United States General Accounting Office

GAO Testimony

Before the House International Relations Committee

For Release on Delivery

Expected at

9:30 a.m., EDT

Wednesday,

September 16, 1998

HIV/AIDS

Observations on USAID and

U.N. Prevention Efforts

Statement for the Record by Benjamin F. Nelson, Director,

International Relations and Trade Issues, National

Security and International Affairs Division

GAO/T-NSIAD-98-232

Mr. Chairman and Members of the Committee:

We are pleased to be able to provide this statement for the record which

summarizes our observations on international efforts to address the

spread of the human immunodeficiency virus/acquired immunodeficiency

syndrome (HIV/AIDS) in the developing world. This statement is based on

the results of a study requested by this Committee, HIV/AIDS: USAID and U.N.

Response to the Epidemic in the Developing World (GAO/NSIAD-98-202,

July 27, 1998). In conducting our work, we reviewed the U.S. Agency for

International Development’s (USAID) and United Nation’s HIV/AIDS programs

and activities at their headquarters and in the Dominican Republic,

Honduras, India, the Philippines, and Zambia.

Specifically, this statement discusses USAID’s response to the HIV/AIDS

epidemic in the developing world. USAID’s efforts began in 1986. In

addition, this statement discusses the progress of the United Nations’

effort, commonly called UNAIDS, in coordinating U.N. activities and

mobilizing the international response to the epidemic since it was created

in 1996. We did not attempt to assess the contribution of the U.N.’s effort

or the impact of individual U.N. agency programs1

 in stemming the

epidemic. However, in the countries we visited we observed innovative

activities, which are summarized in this statement.

Background HIV/AIDS exacts enormous economic and social costs on the developing

world where more than 90 percent of the 30 million people afflicted with

the disease reside. The epidemic continues to spread rapidly there, and

according to UNAIDS and the World Health Organization (WHO), accounts for

more than 90 percent of the 5.8 million new infections worldwide in 1997.

USAID and the United Nations first began to address the HIV/AIDS epidemic in

the mid-1980s. USAID works in partnership with governments, other donors,

and private organizations to support research and HIV/AIDS interventions in

28 countries. In 1997, USAID spent $81 million on specific projects and

$20 million on technical assistance and research. It also provided

$16 million to UNAIDS.

The Joint United Nations Program on HIV/AIDS (UNAIDS) was created in

response to the conclusion drawn by U.N. officials and donor countries in

1

UNAIDS consists of the following six agencies: the United Nations Children’s Fund (UNICEF); the

United Nations Development Program (UNDP); the United Nations Population Fund (UNFPA); the

United Nations Educational, Scientific, and Cultural Organization (UNESCO); the World Health

Organization (WHO); and the World Bank.

Page 1 GAO/T-NSIAD-98-232
the early 1990s that a more comprehensive approach was needed to

address the sociological and developmental factors that affect the spread

of the disease. To meet this objective, on January 1, 1996, the United

Nations created the UNAIDS Secretariat to replace WHO as the lead

organization for the U.N. HIV/AIDS effort. Together, the UNAIDS Secretariat

and six U.N. agency cosponsors, were expected to coordinate and lead a

broad-based, expanded worldwide response to HIV/AIDS. It was agreed that

each U.N. cosponsor agency would (1) increase resources devoted to their

agencies’ HIV/AIDS activities; (2) mobilize resources for HIV/AIDS in affected

countries, including the private sector; and (3) coordinate with each other

at the country level. The UNAIDS Secretariat was expected to (1) advocate

increased political and financial support for HIV/AIDS activities, (2) develop

a framework to measure progress, (3) organize theme groups as the forum

for coordinating U.N. activities, and (4) provide technical support and

information on what interventions work.

Summary Although HIV/AIDS continues to spread at a rapid rate in the developing

world, USAID has made important contributions in the fight against the

disease. USAID supported research that helped to identify interventions

proven to curb the spread of HIV/AIDS. These interventions have become the

basic tools for the international response to the epidemic. The evidence

we gathered suggests that USAID projects have increased awareness of the

disease, changed risky behaviors, and enhanced access to treatment of

sexually transmitted diseases (STD) and to condoms, which have helped

slow the spread of the disease in target groups. For example, in the

Dominican Republic, USAID’s efforts contributed to reduced incidence of

HIV among targeted commercial sex workers. In one clinic funded by USAID,

the percentage of commercial sex workers testing positive for HIV/AIDS

dropped from 5.8 percent in 1995 to 3.5 percent in 1996.

To date, the United Nations has made only limited progress toward

meeting its goal of leading a broad-based, expanded, and well-coordinated

worldwide effort to prevent the transmission of HIV/AIDS. While information

is not yet available to measure UNAIDS’ progress in promoting increased

spending by donor countries, the private sector, or affected countries,

available data indicate that U.N. cosponsor agencies have not raised their

overall spending on HIV/AIDS as had been anticipated. U.N. spending

declined from $337 million in 1994-95 to $332 million in 1996-97 after the

creation of UNAIDS.

Page 2 GAO/T-NSIAD-98-232
The UNAIDS Secretariat has only just begun to establish a framework for

measuring the performance and objectives of the U.N.’s HIV/AIDS program.

In addition, success with so-called “theme groups,” which were designed

to create a single focus and strategy for cosponsors at the country level,

has been uneven. In some countries, cosponsor agencies conduct joint

projects and meet regularly, while in others, they are just beginning to

work together. Moreover, theme group representatives told us that the

UNAIDS Secretariat has not provided useful technical assistance and best

practice information to facilitate their activities.

Available quantitative and qualitative data show that USAID has had success

in reducing the incidence of HIV/AIDS among targeted groups. Moreover,

experts agree with the overall approaches of both USAID and UNAIDS.

However, the continued rapid rate at which the disease is spreading in the

developing world would suggest that a larger response may be required to

slow the spread of the disease.

Usaid Has Made

Important

Contributions to

HIV/AIDS Prevention

USAID’s main contributions to preventing HIV/AIDS have been (1) providing

support for research that helped to identify interventions ultimately

proven to prevent HIV transmission and (2) implementating projects at the

country level that raised awareness of the disease, reduced risky

behaviors, and increased access to treatment of STDs and condoms. These

activities have helped slow the spread of the disease in target groups, such

as commercial sex workers and youth.

USAID Supported the

Development of Accepted

Interventions

Starting in 1986, USAID funded public and private research efforts that

identified interventions proven through clinical trials and longitudinal

studies to have an impact on the spread of HIV/AIDS. These interventions

became the principal tools used in the global response to HIV/AIDS. They are

• information, education, and counseling to raise awareness of the threat of

HIV/AIDS in an effort to promote positive behavior changes such as

abstinence or reduction in the number of sexual partners, and safer sex

practices;

• treatment of STDs which, if left untreated, can facilitate transmission of HIV

infections; and

• promotion of increased condom use through condom “social

marketing”—or publicizing the appeal of condoms—to prevent

transmission of the virus.

Page 3 GAO/T-NSIAD-98-232
USAID Projects Made

Important Contributions

Our analysis of data from internal and external evaluations and

discussions with representatives of high-risk groups indicate that USAID

projects have helped slow the spread of the disease in targeted groups.

Evaluations conducted of USAID’s largest project, the AIDS Control and

Prevention Project, or AIDSCAP, determined that its activities were

successful in the 18 countries where it had programs. For example, in

Honduras, AIDSCAP improved access to STD treatment and condoms and

established a network of nongovernmental organizations (NGO) with the

capacity to provide HIV/AIDS prevention activities. In the Dominican

Republic, AIDSCAP improved knowledge and access to AIDS prevention

practices and services to target groups, such as commercial sex workers

and hotel workers.

Although there were management difficulties in Zambia, we found

successful programs in all of the countries we visited. For example, USAID’s

program in the southern state of Tamil Nadu, India, focused on educating

truck drivers and factory workers on the risks of HIV/AIDS and the use of

condoms. For drivers who were targeted by USAID’s program, the portion

that patronized commercial sex workers and engaged in nonregular sex

dropped from 38 percent to 27 percent between 1996 and 1997, according

to USAID. Similarly, the portion of factory workers targeted by the program

that reported using condoms increased from 28 percent to 41 percent. In

the Philippines, an independent evaluation conducted in 1997 indicated

that USAID’s activities helped avert an increase in HIV/AIDS; the percentage of

people who are HIV-positive remained below 1 percent in targeted groups.

Moreover, in both countries USAID increased the capacity of local

organizations to manage and deliver prevention activities.

UNAIDS Has Made

Limited Progress

Toward Meeting Its

Goal

UNAIDS has made limited progress over the past 2 years toward achieving

its goal of leading a broad-based, expanded, and well-coordinated

worldwide response to the HIV/AIDS epidemic. While data are not yet

available to measure spending from donors and affected countries, U.N.

cosponsor organizations have not increased resources devoted to HIV/AIDS.

In addition, despite the UNAIDS Secretariat’s international efforts, it reports

that private sector HIV/AIDS activities have remained few to date. Moreover,

the Secretariat only recently began to develop a framework for measuring

the performance of HIV/AIDS activities and—to date—has not been able to

provide useful technical support and best practice information to

country-level theme groups as expected.

Page 4 GAO/T-NSIAD-98-232
Lack of Data to Measure

UNAIDS’ Progress in

Mobilizing Resources

From Other Sources

One of UNAIDS’ objectives was to bolster spending by donors and affected

countries and to increase private sector involvement in fighting the

epidemic. The Secretariat is completing the analysis to establish a baseline

to measure UNAIDS’ progress in mobilizing donor and affected country

resources.2

 Preliminary data from a survey conducted by the UNAIDS

Secretariat indicate that spending by major donors3 remained relatively

stable between 1993 and 1996, at approximately $250 million a year;

however, data were not available for 1997.

The UNAIDS Secretariat has encouraged private sector support at the

international level through advocacy efforts with leading corporate

organizations such as the Conference Board and Rotary International.

International efforts by the Secretariat have led to some successes,

particularly in working with individual companies to advocate research

and distribution of medical interventions. For example, Glaxo Wellcome, a

major pharmaceutical company, recently announced that it would provide

zidovudine (AZT) a viral inhibitor, to pregnant, HIV-positive women in

developing countries at a substantially reduced price. However, at the

country level, cosponsor agency efforts to involve private companies in

HIV/AIDS have been limited. U.N. officials noted that the reason for a lack of

focus on private involvement was because the United Nations is not

accustomed to working with private partners and that its contacts in the

field are almost exclusively with government ministries.

U.N. Expenditures for

HIV/AIDS Did Not Increase

When the U.N. Economic and Social Council created UNAIDS, it noted that

the success of the program was dependent on the provision of increased

resources by the six cosponsor agencies. However, spending by these

agencies declined by 1.6 percent, from $337 million in 1994-95 to

$332 million in 1996-97. While the U.N. Population Fund and the U.N.

Development Program increased spending for HIV/AIDS after UNAIDS was

established, and the U.N. Educational, Scientific, and Cultural

Organization and WHO began programming funds to support HIV/AIDS

activities, the World Bank and the U.N. Children’s Fund decreased

expenditures. This decline occurred despite the 6.5 percent increase in

overall spending by cosponsor agencies during the same period.

2

Study on the National and International Financing of the National Response to HIV/AIDS,

UNAIDS/PCB(6)/98.3 (Geneva, Switzerland: May 24, 1998).

3

Major donors were identified by the United Nations as Australia, Canada, Denmark, France, Germany,

Japan, Luxembourg, the Netherlands, Norway, Sweden, the United Kingdom, and the United States.

Page 5 GAO/T-NSIAD-98-232
Table 1: U.N. HIV/AIDS Funding Under WHO’s Global Program on AIDS and UNAIDS, 1992-97

GPA period UNAIDS Period

Not active.

WHO core funding support included in overall GPA figures.

1992-1993 1994-1995 1996-1997

GPA 179.1 147.7

UNAIDS 119.6

WHO 16.4

World Bank 197.7 84.6 74.1

UNICEF 17.4 13.7 10.2

UNDP 29.1 53.8 64.6

UNFPA a 37.5 42.9

UNESCO 0 0 4.1

Total 423.4 337.3 331.9

In millions of 1997 dollars

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

Unavailable.

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

Difficult Beginning for

Theme Groups

The UNAIDS Secretariat was expected to organize theme groups as the

coordinating entity for U.N. activities in the field, and U.N. cosponsor

agencies agreed to work together to ensure a unified response to HIV/AIDS.

UNAIDS’ surveys of theme groups and our work in the field indicate that

cosponsor agencies met regularly and even conducted joint projects in

Page 6 GAO/T-NSIAD-98-232
some countries, but in others that was not the case. In the Dominican

Republic, for example, cosponsor representatives contributed to a central

fund to support HIV/AIDS activities and met regularly to discuss progress.

However, in India and Honduras representatives rarely met. A 1997 survey

of theme groups, compiled by the Secretariat in April 1998 after we

completed our fieldwork, showed that U.N. cosponsor agencies were

making some progress in working together. However, in areas where

theme groups reported progress, such as national resource mobilization,

less than half of the respondants said they were operating effectively.

U.N. officials reported several reasons for theme group difficulties:

(1) lack of guidance to agency country representatives regarding the

operation of theme groups and the scope of their mission, (2) lack of

individual accountability for theme group success, and (3) lack of

commitment to working together in theme groups because of concerns

held by some cosponsor representatives about UNAIDS’ role as the

organizational vehicle for the U.N. response. Secretariat officials told us

that they met with cosponsor agencies in March 1998 to address these

problems and to develop strategies to improve coordination.

UNAIDS Secretariat Has

Not Provided Support

Required to Facilitate

Country Programs

A key role for the UNAIDS Secretariat was to provide technical assistance

and best practice information to theme groups. However, in countries we

visited, cosponsor agency officials did not think that best practices

information and technical support available from the UNAIDS Secretariat

were useful. For example, U.N. officials told us that the best practices

information was too theoretical and lacked project implementation

guidance. Cosponsor agency officials also said they rarely used technical

support from the Secretariat because it was not tailored to their specific

needs and, in some cases, because these officials were unaware of its

availability. Recognizing these weaknesses, Secretariat officials noted that

it, along with other bilateral donors, is working to establish a network of

technical resources that can be used by U.N. field staff to enhance the

design and implementation of national HIV/AIDS programs.

No Evaluation Framework Despite being directed by its governing board to develop a framework for

measuring the performance of the U.N.’s HIV/AIDS programs within a year of

UNAIDS’ establishment, the Secretariat did not staff the evaluation unit until

September 1997 and hopes to have a pilot project in place to field test

performance measures at the end of 1998.

Page 7 GAO/T-NSIAD-98-232
Cosponsor Agencies

Undertook Innovative

Grassroots

Interventions

Although we did not conduct a systematic evaluation of U.N. agency

projects, we observed innovative prevention activities in each of the

countries we visited. Cosponsor agencies utilized accepted interventions,

such as condom education and promotion and encouragement of STD

treatment. These activities ranged from peer group counseling to theatrical

productions that highlighted the danger of the virus. These activities were

generally targeted to high-risk groups. In addition, U.N. agencies

encouraged program sustainability by training Health Ministry staff and

NGOs in affected countries to provide interventions.

Mr. Chairman and members of the Subcommittee, this concludes our

statement for the record. Thank you for permitting us to provide you with

this information.

(711364) Page 8 GAO/T-NSIAD-98-232
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