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U.S. Department of State July 1995 US International Strategy on HIV/AIDS Bureau of Oceans, International Scientific and Environmental Affairs U.S. INTERNATIONAL STRATEGY ON HIV/AIDS July, 1995 Dear Friend, Every region of the world has been affected by the devastation caused by HIV/AIDS. As the numbers of new infections continue to rise, we face the enormous challenge of developing more effective approaches to dealing with this pandemic. The U.S. International Strategy on HIV/AIDS is designed to assist U.S. government efforts in meeting the challenge. The Strategy is an interagency effort led by the Department of State. Representatives from the Departments of Health and Human Services, Defense, Commerce, Education, Labor, Justice, as well as USAID, Peace Corps, the intelligence community, and the National AIDS Policy Director worked in close collaboration in the development of this report. The result is a Strategy which contains a set of priorities for action which all relevant U.S. agencies will work to achieve. In this effort, I was particularly pleased to have the full participation of over twenty non-governmental groups -- including representatives from the AIDS activist community, health service providers and the business community and people living with HIV/AIDS. I look forward to a more comprehensive effort to prevent new HIV infections and mitigate the impact of AIDS. In this Strategy, we now have a plan of action. Sincerely, (signed) Timothy E. Wirth I. INTRODUCTION ABOUT THIS DOCUMENT SCOPE OF THE PANDEMIC PREVENTING INFECTIONS TREATMENT U.S. FOREIGN POLICY IN THE GLOBAL COMBAT AGAINST HIV/AIDS II. ACTION STRATEGY: MEETING U.S. INTERNATIONAL HIV/AIDS GOALS A. PREVENT NEW HIV INFECTIONS 1. TAKE DIPLOMATIC INITIATIVES TO PROMOTE MORE ACTIVE INVOLVEMENT ON HIV/AIDS ISSUES BY NATIONAL GOVERNMENTS. 2. DEVELOP BEHAVIORAL PREVENTION STRATEGIES. 3. AUGMENT RESEARCH. 4. SAFEGUARD THE BLOOD SUPPLY. 5. PROVIDE ACCESS TO HEALTH SERVICES AND TECHNOLOGIES. 6. ADDRESS THE ADVERSE IMPACT OF POVERTY AND OTHER FACTORS ON PREVENTION EFFORTS. B. REDUCE PERSONAL AND SOCIAL IMPACT 1. PROVIDE CARE AND SUPPORT. 2. GUARANTEE HUMAN RIGHTS. 3. PROTECT POLITICO-MILITARY STRUCTURES AT RISK. 4. PLACE HIV/AIDS ON THE SUSTAINABLE DEVELOPMENT AGENDA. C. MOBILIZE AND UNIFY NATIONAL AND INTERNATIONAL EFFORTS APPENDIX A: AN AGENDA FOR ACTION APPENDIX B: INTERNATIONAL RESEARCH COOPERATION APPENDIX C: PREVENTION APPENDIX D: THE IMPACT OF AIDS -- U.S. SECURITY INTERESTS/CONCERNS APPENDIX E: DONOR COORDINATION ACRONYMS AIDS Acquired Immune Deficiency Syndrome CDC Centers for Disease Control and Prevention CIA Central Intelligence Agency DHHS Department of Health and Human Services DOD Department of Defense FDA Food and Drug Administration HIV Human Immunodeficiency Virus NGO non-governmental organization NIH National Institutes of Health PHS Public Health Service STD sexually transmitted disease U.N. United Nations UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organization I. INTRODUCTION The HIV/AIDS pandemic poses major challenges to all nations. HIV/AIDS is, as President Clinton observed, "the health crisis of this century." HIV/AIDS will also have economic, social, political and security implications throughout the world. While human suffering is the most significant implication of HIV/AIDS, the pandemic is affecting a widening spectrum of society both in the United States and abroad. The spread of HIV/AIDS threatens to undermine democratic initiatives by destabilizing societies. HIV/AIDS threatens the sustainable economic development of many countries, including current and potential trading partners. U.S.-based multinational companies will face difficult challenges in addressing the impact of global HIV/AIDS on trade and investment considerations. National security interests are affected by the high rate of HIV infections among the military of certain countries. The international community is becoming increasingly concerned that some governments use HIV/AIDS as a justification for the violation of human rights. In many countries women's lower socio-economic status puts them at higher risk of becoming infected. The United States must struggle against the HIV/AIDS pandemic. As the major contributor to multilateral and bilateral prevention efforts and as the world's standard bearer for biomedical research, the United States has been a central player in efforts to stem the spread of global HIV/AIDS. Our strong support for the streamlined newly established Joint U.N. Programme on AIDS provides another example of U.S. leadership on this issue. Yet much hard work remains. Success will require a sustained and vigorous commitment by the United States and its international partners. About this document This Strategy and action plan seeks to assist U.S. policymakers in working more effectively with international partners in the fight against global HIV/AIDS. Even as an early draft, this framework proved useful in guiding our preparation for the Paris AIDS Summit in December, 1994, and will help guide the U.S. planning for the IVth World Conference on Women to be held in September, 1995 and other future international meetings. A USG interagency working group developed the document in consultation with non-governmental AIDS activist groups, business and trade representatives, and service organizations. The strategy articulates a set of U.S. international objectives for the fight against HIV-infection and AIDS and a set of actions aimed at meeting these objectives. The paper is intended mainly for the traditional foreign affairs agencies, such as the Department of State and USAID, as well as domestic agencies such as the Department of Health and Human Services to the extent that their activities promote international HIV/AIDS policy objectives. Appendices B-E are interagency working group reports which formed the basis of the Strategy. Reports were prepared on Research (chaired by NIH), Prevention (chaired by USAID), National Security (chaired by CIA) and Donor Coordination (chaired by USAID). The Strategy itself, which has been cleared by all concerned USG agencies, is based on the interagency working group reports and State Department input and was developed through coordination and synthesis by the State Department. The Strategy does not describe all AIDS-related activities of all agencies but rather highlights activities that advance foreign policy objectives (USAID activities, for example, are described in a separate, comprehensive document). The interagency working groups made rapid progress in outlining the fundamental tenets of the present document. This permitted the United States to support the inclusion of many of the principles contained herein in the Paris AIDS Declaration which was signed by leaders from 42 countries at the 1994 Paris AIDS Summit. The document is the basis in principle for U.S. support for the establishment of the U.N. Joint and Co-Sponsored Programme on HIV/AIDS and for the World Health Organization's Global Programme on HIV/AIDS. HIV/AIDS is a long-term problem requiring a long-term commitment. The present Strategy should therefore be considered a long-term foreign policy framework supported by a near-term set of action items. As the present pandemic changes, and as we learn more about successful approaches to combat HIV/AIDS, our overall strategy and action plan should change accordingly. The Strategy should be viewed as a dynamic and flexible document, to be reviewed and revised as appropriate and at least biennially. The State Department will monitor progress toward reaching the goals outlined in the present Strategy. Scope of the Pandemic No region of the world has been spared the steady, silent spread of human suffering associated with AIDS. While the poorest regions of the world have been spared the least, industrialized countries will also be faced with increasing numbers of AIDS cases well into the foreseeable future. In the United States, HIV/AIDS is now the number one killer of Americans in the 25 - 44 year old age group, according to the Centers for Disease Control and Prevention. Two to three million new HIV infections worldwide are expected annually. By the year 2000, the WHO estimates conservatively that 30-40 million people will have been infected. Harvard's Global AIDS Policy Coalition estimates that between 40 to 110 million people will have been infected by that time. While a small percentage of HIV-infected individuals have lived for twelve years or more with no sign of AIDS, the large majority of HIV-infected individuals develop AIDS and die within years. Unlike other infectious disease epidemics such as cholera or plague, AIDS will not likely run its course and subside, at least in the foreseeable future. Without more effective response strategies and massive behavioral and societal change, or an effective vaccine, AIDS will continue to spread, especially in the Third World, reaching staggering levels of infection, death, human suffering, and social disorder. Thus, without human intervention, the number of AIDS cases will continue to rise in all regions of the world well into the next century. Thus HIV/AIDS presents a unique set of health, social, economic and political challenges which will affect both developed and developing countries. For the most part, HIV/AIDS affects those in the 25-44 age group, arguably the most productive in society. Developing countries and countries in transition will suffer the most from the loss of productivity. The incubation period from initial infection to disease onset is usually upward of ten years, during which time the infection may be unknowingly spread. Almost 80% of infections occur through sexual transmission; current prevention strategies rely primarily on changes in high-risk sexual behaviors, notoriously difficult to control. As governments cope with increasing numbers of cases and already weakened health care systems, the economic impact on the most productive segments of society, and the impact on their military and political forces will become increasingly evident. Some specific examples of the broad impact of HIV/AIDS include: The World Health Organization (WHO) estimates there will be between 10 and 15 million orphans worldwide attributable to HIV/AIDS by the turn of the century. The proportion of women infected with HIV is increasing rapidly; by the year 2000, the WHO predicts that more than half of newly infected adults will be women. In 1992 in Thailand, multinational firms invested $1.3 billion. If projected rates of HIV infection in Thailand hold, a labor force increasingly weakened by AIDS-related illness and reduced by AIDS deaths could discourage foreign investors and jeopardize advances in the Thai standard of living. Tourism in Bangkok, a major source of income in the Thai economy, is lagging already, in part because of the fear of HIV/AIDS. A World Bank and U.S. Census Bureau modeling exercise found that by 2015, Africa's total GDP could be reduced by up to 22 percent relative to a no-AIDS scenario, which assumed moderate economic growth through the period. Certain militaries may begin to experience the adverse effects of AIDS in the next five years as rising HIV infections among young men reduce conscript pools and as an increasing number of officers, senior NCOs, and trained technicians become ill and die. HIV/AIDS could begin to degrade military manpower pools and readiness within the next ten years. In the industrialized countries, HIV/AIDS will raise a number of questions that governments and businesses must address: U.S. and other multinationals will be forced to consider HIV/AIDS in foreign investment and trade discussions. HIV/AIDS is already straining the health care systems in cities that are hard-hit. In some U.S. cities, the majority of beds in some hospitals are filled with AIDS patients. Worldwide peacekeeping operations will become increasingly controversial as militaries with high infection rates find it difficult to supply healthy contingents. The United Nations will have to grapple with politically sensitive choices, such as refusing HIV-infected troops. Human rights violations of HIV-infected persons are likely to increase and require attention. Preventing Infections Despite enormous progress in understanding the AIDS virus and its effects, there is presently no available vaccine that can prevent HIV infection or progression to AIDS. At present, however, there are over a dozen vaccine candidates in the early phases of clinical trials. Even if one of these vaccines proves effective in preventing infection or progression of illness, it will be years before it could be produced and distributed on a global basis. In addition to the long-range goal of vaccine development, our strategies must focus on two broad areas: the reduction of high-risk sexual and drug behaviors and the development of non-vaccine preventive technologies, especially those that allow women the option of protecting themselves from infection, including vaginal microbicides and the female condom. Improvements in female-controlled preventive technologies are promising; these technologies will be the most effective in preventing HIV infection in women, at least in the near term. Further, female- controlled technologies may be more viable options in the long run for developing countries. Also, biomedical researchers have recently demonstrated that use of an antiviral therapy appears to reduce the likelihood for HIV-infected mothers to pass the infection to their infants. In addition, preliminary studies indicate that higher levels of a particular nutrient in the mother's bloodstream are associated with decreased risk of mother-to-fetus transmission, although the nature of this relationship needs more study. WHO estimates that if all developing countries were to implement a basic HIV prevention program about one-half of the 20 million new infections expected worldwide between now and 2000 (based on conservative estimates) could be averted. However, such a program presupposes a full commitment by national political leaders -- often in conflict with strongly held cultural and religious sentiments. While some leaders have made strong commitments to preventing the spread of HIV/AIDS, much more needs to be done to implement government policies and programs. The United States respects the sovereign right of each nation to make its own policies. Truly successful strategies should draw on multiple sectors of society, including business and labor. A strong commitment to prevention activities could stave off the enormous adverse impact of HIV/AIDS that is projected for expanding economies. Education is critical, including discussions of abstinence and mutual monogamy. Treatment Although HIV infection cannot be "cured" at present, biomedical research in the 1980's and 1990's produced several drugs that prolong and improve the quality of life for those infected with HIV. In addition, relatively inexpensive non-drug therapies and other strategies are being developed to help slow the progression of HIV disease. In poorer areas these interventions may be more appropriate than more costly antiviral drugs. Further research is needed to determine how effective and feasible these interventions may be. Nevertheless, the issue of access to adequate and affordable supplies of drugs for HIV and related opportunistic infections will surface increasingly in international discussions. U.S. Foreign Policy in the Global Combat Against HIV/AIDS The HIV/AIDS pandemic increasingly threatens economic, social and political stability (see Appendix D), and also threatens to undermine U.S. foreign policy initiatives including the promotion of democratization and sustainable development, conflict resolution and peacekeeping, and human rights. With no effective and affordable long- term medical treatment or vaccine on the horizon and without more aggressive efforts to prevent new infections, the AIDS pandemic will have greater and greater impact on developed and developing countries well into the next century. How can the United States advance the worldwide struggle to contain the HIV/AIDS pandemic and to mitigate its effects? This strategy lays out a plan of action for U.S. leadership: Increase the political and economic commitment by foreign leaders to stem the spread and mitigate the impact of HIV/AIDS; Persuade other donor countries to shoulder a greater share of the technical assistance burden for HIV/AIDS; Focus world attention on the special needs of women, children and youth and their predisposition to become infected with HIV; Support the concept that sustainable development, family stability and personal responsibility are inextricably linked to stemming the spread of HIV/AIDS; Improve international cooperation on AIDS research and vaccine development; Encourage the efforts of the United Nations on HIV/AIDS, including continued support for the Joint U.N. Programme on AIDS; Address the human rights implications of HIV/AIDS in all appropriate fora; and, Foster greater involvement by non-governmental organizations, communities, business and labor leaders, and people infected with, and affected by, HIV/AIDS in AIDS policy and program formulation. The U.S. Strategy is divided along thematic lines that reflect the three main objectives of the World Health Organization's "Global Strategy for the Prevention and Control of AIDS." These WHO objectives provide a useful framework from which to delineate an action plan to meet the U.S. foreign policy goals described above: Prevent new infections; Reduce personal and social impact; and, Mobilize and unify national and international efforts. II. ACTION STRATEGY: Meeting U.S. International HIV/AIDS Goals A. PREVENT NEW HIV INFECTIONS One focus of U.S. and global efforts is on preventing new infections and AIDS cases by more effectively promoting the utilization of existing technologies and strategies, including the promotion of condom use; by working toward the development of more effective biomedical interventions, including vaginal microbicides and female- controlled barriers; by continuing to support health-promoting behaviors; and, by working to address underlying social conditions that enhance the transmission of HIV. 1. Take Diplomatic Initiatives to Promote More Active Involvement on HIV/AIDS Issues by National Governments. National governments have the primary responsibility for sounding the alarm and for instituting programs to prevent the spread of HIV/AIDS. Prevention strategies are boosted by the active involvement of political leaders who openly address the HIV/AIDS issue. The USG should work with other governments to increase their recognition of the need for strong political and governmental leadership in stemming the spread of HIV/AIDS. The State Department and senior U.S. officials will: -- urge foreign leaders to openly address the HIV/AIDS pandemic in their own countries; -- urge other governments to consider the adverse economic and social impact of HIV/AIDS in their countries; -- urge other governments to increase spending or to reallocate funds to prevent the spread of HIV/AIDS and strengthen AIDS research efforts; -- emphasize the importance of National AIDS Action Plans which involve all relevant governmental agencies, Ministries, NGOs and the private sector; -- encourage foreign leaders to support the Joint U.N. Programme on AIDS; and, -- urge foreign leaders to join the United States and 41 other countries in endorsing the Paris AIDS Declaration. U.S. ambassadors and other embassy representatives will meet with host country counterparts to describe the U.S. International Strategy on HIV/AIDS and will encourage leaders to expand HIV/AIDS prevention and mitigation programs. Emphasis will also be placed on the important role that non-governmental organizations, business groups, people living with HIV/AIDS and community organizations should play in an effective response to HIV/AIDS. The State Department will seek to heighten the awareness of the foreign policy implications of HIV/AIDS in the foreign service community, through all available mechanisms, including training and conferences for foreign service officers. The State Department will transmit this Strategy in a cable to all posts. 2. Develop Behavioral Prevention Strategies. Prevention programs aimed at reducing high-risk behavior are the best hope for reducing the numbers of new HIV infections. The Congress will be asked to support increases in the funding for global prevention programs that have been shown to reduce high risk behaviors that lead to the spread of HIV infection. The Secretary of State will describe in a letter to Congress the implications of the global HIV/AIDS issue for U.S. foreign policy and the need for U.S. funding for international programs aimed at reducing high-risk behaviors associated with HIV infection. (This letter, to be sent jointly with the Secretary of Health and Human Services, will address other AIDS-related issues, as described below.) Successful prevention strategies can provide cost-effective ways to improve both domestic and international prevention efforts. Low- cost, effective and culturally relevant programs that are designed and implemented in collaboration with affected communities hold great promise. As HIV/AIDS becomes increasingly a disease of the poor in the United States, lessons gained from community-based organizations overseas become highly relevant. Similarly, community-based organizations in other countries can benefit from the U.S. experience, for example, in community planning for HIV/AIDS prevention. USAID combats global HIV/AIDS by identifying successful prevention strategies and applying them to appropriate new regions or countries. Such strategies should be publicized to government and community health workers. The Peace Corps incorporates HIV/AIDS education into other services, such as the teaching of English. This model approach for successful and integrated intervention should receive continued support. Through continued military-to-military educational programs on HIV/AIDS, The Department of Defense will collaborate to reduce the rate of infection in foreign militaries. Governmental groups should seek the expertise of those on the front lines of the HIV/AIDS battle, including people living with HIV/AIDS and non-governmental experts. The NGO community, business and labor leaders, and people living with HIV/AIDS should be included as appropriate in AIDS policy dialogue as well as in designing and implementing of prevention strategies aimed at changing high-risk behaviors. The State Department will host a conference with U.S.-based international business leaders to discuss a range of HIV/AIDS-related issues, including the impact of HIV/AIDS on trade and investment decisions and on sustainable economic development. The State Department will work with non-governmental organizations that bring together private sector and public health interests to prepare the conference. The State Department, USAID and the National AIDS Policy Director will host a conference for domestic and international non-governmental organizations to discuss the U.S. response to global HIV/AIDS and to foster the exchange of information and experiences between domestic and international groups. Expected participants include representatives from the private sector, the religious community, activist groups and service organizations. USAID, the National AIDS Policy Director and the State Department will explore the feasibility of hosting satellite meetings at the International AIDS Conferences and regional AIDS conferences at which large cohorts of domestic and international NGOs are represented in order to foster dialogue between domestic and international NGOs. 3. Augment Research. The U.S. maintains the world's most advanced biomedical and behavioral research base on HIV/AIDS. Advances made domestically will have international applications and impact. The U.S. research agenda on HIV/AIDS emphasizes the development of preventive vaccines and other interventions to reduce the spread of HIV/AIDS, including microbicides, and more effective behavioral strategies and therapies to suppress opportunistic infections. The National Institutes of Health (NIH) have primary USG responsibility for conducting and funding basic and clinical research on AIDS. USAID and the Centers for Disease Control and Prevention (CDC) conduct international surveillance, behavior research, and prevention activities. The Department of Defense conducts mission relevant biomedical research activities toward candidate vaccine development. International research collaboration helps: (a) expand the knowledge base for diverse strains of HIV, (b) boost understanding of epidemiologic trends and mechanisms of HIV transmission, and (c) identify successful behavioral strategies for prevention. Such collaboration will provide the basis for eventual large-scale testing of vaccines, therapies and other interventions. The Congress should be encouraged to support the substantial U.S. research agenda on HIV/AIDS since these activities are most likely to produce a vaccine, drugs, technologies or behavioral strategies that could be used on a global scale. In their joint letter to the Congress, The Secretary of State the and Secretary of Health and Human Services will describe the important role of U.S. biomedical and behavioral research in the global strategy to prevent infections. The letter will explain why Congress should support fully the Administration's budget request for biomedical research. USG representatives, including embassy personnel, will encourage foreign governments to recognize the value of supporting, both financially and in principle, HIV-related research. Where appropriate, embassies will assist in gaining approval for HIV/AIDS vaccine trials and other research efforts in host countries. Through training and education, foreign representatives and health professionals will be more able to address the epidemic in their own countries. They will develop more reliable statistics and better train more staff to monitor the spread of HIV/AIDS. The NIH and its Fogarty International Center will establish and strengthen international biomedical scientific collaborations and training. NIH's Office of AIDS Research, in collaboration with the Fogarty International Center, will develop an inventory of NIH-supported research being conducted in both developing and developed countries. The State Department will assist USG agencies as necessary in strengthening or establishing international research and training collaborations. USG technical agencies will maintain, expand or improve their research-related AIDS efforts: The National Institutes of Health will continue its strong AIDS research program with the aim of developing effective behavioral strategies, drugs, vaccines, other prevention technologies and approaches, including vaginal microbicides, and low-cost diagnostics to reduce the spread and impact of HIV/AIDS. NIH will work with the private sector, as appropriate, in this endeavor. A key element of USAID's strategy on HIV/AIDS is to continue to support behavioral research, with the aim of developing culturally appropriate prevention strategies, and studies of the economic impact of HIV/AIDS, particularly at the household level. FDA will work with product manufacturers to facilitate the rapid development of new agents for the prevention and treatment of HIV- related conditions as well as medical devices for the prevention of HIV transmission. CDC will continue to support behavioral research that provides information on risk behaviors and assists in targeting prevention strategies more appropriately. The Department of Defense will continue mission relevant biomedical research efforts toward candidate vaccine development. NIH's Office for Protection from Research Risks will continue its advisory and regulatory role in ensuring that international research is conducted in an ethical manner, consistent with agreed principles for protecting human subjects. Recognizing that international health problems portend domestic concerns, CDC, in collaboration with other agencies, will work toward improved global monitoring of the spread of HIV/AIDS. The State Department will convene a meeting of the National Science and Technology Council's Committee on International Science, Engineering and Technology to address the global challenge of emerging and re-emerging diseases, including HIV/AIDS. Enhanced federal efforts to improve global surveillance of disease will be one major focus of the meeting. The U.S. Census Bureau will expand its international HIV/AIDS database to include statistics from developed countries and countries where data had not been available previously, such as those of the Former Soviet Union. The State Department, in collaboration with the CDC, will organize a workshop to examine surveillance and epidemiological issues and related policy concerns in the Former Soviet Union. The Department of Defense will continue its biomedical research efforts toward vaccine development and toward improving the understanding of strains of HIV which pose potential risks to U.S. troops serving overseas. 4. Safeguard the Blood Supply. The overall number of HIV infections which is attributed to receiving infected blood is relatively small. Yet technology exists that can safeguard the blood supply and effectively prevent these infections. Making this technology available to countries in need and reducing the number of unnecessary blood transfusions will prevent the majority of infections acquired through this mechanism. The Department of Health and Human Services will work with international partners, including NGOs and international development agencies and organizations, to assist in safeguarding the world blood supply. FDA will work with manufacturers to facilitate the development of new testing methodologies and other approaches to help assure the safety of the blood supply. 5. Provide Access to Health Services and Technologies. Access to health services, and particularly those related to reproductive health and treatment of sexually transmitted disease, is essential in enhancing the efficacy of prevention strategies. The U.S. will give priority to ensuring access to primary health care services, and particularly to reproductive health and STD services; At international meetings the USG will emphasize the importance of access to health services as an important component of HIV/AIDS prevention and care strategies. USAID's HIV/AIDS strategy includes programs that underscore the linkage between reproductive health services, the treatment of sexually transmitted diseases, and reduction in the spread of HIV/AIDS. The USG will stress the important role that communities play in delivery of health services. Access to effective prevention and treatment technologies for HIV/AIDS remains a major concern for many groups. The USG will work with international partners to improve access to effective and affordable condoms and drugs, critical to effective HIV/AIDS prevention. Concerned USG agencies will consider alternative and innovative ideas, including the establishment of an international fund, aimed at improving access to prevention and treatment technologies, including condoms and vaginal microbiocides once they are developed. 6. Address the Adverse Impact of Poverty and Other Factors on Prevention Efforts. The epidemic is steadily increasing in poorer populations who have limited access to information about HIV and AIDS and/or preventive health services and limited ability to act on the information they may have. As societies improve access to information and services for all members and promote the rights and dignity for all members, thereby reducing discrimination, they will be increasingly successful in reducing the social and economic damage caused by AIDS. The USG will work with other governments and in every appropriate forum, including international conferences and within the U.N. system, toward improving conditions which foster HIV/AIDS prevention efforts for groups that may be at higher risk for HIV infection, including women, children, youth, members of minority groups, the poor, homosexuals, mobile populations, and intravenous drug users. Illustrative examples of USG actions are outlined below. Women: Coupled with their biological susceptibility to infections through heterosexual transmission, the lower social, educational, and economic status of women in some countries puts them at even higher risk for becoming infected with HIV. Their subordinate role in some countries prevents them from refusing unsafe sex or from leaving marriages in which their partner is engaging in behaviors which places him at high risk for becoming HIV-infected. The improvement of the status and self-esteem of women and their role in the family will have far-reaching effects in reducing HIV infections in women and in stemming the spread of HIV/AIDS. Several conditions may directly or indirectly impact the rates of HIV infection in women: -- Human rights abuses, such as the selling of women and girls into prostitution and the traditional practice of female genital mutilation; -- Increasing trend toward early childhood marriage; and, -- Discriminatory land-tenuring and inheritance laws. In all appropriate fora, the USG will emphasize the special needs of women, including the protection of women's human rights. DHHS and the National AIDS Policy Director will establish an interagency working group to discuss women's health issues related to HIV/AIDS and associated concerns as they relate to key international meetings. USAID programs to increase the education of girls and women and their economic potential will address the socio-economic factors contributing to women vulnerable to HIV-infection. The USG will support global research priorities that emphasize protecting women from infection. Research aimed at development of technologies that increase women's ability to protect themselves from infection is of global import since such technologies may be the best hope to decrease heterosexual spread of AIDS in the near term. USAID and the PHS will prioritize efforts in the development of technologies such as microbicides and the female condom and behavior strategies which will provide greater options for women to protect themselves from infection. As a means to provide greater protection for women as well as men, USAID and PHS will prioritize efforts to develop new and better male condoms. Children and Youth: Cultural and societal attitudes which inhibit frank discussions about sex and gender issues and which condone high-risk sexual behavior can be counterproductive to HIV/AIDS prevention efforts. Successful and long-term HIV/AIDS prevention strategies must include age-appropriate education and others which instill a sense that individuals are able and have a responsibility to protect themselves from infection. In addition, research aimed at preventing infection of infants born to infected mothers should remain a central focus. In every appropriate forum the USG will recommend adoption of age- appropriate education on HIV/AIDS. The NIH will place a high priority on following up initial studies which could lead to methods for preventing HIV transmission from mother to fetus, including antiviral therapy (AZT) and micronutrient treatment (vitamin A) during pregnancy and on further defining the context of their use. The State Department will emphasize to appropriate U.N. agencies, including UNICEF, UNDP, WHO, and UNFPA, the importance the USG places on prevention of HIV infection of children and youth and will urge U.N. bodies to prioritize their efforts for preventing infections and mitigating the impact of HIV/AIDS on children and youth. Mobile Populations: Millions of people who daily move across national borders pose global economic, security and health concerns. This mobile population constitutes one of the world's largest potential transmission pools of HIV. Members of militaries, multinational companies, refugee groups, teams on large development projects, farm groups, trucking companies, and others in this mobile group may engage in high-risk behaviors that would lead to HIV infection. Members of these groups should have access to information and services that would assist in preventing infection, either of themselves or of others. Reducing HIV infections in mobile populations would presumably have a secondary benefit of decreasing rates of transmission once the worker returned home. The USG will work to improve access to information and services for mobile populations. The State Department will convene an interagency working group to discuss cooperation more closely with development banks to reduce the spread of HIV/AIDS at development project sites and particularly among workers who migrate to work at those sites. When appropriate and feasible, USAID will incorporate HIV/AIDS prevention activities into the overall health strategy for well- established refugee camps. B. REDUCE PERSONAL AND SOCIAL IMPACT Medical services and social support are vital for persons with HIV and their families. Nations need long-term treatments for HIV and AIDS and for the opportunistic infections which complicate HIV infection, such as tuberculosis. HIV/AIDS poses problems to infected persons which go beyond the medical and health implications, such as the potential for human rights abuses and discrimination in the workplace. Further, the impact of HIV/AIDS on society as a whole is manifested in destabilized family structures, adverse impact on the economy, and the threat of political and military destabilization. These broader issues must be considered in any strategy to mitigate the impact of HIV/AIDS on the individual and the society. 1. Provide Care and Support. Most countries aspire to ensure access to health care services for all citizens. In developed and developing countries alike, however, the growing numbers of AIDS cases will strain health care systems. In developing countries, health care systems have been inadequate even before HIV/AIDS. The result is less access to service for those in need. The effects are multiplied because governments will be forced to buttress weak health care systems by diverting scarce resources from national savings or other sources that are critical for national economic stability. While working to boost health care infrastructures, governments should work with non-governmental groups and people infected and affected by HIV/AIDS to more effectively meet the care and support needs of HIV-infected individuals. o With the goal of developing effective and affordable long-term treatments and strategies to provide care and to assist HIV-infected persons and their families, USAID and PHS, with support from the State Department as needed, will continue and expand efforts to bolster health care infrastructures, including strengthening of tuberculosis control programs. USAID and DHHS agencies will provide technical assistance to countries for the identification and development of international procurement and distribution mechanisms for drugs, vaccines and other preventive technologies. The USG will support the inclusion of non-governmental organizations and people infected with and affected by HIV/AIDS in the design of care strategies. In appropriate international meetings the USG will support a strong role for community-based provision of care and support to those affected by HIV/AIDS. Special emphasis on families: The impact of HIV/AIDS on families is cause for alarm. By the year 2000, it is estimated that 10 - 15 million children will have become orphans because of HIV/AIDS. They may swell the ranks of the unemployable, become part of the alienated and increasingly criminal class in many cities, and add to the worldwide increase in street children. The impact on women is equally alarming. As infected women become sick and die, families will increasingly feel the burden of lost economic income, especially in agricultural-based societies, as well as the loss of the major caregiver for the family. The USG will advance the recognition in every appropriate forum that HIV/AIDS can have a devastating and destabilizing impact on families, and particularly on women, children and youth. The State Department will stress the urgent need of addressing the impact of HIV/AIDS on families in all appropriate international fora, including the IVth World Conference on Women and the Joint U.N. Programme on AIDS. USAID will work with other donors to establish innovative programs, including the establishment of trust funds, in order to provide social services and support for the burgeoning number of AIDS orphans in developing countries. 2. Guarantee Human Rights. Universal recognition of the human rights of HIV-infected persons is essential to reducing the personal and social impact of HIV/AIDS. The USG will promote non-discriminatory workplace policies, protection from punitive or coercive measures with respect to HIV testing, policies relating to entry into foreign countries that are based on sound public health practice, and non-discriminatory access to education and medical treatment as well as the protection of civil and political rights. In all appropriate international fora the State Department and other appropriate USG representatives will promote the safeguarding of equal protection under the law for persons living with HIV/AIDS with regard to access to health care, employment, education, travel, housing and social welfare. The State Department will continue to include HIV/AIDS-related di scrimination and human rights abuses in regular embassy reporting. 3. Protect Politico-Military Structures at Risk. HIV has the potential to affect the stability and readiness of militaries, especially those in developing countries with very high HIV rates of infection. The overall impact on military capabilities in most instances appears to be slight thus far; however, as key career personnel increasingly move past the long HIV latency stage and contract AIDS, their loss will have a detrimental effect, particularly in the more sophisticated developing-country militaries that depend significantly on well trained and experienced technical personnel. Militaries are composed largely of young men and women who are susceptible to behaviors that carry with them the risk of contracting HIV. Nethertheless educated and disciplined troops can be trained to avoid high-risk behaviors by a military establishment that recognizes and responds to the threat of HIV/AIDS. That explains, in part, the relatively low HIV prevalence in developed-country militaries. World-wide peacekeeping operations may pose a danger of spreading HIV, particularly as traditional developing-country suppliers of troops find it increasingly difficult to supply units that are free of HIV infection. The risk runs both ways; peacekeepers could both be a source of HIV infection to local populations and be infected by them, thus becoming a source of the infection when they return home. In combat situations, there may also be increased risk of HIV transmission among peacekeepers, and between them and local populations, through contact with HIV contaminated blood. A more substantial overall risk, however, is the transmission of HIV-related secondary infections, such as tuberculosis, which are far more contagious and more easily transmitted. The spread of those diseases cannot be largely avoided by controlling high-risk behaviors, as is the case with HIV. All appropriate support should be given to DOD's military-to-military educational programs on HIV/AIDS that are geared to improving prevention strategies in foreign militaries. The State Department will convene an interagency meeting to address the impact of HIV/AIDS on international peacekeeping operations and humanitarian missions. Issues to be considered include risk of exposure of U.S. troops to HIV/AIDS and to HIV-associated and possibly multi-drug resistant TB; combat medical conditions, including safety of the blood supply and medical personnel and treatment of non-U.S. troops; the importance of military training in the U.S. as a democracy promoting measure and the impact of restrictive U.S. entry requirements on such training, and the degree of spread of various strains of HIV due to peacekeeping operations. Recommendations for action will be made to appropriate officials, including those responsible for development of U.S. policy on U.N. peacekeeping operations. The National Intelligence Council will coordinate the preparation of a National Intelligence Estimate on the impact of HIV/AIDS on military establishments. 4. Place HIV/AIDS on the Sustainable Development Agenda. The growing AIDS epidemic will complicate ongoing sustainable development efforts. While AIDS has adversely impacted the skilled, urban workforce in developing countries, the disease will also have an increasingly devastating impact in rural regions over the next several years. Because remittances from urban workers are often critical sources of income for family members who remain in the countryside, the illness and death of urban workers may mean fewer resources are available to rural communities and households. The loss of trained workers and supervisors will reduce the professional and technical and skills base, especially in smaller countries, while infection among the unskilled will disrupt routine operations even in sectors where replacements are readily available. Losses in the agricultural labor pool could lead to decreased production of cash crops as subsistence farming consumes all available labor in some communities. The credit-worthiness of those seeking loans for low-cost housing, farm improvements, or to expand small businesses is weakened if family incomes are reduced by illness and death. Education is vital for development, but children are leaving school early to care for ill relatives or because falling family incomes do not allow for payment of school fees. Moreover, since infected people die during their most productive years, tough decisions will have to be made regarding expenditures for training. The State Department will work with the Departments of Commerce and Treasury and USTR to propose AIDS as an agenda item at the G-7 and other appropriate international economic meetings. The State Department, in consultation with business and labor groups, other NGOs and appropriate USG agencies, will host a 1-5 day conference on a range of HIV/AIDS-related issues, including the impact of HIV/AIDS on sustainable development of trading partners. The intelligence community will produce and update analyses of the impact of HIV/AIDS in selected countries and regions, as needed. C. MOBILIZE AND UNIFY NATIONAL AND INTERNATIONAL EFFORTS Strengthened collaboration within and among countries is an essential component to improving efforts to combat global HIV/AIDS. The U.S.G. should use a variety of mechanisms to meet these objectives, including the following: The Interdepartmental Task Force on HIV/AIDS, chaired by the National AIDS Policy Director, will develop a national action plan for HIV/AIDS, as directed by the President. -- The State Department will work to ensure that the objectives outlined in the present document support and complement those of the national action plan. The Joint U.N. Programme on AIDS is expected to provide an excellent framework for the coordination of bilateral and multilateral HIV/AIDS efforts. Continued support for the Programme sends the message that the U.S. sees coordination of efforts as a critical element in a successful effort to combat global HIV/AIDS. -- The State Department and senior USG officials will support -- and will urge other governments to support -- the speedy establishment of the Joint U.N. Programme on AIDS. The State Department and senior USG officials will urge other governments to increase their contributions to the UN's efforts on HIV/AIDS to the already high levels being contributed by the USG. Since the HIV/AIDS issue is taken up in a number of intergovernmental fora, both within and without the U.N system, the State Department will convene regular interagency meetings to discuss the international agenda and to develop common approaches on HIV/AIDS issues. Using the HIV/AIDS component of the Common Agenda with Japan as a model, the State Department and USAID will pursue agreements with other donors to work more closely on HIV/AIDS in priority countries. To the extent possible, U.S. international policy on HIV/AIDS will be consistent with other international efforts, and those of the U.N. system in particular. APPENDIX A: An Agenda for Action The following breakdown by agency re-capitulates the action items outlined in the body of the document in their order of appearance. For actions in which more than one agency is involved, the action, in most cases, is listed according to the agency which will take the lead. State Department 1a The State Department will ensure that the major tenets of this document are promoted in relevant international meetings of the U.N. and other bodies, including the IVth World Conference on Women, as well as within U.N. agencies themselves, and particularly in the Joint U.N. Programme on AIDS. 1b The State Department will develop policy guidance materials to ensure that U.S. international HIV/AIDS objectives are promoted in discussions between senior USG representatives and national leaders from key countries. In addition to encouraging leaders to join the United States in endorsing the 1994 Paris AIDS Declaration and the Joint U.N. Programme on AIDS, USG representatives will emphasize a range of concerns, including the urgent need for leaders to openly address the HIV/AIDS pandemic in their own countries, the need for governments to consider the adverse economic impact of HIV/AIDS in their countries, the need for other governments to increase spending on HIV/AIDS prevention and research, and the need to establish or implement National AIDS Action Plans. 1c U.S. ambassadors and other embassy representatives will meet with host country counterparts to describe the U.S. International Strategy on HIV/AIDS and to encourage leaders to expand HIV/AIDS prevention and mitigation programs. Emphasis will be placed on the important role that NGOs, business groups, people living with HIV/AIDS, and community organizations should play in an effective response to HIV/AIDS. 1d The State Department will transmit this Strategy on HIV/AIDS in a cable to all posts. 1e The State Department will seek to heighten the awareness of the foreign policy implications of HIV/AIDS to the foreign service community through all available mechanisms. 1f The Secretary of State will join the Secretary of the Department of Health and Human Services in sending a joint letter to Congress describing the broad impact of HIV/AIDS, including the implications for U.S. foreign policy and national security interests. The letter should describe the important role of U.S. biomedical research in the global strategy to prevent infections. The letter should urge Members to support fully the Administration's budget request for biomedical research and international AIDS prevention. 1g The State Department will host a 1-5 day conference with U.S.- based international business leaders to discuss a range of HIV/AIDS- related issues, including the impact of HIV/AIDS on trade and investment decisions and on sustainable economic development of trading partners. 1h The State Department will assist USG agencies as necessary in strengthening or establishing international research and training collaborations and will assist, as necessary, in gaining approval for HIV/AIDS vaccine trials and other research efforts in host countries. 1i The State Department will convene a meeting of the National Science and Technology Council's Committee on International Science, Engineering, and Technology to address the global challenge of emerging and re-emerging diseases, including HIV/AIDS. 1j The State Department, in collaboration with the CDC, will organize a workshop to examine surveillance and epidemiological issues and related policy concerns in the Former Soviet Union. 1k The State Department will emphasize to appropriate U.N. agencies, including UNICEF, UNDP, WHO and UNFPA, the importance which the USG places on prevention of HIV infection of children and youth and will urge U.N. bodies to prioritize their efforts for preventing infections and mitigating the impact of HIV/AIDS on children and youth. 1l The State Department will convene an interagency working group to discuss mechanisms whereby the USG may work more closely with development banks to reduce the spread of HIV/AIDS at development project sites. 1m The State Department and other appropriate USG representatives will promote the safeguarding of the protection under the law for persons living with HIV/AIDS with regard to access to health care, employment, education, travel, housing and social welfare in all appropriate fora. 1n The State Department will continue to include HIV/AIDS-related discrimination and human rights abuses in regular embassy reporting. 1o The State Department will convene an interagency meeting to address the impact of HIV/AIDS on international peacekeeping operations and humanitarian missions. Recommendations for action will be made to appropriate officials, including those responsible for U.S. policy on U.N. peacekeeping operations. 1p The State Department will work with the Departments of Commerce and Treasury and USTR to include AIDS as an agenda item at the G-7 and other appropriate international economic meetings. 1q The State Department will work to ensure that the objectives outlined in the present document support and complement those of the national HIV/AIDS action plan, now being developed. 1r The State Department and senior USG officials will support -- and will urge other governments to support -- the speedy establishment of the Joint U.N. Programme on AIDS. They will also urge other governments to increase their contributions to the U.N.'s efforts on HIV/AIDS to the already high levels being contributed by the USG. 1s The State Department will convene regular interagency meetings to discuss the international calendar and to develop common approaches on HIV/AIDS issues. 1t Using the HIV/AIDS component of the Common Agenda with Japan as a model, the State Department and USAID will pursue agreements with other donors to work more closely on HIV/AIDS in priority countries. USAID As outlined in the body of the present document, the following are some of the key elements of USAID's global HIV/AIDS strategy: 2a Identify successful prevention strategies and, through USAID missions and U.S. embassies, publicize successes to government and community health workers so that they may be duplicated elsewhere, including in other regions of the same country as well as in other countries. 2b Continue to support behavioral research, with the aim of developing culturally appropriate prevention strategies, and studies of the economic impact of HIV/AIDS, particularly at the household level. 2c Continue to develop programs which underscore the linkage between provision of reproductive health services, the treatment of sexually transmitted diseases, and reduction in the spread of HIV/AIDS. 2d Address the socio-economic factors which contribute to women's vulnerability to HIV infection through programs to increase the level of education in girls and women and their economic potential. 2e Support efforts in the development of technologies such as microbicides and the female condom and behavior strategies which will provide greater options for women to protect themselves from infection. 2f Develop new and better male condoms. 2g When appropriate and feasible, incorporate HIV/AIDS prevention activities into the overall health strategy for well-established refugee camps. 2h With the goal of developing long-term treatment and care strategies for HIV/AIDS affected persons, USAID, with support from the State Department as needed, will continue and expand efforts to bolster health care infrastructures in countries in need. 2i Continue to provide technical assistance to countries for the identification and development of international procurement and distribution mechanisms for drugs, vaccines and other preventive technologies. 2j Work with other donors to establish innovative programs, including the establishment of trust funds, in order to provide social services and support for the burgeoning number of AIDS orphans in developing countries. DHHS AGENCIES 3a NIH's Office of AIDS Research, in collaboration with the Fogarty International Center, will develop an inventory of NIH-supported research being conducted in both developing and developed countries. 3b NIH will continue its strong AIDS research program with the aim of developing effective behavioral strategies, drugs, vaccines and other preventive technologies and approaches, including vaginal microbicides, and low-cost diagnostics to reduce the spread and impact of HIV/AIDS. NIH will work with the private sector, as appropriate, in this endeavor. 3c FDA will work with product manufacturers to facilitate the rapid development of new agents for the prevention and treatment of HIV- related conditions as well as medical devices for the prevention of HIV transmission. 3d CDC will continue to support behavioral research which provides information on risk behaviors and which assists in targetting prevention strategies more appropriately. 3e NIH's Office for Protection from Research Risks will continue its advisory and regulatory role in ensuring that international research is conducted in an ethical manner and one that is consistent with agreed principles for protecting human subjects. 3f DHHS will work with international partners, including NGOs and international development agencies and organizations, to assist in safeguarding the world blood supply. 3g FDA will work with manufacturers to facilitate the development of new testing methodologies and other approaches to help assure the safety of the blood supply. 3h PHS will prioritize efforts in the development of technologies such as microbicides and the female condom and behavior strategies which will provide greater options for women to protect themselves from infection. 3i PHS will prioritize efforts to develop new and better male condoms. 3j The NIH will place a high priority on following up initial studies which could lead to methods for preventing HIV transmission from mother to fetus, including antiviral therapy (AZT) and micronutrient treatment (vitamin A) during pregnancy and on further defining the context of their use. 3k With the goal of developing effective and affordable long-term treatments and strategies to provide care and to assist HIV-infected persons and their families, PHS, with support from the State Department as needed, will continue and expand efforts to bolster health care infrastructures. 3l DHHS agencies will continue to work toward the identification and development of international procurement and distribution mechanisms for drugs, vaccines and other preventive technologies. 3m CDC, in collaboration with other agencies, will work toward improved global monitoring of the spread of HIV/AIDS. This includes working with the U.S. Census Bureau to expand its international HIV/AIDS database to include statistics from developed countries and the Former Soviet Union. Peace Corps 4a The Peace Corps' programs which incorporate HIV/AIDS education into other services, such as the teaching of English, should be viewed as models for successful and integrated interventions and should receive continued support. Defense Department 5a The Department of Defense will continue to conduct military-to- military educational programs on HIV/AIDS, which are expected to contribute to changes in high-risk behaviors and overall decreases in the rate of infection in foreign militaries. All appropriate support should be given to these programs. 5b The Department of Defense will continue mission relevant biomedical research efforts toward candidate vaccine development. The Intelligence Community 6a The National Intelligence Council will coordinate the preparation of a National Intelligence Estimate on the impact of HIV/AIDS on military establishments. 6b The intelligence community will produce and update analyses of the impact of HIV/AIDS in selected countries and regions, as needed. Multiple Agency Efforts: 7a The State Department, USAID and the National AIDS Policy Director will host a conference for domestic and international AIDS non- governmental organizations to discuss the U.S. response to global HIV/AIDS and to foster the exchange of information between domestic and international groups. 7b USG representatives, including embassy personnel, will encourage foreign governments to recognize the value of supporting, both financially and in principle, HIV-related research. 7c USAID, the National AIDS Policy Director and the State Department will explore the feasibility of hosting satellite meetings at the International AIDS Conferences and regional AIDS conferences at which large cohorts of domestic and international NGOs are represented in order to foster dialogue between domestic and international NGOs. 7d Concerned USG agencies will consider alternative and innovative ideas and will work with international partners to improve access to essential commodities, including condoms, vaginal microbicides (once they are developed and made available) and drugs to treat sexually transmitted diseases. 7e DHHS and the National AIDS Policy Director will establish an interagency working group to discuss women's health issues and associated concerns as they relate to key meetings on the international agenda. 7f Representatives from the State Department, USAID, the National AIDS Policy Director's office, and others will meet on a regular basis to discuss key issues of common concern. APPENDIX B: International Research Cooperation INTRODUCTION Science is an international enterprise, and international scientific dialogue and research are essential in advancing knowledge about HIV infection and AIDS. International HIV-related research intersects with other foreign policy issues as it develops information to address a fundamental health issue contributing to social and economic instability in many countries. The U.S, has much to gain by continued strong international cooperative and collaborative efforts with nations with highly advanced biomedical research programs and health delivery systems and with nations with less developed research and public health capabilities. Such efforts are a key part of a comprehensive U.S. international HIV/AIDS strategy. Information from international research benefits U.S. citizens, as well as people in the country where research is conducted and people world-wide who are affected by HIV. Some of the most critical scientific information on HIV/AIDS has been derived from collaboration with colleagues in other countries, with implications for prevention and treatment of HIV infection and disease, as well as the impact on societies. These studies provide information on the variation of strains of HIV from various geographical regions; risk factors for heterosexual and mother to child transmission of HIV; the role of other sexually transmitted diseases in HIV transmission; the relationships between HIV infection and other diseases; and the demographic and socioeconomic impact of HIV/AIDS/ Global monitoring of the epidemic is crucial to further understand mutation and evolution of HIV and patterns of spread. The recent explosive epidemic in Asia caused by variants differing from that found in the U.S. warrants close attention; HIV evolutionary patterns in foreign settings may foreshadow unanticipated events in the U.S. The development of HIV-related research skills in scientists and health professionals is central to an international research strategy. Scientist exchanges facilitate the generation of new research ideas. In addition, international training programs increase the expertise of both American and foreign scientists in HIV/AIDS research, provide the opportunity to develop collaborative relationships between American and foreign scientists, and will facilitate the international testing of anti-HIV drugs and vaccines. Consideration of human rights must be fundamental to the philosophy guiding U.S.-sponsored research in foreign countries. Ethical and legal issues related to the conduct of international HIV- related research will be continually examined, including issues such as the protection of human participants in research in vastly differing cultural contexts and the rights of collaborating researchers and institutions. These principles are well-articulated in recent documents (see references 1,2,3). A basic ethical responsibility of developed nations is to ensure that developing countries receive benefits from research. Issues include the dissemination of research information to researchers, care providers, and program managers; dialogue with vaccine and drug manufacturers concerning the need to develop products with global utility; and the development of scientific and laboratory capabilities in developing countries. Research collaboration and training strengthen the scientific foundation and help to establish the knowledge, skills, and laboratory capacity upon which countries can further develop public health infrastructure to deliver HIV vaccines, when available, and cost effective interventions. Such efforts will have far-reaching effects through application to other infectious diseases prevalent or emerging in developing countries. CURRENT INTERNATIONAL HIV-RELATED RESEARCH ACTIVITIES Several government agencies conduct international HIV-related research efforts, the nature and perspective varying with the mandates of the individual agencies. In addition to U.S. and other countries' government agencies, activities related to international research on HIV are conducted by multilateral organizations, including U.N. agencies and the World Bank, and by private foundations. National Institutes of Health (NIH) supports over 100 collaborative HIV/AIDS research projects, in both developed and less developed countries. These include basic research studies, such as genetics and immunology; research related to the development of vaccines and therapeutics; population-based research on transmission of HIV and progression of HIV disease; the behaviors associated with increased risk for HIV infection. These studies help to develop the infrastructure for clinical trials of vaccines by defining potential study populations and developing laboratory and research capabilities. The AIDS International Training and Research Program (AITRP) provides research training designed to increase the capacity of developing countries to address AIDS. A reagent repository provides access to research reagents world- wide. The NIH has developed formal agreements with several foreign countries to collaborate on AIDS-related research, including Japan, Germany, and Thailand. Centers for Disease Control and Prevention (CDC) international AIDS research activities include two collaborative research projects with CDC professional staff posted overseas in Cote d'Ivoire and Thailand, transfusion safety research and assessment in Africa, characterization of viral isolates, field evaluations of low-technology diagnostics, epidemiologic and research training, plus short-term technical consultations and long-term assignment of professional staff to U.N. agencies. The principal areas of current and near future activities include epidemiologic and intervention research in mother-to-child transmission, heterosexual transmission and its interactions with other sexually transmitted diseases, TB-HIV interactions, and blood safety. Training of international public health professionals in epidemiology and research includes courses in Atlanta and overseas, one-on-one mentoring in research projects abroad, and longer-term training for foreign nationals in the U.S. and Belgium, supported in part by funding from the NIH. U.S. Agency for International Development (USAID) has supported research on behavior change, social marketing for condom promotion, and sexually transmitted disease (STD) reduction via its AIDSCAP project. In addition, USAID supports several grants to non-governmental organizations (or private voluntary organizations, NGO/PVO), as well as epidemiological and biomedical research administered by the NIH, CDC, and the Global Programme on AIDS of the WHO. Specific areas of research include female-controlled vaginal spermicides and microbicides, female condoms, the economic impact of HIV/AIDS, inexpensive STD diagnostics, and novel testing and counselling strategies. Department of Defense (DoD) HIV/AIDS efforts comprise militarily relevant, product oriented, applied research aimed at reducing the rate of new infections, disease progression, and death of DoD personnel. A key objective is to develop a vaccine(s) offering protection from HIV for U.S. military personnel world-wide, including: isolation and characterization of the genetic diversity of HIV from international sites; initiation of joint U.S./Thai preventive vaccine field trials in late 1994 or 1995. A collaborative program with other militaries through DoD's world-wide network of military research laboratories forms the basis for potential HIV/AIDS clinical and research observations, especially in the development and pre-clinical testing of vaccines corresponding to virus prevalent in developing countries. A behavioral prevention program includes intervention-based prevention research directed at reducing high risk behaviors among uninfected military personnel. FUTURE DIRECTIONS IN INTERNATIONAL HIV RESEARCH COOPERATION International research collaboration will continue to provide unique research opportunities that allow us to obtain useful scientific information more rapidly and at less cost, benefitting all concerned. The following are critical areas of international HIV-related research collaboration to be pursued. Basic biomedical research in areas such as virology, immunology, and molecular biology will provide the basis for the development of AIDS vaccines and therapeutic strategies. Study of the clinical and molecular epidemiology of HIV/AIDS and mathematic modelling of individual epidemics is central to an international strategy to address AIDS, particularly in areas already greatly impacted by the pandemic, such as Africa and Latin America, and in areas of escalating epidemics, such as the Far East and Western Pacific. Research on risk behaviors and the factors that motivate and sustain behavior change in difference populations and under a variety of social, cultural, and economic circumstances will provide the foundation for the development, testing, and implementation of behavioral interventions. Studies of risk factors and mechanisms of HIV transmission will provide information critical to the development of biologically-based strategies to interrupt transmission, including transmission from mother to infant, sexual transmission, and transmission through injection drug use. In particular, studies of the role of treatment of STDs in control of HIV transmission will be critical to efforts to link STD programs with HIV prevention. Studies of the progression of HIV-related disease from early infection through long-term consequences, including opportunistic infections, will provide information central to the clinical management of HIV-infected patients. The development and evaluation of non-vaccine interventions that are effective against HIV infection and disease progression, cost effective, and useful in a variety of settings are critical to a comprehensive approach to aids prevention and an international research strategy. The development of HIV vaccines that are safe and effective in preventing infection in exposed individuals is a major international public health priority. The evaluation of vaccines for efficacy, including vaccines for mother to child transmission, will likely involve international vaccines trials at international sites. The development of technologies that are applicable to research and patient care in less developed country settings is essential to effective research and care infrastructure. Basic social science research that addresses the impact of social, economic, demographic, and cultural factors on AIDS epidemics, as well as the consequences of the epidemic for the family, society, culture, economic stability, national security, and demographic change, including worker migration, the role of poverty, the status of women, and political repression, will provide information of use to governments in developing broad social and political strategies to combat their epidemics. Additional activities will include the continued development of training programs; expansion of the use of established repositories, including encouragement for foreign scientists to submit specimens and facilitation of access to repositories by foreign scientists; collaboration in the development of a database of international clinical trials; and the dissemination of state-of-the-art research information to foreign scientists. For international research efforts to proceed smoothly, it is critical that mechanisms e developed for coordination and information sharing among agency program staff. Such activities might include developing briefing materials applicable across agencies; maintaining a database of international research activities; and convening meetings to share information and collaborate on program planning, collectively identifying opportunities to address problems cost-effectively. The U.S. should also coordinate effectively with other organizations with roles in international research on HIV, including the WHO Global Programme on AIDS, WHO regional offices, other U.N. organizations, the World Bank, private foundations, and regional non- governmental organizations. The U.S. government should also nurture partnerships with private industry and academia to further research with international relevance. Specifically, the U.S. should collaborate with industry in developing vaccine candidates with global potential, perhaps through joint ventures between the U.S. government and industry. To advance the research agenda, it is necessary to consider policy issues in the context of research. In this regard, the research community will rely on the efforts and expertise of other branches of the Government as noted below. The U.S. should utilize diplomatic channels to encourage foreign governments to recognize the value of supporting, both financially and in principle, HIV-related research. Of particular importance is research that will provide information relative to the empowerment of women and other disenfranchised segments of societies. Where necessary, U.S. agencies and investigators should enlist assistance from Embassies to facilitate the establishment of relationships and the development of in-country infrastructure for research and dissemination of research findings. Other efforts that would complement the international research agenda related to the investigation of mechanisms to remove barriers to infrastructure development for HIV-related research in foreign countries, including re- examining existing authorities in relation to agency programs, addressing immigration issues, and initiating international dialogue concerning taxes and tariffs on equipment imports. Most important, close ties between U.S. and foreign scientists are essential for advancement of international collaborative research on AIDS. To this end, a variety of formal and informal relationships should be cultivated, including scientist-to-scientist relationships, as well as formal agreements between the U.S. and foreign governments and institutions. Where possible, the U.S. should attempt to develop full collaborative relationships with foreign investigators and maintain long-term institutional and personal relationships, whether through funding of projects, exchange of scientific expertise and information, or collegial communication. REFERENCES 1. U.S. Public Health Service (PHS) consultation on International Collaborative HIV Research, Law, Medicine, and Health Care, vol. 19, 1991. 2. International Ethical Guidelines for Biomedical Research Involving Human Subjects, Council for International Organizations of Medical Sciences (CIOMS), 1991. 3. The Human Immunodeficiency Virus Vaccine Challenge: Issues in Development and International Trials, a report by the Committee on Life Sciences and Health, Federal Coordinating Council on Science, Engineering, and Technology, 1993. APPENDIX C: Prevention There is currently no cure for AIDS nor an effective treatment for HIV. Therefore the main focus of current global efforts must be on prevention of new infections in order to break the chain of transmission. In order to prevent the spread of HIV, it is necessary in each country to identify behaviors which place individuals at the highest risk for transmission and to target these behaviors for intensive intervention efforts. Active efforts are required to determine community needs, perceptions, and the basis for risk behavior, as well as assessment of which activities will be most likely to result in lower risk behaviors. In some instances, mitigation of the social effects of high rates of AIDS-related illness will contribute to these efforts. The prevention strategy which is developed will need to be carefully coordinated with other donors and international organizations to maximize impact. Additionally, the success of our national, regional and global programs to confront HIV/AIDS effectively requires active of participation of people infected and affected by HIV/AIDS and community- based non-governmental organizations in the design, development, implementation and evaluation of policies and programs whose purpose is to affect their communities. ELEMENTS OF AN EFFECTIVE U.S. GLOBAL HIV/AIDS PREVENTION STRATEGY: Policy Dialogue U.S. HIV/AIDS efforts should seek to identify and foster policies which promote the successful implementation of HIV/AIDS prevention programs. Consideration of both public policy and individual human rights should be included in the U.S. effort. U.S. interventions in the policy arena, both at the diplomatic and community level, will seek to promote policies which enhance HIV/AIDS prevention and address the social, political, and economic underpinnings and consequences of the pandemic. They should also seek to eliminate policies that undermine successful HIV/AIDS prevention interventions. These policies often include cross- sectoral and multi-sectoral issues outside the realm of health and will require a coordinated U.S. response. Information, Education and Communication for Behavior Change Key to the U.S. strategic response to the HIV/AIDS pandemic are prevention interventions which lead to behavior change, including the establishment of community and individual norms that reinforce safe behavior to lower the risk of acquiring sexually transmitted diseases and HIV. Education and information interventions should take into full consideration the cultural beliefs of the community and work from within the community to alter behaviors which place individuals at risk. Increase Condom Use Condoms are a major component of front line interventions in HIV/AIDS prevention. The U.S. response includes interventions to assure the availability and affordable pricing of condoms through improved logistical systems, condom social marketing and, when appropriate, the provision of condoms as well as efforts to facilitate the development of more effective and acceptable barrier devices. HIV Testing and Counselling HIV testing and counselling can be a useful element in the U.S. response as a methods to provide individuals with the knowledge of their personal HIV status and as a diagnostic to obtain treatment. The effectiveness of HIV testing and counselling as a behavior change mechanism is still uncertain, but the U.S. is currently undertaking research activities to assess the efficacy and cost of this intervention as a behavior change tool. Biomedical Interventions An important correlate to prevention education and behavior change interventions is improved STD case management through support to the provision of STD diagnostic and treatment services. Treatment of opportunistic and secondary infections associated with HIV and a compromised immunological status should also be included in the U.S. strategy. Additionally, the development, testing and dissemination of new prevention technologies, including vaginal microbicides and the female condom, is a high priority. Injection Drug Use There are many adverse consequences of illicit drug injection, including the risk of HIV transmission, and so an important U.S. policy goal is to reduce the demand for psychoactive drugs. Simultaneously, efforts must be carried out to help drug abusers prevent sexual transmission of HIV. Behavioral change research into the prevention of bloodborne transmission is also needed. Blood Screening and Blood Safety The U.S., when appropriate, provides technical assistance in ensuring the safety of national and transnational blood supplies, and in helping to develop safe medical practices for health care. Evaluation and Analysis of Data The compilation and analysis of data with respect to the epidemiological, political, social and economic impact of the HIV/AIDS pandemic is essential to U.S. efforts to assist host governments. It is required to assess the effectiveness of ongoing interventions as well as inform future program development. The U.S. assists in improving surveillance of HIV infections and monitoring of related indicators. Research U.S. research institutions, with their extensive capacity and expertise, provide an invaluable contribution to HIV/AIDS prevention. The objective basis for the implementation and evaluation of HIV/AIDS and other STD prevention and treatment interventions, as well as a full understanding of socio-economic impact, derives from basic and applied bio-medical and behavioral research. Research areas should include STD/HIV epidemiological analysis, vaccine development and female- controlled methods of HIV/SD protection, as well as behavioral and social determinants of HIV infection. U.S. EFFORTS TO ADDRESS THE ELEMENTS OF THIS PREVENTION STRATEGY: Policy Dialogue: HIV/AIDS should be introduced to a greater extent in the U.S. diplomatic and policy dialogue in order to underscore the recognition of HIV/AIDS as an international problem with political, social and economic impact which go well beyond the boundaries of the traditional health sector. Nations must address HIV/AIDS as a pandemic fueled by socio-economic inequities, human rights issues and questions of gender status. Discussion and resolution of these and related issues begin at senior policy levels. The State Department should play a central role in raising HIV/AIDS in international fora. Prevention Interventions: USAID implements HIV/AIDS prevention interventions in over 40 countries through NGOs, the private sector and governments. The focus of USAID prevention programs is to engage in efforts to change high-risk behaviors, encourage health seeking behaviors for individuals with STDs, improve the case management of STDs, and to provide individuals with access to affordable condoms. USAID also supports efforts in policy analysis and dialogue and the incorporation of HIV/AIDS prevention efforts into ongoing development assistance programs. For example, the Peace Corps has developed education materials and curricula integrating HIV/AIDS prevention with the teaching of English. CDC provides technical assistance in surveillance, STD case management and program development. Behavior Research: USAID's behavioral research program includes knowledge, attitude and practices surveys, behavior change research and the impact of counselling and testing on HIV prevention, as a part of its intervention agenda. Several U.S. agencies carry out behavior research which is designed to provide indirect or direct information for HIV efforts in the global context. The DOD Behavioral Prevention research effort focuses on behavior change interventions to prevent HIV transmission in military- associated populations. This effort places priority on data-derived interventions to prevent transmission in various populations, through educational interventions for individuals with higher levels of risk- relevant behaviors for HIV infection, and counselling interventions for individuals who are HIV infected. The approaches developed may be applicable in certain military or civilian populations in other areas, including some global efforts. CDC has increased its domestic behavior agenda which may provide insight into persistent behavior change issues in other settings. Biomedical Research: The research of the National Institutes of Health and the Centers for Disease Control and Prevention includes basic research and applied retroviral research, vaccine development and drug therapy. The Department of Defense biomedical effort places emphasis on applied retroviral research, with a focus on vaccines for prevention of HIV infection. These research efforts are considered to be essential contributions to the global HIV/AIDS prevention effort and results of these efforts will continue to have an impact on prevention worldwide. APPENDIX D: The Impact of AIDS -- U.S. Security Interests/Concerns The number of AIDS cases worldwide will rise rapidly during the remainder of the 1990s and will increasingly undermine other projects intended to foster key US policy goals, including democratization, economic development, conflict resolution and peacekeeping, and promotion of individual and political rights. The AIDS pandemic will overwhelm underfunded and inadequate health delivery systems in much of the developing world and could undo hard-won health, social, and economic gains. Moreover, because AIDS mainly affects adults in their most productive years and is virtually always fatal, AIDS will have a more severe economic impact than do myriad other diseases. The World Health Organization (WHO) estimates there were 14 million HIV infections by mid-1993. As many as 30 million to 40 million people worldwide will have been infected by the year 2000. While the largest number of infections are in Africa, southeast Asia could soon claim that distinction. -- An average of one in 40 African adults is infected with the virus. In some East and Central African cities the rate is one in three. -- If unchecked, infection could reach African magnitude -- affecting 5 percent or more of the population -- in several countries, notably Brazil, the Dominican Republic, and Haiti over the next decade. Major social and economic disruptions are possible in many others, including The Bahamas and Honduras. -- More than 1 million people in South Asia are infected, with small numbers of cases reported in Bangladesh, Sri Lanka, Pakistan, and Nepal. Most cases are in India, however, with HIV present in both rural and urban populations in every state. Indian Government neglect of the problem has the potential of allowing replication of the African experience in 10 or 15 years. -- The incidence of HIV and AIDS is increasing in almost every country in Southeast Asia. Thailand has one of the world's highest infection rates and the epidemic is rapidly spreading to neighboring countries, especially Burma. -- Although China claims to have only 1,100 reported AIDS cases, if effective measures to fight the disease are not enacted soon some 10 to 20 million Chinese could be infected by the year 2000. -- Little information is available on rates of HIV infection in North Africa and the Middle East although measurable levels of infection are present in many countries of the region and the problem is believed to be understated. -- The AIDS problem in the former Soviet Union is small but growing, and deteriorating health services will make diagnosis and treatment difficult. -- Romania appears to have the greatest AIDS problem in Central Europe, although infections have been reported in almost all countries in the region. The infection pattern found in Africa is similar throughout the developing world -- highest rates in urban areas, along major trade routes, and in former areas of conflict. Although homosexual contact and intravenous drug use account for most the spread of the disease in North America and Europe, most HIV transmission in the developing world occurs through heterosexual contact or from mother to child. Highly mobile population groups -- refugees and displaced persons, truck drivers and other labor migrants, and demobilizing soldiers -- quicken the spread within and across national boundaries. People at highest risk are those with multiple sex partners who do not use condoms, prostitutes and their clients, and people with sexually transmitted diseases. -- Intravenous drug use is a significant vector for transmission in the Middle East, Asia -- particularly China, Burma and Pakistan -- and in some urban areas of Latin America. -- Contaminated blood products also contribute significantly to the epidemic in the former Soviet Union and some developing countries. Social and Economic Impact The epidemic's indirect costs will be enormous. Such costs will be incurred as skill losses, decreased worker output, lost income, and increasingly inefficient business and government operations. Losses of trained workders and supervisors will reduce the professional and technical and skills base, especially in smaller countries, while infection among the unskilled will disrupt routine operations even in sectors where replacements are readily available. Seriously affected countries could experience losses in the tourist industry as the extent of the epidemic becomes widely known. Moreover, there is anecdotal evidence that businessmen and investors are increasingly reluctant to visit and live where there is a major impact. -- In Thailand, for example, multinational firms spent $1.3 billion in 1992, but if projected rates of HIV infection hold, a labor force increasingly weakened by AIDS-related illness and reduced by AIDS deaths could discourage foreign investors and jeopardize advances in the standard of living. Tourism in Bangkok is lagging already, in part because of the fear of HIV/AIDS.; -- A World Bank and US Census Bureau modeling exercise found that by 2015, Africa's total GDP would be reduced by up to 22 percent relative to a no-AIDS scenario, which assumed moderate economic growth through the period. The growing epidemic threatens to overwhelm fragile health delivery systems in many countries. In many developing countries the annual cost of care for patients with HIV and AIDS -- if provided at US levels of care -- would exceed the per capita gross national product of these nations. In Brazil, for example, the cost of such care could be as high as 838 percent of GNP per capita. Moreover, both money and scarce physical and human health resources are increasingly commandeered for AIDS care; AIDS patients fill 80 percent of hospital beds in the capital of Ethiopia and 40 percent of available beds in Kenya, for example. Infectious diseases linked to AIDS are soaring. Tuberculosis (TB) -- the most important HIV-associated disease and already the leading cause of death in Africa among HIV-infected and AIDS patients -- has again reached epidemic proportions in many countries after decades of decline. TB also is making swift inroads into non-HIV infected populations. The proportion of women infected with HIV is increasing rapidly; by the year 2000, WHO predicts that more than half of newly infected adults will be women. Economic and social realities such as poverty, a lower level of education, and subordinate social status put women at particular risk of HIV infection. AIDS-related deaths among women will contribute to reduced productivity in Africa and other parts of the developing world because of the extensive agricultural role of women. Moreover, the loss of women to AIDS will result in decreased home care and will further strain beleaguered health care systems. WHO estimates there will be between 10 to 15 million orphans worldwide by the turn of the century. Many are abandoned and barely eke out a living, are without health care, and frequently do not attend school. They will swell the ranks of the unemployable, could become part of the alienated and increasingly criminal class in many cities, and are adding to the worldwide increase in street children. -- Growing numbers of street children in Brazil, Columbia, and other countries are particularly vulnerable to infection because they are frequent targets of sexual abuse and because they often resort to prostitution and drug use. One-third of street children recently tested in Columbia were HIV-positive. AIDS also is beginning to reverse the hard-won gains in improved child health care in parts of the developing world. The US Census Bureau projects that the infant and child mortality rates will increase significantly in Thailand, more than doubling for infants and rising nearly fivefold for children. -- In Uganda by 1991, AIDS had halted improvements in infant mortality rates and by 1993 had risen beyond 1986 levels. Impact on Rural Areas. While AIDS impacts most visibly on the highly skilled, mainly urban workforce, the disease could also have a devastating impact on the countryside over the next several years. The UN Food and Agricultural Organization estimates that a quarter of the farms in the most affected countries in Africa may fail as the disease decimates the rural population. Moreover, as remittances from urban workers are often critical sources of income for family members who remain in the countryside, the illness and death of urban workers will mean fewer resources are available to rural communities and households. Impact on Development. The growing AIDS epidemic will compound the difficulty of sustaining development already underway. Even the methods of achieving market-based development are being increasingly undermined by the consequences of AIDS. For example, the credit worthiness of those seeking loans for low-cost housing, farm improvements, or to expand small businesses is weakened if family incomes are reduced by illness and death. Labor mobility -- including rural-urban, among regions, and between countries -- has always promoted access to jobs and income, but migrant labor also spreads the infection. Education is vital for development, but children are leaving school early to care for ill relatives or because falling family incomes do not allow for payment of school fees. Moreover, since infected people die during their most productive years, tough decisions will have to be made regarding expenditures for training. For example, if AIDS reduces school graduates' work life by 15 years, then the payoff to investment in education is greatly reduced. Potential Human Rights Problems. Gains in personal and political freedoms could be endangered by the spreading epidemic. Pushed to respond to an increasingly difficult domestic situation, leaders could search for scapegoats or advocate repressive or discriminatory policies toward unpopular, ethnic, regional, or religious groups, or AIDS victims themselves. Governments could restrict movement across borders, refuse refugees from highly-infected countries, or take other legal measures. -- At least 50 countries have some explicit requirement for HIV testing of foreigners. -- Cuba's aggressive AIDS control program of lifetime quarantine of those who test positive is a human rights concern that could increase if other countries attempt to emulate such controls. National Leadership Essential. Recognition of the problem and promotion of AIDS education and prevention programs by high level government officials is vital to the success of AIDS prevention. Many leaders, especially in the hardest-hit countries in Africa, have begun speaking out but some officials will likely remain on the sidelines, reluctant to court controversy for fear of losing foreign investment or domestic support. A few governments, like Thailand, have begun aggressive AIDS prevention programs, but those programs tend to be targeted only at high-risk groups, particularly sex workers, giving the mistaken impression that the bulk of the population is not at risk. -- Most African leaders have yet to translate words into action by putting AIDS at the top of the political agenda. Moreover, most leaders have spoken out more as a result of international donor pressure or a bid to gain aid rather than in response to domestic needs. Prevention Strategies and Cost Although anti-AIDS programs are widespread, there is little evidence that greater knowledge has changed attitudes and altered sexual behavior on a scale needed to slow the epidemic. While current programs may be worthwhile in terms of lives saved per dollar spend, in the developing world they are still small in scale. Condom use, education to promote behavior change and treatment for STDs are critical components of an effective HIV/AIDS prevention strategy. -- Many men are unreceptive to condom use, however, despite having multiple partners. Many Ugandans tell researchers that condoms stigmatize users as being promiscuous. Costs of Prevention. A strategy to stem the AIDS epidemic would require enormous resources, but there is no guarantee that even significant expenditures could stop the spread of the disease. However, WHO estimates that if all developing countries were to implement a basic HIV prevention project -- information on how to avoid infection, promotion of condom use, treatment of sexually transmitted diseases, and the maintenance of a safe blood supply -- about one-half of the 20 million new infections expected worldwide between now and 2000 could be averted. Such a program would cost about $1.5 to $2.9 billion a year. Currently, worldwide AIDS expenditure on AIDS prevention is about $1.5 billion a year, but only about $120 million a year is spent in developing countries where 85 percent of all infections occur. -- Thailand spends the most for AIDS prevention, with 1992 spending of$45 million. -- Total AIDS spending on prevention in Africa is only about $90 million, less than 10 percent from host-nation government funds. Developing country leaders are likely to turn to donors with a host of increased assistance needs, and international cooperation will be needed to set priorities and fund programs in the anti-AIDS effort. At least some countries would probably respond positively to suggestions that the AIDS epidemic has made imperative more realistic planning of future development efforts, a more careful use of human and financial resources, and serious AIDS prevention efforts. In return, however, the United States and the West will be expected to underwrite broader and more costly assistance programs to cope with the disease. Impact of AIDS on Military Forces In terms of military significance, HIV/AIDS is not a "war- stopper;" it will not immediately render large numbers of field troops unfit for combat. However, as the HIV/AIDS pandemic erodes economic and security bases of affected countries, it may be a potential "war- starter" or "war-outcome-determinant." HIV directly impacts military readiness and manpower, causing loss of trained soldiers and military leaders and shrinkage of recruit and conscript pools. Military populations are at heightened risk for HIV/AIDS. Militaries typically comprise large groups of young, sexually active men who are conditioned to feelings of invincibility and bravado, have money and time to spend on prostitutes and other forms of casual sex, and are removed from traditional mores and societal constraints on their behavior. In addition to their higher risk of contracting hIV/AIDS, military forces also are a significant factor in spreading the disease. Peacekeeping and demobilization present particular dangers in this regard. Worldwide peacekeeping operations will become increasingly controversial as militaries with high infection rates find it difficult to supply healthy contingents. Infected troops could be a risk to populations in host countries, and, given battlefield conditions, a risk to the troops with whom they serve. Moreover, peacekeepers from lower incidence countries may contract AIDS during operations in high incidence areas and spread it on their return home. The UN will have to grapple with politically sensitive choices, such as refusing HIV- infected troops, leading to charges of racial bias and meddling in what most militaries consider to be national security concerns. Growing efforts to demobilize in many regions, including Latin America, Southeast Asia, and Africa, in part prodded by economic considerations and Western donors, may exacerbate the epidemic, particularly if released soldiers take advantage of incentives to return to rural areas, which usually have lower infection rates than cities. On the other hand, former soldiers who remain in cities probably will add to urban health problems. HIV and AIDS impose enormous economic burdens on military health care organizations. The cost of AIDS treatment may divert funds and resources from other vital medical services. As most military medical systems are not equipped to deal with long-term care, military AIDS patients may be diverted into already overburdened civilian health care systems or released without treatment to their homes. Regional Assessments. The pandemic's effects on military forces are most pronounced in Africa. South and Southeast Asia and, to a lesser degree, Latin America, may follow the African model in five to 15 years. -- Africa. AIDS is a significant operational problem for many Sub- Saharan militaries. With HIV infection rates in some forces exceeding 60 percent, a serious degradation of military capabilities may begin soon. Within the next five to 10 years, most militaries in the region will experience loss of readiness from decreased force levels. More importantly, HIV infection and AIDS among military leaders and skilled technicians will have an impact far greater than in numbers alone as hard to replace leadership experience and technical capabilities are lost. -- Asia. The militaries of India, Burma, and Thailand could begin to experience the adverse effects of AIDS in the next five years as rising HIV infections among young men decrease conscript pools and as an increasing number of officers, senior NCOs, and trained technicians become ill and die. HIV/AIDS could begin to degrade military manpower pools and readiness in Vietnam, Cambodia, and Indonesia within the next 10 years. -- Latin America. Haiti's military is already severely impacted and will suffer serious personnel and leadership losses in the next five years. In 10 years, HIV/AIDS will play an increasing role in the militaries of Brazil, Honduras, and the Dominican Republic. On a more positive note..As the world's militaries have common features that place them at greater risk of HIV/AIDS, they also share characteristics that may favor effective responses to HIV/AIDS. These include command, control, and communications systems that facilitate rapid dissemination of policy and directives, higher literacy rates among senior personnel who can pass on education materials to subordinates, better funded health systems that are often independent of civilian systems and less subject to non-medical pressures (funding, politics, etc.), less and a leadership that views HIV/AIDS control as being in their vital interests. Militaries are also less likely to have reservations about mandatory testing programs (although they may not publish results). Implications for the United States The negative effects of HIV/AIDS in AFRICA, Asia, and Latin America in the next five to 15 years will have consequences for the United States. -- US military personnel, operating in high-incidence countries, will be at increased risk of exposure to HIV/AIDS. -- Medical cooperation between US and allied or coalition forces will be difficult if high HIV incidence exists in non-US troops. It is virtually impossible to employ universal blood precautions under combat medicine conditions forward of the first hospital in the evacuation chain. Therefore, US medical personnel may be forced to choose between diverting or even refusing foreign patients or placing US health care workers at elevated risk. US military personnel may also be at higher risk of exposure to HIV-associated and possibly multi-drug resistant tuberculosis. -- The US could find itself embroiled in the explosive problem of devising UN guidelines for the participation of HIV-infected militaries in peacekeeping. Many otherwise qualified potential students have declined training in the West due in part to the requirement of US and other Western militaries for students to be free of HIV infection. The loss of such training opportunities, which are viewed as mechanisms to promote civilian control over the military, democratic principles, and respect for human rights, and slow the transformation of the military into an apolitical institution in many countries. APPENDIX E: Donor Coordination Introduction The United States is the largest contributor to global HIV/AIDS activities, providing bilateral support primarily for HIV prevention activities, research and training and multilateral support for HIV/AIDS program development within the U.N. system. Along with these financial and scientific contributions, the United States plays a lead role in working with other governments and non-governmental organizations to improve coordination of the global HIV/AIDS effort. Because of the seriousness of the HIV/AIDS epidemic and the necessity to involve a wide, diverse range of people and organizations to mobilize an effective response, coordination of national and international efforts is complex but critical. This is especially true given the current worldwide economic environment and the need to optimize the use of existing scarce resources. Obstacles and limitations to coordination While accepting its importance, coordination among organizations and governments presents many obstacles and has inherent limitations. Within the USG, there are multiple Departments and Agencies involved in our response to the HIV/AIDS epidemic. Each of these organizations has its own mandate, set of priorities, and decision-making structures. The same is true for our multilateral, bilateral and host country partners and the respective organizations. In addition, while the host of actors involved in this effort have distinct mandates, they are nonetheless interrelated. Setting each group's mandate into operation can lead to overlap in activities and perceived areas of responsibility. The World Health Organization's Global Programme on AIDS (WHO/GPA) Task Force on HIV/AIDS Coordination proposed the following definition of coordination: Coordination of HIV/AIDS activities is a process which promotes information exchange, builds alliances and facilitates the creation of complementary and reinforcing programmes, rather than being mechanisms of control. The process should be based on a partnership approach, with mutually respectful pursuit of jointly accepted goals and targets of national AIDS strategies and plans. This definition is supported by the following elements: Understanding and common acceptance by all participating parties of objectives and priorities, e.g., of the WHO/GPA Global AIDS Strategy and National AIDS Strategy; Agreement on the need for consultation and exchange of information; Joint recognition of the mandates, unique roles and responsibilities, and the areas of comparative advantage of each of the parties; Concerted effort by all participating parties to ensure information sharing, harmonious policies and action; and, Concerted actions for mobilization and optimal use of resources according to nationally identified priorities and strategies, with the aim of minimizing gaps and overlaps in programme activities and reach. These are important guidelines for our efforts in coordination within our own government and among our international partners. Past and present coordination efforts The USG has developed different approaches to coordination of its international HIV research and program activities: The International Subcommittee of the Federal Coordinating Committee on AIDS was a subcommittee of the PHS Federal Coordinating Committee on AIDS that was convened to coordinate activities of the federal government agencies working on HIV/AIDS internationally. Participation extended beyond PHS to all involved USG organizational units. Besides information exchange, this group had developed a database on USG international HIV/AIDS activities. This group became inactive after changes in the parent committee and in anticipation of new coordination efforts in this administration. The International Forum of AIDS Research (IFAR) was established in 1988 after a group of USG agencies funding international AIDS research saw a need for more regular opportunities to exchange information about their activities. The secretariat for IFAR was the Institute of Medicine/National Academy of Sciences and membership included government and private organizations from the United States and Canada. This served as a useful forum for information exchange and led to some cross- agency international collaborative activities. IFAR was discontinued in 1992 due primarily to lack of continued financial support. The Office of AIDS Research (OAR), established in 1993, at the National Institutes of Health has primary responsibility for planning, coordinating and funding all AIDS-related research in the NIH. The mandate of the OAR is to evaluate the entire NIH AIDS research program, and to set in place refocused scientific priorities through the development of a comprehensive research plan and budget. It is expected that the OAR will improve the effectiveness of the U.S. biomedical effort on HIV/AIDS and will ensure that HIV/AIDS research priorities are given appropriate attention. This refocused effort has significant international implications, since the USG is the world's standard for biomedical research in this area. The Federal Coordinating Committee on Science, Engineering and Technology (FCCSET) Working Group on HIV Vaccine Development and International Field Trials was established in 1992 to focus on issues related to the development, testing and coordination of multinational field trials for candidate HIV vaccines and to help coordinate USG Agencies' activities in this area. The Working Group developed a report, "The Human Immunodeficiency Virus Vaccine Challenge: Issues in Development and International Trials," that was issued in July, 1993. The group continues to meet under the auspices of the National Science and Technology Council to further develop a strategy and plan for vaccine development and international trials. Several structures and initiatives have facilitated and continue to facilitate the coordination of HIV/AIDS within the U.N. system: The WHO/GPA Management Committee (GMC) has provided an opportunity for member states of WHO that contribute to GPA and other U.N. organizations to discuss overall management of GPA and its progress towards achieving its goals. The GMC Task Force on HIV/AIDS Coordination was set up in 1993 to facilitate coordination of the response to the HIV/AIDS pandemic. The Task Force was established by the Management Committee of the WHO/GPA with an initial two year term and is now being dissolved. In the first year, the Task Force focused its work on: (1) developing a comprehensive report summarizing HIV/AIDS-related activities of all major organizations within the United Nations system, intergovernmental organizations, bilateral agencies, and non-governmental organizations; (2) preparing an inventory and summary analysis of coordination issues and problems; (3) elaboration of a framework for guiding principles for HIV/AIDS coordination at country level; and (4) providing input in the process towards developing a joint and cosponsored U.N. programme on HIV/AIDS, which is now being established. TheTask Force also served as a clearinghouse for exchange of views and coordination of decisions relating to HIV/AIDS in different governance fora for other related U.N. organizations. The United States was one of twelve members on the Task Force and represented itself, Canada, Australia and Japan. In response to concerns about the coordination of the United Nations' efforts on HIV/AIDS, a resolution was adopted by the World Health Assembly to direct WHO to explore with its U.N. partners options for a joint and co-sponsored U.N. programme on HIV/AIDS. The governing bodies of WHO, UNICEF, UNDP, UNFPA, UNESCO and the World Bank have endorsed the establishment of such a program. It is anticipated that the program will be operational by January 1996. The program is expected to provide a framework for better coordination for all actors in the global HIV/AIDS effort, including bilateral agencies and governments, and to improve the effectiveness of HIV/AIDS activities in-country. The United States has strongly supported the establishment of this program and continues to work toward making it operational by the target date of January 1996. Conclusions and Recommendations Considerable efforts have begun to improve coordination among the multiple international partners involved in the response to the HIV/AIDS pandemic. The USG role has and will continue to be key in this evolution. International initiatives such as Joint U.N. Programme on AIDS should assist in coordinating the HIV/AIDS efforts within the U.N. system and among governments and non-governmental institutions. Given the involvement of multiple USG Departments and Agencies in international HIV/AIDS activities, exchange of information and coordination of activities is critical. An ongoing process should be developed to facilitate this. Possible mechanisms for increasing coordination within the USG include: The convening of annual or semiannual meetings of high level Department and Agency representatives to review ongoing and planned activities within the framework of an international HIV/AIDS strategy and development of related interagency policies. Establishment of a regular forum at the working level to exchange information among agencies on international HIV/AIDS activities. This forum could involve non-governmental organizations as appropriate based on the topics to be discussed. Collaboration with the National AIDS Policy Director to ensure that international activities are incorporated within the framework of a national policy and strategy.
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