[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
HIV PREVENTION: HOW EFFECTIVE IS THE PRESIDENT'S EMERGENCY PLAN FOR
AIDS RELIEF [PEPFAR]
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY,
EMERGING THREATS, AND INTERNATIONAL
RELATIONS
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 6, 2006
__________
Serial No. 109-239
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
http://www.house.gov/reform
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
CHRISTOPHER SHAYS, Connecticut HENRY A. WAXMAN, California
DAN BURTON, Indiana TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
GIL GUTKNECHT, Minnesota CAROLYN B. MALONEY, New York
MARK E. SOUDER, Indiana ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio DENNIS J. KUCINICH, Ohio
TODD RUSSELL PLATTS, Pennsylvania DANNY K. DAVIS, Illinois
CHRIS CANNON, Utah WM. LACY CLAY, Missouri
JOHN J. DUNCAN, Jr., Tennessee DIANE E. WATSON, California
CANDICE S. MILLER, Michigan STEPHEN F. LYNCH, Massachusetts
MICHAEL R. TURNER, Ohio CHRIS VAN HOLLEN, Maryland
DARRELL E. ISSA, California LINDA T. SANCHEZ, California
JON C. PORTER, Nevada C.A. DUTCH RUPPERSBERGER, Maryland
KENNY MARCHANT, Texas BRIAN HIGGINS, New York
LYNN A. WESTMORELAND, Georgia ELEANOR HOLMES NORTON, District of
PATRICK T. McHENRY, North Carolina Columbia
CHARLES W. DENT, Pennsylvania ------
VIRGINIA FOXX, North Carolina BERNARD SANDERS, Vermont
JEAN SCHMIDT, Ohio (Independent)
BRIAN P. BILBRAY, California
David Marin, Staff Director
Lawrence Halloran, Deputy Staff Director
Benjamin Chance, Chief Clerk
Phil Barnett, Minority Chief of Staff/Chief Counsel
Subcommittee on National Security, Emerging Threats, and International
Relations
CHRISTOPHER SHAYS, Connecticut, Chairman
KENNY MARCHANT, Texas DENNIS J. KUCINICH, Ohio
DAN BURTON, Indiana TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida BERNARD SANDERS, Vermont
JOHN M. McHUGH, New York CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio CHRIS VAN HOLLEN, Maryland
TODD RUSSELL PLATTS, Pennsylvania LINDA T. SANCHEZ, California
JOHN J. DUNCAN, Jr., Tennessee C.A. DUTCH RUPPERSBERGER, Maryland
MICHAEL R. TURNER, Ohio STEPHEN F. LYNCH, Massachusetts
JON C. PORTER, Nevada BRIAN HIGGINS, New York
CHARLES W. DENT, Pennsylvania
Ex Officio
TOM DAVIS, Virginia HENRY A. WAXMAN, California
R. Nicholas Palarino, Staff Director
Beth Daniel, Professional Staff Member
Robert A. Briggs, Clerk
Andrew Su, Minority Professional Staff Member
C O N T E N T S
----------
Page
Hearing held on September 6, 2006................................ 1
Statement of:
Dybul, Mark R., U.S. Global AIDS Coordinator, U.S. Department
of State; and Kent Hill, Assistant Administrator, Bureau
for Global Health, U.S. Agency for International
Development................................................ 16
Dybul, Mark R............................................ 16
Hill, Kent............................................... 27
Gootnick, David, Director, International Affairs and Trade,
Government Accountability Office; Helene Gayle, president
and chief executive officer, Care USA; Lucy Sawere Nkya,
member of Tanzanian Parliament (MP, Women Special Seats),
medical chairperson, Medical Board of St. Mary's Hospital
Morogoro, director, Faraja Trust Fund; and Edward C. Green,
senior research scientist, Harvard Center for Population
and Development Studies.................................... 57
Gayle, Helene............................................ 85
Green, Edward C.......................................... 119
Gootnick, David.......................................... 57
Nkya, Lucy Sawere........................................ 111
Letters, statements, etc., submitted for the record by:
Dybul, Mark R., U.S. Global AIDS Coordinator, U.S. Department
of State, prepared statement of............................ 21
Gayle, Helene, president and chief executive officer, Care
USA, prepared statement of................................. 89
Gootnick, David, Director, International Affairs and Trade,
Government Accountability Office, prepared statement of.... 60
Green, Edward C., senior research scientist, Harvard Center
for Population and Development Studies, prepared statement
of......................................................... 122
Hill, Kent, Assistant Administrator, Bureau for Global
Health, U.S. Agency for International Development, prepared
statement of............................................... 30
Kucinich, Hon. Dennis J., a Representative in Congress from
the State of Ohio, prepared statement of................... 143
Lee, Hon. Barbara, a Representative in Congress from the
State of California, prepared statement of................. 55
Nkya, Lucy Sawere, member of Tanzanian Parliament (MP, Women
Special Seats), medical chairperson, Medical Board of St.
Mary's Hospital Morogoro, director, Faraja Trust Fund,
prepared statement of...................................... 115
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut, prepared statement of............ 3
Waxman, Hon. Henry A., a Representative in Congress from the
State of California, prepared statement of................. 8
HIV PREVENTION: HOW EFFECTIVE IS THE PRESIDENT'S EMERGENCY PLAN FOR
AIDS RELIEF [PEPFAR]
----------
WEDNESDAY, SEPTEMBER 6, 2006
House of Representatives,
Subcommittee on National Security, Emerging
Threats, and International Relations,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 1:07 p.m., in
room 2154, Rayburn House Office Building, Hon. Christopher
Shays (chairman of the subcommittee) presiding.
Present: Representatives Shays, Duncan, and Waxman (ex
officio).
Staff present: Beth Daniel, professional staff member;
Nicholas R. Palarino, Ph.D., staff director; Robert Briggs,
analyst; Naomi Seller, minority counsel; Andrew Su, minority
professional staff member; Earley Green, minority chief clerk;
and Jean Gosa, minority assistant clerk.
Mr. Shays. A quorum being present, the Subcommittee on
National Security, Emerging Threats, and International
Relations hearing entitled, ``HIV Prevention: How Effective is
the President's Emergency Plan for AIDS Relief [PEPFAR]'' is
called to order.
In 1981, scientists diagnosed the first cases of the
disease we now call HIV/AIDS, Human Immunodeficiency Virus/
Acquired Immune Deficiency Syndrome. Today, 25 years later,
nearly 40 million people live with HIV/AIDS. Worldwide last
year, 4.1 million people were newly infected with HIV, and 2.8
million people died from AIDS, of whom 570,000 were children. A
third of these deaths occurred in Sub-Saharan Africa.
A January 2000 U.S. Central Intelligence Agency National
Intelligence Estimate warns HIV/AIDS could deplete a quarter of
the populations of certain countries. There is no cure for the
disease.
The United States has committed massive amounts of foreign
assistance to fight HIV/AIDS. After Congress passed the
Leadership Act of 2003, President Bush announced a $15 billion,
5-year initiative known as PEPFAR, the President's Emergency
Plan for AIDS Relief. PEPFAR fights HIV/AIDS through
initiatives in prevention, treatment and care.
By 2010, the goal of PEPFAR is to prevent 7 million new
infections, support treatment for 2 million HIV-infected people
and provide care for 10 million people affected by HIV/AIDS,
including orphans and vulnerable children. Multiple branches of
the U.S. Government are engaged in this vast effort, including
the Department of State, U.S. Agency for International
Development, Health and Human Services, the Department of
Defense, and the Peace Corps.
PEPFAR assistance will eventually reach 120 countries, but
concentrates the bulk of its funds in 15 hardest hit focus
countries, most of which are in Sub-Saharan Africa.
Today, we examine PEPFAR's prevention component. The 2003
Leadership Act, which authorized PEPFAR, recommended and now
requires 20 percent of total PEPFAR funds be spent on HIV
prevention. The act endorses HIV sexual transmission prevention
through the model for Abstinence, Being Faithful and Correct
and Consistent Use of Condoms, known for short as ABC, and
includes a spending requirement that one-third of prevention
funds go to abstinence-until-marriage initiatives. This
spending requirement has come under intense scrutiny as a
conservative political vehicle rather than a scientifically
based policy.
Supporters of ABC contend it is evidence based and shows
promising results. Critics assert the spending requirement is
an arbitrary figure that ignores human nature and hinders local
ability to respond to the epidemic appropriately in each
different country. Others argue the key is integration of
different prevention methods to create comprehensive
initiatives that reach as many as possible, as effectively as
possible, and flexibility so local implementers can respond to
the specific conditions where they work.
This June, I joined Congresswoman Barbara Lee and others in
introducing the Protection Against Transmission of HIV for
Women and Youth, referred to as PATHWAY, Act of 2006, which
includes a provision to lift the abstinence-until-marriage
funding earmark from PEPFAR.
Our witnesses today represent a broad spectrum of opinion
and world-class expertise in their respective fields. We
welcome Ambassador Mark Dybul, Global AIDS Coordinator at the
Department of State, and the Honorable Kent Hill, head of
Global Health at the U.S. Agency for International Development.
We also welcome our second panel, including Dr. David
Gootnick of the Government Accountability Office, Dr. Helene
Gayle from CARE USA, Dr. Edward Green from Harvard University,
and a special welcome to Dr. Lucy Sawere Nkya, a member of
Parliament from Tanzania and a long time luminary in HIV/AIDS
work. I will just say she's one of the most impressive persons
I have ever met.
HIV/AIDS is a pandemic that has produced consequences
unimaginable 25 years ago. Today, we need to imagine that we
can conquer this disease. The world needs PEPFAR and other
programs like it to fight HIV/AIDS. We must make sure our
funding is responsive, and that the money is being used
sustainably and wisely.
That concludes my statement. At this time I would call on
Mr. Waxman, the ranking member of the full committee.
[The prepared statement of Hon. Christopher Shays follows:]
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Mr. Waxman. Thank you very much, Mr. Chairman.
We're here to discuss the progress of prevention programs
under the U.S. Global AIDS Program, and I want to thank the
chairman for holding this important hearing, and for all of our
witnesses for coming here to share their experience and
expertise.
The President's Emergency Plan for AIDS Relief has made
important progress in some areas. In particular, U.S.
assistance has helped bring the number of people getting
treatment in the 15 focus countries from a few thousand to over
1 million. I applaud the work of Dr. Dybul and Mr. Hill and all
of the in-country staff contributing to this effort.
But worldwide, for each person who gained access to HIV
treatment last year, seven more people became infected with
HIV. There is no way for the pace of treatment access to keep
up with that rate of new infections.
So as we pass the halfway point of this first 5 years of
this program, it's time that Congress take a serious look at
prevention. We need to examine what's working and what isn't.
We need to identify programs that are most effective in
reducing vulnerabilities and risk behaviors, and we need to
figure out why they work and where they work, and we need to
replicate the most successful ones.
Today, we're going to look in particular at the results of
a GAO investigation into one element of U.S. HIV prevention
policy. It's the requirement that one-third of prevention funds
be spent on Abstinence and Be Faithful programs. When the House
debated the abstinence requirements, the focus of the debate
was the proper balance of abstinence funding, be-faithful
funding and condom funding to stop the transmission of HIV.
As depicted in the chart, we had a debate over whether one-
third of the funds should be designated for abstinence or if
instead we should let the experts determine the right balance.
Like several of my colleagues, I felt strongly that we should
let the experts decide. But what the GAO report makes clear is
that we weren't discussing the right pie, we were focused on
three interventions that address sexual transmission. And the
behavior changes these programs tried to create, delayed sexual
debut, partner reduction and condom use, are crucial elements
of HIV prevention, but we didn't discuss all of the other
elements of prevention. We didn't talk about antiretroviral
therapy to reduce mother-to-child transmission. We didn't talk
about blood supply safety. We didn't talk about the medical
injection safety. We didn't talk about programs that address
the myriad social problems that render people vulnerable to HIV
infection. And we didn't talk about the possibility of new
types of interventions like male circumcision.
When we look at the full picture, as shown in this second
chart, a few things are much clearer. First, when we say that
one-third of prevention funds have to go to abstinence
programs, we cut into many other types of prevention programs.
The administration has determined that the be-faithful message
is linked to the abstinence message, and as reported to us, the
programs that cover both abstinence and faithfulness will be
counted toward the one-third requirement.
But other interventions, like those that save the lives of
babies born to women with HIV, have to compete for the rest of
the prevention funds. As GAO found, countries have had to
restrict funding for many other kinds of prevention programs to
meet the abstinence requirement.
What's also clear from this chart is that HIV prevention is
extremely complicated. There is no question that determining
the right mix for any given country requires an enormous amount
of time and expertise. No formula that we try to write in
Congress will ever be right for the epidemiology and culture of
each country.
It's difficult to overstate the role of the USAIDS program.
We are the biggest donor of the world. Our policies carry great
weight and very strong sway over countries and individual
grantees. We must not shrug off the responsibility we have to
pursue the best evidence-based prevention policies.
So it's time for us to stop focusing on arbitrary
formulations and have a meaningful discussion of U.S.
prevention policy that extends beyond ideology and rhetoric and
domestic politics, and I hope we can start this debate today.
Thank you very much.
[The prepared statement of Hon. Henry A. Waxman follows:]
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Mr. Shays. I thank the gentleman.
At this time, Mr. Duncan.
Mr. Duncan. I have no statement, Mr. Chairman, but I do
think this is a very important topic, and I'm pleased that you
would call a hearing in a continuation of many important
hearings in your subcommittee. Thank you very much.
Mr. Shays. I thank the gentleman very much.
Let me take care of some business before calling on our
first panel.
I ask unanimous consent that all members of the
subcommittee be permitted to place an opening statement in the
record and that the record remain open for 3 days for that
purpose, and without objection, so ordered.
I ask future unanimous consent that all witnesses be
permitted to include their written statements in the record,
and without objection, so ordered.
And at this time the Chair would acknowledge our first
panel. We have Ambassador Mark Dybul, U.S. Global AIDS
Coordinator, U.S. Department of State, and the Honorable Kent
Hill, Assistant Administrator, Bureau for Global Health, U.S.
Agency for International Development. And as you gentlemen
know, we swear in all of our witnesses, and if you will just
stand, I'll swear you in.
[Witnesses sworn.]
Mr. Shays. I'll note for the record that both of our
witnesses have responded in the affirmative.
It's truly an honor to have both of you here. You are real
experts doing very important work. And I know the committee
welcomes you and looks forward to the dialog that we'll have.
At this time, Mr. Dybul--Ambassador, excuse me--we'll ask
you to make an opening statement. What we do with the clock, we
have 5 minutes, but we roll it over another 5 minutes. So we'll
ask you not to be more than 10, but somewhere in between 5 and
10 would be helpful.
Thank you.
STATEMENTS OF MARK R. DYBUL, U.S. GLOBAL AIDS COORDINATOR, U.S.
DEPARTMENT OF STATE; AND KENT HILL, ASSISTANT ADMINISTRATOR,
BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL
DEVELOPMENT
STATEMENT OF MARK R. DYBUL
Ambassador Dybul. Thank you, Mr. Chairman, Congressman
Waxman, and Congressman Duncan. Thank you for this opportunity
to discuss President Bush's unprecedented emergency plan for
AIDS relief. We've been grateful for the strong bipartisan
support of Congress, including members of this subcommittee.
I'm pleased to be here with Dr. Hill, who leads the U.S.
Agency for International Development work toimplement PEPFAR.
Fundamentally, it's the generosity of the American people
that has created the largest international health initiative in
history dedicated to a specific disease.
In looking at just 15 focus countries of the more than 120
countries where we have worked through bilateral programs in
the first 2 years of the Emergency Plan, we've seen remarkable
results to date, as both the chairman and Mr. Waxman have
noticed. We supported treatment for over 560,000 people, 61
percent of whom are women, and 8 percent of whom are children.
We have supported care for 3 million, including 1.2 million
orphans and vulnerable children. We've supported counseling and
testing for 13.6 million, 69 percent of whom are female.
And these figures do not include work in other countries
with bilateral U.S. Government programs under the Emergency
Plan. More importantly, the American people's support for the
programs of the Global Fund to Fight Aids, Tuberculosis and
Malaria, other bilateral programs and the Global Fund are
integral components of PEPFAR.
Yet as was noted, treatment and care for those already
infected with HIV/AIDS are not enough. If we do not slow the
rate of infections, it will be impossible to sustain the
resources, financial, human, institutional, for care and
treatment of an ever expanding pool of infected individuals.
Ultimately, effective prevention is the only way to achieve the
elusive goal of an AIDS free generation.
More than 3\1/2\ years ago, President Bush had the vision
to insist that prevention, treatment and care be addressed
together, an idea that now commands wide respect. The lessons
learned from the Emergency Plan are now helping to fuel
transformation of the HIV/AIDS responses in nations around the
world.
PEPFAR's unparalleled financial commitment has permitted
the U.S. Government to support a balanced, multi-dimensional
approach, one that was not possible at pre-PEPFAR funding
levels. The total annual spending on HIV/AIDS prevention as
well as treatment and care has continually increased since the
passage of the Leadership Act.
If Congress enacts the President's request for $4 billion
for HIV/AIDS in 2007, that will be the fourth straight year of
increased funding under the President's plan. In comparison
with the fiscal year 2001 total of $840 million for global HIV/
AIDS, these PEPFAR funding levels represent a quantum leap.
Even with the massive and highly successful scale-up of
treatment and care services with PEPFAR support, PEPFAR
preventionfunding in the focus countries has grown
substantially from 2004 to 2006, yet there has been a
significant constraint on resources in the focus countries, as
was noted in the GAO report. Almost $527 million from focus
country programs has been redirected to the Global Fund, and
other components of the Emergency Plan over PEPFAR's first 3
years.
The effectiveof this trend has been to force country teams
to make difficult tradeoffs. In 2007 and beyond, full funding
for focus country activities is essential if PEPFAR is to meet
its 2-7-10 goals, including the prevention goal.
If I accomplish nothing else today, I hope I will be able
to persuade you of the importance of full funding, meeting the
President's request for the focus countries to ensure effective
prevention.
Now if I could, I'd like to turn briefly to what
constitutes effective prevention.
As Mr. Waxman noted, PEPFAR--and effective prevention is a
complicated matter. PEPFAR supports the most comprehensive
prevention strategy in the world, including interventions for
sexual transmission, prevention of mother-to-child
transmission, safe blood, safe medical injections, all the
pieces of the pie that are up there. However, prevention must
squarely address the reality that the overwhelming majority of
cases of HIV/AIDS infection are due to sexual activity, 80
percent worldwide.
Effective prevention must address risky sexual behavior
because it is the heart of this epidemic.
The people of Africa have been leaders in developing a
prevention strategy that responds to the special challenges
that they face, the ABC approach, which stands for Abstinence,
Being Faithful and Correct and Consistent Use of Condoms. In
fact, the strategies of many nations in Africa and elsewhere
included the ABC approach, delivered in culturally sensitive
ways, long before the advent of the Emergency Plan.
The past year has been a particularly important moment in
the effort for sustainable development. Impressive new
demographic health survey evidence from a growing number of
nations is expanding the evidence base for the ABC strategy and
generalized epidemics such as those in most Sub-Saharan Africa.
Recent data from Kenya, Zimbabwe and urban Haiti show
declines in HIV prevalence. A new study has concluded that
these reductions in prevalence do not simply represent the
natural course of these nations' epidemics, but can only be
explained by changes in sexual behavior.
In Kenya, the Ministry of Health estimated that prevalence
dropped by 30 percent over a 5-year period ending in 2003. The
decline correlated with a broad reduction in sexual behavior,
including increased male faithfulness, as measured by a 50
percent reduction in young men with multiple sexual partners;
primary abstinence, as measured by delayed sexual debut; and
secondary abstinence, as measured by those that have been
sexually active but refrained from activity over the past year,
and increased use of condoms by young women who engage in risky
activity.
In an area in Zimbabwe, the journal Science reported a 23
percent reduction in prevalence among young men, and a
remarkable 49 percent decline among young women, also during
the 5-year period ending in 2003. Again, the article correlates
significant behavior change consistent with ABC with the
decrease in prevalence.
Because of the data, ABC is now recognized as the most
effective strategy to prevent HIV/AIDS in generalized
epidemics. The GAO report notes the consensus among U.S.
Government field personnel that ABC is the right approach to
prevention.
To the extent any controversy remains around ABC, I believe
that it stems from a misunderstanding. ABC is not a narrow one-
size-fits-all recipe, it encompasses a wide variety of
approaches through a myriad of factors that lead to sexual
transmission. For example, the Emergency Plan recognizes the
critical need to address the inequalities among women and men
that influence behavior change necessary to prevent HIV.
PEPFAR-supported ABC programs address gender issues, to include
violence against women, cross generational sex and
transactional sex. Such approaches are not in conflict with
ABC, they are integral to it.
Some of the most striking data presented at our recent
implementers meeting in Durban concerned behavior change by
men, the B, or being faithful element of the ABC strategy. In a
number of places men have begun toreduce their number of sexual
partners through ABC interventions.
The ABC programs also address the issue of prevention for
HIV positive people, helping infected people to choose whether
to abstain from activity, to be faithful to a single partner
whose status is known, and use of condoms. ABC programs offers
people information on how alcohol abuse can lead them into
risky sexual behavior, and work with HIV positive injecting
drug users so they can avoid sexual transmission of HIV/AIDS.
And ABC programs link people to counseling and testing
because we know people who know their HIV status are more
likely to protect themselves and others from infection.
Now of course we also support national strategies to
prevent mother-to-child transmission and transmission through
unsafe blood and medical injections, in addition to programs
that teach ABC messages to injection drug users. The Emergency
Plan supports programs that work with drug users to free them
from their addiction through prevention and education, and
through substitution therapy, an approach that has been
scientifically proven to reduce HIV/AIDS infection while
providing clinical treatment for addiction.
I'd like to address the effect of the congressional
prevention directive. The authorizing legislation recommends
that 20 percent of funds in the focus country be allocated for
prevention, and directs that at least 33 percent of prevention
funding be allocated to abstinence-until-marriage programs. As
has been noted, we count programs that focus on abstinence and
faithfulness for this purpose, and this 33 percent requirement
is applied to all countries collectively, and PEPFAR has met
it.
The legislation's emphasis on ABC activities has been an
important factor on the fundamental and needed shift in U.S.
Government prevention strategy from a primarily C approach
prior to PEPFAR to a balanced ABC strategy. PEPFAR has followed
Congress' mandate that it is possible and necessary to strongly
emphasize A, B and C.
The congressional directive, which itself reflects an
evidence-based public health understanding of the importance of
ABC, has helped to support PEPFAR's field personnel in
appropriately broadening the range of prevention efforts. The
directive has helped PEPFAR to align itself with the host
nations, of which ABC is a key element.
PEPFAR does offer each focus country team the opportunity
to propose and provide justification for a different prevention
funding allocation based on the circumstances in that country.
To date, all such justifications have been approved without
requiring other countries to make offsetting judgments to their
proposed prevention allocations.
It is also important to remember that the U.S. Government
is not the only source of funding in-country, and that partners
can seek funding from other sources to balance their mix of
prevention interventions if they find that necessary. In fact,
money does not always follow the evidence. As the Minister of
Health in Namibia noted in a recent letter to the editor of the
Lancet, PEPFAR support for AB is needed to ensure the balanced
ABC approach that Namibia seeks, and this is because other
international partners primarily support C interventions.
Last, let me address the issue of how we are monitoring and
evaluating our prevention efforts. We strongly believe that we
need to focus not only on the inputs but on results, the number
of HIV infections averted to PEPFAR interventions.
Obviously we cannot measure directly the number of
infections that would have occurred without U.S. Government
support. One area for prevention for which we are using a model
to estimate infections averted is prevention of mother-to-child
transmission, or PMT CT.
Through March 2006, we supported PMTCT services for more
than 4.5 million pregnancies. It is noteworthy that the number
of women served grew dramatically from 821,000 in the first
half of 2005 to almost 1.3 million in the first half of 2006, a
57 percent increase. This is clearly related to the 59 percent
increase in PMTCT funding managed in the focus countries over
the course of PEPFAR, from $44 million in 2004 to $71 million
this year. And these numbers do not include HIV positive
pregnant women who receive other PEPFAR supported services,
including treatment, care, counseling and testing, and other
prevention interventions.
In over 342 pregnancies, the women were identified as HIV
positive and given antiretroviral prophylaxis to prevent
infections of their children. Using an internationally agreed
model, we estimate that this intervention averted approximately
65,100 infant infections through March of this year.
For prevention as a whole, including sexual and medical
transmission, we are working to develop the best possible
models to allow us to estimate the numbers of infections that
PEPFAR supported programs have averted.
Mr. Chairman, there has been a sense of fatalism about HIV
prevention in many quarters; it is long past time to discard
that attitude. The world community must come alongside
governments, civil society, faith-based organizations and
others to support their leadership in the sustainability of the
HIV prevention programs through effective prevention. The U.S.
Government, for our part, considers it a privilege to do so.
The initial years of the Emergency Plan have demonstrated
that prevention can work in many of the world's most difficult
places. Through PEPFAR, the American people have become leaders
in the world effort to turn the tide against HIV/AIDS.
Mr. Chairman, thank you very much, and I'd be happy to
address your questions.
[The prepared statement of Ambassador Dybul follows:]
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Mr. Shays. Thank you very much. Dr. Hill.
STATEMENT OF KENT HILL
Dr. Hill. Mr. Chairman, and members of the subcommittee, as
Assistant Administrator of the Bureau for Global Health at
USAID, it is my privilege to testify on the importance of
prevention in the President's Emergency Plan for AIDS, and to
testify with my friend, Ambassador Dybul.
This discussion is particularly timely as only 3 weeks ago
the 16th International AIDS Conference came to a close in
Toronto, Canada. Against the backdrop of that conference, I
returned to Washington with three overarching themes dominant
in my thinking.
First, the United States is recognized as a global leader
in the fight against HIV/AIDS. The sheer magnitude of the
resources the United States has committed to this single
disease is unprecedented beyond that of any other nation in the
world.
Second, the fight against HIV/AIDS is far from over. Four
million new infections every year means that we must markedly
scale up and strengthen the prevention of new HIV infections
globally.
And third, although opinions can and do diverge regarding
the relative importance of various prevention interventions, we
must differentiate between legitimate debate and the much more
common misinformation so often associated with discussion of
the U.S. endorsement of ABC, the abstinence or delay of sexual
debut, the be faithful or at least the reduction of partners,
and the correct and consistent use of condoms.
As Ambassador Dybul said, the ABC approach is an evidence-
based, flexible approach and common sense based strategy which
plays a major role in stemming the tide of HIV/AIDS pandemic.
It is too important to be bogged down in the politics of
passion, too much is at stake, too many lives hang in the
balance, too many children are vulnerable to become orphans if
we fail in our prevention efforts. And it should be noted that
one way to raise the quality of the discussion of ABC
prevention intervention is to absolutely insist that it take
place in the context of gender issues. After all, many of the
problems associated with the spread of HIV are intimately
connected with the absence of gender equity, the presence of
gender-based violence and coercion typical of transactional and
transgenerational sex. For all too many young girls, abstinence
is not about being morally conservative, it is about having the
right to abstain. The double standards of men who are
unfaithful while their wives are is a gender equity issue. In
short, AB interventions much be seen as fundamentally linked to
gender and equality issues, a topic which can unite left and
right, liberals and conservatives. We need to focus on the
common ground.
The ABC approach to HIV prevention is good public health,
based on respect for local culture. As has been stated, is it
an African solution developed in Africa, not in the United
States, and it has universally adaptable themes. To amplify
this point, in May 2006 the Southern Africa Development
Community, an alliance of several countries in southern Africa,
convened an expert think tank meeting to identify and mobilize
key regional priorities of HIV prevention. The media report
characterized multiple and concurrent sexual partnerships as
essential drivers of the HIV/AIDS epidemic in the southern
Africa region. They recommended in light of this fact that
priority be given to the interventions that reduce the number
of multiple and concurrent partnerships, address male behavior
involvement, increase consistent and correct condom use, and
continue programming around delayed sexual debut. Clearly these
are African derived interventions that address ABC behaviors.
In the field, we are taking steps to find out how well our
programs are working. In addition to our normal evaluation of
program effectiveness, USAID is leading U.S. Government
agencies in an independent evaluation, one not done by USG
folks, of some PEPFAR supported ABC programs. An expert meeting
was convened to develop new evaluation tools to measure program
implementation and strengths. This will be followed by a longer
term program evaluation that will be multi-country in nature,
and will provide important information on program strengths and
outcomes. We're excited about this progress and look forward to
the findings which will be used to improve program performance.
One promising, yet overlooked aspect of the Emergency Plan,
is its increased attention to issues of male behavior, which
lie at the heart of women's sexual vulnerability and sexual
coercion. I'd like to give you some examples of what I'm
talking about here.
In South Africa, the Emergency Plan works with the
Institute For Health and Development Communication's Soul City,
the most expansive HIV/AIDS communication intervention in the
country, reaching about 80 percent of the population. Soul City
emphasizes the role of men in parenting and caring. It
challenges social norms around men's perceived right to sex,
sexual violence, and intergenerational sex. There is
statistical correlation between exposure to Soul City
programming and improved norms and values amongst men.
Also in South Africa, the Emergency Plan supports a very
successful male involvement program known as Men As Partners.
In addition to dealing HIV/AIDS prevention issues that include
masculinity, stigma, domestic violence, men are encouraged to
assume a larger share of responsibilities for family and
community care by spending more time with their children,
mentoring young boys in the community, and visiting terminally
ill AIDS patients.
Or take for example, Zambia. The United States is working
with the Zambian Defense Force to train peer educators and
commanding officers to raise awareness among men in the
military about the threat posed by HIV/AIDS and to enlist their
support in addressing it. Training workshops cover basic facts
about HIV/AIDS and its impact, including transmission,
prevention, stigma, sexuality, gender, positive living,
counseling, testing and care.
I'm going to skip Uganda. A lot has been said about that
before, but there are a lot of good things that can be said
here, and go on to Namibia.
The Lifeline Childline program addresses the root causes of
gender violence. It uses age-appropriate messages to teach
boys--as well as girls--about HIV/AIDS sexual abuse, domestic
violence, and the resources available to vulnerable children
through specialized counseling and other services.
And I'd like to conclude by underscoring the 2004 Lancet
commentary on finding common ground. This was a piece signed by
150 AIDS experts, some in this room, from around the world,
noting that the ABC approach can play an important role in
reducing the prevalence in a generalized epidemic, and that
partner reduction is of central epidemiological importance in
achieving large scale HIV incidents reduction, both in
generalized and in more concentrated epidemics.
Through partnership with host nations, effective programs
for HIV prevention are possible even in the most difficult
places. We will continue to support this common ground as we
continue our massive response to HIV and AIDS.
Congressional commitment to a comprehensive HIV prevention
strategy is the correct approach, and one clearly supported by
the evidence. Thank you.
[The prepared statement of Dr. Hill follows:]
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Mr. Shays. Thank you very much.
Mr. Duncan, we'll have you start off.
Mr. Duncan. Well, thank you very much, Mr. Chairman.
Let me ask this. We have a GAO report that says that the
PEPFAR prevention budget is $322 million, and that's 20 percent
of the total PEPFAR budget, which would mean the total PEPFAR
budget would be approximately $1.6 billion; is that close to
being correct?
Ambassador Dybul. Yes, sir, that is correct, in terms of
the 15 focus countries that were mentioned by the chairman. The
entire PEPFAR budget encompasses other bilateral programs, it
encompasses international research on HIV/AIDS, and it also
encompasses our contribution to the Global Fund for AIDS,
tuberculosis and malaria, which is substantial. So it would be
$1.6 of $3.2 billion, approximately.
Mr. Duncan. According to CRS, it says we're giving about
$350 million, roughly, to the Global Fund over the last couple
of years, each year.
Ambassador Dybul. Correct.
Mr. Duncan. So the total PEPFAR budget is $3.2 billion.
Is there any other country that is contributing figures
like that to fight AIDS outside of their own country that you
know of?
Ambassador Dybul. Tragically, no. According to a recent
analysis by the Kaiser Family Foundation, the American people
are providing approximately half of all global partner
resources for HIV/AIDS. No one is in the category of the United
States. In fact, the United States provides as much as all
other international what is called donors,a word I really don't
like because we're talking about donors/recipients, we're
talking about partners--but yes, we provide as much as everyone
else combined.
Mr. Duncan. You know, I think that's very important because
I think some of these are really good things for us to do, but
so often the American taxpayers just don't get nearly the
credit that they deserve because we're doing far more in this
area than any other country. No other country, even developed
nations, are coming close. And this money for the most part is
being spent in countries where the cost of medical care is far,
far cheaper or far less than it is in this country; is that
correct?
Ambassador Dybul. Yes, sir. It would be true that the cost
per person for nearly every intervention is lower in the
countries in which we're working than it would be in the United
States.
Mr. Duncan. Let me ask you this, a later witness apparently
will testify, or part of his statement says, now PEPFAR and
USAID lead the world in AIDS prevention, promoting a balanced
and targeted set of interventions that include abstinence,
being faithful and condoms for those who cannot and will not
follow A or B behaviors. This is in spite of formidable and
continuing institutional resistance to change. As a senior
USAID officer commented not long ago, ``USAID is in the condom
and contraceptive business, that is our business.''
Do either one of you, are you finding this formidable and
continuing institutional resistance to change that this later
witness refers to?
Ambassador Dybul. Well, sir, let me begin, and then Dr.
Hill, I'm sure, will want to comment on that.
I think one of the important pieces of the GAO report that
has not been commented on often is that in three or four places
it states that there is now a consensus by American government
personnel in the field that ABC is a balanced approach as what
is needed. Now that doesn't mean there aren't people who are
still attached to older philosophies. I actually come to HIV/
AIDS as a therapeutic scientist and researcher, and it's become
very clear, if you look at prevention data--which I've done, I
didn't enter this with any particular dog in the race, I just
wanted to look at the data as a scientist--that the data for
ABC are overwhelming. There is no example of a decline in HIV
prevalence in a generalized epidemic such as Africa without all
three components, without all three ABC components.
But most of the initial prevention work that was done was
not in generalized epidemics, it was in what's called
concentrated epidemics, places where identified populations are
at high risk, prostitutes, men having sex with men, truck
drivers, and much of the initial work was done in those
populations. And they're more of a BC message, which is shown
to be highly effective. Unfortunately what's happened is some
people tried to transfer data from a concentrated epidemic--
because that's the work they were familiar with--to a
generalized epidemic, and we still have people holding on to
the old data set, not moving to the new data set. But that is
increasingly becoming less and less of an issue as the data are
overwhelming. But we see this unfortunately in any
circumstance. In treatment we still have people who want to use
two instead of three drugs because they haven't caught up with
the data. So we do have to continually educate and provide the
data, and the data base is growing substantially.
I think we've largely overcome some of those earlier
prejudices as the data become available, but it's a constant
effort and we're still working on it.
Mr. Duncan. Before Dr. Hill comments, let me, before my
time runs out--and maybe Dr. Hill will want to comment on
this--that's a very good answer, Mr. Ambassador, that you've
just given me, but also another later witness will mention the
point about where women do not have the power to refuse
unprotected sex and it says that's the problem, not the
presence of abstinence or faithfulness per se. Now maybe one or
both of you might want to comment about that, in addition to
these other comments or answers.
Ambassador Dybul. Again, if I could start and then Dr. Hill
could answer both of those two pieces.
You know, in the case of gender equality or violence
against women, negotiating A, B or C is a very difficult
endeavor. So as Dr. Hill mentioned, we need to deal with some
of the entrenched gender issues, and we are, in fact, dealing
with those. We're dealing with those in terms of transactional
sex, transgenerational sex, we're teaching young men a lot of
important lessons about respecting women. We're tying our
programs to issues of gender violence, including the
President's initiative on women's empowerment. All of those are
important, but I think it is also important that the ABC
message is relevant for gender inequality; if men learn ABC, if
men practice ABC, gender issues become easier to deal with
because the men themselves will allow for the negotiation of an
A, B or C intervention. We've seen over and over again the data
for young men radically changing their B behavior, becoming
faithful, reducing their partners as a major reason for
declines in prevalence, and that is very much affecting the
gender issue.
So I think as in most things related to HIV/AIDS, any time
we begin with this or that, we're making a mistake, it's
generally everything and all and more. And so we need all of
these approaches to deal with gender. But ABC is very relevant
for gender, particularly if you target the men, and we have a
lot of programs to do that, particularly young men.
Mr. Duncan. Plus some of that training for men on teaching
respect for women and so forth would help curb this program in
the future. You can't solve this problem immediately or all at
once.
Dr. Hill, I didn't mean to cut you off. I'd be interested
in your comment.
Dr. Hill. Congressman Duncan, let me begin with your first
question as to whether in fact there is resistance among career
people to a comprehensive ABC approach and if there is a
favoritism toward the C.
I think if you talk to career people about this, they will
be the first to acknowledge that the international approach,
including much the of the U.S. approach, in the initial years
did tend to view condoms as a kind of silver bullet that might
have a huge impact on this. But as the evidence begin to mount
that condoms were not going to be enough, and as the evidence
mounted as to how prevalence rates were going down in Uganda
precisely by using a comprehensive approach, a lot of talk
about what they would refer to as zero grazing or partner
reduction or monogamy within marriage, etc., faithfulness
within the sexual partnerships, when the evidence began to come
in that it was this behavior change that was having a dramatic
impact on the lowering of prevalence, career people, it didn't
matter if they were Democrat or conservative, religious or non-
religious, they could see the facts, they could tell that these
interventions had a lot more potential than they at first
perhaps thought. And so I feel very strongly that the core team
of professionals with whom I work with at USAID--and I think
this is true of the other Federal agencies--have really had a
remarkable shift toward understanding the importance of a
comprehensive approach. I feel very good about that.
Now, internationally, we have a long ways to go to have won
that battle. And in fact, I really honestly believe that the
battle is there. And Ambassador Dybul is absolutely right to
point out that one of the reasons is so critical that the
United States spend sufficient attention on AB is because
you're not likely to find it anywhere else. It's not going to
be there yet because people don't yet believe that it's going
to be that effective.
And so what I really think we've got to do is two things.
We have simply got to focus the world's attention on the fact
that this is an evidence-based approach, that all the data
suggests that it can be very, very effective. What I find
fascinating is that even in a place like Asia where we focused
on condoms, AB behaviors changed as well. The percentages of
young men that were having their first sexual experience with
sex workers or prostitutes went down. The number of police that
were visiting sex workers or prostitutes went down. Throughout
many parts of Africa, the evidence suggested people could
change their behavior, even to the point of changing to
abstinence or to partner reduction if they were sexually
experienced. So the evidence is very strong.
The second thing that I think will help get this out of
what I call the culture wars debate is to emphasize the
connection to gender issues. This is a winner of an approach
that will affect gender issues. You cannot affect gender
inequality issues or equality issues without doing AB
interventions, they're critically important to it.
Your last point about--I'm trying to remember what your
last point was--had to do with----
Mr. Duncan. It was about the women who----
Dr. Hill. Right. Whether it's realistic--and I think there
have been two myths that have been perpetrated. One is that
abstinence is not realistic with the young. They simply aren't
capable of it. Their hormones are too strong. And the second of
course is that be faithful programs don't work when the husband
is not faithful. The latter point of course is absolutely
obvious. That's why you have to focus on male behavior and not
just female behavior. But the evidence is also overwhelming
that young people are quite capable of moderating their
behavior as well.
So I think what's really needed is for more than ABC, it's
gender programs, it's working with pregnant women, it's
treatment programs so that people when they get tested and
change their behaviors have some hope for the future. It's all
connected, and we've got to never treat it in an isolated
fashion.
Mr. Duncan. Thank you, Mr. Chairman.
Mr. Shays. Thank you. Mr. Waxman, you have the floor.
Mr. Waxman. Thank you, Mr. Chairman.
Ambassador Dybul, there are several countries where overall
prevalence rates have come down significantly. They include
Uganda, Kenya and Zimbabwe; is that correct?
Ambassador Dybul. That is correct, those three; there are
many others, actually.
Mr. Waxman. Well, experts have identified multiple reasons
for these declines. Some factors have nothing to do with
behavior change. For example, when young people who have high
infection rates leave the country for economic reasons, average
prevalence goes down; and sadly, prevalence also goes down when
death rates are high. But we do know that in these countries
there have been some positive behavior changes. Can you give us
some of the examples?
Ambassador Dybul. Yes, I'd be glad to. And I think you
raise a very important point about other factors. There's no
question there are other factors, and this is a very
complicated scientific approach. However, the recent report
from Zimbabwe, for example, looked very specifically at whether
or not death contributed to the decline in prevalence, and they
looked very scientifically at that in Science Magazine. Only 6
percent of the decline in prevalence was due to death or other
factors, only 6 percent. And the report, I mentioned in my
testimony where a group looked across the board at multiple
countries, about 10 actually, they determined that the decline
in prevalence was in fact substantial behavior change. While
these other things contributed, it was substantial behavior
change.
A couple of the examples that we can give, whether it's
Uganda, Kenya or Zimbabwe, which probably have the most up to
date solid data in this respect--we're still looking at some of
the other countries--as I mentioned, 50 percent decline in
young men who had multiple partnerships. Increase in age of
first sexual activity by a year or so, and in fact this overall
survey determined that, as in Uganda, was probably one of the
most substantial reasons why we saw a decline in prevalence
because just that shift in a year remarkably shifts the
epidemiology of the infection as less people become infected
early who then infect less people. That's a very significant
impact.
Importantly, secondary abstinence, building on what Dr.
Hill just said, Kenya actually looked in their demographic
health survey at people who had previously been sexually active
versus those who had been sexually active in the last year;
secondary abstinence, people who have been active sexually and
no longer were, and saw remarkable progress there, 50 percent.
We also saw, both in the Zimbabwe data and in the Kenya
data, as in the Uganda data, some increase in condom use
particularly among young women, now a doubling of the use of
condom use among young women. Unfortunately we didn't quite see
a commensurate change among the young men.
So it is a complex picture, but the data are repeated over
and over again supporting A, B and C.
Mr. Waxman. My understanding of the epidemiology is that we
can link these behavior changes to lower prevalence rates, but
what we generally can't do is say this program led to that
behavior change, resulting in lower prevalence. Can you explain
that?
Ambassador Dybul. Yes, and this gets to the complicated
nature of behavioral science. Aristotle once said you can only
be as precise as your subject matter allows, and unfortunately
that is the case with behavioral science. Unlike treatment,
where you can follow someone's CD-4 cell count or follow their
viral load, behavior signs is a much different thing. So what
we do is look at prevalence rates, as we've talked about, and
we look at behavior change that has occurred over that same
time period. You can then link and say this program led to this
effect. You can look to see where programs were introduced and
whether or not they were introduced largely, and whether or
not--you can basically guesstimate that those programs in fact
led to the change in behavior that was correlated with the
decline in prevalence. It's a much more complicated matter than
most sciences.
Mr. Waxman. I think that's an important point to highlight
because there's a tendency to get bogged down in arguments over
exactly which kind of program got results at a national level,
but we can't make that kind of claim. We can only know that in
certain countries that did implement comprehensive programs,
significant behavior changes have led to decreased prevalence.
While it's important to clarify the limits of our current
knowledge, we do need to get more precise information on how
specific interventions impact behavioral change. What are we
doing to study this?
Ambassador Dybul. And that's an important point because
that is something you can do in a scientific way is look at
programs and see what impact they've had on behavior change. We
actually do this in a variety of ways. Many partners do it
themselves, and in fact we just had a meeting in Durban, South
Africa where 700 scientific abstracts were presented, including
quite a few on this topic, where, for example, in Nigeria they
introduced what's called the zip-up campaign, and during the
time that the zip-up campaign--which was an abstinence
campaign--was in play, they saw a dramatic increase in
abstinence activities. We have looked at programs on college
campuses where we've introduced such ABC programs and looked at
the change among those participants.
We have done a number of what we call targeted evaluations
to look at this approach. These take a long time. They
generally take a couple of years. Dr. Hill talked about a
couple that USAID is doing. We're also shifting the way we're
doing things, moving from a targeted evaluation approach to
public health evaluation approach so that we can do more and
more of these efforts, and they are ongoing----
Mr. Waxman. Ambassador Dybul, I have a lot of other
questions, but I appreciate your answer to that. And I think
these evaluations are extremely important. I also think that
country teams should have the flexibility to refine their
prevention programs based on the evidence we glean from these
studies in the coming years.
Your office has turned the one-third requirement into two
parts; countries must spend at least 50 percent of prevention
funds on sexual transmission; then they must spend 66 percent
of those funds on AB programs. I understand that a number of
countries were able to get exemption from one or both of these
requirements; isn't that correct?
Ambassador Dybul. That's correct.
Mr. Waxman. Now for the countries that didn't get
exemptions, the formula means that if they spend more than 50
percent on sexual transmission, they must spend more than 33
percent on AB programs; is that right?
Ambassador Dybul. That's correct. And that makes some
sense. I'd be happy to explain that.
Mr. Waxman. In response to the GAO report, the
administration said that--you asked those countries that didn't
apply for exemptions if they wanted to, and you wrote that the
answer was a resounding no. I'd like to read into the record
what U.S. guidance is to these countries.
Both in 2006 and 2007 guidance state, ``please note that in
a generalized epidemic a very strong justification is required
to not meet the 66 percent AB requirement.'' The 2006 guidance
also said, ``we expect that all focus countries, and in
particular those with budgets that exceed $75 million, will
meet these requirements.''
In addition, both years guidance state, ``in any case, no
country should decrease from 1 year to the next the percent of
sexual transmission activities that are AB. There will be no
exceptions to this requirement.''
I think that it's difficult to know what country would
really have deferred, absent this strong language from their
biggest donor.
Ambassador Dybul, I'd like to ask you a few questions about
male circumcisions. I understand that four of these studies
have indicated male circumcision decreases the risk of a man
contracting HIV, and one randomized control study showed that
male circumcision lowered the risk by about 75 percent. Lower
rates of HIV among men will mean fewer risks for women in the
population. Can you tell us what the United States is doing to
assess the appropriate role of male circumcision in HIV
prevention?
Ambassador Dybul. I'd be happy to. I'd first like to get
back to some of the difficult issues you raised with behavioral
data.
Mr. Waxman. Excuse me, Ambassador Dybul. My problem is that
in another second or two the light is going to switch, so I
really do have to move on.
Ambassador Dybul. I would just say in a sentence that most
of those studies----
Mr. Waxman. The chairman said I can have as much time as I
want, so please feel free to go back. And we'll stay here all
day.
Mr. Shays. No. The bottom line is that we don't have a lot
of members, but if Mr. Waxman wants you to answer another
question, he has the privilege to ask you to go to the next
one.
Ambassador Dybul. Most of those studies just showed an
association between people who were circumcised and the
protection. There are now a couple of studies that were just
presented in Toronto that showed that in fact isn't holding up.
That one randomized control target you mentioned looked at the
actual intervention; programmatically if we proactively did
circumcision, would there be a benefit. One trial has shown a
benefit, a 60 to 70 percent reduction to men, it said nothing
about the women. It also showed an increase in sexual activity
by the young men, and there's actually a mathematical model
that shows if men think they're fully protected and have more
activity, you can actually offset the benefit of the
circumcision.
Mr. Waxman. Let's take that first part. If men don't get
HIV because they're circumcised, it does help the women because
if they do have sexual activity----
Ambassador Dybul. The problem is that they do, they just
get a lower rate. It's a 60 to 70 percent reduction. So that's
why you can actually mathematically show that if men increase
their activity by a certain percent it will offset the benefit
of the circumcision. We don't know that. That's a guesstimate.
There are two other randomized controlled trials, large
trials that are underway right now, they're ongoing. The Data
Safety Monitoring Board has twice not stopped the studies; in
other words, allowed them to continue. We don't know what that
means. We are expecting data in the next 6 to 12 months,
depending on whether they get to their end points.
These studies look a little more carefully at some of the
other issues involved. In anticipation of those studies,
because we don't know the results and it would not be
responsible, no one in the world right now is advocating--no
major international organizations are advocating active
programmatic use of circumcision, but what we have done is
given countries flexibility--and several have through our
resources--to do preliminary work, to do preparatory work.
Unfortunately, as you know, circumcision does have cultural
connotations to many people, and so we're doing some of the
cultural sensitivity work, just like we have to do for vaccines
and other work. Should circumcision be proven to be effective
and have normative guidance, one implementing agency, not a
scientific agency, that's NIH and other people's business,
should there be normative guidance on the use of circumcision,
it is something we would fund, but we will do it carefully
because you need to provide the ongoing ABC behavior change
with the circumcision or you can actually offset the benefit.
Mr. Waxman. I appreciate that answer. I certainly hope--and
we're going to have to look at the evidence--that this can help
in reducing HIV transmission. I also hope that if and when the
time is right program staff will have the funding and
flexibility to implement it, and I see you shaking your head.
Mr. Hill, I'd like to ask you about the role that the one-
third earmark has played in the policy. There are some who say
before the President's program started there was too much
emphasis on condoms. And I gather that was your view as you
expressed it earlier; is that correct?
Dr. Hill. I think that's what my career folks tell me; they
tell me that there was a tendency to focus on condoms, yes.
Mr. Waxman. And do you think things have changed since
PEPFAR started?
Dr. Hill. Yes. Both because of the evidence, because we
were forced to look at the evidence closely. So no, I think
it's quite a different situation now. The best empirical
studies on this are given by career people, not by political
appointees.
Mr. Waxman. If the legislative earmark were to be removed
or modified, would USAID and its partner agencies still work to
ensure that abstinence and be faithful programs play an
appropriate role in country's HIV prevention programs?
Dr. Hill. I'd like to think we would. As an implementer,
you know that all implementers like flexibility, they like the
options of making their own decisions on how to do things. But
I do think it's appropriate and right for Congress to insist
that we have a comprehensive strategy, but I'd like to believe
we would do the right thing anyway.
Mr. Waxman. Well, Dr. Dybul's office has the authority to
approve or reject a country team's plans each year, and I trust
that if the arbitrary quota for abstinence programs is removed,
you both, along with our health experts in the field, would
maintain AB programming where it is supported by evidence and
by local needs.
Ambassador Dybul, you noted in your testimony the U.S.
continues to support condoms and condoms programs. While many
believe that we are not doing enough to promote and fund condom
use, you clearly agree that condoms are a crucial component of
an effective prevention program.
I have a question about appropriations language that has
been referred to as the condom nondisparagement provision. It
says, ``information provided about the use of condoms as part
of projects or activities that are funded from amounts
appropriated by this act shall be medically accurate and shall
include the public health benefits and failure rates of such
use.''
Well when used consistently and correctly, condoms reduce
HIV transmission by 85 percent to 95 percent. But there have
been disturbing reports of programs that teach that condoms
have holes or that they don't block HIV.
What is the administration doing to ensure that U.S.-funded
programs do not spread false information about condoms?
Ambassador Dybul. Thank you for that question because it is
an important one. Because we do have a full ABC approach as is
evidenced by our funding distribution and by our guidance. We
would take that provision of the law as seriously as any other
provision. And so we make clear to everyone, and have done so
on multiple occasions, that should anyone be aware of such
activity occurring, such medical misinformation occurring, in a
PEPFAR-funded program, we need to know about that, and we need
to intervene either at the level of the cognizant technical
officer and, if that is not successful, higher than that.
Dr. Hill. There is actually in the USAID contract, for
example, a very specific provision which requires any recipient
of funds, even if all they are doing is AB programming, if they
mention C, they have to mention it in a medically accurate way.
If a report reaches us that they are not, that is a breach of
what they signed.
Mr. Waxman. I appreciate that answer.
Thank you, Mr. Chairman.
Mr. Shays. In answer to almost every question, there was
the word ``evidence.'' And I am not quite sure how to take the
word ``evidence.'' I am more inclined to want to say there are
indications that. What scientific evidence is available that
says that one-third should be for abstinence as opposed to two-
thirds or as opposed to one-sixth? Why one-third?
Ambassador Dybul. Well, there is certainly no randomized
controlled clinical trial that gives a percent of a program
that should be dedicated to one or the other. What we do have
are data that suggests very clearly that you need all three
components, A, B and C, and 33 percent gives us a very balanced
program.
So you can't find a randomized controlled trial to give you
that number, but you can find an interpretation or application
of available data for a balanced approach that would get you to
33 percent for AB.
Mr. Shays. Dr. Hill, how would you answer the question?
Dr. Hill. Well, I think the experience of PEPFAR in
practice illustrates that, in fact, it is not viewed as rigid.
There has been enough flexibility, Congress has allowed enough
flexibility, that when it was appropriate to not spend that
amount, exceptions have been made. In some cases it would be
appropriate to have a higher percentage.
So, in fact, the way the program has been implemented shows
a fair amount of flexibility.
Mr. Shays. When would it make sense to have it higher than
one-third?
Dr. Hill. If it was a generalized epidemic, it is very
possible that the messages to the general public that have to
do with behavior and the behavior of young people and the
behavior of sexually active people could have the biggest
impact on lowering the prevalence rate. If it is not primarily
being spread by truck drivers or by sex workers or prostitutes
or in the high-risk groups, that it is a very good possibility
the behavior change messages in AB are the things that will
likely bring the prevalence rates down the fastest.
Ambassador Dybul. In addition to that, Mr. Chairman, if I
could add, again, we are not the only player. While we are as
much as everyone else in the world combined, there are others.
And so we ask our country teams to look at the circumstance in
their country, getting to the comment by the Minister of Health
in Namibia that he needs us, the United States, to provide
substantial support for AB because no one else is doing it.
Mr. Shays. Briefly describe three or four abstinence
programs to me.
Ambassador Dybul. I can describe some of the ones I have
seen. I can give you a couple from different age groups, and,
again, we have very few abstinence-only programs except for
young kids. What we have are AB programs and ABC programs once
you got above 15. So an example of an A only program would be a
10-year-old school program where for 10-year-olds in schools,
the teachers have sessions on a daily basis. And this is a
program in Uganda where the kids in the morning learn about the
importance of HIV-AIDS in their community and how they as a 10-
year-old can avoid it through abstinence.
As you get older, the message changes to AB messages. So we
have programs in older kids, but still under 14, where they
talk about the importance of HIV-AIDS in the community, but
also abstinence and fidelity overall. And this is in the
school.
Mr. Shays. So abstinence and fidelity in what terms?
Ambassador Dybul. People use different terms, and, again,
it is culturally sensitive. In many countries being faithful
means go to church. So they use different terms such as zero
grazing. In some countries the term abstinence doesn't
resonate----
Mr. Shays. I can see you explaining to someone that maybe
they don't want to smoke because they will get cancer. That
would have a huge impact.
Ambassador Dybul. Absolutely. And that is----
Mr. Shays. But it is more than just explaining that
abstinence will protect you from getting HIV-AIDS. It is into
more than just that, correct?
Ambassador Dybul. If I understand the question correctly,
it begins with the danger, the risk to you for HIV-AIDS.
Mr. Shays. Let me say it this way: I think being honest
with people is essentially important. Being able to tell
someone that if they don't protect themselves, they will get--
and are involved in sexual activities, the risk is very high
they will get HIV-AIDS.
That seems like an honest thing to tell people. It seems
like an honest thing to tell people that a lot of people are
dying because of it. Those--if that is an abstinence program,
it seems pretty logical.
If you get into issues about, you know, about lifestyles,
and how you might go to hell because you are not abstaining,
and you are choosing the wrong direction, then I am just
wondering about that. And is that part of the program?
Ambassador Dybul. Our program is based in public health and
in public health evidence, and different people come to that
from different perspectives. The majority of, vast majority of,
our programs--in fact, all the ones I have ever seen--begin
with what you began with, which is that HIV-AIDS is a risk to
you, and you need to protect yourselves so that you can live a
healthy, productive life, and that is where most of them begin,
nearly all of them begin.
Mr. Shays. Do you have the scientific evidence to know
which kind of abstinence program works better? Because I keep
hearing the word ``evidence.'' I will tell you this: If you
told me I would get AIDS, that gives me religion real quick.
Ambassador Dybul. Well, it might, but unfortunately that is
not always the case. Some of the most disturbing data I have
seen are that children who are orphaned from AIDS, they watched
both of their parents die from AIDS--they know they died from
AIDS--still don't necessarily practice safe sex, still don't
abstain, be faithful, or correct and consistent condom use. So
even that immediate experience did not alter their behavior.
On the other hand, I think there is general agreement that
the data are not particularly good on this, but the fear of
death has driven behavior change, whether it be in this country
or in Africa, and perhaps one of the reasons we are starting to
see an uptick in infection rates in this country and in Europe
and in some parts of Africa might be fatigue with that message,
that you hear it so many times, you don't respond to it. And
there are some data on that as well.
So the problem with behavior change is it is a long-term
thing. If you keep telling the people the same thing for 5
years, eventually it is going to go over their heads. And that
is why behavior change is so difficult, why behavior medicine,
why behavior science is so difficult, because it is finding
messages that link to and lead to changes in behavior.
And that is fundamentally what we do, culturally
appropriate messages that resonate with people, which is why
Nigerians talked about zip up and Ugandans talk about zero
grazing. People look at what will be the best message.
Sometimes that message is within your cultural context, within
your religious context, in addition to the HIV-AIDS practices
and the effect of HIV-AIDS within your culture, there are other
reasons that you should practice safe sex.
Sometimes it is because of the tribal system. One of our
most effective is Massai warriors. Massai warriors become
warriors when 13 or 14, I can't remember which. They are
collected together as young men and are taught to go out and
abuse women. Well, the program we intervened with was to teach
them that it is actually manly to actually becoming a warrior
to refrain and to respect women; that is, in fact, a manly
action within that tribal tradition.
So you have to find the right messages which will lead to
behavior change. The Minister of Health----
Mr. Shays. Let me comment on that last point.
I have no problem with the logic of what you just said. I
have a problem with saying that one-third goes toward this
program. And, you know, what I am hearing, being very candid
with each other, basically what I believe is that when we
appropriated the dollars, frankly, it was--one way to get it
done was to win over some who don't want condoms as--their
dollars being spent on condoms so that they then say, at least
I can justify that we are spreading the word of God to folks
through abstinence and so on and feel comfortable. And what I
then feel is that both of you have to step up to the plate and
justify why we have done that.
And so when I hear the word ``evidence,'' I have a hard
time knowing the definition of evidence, but the program you
just described, teaching a different behavior, I think there is
logic to that. But there is no logic to me that says, that one-
third should go that way.
Dr. Hill, as well, would you be able to just tell me some
more examples of abstinence programs?
Dr. Hill. Yes. The point I alluded to in my oral comments
about Soul City in South Africa is probably one of the best I
have heard about recently. They produced a whole series of
films that were shown on prime-time television which all
address different values, different responsible behavior, etc.
It wasn't heavy hitting, always talking about HIV, but it set
the context for how men should treat women, etc.
And the initial evidence of this suggests that people are
reconsidering behavior that, in fact, is problematic, that
leads to the spread of HIV-AIDS. That's a good example of a
very sophisticated behavior change program using medium.
But if I might, I would like to just address this question
of what reasons we give----
Mr. Shays. I will give you a chance. I want to know more
programs. So if either one of you want to tell me others.
Dr. Hill. Other examples? A lot of what we do in countries
is that we will fund youth clubs, so after-school activities
where kids get together anyway to do sports or just get
together to get help with respect to certain things, we find
ways; we have implementers that will introduce topics that will
bring up sexual conduct, etc. They can ask questions. We try to
be age appropriate, etc. I met with some of these groups, had
discussions with these kids, and there is every reason to
believe that kind of discussion can be useful. And there is a
lot of countries in which we fund those kind of youth clubs.
Ambassador Dybul. A specific example of that would be in
Kenya. I just visited a program where college kids became
concerned about the pressures, the peer pressures. College kids
themselves were concerned about the pressures that they saw
themselves and their classmates under to engage in sexual
activity. They conducted a survey which showed that only 20
percent of the entering freshman had engaged in sexual activity
in college, but 80 percent thought that their friends had. So
you can see kind of the peer pressure and the disconnect
between what people are actually doing and what they thought
was going on.
As a result of that, they put together a program that we
are supporting to teach people that it is OK, in fact it is a
good thing, both for public health and your own self-worth and
respecting yourself, to remain abstinent, or, if you had been
sexually active, to become abstinent. And these are the
students themselves that put this program together.
Dr. Hill. And these programs are called life skills
programs in which they will set up drama, set up scenarios in
which a young person might encounter, for example, an older
man, some other generation offering a girl tuition or books or
something in exchange for sexual services. This explains or
this shows them, demonstrates for them, how they could say no,
why they should say no.
It addresses other questions where they are being coerced:
How do you say no? How do you make sure that what you want is
respected? You have to model that, and we often do that through
drama.
Ambassador Dybul. Another example of these types of
programs which I think are important ones and get missed are
ones that target men specifically. There are actually programs
in Namibia that say sometimes stigma is a good thing to
stigmatize older men who prey on younger women.
Mr. Shays. We call them, what, sugar daddies.
Ambassador Dybul. Exactly. So to stigmatize them, basically
drive men out of the community who engage in and who
participate in such activity, that is an ABC program.
In a similar way the program Dr. Hill mentioned in South
Africa, a wonderful young man started on his own when he was 14
or 15, his father was an alcoholic, and he drew on the program
because he saw the same thing, that his friends were abusing
women. He started the program to go around from his own
personal experience to explain why young men shouldn't behave
that way toward women, why young men should respect women, why
they are equal to each other, why you would have a healthier
life as you move forward, and it has grown into now he is a
national representative for a national program to target young
men to teach them to respect women in an ABC way and to give
ABC messages. So----
Mr. Shays. Finish your sentence.
What did you want to say, Dr. Hill, when I wanted to----
Dr. Hill. I think you were onto something when you were
probing the question of about sort of what are acceptable
reasons to sort of pursue a behavior change. And there is this
fear out there, I have heard it a lot internationally, I have
heard it sometimes in this country, if it can be demonstrated
that somebody used a moral argument for behavior change, that
somehow we may be dangerously close to crossing some line that
USG dollars should not be spent for. And I just want to suggest
that I think as important the health reasons are, it would be
counterproductive to misunderstand that human beings are far
more than just material creatures. They don't just respond to
motivations that have to do with their appetites. They often
respond to motivations that have to do with doing the right
thing, whether it is treating another person with respect. They
get nothing out of it, they certainly don't get sex out of it,
and yet people, young people, repeatedly demonstrate that they
can respond to stimuli which says, you know, be a man, do
something that shows that you are more than just an animal that
is going to follow your sexual urges.
One of the reasons that we like to work with faith-based
groups is that they often approach people at that deeper level.
And you can sometimes get young people to respond to moral
pushing and prodding as easily or more easily and with more
passion than just the health issues.
So I think the tent has to be big enough to include people
making all sorts of arguments. We tell the faith-based folks,
use health arguments as well. And I tell the folks who just
want to use faith arguments, be sensitive to your culture. And
if these folks are from a Muslim culture or an orthodox culture
or whatever the culture is, if there is something there which
stresses monogamy or faithfulness or not lying, for goodness
sakes use those arguments as well. We he have to stop the
spread of HIV.
Mr. Shays. I have absolutely no problem with there being an
abstinence problem. I have a problem with stating that it needs
to be one-third. That is my problem, and because some places
maybe it should be two-thirds. I don't know.
I doubt it. But I would think--and part of it, admittedly
it is not based on a wide experience, but when I was in
Tanzania and Uganda to hear people describe using condoms more
than once because then they weren't available is pretty gross.
To hear people describe having sex without condoms because they
couldn't get it was pretty gross. To see people waiting in
clinics to learn if they had HIV-AIDS--and I will tell you, it
was--there were hundreds in every place we went, and we got to
interview them. And we got to ask them--you know, here I am
thinking they are waiting to learn if they are going to die.
They are willing to answer questions about whatever I wanted to
ask them.
And what I was struck with was it would be an absolute
outrage if someone could have had a condom and didn't, but
somehow they weren't available because we were diverting money
in a different direction.
If you had a choice of teaching someone abstinence, and
they weren't going to abstain, is it better that we did that,
or is it better that we make sure that they have a condom?
Dr. Hill. It is why you made a great case for a
comprehensive approach. You can't do any of these interventions
alone. There is a place for A. There is a place for B. There is
a place for C.
Mr. Shays. Let's agree with that, provided that the other
two get what they need before abstinence gets what it needs.
Dr. Hill. If you look at the statistics on condoms over the
last 8 or 10 years, during the PEPFAR years we provided more
condoms than in the previous years. So it is not that condoms
are actually going down in terms of the number that we are
providing. That is a robust and major part of our prevention.
So we are not arguing that it should go down. It should be a
big part of what we do.
It also should be the case, and, as you know, it is not
abstinence that is one-third, it is allowed to be interpreted
as AB. And that is a very important part of the message, just
as C is.
Ambassador Dybul. If I could build on what Dr. Hill said,
we, in fact, have had substantial increase in support for
condoms under the emergency plan, 130 percent increase, and 110
percent increase for AB. So we have had substantial increases
across the board for A, B and C.
Unfortunately it is not enough. We cannot, with the
resources of the American people, cover everything, which is
why we need the rest of the world to be doing a lot more they
are doing.
Mr. Shays. That we agree, but what I think I heard you say
is that some people are not getting condoms because we simply
can't provide them.
Ambassador Dybul. And some people aren't getting AB
messages yet because we can't them get to them. And some people
are not getting PMTCT because we don't have----
Mr. Shays. So what comes first?
Ambassador Dybul. What comes first is what makes you avoid
infection, which is A and B and, if you can't do that, C.
Mr. Shays. What happens if you are trying to convince
someone to abstain, but, guess what, they are going to have
sex? Because as much as you both may not want them to for their
own good, they are still going to do it.
Ambassador Dybul. And that is precisely why when you are
above the age of 14 the message is an ABC message. It is not
one or the other. It is the public health information to allow
people to have a choice. It is giving them the information that
abstinence or fidelity to an HIV-negative partner is a 100
percent way to avoid HIV infection, and there may be tribal and
other messages that come into play with that. But if that isn't
possible, if someone doesn't choose to do that, they have the
information available through some vehicle that condoms will
protect them. But we can't cover everything because we don't
have the money.
Mr. Shays. Let me ask you, if countries were allowed to
decide for themselves whether to put one-third toward
abstinence, would countries still decide to do it, or would
they choose not to?
Ambassador Dybul. I have little doubt that they would.
Mr. Shays. Would what?
Ambassador Dybul. Would support full ABC and put
considerable resources toward AB, or more.
Mr. Shays. Why require it?
Ambassador Dybul. Because it is coming from the U.S.
Government and not from those countries. If you look at the
national strategies----
Mr. Shays. That is the problem I have. If your answer to us
is that they prove their worth to these countries, why do we
just have--why do--in the only area why do we set aside one-
third for abstinence?
Ambassador Dybul. It is actually not the only area. There
are a number of congressional directives for other resource
requirements of the emergency plan besides the 33 percent.
There is treatment, there is orphans and vulnerable children,
there are other directives. The national strategies of
virtually every country in Africa where they have them lists
ABC as their approach, not C. ABC.
The Minister of Health of Namibia was very clear in his
response in the Lancet report saying, I need the American
people to be doing heavy AB because no one else is doing it. We
get C from other folks. We don't get AB from anyone else. We
need a direction that allows us to provide the full balanced
message, not a single message.
Mr. Shays. You kind of turned my question on end. I wasn't
saying you would limit it. I would say if they want to spend
two-thirds they could spend two-thirds. So I don't really think
you were answering the question. The question was, why require
it? And your answer, I guess, in the end is not based on
science; based on the fact that Congress has required it, that
is why we have it.
You have done a very good job--I am interrupting you but
you have done a very job of putting the best case forward I
think you can do. But it still doesn't answer the question why
it is one-third.
Ambassador Dybul. I think you are right. Maybe it should be
more than a third. I don't know, but the law is at least a
third if not----
Mr. Shays. I never said it should be nothing. I am saying
if a country wants to spend more, that it could spend more. We
are going to hear from other people in the second panel, but in
my brief visit to Uganda and Tanzania, it was--I was struck by
this fact. I was struck by the fact that when I spoke to
college kids, they were telling me if they don't have condoms,
they are still going to have sex, and so are their friends.
That is what they said.
And what they said is kids back in villages are still going
to have sex no matter what you think about--however, you know,
effective your abstinence programs are, they are still going to
have sex. So you can decide to let them have sex without
condoms, or you can let them decide to have sex with condoms.
They are still going to have sex.
Ambassador Dybul. Mr. Chairman, I think it gets back to
your point on evidence. The evidence is that people are
changing their behavior. The evidence is that we are seeing a
reduction in partnerships and sexual activity.
Mr. Shays. But the evidence is not clear if they are
changing their behavior because we have an abstinence program
that tells them the truth, by the way, you may get AIDS, or we
have an abstinence program because it is better for your soul
and you will grow up to be a better person. We don't have
evidence as to what, why and which programs work.
Ambassador Dybul. I think that is true, and I have stated
that we don't know that yet. We do have some data on some
programs; for example, the Zip Up Program in Nigeria. We do
have data from some other programs, Soul City and a few others,
and we are still working on those.
The fact of the matter is that we need to have a broad-
scale ABC message to everyone in every place that condoms
should be available to all those who need them. But the issue
of priority of just providing condoms without AB we know is
wrong, too.
Unfortunately, and again this gets somewhat to the
President's request, were the President's request met for the
focused countries, we could increase AB and C. Would the rest
of the world step up to its responsibility to match the United
States, we could do enough AB and C.
I don't think it has to do with the lack of availability of
condoms to college kids any more than it has to do with lack of
AB messages. It is a problem of resources and the rest coming
from the rest of the world and the President's full budget
being supported. But we have increased AB and C. We would like
to increase it more, and we will increase all three of those
more with additional resources.
Mr. Shays. Is there any other comments you want to make
before we get to the next panel? Is there anything we need to
put on the record?
Dr. Hill. I think I would just add that one way or another,
whether it is by congressional directive of some sort which
instructs us to make sure that we do a comprehensive approach--
because the basic message of ABC is critically important, it is
going to vary little from country to country--one way or
another, whether that prodding comes from you or comes from the
Office of Global AIDS Coordinator or from central authorities
in Washington, it is like any other guidance. It is given
because you want to ensure that you get a balanced program that
does as much as possible. Having some flexibility is fine, but
we have to make sure that we push hard on this because, in
fact, in the past it wasn't a balanced program, and this was an
effort to try to make it more balanced.
Mr. Shays. You wanted to say something?
Ambassador Dybul. I would say I think this has been a very
important hearing. I would just want to state that the American
people through PEPFAR are supporting the broadest comprehensive
HIV-AIDS prevention strategy in the world beyond question.
I think we may do all of ourselves a disservice by
concentrating too much on various percents when we know ABC is
the proper message, and stick to supporting things and
expanding programs and having that comprehensive base shifting
as we go, should male circumcision, microbicides or other
things become more available, but sticking to the basic sense
that ABC is the foundation. Gender is something we need to deal
with, alcohol, all of the things we are supporting, and try to
focus more on what we can do going forward rather than focusing
too much on a percent that isn't radically affecting things in
the field in a negative way at all and, in fact, had some very
positive----
Mr. Shays. Let me put on the record my own view that you
both are very dedicated people. You are taking a law that has
been passed by Congress, and you are seeking to implement it. I
know this is a morning, noon and night effort on your part and
the people that work with you.
I happen to be a very proud American of what we have done,
and I know the President is criticized for a lot of things,
some of which I have been, you know, out there criticizing him
for. But I am very proud of our country's focus on this issue.
As a former Peace Corps volunteer, I know that we are doing so
much more than any other country, and so while we are asking
you these questions, and we might have some disagreements, we
don't have any disagreements over the importance of this issue
and the dedication of your people, and we do appreciate your
being here.
I do want to recognize Barbara Lee. We are going to get on
to our next panel, but I would just note that she has unanimous
consent to participate in these hearings, and she is a real
leader on this issue. Maybe you would like to just address
these two gentlemen before they get on their way, and if you
would like----
Ms. Lee. Let me just first thank you. Forgive me for being
late. I will definitely, though, review testimony, and
appreciate everything that you are doing. And, Mr. Chairman, I
just thank you for giving me the opportunity to sit in on this
very important hearing.
As you know, I helped write the PEPFAR legislation, and we
want it to work. And I think today's hearing will let us know
if it is working, if it is not working, what the abstinence-
only policies mean in the field, and what to do about them if
they are not working.
And I thank you very much, Mr. Chairman.
[The prepared statement of Hon. Barbara Lee follows:]
[GRAPHIC] [TIFF OMITTED] T5621.025
[GRAPHIC] [TIFF OMITTED] T5621.026
Mr. Shays. Thank you.
Gentlemen, thank you both so very much. Appreciate your
being here.
Mr. Shays. We will ask the next panel to come in just 1
minute.
Our next panel is Dr. David Gootnick, Director,
International Affairs and Trade, U.S. Government Accountability
Office; Dr. Helene Gayle, president, chief executive officer,
CARE USA; and Dr. Lucy Nkya, member of Tanzania Parliament,
medical chairperson, Medical Board of St. Mary's Hospital,
director, Faraja Trust Fund, to which I have denoted $100 since
she shook me up for it; and Dr. Edward C. Green, senior
research scientist, Harvard Center for Population and
Development Studies, director, AIDS prevention and research
project at Harvard University.
Now that you have sat down, Dr. Gootnick, we are going to
ask you to rise and--we will ask you to rise, and we will swear
you all in.
[Witnesses sworn.]
Mr. Shays. What we do is we swear in all our witnesses. You
can swear or affirm, but raise your right hands.
In 10 years as a chairperson, there is only one person we
have never sworn in, and that was the good Senator in West
Virginia. I chickened out, Dr. Green, I just couldn't do it.
We will start with you, Dr. Gootnick, and then we will go
to you, Dr. Gayle.
Welcome. Let me explain, we didn't do too good a job last
time, but we have a green light there on both ends. We leave
them on for 5 minutes, and then we allow you another 5 minutes
if you need it. But we have four on the panel, so it would be
good not to go beyond the 10 minutes. I will interrupt you
after that certainly. So welcome.
STATEMENTS OF DAVID GOOTNICK, DIRECTOR, INTERNATIONAL AFFAIRS
AND TRADE, GOVERNMENT ACCOUNTABILITY OFFICE; HELENE GAYLE,
PRESIDENT AND CHIEF EXECUTIVE OFFICER, CARE USA; LUCY SAWERE
NKYA, MEMBER OF TANZANIAN PARLIAMENT (MP, WOMEN SPECIAL SEATS),
MEDICAL CHAIRPERSON, MEDICAL BOARD OF ST. MARY'S HOSPITAL
MOROGORO, DIRECTOR, FARAJA TRUST FUND; AND EDWARD C. GREEN,
SENIOR RESEARCH SCIENTIST, HARVARD CENTER FOR POPULATION AND
DEVELOPMENT STUDIES
STATEMENT OF DAVID GOOTNICK
Dr. Gootnick. Thank you, Mr. Chairman. Mr. Chairman,
Congresswoman Lee, members of the subcommittee, thank you for
the opportunity to discuss GAO's recent report on prevention
funding under PEPFAR.
As you know, the May 2003 leadership authorized PEPFAR;
established the Office of the Global AIDS Coordinator, or OGAC;
and established the GHAI account as the primary funding source
for PEPFAR. The act also endorsed the ABC approach, recommended
that 20 percent of the funds under the act support prevention,
and requires starting in fiscal 2006 that one-third of
prevention funds be spent on activities promoting abstinence
until marriage.
Our report reviews PEPFAR prevention funding, describes
PEPFAR strategy to prevent sexual transmission of HIV, and
examines key challenges associated with the strategy. In
addition to document review and analysis, we present the
results of structured reviews with key U.S. officials or
country teams in each of the focus countries who are
responsible for implementing PEPFAR programs.
Regarding our findings, PEPFAR prevention funding in the
focused countries rose by more than 55 percent between fiscal
2004 and 2006, increasing from roughly $207 to $322 million. I
note that our figures differ somewhat from those presented by
Ambassador Dybul and would be happy to discuss that in the Q
and A.
During this time the prevention share of focused country
funding fell by about one-third, bringing it into alignment
with the act's recommendation that 20 percent of PEPFAR funds
support prevention.
The PEPFAR preventing strategy for preventing sexual
transmission is largely shaped by the ABC approach, Congress's
one-third abstinence-until-marriage spending requirement, and
local prevention need. OGAC adopted broad principles associated
with the ABC model.
Mr. Shays. Doctor, why don't we move the mic a little to
the left because you pronounce Ps very well.
Dr. Gootnick. OGAC adopted broad principles associated with
the ABC model, directing country teams to employ best practices
coordinated with national strategies and focused countries,
integrate across A, B and C activities, and be responsive to
the key drives of the epidemic and local cultural norms in each
country.
To meet the spending requirement for fiscal 2006, OGAC
directed that each focus country team, amongst other things,
direct at least half of their prevention funds to the
prevention of sexual transmission and within that spend $2 on
AB programs for every dollar spent on what OGAC refers to as
condoms and related prevention activities. Of note, activities
that support IV drug, alcohol reduction and others are
considered under condoms and related prevention activities.
Seven focus country teams, primarily those with smaller PEPFAR
budgets, received exemptions from this requirement.
Regarding key challenges, although several teams noted the
importance of promoting abstinence, more than half of the focus
country teams reported that the spending requirement limited
their ability to design prevention programs that were
integrated across A,B and C, and most teams reported that
fulfilling the spending requirement challenged their ability to
respond to the local conditions and social norms in their
countries.
Between fiscal 2005 and 2006, funding in the focus
countries for abstinence-until-marriage programs rose from $76
to $108 million. During the same interval, condoms and related
activities and prevention of mother-to-child transmission
programs in these countries had roughly level funding. These
program shifts allowed OGAC to project that it will meet
Congress's one-third abstinence-until-marriage spending
requirement. However, to meet the requirement for fiscal 2006,
seven countries planned declines in PMTCT funding that ranged
from roughly 5 to over 60 percent and seven projected cuts to
programs aimed primarily at high-risk activities in vulnerable
populations. These cuts ranged from 7 to over 40 percent.
Finally, as a matter of policy, OGAC also applied the
spending requirement to certain USAID and HHS funds despite its
determination that by law the requirement applies only to funds
appropriated to the GHAI account. These non-GHAI funds are a
small part of the focus country prevention budgets; however,
they represent more than 80 percent of U.S. prevention dollars
for five additional countries, India, Russia, Zimbabwe, Malawi
and Cambodia were also held to OGAC's policies on the spending
requirement. This decision could especially challenge these
country teams' ability to address local prevention needs.
Our report recommended that OGAC collect and report
information on the effects of this spending requirement on its
programs and ask Congress to use this information to assess how
well the requirement supports the act's key goals.
GAO also recommended that OGAC use this information to
reassess its decision to apply the spending requirement to
PEPFAR funds in the nonfocus countries as previously mentioned.
In commenting on our report, OGAC acknowledged that
countries face difficult tradeoffs with their prevention
programs, and Dr. Dybul reiterated that this afternoon. They
agreed with our recommendation to collect and report
information on the spending requirement; however, they did not
agree that the requirement should be applied only to the GHAI
account.
Mr. Chairman, this concludes my statement. I am happy to
answer any questions you or members of the subcommittee may
have.
Mr. Shays. Thank you very much, Dr. Gootnick.
[Note.--The GAO report entitled, ``Global Health, Spending
Requirement Presents Challenges for Allocating Prevention
Funding Under the President's Emergency Plan for AIDS Relief,''
may be found in subcommittee files.]
[The prepared statement of Dr. Gootnick follows:]
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Mr. Shays. Dr. Gayle.
STATEMENT OF HELENE GAYLE
Dr. Gayle. Thank you, and thank you very much, Mr.
Chairman, Congresswoman Lee, and thank your subcommittee for
the opportunity to join today to consider issues related to HIV
prevention programs funded by the President's Emergency Plan
for AIDS. We clearly feel that ensuring PEPFAR achieve its
success in reducing HIV rates while we continue to focus on
equitable treatment and humane care for those already infected
is a key critical challenge for U.S. policymakers.
Organizations like CARE who implement programs at the
country level share your commitment to make sure that we use
these resources in the most effective way as possible. We feel
we owe that to the people in those countries and clearly to the
U.S. taxpayers who make these resources available.
We applaud the focus on prevention because clearly while
treatment is critical, we can't treat our way out of this
epidemic, and we really do need to think about how we are using
the resources to keep people from getting infected to begin
with. And we know that without effective prevention strategies,
the numbers of infected individuals will continue to grow.
We are here because we feel strongly that PEPFAR and the
U.S. Government have shown real leadership and have contributed
major resources and critical momentum to prevention, treatment
and care, and we know that the program has already saved
countless lives and provided much-needed support to
communities, and we strongly support the continuation of this
vital initiative beyond 2008. And so we are here today because
we believe in the program, believe that it has a strong role,
and want to provide instructive feedback.
I would just say--and that feedback, that comes, from our
experience, at the field level so that this program can be
strengthened.
Just say from the outset there was a lot of discussion, the
first panel, about the ABC approach and whether this is the
right approach. And I think we would go on record saying that
we strongly believe that a behavioral approach, approach that
changes people's risk of acquiring this infection or avoids it
altogether, is the right approach. And so ours is not an
argument about the merits of an ABC approach, but rather a look
at how the current legislation may be construed in ways that
don't allow for a balanced approach to the use of an ABC and
behavioral change approach.
And I also say this as somebody who worked in the U.S.
Government for 20 years and was responsible for developing
program guidance, and understand that what may be written at
one level has huge implications in how it actually gets
translated at the country level. So it is with that perspective
that I want to talk about some things that we think would
really help and make more effective the current program and
make a bigger difference in lives.
So I want to talk about, first of all, the importance of
being able to more flexibly implement the current guidance to
best respond to the needs at the country level; that we feel
that the issue of--as a result of vulnerability of women and
girls must be even more strongly focused on; that it is
important that a focus on engaging other highly vulnerable
populations is incorporated; look at the better need to
integrate efforts to address underlying determinants that drive
or compound vulnerability to HIV; and then finally to look at a
greater commitment to look at the impact and the evaluation and
long-term sustainability of this program.
So I will try to be brief. I have a written statement that
goes into much more detail. But our first point, that in our
experience on the ground and resources for countries throughout
the developing world, the PEPFAR country teams responsible for
interpreting program guidance have articulated prevention
policies and programs with a strong AB preference, leaving
little room and funding for integrated local responses, HIV-
AIDS prevention programs. And again, we understand that this
may not be the intent, but the experience on the ground
suggests that this is a real issue.
Let me just give you one example from our many
conversations with CARE field staff in preparation for this
hearing. In one of the PEPFAR focus countries with a
generalized epidemic, our country office approached the PEPFAR
country team with an innovative proposal to work with sexually
active youth who were exchanging sex for money. Our proposal
would have provided treatment for sexually transmitted
diseases, training for alternative livelihood so that youth
would not have to exchange sex for livelihood and for money,
and a variety of--a more comprehensive approach to address
these issues.
This proposal was turned down for AB prevention funding
because it was seen as not having a focus on those two
elements, and I think highlights the fact that there is a real
difficulty and a bias that works against having a comprehensive
approach in the way that programs are actually implemented in
the field because the funding categories of AB and other often
end up being applied in a very rigid fashion.
We have other examples of how this interpretation of the
need to partition funding works against a more comprehensive
approach, and as I stated in the beginning, our strong feeling
is that all of those components are important, and it is only
through having a comprehensive approach, a truly comprehensive
approach, that the prevention efforts can be most effective.
We believe that countries left to make the decisions, that
have the freedom to make their own decisions that meet the
needs of their country's circumstances, will, in fact, apply
the funds in a way that provides for a balanced approach, and
that countries don't need to be dictated to about the
percentage of resources that are used for any particular
strategies. So we believe that countries left to their own
wisdom will, in fact, make good use and make--and use a
balanced approach in their effort.
Second, in sub-Saharan Africa, women represent 60 percent
of those infected with HIV and 75 percent of infections between
the ages of 15 and 24.
Women and girls in Africa are well served by the ABC model
only when they are free to make choices about abstaining from
sex, or choosing to remain in a relationship where faithfulness
is meaningful, or to access condoms and negotiate their correct
and consistent use.
But wherever women cannot control the sexual encounters
they engage in, either for reasons of rape, abuse, gender
disempowerment, economic dependency and cultural practices, ABC
in its current formulation is significantly more problematic.
And we have a lot of examples from countries that have high
rates of rape and sexual exploitation where girls report that
they feel compelled to exchanges sex for food.
So clearly a message that focuses on abstinence and being
faithful misses the point of the circumstances of these women
and their lives. And so having a focus that really addresses
the needs of women and the circumstances in which they find
themselves is critical.
I just give one quote, a predicament of one African woman
interviewed by CARE which is all too widespread. She said, I am
a widow and have no family around me except my small children.
People in the community know I am poor and alone and thus more
vulnerable. As I have no one to protect me and no money, I am
often forced to provide sexual favors to officials, military
and even my brother-in-law.
We know that the OGAC has given more support to the issue
of including gender issues, but we feel that needs to be a much
stronger focus, recognizing that the ABC approach alone does
not take into consideration the entrenched cultural and social
norms that drive women's vulnerability. But we know that a
difference can be made, and particularly when more focus is
placed on changing male behavior.
Again, to illustrate, an African man recounted the
following to CARE field staff: My wife was raped, and I threw
her out of out of the house. A neighbor helped her and talked
to me, but I refused to listen to that woman. Later the men
from the association came to talk to me. They explained what
had happened, and it wasn't my wife's fault. They encouraged me
to take her back into the home, and I did.
So we know that, in fact, that by focusing on men's
behavior at the same time, that we can have an impact on making
a difference in the circumstances that affect the lives of
women.
Third point, the risk of HIV infection is significantly
higher among certain vulnerable populations, including sex
workers, injection drug users, men who have sex with men, and
prisoners and sexually active adolescents. In many countries
CARE HIV-AIDS and reproductive health programs reach sex
workers and those engaged in transactional sex through
interventions designed to reduce the risk of infection or
identify activities to expand livelihood activities. PEPFAR's
funding is often supporting too little and too little
innovation in prevention programs among vulnerable populations.
And in view of the time, I won't go into a lot of detail
other than to say that I think the focus on vulnerable
populations has to be included in that regard. And we think
that the antiprostitution pledge is particularly
counterproductive in the fight against HIV-AIDS.
Our fourth point is that as we look toward PEPFAR
reauthorization----
Mr. Shays. Is this your final point? Because we need to
conclude here.
Dr. Gayle. Yes.
It is important to learn from experience to date and begin
to articulate components of a truly comprehensive HIV
prevention policy that looks beyond the ABC formula and also
addresses the broader underlying issues linked to HIV
vulnerability and related issues.
In that regard we look at issues of poverty, gender
inequality and livelihood, understanding that all of that can't
be funded through PEPFAR, but a better approach to integrating
sources of U.S. funding, like food, nutrition, agriculture and
economic growth resources so that those components can be
integrated with prevention will clearly make a huge impact on
the effectiveness of prevention programs.
And I won't go into detail in the final one only to say
that evaluation of this program and looking at the long-term
impact of sustainability is also going to be critical.
So I will just close there and look forward to your
questions.
Mr. Shays. You will have plenty of time to elaborate on any
point in your statement and questions.
[The prepared statement of Dr. Gayle follows:]
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Mr. Shays. Dr. Nkya, you are most welcome here. And the
only thing that concerns me is when I saw you in Africa, you
had a smile on your face. You look too serious to me. I need to
see that smile.
This is a wonderful opportunity for us to have you here,
and I just want to say before you speak, I don't want to put
pressure on you, but our visit to Africa was made very special
by getting to meet you. You are a remarkable person, and you
honor us with your presence, and it is lovely to have you here.
STATEMENT OF LUCY SAWERE NKYA
Dr. Nkya. Mr. Chairman, Congresswoman Ms. Lee, members of
the subcommittee, I am honored to be here to speak on behalf of
the African continent, and more specifically for my people from
Tanzania.
Mr. Chairman, before I discuss or give the evidence of what
is happening with PEPFAR funding in Tanzania, I would like to
give a few statistics of information about the epidemic in
Tanzania.
The AIDS Tanzania epidemic was first recognized in Tanzania
in 1983 with three cases from the northwestern part of Tanzania
called Kagera region. Within 3 years, the epidemic had spread
throughout the whole country. That means it assumed a disaster
proportion, and that is why in the year 2000 our President,
when launching the AIDS policy, announced that AIDS was a
national disaster in Tanzania.
Mr. Chairman, I would like to bring to the attention that
there is only 1 case out of 14 of AIDS cases in Tanzania who
are reported to the nationalized control program, which is
charged with the following of the money that are in the
epidemic in Tanzania. That means that the statistics which are
released are really, you know--and the reporting, and they are
downplaying the epidemic and the proportion of the epidemic in
the country.
Out of all the cases reported, they referred that the peak
of the epidemic is between 20 and 49 years that contributes 73
percent of all the AIDS cases in the country, which means that
this age group has been infected during adolescence or during
their youthful years; that is, between 15 and 20 years of age.
Then 10 years later that is when the epidemic starts showing
up.
Another point to take, to note, is the, you know,
preponderance of----
Mr. Shays. Let me ask you to put the mic a little closer to
you. Just a little.
Dr. Nkya. Is the early age of infection in women. The peak
is between 20 and 29 years. That means women are infected at a
very young ages compared to male counterparts, and that married
people contribute 56 percent of all the cases of AIDS which are
reported in the country as compared to the 32 percent of the
singles.
And the currently AIDS infection in Tanzania now is 7.7
percent. This does not mean that the prevalence rate has gone
down, but it is because it is based on blood donor,
surveillance reports, which have proved that people now who are
going go to donate blood have known about HIV-AIDS, so a person
who suspects himself as being infected will not go. So this has
brought down the infection rate.
Let me tell you that we aimed at treating only 1,200 people
out of 2,000 who are infected, but this is only in urban areas,
and the legality is if your city or county is less than 200
percent--200, that means a lot of people infected who could be
healthy and lead a meaningful life--are denied opportunity for
treatment. I don't know who brought in this cut point, but it
is there.
Let me say that the initial response is good, and I do have
a very good HIV prevention strategy which includes ABC, plus
other contributing factors like using the same instruments,
ear-piercing and injections, and more on cultural behaviors and
beliefs which contribute to the, you know, spread of the HIV-
AIDS.
Now, what about my experience now with PEPFAR fund. And I
am going to talk in relation to for trust fund.
Mr. Shays. Your experience with what?
Dr. Nkya. With PEPFAR funding program, the AB program.
I am going to talk about my experience with FARAJA Trust
Fund, which is an agency which I am directing. Before I started
working with Deloitte through a program called ISHI--ISHI means
live. It was a campaign which was targeting young people in
Morogoro municipality with one message, that you should wait
until marriage, and if you cannot, you can use a condom and
engage in dialog.
Dr. Nkya. Yes. The message is this: It means wait, don't be
afraid. You know, engage him in a dialog or her in a dialog, or
abstain. If you cannot, use a condom.
That was the message. And you know, we produced a lot of
teachers with the message. And it was all over the radio
program, television programs, even the national television.
Unfortunately during the last session of the Parliament, this
message was banned from being transmitted through our
television programs in Tanzania.
Dr. Nkya. It was a successful program, it was a 1-year
program. We had more than 7 million shillings from Deloitte.
And it give the youth an opportunity to discuss openly about
HIV/AIDS, to get access to condoms, the few condoms which I had
because we could not access new condoms through the ministry
because they were not available, there were no funds.
And then the second message came in 2005, 2006 through
Family Health International. Now the message changed, it was
now AB, that was abstain or change your behavior. That was the
message that was being given to the young people. Now what was
the reaction? The reaction was very confusing. The young people
would come to us and ask us, are you going mad? It was a bit
embarrassing. You have been advocating condom use, behavioral
change and abstinence where it is applicable, but now you
change and say OK guys, it is time to be more realistic,
abstain from sex until you get married--as if everybody's going
to get married--or change your behavior, be faithful in
marriage.
So several questions came up. The first question was, what
will happen to the sexually active young people who are HIV
positive? What will happen to the couples who are HIV positive
if free condoms--because many people in Tanzania are poor--if
no free condoms are available? They're asking me, you know,
have you changed the behavior and the culture of the people
whereby, you know, rich men, especially affluent men, in the
community that they are rich and influential, the number of
concubines or sexual partners they're going to have, they came
to ask me, you know, don't you know, mom, that the problem here
is poverty, not even, you know, we being promiscuous.
And this brought me back to the project which we started in
the brothels. It is one of the biggest brothels where a lot of
young women were in the 1990's, and I talked with one and asked
her what is your problem, why do you have to leave your home
and come to this place, which is filthy and they're being
abused by men. She said, look here--they used to call me
mother-in-law--mother-in-law, look here, it is better to die
slowly than to die of starvation to death, and better off dying
10, 20 years to come if the message is this, rather than dying
today because the 10 years will give me time, first of all, to
work and build a house for my children, and give enough time
for my children to grow up and to become self-reliant, and also
be able to purchase a farm. And then very slowly given enough
time to repent of my sins, that's what they told me.
Then probably, if I would give another example, another
example is about a young girl who is 15 years old and she has a
child. This woman, this girl asked how come she have a child.
She told me that she was forced into marriage by her father,
and that is, you know, perfectly in order, depending on the
culture of our people in Tanzania, to marry a man as his
official wife, and when this man died, she was forced to be
inherited by the older brother of the dead man that she managed
to run away and escape.
Now what was her refugee? How could she leave with two
children? So she had to engage in commercial sex work in order
to live. And now I'm talking to her, telling her now, you see,
if we check you--you come for physical, and we refer to you as
either negative or positive, you should be abstaining from sex.
Then she asked me, what am I going to do? How am I going to
feed my children? My mother also expects me to support her from
where I am now.
That's the issue, Mr. Chairman. Let me say that the
approach and the policy of AB does not take into consideration
the culture of the people in the developing countries. It does
not take into consideration the socioeconomic situations,
things like poverty.
Let me tell you that even empowering women or gender
empowerment will never succeed if we don't address the issue of
poverty, especially among women. This is evidenced by a program
I conducted in a brothel whereby I was able to empower those
woman economically, and we managed to remove more than 67
percent of those women from prostitution, they are living, and
their children are now going to school.
Mr. Chairman, I have a lot of testimony, but----
Mr. Shays. Well, maybe we'll get some of your testimony
from the questions, but I remember your conversation with us,
and as you--this brothel, as I remember, had literally hundreds
of women, didn't it?
Dr. Nkya. There were about 450 women, and we managed to
rescue 270 women who were HIV negative to stop prostitution,
and they moved back into their homes. The remaining, we were
able to give them some money so that they could take care of
themselves. Although they were positive, they could do some
work, ideas to get food, to meet their present medical
requirements and to feed their children. And eventually, as I'm
talking today, Mr. Chairman, the brothel has been demolished,
and these women now are living, they are respected and they're
living.
So that is a living example which has been by many people
and organizations in Tanzania and some organizations from the
countries that empowering women should complement economic
empowerment because poverty is the basis of HIV. HIV is
epidemic in our countries. Whether you are infected or not
infected, you are in the rural area or in the urban area, if
you are poor, you are going to engage into behavior which is
going to put you into risk of getting infected. I'm not
forgetting that.
44 percent of our population is young people. That means
these young people, as we have seen in the statistics here,
they are more vulnerable than the others. So let's say that
they're all vulnerable to getting HIV infection. So telling
them to abstain, that is not really going to hold water, and
backed by the fact that we did the survey in Morogoro in year
2000 and year 2003, whereby we found that the minimum age of
sexual activity started from 10 years, and for some were 9
years of age.
So given that basic fact, and I think, you know, it would
be better off if HIV prevention strategies, that means
including AB plus the other cultural factors, and economic
factors which are contributing to this plague of HIV/AIDS.
Mr. Shays. Well, we will get into some of this in the
questions that Ms. Lee and I will be asking. So thank you for
your testimony.
I'm struck by the memory that as you went to this brothel
to deal with these women, as I recall, your husband, who
traveled, got a note from one of his friends saying your wife
has become a prostitute. He didn't quite understand the role
you were playing. You are obviously a magnificent lady.
[The prepared statement of Ms. Nkya follows:]
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Mr. Shays. Dr. Green.
STATEMENT OF EDWARD GREEN
Dr. Green. Thank you. Mr. Chairman, members of the
Government Reform Committee, thank you for inviting me to
participate in this important hearing on AIDS prevention and
PEPFAR. I'm a senior research scientist at the Harvard Center
for Population and Development Studies.
For most of my career I have not been an academic. I've
worked in less developed countries as an applied behavioral
science researcher and as designer and evaluator of public
health programs, mostly under funding of USAID. I've worked
extensively in Africa and other resource-poor parts of the
world. I've worked in AIDS prevention since the mid 1980's, at
which time I was working in the field of family planning and
contraceptive social marketing in Africa and the Caribbean, and
I've served on the Presidential Advisory Council for HIV/AIDS
since 2003.
I might add that I worked with Dr. Nkya in 1984 in Morogoro
in that very project for sex workers. We were helping them not
get infected or pass on infections, treat their STDs, and
provide income generating skills if they wanted to get out of
sex work, which the great majority did.
I would say that obviously abstinence is not the very
relevant message if you're an active sex worker, but then
neither are condoms and clean syringes, the primary message
that you would bring to primary schools.
Since my time too is very short, let me just cut to the
chase. And I feel that amending the 2003 act that requires that
33 percent of PEPFAR prevention funds be spent on abstinence
and fidelity programs, moving this would be a bad move,
removing this earmark would remove the essential primary
prevention foundation from the U.S. Government response to the
AIDS pandemic. It would leave only risk reduction, which is
different in intent and effectiveness from true prevention.
A risk reduction approach assumes that behavior
contributing to morbidity and mortality cannot be changed;
therefore, the best we can do is to reduce risk. And this was
our strategy with those sex workers in Morogoro. Risk reduction
alone has never brought down HIV infection rates in Africa.
This conclusion was reached by three separate studies under the
rubric of the USAID funded ABC study in 2003, and later. It was
also reached by a U.N. AIDS study of a 2003 study condom
effectiveness review by Herston Chen, and it was the conclusion
implicit in the UN/AIDS multi-site African study published in
2003.
Prevention based on risk reduction had some early success
in Thailand, and later in Cambodia, but never in Africa, or at
least outside of the few high risk groups. Now PEPFAR and USAID
lead the world in AIDS prevention, promoting a balanced and
targeted set of interventions that include Abstinence, Being
Faithful and Condoms for those who cannot or will not follow A
or B behaviors. And I'm the person who said this is in spite of
formidable and continuing institutional resistance to change,
and maybe we can talk more about that.
Removing primary prevention from this mix by removing the
present earmark would almost certainly return AIDS prevention
to the era when HIV prevalence continued to rise in every
country in Africa, with the exception of Uganda and Senegal,
the first two countries in Africa to implement ABC programs.
Since then, ABC programs and changes specifically in A and B
behaviors, especially in B behaviors, as has been said earlier,
which is measured in the decline in the proportion of men and
women reporting two or more partners in the last year, are
credited with reducing HIV prevalence not only in Uganda, but
in Kenya, Zimbabwe and Haiti, and possibly in Rwanda. These
last three countries' successes were all the more remarkable
considering the political and economic devastation they've
suffered.
As was mentioned, a consensus statement published for the
2004 World Aids Day special issue of the Lancet proposed that
mutual faithfulness with an unaffected partner should be the
primary behavioral approach promoted for sexually active adults
in generalized epidemics. Abstinence or the delay of age of
sexual debut should be the primary behavior approach promoted
for youth. This represents a fairly marked departure from many
previous prevention approaches which emphasized condom use
almost exclusively as the first line of defense for sexually
active adults for all types, in other words, regardless of the
country, the culture or the type of epidemic. This statement
was endorsed by over 150 global AIDS experts, including
representatives of five U.N. agencies, the WHO, the World Bank,
as well as President Museveni, and two of the authors were
myself and Dr. Gayle.
A growing number of public and international health
professionals recognized the previously missing AB component of
ABC as logical, sensible, cost effective, sustainable,
culturally appropriate interventions for general as distinct
from high risk populations. Moreover, the evidence is clear
that these components work, and that risk reduction alone has
not lead to a simple success in generalized epidemics.
I wish I had more time to present more evidence, I thought
we were going to be kept on our 5 minutes.
For example, DHS, Demographic and Health Survey data showed
that higher levels of AB behaviors--and it's assumed by many
that we already see that, including people who work in the AIDS
field ought to be familiar with the data. For example, only 23
percent of African men and 3 percent of African women reported
multiple sex partners in the last year, according to the most
recent DHS surveys. Among unmarried youth 15 to 24, only 41
percent of young men and 32 percent of young women in Africa
reported premarital sex in the last year. This means that most
African men and women practice B behaviors, or do not have
outside sexual partners, and most unmarried African youth do
not report sexual intercourse in the past year.
I hate to use the controversial A word, abstinence, but
that's what surveys show. And I wish we could take away the
word only after abstinence.
Moreover, the trend in Africa is toward higher levels of A
and B behavior, it is toward incrementally lower HIV
prevalence. HIV prevalence is an average of 7.2 percent for
Sub-Saharan Africa in 2005, compared to 7.5 percent in 2003. I
mention this because critics of the African ABC model often
depict African men in particular as incapable of monogamy or
fidelity, which is simply not true. When critics of fidelity
and abstinence programs argue that these behaviors sound nice
but don't get the reality of Africa, one only needs to look at
the available behavioral and epidemiologal evidence--this is
from DHS, studies by Population and Services International of
Family Health International, a number of USAID recipients of
funds.
In conclusion, I hope Congress will take no actions that
would seriously undercut the one major donor agency in the
world that is conducting effective AIDS prevention, the
generalized epidemics by in effect removing the very
interventions that have been proven to have the most impact. I
believe that the simple effect of the African model of AIDS
prevention is still so new and different from the old way of
doing things that without some direction from Congress, the
bureaucracies involved in guiding implementation would probably
fall back into old habits and once again limit AIDS prevention
to its reduction to condoms, drugs and testing. These three are
all necessary, but A and B is the missing part.
If I could just take a moment to answer the question that
you were asking the government panel, why not simply leave
allocations to the countries themselves. We had an example of
that happening in 1998, the Ministry of Health in Jamaica
convinced USAID, they said basically we feel we have the
expertise in our government and our NGO's, give us the money
and we'll give you the results. After 5 years, we'll account
for every dollar to see how we do results-wise. And what they
did, what Jamaica did is they developed a program very much
like that of Uganda or Senegal, it was a balanced ABC program,
and I was one of the three American evaluators, and STD rates
were coming down, and it seemed like HIV rates were coming
down, and it was one of the better programs I've seen in
developing countries.
I think where the problem is, Mr. Chairman, is with us, is
we technocrats from the United States and Europe, we're used to
the American model of AIDS prevention which is focused on MSM
and IDU, focused on high risk groups. And so if you come from a
family planning background the way I do and you're used to
preventing contraception, which I am and USAID is
institutionally, and all of a sudden, you find out that Uganda
and some other countries are quietly doing something a little
bit differently and having results, it takes a while to change
your thinking and to change what the bureaucracy does. And when
you think of all the grantees, the contractors and what they
do, what they do best, it takes some change. So I really think
that if the earmark were removed right now, we would go back to
the AIDS prevention before 2002, and we wouldn't be having as
many successes as we now have. Thank you.
Mr. Shays. Thank you, Dr. Green.
[The prepared statement of Dr. Green follows:]
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Mr. Shays. We're going to start with Ms. Lee.
Ms. Lee. Thank you very much, Mr. Chairman.
Let me first say once again, thank you for this hearing.
It's very important. And as I listen to the testimony, the only
thing I can think of is we're talking about saving lives right
now, and finding the best way to do that and to help people
live longer lives until we do find a vaccine or a cure. And I
need to say up front that I think we need to repeal this
earmark. I intend to do everything I can do to try to get that
repealed.
Dr. Green, now you're at Harvard University, and I
appreciate Harvard and know of your good work and Harvard's
good work throughout the world. And I have to ask you, though,
in one who believes that ABC makes sense, abstinence, be
faithful, use condoms, why in the world would you believe that
ABC is not what we're talking about when we talk about
abstinence, be faithful, use condoms, I mean, we're talking
about a balanced comprehensive approach. And with this earmark
being what it is, we have seen in and GAO has indicated that
this is probably hindering our efforts in the prevention arena.
And let me just say, I was at the last AIDS conference in
Toronto, the rest of the world, quite frankly, disagrees with
what you're saying, Dr. Green, the rest of the world
understands and gets it. The rest of the world believes that
they know how to develop country-specific plans that come up
with their specific ways of addressing prevention, care,
treatment. And so why would we not listen to what works in
countries and not be as heavy handed in our approach?
Dr. Green. With all due respect, that's exactly what I'm
doing, my rethinking AIDS prevention in 2003 was looking
specifically at the first five or six countries to experience
prevalence decline. I also have to say, with all due respect,
that the people who attend the global AIDS conference are not a
cross-section of Africa, Asia, Latin America--this is not the
best of the world.
Ms. Lee. Well, Dr. Green, what countries do you think would
not want to see the earmark repealed?
Dr. Green. What countries would not want to see it
repealed? Who would you ask in those countries? If you put it
to a vote of the people, the majority of the population, I'm
certain that all of the countries would want to keep the
earmark there if they understood that----
Ms. Lee. They knew they could get some money.
Dr. Green. No, if they understood that AIDS prevention
would go back to risk reduction only.
The head of the National Aids Committee for Kenya 2 or 3
years ago posted a complaint on an AIDS discussion group on
line that the ministry--that the government of Kenya had
received an additional $10 or $15 million for AIDS prevention.
And part of what the government wanted to do was have a program
to reach kids before they become sexually active, to promote
abstinence or delay of sexual debut, not abstinence only, but
to include. And they were told no, this is money from the U.S.
Government, it has to be spent on condoms. And he wrote a
letter to complain, and I asked if I could put his letter in my
book, which I did. I, again, say I think the problem is with we
technocrats--and I mean European and American experts who work
in AIDS, we're used to thinking in terms of the American
epidemic, the European epidemic, high risk groups--which are
some of the first groups we went after in Africa and the
Caribbean, I was working in the Dominican Republic in the mid
`80's. We went after--we tried to reach sex workers and their
clients. But again, if you look at the data, most Africans,
most people everywhere are already engaged in primarily B
behaviors, and young people are primarily engaged in A
behaviors. I don't even like the word ``behavior change.''
Ms. Lee. Dr. Green, all I'm saying is that the
conditionality aspect of this, even telling a country that they
must have a strategy that only uses condom as part of their
strategy----
Dr. Green. I'm glad you agree that's wrong.
Ms. Lee. I'm talking about ABC; I'm talking about allowing
countries to come up with their culturally specific, their
scientifically specific, their gender specific, their overall
approach to how they want to deal with this pandemic. So no, we
shouldn't say----
Dr. Green. I think we should do that, I think we should
find out----
Ms. Lee. I think we shouldn't say if we don't like the way
you approach it. What I've heard--and again, I think that we,
at the international AIDS conferences and throughout the year
we hear from many, many people around the world who want to get
rid of this earmark because of one point, they want to be able
to be unencumbered by their approach to addressing this
pandemic because it's so serious.
And with regard to women, what happens to women? We all
know what happens to women. We heard earlier, the empowerment
of women, women's equity, gender equity, female condoms, all of
these strategies.
Dr. Green. That's part of the B strategy. If faithless men
are infecting their wives, then it's the men's behavior that
needs to change, and that's B.
Ms. Lee. But what about women and the access to condoms? If
a country or the United States has precluded the funding for
that, what if women----
Dr. Green. Well, they shouldn't.
Ms. Lee. Well, the earmark, in many ways, precludes a
comprehensive balanced approach.
Dr. Green. I don't see it that way. There is a larger pie
now to divide up than there was a year ago, 2 years ago, 3
years ago. As I've been saying for some years now, as we have
gained more to work with in AIDS prevention, let's not put all
of our money into programs that have not worked in Africa and
the Caribbean.
Ms. Lee. I'm not talking about putting all of our money
into programs that don't work. All I'm saying is why can't we
just repeal the earmark and say to countries, develop whatever
plan makes sense to address this terrible deadly disease.
That's all I'm saying, period, dot dot.
Dr. Green. I agree with the intent of what you're saying,
but I think in practice what happens is poor countries ask for
the program that they know that there is money for.
Ms. Lee. Oh, Dr. Green, come on. You know how you're
sounding, very patronizing. Countries have the ability--and
I've spent quite a bit of Africa----
Dr. Green. I lived there.
Ms. Lee. Countries around the world have many unbelievable
people who know how to address epidemics, pandemics, disease if
only provided the resources and the support and the technical
assistance. I can't believe that in any country at this point,
if we didn't help develop and go in and do the things we need
to do to support their efforts, that they couldn't be
successful. So I can't buy the poor country notion.
Dr. Green. Again, I agree with your intent. I wish there
was some way to let these countries choose for themselves
without imposing our priorities on them.
Ms. Lee. Well, I think we can.
Let me just say to Dr. Gayle, I want to congratulate you on
the successful conference in Toronto, it was really quite
successful, quite powerful. I've been to four, and intend to go
to the next one in Mexico City. And as I was thinking about
Toronto today, I said when in the world are we going to have an
international AIDS conference in America? And then it dawned on
me that we have certain travel restrictions for people living
with HIV and AIDS that precludes us from having such an
important conference in our own country.
So I'm going to work with others to try to--again, I hate
to keep trying to repeal stuff, but we want to get rid of that,
too.
You know, I mean, I think that the world is a small place
now, and we need to figure out ways to work together. And for
us not to be part of this conference and not to be able to have
it on our own soil to me is just downright wrong and, quite
frankly, it's immoral. I was proud to carry the American flag
in a rally in Toronto. I knew I couldn't carry the American
flag in a rally here in America at an international AIDS
conference. Mr. Chairman, I think that's pretty bad and it
doesn't bode well for our standing in the world.
And so I just to want congratulate you and also just to ask
you your take on--you heard what Dr. Green said about the
conference in terms of who goes and who doesn't go. What is
your take on the abstinence only policy, and by the rest of the
world, the rest of the world that didn't come to the
international AIDS conference.
Dr. Gayle. Yes, thank you. And we appreciate you and the
Chair's leadership in this issue. And I also appreciate your
comment about repealing the travel restrictions. We really
would love to see an international conference on U.S. soil
again and feel that there's a real value to it because I think
it goes along with the leadership role that the United States
is playing. And that's why we feel so strongly about getting it
right because we feel that not only are the resources that the
U.S. Government contributes critically important, but the
leadership role that the U.S. Government can play and does play
is critically important. And so the consistency in that
leadership role we feel is extremely important on all these
issues.
I would disagree, I think the International Aids
Conference, I disagree with Dr. Green that the International
Aids Conference is a wide cross section of people working on
HIV at a grassroots level as well as the international arena.
So while perhaps it isn't perhaps totally inclusive, 24,000
people working on HIV from all different continents I think
does speak to a pretty inclusive gathering. And we didn't take
a poll on what people thought about the restrictions, but I
think it's fair to say that there are concerns because not only
does what the U.S. Government do impact U.S. Government
funding, but again, the United States plays a strong leadership
role. And so I think it does also influence other people's
thinking about what is the right way to do things. And so what
we do with our funding does influence the world, and I think
sending a message to the world that we don't see this in a
comprehensive way, that we do have biases, has an impact. And I
think all efforts to really allow for countries to make
decisions to have an integrated program, just like we talk
about combination treatment, we also have to talk about
combination prevention. There is no one-size-fits-all, it is by
the ability to make programs that fit the country needs and
country circumstances that we can have the most effect
prevention response.
And I would argue that as somebody who's been doing HIV
prevention programs for over 20 years, I don't remember a time
when we as public health professionals said that condoms were
the only answers. So this idea of going back to that day, I'm
not sure where that perception comes from. I think that the
understanding and the evidence around what works for HIV
prevention has evolved. And so I think it is not legislation
that leads to the understanding that a comprehensive approach
is right, it is evidence, it's the fact that we have growing
evidence that this is the right approach.
So I don't think the clock will be turned back, whether you
think that it was there or not. I don't think that it is
legislation that keeps people looking at a comprehensive
approach, it's the evidence, it's the evidence that says this.
And I think whether it's technocrats or whether it's the
country level, it is a comprehensive approach that must move
forward. And I don't think that it is a need for a proscriptive
approach what is what will keep a comprehensive approach on the
books and in our policies and in our program, it's the fact
that we all know that is the best way to have an impact on
prevention by doing it in an integrated fashion, doing it in a
comprehensive way. The evidence is there, and I think that
stands for itself.
And I would just add that I do think that the issues that
were raised around making sure that we address the other
issues, the issues of poverty, the issues of gender and equity,
we must do that in order to support a behavioral prevention
strategy because people's behavior, individual behaviors occur
in the context of social realities.
Mr. Shays. Let me jump in here, I'd like to take some time.
Dr. Green, first let me say you bring tremendous
credibility to whatever position you take based on the work
you've done for so many years. So even if Ms. Lee does not
agree with you, it's important that we hear exactly what you
think, and then kind of wrestle those out.
I would like to know, coming all the way from Africa, what
would be the most important thing that you would want us to
know about the continent as it wrestles with this disease? And
what is the biggest area that you would want, Dr. Nkya, to
impress upon us so that I'm very clear as to the most important
thing that you want us to know.
Dr. Nkya. Thank you, Mr. Chairman.
Coming all the way from Africa, I'd like to insist that
AIDS is a disease of poverty. And it is compounding on the
threat of disease, poverty, it is also compounding on the
socioeconomic impact and even the physical well-being of the
people, which also in turn compounds the vicious cycle of
compounding poverty itself.That is one.
Two; it is unfortunate that we in Africa, especially in
Sub-Saharan Africa, we are always the recipients; we totally
depend on external support on most of our intervention
packages. So whoever comes with assistance in HIV intervention,
they come with their own prescription for intervention package.
Whether we agree to it or not, we have to adhere because we
need the money. And it's unfortunate that we cannot even become
a bit flexible to fit into our own, you know, what is really
workable in our own environment.
So what I would like to, you know, ask you or request from
this package or from the funding is like what Congresswoman Lee
was saying, that if countries were given the opportunity to
choose and to plan for themselves, could it really have an
impact on the spread of the disease? I'm saying yes. Yes,
because, for example, in Tanzania, we recognize that women are
very vulnerable. We know that when we are addressing ABC, and
there are free condoms for those who want to use condoms and
have the information, the impact is really good, but now we
cannot produce condoms because most of the money for condoms
came from the United States of America. So now we do not have
access to free condoms.
Money comes for treatment and for prevention for mother to
child. It's unfair to just giving the women some medicine to
prevent the child from getting infection at birth and while the
child is newborn, but after that there is no form of support of
counseling. So I would like to see more money being allocated
to provide holistic HIV--I would like to see some money being
allocated to provide holistic HIV/AIDS prevention package, like
for primary schools, very young children we can talk about
abstinence and behavioral change. For the grown up children,
because we know, whether we want to talk about it or not, they
are practicing sex.
We should be able to give them more information about, you
know, productive health, more information about behavior
changes through life skills training, which is not really
widespread in Tanzania and that's why we have so much AIDS.
Mr. Shays. What I find myself wrestling with, and I'd like
all of you to respond to it, and I'll start with you, Dr.
Green, when I heard the first panel talk about basically a
holistic approach, looking at all abstinence as well as condoms
as well as be faithful and so on, what I'm realizing though is,
from the testimony that we've heard from this panel, that we
really separate them. And so I'm thinking, is it a crapshoot in
a way? Do some students only get abstinence and some students
only get condoms, and is it really an integrated program
because of that? And you know, you, Doctor, are getting me to
think that way, that if that's where the money is--first off, I
believe that folks will go wherever the money is, I mean,
they're going to design a program, we give them money they're
going to design a program to be able to attract that money. Do
you get the gist of my question, Dr. Green?
Dr. Green. Did I get the question?
Mr. Shays. Do you understand what I'm asking?
Dr. Green. Not quite.
Mr. Shays. OK, let me ask it this way. If we are mandating
that a certain amount be for abstinence--there's going to an
abstinence program that's provided, correct?
Dr. Green. Yes.
Mr. Shays. But I suspect in most instances, the abstinence
program is not going to also tell you you can use a condom, and
that you're going to see a program in abstinence. And that you
might see a program that, you know, is providing condoms, but
you don't integrate it. So it's not like what people are
suggesting. You know, trying to persuade a young person about
abstinence is the best way, but here is a condom if you're not
going to go that route, it almost seems like a contradiction.
Dr. Green. Well, I agree with your implicit criticism of
compartmentalizing, you know, this program is for this and only
this, and the B and the C are only for the--and that's not
integration and that's not real life and that's not responding
to people's actual needs. So I think we're in agreement there.
I think the government panel testified that after the age
of 14, that the B and C message are brought in. You know, if
there is evidence that children are sexually active at age 10
or 11 and that's their situation, you can't change it--I would
try to change it--then you need to bring in condoms earlier. So
I'm not in favor of abstinence only.
You know, if we just look at the Uganda model, and we can
look at the other models, Senegal and more recently Kenya and
so forth, I didn't see much evidence of condoms only. I have
pages of teachers books and student books from primary schools
in Uganda, and condoms are part of the education. So there
should be integration. I don't know that much about how PEPFAR
is integrating, but that's the way it should be.
Mr. Shays. Dr. Gootnick.
Dr. Gootnick. Thank you. I think the particular lens that
GAO can bring to this discussion is really two-fold. One, if
you offer the U.S. Government implementers in the field, the
USAID and CDC staff in the field some degree of candor and ask
them how this spending requirement affects their programming,
you'll get some interesting information. That's the first
thing. And second----
Mr. Shays. And the interesting information is?
Dr. Gootnick. Well, the interesting information is that
more than half of the respondents will tell you that while
Office of Global AIDS coordinator will certainly allow an
integrated program, an ABC program--and if Ambassador Dybul was
here, I think he would tell you that these programs, the vast
majority of them are integrated. But if you speak to the
implementers in the field, they will tell you that program
dollars in these different buckets has consequences, and that
there are programs that could be much better integrated but for
the spending requirement that the program works with.
The second point is if you look at where the dollars have
had to move, and the difference between 2005 and 2006 really is
enlightening. And there will never be another set of data like
the transition between 2005 and 2006 and that's because 2006
was the first year that the one third abstinence requirement
became law.
So looking at what happened in the shift between 2005 and
2006, it is informative that no other data set will be. And as
I mentioned in my prepared remarks, if you look at in the
aggregate, AB programs went up very significantly whereas
prevention mother-to-child transition and condoms and related
program activities remain level. If you look at a country
level, you see some real tradeoffs that have been made there.
If you look at a country like Zambia, you see that there has
been nearly a 40 percent cut in condoms and related program
activities at the same time that abstinence programs have
risen. You see in that country also as you well know that sex
workers, migrant populations, and other vulnerable populations
are perhaps key to the epidemic there. You see that sexual
transmission in discordant couples, in a couple where one
individual is positive, the other is negative and may not know
it, the rates of transmission in discordant couples are very
similar to the rates of transmission in the general population,
so----
Mr. Shays. I'm not getting the point as to how that relates
to my question.
Dr. Gootnick. Well, the point is that an integrated
program--the U.S. Government implementers will tell you that
the counting of the money in the buckets of abstinence,
faithfulness and condoms related programs does hamper their
integration. And you will see, if you look at the dollars,
considerable shifts in program dollars in order to meet the
spending requirement.
Mr. Shays. OK, thank you. Doctor.
Dr. Gayle. Yes, briefly to add to that, I would agree our
experience at the field level is that while the guidance,
strictly speaking, does allow for an integrated approach, the
way it's practiced inconsistently and the guidance that is used
does bias programs often in an AB category where the preferred
program would be to implement an integrated approach so that we
do have in the field programs that end up being not integrated,
only having one element or the AB approach not being able to
integrate condom funding, and again, not because that is
necessarily explicit, but the guidance is confusing, and it
ends up being interpreted in the field in a very
compartmentalized way.
Mr. Shays. Does your organization provide all three, ABC,
all three?
Dr. Gayle. Right. But we're in 70 different countries. So
at a country level, the guidance is applied differently. As an
organization overall, yes, we definitely focus on a
comprehensive integrated approach. But by country by country,
the way the guidance is interpreted pushes people in one
direction or the other, and compartmentalizes programs much
more than the original intent would have been.
Mr. Shays. OK, thank you.
Dr. Nkya. But Mr. Chairman, my concern is this; whether we
talk about ABC, but for poorer countries like Tanzania, you
can, you know, violate the rule and talk about ABC. But there
are many people who would like to use the condom, and young
people cannot access condoms because they're not there. I go
and ask the minister of health what is happening, we don't have
condoms, we says we are not getting money from the United
States of America to buy condoms----
Mr. Shays. Let me ask you this; OK. You're not getting it
from the United States, but you're not getting it from anyone
either?
Dr. Nkya. We're not getting it from anybody else because
the others who are funding something like integration impact,
and others have some other interests like working with other
organizations, but initially, all the condoms in that country
were being funded by the USAID from America. So now we don't
access--for the past 5 years--4 years we don't access free
condoms for anybody in that country.
Mr. Shays. So I make an assumption that if condoms aren't
available, we're basically transmitting AIDS. If condoms aren't
available, sex--I mean, I have not yet known a society that's
decided to give up sex. So what I make an assumption is, from
your testimony--and it's pretty powerful because, unlike the
others, you're there, you're working with young people all the
time, and you're saying and testifying before this committee
that condoms are not available. That is a powerful message
because we know that is one way to prevent the transmission of
AIDS. We could talk long and hard about whatever we want to
talk about, the value of abstinence, but if in the end condoms
aren't available and young people and older people are having
sex, they are at huge risk. And what I'm trying to understand
is why would it have to be, Dr. Green and Dr. Gootnick and Dr.
Gayle, if we are saying it's an integrated approach, why can't
it include all of the above? And why, in the end, are condoms
not available? Are they that expensive that--so someone help me
out here.
Dr. Gayle. Well, I guess I would agree with the earlier
statements, that in order to have the best chance at having a
balanced approach is to let countries develop programs that
meet their needs at the country level, and that countries make
those decisions about what proportion gets spent on what part
of the ABC approach based on what their greatest needs are. So
that if condoms and condom shortage was the greatest need for a
given country, that they have the ability to use resources for
condoms. If, on the other hand, they had other funders that
allowed them to use those resources for purchasing condoms,
that more focus be put on the other parts of the approach, so
that countries have the ability to make those decisions without
having arbitrary proportions that need to be spent, and can
develop a truly integrated approach.
So I think the lack of funding for condoms is reflected by
the inability too use resources to spend it on what countries
need it for the most.
Mr. Shays. I'm going to react to something--thank you. Dr.
Green, I'd like you to react to--I'm going to tell you what I'm
hearing and I'd like you to react to it.
What I'm hearing is a better and more powerful message than
I thought in support of abstinence programs. I thought that the
first panel did a better job than I anticipated. You believe in
this program and you carry a lot of weight; you've had
tremendous experience and you do research and so on, so that
carries weight with me. But I'm left with the fact that if it's
a mutually exclusive issue--in other words, if you go the route
of abstinence, you are not providing enough condoms, for
instance, as one preventative way, then one, it isn't know an
integrated approach. But No. 2, if I had my child--let's not
use my child, let's just use any child, if they only had one
choice, they were going to have an abstinence program but still
have sex, I'd prefer they had a condom instead of an abstinence
program and still have sex. I mean, so react to what I'm
saying.
Dr. Green. It seems like we always fall back into talking
about abstinence versus everything else. Keeping in mind that
both government panelists and I have reported, which is that
it's part of reduction, it's not having--what drives epidemics,
sexually transmitted epidemics whether heterosexual or
homosexual, what drives these epidemics is having multiple
concurrent partners. And what brings prevalence down at the
population level is not having multiple concurrent partners.
So I wish I didn't always have to be put in the position of
defending abstinence--and we're leaving out the thing that
works best. So having said that, how often have I heard African
health educators and others say if it was--you know, it's not
if it was only one program, they would say if it was only one
behavior, I would want my child to abstain and not have sex
using a technology that, if used consistently is 80 to 85
percent effective in reducing HIV infection.
The problem is that rarely are condoms used consistently in
Africa, in the United States, anywhere in the world. I didn't
want to bring this up because it just makes me even more
unpopular than I probably already am to talk about
uncomfortable data, but there is an unwanted and unfortunate
correlation between populations where you find more condoms
available and people use them more, and higher infection rates.
The demographic and health surveys, we now have serologic
data to go with behavior data, so we can easily cross tabulate
those who are--we can look at the sero status of those who are
practicing A, B and C behaviors. And the first countries we
have evidence from from the demographic and health surveys--and
I don't think these have been published yet because there are
uncomfortable data--from Tanzania, from Ghana, from Uganda--I
think there may be one other country--we see that condom users
are more likely to be HIV infected than non-users. This is
counterintuitive, it's not what we want, it's not where we put
billions of dollars, but it may be because--it's probably
because condoms are not used consistently usually, and second,
there's a disinhibiting effect. If the message is you can do
what you want, be sure to use American brand condoms, then
people will probably take more chances than they would if they
weren't using condoms. Again, this seems to be
counterintuitive.
Mr. Shays. One last question. I heard the data is 85
percent; is that because they're not used properly?
Dr. Green. 85 percent is about right.
Mr. Shays. Basically, what you're saying is so someone is
having sex with someone who had AIDS, by one out of ten, you're
going to get AIDS even with a condom. But is that because
they're not being used properly?
Dr. Green. We don't know the reasons. It's probably more
improper use. It's not being consistent; this is when condoms
are used consistently, it's probably that they're not used
correctly. In poor countries, you don't have good storage,
condoms may be the wrong size. How often in Africa I see
condoms made in Thailand, wrong size. There's product failure,
in part, because they may be old condoms, expired and so forth,
especially in poor countries.
So those reasons are--those figures are pretty consistent
every time. We knew this from family planning. Before the AIDS
pandemic I worked in family planning; the condom was not one of
the more effective methods of prevention----
Mr. Shays. Let me do this; if any of the panelists want to
just respond to any question I asked Dr. Green.
Dr. Nkya. Mr. Chairman, I would like to comment. I would
like to ask him, at that particular time when condom
distribution was started, was there a survey, you know, a
serological test to know who was positive and who was negative?
Because when you start giving condoms, you don't know who's
positive or who's negative. So when you started giving condoms,
that's the majority of those people are already infected, but
we are preventing infection. So that is my concern.
And another thing about the storage, and the condoms being
made in Thailand being shorter than, you know, the private
parts of men in Africa it is true, but that is another
aberration which I'm seeing that if someone wants to give us
assistance and he goes ahead and orders condoms for us without
taking into consideration of sizes of our people, that is
another thing that I'm saying that I disagree with completely.
The storage part of it, you know, you give the condoms. You
don't give money for logistic support whereby you could be able
to transport and store the condoms in the situation whereby
they remain, you know, protective, that is another problem,
because someone says I'm giving you condoms, I'm ordering them,
not to take into consideration about the sizes, the needs and
other logistical support which is needed to transport the
condoms from where it is manufactured, and to the end point to
where, you know, the beneficiary is. That is another problem.
And that's why I support the idea that the developing countries
should be given the opportunity to plan how to use the PEPFAR
funds whenever the funds are available.
Mr. Shays. Let me go to Ms. Lee. Oh, I'm sorry----
Dr. Gayle. I was just going to make an additional comment.
I agree with the comment that was made about the shortcomings
of the survey which are cross-sectional data, and I think it
needs to be put into broader context. It could be that people
with condoms were already infected, it could be that by
definition, those in the population are already at greater
risk, so it's not surprising that the rates would be higher,
but I think what it really points to is the fact of what we've
been talking about, that it isn't one or the other, even condom
use needs to be in concert with a focus on changing risk
behavior to begin with. And I think most people in this
business believe that it isn't one or the other and that they
reinforce each other, and it's not just a condom message, it's
a condom message that also talks about reducing risk behavior,
reducing the number of partners. And it's by doing all of those
things together that you have the greatest impact and are
synergistic.
So it is not one or the other, and that's, again, why this
whole focus on being able to have a comprehensive approach
can't be said enough.
Mr. Shays. Thank you. Did you want to say something?
Dr. Green. Yes.That last statement I completely agree with.
Mr. Shays. Thank you.
Ms. Lee.
Ms. Lee. Thank you, Mr. Chairman. I'm not sure who to
direct this question to, so whoever can answer it, please do.
Let me ask you this; with regard to the guidance document,
abstinence or return to abstinence must be the primary message
that youth receive or for youth in PEPFAR countries, and
information about consistent and correct condom use is only
provided to youth who are identified as those who engage in
risky behavior. But I want to ask you just from a practical
point of view, in a classroom setting, how do you distinguish
between youth who are engaged in risky sexual behaviors and
those who are not? And doesn't it make sense to provide again
age-appropriate, scientifically medically sound information
that includes all aspects of ABC without stigmatizing or
segmenting part of that message? And so how is that addressed
at this point? Dr. Gayle or Dr. Gootnick.
Dr. Gayle. I would just agree that I think that the ability
to provide the complete message as appropriate at a given age
is a--seems to me be more effective than segmenting information
by age group. I think that most of us would agree that we would
want to have young people abstain from sex as long as possible
and that would be desirable. But when you're looking at a
population of young people, it is difficult to segregate
information based on whether or not somebody's currently
abstaining from sex or not. And so having half information, not
complete information, seems to be a less effective approach
than looking at what's an age-appropriate way of giving people
more complete information because somebody who is sexually
inactive and are abstaining 1 day may become sexually active
the next day, and we want them to have the information that
allows them to reduce their risk even if they're not totally
avoiding risk. So I think the ability to do that in a
comprehensive way at any age would be desirable.
Ms. Lee. So how is one supposed to separate out youth who
are high-risk youth in terms of youth who engage in risky
sexual behavior being the ones who get the information with
regard to correct and consistent condom use versus those who
are not identified?
Dr. Gayle. I think that raises a good point. I think it's
difficult. I think it is easier for a group of youth who are at
risk and who are currently sexually active to know that. I
think it's difficult in a situation of youth who are not
specifically at high risk who are in a classroom setting, who
are within a civic organization or other settings where there
is going to be a mix of young people, to be able to segregate
information accordingly in a practical sense.
Dr. Nkya. I would like to add on that. You know, for me,
according to my experience, 20 years of working with AIDS, I
have come to discover that all young people are at risk. So
trying to segregate who is to get it is going to bring some
problems. I think our message here should be that we should
target all the youth, whether in school or out of school, give
them the message and correct information. And more probably,
try to make sure that every child has the right health
information because the survey which was conducted in Dar es
Salaam in high schools in Dar es Salaam, in 1988, zero percent
of the girls were infected with HIV, and then only one boy was
found to be infected because of transfusion.
Two years later, the infection went up 10 times, it was 8
percent. That means that there is a high, you know, sexual
activity taking place among schoolgirls, especially where
poverty is a problem.
So we should target the girls together with the boys,
although the infection with the boys was not significant, but
we should target all the children, even as young as, you know,
in primary one, to tell them that there is AIDS, do you know
AIDS, and then we start from there. And make it a sustainable
program, not just a one-time seminar in school and then you
disappear. So that is my concern there.
So that is my concern there, a sustainable program from,
you know, primary 1, up to university if it is possible.
Ms. Lee. Thank you very much. I hope the powers that be
heard you, Doctor, because I think you make a lot of sense and
it makes sense. And, to me, listening to you, I am trying to,
again, figure out why the guidance documents instruct--you
know, in PEPFAR countries--instruct organizations to have the
primary message as being abstinence only, except the youth that
they think are identified are at risk in terms of risky
behavior.
Doctor Gootnick.
Dr. Gootnick. I would say briefly that the guidance
document we refer to is used extensively by the program
officials in the field and it is valued by them. They cite 3
key issues and key areas where this guidance may be indeed--
although clear if you read it word for word--hard to apply in
the field; one of which is the case that you mentioned, the
issue of how to deal with youth of different age. There are
different messages that can't under PEPFAR's guidance be
offered to youths less than 14, youths who are older than 14,
populations who may be at risk or most at risk, and as a
practical matter it is difficult for them to apply the
guidance.
The second area of confusion is permissible activity with
respect to condom use. There is guidance for different
populations that allows you to discuss condoms but not promote
condoms, and that becomes very difficult for the program
officials to apply in the field.
And the third area where there is some confusion is in
high-risk activities or individuals. There is certain programs
that PEPFAR may implement for high-risk or most-at-risk
populations, but in a generalized epidemic it is often very
difficult to determine who indeed is high risk or most at risk,
because the fairest way to define that is almost anybody who is
having sex outside of a known mutually monogamous relationship
with a noninfected partner or someone who is abstinent.
Dr. Green. If we go by data, the epidemiologic data, we see
that 7.2 percent of subSaharan Africans, if you average all the
countries together in subSaharan Africa, about 7 percent of
Africans are HIV positive, which means 93 percent are not
positive. You don't agree?
Mr. Shays. I was shaking my head because I was thinking 7
percent of a population is such a huge number. It blows me
away.
Dr. Green. Yes it is way too high.
Mr. Shays. I think of kids going to school with no
teachers, coming home to no parent.
Dr. Green. I mention that as an antidote to the thinking
that everyone is a current risk and all African men are
promiscuous and all African women have no power--African women
have more power than we foreigners give them credit for.
I agree with most of the comments I just heard, Dr. Nkya. I
feel certain that if we had time to sit down and if you just
interviewed me and Dr. Nkya and try to find points of
disagreement, there wouldn't be many. And if Africans could
choose for themselves, without being influenced by what is on
the donor menu not only from the U.S. Government but from the
United Nations, AID, and other organizations I think that would
be ideal.
I see a lot of of these problems as growing pains. It is as
if we were putting billions of dollars into reducing lung
cancer and we for some reason, because it might hurt people's
feelings, we didn't have don't start smoking or give up smoking
if you are already smoking or at least smoke fewer cigarettes
per day.
And I have never said that condoms were the only message,
but it was the main message before PEPFAR, and the other
interventions were and are for all other major donors treating
STDs, VCT, voluntary counseling and testing, and treating HIV-
infected mothers with nevirapine. And I think it is a great
step forward that the U.S. Government for whatever reasons,
maybe it was for, I don't know, ideological reasons--
Congresswoman Lee, you said you were in on the planning of
PEPFAR so maybe you know, but I don't know what the reasons
were, but I think it was a genuine positive step forward to
include primary prevention, avoid the risk altogether if you
can.
But here are the other things you can do if that is not
possible. And I think programs should be integrated and not
compartmentalized, and if some people in the field are having
problems because of the way the earmark is written, nobody
likes earmarks. I come from 2 generations of foreign service
officers. My father and grandfather always complained about
congressional earmarks. I sympathize, but I think it has
brought us forward.
Mr. Shays. Let me quickly get a quick response. I am
surprised that other countries aren't doing more. And am I just
misreading it? I am surprised that other countries aren't doing
more, and am I misreading what other countries are doing, No.
1? And I am also told sometimes when the United States really
steps up to the plate, other countries feel they don't have to.
And so, one, is the United States stepping up to the plate,
even if we had this disagreement about where one-third of the
prevention dollars go? And No. 2, are other countries doing
what they should do? Maybe, Dr. Gayle, I could just ask you
that, and Dr. Gootnick.
Dr. Gayle. Definitely the United States is stepping up to
the plate, and, as the earlier panel said, we fund anywhere
from one-third to one-half depending on how the numbers come
out in terms of funding. I think the difference is that the
U.S. Government has always had a strong bilateral program where
other countries have not, and more of the countries put their
money through the pooled resources, through the global fund. So
I think there are a variety of different ways of looking at
funding, and a lot of the other countries also put their money
either in the global fund or through programs that are not
specific sectorial programs and are going to much more combined
funding approach where they put it into a pool that then gets
used, so it is harder to track it as AIDS funding.
That being the case, clearly the U.S. Government is the
largest funder of HIV programs, and the work needs to be done
to continue to encourage others to increase their resources.
Mr. Shays. Quickly, what is the close second? Maybe there
isn't a close second. Who is second?
Dr. Gayle. England.
Mr. Shays. There is certainly not a close second. We take a
lot of hits on a lot of things but sometimes we don't pat
ourself on the back.
Dr. Gayle. I think we should pat ourselves on the back. I
also think we have to remember that we are the largest economy,
and when you start looking at our contribution per capita, we
don't have quite as much to be proud of; we still should be
proud and we still are the largest contributor, but in terms of
per capita funding, if you look at some of the smaller
countries per capita, they actually are contributing
substantial amounts. So I think we need to look at it in a
variety of different ways.
Mr. Shays. Fair enough. Dr. Gootnick.
Dr. Gootnick. Just to put a couple of numbers to those
comments, and while not the subject of our analysis, roughly
speaking it is estimated about $8.3 billion was spent on AIDS
last year, global spending. About $2.5 billion of that was
national spending, spending by the Governments of Tanzania, the
so-called recipient nations. And the remainder of that would be
donor spending. Of that, OGAC was more than half, about $3.2
billion, with the rest of the two nations combined somewhere in
the $2.5 to $2.7 billion range.
Mr. Shays. That would suggest our economy at 25 percent of
the world's economy, we are doing 50 percent of the
contributions.
Dr. Gootnick. Yes. The other way to look at it is to look
at the percentage, our share of GDP. There is an aspirational
notion that donor countries would provide .7 percent of their
GDP for development assistance, humanitarian assistance,
broadly speaking. Some countries in Europe get closer to that
and a few reach it. The United States is about at .1 percent of
GDP.
Mr. Shays. Let me do this. Is there any closing comment
that any of you would like to make, something that we should
have brought up that we didn't, something that needs to be put
on the record? And we will start with you, Dr. Green.
Dr. Green. Just to continue the answer to that question,
but it brings out something that I would like to say, that I am
not so concerned about the amounts or even the proportions of
money; rather, that money is well spent. Daniel Lobier,
formerly of Cambridge University, now with the Global Fund for
ATM, estimated that between 1986 and 1991 in Uganda, when
Uganda turned that epidemic around using its own approach
before we donors really moved in there, it was before the U.S.
aid, the first bilateral program, Uganda spent about 25 cents
per person per year for this highly effective program. It was
the first really effective program in the world.
So if money is well spent, we--it is less an issue of how
much and--but the other important point I would like to leave
the subcommittee with is that there is a perception out there
that ABC is something to do with the Bush administration, and
like a faith-based initiative and something to appease the
religious right. And for that reason the major donors, United
Nations, AID, WHO, all the major bilateral multilateral donors
pretty much are very suspicious of it and don't support the A
and B parts, by and large, and that is what the government
panel said.
Mr. Shays. Very interesting. Dr. Gootnick.
Dr. Gootnick. Just briefly to reiterate what GAO
recommended in the aftermath of this study was that Congress--
that the Office of Global AIDS Coordinator collect and report
information on the downstream implications of the spending
requirement report it to Congress, and that Congress use it in
its ongoing oversight of the program. And we reiterate that
recommendation.
Mr. Shays. Thank you for doing that. Dr. Gayle.
Dr. Gayle. Yes, three very brief points, I think this panel
is the first one where all agree that the ABC approach is
important and should be the cornerstone of behavioral
prevention. I think where we disagree is how do we get to that
comprehensive approach.
And I would just like to somewhat differ with some of the
comments that before the PEPFAR program there was not a
commitment to comprehensive programming. Having run USAIDS
prevention programs from the very early days, CDC's programs,
that in fact the U.S. Government strategy was behavior change,
treatment of STDs and condoms before the PEPFAR. So the idea
that the--only by having that earmark will we make--keep a
commitment to comprehensive prevention doesn't speak to the
facts that a comprehensive approach that includes behavior
change, has been part of the U.S. Government program for the
last couple of decades.
Second, I think that the issues that have been raised that
there needs to be greater flexibility to integrate programs
that focus on the other dimensions, the vulnerability that
people face, the poverty, gender inequity, food insecurity,
that the other issues that put people at risk for HIV to begin
with, particularly women, need to be able to be addressed,
perhaps not directly through resources from PEPFAR, but a
greater flexibility and much greater coordination of U.S.
Government funding, so that in fact there is the ability to
knit together these other aspects that, after all, if we don't
attack the context in which people's behaviors occur, we are
not going to be able to change individual behavior, because it
is often based on just life survival. And so we have to be
cognizant of those issues.
And, third, that the importance of a long-term commitment
to sustainability, many of the programs that we are involved
in, the aspects that would allow for community buy-in and long-
term sustainability are not allowed, and that we have to
recognize that if we are going to commit to these programs
being sustainable in the future, we have to look at how we do
that and how do we make sure that there is community buy-in,
there is capacity development, and that these things go hand in
hand with the immediate need to get programs up and running.
Mr. Shays. Thank you.
Dr. Sawere Nkya, you have the last word----
Dr. Nkya. Mr. Chairman.
Mr. Shays [continuing]. Before I get the last word.
Dr. Nkya. I am the last word at home, too.
Mr. Chairman, I totally agree with what, you know, my
fellow testimony givers have talked about. But I would like to
emphasize on flexibility and just bring to attention that, you
know, empowering women in developing countries is through
education. If women are not educated we will never, ever be
able to empower them and they will always remain as vulnerable.
So probably if there could be some way whereby countries are
made accountable into promoting women or female education, like
giving them free education, giving free primary school
education, because it makes a difference if you are educated or
not.
And another thing is that of, you know, trying to remove
the component of compartmenting people as risky groups or non-
risky groups because that is stigmatizing them. It makes
people, even if they know they are at risk, they never go for
anything to help them preserve life, because here we are
talking about preserving life and as a result also promoting
the economies of the developing countries through reduction of
morbidity and mortality.
So, Mr. Chairman, I request for flexibility and probably a
change of direction of looking into all countries' needs;
specifically, you know, to that country, not, you know, the
comparison with another country.
Mr. Chairman, thank you very much.
Mr. Shays. Thank you very much. And we should pay attention
to you. You came all the way, 6,000 miles, to tell us this, and
you have been doing this work for decades.
You are a true hero, a true hero, and we really value your
testimony. We value the testimony of all our panelists but I
particularly want to thank you.
Mrs. Lee, a comment to close.
Ms. Lee. I want to say, Mr. Chairman, thank you for your
leadership and for your commitment to address this entire issue
in a bipartisan way and in a way that makes sense and it works;
because, as I said earlier, this is about saving lives and it
is about making sure that people who are living with HIV and
AIDS can live longer.
I want to thank all of our panelists. Whether we agree or
disagree, I think we have to muddle through all of this
together because it is so serious.
And the United States must continue to be out front in
terms of leadership, in terms of resources, and in terms of
really being committed to allowing countries to do their thing
in the way that they know how to do it best. And so I hope that
we can get to that point where we can go back when we do
reauthorize PEPFAR, look at your testimony, the suggestions you
have made, and try to figure out how we can incorporate some of
these very thoughtful suggestions and ideas into what we have
to come up with in the future. So thank you again, Mr.
Chairman.
Mr. Shays. Thank you. I just want to say you are the true
leader on this. I eat the crumbs off your table. I thank you
for what you have done, and thank you for participating in this
hearing and, again, thank both panels, our first and second
panel, and just to say to Planned Parenthood that enabled me to
take a really good look at what two countries were doing. I
went with the expectation I would come back somewhat, frankly,
disheartened, and I came back with a tremendous amount of
gratitude for the spirit that I saw in both Tanzania and
Uganda, particularly among the young people that I met. I
thought this is an alive place. And I met so many young kids
who just want to have a better future, that were excited about
their future, not asking for a lot.
And it made me feel--and I met a lot of people who are
running great programs.
So I came back from my visit to Africa with a feeling that
it has such unbelievable potential.
And I just kind of feel that Africa is on the cusp, at
least in the two countries that I saw, of really turning
around, not just their concerns with AIDS, but a whole host of
other issues. So I thank you. And with that, we will adjourn.
Thank you very much.
[Whereupon, at 4:22 p.m., the subcommittee was adjourned.]
[The prepared statement of Hon. Dennis J. Kucinich and
additional information submitted for the hearing record
follows:]
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