24. Telegram From the Department of State to Agency for International Development Mission Directors and Representatives1
100959. Subject: A.I.D. Policy Guidance on AIDS. From Administrator M. Peter McPherson.
I have recently approved the following policy guidance on AIDS.
The guidance is designed to provide missions with guidelines on which to base decisions on how to respond to requests for A.I.D. support of AIDS-related activities, and to describe what kinds of activities will be undertaken by A.I.D. regionally, centrally, and in support of the WHO Global Programme on AIDS. This policy will be reviewed and revised as our understanding of the disease increases.
The policy guidance is reproduced in its entirety. Quote:
I. Context for Agency Policy Guidance on AIDS
Acquired immune deficiency syndrome (AIDS) is a relatively newly recognized and devastating disease. Our knowledge about the causative agent of the disease, the possibilities for its prevention and control, and the course of the epidemic are changing rapidly. For these reasons and because of sensitivities surrounding the disease, this policy guidance is designed to be flexible. It is based on the situation now and will be revised as changes in technology, knowledge, incidence and sensitivities occur.
Despite these uncertainties, an agency policy on AIDS is important. The incidence of AIDS cases this year is the result of infection which was transmitted as long as five years ago. It is imperative to tackle the problem now because infections transmitted this year will result in actual AIDS cases five or more years from now.[Page 60]
If the course of the disease results in outbreaks of major proportion in some countries as is predicted by many experts, there will be many serious implications for ongoing A.I.D. programs and for development prospects in those countries. Activities begun now, as outlined in the following policy guidance, should be the groundwork for major efforts later as they become necessary.
A.I.D. support for AIDS activities will depend upon the particular activity and whether it could best be supported by A.I.D. or another domestic or international agency; availability of funding and staff; absorptive capacity in LDCS as well as in donor agencies; political considerations and sensitivities; and available technology and knowledge upon which to base program responses.
At this point development of major bilateral efforts is constrained by political sensitivities in LDCS about the disease; lack of knowledge, expertise and experience in this area; inadequate financial and human resources; and, finally limited absorptive capacity of LDCS. This policy guidance will be reviewed and revised as knowledge and understanding of the disease and its spread are accumulated.
Acquired immune deficiency syndrome (AIDS) is an epidemic of global concern. There are currently some five to ten million individuals infected worldwide. It is estimated that at least 10–30 percent of infected individuals will develop AIDS within five years, and an unknown percent will develop the disease eventually. Once frank AIDS develops it is fatal. Worldwide an estimated 50 to 100 million additional people will become infected over the next five years.
Human immunodeficiency virus (HIV), the cause of AIDS, is transmitted by sexual intercourse, through blood or blood products, and from mother to fetus. In the United States to date the epidemic has been confined largely to high risk groups including male homosexuals, intravenous drug users, and hemophiliacs. In Africa and certain Caribbean and South American countries AIDS and HIV infection occur among heterosexually active men and women and in their offspring. In Asia and the Near East, AIDS and HIV infection are still rare, but both the virus and the disease have recently been identified among high risk groups, indicating that the disease may also become epidemic in these areas.
A number of characteristics of the AIDS phenomenon make it a difficult problem with which to deal:
1) Its causative agent and its transmission are not completely understood;
2) It is a devastating disease for which there is now no cure or vaccine;[Page 61]
3) Its transmission is most frequently related to highly emotional and private behavior, e.g. sexual relations;
4) It has been associated in particular with the U.S. and with certain developing countries, and its origins and spread have been characterized variously for political reasons;
5) It could become a major epidemic of the type we have not seen in this century.
III. Political and Developmental Implications of AIDS
Transmission of AIDS is predominantly sexual, and to date its incidence is often associated with either homosexual practices or heterosexual prostitution. Prevention of the transmission of HIV infection will depend in large part upon changes in sexual behavior, an aspect of life which is one of the most intimate, sensitive and difficult to change. Educational messages will need to be very culture specific and have political backing within the country. Even so, this behavior will be difficult to change sufficiently to have an effect on transmission of the disease.
Promotion of condom use for AIDS control which is appropriate and effective in the U.S. and other Western countries could be construed by some as an indirect means of imposing population control in countries where family planning can still be somewhat sensitive.
B. Implications for other A.I.D. programs
Regardless of how the agency becomes involved in AIDS programs, the disease has implications for other ongoing A.I.D.-funded programs. For example, AIDS may affect immunization, breastfeeding, and family planning programs. In immunization programs there is the possibility of transmission through unsterile needles, as well as the theoretical potential for activation of AIDS symptoms in already infected individuals by vaccines and the possibility of disseminated infections following the receipt of live vaccines. The possibility of transmission through breastmilk could affect A.I.D.-supported milk bank programs. Increasing numbers of AIDS cases may result in restrictions on international travel and training opportunities.
The implications of AIDS for the Agency’s family planning program are several. AIDS prevention activities may have a positive effect on family planning efforts; on the other hand, promotion of condoms for AIDS prevention could create an association between condoms and high risk sexual behavior (including homosexual practices and prostitution). In addition, in areas where AIDS is widespread, it may become necessary to revise recommendations on use of other forms of contraceptives which do not simultaneously protect against AIDS.[Page 62]
C. Long-term Impact on Development
The long-term impact of AIDS on development is likely to be significant. The cost of dealing with AIDS in many countries will take funds and personnel that are needed for other government programs in health, family planning, education, and other priority areas, and could severely jeopardize the gains made in these sectors. The deaths of significant numbers of the population of productive age (e.g., from 20 to 40 years old) could constrain economic productivity. The disease is already present among the educated elite in a number of countries, and loss of this human resource could severely damage prospects for economic stability and progress. The economic and social impact of AIDS will in all likelihood be significant for individuals, families and countries.
IV. Global AIDS Efforts—the World Health Organization (WHO) Global AIDS Programme
WHO has taken the lead in developing and coordinating international AIDS programs. A special global programme for AIDS has been established, reporting directly to the Director General. The proposed budget for this programme for 1987 is about dollars 44 million. A.I.D. played an important catalytic role in encouraging the formation of this programme, and in stimulating funding from other member countries. Financial contributions made by A.I.D. to WHO in FY 1986 were significant because they were the first contributions made to the worldwide programme (dollars 1 million) and to the WHO Africa Regional Programme (dollars 1 million). A.I.D. will continue to support and collaborate actively with the WHO Programme.
V. Policy Guidelines
A. A.I.D. Support Mechanisms for AIDS Activities
1. Bilateral Activities
A.I.D. resources for AIDS are limited because of other A.I.D. priorities, such as child survival. Staff resources to deal with AIDS are also limited. A.I.D. health/population/nutrition and education staff are already stretched in dealing with existing health, population, nutrition, child survival and human resource programs. AIDS is still a sensitive subject in many countries with political ramifications for bilateral programs aimed specifically at AIDS at this time, although some bilateral activities are appropriate. The types of bilaterally-funded activities which are appropriate are spelled out in the following section outlining specific activities addressing AIDS. Bilateral activities should complement WHO programs and centrally-funded activities. Many activities of interest to missions can be supported through existing or emerging centrally-funded mechanisms.[Page 63]
2. Central Activities
Central projects should complement WHO programs and bilateral health and family planning programs which may include some AIDS activities. Types of central support also will be discussed under the next section of the guidance.
Large centrally funded cooperating agencies (especially through the Office of Population) may be able to carry out some activities addressing AIDS through their existing contracts without incurring significant additional expenses. However, there will undoubtedly be requests for help from these groups from LDCs which will require additional funding. Cooperating agencies should respond to such requests (consistent with the following guidance) if this can be done without jeopardizing other priority activities or without risking a backlash due to LDC sensitivities.
3. Regional Activities
Regional activities should generally follow the guidelines for centrally funded activities.
B. Specific Activities Addressing AIDS
Because AIDS is endemic within the U.S., basic biomedical and social science research activities are carried out by DHHS. The epidemic nature of the disease means that the health of U.S. citizens can benefit from international research, including collaborative epidemiologic, serologic, and virologic studies in different settings. As a result, CDC, NIH, and DOD, have undertaken studies in Africa and elsewhere. WHO’s programme includes epidemiological research. While U.S. efforts overseas should be undertaken in a coordinated fashion, A.I.D. is not the appropriate agency to coordinate these efforts since they are beyond the scope of U.S. foreign assistance or are being undertaken by WHO.
Biomedical research, such as development of vaccines and drugs, is of interest to and can be undertaken by private sector firms and is being undertaken by other parts of the U.S. Government and therefore should not be undertaken by A.I.D.
Epidemiological and Behavioral Research
Both epidemiological research to determine the pattern of infection and disease, and behavioral or anthropological research to determine the implications of changing the behavior which is associated with the transmission of the disease are important.
Epidemiological research is being undertaken by WHO, USG agencies and national researchers. A.I.D. will not undertake research which can be funded by other USG agencies, other donors or WHO.[Page 64]
Where A.I.D. has expertise and experience the agency could support behavioral or anthropological research into the particular practices and their contexts, in order to provide information on how these practices may be changed. This research may be supported bilaterally or centrally.
Operations research can help determine, for example, under what circumstances an AIDS health communication effort using mass media is feasible; whether family planning workers are effective sources of information about AIDS control; and, whether it is possible to change sexual practices through the media, health worker training and availability of spermicides or other viricidal agents. Operations research can improve our understanding of the circumstances in which existing family planning programs might be constructively linked with prevention of AIDS, or on the other hand might be adversely affected by being linked to an AIDS campaign. A.I.D. has considerable experience in operations research, particularly as part of our population and health programs, and should support these efforts where appropriate bilaterally or centrally. Operations research can also explore the role of public health communications in reducing risk due to other means of transmission.
Because of the serious implications of AIDS for development and especially for A.I.D. programs, A.I.D. will support research on the longer-term development and economic effects of the AIDS epidemic through central or bilateral mechanisms. This includes the potential impact on health budgets, economic productivity, child survival, and other issues.
2. Information Exchange
Many unknowns, uncertainties and sensitivities about AIDS and the speed with which it has spread make sharing and exchange of information between scientists, politicians, and development workers critical. There is a danger of inadvertent as well as deliberate misinformation about AIDS, and steps are being taken through WHO and other channels to correct such information. WHO has the primary role in coordinating and disseminating information and A.I.D. will support WHO in this area.
A.I.D./Washington will provide information to missions on a regular basis so that A.I.D. field staff is fully informed with the latest information on the disease and worldwide activities addressing it.
A.I.D. may join other donors or agencies in supporting international meetings and we may support participation of LDC representatives, but we will not directly and solely sponsor international meetings or [Page 65]clearing houses on AIDS. A.I.D. may support efforts to compile and disseminate reliable technical information on AIDS.
Information, education and training about how to deal with prevention and control of AIDS are very important. Training can include in-country training in the context of ongoing health and population programs; participant training, including study tours; and funding for attendance at international meetings on AIDS. Mission or central funds may be used to support study tours or participation in meetings on AIDS. In-country service worker training or retraining should probably be mission funded.
In some cases with very little additional resource input, A.I.D. could become more actively involved in health and family planning worker training on AIDS. A.I.D. centrally funded contractors have already begun and will continue to include AIDS information in training curricula for health and family planning workers.
Information and education about the transmission by skin piercing instruments should be built into training components of A.I.D.-funded immunization programs.
4. Public Health Education
Public health education methods, including social marketing techniques, aimed at preventing transmission of AIDS is critical since there is no cure for the disease at this time. Given the poorly understood nature of AIDS and its potential for misunderstanding, we need to be sure we have the right message(s), and that the media are used sensitively with proper attention to cultural and other factors, particularly in regard to communications dealing with sexual transmission. The WHO Global AIDS Programme includes a component on education for prevention of transmission. A.I.D. will support and collaborate with this WHO activity. Several developing countries have already begun public education campaigns about the risk behaviors which are associated with transmission of the infection. A.I.D. support for education about prevention of sexual transmission will emphasize the importance of sexual abstinence or long term stable relationships. Assistance for education efforts and distribution of prophylactics against transmission will be based on the cultural and religious norms of the countries being assisted.
The U.S. has considerable experience in social marketing of contraceptives and with other health promotion modalities which could be useful in developing campaigns to prevent AIDS. Use of condoms will play a role, but will not be the only behavioral change indicated. However, behavioral changes to prevent particularly sexual transmission of AIDS differ from those required for other health or family [Page 66]planning behaviors, and we do not yet know which messages about AIDS will be effective in particular situations and with different target groups. Moreover, information and education used in the U.S. about AIDS does not translate easily to developing countries.
Before we become directly involved in free-standing AIDS information, education and communication (IE&C) efforts we need to answer some critical questions through social science and operations research and to ensure that host countries really want our help. Initially, A.I.D. support for IE&C efforts should be approached through operations research projects and through the WHO program. Direct bilateral support for free-standing communications programs for AIDS prevention may be appropriate in the future.
5. Prevention of Sexual Transmission
In addition to support for operations research on public health education aimed at preventing sexual transmission of AIDS, A.I.D. will procure and provide condoms for AIDS prevention programs on request. Condoms will be procured through the existing central procurement mechanism, which is a buy-in project. If there is substantial demand for additional condoms, funding will probably need to come from both bilateral and central sources. A.I.D. may also assist in procurement of condoms for WHO on a reimbursable basis.
6. Prevention of Blood Transmission
Blood screening programs are an important means of preventing transmission of the virus through blood transfusions. The WHO programme includes support for development of these programs, and WHO has already provided equipment and supplies for such programs to some countries. A.I.D. will support WHO efforts to prevent blood transmission of AIDS. A.I.D. will also fund the purchase of equipment and supplies for blood screening programs on request and where funds are available (and where WHO funding is not available), keeping in mind the recurrent cost implications of blood screening programs, including costs for reagents, and the need for host countries to plan for this continued expense.
The cost of reagents for blood screening may decrease as new, technologically appropriate diagnostic tests become available. If private firms are not interested in developing diagnostic tests for LDC markets, A.I.D. may need to support adaptation of diagnostic tests to make them technologically appropriate for LDCS and may need to facilitate their distribution.
7. Prevention of Perinatal Transmission
WHO will support efforts to reduce perinatal transmission of HIV. This may involve counseling of infected women not to have children and the option of abortion for infected pregnant women. A.I.D.’s prior[Page 67]ity on child survival makes perinatal transmission a real concern. The need to counsel women and men who wish to become parents about the risks of passing on the infection to their offspring may arise within the context of A.I.D. MCH and family planning programs. However, A.I.D. will not support any involvement in any activities that include abortion.
8. Vaccination Efforts
As previously stated, A.I.D. will not fund vaccine research and development efforts. Due to the sensitivities of setting up vaccine testing sites in LDCs and disputes over data between researchers, A.I.D. should let WHO take the lead in this area.
Should a vaccine become available, A.I.D. will consider supporting procurement of vaccines and immunization materials and the implementation of vaccination programs.
9. Care for AIDS Cases
Under the Agency health policy, A.I.D. does not generally support curative health care. In the case of AIDS there are currently no known therapeutic agents for HIV infection.
A.I.D. will support WHO efforts to reduce the impact of HIV infection on individuals, groups and society.
C. Implications for Other A.I.D. Programs
In addition to support for some activities to address AIDS, A.I.D. must be concerned about and monitor the implications of the disease and its prevention and control for other A.I.D. programs. AIDS concerns affecting on-going A.I.D. programs include: immunization, breastfeeding, and family planning activities. A.I.D. Missions should monitor these areas closely. A.I.D./Washington will develop further guidance if necessary.
1. Immunization Programs
Although there are no known cases in which the AIDS virus has been transmitted through immunization programs, use of unsterile needles and syringes has been documented to result in transmission. Even if immunization programs do not transmit the virus, it is possible that use of unsterile implements could transmit HIV. Even if this means of transmission is not in fact a viable means of spread, associations may be made between use of unsterile implements in A.I.D.-funded vaccination programs and incidence of disease. For these reasons, caution must be taken to ensure use of sterile equipment. A.I.D. is following the WHO guidance which recommends against use of disposable needles because they cannot be sterilized and are often reused. Use of reusable needles and care about their sterilization is the recommended procedure. All A.I.D.-funded immunization programs should make certain that adequate supplies of reusable needles and syringes are [Page 68]available, that adequate sterilizing equipment is in use, and that upgraded training is provided for health workers to ensure use of sterile implements.
A.I.D. will continue to follow WHO guidelines on immunization of all children and pregnant women in spite of the theoretical potential for activation of AIDS symptoms in already infected individuals by vaccines and the possibility of disseminated infections following the receipt of live vaccines. As long as the threat of immunizable diseases to the health of children in LDCs remains higher than the threat of AIDS, the WHO guidelines will be followed by A.I.D.
2. Breastfeeding Programs
There is no convincing evidence that AIDS has been spread through breastmilk, yet there is the possibility that the virus could be transmitted in this way. It is important that A.I.D. Missions be aware of this potential and of the possibility that association could be drawn between confirmed pediatric AIDS cases and this mode of transmission if found, new guidance on promotion of breastfeeding and milk banks will be issued.
3. Family Planning
The family planning community has a number of advantages that can be brought to bear on AIDS prevention. It has a strong PVO infrastructure which is now in place and in large measure eager to undertake AIDS prevention activity. It also has experience reaching the reproductive age group with somewhat similar services. There is also significant commonality between means used to interrupt the transmission of AIDS—including promotion of monogamy, abstinence, condom and spermicide/viricide use—and methods used to space births.
On the negative side, there is legitimate concern that the association of AIDS with condoms could result in a stigma for condoms which family planning organizations have spent years and substantial resources to counteract. Similarly, there is a potential stigma for family planning organizations more generally, particularly if activities are targeted toward high risk groups such as prostitutes or drug users.
Lastly, there is the clear potential dilemma both for individuals and programs regarding condom use versus other effective contraceptive methods. Without clear confidence that a couple is monogamous and that neither partner is infected, there may be a compelling argument for condom use. While condom use and the use of other methods are not mutually exclusive, this may pose a significant operational problem. It is anticipated that most or all of these issues regarding potential effects on family planning will be addressed through operations research.
- Source: Department of State, AIDS, 1984–1987, Lot 89D137, AIDS Apr 13. Unclassified. Drafted by Blakeslee; cleared in AID/AA/PPC, AID/DAA/ST, AID/AFR/TR, AID/ANE/TR, AID/LAC/DR, AID/ES, and OES/ENH; approved by McPherson.↩