[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
PEPFAR: FROM EMERGENCY TO SUSTAINABILITY AND ADVANCES AGAINST HIV/AIDS
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HEARING
BEFORE THE
COMMITTEE ON FOREIGN AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 29, 2010
__________
Serial No. 111-129
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Printed for the use of the Committee on Foreign Affairs
Available via the World Wide Web: http://www.foreignaffairs.house.gov/
______
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COMMITTEE ON FOREIGN AFFAIRS
HOWARD L. BERMAN, California, Chairman
GARY L. ACKERMAN, New York ILEANA ROS-LEHTINEN, Florida
ENI F.H. FALEOMAVAEGA, American CHRISTOPHER H. SMITH, New Jersey
Samoa DAN BURTON, Indiana
DONALD M. PAYNE, New Jersey ELTON GALLEGLY, California
BRAD SHERMAN, California DANA ROHRABACHER, California
ELIOT L. ENGEL, New York DONALD A. MANZULLO, Illinois
BILL DELAHUNT, Massachusetts EDWARD R. ROYCE, California
GREGORY W. MEEKS, New York RON PAUL, Texas
DIANE E. WATSON, California JEFF FLAKE, Arizona
RUSS CARNAHAN, Missouri MIKE PENCE, Indiana
ALBIO SIRES, New Jersey JOE WILSON, South Carolina
GERALD E. CONNOLLY, Virginia JOHN BOOZMAN, Arkansas
MICHAEL E. McMAHON, New York J. GRESHAM BARRETT, South Carolina
THEODORE E. DEUTCH, CONNIE MACK, Florida
FloridaAs of 5/6/ JEFF FORTENBERRY, Nebraska
10 deg. MICHAEL T. McCAUL, Texas
JOHN S. TANNER, Tennessee TED POE, Texas
GENE GREEN, Texas BOB INGLIS, South Carolina
LYNN WOOLSEY, California GUS BILIRAKIS, Florida
SHEILA JACKSON LEE, Texas
BARBARA LEE, California
SHELLEY BERKLEY, Nevada
JOSEPH CROWLEY, New York
MIKE ROSS, Arkansas
BRAD MILLER, North Carolina
DAVID SCOTT, Georgia
JIM COSTA, California
KEITH ELLISON, Minnesota
GABRIELLE GIFFORDS, Arizona
RON KLEIN, Florida
Richard J. Kessler, Staff Director
Yleem Poblete, Republican Staff Director
C O N T E N T S
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Page
WITNESSES
The Honorable Eric Goosby, United States Global AIDS Coordinator,
U.S. Department of State....................................... 8
Thomas R. Frieden, M.D., M.P.H., Director, Centers for Disease
Control and Prevention, and, Administrator, Agency for Toxic
Substances & Disease Registry.................................. 19
Anthony S. Fauci, M.D., Director, National Institute of Allergy
and Infectious Diseases (NIAID), National Institutes of Health. 37
Ms. Paula Akugizibwe, Advocacy Coordinator, AIDS and Rights
Alliance for Southern Africa (ARASA)........................... 72
Wafaa El-Sadr, M.D., M.P.H., Director, International Center for
AIDS Care and Treatment Programs (ICAP), Mailman School of
Public Health, Columbia University............................. 84
LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
The Honorable Howard L. Berman, a Representative in Congress from
the State of California, and Chairman, Committee on Foreign
Affairs: Prepared statement.................................... 3
The Honorable Eric Goosby: Prepared statement.................... 11
Thomas R. Frieden, M.D., M.P.H.: Prepared statement.............. 21
Anthony S. Fauci, M.D.: Prepared statement....................... 39
Ms. Paula Akugizibwe: Prepared statement......................... 76
Wafaa El-Sadr, M.D., M.P.H.: Prepared statement.................. 88
The Honorable Ileana Ros-Lehtinen, a Representative in Congress
from the State of Florida: Prepared statement.................. 96
APPENDIX
Hearing notice................................................... 104
Hearing minutes.................................................. 105
The Honorable Donald M. Payne, a Representative in Congress from
the State of New Jersey: Prepared statement.................... 106
The Honorable Russ Carnahan, a Representative in Congress from
the State of Missouri: Prepared statement...................... 108
The Honorable Sheila Jackson Lee, a Representative in Congress
from the State of Texas: Prepared statement.................... 110
The Honorable Christopher H. Smith, a Representative in Congress
from the State of New Jersey: Material submitted for the record 117
Written responses from the Honorable Eric Goosby, Thomas R.
Frieden, M.D., M.P.H. and Anthony S. Fauci, M.D., to questions
submitted for the record by the Honorable Russ Carnahan........ 132
Written responses from the Honorable Eric Goosby, Thomas R.
Frieden, M.D., M.P.H. and Anthony S. Fauci, M.D., to questions
submitted for the record by the Honorable Barbara Lee, a
Representative in Congress from the State of California........ 135
PEPFAR: FROM EMERGENCY TO SUSTAINABILITY AND ADVANCES AGAINST HIV/AIDS
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WEDNESDAY, SEPTEMBER 29, 2010
House of Representatives,
Committee on Foreign Affairs,
Washington, DC.
The committee met, pursuant to notice, at 9:40 a.m., in
room 2172, Rayburn House Office Building, Hon. Howard L. Berman
(chairman of the committee) presiding.
Chairman Berman. The hearing will come to order. We are
going to be joined very soon by my friend from New Jersey Mr.
Smith, and he is okay with us starting the hearing. In a moment
I will recognize myself and then Mr. Smith for up to 7 minutes
each for the purpose of making an opening statement.
The chair and ranking member of the Africa and Global
Health Subcommittee aren't here, and Mr. Payne probably won't
be able to get here until 10 o'clock or so, so if the other
members here want to make a 1-minute opening statement, you are
welcome to do so. I know you are both very interested in this
subject.
The purpose of today's hearing is to review the progress
PEPFAR has made toward reversing the global threat posed by the
AIDS pandemic and how those efforts have set the stage to
transform PEPFAR from an emergency initiative to a sustainable
program.
This morning, we are going to hear about some outstanding
achievements and promising research that gives hope for
increasing our ability to reverse the spread of the disease. We
also will hear about the challenges we still face if we are to
accomplish the ambitious goals set forth in the Tom Lantos and
Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis and Malaria Reauthorization Act of 2008.
This legislation, which built on the successes of the
original legislation, the U.S. Leadership Against HIV/AIDS,
Tuberculosis and Malaria Act of 2003, is a prime example of the
bipartisan support that exists to fight the global HIV/AIDS
pandemic. The fact that both sides joined together to bring
positive change demonstrates that saving lives around the world
is not a Republican or Democratic issue. It is a priority that
all Americans share.
PEPFAR faced many challenges during its first 5 years,
including weak health care delivery systems, poor
infrastructure, expensive and unavailable drugs, and limited
workforce. These factors kept millions infected with the
disease isolated from the care and treatment they needed.
Social barriers like stigma, gender inequality, and
prejudices against men-who-have-sex with men, commercial sex
workers, and intravenous drug users, compounded the challenges
to expanding services to those in need.
But PEPFAR successfully invested in strengthening health
care systems, training new health care personnel, purchasing
affordable drugs, and helped to remove stigma and empower women
and girls and other at-risk populations.
In the face of controversy and our own economic challenges,
Congress remained unified behind a single humanitarian purpose.
Even in the face of our differences, we never lost sight of the
goal to save the lives of millions of poor human beings who do
not have the resources and means to save themselves and prevent
the spread of AIDS.
In preventing the spread of AIDS, we are not simply
achieving the humanitarian objective of saving lives and
preventing suffering. We also are advancing economic growth and
building democratic stability by preserving the health of
productive citizens, enabling people to support their families
and contribute to the economic, social and political life of
their communities.
Last week the United Nations General Assembly convened a
summit to discuss progress to date on achieving the Millennium
Development Goals. Addressing the AIDS pandemic has had an
impact across all of the MDGs. We must ensure that our
commitment to fighting AIDS is designed to reinforce other
critical health and developmental priorities.
Today we have some good news in spite of the sobering
impact the pandemic continues to have in poor countries.
Globally, the overall rate of new HIV infections has slowed and
prevalence rates have leveled off. According to the 2009 UNAIDS
report, new HIV infections have been reduced by 17 percent over
the past 8 years.
In 2008, sub-Saharan Africa reported 14 percent fewer new
infections than in 2001. In East Asia, new HIV infections
declined by nearly 25 percent and in South and Southeast Asia
they declined by 10 percent.
Scientists from the U.S. and Africa are conducting research
on the use of anti-retroviral drug treatment as part of
prevention. Preliminary results demonstrated that ARVs could
both keep a people well and prevent infections. For example, in
Africa, a seven-country study was undertaken in which one
partner was infected and the other was not. After 3 years, only
one uninfected partner was HIV-positive when the infected
partner was on an antiretroviral therapy. And in South Africa,
researchers recently identified a new microbicide that may
significantly reduce HIV infection rates in women.
Based on these and other promising developments, it is fair
to conclude that our ambitious investment in AIDS prevention,
treatment and care programs has helped make an historical
difference and there is sufficient epidemiological evidence to
give us hope that this scourge on humankind can be defeated
within our lifetime.
While there is good news to report, we can't forget about
the sheer magnitude of the epidemic. We still have 33.4 million
people living with HIV worldwide and only 42 percent of those
in need of treatment have access. Two-point-seven million
people were newly infected in 2008, 14 million children in
Africa have been orphaned by AIDS and around 430,000 children
are born with HIV each year.
U.S. global leadership has been extremely important in the
fight against HIV/AIDS. President Obama, like President Bush
before him, has made it clear the U.S. has a moral commitment
to combat this deadly disease. We owe it to ourselves and our
fellow Americans to ensure that we live up to these
commitments, enshrined in law and policy. To that end, we must
continue to strengthen our work with other bilateral donors,
multilateral institutions, recipient countries, and local and
international NGOs.
[The prepared statement of Mr. Berman follows:]
Chairman Berman. We have two very distinguished panels of
witnesses here today to discuss these important issues. I look
forward to hearing their testimony. Before I turn it over to
Mr. Smith, who has done a tremendous amount on this issue, I do
want to acknowledge and welcome the presence of a number of
women members of Parliament from 12 African countries,
including the Deputy Prime Minister of Zimbabwe, the Honorable
Khupe. Thank you very much for being here, and we welcome you.
Now I am pleased to yield to the gentleman from New Jersey
for any remarks he may like to make.
Mr. Smith. Thank you very much, Mr. Chairman, for holding
this very important hearing on the President's Emergency Plan
for AIDS Relief. I want to thank you and your predecessor Tom
Lantos, and certainly Congressman Henry Hyde, both who chaired
this committee, like you, who were very, very aggressive in
promoting this program as well as the legislation.
President George W. Bush described in his 2003 State of the
Union Address how hospitals in rural South Africa were telling
people, ``You have got AIDS, we can't help you, go home and
die.'' President Bush committed the United States to assist
African countries in overcoming the HIV/AIDS scourge not only
with substantial resources, but also by achieving specific
goals with measurable targets. And this effort was to be
undertaken in countries that for the most part had poor health
infrastructures, a sick and dying health care workforce, and
other daunting obstacles. Many said it couldn't be done. PEPFAR
proved them wrong.
Working with the President, Congress passed the United
States Leadership against HIV/AIDS, Tuberculosis and Malaria
Act. Thanks to strong continued bipartisan support, PEPFAR can
now boast about directly treating over 2.4 million people with
lifesaving antiretroviral drugs. Nearly 340,000 babies born to
HIV-positive mothers were born HIV free thanks to PEPFAR
prevention of mother-to-child transmission programs. Almost 11
million people affected by HIV/AIDS have received care,
including 3.6 million orphans and vulnerable children. And in
Fiscal Year 2009 alone, 29 million people were counseled and
tested for HIV thanks to PEPFAR.
Despite these successes I would like to highlight several
concerns. One is the administration's implementation of PEPFAR
as part of the new Global Health Initiative, of which PEPFAR is
the major component, in the absence of authorizing legislation.
I understand the administration intends through the Global
Health Initiative to change the way the U.S. Government
conducts its foreign assistance in this area at a fundamental
level. I would strongly argue that such a change requires
legislative authorization, given the amount of taxpayer money
and important policies that are at stake.
Another major concern is GHI's emphasis on integrating HIV/
AIDS programming with family planning as well as various health
programs. This is being undertaken in the context of a family-
planning program, which, due to President Obama's rescission of
the Mexico City policy, now includes foreign nongovernmental
organizations that provide, support and seek the expansion of
access to abortion. When one considers that this involves over
$715 million in family-planning funding under the Fiscal Year
2011 proposed budget, the ability for abortion groups to
leverage this funding in relation to U.S. HIV/AIDS funding
under the GHI is deeply disturbing.
Furthermore, it now appears that the considerable sums that
the United States contributes to the Global Fund to Fight AIDS,
TB and Malaria--$1 billion in Fiscal Year 2010--may contribute
to a new Global Fund initiative to fund abortions. This
possible intervention, part of the Global Fund's effort to
contribute to the Millennium Development Goals, is described in
a document presented to the Global Fund Board at its meeting in
April of this year. This paper is intended to facilitate the
Board's discussion of the Fund's role as a,
quote, deg. ``strategic investor in maternal and child
health.'' It asserts that the Global Fund will optimize--this
is a quote--``existing interventions to improve the health
outcomes for women and children'' by identifying areas for
greater integration of HIV, TB and malaria services with
``sexual and reproductive health services.'' In the chart
identifying ``interventions that could be supported with the
new funding,'' the paper explicitly proposes abortion.
Abortion, I would say to my colleagues and to our
distinguished panelists, is by definition infant mortality, and
it undermines the achievement of the fourth millennium goal.
There is nothing, nothing benign or compassionate about
procedures that dismember, poison, induce premature labor or
starve to death a child. Indeed the misleading term ``safe
abortion'' misses the point that abortion, all abortion, legal
or illegal, is unsafe for the child, and all is fraught with
negative health consequences, including emotional and
psychological damage, for the mother.
Monies that the U.S. contributes to the Global Fund are
ultimately taxpayer dollars, and polls show that 61 percent of
U.S. taxpayers do not want government funding paying for
abortions. Our U.S. delegation should keep this in mind as it
takes up this question with the rest of the Board at the next
meeting in December.
And finally, one final concern is the importance of not
only including but also reaching out to faith-based
organizations in all of our global health programming. Given
studies that show up to 70 percent of health care in Africa--
and that is a WHO number--is provided by faith-based hospitals,
clinics and organizations, it is imperative for the continued
success of PEPFAR to have them as a primary partner. Thus I
would hope that the administration is assisting local
governments in developing strategies that include faith-based
networks as an integral part of their health system. Their
effort also necessitates respect for the conscience clause
provisions contained in the Leadership Act and reaffirmed and
strengthened by this committee and by this House and the Senate
in the 2008 reauthorization.
Mr. Chairman, I look forward to our distinguished
panelists' comments, and I thank you for yielding.
The gentleman has yielded back his remaining time, and for
1-minute opening statements any members of the committee?
Ambassador Watson, are you----
Ms. Watson. I was going to defer to Barbara Lee.
Chairman Berman. The gentlelady from California has
deferred to the gentlelady from California.
Ms. Lee. Thank you again, Congresswoman Watson.
Thank you again, Chairman Berman, for this hearing. Thank
all of you for being here and specifically for the work that
you do each and every day to save lives.
I, of course, as you know, helped write the initial PEPFAR
with Chairman Hyde, and we sorted through many of these issues
that have been raised by Congressman Smith, and believe you me,
I believed then as I believe now the countries should be able
to determine their own plan. However, we didn't win that one,
and we know for a fact that PEPFAR funds are not used for
abortions. I have been out many times, as have members of this
committee, so I thought we had settled that, not to my
satisfaction, but I thought we had settled it.
Secondly, let me just say I did participate recently at the
International AIDS Conference in Vienna, and I know there is a
lot of concern about the extent of our commitment to fighting
this disease. The global economic crisis has seemed to have
dried up in many quarters, the political will and the
resources. Yet here in our own country we know that the drive
for military spending to build new and even more deadly weapons
systems, this debate continues to go unabated.
And so I think we need to really focus on how we can move
forward with PEPFAR, with the International AIDS Conference
coming to Washington, D.C., in 2012. I hope we can show the
world that the United States is seriously committed to fighting
this pandemic, and to setting our goal of an AIDS-free
generation, and to use PEPFAR as an example for our own
domestic strategy here in America.
Thank you again, Mr. Chairman.
Chairman Berman. Thank you. And just before that I do want
to--Ms. Lee's opening comments reminded me that in the very
beginning of all this back in 2001, 2002, she was a driving
force to the initial legislation.
Ambassador Watson.
Ms. Watson. Yes. Good morning, Mr. Chairman, and I want to
thank you for holding this timely hearing on PEPFAR and the
advances against HIV/AIDS. I concur with the two of you, Ms.
Lee and the chair.
Currently 33.4 million people are living with HIV and AIDS
worldwide, with 2.7 million new infections in the year 2008.
Through President Bush's PEPFAR initiative, it has made great
strides in responding to the emergency of the global pandemic,
and we must now look to create a substantial approach to
confronting HIV/AIDS.
President Obama's 5-year strategy aims to achieve just
that. Unfortunately, it is unclear how we will transition to a
country-owned, sustainable health system in struggling nations
that will be able to respond to the plethora of diseases that
plague the developing world. I look forward to hearing from the
administration about how this transition will take place.
So I want to yield back and thank you, Mr. Chairman.
Chairman Berman. The time of the gentlelady is expired.
Anyone else seek recognition for an opening statement? The
gentlelady from California.
Ms. Woolsey. What would you do without us, Mr. Chairman?
Chairman Berman. I wouldn't be here.
Mr. Woolsey. The women from California. That is true.
Thank you all for being here, and I am looking forward to
your testimony.
I have to apologize. We will be in and out because of other
things. But I am really interested in hearing how you are
integrating HIV/AIDS treatment and prevention with a larger
role of women's health and maternal health. I think that
pulling all of this together into one conversation is very,
very important. Are we getting more bang for our buck with
PEPFAR by doing this? And are women getting health care in a
one-stop shop style?
So I am just looking forward to hearing all of that from
you, and I thank you for all you know and all you do for
PEPFAR. Thank you very much.
Chairman Berman. The time of the gentlelady has expired.
Any other members seeking recognition for an opening statement?
If not, it is my pleasure now to introduce our first panel.
It is an amazing logistical feat that the three of you
could actually get together in terms of your calendars and ours
to be here, and we are very grateful that you are.
Ambassador Eric Goosby serves as United States Global AIDS
Coordinator. In this capacity Ambassador Goosby oversees
implementation of the U.S. President's Emergency Plan for AIDS
Relief--that is the PEPFAR program--and leads all U.S.
Government international HIV/AIDS efforts, including engagement
with the Global Fund to fight AIDS, tuberculosis and malaria.
Ambassador Goosby has over 25 years of experience developing
health care delivery systems, served as the first director of
the Ryan White Care Act at the U.S. Department of Health and
Human Services, and I believe has a California connection.
Dr. Thomas Frieden became director of the Centers for
Disease Control and Prevention and administrator of the Agency
for Toxic Substances and Disease Registry in June 2009. From
2002 to 2009, he served as a commissioner of the New York City
Health Department, one of the world's largest public health
agencies. Dr. Frieden previously worked for CDC from 1990 to
2002, where he began his career as an epidemiologic
intelligence service officer.
Dr. Anthony Fauci was appointed director of the National
Institute for Allergy and Infectious Diseases in 1984. He
oversees an extensive research portfolio of basic and applied
research to prevent, diagnose and treat infectious diseases
such as HIV/AIDS and other sexually transmitted infections,
influenza, tuberculosis, malaria, and potential agents of
bioterrorism. Dr. Fauci is the recipient of numerous
prestigious awards for his scientific accomplishments,
including the Presidential Medal of Freedom and the National
Medal of Science.
Gentlemen, we are honored to have you here.
Ambassador Goosby, why don't you start? All of your
prepared statement will be included in the record, and we will
be grateful for you summarizing your main points.
STATEMENT OF THE HONORABLE ERIC GOOSBY, UNITED STATES GLOBAL
AIDS COORDINATOR, U.S. DEPARTMENT OF STATE
Ambassador Goosby. Thank you very much, Chairman Berman,
Ranking Member Ros-Lehtinen and members of the committee. Thank
you for this opportunity to discuss the progress we have made
under PEPFAR with your long-standing bipartisan support.
I am pleased to be here with my friends and colleagues Dr.
Tom Frieden and Dr. Tony Fauci. All of the agencies involved in
PEPFAR contribute their strengths to a unified interagency
effort that has maximized our impact.
I serve with Dr. Frieden and Dr. Shah of USAID as the
operations committee for President Obama's Global Health
Initiative. GHI builds on our shared interagency experience,
and I appreciate the committee allowing us to speak to it and
the commitment on all agencies' parts to collaboration.
I have been working on HIV/AIDS for almost 30 years. Five
to six years ago those of us who engaged in HIV work in Africa
saw daily tragedies on a vast scale. Yet today with American
leadership, PEPFAR has brought about a dramatic transformation.
I have outlined the results to date in my written
testimony. With PEPFAR as its cornerstone, GHI will support
coordinated interventions to increase our ability to save lives
from AIDS and other challenges. With the support of this
Congress and the Obama administration, the number of people
receiving HIV prevention, treatment and care will continue to
grow. In addition to doubling the number of babies born HIV-
free, the United States will support the prevention of more
than 12 million new HIV infections, HIV treatment for more than
4 million, and care for more than 12 million, including 5
million orphans and vulnerable children.
Our prevention, care and treatment programs are integrally
linked. We have led the world in rapidly scaling up biomedical
prevention, such as male circumcision and prevention of mother-
to-child transmission.
PEPFAR has also worked to reduce treatment costs and to
expand service delivery. Reflecting a key GHI principle, we
support operations research to identify innovations and best
practices to save more lives.
Simply put, our work has been and continues to be about
saving lives as part of our shared global responsibility to
make smart investments. Partnerships are an overarching
principle for the Global Health Initiative. The United States
provides nearly 60 percent of donor government funding for HIV/
AIDS, a leadership role we are proud of and which, thanks to
Congress' reauthorization of PEPFAR, will continue.
Yet the global need is a global responsibility and all have
roles to play. An important mechanism for this is the Global
Fund. The United States has been its largest donor, providing
more than $5.1 billion, and providing support for grant
implementation at the country level that has proven crucial to
ensuring the grants can deliver.
As we implement PEPFAR's 5-year strategy, let me highlight
three priorities that reflect the GHI principles. First, saving
more lives through PEPFAR activates our ability to focus on and
be part of the Global Health Initiative. During its first phase
PEPFAR focused on meeting ambitious goals for delivery of
prevention, care and treatment. Moving forward, make no
mistake, we will support expansion of these core services.
Yet people affected by HIV are not defined by the virus
alone. Like everyone else, they have a change and range of
other health needs. That is why integration is a core GHI
principle, and GHI will help to holistically address these
needs. At the same time we also want to reach the clients of
other programs, such as maternal and child health, with HIV
interventions. For example, women who come to antenatal clinics
are an ideal population for PMTCT programs. Integration under
GHI offers the real opportunity of increasing our impact on
health and, again, saving more lives.
A second priority is addressing gender issues with HIV
programming. GHI recognizes that focusing on women, girls and
gender equity is a force multiplier benefiting women, their
families and the communities. AIDS is the leading cause of
death of women of reproductive age worldwide, and in Africa
nearly 60 percent of those living with HIV are women. During
its first phase PEPFAR began a five-point gender strategy
seeding countries with small initiatives. We are now expanding
them with a focus on PMTCT and country-led projects.
One risk factor for HIV is the tragedy of gender-based
violence. We are investing $30 million to combat it in three
severely burdened countries, and in all countries we are
supporting post-rape care, while also seeking to prevent sexual
violence in the first place. Last week at the Clinton Global
Initiative, we joined the Together for Girls public-private
partnership to combat violence against girls.
Lastly, we are focused on the GHI principle of expanding
country ownership and local capacity to build a sustainable
program. As we responded to the HIV emergency in the first
phase of PEPFAR, we worked largely through international
partners. A major priority we have now added is increasing the
capacity of countries to manage, oversee and operate their
health-delivery systems.
Moving forward we will increasingly emphasize a third
dimension, community empowerment. As we pursue support for
health systems under GHI, we know local communities can ensure
accountability in a way that outsiders never can. That feedback
dialogue is essential for true sustainability.
In conclusion, we are making great strides, but much work
remains. We must keep our eyes on the prize, and that is to
save more lives. I remain grateful for your ongoing support for
this effort and look forward to the questioning.
[The prepared statement of Ambassador Goosby follows:]
Chairman Berman. Dr. Frieden.
STATEMENT OF THOMAS R. FRIEDEN, M.D., M.P.H., DIRECTOR, CENTERS
FOR DISEASE CONTROL AND PREVENTION, AND, ADMINISTRATOR, AGENCY
FOR TOXIC SUBSTANCES & DISEASE REGISTRY
Dr. Frieden. Thank you very much. Good morning, Chairman
Berman and Ranking Member Smith. It is a pleasure and an honor
to be here along with my friends and colleagues, Dr. Goosby and
Dr. Fauci.
Over the past year I have had the great privilege of
visiting PEPFAR services in Ethiopia, Tanzania, Mozambique,
Nigeria and other countries. I have been inspired by the proof
that there is a critical impact of the leadership and support
of this committee of the wonderful work of our staff and our
partners on the ground and of the effectiveness of the PEPFAR
model as a true whole-of-government approach.
The CDC deeply appreciates the leadership provided by OGAC
and the important work of NIH, as well as USAID and other
implementing partners.
CDC has a unique role and history in global health. It is
essentially in CDC's DNA, going back to the 1960s and 1970s
when, with WHO, CDC led the global smallpox eradication
program. Among other initiatives today we detect and stop
outbreaks, support epidemiologic and laboratory systems, help
prevent and control malaria, support progress in the control of
measles and the eradication of polio.
We also fundamentally improved the capacity of partner
governments to plan, implement and monitor their own programs.
We have a unique role supporting international organizations,
providing consultations, training and embedded staff.
Today more than 2.5 million people are alive, productive
and healthy who would otherwise have been dead or dying without
PEPFAR. Last year 100,000 babies who would otherwise have been
infected were born HIV free because of PEPFAR.
The first slide shows the dramatic expansion in the
proportion of met need for treatment in countries, the original
PEPFAR countries, in the southern cone of Africa. The second
slide shows the dramatic scale-up in treatment in recent years.
In short, not only are communities and systems throughout
the world dealing with HIV better, but they are better prepared
to deal with other health problems. PEPFAR, with OGAC's whole-
of-government leadership, is working.
We face two key challenges going forward. First we need to
scale up treatment sustainably and cost-effectively to reach
even more people; and second, we need to take prevention to the
next level.
When Congress had the wisdom to authorize PEPFAR and OGAC's
whole-of-government model, CDC was well poised to contribute
because of our work globally and in this country, and their
involvement in HIV since the first days of the epidemic. We
were already on the ground in sub-Saharan Africa, monitoring
and directing efforts to understand the nature of the epidemic,
and developing and disseminating the latest science, an
effective tool to control HIV.
CDC and HHS is the counterpart of ministries of health, and
we work in a peer-to-peer relationship. To implement programs
effectively and sustainably, it is essential that they be
inextricably linked with rigorous evaluation, capacity
development, systematic laboratory and capacity tracking, and
practical research. We have unique expertise evaluating whether
investments are working, and doing cutting-edge research to
drive improved service delivery, and to make more effective use
of scarce resources.
The committee has recognized that sustainable systems and
country ownership are essential components in PEPFAR, and that
is our commitment at CDC as well. To further scale up
effectively, PEPFAR is transitioning to more local, sustainable
and cost-effective programs. Already nearly half of CDC's
funding is implemented thorough cooperative agreements with
health ministries or other local in-country partners,
including, very importantly, faith-based organizations resident
in their country, which are very important service delivery
partners for us.
Treatment costs continue to decrease as we decentralize
care. And the next slide shows that steady decrease in unit
costs as we transition management to local partners, streamline
monitoring, realize cost savings through generics, and ensure
treatment at the most high-prevalent sites for pregnant women
and TB/HIV coinfected people.
Prevention is critical. We can drive incidence down with a
comprehensive package of interventions as shown on the next
slide, including a series of proven and some potential but
high--potentially high-impact interventions. Prevention of
maternal-to-child transmission, HIV screening link to care and
treatment, safe blood, male circumcisions, condoms and other
proven interventions can make a big difference not only
individually, but, as the next slide shows, in combination. We
anticipate that there can be synergistic decreases in
incidence.
As we think of multicomponent prevention, we make the
analogy to multidrug treatment for HIV. The breakthrough in HIV
treatment came when we were able to use multiple drugs to stop
replication of the virus in multiple pathways. In the same way
we hope to have multiple ways of stopping transmission in a
community to drive incidence down.
PEPFAR is a critical platform to build the Global Health
Initiative, and the whole-of-government process overseen by
Ambassador Goosby is a model of effective collaboration. This
gains efficiencies by using existing infrastructure of various
agencies and funding programs based on comparative advantage.
PEPFAR embodies the principles of GHI to achieve specific
health outcomes, strengthen systems for sustainable
improvements, maximize impact of all dollars, encourage country
ownership, improve monitoring and evaluation, and accelerate
research and innovation.
In conclusion, PEPFAR is a tremendous success. The
confidence this committee has had in us all is paying off in
lives saved, infections prevented and systems strengthening.
The interagency, OGAC-led model that Congress has been so
supportive of is working. We are proud of the important role
CDC is having in this success and will amplify PEPFAR's success
as we move forward with GHI by implementing programs which
reach more people and stretch our dollars even further.
We are optimistic about the future, about the ability to
reach more people, drive down incidence, reduce costs, and
build sustainable capacity.
Thanks you very much for the opportunity to be here today,
and I look forward to answering your questions.
Chairman Berman. Thank you.
[The prepared statement of Dr. Frieden follows:]
Chairman Berman. Dr. Fauci.
STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL
INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES (NIAID), NATIONAL
INSTITUTES OF HEALTH
Dr. Fauci. Mr. Chairman, thank you for calling this
hearing. Mr. Smith, thank you, and members of the committee. It
is really a great pleasure for me to be able to testify before
you today together with my close friends and colleagues Dr.
Frieden and Dr. Goosby.
What I would like to present to you over the next few
minutes is the role of the NIH basic and clinical research
endeavor in partnership to help the PEPFAR program implement
its fundamental mission.
As shown in this first slide, the advances in HIV research
over the last 29 years have been really nothing short of
breathtaking from the very beginning of the determination of
the etiology, to the pathogenesis, rapid diagnosis, prevention
modalities, treatment, and now the promising advances made in
the arena of an AIDS vaccine.
On the next slide you see the four areas that I would like
to address very briefly with regard to the importance of these
findings to the mission of PEPFAR--importantly treatments,
obviously prevention, but also a word or two on capacity
building and implementation science.
On the third slide is a list of the 30 FDA-approved
antiretroviral drugs that have been successfully used in
combination to literally transform the lives of HIV-infected
individuals. From the very beginning, in the mid-1980s, after
we identified the etiologic agents, we began the basic and
clinical research to develop these drugs, to prove their
effectiveness in clinical trials, and to ultimately determine
the optimal way to use them. This has been a great success.
On the next slide you see some interesting figures. I began
taking care of HIV-infected individuals in the summer of 1981,
within 2 months after the first cases were identified by the
CDC. I have been doing that ever since, up to the present time.
When a person would walk into my clinic in the summer of 1981,
usually with advanced disease, the person had a life expectancy
of approximately 26 weeks. If a 20-year-old comes into my
clinic tomorrow with newly acquired HIV infection, and I start
him on this drug, I can confidently tell him that if he adheres
to the regimen, we mathematically predict that that person will
live an additional 50 years until they are at least 70 years
old.
PEPFAR is now beginning to translate those findings to the
developing world, the countries in which they have a major
impact. We are not exactly at those life-expectancy numbers
yet, but were it not for PEPFAR, we would still be in the
situation that I was in in the summer of 1981 with essentially
nothing to do for these patients.
If you go to the next slide, these are the proven
prevention modalities for HIV. Many of these have been proven
by the work of the NIH and the work of the CDC and other
agencies. I want to point out three of them that have
particular applicability to PEPFAR.
The first is the prevention of mother-to-child
transmission, the use of antiretroviral drugs to block the
transmission from mother to child, something that is being
implemented with great lifesaving effect by PEPFAR. Another is
adult male circumcision, which NIH-funded studies proved beyond
a doubt is an important way to prevent the acquisition of HIV
infection. And the other is proving that the proper use of
condoms can block the transmission of HIV. The issue is that we
need to implement these, because only 20 percent of people who
benefit from these preventive modalities actually have access
to them. What PEPFAR is doing is bridging that gap.
If could I have the next slide. You mention treatment as
prevention. This is really, in my opinion as an AIDS researcher
and public health official, an important wave of the future.
Some examples of success already are shown on this slide.
A very exciting study that took place in southern Africa,
called the CAPRISA study, used 1 percent tenofovir, an
antiviral, in a gel, to block the transmission of HIV to women
who used this microbicide. We need to improve on this, and we
will. And this is something that PEPFAR is very interested in
implementing.
It was shown in a study in Africa that discordant couples,
one of whom was infected and the other one was not, if you
treated the infected person, you had a 92 percent decrease in
the transmission to the uninfected partner.
And then you mentioned the issue of test and treat, which
Dr. Frieden was mentioning. If you could penetrate the
community and get as many people as possible on therapy, it
looks now from mathematical models and as evidenced in places
like Vancouver and San Francisco that you could actually, by
decreasing the community viral load, prevent HIV transmission
to a certain degree.
And then finally there is the development of a vaccine. We
are not there yet, but the results over the past few years have
been very encouraging.
I want to close by mentioning two additional issues. One is
capacity-building, and that is to develop in-country leadership
and strengthen the clinical and research capacity. The
President mentioned this in his recent speech to the U.N., and
Ambassador Goosby has stressed this from the very beginning. We
want these countries and their people to be able to have the
capacity to continue to do these things on their own. An
example of this is the Medical Education Partnership Initiative
with HRSA, which builds clinical-care capacity in sub-Saharan
Africa.
In addition, on this last slide is implementation science.
What we mean by that is how can we best translate the research
findings that now work in the developed world to the in-the-
trenches, on-the-ground situation that Dr. Goosby and his
colleagues have to deal with in places like sub-Saharan Africa
and the Caribbean, and we are in strong partnership with PEPFAR
in this regard.
On the final slide I want to emphasize the common goal that
all of us have. The NIH, the CDC, HHS, PEPFAR, USAID, all of us
have the common goal of controlling and ultimately ending the
HIV pandemic. PEPFAR is completely integral and essential to
the accomplishment of that goal. So I strongly urge you to
continue your strong support for the truly lifesaving program
that is PEPFAR. Thank you.
[The prepared statement of Dr. Fauci follows:]
Chairman Berman. Thank you, and thank all of you. And I now
yield myself 5 minutes to begin the questioning.
Now, Ambassador Goosby, you touched on it, but develop this
a little more fully. We are trying to move from emergency to
sustainability. The issue of financing, of course, is quite
critical. The majority of countries receiving either PEPFAR or
Global Fund resources don't have the budget to take on the full
funding of these programs, yet these programs have to be
integrated within their national health care system.
Could you sort of spell out PEPFAR's strategy to integrate
AIDS programs into their systems and without overwhelming their
budgets?
Ambassador Goosby. Well, thank you, Mr. Chairman.
You are correct to highlight that as a critical need in all
of our program, thinking both in the past and in the future.
Our ability to move from an emergency response to a sustained
response is integrally related, and our ability to make sure
that the programs that we have put up and established in the
emergency phase do not lose their impact or their ability to
expand to the changing needs of the population that use them.
Our feeling is that country ownership is critical. By
country ownership we are focused really on both the government
as the public sector component, but also just as importantly on
the community and the civil society around it. All three are
required for the appropriate establishment of a continuum of
care and services, a continuum of prevention interventions that
impact the community in the region and areas that they are most
vulnerable. So understanding the epidemic in the context of
each country's epidemic is the critical piece.
Our commitment to working with countries to continue to
support programming includes both a financial commitment as
well as the realization that capacity expansion within the
ministries of health, the ministries' ability to play a
technical assistance role for provincial ministries of health,
are all part of the vision that we carry and try to align in
each of the countries that we are in.
Chairman Berman. Thank you.
Dr. Frieden, you made reference in your testimony, you
talked about your trips, and in your prepared testimony you
made reference to CDC's relationship with the African Center
for Integrated Laboratory Training.
Who has been trained? And does the laboratory training
prepare technical personnel to work with diseases other than
AIDS, TB and malaria?
Dr. Frieden. Thank you very much for the question, Mr.
Chairman. The African Center trains people not just from the
country where it is resident, but throughout the region. We
have been able to promote laboratory network strengthening,
including the beginnings of an accreditation system, so that
when you get a result back from a laboratory, you can be
confident in its accuracy. We have trained not only the
laboratorians, but the people who supervise and manage the
laboratory systems to establish sustainable laboratory services
not just in HIV, but also more broadly to strengthen the health
systems, whether that is TB testing or basic laboratory
testing.
I have been quite impressed by the systems that I have seen
out there. They are very reliable. They include very complex
testing, including CD4 counts and early infant diagnosis using
the latest technologies, but also applied effectively within
PEPFAR and to strengthen the system.
So we see laboratory strengthening as one of the core
pillars of strengthening a health system, and we have been
delighted to be able to that with support from PEPFAR.
Chairman Berman. The question--if I had time to ask and
hear the answer to--I would be asking now to Dr. Fauci, is your
remarkable testimony about some of the advances and connections
between treatment and prevention. Unless you can say sort of in
three words, but the question would be to what extent should
that alter the way Congress approaches the funding of PEPFAR,
or do you have the discretion within the program to make the
adjustments that these conclusions might cause you to make
without any particular changes in the way we are approaching
the appropriations process? That is the question. We don't have
time for the answer.
Mr. Smith. I ask unanimous consent the gentleman have 2
additional minutes.
Chairman Berman. Could we make it at least 1 additional
minute with unanimous consent, because I think it is----
Dr. Fauci. Well, to answer it in as broad an applicable way
as possible is this just underscores in my mind how important
what PEPFAR doing is. I mean, people often say we put a lot of
money in something; is it really worth it? Well, the fact is
that if you are trying to prevent infection and treat people
who are infected, you actually get two for the price of one,
because what we are starting to see is the support for
treatment isn't at odds or in competition with prevention, it
is actually part of prevention. So when you hear people from
PEPFAR say that, when you hear Tom Frieden and his colleagues
from the CDC say that, it really is true.
I mean, all the data that is starting to accumulate now
means that, in fact, you can, by treating people appropriately,
ultimately prevent infection. So we have got to put aside the
tension between treatment and prevention. They synergize with
each other.
Chairman Berman. Thank you.
And now I am pleased to yield 5 minutes to the gentleman
from New Jersey Mr. Smith.
Mr. Smith. Thank you, Mr. Chairman.
First of all, let me thank you for the most recent addition
of enrollees for Uganda. I had been very critical--I am not the
only one--that there was a straight-lining, and some additional
36,000 people in Uganda will now get ARVs courtesy of the
United States Government. So thank you for doing that,
especially in light of the double duty that treatment is
prevention, and I think that is very, very encouraging.
Dr. Frieden, if you could maybe touch on briefly the issue
of safe blood. I actually held a hearing several years ago when
I chaired the Africa Subcommittee, and one of the issues we
learned from WHO is maternal mortality can be reduced by 44
percent, according to the witness from WHO, if safe blood were
available. I know you have 14 initiatives going. In your
testimony you speak to it. Maybe you might want to touch on
that.
And secondly, according to the WHO, and I said this in my
opening statement, an overwhelming amount of health care is
provided by faith-based entities--under the auspices of faith-
based communities in Africa. Forty percent of that is delivered
by the Catholic community, and worldwide the Catholic community
provides 25 percent of all care and prevention for HIV/AIDS
patients.
I would argue that failure to aggressively include faith-
based organizations in the Global Health Initiative will
seriously undermine the efficacy and sustainability of our
struggle to mitigate and hopefully end this pandemic that has
so ravaged Africa and other parts of the world.
I understand that the country ownership issue is central to
the Global Health Initiative. Yet given the poor track record
of the Global Fund, to which U.S. taxpayers donate over $5
billion and counting, in its national ownership scheme known as
the Country Coordinating Mechanisms, could you tell us what the
administration is doing to ensure that faith-based
organizations are not discriminated against in the allocation
of grants at the country level? How does that figure into our
partnership framework agreements? Are we saying this is
something we think is important? Why create a new
infrastructure when there is a preexisting one where rollouts
can occur? And how do you plan to ensure that PEPFAR's
conscience clause, which I offered to the original law--and it
was actually strengthened when we went through the
reauthorization. And Chairman Berman, the Democrats and
Republicans were of one accord in strengthening that conscience
clause--so that when it gets to that country level, the
conscience clause is not shredded, and these faith-based
organizations are not shown the door, and they are part of
delivery of services?
Dr. Frieden. Thank you very much. I will start, and then
perhaps Ambassador Goosby will address it as well.
The safe blood program really is a success story. It is now
scaled up to all 60 countries with technical assistance, and it
has been done in a way that builds local capacity. It has not
been an external system imposed, but a system of helping
countries establish, monitor and maintain a safe blood system,
and that is critically important and a real win in HIV
prevention and in confidence in the health care system.
So I think it is a great example. It is an example of
prevention. It is working, and, very importantly, it is working
by building systems. I met with the staff who had helped to
grow that. They were essential in improving that quality.
And as we transition through the Global Health Initiative,
we will be looking also at the appropriate use of blood and
increasing to make sure that it is not being used when it is
unnecessary, and is being used adequately, such as in the
reduction of infant mortality where hemorrhage is a leading
cause of death. And addressing emergency hemorrhage is
something that we hope to be able to do in the Global Health
Initiative as we transition from prevention of mother-to-child
transmission to a broader sense of protecting mothers' lives.
In terms of faith-based organizations, I agree completely.
In many countries in which we work, there are superb service
delivery platforms. They provide services where there are no
other service providers. They provide them with very high
quality and at very low cost, and we see them as essential
partners, and we continue to work with them. In fact, as I
mention in my oral statement, as we transition to local
partners increasingly, and we are already--45 percent of our
grants are local partners rather than U.S.-based--but as we
continue and expand that transition, faith-based organizations
have a very essential role to play.
Mr. Smith. Real quick.
Chairman Berman. We can give you unanimous consent for 1
additional minute for the full answer to this.
Mr. Smith. I mentioned the Global Fund because I have met
with the Global Fund many times and their leadership about the
exclusion of faith-based organizations, especially at the
country coordinating mechanism level.
In many of these countries, as we know, for years the
churches collectively have been the bulwark in protecting human
rights, and very often they are seen as the thorn in the side
of governments, particularly as they matriculate from
dictatorship to a democracy. So there is a reason to keep them
at bay and look for other partners. And again, who hurts? It
would be the potential patients.
Ambassador Goosby. Well, let me just echo Dr. Frieden's
statements around the faith-based organizations. They have
historically played, as you have really eloquently outlined, a
critical role in the delivery of health care in sub-Saharan
Africa in particular. As you move from urban to rural, their
importance increases, and in many countries where PEPFAR is
working, the faith-based organizations really comprise the
district hospital-level capability in many of the rural areas
that we are in.
That role is not going to change. Indeed, in many countries
the faith-based organizations are part of the public health
system. When a graph is charted of their referral, tertiary,
secondary and district-level hospitals, the faith-based
organization is often playing that role solely, as I said. They
also have a series of clinics that reach out from that hospital
base that again extend their reach and have been extensively
engaged with in all of our programs in PEPFAR with completing
continuums of care in services in both treatment and prevention
fronts.
So we are committed to continuing that and would look, if
you had examples of concern or issues where it has come to your
attention that someone has been excluded, we would be very
interested in engaging with that directly.
I would finally answer your Global Fund question to say
that the CCM process, the country coordinating committees, are
locally determined as to who sits on those seats. We do give a
significant amount of resources to it. We see the Global Fund
and PEPFAR as joined at the hip; our success is interdependent.
Our planning together and defining unmet need and allocating
resources is now getting much more sophisticated so the
duplication overlap, the ability to take advantage of common
procurement distribution systems, administrative oversight
management, et cetera, it is all moving forward.
We believe----
Chairman Berman. Ambassador, the time has more than
expired. So perhaps there is a way to get back to that.
The gentlelady from California Ms. Lee is recognized.
Ms. Lee. Thank you very much. And, yes, Mr. Chairman, we
will get back to that.
And let me just say I am glad you mentioned that Dr. Goosby
has a California connection, but I am very proud to say he is
my constituent----
Ambassador Goosby. Absolutely.
Ms. Lee [continuing]. And has done a very fine job in this
position also, as he has in previous positions.
With regard to the Global Fund, following the International
AIDS Conference, of course, I sent a letter to the President
along with 100 Members of Congress asking for $6 billion over 3
years to fight--well, committed to the Global Fund. Together
with PEPFAR our contributions have been responsible for
treatment of 5 million people worldwide. So next week in New
York, of course, the Global Fund is holding its replenishment
hearing, and I wanted to find out where the administration
stands on this request for a $6 billion pledge. Can we reach
that target? If so, great; if not, why not?
I think it is very important, because we want this
announcement to be clear so that we can begin to leverage
contributions from other donors who are still considering their
pledge. So that is one question, Dr. Goosby.
And then my second question any member of the panel could
answer as it relates to the joint United Nations program on
HIV/AIDS. I have been asked to serve as a Commissioner on the
Global Commission on HIV and the Law. This new international
Commission, the objective is to develop actionable, evidence-
informed, and human-rights-based recommendations supporting
national legal environments that enable effective HIV responses
and realize the human rights of those living and affected by
HIV. The Commission will hold three meetings over the course of
18 months. The first meeting, of course, is next week in
Brazil.
So I wanted to find out if you are aware of the Commission
and its goal? Is the United States providing any direct
support, whether technical or material, of the Commission? And
can we count on your input, because I would like to talk to you
about our input in terms of helping to overcome some of these
legal barriers to providing access to services and to
encouraging the research that is really necessary to fight this
disease.
Ambassador Goosby. Well, thank you, Congresswoman Lee, and
you are my Congresswoman. Thank you.
I think that the relationship between PEPFAR and the Global
Fund has evolved. Our presence as a Board member on the Global
Fund and our engagement with both the Executive Director and
the Secretariat has given us an increasing opportunity to again
lay this trackwork to merge our resources in a way that is
highly efficient and increases both of our programs' impact at
the country level. We are excited about that merging. We
believe this will bring many more people into our care and
treatment and prevention services and will save many more
lives.
Our ability to have a meaningful relationship with the
Global Fund has been one of iterative dialogue around
strengthening mechanisms for both the Secretariat as well as
the CCM process.
As the PEPFAR programs have staff in country, we are
intimately aware in 80 countries in which we overlap with
Global Fund of a lot of the implementation issues that come to
bear, such as we saw in Uganda where our programs are connected
to theirs. If Global Fund programs are performing well, we move
together. If either of us fall in that ability to move patients
through, to identify clients, to address and deliver services,
there is a displacement of patients into the other's programs.
And we have seen this in many of the other countries we are in.
In order to minimize that, to anticipate it and to prevent
it, we are really moving aggressively over the next few months
to a shared planning and implementation vision.
The Global Fund is part of our success and will continue to
be an integral piece of how we are able to increase our ability
to impact.
Ms. Lee. Bottom line is how about our pledge for 3 years?
Ambassador Goosby. We have been aggressively involved in a
dialogue over the last few weeks. That dialogue has continued
through this week. We will come to replenishment next week with
a proposal that I believe is strongly supported within the
administration. It has required a new vision and new
commitments being made on our part----
Ms. Lee. Dr. Goosby, do you think that the 101 members that
signed that letter will be strongly supportive of the
recommendation?
Ambassador Goosby. I think that we always appreciate the
input from our congressional leaders and the insight and wisdom
that they bestowed on us through that letter was greatly
appreciated, and all of those issues were taken into account in
the discussion.
Ms. Lee. You sound like a lawyer.
Thank you very much.
Chairman Berman. They appreciate the 101. We don't know
whether the 101 appreciate them.
Ms. Lee. Can I get a response?
Chairman Berman. By unanimous consent, the gentlelady has
an additional minute.
Ambassador Goosby. We are very supportive of that effort.
We are thrilled that you have committed to giving your time and
thoughts to this. The connection to health and human rights is
basic, fundamental, needs to be amplified and we are supportive
and will be supportive of the committee.
Dr. Frieden. Similarly, we would be delighted to be
supportive in any way with our colleagues. I will emphasize one
area in particular, which is gender-based violence, where CDC
studies in multiple countries in Africa have shown this,
particularly intergenerational gender-based violence to be far
too common and a driving force behind the epidemic. So this is
one area which is not only a terrible human rights violation
but also a driver of the epidemic.
Chairman Berman. The gentleman from Arizona, Mr. Flake, is
recognized for 5 minutes.
Mr. Flake. Ambassador Goosby, when the last reauthorization
came in in 2008, there were several requirements put into law
in terms of reporting having to do with best practices and
efficiencies. It is my understanding that those reports have
not been issued. If not, why not? And how can we be expected to
reauthorize or appropriate more money without some of the
requirements having been met?
Ambassador Goosby. Well, thank you, Congressman Flake.
Perhaps the central emphasis since I have started this position
has been to look at, especially in this economic decline, all
areas that we can engage in to become more efficient, to take
advantage of synergies and collapsing of resources so they are
truly additive within the program as well as between the
programs.
We have created a process that has canvassed every country
that we are in. Thirty at a high level, but all 80 countries.
And we have compiled a strategy that is focused specifically on
identifying and integrating these strategies into an
identification of efficiencies that become programmatic and
entered into our budgetary relationships.
We have completed a document that I had thought had come to
you. It has been submitted to the committee, but you obviously
haven't seen it. We will work with your staff to make sure that
you get that forthwith.
Mr. Flake. This will comply, or be responsive to the
requirements in the 2008 reauthorization?
Ambassador Goosby. Yes, sir.
Mr. Flake. I will yield the rest of my time to Congressman
Smith.
Mr. Smith. I thank my good friend for yielding.
If I could just, Dr. Goosby, get an answer. In the
partnership framework, is the conscience clause included there,
because obviously, while we are encouraging local control, it
is never absolute. Obviously, we have parameters. Is it in
there?
Secondly, I was at a roundtable last week at the U.N.
Development Goals Summit at the United Nation run by the
Rockefeller Foundation and GAIN, and seven first ladies, led by
Lady Odinga, emphasized the first 1,000 days of life from the
moment of conception is a wonderful event, which obviously that
will predict what happens in the next, 25,000 hopefully, days
of life, if someone can live into the seventies.
But it was from the moment of conception, it was all about
good nutrition and it was an affirmation of life before birth,
that an unborn child is sacred and precious, and birth is just
an event that happens to all of us. It's not just the beginning
of life.
I would note the next day the Secretary of State was at a
similar unveiling with the foreign minister of Ireland during
which she wouldn't say the words ``moment of conception.''
Okay. That is unfortunate. But it is still the same idea. Those
first 1,000 days are absolutely crucial. And with PEPFAR, Don
Payne was very emphatic on this, as was I, as chairman and
ranking member of the Africa Subcommittee, that nutrition is
crucial to PEPFAR.
It is contradictory to me that on the one hand, Global Fund
is talking about reproductive health including the killing of
the unborn child by way of abortion, and we are also talking
about nutrition and providing protection and all the possible
enforcement backstopping for that baby in the first 1,000 days.
Finally, behavior modification, and I assume that is A and
B of the ABC model. Doctor Eliodo--head of the Ugandan member
of parliament--has said very clearly that the B is so
important--A is important--but the B is so important. When
there are multiple concurrent partners, the epidemic continues
to spread notwithstanding perhaps ARVs. So what about the
emphasis on the B?
But if you could get into the conscience clause first.
Ambassador Goosby. Yes, Congressman.
The partnership framework is an attempt to engage in a new
dialogue with country to establish a commitment to relative
contributions from our partner country as well as the United
States Government over a 5-year period. It is under the PEPFAR
legislation, and the conscience clause does apply to that
dialogue. In terms of the Global Fund and the chart that you
mentioned----
Mr. Smith. Is it binding or is it just part of the
dialogue?
Ambassador Goosby. We legislatively are bound by the
conscience clause legally so we cannot agree to something that
is outside of the parameter.
Chairman Berman. The gentleman from North Carolina, Mr.
Miller, is recognized for 5 minutes.
Mr. Miller. Thank you, Mr. Chairman.
I think all of you have spoken of pediatric HIV/AIDS. And I
have been stunned when I traveled in Uganda on a congressional
delegation 3 years ago at how pervasive transmission from
mother to child is very rarely in the United States and very
common in the developing world. It certainly makes the goal of
eliminating all pediatric HIV by 2015 look to be an enormous
task.
And the precautions that are routine that are universal in
the United States are almost unheard of in other parts of the
world, and as a result, thousands of children every year begin
life with HIV, either born with it or through contracting it
through breast feeding. The routine precautions beginning with
the testing of pregnant women with HIV is almost unheard of
almost all the way through.
What are the barriers? Is it all the amount of resources?
Are there other barriers? What stands between us and having the
transmission of HIV to children from their mothers is as rare
in other parts of the world as it is in the United States? Dr.
Frieden?
Dr. Frieden. Thank you very much, Congressman Miller.
It is a great question, and I think this is an area where
we are poised--we have had a lot of progress in the last couple
of years and we are poised to have even more progress. We have
countries that now have moved to a universal screening for HIV
and pregnancy. So we are seeing a substantial scale-up of
effective prevention.
There are a series of barriers. First, in some countries
the proportion of women who give birth in an institution or are
attended is in the single digits. So when you have a service
delivery gap that is that large, it shows you some of the
limitations of a program that is within the envelope of HIV
only. That is one of the reasons why we think the global
initiative will actually greatly strengthen not only health
systems but also HIV prevention and prevention in terms of the
mother-to-child transmission. But there has been tremendous
progress in recent years, testing more women, getting more
women on treatment, getting the children appropriately cared
for.
The second key issue is the effectiveness of treatments.
Some of the regiments require the women to take medications and
take additional medications during delivery. But if that
delivery is not attended because, for example, of co-payment
charges at institutions, then the investment that we have had
to protect that child is not fulfilled really and the child
becomes infected.
So there are ways that we need to change the way women are
cared for and focus on women getting care before, during and
after pregnancy. There is also the challenge of breast feeding
and reducing the risk during breast feeding. And there are some
real challenges there in terms of the women's experience. The
data from this comes from trials led by both CDC and NIH, and I
think it is a success area, but one where I think we need more
progress.
Dr. Fauci. I agree completely with Dr. Frieden's
assessment. I think it also underscores what we were saying
before about the penetration into the community of getting
people tested and treated. We need to think not only that we
have to prevent transmission to the baby, but also that we have
to treat the mother as an individual, and then you will do two
things: You will prevent transmission to the child, and you
will also prevent transmission through breast feeding.
As Dr. Frieden said, really the opportunity is
extraordinary. The more people we test, the more people we
treat. Among those will be women who either will be pregnant or
are pregnant, and then you have the secondary benefit of
preventing the transmission to the child.
Mr. Miller. Similarly there have been--the other parts of
the world lag well behind in early diagnosis of children with
HIV. What are the barriers to earlier diagnosis and therefore
earlier treatment?
Dr. Frieden. We have been delighted to be able to work with
a series of African countries to build up a capacity for early
infant diagnosis, and I was delighted to see, for example, in
Mozambique, the reference laboratory using the text messaging
technologies secure through return results very rapidly so that
children, infants, could get on treatment. And that kind of
innovation is what we hope to see more of, getting cutting-edge
laboratory services through dried blood spot and then getting
the results back to the treating physician right away so that
they can start treatment rapidly right away if needed. That
early infant diagnosis is also very important. Has a quality
assurance mechanism. We know we are treating women, testing
women, but are we preventing transmission? And that is a
critical mission for us.
Ambassador Goosby. If I could just add an anecdote to that.
The remarkable moment at birth and having the child there and
having to wait for antibody production over an 18-month to 2-
year period has been preempted with the ability of early infant
diagnosis. And PEPFAR is committed to expanding that capability
in all of our programs to allow individual children to get on
both cotrimoxazole as well as antiretrovirals at birth.
Chairman Berman. The gentlelady from California, Ms.
Woolsey, is recognized for minutes.
Ms. Woolsey. Thank you, Mr. Chairman, and thank you to the
panel. I want to take this just one step further and then I
have another question to ask also.
So when women are unable to obtain family planning
information and the appropriate prevention methods, NuvaRing,
shots, condoms, because of the complications that come along
with the conscience clause, or maybe that doesn't happen, tell
me if I am wrong. But when we make it difficult for women to
prevent pregnancy in the first place, and quite often that
would prevent AIDS and HIV with the appropriate prevention
products, what impact does that have on HIV/AIDS and the
numbers before we start treating it?
Ambassador Goosby. Well, I can take an attempt at that. It
is a difficult question. It is a good question. We have been
very aggressive at talking with our partners who we are engaged
with at the country level to understand their concerns around
making available a referral mechanism to family planning
reproductive health services. That usually is doable. And it is
a commitment on part of the institution itself who has
difficulty moving forward with those services on their own
site, but allowing the patient in front of them with that
immediate need to be addressed and referred in a seamless way
is our goal.
We have been able to engage in that in most every instance
that it has come up, and will continue to honor both the
conscience clause in that effort, but also being clear that our
real responsibility to the patient in front of us is to respond
to her needs. Thank you.
Ms. Woolsey. Speaking about her needs, without taking
anything away from HIV/AIDS support and investment, both from
the United States and internationally, what would it take for
this same group of partners to invest in maternal mortality and
child mortality at the same time? I mean, my goal is not to
take anything away from the successful HIV programs, but to
build on that and to go into the next level of maternal health.
Ambassador Goosby. I will take the first attempt at that.
We are thinking alike. President Obama's Global Health
Initiative is an attempt to do just that, to take the
successful programming that we already have in place--in this
instance HIV/AIDS--to use that robust medical platform to build
onto, to add to, services that allow the same patient with HIV
in front of us who has needs in maternal and child health,
family planning, neglected tropical diseases, immunizations for
the children, other family members, as well as a package of
essential services for hypertension, diabetes, whatever,
defined by each country, this is an attempt to do just that.
Build on the platform that is already in place, to expand the
services that are needed by the population that we have already
captured.
Ms. Woolsey. Dr. Frieden, I am not suggesting that we take
the same pot of money, and then expand the services and I am
also suggesting that there are women, and young women, that
don't have HIV. So how do we get to them and set up--I don't
want it to only be women who are already infected.
Dr. Frieden. Through the PEPFAR support we have been able
to strengthen health systems; we have been able to improve the
quality of delivery; we have been able to increase access to
emergency obstetrical care, and this is critically important
for HIV prevention, and also to support women's health and
child health. And I think, you can see an evolution from the
PEPFAR reauthorization, which enables us to strengthen systems
more comprehensively, so that we would not only have a more
sustainable way of achieving the outcomes of PEPFAR, but also
improve other health conditions through the Global Health
Initiative, where we are saying we are going to take all of our
investments we know that we are in a scarce resource
environment, we know that every dollar is precious, and we are
going to stretch each of them as far as we can by having the
services that are available as efficiently and as close to the
client as possible.
Ms. Woolsey. Dr. Fauci, before you answer, try to add into
if this were a perfect world, and we really cared about
children and their mothers, what would it take from the United
States?
Chairman Berman. By unanimous consent, the gentlelady has 1
minute--not until we have a perfect world.
Dr. Fauci. I can do it in less than one.
In fact, Congresswoman, that is exactly what the
fundamental philosophy and strategy of the President's Global
Health Initiative is--exactly what you are saying. PEPFAR is a
major component of that, but within the Global Health
Initiative is exactly what you are referring to, not only have
both an independent as well as interdigitating approach toward
women's health and child mortality but also have it something
that has its own force and its own life apart from PEPFAR.
But they are so closely joined, that you can almost not
separate them.
Ms. Woolsey. Thank you very much, Mr. Chairman.
Chairman Berman. Time of the gentlelady has expired. The
gentleman from Minnesota, Mr. Ellison, is recognized for 5
minutes.
Mr. Ellison. Mr. Chair, thank you for this really important
hearing and thank you to our witnesses.
Could you talk about the issue about the scarcity that you
mentioned a moment ago? I am curious to know how are our
country partners addressing and augmenting the battle to
overcome AIDS and HIV? Are we seeing legislatures from the
countries that we are partnering with appropriating money to
the degree that can handle some of the outyear cost associated
with the ARTs and so? Could you address this?
Ambassador Goosby. Thank you, Congressman. It is an
excellent question.
Our whole approach with the partnership framework is to
engage in a different dialogue with each country around the
human resources, the financial resources, the administrative
resources that are needed to continue a specific outline of
programs that the partner government is contributing to and the
United States Government is contributing to.
Over a 5-year period, we define it explicitly and include
in that an expectation and time line around commitments.
The dialogue is with country leadership. That leadership
has largely been central with the Ministry of Health, but the
Minister of Finance comes into it eventually always. The
President frequently blesses it and/or signs it. We have had
multiple, in every country that I go to, I meet with
leadership, including legislative appropriators, and have had
difficult discussions around relative contributions on a
financial level to this effort.
Nigeria is a good example of this. Deputy Secretary Lew and
myself went to Nigeria and in addition to looking at programs,
we met with the President, with the Appropriations Committee,
with legislative leadership on multiple party levels. We have
also met at the provincial level with leadership as well.
All of it was a discussion around what can we expect in a
country with an emerging economy, such as Nigeria, to assume in
the monetary support of these services. Again, remaining
committed to administrative and continued support on part of
the United States, it was the first time we got into an
explicit dialogue around what portion of that monetary
allotment can you realistically begin to assume for yourself.
Nigeria came in within at the end of their 5-year period
that they would assume 50 percent of the cost. That was a huge
increase from where they are currently, and a sincere
commitment made by both appropriators and the President.
Mr. Ellison. I am glad you all have that conversation
because I think it could have some benefits to other health
challenges that a lot of other emerging countries are facing.
If you can develop a system to address HIV/AIDS, you can do
that, perhaps, for malaria and other things.
Let me ask you this much, too. How much input do partner
countries have into how we are appropriating PEPFAR dollars in
their own country? I have had a chance to spend some time in
Kenya and learned they have more deaths from malaria than they
do from HIV--of course, both are serious problems. But talk to
me about how much input our partner countries have into
directing how PEPFAR resources are allocated?
Ambassador Goosby. I will very quickly say that our initial
response with PEPFAR was an emergency response, and we deployed
largely through NGO continuums of care and services with
partnered governance and civil society.
We, in the second phase of PEPFAR, looking at the emergency
response, moving into now sustained responses, see the need to
move more aggressively and to a different dialogue with partner
countries around their relative management, ownership,
oversight, defining unmet need, prioritizing unmet need, and
being in and part of the allocation discussion.
This is in most of our countries a new and expanded
dialogue for PEPFAR. It is a dialogue that the President and
the Secretary of State feel very strongly about, I feel very
strongly about, that this is the conduit through which we will
really achieve sustainable, durable programming.
Mr. Ellison. I guess my last question is the U.S. Congress
is a highly political body. How is that for stating the
obvious? And people bring their agendas here. Unfortunately
when it comes to foreign affairs, our agenda gets pressed on
other people outside of our borders allotted. And when it comes
to----
Chairman Berman. The gentleman has an additional minute.
Mr. Ellison. When it comes to programs like PEPFAR and
PEPFAR, for example, are there certain things that Members of
Congress here think are very important to them and maybe
important to their constituents but that create complications
when they are translated into the work that you have to do? So,
for example, well, I'll leave the example out for the moment.
Ambassador Goosby. It is a an astute question. But an
understandable dissonance is created with our congressional
bodies and the constituencies within our Congress moving
forward in a Congress. We have that same dissonance set up in
our country dialogue as well because each country is different,
has different norms and self-expectations that must be
considered and acknowledged and incorporated into the plan as
we move forward.
That sensitivity and where we draw that line is much of
what our dialogue becomes in the actual final partnership
framework discussion. We are acutely sensitive to it, but also
have frames and references that kind of define our parameters
and how far we can go in both ways.
So it becomes a dialogue.
Chairman Berman. The time of the gentleman has expired.
The gentleman from New Jersey, the chair of the Africa and
Global Health Subcommittee, Mr. Payne, is recognized for 5
minutes.
Mr. Payne. Thank you very much, Mr. Chairman. Let me
commend you for having a full committee hearing on this very
important subject. It is so good to see our panelists, Dr.
Goosby and Dr. Frieden, and who has been a longtime friend from
New Jersey, Dr. Fauci. We can't think of anything that is more
important right now as it relates to the developing world. And
I think that the program of PEPFAR was really a program that
made many of us very proud, even with the first authorization
of the $15 billion over 3-year period. This was a quantum leap
from what we had been funding.
As you know, funding for HIV/AIDS has--even here in the
U.S.--gone very slowly, and when it was first diagnosed, in the
early 1980s, there was only several hundred thousand dollars
that actually was appropriated over the course of 3 or 4 years
in the 1980s, where we simply allowed this to fester and
continue. There was very little attention given.
So we have continually commended President Bush when the
notion of increasing the PEPFAR program--of course, we had the
majority in the House, but we did need the cooperation from the
White House and the President did agree to double it from $15
billion, and I was advocating with them. But then I thought if
he was willing to go along with $30 billion, that that wasn't
enough. So we pushed the $50 billion number, and we were able
to get a $48 billion reauthorization, which I think was one of
the greatest marks of our country's foreign assistance program
in its history, and has done so much to save so many lives.
I know they have been recognized, but I understand the 24
women from Parliament, and several First Ladies from Ethiopia,
and Deputy Prime Minister of Zimbabwe are here. It is great to
have you here in the audience. I look forward to meeting with
you later in the day.
Let me ask, Ambassador Goosby, we do know that you need to
have the participation and cooperation from local people to
move this program forward, and anyone can chime in.
But specifically, let me ask you, what is the role of
local, national, and international nongovernmental
organizations and civil society in designing and implementing
the PEPFAR program? Just how much are they engaged on the
ground and so forth?
Ambassador Goosby. Congressman Payne, let me first say
thank you for your leadership, longstanding leadership in this
arena, both domestically and internationally.
We have seen an emergency response in PEPFAR move to a
sustained response. We are scrambling now to implement that
shift from emergency to sustainable. It brings in country
ownership. The country ownership aspect includes government as
well as civil society. And I would include certainly the NGO
community as an integral part of that civil society component.
We feel that they have and will continue to play the
critical role in prioritizing and defining our implementation
needs with the dialogue in our partner countries.
The final role that we seek to complete and improve the
chances of sustainable durable program is to work in civil
society, to establish a voice that is in and amongst those who
use the services to give feedback to allocators and
appropriators around the appropriateness of their allocation.
When you keep that dialogue present, and when you create a safe
space for that dialogue to occur, the program becomes self-
correcting. When you don't, it is ephemeral and fragile. So we
are committed to that third component.
Mr. Payne. Thank you very much.
Let me just ask this last question before my time expires.
The good news is that HIV-infected persons with either
latent TB infections or active TB can be effectively treated.
It would maybe be Dr. Frieden or Dr. Fauci who would want to
answer. How is PEPFAR aggressively addressing the TB/HIV co-
infection issue?
Chairman Berman. Without objection, the gentleman has 1
additional minute.
Mr. Payne. Thank you, Mr. Chairman.
As you may recall, about 4 or 5 years ago, we found in
South Africa about 53 or 54 persons who had the virus, Bishop
Desmond Tutu wrote a letter that when the infection of the TB
came through, 53 of the 54 people died within several weeks. So
I wonder if you could respond to that in the time that I have
left.
Dr. Frieden. Thank you. I will try to summarize my 10-15
years working in tuberculosis control globally in the next 30
seconds.
Fundamentally, it is a question of good management and
significant PEPFAR resources are going into improving the
management of tuberculosis. Many of the countries in Africa had
functioning tuberculosis-control systems, but when HIV came in
and tripled the number of cases they were overwhelmed.
The most effective way we can reduce TB is to scale-up
treatment for HIV at this point because that drives down
numbers, but often, TB comes before we treat at the current
guidelines. So the challenge is to make sure that the patients
are promptly treated and fully treated and we work closely with
countries throughout Africa to improve their treatment systems
and improve the ability to diagnose and ultimately treat the
resistant forms of drug-resistant forms of tuberculosis.
What we do hope is that by scaling up effective treatment,
we can prevent that in the first place.
Chairman Berman. The time of the gentleman has expired.
We don't often get the three of you here together so that
we are going to allow Mr. Smith and then Ms. Lee to each have 1
minute for a last question and answer.
Mr. Smith. Because of time, some of the questions were
unanswered. Dr. Goosby, again, the Board of the Global Fund
talks about funding abortion. Is that the administration's
view? And secondly what priority is given to A and B, the
abstinence and be-faithful part of the ABC model?
Ambassador Goosby. Congressman Smith, I really have to say
I need to look at that because that will be something that we
would want to understand better and we will definitely get back
to you on that in terms of what the Global Fund is saying.
In terms of what the commitment to our conscience clause
and the abstinence and being faithful. The abstinence and being
faithful, we continue to fund at high levels, and I would be
very happy to go over it in great detail with you country by
country, the abstinence and be faithful efforts. And as I said
in the previous question, we had linked referral mechanisms so
services that are needed that fall out of the abstinence and be
faithful response can be addressed as well.
Chairman Berman. The time of the gentleman has expired. The
gentlelady from California, 1 minute.
Ms. Lee. Let me just say when we were in Vienna, there was
a lot of discussion about men having sex with men and how they
are 19 times more likely to be living with HIV other than the
general population. So what are we doing to ensure that
countries are actually attempting to provide services to this
vulnerable population without stigmatizing or jeopardizing the
privacy and safety of these individuals?
Ambassador Goosby. It is a very good question,
Congresswoman, in terms of in a high interest and focus for
PEPFAR.
Men who have sex with men are complicated in sub-Saharan
Africa. For example, in Malawi, 67 percent of the men who have
sex with men are married. They have families. And they perceive
themselves in the community and present themselves in the
community as heterosexual. That kind of stigma that pushes that
revealing oneself to family and community down is something
that PEPFAR has attempted to develop unique strategies that are
different in each neighborhood and each region to try to create
safe spaces so an individual can indeed access services.
We also have a diplomatic component that engages in
dialogue at the Presidential level and at legislative levels in
country to express concern with legislative responses to
behavior patterns that are unacceptable in the country but have
criminal associated consequences for them. And we are engaged
in multiple countries on that front.
Chairman Berman. The time of the gentlelady has expired. I
want to thank all of you very much for making time in your
schedules to be here today, and I appreciate all you are doing
in this effort and your leadership, and thank you.
We now have a second panel, people right out there in the
field. If the two witnesses could come up.
Paula Akugizibwe is a citizen of Rwanda, is currently based
in Cape Town as the advocacy coordinator at the AIDS and rights
alliance for South Africa. ARASA conducts training and self-
advocacy in the southern region to improve access to TB, HIV
services and to advance a human rights base response to health.
Dr. Wafaa El-Sadr is professor of medicine and epidemiology
at Columbia University, the director of the International
Center for AIDS care and treatment programs, and the director
of the Global Health Initiative at Columbia University's
Mailman's School of Public Health. ICAP, the center she founded
and currently directs, works in 14 countries in sub-Saharan
Africa in partnership with governmental and nongovernmental
organizations building in-country capacity for HIV prevention
care and treatment.
We are delighted to have you with us this morning. And we
look forward to your testimony. Your entire statements will be
included in the record.
Ms. Akugizibwe.
STATEMENT OF MS. PAULA AKUGIZIBWE, ADVOCACY COORDINATOR, AIDS
AND RIGHTS ALLIANCE FOR SOUTHERN AFRICA (ARASA)
Ms. Akugizbwe. Mr. Chairman, committee members and
distinguished guests, good morning and thank you for this
invitation to testify before one of the most historically
significant committees on global policy on what is probably the
most significant issue on global health.
The establishment of PEPFAR in 2003 represented an
unprecedented response by the United States to a global health
problem which had far-reaching implications with development.
The founder of the U.N. AIDS wrote that PEPFAR changed the
landscape elevating AIDS issues to one of the big political
themes of our time.
In 2008, under the leadership of this committee, you
enhanced that commitment with the visionary Lantos-Hyde Act
which set forth a ground-breaking direction for the future of
global HIV funding and helped to significantly strengthen our
resolve to fight HIV in African countries. As the Lantos
Foundation previously stated, to some, HIV treatment and
prevention is seen as a burden on the U.S. taxpayer. Instead,
it should be seen as an investment that has already paid for
itself many times over in goodwill toward our country and hope
restored in African communities.
There is no question that PEPFAR has great erased the
stigma in the African region and rightly so. It remains an
initiative for which millions of people across the continent
are grateful, an unquestionable investment in public perception
of the U.S. enhancing global security.
It is critical to acknowledge from the outset that the
value of PEPFAR is not limited to dollars, cents, and public
health statistics, but extends to significant political impact.
The political world resources that were mobilized by the
U.S. for the fight against HIV reverberates across the world at
a time when AIDS was estimated to be decreasing the TDB of
high-prevalence countries in Africa by an average of 1.5
percent per year. Increased investment in HIV gave us an
opportunity to bend these economic and epidemic curves which
has led us to where we are today--at a tipping point for global
health, balancing precariously between the good news and the
bad news.
The good news, which we have heard this morning, is that we
are not fighting a losing battle. There is ample evidence that
we are bending the curves, that the once illusive dream of an
HIV-free generation is eminently achievable changing the
question from ``can we?'' to ``do we want to?''
The bad news is that without increased resources now, our
chance to defeat HIV must slip from our grasp and the climate
of AIDS could return. It would be tragic for this to happen in
the context of some of the most encouraging leaders in the
history of the HIV epidemic, which we have heard in the past
couple of years and we have heard this morning as well that
AIDS deaths are declining globally for the first time since
2007. The HIV incidents is declining especially in sub-Saharan
Africa, and that treatment has turned out to be a most
effective biomedical prevention tool.
A U.S.-funded study as was cited earlier showed that
treatment reduces the transmission of HIV by approximately 90
percent with incredible long-term cost saving potential.
Modeling studies presented at the Vienna Conference
indicated that universal access in South Africa, if fully
funded today, would result in a 17 percent reduction of
transmission over 3 years achieving cost break even in the same
space of time.
In the time of economic crisis, it is politically and
financially expedient to look to short-term savings, but long-
term social economic rationale tells us that greater investment
now will mean smaller expenditure down the line. This has
already been retrospectively validated by data released this
month from one of the largest PEPFAR-funded treatment sites in
South Africa, which demonstrated even further cost savings
associated with an incredible impact of ARV therapy on boosting
our response to other health challenges such as TB and maternal
and child health.
On maternal and child health, earlier this year HIV was
described by The Lancet, the world's leading medical journal,
as the greatest cause of paralysis in efforts to address
maternal and child mortality in sub-Saharan Africa, a paralysis
that has been alleviated by PEPFAR's provision of ARV services
to at least 1.7 million women and children in the region, as
well as a provision of prevention and testing services to
millions more.
An analysis that I got from the Journal of AIDS last year,
which I will be happy to share with you, also demonstrated the
scale-up of ARC has increased access to reproductive health
services across the board--not just women living with HIV.
President's Obama's Global Health Initiative is welcome in
its recognition of the need for comprehensive package of health
services and an increased focus in maternal and child health.
However, the lack of a sufficient correlating increase in
funding to support this expansion, such as the fulfillment that
will come at the cost of HIV, TB, and malaria programs. Any
slackening of efforts to scale-up HIV treatment will scale back
progress in all other areas of health and development
identified as a priority by the GHI and will push us toward a
loss at a time when we are more poised than ever to win.
Unfortunately, the trend toward flatlining PEPFAR funding
has already begun to do this. The Global Fund rotation
requested by President Obama was $50 million less than what was
given last year, and even with the current known level of $1.1
billion, still falls far short of the $2 billion per year that
was authorized by the Lantos-Hyde legislation.
We are not worried about money for its own sake but the
impact of these financing decisions on our communities. We are
worried that given these trends of flatlining, the 2009
directive to Uganda PEPFAR centers is namely that new patients
could only be enrolled when others died or lost a follow-up
might be repeated elsewhere in the future and wreak similar
havoc.
Doctors Without Borders has already reported increasing
treatment of migrants at many of its sites in Mozambique where
it notes that PEPFAR has warned of an annual 10-15 percent
reduction in the ARV supplies over the next 4 years. Similar
concerns have been reported in other countries.
These developments seriously threaten to undo our progress
in the fight against HIV. I would like to emphasize that we, of
course, appreciate that the U.S. cannot do it alone. Advocacy
and increased funding has been directed to a wide variety of
governments. However, we do have to recognize that much like
the establishment of PEPFAR changed the landscape of global
AIDS response for the better, so the current slackening of U.S.
Government efforts on scaling up HIV treatment is leading a
regression back to the landscape where HIV was a death sentence
because the price tag of life was deemed too high by
governments.
But the longer-term price tag will be even greater. The
World Bank warned us last year that responding to immediate
fiscal pressure by reducing spending on HIV treatment and
prevention will reverse recent gains and require costly
offsetting measures over the long term. It would be sad to see
this come at a time when we are poised to turn the tide and
when advocacy to hold national governments accountable for
their contribution to the fight against AIDS is rapidly gaining
momentum.
In the African region over the past 15 months, civil
society organizations have intensified efforts to scrutinize
government budgets and expenditure and advocate for increased
transparency and accountability.
Yesterday, more than a dozen countries across the region
took part in the first ever regional day of action on health
funding. Thousands of people took to the streets in public
demonstrations, health press conferences and public meetings
all geared as calling on our governments to increase the
domestic investment in helping, including HIV treatment, and as
global leaders to fully replenish the Global Fund.
This advocacy drew in a remarkable variety of partners
under the leadership of NGOs working on HIV, thus demonstrating
that the extensive community networks and movements that have
been created through the HIV response present extraordinary
platforms for mobilization and national government
accountability, which will be severely undercut if funding
retreat persists.
We also note that we have seen positive government response
from countries around the region. For example, in Kenya the
2010-2011 budget for HIV treatment has doubled compared to the
previous year due in large part to the Kenya PEPFAR partnership
framework. In South Africa, the HIV budget showed a 3 percent
increase this year. Following advocacy in Swaziland earlier
this year, the government exempted the Ministry of Health from
a sweeping budget that affected all other sectors. And we have
heard earlier from Ambassador Goosby about the positive
developments in Nigeria.
Some of the poorest countries in the regions, such as
Rwanda, Malawi, and Tanzania are leading the region when it
comes to the domestic investment in health. Rwanda and Botswana
are two of only eight countries in the world where universal
access to treatment has been achieved.
All of this goes to show that the vision originally
embraced by this committee with establishment of PEPFAR and the
Lantos-Hyde legislation is entirely attainable but the key to
determine success as we move ahead is political will.
The crucial bottlenecks that we face with the future
progress in the fight against HIV are not related to economics
or to science but to political priorities. When the Lantos-Hyde
Act was passed 2 years ago, you took a very definitive landmark
step toward realigning these political priorities and gave
people living with HIV all around the world, as well as the
communities, great hope that finally, a lasting precedent had
been set for an energized global response to HIV, which would
set the tone for a much broader response from all countries,
and influence responses to other health needs as well. This has
already been seen.
Next week as mentioned earlier, donors will meet in New
York to determine the fate of the Global Fund which requires a
minimum of $20 billion U.S. dollars over the next 20 years. The
United States could transform the replenishment with a promise
of a bold 3-year pledge at the levels authorized through
Lantos-Hyde of up to $2 billion per year.
I am here today to urge you to make this happen or to help
make this happen, and best meet global efforts to making
history by winning the fight against AIDS.
Third, as you move toward a more long-term strategy for
PEPFAR, it is my hope that you will recognize that
sustainability will be achieved not by relaxation, but rather
by intensification of efforts and investment because while this
might cost us more today, evidence clearly shows that it will
save us much more tomorrow. And that is the true basis of
sustainable development.
So I hope this committee will help us make a decision for
tomorrow.
Thank you.
[The prepared statement of Ms. Akugizbwe follows:]
Chairman Berman. Thank you for reminding us of the dangers
of backsliding.
Dr. El-Sadr.
STATEMENT OF WAFAA EL-SADR, M.D., M.P.H., DIRECTOR,
INTERNATIONAL CENTER FOR AIDS CARE AND TREATMENT PROGRAMS
(ICAP), MAILMAN SCHOOL OF PUBLIC HEALTH, COLUMBIA UNIVERSITY
Dr. El-Sadr. Good morning, and thank you for the
opportunity to testify today at this very important hearing.
I have personally been working in the field of HIV medicine
since the very beginning of the epidemic when I was working at
Harlem Hospital in New York City. And over the past decade, I
have spent a great deal of my time working on PEPFAR-supported
HIV and related capacity building, program development, and
implementation in sub-Saharan Africa.
As mentioned, I serve as director of ICAP, which is
situated at Columbia's Mailman School of Public Health, an
institution with a long history of work, not just in HIV, but
also in maternal mortality and child health.
ICAP is a PEPFAR-implementing partner that supports more
than 1,200 health systems in 15 countries in Africa today, and
to date, it has supported services for over one million HIV-
infected adults and children in a family-focused, women-
centered approach. Roughly half of these individuals have
initiated treatment. More than a million pregnant women with
HIV have received HIV care for their own health, as well as
prevention of transmission to their babies. Other supports
include integration of TB/HIV services, HIV testing counseling,
laboratory support, amongst many others. It has also supported
the dynamic evaluation methods to inform programs and to ensure
quality of the programs.
We have witnessed firsthand the impact of PEPFAR on
individuals, families, and communities, the rapid expansion of
host country capacity, and the remarkable goodwill generated by
PEPFAR for the U.S. and its people. Yet the work is far from
done. The success of PEPFAR is widely acknowledged by the
millions who have benefited from its program. Thus it is
sometimes puzzling when one hears some misunderstandings
regarding PEPFAR. I will briefly address these through the
lense of my own experience and observations.
First, some claim that PEPFAR works in isolation
disconnected from country ownership. My experience says
otherwise. PEPFAR is demand-driven at the community and host
government levels. The work has been planned and implemented in
partnership with Ministries of Health, regional district and
facility health teams, as well as nongovernmental
organizations, including faith-based organizations and with the
affected communities.
PEPFAR implementers play important and complementary roles
in the scale-up of these programs, all contributing to the
national AIDS control programs developed within the countries
themselves. U.S. agencies, such as CDC and USAID, play key
roles in forming these efforts under other coordination and
guidance.
Second, some claim that PEPFAR-supported programs have been
developed as separate and distinct services in silos that are
not integrated and linked to established services within the
countries. Again, my own experience differs from this
perception. The majority of health facilities deliver
integrated HIV and primary care services right where these
services are provided, including linkages to other key services
such as reproductive health.
In Nigeria, for example, ICAP supports PMTCT services for
pregnant women within existing antenatal clinics. In Rwanda,
ICAP in collaboration with the Rwandan Government, has
supported integration of TB and HIV services and synergies
between these two programs.
In Ethiopia, in collaboration with the regional health
bureaus, ICAP supports scale-up of routine HIV screening for
all in-patients and out-patients at health facilities,
including testing of mothers and babies integrated in
immunization clinics. And there are many, many other examples.
Fundamentally on the ground, there is no distinction
between Global Fund and PEPFAR funding. The inputs are all
integrated at the delivery site.
Third, some claim that PEPFAR has had limited contributions
to the country's health systems, but the evidence says
otherwise. In many of the countries where ICAP works, it has
supported the development of tiered laboratory systems as we
heard before. Good national regional local laboratories provide
training and mentorship to staff. Health work toward
innovations have also built up on the skills and morale of tens
of thousands of existing health care workers in new countries
through training and mentorship.
Pharmacies across the continent have been supported through
the provision of infrastructure, training, mentorship, capacity
building for stock management and many, many other inputs--all
of them contributing to stronger health systems that can
respond to HIV as well as to all other health threats.
A fourth misconception is that evidence of PEPFAR's impact
is difficult to discern. In reality, a key attribute of PEPFAR
is its focus on concrete measurable outcomes, an approach that
should serve as a model for other health and development
programs. Without a doubt, PEPFAR has saved millions of lives
and has preserved families and communities through access to
HIV treatment. More than 7 million pregnant women have received
counseling and treatment to prevent HIV transmission.
Expansion of prevention counseling programs for male
circumcision for HIV prevention are taking off in several
countries. Overall, there is encouraging information indicating
a 25 percent decrease in new HIV infections.
Remarkably, with the expansion of HIV treatment, we are now
witnessing a decrease in death rates in the most severely
affected countries, including South Africa and Botswana.
Different contributions to other health outcomes beyond HIV can
also be noted. ICAP-supported programs in Nigeria offer
pregnant women insecticide-treated bed nets for malaria
prevention, water purification systems and ``mama packs'' to
encourage safe pregnancy and facility-based deliveries thus
impacting maternal and child health.
Renovation of antenatal clinics, labor and delivery wards
in support of orphans and vulnerable children are just a few
examples of the broad impact of PEPFAR on the health of
children.
Encouraging evidence from South Africa shows a decrease in
under five child deaths with expansion of HIV treatment to
women in one community.
But we are at a critical point in the response to the HIV
epidemic. Scale-up of HIV treatment in PEPFAR-focused countries
has been phenomenal, but it has only reached about a third of
those in urgent need. Desperately ill men, women, and children
living in communities near and far continue to line up at
clinics in urgent need of services. For these individuals, the
emergency is far from over.
In addition, the more we learn about HIV, the clearer it
becomes that earlier diagnosis and earlier treatment is more
successful, and most importantly, more cost effective.
New WHO guidelines support earlier treatment for adults,
and it is now recommended that all children with HIV receive
treatment. Similarly, a global consensus has arisen that all
pregnant HIV-infected women must be reached if we are to
eliminate HIV.
There is also evidence that treatment for persons with HIV
can prevent them from developing tuberculosis, a leading
complication. Here is a chance to impact the TB epidemic in
countries hit hard by the dual epidemics of HIV and TB.
However, despite the scientific evidence, some national
programs are reluctant to expand HIV treatments and the
achievements of all of these benefits are outdone due to
resource constraints.
Another critical need is to scale-up evidence-based
prevention programs, as well as to engage marginalized groups
like men who have sex with men, injection drug users and
commercial sex workers in both care and prevention services.
Recent guidance from OGAC in terms of emphasis on addressing
gender equity and support for harm reduction, including syringe
exchange programs, go a long way to reinvigorating HIV
prevention efforts.
Thus, we are poised now with many of the new tools that you
heard about earlier today to have a profound impact on stemming
the epidemic and preventing new infections.
There is little doubt that PEPFAR can and does provide a
platform for addressing some of the key priorities of President
Obama's Global Health Initiative. Rather than reinventing the
wheel or starting from zero, we can build on the platform
established by PEPFAR at the tens of thousands of health
facilities and under partnerships already established within
the many communities.
However, if we stall the expansion of PEPFAR in the name of
a greater balance in global health spending, then we risk
limiting advances in maternal and child survival as well as
many other advances that go beyond HIV/AIDS per se.
This committee envisioned a scale-up of resources when it
reauthorized PEPFAR and set bold targets and new policies that
would move us toward a world without an AIDS crisis. But the
potential to truly turn the tide against the HIV epidemic and
to achieving the durable impact, we all desire will not be
realized if current funding crisis is not addressed. People
will be turned away from clinics, services will be rationed,
women and children and their families will suffer. The optimism
we have witnessed will evaporate and this remarkable potential
will be squandered.
Time is of the essence. The sooner we continue the scale-
1up of HIV treatment and prevention, the more lives will be
saved, the more tuberculosis cases can be prevented, the more
families, communities and livelihoods will be preserved.
Greater investments aiming at universal access, continued
commitment to research in conjunction with an emphasis on
building capacity and meaningful partnerships can change the
trajectory of the HIV epidemic in the most severely-affected
countries. It can also contribute substantially to the overall
health and well-being of women and children and communities.
Strong U.S. leadership and partnership with the affected
countries and communities, as well as other donor nations can
bring this goal within our reach.
Thank you.
[The prepared statement of Dr. El-Sadr follows:]
Chairman Berman. Thank you for that testimony.
I am now going to recognize Ambassador Watson for 5
minutes. We are told there will be votes on the House floor in
the next 10 or 15 minutes. So I think this will be our last
shot.
Ms. Watson. Thank you so very much. You did mention in your
testimony, and I missed the other witnesses, but our
administration really would like to now focus on women and
girls. They tend to be victimized more so in many different
ways you mentioned. What is the common treatments and thinking
in terms of securing the health and reducing the risk for women
and girls?
Dr. El-Sadr. There are many, many opportunities to do that,
and some of them are ongoing. There clearly is the effort to
prioritize the needs of women in the context of PEPFAR. For
example, in the expansion of treatment, almost 60 percent of
individuals receiving treatment through PEPFAR are women. In
addition, the expansion of reach for prevention of mother-to-
child transmission in enhancing the potential for a safe
pregnancy and safe delivery is actually very profound in terms
of trying to address the needs of these women.
Lastly, I think the engagement of women in the context, of
course, of taking care of their own families by providing them
with all the resources that they need, recognizing that women
are the central fulcrum for the health of the families
themselves is also a very important contribution of what--the
ongoing work of PEPFAR.
Ms. Watson. I understand that myths are flying all over the
place, and there are certain beliefs in certain areas of
Africa, in particular South Africa. And I go often to South
Africa, but I heard that there is a belief in the southern tip
that if men had sex with babies, it would relieve them of AIDS.
What do we have to do--and, you know, women cannot refuse
their men when they want to have sex. That is a belief in some
areas. How do we go about changing the way, the old customary
ways, of believing when it comes to women and girls? And I am
just wondering what we can do to enhance the obliteration of
those kinds of cultural mythical beliefs.
Ms. Akugizibwe. Well, you know. I think one of the reasons
why HIV--the HIV epidemic was exceptional is because it has
highlighted a lot of these long-standing cultural challenges.
And it has really brought in to bear the public health context,
but underlying that are much more deep-rooted social issues.
And speaking from my experience in working with an NGO that
does community training and community advocacy, issues such as
this are a fundamental component of all the training that we do
related to HIV, because unless we can address underlying
dynamics, we can't actually overcome the HIV epidemic.
And I think that possibly one of the most valuable things
that the HIV response has brought us is the creation of these
extensive, far-reaching, community-based networks that give us
space to start discussing a lot of otherwise issues that would
otherwise never have had the opportunity to explore.
But to also touch on the earlier point about women and
girls and how they fit into this, one of the things that I had
mentioned is that HIV in South Africa, for example, is the
cause of more than 40 percent of maternal mortality. And so for
us to separate these two things can get a bit misleading
sometimes. And I think what we need to be doing is seeing how
we can strengthen the value that HIV response has brought to
efforts to advance women's health while adding resources to us
to expand, to address a wider range of issues that don't
necessarily fall within HIV.
Ms. Watson. The most successful programs that I saw in
areas of South Africa were the programs where we gave them the
resources and let them, through their own techniques, deal, and
they can talk a small amount of money and stretch it. And so I
believe that we can better serve the people we are targeting
with our resources by going through the structure that is
already it socially and culturally.
I yield back. You have got 30 seconds, Mr. Chairman, to
give to someone else.
Chairman Berman. The gentlelady has yielded back. The votes
have just been called, so we have about 10 more minutes here.
Can I just arbitrarily say let us take 4 minutes a witness
rather than 5?
Mr. Smith, 4 minutes.
Mr. Smith. Thank you very much.
Chairman Berman. 4 minutes.
Mr. Smith. Sorry I missed our distinguished witnesses. I
was at a press conference with Jim Moran on a child abduction
case. The chairman was kind enough to place on the calendar
yesterday a very important resolution that calls for the
release of American children who have been abducted to Japan.
So I do apologize for missing that.
I would ask unanimous consent that the ranking member's
statement, Ileana Ros-Lehtinen, be included in the record.
Chairman Berman. Without objection.
[The prepared statement of Ms. Ros-Lehtinen follows:]
Mr. Smith. As well as that of Joseph O'Neill and Michael
Miller, who have transcripts of testimony that----
Chairman Berman. Will be included.
Mr. Smith [continuing]. An op-ed that I wrote for the
Washington Post, and the African First Lady's declaration.
Chairman Berman. It will all be in there.
Mr. Smith. I appreciate that.
Let me just very briefly raise for all my colleagues, I am
sure our distinguished witnesses know all about this as well,
the Call for Action at the Millennium Development Summit last
week. The First Ladies of Africa--there were nine in total, and
I believe there were seven in the room--I was at the roundtable
discussion--they made a very, very important contribution, as
they always do. Part of their statement was good nutrition is a
requirement, a way to advance the Millennium Development Goals.
There is a direct link between malnutrition, hunger and
poverty, MDG 1; child mortality, MDG number 4; maternal health,
MDG 5; and AIDS and other infectious diseases, MDG number 6.
Equally important, poor nutrition has a causal effect in
eliminating achievement of education, MDG 2, and gender
equality, MGD number 3.
They went on to say in their declaration, we now know how
to reduce malnutrition through the life cycle by a number of
simple, targeted and cost-effective solutions. The critical
window of opportunity is the 1,000-day period from conception
to 2 years old. Fortified staples; good infant-feeding
practices; more nutritious, complementary foods are some of the
tools available to help permanently break the intergenerational
cycle of malnutrition. New ways to mobilize business, develop
agriculture and food security, improved feeding and health
practices are available. And then they go on in their
declaration to make a number of very important mutually
reinforcing statements.
I am wondering from our distinguished witnesses how you see
this playing out, because as we did in the last PEPFAR
reauthorization, we made sure that nutrition was included. I
mean, I recall once when I was taking antibiotics, and I wasn't
eating as much, it causes a backlash even from something as
simple as doxycycline or some other antibiotic. I can only
imagine with ARVs, on an empty stomach, in a malnourished
person, how that could not only be difficult, but also
counterproductive.
Obviously nutrition is important. But this idea of the
first 1,000 days from the moment of conception, could you speak
to that, if you would?
Dr. El-Sadr. I will start.
I think from day 1 in terms of implementation of PEPFAR-
supported programs, there had been attention given to nutrition
and clearly integration of and provision of nutritional
supplements to individuals who need it, as well as often to
families of these individuals. So that has been part and parcel
of the work on the ground.
In addition, there has also been very innovative programs
to try to enable people living with HIV and their families to
support themselves and to grow their own foods. There are some
very--programs that I am aware of and some of them we have
supported in terms of income generation and generating food and
nutrition for the families and for the communities.
I think that the third point I want to make in terms of
nutrition is the importance of, obviously, within the PMTCT
programs, programs for prevention of mother-to-child
transmission, there are situated right in antenatal care to
provide counseling to these women regarding nutrition in terms
of their own health as well as also in terms of feeding of
their babies after their babies are born.
So there is a package that includes--that focuses on
nutrition that is part and parcel of several components of the
work that we do, whether it be in the PMTCT antenatal setting,
in the postnatal setting, or just in terms of the ongoing care
and treatment activities.
Ms. Akugizibwe. Your question reminds me of a conversation
we had with the Canadian national AIDS coordinator and someone
living in a low-income part of Nairobi.
Chairman Berman. Our problem is the 4 minutes has expired.
I am sorry to do this, but maybe you can worm it into the next
answer here.
The gentlelady from California, Ms. Lee, is recognized for
4 minutes.
Ms. Lee. Thank you, Mr. Chairman.
Let me just say the importance of women's voices and the
work of women, the empowerment of women is so key to stamping
HIV and AIDS from the face of the Earth. You both are really
wonderful examples of why women have to be at the lead in this
effort, so thank you very much.
I just wanted to ask you one question about--and I
mentioned earlier that I was appointed as a Commissioner on the
Global Commission on HIV and the Law. We will be meeting next
week in Brazil. I wanted to find out from you in terms of--and
part of our job is to look at some of the legal impediments for
vulnerable populations: Gender violence, men having sex with
men, commercial sex workers. What you would say should be some
of your top priorities that we should consider?
Ms. Akugizibwe. I think the issues that you have
highlighted around vulnerable groups and the way that legal
frameworks present the ability to access health services, such
as sex workers, such as men who have sex with men, are some of
the biggest challenges we are facing in the African region.
Additionally, the introduction of laws that give punitive
sanctions for what is called willful HIV transmission, which is
often interpreted in many ways. For example, a woman who cannot
negotiate safe sex with her husband and never had sex without a
condom, but is HIV positive could then be prosecuted under
these laws for willful transmission, and that has happened in
several countries. I would be happy to provide you with more
detail on some of the work that is highlighting these issues.
I think another, much bigger challenge is also around the
way that legal systems recognize other socioeconomic rights,
such as nutrition, and it affects the success of HIV programs.
And I think the failure by many countries to recognize basic
socioeconomic rights is impacting our ability to successfully
implement HIV programs, especially when it is compounded by the
flatlining of budgets that we are seeing in many HIV programs
as a result of global declines and funding. You have situations
where people are willing to take treatment that is readily
available, an anecdote I referred to earlier, but are not able
to start it because they don't have food, because the HIV
program, because of its reduced budget, has cut food packages
out of the overall package of services, and the government
hasn't stepped in to fill that gap.
So those are the social challenges.
Chairman Berman. The gentlelady has yielded back her time.
All right. In that case I recognize for a couple of
minutes--we do have to leave for vote--but for 3 minutes the
gentlelady from Texas Ms. Sheila Jackson Lee.
Ms. Jackson Lee. Thank you very much, Mr. Chairman, and I
thank the witnesses.
If I understand, the earlier testimony by Dr. Goosby and
other--Ambassador Goosby, rather, and a number of the witnesses
on the first panel was to affirm the importance of PEPFAR,
Global Health Initiative. I want to affirm the importance of
sustainability and to comment that when we have made progress,
but still see sub-Sahara Africa with 67 percent of worldwide
HIV infections and infections still occurring in 2008, it means
that we still have work to do. And I would like to make our
program focus itself more clearly on sustainability and a
combined effort as I know we are with malaria and tuberculosis.
So I would like to ask Ms. Akugizibwe, if I could, about
the point that you just made about more funding and the lack of
food packages, because at one time there was some dialogue that
it was a nutrition issue. We know that we have dispelled that
myth, but there is no doubt that you need to have nutrition,
and you need to have a basis of healthiness, diet, so that you
can continue to have people live longer if they are already
HIV-infected.
Would you just highlight and emphasize how we need to use
our monies for sustainability in this fight against HIV/AIDS?
Ms. Akugizibwe. I think, as I mentioned in my testimony,
that sustainability, a key component of that is recognizing
that investments now are beginning to pay off and will continue
to do so at a greater scale if they are sustained. Although we
are still seeing infections, we are also seeing for the first
time a decline in the rate of new infections, especially in
sub-Saharan Africa, and this is due in large part to the
investment that has been made into treatment.
And I can mention this investment in HIV programs and
treatment has highlighted a lot of other social issues, such as
gender violence, such as nutrition. And what is more
interesting is that the HIV response and the civil society
mobilization that just happened around that has been probably
the most effective vehicle for mobilizing advocacy around our
own Government's accountability in addressing these other
challenges.
So when we talk about government's investment in HIV
treatment, it also gives us an opportunity to raise the
investment in food and other----
Ms. Jackson Lee. Can I ask Dr. El-Sadr to give a comment in
my remaining short seconds? Can you just comment very quickly
on that question, sustainability?
Dr. El-Sadr. I think that we have had remarkable success,
and I think, again--and it should be recognized even in the
hardest hit countries. So the effect has been profound.
There are investments today by the countries themselves in
terms of the response to HIV/AIDS. So it is not a unilateral
U.S.-supported response or largely from donors, but it is joint
investment from the countries and from the external resources.
The conversations that are happening within the countries
now are to identify and recognize the national--the country
contributions as well as the external investments.
I think an investment today--what we need to do today will
absolutely ensure the durability of this response and the
ability to actually sustain it beyond the next 5 years. So
stalling on the commitment today can have far-reaching impact
on the ability to actually have a durable and sustainable
response.
Ms. Jackson Lee. Thank you very much.
Thank you, Mr. Chairman.
Chairman Berman. The time of the gentlelady has expired.
You were great witnesses. Thank you very much for coming,
and, without objection, the opening statement of the gentleman
from New Jersey Mr. Payne will be included in the record.
The committee is now adjourned. Thank you.
[Whereupon, at 11:55 a.m., the committee was adjourned.]
A P P E N D I X
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Material Submitted for the Hearing RecordNotice deg.
Minutes deg.
Payne statement deg.
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Carnahan statement deg.
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Jackson Lee statement deg.
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Material submitted for the recrord by the Honorable Christopher H.
Smith, a Representative in Congress from the State of New Jersey
QFRs--Carnahan deg.
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QFR--Lee deg.__