37. Paper Prepared in the Department of State1
EXECUTIVE SUMMARY
In his memorandum of August 5, 1988 to the Secretary of State, the President directed the development of a three-year plan for international efforts against human immunodeficiency virus (HIV) infection, with emphasis on less-developed countries.2 The attached action plan summarizes the current international efforts by federal Departments and Agencies against the HIV pandemic and presents the strategy and plan for their programs for the period FY 1989–1991.
The HIV pandemic continues to grow rapidly. At present, 142 countries report 124,114 cases of the acquired immunodeficiency syndrome (AIDS) worldwide. The AIDS case count, however, represents only a fraction of the extent of HIV infection and is also subject to substantial under-reporting, particularly in the infrastructure-poor developing world.
HIV infection is transmitted in only three ways: through sexual activity, by the exchange of blood or blood products, or perinatally from mother to child. Worldwide, the dominant mode of transmission is through sexual activity.
The extent of HIV infection in many parts of the world and the potential for further spread make control and treatment of infection and related disease a major public policy challenge in many developing countries. The potential implications for the economic and political stability of these countries, their internal security, and regional security, make the control of HIV infection an important foreign policy issue for the United States.
Given the extent of infection and modes of transmission, a worldwide effort will be required to control the further spread of infection. Because of the exceptional public and private sensitivity of human sexuality in all societies, programs to control the spread of infection will require extraordinary social, cultural, and political specificity. These factors require that policy leadership in the worldwide effort be given to an organization such as the World Health Organization (WHO), which has the capacity to interact effectively on international health [Page 110] issues and can provide the framework for effective multilateral and bilateral coordination.
The modes of HIV transmission and the current level of technology dictate that control of the spread of infection will largely depend on changes in sexual behavior. At present, there is no vaccine to protect against infection and no treatment for those who are infected to prevent them from infecting others. Furthermore, there is at present no cure for AIDS or other HIV-related disease, and the limited methods of treatment available are only partially effective and very costly.
The principal program tools for eliciting voluntary changes in the behavior of those at risk of transmitting the infection are information and education. These must be targeted to those at risk and specific to their social, cultural, and political environment. There are encouraging signs that behavior will change when those at risk understand the full extent of the risks and the methods for avoiding them. However, the process of changing behavior will, even under the best of conditions, be slow.
The urgent need for HIV prevention and control worldwide demands the development of better tools. Of highest priority for research are a better understanding of the process of behavior change, an affordable, heat-stable vaccine against HIV infection, and affordable treatment regimens that prevent HIV transmission and development of disease, and, ideally, eliminate infection. Successful development and testing of these tools will depend on international collaboration.
The U.S. has committed itself internationally to support the WHO Global Programme on AIDS (WHO/GPA) in its planning and coordination of programs to control the spread of HIV and to coordinate the research needed to eventually eliminate infection. The WHO/GPA has moved quickly and effectively to develop global and country-specific plans and expects to have put them into place in all cooperating countries within the next three years. Therefore, the WHO/GPA plan for the period from 1989 to 1991 is the framework for U.S. participation in the worldwide effort. The three-year action plan by federal Departments and Agencies outlines program implementation within that framework.
U.S. government actions against the HIV pandemic must be well-coordinated internally and internationally with those of the WHO/GPA and with those of other donor and recipient countries. Coordination mechanisms are in place and are expected to be strengthened in the next three years.
The three-year action plan presented here represents a continuation of programs this Administration has already put into place, is consistent with and supportive of the major international recommendations of the Report of the Presidential Commission on the Human Immunodeficiency [Page 111] Virus Epidemic chaired by Admiral Watkins.3 Current budget plans of the concerned Departments and Agencies will continue these programs. The action plan in FY 1989–91 anticipates expansion of technical assistance and other activities for AIDS prevention and control worldwide and increasing effectiveness of these activities.
The following achievements are illustrative of the progress anticipated during the period of this three-year action plan:
1. All countries with which the U.S. is working will have implemented AIDS and HIV public information campaigns.
2. All of these countries will also have implemented, and most will have evaluated, targeted educational programs aimed at the reduction of high-risk behavior.
3. All of these countries will have implemented blood transfusion screening programs for HIV. There will be a safe source in each country, however, only a few will have ensured complete freedom of the blood supply from HIV infection.
4. New rapid, simple HIV diagnostics appropriate for developing countries will have been field-tested and will be in common use.
5. Development of vaccine field trial sites will have taken place.
6. Models of the economic and demographic impact of the pandemic in the developing world will have been completed and validated and will be in use to further understanding and to more effectively target HIV control strategies.
- Source: Department of State, Central Foreign Policy File, P880041–2106. No classification marking. Levitsky sent the paper to Powell under a December 9 covering memorandum with the subject line: “Three-Year Plan for International Effort Against HIV Infection.”↩
- A copy is in Department of State, Central Foreign Policy File, P880041–2108.↩
- Reference is to James A. Watkins, “Report of the Presidential Commission on the Human Immunodeficiency Virus,” Washington: U.S. Government Printing Office, June 24, 1988.↩