www.cgdev.org
www.gatesfoundation.org
www.jsi.com
www.hewlett.org

The Center for Global Development and
John Snow, Inc. (JSI) convened the conference HIV/AIDS in Africa: What Works in the interest of highlighting successful strategies in response to the growing HIV/AIDS crisis in Africa. The conference was designed to counter the perception that nothing can be done in the face of the daunting situation in the continent. Participants examined successful programs currently being implemented at the community, district, and national levels across Africa and identified the factors that can help expand these pockets of success into a comprehensive international, national, and regional response to the epidemic.
For the Center for Global Development and
John Snow, Inc. the HIV/AIDS epidemic is a topic in which our respective areas of expertise—economic development and public health—are inextricably linked. AIDS is both a direct threat to the physical and mental health of many Africans and an overwhelming challenge to the economic development of African families, communities, and nations. Although manifested in the individual, HIV/AIDS affects health systems, family and community structures, education, agricultural production, national budgets, business development, national security, and global trade. Addressing the challenge of
AIDS requires attention to a full range of policy issues and responses. development professionals to address pressing development issues of our time.
Participants at the conference emphasized that success in combating and even reversing
HIV/AIDS is evident in programs from the community to the national level around
Africa. They outlined seven key elements that have contributed to these successes and that must be expanded to reach other people, communities, and nations affected by HIV/AIDS:
1.
Leadership and political will are central to combating the HIV/AIDS epidemic effectively.
2.
A continuum of care—integrating prevention, care, treatment, and support—is the most effective approach to managing
HIV/AIDS.
3.
A multisectoral approach is the foundation for a strong national HIV/AIDS program.
4.
Infrastructure is essential to sustaining and replicating programs, and programs should build on infrastructure already in place.
5.
Research, monitoring, and evaluation are key to combating the epidemic because they allow for the replication of best practices.
6.
HIV/AIDS has far-reaching consequences beyond the health sector; it affects the productive resources crucial to human and economic development.
7.
More financial resources are needed.
This conference builds on the Center’s tradition of fostering dialogue on research-based policy analysis between policymakers and
Transcripts of the presentations and discussions, and biographies of the participants, are available at www.cgdev.org
.

Dr. Geeta Rao Gupta
President, International Center for Research on Women
Setting the stage for the day’s discussion on
HIV/AIDS in Africa, Dr. Rao Gupta summarized the statistics that highlight the magnitude of the problem in Africa (see Box 1).
By focusing on the numbers, it is easy to forget that HIV/AIDS is a problem with a solution. There is no cure, but there are proven ways to prevent infection, prolong life, treat secondary illnesses and infections, and provide care and support. Dr. Rao
Gupta presented five overarching lessons learned over the past two decades of combating HIV/AIDS:
Prevention, care, support, and treatment are mutually reinforcing elements of an effective response to the epidemic: It is not useful to pit prevention against treatment or treatment against care because each is an essential part of the required comprehensive approach that must be used to fight HIV/AIDS.
-
A disproportionate burden of HIV/AIDS has been borne by women: Today, we are faced with an incontrovertible fact— gender inequality is fatal. It is killing
African women and men in their most productive years, leaving behind more orphans than half the size of the population of Canada and leaving women with a large share of the burden of caring for others. Gender norms and policies based on those norms greatly restrict women’s access to the rights and resources necessary to protect themselves from HIV/
AIDS and to support those affected by it.
Effective scientific research is the only way forward: Good community-based research guides the formulation and development of interventions, operations research guides the implementation of interventions, and monitoring and evaluation
Box 1: HIV/AIDS Statistics for
Sub-Saharan Africa
-
29.4 million people live with HIV/AIDS
-
More than 14 million are women
10 million are between the ages of 15 and 24
Almost 3 million are children less than 15 years old
-
11 million children are orphans, having lost parents to AIDS
In 2001,
-
6–11% of all young women aged 15–24 lived with HIV/AIDS
3–6% of all young men aged 15–24 lived with HIV/AIDS
National HIV Prevalence Rates
Botswana: 38.8%
Zimbabwe: 33.7%
-
Swaziland: 33.4%
Source: UNAIDS, AIDS Epidemic Update , December 2002.

research highlight best practices and lessons learned to improve program effectiveness.
Stigma and discrimination against those infected with or affected by HIV/AIDS can undermine the success of AIDS prevention, testing, and care efforts: Stigma and discrimination impede individuals from discovering that they are at risk, create barriers to testing, reduce access to treatments, hinder the individual’s ability to negotiate protection, and prevent individuals from providing humane care to loved ones who are infected.
-
The most important ingredients in successful national programs are political will and committed leadership: Leaders at the local, national, and international levels are needed to champion the cause of AIDS prevention, care, treatment, and support. Advances come from individuals being bold enough to speak openly about sex and sexuality and about the results of public health research, even if frank discussion is politically expensive.
The full text of Dr. Rao Gupta’s speech can be found at www.cgdev.org
3
—Dr. Geeta Rao Gupta

Participants in two panel discussions highlighted pockets of success in combating HIV/AIDS in Africa and outlined seven key elements that have contributed to these successes and that must be expanded to reach other people, communities, and nations affected by HIV/AIDS.
Success in combating and even reversing the
AIDS epidemic is evident in programs from the community to the national level across
Africa. Programs such as The AIDS Support
Organization in Uganda and MSF in Malawi effectively offer integrated care services in poor urban and rural communities with minimal infrastructure (see Box 2). Uganda, which had experienced alarmingly high prevalence rates, was the first nation to reverse prevalence trends and now sees a decrease in rates of infection. And Senegal, through bold leadership and collaboration across sectors, has managed to keep prevalence rates below 1%. Zambia, South Africa, and Ethiopia have also begun to see a decrease in the rates of infection among some population groups. These successes show that the spread of HIV can be contained and that people living with HIV/AIDS can enjoy productive lives.
1. Leadership and political will are central to combating the HIV/AIDS epidemic effectively.
Political will and bold leadership at the com-
Co-Director of the JSI/World Education Center for
HIV/AIDS and Senior Technical Advisor for the
Uganda AIM Project
Senior Clinical Advisor, John Snow Inc.; Assistant
Professor of Clinical Medicine, Harvard Medical
School; and, Director of HIV Medical Care and
Research, Dimock Community Health Center, Boston.
Executive Director of the Harvard AIDS Institute
Director of the Global AIDS Program at the Centers for Disease Control and Prevention (CDC)
Senior AIDS Program Officer at the Global Health
Council; former Director of The AIDS Support
Organization (TASO) in Uganda
Director of the Conseil National de Lutte contre le
SIDA et les MST, Senegal
Associate Director for Surveillance, Research,
Monitoring and Evaluation in the Department of
HIV/AIDS at the World Health Organization

– Dr. Eugene McCray munity, district, and national levels are two of the most important factors in winning the war against
HIV/AIDS. In both Senegal and Uganda, the
Heads of State demonstrated their strong commitment to combating the epidemic by spearheading national programs to mobilize leadership throughout their countries at all levels. (For more on the programs in these two countries, see
Boxes 3 and 4.)
2. A continuum of care—integrating prevention, care, treatment, and support—is the most effective approach to managing HIV/AIDS.
The importance of integrating prevention, care, and treatment—a resounding topic throughout the conference—was only a year ago not accepted. Experience now shows that elements of the continuum of care are mutually reinforcing and indispensable to each other. Prevention programs bring people into voluntary counseling, testing, and other services. Treatment programs offer hope and motivation for people to engage in prevention and greatly reduce the stigma associated with the epidemic. For example, providing treatment increased patient uptake in
South Africa, where the number of HIV tests increased geometrically—from 1,000 per month in 1998 to 12,000 per month in 2002. Care and support for families affected by AIDS provide a vehicle for positive prevention and assistance in ensuring compliance with treatment. The whole of a continuum of care program is more than the sum of its parts.
Box 2: HIV Treatment in Resource-Poor Settings—
Doctors Without Borders/Médecins Sans Frontières (MSF)
Finding Success in Poor Areas
Doctors Without Borders has established 10 projects that provide anti-retroviral (ARV) therapy. Operating in some of the poorest places in Malawi, MSF offers free treatment to 2,300 patients.The success of these pilot programs refutes the assertion that ARV therapy is not feasible in poor countries due to a lack of, among other things, infrastructure and treatment programs. MSF consolidated one year’s data from seven projects to present at the HIV/AIDS conference in Boston.They proved significant improvement in patients’ overall well-being, including weight gain, and equally important, they demonstrated an adherence or compliance rate of 93%—something that was previously considered impossible.
The Importance of Access to Drugs
Since the projects were begun in 2001, drug prices have decreased, largely due to the influx of generic competition.
Originally, combinations of the basic drugs cost
$10,000 per patient per year.
-
Three-tier pricing brought this total down to $700 per patient per year.
Generic competition from Brazil,Thailand, and India has reduced costs to just $200 per patient per year.
The World Health Organization recommends a sixdose combination, given once a day, at $70 per patient per year.
An additional challenge is to simplify drug combinations.
The differences across countries in infrastructure and training demand that protocols are simplified. At present the generic companies provide dose combinations that must be taken twice a day. AIDS patients are often taking other necessary medications that can bring the total to
15 tablets a day. Compliance is essential for AIDS patients, and having to take this amount of medication a day is a strong reason for defaulting.The next steps would include simplifying laboratory monitoring and getting experts in anti-retroviral therapies to work with physicians and institutions in developing countries to formulate reasonable, cost-effective, replicable programs.
5

6
Components of the prevention package include behavior-change programs to promote abstinence, reduction in the number of partners, and condom use, as well as outreach to those who are most vulnerable, including sex workers and their clients, intravenous drug users, men who have sex with men, and youth. In addition, treatment of sexually transmitted infections (STIs), prevention of mother-to-child transmission, family planning, and voluntary counseling and testing are essential. Prevention programs at the institutional level are also key to ensuring infection control in health care settings—including safe injection practices, blood safety and surveillance, and continuing research into microbicides and vaccines.
– Sophia Mukasa Monico
Components of care and treatment include homebased care, palliative care to alleviate symptoms, treatment of opportunistic infections, and antiretroviral therapies. Strategies to support those who are affected by HIV and AIDS include support for orphans, legal reforms, training in income-generating activities, educational programs, and food security.
3. A multisectoral approach is the foundation for a strong national HIV/AIDS program.
A multisectoral approach is required because the public and private sectors each offer resources needed for the various components of the continuum of care. The most successful programs and strategies are those designed and implemented by a coalition of national and local leaders, government agencies, community-based and nongovernmental organizations, businesses, professional associations, researchers and scientists, and people living with HIV/AIDS. A multisectoral approach makes best use of the resources available to a national program and ensures that mutually reinforcing efforts are sustained.
Box 3: Success on the Ground: Comprehensive and Coordinated Interventions in Uganda
The AIDS Information Center was the first voluntary counseling and testing center for HIV in Africa. It uses a three-pronged approach:
-
Service delivery that includes prevention education, condom distribution, and anonymous voluntary counseling and testing
-
Referral to other organizations for higher levels of medical care for those who are HIV-positive
-
Post-test classes for both HIV-positive and HIVnegative clients—the classes offer counseling, medical care, HIV education, and family planning education
The largest nongovernmental organization (NGO) in
Africa, The AIDS Support Organization (TASO) , served
10,000 new clients in 2002; all clients were HIV-positive,
65% were female, and 90% lived below the poverty line.
TASO’s model of service delivery includes:
A full line of counseling services
-
Social support for clients and their families
Advocacy and mobilization programs to protect the rights of people living with HIV
Community and institutional capacity building that empowers communities and organizations to sustain programs locally
-
Home-based care , including training for families and community members
-
Training for counselors and community AIDS workers, and medical care for people living with HIV and AIDS

7
4. Infrastructure is essential to sustaining and replicating programs, and programs should build on infrastructure already in place.
To be expanded effectively and replicated, programs must invest in human and institutional capacity; improve logistics, laboratory, and clinical services; strengthen management systems; and support community involvement.
Human resources are critical to the effective delivery of HIV-related services. This means recruiting, training, supporting, supervising, evaluating, and retaining staff to deliver services. It is critical to draw from local human resources to design program models that reflect local conditions and capacities and meet specific standards of care.
Box 4:The Senegal Experience
Senegal initiated its open and progressive response to the epidemic as soon as HIV/AIDS was identified within its borders.
Since then it has managed one of the strongest national
HIV/AIDS programs in the world. Effective leadership within the National AIDS Program and the support of formal and informal decisionmakers from the President down to the local imam have contributed significantly to its success. From the very beginning, the National AIDS Program has been founded on evidence-based programming and the rapid application of best practices and state-of-the-art strategies, including early support for multisectoral strategies.
In 2001, an assessment of injection practices and waste management resulted in the development of a draft injection safety and waste management policy.
Changing Behaviors/Reducing Stigma:
-
More than 1,000 NGOs are involved in HIV prevention, care, treatment, and mitigation, including organizations of
People Living with HIV/AIDS.
-
A national strategy was put in place for the social marketing of condoms.
-
Programs targeted those most at risk of infection, including commercial sex workers and their clients, military personnel, truck drivers, young people, and migrants.
Successes:
-
HIV prevalence rates have stabilized at very low levels
(adult prevalence rate of 1.77%).
HIV-1 prevalence rates for male STI patients fell from 5% in
1993 to 3% in 1998.
HIV-1 prevalence rates among women attending antenatal clinics in Dakar, the major urban area, fell from 1% in 1995 to 0.5% in 1998.
Multisectoral Approach:
-
NGOs, community organizations, and religious groups work together.
-
Branches of the public sector are involved, including the
Ministries of Health, Education,Youth and Sports, and Labor and Defense, as well as schools, women’s groups, and the army.
The private sector played its part as well, with the involvement of private companies.
Brief Timeline:
-
In 1970, Senegal instituted a blood transfusion bank to ensure a national and safe blood supply.
In 1978, the National Sexually Transmitted Disease Program and the STI prevention program for Commercial Sex
Workers began.
-
In 1986, the National AIDS Control Program was initiated.
The following year, HIV and STI services were integrated for efficiency and effectiveness.
-
In 1989, the Blood Transfusion Safety Policy was passed.
Leadership:
The Head of State is personally committed to participating in national efforts to control the epidemic.
-
The government empowered and financed the National
AIDS Control Program to fulfill its mandate.
-
Political support translated into an annual budget of
$2 million in 2002, up from $250,000 in 1985.

8 munity are met while mobilizing and expanding resources. Community networks, existing facilities, and multisectoral initiatives can all serve as catalysts to expand programs’ impact.
Programs that build community ownership and capitalize on local expertise hold the greatest potential for sustainability.
– Dr. Richard Marlink
HIV services require significant amounts of supplies. Effective logistics management guarantees that these supplies are available. Secure supply chains must provide the required quantities of condoms, laboratory materials, medications, and other supplies at the right place, time, and cost. Well-planned logistics infrastructure can save money and improve the effectiveness of programs.
Strong management infrastructure is required at the national, district, local, and site/program levels. Management systems may be completely internal to programs or be achieved through collaboration with other agencies.
Community involvement supports the infrastructure of service programs by addressing care and stigma and ensuring that the needs of the com-
5. Research, monitoring, and evaluation are key to combating the epidemic because they allow for the replication of best practices.
Strong research—both scientific and operational—and monitoring and evaluation systems are essential to gauge progress, confirm the effectiveness of key interventions, and make the best use of resources.
When monitoring and evaluation systems are inadequate or absent, opportunities for learning are lost. For example, The ABC (Abstinence, Be faithful, Condoms) initiative is touted as having contributed to the reversal of growth in infection rates in Uganda. While it is clear that leadership played a key role in the success of this program, little else is known about the specific impacts of each of its components, making it difficult and perhaps inappropriate to exactly replicate the program in other nations.
– Dr. Kevin O’Reilly
Recognizing the importance of research, monitoring, and evaluation, The Global Fund has committed to strengthen existing data collection mechanisms and monitoring and evaluation systems. In addition, to monitor progress on the goals of the United Nations General Assembly
Special Session on HIV/AIDS, core indicators

9 and data collection mechanisms are being established in countries lacking such systems.
U.S. Agency for International Development
(USAID) funding and direction have helped establish a simple, small core set of indicators to monitor key interventions. These positive steps will help countries and communities track successes, identify weaknesses, and expand programs effectively.
6. HIV/AIDS has far-reaching consequences beyond the health sector; it affects the productive resources crucial to human and economic development.
In Zambia 2,000 teachers die of AIDS each year, while only 1,000 trained teachers graduate in the same time period. In Malawi, farmers weakened by the virus are too sick to work their land, resulting in one of the first famines in history that is generated by a disease, not by weather. To stabilize the development of their countries, there is a critical need to increase the number of people who both survive and are actively engaged in fighting the epidemic. Accelerated training and support for local professionals in a range of sectoral areas is necessary to safeguard development gains and ensure sustainability of programs in every sector.
7. More financial resources are needed.
The AIDS epidemic is taxing developing-country health budgets to an unprecedented degree. In many countries, annual health spending amounts to just a few dollars per person—barely enough to cover prevention and care programs, let alone treatment for HIV/AIDS. In many countries, it is
NGO programs that are reaching the very poorest; for example, 90% of the clients seen in
Uganda by TASO in 2002 lived below the poverty line. It is clear that more financial resources are needed to expand and replicate successful programs, but as is always that case with scarce resources, there are inherent trade-offs. In this case, the trade-off entails difficult decisions between the components of a continuum of care.
These trade-offs will be eased with increased financial resources, and can be made more wisely with increased research and learning about what works best to combat the epidemic and save lives in different settings.

Congressman
Jim McDermott
Washington Seventh District the epidemic in Africa will soon be replicated in India and China and may even be much worse.
Congressman Jim McDermott is in his eighth term in the U.S. Congress. He is trained as a medical doctor, has practiced in both the United States and abroad (including in Africa), and is a strong advocate for HIV/AIDS and other health issues in
Congress. Congressman McDermott is founder and Co-Chair of the Congressional Taskforce on
International HIV/AIDS, a bipartisan group concerned with the spread of the AIDS epidemic around the world. The Taskforce’s purpose is threefold: to share information about the spread of
HIV/AIDS in the world, to examine the social and economic effects of the disease, and to plan legislative strategies for improving the U.S. government’s response to this worldwide epidemic.
U.S. Secretary of State Colin Powell said just last November, “The biggest problem in the world right now is not terrorism. It is the
AIDS epidemic.” Secretary Powell’s profound understanding of this epidemic risks being lost in the country’s other foreign policy concerns, but the impact the AIDS epidemic has on the United States cannot be ignored.
– Congressman Jim McDermott
The crisis of HIV/AIDS is a global development issue that must concern the current
Administration and, in fact, all Americans. It is much more than an issue of health care and of AIDS; it is inherently linked to peace and development in the world. In addition to the compelling moral and humanitarian interests that drive efforts to reduce the threat of AIDS, the loss of human productivity, threats to already weak health systems, and increased instability in societies far from our shores must all be recognized for their potential impact on us as Americans. The epidemic is not going away. The intensity of
The United States must show global leadership and set the precedent for other countries to follow by fully funding the Global
Fund. Leading by example should entail not only the quantity of its funding commitments, but also the quality of its support.
Effective programs must draw from the expertise and knowledge of the communities they are meant to serve, and must support strategies that are indigenously designed and implemented.

The seminar culminated in a roundtable discussion designed to highlight key lessons learned from the day’s discussion and provide a forum for a select group of senior policymakers and HIV/AIDS experts to discuss how successful programs and the elements that support them can be developed into comprehensive strategies for combating the HIV/AIDS pandemic.
President, Center for Global Development
Director for African Affairs, National Security
Council
Senior Clinical Advisor, JSI; assistant professor of clinical medicine, Harvard Medical School; director of HIV medical care and research, Dimock
Community Health Center, Boston
Executive Vice President, Partners in Health, and Assistant Professor of Medical Anthropology,
Department of Social Medicine, Harvard
Medical School
Under Secretary of State for Economic, Business, and Agricultural Affairs
Executive Director, Harvard AIDS Institute
Director of International Programs, National
Association of People with AIDS; founder, Women
Fighting AIDS in Kenya
Senior AIDS Program Officer, Global Health
Council; former Director, The AIDS Support
Organization, Uganda
Director, Conseil National de Lutte contre le SIDA et les MST, Senegal
Director, Doctors Without Borders/Médecins Sans
Frontières Treatment Program, Malawi
Assistant Administrator of the Bureau for Global
Health, United States Agency for International
Development
Assistant Secretary for Health, Department of
Health and Human Services
Special Assistant to the Secretary of the Department of Health and Human Services, International
Affairs

12
– Dr. Jim Kim
National Association of People with AIDS
As a woman living with HIV, Ms. Mason noted with approval that people living with HIV were represented and invited to speak at this conference. She said that the current commitment to fighting AIDS in Africa is far from sufficient. The
United States is more than willing to spend resources to fight terrorism and should also devote substantial resources to fighting AIDS—
AIDS is a terror. The country already set an example by putting the Global Fund in motion, and now the United States should set an example by providing the necessary resources: $10 billion is needed to fight AIDS, and the United States should provide $2.5 million of that. The key question is what needs to be done to move the
Administration to give priority to AIDS in Africa and the rest of the world, the way it has to fighting terrorism.
Doctors Without Borders
Médecins Sans Frontières began 10 projects providing anti-retroviral treatment in 2001 and currently has patients being treated in the poorest parts of the world. Treatment is purchased at
$200 per year per patient, but this is still too expensive for most countries in sub-Saharan
Africa. MSF initiated ARV pilot projects partly to combat the belief that ARV treatment was not feasible in poor countries. Patients in their projects have demonstrated treatment adherence at
93%, above levels in the United States, and MSF has also found that providing ARV treatment increases uptake of voluntary counseling and testing. Complex drug combinations and regimens—up to 15 pills a day—are still a challenge, and MSF is pushing for development of simpler drug regimens to facilitate adherence.
Treatment protocols and lab monitoring for developing countries also need to be simpler because of limited infrastructure and the level of training. Yet MSF’s programs are evidence that
ARV therapy can be provided effectively in resource-poor settings.
U.S. Department of Health and Human
Services (HHS)
The U.S. Administration’s strategy to ensure a comprehensive response to the epidemic includes four pillars:
The Global Fund to Fight AIDS, Tuberculosis and Malaria
Bilateral assistance programs
A worldwide research effort
The Millennium Challenge Account
– Bill Steiger
The United States also works with NGOs to identify best practices and assess the potential for replication in other needy areas. Prevention is the largest component of the bilateral assistance programs, both at HHS and USAID, and is complemented by training of health care personnel,

13 advocacy, outreach care (including for orphans), the development of a care infrastructure, and social mobilization. The U.S. resource commitment is as high as 43% of the global total, which is important if the United States is to encourage other countries to increase and sustain their commitments through the Global Fund and through targeted, well-designed bilateral assistance programs.
U.S. National Security Council
The goal of U.S. policy is to create an integrated approach: a focus on prevention while working toward care, treatment, and a strong health infrastructure. The Administration established an institutional structure to ensure that officials at the highest levels of the government are committed and engaged on African policy. The United
States set a global precedent by making the first contribution to the Global Fund, elevating its visibility, and dedicating officials to its operations.
More money is needed, though, and the United
States could do more.
Another program of the Administration is the
Mother-to-Child Transmission Initiative, designed to address care and treatment and explore the most productive and efficient methods for introducing anti-retrovirals in Africa.
U.S. Department of State
Any strategy to combat HIV/AIDS has to recognize that we cannot effectively deal with the HIV/AIDS pandemic without also addressing broader development issues. The epidemic has undone much hard-won development progress in many countries, and low levels of development have provided a breeding ground for HIV/AIDS. Private-sector research and development have their place, but not at the expense of moving forward with immediate operational programs.
U.S. Agency for International
Development (USAID)
The barriers to expanding success to a national level have to be acknowledged, both in terms of human resources and dollars, but funders can work with community-based organizations and faith-based organizations on the ground in recipient countries. While promoting a balanced ABC approach, USAID allows partners, particularly faith-based partners, to choose any or all of the components—abstinence, being faithful, and condoms—depending on their comfort level.
Discussions about the impacts of AIDS and the stories of successes in fighting it seldom include policymakers beyond the health sector. Because
AIDS has significant ramifications for human and economic development more widely, policymakers in other areas need more information to assess the impact of the epidemic on their sectors.
Policymakers in all sectors will be more motivated to dedicate resources to AIDS interventions when they can see that the epidemic affects their area of interest, and when they see that the dollars invested do make a difference.

Nancy Birdsall
President, Center for Global Development
In her closing remarks, Nancy Birdsall summarized the day’s discussion from the perspective of a development economist.
Combining her two decades of work in economic development and the main themes of the day, she listed four overarching lessons from the conference:
-
It must be made clearer to the American public, the Congress, and some in the
Administration that Africa is a place where there is good government.
As everywhere, there are problems. The region, though, has many countries with incredible leadership and programs that are successful. This is a message that must be sustained outside of the development community.
It has taken this fight against HIV/AIDS to transform health systems around the developing world; it is also transforming societies.
It is transforming the way people think about the role and accountability of governments. And it is transforming the way people think about issues such as discrimination, stigma, and the role of women.
The fight against HIV/AIDS also has the potential to transform how the business of development assistance works.
In part because of the local successes in combating the epidemic, the development assistance community is seeing the value of ownership on the part of developing countries and the importance of working with
NGOs and community-based groups.
-
The idea of reasonable risk must be introduced in a new framework for addressing the epidemic.
The risks of wasting money have fallen because we have learned how to spend money better and because there is significant evidence of success in combating HIV/AIDS. The returns to investment in fighting the epidemic are huge, and as with investment in all other areas, it is necessary to take some risks to find out what does and does not work.
– Nancy Birdsall

The open exchange of ideas and opinions left many questions unanswered. In the interest of keeping the debate alive, we pose several overarching questions that were heard throughout the conference. We hope these will be the foundation for further discussion and a catalyst for action.
1.
How can the HIV/AIDS programs of individual U.S. agencies be woven into a comprehensive strategy to fight the epidemic? Who can take leadership for this within the U.S.
government?
2.
How can we generate the public and political support and the international coalition for a war on HIV/AIDS commensurate to those for the war on terrorism? What will it take to generate the political will to increase funds to combat what U.S. Secretary of State
Colin Powell has referred to as the biggest problem in the world right now?
uum of care approach be respected when making funding choices? What proportion of funds should go to each of the four elements—prevention, care, treatment, and mitigation?
4.
What is the plan to expand and replicate successful programs? What will work globally to stop the epidemic?
5.
Exactly how much money has the United
States committed to fighting HIV/AIDS, and how much has it spent? What are the plans for fulfilling the U.S. financial commitments? And is it certain that the newly pledged funding will be “new dollars,” not diverted from other social development programs such as family planning, education support, maternal and child health programs, or safe water programs?
3.
Given the current political realities of a limited budget for HIV/AIDS, how are funds best spent? How can the integrated contin-
6.
Why are the efforts of pharmaceutical companies to donate or sell medications at a reduced price not as successful as would be desired? What infrastructure is necessary to facilitate wide distribution of medications?

16
The Center for Global Development is an independent, non-partisan, non-profit think tank dedicated to reducing global poverty and inequality through policy-oriented research and active engagement on development issues with the policy community and the public. A principal focus of the Center’s work is the policies of the United
States and other industrialized countries that affect development prospects in poor countries. The Center’s research assesses the impact on poor people of globalization and of the policies of governments and multilateral institutions. In collaboration with civil society groups, the
Center seeks to identify policy alternatives that will promote equitable growth and participatory development in low-income and transitional economies. The Center works with other institutions to improve public understanding in industrialized countries of the economic, political, and strategic benefits of promoting improved living standards and governance in developing countries.
The Center for Global Development currently conducts research on intellectual property issues in the health sector and is initiating a set of research projects that will examine the effectiveness of distinct mechanisms for delivering aid in health (with special emphasis on global health alliances) and the effects of globalization on health and the health sector. In addition, with funding from the
Bill & Melinda Gates Foundation, the Center hosts the
Global Health Policy Research Network (PRN), a network of leading researchers from both within and outside the health sector whose expertise is applied to priority policy questions in global health. For example, the PRN considers “How can pharmaceutical companies be induced to invest in development of drugs for diseases that primarily affect developing-country populations?” and “What are the constraints to greater financial resources for the health sector in developing countries?” The work of the
PRN will result in research-based policy reports on these specific questions.
John Snow, Inc. (JSI) is dedicated to improving the health of individuals and communities in the United States and around the world. Headquartered in Boston,
Massachusetts, JSI and its affiliated organizations, including JSI Research and Training Institute, JSI Brasil, and
JSI/UK, provide high-quality technical and managerial assistance to public health programs worldwide. JSI’s goal is to build local capacity to address critical health problems, including HIV/AIDS, reproductive health, child survival, and environmental health. JSI collaborates with local partners to assist countries, governments, communities, families, and individuals to develop their own skills and identify solutions that meet their public health needs.
Through management assistance, research, behavior change interventions, information, and training, JSI works to improve access to and the quality of health care to prevent illness and disease throughout the life cycle, especially for the poor and underserved. Incorporated in 1978, JSI has implemented projects in 84 countries. Currently, JSI operates from four U.S. and 28 international offices, with more than 375 U.S.-based staff, and 700 field-based staff.
Since the early 1980s, JSI has been responding to the
HIV/AIDS epidemic in communities across the United
States and around the world through innovative public health and research interventions. World Education, Inc.
brings 50 years of domestic and global leadership in building the capacity of individuals, communities, local institutions, and societies to the fight against HIV/AIDS. The
JSI/World Education Center for HIV/AIDS links the expertise and experience of the two organizations to help individuals, families, communities, and countries fight the epidemic. The Center adopts multisectoral approaches to combat the epidemic; strengthens local capacity to implement sustainable solutions; works with communities to stem the spread of HIV/AIDS; targets special populations at high risk of infection; strengthens prevention, care, and support services for those who are vulnerable; improves management of HIV/AIDS commodities; effectively monitors and evaluates programs and documents best practices; and influences leaders in decision making.