GAO

United States General Accounting Office

Report to the Chairman, Subcommittee 

on African Affairs, Committee on Foreign 

Relations, U.S. Senate

March 2001 GLOBAL HEALTH

U.S. Agency for 

International 

Development Fights 

AIDS in Africa, but 

Better Data Needed to 

Measure Impact

GAO-01-449

Page 1 GAO-01-449 Global Health

Contents

Letter 3

Appendixes Appendix I: Objectives, Scope, and Methodology 36

Appendix II: Contributions of USAID’s Global and Africa 

Bureaus 38

Appendix III: Comments From the U.S. Agency for International 

Development 41

Appendix IV: GAO Contact and Staff Acknowledgments 48

Tables Table 1: USAID’s Fiscal Year 2000 HIV/AIDS Funding in 23 

African Countries, in Order of Per Capita Spending 15

Table 2: Funding for USAID HIV/AIDS in Sub-Saharan Africa, 

by Mission or Regional Office for Fiscal Years 2000

and 2001 27

Figures Figure 1: The USAID Organizational Structure 7

Figure 2: The Evolution of HIV Prevalence in Africa from 

1989 to 1999 8

Figure 3: The Effect of AIDS on Life Expectancies in 13 

Sub-Saharan African Countries, 1999 10

Figure 4: Numbers of AIDS Orphans in 12 African 

Countries, 1999 12

Abbreviations

GDP Gross domestic product

HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency 

Syndrome

USAID U.S. Agency for International Development

UNAIDS Joint United Nations Programme on HIV/AIDS
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United States General Accounting Office

Washington, D.C. 20548

Letr

March 23, 2001

The Honorable Bill Frist, M.D.

Chairman, Subcommittee on African Affairs

Committee on Foreign Relations

United States Senate

Dear Mr. Chairman:

The Human Immunodeficiency Virus/Acquired Immunodeficiency 

Syndrome (HIV/AIDS) is the leading cause of death in the countries of 

sub-Saharan Africa, where more than two-thirds of the people who are 

infected with HIV live. Despite efforts by the international community to 

reduce the spread of HIV/AIDS in sub-Saharan Africa, the National 

Intelligence Council estimates1

 that as many as one-quarter of the 

population of the hardest-hit countries in that region will die from AIDS 

over the next 10 years. Further, given the scale of the epidemic, AIDS has 

grown beyond a public health problem to become a humanitarian and 

developmental crisis. For example, the National Intelligence Council 

concluded that the persistence of infectious diseases, such as HIV/AIDS, is 

likely to aggravate and in some cases provoke economic decline, social 

fragmentation, and political destabilization. In addition, the Council found 

that the epidemic threatens to weaken the military capabilities of countries 

and because of the involvement of sub-Saharan African troops in 

international peacekeeping efforts it could hinder those activities as well. 

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

provided assistance to help fight AIDS in sub-Saharan Africa.

The Agency for International Development allocated a 53-percent increase 

in funding, from $114 million to $174 million, for fiscal year 2001 to expand 

its HIV/AIDS efforts in sub-Saharan Africa.2

 This report responds to your 

1

 “The Global Infectious Disease Threat and Its Implications for the United States,” No. 

NIED 99-17 of the National Intelligence Estimates (Washington, D.C.: National Intelligence 

Council, Jan. 2000).

2

 Under the Foreign Operations Appropriations Act for Fiscal Year 2001 (P.L. 106-429), 

Congress appropriated $330 million for the U.S. Agency for International Development’s 

HIV/AIDS programs worldwide, which included $15 million earmarked for orphans and 

vulnerable children. 
Page 4 GAO-01-449 Global Health

request that we examine the agency’s current efforts to reduce the spread 

of the HIV/AIDS epidemic in sub-Saharan Africa. Specifically, we

(1) identified the development and impact of the HIV/AIDS epidemic in 

sub-Saharan Africa and the challenges to slowing its spread, (2) assessed 

the extent to which the U.S. Agency for International Development’s 

initiatives have contributed to the fight against AIDS in sub-Saharan Africa, 

and (3) identified the approach the agency used to allocate increased 

funding and the factors that may affect the agency’s ability to expand its 

HIV/AIDS program in sub-Saharan Africa. 

As part of our review, we spoke with key U.S. Agency for International 

Development officials and reviewed written responses to GAO questions 

from the 19 agency field missions and 3 regional offices in sub-Saharan 

Africa that conducted HIV/AIDS activities. To supplement this work, we 

also visited U.S. Agency for International Development missions in Malawi, 

Tanzania, Uganda, and Zimbabwe. More detailed information about our 

scope and methodology is in appendix I.

Results in Brief The AIDS epidemic has had a significant negative impact in sub-Saharan 

Africa, reducing population growth and offsetting gains from investment in 

social and economic development. Since 1993, the number of people 

infected with HIV/AIDS in sub-Saharan Africa has tripled to 25.3 million, 

and more than 17 million people have died, according to the Joint United 

Nations Programme on HIV/AIDS. Life expectancy in nine countries in the 

region is also declining dramatically. According to the U.S. Census Bureau, 

a child born in 2000 in Botswana can expect to live only 39 years. Without 

AIDS, that child would have a life expectancy of 71 years. Further, the Joint 

U.N. Programme on HIV/AIDS estimated that by the end of 1999, 

approximately 13 million children worldwide had been orphaned by AIDS, 

with 95 percent of them in Africa. While efforts have been made to stem the 

disease’s spread, the U.S. Agency for International Development and 

United Nations officials have identified several challenges that have 

hindered their ability to reduce HIV/AIDS in Africa. These challenges 

include limited funding available to combat the epidemic, social stigma and 

cultural and social customs that make it difficult to discuss traditional sex 

practices that facilitate the spread of HIV, the low socioeconomic status of 

women in sub-Saharan Africa, weak national health care systems, difficulty 

reaching African militaries with high infection rates, and the slow response 

of African leaders to recognize and address the issue. 
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The U.S. Agency for International Development has contributed to the fight 

against HIV/AIDS in sub-Saharan Africa, focusing on proven effective 

interventions such as providing information and counseling to encourage 

behavior change in high-risk groups; promoting increased condom use; and 

supporting prevention, diagnosis, and treatment of sexually transmitted 

diseases.3 Some countries have shown declines in disease prevalence 

rates,4

 which the U.S. Agency for International Development attributes in 

part to its activities. However, an overall picture of the agency’s 

contribution is difficult to determine due to several factors. Although 

agency officials informed us that the agency’s country-level missions use 

data to track day-to-day operations, the agency’s missions do not always 

use consistent indicators to measure progress in combating the disease, do 

not routinely gather comprehensive program performance data, and do not 

regularly report those data to headquarters. As a result, decisionmakers in 

the agency’s headquarters lack the information needed to measure the 

overall impact on reducing HIV transmission in the region, target the 

agency’s resources to their best possible use, and identify best practices.

The U.S. Agency for International Development has developed an approach 

for expanding its HIV/AIDS program in response to the 53-percent increase 

in funding for fiscal year 2001. This approach included new HIV/AIDS 

prevention efforts and the development of a monitoring and evaluation 

plan. However, agency officials cited several internal and external factors 

that may limit their ability to expand the program. These factors include 

limitations associated with the agency’s procurement and contracting 

processes and capacities, its reliance on weak national health care systems, 

and the unknown capabilities of indigenous nongovernmental 

organizations to conduct prevention activities. The agency has identified 

steps to help mitigate some of these factors. 

This report makes recommendations to improve how the U.S. Agency for 

International Development can measure its effectiveness in reducing HIV 

transmission in Africa through greater use of consistent performance 

indicators and data collection efforts. In written comments on a draft of 

3

 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.

4

 The prevalence rate is the percentage of the adult population that is currently infected with 

HIV.
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this report, the U.S. Agency for International Development acknowledged 

our key concern that performance indicators at the country level were 

inconsistent to measure progress over time and stated that it is taking 

action to facilitate the collection and dissemination of comparable national 

data.

Background The United States has been the largest single donor to HIV/AIDS prevention 

in developing countries, contributing over $500 million in Africa between 

fiscal year 1988 and 2000 through the U.S. Agency for International 

Development (USAID). The agency’s efforts have mainly been directed at 

specific target groups to reduce the spread of the disease through behavior 

change communication activities; promotion of increased condom use; and 

improved prevention, diagnosis, and treatment of sexually transmitted 

infections. In July 2000, USAID also began to fund other activities—such as 

treatment for tuberculosis and other opportunistic infections and care for 

AIDS orphans—aimed at mitigating the impact of the disease. 

USAID has a decentralized organizational structure (see fig. 1), which vests 

most of the authority for developing and implementing programs in the 

country offices, or missions. Four regional bureaus, such as the Africa 

Bureau, support field mission activities through the provision of technical, 

logistical, and financial assistance. The Global Bureau’s HIV/AIDS Division 

negotiates contracts, grants, and cooperative agreements with private 

voluntary organizations that missions can access for particular expertise, 

such as development of HIV/AIDS prevention communication campaigns. 

The Global Bureau also funds research that can be used to improve mission 

programs, supports the Joint United Nations Programme on HIV/AIDS 

(UNAIDS), and coordinates efforts by other U.S. government agencies, 

such as the Centers for Disease Control, to address the epidemic in 

developing countries. At the time of this review, USAID conducted 

HIV/AIDS activities at 19 missions in sub-Saharan Africa and implemented 

activities in other countries in the region from three of its regional offices.
Page 7 GAO-01-449 Global Health

Figure 1: The USAID Organizational Structure

Source: GAO based on USAID documentation.

AIDS Has Negatively 

Affected Sub-Saharan 

Africa, but Slowing the 

Epidemic Presents 

Challenges 

Throughout the 1990s HIV/AIDS prevalence continued to increase in most 

of the countries in sub-Saharan Africa (see fig. 2).5

 The increasing 

prevalence of HIV/AIDS has had a substantial impact on the region’s 

population, resulting in (1) high death rates, (2) increased infant and child 

mortality, (3) reduced life expectancy, and (4) large numbers of orphans. 

The epidemic has also offset gains from investment in social and economic 

development. Despite the efforts of USAID and international donors, 

however, several challenges to slowing the epidemic’s spread remain. 

These include social, cultural, and political issues endemic to the region.

Office of the Administrator

Deputy Administrator

Executive Secretariat

Bureau for

Global Programs

(HIV/AIDS Division)

Bureau for Africa

Bureau for Asia

and the

 Near East

Bureau for 

Latin America

and the Caribbean

Bureau for

Europe 

and Eurasia

Bureau for 

Humanitarian

Response

Field Missions

 and

Regional Offices

Field Missions

 and

Regional Offices

Field Missions

 and

Regional Offices

Field Missions

 and

Regional Offices

Field Missions

 and

Regional Offices

USAID units implementing HIV/AIDS activities in Sub-Saharan Africa.

5

 According to USAID, due to the combined efforts of donors and host governments, HIV 

prevalence rates have decreased from 12 percent to 8 percent in Uganda between 1994-1999 

and stabilized below 2 percent in Senegal between 1997-1999.
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Figure 2: The Evolution of HIV Prevalence in Africa from 1989 to 1999

Source: GAO based on UNAIDS map.

Effect of the AIDS Epidemic 

on the Population of

Sub-Saharan Africa

The most direct impact of AIDS has been to increase the overall numbers of 

deaths in affected populations. UNAIDS estimates that since 1993, the 

number of people infected with HIV/AIDS in sub-Saharan Africa has tripled 

to 25.3 million and more than 17 million people have died. According to the 

U.S. Census Bureau, estimated death rates have increased by 50 to 500 

percent in eastern and southern Africa over what they would have been 

without AIDS. For example, in Kenya the death rate is twice as high, at 14.1 

per 1,000 population, as opposed to the 6.5 per 1,000 it would have been 

without AIDS. 

1989 1999

Estimated percentage of adults

(15-49) infected with HIV

20.0% - 36.0%

10.0% - 20.0%

 5.0% - 10.0%

 < 1.0% - 5.0%

 Trend data unavailable

 Lake
Page 9 GAO-01-449 Global Health

According to the U.S. Census Bureau, infant and child mortality rates6 in 

sub-Saharan Africa are also significantly higher than they would have been 

without AIDS. For example, in Zimbabwe infant mortality without AIDS 

would have been 30 per 1,000 in 2000. With AIDS, the infant mortality rate 

in 2000 was 62 per 1,000. The Census Bureau estimates that by 2010, more 

infants in Botswana, Zimbabwe, South Africa, and Namibia will die from 

AIDS than from any other cause. Rising child mortality rates due to AIDS 

are most dramatic in countries where death from other causes, such as 

diarrhea, had been significantly reduced. For example, in South Africa, 

Census Bureau data show that 45 percent of all deaths among children 

under age 5 in 2000 were AIDS related. In Zimbabwe, 70 percent of child 

deaths in 2000 were AIDS related, and AIDS-related deaths there are 

expected to increase to 80 percent by 2010. 

According to the World Bank, one of the most disturbing long-term trends 

associated with the HIV/AIDS epidemic is reduced life expectancy. By 2010 

to 2015, life expectancy is expected to decline 17 years in nine countries in 

sub-Saharan Africa, to an average of 47 years. For example, the Census 

Bureau estimates that a child born in 2000 in Botswana can expect to live 

only 39 years. Without AIDS, that child would have a life expectancy of 

71 years. In addition, the Census Bureau estimates that life expectancy in 

Botswana will decline to 29 years by 2010, a level not seen since the 

beginning of the 20th century. This dramatic decrease in life expectancy in 

the region represents a reversal of the gains of the past 30 years. Figure 3 

shows the impact of AIDS on longevity in 13 sub-Saharan African countries.

6

 Infant mortality rates are defined as deaths of children under 1 year of age. Child mortality 

rates are defined as deaths of children under 5 years of age.
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Figure 3: The Effect of AIDS on Life Expectancies in 13 Sub-Saharan African Countries, 1999

Source: U.S. Bureau of the Census.

Also, because of AIDS, children in sub-Saharan Africa are being orphaned 

in increasingly large numbers. According to UNAIDS, by the end of 1999, 

approximately 13 million children worldwide had been orphaned by AIDS,7

with 95 percent of them in Africa. Further, according to a report prepared 

for USAID, orphans will eventually comprise up to 33 percent of the 

Botswana

Zimbabwe

South Africa

Kenya

Tanzania

Zambia

Côte d'Ivoire

Nigeria

Ethiopia

Uganda

Malawi

Rwanda

Mozambique

        	 


Life expectancy at birth (years)

With AIDS

Without AIDS

7

UNAIDS defines AIDS orphans as children who lose their mother to AIDS before reaching 

the age of 15 years.
Page 11 GAO-01-449 Global Health

population under age 15 in some African countries.8 While orphans in 

Africa have traditionally been absorbed into extended families, the advent 

of the HIV/AIDS epidemic has caused these family structures to be 

overburdened, leaving many children without adequate care. The World 

Bank notes that orphans are more likely to be malnourished and less likely 

to go to school. According to UNAIDS, orphans are frequently without the 

means to survive and therefore may turn to prostitution or other behaviors 

that heighten their risk of contracting HIV themselves. Figure 4 shows the 

numbers of AIDS orphans in 12 African countries9

 in 1999.

8

 “Children on the Brink: Strategies to Support Children Isolated by HIV/AIDS,” TVT 

Associates (Washington, D.C.).

9

 These 12 countries and India were included in the Leadership and Investment in Fighting 

an Epidemic (LIFE) initiative, which increased funding for HIV/AIDS activities in fiscal year 

2000.
Page 12 GAO-01-449 Global Health

Figure 4: Numbers of AIDS Orphans in 12 African Countries, 1999

Source: UNAIDS.

The spread of HIV/AIDS has begun to negatively affect population growth 

rates in sub-Saharan Africa. Typically, developing countries experience a 

population growth rate of 2 percent or greater, compared with much lower 

rates in developed countries. As late as 1998, the Census Bureau predicted 

that the AIDS epidemic would have no effect on population growth in 

sub-Saharan Africa because of the region’s high fertility rate. However, the 

Census Bureau now predicts that by 2003, Botswana, South Africa, and 

Zimbabwe will all be experiencing negative population growth due to high 

prevalence of HIV and the low fertility and high infant and child mortality 

rates in these three countries. By 2010, the Census Bureau estimates that 

the growth rate for these countries will be (-1) percent, the first time that 

negative population growth has been projected for developing countries. 

Population growth is expected to stagnate in at least five other countries in 

Ethiopia 1,200,000

Kenya 730,000

Malawi 390,000

Mozambique 310,000

Nigeria 1,400,000

Rwanda 270,000

Senegal 42,000

South Africa 420,000

Tanzania 1,100,000

Zambia 650,000

Zimbabwe 900,000

Uganda 1,700,000
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the region, including Lesotho, Malawi, Mozambique, Namibia, and 

Swaziland. 

Effect of AIDS Epidemic on 

Social and Economic 

Development

AIDS has had a significant effect on social and economic development in 

the region as increasing numbers of people in their most productive years 

have died. For example, according to USAID, AIDS directly affects the 

education sector as the supply of experienced teachers is reduced by 

AIDS-related illness and death. The World Bank estimates that more than 

30 percent of the teachers in Malawi and Zambia are already infected with 

HIV. According to UNAIDS, during the first 10 months of 1998 1,300 

teachers in Zambia died of AIDS—the equivalent of about 66 percent of all 

new teachers trained annually. In addition, fewer children are attending 

school. The death of a parent is a permanent loss of income that often 

requires the removal of children from school to save on educational 

expenses and to increase household labor and income.

The agriculture sector has also been affected by the epidemic. Agriculture, 

the biggest sector in most African economies, accounts for a large portion 

of economic output and employs the majority of workers. However, as 

farmers become too ill to tend their crops, agricultural production declines 

for the country. For example, according to UNAIDS, in Côte d’Ivoire, many 

cases of reduced cultivation of crops such as cotton, coffee, and cocoa 

have been reported. Likewise, in Zimbabwe, agricultural output has fallen 

by 50 percent over a 5-year period during the late 1990s, due in part to 

farmers becoming sick and dying from AIDS. 

In addition, the cost of doing business in Africa has increased in many 

sectors of the economy due to HIV/AIDS. The epidemic’s costs to 

employers include expenditures for medical care and funeral expenses. A 

1999 report prepared for USAID10 found that because of the increased 

levels of employee turnover due to HIV/AIDS, employers also are 

experiencing greater expenses due to the recruitment and training of new 

employees. According to the United Nations International Labour Office, to 

combat increased costs, some employers in sub-Saharan Africa have begun 

to hire or train two or three employees for the same position because of the 

concern that employees in key positions may get sick and die from AIDS. 

10 “Economic Impact of AIDS,” The POLICY Project of The Futures Group International 

(Mar. 16, 1999).
Page 14 GAO-01-449 Global Health

Several Challenges Have 

Hindered International 

Efforts to Slow the Spread 

of HIV/AIDS in Sub-Saharan 

Africa

While international organizations have worked to stem the spread of the 

disease, funding constraints, cultural and social traditions, the low 

socioeconomic status of women, weak health care infrastructure, difficulty 

reaching men in uniform, and the slow response of national governments 

have impeded their efforts.

Donor Spending Falls Short of 

Need

In 2000, UNAIDS estimated that at least $3 billion is needed annually for 

HIV prevention and care in sub-Saharan Africa. By contrast, according to 

USAID, international donors contributed less than 20 percent of what was 

needed in fiscal year 2000 to support HIV/AIDS activities in the region. 

USAID—which has been the largest international donor to fight HIV/AIDS 

in Africa—spent $114 million in the region in fiscal year 2000, of its total 

worldwide HIV/AIDS budget of $200 million. As shown in table 1, USAID 

efforts translated into per capita expenditures for 23 sub-Saharan African 

countries in fiscal year 2000 ranging from $0.78 in Zambia to $0.03 in the 

Democratic Republic of the Congo. 
Page 15 GAO-01-449 Global Health

Table 1: USAID’s Fiscal Year 2000 HIV/AIDS Funding in 23 African Countries, in 

Order of Per Capita Spending

N/A = Not available.

Source: USAID and UNAIDS.

Social Stigma and Traditional 

Beliefs Contribute to the Spread 

of HIV/AIDS

The social stigma surrounding issues of sex and death in African culture 

makes it difficult to discuss the risks of HIV/AIDS and measures to prevent 

the disease. A 2000 report by the Congressional Research Service11 notes 

that unwillingness by religious or community leaders to discuss condom 

Country

Total funding

(millions)

Total population

(millions)

Per capita

spending

Zambia $7.0 9.0 $0.78

Namibia 1.0 1.7 0.59

Rwanda 3.5 7.2 0.49

Malawi 5.0 10.7 0.47

Zimbabwe 5.0 11.5 0.43

Senegal 3.7 9.3 0.40

Uganda 6.9 21.2 0.33

Mozambique 5.1 19.2 0.27

Guinea 1.7 7.4 0.23

Mali 2.5 11.0 0.23

Ghana 4.0 19.7 0.20

Kenya 5.7 29.5 0.19

Tanzania 6.0 32.8 0.18

Benin 1.0 5.9 0.17

South Africa 5.7 39.8 0.14

Eritrea 0.5 3.7 0.14

Ethiopia 6.7 61.1 0.11

Angola 1.0 12.5 0.08

Nigeria 6.8 109.0 0.06

Madagascar 0.8 15.5 0.05

DRCongo 1.5 50.4 0.03

Liberia N/A 2.9 N/A

Somalia N/A 9.7 N/A

11 Raymond W. Copson,“AIDS in Africa” (Washington D.C.: the Congressional Research 

Service, June 2000).
Page 16 GAO-01-449 Global Health

use or risky behavior limits efforts to introduce condoms or HIV testing as 

ways to prevent further spread of the disease. According to UNAIDS, 

discrimination may also lead people who are infected to hide their status to 

protect themselves and their families from shame. For example, a 2000 

UNAIDS report12 stated that in 1999 in Rusinga Island, Kenya, children 

whose parents had died of AIDS would tell others that witchcraft or a curse 

had been the cause of death instead. Traditional beliefs and practices in 

sub-Saharan Africa also contribute to the spread of the disease and limit 

the effectiveness of prevention programs. For example, a common custom 

promoted by traditional healers in Zambia is for a widow to engage in 

sexual relations to “cleanse” herself of the spirit of the deceased.

Low Socioeconomic Status of 

Women Impedes Their Ability to 

Take Precautions Against 

Infection

Transmission of HIV in sub-Saharan Africa is primarily from heterosexual 

contact and, unlike other places in the world where men have higher rates 

of infection, 55 percent of people with AIDS in the region are women. 

According to UNAIDS, African girls aged 15 to 19 are approximately eight 

times more likely to be HIV positive than are boys their own age. Between 

the ages of 20 and 24, women are still three times more likely to be infected 

than men their age. These young women are usually infected by older men, 

often through coerced or forced sex, according to the Congressional 

Research Service. The higher infection rates among women are due, in 

part, to the higher vulnerability of the female reproductive tract to 

infection. However, according to UNAIDS, high infection rates are also 

caused by women’s limited ability to make informed choices to prevent the 

disease, due to their low socioeconomic status. Low levels of education for 

women in the region make it more difficult for them to find work, forcing 

them to rely on men for economic sustenance. According to USAID, laws in 

some countries, such as Kenya, do not allow women to inherit property. As 

a result, with no job skills or education, a woman may choose prostitution 

to support her children following the death of her spouse. In addition, 

because women lack economic resources of their own and may fear 

abandonment by or violence from their male partners, they have little or no 

control over how and when they have sex. According to UNAIDS, a woman 

may be fearful to ask her male partner to use a condom because he may 

interpret her actions as implying that she knows of his infidelities or that 

she has been unfaithful. 

12 “Report on the Global HIV/AIDS Epidemic” (Geneva, Switzerland: Joint United Nations 

Programme on HIV/AIDS, June 2000).
Page 17 GAO-01-449 Global Health

Weak Health Care Systems Make 

It Difficult to Stem the Epidemic

The epidemic is overwhelming the already fragile health care systems in 

sub-Saharan Africa,13 and weak health care infrastructure is a barrier to 

diagnosis, treatment, and care of the affected populations. For example, in 

many countries in the region, up to one-half of the population does not 

have access to health care. The countries of the region frequently lack 

basic commodities such as syringes as well as safe drug storage, 

laboratories, and trained clinicians. Further, according to USAID, 

mother-to-child transmission of HIV is increased by the lack of access to 

drugs that block HIV replication, while this treatment has reduced

mother-to-child transmission to less than 1 percent in developed countries. 

According to UNAIDS, AIDS patients take up a majority of the hospital 

beds in many cities, leaving non-AIDS patients without adequate care. For 

example, a 2000 World Bank report14 notes that in Côte d’Ivoire, Zambia, 

and Zimbabwe, HIV-infected patients occupy 50 to 80 percent of all beds in 

urban hospitals.

Military and Police Have Been 

Difficult to Reach With 

Prevention Efforts

According to the National Intelligence Council, HIV prevalence in African 

militaries is considerably higher than that of the general population. The 

Council estimates prevalence rates of 10 to 60 percent among military 

personnel in the region. For example, the HIV infection rate for the armed 

forces of Tanzania is estimated to be 15 to 30 percent, compared with about 

an 8 percent prevalence rate for the general population. According to 

USAID, in developing countries, military and police forces generally tend to 

be a young and highly mobile population that spends extended periods of 

time away from families and home communities. As a group, this 

population is likely to have more contact with casual sexual partners and 

commercial sex workers and engage in high-risk sexual behavior. As a 

result, the group is at increased risk of acquiring HIV/AIDS and transmitting 

it to the general population. Military and police forces have constant 

interaction with civilian populations where they are posted; therefore, they 

have been identified as an important target group for campaigns for the 

prevention and mitigation of HIV/AIDS. However, according to USAID, 

militaries have been unwilling to release detailed reports on HIV 

prevalence among troops, which has limited the ability of donor assistance 

13 In 2000, the World Health Organization ranked the overall health system performance of 

its 191 members using factors such as health expenditures per capita. Of 40 sub-Saharan 

African countries, 38 ranked between 132 and 191, in the bottom third of rankings. The 

remaining two countries, Senegal and Benin, ranked 59th and 97th, respectively.

14 Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis

(Washington, D.C.: The World Bank, 2000). 
Page 18 GAO-01-449 Global Health

groups such as USAID from working with African militaries and police 

forces.

Another factor limiting USAID in working with African military and police 

forces is a legislative restriction prohibiting assistance for training, advice, 

or financial support to foreign military and law enforcement forces.15 In 

1996, USAID’s General Counsel took the position that the restrictions do 

not prohibit participation of foreign police or military forces in USAID’s 

HIV/AIDS prevention programs if three conditions are met: (1) the 

programs for police and military forces are part of a larger public health 

initiative, and exclusion of these groups would impair achievement of the 

overall public health objectives; (2) the programs must be the same as 

those offered to the general population; and (3) neither the programs nor 

any commodities transferred under them can be readily adapted for law 

enforcement, military, or internal security functions. A USAID official in 

one country told us that the USAID legal adviser in her region requires a 

justification for each activity directed toward police or military forces and 

that this is a disincentive to pursuing such activities. Overall, we found that 

only 8 of the 19 missions reported working with the military or police 

forces. The mission in Nigeria indicated that it has provided HIV/AIDS 

prevention and impact mitigation services to military and police personnel. 

Also, the USAID missions in Ethiopia and Guinea have promoted condom 

acceptability and use among military personnel.

National Governments Have 

Been Slow to Respond

Most national governments in sub-Saharan Africa have been slow to put 

effective HIV/AIDS policies in place. According to the World Health 

Organization, many countries in sub-Saharan Africa have not developed or 

completed a national strategic plan for reducing HIV/AIDS or provided 

sufficient resources or official support for HIV prevention efforts. For 

example, until 1999, the President of Zimbabwe denied that AIDS was a 

problem, and the President of Kenya did not endorse the use of condoms as 

a prevention method. In contrast, the President of Uganda has led a 

successful campaign against AIDS in his country, which, according to the 

Director of the Office of National AIDS Policy, contributed to the decrease 

in HIV prevalence.

15 Section 660 of the Foreign Assistance Act of 1961, as amended (22 U.S.C. 2420), prohibits 

the provision of training, advice, or financial support for police, prisons, or other law 

enforcement forces, subject to the exceptions of the act’s section 660. In addition, principles 

of appropriation law generally prohibit the use of foreign assistance funds for military 

purposes. 
Page 19 GAO-01-449 Global Health

USAID Made 

Contributions but Has 

Difficulty Measuring Its 

Overall Impact on 

Reducing HIV 

Transmission

USAID has contributed to the fight against HIV/AIDS in sub-Saharan Africa, 

particularly through country-level activities, including education and 

counseling; condom promotion and distribution; and improved prevention, 

diagnosis, and treatment of sexually transmitted infections. In addition, 

USAID’s Global and Africa bureaus supported various activities in the areas 

of research, capacity building, integration of HIV/AIDS prevention activities 

into other development efforts, and advocacy for policy reform. (See app. II 

for a description of specific contributions made by the Global and Africa 

bureaus in these areas.) 

However, measuring the impact of HIV/AIDS interventions on reducing 

transmission of the virus is difficult, according to experts at Family Health 

International and the University of California Los Angeles. Overlapping 

contributions of HIV/AIDS prevention programs of national governments 

and of other donors make direct causal linkage of behavior or prevalence 

changes to USAID’s activities hard to measure. To assess its programs, 

USAID must rely on proxy measures because HIV has a long latency period, 

and limited surveillance data are available in the region. Generally 

accepted proxy measures include knowledge of HIV/AIDS and sexual 

behavior changes, such as increased condom use. However, gaps in data 

gathering and reporting, including the inconsistent use of indicators and 

the lack of a routine system for reporting program results, further limit 

USAID’s ability to measure its overall impact on reducing HIV transmission.

USAID Activities Focused 

on Three Key Interventions 

Targeted to High-Risk 

Groups

USAID has focused its HIV/AIDS prevention activities in sub-Saharan 

Africa on three interventions that have been proven to be effective in the 

global fight against the epidemic: behavior change communications, 

condom social marketing, and treatment and management of sexually 

transmitted infections. USAID missions and regional offices in sub-Saharan 

Africa targeted their HIV/AIDS prevention activities to high-risk groups, 

such as commercial sex workers and interstate truck drivers. USAID 

maintains that a targeted approach remains the best way to reduce the 

number of new infections in the general population and to allow for more 

efficient use of limited HIV/AIDS prevention funds. Because of the 

difficulty obtaining accurate information on incidence and prevalence, 

however, USAID must rely on proxy indicators to measure the impact of its 

HIV/AIDS programs.

Behavior Change 

Communications

USAID promotes behavior change through voluntary counseling and 

information campaigns to heighten awareness of the risks of contracting 
Page 20 GAO-01-449 Global Health

HIV/AIDS and spreading it to others. Specifically, these activities are to 

help motivate behavior change, heighten the appeal of health products and 

services, and decrease the stigma related to purchase and use of condoms. 

For example, the mission in Nigeria reported supporting an information 

campaign among sex workers, transport workers, and youth to increase 

condom use. In addition, the mission in Malawi supported voluntary HIV 

testing and counseling services in two cities, Lilongwe and Blantyre.

Ten USAID missions and one regional office that conducted behavior 

change communication activities reported increased knowledge and 

awareness about HIV/AIDS, to measure the effectiveness of these types of 

programs. For example, six missions and one regional office provided 

information that showed an increase in knowledge of condoms as a means 

of preventing HIV infection among people surveyed. The mission in Ghana 

reported that there was an increase in the proportion of people who knew 

that a healthy-looking person could have HIV (from 70 percent of women 

and 77 percent of men in 1993 to 75 percent and 82 percent, respectively, in 

1998) but reported no change in the proportion who were aware of 

mother-to-child transmission (82 percent of women and 85 percent of men 

in 1993; 83 percent and 85 percent, respectively, in 1998). Moreover, surveys 

conducted for the mission in Tanzania showed that, between 1994 and 

1999, the percentage of women who could name three ways to avoid 

getting HIV/AIDS increased from 11.4 percent to 24.2 percent. In the same 

country, the increase for men was from 22.6 percent to 28.6 percent. 

USAID has also attempted to measure the effectiveness of behavior change 

communication activities to help change sexual behavior. In seven 

countries where USAID undertook such prevention programs, surveys 

suggested reductions in risky sexual behavior. For example, in Senegal, 

more men and women who were surveyed reported having used a condom 

in 1999 than in 1992. More male youth surveyed reported that they were 

using condoms with their nonregular sex partners in 1998 than in 1997. The 

same sexual behavior survey of female commercial sex workers showed an 

increased use of condoms with regular clients; however, female 

commercial sex workers also reported less frequent use of condoms with 

their nonregular partners. Also in Senegal, a greater percentage of girls 

reported in 1998 that they had never had sex compared to a prior survey 

conducted in 1997. However, there was no change for boys. In Zambia, 

more sexually active women who were surveyed in 1998 reported having 

ever used a condom than in a similar survey in 1992, and in 1998, fewer 

married men in Zambia’s capital city reported having had extramarital sex 

than in a survey conducted 8 years earlier.
Page 21 GAO-01-449 Global Health

Condom Social Marketing Condom social marketing, which relies on increasing the availability, 

attractiveness, and demand for condoms through advertising and public 

promotion, is another intervention that USAID supports at the country 

level. It is well established that condoms are an effective means to prevent 

the transmission of the HIV virus during sexual contact. The challenge for 

HIV/AIDS prevention then is one of expanded acceptance, availability, and 

use by high-risk groups. USAID projects in sub-Saharan Africa encourage 

production and marketing of condoms by the private sector to ensure the 

availability of affordable, quality condoms when and where people need 

them. 

USAID uses sales of condoms marketed through its program as a measure 

of the results of its condom promotion activities. USAID missions in 15 of 

19 countries and one of three regional offices reported increased condom 

sales, with decreased sales reported in Malawi and Uganda.16 According to 

a USAID contractor, sales of condoms promoted under USAID’s program 

decreased in Malawi because of an economic downturn in that country and 

because another donor was providing free condoms. Sales in Uganda were 

affected by the introduction of a competing brand of condoms distributed 

by another donor. Between 1997 and 1999, the number of condoms sold 

more than doubled in Benin, from 2.9 million to 6.5 million, and increased 

in Zimbabwe from 2 million to 9 million. Condom sales in the Democratic 

Republic of the Congo grew more than 800 percent, from about 1 million in 

1998 to 8.4 million in 1999. The number of sales outlets carrying socially 

marketed condoms also increased in Benin, Guinea, Malawi, and 

Mozambique. In addition to male condom marketing, five missions 

conducted social marketing of female condoms. Between 1998 and 1999, 

female condom sales increased in three of the four countries for which data 

were available but decreased in Zambia.

Management of Sexually 

Transmitted Infections

Management of sexually transmitted infections through improved 

prevention, diagnosis, and treatment is another important component of 

USAID’s HIV/AIDS efforts, because the risk of HIV transmission is 

significantly higher when other infections, such as genital herpes, are 

present. USAID has continued to support standardized diagnosis and 

treatment of sexually transmitted infections. For example, in Madagascar, 

USAID’s program supported improved diagnosis and treatment by targeting 

16 USAID missions in Mali and Rwanda and the USAID East Africa and Southern Africa 

regional offices were in the process of collecting condom sales data at the time of this 

review. 
Page 22 GAO-01-449 Global Health

interventions to high-risk populations. USAID has also worked to integrate 

the teaching of how to prevent sexually transmitted infections into its 

existing reproductive health and outreach activities.

As a way to measure the impact of its activities to improve management of 

sexually transmitted infections, USAID tracks the number of people trained 

in prevention, diagnosis, and treatment in that area. Seven USAID missions 

in sub-Saharan Africa reported assisting in the expansion of services for 

management of sexually transmitted infections. For example, USAID 

reported that it worked in 10 primary health facilities in Kenya to develop 

guidelines for diagnosing symptoms typical of sexually transmitted 

infections, and to develop health worker training materials. A total of 1,112 

outreach workers and 55 health care providers were trained in sexually 

transmitted disease case management. In addition, the mission in Ghana 

stated that in 1999 it trained more than 200 medical practitioners and a total 

of 502 health care workers in public health facilities in the management of 

sexually transmitted infections. In Ghana’s police services, USAID trained 

12 health care providers to recognize symptoms of sexually transmitted 

infections, trained 65 police peer educators, and helped establish an 

HIV/Sexually Transmitted Disease Unit at the police hospital. 

Other Prevention Activities In addition to these three main prevention interventions, USAID missions 

also implemented activities in other areas. A few missions had activities 

aimed at improving the safety of blood for transfusions. In 2000, for 

example, the mission in Tanzania began collaborating with the U.S. Centers 

for Disease Control and the Tanzanian Ministry of Health to improve blood 

safety and clinical protocols. The mission in Ethiopia continued programs 

that are directed at strengthening the capacity of nongovernmental 

organizations in the region to provide HIV services, while other missions 

worked to promote community involvement in providing care to those 

persons living with HIV. 

Twelve USAID missions and two regional offices promoted host 

government advocacy for improved HIV/AIDS policy environments. Some 

missions, such as Malawi, conducted workshops with key decisionmakers 

focusing on specific policy issues such as HIV testing and drug treatment 

for AIDS patients. The mission in Ghana sought to improve policies for 

reproductive health services through advocacy and policy development. 

According to USAID, its advocacy and policy development activities in 

Ghana led to the development of a national AIDS policy, which at the time 

of our review was available for parliamentary approval. Also, the mission in 

Nigeria indicated that its advocacy work on behalf of orphans and 
Page 23 GAO-01-449 Global Health

vulnerable children led the Nigerian President to announce in 2000 his 

intention to pursue free and compulsory education for them. The mission 

in Nigeria also reported helping establish three regional networks of people 

living with HIV/AIDS that later served as the precursor for a national 

HIV/AIDS support network.

Gaps in Data Collection and 

Reporting Hinder USAID’s 

Ability to Measure Overall 

Impact on Reducing HIV 

Transmission in 

Sub-Saharan Africa

Although USAID has collected data about its HIV/AIDS activities, in 

reviewing the information we received from USAID, we found that the 

agency’s overall monitoring and evaluation efforts are weak in three areas: 

(1) missions and regional offices use inconsistent indicators to measure 

program performance, (2) data collection is sporadic, and (3) there is no 

requirement for missions and regional offices to regularly report the data 

they collect.

Inconsistent Indicators Are Used 

to Measure Outcomes

USAID’s response to our request for baseline and trend data to demonstrate 

program results showed that missions and regional offices did not use 

indicators of program outcomes that were consistent over time. Unless the 

scope of the missions’ surveys and the questions asked remained constant 

over time, comparing results would be difficult. For example, a 1994 survey 

in Ethiopia asking females to cite at least two ways to prevent HIV focused 

on females living in urban areas, whereas a 2000 survey focused on females 

nationwide. In another example, ever-use of condoms among men in 

Zimbabwe in 1999, as an indicator, did not directly relate to the proportion 

of men who in 1994 reported currently using condoms. The missions also 

did not link each prevention activity to a performance indicator, as we had 

requested, in their written responses to our questions. This made it difficult 

for us to assess the progress of the activities. For example, the mission in 

Mozambique provided training to health care and non-health care providers 

in the treatment of sexually transmitted infections but did not link specific 

performance indicators related to these activities. 

Data Collection Is Sporadic Information obtained from USAID showed that the amount and frequency 

of data collection on HIV/AIDS prevention activities varied considerably. 

Several missions had implemented activities only recently, so baselines had 

not been established or trend data were still being collected. Ten missions17

were still in the process of gathering baseline or trend data for many of 

17 The USAID missions in Benin, the Democratic Republic of the Congo, Ghana, Guinea, 

Kenya, Madagascar, Malawi, Mozambique, Uganda, and Zambia.
Page 24 GAO-01-449 Global Health

their activities. For example, although the mission in Mozambique provided 

us with baseline and trend data on condom sales and a baseline for risky 

sexual behavior, comparison data for the latter measure will not be 

available until 2001. The Democratic Republic of the Congo and 

Madagascar have conducted activities in a number of areas, such as 

treatment of sexually transmitted infections, but only provided data to us 

for condom sales. Three missions that indicated having blood safety 

programs did not provide output or outcome measures to evaluate those 

programs.

These inconsistencies in data collection hindered our ability to assess 

whether USAID’s HIV/AIDS prevention activities were meeting USAID’s 

objectives in sub-Saharan Africa. For example, we could not evaluate 2 of 

the 19 missions and two of the three regional offices with HIV/AIDS 

programs because they did not provide any data.18 Four missions only 

provided information on condom sales and distribution. Eleven missions 

and one regional office offered a much broader range of information, 

although the data provided did not directly relate to all of each program’s 

indicators or major activities, making it too difficult to evaluate fully the 

result of each activity. For example, USAID’s Mozambique mission 

provided data on condom sales and distribution but not on 

mission-supported voluntary counseling and testing activities or on stigma 

reduction efforts. 

USAID Has Few Monitoring and 

Evaluation Reporting 

Requirements

According to USAID, missions are not required to produce comprehensive 

monitoring and evaluation reports for each HIV/AIDS activity or indicator. 

Although in 1998 the Global Bureau established a repository for collecting 

and tracking performance data available to USAID organizational 

structures, including missions, there is no requirement for the missions to 

provide information to that database. Each mission provides USAID’s 

Africa Bureau with an annual Results Review and Resource Request, in 

which the mission presents some results from the previous year in order to 

justify budget requests. However, according to senior USAID officials in 

headquarters, this report is not a monitoring and evaluation tool.

According to an epidemiologist from the University of California and a 

USAID contractor specializing in HIV/AIDS evaluation, surveillance, and 

epidemiological research, regular monitoring and evaluation of HIV 

18 These missions and regional offices could not provide baseline and trend data because 

their HIV/AIDS indicators were relatively new at the time of this review.
Page 25 GAO-01-449 Global Health

prevention programs is necessary to prevent wasting resources on 

programs that do not function properly. USAID officials noted that while its 

missions use data to track day-to-day operations, the lack of a reporting 

requirement affects the agency’s ability to generalize about agency 

performance and make management and funding decisions based on the 

data. This lack also inhibits sharing best practices because the agency 

cannot compare across countries which approach may be best. Therefore, 

allocation of resources may not be optimal because the agency does not 

necessarily know which programs could benefit the most from financial 

investments. Without a reporting requirement, the agency has a limited 

ability to demonstrate the effectiveness of its programs. For example, 

USAID was unable to provide sufficient information as a basis for 

determining if it met its 1999 performance goal of reducing HIV 

transmission and impact in developing countries to meet the requirements 

of the Government Performance and Results Act of 1993.19

Internal and External 

Factors May Limit 

USAID’s Ability to 

Expand its HIV/AIDS 

Activities in 

Sub-Saharan Africa

USAID has developed a three-pronged approach for programming the

53-percent funding increase from fiscal year 2000 to fiscal year 2001 

($114 million to $174 million) for HIV/AIDS prevention in sub-Saharan 

Africa. Under this approach, USAID (1) provided additional funds to 

countries designated in need of assistance, (2) allowed missions to expand 

or implement new activities and services, and (3) developed a plan for 

expanded monitoring and evaluation of the programs. To rank countries for 

funding priorities and allocations, USAID’s approach used several criteria, 

such as HIV/AIDS prevalence in a country, and economic impacts from the 

disease. Separately, USAID identified several internal and external factors 

that may affect its ability to expand its HIV/AIDS activities. USAID has 

identified steps to mitigate some of the problems associated with these 

factors.

USAID’s Approach for 

Allocating HIV/AIDS 

Program Funding and 

Activities

USAID identified three categories of countries that are to receive expanded 

HIV/AIDS assistance based on their relative priority for action. Four “Rapid 

Scale-Up Countries” were designated as those that will receive significant 

increases in assistance for prevention, care, and support activities “to 

achieve measurable impact within 1-to-2 years.” Eleven “Intensive Focus 

19 Observations on the U.S. Agency for International Development’s Fiscal Year 1999 

Performance Report and Fiscal Years 2000 and 2001 Performance Plans 

(GAO/NSIAD-00-195R, June 2000). 
Page 26 GAO-01-449 Global Health

Countries” (including one regional program) will receive a significant 

scaling-up of prevention activities and expanded services that will provide 

care and support. USAID’s plans are to work with other donors in these two 

country categories to expand programs to cover at least

80 percent of their populations with a comprehensive package of 

prevention and care services. USAID also plans to expand the scope, 

targeted populations, and geographic coverage of current HIV/AIDS 

programs in 10 countries in the “Basic Program Countries” (including two 

regional programs).

To determine which countries to include under each category, USAID used 

a number of criteria and conducted a worldwide survey of all USAID 

missions and regional offices. The criteria included

• the relative severity of the epidemic in the country, 

• the magnitude of the epidemic in the country, 

• the impact of the epidemic on the economy and society,

• the risk of a rapid increase in HIV prevalence,

• the availability of other funding sources,

• U.S. national interests, and

• strength of host country partnerships. 

USAID planners then supplemented these criteria with the missions’ and 

regional offices’ survey responses. Factors considered were the total level 

of resources that could be effectively obligated, the rapidity for obligating 

those funds, the likely programmatic impacts, the nature of new and 

expanded activities, and the personnel constraints that might be 

encountered, among other items. Table 2 shows the amount of increased 

funding from fiscal year 2000 to fiscal year 2001, by mission and regional 

program by category of country. 
Page 27 GAO-01-449 Global Health

Table 2: Funding for USAID HIV/AIDS in Sub-Saharan Africa, by Mission or Regional 

Office for Fiscal Years 2000 and 2001

Dollars in millions

Mission/regional program

Fiscal year 2000

fundinga

Fiscal year 2001

fundingb

Percent

increasec

Rapid scale-up countries

Uganda $6.9 $13.5 95.7

Zambia 7.0 13.0 85.7

Kenya 5.7 10.5 84.2

Intensive focus countries

Nigeria 6.8 11.9 76.3

South Africa 5.7 9.5 66.7

Namibia 1.0 1.5 50.0

Rwanda 3.5 5.2 48.6

Malawi 5.0 7.3 45.0

Mozambique 5.1 6.7 31.4

Senegal 3.7 4.7 27.0

Tanzania 6.0 7.5 25.0

Ethiopia 6.7 8.2 22.4

Ghana 4.0 4.5 12.5

West Africa region 7.4 8.1 9.8

Basic program countries

Eritrea 0.5 1.5 200.0

Southern Africa region 1.5 4.0 166.7

Democratic Republic of 

Congo

1.5 3.5 133.3

Benin 1.0 2.0 97.6

Madagascar 0.8 1.5 87.5

Angola 1.0 1.5 50.0

East/southern region 1.2 1.7 41.7

Zimbabwe 5.0 6.5 30.0

Guinea 1.7 2.2 29.0

Mali 2.5 3.2 28.0

Support to field programs

Global Bureau 19.4 30.6 58.1

Africa Bureau 3.3 4.0 21.2

Totald $113.9 $174.4 53.1
Page 28 GAO-01-449 Global Health

a

 Does not include funding for vulnerable children.

b

 Includes funding for vulnerable children. The total for HIV/AIDS programs is $162.2 million, and the 

total for vulnerable children programs is $12.3 million.

c

 Percent increase based on actual, not rounded, funding levels.

d

Totals may not add due to rounding.

Source: USAID.

New and expanded activities under USAID’s scaled-up efforts will include

• prevention of HIV transmissions from mother to child;

• development of community-based programs designed to provide care to 

children affected by HIV/AIDS; 

• provisions of treatment and prevention of tuberculosis and other 

opportunistic diseases; and

• development of multisectoral programs, such as for girls’ education and 

finance for economic development efforts.

USAID’s approach for scaling-up its HIV/AIDS programs in fiscal year 2001 

included a plan for expanded monitoring and evaluation of the agency’s 

HIV/AIDS programs.20 Under the plan, USAID expects all missions 

receiving HIV/AIDS funding to collect and report data annually on HIV 

prevalence rates for 15- to 24-year-olds, and on condom usage with the last 

non-regular sexual partner. Depending on USAID activities in country, 

USAID missions may also be required to report periodically on additional 

indicators, such as total condoms sold, the percent of target populations 

requesting HIV tests, and others included in USAID’s “Handbook of 

Standard Indicators.” According to USAID, when implemented, these 

efforts will be conducted at routine intervals ranging from annual 

assessments to surveys conducted every 3 to 5 years. While the monitoring 

and evaluation plan applies to all country missions receiving HIV/AIDS 

funding, initial priority will be placed upon rapid scale-up and intensive 

focus countries. However, it is not clear when USAID plans to require the 

remaining countries to apply the standard indicators and collect and report 

the performance data. In addition, the plan does not specify to whom these 

performance data will be reported beyond the mission level or how the 

information will be used, for example, for resource allocation or 

identification of best practices.

20 The Global Bureau and the Centers for Disease Control will provide funding and technical 

expertise; missions will be expected to provide some funding to support the monitoring and 

evaluation efforts.
Page 29 GAO-01-449 Global Health

Internal Factors May Affect 

USAID’s HIV/AIDS Program 

Expansion

While USAID’s approach provides criteria for funding new USAID activities 

to reduce the spread of HIV/AIDS, USAID officials reported that a number 

of factors internal to USAID may hamper its efforts to expand HIV/AIDS 

programs in sub-Saharan Africa. These factors include problems with 

contracting and procurement, and reported declines in program and 

technical staff in both missions and headquarters. 

Contracting and Procurement 

Problems

To deliver HIV/AIDS assistance programs, USAID uses competitive 

contracts and grants, including cooperative agreements. These agreements 

are generally made between USAID and private voluntary organizations, 

not-for-profit organizations, research centers, universities, and 

international organizations. The agreements involve substantial interaction 

between USAID and the recipient organization during performance of the 

assistance programs.

USAID contracting officials reported that, on average, it takes 210 days for 

concluding cooperative agreements for the Global Bureau’s population, 

health, and nutrition activities, which include HIV/AIDS. This is one of the 

longest cycles for such agreements within the federal government. The 

officials further reported that USAID has been unable to recruit and retain 

sufficient numbers of qualified contract specialists, both in the missions 

and in Washington, and, as a result, the workload for the current specialists 

is high. For example, USAID reported that in 1998 its procurement 

personnel were responsible for $18.3 million worth of agreements per 

specialist. This was relatively higher than for procurement specialists in 

other federal agencies, such as the Departments of the Treasury and of 

Transportation ($5.3 million per specialist) and the Department of Energy 

($2.9 million per specialist). In addition, USAID reported that currently 

each specialist is responsible, on average, for 26 distinct types of 

agreements, while some contract specialists in the field are responsible for 

procurements in multiple missions and regional programs. USAID officials 

said that the agency has worked to lessen the workload burden on contract 

specialists by taking such actions as developing a vehicle that allows 

missions to contract directly with contract awardees rather than through 

USAID headquarters.

Agency officials reported that the requirement to “Buy American” is a 

second procurement issue that could affect the timing of USAID’s program 

expansion. According to USAID officials, when purchasing commodities 

for assistance programs, USIAD is required to buy those made in the United 

States. USAID officials stated that although this rule may be waived when a 
Page 30 GAO-01-449 Global Health

specific commodity required for the program can only be purchased from a 

foreign manufacturer, a waiver must be sought each time the commodity is 

purchased. According to these officials, the waiver process can take up to

4 weeks for each waiver, depending on the workload of the contracting 

specialist, the location of the office applying for the waiver, and the amount 

of the purchase. In January 2001, USAID instituted a policy to grant source 

and origin waivers for extended periods of time in emergency situations. 

For example, under this policy, USAID has approved an extended waiver 

through 2007 for HIV testing kits manufactured off shore. According to 

USAID, these kits allow for quicker test results and cost significantly less 

than those manufactured in the United States.21

Personnel Shortages Another factor USAID identified that may affect program expansion is the 

lack of sufficiently experienced personnel in missions to staff the scaled-up 

programs. From the end of fiscal year 1992 to the end of fiscal year 1999, 

total staff levels of USAID foreign service employees working overseas 

declined by 40 percent, from just over 1,080 to about 650. Between the end 

of fiscal year 1992 and the end of fiscal year 1999, the total number of 

overseas foreign service employees working in program management 

declined by 41 percent, while those working in support management (such 

as financial management and contracts) declined by almost 31 percent. 

USAID has tried to compensate for the loss of experienced personnel by 

entering into personal service contracts, particularly for support 

management positions like procurement. These contracts are short term, 

however, and officials stated that the contractors generally lack the 

experience, capabilities, and organizational knowledge of permanent 

employees.

In addition, USAID reported it lacks sufficient personnel in some missions 

with the specialized, technical skills necessary for conducting new 

activities. For example, programs designed to reduce the incidence of 

mother-to-child HIV transmissions will require professionals experienced 

in medical fields, particularly those with nursing and pharmacological 

backgrounds. USAID also reports that in developing countries, the labor 

pool from which to draw individuals with medical backgrounds is small. 

Professionals were often recruited from organizations that provided similar 

21 The applicable statute and regulations covering USAID’s waiver of the “buy American” 

requirements for pharmaceuticals (including test kits) can be found in section 604(a) of the 

Foreign Assistance Act of 1961, as amended, ADS section 312.5(a), and in 22 C.F.R. 228.
Page 31 GAO-01-449 Global Health

services—the United Nations, other multinational assistance agencies, and 

private voluntary organizations. 

External Factors May Also 

Affect USAID’s HIV/AIDS 

Program Expansion

USAID also faces external factors related to the weak health care 

infrastructure common in sub-Saharan Africa that may affect the agency’s 

ability to expand its programs. These factors include a lack of surveillance, 

response, and prevention systems; limited numbers of skilled health care 

workers; and underdeveloped pharmaceutical distribution capabilities. 

Further, the capability of local, nongovernmental organization sectors to 

expand the scope of current services and deliver new services is not 

known. 

Weak Health Care Systems The low level of health care spending as a proportion of gross domestic 

product (GDP) derived from publicly financed health care spending has 

resulted in poor health care infrastructure and could affect USAID’s efforts 

to expand and create HIV/AIDS programs. In 1999, the U.S. Armed Forces 

Medical Intelligence Center reported that, with the exception of South 

Africa, sub-Saharan governments view health care as a low national 

priority. World Health Organization data indicate that in 1995, 1.7 percent of 

total GDP in sub-Saharan Africa derived from publicly financed health care 

spending. This rate was 35 percent lower than the proportion of GDP 

derived from publicly financed health care spending for all World Health 

Organization member states and 74 percent lower than the Organization’s 

figures for publicly financed health care spending in the United States. The 

Armed Forces Medical Intelligence Center reported that as a result of the 

low levels of publicly financed health care spending, the majority of

sub-Saharan African countries have only rudimentary or no domestic 

systems for epidemiological surveillance, response, or prevention.

Few Skilled Health Care Workers Another external factor that could affect USAID’s efforts to improve care 

and treatment for people with AIDS is the low numbers of skilled health 

care workers. In a 1998 report, the World Health Organization showed that 

in the sub-Saharan African countries in which USAID maintains missions, 

the number of physicians per 100,000 people ranged from a low of 2.3 per 

100,000 people in Liberia (1997) to a high of 56.3 per 100,000 people in 

South Africa (1996).22 As a comparison, the ratio for the United States in 

22 While the report was issued in 1998, data reflect the most current information possessed 

by the Organization, some of which dated to 1994.
Page 32 GAO-01-449 Global Health

1995 was 279 physicians per 100,000 people. The number of nurses per 

100,000 people is similarly low. South Africa showed the highest ratio, with 

472 nurses per 100,000 people (1996), still less than one-half the rate of

972 per 100,000 in the United States (1996). Without adequate numbers of 

health care personnel, it will be difficult for USAID to meet its goals to 

improve care and treatment for people with AIDS.

Limited Pharmaceutical Delivery 

Capabilities

Underdeveloped pharmaceutical distribution and delivery capabilities 

could also affect USAID’s ability to provide the drugs needed for the 

prevention of mother-to-child HIV transmission and other care and 

treatment programs for opportunistic diseases. As stated in a 1999 GAO 

report, problems associated with these networks include outdated 

refrigeration units; a lack of reliable delivery trucks; and health care 

workers who have not been trained in the storage, handling, and usage of 

the pharmaceuticals.23 These factors tend to lead to low coverage rates for 

people needing the medicines, as well as high costs due to large amounts of 

wasted product.

Unknown Capacities of 

Nongovernmental Organizations

Most indigenous nongovernmental organizations currently delivering 

HIV/AIDS services in sub-Saharan Africa are small and operate solely in 

their home localities. However, missions do not routinely assess 

nongovernmental organization capacity on a countrywide basis. Therefore, 

it is unclear whether in the short term existing nongovernmental 

organizations have the capacity to expand their services either to new 

geographic areas or by increasing efforts within the presently served area. 

In addition, it is unclear whether capacity and technical expertise exist 

among nongovernmental organizations to provide new services, such as 

those for the prevention of mother-to-child transmission and other 

treatment and care. According to USAID, some of the new programmatic 

activities for this year’s increase will be directed toward helping 

nongovernmental organizations develop both technical expertise and 

managerial systems so that future year funding increases may be absorbed 

more readily.

Conclusions The AIDS epidemic in sub-Saharan Africa has grown beyond a public health 

problem to become a humanitarian and developmental crisis. USAID has 

23 Global Health: Factors Contributing to Low Vaccination Rates in Developing Countries 

(GAO/NSIAD-00-195R, Oct. 15, 1999).
Page 33 GAO-01-449 Global Health

contributed to the fight against HIV/AIDS in sub-Saharan Africa by focusing 

on interventions proven to slow the spread of the disease. However, 

USAID’s ability to measure the impact of its activities on reducing 

transmission of HIV/AIDS is limited by (1) inconsistent use of performance 

indicators, (2) sporadic data collection, and (3) lack of routine reporting of 

results to headquarters. As part of its approach for allocating the 

53-percent increase in funding ($114 million to $174 million) for HIV/AIDS 

prevention activities in sub-Saharan Africa for fiscal year 2001, USAID 

prepared a plan to expand monitoring and evaluation systems in “rapid 

scale-up” and “intensive focus countries”—countries designated as in need 

of significant increases in assistance. However, when implemented, the 

monitoring and evaluation requirements in the plan will not initially include 

all countries where USAID missions and regional offices in sub-Saharan 

Africa implement HIV/AIDS programs. Further, the plan does not specify to 

whom these data will be reported or how the information will be used. 

Failure to address these issues not only inhibits USAID’s ability to measure 

the performance of its HIV/AIDS activities but also hinders the agency’s 

decision-making regarding allocation of resources among missions and 

regional offices and limits efforts to identify best practices. 

Recommendations for 

Executive Action

To enhance USAID’s ability to measure its progress in reducing the spread 

of HIV/AIDS in sub-Saharan Africa and better target its resources, we 

recommend that the Administrator, USAID, require that all missions and 

regional offices that conduct HIV/AIDS prevention activities

• select standard indicators to measure the progress of their HIV/AIDS 

programs; 

• gather performance data, based on these indicators, for key HIV/AIDS 

activities on a regular basis; and

• report performance data to a unit, designated by the Administrator, for 

analysis.

Agency Comments We received written comments on a draft of this report from the U.S. 

Agency for International Development that are reprinted in appendix III. 

The agency acknowledged our key concern that performance indicators at 

the country level were inconsistent to measure progress over time and 

agreed that more comparable data are needed to assure better 

measurement of the overall impact of its HIV/AIDS programs. The agency 

stated that it is taking important steps, as recommended in the report, to 
Page 34 GAO-01-449 Global Health

facilitate the collection and dissemination of comparable national data. We 

modified our draft where appropriate to better reflect the agency’s 

contributions and actions it has recently taken to address some of the 

problems identified in our report. In addition, the agency also provided 

technical comments to update or clarify key information that we 

incorporated, where appropriate.

We are sending this report to appropriate congressional committees and to 

the Administrator of USAID. We will also make copies available to other 

interested parties upon request.

If you or your staff have any questions concerning this report, please call 

me at (202) 512-8979. Other GAO contact and staff acknowledgments are 

listed in appendix IV.

Sincerely yours,

Joseph A. Christoff, Director

International Affairs and Trade 
Page 35 GAO-01-449 Global Health
Page 36 GAO-01-449 Global Health

Appendix I

Objectives, Scope, and Methodology ApApenednxidxeiIs

At the request of the Chairman of the Senate Subcommittee on African 

Affairs, Committee on Foreign Relations, we examined the U.S. Agency for 

International Development’s (USAID) efforts to reduce the spread of the 

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome 

(HIV/AIDS) epidemic in sub-Saharan Africa. Specifically, we (1) identified 

the development and impact of the HIV/AIDS epidemic in sub-Saharan 

Africa and the challenges to slowing its spread, (2) assessed the extent to 

which the U.S. Agency for International Development’s initiatives have 

contributed to the fight against AIDS in sub-Saharan Africa, and 

(3) identified the approach the agency used to allocate increased funding 

and the factors that may affect the agency’s ability to expand its HIV/AIDS 

program in sub-Saharan Africa in response to this funding.

To identify the development and impact of the HIV/AIDS epidemic in 

sub-Saharan Africa and the challenges to slowing its spread, we spoke with 

senior officials from the U.S. Agency for International Development’s 

Washington, D.C., headquarters (the Global Bureau’s HIV/AIDS Division 

and the Africa Bureau), the U.S. Bureau of the Census, the Office of 

National AIDS Policy, the State Department, and the Joint United Nations 

Programme on HIV/AIDS (UNAIDS). We reviewed relevant documents and 

reports from these agencies and from the U.N. International Labour Office; 

the National Intelligence Council; the World Bank; the World Health 

Organization; summaries of papers presented at the XIII International AIDS 

Conference in Durban, South Africa, in July 2000; and articles from 

scientific journals. 

To assess the extent to which USAID initiatives have reduced HIV 

transmission in sub-Saharan Africa, we reviewed USAID program 

documents that described the agency’s objective to reduce the 

transmission and mitigate the impact of HIV/AIDS. We reviewed 

documentation from the Global Bureau’s HIV/AIDS Division that described 

the activities and accomplishments of its portfolio of HIV/AIDS programs, 

and we held discussions with key USAID officials and contractors, 

including Family Health International, Population Services International, 

TVT Associates, and the Futures Group. To assess the contributions of the 

agency’s Africa Bureau, we reviewed the Results Review and Resource 

Request for the bureau and discussed performance data with key officials. 

At the country level, we sent a list of questions about activities, 

performance indicators used, and results achieved through fiscal year 2000 

to the Africa Bureau, which distributed the questions to those missions and 

regional offices in sub-Saharan Africa that had implemented HIV/AIDS 

activities. We reviewed and consolidated the answers received from 
Appendix I

Objectives, Scope, and Methodology

Page 37 GAO-01-449 Global Health

19 USAID field missions and 3 regional offices that had HIV/AIDS activities. 

We examined program performance based on data received, which 

included results from local activity records and surveys, demographic and 

health surveys, behavioral surveillance surveys, and condom sales. We 

included country-specific information gathered from mission and regional 

Results Review and Resource Requests for fiscal year 2002, the Global 

Bureau’s HIV/AIDS Division, Population Services International, and Family 

Health International. We also contacted several missions via e-mail to 

follow up on and clarify information they provided in response to our 

questions. In addition, we supplemented our work by visiting USAID 

missions in Malawi, Tanzania, Uganda, and Zimbabwe and held discussions 

with the USAID Population, Health, and Nutrition officers to verify data 

provided in the written responses to our questions and to follow up on 

some key points. We chose these four countries to work in conjunction 

with other ongoing GAO work on disease surveillance in the region. These 

countries have some of the highest HIV/AIDS prevalence rates in the region 

and provide perspective on countries with new and established USAID 

HIV/AIDS programs. To discuss the impact of limited monitoring and 

evaluation data on USAID strategic planning, budgeting, and dissemination 

of best practices, we met with officials from USAID’s Bureau of Policy and 

Program Coordination.

To identify the process USAID used to allocate increased funding and the 

factors that may affect how quickly USAID can expand its HIV/AIDS 

programs in the region, we held discussions with officials at USAID 

headquarters in Washington from the Global Bureau’s HIV/AIDS Division, 

Africa Bureau, and the Office of Procurement. We also conducted 

interviews of mission officials based in Kenya, Malawi, Tanzania, Uganda, 

Zambia, and Zimbabwe, and personnel employed by private voluntary 

organizations providing HIV/AIDS services under cooperative agreements 

with USAID. In addition, we reviewed budgetary, personnel, and 

contracting documentation and examined mission responses to a field 

survey on implementation of HIV/AIDS fiscal year 2001 that was conducted 

by the Africa Bureau, and planning documents based upon these surveys. 

Finally, we reviewed additional information provided by USAID, foreign 

governmental health ministries, the United Nations, and other multilateral 

assistance agencies. 

We conducted our work from April 2000 through January 2001 in 

accordance with generally accepted government auditing standards.
Page 38 GAO-01-449 Global Health

Appendix II

Contributions of USAID’s Global and Africa 

Bureaus ApendxiI

In sub-Saharan Africa, USAID primarily implemented HIV/AIDS programs 

through three of its organizational structures: the Global Bureau’s 

HIV/AIDS Division, the Africa Bureau, and the field missions and regional 

offices. This appendix focuses on the key contributions of USAID’s Global 

and Africa Bureaus. The Global Bureau provided leadership in the areas of 

operations research, technical assistance, and capacity building for 

surveillance. The Africa Bureau led the effort to integrate HIV/AIDS 

activities into other sectors of country development programs. We 

discussed field mission contributions in the body of this report.

Global Bureau 

Contributions

In conducting operations research, the bureau is currently supporting 

60 ongoing studies to test solutions to problems in the areas of 

management of sexually transmitted infections, care and support services, 

and policy analysis and change. Another Global Bureau project, started in 

1995, has helped reform host government HIV/AIDS policies. For example, 

the project assisted Ethiopia in developing the regulations that established 

its National AIDS Council, which is responsible for coordinating and 

integrating HIV/AIDS initiatives. In addition, the project provided technical 

assistance, equipment, and training to the secretariats of the Addis Adaba 

Regional AIDS Council, which was formed in February 2000, and the 

Amhara Regional HIV/AIDS Task Force, formed in 1999.

The Global Bureau provided technical assistance through several 

initiatives. For example, one project, begun in 1998, provides technical 

assistance to the Global Bureau’s HIV/AIDS Division, the regional bureaus, 

and the field missions. In addition to being a resource for the expertise 

needed to design HIV/AIDS strategic objectives and plans, the project was 

initiated to monitor processes, outcomes, and impacts of HIV/AIDS 

prevention programs. To achieve this goal, the project established a 

database to aggregate and disseminate research, implementation, and 

evaluation assessment findings. Another initiative was the development of 

a handbook of standard indicators, completed in March 2000, for 

measuring and evaluating HIV/AIDS prevention activities. This handbook is 

an important step toward providing universal measurement of HIV/AIDS 

prevention programs and could be used for comparison and tracking of 

program successes worldwide.
Appendix II

Contributions of USAID’s Global and Africa 

Bureaus

Page 39 GAO-01-449 Global Health

The Global Bureau is also working in concert with the U.S. Centers for 

Disease Control to assist countries in sub-Saharan Africa develop 

appropriate HIV/AIDS surveillance guidelines; carry out research to 

address how to best measure HIV incidence,1

 and estimate national HIV 

prevalence; and provide assistance to USAID missions to develop, improve, 

and use HIV/AIDS surveillance systems. According to USAID, the improved 

national surveillance systems should be in place to allow for annual 

measurement of HIV prevalence beginning in 2001.

Africa Bureau 

Contributions 

The Africa Bureau provided technical assistance to support mission 

activities and led the effort to promote the integration of HIV/AIDS 

prevention efforts into other development activities, such as economic 

growth, democracy and governance, education, and agriculture. Because of 

the impact of HIV/AIDS on the economies of the most affected countries, 

according to Africa Bureau officials, USAID’s strategy for economic growth 

must integrate HIV/AIDS activities to reach successful results. In the same 

way, the Africa Bureau is supporting the integration of HIV/AIDS activities 

into democracy and governance programs, including human rights, 

particularly those that advocate for women. According to USAID, it is 

important to integrate HIV/AIDS activities into the education sector 

because much of the progress made in developing countries over the past 

three decades has been due to greater numbers of youth going to school. 

Agriculture and natural resource development is important, since 

sustainable agriculture is necessary for economic development, and 

HIV/AIDS is a factor that leads to decreased production as more and more 

people get sick and die. 

To help national governments understand the effects of HIV/AIDS on 

various sectors and to help missions advocate for the development of 

sector-specific responses to the epidemic, the Africa Bureau funded the 

development of a set of toolkits and briefs. For example, the AIDS toolkit 

for the Ministry of Education helps officials recognize the internal and 

external impacts of HIV/AIDS—such as higher employee absenteeism and 

reduced school enrollment—and identify appropriate action responses. 

The commercial agriculture brief indicates how AIDS affects human 

resources and agricultural operations and provides some suggestions for 

contingency planning to deal with the impact of HIV/AIDS. The toolkits 

1

 Incidence is the number of new infections.
Appendix II

Contributions of USAID’s Global and Africa 

Bureaus

Page 40 GAO-01-449 Global Health

were discussed at two regional workshops organized by the University of 

Natal as part of a USAID contract held in Durban, South Africa, in 2000. The 

first workshop on education resulted in the formation of a task force. The 

purpose of the task force was to help ministries of education in different 

countries assess the impact of HIV/AIDS and apply the toolkit. The second 

workshop was for officials from the ministries of Planning and Finance. It 

offered a forum to discuss the impact of HIV/AIDS on the economy and 

changes in the government and development strategies that may be 

necessary to meet the crisis.
Page 41 GAO-01-449 Global Health

Appendix III

Comments From the U.S. Agency for 

International Development ApendxiI

Note: GAO comments 

supplementing those in the 

report text appear at the end of 

this appendix.
Appendix III

Comments From the U.S. Agency for 

International Development

Page 42 GAO-01-449 Global Health

See comment 1.
Appendix III

Comments From the U.S. Agency for 

International Development

Page 43 GAO-01-449 Global Health

See comment 2.

See comment 3.
Appendix III

Comments From the U.S. Agency for 

International Development

Page 44 GAO-01-449 Global Health

See comment 4.
Appendix III

Comments From the U.S. Agency for 

International Development

Page 45 GAO-01-449 Global Health
Appendix III

Comments From the U.S. Agency for 

International Development

Page 46 GAO-01-449 Global Health

The following are GAO’s comments on the U.S. Agency for International 

Development’s letter dated February 23, 2001.

GAO Comments 1. USAID commented that the introduction and conclusions sections of 

the report did not reflect its accomplishments as presented in the body 

of the report. To highlight their accomplishments, USAID noted that the 

agency is the single largest donor in Uganda, Senegal, and Zambia, 

countries where the fight against AIDS has been successful. However, 

the agency fails to note that other sub-Saharan African countries, where 

USAID has HIV/AIDS programs, have not been as successful in the fight 

against AIDS. USAID acknowledges that success in countries is the 

result of the combined efforts of national governments, USAID, and 

other donors, not exclusively the work of one donor. Finally, appendix 

II of the report recognizes many of USAID’s contributions in operations 

research, technical assistance, and partnerships with other 

organizations, such as the U.S. Centers for Disease Control. 

Nonetheless, we have modified the report to describe the agency’s 

accomplishments contained in the body of the report.

2. USAID stated that the report did not fully recognize that performance 

data is collected and utilized for decision-making at both the mission 

and headquarters and for sharing lessons learned. We modified the 

report to clarify that USAID’s country-level missions use data to 

manage day-to-day operations. However, we found that inconsistent 

performance indicators and the lack of routine reporting of results to 

headquarters limits USAID’ s ability to assess its overall policies and 

approaches and thereby develop lessons learned from across all its 

missions. The UNAIDS publication cited by USAID is a summary of 

USAID supported research efforts shared with its partners. This 

document does not address our concern that USAID, based on 

information reported by its missions, develop a lessons learned 

assessment of best practices in combating AIDS that USAID 

headquarters can disseminate to all its missions. 

3. USAID commented that the report did not cite important actions it has 

taken, such as developing a handbook of standardized indicators for 

HIV/AIDS programs. This handbook was discussed in the body of the 

report and highlighted among the contributions we cited in appendix II. 

The report recognized the handbook as an important step toward 

providing universal measurement of HIV/AIDS prevention programs. 

We have made no additional changes to the report. 
Appendix III

Comments From the U.S. Agency for 

International Development

Page 47 GAO-01-449 Global Health

4. USAID commented that the report did not include some important 

steps that USAID has taken to overcome internal factors that could 

hinder HIV/AIDS program expansion. USAID provided documentary 

evidence to support its assertion that the agency has streamlined its 

procurement policies for purchasing HIV/AIDS diagnostic kits. We 

therefore modified our report to add a specific reference to USAID’s 

initiation of a policy in January 2001 that extends a waiver of the “Buy 

American Act” requirements to allow for the purchase of HIV products 

manufactured offshore.
Page 48 GAO-01-449 Global Health

Appendix IV

GAO Contact and Staff Acknowledgments ApendxiIV

GAO Contact John P. Hutton (202)-512-7773

Acknowledgments In addition to Mr. Hutton, David Bernet, Leslie Bharadwaja, Aleta Hancock, 

Lynne Holloway, Jessica Lucas, Rona Mendelsohn, and Tom Zingale made 

key contributions to this report.

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