Global Health: U.S. Agency for International Development Fights AIDS in Africa, but Better Data Needed to Measure Impact
Published: 2001-03-23T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: The AIDS epidemic in sub-Saharan Africa has grown beyond a public health problem to become a humanitarian and developmental crisis. The Agency for International Development (AID) has contributed to the fight against human immunodeficiency virus (HIV)/AIDS in sub-Saharan Africa by focusing on interventions proven to slow the spread of the disease. However, AID'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 for HIV/AIDS prevention activities in sub-Saharan Africa for fiscal year 2001, AID prepared a plan to expand monitoring and evaluation systems in 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 AID 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 AID'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.

section_title: Letter
paragraphs: 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 estimates 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. This report responds to your  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.
subsections: section_title: Background
paragraphs: 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.
section_title: AIDS Has Negatively Affected Sub-Saharan Africa, but Slowing the Epidemic Presents Challenges
paragraphs: Throughout the 1990s HIV/AIDS prevalence continued to increase in most  of the countries in sub-Saharan Africa (see fig. 2). 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.
subsections: section_title: Effect of the AIDS Epidemic on the Population of Sub-Saharan Africa
paragraphs: 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.
According to the U.S. Census Bureau, infant and child mortality rates 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.
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,  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  population under age 15 in some African countries. 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 countries in 1999.
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  the region, including Lesotho, Malawi, Mozambique, Namibia, and  Swaziland.
section_title: Effect of AIDS Epidemic on Social and Economic Development
paragraphs: 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 USAID 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.
section_title: Several Challenges Have Hindered International Efforts to Slow the Spread of HIV/AIDS in Sub-Saharan Africa
paragraphs: 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.
subsections: section_title: Donor Spending Falls Short of Need
paragraphs: 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.
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 Service notes  that unwillingness by religious or community leaders to discuss condom  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 report 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.
section_title: Low Socioeconomic Status of Women Impedes Their Ability to Take Precautions Against Infection
paragraphs: 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.
section_title: Weak Health Care Systems Make It Difficult to Stem the Epidemic
paragraphs: The epidemic is overwhelming the already fragile health care systems in  sub-Saharan Africa, 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 report notes that in Côte d’Ivoire, Zambia,  and Zimbabwe, HIV-infected patients occupy 50 to 80 percent of all beds in  urban hospitals.
section_title: Military and Police Have Been Difficult to Reach With Prevention Efforts
paragraphs: 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  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. 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.
section_title: National Governments Have Been Slow to Respond
paragraphs: 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.
section_title: USAID Made Contributions but Has Difficulty Measuring Its Overall Impact on Reducing HIV Transmission
paragraphs: 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.
subsections: section_title: USAID Activities Focused on Three Key Interventions Targeted to High-Risk Groups
paragraphs: 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.
subsections: section_title: Behavior Change Communications
paragraphs: USAID promotes behavior change through voluntary counseling and  information campaigns to heighten awareness of the risks of contracting  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.
section_title: Condom Social Marketing
paragraphs: 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. 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.
section_title: Management of Sexually Transmitted Infections
paragraphs: 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  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.
section_title: Other Prevention Activities
paragraphs: 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  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.
section_title: Gaps in Data Collection and Reporting Hinder USAID’s Ability to Measure Overall Impact on Reducing HIV Transmission in Sub-Saharan Africa
paragraphs: 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.
subsections: section_title: Inconsistent Indicators Are Used to Measure Outcomes
paragraphs: 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.
section_title: Data Collection Is Sporadic
paragraphs: 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 missions  were still in the process of gathering baseline or trend data for many of  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. 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.
section_title: USAID Has Few Monitoring and Evaluation Reporting Requirements
paragraphs: 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  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.
section_title: Internal and External Factors May Limit USAID’s Ability to Expand its HIV/AIDS Activities in Sub-Saharan Africa
paragraphs: 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.
subsections: section_title: USAID’s Approach for Allocating HIV/AIDS Program Funding and Activities
paragraphs: 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  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.
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   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. 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.
section_title: Internal Factors May Affect USAID’s HIV/AIDS Program Expansion
paragraphs: 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.
subsections: section_title: Contracting and Procurement Problems
paragraphs: 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  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.
section_title: Personnel Shortages
paragraphs: 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  services—the United Nations, other multinational assistance agencies, and  private voluntary organizations.
section_title: External Factors May Also Affect USAID’s HIV/AIDS Program Expansion
paragraphs: 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.
subsections: section_title: Weak Health Care Systems
paragraphs: 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). As a comparison, the ratio for the United States in  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.
section_title: Limited Pharmaceutical Delivery Capabilities
paragraphs: 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. 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.
section_title: Unknown Capacities of Nongovernmental Organizations
paragraphs: 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.
section_title: Conclusions
paragraphs: The AIDS epidemic in sub-Saharan Africa has grown beyond a public health  problem to become a humanitarian and developmental crisis. USAID has  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.
section_title: Recommendations for Executive Action
paragraphs: 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   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.
section_title: Agency Comments
paragraphs: 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  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.
section_title: Objectives, Scope, and Methodology
paragraphs: 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  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.
section_title: Contributions of USAID’s Global and Africa Bureaus
paragraphs: 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.
subsections: section_title: Global Bureau Contributions
paragraphs: 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.
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, 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.
section_title: Africa Bureau Contributions
paragraphs: 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  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.
section_title: Comments From the U.S. Agency for International Development
paragraphs: The following are GAO’s comments on the U.S. Agency for International  Development’s letter dated February 23, 2001.
subsections: section_title: GAO Comments
paragraphs: 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.  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.
section_title: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: 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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