increased investment in health programs. Additional topics will include AIDS care and treatment and support for children orphaned by AIDS.
  • UN Conference on Children Orphaned by AIDS. On December 1, 1999 (World AIDS Day), the United Nations in conjunction with the National Black Leadership Commission on AIDS, The White House Office of National AIDS Policy, The Magic Johnson Foundation and a variety of
    NGOs, will organize a conference to focus attention on the growing number of children orphaned by AIDS worldwide. Special emphasis will be placed on assessing the needs of orphaned children in sub-Saharan Africa and the Americas. Participants will include noted experts on the priority issues identified by UNAIDS, UNICEF, and other UN agencies.
  • Business. The Department of Commerce will facilitate a meeting of business leaders active in Africa to encourage them to increase their efforts to rise to the AIDS challenge. Given the impact that AIDS is having on businesses as well as the overall economic-impact on African
    countries, such a meeting will seek enhanced business commitment and involvement in AIDS programs.

The Commerce Department will work with American Chambers of Commerce abroad and other business organizations to publicize the successful AIDS efforts of US firms in Africa and to support others taking similar action. In addition, the Department will direct work to promote closer coordination in Africa between Commercial Service Offices, other USG agencies, the business community, and African NGOs in a united effort to promote corporate partnership in AIDS programs.
  • Labor. The Secretary of Labor will facilitate a meeting of US and African labor leaders, and will be co-chaired by the AFL-CIO. The success of the AFL-CIO and its Solidarity Center in South Africa (supported by USAID) in working with the South African Trade Union Federations to include AIDS as a key labor outreach and policy issue provides a model for similar action elsewhere. Outcomes include assisting labor organizations in educating their members and securing commitments to develop workplace-based AIDS education and prevention programs, including outreach to youth.
  • Religious Leaders Summit. The US government will facilitate a meeting of African, American, and other religious leaders to discuss the important role of communities of faith in the fight against AIDS. In Uganda and Senegal, the involvement of religious communities and leaders had a dramatic impact on the ability of these two countries to reduce HIV incidence and to maintain it at low levels over time. The outcome of such a meeting would be to increase attention to the need for involving religious communities, to mobilize these organizations and leaders in the fight against AIDS, and to identify ways to support their efforts.
  • Diplomatic Initiatives. The Department of State, NSC, and ONAP will work with US and African ambassadors to increase attention to AIDS within the diplomatic community. The NSC, the Department of State, and USAID will work with G-8 and other donors, and challenge them to match the increased investment put forward in this initiative.


Conclusion

Nelson Mandela, in accepting the Congressional Medal of Honor, said:

"Though the challenges of the present time for our country, our continent and the world are greater than those we have already overcome, we face the future with confidence. We do so because despite the difficulties and the tensions that confront us, there is in all of us the capacity to touch one another's hearts across oceans and continents."

We are living in wartime and the stakes are high. Tragically, we know the severity of the horror that lies ahead. Fortunately, we also know a great deal about what can be done to protect children and to support families and communities in their battle against AIDS. Across Africa, valiant efforts are being made to stem the rising tide of HIV infection, to prolong the lives of those who are sick and to stitch together a tapestry of family or family-like support systems for the growing millions of children orphaned by AIDS. Partnerships between our government and other donors, host governments, non-governmental organizations, consumer groups, and communities are generating hope and demonstrating promising results.

But the battle against AIDS has just begun, and the worst is yet to come. We need to continue to promote and reward leadership, and to remove barriers that impede a cooperative multi-sectoral response. We need to expand our vision, our capacity, and our resource base -- in the face of an ever expanding nightmare that just won't take no for an answer. Living in wartime means pushing forward on several fronts at the same time.

As we seek to keep pace and even gain ground, the magnitude of this challenge looms large. Nevertheless, the faces of the children and families crying out for our help beckon us all to find ways to do better, to be smarter, to move faster, and to develop whatever capacity and partnerships we lack, as we gear up for the long haul. (end excerpts)