The White House

July 19, 1999
HIV/AIDS is not someone else’s problem.

It is my problem.

HIV/AIDS is not someone else’s problem. It is my problem.

It is your problem.

For too long we have closed our eyes as a nation, hoping the truth was not so real. For many years,

we have allowed the human immunodeficiency virus to spread...at times we did not know that we

were burying people who had died from AIDS. At other times we knew, but chose to remain silent.

Now we face the danger that half of our youth will not reach adulthood. Their education will be

wasted. The economy will shrink. There will be a large number of sick people whom the healthy will

not be able to maintain. Our dreams as a people will be shattered.

South African President Thabo Mbeki

(Remarks delivered as Deputy President,

launching the South African Partnership

Against AIDS, October 1998)
TABLE OF CONTENTS

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

The Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Plan of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Background. . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Initiative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Attachment A: Trip Manifest . . . . . . . . . . . . . . . . . . . . . 29

Attachment B: Groups Visited . . . . . . . . . . . . . . . . . . . 31

Attachment C: US Government Agencies Engaged . . . 33

Attachment D: Key Reference Documents . . . . . . . . . . 35

1
SUMMARY

1. AIDS is the leading cause of death in Africa. In the next decade, 40 million children will

become orphans - by losing one or both parents to AIDS.

2. AIDS is wiping out decades of progress on a variety of development fronts,

including per capita GNP, infant mortality, and life expectancy.

3. AIDS is not just taking lives, it is threatening economies, stability, and civil society.

4. As goes Africa, so will go India, South-East Asia, and the Newly Independent

States of the former Soviet Union, and by 2005, more than 100 million people

worldwide will have been infected with HIV.

5. We know what works. Scaling up these proven interventions to meet the

magnitude of this crisis is essential.

6. Leadership and resources are desperately needed if we are to turn the tide.

3
BACKGROUND

On December 1, 1998, World AIDS Day, President Clinton highlighted the growing

global tragedy of children orphaned by AIDS in sub-Saharan Africa. At that time, he

directed Sandra Thurman, Director of the Office of National AIDS Policy, to lead a

fact-finding mission to the region and to report back to him with recommendations for

productive action. From March 27 through April 5, Director Thurman led a Presidential

Mission to Zambia, Uganda, and South Africa. Director Thurman was accompanied

by Representatives Jackson-Lee, Kilpatrick, and Lee, and senior staff from the offices

of Senators Hatch, Helms, and Kennedy, and Representative Pelosi. Also joining the

Mission was a group of community leaders from outside of government including

Mayor David Dinkins, Bishop Felton May, and William Harris.

[Attachment A: Trip Manifest] 

The goals of the trip were to:

■ investigate the extent of the AIDS crisis in sub-Saharan Africa particularly

as it relates to children orphaned by AIDS;

■ identify proven and promising interventions; and, 

■ promote leadership both at home and abroad.

I believe that if we could reach to the heart of people, we would always do better in

dealing with problems, for our mind always conjures a million excuses. We cannot

restore to [these children] all they have lost, but we can give them a future - a foster

family, enough food to eat, medical care, a chance to make the most of their lives by

helping them to stay in school.

President Clinton, World AIDS Day 1998

Information for this report was gathered from meetings with African presidents,

government ministers, donors, experts, providers, children, parents, and

community leaders. In addition, site visits were made to a wide variety of

community-based programs serving children and families affected by AIDS.

Both the meetings and the visits provided an important perspective on the

problem regarding actions taken, lessons learned, and further progress

needed. [Attachment B: Groups Visited]

5
FINDINGS

The Problem:

AIDS in sub-Saharan Africa is a plague of biblical proportions.

AIDS in sub-Saharan Africa, notes The United Nations, is the “worst infectious

disease catastrophe since the bubonic plague.” Deaths due to AIDS in the region will

soon surpass the 20 million people in Europe who died in the plague of 1347 and the

more than 20 million people worldwide who died in the influenza epidemic of 1917.

Over the next decade, AIDS will kill more people in sub-Saharan Africa than the total

number of casualties lost in all wars of the 20th century combined.

While sub-Saharan Africa accounts for only one-tenth of the global population, it

currently carries the burden of more than 80% of AIDS deaths worldwide:

■ In the past decade, 12 million people in sub-Saharan Africa have died of AIDS -

one-quarter of them children - and each day AIDS buries another 5,500 men,

women and children.

■ In 1998, AIDS was the largest killer and accounted for 1.8 million deaths in subSaharan Africa, nearly double the 1 million deaths from malaria and eight times the

209,000 deaths from tuberculosis.

■ By 2005, the daily death toll will reach 13,000 people with nearly 5 million AIDS

deaths in that year alone.

And yet, the pandemic rages on:

■ In sub-Saharan Africa, more than 22 million adults and 1 million children are

currently living with HIV.

■ Every day, 11,000 additional people are infected - one every 8 seconds.

■ Since the Administration launched this effort on World AIDS Day (December 1,

1998), more than 2.5 million people in sub-Saharan Africa have been infected with

HIV, 368,000 in South Africa alone.

■ Half of all new infections in southern Africa, and 10% of new infections worldwide,

occur in South Africa, now experiencing the fastest growing AIDS disaster.

7
HIV Prevalence Trends in Selected African Countries

Source: UNAIDS

Fragile health care systems are already buckling beneath the weight of the rapidly

growing number of people with AIDS and the growing loss of health personnel as a

result of AIDS. For example, The World Bank estimates that in Zimbabwe, Zambia, and

Cote d’Ivoire, people with AIDS already occupy 50-80% of all beds in urban hospitals.

In addition, the escalating incidence of tuberculosis (TB), the most common

opportunistic infection associated with AIDS, now accounts for between one-third and

one-half of all AIDS deaths in Africa.

AIDS in sub-Saharan Africa is stalking women and young people, shattering

families, and placing extraordinary burdens on the extended family and village

systems that have been the backbone of African child-rearing tradition.

While AIDS in sub-Saharan Africa is an equal opportunity killer, women, children, and

young people are increasingly caught in the path of this relentless pandemic.

All too often, cultural norms place women at heightened risk of HIV. In many parts of

sub-Saharan Africa, and around the world, discrimination against women begins early

and continues throughout life. Girls are far less likely to have access to education,

information, and skill training. And in turn, women are far less likely to have access to

essential health care and income generating opportunities. These realities increase

their vulnerability to both poverty and HIV.

The low status of women in sub-Saharan Africa severely restricts their power to make

informed and safe choices. As a result, more than half of all new HIV infections in subSaharan Africa are among women and 80% of the 14 million HIV-positive women of

childbearing age worldwide reside in sub-Saharan Africa.

8

Rates per 100,000
In many areas throughout the region, pregnant women have astronomically high rates

of HIV infection including 73% in Beit Bridge, Zimbabwe and 43% in Francistown,

Botswana. Nine out of every ten infants infected with HIV at birth and through

breastfeeding live in sub-Saharan Africa - with nearly 600,000 new infections each year

among babies.

There are many places throughout the region where up to one-quarter of all children are

already living with an HIV-positive parent. And in nine sub-Saharan African countries,

between one-fifth and one-third of all children will be orphaned by AIDS by the end of this

year. In human terms, the AIDS orphan emergency is causing unprecedented threats to

child welfare. This vulnerability includes decreased access to life-sustaining food,

education, health care, housing, and clothing, and increased psycho-social distress

brought on by the death of a parent, isolation, and stigma. These children are also at

extraordinary risk of physical and sexual abuse as well as child labor exploitation. And

while most of these orphans were born HIV-negative - this vulnerability leaves them at

seriously increased risk of becoming HIV infected themselves.

Tragically, the worst is yet to come. During the next decade, more than 40 million

children will be orphaned by AIDS, and this “slow burn disaster” is not expected to peak

until at least 2O3O. According to UNICEF, the AIDS pandemic in sub-Saharan Africa is

having and will continue to have a more significant impact on child survival and

maternal mortality than all other emergencies on the continent combined. Without a

doubt, AIDS has placed an entire generation of Africa’s children in jeopardy.

In 9 sub-Saharan African countries, one-fifth to one-third of all children under

the age of 15 will be orphaned by the year 2000

Source: USAID

9

Percent Children Orphaned by AIDS
AIDS is wiping out decades of progress on a host of development objectives.

After hundreds of millions of dollars of donor investment and well-documented results,

AIDS is now turning back the development clock to the 1960s. In the coming decade in

many areas of sub-Saharan Africa, infant mortality (those less than one year old) will

double and child mortality (those under age five) will triple. In addition, despite steady

advances in access to education, a rapidly increasing number of children (particularly

girls) are now dropping out of school to act as substitute labor or as caregivers for their

dying parents. Far too few are finding their way back to school. Finally, according to the

US Census Bureau, AIDS has already reduced life expectancy in Zimbabwe by 25

years and in Zambia from 56 years old to 37. In the next few years, AIDS will reduce

life expectancy in South Africa by a third, from 60 years old to 40.

Projected Under-5 Mortality Rates in 2010 for Selected African Countries

Per 1000 Births

Source: US Census Bureau

10
AIDS is not only causing unfathomable human suffering, it is jeopardizing

economic growth, political stability, and civil society in many sub-Saharan

African nations.

AIDS is a trade and investment issue. The Blueprint for a US/Africa

Partnership for the 21st Century, adopted at the US/Africa Ministerial Meeting states:

“African-US economic ties continue to grow. For example, US exports to Africa grew

more rapidly in 1998 than did US exports to most other regions and are now 45%

greater than its exports to all countries of the former Soviet Union combined. As a

source of crude oil, Africa is as important to the United States as the Persian Gulf.

On a balance of payment basis, American private investment consistently produces a

higher rate of return in Africa than in any other region.”

According to Professor Jeffrey Sachs, Director of the Harvard Institute for

International Development, “a frontal attack on AIDS in Africa may now be the single

most important strategy for economic development.” This is true because as the

Southern Africa AIDS Information Dissemination Service estimates, over the next 20

years AIDS will reduce by a fourth the economies of sub-Saharan Africa. In fact, this

AIDS related economic impact has already begun. According to the Economist, a

recent study in Namibia estimated that AIDS costs the country almost 8% of GNP in

1996 and by 2005, Kenya’s GNP will be 14.5% smaller than it would have been

without AIDS. In Tanzania, The World Bank predicts that GNP will be 15-25% lower

as a result of AIDS. The South African government estimates that AIDS costs the

country 2% of GNP each year.

AIDS has hit professionals hard in sub-Saharan Africa, particularly civil servants,

engineers, teachers, miners, and military personnel. In Malawi and Zambia, 30% of

teachers are HIV-positive, and in Zambia, 1,500 teachers died of AIDS in 1998

alone. In South Africa, 1 in 5 miners is currently infected with HIV. Uganda Railways

has already lost 5,600 employees (10% of its workforce) to AIDS and now has an

AIDS-related labor turnover rate of 15% annually. And in Zimbabwe, a major

transportation company employing 12,000 workers found that by 1996 more than

one-third were already HIV-positive. According to a World Bank study in Kigali,

Rwanda, 34% of people with post-secondary education were HIV-positive, compared

to 18% of those with primary education, and civil servants were more than three

times more likely to be HIV-positive than farmers.

Increased benefits and training costs, and the disruption to regular production due to

sick and bereavement leave, are seriously affecting both the private and public

sectors. A study in South Africa found that at current levels of benefits per employee,

the total cost of benefits would rise from 7% of salaries in 1995 to 19% by 2005 due

to AIDS. Companies like British Petroleum and Barclays Bank have stated that

they are now hiring two employees for every one skilled job, assuming that one

will die of AIDS. The Indeni Petroleum Refinery in Zambia reportedly spent more

on AIDS-related costs than it declared in profits.

11
Annual Costs of AIDS Per Employee in Various Industries

in Selected Sub-Saharan African Countries

Source: Futures Group International, USAID Policy Project, 1999.

AIDS is a security and stability issue. According to the Economist, “the estimated HIV

prevalence in the seven armies embroiled in the Congo range from 50% to 80%.” Recent

reports project that the South African military and police are also already heavily infected

by HIV. Moreover, as these troops participate in an increasing number of regional

interventions and peacekeeping operations, the pace of the epidemic is likely to

accelerate. Extremely high levels of HIV infection among senior officers could lead to

rapid turnover in those positions. In countries where the military plays a central or strong

role in government, such rapid turnover could weaken the central government’s authority.

For those countries in political transition, instability in the military and security forces

could slow or even reverse the transition process. This dynamic merits attention, not

only in Africa where the pandemic is already entrenched, but also in India and the Newly

Independent States where the pandemic is intensifying its grip.

AIDS is a crime issue. The South African Institute for Security Studies has linked the

growing number of children orphaned by AIDS to future increases in crime and civil

unrest. The assumption is that as the number of disaffected, troubled, and

undereducated young people increases, many sub-Saharan African countries may

face serious threats to their social stability. Without appropriate intervention, many of

the two million children projected to be orphaned by AIDS in South Africa alone will

raise themselves on the streets, often turning to crime, drugs, commercial sex, and

gangs to survive. This seriously affects stability and promotes the spread of HIV

among these highly vulnerable young people.

12
In Lusaka, Zambia alone, 100,000 children are estimated to be living on the streets. Most have

been orphaned by AIDS. By the year 2000, one million children in Zambia, or one out of every

three children, will be orphaned by AIDS. Hundreds and hundreds of these children spend their

nights on Cairo Road, sleeping in gutters and in trees, hoping to remain out

of the “line of fire”. Some are new to the streets, others have called it home

for years. The longer they stay, the harder they get. In an effort to survive,

too many are forced into crime, sex, and drug operations. While none would

actually “choose” this life, once they “belong to the streets” it is difficult to turn

back. Though good data are lacking, it is likely that HIV infection is

spreading like wildfire among these children. Given their grim reality, it is

amazing that as the dawn breaks, so many of them gather at the gate of the

Fountain of Hope to attend school. While this school is simply a collection of

wooden benches around outdoor blackboards, the desire to learn among

these hungry, homeless children gives us hope.

As goes Africa, so will go India, South-East Asia, and the Newly Independent

States, and by 2005, more than 100 million people worldwide will be HIV-positive.

According to current projections, by 2005, AIDS deaths in Asia will mirror those

in Africa. As the world’s most populous continent, Asia will soon come to

dominate the HIV picture accounting for one out of every four infections

worldwide by the end of the year. Already, trends suggest that Asia may

surpass Africa with the highest number of new infections.

India is increasingly at the center of the global epidemic, with more HIV infected

people than any other country in the world - an estimated 5 million. While the

current death rate remains low in comparison to sub-Saharan Africa, infection

rates are increasing rapidly and are expected to double every 14 months.

Surveillance of the disease is particularly difficult in India as cultural norms,

gender inequities, and stigma continue to drive the epidemic underground. As a

result, AIDS cases in India are thought to be under-diagnosed, and therefore,

poorly treated. By 2000, AIDS will cost India $11 billion or 5% of GNP.

According to Surgeon General Satcher, “It was only a few years ago that

epidemiologists offered projections of disease prevalence for sub-Saharan Africa

that were met with disbelief. If the present warnings go unheeded, South Asia,

South-East Asia, and, perhaps, China will follow the disastrous course of subSaharan Africa.”

13
The Newly Independent States have also registered astronomical growth in HIV

infection rates over the past few years. In the last four years alone, Eastern Europe and

Central Asia have seen six-fold increases in HIV infections. In the Russian Federation,

HIV infections have increased 27-fold between 1994-1997. And in the Ukraine, HIV

infections have increased 70-fold. Injection drug use now accounts for 80% of new

infections in the Russian Federation and the increasing number of new users signals a

growing dual epidemic of AIDS and drugs.

14

Region Epidemic Started Adults & Children Adults & Children

Living With HIV/AIDS Newly Infected

With HIV

Sub-Saharan Africa Late 70’s - Early 80’s 22,500,000 4,000,000

South & South-East Asia Late 80’s 7,260,000 1,400,000

Eastern Europe & Central Asia Early 90’s 270,000 80,000

Source: UNAIDS
The Response:

Determined leadership and sustained investment have made, and can continue to

make, an extraordinary difference and will save millions of lives.

Leadership matters. Amidst the tragedy of AIDS, there is hope. Uganda has shown

that even a country with limited resources and a low literacy level can turn the tide on

this burgeoning epidemic. President Museveni demonstrated bold leadership early in

the epidemic by making every government ministry take the problem seriously,

requiring them to develop and implement a plan to reduce AIDS stigma and HIV

transmission, and to support those who became sick. In so doing, Uganda created

an “enabling environment” for donors to assist in this effort. Over the past decade, the

US has invested $46 million (26% of the donor contributions to AIDS in Uganda) in

partnership with the Ugandan government, other donors, and non-governmental

organizations (NGOs) to provide HIV prevention, care and support. As a result, HIV

rates in urban Uganda have been cut in half.

Effective solutions for children orphaned by AIDS are community-based and

multi-sectoral. Families and communities not only bear the brunt of the impact of

AIDS, they form the frontline of an effective response. In the long-standing African

tradition, communities across the continent are searching for creative ways to support

the village in its efforts to raise its children. Unfortunately, the growing number of

young deaths and orphaned children is beginning to overwhelm many of these small

villages. Nevertheless, when residents are brought together to organize in the face of

seemingly insurmountable odds. These community partnerships are making the

difference by helping to strengthen the capacity of those on the frontline to cope with

this ever unfolding crisis.

Through village banks and micro-finance programs, women are receiving loans,

starting small businesses, and with increased household incomes, are taking in

children orphaned by AIDS. With support, communities are mobilizing to deal with

school fees, food assistance, counseling, material support, immunizations and basic

healthcare, and the range of other services orphaned and other vulnerable children

desperately need.

These efforts are low cost strategies designed to empower women (many of whom

are HIV-positive), protect children, and support extended families and communities in

caring for their own. Community mobilization and micro-finance programs are

affordable, mutually reinforcing ways to build the capacity of families and communities

to cope with the impact of AIDS. This approach is universally preferred to the use of

orphanages, a solution that can never keep pace with this burgeoning pandemic. For

a small fraction of the cost of one orphanage bed, many more vulnerable children can

receive care in a family setting. The problem is, only a very tiny fraction of those

children in need actually receive even this modest level of support.

15
Bernadette Nakayima is a remarkable woman from a small village called

Kyahusome outside of Maskaka, Uganda. Bernadette has lost 10 of her 11 adult

children to AIDS. Today, at age 70, she is caring for her 35 grandchildren. With loans

from a village banking system, she has begun growing sweet potatoes, beans, and

maize, raising goats and pigs, and trading in fish, sugar, and cooking oil. With the

money she earns, she is now able to send 15 of her grandchildren to school, provide

modest treatment for the 5 who are now HIV-positive, and begin construction on a

house big enough to sleep them all. In her spare

time, she participates in an organization called

“United Women’s Effort to Save Orphans” - founded

by the First Lady of Uganda, Janet Museveni -

linking in solidarity thousands of women allied in this

same great struggle.

A focus on children orphaned by AIDS can and

should be a catalyst for a more comprehensive

fight against AIDS. It is almost impossible to

consider the issues surrounding the care and

protection of children orphaned by AIDS without also

considering HIV prevention and AIDS treatment. It is

certainly true that the only way to slow the number

of children orphaned by AIDS is to reduce the

transmission of HIV infection among parents and

prospective parents. Yet today, young people under the age of 25 represent at least

60% of all new infections in sub-Saharan Africa. Until there is an available vaccine,

more aggressive prevention efforts, particularly programs targeted to youth, are

essential to stem this rising tide of devastation.

Community action to save orphans can help to facilitate effective prevention efforts by

reducing stigma, denial, and fatalism in the face of AIDS. Planning for children

orphaned by AIDS brings home the very real consequences of HIV - death and

orphanhood. These grim realities are all too often denied due to the “conspiracy of

silence” that surrounds this illness and its long latency period. But this is a matter of life

and death and more. Once denial fades, community mobilization enables those

involved to believe that they can change their circumstances for the better. This sense

of possibility is a powerful behavior change tool.

16
Preventing Mother-to-Child Transmission

Ten percent of all new HIV infections in Africa occur

through mother-to-child transmission, with nearly

600,000 infants becoming infected per year. In Africa

today, for every ten children born to HIV-positive

mothers, two become infected during delivery and one

becomes infected through breastfeeding.

Developing methods to reduce mother-to-child

transmission of HIV that are feasible in Africa is a high

priority. For the past three years, multiple studies

have been initiated to find proven interventions that

could be workable in poor countries. In February

1998, data from the first of these studies were

released from Thailand, which demonstrated that a

short course of AZT (Zidovidene) could reduce

mother-to-infant HIV transmission by nearly 40% in

non-breastfeeding infants. Even more recently, on

July 14, 1999, the National Institutes of Health

announced a joint Uganda-US study breakthrough

identifying a low cost drug, nevirapine (NVP) that can

reduce mother-to-child transmission of HIV at birth by

an additional 50% as compared to the short course of

AZT regimen. These drug regimens are far simpler

and less expensive than the antiretroviral regimens

used in the United States, and potentially just as

effective. These new interventions will give pregnant

women an incentive to seek HIV testing and

counseling, and if infected, to receive treatment

where it is available.

These new developments are extremely encouraging

and provide hope for being able to save the lives of

hundreds of thousands of babies a year - most of

whom will live in sub-Saharan Africa. However, a host

of additional issues needs to be explored and

addressed before this knowledge can be effectively

translated into productive action. For example, to

receive maximum benefit from AZT and perhaps NVP,

mothers should not breastfeed. In many areas of subSaharan Africa, infant formula is unaffordable and

lack of clean water often makes it unworkable. In

some cases, babies are as likely to die from diarrhea

resulting from incorrect use of formula as they are

from AIDS.

The lack of health care infrastructure is also a serious

issue. At least 95% of pregnant women do not know

they are HIV-positive and currently lack access to the

testing and counseling services needed to find out. In

many areas, most women deliver their children with

the assistance of midwives in their homes, or in

makeshift clinics currently unequipped for complex

interventions. In the poorest parts of Africa, nearly

80% of women lack access to any kind of health care

at all. Further, the stigma of AIDS is often so great

that fear of discrimination, violence and abandonment

dramatically restrict the ability of women to make safe

choices. In cultures where breastfeeding is the norm,

women who choose not to breastfeed are assumed to

be HIV-positive, often with dire consequences.

Recently, an HIV-positive woman in South Africa went

public with her status and was stoned to death by her

neighbors. Countless other women and children have

been left destitute after their husbands discovered, or

decided, they were HIV-positive. These technical and

ethical challenges deserve our immediate and urgent

attention, so that the promise of these exciting new

technologies can become a reality for as many

women and children as possible.

17
18

Helping keep parents alive assures a better future for their children.

The number of children being orphaned by AIDS in Africa is staggering, and

those children orphaned are at greater social, economic and health risk than

their non-orphaned peers. Parents, guardians, and extended families are

best able to provide the nurturing environment for these children. Basic care

and psycho-social support can make a huge difference. The delivery of low

cost treatments for opportunistic infections (especially TB), and the provision

of psycho-social support, helps people with HIV and AIDS live longer and

better lives, and enables them to plan for the future of their children. In

addition, the availability of care and support gives increased credibility to

prevention efforts by demonstrating the merits of pursuing HIV testing and

counseling.

Ultimately, it is important to remember that children and families caught in

the crossfire of this epidemic do not segment their lives into pieces that

follow programmatic or budgetary line items. Therefore, the more holistic and

integrated the approach to this complex problem - the more effective the

result.

The Challenge:

It’s time to bring effective interventions to scale. We know what works.

Unfortunately, these proven interventions currently fail to reach the

overwhelming majority of those in need. Successful small scale efforts must

be dramatically expanded. While the magnitude of the global AIDS pandemic

is far too extensive for any donor, host government, or multilateral institution

to ignore, it is also too great for any single entity to address adequately by

itself. To make a real difference, an effective response must mobilize and

coordinate the commitment and resources of the full range of key

stakeholders, including governments, bi-lateral and multi-lateral development

bodies, international organizations, religious networks, the private sector,

NGOs, families and communities, and people living with HIV/AIDS. AIDS is

everyone’s problem and everyone must be a part of the solution.
19

These are the faces of children and families living in a world with AIDS. Their spirit, their

determination, and their resilience inspire all of us to join the fight. We are one world, and these

children are our children. Their destiny is our destiny. Each of us can make a difference. Each of us

can help save lives. Let us wage this holy war together. And for the sake of our children, we will win.

Archbishop Desmond Tutu
21

PLAN OF ACTION

The Background:

Throughout the Mission’s travel in Africa, it was clear that President Clinton’s “Partnership

with Africa” is making hope a reality, even at the village level. From Kampala to Cape

Town, people across Africa know of this historic initiative. Unfortunately, AIDS threatens to

decimate the progress of this partnership and everything else in its path. To protect and

defend the legacy of growth and opportunity we have built with Africa, and the children

and families who depend on it, an aggressive AIDS initiative, involving concrete action

both at home and abroad, is essential.

Given the magnitude of the AIDS pandemic and its devastating impact on child survival,

economic development, trade, regional stability, and civil society in Africa today, and in

India tomorrow, the President established a Global AIDS Emergency Working Group.

Included were the National Security Council, Office of Management and Budget, Office of

the Vice President, USAID, and the Departments of Defense, State, Treasury, Commerce,

and HHS. The Office of National AIDS Policy coordinated this effort, and together the

Working Group and the members of the Presidential Mission made specific

recommendations. These recommendations form the basis of the Plan of Action now put

forward by the Administration.

The Goals:

UNAIDS, in cooperation with its bi-lateral and multi-lateral partners, has laid out a

series of goals for the next five years as described below. The Administration seeks to

further these goals through an initiative entitled “Joining Forces for LIFE: Leadership

and Investment in Fighting an Epidemic.”

■ The incidence of HIV infection will be reduced by 25% among 15-24 year olds by

2005. (Currently 2 million young adults are infected each year in sub-Saharan Africa.)

■ At least 75% of HIV infected persons will have access to basic care and support

services at the home and community levels, including drugs for common opportunistic

infections (TB, pneumonia, and diarrhea). (Currently, less than 1% of HIV infected

persons have such access.)

■ Orphans will have access to education and food on an equal basis with their nonorphaned peers.

■ By 2001, domestic and external resources available for HIV/AIDS efforts in Africa will

have doubled to $300 million per year. (Currently, approximately $150 million per year

is spent on HIV/AIDS prevention in sub-Saharan Africa.)
22

■ By 2005, 50% of HIV infected pregnant women will have access to

interventions to reduce mother-to-child HIV transmission. (Currently, less

than 1% of HIV infected pregnant women have access to such services in

sub-Saharan Africa.)

The Initiative:

I. Increasing the US Government investment in the global battle against AIDS to

begin to reflect the magnitude of this rapidly escalating pandemic

Making a difference in Africa and in other highly impacted areas requires

broader political commitment, enhanced community mobilization, and, most

urgently, increased resources. In 1998, spending on AIDS in Africa totaled

only $165 million. Compared to the ever-escalating need and other health

programs, this amount is woefully inadequate. For example, in 1998, over

$500 million was spent for basic childhood immunization programs in Africa.

Based on our experience in those countries that are starting to demonstrate

success, such as Uganda and Senegal, UNAIDS and donors now agree that a

minimum of $600 million is needed in sub-Saharan Africa per year for HIV

prevention alone ($2 per adult per year).

While we acknowledge the leadership role that the US plays globally and

the urgent need to act, clearly an effort to combat AIDS must be driven by

many actors including host countries, multi-lateral organizations, and bilateral donors, to be successful. In FY1999, the US Government spent $74

million in USAID prevention and care in Africa and $38 million in HHS

research and surveillance/prevention. But more remains to be done in subSaharan Africa and in other seriously affected parts of the world.

Joining Forces for LIFE:

LEADERSHIP AND INVESTMENT IN FIGHTING AN EPIDEMIC

A Global AIDS Initiative
23

The Administration proposes to commit an additional $100 million in FY2000 to the

global battle against AIDS. This initiative will enable us to move forward on four

critically important and interconnected fronts including:

■ Containing the AIDS Pandemic ($48 million) Implement a variety of prevention

and stigma reduction strategies, especially for women and youth, including: HIV

education, engagement of political, religious, and other leaders; voluntary

counseling and testing; interventions to reduce mother-to-child transmission

(MTCT); and enhance training and technical assistance efforts, including

Department of Defense efforts with African militaries.

■ Providing Home and Community-Based Care ($23 million) Deliver counseling,

support, and palliative and basic medical care including treatment for sexually

transmitted diseases, opportunistic infections (OIs), and tuberculosis (TB) through

community-based clinics and home-based care workers. Enhance training and

technical assistance efforts.

■ Caring for Children Orphaned by AIDS ($10 million) Assist families, extended

families, and communities in caring for their children through nutritional assistance,

education, training, health, and counseling support, in coordination with microfinance programs.

■ Strengthening Prevention and Treatment by Augmenting Planning,

Infrastructure, and Capacity Development ($19 million) Strengthen host country

ability to plan and implement effective interventions. Strengthen the capacity for

effective partnerships and the ability of community-based organizations to deliver

essential services. Strengthen surveillance systems to track the epidemic and

target HIV/AIDS programs.

This US Government assistance would be provided through USAID ($55 million), HHS

($35 million), and DoD ($10 million). The focus of this funding is HIV prevention, and

AIDS care and treatment. In those areas, this initiative represents nearly a doubling of

funding in Africa from current levels ($81 million in FY99, which excludes research). The

Administration recognizes the fight against AIDS must be sustained to keep pace with

this burgeoning epidemic, and is committed to a multi-year effort in this critical area.
24

II. Building partnerships with other key stakeholders to maximize our impact

on the rapidly expanding pandemic 

Increasing US investment in the global battle against AIDS is critical, but is not

sufficient to achieve the outcomes needed. The commitment of in-country political

leaders and of various segments of civil society are key to success. Moreover,

resources provided by the US Government need to help leverage, and to be

coordinated with those of other donors, the private sector, and national

governments to ensure synergy and to maximize impact. Building partnerships

with key stakeholders in support of effective action at the community level is our

greatest hope for progress.

This initiative will pursue a variety of strategic opportunities for challenging

other partners to join in an enhanced effort, including:

■ Leadership Meeting On September 7, 1999, First Lady Hillary Rodham

Clinton will convene a meeting of key US officials, The World Bank, UNAIDS,

as well as heads of foundations, corporate CEOs, and others to discuss how

best to enhance AIDS prevention and treatment efforts in Africa and around

the world. The meeting will focus not only on leveraging additional resources,

but also on establishing priorities, identifying effective public/private

partnerships, and identifying targets for action to combat the crisis of

HIV/AIDS.

■ African Leaders Summit We propose hosting a high-level meeting with

Africa government and community leaders within the next ten months. This

meeting will highlight the critical role of leadership in arresting the epidemic

and will work to encourage increased leadership efforts. Topics will include

the economic impact of HIV/AIDS, examination of models of success in

reducing the transmission of HIV, and addressing the need for increased

investment in health programs. Additional topics will include AIDS care and

treatment and support for children orphaned by AIDS.

■ UN Conference on Children Orphaned by AIDS On December 1, 1999

(World AIDS Day), the United Nations in conjunction with the National Black

Leadership Commission on AIDS, The White House Office of National AIDS

Policy, The Magic Johnson Foundation and a variety of NGOs, will organize a

conference to focus attention on the growing number of children orphaned by

AIDS worldwide. Special emphasis will be placed on assessing the needs of

orphaned children in sub-Saharan Africa and the Americas. Participants will

include noted experts on the priority issues identified by UNAIDS, UNICEF, and

other UN agencies.
25

■ Business The Department of Commerce will facilitate a meeting of business leaders

active in Africa to encourage them to increase their efforts to rise to the AIDS

challenge. Given the impact that AIDS is having on businesses as well as the overall

economic-impact on African countries, such a meeting will seek enhanced business

commitment and involvement in AIDS programs.

The Commerce Department will work with American Chambers of Commerce

abroad and other business organizations to publicize the successful AIDS

efforts of US firms in Africa and to support others taking similar action. In

addition, the Department will direct work to promote closer coordination in

Africa between Commercial Service Offices, other USG agencies, the business

community, and African NGOs in a united effort to promote corporate

partnership in AIDS programs.

■ Labor The Secretary of Labor will facilitate a meeting of US and African labor

leaders, which will be co-chaired by the AFL-CIO. The success of the AFL-CIO

and its Solidarity Center in South Africa (supported by USAID) in working with the

South African Trade Union Federations to include AIDS as a key labor outreach

and policy issue provides a model for similar action elsewhere. Outcomes include

assisting labor organizations in educating their members and securing

commitments to develop workplace-based AIDS education and prevention

programs, including outreach to youth.

■ Religious Leaders Summit The US government will facilitate a meeting of

African, American, and other religious leaders to discuss the important role of

communities of faith in the fight against AIDS. In Uganda and Senegal, the

involvement of religious communities and leaders had a dramatic impact on the

ability of these two countries to reduce HIV incidence and to maintain it at low

levels over time. The outcome of such a meeting would be to increase attention to

the need for involving religious communities, to mobilize these organizations and

leaders in the fight against AIDS, and to identify ways to support their efforts.

■ Diplomatic Initiatives The Department of State, National Security Council, and

ONAP will work with US and African ambassadors to increase attention to AIDS

within the diplomatic community. The NSC, the Department of State, and USAID

will work with G-8 and other donors, and challenge them to match the increased

investment put forward in this initiative.
27

CONCLUSION

Nelson Mandela, in accepting the Congressional Medal of Honor, said:

“Though the challenges of the present time for our country, our continent and

the world are greater than those we have already overcome, we face the

future with confidence. We do so because despite the difficulties and the

tensions that confront us, there is in all of us the capacity to touch one

another’s hearts across oceans and continents.”

We are living in wartime and the stakes are high. Tragically, we know the severity

of the horror that lies ahead. Fortunately, we also know a great deal about what

can be done to protect children and to support families and communities in their

battle against AIDS. Across Africa, valiant efforts are being made to stem the

rising tide of HIV infection, to prolong the lives of those who are sick and to stitch

together a tapestry of family or family-like support systems for the growing millions

of children orphaned by AIDS. Partnerships between our government and other

donors, host governments, non-governmental organizations, consumer groups,

and communities are generating hope and demonstrating promising results.

But the battle against AIDS has just begun, and the worst is yet to come. We

need to continue to promote and reward leadership, and to remove barriers that

impede a cooperative multi-sectoral response. We need to expand our vision, our

capacity, and our resource base - in the face of an ever expanding nightmare that

just won’t take no for an answer. Living in wartime means pushing forward on

several fronts at the same time.

As we seek to keep pace and even gain ground, the magnitude of this challenge

looms large. Nevertheless, the faces of the children and families crying out for

our help beckon us all to find ways to do better, to be smarter, to move faster,

and to develop whatever capacity and partnerships we lack, as we gear up for

the long haul.
29

ATTACHMENT A

Trip Manifest

PRESIDENTIAL MISSION TO AFRICA

MARCH 27 - APRIL 5, 1999

MEMBERS OF CONGRESS

Representative Carolyn Kilpatrick

Foreign Operations Subcommittee, Appropriations,

and Congressional Black Caucus

Representative Barbara Lee

Africa Subcommittee, International Relations, and

Congressional Black Caucus

Representative Sheila Jackson Lee

Founder and Chair, Congressional Children’s Caucus,

and Congressional Black Caucus

CONGRESSIONAL STAFF

Bruce Artim, Health Staff, Senator Hatch

Mary Lynn Qurnell, Legislative Assistant, Senator Helms

Stephanie Robinson, General Counsel, Senator Kennedy

Carolyn Bartholomew, Legislative Director, 

Representative Pelosi, Minority Staff, Foreign Operations

Subcommittee, Appropriations

NON-GOVERNMENTAL PARTICIPANTS

William Harris, President,

Children’s Education and Research Institute

Bishop Felton May, General Board of Global Ministries, 

United Methodist Church

David Dinkins, Chair, Black Leadership Commission on AIDS

Dr. Jacob Gayle, UNAIDS Technical Advisor and Liaison to The World Bank

Rory Kennedy, Documentary filmmaker, Moxie Films

Nick Doob, Documentary filmmaker, Moxie Films

ADMINISTRATION OFFICIALS

Sandra L. Thurman, Director, Office of National AIDS Policy

Michael Iskowitz, Consultant, USAID

Dr. Paul DeLay, Director, HIV/AIDS Programs, USAID

Maria Sotiropoulos, Protocol Officer, State Department

Phil Drouin, Desk Officer, Bureau of African Affairs, State Department
31

ATTACHMENT B

Groups Visited

Zambia

Uganda

Community Organizations

Bwanfanon 

CHIN

Christian Council of Zambia

Evangelical Fellowship of Zambia

Family Health Trust

Fountain of Hope

McKinney Islamic Center

Mulenga Compound

National AIDS Network

Ndeke House

Project Concern International

Society of Women Against HIV/AIDS

St. Anthony’s Compound 

Twapia Windows Group

AIDS Development Foundation

AIDS Information Center 

The AIDS Support Organization (TASO)

Foundation for International Community Assistance

(FINCA)

Joint Clinical Research Centre

Makerere University

National Community of Women Living with AIDS

Save the Children (UK)

Uganda AIDS Commission

Uganda Cancer Institute

Uganda Virus Research Institute

United Women’s Effort to Save Orphans

Government Officials

President Jacob Titus Chiluba

Dr. Nkandu Luao, Minister of Health

Peter McDermott, UNICEF Country

Representative

Vincent Malambo, Minister of Legal Affairs

Edith Z. Nawakwi, Minister of Finance

and Economic Development

Abel Chambeshi, Minister of Youth,

Sports and Child Health

Keli Walubita, Minister of Foreign Affairs

Dawson Lupunga,

Minister of Community Development

Dr. Moses Sichone,

HIV/AIDS Coordinator, GRZ

GRZ public-private orphan task force

Ambassador Arlene Render

President Yoweri Kaguta Museveni

First Lady Janet Museveni

Dr. Crispus Kiyonga, Minister of Health

Hajat Janat Mukwaya, Minister of Gender,

Labor and Development

Dr. Elizabeth Madraa, AIDS/STD Control

Program, Ministry of Health

Rafina Ochago, Commissioner for Child Care

and Protection, Ministry of Gender, Labor and

Development

Ambassador Nancy J. Powell

Nkosa Zana Zuma, Minister of Health

GJ Fraser-Moleketi, Minister of Welfare and

Population Development

Dr. Ben S. Ngubane, Premier, KZN

Dr. Zweli Mkhize, Minister of Health, KZN

Siphiwe Gwala, Mayor, KZN

Ambassador James Joseph 

Bethesda House

CINDI Coalition (Children in Distress)

Don McKenzie TB Hospital

Edendale Hospital

Edith Benson Babies Home

Ethembeni Centre

Grey’s Hospital

Highway Hospice

Hope Worldwide-Jabavu Clinic

King Edward Hospital

Lilly of the Valley 

Makaphuthu Children’s Home

Project Gateway

Streetwise Shelter

South Africa 
ATTACHMENT C

US Government Agenices Engaged

Office of National AIDS Policy, The White House

Sandra Thurman, Director

Todd Summers, Deputy Director

(202) 456-2437 

Web: www.whitehouse.gov/ONAP

U.S. Department of State

Frank Loy, Under Secretary for Global Affairs

(202) 647-6240 

Web: www.state.gov

Bureau of Oceans and International Environmental and Scientific Affairs — 

Emerging Infectious Diseases and HIV/AIDS Program 

Nancy Carter-Foster, Director

(202) 647-2435 

Web: www.state.gov/www/global/oes/health

U.S. Agency for International Development

Web: www.info.usaid.gov

Bureau for Global Programs,

Field Support and Research — Center for Population, Health and Nutrition 

Duff Gillespie, Deputy Assistant Administrator

(202) 712-4120

HIV/AIDS Division 

Paul DeLay, Division Chief

(202) 712-0683

Bureau for Africa, Office of Sustainable Development, Human Resources Division

Alex Ross, Deputy Chief

(202) 219-0476

U.S. Information Agency

Joseph D. Duffey, Director

(202) 619-4742 

Web: www.usia.gov

U.S. Peace Corps

Center for Field Assistance and Applied Research 

(202) 692-2666 

U.S. Department of Health and Human Services 

Secretary Donna Shalala

Web: www.os.dhhs.gov

David Satcher, Surgeon General and Assistant Secretary for Public Health and Science

(202) 690-7694 

(301) 443-4000 

Office of HIV/AIDS Policy 

Eric Goosby, Director

(202) 690-5560

Office of International and Refugee Health 

Tom Novotny, Deputy Assistant Secretary for Health

(301) 443-1774

33
National Institutes of Health 

Harold Varmus, Director

Web: www.nih.gov

Office of AIDS Research 

Neal Nathanson, Director

(301) 496-0357 

Web: www.nih.gov/od/oar

Centers for Disease Control and Prevention

Jeffrey P. Koplan, Director

(404) 639-7000 

Web: www.cdc.gov

Office of Global Health 

Steve Blount, Director

(404) 488-1085

National Center for HIV, Sexually Transmitted Diseases,

and Tuberculosis Prevention 

Helene D. Gayle, Director

(404) 639-8000

National Center for Infectious Diseases 

Director James M. Hughes 

(404) 639-3401

Food and Drug Administration 

Office of Special Health Issues 

Terry Toigo, Associate Commissioner

(301) 827-4460

Email: ttoigo@oc.fda.gov

Office of International Affairs 

Walter Batts, Director

(301) 827-4480

Email: wbatts@oc.fda.gov

U.S. Department of Commerce 

William Daley, Secretary

Web: www.doc.gov

Bureau of the Census - International Programs Center 

Peter O. Way, Chief

(301) 457-1390 

Health Studies Branch 

Karen A. Stanecki, Chief

(301) 457-1406 

International Trade Administration 

Michael J. Copps, Assistant Secretary for Trade Development

(202) 482-1461 

U.S. Department of Defense 

Office of the Deputy Assistant Secretary for Clinical and Program Policy 

Lynn Pahland, Director of Health Promotion/ Health Affairs

(703) 681-1703

Walter Reed Army Institute of Research 

Division of Preventive Medicine 

Lt. Col. Patrick Kelley 

(202) 782-1353 

34
ATTACHMENT D

Key Reference Documents

AIDS Epidemic Update. UNAIDS, December 1998.

AIDS in the World, vol. 1 and 2. Jonathan Mann, Daniel Tarantola, and Thomas Netter, ed.

1992 and 1995.

Blueprint for a US/Africa Partnership for the 21st Century. Adopted at the US/Africa Ministerial

Meeting, March 1999.

Children on the Brink: Strategies to support children isolated by HIV/AIDS. Susan Hunter and

John Williamson. USAID, 1998.

Confronting AIDS: Public Priorities in a Global Epidemic. The World Bank, 1997.

The Economic Impact of AIDS in Africa, An Overview. The Futures Group International for

USAID, March 1999.

The Economist, January 2, 1999.

Public Health as Part of the Strategy of African Economic Growth. Prof. Jeffrey Sachs,

Harvard Institute for International Development, March 10, 1999.

Recent HIV Seroprevalence Levels by Country. Research Note No. 26. US Bureau of the

Census, February 1999.

Regional Overview of AIDS in Africa. Family Health International for USAID, March 15, 1999.

UNAIDS Fact Sheet: AIDS in Africa. November 30, 1998.

USAID funding statistics. USAID. 1999.

World Population Profile, 1998, Special Chapter: Focusing on HIV/AIDS in the Developing

World. US Bureau of the Census.

35