AIDS in Africa.

SUMMARY

Sub-Saharan Africa has been far more severely affected by AIDS than any other part of the world. The United Nations reports that 29.4 million adults and children are infected with the HIV virus in the region, which has about 10% of the world's population but more than 70% of the worldwide total of infected people. The overall rate of infection among adults in sub-Saharan Africa is 8.8%; compared with 1.2% worldwide. Twelve countries, mostly in east and southern Africa, have HIV infection rates of more than 10%, and the rate has reached 38.8% in Botswana. As of 2001, an estimated 21.5 million Africans had died of AIDS, including 2.2 million who died in that year. AIDS has surpassed malaria as the leading cause of death in Africa, and it kills many times more Africans than war. In Africa, 58% of those infected are women.

Experts relate the severity of the African AIDS epidemic to the region's poverty. Health systems are ill-equipped for prevention, diagnosis, and treatment. Poverty forces many men to become migrant workers in urban areas, where they may have multiple sex partners. Poverty leads many women to become commercial sex workers, vastly increasing their risk of infection.

AIDS' severe social and economic consequences are depriving Africa of skilled workers and teachers while reducing life expectancy by decades in some countries. An estimated 11 million AIDS orphans are currently living in Africa, facing increased risk of malnutrition and reduced prospects for education. AIDS is being blamed for declines in agricultural production in some countries, and is regarded as a major contributor to the famine threatening southern Africa.

Donor governments, non-governmental organizations, and African governments have responded primarily by attempting to reduce the number of new HIV infections and by trying to ameliorate the damage done by AIDS to families, societies, and economies. The adequacy of this response is the subject of much debate. U.N. experts estimate 2003 spending from all sources on HIV/AIDS in low- and middle-income countries worldwide at $4.7 billion, compared with an estimated need of $10.5 billion by 2005.

Treatment of AIDS sufferers with medicines that can result in long-term survival is reportedly available to fewer than 30,000 Africans. Advocates of expanded treatment argue that in view of recent drug price reductions, treatment is an affordable means of reducing AIDS damage to African economies, reinforcing prevention programs, and keeping parents alive. Skeptics argue that treatment is still too expensive to be an option for most Africans and would require costly improvements in health infrastructure.

U.S. concern over AIDS in Africa grew during the 1980s, as the severity of the epidemic became apparent. Legislation enacted in the 106th and the 107th Congresses increased funding for worldwide HIV/AIDS programs. H.R. 1298, which was signed into law (P.L. 108-25) on May 27, 2003, would authorize $15 billion over five years for international AIDS programs. President Bush has launched an International Mother and Child HIV Transmission Initiative that will benefit 8 African countries, and 12 are slated for added support under the global aids initiative announced in the January 28, 2003 State of the Union message. Nonetheless, activists and others urge that more be done in view of the scale of the African pandemic.

MOST RECENT DEVELOPMENTS

On July 10, 2003, speaking in Botswana, the third stop on a 5-day trip to Africa, President Bush said with respect to AIDS, "This is the deadliest enemy Africa has ever faced, and you will not face this epidemic alone." On July 8, in Senegal, the President told Africans "we will join with you in turning the tide against AIDS in Africa." The President also spoke on the epidemic in South Africa on July 9. According to a Financial Times report that same day, a representative of the United Nations Development Program (UNDP) said that South Africa had fallen 28 places on the UNDP Human Development Index since 1990--to 111th place out of 175 countries--primarily due to AIDS. As of July 9, the South African government had not made public a report completed in April on the feasibility of providing universal treatment to patients needing antiretroviral therapy.

President Bush, on July 2, nominated Randall Tobias, former chairman and chief executive officer of Eli Lilly and Company, to be Global AIDS Coordinator, a position at the Department of State carrying the rank of Ambassador. Many praised the appointment on grounds that Tobias has the management experience needed for a quick launch of the President's Global AIDS Initiative, but skeptics noted that the nominee has little experience with Africa or with AIDS generally. The United Nations Joint Program on AIDS (UNAIDS) reported on June 26 that about $4.7 billion would be spent combating AIDS in low- and middle-income countries worldwide in 2003, as compared with the $10.5 million estimated to be needed annually by 2005. On June 10, President Bush welcomed President Yoweri Museveni of Uganda to the White House with praise for the Ugandan leader's "extraordinary leadership on HIV/AIDS in your country." On May 27, 2003, President Bush signed into law H.R. 1298 (P.L. 108-25), the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, authorizing $15 billion over 5 years for international AIDS, tuberculosis, and malaria activities. For details, see CRS Report RS21181, HIV/AIDS International Programs: Appropriations, FY2002-FY2004; and CRS Report RL31712, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background and Current Issues.

BACKGROUND AND ANALYSIS

Sub-Saharan Africa has been far more severely affected by AIDS than any other part of the world. In November 2002, UNAIDS (the Joint United Nations Program on HIV/AIDS) reported that in 2002, 29.4 million people were living with HIV and AIDS in sub-Saharan Africa, up from 28.5 million in 2001. Africa, where an estimated 3.5 million people were newly infected in 2002, has about 10% of the world's population but more than 70% of the worldwide total of infected people. The infection rate among adults is about 8.8% in Africa, compared with 1.2% worldwide. Through 2001, an estimated 21.5 million Africans had lost their lives to AIDS, including an estimated 2.2 million who died in that year(UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002). UNAIDS estimates that by 2020, an additional 55 million Africans will loose their lives to the epidemic. In Botswana, the worst-affected country, 55.6% of urban pregnant women aged 25-29 and attending ante-natal clinics were HIV positive in 2001. Rising infection rates continue to be seen in Zimbabwe, Namibia, and other countries as well. AIDS has surpassed malaria as the leading cause of death in sub-Saharan Africa, and it kills many times more people than Africa's armed conflicts.

Reports by scientists at the XIV International AIDS Conference, held in Barcelona in July 2002, noted that the HIV virus probably could not be eliminated by drug treatment, due to its newly discovered ability to "hide" in cells of the immune system for decades. Thus, drug therapy, once begun, would have to be provided throughout a patient's lifetime. Some progress was reported in vaccine research, but most reports suggested that an effective vaccine was still years in the future. The limited availability of AIDS treatment in Africa was another focus of the meeting, but success was reported in small-scale treatment programs. Some successes in prevention were also noted, and many speakers urged sharply increased spending both for treatment and prevention.

Characteristics of the African Epidemic

* HIV, the human immunodeficiency virus that causes AIDS, is spread in Africa, most experts believe, primarily by heterosexual contact. (A February 2003 article published by David Gisselquist and others in the International Journal of STD and AIDS asserted that the importance of unsafe medical practices in the spread of HIV may have been underestimated and called for further research. The article has caused some controversy, and the Senate Health, Education, Labor, and Pensions Committee held a hearing on March 27 to examine the issue.)

* Women make up an estimated 58% of the HIV-positive adult population in sub-Saharan Africa, as compared with 50%…