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. 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. 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. 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. 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. 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.