I. INTRODUCTION

ABOUT THIS DOCUMENT

SCOPE OF THE PANDEMIC

PREVENTING INFECTIONS

TREATMENT

U.S. FOREIGN POLICY IN THE GLOBAL COMBAT AGAINST HIV/AIDS

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II. ACTION STRATEGY: MEETING U.S. INTERNATIONAL HIV/AIDS GOALS

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A. PREVENT NEW HIV INFECTIONS

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1. TAKE DIPLOMATIC INITIATIVES TO PROMOTE MORE ACTIVE INVOLVEMENT ON HIV/AIDS ISSUES BY NATIONAL GOVERNMENTS.

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2. DEVELOP BEHAVIORAL PREVENTION STRATEGIES.

3. AUGMENT RESEARCH.

4. SAFEGUARD THE BLOOD SUPPLY.

5. PROVIDE ACCESS TO HEALTH SERVICES AND TECHNOLOGIES.

6. ADDRESS THE ADVERSE IMPACT OF POVERTY AND OTHER FACTORS ON PREVENTION EFFORTS. 12 B. REDUCE PERSONAL AND SOCIAL IMPACT

1. PROVIDE CARE AND SUPPORT.

2. GUARANTEE HUMAN RIGHTS.

3. PROTECT POLITICO-MILITARY STRUCTURES AT RISK.

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C. MOBILIZE AND UNIFY NATIONAL AND INTERNATIONAL EFFORTS

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APPENDIX A: AN AGENDA FOR ACTION

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4. PLACE HIV/AIDS ON THE SUSTAINABLE DEVELOPMENT AGENDA.

APPENDIX B: INTERNATIONAL RESEARCH COOPERATION

APPENDIX C: PREVENTION

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APPENDIX D: THE IMPACT OF AIDS -- U.S. SECURITY INTERESTS/CONCERNS

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APPENDIX E: DONOR COORDINATION

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UNDP United Nations Development Programme

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

WHO World Health Organization

I. INTRODUCTION

The HIV/AIDS pandemic poses major challenges to all nations. HIV/AIDS is, as President Clinton observed, "the health crisis of this century." HIV/AIDS will also have economic, social, political and security implications throughout the world.

While human suffering is the most significant implication of HIV/AIDS, the pandemic is affecting a widening spectrum of society both in the United States and abroad. The spread of HIV/AIDS threatens to undermine democratic initiatives by destabilizing societies. HIV/AIDS threatens the sustainable economic development of many countries, including current and potential trading partners. U.S.-based multinational companies will face difficult challenges in addressing the impact of global HIV/AIDS on trade and investment considerations. National security interests are affected by the high rate of HIV infections among the military of certain countries. The international community is becoming increasingly concerned that some governments use HIV/AIDS as a justification for the violation of human rights. In many countries women's lower socio-economic status puts them at higher risk of becoming infected.

The United States must struggle against the HIV/AIDS pandemic. As the major contributor to multilateral and bilateral prevention efforts and as the world's standard bearer for biomedical research, the United States has been a central player in efforts to stem the spread of global HIV/AIDS. Our strong support for the streamlined newly established Joint U.N. Programme on AIDS provides another example of U.S. leadership on this issue. Yet much hard work remains. Success will require a sustained and vigorous commitment by the United States and its international partners.

About this document

This Strategy and action plan seeks to assist U.S. policymakers in working more effectively with international partners in the fight against global HIV/AIDS. Even as an early draft, this framework proved useful in guiding our preparation for the Paris AIDS Summit in December, 1994, and will help guide the U.S. planning for the IVth World Conference on Women to be held in September, 1995 and other future international meetings.

A USG interagency working group developed the document in consultation with nongovernmental AIDS activist groups, business and trade representatives, and service organizations. The strategy articulates a set of U.S. international objectives for the fight against HIV-infection and AIDS and a set of actions aimed at meeting these objectives. The paper is intended mainly for the traditional foreign affairs agencies, such as the Department of State and USAID, as well as domestic agencies such as the Department of Health and Human Services to the extent that their activities promote international HIV/AIDS policy objectives.

Appendices B-E are interagency working group reports which formed the basis of the Strategy. Reports were prepared on Research (chaired by NIH), Prevention (chaired by USAID), National Security (chaired by CIA) and Donor Coordination (chaired by USAID). The Strategy itself, which has been cleared by all concerned USG agencies, is based on the interagency working group reports and State Department input and was developed through coordination and synthesis by the State Department. The Strategy does not describe all AIDS-related activities of all agencies but rather highlights activities that advance foreign policy objectives (USAID activities, for example, are described in a separate, comprehensive document).

The interagency working groups made rapid progress in outlining the fundamental tenets of the present document. This permitted the United States to support the inclusion of many of the principles contained herein in the Paris AIDS Declaration which was signed by leaders from 42 countries at the 1994 Paris AIDS Summit. The document is the basis in principle for U.S. support for the establishment of the U.N. Joint and Co-Sponsored Programme on HIV/AIDS and for the World Health Organization's Global Programme on HIV/AIDS.

HIV/AIDS is a long-term problem requiring a long-term commitment. The present Strategy should therefore be considered a long-term foreign policy framework supported by a near-term set of action items. As the present pandemic changes, and as we learn more about successful approaches to combat HIV/AIDS, our overall strategy and action plan should change accordingly. The Strategy should be viewed as a dynamic and flexible document, to be reviewed and revised as appropriate and at least biennially. The State Department will monitor progress toward reaching the goals outlined in the present Strategy.

Scope of the Pandemic

No region of the world has been spared the steady, silent spread of human suffering associated with AIDS. While the poorest regions of the world have been spared the least, industrialized countries will also be faced with increasing numbers of AIDS cases well into the foreseeable future. In the United States, HIV/AIDS is now the number one killer of Americans in the 25 - 44 year old age group, according to the Centers for Disease Control and Prevention.

Two to three million new HIV infections worldwide are expected annually. By the year 2000, the WHO estimates conservatively that 30-40 million people will have been infected. Harvard's Global AIDS Policy Coalition estimates that between 40 to 110 million people will have been infected by that time. While a small percentage of HIVinfected individuals have lived for twelve years or more with no sign of AIDS, the large majority of HIV-infected individuals develop AIDS and die within years.

Unlike other infectious disease epidemics such as cholera or plague, AIDS will not likely run its course and subside, at least in the foreseeable future. Without more effective response strategies and massive behavioral and societal change, or an effective vaccine, AIDS will continue to spread, especially in the Third World, reaching staggering levels of infection, death, human suffering, and social disorder. Thus, without human intervention, the number of AIDS cases will continue to rise in all regions of the world well into the next century.

Thus HIV/AIDS presents a unique set of health, social, economic and political challenges which will affect both developed and developing countries. For the most part, HIV/AIDS affects those in the 25-44 age group, arguably the most productive in society. Developing countries and countries in transition will suffer the most from the loss of productivity. The incubation period from initial infection to disease onset is usually upward of ten years, during which time the infection may be unknowingly spread. Almost 80% of infections occur through sexual transmission; current prevention strategies rely primarily on changes in high-risk sexual behaviors, notoriously difficult to control. As governments cope with increasing numbers of cases and already weakened health care systems, the economic impact on the most productive segments of society, and the impact on their military and political forces will become increasingly evident.

Some specific examples of the broad impact of HIV/AIDS include:

The World Health Organization (WHO) estimates there will be between 10 and 15 million orphans worldwide attributable to HIV/AIDS by the turn of the century. The proportion of women infected with HIV is increasing rapidly; by the year 2000, the WHO predicts that more than half of newly infected adults will be women.

In 1992 in Thailand, multinational firms invested $1.3 billion. If projected rates of HIV infection in Thailand hold, a labor force increasingly weakened by AIDS-related illness and reduced by AIDS deaths could discourage foreign investors and jeopardize advances in the Thai standard of living. Tourism in Bangkok, a major source of income in the Thai economy, is lagging already, in part because of the fear of HIV/AIDS.

A World Bank and U.S. Census Bureau modeling exercise found that by 2015, Africa's total GDP could be reduced by up to 22 percent relative to a no-AIDS scenario, which assumed moderate economic growth through the period. Certain militaries may begin to experience the adverse effects of AIDS in the next five years as rising HIV infections among young men reduce conscript pools and as an increasing number of officers, senior NCOs, and trained technicians become ill and die. HIV/AIDS could begin to degrade military manpower pools and readiness within the next ten years.