July 2000

Introduction

Ten years ago, when the AIDS death toll in the United States crossed 100,000, few paid heed to a grim prediction by the World Health Organization (WHO) that “by the year 2000, 40 million persons may be infected with HIV” (CDC 1991). In the rich world, AIDS was seen as a serious but smallish disease, restricted to gay men, drug users, hemophiliacs, and the innocent offspring of all three. In the developing world, just a few courageous voices were warning about the silent spread of a deadly new plague. Today WHO’s grim prediction has come true. Africa is in crisis. In some countries, a quarter or more of the adult population is infected. Millions have died, and millions more will die, leaving their societies trapped in poverty, burdened with a generation of orphans, and facing demographic catastrophe. The grim statistics are not confined to Africa. Asia and the Caribbean face explosive HIV epidemics, while the nations of the former Soviet empire peer over the precipice of drug addiction, untreated sexual diseases, and unchecked HIV spread. HIV is out of control, and finally the world has begun to take notice.

In January 2000, the United Nations Security Council held a special session in which, for the first time, it identified a disease — AIDS — as a global security threat. Some American cynics have mocked this move as domestic political theater. But no serious observer denies that HIV is undermining nations and economies. HIV kills young people in their most productive years. In a growing number of countries, workers, teachers, nurses, civil servants, and others will perish in astonishing numbers. The backbone of civil society is threatened in many nations, and the threat remains uncontrolled.

The security threat is real, but only half the story. HIV began as an obscure simian virus in equatorial Africa in the first half of the twentieth century and, within fifty years, had spread throughout the world. The forces that brought HIV to America in the 1970s — world travel, globalization, and urbanization — are accelerating. One need only look at the number of variant strains of HIV-1 spreading worldwide, at the outbreak of West Nile Virus in New York, or at the number of HIV-2 cases now emerging in New York and other gateway American cities to see how the forces of globalization are adding new ingredients to the world’s microbial soup. When HIV remains unchecked in large regions of the globe, as it does now, no country is safe, including America. Fighting AIDS abroad is in America’s own interest.

In response, the U.S. government now proposes new initiatives to fight the global spread of AIDS. We welcome them. But the U.S. has conducted global AIDS programs for more than a decade, and related international health programs for even longer. Any new AIDS funding builds on this foundation. Yet no analysis exists of the present U.S. role in the global AIDS pandemic. Without review and evaluation, any new programs run the risk of being scattershot and ineffective. In other words, recent good intentions may, without good planning and evaluation, lead nowhere. If the U.S. cannot summarize its current programs accurately, how can they grow effectively?

This report is a first, imperfect documentation of what the U.S. government spent in 1998 on international HIV programs. We hope this analysis can serve as a foundation, a basis for decision- making, a hopeful call to action. Inside, we describe what the U.S. government has done, so others may better answer what can and should be done. We hope others in the developed, democratic world take this report as a model to press for more and better responses from their governments. We hope people in poorer countries use this report to navigate the U.S. government and become full partners with the American effort.