The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) epidemic continues to spread rapidly in the developing world, where more than 90 percent of the 30 million people living with the HIV infection live (see fig. 1.1). Moreover, the UNAIDS Secretariat recently reported that more than 90 percent of the 5.8 million new infections in 1997 (up from 3.1 million in 1996) were in developing countries (see fig. 1.2). Sub-Saharan Africa has the worst infection rate, accounting for 3.4 million new infections in 1997. In that region, 7.4 percent of people aged 15 to 49 are infected. Estimates for South and South-East Asia indicate the disease is also rapidly spreading in that region, with 6.4 million currently living with HIV/AIDS and 1.3 million new infections in 1997. Established market economies include North America, Western Europe, Australia, and New Zealand. In many developing countries, HIV/AIDS has begun to erode decades of gains in health, child survival, life expectancy, education, and economic development. For example, U.S. Bureau of the Census projections for Zambia indicate that by 2010, AIDS may increase infant mortality rates nearly 60 percent higher than would have been expected without the disease. Similarly, projections for Zimbabwe indicate that by 2010, life expectancy will decline from 70 years to less than 35 years as a result of AIDS and in Uganda from 54.5 years to 35.5 years. Since the start of the epidemic, more than 8 million children have lost either their mother or their father because of AIDS. AIDS’ impact on families and public health systems is weakening economies as people in their prime working years are afflicted by the disease and governments and families divert scarce resources to care for them for extended periods of time. The donor community is spending approximately $250 million a year to address the HIV/AIDS epidemic in the developing world. The United States is the largest single donor, contributing $117 million in 1997 through the U.S. Agency for International Development (USAID) that includes specific support for UNAIDS. However, HIV/AIDS poses serious challenges to the world community because of the extent of the epidemic and the cost and difficulty of changing deeply rooted traditions and behaviors that contribute to the spread of the disease: according to a study commissioned by WHO, between $1.5 billion and $2.9 billion would be needed from donors and affected countries annually to implement behavioral and blood safety strategies to prevent HIV/AIDS in developing countries. Moreover, other epidemics had their roots essentially in medical problems and could be addressed through biomedical remedies from public health systems. However, absent a vaccination or cure, slowing the reach of the virus must be accomplished by addressing such fundamental cultural and social traditions as the role of women, sexual practices, and inheritance laws. For example, according to USAID, tradition and laws in Kenya do not allow women to inherit property. Without skills or experience in earning money, if their husbands die, women often have no other recourse than to engage in prostitution. USAID and the United Nations first began to address the epidemic in the mid-1980s. While both USAID and the United Nations seek to reduce the spread of the epidemic, they have somewhat different yet mutually supporting roles, objectives, and coverage. As a bilateral agency, USAID works in partnership with governments, other donors, and private organizations to support research and implement HIV/AIDS interventions in the 28 countries where it has major programs. The U.N.’s role is in advocating, mobilizing, and coordinating the international response worldwide in addition to managing HIV/AIDS activities in 152 countries. Since it began its HIV/AIDS assistance program in 1986, USAID’s goal has been to reduce the incidence of new HIV/AIDS infections. In the 1980s, very little was known about the epidemic or how to fight it. As a result, USAID focused its initial efforts on understanding the causes and extent of the epidemic and on identifying ways to prevent its spread. At the direction of Congress in 1986, USAID supported WHO’s Global Program on AIDS (GPA), and it also paid for public and private research efforts and activities in the field. These field activities included operations research on interventions that prevent the spread of HIV/AIDS; surveillance and analysis of the incidence, spread, and impact of the disease; and assistance in countries’ design and implementation activities. During this learning phase, USAID reported that it was the first donor to introduce HIV/AIDS prevention activities in most countries. Further, by providing short-term technical assistance to USAID missions in more than 74 countries and funding small-scale projects to prevent new infections, it educated USAID staff and host country officials about the epidemic. By the early 1990s, USAID became more knowledgeable about the disease, and Congress increased funding for HIV/AIDS (see fig.1.3). USAID designed a strategy to focus on country-level projects that could have a measurable impact on the epidemic. From 1991 to 1997, USAID supported the AIDS Control and Prevention (AIDSCAP) project. By far the most ambitious international HIV/AIDS prevention effort ever undertaken, AIDSCAP was a worldwide program intended to help USAID overseas missions design and implement HIV/AIDS prevention projects. AIDSCAP directly managed comprehensive projects in some countries and supplied technical assistance to USAID missions as requested. USAID relied primarily on private voluntary organizations (PVO) and nongovernmental organizations (NGO) to implement its HIV/AIDS programs, both at its Washington, D.C., headquarters and in the field. By 1997, USAID had incorporated the goal of reducing HIV/AIDS transmission as one of five objectives in its global health improvement portfolio and had delineated performance goals and indicators to measure its progress. Agency funding for HIV/AIDS activities had increased (to about $125 million in 1993, leveling off at about $117 million a year), and USAID shifted more resources to missions to develop their own comprehensive programs. Headquarters’ efforts became focused on providing technical assistance as needed and supporting research. In fiscal year 1997, the majority of USAID’s funds supported project activities at the country level—with major programs in 28 countries ($81 million), followed by centrally managed technical assistance and research support ($20 million), and grants to UNAIDS ($16 million). In 1997, USAID initiated three cooperative agreements with several PVOs and has a fourth in process. These agreements provide up to $290 million over 5 years for HIV/AIDS activities—about $40 million to conduct operations research and field testing to refine and develop best practices for prevention and care; up to $150 million for technical assistance, as requested by missions; up to $75 million to implement programs that advertise and promote the appeal, availability, and use of condoms, as requested by missions; and about $25 million to provide program design/monitoring and evaluation, lessons learned, and information dissemination services. WHO first began collecting and publishing information on HIV/AIDS in 1981. The U.N. General Assembly directed WHO to develop and coordinate the agency’s first program to respond to HIV/AIDS by creating the Special Program on AIDS in 1987, subsequently renamed GPA in 1988. GPA’s mission was to strengthen the capacity of governments to respond to the epidemic and to help establish national AIDS programs. WHO provided technical and financial support, ranging from $100,000 to $400,000 to initiate national programs. WHO is credited with making major contributions to nations’ efforts against the epidemic, including protecting blood supply systems, strengthening national behavior research, and improving disease surveillance. In the early 1990s, U.N. officials and donors increasingly recognized the need for a multisectoral response to the complex challenges of the HIV/AIDS epidemic—including the social, economic, and development issues affecting the spread of the virus. They realized that WHO’s medically based response was insufficient. They were concerned that countries were dependent on GPA for operational support and, as a result, were not devoting enough of their own resources to the effort. Also, they expressed the need for better coordination and delineation of roles and responsibilities among various U.N. agencies. To address these concerns, on January 1, 1996, the United Nations replaced GPA with the Joint United Nations Programme on HIV/AIDS (UNAIDS). The 1996-97 biennial budget for the UNAIDS Secretariat was $120 million, of which the United States contributed $34 million, or about 28 percent. The U.N.’s goal in creating UNAIDS was to lead a broad-based, expanded, worldwide effort to prevent the transmission of HIV/AIDS. UNAIDS is composed of a Secretariat and six U.N. agency cosponsors: the United Nations Children’s Fund (UNICEF); the United Nations Development Program (UNDP); the United Nations Population Fund (UNFPA); the United Nations Educational, Scientific, and Cultural Organization (UNESCO); WHO; and the World Bank. Each cosponsor was expected to expand its financial support for HIV/AIDS efforts, to try to mobilize resources for HIV/AIDS in affected countries, and to coordinate with other cosponsor agencies at the country level. Unlike WHO’s role in GPA, the UNAIDS Secretariat was not expected to provide significant financial support and technical advisers to countries. Instead, it was established primarily as a coordinating body and was expected to advocate increased political and financial support for HIV/AIDS activities, to devise a framework for performance measures to be used in managing HIV/AIDS activities, to provide technical support and best practice information to help develop and carry out national HIV/AIDS strategies, and to organize entities at the country level—called “theme groups”—as the forum for coordinating U.N. efforts.