Text: Natsios Outlines USAID's Strategy for Battling HIV/AIDS

15 February 2002

Text: Natsios Outlines USAID's Strategy for Battling HIV/AIDS

U.S. gave Global Fund $300 million, requests $200 million more

Appearing before the Senate Foreign Relations Committee February 13, Andrew Natsios, administrator of the U.S. Agency for International Development, laid out USAID's strategy for battling HIV/AIDS, a disease which most often strikes the youth of a country, and has decimated much of the young populations of sub-Saharan Africa, the Caribbean, Haiti, Russia, and other parts of the world.

In May, Natsios said, "President Bush was the first to announce a contribution to the newly formed Global Fund to Fight AIDS, TB, and Malaria. To date, the U.S. has pledged $300 million, and President Bush requested an additional $200 million for the next fiscal year. Approximately half of that will come from USAID."

He said there are six parts to USAID's HIV/AIDS strategy: prevention; care, treatment, and support; working with children affected by AIDS; surveillance; encouraging other donors; and engaging national leaders in the campaign against the disease.

Among the "alarming" statistics Natsios pointed out were that:

-- Infection rates in some parts of the Caribbean are now the second-highest in the world.

-- In Haiti and the Dominican Republic, HIV testing suggests that more than one adult in 12 is living with the virus, and

-- In Russia and the republics of the former Soviet Union, the rate of increase in HIV/AIDS cases is the highest in the world.

Following is the text of Natsios's remarks as prepared for delivery:

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Andrew S. Natsios
Administrator, U.S. Agency for International Development HIV/AIDS

Senate Foreign Relations Committee
February 13, 2002

Chairman Biden, members of the Committee, thank you for inviting me to speak today on this topic of singular importance.

I would like to begin by thanking this Committee for supporting our efforts to address HIV/AIDS. Your cooperation and your understanding of the magnitude and complexity of the pandemic has helped USAID maintain its leadership in the fight against this terrible disease. There are many aspects to the disease, the consequences of which are felt every day by millions of people throughout the world. We look forward to working with you closely as you draft a new authorization bill for HIV/AIDS this year.

The U.S. Agency for International Development has a budget of $8.7 billion this fiscal year and programs in more than a hundred countries, but there is nothing more important to our agency -- and to me personally -- than dealing with HIV/AIDS.

Time is not on our side. Since becoming USAID Administrator, I have made it a priority to streamline our procedures, so that more of our program money goes directly to the field and it gets there faster. We are also increasing the number of priority countries we focus our resources on, strengthening our regional programs and taking steps to improve our accountability.

You all know the grim statistics that drive our policy. Twenty-two million people have already died of HIV/AIDS. Ten percent of that number -- 2.3 million people -- died last year in sub-Saharan Africa alone. Thirteen million African children have already lost a parent to the disease, and we expect that figure to triple by the end of this decade. The cost -- to individual citizens, to families, communities, and countries -- is almost beyond reckoning.

An estimated 40 million people are living with HIV/AIDS today. Far too many of them will die unless a cure is found -- and none is yet in sight. Ninety-five percent of those who are infected live in the developing world. A third of them are between the ages of 15 and 24. Many do not even know they are infected or what to do if they are. Every six seconds another person gets the virus. By the end of this decade, another 40 million people may become infected.

Ten years ago no one anticipated the speed at which the pandemic would grow or the way it would spread through different sectors of society. HIV infection has reached alarming levels in southern Africa. One-third of the adults in Botswana, Lesotho, Swaziland and Zimbabwe are living with it now. In South Africa, one adult in five is infected. For many years, prevalence rates in West Africa were lower than elsewhere on the continent, but now we are seeing worrisome increases in infection rates in countries like Nigeria and Cameroon.

And it is not just sub-Saharan Africa that is affected. Infection rates in some parts of the Caribbean are now the second-highest in the world. In Haiti and the Dominican Republic, for example, HIV testing suggests that more than one adult in 12 is living with the virus.

It is not just the millions who are infected today, but the speed at which the infection rate is growing that makes it so threatening. In Russia and the republics of the former Soviet Union, the rate of increase in HIV/AIDS cases is the highest in the world. In Russia alone, the number of officially recorded cases rose from just under eleven thousand in 1998 to 147,000 by late last year, and some suspect the numbers could be considerably higher.

In Asia, where prevalence has generally been low, there are signs of troubling change. India now has some four million people with the virus. In Indonesia, where HIV among prostitutes was once virtually non-existent, the infection rate among this group is now as high as 26 percent. Prevalence has risen very quickly among these same groups in Vietnam: in Ho Chi Minh City, over 30 percent of them are now HIV-positive. Prevalence among injecting drug users is over 50 percent in some Vietnamese cities.

Apart from the individual human costs, the economic, political and social consequences of these facts are staggering. Clearly, HIV/AIDS is not just a health problem. In some parts of the world the pandemic is threatening the very fabric of society. There are places in Malawi, Uganda, Zambia, and Zimbabwe, for example, where HIV/AIDS has taken such a toll on farmers and farm workers that we are seeing alarming rates of malnutrition, even near famine-like conditions where food supply should be abundant and the people healthy.

It is no secret either, that population is declining in some countries, in part because women are dying before they live long enough to bear children. By the end of this decade, average life expectancy in the countries hardest hit by HIV/AIDS could be less than 40 years -- comparable to what it was one hundred years ago.

Studies in Cameroon, Kenya, Swaziland, Tanzania, Zambia, and other sub-Saharan countries suggest that gross domestic product could be reduced by as much as 25 percent over a 20-year period. Some African companies have estimated the cost of HIV/AIDS in terms of health care, sick days and training new hires is reducing their productivity by 5 percent annually, and profits by 6 to 8 percent.

AIDS is like few other diseases, in that it strikes young adults most frequently. Young women are particularly vulnerable, for both biological and social reasons. Indeed, women below the age of 24 appear to be six times more likely to be infected than men their age. And we are now seeing girls being infected at ever-younger ages.

HIV/AIDS hits people in their most productive years, leaving children and the elderly to do increasing amounts of the work upon which society depends. That means fewer children can attend school, less efficient farms and businesses, and more stress on local governments that must divert already inadequate resources away from development to health care and related services. A generation risks being lost. More and more children are acting -- or trying to act -- as caretakers for other children or for the elderly, and more and more families are forced to divert badly needed income for care and treatment of the sick.

As Secretary Powell said on World AIDS Day, "If humankind is to realize the great potential that the 21st century holds for prosperity and peace, the global response to this crisis must be no less comprehensive, no less relentless, and no less swift than the AIDS pandemic itself."

USAID's HIV/AIDS Strategy

There are six parts to our HIV/AIDS strategy: prevention; care, treatment and support; working with children affected by AIDS; surveillance; encouraging other donors; and engaging national leaders.

First: prevention. This has been the cornerstone of our policy for the past 15 years. The single most important aspect of our prevention strategy is reaching young people and changing their behavior. Young people are often difficult to reach, but we have had some notable success working with local organizations to craft a message that they can embrace. In Zambia, for example, our work with 15-19-year-olds has helped delay the age of sexual debut by two years. As a result, HIV/AIDS prevalence rates have dropped by 50 percent in this group.

We also stress the importance of abstinence and faithfulness through our faith-based and community-based partners. We have seen in Uganda how effective a partnership of political and religious leaders can be and we have given them our strong support. And, of course, we distribute over 300 million condoms a year throughout the world.

We are also expanding our programs that prevent mother-to-child transmission of HIV/AIDS through the use of anti-retroviral medication. Currently, we have them in Kenya, South Africa, Uganda, Ukraine, and Zambia.

Another important aspect of our prevention strategy is voluntary counseling and testing, for our experience has shown that those who know their HIV/AIDS status -- and receive counseling if they are infected -- are much more likely to behave responsibly than those who do not. They also make for very good counselors and care givers. So we work with them in programs all over the world. In the Dominican Republic, for example, we fund groups of HIV/AIDS-infected people who support 5,000 others who have the disease, as well as 19 self-help groups.

The second part of our strategy is the care, treatment, and support of those infected by the virus. While there obviously is no cure yet, we can help people survive longer by treating opportunistic infections such as tuberculosis and continuing to help countries build up their health care systems and infrastructure. Although prevention remains our primary focus, we have been providing funding for the care and treatment of people living with HIV/AIDS since 1987. Currently, we have 25 such projects in 14 countries. One example is Cambodia, where USAID funds an organization known as KHANA which organizes government nurses and staff from nongovernmental organizations to provide home-based care.

As the cost of anti-retrovirals (ARVs) has declined and the funding we have available has increased, it is now possible to consider incorporating ARVs gradually and selectively into our care and treatment programs. Accordingly, we have begun identifying potential sites in sub-Saharan Africa where the health care infrastructure is sufficiently advanced to permit their use. There continue to be a number of challenges we must address before we can make full use of ARV therapies, however. Among these are the adverse interactions between ARVs and TB medication and the need for basic laboratory services.

The third part of our strategy involves attending to the millions of children who have lost parents to HIV/AIDS or are at risk of doing so. I have been to Africa many times, and I have seen the faces of these children. The fact is we cannot give them what they need the most -- their parents alive and well. But we can do our best to help them, and we are. We now have 60 projects in 22 countries that provide these children food, shelter, clothing, school fees, counseling, psychological support and community care.

In Romania, for example, USAID is sponsoring a modern pediatric AIDS Center that gives HIV-infected children and families care, support, and counseling. In South Africa, we are working with the Nelson Mandela Children's Fund to provide microfinance loans and community initiatives to support orphans and vulnerable children. This targets 250,000 affected children.

The fourth part of our strategy is surveillance. The nature of the HIV/AIDS pandemic is that we are always learning new things about it. Just as people's behavior differs from region to region, so, too, does the pathology of the infection. There are now at least 15 different sub-types of the virus that have been identified, and we fund research with the Centers for Disease Control and Prevention to understand better their dynamics of transmission.

Through our program with the Census Bureau, we have been tracking HIV/AIDS data for many years, and our figures have become the standard for the international community. But it is important that we keep monitoring the disease, tracking our programs, measuring their impact, developing new strategies with our partner organizations and coordinating our policies with other donor nations. This is the fourth part of our strategy and one that we must continue to expand.

The fifth component is our ongoing effort to encourage other governments and multilateral institutions to increase their financial commitments to the fight against the pandemic. The United States provides one-third of the world's resources to fight HIV/AIDS, four times what the next largest donor gives. We also supply one-fourth of the UNAIDS' funds and are the largest donor to the new Global Fund to Fight AIDS, Tuberculosis and Malaria. We have been able to leverage funding from other governments and foundations as well as coordinate strategies with other donors to get the maximum benefit from our programs and avoid duplication.

Finally, there is simply no substitute for leadership. Whether the issue is HIV/AIDS or democracy or building free markets and institutions, the single most important factor in a country's development is the quality of its leaders and their commitment to their people's well-being. As our experience in countries like Uganda clearly shows, leadership can make an important difference. So the sixth part of our strategy is to encourage national leaders to become strong advocates for programs that educate people about the disease and what they must do to prevent its spread. In addition, we work with host governments to develop HIV/AIDS policies, to make the best use of their resources, and to utilize state media to broadcast prevention messages.

USAID's Commitment to Fighting HIV/AIDS

USAID has been the U.S. Government's lead agency on fighting international HIV/AIDS for more than 15 years. For many years, we were this country's only federal agency that devoted resources to fighting the pandemic internationally.

In 1986, we provided funding for the global program on AIDS launched by Dr. Jonathan Mann at the World Health Organization. Our HIV/AIDS budget that year was just over $1 million; but our commitment has grown considerably since then. By FY '01 our budget had risen to $433 million and in FY '02 it reached $535 million. This means that by the end of this fiscal year, we will have spent more than $2 billion on HIV/AIDS prevention and care programs. This does not count additional funds that other branches of the US Government are spending on programs and research.

For fiscal year 2003, I am proud to say that President Bush has requested $640 million for our HIV/AIDS programs. This represents a five-fold increase since 1999.

Over time, USAID has developed an expertise on international HIV/AIDS programs that is second to none. Ours is hands-on knowledge, derived from years of running programs in over 50 countries. One thing we know for certain: fighting AIDS requires a wide range of technical experts. It calls for pharmacists, teachers, social scientists, specialists in behavior change, lawyers, as well as doctors, care givers, and epidemiologists. We have learned many lessons that have helped us make a difference in people's lives, and we have no intention of stopping now. We are continually looking for new ways to make a difference, to shape new programs, identify promising new techniques and innovative strategies. And as we learn, we are constantly evaluating ourselves and our programs so that we can fine-tune our approach.

It is important that we continue to provide a direct link between ongoing research and those who live in the developing world. An essential part of our strategy, therefore, is to fund the science. Our spending in fiscal years 2001 and 2002, for example, will total $16 million for vaccine research and another $27 million for the development of microbicides.

We fund applied research in 21 countries. Among the things we are working on are ways to reach youth -- the most vulnerable group -- with effective messages about HIV transmission and prevention; integrating HIV testing into existing health care procedures; improving programs to prevent mother-to-child transmission prevention; providing home and community-based care for those affected by the disease; and reducing the stigma of infection, so that those who have the virus can make use of the services that are available.

In addition, we monitor research that may have practical uses in the field. We test the findings in small pilot projects and adapt them for use in countries where they seem most promising. Then we develop the systems, protocols and training necessary to use these approaches on a larger scale so that we can help countries reach as many people as possible.

Technological Innovations

Over the years, USAID has introduced many techniques and strategies that would later become standard practices across the world. In the late 1980s, USAID supported the development of simple HIV tests to ensure the safety of blood transfusions. This prevented countless new infections and enabled hospitals to ensure the quality of their blood supplies.

In 1991, a study in Tanzania showed that treating other sexually transmitted infections (STIs), such as syphilis and chancroid, reduced HIV transmission by almost a half. After that, treating STIs became a standard part of our HIV/AIDS prevention programs. Four years later we began a new approach known as periodic presumptive treatment. This entails foregoing lab tests, which are costly and time-consuming, and giving medication to high-risk populations, such as truck drivers, migrant workers and prostitutes on a regular basis, an approach which has been shown to reduce STIs significantly.

In 1995 USAID supported a three-country study that demonstrated clearly what many had long suspected -- that those who voluntarily undergo counseling and testing and know their HIV/AIDS status are much less prone to engage in unsafe behavior. In many cases, these individuals become powerful voices within their communities. In Uganda, for instance, where great strides have been made in lowering the prevalence of the disease, more than 500,000 people used these services. We now have voluntary counseling and testing programs in over 20 countries.

In 1996, USAID played a key role in the creation of UNAIDS. While UNAIDS has been a forceful advocate for HIV/AIDS funding, their function is not to fund services on the ground. That is done by individual donor nations such as the United States, Japan, Canada, Australia, and the Western Europeans.

In 1997 USAID was one of the first organizations to recognize the essential role that care, treatment and support plays in enhancing prevention efforts. Working with the World Health Organization (WHO) and UNAIDS, we developed the concept known as the "prevention to care continuum." This has now become universally accepted. Prevention, care and treatment are all critical components of an effective HIV/AIDS program. Care enhances our prevention efforts, reduces secondary epidemics like TB, and keeps people alive for their families and communities.

In 1998 USAID issued "Children on the Brink," a paper that focused attention on the plight of AIDS orphans. This was the first time that many statistics about these children were published, and it helped reveal another aspect of this terrible pandemic. Since then, we have launched support projects for HIV/AIDS orphans in 22 countries. An updated edition is expected this summer.

The first treatments that reduce mother-to-child HIV transmission were developed in this country in 1994, but at the time the process was very expensive and hard to duplicate in much of the developing world. By 1999, however, new studies revealed that Nevirapine could provide a much more cost-effective approach. The drug, which requires a single dose each for the mother and the newborn child, costs only about a dollar. And better yet, the drug's manufacturer, Boerhinger Ingelheim, is making it available at no cost to developing countries.

Programs That Make a Difference

Unlike diseases that can be treated by vaccines or antibiotics, the best strategy available to prevent the spread of HIV/AIDS is to change people's behavior. Doing this is never easy, especially when it comes to a subject as delicate and private as human sexuality. But we have learned techniques that work. Thirty million people over the last five years have received face-to-face counseling that has brought home their own risks and taught them how to protect themselves. We are confident that this has saved millions of lives.

Our mass media campaigns have reached hundreds of millions. And our annual condom distribution and social marketing activities probably avert a half a million infections every year.

In the early 1990's, we worked with the Government of Thailand to make it national policy that condoms be used in all the country's brothels. This helped decrease HIV and STI transmission rates substantially and has made Thailand one of the world's success stories. Lessons learned in Thailand are now being practiced within Cambodia and the Dominican Republic.

HIV prevalence among pregnant women in Cambodia declined by 28 percent from 1997 to 2000, and the infection rate among sex workers dropped by 57 percent between 1998 and 2000. In the Dominican Republic, too, condom use among the most vulnerable populations has increased, and men are reporting fewer sexual partners.

Another success story is Zambia, where as I noted above, HIV prevalence has fallen significantly among young people. A USAID-supported youth mass media campaign stressed abstinence for those who are not sexually active and condom use for those who are. The campaign also produced five television advertisements and an award-winning music video entitled "Abstinence is Cool." About 70 percent of the young people who live in the cities and 37 percent of those who live in rural areas reported seeing at least one of the ads.

Thanks to the support we have received from the White House and the Congress, we finally have the resources to begin making a difference on a global scale. As a consequence we are stepping up the war against the HIV/AIDS pandemic. I have already taken the first steps, upgrading our HIV/AIDS division to an office and putting it in the heart of our new Bureau for Global Health. Some of you may have already met the assistant administrator of that bureau, Dr. Anne Peterson. She is a medical doctor who has spent six years in Africa working on HIV/AIDS and other issues.

One of my most important management goals is to get more impact out of every dollar we spend. This means spending more of our resources in the field -- where it is needed -- and less of it here in Washington. Resources for field programs will increase from $192 million, or 61 percent, of our budget last year, to $389 million, or 78 percent, of our budget next year. So not only will we have more money to spend on prevention, care and treatment and children's programs, but more of the money will be spent directly on them.

We are also increasing our HIV/AIDS priority countries from 17 to 23 and adding substantially to what we spend on them. We have listened carefully to what Congress has been telling us. Sub-Saharan Africa continues to be our highest priority. Our new plan increases funding to it substantially.

We will also work to strengthen our regional programs so we can focus more strategically on regional "hot spots" where the epidemic is expanding rapidly, as well as migrant populations and cross-border interventions. We will be convening regional workshops to familiarize our staff with our new strategies. And we are working to establish a comprehensive monitoring and reporting system that will improve our ability to track the programs in our 23 priority countries.

We are also in the process of creating a central Condom Fund to consolidate our acquisition, save money, and get them to the field more quickly. This should allow us to double the number of condoms we purchase.

In addition, we are working with WHO [World Health Organization], CDC [U.S. Centers for Disease Control and Prevention], NIH [U.S. National Institutes of Health] and country partners to simplify and standardize treatment protocols. We are assessing the health care infrastructure in a number of countries to determine what needs to be done to introduce antiretroviral therapy. At the same time, we will continue to support and expand those low-tech but very effective services that improve the quality of life for people affected by this epidemic. These include home- and community-based care, treating tuberculosis, providing microfinance assistance, supporting families caring for additional children, and supporting organizations of people living with AIDS, giving them a voice and a seat at the table.

Last May, President Bush was the first to announce a contribution to the newly formed Global Fund to Fight AIDS, TB and Malaria. To date, the U.S. has pledged $300 million, and President Bush requested an additional $200 million for the next fiscal year. Approximately half of that will come from USAID.

We have been actively involved in the formation of the Global Fund from the beginning, and participated in the first official meeting of the Fund at the end of January. USAID loaned staff to the Fund's Transitional Secretariat for six months, provided $1 million for Secretariat operations, and was key in providing technical guidance on AIDS issues during the formation of the Board.

We believe our experience and programs can serve as useful models for the Global Fund and can complement its aims.

In conclusion, I would like to emphasize once again how committed USAID is to stepping up the war against HIV/AIDS. We are in a race against time with a virus that shows no sign of letting up. As the rate of infection is still growing in many places, we have to redouble our efforts, speed up our processes, and constantly seek to refine our approach. While we have recorded some success stories, there are still many others that must be written. The war on AIDS will be a long and arduous one, but it is a way that we can, and ultimately, will win.

Thank you.

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