The Center for Public Integrity

When George W. Bush proposed his five-year, $15 billion initiative to "turn the tide against AIDS" in the developing world in 2003, he said the availability of low-cost drugs to fight the disease "places a tremendous possibility within our grasp."

Bush told Americans in his State of the Union address that the per-patient cost of antiretroviral drugs (ARVs), which improve the health and extend the lives of people who have HIV/AIDS, had dropped "from $12,000 a year to under $300 a year."

That significant decrease was a result of the competition from generic drug manufacturers. Yet Bush's initiative, the President's Emergency Plan for AIDS Relief (PEPFAR), funded by Congress a few months after that speech, has been slow to embrace funding cheaper generic ARVs.

ARV treatment is a major focus of PEPFAR and similar international programs. In addition to providing the drugs, it typically includes things such as HIV testing, counseling, monitoring for side-effects, lab tests and hospitalization.

Estimates released by PEPFAR reveal that in 2004 and 2005, its first two fully funded years, the plan allocated only about 5 percent of its overall ARV drug budget — less than $15 million — for generic drugs. A key reason for that lies in PEPFAR's own rules: only ARVs approved by the U.S. Food and Drug Administration (or given tentative FDA approval through an expedited review process set up in May 2004) can be procured with the program's funds.

While the president's AIDS initiative was still on the drawing board, that proposed stipulation drew fire from some, including Rep. Henry Waxman of California.

Background

Haiti, or Ayiti in Creole, the first independent country borne of slave rebellion in 1804, is populated primarily by descendents of slaves taken from Africa by the Europeans. Haiti is slightly smaller than Maryland and encompasses the western third of the island of Hispaniola.

Less than two hours by plane from Miami, Haiti has the highest number of HIV/AIDS cases in the Caribbean. Ten percent of those living with HIV in Haiti are children, and in 2005 there were an estimated 400,000 orphans, many of whose parents died of AIDS.

Traditional medicine continues to play an important role in Haiti. Voodoo priests and priestesses are considered to be traditional healers. Catholicism is the official religion, but it is said by many that voodoo is the national religion.

Haiti shares an island with the Dominican Republic, but the two countries differ greatly. The HIV rate in Haiti is three times that of the Dominican Republic. Socially and economically, the Dominican Republic is also more stable, with a higher life expectancy and a gross national income per capita that is five times as high as Haiti's.

The face of HIV

In 1982, the Centers for Disease Control and Prevention put Haitian-born U.S. residents on the list of "groups at highest risk of acquiring AIDS" along with intravenous drug users, hemophiliacs and homosexual and bisexual men. The stigma attached to the disease at that time affected immigrant Haitians in their searches for employment, citizenship and more. Years later, just being Haitian was no longer considered to be a risk factor in itself, but the damage had been done. Discrimination against Haitians, along with other high-risk groups, and ignorance about the transmission of HIV/AIDS had spread.

ICIJ Director: Wendell Rawls
Editor: Diane Brozek Fancher
Editorial Projects Coordinator: Leah Rush

Writers: Sheetal Doshi, Prangtip Daorueng, Alejandra Fernández Morera, Sarah Fort, M. Asif Ismail, Daniel Kalinaki, Patrick Kiger, Adri Kotze, Victoria Kreha, Anna-Maria Lombard, Arthur Okwemba, Olayinka Oyegbile, Devin Varsalona, Marina Walker Guevara

Translators: Kaleyesus Bekele (Ethiopia), Guy-Claude Jean-Baptiste Jr. (Haiti)

Researchers: Susanna Hamblin, Rakesh Kalshian, Rachel Leven, Sarah Laskow

Associate Editor: Tom Stites
Copy Editors: Marcia Kramer, Tonia E. Moore
Research Editors: Michelle R. Harris, Elizabeth Levine, Peter Newbatt Smith
Database Editor: Helena Bengtsson
Graphic Designer: Jyoti Sauna

Network Administrator: Chatchai Sae-Tung
Web Site Architect: Han Nguyen

Background

Located in southeastern Africa, Zambia is a landlocked country bordered by the Democratic Republic of the Congo, Tanzania, Malawi, Mozambique, Zimbabwe, Botswana, Namibia and Angola.

For centuries, Zambia remained largely unexplored by Western powers. In the mid-19th century, famed British explorer David Livingstone was the first European to reach the Zambezi River's majestic waterfalls, which he later renamed Victoria Falls. Thirty years later, in 1888, Northern and Southern Rhodesia — named for their colonizer Cecil Rhodes — became part of the British sphere of influence.

Zambia is split into nine provinces. Lusaka is the capital city. The country is 35 percent urban and has more than 70 ethnic groups. Many of the groups speak Bantu, an African language, but the official language is English.

Formerly known as Northern Rhodesia, Zambia was renamed for the Zambezi River after gaining independence from Great Britain in 1964. For its first years of independence, Zambia was one of the most prosperous countries in Africa, mainly due to its copper exports. But the copper market crashed in the mid-1970s, and as a result, Zambia is now one of the poorest countries in the world.

The current president is Levy Mwanawasa, who was reelected to a second term in September 2006, despite his opponent's accusations of corruption.

The face of HIV

The first AIDS case in Zambia was diagnosed in 1984. Urban areas have infection rates two to four times as high as in rural areas. According to a study by the University of California, San Francisco, the disease is primarily transmitted by heterosexual intercourse, but mother-to-child transmission accounts for 30,000 new infections a year.

The study estimates that AIDS will reduce the life expectancy of a Zambian by 26 to 39 percent through 2050. By the same year, a cumulative 6.2 million people in Zambia will have died of AIDS-related deaths.

International Orthodox Christian Charities (IOCC) was established in 1992 as the official international humanitarian arm of the Standing Conference of Canonical Orthodox Bishops in the Americas (SCOBA).

Since 1960, SCOBA has brought together Orthodox religious leaders from Albanian, Greek, Antiochian, Serbian, Ukrainian, Romanian, Bulgarian and Russian Orthodox churches in the U.S. and Canada. IOCC is one of six charity and outreach agencies supported by SCOBA.

Since its inception, IOCC has administered more than $200 million. The organization has received funding from the U.S. Agency for International Development (USAID), the U.S. Department of Agriculture and the U.S. State Department Bureau of Population, Refugees and Migration.

In 2004, contributions and grants to IOCC totaled almost $15.9 million, with 47 percent from government sources. In 2003, government grants represented a bigger chunk of the total contributions: 68 percent of $16.1 million.

Over the past 14 years, most IOCC programs have addressed disaster and emergency relief, shelter construction and repair, and refugee return and assistance in 30 countries in Europe, Asia, Africa, the Middle East and Latin America. The countries, most with a strong Orthodox Church presence, include Albania, Greece, Romania, Georgia, Turkey, the former Yugoslavia and Russia.

A newcomer to the AIDS battle

IOCC's first HIV/AIDS program was launched in Ethiopia in January 2004 after the organization received a $4.6 million, three-year grant from the U.S. government. Its preexisting partnership there with the Ethiopian Orthodox Church (EOC), which has more than 40 million followers and 35,000 churches and monasteries, gave IOCC access to the most remote parts of the country.

Background

Kenya lies on the eastern coast of Africa, bordered by Ethiopia, Somalia, Tanzania, Uganda, Sudan and the Indian Ocean.

Germany colonized parts of Kenya in the mid-1880s. After the arrival of the Imperial British East Africa Company in 1888, Germany leased its holdings to Britain. Europeans began to settle the interior regions of Kenya in the first part of the 20th century and numbered nearly 30,000 by the 1930s. They farmed tea and coffee and became increasingly wealthy and politically powerful, while subjugation of the indigenous inhabitants grew.

From 1952 until 1956, the Kikuyu tribe revolted against the white settlers in what is known as the Mau Mau Uprising. The rebellion, though not a military success, helped to set the stage for Kenyan independence, attained in 1963.

The first president of Kenya was Jomo Kenyatta, a jailed nationalist leader during the Mau Mau Uprising who led the country from its independence in 1963 until his death in 1978. His successor was Daniel Toroitich arap Moi, who led the country until he peacefully stepped down after being voted out of office in 2002. The current president is Mwai Kibaki.

The face of HIV

The first diagnosed case of AIDS in Kenya was in 1984. Infection rates peaked in the 1990s at 10 percent. Today, 22 years after the first official diagnosis, 300 Kenyans die each day of AIDS-related causes. The U.N. estimates the number of children living with HIV/AIDS at 55,000 to 290,000.

But Kenya is one of the few sub-Saharan African countries where HIV rates have consistently declined in recent years. The decline is attributed to such factors as behavior change and condom use, as well as increased death rates.

Divine Intervention was made possible through generous grants from the Popplestone Foundation and the William and Flora Hewlett Foundation.

Core support of the Center for Public Integrity was provided by:

Carnegie Corporation of New York
Park Foundation, Inc.
Rockefeller Brothers Fund
John D. & Catherine T. MacArthur Foundation
John S. and James L. Knight Foundation
Supporters and members of the Center for Public Integrity

Abt Associates is a private, for-profit company that is one of the world's largest employee-owned research and consulting firms.The company was founded in 1965 by German native Clark Abt, engineer and political scientist who sought to transfer defense industry technology and systems to civilian use. It has since expanded its mission to address economic and social issues at home and abroad. The company reported revenues totaling $193 million for the fiscal year ending in March 2006.

Abt Associates works through businesses, nonprofits, international organizations, and through federal and local governments in the United States. The company has a presence in 35 countries, including Côte d'Ivoire, Ethiopia, Mozambique, Nigeria and Zambia, where the President's Emergency Plan for AIDS Relief (PEPFAR)— a five year, $15 billion initiative to fight AIDS in 15 focus countries (Vietnam, as well as 14 in Africa and the Caribbean) and more than 100 other nations — awarded it more than $6 million in 2005 for consulting and management projects.

Of Abt's 1,010 employees, 500 are based in the Cambridge, Mass. corporate office. The areas of its professional staffers' expertise are wide-ranging — including medicine, economics, statistics, international development, epidemiology and engineering. The company does not publish information on its employees abroad.

Government contracting and global work

Abt Associates has a long and lucrative history as a contractor for the U.S. government, having worked for more than 30 federal departments, agencies, offices and other related organizations. In the span from 1990 through 2002, it received nearly 420 government contracts worth more than $900 million.

Background

Mozambique is a large country situated on the southeastern coast of Africa. To the north lie Tanzania and Malawi; Zambia lies to the northwest; Zimbabwe lies to the west; and Swaziland and South Africa lie to the south. Mozambique has a 1500 mile shoreline on the Indian Ocean.

This country of just under 20 million people is divided into 10 provinces. Maputo, the capital, lies on the southern coast. The majority of the population lives below the poverty level, and foreign aid comprises much of the country's budget.

A former colony of Portugal — which controlled of the country for nearly five centuries — Mozambique won independence in 1975, a decade after most other European colonies in Africa had gained autonomy. Portuguese is the official language.

From 1977 to 1992, nearly 1 million Mozambicans died from famine and fighting in conflicts between the ruling Front for the Liberation of Mozambique and the Mozambique National Resistance, a group of rebels funded by South Africa. Though a U.N.-negotiated ceasefire formally ended the fighting in 1992, the countryside remains riddled with landmines.

The face of HIV

AIDS is the leading cause of death for adult Mozambicans and fifth for children under 5. The country has the 10th-highest HIV rate in the world. The first case of AIDS in Mozambique was a Haitian doctor who was diagnosed in 1986 and died three days later.

According to the U.S. Centers for Disease Control and Prevention, the epidemic in Mozambique mainly strikes in areas where there is poverty and limited health care services and in corridors through which large numbers of people pass.

Measuring the success of World Vision's efforts might require little more than turning on a TV. The Christian relief organization has capitalized on direct funding appeals since 1950, most notably commercials featuring hungry children in impoverished countries that encourage child sponsorship.

The result? Almost $650 million in annual direct giving in fiscal 2005, supplying the bulk of World Vision's $900 million revenue that year.

World Vision has spread its wealth over nearly 100 countries in which its 22,000 employees work to improve the lives of Third World children and families. The organization is known for providing access to clean water, food and education for sponsored children, and more recently has tackled natural disaster and HIV/AIDS relief.

Child and family sponsors, whom World Vision calls "stewards of God's resources," are the nonprofit's primary funders, but a fair share of the budget is also supported by the U.S. government.

In fiscal 2005, World Vision received more than $240 million in federal funding, continuing a 30-year financial relationship. Although direct sponsorship can be used to provide "spiritual nurture" and all employees must assent to a statement of Christian faith, World Vision said its government funds are not used for religious purposes.

In HIV/AIDS relief specifically, World Vision's prevention, care and advocacy work has been largely financed through U.S. Agency for International Development (USAID) grants.

Its work has carried over into the President's Emergency Fund for AIDS Relief (PEPFAR), the Bush administration's five-year, $15 billion initiative to fight HIV/AIDS in the world. Through PEPFAR, World Vision administered more than $11.7 million for programs in Haiti, Kenya, Mozambique, Tanzania, Uganda and Zambia in 2005.