HIV/AIDS: Observations on USAID and U.N. Prevention Efforts
(Statement/Record, 09/16/1998, GAO/T-NSIAD-98-232).

This testimony, which summarizes the findings of a July 1998 report
(GAO/NSIAD-98-202), focuses on international efforts to combat the
spread of the AIDS virus in the developing world. GAO reviewed efforts
by the U.S. Agency for International Development (USAID) and the United
Nations at their headquarters and in the Dominican Republic, Honduras,
India, the Philippines, and Zambia. GAO discusses (1) USAID's response
to the HIV/AIDS epidemic in the developing world and (2) the progress
since 1996 of the U.N.'s efforts, commonly called UNAIDS, to coordinate
U.N. activities and mobilize the international response to the epidemic.

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

 REPORTNUM:  T-NSIAD-98-232
     TITLE:  HIV/AIDS: Observations on USAID and U.N. Prevention
	     Efforts
      DATE:  09/16/1998
   SUBJECT:  International organizations
	     Acquired immunodeficiency syndrome
	     Developing countries
	     Financial management
	     Infectious diseases
	     Health care services
	     Sexually transmitted diseases
	     Health statistics
	     International cooperation
IDENTIFIER:  Dominican Republic
	     Honduras
	     India
	     Philippines
	     Zambia
	     U.N. Joint Program on HIV/AIDS
	     AIDS
	     AID AIDS Control and Prevention Project

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GAO/T-NSIAD-98-232

Cover
================================================================ COVER

Before the House International Relations Committee

For Release on Delivery
Expected at
9:30 a.m., EDT
Wednesday,
September 16, 1998

HIV/AIDS - OBSERVATIONS ON USAID
AND U.N.  PREVENTION EFFORTS

Statement for the Record by Benjamin F.  Nelson, Director,
International Relations and Trade Issues, National Security and
International Affairs Division

GAO/T-NSIAD-98-232

GAO/NSIAD-98-232t

(711364)

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

  AIDS -
  AZT -
  AIDSCAP -
  GAP -
  NGO -
  USAID -
  UNAIDS -
  HIV/AIDS -
  HIV -
  STD -
  WHO -
  HIV -

============================================================ Chapter 0

Mr.  Chairman and Members of the Committee:

We are pleased to be able to provide this statement for the record
which summarizes our observations on international efforts to address
the spread of the human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) in the developing world.  This
statement is based on the results of a study requested by this
Committee, HIV/AIDS:  USAID and U.N.  Response to the Epidemic in the
Developing World (GAO/NSIAD-98-202, July 27, 1998).  In conducting
our work, we reviewed the U.S.  Agency for International
Development's (USAID) and United Nation's HIV/AIDS programs and
activities at their headquarters and in the Dominican Republic,
Honduras, India, the Philippines, and Zambia.

Specifically, this statement discusses USAID's response to the
HIV/AIDS epidemic in the developing world.  USAID's efforts began in
1986.  In addition, this statement discusses the progress of the
United Nations' effort, commonly called UNAIDS, in coordinating U.N.
activities and mobilizing the international response to the epidemic
since it was created in 1996.  We did not attempt to assess the
contribution of the U.N.'s effort or the impact of individual U.N.
agency programs\1 in stemming the epidemic.  However, in the
countries we visited we observed innovative activities, which are
summarized in this statement.

--------------------
\1 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);
the World Health Organization (WHO); and the World Bank.

   BACKGROUND
---------------------------------------------------------- Chapter 0:1

HIV/AIDS exacts enormous economic and social costs on the developing
world where more than 90 percent of the 30 million people afflicted
with the disease reside.  The epidemic continues to spread rapidly
there, and according to UNAIDS and the World Health Organization
(WHO), accounts for more than 90 percent of the 5.8 million new
infections worldwide in 1997.

USAID and the United Nations first began to address the HIV/AIDS
epidemic in the mid-1980s.  USAID works in partnership with
governments, other donors, and private organizations to support
research and HIV/AIDS interventions in 28 countries.  In 1997, USAID
spent $81 million on specific projects and $20 million on technical
assistance and research.  It also provided $16 million to UNAIDS.

The Joint United Nations Program on HIV/AIDS (UNAIDS) was created in
response to the conclusion drawn by U.N.  officials and donor
countries in the early 1990s that a more comprehensive approach was
needed to address the sociological and developmental factors that
affect the spread of the disease.  To meet this objective, on January
1, 1996, the United Nations created the UNAIDS Secretariat to replace
WHO as the lead organization for the U.N.  HIV/AIDS effort.
Together, the UNAIDS Secretariat and six U.N.  agency cosponsors,
were expected to coordinate and lead a broad-based, expanded
worldwide response to HIV/AIDS.  It was agreed that each U.N.
cosponsor agency would (1) increase resources devoted to their
agencies' HIV/AIDS activities; (2) mobilize resources for HIV/AIDS in
affected countries, including the private sector; and (3) coordinate
with each other 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 to measure progress,
(3) organize theme groups as the forum for coordinating U.N.
activities, and (4) provide technical support and information on what
interventions work.

   SUMMARY
---------------------------------------------------------- Chapter 0:2

Although HIV/AIDS continues to spread at a rapid rate in the
developing world, USAID has made important contributions in the fight
against the disease.  USAID supported research that helped to
identify interventions proven to curb the spread of HIV/AIDS.  These
interventions have become the basic tools for the international
response to the epidemic.  The evidence we gathered suggests that
USAID projects have increased awareness of the disease, changed risky
behaviors, and enhanced access to treatment of sexually transmitted
diseases (STD) and to condoms, which have helped slow the spread of
the disease in target groups.  For example, in the Dominican
Republic, USAID's efforts contributed to reduced incidence of HIV
among targeted commercial sex workers.  In one clinic funded by
USAID, the percentage of commercial sex workers testing positive for
HIV/AIDS dropped from 5.8 percent in 1995 to 3.5 percent in 1996.

To date, the United Nations has made only limited progress toward
meeting its goal of leading a broad-based, expanded, and
well-coordinated worldwide effort to prevent the transmission of
HIV/AIDS.  While information is not yet available to measure UNAIDS'
progress in promoting increased spending by donor countries, the
private sector, or affected countries, available data indicate that
U.N.  cosponsor agencies have not raised their overall spending on
HIV/AIDS as had been anticipated.  U.N.  spending declined from $337
million in 1994-95 to $332 million in 1996-97 after the creation of
UNAIDS.

The UNAIDS Secretariat has only just begun to establish a framework
for measuring the performance and objectives of the U.N.'s HIV/AIDS
program.  In addition, success with so-called "theme groups," which
were designed to create a single focus and strategy for cosponsors at
the country level, has been uneven.  In some countries, cosponsor
agencies conduct joint projects and meet regularly, while in others,
they are just beginning to work together.  Moreover, theme group
representatives told us that the UNAIDS Secretariat has not provided
useful technical assistance and best practice information to
facilitate their activities.

Available quantitative and qualitative data show that USAID has had
success in reducing the incidence of HIV/AIDS among targeted groups.
Moreover, experts agree with the overall approaches of both USAID and
UNAIDS.  However, the continued rapid rate at which the disease is
spreading in the developing world would suggest that a larger
response may be required to slow the spread of the disease.

   USAID HAS MADE IMPORTANT
   CONTRIBUTIONS TO HIV/AIDS
   PREVENTION
---------------------------------------------------------- Chapter 0:3

USAID's main contributions to preventing HIV/AIDS have been (1)
providing support for research that helped to identify interventions
ultimately proven to prevent HIV transmission and (2) implementating
projects at the country level that raised awareness of the disease,
reduced risky behaviors, and increased access to treatment of STDs
and condoms.  These activities have helped slow the spread of the
disease in target groups, such as commercial sex workers and youth.

      USAID SUPPORTED THE
      DEVELOPMENT OF ACCEPTED
      INTERVENTIONS
-------------------------------------------------------- Chapter 0:3.1

Starting in 1986, USAID funded public and private research efforts
that identified interventions proven through clinical trials and
longitudinal studies to have an impact on the spread of HIV/AIDS.
These interventions became the principal tools used in the global
response to HIV/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 HIV infections; and

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

      USAID PROJECTS MADE
      IMPORTANT CONTRIBUTIONS
-------------------------------------------------------- Chapter 0:3.2

Our analysis of data from internal and external evaluations and
discussions with representatives of high-risk groups indicate that
USAID projects have helped slow the spread of the disease in targeted
groups.  Evaluations conducted of USAID's largest project, the AIDS
Control and Prevention Project, or AIDSCAP, determined that its
activities were successful in the 18 countries where it had programs.
For example, in Honduras, AIDSCAP improved access to STD treatment
and condoms and established a network of nongovernmental
organizations (NGO) with the capacity to provide HIV/AIDS prevention
activities.  In the Dominican Republic, AIDSCAP improved knowledge
and access to AIDS prevention practices and services to target
groups, such as commercial sex workers and hotel workers.

Although there were management difficulties in Zambia, we found
successful programs in all of the countries we visited.  For example,
USAID's program in the southern state of Tamil Nadu, India, focused
on educating truck drivers and factory workers on the risks of
HIV/AIDS and the use of condoms.  For drivers who were targeted by
USAID's program, the portion that patronized commercial sex workers
and engaged in nonregular sex dropped from 38 percent to 27 percent
between 1996 and 1997, according to USAID.  Similarly, the portion of
factory workers targeted by the program that reported using condoms
increased from 28 percent to 41 percent.  In the Philippines, an
independent evaluation conducted in 1997 indicated that USAID's
activities helped avert an increase in HIV/AIDS; the percentage of
people who are HIV-positive remained below 1 percent in targeted
groups.  Moreover, in both countries USAID increased the capacity of
local organizations to manage and deliver prevention activities.

   UNAIDS HAS MADE LIMITED
   PROGRESS TOWARD MEETING ITS
   GOAL
---------------------------------------------------------- Chapter 0:4

UNAIDS has made limited progress over the past 2 years toward
achieving its goal of leading a broad-based, expanded, and
well-coordinated worldwide response to the HIV/AIDS epidemic.  While
data are not yet available to measure spending from donors and
affected countries, U.N.  cosponsor organizations have not increased
resources devoted to HIV/AIDS.  In addition, despite the UNAIDS
Secretariat's international efforts, it reports that private sector
HIV/AIDS activities have remained few to date.  Moreover, the
Secretariat only recently began to develop a framework for measuring
the performance of HIV/AIDS activities and--to date--has not been
able to provide useful technical support and best practice
information to country-level theme groups as expected.

      LACK OF DATA TO MEASURE
      UNAIDS' PROGRESS IN
      MOBILIZING RESOURCES FROM
      OTHER SOURCES
-------------------------------------------------------- Chapter 0:4.1

One of UNAIDS' objectives was to bolster spending by donors and
affected countries and to increase private sector involvement in
fighting the epidemic.  The Secretariat is completing the analysis to
establish a baseline to measure UNAIDS' progress in mobilizing donor
and affected country resources.\2 Preliminary data from a survey
conducted by the UNAIDS Secretariat indicate that spending by major
donors\3 remained relatively stable between 1993 and 1996, at
approximately $250 million a year; however, data were not available
for 1997.

The UNAIDS Secretariat has encouraged private sector support at the
international level through advocacy efforts with leading corporate
organizations such as the Conference Board and Rotary International.
International efforts by the Secretariat have led to some successes,
particularly in working with individual companies to advocate
research and distribution of medical interventions.  For example,
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.  However, at the country level,
cosponsor agency efforts to involve private companies in HIV/AIDS
have been limited.  U.N.  officials noted that the reason for a lack
of focus on private involvement was because the United Nations is not
accustomed to working with private partners and that its contacts in
the field are almost exclusively with government ministries.

--------------------
\2 Study on the National and International Financing of the National
Response to HIV/AIDS, UNAIDS/PCB(6)/98.3 (Geneva, Switzerland:  May
24, 1998).

\3 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.

      U.N.  EXPENDITURES FOR
      HIV/AIDS DID NOT INCREASE
-------------------------------------------------------- Chapter 0:4.2

When the U.N.  Economic and Social Council created UNAIDS, it noted
that the success of the program was dependent on the provision of
increased resources by the six cosponsor agencies.  However, spending
by these agencies declined by 1.6 percent, from $337 million in
1994-95 to $332 million in 1996-97.  While the U.N.  Population Fund
and the U.N.  Development Program increased spending for HIV/AIDS
after UNAIDS was established, and the U.N.  Educational, Scientific,
and Cultural Organization and WHO began programming funds to support
HIV/AIDS activities, the World Bank and the U.N.  Children's Fund
decreased expenditures.  This decline occurred despite the 6.5
percent increase in overall spending by cosponsor agencies during the
same period.

   Table 1:  U.N.  HIV/AIDS
   Funding Under WHO's Global
   Program on AIDS and UNAIDS,
   1992-97

   (See figure in printed
   edition.)

Note:  The Global Program on AIDS (GPA) was superseded by UNAIDS in
1996.

\a Unavailable.

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

      DIFFICULT BEGINNING FOR
      THEME GROUPS
-------------------------------------------------------- Chapter 0:4.3

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.  UNAIDS' surveys of theme groups and our work
in the field indicate that cosponsor agencies met regularly and even
conducted joint projects in some countries, but in others that was
not the case.  In the Dominican Republic, for example, cosponsor
representatives contributed to a central fund to support HIV/AIDS
activities and met regularly to discuss progress.  However, in India
and Honduras representatives rarely met.  A 1997 survey of theme
groups, compiled by the Secretariat in April 1998 after we completed
our fieldwork, showed that U.N.  cosponsor agencies were making some
progress in working together.  However, in areas where theme groups
reported progress, such as national resource mobilization, less than
half of the respondants said they were operating effectively.

U.N.  officials reported several reasons for theme group
difficulties:  (1) lack of guidance to agency country representatives
regarding the operation of theme groups and the scope of their
mission, (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 UNAIDS' role as the organizational vehicle for the U.N.
response.  Secretariat officials told us that they met with cosponsor
agencies in March 1998 to address these problems and to develop
strategies to improve coordination.

      UNAIDS SECRETARIAT HAS NOT
      PROVIDED SUPPORT REQUIRED TO
      FACILITATE COUNTRY PROGRAMS
-------------------------------------------------------- Chapter 0:4.4

A key role for the UNAIDS Secretariat was to provide technical
assistance and best practice information to theme groups.  However,
in countries we 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 us 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, because these officials were unaware of its availability.
Recognizing these weaknesses, Secretariat officials noted that it,
along with other bilateral donors, is working to establish a network
of technical resources that can be used by U.N.  field staff to
enhance the design and implementation of national HIV/AIDS programs.

      NO EVALUATION FRAMEWORK
-------------------------------------------------------- Chapter 0:4.5

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 Secretariat did not staff the
evaluation unit until September 1997 and hopes to have a pilot
project in place to field test performance measures at the end of
1998.

   COSPONSOR AGENCIES UNDERTOOK
   INNOVATIVE GRASSROOTS
   INTERVENTIONS
---------------------------------------------------------- Chapter 0:5

Although we did not conduct a systematic evaluation of U.N.  agency
projects, we observed innovative prevention activities in each of the
countries we visited.  Cosponsor agencies utilized accepted
interventions, such as condom education and promotion and
encouragement of STD treatment.  These activities ranged from peer
group counseling to theatrical productions that highlighted the
danger of the virus.  These activities were generally targeted to
high-risk groups.  In addition, U.N.  agencies encouraged program
sustainability by training Health Ministry staff and NGOs in affected
countries to provide interventions.

-------------------------------------------------------- Chapter 0:5.1

Mr.  Chairman and members of the Subcommittee, this concludes our
statement for the record.  Thank you for permitting us to provide you
with this information.
*** End of document ***