United States General Accounting Office

GAO Report to Congressional Requesters

July 1998 HIV/AIDS

USAID and U.N.

Response to the

Epidemic in the

Developing World

GAO/NSIAD-98-202

GAO United States

General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-280249 

July 27, 1998

The Honorable Benjamin Gilman

Chairman, Committee on International Relations

House of Representatives

The Honorable Jim McDermott

House of Representatives

This report responds to your request that we review the Human Immunodeficiency

Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) prevention activities of the U.S. Agency

for International Development (USAID) and the Joint United Nations Programme on HIV/AIDS

(UNAIDS). Specifically, we examined (1) the contributions USAID has made to the global effort to

prevent AIDS and the methods USAID uses to provide financial oversight over its AIDS prevention

activities and (2) the extent to which UNAIDS has met its goal of leading an expanded and

broad-based, worldwide response to the HIV/AIDS epidemic.

As arranged with your office, unless you publicly announce its contents earlier, we plan no

further distribution of this report until 30 days after the date of this report. We will then send

copies of this report to the Secretary of State, the Administrator of USAID, the Director of the

Joint United Nations Programme on HIV/AIDS, and to other appropriate congressional

committees. We will make copies available to others upon request.

Please call me at (202) 512-4128 if you or your staff have any questions. Major contributors to

this report are listed in appendix V.

Benjamin F. Nelson

Director, International Relations

 and Trade Issues
Executive Summary

Purpose The Human Immunodeficiency Virus/Acquired Immunodeficiency

Syndrome (HIV/AIDS) epidemic is spreading rapidly throughout the

developing world, where over 90 percent of the 30 million people living

with the disease reside. In these countries, the epidemic has begun to

erode gains in health, child survival, education, and economic

development.

Since the mid-1980s, the U.S. Agency for International Development

(USAID) and the United Nations have established efforts to address the

epidemic. USAID primarily uses private voluntary organizations to

implement HIV/AIDS prevention activities in developing countries. In 1996,

the United Nations reorganized its HIV/AIDS program in response to donor

concerns that the U.N. effort was too heavily focused on the medical and

public health aspects of the disease and did not sufficiently address the

social, economic, and developmental issues affecting the spread of

HIV/AIDS. In light of the importance of these efforts to address the HIV/AIDS

epidemic in the developing world, the Chairman, House Committee on

International Relations, and Representative Jim McDermott asked GAO to

examine USAID and U.N. programs. This report examines (1) the

contributions USAID has made to the global effort to prevent HIV/AIDS and

the methods USAID uses to provide financial oversight over its HIV/AIDS

prevention activities; and (2) the extent to which the Joint United Nations

Programme on HIV/AIDS (UNAIDS) has met its goal of leading an expanded

and broad-based, worldwide response to the HIV/AIDS epidemic.

Background UNAIDS and the World Health Organization (WHO) estimate that over

30 million people were living with the HIV infection at the end of 1997. Most

people living with HIV/AIDS reside in the developing world—two-thirds live

in sub-Saharan Africa—where the disease continues to spread rapidly.

According to the UNAIDS Secretariat, the number of new infections

increased from 3.1 million in 1996 to 5.8 million in 1997. International

donors contribute about $250 million a year to support HIV/AIDS prevention

activities in the developing world. The United States has been the largest

single donor, contributing $117 million a year, through USAID and in

support of the U.N. HIV/AIDS program.

USAID and the United Nations have been important contributors to the fight

against HIV/AIDS since the mid-1980s. While both the United Nations and

USAID have sought to reduce the spread of the epidemic, they have

somewhat different, yet mutually supporting, roles and objectives. As a

bilateral agency, USAID works in partnership with governments, other

Page 2 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

donors, and private organizations to support research and implement

HIV/AIDS interventions in countries. The U.N.’s role is in advocating,

mobilizing, and coordinating the international response worldwide in

addition to managing HIV/AIDS activities in 152 countries.

USAID began its HIV/AIDS assistance program in 1986, when very little was

known about the epidemic or how to fight it. USAID’s initial efforts

primarily consisted of research on the causes, extent of the problem, and

ways to prevent the disease’s spread and of short-term technical

assistance to more than 74 countries. In the 1990s, Congress began

appropriating more money specifically to combat the HIV/AIDS problem, and

it was elevated to a USAID priority for planning and budgeting. USAID

developed an agencywide goal to reduce the number of new HIV infections

by identifying and applying interventions to prevent HIV transmission. It

designed targeted programs to meet this goal and, by 1997, USAID was

directly supporting major HIV/AIDS programs in 28 countries. USAID relied

heavily on cooperative agreements1

 with the private sector to implement

its program. Under the terms of these agreements, the primary financial

oversight responsibility is on the funding recipient.

The U.N. efforts to address HIV/AIDS began in 1987 under the auspices of

WHO. WHO provided technical and financial support to fight the epidemic

worldwide, primarily focusing on the medical and public health aspects of

the disease. By the early 1990s, the United Nations and donors agreed that

a more comprehensive approach was needed. On January 1, 1996, UNAIDS

replaced WHO’s Global Program on AIDS in an attempt to draw upon the

experience and skills of all U.N. agencies.

UNAIDS is composed of six U.N. agency cosponsors2 and a Secretariat,

which is the coordinating unit. When forming UNAIDS, the cosponsor

agencies agreed to increase resources devoted to HIV/AIDS activities; to

mobilize resources for HIV/AIDS in affected countries, including increased

private sector involvement; and to coordinate with other cosponsor

agencies 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 for measuring the performance and objectives of

HIV/AIDS activities; (3) organize entities at the country level—called “theme

1

A cooperative agreement is a funding mechanism used by a federal agency to transfer funds to an

organization to support an agency program.

2

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); WHO; and the World

Bank.

Page 3 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

groups”—as the forum for coordinating U.N. efforts; and (4) provide

technical support and information to theme groups on what activities

work best to facilitate development and implementation of national

HIV/AIDS strategies. The biennial budget for the UNAIDS Secretariat in 1996-97

was $120 million, of which the United States contributed $34 million, or

about 28 percent.

Results in Brief Despite the continued spread of HIV/AIDS in many countries, USAID has made

important contributions to the fight against HIV/AIDS. USAID-supported

research helped to identify interventions proven to curb the spread of

HIV/AIDS that have become the basic tools for the international response to

the epidemic. Applying these interventions, USAID projects have increased

awareness of the disease; changed risky behaviors; and increased access

to treatment of sexually transmitted diseases and to condoms, which have

helped slow the spread of the disease in target groups.

Under the terms of cooperative agreements with private implementing

organizations, USAID managers are expected to closely monitor projects,

but the major responsibility for internal financial management and control

rests with recipient organizations. USAID’s financial oversight primarily

consists of conducting pre-award evaluations of prospective funding

recipients, reviewing quarterly expenditure reports, and requiring audits.

Officials from USAID’s Office of the Inspector General said that there were

no indications of systemic problems from audits conducted.

In its first 2 years of operation, UNAIDS has made limited progress in

achieving its goal of leading a broad-based, expanded global effort against

HIV/AIDS. While available information indicates that spending by the

cosponsors has not increased, data are not yet available to measure

UNAIDS’ progress in increasing spending by donor countries, the private

sector, or affected countries.3

 Moreover, theme groups, the forum for

coordinating U.N. efforts in the field, have had a difficult start and, in some

countries, cosponsor agencies are just beginning to work together. Finally,

the UNAIDS Secretariat has not been successful in providing technical

assistance and other support to facilitate theme group activities and has

only recently begun to establish a framework for developing performance

measures for the U.N.’s HIV/AIDS programs. Despite UNAIDS’ limited progress

in meeting its broader coordination and resource mobilization objectives,

3

Throughout this report, reference to U.N. funding for HIV/AIDS activities is limited to the six

cosponsoring agencies and the Secretariat.

Page 4 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

GAO observed innovative activities that were implemented by cosponsor

agencies.4

Principal Findings

USAID Funded

Development and

Implementation of

Effective

Interventions

The interventions developed, in part, by USAID-supported efforts, have

become the basic tools for HIV/AIDS prevention. They are

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

HIV/AIDS in an effort to promote behavior changes, such as abstinence, that

will reduce risk;

• treatment of sexually transmitted diseases which, if untreated, can

facilitate transmission of the HIV virus; and

• promotion of increased condom use through condom “social marketing,”

or advertising the availability and appeal of using condoms.

In elevating HIV/AIDS prevention to an agency priority, USAID devised a

strategy that relies on development and application of interventions in

target groups based on specific country needs. Programs in countries GAO

visited focused on the high-risk groups that spread the disease and used

proven interventions to change behavior and reduce the chance of

infection.

These interventions have been proven to have an impact on HIV/AIDS

because they result in behavior changes that reduce the risk of disease

transmission. However, it is difficult to determine the link between a

particular activity or program and reductions in the incidence of HIV/AIDS

because of the long incubation period for the disease; a person can be

infected as a result of activity from 7 to 10 years previously. Thus, in

addition to blood testing to measure the impacts of its HIV/AIDS activities in

target groups, USAID also relies upon proxy indicators, such as behavioral

change. Public health experts agree that the proxy indicators used by USAID

are reasonable indicators of changes in HIV incidence.

GAO’s review of internal and external evaluations, conducted by technical

experts from the public and private sectors and academia, and other data

collection efforts, as well as discussions with representatives of high-risk

groups, found that USAID projects have increased knowledge of HIV,

changed risky behaviors, and increased access to treatment for sexually

4

GAO conducted fieldwork in the Dominican Republic, Honduras, India, the Philippines, and Zambia.

Page 5 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

transmitted diseases and to condoms, thus helping slow the spread of the

disease in targeted groups such as commercial sex workers. Evaluations

conducted for USAID’s largest project, the AIDS Control and Prevention

Project (AIDSCAP), determined that its activities were successful in the

countries where it had projects. For example, in the Dominican Republic,

USAID found that commercial sex workers and tourist resort staff were the

primary conduits for HIV/AIDS. USAID focused its efforts on these groups,

providing information about the disease to the workers, distributing

condoms, and counseling them on alternative employment options. The

percentage of HIV-positive commercial sex workers at one clinic funded by

USAID slowed from 5.8 percent in 1995 to 3.3 percent in 1996.

Nature of USAID’s

Financial Oversight

Following direction from Congress, USAID primarily relies on U.S.-based

private voluntary organizations and indigenous nongovernmental

organizations to implement its HIV/AIDS programs. USAID has mainly used

cooperative agreements to fund these organizations’ efforts. Under these

agreements, project managers are expected to be substantially involved in

planning and monitoring project progress; however, recipient

organizations have the primary responsibility for their internal financial

management and control. According to USAID officials, these agreements

provide maximum flexibility to USAID and its private partners to design,

implement, and change work plans without a formal process for review

and approval.

USAID’s financial oversight generally consists of (1) conducting pre-award

evaluations to determine if a recipient has appropriate financial and

management systems in place to handle the USAID financing; (2) reviewing

quarterly expenditure reports submitted by the funding recipient to

monitor the level of funds expended; and (3) obtaining annual external

audits which, in accordance with the Single Audit Act,5

 provide

information to oversight officials and program managers on whether

funding recipients’ financial statements are fairly presented. The audits are

also intended to provide reasonable assurance that federal assistance

programs are carried out in accordance with applicable laws and

regulations. The annual single audit reports of USAID’s $200 million, 6-year

AIDSCAP project did not indicate any financial management or reporting

problems. The Office of the Inspector General determined that there were

no indications from audits conducted that systemic problems existed.

5

The Single Audit Act of 1984 (31 U.S.C. 7501-7507), requires organizations that meet a minimum

threshold of federal funding to undergo a single, nonfederal audit each year.

Page 6 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

UNAIDS Has Made

Limited Progress

Toward Meeting Its

Goal

UNAIDS has made limited progress toward achieving its goal of leading a

broad-based, expanded global response to HIV/AIDS. Expenditure data for

cosponsor agencies indicate that U.N. spending has not increased since

the establishment of UNAIDS, but data are not available to measure

spending from other sources. At the country level, the success of theme

groups has been uneven. The UNAIDS Secretariat has not provided support

to facilitate country programs.

HIV/AIDS Spending by

Cosponsor Agencies Has

Not Increased

Although one of UNAIDS’ objectives was to increase resources devoted to

HIV/AIDS by cosponsor agencies, spending on HIV/AIDS has not risen since the

creation of UNAIDS. Instead, spending declined from $337 million in 1994-95

to $332 million in 1996-97. While UNFPA and UNDP increased spending for

HIV/AIDS after UNAIDS was established and UNESCO began programming for

HIV/AIDS activities, these increases were outweighed by decreased

expenditures by the World Bank and UNICEF. The decline in U.N. spending

for HIV/AIDS occurred despite an increase in overall spending by cosponsor

agencies of 6.5 percent.

Data Are Not Available to

Measure Progress in

Mobilizing Resources

From Other Sources

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

countries and to increase private sector involvement in fighting the

epidemic. However, the UNAIDS Secretariat is still analyzing survey data

that should assist in developing a baseline to measure UNAIDS’ progress in

mobilizing donor and affected country resources.6

 Preliminary data from

the survey indicate that contributions from major donors7

 remained

relatively stable between 1993 and 1996 at about $250 million a year. Data

for 1997 were not available. Despite Secretariat efforts at the international

level to encourage private sector involvement in the fight against HIV/AIDS,

the UNAIDS Secretariat reports that private sector HIV/AIDS activities have

remained limited to date. GAO’s work in the field and the Secretariat’s

reports indicate that at the country level U.N. agencies have only made

limited efforts to encourage private sector support of HIV/AIDS activities.

U.N. officials offered several reasons for the lack of private involvement,

including inadequate information about the impact of the disease on its

workforce and the lack of government encouragement.

6

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

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

7

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 7 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

Difficult Beginning for

Theme Groups

The UNAIDS Secretariat was expected to organize theme groups as the

forum for coordinating cosponsor agency activity in the field. Cosponsor

agencies were expected to work together in the theme groups to support

national governments’ HIV/AIDS programs. UNAIDS’ surveys of theme groups

and GAO’s work in the field indicate that cosponsor agencies met regularly

and even conducted joint projects in some countries, such as the

Dominican Republic. In others, such as Honduras and India,

representatives rarely met. Despite the presence of World Bank projects in

three of the five countries GAO visited, the World Bank representative did

not attend any of the theme group meetings. A 1997 survey of theme

groups, compiled by the Secretariat after GAO conducted its fieldwork,

showed that theme groups were making some progress in working

together. However, in areas where the groups reported progress, such as

national resource mobilization, less than half of the theme groups that

responded to the survey were operating effectively. U.N. officials reported

several reasons for theme group difficulties: (1) lack of guidance to agency

field representatives regarding how theme groups should operate and

what the scope of their mission should be, (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 the role of UNAIDS as the organizational

vehicle for the U.N. response. Officials from the UNAIDS Secretariat said

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

problems and develop strategies to improve theme group coordination.

UNAIDS Secretariat Has

Not Provided Support

Required to Facilitate

Country Programs

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 UNAIDS Secretariat has been slow to create an

evaluation framework. Only recently has the Secretariat: (1) staffed the

evaluation unit that is charged with developing performance measures and

(2) funded a survey to gather data on spending by donors and affected

countries on HIV/AIDS. The survey data are necessary to measure UNAIDS’

progress toward meeting its objectives. In addition, in countries GAO

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 GAO 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, they were not aware of its availability.

Secretariat officials acknowledged deficiencies in its country support

Page 8 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

activities and have begun to develop more country-specific materials that

include implementation guidance.

Recommendations GAO is making no recommendations in this report.

Agency Comments

and GAO’s Evaluation

USAID, the Department of State, the Department of Health and Human

Services, and the UNAIDS Secretariat provided written comments on a draft

of this report. These agencies emphasized the unique and important role

UNAIDS plays in the global fight against HIV/AIDS. USAID, the UNAIDS

Secretariat, and State had concerns about information GAO presented on

UNAIDS. The agencies’ comments and GAO’s detailed evaluation of them are

included in the report where appropriate.

USAID shared GAO’s concerns about the areas in which UNAIDS has not made

sufficient progress and noted that it is working with UNAIDS to strengthen

UNAIDS’ role. USAID, State, and the UNAIDS Secretariat noted that UNAIDS has

only been in existence for 2-1/2 years and were concerned that it may have

been too early to assess the program. State also said it was disappointed at

the very negative tone in the report concerning UNAIDS’ activities and

believed that the report did not give any credit to UNAIDS for what it had

achieved. Furthermore, State said that GAO implied that U.N. agencies and

the U.S. government should stop supporting UNAIDS. The UNAIDS Secretariat

stated that it was pleased with the overall presentation and objectivity of

the report but was concerned that GAO’s presentation of USAID’s and UNAIDS’

programs obscured the important distinctions between them. The

Secretariat also noted that it had expected a more positive perspective on

the program.

GAO agrees that UNAIDS plays an important and unique role in the global

response to HIV/AIDS and clarified the report to better reflect the distinction

between the UNAIDS and USAID’s program. While GAO recognizes that UNAIDS

has been in existence for only 2-1/2 years, GAO did not evaluate the

program’s impact on the HIV/AIDS epidemic. In its report, GAO presents the

facts as it found them to be, including areas needing improvement and

areas that have worked well. In fact, the report specifically identifies

UNAIDS’ accomplishments, including information on innovative grassroots

interventions. Also, GAO did not evaluate whether support for UNAIDS

should be continued. GAO’s objective, as stated in the report, was to

examine the program’s progress, since its inception, in meeting

Page 9 GAO/NSIAD-98-202 HIV/AIDS
Executive Summary

established objectives such as increasing resources devoted to HIV/AIDS and

working together in theme groups at the country level.

Page 10 GAO/NSIAD-98-202 HIV/AIDS
Page 11 GAO/NSIAD-98-202 HIV/AIDS
Contents

Executive Summary 2

Chapter 1 

Introduction

14

The Extent and Impact of the Human Immunodeficiency

Virus/Acquired Immunodeficiency Syndrome Epidemic

14

USAID and U.N. Response to the Epidemic 17

Objectives, Scope, and Methodology 21

Chapter 2 

USAID Has Made

Important

Contributions to

HIV/AIDS Prevention

25

USAID Supported the Development of Accepted Interventions 25

USAID Projects Made Important Contributions 28

Nature of USAID’s Financial Oversight 34

Conclusions 36

Agency Comments 37

Chapter 3 

The Joint U.N.

Programme on

HIV/AIDS Has Made

Limited Progress

38

U.N. Expenditures For HIV/AIDS Did Not Increase 38

Baseline Spending by Major Donors and Affected Countries Is

Being Developed

40

UNAIDS Had Limited Success in Mobilizing the Private Sector 41

Difficult Beginning for Theme Groups 43

Limited Success in Providing Technical Support for UNAIDS

Country Activities

45

Performance Indicators 46

U.N. Agencies Undertook Innovative Grassroots Interventions 47

Conclusions 49

Agency Comments and Our Evaluation 50

Appendixes Appendix I: Comments From the U.S. Agency for International

Development

52

Appendix II: Comments From the Department of State 58

Appendix III: Comments From the Department of Health and

Human Services

62

Appendix IV: Comments From the UNAIDS Secretariat 64

Appendix V: Major Contributors to This Report 72

Figures Figure 1.1: Map of HIV/AIDS Prevalence, 1997 15

Figure 1.2: Annual Number of New HIV Infections in Selected

Regions, 1980-97

16

Page 12 GAO/NSIAD-98-202 HIV/AIDS
Contents

Figure 1.3: USAID Funding for HIV/AIDS Prevention, 1986-97 19

Figure 2.1: Director of USAID-Supported Health Clinic Discussing

HIV/AIDS Prevention Activities, in Tamil Nadu, India

31

Figure 2.2: HIV/AIDS Education Program for Community Health

Workers in Lusaka, Zambia

34

Figure 3.1: U.N. HIV/AIDS Funding Under GPA and UNAIDS,

1992-97

39

Figure 3.2: A USAID and UNICEF-supported Community Center

and Youth Theater in San Pedro Sula, Honduras

48

Abbreviations

AIDS Acquired Immunodeficiency Syndrome

AIDSCAP AIDS Control and Prevention Project

AZT zidovudine

GPA Global Program on AIDS

HIV Human Immunodeficiency Virus

HIV/AIDS Human Immunodeficiency Virus/Acquired

Immunodeficiency Syndrome

NGO non-governmental organization

OIG Office of the Inspector General

OMB Office of Management and Budget

PVO private voluntary organization

STD sexually transmitted disease

UNAIDS Joint United Nations Programme on HIV/AIDS

UNDP United Nations Development Program

UNESCO United Nations Educational, Scientific, and Cultural

Organization

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID U.S. Agency for International Development

WHO World Health Organization

Page 13 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

The Extent and

Impact of the Human

Immunodeficiency

Virus/Acquired

Immunodeficiency

Syndrome Epidemic

The Human Immunodeficiency Virus/Acquired Immunodeficiency

Syndrome (HIV/AIDS)1

 epidemic continues to spread rapidly in the

developing world, where more than 90 percent of the 30 million people

living with the HIV infection live (see fig. 1.1). Moreover, the UNAIDS

Secretariat recently reported that more than 90 percent of the 5.8 million

new infections in 1997 (up from 3.1 million in 1996) were in developing

countries (see fig. 1.2). Sub-Saharan Africa has the worst infection rate,

accounting for 3.4 million new infections in 1997. In that region, 

7.4 percent of people aged 15 to 49 are infected. Estimates for South and

South-East Asia indicate the disease is also rapidly spreading in that

region, with 6.4 million currently living with HIV/AIDS and 1.3 million new

infections in 1997.

1

HIV is the viral infection that causes AIDS.

Page 14 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

Figure 1.1: Map of HIV/AIDS Prevalence, 1997

North America

806 000

Latin America

1.3 million

Caribbean

310 000

Western Europe

530 000

Eastern Europe and Central Asia

150 000

East Asia and Pacific

440 000

South and South-East Asia

6.0 million

Australia/New Zealand

12 000

Sub-Saharan Africa

20.8 million

North Africa and Middle East

210 000

Total: 30.6 million

Sources: The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health

Organization (WHO).

Page 15 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

Figure 1.2: Annual Number of New HIV Infections in Selected Regions, 1980-97

a

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

1,000,000

2,000,000

3,000,000

4,000,000

Sub-Saharan

Africa

Established market

economies

Latin America

and Caribbean

South and SouthEast Asia

aEstablished market economies include North America, Western Europe, Australia, and New

Zealand.

Source: UNAIDS.

In many developing countries, HIV/AIDS has begun to erode decades of gains

in health, child survival, life expectancy, education, and economic

development. For example, U.S. Bureau of the Census projections for

Zambia indicate that by 2010, AIDS may increase infant mortality rates

nearly 60 percent higher than would have been expected without the

disease. Similarly, projections for Zimbabwe indicate that by 2010, life

expectancy will decline from 70 years to less than 35 years as a result of

AIDS and in Uganda from 54.5 years to 35.5 years. Since the start of the

Page 16 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

epidemic, more than 8 million children have lost either their mother or

their father because of AIDS. AIDS’ impact on families and public health

systems is weakening economies as people in their prime working years

are afflicted by the disease and governments and families divert scarce

resources to care for them for extended periods of time.

The donor community is spending approximately $250 million a year to

address the HIV/AIDS epidemic in the developing world. The United States is

the largest single donor, contributing $117 million in 1997 through the U.S.

Agency for International Development (USAID) that includes specific

support for UNAIDS. However, HIV/AIDS poses serious challenges to the world

community because of the extent of the epidemic and the cost and

difficulty of changing deeply rooted traditions and behaviors that

contribute to the spread of the disease: according to a study commissioned

by WHO, between $1.5 billion and $2.9 billion would be needed from donors

and affected countries annually to implement behavioral and blood safety

strategies to prevent HIV/AIDS in developing countries. Moreover, other

epidemics had their roots essentially in medical problems and could be

addressed through biomedical remedies from public health systems.

However, absent a vaccination or cure, slowing the reach of the virus must

be accomplished by addressing such fundamental cultural and social

traditions as the role of women, sexual practices, and inheritance laws.

For example, according to USAID, tradition and laws in Kenya do not allow

women to inherit property. Without skills or experience in earning money,

if their husbands die, women often have no other recourse than to engage

in prostitution.

USAID and U.N.

Response to the

Epidemic

USAID and the United Nations first began to address the epidemic in the

mid-1980s. While both USAID and the United Nations seek to reduce the

spread of the epidemic, they have somewhat different yet mutually

supporting roles, objectives, and coverage. As a bilateral agency, USAID

works in partnership with governments, other donors, and private

organizations to support research and implement HIV/AIDS interventions in

the 28 countries where it has major programs. The U.N.’s role is in

advocating, mobilizing, and coordinating the international response

worldwide in addition to managing HIV/AIDS activities in 152 countries.

USAID Response to the

Epidemic

Since it began its HIV/AIDS assistance program in 1986, USAID’s goal has been

to reduce the incidence of new HIV/AIDS infections. In the 1980s, very little

was known about the epidemic or how to fight it. As a result, USAID

focused its initial efforts on understanding the causes and extent of the

Page 17 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

epidemic and on identifying ways to prevent its spread. At the direction of

Congress in 1986, USAID supported WHO’s Global Program on AIDS (GPA), and

it also paid for public and private research efforts and activities in the

field. These field activities included operations research on interventions

that prevent the spread of HIV/AIDS; surveillance and analysis of the

incidence, spread, and impact of the disease; and assistance in countries’

design and implementation activities. During this learning phase, USAID

reported that it was the first donor to introduce HIV/AIDS prevention

activities in most countries. Further, by providing short-term technical

assistance to USAID missions in more than 74 countries and funding

small-scale projects to prevent new infections, it educated USAID staff and

host country officials about the epidemic.

By the early 1990s, USAID became more knowledgeable about the disease,

and Congress increased funding for HIV/AIDS (see fig.1.3). USAID designed a

strategy to focus on country-level projects that could have a measurable

impact on the epidemic. From 1991 to 1997, USAID supported the AIDS

Control and Prevention (AIDSCAP) project. By far the most ambitious

international HIV/AIDS prevention effort ever undertaken, AIDSCAP was a

worldwide program intended to help USAID overseas missions design and

implement HIV/AIDS prevention projects. AIDSCAP directly managed

comprehensive projects in some countries and supplied technical

assistance to USAID missions as requested. USAID relied primarily on private

voluntary organizations (PVO) and nongovernmental organizations (NGO) to

implement its HIV/AIDS programs, both at its Washington, D.C., headquarters

and in the field.

Page 18 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

Figure 1.3: USAID Funding for HIV/AIDS Prevention, 1986-97

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

20

40

60

80

100

120

140

34.7

47.1 48.2

78.4

95.7

124.5

112.8

120.7 117.8 117.5

Fiscal year

Dollars in millions

USAID projects U.N. funding

15.0

19.7

25.5 20.6

25.6

27.6

23.0

55.4

25.0

70.7

35.0

89.5

29.5

83.3

26.9 18.0

93.8

99.8

16.0

101.5

Note: Only U.N. grant funding was provided in fiscal years 1986 ($1.1 million) and 1987

($5 million).

Source: USAID.

By 1997, USAID had incorporated the goal of reducing HIV/AIDS transmission

as one of five objectives in its global health improvement portfolio and had

delineated performance goals and indicators to measure its progress.

Agency funding for HIV/AIDS activities had increased (to about $125 million

in 1993, leveling off at about $117 million a year), and USAID shifted more

resources to missions to develop their own comprehensive programs.

Headquarters’ efforts became focused on providing technical assistance as

needed and supporting research. In fiscal year 1997, the majority of USAID’s

funds supported project activities at the country level—with major

programs in 28 countries ($81 million), followed by centrally managed

Page 19 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

technical assistance and research support ($20 million), and grants to

UNAIDS ($16 million).

In 1997, USAID initiated three cooperative agreements2

 with several PVOs

and has a fourth in process. These agreements provide up to $290 million

over 5 years for HIV/AIDS activities—about $40 million to conduct

operations research and field testing to refine and develop best practices

for prevention and care; up to $150 million for technical assistance, as

requested by missions; up to $75 million to implement programs that

advertise and promote the appeal, availability, and use of condoms, as

requested by missions; and about $25 million to provide program

design/monitoring and evaluation, lessons learned, and information

dissemination services.

The U.N. Response to

HIV/AIDS

WHO first began collecting and publishing information on HIV/AIDS in 1981.

The U.N. General Assembly directed WHO to develop and coordinate the

agency’s first program to respond to HIV/AIDS by creating the Special

Program on AIDS in 1987, subsequently renamed GPA in 1988. GPA’s mission

was to strengthen the capacity of governments to respond to the epidemic

and to help establish national AIDS programs. WHO provided technical and

financial support, ranging from $100,000 to $400,000 to initiate national

programs. WHO is credited with making major contributions to nations’

efforts against the epidemic, including protecting blood supply systems,

strengthening national behavior research, and improving disease

surveillance.

In the early 1990s, U.N. officials and donors increasingly recognized the

need for a multisectoral response to the complex challenges of the HIV/AIDS

epidemic—including the social, economic, and development issues

affecting the spread of the virus. They realized that WHO’s medically based

response was insufficient. They were concerned that countries were

dependent on GPA for operational support and, as a result, were not

devoting enough of their own resources to the effort. Also, they expressed

the need for better coordination and delineation of roles and

responsibilities among various U.N. agencies. To address these concerns,

on January 1, 1996, the United Nations replaced GPA with the Joint United

Nations Programme on HIV/AIDS (UNAIDS). The 1996-97 biennial budget for

the UNAIDS Secretariat was $120 million, of which the United States

contributed $34 million, or about 28 percent.

2

A cooperative agreement is a funding mechanism used by a federal agency to transfer funds to an

organization to support an agency program.

Page 20 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

The U.N.’s goal in creating UNAIDS was to lead a broad-based, expanded,

worldwide effort to prevent the transmission of HIV/AIDS. UNAIDS is

composed of a Secretariat and six U.N. agency cosponsors: 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); WHO;

and the World Bank. Each cosponsor was expected to expand its financial

support for HIV/AIDS efforts, to try to mobilize resources for HIV/AIDS in

affected countries, and to coordinate with other cosponsor agencies at the

country level.

Unlike WHO’s role in GPA, the UNAIDS Secretariat was not expected to

provide significant financial support and technical advisers to countries.

Instead, it was established primarily as a coordinating body and was

expected to advocate increased political and financial support for HIV/AIDS

activities, to devise a framework for performance measures to be used in

managing HIV/AIDS activities, to provide technical support and best practice

information to help develop and carry out national HIV/AIDS strategies, and

to organize entities at the country level—called “theme groups”—as the

forum for coordinating U.N. efforts. Theme groups were to be composed

of field representatives of U.N. cosponsor agencies. The groups were

expected to work together to assist national governments develop and

implement HIV/AIDS programs. As of May 1998, 127 HIV/AIDS theme groups

were operating in 152 countries.

Objectives, Scope,

and Methodology

At the request of the Chairman of the House International Relations

Committee and Representative Jim McDermott, we reviewed the

contributions made by USAID and the United Nations in designing and

implementing programs to slow the spread of HIV/AIDS. Specifically, we

examined (1) the contributions USAID has made to the global effort to

prevent HIV/AIDS, and the methods USAID uses to provide financial oversight

for its HIV/AIDS prevention activities; and (2) the extent to which UNAIDS has

met its goal of leading an expanded and broad-based, worldwide response

to the HIV/AIDS pandemic. We did not evaluate the program’s impact on the

HIV/AIDS epidemic or whether U.S. support for the program should

continue.

To examine USAID’s contributions to the global effort to prevent HIV/AIDS,

we reviewed expert studies on the disease and interventions, and reviewed

internal and external USAID project evaluations from 1995 to 1998. We

compared the reported data with evidence we gathered in the field. To

Page 21 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

view USAID efforts in the field, we chose countries in different parts of the

world with both emerging and advanced epidemics. In countries with

emerging epidemics, HIV/AIDS is primarily concentrated in high-risk groups,

and in countries with advanced epidemics it has spread to the general

population. In Latin America and the Caribbean, we visited the Dominican

Republic and Honduras, both of which have emerging epidemics. USAID

considers Honduras the epicenter of the epidemic in Central America

because it has the highest concentration of HIV-positive people in its

high-risk groups. In Asia we visited India, which has more HIV-positive

people than any other country in the world, although still largely

concentrated in high-risk groups, and the Philippines, which has an

emerging epidemic. In Africa, we visited Zambia, which has an advanced

epidemic, with about 20 percent of the general population infected with

HIV. In the countries we visited, we reviewed internal USAID mission project

papers and 1997 mission progress reports and observed USAID projects. To

gather evidence of the effectiveness of USAID’s country-level projects, we

reviewed behavior surveys and available surveillance data; and met with

mission directors, population, health, and nutrition officers, HIV/AIDS

project officers, staff from PVOs and NGOs implementing projects, host

government officials, project participants, and recipients of services,

including commercial sex workers, men who have sex with men, and

youth, volunteers, a condom social marketing organization, and private

sector representatives involved in HIV/AIDS activities, and people living with

HIV/AIDS. We visited project sites to see how interventions were

implemented and to discuss the views of the recipients of USAID activities.

To examine the level of financial oversight USAID exercised over program

activities, we reviewed Office of Management and Budget (OMB) and USAID

guidance relating to the use of cooperative agreements and contracts. We

reviewed several relevant contracts, cooperative agreements, and

associated procurement records relating to active HIV/AIDS projects to

determine whether they provided for appropriate oversight as required by

federal procurement regulations and guidance from OMB and USAID. We

discussed financial oversight responsibilities with USAID project managers,

procurement staff, and financial management officers in headquarters and

in the five countries we visited. We also reviewed the financial

record-keeping and reporting requirements that USAID placed on recipients

of USAID funds. In addition, we reviewed quarterly expenditure reports

from PVOs from 1994 through 1997 and discussed financial reporting and

selected management and accounting policies with PVO staff to determine

their compliance with OMB and agency provisions. We reviewed USAID’s

administrative approval and payment procedures and studied recent USAID

Page 22 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

assessments of its financial and operational oversight responsibilities with

PVOs. We reviewed pre-award evaluations for four headquarters-led

projects and two mission-led projects and reviewed audit reports related

to the centrally managed projects in the five countries we visited. We also

met with Office of the USAID Inspector General (OIG) staff to discuss their

reviews of these reports and independent audit assessments.

As an agency of the U.S. government, we have no direct authority to

review the operations of multilateral organizations such as the United

Nations. However, throughout this review we obtained broad access to

agency staff members and official information at the headquarters,

regional, and country level. To determine whether UNAIDS has achieved its

goal to lead an expanded and broad-based, worldwide response to the

HIV/AIDS epidemic, we measured progress against criteria set forth in the

U.N.’s Economic and Social Council resolution endorsing the creation of a

Joint United Nations Program on HIV/AIDS, the memorandum of

understanding signed by the six cosponsoring agencies, and the strategic

plans of the UNAIDS Secretariat and the cosponsoring agencies. We

conducted audit work at the UNAIDS Secretariat in Geneva, Switzerland,

and at the headquarters of each of the six cosponsor agencies, including

the Washington headquarters of the Pan-American Health Organization.

At the UNAIDS Secretariat, we interviewed officials from the Office of the

Executive Director and the Departments of External Relations; Policy,

Strategy and Research; and Country Support. We obtained and analyzed

staffing and budget documents of the Secretariat and analyzed the scope

of work for each department. We also reviewed several of the “best

practices” documents produced by the Department of Policy, Strategy and

Research and discussed the best practices outputs with knowledgeable

officials from USAID. We interviewed officials from the cosponsor agencies

charged with directing their agencies’ HIV/AIDS activities and with officials

from other offices and departments of cosponsor agencies that are

relevant to addressing HIV/AIDS—such as WHO’s Global Tuberculosis

Program.

To determine U.N. spending on HIV/AIDS, we obtained expenditure data for

1992 to 1997 directly from the UNAIDS Secretariat and from the

headquarters offices of the six cosponsor agencies. We also obtained

agency expenditure data reported by the UNAIDS Program Coordinating

Board. We did not verify the data reported by or provided directly to us

from the agencies and the UNAIDS Secretariat. In attempting to determine

the level of spending by the major donors and developing nations, we

Page 23 GAO/NSIAD-98-202 HIV/AIDS
Chapter 1 

Introduction

reviewed preliminary data from a study on global HIV/AIDS expenditures

conducted by the UNAIDS Secretariat and Harvard University’s School of

Public Health.3

 We also met with government officials to discuss the level

and type of financial support for HIV/AIDS activities and to discuss barriers

to increasing resources to fight the disease. To determine the level of

activity by the private sector in support of HIV/AIDS, we interviewed host

government, U.N., USAID, and NGO officials in our case study countries and

analyzed reports prepared by the UNAIDS Secretariat.

To gain an understanding of UNAIDS’ progress in addressing the HIV/AIDS

pandemic over time and issues surrounding the transition from WHO’s

Global Program on AIDS to the current Joint Program on HIV/AIDS, we

interviewed a U.N. diplomat instrumental in the negotiations establishing

UNAIDS and knowledgeable officials from U.N. agencies, USAID, the

Department of State, and the U.S. Centers for Disease Control.

To determine how well cosponsor agencies work together and the types of

interventions provided, we reviewed surveys of theme group participants

provided by the UNAIDS Secretariat and conducted case studies of U.N.

programs in the five countries we visited. While in these countries, we

interviewed officials and obtained strategic planning documents from

most of the U.N. cosponsor agencies active in the country; host

government officials, including officials from the national AIDS program

and the Ministries of Health; USAID; other bilateral donor programs;

international and local PVOs and NGOs; and local activists and people living

with HIV/AIDS. We also observed firsthand the intervention activities of the

U.N. agencies.

We conducted our work from July 1997 through June 1998 in accordance

with generally accepted government auditing standards.

3

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

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

Page 24 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

USAID has elevated HIV/AIDS to an agency priority and developed a targeted

strategy to achieve its objective of reducing the incidence of HIV/AIDS.

USAID’s main contributions have been (1) support for research that helped

to identify interventions ultimately proven in clinical trials to prevent HIV

transmission; and (2) implementation of projects at the country level that

increased awareness of the disease, reduced risky behaviors, and

increased access to treatment of sexually transmitted diseases (STD) and to

condoms, which have helped slow the spread of the disease in target

groups.

USAID relies primarily on cooperative agreements with PVOs to implement

its programs, both at headquarters and in the field. Under the terms of

these agreements, the primary responsibility for financial oversight rests

with recipients. USAID’s oversight consists of pre-award evaluations,

quarterly expenditure reports, and annual external audits. OIG officials said

that there were no indications from audits conducted that systemic

problems existed.

USAID Supported the

Development of

Accepted

Interventions

USAID has funded public and private research efforts to identify

interventions that became the principal tools used in the global response

to HIV/AIDS. When USAID began its program in the mid-1980s, medical

experts recognized that the key to slowing HIV transmission was behavior

change and that traditional medical responses were not sufficient.

However, research was only beginning to identify effective interventions.

USAID capitalized on expertise developed in its health and child survival

programs and built upon the research conducted by WHO to test and

implement interventions targeted at HIV/AIDS prevention.

With support from USAID and other donors, experts identified interventions

that, when implemented in a culturally appropriate manner and combined

in a coordinated effort, have been proven through clinical trials and

longitudinal studies to have an impact on the spread of 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 the

HIV infection; and

• promotion of increased condom use through condom “social marketing” to

prevent transmission of the virus.

Page 25 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

Information, Education,

and Counseling

The first intervention, attempting to change risky behavior through

increased awareness, has posed a particular challenge to HIV/AIDS experts.

The behaviors that result in transmission of the virus are often deeply

rooted in social and cultural traditions, and people often find them

difficult to discuss. For example, in some African countries, polygamous

unions may force “junior wives” into prostitution to earn money. In

addition, research on ways to promote change in sexual behaviors is not

advanced. Even when effective approaches have been identified, they may

not always be transferable from one cultural environment to another. For

example, USAID’s largest HIV/AIDS program—AIDSCAP—noted the difficulty in

encouraging Rwandan refugees to take individual action to change their

risky behavior when they had no control over the rest of their life.

USAID supported a number of efforts to identify approaches to achieve

behavioral change through clinical trials of HIV prevention counseling and

testing in Africa, Asia, Latin America, and the Caribbean.1

 For example,

AIDSCAP worked with the United Nations and research institutions from

Kenya, Tanzania, Trinidad, and the United States to assess the efficacy of

efforts intended to promote voluntary HIV counseling and testing. In 1997,

USAID signed a cooperative agreement to support a 5-year, $40-million

program for operations research and field testing of interventions to

further refine and develop best practices for prevention and care activities.

In the five countries we visited, USAID projects used creative approaches to

increase HIV/AIDS awareness and promote behavior change. For example, in

Honduras, USAID—in conjunction with UNICEF—supported youth theater

groups to develop plays with HIV/AIDS-related themes. To reach

out-of-school youth, USAID supported pregame mock soccer matches,

where HIV Virus and Death teams battled Abstinence and Condom teams.

Also, in the Indian state of Tamil Nadu, USAID targeted education efforts at

truck drivers, who had been identified as key transmitters of the virus. On

a field trip, we saw roadside meetings between counselors and truckers to

discuss the risks of HIV transmission and demonstrate how to use condoms

correctly.

Treatment of Sexually

Transmitted Diseases

USAID was among the pioneers in funding research to determine whether

having an STD increases the risk of transmitting HIV. This research

concluded that STDs, especially those that cause lesions, provide a pathway

for the HIV virus to enter the body and that STDs were highly prevalent in

many of the populations most affected with HIV/AIDS. As early as 1991, USAID

1

Conducted by the University of California’s Center for AIDS Prevention Studies.

Page 26 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

reported that the risk of HIV transmission significantly increased when

other STDs are present and worked with WHO to develop standardized

treatments. The link between STDs and HIV transmission was eventually

confirmed by the results of a 3-year trial in Tanzania. The trial concluded

that increased STD treatment reduced HIV incidence by about 40 percent.

Improving STD treatment capacity was a component of USAID’s AIDS

prevention strategy in every country we visited. In Honduras, USAID

supported the expansion of health clinic services to include treatment of

STDs. Further, USAID’s AIDSCAP program supported STD research in the

Philippines, trained health care providers in STD treatment in India, and

developed national guidelines for improved STD care in 18 other countries.

Condom Social Marketing Another intervention developed and tested with USAID’s support is condom

social marketing, which relies on increasing the availability, attractiveness,

and demand for condoms among target populations through advertising

and public promotions. USAID projects encourage production and

marketing of condoms by the private sector to ensure the availability of

affordable and quality condoms when and where people need them. The

development of this marketing strategy was based on USAID-sponsored

research and experience that showed that people are more likely to use a

condom if they were affordable, high quality, and available when and

where needed. World Bank data demonstrated that condom sales

increased dramatically in many developing countries after condom social

marketing programs were introduced. For example, condom sales in Brazil

rose from 406,000 in 1991 to nearly 27 million in 1996 after condom social

marketing programs began.

Impacts on Incidence of

AIDS Are Difficult to

Measure

USAID, as well as UNAIDS, World Bank, and private research institutions,

have noted the difficulty in determining the direct impact of interventions

on the incidence of AIDS. The interventions used by USAID have been proven

to affect HIV/AIDS incidence because they result in behavior changes that

reduce the risk of disease transmission. However, it is difficult to

determine the link between a particular activity or program and reductions

in the incidence of HIV/AIDS because of the long incubation period for the

disease; a person can be infected as a result of an activity from 7 to

10 years previously. USAID measures the impact of its HIV/AIDS activities in

its target groups by conducting blood tests for HIV incidence but also uses

proxy indicators such as behavioral change and condom sales. Public

Page 27 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

health experts agree that these proxy indicators are reasonable indicators

of changes in HIV incidence.

USAID Projects Made

Important

Contributions

Despite the limitations in evaluating impact, USAID can demonstrate that it

has contributed to the fight against HIV/AIDS through its interventions in the

countries where it had programs. For the global project—AIDSCAP—and

each mission, USAID established goals and identified target groups based on

country needs. To assess the countries’ progress toward achieving these

goals, USAID conducted internal and external evaluations and behavioral

surveys, and tested people in the target groups for HIV. Data show that

USAID projects increased knowledge about HIV/AIDS and how to prevent it,

changed risky behaviors, and increased access to STD treatment and

condoms, thus helping to slow the spread of AIDS in target groups.

Centrally Managed

AIDSCAP Project

From 1991 to 1997, the goal of USAID’s $200-million global project, AIDSCAP,

was to support research, help missions develop and implement HIV/AIDS

programs and to provide technical assistance for mission-led programs.

AIDSCAP devised and carried out AIDS prevention programs in 18 countries

and supplied technical assistance to 25 other USAID programs.

Using a variety of evaluation instruments such as behavioral surveys and

blood testing for the HIV virus, USAID evaluated AIDSCAP’s projects and

concluded that AIDSCAP’s activities increased knowledge about HIV and

effected a change in attitude toward those affected by the virus. In target

groups in many of the countries, data indicate that AIDSCAP activities

resulted in altered perceptions of individual risk and less risky sexual

behaviors. For example, in the Ivory Coast, a USAID survey of 1,000 15- to

25-year olds in 30 targeted villages indicated that 47 percent had reduced

their number of sexual partners in response to AIDSCAP activities. USAID also

reported that more than 275 million condoms were distributed with USAID

support in 1996, or approximately 27 percent of all socially marketed

condoms in developing countries.

AIDSCAP implemented HIV/AIDS programs in the Dominican Republic and

Honduras. Our observations on these two efforts follow.

Dominican Republic The goal of USAID’s AIDSCAP project in the Dominican Republic was to

improve knowledge and access to AIDS prevention practices and services in

target groups.2

 Our review of behavioral and HIV surveillance data and our

2

These groups were commercial sex workers, men who have sex with men, hotel workers, and youth.

Page 28 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

interviews with participants indicate that USAID had an impact in both

areas. USAID reported that the percentage of young people who knew of at

least two preventive measures increased from 45 percent to 100 percent

between 1993 and 1996 after receiving AIDSCAP-developed information on

the disease. In addition, the use of condoms by commercial sex workers

rose from 65 percent in 1992 to 98 percent in 1996; commercial sex

workers with whom we met said they always tried to convince their clients

to use condoms. Moreover, USAID helped develop a low-cost condom with

a multinational pharmaceutical company, which significantly increased

the availability of condoms. USAID also obtained free air time on radio

stations to broadcast prevention messages. Data on HIV incidence among

commercial sex workers at one clinic targeted by AIDSCAP projects

indicated that the percentage of HIV-positive workers who came to a

USAID-supported clinic declined from 5.8 percent in 1995 to 3.3 percent in

1996. Moreover, surveys undertaken upon completion of the project

showed significant declines in risky behavior in targeted groups. For

example, the number of youth who said they were sexually active declined

from 73 percent in 1992 to 30 percent in 1996.

Honduras In Honduras, AIDSCAP designed and implemented a program to support the

government’s HIV/AIDS control program and to increase the use of STD/AIDS

prevention practices among high-risk groups,3 including increasing access

to STD treatment. The goal of the program was to reduce the incidence of

HIV/AIDS in specific regions of the country. However, because of difficulties

getting started, the project operated for only 2 years. According to USAID

officials in Honduras, they began negotiating with AIDSCAP in 1993 to

develop a program, but that AIDSCAP’s proposals did not adequately

emphasize participation by the government or involvement by local NGOs.

USAID did not reach agreement with AIDSCAP until 1995, 2 years before it

was scheduled to end. USAID evaluations and discussions with NGO

personnel indicated that the project had successes but should have done

more to prepare their local country office to assume the financial and

managerial responsibilities for the projects in an effort to ensure

sustainability. In 1997, after the AIDSCAP office was converted to a locally

registered NGO, the mission awarded the new NGO a USAID grant to continue

prevention efforts. However, because of its lack of financial and

managerial capacity, it was required to take corrective actions before the

new project could begin.

Data are not yet available to determine the impact of AIDSCAP on the

incidence of HIV/AIDS in Honduras. Early in the AIDSCAP project, USAID

3

These groups were commercial sex workers, men who have sex with men, and factory workers.

Page 29 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

conducted a behavioral survey to gather baseline data on risky behaviors.

However, because the project was only operating for 2 years, USAID will not

follow up with a survey to measure behavioral change as a result of its

activities until 1999.

The mission used other indicators to measure the success of the project. It

reported that it had exceeded its goal in increasing the numbers of

condoms distributed and that it had expanded access to STD treatment.

USAID upgraded a number of Ministry of Health-run health clinics to

increase access to STD prevention and treatment. Government officials

informed us that the number of women seeking STD treatment had risen

since completion of a USAID-funded STD clinic in a poor area of the capital

city, Tegucigalpa. Recipients of USAID-supported activities also told us that

risky behavior had declined. For instance, the leader of a gay men’s group

said that the amount of information and condoms requested by the gay

Honduran community had increased significantly since an

AIDSCAP-supported NGO began aggressive education activities.

Furthermore, mission officials stated that the AIDSCAP project had helped

publicize HIV/AIDS, had encouraged the host government to begin to address

the epidemic, and had established a network of NGOs that have the

capacity to promote HIV/AIDS prevention activities. We met with a number

of NGOs that, according to USAID officials, are competent and provide the

key to sustaining activities after USAID funding ends.

Mission-Level Projects We also reviewed mission-level projects in three countries: India, the

Philippines, and Zambia. In these countries, USAID missions designed their

own projects and hired PVOs and other organizations to manage activities.

AIDSCAP provided limited technical support to these missions. We found

that most programs were successful, with the exception of Zambia, where

problems significantly affected USAID’s ability to have an impact on the

spread of the disease.

India Our review of HIV surveillance and behavioral survey data, visits to

projects, and interviews with recipients of assistance indicate that USAID

has made progress toward meeting its goal of reducing HIV transmission

among target groups4

 in the southern Indian state of Tamil Nadu (see

fig. 2.1). The mission measured increased awareness about the disease and

behavioral change as indicators of change in HIV transmission and reported

4

These groups were commercial sex workers, their clients (for example, truck drivers), and people

with STDs.

Page 30 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

progress in its target groups. USAID is accomplishing its objective by

establishing and building a network of technically capable NGOs working to

alter behaviors and increase STD treatment and condom distribution. At the

time of our fieldwork, USAID had worked in only 1 of India’s 27 states,

though USAID officials said they planned to expand to 1 other state,

Maharashtra, because available funding did not permit USAID to develop

comprehensive programs nationwide. However, other donors were active

elsewhere in India. States, rather than the national government, manage

health care delivery, and USAID chose Tamil Nadu and Maharashtra

because they have a high percentage of HIV-positive people, and the state

governments are politically and financially supportive of AIDS prevention

efforts.

Figure 2.1: Director of

USAID-Supported Health Clinic

Discussing HIV/AIDS Prevention

Activities, in Tamil Nadu, India

Data generated from USAID’s last behavioral survey conducted in 1997 in

Tamil Nadu demonstrated significant behavior changes among high-risk

groups. Specifically, between 1996 and 1997, truck drivers reported

declines in their patronage of commercial sex workers and in the number

Page 31 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

of nonregular sex partners from 38 percent to 27 percent and increased

condom use from 55 percent to 66 percent. Among factory workers,

condom use increased from 28 percent to 41 percent. USAID has trained 

800 volunteers, peer educators, and NGO leaders to implement

community-based interventions and trained 60 health care providers in the

diagnosis and management of STDs since 1992.

Philippines In the Philippines, the USAID mission’s goals were to increase knowledge

and to change attitudes and behaviors to prevent STD/AIDS infection among

high-risk groups5

 and to collect comprehensive baseline data on the

incidence of HIV and behavior at 10 sites. Our review of an independent

evaluation and discussions with target groups in the Philippines indicated

that USAID interventions had been effective in increasing awareness and

changing behavior. In addition, USAID’s surveillance activities provided data

on HIV incidence and risky behavior among target group populations. An

independent evaluation conducted in 1997 concluded that USAID’s activities

helped avert an increase of HIV/AIDS,

6

 as the percentage of people who are

HIV-positive remained below 1 percent in targeted groups. Behavioral

surveys demonstrated that USAID activities to expand knowledge about the

disease led commercial sex workers to increase their use of condoms.

Data also indicated that male clients exposed to USAID interventions used

condoms much more frequently than those with no contact with the

project (75 percent compared to 41 percent). Our reviews of evaluations

and interviews with NGO staff also indicated that USAID increased the

capacity of the NGO staff to implement AIDS prevention activities. USAID

project activities are carried out by staff working for 20 local organizations

that have been trained as a result of USAID activities. We met with a number

of NGOs that were successfully implementing prevention strategies under

the guidance of USAID. For example, we accompanied a local NGO to a site

frequented by gay men, where the NGO distributes pamphlets, discusses

HIV/AIDS risks, and promotes condom use.

Zambia Our review of USAID activities in Zambia indicated that the mission has had

a difficult time developing an HIV/AIDS prevention program. Despite its

problems designing an effective program, it did have some successes.

Since 1992, the mission has redesigned its program three times with

different goals and implementing organizations. Initially, the USAID mission

in Zambia established a goal of reducing HIV transmission. It subsequently

determined that this goal was unrealistic and refocused its objective on

5

These groups were registered female commercial sex workers, freelance commercial sex workers,

men who have sex with men, and intravenous drug users.

6

The evaluation used a simulation model developed by AIDSCAP that calculates the number of

infections averted when accepted interventions are applied to high-risk groups.

Page 32 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

changing behavior in high-risk groups. USAID’s difficulty in developing a

program stemmed, in part, from the national government’s transition to a

decentralized approach to HIV/AIDS and health care delivery. However,

according to USAID mission officials and an independent evaluation,

problems occurred primarily because the U.S. educational institution

managing USAID’s program did not have the necessary expertise to

implement large-scale HIV/AIDS activities overseas. An evaluation of the

project found a number of weaknesses, including a lack of project

monitoring and a reliance on U.S.-based institutions to implement

activities rather than building the capability of local NGOs. In addition, host

government officials informed us the implementing agency designed and

implemented activities without host country involvement. The evaluation

also found that the project had not increased the number of patients

treated for STDs, an important component of USAID’s HIV/AIDS strategy.

Despite USAID’s management problems, we saw some successes in Zambia

(see fig. 2.2). Our discussions with youth groups indicated an increased

awareness of HIV/AIDS. USAID reported that condom sales exceeded

expectations and increased by 22 percent in 2 years and that the number

of casual sex partners in the target groups decreased. Additionally, USAID

mission officials said that they had been instrumental in convincing the

Zambian government to integrate HIV/AIDS activities into the national health

plan and that they have had some successes in addressing one of the social

and cultural factors that contribute to the spread of the disease.

Specifically, USAID worked with traditional healers and the legal

community to discourage a custom whereby recently widowed women

engage in sexual relations to “cleanse” their bodies of the spirit of the

deceased.

Page 33 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

Figure 2.2: HIV/AIDS Education

Program for Community Health

Workers in Lusaka, Zambia

Nature of USAID’s

Financial Oversight

USAID conducts financial oversight for its HIV/AIDS activities primarily

through pre-award evaluations, quarterly financial reports, and annual

financial audits of its private sector partners. Largely in response to

congressional direction, USAID officials decided to rely on U.S.-based PVOs

and indigenous NGOs to implement its HIV/AIDS program.7

 To manage their

private partners, USAID officials in headquarters and the field told us that

they have chosen almost without exception to use a funding arrangement

called a “cooperative agreement.” Cooperative agreements are similar to

grant agreements8

 but are used when agencies expect to be substantially

involved in the activity to be carried out. These agreements allow USAID

and recipients to easily adapt the scope of work and shift budgeted

resources to changing needs. Therefore, they are able to adjust activities

to meet agency goals without a formal process for review and approval.

Recipient organizations have the primary responsibility for financial

management. OIG officials said that there were no indications from audits

conducted of systemic problems.

7

Since 1990, the House and Senate Appropriations Committees have urged USAID to maximize its use

of PVOs and NGOs to implement HIV/AIDS prevention activities.

8

See The Federal Grant and Cooperative Agreement Act of 1977 (31 U.S.C. 6301-8).

Page 34 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

OMB Guidance Places

Financial Management

Responsibilities on

Recipient Organizations

OMB guidance outlines the responsibilities of awarding agencies and

funding recipients under cooperative agreements.9

 The guidance states

that agencies should require organizations to have requisite financial and

management systems in place; agree to comply with various requirements,

such as guidelines for allowable costs; and provide procedures for

periodic financial and progress reporting.

With respect to monitoring, OMB’s general guidance is that while the

agency has the responsibility to ensure that public funds are managed

prudently, day-to-day financial management is the responsibility of the

recipient. USAID project managers use several methods to ensure financial

oversight: pre-award evaluations, quarterly expenditure reports, and

annual audits.

Pre-award Evaluations Pre-award evaluations are conducted as necessary before an award is

granted, to assess whether prospective recipients have adequate financial

and management control systems to properly manage, report, and account

for USAID funds. If a recipient has recently received a federal award and is

known to have the technical and financial capacity to perform the job,

USAID conducts an informal review of its systems and controls. Otherwise,

a team will go on-site to conduct a formal evaluation. We examined

pre-award surveys for four headquarters projects and two mission bilateral

projects. USAID conducted pre-award evaluations for all of them, and with

the exception of the award to a local NGO in Honduras, they were informal

reviews because the recipients were known to USAID. In Honduras, USAID

conducted a formal evaluation because the NGO selected to manage the

mission’s HIV/AIDS project after AIDSCAP ended did not have previous

experience managing a USAID project. USAID found problems with the NGO’s

accounting system, procurement and contracting procedures, and

personnel management system. Before the award was made, the NGO was

required to undertake corrective actions.

Quarterly Expenditure Reports Recipients of cooperative agreements are also required to provide

quarterly expenditure reports to the USAID project manager. These are

summaries of expenditures listed in categories such as salaries and travel.

For the 6 years of the AIDSCAP project, we found that USAID reviewers

approved all expenditure reports without disapproving any costs. OMB

guidance stipulates that agencies must determine whether costs incurred

are in accordance with terms of agreements and are reasonable and

allowable. However, the guidance does not define the roles and

9

OMB Circulars A-110, “Uniform Administrative Requirements for Grants and Agreements with

Institutions of Higher Education, Hospitals and Other Non-Profit Organizations”; and A-122, “Cost

Principles for Non-Profit Organizations.” See also 22 C.F.R. 226.

Page 35 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

responsibilities of an awarding agency for monitoring the recipient’s

compliance with these standards. Project managers told us that they

reviewed expenditure reports primarily to compare the level of funds

expended with the progress toward completion of project activities.

Annual Audits According to USAID officials, USAID uses annual financial audits required by

the Single Audit Act as its principal tool for financial oversight.10 These

audits are intended, among other things, to promote sound financial

management, including effective internal controls, with respect to federal

awards administered by nonfederal entities such as PVOs. As such, they

provide information to federal oversight officials and program managers

on whether an entity’s financial statements are fairly presented and

reasonable assurance on whether federal assistance programs are carried

out in accordance with applicable laws and regulations. The single audit

reports from 1992 to 1996 of the PVO that implemented the AIDSCAP project

did not indicate any financial management or reporting problems. OIG

reviews of these audits found that they were performed in accordance

with the Single Audit Act’s requirements.

In 1994, the OIG conducted an audit primarily focused on salaries, fringe

benefits, and travel, based on specific allegations regarding these matters.

As a result of this review, the OIG questioned 11 percent of the $14.6 million

of expenditures examined. Following negotiations, the PVO repaid $540,000

to USAID. OIG officials said that there were no indications, from either this

review or the single audits, that systemic problems existed.

Conclusions USAID has made important contributions in the fight against HIV/AIDS by

helping to support the development and implementation of interventions

that have been proven effective in the global fight against the disease.

These interventions include information, education, and counseling;

treatment of sexually transmitted diseases; and promotion of increased

condom use through condom social marketing.

At the country level, USAID implemented projects that increased awareness

of the disease, reduced risky behaviors, and increased access to STD

treatment and condoms. These actions have helped slow the spread of the

disease in target groups. Evaluations of USAID’s largest HIV/AIDS project,

AIDSCAP, determined that its activities had successes in the countries where

10The Single Audit Act of 1984 (31 U.S.C. 7501-7507) requires organizations that meet a minimum

threshold of federal funding to undergo a single, nonfederal audit each year.

Page 36 GAO/NSIAD-98-202 HIV/AIDS
Chapter 2 

USAID Has Made Important Contributions

to HIV/AIDS Prevention

it had projects. Our fieldwork and evaluations conducted for a number of

other mission-led projects also showed important impacts.

USAID implements its programs at headquarters and in the field primarily

through PVOs and NGOs. To manage their private partners, USAID has chosen

almost without exception to use a funding arrangement called a

cooperative agreement. Because they are similar to grant agreements,

cooperative agreements allow flexibility to USAID in adjusting their scope,

and recipient organizations have the primary responsibility for financial

management. USAID managers primarily rely on pre-award evaluations,

review of quarterly expenditure reports, and annual audits for their

financial oversight of its funding recipients. OIG officials said that there

were no indications from audits conducted that systemic problems

existed.

Agency Comments USAID stated that it was pleased with the overall presentation and

objectivity of the report.

Page 37 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

UNAIDS has made limited progress toward achieving its goal of leading a

broad-based, expanded worldwide response to the HIV/AIDS epidemic.

Reasons for the limited progress include a lack of clarity in the mission

and roles of cosponsor agencies in the field and lack of staff accountability

for theme group success. Cosponsor agency estimates of overall U.N.

spending on HIV/AIDS show that resources have not increased with the

creation of UNAIDS.

1

 In addition, while the UNAIDS Secretariat has made

significant efforts at the international level to mobilize private sector

support, Secretariat officials acknowledge that U.N. efforts at the local

level have been limited. Data are not available to get an accurate measure

of UNAIDS’ success in mobilizing an expanded response among donors or

affected countries. In some countries, cosponsor agencies are just

beginning to work together in theme groups. Finally, the UNAIDS Secretariat

has not been very successful in providing technical assistance and other

support to facilitate theme group activities and has only started to

establish a framework to measure performance.

U.N. Expenditures

For HIV/AIDS Did Not

Increase

The U.N. Economic and Social Council, which created UNAIDS, stated that

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

resources for HIV/AIDS activities by the cosponsor agencies. U.N. agency

spending began to decrease under WHO’s GPA, declining by 20.3 percent

during the last 2 years of the program (1994-95). For the first 2 years since

the creation of UNAIDS in 1996, cosponsor agencies estimate that the

decline has leveled off, with spending at about $332 million—a slight

decline from the $337 million spent during the last 2 years of GPA. Funding

for HIV/AIDS-related activities remained stable even though overall

cosponsor agency spending increased by 6.5 percent during the same

period.

Data in figure 3.1 demonstrate differences among cosponsor agencies that

underlie the overall U.N. expenditure estimates for HIV/AIDS. Two agencies,

UNDP and UNFPA, increased spending on HIV/AIDS by $10.8 million and

$5.4 million, respectively, and UNESCO began programming money for

HIV/AIDS after the creation of UNAIDS. However, the World Bank and UNICEF

decreased funding by $10.5 million and $3.5 million, respectively.2

Spending on HIV/AIDS also declined as a percentage of these agencies’

1

Throughout this report, reference to overall U.N. funding for HIV/AIDS activities is limited to the six

cosponsor agencies and the Secretariat.

2

The decrease in World Bank spending is based on official estimates provided by the World Bank.

Preliminary data on World Bank spending gathered by the UNAIDS Secretariat at the country level are

significantly higher than these data. According to Secretariat UNAIDS officials, they are working on

reconciling the differences.

Page 38 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

budgets. Finally, WHO, the agency that spearheaded U.N. efforts to fight the

HIV/AIDS epidemic in the early 1990s, with about $140 million added to its

core budget every 2 years for HIV/AIDS activities, first began programming

core funds following the creation of UNAIDS. It spent $16 million in 1996-97.

Figure 3.1: U.N. HIV/AIDS Funding Under GPA 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

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

UNAIDS

Secretariat

aUnavailable.

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

U.N. agency officials gave several reasons for the lack of increased

spending on HIV/AIDS programs. A WHO official said that because WHO no

longer had additional funding for its HIV/AIDS efforts after GPA ended, 200

professionals who had been working on the program left or changed jobs,

and the agency had to reorganize its staff and budget to undertake HIV/AIDS

Page 39 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

activities. According to cosponsor officials and the Secretariat, other

agencies did not increase support for HIV/AIDS due to difficulties

incorporating HIV/AIDS activities into programs in the midst of their 5-year

planning cycle; lack of commitment to HIV/AIDS by affected governments;

and lack of commitment to HIV/AIDS as a priority on the part of field

representatives.

Baseline Spending by

Major Donors and

Affected Countries Is

Being Developed

Building worldwide support for HIV/AIDS was a key objective of UNAIDS. The

U.N. Secretary General noted that in order to achieve an expanded

response, governments of countries most affected by the epidemic would

have to increase resources for HIV/AIDS. Officials from the UNAIDS

Secretariat also noted the importance of increasing the financial support

of donor countries. However, the Secretariat is not yet in a position to

measure USAIDs’ progress because it does not yet have baseline data on

spending for HIV/AIDS at the country level. It has only recently developed

baseline data for donors.

The UNAIDS’ Secretariat is in the process of analyzing survey data to

develop estimates of spending on HIV/AIDS by affected countries. Secretariat

officials said that the data would be available in the fall of 1998. While half

of the theme groups surveyed by UNAIDS reported that in 1997 they had

mobilized resources at the country level, they noted that the large majority

of these resources was from U.N. agencies.

U.N. officials told us that the lack of data on the impact of HIV/AIDS,

measured in the number of deaths and illnesses, made it difficult to

persuade developing countries to divert limited national resources from

other important health problems. In many developing countries, the

numbers of deaths and the costs of caring for HIV/AIDS patients are not

identifiable because records only indicate secondary causes of illness or

death, such as pneumonia, rather than HIV/AIDS infection.

Preliminary data from its most recent survey3

 indicate that contributions

by major donors4

 have remained relatively stable between 1993 and 1996,

at approximately $250 million a year. However, data are not available for

1997. Thus, it is not possible to determine whether UNAIDS’ first year’s

efforts have led to increased spending by donors. A USAID official told us

that Secretariat officials made regular visits to executive and

3

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

4

The United Nations defines major donors as Australia, Canada, Denmark, France, Germany, Japan,

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

Page 40 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

parliamentary branches of governments in donor countries, including the

United States, in an attempt to keep the spotlight on HIV/AIDS issues and

avert “donor fatigue.”

UNAIDS Had Limited

Success in Mobilizing

the Private Sector

The UNAIDS Secretariat and cosponsor agencies were expected to mobilize

the private sector as part of the comprehensive global response to the

HIV/AIDS epidemic. Despite this objective, efforts have been limited at the

country level, and overall results are not clear. UNAIDS officials reported

they have made efforts to encourage support for HIV/AIDS activities in the

international community. However, at the country level, cosponsor

agencies had solicited private involvement in only one country we visited.

Moreover, UNAIDS lacks data to determine whether the level of resources

devoted to HIV/AIDS by the private sector has increased or decreased.

Secretariat officials told us that they believe the level of private sector

resources dedicated to HIV/AIDS activities has remained limited.

In the international community, the UNAIDS Secretariat has encouraged

private sector support through advocacy efforts with leading corporate

organizations, such as The Conference Board and Rotary International,

and individual companies. For example, the Secretariat organized a 1997

World Economic Forum plenary session in which South African President

Nelson Mandela gave the keynote address to the world’s business leaders

calling for a public/private partnership to fight HIV/AIDS. The Secretariat

also organized a Public/Private Sector Partnership Strategy Meeting on

International HIV/AIDS in London, England, in November 1996 and is

working to establish a Global Business Council to organize businesses to

serve as advocates in their industry and region.

As a result of its efforts, the UNAIDS Secretariat has had some successes,

particularly in advocating research and distribution of medical

interventions appropriate in the developing world. According to a senior

USAID official, the UNAIDS Secretariat and WHO should be credited with

encouraging pharmaceutical companies to continue and increase their

efforts to develop affordable HIV/AIDS vaccines. 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. In addition, for more

than 2 years, the UNAIDS Secretariat has been coordinating international

research on mother-to-child transmission and addressing ways to

implement clinical trials with the private sector, international agencies,

and donor countries. USAID also credits the Secretariat with working with

Page 41 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

the private sector to increase the availability and affordability of the

female condom.

However, according to a report produced by the UNAIDS Secretariat and the

Prince of Wales’ Business Leaders’ Forum,5

 the corporate response to

HIV/AIDS has generally been limited and largely defensive. With few

exceptions, the business community around the world has not sought a

leadership role in confronting the epidemic. Among the reasons for this

lack of involvement are

• inadequate information on the disease and understanding about how it

affects their companies,

• unease about association with a controversial issue,

• lack of encouragement by the public sector, and

• competition for resources for HIV/AIDS with other good causes.

Unlike the Secretariat’s efforts with the international business community,

in-country efforts by the cosponsor agencies to encourage private sector

involvement in HIV/AIDS activities have been very limited. We saw examples

of private, in-country activities that indicated that companies could play an

important role in the U.N.’s efforts to reduce the spread of HIV/AIDS. For

example, the theme group in India solicited free air time from an Indian

television network and worked jointly to develop a media campaign

involving national artists in on-air promotions and public events. We saw

other private-sponsored activities such as companies in Honduras

allowing government or NGO-sponsored HIV/AIDS prevention and control

activities to occur within their place of business. Another example was in

the Philippines, where a manufacturing company provided direct financial

support for prevention activities. None of these was initiated by U.N.

agencies.

Several U.N. agency officials said that the reason for a lack of focus on

private involvement in HIV/AIDS activities was that U.N. agencies did not

generally work with the private sector. Their contacts in the field are

almost exclusively with government ministries. Officials added that

because the United Nations is not accustomed to working with private

partners, guidance on best practices in this area would be useful.

5

The report was entitled The Business Response to HIV/AIDS: Innovation and Partnership (Geneva and

London: 1997). The Prince of Wales’ Business Forum was established in 1990 as a global network of

business leaders and their companies to work to promote continuous improvement in the practice of

corporate citizenship and sustainable development internationally.

Page 42 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

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.

Their ultimate objective was to support host countries’ national HIV/AIDS

programs. To operate effectively, agency representatives were expected to

meet regularly to discuss opportunities for joint programming and

assistance to the host country. We found such an example in the

Dominican Republic where agencies met regularly and even conducted

joint programming. However, Secretariat officials acknowledged that as of

1997 most theme groups were not working effectively and that they

underestimated the difficulty of getting U.N. agencies to coordinate and

conduct joint programming. For example, in two of the five countries we

visited—Honduras and India—we found poorly functioning theme groups

that rarely met. Preliminary results from a 1997 survey conducted by the

UNAIDS Secretariat of theme groups showed that data received as of

April 30, 1998, indicated that theme groups had made some progress in

cosponsor coordination since their 1996 survey of theme groups,

particularly in the areas of advocacy and resource mobilization. However,

of the theme groups that responded to the 1997 survey, less than

50 percent were judged effective in those areas. In addition, while

respondents said that the level of U.N. coordination at the country level

had improved over the last year, only 28 percent rated it strong or better.

Overall, fewer than half of the theme groups had undertaken efforts in 7

out of 10 of the key outputs measured.

Several factors have hindered theme group operations, including the

following:

• Cosponsor agencies and the UNAIDS Secretariat did not provide guidance to

staff in the field regarding how theme groups should operate and the

scope of their mission.

• Cosponsor agencies did not hold their staff accountable for theme group

success, and UNAIDS Secretariat staff lacked authority to require

participation.

• Concerns about the concept of a joint program and theme group

operations led to lack of commitment to working together on the part of

some agency representatives.

Lack of Timely Guidance According to cosponsor agency officials, neither the Secretariat nor the

cosponsors issued timely guidance to theme group participants about how

to operate or about their roles and responsibilities within the theme

groups. In a 1996 UNAIDS survey of theme group operations conducted by

Page 43 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

the UNAIDS Secretariat, U.N. officials in the field cited the lack of

understanding about the roles of each agency at the country level and lack

of support from cosponsor agencies and the Secretariat as major obstacles

to progress. Acknowledging these problems, the Secretariat provided

operational guidelines to theme groups early in 1998.

Lack of Requirements to

Participate

The individual job expectations provided for U.N. cosponsor

representatives in the field did not include an expectation to participate in

the theme groups. Field staff with whom we met said that their annual

personnel assessments did not mention participation in UNAIDS activities.

The career, promotion, and reward paths for U.N. officials are through

their parent organizations, and their work on UNAIDS activities was

considered an adjunct to their regular duties. Typical of the responses we

heard was a U.N. cosponsor agency official in Honduras who described

UNAIDS work as “an add-on, an additional function outside of regular work

responsibilities.” Secretariat representatives who were responsible for

organizing theme groups and encouraging joint participation did not have

the authority to require participation.

Lack of Commitment to Work

Together

Despite agreements by cosponsor agencies to support and work

collaboratively in the theme groups, according to senior U.N. officials,

concerns about the concept of a joint program held by some senior agency

officials contributed to their lack of commitment to working together.

Such concerns were reflected in a 1997 USAID survey of 31 of its overseas

missions that addressed problems faced by U.N. agencies in planning and

implementing their HIV/AIDS activities. Respondents cited uneven U.N.

agency commitment to HIV/AIDS-related endeavors and the lack of

coordination among U.N. agencies.

In particular, some officials from the World Bank and WHO said that they

questioned the role of UNAIDS as the organizing vehicle for the U.N.

response. One WHO representative in the field said that because he works

directly with the host government, he views UNAIDS as irrelevant. In

addition, a World Bank official said he did not see the usefulness or

relevancy of coordinating or integrating the Bank’s activities with other

cosponsor agencies, noting that U.N. agencies were already doing all they

could to address HIV/AIDS.

6

 The World Bank’s lack of commitment to the

theme groups and UNAIDS was evident in a number of our case study

countries where the World Bank had programs. Though the country

6

According to officials from the UNAIDS Secretariat, senior-level meetings between World Bank and

the Secretariat January 1998 addressed outstanding complaints concerning the Bank’s participation in

UNAIDS and should result in greater coordination and collaboration with the other cosponsor

agencies.

Page 44 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

representative of each U.N. cosponsor agency is automatically a member

of the theme group and is expected to participate in its activities, in three

of the five countries we visited, the World Bank representative never

attended a theme group meeting, according to other cosponsor agency

officials. However, in two of the countries, a lower-level staff member was

present at a couple of theme group meetings.

UNAIDS Secretariat officials said they recognized these problems and met

with cosponsor agencies in March 1998 to address interagency

cooperation and develop strategies to improve theme group coordination.

Limited Success in

Providing Technical

Support for UNAIDS

Country Activities

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

to theme groups to facilitate cosponsor agency efforts. The two Secretariat

departments responsible for providing technical support and

disseminating best practices accounted for 80 percent of the Secretariat’s

budget. However, during our site visits, we found few U.N. agencies

utilizing the Secretariat’s technical support, and some agency officials

were unaware of the services or technical assistance that were available.

For example, cosponsor agencies in the Philippines stated that best

practice information is useful for introducing an idea to the government,

but not particularly helpful in defining how to implement it. The UNDP

representative said it would be useful to obtain information on how to

incorporate HIV/AIDS prevention in their good governance projects. UNAIDS

official acknowledged the Secretariat had poorly marketed available

support and noted that its fixed menu of technical support was not always

relevant or flexible enough to meet a country’s specific needs. In addition,

because of the limited number of experts on the UNAIDS’ staff, he noted that

the Secretariat should have made more of an effort to mobilize regional

resources to provide technical assistance. Secretariat officials indicated

substantial investments in this area will be needed in the future.

Another key role of the UNAIDS Secretariat was to identify, develop, and

function as a major source of information on best practices; that is, to

identify and disseminate information about HIV/AIDS prevention policies and

strategies and to promote research to develop new tools to address

HIV/AIDS. According to cosponsor agency officials we interviewed, best

practices information from the Secretariat was disseminated and read, but

the information was too general to be of practical use and lacked practical

“how-to” guidance. For example, according to a USAID official familiar with

material on best practices produced by the Secretariat, the information

provided a good summary and starting point for discussion of a particular

Page 45 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

issue, such as how to deal with AIDS in prisons. However, he noted that

practitioners in the field, who are generally well informed, needed

practical guidance on how to carry out specific projects. According to a

Secretariat official, the focus was on producing the most up-to-date,

comprehensive document on a particular issue but not to tailor best

practices to meet the needs of officials in the field. He added that the

department responsible for best practices needed to begin by improving

its knowledge of customers’ needs so that it could make itself more

relevant. According to Secretariat officials, steps are under way to address

these deficiencies. For example, the Secretariat has reorganized the

support departments and instituted management changes. Additionally,

USAID stated that along with other bilateral donors, USAID is helping to

establish a network of technical resources that can be used by Secretariat

and cosponsor staff in-country staff to enhance the design and

implementation of national HIV/AIDS programs. However, it is too early to

evaluate the impact of these efforts.

Performance

Indicators

The Secretariat was directed by its governing board to coordinate the

development of performance-based programming and measurable

objectives. As an international organization, the United Nations is not

required to comply with the U.S. Results Act.7

 However, the act sets forth

the characteristics of a performance-based system, requiring (1) the

statement of a clearly defined mission; (2) the establishment of long-term

strategic goals, as well as annual goals that are linked to them; (3) the

measurement of performance against the goals; and (4) the public

reporting of how well the agency is doing. Development of performance

indicators will assist in making the Secretariat and the cosponsor agencies

accountable for their performance, to gauge progress toward meeting

objectives, to promote UNAIDS activities with host governments, and to

generate information decisionmakers need in considering ways to improve

performance.

However, the Secretariat has been slow to create and implement an

evaluation framework that employs performance indicators. Despite being

instructed to start efforts immediately, it did not begin staffing an

evaluation unit until September 1997. According to the Secretariat’s

evaluation officer, the goal is to field-test a performance-based evaluation

system in 20 to 30 countries by the end of 1998. Secretariat officials

attribute the slow start in developing performance indicators to the rush to

get UNAIDS up and running programmatically and country-level activities

7

The Government Performance and Results Act of 1993 (P.L. 103-62).

Page 46 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

under way. Results from the theme group survey covering 1997 activities

showed that, where theme groups had developed an integrated U.N. work

plan, only 22 percent had developed indicators to measure progress, and

only 13 percent had assessed their performance using the indicators.

USAID officials noted that the lack of a credible monitoring and evaluation

plan by the UNAIDS Secretariat is a significant weakness. Officials added

that at the May 1998 meeting of UNAIDS’ governing board, a Monitoring and

Evaluation Technical Review Group was created. This group is expected

to develop a plan for approval by the board at its next meeting, scheduled

for December 1998.

U.N. Agencies

Undertook Innovative

Grassroots

Interventions

Although we did not conduct an evaluation of individual cosponsor

HIV/AIDS activities, in the countries we visited we observed innovative

cosponsor activities in each of our case study countries. U.N. agencies

relied on proven control and prevention activities such as condom

education and promotion, information and behavioral change

communication, and treatment of STDs. In addition, the activities were

targeted to high-risk groups (such as commercial sex workers and

truckers), individuals who engage in high-risk activity (clients of

commercial sex workers, men who have sex with men, intravenous drug

users), and those considered particularly vulnerable (women and youths).

Moreover, the activities we observed were generally inexpensive, ranging

from $200 to several thousand dollars. In addition, in an effort to increase

sustainability, the activities were often managed by host country officials

and implemented by locally recruited activists. While many developing

countries remain dependent on external donor support to finance HIV/AIDS

activities, a cadre of trained and experienced HIV/AIDS activists existed in all

the countries. Particularly noteworthy was the use of peer

educators—such as commercial sex workers and intravenous drug

users—who are able to reach and communicate effectively with at-risk

populations who normally fall outside the reach of government-sponsored

public health programs.

Examples of intervention activities we observed in our case study

countries include the following:

• In the Dominican Republic, an adolescent peer educator training session

and a prison AIDS awareness workshop were funded by joint contributions

from all the theme group members.

Page 47 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

• In Honduras, a street theater organization conducted HIV/AIDS awareness

skits at schools and festivals and during half-time at professional and

amateur soccer matches (see fig. 3.2).

Figure 3.2: A USAID and

UNICEF-supported Community Center

and Youth Theater in San Pedro Sula,

Honduras (with props used in

HIV/AIDS skits)

• In the Philippines, commercial sex workers and

men-who-have-sex-with-men peer educators provided counseling,

information packets, and condoms in brothels and locales frequented by

individuals who engage in high-risk behavior.

• In India, the first HIV testing center in New Delhi was developed, providing

free voluntary testing; counseling services; dissemination of information

about HIV/AIDS, STDs, and condom use; support and care services for

HIV-positive clients; and advocacy and sensitization about the rights and

needs of HIV-positive individuals.

• In Zambia, a pilot project for home-based care mobilized community

groups to deal with the consequences of the HIV/AIDS epidemic, including

(1) educating the community about HIV/AIDS; (2) caring for orphans, the

Page 48 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

chronically ill, and the dying; and (3) developing income-generating

projects for women, orphans, and people living with AIDS.

Conclusions UNAIDS has made limited progress toward achieving its goal of leading a

broad-based, expanded, worldwide response to the HIV/AIDS epidemic.

Cosponsor agency estimates of overall U.N. spending on HIV/AIDS show that

resources have not increased with the creation of UNAIDS, as was expected.

Agency spending on HIV/AIDS began declining before the creation of UNAIDS

in 1996 and since then has leveled off, despite an increase in overall

cosponsor agency spending of 6.5 percent.

Building worldwide support for HIV/AIDS was a key objective of UNAIDS.

However, the UNAIDS Secretariat is not able to measure progress in meeting

this goal because it does not yet have baseline data on spending on HIV/AIDS

at the country level and has only recently developed baseline data for

contributions by donor countries. Secretariat officials said that spending

estimates for affected countries should be available in the fall of 1998. In

addition, the Secretariat lacks data to determine whether the level of

private sector resources directed to HIV/AIDS has increased or decreased.

While the UNAIDS Secretariat has made significant efforts at the

international level to mobilize private sector support, we found that U.N.

efforts at the local level were very limited in the countries we visited.

Secretariat officials acknowledged that as of 1997, most theme groups

were not working effectively and that they underestimated the difficulty of

getting U.N. agencies to coordinate and conduct joint programming. For

example, in two of the five countries we visited, we found poorly

functioning theme groups that rarely met. Factors that hindered theme

group operations included insufficient guidance to staff in the field

regarding how theme groups should operate, not holding staff accountable

for theme group success, and U.N. agency staff’s lack of commitment to

working together.

In addition, the UNAIDS Secretariat has not been very successful in

providing technical assistance and other support to facilitate theme group

activities and has only started to establish performance measures. Despite

UNAIDS’ difficulties, we observed innovative and U.N. agency intervention

projects in each of our case study countries.

Page 49 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

Agency Comments

and Our Evaluation

Comments from USAID, the Department of State, and the UNAIDS Secretariat

generally focused on concerns about our review of UNAIDS. USAID stated

that it shares our concerns about areas in which UNAIDS has not made

sufficient progress. However, USAID expressed its strong endorsement and

support for the program and the unique role UNAIDS plays in the global

response to HIV/AIDS. USAID also pointed to the difficulty of UNAIDS’ mandate

and UNAIDS’ relatively short existence (2 years at the time of our review).

USAID stated that progress had been made in some areas since our review.

For example, USAID noted that at a recent meeting, a Monitoring and

Evaluation Technical Review Group was created to develop a monitoring

and evaluation plan targeted for December 1998.

UNAIDS Secretariat officials agreed with our conclusion that U.N.

expenditures for HIV/AIDS did not substantially increase since the creation

of UNAIDS. However, it questioned the quality of the financial data reported

by the cosponsor agencies because agencies have difficulty estimating

expenditures and use different methods of reporting. The Secretariat

stated that relying on financial expenditures alone masks the increased

expenditures of human resources on HIV/AIDS by cosponsor agencies in

many countries. The Secretariat stated that progress has been made

toward mobilizing the private sector and coordinating efforts at the

country level, providing support to theme groups, and developing a

framework for measuring the progress of the U.N. effort on HIV/AIDS was

reasonable given the challenges it faced and the short time since the

creation of UNAIDS. The Secretariat provided updated information on

activities undertaken after we completed our fieldwork.

Our conclusion about the decline in U.N. spending on HIV/AIDS is based on

data reported by the respective cosponsor agencies. We recognize that

agencies use different methods to report expenditures and that it is

difficult to estimate expenditures, particularly when HIV/AIDS expenditures

are integrated into spending for other activities. However, because each

agency has reported the data in a consistent manner over time, we believe

that the data are useful to identify trends. We also agree with the

Secretariat that adding other measures of the U.N. effort, such as human

resources, would be useful. However, the Secretariat does not currently

have an evaluation and monitoring system to measure non-financial

contributions to HIV/AIDS.

We did not make a judgment about whether cosponsor agencies should

have made more progress toward mobilizing the private sector. The

concern we raised in the report was less about the level of private

Page 50 GAO/NSIAD-98-202 HIV/AIDS
Chapter 3 

The Joint U.N. Programme on HIV/AIDS Has

Made Limited Progress

involvement than the fact that cosponsor agencies in all but one of the

countries we visited were not making efforts to involve the private sector.

We acknowledge in the report that theme groups have made some

progress since the Secretariat’s 1996 survey; it was conducted the same

year that most theme groups were established, so some progress would be

expected. However, the 1997 survey indicated that half or fewer of the

theme groups had undertaken efforts in 7 out of 10 of the key outputs

measured. We also note that despite being instructed by its governing

board to immediately begin developing an evaluation and monitoring plan,

the Secretariat did not hire staff to develop the plan until a year and a half

after UNAIDS was established.

USAID, State, and the UNAIDS Secretariat also noted that UNAIDS has only

been in existence for 2-1/2 years and were concerned that it may have

been too early to assess the program. State also said it was disappointed at

the very negative tone in the report concerning UNAIDS’ activities and

believed that the report did not give any credit to UNAIDS for what it had

achieved. Furthermore, State said that we implied that U.N. agencies and

the U.S. government should stop supporting UNAIDS.

While we recognize that UNAIDS has been in existence for only 2-1/2 years,

we did not evaluate the program’s impact on the HIV/AIDS epidemic. In our

report, we present the facts as we found them to be, including areas

needing improvement and areas that have worked well. In fact, the report

specifically identifies UNAIDS’ accomplishments, including information on

innovative grassroots interventions. Also, we did not evaluate whether

support for UNAIDS should be continued. Our objective, as stated in the

report, was to examine the program’s progress, since its inception, in

meeting established objectives such as increasing resources devoted to

HIV/AIDS and working together in theme groups at the country level.

Page 51 GAO/NSIAD-98-202 HIV/AIDS
Appendix I 

Comments From the U.S. Agency for

International Development

Note: GAO comments

supplementing those in the

report text appear at the

end of this appendix.

Page 52 GAO/NSIAD-98-202 HIV/AIDS
Appendix I 

Comments From the U.S. Agency for

International Development

Page 53 GAO/NSIAD-98-202 HIV/AIDS
Appendix I 

Comments From the U.S. Agency for

International Development

See comment 1.

Now on p. 2.

Now on p. 6.

See comment 2.

Now on p. 29.

See p. 50.

Page 54 GAO/NSIAD-98-202 HIV/AIDS
Appendix I 

Comments From the U.S. Agency for

International Development

Now on p. 41.

Now on p. 7.

Now on pp. 8 and 43.

Page 55 GAO/NSIAD-98-202 HIV/AIDS
Appendix I 

Comments From the U.S. Agency for

International Development

Now on p. 46.

See comment 3.

Now on p. 45.

See comment 4.

Page 56 GAO/NSIAD-98-202 HIV/AIDS
Appendix I 

Comments From the U.S. Agency for

International Development

The following are GAO’s comments on the U.S. Agency for International

Development’s (USAID) letter dated June 24, 1998.

GAO Comments 1. We modified the language to note that USAID primarily uses private

voluntary organizations (PVO) to implement its programs.

2. We agree that the AIDS Control and Prevention (AIDSCAP) program in

Honduras was in existence for a short period of time before the global

AIDSCAP project ended. However, our analysis showed that the program’s

short duration was due to the difficulty it had in getting started. We

modified the report with the following information to clarify what we

found. USAID officials in Honduras said that they began negotiating with

AIDSCAP in 1993 to develop a program, but that AIDSCAP’s proposals did not

adequately emphasize participation by the government or involvement by

local non-governmental organizations (NGO). As a result, USAID did not

reach agreement with AIDSCAP until 1995, 2 years before it was scheduled

to end.

3. We modified the report to reflect efforts by the Joint United Nations

Programme on HIV/AIDS (UNAIDS).

4. We modified the report to reflect efforts by U.N. donor countries.

Page 57 GAO/NSIAD-98-202 HIV/AIDS
Appendix II 

Comments From the Department of State

Note: GAO comments

supplementing those in the

report text appear at the

end of this appendix.

Page 58 GAO/NSIAD-98-202 HIV/AIDS
Appendix II 

Comments From the Department of State

See p. 51.

See comment 1.

See comment 2.

Page 59 GAO/NSIAD-98-202 HIV/AIDS
Appendix II 

Comments From the Department of State

See p. 51.

Page 60 GAO/NSIAD-98-202 HIV/AIDS
Appendix II 

Comments From the Department of State

The following are GAO’s comments on the Department of State’s letter

dated June 25, 1998.

GAO Comments 1. Our conclusions are not based on the criticisms of U.N. officials. Rather,

we gathered data from fieldwork in five countries, from the Secretariat’s

surveys of all theme groups in 1996 and 1997, as well as from a survey of

field staff conducted by USAID that also included questions on the progress

of UNAIDS.

2. We agree that the evidence in our case studies showed that three of the

five theme groups in the countries we visited were operating effectively.

However, our conclusion was also based on the Secretariat’s overall

assessment of theme group operations. As we point out in the report,

Secretariat officials acknowledged that as of 1997 most theme groups were

not working effectively and that they underestimated the difficulty of

getting U.N. agencies to coordinate and conduct joint programming.

Moreover, the Secretariat’s 1997 survey of its theme groups indicated that

less than half of the theme groups were judged effective in cosponsor

coordination.

Page 61 GAO/NSIAD-98-202 HIV/AIDS
Appendix III 

Comments From the Department of Health

and Human Services

Page 62 GAO/NSIAD-98-202 HIV/AIDS
Appendix III 

Comments From the Department of Health

and Human Services

Page 63 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

Page 64 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

See comment 3.

See p. 50.

See comment 1.

See p. 50.

Page 65 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

See p. 50.

Page 66 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

See p. 50.

See p. 50.

See comment 2.

See comment 2.

Page 67 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

See comment 3.

See p. 50.

See comment 2.

Page 68 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

See comment 2.

See comment 2.

See comment 2.

Page 69 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

See comment 2.

Page 70 GAO/NSIAD-98-202 HIV/AIDS
Appendix IV 

Comments From the UNAIDS Secretariat

The following are GAO’s comments on UNAIDS’ letter dated June 24, 1998.

GAO Comments 1. We made a judgment that the U.N.’s progress was limited based on its

progress relative to the criteria set forth in the U.N.’s Economic and Social

Council resolution endorsing the creation of UNAIDS.

2. Because this updated information was provided subsequent to our visits

to the five countries, we could not verify it and therefore have not

included the information in the report. Although the Secretariat reports

progress since our visits, we note that its April 1998 report on a 1997

survey of theme groups indicates that, as of April 30, 1998, less than half of

the groups responding had undertaken efforts in 7 out of 10 of the key

outputs measured.

3. We modified the text to reflect this information.

Page 71 GAO/NSIAD-98-202 HIV/AIDS
Appendix V 

Major Contributors to This Report

National Security and

International Affairs

Division, Washington,

D.C.

Jess T. Ford

Lynne M. Holloway

Joan M. Slowitsky

Patrick A. Dickriede

Rolf A. Nilsson

Rona H. Mendelsohn

Office of the General

Counsel, Washington,

D.C.

Mark C. Speight

Los Angeles Field

Office

Aleta L. Hancock

Thomas W. Zingale

(711298) Page 72 GAO/NSIAD-98-202 HIV/AIDS
Ordering Information

The first copy of each GAO report and testimony is free.

Additional copies are $2 each. Orders should be sent to the

following address, accompanied by a check or money order

made out to the Superintendent of Documents, when

necessary. VISA and MasterCard credit cards are accepted, also.

Orders for 100 or more copies to be mailed to a single address

are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office

P.O. Box 37050

Washington, DC 20013

or visit:

Room 1100

700 4th St. NW (corner of 4th and G Sts. NW)

U.S. General Accounting Office

Washington, DC

Orders may also be placed by calling (202) 512-6000 

or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and

testimony. To receive facsimile copies of the daily list or any

list from the past 30 days, please call (202) 512-6000 using a

touchtone phone. A recorded menu will provide information on

how to obtain these lists.

For information on how to access GAO reports on the INTERNET,

send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov

PRINTED ON RECYCLED PAPER
United States

General Accounting Office

Washington, D.C. 20548-0001

Official Business

Penalty for Private Use $300

Address Correction Requested

Bulk Rate

Postage & Fees Paid

GAO

Permit No. G100