COMMISSION OF THE EUROPEAN COMMUNITIES 
Brussels, 03.07.1998 
COM(1998) 407 final 
COMMUNICATION FROM THE COMMISSION 
TO THE COUNCIL AND THE EUROPEAN PARLIAMENT 
FOR INCREASED SOLIDARITY TO CONFRONT AIDS IN DEVELOPING 
COUNTRIES 

DOCUMENT MOTIVATION 
This document aims to: 
• Give a first basis for a debate on the response to the request of the European Council 
in Luxembourg asking the Commission "d'étudier les modalités de l'établissement 
d'un fonds de solidarité thérapeutique sous l'égide de l'ONUSIDA destiné à la lutte 
contre le SIDA dans les pays en voie de développement "" 
respond to the request of the Parliament, approved by the Council of Ministers, within 
the framework of the regulation of the AIDS (Acquired Immune Deficiency 
Syndrome) budgetline n° B7. 6211 "Studying ways and means of improving access to 
treatment for people infected with HIV in the poorest countries ... in close 
collaboration with the United Nations agencies, concerned NGO's, pharmaceutical 
laboratories and the Members States of the European Union." 
recognise and welcome all of the calls for increased and enhanced international 
solidarity to confront AIDS, including those made at the Denver and Birmingham G8 
meeting, the UNAIDS (United Nations Joint Programme on AIDS) meeting on 
perinatal transmission, the International AIDS Vaccine Initiative (IAVI) and the 
World Bank's call for the creation of a vaccine purchase fund. 
recapitulate the Commission's existing priorities with respect to HIV (Human 
Immuno-deficiency Virus) and AIDS in developing countries. 
outline the Commission's position on several recent calls for increased international 
solidarity to confront AIDS in developing countries and the possible EC specific 
contribution to a new international initiative. 
propose a framework for an additional strategy and some elements to consider in 
relation to financial resources through which the EU could participate in an enhanced 
international solidarity effort to confront AIDS in the domains of prevention (vaccine) 
and improved care in developing countries. 
i:\emma\aids\communic.final.vers.I.EN 
1/07/98 
A&-
COMMISSION COMMUNICATION 
FOR INCREASED SOLIDARITY TO CONFRONT AIDS IN DEVELOPING 
COUNTRIES 
EXECUTIVE SUMMARY 
This Communication: 
1) Provides a context to the calls for international solidarity, describing the present 
situation with respect to HIV/AIDS (Human Immuno-deficiency Virus and Acquired 
Immune Deficiency Syndrome) in developing countries. 
2) Outlines the European Commission's (EC's) position on national and international 
priorities for the use of public funds in confronting AIDS in developing countries. It 
highlights the mutual reinforcement of prevention and care through the provision of 
public goods. 
3) Summarises the EC's existing efforts in confronting HIV/AIDS in developing 
countries, before discussing how these may be strengthened. Firstly, it highlights the 
success of cost-effective targeted preventative interventions, and the importance of their 
expansion. Secondly, it stresses the importance of support to strengthen health care 
systems, outlining possible improvements. 
4) Explores the possibility of creating new solidarity mechanisms, and examines and 
several alternatives. Firstly the prospect of financing care including anti-retrovirals in 
developing countries is explored, and concerns of technical uncertainties, relative 
priorities, affordability, and public policy are raised. Secondly the possibility of 
developing vaccines and microbicides, and creating a purchase fund for these products 
once developed is discussed and given general support. 
5) Outlines the potential for additional specific contribution of the EC, including the 
allocation of additional financial resources to: 
• support countries m purchasing existing commodities, namely, in order of priority 
a) AZT (Azidothymidine) in monotherapy for pregnant seropositive women 
b) medicines for sexually transmitted diseases (STD's), tuberculosis (TB) and 
other opportunistic diseases 
c) anti-retroviral (ARV) therapy for pilot testing in a few countries already 
selected by UNAIDS 
• leverage further investment by the private sector in developing vaccines and 
microbicides and providing purchase funds for these commodities once they exist 
¥> 
6) Stresses the global responsibility of UNA1DS in the management of new solidarity 
instruments, whilst nevertheless leaving major decisions in developing countries, and 
underlines the importance of monitoring. 
TABLE OF CONTENTS 
I: Introduction 
A. The challenge for the coming decade 
B. Confronting HIV/AIDS 
1. Care for people with HIV/AIDS: A World Apart 
2. Preventing the spread of HIV/AIDS 
C. Political momentum for additional international efforts and renewed international 
solidarity 
D. Document Outline 
II; The EC'S position on National and International priorities for the use of 
presently available public funds in confronting AIDS in developing countries. 
HI: The EC's existing efforts in confronting HIV/AIDS and recommendations on 
strengthening these areas in the future 
A. Prevention - Low cost interventions 
The special issue of preventing mother to child transmission 
B. Support to National Health Care Systems 
IV: New international solidarity initiatives 
A. Financing health care and anti-retrovirals for people with HIV/AIDS in developing 
countries 
1. The situation of the health care systems in developing countries and how to 
face the extra burden caused by HIV/AIDS 
2. The specific issue of combination therapy with anti-retrovirals 
a) Technical issues regarding the generalised use of combination 
therapy for the treatment of HIV infection. 
b) Relative priorities 
c) Affordability. 
d) Public policy towards anti-retroviral treatment. Experience to date 
in some developing countries 
B. Private and public partnership to develop a vaccine and microbicides 
C. Modalities of new international solidarity instruments 
V: The EC's specific contribution 
A. What is to be financed by additional EC resources? 
B. The main commodities which could be purchased 
1. Commodities that already exist 
2. Commodities still to be developed 
C. A framework for what would be financed by additional resources 
D. How are the funds to be to provided to the countries? 
E. Some examples of conditions to be in place for the use of the EC's budget support at 
country level. 
1. Medicines already available 
2. Products not yet available 
VI: Management of new solidarity instruments 
A. International level. 
B. National management of a fund to provide commodities for developing countries 
C. Monitoring 
D. Regarding management of a new international financing instrument for the testing and 
purchase of vaccines for developing countries 
VII: Conclusion about International co-operation and the European Community's 
specific contribution 
Annex 1 - Quotes concerning international solidarity with respect to HIV/AIDS 
I: INTRODUCTION 
A. The challenge for the coming decade 
From the beginning of the AIDS epidemic it was recognised that AIDS could not be dealt 
with by households and countries alone. The international community had to be 
mobilised and their efforts could only be sustained through sufficient political 
momentum and financial resources over a long time period. 
It is in this context that the European Community in 1984 first began research on 
HIV/AIDS, and in 1987 first became involved in actions dealing with HIV/AIDS in 
developing countries. At that stage the EC and the African, Caribbean and Pacific (ACP) 
countries agreed that "AIDS would be a major challenge for development and should be 
dealt with as such". Only six months after the programme started in the ACP countries, 
other developing countries became eligible for support through a specially created 
budgetline. 
In the 1980's the challenge faced by the countries was to rapidly develop effective 
interventions to prevent the spread of AIDS, to strengthen the different systems to deal 
with the virus whilst at the same time increasing the scientific learning and knowledge 
basis. The EC together with the international community supported national and regional 
efforts. 
The policies and strategies for EC support were widely debated as formulated in the 
Communication of 7th January 1994 from the Commission to the Council and the 
European Parliament entitled "AIDS policy of the Community and the Member States in 
the developing world", and also in the legal basis for the special AIDS budgetline n° B7. 
6211 (Ref. 95/0164(SYN) dated 26.6.95). 
Now, at the end of the 1990's, the challenge is to implement the most effective 
interventions at a large enough scale whilst simultaneously supporting health care 
systems to deal with those already infected and further developing knowledge to improve 
interventions and develop new methods. This has been explored in detail in 
"Confronting AIDS: Public priorities in a global epidemic", a joint exercise carried out 
by The World Bank, the European Commission, and UNAIDS, published in 1997. 
These challenges for the future were presented by the Commission at a public hearing at 
the Parliament where the continuation and strengthening of support for AIDS actions in 
third countries in the future was announced1. The European Commission (EC) also 
proposed priorities for its financial support in the future. These priorities are summarised 
and explained in Chapter II. 
B. Confronting HIV/AIDS 
1. Care for people with HIV/AIDS: A World Apart 
It is estimated that today in 1998 more than 30 million people are infected with the HIV 
virus world-wide, of whom 90% live in the developing world and 20 million are living in 
sub-Saharan Africa. Of those living in sub-Saharan Africa, half are women. 
1 Hearing at the European Parliament, 25th November 1997 
5 
Until recently, it was considered that the disease had a lethal outcome in close to 100% of 
all infected individuals, though there were significant differences between rich and poor 
countries in the prevention of mother to child transmission, the care of patients, and the 
course of the illness. 
In rich countries, the great majority of the population received specialist care in public or 
private health services. Even though no cure was available, it was possible to extend life 
by preventing and treating opportunistic infections, making use of AZT monotherapy, 
providing psychological support, and ensuring good nutrition, with the result that the 
average duration between infection and death was around 12 years. 
In poor countries, only a small proportion of patients received any specialist care, and 
against a background of poverty, poor nutrition, weak health sectors and insufficient 
treatment of opportunistic infections, duration of life after seroconversion was generally 
considerably less than ten years, and transmission from mother to child remains common. 
However two years ago the perception that AIDS always had a fatal outcome changed 
with the development and introduction of therapeutic strategies involving the use of 
combinations of anti-retroviral drugs and protease inhibitors which not only improve the 
quality of life of nearly 80% of the persons under medication, but hold out the possibility 
that future developments in drug research may allow a permanent arrest of the disease 
process. Furthermore, in the richer countries, the advent in 1996 of monotherapy for 
pregnant women, and the availability of alternatives to breastfeeding and options for 
testing and counselling, has rapidly minimised the transmission of HIV during 
pregnancy. 
For the first time, it appeared that HIV infection did not necessarily have a fatal 
conclusion. Following these discoveries, protease inhibitors and anti-retroviral drugs 
have been widely used in the richer countries. 
The discovery of effective monotherapy for pregnant women and combination therapy 
for people with HIV has still further widened the difference in the prospects of HIV 
infected individuals in rich and poor countries. Whereas in the industrialised world, the 
number of new infections is falling (as a result of successful prevention campaigns) and 
the prospect of effective therapy has appeared, in the poorer countries new infections 
continue to occur at a high rate and the outcome is still universally fatal. Several 
countries in the developing world have seen a serious decrease of life expectancy due to 
AIDS, and adult mortality due to AIDS is still increasing in the most affected areas. It is 
likely that 40 million people will die as a result of HIV infection over the next decade. 
Children will also become infected in large numbers. 
This reality of two different worlds facing AIDS and its consequences is a reminder of 
the major differences in quality and access to health care between industrialised and 
developing countries in general and the difficult choices this entails. For example 1 in 50 
women in developing countries dies as a consequence of the complications of pregnancy 
and childbirth compared with only 1 in 2700 in the established market economies. 
It is in this context, of huge disparities in health status and the capacities of health care 
systems dealing with all health problems including HIV/AIDS, that the call for greater 
international solidarity to increase the accessibility to prevention, care, and combination 
therapy has to be seen. 
2. Preventing the spread of HIV/AIDS 
It is now widely recognised that increased efforts should be made to contain the epidemic 
where possible through improving the efficiency of the existing interventions such as 
information, targeted education, counselling, testing, condom use, and treatment of 
sexually transmitted diseases (STD's), but also through the development of new 
methodologies to prevent the transmission of the virus, especially amongst populations in 
developing countries. 
One of the additional preventive methods that became available recently is the provision 
of Zidovudine or AZT for pregnant women to reduce the transmission of the virus to the 
child. At the same time as the results became available of the clinical trials, AZT was 
also put on the essential drug list by WHO and the price was significantly decreased §€ in 
order to make the intervention accessible to parts of the populations. 
At the present time, the undertaking to increase access to care and treatment for people 
with HIV goes in parallel to the efforts to make existing and new preventive interventions 
more available, because it is recognised that for countries to be able to deal with the 
increasing burden caused by AIDS, the only serious option is to stop the spread as soon 
and as efficiently as possible. The countries that are able to contain the epidemic will also 
be the optimal placed to provide the optimal and appropriate care to their populations 
with and without HIV. 
It is therefore in this complex context that new appeals to make AZT widely available for 
pregnant women to enlarge access to other anti-retroviral medicines, and to develop or 
leverage investment in the production of products such as vaccines and microbicides are 
to be seen. These developments would make a real difference if supported in the near 
future and if new financial instruments were made available for developing countries to 
purchase these products once developed. 
C. Political momentum for additional international efforts and renewed 
international solidarity 
With the purpose to organise additional efforts and mechanisms to further increase 
international solidarity with respect to AIDS, the European Council in Luxembourg 
requested the Commission "d'étudier les modalités de l'établissement d'un fonds de 
solidarité thérapeutique sous l'égide de l'ONUSIDA destiné à la lutte contre le SIDA 
dans les pays en voie de développement " A similar request had already been introduced 
by the European Parliament and approved by the Council of Ministers within the 
framework of the regulation of the AIDS budgetline n° B7. 6211 "Studying ways and 
means of improving access to treatment for people infected with HIV in the poorest 
countries ... in close collaboration with the United Nations agencies, concerned NGO's, 
pharmaceutical laboratories and the Members States of the European Union."2 
This document is a first phase of the response to these requests and is designed to spell 
out the specific role the Community's programme in developing countries proposes to 
play in contributing to increased international solidarity for prevention and improved 
care for people with HIV, recognising that this objective must be a shared responsibility. 
Only an increased and well co-ordinated effort will be able to confront AIDS in the larger 
Article 2, paragraph 2b of EC regulation no. 550/p7 
7 
context of competing priorities. The document mainly focusses at the different priorities 
and dicusses strategy. Once consensus is reached on the basis of this document it will be 
possible to go into further details and proposals for modalities and financing. 
D. Document Outline 
This introduction has provided a context to the calls for international solidarity, 
describing the present situation with respect the HIV/AIDS. 
In the second chapter, the document proceeds to outline the EC's position on national and 
international priorities for the use of public funds in confronting AIDS in developing 
countries, highlighting the mutual reinforcement of prevention and care through the 
provision of public goods. 
Chapter three then briefly summarises the EC's existing efforts in confronting 
HIV/AIDS, before discussing how these may be strengthened. In particular low cost 
prevention initiatives, and support to national health systems are explored. 
In the fourth chapter the possibility of creating new solidarity instruments is discussed, 
and several alternatives are examined. Firstly the prospect of financing anti-retro virais in 
developing countries is explored with respect to concerns of technical issues, relative 
priorities, affordability, and public policy. Secondly the possibility of developing 
vaccines and microbicides, and creating a purchase fund for these products once 
developed is discussed. The modalities of finding funds for new solidarity instruments 
are only briefly examined. 
In Chapter five, the specific contribution of the EC is outlined. This includes allocating 
additional resources both to support countries in purchasing existing commodities, and to 
leverage further investment by the private sector in developing vaccines and 
microbicides. 
An introduction to the discussion on the management of new solidarity instruments 
follows in Chapter six, clarifying the position of the EC in relation to other international 
bodies and highlighting the importance of monitoring. 
Finally the conclusion summarises the major issues discussed, and suggests future action 
at strategic level including a refocussing of current undertakings complemented by new 
efforts to i) purchase medicinal commodities at the country level once they exist, and ii) 
leverage larger and more appropriate finances for the testing and purchase of vaccines at 
the international level. The annex provides a summary of various statements on 
international solidarity with respect to HIV/AIDS. 
Il: THE EC'S POSITION ON NATIONAL AND INTERNATIONAL rcioRmeâ yon THE USE 
OF PRESENTLY AVAILABLE PUBLIC. FUNDS IN CONFRONTING AIDS IN 
REVeLO?lNC COl*HTR3ES. 
Individuals, countries and ths international community have worked hand in hand over 
the past ten years to deal with the new and enormous challenges created by AIDS. 
However in view cf decreasing public funds, an increasing number of .people infected 
world-wide and several other competing priorities facing people in developing countries, 
governments and donors have had to make difficult choices. The EC together with 
developing countries and with the major other donors have discussed the need to 
prioritise the use of available public funds and increase their commitments and 
partnerships with the private sector. The EC has also come to some conclusions about it's 
own comparative advantage and the way forward for the future. These choices were 
presented by the Commission in November 1997 and as summarised as follows: 
The overall objectives of the EC's actions on HIV/AIDS at national level are to limit the 
spread of the virus whilst helping the health sectors in developing countries to cope with 
the consequences and improve quality of care without discrimination. The overall 
objective of the EC at the international level is to collaborate to improve knowledge and 
to invest in international public goods as related to HIV/AIDS. 
The lessons learned over the last years show convincingly that developing countries 
cannot ignore the HIV/AIDS epidemic. In developing countries, where 90 percent of all 
HIV infections occur, AIDS is reversing hard won gains in improving quality of life. 
Between 1950 and 1990 average life expectancy in developing countries has increased 
from 40 to 63 years. But in many countries AIDS has now reduced life expectancy by 
more than 10 years. HIV/AIDS is also exacerbating poverty and inequality as the poor 
have the fewest resources to cope. It is therefore at the core of development and poverty 
alleviation concerns. 
However poor people and poor countries face many pressing problems beside 
HIV/AIDS, and public resources are scarce and choices are difficult. For example, in a 
typical developing country it costs as much to treat one AIDS patient for a year as it does 
to educate 10 primary school students for a year. Balancing these objectives is difficult 
but essential. 
The EC has therefore recognised that the essential use of national and international public 
funds regarding AIDS should be focused firstly at the public good nature of information, 
education and knowledge, and secondly at the extra benefits associated with the 
prevention of communicable diseases (such as HIV, tuberculosis, and sexually 
transmitted diseases (STD's)) which is a public as opposed to a private health issue. 
Prevention is therefore essential and remains so even at later stages when the epidemic 
has spread throughout the general population. At the end of 1997 it was estimated that 
more than 250 million people lived in countries where HIV infection had spread widely. 
These countries have no other choice but to confront the epidemic both through further 
preventative efforts and through facing the rising burden of AIDS related sickness and 
death and the impact this has on the care given to all people within the country. 
When a country reaches this stage, and when public funds are used to help the health 
sector to cope, AIDS can push up government spending on health care by over 40%, 
while people without HIV sometimes still may have less access to health care then 
before. Within this concern special care should therefore be given to not discriminate 
between allocations for care to people with and without AIDS, and special efforts should 
be made to focus available public funds on basic care to the poorest. 
A few hard hit countries that focused their resources in this way in the past and sustain 
their efforts today are now seeing results. For example Uganda, Thailand and Senegal 
have succeeded for the moment to relatively stabilise the epidemic through vigorous and 
targeted preventative efforts. However, these successes are recent and need to be 
sustained through continued efforts in the same direction. 
The international donor community, including the EC, have given the priority to 
generously support developing countries efforts in response to the AIDS pandemic, and 
simultaneously providing ongoing funds for investment in international public goods. 
Examples of international public goods are operational and fundamental research into 
policies, systems, clinical effectiveness of mother to child prevention, and the 
development of microbicides and vaccines. The EC has also greatly increased its support 
to strengthening health sectors in developing countries. 
The EC has committed itself to continue its efforts to strengthen the response organised 
in the developing countries and focus on the mutual reinforcement of prevention and 
care. At the same time, the EC is further committed to invest with its international 
partners in the development of new knowledge and products to increase the choice of 
people in protecting themselves from HIV/AIDS. 
The EC recognises the importance of the political momentum created to mobilise 
additional support to confront AIDS in developing countries and examines the best 
opportunities for the EC to contribute to those efforts. With this consideration in mind 
this document identifies the issues and the opportunities related to an additional 
international support with a special focus on the specific role and comparative advantage 
of the EC. Only in a second stage when the strategies are discussed will it be possible to 
prepare more detailed discussion documents on modalities, instruments and financial 
requirements. 
Ill: THE EC'S EXISTING EFFORTS IN CONFRONTING HIV/AIDS AND 
RECOMMENDATIONS ON STRENGTHENING THESE AREAS IN THE FUTURE 
The EC's existing efforts to confront HIV/AIDS in developing countries are organised 
with finances from a special budgetlines, national and regional programmes under EDF 
in ACP countries, and country programmes in Asia, Latin America, and Meditteranean. 
A. Prevention - Low cost interventions 
The EC has targetted 50% of its aids programme financial resources to cost effective, 
preventative interventions. Initiatives have included information campaigns targetted at 
high-risk groups, youth education especially in schools, peer-group education for 
example amongst truck-drivers and sex-workers, guaranteeing safe blood transfusions, 
and treating STD's. These projects have met with considerable success, and prevention 
activities remain a priority. 
10 
In view of recent developments, if national health services are adequately strengthened 
and if the country considers making anti-retrovirals available within this context, priority 
should he given to medicines preventing the transmission from mother to child. Every 
year 2 million HIV positive women get pregnant and 550,096 infants are bom infected 
with HTV. They live m fee world's poorest countries. As a comparison, in Tanzania, ome 
of Africa's poorest nations, mosquito contool to prevent malaria costs $5-$25© for every 
year of healthy hfe gamed. The cost of AZT for all HTV infected pregpant women in 
Tanzania works out at about $50 per healthy life gamed. U was calculated that Tanzania 
already spends $3.10 per capita on AIDS prevention, and that providing AZT for 
seropositive pregnant women would add about BO cents per capita to that. 
Since 1987, the EC has set up and collaborated world-wide in aie research and 
development of a strategy for preventing mother to child transmission of HIV. At aie 
present time, further operational and clinical research is still needed while 
operationalisation lias begun in several countries. 
The EC could contribute further in this area in a preliminary stage %y financing a 
feasibility assessment of an essential package for pregnant women in developmg 
countries, which would include different options for HIV testing and counselling, 
breastfeeding or bottle feeding, and other priority interventions. Existing instrumente and 
funds are adequate for this work for the present time. Therefore funds could be mobilised 
within EC's regular instruments to develop and evaluate such interventions on a large 
scale. 
In summary the existing instruments from the EC to provide support for prevention and 
care for people with HTV, and the possibility to prevent perinatal transmission of HIV 
within the context of general health care support are appropriate but additional efforts to 
increase and improve the existing support could be made if more flexible instruments and 
more human resources were made available within the overall context of health sector 
support to developing countries. 
B. Support to National Health Care Systems 
The EC has increased its support to health sectors in developing countries over the last 
years both in terms of quantity and quality, including support in the fields of access to 
care and prevention of AIDS. 
This is reflected by the fact that from the 6th to the 7 m EDF the EC's support for health 
projects has increased from 184 MECU to 415 MECU. hi addition, 633 MECU has been 
used for support to national health budgets in ACP countries through the counterpart 
funds of structural adjustment operations. Efforts in the ALAMED countries have also 
significantly increased. A substantial part of these funds are used on essential drugs 
programmes, including restructuring central medical stores. 
In order not to discriminate against or for persons with iïïV, the main way the EC 
supports access to care and treatment for all people (including for HIV infected persons) 
is through general health sector support, within which access to essential drugs is a major 
focal area for the EC. 
In addition to the main financial instruments which are used to support the health systems 
and fund essential drugs, the special budgets for AIDS are used to facilitate studies, 
innovative interventions and technical support to promote the inclusion of HIV/AIDS 
issues within the general health system. 
EC support, as a part of national and international efforts, has ensured a greater 
development of the medicines system in several countries and has improved access to 
medicines for people in general. However, because of the scale of the problem, and the 
lack of financial and human resources both in the developing countries and within the 
EC, this is not done in all developing countries where it is needed and it is a long term 
process. The existing instruments are in general appropriate for the purpose for which 
they have been created. 
However, the main constraints are insufficient funds allocated by the countries within the 
context of competing priorities, limited technical capacity in developing countries and in 
the EC, and a lack of rapid and flexible instruments to access human resources and 
expertise in this field. Additional efforts and instruments and a technical assistance 
group would be beneficial and would provide the opportunity to do more, to do it faster 
and with a higher degree of quality. This could be considered within the context of the 
EC's general health sector work strengthening activities at national level, and could 
specifically focus upon the following areas: 
• Improve co-ordination of all efforts in the health sector at country level with a special 
emphasis on the provision of medicines under the leadership of the country involved 
and in close co-operation with the WHO and other donors. 
• Consider HIV/AIDS, its consequences, and the public requirements within general 
public expenditure and health sector reviews, on the basis of a rapid assessment tool 
which should be developed and validated. 
• Encourage a more rapid development of adequate sustainable medicine systems in 
developing countries which also includes essential drugs for STD's/HIV, 
opportunistic communicable diseases such as TB, and AZT to prevent transmission 
from mother to child, and give special attention to developing a system for nationals to 
decide which medicines are to be subsidised and for which illnesses the costs need to 
and can be recovered. 
• Provide training for the adequate and appropriate use of medicines and set up 
monitoring systems to follow up performances and trends. 
• Strengthen systems to include testing and counselling for populations which could not 
benefit from them otherwise. 
• Strengthen collaboration of the public sector with profit and no-profit-making private 
sector to support general care for diseases such as AIDS, for example by providing 
more facilities for home care. 
12 
IV: NEW INTERNATIONAL SOLIDARITY INITIATIVES 
The increased international efforts to improve world-wide solidarity in confronting AIDS 
are welcomed. Clearly however, the new effort should have an additional character, and 
must not cause a decrease in supporting existing HIV/AIDS activities. 
From the discussion developed earlier in the text, the EC identifies a few priority focal 
areas as concerns where international renewed and additional efforts could occur. It also 
identifies the possibility of international co-operation in creating new initiatives. 
Specifically the new international solidarity initiatives focus upon i) strengthening the 
health system in developing countries to enable the purchase of most needed medicines 
and to generally improve the quality of care for affected people, and ii) creating a new 
financial instrument to increase private sector investment developing new preventative 
methods such as vaccines and microbicides. These options are explored in detail below. 
A. Financing health care and anti-retrovirals for people with HIV/AIDS in 
developing countries 
1. The situation of the health care systems in developing countries and how to face the 
extra burden caused by AIDS 
Even without the challenge of HIV/AIDS, the publicly funded health care systems in the 
poorer developing countries are under enormous pressure. Whereas the World Bank 
calculated that it would cost around $12 per capita or 3.4% of GNP to deliver a basic 
package of care, the actual levels of expenditure achieved are often much lower. For 
example, the average public expenditure on health for sub-Saharan African countries was 
2.5% of GNP in 1990, and it fell as low as 0.5% in the case of Sudan. Total expenditure 
from all sources was $5 per capita or less in Mozambique, Tanzania, Ethiopia, Sierra 
Leone and Sudan. In comparing this figure with the required $12, it needs to be 
remembered that much of the actual expenditure is incurred on services outside the 
package. Such low levels of expenditure are manifest in minimally functional health 
services, with demoralised and frequently absentee labour forces, frequent drug stock-
outs, and low rates of effective coverage of the population. 
Faced with such momentous problems, few of the poorer countries were able to mount an 
effective response to HIV/AIDS using only domestic resources. The general pattern has 
been that a considerable proportion of public resources has been expended on curative 
care of AIDS patients. This has not been the intended consequence of public policy, but 
has arisen spontaneously as ever higher proportions of beds in public hospitals are 
occupied by AIDS patients. A particularly unfortunate consequence has been that 
patients with other diagnoses have found it increasingly difficult to gain admission to 
hospital, even when their prognosis is much better. Furthermore, private expenditures are 
almost exclusively for curative care. The great majority of funds for preventive actions, 
such as public education, condom promotion and treatment of STDs, have been provided 
by external donors. This leads to divergent patterns of expenditure, depending on the 
share of the public and private sectors, and the extent of external funding. In Tanzania, 
where the private sector is small and there has been much external support, 85% of total 
expenditure on HIV/AIDS has been on prevention. By contrast, in Cote d'Ivoire, the 
bulk of public spending has been on treatment and less external aid, with the 
consequence that treatment accounted in 1995 for 92% of total AIDS expenditures. 
13 
2- The specific issue of combination therapy with anti-retrovirals 
The problem of lack of accessibility to anti-retrovirals in developing countries was raised 
acutely when scientists announced at the International AIDS Conference in Vancouver 
that new triple therapy for HIV was improving and extending people's lives in the West. 
There have since been further reports confirming these results. The question then posed 
is: "is it feasible and desirable to provide combination therapy to HIV infected 
individuals in developing countries ?" 
Calls from different groups were made to make these drugs " available for all", implying 
availability for the majority of people infected in developing countries. However the 
difficulties in complying with this demand are manifold, and raise four main concerns: 
a) Technical issues regarding the generalised use of combination therapy for the 
treatment of HIV infection. 
From the clinical perspective, it is now clearly established that anti-retroviral 
combination therapies have beneficial effects for the quality of life of HIV/AIDS 
patients: they diminish morbidity and mortality, significantly improve quality of life and 
possibly decrease infectivity. However multiple challenges still need to be overcome. 
Issues to consider include the long term effectiveness of the medicines, the absence of 
more patient-friendly medicine combinations or regimes (present regimes involve a 
multiple of pills to take at precise times), the need to have specialised laboratories, tests 
and clinical surveillance to ensure treatments, and the nutritional status and compliance 
of the patients. Only a maximum of 80% of patients respond to treatment in the 
industrialised world. Treatment requires indefinite disciplined compliance and extensive 
monitoring of liver and renal functions. It also requires expensive and yet not very 
efficient viral load testing as well as trained doctors to supervise the treatment. If these 
conditions are not in place, there is a risk of producing world-wide resistance to the new 
drugs. In addition to this, specific clinical problems remain unanswered due to the 
absence of data from the countries concerned. These issues include the use of less 
expensive bitherapies and drugs, the lack of experience in treating HIV-2 infections 
(which account for 50% of the cases in Senegal, but which are not commonly 
encountered in the Western countries where most treatment trials have been conducted 
and where HIV 1 is the most common strain) with the newest anti-retrovirals, and the 
reactivation of tuberculosis during anti-retroviral treatment. 
b) Relative priorities 
When resources are scarce, as they are in developing countries, so that it is not possible 
to finance all the potentially life-saving interventions, it has to be asked whether the 
public resources which might be allocated to combination therapy for HIV patients would 
be more productive if applied elsewhere, targeted towards more cost-effective 
interventions. This question can be r.:ked in various contexts. In terms of existing 
interventions which are specific to AIDS, there is strong evidence to show that resources 
applied to prevention are more effectiv , than those applied to treatment even in terms 
of reducing human suffering. However proven low cost preventive measures, such as 
treatment of other sexually transmitted diseases (STD's), are insufficiently funded, even 
though the cost of treating an STD case is $10.15 including only $2.11 for medications. 
A field trial in Tanzania has established that the cost of averting an HIV case by 
improved STD treatment is only $218, far less than the cost of annual treatment with 
14 
combination therapy which is at least $10,000. Given that our ultimate aim is to minimise 
the toll of human misery caused by HIV/AIDS, it is important to channel the available 
resources into those actions that are most effective in preventing the spread of the disease 
and in caring for those already infected. 
If the context is confined to those who are already infected with HIV, there are treatment 
alternatives to consider. In sub-Saharan Africa, the annual cost for comprehensive care 
without anti-retroviral drugs is around $500 per person (only $300 if the most expensive 
opportunistic infections are omitted). The provision of this care can add several years to 
the life of an HIV infected individual. Furthermore, it is also worth remembering that 
treating people with HIV for their opportunistic infections is a pre-requisite for any more 
sophisticated treatment and in itself is also a means of improving quality of life. 
However, in practice, treatment in general has encountered chronic problems in most 
developing countries. The treatment of the most frequent and dramatic opportunistic 
infection linked to AIDS, tuberculosis, costs around $20, but the effectiveness of most 
control programmes have decreased in the last decade and the availability of this 
treatment is far from universal in most countries. 
In the context of anti-retroviral therapy itself, there are strong arguments to give priority 
to finance a short course of AZT for seropositive pregnant women in order to prevent 
transmission of HIV to the new-born. This monotherapy has been proven effective and 
decreases transmission by 50% among non-breastfeeding populations. The price has been 
cut by the company by 75% and comes now to $50-$ 150 for a short course. 
If the context is widened again to consider interventions for other conditions in addition 
to HIV infection, there are strong inferences that a given expenditure would have greater 
impact if applied to other life-saving actions, such as infant immunisation, or the 
treatment of diarrhoea with oral rehydration salts, which all cost less than $15 per life 
year saved. These simple and low cost technologies remain widely neglected, and 
adequate financing of these should be a pre-condition for public sector spending on the 
extremely high cost intervention of combination therapy for HIV patients. 
The potential for competition with many other public priorities in developing countries is 
great. Pilot programmes for combination drug therapy should also be considered in that 
light because even if they are largely funded by grant or loan money from outside the 
recipient country, they are likely to attract substantial national resources (financial or 
human) which could otherwise have provided effective care to many more patients or 
helped prevent the spread of the epidemic to thousands more. 
To be fair to both people with HIV infection and those without, the heath system must 
first avoid discrimination against people with AIDS. It is also unfair, however, for the 
care of AIDS patients to be subsidised more than that of patients with similar diseases 
such as liver cancer or kidney diseases which are extremely frequent in Africa. Indeed, 
the main issue of concern is the combination of direct and indirect pressures caused by 
HIV, which are compromising the functioning of health structures. It appears that the 
emergence of the HIV mortality burden is to be considered as the most important 
challenge to the health sector and a strong reason to speed up and reinforce the health 
sector reform process including the proper organisation and financing of medicines and 
care. However, focusing only on specific HIV treatments could jeopardise the highly 
needed more general reforms in medicine financing and health care. 
15 
c) Affordability. 
The annual cost for treatment with anti-retrovirals (triple therapy) is around $10-20,000 
per person, the lower figure being derived from Thailand, a country which uses 
bitherapies excluding the expensive antiproteases, and the higher from USA and UK. 
These figures are a huge multiple of the average per capita expenditure on health in 
developing countries, and many times what is currently being spent per HIV patient. 
While it is to be expected that the cost of drugs may fall substantially over time, 
treatment of HIV patients using combination therapy will remain expensive due to the 
cost of testing and monitoring which must be taken into account. It has been estimated 
that to treat all HIV infected people in sub-Saharan Africa would cost annually $20-$40 
billion. There is no indication that anyone, patients, governments or external donors, is 
willing and able to meet more than a tiny fraction of this cost. This clearly means that 
access to anti-retro viral treatment cannot be financed for all people who are seropositive. 
Therefore choices will have to be made, probably focusing on the poorest. 
d) Public policy towards anti-retroviral treatment. Experience to date in some 
developing countries 
The situation regarding public policy in favour of generalised use of combination therapy 
for treatment of HIV infection is very varied and changing constantly. The wealthiest 
people in many developing countries are already finding ways to get anti-retrovirals 
(ARV), but the poorest people are unlikely to do so. Therefore the public financing of 
ARV in the poorest countries could disproportionately subsidise health care for the rich 
unless clear criteria for targeting towards the poor are organised. Some countries provide 
universal health care which does not include anti-retrovirals (Kenya), and others have 
provided for specific legislation to provide ARV to persons living with HIV/AIDS under 
different health care systems: under the social security system (Argentina), or private 
insurance (South Africa), or from public funds (Brazil). 
Most often however these decisions are taken without sufficient clarity concerning 
whether additional funds will be added to the health care budget or if existing funds will 
be reallocated (for example from prevention to care). For example, Brazil's government 
has guaranteed AIDS patients complete funding of ARV. The drugs alone will cost Brazil 
$700 million in 1998 or 4% of the Ministry Of Health's budget. This represents more 
than twice what the international community spends each year on AIDS prevention in the 
developing world. 
Countries such as South Africa, Botswana, Zimbabwe or Thailand have a policy to make 
the short cause of AZT available for seropositive pregnant women and are prepared to 
strengthen the health services where needed in order to make this possible. 
However in countries where STD's and tuberculosis (TB) are not adequately treated the 
idea of starting a national HIV/AIDS screening and treatment programme, or national 
HIV treatment in general seriously needs to be reconsidered at national policy level. 
Some of these interventions could be financed and carried out by the private sector or by 
NGO's in countries where governments have more pressing priorities, and where such 
policies could not yet be implemented at the national level. 
For example, the first policy implication of the Thai trial on mother to child transmission 
could be that an individual woman who knows that she is HIV positive, has fully been 
counselled, has the resources to purchase AZT, and is willing and able to forgo 
16 
breastfeeding should be offered treatment. It could also be suggested that this could be 
done in the first instance through the private sector or NGO's. 
B. Private and public partnership to develop a vaccine and microbicides 
New investment and financial instruments are needed to facilitate the development and 
general availability of new preventive methodologies against HIV/AIDS for developing 
countries. 
Over recent years several calls were made to develop additional preventive methods 
designed to reduce the specific vulnerability of women, such as a female condom and a 
vaginal microbicide. Responding to this demand, a female condom was developed and 
is now being used by an increasing number of women in some countries. Work is 
continuing to develop an effective and affordable microbicide. 
However, there is a wide consensus that "in the long term, the development of safe, 
accessible and effective vaccines against HIV/AIDS holds the best chance of limiting, 
and eventually eliminating, the threat of this disease" (communiqué of G7, Denver, 1997 
- see Annex 1). The development of a microbicide and a vaccine encounter several 
barriers, that can be categorised as scientific, technical, economic and financial. 
The European Commission has in past and present R&D framework programmes put in 
substantial efforts in developing vaccine-orientated AIDS research in Europe. Major 
efforts have been invested in large scale facilities providing reagents and animals for HIV 
vaccine trials. These efforts will be continued through the newly established Key Action 
II of the FPV's Life Sciences Programme and the specific activities of the INCO 
programme. 
The scientific and technical areas for the debate will not be further developed here but 
it is strongly believed that improved scientific leadership and co-ordination could make a 
qualitative difference and allow faster and more efficient progress. 
The economic and financial issues are of more specific concern for this Communication 
on increased international solidarity and will therefore be developed here. In the 
development of new products, the traditional division of funding responsibility is 
between the public sector supporting pure research, and the private sector supporting the 
development of commercial applications. However, the fundamental issue is that there is 
insufficient investment by the private sector in developing microbicidal products or 
vaccines protecting against HIV/AIDS, as a result of the perception of inadequate 
purchasing power in developing countries. 
Private sector spending on research and development of an AIDS vaccine for developing 
countries is inadequate. Evidence suggests that existing marked-based incentives are 
biased in favour of the development of AIDS treatments, which are products with weak 
external benefits demanded by high income AIDS patients, as opposed to the 
development of a microbicide or vaccine which are products with large external benefits, 
especially for residents of developing countries. 
Total global research and development for preventive HIV vaccines in both the public 
and private sectors in 1993 was estimated by the National Institute of Health (NIH) at 
$160 million, which is less than 7 percent of annual global research and development 
17 
expenditure on HIV/AIDS. Within the total of $160 million spent on vaccine research, 
only $5 million per year is spent on vaccines for potential use in developing countries. 
By contrast, there is far less uncertainty about the market and profitability of research on 
medicines to treat HIV/AIDS. Three million of the people infected world-wide live in 
industrialised countries where individual or insurance purchasing power is high. The 
global market for medicines for HIV/AIDS and related infections in 1995 was estimated 
at $1.3 billion. 
The recent history of the development of other products, such as hepatitis vaccines, has 
demonstrated that those products are not widely purchased by individuals or governments 
in developing countries. One or two decades ago, the international community argued 
for investments in those products because of the serious consequences of those diseases 
in developing countries and the potentially high cost-benefit ratio of such products. The 
reluctance of the international bio-medical industry to invest heavily in products destined 
for markets in developing countries is entirely understandable in the light of this history. 
The creation of a particular special research fund is probably not a solution and would 
add to the dispersion of ongoing efforts. Additional funding of pure research would have 
only a small effect on the incentives facing the private sector in incurring the high costs 
and high risks of developing an AIDS vaccine. What is needed is a financial mechanism 
ensuring that when vaccines appropriate for developing countries are developed by the 
private sector, there will be adequate purchasing power in the market to enable the 
private firms to recover the costs of their development and production. 
Given the weakness of purchasing power in developing countries themselves, 
international public investment is needed to provide that guarantee of a sufficient market. 
Since the product itself does not yet exist, innovative mechanisms to assure a market for 
a hypothetical product are required. In this context the International AIDS Vaccine 
Initiative (IAVI), the World Bank (as announced in the policy research report on AIDS) 
and the preparatory group for the G-8 (Group of eight most industrialised countries) 
meeting in Birmingham are making interesting proposals to create new international 
solidarity instruments. One particularly attractive idea under consideration is the notion 
of a contingent purchase fund, whereby donors issue promissory notes for a number of 
years ahead, to be drawn down for vaccine purchase in the event that the conditions are 
met, of a safe and effective vaccine suitable for use in developing countries. 
C. Modalities of new international solidarity instruments 
It is recognised that the creation of new solidarity instruments at international level could 
only help if the purpose was well focused and collectively prepared. Problems which are 
related to the weakness of the economy and the social sectors in many developing 
countries cannot be solved through the creation of specific funds at international level. 
Furthermore, it is important to realise the difficulties of increasing solidarity at 
international level in a period of budgetary constraints at national and regional level 
world-wide. It would also not be an answer to the lack of rapid progress in donor co­
ordination and collaboration within the EU and the international community. 
Extra public funds will have to be mobilised within the context of international 
budgetary constraints and the relative decrease of funds available for development in 
general. In the EC context, a reallocation of funds in order to increase spending on 
KIV/AIDS related activities will have to be discussed with the budgetary authorities but 
18 
also with our developing countries partners (for example in the context of the 
(re)negotiations of future conventions post Lomé). Funds which were not used from 
previous EDF's could for example be proposed to be used by a new funding instrument. 
Funds could be mobilised through two main mechanisms at EC level: firstly through the 
EIB (European Investment Bank), and secondly through European NGO's and 
foundations. EIB funds, which are traditionally applied to market oriented operations, 
might be used in drug manufacture and distribution. NGO's and foundations could raise 
funds from the citizens of European countries to provide care for HIV/AIDS patients in 
the developing countries. 
Other options for raising funds include: 
• Contributions by pharmaceutical companies. Discussions are being held by UNAIDS 
• A special tax raised as a percentage of the price paid for drugs in Europe to be 
transferred to the fund by the European country's national security system or to the 
pharmaceutical industry. At this stage, such options seem difficult in view of the 
problems encountered by the social security systems in Europe and the already high 
taxes paid by European citizens. 
• Voluntary contributions from health insurance systems in Europe. The potential for 
this option appears limited as in many countries statutory rules would exclude this 
kind of transfer. 
• Contribution from philanthropists. These would have to be linked to tax relief but 
could be available. Some potential names were put forward in the communications 
from Abidjan, but need to be confirmed. 
V: THE SPECIFIC CONTRIBUTION OF THE EC 
The EC's programme on AIDS in developing countries is committed to further support 
countries to finance the priorities as detailed in Chapter II. 
This is to be seen in the context of the EC's efforts to strengthen the social sectors and to 
alleviate poverty alteration through greater efficiency of public finances and equity 
concerns. 
It is argued that the EC's instruments to finance priorities for the relevant areas in the 
health sector at country, regional and international level are largely adequate and in 
equilibrium with the human resources available. Any new effort would have to be 
additional to these instruments and activities, as outlined in Chapter III. 
A. What is to be financed by additional EC resources? 
New additional finance resources could best be used for the purchase of additional 
commodities to prevent HIV/AIDS and to care for people with HIV/AIDS. This should 
have two components, i) to support countries to purchase existing commodities, and ii) 
19 
internationally to leverage further investment by the private sector in developing vaccines 
and microbicides. 
B. The main commodities which could be purchased 
1. Commodities that already exist 
• AZT in monotherapy for pregnant seropositive women 
• medicines for STD's, tuberculosis and other opportunistic infections 
• anti-retroviral therapy for pilot testing in a few countries selected by UNAIDS 
2. Commodities still to be developed 
• vaccines and microbicides 
In this context, more detailed work is needed in a 2nd stage and jointly with other 
development partners to look into the possibilities of creating a fund which could 
leverage investment by i) the private sector to develop such products, and/or ii) the 
countries to test these products once available. The World Bank is presently examining 
the different options for this. 
C. A framework for what would be financed by new additional resources 
It is proposed that the commodities mentioned under B.l. are procured and financed by 
and through the national medicine systems in the respective developing countries. 
However the EC's additional resources could provide funds for pilot testing and 
purchasing of these commodities. The country involved could then start with a revolving 
fund to procure those commodities in a sustainable way. 
A different choice can be made for the different products. For example, vaccines, once 
available, could be subsidised for a certain time in a degressive manner whereas 
microbicides will probably be cheap enough for the majority of persons to pay for them 
themselves. In that case it could still be beneficial however to provide a facility for the 
poorest and the higher risk persons to access the commodity through a targeted system 
such as vouchers. 
Regarding monotherapy with AZT for pregnant women and treatment for STD's, 
tuberculosis and other opportunistic infections it is proposed to help countries to procure 
these medicines through the essential drugs system and to finance the start up of the 
system as well as subsidise the medicines for a certain period, if it can be ensured that the 
poorest would be targeted through adequate systems. 
Concerning combination anti-retroviral therapy, it is proposed that some additional 
resources be used for testing of such products in a few countries selected by UNAIDS. 
The provision of the medicines could be carried out by private companies involved and 
the EC could provide for funds of notably technical assistance to monitor and evaluate 
the pilot phase and to disseminate the lessons learned. This evaluation could draw easily 
20 
on experience accumulated by European research groups during projects involving the 
set-up of these treatments in Europe and elsewhere. 
The additional financial resources could furthermore be used to set such a system in 
place, test it and help develop national policies concerning all those commodities, their 
financing and the quality control required. 
D. How are the funds be provided to the countries? 
Additional finances could be provided to the national budgets of developing countries 
which would be allocated on the basis of action plans, and which include the guarantees 
for conditions to be in place as required and specified further. Detailed modalities and 
criteria will have to be examined at a later stage. 
E. Some examples of conditions to be in place for the use of the EC's budget support 
at country level. 
1. Medicines already available on the market 
The provision of those products should be integrated in the overall system of procuring, 
financing and distributing all essential drugs in the country. The national plan should 
include provision for subsidies or cost recovery in harmony with the policies of the 
country. 
2. Products not yet available 
a) Vaccines 
• an integrated HIV vaccine policy should be in place. 
• a sustainable plan should be proposed to ensure longer term viability including 
financing mechanisms 
b) Microbicides 
Similar to above but probably less stringent as it might be an over the counter product 
rather than a medicinal product 
F. Modalities for mobilising additional resources at the EC level 
Once an agreement has been reached on the purposes of the new debate around the 
present communication, several options could be available to implement the initiatives 
described above: 
Funding could be provided from different sources (budgetlines and EDF) which allow the 
use of resources for aids related activities in developing countries. 
21 
VI: MANAGEMENT OF NEW INTERNATIONAL SOLIDARITY INSTRUMENTS 
A. International level. 
UNAIDS has a global responsibility in the monitoring of all these initiatives in the 
normative and ethical domains, and the EC supports this position. If new instruments at 
the international level are set up, it is understood that they would be managed by existing 
organisations with adequate technical capabilities and capacities. 
B. National management of finances to provide commodities for developing 
countries 
The international community has the responsibility to assure that they are achieving their 
stated purposes and not having any perverse effects on the existing health care systems or 
on preventive efforts. 
However, in general, it is crucial that the main decisions about systems and priorities for 
subsidised or other care should remain in the developing countries because the 
effectiveness, affordabilility, equity and sustainability concerns are primarily a national 
responsibility. External interventions may nevertheless strengthen national efforts in 
these areas. 
C. Monitoring 
It is crucial to set up and finance a monitoring system that can capture any impact of 
these initiatives on the rest of the health sector whether they are positive or negative. This 
could be done as follows. 
In conjuncture with any pilot programme to introduce medicines including ARV therapy 
in a very poor setting, a responsible international institution funding country-level 
implementation would first do baseline surveys on the health system in the vicinity of the 
pilot programme to determine the quality and accessibility of curative care and the 
distribution of financial and human resources to the introduction of the programme. The 
same surveys could then be conducted after 6 months during the implementation. For 
ARV, the results of these surveys could then be monitored to assure that funds allocated 
to provide ARV therapy to AIDS patients are spent in such a way so as to: 
a) Maximise patient compliance, thereby minimising the risk that ARV therapy would 
create new, drug resistant strains to HIV which could subsequently spread throughout 
the entire world. 
b) Minimise the diversion of human and financial resources from: 
• The prevention of AIDS 
• The prevention of easy to prevent fatal illnesses like measles 
• The treatment of curable illnesses, including the easily treated opportunistic 
infections related to HIV. 
22 
D. Regarding management of new international financing instruments for the 
testing and purchase of vaccines for developing countries 
It is proposed that the international community of donors collaborates with existing and 
new mechanisms. The EC would be ready to participate in this process. Detailed 
modalities will have to be further analysed and discussed at later stages. 
VII: CONCLUSION ABOUT INTERNATIONAL CO-OPERATION AND THE EUROPEAN 
COMMUNITY'S SPECIFIC CONTRIBUTION 
It goes without saying that no single nation alone, nor any group of nations, can provide 
effective solutions to the problems created by HIV/AIDS. Rather it is crucial to secure a 
high degree of international co-operation if the world community is to have a chance of 
finding just and sustainable solutions and of achieving both intergenerational and 
intragenerational equity on economical and political terms. 
At the international level, UNAIDS must take global responsibility for any new solidarity 
initiatives. Though new mechanisms are welcomed it is highly important that their 
financing is additional to existing efforts to confront HIV/AIDS. 
Over the past 10 years, the Community has been playing an important part in 
international action in the field of AIDS and plans to continue to do so. 
• Regarding HIV/AIDS control, a European Community commitment was made by the 
Commission to reinforce actions to stabilise and minimise the spread of the epidemic 
in most of the developing countries in the next decade. 
• Regarding health services, including those dealing with people infected with HIV, the 
Community's commitment to support developing countries' efforts to strengthen their 
health systems and focus on sustainable effective systems mainly for the poorest will 
be a major task for next decades. The Community is also proposing to make greater 
efforts to implement new strategies faster and more effectively jointly with all its 
partners. Furthermore, it will additionally give renewed attention to developing 
appropriate medicines systems in the countries requesting support for HTV and include 
appropriate care for AIDS. 
• We are at the turning point in the action related to HIV/AIDS in developing countries. 
The lack of effective vaccines, the lack of accessibility to medicines for STD's and 
opportunistic infections (including TB), and the recently discovered anti-retroviral 
therapy is at the heart of the concerns world-wide and especially in the poorest 
developing countries affected. 
The EC is committed to renew its existing efforts in order to ensure a decline in infected 
persons in most of the developing countries where able to give support. 
Furthermore, new additional efforts and additional financial resources of the EC could 
be concentrated in two areas: 
© at the country level to purchase commodities once they are on the market 
o at the international level to leverage further investment of the private sector to develop 
and purchase vaccines and/or microbicides 
2.1 
ANNEX 1 
1) Regulation for AIDS budgetline: "Art. 2b": 
" Studying ways and means of improving access to treatment for people infected with 
HIV in the poorest countries. This study should be conducted in close collaboration 
with the United Nations agencies, concerned NGO's, pharmaceutical laboratories and 
the Members States of the European Union." 
2) Luxemburg Council: 
"Le Conseil européen demande à la Commission d'étudier les modalités de 
l'établissement d'un fonds de solidarité thérapeutiques sous l'égide de l'ONUSIDA 
destiné à la lutte contre le SIDA dans les pays en voie de développement" 
3) Parliament ACP document amendment: 
"rappelle à la Commission que le Conseil européen de Luxembourg lui a demandé: 
d'étudier les modalités de l'établissement d'un fonds de solidarité thérapeutique sous 
l'égide de l'ONUSIDA destiné à la lutte contre le SIDA dans les pays en voie de 
développement" et demande à la Commission de prévoir la mise en oeuvre de ce 
fonds dans le cadre de la prochaine convention." 
4) G8 in Denver: 
" Preventing the transmission of HIV infection and the development o ADDS is an 
urgent global public health imperative. While other prevention and treatment methods 
must be pursued, in the long term the development of safe, accessible and effective 
vaccines against AIDS holds the best chance of limiting and eventually eliminating, 
the threat of this disease. We will work to provide the resources necessary to 
accelerate AIDS vaccines research and together will enhance international scientific 
cooperation and collaboration" 
5) UNAIDS statement on mother to child transmission (23-24 March 98): 
" A global effort is needed to promote the updating and scaling up of interventions to 
prevent mother to child transmission of HIV. Furthermore, there is on ethical 
imperative to support the introduction of the shorter AZT (zidovudine) regime in 
countries in which trials have been completed and to encourage such interventions in 
countries which have capacity and willingness to support them" 
6) WORLD BANK: Vaccine Purchase Fund: 
This initiative seeks to assure industry of a commercially viable market in developing 
countries by establishing an international Vaccine Purchase Fund. Such a fund can 
create a guaranteed paying market in the developing world of known minimum size. 
By encouraging industrial investment in vaccine development, the Vaccine Purchase 
Fund could be financed by current country or donor funds, or by a guaranteed line of 
credit through the World Bank. Ten to 15 participating countries, providing $50-$ 100 
million each, would create a $0.5-$1.0 billion dollar developing country vaccine 
market. Funds would only be made available to purchase a vaccine once it was 
24 
successfully developed. A World Bank line of credit conditional loan is a particularly 
attractive approach as current funds allocated to HIV could continue to be used for 
prevention and treatment until a vaccine was developed. Ultimately, having funds 
available for purchase will be essential for assuring vaccine availability, but by itself 
will most likely not be sufficient to fully overcome the reluctance of major vaccine 
companies to invest in developing HTV vaccines for low income countries. 
7) UMAfl>S: HIV drugs access initiative pilot project on providing wider access. 
ONUSIDA: lance l'initiative visant à améliorer l'accès aux médicaments pour la prise 
en charge de l'infection au VIH et du SIDA dans les pays en voie de développement, 
"En raison de l'ampleur et du potentiel de destruction massive et durable dus au 
SIDA, il est encore plus urgent et prioritaire de renforcer et d'actualiser les systèmes 
de prestations de soins de santé. L'initiative de l'ONUSIDA lance un phase pilote qui 
englobe la mise en oeuvre et le suivi de nouvelles stratégies destinées à éliminer les 
obstacles entravant l'amélioration de la prise en charge de VIH/SIDA et se déroulera 
au Chili, en Côte dTvoire, en Uganda et au Vietnam, pays qui permettent une 
évaluation adéquate de l'initiative dans des contextes géographiques, sociaux, 
culturels, économiques et structurels très divers" 

ISSN 0254-1475 
COM(98) 407 final 
DOCUMENTS 
EN 05 11 15 16 
Catalogue number : CB-CO-98-421-EN-C 
ISBN 92-78-37558-6 
Office for Official Publications of the European Communities 
L-2985 Luxembourg 
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