HIV/AIDS: USAID and U.N. Response to the Epidemic in the Developing World
(Chapter Report, 07/24/98, GAO/NSIAD-98-202).

Pursuant to a congressional request, GAO reviewed the human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)
prevention activities of the Agency for International Development (AID)
and the United Nations' (U.N.) Joint Program on HIV/AIDS (UNAIDS),
focusing on the: (1) contributions AID has made to the global effort to
prevent AIDS and the methods AID uses to provide financial oversight
over its AIDS prevention activities; and (2) extent to which the United
Nations has met its goal of leading an expanded and broad-based,
worldwide response to the HIV/AIDS epidemic.

GAO noted that: (1) AID has made important contributions to the fight
against HIV/AIDS; (2) AID-supported research helped to identify
interventions proven to curb the spread of HIV/AIDS that have become the
basic tools for the international response to the epidemic; (3) applying
these interventions, AID projects have increased awareness of the
disease; changed risky behaviors; and increased access to treatment of
sexually transmitted diseases and to condoms, which have helped slow the
spread of the disease in the target groups; (4) under the terms of
cooperative agreements with private implementing organizations, AID
managers are expected to closely monitor projects, but the major
responsibility for internal financial management and control rests with
recipient organizations; (5) AID's financial oversight primarily
consists of conducting preaward evaluations of prospective funding
recipients, reviewing quarterly expenditure reports, and requiring
audits; (6) officials from AID's Office of Inspector General said that
there were no indications of systemic problems from audits conducted;
(7) in its first 2 years of operation, the U.N. has made limited
progress in achieving its goal of leading a broad-based, expanded global
effort against HIV/AIDS; (8) while data indicate that spending by the
cosponsors has not increased, data are not yet available to measure the
U.N.'s progress in increasing spending by donor countries, the private
sector, or affected countries; (9) moreover, theme groups, the forum for
coordinating U.N. efforts in the field, have had a difficult start and,
in some countries, cosponsor agencies are just beginning to work
together; (10) the UNAIDS Secretariat has not been successful in
providing technical assistance and other support to facilitate theme
group activities and performance measures for the U.N.'s HIV/AIDS
programs; and (11) despite the U.N.'s limited progress in meeting its
objectives, GAO observed innovative and low-cost activities that were
implemented by cosponsor agencies.

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

 REPORTNUM:  NSIAD-98-202
     TITLE:  HIV/AIDS: USAID and U.N. Response to the Epidemic in the 
             Developing World
      DATE:  07/24/98
   SUBJECT:  International organizations
             Acquired immunodeficiency syndrome
             Developing countries
             Financial management
             Infectious diseases
             Health care services
             Sexually transmitted diseases
             Health statistics
             International cooperation
IDENTIFIER:  AID AIDS Control and Prevention Project
             AIDS
             U.N. Joint Program on HIV/AIDS
             
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Cover
================================================================ COVER


Report to Congressional Requesters

July 1998

HIV/AIDS - USAID AND U.N. 
RESPONSE TO THE EPIDEMIC IN THE
DEVELOPING WORLD

GAO/NSIAD-98-202

HIV/AIDS

(711298)


Abbreviations
=============================================================== ABBREV

  AIDS - Acquired Immunodeficiency Syndrome
  AIDSCAP - AIDS Control and Prevention Project
  AZT - zidovudine
  GPA - Global Program on AIDS
  HIV - Human Immunodeficiency Virus
  HIV/AIDS - Human Immunodeficiency Virus/Acquired Immunodeficiency
     Syndrome
  NGO - non-governmental organization
  OIG - Office of the Inspector General
  OMB - Office of Management and Budget
  PVO - private voluntary organization
  STD - sexually transmitted disease
  UNAIDS - Joint United Nations Programme on HIV/AIDS
  UNDP - United Nations Development Program
  UNESCO - United Nations Educational, Scientific, and Cultural
     Organization
  UNFPA - United Nations Population Fund
  UNICEF - United Nations Children's Fund
  USAID - U.S.  Agency for International Development
  WHO - World Health Organization

Letter
=============================================================== LETTER


B-280249

July 27, 1998

The Honorable Benjamin Gilman
Chairman, Committee on International Relations
House of Representatives

The Honorable Jim McDermott
House of Representatives

This report responds to your request that we review the Human
Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)
prevention activities of the U.S.  Agency for International
Development (USAID) and the Joint United Nations Programme on
HIV/AIDS (UNAIDS).  Specifically, we examined (1) the contributions
USAID has made to the global effort to prevent AIDS and the methods
USAID uses to provide financial oversight over its AIDS prevention
activities and (2) the extent to which UNAIDS has met its goal of
leading an expanded and broad-based, worldwide response to the
HIV/AIDS epidemic. 

As arranged with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days after the date of this report.  We will then send
copies of this report to the Secretary of State, the Administrator of
USAID, the Director of the Joint United Nations Programme on
HIV/AIDS, and to other appropriate congressional committees.  We will
make copies available to others upon request. 

Please call me at (202) 512-4128 if you or your staff have any
questions.  Major contributors to this report are listed in appendix
V. 

Benjamin F.  Nelson
Director, International Relations
 and Trade Issues


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
(HIV/AIDS) epidemic is spreading rapidly throughout the developing
world, where over 90 percent of the 30 million people living with the
disease reside.  In these countries, the epidemic has begun to erode
gains in health, child survival, education, and economic development. 

Since the mid-1980s, the U.S.  Agency for International Development
(USAID) and the United Nations have established efforts to address
the epidemic.  USAID primarily uses private voluntary organizations
to implement HIV/AIDS prevention activities in developing countries. 
In 1996, the United Nations reorganized its HIV/AIDS program in
response to donor concerns that the U.N.  effort was too heavily
focused on the medical and public health aspects of the disease and
did not sufficiently address the social, economic, and developmental
issues affecting the spread of HIV/AIDS.  In light of the importance
of these efforts to address the HIV/AIDS epidemic in the developing
world, the Chairman, House Committee on International Relations, and
Representative Jim McDermott asked GAO to examine USAID and U.N. 
programs.  This report examines (1) the contributions USAID has made
to the global effort to prevent HIV/AIDS and the methods USAID uses
to provide financial oversight over its HIV/AIDS prevention
activities; and (2) the extent to which the Joint United Nations
Programme on HIV/AIDS (UNAIDS) has met its goal of leading an
expanded and broad-based, worldwide response to the HIV/AIDS
epidemic. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

UNAIDS and the World Health Organization (WHO) estimate that over 30
million people were living with the HIV infection at the end of 1997. 
Most people living with HIV/AIDS reside in the developing
world--two-thirds live in sub-Saharan Africa--where the disease
continues to spread rapidly.  According to the UNAIDS Secretariat,
the number of new infections increased from 3.1 million in 1996 to
5.8 million in 1997.  International donors contribute about $250
million a year to support HIV/AIDS prevention activities in the
developing world.  The United States has been the largest single
donor, contributing $117 million a year, through USAID and in support
of the U.N.  HIV/AIDS program. 

USAID and the United Nations have been important contributors to the
fight against HIV/AIDS since the mid-1980s.  While both the United
Nations and USAID have sought to reduce the spread of the epidemic,
they have somewhat different, yet mutually supporting, roles and
objectives.  As a bilateral agency, USAID works in partnership with
governments, other donors, and private organizations to support
research and implement HIV/AIDS interventions in countries.  The
U.N.'s role is in advocating, mobilizing, and coordinating the
international response worldwide in addition to managing HIV/AIDS
activities in 152 countries. 

USAID began its HIV/AIDS assistance program in 1986, when very little
was known about the epidemic or how to fight it.  USAID's initial
efforts primarily consisted of research on the causes, extent of the
problem, and ways to prevent the disease's spread and of short-term
technical assistance to more than 74 countries.  In the 1990s,
Congress began appropriating more money specifically to combat the
HIV/AIDS problem, and it was elevated to a USAID priority for
planning and budgeting.  USAID developed an agencywide goal to reduce
the number of new HIV infections by identifying and applying
interventions to prevent HIV transmission.  It designed targeted
programs to meet this goal and, by 1997, USAID was directly
supporting major HIV/AIDS programs in 28 countries.  USAID relied
heavily on cooperative agreements\1 with the private sector to
implement its program.  Under the terms of these agreements, the
primary financial oversight responsibility is on the funding
recipient. 

The U.N.  efforts to address HIV/AIDS began in 1987 under the
auspices of WHO.  WHO provided technical and financial support to
fight the epidemic worldwide, primarily focusing on the medical and
public health aspects of the disease.  By the early 1990s, the United
Nations and donors agreed that a more comprehensive approach was
needed.  On January 1, 1996, UNAIDS replaced WHO's Global Program on
AIDS in an attempt to draw upon the experience and skills of all U.N. 
agencies. 

UNAIDS is composed of six U.N.  agency cosponsors\2 and a
Secretariat, which is the coordinating unit.  When forming UNAIDS,
the cosponsor agencies agreed to increase resources devoted to
HIV/AIDS activities; to mobilize resources for HIV/AIDS in affected
countries, including increased private sector involvement; and to
coordinate with other cosponsor agencies at the country level.  The
UNAIDS Secretariat was expected to (1) advocate increased political
and financial support for HIV/AIDS activities; (2) develop a
framework for measuring the performance and objectives of HIV/AIDS
activities; (3) organize entities at the country level--called "theme
groups"--as the forum for coordinating U.N.  efforts; and (4) provide
technical support and information to theme groups on what activities
work best to facilitate development and implementation of national
HIV/AIDS strategies.  The biennial budget for the UNAIDS Secretariat
in 1996-97 was $120 million, of which the United States contributed
$34 million, or about 28 percent. 


--------------------
\1 A cooperative agreement is a funding mechanism used by a federal
agency to transfer funds to an organization to support an agency
program. 

\2 UNAIDS consists of the following six agencies:  the United Nations
Children's Fund (UNICEF); the United Nations Development Program
(UNDP); the United Nations Population Fund (UNFPA); the United
Nations Educational, Scientific and Cultural Organization (UNESCO);
WHO; and the World Bank. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

Despite the continued spread of HIV/AIDS in many countries, USAID has
made important contributions to the fight against HIV/AIDS. 
USAID-supported research helped to identify interventions proven to
curb the spread of HIV/AIDS that have become the basic tools for the
international response to the epidemic.  Applying these
interventions, USAID projects have increased awareness of the
disease; changed risky behaviors; and increased access to treatment
of sexually transmitted diseases and to condoms, which have helped
slow the spread of the disease in target groups. 

Under the terms of cooperative agreements with private implementing
organizations, USAID managers are expected to closely monitor
projects, but the major responsibility for internal financial
management and control rests with recipient organizations.  USAID's
financial oversight primarily consists of conducting pre-award
evaluations of prospective funding recipients, reviewing quarterly
expenditure reports, and requiring audits.  Officials from USAID's
Office of the Inspector General said that there were no indications
of systemic problems from audits conducted. 

In its first 2 years of operation, UNAIDS has made limited progress
in achieving its goal of leading a broad-based, expanded global
effort against HIV/AIDS.  While available information indicates that
spending by the cosponsors has not increased, data are not yet
available to measure UNAIDS' progress in increasing spending by donor
countries, the private sector, or affected countries.\3 Moreover,
theme groups, the forum for coordinating U.N.  efforts in the field,
have had a difficult start and, in some countries, cosponsor agencies
are just beginning to work together.  Finally, the UNAIDS Secretariat
has not been successful in providing technical assistance and other
support to facilitate theme group activities and has only recently
begun to establish a framework for developing performance measures
for the U.N.'s HIV/AIDS programs.  Despite UNAIDS' limited progress
in meeting its broader coordination and resource mobilization
objectives, GAO observed innovative activities that were implemented
by cosponsor agencies.\4


--------------------
\3 Throughout this report, reference to U.N.  funding for HIV/AIDS
activities is limited to the six cosponsoring agencies and the
Secretariat. 

\4 GAO conducted fieldwork in the Dominican Republic, Honduras,
India, the Philippines, and Zambia. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


   USAID FUNDED DEVELOPMENT AND
   IMPLEMENTATION OF EFFECTIVE
   INTERVENTIONS
---------------------------------------------------------- Chapter 0:5

The interventions developed, in part, by USAID-supported efforts,
have become the basic tools for HIV/AIDS prevention.  They are

  -- information, education, and counseling to raise awareness of the
     threat of HIV/AIDS in an effort to promote behavior changes,
     such as abstinence, that will reduce risk;

  -- treatment of sexually transmitted diseases which, if untreated,
     can facilitate transmission of the HIV virus; and

  -- promotion of increased condom use through condom "social
     marketing," or advertising the availability and appeal of using
     condoms. 

In elevating HIV/AIDS prevention to an agency priority, USAID devised
a strategy that relies on development and application of
interventions in target groups based on specific country needs. 
Programs in countries GAO visited focused on the high-risk groups
that spread the disease and used proven interventions to change
behavior and reduce the chance of infection. 

These interventions have been proven to have an impact on HIV/AIDS
because they result in behavior changes that reduce the risk of
disease transmission.  However, it is difficult to determine the link
between a particular activity or program and reductions in the
incidence of HIV/AIDS because of the long incubation period for the
disease; a person can be infected as a result of activity from 7 to
10 years previously.  Thus, in addition to blood testing to measure
the impacts of its HIV/AIDS activities in target groups, USAID also
relies upon proxy indicators, such as behavioral change.  Public
health experts agree that the proxy indicators used by USAID are
reasonable indicators of changes in HIV incidence. 

GAO's review of internal and external evaluations, conducted by
technical experts from the public and private sectors and academia,
and other data collection efforts, as well as discussions with
representatives of high-risk groups, found that USAID projects have
increased knowledge of HIV, changed risky behaviors, and increased
access to treatment for sexually transmitted diseases and to condoms,
thus helping slow the spread of the disease in targeted groups such
as commercial sex workers.  Evaluations conducted for USAID's largest
project, the AIDS Control and Prevention Project (AIDSCAP),
determined that its activities were successful in the countries where
it had projects.  For example, in the Dominican Republic, USAID found
that commercial sex workers and tourist resort staff were the primary
conduits for HIV/AIDS.  USAID focused its efforts on these groups,
providing information about the disease to the workers, distributing
condoms, and counseling them on alternative employment options.  The
percentage of HIV-positive commercial sex workers at one clinic
funded by USAID slowed from 5.8 percent in 1995 to 3.3 percent in
1996. 


      NATURE OF USAID'S FINANCIAL
      OVERSIGHT
-------------------------------------------------------- Chapter 0:5.1

Following direction from Congress, USAID primarily relies on
U.S.-based private voluntary organizations and indigenous
nongovernmental organizations to implement its HIV/AIDS programs. 
USAID has mainly used cooperative agreements to fund these
organizations' efforts.  Under these agreements, project managers are
expected to be substantially involved in planning and monitoring
project progress; however, recipient organizations have the primary
responsibility for their internal financial management and control. 
According to USAID officials, these agreements provide maximum
flexibility to USAID and its private partners to design, implement,
and change work plans without a formal process for review and
approval. 

USAID's financial oversight generally consists of (1) conducting
pre-award evaluations to determine if a recipient has appropriate
financial and management systems in place to handle the USAID
financing; (2) reviewing quarterly expenditure reports submitted by
the funding recipient to monitor the level of funds expended; and (3)
obtaining annual external audits which, in accordance with the Single
Audit Act,\5 provide information to oversight officials and program
managers on whether funding recipients' financial statements are
fairly presented.  The audits are also intended to provide reasonable
assurance that federal assistance programs are carried out in
accordance with applicable laws and regulations.  The annual single
audit reports of USAID's $200 million, 6-year AIDSCAP project did not
indicate any financial management or reporting problems.  The Office
of the Inspector General determined that there were no indications
from audits conducted that systemic problems existed. 


--------------------
\5 The Single Audit Act of 1984 (31 U.S.C.  7501-7507), requires
organizations that meet a minimum threshold of federal funding to
undergo a single, nonfederal audit each year. 


   UNAIDS HAS MADE LIMITED
   PROGRESS TOWARD MEETING ITS
   GOAL
---------------------------------------------------------- Chapter 0:6

UNAIDS has made limited progress toward achieving its goal of leading
a broad-based, expanded global response to HIV/AIDS.  Expenditure
data for cosponsor agencies indicate that U.N.  spending has not
increased since the establishment of UNAIDS, but data are not
available to measure spending from other sources.  At the country
level, the success of theme groups has been uneven.  The UNAIDS
Secretariat has not provided support to facilitate country programs. 


      HIV/AIDS SPENDING BY
      COSPONSOR AGENCIES HAS NOT
      INCREASED
-------------------------------------------------------- Chapter 0:6.1

Although one of UNAIDS' objectives was to increase resources devoted
to HIV/AIDS by cosponsor agencies, spending on HIV/AIDS has not risen
since the creation of UNAIDS.  Instead, spending declined from $337
million in 1994-95 to $332 million in 1996-97.  While UNFPA and UNDP
increased spending for HIV/AIDS after UNAIDS was established and
UNESCO began programming for HIV/AIDS activities, these increases
were outweighed by decreased expenditures by the World Bank and
UNICEF.  The decline in U.N.  spending for HIV/AIDS occurred despite
an increase in overall spending by cosponsor agencies of 6.5 percent. 


      DATA ARE NOT AVAILABLE TO
      MEASURE PROGRESS IN
      MOBILIZING RESOURCES FROM
      OTHER SOURCES
-------------------------------------------------------- Chapter 0:6.2

One of UNAIDS' objectives was to increase spending by donors and
affected countries and to increase private sector involvement in
fighting the epidemic.  However, the UNAIDS Secretariat is still
analyzing survey data that should assist in developing a baseline to
measure UNAIDS' progress in mobilizing donor and affected country
resources.\6

Preliminary data from the survey indicate that contributions from
major donors\7 remained relatively stable between 1993 and 1996 at
about $250 million a year.  Data for 1997 were not available. 
Despite Secretariat efforts at the international level to encourage
private sector involvement in the fight against HIV/AIDS, the UNAIDS
Secretariat reports that private sector HIV/AIDS activities have
remained limited to date.  GAO's work in the field and the
Secretariat's reports indicate that at the country level U.N. 
agencies have only made limited efforts to encourage private sector
support of HIV/AIDS activities.  U.N.  officials offered several
reasons for the lack of private involvement, including inadequate
information about the impact of the disease on its workforce and the
lack of government encouragement. 


--------------------
\6 Study on the National and International Financing of the National
Response to HIV/AIDS, UNAIDS/PCB(6)/98.3 (Geneva, Switzerland:  May
24, 1998). 

\7 Major donors were identified by the United Nations as Australia,
Canada, Denmark, France, Germany, Japan, Luxembourg, the Netherlands,
Norway, Sweden, the United Kingdom, and the United States. 


      DIFFICULT BEGINNING FOR
      THEME GROUPS
-------------------------------------------------------- Chapter 0:6.3

The UNAIDS Secretariat was expected to organize theme groups as the
forum for coordinating cosponsor agency activity in the field. 
Cosponsor agencies were expected to work together in the theme groups
to support national governments' HIV/AIDS programs.  UNAIDS' surveys
of theme groups and GAO's work in the field indicate that cosponsor
agencies met regularly and even conducted joint projects in some
countries, such as the Dominican Republic.  In others, such as
Honduras and India, representatives rarely met.  Despite the presence
of World Bank projects in three of the five countries GAO visited,
the World Bank representative did not attend any of the theme group
meetings.  A 1997 survey of theme groups, compiled by the Secretariat
after GAO conducted its fieldwork, showed that theme groups were
making some progress in working together.  However, in areas where
the groups reported progress, such as national resource mobilization,
less than half of the theme groups that responded to the survey were
operating effectively.  U.N.  officials reported several reasons for
theme group difficulties:  (1) lack of guidance to agency field
representatives regarding how theme groups should operate and what
the scope of their mission should be, (2) lack of individual
accountability for theme group success, and (3) lack of commitment to
working together in theme groups because of concerns held by some
cosponsor representatives about the role of UNAIDS as the
organizational vehicle for the U.N.  response.  Officials from the
UNAIDS Secretariat said that they met with cosponsor agencies in
March 1998 to address these problems and develop strategies to
improve theme group coordination. 


      UNAIDS SECRETARIAT HAS NOT
      PROVIDED SUPPORT REQUIRED TO
      FACILITATE COUNTRY PROGRAMS
-------------------------------------------------------- Chapter 0:6.4

Despite being directed by its governing board to develop a framework
for measuring the performance of the U.N.'s HIV/AIDS programs within
a year of UNAIDS' establishment, the UNAIDS Secretariat has been slow
to create an evaluation framework.  Only recently has the
Secretariat:  (1) staffed the evaluation unit that is charged with
developing performance measures and (2) funded a survey to gather
data on spending by donors and affected countries on HIV/AIDS.  The
survey data are necessary to measure UNAIDS' progress toward meeting
its objectives.  In addition, in countries GAO visited, cosponsor
agency officials did not think that best practices information and
technical support available from the UNAIDS Secretariat were useful. 
For example, U.N.  officials told GAO that the best practices
information was too theoretical and lacked project implementation
guidance.  Cosponsor agency officials also said they rarely used
technical support from the Secretariat because it was not tailored to
their specific needs and, in some cases, they were not aware of its
availability.  Secretariat officials acknowledged deficiencies in its
country support activities and have begun to develop more
country-specific materials that include implementation guidance. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:7

GAO is making no recommendations in this report. 


   AGENCY COMMENTS AND GAO'S
   EVALUATION
---------------------------------------------------------- Chapter 0:8

USAID, the Department of State, the Department of Health and Human
Services, and the UNAIDS Secretariat provided written comments on a
draft of this report.  These agencies emphasized the unique and
important role UNAIDS plays in the global fight against HIV/AIDS. 
USAID, the UNAIDS Secretariat, and State had concerns about
information GAO presented on UNAIDS.  The agencies' comments and
GAO's detailed evaluation of them are included in the report where
appropriate. 

USAID shared GAO's concerns about the areas in which UNAIDS has not
made sufficient progress and noted that it is working with UNAIDS to
strengthen UNAIDS' role.  USAID, State, and the UNAIDS Secretariat
noted that UNAIDS has only been in existence for 2-1/2 years and were
concerned that it may have been too early to assess the program. 
State also said it was disappointed at the very negative tone in the
report concerning UNAIDS' activities and believed that the report did
not give any credit to UNAIDS for what it had achieved.  Furthermore,
State said that GAO implied that U.N.  agencies and the U.S. 
government should stop supporting UNAIDS.  The UNAIDS Secretariat
stated that it was pleased with the overall presentation and
objectivity of the report but was concerned that GAO's presentation
of USAID's and UNAIDS' programs obscured the important distinctions
between them.  The Secretariat also noted that it had expected a more
positive perspective on the program. 

GAO agrees that UNAIDS plays an important and unique role in the
global response to HIV/AIDS and clarified the report to better
reflect the distinction between the UNAIDS and USAID's program. 
While GAO recognizes that UNAIDS has been in existence for only 2-1/2
years, GAO did not evaluate the program's impact on the HIV/AIDS
epidemic.  In its report, GAO presents the facts as it found them to
be, including areas needing improvement and areas that have worked
well.  In fact, the report specifically identifies UNAIDS'
accomplishments, including information on innovative grassroots
interventions.  Also, GAO did not evaluate whether support for UNAIDS
should be continued.  GAO's objective, as stated in the report, was
to examine the program's progress, since its inception, in meeting
established objectives such as increasing resources devoted to
HIV/AIDS and working together in theme groups at the country level. 


INTRODUCTION
============================================================ Chapter 1


   THE EXTENT AND IMPACT OF THE
   HUMAN IMMUNODEFICIENCY
   VIRUS/ACQUIRED IMMUNODEFICIENCY
   SYNDROME EPIDEMIC
---------------------------------------------------------- Chapter 1:1

The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
(HIV/AIDS)\1 epidemic continues to spread rapidly in the developing
world, where more than 90 percent of the 30 million people living
with the HIV infection live (see fig.  1.1).  Moreover, the UNAIDS
Secretariat recently reported that more than 90 percent of the 5.8
million new infections in 1997 (up from 3.1 million in 1996) were in
developing countries (see fig.  1.2).  Sub-Saharan Africa has the
worst infection rate, accounting for 3.4 million new infections in
1997.  In that region,
7.4 percent of people aged 15 to 49 are infected.  Estimates for
South and South-East Asia indicate the disease is also rapidly
spreading in that region, with 6.4 million currently living with
HIV/AIDS and 1.3 million new infections in 1997. 

   Figure 1.1:  Map of HIV/AIDS
   Prevalence, 1997

   (See figure in printed
   edition.)

   Sources:  The Joint United
   Nations Programme on HIV/AIDS
   (UNAIDS) and the World Health
   Organization (WHO).

   (See figure in printed
   edition.)

   Figure 1.2:  Annual Number of
   New HIV Infections in Selected
   Regions, 1980-97

   (See figure in printed
   edition.)

\a Established market economies include North America, Western
Europe, Australia, and New Zealand. 

Source:  UNAIDS. 

In many developing countries, HIV/AIDS has begun to erode decades of
gains in health, child survival, life expectancy, education, and
economic development.  For example, U.S.  Bureau of the Census
projections for Zambia indicate that by 2010, AIDS may increase
infant mortality rates nearly 60 percent higher than would have been
expected without the disease.  Similarly, projections for Zimbabwe
indicate that by 2010, life expectancy will decline from 70 years to
less than 35 years as a result of AIDS and in Uganda from 54.5 years
to 35.5 years.  Since the start of the epidemic, more than 8 million
children have lost either their mother or their father because of
AIDS.  AIDS' impact on families and public health systems is
weakening economies as people in their prime working years are
afflicted by the disease and governments and families divert scarce
resources to care for them for extended periods of time. 

The donor community is spending approximately $250 million a year to
address the HIV/AIDS epidemic in the developing world.  The United
States is the largest single donor, contributing $117 million in 1997
through the U.S.  Agency for International Development (USAID) that
includes specific support for UNAIDS.  However, HIV/AIDS poses
serious challenges to the world community because of the extent of
the epidemic and the cost and difficulty of changing deeply rooted
traditions and behaviors that contribute to the spread of the
disease:  according to a study commissioned by WHO, between $1.5
billion and $2.9 billion would be needed from donors and affected
countries annually to implement behavioral and blood safety
strategies to prevent HIV/AIDS in developing countries.  Moreover,
other epidemics had their roots essentially in medical problems and
could be addressed through biomedical remedies from public health
systems.  However, absent a vaccination or cure, slowing the reach of
the virus must be accomplished by addressing such fundamental
cultural and social traditions as the role of women, sexual
practices, and inheritance laws.  For example, according to USAID,
tradition and laws in Kenya do not allow women to inherit property. 
Without skills or experience in earning money, if their husbands die,
women often have no other recourse than to engage in prostitution. 


--------------------
\1 HIV is the viral infection that causes AIDS. 


   USAID AND U.N.  RESPONSE TO THE
   EPIDEMIC
---------------------------------------------------------- Chapter 1:2

USAID and the United Nations first began to address the epidemic in
the mid-1980s.  While both USAID and the United Nations seek to
reduce the spread of the epidemic, they have somewhat different yet
mutually supporting roles, objectives, and coverage.  As a bilateral
agency, USAID works in partnership with governments, other donors,
and private organizations to support research and implement HIV/AIDS
interventions in the 28 countries where it has major programs.  The
U.N.'s role is in advocating, mobilizing, and coordinating the
international response worldwide in addition to managing HIV/AIDS
activities in 152 countries. 


      USAID RESPONSE TO THE
      EPIDEMIC
-------------------------------------------------------- Chapter 1:2.1

Since it began its HIV/AIDS assistance program in 1986, USAID's goal
has been to reduce the incidence of new HIV/AIDS infections.  In the
1980s, very little was known about the epidemic or how to fight it. 
As a result, USAID focused its initial efforts on understanding the
causes and extent of the epidemic and on identifying ways to prevent
its spread.  At the direction of Congress in 1986, USAID supported
WHO's Global Program on AIDS (GPA), and it also paid for public and
private research efforts and activities in the field.  These field
activities included operations research on interventions that prevent
the spread of HIV/AIDS; surveillance and analysis of the incidence,
spread, and impact of the disease; and assistance in countries'
design and implementation activities.  During this learning phase,
USAID reported that it was the first donor to introduce HIV/AIDS
prevention activities in most countries.  Further, by providing
short-term technical assistance to USAID missions in more than 74
countries and funding small-scale projects to prevent new infections,
it educated USAID staff and host country officials about the
epidemic. 

By the early 1990s, USAID became more knowledgeable about the
disease, and Congress increased funding for HIV/AIDS (see fig.1.3). 
USAID designed a strategy to focus on country-level projects that
could have a measurable impact on the epidemic.  From 1991 to 1997,
USAID supported the AIDS Control and Prevention (AIDSCAP) project. 
By far the most ambitious international HIV/AIDS prevention effort
ever undertaken, AIDSCAP was a worldwide program intended to help
USAID overseas missions design and implement HIV/AIDS prevention
projects.  AIDSCAP directly managed comprehensive projects in some
countries and supplied technical assistance to USAID missions as
requested.  USAID relied primarily on private voluntary organizations
(PVO) and nongovernmental organizations (NGO) to implement its
HIV/AIDS programs, both at its Washington, D.C., headquarters and in
the field. 

   Figure 1.3:  USAID Funding for
   HIV/AIDS Prevention, 1986-97

   (See figure in printed
   edition.)

Note:  Only U.N.  grant funding was provided in fiscal years 1986
($1.1 million) and 1987 ($5 million). 

Source:  USAID. 

By 1997, USAID had incorporated the goal of reducing HIV/AIDS
transmission as one of five objectives in its global health
improvement portfolio and had delineated performance goals and
indicators to measure its progress.  Agency funding for HIV/AIDS
activities had increased (to about $125 million in 1993, leveling off
at about $117 million a year), and USAID shifted more resources to
missions to develop their own comprehensive programs.  Headquarters'
efforts became focused on providing technical assistance as needed
and supporting research.  In fiscal year 1997, the majority of
USAID's funds supported project activities at the country level--with
major programs in 28 countries ($81 million), followed by centrally
managed technical assistance and research support ($20 million), and
grants to UNAIDS ($16 million). 

In 1997, USAID initiated three cooperative agreements\2 with several
PVOs and has a fourth in process.  These agreements provide up to
$290 million over 5 years for HIV/AIDS activities--about $40 million
to conduct operations research and field testing to refine and
develop best practices for prevention and care; up to $150 million
for technical assistance, as requested by missions; up to $75 million
to implement programs that advertise and promote the appeal,
availability, and use of condoms, as requested by missions; and about
$25 million to provide program design/monitoring and evaluation,
lessons learned, and information dissemination services. 


--------------------
\2 A cooperative agreement is a funding mechanism used by a federal
agency to transfer funds to an organization to support an agency
program. 


      THE U.N.  RESPONSE TO
      HIV/AIDS
-------------------------------------------------------- Chapter 1:2.2

WHO first began collecting and publishing information on HIV/AIDS in
1981.  The U.N.  General Assembly directed WHO to develop and
coordinate the agency's first program to respond to HIV/AIDS by
creating the Special Program on AIDS in 1987, subsequently renamed
GPA in 1988.  GPA's mission was to strengthen the capacity of
governments to respond to the epidemic and to help establish national
AIDS programs.  WHO provided technical and financial support, ranging
from $100,000 to $400,000 to initiate national programs.  WHO is
credited with making major contributions to nations' efforts against
the epidemic, including protecting blood supply systems,
strengthening national behavior research, and improving disease
surveillance. 

In the early 1990s, U.N.  officials and donors increasingly
recognized the need for a multisectoral response to the complex
challenges of the HIV/AIDS epidemic--including the social, economic,
and development issues affecting the spread of the virus.  They
realized that WHO's medically based response was insufficient.  They
were concerned that countries were dependent on GPA for operational
support and, as a result, were not devoting enough of their own
resources to the effort.  Also, they expressed the need for better
coordination and delineation of roles and responsibilities among
various U.N.  agencies.  To address these concerns, on January 1,
1996, the United Nations replaced GPA with the Joint United Nations
Programme on HIV/AIDS (UNAIDS).  The 1996-97 biennial budget for the
UNAIDS Secretariat was $120 million, of which the United States
contributed $34 million, or about 28 percent. 

The U.N.'s goal in creating UNAIDS was to lead a broad-based,
expanded, worldwide effort to prevent the transmission of HIV/AIDS. 
UNAIDS is composed of a Secretariat and six U.N.  agency cosponsors: 
the United Nations Children's Fund (UNICEF); the United Nations
Development Program (UNDP); the United Nations Population Fund
(UNFPA); the United Nations Educational, Scientific, and Cultural
Organization (UNESCO); WHO; and the World Bank.  Each cosponsor was
expected to expand its financial support for HIV/AIDS efforts, to try
to mobilize resources for HIV/AIDS in affected countries, and to
coordinate with other cosponsor agencies at the country level. 

Unlike WHO's role in GPA, the UNAIDS Secretariat was not expected to
provide significant financial support and technical advisers to
countries.  Instead, it was established primarily as a coordinating
body and was expected to advocate increased political and financial
support for HIV/AIDS activities, to devise a framework for
performance measures to be used in managing HIV/AIDS activities, to
provide technical support and best practice information to help
develop and carry out national HIV/AIDS strategies, and to organize
entities at the country level--called "theme groups"--as the forum
for coordinating U.N.  efforts.  Theme groups were to be composed of
field representatives of U.N.  cosponsor agencies.  The groups were
expected to work together to assist national governments develop and
implement HIV/AIDS programs.  As of May 1998, 127 HIV/AIDS theme
groups were operating in 152 countries. 


   OBJECTIVES, SCOPE, AND
   METHODOLOGY
---------------------------------------------------------- Chapter 1:3

At the request of the Chairman of the House International Relations
Committee and Representative Jim McDermott, we reviewed the
contributions made by USAID and the United Nations in designing and
implementing programs to slow the spread of HIV/AIDS.  Specifically,
we examined (1) the contributions USAID has made to the global effort
to prevent HIV/AIDS, and the methods USAID uses to provide financial
oversight for its HIV/AIDS prevention activities; and (2) the extent
to which UNAIDS has met its goal of leading an expanded and
broad-based, worldwide response to the HIV/AIDS pandemic.  We did not
evaluate the program's impact on the HIV/AIDS epidemic or whether
U.S.  support for the program should continue. 

To examine USAID's contributions to the global effort to prevent
HIV/AIDS, we reviewed expert studies on the disease and
interventions, and reviewed internal and external USAID project
evaluations from 1995 to 1998.  We compared the reported data with
evidence we gathered in the field.  To view USAID efforts in the
field, we chose countries in different parts of the world with both
emerging and advanced epidemics.  In countries with emerging
epidemics, HIV/AIDS is primarily concentrated in high-risk groups,
and in countries with advanced epidemics it has spread to the general
population.  In Latin America and the Caribbean, we visited the
Dominican Republic and Honduras, both of which have emerging
epidemics.  USAID considers Honduras the epicenter of the epidemic in
Central America because it has the highest concentration of
HIV-positive people in its high-risk groups.  In Asia we visited
India, which has more HIV-positive people than any other country in
the world, although still largely concentrated in high-risk groups,
and the Philippines, which has an emerging epidemic.  In Africa, we
visited Zambia, which has an advanced epidemic, with about 20 percent
of the general population infected with HIV.  In the countries we
visited, we reviewed internal USAID mission project papers and 1997
mission progress reports and observed USAID projects.  To gather
evidence of the effectiveness of USAID's country-level projects, we
reviewed behavior surveys and available surveillance data; and met
with mission directors, population, health, and nutrition officers,
HIV/AIDS project officers, staff from PVOs and NGOs implementing
projects, host government officials, project participants, and
recipients of services, including commercial sex workers, men who
have sex with men, and youth, volunteers, a condom social marketing
organization, and private sector representatives involved in HIV/AIDS
activities, and people living with HIV/AIDS.  We visited project
sites to see how interventions were implemented and to discuss the
views of the recipients of USAID activities. 

To examine the level of financial oversight USAID exercised over
program activities, we reviewed Office of Management and Budget (OMB)
and USAID guidance relating to the use of cooperative agreements and
contracts.  We reviewed several relevant contracts, cooperative
agreements, and associated procurement records relating to active
HIV/AIDS projects to determine whether they provided for appropriate
oversight as required by federal procurement regulations and guidance
from OMB and USAID.  We discussed financial oversight
responsibilities with USAID project managers, procurement staff, and
financial management officers in headquarters and in the five
countries we visited.  We also reviewed the financial record-keeping
and reporting requirements that USAID placed on recipients of USAID
funds.  In addition, we reviewed quarterly expenditure reports from
PVOs from 1994 through 1997 and discussed financial reporting and
selected management and accounting policies with PVO staff to
determine their compliance with OMB and agency provisions.  We
reviewed USAID's administrative approval and payment procedures and
studied recent USAID assessments of its financial and operational
oversight responsibilities with PVOs.  We reviewed pre-award
evaluations for four headquarters-led projects and two mission-led
projects and reviewed audit reports related to the centrally managed
projects in the five countries we visited.  We also met with Office
of the USAID Inspector General (OIG) staff to discuss their reviews
of these reports and independent audit assessments. 

As an agency of the U.S.  government, we have no direct authority to
review the operations of multilateral organizations such as the
United Nations.  However, throughout this review we obtained broad
access to agency staff members and official information at the
headquarters, regional, and country level.  To determine whether
UNAIDS has achieved its goal to lead an expanded and broad-based,
worldwide response to the HIV/AIDS epidemic, we measured progress
against criteria set forth in the U.N.'s Economic and Social Council
resolution endorsing the creation of a Joint United Nations Program
on HIV/AIDS, the memorandum of understanding signed by the six
cosponsoring agencies, and the strategic plans of the UNAIDS
Secretariat and the cosponsoring agencies.  We conducted audit work
at the UNAIDS Secretariat in Geneva, Switzerland, and at the
headquarters of each of the six cosponsor agencies, including the
Washington headquarters of the Pan-American Health Organization. 

At the UNAIDS Secretariat, we interviewed officials from the Office
of the Executive Director and the Departments of External Relations;
Policy, Strategy and Research; and Country Support.  We obtained and
analyzed staffing and budget documents of the Secretariat and
analyzed the scope of work for each department.  We also reviewed
several of the "best practices" documents produced by the Department
of Policy, Strategy and Research and discussed the best practices
outputs with knowledgeable officials from USAID.  We interviewed
officials from the cosponsor agencies charged with directing their
agencies' HIV/AIDS activities and with officials from other offices
and departments of cosponsor agencies that are relevant to addressing
HIV/AIDS--such as WHO's Global Tuberculosis Program. 

To determine U.N.  spending on HIV/AIDS, we obtained expenditure data
for 1992 to 1997 directly from the UNAIDS Secretariat and from the
headquarters offices of the six cosponsor agencies.  We also obtained
agency expenditure data reported by the UNAIDS Program Coordinating
Board.  We did not verify the data reported by or provided directly
to us from the agencies and the UNAIDS Secretariat.  In attempting to
determine the level of spending by the major donors and developing
nations, we reviewed preliminary data from a study on global HIV/AIDS
expenditures conducted by the UNAIDS Secretariat and Harvard
University's School of Public Health.\3 We also met with government
officials to discuss the level and type of financial support for
HIV/AIDS activities and to discuss barriers to increasing resources
to fight the disease.  To determine the level of activity by the
private sector in support of HIV/AIDS, we interviewed host
government, U.N., USAID, and NGO officials in our case study
countries and analyzed reports prepared by the UNAIDS Secretariat. 

To gain an understanding of UNAIDS' progress in addressing the
HIV/AIDS pandemic over time and issues surrounding the transition
from WHO's Global Program on AIDS to the current Joint Program on
HIV/AIDS, we interviewed a U.N.  diplomat instrumental in the
negotiations establishing UNAIDS and knowledgeable officials from
U.N.  agencies, USAID, the Department of State, and the U.S.  Centers
for Disease Control. 

To determine how well cosponsor agencies work together and the types
of interventions provided, we reviewed surveys of theme group
participants provided by the UNAIDS Secretariat and conducted case
studies of U.N.  programs in the five countries we visited.  While in
these countries, we interviewed officials and obtained strategic
planning documents from most of the U.N.  cosponsor agencies active
in the country; host government officials, including officials from
the national AIDS program and the Ministries of Health; USAID; other
bilateral donor programs; international and local PVOs and NGOs; and
local activists and people living with HIV/AIDS.  We also observed
firsthand the intervention activities of the U.N.  agencies. 

We conducted our work from July 1997 through June 1998 in accordance
with generally accepted government auditing standards. 


--------------------
\3 Study on the National and International Financing of the National
Response to HIV/AIDS, UNAIDS/PCB(6)/98.3 (Geneva, Switzerland:  May
24, 1998). 


USAID HAS MADE IMPORTANT
CONTRIBUTIONS TO HIV/AIDS
PREVENTION
============================================================ Chapter 2

USAID has elevated HIV/AIDS to an agency priority and developed a
targeted strategy to achieve its objective of reducing the incidence
of HIV/AIDS.  USAID's main contributions have been (1) support for
research that helped to identify interventions ultimately proven in
clinical trials to prevent HIV transmission; and (2) implementation
of projects at the country level that increased awareness of the
disease, reduced risky behaviors, and increased access to treatment
of sexually transmitted diseases (STD) and to condoms, which have
helped slow the spread of the disease in target groups. 

USAID relies primarily on cooperative agreements with PVOs to
implement its programs, both at headquarters and in the field.  Under
the terms of these agreements, the primary responsibility for
financial oversight rests with recipients.  USAID's oversight
consists of pre-award evaluations, quarterly expenditure reports, and
annual external audits.  OIG officials said that there were no
indications from audits conducted that systemic problems existed. 


   USAID SUPPORTED THE DEVELOPMENT
   OF ACCEPTED INTERVENTIONS
---------------------------------------------------------- Chapter 2:1

USAID has funded public and private research efforts to identify
interventions that became the principal tools used in the global
response to HIV/AIDS.  When USAID began its program in the mid-1980s,
medical experts recognized that the key to slowing HIV transmission
was behavior change and that traditional medical responses were not
sufficient.  However, research was only beginning to identify
effective interventions.  USAID capitalized on expertise developed in
its health and child survival programs and built upon the research
conducted by WHO to test and implement interventions targeted at
HIV/AIDS prevention. 

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.  They are

  -- information, education, and counseling to raise awareness of the
     threat of HIV/AIDS in an effort to promote positive behavior
     changes such as abstinence or reduction in the number of sexual
     partners, and safer sex practices;

  -- treatment of STDs which, if left untreated, can facilitate
     transmission of the HIV infection; and

  -- promotion of increased condom use through condom "social
     marketing" to prevent transmission of the virus. 


      INFORMATION, EDUCATION, AND
      COUNSELING
-------------------------------------------------------- Chapter 2:1.1

The first intervention, attempting to change risky behavior through
increased awareness, has posed a particular challenge to HIV/AIDS
experts.  The behaviors that result in transmission of the virus are
often deeply rooted in social and cultural traditions, and people
often find them difficult to discuss.  For example, in some African
countries, polygamous unions may force "junior wives" into
prostitution to earn money.  In addition, research on ways to promote
change in sexual behaviors is not advanced.  Even when effective
approaches have been identified, they may not always be transferable
from one cultural environment to another.  For example, USAID's
largest HIV/AIDS program--AIDSCAP--noted the difficulty in
encouraging Rwandan refugees to take individual action to change
their risky behavior when they had no control over the rest of their
life. 

USAID supported a number of efforts to identify approaches to achieve
behavioral change through clinical trials of HIV prevention
counseling and testing in Africa, Asia, Latin America, and the
Caribbean.\1 For example, AIDSCAP worked with the United Nations and
research institutions from Kenya, Tanzania, Trinidad, and the United
States to assess the efficacy of efforts intended to promote
voluntary HIV counseling and testing.  In 1997, USAID signed a
cooperative agreement to support a 5-year, $40-million program for
operations research and field testing of interventions to further
refine and develop best practices for prevention and care activities. 

In the five countries we visited, USAID projects used creative
approaches to increase HIV/AIDS awareness and promote behavior
change.  For example, in Honduras, USAID--in conjunction with
UNICEF--supported youth theater groups to develop plays with
HIV/AIDS-related themes.  To reach out-of-school youth, USAID
supported pregame mock soccer matches, where HIV Virus and Death
teams battled Abstinence and Condom teams.  Also, in the Indian state
of Tamil Nadu, USAID targeted education efforts at truck drivers, who
had been identified as key transmitters of the virus.  On a field
trip, we saw roadside meetings between counselors and truckers to
discuss the risks of HIV transmission and demonstrate how to use
condoms correctly. 


--------------------
\1 Conducted by the University of California's Center for AIDS
Prevention Studies. 


      TREATMENT OF SEXUALLY
      TRANSMITTED DISEASES
-------------------------------------------------------- Chapter 2:1.2

USAID was among the pioneers in funding research to determine whether
having an STD increases the risk of transmitting HIV.  This research
concluded that STDs, especially those that cause lesions, provide a
pathway for the HIV virus to enter the body and that STDs were highly
prevalent in many of the populations most affected with HIV/AIDS.  As
early as 1991, USAID reported that the risk of HIV transmission
significantly increased when other STDs are present and worked with
WHO to develop standardized treatments.  The link between STDs and
HIV transmission was eventually confirmed by the results of a 3-year
trial in Tanzania.  The trial concluded that increased STD treatment
reduced HIV incidence by about 40 percent. 

Improving STD treatment capacity was a component of USAID's AIDS
prevention strategy in every country we visited.  In Honduras, USAID
supported the expansion of health clinic services to include
treatment of STDs.  Further, USAID's AIDSCAP program supported STD
research in the Philippines, trained health care providers in STD
treatment in India, and developed national guidelines for improved
STD care in 18 other countries. 


      CONDOM SOCIAL MARKETING
-------------------------------------------------------- Chapter 2:1.3

Another intervention developed and tested with USAID's support is
condom social marketing, which relies on increasing the availability,
attractiveness, and demand for condoms among target populations
through advertising and public promotions.  USAID projects encourage
production and marketing of condoms by the private sector to ensure
the availability of affordable and quality condoms when and where
people need them.  The development of this marketing strategy was
based on USAID-sponsored research and experience that showed that
people are more likely to use a condom if they were affordable, high
quality, and available when and where needed.  World Bank data
demonstrated that condom sales increased dramatically in many
developing countries after condom social marketing programs were
introduced.  For example, condom sales in Brazil rose from 406,000 in
1991 to nearly 27 million in 1996 after condom social marketing
programs began. 


      IMPACTS ON INCIDENCE OF AIDS
      ARE DIFFICULT TO MEASURE
-------------------------------------------------------- Chapter 2:1.4

USAID, as well as UNAIDS, World Bank, and private research
institutions, have noted the difficulty in determining the direct
impact of interventions on the incidence of AIDS.  The interventions
used by USAID have been proven to affect HIV/AIDS incidence because
they result in behavior changes that reduce the risk of disease
transmission.  However, it is difficult to determine the link between
a particular activity or program and reductions in the incidence of
HIV/AIDS because of the long incubation period for the disease; a
person can be infected as a result of an activity from 7 to
10 years previously.  USAID measures the impact of its HIV/AIDS
activities in its target groups by conducting blood tests for HIV
incidence but also uses proxy indicators such as behavioral change
and condom sales.  Public health experts agree that these proxy
indicators are reasonable indicators of changes in HIV incidence. 


   USAID PROJECTS MADE IMPORTANT
   CONTRIBUTIONS
---------------------------------------------------------- Chapter 2:2

Despite the limitations in evaluating impact, USAID can demonstrate
that it has contributed to the fight against HIV/AIDS through its
interventions in the countries where it had programs.  For the global
project--AIDSCAP--and each mission, USAID established goals and
identified target groups based on country needs.  To assess the
countries' progress toward achieving these goals, USAID conducted
internal and external evaluations and behavioral surveys, and tested
people in the target groups for HIV.  Data show that USAID projects
increased knowledge about HIV/AIDS and how to prevent it, changed
risky behaviors, and increased access to STD treatment and condoms,
thus helping to slow the spread of AIDS in target groups. 


      CENTRALLY MANAGED AIDSCAP
      PROJECT
-------------------------------------------------------- Chapter 2:2.1

From 1991 to 1997, the goal of USAID's $200-million global project,
AIDSCAP, was to support research, help missions develop and implement
HIV/AIDS programs and to provide technical assistance for mission-led
programs.  AIDSCAP devised and carried out AIDS prevention programs
in 18 countries and supplied technical assistance to 25 other USAID
programs. 

Using a variety of evaluation instruments such as behavioral surveys
and blood testing for the HIV virus, USAID evaluated AIDSCAP's
projects and concluded that AIDSCAP's activities increased knowledge
about HIV and effected a change in attitude toward those affected by
the virus.  In target groups in many of the countries, data indicate
that AIDSCAP activities resulted in altered perceptions of individual
risk and less risky sexual behaviors.  For example, in the Ivory
Coast, a USAID survey of 1,000 15- to 25-year olds in 30 targeted
villages indicated that 47 percent had reduced their number of sexual
partners in response to AIDSCAP activities.  USAID also reported that
more than 275 million condoms were distributed with USAID support in
1996, or approximately 27 percent of all socially marketed condoms in
developing countries. 

AIDSCAP implemented HIV/AIDS programs in the Dominican Republic and
Honduras.  Our observations on these two efforts follow. 


         DOMINICAN REPUBLIC
------------------------------------------------------ Chapter 2:2.1.1

The goal of USAID's AIDSCAP project in the Dominican Republic was to
improve knowledge and access to AIDS prevention practices and
services in target groups.\2 Our review of behavioral and HIV
surveillance data and our interviews with participants indicate that
USAID had an impact in both areas.  USAID reported that the
percentage of young people who knew of at least two preventive
measures increased from 45 percent to 100 percent between 1993 and
1996 after receiving AIDSCAP-developed information on the disease. 
In addition, the use of condoms by commercial sex workers rose from
65 percent in 1992 to 98 percent in 1996; commercial sex workers with
whom we met said they always tried to convince their clients to use
condoms.  Moreover, USAID helped develop a low-cost condom with a
multinational pharmaceutical company, which significantly increased
the availability of condoms.  USAID also obtained free air time on
radio stations to broadcast prevention messages.  Data on HIV
incidence among commercial sex workers at one clinic targeted by
AIDSCAP projects indicated that the percentage of HIV-positive
workers who came to a USAID-supported clinic declined from 5.8
percent in 1995 to 3.3 percent in 1996.  Moreover, surveys undertaken
upon completion of the project showed significant declines in risky
behavior in targeted groups.  For example, the number of youth who
said they were sexually active declined from 73 percent in 1992 to 30
percent in 1996. 


--------------------
\2 These groups were commercial sex workers, men who have sex with
men, hotel workers, and youth. 


         HONDURAS
------------------------------------------------------ Chapter 2:2.1.2

In Honduras, AIDSCAP designed and implemented a program to support
the government's HIV/AIDS control program and to increase the use of
STD/AIDS prevention practices among high-risk groups,\3 including
increasing access to STD treatment.  The goal of the program was to
reduce the incidence of HIV/AIDS in specific regions of the country. 
However, because of difficulties getting started, the project
operated for only 2 years.  According to USAID officials in Honduras,
they began negotiating with AIDSCAP in 1993 to develop a program, but
that AIDSCAP's proposals did not adequately emphasize participation
by the government or involvement by local NGOs.  USAID did not reach
agreement with AIDSCAP until 1995, 2 years before it was scheduled to
end.  USAID evaluations and discussions with NGO personnel indicated
that the project had successes but should have done more to prepare
their local country office to assume the financial and managerial
responsibilities for the projects in an effort to ensure
sustainability.  In 1997, after the AIDSCAP office was converted to a
locally registered NGO, the mission awarded the new NGO a USAID grant
to continue prevention efforts.  However, because of its lack of
financial and managerial capacity, it was required to take corrective
actions before the new project could begin. 

Data are not yet available to determine the impact of AIDSCAP on the
incidence of HIV/AIDS in Honduras.  Early in the AIDSCAP project,
USAID conducted a behavioral survey to gather baseline data on risky
behaviors.  However, because the project was only operating for 2
years, USAID will not follow up with a survey to measure behavioral
change as a result of its activities until 1999. 

The mission used other indicators to measure the success of the
project.  It reported that it had exceeded its goal in increasing the
numbers of condoms distributed and that it had expanded access to STD
treatment.  USAID upgraded a number of Ministry of Health-run health
clinics to increase access to STD prevention and treatment. 
Government officials informed us that the number of women seeking STD
treatment had risen since completion of a USAID-funded STD clinic in
a poor area of the capital city, Tegucigalpa.  Recipients of
USAID-supported activities also told us that risky behavior had
declined.  For instance, the leader of a gay men's group said that
the amount of information and condoms requested by the gay Honduran
community had increased significantly since an AIDSCAP-supported NGO
began aggressive education activities. 

Furthermore, mission officials stated that the AIDSCAP project had
helped publicize HIV/AIDS, had encouraged the host government to
begin to address the epidemic, and had established a network of NGOs
that have the capacity to promote HIV/AIDS prevention activities.  We
met with a number of NGOs that, according to USAID officials, are
competent and provide the key to sustaining activities after USAID
funding ends. 


--------------------
\3 These groups were commercial sex workers, men who have sex with
men, and factory workers. 


      MISSION-LEVEL PROJECTS
-------------------------------------------------------- Chapter 2:2.2

We also reviewed mission-level projects in three countries:  India,
the Philippines, and Zambia.  In these countries, USAID missions
designed their own projects and hired PVOs and other organizations to
manage activities.  AIDSCAP provided limited technical support to
these missions.  We found that most programs were successful, with
the exception of Zambia, where problems significantly affected
USAID's ability to have an impact on the spread of the disease. 


         INDIA
------------------------------------------------------ Chapter 2:2.2.1

Our review of HIV surveillance and behavioral survey data, visits to
projects, and interviews with recipients of assistance indicate that
USAID has made progress toward meeting its goal of reducing HIV
transmission among target groups\4 in the southern Indian state of
Tamil Nadu (see
fig.  2.1).  The mission measured increased awareness about the
disease and behavioral change as indicators of change in HIV
transmission and reported progress in its target groups.  USAID is
accomplishing its objective by establishing and building a network of
technically capable NGOs working to alter behaviors and increase STD
treatment and condom distribution.  At the time of our fieldwork,
USAID had worked in only 1 of India's 27 states, though USAID
officials said they planned to expand to 1 other state, Maharashtra,
because available funding did not permit USAID to develop
comprehensive programs nationwide.  However, other donors were active
elsewhere in India.  States, rather than the national government,
manage health care delivery, and USAID chose Tamil Nadu and
Maharashtra because they have a high percentage of HIV-positive
people, and the state governments are politically and financially
supportive of AIDS prevention efforts. 

   Figure 2.1:  Director of
   USAID-Supported Health Clinic
   Discussing HIV/AIDS Prevention
   Activities, in Tamil Nadu,
   India

   (See figure in printed
   edition.)

Data generated from USAID's last behavioral survey conducted in 1997
in Tamil Nadu demonstrated significant behavior changes among
high-risk groups.  Specifically, between 1996 and 1997, truck drivers
reported declines in their patronage of commercial sex workers and in
the number of nonregular sex partners from 38 percent to 27 percent
and increased condom use from 55 percent to 66 percent.  Among
factory workers, condom use increased from 28 percent to 41 percent. 
USAID has trained
800 volunteers, peer educators, and NGO leaders to implement
community-based interventions and trained 60 health care providers in
the diagnosis and management of STDs since 1992. 


--------------------
\4 These groups were commercial sex workers, their clients (for
example, truck drivers), and people with STDs. 


         PHILIPPINES
------------------------------------------------------ Chapter 2:2.2.2

In the Philippines, the USAID mission's goals were to increase
knowledge and to change attitudes and behaviors to prevent STD/AIDS
infection among high-risk groups\5 and to collect comprehensive
baseline data on the incidence of HIV and behavior at 10 sites.  Our
review of an independent evaluation and discussions with target
groups in the Philippines indicated that USAID interventions had been
effective in increasing awareness and changing behavior.  In
addition, USAID's surveillance activities provided data on HIV
incidence and risky behavior among target group populations.  An
independent evaluation conducted in 1997 concluded that USAID's
activities helped avert an increase of HIV/AIDS,\6

as the percentage of people who are HIV-positive remained below 1
percent in targeted groups.  Behavioral surveys demonstrated that
USAID activities to expand knowledge about the disease led commercial
sex workers to increase their use of condoms.  Data also indicated
that male clients exposed to USAID interventions used condoms much
more frequently than those with no contact with the project (75
percent compared to 41 percent).  Our reviews of evaluations and
interviews with NGO staff also indicated that USAID increased the
capacity of the NGO staff to implement AIDS prevention activities. 
USAID project activities are carried out by staff working for 20
local organizations that have been trained as a result of USAID
activities.  We met with a number of NGOs that were successfully
implementing prevention strategies under the guidance of USAID.  For
example, we accompanied a local NGO to a site frequented by gay men,
where the NGO distributes pamphlets, discusses HIV/AIDS risks, and
promotes condom use. 


--------------------
\5 These groups were registered female commercial sex workers,
freelance commercial sex workers, men who have sex with men, and
intravenous drug users. 

\6 The evaluation used a simulation model developed by AIDSCAP that
calculates the number of infections averted when accepted
interventions are applied to high-risk groups. 


         ZAMBIA
------------------------------------------------------ Chapter 2:2.2.3

Our review of USAID activities in Zambia indicated that the mission
has had a difficult time developing an HIV/AIDS prevention program. 
Despite its problems designing an effective program, it did have some
successes.  Since 1992, the mission has redesigned its program three
times with different goals and implementing organizations. 
Initially, the USAID mission in Zambia established a goal of reducing
HIV transmission.  It subsequently determined that this goal was
unrealistic and refocused its objective on changing behavior in
high-risk groups.  USAID's difficulty in developing a program
stemmed, in part, from the national government's transition to a
decentralized approach to HIV/AIDS and health care delivery. 
However, according to USAID mission officials and an independent
evaluation, problems occurred primarily because the U.S.  educational
institution managing USAID's program did not have the necessary
expertise to implement large-scale HIV/AIDS activities overseas.  An
evaluation of the project found a number of weaknesses, including a
lack of project monitoring and a reliance on U.S.-based institutions
to implement activities rather than building the capability of local
NGOs.  In addition, host government officials informed us the
implementing agency designed and implemented activities without host
country involvement.  The evaluation also found that the project had
not increased the number of patients treated for STDs, an important
component of USAID's HIV/AIDS strategy. 

Despite USAID's management problems, we saw some successes in Zambia
(see fig.  2.2).  Our discussions with youth groups indicated an
increased awareness of HIV/AIDS.  USAID reported that condom sales
exceeded expectations and increased by 22 percent in 2 years and that
the number of casual sex partners in the target groups decreased. 
Additionally, USAID mission officials said that they had been
instrumental in convincing the Zambian government to integrate
HIV/AIDS activities into the national health plan and that they have
had some successes in addressing one of the social and cultural
factors that contribute to the spread of the disease.  Specifically,
USAID worked with traditional healers and the legal community to
discourage a custom whereby recently widowed women engage in sexual
relations to "cleanse" their bodies of the spirit of the deceased. 

   Figure 2.2:  HIV/AIDS Education
   Program for Community Health
   Workers in Lusaka, Zambia

   (See figure in printed
   edition.)


   NATURE OF USAID'S FINANCIAL
   OVERSIGHT
---------------------------------------------------------- Chapter 2:3

USAID conducts financial oversight for its HIV/AIDS activities
primarily through pre-award evaluations, quarterly financial reports,
and annual financial audits of its private sector partners.  Largely
in response to congressional direction, USAID officials decided to
rely on U.S.-based PVOs and indigenous NGOs to implement its HIV/AIDS
program.\7 To manage their private partners, USAID officials in
headquarters and the field told us that they have chosen almost
without exception to use a funding arrangement called a "cooperative
agreement." Cooperative agreements are similar to grant agreements\8
but are used when agencies expect to be substantially involved in the
activity to be carried out.  These agreements allow USAID and
recipients to easily adapt the scope of work and shift budgeted
resources to changing needs.  Therefore, they are able to adjust
activities to meet agency goals without a formal process for review
and approval.  Recipient organizations have the primary
responsibility for financial management.  OIG officials said that
there were no indications from audits conducted of systemic problems. 


--------------------
\7 Since 1990, the House and Senate Appropriations Committees have
urged USAID to maximize its use of PVOs and NGOs to implement
HIV/AIDS prevention activities. 

\8 See The Federal Grant and Cooperative Agreement Act of 1977 (31
U.S.C.  6301-8). 


      OMB GUIDANCE PLACES
      FINANCIAL MANAGEMENT
      RESPONSIBILITIES ON
      RECIPIENT ORGANIZATIONS
-------------------------------------------------------- Chapter 2:3.1

OMB guidance outlines the responsibilities of awarding agencies and
funding recipients under cooperative agreements.\9 The guidance
states that agencies should require organizations to have requisite
financial and management systems in place; agree to comply with
various requirements, such as guidelines for allowable costs; and
provide procedures for periodic financial and progress reporting. 

With respect to monitoring, OMB's general guidance is that while the
agency has the responsibility to ensure that public funds are managed
prudently, day-to-day financial management is the responsibility of
the recipient.  USAID project managers use several methods to ensure
financial oversight:  pre-award evaluations, quarterly expenditure
reports, and annual audits. 


--------------------
\9 OMB Circulars A-110, "Uniform Administrative Requirements for
Grants and Agreements with Institutions of Higher Education,
Hospitals and Other Non-Profit Organizations"; and A-122, "Cost
Principles for Non-Profit Organizations." See also 22 C.F.R.  226. 


         PRE-AWARD EVALUATIONS
------------------------------------------------------ Chapter 2:3.1.1

Pre-award evaluations are conducted as necessary before an award is
granted, to assess whether prospective recipients have adequate
financial and management control systems to properly manage, report,
and account for USAID funds.  If a recipient has recently received a
federal award and is known to have the technical and financial
capacity to perform the job, USAID conducts an informal review of its
systems and controls.  Otherwise, a team will go on-site to conduct a
formal evaluation.  We examined pre-award surveys for four
headquarters projects and two mission bilateral projects.  USAID
conducted pre-award evaluations for all of them, and with the
exception of the award to a local NGO in Honduras, they were informal
reviews because the recipients were known to USAID.  In Honduras,
USAID conducted a formal evaluation because the NGO selected to
manage the mission's HIV/AIDS project after AIDSCAP ended did not
have previous experience managing a USAID project.  USAID found
problems with the NGO's accounting system, procurement and
contracting procedures, and personnel management system.  Before the
award was made, the NGO was required to undertake corrective actions. 


         QUARTERLY EXPENDITURE
         REPORTS
------------------------------------------------------ Chapter 2:3.1.2

Recipients of cooperative agreements are also required to provide
quarterly expenditure reports to the USAID project manager.  These
are summaries of expenditures listed in categories such as salaries
and travel.  For the 6 years of the AIDSCAP project, we found that
USAID reviewers approved all expenditure reports without disapproving
any costs.  OMB guidance stipulates that agencies must determine
whether costs incurred are in accordance with terms of agreements and
are reasonable and allowable.  However, the guidance does not define
the roles and responsibilities of an awarding agency for monitoring
the recipient's compliance with these standards.  Project managers
told us that they reviewed expenditure reports primarily to compare
the level of funds expended with the progress toward completion of
project activities. 


         ANNUAL AUDITS
------------------------------------------------------ Chapter 2:3.1.3

According to USAID officials, USAID uses annual financial audits
required by the Single Audit Act as its principal tool for financial
oversight.\10 These audits are intended, among other things, to
promote sound financial management, including effective internal
controls, with respect to federal awards administered by nonfederal
entities such as PVOs.  As such, they provide information to federal
oversight officials and program managers on whether an entity's
financial statements are fairly presented and reasonable assurance on
whether federal assistance programs are carried out in accordance
with applicable laws and regulations.  The single audit reports from
1992 to 1996 of the PVO that implemented the AIDSCAP project did not
indicate any financial management or reporting problems.  OIG reviews
of these audits found that they were performed in accordance with the
Single Audit Act's requirements. 

In 1994, the OIG conducted an audit primarily focused on salaries,
fringe benefits, and travel, based on specific allegations regarding
these matters.  As a result of this review, the OIG questioned 11
percent of the $14.6 million of expenditures examined.  Following
negotiations, the PVO repaid $540,000 to USAID.  OIG officials said
that there were no indications, from either this review or the single
audits, that systemic problems existed. 


--------------------
\10 The Single Audit Act of 1984 (31 U.S.C.  7501-7507) requires
organizations that meet a minimum threshold of federal funding to
undergo a single, nonfederal audit each year. 


   CONCLUSIONS
---------------------------------------------------------- Chapter 2:4

USAID has made important contributions in the fight against HIV/AIDS
by helping to support the development and implementation of
interventions that have been proven effective in the global fight
against the disease.  These interventions include information,
education, and counseling; treatment of sexually transmitted
diseases; and promotion of increased condom use through condom social
marketing. 

At the country level, USAID implemented projects that increased
awareness of the disease, reduced risky behaviors, and increased
access to STD treatment and condoms.  These actions have helped slow
the spread of the disease in target groups.  Evaluations of USAID's
largest HIV/AIDS project, AIDSCAP, determined that its activities had
successes in the countries where it had projects.  Our fieldwork and
evaluations conducted for a number of other mission-led projects also
showed important impacts. 

USAID implements its programs at headquarters and in the field
primarily through PVOs and NGOs.  To manage their private partners,
USAID has chosen almost without exception to use a funding
arrangement called a cooperative agreement.  Because they are similar
to grant agreements, cooperative agreements allow flexibility to
USAID in adjusting their scope, and recipient organizations have the
primary responsibility for financial management.  USAID managers
primarily rely on pre-award evaluations, review of quarterly
expenditure reports, and annual audits for their financial oversight
of its funding recipients.  OIG officials said that there were no
indications from audits conducted that systemic problems existed. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 2:5

USAID stated that it was pleased with the overall presentation and
objectivity of the report. 


THE JOINT U.N.  PROGRAMME ON
HIV/AIDS HAS MADE LIMITED PROGRESS
============================================================ Chapter 3

UNAIDS has made limited progress toward achieving its goal of leading
a broad-based, expanded worldwide response to the HIV/AIDS epidemic. 
Reasons for the limited progress include a lack of clarity in the
mission and roles of cosponsor agencies in the field and lack of
staff accountability for theme group success.  Cosponsor agency
estimates of overall U.N.  spending on HIV/AIDS show that resources
have not increased with the creation of UNAIDS.\1 In addition, while
the UNAIDS Secretariat has made significant efforts at the
international level to mobilize private sector support, Secretariat
officials acknowledge that U.N.  efforts at the local level have been
limited.  Data are not available to get an accurate measure of
UNAIDS' success in mobilizing an expanded response among donors or
affected countries.  In some countries, cosponsor agencies are just
beginning to work together in theme groups.  Finally, the UNAIDS
Secretariat has not been very successful in providing technical
assistance and other support to facilitate theme group activities and
has only started to establish a framework to measure performance. 


--------------------
\1 Throughout this report, reference to overall U.N.  funding for
HIV/AIDS activities is limited to the six cosponsor agencies and the
Secretariat. 


   U.N.  EXPENDITURES FOR HIV/AIDS
   DID NOT INCREASE
---------------------------------------------------------- Chapter 3:1

The U.N.  Economic and Social Council, which created UNAIDS, stated
that the success of the program was dependent on the provision of
increased resources for HIV/AIDS activities by the cosponsor
agencies.  U.N.  agency spending began to decrease under WHO's GPA,
declining by 20.3 percent during the last 2 years of the program
(1994-95).  For the first 2 years since the creation of UNAIDS in
1996, cosponsor agencies estimate that the decline has leveled off,
with spending at about $332 million--a slight decline from the $337
million spent during the last 2 years of GPA.  Funding for
HIV/AIDS-related activities remained stable even though overall
cosponsor agency spending increased by 6.5 percent during the same
period. 

Data in figure 3.1 demonstrate differences among cosponsor agencies
that underlie the overall U.N.  expenditure estimates for HIV/AIDS. 
Two agencies, UNDP and UNFPA, increased spending on HIV/AIDS by $10.8
million and $5.4 million, respectively, and UNESCO began programming
money for HIV/AIDS after the creation of UNAIDS.  However, the World
Bank and UNICEF decreased funding by $10.5 million and $3.5 million,
respectively.\2 Spending on HIV/AIDS also declined as a percentage of
these agencies' budgets.  Finally, WHO, the agency that spearheaded
U.N.  efforts to fight the HIV/AIDS epidemic in the early 1990s, with
about $140 million added to its core budget every 2 years for
HIV/AIDS activities, first began programming core funds following the
creation of UNAIDS.  It spent $16 million in 1996-97. 

   Figure 3.1:  U.N.  HIV/AIDS
   Funding Under GPA and UNAIDS,
   1992-97

   (See figure in printed
   edition.)

\a Unavailable. 

   Sources:  U.N.  cosponsor
   agencies and UNAIDS Secretariat
   (funding not verified).

   (See figure in printed
   edition.)

U.N.  agency officials gave several reasons for the lack of increased
spending on HIV/AIDS programs.  A WHO official said that because WHO
no longer had additional funding for its HIV/AIDS efforts after GPA
ended, 200 professionals who had been working on the program left or
changed jobs, and the agency had to reorganize its staff and budget
to undertake HIV/AIDS activities.  According to cosponsor officials
and the Secretariat, other agencies did not increase support for
HIV/AIDS due to difficulties incorporating HIV/AIDS activities into
programs in the midst of their 5-year planning cycle; lack of
commitment to HIV/AIDS by affected governments; and lack of
commitment to HIV/AIDS as a priority on the part of field
representatives. 


--------------------
\2 The decrease in World Bank spending is based on official estimates
provided by the World Bank.  Preliminary data on World Bank spending
gathered by the UNAIDS Secretariat at the country level are
significantly higher than these data.  According to Secretariat
UNAIDS officials, they are working on reconciling the differences. 


   BASELINE SPENDING BY MAJOR
   DONORS AND AFFECTED COUNTRIES
   IS BEING DEVELOPED
---------------------------------------------------------- Chapter 3:2

Building worldwide support for HIV/AIDS was a key objective of
UNAIDS.  The U.N.  Secretary General noted that in order to achieve
an expanded response, governments of countries most affected by the
epidemic would have to increase resources for HIV/AIDS.  Officials
from the UNAIDS Secretariat also noted the importance of increasing
the financial support of donor countries.  However, the Secretariat
is not yet in a position to measure USAIDS' progress because it does
not yet have baseline data on spending for HIV/AIDS at the country
level.  It has only recently developed baseline data for donors. 

The UNAIDS' Secretariat is in the process of analyzing survey data to
develop estimates of spending on HIV/AIDS by affected countries. 
Secretariat officials said that the data would be available in the
fall of 1998.  While half of the theme groups surveyed by UNAIDS
reported that in 1997 they had mobilized resources at the country
level, they noted that the large majority of these resources was from
U.N.  agencies. 

U.N.  officials told us that the lack of data on the impact of
HIV/AIDS, measured in the number of deaths and illnesses, made it
difficult to persuade developing countries to divert limited national
resources from other important health problems.  In many developing
countries, the numbers of deaths and the costs of caring for HIV/AIDS
patients are not identifiable because records only indicate secondary
causes of illness or death, such as pneumonia, rather than HIV/AIDS
infection. 

Preliminary data from its most recent survey\3

indicate that contributions by major donors\4

have remained relatively stable between 1993 and 1996, at
approximately $250 million a year.  However, data are not available
for 1997.  Thus, it is not possible to determine whether UNAIDS'
first year's efforts have led to increased spending by donors.  A
USAID official told us that Secretariat officials made regular visits
to executive and parliamentary branches of governments in donor
countries, including the United States, in an attempt to keep the
spotlight on HIV/AIDS issues and avert "donor fatigue."


--------------------
\3 Study on the National and International Financing of the National
Response to HIV/AIDS. 

\4 The United Nations defines major donors as Australia, Canada,
Denmark, France, Germany, Japan, Luxembourg, the Netherlands, Norway,
Sweden, the United Kingdom, and the United States. 


   UNAIDS HAD LIMITED SUCCESS IN
   MOBILIZING THE PRIVATE SECTOR
---------------------------------------------------------- Chapter 3:3

The UNAIDS Secretariat and cosponsor agencies were expected to
mobilize the private sector as part of the comprehensive global
response to the HIV/AIDS epidemic.  Despite this objective, efforts
have been limited at the country level, and overall results are not
clear.  UNAIDS officials reported they have made efforts to encourage
support for HIV/AIDS activities in the international community. 
However, at the country level, cosponsor agencies had solicited
private involvement in only one country we visited.  Moreover, UNAIDS
lacks data to determine whether the level of resources devoted to
HIV/AIDS by the private sector has increased or decreased. 
Secretariat officials told us that they believe the level of private
sector resources dedicated to HIV/AIDS activities has remained
limited. 

In the international community, the UNAIDS Secretariat has encouraged
private sector support through advocacy efforts with leading
corporate organizations, such as The Conference Board and Rotary
International, and individual companies.  For example, the
Secretariat organized a 1997 World Economic Forum plenary session in
which South African President Nelson Mandela gave the keynote address
to the world's business leaders calling for a public/private
partnership to fight HIV/AIDS.  The Secretariat also organized a
Public/Private Sector Partnership Strategy Meeting on International
HIV/AIDS in London, England, in November 1996 and is working to
establish a Global Business Council to organize businesses to serve
as advocates in their industry and region. 

As a result of its efforts, the UNAIDS Secretariat has had some
successes, particularly in advocating research and distribution of
medical interventions appropriate in the developing world.  According
to a senior USAID official, the UNAIDS Secretariat and WHO should be
credited with encouraging pharmaceutical companies to continue and
increase their efforts to develop affordable HIV/AIDS vaccines. 
Glaxo Wellcome, a major pharmaceutical company, recently announced
that it would provide zidovudine (AZT), a viral inhibitor, to
pregnant, HIV-positive women in developing countries at a
substantially reduced price.  In addition, for more than 2 years, the
UNAIDS Secretariat has been coordinating international research on
mother-to-child transmission and addressing ways to implement
clinical trials with the private sector, international agencies, and
donor countries.  USAID also credits the Secretariat with working
with the private sector to increase the availability and
affordability of the female condom. 

However, according to a report produced by the UNAIDS Secretariat and
the Prince of Wales' Business Leaders' Forum,\5 the corporate
response to HIV/AIDS has generally been limited and largely
defensive.  With few exceptions, the business community around the
world has not sought a leadership role in confronting the epidemic. 
Among the reasons for this lack of involvement are

  -- inadequate information on the disease and understanding about
     how it affects their companies,

  -- unease about association with a controversial issue,

  -- lack of encouragement by the public sector, and

  -- competition for resources for HIV/AIDS with other good causes. 

Unlike the Secretariat's efforts with the international business
community, in-country efforts by the cosponsor agencies to encourage
private sector involvement in HIV/AIDS activities have been very
limited.  We saw examples of private, in-country activities that
indicated that companies could play an important role in the U.N.'s
efforts to reduce the spread of HIV/AIDS.  For example, the theme
group in India solicited free air time from an Indian television
network and worked jointly to develop a media campaign involving
national artists in on-air promotions and public events.  We saw
other private-sponsored activities such as companies in Honduras
allowing government or NGO-sponsored HIV/AIDS prevention and control
activities to occur within their place of business.  Another example
was in the Philippines, where a manufacturing company provided direct
financial support for prevention activities.  None of these was
initiated by U.N.  agencies. 

Several U.N.  agency officials said that the reason for a lack of
focus on private involvement in HIV/AIDS activities was that U.N. 
agencies did not generally work with the private sector.  Their
contacts in the field are almost exclusively with government
ministries.  Officials added that because the United Nations is not
accustomed to working with private partners, guidance on best
practices in this area would be useful. 


--------------------
\5 The report was entitled The Business Response to HIV/AIDS: 
Innovation and Partnership (Geneva and London:  1997).  The Prince of
Wales' Business Forum was established in 1990 as a global network of
business leaders and their companies to work to promote continuous
improvement in the practice of corporate citizenship and sustainable
development internationally. 


   DIFFICULT BEGINNING FOR THEME
   GROUPS
---------------------------------------------------------- Chapter 3:4

The UNAIDS Secretariat was expected to organize theme groups as the
coordinating entity for U.N.  activities in the field, and U.N. 
cosponsor agencies agreed to work together to ensure a unified
response to HIV/AIDS.  Their ultimate objective was to support host
countries' national HIV/AIDS programs.  To operate effectively,
agency representatives were expected to meet regularly to discuss
opportunities for joint programming and assistance to the host
country.  We found such an example in the Dominican Republic where
agencies met regularly and even conducted joint programming. 
However, Secretariat officials acknowledged that as of 1997 most
theme groups were not working effectively and that they
underestimated the difficulty of getting U.N.  agencies to coordinate
and conduct joint programming.  For example, in two of the five
countries we visited--Honduras and India--we found poorly functioning
theme groups that rarely met.  Preliminary results from a 1997 survey
conducted by the UNAIDS Secretariat of theme groups showed that data
received as of April 30, 1998, indicated that theme groups had made
some progress in cosponsor coordination since their 1996 survey of
theme groups, particularly in the areas of advocacy and resource
mobilization.  However, of the theme groups that responded to the
1997 survey, less than 50 percent were judged effective in those
areas.  In addition, while respondents said that the level of U.N. 
coordination at the country level had improved over the last year,
only 28 percent rated it strong or better.  Overall, fewer than half
of the theme groups had undertaken efforts in 7 out of 10 of the key
outputs measured. 

Several factors have hindered theme group operations, including the
following: 

  -- Cosponsor agencies and the UNAIDS Secretariat did not provide
     guidance to staff in the field regarding how theme groups should
     operate and the scope of their mission. 

  -- Cosponsor agencies did not hold their staff accountable for
     theme group success, and UNAIDS Secretariat staff lacked
     authority to require participation. 

  -- Concerns about the concept of a joint program and theme group
     operations led to lack of commitment to working together on the
     part of some agency representatives. 


         LACK OF TIMELY GUIDANCE
------------------------------------------------------ Chapter 3:4.0.1

According to cosponsor agency officials, neither the Secretariat nor
the cosponsors issued timely guidance to theme group participants
about how to operate or about their roles and responsibilities within
the theme groups.  In a 1996 UNAIDS survey of theme group operations
conducted by the UNAIDS Secretariat, U.N.  officials in the field
cited the lack of understanding about the roles of each agency at the
country level and lack of support from cosponsor agencies and the
Secretariat as major obstacles to progress.  Acknowledging these
problems, the Secretariat provided operational guidelines to theme
groups early in 1998. 


         LACK OF REQUIREMENTS TO
         PARTICIPATE
------------------------------------------------------ Chapter 3:4.0.2

The individual job expectations provided for U.N.  cosponsor
representatives in the field did not include an expectation to
participate in the theme groups.  Field staff with whom we met said
that their annual personnel assessments did not mention participation
in UNAIDS activities.  The career, promotion, and reward paths for
U.N.  officials are through their parent organizations, and their
work on UNAIDS activities was considered an adjunct to their regular
duties.  Typical of the responses we heard was a U.N.  cosponsor
agency official in Honduras who described UNAIDS work as "an add-on,
an additional function outside of regular work responsibilities."
Secretariat representatives who were responsible for organizing theme
groups and encouraging joint participation did not have the authority
to require participation. 


         LACK OF COMMITMENT TO
         WORK TOGETHER
------------------------------------------------------ Chapter 3:4.0.3

Despite agreements by cosponsor agencies to support and work
collaboratively in the theme groups, according to senior U.N. 
officials, concerns about the concept of a joint program held by some
senior agency officials contributed to their lack of commitment to
working together.  Such concerns were reflected in a 1997 USAID
survey of 31 of its overseas missions that addressed problems faced
by U.N.  agencies in planning and implementing their HIV/AIDS
activities.  Respondents cited uneven U.N.  agency commitment to
HIV/AIDS-related endeavors and the lack of coordination among U.N. 
agencies. 

In particular, some officials from the World Bank and WHO said that
they questioned the role of UNAIDS as the organizing vehicle for the
U.N.  response.  One WHO representative in the field said that
because he works directly with the host government, he views UNAIDS
as irrelevant.  In addition, a World Bank official said he did not
see the usefulness or relevancy of coordinating or integrating the
Bank's activities with other cosponsor agencies, noting that U.N. 
agencies were already doing all they could to address HIV/AIDS.\6 The
World Bank's lack of commitment to the theme groups and UNAIDS was
evident in a number of our case study countries where the World Bank
had programs.  Though the country representative of each U.N. 
cosponsor agency is automatically a member of the theme group and is
expected to participate in its activities, in three of the five
countries we visited, the World Bank representative never attended a
theme group meeting, according to other cosponsor agency officials. 
However, in two of the countries, a lower-level staff member was
present at a couple of theme group meetings. 

UNAIDS Secretariat officials said they recognized these problems and
met with cosponsor agencies in March 1998 to address interagency
cooperation and develop strategies to improve theme group
coordination. 


--------------------
\6 According to officials from the UNAIDS Secretariat, senior-level
meetings between World Bank and the Secretariat January 1998
addressed outstanding complaints concerning the Bank's participation
in UNAIDS and should result in greater coordination and collaboration
with the other cosponsor agencies. 


   LIMITED SUCCESS IN PROVIDING
   TECHNICAL SUPPORT FOR UNAIDS
   COUNTRY ACTIVITIES
---------------------------------------------------------- Chapter 3:5

One key role for the UNAIDS Secretariat was to provide technical
assistance to theme groups to facilitate cosponsor agency efforts. 
The two Secretariat departments responsible for providing technical
support and disseminating best practices accounted for 80 percent of
the Secretariat's budget.  However, during our site visits, we found
few U.N.  agencies utilizing the Secretariat's technical support, and
some agency officials were unaware of the services or technical
assistance that were available.  For example, cosponsor agencies in
the Philippines stated that best practice information is useful for
introducing an idea to the government, but not particularly helpful
in defining how to implement it.  The UNDP representative said it
would be useful to obtain information on how to incorporate HIV/AIDS
prevention in their good governance projects.  UNAIDS official
acknowledged the Secretariat had poorly marketed available support
and noted that its fixed menu of technical support was not always
relevant or flexible enough to meet a country's specific needs.  In
addition, because of the limited number of experts on the UNAIDS'
staff, he noted that the Secretariat should have made more of an
effort to mobilize regional resources to provide technical
assistance.  Secretariat officials indicated substantial investments
in this area will be needed in the future. 

Another key role of the UNAIDS Secretariat was to identify, develop,
and function as a major source of information on best practices; that
is, to identify and disseminate information about HIV/AIDS prevention
policies and strategies and to promote research to develop new tools
to address HIV/AIDS.  According to cosponsor agency officials we
interviewed, best practices information from the Secretariat was
disseminated and read, but the information was too general to be of
practical use and lacked practical "how-to" guidance.  For example,
according to a USAID official familiar with material on best
practices produced by the Secretariat, the information provided a
good summary and starting point for discussion of a particular issue,
such as how to deal with AIDS in prisons.  However, he noted that
practitioners in the field, who are generally well informed, needed
practical guidance on how to carry out specific projects.  According
to a Secretariat official, the focus was on producing the most
up-to-date, comprehensive document on a particular issue but not to
tailor best practices to meet the needs of officials in the field. 
He added that the department responsible for best practices needed to
begin by improving its knowledge of customers' needs so that it could
make itself more relevant.  According to Secretariat officials, steps
are under way to address these deficiencies.  For example, the
Secretariat has reorganized the support departments and instituted
management changes.  Additionally, USAID stated that along with other
bilateral donors, USAID is helping to establish a network of
technical resources that can be used by Secretariat and cosponsor
staff in-country staff to enhance the design and implementation of
national HIV/AIDS programs.  However, it is too early to evaluate the
impact of these efforts. 


   PERFORMANCE INDICATORS
---------------------------------------------------------- Chapter 3:6

The Secretariat was directed by its governing board to coordinate the
development of performance-based programming and measurable
objectives.  As an international organization, the United Nations is
not required to comply with the U.S.  Results Act.\7

However, the act sets forth the characteristics of a
performance-based system, requiring (1) the statement of a clearly
defined mission; (2) the establishment of long-term strategic goals,
as well as annual goals that are linked to them; (3) the measurement
of performance against the goals; and (4) the public reporting of how
well the agency is doing.  Development of performance indicators will
assist in making the Secretariat and the cosponsor agencies
accountable for their performance, to gauge progress toward meeting
objectives, to promote UNAIDS activities with host governments, and
to generate information decisionmakers need in considering ways to
improve performance. 

However, the Secretariat has been slow to create and implement an
evaluation framework that employs performance indicators.  Despite
being instructed to start efforts immediately, it did not begin
staffing an evaluation unit until September 1997.  According to the
Secretariat's evaluation officer, the goal is to field-test a
performance-based evaluation system in 20 to 30 countries by the end
of 1998.  Secretariat officials attribute the slow start in
developing performance indicators to the rush to get UNAIDS up and
running programmatically and country-level activities under way. 
Results from the theme group survey covering 1997 activities showed
that, where theme groups had developed an integrated U.N.  work plan,
only 22 percent had developed indicators to measure progress, and
only 13 percent had assessed their performance using the indicators. 

USAID officials noted that the lack of a credible monitoring and
evaluation plan by the UNAIDS Secretariat is a significant weakness. 
Officials added that at the May 1998 meeting of UNAIDS' governing
board, a Monitoring and Evaluation Technical Review Group was
created.  This group is expected to develop a plan for approval by
the board at its next meeting, scheduled for December 1998. 


--------------------
\7 The Government Performance and Results Act of 1993 (P.L.  103-62). 


   U.N.  AGENCIES UNDERTOOK
   INNOVATIVE GRASSROOTS
   INTERVENTIONS
---------------------------------------------------------- Chapter 3:7

Although we did not conduct an evaluation of individual cosponsor
HIV/AIDS activities, in the countries we visited we observed
innovative cosponsor activities in each of our case study countries. 
U.N.  agencies relied on proven control and prevention activities
such as condom education and promotion, information and behavioral
change communication, and treatment of STDs.  In addition, the
activities were targeted to high-risk groups (such as commercial sex
workers and truckers), individuals who engage in high-risk activity
(clients of commercial sex workers, men who have sex with men,
intravenous drug users), and those considered particularly vulnerable
(women and youths). 

Moreover, the activities we observed were generally inexpensive,
ranging from $200 to several thousand dollars.  In addition, in an
effort to increase sustainability, the activities were often managed
by host country officials and implemented by locally recruited
activists.  While many developing countries remain dependent on
external donor support to finance HIV/AIDS activities, a cadre of
trained and experienced HIV/AIDS activists existed in all the
countries.  Particularly noteworthy was the use of peer
educators--such as commercial sex workers and intravenous drug
users--who are able to reach and communicate effectively with at-risk
populations who normally fall outside the reach of
government-sponsored public health programs. 

Examples of intervention activities we observed in our case study
countries include the following: 

  -- In the Dominican Republic, an adolescent peer educator training
     session and a prison AIDS awareness workshop were funded by
     joint contributions from all the theme group members. 

  -- In Honduras, a street theater organization conducted HIV/AIDS
     awareness skits at schools and festivals and during half-time at
     professional and amateur soccer matches (see fig.  3.2). 

   Figure 3.2:  A USAID and
   UNICEF-supported Community
   Center and Youth Theater in San
   Pedro Sula, Honduras (with
   props used in HIV/AIDS skits)

   (See figure in printed
   edition.)

  -- In the Philippines, commercial sex workers and
     men-who-have-sex-with-men peer educators provided counseling,
     information packets, and condoms in brothels and locales
     frequented by individuals who engage in high-risk behavior. 

  -- In India, the first HIV testing center in New Delhi was
     developed, providing free voluntary testing; counseling
     services; dissemination of information about HIV/AIDS, STDs, and
     condom use; support and care services for HIV-positive clients;
     and advocacy and sensitization about the rights and needs of
     HIV-positive individuals. 

  -- In Zambia, a pilot project for home-based care mobilized
     community groups to deal with the consequences of the HIV/AIDS
     epidemic, including (1) educating the community about HIV/AIDS;
     (2) caring for orphans, the chronically ill, and the dying; and
     (3) developing income-generating projects for women, orphans,
     and people living with AIDS. 


   CONCLUSIONS
---------------------------------------------------------- Chapter 3:8

UNAIDS has made limited progress toward achieving its goal of leading
a broad-based, expanded, worldwide response to the HIV/AIDS epidemic. 
Cosponsor agency estimates of overall U.N.  spending on HIV/AIDS show
that resources have not increased with the creation of UNAIDS, as was
expected.  Agency spending on HIV/AIDS began declining before the
creation of UNAIDS in 1996 and since then has leveled off, despite an
increase in overall cosponsor agency spending of 6.5 percent. 

Building worldwide support for HIV/AIDS was a key objective of
UNAIDS.  However, the UNAIDS Secretariat is not able to measure
progress in meeting this goal because it does not yet have baseline
data on spending on HIV/AIDS at the country level and has only
recently developed baseline data for contributions by donor
countries.  Secretariat officials said that spending estimates for
affected countries should be available in the fall of 1998.  In
addition, the Secretariat lacks data to determine whether the level
of private sector resources directed to HIV/AIDS has increased or
decreased.  While the UNAIDS Secretariat has made significant efforts
at the international level to mobilize private sector support, we
found that U.N.  efforts at the local level were very limited in the
countries we visited. 

Secretariat officials acknowledged that as of 1997, most theme groups
were not working effectively and that they underestimated the
difficulty of getting U.N.  agencies to coordinate and conduct joint
programming.  For example, in two of the five countries we visited,
we found poorly functioning theme groups that rarely met.  Factors
that hindered theme group operations included insufficient guidance
to staff in the field regarding how theme groups should operate, not
holding staff accountable for theme group success, and U.N.  agency
staff's lack of commitment to working together. 

In addition, the UNAIDS Secretariat has not been very successful in
providing technical assistance and other support to facilitate theme
group activities and has only started to establish performance
measures.  Despite UNAIDS' difficulties, we observed innovative and
U.N.  agency intervention projects in each of our case study
countries. 


   AGENCY COMMENTS AND OUR
   EVALUATION
---------------------------------------------------------- Chapter 3:9

Comments from USAID, the Department of State, and the UNAIDS
Secretariat generally focused on concerns about our review of UNAIDS. 
USAID stated that it shares our concerns about areas in which UNAIDS
has not made sufficient progress.  However, USAID expressed its
strong endorsement and support for the program and the unique role
UNAIDS plays in the global response to HIV/AIDS.  USAID also pointed
to the difficulty of UNAIDS' mandate and UNAIDS' relatively short
existence (2 years at the time of our review).  USAID stated that
progress had been made in some areas since our review.  For example,
USAID noted that at a recent meeting, a Monitoring and Evaluation
Technical Review Group was created to develop a monitoring and
evaluation plan targeted for December 1998. 

UNAIDS Secretariat officials agreed with our conclusion that U.N. 
expenditures for HIV/AIDS did not substantially increase since the
creation of UNAIDS.  However, it questioned the quality of the
financial data reported by the cosponsor agencies because agencies
have difficulty estimating expenditures and use different methods of
reporting.  The Secretariat stated that relying on financial
expenditures alone masks the increased expenditures of human
resources on HIV/AIDS by cosponsor agencies in many countries.  The
Secretariat stated that progress has been made toward mobilizing the
private sector and coordinating efforts at the country level,
providing support to theme groups, and developing a framework for
measuring the progress of the U.N.  effort on HIV/AIDS was reasonable
given the challenges it faced and the short time since the creation
of UNAIDS.  The Secretariat provided updated information on
activities undertaken after we completed our fieldwork. 

Our conclusion about the decline in U.N.  spending on HIV/AIDS is
based on data reported by the respective cosponsor agencies.  We
recognize that agencies use different methods to report expenditures
and that it is difficult to estimate expenditures, particularly when
HIV/AIDS expenditures are integrated into spending for other
activities.  However, because each agency has reported the data in a
consistent manner over time, we believe that the data are useful to
identify trends.  We also agree with the Secretariat that adding
other measures of the U.N.  effort, such as human resources, would be
useful.  However, the Secretariat does not currently have an
evaluation and monitoring system to measure non-financial
contributions to HIV/AIDS. 

We did not make a judgment about whether cosponsor agencies should
have made more progress toward mobilizing the private sector.  The
concern we raised in the report was less about the level of private
involvement than the fact that cosponsor agencies in all but one of
the countries we visited were not making efforts to involve the
private sector.  We acknowledge in the report that theme groups have
made some progress since the Secretariat's 1996 survey; it was
conducted the same year that most theme groups were established, so
some progress would be expected.  However, the 1997 survey indicated
that half or fewer of the theme groups had undertaken efforts in 7
out of 10 of the key outputs measured.  We also note that despite
being instructed by its governing board to immediately begin
developing an evaluation and monitoring plan, the Secretariat did not
hire staff to develop the plan until a year and a half after UNAIDS
was established. 

USAID, State, and the UNAIDS Secretariat also noted that UNAIDS has
only been in existence for 2-1/2 years and were concerned that it may
have been too early to assess the program.  State also said it was
disappointed at the very negative tone in the report concerning
UNAIDS' activities and believed that the report did not give any
credit to UNAIDS for what it had achieved.  Furthermore, State said
that we implied that U.N.  agencies and the U.S.  government should
stop supporting UNAIDS. 

While we recognize that UNAIDS has been in existence for only 2-1/2
years, we did not evaluate the program's impact on the HIV/AIDS
epidemic.  In our report, we present the facts as we found them to
be, including areas needing improvement and areas that have worked
well.  In fact, the report specifically identifies UNAIDS'
accomplishments, including information on innovative grassroots
interventions.  Also, we did not evaluate whether support for UNAIDS
should be continued.  Our objective, as stated in the report, was to
examine the program's progress, since its inception, in meeting
established objectives such as increasing resources devoted to
HIV/AIDS and working together in theme groups at the country level. 




(See figure in printed edition.)APPENDIX I
COMMENTS FROM THE U.S.  AGENCY FOR
INTERNATIONAL DEVELOPMENT
============================================================ Chapter 3



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


The following are GAO's comments on the U.S.  Agency for
International Development's (USAID) letter dated June 24, 1998. 

GAO COMMENTS

1.  We modified the language to note that USAID primarily uses
private voluntary organizations (PVO) to implement its programs. 

2.  We agree that the AIDS Control and Prevention (AIDSCAP) program
in Honduras was in existence for a short period of time before the
global AIDSCAP project ended.  However, our analysis showed that the
program's short duration was due to the difficulty it had in getting
started.  We modified the report with the following information to
clarify what we found.  USAID officials in Honduras said that they
began negotiating with AIDSCAP in 1993 to develop a program, but that
AIDSCAP's proposals did not adequately emphasize participation by the
government or involvement by local non-governmental organizations
(NGO).  As a result, USAID did not reach agreement with AIDSCAP until
1995, 2 years before it was scheduled to end. 

3.  We modified the report to reflect efforts by the Joint United
Nations Programme on HIV/AIDS (UNAIDS). 

4.  We modified the report to reflect efforts by U.N.  donor
countries. 




(See figure in printed edition.)APPENDIX II
COMMENTS FROM THE DEPARTMENT OF
STATE
============================================================ Chapter 3



(See figure in printed edition.)



(See figure in printed edition.)


The following are GAO's comments on the Department of State's letter
dated June 25, 1998. 

GAO COMMENTS

1.  Our conclusions are not based on the criticisms of U.N. 
officials.  Rather, we gathered data from fieldwork in five
countries, from the Secretariat's surveys of all theme groups in 1996
and 1997, as well as from a survey of field staff conducted by USAID
that also included questions on the progress of UNAIDS. 

2.  We agree that the evidence in our case studies showed that three
of the five theme groups in the countries we visited were operating
effectively.  However, our conclusion was also based on the
Secretariat's overall assessment of theme group operations.  As we
point out in the report, Secretariat officials acknowledged that as
of 1997 most theme groups were not working effectively and that they
underestimated the difficulty of getting U.N.  agencies to coordinate
and conduct joint programming.  Moreover, the Secretariat's 1997
survey of its theme groups indicated that less than half of the theme
groups were judged effective in cosponsor coordination. 




(See figure in printed edition.)APPENDIX III
COMMENTS FROM THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES
============================================================ Chapter 3



(See figure in printed edition.)




(See figure in printed edition.)APPENDIX IV
COMMENTS FROM THE UNAIDS
SECRETARIAT
============================================================ Chapter 3



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


The following are GAO's comments on UNAIDS' letter dated June 24,
1998. 

GAO COMMENTS

1.  We made a judgment that the U.N.'s progress was limited based on
its progress relative to the criteria set forth in the U.N.'s
Economic and Social Council resolution endorsing the creation of
UNAIDS. 

2.  Because this updated information was provided subsequent to our
visits to the five countries, we could not verify it and therefore
have not included the information in the report.  Although the
Secretariat reports progress since our visits, we note that its April
1998 report on a 1997 survey of theme groups indicates that, as of
April 30, 1998, less than half of the groups responding had
undertaken efforts in 7 out of 10 of the key outputs measured. 

3.  We modified the text to reflect this information. 


MAJOR CONTRIBUTORS TO THIS REPORT
=========================================================== Appendix V

NATIONAL SECURITY AND
INTERNATIONAL AFFAIRS DIVISION,
WASHINGTON, D.C. 

Jess T.  Ford
Lynne M.  Holloway
Joan M.  Slowitsky
Patrick A.  Dickriede
Rolf A.  Nilsson
Rona H.  Mendelsohn

OFFICE OF THE GENERAL COUNSEL,
WASHINGTON, D.C. 

Mark C.  Speight

LOS ANGELES FIELD OFFICE

Aleta L.  Hancock
Thomas W.  Zingale

*** End of document. ***