Global Health: U.S. Agency for International Development Fights AIDS in
Africa, but Better Data Needed to Measure Impact (Letter Report,
03/23/2001, GAO/GAO-01-449).

The Acquired Immunodeficiency Syndrome (AIDS) epidemic in sub-Saharan
Africa has grown beyond a public health problem to become a humanitarian
and developmental crisis. The Agency for International Development (AID)
has contributed to the fight against human immunodeficiency virus
(HIV)/AIDS in sub-Saharan Africa by focusing on interventions proven to
slow the spread of the disease. However, AID's ability to measure the
impact of its activities on reducing transmission of HIV/AIDS is limited
by (1) inconsistent use of performance indicators, (2) sporadic data
collection, and (3) lack of routine reporting of results to
headquarters. As part of its approach for allocating the 53 percent
increase in funding for HIV/AIDS prevention activities in sub-Saharan
Africa for fiscal year 2001, AID prepared a plan to expand monitoring
and evaluation systems in countries designated as in need of significant
increases in assistance. However, when implemented, the monitoring and
evaluation requirements in the plan will not initially include all
countries where AID missions and regional offices in sub-Saharan Africa
implement HIV/AIDS programs. Further, the plan does not specify to whom
these data will be reported or how the information will be used. Failure
to address these issues not only inhibits AID's ability to measure the
performance of its HIV/AIDS activities but also hinders the agency's
decision-making regarding allocation of resources among missions and
regional offices and limits efforts to identify best practices.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  GAO-01-449
     TITLE:  Global Health: U.S. Agency for International Development
	     Fights AIDS in Africa, but Better Data Needed to
	     Measure Impact
      DATE:  03/23/2001
   SUBJECT:  Acquired immunodeficiency syndrome
	     Program evaluation
	     Federal aid to foreign countries
	     Strategic planning
	     Performance measures
	     Reporting requirements

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GAO-01-449

A

Report to the Chairman, Subcommittee on African Affairs, Committee on
Foreign Relations, U. S. Senate

March 2001 GLOBAL HEALTH U. S. Agency for International Development Fights
AIDS in Africa, but Better Data Needed to Measure Impact

GAO- 01- 449

Lett er

March 23, 2001 The Honorable Bill Frist, M. D. Chairman, Subcommittee on
African Affairs Committee on Foreign Relations United States Senate

Dear Mr. Chairman: The Human Immunodeficiency Virus/ Acquired
Immunodeficiency Syndrome (HIV/ AIDS) is the leading cause of death in the
countries of sub- Saharan Africa, where more than two- thirds of the people
who are

infected with HIV live. Despite efforts by the international community to
reduce the spread of HIV/ AIDS in sub- Saharan Africa, the National
Intelligence Council estimates 1 that as many as one- quarter of the

population of the hardest- hit countries in that region will die from AIDS
over the next 10 years. Further, given the scale of the epidemic, AIDS has
grown beyond a public health problem to become a humanitarian and
developmental crisis. For example, the National Intelligence Council
concluded that the persistence of infectious diseases, such as HIV/ AIDS, is
likely to aggravate and in some cases provoke economic decline, social
fragmentation, and political destabilization. In addition, the Council found
that the epidemic threatens to weaken the military capabilities of countries
and because of the involvement of sub- Saharan African troops in
international peacekeeping efforts it could hinder those activities as well.

Since the 1980s, the U. S. Agency for International Development has provided
assistance to help fight AIDS in sub- Saharan Africa.

The Agency for International Development allocated a 53- percent increase in
funding, from $114 million to $174 million, for fiscal year 2001 to expand
its HIV/ AIDS efforts in sub- Saharan Africa. 2 This report responds to your

1 “The Global Infectious Disease Threat and Its Implications for the
United States,” No. NIED 99- 17 of the National Intelligence Estimates
(Washington, D. C.: National Intelligence Council, Jan. 2000). 2 Under the
Foreign Operations Appropriations Act for Fiscal Year 2001 (P. L. 106- 429),
Congress appropriated $330 million for the U. S. Agency for International
Development's HIV/ AIDS programs worldwide, which included $15 million
earmarked for orphans and vulnerable children.

request that we examine the agency's current efforts to reduce the spread of
the HIV/ AIDS epidemic in sub- Saharan Africa. Specifically, we (1)
identified the development and impact of the HIV/ AIDS epidemic in sub-
Saharan Africa and the challenges to slowing its spread, (2) assessed

the extent to which the U. S. Agency for International Development's
initiatives have contributed to the fight against AIDS in sub- Saharan
Africa, and (3) identified the approach the agency used to allocate
increased funding and the factors that may affect the agency's ability to
expand its

HIV/ AIDS program in sub- Saharan Africa. As part of our review, we spoke
with key U. S. Agency for International Development officials and reviewed
written responses to GAO questions from the 19 agency field missions and 3
regional offices in sub- Saharan

Africa that conducted HIV/ AIDS activities. To supplement this work, we also
visited U. S. Agency for International Development missions in Malawi,
Tanzania, Uganda, and Zimbabwe. More detailed information about our scope
and methodology is in appendix I.

Results in Brief The AIDS epidemic has had a significant negative impact in
sub- Saharan Africa, reducing population growth and offsetting gains from
investment in social and economic development. Since 1993, the number of
people

infected with HIV/ AIDS in sub- Saharan Africa has tripled to 25.3 million,
and more than 17 million people have died, according to the Joint United
Nations Programme on HIV/ AIDS. Life expectancy in nine countries in the
region is also declining dramatically. According to the U. S. Census Bureau,
a child born in 2000 in Botswana can expect to live only 39 years. Without
AIDS, that child would have a life expectancy of 71 years. Further, the
Joint U. N. Programme on HIV/ AIDS estimated that by the end of 1999,
approximately 13 million children worldwide had been orphaned by AIDS, with
95 percent of them in Africa. While efforts have been made to stem the
disease's spread, the U. S. Agency for International Development and United
Nations officials have identified several challenges that have hindered
their ability to reduce HIV/ AIDS in Africa. These challenges include
limited funding available to combat the epidemic, social stigma and

cultural and social customs that make it difficult to discuss traditional
sex practices that facilitate the spread of HIV, the low socioeconomic
status of women in sub- Saharan Africa, weak national health care systems,
difficulty

reaching African militaries with high infection rates, and the slow response
of African leaders to recognize and address the issue.

The U. S. Agency for International Development has contributed to the fight
against HIV/ AIDS in sub- Saharan Africa, focusing on proven effective
interventions such as providing information and counseling to encourage
behavior change in high- risk groups; promoting increased condom use; and

supporting prevention, diagnosis, and treatment of sexually transmitted
diseases. 3 Some countries have shown declines in disease prevalence rates,
4 which the U. S. Agency for International Development attributes in part to
its activities. However, an overall picture of the agency's contribution is
difficult to determine due to several factors. Although

agency officials informed us that the agency's country- level missions use
data to track day- to- day operations, the agency's missions do not always
use consistent indicators to measure progress in combating the disease, do
not routinely gather comprehensive program performance data, and do not
regularly report those data to headquarters. As a result, decisionmakers in

the agency's headquarters lack the information needed to measure the overall
impact on reducing HIV transmission in the region, target the agency's
resources to their best possible use, and identify best practices. The U. S.
Agency for International Development has developed an approach for expanding
its HIV/ AIDS program in response to the 53- percent increase in funding for
fiscal year 2001. This approach included new HIV/ AIDS prevention efforts
and the development of a monitoring and evaluation plan. However, agency
officials cited several internal and external factors that may limit their
ability to expand the program. These factors include limitations associated
with the agency's procurement and contracting processes and capacities, its
reliance on weak national health care systems, and the unknown capabilities
of indigenous nongovernmental organizations to conduct prevention
activities. The agency has identified

steps to help mitigate some of these factors. This report makes
recommendations to improve how the U. S. Agency for International
Development can measure its effectiveness in reducing HIV transmission in
Africa through greater use of consistent performance indicators and data
collection efforts. In written comments on a draft of 3 With support from
USAID and other donors, experts identified interventions that, when
implemented in a culturally appropriate manner and combined in a coordinated
effort, have been proven through clinical trials and longitudinal studies to
have an impact on the spread of AIDS.

4 The prevalence rate is the percentage of the adult population that is
currently infected with HIV.

this report, the U. S. Agency for International Development acknowledged our
key concern that performance indicators at the country level were
inconsistent to measure progress over time and stated that it is taking

action to facilitate the collection and dissemination of comparable national
data. Background The United States has been the largest single donor to HIV/
AIDS prevention

in developing countries, contributing over $500 million in Africa between
fiscal year 1988 and 2000 through the U. S. Agency for International
Development (USAID). The agency's efforts have mainly been directed at
specific target groups to reduce the spread of the disease through behavior
change communication activities; promotion of increased condom use; and

improved prevention, diagnosis, and treatment of sexually transmitted
infections. In July 2000, USAID also began to fund other activities- such as
treatment for tuberculosis and other opportunistic infections and care for

AIDS orphans- aimed at mitigating the impact of the disease. USAID has a
decentralized organizational structure (see fig. 1), which vests most of the
authority for developing and implementing programs in the country offices,
or missions. Four regional bureaus, such as the Africa Bureau, support field
mission activities through the provision of technical, logistical, and
financial assistance. The Global Bureau's HIV/ AIDS Division negotiates
contracts, grants, and cooperative agreements with private voluntary
organizations that missions can access for particular expertise, such as
development of HIV/ AIDS prevention communication campaigns. The Global
Bureau also funds research that can be used to improve mission programs,
supports the Joint United Nations Programme on HIV/ AIDS

(UNAIDS), and coordinates efforts by other U. S. government agencies, such
as the Centers for Disease Control, to address the epidemic in developing
countries. At the time of this review, USAID conducted HIV/ AIDS activities
at 19 missions in sub- Saharan Africa and implemented activities in other
countries in the region from three of its regional offices.

Figure 1: The USAID Organizational Structure

Office of the Administrator Deputy Administrator Executive Secretariat

Bureau for Bureau for Asia

Bureau for Bureau for

Bureau for Global Programs

Bureau for Africa and the

Latin America Europe Humanitarian (HIV/ AIDS Division)

Near East and the Caribbean

and Eurasia Response Field Missions

Field Missions Field Missions

Field Missions Field Missions and

and and

and and Regional Offices

Regional Offices Regional Offices

Regional Offices Regional Offices USAID units implementing HIV/ AIDS
activities in Sub- Saharan Africa.

Source: GAO based on USAID documentation.

AIDS Has Negatively Throughout the 1990s HIV/ AIDS prevalence continued to
increase in most of the countries in sub- Saharan Africa (see fig. 2). 5 The
increasing Affected Sub- Saharan

prevalence of HIV/ AIDS has had a substantial impact on the region's Africa,
but Slowing the population, resulting in (1) high death rates, (2) increased
infant and child

Epidemic Presents mortality, (3) reduced life expectancy, and (4) large
numbers of orphans.

Challenges The epidemic has also offset gains from investment in social and
economic development. Despite the efforts of USAID and international donors,

however, several challenges to slowing the epidemic's spread remain. These
include social, cultural, and political issues endemic to the region. 5
According to USAID, due to the combined efforts of donors and host
governments, HIV prevalence rates have decreased from 12 percent to 8
percent in Uganda between 1994- 1999 and stabilized below 2 percent in
Senegal between 1997- 1999.

Figure 2: The Evolution of HIV Prevalence in Africa from 1989 to 1999

1989 1999 Estimated percentage of adults (15- 49) infected with HIV

20. 0% - 36. 0% 10. 0% - 20. 0%

5.0% - 10. 0% < 1.0% - 5. 0%

Trend data unavailable Lake

Source: GAO based on UNAIDS map.

Effect of the AIDS Epidemic The most direct impact of AIDS has been to
increase the overall numbers of

on the Population of deaths in affected populations. UNAIDS estimates that
since 1993, the

Sub- Saharan Africa number of people infected with HIV/ AIDS in sub- Saharan
Africa has tripled

to 25.3 million and more than 17 million people have died. According to the
U. S. Census Bureau, estimated death rates have increased by 50 to 500
percent in eastern and southern Africa over what they would have been
without AIDS. For example, in Kenya the death rate is twice as high, at 14.
1 per 1,000 population, as opposed to the 6.5 per 1,000 it would have been
without AIDS.

According to the U. S. Census Bureau, infant and child mortality rates 6 in
sub- Saharan Africa are also significantly higher than they would have been
without AIDS. For example, in Zimbabwe infant mortality without AIDS would
have been 30 per 1,000 in 2000. With AIDS, the infant mortality rate in 2000
was 62 per 1,000. The Census Bureau estimates that by 2010, more infants in
Botswana, Zimbabwe, South Africa, and Namibia will die from AIDS than from
any other cause. Rising child mortality rates due to AIDS

are most dramatic in countries where death from other causes, such as
diarrhea, had been significantly reduced. For example, in South Africa,
Census Bureau data show that 45 percent of all deaths among children under
age 5 in 2000 were AIDS related. In Zimbabwe, 70 percent of child deaths in
2000 were AIDS related, and AIDS- related deaths there are expected to
increase to 80 percent by 2010.

According to the World Bank, one of the most disturbing long- term trends
associated with the HIV/ AIDS epidemic is reduced life expectancy. By 2010
to 2015, life expectancy is expected to decline 17 years in nine countries
in sub- Saharan Africa, to an average of 47 years. For example, the Census
Bureau estimates that a child born in 2000 in Botswana can expect to live

only 39 years. Without AIDS, that child would have a life expectancy of 71
years. In addition, the Census Bureau estimates that life expectancy in
Botswana will decline to 29 years by 2010, a level not seen since the
beginning of the 20th century. This dramatic decrease in life expectancy in
the region represents a reversal of the gains of the past 30 years. Figure 3
shows the impact of AIDS on longevity in 13 sub- Saharan African countries.

6 Infant mortality rates are defined as deaths of children under 1 year of
age. Child mortality rates are defined as deaths of children under 5 years
of age.

Figure 3: The Effect of AIDS on Life Expectancies in 13 Sub- Saharan African
Countries, 1999

Botswana Zimbabwe South Africa

Kenya Tanzania

Zambia Cï¿½te d'Ivoire

Nigeria Ethiopia

Uganda Malawi Rwanda Mozambique

Life expectancy at birth (years) With AIDS Without AIDS

Source: U. S. Bureau of the Census.

Also, because of AIDS, children in sub- Saharan Africa are being orphaned in
increasingly large numbers. According to UNAIDS, by the end of 1999,
approximately 13 million children worldwide had been orphaned by AIDS, 7
with 95 percent of them in Africa. Further, according to a report prepared
for USAID, orphans will eventually comprise up to 33 percent of the 7 UNAIDS
defines AIDS orphans as children who lose their mother to AIDS before
reaching the age of 15 years.

population under age 15 in some African countries. 8 While orphans in Africa
have traditionally been absorbed into extended families, the advent of the
HIV/ AIDS epidemic has caused these family structures to be overburdened,
leaving many children without adequate care. The World Bank notes that
orphans are more likely to be malnourished and less likely to go to school.
According to UNAIDS, orphans are frequently without the means to survive and
therefore may turn to prostitution or other behaviors that heighten their
risk of contracting HIV themselves. Figure 4 shows the numbers of AIDS
orphans in 12 African countries 9 in 1999.

8 “Children on the Brink: Strategies to Support Children Isolated by
HIV/ AIDS,” TVT Associates (Washington, D. C.). 9 These 12 countries
and India were included in the Leadership and Investment in Fighting an
Epidemic (LIFE) initiative, which increased funding for HIV/ AIDS activities
in fiscal year 2000.

Figure 4: Numbers of AIDS Orphans in 12 African Countries, 1999

Senegal 42, 000 Nigeria 1,400,000

Ethiopia 1,200,000 Uganda 1, 700,000 Rwanda 270,000

Kenya 730,000 Tanzania 1,100,000

Malawi 390,000 Zambia 650,000

Mozambique 310, 000 Zimbabwe 900,000

South Africa 420,000

Source: UNAIDS.

The spread of HIV/ AIDS has begun to negatively affect population growth
rates in sub- Saharan Africa. Typically, developing countries experience a
population growth rate of 2 percent or greater, compared with much lower
rates in developed countries. As late as 1998, the Census Bureau predicted
that the AIDS epidemic would have no effect on population growth in sub-
Saharan Africa because of the region's high fertility rate. However, the
Census Bureau now predicts that by 2003, Botswana, South Africa, and
Zimbabwe will all be experiencing negative population growth due to high
prevalence of HIV and the low fertility and high infant and child mortality

rates in these three countries. By 2010, the Census Bureau estimates that
the growth rate for these countries will be (- 1) percent, the first time
that negative population growth has been projected for developing countries.
Population growth is expected to stagnate in at least five other countries
in

the region, including Lesotho, Malawi, Mozambique, Namibia, and Swaziland.

Effect of AIDS Epidemic on AIDS has had a significant effect on social and
economic development in Social and Economic

the region as increasing numbers of people in their most productive years
Development

have died. For example, according to USAID, AIDS directly affects the
education sector as the supply of experienced teachers is reduced by AIDS-
related illness and death. The World Bank estimates that more than 30
percent of the teachers in Malawi and Zambia are already infected with HIV.
According to UNAIDS, during the first 10 months of 1998 1,300 teachers in
Zambia died of AIDS- the equivalent of about 66 percent of all new teachers
trained annually. In addition, fewer children are attending school. The
death of a parent is a permanent loss of income that often requires the
removal of children from school to save on educational expenses and to
increase household labor and income.

The agriculture sector has also been affected by the epidemic. Agriculture,
the biggest sector in most African economies, accounts for a large portion
of economic output and employs the majority of workers. However, as farmers
become too ill to tend their crops, agricultural production declines

for the country. For example, according to UNAIDS, in Cï¿½te d'Ivoire, many
cases of reduced cultivation of crops such as cotton, coffee, and cocoa have
been reported. Likewise, in Zimbabwe, agricultural output has fallen by 50
percent over a 5- year period during the late 1990s, due in part to farmers
becoming sick and dying from AIDS.

In addition, the cost of doing business in Africa has increased in many
sectors of the economy due to HIV/ AIDS. The epidemic's costs to employers
include expenditures for medical care and funeral expenses. A 1999 report
prepared for USAID 10 found that because of the increased levels of employee
turnover due to HIV/ AIDS, employers also are experiencing greater expenses
due to the recruitment and training of new employees. According to the
United Nations International Labour Office, to combat increased costs, some
employers in sub- Saharan Africa have begun to hire or train two or three
employees for the same position because of the

concern that employees in key positions may get sick and die from AIDS. 10
“Economic Impact of AIDS,” The POLICY Project of The Futures
Group International (Mar. 16, 1999).

Several Challenges Have While international organizations have worked to
stem the spread of the Hindered International

disease, funding constraints, cultural and social traditions, the low
Efforts to Slow the Spread socioeconomic status of women, weak health care
infrastructure, difficulty of HIV/ AIDS in Sub- Saharan reaching men in
uniform, and the slow response of national governments have impeded their
efforts. Africa

Donor Spending Falls Short of In 2000, UNAIDS estimated that at least $3
billion is needed annually for Need

HIV prevention and care in sub- Saharan Africa. By contrast, according to
USAID, international donors contributed less than 20 percent of what was
needed in fiscal year 2000 to support HIV/ AIDS activities in the region.
USAID- which has been the largest international donor to fight HIV/ AIDS in
Africa- spent $114 million in the region in fiscal year 2000, of its total
worldwide HIV/ AIDS budget of $200 million. As shown in table 1, USAID

efforts translated into per capita expenditures for 23 sub- Saharan African
countries in fiscal year 2000 ranging from $0.78 in Zambia to $0.03 in the
Democratic Republic of the Congo.

Table 1: USAID's Fiscal Year 2000 HIV/ AIDS Funding in 23 African Countries,
in Order of Per Capita Spending Total funding

Total population Per capita Country (millions) (millions) spending

Zambia $7. 0 9.0 $0.78 Namibia 1. 0 1.7 0. 59 Rwanda 3. 5 7. 2 0.49 Malawi
5.0 10. 7 0. 47 Zimbabwe 5. 0 11. 5 0.43 Senegal 3. 7 9. 3 0.40 Uganda 6.9
21. 2 0. 33 Mozambique 5.1 19. 2 0. 27 Guinea 1. 7 7. 4 0.23 Mali 2.5 11. 0
0. 23 Ghana 4. 0 19. 7 0. 20 Kenya 5. 7 29. 5 0. 19 Tanzania 6. 0 32. 8 0.18
Benin 1. 0 5.9 0. 17 South Africa 5. 7 39.8 0. 14 Eritrea 0. 5 3.7 0. 14
Ethiopia 6.7 61. 1 0. 11 Angola 1. 0 12. 5 0.08 Nigeria 6. 8 109.0 0. 06
Madagascar 0. 8 15.5 0. 05 DRCongo 1. 5 50. 4 0. 03 Liberia N/ A 2.9 N/ A
Somalia N/ A 9. 7 N/ A N/ A = Not available. Source: USAID and UNAIDS.

Social Stigma and Traditional The social stigma surrounding issues of sex
and death in African culture

Beliefs Contribute to the Spread makes it difficult to discuss the risks of
HIV/ AIDS and measures to prevent of HIV/ AIDS

the disease. A 2000 report by the Congressional Research Service 11 notes
that unwillingness by religious or community leaders to discuss condom 11
Raymond W. Copson,“ AIDS in Africa” (Washington D. C.: the
Congressional Research Service, June 2000).

use or risky behavior limits efforts to introduce condoms or HIV testing as
ways to prevent further spread of the disease. According to UNAIDS,
discrimination may also lead people who are infected to hide their status to
protect themselves and their families from shame. For example, a 2000 UNAIDS
report 12 stated that in 1999 in Rusinga Island, Kenya, children whose
parents had died of AIDS would tell others that witchcraft or a curse had
been the cause of death instead. Traditional beliefs and practices in sub-
Saharan Africa also contribute to the spread of the disease and limit

the effectiveness of prevention programs. For example, a common custom
promoted by traditional healers in Zambia is for a widow to engage in sexual
relations to “cleanse” herself of the spirit of the deceased.
Low Socioeconomic Status of Transmission of HIV in sub- Saharan Africa is
primarily from heterosexual Women Impedes Their Ability to

contact and, unlike other places in the world where men have higher rates
Take Precautions Against of infection, 55 percent of people with AIDS in the
region are women. Infection

According to UNAIDS, African girls aged 15 to 19 are approximately eight
times more likely to be HIV positive than are boys their own age. Between
the ages of 20 and 24, women are still three times more likely to be
infected than men their age. These young women are usually infected by older
men, often through coerced or forced sex, according to the Congressional
Research Service. The higher infection rates among women are due, in part,
to the higher vulnerability of the female reproductive tract to infection.
However, according to UNAIDS, high infection rates are also caused by
women's limited ability to make informed choices to prevent the disease, due
to their low socioeconomic status. Low levels of education for

women in the region make it more difficult for them to find work, forcing
them to rely on men for economic sustenance. According to USAID, laws in
some countries, such as Kenya, do not allow women to inherit property. As a
result, with no job skills or education, a woman may choose prostitution

to support her children following the death of her spouse. In addition,
because women lack economic resources of their own and may fear abandonment
by or violence from their male partners, they have little or no

control over how and when they have sex. According to UNAIDS, a woman may be
fearful to ask her male partner to use a condom because he may interpret her
actions as implying that she knows of his infidelities or that she has been
unfaithful.

12 “Report on the Global HIV/ AIDS Epidemic” (Geneva,
Switzerland: Joint United Nations Programme on HIV/ AIDS, June 2000).

Weak Health Care Systems Make The epidemic is overwhelming the already
fragile health care systems in It Difficult to Stem the Epidemic sub-
Saharan Africa, 13 and weak health care infrastructure is a barrier to
diagnosis, treatment, and care of the affected populations. For example, in

many countries in the region, up to one- half of the population does not
have access to health care. The countries of the region frequently lack
basic commodities such as syringes as well as safe drug storage,
laboratories, and trained clinicians. Further, according to USAID, mother-
to- child transmission of HIV is increased by the lack of access to drugs
that block HIV replication, while this treatment has reduced mother- to-
child transmission to less than 1 percent in developed countries. According
to UNAIDS, AIDS patients take up a majority of the hospital beds in many
cities, leaving non- AIDS patients without adequate care. For example, a
2000 World Bank report 14 notes that in Cï¿½te d'Ivoire, Zambia, and Zimbabwe,
HIV- infected patients occupy 50 to 80 percent of all beds in

urban hospitals. Military and Police Have Been

According to the National Intelligence Council, HIV prevalence in African
Difficult to Reach With militaries is considerably higher than that of the
general population. The Prevention Efforts

Council estimates prevalence rates of 10 to 60 percent among military
personnel in the region. For example, the HIV infection rate for the armed
forces of Tanzania is estimated to be 15 to 30 percent, compared with about
an 8 percent prevalence rate for the general population. According to USAID,
in developing countries, military and police forces generally tend to

be a young and highly mobile population that spends extended periods of time
away from families and home communities. As a group, this population is
likely to have more contact with casual sexual partners and commercial sex
workers and engage in high- risk sexual behavior. As a result, the group is
at increased risk of acquiring HIV/ AIDS and transmitting it to the general
population. Military and police forces have constant interaction with
civilian populations where they are posted; therefore, they

have been identified as an important target group for campaigns for the
prevention and mitigation of HIV/ AIDS. However, according to USAID,
militaries have been unwilling to release detailed reports on HIV prevalence
among troops, which has limited the ability of donor assistance 13 In 2000,
the World Health Organization ranked the overall health system performance
of its 191 members using factors such as health expenditures per capita. Of
40 sub- Saharan

African countries, 38 ranked between 132 and 191, in the bottom third of
rankings. The remaining two countries, Senegal and Benin, ranked 59th and
97th, respectively. 14 Intensifying Action Against HIV/ AIDS in Africa:
Responding to a Development Crisis (Washington, D. C.: The World Bank,
2000).

groups such as USAID from working with African militaries and police forces.
Another factor limiting USAID in working with African military and police
forces is a legislative restriction prohibiting assistance for training,
advice, or financial support to foreign military and law enforcement forces.
15 In 1996, USAID's General Counsel took the position that the restrictions
do

not prohibit participation of foreign police or military forces in USAID's
HIV/ AIDS prevention programs if three conditions are met: (1) the programs
for police and military forces are part of a larger public health
initiative, and exclusion of these groups would impair achievement of the

overall public health objectives; (2) the programs must be the same as those
offered to the general population; and (3) neither the programs nor any
commodities transferred under them can be readily adapted for law
enforcement, military, or internal security functions. A USAID official in
one country told us that the USAID legal adviser in her region requires a

justification for each activity directed toward police or military forces
and that this is a disincentive to pursuing such activities. Overall, we
found that only 8 of the 19 missions reported working with the military or
police forces. The mission in Nigeria indicated that it has provided HIV/
AIDS

prevention and impact mitigation services to military and police personnel.
Also, the USAID missions in Ethiopia and Guinea have promoted condom
acceptability and use among military personnel. National Governments Have

Most national governments in sub- Saharan Africa have been slow to put Been
Slow to Respond effective HIV/ AIDS policies in place. According to the
World Health Organization, many countries in sub- Saharan Africa have not
developed or completed a national strategic plan for reducing HIV/ AIDS or
provided

sufficient resources or official support for HIV prevention efforts. For
example, until 1999, the President of Zimbabwe denied that AIDS was a
problem, and the President of Kenya did not endorse the use of condoms as a
prevention method. In contrast, the President of Uganda has led a successful
campaign against AIDS in his country, which, according to the Director of
the Office of National AIDS Policy, contributed to the decrease in HIV
prevalence.

15 Section 660 of the Foreign Assistance Act of 1961, as amended (22 U. S.
C. 2420), prohibits the provision of training, advice, or financial support
for police, prisons, or other law enforcement forces, subject to the
exceptions of the act's section 660. In addition, principles

of appropriation law generally prohibit the use of foreign assistance funds
for military purposes.

USAID Made USAID has contributed to the fight against HIV/ AIDS in sub-
Saharan Africa,

Contributions but Has particularly through country- level activities,
including education and counseling; condom promotion and distribution; and
improved prevention,

Difficulty Measuring Its diagnosis, and treatment of sexually transmitted
infections. In addition,

Overall Impact on USAID's Global and Africa bureaus supported various
activities in the areas

Reducing HIV of research, capacity building, integration of HIV/ AIDS
prevention activities into other development efforts, and advocacy for
policy reform. (See app. II Transmission

for a description of specific contributions made by the Global and Africa
bureaus in these areas.) However, measuring the impact of HIV/ AIDS
interventions on reducing transmission of the virus is difficult, according
to experts at Family Health International and the University of California
Los Angeles. Overlapping contributions of HIV/ AIDS prevention programs of
national governments and of other donors make direct causal linkage of
behavior or prevalence

changes to USAID's activities hard to measure. To assess its programs, USAID
must rely on proxy measures because HIV has a long latency period, and
limited surveillance data are available in the region. Generally accepted
proxy measures include knowledge of HIV/ AIDS and sexual

behavior changes, such as increased condom use. However, gaps in data
gathering and reporting, including the inconsistent use of indicators and
the lack of a routine system for reporting program results, further limit
USAID's ability to measure its overall impact on reducing HIV transmission.

USAID Activities Focused USAID has focused its HIV/ AIDS prevention
activities in sub- Saharan on Three Key Interventions

Africa on three interventions that have been proven to be effective in the
Targeted to High- Risk

global fight against the epidemic: behavior change communications, Groups

condom social marketing, and treatment and management of sexually
transmitted infections. USAID missions and regional offices in sub- Saharan
Africa targeted their HIV/ AIDS prevention activities to high- risk groups,
such as commercial sex workers and interstate truck drivers. USAID maintains
that a targeted approach remains the best way to reduce the number of new
infections in the general population and to allow for more

efficient use of limited HIV/ AIDS prevention funds. Because of the
difficulty obtaining accurate information on incidence and prevalence,
however, USAID must rely on proxy indicators to measure the impact of its

HIV/ AIDS programs. Behavior Change

USAID promotes behavior change through voluntary counseling and
Communications information campaigns to heighten awareness of the risks of
contracting

HIV/ AIDS and spreading it to others. Specifically, these activities are to
help motivate behavior change, heighten the appeal of health products and
services, and decrease the stigma related to purchase and use of condoms.
For example, the mission in Nigeria reported supporting an information

campaign among sex workers, transport workers, and youth to increase condom
use. In addition, the mission in Malawi supported voluntary HIV testing and
counseling services in two cities, Lilongwe and Blantyre.

Ten USAID missions and one regional office that conducted behavior change
communication activities reported increased knowledge and awareness about
HIV/ AIDS, to measure the effectiveness of these types of programs. For
example, six missions and one regional office provided information that
showed an increase in knowledge of condoms as a means of preventing HIV
infection among people surveyed. The mission in Ghana reported that there
was an increase in the proportion of people who knew

that a healthy- looking person could have HIV (from 70 percent of women and
77 percent of men in 1993 to 75 percent and 82 percent, respectively, in
1998) but reported no change in the proportion who were aware of mother- to-
child transmission (82 percent of women and 85 percent of men

in 1993; 83 percent and 85 percent, respectively, in 1998). Moreover,
surveys conducted for the mission in Tanzania showed that, between 1994 and
1999, the percentage of women who could name three ways to avoid getting
HIV/ AIDS increased from 11.4 percent to 24.2 percent. In the same country,
the increase for men was from 22.6 percent to 28. 6 percent. USAID has also
attempted to measure the effectiveness of behavior change communication
activities to help change sexual behavior. In seven

countries where USAID undertook such prevention programs, surveys suggested
reductions in risky sexual behavior. For example, in Senegal, more men and
women who were surveyed reported having used a condom in 1999 than in 1992.
More male youth surveyed reported that they were using condoms with their
nonregular sex partners in 1998 than in 1997. The

same sexual behavior survey of female commercial sex workers showed an
increased use of condoms with regular clients; however, female commercial
sex workers also reported less frequent use of condoms with their nonregular
partners. Also in Senegal, a greater percentage of girls reported in 1998
that they had never had sex compared to a prior survey

conducted in 1997. However, there was no change for boys. In Zambia, more
sexually active women who were surveyed in 1998 reported having ever used a
condom than in a similar survey in 1992, and in 1998, fewer married men in
Zambia's capital city reported having had extramarital sex

than in a survey conducted 8 years earlier.

Condom Social Marketing Condom social marketing, which relies on increasing
the availability, attractiveness, and demand for condoms through advertising
and public promotion, is another intervention that USAID supports at the
country level. It is well established that condoms are an effective means to
prevent the transmission of the HIV virus during sexual contact. The
challenge for HIV/ AIDS prevention then is one of expanded acceptance,
availability, and

use by high- risk groups. USAID projects in sub- Saharan Africa encourage
production and marketing of condoms by the private sector to ensure the
availability of affordable, quality condoms when and where people need them.

USAID uses sales of condoms marketed through its program as a measure of the
results of its condom promotion activities. USAID missions in 15 of 19
countries and one of three regional offices reported increased condom sales,
with decreased sales reported in Malawi and Uganda. 16 According to

a USAID contractor, sales of condoms promoted under USAID's program
decreased in Malawi because of an economic downturn in that country and
because another donor was providing free condoms. Sales in Uganda were
affected by the introduction of a competing brand of condoms distributed by
another donor. Between 1997 and 1999, the number of condoms sold more than
doubled in Benin, from 2.9 million to 6. 5 million, and increased in
Zimbabwe from 2 million to 9 million. Condom sales in the Democratic
Republic of the Congo grew more than 800 percent, from about 1 million in
1998 to 8.4 million in 1999. The number of sales outlets carrying socially
marketed condoms also increased in Benin, Guinea, Malawi, and

Mozambique. In addition to male condom marketing, five missions conducted
social marketing of female condoms. Between 1998 and 1999, female condom
sales increased in three of the four countries for which data were available
but decreased in Zambia.

Management of Sexually Management of sexually transmitted infections through
improved

Transmitted Infections prevention, diagnosis, and treatment is another
important component of USAID's HIV/ AIDS efforts, because the risk of HIV
transmission is significantly higher when other infections, such as genital
herpes, are

present. USAID has continued to support standardized diagnosis and treatment
of sexually transmitted infections. For example, in Madagascar, USAID's
program supported improved diagnosis and treatment by targeting 16 USAID
missions in Mali and Rwanda and the USAID East Africa and Southern Africa
regional offices were in the process of collecting condom sales data at the
time of this review.

interventions to high- risk populations. USAID has also worked to integrate
the teaching of how to prevent sexually transmitted infections into its
existing reproductive health and outreach activities. As a way to measure
the impact of its activities to improve management of sexually transmitted
infections, USAID tracks the number of people trained in prevention,
diagnosis, and treatment in that area. Seven USAID missions in sub- Saharan
Africa reported assisting in the expansion of services for management of
sexually transmitted infections. For example, USAID

reported that it worked in 10 primary health facilities in Kenya to develop
guidelines for diagnosing symptoms typical of sexually transmitted
infections, and to develop health worker training materials. A total of
1,112 outreach workers and 55 health care providers were trained in sexually
transmitted disease case management. In addition, the mission in Ghana

stated that in 1999 it trained more than 200 medical practitioners and a
total of 502 health care workers in public health facilities in the
management of sexually transmitted infections. In Ghana's police services,
USAID trained

12 health care providers to recognize symptoms of sexually transmitted
infections, trained 65 police peer educators, and helped establish an HIV/
Sexually Transmitted Disease Unit at the police hospital.

Other Prevention Activities In addition to these three main prevention
interventions, USAID missions also implemented activities in other areas. A
few missions had activities aimed at improving the safety of blood for
transfusions. In 2000, for example, the mission in Tanzania began
collaborating with the U. S. Centers for Disease Control and the Tanzanian
Ministry of Health to improve blood safety and clinical protocols. The
mission in Ethiopia continued programs that are directed at strengthening
the capacity of nongovernmental

organizations in the region to provide HIV services, while other missions
worked to promote community involvement in providing care to those persons
living with HIV. Twelve USAID missions and two regional offices promoted
host government advocacy for improved HIV/ AIDS policy environments. Some
missions, such as Malawi, conducted workshops with key decisionmakers

focusing on specific policy issues such as HIV testing and drug treatment
for AIDS patients. The mission in Ghana sought to improve policies for
reproductive health services through advocacy and policy development.
According to USAID, its advocacy and policy development activities in Ghana
led to the development of a national AIDS policy, which at the time of our
review was available for parliamentary approval. Also, the mission in
Nigeria indicated that its advocacy work on behalf of orphans and

vulnerable children led the Nigerian President to announce in 2000 his
intention to pursue free and compulsory education for them. The mission in
Nigeria also reported helping establish three regional networks of people
living with HIV/ AIDS that later served as the precursor for a national HIV/
AIDS support network.

Gaps in Data Collection and Although USAID has collected data about its HIV/
AIDS activities, in

Reporting Hinder USAID's reviewing the information we received from USAID,
we found that the Ability to Measure Overall agency's overall monitoring and
evaluation efforts are weak in three areas: Impact on Reducing HIV

(1) missions and regional offices use inconsistent indicators to measure
program performance, (2) data collection is sporadic, and (3) there is no
Transmission in requirement for missions and regional offices to regularly
report the data Sub- Saharan Africa

they collect. Inconsistent Indicators Are Used USAID's response to our
request for baseline and trend data to demonstrate to Measure Outcomes

program results showed that missions and regional offices did not use
indicators of program outcomes that were consistent over time. Unless the
scope of the missions' surveys and the questions asked remained constant
over time, comparing results would be difficult. For example, a 1994 survey

in Ethiopia asking females to cite at least two ways to prevent HIV focused
on females living in urban areas, whereas a 2000 survey focused on females
nationwide. In another example, ever- use of condoms among men in

Zimbabwe in 1999, as an indicator, did not directly relate to the proportion
of men who in 1994 reported currently using condoms. The missions also did
not link each prevention activity to a performance indicator, as we had
requested, in their written responses to our questions. This made it
difficult for us to assess the progress of the activities. For example, the
mission in Mozambique provided training to health care and non- health care
providers

in the treatment of sexually transmitted infections but did not link
specific performance indicators related to these activities. Data Collection
Is Sporadic Information obtained from USAID showed that the amount and
frequency

of data collection on HIV/ AIDS prevention activities varied considerably.
Several missions had implemented activities only recently, so baselines had
not been established or trend data were still being collected. Ten missions
17 were still in the process of gathering baseline or trend data for many of
17 The USAID missions in Benin, the Democratic Republic of the Congo, Ghana,
Guinea, Kenya, Madagascar, Malawi, Mozambique, Uganda, and Zambia.

their activities. For example, although the mission in Mozambique provided
us with baseline and trend data on condom sales and a baseline for risky
sexual behavior, comparison data for the latter measure will not be
available until 2001. The Democratic Republic of the Congo and

Madagascar have conducted activities in a number of areas, such as treatment
of sexually transmitted infections, but only provided data to us for condom
sales. Three missions that indicated having blood safety programs did not
provide output or outcome measures to evaluate those

programs. These inconsistencies in data collection hindered our ability to
assess whether USAID's HIV/ AIDS prevention activities were meeting USAID's
objectives in sub- Saharan Africa. For example, we could not evaluate 2 of
the 19 missions and two of the three regional offices with HIV/ AIDS
programs because they did not provide any data. 18 Four missions only

provided information on condom sales and distribution. Eleven missions and
one regional office offered a much broader range of information, although
the data provided did not directly relate to all of each program's
indicators or major activities, making it too difficult to evaluate fully
the result of each activity. For example, USAID's Mozambique mission
provided data on condom sales and distribution but not on mission- supported
voluntary counseling and testing activities or on stigma reduction efforts.
USAID Has Few Monitoring and

According to USAID, missions are not required to produce comprehensive
Evaluation Reporting

monitoring and evaluation reports for each HIV/ AIDS activity or indicator.
Requirements

Although in 1998 the Global Bureau established a repository for collecting
and tracking performance data available to USAID organizational structures,
including missions, there is no requirement for the missions to provide
information to that database. Each mission provides USAID's

Africa Bureau with an annual Results Review and Resource Request, in which
the mission presents some results from the previous year in order to justify
budget requests. However, according to senior USAID officials in
headquarters, this report is not a monitoring and evaluation tool. According
to an epidemiologist from the University of California and a USAID
contractor specializing in HIV/ AIDS evaluation, surveillance, and
epidemiological research, regular monitoring and evaluation of HIV

18 These missions and regional offices could not provide baseline and trend
data because their HIV/ AIDS indicators were relatively new at the time of
this review.

prevention programs is necessary to prevent wasting resources on programs
that do not function properly. USAID officials noted that while its missions
use data to track day- to- day operations, the lack of a reporting

requirement affects the agency's ability to generalize about agency
performance and make management and funding decisions based on the data.
This lack also inhibits sharing best practices because the agency cannot
compare across countries which approach may be best. Therefore, allocation
of resources may not be optimal because the agency does not

necessarily know which programs could benefit the most from financial
investments. Without a reporting requirement, the agency has a limited
ability to demonstrate the effectiveness of its programs. For example, USAID
was unable to provide sufficient information as a basis for determining if
it met its 1999 performance goal of reducing HIV transmission and impact in
developing countries to meet the requirements of the Government Performance
and Results Act of 1993. 19

Internal and External USAID has developed a three- pronged approach for
programming the

Factors May Limit 53- percent funding increase from fiscal year 2000 to
fiscal year 2001

($ 114 million to $174 million) for HIV/ AIDS prevention in sub- Saharan
USAID's Ability to Africa. Under this approach, USAID (1) provided
additional funds to Expand its HIV/ AIDS countries designated in need of
assistance, (2) allowed missions to expand

Activities in or implement new activities and services, and (3) developed a
plan for

expanded monitoring and evaluation of the programs. To rank countries for
Sub- Saharan Africa

funding priorities and allocations, USAID's approach used several criteria,
such as HIV/ AIDS prevalence in a country, and economic impacts from the
disease. Separately, USAID identified several internal and external factors
that may affect its ability to expand its HIV/ AIDS activities. USAID has
identified steps to mitigate some of the problems associated with these

factors. USAID's Approach for

USAID identified three categories of countries that are to receive expanded
Allocating HIV/ AIDS

HIV/ AIDS assistance based on their relative priority for action. Four
“Rapid Program Funding and Scale- Up Countries” were designated
as those that will receive significant

Activities increases in assistance for prevention, care, and support
activities “to

achieve measurable impact within 1- to- 2 years.” Eleven
“Intensive Focus 19 Observations on the U. S. Agency for International
Development's Fiscal Year 1999 Performance Report and Fiscal Years 2000 and
2001 Performance Plans (GAO/ NSIAD- 00- 195R, June 2000).

Countries” (including one regional program) will receive a significant
scaling- up of prevention activities and expanded services that will provide
care and support. USAID's plans are to work with other donors in these two
country categories to expand programs to cover at least 80 percent of their
populations with a comprehensive package of prevention and care services.
USAID also plans to expand the scope,

targeted populations, and geographic coverage of current HIV/ AIDS programs
in 10 countries in the “Basic Program Countries” (including two
regional programs).

To determine which countries to include under each category, USAID used a
number of criteria and conducted a worldwide survey of all USAID missions
and regional offices. The criteria included ? the relative severity of the
epidemic in the country, ? the magnitude of the epidemic in the country, ?
the impact of the epidemic on the economy and society, ? the risk of a rapid
increase in HIV prevalence, ? the availability of other funding sources, ?
U. S. national interests, and ? strength of host country partnerships.

USAID planners then supplemented these criteria with the missions' and
regional offices' survey responses. Factors considered were the total level
of resources that could be effectively obligated, the rapidity for
obligating

those funds, the likely programmatic impacts, the nature of new and expanded
activities, and the personnel constraints that might be encountered, among
other items. Table 2 shows the amount of increased funding from fiscal year
2000 to fiscal year 2001, by mission and regional program by category of
country.

Table 2: Funding for USAID HIV/ AIDS in Sub- Saharan Africa, by Mission or
Regional Office for Fiscal Years 2000 and 2001

Dollars in millions

Fiscal year 2000 Fiscal year 2001

Percent Mission/ regional program funding a funding b increase c

Rapid scale- up countries

Uganda $6. 9 $13.5 95. 7 Zambia 7.0 13. 0 85.7 Kenya 5. 7 10. 5 84. 2

Intensive focus countries

Nigeria 6. 8 11. 9 76. 3 South Africa 5. 7 9. 5 66. 7 Namibia 1. 0 1. 5 50.0
Rwanda 3. 5 5. 2 48. 6 Malawi 5. 0 7. 3 45. 0 Mozambique 5.1 6. 7 31. 4
Senegal 3. 7 4. 7 27. 0 Tanzania 6. 0 7.5 25. 0 Ethiopia 6.7 8. 2 22. 4
Ghana 4. 0 4. 5 12.5 West Africa region 7. 4 8. 1 9. 8

Basic program countries

Eritrea 0. 5 1.5 200. 0 Southern Africa region 1.5 4. 0 166.7 Democratic
Republic of

1.5 3. 5 133.3 Congo Benin 1. 0 2.0 97. 6

Madagascar 0. 8 1. 5 87. 5 Angola 1. 0 1.5 50. 0 East/ southern region 1. 2
1. 7 41. 7 Zimbabwe 5. 0 6.5 30. 0 Guinea 1. 7 2. 2 29. 0 Mali 2. 5 3. 2 28.
0

Support to field programs

Global Bureau 19. 4 30. 6 58. 1 Africa Bureau 3. 3 4. 0 21. 2

Tot al d $113. 9 $174.4 53. 1

a Does not include funding for vulnerable children. b Includes funding for
vulnerable children. The total for HIV/ AIDS programs is $162.2 million, and
the

total for vulnerable children programs is $12.3 million. c Percent increase
based on actual, not rounded, funding levels.

d Totals may not add due to rounding. Source: USAID.

New and expanded activities under USAID's scaled- up efforts will include ?
prevention of HIV transmissions from mother to child; ? development of
community- based programs designed to provide care to children affected by
HIV/ AIDS;

? provisions of treatment and prevention of tuberculosis and other
opportunistic diseases; and ? development of multisectoral programs, such as
for girls' education and

finance for economic development efforts. USAID's approach for scaling- up
its HIV/ AIDS programs in fiscal year 2001 included a plan for expanded
monitoring and evaluation of the agency's HIV/ AIDS programs. 20 Under the
plan, USAID expects all missions

receiving HIV/ AIDS funding to collect and report data annually on HIV
prevalence rates for 15- to 24- year- olds, and on condom usage with the
last non- regular sexual partner. Depending on USAID activities in country,
USAID missions may also be required to report periodically on additional
indicators, such as total condoms sold, the percent of target populations
requesting HIV tests, and others included in USAID's “Handbook of
Standard Indicators.” According to USAID, when implemented, these

efforts will be conducted at routine intervals ranging from annual
assessments to surveys conducted every 3 to 5 years. While the monitoring
and evaluation plan applies to all country missions receiving HIV/ AIDS
funding, initial priority will be placed upon rapid scale- up and intensive
focus countries. However, it is not clear when USAID plans to require the
remaining countries to apply the standard indicators and collect and report
the performance data. In addition, the plan does not specify to whom these

performance data will be reported beyond the mission level or how the
information will be used, for example, for resource allocation or
identification of best practices.

20 The Global Bureau and the Centers for Disease Control will provide
funding and technical expertise; missions will be expected to provide some
funding to support the monitoring and evaluation efforts.

Internal Factors May Affect While USAID's approach provides criteria for
funding new USAID activities

USAID's HIV/ AIDS Program to reduce the spread of HIV/ AIDS, USAID officials
reported that a number Expansion

of factors internal to USAID may hamper its efforts to expand HIV/ AIDS
programs in sub- Saharan Africa. These factors include problems with
contracting and procurement, and reported declines in program and

technical staff in both missions and headquarters. Contracting and
Procurement

To deliver HIV/ AIDS assistance programs, USAID uses competitive Problems
contracts and grants, including cooperative agreements. These agreements are
generally made between USAID and private voluntary organizations,

not- for- profit organizations, research centers, universities, and
international organizations. The agreements involve substantial interaction
between USAID and the recipient organization during performance of the

assistance programs. USAID contracting officials reported that, on average,
it takes 210 days for concluding cooperative agreements for the Global
Bureau's population, health, and nutrition activities, which include HIV/
AIDS. This is one of the longest cycles for such agreements within the
federal government. The officials further reported that USAID has been
unable to recruit and retain sufficient numbers of qualified contract
specialists, both in the missions

and in Washington, and, as a result, the workload for the current
specialists is high. For example, USAID reported that in 1998 its
procurement personnel were responsible for $18.3 million worth of agreements
per

specialist. This was relatively higher than for procurement specialists in
other federal agencies, such as the Departments of the Treasury and of
Transportation ($ 5.3 million per specialist) and the Department of Energy
($ 2.9 million per specialist). In addition, USAID reported that currently
each specialist is responsible, on average, for 26 distinct types of
agreements, while some contract specialists in the field are responsible for
procurements in multiple missions and regional programs. USAID officials
said that the agency has worked to lessen the workload burden on contract
specialists by taking such actions as developing a vehicle that allows
missions to contract directly with contract awardees rather than through
USAID headquarters. Agency officials reported that the requirement to
“Buy American” is a second procurement issue that could affect
the timing of USAID's program expansion. According to USAID officials, when
purchasing commodities for assistance programs, USIAD is required to buy
those made in the United States. USAID officials stated that although this
rule may be waived when a

specific commodity required for the program can only be purchased from a
foreign manufacturer, a waiver must be sought each time the commodity is
purchased. According to these officials, the waiver process can take up to 4
weeks for each waiver, depending on the workload of the contracting
specialist, the location of the office applying for the waiver, and the
amount of the purchase. In January 2001, USAID instituted a policy to grant
source and origin waivers for extended periods of time in emergency
situations.

For example, under this policy, USAID has approved an extended waiver
through 2007 for HIV testing kits manufactured off shore. According to
USAID, these kits allow for quicker test results and cost significantly less
than those manufactured in the United States. 21

Personnel Shortages Another factor USAID identified that may affect program
expansion is the lack of sufficiently experienced personnel in missions to
staff the scaled- up programs. From the end of fiscal year 1992 to the end
of fiscal year 1999, total staff levels of USAID foreign service employees
working overseas declined by 40 percent, from just over 1,080 to about 650.
Between the end of fiscal year 1992 and the end of fiscal year 1999, the
total number of overseas foreign service employees working in program
management declined by 41 percent, while those working in support management
(such as financial management and contracts) declined by almost 31 percent.
USAID has tried to compensate for the loss of experienced personnel by

entering into personal service contracts, particularly for support
management positions like procurement. These contracts are short term,
however, and officials stated that the contractors generally lack the
experience, capabilities, and organizational knowledge of permanent
employees.

In addition, USAID reported it lacks sufficient personnel in some missions
with the specialized, technical skills necessary for conducting new
activities. For example, programs designed to reduce the incidence of
mother- to- child HIV transmissions will require professionals experienced
in medical fields, particularly those with nursing and pharmacological
backgrounds. USAID also reports that in developing countries, the labor pool
from which to draw individuals with medical backgrounds is small.
Professionals were often recruited from organizations that provided similar
21 The applicable statute and regulations covering USAID's waiver of the
“buy American”

requirements for pharmaceuticals (including test kits) can be found in
section 604( a) of the Foreign Assistance Act of 1961, as amended, ADS
section 312. 5( a), and in 22 C. F. R. 228.

services- the United Nations, other multinational assistance agencies, and
private voluntary organizations.

External Factors May Also USAID also faces external factors related to the
weak health care Affect USAID's HIV/ AIDS

infrastructure common in sub- Saharan Africa that may affect the agency's
Program Expansion

ability to expand its programs. These factors include a lack of
surveillance, response, and prevention systems; limited numbers of skilled
health care workers; and underdeveloped pharmaceutical distribution
capabilities. Further, the capability of local, nongovernmental organization
sectors to expand the scope of current services and deliver new services is
not known.

Weak Health Care Systems The low level of health care spending as a
proportion of gross domestic product (GDP) derived from publicly financed
health care spending has resulted in poor health care infrastructure and
could affect USAID's efforts to expand and create HIV/ AIDS programs. In
1999, the U. S. Armed Forces Medical Intelligence Center reported that, with
the exception of South Africa, sub- Saharan governments view health care as
a low national priority. World Health Organization data indicate that in
1995, 1.7 percent of

total GDP in sub- Saharan Africa derived from publicly financed health care
spending. This rate was 35 percent lower than the proportion of GDP derived
from publicly financed health care spending for all World Health
Organization member states and 74 percent lower than the Organization's
figures for publicly financed health care spending in the United States. The

Armed Forces Medical Intelligence Center reported that as a result of the
low levels of publicly financed health care spending, the majority of sub-
Saharan African countries have only rudimentary or no domestic systems for
epidemiological surveillance, response, or prevention.

Few Skilled Health Care Workers Another external factor that could affect
USAID's efforts to improve care and treatment for people with AIDS is the
low numbers of skilled health care workers. In a 1998 report, the World
Health Organization showed that in the sub- Saharan African countries in
which USAID maintains missions,

the number of physicians per 100,000 people ranged from a low of 2.3 per
100,000 people in Liberia (1997) to a high of 56.3 per 100,000 people in
South Africa (1996). 22 As a comparison, the ratio for the United States in
22 While the report was issued in 1998, data reflect the most current
information possessed by the Organization, some of which dated to 1994.

1995 was 279 physicians per 100,000 people. The number of nurses per 100,000
people is similarly low. South Africa showed the highest ratio, with 472
nurses per 100,000 people (1996), still less than one- half the rate of

972 per 100,000 in the United States (1996). Without adequate numbers of
health care personnel, it will be difficult for USAID to meet its goals to
improve care and treatment for people with AIDS. Limited Pharmaceutical
Delivery

Underdeveloped pharmaceutical distribution and delivery capabilities
Capabilities

could also affect USAID's ability to provide the drugs needed for the
prevention of mother- to- child HIV transmission and other care and
treatment programs for opportunistic diseases. As stated in a 1999 GAO
report, problems associated with these networks include outdated
refrigeration units; a lack of reliable delivery trucks; and health care
workers who have not been trained in the storage, handling, and usage of the
pharmaceuticals. 23 These factors tend to lead to low coverage rates for

people needing the medicines, as well as high costs due to large amounts of
wasted product. Unknown Capacities of Most indigenous nongovernmental
organizations currently delivering Nongovernmental Organizations

HIV/ AIDS services in sub- Saharan Africa are small and operate solely in
their home localities. However, missions do not routinely assess
nongovernmental organization capacity on a countrywide basis. Therefore, it
is unclear whether in the short term existing nongovernmental organizations
have the capacity to expand their services either to new geographic areas or
by increasing efforts within the presently served area.

In addition, it is unclear whether capacity and technical expertise exist
among nongovernmental organizations to provide new services, such as those
for the prevention of mother- to- child transmission and other treatment and
care. According to USAID, some of the new programmatic activities for this
year's increase will be directed toward helping nongovernmental
organizations develop both technical expertise and managerial systems so
that future year funding increases may be absorbed more readily.

Conclusions The AIDS epidemic in sub- Saharan Africa has grown beyond a
public health problem to become a humanitarian and developmental crisis.
USAID has 23 Global Health: Factors Contributing to Low Vaccination Rates in
Developing Countries (GAO/ NSIAD- 00- 195R, Oct. 15, 1999).

contributed to the fight against HIV/ AIDS in sub- Saharan Africa by
focusing on interventions proven to slow the spread of the disease. However,
USAID's ability to measure the impact of its activities on reducing
transmission of HIV/ AIDS is limited by (1) inconsistent use of performance
indicators, (2) sporadic data collection, and (3) lack of routine reporting
of results to headquarters. As part of its approach for allocating the 53-
percent increase in funding ($ 114 million to $174 million) for HIV/ AIDS
prevention activities in sub- Saharan Africa for fiscal year 2001, USAID
prepared a plan to expand monitoring and evaluation systems in “rapid
scale- up” and “intensive focus countries”- countries
designated as in need of significant increases in assistance. However, when
implemented, the monitoring and evaluation requirements in the plan will not
initially include all countries where USAID missions and regional offices in
sub- Saharan Africa implement HIV/ AIDS programs. Further, the plan does not
specify to whom these data will be reported or how the information will be
used.

Failure to address these issues not only inhibits USAID's ability to measure
the performance of its HIV/ AIDS activities but also hinders the agency's
decision- making regarding allocation of resources among missions and
regional offices and limits efforts to identify best practices.
Recommendations for

To enhance USAID's ability to measure its progress in reducing the spread
Executive Action of HIV/ AIDS in sub- Saharan Africa and better target its
resources, we recommend that the Administrator, USAID, require that all
missions and regional offices that conduct HIV/ AIDS prevention activities

? select standard indicators to measure the progress of their HIV/ AIDS
programs; ? gather performance data, based on these indicators, for key HIV/
AIDS

activities on a regular basis; and ? report performance data to a unit,
designated by the Administrator, for analysis.

Agency Comments We received written comments on a draft of this report from
the U. S. Agency for International Development that are reprinted in
appendix III.

The agency acknowledged our key concern that performance indicators at the
country level were inconsistent to measure progress over time and agreed
that more comparable data are needed to assure better measurement of the
overall impact of its HIV/ AIDS programs. The agency stated that it is
taking important steps, as recommended in the report, to

facilitate the collection and dissemination of comparable national data. We
modified our draft where appropriate to better reflect the agency's
contributions and actions it has recently taken to address some of the
problems identified in our report. In addition, the agency also provided
technical comments to update or clarify key information that we
incorporated, where appropriate.

We are sending this report to appropriate congressional committees and to
the Administrator of USAID. We will also make copies available to other
interested parties upon request. If you or your staff have any questions
concerning this report, please call me at (202) 512- 8979. Other GAO contact
and staff acknowledgments are listed in appendix IV. Sincerely yours,

Joseph A. Christoff, Director International Affairs and Trade

Appendi Appendi xes x I

Objectives, Scope, and Methodology At the request of the Chairman of the
Senate Subcommittee on African Affairs, Committee on Foreign Relations, we
examined the U. S. Agency for International Development's (USAID) efforts to
reduce the spread of the Human Immunodeficiency Virus/ Acquired
Immunodeficiency Syndrome (HIV/ AIDS) epidemic in sub- Saharan Africa.
Specifically, we (1) identified the development and impact of the HIV/ AIDS
epidemic in sub- Saharan Africa and the challenges to slowing its spread,
(2) assessed the extent to which the U. S. Agency for International
Development's initiatives have contributed to the fight against AIDS in sub-
Saharan Africa, and

(3) identified the approach the agency used to allocate increased funding
and the factors that may affect the agency's ability to expand its HIV/ AIDS
program in sub- Saharan Africa in response to this funding.

To identify the development and impact of the HIV/ AIDS epidemic in sub-
Saharan Africa and the challenges to slowing its spread, we spoke with
senior officials from the U. S. Agency for International Development's
Washington, D. C., headquarters (the Global Bureau's HIV/ AIDS Division and
the Africa Bureau), the U. S. Bureau of the Census, the Office of National
AIDS Policy, the State Department, and the Joint United Nations Programme on
HIV/ AIDS (UNAIDS). We reviewed relevant documents and

reports from these agencies and from the U. N. International Labour Office;
the National Intelligence Council; the World Bank; the World Health
Organization; summaries of papers presented at the XIII International AIDS
Conference in Durban, South Africa, in July 2000; and articles from
scientific journals. To assess the extent to which USAID initiatives have
reduced HIV

transmission in sub- Saharan Africa, we reviewed USAID program documents
that described the agency's objective to reduce the transmission and
mitigate the impact of HIV/ AIDS. We reviewed documentation from the Global
Bureau's HIV/ AIDS Division that described the activities and
accomplishments of its portfolio of HIV/ AIDS programs, and we held
discussions with key USAID officials and contractors, including Family
Health International, Population Services International,

TVT Associates, and the Futures Group. To assess the contributions of the
agency's Africa Bureau, we reviewed the Results Review and Resource Request
for the bureau and discussed performance data with key officials. At the
country level, we sent a list of questions about activities, performance
indicators used, and results achieved through fiscal year 2000 to the Africa
Bureau, which distributed the questions to those missions and

regional offices in sub- Saharan Africa that had implemented HIV/ AIDS
activities. We reviewed and consolidated the answers received from

19 USAID field missions and 3 regional offices that had HIV/ AIDS
activities. We examined program performance based on data received, which
included results from local activity records and surveys, demographic and
health surveys, behavioral surveillance surveys, and condom sales. We
included country- specific information gathered from mission and regional
Results Review and Resource Requests for fiscal year 2002, the Global
Bureau's HIV/ AIDS Division, Population Services International, and Family
Health International. We also contacted several missions via e- mail to
follow up on and clarify information they provided in response to our
questions. In addition, we supplemented our work by visiting USAID

missions in Malawi, Tanzania, Uganda, and Zimbabwe and held discussions with
the USAID Population, Health, and Nutrition officers to verify data provided
in the written responses to our questions and to follow up on some key
points. We chose these four countries to work in conjunction with other
ongoing GAO work on disease surveillance in the region. These countries have
some of the highest HIV/ AIDS prevalence rates in the region and provide
perspective on countries with new and established USAID HIV/ AIDS programs.
To discuss the impact of limited monitoring and evaluation data on USAID
strategic planning, budgeting, and dissemination of best practices, we met
with officials from USAID's Bureau of Policy and Program Coordination.

To identify the process USAID used to allocate increased funding and the
factors that may affect how quickly USAID can expand its HIV/ AIDS programs
in the region, we held discussions with officials at USAID headquarters in
Washington from the Global Bureau's HIV/ AIDS Division,

Africa Bureau, and the Office of Procurement. We also conducted interviews
of mission officials based in Kenya, Malawi, Tanzania, Uganda, Zambia, and
Zimbabwe, and personnel employed by private voluntary organizations
providing HIV/ AIDS services under cooperative agreements with USAID. In
addition, we reviewed budgetary, personnel, and

contracting documentation and examined mission responses to a field survey
on implementation of HIV/ AIDS fiscal year 2001 that was conducted by the
Africa Bureau, and planning documents based upon these surveys. Finally, we
reviewed additional information provided by USAID, foreign governmental
health ministries, the United Nations, and other multilateral assistance
agencies. We conducted our work from April 2000 through January 2001 in

accordance with generally accepted government auditing standards.

Contributions of USAID's Global and Africa

Appendi x II

Bureaus In sub- Saharan Africa, USAID primarily implemented HIV/ AIDS
programs through three of its organizational structures: the Global Bureau's
HIV/ AIDS Division, the Africa Bureau, and the field missions and regional
offices. This appendix focuses on the key contributions of USAID's Global
and Africa Bureaus. The Global Bureau provided leadership in the areas of
operations research, technical assistance, and capacity building for
surveillance. The Africa Bureau led the effort to integrate HIV/ AIDS
activities into other sectors of country development programs. We discussed
field mission contributions in the body of this report.

Global Bureau In conducting operations research, the bureau is currently
supporting Contributions 60 ongoing studies to test solutions to problems in
the areas of management of sexually transmitted infections, care and support
services,

and policy analysis and change. Another Global Bureau project, started in
1995, has helped reform host government HIV/ AIDS policies. For example, the
project assisted Ethiopia in developing the regulations that established its
National AIDS Council, which is responsible for coordinating and integrating
HIV/ AIDS initiatives. In addition, the project provided technical
assistance, equipment, and training to the secretariats of the Addis Adaba

Regional AIDS Council, which was formed in February 2000, and the Amhara
Regional HIV/ AIDS Task Force, formed in 1999.

The Global Bureau provided technical assistance through several initiatives.
For example, one project, begun in 1998, provides technical assistance to
the Global Bureau's HIV/ AIDS Division, the regional bureaus, and the field
missions. In addition to being a resource for the expertise needed to design
HIV/ AIDS strategic objectives and plans, the project was initiated to
monitor processes, outcomes, and impacts of HIV/ AIDS prevention programs.
To achieve this goal, the project established a database to aggregate and
disseminate research, implementation, and evaluation assessment findings.
Another initiative was the development of a handbook of standard indicators,
completed in March 2000, for

measuring and evaluating HIV/ AIDS prevention activities. This handbook is
an important step toward providing universal measurement of HIV/ AIDS
prevention programs and could be used for comparison and tracking of program
successes worldwide.

The Global Bureau is also working in concert with the U. S. Centers for
Disease Control to assist countries in sub- Saharan Africa develop
appropriate HIV/ AIDS surveillance guidelines; carry out research to address
how to best measure HIV incidence, 1 and estimate national HIV prevalence;
and provide assistance to USAID missions to develop, improve, and use HIV/
AIDS surveillance systems. According to USAID, the improved national
surveillance systems should be in place to allow for annual measurement of
HIV prevalence beginning in 2001.

Africa Bureau The Africa Bureau provided technical assistance to support
mission

Contributions activities and led the effort to promote the integration of
HIV/ AIDS

prevention efforts into other development activities, such as economic
growth, democracy and governance, education, and agriculture. Because of the
impact of HIV/ AIDS on the economies of the most affected countries,
according to Africa Bureau officials, USAID's strategy for economic growth
must integrate HIV/ AIDS activities to reach successful results. In the same
way, the Africa Bureau is supporting the integration of HIV/ AIDS activities
into democracy and governance programs, including human rights, particularly
those that advocate for women. According to USAID, it is important to
integrate HIV/ AIDS activities into the education sector

because much of the progress made in developing countries over the past
three decades has been due to greater numbers of youth going to school.
Agriculture and natural resource development is important, since sustainable
agriculture is necessary for economic development, and HIV/ AIDS is a factor
that leads to decreased production as more and more people get sick and die.

To help national governments understand the effects of HIV/ AIDS on various
sectors and to help missions advocate for the development of sector-
specific responses to the epidemic, the Africa Bureau funded the

development of a set of toolkits and briefs. For example, the AIDS toolkit
for the Ministry of Education helps officials recognize the internal and
external impacts of HIV/ AIDS- such as higher employee absenteeism and
reduced school enrollment- and identify appropriate action responses. The
commercial agriculture brief indicates how AIDS affects human resources and
agricultural operations and provides some suggestions for

contingency planning to deal with the impact of HIV/ AIDS. The toolkits 1
Incidence is the number of new infections.

were discussed at two regional workshops organized by the University of
Natal as part of a USAID contract held in Durban, South Africa, in 2000. The
first workshop on education resulted in the formation of a task force. The
purpose of the task force was to help ministries of education in different
countries assess the impact of HIV/ AIDS and apply the toolkit. The second

workshop was for officials from the ministries of Planning and Finance. It
offered a forum to discuss the impact of HIV/ AIDS on the economy and
changes in the government and development strategies that may be necessary
to meet the crisis.

Comments From the U. S. Agency for

Appendi x II I International Development Note: GAO comments supplementing
those in the report text appear at the end of this appendix.

See comment 1.

See comment 2. See comment 3.

See comment 4.

The following are GAO's comments on the U. S. Agency for International
Development's letter dated February 23, 2001. GAO Comments 1. USAID
commented that the introduction and conclusions sections of the report did
not reflect its accomplishments as presented in the body of the report. To
highlight their accomplishments, USAID noted that the

agency is the single largest donor in Uganda, Senegal, and Zambia, countries
where the fight against AIDS has been successful. However, the agency fails
to note that other sub- Saharan African countries, where USAID has HIV/ AIDS
programs, have not been as successful in the fight against AIDS. USAID
acknowledges that success in countries is the

result of the combined efforts of national governments, USAID, and other
donors, not exclusively the work of one donor. Finally, appendix II of the
report recognizes many of USAID's contributions in operations research,
technical assistance, and partnerships with other organizations, such as the
U. S. Centers for Disease Control. Nonetheless, we have modified the report
to describe the agency's accomplishments contained in the body of the
report.

2. USAID stated that the report did not fully recognize that performance
data is collected and utilized for decision- making at both the mission and
headquarters and for sharing lessons learned. We modified the report to
clarify that USAID's country- level missions use data to manage day- to- day
operations. However, we found that inconsistent performance indicators and
the lack of routine reporting of results to headquarters limits USAID' s
ability to assess its overall policies and

approaches and thereby develop lessons learned from across all its missions.
The UNAIDS publication cited by USAID is a summary of USAID supported
research efforts shared with its partners. This document does not address
our concern that USAID, based on information reported by its missions,
develop a lessons learned assessment of best practices in combating AIDS
that USAID headquarters can disseminate to all its missions.

3. USAID commented that the report did not cite important actions it has
taken, such as developing a handbook of standardized indicators for HIV/
AIDS programs. This handbook was discussed in the body of the report and
highlighted among the contributions we cited in appendix II. The report
recognized the handbook as an important step toward providing universal
measurement of HIV/ AIDS prevention programs. We have made no additional
changes to the report.

4. USAID commented that the report did not include some important steps that
USAID has taken to overcome internal factors that could hinder HIV/ AIDS
program expansion. USAID provided documentary evidence to support its
assertion that the agency has streamlined its procurement policies for
purchasing HIV/ AIDS diagnostic kits. We therefore modified our report to
add a specific reference to USAID's

initiation of a policy in January 2001 that extends a waiver of the
“Buy American Act” requirements to allow for the purchase of HIV
products manufactured offshore.

Appendi x V I GAO Contact and Staff Acknowledgments GAO Contact John P.
Hutton (202)- 512- 7773 Acknowledgments In addition to Mr. Hutton, David
Bernet, Leslie Bharadwaja, Aleta Hancock,

Lynne Holloway, Jessica Lucas, Rona Mendelsohn, and Tom Zingale made key
contributions to this report.

(711512) Lett er

GAO United States General Accounting Office

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Contents Letter 3 Appendixes Appendix I: Objectives, Scope, and Methodology
36

Appendix II: Contributions of USAID's Global and Africa Bureaus 38 Appendix
III: Comments From the U. S. Agency for International

Development 41 Appendix IV: GAO Contact and Staff Acknowledgments 48

Tables Table 1: USAID's Fiscal Year 2000 HIV/ AIDS Funding in 23 African
Countries, in Order of Per Capita Spending 15 Table 2: Funding for USAID
HIV/ AIDS in Sub- Saharan Africa, by Mission or Regional Office for Fiscal
Years 2000

and 2001 27 Figures Figure 1: The USAID Organizational Structure 7

Figure 2: The Evolution of HIV Prevalence in Africa from 1989 to 1999 8
Figure 3: The Effect of AIDS on Life Expectancies in 13 Sub- Saharan African
Countries, 1999 10 Figure 4: Numbers of AIDS Orphans in 12 African

Countries, 1999 12

Abbreviations

GDP Gross domestic product HIV/ AIDS Human Immunodeficiency Virus/ Acquired
Immunodeficiency

Syndrome USAID U. S. Agency for International Development UNAIDS Joint
United Nations Programme on HIV/ AIDS

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Appendix I

Appendix I Objectives, Scope, and Methodology

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Appendix II

Appendix II Contributions of USAID's Global and Africa Bureaus

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Appendix III

Appendix III Comments From the U. S. Agency for International Development

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