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USAID: From The American People
USAID's 50th Anniversary

This is an archived USAID document retained on this web site as a matter of public record.

Testimony of Vivian Lowery Derryck,
Assistant Administrator
Bureau for Africa

before the Committee on International Relations Subcommittee on Africa,
United States House of Representatives
Hearing on HIV/AIDS: Steps to Prevention
September 27, 2000

Introduction

Mr. Chairman, I want to thank you for holding this hearing on one of the gravest threats the world faces today. We are all too familiar with the grim reality of over 23 million people already infected and almost 16,000 persons becoming infected every day in sub-Saharan Africa. At least 10 persons get infected every minute. Half of all new infections in southern Africa, and 10 percent of new infections worldwide, occur in South Africa, now experiencing the fastest growing AIDS disaster. In 1999, AIDS was the largest killer, accounting for 2.2 million deaths in sub-Saharan African, more than double the 1 million deaths from malaria. By 2005, the daily death toll will reach 13,000 people with nearly 5 million AIDS deaths in that year alone. Although 70 percent of AIDS cases are in Africa, the continent is home to only 10 percent of the world's population, reflecting the disproportionate impact of this epidemic. Preventing these infections and thereby pro-tecting 70%-80% of the population not yet infected (even in high prevalence countries) should be the highest priority of both the affected countries and the inter-national community. The proportion of the population not yet infected is as high as 95%-99% in a number of West African countries and in Madagascar. However, time is running out, and stronger actions are needed now.

Apart from the devastating impact of the epidemic on economic development, HIV/AIDS has played havoc with the lives of African families and has become one of the greatest human tragedies in recent history. Over 40 million children are estimated to become orphans by 2010 from all causes but 80% of them will lose one or both parents to HIV/AIDS. Mr. Chairman, this number amounts to 40 times the population of a country like Botswana. Reducing the vulnerability of these orphans to the disease to which their parents succumbed and reducing the stigma and social and economic problems are challenges not only for Africa but also for the entire world. The orphan issue represents the complexity of approaches that we must take to conquer HIV/AIDS and the interlinked cycle of needs: preventing HIV/AIDS in the first place, caring for infected parents to keep them alive longer, providing medical care and support for affected children, sup-porting orphan's and vulnerable children's attendance in school, providing critical food aid to affected children and their families, and providing youth-oriented prevention messages to prevent future HIV transmission. These children, with proper care and training, can become responsible citizens and strong proponents of prevention messages.

USAID has led the fight against this epidemic since 1986. In the almost 15 years that have passed, we and the international community have learned valuable lessons to prevent the spread of the epidemic and to care for those affected. The Leadership and Investment in Fighting an Epidemic (LIFE) initiative launched by the Administration, and supported by the Congress, last year reflected the package of interventions that have been shown to work to reduce HIV prevalence, as in Uganda, and to keep low rates low, as in Senegal. The initiative also provided necessary additional funds to begin scaling up these interventions. Our challenge is to apply the numerous prevention interventions that are currently available and that have proven their effectiveness.

Successful prevention programs incorporate a set of interventions: better availability of information, condoms and social marketing, mother-to-child transmission prevention, voluntary counseling and testing, access to support services for persons infected, and broad multisectoral approaches to the epidemic. In addition, the success of these interventions relies on efforts to reduce stigma, especially for women and youth; engage political, religious, and other leaders; and enhance training and technical assistance efforts, including Department of Defense efforts with African militaries.

USAID and other U.S. government agencies are supporting the expansion of these interventions. USAID is the largest bilateral donor for HIV/AIDS with a large presence of technical expertise in the field. Thanks to the commitment of the Administration and the Congress, USAID's response to the epidemic is constantly being enhanced. I must stress, however, that there is one significant constraint to stepping up our attack on HIV/AIDS. We need a strong commitment on the part of countries to effectively use the resources being pledged by the international community. We cannot, however, cate-gorically refuse to undertake programs in countries where leaders do not demonstrate the desired level of commitment. The suffering of the affected populations, not to mention the threat posed to neighboring countries, would simply be too great. In those instances where the necessary commitment is lacking, we must still persist in establishing anti-AIDS programs by working with willing non-governmental organizations (NGOs) and communities. At the same time, we are acutely aware of the fact that the outcomes will not be as successful as in places where we have good public sector partners. Accordingly, we will work to strengthen countries' commitments to fight HIV/AIDS at all levels and work most closely with the private sector and NGOs already doing their utmost to prevent the spread of the epidemic.

With your permission, Mr. Chairman, in my testimony today I will mention several examples of effective prevention strategies: use of information and education to encourage behavior change; condom social marketing; confidential voluntary counseling and testing (VCT) programs; prevention of mother-to-child transmission (MTCT); and providing support to orphans and vulnerable children. VCT and MTCT, in particular, represent new and innovative strategies for prevention. USAID recognizes that provision of care services is also instrumental to encouraging prevention by creating entry points for prevention services and to provide affected persons with incentives to change behavior.

Use of Information and Education for Behavior Change

In the last decade, extraordinary progress has been made in disseminating information about HIV/AIDS in different countries. Despite these efforts, however, millions of people are still not well informed and thus are vulnerable. The vulnerability is especially high among girls due to lack of education, inadequate access to information from other sources, and generally lower economic and social status. For example, in many severely affected countries (e.g., Zimbabwe, Zambia and Cote d'Ivoire), twice as many boys as girls aged 15-19 know how to protect themselves.

Peer education has been effective among youth, as well as among certain vulnerable groups such as truck drivers and sex workers. USAID has funded, as one example, a new program called Africa Alive whereby music is used to reach youth with key HIV pre-vention messages. However, we have learned that information alone is not sufficient to change behavior. Issues such as stigma must be addressed. Giving people the tools to change behavior is also critical, as is the case with voluntary counseling and testing, which I will discuss later.

A study by UNAIDS indicated that people with more education were far more likely to protect themselves by using condoms for casual sex. An increase of even a few more years of schooling translated into a rise in condom use, especially among girls. USAID therefore has linked HIV prevention efforts with those to increase girls' access to educa-tion. The latter includes life-skill education as part of the multisectoral approaches to HIV/AIDS. USAID is leading donor efforts to mitigate the impact of HIV/AIDS on education systems in a number of countries such as South Africa, Zambia, Malawi and Ghana.

Delay in Sexual Debut

One of the main factors responsible for decline in prevalence in Uganda has been the delay in sexual debut by youth. Religious leaders were instrumental in inculcating ideas about sex within marriage and delays in the age of sexual debut. USAID has supported the involvement of religious leaders in programs such as those in Uganda and to promote safe sex. In Ethiopia, USAID support has helped religious leaders organize to tackle HIV/AIDS. USAID also is working with the White House Office of National HIV/AIDS Policy to plan a White House Religious Leaders Conference on HIV/AIDS in December 2000.

Social Marketing of Condoms

Without a vaccine, the only available means of protecting oneself from HIV is either changing behavior or use of condoms. In Africa, social marketing programs have been increasingly effective in educating about the use of condoms, and sales have soared during the last few years. As a result, many countries are not able to meet the demand. On the whole, more men report using condoms than women and both sexes are more likely to use condoms for sex with casual partners. Studies have shown that young people are more likely than their elders to use condoms. This bodes well for the prevention of HIV/AIDS infections in the future.

USAID has been a major source of funding social marketing and condom distribution programs. Condom sales increased rapidly during the last three years in high and low prevalence countries. The former includes Uganda, Kenya, Zimbabwe and Tanzania and the latter includes Benin, Guinea, Ghana and Madagascar.

The availability of female condoms can add to the measures that women can undertake to protect themselves. The female condom is not meant to replace male condoms. Rather, its availability increases the options available to women to protect themselves. Unfor-tunately, the price of the female condom remains high and thus is not affordable by a large number of women. There are also issues concerning the design and ease of use of the device. USAID has provided funding to study the cost and design issues.

Voluntary Counseling and Testing

An Essential Part of Prevention

In the last few years, USAID support has been critical to expanding a promising and effective prevention strategy: voluntary counseling and testing (VCT). VCT is the process by which an individual undergoes counseling, enabling him or her to make an informed choice about being tested for HIV. If he or she chooses to be tested, there are provisions for post-test counseling and follow-up.

Let me stress that our efforts support this service only in a confidential manner. By expanding access to confidential VCT, we may also counteract the alarming trend growing in some areas and sectors, especially in certain workplaces, of mandatory or even secretive testing. This is a deplorable violation of the right of the people being tested, and is actually counterproductive to efforts to slow the spread of the disease.

There are compelling reasons for provision of VCT facilities in sub-Saharan Africa. UNAIDS estimates that 90 to 95 percent of Africans do not know their HIV status. As a basic human right, individuals should have access to information and services that will inform them of their status, whether they are sero-positive or sero-negative, if they wish to be so informed. As a public health measure it is important that people should know the risk of their behavior to themselves and to others. VCT enables people to plan their lives and is most effective for those who are about to make critical life decisions. Pregnant women who are aware of their sero-positive status can prevent transmission to their children, and parents can plan for the care of their children after they die. VCT has been shown to cause sexual behavior changes, at least in the short run. VCT also provides the necessary psychological support to those found to be sero-positive, even in the absence of antiretroviral drugs. VCT to screen for HIV/AIDS, when done in concert with efforts to diagnose other STDs, can help make people less susceptible to infection. Other sexually transmitted diseases can make people many times more likely to contract HIV. One of the most important contributions of VCT programs is the normalization and destigmatiza-tion of HIV/AIDS. VCT contributes a collective sense that HIV infection is something that can happen to anyone, making it easier to engage in public discourse on prevention of HIV. This also creates the opportunity for people living with HIV/AIDS to organize into groups that can be pivotal in carrying forward messages about prevention and in the provision of care and support to others with HIV/AIDS. Finally, VCT provides an entry point to care.

Impact and Effectiveness of Voluntary Counseling and Testing

USAID supported the earliest efforts in providing VCT services in Uganda ten years ago, where national leadership and public demand created a supportive environment. As a result, the 1995 demographic and health survey indicated that over 67% of Ugandans were eager to know their HIV status. The USAID-supported AIDS Information Center became the major non-medical site to provide voluntary counseling and testing, which had served over 400,000 clients by the end of 1999. The number of clients and the demand has grown rapidly, and the facilities are being expanded nationally. The Uganda experience illustrates the importance of strong linkages between VCT services and support services for those testing positive and negative. Referrals to organizations, such as The AIDS Support Organization (TASO) in Uganda, provide clients with long-term social support, access to post-test clubs where both HIV-positive and negative persons meet and reinforce behavioral changing efforts, and care and support services for HIV-positive clients. TASO is now being replicated in other African countries. In Uganda, HIV prevalence among those seeking VCT declined from 23% to 15% among males and from 35% to 28% among females during 1993-97. Following Uganda's success, USAID helped introduce VCT in Kenya, Malawi, Zimbabwe, South Africa, Zambia and Tanzania. VCT has become one of the major responses to the epidemic.

In Zimbabwe, recent USAID efforts have led to large increases in demand. Using a social marketing approach, 31 sites were selected based on criteria such as availability of trained counselors, expected demand, and consultations with the stakeholders and communities. Both governments and non-governmental organizations run clinics.

VCT efforts in Kenya and Tanzania demonstrate that the proportion of individuals reporting unprotected intercourse with non-primary partners declined significantly for those receiving VCT compared to those receiving simply health information: reduction among men with VCT was 35% as compared to 13% with health information only. The corresponding figures for women were 39% and 17%, respectively. Condom use among all participants increased.

Future Prospects for VCT

The demand for VCT is growing in sub-Saharan Africa. Evidence in Zimbabwe and Malawi indicates that, once VCT services are made available, demand for the service is greater than had been anticipated. Additional efforts to increase the availability of mother-to-child transmission prevention rely heavily on the availability of VCT services to identify vulnerable women. New technologies, such as rapid tests allowing same-day results, is making VCT easier for people by reducing the burden of having to travel back to a clinic to learn the results. VCT currently costs between $12 to $24 per person. However, personnel costs are the largest component of the total cost, as the test kits themselves cost $1 to $2.

Given the high value of VCT programs, countries and donors need to:

Prevention of Mother-to-Child Transmission

The problem of mother-to-child transmission (MTCT) is becoming increasingly urgent. MTCT is estimated to be the cause of about 10 percent of all new HIV infections and nearly 100 percent of all cases of pediatric HIV. About half-a-million babies become infected with HIV every year. Mother-to-child infections are likely to increase because of the growing epidemic among women. About 55 percent of all new infections in Africa occur among women. Of these, 70 percent are between the ages of 15 and 24 years. These are new infections among women who are beginning their reproductive lives.

Over the last several years, use of antiretroviral drugs have been shown to reduce the transmission of HIV to infants. MTCT can occur during pregnancy, at the time of delivery, and after birth through breastfeeding. In Africa, of 10 children born to HIV-infected mothers, it is estimated that two will be infected during pregnancy or delivery, one will be infected through breastfeeding, and seven will remain uninfected. Because multiple factors influence transmission of HIV from parent to child, USAID is supporting a broad set of interventions to prevent MTCT.

Carefully implemented MTCT programs have the potential not only to save the lives of infants, but also to serve as a catalyst for improving and expanding HIV prevention and care services. MTCT programs highlight the need for expanded voluntary counseling and testing, for high-quality prevention programs for women who test negative for HIV, and for expanded programs to care for those infected with HIV.

USAID's approach to MTCT includes:

This package of interventions holds promise of preventing up to 10 percent of new infections in Africa. However, it is one of the most complex interventions to deliver.

Women who are infected with HIV are at great risk for discrimination, rejection, and violence by their families and communities. MTCT interventions have the potential to disclose a woman's HIV status. For instance, in many communities, breastfeeding is the norm. To be seen giving breastmilk substitutes discloses one's HIV status. USAID will undertake MTCT programs that have been designed with adequate community participation and sensitization. Health worker training will include emphasis on confidentiality, stigma, and health worker attitudes toward persons with HIV/AIDS.

Orphans and Vulnerable Children

As I mentioned earlier, the HIV/AIDS epidemic is producing orphans on a scale unrivaled in world history. It is difficult to overstate the trauma and hardship that the increase in AIDS-related morbidity and mortality has brought upon children. Denied the basic closeness of family life, children lack love, attention and affection, similar to children living in war-affected areas. They are pressed into service to care for ill and dying parents, removed from school to help with family or household work, or pressured into premature sexual activity to help pay for necessities their families can no longer afford, thereby escalating their own risk of infection. Often it is girls who suffer the most. Finally, these children frequently receive less health care attention.

Unfortunately the traditional responses to orphans -- developing institutions and orphanages -- is not appropriate for this crisis. Though in AIDS-affected areas there are increasing stresses to the capacity of extended families and communities to provide care, in most cases institutions are not an appropriate alternative. Institutions generally do not adequately meet key developmental needs such as consistency of care, especially for younger children. In addition, when children grow up without family and community connections, they are cut off from the support networks they will need as adults, as well as the opportunities to learn the skills and culture that children learn in families and in their communities.

Economically, institutional care is not financially feasible for large numbers of children. As African leaders have pointed out to us, this same level of resources can support many more children and families at the community level. In communities under economic stress, increasing the number of places available in institutions has often led to more children being pushed from family care to fill those places, where the material standards are seen as being higher than families can provide. This increases the scale of the problem and consumes resources that could do more if directed towards strengthening family and community capacities to care for vulnerable children. Institutional care can be helpful in those cases where there is no other immediate option, and it can serve as an interim solution while a fostering situation is arranged. However, children in this situation should be reintegrated into the community as soon as a reliable caregiver is identified.

Strategy for Intervention

When HIV/AIDS strikes, the first line of response comes from the children's families and communities. The extent to which the work of others -- governments, NGOs, religious institutions and donors -- is effective is a function of how well they support the efforts of children, families and communities. Children on the Brink, the seminal work supported by USAID, identifies five basic strategies of intervention that can help such efforts:

  1. Strengthen the capacity of families to cope with their problems;
  2. Mobilize and strengthen community-based responses;
  3. Increase the capacity of children and young people to meet their own needs;
  4. Ensure that governments protect the most vulnerable children and provide essential services; and
  5. Create an enabling environment for affected children and families.

The illness or death of a parent often catapults a child into a harsh world. The first line of defense is to enable children to stay in school so they may acquire the skills to care for themselves. Interventions to help them remain in school must address the institutional, financial and other factors that cause them to fall out of the educational system. Examples of effective interventions include: changing policies regarding fees or uniform requirements, providing at least one meal a day at school, providing schools with equipment, or renovation, in exchange for admitting vulnerable children and arranging apprenticeships with local artisans.

Conclusion

Mr. Chairman, one of the main lessons of Uganda is that a successful national effort must utilize all available tools and resources to achieve its goal. We cannot rely on one or two interventions to turn around the kind of epidemics we see raging in Africa. USAID is supporting comprehensive strategies that include the most innovative new strategies such as VCT and MTCT. USAID is committed to expanding and strengthening efforts in these areas. We will work with other donors to increase and coordinate support. However, as I stated earlier, national commitment is essential for making donor efforts more effective. As part of these comprehensive strategies, USAID will address the special challenge of orphans. All parties -- donors, governmental and non-governmental organizations and communities -- must work together toward the overarching goal of creating an enabling environment for the affected families. Stigma should be reduced; vulnerabilities of children and families should also be reduced. This means changing public recognition of HIV/AIDS from "their problem" to "our problem" in this interdependent world.

This is an archived USAID document retained on this web site as a matter of public record.

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Last Updated on: July 18, 2001