[Senate Hearing 107-330]
[From the U.S. Government Publishing Office]
S. Hrg. 107-330
HALTING THE SPREAD OF HIV/AIDS: FUTURE EFFORTS IN THE U.S. BILATERAL
AND MULTILATERAL RESPONSE
=======================================================================
HEARINGS
BEFORE THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 13 AND 14, 2002
__________
Printed for the use of the Committee on Foreign Relations
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
77-846 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2002
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpr.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001
COMMITTEE ON FOREIGN RELATIONS
JOSEPH R. BIDEN, Jr., Delaware, Chairman
PAUL S. SARBANES, Maryland JESSE HELMS, North Carolina
CHRISTOPHER J. DODD, Connecticut RICHARD G. LUGAR, Indiana
JOHN F. KERRY, Massachusetts CHUCK HAGEL, Nebraska
RUSSELL D. FEINGOLD, Wisconsin GORDON H. SMITH, Oregon
PAUL D. WELLSTONE, Minnesota BILL FRIST, Tennessee
BARBARA BOXER, California LINCOLN D. CHAFEE, Rhode Island
ROBERT G. TORRICELLI, New Jersey GEORGE ALLEN, Virginia
BILL NELSON, Florida SAM BROWNBACK, Kansas
JOHN D. ROCKEFELLER IV, West MICHAEL B. ENZI, Wyoming
Virginia
Edwin K. Hall, Staff Director
Patricia A. McNerney, Republican Staff Director
(ii)
?
C O N T E N T S
----------
HALTING THE SPREAD OF HIV/AIDS: FUTURE EFFORTS
IN THE U.S. BILATERAL AND MULTILATERAL RESPONSE
february 13, 2002
Page
Dobriansky, Hon. Paula, Under Secretary for Global Affairs,
Department of State, Washington, DC............................ 29
Responses to Additional Questions Submitted for the Record
by the Committee to Under Secretary of State Paula
Dobriansky................................................. 48
Lyman, Hon. Princeton, working group co-chair, Center for
Strategic and International Studies Task Force on HIV/AIDS;
executive director, Global Interdependence Initiative, Aspen
Institute, Washington, DC...................................... 78
Prepared statement......................................... 82
Natsios, Hon. Andrew, Administrator, U.S. Agency for
International Development, Washington, DC...................... 20
Prepared statement......................................... 24
Okaalet, Peter, M.D., Africa director, Medical Assistance Program
International, Nairobi, Kenya.................................. 98
Prepared statement......................................... 102
Piot, Dr. Peter, executive director, UNAIDS, Geneva, Switzerland. 53
Prepared statement......................................... 56
Ray, Dr. Sunanda, director, Southern Africa AIDS Information
Dissemination Service, Harare, Zimbabwe........................ 88
Prepared statement......................................... 92
Thompson, Hon. Tommy G., Secretary, Department of Health and
Human Services, Washington, DC; Accompanied by Claude Allen,
Deputy Secretary............................................... 11
Prepared statement......................................... 14
RESPONDING TO AFRICA'S HIV/AIDS CRISIS:
ROLES OF PREVENTION AND TREATMENT
february 14, 2002
Kim, Dr. Jim Yong, director, Program in Infectious Disease and
Social Change, Harvard Medical School, Boston, MA.............. 158
Prepared statement......................................... 161
McCray, Dr. Eugene, director, Global AIDS Program, National
Center for HIV, STD, and TB Prevention, Centers for Disease
Control and Prevention, Atlanta, GA............................ 119
Prepared statement......................................... 123
Peterson, Dr. E. Anne, Assistant Administrator, Bureau of Global
Health, U.S. Agency for International Development [USAID],
Washington, DC................................................. 130
Prepared statement......................................... 134
Sachs, Dr. Jeffrey, director, Center for International
Development, Harvard University, Cambridge, MA................. 146
Prepared statement......................................... 149
Vorster, Martin J., Mahyeno Tributary Mamelodi, Pretoria, South
Africa......................................................... 174
Prepared statement......................................... 177
(iii)
HALTING THE SPREAD OF HIV/AIDS: FUTURE EFFORTS IN THE U.S. BILATERAL
AND MULTILATERAL RESPONSE
----------
Wednesday, February 13, 2002
United States Senate,
Committee on Foreign Relations,
Washington, DC.
The committee met at 11:12 a.m., in room SD-419, Dirksen
Senate Office Building, Hon. Joseph R. Biden, Jr. (chairman of
the committee), presiding.
Present: Senators Biden, Feingold, Smith, and Frist.
The Chairman. The hearing will come to order.
Mr. Secretary, who is not here, Madam Secretary, Mr.
Natsios, thank you for coming this morning to speak to the
committee about what has become one of the most, if not the
most, pressing global health concerns of our time, and that is
the spread of HIV/AIDS.
As you know, this is the first in a series of hearings that
this committee will hold on HIV/AIDS. Senator Feingold will
chair a hearing on HIV/AIDS in Africa tomorrow afternoon, and
others on this committee will chair hearings on the same issue
after the recess as it relates to the problem in other parts of
the world.
I do not have to tell any one of you how devastating this
epidemic is. The disease has killed more people than the
bubonic plague of the Middle Ages. And it is spreading. Five
million people were infected with HIV/AIDS in the past year
alone. It has ravaged the continent of Africa and is spreading
like wildfire.
There are countries in the region that have infection rates
of over 30 percent. Africa is not alone. The number of people
affected in India could soon be greater than that of any
African country. China has recently acknowledged its problem,
and the countries of the Caribbean have infection rates second
only to those in Africa.
And lest we in the north begin to think that we are
insulated from this problem, all we have to do is look at the
increase in the infection rate in Russia--up 1,300 percent in
the last 5 years--to know that nowhere on the planet are we
invulnerable to this disease.
Ladies and gentlemen, we are facing a disaster of epidemic
proportions in my view. This disease could wipe out a
generation. It has already created millions of orphans in
Africa. Who is going to care for those children when the
parents and relatives are dead? Who will educate them when
their teachers are dying of AIDS faster than universities can
train them? Where will they go for medical attention in
countries where the health care system is underfunded,
overburdened, and understaffed due to HIV/AIDS?
I do not think that the security, social, and economic
implications of the spread of AIDS have been fully appreciated
by most. I submit that we must begin taking them much more
seriously. The consequences of this disease running unchecked
throughout the world are everything from 3 decades of
development gains lost to rampant instability and state failure
in parts of the world. The potential for political instability
due to the deaths of political and military leaders is a cause
for concern in newly emerging democracies, according to
reports. Gross domestic products are set to decline anywhere
from 8 to 20 percent depending on how many years out one
calculates the loss.
This cannot be allowed to happen. We must attack this
disease on all fronts, using every technique feasible from
prevention to care to treatment--or we will fail.
It is imperative that the United States engage in a
considered coordinated strategy in its bilateral assistance
programs. We cannot afford to waste a single dollar with
duplicative, overlapping efforts among various U.S. Government
agencies. The problem is big enough for more than one of our
agencies to constructively contribute something, but it is far
too big for every agency to focus its efforts on doing the same
thing.
One important tool to contain the spread of infectious
disease and to spot biological terrorism efforts is effective
disease surveillance. Senator Helms and I plan to introduce a
bill to bolster U.S. assistance to developing nations to
improve their national disease surveillance capabilities so
that the world can track these outbreaks. I know that Senator
Frist and Senator Kennedy have worked extensively on this
matter as well regarding the infrastructure.
I have administration promises to work with us on this
legislation, and I think it is important that we make a real
effort in this area. But that should be only part of the
necessary response if we are to have any hope of containing
HIV/AIDS.
There is a lot more to say, but I and my colleagues are
eager to hear testimony and ask questions about the United
States' efforts to stop the spread of HIV/AIDS throughout the
world.
Before we begin, though, let me say this. Without
leadership both here and abroad, none of our efforts will be
successful. We need strong leadership here in the United States
to devote the necessary resources to both our bilateral
programs and to the Global Fund. We need leadership from our
donor partners for the same reason, and we need leadership from
recipient countries. I do not believe for a moment that any
assistance program for HIV/AIDS can be successful without
committed, sustained public leadership from recipient
countries. In the absence of leadership at the highest level,
any program that donor countries fund or support will, at best,
generate mediocre results, and at worst, be doomed to failure.
Again, I thank you all for coming and I look forward to
hearing your testimony.
At one point from the perspective of what we are all
focusing on now, I would suggest that--and we will make
available a report--my colleagues and the country look to the
fact that even from purely a defense standpoint, purely from
the standpoint of U.S. security interests, the Defense
Department as well as the CIA, has listed this as one of the
great threats to U.S. security. This is not merely a health
problem.
Before we hear from our first panel, we have before us
submissions from Senators Corzine and Durbin, and without
objection, I would like to enter their statements in the record
so we can move right to witnesses. There being no objection, it
is so ordered.
[The prepared statements of Senators Corzine and Durbin
follow:]
Prepared Statement of Senator Jon S. Corzine,
U.S. Senator from New Jersey
u.s. bilateral and multilateral response to hiv/aids
Mr. Chairman, I commend you for holding this hearing today on a
topic of immense consequence. As this Committee considers how best to
respond to the global HIV/AIDS pandemic, I want to bring special focus
to the plight of women and their families across the developing world.
Mr. Chairman, two decades after the start of the HIV/AIDS pandemic,
AIDS kills more people worldwide than any other infectious disease. And
of the 40 million people now living with HIV/AIDS, nearly half are
women.
Yet, despite twenty years of experience with this crisis, and at a
time when the incidence of sexually transmitted infections (STIs) is
reaching epidemic proportions, the only public health messages women
receive about the prevention of HIV and other STIs are about monogamy
and condom use. While these are critical messages, for many women these
messages are, unfortunately, inadequate or unrealistic. They may also
be life threatening. Millions of women lack both the power within
relationships to insist on condom use and the social and economic
resources to abandon partners who put their health at risk. And we also
know that due to their biology, women are four times more vulnerable to
HIV infection than men.
Given these realities, there is no question that female-controlled
HIV prevention methods such as microbicides are vital to controlling
the spread of HIV. Microbicides are a new class of products currently
under research and development that are topically applied to prevent
the transmission of HIV and other sexually transmitted infections. If
we want to defeat the AIDS virus, we must be committed to developing
new prevention tools, like microbicides, in the same way that we are
committed to the development of an AIDS vaccine. Women worldwide need
this commitment.
Recognizing this, last year Senator Olympia Snowe and I, along with
Senators Cantwell, Leahy, Murray, Kerry, and Dodd, introduced S. 1752,
legislation aimed at redoubling federal efforts to develop safe and
effective microbicides. Our legislation focuses on microbicides
research efforts already underway at the National Institutes of Health
and the Centers for Disease Control. However, I know that USAID also
does important work in this area, and I hope that this hearing can help
ensure greater coordination between relevant federal agencies as they
seek to advance microbicide research and development so that we can
more quickly get these products to those women in greatest need. With a
greater federal commitment to microbicides research, leading
microbicide research groups, including the Global Campaign for
Microbicides and the Rockefeller Foundation Microbicide Initiative,
estimate that a microbicide could be brought to market within the next
five years.
Just yesterday, the Rockefeller Foundation released the findings of
their two-year study on the science and policy challenges in
microbicide research. This new set of studies conclude that even by the
most conservative of estimates, microbicides have the potential to
dramatically prevent new infections and emerge as a critical tool in
our HIV prevention arsenal.
Without increased federal investment in microbicide research,
however, we will not achieve this goal. The Rockefeller ``Pharmaco-
Economics Working Group'' of experts estimates that the cost of
developing the existing pipeline of products would be roughly $775
million over five years, with the expectation that this investment
would generate several safe, effective microbicides by 2010. However,
the public and private funding currently estimated to be committed over
the next five years is roughly $230 million. This leaves a shortfall of
at least $545 million dollars.11If we could muster public and private
sector funds to meet this shortfall, what would be the potential impact
of this investment? Using conservative assumptions, researchers at the
London School of Hygiene and Tropical Medicine, who worked with the
Rockefeller Foundation on these studies, estimate that a 60 percent
efficacious microbicide used in 73 lower income countries could avert
2.5 million HIV infections over three years.
2.5 million fewer infections translates into a cost savings of $3.7
billion for already over-burdened governments in developing countries--
$2.7 billion in averted health care costs and $1 billion in
productivity benefits.
So, Mr. Chairman, where are we now? The short answer is: not even
close. In FY 2001, the National Institutes of Health invested only
$34.6 million in microbicide R&D--less than 2% of the Institute's AIDS-
related research budget. My bill--and its companion legislation in the
House--would greatly strengthen the federal commitment to microbicide
research at NIH and elsewhere. Microbicides will give women in this
country and around the world one more way of protecting themselves
against the ravage of HIV/AIDS. We need to act now.
Thank you for your interest in this important matter.
______
Prepared Statement of Senator Richard J. Durbin
Mr. Chairman, I commend you for calling this very important hearing
to discuss U.S. efforts to address the global HIV/AIDS pandemic. Thank
you for permitting me to testify today. I look forward to working with
the Committee to develop a strong response to this crisis that will
clearly state the Congressional commitment to halting the spread of
this devastating disease around the world. I would like to present to
the Committee a comprehensive legislative proposal that I have
developed in the hope that we can begin in earnest a dialogue that
moves this issue forward before the year is out.
Yesterday, I introduced the Global Coordination of HIV/AIDS
Response Act, known as the Global CARE Act. As we all know, HIV/AIDS is
a national security issue, an economic issue, a health and safety
issue, and most importantly a moral issue. My bill will not solve all
of the problems caused by the AIDS pandemic. But it does set the bar
where the need is, and I believe it does offer some innovative ideas to
address the global AIDS crisis in a strategic, coordinated, and
accountable manner.
It is critically important that we demonstrate the political will
to act on this issue. I think it would be productive for Congress to
establish clear policy goals and funding targets that represent the
real need. It is also our job to ensure that there is accountability
for the money that we appropriate, and that we are able to articulate
the results of our U.S. investment. It is my hope that by doing this we
will secure a serious, effective financial commitment that to date has
been woefully inadequate.
The Global CARE Act is grounded in the principles of leadership and
accountability.
The policy goals I have set forth in this bill are the following:
better coordination among the myriad of U.S. agencies active in the
global AIDS fight; a more focused strategic planning initiative that
makes the best use of U.S. bilateral assistance; increased
accountability for the health and policy objectives we seek to achieve
with our financial and human investment in AIDS-ravaged countries; the
ability to mobilize the most effective human and capacity-building
tools to provide some of the building blocks that are needed; and a
clear articulation of the broader issues that need to be addressed to
have a real impact on HIV/AIDS, including not just prevention but
treatment and care, and not just health initiatives but also economic
investments.
The Global CARE Act provides specific funding authorizations for
the key agencies working on global AIDS, as well as for the Global
Fund. Both bilateral and multilateral assistance is needed to address
this problem. Before the Leadership and Investment in Fighting and
Epidemic (LIFE) initiative authorized USAID to conduct activities
specifically focused on global AIDS in FY2000, there was little
direction from Congress on this issue. And up until the United Nations
and President Bush specifically requested money for the Global Fund,
there was little agreement about what was needed. It is now time for
Congress to step up to the plate and provide some direction.
The authorized funding levels in the Global CARE Act represent a
need that has been well documented. The World Health Organization's
Macroeconomics and Health Commission has determined that by 2007, the
international community--donor and affected countries--should be
spending $14 billion in response to the AIDS pandemic. Last year, the
United Nations called for roughly $10 billion annually.
America has by far the greatest giving capacity, yet we devote the
smallest percentage of our overall wealth to efforts aimed at
alleviating global poverty and disease. Last year the United States
gave one-tenth of 1 percent of its GNP to foreign aid--or $1 for every
thousand dollars of its wealth--the lowest giving rate of any rich
nation. By comparison, Canada, Japan, Austria, Australia and Germany
each gave about one-quarter of 1 percent--or $2.50 for every thousand
dollars of wealth. Many other countries give even more, at rates 8 to
10 times higher than the United States. Based on its share of global
GNP, the United States should contribute at least 25 percent of the
total AIDS response cost in 2003. Twenty-five percent of the estimated
$10 billion needed next year would be $2.5 billion. Hundreds of civic
groups and religious leaders have joined together, calling on Congress
to provide at least $2.5 billion to combat the pandemic.
The Global CARE Act establishes broad policy goals and activities
that are embodied in an international HIV/AIDS Prevention and Capacity
Building Initiative and an International Care and Treatment Access
Initiative. These goals and activities, which range from education,
voluntary testing and counseling to helping preserve families and
ameliorate the orphan crisis, are not parceled out to the various
agencies we know are actively engaged in this issue such as the U.S
Agency for International Development (USAID) and the Centers for
Disease Control and Prevention (CDC). Rather this legislation generally
relies on the existing authorities of the agencies to carry out these
broad activities with the requirement that they coordinate their
activities with each other and with host country needs and host country
plans.
The development of a coordinated, effective, and sustained plan for
U.S. bilateral aid in relation to multilateral aid and other nation's
bilateral aid is paramount. The U.S. has the opportunity to provide the
requisite leadership in this global effort though operating
strategically, and in an accountable and transparent manner.
To provide an incentive for such coordination, the bill establishes
an interagency working group charged with ensuring that global HIV/AIDS
activities are conducted in a coordinated, strategic fashion. Members
of this working group include agencies within the Department of State,
specifically USAID; agencies within the Department of Health and Human
Services, including the Centers for Disease Control and Prevention, the
Health Resources and Services Administration, and the National
Institutes of Health; the Departments of Defense, Labor, Commerce and
Agriculture, and the Peace Corps.
It is my intention to create a policy working group with
representatives from the agency programs doing the real work. The
working group will help to ensure that the various agencies we fund to
provide bilateral assistance are making the most of the money we
appropriate; that they are not duplicating efforts; that they are
learning from each others' programmatic experience and research in
order to implement the best practices; and that they are accountable to
Congress and the American people for achieving measurable goals and
objectives. In fact, the function of this group is very similar to the
interagency working group established in H.R. 2069, legislation that
passed the House of Representatives last year.
The Global CARE Act very specifically directs the working group to
report back to the Senate Committee on Foreign Relations, the Senate
Committee on Health, Education, Labor and Pensions, and the Senate
Appropriations Committee, and the corresponding Committees in the House
of Representatives, with the following information: 1) the actions
being taken to coordinate multiple roles and policies, and foster
collaboration among Federal agencies contributing to the global HIV/
AIDS activities; 2) a description of the respective roles and
activities of each of the working group member agencies; 3) a
description of actions taken to carry out the goals and activities
authorized in the International AIDS Prevention and Capacity Building
Initiative and the International AIDS Care and Treatment Access
Initiative set out in the legislation; 4) recommendation to specific
Congressional committees regarding legislative and funding actions that
are needed to carry out the activities articulated in the bill; and 5)
the results of the HIV/AIDS goals and outcomes as established by the
working group. In my view, only by requiring very specific reporting
requirements will the working group actually work.
The Global CARE Act includes a number of other provisions. Some
have been discussed on the Hill, others have not. It authorizes a
Global Physician Corps to utilize the human capital we have in our
working and retired physicians by providing a mechanism for them to
serve overseas where their expertise is so needed.
The bill authorizes a small amount for USAID to work on developing
and implementing initiatives to improve injection safety. According to
the World Health Organization (WHO), each year the overuse of
injections and unsafe injections combine to cause an estimated 8 to 16
million hepatitis B virus infections, 2.3 million to 4.7 million
hepatitis C infections and 80,000 to 160,000 HIV infections. Together,
these chronic infections are responsible for an estimated 10 million
new infections, more than 1.8 million deaths, 26 million years of life
lost, and more than $535 million in direct medical costs.
It includes a new pilot program to provide a limited procurement of
antiretroviral drugs and technical assistance to programs in host
countries. And it includes a very important orphan relief and
microcredit component that acknowledges that addressing the AIDS
problem requires both an economic and social investment in women and
families.
I hope that the Committee will consider the framework and policy
that I have developed as we work to introduce a unified proposal to
address this problem. Tackling this pandemic will take more than one
good bill--it will take a concerted effort to combine the best ideas
and realistic initiatives to get the job done.
The Chairman. I would also like to acknowledge the
presence of a contingent from the African ambassadorial corps
here today. As you know, that continent has been ravaged by
this disease and their presence indicates a commitment by their
countries to acknowledge and to deal with the spread of this
disease.
Lastly I will say because of the diplomatic--how can I
say--as Kofi might say, the diplomatic niceties that have to be
observed, Kofi Annan, who has been leading in this area as well
on the international stage, has been extremely cooperative with
this committee. He was going to testify before the committee,
but quite frankly, I think it would have put him in a difficult
position as the head of the United Nations sitting down and
being asked questions by Senators.
So, we have come up with a diplomatic solution. He is going
to come and speak to us at 3 o'clock this afternoon at a coffee
I have invited many of my colleagues to attend, and we will
treat it as we would treat a head of state and/or a foreign
minister coming, not in terms of him being in a position of
answering our questions, but in terms of sharing with us his
incredible sense of urgency about what we must do and the part
he thinks that we and others have to play.
With that, let me yield to my good friend, the good doctor
from Tennessee, who has been a genuine leader, along with
Senator Feingold, on this issue.
Senator Frist. Thank you, Mr. Chairman. I would just ask
unanimous consent that my remarks be made a part of the record
as well.
The Chairman. Without objection.
Senator Frist. But let me briefly thank both of my
colleagues who are here, the chairman for bringing this issue,
HIV/AIDS, the global pandemic, to this level with the
presenters and the witnesses before us today, and also the
chairman of the Africa Subcommittee. Over the last several
years, we have worked side by side in addressing this issue and
many issues. He is holding the hearing tomorrow which, in many
ways, is a sequel and will build upon the foundation today,
again representing the commitment of this committee, the
Foreign Relations Committee, in addressing what is the most
devastating, destructive public health challenge that we will
have clearly had since the 1300's, but probably of all time.
Before coming to the United States Senate, I was a
physician, and because I did heart transplants and lung
transplants, all of my patients were on immunosuppression. The
risk is not of heart rejection or of lung rejection, but
because of the medicines we gave, it was infectious disease.
When a patient, after a successful transplant, got an
infection, the infection would set in, he or she would stop
working, he or she would have to drop out of school, would lose
income to support the family, could no longer support their
children, could no longer participate in the community, a
family would become less secure and lost hope became the
dictum. Well, with that, all normal life would dissolve. That
is one patient. That is what I had the opportunity to see.
Two weeks ago, three weeks ago, I was in Africa once again,
and as we went from Uganda to Tanzania to Kenya, looking at
HIV/AIDS programs, exactly what is happening to that patient,
that individual patient whose life is destroyed by this
infectious disease, this virus, is happening to a continent.
That is really what we are struggling to address. We will hear
much more about how it is being done structurally from our
witnesses today.
Let me just close my opening remarks by really taking what
we all have to do and that is putting real faces on what we are
addressing when we talk of statistics and 3 million people and
40 million people and the staggering growth.
In Nairobi, Kenya, I went to the Kabarro slum. Many people
in this room have been to the slum. It is right there, right in
the city itself, a population of over 750,000 people there. One
out of five of those are HIV/AIDS-positive. As you walk through
the crowded streets with all the shanties and the tin roofs,
you are amazed that you see just young children. You literally
do not see people of middle age. You see some older people and
you see 20, 30, or 40 young people around them, but this whole
middle generation is being wiped out. We will hear more about
the details, but it is just remarkable when you walk into that
slum and you see that there is nobody there middle-aged.
Teachers are gone. The military has been destroyed in many
countries. The workers, the providers.
In Arusha, Tanzania, I met Nema whose name means grace. She
sells bananas to survive and to provide for her year-and-a-
half-old son Daniel. When Daniel cried from the hunger, Nema
kissed his hand because she had nothing to give him but love,
again suffering from the ravages of HIV/AIDS.
Also in Arusha, there was Margaret whose symptoms first
came in 1990. When her husband died, despite her illness, she
found the strength to fight his family because of cultural
norms there. The property automatically goes to the husband's,
who has died, family. Automatically it is stripped away. Thanks
to her brother, she has a house for her six children.
Tabu, a 28-year-old prostitute, met, talked, spent a couple
hours with in Arusha. She was going back to her village to die.
She stayed an extra day just so she could meet with us, and I
will never forget that smile, the cheerful demeanor, as we met
in a small, stick-framed hut no more than 12 by 12.
Well, these are the real faces. As we talk about the big
issues, it is that little virus. There is no cure today. There
is treatment, but there is no cure. Nine out of 10 people in
the world do not even know that they have it. As we talk about
the big numbers, the big programs, again we have got to
remember it translates down to those individuals that are now
in the millions in Africa.
With that, Mr. Chairman, I will close and mention some of
my other things in my opening statement as we go forward. Thank
you.
[The prepared statement of Senator Frist follows:]
Prepared Statement of Senator Bill Frist
AIDS IS THE HEALTH CRISIS OF OUR TIME
Before I became a Senator, I was a heart and lung transplant
surgeon. To increase the effectiveness of the surgery, I gave my
patients powerful immunosuppressant drugs--drugs that allowed the heart
to survive but which made one highly prone to infections. I was an
infectious disease expert--to do the actual transplant operation took
only about 5 hours; the real challenge required never ending vigilance
and action of beating back every infection so that my patients could
lead normal and fulfilling lives. That is what I did every day for
hundreds of patients.
I had the honor of giving my patients, suffering from fatal
diseases, a second chance at life. But if an infection set in--an
infection I could not control--my patient stopped working, he dropped
out of school, he lost income to support his family, he could not be
the parent he wanted to be for his children, his family became less
secure, he could not participate in his larger community, he lost hope.
All normal structure to his life would dissolve. Life around him would
crumble.
Now, as I sit on the Foreign Relations Committee, I see regions of
the world where the scourge of HIV and AIDS is destroying the lives of
millions. Just like that patient with fatal heart disease who can
either get better with appropriate intervention or who will die, now is
the critical moment to intervene to address this epidemic--the health
crisis of our time.
We are all aware of the chilling state of the global AIDS pandemic.
Each year, a staggering 3 million persons die of AIDS and an additional
6 million more are infected with HIV--mostly in poor countries. Over
the next ten years, AIDS will have claimed the lives of more people
than all those, both civilian and military, killed in World War II.
Globally, nearly 37 million are infected, with 23 million more having
already died.
Particularly hard hit is the continent of Africa. In January, I
traveled to East Africa and witnessed first hand the toll HIV and AIDS
is taking on that continent. Africa is losing an entire generation as
40 million children will be orphaned by AIDS in the next decade--a
number equivalent to all children living east of the Mississippi.
Trained personnel--teachers, health care, military and police--are in
some countries dying faster than they can be trained. The orphans of
Africa are left without parents, without teachers, without role models
and without leaders making them susceptible to recruitment by criminal
organizations, revolutionary militias, and terrorists. AIDS is
destroying entire societies.
In Nairobi, Kenya, I visited the Kibera slum. With a population of
over 750,000, one out of five of those who live in Kibera are HIV/AIDS
positive. As I walked the crowded, dirty pathways sandwiched between
hundreds of thousands of aluminum shanties, I was amazed that everyone
was a child, or very old. The disease had wiped out the parents--the
most productive segment of the population--teachers, military, workers,
the providers.
In Arusha, Tanzania, I met Nema whose name means ``Grace.'' She
sells bananas to survive and provide for her year-and-a-half-old son,
Daniel. When Daniel cried from hunger, Nema kissed his hand because she
had nothing to give him but her love.
Margaret, also in Arusha, whose symptoms first came on in 1990.
When her husband died, despite her illness, she found the strength to
fight his family to keep the family property. Thanks to her brothers,
she has a house for her six children.
And Tabu, a 28-year-old prostitute, who was leaving Arusha to
return to her village to die. She stayed an extra day to meet with us,
and I will never forget her cheerful demeanor and mischievous smile as
we met in her small stick-framed mud hut, no more than 12 by 12. Her
two sisters are also infected, another sister has already died. Tabu
will leave behind an eleven-year-old daughter, Adija.
These stories of a lost generation--of young mothers and their
children are--sadly--not unique to Africa.
Africa has suffered the most but it is not alone--India, with well
over 4 million cases, is on the edge of an explosive epidemic, which
could result in 50 million cases in the next 10 years if awareness and
prevention campaigns are not rapidly implemented. The Caribbean
currently has the second highest rate of infection of any region in the
world--2.3% of the adult population. And Russia had the biggest
increase in rate of new cases last year.
AIDS is truly a global crisis.
LEADERSHIP AND COORDINATION
The good news is we know a lot about how to reverse the epidemic.
And as a first step, it takes strong leadership at all levels, but as
with most things in life, that leadership must start at the top.
President Museveni in Uganda, with whom I spent some time on my
trip, has not been bashful about speaking very publicly to citizens of
his country about HIV/AIDS. Bakili Muluzi, President of Malawi, was in
my office here in Washington just a few days ago. He told me that he
opens every speech to his countrymen with an admonition about HIV/AIDS.
These two presidents underscore the need to bring the disease out
into the light, helping to eliminate the stigma often associated with
the disease, and opening the way for public education.
With leadership, we must also coordinate our efforts, understanding
the importance of enlisting all stakeholders in the fight against HIV/
AIDS. From governments, to the U.N. and the World Bank, to world
leaders, corporations and philanthropies, each has an important role to
play.
An effective strategy to combat HIV/AIDS must coordinate within
national governments as well as across them to ensure that our
resources are leveraged and put to best use by avoiding duplication of
effort. Each national sector--agriculture, labor, finance, health,
education--can contribute unique expertise and resources. For example,
the education ministry can develop programs that target the younger
generation, teaching them how to avoid risky behavior. The labor sector
can resolve difficult employment issues; the financial sector can
mobilize national resources.
Each level of society has a role to play--political, ethnic, and
religious leaders can coalesce national support and reduce stigmas
attached to the disease. And, as I learned in East Africa, many of the
best ideas come from those working in the trenches to fight this
disease. Local community participation is indispensable.
PREVENTION AND TREATMENT
We must fight this battle on two fronts: by improving primary
prevention and expanding access to treatment.
Until science produces a vaccine, prevention through behavioral
change is the key. Even in HIV ravaged Africa, most of those who come
in to be tested will test negative. This presents a real opportunity to
save countless lives. I believe we should increase investments in rapid
HIV testing kits and counseling for developing countries. Access to
inexpensive and rapid HIV testing can help reinforce prevention
messages and guide treatment options. And as I saw in Africa, testing
centers become centers of hope for the community, a place where those
struggling with HIV/AIDS can share ideas, support each other, learn
important coping strategies, and receive medical treatment and
nutritional support.
Treatment is an important part of the mix. When persons with AIDS
receive medical and nutritional support, they live longer and
healthier, avoiding opportunistic infections such as tuberculosis;
providing income for themselves and their families; and ensuring a
better future for their dependents. There are other potential public
health advantages to treatment that require further research and
evaluation. Treatment with antiretroviral drugs lowers the amount of
virus in the blood, potentially decreasing the risk of transmission,
both among adults and among mother to child transmissions.
New treatment regimes may make an even bigger difference in
extending life and holding families together. Just as importantly, the
hope of some kind of treatment will encourage more people to have
themselves tested. The more people know about infection; the more
likely they are to do something about it. Finally, support of health
care delivery systems including personnel training is essential to
effective programs.
I would like to take this opportunity to thank Secretary Thompson
and Administrator Natsios and compliment them for the great work that
USAID and the Centers for Disease Control for their efforts in
prevention and treatment in East Africa. When I was in Uganda in
January, I witnessed firsthand the cooperation between USAID and the
Centers for Disease Control at such centers of excellence as the AIDS
information center and TASO (The AIDS Support Organization) outreach
program.
WHERE DO WE GO FROM HERE?
I believe we must focus our efforts around eight main goals:
We must continue our efforts to unite the political,
religious, and business leaders of the world in the
international commitment to provide financial and human
resources to halt the spread of HIV/AIDS; and to help those who
are afflicted with the disease.
We can lend support to the Global Fund for HIV/AIDS, TB and
malaria in its critical start-up phase and assist in the Fund's
efforts to meet the challenges ahead with financial and
political support. The Global Fund was envisioned as a public/
private partnership. Donations from governments to the Fund are
only part of the effort. We must also take steps to encourage
corporate, non-profit, and private donations to the Fund. For
example, we could consider ways to mobilize resources for the
Fund by creating tax incentives for private sector and
individual contributions. We should consider the development of
dynamic methods of support for the Fund, such as non-cash
contributions of pharmaceutical and medical instrument
donations to the provision of technical expertise and staffing
to public health personnel.
Our nation's public health community is doing great work in
the fight against HIV/AIDS. But I believe we can do still more.
We should consider ways to further leverage our nation's public
health care resources and talent to address the global HIV/AIDS
challenge.
We must continue to encourage and empower coalitions of
governments, multi-lateral institutions, corporations,
foundations, scientific institutions, and NGOs to help fill the
gap between the available resources and the unmet needs for
prevention, care and treatment. Each has unique contributions
to make to the battle. We in government should seek ways to
expedite these connections through legislation if necessary.
We should put non-governmental and community based
organizations, both religious and secular, at the forefront of
action on the ground, getting funds to them quickly so that
they can most effectively do their jobs reaching out to those
who need help most.
We must ensure that international research efforts on
disease affecting poor countries, such as AIDS, malaria and TB,
are reinforced in a manner that assures that the best
scientific work in the world can lead to real benefits for the
developing world--at a cost they can afford. (CDC protocols and
guidelines, research on alternative drug schedules.)
We must find ways to balance prevention with support, care,
and treatment options that combine low cost pharmaceuticals
with enhanced health care delivery systems.
We must take steps to provide comfort to the families and
orphans affected--to give them hope.
Our challenge is great. But as Americans, it is not in our nature
to turn away from great challenges. And I have no doubt that, as a
nation, and as a people, we will rise to it.
The Chairman. Thank you.
Today we have with us a very distinguished and important
panel, beginning with Secretary Tommy G. Thompson, the
Secretary of Health and Human Services. Everyone knows of his
bio.
The Chairman. He was one of the Nation's great Governors
in my view and one heck of a Secretary of HHS. I quite frankly,
for the record, although it is all past, I appreciated your
optimism during 9/11. Without you, I think there would have
been a little more panic out there. As you may recall, this is
not hindsight. I said it at the time as well. I am glad we had
somebody who had been a plain old politician in that position
because of the significance of how things would be read based
on your facial and your verbal gestures. It would have made a
big difference. You communicated a sense of some optimism to
the American people at a very important time. So, I think your
critics can go to the devil.
The Chairman. Mr. Natsios is a man well-known to us here.
He is Administrator of the U.S. Agency for International
Development. USAID is a Government agency that administers
economic and humanitarian assistance worldwide and is always a
whipping boy in the past 30 years I have been here. But I think
the rest of our colleagues are beginning to realize what I
think we all on this committee have realized, its incredible
importance and significance. I suggest that, unless we make
USAID even more robust over the next decade or so, we will be
making a gigantic mistake.
Also we have the Ambassador with us who is in a position
nominated by President Bush. She was unanimously confirmed by
the Senate and sworn in as the Under Secretary of State for
Global Affairs, a job that I doubt she even fully appreciated
would take on the significance it has since she has been sworn
in beyond what it already was.
So, I welcome you all. I will not take any more time.
It is very seldom that we ever do this, but I am going to
recognize a man to your right, Chad Allen, because he used to
be a staffer here. As long as you know you cannot speak, Chad,
you are welcome. I am joking. That is a joke.
Claude. I said Chad. It is Claude. I have just been
corrected, which means I will be corrected again before this is
over.
So, Claude, it is good to see you back, although as I
understand it, you are assisting the Secretary at this point,
and at some point he may yield to you. I do not know.
With that, why do we not begin. We will start with you, Mr.
Secretary, and welcome any opening statement you would like to
make.
STATEMENT OF HON. TOMMY G. THOMPSON, SECRETARY, DEPARTMENT OF
HEALTH AND HUMAN SERVICES, WASHINGTON, DC; ACCOMPANIED BY
CLAUDE ALLEN, DEPUTY SECRETARY
Secretary Thompson. Let me just start out by thanking you,
Senator Biden, for your leadership in this area. I cannot think
of a more important hearing to take place today, and I applaud
you for your leadership in this effort and thank you so very
much for having us.
The Chairman. The real leaders are the fellows on either
side of me here. But thank you.
Secretary Thompson. Senator Frist is one of those
wonderful outstanding leaders, and I appreciate what you do in
Africa, Senator Frist. And, Senator Feingold, it is always a
pleasure to be with you and thank you for your leadership in
Africa as well. It is a great panel and I thank you so very
much.
I am on the Global Fund Board and that is why I wanted to
come and testify, Senator. I am going to have to leave, but
Claude Allen is here as my Deputy, who is very interested and
very much involved in this as well. He will be answering any
questions that may come after my testimony.
Mr. Chairman, thank you for your leadership in responding
to this devastating disease. And, Senator Frist and Senator
Feingold, thank you for all your efforts. And, Senator Frist,
thank you for your leadership on the GLIDER legislation. We may
not have succeeded yet, but your efforts certainly showed
leadership and your commitment to this issue.
The administration and the Department of Health and Human
Services are fighting the war against AIDS on two fronts: here
in our own country and around the world. In all, HHS will
devote $13 billion in fiscal year 2003 to fighting HIV/AIDS at
all levels, an 8 percent increase over current spending.
In today's hearing, we are discussing the global efforts,
but I can assure you and the members of the committee that our
efforts within the United States are as aggressive and focused
as well.
Mr. Chairman, as you know, Secretary of State Colin Powell
and I serve as the co-chairs of the Task Force on HIV/AIDS,
which was created by President Bush. We all know too well the
dreadful, terrible statistics: 40 million individuals around
the world living with HIV//AIDS and 3 million deaths from AIDS
last year alone.
The scourge of AIDS threatens to destroy economies and
social systems, to promote national instability and civil
unrest, and to draw the United States and other developed
nations into national and regional conflicts.
The administration is aggressively responding on numerous
fronts, gathering resources from all across the Federal
Government to battle HIV/AIDS and other infectious diseases.
Within my Department of Health and Human Services, the
Centers for Disease Control and Prevention, the Health
Resources and Services Administration (HRSA), and the NIH are
world leaders in research and assistance. In addition, we are
closely cooperating with private groups, the religious and non-
sectarian charities that do so much good work internationally.
President Bush took the bold step last May 11th of
announcing the first national contribution to the Global Fund
to Fight HIV/AIDS, Tuberculosis, and Malaria. I am keenly aware
of this committee's support for this effort and thank you and
applaud you for it.
Organization of the fund has moved forward with remarkable
speed since then. I am pleased to report to you, Mr. Chairman,
that the fund now totals almost $2 billion in resources pledged
by public and private sources.
The Global Fund held its first board meeting January 28 and
29 in Geneva. It was a great pleasure for me to be able to
announce the President's pledge to the fund of an additional
$200 million in fiscal year 2003. This latest contribution
brings the total U.S. contribution to a half a billion dollars,
by far the largest donation from any one country or entity,
representing more then one-quarter of the overall commitments
to the fund.
I can also report that a consensus has formed within the
board that coincides with the President's priorities and the
principles for the fund's operation. Let me, please, quickly
highlight them.
First, the President spoke of the need for partnerships
across borders and among both the public and private sectors.
Accordingly, the fund is an independent, nonprofit foundation
under Swiss law, located in Geneva in space separate from the
United Nations.
Its board consists of seven donor governments, seven
developing country governments, one representative from the
philanthropic sector, one representative from the for-profit
sector, and two representatives from nongovernmental
organizations.
The second issue. The President called for an integrated
approach to the three diseases, HIV/AIDS, malaria, and
tuberculosis, emphasizing prevention and training of medical
personnel, as well as treatment and care, including the use of
new medicines. We are very pleased to be able to report to you
today the rest of our colleagues on the fund's board are in
agreement with these principles.
The third principle. The President called for financial
accountability. To that end, the board has agreed to put in
place strong financial and programmatic accountability
mechanisms. The World Bank is going to serve as the fund's
trustee and have the responsibility for the financial
accountability.
All partnerships that receive grants will be subject to
independent audits and provide assurances of adequate fiscal
controls. Grantees must be able to demonstrate that their
approaches are having a real impact in reducing mortality and
illness.
Fourth principle. The President wanted scientific
accountability. A plague of this magnitude demands results. So,
medical and public health experts must review all proposals for
their effectiveness.
A 17-member independent technical review panel, composed of
six experts in HIV/AIDS, three in malaria, three in TB, and
five from other disciplines, will evaluate all the proposals
for soundness, feasibility, and financial management.
Finally, the President underlined the importance of
innovation in creating lifesaving medicines that will combat
this horrendous disease. We believe the fund must respect
intellectual property rights as an incentive for vital research
and development.
The fund, gentlemen and members of this committee, is on
track and open for business. Contracts with the World Bank and
the World Health Organization for financial and administrative
services should be finalized within the next couple weeks. We
are also currently looking for an executive director.
Applications are currently being taken for the first round
of partnership grants. The board plans to make decisions on
applications when it meets again in New York City the end of
April.
In short, the President, Secretary Powell, and myself are
delighted that the fund has surpassed even our most ambitious
expectations, and we remain convinced that innovative
approaches like the fund are truly our best hope for curbing
this terrible disease in the developing world.
Of course, there is another important work that is being
performed each and every day, contributing greatly to the
plight against the scourge of HIV/AIDS. My Department is on the
ground currently in 18 countries and will be in 25 by the end
of the year, working intensely with governments, NGO's, and
community groups to build infrastructure, assist in prevention,
and provide direct care and treatment.
Certainly we concentrate on Africa where the disease is
most widespread and at its deadliest. But I am also very
concerned about the Caribbean Basin, which is the second real
troubling spot. This April I will be meeting in Guyana with
Caribbean health ministers to assess the regional status of the
disease and develop new ideas for addressing HIV/AIDS.
The President's fiscal year 2003 budget calls for $144
million for the HHS global AIDS program, separate from the
Global Fund, the same funding level as the current year.
In addition, the budget includes $11 million for
international HIV prevention research at the Centers for
Disease Control and Prevention in Atlanta.
At HHS, we do provide funding and technical assistance to
ministries of health to bolster disease surveillance and
essential laboratory services, including training for
laboratory personnel and purchasing needed equipment. We also
offer technical assistance and funding for a variety of
prevention activities, including voluntary counseling and
testing, preventing, which I think is so important, especially
in Africa, mother-to-child transmission, blood safety, and
sexually transmitted disease prevention. Even our treatment and
care activities, like technical assistance on antiretroviral
therapies, or ARV's, are proving to be vital pathways to
prevention activities.
The team at HHS is assessing ways to be more effective, to
safely and affordably bring these treatments to desperate
countries and their people.
Finally, I would be remiss if I did not mention this
country's commitment to research and practical assistance to
battle HIV/AIDS. President Bush's budget and proposed funding
for fiscal year 2003 for NIH includes $2.77 billion for AIDS-
related research and an increase of $225 million specifically
for vaccine, microbicide, and treatment research. Next year we
will devote more than $420 million to the search for an HIV
vaccine, a 24 percent increase over fiscal year 2002. Of
course, the benefits of research into a cure for HIV know no
boundaries.
Mr. Chairman, members of the committee, we have a
compelling moral interest in helping poor nations fight a
disease that is literally killing millions of their citizens.
Through the Global Fund and our continued dedicated efforts at
HHS and its agencies, we can offer real and effective help to
those in need.
I thank you again, all of you, for your support, your
passion on this very important endeavor. I am sorry I must
depart, but Deputy Secretary Claude Allen will be here to
answer any and all questions you may have.
[The prepared statement of Secretary Thompson follows:]
Prepared Statement of Hon. Tommy G. Thompson, Secretary, Department of
Health and Human Services
Mr. Chairman, members of the Foreign Relations Committee, I am
pleased to be here today to provide an overview of the activities of
the Department of Health and Human Services (HHS) to combat HIV/AIDS
worldwide.
Thank you, Mr. Chairman, for you leadership in responding to this
devastating disease. I want to acknowledge Senators Frist and Kerry for
their work as co-chairs of an important task force organized by the
Center for Strategic and International Studies (CSIS) on America's role
in addressing the global HIV/AIDS pandemic. We at HHS, along with the
U.S. Agency for International Development and the U.S. Department of
State, are working with CSIS to ensure that this two-year project reaps
benefits for both the U.S. and nations around the world hard-hit by
HIV/AIDS.
We all know the dreadful statistics--40 million people worldwide
now living with HIV/AIDS, 3 million deaths from AIDS last year--but
they don't begin to represent the devastation this disease wreaks upon
the developing world. The relentless onslaught of AIDS has the
potential to devastate national economies and social systems, cause
national instability and civil unrest, and thaw the United States and
other developed nations into national and regional conflicts. This
Country has a moral obligation to provide leadership in mobilizing
resources for this international health crisis.
Secretary of State Colin Powell and I serve as co-chairs of the
Task Force on HIV/AIDS created by President Bush, and, under his
leadership, the United States has continued its commitment to battle
HIV/AIDS and other infectious diseases and assist the world in disease
control, surveillance and treatment activities. At HHS, the Centers for
Disease Control and Prevention (CDC), the Health Resources and Services
Administration (HRSA), and the National Institutes for Health (NIH) are
world leaders in research and assistance in the worldwide battle
against this scourge.
Last May 11, President Bush announced the creation of the Global
Fund to Fight HIV/AIDS, Tuberculosis and Malaria. I have the honor of
serving as the U.S. representative to the Global Fund Board, a post I
sought because I believe the Fund can make a real difference. Both
Secretary Powell and I have championed the concept of a trust fund for
these three diseases from our first days in office. And, I might add,
so have many of you on this committee supported this effort. Thank you,
Senator Frist, for your contributions in this area. Why is this idea so
important? Because Africa and other parts of the world urgently need a
public health delivery system that includes prevention of new
infections; treatment for the sick, including the provision of drugs;
and training of medical professionals.
The speed with which the Fund's architecture has been established
is remarkable, and President Bush's founding pledge of $200 million has
produced a 10-fold return on that investment in 9 months. I am pleased
to report to you, Mr. Chairman, that the Fund is now up to just below
$2 billion in promised resources.
The Global Fund held its first Board meeting on January 28 and 29,
2002, in Geneva. Because President Bush asked me to stay in Washington
to meet with Ministers from the newly formed provisional government of
Afghanistan, I was unable to attend. I did, however, address my fellow
Board members by videoconference to announce the President's pledge to
the Fund of an additional $200 million in FY 2003. This latest proposed
contribution would bring the total U.S. contribution to half a billion
dollars, by far the largest donation from any one country or entity,
and over one-quarter of the overall commitments to the Fund.
The establishment of the Fund reflects the principles and
priorities President Bush outlined last May. First, the President spoke
of the need for partnerships across borders and among both the public
and private sectors. The Fund embodies this principle; it is an
independent non-profit foundation under Swiss law, located in Geneva in
space separate from the United Nations and any of its agencies. The
Board of the Fund consists of 7 donor governments, 7 developing country
governments, 1 representative from the philanthropic sector, 1
representative from the for-profit sector, and 2 representatives from
non-governmental organizations (NGOs).
Second, the President wanted the Fund to pursue an integrated
approach to the three diseases that emphasizes prevention, training of
medical personnel, as well as treatment and care. We are pleased that
the rest of our colleagues on the Fund Board have agreed that proposals
may cover prevention, treatment, and care and support in dealing with
the three diseases in ways that local partnerships deem appropriate.
The Board has decided not to institute quotas or percentages for
particular interventions. Prevention is indispensable to any strategy
of controlling a pandemic such as we now face, but so are treatment
activities, including carefully designed programs employing
antiretroviral therapies.
Third, the Fund should concentrate on programs that work. We must
know that the money is well spent, people living with HIV/AIDS are well
cared for, and local populations are well served. To that end, the Fund
Board has agreed that strong financial and programmatic accountability
mechanisms must be put in place. The World Bank will serve as the
trustee for the Fund, and have the responsibility for financial
accountability, including collection, investment and management of
funds, disbursement of funds to countries and programs, and financial
reporting to stakeholders. All partnerships that receive grants will be
subject to independent audits and provide assurances that adequate
fiscal controls are in place. While the Board has not yet decided
exactly how ongoing monitoring and post facto evaluation of grants will
be done, the Board has embraced the principle that funding must be tied
to measurable results. Grantees must be able to demonstrate that their
approaches are having a real impact in reducing mortality and illness.
The President's fourth criterion asks for scientific
accountability. All proposals must be reviewed for effectiveness by
medical and public health experts, because a plague of this magnitude
demands results. The Board will have ultimate decision-making authority
and be accountable for results, but no proposal will move forward
without a rigorous review and endorsement by a group of technical
experts. This 17-member, independent Technical Review Panel, composed
of 6 experts in HIV/AIDS, 3 in malaria, 3 in TB, and 5 from other
disciplines, will evaluate all proposals for programmatic and medical
soundness, feasibility, and financial management, taking into account
local realities and priorities. Indeed, my Department hosted a meeting
of eminent experts from around the world last month, at the NIH's
Fogarty International Center, to develop recommendations to the Fund
Board on the operating procedures of the Technical Review Panel--advice
the Board has accepted.
And, finally, the President underlined the importance of innovation
in creating lifesaving medicines that combat diseases. Our position has
been that the fund must respect intellectual property rights, as an
incentive for vital research and development.
I will not hesitate to admit that much work remains to be done, but
the Fund is on track and open for business. Contracts with the World
Bank and the World Health Organization for financial and administrative
services should be finalized in the near future. We are also looking
for an Executive Director. Proposals for grants need to be written; in
fact, applications are currently being taken for the first round of
partnership grants. The Board plans to make decisions on applications
during its next meeting in April.
So, as I have mentioned, the Fund is open for business and we at
HHS intend to participate actively in helping partnerships to design
their proposals and perhaps even join in monitoring and evaluation if
asked. I see the Fund as a critical opportunity to force better
coordination between bilateral and multilateral programs and to hone
their focus on results and performance.
The President, Secretary Powell and I are all delighted that the
Fund has surpassed even our most ambitious expectations, and we remain
convinced that innovative approaches like the Fund are truly our best
hope for curbing these diseases in the developing world.
HHS PROGRAMS IN THE GLOBAL HIV/AIDS ARENA
My Department's contributions in this arena also include the
efforts of the CDC, HRSA, and NIH. Let me briefly share with you the
very important work that these agencies are performing. The President's
Fiscal Year 2003 budget calls for $144 million for the HHS Global AIDS
Program within the Centers for Disease Control and Prevention, the same
funding level as this year. In addition, the CDC budget includes $11
million for international HIV prevention research.
The Department is on the ground in 25 countries in sub-Saharan
Africa, South and Southeast Asia, Latin America, and the Caribbean,
working intensively with governments, NGOs and community groups to
build infrastructure and capacity, assist in prevention activities, and
provide direct care and treatment.
Most developing nations lack the necessary infrastructure to
address their HIV/AIDS epidemics. Disease surveillance systems and
epidemiology are often nonexistent or greatly compromised, making it
difficult if not impossible to accurately determine at-risk and
infected populations.
HHS provides funding and technical assistance to Ministries of
Health to bolster disease surveillance and essential laboratory
services, including training for laboratory personnel, information
systems program monitoring and evaluation, and purchasing needed
equipment.
We also offer technical assistance and funding for a variety of
prevention activities, including voluntary counseling and testing,
preventing mother-to-child transmission, blood safety, sexually
transmitted disease prevention and care, behavior change
communications, and prevention for populations at high risk for
acquiring or transmitting HIV.
For example, preventing mother-to-child transmission is a priority
for our programs--it is the only proven therapy to avert transmission
from one person to another. HHS works with host countries and other
partners to provide drug therapy to pregnant and post-partum women and
their newborns and promotes replacement feeding strategies to avoid
transmission via breast milk.
Our treatment and care activities focus on tuberculosis and other
opportunistic infections, palliative care, and, more recently,
technical assistance on antiretroviral therapies, or ARVs. Within HHS,
the HRSA and CDC are training local health care providers in safe and
effective patient care and monitoring. Working together, our agencies
are fostering hospital- and clinic-based care programs, as well as
community- and home-based care, for people living with HIV/AIDS.
Let me say a few words about ARV treatment, a subject that has
drawn intense interest here and around the world. ARV treatment is now
more affordable in sub-Saharan Africa than ever, thanks to the
assistance of drug manufacturers in this country and others. While most
developing countries lack the sophisticated medical monitoring
equipment and tests that are adjunct to ARV treatment, my team at HHS
is assessing ways to effectively, safely and affordably bring these
treatments to desperate countries and their people. CDC and HRSA are
also examining the safety and effectiveness of what is known as
``syndrome management,'' which means that diagnosis and continuing care
are based on observable signs and symptoms, rather than sophisticated
lab tests. These tests are not feasible in most countries in which the
Fund will be working, so in such situations, clinicians there have to
manage patient care by look and touch and feel--all skills that can be
taught, and we hope that this effort will be another part of our
contribution to the Fund.
Tuberculosis presents special dangers to those who are HIV-
infected, and HHS currently is assessing a rapid TB diagnostic test
that is effective among HIV-positive persons; the optimal duration of
TB treatment among those who are HIV infected; and the acceptability of
directly observed antiretroviral therapy for HIV. With the Botswana
Ministry of Health, HHS research showed that TB is the leading cause of
death for HIV-positive persons in Botswana and another showed that
saliva tests for HIV can be used on TB sputum specimens, offering an
effective tool for HIV surveillance.
Finally, the importance of research in attacking HIV/AIDS has long
been recognized, and the United States has long been the world's leader
in research and practical assistance to battle HIV/AIDS. President
Bush's proposed FY 2003 funding for the National Institutes of Health
includes $2.77 billion for AIDS-related research, an increase of $255
million that includes expansions for vaccine, microbicide, and
treatment research. Next year, we will devote more than $422 million to
the search for an HIV vaccine, a 24 percent increase over FY 2002.
Last year, the NIH Office of AIDS Research developed the Global
AIDS Research Initiative and Strategic Plan which reaffirmed NIH's
long-standing commitment to international HIV/AIDS research. NIH
supports a growing portfolio of HIV/ATDS research conducted in
collaboration with investigators in developing countries, and supports
international training programs and initiatives to help build research.
Altogether, NIH expects to spend $222 million in FY 2003, an increase
of $34 million over FY 2002, specifically related to international HIV/
AIDS research.
The NIH supports the HIV Vaccine Trials Network (HVTN), composed of
16 domestic and 13 international sites. Directly and through
collaborations with mostly university-based investigators worldwide,
the HVTN also supports laboratory research to ensure vaccines are
efficacious against a variety of HIV strains found around the world.
HHS also supports university-based biomedical and behavioral
research on interventions to prevent sexual transmission, and
strategies to reduce perinatal transmission. The NIH-sponsored HIV
Prevention Trials Network (HPTN) is a worldwide collaborative network
designed to conduct research in 16 international and nine domestic
sites on promising and innovative biomedical/behavioral strategies for
the prevention or reduction of HIV transmission among at-risk adult and
infant populations.
HHS works to strengthen--or create--the research and laboratory
infrastructure of developing countries and train local investigators to
conduct clinical trials of therapeutic and preventive therapies. These
efforts include NIH's Fogarty International Center, which funds
training in the U.S. for scientists from developing countries in
Africa, Asia, Latin America and the Caribbean. Through grants to U.S.-
based institutions, we have also conducted training courses in 60
countries. A new initiative, the Comprehensive International Program of
Research on AIDS, also provides funding directly to foreign
institutions for HIV research that is relevant to the host country.
These grants focus on training of investigators and enhancement of
laboratory and clinical capabilities, and to date, we have made five
such awards.
None of the activities I've just outlined--infrastructure
development and capacity building, prevention activities, care and
treatment efforts, and research--could be accomplished or even
attempted without the integral cooperation and collaboration between
CDC, HRSA and NIH, as well as other parts of the U.S. government, most
particularly USAID. At HHS, I am working to ensure that research and
activities conducted throughout the Department, as well as within other
entities, is complementary and not duplicative, and that it sees
practical application in programs. HHS has a 20-year history of
international intervention research, established CDC field stations,
and many NIH projects worldwide. We strive to keep these efforts
coordinated, and with the help of our other government partners, I
believe we are succeeding.
CONCLUSION
Enormous challenges lie ahead. Just last month, the president of
Family Health International, one of our NGOs, asserted that without
treatment and prevention, AIDS will outstrip the bubonic plague as the
world's worst pandemic. Bubonic plague killed 40 million people in the
14th century. Seven centuries later, we stand at the brink of an even
worse catastrophe. But working together, we can change the course of
the AIDS epidemic. Our research and its practical application have
shown us that prevention, care, and treatment work. It is our
responsibility to ensure that those at risk and those already infected
have the benefits of that knowledge.
We are seldom presented with such clear and pressing need and such
clear means to intervene. The Administration stands ready to contribute
to a comprehensive plan for Africa and other parts of the world where
HIV/AIDS is rapidly expanding.
I thank you again for your support of this important endeavor.
The Chairman. Mr. Secretary, before you depart, if we each
can ask you one brief question. Then we will ask Claude a
number of questions.
Congress appropriated $300 million in fiscal year 2002 for
the Global Fund for AIDS, Tuberculosis and Malaria. The
President's budget for 2003 requests only $200 million. Are you
concerned that, by requesting less than what was appropriated
last year, we are sending a negative signal to the
international community?
Secretary Thompson. No, I am not because at the time that
we said we were going to set up this fund and the President
announced it, he indicated it was only going to be a 1-year
contribution. The second year Colin Powell and myself requested
of the President that there should be some additional money put
into it. The President agreed. $200 million under the
circumstances that we are facing right now I think is a
tremendous, generous contribution.
The fund board, I want to be able to report to you,
Senator, was ecstatic when I was able to announce that we were
going to have an additional contribution this year of $200
million. It certainly would be nice if we had $300 million, but
the $200 million was certainly well received by the board and
by the countries represented at the meeting in Geneva.
The Chairman. The Congress may help you along again this
year.
Secretary Thompson. Thank you, Senator. We certainly would
not turn it down, Senator.
The Chairman. Do you have a question?
Senator Frist. Thank you, Mr. Chairman.
Mr. Secretary, an issue that would probably be useful for
you to comment on before you leave is this idea of
coordination, and we will hear a little bit more about that
later. But as you read through the materials both provided to
us and where a lot of the discussion is, we have the funding
issues, we have this whole linkage between prevention, care,
and treatment, which is important to me, but then also
internally how things are going to best be coordinated with
this administration. We can compare it to the previous
administration, which will be done. But I guess the real
concern is how can we best coordinate who we are going to hear
from today as well as tomorrow in a way that really does most
effectively use the inputs. Everybody will be looking at the
dollar figure as a measure of input, but it is much more
complex than that.
We know we have the group at the cabinet level between you
and the Secretary of State and others. Could you give us some
sort of feel--again, we will explore it in more detail in later
questioning--of both your commitment, but also to the potential
for success of the current organization as both proposed and as
carried out in the last several months?
Secretary Thompson. I think the coordination is
exceptional. This is an issue that both Colin Powell and myself
are passionate about. We have got other members of the cabinet
very much involved in this. Our staffs meet regularly, almost
weekly on the fund. In setting up the fund, they have been
meeting more than weekly. The Secretary of State was
represented at the fund, as I was, and we will continue to do
that kind of cooperation and coordination.
We are also setting up this task force of 17 members which
is going to review scientifically the grants, and we are going
to have a lot of input from NIH and CDC to make sure that that
is done correctly and properly. This is the ongoing thing. I
can assure you that the cooperation and the coordination
between State and the Department of Health and Human Services
are at the utmost and we will continue to do so in the future.
Senator Frist. Again, I know you need to leave.
The issues of the Department of Defense and Labor--clearly,
we need to get all of these efforts together with a real focus.
I guess what I am searching for is some reassurance that
beneath the President of the United States at the highest
level, we have people addressing it with the idea of
coordinating all of it. Obviously, what State is doing and HHS
is the prominent role, but is the structure there to take all
the resources beyond the Global Fund itself?
Secretary Thompson. Absolutely, Senator. The Department of
Defense is very much involved in it with their staff people
with our staff people, and they meet with us. This cooperation
continues and will continue. I can assure you.
Senator Feingold. Thank you, Mr. Chairman. It is good to
see my friend here. I know you have to get going. You and I
have made an art in Wisconsin out of usually agreeing and then
disagreeing agreeably when we need to.
Secretary Thompson. Minimally on the last one, Senator.
Senator Feingold. Usually agreeable.
Of course, I admire all you have done here and in
Wisconsin.
Let me just say, as I said to Secretary Powell last week. I
am afraid I do not see the $200 million as an adequate
contribution in light of what Kofi Annan has called for. I know
you are very sincere in your desire to get after this problem.
I know that having watched you go after health care issues in
Wisconsin. But let me just say that for the record, that I just
do not think it does the job and it does not reflect the
leadership role that our country has to take.
But let me just ask you a different kind of question. What
kinds of positive spill-over effects that are not directly
related to HIV/AIDS but perhaps encouraging or encompassing
other health and development issues are gained when in places
around the world we have a robust U.S. effort to help fight
AIDS?
Secretary Thompson. I think so much, and the Caribbean
Basin is an absolute prime example of that. The Caribbean
nations are coming together recognizing that they have a
serious problem with HIV/AIDS, and the fact that the fund is
set up, they are going to be very much involved in it. They
have asked me to come down and meet with their health ministers
to see how they could play a larger role in being able to stem
the threat of AIDS and the growth of AIDS. That is just a prime
example of what this Global Fund has been able to set up, is
more people interested.
You are going to find the same in China, India, and
Pakistan where the next, probably, threats are going to be for
HIV/AIDS, and Russia. All of these countries now are taking a
look at Africa and saying we have got to make sure that that
does not occur in our country. I am much more cognizant of
that, and the AIDS fund, the Global Fund, is going to allow for
the dollars, hopefully not only to be in Africa, but these
other countries to take a leadership role.
Senator Feingold. Thank you, Mr. Secretary.
The Chairman. Thank you, Mr. Secretary, for being here.
Secretary Thompson. Thank you, Senator.
The Chairman. Mr. Natsios, thank you for your patience.
STATEMENT OF HON. ANDREW NATSIOS, ADMINISTRATOR, U.S. AGENCY
FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC
Mr. Natsios. Thank you, Chairman Biden, members of the
committee, Dr. Frist, and Senator Feingold. Thank you for
leadership on this issue.
I will make some brief remarks and ask that the full
version of my remarks be included in the record, if I could.
We are all familiar with the grim statistics that drive our
policy and our programs in this terrible epidemic. An estimated
40 million are now living with HIV/AIDS. Another 40 million are
expected to become infected in just the next 8 years unless we
act. Economic and social and human costs of the pandemic are
almost beyond reckoning.
One of the first actions I took as Administrator, when I
was confirmed by the Senate in May of last year, was to send a
cable out to our missions to tell them that they needed to
integrate not just in the health sector our program in HIV/AIDS
in our 75 field missions but across all sectors.
We know, for example, in Zambia that more teachers are
dying of AIDS than are being graduated from the teachers
colleges.
We are challenged in agriculture, for example. There are
villages in Uganda where there are no adults alive who are
capable of farming. So, there are only children and elderly
people left. Everyone else has died. So, you are seeing
malnutrition rates that are famine level in some areas not
because there is a drought or a war or a pestilence attacking
the crops or there is a problem of the farmers. The problem is
the farmers have died and there is no one to grow the crops.
So, we have integrated into our programs in a number of
countries that are particularly hard hit a food aid component
to support the AIDS orphans and elderly people who do not have
breadwinners capable of supporting them anymore. We are doing
this in conjunction with the ministries of health and the
ministries of agriculture.
There is nothing more important to the U.S. Agency for
International Development and to me personally than dealing
with the HIV/AIDS pandemic. For the last 15 years, we have led
the effort in AID to fight this dreaded disease. Based on our
experience in more than 50 countries, we have devised a six-
part strategy to combat the pandemic, and I would like to just
go through those six points.
The first is prevention. This has been the cornerstone of
our policy since 1986. The single most important element in
preventing the spread of HIV/AIDS is changing people's
behavior. This is whether you are in the north or the south,
whether you are in the United States or whether you are in
eastern Europe or Africa, especially among 15- to 24-year-olds.
Young people are often difficult to reach and we have had
success in crafting messages that they embrace and that will
change their behavior.
In Zambia, for example, our work helped delay the age of
sexual debut by 2 years, and as a result, the prevalence rates
in this age group have now dropped by 50 percent in that
country. The same thing has happened in Uganda.
Our programs stress abstinence and faithfulness, working
through our faith-based and community-based partners. We have
seen in Uganda how effective partnerships can be between
political and religious leaders, and we have given them our
strong support.
When I traveled with Colin Powell last May on his first
trip to Africa, I asked in each country to meet with religious
leaders from all denominations. I had an interesting
conversation with the deputy head of the Islamic Doctors
Association of Uganda, two Catholic bishops, an Anglican
bishop, and a Pentecostal pastor who explained to us what they
were doing in their parishes and in their mosques to combat the
epidemic. It is very interesting. Since that lunch we had, they
had not been actually talking to each other in an organized,
aggressive way, and the fact that they had very similar
problems and very similar approaches to this led to a
successive set of meetings that now are integrating the
religious community in Uganda.
The second strategy that we are focusing on beyond
prevention is treatment, care, and support. While there is no
cure yet, we can help people survive longer by treating
opportunistic infections like tuberculosis and helping
countries build up their health care systems. As the cost of
antiretrovirals declines--and there has been a dramatic drop in
the last year in these costs--our funding increases, we are now
considering incorporating ARV's into our care and treatment
program. Accordingly, we are now finalizing arrangements for
four sites in sub-Saharan Africa where the health
infrastructure permits their use, and we hope within the next
few weeks we will be announcing agreements with the ministries
of health in those four countries to begin the new
antiretroviral therapies.
The third part of our strategy involves the millions of
children who have lost parents to HIV/AIDS. I have been to
Africa dozens and dozens of times over the last 13 years and I
have seen the faces of these children. When I was with an NGO,
World Vision, we cared for 6,000 AIDS orphans in Uganda with a
World Bank loan that was organized through the Ugandan
Government. Of course, Uganda was one of the hardest hit
earliest. The Ugandan Government has been very aggressive in
combating the epidemic. But there are many things that need to
be done in upbringing of children who are AIDS orphans.
We now have 60 projects in 22 countries that provide
children with food, shelter, clothes, school fees, counseling,
psychological support, and community care.
The fourth element of our strategy involves surveillance
and monitoring. We are always learning new things about HIV/
AIDS. There are now at least 15 different subtypes of the
virus. One of our programs funds the Centers for Disease
Control and Prevention research to understand better the
dynamics of transmission.
Through the Census Bureau, we have been tracking HIV/AIDS
data for years. Our figures are the standard now that are used
in the international community. Nevertheless, we must keep
monitoring the disease so we can track our programs and improve
our strategies.
The fifth component is encouraging governments and
multilateral institutions to increase their financial
commitments to fight the pandemic. The United States now
provides one-third of the total world's resources to fight the
HIV/AIDS pandemic, four times what the next largest donor
gives. We supply one-fourth of the UNAIDS fund and one-third of
the Global Fund to Fight AIDS, Tuberculosis, and Malaria. I
might add that USAID has staffed with our staff, that we
secunded the initial executive secretariat of the trust fund to
work out the technical details of managing this. In addition,
we have contributed $1 million toward the management of the
fund.
Finally, there is no substitute for leadership. Whether the
issue is HIV/AIDS, democracy, or building free markets and
institutions, the most important factor in development is the
quality of national leaders and their commitment to their
people's well-being. So, the sixth part of our strategy is to
encourage and support national leaders to become strong
advocates for programs that educate people about the disease
and what they must do to prevent its spread. I have met with at
least a dozen presidents and heads of states in Africa, in
particular, but also now in other areas of the world, Central
America for example, who are now leading the fight in their
countries.
I would commend in particular the President of Tanzania.
President Museveni was the first African leader in Uganda to
lead the fight. The President of Senegal, the President of Mali
has been a leader. The President of Mozambique, and Dr.
Mocumbi, who is the Prime Minister of Mozambique, a friend of
mine, is a medical doctor, and he has been leading the charge
in Mozambique against the spread of the disease. I just met
Friday with the President of Malawi who has also becoming very
aggressive and very public in his champion of the effort to
defeat the disease.
USAID was the first U.S. agency to fund international HIV/
AIDS programs. Our program budget grew each year until the
early 1990's and then leveled out for several years. It is now
growing significantly again and will reach $435 million this
fiscal year for bilateral programs. This does not include the
$100 million that we are giving next fiscal year for HIV/AIDS
or the $50 million we gave in the current fiscal year.
By the end of this fiscal year, we will have spent in AID
$2 billion on HIV/AIDS prevention and care.
For fiscal year 2003, I am proud that President Bush has
requested $540 million for HIV/AIDS programs within the
bilateral program of AID, a five-fold increase since 1999.
Secretary Powell has placed this crisis at the top of our
foreign policy agenda in the developing world and has been one
of the leaders worldwide in focusing the world's attention on
this terrible disease.
Thanks to the White House and the leadership of the
Congress, we have resources now to begin making a difference on
a global scale. Much of the period during the 1990s, Mr.
Chairman, we experimented with various programs. Some of the
programs were successful in driving the infection rate, some
were not. What we are now capable of doing, because of the
level of resources we have been giving, is to scale up these
pilot programs to a national level. We know that they work.
After you try them in three countries and they have the same
result in all three countries, you know that if you extend it
worldwide in the developing world, it will be successful.
We have been working carefully with the ministries of
health, and there is now a consensus in the developing world
among the ministers of health that we work with on a daily/
weekly basis with our health offices and our mission directors,
what works, what does not work, where we need to focus our
attention.
One of our most important management tools is to get more
impact from every dollar we spend. This means spending more
money in the field and cutting back here in Washington. Funding
for country programs, therefore, will grow from $192 million to
$398 million in our next budget, increasing the percentage we
spend in the field from 61 percent to 78 percent. So, not only
will we have more money for prevention, care, and treatment and
children's programs, but more of it will be spent where it is
needed the most.
We are increasing our HIV/AIDS priority countries from 17
to 23, adding substantially to what we spend in each of them.
We have listened carefully to what Congress has told us. Sub-
Saharan Africa continues to be our highest priority. Our new
plan significantly increases funding for this region.
We are also focusing more strategically on hot spots where
the epidemic is expanding and creating a central Condom Fund to
consolidate our acquisitions, save money, and double what we
purchase in terms of the volume of condoms in this next year.
Before closing, I would like to thank the committee for
approving the nomination of our new Assistant Administrator for
the Bureau of Global Health, a new bureau that I created to
focus attention of our program on the health issue. The person
that the President nominated who is now in place, Dr. Anne
Peterson, is a medical doctor herself. She spent 6 years in
Africa working on HIV/AIDS programs in Kenya and Zimbabwe and
on other health problems. So, we now have a professional who
has been confirmed by the Senate who is in charge of our health
programs worldwide. We are fortunate to have her.
We are in a race against time, Mr. Chairman, with a virus
that shows no signs of letting up. The war on AIDS will be a
long and arduous one, but it will be one that we ultimately
will win. Thank you.
[The prepared statement of Mr. Natsios follows:]
Prepared Statement of Hon. Andrew S. Natsios, Administrator, U.S.
Agency for International Development [USAID]
Chairman Biden, members of the Committee, thank you for inviting me
to speak today on this topic of singular importance.
I would like to begin by thanking this Committee for supporting our
efforts to address HIV/AIDS. Your cooperation and your understanding of
the magnitude and complexity of the pandemic has helped USAID maintain
its leadership in the fight against this terrible disease. There are
many aspects to the disease, the consequences of which are felt every
day by millions of people throughout the world. We look forward to
working with you closely as you draft a new authorization bill for HIV/
AIDS this year.
The U.S. Agency for International Development has a budget of $8.7
billion this fiscal year and programs in more than a hundred countries,
but there is nothing more important to our agency--and to me
personally--than dealing with HIV/AIDS.
Time is not on our side. Since becoming USAID Administrator, I have
made it a priority to streamline our procedures, so that more of our
program money goes directly to the field and it gets there faster. We
are also increasing the number of priority countries we focus our
resources on, strengthening our regional programs and taking steps to
improve our accountability.
You all know the grim statistics that drive our policy. Twenty-two
million people have already died of HIV/AIDS. Ten percent of that
number 2.3 million people--died last year in sub-Saharan Africa alone.
Thirteen million African children have already lost a parent to the
disease, and we expect that figure to triple by the end of this decade.
The cost--to individual citizens, to families, communities, and
countries--is almost beyond reckoning.
An estimated 40 million people are living with HIV/AIDS today. Far
too many of them will die unless a cure is found--and none is yet in
sight. Ninety-five percent of those who are infected live in the
developing world. A third of them are between the ages of 15 and 24.
Many do not even know they are infected or what to do if they are.
Every six seconds another person gets the virus. By the end of this
decade, another 40 million people may become infected.
Ten years ago no one anticipated the speed at which the pandemic
would grow or the way it would spread through different sectors of
society. HIV infection has reached alarming levels in southern Africa.
One-third of the adults in Botswana, Lesotho, Swaziland and Zimbabwe
are living with it now. In South Africa, one adult in five is infected.
For many years, prevalence rates in West Africa were lower than
elsewhere on the continent, but now we are seeing worrisome increases
in infection rates in countries like Nigeria and Cameroon.
It is not just sub-Saharan Africa that is affected. Infection rates
in some parts of the Caribbean are now the second-highest in the world.
In Haiti and the Dominican Republic, for example, HIV testing suggests
that more than one adult in 12 is living with the virus.
It is not just the millions who are infected today, but the speed
at which the infection rate is growing that makes it so threatening. In
Russia and the republics of the former Soviet Union, the rate of
increase in HIV/AIDS cases is the highest in the world. In Russia
alone, the number of officially recorded cases rose from just under
eleven thousand in 1998 to 147,000 by late last year, and some suspect
the numbers could be considerably higher.
In Asia, where prevalence has generally been low, there are signs
of troubling change. India now has some four million people with the
virus. In Indonesia, where HIV among prostitutes was once virtually
non-existent, the infection rate among this group is now as high as
26%. Prevalence has risen very quickly among these same groups in
Vietnam: in Ho Chi Minh City, over 30 percent of them are now HIV
positive. Prevalence among injecting drug users is over 50 percent in
some Vietnamese cities.
Apart from the individual human costs, the economic, political and
social consequences of these facts are staggering. Clearly, HIV/AIDS is
not just a health problem. In some parts of the world the pandemic is
threatening the very fabric of society. There are places in Malawi,
Uganda, Zambia, and Zimbabwe, for example, where HIV/AIDS has taken
such a toll on farmers and farm workers that we are seeing alarming
rates of malnutrition, even near famine-like conditions where food
supply should be abundant and the people healthy.
It is no secret either, that population is declining in some
countries, in part because women are dying before they live long enough
to bear children. By the end of this decade, average life expectancy in
the countries hardest hit by HIV/AIDS could be less than 40 years--
comparable to what it was one hundred years ago.
Studies in Cameroon, Kenya, Swaziland, Tanzania, Zambia, and other
sub-Saharan countries suggest that gross domestic product could be
reduced by as much as 25 percent over a 20-year period. Some African
companies have estimated the cost of HIV/AIDS in terms of health care,
sick days and training new hires is reducing their productivity by 5
percent annually, and profits by 6 to 8 percent.
AIDS is like few other diseases, in that it strikes young adults
most frequently. Young women are particularly vulnerable, for both
biological and social reasons. Indeed, women below the age of 24 appear
to be six times more likely to be infected than men their age. We are
now seeing girls being infected at ever-younger ages.
HIV/AIDS hits people in their most productive years, leaving
children and the elderly to do increasing amounts of the work upon
which society depends. That means fewer children can attend school,
less efficient farms and businesses, and more stress on local
governments that must divert already inadequate resources away from
development to health care and related services. A generation risks
being lost. More and more children are acting--or trying to act--as
caretakers for other children or for the elderly, and more and more
families are forced to divert badly needed income for care and
treatment of the sick.
As Secretary Powell said on World AIDS Day, ``If humankind is to
realize the great potential that the 21st century holds for prosperity
and peace, the global response to this crisis must be no less
comprehensive, no less relentless, and no less swift than the AIDS
pandemic itself.''
USAID'S HIV/AIDS STRATEGY
There are six parts to our HIV/AIDS strategy: prevention; care,
treatment and support; working with children affected by AIDS;
surveillance; encouraging other donors; and engaging national leaders.
First: prevention. This has been the cornerstone of our policy for
the past 15 years. The single most important aspect of our prevention
strategy is reaching young people and changing their behavior. Young
people are often difficult to reach, but we have had some notable
success working with local organizations to craft a message that they
can embrace. In Zambia, for example, our work with 15- to 19-year-olds
has helped delay the age of sexual debut by two years. As a result,
HIV/AIDS prevalence rates have dropped by 50 percent in this group.
We also stress the importance of abstinence and faithfulness
through our faith-based and community-based partners. We have seen in
Uganda how effective a partnership of political and religious leaders
can be and we have given them our strong support. And, of course, we
distribute over 300 million condoms a year throughout the world.
We are also expanding our programs that prevent mother-to-child
transmission of HIV/AIDS through the use of antiretroviral medication.
Currently, we have them in Kenya, South Africa, Uganda, Ukraine, and
Zambia.
Another important aspect of our prevention strategy is voluntary
counseling and testing, for our experience has shown that those who
know their HIV/AIDS status--and receive counseling if they are
infected--are much more likely to behave responsibly than those who do
not. They also make for very good counselors and care givers. So we
work with them in programs all over the world. In the Dominican
Republic, for example, we fund groups of HIV/AIDS-infected people who
support 5,000 others who have the disease, as well as 19 self-help
groups.
The second part of our strategy is the care, treatment, and support
of those infected by the virus. While there obviously is no cure yet,
we can help people survive longer by treating opportunistic infections
such as tuberculosis and continuing to help countries build up their
health care systems and infrastructure. Although prevention remains our
primary focus, we have been providing funding for the care and
treatment of people living with HIV/AIDS since 1987. Currently, we have
25 such projects in 14 countries. One example is Cambodia, where USAID
funds an organization known as KHANA which organizes government nurses
and staff from non-governmental organizations to provide home-based
care.
As the cost of antiretrovirals (ARVs) has declined and the funding
we have available has increased, it is now possible to consider
incorporating ARVs gradually and selectively into our care and
treatment programs. Accordingly, we have begun identifying potential
sites in sub-Saharan Africa where the health care infrastructure is
sufficiently advanced to permit their use. There continue to be a
number of challenges we must address before we can make full use of ARV
therapies, however. Among these are the adverse interactions between
ARVs and TB medication and the need for basic laboratory services.
The third part of our strategy involves attending to the millions
of children who have lost parents to HIV/AIDS or are at risk of doing
so. I have been to Africa many times, and I have seen the faces of
these children. The fact is we cannot give them what they need the
most--their parents alive and well. But we can do our best to help
them, and we are. We now have 60 projects in 22 countries that provide
these children food, shelter, clothing, school fees, counseling,
psychological support and community care.
In Romania, for example, USAID is sponsoring a modem pediatric AIDS
Center that gives HIV-infected children and families care, support, and
counseling. In South Africa, we are working with the Nelson Mandela
Children's Fund to provide microfinance loans and community initiatives
to support orphans and vulnerable children. This targets 250,000
affected children.
The fourth part of our strategy is surveillance. The nature of the
HIV/AIDS pandemic is that we are always learning new things about it.
Just as people's behavior differs from region to region, so, too, does
the pathology of the infection. There are now at least 15 different
sub-types of the virus that have been identified, and we fund research
with the Centers for Disease Control and Prevention to understand
better their dynamics of transmission.
Through our program with the Census Bureau, we have been tracking
HIV/AIDS data for many years, and our figures have become the standard
for the international community. But it is important that we keep
monitoring the disease, tracking our programs, measuring their impact,
developing new strategies with our partner organizations and
coordinating our policies with other donor nations. This is the fourth
part of our strategy and one that we must continue to expand.
The fifth component is our ongoing effort to encourage other
governments and multilateral institutions to increase their financial
commitments to the fight against the pandemic. The United States
provides one-third of the world's resources to fight HIV/AIDS, four
times what the next largest donor gives. We also supply one-fourth of
the UNAIDS' funds and are the largest donor to the new Global Fund to
Fight AIDS, Tuberculosis and Malaria. We have been able to leverage
funding from other governments and foundations as well as coordinate
strategies with other donors to get the maximum benefit from our
programs and avoid duplication.
Finally, there is simply no substitute for leadership. Whether the
issue is HIV/AIDS or democracy or building free markets and
institutions, the single most important factor in a country's
development is the quality of its leaders and their commitment to their
people's well-being. As our experience in countries like Uganda clearly
show, leadership can make an important difference. So the sixth part of
our strategy is to encourage national leaders to become strong
advocates for programs that educate people about the disease and what
they must do to prevent its spread. In addition, we work with host
governments to develop HIV/AIDS policies, to make the best use of their
resources, and to utilize state media to broadcast prevention messages.
USAID'S COMMITMENT TO FIGHTING HIV/AIDS
USAID has been the U.S. Government's lead agency on fighting
international HIV/AIDS for more than 15 years. For many years, we were
this country's only federal agency that devoted resources to fighting
the pandemic internationally.
In 1986, we provided funding for the global program on AIDS
launched by Dr. Jonathan Mann at the World Health Organization. Our
HIV/AIDS budget that year was just over $1 million; but our commitment
has grown considerably since then, By FY '01 our budget had risen to
$433 million and in FY '02 it reached $535 million. This means that by
the end of this fiscal year, we will have spent more than $2 billion on
HIV/AIDS prevention and care programs. This does not count additional
funds that other branches of the U.S. Government are spending on
programs and research.
For fiscal year 2003, I am proud to say that President Bush has
requested $640 million for our HIV/AIDS programs. This represents a
five-fold increase since 1999.
Over time, USAID has developed an expertise on international HIV/
AIDS programs that is second to none. Ours is hands-on knowledge,
derived from years of running programs in over 50 countries. One thing
we know for certain: fighting AIDS requires a wide range of technical
experts. It calls for pharmacists, teachers, social scientists,
specialists in behavior change, lawyers, as well as doctors, care
givers, and epidemiologists. We have learned many lessons that have
helped us make a difference in people's lives, and we have no intention
of stopping now. We are continually looking for new ways to make a
difference, to shape new programs, identify promising new techniques
and innovative strategies. And as we learn, we are constantly
evaluating ourselves and our programs so that we can fine-tune our
approach.
It is important that we continue to provide a direct link between
ongoing research and those who live in the developing world. An
essential part of our strategy, therefore, is to fund the science. Our
spending in fiscal years 2001 and 2002, for example, will total $16
million for vaccine research and another $27 million for the
development of microbicides.
We fund applied research in 21 countries. Among the things we are
working on are ways to reach youth--the most vulnerable group--with
effective messages about HIV transmission and prevention; integrating
HIV testing into existing health care procedures; improving programs to
prevent mother-to-child transmission prevention; providing home and
community-based care for those affected by the disease; and reducing
the stigma of infection, so that those who have the virus can make use
of the services that are available.
In addition, we monitor research that may have practical uses in
the field. We test the findings in small pilot projects and adapt them
for use in countries where they seem most promising. Then we develop
the systems, protocols and training necessary to use these approaches
on a larger scale so that we can help countries reach as many people as
possible.
TECHNOLOGICAL INNOVATIONS
Over the years, USAID has introduced many techniques and strategies
that would later become standard practices across the world. In the
late 1980s, USAID supported the development of simple HIV tests to
ensure the safety of blood transfusions. This prevented countless new
infections and enabled hospitals to ensure the quality of their blood
supplies.
In 1991, a study in Tanzania showed that treating other sexually-
transmitted infections (STIs), such as syphilis and chancroid, reduced
HIV transmission by almost a half. After that, treating STIs became a
standard part of our HIV/AIDS prevention programs. Four years later we
began a new approach known as periodic presumptive treatment. This
entails foregoing lab tests, which are costly and time-consuming, and
giving medication to high-risk populations, such as truck drivers,
migrant workers and prostitutes on a regular basis, an approach which
has been shown to reduce STIs significantly.
In 1995 USAID supported a three country study that demonstrated
clearly what many had long suspected--that those who voluntarily
undergo counseling and testing and know their HIV/AIDS status are much
less prone to engage in unsafe behavior. In many cases, these
individuals become powerful voices within their communities. In Uganda,
for instance, where great strides have been made in lowering the
prevalence of the disease, more than 500,000 people used these
services. We now have voluntary counseling and testing programs in over
20 countries.
In 1996, USAID played a key role in the creation of UNAIDS. While
UNAIDS has been a forceful advocate for HIV/AIDS funding, their
function is not to fund services on the ground. That is done by
individual donor nations such as the United States, Japan, Canada,
Australia, and the Western Europeans.
In 1997 USAID was one of the first organizations to recognize the
essential role that care, treatment and support plays in enhancing
prevention efforts. Working with the World Health Organization (WHO)
and UNAIDS, we developed the concept known as the ``prevention to care
continuum.'' This has now become universally accepted. Prevention, care
and treatment are all critical components of an effective HIV/AIDS
program. Care enhances our prevention efforts, reduces secondary
epidemics like TB, and keeps people alive for their families and
communities.
In 1998 USAID issued ``Children on the Brink,'' a paper that
focused attention on the plight of AIDS orphans. This was the first
time that many statistics about these children were published, and it
helped reveal another aspect of this terrible pandemic. Since then, we
have launched support projects for HIV/AIDS orphans in 22 countries. An
updated edition is expected this summer.
The first treatments that reduce mother-to-child HIV transmission
were developed in this country in 1994, but at the time the process was
very expensive and hard to duplicate in much of the developing world.
By 1999, however, new studies revealed that Nevirapine could provide a
much more cost-effective approach. The drug, which requires a single
dose each for the mother and the newborn child, costs only about a
dollar. And better yet, the drug's manufacturer, Boerhinger Ingelheim,
is making it available at no cost to developing countries.
PROGRAMS THAT MAKE A DIFFERENCE
Unlike diseases that can be treated by vaccines or antibiotics, the
best strategy available to prevent the spread of HIV/AIDS is to change
people's behavior. Doing this is never easy, especially when it comes
to a subject as delicate and private as human sexuality. But we have
learned techniques that work. Thirty million people over the last five
years have received face-to-face counseling that has brought home their
own risks and taught them how to protect themselves. We are confident
that this has saved millions of lives.
Our mass media campaigns have reached hundreds of millions. And our
annual condom distribution and social marketing activities probably
avert a half a million infections every year.
In the early 1990's, we worked with the Government of Thailand to
make it national policy that condoms be used in all the country's
brothels. This helped decrease HIV and STI transmission rates
substantially and has made Thailand one of the world's success stories.
Lessons learned in Thailand are now being practiced within Cambodia and
the Dominican Republic.
HIV prevalence among pregnant women in Cambodia declined by 28
percent from 1997 to 2000, and the infection rate among sex workers
dropped by 57 percent between 1998 and 2000. In the Dominican Republic,
too, condom use among the most vulnerable populations has increased,
and men are reporting fewer sexual partners.
Another success story is Zambia, where as I noted above, HIV
prevalence has fallen significantly among young people. A USAID-
supported youth mass media campaign stressed abstinence for those who
are not sexually active and condom use for those who are. The campaign
also produced five television advertisements and an award-winning music
video entitled ``Abstinence is Cool.'' About 70 percent of the young
people who live in the cities and 37 percent of those who live in rural
areas reported seeing at least one of the ads.
Thanks to the support we have received from the White House and the
Congress, we finally have the resources to begin making a difference on
a global scale. As a consequence we are stepping up the war against the
HIV/AIDS pandemic. I have already taken the first steps, upgrading our
HIV/AIDS division to an office and putting it in the heart of our new
Bureau for Global Health. Some of you may have already met the
assistant administrator of that bureau, Dr. Anne Peterson. She is a
medical doctor who has spent six years in Africa working on HIV/AIDS
and other issues.
One of my most important management goals is to get more impact out
of every dollar we spend. This means spending more of our resources in
the field--where it is needed--and less of it here in Washington.
Resources for field programs will increase from $192 million, or 61
percent, of our budget last year, to $389 million, or 78 percent, of
our budget next year. So not only will we have more money to spend on
prevention, care and treatment and children's programs, but more of the
money will be spent directly on them.
We are also increasing our HIV/AIDS priority countries from 17 to
23 and adding substantially to what we spend on them. We have listened
carefully to what Congress has been telling us. Sub-Saharan Africa
continues to be our highest priority. Our new plan increases funding to
it substantially.
We will also work to strengthen our regional programs so we can
focus more strategically on regional ``hot spots'' where the epidemic
is expanding rapidly, as well as migrant populations and cross-border
interventions. We will be convening regional workshops to familiarize
our staff with our new strategies. And we are working to establish a
comprehensive monitoring and reporting system that will improve our
ability to track the programs in our 23 priority countries.
We are also in the process of creating a central Condom Fund to
consolidate our acquisition, save money, and get them to the field more
quickly. This should allow us to double the number of condoms we
purchase.
In addition, we are working with WHO, CDC, NIH and country partners
to simplify and standardize treatment protocols. We are assessing the
health care infrastructure in a number of countries to determine what
needs to be done to introduce antiretroviral therapy. At the same time,
we will continue to support and expand those low-tech but very
effective services that improve the quality of life for people affected
by this epidemic. These include home- and community-based care,
treating tuberculosis, providing microfinance assistance, supporting
families caring for additional children, and supporting organizations
of people living with AIDS, giving them a voice and a seat at the
table.
Last May, President Bush was the first to announce a contribution
to the newly-formed Global Fund to Fight AIDS, TB and Malaria. To date,
the U.S. has pledged $300 million, and President Bush requested an
additional $200 million for the next fiscal year. Approximately half of
that will come from USAID.
We have been actively involved in the formation of the Global Fund
from the beginning, and participated in the first official meeting of
the Fund at the end of January. USAID loaned staff to the Fund's
Transitional Secretariat for six months, provided $1 million for
Secretariat operations, and was key in providing technical guidance on
AIDS issues during the formation of the Board.
We believe our experience and programs can serve as useful models
for the Global Fund and can complement its aims.
In conclusion, I would like to emphasize once again how committed
USAID is to stepping up the war against HIV/AIDS. We are in a race
against time with a virus that shows no sign of letting up. As the rate
of infection is still growing in many places, we have to redouble our
efforts, speed up our processes, and constantly seek to refine our
approach. While we have recorded some success stories, there are still
many others that must be written. The war on AIDS will be a long and
arduous one, but it is a war that we can, and ultimately, will win.
Thank you.
The Chairman. Thank you very much.
Madam Secretary.
STATEMENT OF HON. PAULA DOBRIANSKY, UNDER SECRETARY FOR GLOBAL
AFFAIRS, DEPARTMENT OF STATE, WASHINGTON, DC
Ms. Dobriansky. Thank you, Mr. Chairman, members of the
committee. On behalf of Secretary of State Colin Powell, who is
testifying elsewhere on the Hill on the State Department's
budget today, I am pleased to appear before you to discuss one
of the Bush administration's highest priorities, the global
fight against HIV/AIDS, tuberculosis, and malaria.
As you very correctly pointed out in your opening remarks,
the spread of HIV/AIDS continues unabated with some 8,000
deaths per day and 5 million new infections last year alone.
There are 40 million people living with HIV/AIDS worldwide,
nearly 3 million of whom are children under 15 years of age. We
simply have no choice but to confront this pandemic.
Mr. Chairman, our battle against the HIV/AIDS, TB, and
malaria pandemics is made easier by the steadfast support we
have received from you and your colleagues on both sides of the
aisle and in both houses of Congress. Simply holding this
hearing today is critical in raising awareness and manifests
how both branches of Government can and must work together if
we hope to staunch the spread of these diseases, treat their
victims, and find cures.
Two of your committee colleagues, Senators Frist and Kerry,
deserve, I may say, special mention for their involvement with
the work done by the Center for Strategic and International
Studies on HIV/AIDS, work in which my colleagues and I have
participated very directly and from which I know not only
myself but others have benefited greatly. Many of your
colleagues in Congress, including those on this committee, have
played vital roles in backing the bilateral programs
implemented by USAID and the vital work done by HHS and its
agencies, as well as in facilitating the start-up of the Global
Fund to Fight AIDS, Tuberculosis, and Malaria.
Mr. Chairman, I want to underscore this administration's
commitment to this battle. Under the leadership of President
Bush, the U.S. Government continues to be the global leader in
the fight against HIV/AIDS. As Secretary Thompson referred to
in his testimony, President Bush made the first pledge to the
Global Fund by any government, and his request of an additional
$200 million for the fund in fiscal year '03 sets an example
for other governments and potential donors. The half billion
dollars this administration has committed to the Global Fund
constitute the world's single biggest source of support.
Last fall, the President came to the State Department for
the Forum on Africa Growth and Opportunity Act and talked to
the participants about AIDS in Africa. He included the fight
against AIDS in his speech to the UN General Assembly. Also, he
established a cabinet task force on HIV/AIDS, which is co-
chaired by Secretaries Powell and Thompson, to coordinate his
administration's efforts and to signify its high level of
engagement. Like Secretary Thompson and Administrator Natsios,
Secretary Powell has invested vast amounts of time and energy
to this cause, for instance, having toured Africa last May
where he saw firsthand the devastation these diseases have
caused there.
In fact, last fall, to bolster and coordinate our fight
against infectious diseases, Secretary Powell created a new
Deputy Assistant Secretary position for International Health
and Science in the Bureau of Oceans, Environment, and Science,
a post filled by Dr. Jack Chow, who is here with me this
morning. Dr. Chow was our chief representative at the
negotiating sessions last fall of the transitional working
group, the precursor to the Global Fund, with a delegation that
included representatives from HHS, USAID, and the Department of
the Treasury.
Dr. Chow spearheads an interagency working group that meets
frequently to ensure that the U.S. approach is fully
coordinated. This working group got started last fall in
connection with the work on the Global Fund and will continue
to meet on the fund as well as on bilateral programs. Indeed,
the State Department works closely with other Government
agencies and Departments, including USAID, HHS, CDC, and
others, which contribute their own widely sought technical
support, expertise, and experience.
Let me say a few words about the fund. The Bush
administration views the creation of the Global Fund to Fight
AIDS, Tuberculosis, and Malaria, which held its first board
meeting last month, as one of the most promising steps in this
2-decade-old battle. The Global Fund, established as an
independent foundation under Swiss law and based in Geneva, was
created in record time by an unprecedented public/private
partnership and thanks to the tireless efforts of a number of
people here in this room today.
In approaching the establishment of the Global Fund, the
President outlined a vision for what was needed for it to be
most effective. All of the parameters we set forth during the
negotiations on the fund were agreed to, and I would like to
just share a few with you.
That the fund be based on a public/private partnership.
That the fund scale up the international response to these
diseases with an approach that would complement, not compete
with, existing international and bilateral programs.
That it promote an integrated approach, emphasizing
prevention in a continuum of treatment, care, and response.
That it operate according to principles of proven
scientific and medical accountability.
That it focus on best practices proven to work in the
field.
That it involve developing countries in the design and
operation of the fund and in the projects to ensure ownership.
That it ensure respect for intellectual property rights as
a spur to research and development.
We are pleased that the preparations leading to creation of
the fund, as well as the operations of the fund itself, have
been conducted in an open and transparent manner, with a strong
emphasis on attaining financial and program accountability.
Along with governments, NGO's, foundations, and the private
sector were represented in the transitional working group that
met three times last fall to establish the principles and
operating mechanisms for the fund. Some of those participants
continue to serve on the fund's board. Secretary Thompson
already outlined the 18 voting members, including seven donor
countries, seven developing countries, two NGO representatives,
one foundation representative, and one for-profit private
sector representative. In addition, UNAIDS, the World Health
Organization, and the World Bank, as the fund's fiduciary
agent, as well as a third NGO serve as nonvoting members.
I am delighted that the fund's board issued a call for
proposals just last week and hopes to announce the first grant
awards at its next meeting in April, which will be held in New
York City. The board will have the final decision making
authority on proposals. It will benefit from a technical review
panel composed of experts in a variety of disciplines and
serving in their independent capacities to review all proposals
to ensure that submissions are based on best practices and are
technically sound.
Proposals will come from partnerships of Government, NGOs,
and the private sector through what is called a country
coordinating mechanism. Significantly, where such partnerships
are not possible, NGOs will have the right to submit proposals
directly to the fund. Proposals from those countries and
regions with the highest burden of disease and the least
ability to bring financial resources to bear will receive
highest priority. Proposals from countries and regions with a
high potential for risk will also receive strong consideration.
Because HIV/AIDS, TB, and malaria know no boundaries, the
fight against them, to be successful, must be waged on a
worldwide scale. Accordingly, recipients of fund grants will
not be confined to one region of the world at the expense of
other regions. Nor will the fund focus on just one disease. As
the name of the fund itself reveals, it targets AIDS,
tuberculosis, and malaria. There are no set limits on how much
of the fund's resources will go toward either a particular
region or toward one of the three diseases. The U.S. approach
has been to afford the fund's board maximum flexibility in
responding to proposals that come in from around the world.
The Global Fund is to complement significant bilateral
programs of the United States as well as the bilateral programs
of other countries and the efforts of the UN agencies and the
World Bank. It is not a substitute for these efforts that are
already underway. It will dispense the money it provides as
grants, not loans. While the fund will be fully independent of
the UN, it will benefit from and work with the UN agencies
charged with improving global health, such as the World Health
Organization and UNAIDS.
Of the $1.9 billion that has been pledged to date, some
over several years, we expect $700 million to be available this
year for disbursal. As you know, our contribution totals $300
million so far and President Bush's budget proposes adding
another $200 million for next year.
The President announced the initial U.S. pledge last May in
a Rose Garden ceremony with Secretary-General Kofi Annan, to
whom we do owe a debt of gratitude for his tireless work, as we
do to Dr. Peter Piot, who will be testifying next. At that
ceremony, the President stated: ``The devastation across the
globe left by AIDS, malaria, and tuberculosis, the sheer number
of those infected and dying is almost beyond comprehension.
Only through sustained and focused international cooperation
can we address problems so grave and suffering so great.'' In
sum, that is why the fund is so important.
In conclusion, Mr. Chairman, there is, of course, a great
deal of work still to be done, and the best indicators of our
success will be the decline in deaths from and spread of AIDS,
TB, and malaria. We cannot afford to take a deliberate approach
for one simple reason: the fight against these diseases cannot
wait.
AIDS alone has left at least 11 million orphans in sub-
Sarahan Africa, and in several African countries, as many as
half of today's 15-year-olds could die of AIDS. By 2010, the
Asia/Pacific region could surpass Africa in the number of HIV
infections. The fastest rate of HIV infection in the world is
in Central and Eastern Europe and Central Asia. The disease is
also spreading in regions close to home, particularly Central
America and the Caribbean. Tuberculosis claims almost half a
million people a year in India alone. Malaria, long thought to
kill a million people a year, mostly young children, may
actually kill up to 2.7 million people each year.
Time is not on our side and we must resolve to move as
expeditiously as possible. Human lives depend on our ability to
get the funding underway in an effective and successful
fashion. Congress's role in this endeavor is critical, and that
is why this hearing is so timely and so important.
Thank you.
The Chairman. Thank you very much.
Obviously, we cannot fund a good audio system in this room.
Ms. Dobriansky. I tried to speak loudly.
The Chairman. No. It is not you, it is us. We are the
world's greatest economic engine, and we do not have
microphones that function. I apologize.
Let me ask both of you, because there is a good deal of
confusion that surrounds the Global Fund. When the Secretary-
General of the United Nations called for a fund of $7 billion
to $10 billion, he was calling for the need for $7 billion to
$10 billion a year being spent to combat this disease. I think
the vast majority of people who are aware of that, even
reporters and those reading the newspaper and watching
television, assumed that that related to this Global Fund. Then
when they see that there is $1.9 billion pledged or in that
range, the conclusion reached is that the world is vastly
underfunding the need on a yearly basis. Notwithstanding the
fact that we are funding roughly 50 percent of all the money
being spent on all efforts worldwide, including here, relating
to AIDS, we quite frankly look like pikers when the number
comes up of what we are committing relative to the need.
Would one of you try to rationalize for me those numbers
and those percentages so we can, at the outset, get a clearer
picture of, (A) what is needed, (B) what the world is spending
relative to the need, and (C) what we are doing relative to our
share and responsibility of leading the world on this issue?
Mr. Natsios. Let me first say that the total amount that
the United States Government will be spending, both bilaterally
through CDC, through State, and through AID--the Defense
Department has a small program; there is a small amount from
Labor as well--next year will be $1,117,000,000. That is what
is in the budget. Of course, we do not know what Congress will
give us, but usually they do not give us less.
The Chairman. We usually give you more than you ask for.
Mr. Natsios. Yes, you do. That is correct.
The Chairman. So, go ahead.
Mr. Natsios. That includes our contribution to the Global
Trust Fund. So, internationally the amount that we will spend
at a minimum next year--I expect it will probably be higher,
but what we have proposed is $1,117,000,000.
The Chairman. Now, how firm do you think the number
attributed to the Secretary-General is which, as I understand
it, is between $7 billion and $10 billion? What do we assess,
if we were making such a judgment, is needed worldwide? Is that
a number that makes sense? If it is $10 billion, we are
contributing over 10 percent a year of the need, not actually
committed, and if it is $7 billion, we are committing over one-
seventh of all that is needed.
The reason this is so important to get on the record at the
front end here is to give the American people a sense of the
degree to which we think it is a problem, the degree to which
we are responding to the problem, and the degree to which the
problem remains unresponded to in the rest of the world.
Mr. Natsios. Let me add a few other comments in terms of
this issue.
The Chairman. Please.
Mr. Natsios. The first is that we should not see the trust
fund as the only or even primary mechanism for responding to
the pandemic. Is it one of many mechanisms. The front-line
troops are the ministries of health in these countries. The
medical doctors, the public health professionals in the
ministries are the ones who have to lead the charge. The second
group is the NGO's that do international health programs in
these countries.
There are UN agencies that spend money directly from their
own fund. UNAIDS, for example. You are going to hear from the
Director of that program. We give money to that. Now, that is
not included in the money we give to the trust fund because it
is a separate account.
In fact, WHO also has programs in various areas.
There are specialties in different institutions. For
example, CDC are the best in terms of surveillance from the
biological side of surveillance. So, we rely on them in the
field. They have set up laboratories. I have visited the
laboratories and seen the work they do in actually testing
blood and that sort of thing and watching the spread of the
disease, examining the 15 different subvariants of the disease
that have developed. We do the surveillance on the public
health side, on the behavioral side of it.
A lot of the coordination that you asked about earlier in
fact takes place not in Washington or in the UN agencies. It
takes place in the capitals of the countries that are fighting
the disease because there are different problems in each
country.
The Chairman. I would like to get to that later.
Again, I want the record set straight so we are all singing
from the same hymnal and the same page of that hymnal. When you
hear criticism--each of your departments--when it occurs that
we are not doing enough, that the degree to which we are
funding is insufficient, et cetera, it is a useful thing for us
to factually understand the context in which what we are doing
contributes to the solution.
So, when I travel around the world, I will occasionally get
lectures on why we are not doing more on this particular issue,
and yet, when you look at the overall numbers and you look at
the percentages of the total expenditure that impacts upon the
problem worldwide, maybe we should do more, but we are doing
the lion's share relative to any other single entity in the
world.
It is important for you all to lay that out because, as the
doctor and I were saying earlier, we focus on the Global Fund
as if that is the totality. When the Secretary-General says the
problem is a $7 billion to $10 billion problem a year and you
look at the Global Fund and the total pledges do not come
anywhere near that, then the conclusion that reasonable people
could reach, if that is all the information they have, is wow,
we obviously are not very serious.
Yet, you tell me, and you have said in your testimony, that
$1.117 billion is requested for fiscal year 2003. I am telling
you that I expect that will be higher. So, somewhat in excess
of $1 billion to what is labeled a $7 billion to $10 billion
problem a year is going to be committed by the United States of
America. At least for reasonable people, it should change the
attitudes a little bit about whether or not we are being
responsible.
What I am trying to do is make your case for you. You are
not making it very well. Let me help you a little more.
Mr. Natsios. Thank you, Senator.
Mr. Allen. Mr. Chairman, if I may try to address that for
you.
The Chairman. As a former staffer, you probably know how
to do it better.
Mr. Allen. Thank you.
One of the things we cannot fail to realize is in addition
to the $1.1 billion that is being requested directly from the
administration to fund, we have also left out those funds that
are being put into this global issue through U.S.-based NGO's,
through the private sector, and particularly in terms of the
antiretroviral treatment. The pharmaceutical companies are
putting billions of dollars either by, one, providing free the
antiretroviral therapies or cutting their costs significantly,
some even 90 percent of cost. So, I think that you are actually
right.
Let us assume the worst case scenario of Secretary-General
Annan's estimates of $10 billion a year. At a minimum, the
United States is doing in excess of 10 percent of that, whereas
we are providing that. I think that the estimates would be much
higher than that when you take all in total what our
nongovernmental organizations are putting in as well as what
the private sector of the United States is putting in as well.
The Chairman. I am not suggesting we do not do more. I
think we should do even more. What I am trying to get at here
is a baseline so that we are all again speaking from the same
baseline, so we know what is going on here. That is the reason
I asked the question.
Mr. Natsios. Senator, let me add to the comments I made.
You asked me whether we think this figure is right. We do not
have a precise figure. We do not now for sure. There are some
countries where the rates may be higher than we realize or
lower than we realize. These are sort of global estimates.
We think in AID that the Secretary-General's estimate was a
reasonable one. Let me say that first.
Secondly, I have always believed, doing this work over the
last 13 years, that you do not put all your humanitarian or
development eggs in one basket because if you put it into one
institution, whether it is a bilateral institution,
international institution, a national institution, and it
fails, you have a lot of people who die. So, having multiple
actors who coordinate with each other and work together is a
much better approach because then whoever is most successful,
whichever institution moves most rapidly is the one that should
get more funding. If this trust fund works as well as we hope
it will, we should put more money into it, but it has not
proven itself yet.
Some international funds have been remarkably successful
over the years, without mentioning names. Some have been
remarkably unsuccessful. We think this one is going to be a
successful one, but it has yet to prove itself.
The Chairman. I have a whole line of questioning. I would
like to get into the coordination issue and how we measure
success and how we measure failure.
But what I am trying to focus on now is the simple
proposition that in terms of gross numbers of what is needed, I
think most Americans would think that we have been behind the
curve, as we are I might add in a lot of aid programs in other
areas behind the curve relative to other countries in terms of
their percent of GDP and the like. So, I just want to get a
sense of where it is coming.
With the permission of my colleagues, I will follow up with
one question, even though my time is up. Can you give me, any
of you or all of you, an assessment of why you think, if my
perception is accurate, other G-7 nations and the EU generally
have not, in relative terms--or have they in relative terms--
made similar commitments to this worldwide fight on AIDS? Have
they? And if they have not, do you have a sense of why? Is it
just not viewed as urgent? Or can you give me some sense or
feel? This is not to say who are the good guys and bad guys. We
are trying to get a sense of what kind of urgency has to be
created worldwide in order to be able to do what we are by any
standard as a world not doing nearly enough to deal with it.
Ms. Dobriansky. Senator, if I may comment.
The Chairman. You can call me Mr. Chairman. That is OK.
Ms. Dobriansky. Mr. Chairman, thank you.
The Chairman. It may not last, but you can call me that.
I know it is hard for a Republican to say that, but give it
a shot.
Ms. Dobriansky. I think that one of the reasons that maybe
we have not seen others being as forthcoming as we would like
to see them is I think a point that Andrew referred to, which
in a way has impacted our own contribution to the fund. That
is, the point that the fund is but one instrument in this
effort. There is the expectation that we look toward its
success. There is the anticipation that it will be successful,
but there may be other countries that may be hesitant, trying
to anticipate what its success will be.
In terms of bilateral efforts, I personally believe that we
need to be more vigilant. In fact, I know that the Secretary of
State has used every means--bilateral meetings, multilateral
fora--with which to get this point across and drive the point
home, that this is an urgent issue. It is one that we all must
have a stake in and which we all must address.
But I would say with respect to the fund, some of the lack
of movement may be grounded in the Fund not yet having a
proven, successful track record.
Mr. Natsios. Let me add. Most of my friends in Europe who
are development ministers who have the same portfolio I do--we
talk about these things. We have an annual meeting called the
Tidewater meeting that has gone on for decades that is
development ministers off the record speaking. The Europeans do
take a different approach to health problems than we do. We
take a disease-directed approach. In other words, we will
target malaria or tuberculosis or HIV/AIDS. They take a health
systems approach. We do that too, but if you looked relative to
the amount of money we spend, Congress has preferred--and AID
agrees with this approach--that a disease-focused approach is a
better one.
It is legitimate disagreement. We do not have yelling
matches over this. In fact, they complement each other. They
put more money into systems. We put more money in fighting
specific diseases, but we need the systems to do that. So, the
two actually complement each other in many ways. So, the
Europeans will say, if they were here, well, you are being a
little unfair to us. We put the money into systems.
I might also add our other health programs are also
integrated in our programming in the field. We do not have
programs that are sort of isolated from the rest of the
mission. We do a country strategy in each of the 75 countries
we are in, and there is a health strategy which includes HIV/
AIDS. It also includes population, women's health, and child
survival programming. Those get woven together and they all
affect each other because we know that, for example, by the
antiretroviral nevirapine being administered once prior to a
woman delivering, we can reduce more than 50 percent the
transfer of the infection to her newborn child. Well, that is
also a child survival program. So, we are looking at this sort
of in a tunnel way, when in fact the reality in the field with
the ministries of health, with the NGO's, and with the AID
agencies is a much more integrated approach.
The Chairman. That was the point I was trying to get at
because I am not in any way criticizing or castigating
Europeans or anyone else. I think it is important, this notion
you have just put forward, this sort of holistic approach, that
we are as a community and the industrialized world actually
paying more attention to this collectively than is essentially
given credit for.
We are not looking for credit. We are looking for a sense
of cooperation. There is a whole range of issues that are
north-south issues, that if we could communicate more
accurately the degree of the concerns, we would also impact on
the political side of this equation as it relates to things
having nothing to do with AIDS or health issues. That is why I
raise it.
But I will come back because I have gone over my time. I
thank my colleague. I yield to the Senator from Tennessee.
Senator Frist. Thank you, Mr. Chairman.
I want to continue a little bit on the question that I
started with Secretary Thompson, or without him here or the
Secretary of State here, instead of talking about cabinet level
organization and focus at that level, I would like to explore
what has been fascinating to me, and that is the relationship
between the CDC and USAID on the ground.
Most of the people on this particular committee understand
the importance of being on the ground, traveling to the various
countries around the world, talking to real people, seeing what
the policy or the money that we have been talking about
actually translates into.
Mr. Natsios, in your written testimony, you stressed the
importance of not just spending money and seeing money is
allocated here, but to make sure it gets down to the local
level where very successful programs, again that you outlined,
like voluntary counseling and testing, we know works. We know
it works. The problem is a lot of times our support, our
intentions do not translate to on-the-ground. That is why I try
to get to Africa every 6 months to a year and try to go and
look at individual programs and talk to real people. The
answers are there. Now we need to highlight them and make sure
they are adequately supported.
I mention all of that because about 3 or 4 years ago, when
I went to Kenya and I think it was Uganda the other day,
comparing the relationship between the CDC and USAID, it seems
to be different. I cannot figure it out yet. So, I would like
for maybe Mr. Allen and then maybe Mr. Natsios, both of you, to
explain to me your perception of the relationship between what
the CDC is doing and what USAID is doing. Are they duplicative
still at all, or through contract relationships and working
side by side, are those differing roles beginning to merge in a
more coordinated way?
It is clearly different, for example, in Kenya now versus 3
years ago, and in Uganda the same. A tremendous success story.
We spent about $120 million there over the last 10 years of
taxpayer money, last year probably $25 million. Those are very
rough figures. By CDC and USAID working together on the ground,
supporting programs like VCT, voluntary counseling and testing,
we have seen a 30 percent incidence of infection go to 6
percent or 7 percent. That is dramatic. A good investment for
the American people and for the support of issues like the
Global Fund.
My question after all of that is basically what is the role
of CDC and USAID on the ground, and are they working hand in
hand as effectively as they might?
Mr. Allen. From the HHS perspective--I think probably all
three would share this view--on the ground we take direction
from the ambassador. So, therefore, the State Department takes
the lead in government relations there.
From HHS' perspective our relations differ in some sense--
are not duplicative of what USAID does in that we work directly
with the public health system, the public health service in
country. Unlike USAID, CDC does not do direct contracting. We
do not contract with providers. We have to work directly with
the public health authorities. So, therefore, any country in
which CDC is operating, we would have somebody on the ground
working through the public health system in that country to
develop capacity to provide infectious disease surveillance,
response, training, but we do coordinate our activities very
closely with what USAID is doing on the ground. So, I think
just starting with that, it really is a different role because
what we are required to do under statute, what we do not have
authority to do on the ground.
Senator Frist. How many countries, HIV/AIDS-related, is
the CDC in right now?
Mr. Allen. We are, right now, in 18 countries, and by the
end of the year, we will be in 25.
Senator Frist. Mr. Natsios?
Mr. Natsios. Yes. Let me sort of go over the two
respective specific focuses or ways we operate. We have a
written memorandum of understanding. It is several years old.
If you wish a copy of it. It goes into some detail as to what
we do and what CDC does.
Senator Frist. Can I ask you one question just so I can
keep it in the record about the same?
Mr. Natsios. Sure.
Senator Frist. They are in 18 countries now, HIV/AIDS-
related. How many countries are you in?
Mr. Natsios. We are in 17 countries. We will be in 23
countries. This is in big programs, in major focuses. We have
programs in a lot more countries that are more modestly sized.
Senator Frist. That is helpful.
Mr. Natsios. CDC has expertise in disease surveillance. In
fact, when we designed the disaster assistance response teams
in OFDA, which you are familiar with, 10 years ago, there is a
specific seat for CDC on that DART team. So, we take them to
the field with us in most major emergencies, whether they be
natural disasters or famines because they set up the
surveillance system for us. We have money, for example, the
$600,000 in the Afghanistan budget for CDC to set up a
surveillance system for disease in Afghanistan. We do not want
to replicate that.
The second thing they do very well is on blood supply
safety. You know that is one of the way in which the disease
spread in the United States in the early years and continues in
many countries because there are not adequate systems in place
to test the blood. CDC has expertise in that that we do not
have. We do not want to develop it. So, they do that.
They also have laboratories in which they conduct clinical
studies in the field, once again, from sort of a biological
standpoint.
Our expertise in AID is in public health. We have hundreds
of people with master's degrees in public health or Ph.D.'s. We
have a lot of medical doctors too. But the focus in AID is
community health prevention in all our programming, not just in
HIV/AIDS.
So, on the prevention side, we actually work through the
ministries of health, NGO's, faith-based communities, and
community groups and private contracting companies. We will
hire private companies that will go in and do social marketing
for us. If we want to do an advertising campaign, we do it with
the ministry of health, but they actually come in and design
the advertisements with the ministry of health's approval for
billboards and radio ads and posters. If you go to many
countries and you see them, if you look very carefully, at the
bottom it will say it is an AID funded project. That is one of
our great strengths. Those programs are successful.
We will give grants to NGO's to create a mechanism for
community-based counseling for teenagers, for example. We do
after school programs through the mosques and the churches and
through the NGO's to counsel teenagers on postponing their
sexual debuts. That is the term used by the clinical people. It
is not my term. That has a profound effect on infection rates.
We know that works. We are expanding that.
We just did an Africa-wide----
Senator Frist. Let me just say that has been hugely
successful, having been on the ground again, to see that that
delay of 18 months or 2 years radically changes both behavior
after that period of time but also during it.
Mr. Natsios. It does.
Senator Frist. I just want to commend you because it is
one of the great successes.
Mr. Natsios. Thank you.
We also do a lot in the treatment of STD's. We know that
sexually transmitted disease, if you have it and then you are
exposed to HIV/AIDS, there is a dramatic increase in the
incidence of infection. So, if you treat the STD's, you reduce
the spread of the infection of the HIV.
Senator Frist. I am going to ask you to speed up. We are
in the middle of a vote. So, I am going to go in a second. Go
ahead and make your final point.
Mr. Natsios. In any case, so they are program design,
program implementation. They tend to not be laboratory centered
but on the prevention side and the public health side.
Senator Frist. That is helpful.
Mr. Natsios. But we have a detailed MOU on that. We have
had it for several years, and it goes into some detail as to
what we do and do not do.
Senator Frist. That is good. That is very helpful.
The Chairman I think in the point he made initially, in
terms of the overall global spin, I think is important. It more
addresses policy makers because we, like all of you, are
traveling around the world answering questions. I think most of
us think we need to put a lot more money in, but we need to
really be able to document where we are putting money now, how
much, as well as do what Jeffrey Sachs and others we will hear
tomorrow about defining the big, big problem. I think that is a
useful exercise for us.
Let me jump to something conceptually again. The Global
Fund, as important as it is, does not reflect the overall
efforts of the United States. It did not exist a year ago.
There have been no programs approved. Yet, we have already
committed or intend to commit $500 million, and that is a third
of the fund. So, I think we ought to put more in it and I am
going to argue for it. Yet, people do have to remember that
fund did not exist a year ago. There have been no programs
approved. The applications are just not out there. So, we need
to do it in a step-wise, systematic way.
Right now we have got the CDC. We have got USAID that have
been in the field. I have seen the programs work. Some do not
work. We need to move beyond those. On the Global Fund, we do
not know if it is going to work or not. We are trying to
construct it in such a way with the right oversight. When
people say why do you put money in the Global Fund, why not put
it in the programs like CDC, USAID who are in the field already
working--so my question is how you answer that, number one.
Number two, as we spend out of the Global Fund, will this
money end up coming in part back to CDC, USAID type programs?
Will some of that money that we are spending there, through the
applications being made, feed back to the support of CDC, USAID
on the ground?
Ms. Dobriansky. If I may answer this. First, I think the
fund has, even in its present state since coming into being
January 1 of this year, significantly elevated global awareness
and consciousness of HIV/AIDS, tuberculosis, and malaria.
Second, I think we have already referred to the importance
of a diversified approach. In this case, I think the great
value of the fund is that you have a global response. You have
a diversified set of stakeholders coming together in support of
an urgent issue, one that must be dealt with, one that deserves
a remedy and a quick one.
Third, I would say that it is also very unique in terms of
the public and private partnership. The fact that proposals are
being solicited, are open to country coordinating mechanisms,
which I referred to in my testimony, which basically pull
together not only government entities but elements of civil
society--the full scope of civil society. As you very well
know, that is the most effective strategy to combine all
efforts together, not just one. I think in that regard, our
investment is a very worthwhile one for all of these reasons.
Mr. Natsios. Senator, if I could just expand on that just
slightly. The fund will allow us in addition several benefits.
It is the same rationale for GAVI, the Global Fund for
Vaccinations and Immunizations, and that is economies of scale
in terms of purchase. You know when you do volume purchases,
you can get the price down per unit of what you are purchasing.
The Global Fund will allow us to do that. While we do huge
purchases--we will purchase 500 million condoms this year, for
example--if you buy 3 billion, you obviously get a lower price
and you can set up logistics systems for distribution that can
be very useful. So, there are economies of scale that will
allow us to reduce costs per unit.
The second is that we are providing and will continue to
provide technical assistance to the applicants to the fund to
make sure that their proposals are going to meet the standards
that have been set up that everybody has agreed to. The
southern countries have agreed and the northern countries have
agreed what the standards are. We want to make sure that the
institutions that we think have the execution capability, the
implementation capability actually write the proposals so they
get through this process properly. We are providing technical
assistance to them to do that.
We are not going to apply. AID will not apply for any money
in the fund. That would be self-defeating.
But it is also the case, I might add, that the way this
will work is many ministries of health will work with local
NGO's jointly to do proposals. The NGO community does not get
one grant. Having been in the community for 5 years, I can tell
you how it works. You do not get one grant from one donor and
that is your program. You can get 10 donors to give money
toward one huge program in one province, and you put them all
together. You piece them together. There is one common program
design, but you get multiple donors. That is what the UN
agencies do too.
I expect some of the NGO's and ministries of health that
are getting money from this fund are also getting resources
from either CDC or from us at the country level. The benefit
is, again, this economies of scale once again.
Senator Frist. Let me move on. I think that has been very
helpful to me, the whole discussion on the relationship between
the two.
Madam Secretary, I appreciate you mentioning the CSIS
project that many people in the room and many people on this
committee are participating in, which is a longstanding project
looking at a number of the issues that we can touch upon in
these hearings but we do not have the time to really go into
much more depth. So, I look forward to continue working with
many people in the room on that.
We have three panels today and we are in the middle of a
vote. I am going to leave in about 2 minutes, and the chairman
is on his way back. So, we may suspend for bout 3 or 4 minutes.
But the issue of treatment is fascinating when you are on
the ground. We have already talked a little bit about it, the
antiretrovirals, which from sort of the north standpoint,
western standpoint, are very effective. We do not have a cure
for HIV/AIDS. We need to keep saying that. It is an incurable
disease as we know it today.
Then you start thinking of linking prevention, care, and
treatment. Again, as a physician, you have got to have care and
treatment part of this equation. Prevention is where the answer
is because we do not have a cure. Behavior is where the answer
is for the time being, but the care and treatment opens up
hope. It brings people in. The rapid testing, revolutionary
because technology has made that possible over the last 6
months where you can come in and in an hour, a teachable moment
because of this new test that costs about $1.20 instead of a
$335 test which would take 2 weeks. To me it shows where this
merger of technology, social policy, teachable moment all come
together and has been very successful to date.
The antiretrovirals are a big part of potential treatment,
but you have to look at some basic things like the treatment
for opportunistic infections, other sexually transmitted
disease, nutrition, all of which we know also does what
antiretrovirals do, and that is prolong life and in many cases
even in a more powerful way. So, we cannot just focus on the
antiretrovirals.
With that, could any of the three of you--actually I am
going to leave. So, I am going to throw that question out
there. When the chairman comes back--I know we have got two
more panels to go, but I would ask that you stay for a few
minutes because I am sure he will have one more round of
questions with you.
But this issue of treatment--and my question is going to be
what is the CDC doing, what is State doing, what is USAID doing
in terms of programs to look at this more complex,
comprehensive, really more intricate way of treating which in
truth is equally important, I would argue, to antiretrovirals
today.
With that, I think we will suspend, though we will start
back within about 5 minutes. Thank you.
[Short recess.]
The Chairman. We will come back in session, please.
Senator Frist has a few more questions, as I do. The reason
I left early is to be able to go vote at the front end here and
he is now voting. By the time I finish my questions, he will be
back and will ask his questions. Then we can release this
panel, which has been very, very helpful to us. I appreciate
it.
Mr. Natsios, I would like to ask you, as well as anyone
else who would like to respond. I have been told that less than
50 percent of the African countries have adopted a national
blood transfusion policy, and less than one-third of the
African countries have a system in place to limit HIV
transmission through blood transfusions.
The first question I have is, is this accurate, to the best
of your knowledge, or do any of you know?
Mr. Natsios. We believe it is pretty close to accurate,
Senator.
The Chairman. What programs does the United States have to
ensure, if there are any, that developing countries,
particularly in Africa, are able to put in place systems for
handling blood supply? Are we working with individual
countries? What are the programs we have?
Mr. Natsios. CDC runs the programs that set up the
laboratory systems to do the testing with the ministries of
health. In the countries that they have been able to do this, I
understand that they have been successful in treating and
testing. I am less familiar with the details of how the
laboratories work. I visited a couple of them.
Mr. Allen. Through the Food and Drug Administration and
the Department of Health and Human Services, it really has the
focus on protecting the blood supply. We work in coordination
with CDC and countries, but we also work with NGO's, such as
the American Red Cross, to ensure safe blood supplies. So,
working on the ground in those countries, we are being very
effective in addressing and securing the blood supply, and that
is a critical step in stemming the tide of the spread of HIV/
AIDS, but also in bringing down the risk associated with others
contracting the disease through tainted blood.
The Chairman. Do we have any sense of to what degree, if
any, the transmission occurs through tainted blood in Africa or
generically? In other words, if you have 50 percent of the
countries, roughly, that do not have anything in place that
would in any way be able to guarantee the blood supply,
particularly as it relates to the transmission of AIDS, do we
have any sense of how big a problem that is as a percent of the
problem?
Mr. Allen. I do not have those numbers. We can certainly
get that information for you.
Mr. Natsios. It is about 5 percent, Senator. Five percent
of the incidence of HIV is attributable to blood transmission,
that is, transmission through blood supply. As you can see by
the 5 percent, it is not the predominant problem.
The Chairman. No, no.
Mr. Natsios. It is a problem but not the predominant
problem.
The Chairman. But it seems to me that it may be one of
those problems where you could--nothing is easy. You have at
least the theoretical capacity to close that window of 5
percent, whereas you cannot quantify and/or be as certain that
you can do that as easily with regard to teaching abstention or
other things that are not as measurable, not as easily
measured. That is why I raise the question.
Mr. Natsios. There are actually four or five countries now
where we do have programs that CDC runs. We do not run them.
Mr. Allen. Right. We have programs currently in India,
Kenya, Uganda, Tanzania. I do know that while in New York at
the Global AIDS Summit, we had discussions with the Chinese who
were very interested in looking at what the United States was
doing in terms of our blood safety programs. Others are looking
to the U.S. and our Government agencies to work in those areas
of securing the blood supply.
The Chairman. Is there any institutional or infrastructure
and/or cultural resistance? Is there anything preventing us
from assisting in improving blood supply systems other than we
just have not been able to get to it yet? I am not focusing on
this as any failure. I am just trying to get a sense of whether
or not there is any reason, other than just not being able to--
because this is such a gigantic problem--get to it more
effectively, more quickly? Or does it relate to dollars? Does
it relate to infrastructure in the country?
Mr. Allen. I think it goes to all of that. I think part of
it is infrastructure. If you cannot store blood, if you cannot
test blood, if you do not have the laboratory facilities to
assure that, that is all part of the problem. Of course, money
goes to the heart of that in many ways.
The Chairman. That is why I was asking.
Mr. Allen. I would think it is less of the former, the
cultural differences that might exist. I think it is really
technology.
Mr. Natsios. If I could add a couple of things. We are
doing very extensive use of this rapid testing. It was AID
field research that discovered that a rapid test will double
the number of people who go into the clinics to get it done. If
you use a rapid test as opposed to a test that takes days for
the results to come back, if they get the results immediately,
the number of people who are willing to go in and be tested
doubles. This is true in the United States. It is true in the
developing world. It is just a part of human nature. If you can
do the tests rapidly and people know, their behavior does
change fairly quickly for a large number of people. So, that
can stem the spread of the disease.
In some countries, Senator, there is not a very large blood
supply, I have to tell you, because there are not large
hospitals. There health systems are more clinic-based and
preventive-based as opposed to treatment in terms of surgery
and that sort of thing. So, you will find a lot of countries
without large blood supplies where this is an issue.
The Chairman. That was my next question.
One other thing I would like to ask you about is to the
extent that you can characterize it with any degree of
certainty or accuracy, how widespread--let us start with the
continent of Africa, which is obviously a gigantic continent
and is as diverse as any other continent in the world. But we
have been focusing a little bit on it. How widespread do you
believe among the populations at large is the knowledge of the
extent of the virulence attached to and the method by which the
disease is communicated in terms of just public education? How
much awareness is there? I am not talking about the government
level. We always talk about the government level and whether
governments are willing to admit to or acknowledge or deal with
it, et cetera. I am not talking about an official response. I
am talking about if you were to walk into a low-income area
populated with 750,000 people and you asked about HIV/AIDS,
would you find an awareness as to the extent of the disease, as
well as the means of transmitting the disease and the means of
slowing the disease?
Mr. Natsios. The understanding of the disease, the
existence of the disease, and the risk generally is very high
in Africa. It is perhaps well over 90 percent. If you did a
survey of the population, have you heard of this disease and do
you know what it does to you in a generic sense, the answer is
virtually the entire adult population in many countries do. The
social marketing has been very effective. When the heads of
state begin campaigns on this, they do not just make one
speech. They make repeated speeches. They go to the
countryside. They use radio. They use newspapers and posters
and all this.
The problem is--and it is the same problem in the United
States--whether you yourself are at risk. And this is the
problem with teenagers here in the United States where the kids
will say, yes, I know drunk driving is a problem, but it does
not affect me and I am not personally at risk. That is a
problem with teenagers everywhere in the world in particular.
So, the understanding of the risk that a person has of getting
is not very high.
The Chairman. Let me ask you. My impression from dealing
with this for some time is that the perception of risk is not
as cavalierly viewed in the United States as you made it appear
to be. The perception seems to be less pronounced in other
countries. In other words, it has impacted on behavior here in
terms of sexual behavior, not to the extent we want it to, but
it has had impact. It is not like drunk driving, at least the
statistics I have seen.
What I am trying to get at is what portion of your efforts
to change behavior--again, please do not read into this that I
am suggesting that is the answer, that all we have got to do is
just say no. I am not suggesting that at all. I am trying to
get a sense, though, of how real a risk it is viewed to be, and
is it just like it is in any other--that is, there is no
distinction.
Mr. Natsios. There is a distinction regionally and there
is a distinction on different age groups. There is, for
example, a very high understanding in East Africa. There is
less understanding in West Africa.
The Chairman. To what do you attribute that?
Mr. Natsios. It is a matter of how advanced the disease
is, the religious traditions of the country. Muslim countries
have lower prevalence rates I have to tell you, substantially
lower in many cases. It does not mean it is not present. It
means the infection rates for a country that is 100 percent
Muslim is substantially lower than it is in other parts of the
developing world. So, those value systems, the religious
traditions do affect this.
We are seeing success in behavior change in a number of
countries where the disease is advanced. I have many Ugandan
friends for many years, and some of them are fairly prominent
people in their country. Several of them have decided not to
marry because they can never be sure that their marital partner
would not be infected because the infection rates are so high.
It is a tragedy because they would like to marry, but these are
some prominent people who have actually said we will be
celibate our entire lives because of the extent of the disease.
I am sure if the same level of disease spread took place in the
United States, people would make the same judgment in the
United States. It is a matter of survival.
It is changing people's behavior, I have to tell you,
without even our program, because when you have a certain
number of deaths in a village--in South Africa now in some
areas, they are burying people in the same grave on top of each
other. They are layering them because there is no room left in
the graveyards. One NGO I was talking to in South Africa where
I visited one of the clinics was telling me that they will have
in some villages funerals from 6:00 in the morning till 6:00 at
night on the weekends continuously all day long for what is
happening. Now, that does have an effect on the population.
People see what is happening. They understand it.
The problem is when it reaches that level, then it is too
late, obviously, in many cases to stem the spread of the
disease. So, our job is to prevent it from spreading so that
eventuality does not take place.
The Chairman. Do you want to make a comment?
Mr. Allen. I was just going to comment that I think that
the other component to that is political leadership. I think
that you will see the level of awareness of the program closely
attributed to political leadership. Countries like Uganda,
Senegal, Malawi, countries that have taken a very aggressive
stand from the very highest ranks of government, have been very
successful in addressing the low-hanging fruit, those areas of
mother-to-child transmission, securing the blood supply. I
think that we have seen, through those leaders, the ability to
get a message out. I think that is where we have to engage
across the spectrum the political leadership as well in this
debate and discussion to begin to educate the public about how
the disease is contracted and how one can prevent from
contracting it.
The Chairman. Senator Feingold.
Senator Feingold. Thank you, Mr. Chairman.
I understand there was some very useful discussion of the
Global Fund after I left, and I will certainly review the
transcript with interest. I had indicated that I feel we do
need to dedicate more resources to supporting the Global Fund,
but I also do strongly agree with the statements that were made
in my absence about the importance of a diversified approach,
whether it be bilateral or multilateral mechanisms, and it is
especially true if those efforts are well coordinated.
I think there is no doubt that the United States is a
leader in the donor community when it comes to the fight
against AIDS. You just mentioned Senegal. I saw that last
February. In part, the efforts of USAID and others have led to
a terrific program and success of bringing together seemingly
all elements of society in a very positive effort in this
regard.
But it is precisely for that reason that I am concerned
about the fund. I think U.S. leadership is going to be required
to actually make the fund the strong tool in our arsenal that
it has to be.
Mr. Chairman, I am just going to leave it at that. I will
have an opportunity tomorrow in the hearing that you have urged
me to chair to explore this with some of your colleagues. I
just want to thank the panel for all your effort and time.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Before the panel departs, I had contemplated today having
in the panel of Government witnesses the CIA, as well as the
Defense Department, which I may yet do. But I will not take the
time now, but the national intelligence estimate produced by
the Central Intelligence Agency entitled A Global Infectious
Disease Threat and its Implications for the United States, the
January 2000 report, has a pretty sobering estimate. Actually
it is more pessimistic than what was communicated here today.
But the point is that they reached several conclusions, one of
which is that this epidemic will challenge democratic
development and transitions and possibly contribute to
humanitarian emergencies and civil conflicts in the world. The
Defense Department rates this as a greater concern than an
attack from an ICBM, for example, in terms of their interests.
So, this is not merely--it need only be the humanitarian
catastrophe that it is producing, but our security agencies are
saying that the cost is not only in school teachers, for
example, and doctors and people who run the country, but it is
among officers of mobilized militaries in sub-Saharan Africa,
and increasingly among those states, which I will not name,
that have the possibility of being categorized as rogue states.
So, this is a multi-faceted dilemma that the world faces
and the U.S. faces that goes beyond what we tend to only
think--not you all, but when we talk about AIDS and we think of
it, as we should, in terms of the humanitarian catastrophe,
that it has so many implications, including national security
implications, which I think warrants us paying even more
attention. Through the leadership of all of you and the
agencies you represent in the administration, I think we are on
the right track here.
Yes.
Ms. Dobriansky. Mr. Chairman, if I may just make a comment
on that. Before taking this position, I had seen a product of
the National Intelligence Council, which was a precursor to the
one you are citing, which was on global trends 2015. It
addresses a range of global issues, citing that if they are not
dealt with, that they will cause conflict and instability in
the future. And then the report that you mentioned was singled
out on infectious diseases.
I have to say we have at the Department, through the Bureau
of Intelligence and Research, held a number of conferences
which have brought in both the public sector, different parts
of the public sector including DOD and other agencies, and the
private sector, to discuss not only the humanitarian
ramifications but as you pointed out, the security
considerations.
Also, the Council on Foreign Relations published a report
which concluded that the spread of HIV/AIDS and infectious
diseases is a security threat and one that the U.S. Government
and the world at large must address because it affects us all.
The Chairman. The International Crisis Group issued a
report on the 19th of June of 2001 which reached several
conclusions. I will just read part of one and let you go.
On page 21 of the report, it says, ``Anything that weakens
a state, threatens its military, but also its institutions may
create an environment in which states pose outside aggressors a
more tempting target. When major powers are weakened, the
effect is less likely to present itself as an invasion in war,
but instead increase turbulence and minor violence in the
international system. The larger the country, the larger the
potential to stabilize an impact in the international arena.
What happens in Russia, India, China, with huge populations,
large militaries, historic rivalries matters a great deal
elsewhere.'' And this goes on.
So, I just hope those who are listening to this hearing
from the public at large who think maybe we are spending too
much time and energy focusing on, as not many, but some say,
the problems in other parts of the world understand that this
is our problem. This is our problem.
I thank you all very, very much. I appreciate your
consideration and your time and your patience in the way this
has been running. So, thank you.
By the way, we will, with your permission, probably have
some questions submitted to you, if we may, in writing.
[The questions referred to and the answers submitted
thereto, follow:]
Responses to Additional Questions Submitted for the Record by the
Committee to Under Secretary of State Paula Dobriansky
A recent article appearing in The Lancet raised concerns over
the capacity of potential African grant recipients to meet the
standards the Global Fund has set for the preparation of
applications and the implementation of Fund-supported
activities, including project monitoring. The authors suggest
that the Fund's standards and objectives could pose undue
burden on ministries of health in Africa and lead to early
disappointment with the Fund's performance.
Question. Would you share with us the requirements for fund
applications and monitoring?
Answer. The Global Fund to Fight AIDS, Tuberculosis and Malaria has
established the principle of public-private partnership as a critical
aspect of its functioning. This principle is particularly important at
the country level, where proposals are developed and implementation
will occur. The work of preparing applications can and should be shared
among all partners, not only ministries of health. The Fund requires
that proposals be developed and implemented by Country Coordination
Mechanisms (CCMs) that include all relevant partners at the country
level, although there is a provision allowing NGOs to submit proposals
directly to the Fund where such partnerships are not possible. These do
not have to be new groups. The intent is to build on already existing
coordination mechanisms to develop initial proposals, and over time to
strengthen them. The Fund has been able to learn from the experiences
of others, including the Global Alliance for Vaccines and Immunizations
(GAVI), the subject of The Lancet article.
While one goal of the application process is to be as simple as
possible, there must be sufficient information to ensure that only
high-quality projects are funded. There is also a need to ensure that
appropriate financial and program accountability structures are in
place at the country level.
Each proposal will include a monitoring and evaluation plan. The
Fund itself is establishing its own monitoring and evaluation framework
at the global level. To the extent possible, the Fund will build upon
monitoring and evaluation frameworks established by other donor
organizations and multilateral agencies such as the World Health
Organization. It is expected that Fund partners such as USAID and HHS
at the country level will contribute to the process of establishing,
strengthening, and supporting data collection systems at the country
level.
The details for monitoring and evaluation are currently being
discussed in an international working group that includes
representation from HHS and USAID, both of which have extensive
expertise in monitoring and evaluation. The goal is to have meaningful
measures that not only enable countries to monitor their own progress,
but also allow the donor organizations and countries to assess the
impact of the Fund's grants portfolio.
Each proposal will also have to demonstrate strong and transparent
arrangements for financial management and control.
Question. To what extent do you share the concerns raised in the
article?
Answer. There is broad recognition among those involved in creating
the Fund that many prospective recipients have capacity constraints.
That is why USAID, HHS, other donor countries and multilateral
organizations have committed to providing technical assistance, as
appropriate and upon request, to help country partnerships prepare
proposals, implement projects, and conduct monitoring and evaluation.
These partners can help the country partnerships identify existing
programs and resource availability, as well as programmatic and
resource gaps that the Fund can fill.
The Fund has been established as a public-private partnership and
proposals will come from partnerships, not from governments, although
governments are expected to be important partners in most instances.
The Fund was established based on the premise that no one sector or
institution has the capability alone to deal with the problems posed by
AIDS, tuberculosis and malaria, and that partnerships are, therefore,
vital. However, the Fund also recognizes that building country capacity
to implement and monitor programs is an appropriate area for Fund
support. Fund donor partners, such as USAID and EMS, will continue to
emphasize capacity building as part of their bilateral programs.
We consider financial accountability and monitoring and evaluation
critical to establishing and maintaining credibility and transparency.
Meeting these requirements will require some attention and effort on
the part of country partnerships, and should be considered as
worthwhile investments. The Fund can help countries build adequate
systems for health data and fiscal accounting that will not only assist
in monitoring the progress of the Fund, but also will aid the countries
in improving their health care infrastructure.
Question. What role do you see the Agency for International
Development, the Center for Disease Control and Prevention, or other
U.S. agencies in helping African applicants meet the standards the Fund
has set? What assistance, if any, has already been provided?
Answer. It is not only African applicants who will need assistance
in meeting the reasonable and prudent standards set by the Fund. State
and USAID have sent a series of cables to the field to brief our
embassies and missions overseas on the Fund and to encourage them to
work with Country Coordination Mechanisms (CCMs) to help in the
proposal preparation process.
USAID is presently developing a strategy to utilize mechanisms and
capacity at the global and regional levels to provide technical
assistance to CCMs for proposal development, and to ensure that our
bilateral support is coordinated with expected support from the Fund.
USAID is also developing a process to mobilize technical assistance
resources from a range of its contractors to provide assistance to CCMs
at the country level, to help identify critical gaps and constraints to
scaling up successful activities, so that Fund proposals submitted to
the Fund can address those gaps and constraints.
Thus far, HHS, through field staff of the Centers for Disease
Control and Prevention (CDC), has been invited to assist with the
Global Fund proposal process in six countries: Botswana, Kenya,
Mozambique, Tanzania, Uganda, and Zambia.
In Botswana, HHS will serve on the MOM's technical advisory
committee for review of incoming TB proposals and on the
National AIDS Coordinating Agency's technical advisory
committee for review of incoming HIV proposals.
In Kenya, HHS, along with other donor groups, will be given
the opportunity to review the submission.
At the request of those involved in preparing a proposal,
the HHS Global AIDS Program staff in Mozambique has provided
input.
HHS Global AIDS Program staff in Tanzania will provide
technical input on that country's proposal.
HHS staff in Uganda has been invited to meetings at the
Uganda AIDS Commission.
In Zambia, HHS Global AIDS Program staff has worked on the
TB portion of the proposal.
Furthermore, staff at HHS and USAID has been involved in the
various working groups established by the Fund to develop guidelines
for monitoring and evaluation and other technical matters. Once these
initial consultations are complete, we expect that staff will continue
to be involved once grants have been made, in assisting the countries
directly, when requested.
In providing support on proposals, we cannot, of course, guarantee
that specific requests will receive funding. Our goal is to provide
advice and expertise not only in the proposal writing stage but with
the actual work that is being suggested to ensure that it fills gaps in
current programs.
Question. What measures for evaluating the performance of grant
recipients is the United States advocating?
Answer. Program and financial accountability have been identified
by the Fund as critical components of proposals to be considered for
funding. The Fund has created a working group to develop a monitoring
and evaluation strategy and procedures that can be further developed
and strengthened over time. This group will also look into the
possibility of making funding available in tranches, with continued
funding of projects based on achievement of agreed milestones and
targets. The U.S. intention is to ensure that these milestones and
targets are both measurable and meaningful. A panel of experts from HHS
and USAID is helping to determine what such indicators might be and to
develop appropriate mechanisms and procedures to insure that valid data
on these indicators can be provided. While demonstrable reductions in
some disease or infection rates may take time, we do expect certain
operational milestones, such as increased coverage with proven
effective interventions, to be met before continued funding is made
available.
Establishing fair and realistic targets and indicators, neither too
high nor too low, is extremely important as the Fund prepares to accept
the first round of proposals. One of the early recommendations of the
United States was to have each application reviewed from the
perspective of monitoring and evaluation to ensure the soundness of
applicants' plans and their ability to utilize existing or planned
monitoring and evaluation systems and indicators.
The United States is also insisting that appropriate fiscal
controls be in place, both at the country and global levels to ensure
that funds are used for the purposes intended.
Question. To what extent are these measures likely to be effective?
Answer. The Global Fund is a new mechanism to provide additional
funding for the scale-up of programs at the country level. It has been
developed very rapidly, and is about to enter an operational phase in
which it may take several years before we see meaningful changes at the
global level. Nonetheless, the Fund must be sufficiently flexible to
learn from lessons learned both by others and itself and to change
procedures to help ensure better performance over time.
Experience gained through the review and initial implementation of
the first grants that will be approved in April will be the basis of
future modifications to improve capacity in this critical area. The
United States Government (USG), especially USAID and HHS, have
particularly good experience at the country level in the areas of
monitoring and evaluation. The USG will play a leadership role on the
monitoring and evaluation working group, and should be able to offer
specific assistance in proposal development and strengthening local
capacity to improve surveillance and monitoring systems.
Question. What burdens, if any, do they impose on health
ministries, other government agencies, and non-governmental
organizations in the recipient countries?
Answer. The Fund has tried to strike a reasonable balance between
simplicity and accountability, but it will be dealing with large
grants. It is not unreasonable to ensure that recipients are able to
use such funds for the purposes for which they are intended and to
reach the greatest number of people in a safe and efficient manner. The
application process is the first demonstration of the capacity of
recipients to fulfill their commitments. The intent, wherever possible,
is to use existing plans and processes as the basis for proposals and
for monitoring and evaluation. However, many country partnerships, with
the aid of bilateral and multilateral partners, will have to engage in
planning processes and write new proposals because they have not done
the work previously. There is no other way to ensure that Fund
proposals fit into national priorities, are feasible, and
scientifically and technically appropriate. The Fund will work to keep
the burden as low as reasonably feasible, within the limits of prudent
grant-making.
It is especially important to use the additional resources and
attention coming through the Global Fund to identify weaknesses and
assist country personnel to improve surveillance capacity to monitor
the progress of the epidemics and contribute to tracking impact of
Global Fund-supported programs. The Fund will benefit from work already
developed by its partners on monitoring and indicators. It expects to
be able to use procedures and systems already in place, and in many
cases supported by other Fund partners to meet the requirements of a
rigorous monitoring and evaluation system.
Question. A couple of years ago, this Committee [the Senate
Committee on Foreign Relations] and the Congress made a strong
commitment to relieve the international debts of the poorest countries.
And yet, it is my understanding that many of these countries still pay
more in debt service to multilateral creditors than on health care.
Answer. The Administration greatly appreciates--and strongly
endorses--the support the Congress has provided for debt relief under
the Heavily Indebted Poor Countries (HIPC) Initiative. The HIPC
Initiative greatly increases the prospects for economic and social
development in beneficiary countries by allowing them to redirect into
social sector spending funds that would have been due for debt service.
A recent IMF/IDA report, ``The Impact of Debt Reduction under the
HIPC Initiative on External Debt Service and Social Expenditures,''
provides information on initial results for the first 24 HIPC countries
to reach their decision points. After HIPC implementation, debt service
due has fallen sharply from 29 percent of government revenue in 1998 to
an expected 11 percent in 2003. The report also notes that social
sector spending rises from 33 percent of government revenue in 1999 to
39 percent in 2002, suggesting the desired redirection of spending is
taking place. The above data would suggest that the HIPC Initiative has
caused a broad and pronounced shift from all categories of external
debt service (not just multilateral) to social sector spending.
Typically, the health and education sectors receive special
emphasis in social sector spending. Examples of programs in the health
sector that HIPC savings will help fund include:
Mozambique has committed to use debt service savings to
expand the stock of basic medicines in government health
clinics.
Uganda will use enhanced HIPC relief to expand the country's
successful HIV/AIDS awareness programs.
Madagascar intends to use about 20% of its HIPC savings for
programs in the health sector, to include immunization
programs, an anti-HIV/AIDS campaign, the recruitment of medical
personnel, and the supply of drugs and medicines.
In Cameroon, the U.S. Embassy reports that the 2001-02
budget breaks out $49.3 million of HIPC debt relief savings, of
which $9.1 million will be spent on health programs, with an
emphasis on HIV/AIDS and malaria. 1,000 public health workers
will be recruited.
Yet, the success of the HIPC Initiative and broader development
assistance ultimately depends not only on the assistance provided, but
even more importantly on country efforts to undertake the necessary
economic and social reforms that create the basis for sustained
economic growth. In this regard, quality and effectiveness of spending
in the health sector will be as important as amounts of spending.
Question. Is the level of debt relief currently provided
sustainable over the long term, and sufficient to enable highly
indebted countries to deal with the AIDS crisis and meet their critical
development needs?
Answer. The HIPC Initiative will greatly enhance the prospects of
debt sustainability through a substantial reduction in the HIPC
countries' debt. The World Bank and IMF estimate that for the first 24
countries, HIPC debt relief will total more than $36 billion over time.
However, given that these countries face steep development challenges
and are highly vulnerable to external shocks, it will be important to
focus on maintaining long-term debt sustainability. Most importantly,
this will require sound economic policies in HIPC countries that create
the basis for sustained economic growth. In addition, strong debt
management, including prudent borrowing policies, will play an
important role. Finally, creditors need to ensure that new financial
assistance is provided on appropriate terms, including through
increased use of grants.
With regard to the AIDS pandemic and the fight against other
infectious diseases, the U.S. and other donors have recognized the need
for additional resources above and beyond those freed up by the HIPC
Initiative. The Administration's 2003 budget request proposes total
bilateral and multilateral assistance for HIV/AIDS, TB and malaria
programs in developing countries of nearly $1.2 billion, up from $1
billion in 2002. This $1.2 billion includes $200 million for the Global
Fund to Fight AIDS, Tuberculosis and Malaria, raising the overall U.S.
pledge to $500 million. The U.S. commitments in FY 2002 and FY 2003
will account for more than a third of estimated international donor
funds. USAID is the single largest bilateral donor.
Question. Are countries that are benefiting from debt relief
savings able to channel a substantial amount into the health sectors of
their national budgets? If not, why not, and is there some assistance
we could be providing to help them do so?
Answer. Although it is early in the HIPC process to provide an
authoritative response based on how HIPC countries have actually spent
their money, the IDA/IMF reports 2001 and 2002 budgets have a
significantly higher level of social sector expenditure in the HIPC
countries that have begun to benefit from debt reduction. In the 24
countries that have reached their Enhanced HIPC decision points, the
report indicates that social sector spending rose from $5.1 billion in
2000 to $6.0 billion in 2001, and is projected to rise to $6.9 billion
in 2002.
Question. You mentioned in your testimony that Secretary Powell
created a new Deputy Assistant Secretary for International Health and
Science, a role to be filled by Dr. Jack Chow. Dr. Chow is also to
serve as the special representative of the Secretary of State for HIV/
AIDS with the rank of Ambassador, subject to the Senate's confirmation.
What effect will the creation of this office have on HIV/AIDS
policy?
Answer. By establishing the post of Deputy Assistant Secretary for
International Health and Science, the State Department effectively
raised the profile of health issues on the foreign policy agenda.
Confirmation of Dr. Chow as the special representative of the Secretary
of State for HIV/AIDS with the rank of Ambassador will signal to our
contacts around the world the importance the United States attaches to
health issues.
As Deputy Assistant Secretary, Dr. Chow serves as the primary focal
point in the USG on international issues related to HIV/AIDS and other
infectious diseases, especially tuberculosis and malaria. He represents
the United States in international negotiations.
If confirmed as special representative, Dr. Chow will work with
presidential envoys and senior representatives from other nations to
ensure an international response to HIV/AIDS. He will work to
strengthen the Department's capabilities and to promote inter-agency
coordination and cooperation on global HIV/AIDS.
Question. The President's budget request for FY 2003 includes $2
million in for [sic] the State Department's Foreign Military Financing
program to ``complement'' a Department of Defense program that is aimed
at educating African militaries about HIV/AIDS. $2 million is not a lot
of money. Do you know how much funding did the President ask for in the
FY 2003 Department of Defense budget for the program.
Answer. Resources for DoD's Africa Initiative in Military Medicine
(AIMM), which seeks to provide training and education on HIV/AIDS for
sub-Saharan militaries, total $10 million in FY2001 and $14 million in
FY2002. It is my understanding that DoD's FY 2003 budget request does
not include funding for AIMM.
Question. What activities will the State Department engage in that
are complementary to the Department of Defense program?
Answer. The fight against HIV/AIDS and other maladies in Africa
requires a multi-agency effort. HIV/AIDS and other diseases have
weakened and reduced the security capacity of Africa's militaries.
DoD's Africa Initiative in Military Medicine (AIMM) seeks to provide
training and education on HIV/AIDS for sub-Saharan militaries. It is my
understanding that in FY 2002 the Department of Defense was allocated
$14 million for AIMM.
Subject to Congressional approval, the Department of State Foreign
Military Financing program plans to allocate $2 million of FY 2003 FMF
funds to purchase equipment such as computers and resource management
software for creating and maintaining databases, laboratory and medical
supplies, testing equipment, and rapid test field kits. This equipment
will both complement and sustain the training initiative in African
partner countries.
Question. According to a recent GAO report (December, 2001) the
United Nations does not know how many peacekeepers have HIV/AIDS
because it opposes mandatory HIV testing before, during or after
deployment to a peacekeeping mission. With all that we now know, with
all the evidence we have that peacekeepers, like other military
personnel, are likely to engage in behaviors such as unsafe sexual
practices that increase the risk of contracting and spreading HIV, what
is the rationale for continuing the policy of NOT testing peacekeepers?
Answer. UN policy on HIV testing in the context of peacekeeping
operations is under review. In November 2001, an expert panel on HIV
Testing in UN Peacekeeping Operations met in Bangkok, Thailand.
Participants included UNAIDS, the UN's Department of Peacekeeping
Operations (DPKO), military officials from peacekeeping contributing
nations, and legal experts. In addition, a pilot project funded by
Norway and Denmark is being developed to begin a further assessment of
UNAIDS's prevention strategies for peacekeepers
The DPKO has designed its current HIV/AIDS policy to comply with
the wishes of its member states, which have divergent views on HIV
testing. The UN in general and the DPKO specifically are also conscious
to avoid policies that might increase discrimination against HIV-
positive individuals.
The UN's policy on HIV testing of peacekeepers is largely
determined by its contributing countries. For instance, some countries
do not screen their military personnel for HIV. Others may test their
forces but do not share this information publicly, considering such
information sensitive. There is further concern among other countries
that mandatory testing could be used for political decisions on the
suitability of certain national forces to serve as peacekeepers.
This position is also based on human rights concerns. The UN has
resisted screening for HIV on the grounds that it could increase
discrimination against and stigmatization of those infected with the
virus. In addition, the UN's personnel policy states that the only
appropriate medical criterion is fitness to work. Accordingly, those
not exhibiting clinical signs of AIDS are not precluded from
peacekeeping service.
UN Security Council Resolution 1308 (July 2000) encourages UN
agencies to take action with UN member states to develop strategies to
mitigate the spread of HIV/AIDS in peacekeeping missions. These efforts
have focused on three interventions: the development and use of an HIV/
AIDS awareness card; training of troops in HIV/AIDS prevention; and the
distribution of condoms to peacekeepers.
DPKO recommends that countries contributing to UN operations should
not send HIV-positive individuals on peacekeeping missions. However, UN
policy opposes mandatory testing and countries retain control over
their forces, so DPKO cannot force countries to test or keep data on
HIV prevalence.
Our next witness will be Dr. Peter Piot. He is the
Executive Director of the joint United Nations Programme on
HIV/AIDS and is Assistant Secretary-General of the United
Nations as of December way back in 1994. He has done a great
deal of work in this area. We are flattered he would take the
time to be here, and we welcome his testimony. Doctor?
STATEMENT OF DR. PETER PIOT, EXECUTIVE DIRECTOR, UNAIDS,
GENEVA, SWITZERLAND
Dr. Piot. Thank you, Mr. Chairman, Senator Frist, Senator
Feingold, ladies and gentlemen. It is up to me to thank you for
the opportunity to testify this morning, and I would like to
applaud you for your commitment and also for the focus on the
global AIDS epidemic.
I am here today on behalf of the UN system organizations,
in particular those AIDS agencies who make up UNAIDS, the Joint
United Nations Programme on HIV/AIDS.
Twenty years since the world became first aware AIDS, three
things have become clear. First, that we are facing the most
devastating epidemic in human history. Second, that for all the
devastation it has already caused, the AIDS epidemic is still
in its early phases. A sobering thought. And third, that we are
in a position to bring the epidemic under control. Today, I
would like to focus on this third lesson, that we are prepared
to succeed.
Mr. Chairman, I believe that for the first time in the
short history of this epidemic, the world is in a position to
translate the few local and national examples of success into a
truly global movement and also a global success.
So, what is different now from 5 years ago?
One, manifestly greater political momentum to address the
AIDS epidemic. It is really everywhere and not least in this
country and right here on Capitol Hill. You will hear
Secretary-General Kofi Annan this afternoon. He has made the
fight against AIDS his personal priority. Five years ago, it
was often difficult to persuade even health ministers that they
ought to take AIDS seriously. Today when global leaders meet,
AIDS is on their agenda from the G-7 to the World Economic
Forum (at its meeting last week, for example), and especially
among African heads of state.
Second, there is now a clear set of global priorities in
the fight against AIDS. The series of benchmark targets adopted
by all the world's countries at the Special Session on AIDS of
the UN General Assembly last June in New York provide a common
platform for accountability, and we have clear international
consensus on a global strategy which stresses young people as a
priority for action on AIDS and recognizes that prevention and
treatment and care are integral parts of an effective response.
The third advance is that we have empirical evidence that
action around such a strategy actually results in success. Very
importantly, it results in fewer people becoming infected. No
longer only Uganda and Thailand and Senegal, but also a country
like Cambodia--after decades of genocide and civil war, it has
less infections today than 5 years ago. Zambia, Tanzania,
Brazil and others are also examples of success.
The fourth advance from 5 years ago is in the new realism
about the resources required to effectively tackle AIDS in the
developing world. As we heard this morning, roughly $10 billion
annually is needed for a comprehensive AIDS response.
Mr. Chairman, I will now focus on two issues related to
achieving success. The first one is on the question of the
degree of program readiness in developing countries and second
is on the resource gap. I will then conclude with discussing
some opportunities and challenges for spending resources wisely
and effectively.
First, we should remind ourselves that today we need to
plan for success, and wherever effective AIDS responses are
found, there are five key principles at work. There is
leadership at all levels, mobilization of broad coalitions and
good coordination. Overcoming stigma is one of the major
obstacles to prevention and care. Fourth, responding at the
scale commensurate with the epidemic. Finally, applying
strategies based on good science, whether that is biomedical
science or political science.
All this requires resources, not only dollars, but also
capacity, people, systems, institutions. And that brings me
then to the first broad issue.
Do developing countries, developing societies have the
capacity to program greatly increased funds to combat AIDS in
their communities? We have been looking into this crucial
question. We have been looking into this crucial question as
part of an ongoing UNAIDS assessment of the current status of
AIDS programs in 114 low- and middle-income countries.
We used five core indicators of AIDS readiness: national
AIDS plans, the capacity to operationalize the plan, costings
of the plan, a monitoring and evaluation strategy, and
mechanisms that can achieve coordination among governments,
nongovernment actors, the UN system, and bilateral donors.
Across the globe, of 114 countries there are 24 countries
assessed where all the elements of comprehensive AIDS
programming are already in place. At the other extreme there
are eight countries which are yet to develop any of the
elements of readiness. Most are in the middle range.
These results are encouraging, but at the same time they
also identified some generic weaknesses, such as insufficient
monitoring and evaluation capacity. Above all, they tell us
that unless we invest equally in people, systems, and
institutions, as much as in activities and interventions, we
have less chance of getting the dollars to do their work.
It also tells me, also as Mr. Natsios alluded to, that it
is time for some out-of-the-box thinking, meaning for me
outside of the public health system, outside the health
services when it comes to tackling AIDS. Particularly in many
African countries, the capacity of these health systems today
is probably lower than it was at the beginning of the AIDS
epidemic for a variety of reasons, including because of AIDS
itself which is killing the doctors and the nurses. So, let our
AIDS programs go to where the capacity is, business and unions,
churches and mosques, schools and sports.
Mr. Chairman, let me now turn to the issue that is on
everybody's mind in this room apparently and that is the other
side of the resources. That is the dollars. The needs are now
well documented. They were mentioned many times this morning.
But where are we today with the money available?
The total available this year, we estimate, is going to be
roughly about $2 billion in terms of international resources,
which by the way is less than the NIH budget for AIDS research,
as I heard this morning.
The good news and real progress is that the Global Fund
represents a 50 percent increase this year in currently
available international funds for AIDS, and it has really
generated additional money not only in this country but also
from the European and Japanese side. That in itself I think is
already a proven value-added of this Global Fund.
As Secretary Thompson mentioned, less than a year ago, UN
Secretary-General Kofi Annan called for a war chest at an OAU
Summit on AIDS in Abuja. And we had already the first meeting
of the board of directors, and most probably in April, the
first grants will be given, and that will be less than a year
after the first pledge to the fund by President Bush.
But let me be clear, Mr. Chairman, since you raised it
yourself as well. The Secretary-General, when he was mentioning
$7 billion to $10 billion, said that this represents the
current need of programmable AIDS funds in the world. He never
meant to say that all this money should go through one single
mechanism, the Global Fund.
Since Secretaries Thompson and Dobriansky gave a very
accurate description of where we are with the Global Fund, I
will not repeat it. But I would say that the comparative
advantage of this newest actor must be in its ability to focus
new resources, additional resources, rapidly and directly, on
the programs with the best chance of success in the countries
with the greatest needs. I think what has come out of the fund
negotiations is very close to what was called for in the
original legislation in this house.
I feel that this is a good and very promising start, but
Mr. Chairman, allow me to focus now on the resources gap today
and tomorrow.
Our estimates take into account what we believe the growing
needs and growing program capacity will be in the near future.
The Global Fund represents one-third of currently available
international resources for AIDS; it accounts for about 16
percent of the total need.
The gap between current expenditure and total needs is so
large, that moving immediately to the $10 billion of
expenditure is impractical. Instead, we need to envisage a
route to a comprehensive response where the available funds
progressively increase over the next 4 years. If today's
expenditure on AIDS were to be maintained only, next year's
funding gap will be greater than $2 billion. By 2005, it will
be about $7 billion.
But if we build on current activity and make a reasonable
estimate of where it can be scaled up, then for each of the
next 4 years, expenditures need to be increased by roughly 50
percent. This should not only happen in terms of the Global
Fund to Fight AIDS, TB, and Malaria, but in terms of all
resources that are there to fund AIDS programs, including
resources of the governments of the countries that are
affected. Some large, middle income countries have already
started to spend significant amounts of money on AIDS. I am
thinking of Brazil, India, South Africa, and incidentally,
Brazil and South Africa at the board meeting indicated that
they will not seek funding from the Global Fund on AIDS, TB,
and malaria.
So, Mr. Chairman, the fight against AIDS is a race and so
far it is the virus that has been winning. There is no doubt
about that. But we are now in a position to make a leap
forward, a leap that for the first time will put us ahead of
HIV.
I would be kidding myself, of course, and all of you if I
said that this task was going to be a very easy one. There are
huge challenges, and collectively we have to turn thousands of
really effective AIDS programs and activities around the world
into hundreds of thousands, reaching all nations. We have got
to coordinate all the players in the AIDS response--very
important now with increasing resources. We have got to unblock
the resource pipelines so resources get to communities
effectively. We have got to meet the challenge to be led by
science and evidence, and we have got to put in place strong
mechanisms of programmatic and financial accountability.
You, the U.S., have already proved yourself willing to take
a leadership role and make the required leap forward. We would
strongly encourage you to continue in that leadership role,
because I know that it is contagious--in the good sense of the
word--to other countries. And I look forward to our continued
partnership in meeting this great challenge. Thank you.
[The prepared statement of Dr. Piot follows:]
Prepared Statement of Dr. Peter Piot, Executive Director, UNAIDS
Mr. Chairman, distinguished members of the committee, ladies and
gentlemen.
I thank you for the opportunity to testify this morning, and I
applaud you for your focus on the global AIDS epidemic.
I am here today on behalf of the UN System organisations responding
to the global epidemic, and in particular the eight UN agencies whose
collective efforts on AIDS make up UNAIDS, namely UNICEF, UNESCO, ILO,
the United Nations Development Programme, UNFPA, UNDCP, the World
Health Organization and the World Bank.
AIDS IS DIFFERENT
And Mr. Chairman, I am here today to tell you that the AIDS
epidemic is different from any other epidemic the world has faced, and
as such, requires a response from the global community that is broader
and deeper than has ever before been mobilized against a disease.
Twenty years since the world first became aware of AIDS three
things have become clear:
that humanity is facing the most devastating epidemic in
human history, the impact of which threatens development and
prosperity in major regions of the world.
that for all the devastation it has already caused, the AIDS
epidemic is still in its early stages; and
that we are in a position to bring the epidemic under
control.
The first twenty years in the history of an epidemic is only the
blink of an eye. The other communicable diseases that ravage many parts
of the world have been known for many centuries. Their patterns of
spread have become well-established and predictable.
Mr. Chairman, committee members, AIDS is unlike any other epidemic
that we have faced:
It affects every strata of society--wealth is no protection
against the virus;
Young adults are its biggest target--so it kills people just
when they are in the most productive--and reproductive--phases
of their lives;
It has far-reaching ripple effects, on the economy, on the
family and for the generation of children left without parents;
It remains surrounded by taboo and stigma--still a huge
barrier to effective responses.
It spreads silently, so millions can be infected with HIV in
a population before the impact in illness and death becomes
apparent.
This silent spread and slow impact of AIDS have meant that the
threat it poses has been consistently underestimated. For a moment, let
us compare it to the much feared Ebola, a virus I have had first-hand
experience of, dating back to when I was a member of the team that
investigated the first known epidemic of Ebola virus infection in 1976
in then-Zaire.
Ebola spreads rapidly and causes illness instantly, so there is
never any doubt about the need for a rapid and comprehensive response.
Today, when Ebola breaks out anywhere, action teams are dispatched
without delay. The immediate and present danger it represents is
readily recognized and the international community immediately mounts
an appropriate response to halt the new epidemic--and Ebola has caused
probably no more than 1000 deaths in total.
Now, let us imagine a much smarter virus than Ebola. A virus just
as deadly, but one capable of creeping silently through whole
populations before it revealed itself. A virus whose casualties from
its local epidemics are not measured in the hundreds, but in the
hundreds of thousands. A virus that kills slowly, and painfully, and
generally only after stigmatizing and pauperizing the entire family of
an infected person.
It is difficult to imagine a smarter, more devastating virus than
the subject of this hearing, the virus that causes AIDS. And it is
equally difficult to imagine a world unwilling to mobilize to slow the
spread and eventually contain this virus. All the more so, given what
we know about it, how long we have seen it coming, and where we can now
see it going.
THE STATE OF THE GLOBAL EPIDEMIC
More than 60 million people worldwide have been infected with the
virus--nearly double the population of California. Since the epidemic's
start, twenty million of the sixty million people infected with HIV
have died--a number equivalent to the populations of Texas or New York
State.
HIV/AIDS is now by a large margin the leading cause of death in
sub-Saharan Africa and the fourth-biggest global killer. Life
expectancy in sub-Saharan Africa is now 47 years, when it would have
been 62 years without AIDS. In 2001 alone, an estimated 5 million
people became infected with HIV, and half of them were young people
between the ages of 15 and 24. There were an estimated 800,000 children
under 15--mainly infants--infected with HIV in 2001, and 580,000 child
deaths as a result of AIDS.
Sub-Saharan Africa is the region of the world where the epidemic
has been worst and where its impact increasingly threatens the
stability of whole societies.
Average prevalence in sub-Saharan Africa is 8.8 per cent in the
adult population (15-49 years old). There are seven countries, all in
the southern cone of Africa, where more than twenty per cent of adults
are infected with HIV, and a further nine countries where infection
rates exceed ten per cent.
We still do not know what is the upper limit for the extent of HIV
spread in a population. Botswana is the country with the highest HIV
rate to date with 36 per cent of adults infected. It is followed by
Swaziland, Zimbabwe and Lesotho all between 24 and 25 per cent.
While the scale and impact of AIDS in sub-Saharan Africa is the
worst in the world, HIV is a rapidly expanding problem in other
regions.
HIV/AIDS is growing fastest in the countries of the former Soviet
Union. There are a million cases in the region, and at least 250,000
new HIV infections in the past year--most of them in the Russian
Federation. Ukraine has the highest prevalence with nearly 1% of the
adult population living with HIV.
In Asia, China and India currently have relatively small overall
prevalence, but given their huge populations, within each there are
large numbers of people and locally high proportions that are infected
with HIV. For example, the Indian states of Maharashtra, Andhra Pradesh
and Tamil Nadu, each with over fifty million people, have HIV rates
measured in pregnant women above three per cent, over four times the
national average. In China, we have estimated that concerted action
taken now will be able to avert ten million new HIV infections over the
coming decade.
Adjacent to the U.S. mainland, the Caribbean is, next to Africa,
the second-most affected region in the world. In a number of countries
in the Caribbean and Central America more than two per cent of the
population is HIV infected and adult HIV prevalence has risen to over
4% in Haiti and the Bahamas.
Nor can we declare HIV a problem that is over in the U.S., western
European, and other wealthy countries--the rate of new infections in
the U.S. and Western Europe has not been significantly reduced in the
last decade. In the course of 2001, an estimated 30,000 adults and
children became infected with HIV in Western Europe and 45,000 in North
America, taking the total numbers living with HIV in these regions
combined to 1.5 million. In these countries the face of the epidemic
has changed, and it is among the poorer, ethnic minority and immigrant
populations that the numbers infected with HIV are growing fastest.
Ironically, access to more effective HIV treatment may also be
associated with rises in unsafe sex among some of the populations that
historically have shown the greatest level of behaviour change, such as
gay men.
the impact of aids: every sector is affected
Mr. Chairman, distinguished committee members, AIDS is currently
one of the greatest threats to global development and stability. It is
a long-term humanitarian crisis of unprecedented proportions--the death
and misery it has caused in the past twenty years dwarfs all of the
natural disasters that have occurred in that time combined. The HIV
epidemic has not only disrupted many millions of individual and family
lives, it has threatened the stability of entire societies.
Economic Impact
In the worst affected countries, AIDS has a major impact on
business productivity, on livelihoods and the supply of food, and on
professionals: from doctors through to police forces. For example, in
Kenya, AIDS accounts for 75 per cent of all deaths in the police force
over the past two years. AIDS not only affects the poor, but also the
educated and skilled. In South Africa, for example, ING Barings Bank
projects that one-third of the semi-skilled and unskilled workforce
will be HIV-positive by 2005, 23 per cent of the skilled workforce and
13 per cent of the highly skilled workforce. In the mining industry
throughout Africa there is now an acute problem in replacing skilled
mine workers lost to AIDS. And in Zambia, nearly two thirds of deaths
among managers have been found to be attributable to AIDS, a higher
proportion than among middle-ranking workers.
Consequently, AIDS has a direct impact on rates of economic growth
in the most affected developing countries. There is a direct
relationship between the extent of HIV prevalence and the severity of
negative growth in GDP. When the rate of HIV in a population reaches 5
per cent, per capita GDP can be expected to decline by 0.4 per cent a
year. And when HIV reaches 15 per cent, a country can expect a one
percentage annual drop in GDP.
The cumulative impact of HIV on the total size of economies is even
greater. By the beginning of the next decade, South Africa, which
represents 40 per cent of the region's economic output, is facing a
real gross domestic product 17 per cent lower than it would have been
without AIDS. Similar studies in the Caribbean suggest Jamaica and
Trinidad and Tobago face a five per cent loss in GDP by 2005 as a
result of AIDS.
In settings where subsistence agriculture predominates, measured
economic productivity only scratches the surface of the total impact of
HIV on livelihoods. For example, AIDS hits the long term capacity for
agricultural production, as livestock is often sold to pay funeral
expenses, or orphaned children lack the skills to look after livestock
in their care.
Armies are among those most affected by HIV. HIV rates in the armed
services are in many cases two or three times higher than those in the
respective civilian populations. When armies are deployed they spread
HIV in the populations where they are stationed, and when they are
demobilized they spread HIV in the towns and villages to which they
return.
Human Impact
But measures of per capita GDP in fact underestimate the human
impact of AIDS, as AIDS kills people, not just economic activity. We
should reflect on what it means for a society when 10, 20 or 30 per
cent of the population is HIV infected:
with today's rates of infection, there is a more than 80 per
cent chance that a fifteen year old boy today in Botswana will
eventually die as a result of AIDS;
nurses and teachers are dying faster than they can be
replaced. Last year there were around a million African
schoolchildren who lost their teachers to AIDS. In Malawi 6 to
8 per cent of the teaching workforce die each year.
The immediate impact of AIDS is felt most acutely in families where
one or more members are HIV infected. In South Africa, households will
on average have 13 per cent less to spend per person by 2010 than they
would if there were no HIV epidemic. In Cote d'Ivoire in West Africa,
the household impact of HIV/AIDS has been shown not only to reverse the
capacity to accumulate savings, but also to reduce household
consumption. AIDS not only affects income, with lower earning capacity
and productivity, it also generates greater medical, funeral and legal
costs, and has long term impact on the capacity of households to stay
together.
This is most manifest in the number of children orphaned by AIDS,
which now totals nearly 14 million. In developing countries, before
AIDS around 2 per cent of children were orphaned, but now in many
countries, 10 per cent or more of children are orphans. The war in
Sierra Leone left 12,000 children without families. AIDS in Sierra
Leone has already orphaned five times that number.
A fundamental part of our response to the epidemic must address how
families and communities will cope.
How many orphaned boys, and particularly girls, will not go
to school because there is no one to pay their school fees, or
no one to dress them and get them out of the house in the
morning, or because they have to help grow the food to feed the
remaining family?
What does it mean for society to have a significant
proportion of desocialized youth?
How many will end up desperate and easy prey for militias
and warlords?
Progress in the global response
Mr. Chairman, distinguished committee members, for too long we have
been transfixed by the toll of the increasing HIV epidemic, unfolding
before our eyes. Now we are shifting our gaze: success is squarely in
our sights.
I believe that for the first time in the short history of this
epidemic, the world is in a position to translate local and national
examples of success into a truly global movement against the HIV
epidemic. This is a great leap forward from where we were even a few
years ago.
Five major elements define what today gives us the ability to
seriously and successfully approach this epidemic on a global scale.
First: there is manifestly greater political momentum dedicated to
addressing AIDS. We have learned that political leadership is required
at all levels to marshal the necessary commitment and resources for the
social mobilisation on which the response must be built.
The level of political commitment to addressing AIDS has
dramatically increased on every continent--and not least in
this country, and very importantly, right here on Capitol Hill.
Within the United Nations, increasing momentum is being led
by the Secretary-General Kofi Annan. His public declaration
that the fight against AIDS is his personal priority has helped
to energize the whole of the UN system in its focus on AIDS, as
well as opening doors to key political and business leaders
around the world on this issue.
In many cases, it has been when Presidents and Prime
Ministers have taken control of the AIDS response that the most
rapid advances have been made. Five years ago, we were
challenged just to persuade Health Ministers that they ought to
take AIDS seriously. Now, we find ourselves responding to
Presidents and Prime Ministers throughout Africa, the
Caribbean, the Americas, Asia and Eastern Europe who display
deep personal commitment to the fight against AIDS.
Some of the most prominent political leadership has been in
Africa. For example, two years ago Botswana's President Mogae
declared ``as long as we still talk derisively about the HIV/
AIDS virus and its victims . . . the pandemic will remain the
invisible monster that stalks us in the darkness.'' With these
words, he immediately opened up new opportunities across the
nation for social dialogue and with his continuing strong
leadership Botswana's AIDS response has since gone from
strength to strength.
Today, when political and other leaders come together, AIDS
is on the agenda--from the G-8 to the World Economic Forum to
the Organization of American States.
The second major element is that we can now point to increasing
success in countries. In the developing world there are a number of
familiar examples. In Uganda, surveys in urban areas in the early 1990s
found 30 per cent of pregnant women were infected with HIV, but there
have been sustained drops since then to less than 10 per cent. In
Thailand comprehensive prevention efforts mean that the number of new
HIV infections today is less than a quarter of the number a decade ago.
And Senegal is a prime example of a country where the HIV epidemic has
been kept small.
But today I would also like to draw attention to less familiar
examples of success. For example:
In Cambodia, despite the pressures on a society emerging
from genocide and conflict, the threat of HIV in the mid-1990s
was responded to, and as a result there are measurable declines
in both risk behaviours and in the levels of HIV--the infection
rate among pregnant women in Cambodia declined by almost a
third between 1997 and 2000.
Elsewhere in South-East Asia, the Philippines has kept HIV
rates low with strong prevention efforts and mobilisation
across society involving community and business organisations.
Tamil Nadu state in India has recorded reductions in risk
behaviour, reflecting the success of the state's comprehensive
HIV prevention programme. Here, as everywhere, these efforts
need continual renewal, with evidence that reductions in risky
behaviour may have plateaued.
In Africa, Zambia's focus on HIV prevention among youth and
its efforts to involve business, farmers, schools and religion
in the fight against AIDS have also shown success. In response
to AIDS, young women in cities in Zambia have reported less
sexual activity as well as increases in condom use, and the age
at which they first become sexually active is increasing. As a
result, the proportion of pregnant women under 20 who were HIV-
positive had fallen from 27% in 1993 to 17% by 1998. In the
Mbeya region in Tanzania, falls in HIV incidence have come
through a decade of sustained action. Building local skills and
infrastructure has been a core part this effort, along with
generating political support and working through schools,
health centres, churches, village committees and local
businesses to deliver AIDS information and education, treat
sexually transmitted diseases, deliver condoms, and provide
community care for people with HIV.
Brazil provides a leading example of integrating renewed
commitment to prevention with comprehensive care. In 1994, the
World Bank estimated that Brazil was heading towards 1.2
million HIV infections by 2000, but success in prevention in
the second half of the 1990s kept the total down to 540,000. In
1996, Brazil established a legal right to free medication. The
numbers of patients using antiretrovirals grew from 25,000 in
1997 to 100,000 today, and the number of AIDS deaths has fallen
by 60 per cent.
Similarly, in Barbados, planning for universal treatment
access has been a core element of a major renewal in the
national effort against HIV. With an expanding epidemic in a
small population, Barbados is becoming a leading regional
example with the strength of its government-wide AIDS response,
led by the Prime Minister and supported by the World Bank.
The third major element is that there are now widely accepted
strategic approaches which are derived from these successful country
experiences. The Global Strategy Framework for AIDS which has been
endorsed by all the members of the UNAIDS Programme Coordinating
Board--including, of course, the U.S.--sets out a common understanding
of the dynamics of the epidemic and the leadership commitments that are
required to reverse it. As a consequence within the UN system, 29
different UN system bodies share a common strategic plan.
The global response to AIDS has moved beyond the stage of trying
small scale experiments to see what might or might not have an effect.
We are now at the stage of translating proven approaches to full scale
national responses. These approaches include:
Building broad coalitions between governments and other
partners from outside government, including community
organisations and business, that expand the response to AIDS to
include all fields of economic and social life.
Addressing changes in the behaviour of individuals and
equally of institutions. The levers of change are to be found
in pulpits and press rooms as much as they are in health
centers. Changing the norms surrounding sex--which is at the
heart of HIV prevention--has never been a task best left to men
in white coats. We need doctors and nurses to provide
treatments, but when it comes to HIV prevention, more lives
will be saved by journalists, clergy, teachers and politicians.
Addressing the stigma surrounding HIV. A major barrier to
comprehensive AIDS prevention and care efforts remains stigma
against people infected with HIV or against those groups where
HIV is thought to be most common. We know we have a long way to
go in fighting AIDS stigma when children from AIDS affected
households are excluded from school, or AIDS patients are
routinely turned away from medical services for even the most
straight-forward of complaints. Responding to stigma requires
involving people living with HIV centrally in the AIDS effort.
Ensuring that responses to HIV are on a scale commensurate
with the scale of the epidemic itself. We make a real
difference to the epidemic when we ensure that local actors
have the information they need to respond, and when the systems
are in place that make sure they have the necessary resources
available. By delivering responses that are rooted in
communities, we build to the scale of response required.
Responding to the epidemic with a combination of efforts.
Just as combination therapy has proved the key to cracking the
nut of HIV treatment, so too combination prevention is the key
to stopping the spread of HIV. There will never be a single,
one-size-fits-all solution to HIV.
The fourth major element, is that there is now a clear set of
global priorities in the fight against AIDS.
The series of benchmark targets adopted by all the world's
countries in the UN General Assembly Special Session on AIDS
last June in New York provide a common platform for
accountability. Countries unanimously pledged themselves to a
series of targets and goals, including a 25% reduction in the
level of HIV among youth people in the hardest-hit countries by
2005, and a 50% reduction in the proportion of infants infected
with HIV by 2010. Countries also pledged to promote access to
vital drugs and ensure a supportive environment for children
orphaned by HIV/AIDS. The most important legacy of that meeting
has been the upsurge in country activity dedicated to meeting
these targets.
The clear international consensus that has formed around
young people as a priority for action has been particularly
important. Young women and young men need to take joint
responsibility for reducing the impact of AIDS on their lives.
They have proved themselves capable of changing the course of
the epidemic if they have the right knowledge and support. In
every country where HIV transmission has been reduced, it has
been among young people that the most spectacular reductions
have occurred. The UN General Assembly Special Session on
children coming up in May will again be an opportunity for all
the world's nations to set themselves on course to reducing the
toll of AIDS on infants and young people. UNAIDS, and in
particular our Cosponsor UNICEF, is ensuring that responding to
AIDS is a core element of the global response to children's
needs.
The fifth major advance is in the new realism about the resources
required to tackle AIDS.
additional resources required to address the aids epidemic
Before I come to the total requirements, I will first try to put
into perspective how additional resources could make a real difference
to the epidemic. Let me take the example of a modest annual investment
of $10,000.
If we spent that money on voluntary counseling and testing in
India, there are non-government organisations that would provide good
quality HIV counseling and testing services to 10,000 people. Or in
Gujarat, a hundred buses that could carry AIDS messages for a year,
reaching many thousand town and village dwellers.
$10,000 would allow the Brazilian Girl Guide and Scout movement to
reach another ten thousand young Brazilians with an AIDS education kit.
It would support 80 peer educators to reach hundreds of street children
in every part of Brazil. It would allow the Living Positively project
in the central Goias state to reach more women with HIV, helping them
to avoid transmission to their babies and training them as peer
educators.
In Zambia, with $10,000 there are 1000 orphans who could receive
bursaries so they can stay in school. $10,000 would let the Catholic
church in Zambia train another 100 rural caregivers a year in providing
community home-based care. There are six more health workers who could
be trained and supported to provide antenatal care and antiretroviral
drugs to help prevent mother to child transmission.
What does this add up to?
There is wide global recognition, including from the UN General
Assembly, that AIDS spending in low and middle income countries needs
to rise to $7 to $10 billion annually for a comprehensive AIDS
response. The task we face today is to strategically multiply the
number of these $10,000 investments until they reach the scale of the
epidemic itself. It is no small undertaking--a million such investments
make up the ten billion dollar target. But there are tens of thousands
of communities that stand ready to take action and are desperate to do
so, and there are hundreds of thousands more to which success could be
spread.
A more detailed breakdown of the estimated total spending need has
been made by an international group convened by UNAIDS and published
last year in Science magazine. It shows there are major differences
between regions in the balance of spending needed to respond to the HIV
epidemic. In Africa, where 28 million people are already living with
HIV, roughly two out of every three dollars would be needed for care
and support. In Asia and other regions where the greatest opportunity
still exists to prevent massive spread of HIV, the majority of funding
would be directed toward prevention programs.
Almost one-quarter of the estimated need in prevention expenditure
is for education, counseling and mass media communications aimed at
youth to help them avoid becoming infected. We need to provide good
information and support to youth before they become sexually active and
provide better services and a safer environment once they do become
sexually active.
Also included in the estimates are the costs to achieve the global
goal to reduce mother to child transmission of HIV and thereby reduce
the proportion of children infected with HIV by 20% by 2005 and by 50%
by 2010. We can achieve this with known technologies that are
appropriate in developing country settings. Our challenge is to build
up the infrastructure and enhance human capacity to implement these
programs for the largest possible number of women. Achieving this goal
will save over 100,000 infant lives in 2005 and by 2010 the cumulative
number of babies saved would be more than 1.3 million.
Assistance to communities and for school fees could require $700
million in 2005. By 2005 there may be as many as 19 million children
orphaned by AIDS. This number is so large that even extended families
will find it hard to cope. We must assist the communities where these
children live to provide care and support and provide special
assistance to ensure that these children have educational opportunities
and do not end up in the street.
The business sector has an important role to play in funding the
expanded response. Approximately 7% of the total resource need is for
workplace prevention programs that can be funded by private
enterprises. Many employers are also funding advanced treatment for
their employees. Business involvement is crucial, not only because
bottom lines are being hurt by AIDS, but also because business is often
in the best position to reach its staff and the communities they live
in. This is especially the case where there are mobile workforces, and
men especially are removed from their families to find work--in this
context, our definition of risk group need to expand beyond the obvious
examples, like miners, to include others, for example trainee bank
managers.
Roughly a quarter of the total resource need is for anti-retroviral
drugs. Negotiations with the pharmaceutical industry have resulted in
significant price reductions that are beginning to make it feasible to
deliver these life saving drugs to those who need them. But progress in
delivering treatment needs advances on three fronts simultaneously:
--finance;
--stronger health systems, so these drugs can be delivered and their
health benefits maximized; and
--the expansion of voluntary counseling and testing services since
the great majority of people around the world who are living
with HIV do not know whether they are HIV infected, an obvious
prior condition of treatment access.
can extra resources be spent wisely and effectively?
Countries do have the capacity to programme substantially increased
levels of new AIDS funds. UNAIDS has just finished an assessment of the
current state of programme readiness which has shown that the majority
of countries assessed have already completed much of the planning and
programme development work required to be confident of success in
expanding their responses to AIDS. There are still some gaps in
programme preparedness, especially in the monitoring and costing of
plans. However, it is clear that developing countries are seriously
engaged in detailed strategic planning on AIDS.
AIDS planning was well developed in 93 out of the 114 countries
assessed--though there remain major challenges in roughly a third of
the countries assessed--particularly in Africa. There are five core
components to AIDS readiness: national AIDS plans, the capacity to
operationalize the plan, costings, a monitoring and evaluation strategy
and mechanisms that can achieve coordination among governments, non-
government actors, the UN system and bilateral donors. Across the
globe, there are 24 countries assessed where all the elements of
comprehensive AIDS programming are already in place. At the other
extreme, there are 8 countries which are yet to develop any of the
elements of readiness.
One of the ironic benefits of a well-advanced epidemic in much of
Africa is that there are good estimates both of the scale of the
epidemic and of the resources needed to mount a response. The sea
change among African leaders and communities to deal frankly and firmly
with the challenge of AIDS is now apparent. Most governments have shown
themselves willing to channel public resources to community and civil
society organisations. But the systems to support the renewed
commitment in most areas of prevention, treatment, care and impact
mitigation remains weak. An important positive development has been the
more effective and transparent use of resources. There are twelve
African countries that have established a management capacity to deal
with big increases in funding through the World Bank's Multi-country
AIDS Programme for Africa and another 15 are establishing the fiduciary
infrastructure required.
Our assessments of AIDS programming around the world also indicate
that there is a compelling need for more intensive planning and
programme development for effective responses in the education, social
welfare, agriculture, and other sectors. Programme development in these
sectors has lagged considerably behind the health sector.
The resources gap
Mr. Chairman, committee members, we are currently far from having
secured the $10 billion required for a comprehensive AIDS response in
the world's low and middle income countries.
In these countries in 2002, somewhat over $2 billion will be spent
on AIDS, including the $1.7 billion made available by the international
community. International spending is joined by significant national
government expenditures on AIDS, which in middle income countries like
South Africa, Brazil or India run to the hundreds of millions, but
elsewhere are much smaller.
The gap between current expenditure and total needs is so large,
that moving to $10 billion of expenditure immediately is impracticable.
Instead, we need to envisage a route to a comprehensive response where
the available funds progressively increase over the next four years.
If today's expenditure on AIDS were to be maintained only, next
year's funding gap will be greater than $2 billion growing to at least
$7 billion by 2005. The implications are quite clear and represent a
major challenge for the development of vigorous resource mobilisation
strategies.
To achieve our objective of scaling resource availability to keep
pace with programming capacities, we need to see a roughly 50 per cent
increase in funding each year, in each of the next four years.
The funding required neither could nor should come from a single
source. Only when funds are maximized from all sources can we claim a
comprehensive AIDS response.
There are five distinct groups of actors involved in responding to
AIDS. Each of them has their own advantages in supporting a
comprehensive AIDS response, both in relations to the resources the can
mobilize but also in the tasks and responsibilities they perform best.
First are developing countries themselves. National
ownership and responsibility is a sine qua non of effective
AIDS responses and it needs to be accompanied by budgetary
allocations. A clear expression of commitment has come from the
African continent with the Abuja Declaration adopted at the
Organization of African Unity's special summit on AIDS last
year which included a pledge that 15 per cent of national
budgets would be allocated to health to help fight AIDS and
related diseases.
Second are bilateral donors whose comparative advantage lies
in being able to draw on domestic technical resources, for
example within their universities and national programmes, and
their capacity to build solidarity directly between their own
communities at home and those in the recipient countries--for
example through networks of non-profit organisations.
Currently, the U.S. accounts for approximately one-third of the
bilateral resources focussed on HIV/AIDS.
Third are multilateral organisations which are particularly
well placed to ensure that internationally accepted scientific
and technical standards are applied, to help promote consensus
on the effective approaches to complex and difficult social
issues, and in the case of the World Bank credits, to
facilitate the internalisation of new resources within the
budget and finance mechanisms of countries, contributing to
longer term financial sustainability of programmes.
The fourth group, international NGOs and business, is
becoming increasingly important. The size, range and
sophistication of business involvement in the fight against
AIDS has grown enormously over the past few years, although it
is still only a faction of its potential. Business knows it
needs to protect its investments in workforces and in markets
against the impact of AIDS. Some of the most productive
business initiatives in AIDS have capitalized on key business
strengths. For example, UNAIDS has worked with MTV, which knows
a lot more about holding the attention of a teenager than we
do. UNAIDS is also working with Coca Cola in Africa--where in
Kenya Coke's vast distribution network has been used to get out
educational material on AIDS. There are also now a number of
primarily U.S.-based foundations that have made significant
commitment to global AIDS efforts, notably the Bill and Melinda
Gates Foundation. But as well, there are many other U.S.-based
foundations whose AIDS work joins their long history of concern
about health and progress--the coalition of Foundations
supporting the HIV prevention among women and prevention of
mother-to-child transmission is just one of the many examples,
and it includes the Rockefeller, Bill & Melinda Gates, William
and Flora Hewlett, Robert Wood Johnson, Henry J. Kaiser Family,
John D. and Catherine T. MacArthur, David and Lucile Packard,
and UN foundations.
The fifth and the newest actor is the Global Fund. Its
comparative advantage must be in its ability to focus new
resources, rapidly and directly, on the programmes with the
best chance of success, in the countries with the greatest
need.
the global fund to fight aids, tuberculosis and malaria
The establishment of the Global Fund to fight AIDS, Tuberculosis
and Malaria has signaled the new decisiveness in global AIDS efforts.
It was only April of last year that UN Secretary-General Kofi Annan
declared at the Organization of African Unity's Special Summit in Abuja
that the world needed a new ``war chest'' in the fight against AIDS.
The Fund will approve its first proposals this April--less than a year
after the Secretary-General's call to action.
In 2002 the Global Fund has around $800 million available to it to
disburse, and the sources of these funds are largely G-7 pledges. Of
course, the Fund will be considering TB and malaria as well as AIDS,
although AIDS clearly has the greatest proportion of the needs. The
presentation I and Dr. Brundtland, Director-General of the World Health
Organization, made to the first meeting of the Board of the Global Fund
estimated that AIDS accounts for 76 per cent of total global needs,
tuberculosis 19 per cent and malaria per cent.
The Fund has been constituted as a financing instrument to
complement the work and responsibilities of existing organisations. Its
efforts will therefore be concentrated where they are most needed: on
generating and making available additional resources. The Fund is there
to support what is happening at community and country level--proposals
have to be owned in the places where the money is going to.
The Fund is a public-private partnership--its Board includes
business representation, as well as non-government organisations and
representatives of the communities directly affected. The UNAIDS
Secretariat, together with our Cosponsors the World Health Organization
and the World Bank, sit on the Board. Part of our role will be to help
countries in the development and preparation of proposals and to make
available our expertise and networks available to the Fund to ensure it
has the best possible advice about where its money will make a key
difference.
Already, regional planning has taken place-- earlier this month a
meeting for the Asia-Pacific region demonstrated the enormous interest
in the Fund from countries, and their preparedness to put forward the
best possible proposals.
In calling for proposals, the Fund has declared its intention to
promote partnerships among all relevant players within countries and
across all sectors of society. It will build on existing coordination
mechanisms, and promote new and innovative partnerships where none
exist. Proposals will be considered through country coordination
mechanisms, but eligibility for funding is not restricted to
governments: public, private and nongovernmental programmes can be
funded.
The Fund will support programmes both within and outside the health
sector if they are technically sound, cost-effective and focus on
performance by linking resources to the achievement of clear,
measurable and sustainable results.
The support for the Fund in the U.S. Congress was a crucial factor
in meeting the rapid timetable for its establishment. The two tranches
of $200 million so far allocated to the Fund by the U.S. government
have also set the pace for pledges from the rest of the world: total
pledges to the Fund now stand at just under $2 billion.
A very wide international coalition has come together in the Fund,
and in spite of the range of interests represented, it is notable that
key considerations set by the U.S. Congress have been met including
that:
--it will coordinate its activities with governments, civil society
nongovernmental organisations, UNAIDS the private sector and
donor agencies; and
--nongovernmental organisations, including faith-based organisations,
will be eligible for assistance, and eligible areas include
treatment and the provision of interventions to reduce mother-
to-child transmission.
Mr. Chairman, committee members, pledges to the Global Fund already
represent a 50 per cent increase on the international funds available
to fight AIDS. This is progress!
The challenge now is to build on this progress: to make the Fund
work well by demonstrating that it can spend wisely, spend rapidly, and
show results. If it does this, it is our hope that it will be an
increasingly attractive proposition for donors, and the Fund will grow.
moving forward
Mr. Chairman, committee members, AIDS is a massive global problem,
but it is a problem with a solution.
The tools for effective responses exist. In the vast majority of
countries around the world, there are detailed plans for dealing with
AIDS. There are countless communities ready to take action. And in
order to build success, increased financial investment needs to be
equally matched with investment in human resource and institutional
capacities.
If we are to achieve success, we need to know how our progress is
going. Critical U.S. support in monitoring the epidemic and in
evaluating the success of AIDS programs has put us in a better position
than a few years ago. The cooperative framework for monitoring and
evaluation that the UNAIDS Secretariat has been able to deliver has
resulted in a level of consensus and influence at country level which
has far surpassed what any one agency alone could have achieved.
Of course, for AIDS spending to be worthwhile, it needs to be able
to flow efficiently to the levels it is needed. Improving both
governance and the efficiency of resource transfer mechanisms remains a
core priority for UNAIDS, including our Cosponsors, particularly UNDP.
Mr. Chairman, committee members, the fight against AIDS is a race,
and so far, it is the virus that has been winning. But we are now in a
position to make a leap forward--a leap that will for the first time
put us ahead of HIV. I would be kidding myself as well as all of you if
I said the task was an easy one. There are huge challenges:
First, the challenge of scale. There are perhaps a few thousand
really effective AIDS programmes and activities around the world today.
Unless we can rapidly escalate this number to a few hundred thousand,
we will fall behind in the race.
Second, the challenge of coordination. Funding for AIDS has
increased. The number of players has increased. Different parts of
government are now substantively involved. International and national
non-governmental players are increasingly important. But while we must
celebrate this renewed level of activity, unless there is a
corresponding increase in coordination, we will still fall behind in
the race.
Third, the challenge of resources flow. There are still far too
many blockages between resource availability at global level and
resource needs at the local, village and neighborhood level. Unless we
can unblock the resources pipeline, we will fall behind in the race.
Fourth, the challenge to be led by science. A pragmatic response to
evidence must be our guide in the AIDS response, already too much
effort has been diverted by those wishing to turn AIDS into their own
private bandwagon. Responding to AIDS will always touch raw nerves
around sexuality, drug use, relations between men and women, and the
limits of personal confidentiality. But unless we can find the ways to
agree to be guided by evidence and reason, then we will fall behind in
the race.
Meeting these challenges requires us to marshal all we know about
moving forward against the HIV epidemic. We know what to do. We know
how to do it. We know it needs to be done at the right scale. We know
what it costs. We are clearer than ever before about the ways in which
increased spending would make a real difference to the course of the
epidemic.
All these elements must now be put together. Success against the
epidemic will be achieved when all the players involved play to their
strengths.
Mr. Chairman, committee members, U.S. support for the global AIDS
effort is directed in three areas:
One, to the multilateral system, in particular the
international organisations including UNAIDS and our
Cosponsors;
Two, to the new Global fund to Fight AIDS, Tuberculosis and
Malaria; and
Three, in bilateral efforts, including those of USAID,
Health and Human Services, the CDC and research efforts through
the NIH, as well as other programmes including that of the
Department of Labor.
The United States government has long supported global AIDS
programs and underwritten a research effort that remains a beacon of
hope for people affected by the disease. It remains to the enormous
credit of the U.S. Department of Health and Human Services through its
Centers for Disease Control and Prevention that its expertise in
identifying disease outbreaks was applied rapidly and effectively in
the case of AIDS, and its continuing role both internationally and
domestically has contributed enormously to the effectiveness of AIDS
responses. More recently, initiatives have expanded--the U.S.
Department of Defense, through the LIFE project, has been a key player
in responding to AIDS awareness among the uniformed services, working
with UNAIDS together with the contribution of one of our Cosponsors,
UNFPA.
The U.S. is the first developed country to publish its 2003 budget.
Most others will be following suit in the next few months--and I hope
they will be able to take note that U.S. proposals for international
HIV/AIDS assistance for 2003 are on an upward trend. The U.S., like
every other donor, will need to do more if the world is to respond
effectively to AIDS. American bilateral efforts on HIV/AIDS--at USAID,
Health and Human Services including CDC, and the Departments of Labor,
Agriculture and Defense--and critically now the Department of State--
will also require further strengthening to keep up with country needs.
Unparalleled American know-how in such vital fields as medical
training, core public health functions, and service delivery are needed
more than ever to assist developing countries.
The U.S. has already proved itself willing to take its leadership
role in making the required leaps forward. We would strongly encourage
you to continue in that leadership role, and look forward to our
continued partnership with you in meeting this great challenge.
Thank you for your attention.
The Chairman. Thank you very much, Doctor.
Why don't begin with Senator Feingold?
Senator Feingold. I thank you, Mr. Chairman. I thank you
for your testimony.
Some in the advocacy community have called for the
establishment of a global procurement fund that would try to
secure economies of scale when it comes to pharmaceuticals to
treat HIV/AIDS and opportunistic infections that are associated
with the disease. What is your opinion of that idea and what
role, if any, is to be played by the UN and UN agencies in
terms of drug procurement today?
Dr. Piot. Thank you, Senator.
There are certainly advantages of large procurement
schemes. But as was said this morning also, the Global Fund is
meant to benefit from existing mechanisms, and when it comes to
global procurement, for example, UNICEF has a major supply
division which is taking on procurement for medical supplies
and others. I think it is probably the most cost effective way
to make use of these existing procurement systems. That is one
of the conclusions also of the board of the Fund a few weeks
ago where a small working group is now looking into the most
efficient and effective procurement mechanisms. But there is no
doubt that that will drive the price down just because of
economies of scale.
Senator Feingold. So, that is not a role that is
envisioned for the Global Fund.
Dr. Piot. For the fund itself, no, but it should tap into
existing procurement schemes.
Senator Feingold. In your experience, do different members
of the donor community have different priorities when it comes
to addressing the AIDS crisis? What about the priorities of
states that receive assistance from UNAIDS? Do you find that
their priorities are different from those of the donors?
Dr. Piot. Well, I could safely say that today the
situation has changed dramatically from where we were, as I
mentioned, 5 years ago, and that in my mind in all African
countries, for example, and in all Caribbean nations, AIDS is
one of the top priorities for the leadership. That is less so,
I would say, in Eastern Europe with the exception of Ukraine
where the President himself is chairing the National AIDS
Council and has declared 2002 the Year of AIDS. And it is also
highly variable in Central Asia. Let us not forget that in
Eastern Europe and Central Asia, we have got the fastest
growing AIDS epidemic in the world. So, it is a very variable
picture but there is good progress.
The key challenge now is not to convince any of these
leaders, certainly not in Africa, that AIDS is a threat to
their security, to the survival of the nation, but is to assist
with the how. How are we going to put in place effective
mechanisms that are going to make a difference at the community
level?
Senator Feingold. Let me try another angle on this. How
does UNAIDS work to avoid sort of a one-size-fits-all formula
in the approach to prevention, care, and treatment around the
world? If you could actually give an example of two very
different approaches that UNAIDS is taking in different places
just to illustrate it, I would appreciate it.
Dr. Piot. Yes. When I got into this job, this was one of
the questions I was struggling with because before UNAIDS
existed in the UN system, there was indeed the blueprint
approach to AIDS. Whether you were in China or in Uganda, it
was all the same. First of all, culturally that will never
work, and second, the needs are different.
When I look at the resource needs, for example, the
estimates that we made to come to the $7 billion to $10 billion
figure, are based on the fact that in Africa the needs, in
terms of treatment and care, are far greater than, for example,
in Asia where a much, much lower percentage of the population
is infected.
The principle should be really that each country has to
define its own road map, but the principles and the goals are
the same everywhere.
So, concretely in China, our approach has been one of
working with the government more at the political level to lead
to a recognition that AIDS is a problem and working with the
various provinces, because it is a highly decentralized
country.
When it comes to a country like Uganda, there we have been
working trying to set in place two things. One is, mainly
through UNICEF, youth programs, prevention of HIV among young
people, saving the current generation, which should be a top
priority, and then second, expanding access to treatment and
care by decreasing the price of antiretroviral drugs, by
putting in place care centers and training of health care
workers.
So, these are two examples, but there are so many.
Senator Feingold. Thank you very much, Doctor. Thank you,
Mr. Chairman.
The Chairman. Senator Frist.
Senator Frist. Thank you, Mr. Chairman.
Dr. Piot, thank you for your leadership. I was just talking
to the chairman impolitely as you were talking, basically
saying that of all the witnesses that we will see today, the
person who has seen the most on the ground, has had the most
sort of global exposure but really on-the-ground exposure as to
what works and what does not work in a range of countries, like
in your first slide presented, is you. Therefore, I would like
to have you comment further or elaborate a little bit more on
what you just closed with.
You heard me ask the first panel, and I will get their
answers in writing. But to link care and treatment to
prevention, which as a physician and as a real believer in
public health and the impact you can make, but the demand must
be that you link all three.
In this country today, if you look at the President's
budget, there is an emphasis on really all three, with a heavy
emphasis on research, but also the treatment end as well as the
prevention end. Here in this country when people look globally,
they think of treatment being antiretrovirals. Period. The
concentration has been on intellectual property rights, which I
think is a very appropriate discussion. It has been on
diminishing or lessening the cost.
In Africa, it was amazing, Mr. Chairman. Now
antiretrovirals are down probably a tenth of what they were 18
months ago. Still not low enough. We still have got to go a
long way, and we have got to keep pushing in appropriate ways
there.
But what has been remarkable to me that I think we need to
understand better is this linkage of care and treatment,
opening up hope, the power of nutrition, the power of even
herbal treatments that in this country many times are
diminished, that care and treatment is not just
antiretrovirals. If you focus just on antiretrovirals, they
will not be delivered because of really what you said initially
in terms of capacity and capacity building as we go forward.
Could you just paint that picture based on your experience?
Not in my words but your experience.
Dr. Piot. Thank you, Dr. Frist.
I think it is really at the heart of, let us say, the
substantive strategic debate at the moment.
When I look at Uganda, for example, the success has been
mostly in declining infection rates.
Now, I mentioned the elements of success, but one very
important element for me was that people with HIV who were
affected or whose partners have it or died from AIDS organized
themselves and started to organize also some care, some
treatment. This was even before antiretrovirals existed and
were introduced here.
There is one element that never figures into economists'
cost effectiveness calculations and so on, and you mentioned
it, Dr. Frist, and that is hope. It is hope that drives
communities that drives social reform. So, this is where I
believe now, as recognized by the declaration of commitment
that came out of the UN General Assembly, that care and
treatment are an integral part of the response, just as
prevention. But sometimes I feel that the debate is only on
treatment or sometimes it is only on prevention, and we have
got the supporters of both. We really need both together.
What is the link between these two? That is the voluntary
counseling and testing. Ninety-five percent of people with HIV
in the developing world have no clue that they are infected,
that they are HIV-positive. Just imagine what that is. Of the
40 million people who are infected, they do not know. Not that
they do not want to know, but first, there are no testing
centers or they do not have the money to pay for a test. Or if
they go for a test, all that is at the end of the test is
discrimination. They lose their job. Their husband may kick
them out and there is no treatment. So, this is a crucial issue
to put in place in terms of programs.
When we talk about treatment, I think we have learned a
lot. Four years ago, we started with UNAIDS in Kampala and in
Abidjan, in Ivory Coast with some pilot projects to learn what
are the best ways to improving access to treatment and care for
people with HIV in really poor resource environments. What we
have learned is that you can do a lot. You can do a lot on the
one hand, with no antiretrovirals, treating the symptoms,
keeping people alive with treating and preventing opportunistic
infections, but also that antiretroviral therapy in Africa in
capitals is possible. It is not possible, I think, to offer it
overnight for everybody, both for economic reasons and because
of the infrastructure that is not there, but it can be
introduced. Patient compliance is as good as anywhere else in
the world. Why would it be different?
So, what I feel is that in each country we need to define
exactly what we are meaning. There needs to be a societal
debate and if that debate is not there, if it is not planned in
a way that access to treatment will be widened, what happens is
that only those who have the means to pay privately will have
access to treatment. We need to make sure that systems are
being put in place, that money is going to come--and I think it
is starting to come.
The Chairman. How do you do that, Doctor? How do you do
the first piece?
Dr. Piot. We are not living in a desert in the capitals.
When Dr. Frist is doing surgery in Africa, it is in existing
hospitals and health care facilities. That is where we can
start, and that will be the easier part, the first part.
To go beyond that is going to be the more difficult one,
and that is where we will have to invest in training, in, let
us say, community-to-community programs, medical assistance,
and all the things that we have said this morning. But I think
for today to expand that, that is feasible.
In terms of the financing of all that, who is going to pay
for it? That is also another part. Here we have got to see that
the pots of money that pay for prevention and that pay for
treatment and care in about every country in the world are
different pots of money. So, I think we need also to look at
that in a more refined way. Financing for health care,
including in developing countries, is not going to come only
from the outside. People are already paying. The problem is
that to pay for antiretroviral therapy, it is just not going to
be possible without massive external funding, at least in
Africa.
Senator Frist. Again, even in listening to your comments,
when you are really on the ground, Dr. Piot, the
antiretrovirals are there. I do not know what the number one
killer really is with HIV/AIDS, but say it is tuberculosis.
Dr. Piot. TB.
Senator Frist. TB and that is what we say because so many
people have TB. I do not think it really is. Anyway, it is an
opportunistic infection of some sort.
Dr. Piot. Right.
Senator Frist. It is hard for me to explain to people,
when you have that little virus which is winning the war--and I
love your analogy. It is winning the war. Even with the number
of people that die, it is winning the war as we go forward in
terms of the new infections.
If we cannot even treat the opportunistic infections or we
do not have the capacity, it is going to be asking a lot to
pull down an antiretroviral. I agree compliance will be there
if the system is there, but globally I do not think we are
adequately addressing the treatment for other sexually
transmitted diseases, the opportunistic infections which we
know with a certain input, will prolong life significantly if
we can adequately treat tuberculosis or any of the other
infections. I do not see, even in your comments, why we do not
put more emphasis on treatment of those opportunistic
infections and nutrition, which when you go into these
communities, you see it has such a huge, huge impact.
Dr. Piot. No. I do not think we disagree at all because
the way I see it is prevention has to be scaled up, treatment
for opportunistic infections, care for orphans and support, but
then at the same time, I think we should not wait until
everything is in place to start with the antiretroviral therapy
there where it is possible. Because I also think that we can
never have a real impact on this epidemic if we go with, let us
say, a 10 percent approach--we have tried that for 20 years--
and do a little bit of this and a little bit of that. I think
that is where we are now getting into at least gearing up to a
full response. But I am the last one to underestimate all the
problems.
My biggest question is how to do this outside the big
cities. In the cities I think it is possible, but outside is
where we have got to build the systems. That is why I put so
much emphasis on the capacity building, and the illusion that
we sometimes have in the development assistance community is we
give a bit of money to do certain things, but then we tell that
NGO or that church or government you are not allowed to use
that money to train your people. We are pushing education but
we do not invest in the teachers who need to be trained because
there are so many who die from AIDS. That is a real problem.
Senator Frist. To even take that one step further, it is
easier from our perspective, as we try to build support to
increase the funding, for people to focus on one element of
like antiretroviral therapy and just say, oh, it is too
expensive, we cannot do anything, and hide behind that and not
address the capacity building. I link it very much to treatment
of opportunistic infections because you get your nurses out
there and you get the communication, you get those teachable
moments there. I think that is the challenge we have.
Mr. Chairman, I know we have got another whole panel, but
can I just bring up one thing?
The Chairman. No, no, keep going.
Senator Frist. It is totally different. And that is the
orphans. Again, the last panel will bring it up. But having the
opportunity to have somebody such as yourself here. Ten
million, thirteen million. And orphans--the definition just so
people understand--does not necessarily mean both parents are
dead. You might give me the real definition, but what it means
is one of the two parents have died of HIV/AIDS.
But, in essence, we have got 10 million to 13 million out
there. We will go to 40 million within 10 years. We have got to
address it. As I said, when you are going through the areas and
you do not see any people middle aged because the parents are
dead and you have a grandmother taking care of one generation
and the next generation, and then the generation of all the
children of 28 children, you know we have got to address that
issue.
Now I am at a loss of what we do. You can talk about it and
you can link the care and you can link the hope. But what can
we, sitting up here, really be doing to address that issue?
Dr. Piot. Well, that is probably one of the most
complicated issues, in addition to being the most tragic one.
First of all, on the definition, what we use is that
children who lost their mother because that is the key in terms
of survival. By June we will have also statistics on orphans
who lost both of their parents and so on. So, we are refining
the definition.
I think that one of the main consequences will be more
street kids, more teenagers on the street. Some of these
orphans are infected with HIV as well. Others will grow up and
will become teenagers. We have a whole generation of what is
called desocialized youth that is growing up.
Senator Frist. Can I just add to that? When we think of
terrorism, when we think of lack of civil society, when you see
kids--they are good kids, but they just have nobody to look
to--and you think of terrorism and you think of the lack of
order and the risks of terrorism in the past, all of a sudden,
all these images start linking together because it gives them
nobody to turn to.
Dr. Piot. Exactly. I think these are an ideal reserve of
kids, adolescents who, you know, you put a collection cup in
their hands and here we go. Anybody who is looking for cheap
soldiers.
The Chairman. On this orphan question, which sounds so
antiseptic the way I just said it--I do not mean it that way--
based on the definition being used for an orphan, are any of
these orphans in collective care anywhere? Most Americans think
of orphans as being in an orphanage. They think of it as being
in some sort of state-provided care. Paint a picture for us of
what we are talking about when we are talking about the
millions orphans we are referring to. Are these kids like the
orphans that existed in Brazil earlier on, literally wandering
gangs of 12- and 13-year-olds led by 14-year-olds? I do not
mean gangs in the sense they are murderers. I mean just in
terms of their family. What are we talking about when we talk
about these orphans in terms of where they are located?
Dr. Piot. Sorry. Wherever----
The Chairman. No. I do not mean what country. Let me just
give you my conclusion and maybe you can respond. My impression
is that when we talk about orphans in Africa, orphans as a
consequence of the loss of a mother to AIDS, we are talking
about that child being in the extended care of a grandmother or
of the family next door or just literally subsisting on his or
her own on the street as opposed to orphans being collected
into a social agency where they are given three square meals a
day, able to be tested as to whether or not they are HIV-
positive, et cetera. That is what I am trying to get at.
Dr. Piot. Right. First, a kid who lost her mother, in
general, also will have no father or have lost the father to
AIDS because of the sexual transmission issue.
But second, indeed, very few of these children will be in
institutions. We also do not think it is the first option, the
first solution. Fortunately, particularly in Africa, there are
extended families where there is a tradition that not only
orphans but children in difficulty will be taken up. But these
families are stretched to the limit, and that is not working.
There are three priorities for dealing with orphans. We
have done some work--this was in Zambia with UNICEF and with
USAID--mapping out the orphans, where are they, what are their
needs. It is quite predictable. It is food, it is a roof, and
it is school. The most important investment I believe is in
keeping these kids in school. For example, I know in Zambia,
because I just talked about it at the World Economic Forum, for
$10,000 you can keep 1,000 orphans in school for 1 year. We are
not talking about billions here. That is very concrete. And
emphasizing vocational training so that they learn a job and
that they do not end up in the street in gangs and so on.
The Chairman. The reason I ask such basic questions here
is that to a lesser extent than Dr. Frist, but nonetheless to a
significant degree, most of us who serve on this committee and
serve in the Congress or the Senate or in various positions of
authority are aware of the nature, scope, and the demographics
of the problem we are talking about. Most Americans and I
suspect most Europeans do not have it down to intellectual
bite-sized chunks that they can understand.
For example, when I go home, Doctor, my constituency is a
fairly well educated constituency. Where I come from, in
relative terms, is one of the most affluent States in the
Nation. I will get off the train tonight and someone will have
watched this on C-SPAN or watched some news coverage of it, and
they will ask questions that in a sense, to use the vernacular,
bring me up straight, make me realize that I speak too much
like a foreign relations expert or I speak too much of the
international lingo about what the problem is.
When I go home someone will ask me about orphans. The
conductor will ask me on the train, he will say, if you have
all these orphans, why do we not just test them all in the
orphanage and find out who has AIDS and cannot we help deal
with the problem that way? And I say, no, no, no, that is not
how it works.
When you talk about education--how can I say this politely?
One of the problems the Senator and I have had--and it is
presumptuous of me to speak for him. Our interest in this
subject is something that 10 years ago, for example, was not
immediately embraced by our constituencies. Among some Members
of this Congress, the notion that we would spend time, energy,
resources on this issue were almost viewed in moral terms.
But once you begin to break this problem out and the reason
why I think Senator Frist is so effective, if you notice, he is
always talking about on the ground. He has changed the mind of
some of our colleagues to vote for more money or vote for the
money requested by the administration by saying ``are you
aware.'' I notice he has a picture in his lap right here. Are
you aware that this is what we are talking about? And he shows
a picture of a village or shows a picture of 10 or 12 children
surrounding him in an area, or he tells a story about how in an
extended community where, to use the phrase which got battered
around for political reasons up here, it takes a village to
raise a child, that African proverb is one that actually
functions, that people actually reach out. When you put it in
those terms, we find that people come along and say, oh, I got
that. I will vote for that.
I am going to get in trouble here, but for example, we have
a great fight here in the United States about the availability
of condoms for youth. Yet, we fund a significant amount of
money for condoms for the rest of the world. People do not make
that connection here. They do not think about it.
So, the reason why I am trying to get you to even paint a
more vivid picture about orphans or prevention, it is because
the more it can be broken down into terms that our collective
constituencies, whether it is in France or in the United
States, whether it is in Germany or it is in Brazil, the more I
believe generic and broad support we get across the board for
doing more and more.
I am going to ask you this one question and perhaps you
could give me some concrete notions about prevention. When you
say prevention here in the United States, a whole bunch of
different images pop up in people's minds. Not negative, but
what do you mean by prevention? What are the prevention
programs or initiatives that are the most successful in your
experience? And it may vary from country to country to country.
But give us some examples of prevention programs, if we were
able to fund more of them, encourage more of them, that would
have a greater impact on the spread of this disease.
Dr. Piot. Well, thank you, Senator. That is a long story,
but I will try to be as concrete as possible.
I think that all evidence today shows that it is in young
people, youngsters, that we have the greatest chance to succeed
with prevention programs, with education, contrary to what many
older people think. When you look at the curves of declining
infections in the countries that I mentioned, it is always in
young people 15- to 24-year-olds that you see the first
decline, the most rapid one, and we heard some examples also of
postponement of first sexual intercourse, higher condom use,
less partners, and all that.
And what works there? It is not someone like me telling
them this is good for you or this is not good for you. That
does not work. Certainly when I was 15, I would not have
listened. It is using the youth culture. What we have been most
successful with is working with singers like Youssom N'Douf in
Senegal who gives concerts, working with MTV. I think our most
successful partnership with a private company in UNAIDS is that
with MTV, a very unlikely partnership between a UN organization
and MTV for the last 4 years.
The Chairman. I do not think it is unlikely at all.
Dr. Piot. Last year on World AIDS Day, we reached 1
billion young people--1 billion--at a cost to us of half a
staff member, helping to formulate the message and then MTV
does the packaging in India, in the Caribbean, in Brazil and so
on.
So, that is one principle, trying to work with sports
heroes and singers. Sports and music. That is the youth
culture. There were the soccer games in Africa 2 weeks ago in
Mali. For those of you who have seen it and watched it on TV,
it is mostly young boys watching it in Africa. Every match,
there were eight messages, and we know that that has more
impact again than 1,000 billboards.
The second way is so-called peer education, young people
talking to young people in the language that they understand.
So investing into that, but making sure that there is quality
control in the sense that it is not just anything that they
say, but things that make sense.
We have also been working with church groups because there
are different types of young people. So, you are reaching
another one. And in Kampala, for example, there is
facilitation, as we say in the UN, to an open environment.
Create a space for young kids that they can talk about that.
Radio programs. In Zambia, there is a whole club which is
called Post-test Clubs and clubs of students against AIDS. It
is relatively different from one place to another, but the
principles are exactly the same.
The Chairman. Now, one last question on that point because
at least I think this is helpful in being able to carry the
case beyond where we have already carried it here and what we
need to do in terms of resources because you talk about the gap
between projected resource availability and program capacity,
that you are building program capacity, but in resource
availability there may be a very wide gap.
What kind of resistance institutionally from the
governments do you get, and does it vary, for these kinds of
initiatives, the kinds you have just acknowledged and you have
just stated? Because we find even in this country initially
there was real reluctance to talk about it, talk about safe
sex. There are cultural impediments. Without getting into which
countries, but how much of an impediment toward this notion of
prevention are due to cultural impediments that exist? Or is it
not that much of a problem?
Dr. Piot. Well, first I would say, Senator, that every
society, every country I have been in is going through the same
problems in recognizing that there is an AIDS problem and then
has the same difficulties in talking about sex, the openness
about it. Everybody does it or most people, but to talk about
it in a way that will protect people and save lives is one
thing.
Then the other thing that I see in common everywhere is the
stigma associated with AIDS that makes it difficult. That is
why this leadership thing is so important. I was with President
Mandela on World AIDS Day in '99. He addressed the nation on
AIDS for the first time, and he extensively used the word
``condom,'' talked about it and was very explicit. That makes a
real difference because there is resistance in South Africa or
in my own country.
There is usually also resistance particularly when it comes
to HIV prevention among young people. My kids do not do this.
Or sex education in schools. We know from surveys that sexual
activity may start at a very early date. So, it is really
critical that problems are being addressed before they become
sexually active. These are problems we see in every society.
We have really taken an approach that is extremely
inclusive, working from above and from below, above with the
leadership. I am not only thinking of the president, although a
president talking about it makes a difference, or the first
lady in many countries. In Ivory Coast, for example, or in
Rwanda, the first lady is really spearheading the AIDS campaign
and it is easier, when she talks about it, for others who are
teachers to talk about it because our big chief has talked
about it, our first lady.
Also, this is why it is so important to have the
traditional chiefs and the religious leaders, wherever they
come from, to have them on board. That is changing. I can see
there also a sea change over 5 years ago.
Perhaps the most important factor has been that certainly
in Africa there is not a single family who has not lost a
relative from HIV. So, it has come much closer to wherever we
are. [start]
The Chairman. My last question is this: one of the most
troubling aspects of the spread of HIV/AIDS in some countries
is that teenage girls are becoming infected at rates that are
significantly higher than their male counterparts. The number
of HIV positive women seems to be on the rise. There are a
variety of reasons for this, but one of them seems to be the
fact that women do not have as great a say in when and with
whom they wish to have sex.
What programs, if any, specifically address the special
needs of women and children in terms of their vulnerability to
the exposure to AIDS? Is there any particular focus on that?
Dr. Piot. Yes. Certainly it is one of the most shocking
aspects of the AIDS epidemic. We have done some work, for
example, in Kenya, in Zambia, in Cameroon, and in each place,
when you look at 15- to 18-year-old girls, their infection rate
is two to five times as high as in boys of the same age. How
are these girls becoming infected? Not from the boys of their
age group, but from older men. So, the problem is not so much
with the girls, but with the sexual behavior of the older men.
That is what our programs have to address.
And it is both for behavioral reasons--the older men having
sex with younger girls, which is the case in most societies.
When you look at relationships between men and women, the males
are usually a bit older than the women, but the distance can be
enormous in some societies.
And second, there is a biological reason also, and that is
that young girls, young women are biologically far more
vulnerable to infection with HIV than boys of the same age or
than older women for anatomical reasons, et cetera. We are not
going to go into that now. So, there is clearly a
vulnerability, a social one and a biological one.
Ultimately there are two things that have to change. That
is male sexual behavior, particularly men over 30, the most
difficult thing to change. That is why over the last 3 years we
have been promoting that as a theme, which created a lot of
resistance in many societies, not only in developing countries
but also in the West. I can tell you.
The Chairman. I agree.
Dr. Piot. Second is education for girls. We know also from
several surveys, from Kenya to Zambia to Tanzania, that women
with a higher level of education are in a much better position
to protect themselves, to say no to unwanted sex if it is not
associated with violence. So, that would mean that if we would
take away funds from education programs to put them into AIDS
programs, the net result may be ultimately zero. That is, I
think, also something we have to bear in mind.
The Chairman. Let me ask one other question on that score.
If 95 percent--I think that is the number somebody used; maybe
you, Doctor--of the people infected in--just focus on Africa,
as we have, for a moment--are unaware that they are infected,
but if 95 percent of the population is aware of the extent of
the disease, not that they have it, but that it is a widespread
disease, would not that, particularly in male-dominated
societies, increase further pressure on young women because the
percentage play that most older men would conclude would
diminish their prospects of being infected would be to have sex
with a younger woman? Is there any evidence? Is that beyond
just sort of a common sense assessment or is that real?
Dr. Piot. Well, Senator, there is anecdotal evidence for
that but not systematic evidence. It makes good sense, if you
want.
But I think in all these areas, the real crime is that we
have lots of successful examples of what works and an order of
magnitude less resource than is required when we talk about all
these things. So, I hope that the U.S. will continue to lead
there.
The Chairman. Well, I can assure you that with the
leadership of Senator Frist and others, the U.S. will try to
not only maintain, but maybe even increase the U.S.
participation.
Senator Frist. Can I make one more comment?
The Chairman. Oh, please. I am sorry.
Senator Frist. No, I am done. I know we have got to get to
the next panel, but just following up a couple of points.
The women's issue is huge. I will tell you, again going to
Tanzania, Kenya, Uganda, and just asking the question, the same
question you asked, the answer is focusing on education for
young women. It is not just that you educate to make more
prudent decisions, but during this vulnerable period where, for
biological reasons, which most people do not know unless you
are told--in part. That is part of the reason. But just by
having the opportunity to go to school over that year or 2
years changes behavior for the rest of life. It is just
critically important. So, something that can be done that will
get these curves moving in the other direction as simple as
keeping young girls in school for an additional 2 years. What
happens when there is a family tragedy or times are tough, the
girls are pulled out of school first and the boys are left in
school. So, I think the question is a perfect question, and I
think we need to understand that.
Second, we have not talked about the United Nations. We
talked about leadership. Mr. Natsios implied that the
leadership has come a long way and you have done the same. I am
still sorely disappointed in the leaders of the African
countries, as well as people in the United Nations, of where we
are today because the leaders have to come out and take a
strong stand as we go forward. I just would encourage you. I
know you are in the middle of that. In the United Nations,
Richard Holbrooke I think did a superb job elevating this
issue, a little bit uncomfortably at first, but to the leaders
of the United Nations. But I think we have got a lot more to do
there. Again, I know that you are right there.
The First Lady of Uganda is going to be here next week to
speak to essentially a church-sponsored conference on HIV/AIDS.
And I agree with you. You have got to have sort of the top
person, whoever it is, but having their spouses out there makes
a huge difference.
Thanks for really helping us understand the issue.
The Chairman. Doctor, thank you very, very much, and thank
you for your work for so many years. I appreciate it. Thank you
for being here.
With that, we will move to our third and final panel.
Princeton Lyman, the Executive Director of the Global
Interdependence Initiative at the Aspen Institute. He is also a
member of the Center for Strategic and International Studies
Task Force on HIV/AIDS.
I tell you what. We will take a 5-minute break here.
[Short recess.]
The Chairman. If we can come back to order here.
As I started to say before, our panel now is Ambassador
Princeton Lyman. I spoke briefly about his career in Government
includes service as Assistant Secretary of State for
International Organization Affairs, Ambassador to Nigeria,
Ambassador to South Africa. He received his Ph.D. in political
science from Harvard and has written extensively on
development, foreign policy, and conflict resolution. His book
on the U.S. role in South Africa's transition to democracy will
be published this June by the U.S. Institute of Peace.
Hopefully, he will not have an extensive chapter on my shouting
match with the former Secretary of State during that period.
Dr. Ray is a public health specialist, working as Director
of the Southern Africa AIDS Information Dissemination Service,
a regional information service serving the South African
region. She has worked since 1983 in Zimbabwe on both rural and
urban strategies mainly in public health specializing in gender
issues and communicable diseases, including HIV and
tuberculosis.
And Dr. Peter Okaalet. I am pronouncing it correctly, am I
not, Doctor?
Dr. Okaalet. Yes.
The Chairman. Is that close enough for government work? If
I mispronounced it, you can call me ``Bidden'' if you like.
Dr. Okaalet is the Director for Africa Division of Medical
Assistance Program International. He is a medical doctor,
licensed to practice in both Kenya and Uganda, and he holds two
master's degrees in theology, in addition to his medical
training. He is not 112 years old. It is amazing you got all
that in a short amount of time.
With that, let me move right to the witnesses and invite
them in the order they have been introduced to make their
statements. Again, we appreciate your patience and being here
and waiting this long. Mr. Ambassador.
STATEMENT OF HON. PRINCETON LYMAN, WORKING GROUP CO-CHAIR,
CENTER FOR STRATEGIC AND INTERNATIONAL STUDIES TASK FORCE ON
HIV/AIDS; EXECUTIVE DIRECTOR, GLOBAL INTERDEPENDENCE
INITIATIVE, ASPEN INSTITUTE, WASHINGTON, DC
Ambassador Lyman. Thank you, Mr. Chairman. Thank you very
much. It has not been a problem to sit here because this has
been an extraordinarily good hearing, and certainly I want to
join others in commending you and Senator Frist for this
hearing, which I think has contributed a great deal.
The Chairman. Doctor, as my friend, our friend, the
Senator from South Carolina, Senator Thurmond, would say, would
you pull that machine close to your face there? Because I do
not think they can hear you in the back.
Ambassador Lyman. Okay. I hope they can now. Thanks.
I have submitted a statement which I would appreciate being
put in the record.
The Chairman. Your entire statement will be placed in the
record.
Ambassador Lyman. Thank you, and I will just summarize it
here.
I have just also returned from South Africa. You can see
firsthand in South Africa not only the magnitude of this
problem, but the painful and often divisive debate that this
issue creates within societies, and I will come back to that a
little bit.
Here today I want to speak to the work of the CSIS Task
Force, which you have mentioned. Senator Frist and Senator
Kerry have been, kindly, co-chairs of this effort. Steve
Morrison and I are working on a 5-year approach to this
problem, and I want to concentrate on that today because the
need now, as awareness is growing and has been created with
hearings like this and a lot of other things, is now to have
for the United States and then internationally a strategic,
multi-sectoral, 5-year approach that has very specific
objectives and is assured of adequate support and resources
each year along the way.
I think first we need to understand where this pandemic is
moving in the next 5 years, and much of that has been discussed
here. But then we must move to such a plan.
We talked a little bit about greater awareness. Mr.
Chairman, you have talked about the American public. We have a
survey that will be just issued in the next day that was done
for the CSIS Task Force that shows a very great awareness among
the American public about this problem, a receptiveness to the
type of information that has been discussed here today, a
serious concern about it, and a great interest in those
programs which work, knowledge about programs that work, and
those programs will get, if this survey is at all accurate, the
strong support of the American public. And I think that is an
important element.
But there is also increased international awareness of the
need for a broad strategy. The UN General Assembly Special
Session outlined such a thing. There is a WHO commission on the
relationship of macroeconomics and health, and there is, of
course, the Global Fund which deals with several different
diseases.
When we look at the structure and operation of our own
Government in this regard--and Senator Frist has talked about
this earlier in the hearing--obviously a number of very
important things have been done, and the Bush administration
has taken a number of very important steps, the joint task
force that is chaired by Secretaries Thompson and Powell, the
contributions to the Global Fund, the increase in bilateral
funding. But I think, if we could suggest, that there needs to
be more understanding and perhaps joint planning between the
administration and Congress on the roles of the various
Government agencies and to assure that they have the mandates
as well as the funding to do this international work.
If we look at the role, for example, of HHS, if it is going
to assume a greater role in helping build the infrastructure,
train the people, create the capabilities abroad--and that is
true of NIH and HRSA--we have to make sure that the funding is
there, that the mandates are there, that the committees that
control their funding are seized with the importance of this.
And that goes for other agencies as well.
Now, I would like to say a word about American leadership
in this area because it is so critical. But let me put my other
hat on for a moment, work we have done at the Aspen Institute
about what the American public thinks about leadership. It is
interesting that the focus groups that we have done show that
the public thinks of a leader as someone who steps forward from
the community and helps the community solve a problem, not one
that dominates that issue.
In this case, the United States has the skills, the
resources and the world responsibility to step forward, not to
take over this issue, but to help the world community come
together to solve it. Mr. Chairman, you have talked recently
about the importance of engagement, and I think this is a
classic example of where this is an issue that can only be
solved by global cooperation and engagement, but it is one that
we, by stepping forward, can help shape tremendously. And we
have a lot of the resources and skills to be able to do that.
Now, let me just say a word about where this pandemic is
going. We heard a lot about that earlier in the hearing. Let me
just say that one thing we see over the next 5 years is that
this issue is clearly going global. It is concentrated now
heavily in Africa. Secretary Thompson talked about the
Caribbean. We know it is spreading rapidly, as Dr. Piot said,
in Eastern Europe. It is in China. It is in India, et cetera.
And while these situations are different and have to be
addressed differently, as this issue becomes more global, the
issues become more global. I think we will see over the next 5
years an even deeper and perhaps more contentious debate over
questions of access, questions of resources, poor versus rich,
prevention versus treatment, and this could become one of the
most divisive and contentious debates of the 21st century. We
must anticipate that debate and begin now to try to resolve
those issues.
There is, it seems to me, in this area a danger of being
overwhelmed by the problem. That is, we hear how incurable it
is, how many deaths have taken place, et cetera. I think it is
also very important, as Dr. Piot said, that we realize that we
have an opportunity to address this problem, contain it, and
bring it under control.
When I was in South Africa last summer, one of the members
of the Anglo-American Corporation that leads an AIDS program
said he always starts his presentations in South Africa by
saying that 75 to 80 percent of South Africans are HIV-free and
that this is a problem that they can contain and address. I
think we have to look at it that way as well, that if we take
the steps needed, we can in the next 5 years make a tremendous
impact on this problem.
If we have a 5-year strategic plan, we should be able by
2007 to get to a situation where the pandemic has reached a
turning point in its history, where the spread of infection has
greatly diminished, where it has dropped significantly in a
number of countries, and where we have far more agreement on
the kinds of interventions and steps that need to be taken.
Now, to get there in 5 years, we need to do a number of
things, and they have to be started now in order to get there
in 5 years.
Prevention, of course, is as people have talked about,
absolutely critical if the rate of infection is going to be
stabilized and reduced. And this means putting in place
national interventions that overcome ignorance and myth and
alter the behavior of high-risk populations.
Second, the U.S. will have had to contribute to the
building of health infrastructures throughout the developing
countries, and I want to come back to that in terms of
resources.
Third, as has been mentioned already, it is going to be
extremely important to support the education and other programs
to enhance the ability of women to play an important role in
containing this disease.
Fourth, we need to address the questions of orphans and
have in place programs that enable communities to take care of
this very large problem on the horizon.
Now, coming to resources, which you, Mr. Chairman, talked
about greatly--and you notice that Dr. Piot indicated a rising
requirement, and I think this is very clearly going to be
needed. We know that right now this year, according to the
testimony, there will be somewhere around $2 billion available
this year for addressing this problem. By the end of the 5
years, we should be at the $7 billion to $8 billion a year
level, and we need to start planning for that and how to get
there.
But let me emphasize that none of the additional resources
for HIV and AIDS should come from current and future programs
aimed at poverty alleviation. That would be self-defeating. If
these countries remain poor, they will be unable to deal with
or sustain any of the programs we put into place over the next
5 years. Moreover, poverty not only aggravates the problem, it
poses terrible choices for these countries. A South African
official said to me, yes, we can go forward and offer
antiretrovirals to all the people affected by HIV and AIDS, but
what about the people dying today of cholera because they do
not have access to clean water? That kind of issue has to be
addressed concurrently with our efforts on HIV/AIDS. So, the
poverty alleviation programs cannot suffer as we increase the
resources for HIV/AIDS.
Now, the question of access, the question of access to
drugs and care is, as already has been indicated, one of the
most difficult issues. There has been a lot of progress on
this. There have been steps by the pharmaceutical companies
themselves to provide drugs at greater prices. There are
organizational programs that Dr. Piot mentioned. But we still
have a long way to go, and one of the issues that concerns
countries who are faced with this problem is how sustainable
are these programs that are now being put into place.
In South Africa, one of the things that concerns the
government most is, if they start down this path of promising
treatment to everyone living with HIV/AIDS, will the price
reductions, will the support be there 5 years from now, 10
years from now to enable them to continue those programs? Of
course, it would be a political disaster if, having started
down that path, they suddenly found that the programs could not
be sustained. In the next 5 years, we need to have the answers
to that and we need to have the institutions and the
arrangements in place. I might add those arrangements must be
such that they keep the pharmaceutical companies in the game in
the investment in research and the development of new drugs and
treatments, et cetera.
The Chairman. If you get that right, you will win the
Nobel Peace Prize.
Ambassador Lyman. Well, I tend to be optimistic because
there has been a lot of progress. I think there is an interest
in the industry on this front, and I think that it is possible
to do those things.
Now, one other aspect that has only been touched on here
which has to be part of the 5-year effort, and that is to
address the problem of HIV in the military establishments in
developing countries. It is having a major impact on
peacekeeping, on the options for peacekeeping, and we certainly
do not want peacekeeping contributing to the problem. So, that
has to be built into it as well.
There are a number of other steps that we can build into
this 5-year plan, but the point that we would like to make is
that the time is ripe for having a clear-cut, multi-sector 5-
year strategy, that we can start not just dealing with it
annually, but know that these are steps toward a 5-year program
that we are confident at the end of the 5 years we can say we
have got a real handle on this problem. I think now we have
enough knowledge, we have growing awareness, we have the skills
to be able to achieve that.
Thank you very much.
[The prepared statement of Ambassador Lyman follows:]
Prepared Statement of Amb. Princeton Lyman, Executive Director, Global
Interdependence Initiative, The Aspen Institute, on Behalf of the CSIS
HIV/AIDS Task Force
INTRODUCTION
Mr. Chairman, I am grateful for the opportunity to appear here
today, and commend you and other members of the Senate Committee on
Foreign Relations for focusing on the global HIV/AIDS pandemic, a
subject of profound urgency to U.S. foreign policy stakes.
I have the fortune of having just returned from a two-week visit to
South Africa, where I witnessed firsthand the intense, combative debate
there over national priorities, in the face of a pandemic that directly
touches every family in that society and that threatens an entire
generation. South Africa, like other acutely affected countries in
Africa and elsewhere, is truly in the midst of a complex and painful
national emergency that will be with it--and with us, by extension--for
the next few decades. From where we sit, it is difficult to grasp the
urgency, magnitude and innate controversy of what South Africans and
others confront on a daily basis.
Also, I am a member of the international supervisory panel
overseeing the evaluation of the first five years of the UNAIDS
program.
I am here today however on behalf of the Center for Strategic and
International Studies' Task Force on HIV/AIDS. The CSIS Task Force is a
two-year effort, funded by the Gates and Catherine Marron Foundations,
intended to strengthen U.S. international leadership on HIV/AIDS. I am
grateful to Senators William Frist and John Kerry for agreeing to co-
chair the Task Force.
Today, I will concentrate my testimony on how we might best design
a five-year approach to battling HIV/AIDS. I and J. Stephen Morrison,
Director of the overall CSIS Task Force, co-chair a working committee
charged with looking into this question.
Such an approach will require a strategic vision that looks far
beyond immediate responses. It will demand sustained U.S. global
leadership, a reliable grasp of how the pandemic will likely evolve in
coming years, and feasible, prioritized medium-range goals. To build
support at the popular level and among foreign policy experts, this
vision should also draw systematically upon the American people's
growing awareness of the pandemic and their deepening well of support
for a substantial U.S. commitment.
In this context, and because it is such an important element in any
such strategy, I wish to discuss how the international debate over
intellectual property rights and affordable access to essential
medicines has changed in the past year. Several recent developments now
focus our attention particularly upon sustainment of access: through
more reliable financing, greater transparency in global pricing, and
strengthened infrastructure.
LOOKING FIVE YEARS OUT
In the 1990s, ad hoc, stove-piped responses could not keep pace
with the powerful, swift momentum of HIV/AIDS. We now recognize that
combating HIV/AIDS requires attention not only to health, but also
economic, social and cultural factors. Recent increases in U.S. high-
level attention and resource commitments have achieved significant
gains and brought greater coherence to U.S. efforts, and encouraged
others to do more. In its first year, the Bush administration showed
sustained leadership, even in the aftermath of September 11. It
established the joint task force on HIV/AIDS, co-chaired by Secretaries
Powell and Thompson, assembled a strong interagency team of experts,
raised aggregate international spending levels on HIV/AIDS to over $800
million in this fiscal year, and contributed substantially, both
politically and financially, to the establishment of the Global Fund to
Fight AIDS, TB and Malaria.
These commendable steps reflect the deepening awareness, among our
leaders and the American public, that the AIDS pandemic threatens an
unprecedented moral, human, societal and economic catastrophe, and that
it demands an unprecedented mobilisation that will stretch beyond this
generation. Secretary of State Powell captured this reality very
succinctly when he stated earlier this year: ``I know of no enemy in
war more . . . vicious than AIDS, an enemy that poses a clear and
present danger to the world.''
The risk remains, however, that fatigue or complacency with
existing efforts may set in.
If the international community is to assert effective authority
over the pandemic in coming years, the United States, in concert with
partner governments, international organisations and others, will need
a long-term, strategic, multi-sectoral, and highly collaborative
approach that steadily enlarges the pool of resources, with a focus on
clear, achievable priorities. To strengthen consensus and clarity of
purpose, the Bush administration needs to join with Congress, on an
urgent basis, in forging an ambitious multi-year plan of action. That
plan should spell out clearly how U.S. leadership will be deployed
strategically over the next several years to build on recent momentum.
The realisation of the need for a long-term strategic international
mobilisation motivated broad endorsement of the detailed Declaration of
Commitment on HIV/AIDS issued at the UN General Assembly Special
Session on AIDS (UNGASS) in June 2001. It prompted the World Health
Organization to launch the WHO Commission on Macroeconomics and Health,
charged with analyzing the linkage between infectious diseases and
economic productivity and proposing a multi-year plan of action to
redress weak health infrastructures in developing countries. UNDP has
subsequently committed itself to a broad based approach in all its
country programs that links health, development and political action to
stem the pandemic. UNGASS finally inspired the intensive international
efforts that launched in early 2002 the Global Fund to Fight AIDS, TB
and Malaria, first endorsed at the UNGASS in June. (The CSIS Task Force
has also today released a briefing paper on the Global Fund that is
available at this hearing in hard copies and accessible in electronic
form through the CSIS web site.)
No less important, in the aftermath of September 11, an additional,
powerful factor entered the debate over the HIV/AIDS pandemic: the
awareness that runaway infectious diseases, accompanied by and
contributing to broken states and damaged economies, are generating
desperation and rising criminality. If we are to sustain an anti-
terrorist coalition, we cannot afford a lackluster response to the
threat that HIV/AIDS and related problems pose to developing societies.
THE CRITICAL IMPORTANCE OF U.S. LEADERSHIP
Over the next five years and beyond, global outcomes in battling
the HIV/AIDS pandemic will hinge, to an overwhelming degree, on U.S.
leadership. Leadership means using our strengths, our economic
resources, and our skills to enable and empower the world community
working together to combat this disease. The U.S. role is critical for
several reasons:
The U.S. plays a leading role in the international policy dialogue
on HIV/AIDS and related infectious diseases--in the G-8, the UN
Security Council, deliberations on the newly formed Global Fund to
fight against AIDS, TB and Malaria, and elsewhere.
The U.S. is the preeminent force in global scientific research and
the development of new medical technologies.
The U.S. funds half of the worldwide programmatic response to HIV/
AIDS and related diseases, in the areas of prevention, care and
treatment.
Washington is the best positioned of any power to move
international trade policy to promote enhanced access to affordable
medications.
So too, Washington is the best positioned power to link
international debt relief and other poverty-alleviation programs to
heightened local investment in public health interventions.
In exercising its leadership over the next five years, the United
States should concentrate its efforts in three priority areas:
1. Expand existing U.S. strengths
The United States should consciously build upon its core strengths.
These include its leading role on global health issues; its record of
appropriating an ample contribution to global funding; its vast
institutional expertise in public health policy; its long developmental
experience in strengthening local infrastructure in resource poor
setting; and its predominant scientific research and development
capacities across public, educational, philanthropic and corporate
sectors.
A key challenge is ensuring that there is coherence and effective
coordination of U.S. efforts, given the range and rising number of
agencies operating overseas. Increasingly, there is overlap and
duplication of effort, and it is frequently difficult to identify who
at a senior level position is actually in charge of the overall U.S.
campaign.
A related, pressing issue is which agency will carry lead
responsibility in training skilled medical personnel to address the
critical personnel shortfalls in acutely affected countries. If that
role is to be filled by the agency within HHS responsible for such
training, the Health Resources and Services Administration (HRSA),
Congress will need to act quickly to provide it the legal mandate and
funding to meet this requirement.
The Joint Task Force can, and should, pursue these issues on an
urgent basis.
2. Build key bilateral relationships
Modeled upon creative new public/private partnerships in Botswana,
Uganda and elsewhere, the United States should give priority to forging
new programmatic partnerships with institutions, public and private, in
acutely affected countries. These partnerships should focus not only on
HIV/AIDS assistance, but also trade and investment initiatives that
will address poverty and weak infrastructure.
Integral to the success of those partnerships will be a new
emphasis in U.S. diplomacy, at the country level, on battling global
infectious diseases. That calls for mainstreaming, and elevating within
the foreign policy establishment, public health professionals. The
State Department has taken an important step in this direction by
creating the Office of International Health and Science, headed by
Deputy Assistant Secretary Dr. Jack Chow. Equally important will be
systematically integrating America's non-governmental organisations
into U.S. programs and policy consultations.
3. Consolidate global coordination
The United States will need to act in close concert with--and
leverage ample, focused contributions from--UN agencies, the World
Bank, major foundations, corporations, and other bilateral donors. It
should work to develop an international steering committee on HIV/AIDS
to ensure proper coordination and division of responsibilities between
international donors, the Global Fund, UNAIDS, and bilateral programs--
limiting duplication and achieving an appropriate balance between
research, prevention, treatment, and care.
The U.S. role will neither be to dominate, nor carry a
disproportionate share of responsibility. The essence of its leadership
will be to rise to the task of mobilizing the world community to better
address this highly fluid, dynamic and complex pandemic. In practice,
that means the U.S. will need to assign a far higher priority to
forging greater conceptual integration and coordination among the far-
flung agencies committed to battling the pandemic, both within the
United States and internationally.
STRONG SUPPORT FROM THE AMERICAN PEOPLE
This is a program that will receive strong support from the
American people. Indeed the public will expect strong leadership by the
Government in this area. The American public and American foreign
policy elites now exhibit a surprisingly high knowledge of the HIV/AIDS
pandemic, high levels of concern, and considerable support for
substantial engagement overseas to combat the pandemic. Americans not
only strongly support U.S. leadership but also are open to new, more
robust initiatives from American leaders.
This dramatic shift from the opinion environment of the late 1990s
is the core finding of a recently completed survey of popular and
foreign policy expert opinion, that was conducted to inform the work of
the CSIS Task Force. The survey was carried out by Public Opinion
Strategies and Greenberg Quinlan Rosner Research, generously funded
through the UN Foundation/Better World Foundation. Those surveyed were
particularly responsive to information on the scope and gravity of the
pandemic, its impact upon children, exhortations from Secretary Powell,
and evidence that prevention and education programs are achieving
concrete results.
TRACKING THE PANDEMIC
A U.S. multi-year plan should be informed by how the pandemic will
evolve in the next five years.
First, in the next five years the pandemic will have become
globalized and will be seen by world leaders as such.
The pandemic's epicenter will remain in Africa, where heightened
attention will be paid to its course in Ethiopia, other areas of the
Horn, and Nigeria. At the same time, the pandemic will have extended
its reach more deeply into China, Russia, other states of the former
Soviet Union, India, and the Caribbean states of Haiti, Dominican
Republic and Jamaica.
Second, we will see regionally differentiated approaches.
Africa will struggle overwhelmingly with acute constraints on
access to health services, borne of insufficient financing, weak
infrastructure, and insufficient trained health personnel. Young women
and infants will bear the highest vulnerability, while millions of
newly orphaned children will also attract significant attention. A
handful of African states will likely dominate, intellectually,
programmatically, and scientifically:Uganda, Botswana, Senegal, and
Ivory Coast. Nigeria, South Africa and Kenya, if they can overcome
respective formidable internal barriers to effective action, could each
quickly advance ambitious national programs and establish prominent
continental positions for themselves.
In Asia, the central preoccupation will be stemming at an early
point the pandemic's spread. Strategies will vary widely.
In China, the focus will be upon mobilizing the inherited central
command state and newly emergent, scattered private medical enterprises
to combat China's deep social stigma and contain four sub-epidemics:
rural blood markets; medical re-use of syringes; injecting drug use;
and prostitution. Already, as new infections spread into the general
population, the Chinese government is coming under intensive pressure
to institute new, nationwide public health campaign. By 2007, that
campaign will be fully operational.
In Thailand and Cambodia, the focus will be upon consolidating
solid, state-led gains in reversing infection rates.
In India, the central challenge will be circumventing its dense
federal and state-level bureaucracies, along with social and cultural
barriers, in time to implement meaningful programs before infection
rates mushroom. By 2007, the pandemic will have moved beyond the
current six focal states to affect significantly virtually every state.
In Russia and former Soviet states, the priority challenge will be
overcoming the collapse of the Soviet-era health infrastructure, in the
midst of weak economies, and altering high-risk behaviour among pariah
sub-populations: of prisoners, prostitutes and injecting drug users.
HIV is poised to break out of these sub-populations; hence the urgent
need for a public education/prevention campaign in Russia and Ukraine.
Third, the struggle between the pandemic and efforts to control it
will have generated mixed results at the country level. In many places,
the disease will continue to out distance local and international
responses. In many other places, however, determined, smart
interventions will have begun to tame the pandemic.
In this context, individual country responses will inexorably have
become increasingly differentiated.
Several countries will have steadily distinguished themselves and
thereby attracted a major share of new resource flows: those which
demonstrate strong leadership and probity of national institutions;
which make substantial budgetary commitments to health; and which
aggressively build affordable access to medical products, indigenous
skilled medical talent and scientific research capacity.
Occupying a middle tier will be states that struggle to overcome
confusion, financial weakness and internal resistance. They will
benefit from expanded international assistance, but on a comparatively
more cautionary, and conditioned basis.
A third tier of distressed, internally conflicted or otherwise
broken states will likely find themselves further on the margins.
Fourth, despite these differentiations, as the pandemic spreads and
deepens, global norms will have evolved towards universal demand for
expanded access to treatment.
This will intensify a debate: over prevention versus treatment;
equity in the allocation of treatment (rich versus poor; urban versus
rural); and the sustainability of antiretroviral regimes and palliative
care in resource poor countries. This debate could become one of the
most contentious and divisive of the 21st century unless we act now to
address it and plan for its resolution.
THE EMERGENT AGENDA ON AFFORDABLE ACCESS
Because this debate will become so important, it is relevant to
examine in more detail the direction of the debate on this issue so
far, because it points to promising ways by which it can be resolved.
In the past two years, there have been several major developments
that have broadened the landscape of debate over how best to promote
affordable access to essential medicines by poor countries acutely
affected by HIV/AIDS and related infectious disease.
First, the prices of many essential drugs have fallen radically.
The WHO Accelerated Access Initiative, begun in mid-2000, has
brought now 70 countries into discussions with five pharmaceutical
companies and provided enhanced technical expertise in determining
which drugs are most appropriate. Negotiated and unilateral prices
reductions, along with increased availability of some new generic
drugs, have reduced prices by as much as 90%, more in some instances.
Developing countries remain concerned that these price outs may
last only for a fixed period. Moreover, even at reduced prices, many of
these drugs are still not affordable among the poorest countries: some
expanded financing mechanism will be required, along with concerted
investment in basic infrastructure, if essential medicines are to be
deliverable in the poorest settings.Second, the intellectual property
rights debate has shifted significantly.
At the Doha world trade talks in November 2001, trade ministers
agreed that intellectual property protection is not and should not be a
barrier to access. They also agreed that the poorest developing
countries will have no patent obligations until 2016; that means, in
effect, that there are no legal arguments in those countries over
patents or compulsory licenses.
Related to these developments, one recent study has shown that most
essential drugs are not patented in the poorest countries (See Amir
Attaran, ``Do Patents for Antiretroviral Drugs Constrain Access to AIDS
Treatment in Africa?'' JAMA, 286, pp. 1886-1892, October 17, 2001).
Also during 2001, litigation actions by pharmaceutical companies to
enforce patent protection in South Africa and Brazil were dropped in
the face of intense public and media criticism, and in both countries
cooperative arrangements between the companies and the governments are
being developed to provide adequate access.
Third, the Global Fund to Fight Against AIDS,TB and Malaria, will
soon launch its efforts in April when it will respond to the first set
of country funding proposals.
In 2001, the Fund will have up to $700 million to disburse, some of
it on a multi-year basis. An estimated 80% will go to countries in
Africa. At least an equal amount will be available in 2002, perhaps
more.
The Fund is uniquely well positioned to leverage the resources at
its disposal to improve country-level coordination, and to assist
developing countries to develop the technical capacity to refine their
programs and negotiate most effectively with large international and
corporate entities to strengthen their affordable access. Most
obviously, the Fund is will positioned to press for far greater
transparency and consistency in global pricing of essential medicines.
Fourth, the WHO Commission on Macroeconomic and Health completed
its major work at the end of 2001. The committee headed by Dr. Richard
Feachem developed a pragmatic framework for action, by ``the
pharmaceutical industry (both patent holders and generic producers) to
agree jointly to guidelines for pricing and licensing of production for
low income markets. The guidelines would provide for transparent
mechanisms of differential pricing that would target low-income
countries.'' (page 89) This proposal, which envisions a set of
reciprocal obligations between industry and poor countries, is now in
need of a plan to operationalize it. The Bush administration's Joint
Task Force should make that a priority for 2002 and beyond.
Fifth are the emergent public-private partnerships now a
conspicuous part of national efforts in Botswana and Uganda.
Nevertheless, important issues remain. In the next few years there
will be continued debate over aspects of TRIPS, most notably rules
governing parallel imports. But at the same time far greater attention
will be paid to the sustairiability of initiatives intended to deliver
essential medicines at affordable costs. This is one of the principal
issues that has troubled the South African Government and has inhibited
that Government's willingness to make clear-out policy decisions that
are desperately needed.
So too, much urgent work will proceed on how best to balance
complex, competing demands (how to block transmission from mother to
child, while also oaring for an infected mother), how to meet human
skill and training requirements, how to measure the cost effectiveness
of interventions, and how best to monitor and evaluate delivery
systems. All of these issues must be addressed in a comprehensive
response to the HIV/AIDS crisis.
FEASIBLE, PRIORITIZED OBJECTIVES FOR 2002-2007
If the international community, with strong U.S. leadership acts
forcefully now and throughout the next five years, we can stem this
pandemic and avoid a major world catastrophe. By 2007, we should be
able and should commit ourselves to a situation where the pandemic
should have reached a turning point in its history. The pandemic's
speed should be far better contained than it is today, prevalence rates
will have dropped significantly in several acutely affected areas, and
efforts to mitigate the pandemic's impact on societies and economies
will have begun to achieve concrete results.
To achieve this set of goals, we envision U.S. programs and
policies put in place over the next five years organized around four
priority areas:
1) Programmatic interventions
Prevention is the mainstay, if in the next five years we are
to see the rate of new infections stabilized and reduced. Most
importantly, that means putting in place national interventions
that overcome mass sero-ignorance and myths, and alter the
behaviour of high-risk populations. Cooperative efforts among
governments, international organisations, NGOs, local
communities, and religious organisations, will have been
fostered in every affected country.
The U.S. will have contributed significantly to
strengthening healthcare infrastructures in the most heavily
impacted countries, increasing the availability of treatment
for opportunistic infections as well as direct HIV/AIDS
treatment.
The U.S. will also have given special attention to
strengthening women's organisations to provide women greater
protection and a greater voice in prevention, treatment, and
care of family members.
To more adequately address the challenge of AIDS orphans,
communities will have also been strengthened with widespread
assistance programs, scholarships, and other support services.
For virtually every programmatic intervention, urgent
training of skilled personnel will have been a top priority.
2) Bilateral and global resource mobilisation
The U.S. will have helped leverage significant increases in
funding, from multiple sources, that narrow the gap between
supply and demand.
In 2001, approximately $1.8 billion in external assistance
worldwide went towards prevention, care and treatment in
developing countries acutely affected by HIV/AIDS, of which
slightly less than half came from public and private sources in
the U.S.
By 2007, that figure should have risen to the $7-8 billion
range annually, with aggregate U.S. contributions amounting to
at least $3 billion per year. That translates into a tripling
of resources over the next five years, roughly the same level
of growth between 1997-2002.
None of the resources for HIV/AIDS must come from current
and future programs for development and poverty alleviation.
Rather, these latter programs should themselves be strengthened
and increased because poverty alleviation will have a major
impact on the capacity of affected countries to address in a
sustained manner the many issues associated with this pandemic.
3) U.S. investment in research and technology
The current potential of U.S. research efforts will have
been realized and significant progress made on vaccine
development and trials.
The U.S. will have collaborated on and contributed to
significant research on social and cultural factors in every
acutely affected country, enabling messages on prevention,
especially among youth, to have greater impact.
U.S. health institutions will also be mobilized and
effectively engaged in strengthening the research and treatment
capacities of the comparatively advanced healthcare
infrastructures in Asia and CIS.
4) Concerted multilateral action
The U.S. will have helped elaborate and strengthen a new
global health architecture--centered on WHO, UNAIDS, and the
Global Fund--that increases the capacity and reliability of
surveillance systems, creates greater coherence and integration
of responses, that mobilizes new financial flows, and that
promotes exchange of data and debate of emergent issues.
To increase financial transparency and affordable access to
treatment, appropriate pricing and distribution policies and
programs will have been established in all acutely affected
countries, with a combination of private, host government, and
international financing as appropriate. These policies will
have been structured and financed in ways that assure universal
access as well as continued private sector investment in new
treatments and drugs.
Major progress will have been made to control HIV/AIDS
infections in international military establishments, preventing
peacekeeping operations and other international deployments
from further contributing to the pandemic.
Only with this degree of commitment and action, beginning now, can
the world stem this crisis. But the good news is that if we so act now,
we can do it and leave the next generation safe from this plague and
its dire consequences.
The Chairman. Thank you.
Let me say to the other two witnesses, who I would like to
go to right away, I am going to be necessarily absent for a few
minutes here, and I am not sure, since we are to host the
Secretary-General at 3 o'clock--this all got backed up because
of the late start with the five votes. But I will try to come
back between now and 3:00 to ask questions, but Senator Frist
has kindly suggested he would be able to--I am sure he is able.
He is willing to continue and bring this hearing to a close in
the event I cannot get back. I would like to suggest that I
have a number of questions that I would like to submit to you
in the event I cannot get back. My leaving is not a lack of
interest or disrespect. It is a scheduling dilemma that I do
not know quite how to resolve at the moment except with the
help of Dr. Frist.
I would like to proceed with you, Doctor, now with your
testimony. Again, I apologize for not being here. I will read
your testimony, but I apologize for not being here while you
testify. Please proceed.
STATEMENT OF DR. SUNANDA RAY, DIRECTOR, SOUTHERN AFRICA AIDS
INFORMATION DISSEMINATION SERVICE, HARARE, ZIMBABWE
Dr. Ray. Thank you very much to the Senator, as he leaves,
but to the committee as well for inviting me to come and make a
testimony today.
I should just say again my name is Sunanda Ray. I am the
Director of SAfAIDS which is a southern Africa information
dissemination service for HIV and AIDS. It covers the SADC
region essentially which includes Tanzania, but we have lots of
links with East Africa. So, sometimes we do things together,
but in the main we are trying to target the countries that
actually are hardest hit by HIV which have been less referred
to here today. Botswana, Zimbabwe, Swaziland, all have very
high HIV rates. South Africa has the largest number of people
with HIV and the most rapid incidence and Zambia, Malawi,
Mozambique also have major problems, though Zambia has
successes also that we can learn from.
I am going to speak today really from the basis of being a
nongovernmental organization, and it was referred to earlier
that the NGO's actually pick up a lot of the work that the
government is not able to do. And to some extent, NGO's and
civil society organizations are more flexible in what they can
do. But in many ways, they are also the least resourced
depending on who their donors and funders are.
One of the resources that is probably less used because of
funding problems is a mushrooming number of civil society
organizations, community-based organizations. And our plea to
the committee would be that you, along with other donors, look
at how the funding arrangements can be made more flexible so
that a lot of the innovative work that is coming from small
organizations can be considered, but recognizing that these
organizations do not have the infrastructure or the skills to
actually fulfill the kinds of reporting requirements that are
laid out by the donors.
Now, the way the donors usually respond to this is by
asking a bigger umbrella organization to, in a way, mentor the
smaller organizations. We get asked to do this a lot, and what
happens as a result is it is like saying if something is good,
let us throw more work at it until people who are already
overcommitted completely drown in the work. And that creates a
lot of problems because we do not have the capacity to absorb
the work of lots of small organizations.
Our answer to that would be that we would like much more
investment in the kinds of skills and capacity building that
has been referred to, but specifically within small
organizations to help these organizations to do the work that
they are good at but also to fulfill fairly basic reporting
requirements, that they should not be asked to fill in these
huge forms that they are asked to do, but also that larger
organizations can also have investment as trainers of those
organizations.
This tends to be a whole area that is neglected. It is
either there that people have the management capacity or it is
not. As much as we need to train doctors in how to treat people
with ARV's, we need to train managers within organizations in
how to properly manage them and how to account for the money
that they are given, but also as part of the monitoring and
evaluation, how they should be looking at evaluating how well
they are doing because that is a resource that many developing
countries do not have. That is the first thing.
Then the second thing is that we are asking for more
consideration on time frames. There is a contradiction here. On
one hand, we want HIV to be treated as the emergency that it
is. If we had the same numbers of people dying in a terrorist
attack or in a cholera epidemic or a flood, there would be an
immediate emergency response, a multi-sectoral response from
the donors getting together and planning how they were going to
respond to this. I would argue that we really need that level
intervention right now. There are areas of southern Africa
where one in three women coming into an antenatal clinic is
HIV-positive. That is an emergency. This is usually a young
woman, maybe in her first or second pregnancy. That is an
emergency.
At the same time, we have to recognize that this is also a
long-term development problem. So, we need plans that go beyond
the 2- to 3-year funding plans that are made out. People need
to be able to plan for the next 10 years how they are going to
manage their programs and they need support in doing that from
the donors. It is very difficult to hire staff, who are of the
caliber that are required to manage these programs, and make a
commitment to them on a 2- or 3-year basis. Usually as soon at
the UN needs to fill a position, that person will leave to get
a higher paid job, even if they are personally committed to the
work that they are doing in an NGO. We need to be able to give
people commitments that they will be employed for much longer,
and we need to develop plans which involve the work that they
are doing in communities.
So, the length of time and the basis on which things get
treated as an emergency and development need to be reviewed by
all the donors, not just by USAID.
And the third issue is this issue of grants. We have heard
about huge amounts of money being discussed here. And the
people living with HIV that we are in contact with on a daily
basis often say to us, where is all this money? Because we do
not see it. I might say to them, well, we see a little bit of
it. And they will say, well, we do not see any of it. Often the
issue is that they believe that they are the ones who are
living with the problem, but there has been a huge industry
that has been developed out of AIDS and they have very little
part of that cake.
So, we would like to see more of the money that is
allocated to HIV and AIDS actually spent in the countries which
have the problem and, in particular, that are hardest hit.
A typical case is where you will get a donor coming into a
country and they want to do some work. They will set up a
tendering process whereby organizations have to tender for
money. If you take southern Africa, it will be the same
organizations that are asked to bid on these huge amounts of
money, and usually we do not have the capacity to do it. So,
then outside organizations win the contract, which means that
essentially we are paying for salaries in Europe or in the U.S.
The same thing happens when consultants come out. Their
salaries and all the other structures that support them are
earning the money usually in their host countries.
And we want more of that money to be spent in our
countries. But we acknowledge that we do not yet have the level
of skills to perform the same kinds of duties. So, what we are
asking for is that each of those consultants, when they come,
they come as trainers. So, for instance, when CDC sends people
out to do surveillance or epidemiological reviews or any of the
programs they do, part of their commitment has to be to train
local people. Now, if they cannot train local people because of
government issues, then they should look for alternative
structures that they can train people.
And we have got good partnerships. In Zimbabwe, we have a
good relationship with the CDC group there and with the USAID
group. And there are ways whereby their skills can be
transferred to local people, even if it is just straightforward
analytical skills. It needs a mind set which says that we are
here to support local people, rather than saying we are coming
in to do the job, which is a little bit what I have been
hearing at the presentations today. People are saying we are
doing this, we are doing that. Actually what we are saying is
we want to do it and we want you to do skills transfer. We want
to learn from you how to do it, but we want you to leave
knowing that there are people here who can take over and do the
same work. It is solidarity rather than patronage I think is
perhaps the way of looking at it.
My last point is that all of these structures that we have
been talking about and all of the programs that we know are
effective should all be linking together and they all require
much, much more investment in public health infrastructure. So,
for instance, to spell it out, we are talking about the Global
Health Fund looking at TB, HIV, and malaria, and these are
three programs that traditionally have been done in a vertical
way--TB and malaria anyway--and that they do not link up
together enough. That means that there is an awful lot of
opportunity that is lost in trying to get the best benefit for
each of those programs.
If you take voluntary counseling and testing, linking that
with TB programs means that every person who goes through a VCT
center who is told that they are positive should be screened by
the person giving them the results symptomatically to see
whether they also have TB, not saying to them, okay, for the
screening, you have to go to another center, because the
chances are they do not have transport money to go to both
places.
If they get through the TB screening, they should come out
knowing that they are at risk of TB and how they can protect
themselves or how they can know whether they need further
referral.
Similarly, people who go through a TB screening service or
a TB case finding service should also know about the link with
HIV and should be referred to VCT, not just them but their
families as well. So that then those linkages are made and the
messages are repeated often about the risks of HIV and the
risks of TB.
The issue about parent-to-child transmission is a very hot
one. We insist on calling it parent-to-child not mother-to-
child because it is the only way of drawing in men to the
problem. When people talk about mother-to-child transmission,
often the responsibility of men, both in preventing infection
but also in helping cope with it, is ignored. You find that
when you are talking to groups of people, they actually assume
that this is a woman's problem and that they do not have
anything to do with it. But if you can get men to attend one
antenatal care clinic, one clinic session with their partners,
there is a whole range of activities that should open up to
both the man and woman, and testing is just part of that,
bearing in mind what the earlier speaker said, that 70 percent
of the women coming through antenatal care will be negative,
and they need to know how to protect themselves. But they do
not have power to protect themselves. They rely on their
partner's cooperation. So, the partners need to know how to
protect their families.
And men do not like getting information from their wives or
their girlfriends or their partners. They like getting it
firsthand usually from professionals.
So, having a whole system that encourages men to come in
means that you have to have the resources to be able to provide
all those services. You cannot expect overworked health staff
to provide all of these functions without any additional
investment, and this is where we are proposing that we have to
get back to that concept of good quality comprehensive health
services where all the health staff are trained in how to deal
with all these issues, not necessarily to become full-fledged
counselors, but to know when the opportunities arise to be able
to provide that advice.
I think I better stop because I know we are short of time.
But my last point is that we have to remember that poverty
underlies all of this. The reason why young girls are so at
risk of infection, even when they know how they get infected,
even when they know how to protect themselves, is because they
are usually using sex as a way of getting out of poverty. Until
that changes, they will continue to be at risk.
Thank you.
[The prepared statement of Dr. Ray follows:]
Prepared Statement of Dr. Sunanda Ray, Director of Southern Africa HIV/
AIDS Information Dissemination Service [SAfAIDS]
hiv/aids: prevention, care, treatment and impact mitigation needs in
southern africa
Summary
The southern Africa region is confronted by a major catastrophe in
the form of an HIV epidemic that has not yet spent its force. We are
facing 50% of our current 15 year old cohort being dead before age 50
mainly through AIDS related mortality. The burden of HIV is greatest
for the poorest people, felt hardest at household level, with families
staggering to cope with loss of their main income earners and food
producers dying of AIDS while elders are looking after increasing
numbers of orphans and vulnerable children. Children themselves are now
becoming the carers, giving up aspirations of education and employment
to do so. This is happening at a time when many of our countries are in
economic difficulties and we do not have the resources to adequately
respond to this epidemic.
Many interventions are known to be effective in prevention of HIV
transmission, treatment and care of those affected in developing
countries. Some are:
provision of voluntary confidential counselling and testing
facilities, particularly targeting young people;
prevention of parent-to-child transmission through antenatal
clinic advice, testing and provision of ARVs to mothers and
infants, as well as infant feeding guidance;
a management and control of sexually transmitted infections;
male and female condom promotion;
peer facilitation with young people, sex workers, mobile
populations such as truck drivers;
youth friendly sexual health services;
community based care for people living with AIDS;
integrated comprehensive tuberculosis and HIV care.
All these programmes require good quality public health
infrastructure extending from hospitals, health centres and clinic to
community based workers and the communities themselves, the so-called
continuum of care approach. This is a major area for investment from
donors: in training and staff development; maintaining standards of
care; reliability of commodities and supplies of drugs, male and female
condoms; home care materials; destigmatisation of HIV; workplace
policies against discrimination; information exchange especially in
good practices and lessons learnt. Integration and interlinkages
between programmes such as family planning, antenatal care, STI
control, infant feeding, TB management, home based care and VCT provide
the best opportunity for maximum gain in breaking down the paralyzing
stigma and denial that haunt our programmes. Each sector reinforces the
messages promoted in support and care, maximizes the efforts of staff,
community workers and volunteers, with structured referral between
services to avoid duplication and repetition. All this activity will
need a good overall national strategic framework to pull it together,
the development of which is a major priority for each government and
will require donor input and expertise to facilitate the process.
Donors need to become more flexible and responsive to the needs of
non-governmental organisations, community groups and support groups in
providing funding in small chunks to enable them to do what they are
good at without getting overwhelmed with administration and accounting.
Larger organisations would also benefit from training and organisation
development in managerial skills so that they can oversee and support
these smaller community groups in their activities. Regional investment
in drugs and condom manufacture would provide employment and avoid
transfer of valuable scarce resources to industrialized countries.
Similarly, investment in local expertise would circumvent paying
salaries in rich countries for work done in the region. These solutions
require a longer time-frame than most donors plan for, probably 10-20
years to properly achieve the goals and benefits set out in strategic
planning.
introduction
Globally, by the end of 2001, 40 million people were living with
HIV, with 28.1 million, or 70%, from sub-Saharan Africa. In addition
21.8 million people had died of AIDS, with 19 million, or 87%, coming
from sub-Saharan Africa. The highest number of new infections is still
in Southern Africa, which has 50% of Africa's cases and the world's
nine most affected countries. Illnesses and deaths from AIDS will
continue to rise for many more years, even when HIV incidence has
stabilized or begun to drop. Consequently life expectancy has been
drastically lowered, with Swaziland and Zimbabwe reduced to 30-40 years
by 2010 if current trends continue.
South Africa has an estimated 20% of adults infected with HIV, an
increase from 13% two years ago. This translates into 4.2 million
people living with HIV/AIDS, the highest individual country total in
the world. The two countries in the region with the highest population
percentages are Botswana and Zimbabwe, with estimates of 36% and 35% of
adults infected respectively. In Botswana the prevalence rate has
increased to 46% among women aged 25-29. Health services are obviously
overwhelmed--an estimated 70% of Zimbabwean hospital bed occupancy is
HIV related. In Malawi only 400 out of 900,000 persons with HIV receive
antiretroviral therapy: in the region ARV treatment is generally
inaccessible due to extremely high costs and spiralling poverty. The
effect of HIV/AIDS on other sectors such as education is enormous: in
1998 Zambia lost 1500 teachers, 70% of the new teachers trained
annually. In much of southern Africa half our 15-year old boys will be
dead before they reach age 50 years, with mortality mainly due to HIV-
related causes [UNAIDS].
Although these figures are very dramatic, there are some positive
trends. For example UNAIDS reports that for the first time there are
signs that the annual number of new infections may have stabilized in
some parts of sub-Saharan Africa. In Zambia, recent surveillance data
suggest a drop in HIV incidence among young people aged 15-19 years in
the two main towns of Ndola and Lusaka. Uganda has also been notable in
reducing HIV prevalence in young people as evidenced by antenatal
trends.
In order to encourage and build on these developments, HIV-related
activities have to concentrate more on targeting young men and women
for prevention. Early sexual debut and early marriage are risk factors
for HIV for women, because of biological susceptibility during
adolescence and because of the age gap between women and men, whereby
men would be in older age groups with higher HIV prevalence. The best
opportunity for significant prevention of infection is targeting young
people before the age of sexual debut, since it is easier to influence
safer sex patterns from the outset than change established patterns of
behaviour in adults. Supporting women in self-efficacy skills that
enable them to refuse early sex provide better chances that they will
be able to negotiate for condom use later. Social and community norms
that hinder prevention efforts, that encourage stigma and
discrimination, have to be challenged. In addition, families living
with AIDS need practical and emotional support including caring for the
carers. The HIV epidemic has exposed areas of gender inequity in all
our countries that were already the basis for poor health and
inadequate social development in the past, which need addressing even
more urgently now. HIV, maternal mortality and sexually transmitted
infections [STIs] are the greatest causes of women's ill health,
accounting for over 50% of disease burden among women in southern
Africa. By promoting understanding of the long-term development impacts
of the epidemic, we can stimulate more effective responses including
tackling the poverty/HIV cycles whereby each makes the other worse.
what do we know about what is effective in prevention and treatment
programmes in developing countries?
The response to HIV/AIDS includes three essential components;
Prevention of new infection.
Treatment and care of people living with HTV and AIDS.
Mitigation of current and future social and economic impacts
of the epidemic.
Key elements of prevention include what is known as the ``abc'' in
southern Africa: abstinence, be faithful and condom use. All of these
depend on the ability of individuals to negotiate for these behaviours.
The literature on gender dynamics permitting or otherwise women and men
to carry out these behaviours is extensive. A major failing of previous
HIV prevention programmes in the region is that there was undue
reliance on individual behaviour change without concurrent supportive
changes in societal norms and values, the so-called enabling
environment. Now it is clearer that community education and community
behaviour change are essential to support people to undertake all these
protective behaviours.
In addition, condoms have to be accessible for those who want to
use them. The Thailand experience of the 100% condom campaign targeting
sex workers and clients led to a reduction in new infections from
143,000 in 1991 to 20,000 in 2000. In Cambodia new infections in sex
workers dropped from 40% to 23% in 2000, with sales of condoms climbing
from 100,000 in 1994 to 11.5 million in 1998. If condoms are available
in sufficient quantities for those who want to use them, there can be
significant impact on STI/HIV transmission. Provision of male condoms
per year by donors in six countries of sub-Saharan Africa with the
highest provision averaged 17 condoms per man aged 15-59. These
countries were Botswana, South Africa, Zimbabwe, Togo, Congo and Kenya.
In South Africa, it is estimated that 84 condoms per man aged 14-63
years would be required per year based on an average of 7 episodes of
sex per month. Obviously, some would be more and some less, and some
men would not need to use condoms at all if they were with a steady
partner. However, based on these statistics one billion condoms would
be required for South Africa alone for men aged 15-59 years. The number
of condoms distributed free by the government rose from 6 million in
1994 to 198 million in 1999, still indicating a considerable condom gap
in a country with rapidly growing HIV incidence. Locating condom
manufacture within the region [as is the case with East Asia] with
suitable quality control would make a substantial difference.
Other essential components of prevention are STI control and
prevention of parent-to-child transmission [PTCT]. STI control requires
reliable supplies of condoms for prevention, drugs for syndromic
management with laboratory back up for resistant cases. Prevention of
PTCT requires access to good quality antenatal care, health workers
trained to provide advice, testing facilities. For women identified as
HIV positive, the options available for prevention of transmission to
their infants are Nevirapine or AZT given to mother and infant,
caesarean section as method of delivery and advice on exclusive
breastfeeding or exclusive artificial feeding [mixed feeding presenting
the highest risk]. Most countries cannot afford to offer free formula
feeding and there is enormous stigma attached to being seen to bottle
feed since this labels the women as HIV positive. Nevirapine has been
provided free to countries with high prevalence but the above account
shows that drug costs are a small part of the overall infrastructure
required to prevent PTCT. The benefits of PTCT programmes extend beyond
prevention of infection to infants. Voluntary counselling and testing
[VCT] has been shown to provide motivation to individuals to stay
negative or to seek support if they are positive. If antenatal care
includes this process of VCT in addition to public education about HIV,
there is potential benefit at each stage, particularly in informing
women about the risks of HIV, how to protect themselves. With more
discussion about HIV, there could be more openness leading to potential
benefits of destigmatisation in communities. Even where 30% of women
attending antenatal clinics are HIV positive, the majority will be
negative, and need the opportunity to protect themselves. At present,
there is so much fear surrounding the presence of HIV, that many women
assume they are HIV positive and lose opportunities to prevent
infection. Where men are encouraged and motivated to attend antenatal
clinics with their partners, they may access advice and testing also,
with potential benefit to themselves and their families. One
generalized intervention that is being proposed is motivating men,
without testing, to use condoms for a defined period of time during
their partner's pregnancy and breastfeeding to avoid the higher risk of
passing on infection during seroconversion. It is estimated that 5% of
women become positive during the year of their pregnancy and
breastfeeding, probably because their husbands have had casual sex
during that time.
For all these behaviours in prevention to be successful, they have
to be promoted within an environment that is supportive of protection,
and with good quality health service infrastructures in place. Apart
from Botswana most PTCT programmes are in the pilot stage, but are
ready to be scaled up nationally. The main obstacle will be the lack of
trained staff to properly support women and their partners in making
decisions about their HIV status and their pregnancies.
As far as treatment and care are concerned, the problems in
providing services are even greater. The HIV epidemic has increased the
burden of disease up to sevenfold increasing demand for public health
care at the same time as spending on health care has decreased in many
countries in southern Africa. Most people with AIDS are cared for at
home by relatives who have very little formal support with protective
materials or emotional support. Many of these relatives will be
themselves living with HIV, or caring for other children from parents
who have died of AIDS. Many of the carers are themselves children
looking after dying parents. Most support comes from NGOs or faith
based organisations, rather than public health services. These either
do not have transport to do home visits, or are struggling to cope with
their inpatient load. They also do not have spare materials to provide
in home care. People dying of AIDS do not have basic analgesia to ease
their pain, suffer from malnutrition because they have terrible mouth
sores from fungal infections and cannot swallow, do not have access to
anti-diarrhoea drugs or drugs to stop their vomiting. For many, therapy
to ease opportunistic infections and pain are higher priority than
antiretroviral drugs. Although ARVs have made a major impact on
survival of people with HIV in industrialized countries, differences in
life expectancy were already stark because of the difference in access
to basic health services and early treatment of opportunistic
infections.
If cheaper sources of ARVs are made available, the infrastructure
costs of provision must be factored into the costs, including costs of
VCT and provision for spouses and other HIV positive children.
Activists and the medical profession alike often overlook equity of
provision when campaigning for ARVs. If public money is spent on
acquisition of ARVs with the support of donors, the best way of
ensuring equity is to channel the drugs through programmes such as
prevention of PTCT so that women attending antenatal care and found to
be HIV positive, are prioritized for treatment if appropriate. Their
partners can also be drawn in through the provision of treatment which
if accompanied by good quality VCT, would work towards caring for
affected families, linking them with support networks and advising them
on positive living and early treatment of infections. Tuberculosis
programmes that have good mechanisms already for registration of
patients, with good follow up and care, would be another appropriate
means of identifying families for VCT and ARV therapy while keeping
equity of access foremost in priority. If these strategies are not in
place, ARV therapy will mainly be used to benefit the rich and
influential without safeguards for poorer people, especially those in
rural areas.
where should donors channel resources?
For the HIV epidemic to be adequately addressed, major investments
are needed on a crisis scale in public health sectors of countries in
the southern Africa region. This need is underscored in every aspect of
prevention, treatment and care. In addition, recognizing that the
impact of HIV is wider than the health field, and is greatly felt in
all aspects of social and economic development, investment is also
needed in other sectors such as in education of young women and men,
provision of further education and employment possibilities,
restructuring of social welfare to serve the needs of families
decimated by AIDS, in particular orphans and vulnerable children,
training of all levels of public sector workers in all these fields, to
account for attrition due to ill health as well to cope with the
increasing demands.
Interventions that are known to be effective have to move urgently
from pilot projects to national scaling up. The public and private
sectors have to be prepared for this, and linkages between the
programmes maximized for greatest benefit. So for instance, all VCT
services should also provide basic symptomatic screening for STIs and
tuberculosis, with onward referral to services as appropriate. They
should also provide family planning advice to prevent unwanted
pregnancies. Public health services similarly should refer persons
screened for TB to VCT in view of the linkage between TB and HTV.
Family members should also be referred. For these referrals to be
effective, STI, TB, family planning and VCT services need to
drastically intensify their advisory services, bringing up HIV with
clients as much as possible, especially to break down the denial and
stigma patterns that have fostered the epidemic. In this prevention,
treatment and care are closely intertwined, with intensive promotion
that the majority of people are negative and need to stay that way.
Primary health care gains in many countries in southern Africa have
been reversed by the HIV epidemic. However, the developments that led
to those gains have to be urgently revitalized to link quality
antenatal care, family planning, infant feeding, child health,
syndromic STI management, TB control, support for home based care and
management of opportunistic infections in people living with AIDS under
the banner of comprehensive health care. Added to this will need
reliable provision of sufficient quantities of commodities such as male
and female condoms, antibiotics, pain relief, symptomatic treatment for
HIV related illness including opportunistic infections, and protective
materials for home based care. This will be even more effective if
coupled with public education so that health services are actively
supported by their communities, with linkages with volunteers, faith
institutions and NGOs. All this activity will need a good overall
national strategic framework to pull it together, the development of
which is a major priority for each government and will require donor
input and expertise to facilitate the process.
All these programmes need to give special attention to targeting
young people. Linkages with school health programmes, peer facilitation
projects, media work with young people, youth friendly clinics and
advice centres, sports and educational entertainment programmes are
various ways in which this can be achieved. More action research is
needed on where young people get their information from, who they
respect as peer facilitators, what influences are successful in
persuading them to protect themselves, how they arrive at realistic
decision making, and how to increase self efficacy for young women and
men. The behaviour changes desired are delay in sexual debut,
consistent condom use, early attendance for STI treatment and
understanding the link between infertility and STIs at young ages,
prevention of young women treating sex as a commodity thereafter ending
up as sex workers.
Donors have an additional role to play in providing flexible
systems and mechanisms to support small-scale community development,
local structures and organisations. This is partly through funding but
also through capacity building, supporting information exchange and
dissemination in accessible formats, supporting innovative methods of
interactive information exchange such as through media, email
discussion fora, theater and performing arts. At SAfAIDS we do all
these things entirely through donor funding. In addition we link
researchers with organisations involved in implementation, so that
research findings can inform the design of programmes, provide feedback
on research and implementation across groups, and translate information
found on the internet or e-mail discussions into print formats such as
newsletters and bulletins so that those without computer access can
still be updated.
critical appraisal of u.s. bilateral assistance efforts
My main experience with U.S. assistance for HIV programmes is in
Zimbabwe. USAID has focused on several areas of proven effectiveness
combined with operational research components to establish what works
where the evidence is not so clear. These programmes are:
Social marketing programmes for high quality voluntary
confidential counselling and testing [VCT] services through the
private sector; this is mainly in urban areas but provision of
mobile outreach clinics for more rural areas is being explored.
These programmes particularly target young people.
Social marketing of male and female condoms and oral
contraceptives through pharmacies and supermarkets. Procurement
of condoms is done in conjunction with the British Department
of International Development [DFID].
Support for the Zimbabwe National Family Planning Council
[ZNFPC], in particular to train and upgrade community based
distributors of oral contraceptives so that they can provide
other forms of sexual health advice.
In conjunction with the U.S. Centres for Disease Control
[CDC] programme in Zimbabwe, there is support for monitoring
the spread of HIV in Zimbabwe through serological surveillance
and a youth sexual health survey. They are also embarking on a
media programme targeting young people.
Impact mitigation through orphan care, educational support
for girls, microfinance projects targeting women, vulnerable
groups such as street children and farm workers.
A policy and advocacy programme has just started which plans
to provide support and grants for private sector and NGO
initiatives to destigmatise HIV and reduce discrimination such
as through workplace policies, capacity building, lobbying
parliamentarians, and use of media.
The main constraint we face in the NGO sector in the region related
to U.S. funding for our projects is that the process of procuring funds
is very bureaucratic and cumbersome. In the words of one friend, big
money is not always the answer if it cannot be delivered in small
enough chunks. There is little flexibility in the system to make small
grants to NGOs with good ideas but little absorptive capacity for large
amounts of money. A grant of 50,000 U.S.$ to support VCT activities in
an NGO involves the same arduous process as a grant of 20 times that
amount. The justification for this is in need for organisational
accountability and financial accounting mechanisms. However, it means
the funding cannot be used in ways that are dynamic, responsive or
empowering to community groups where the impact of the HIV epidemic is
felt the hardest and who have the least means to protect themselves.
Another problem is that the time scales for programme planning and
funding are short, sometimes 2 to 3 years. A much longer-term
perspective is essential for strategic planning to achieve its goals,
probably 10-20 years. The effects of HIV in communities will continue
to be experienced for that long even if new infections are entirely
prevented. At the same the urgency of the current HIV epidemic in
southern Africa has to be regarded and dealt with as a crisis rather
than a chronic development issue, so that disbursement of funds are
more quickly facilitated to multiple sectors and groups working to
ameliorate the impact. Some have called for mobilisation of ``war
budgets'' with all resources reoriented towards this effort.
training and infrastructure needs in developing countries
Many training and infrastructure needs have been referred to in
earlier sections but it is worth emphasizing some needs in particular.
At SAfAIDS we are often asked to act as an umbrella body to smaller
organisations to enable them to get grants through us because we have
the skills and accounting mechanisms to fulfill donors reporting
requirements. If we agreed with this, our attention would be divided
between doing what our mission is, which is using information as a
change agent, and mentoring smaller organisations with varying capacity
and ability to carry out what their purpose is. There are not
sufficient indigenous organisations with the necessary skills and
infrastructure to carry out this kind of mentoring because it is
difficult to retain skilled staff within the NGO sector. For this
reason donors often commission international agencies to develop
networks of partners to carry out their work but the sad consequence is
that valuable funds then go to pay salaries in Britain, U.S. and Europe
rather than investing in capacity building within the region. South
Africa is one country that has private companies competing for many of
these contracts and we could make more of developing regional
partnerships with them. One essential training need here is to build up
managerial and financial accounting capacity within small organisations
so that they are better able to report on the funds they receive, and
among larger organisations so that they can capacity build smaller
organisations. Developing centres within universities to carry out
these functions would be another way to support training as well as
skills expansion, staff development and consultancy.
A major gap that has developed between rich and poor countries is
access to computer skills and information technology, with the access
this provides to updated information. Most secondary schools in the
region do not have computers even when they have access to electricity
and phone lines, so students do not even have keyboard skills. Access
to IT has been liberating in many circumstances. Many academics are now
able to access medical and other health journals free on the internet
whereas they previously received print journals very late, if at all.
Discussion fora prior to conferences are often more interesting than
the conference proceedings themselves, and usually more democratic. The
youth e-mail discussion forum for the African Development Forum 2000 in
Addis Ababa was a case in point. We provide cyber training for small
groups of NGOs that have access to email and internet but do not know
how to use them. This is an area that could develop rapidly with
investment beyond what we can offer, taken up by major training in each
country. Email discussion groups in each country could enable the
National AIDS Councils to keep their partners and member organisations
informed of grants, funding, activities as well as stimulate debate on
various aspects of the crisis, such as how the money is being spent!
Other use of technology is that the rapid acquisition of cell phones in
the region has meant that setting up telephone helplines for the public
are now a possibility whereas in the past this only served urban
elites.
Finally, there are major training needs for all levels of public
sector workers related to HIV/AIDS, in health, education, social
welfare, industry, agriculture and so on. For health sector workers,
training in provision of sensitive non-judgemental sexual health
services for all who walk in the door is crucial so that they do not
create barriers to uptake of services as often happens at present. In
particular they need training in how to provide youth friendly services
in imaginative ways [such as having peer facilitators working alongside
them in clinics], how to encourage sex workers to use public facilities
without fear of discrimination, and other marginalized groups such as
street children. Training is needed in how to provide advice for
prevention in PTCT, such as management of mastitis and breast problems
[that may facilitate HIV transmission], support for exclusive breast-
feeding or exclusive artificial feeding. Many of these activities we
assume health workers must know, but in fact they do not. Doctors are
the least equipped to support infant feeding or to give advice on
testing. In addition doctors and other health workers need more
intensive training in how to support relatives in home based care and
symptomatic management of HIV related pain and illness. If ARVs become
available this will be a further area for training, not only in
treatment and monitoring of treatment, but also in how to ensure equity
in provision of treatment. There are training courses usually
associated with universities in the region that can cater for many of
these training needs but they are often inaccessible because of costs
of travel, accommodation, course fees. Again, facilitating attendance
and follow up at these courses would be an important use of donor money
but is often not provided because of the administration involved in
small grants.
In conclusion, the literature around what is effective in
prevention, treatment and care in HIV/AIDS is vast and could not be
covered adequately in this paper. What is crucial now is learning how
to put what we know into practice, with feedback and follow up built in
to research and programme work. It is difficult to implement any of
these programmes beyond pilot projects when health staff are deskilled
and in poor morale, when health services are run down and unable to
provide comprehensive care, with poor linkages with communities. To
respond to the HIV epidemic in appropriate and timely ways requires
massive investment and support to public health service provision,
training and skills development in all public sectors on HIV, and
flexible, streamlined and coordinated donor responses to the most major
and catastrophic social disaster of our time in the southern Africa
region.
Senator Frist [presiding]. Thank you, Dr. Ray.
Dr. Okaalet.
STATEMENT OF PETER OKAALET, M.D., AFRICA DIRECTOR, MEDICAL
ASSISTANCE PROGRAM INTERNATIONAL, NAIROBI, KENYA
Dr. Okaalet. Chairman Biden, in absentia, distinguished
Senator Frist, fellow partners in the struggle against HIV and
AIDS, thank you for inviting me to bring before you today both
a challenge and an opportunity.
My name is Peter Okaalet. I am a Ugandan-born physician who
leads MAP International's HIV and AIDS work in Africa. The
credentials I offer on this subject are three-fold. As an
African physician, I have treated dying patients of HIV and
AIDS. As an African theologian, I have counseled them and
comforted their grieving relatives. And as a family member, I
have been, and still am, brother, uncle, and cousin to those
dying of HIV and AIDS.
I do not wish to discuss the program today, but instead to
speak of a unique resource to combat the disease. In every
community, from the smallest, most remote village to the
largest urban centers, there is an institution that is always
present. It can muster tremendous human resources. It has
infrastructure in place. It is truly grassroots, and it can
influence behavior, politics, and social justice. In fact, in
many instances, it has changed the course of human events. From
my Christian background, I will refer to this simply as the
church, but please hear the term and recognize that for the
purpose of this testimony, I will use that to encompass all
organized religion and all faith-based institutions.
To quote from a 1995 UNICEF report: ``Religion plays a
central, integrating role in social and cultural life in most
developing countries. There are many more religious leaders
than health workers. They are in closer and regular contact
with all the groups in society and their voice is highly
respected. In traditional communities, religious leaders are
often more influential than local government officials or
secular community leaders.''
I offer you today the church as a powerful tool with which
to address both HIV and AIDS prevention and care. In truth and
humility, we in the church recognize that our tool has been
badly flawed. As the AIDS pandemic spread, it exposed fault
lines that ran in the heart of our theology, ethics, and
actions. The church was too often an obstacle in the fight. We
looked the other way when customs and traditions flew in the
face of religious teachings, and we created unnecessary
factions over the condom issue. We called people living with
HIV and AIDS sinners, and we too often ostracized them rather
than embraced. We as religious leaders were loathe to discuss
the issue of sex and death with our families, communities, and
never from the pulpit. In many cases, we increased rather than
ameliorated the suffering and separation of the ill and the
dying.
But I am here to tell you that in Africa, I am hearing
recognition that we have been part of the problem. I am also
seeing that we are an integral part of the solution. Religious-
based institutions, when properly supported and coordinated,
can be some of the most strategic vehicles through which to
slow the spread of HIV and AIDS.
This past November, for example, at the Global Consultation
of the Ecumenical Response Against HIV and AIDS was held in
Nairobi. Also in November of last year, 580 representatives
from 31 nations, representing 70 million members of the
Association of the Evangelicals in Africa met in Burkina Faso
and together declared that the church must address poverty and
HIV and AIDS. The participants left energized and committed for
the raging battle. The call to action does not demand
uniformity in response, but it does demand a resolve to speak
openly and honestly about the disease.
The church also recognizes that the AIDS pandemic has
systemic issues that are rightly the domains of the church:
namely, violence, gender inequality, poverty, human rights, and
social justice. The future holds great promise, building upon
what the church has already done to address HIV and AIDS. I
would like to cite a few success stories.
Uganda, my home country, is often cited for the most
dramatic reduction in HIV infection rates. It is not mere
coincidence that the period when the rates plummeted,
especially between 1991 and 1998, was a period of marked
involvement by the Anglican, Catholic, and Muslim religious
organisations. Their messages of fidelity and abstinence echoed
the approach strongly favored by President Museveni. Senator
Frist, you have already refereed to his wife coming to address
a conference that will be taking next week.
Several studies have documented behavior change, including
reduction in sexual partners, delay of sexual debut, and
abstinence. A UNAIDS best practices study of the Islamic
Medical Association in Uganda shows that AIDS prevention
activities carried out through religious leaders did have a
significant impact in reducing the spread of AIDS. As behavior
continued to change and HIV infection rates declined, several
other religious groups became involved under the coordination
of the ministry of health. Dr. Edward Green, a consultant of
the Synergy Project and Harvard School of Public Health,
studied the Ugandan model and estimated that in 1995 over 2,700
trainers and peer educators, as well as about 5,600 community
volunteers in the Muslim IMAU project alone, had reached nearly
200,000 households and had counseled or sensitized over 1
million sexually active people.
In Zambia, the Salvation Army has been on the forefront of
HIV and AIDS prevention and control strategies. They have
supported institutional care of people living with HIV and AIDS
in Chikankata Hospital, for example. Their program reflects the
continuum of care model that is essential in the face of this
pandemic.
The organization that I represent, a Georgia-based PVO,
Medical Assistance Program International, has its own success
stories in Kenya. With funds received from USAID through Family
Health International, MAP launched its project which was dubbed
Integrated Action Against AIDS with Kenyan Churches in 1994.
MAP has worked since, across the denominational spectrum, from
Pentecostal to Roman Catholic congregations, conducting
training in HIV and AIDS prevention and compassionate care
ministries. The project incorporated baseline research,
material development and dissemination, networking, and policy
formation with top-level leaders and grassroots practitioners.
It developed a peer education program, youth-to-youth, training
adolescents in various parts of Kenya, especially in the
schools and churches.
MAP, in partnership with a select number of theological
institutions in Kenya, began to develop a curriculum on HIV and
AIDS targeting seminaries and bible schools in sub-Saharan
Africa. The rationale for this project was the simple fact that
clergy and church leaders were sadly unprepared to deal with
the HIV and AIDS impact, especially in the churches and in the
communities. As most of us have found out working with
religious leaders, the official duty that a young African
clergy fresh from seminary or bible school would be called upon
to perform would most likely be a graveside service for someone
who had died of HIV and AIDS, not a biblical exegesis from the
pulpit on a Sunday morning. Seminarians usually graduate with a
knowledge of Hebrew, but have little knowledge on the subject
of the prevention of sexually transmitted diseases, including
HIV and AIDS.
In 1996, MAP developed a series of curriculum modules that
address HIV and AIDS, targeting especially again the
theological schools. Some of the modules included such modules
as facts about transmission, advice on mobilizing church
resources, information about home-based care, and other AIDS-
related issues imperative for a church leader to grapple with
when they graduate from theological school.
In June of 2000, the ministry of health in Kenya opened
another workshop that brought together theologians from east
and southern Africa to discuss the subject of HIV and AIDS and
try to create a curriculum targeting theological schools again
in that region. We are pleased to report that through a grant
from the Episcopal Relief and Development Fund in New York this
fall, four Anglican seminaries in Kenya, Uganda, Zambia, and
South Africa have accepted the challenge and will integrate HIV
and AIDS courses in their curriculum.
MAP has worked closely with people of other faiths,
especially the Muslims in Kenya. Last October, for example, at
the request of the National AIDS Control Council, MAP organized
an inter-religious conference on the role of faith-based
organizations in combating HIV and AIDS that included
Christians, Muslims, Sikhs, and Hindus.
The examples I cite above have a number of common threads:
a proactive program reaching across denominations, strong
coordination and effective follow-up, and a partnership among
government, secular, and religious sectors. Partnership is
essential to any effective broad-based program such as the one
that I am talking about.
The Uganda model used World Bank funding, government
backing, and faith-based organizations' networks and training
ability. MAP's experience in Kenya would never have been
possible without the initial funding from USAID's AIDS Control
and Prevention Project, AIDSCAP. MAP was supported by the World
Health Organization to carry out also some other home-based
care in western Kenya. UNAIDS has funded most of the work that
we have done, and I am sorry that Dr. Peter Piot is not here to
hear some of the vote of thanks that I wanted to give to him at
this time.
AIDS is not just a medical problem and not just a public
health issue. It is also a behavioral issue. MAP International
promotes the ABC approach: abstinence until marriage, being
faithful in marriage, and condom usage where warranted.
While MAP does not make a judgment for other groups about
the use of condoms, it does advocate for a participatory
approach in discussion of the issue. I wish to stress that
behavior change is not synonymous with condom usage. Like a
pebble tossed into a lake, behavior is but a ripple effect of
deeper issues, values and choices. This would suggest that one
cannot speak of behavior change necessary to combat HIV and
AIDS without addressing the core issues of poverty, injustice,
and the exploitation of women, what my other colleagues have
already referred to, basic human rights, enough food to eat,
enough clean water to drink, a roof over one's head, and a way
to make a living.
A mother of four in my country who can make the equivalent
of $3 for having unprotected sex with a client or $1 if she
demands he wear a condom can hear the message of safe sex all
day, but it will not drown out the hungry cries of her
children.
A 10-year-old in South Africa who is forced to have sex
with an HIV-infected person, especially a man much older than
her, who believes that sex with a virgin will cure him, is an
inappropriate target for the ``wait until you are married''
kind of talk.
Neither faith-based organizations nor governments nor world
assemblies can separate the AIDS pandemic from the larger
social and political issues. One of the most effective
strategies in the Uganda AIDS success story was the use of debt
relief to expand the AIDS control effort. Recognition of the
root causes, resource pooling, and coordination are key, with
each player bringing to the table the very finest resource in
their arsenal.
Last May, Christian Connections for International Health
brought together about 166 participants representing 25
countries to an AIDS, TB, and malaria conference which was held
at the First Presbyterian Church of Arlington, Virginia. The
venue was a house of worship, but the participants represented
WHO, UNAIDS, USAID, CDC, pharmaceutical representatives,
academicians, congressional staff, and secular NGO's, in
addition to the faith-based organizations represented.
As already alluded to, next week another assembly convened
by the Samaritan's Purse, whose team is here present under the
leadership of Ken Isaacs, will draw representatives, over 900
of them at least, from the same diverse sectors, all focused on
AIDS and the broader issues of poverty and human rights, all
committed to the fact that the time has come to present a
united front in face of this pandemic.
I would now like to pose three key questions and suggest a
few answers as I close.
Senator Frist. Dr. Okaalet, just because the Secretary-
General is going to start here in a few minutes, summarize in a
couple of minutes. Your testimony will be read by everybody.
The questions are great and the answers are great because I had
an opportunity to look at those earlier. But summarize those
and we will go through one round of questions. Then we will
have to close.
Dr. Okaalet. Thank you.
The first question, what do we, the faith community, offer
the world in the fact of this pandemic? A track record of 2,000
years of history of care and support to those who are in
situations like those HIV and AIDS people find themselves in.
Responsiveness and commitment, integrity, access, moral
authority, advocacy, and a holistic approach.
Second, how do we, the faith community, construct a new
plan of action to address HIV and AIDS? We will condemn
discrimination and stigmatization. We will seek out partners.
We will advocate broadening the discussion on HIV and AIDS to
include other issues that are no-touch subjects like sex and
sexuality, even preaching about them from the pulpit. We will
educate. We will promote effective means of prevention. We will
commit resources to care and counseling. We will challenge
culture and traditions.
Lastly, what do we, the people of faith, ask of you in the
committee? Number one, that you continue to create space in
which to engage us, be it through formal offices for faith-
based initiatives, conferences, or informal discussions.
Second, that you help leverage the tremendous financial
resources of the United States and the western world to engage
the pandemic even more aggressively. And lastly, that you
continue to shift resources like those through the USAID CORE
initiative to grassroots faith-based organizations and
institutions in the front lines of the battle who have proven
that they can indeed be committed allies to defeating this
pandemic.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Okaalet follows:]
Prepared Statement of Peter Okaalet, MD, M.Th, M.Div., African
Director, MAP International
the role of faith based organisations in the fight against hiv and aids
Chairman Biden, distinguished Senators, fellow partners in the
struggle against HIV and AIDS, thank you for inviting me to bring
before you today both a challenge and an opportunity.
My name is Peter Okaalet. I am a Ugandan-born physician who leads
MAP International's HIV and AIDS work in Africa. The credentials I
offer on this subject are three-fold: as an African physician, I have
treated dying AIDS patients; as an African theologian, I have counseled
them and comforted their grieving relatives; as an African family
member, I have been--and still am--brother, uncle, and cousin to those
dying of AIDS.
I do not wish to discuss the problem today, but instead to speak of
a unique resource to combat the disease. In every community--from the
smallest, most remote village, to the largest urban centers, there is
an institution that is always present. It can muster tremendous human
resources; it has an infrastructure in place; it is truly ``grass-
roots;'' and it can influence behaviour, politics, and social justice.
In fact, in many instances it has changed the course of human events.
From my Christian background, I will refer to it as the Church. But
please hear that term and recognize, that for the purpose of this
testimony, I will use that to encompass all organized religion and all
faith-based institutions.
To quote a 1995 UNICEF report:
``Religion plays a central, integrating role in social and
cultural life in most developing countries . . . there are many
more religious leaders than health workers. They are in closer
and regular contact with all age groups in society and their
voice is highly respected. In traditional communities,
religious leaders are often more influential than local
government officials or secular community leaders.'' (Religious
Leaders as Health Communicators. New York, NY:UNICEF, 1995)
I offer you today the Church as a powerful tool with which to
address both HIV and AIDS prevention and care. In truth and humility,
we in the Church recognize that our tool has been badly flawed. As the
AIDS pandemic spread, it exposed fault lines that ran to the heart of
our theology, ethics, and actions. The Church was too often an obstacle
in the fight: we looked the other way when customs and traditions flew
in the face of religious teachings; we created unnecessary factions
over the condom issue; we called people living with AIDS sinners; and
we too often ostracized rather than embraced. We as religious leaders
were loathe to discuss issues of sex and death within our families,
communities, and never from the pulpit. In many cases, we increased,
rather than ameliorated, the suffering and separation of the ill and
the dying.
But I am here to tell you that, in Africa, I am hearing recognition
that we have been part of the problem. I am also seeing that we are an
integral part of the solution. Religious-based initiatives, when
properly supported and coordinated, can be some of the most strategic
vehicles through which to slow the spread of HIV and AIDS. This past
November, at a Global Consultation on the Ecumenical Response to the
Challenge of HIV and AIDS in Africa held in Nairobi, this was
confirmed. Also in November, 580 representatives from 31 African
nations representing 70 million members of the Association of
Evangelicals in Africa met in Burkina Faso and together declared that
the church must address poverty and HIV and AIDS. The participants left
energized and committed for the raging battle. The call to action does
not demand uniformity of response--but it does demand a resolve to
speak openly and honestly about the disease, about sexuality and about
behaviour, and to act practically, compassionately, and nonjudgmentally
in response to it. To quote one of the plans of action from the
conference: ``It is time to speak the truth. It is time to act only out
of love. It is time to overcome fatigue and denial And it is time to
live in hope.''
The Church also recognizes that the AIDS pandemic has exposed
systemic issues that are, rightly, the domains of the Church: namely,
violence, gender inequality, poverty, human rights, and social justice.
The future holds great promise, building upon what the Church has
already done in addressing AIDS. I would like to cite a few success
stories:
Uganda, my home country, is often cited for the most dramatic
reduction in HIV infection rates. It is not mere coincidence that the
period when the rates plummeted, 1991-1998, was a period of marked
involvement by Anglican, Catholic, and Muslim religious organisations.
Their messages of fidelity and abstinence echoed the approach strongly
favored by President Museveni. Several studies have documented
behaviour change--including reduction of sexual partners, delay of
sexual debut, and abstinence. A UNAIDS ``Best Practices' study of the
Islamic Medical Association of Uganda (IMAU) shows that AIDS prevention
activities carried out through religious leaders had significant direct
impact. As behaviour continued to change and HIV infection rates
declined, several other religious groups became involved under the
coordination of the Ministry of Health AIDS prevention activities,
funded by the World Bank. Dr. Edward C. Green, consultant to the
Synergy Project and Harvard School of Public Health, studied the Uganda
model and estimated that in 1995 over 2,745 trainers and peer educators
as well as 5,629 community volunteers in the Muslim IMAU project alone
had reached nearly 200,000 households and had counseled or sensitized
over 1 million sexually active people. The Anglican project had reached
nearly 3/4 million Ugandans.
In Zambia, the Salvation Army has been on the forefront of HIV and
AIDS prevention and control strategies. They have supported
institutional care of people living with HIV and AIDS in Chikankata
Hospital. Their program reflects the continuum of a care model that is
essential in the face of this pandemic.
The organisation I represent, a Georgia-based PVO, MAP (Medical
Assistance Programs) International, has its own success story in Kenya.
With funding from USAID, through Family Health International, MAP
launched its project, ``Integrated Action Against AIDS with Kenyan
Churches'' in 1994. MAP has worked since, across the denominational
spectrum, from Pentecostal to Roman Catholic congregations, conducting
training in HIV and AIDS prevention and compassionate care ministries.
The project incorporated baseline research, material development and
dissemination, networking, and policy formation with top-level leaders
and grass roots practitioners. It developed a peer education program,
youth-to-youth, training adolescents to counsel their peers in Kenyan
churches and schools.
MAP, in partnership with a select number of theological
institutions in Kenya, began to develop a curriculum on HIV and AIDS
targeting seminaries and bible schools in sub-Saharan Africa. The
rationale for this project was the simple fact that clergy and church
leaders were sadly unprepared to deal with AIDS and its impact on their
churches and communities. The first official duty that a young African
clergyman, fresh from seminary or bible school, would be called upon to
perform would most likely be a graveside service for someone who had
died of AIDS, not a biblical exegesis from the pulpit! Seminarians
usually graduate with knowledge of Hebrew, but have limited knowledge
on the subject of the prevention of sexually transmitted diseases.
In 1996 MAP developed a series of curriculum modules addressing the
biblical foundations for an HIV and AIDS church initiative, facts about
transmission, advice on mobilizing church resources, information about
home-based care, and other AIDS-related issues imperative for a church
leader to grapple with. In June 2000, MAP, in partnership with the
World Council of Churches and UNAIDS, hosted a forum that attracted
academic deans, principals, and representatives from 20 theological
institutions from 14 countries in East and Southern Africa. The outcome
was a draft curriculum with a challenge to take it, adapt it to the
particular denomination or country, and require its use in the
seminaries and bible schools.
We are pleased to report that, through a grant from the Episcopal
Relief and Development Fund in New York this fall, four Anglican
seminaries in Kenya, Uganda, Zambia and South Africa have accepted the
challenge and will be integrating the HIV and AIDS courses into their
curriculum.
MAP works closely with the Ministry of Health and has held a seat
on the board of the Kenya AIDS NGO Consortium (KANCO) since its
inception. This consortium includes government, faith-based
organisations, international organisations, and secular NGOs.
Working with the Muslim community in Kenya, MAP has made great
strides in interfaith alliances. HIV and AIDS prevention radio spots,
created by MAP for the Kenya Broadcasting Corporation, patterned
themselves after Islamic calls to prayer. Discussions have been held
with the Imam of the largest mosque in Nairobi. Last October, at the
request of the Kenyan National AIDS Control Council, MAP organized an
inter-religious conference on the role of faith-based organisations in
combating HIV and AIDS, that included Christians, Muslims, Sikhs, and
Hindus.
The examples I cite above have a number of common threads: a
proactive program reaching across denominations; strong coordination,
and effective follow-up; and a partnership among government, secular,
and religious sectors. Partnership is essential to any effective, broad
program.
The Uganda model used World Bank funding, government backing, and
the faith-based organisations' networks and training ability. MAP's
experience in Kenya would never have been possible without the initial
funding from USAID's AIDS Control and Prevention (AIDSCAP) Project. MAP
was supported by the World Health Organization (WHO) to carry out a
home care study. UNAIDS funds much of our conference and networking
work. The faith-based initiative offices of USAID and the World Bank
offer consulting and networking opportunities. Clearly, bilateral and
multilateral agencies are recognizing and responding to the potential
offered by partnering with faith-based organisations to combat HIV and
AIDS. Archbishop Desmond Tutu, among others, has forcefully called for
a concerted effort by all to rise up to the challenge posed by HIV and
AIDS. He challenged global leaders to look beyond their differences and
to join hands in solidarity against this pandemic.
AIDS is not just a medical problem . . . and not just a public
health issue--it is also a behavioural issue. MAP International
promotes the ABC approach: Abstinence until marriage, Being faithful in
marriage, and Condom usage when warranted. To complement this
prevention strategy, MAP also emphasizes care and support of people
infected and affected by HIV and AIDS, thus addressing the entire
continuum of care--prevention, care, and support.
While MAP does not make a judgment for other groups about use of
condoms, it does advocate for a participatory approach in discussion of
the issue. I wish to stress that ``behaviour change'' is not synonymous
with condom usage. Like a pebble tossed into a lake, behaviour is but
the ripple effect of deeper issues, values and choices. This would
suggest that one cannot speak of the behaviour change necessary to
combat HIV and AIDS without addressing the core issues of poverty,
injustice, exploitation of women, and basic human rights to enough food
to eat, enough clean water to drink, a roof over one's head, and a way
to make a living.
A mother of four in my country who can make the equivalent of $3
for having unprotected sex with a client--or $1 if she demands he wear
a condom--can hear the message of safe sex all day, but it will not
drown out the hungry cries of her children. A ten year old in South
Africa who is forced to have sex with an HIV-infected man who believes
that sex with a virgin will cure him, is an inappropriate target for
the ``wait until you are married'' talk.
Neither faith-based organisations, nor governments, nor world
assemblies can separate the AIDS pandemic from these larger social and
political issues. One of the most effective strategies in the Uganda
AIDS success story was the use of debt relief to expand AIDS control
efforts. Recognition of the root causes, resource pooling, and
coordination are key, with each player bringing to the table the very
finest resources in its arsenal. Last May, Christian Connections for
International Health brought together 166 participants from 25
countries to an AIDS, Malaria, TB conference held at the First
Presbyterian Church of Arlington, Virginia. The venue was a house of
worship, but the participants represented WHO, UNAIDS, USAID, CDC,
pharmaceutical representatives, academicians, congressional staff, and
secular NGOs, in addition to the faith-based organisations represented.
Next week, another assembly convened by Samaritan's Purse will draw
representatives from the same diverse sectors--all focused on AIDS and
the broader issues of poverty and human rights. All committed to the
fact that the time has come to present a united front in the face of
this pandemic.
I would now like to pose three key questions, and suggest a few
answers:
What do we, the faith community, offer the world in the face of
this pandemic? (Quoted in part from a Christian Connections in
International Health document):
A track record--A 2,000 year history of quality care for the
sick and the dying. In many African countries, religious
organisations provide 30-50% of the hospital beds in the
country.
Responsiveness and long-term commitment--Faith based
organisations respond quickly to difficult situations,
accepting challenges other institutions ignore or quickly
abandon when they linger or become unfashionable.
Integrity--Individuals in America and around the world give
more of their philanthropic dollars to religious institutions
than to any other group. On the whole, religious groups have a
record of fiscal responsibility and a divine mandate to be good
stewards of the resources allotted them.1
Access to a wide audience and community involvement.
Moral authority--religious leaders can influence
communities, societies, nations, and the course of human
events.
Advocacy--Religious institutions champion the poor, the
marginalized, the disenfranchised.
A holistic approach--melding the spiritual, physical, mental
and social aspects of health and balance.
How do we, the faith community, construct a new plan of action to
address HIV and AIDS? (Quoted in part from the Plan of Action: The
Ecumenical Response to HIV and AIDS in Africa, Kenya, November 2001)
We will condemn discrimination and stigmatisation and will
embrace people living with AIDS.
We will seek out partners in government, business, and the
international community, pooling resources to form the most
efficient, effective response to the pandemic.
We will advocate broadening the discussion of HIV and AIDS
to include issues of gender, violence, political inequity, and
poverty.
We will educate ourselves and those under our care--with
special emphasis on our new generation of leadership and our
youth.
We will promote effective means of prevention. In doing so,
we will support the churches' historic commitment to
faithfulness and abstinence, while allowing latitude for means
beyond these that have proven effective in reducing risky
behaviour.
We will commit resources to care and counseling in addition
to prevention and education.
We will challenge culture and traditions, identifying those
practices that are antithetical to our teachings and harmful to
health, and proposing alternative rites and rituals in place of
these harmful practices.
What do we, the faith community, ask of you?
That you continue to create spaces in which to engage us--be
it through formal offices for faith-based initiatives,
conferences, or informal discussion.
That you help leverage the tremendous financial resources of
the United States and the Western World to engage the pandemic
even more aggressively.
That you continue to shift resources, like those through the
USAID CORE initiative, to grass-roots faith-based organisations
and institutions in the front lines of the battle and have
proven their effectiveness, often with few resources.
In closing, my distinguished colleague, Dr. Peter Piot of UNAIDS,
has said that although AIDS has been an issue for twenty years now,
``it is a tale that is still in its opening chapters.'' While it is
true that because of the long lead-time between infection and
manifestation of the symptoms, what we are seeing, especially in Asia
and Latin America, may only be the first few chapters of this macabre
tale. It is also true, however, that faith-based organisations that
heretofore have been introduced in a supporting role in these first few
chapters, in fact will become integral to the story and may well
determine the story's outcome.
Senator Frist. Thank you very much.
Dr. Okaalet, where do you live? Are you in Uganda or Kenya?
Dr. Okaalet. I live in Nairobi.
Senator Frist. And where did you go to medical school?
Dr. Okaalet. I went to Maketeda Medical School in Uganda.
Senator Frist. And you are licensed to practice in Uganda
then still?
Dr. Okaalet. Both in Uganda and in Kenya.
Senator Frist. Well, you and I--and I say this quite
proudly--are probably the only two people in the room who are
licensed to practice medicine in Uganda. As you may know, I had
the opportunity to operate alongside the Vice President of
Uganda who is a surgeon in the medical center there, which has
a tremendous tradition in terms of producing I guess the first
three physicians in sub-Saharan Africa long ago. It was a real
pleasure for me to operate alongside her.
But in my office, I have a 3-month temporary license to
practice in Uganda. So, I have got another 2 and a half months.
I wish we had more time because each of these three
dimensions are fantastic and they really integrate one with
another. Mr. Lyman mentioned the role of the church and the
role of faith-based organizations. Clearly as we tie in with
the NGO's, the faith-based component, given what the
predominance in Africa is, for the reasons that you closed
with, Dr. Okaalet, in terms of the foundation, the long-term
care, the long-term involvement plays a huge role, and I am
impressed by it every time I go to Africa.
Several questions real quick and then we will wrap up for
the Secretary-General.
Dr. Ray, we have talked a lot about the Global Fund, and I
think over the course of the last 4 hours, it has been an
appropriate perspective where people look to it, know it is not
the answer. It is important that we continue to invest, I would
argue, very heavily in that fund. But whatever we do here in
Washington, DC in making decisions, it is important that that
money gets down to your groups, to your constituents.
In addition to being in Uganda, I was in Tanzania and met
there with Sister Denise, again with the Catholic diocese
there. She told me exactly the same thing. We see this money
coming down. It gets all the way down to the country level. It
gets down to the local level. It gets down to even the
community level, and it is a chunk of money. But it rarely gets
down to right where you need it. We just got to continue to
address that by hearing from people such as you in a direct
way.
My question is for the Global Fund. And you are stressing
you need managers and administrators as well as physicians,
nurses, people on the ground. When we have this new Global Fund
that is being set up, will your NGO's have the expertise to put
together an application that does have enough finances,
accountability there, or not? You made the case of the need of
those sorts of people, but if you do not have those people now
and you have got to fill out an application, that I have not
seen, but I assume asks for a lot of data and all, does that
put you at a disadvantage?
Dr. Ray. The issue with the Global Health Fund is
interesting because we had understood that there had to be one
country response, which means that relies very much on having a
good working partnership usually between government and big
NGO's, so that they put together some kind of proposal and
submit it.
Then my experience with how people get grants is it is
based very much on reputation. So, for instance, in my
organization I can certainly pull together a funding proposal,
and I have a good enough relationship with donors that if I am
convincing, they will consider it. If an organization says we
want to develop a leaflet in local languages on the five
symptoms of TB that every HIV-positive person needs to know and
we want to a print run of 10,000, that activity would probably
have major impact in those 10,000 people, but they will not get
funding for it. So, it depends on whether my organization can
then say, okay, we will administer the grant for you, which
means that then I have to hire three more people just to
administer and to do the reporting for all the little
organizations that need that kind of support.
Some of those organizations will be corrupt. Some of them
will not be able to do what they set out to do just because
they are not skilled or trained. I am not in a position where I
can micromanage them, and that is where the whole thing falls
apart.
I think what we are asking for is just some latitude, some
flexibility so that donors actually have a part of that money
which is available for small grants, and where they are not
asking for great reporting requirements. The kind of stuff that
we get from the donors is like that.
Senator Frist. You understand that a lot of the NGO's
throw money away. It is wasted. And that is the real challenge.
Obviously, having people such as you who can interact with a
lot, but by having too much flexibility and not enough
reporting and not enough accounting, it is hard for me to make
the case with the American people because, as you know, some of
the NGO's do not do a good job or you give it to the NGO and it
still does not make it down to the level. That is the real
challenge that we have as we go forward.
Dr. Ray. But I think the World Bank itself has begun to
face that. The last time they talked with us, they were
actually saying, okay, the majority of our funding has to have
that kind of funding requirement where people fill in these
forms and have audited reports and that kind of thing. But we
can now make small amounts. It is almost like saying it is
worth the risk to have a small amount of money that could be
thrown away, but maybe if a quarter of it works, that it is
worth it.
In a sense organizations like mine can support the product.
What is difficult for us to support is the proposal writing,
the report writing, all the admin that goes in organizing
things. So, in a sense if USAID or DANIDA or the British DFID
said to us, can you help develop this leaflet, we could say,
yes, of course, we can help them develop the leaflet. But what
we cannot do is do their audited accounts for them.
Senator Frist. Very well said.
Mr. Lyman, I feel like I should come back to you, but I am
going to be seeing you so much over the next few months and I
am not going to see the other two. So, selfishly let me again
turn back to Okaalet.
Where have the churches been? I think your written
presentation is really perfect. As a matter of fact, I turned
to my staff and said this really paints the picture where you
have been. The potential is there. United States churches have
locked up too, and they have locked up, have not addressed it,
and we have clearly got to mobilize here. We have the
stigmatization in this country. We have the same problems that
you have had to face in Africa.
You mentioned the Samaritan's Purse conference next week,
the conferences in Africa. Do you think you will be able to
mobilize the churches?
I know in Uganda I guess the person who runs the overall
AIDS program is----
Dr. Okaalet. A bishop.
Senator Frist [continuing]. A Catholic bishop, which is
just again gratifying to me to see because a lot of the work I
have done has been through mission fields and all.
Do you think we could bring them to the table? Not bring
them. Obviously, they are coming to the table, but help paint
the picture for me and for my colleagues. They have not been
there in the past nor have they been in the United States. Is
the opportunity there for us to realize now?
Dr. Okaalet. I believe, Senator Frist, the opportunity is
here and the opportunity is with us now.
When you say where has the church been, I think that there
are many reasons to explain why the church has not been
actively involved. One of them is stigma that several other
speakers already referred to.
The other one is HIV and AIDS causes death, and in Africa
it is not a subject that many people want to talk about freely.
Ninety percent of the people who contract HIV/AIDS is
through heterosexual contact, one infected person and the
other. Sex and sexuality is no-touch subject. In some of the
meetings that we have conducted in western Kenya, a pastor has
come forward to say, doctor, if you are to help us survive this
disease, then you need to be coming more from Nairobi to Kisumu
because I cannot preach about it. I cannot talk about sex and
remain accepted in my community. Because HIV and AIDS touches
on sex and sexuality, Africans have found it very difficult to
talk about it openly. Because it causes death, again it is a
bit difficult.
But there is a Chinese proverb that says a journey of a
thousand miles begins with one step. I think several steps have
already been taken. Our own experience working with the
churches in Kenya are that the church has gone through four
phases. The first phase, those who did not work with us
directly, those who have not helped to train their pastors and
so on, always were resistant. HIV and AIDS is caused through
sin, so let sinners get out of the church. Isolate them. That
is what I characterize as judgmental attitude holding your fist
against the face of another person.
Second, there has been a lame kind of response. I am
talking as a medical doctor. If somebody has a lame hand, it
becomes difficult to greet another person the African way, the
way we greet. Because they will not respond. They are not
trained. There is no capacity as some of my fellow speakers
have already said. The response has been very lame.
Thirdly, there is what I characterize as a gloved response.
People want to respond but they want to be protected. For
example, a pastor would go into a ward and rather than touch
and lay hands on a patient who is sick, he will stand at the
door and say, God bless you, and then walk away before he
touches them. But now we are challenging them if Jesus were
alive today, would he touch an HIV and AIDS person like he
touched leprosy people? Yes, he would.
But we are moving them from the judgmental attitude, from
the lame response, from a protected, over-cautious response to
recognize that we need to embrace those who are sick with HIV
and AIDS. If the church is absent today, it will be irrelevant
tomorrow when so many of the Africans will be dying and
everybody will be asking, as you are correctly asking, Senator,
where were you when we needed you. So, the time to respond for
the church is now.
And I believe as MAP International, working together with
many other partners, we have trained several people in Kenya. I
was in Namibia with another colleague from MAP International
training all the Anglican pastors and two of their bishops in
Namibia about a month ago.
Senator Frist. I think we have a lot to learn from Africa
in so many ways, but I think this is a good example. I think
what is bringing people to the table a lot is that the
continent is being destroyed and so people recognize they have
to face it. When you look in the Caribbean, which has the
second fastest growing, or you look at Russia, which has the
fastest growing incidence of AIDS, or India where we have more
people with AIDS than any other country in the world, I think
all, including the United States, can learn from the faith-
based organizations in Africa who are coming to the table
facing it head on.
I am going to have to close because I have got 3 minutes to
get over to our meeting with the Secretary-General.
For the record, Mr. Lyman, if you could summarize the
survey briefly in, say, two or three pages in terms of some of
the data that I would like to make available to my colleagues
and the record as well in terms of the current attitudes in the
United States.
Ambassador Lyman. We will do that.
Senator Frist. Let me thank all of you. Again, we are
going to be spending the next hour with the Secretary-General.
Tomorrow we have a hearing that will continue the discussions
and the process that we have begun today. The three of you have
been very, very patient, and for everyone who has participated
today, I want to say thank you.
Dr. Ray, in 30 seconds or less.
Dr. Ray. Just a promotion. I did not manage to bring our
materials because they were lost at the airport somewhere. But
they will be available through Heather. If anybody here wants
to see some of the materials we produce, particularly on boys
and men and HIV, they can get copies from her.
Senator Frist. And we will make sure that gets distributed
to the group.
With that, we stand adjourned.
[Whereupon, at 3:15 p.m., the committee was adjourned.]
----------
Additional Statement Submitted for the Record
Prepared Statement of Senator Gordon H. Smith
I want to thank Chairman Biden for the opportunity to talk about
the plight AIDS has caused on not just the world economy but on the
infrastructure of every country and every family it touches.
And I want to thank our panels--especially Secretary Thompson, for
taking the time to talk about the spread of AIDS worldwide.
We come here to talk about the spread of AIDS worldwide--but I want
to take a moment and note since we do have the Secretary of Health and
Human Services present, that this is a disease that touches every state
in the Union--including my home state of Oregon.
Last year marked the 20th anniversary of AIDS in the United States
and sadly, the death of a constituent of mine.
I am speaking of the 1981 CDC report that noted the appearance of a
rare type of pneumonia that had struck five gay men. One of those five
men was an Oregonian--a man named ``Chuck'' whose place in history is a
CDC report that this country took too long to respond to--Chuck has
been dead for almost 20 years now.
But I am pleased with Secretary Thompson's interest in these
issues--we have spoken in the past about Oregon's AIDS crisis--the
numbers--we have had 5,000 cases of AIDS in Oregon alone since 1985.
And I have asked him to expand Medicaid access for those with HIV/AIDS.
Just a few years ago this very committee took the lead in finding
necessary funds for fighting AIDS in sub-Saharan Africa and found the
bipartisan spirit to pass authorizing legislation to fight AIDS world
wide.
But now the world is facing a global health problem of disastrous
proportions in the global HIV/AIDS pandemic.
In the past few years, this issue has received much needed
attention from the international community and the U.S. government.
But, unfortunately, our efforts and the efforts of other
governments, the private sector, and foundations have not been enough
and the pandemic continues to wreak havoc on the lives of millions of
people around the world.
We now face AIDS not just in Africa--but the onslaught in Central
and Eastern Europe, in Russia, in China and in South East Asia . . .
while we may hear many statistics today . . . it is important to
remember that this disease is threatening the whole world--it knows no
boundaries and no politics.
I look forward to our testimony from the Administration, academia
and the private sector.
__________
Response to an Additional Question Submitted for the Record by Senator
Helms to Dr. Peter Piot
Question. According to a recent GAO report (December 2001) the
United Nations does not know how many peacekeepers have HIV/AIDS
because it opposes mandatory HIV testing before, during or after
deployment to a peacekeeping mission. With all that we now know, with
all the evidence we have that peacekeepers--like other military
personnel--are likely to engage in behaviours such as unsafe sexual
practices that increase the risk of contracting and spreading HIV, what
is the rationale for continuing this policy of not testing
peacekeepers?
Answer. UNAIDS commends the GAO report on HIV/AIDS and peacekeeping
(December 2001) for its comprehensive assessment of this important
area, which has also been given high priority by UNAIDS during the last
year.
In view of the number and complexity of issues relating to HIV
testing in UN peacekeeping operations, and in response to concerns
expressed by members of the UN Security Council, the UNAIDS
Secretariat, in close consultation with the UN Department of
Peacekeeping Operations (UNDPKO), initiated a comprehensive review of
United Nations policy in this area. An Expert Panel on HIV Testing in
UN Peacekeeping Operations was established to assist in this effort.
The panel was chaired by a Justice of the High Court of Australia and
included representation from the USA Centers for Disease Control and
Prevention, several military officials from peacekeeper contributor
nations, and other military, medical, social science and legal experts
in this area.
After careful review of the extensive empirical and qualitative
data provided in background documentation commissioned for the meeting
and in other relevant sources and international standards, the members
of the panel unanimously recommended voluntary HIV counseling and
testing as the most effective means of preventing the transmission of
HIV, including among peacekeepers, host populations, and spouses and
partners of peacekeepers. No member of the panel endorsed mandatory HIV
testing by or for the United Nations as a means to prevent the
transmission of HIV to or by peacekeepers. The panel considered
voluntary counseling and testing to be an essential part of the
response to HIV/AIDS among peacekeepers and stressed that voluntary
counseling and testing should be provided to peacekeeping personnel
within a comprehensive package of integrated HIV prevention and care
programs.
In detailed substantiation of its recommendations, the expert panel
also noted that voluntary counseling and testing has been shown to be
more effective than mandatory HIV testing in promoting safe sexual
behaviour and reducing other risks involved in transmitting HIV or
becoming infected. Further, the panel concluded that mandatory HIV
testing has not been shown to have demonstrable individual or public
health benefits and may result in significant negative outcomes. In
sum, while it concluded that mandatory HIV testing was neither
necessary nor advisable in the context of UN peacekeeping operations,
the panel empahsized that voluntary counseling and testing for HIV must
be made available as an essential component of HIV prevention in the
context of peacekeeping and that peacekeepers should be encouraged to
avail themselves of these services.
During the past year, UNAIDS and the UN Department of Peacekeeping
Operations (UNDPKO) have collaborated closely, and the United Nations
has undertaken a number of important measures and initiatives to
address HIV/AIDS in peacekeeping operations. As requested by the UN
Security Council, UNAIDS in collaboration with UNDPKO has produced a
redesigned awareness and prevention strategy for peacekeepers.
Important initiatives also include the recruitment of HIV/AIDS officers
attached to individual peacekeeping operations, and organization of
workshops with relevant medical and training staff of DPKO on putting
in place measures to prevent transmission of HIV/AIDS. At country
level, UNAIDS and UNDPKO have focused their collaborative efforts on
the five main UN peacekeeping missions currently in operation,
specifically those for Ethiopia and Eritrea (UNMEE); Sierra Leone
(UNAMSIL); the Democratic Republic of Congo (MONUC); Kosovo (UNMIK),
and East Timor (UNTAET).
RESPONDING TO AFRICA'S HIV/AIDS CRISIS: THE ROLES OF PREVENTION AND
TREATMENT
----------
THURSDAY, FEBRUARY 14, 2002
U.S. Senate,
Committee on Foreign Relations,
Washington, DC.
The committee met, pursuant to notice, at 2:30 p.m. in room
SD-419, Dirksen Senate Office Building, Hon. Russell D.
Feingold (chairman, Subcommittee on African Affairs),
presiding.
Present: Senators Feingold and Frist.
Senator Feingold. I call the hearing to order. I want to
start off by thanking all the witnesses for being here today.
Yesterday, Senator Biden, the chairman of the full committee,
held a hearing on the future of the United States bilateral and
also multilateral response to the HIV/AIDS crisis, and I
certainly commend him for elevating this issue to the
appropriate level and for making plain that this crisis is
truly one of the most urgent foreign policy priorities we
confront today. We are very fortunate that the chairman has
used his leadership position in this way to face this
tremendous crisis.
Today, the committee will focus on Africa, where the crisis
is most severe, to take stock of what we have learned and what
we still do not know about how to most effectively pursue
prevention, care, and treatment in the region. According to
UNAIDS December 2001 AIDS epidemic update, 2.3 million African
people died in 2001 because of AIDS. The estimated 3.4 million
HIV infections in sub-Saharan Africa in the past year mean that
28.1 million Africans now live with the virus.
The report states that recent antinatal clinic data show
that several parts of southern Africa have now joined with
Botswana with prevalence rates among pregnant women exceeding
30 percent. In West Africa, at least five countries are
experiencing serious epidemics, with adult HIV prevalence
exceeding 5 percent. In South Africa alone, an estimated 6
million people are infected. Approximately 2,300 more are
infected every day. Over 260,000 will die this year because of
AIDS.
Anyone in the hearing room or watching that hearing
yesterday could not help but be impressed with the knowledge
and commitment of my partner on the African Affairs
Subcommittee, Senator Frist. Senator Frist cares deeply about
this issue and so do I. Both of us have seen the individual
tragedies that make up these horrifying statistics. We have
spoken to the orphans and the widows and the widowers. We have
seen the terrible evidence of pervasive death in too many
African communities, but we have also seen ample evidence that
the situation is not a hopeless one.
In Uganda, an aggressive campaign with support from the
highest levels of government is bringing infection rates down.
In Senegal last year, I had the pleasure of meeting with that
country's visionary public health community, which includes
tireless volunteers and dedicated scientists, doctors and
nurses, and clerics who are raising awareness in mosques
throughout the country.
Let me be clear, Africans themselves provide the help and
inspiration that one needs to confront a crisis of this
magnitude head-on. I often recall the very end of my
inspirational meeting in Senegal. A gentleman who had been
waiting very patiently among those briefing me stood up and,
speaking softly, he told me that he is HIV positive. He wanted
to know if there would be any help for him, any assistance with
the kind of treatment that is out of reach for so many in
Africa.
There must be an answer to his question. Increasingly, the
world is recognizing that treatment is a critical component of
the fight against AIDS. Statistics from Botswana suggest that
when treatment comes available, voluntary testing and
counseling rates surge upward.
One of the witnesses yesterday stressed the importance of
integrating tuberculosis screening with HIV/AIDS testing so
that people who come in for the HIV test can also learn their
TB status and at the same time be referred to a treatment
center. In these scenarios, prevention and treatment complement
and reinforce each other, increasing the impact of the overall
effort. But pursuing both treatment and prevention means making
choices, choices about resource allocation, about public health
strategies and, indeed, about treatment options themselves.
As Senator Frist reminded the committee yesterday, there
are a range of options covered by the broad category of
treatment, including options specifically targeted to
opportunistic infections. It seems clear to me that some of
these choices will vary from one community to another,
depending upon the context on the ground.
How we assess that context, how we make those choices
together with our African partners, these are the topics that I
hope we will explore today. They are difficult and complicated
questions, but one thing is perfectly clear and simple, and
that is that there is a moral imperative to act. There are
unquestionably other reasons to act, most notably to protect
our security interest, because devastated societies are
unstable societies. The U.S. Institute of Peace recently issued
a report highlighting the connection between HIV/AIDS and
conflict in Africa, and the economic drain of a disease that
affects the most productive segment of society is setting back
hard-won gains in poverty reduction.
But to explain the sense of urgency surrounding this issue
I think it is enough to return to the basic human decency that
tell us that we cannot stand by as tens of millions die and
societies collapse. That clarity guides all of us as we wrestle
with issues that are anything but clear, and so I look forward
to the testimony today.
[The prepared statement of Senator Feingold follows:]
Prepared Statement of Senator Russell D. Feingold
I want to start out by thanking all of the witnesses for being here
today. Yesterday Senator Biden, the Chairman of the full committee,
held a hearing on the future of the U.S. bilateral and multilateral
response to the HIV/AIDS crisis. I certainly commend him for elevating
the issue to the appropriate level and for making plain that this
crisis is truly one of the most urgent foreign policy priorities that
we confront today.
Today, the committee will focus on Africa, where the crisis is most
severe, to take stock of what we have learned and what we still don't
know about how to most effectively pursue prevention, care, and
treatment in the region. According to UNAIDS' December 2001 AIDS
Epidemic Update, 2.3 million African people died in 2001 because of
AIDS. The estimated 3.4 million new HIV infections in sub-Saharan
Africa in the past year mean that 28.1 million Africans now live with
the virus. The report states that ``recent antenatal clinic data show
that several parts of southern Africa have now joined Botswana with
prevalence rates among pregnant women exceeding 30%. In West Africa, at
least five countries are experiencing serious epidemics, with adult HIV
prevalence exceeding 5%.'' In South Africa alone, an estimated 6
million people are infected. Approximately twenty-three hundred more
are infected everyday. Over two hundred and sixty thousand will die
this year because of AIDS.
Anyone in the hearing room or watching that hearing yesterday could
not help but be impressed with the knowledge and commitment of my
partner on the African Affairs Subcommittee, Senator Frist. Senator
Frist cares deeply about this issue, and so do I. Both of us have seen
the individual tragedies that make up the horrifying statistics, we
have spoken to the orphans and the widows and the widowers, we have
seen the terrible evidence of pervasive death in too many African
communities.
But we have also seen ample evidence that the situation is not a
hopeless one. In Uganda; an aggressive campaign with support from the
highest levels of government is bringing infection rates down. In
Senegal last year, I had the pleasure of meeting with that country's
visionary public health community, which includes tireless volunteers,
dedicated scientists, doctors and nurses, and clerics who are raising
awareness in mosques throughout the country. Let me be clear--Africans
themselves provide the hope and inspiration that one needs to confront
a crisis of this magnitude head-on.
I often recall the very end of my inspirational meeting in Senegal.
A gentleman who had been among those briefing me stood up, and speaking
softly, he told me that he is HIV positive. He wanted to know if there
would be any help for him, any assistance with the kind of treatment
that is out of reach for so many in Africa.
There must be an answer to his question. Increasingly, the world is
recognizing that treatment is a critical component of the fight against
AIDS. Statistics from Botswana suggest that when treatment becomes
available, voluntary testing and counseling rates surge upward. One of
the witnesses yesterday stressed the importance of integrating
tuberculosis screening with HIV testing, so that people who come in for
the HIV test can also learn their TB status and at the same time be
referred to a treatment center. In these scenarios, prevention and
treatment complement and reinforce each other, increasing the impact of
the overall effort.
But pursuing both treatment and prevention means making choices--
choices about resource allocation, about public health strategies, and
indeed about treatment options themselves. As Senator Frist reminded
the committee yesterday, there are a range of options covered by the
broad category of treatment, including options specifically targeted to
opportunistic infections. It seems clear to me that some of these
choices will vary from one community to another, depending upon the
context on the ground. How we assess that context, how we make those
choices together with our African partners--these are the topics that I
hope we will explore today.
These are difficult and complicated questions. But one thing is
perfectly clear and simple, and that is the moral imperative to act.
There are, unquestionably, other reasons to act--most notably to
protect our security interests, because devastated societies are
unstable societies. The U.S. Institute of Peace recently issued a
report highlighting the connection between HIV/AIDS and conflict in
Africa. And the economic drain of a disease that affects the most
productive segment of society is setting back hard-won gains in poverty
reduction. But to explain the sense of urgency surrounding this issue,
I think it is enough to return to the basic human decency that tells us
that we cannot stand by as tens of millions die and societies collapse.
That clarity guides all of us as we wrestle with issues that are
anything but clear.
I look forward to the testimony today.
Senator Feingold. Now, I would like to turn to our ranking
member of the subcommittee, Senator Frist.
Senator Frist. Thank you, Mr. Chairman, and welcome to all
of the witnesses in all three panels today. Especially, I thank
all of you for the work you are going to be talking about, and
that is represented by your presentations and discussions
today.
As the chairman said, if you look over the last 24 hours,
most of the hours, or working hours, have been spent addressing
HIV/AIDS, which I think hopefully makes a statement to others
and to the outside world how important this issue is to this
subcommittee, to this Foreign Relations Committee, and to this
Government in the United States today.
The statistics, we all start and go through the statistics,
and it is tempting to move on beyond them, but when you realize
that every 10 seconds one person dies from AIDS, and another
two are infected, and we have no cure for that infection, you
realize that we are on a curve that can result in devastation
and destruction of a generation, or if we do it right, if we
provide the right leadership, if we have the appropriate
strategy and planning, we can reverse what we all project out
to be a continuation of the most devastating, most destructive
health, yes, public health, but health crisis that mankind has
ever seen.
In January I went to Africa, and there are several people
actually in the room today, Scott and Tricia Hughes, who was
with me, as we look predominantly at HIV/AIDS programs just
now. Three weeks ago we had the opportunity to travel to
Nairobi, where we visited the Kaberra slum, 750,000 people with
one out of five of the individuals in that community HIV
positive. As we walked through the crowds, as we walked down
the streets, they are--most of you have seen pictures of the
narrow passageways there, with the shanties and the aluminum
roofs. You just did not see that many people of middle age. You
saw very young people and you saw older people, but you see
first-hand the devastation, with a whole middle sector of the
generation of people now gone, a sector of people that are
among the most productive in terms of their working lives,
being teachers, participating in the military.
We had the opportunity to go to Tanzania, to Arusha, where
we met Nema, who--I mentioned this in the hearing yesterday--
means ``Grace,'' and is HIV/AIDS positive. She sells bananas on
the side to survive, and to provide for her little year-and-a-
half old son. When that son, as we visited, cried from hunger,
she really had nothing else, nothing else to offer except a
kiss on that little hand.
Marguerite, in Arusha, whose symptoms first came on in
1990, her husband died, and despite her illness she found the
strength to fight his family in order to keep the family
property, and thanks to her brother she has a house for her six
children.
Tabu, a 28-year-old prostitute who was leaving Arusha to
return to her village to die. She stayed an extra day so she
could meet with us, so we could visit with her, and I will
never forget her cheerful demeanor, her smile as we met her in
a small hut 12 x 12 feet in size. Her two sisters, also
infected, another sister has already died, and Tabu, who by now
has probably died, will have left behind an 11-year-old
daughter, and the stories go on and on.
We must fight this battle on two fronts, prevention and
expanding access to treatment. Science will provide a vaccine,
I think, at some point in the future, and it is a goal that we
must all strive to. In the meantime, prevention, care, other
types of treatment should be underway. Behavioral change is
key. Even in HIV-ravaged Africa, most of those who come in
today will be negative. As we all know, however, that 8 out of
10, or 9 out of 10 in Africa today do not know whether they are
negative or positive.
Rapid HIV testing in many ways has revolutionized, I
believe, the opportunity we have to reverse the trends from the
last several years in Africa. A test that is specific, maybe
not so sensitive, combined with a test that is sensitive and
perhaps not so specific, but together for less than $1--or
about $1 a test--someone can come in, be counseled, 50 minutes
later have the results of that test, complete counseling, and
we know that this voluntary counseling and testing works.
A huge challenge, a challenge that seems insurmountable,
but being on the ground, looking at the programs that work,
sharing those stories as to what works, increasing investment
where we know that things work, I am convinced can make a
difference.
In yesterday's testimony we heard a lot of encouraging news
about prevention and treatment, news that we will share with
our colleagues. We were able to visit 2 weeks ago centers of
success like the AID Information Center in Uganda, which is a
USAID-funded project, the Kikoshep project in Nairobi, a
Centers for Disease Control and Prevention [CDC] CDC-funded
project, and you can see the differences that they make. I am
encouraged by the good work of USAID, encouraged by the good
work of the CDC in Africa. We can do a lot more.
Dr. Peter Piot was with us yesterday, as you have heard. As
stated, the scourge of AIDS has been with us for 20 years, but
it is a tale that is still in its opening chapters. It will
take all of our efforts, public and private, pulling together
partnerships, individuals, churches, denominations of all
faiths, to tackle this problem.
I look forward to hearing our witnesses today, and
appreciate all of them taking time to share their experiences
with us.
[The prepared statement of Senator Frist follows:]
Prepared Statement of Senator Bill Frist
I would like to thank our witnesses here today and especially thank
them for all the work they do every day to fight this terrible disease.
We are all aware of the alarming statistics:
22 million persons have already died of HIV/AIDS.
2.3 million died in Africa last year of HIV/AIDS.
13 million African children have already lost a parent to
HIV/AIDS and this number could be as high as 40 million by the
end of the decade.
40 million persons are living with HIV/AIDS today, one third
of the adults in Botswana, Lesotho, and Swaziland are infected.
95 percent of those infected live in the developing world,
and 90 percent of those do not know they are infected.
Every 10 seconds, one person dies from AIDS and nearly two
more are infected.
In January, I went to Africa and witnessed the human face of these
statistics. In Nairobi, Kenya, I visited the Kibera slum. With a
population of over 750,000, one out of five of those who live in Kibera
are HIV/AIDS positive. As I walked the crowded, dirty pathways
sandwiched between hundreds of thousands of aluminum shanties, I was
amazed that everyone was a child, or very old. The disease had wiped
out the parents--the most productive segment of the population--
teachers, military, workers, the providers.
In Arusha, Tanzania, I met Nema whose name means ``Grace.'' She
sells bananas to survive and provide for her year-and-a-half-old son,
Daniel. When Daniel cried from hunger, Nema kissed his hand because she
had nothing to give him but her love.
Margaret, also in Arusha, had symptoms that first appeared in 1990.
When her husband died, despite her illness, she found the strength to
fight his family to keep the family property. Thanks to her brothers,
she has a house for her six children.
And Tabu, a 28-year-old prostitute, who was leaving Arusha to
return to her village to die. She stayed an extra day to meet with us,
and I will never forget her cheerful demeanor and mischievous smile as
we met in her small stick-framed mud hut, no more than 12 by 12. Her
two sisters are also infected, another sister has already died. Tabu
will leave behind an eleven-year-old daughter, Adija.nnnn
These stories of a lost generation--of young mothers and their
children are--sadly--not unique to Africa.
We must fight this battle on two fronts: by improving primary
prevention and expanding access to treatment.
Until science produces a vaccine, prevention through behavioral
change is the key. Even in HIV ravaged Africa, most of those who come
in to be tested will test negative. This presents a real opportunity to
save countless lives. I believe we should increase investments in rapid
HIV testing kits and counseling for developing countries. Access to
inexpensive and rapid HIV testing can help reinforce prevention
messages and guide treatment options. And as I saw in Africa, testing
centers become centers of hope for the community, a place where those
struggling with HIV/AIDS can share ideas, support each other, learn
important coping strategies, and receive medical treatment and
nutritional support.
Treatment is an important part of the mix. Treatment includes a mix
of options that not only suppress the virus but also stave off
opportunistic infections and relieves suffering. For example, treatment
can include not only antiretrovirals but also nutritional support,
antibitoics, and low-cost herbal and other medications to improve
quality of life. When persons with AIDS receive medical and nutritional
support, they live longer and healthier, avoiding opportunistic
infections such as tuberculosis; providing income for themselves and
their families; and ensuring a better future for their dependents.
Prevention and treatment compliment each other. Without prevention,
the disease will continue to spread. The hope of treatment will bring
people to get tested, reinforcing prevention efforts.
In yesterday's testimony, we heard encouraging news that our
efforts at prevention and treatment are making a difference to millions
of Africans. I have been to such centers of success as the AIDS
information center in Uganda (a USAID funded project) and the KICOSHEP
project in Nairobi (a CDC funded project) and I have seen the
difference they can make. I am encouraged by the good work of USAID in
Africa and the CDC's efforts in developing guidelines that will lower
the cost of medicines and testing so that they will be available to all
who have this disease.
But we can do much more. As Dr. Peter Piot, who testified before
this committee yesterday has stated that the scourge of AIDS has been
with us for twenty years but it is a tale that is still in its opening
chapters. It will take all our efforts--the public and the private
sectors, individuals, churches and denominations of all faiths to
tackle this problem.
I look forward to hearing from our witnesses on how we can further
these efforts and bring hope and relief to millions of Africans.
Senator Feingold. Thank you, Senator Frist, for your
eloquent comments and for your obvious devotion to this issue.
We appreciate it.
We have two outstanding panels of witnesses here today, so
let me make the introductions brief to give us time to discuss
the incredibly important issues before us. Let me say that
there could be a vote in a few minutes, in which case we will
just take a 10-minute break and come right back and continue
the proceedings.
Let me begin by introducing both witnesses on the first
panel, then I would ask each witness to testify in the order of
introduction. First, Dr. Eugene McCray. Dr. McCray is the
director of the Global AIDS Program at the National Center for
HIV, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia. The Global AIDS Program
coordinates the CDC response to the global HIV/AIDS pandemic
worldwide. This involves a collaboration with the United States
Agency for International Development in 24 countries in Africa,
Asia, the Caribbean, and Latin America.
Since 1988, Dr. McCray's work at the CDC has focused on HIV
and tuberculosis surveillance both in the United States and
internationally. He serves as a consultant to such agencies as
the World Health Organization and the International Union
Against Tuberculosis, and he has worked on tuberculosis and
HIV/AIDS projects in a number of countries in southern Africa.
He has published a number of articles on tuberculosis and
HIV/AIDS, and he has received numerous awards for his
scientific and public health contributions. He is also a
practicing infectious diseases physician, providing volunteer
services in a primary care clinic for HIV-infected persons.
Dr. Anne Peterson. Dr. Peterson is the Assistant
Administrator in USAID's Bureau of Global Health. Dr. Peterson
provides health leadership at USAID, including technical and
program support to field interventions in the area of HIV/AIDS
infectious disease, reproductive health, child and maternal
health, environmental health, and nutrition.
Before joining USAID, Dr. Peterson served for 3 years as
Commissioner of Health for the State of Virginia. Dr. Peterson
also has an extensive background in both the U.S. and
international public health practice. She has served as a
consultant for the Centers for Disease Control and Prevention
and the World Health Organization, and she has spent almost 6
years in Kenya and Zimbabwe supporting community development,
public health training and AIDS prevention programs.
She is also the author of numerous scientific publications,
and speaks extensively on a wide range of health issues.
So with that, Dr. McCray, we would love to hear from you.
STATEMENT OF DR. EUGENE McCRAY, DIRECTOR, GLOBAL AIDS PROGRAM,
NATIONAL CENTER FOR HIV, STD, AND TB PREVENTION, CENTERS FOR
DISEASE CONTROL AND PREVENTION, ATLANTA, GA
Dr. McCray. Thank you, Chairman Feingold and Dr. Frist,
members of the Subcommittee on African Affairs. I am pleased to
be here today to discuss the efforts of the Centers for Disease
Control and Prevention to address HIV/AIDS worldwide and in
particular in Africa, with a special focus on the necessary
balance on prevention and treatment. My remarks will be mainly
about the Global AIDS Program, or GAP, at CDC, but also touch
in other areas of CDC that are involved in HIV/AIDS
internationally.
At the outset, I would like to acknowledge that we at CDC
are grateful, Mr. Chairman, to you and your colleagues on the
subcommittee and the full Foreign Relations Committee for your
support of these efforts, and I want to thank you for that.
I will not bore you with statistics that I think you are
all familiar with, but today I would like to outline for you
what CDC, in conjunction with other U.S. Government entities,
as well as numerous other partners, is doing to intervene in
this epidemic worldwide. The hardest-hit region by far is sub-
Saharan Africa, which accounts for 70 percent of all the HIV/
AIDS cases, followed by southeast Asia, Latin America, and the
Caribbean. CDC has concentrated its efforts in the 24 countries
in those regions. A 25th country, China, will be added probably
by the end of this fiscal year. We are working intensely with
the governments of these nations to bring the epidemic under
control.
In fiscal year 2003, our budget for GAP was $143.7 million.
Guided by its 5-year HIV prevention strategic plan, CDC works
to mount space for primary prevention programs, as well as
treatment programs, initiatives, in collaboration with USAID,
with Health Resources and Services Administration [HRSA], NIH,
and the Department of Defense and the Department of Labor, and
a number of other countries. In addition, we are working with a
number of multilateral agencies such as the World Bank, WHO,
UNAIDS and so on, and soon the Global Fund for AIDS, TB and
Malaria. We are also working with private foundations such as
the Bill and Melinda Gates Foundation, and with a variety of
international and nongovernmental organizations.
With the advice and assistance of our many partners, CDC
has developed a set of 17 technical strategies for implementing
programs focusing on three key areas. These areas include
infrastructure and capacity development, primary prevention,
and care and treatment, and I would like to talk a little about
each of these areas before turning to the question of balancing
prevention and treatment.
First, let me talk a little about infrastructure and
capacity development. Most developing nations lack the
necessary infrastructure to adequately address their HIV/AIDS
epidemic. Disease surveillance systems and epidemiology are
often not comprehensive, making it difficult, if not impossible
many times to accurately determine how many people are at risk
for infection, what their risks are, and the level of need for
prevention services, as well as how many people are already
infected, which populations are involved, and the need for care
and treatment.
CDC provides funding and technical assistance to ministries
of health and other organizations to bolster essential
laboratory services as well as improve quality assurance and
quality control for HIV testing. We provide training of
laboratory personnel, as well as purchase the needed equipment
to ensure the labs are functioning at a minimal level.
The importance of a functioning public health and health
care delivery infrastructure to comprehensive HIV prevention
care and treatment programs cannot be overstated. Sound
infrastructures are essential to delivering needed services
over time. For example, voluntary counseling and testing or VCT
is the cornerstone for prevention, and the gateway to care and
treatment, but if the procurement systems fail to provide the
needed test kits in insufficient quantities an on-time VCT
cannot be done.
If the laboratory system fails for lack of proper
equipment, supplies, or trained personnel, tests cannot be
performed and interpreted. If information infrastructure fails,
individuals anxiously awaiting test results cannot get them.
Prevention opportunities, both for those who are seronegative
but at high risk, and for those who are already infected, are
lost as a result.
Likewise, the health care infrastructure can impede or
support care and treatment efforts. Training for health care
providers, equipment, drugs, and other essential components
must be in place and remain there over time for care and
treatment programs to succeed.
We in the developed world take these things for granted. In
the countries where we work, these are not a given. Capacity
infrastructure development are critical first component of
every GAP program we are implementing.
Prevention, let me talk a little about prevention.
Currently, a safe and effective vaccine is not available, but
when available will contribute significantly, I think, to
controlling the AIDS pandemic, but while we have made
tremendous progress in vaccine development, the development of
a vaccine is likely years away. Other biomedical intervention
such as vaginal microbicides are likewise as yet not yet proven
and ready for widespread use, so in the interim the world's
best and only hope for controlling this epidemic is through
sound prevention and care programs.
CDC offers technical assistance and funding for a variety
of prevention activities, including averting mother-to-child
transmission and intervention for special populations at high
risk for acquiring HIV, including in and out of school youth,
teacher and other school staff, injecting drug users, sex
workers and their clients, and displaced populations.
Preventing mother-to-child transmission is a high priority
for most developing nations, and is the only proven opportunity
to use drug therapy to avert transmission from one person to
another. CDC works in concert with host countries, the National
Institutes of Health, and other partners to mount effective
programs to provide necessary drug therapy to pregnant and post
partum women and their newborn, and to promote replacement
feeding strategies to avoid transmission via breast milk.
Another innovative program sponsored by CDC looks at ways
to effectively integrate prevention of HIV, other sexually
transmitted infections, and unintended pregnancies, and
reproductive health care. We know prevention works. We also
know that to be effective a prevention program must be mounted
on a large scale. They cannot be scatter-shot, and they must be
sustained over time. With those conditions met, prevention
programs can help countries contain and even reverse the
growing epidemic.
For example, the Uganda national response to HIV has been
recognized as a model program and the effort there has clearly
curbed the epidemic. Uganda's sustained efforts have reaped
enormous benefits, and over the last decades we have seen
consistent declines in HIV prevalence reported through most of
the surveillance systems in that country.
Next, let me turn to care and treatment. CDC's treatment
and care activities focus on tuberculosis and other
opportunistic infections, and more recently technical
assistance on antiretroviral therapies. For the past two fiscal
years, CDC has provided a minimum of $3 million annually to
HRSA for training and in-country health care providers and safe
and effective patient care and monitoring. Working together,
the two agencies are fostering hospital and clinic-based
programs as well as community and home-based care for people
living with HIV and AIDS.
Given that most developing countries lack the sophisticated
medical monitoring equipment and tests available in the United
States and other developed nations, CDC and HRSA are also
examining the safety and effectiveness of what is known as
syndromic management of HIV disease, which means that diagnosis
and continuing care are based upon observable signs and
reported symptoms, rather than sophisticated lab tests. Here in
the U.S., patients' viral load is monitored along with their T-
cell count, both indications of the effect HIV is having on the
body and therefore on the patient's health, but these tests are
not feasible in most countries where CDC and HRSA work.
In such situations, clinicians have to manage patient care
mostly by look, touch, and feel, and these skills can be
taught. Tuberculosis presents special dangers to those who are
HIV-infected, and CDC focuses particular attention on TB
research, prevention, and control. Research conducted by CDC
and the Botswana ministry of health shows that TB is a leading
cause of death for HIV-positive persons in Botswana, and
another study showed that saliva tests for HIV can be used in
TB sputum specimens, offering an effective tool for HIV
surveillance in that population.
Let me state that none of the preceding activities that I
mention could be accomplished or even attempted without the
integral cooperation and collaboration of other parts of the
U.S. Government, most particularly USAID, HRSA, NIH, as well as
other partners. Most importantly, the ministries of health play
a major role in this. Working together, our efforts are
enhanced and multiplied so that the whole is more than the sum
of the parts.
Now I would like to focus on balancing prevention and
treatment. With global infections at 40 million adult rates in
some countries, close to 40 percent, there is no doubt that
targeted, sustained prevention efforts are critical. Lifelong
prevention services are critical for those who are already
infected with or without treatment. Those that are not infected
need support, information, and education to assist them to
remain that way, and GAP country programs focus on prevention
for individuals who are HIV-infected and for those who are at
high risk for becoming infected.
HIV is a top priority for most GAP countries. Faced with
millions of people in need of treatment, however, most of these
countries cannot afford these life-sustaining medications and
the infrastructure required to deliver them safely and
effectively, so in fiscal year 2001 the Congress, through the
appropriations language, specifically directed CDC to support
targeted antiretroviral treatment demonstration projects in
countries where sufficient care and treatment infrastructure
exists.
Working in conjunction with USAID and academic
institutions, CDC is assessing ways to effectively, safely, and
affordably bring antiretroviral [ARV] treatment to countries
and their people. The global fund to fight TB and malaria,
which has a tripartite focus on prevention, care, and
treatment, offers great promise, and CDC looks forward to
helping to implement these countries' proposals that are
funded.
We know with absolute certainty the hope of treatment is a
great inducement to taking HIV tests and learning your
serostatus, and the test is the gateway to prevention, so for
those who are uninfected, post test counseling and entry into
prevention service can help them remain HIV-free. We also
believe treatment can help to destigmatize HIV and can further
the aim of prevention. Stigma associated with HIV/AIDS
continues to profoundly affect prevention efforts, leading
patients to deny their risk, avoid testing, delay treatment if
it is available, and suffer needlessly.
Senator Feingold. We are going to have to go cast our
votes. We will just simply come back as soon as we can and
continue with your testimony. Thank you.
[Short recess.]
Senator Feingold. The committee will come back to order. My
apologies for the delay. Dr. McCray, if you would like to
finish your remarks.
Dr. McCray. Yes. I should be brief. I was just going to
basically state that recent successes in Ivory Coast and Uganda
have demonstrated that antiretrovirals can be provided safely,
effectively, and appropriately in development countries, and we
think that the United States can help capitalize on these
successes and at the same time assist developing countries
where appropriate to build the infrastructure to safely and
effectively provide these drugs and help also create a lasting
health infrastructure.
Let me just basically conclude by saying we clearly
recognize the enormous challenges that lie ahead, but we have
hope and are supported by encouraging gains from programs that
are already underway that our efforts will avert potential
disaster. I think that we are seldom presented with such clear
and pressing need, and such unambiguous means to intervene. I
would like to thank you again for your support of this
important endeavor, and I would be happy to take questions at
the end.
[The prepared statement of Dr. McCray follows:]
Prepared Statement of Eugene McCray, M.D., Director, Global AIDS
Program, Centers for Disease Control and Prevention, Department of
Health and Human Services
Mr. Chairman, members of the Subcommittee on African Affairs, I am
pleased to be here today to discuss the efforts of the Centers for
Disease Control and Prevention (CDC) to address HIV/AIDS worldwide and,
in particular, in Africa, with a special focus on the necessary balance
between prevention and treatment. My name is Eugene McCray; I'm a
physician and I direct the Global AIDS Program (GAP) at CDC. My remarks
will be mainly about the GAP program, but also touch on other areas of
CDC that are involved in HIV/AIDS internationally.
At the outset, I would like to acknowledge that we at CDC are
grateful, Mr. Chairman, to you and your colleagues on this
subcommittee, and larger Foreign Relations Committee, for your support
of these efforts. Thank you.
CURRENT SITUATION
The World Health Organization and the Joint United Nations
Programme on HIV/AIDS report that 40 million people worldwide are now
living with HIV/AIDS. About 3 million people died of AIDS in 2001 and
slightly more than 5 million became infected--or almost 14,000 a day,
every day, for the entire year. More than 95% of the new infections are
in developing countries. Of the 14,000 infected daily, about 12,000 are
people aged 15 to 49 years--and about half are young adults ages 15 to
24. Almost 6,000 are women (Figure 1).
Figure 1
In areas of some countries, as many as 40% or more of the
adult population is infected with HIV. Health care services,
including treatment for HIV/AIDS and its associated illnesses,
such as tuberculosis, are extremely limited. Look around this
room. Imagine if half the people here today were infected with
a deadly disease, doomed to die slowly and painfully and, in
many instances, without care and support (Figure 2). In fact,
WHO and UNAIDS estimate that nearly 22 million people have died
since the beginning of the pandemic, most of them in the
developing world.
Figure 2
These statistics don't begin to represent the devastation
AIDS wreaks upon the developing world. Just this week, at the
African Population Commission meeting in Addis Ababa, it was
reported that life expectancy of Africans is set to reach one
of its lowest levels ever. By 2005, most Africans will die
before they reach their 48th birthday. The spread of HIV/AIDS
in particular, along with wars and poverty, have driven down
life expectancy by 15 years in the last two decades. Unchecked,
AIDS has the potential to destabilize national economies and
social systems, to throw nations into a spiral of instability
and civil unrest, and, possibly, to draw the United States and
other developed countries into national and regional conflicts.
But we have the opportunity and, I would argue, the
responsibility to intervene. Today I'd like to outline for you
what CDC, in conjunction with other U.S. Government entities as
well as numerous other partners, is doing to intervene.
Research
In the research arena, capitalizing on its 20-year history
of international prevention research, CDC's established field
stations in countries such as Uganda, Kenya, Cote d'Ivoire,
Botswana, South Africa, and Thailand are working with the
National Institutes of Health and local researchers in three
key areas: preventing mother-to-child transmission, field
testing a vaginal microbicide, and collaborating on trials of
candidate HIV vaccines, including the development of relevant
cohorts of trial participants. For example, CDC will soon have
a senior researcher stationed in Botswana to head up an
investigation of the effectiveness of an innovative microbicide
made from a seaweed component. CDC's long history of work with
the Ministry of Health in Botswana means that, if this product
is shown to be effective, it can be swiftly deployed in the
field, to help women protect themselves against sexual
transmission of HIV. CDC would also utilize the GAP
infrastructure to extend this product to women in other
countries, as it becomes commercially available.
A safe and effective HIV preventive vaccine is essential to
controlling the AIDS pandemic. But, while we have made
tremendous progress in vaccine development, the deployment of a
vaccine is likely years away. Other biomedical interventions,
such as microbicides, are likewise as yet not proven and ready
for widespread use. In the interim, the world's best--and
only--hope for controlling the epidemic is through sound
prevention programs.
Prevention Programs
Approximately 40 million individuals are now living with
HIV worldwide. The hardest-hit region, by far, is sub-Saharan
Africa, which accounts for 70% of all HIV/AIDS cases, followed
by South and Southeast Asia, Latin America and the Caribbean.
In total, those areas account for 90% of the world's HIV/AIDS
burden. CDC has concentrated its efforts in 24 countries in
those regions (China will be added in Fiscal Year 2002),
working intensively with the governments of these nations to
bring the epidemic under control (Table 1).
Table 1
------------------------------------------------------------------------
------------------------------------------------------------------------
Countries Served By CDC's Global AIDS Program FY2002
Angola Mozambique
Botswana Namibia
Brazil Nigeria
Cambodia Rwanda
China (new for FY 2002) Senegal
Cote d'Ivoire South Africa
Democratic Republic of Congo Tanzania
Ethiopia Thailand
Guyana Uganda
Haiti Vietnam
India Zambia
Kenya Zimbabwe
Malawi Regional: CAREC (Caribbean
Epidemiology Centre)
------------------------------------------------------------------------
CDC's GAP, currently has 38 staff stationed in 17 of those
countries, we hope to add staff to the remaining 8 by mid-year. The
fiscal year 2003 budget for GAP is $143,763,000.
Guided by its five-year HIV Prevention Strategic Plan, and through
GAP, CDC works to mount science-based primary prevention programs as
well as care and treatment initiatives in collaboration with U.S.
agencies such as USAID, NIH, the Health Resources and Services
Administration, the Department of Defense and the Department of Labor
here in the U.S.; with multinational agencies such as the World Bank,
WHO, UNAIDS, and, soon, the Global Fund to Fight AIDS, TB, and Malaria;
private foundations such as the Bill and Melinda Gates Foundation, and
a variety of international non-governmental organizations. With the
advice and assistance of its many partners, CDC has developed a set of
17 technical strategies for implementing programs, focusing on three
key areas:
infrastructure and capacity development, including disease
surveillance, laboratory technical support, information
systems, training, and program monitoring and evaluation;
primary prevention, including voluntary counseling and
testing, preventing mother-to-child transmission, blood safety,
sexually transmitted disease prevention and care, behavior
change communications, and prevention for drug users; and
care and treatment, including treatment of tuberculosis and
other opportunistic infections, palliative care, and
appropriate use of antiretroviral medications.
INFRASTRUCTURE AND CAPACITY DEVELOPMENT
Most developing nations lack the necessary infrastructure to
adequately address their HIV/AIDS epidemics. Disease surveillance
systems and epidemiology are often not comprehensive, making it
difficult if not impossible to accurately determine how many people are
at risk for infection, what their risks are, and the level of need for
prevention services, as well as how many are already infected, which
populations, and the level of need for care and treatment. CDC provides
funding and technical assistance to Ministries of Health and other
organizations working in GAP countries (e.g., local nongovernmental
organizations and international entities) to bolster essential
laboratory services, including quality assurance and quality control
for HIV testing, training for laboratory personnel, and purchasing
needed equipment.
The importance of functioning public health and health care
delivery infrastructures to comprehensive HIV prevention, care, and
treatment programs cannot be overstated. Sound infrastructures are
essential to delivering needed services over time. For example,
voluntary counseling and testing (VCT) is the cornerstone of prevention
and the gateway to care and treatment. But if the procurement system
fails to provide needed test kits in sufficient quantity and on time,
VCT can't be done. If laboratory systems fail for lack of proper
equipment, supplies, or trained personnel, tests can't be performed and
interpreted. If information infrastructure fails, individuals anxiously
awaiting test results can't get them. Vital surveillance information is
lost. Prevention opportunities--both for those who are seronegative but
at high risk and for those who are already infected--are lost.
Likewise, the health care delivery infrastructure can thwart or support
care and treatment efforts. Training for health care providers,
equipment, drugs, and other essential components must be in place and
remain there over time for care and treatment programs to succeed. We
take these things for granted in the developed world. In the countries
where GAP works, they are not givens. Capacity and infrastructure
development are critical first components of every GAP program in every
country.
PREVENTION
CDC also offers technical assistance and funding for a variety of
prevention activities, including averting mother-to-child transmission
and prevention for special populations at high risk for acquiring or
transmitting HIV, including in- and out-of-school youth, teachers and
other school staff, injecting drug users, sex workers and their
clients, and displaced populations.
For example, working with WHO, CDC has successfully brought
together Ministries of Health and Education to work together to
strengthen school-based HIV prevention and to help prevent HIV/AIDS
from decimating the ranks of teachers. According to UNICEF, the United
Nations Children's Fund, HIV/AIDS incidence is disproportionately high
among teachers in sub-Saharan Africa. In Kenya alone, nearly 1,500
teachers died from AIDS-related disease last year, up from just 10
deaths in 1993. The loss of large numbers of teachers in a poor nation
is a serious blow to future development. Unless the trend is reversed,
a generation of young Africans faces the prospect of fewer education
opportunities and reduced job prospects, with corresponding negative
effects on fragile country economies and social systems.
CDC also supports innovative projects aimed at helping women.
Preventing mother-to-child transmission is a high priority for most
developing nations--and is the only proven opportunity to use drug
therapy to avert transmission from one person to another. CDC works in
concert with host countries, NIH, and other partners to mount effective
programs to provide necessary drug therapy to pregnant and post-partum
women and their newborns and to promote replacement feeding strategies
to avoid transmission via breastmilk. Another innovative program
sponsored by CDC looks at ways to effectively integrate prevention of
HIV, other sexually transmitted infections (or STIs), and unintended
pregnancy in reproductive health care.
Data from a large number of biologic and epidemiologic studies show
that STIs are a co-factor for HIV transmission. An untreated STI can
increase both the acquisition and transmission of HIV up to fivefold.
Thus, STI prevention and treatment have the potential to play an
important role in the reduction of sexually acquired HIV transmission
in addition to preventing the other consequences of STIs, such as
infertility and congenital infections. Based on country needs,
available epidemiologic and behavioral data, and ongoing activities by
other partners, CDC focuses on developing and implementing programs
that promote risk reduction behaviors; improve STI health-seeking
behaviors; strengthen availability and quality of and access to STI
treatment services; and increase services for vulnerable populations,
particularly youth.
We know prevention works. Substantial evidence from carefully
controlled scientific studies and from analyses of various developing
countries' experiences shows that prevention is effective, and cost
effective. We also know that to be effective, prevention programs must
be mounted on a large scale. They can't be scattcrshot and they must be
sustained over time. With those conditions met, prevention programs can
help countries contain and even reverse growing epidemics.
For example, in sub-Saharan Africa, Uganda's national response to
HIV/AIDS has been recognized as a model program. The bedrock of this
successful program is strong commitment from national leaders, starting
with the president. In 1986, President Yoweri Museveni first
highlighted the nation's growing HIV epidemic; a national AIDS control
program was established the following year. In 1990, the Uganda AIDS
Commission was created under the president's leadership and supports
comprehensive prevention programming. This includes widespread
voluntary counseling and testing (VCT). Behavior change communications
are implemented through mass media, community-based organizations
(CBOs), and schools. Faith groups, including Roman Catholic,
Protestant, and Islamic organizations, have played an important role in
providing educational materials and encouraging behavior change.
Uganda's sustained effort has reaped enormous benefits. Over the
last decade, consistent declines in HIV prevalence were reported by
most surveillance systems. For example, in Kampala, the major urban
center, data from prenatal clinics has been available since the mid-
1980s. Surveillance showed that HIV prevalence among women attending
prenatal clinics increased from 11% in 1985 to 31% in 1990. Beginning
in 1993, however, HIV prevalence among this population began to
decline, reaching 14% in 1998. Outside Kampala, median HIV prevalence
among prenatal clinic patients has declined from 13% of those tested in
1992 to 8% in 1998.
Similar declines have been observed among patients at STD clinics.
For example, in 1989, 42% of male STD clinic patients in Kampala were
HIV-positive; by 1992, that had increased to 46%. In 1998, only 30% of
male STD clinic patients were HIV-positive. In 1989, 62% of female STD
clinic patients were HIV-positive; by 1997, that had declined to 37%.
In addition to tracking HIV prevalence, behavioral surveillance
also monitors people's sexual behaviors, tracking changes in risky--and
healthy--behaviors and in people's knowledge levels and attitudes. For
example, Uganda tracks people's knowledge of protective practices,
numbers of and behaviors with non-regular sexual partners, condom use,
age at first sexual experience, and adolescent pregnancy. All these
indicators help hone prevention messages and target populations most in
need. Uganda is a GAP country, and CDC staff are working with the
government and other partners to ensure that Uganda's success continues
and multiplies.
CARE AND TREATMENT
CDC's treatment and care activities also include a focus on
tuberculosis and other opportunistic infections and, more recently,
technical assistance on antiretroviral therapies (ARVs). For the past
two fiscal years, CDC has provided $3 million annually to the Health
Resources and Services Administration for training in-country health
care providers in safe and effective patient care and monitoring.
Working together, the two agencies are fostering hospital- and clinic-
based care programs, as well as community- and home-based care, for
people living with HIV/AIDS.
Given that most developing countries lack the sophisticated medical
monitoring equipment and tests available in the U.S. and other
developed nations, CDC and HRSA are also examining the safety and
effectiveness of what is known as ``syndromic management'' of HIV
disease, which means that diagnosis and continuing care are based on
observable signs and symptoms, rather than sophisticated lab tests.
Here in the U.S., patients' viral load is monitored, along with their
T-cell counts, both indications of the effects HIV is having on the
body, and therefore the patient's health. But these tests are not
feasible in most countries where CDC and HRSA work. In such situations,
clinicians there have to manage patient care by look and touch and
feel--all skills that can be taught.
Tuberculosis presents special dangers to those who are HIV-
infected, and CDC focuses particular attention on TB research,
prevention, and control. For example, with the Ministry of Health in
Botswana, CDC has sponsored the BOTUSA project since 1995. Research
conducted by BOTUSA showed that TB is the leading cause of death for
HIV-positive persons in Botswana and another study showed that saliva
tests for HIV can be used on TB sputum specimens, offering an effective
tool for HIV surveillance. Additional studies are underway to assess a
rapid TB diagnostic test that is effective among HIV-positive persons;
the optimal duration of TB treatment among those who are HIV infected;
and the acceptability of directly observed antiretroviral therapy for
HIV.
None of the preceding activities could be accomplished or even
attempted without the integral cooperation and collaboration of other
parts of the U.S. government, most particularly USAID, as well as other
partners. Working together our efforts are enhanced and multiplied, so
that the whole is more than the sum of its parts.
BALANCING PREVENTION AND TREATMENT
With global infections at 40 million and adult seroprevalencc rates
in developing countries of, in some instances, of higher than 40%,
there is no doubt that targeted, sustained prevention efforts are
critical. It is self-evident: Estimates are that 14,000 people are
infected daily. Lifelong prevention services are critical for those who
are already infected, with or without treatment. Those who are not
infected need support, information and education, and assistance to
remain that way. GAP country programs focus on prevention for
individuals who are HIV-infected and for those at high risk of becoming
infected.
HIV treatment is a top priority for most GAP countries. Faced with
millions of people in need of treatment, however, most countries cannot
afford the cost of these life-sustaining medications and the
infrastructure required to deliver them safely and effectively. In
fiscal year 2001, Congress, through appropriations language,
specifically directed CDC to ``support targeted antiretroviral
treatment demonstration projects in countries where sufficient care and
treatment infrastructure exist.'' Working in conjunction with USAID,
WHO, academic institutions like the Harvard AIDS Institute, voluntary
organizations, and the private sector, CDC is assessing ways to
effectively, safely, and affordably bring ARV treatment to desperate
countries and their people. The Global Fund to Fight AIDS, TB, and
Malaria (GFATM), which has a tripartite focus on prevention, care and
treatment, offers great promise in this arena, and CDC looks forward to
helping to implement those country proposals that are funded.
We know with absolute certainty that the hope of treatment is a
great inducement to taking HIV test and learning your serostatus. And a
test is the gateway to prevention. For those who are uninfected, post-
test counseling and entry into prevention services can help them remain
HIV free. For those who are infected, prevention services and support
can help them avoid transmitting the virus to others. Without the
possibility of treatment or even palliative care, many people living in
the dire circumstances of the developing world simply have no reason to
learn whether they are infected or not. Treatment can help destigmatize
HIV/AIDS and can further the aims of prevention. Stigma associated with
HIV/AIDS continues to profoundly affect prevention efforts, leading
people to deny their risk, avoid testing, delay treatment if it is
available, and suffer needlessly. AIDS stigma reflects societal biases
about race/ethnicity, socioeconomic status, sexual orientation, age,
gender, and drug usc. HIV infection evokes and magnifies these biases.
But if HIV is no longer a death sentence because of treatment, then the
stigma associated with infection is likely to diminish, supporting
prevention efforts.
Various factors that must be considered in assessing how best to
control the HIV/AIDS epidemic are:
Level of political will--What is the level of commitment
from the country's public and private-sector leadership to
address prevention and treatment? What are the host country's
priorities for epidemic control?
Surveillance and epidemiologic information--What do we know
about the populations who are infected, how and when they were
infected, and the populations at risk and why they are?
Scalability of pilot or demonstration programs--What is the
likelihood that small-scale demonstration projects can be
scaled up to a national level and sustained?
Age of the epidemic--A country with a young epidemic, with
low seroprevalence rates and few cases of AIDS, may benefit
more from prevention programming than from treatment. As
epidemics mature, with increases in seroprevalence and AIDS
cases, the mix of appropriate services will change, and
treatment may become a greater priority.
Strengths and weaknesses of both the public health and
health care delivery infrastructures--Can treatment efforts be
safely mounted, without running the risk of drug shortages? If
procurement systems are inadequate, this may lead to drug
shortages, resulting in the inability of patients to maintain
therapy regimens, possibly leading to the development of drug-
resistant strains of HIV, as people cycle on and off
medications or substitute less-effective drugs.
Recent successes in Cote d'Ivoire and Uganda demonstrate that ARVs
can be provided safely, effectively, and appropriately in certain
developing countries. Pilot programs in Uganda and Cote d'Ivoire
addressed common concerns about providing ARVs to people in developing
countries, such as patients' clinical response to treatment, ability to
adhere to drug regimens, ability to stay in treatment, survival, the
emergence of drug resistance, and cost. In Uganda, patients were
responsible for payment for all their medical care, drugs and
laboratory tests. There was no direct financial support from the
government or other donor agency. The outcomes were better than
expected and proved that sophisticated treatment programs can work in
developing countries. The United States can help capitalize on these
successes and, at the same time, assist developing nations, where
appropriate, to build capacity to safely and effectively provide ARV
treatment and create a lasting health infrastructure.
GAP's guiding ethos on this topic is to view prevention and
treatment as complementary and, where possible, integrated. Experience
with preventing mother-to-child transmission demonstrates the value of
integrating prevention services with treatment. Thailand was the first
developing country to implement a national program to prevent mother-
child HIV transmission. As part of technical assistance through the
Global AIDS Program, CDC helped the Thai government develop a national
hospital-based monitoring system, now implemented in >95% of Ministry
of Public Health hospitals. Data from >500,000 women giving birth in
the first year show that 93% had an HIV test, 70% of HIV-positive women
received short-course zidovudine (ZDV), and 82% of HIV-exposed children
received infant formula. An estimated 1,000 infant infections were
prevented. CDC is now assisting with other projects to evaluate program
outcomes, enhance HIV care for mothers and children by including
ongoing prevention, train health care workers, and research new
interventions.
We recognize the enormous challenges that lie ahead. But we have
abiding hope, supported by encouraging gains from programs already
underway, that our efforts will avert potential disaster. We are seldom
presented with such clear and pressing need and such unambiguous means
to intervene.
I thank you again for your support of this important endeavor, and
I would be happy now to take your questions.
Senator Feingold. Thank you, Doctor, for your excellent
testimony.
Dr. Peterson.
STATEMENT OF DR. E. ANNE PETERSON, ASSISTANT ADMINISTRATOR,
BUREAU OF GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL
DEVELOPMENT [USAID], WASHINGTON, DC
Dr. Peterson. I would like to thank you, Chairman Feingold
and Dr. Frist, for convening this important hearing and for
inviting me to testify. This is an area of long interest to me,
after having lived in Africa for almost 6 years and worked much
of that time in the area of HIV/AIDS. I have seen first-hand
the devastation both in individual and in collective lives due
to AIDS. I will give some brief remarks, and then I believe you
have my longer written testimony.
Every country in the world has reported cases of HIV/AIDS.
I saw my first case of AIDS in Zaire in 1982, and then worked
in the mid-eighties in Kenya, when the adult prevalence of HIV
was well below 1 percent in the area we were living. Now,
devastatingly, HIV/AIDS prevalence among adults exceeds 20
percent in seven countries in the developing world, all in
Africa, and was above 10 percent in 9 additional countries and
in another 41 countries prevalence equals or exceeds 1 percent.
Twenty-two of these are in Africa, 11 in Latin America, 4 in
Asia, and 1 in Eurasia. As you said, the burden of this disease
is in Africa.
It is also not just different across the world, but it is
also the epidemiology within the countries. Half of the new
infections in Africa are in the 15-to-24-year-old age group,
and with young girls and women, accounting for 75 percent of
these. Over 80 percent of the transmission is heterosexual, and
over 55 percent of infections in sub-Saharan Africa are
occurring in women. This is due to both biological and
socioeconomic vulnerability.
In parts of Kenya, 15 percent of 15-to-19-year-old girls
are now infected, compared to 6 percent of boys in the same age
group. The increasing number of infected women has led to
nearly 600,000 infants becoming infected with HIV annually.
Looking at this epidemiology, we need to recognize both the
gender and geographic differences in the epidemiology of the
disease. We do have simple interventions to reduce mother-to-
child transmissions that are available, though currently less
than 5 percent of women in sub-Saharan Africa have access to
these services. These tragic statistics are well-known to you
all.
Since 1986, USAID has been addressing HIV/AIDS in
developing countries, and has provided nearly $2 billion in
support. I want to also thank you for the increased funding
that has come to USAID in recent years. Our 2002 budget in the
bilateral programs is $435 million for this year, with another
$50 million for the Global AIDS Fund, and we are expecting to
be somewhere in the realm of $540 million for our bilateral
programs for 2003 and another $100 million, as you have heard,
was committed from our budget for the global fund again.
We have HIV/AIDS programs in over 50 countries, of which 23
are receiving priority attention and a larger bulk of funding,
13 of these priority countries are in sub-Saharan Africa, and
as we are looking at the resource allocation for the future,
while not all of the money is going to Africa, an increasing
proportion of the money is going to dealing with HIV/AIDS in
Africa.
Responding to the scope and devastation of HIV/AIDS calls
for an extensive approach, from primary prevention to care and
treatment, and finally, support for those infected and for the
survivors, especially for children orphaned by AIDS, and these
include multisector initiatives. This is one of the comparative
advantages for USAID, that our prevention and treatment
programs can be linked with our other ongoing development
efforts, both our school programs, agriculture, food, as well
as the traditional maternal, child, and other health programs.
Preventing new infections really continues to be the most
urgent priority in the fight against HIV/AIDS. Prevention
programs are designed to slow and ultimately reverse the rising
HIV infection rates, and we know they work, yet there is no
single intervention or magic bullet that can effectively deal
with this pandemic. Changing behavior is complex and difficult,
and what works for one person may not work for others.
All of the prevention initiatives we are talking about
require behavior change by individuals, communities, and
societies. We have long experience that knowledge alone is not
enough. It requires acknowledging personal risk, knowing how to
avoid and reduce it. That means close links to those
individuals and those communities to make the need for behavior
change real and acted upon in their lives.
We work with mobilizing society, providing skills to
opinion and religious leaders. We support intensive personal
counseling and HIV testing. That testing provides a teachable
moment, an opportunity for intervention, social support, and
increased knowledge about the disease itself.
Many of you have heard about Uganda's success story, and it
was mentioned yesterday, but we have success stories that are
now going beyond Uganda, and in Zambia there has been
significant delay in sexual debut, the age at which sexual
intercourse begins, by a full 1 to 2 years, a decreased number
of sexual partners, and increased condom use. We are seeing the
success of those behavior changes in reduced numbers of new
infections.
Recent surveys show nearly a 50-percent reduction in
prevalence rates for the 15-to-19-year-olds in Lusaka and other
urban areas from 28 percent to 15 percent between 1994 and
1998. Prevention is not easy, but it is working in many of the
African countries. Prevention also links to medical
interventions in the critical area of reducing mother-to-child
transmission.
USAID now has programs in four countries, which include the
use of ARV to prevent transmission to the child. In Zambia we
focus on infant-feeding issues, in South Africa we fund 10
outreach centers affiliated with Africa's largest hospital, in
Uganda we fund testing and counseling, in Kenya we work with
the Ministry of Health. An important part of this effort is
operations research, so we can learn from the experience and
share knowledge.
Finally, a review of USAID support of AIDS prevention would
not be complete without mention of our input into vaccine and
microbicide development. We recently finalized a 2-year, $16
million grant agreement with the international AIDS vaccine
initiative, and for almost a decade we supported the
development and evaluation of microbicides to prevent sexual
transmission of HIV/AIDS. We plan to spend about $15 million in
this area this year. One promising microbicide is in the final
stages of field testing, but there is much more to the story
than prevention alone.
More than 13 million children under age 15 have lost their
mother or both parents due to AIDS. By 2010, some 44 million
children in 34 countries will have lost one or both parents
primarily due to AIDS. In sub-Saharan Africa, where the
majority of AIDS orphans resides, gains in health achieved over
recent decades are unraveling. In Zimbabwe, I worked with
street children orphaned by AIDS, gave them medical care, and
talked with them about the risk for HIV/AIDS. I also taught
AIDS prevention in schools, where the children's greatest fear
was that they, too, would lose their parents.
Orphaned children lose their families, their hope for
education, basic necessities of food and shelter, they become
easy prey for violence, sexual exploitation and crime. In some
settings they are fodder for child militias. Again, in
Zimbabwe, I worked with a local NGO now funded, I found out
later, by USAID that has an amazing program of community
support to households that are headed by teenagers.
Facilitating such community support is the foundation of
USAID's support for children and families affected by AIDS.
Since 1999, USAID's help for children has increased to more
than 60 different projects in 22 countries.
These programs can have impressive impact. Care and
treatment is important for humanitarian reasons. It also
enhances prevention by increasing the utilization of voluntary
counseling and testing, as Dr. McCray said. It also prolongs
parenthood and economic productivity.
By treating the most important opportunistic infections
like tuberculosis, we extend the lives of persons infected with
HIV. We also help control the expanding TB epidemic which
threatens all countries, including our own.
People with HIV/AIDS have many needs in addition to health
care. These include psychological support, legal assistance, as
Dr. Frist mentioned, microenterprise opportunities, economic
support, and accurate information about HIV/AIDS. A USAID study
found that a person with HIV requires 10 to 15 percent more
energy a day and 50 to 100 percent more protein a day than an
average adult. We are now incorporating food security
activities into our care and support efforts. We currently have
25 care and treatment projects overall in 14 countries.
Antiretroviral therapy is one of the more recent and
controversial areas, but it has had a dramatic impact in
reducing AIDS mortality in the developed world. There are
challenges that limit the ability to offer treatment and
support to a large number of people, as Dr. McCray again spoke
to, that include the cost of the drug, which is rapidly
decreasing, but also treatment protocol and clinical capacity.
As our Administrator, Mr. Natsios, said yesterday, we are
looking at having an introductory demonstration site for ARV
usage. We hope to be able to announce all of our sites during
the course of the next few months, but today the first site was
finalized and announced. This is since yesterday's hearing.
Ghana has launched the START program. This program is in close
partnership with the Government of Ghana. It will introduce
antiretroviral therapy as part of a comprehensive HIV
prevention and care program, and we are one of the supporters
of that through Family Health International.
This experience is not just a first-time for ARV use. It is
also a demonstration project that we can use the information
for Ghana and for other African Governments and donors,
planning on how best to provide care and treatment for people
living with AIDS. We will be launching three additional
antiretroviral treatment demonstration sites in sub-Saharan
Africa this year.
We need still to remember, as we enter into this new area,
that relying totally on treatment interventions will not stop
the advance of the pandemic. Lessons from the U.S., France, and
Brazil and other countries that offer ARV therapy clearly
demonstrate that introduction of combination therapy does not
retard the epidemic. We must closely link our treatment with
prevention.
The scope of the AIDS problem is immense. No one agency can
do all that needs to be done. We have many new partners who are
wanting now to participate in the AIDS problem, and we really
welcome that interest and concerted work, but with this many
partners, coordination of efforts becomes even more critical.
It is true among government agencies, and we have been working
long and well with CDC. It is also true in our international
partners and partnerships, including the new Global Fund.
The coordination efforts must occur at two levels, actually
probably three, within Washington, at headquarters, in the
international setting, and on the ground in each of the
countries is probably the most vital. This kind of
collaborative work is one of USAID's strengths.
In the past 2 years much progress has been made. We have
learned important lessons on what works and what does not. We
have successful models that are being replicated, and in six
countries we are now seeing reductions in new HIV infections at
the national, not just a program level. Drug costs have come
down dramatically, and treatment protocols have been
simplified. We have tools, and we know they work, and with your
continued support and the new resources you have given us, we
can move ahead to save the lives of millions.
Thank you.
[The prepared statement of Dr. Peterson follows:]
Prepared Statement of Dr. Anne Peterson, Assistant Administrator for
Global Health, U.S. Agency for International Development
I would like to thank Chairman Feingold and Dr. Frist for convening
this important hearing and for inviting me to testify.
Over the past twenty years the AIDS pandemic has continued to
surprise, shock and devastate us. Every country of the world has
reported cases of HIV/AIDS. At the dawn of this 21st century, HIV/AIDS
prevalence among adults exceeded 20% in 7 countries in the developing
world (all in Africa) and was above 10% in 9 additional countries. In
another 41 countries, prevalence equals or exceeds 1%. Twenty-two of
these are in Africa, eleven are in Latin America, four in Asia and one
in Eurasia. In contrast, HIV/AIDS prevalence in the United States was
0.6% at the end of 2000.
THE EPIDEMICS OF SUB-SAHARAN AFRICA
As we learn more about these epidemics, we discover that there is
no single pattern.
In the countries of East Africa, the oldest HIV epidemics in
the world have occurred with slow, steady progression over the
past 30 years. These are seen in the Great Lakes regions of
East Africa--in the countries of Uganda, Tanzania, Malawi,
Kenya, Zambia, and the Democratic Republic of the Congo
(formerly Zaire).
In the countries of West Africa where the epidemic seems to
have started about 10 years later, progression of the epidemic
has been more indolent and is further complicated by the
presence of both HIV 1 and 2. The national prevalence rates are
generally lower between 1 and 8%, except for Cote d'Ivoire,
where the prevalence is estimated to be over 10%.
In Southern Africa where the epidemic started in the mid-to-
late 80's there have been a series of explosive epidemics over
the past 8 years, reaching the highest prevalence levels on
earth, 20-40%. These countries include South Africa, Namibia,
Zimbabwe, Botswana, Swaziland, and Lesotho.
Specific aspects of the epidemics in this region include:
Currently in Africa, half of new infections are in the 15-24
age group, with young girls and women accounting for 75% of
these. Over 80% of HIV transmission is heterosexual, with over
55% of infections in sub-Saharan Africa occurring in women.
This is due to both increased biological and socio-economic
vulnerability.
In parts of Kenya, fifteen percent of 15-19 year old girls
are now infected compared with 6% of boys in the same age
frame. Young girls are frequently infected by older men; these
girls then infect their same age partners and husbands as they
get older; then the men as they get older in turn infect young
girls.
The increasing number of infected women has led to nearly
600,000 infants becoming infected with HIV annually. While
simple interventions to reduce mother-to-child transmission are
available, currently less than 5% of women in sub-Saharan
Africa have access to these services. This is primarily due to
the shortage of systems capable of delivering this care. The
challenge of preventing mother-to-child transmission in Africa
illustrates how difficult it can be to deliver even the
simplest interventions in low resource settings.
These tragic statistics are well known to members of this
Committee. Yesterday, the Administrator for USAID shared USAID's
leadership role in fighting the pandemic. This has included developing
the tools needed and providing direct assistance to countries for
prevention and care services. Since 1986, USAID has been addressing
HIV/AIDS in developing countries and has provided nearly $2 billion is
support. In the late 80's USAID's programs were focused on prevention;
in the mid-1990's USAID expanded its emphasis on sustainable prevention
activities and launched new programs in care, treatment and support for
people and communities coping with HIV/AIDS.
The HIV/AIDS pandemic presents some very special challenges. If one
looks at health interventions from a development perspective, there is
an ongoing predisposition toward ``public health'' strategies. These
often rely on relatively simple interventions. For example, in the
areas of child survival to reduce infant and child mortality most
international assistance revolves around immunizations, use of oral
rehydration salts packets to treat diarrhea, and more recently, the use
of vitamin A to reduce infant mortality and impregnated bednets to
reduce malaria transmission. Interventions have generally cost between
a few cents for an ORS packet and vitamin A, to $20 per person for
immunizations to approximately $300 to cure a case of TB.
HIV/AIDS IS DIFFERENT
Responding to HIV/AIDS calls for a radically different approach. We
must address multiple dimensions of the pandemic and recognize the
essential synergies that enhance effectiveness of our investments. In
developing country settings, we have never attempted such a complex and
comprehensive approach to a single disease--from primary prevention to
care and treatment and finally support for those infected and for
survivors, especially children orphaned by AIDS. The necessary response
is not limited to a single sector. We are drawing upon USAIDs broad
development experience to design and implement multisectoral
approaches. One of USAID's comparative advantages is that HIV/AIDS
prevention and treatment can be incorporated into other ongoing
development assistance efforts, such as school education programs and
training of agricultural workers. Also very important is our strong
partnership with indigenous community organizations throughout Africa.
Prevention continues to be critical. However care and treatment are
also critical. Neither can be neglected.
We have HIV/AIDS programs in over 50 countries of which 23 receive
priority attention. Thirteen of these priority countries are in sub-
Saharan Africa.
A LOOK AT ACTUAL PROGRAMS
I would like to get down to specifics. What do our programs do in
countries? How do they actually work? I will give you some real
examples from USAIDs country programs. Our programs fall into three
broad areas: prevention; treatment/care/support; and children affected
by AIDS. While all of these have substantial research elements, which
ensure that what we learn is quickly shared and applied, today I will
be focusing on the human impact of these programs.
PREVENTION EFFORTS
Preventing new infections continues to be the most urgent priority
in the fight against HIV/AIDS--currently about 70 percent of USAID's
HIV/AIDS budget is committed to prevention. Prevention programs are
designed to slow--and ultimately reverse--rising HIV infection rates.
We have now seen that these programs work in countries where ARVs and
other treatments are not available.
Yet, there is no single intervention or magic bullet that can
effectively deal with this pandemic. Changing behavior is complex and
difficult and what works for one person may not work for others.
There are two basic principles of prevention. The first is to
reduce the frequency of risky acts--by delaying the beginning of sexual
activity and decreasing the number of sexual partners. The second is to
decrease the efficiency of HIV transmission--by treating sexually
transmitted infections, and using condoms. We hope that soon a
microbicide will be developed that will help decrease the efficiency of
transmission. Ultimately, a vaccine will serve this purpose.
All of these interventions require behavior change by individuals,
communities and societies. Knowledge alone is not enough. Behavior
change means far more than having basic knowledge about the disease
AIDS, or even being disturbed or concerned about it. It requires
knowing one's personal risk and how to lessen it. Promoting monogamy
and condom use, and encouraging young people to wait, requires
mobilizing women, men, and communities to rethink policies and social
norms. It also involves creating environments where individuals who
understand these messages are supported, not derided, shunned, or
beaten. We have learned that HIV/AIDS risk reduction needs positive
social change that eliminates stigma and links health, gender and human
rights in new productive ways.
There are very important cultural factors which affect AIDS
prevention programs. We should not be so surprised then, that in the
absence of such social change, even in countries like Zimbabwe,
Botswana, and South Africa, that have raging, visible epidemics, people
have continued in a state of denial about their own personal danger of
becoming infected. The stigma that is associated with AIDS means that
AIDS is always someone else's problem. We have seen this phenomenon in
virtually every country in the world--including our own.
To counter this lack of perceived personal risk, we are now
mobilizing societies, providing skills to opinion and religious leaders
and supporting intensive interpersonal counseling and HIV testing.
Giving the results of an HIV test provides an opportunity for
intervention, social support and increased knowledge about the disease
itself.
Uganda shows how behavior can reverse a severe epidemic. There has
been a delay in sexual debut by one to two years, decreased numbers of
casual partners and increases in condom use. The proportion of Ugandan
girls who have ever had sex declined by almost half between 1989 and
1995. Over half of young sexually active Ugandans report using condoms
in their last sexual contact--this rate was close to zero at the outset
of the epidemic. As a result of these two major changes in behavior,
HIV infection rates among 15 to 19 year old girls have declined from 22
percent in the early 1990's to 8 percent by 1998. In the same period,
national HIV adult prevalence has decreased from 14 percent to 8.3
percent.
In Zambia, we are also seeing the impact of behavior change on the
number of new infections. Recent surveys are showing nearly a 50
percent reduction in prevalence rates for the 15 to 19 year olds in
Lusaka and other urban areas from 28 percent to 15 percent between 1994
and 1998.
Until the mid-1990s, women's role in the AIDS crisis was little
recognized. But women now comprise nearly half of all infections--and
in Africa, more than half. In addition, women bear much of the burden
of caring for HIV-infected family members and risk passing HIV on to
their infants. They often also have the least control over their risk
of contracting AIDS, for both cultural and economic reasons. Because
USAID's HIV/AIDS programs recognize the difficulties women and girls
face, they:
Work through maternal, child, and other health services that
women use;
Help women develop action plans to reduce their risk of HIV
infection and to increase their access to services;
Address economic and social issues that put women at a
disadvantage;
Involve men as well as women in supporting the health and
welfare of women and girls;
Involve women's organizations in the fight against AIDS. For
example, in Senegal, traditional women's associations played a
key role in increasing condom use.
In addition to behavior change, we heed to apply what we have
learned about medical interventions to reduce transmission. One
critical area involves reducing mother to child HIV transmission. USAID
now has programs in 4 countries.
In Zambia, USAID supports an innovative community based
program in Ndola District that provides education on HIV and
infant feeding choices and offers referral to the district
health center for testing and counseling. This program is
adding antiretroviral prophylaxis. This innovative model will
be expanded to Malawi this year.
In South Africa, USAID is providing management support to
the MTCT program at Chris Hani Baragwanath Hospital in Soweto.
This hospital which performs 16,000 deliveries per year
provides MTCT services to women delivering in the hospital and
has established MTCT services in more than 10 outreach centers.
In Uganda, USAID is supporting MTCT services in Mulago
Hospital (in Kampala) along with the Elizabeth Glaser Pediatric
AIDS Foundation. USAID funds the testing and counseling
components, while the hospital is providing the antiretroviral
drugs and antenatal care.
In Kenya, USAID currently supports MTCT prevention projects
in three sites. This is a collaborative effort with the
government of Kenya, UNICEF, UNAIDS, WHO, and African
researchers. An important part of this effort is a
comprehensive operations research study, so that we can learn
from the experience and share the knowledge gained.
Another important way that we can reduce transmission is through
treating other sexually transmitted diseases (STIs). A study in
Tanzania showed that treating these infections, such as syphilis and
chancroid, reduced HIV transmission by almost half. Treating STIs is a
standard part of our HIV/AIDS prevention programs. Recently we have
begun applying an innovative approach, periodic presumptive treatment,
to those at very high risk, such as truck drivers, migrant workers and
prostitutes. This ensures that these populations get regular treatment
even where there is not sophisticated laboratory support.
Finally a review of USAID's support to AIDS prevention would not be
complete without mention of our substantial investments in vaccine and
microbicide development.
The pursuit of a vaccine that will prevent transmission of all
strains of HIV remains one of the most challenging scientific and
technological problems facing the world today. USAID has finalized a
two-year $16 million grant agreement with the International AIDS
Vaccine Initiative (IAVI). IAVI provides scientific leadership by
financing and managing promising international vaccine research and
development projects in developing countries. USAID's funding will
provide support for vaccine research and development and strengthening
clinical and laboratory infrastructure in developing countries. Also
because USAID has extensive developing country experience and on the
ground infrastructure, we stand ready to partner with vaccine
developers to facilitate the contacts with governments NGOs and
academia that will be needed for successful vaccine trials. We will
provide assistance with community preparation and mobilization and the
necessary prevention interventions needed to support AIDS vaccine
trials.
USAID has been supporting the development and evaluation of
microbicides to prevent sexual transmission of HIV for almost a decade.
In FY01 USAID invested $12 million for the development and testing of
microbicides and plans to raise this to $15 million in 2002. One
promising product to come from this process is the seaweed derived
compound, Carraguard, that is currently receiving wide attention. USAID
is supporting field trials of this product in Africa.
TREATMENT, CARE AND SUPPORT ACTIVITIES
Care and treatment is important for humanitarian reasons. It also
enhances prevention by increasing utilization of voluntary counseling
and testing, and helping to decrease stigmatization. It prolongs
parenthood and economic productivity. By treating the most important
opportunistic infection, tuberculosis, we have prolonged the lives of
persons infected with HIV. We also help control the expanding TB
epidemic, which threatens all countries.
People with HIV/AIDS have many needs in addition to health care.
These include psychological support, legal assistance, economic
support, and accurate information about HIV/AIDS. These are often as
important as health care, since HIV infection remains symptom free for
many years. USAID has supported and will expand our programs that
provide non-medical services to people living with AIDS.
USAID produced ``HIV/AIDS: A Guide for Nutrition, Care and
Support'' which shows that, compared with the average adult, a person
with HIV requires 10 to 15 percent more energy a day, and 50 to 100
percent more protein a day. We are now incorporating food security
activities into our care and support efforts.
Currently, we have 25 care and treatment projects in 14 countries.
In Uganda, USAID has begun a five-year, $31 million program to provide
food to HIV/AIDS-affected families, to help reduce the impact of AIDS
on households. We can help people survive longer by treating
opportunistic infections such as tuberculosis and continuing to help
countries build up their health care systems and infrastructure.
Antiretroviral therapy has had a dramatic impact in reducing AIDS
mortality in the developed world. However, there are a number of
challenges that limit the ability to offer treatment and support to a
large number of people. USAID is actively trying to assess and solve
these problems.
The U.S. currently spends close to $4,000 per person per
year on health care. In many countries in sub-Saharan Africa,
annual spending is about $40 per person--a 100 fold difference.
Providing antiretroviral therapy to one person for a year costs
at least $600. Early on, approximately a quarter of those
infected will need treatment. This may seem a manageable
number. However, since therapy is lifelong, the numbers of
people needing it will escalate, causing an ever increasing
expenditure for treatment.
Persons with HIV infection generally lack access to health
care. There are few health care workers trained to administer
therapy, not enough laboratories capable of providing even the
most basic tests to monitor patients for side effects, and drug
management systems that are too weak to prevent leakage of
extremely valuable drugs into the black market.
Without simple standard protocols for therapy and patient
monitoring, it will not be possible to provide therapy to large
numbers of people in Africa. With standard protocols,
healthcare workers, under the supervision of a few physicians,
can be trained to deliver therapy, adherence can be enhanced,
and drug management can be streamlined,
Even with the most ambitious treatment plan, the demand for
therapy will likely exceed the supply. National governments
must address this issue. People living with HIV/AIDS must be
actively engaged in this discussion.
USAID will be launching four antiretroviral (ARV) treatment sites
in sub-Saharan Africa this year. These sites will not only save lives
but will also provide critically needed answers to the challenges noted
above and begin to build much needed local capacity.
All of these efforts must build on a solid prevention strategy. We
must closely link treatment with prevention. Relying totally on
treatment interventions will not stop the advance of the pandemic.
Lessons from the U.S., France, Brazil and other countries that offer
ARV therapy clearly demonstrate that the introduction of combination
therapy does not retard the epidemic. In fact, the belief that HIV is
no longer dangerous may result in increased transmission.
CHILDREN AFFECTED BY AIDS
More than 13 million children under age 15 have lost their mother
or both parents due to AIDS. By 2010 some 44 million children in 34
countries will have lost one or both parents, primarily due to AIDS.
The impact of such large numbers of orphans and other vulnerable
children is substantial for the children themselves, their families and
the communities in which they live.
In sub-Saharan Africa, where the majority of AIDS orphans reside,
gains in child health achieved over recent decades are unraveling. In
Zimbabwe, I worked with street children orphaned by AIDS. I also taught
AIDS prevention in schools where the children's greatest fear was that
they too would lose their parents. Orphaned children lose their
families, their hope for education and the basic necessities of food
and shelter. They become easy prey for violence, sexual exploitation
and crime. In some settings, they are fodder for child militias.
While some communities have organized support for especially
vulnerable children and households, many are weakened by the burden of
illness and death as well as the economic deterioration caused by AIDS.
Helping communities care for their own is a critical area where USAID
can make a difference. We have models that work and that can bring hope
to families and communities.
This is the foundation of USAID's support for children and families
affected by AIDS. Since 1999, USAID's help for children affected by
HIV/AIDS has increased to more than 60 different projects in 22
countries. Supporting communities and families is the most efficient
and effective way to address this tragic problem and reach the millions
who are and will be affected.
In Namibia, community groups work together to keep orphaned
and vulnerable children in school.
In South Africa, the Nelson Mandela Children's Fund aims to
reach an estimated 250,000 orphans and other vulnerable
children through multisectoral initiatives in HIV/AIDS-affected
communities.
In Zambia, an interactive radio and local volunteer program
helps out-of-school and other vulnerable children continue to
learn.
In Uganda, research is underway to identify effective ways
to support families in planning for the care of children upon
their parents' death.
In Rwanda, several programs work together toward the goal of
providing food to 22,000 AIDS-affected children.
I have seen that these programs can have impressive impact. In
Zimbabwe, I met with a local NGO that facilitated amazing community
support to households headed by teenage siblings.
WORKING TOGETHER MATTERS
No one agency can do it all. With so many new partners, the
coordination of our efforts becomes even more critical. This is as true
among the U.S. government agencies as it is among our international
partners, including the new Global Fund. Coordination efforts must
occur at two levels: at headquarters and in the countries we are
assisting.
A good example is our work with CDC over the past two years. We
have decided upon a mutual list of priority countries, we have agreed
upon strategic approaches and we are finalizing new areas of specific
expertise. We have signed a Memorandum of Understanding, which defines
our collaborative efforts and establishes on-going communication
systems. Even more important is the coordination that must take place
within the country between CDC and ourselves and with the host country
government and community groups. It is there on the ground where we
will realize the impact of our combined resources.
An example of how we work together is seen in the area of
surveillance. CDC has taken the lead for the biologic surveillance of
HIV prevalence while USAID is supporting behavior surveys. Together we
use this information to track the epidemic, target our resources and
measure impact.
In the past two years, we have learned important lessons on what
works and what does not. We have successful models that are being
replicated, and in six countries we are now seeing a reduction in new
HIV infections at a national level. Drug costs have come down
dramatically and treatment protocols have been simplified. We have the
tools, we know they work. With your continued support and the new
resources you have given, we can now move ahead to save lives of
millions.
Senator Feingold. Thank you, Dr. Peterson, for your fine
testimony, and I will begin with some questions for the panel
and then turn to Dr. Frist, and go back and forth.
Dr. McCray, you talked about the importance of adequate
health infrastructure for both prevention and treatment. Give
me an idea of what specific interventions the CDC is involved
in laying the groundwork for those components, and if you can
tell the committee about a case in which all three components
of the CDC effort are up and running, infrastructure,
prevention, and treatment, if you could give us an example of
that.
Dr. McCray. Yes. In a number of countries CDC has played a
major role in helping improve the public health laboratory
infrastructure that is sorely needed to help support voluntary
counseling and testing, which is a part of prevention, and help
to support care and treatment, which requires some laboratory
monitoring as well as help to support clinical followup with
patients.
The example I would like to give is Botswana, where we have
been working with the Government of Botswana in implementing
the voluntary counseling and testing program. Those programs,
we have implemented programs in seven districts with an intent
to go to about 15 districts by the end of 2003. Those programs
are directly linked to prevention of mother-to-child
transmission, and are being directly linked to care, and CDC is
playing a major role in implementing those programs in
collaboration with the government, and have been very
successful in doing that, so that is one example of how we do
it.
Senator Feingold. Let me ask both of you, what kinds of
innovative ideas have we developed to help address the
challenges surrounding the cost and treatment protocols in
resource-limited settings? In other words, what are some of the
most promising treatments being considered today? Dr. Peterson.
Dr. Peterson. There are a number of different elements.
Certainly we have been working in our mother-to-child
transmission programs with the pharmaceutical companies, and
they have been providing the drugs for the programs as we work
on the protocols, and I guess again in South America one of the
big things that Brazil and the Ministry of Health partners told
us is laying out negotiations with the pharmaceutical companies
to decrease the prices has been very instrumental in them
coming down.
Overall, the partnerships, and I believe the corporate
partners, including the pharmaceutical industry, wants to be
part of this. They want to make a difference worldwide. They
are actually contributing large amounts of drugs to the
programs, and that is one of the ways that we will make the
most progress.
I do not know if it is innovative, but as you get all of
the partners involved, the ministry of health, the communities
that care, the AIDS patients and victims themselves, working
together with our dollars, with the pharmaceutical companies,
then you have a nexus of people and dollar resources to really
address this cost and begin to make it possible.
The hardest is the public health infrastructure, to have
the services far enough out, in all of the places to address
the scope of need that exists currently, let alone how big it
could be if we do not get a handle on slowing it down or
stopping it.
Dr. McCray. Actually, I was just going to give a concrete
example of what is happening, what is beginning to happen in
Uganda, which is somewhat innovative in Uganda. USAID, CDC is
beginning to work on two fronts, one in an urban setting and
another one in a rural setting, to implement ARV therapy in the
urban setting of Kampala. The Academic Alliance, which is a
private entity that is primarily funded, I think, by Pfizer, we
are going to be working with them to help implement ARV
comprehensive treatment programs in an urban setting, and the
pharmaceutical, of course, is providing a lot of the funds to
support the facility that will be used to evaluate and treat
patients, was well as for providing free drugs.
We are working with other partners to secure
antiretroviral--CDC and USAID with other partners are also
working in a rural setting to implement a pilot ARV program
that will actually use minimal technology. In the urban setting
we will have state-of-the-art technology, viral load testing,
CD-4 testing, et cetera, but in the rural setting there will be
limited resources, and we will use minimal techniques that are
being evaluated to monitor and follow patients, and so those
are all sort of innovative ways we are trying to use to
implement these programs.
Senator Feingold. Thank you. In my opening statement and in
some of your comments we talked about cases where treatment and
prevention appear to complement and reinforce each other. I am
wondering if there are situations where this is not the case,
and if so, what factors cause the difference, for either of
you.
Dr. Peterson. I cannot give a specific case where having
them together would not have some synergy and complement. The
biggest difficulty is, as Dr. Frist pointed out, the resources,
and competing for resources, and balancing how much you put
into the treatment versus the prevention. It does make a
difference.
The other place that we see that sort of synergy is when
you make the rapid testing available, and someone knows that
when they come in they are going to find out that day what
their results are, you get many more people coming in. We found
the same thing. If you know, when you come in and get your
test, you are actually going to be able to do something about
it, it does encourage people to come in more, and it is just,
how are we going to balance the resources, because we both want
to treat and give compassionate care, we also want to stop the
epidemic from spreading and the next generation of youth within
Africa not to become infected.
Dr. McCray. I agree, and I really do not have a lot to add,
except to say I think one of the biggest challenges we are
facing in the countries is the fear by many of the national
programs that once they get engaged in care, moneys are going
to be sucked away from prevention, and they, in turn, see us as
being competitive, and I think part of our job is to help them
understand that the two should not be competitive in any way,
and we need to develop models that clearly demonstrate that the
two activities are complementary, so I think to the bottom line
our biggest challenge is convincing national governments in
many of these countries that it is OK to get involved in care.
Senator Feingold. Let me ask one more question before I
turn to Dr. Frist. Say a little more about the public health
benefits that can come from a solid voluntary counseling and
testing program, including spillover benefits that might not be
AIDS-specific. For example, what effect do such programs have
on other sexually transmitted diseases?
Dr. Peterson. For a long time we would use rates of STD's
as markers for our HIV prevention programs, because as you did
your counseling, your testing, your behavior change
communication and reaching out there, we did not early on have
a way to know, we did not have an HIV test that was reliable,
and so we used rates of STD's, and so that is obviously the
classic place that we see a difference. Sometimes they follow
teenage pregnancy rates. That is not nearly as reliable,
obviously, a way of following it.
The other is a much larger sort of social piece, and that
is, as you do the counseling and people can take ownership for
their own behaviors and risks, you take back some of the fear,
pull them back from the fear that I saw in the kids that I
worked with, what is happening to my family, what will happen
to me and saying, you do not need to just be afraid, some of
this is under your control, and give them back their future and
a chance to plan where they are going to go and what they want
to do, that they can continue in their education, and so all of
those are opportunities that you have as you do your counseling
and testing to transform a culture.
Dr. McCray. Just to add on the biomedical side, voluntary
counseling and testing sites provide opportunities for you to
get people into specific care. In many of the centers we screen
for syphilis as part of voluntary counseling and testing when
the blood is collected. In addition, in some of the centers we
screen for active tuberculosis in patients who fit a certain
syndrome that are referred for screening and further followup
to treat their tuberculosis. Those who are found not to have
tuberculosis in some countries they are now beginning to use
what we call INH preventive therapy to prevent new cases of TB,
so voluntary counseling and testing really is an entry point to
many prevention activities, as well as care and many of the
psychosocial support activities that are mentioned.
Senator Feingold. Thank you very much. Senator Frist.
Senator Frist. Thank you, Mr. Chairman, and I appreciate
the testimony of both of you, and your excellent written
testimony as well, and I really just have one question, and it
has to do with, I think, Dr. Peterson, I know in your written
testimony you mention, and that is the role of women and young
women in what we can do. I would like both of you to comment,
because before going to Africa this most recent time I did not
have a full appreciation--I probably just was not looking for
it, but both the data that was presented in terms of the
initiation of sexual activity, the importance of education.
Again, we talked a little bit about it at our hearing
yesterday, but I am increasingly fascinated by the education
component, by the empowerment component.
I mentioned in my opening statement here that one of the
more impressive people, when with the Hewitts and others, I was
with in Africa, that we interviewed, the story of a woman who
really became empowered culturally is a change in behavior, a
change in culture, but where she stood up really for her
rights, when her husband died and everything normally would
have gone to his family, but just the more I look at this, as
we are looking at places to incrementally have an impact both
short-term and long-term.
It comes down to--an issue in this country we have, it is
not addressed until, well, fairly recently, but the empowerment
of women, but these younger girls as we go forward. I am
struggling with what we do both from the CDC and USAID
component, and what we can do as a Foreign Relations Committee
to both further emphasize that, institutionalize that, support
that as we go forward. I would be interested in both of your
comments.
Dr. Peterson. I think the situation really is remarkable.
When I was there I had similar kinds of stories, only we worked
in rural areas in Kenya. We would have women come to us and
say, I know my husband is coming back from the city and he has
that disease, and I do not have any way of saying no. How do I
protect myself? How do I not--I want to live to take care of my
children, a heartrending kind of question, and early on, really
what we could say is, we will treat you for your STD's, we will
encourage you, but in the last 10 years many huge things are
happening.
There are starting to be policy guidance at national
levels. There are legal groups starting to give some legal
rights to women to protect themselves in specific
circumstances, and we do some of that legal and policy support
type of work. Education is key, working with kids in schools.
One of my favorite posters, that is actually the only AIDS
posters I have in my office, shows a typical sugar daddy
situation with a young schoolgirl, and when you show it in an
African school setting they know exactly what this means, and
the question is, well, what can she do, and we would talk
through, OK, how could she not be in this situation, what could
she do differently, and at first they think there are no
solutions, but when you work with them there are solutions.
But the biggest breakthrough for me was when we talked to
the boys and said, what would you think if this was your
sister, your cousin, how do you want to be part of the solution
to some of these situations that put the young girls, your
girlfriend, your sisters, at risk, and see the light go on in
their eyes, that they have a role and a responsibility within
women's issues and risks for HIV/AIDS and other diseases as
well, and so education is key.
On the biomedical side, one of the things that we have been
researching and starting to do, obviously, is the female
condom, something that would put into women's hands a way, a
choice on how to protect themselves. It has not taken off
wildly, but we are continuing to support research in those
areas to give women a little more choice about their own risks
in places and situations where they may not have other choices.
Dr. McCray. I basically agree with most everything Dr.
Peterson just said. The only thing I would add is that one of
the things we are attempting to do is to support studies,
especially behavioral studies, to try to understand better some
of the cultural and social dynamics that affect women's
inability to prepare themselves and then try to learn from the
communities innovative ways that we can then overcome some of
these barriers, and USAID is also funding some of that kind of
work, but I think we have to do a better job working with local
behavioral scientists, et cetera, trying to understand what
many of the cultural and social factors are and doing something
to change those, because it has to be changed not only at an
individual level, but I think at a societal level as well.
Senator Frist. Thank you, Mr. Chairman. Thank you both very
much.
Senator Feingold. I will have a number of additional
questions, but so we can move on to the next panel let me ask
just one more, unless Dr. Frist decides he wants to ask more
questions.
Dr. Peterson, you indicated USAID is implementing pilot
treatment programs in a few of the African countries. Can you
tell me a little more about how the countries were selected?
Are there characteristics of each that will provide especially
valuable information to the agency about how to pursue
treatment in different contexts? That is for either one of you.
Dr. Peterson. We have the one in Ghana that we announced
today. The other three are still in negotiations, and it really
depends on whether the Ministry of Health, as Dr. McCray
pointed out, are not all ready to move into this arena, that
they are ready and willing to work with us, that the
infrastructure is there to actually do the first pilots, to
have the people there to work with, and that we can get the
other logistical issues put together, so we have actually
talked to a number of different countries, and we have three we
are still negotiating with, and the other that is firmed up, in
addition to the ones that were ongoing with CDC, and they are
all places where there is significant threat and higher
prevalence, so they are areas of concern, but they need to have
the infrastructure for us at least to begin to do the pilots.
Dr. McCray. The three countries that we are beginning to
have these pilot projects in are Uganda, Kenya, and Botswana,
where we are working very closely with Harvard AIDS Institute,
but the criteria differs a little bit for each country. In
Uganda, it was clearly a request that was made through the
Ministry of Health. They wanted us to help them look at ARV, or
treatment, demonstrate treatment projects in various areas. In
Kenya, the initial request for our involvement came through the
Kenya Medical Research Association. It is the Kemri Medical
Research Institute, which includes a group of leading
infectious disease divisions.
They in turn met with the Ministry of Health staff and then
basically got their buy-in, and then we are working with them
to help implement the ARV projects in Kenya, but the bottom
line is that they are usually the Ministry of Health--we feel
it is important that the Ministry of Health be on board and
supportive of whatever projects we plan to do in these
countries, because our goal is to demonstrate that it can be
done, and the assumption is that there will be a will by the
government to then expand the programs to make them available
to others.
Senator Feingold. Just a quick followup. For these pilot
programs to be successful, what kind of resources are we
talking about that will be required to implement these on a
larger scale, if you could give me some sense?
Dr. Peterson. To scale them up once we finished, or to do a
demonstration site?
Senator Feingold. To do them on a larger scale.
Dr. Peterson. I do not know if anyone has estimated how
large the cost would be. If you multiplied the number of people
in Africa who have HIV/AIDS and then look at how many of them,
how many are HIV positive, and then how many are AIDS and
therefore susceptible to treatment, times the cost, and we did
a rough estimate yesterday, it ranges between $600 to $1,300
for drugs, and so if the dollars keep going down, and it may be
another $200 for health clinical costs, you multiply it out,
and it is in a few billion dollars range. We are starting small
to make sure we have got the logistics right, and obviously the
drug costs are continuing to come down.
Dr. McCray. I was just going to say, in Uganda they have
been really successful in getting the prices down to about $90
a month just for the drugs, and with the additional cost for
monitoring and evaluation I would agree with the estimates that
she has come up with, but again, as part of these demonstration
projects we are collecting information on cost so that at the
end we will be able to say, for the expected number of people
living with HIV/AIDS who will need to be on drugs, this is
probably what it is going to cost for you to try to implement
this country-wide. That is one of our goals.
Senator Feingold. Thank you for your answers.
Senator Frist. Can I just ask a followup, because I think
that question there is very helpful for me. Are the
pharmaceutical companies participating, and on board, and
specifically I am thinking of the trials themselves in terms of
these partnerships that I know, Dr. McCray you were talking
about earlier, and Dr. Peterson, because it is critical, and
clearly they are down there. There is good reason for them to
be there, and some people are skeptical in terms of why they
are doing it, but just for us, for the trials--and again, as I
have been on the ground, you hear about these trials that are
coming. Is the partnership working with the pharmaceutical
companies?
Dr. Peterson. We have a long history of working with the
pharmaceutical companies and getting free drugs in other
disease areas. They have been working very well with us and
quietly been very willing to provide selected drugs for us free
or at lowest cost for these projects, mother-to-child, and
these new ARV's, so I think there is an ongoing relationship.
I think there is a hesitation about taking on the millions
of people, and having to do it at less than their cost, and
whether they could actually sustain it, but they have been
making an extra effort.
Dr. McCray. CDC does not work directly with the
pharmaceuticals, but we are working with the foundations that
receive support from the pharmaceuticals, and that is usually
our entry-way. An example is the PMTCT Plus program that is
being supported by the Pediatrics AIDS Foundation as well as a
number of other foundations, and they are providing--we are
collaborating with them on a number of projects, and they will
be providing the drugs, but the pharmaceuticals are making
those drugs available almost free, or at very low cost.
Senator Feingold. Thanks so much to both of you on this
panel. We appreciate it, and we will now move on to the second
panel.
We also have an excellent second panel of witnesses with us
today. I would like to thank them for joining us. Let me
introduce each of them, and then I would ask each witness to
testify in the order of introduction. We will start with Dr.
Jeffrey Sachs. Dr. Sachs is the Galen L. Stone Professor of
International Trade at Harvard University, and the director of
Harvard's Center for International Development. His broad
research interests have focused on the links between health and
development, along with economic geography, globalization, and
macroeconomic policies in developing and developed countries.
He serves as economic advisor to the governments in Latin
America, Eastern Europe, the former Soviet Union, Asia, and
Africa, and I am pleased to note that he was just appointed by
U.N. Secretary Kofi Annan to serve as Special Advisor on the
U.N.'s Millennium Development Goals, and that position, Dr.
Sachs will organize the United Nations' research aimed at
significantly decreasing world poverty, disease, and death by
2015. Dr. Sachs has won many awards and honors, and he is well-
known to this committee, and I am pleased to have him with us
here today.
Dr. Jim Yong Kim. Dr. Kim is a trustee of Partners in
Health, the Harvard affiliated nonprofit organization that
supports health projects in poor communities of Latin America,
Eastern Europe, Asia, and the United States.
One of the leading world authorities on multidrug resistant
tuberculosis, Dr. Kim serves as the director of the Program on
Infectious Disease and Social Change at Harvard Medical School
and is an attending physician at the Brigham and Women's
Hospital in Boston. Working closely with the World Health
Organization, the U.S. Centers for Disease Control and
Prevention, and other stakeholders in the public nonprofit and
commercial sectors, Dr. Kim has played a central role in
developing more effective global policies to control TB. In
1999, he coauthored the global impact of drug-resistant
tuberculosis, a groundbreaking report documenting the epidemic
rise of multidrug resistant TB worldwide.
Dr. Kim's most recent book is, ``Global Inequality and the
Health of the Poor,'' an edited volume focusing on
socioeconomic forces that can undermine the ability to provide
basic social and medical services to people in poor countries.
Mr. Martin Vorster is a very interesting witness from South
Africa with us today. Mr. Vorster is a South African missionary
who has worked on AIDS prevention in a township outside of
Pretoria, South Africa, for the past 5 years. His religious
ministry provides in-home care for those suffering from AIDS,
along with care for AIDS orphans. They also provide assistance
and care for those who have been rejected or isolated by their
families as a result of the stigma that is so often attached to
those who suffer from HIV/AIDS.
We obviously welcome all of you. We are pleased to have all
of you here today. Dr. Sachs, if you would proceed with your
testimony.
STATEMENT OF DR. JEFFREY SACHS, DIRECTOR, CENTER FOR
INTERNATIONAL DEVELOPMENT, HARVARD UNIVERSITY, CAMBRIDGE, MA
Dr. Sachs. Thank you very much, Mr. Chairman. It is really
a pleasure and honor to be back with you and with this
committee. The two of you have led the way in the Senate and
helping the American people and your colleagues in Congress to
understand this issue, and I think we are seeing the fruits of
your very hard labors over the last few years.
This supertanker of ours is very gradually starting to turn
in the right direction, and I think you should take great pride
in what you are accomplishing in these years and in making
better understood this calamitous situation.
But I am here to say also that all is not right by any
means, and I think we still have not really turned the
supertanker in the direction it needs to go, and I do not think
it is a matter of just waiting a bit longer and things will
come out right. Millions of people are dying as a result of the
inaction of the United States and other countries. Time is not
on our side, both in epidemiological terms and in terms of the
real struggles of human beings that are dying for neglect of
modest resources.
I was mildly pleased by what I heard in the first panel,
but I have to say also I continue to be alarmed that we are now
65 million infections into this pandemic, and we have not put
one person on antiretroviral therapy yet, but we are starting,
but we are 65 million people into this. USAID has not had one
single person on a donor-supported program on antiretroviral
therapy, other than the very beginning of the mother-to-child
one or two dose, but in terms of helping to keep the mothers
and fathers, the doctors and nurses, farmers, workers of Africa
alive, the donor world has not figured out yet to put one human
being on treatment.
This is going to be one of the most puzzling and shocking
features of our generation, when we look back, how we let it
happen again. The never again is happening again before our
eyes, and I do not really understand it, actually. Although I
know all of the real political explanations, I do not
understand it or accept it. I would hope that your leadership
could help the U.S. Government get better organized, because my
basic message is, it is not organized yet.
I would ask four questions, first, who is in charge,
second, where is the strategy, third, where is the matching of
resources and need, and fourth, where are your colleagues in
the Congress? I think we need to figure out very fast answers
to those questions. I think there are good answers, but I do
not think we have them yet. It is just not good enough to have
all the high rhetoric that we have and end up with an fiscal
year 2003 request of $200 million for the Global Fund.
The only word that comes to mind is bizarre, and such a
lack of seriousness that one does not even know where to begin
to understand what is happening at OMB or in the White House or
in the State Department or at HHS, or in the Treasury, or other
places where things might get done. There is no conception of
linking needs and actions. The rhetoric gets better and better,
but at the bottom line the one thing I know how to talk about
in this, which is the macroeconomics, we are just nowhere right
now, and it is just impossible to understand, frankly.
In a budget proposal where $62 billion of tax decreases are
budgeted and apparently are not going to be done because we are
not going to have a stimulus package we hear the political
leadership of the United States say there is no more money than
$200 million. It is just not so. We are a $10 trillion economy.
We are a $2.1 trillion budget. We have billions and billions of
dollars built in, $224 billion built in for the military
increases. We have more than $200 billion built in for a
stimulus. We have $141 billion built in for a stimulus package
which is not even going to take place, and then we are told
$200 million is what we can come up with.
We hear our Secretary of Health and Human Services say that
we just do not have more money. I do not know what that means.
What I think it means is we have not done the serious work of
saying what can be accomplished with the money, what happens
with scaling up, how much would it cost, what is a timetable,
what is a multiyear strategy, how do the pieces fit together?
We heard an extraordinary answer just now to your question
both to CDC and to USAID. It is not acceptable, in my opinion,
in the 21st year of this pandemic, that they could not give an
answer of the cost of scaling up. That makes no sense for us,
as the greatest country in the world, that we have not been
able to get organized to give an answer to that question. It is
not so hard to do. The right answer, by the way, is that
roughly, it is $1,000 per person per year for treatment, all
costs included, drugs and all of the ancillary testing,
counseling, medical care.
Probably that is in my view the outer limit. I saw cases a
couple of weeks ago when we had the great pleasure to meet
Senator Frist in Kampala. Just before that I was in Malawi,
where the drugs were $1 a day, $350 a year from Cipla, and the
extra costs were probably about $200 per patient, I would say
under $600 per year to get the job done with a regimen which we
were told was working extremely well.
But let me paint a picture for you, if I could, just very
briefly. In one ward of a hospital I saw a sight which I hope
never to see again, of course, but at the same time I wish
every one of your colleagues could see. The ward had hundreds
of people in it, three to a bed. It is something unbelievable.
There were no drugs in the ward. Everyone was dying. So you
look into a room where there is just death going on, two in a
bed, one under the bed.
Across the hall was the outpatient clinic where, if people
could afford $1 a day, they were getting treated. They were
walking out of the clinic because these drugs are incredibly
effective, and they are not so impossible to deliver as one of
the great practitioners of this is about to tell you, because
this man is an inspiration, and his partner. They prove the
concept just by doing it, but now I have seen all over Africa
it is just being done if you can afford the $1 a day.
So in one room thousands are dying each month, the other
room a few hundred are surviving because they can afford it.
There is nothing lacking but the resources. In that case,
Senators, there is nothing lacking but the few bucks that it
would cost, and we have so far made a calculation that Africans
are not worth $1 a day to keep alive. That is the calculation
the rich world has made, and they agonize over this.
Are Africans really worth $1 a day to keep alive? Are
Africans cost-effective at $1 a day? Is it cost-effective to
have 40 million orphans? Is it cost-effective to have a
continent fulminant in disease? Is it cost-effective to have
millions going hungry because the farmers are dead? Is that
what we mean by cost-effective? Is it cost-effective for us to
be allowing a generation to die for lack of a few dollars per
American?
Well, our government has not even done the calculations,
Senators. I know that. I spent 2 years as chairman of the
Commission on Macroeconomics and Health for the World Health
Organization. We did the calculations, and I hope that everyone
on the committee has gotten the text. I think it is pretty
authoritative. I can say that because I did not make the
calculations, but the London School of Hygiene did, and experts
from all over the world, and we found that for a penny out of
every $10 in the rich world, one penny out of every $10 of
income in the rich world we could save 8 million lives per
year. That is the kind of calculation that the world that we
are really living in.
If the rich countries each raised $1 per person, Senators,
that would be $1 billion per year. That would save a million
lives at least each year, $1. That is the kind of calculation
we need to be making. Our government is absolutely winging it.
That I believe is unacceptable in the greatest pandemic in
history, that they cannot give you a 5-year strategy, a scaling
up cost estimates, and I know they cannot because they do not
do them. No one is in charge. No one is making a strategy. They
are winging it.
They tested the air. They said, we will give $200 million.
Then--it is bizarre. They said, $500 million, but you know,
that is a weird way to say it. I am sorry. People need the
drugs each year. You do not keep adding the pile. It is $300
million this year, then $200 million next year. What kind of
strategy is that?
My God, thank goodness we do not fight wars that way. You
know, we do not just wing it, and that is what we are doing,
and so our basic message--and I have given you detailed
testimony, but my basic message is, we have got to stop winging
it. It is a game right now. It is a game of the minimum amount
that can be gotten away with. To say we are doing it, we have
got a site here, we have got a site there, there is no strategy
right now. There is no scaling up strategy where 40 million
people are affected now, 20 million have died, and they cannot
give you a straight answer of what the cost of scaling up would
be because they have not thought about it even.
[The prepared statement of Dr. Sachs follows:]
Prepared Statement of Prof. Jeffrey D. Sachs, Chairman, WHO Commission
on Macroeconomics and Health, Director, Center for International
Development, Harvard University
Senators, thank you for the opportunity to testify today regarding
one of the most urgent problems facing humanity--the global AIDS
pandemic. The decisions that the Congress and Administration make
regarding the pandemic will determine the life or death of millions of
people in the next few years, and will affect America's security and
standing in the world for decades to come. To date, the United States
and other donor countries have under-financed AIDS control in poor
countries. This has allowed the pandemic to run rampant. Millions of
poor people are needlessly dying every year when their lives could be
extended by appropriate medical care at modest cost and enormous
benefit to the
Last month, I visited some of the dying fields of Africa. I stood
in Queen Elizabeth Hospital in Blantyre, Malawi where 70 percent of the
medical admissions are AIDS-related. Hundreds of patients are crowded
into the wards to die, two or three to a bed, with patients also lying
on the floor under the beds. Hospital services are collapsing under the
weight of the epidemic. There are no life-saving drugs given to these
people because neither the dying patients nor the Government of Malawi
can afford the medications.
Yet across the hall, an outpatient service successfully treats the
small fraction of HIV-infected people who can afford one dollar per
day. Hundreds of people are successfully on antiretroviral therapy. The
problem in this hospital is not infrastructure, doctors, testing
equipment, adherence by patients, the ability to tell time--it is
simply the shortage of $1 per day per patient that would supply life-
saving drugs. Even when one adds in the testing and counseling costs in
addition to the direct costs of drugs, it is very likely that total
spending would remain well under $3 per person per day.
While the stain of U.S. neglect during the first 20 years of the
pandemic can never be washed away, it is not too late to act, for our
direct security needs as well as our moral purpose as a great nation.
The United States should increase its spending on AIDS control by
contributing at least $2.5 billion in FY03 to control of AIDS in poor
countries, of which at least $2 billion should go the Global Fund to
Fight AIDS, tuberculosis, and Malaria, for the reasons described below.
Our contribution of $2.5 billion to AIDS control should be matched by
at least $5 billion from Europe and Japan, for a total outlay of $7.5
billion for HIV/AIDS control. The Global Fund should disburse at least
$6 billion for AIDS, tuberculosis, and malaria in FY03.
The Global Fund has $700 million for disbursements in 2002, of
which the U.S. share is $250 million. The Congress and the
Administration should agree to a supplemental appropriation of at least
$750 million for FY02, to raise the U.S. contribution this year to $1
billion. This in turn should be matched by at least $2 billion from
Europe and Japan, for a total of $3 billion. Without this supplemental
appropriation, the Fund will either run out of money during the year,
or will drastically ration the size of programs that it approves, to
the serious detriment of disease control efforts.
scale of financial assistance for hiv/aids control in poor countries
Table 1 \1\ breaks down the financing of AIDS control in recent
years, and estimates the needs for U.S. contributions for AIDS and for
total disease control efforts in poor countries in the coming years.
---------------------------------------------------------------------------
\1\ Table 1 appears at end of statement.
---------------------------------------------------------------------------
In the second half of the 1990s, America spent around $10 billion
dollars per year battling the AIDS epidemic at home, but only around
$55 million per year in helping Sub-Saharan Africa. It is worth
recalling that the U.S. has about 1 million HIV-infected individuals,
while the developing world has 38 million infected individuals.
Treatment costs, I will note below, are of course much lower in the
poor countries, but the combination of prevention and treatment costs
will still require vastly higher donor assistance to meet the needs of
the tens of millions of individuals already infected and the hundreds
of millions that are at risk of infection.
U.S. international assistance to fight AIDS has recently begun to
increase, to around $680 million in FY02, with perhaps two-thirds of
that aimed at Africa (depending, for example, on allocations from the
new Global Fund to Fight AIDS, TB, and Malaria). The FY03 budget
request again increases the total international spending on HIV/AIDS to
around $844 million, with $200 million requested for the Global Fund.
While these recent spending increases are certainly in the right
direction, U.S. assistance is still woefully short of any realistic sum
needed to help the poorest countries, especially in Sub-Saharan Africa,
fight the AIDS pandemic.
Secretary General Kofi Annan has called for $7 to $10 billion per
year for the control of AIDS in low-income countries, an estimate that
has been supported by several expert studies, published in the world's
leading journals, such as Science Magazine (Schwartlander, et. al.,
2000) and elsewhere. Looking out a few years, the worldwide need for
donor assistance to control AIDS will probably be at the high end,
perhaps reaching $10-15 billion depending on the course of the
epidemic, the evolution of treatment costs, and ability of the low-
income countries to scale up AIDS control efforts.
In the past two years, I chaired the WHO Commission on
Macroeconomics and Health, which was charged in part with determining
donor financing needs to address the interlocking pandemics of AIDS,
malaria, tuberculosis, and other killer diseases. Our study, released
in December 2001, determined that Sub-Saharan Africa would need total
donor assistance for health of around $18 billion per year as of 2007,
of which more than half would be devoted to the control of AIDS, with
the rest directed at other killer diseases such as tuberculosis,
malaria, vaccine-preventable diseases, respiratory infections, and
diarrheal diseases. Since other regions would also need donor
assistance to fight AIDS, the worldwide need for donor assistance to
fight AIDS could reach $10-15 billion per year by 2007.
Since the U.S. represents around 40 percent of the GNP of the donor
world ($10 billion out of $25 billion in total donor GNP), the U.S.
share of the total health assistance will need to be at least one
quarter of the total, if not more. This means that U.S. spending on
AIDS in Africa will require at least $2 billion per year, and total
U.S. foreign assistance for AIDS should reach at least $2.5 to $3
billion per year worldwide in FY03. According to the Report of the
Commission, total worldwide donor spending on all types of health
programs should be approximately $27 billion per year by 2007, so that
total U.S. health assistance would be in the range of $7-$8 billion per
year, roughly five to six times the current level.
These numbers may seem large, Senators, but the amount of suffering
and global risk posed by the pandemic diseases is far greater. The
Commission findings suggest that if the U.S. invests on the order of
$7-$8 billion per year as part of a global program of around $27
billion per year as of FY07, around 8 million deaths will be averted
each year by the end of the decade. We can save 25,000 people every day
from deaths due to AIDS, malaria, tuberculosis, and other killers if we
put our minds, and a modest part of our incomes, to it. Note that $7 to
$8 billion per year for global health needs would represent far less
than one half of one percent of our national budget, and less than one
penny out of every 10 dollars of our income.
The United States, while the second largest donor in absolute terms
(after Japan), has become the smallest donor in the world when aid is
measured as a share of income! (Chart 1) \2\. We are now spending only
0.1 percent of GNP on all forms of official development assistance,
compared with an average of more than 0.3 percent of GNP in Europe. The
oft-repeated excuse that ``aid does not work'' is a cruel abnegation of
U.S. responsibility. We must stop talking about ``aid'' in generic
terms, and start discussing targeted financial support for specific
health interventions--such as prevention and treatment of AIDS,
increased coverage of immunizations, wider dissemination of antimalaria
bednets, and the like. History demonstrates that such targeted
interventions have a high success rate. From the expanded program on
immunization (EPI); to the campaigns against smallpox, polio, African
river blindness, and trauchoma; to the spread of oral rehydration
therapy; directly observed therapy short-course (DOTS) for
tuberculosis, and insecticide-impregnated bednets, foreign assistance
for health has worked well. Unfortunately, the level of aid has always
been tragically meager compared with the level of need.
---------------------------------------------------------------------------
\2\ Chart 1 appears at end of statement.
---------------------------------------------------------------------------
DONOR SUPPORT FOR ANTI-RETROVIRAL THERAPY IN POOR COUNTRIES
Life-saving antiretroviral combination therapies have been
available since the mid-1990s. Yet given the low levels of donor
assistance, the stunning fact is that not one person in the developing
world--out of the more than 60 million who have been infected by the
HIV virus since 1981--has received such drugs through official donor
support from the U.S. or any other country or multilateral institution.
Let me repeat that, Senators. Not one person in the developing world
has yet received donor-supported antiretroviral therapy! The U.S. and
other leading donors have so far turned their backs on millions of
dying people. This dreadful fact is supposed to change, finally this
year, when the Global Fund and USAID both begin to support the
introduction of antiretroviral therapy. Yet the donor sums so far
committed in 2002 will permit only a very small scaling up of treatment
relative to the enormous needs.
For many years it was casually supposed that antiretroviral
treatment was too expensive for low-income countries. Drug regimens
cost $10,000 or more per year in the United States. But it has come to
be understood that the prices of antiretrovirals in the $300-$750
dollars per regimen per year, depending on the precise combination of
medicines. The high margin of the price over marginal production cost
reflects the returns on research and development, a margin that is
properly protected by patent rights. Yet, the lower production costs
make it possible to provide the low-income world with the drugs at the
actual marginal cost of production, close to $1 per day for the least
expensive combinations. The leading pharmaceutical companies, and high-
quality generic producers that have access to the African market (which
has little patent coverage for most of the relevant drugs) have shown
their readiness to provide drugs at the much reduced prices. Still, the
impoverished countries in Africa require donor assistance even to cover
the costs of $1 per day for the drugs (and perhaps another $1 per day
on average for the accompanying testing and medical care).
A high-end estimate is that anti-retroviral treatment will require
around $1,000 per patient per year in low-income settings, including
the costs of drugs, testing, and medical care. This can probably be
reduced to around $500 per patient per year with further reductions in
drug prices, and optimized regimens regarding testing and medical care.
Of the 25 million Africans currently infected with HIV, perhaps 4 to 5
million would qualify for highly active antiretroviral therapy on
clinical grounds. Of these, it is estimated that perhaps 25,000-50,000
are currently receiving the medicines, while the rest are dying. Even
those receiving the medicines are often on sub-optimal regimens, with
interruptions of drug availability, inadequate drug combinations, and
poor monitoring.
UNAIDS, WHO, and other expert groups that have looked closely at
this believe that 5 million people in low-income settings, mainly in
Africa, could be on successful antiretroviral therapy within 5 years.
Indeed, the numbers could be even higher is scaling up is given
adequate support. That would suggest a total cost of around $5 billion
per year for antiretroviral treatment by FY07, plus the costs of
prevention programs and treatment for opportunistic infections, thereby
arriving at the cost estimate of $9-$12 billion of donor support by
FY07.
THE GLOBAL AIDS PANDEMIC AND U.S. SECURITY
Let me briefly address the highly adverse foreign policy
implications of the AIDS epidemic for the United States, and then
discuss the importance of scaling up treatment, including anti-
retroviral therapy, to control the epidemic.
AIDS is destroying the prospects for African economic development and
democracy
The greatest hope for democracy and economic progress in Africa
remain our friends such as South Africa, Nigeria, Botswana, Ghana,
Mozambique, Malawi, and Tanzania. These nations, among many others in
the region, are being ravaged by AIDS. Foreign investment has been
seriously impeded as investors avoid countries where a significant
proportion of the labor force is likely to be HIV-infected. The labor
force, including the most highly productive age groups, is being wiped
out. Sub-Saharan Africa now has 25 million HIV-infected individuals,
roughly 9 percent of the adult population between the ages 15 and 44.
More than two million Africans are dying of AIDS each year. In Southern
and Eastern Africa, the prevalence is well above 10 percent, and in
hard hit countries, 25 percent or more. AIDS has become a dire and
fundamental impediment to economic progress in Africa and leaves an
even more troubling legacy: tens of millions of orphaned children.
AIDS is creating a demographic catastrophe, with profound security
risks
AIDS has already left behind more than 12 million orphans, and
epidemiological estimates suggest that the number could rise to 40
million by the end of the decade unless the pandemic is staunched. As
America lets millions of Africans die for want of $1 per day in
medicines, millions more children are left orphaned. Common sense and
repeated studies have shown that these children are at great risk of
hunger, neglect, withdrawal from schooling, crime and violence.
AIDS is creating a breeding ground for terrorism
Disease is repeatedly found to be one of the most powerful
predictors of state collapse and internal violence. The CIA Task Force
on State Failure identifies high infant mortality rates as one of the
three most powerful predictors of subsequent state failure (in addition
to lack of democracy and lack of open economy). Furthermore, AIDS is
decimating adult populations and increasing the percentage of
populations which are aged between 15 and 24. Research has determined
that such demographic shifts are a major predictor for the outbreak of
conflict.
AIDS is fomenting a social and political backlash against the United
States
Throughout Africa and the developing world, people believe that
they have been left to die by America. They are aware that life-saving
drugs exist to save them, but that those drugs are not being made
available. Conspiracy theories abound in Africa that AIDS is a
deliberate policy of genocide by the United States, or an accident of
the CIA gone awry. These desperate flights of fancy aside, our actions
to date point to one conclusion: America judges African lives to be
worth less than $1 or $2 per day.
AIDS is threatening China and India and other parts of the world
What has come to Africa will soon be true in the populous centers
of Asia, including India and China, where the epidemic is still in its
early stages. The destabilization that could arise from full-fledged
epidemics in those countries is harrowing. We must not ignore the
central truth about epidemics: they are far less costly to control at
an early stage.
AIDS originated in Africa, probably West Africa, sometime around
1930 according to the best current estimates. It went undetected for
decades, in part because of the remarkably poor state of public health
surveillance in Africa, and was only identified as a new disease in
1981 after it had spread to the United States. In this sense, AIDS is
precisely the kind of threat of cross-border transmission of infectious
diseases that public health officials have warned us about for decades.
Our neglect of burgeoning infections abroad--whether from AIDS, or
tuberculosis, or other new and rapidly evolving viral and bacterial
conditions--poses stark risks to American public health. The day has
already arrived when any one of us could, during a flight or in a
theater, be infected with multi-drug resistant tuberculosis, the
treatment of which involves two years of chemotherapy. AIDS is also
evolving rapidly, and there are reasons to suspect that some viral
subtypes may be more transmissible and virulent than others. New forms
of the disease in Africa or elsewhere, especially if uncontrolled, will
readily jump to the United States with dire consequences. Thus, we must
act decisively not only because it will save lives abroad; it will save
lives here at home as well.
DESIGNING A CONTROL STRATEGY THAT CAN MEET THE CHALLENGE OF A GLOBAL
PANDEMIC
AIDS requires a comprehensive strategy, including both prevention and
treatment
The most pernicious myth of donor policy has been that prevention
alone, without treatment, will control the epidemic. This view is
brutally shortsighted and fundamentally flawed. Both prevention and
treatment are necessary. In the Report of the Commission on
Macroeconomics and Health, we concluded that total spending on AIDS
should fall into three roughly equal categories: prevention programs;
treatment of opportunistic infections; and antiretroviral therapy.
Anti-retroviral therapy is necessary for two basic reasons. First,
we cannot afford to allow millions of working-age Africans--mothers and
fathers and core members of the labor force--to die for lack of $1-$2
per day in medicines and treatment costs, given the enormous resulting
losses in economic development, the millions of orphans that would be
left behind, and the resulting threats of violence, political
destabilization, and social upheaval. It is just dreadful economic
miscalculation to believe that it is ``cost effective'' to stand by and
allow a generation to die for lack of $500-$1000 per patient per year
for medicines and ancillary care.
Second, treatment is vital for successful prevention. In the United
States, the Centers for Disease Control terms antiretroviral treatment
a form of ``secondary prevention.'' The availability of treatment
encourages people to get tested for HIV infection, and then to receive
counseling if they are infected. Yet in Africa, where testing is not
now followed by treatment, individuals rarely seek testing and
counseling.
The benefits of treatment for prevention go well beyond encouraging
counseling and testing. Stigma is reduced when the disease is known to
be treatable, and the disease can be addressed in much more direct and
sensible manner. Irrational and often highly destructive social
interpretations of the disease (e.g. that it is a form of witchcraft,
or a CIA form of bioterrorism, or that it can be cured by having sex
with a virgin) are diminished as soon as successful medical
interventions are demonstrated. Politicians stop hiding from the
epidemic when they can offer hope to their populations. Medical staffs,
currently unable to save their dying patients for want of medicines,
are re-energized to fight the epidemic.
Treatment is feasible at a greatly enlarged scale
Physicians experienced in Africa know that treatment can be
successfully scaled up dramatically. Many doctors in Africa and other
resource-poor settings are already successfully treating patients, but
only the small proportion who are able to purchase the drugs out of
pocket. With concerted financial support, training to African medical
personnel could be expanded dramatically; testing facilities could be
expanded or created; and new protocols could be elaborated to ensure a
reliable flow of drugs and high patient adherence to drug regimens. WHO
and UNAIDS estimate that at least 5 million patients in low-income
settings could be on anti-retroviral therapy by the end of 2006.
The Global Fund is the best single investment for the United States in
AIDS control
The Global Fund to Fight AIDS, Tuberculosis, and Malaria is an
important new weapon in the fight against AIDS. The Fund was formally
launched in January 2002, and will receive the first round of proposals
by March 10, 2002. Initial funding is likely to begin by late April.
The Global Fund has several key strengths.
(1) The Fund will be the key source of multilateral grant
financing for AIDS control in low-income countries, especially
since the World Bank is still hamstrung in making loans rather
than grants for AIDS control efforts in low-income countries;
(2) The Fund effectively pools donor resources, so that
countries can create a comprehensive strategy and apply to one
single source of financing, rather than to twenty or more
distinctive and often contradictory assistance programs
supported by individual bilateral donors;
(3) The Fund leverages U.S. funding by encouraging donor
support from Europe, Japan, and other high-income countries.
The initial U.S. contribution of $250 million for FY02 has now
been matched by at least $1.5 billion from other donors.
(4) The Fund offers Congress and the international community
a transparent mechanism for monitoring the flow of funding
proposals and funding decisions, thereby helping to ensure that
donor funds are disbursed in a sensible and evidence-based
manner. One of the strongest features of the Global Fund is
that proposals will be vetted by an independent expert review
committee;
(5) The Fund is already spurring initiative at the grass
roots (including local nongovernmental organizations), as well
as increased collaboration between governments and civil
society;
(6) The Fund will enable selectivity in the choice of
programs and countries that will be funded, so that funds can
be held back from corrupt governments and inappropriate
programs;
(7) The Fund will enable improved monitoring and auditing of
the actual use of donor funds.
The Research Effort to Find a Vaccine and Improved Medicines Should be
Intensified
The U.S., through the National Institutes of Health, is already the
world's leader in basic research in AIDS. This leadership should be
maintained and enhanced, with increased research contributions from
other donors as well. Recent advances in vaccine research suggest that
an effective vaccine may be available within a decade, if not sooner.
There will need to be considerable coordination across countries in the
basic research, product development, and clinical testing, to speed the
process. The International AIDS Vaccine Initiative, among others, has
already made important strides in this area, and work by IAVI and
others should be supported by the U.S. Government.
immediate steps
Budgetaty outlays of $2.5 billion FY03
The Congress and Administration should support a U.S. contribution
to AIDS control of at least $2.5 billion in FY03, of which the Global
Fund should receive at least $2 billion, compared with the
Administration's request of $200 million.
Supplemental budget in FY02
Congress and the Administration should be prepared to make a
supplemental appropriation for the Fund during FY02 of $750 million,
raising the FY02 U.S. contribution to $1 billion.
Bi-partisan Congressional Mission to Africa during this Spring
Given the urgency of the global AIDS pandemic, and the role that
the U.S. must play to overcome it, it is critical for Congressional
leaders and staff to understand the crisis on a first-hand basis. Much
of what is reported, especially the alleged obstacles of effective
treatment in the African context, does not reflect on-the-ground
reality. Moreover, the sheer scale of the crisis is difficult to fathom
without a first-hand view.
For this reason, I strongly urge that the Congressional leadership
appoint a bipartisan mission to travel to Africa and to report back to
the Congress this Spring. The claims and counter-claims can then be
evaluated directly, and the shocking enormity of the crisis will better
be brought to the American people through their Representatives in
Congress.
The Opportunity
The United States has missed an enormous opportunity during the
past two decades to establish global leadership in quelling the AIDS
epidemic. It's been an opportunity to not only save lives and make a
contribution to the global economy; it's been an opportunity to promote
enormous good will towards our nation, to shore up democracy and
economic growth, and to lessen the threats posed by destabilized
states.
I come today bearing one message: today is not too late to act.
While millions have died and instability has grown, we can still avert
the worst. Senators, in our lifetimes our children and grandchildren
will ask us what our country did during the worst epidemic to strike
humankind. With your leadership, I hope that we shall be able to offer
a response that makes us all proud to be Americans.
TABLE 1.--Estimated Budgetary Outlays and Needs for AIDS and All Disease Control
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Estimated Need by
FY1995-1999 FY2000 FY2001 FY2002 FY2003 FY2007
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U.S. AIDS Spending Domestically............................. $10 billion $10 billion $10 billion $11 billion $12 billion ....................
U.S. AIDS Spending in Poor Countries........................ $120 million $235 million $449 million $680 million $844 million ....................
U.S. AIDS Spending in Africa................................ $55 million $109 million (USAID) $145 million (USAID) $450 million (est.) $525 million (est.) ....................
+$25 m (est. CDC) +$75 m (est. CDC)
Estimated AIDS Needs from all Donors........................ .................... .................... .................... .................... $7-10 billion $9-12 billion
Estimated AIDS Needs from U.S............................... .................... .................... .................... .................... $2.5 billion $3.5 billion
U.S. Funding for all disease Control........................ .................... .................... .................... .................... $1 billion (USAID) ....................
+$350 m (est. other)
Estimated Needs for U.S. funding for all Disease Control.... .................... .................... .................... .................... $3-4 billion $7-8 billion
U.S. Contribution to Global Fund............................ .................... .................... .................... $250 million $200 million ....................
Estimated Need for U.S. Global Fund Contribution............ .................... .................... .................... $1 billion $2 billion $3 billion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Senator Feingold. Doctor, let me just say that that is some
of the most powerful and passionate and important testimony I
have ever heard on this subject. I will not soon forget it. I
would agree with you that this amount that the United States is
putting forward is not adequate, and that when the Secretary-
General talks about $7 billion to $10 billion, yes, that figure
is an annual figure, and this idea of counting up everything,
as you just pointed out, and saying we have done $500 million
really is a confusing way, and a rather handy way to point out
an amount of contribution that does not do the job, so thank
you for that.
We are coming to another bind with votes and so on, so I am
going to move on to Dr. Kim. The vote may start shortly, and I
may have to recess us again for a while, but we will return to
hear the other testimony and to have some questions.
STATEMENT OF DR. JIM YONG KIM, DIRECTOR, PROGRAM IN INFECTIOUS
DISEASE AND SOCIAL CHANGE, HARVARD MEDICAL SCHOOL, BOSTON, MA
Dr. Kim. Thank you for inviting me. The introduction
painted me as a multidrug-resistant TB person, but we also run
a project in Haiti in which we are providing antiretroviral
therapies in Central Haiti, one of if not the poorest region in
the entire Western Hemisphere, and what I want to talk to you
about is several things, but much of it has been covered. I was
asked to talk about the synergy of prevention treatment the
notion of antiviral drug-resistance and what we mean by
infrastructure.
I will reflect on those issues, but in terms of my own
personal experience over the last 15 years trying to deal with
not only AIDS and tuberculosis, but many of the other
afflictions that devastate the poor. I am a physician, but I am
also an anthropologist. I did the two degrees together, and I
am also an infectious disease and internal medicine physician
working in a hospital. We do all these things at Harvard
University, but our real work is in developing countries.
We work in the Central Plateau of Haiti, and we work in the
slums of Lima, primarily Lima, Peru, but also more recently
been working in the prisons of Siberia and also in the inner
city of Boston, and I think one message that I will start with
is that we are really in a different time now.
This is the time of AIDS. How we respond to this epidemic
will define certainly my generation of physicians, but it will
define us all as human beings. The traditional approach to
public health has been extraordinarily effective for what it
was designed to do. We felt that the most we could do in
developing countries was take a small amount of money and
divide it up as efficiently and as effectively as possible. We
are no longer living in that age. We need new paradigms in
public health.
Dr. David Heyman, who is the head of the communicable
diseases cluster at the WHO, recently said just that, a
population-based approach which tries to, quote-unquote, ``Keep
It Simple stupid (KISS),'' the classic KISS approach to public
health, is no longer adequate. We, in working in the slums of
Lima, stumbled upon an epidemic of multidrug resistant
tuberculosis [MDR-TB]. This is a form of tuberculosis that is
resistant to the two most powerful antituberculosis drugs. Once
you reach the stage of MDR-TB, the traditional approach does
not work any more. You have to use old, second-line drugs, that
are second-line drugs because no one uses them any more. There
have been no new drugs for tuberculosis in the last 30 years.
Despite the fact that it used to be the No. 1 killer among
infectious disease of adults. We use these drugs over a period
of 2 years. They have very toxic side-effects. We have to
manage the side-effects very aggressively. We did it using
community health workers, student nurses, and we trained some
of the local doctors. Right now, the entire program is being
run by local physicians, and we received a grant from the Bill
and Melinda Gates Foundation of $45 million to do precisely
what you asked about today, which is scale up a very
complicated invention to an entire nation.
We have had to quintuple the number of patients on
treatment, and we have had to train health workers, nurses and
physicians to manage very complicated treatment regimens and to
deal with the side effects. We do directly observed therapy
every day for 2 years. This is clearly the most complicated
intervention that has been undertaken on a national scale
anywhere in the world that we know of. Compared to MDR-TB
therapy antihigh retroviral therapy is easy. It is harder to
sustain, because we have to do it over a much longer period of
time.
In Haiti in 1998 through drug donations we started treating
our most ill patients with the triple combination
antiretroviral drugs. The way we did it was, we did directly
observed therapy for one of the two doses every day. In the
morning, the community health worker goes and gives the patient
their morning dose. Right now, the combination we are using is
one pill in the morning, and four pills in the evening. It is a
twice-a-day regimen, and then the family members supervise the
evening doses.
Every single patient has had a positive outcome. We did not
have access to CD4 testing when we started, so we did it based
on syndromic management, something Drs. Peterson and McCray
talked about a little bit earlier. The results so far, and we
have not even published it yet, but Dr. Bruce Walker of the
Harvard AIDS Institute graciously has been doing some testing
for us for free, of the first 50 patients we have tested we
have 84 percent full file suppression. There is some
resistance, but it is trivial. The resistance that has
developed will not limit our ability to treat any of the
remaining patients. All have had weight gain. We have only had
to change regimens on a few of the patients.
My colleague, Paul Farmer, who is our primary person in
Haiti, tells me that we cannot--we cannot extrapolate our
experiences in the United States to places like Haiti. He says,
the great irony of my life is that in the United States I beg
my patients to take their pills, but in Haiti, the patients beg
me to give them pills. It is a different phenomenon, doing this
in the developing world, where people at every socioeconomic
level are infected and affected.
Let me go on to the question of infrastructure. Often we
hear talk about infrastructure as if it were love or goodwill,
something to decry the lack of, but because we do not really
know exactly what it means, we do not have to define it. Well,
we have looked and we have built our programs on the back of
very minimal infrastructure.
In Peru, the DOT's, the local DOT's basic TB control
program, we had to train some new people. We had to train
specific physicians in the management of MDR-TB, but this was
quite frankly not rocket science in Haiti. The expansion of our
TB program to what we call our DOT, our directly observed
antiretroviral program, was a matter of taking our TB workers
and giving them 2 full days of training on the management of
antiretrovirals. We are still able to do that now. We have not
yet received money to scale up in Haiti, but we are very
hopeful that we will receive funding for that soon.
Infrastructure exists in so many different forms. Often
also we hear Africa spoken about as if it were a country. There
are enormous differences across Africa, and our organization
did a little study where we sent an e-mail out to organizations
that are concerning themselves with HIV. We found 38 that are
effectively involved in treating patients. We also have had
requests through Professor Sachs from corporations, from
churches, from community-based groups for help in translating
some of our tools and our methods to other places in Africa.
Infrastructure exists in so many different forms, for
example, companies are ready to treat the pharmaceutical
industry as setup programs you have already heard about that
provide a very nice infrastructure, community based
organizations, there are public-private partnerships,
tuberculosis and immunizations programs, all of these are ready
to scale up. We simply need the resources to do so.
As I said, this epidemic will define our generation. To
reflect a little bit on the notion of the Black Plague, what is
happening right now is that we have therapy that we can
provide, and we are not providing it. This is not like the
Black Plague. We do not have answers. This is not going to be
easy. We need to start immediately, though, to figure out in
each place, in each local area how to implement these programs,
and the only way to do that is with massive new funding.
I would like to talk to you briefly about one idea that we
have been tossing around. There are many examples of how access
to treatment have been leveraged to achieve other public health
goals. The global drug facility for tuberculosis drugs, the
Green Light Committee for second-line TB drugs, which I was
involved in. Each of these programs have utilized access to
treatment as a way of pushing forward other public health
goals. In other words, what I would argue is that massive
infusions for treatment can accelerate prevention very rapidly.
We heard this story. Ninety percent of the people in Africa
know how the virus is transmitted. Less than 10 percent use
condoms on a regular basis, so it is not a matter of education
and condoms. The one thing that can change behavior more than
anything else is knowing your serostatus, and that we can do
with VCT.
What brings people to VCT? It is treatment. Back in 1990,
when I was caring for my patients with HIV in a hospital, it
was very difficult to get them to get tested. Of course, there
was really very little we had to offer them. In Haiti, in
Brazil, in Botswana, in every situation where you look in which
treatment is offered, the voluntary counseling and testing
centers are swamped. This is the way, if you do not want to
think about it as a treatment program, think about it as a
prevention acceleration program. We need to do both of those
things absolutely immediately.
Thank you very much.
[The prepared statement of Dr. Kim follows:]
Prepared Statement of Jim Yong Kim, M.D., Ph.D, Director, Program in
Infectious Disease and Social Change, Harvard Medical School
INTRODUCTION
I would like to begin by thanking Senator Feingold for inviting me
to testify for such an important hearing. I applaud you for taking so
seriously the problem of AIDS in Africa.
In 1348 Europe was devastated by the first attack of Yersinia
pestis or Black Death. For almost 300 years plague terrorized
communities with profound consequences for the social and economic
organization of Europe. Doctors could offer nothing for those infected,
and perhaps as many as 40 million perished. At the time, city officials
would resort to burning masses of people alive, a method considered a
rational public health strategy, to protect their cities from the
epidemic. Other defensive measures taken in the fourteenth and
fifteenth centuries to prevent the rapid spread of bubonic plague
included banishing those in society who followed irregular life-styles
seen as offensive to God, partaking in public processions to appease
angry deities, and awaiting a realignment of the planets. Wealthy
people of the time sought to avoid the plague by running away from it
``by fleeing early, fleeing far, and returning late.'' \1\ Despite all
these efforts, recurrent waves of bubonic plague ravaged Europe and the
Middle East for centuries.\2\
AIDS has already claimed the lives of 26 million people and 40
million others are infected. Unless drastic measures are taken, AIDS
will become a catastrophic epidemic on the scale of the Black Death.
Yet comparisons to historical epidemics like the plague do not capture
the true tragedy of AIDS. Health officials 600 years ago did not know
how plague was transmitted, much less have a access to a series of
interventions to mitigate its effects. In the 14th century, health
officials were unable to implement successful measures to end the
plague because they lacked knowledge. Today, we have the knowledge, the
medical tools, and the means to change the course of the AIDS pandemic.
What we lack is the conviction and determination to adopt courageous
new measures and rally the resources to implement them. However, unless
we adopt these new measures without delay, AIDS will soon become the
worst public health catastrophe of all time. If we fail to act, the
next decades of the AIDS pandemic will not be examined by future
historians as a tragedy of ignorance so much as one of cold
indifference to its victims, over 90 percent of whom live in resource
poor settings, most notably in sub-Saharan Africa. While we are not
burning people alive as our predecessors did during the Black Death, we
are standing by as over 17,000 people become infected and 8,000 people
die every day of a miserable disease we have the tools to prevent and
treat.
Even as recently as two years ago, we did not possess the means to
control the pandemic--the medications were too costly and there was no
way to responsibly administer therapy and coordinate prevention. Now,
we have the knowledge to proceed. We understand, for example, the
promises and limitations of prevention programs based on behavioral
change and risk reduction. And we have learned that prevention efforts
alone have not altered the course of the epidemic, especially in many
high HIV-prevalence areas. But, as of 1996, we have new triple
combination therapies that when integrated into comprehensive AIDS
control programs have the potential to reduce dramatically AIDS
morbidity and mortality--as these medicines have done in the United
States and Europe. Prior to May 2000, one of the chief obstacles to the
widespread distribution and use of these treatments was their
exorbitant price. But in the last two years, the cost of the
antiretroviral drugs has fallen over 95 percent. Regimens that once
cost in excess of $10,000 are now available for less than $400
annually. Moreover, new drug regimens to fight AIDS are far simpler to
take--requiring only two or three pills two or three times daily--and
come with fewer side effects than previous combination therapies. Other
obstacles preventing resource poor areas from adopting comprehensive
AIDS control programs are rapidly being overcome. This testimony
provides a scientific review of the evidence supporting the case for
intensified efforts and greater funding for AIDS prevention, care, and,
importantly, treatment in sub-Saharan Africa.
institutional profile 15 years of providing healthcare for the poor
Partners In Health is a non-profit charity dedicated to providing
high quality medical care for people living in poverty. Since its
foundation in 1987, PIH has worked with resource poor communities
ranging from inner city Boston to rural Haiti, tackling diseases such
as multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS. Each
intervention is based on an assessment of the disease burden of the
community, a process that focuses on creating partnerships and
fostering the full participation of the local community. In our 15
years of experience working in conditions of severe deprivation PIH has
developed practical experience in implementing complex health
interventions in poor settings. We have learned that the diseases that
are devastating many populations, often in the most poverty stricken
areas of the world, are no longer treatable by simple methods and quick
solutions. Treatments involve more than the provision of drugs; they
necessitate the creation of infrastructure and human capacity.
Since 1996 PIH has been working with community based organizations
in Lima, Peru to provide treatment for multidrug-resistant
tuberculosis. The program serves patients living in squatter
settlements built into barren rocky hills surrounding the City of Lima.
Treatment requires the use of weaker medications with serious side
effects for up to two years. A single course of therapy cost over
$15,000 when the program began. When we announced our intention to
treat MDR-TB, the global TB community said it could not be done.
Critics maintained that the infrastructure didn't exist, the drugs were
too expensive, the clinical work too complex and the medicines too
toxic. Nonetheless, PIH began treatment using nurses, students, and
community health workers to provide directly observed therapy.
International collaborations provided laboratory support, and dedicated
staff developed algorithms that since then have been expanded to a
national level. The treatment results from the first cohort of patients
were very good; 85% successfully cured--a rate rarely achieved in the
developed world. We paid for the medications through the generosity of
individual donors at first, but once the program proved that MDR-TB
could be treated in poor settings the WHO established a mechanism for
pooled drug procurement that slashed prices by as much as 97%. Today,
11 national TB programs have accessed these drugs and more applications
are pending.
MDR-TB treatment is a very difficult and complicated intervention.
In our experience, antiretroviral therapy, by comparison, is
significantly less challenging to implement, but potentially more
difficult to sustain. HIV treatment must continue indefinitely, while
MDR-TB typically involves 18-24 months of therapy for each patient In
1998 we translated our experience with MDR-TB to a rural community in
Haiti and began one of the first ARV therapy programs in developing
countries. Unable to offer the technologically advanced viral load
assays and CD4 cell counts that are the hallmark of ARV programs in
developed nations, physicians relied on clinical presentation to treat
patients. To create an atmosphere of support and care, PIH used
directly observed therapy to administer medications. Our regimens
involve taking pills twice a day and the community health worker
directly observes the morning dose while providing social support and
monitoring adherence and side effects.
Haiti has a per capita gross domestic product below that of many
sub-Saharan African nations. Access to our clinic, only 60 miles from
an international airport, involves a four-hour car trip over roads
four-wheel drive vehicles can barely navigate. The public health
infrastructure is deplorable, with the nearest hospital almost one and
half hours away; there is no sanitation and only partial access to safe
water. Therapy for a single patient cost $10,000 per year when we
began, but PIH firmly believed that drug costs would fall and support
would blossom if proof emerged that ARV therapy is possible in settings
of poverty. After three years of treatment PIH was able to transport
biological samples to the Harvard AIDS Institute to analyze viral
loads, CD4 cell counts, and check for resistance. The results were
spectacular, with 84% of the first cohort achieving viral suppression.
Resistance was found in only three patients, and none of the mutations
were a threat to the efficacy of treatment. But the effects of our
program extended much beyond the patients treated. Rates of voluntary
testing and counseling sky rocketed, and prevention efforts expanded
significantly. People began to search out information about the disease
because they wanted to protect themselves and their families.
Treatment, even for such a small cohort, brought hope and inspiration
to the region and people saw the disease in a new light. Throughout the
world communities like ours are desperately seeking medications that we
know the international community can safely deliver. All that remains
is marshaling the political will and funding to expand pilot efforts
like our own.
1. THE SYNERGY OF PREVENTION AND TREATMENT
Most AIDS specialists now dismiss old debates suggesting that
resources should be devoted to prevention efforts rather than to the
provision of treatment. Public health and medical professionals now
appreciate that AIDS prevention measures are enhanced and rendered far
more effective when AIDS treatment is made available--even in poor
regions of the world. Lamenting the old polemics of the debate between
prevention and treatment, Peter Piot, the Director of UNAIDS reported
recently:
In the South, the slogan ``prevention is the only cure''
began to sound like the hypocritical justification of a morally
bankrupt global divide. Inadequate access to the treatments
that have transformed AIDS in rich countries is tantamount to
robbing poor ones both of a powerful weapon against the
epidemic, and of hope in collective action.\3\
Scientific analyses support the growing consensus that AIDS
prevention and treatment strategies work best when linked and
integrated into a comprehensive AIDS program. Such analyses are
typically organized under four distinct themes (see table 1), which we
will address in turn.
Table 1.--Treatment and Prevention are both essential to an AIDS
control Program
Prevention alone is insufficient to control HIV in highly
impacted areas.
Treatment enhances the effectiveness of voluntary counseling
and testing (VCT).
Treatment reduces viral load, which reduces
transmissibility.
Treatment prevents maternal to child transmission of HIV.
1.1 Prevention Alone is Insufficient to Control HIV in High Prevalence
Areas
Epidemiological modeling confirms that once an epidemic becomes
generalized, effective prevention becomes more difficult. In other
words, prevention campaigns in regions with late stage HIV epidemics,
in which large numbers of the population are infected, may have a
minimal impact on lowering HIV incidence.\4\ Even dramatic increases in
condom usage may have little mitigating effect in high-risk areas
because those infected are now a reservoir of potential infections.
Of the 11 major randomized controlled trials examining the
effectiveness of HIV prevention interventions completed by 2001, none
had successfully demonstrated an impact on HIV incidence.\5\ This is
not to say that prevention is ineffective, but rather to emphasize that
the most dramatic benefits occur in populations with low disease
prevalence. Moreover, prevention efforts are most successful when they
are tailored to the specific needs of a population; when they account
for the population's baseline HIV and STI prevalence, interactions
between high-risk groups and the general population, urban/rural
population patterns, socioeconomic variables, and sociocultural
dynamics between genders and generations. Implementing ongoing and
effective prevention programs that account for these variables is
challenging and absolutely necessary but, unfortunately, they are not
likely to turn the tide of the epidemic without other interventions
like treatment.
Even the most successful prevention campaigns to date in high
prevalence countries have had mixed results. The Ugandan national AIDS
program, initiated in 1986, successfully decreased prevalence from 18%
in 1995 to 8% in 2000.\6\ Uganda achieved success through broad, multi-
sectoral approaches and political commitment. Local districts had
autonomy in implementation and used coalitions among non-traditional
social structures to help mobilize mass awareness.\7\ The treatment of
sexually transmitted infections and targeted interventions in high-risk
populations, were combined with ongoing AIDS education and support.
Yet, even the dramatic gains of the Ugandan program cannot erase the
fact that 8% of the population is still fatally infected with HIV--a
rate that has remained constant for two years, suggesting that the
limits of prevention may have been reached. Uganda continues to be a
pioneer in AIDS control. In response to the reality of sustained HIV
infections in the country, the government has instituted one of the
first antiretroviral (ARV) treatment programs in sub-Saharan Africa.
Even so, less than 10,000 patients are enrolled, a mere fraction of
those in need.
1.2 Treatment Enhances Prevention
In June 2001, government envoys of 189 States and Governments,
dignitaries from around the world, and representatives from a legion of
non-governmental organizations and special interest groups met in a
United Nations General Assembly Special Session devoted to developing
new strategies to control the global AIDS pandemic. In their
resolution, adopted by the General Assembly, representatives recognized
that:
Care, support, and treatment can contribute to effective
prevention through an increased acceptance of voluntary and
confidential counseling and testing, and by keeping people
living with HIV/AIDS and vulnerable groups in dose contact with
health-care systems and facilitating their access to
information, counseling and preventive supplies.
Current studies from several African countries report very high
knowledge about AIDS and basic understanding of how the disease is
transmitted. Some researchers estimate that 90% of African people today
know how AIDS is spread and that condoms can prevent transmission. And
yet barely 10% of the populations of most countries regularly uses
condoms. Moreover, approximately 95% of people in Africa are unaware of
their HIV status.\8\ Data from voluntary counseling and testing
programs throughout the continent suggest that knowledge of serostatus
is the most effective way to catalyze behavioral changes But what
incentive does one have to be tested, to learn of one's HIV status, if
those with the disease remain highly stigmatized and marginalized from
society? If one is tested and learns that they are indeed infected,
without treatment what hope do they have for their future? Based on our
experience treating AIDS in rural Haiti and those of similar programs
around the world, patients are much more likely to change their
behavior if they have hope. The availability of AIDS treatment
encourages individuals to step forward for voluntary AIDS counseling
and testing, because even if they test positive they have hope for a
long and productive life.
Scientists credit the availability of voluntary counseling and
testing to the overall success of the Ugandan AIDS program.\10\ The
efficacy of VCT in promoting risk reduction has been established
through randomized clinical trials,\11\ allowing those who know their
infection status to avoid infecting others, while individuals testing
negative can protect themselves.\12\ Testing allows pregnant women to
access antiretroviral prophylaxis to prevent maternal-to-child
transmission\13\ and counseling mitigates fears of dying and
abandonment through active support. It encourages high-risk populations
to learn risk reduction strategies and promotes decreased numbers of
sexual partners and increased condom usage in the general population.
In Zimbabwe, one study showed that work place prevention strategies
based on such counseling paradigms reduced HIV incidence by 30%.\14\
Without the promise of medical care and the possibility of
receiving life prolonging and improving drugs, individuals have little
incentive to be tested for HIV when the consequences of a positive test
are rejection and isolation. Evidence from Haiti reflects this. When
our clinic began to offer ARV treatment, the percentage of our patients
choosing to be tested and counseled increased dramatically. Similar
results are being reported from ARV programs in countries in
Africa.\15\
1.3 Treatment Reduces Viral Load, Which Lowers Transmission
Antiretroviral therapy reduces the viral load by preventing the
virus from reproducing in the body. Reduced viral loads have been
linked to decreased likelihood of transmission. This means that
patients on ARV therapy may be less likely to transmit the virus to
uninfected partners. An important study from Uganda followed over 400
couples, in which one partner was HIV positive and one partner was HIV
negative. The rate of transmission among this cohort was correlated
with viral load levels; the more virus a person has in their body the
more likely they are to transmit the disease.\16\ Commentators on this
study noted that the potential impact of this information on those
already infected could be significant The majority of disease
transmission occurs from a relatively small sub-set of the population,
and reducing their infectiousness could have dramatic results on
overall incidence in a population.\17\ We now know that reduced viral
load decreases transmission of the disease. ARV therapy reduces viral
load, therefore, treatment may reduce the spread of disease. It is
important to note that data from San Francisco suggests that once
perceived risk of transmission is reduced through providing treatment,
the level of high-risk activity in specific populations increased.\18\
This emphasizes the need to link treatment and prevention in a single,
comprehensive AIDS program.
1.4 Mother To Child Transmission (MTCT)
In sub-Saharan Africa, among the 26 million women who were
pregnant in 2001, more than 2.5 million carried HIV. Assuming a
rate of 20 percent for mother-to-child transmission of HIV, we
can foresee that more than 500,000 babies born to these mothers
will be infected. Many of these infants, as well as the luckier
80 percent who are not themselves infected at birth, are likely
to be motherless by the time they can walk.
--MTCT-Plus Program Brochure\19\
In 1994 zidovudine, or AZT, was reported to reduce the transmission
of HIV-1 from mother to child.\20\ Since that study, the average rate
of MTCT in the United States has fallen to just 3%. Since then new
drugs have resulted in efficacious therapies that require as little as
a single dose delivered to a mother during labor.\21\ These life saving
advances can prevent the spread of disease to a generation of unborn
children. Pilot projects for the delivery of MTCT exist throughout sub-
Saharan Africa, but to integrate prevention and treatment these sites
must be expanded.
It is important to remember that while short-term prophylactic
measures to prevent transmission are important, it is also essential to
promote the health and survival of the family unit through increased
access to effective HIV treatment. Few programs provide ARV therapy to
recent mothers, and without new drugs these women have little hope to
provide a stable future for their children. As a comprehensive global
AIDS strategy is developed, focus on the reduction of maternal viral
load will also decrease the high rate of adult transmission in the
community and prolong the disease-free survival and ongoing social
contributions of women of childbearing age.
1.5 The Peril of Prevention Alone
An AIDS control program that excludes treatment fails to account
for the perilous ramifications of a rapidly spreading fatal disease.
Without treatment, health professionals, educators, agriculturists,
political and business leaders living with AIDS will continue to perish
en masse. When infection rates reach levels in excess of 20-30%--as
they already have in many African countries--the future socioeconomic
viability and political stability of entire African nations are
threatened. Agricultural productivity in the hardest hit areas of
Africa, a major source of food and economic stability, is seriously
compromised due to sickness and death from the AIDS pandemic. The Food
and Agriculture Organization of the United Nations released a 1999
report emphasizing the dramatic consequences of the disease on rural
production.\22\ Due to deprivation and poverty associated with the loss
of parents, orphans are at higher risk for malnutrition, illness, and
illiteracy. Rather than becoming productive members of society they
often become a drain on already strained resources. Worse, desperation
can force children into prostitution and drug use, driving the epidemic
forward. The social consequences of 13 million orphans are already
profound. What will the continent look like when 40 million children
are orphaned, as UNAIDS predicts for Africa in the year 2010? The
manifestations of an AIDS control policy that ignores treatment are
difficult to quantify but horrific to imagine. Public policy that
refuses to recognize the necessity of providing ARV therapy not only
ignores scientific evidence linking prevention and treatment, but it
fails to grasp the long-term socioeconomic and geopolitical
consequences of 65 million people dying in a single generation.
2. ANTIRETROVIRAL DRUG RESISTANCE
2.1 Therapeutic Advances and Drug Resistance
The introduction of antiretroviral therapy can directly inhibit HIV
replication. However, the effectiveness of a single drug on the
clinical outcome of AIDS is limited. HIV can quickly generate
resistance to drug therapy because it is a virus that replicates very
quickly with lots of random mutations. A small number of these
mutations may result in new strains of the virus that are resistant to
one or more antiretroviral drugs. When a patient is prescribed ARV
therapy using only one or two drugs (mono- and dual-therapy), the virus
is capable of randomly developing resistance thus rendering that
specific treatment ineffective. However, if a patient is taking
multiple medications aimed to attack the virus at different stages of
its lifecycle (the so called AIDS ``cocktail''), then a virus resistant
to one type of antiretroviral is destroyed by another. This has led to
new therapeutic strategies in which at least three drugs are prescribed
simultaneously. The presence of a third antiretroviral drug
dramatically reduces the likelihood of resistance. Although ARV therapy
today is very successful at lowering AIDS related morbidity and
mortality in developed countries, it is by no means a simple solution
to the AIDS pandemic. Fortunately, there are ways of preventing
antiretroviral drug resistance.
Table 2.--Preventing Antiretroviral Drug Resistance
Simplified pill counts facilitate adherence.
New drugs have better side effect profiles.
Improved drug regimens helps to prevent resistance.
Clinical management strategies such as Directly Observed
Therapy and peer support groups create supportive environments
that encourage patient drug adherence.
Stable drug supply and procurement reduce supply
interruptions.
The successful administration of ARV therapy requires that patients
have uninterrupted access to medications and ongoing social support to
ensure that doses are not missed. Patients' nonadherence, or failure to
take drugs precisely as prescribed, must be avoided to limit the
development of resistance. The negative consequences of drug resistance
include medication failure, spread of resistant disease to others,
disease progression and death. A decrease in adherence by as little as
10 percent has been associated with a doubling of viral load, the most
important indicator of treatment effectiveness.\23\ Further, even with
strong adherence to medications, a significant long-term risk of
developing resistance remains. Slight variations in dosing provide the
virus with a window of opportunity to mutate into a resistant strain.
Moreover, successful long-term viral suppression requires that patients
adhere extremely closely to their drug therapies.\24\
2.2 Strategies to Control Resistance
The lessons learned from the first stages of drug development and
treatment hold the key to preventing new forms of resistance in future
populations. Early clinical trials using mono- and dual-therapy led to
the development of resistance in the United States and Europe when no
alternative therapies existed. Consequently, many American and European
populations now have high levels of drug resistance, which complicates
therapy and threatens the viability of clinical care. Emphasizing the
rational use of drugs can reduce prescriptions of inadequate regimens
and encourage powerful drug combinations capable of suppressing
antiretroviral drug resistance.
New generations of less toxic medications help patients adhere to
their drug regimens by reducing side effects and pill count. Just a few
years ago many people living with AIDS in the United States were
prescribed as many as 33 pills, to be taken in several intervals,
throughout the day. Other regimens required 14 pills, three times a
day. Today, one of the most common drug regimens is quite simple.
Patients take a total of one tablet in the morning and four tablets at
night.\25\ An important AIDS drug, efavirenz, was approved last summer
in a once daily formulation.\26\ New combination tablets combining more
than one agent in a single pill, such as Combivir (two drugs) and
Trizivir (three drugs), along with blister packs that contain each of
the pills required in a day, greatly simplify and facilitate therapy
adherence. Such strategies have also proven successful in malaria and
TB treatment programs.\27\ In Africa, where exposure to one and two
drug combinations is historically extremely low, initiating treatment
programs with triple therapy could improve long-term prospects of
minimizing drug resistance.
To take their medications properly over long periods, most patients
need supportive environments and individualized attention from
caregivers. The success of ARV therapy in controlled environments such
as the penal system,\28\ where patient adherence is easy to monitor and
enforce, has lead to innovative strategies such as directly observed
therapy (DOT). This allows for precise monitoring of adherence and side
effects, but more importantly creates an environment of support and
trust to accompany therapy. An inner-city clinic in the United States
recently used DOT to successfully administer ARVs to patients in a
community with routinely poor adherence patterns.\29\ Other adherence
interventions and strategies that have proven successful indude
interpersonal support such as peer counseling, medication adherence
counselors, support groups, and home visits.
In resource poor settings, DOT offers clinicians a cost effective
mechanism to begin therapy--even when patients reside far from health
centers. Our experience using this strategy to deliver ARVs to persons
living with AIDS in rural Haiti has been encouraging. Based on DOT by
community health workers, our program trains local residents to
personally administer the daily medications. These community health
workers serve to ensure compliance with prescribed medications and
provide social support for persons living with AIDS. The creation of a
stable environment not only allows for proper medical care, but also
creates community involvement and integration around HIV prevention and
care. DOT facilitates the provision of ARV therapy in settings of
extreme poverty while also preventing the emergence of drug resistance.
2.3 Antiretroviral Anarchy: An Impetus to Action
The unfettered distribution of commercially available ARVs has lead
to an explosion of diffuse and unmonitored treatment programs
throughout the developing world. Preliminary results from a study
conducted by Partners In Health in July 2001 found privately funded ARV
programs in operation in 38 low- to middle-income countries, most
located in sub-Saharan Africa. Without government assistance or
adequate medical oversight, these programs, often relying on
inconsistent drug supplies from donations of unused drugs by patients
in developed countries, will continue to use pharmaceuticals in an
environment void of control. An unregulated environment in which
prescribing practices, drug quality, and adherence rates are unknown
and unmonitored can potentially lead to the widespread development of
resistance.
Despite imaginary scenarios of massive drug resistance, we already
know that when programs are well administered and controlled treatment
can be delivered safely and responsibly. The preliminary assessment of
an ARV program affiliated with the University of Capetown, South
Africa, reveals that of 104 patients who completed 48 weeks of therapy
the mean adherence was 88.6%. Data such as these, combined with the
experience of PIH, suggest that the non-governmental sector can be a
valuable resource in HIV prevention and control. The challenge is to
ensure that they do so effectively, not haphazardly.
National AIDS treatment programs in sub-Saharan Africa have begun
the process of determining what is needed to provide quality care.
Uganda and Senegal have both initiated successful small-scale ARV
programs with encouraging results; in Senegal 87% of patients achieved
the target of 80% adherence.\30\ Even so, isolated programs without
global support face overwhelming obstacles. In Uganda only 58% of
patients enrolling in therapy were alive after 30 months.\31\ Cote
D'Ivoire, another nation providing ARV therapy, has also reported
difficulties. Less than 40% of those treated had viral suppression
after 1 year, according to UNAIDS,\32\ and 57% of patients tested in
Cote D'Ivoire had resistance to at least one anti-AIDS drug.\33\
These programs should be viewed as bold first steps in the public
provision of ARV therapy in Africa. Much can be learned from their
implementation. While some of these data suggest that poor compliance
and drug resistance complicate the introduction of therapy in resource
poor settings, they also indicate substantial success. Stable
distribution and financing can reduce drug supply interruptions and the
need to pay for medications that may have sewed as barriers to
adherence in countries like Senegal and Uganda. Clinical strategies
including directly observed therapy and heightened coordination with
extant disease control services, such as for tuberculosis, offer the
hope of integrated care capable of safely providing ARV medications. As
one CDC expert recently said: ``There is no moral victory when patients
die of drug sensitive disease.''\34\ We have the knowledge and the
tools to vastly scale up treatment efforts in Africa.
3. INFRASTRUCTURE CONSTRAINTS
3.1 What Is Needed?
Putting into operation comprehensive AIDS control programs that
effectively link prevention and treatment poses challenges. Physicians
need special training to administer ARVs and manage side effects;
health sectors require modem and well-stocked laboratories to monitor
patients' viral loads and immune status; drug distribution systems need
to be upgraded and safeguarded to ensure the prompt and consistent
delivery of supplies; and new mechanisms for drug adherence and
clinical effectiveness must be designed. It is not just a matter of
providing antiretroviral drugs, but also that they must be provided
within a structured framework. While daunting, these challenges are by
no means insurmountable. Effective collaboration between African
national governments, international organizations, businesses,
universities and NGOs can pave the way by expanding and improving
existing health infrastructures--leading not only to more effective
AIDS control, but also to a legacy of improved health for all Africans.
Our success in administering ARV therapy in the poorest region of
the most impoverished country in the Western Hemisphere, Haiti,
suggests that substantially less infrastructure may be needed than is
currently believed necessary.
Certainly large sections of the infrastructure necessary are
inadequate or lacking in sub-Saharan Africa. But infrastructure does
exist. A brief review of the state of infrastructure in sub-Saharan
Africa reveals many deficiencies, but also many public health promises.
To preclude treatment for 28.1 million Africans because they do not
have medical facilities as advanced as our own is unjust and unfair.
3.2 What Currently Exists?
I can be ``realistic'' and ``cynical'' with the best of
them--giving all the reasons why things are too hard to change.
We must dream a bit, not beyond the feasible but to the limits
of the feasible, so that we inspire.
--Jeffrey Sachs, Macroeconomics and Health: Inverting
in
Health for Economic Development
In sub-Saharan Africa, a region with an average annual per capita
health expenditure of $8, health systems are not yet able to provide
widespread comprehensive AIDS care. When compared to the health
infrastructures found in North America and Europe, the health sectors
of most African countries are severely deficient. African health care
systems do not compare favorably with those found in the world's
wealthiest countries but this does not mean that the entire continent
lacks the capacity to deliver high quality healthcare. Four times the
size of the United States, the continent is diverse in every
conceivable way, including its health systems. Many countries boast
modern, even state-of-the-art healthcare facilities, while others lack
the most rudimentary healthcare hardware.
In the intervening years since most African countries gained
independence in the early 1960s, dramatic gains were made across the
continent. Large modern hospitals were built, research institutes
established, community dispensary programs initiated, and vertical
disease control programs implemented and expanded. Access to sanitation
and clean water dramatically improved.\35\ An analysis of the 14 sub-
Saharan African nations most heavily impacted by HIV/AIDS reveals that
72% of children in these countries are vaccinated against measles every
year and over 80% of women receive some form of antenatal care.
Immunization coverage is often used as a proxy for the strength of
health delivery systems; high rates reflect a network of health
clinics, a complex management system capable of delivering vaccines
safely and effectively, trained staff, and reporting and accountability
measures.\36\ Even the poorest nations have well-established networks
of primary and secondary care facilities and virtually every country in
the world has an extant branch in place to expand childhood vaccination
coverage and to fight tuberculosis, leprosy and other communicable
diseases.\37\
Most public sector investments in Africa are concentrated on large
urban hospitals. These tertiary care facilities provide a substantial
array of services and are often affiliated with local medical schools
and international institutions. Even so, case studies of health systems
in many of the poorest nations suggest that while the components of
fully functioning health system are not in place, many resources do
exist. Traditional indicators of health infrastructure do not catalog
the extent of potential treatment resources. In addition to public
sector health services are systems of private providers, religious
hospitals, non-governmental organization programs, industrial clinics,
and international civil society volunteer groups, such as Rotary,
Lions, and Zonta. Each of these health service providers serves
communities connected through kinship and social networks that allow
for rapid mobilization of human resources (see table 3).
Table 3.--Non-traditional Infrastructure: Opportunities for scaling up.
Industrial and commercial clinics.
Pharmaceutical industry donation programs.
Community-based organizations.
Public-private partnerships, international collaborations.
Existing disease infrastructure.
The World Health Organization recently released ``Scaling Up,''
\38\ a report that describes a multitude of diverse, untapped sources
of infrastructure that provide clinicians potential platforms to launch
comprehensive AIDS control programs that include treatment. For
example, Zimbabwe has 1,080 health facilities providing outpatient
care, of which 72% are government sponsored. In regions where services
are not available, the Ministry of Health contracts with private
hospitals to provide health care. Such models enable rural inhabitants
and industrial workers access to care that was reserved previously only
for those who could afford private healthcare. They also demonstrate
the potential for public-private partnerships in the coordination of
healthcare services.
Industrial Infrastructure
Corporations throughout the continent are facing labor crises due
to the devastation caused by HIV/AIDS. As a result, several large
companies have begun providing AIDS prevention and treatment to their
workers. For example, Debswana, an African mining consortium and the
largest employer in Botswana, declared in May 2001 that it would pay
90% of the cost of AIDS care and treatment, including ARVs, for workers
and their families. A few car manufacturers and other mining companies
in southern Africa are beginning to follow suit. Coca Cola has
committed to using its vast distribution networks and social marketing
to increase AIDS awareness through prevention campaigns. Several public
utilities have also successfully launched AIDS prevention programs for
their workers.
Pharmaceutical Programs
Some research-based pharmaceutical companies have indicated a
willingness to donate drugs for treatment programs in poor communities.
Historical commitments such as Merck's Mectizan Program to fight river
blindness, and other recent initiatives in sub-Saharan Africa to treat
HIV, indicate promising corporate investments in global public health.
Secure the Future is a $100 million donation program initiated by
Bristol Myers and Squibb. Moreover, GlaxoSmithKline has now licensed
generic manufactures to produce their key ARVs in South Africa, and
Boehringer-Ingleheim has offered free ARVs to prevent mother-to-child
transmission.
Community Based Organizations
Community-based organizations, women's organizations, village
councils, youth groups, and professional trade unions are all important
components of sub-Saharan Africa's social structure. Kinship ties and
regional networks offer vast opportunities for the organizing community
outreach and training of local health workers and volunteers. In
Uganda, TASO is an organization of persons living with AIDS that has
been instrumental in coordinating the sustained government commitment
to fighting HIV in the country. DOTS programs in South Africa have
capitalized on the social organization of women to incorporate civic
groups in the administration and monitoring of tuberculosis
medications. Recent interventions initiated through trade unions have
brought condom promotion to mining camps.
Public-Private Partnerships, International Collaborations
Public private partnerships and institutional collaborations offer
new hope for future AIDS control efforts. The Netherlands, Australia,
and Thailand initiated a program entitled HIV-NAT to address the
burgeoning epidemic through operational research and antiretroviral
therapy in Southeast Asia. As a result of new capacity and expertise,
Thailand recently agreed to help Zimbabwe produce generic ARVs for
domestic use, and if successful intends to offer the service to other
African nations such as Ghana. Similary, directors of the Brazilian
National AIDS Program have hosted groups from southern African
countries to inspect aspects of their comprehensive, universally
available AIDS program. Latin American nations such as Guatemala, which
seeks to capitalize on the Brazilian experience, are being offered
technical assistance from the Brazilian Ministry of Health on drug
production and distribution. In addition, a coalition between an
African government, a pharmaceutical multinational corporation and a
private foundation--the government of Botswana, Merck, and the Bill &
Melinda Gates Foundation--is currently in the final stages of
introducing what will likely become Africa's first, universal HIV/AIDS
treatment program.
Existing Disease Infrastructure
Precedents exist throughout Africa for the successful introduction
of resource intensive health interventions. The STOP TB Initiative and
the Expanded Program for Immunizations (EPI) are two examples. Each of
these interventions, undertaken in almost every African nation, worked
with and built upon the limited local infrastructure, ultimately
creating new public health networks and resources. The STOP TB
initiative relied upon community health workers to implement DOTS,
covering over 50% of the African people.\39\ In the 1980s and 90s, the
EPI established networks of cold chains capable of delivering
environmentally sensitive vaccines, even to remote areas throughout
Africa. It also created immunization management and monitoring systems
to record use and coverage. Although immunization rates have fallen in
many parts of the developing world in recent years, a new, bolder
initiative to improve childhood immunization coverage, the Global
Alliance for Vaccines and Immunizations (GAVI) is providing new
mechanisms for rapid infusions of infrastructure and material support.
One of the cornerstones of effective prevention is the
administration of ARVs to pregnant mothers. Just a single dose of
Nevaripine, a potent new drug, can substantially reduce the likelihood
of mother-to-child transmission (MTCT) of HIV. Across the continent,
systems of clinics capable of providing counseling, testing, and
interventions are being put into place. This network has organized an
initiative called the MTCT Plus program. This will provide an estimated
$100 million to link prevention of MTCT to the treatment of the mother
with ARV therapy. Funding proposals for treatment at clinics already
providing services have already been received, and treatment should be
initiated by summer 2002.
3.3 What Can Be Done?
Innovative programs to address structural deficiencies in health
care are being implemented in several African countries. While current
health infrastructure remains inadequate in most regions, a substantial
foundation for future investments has been laid. A comprehensive review
of strategies addressing structural deficiencies by the Commission for
Macroeconomics and Health (CMH) identified proven interventions to
overcome infrastructure constraints.\40\ Limitations on program
capacity based on weak health systems can be addressed through modem
management techniques. The implementation of tuberculosis control
programs in Malawi and the revitalization of primary health care in
Tanzania are excellent examples of dramatic infrastructure improvement
in two of the poorest nations in sub-Saharan Africa. Many of the
interventions necessary for AIDS control do not require the extensive
facilities of modem hospitals, but can be effectively administered
through small clinics and dispensaries. The CMH study refers to these
as dose-to-client (CTC) systems and suggests that increasing the
capacity of these local clinics and dispensaries through stable
financing is well within the ability of an international effort.
Crucial to the success of such a program is the integration and
mobilization of broad public and private partnerships. Scaling up CTC
will require investments in health personnel, and improvements in
physical structures, transportation, and telecommunications. It will
also involve integration with national drug distribution and
warehousing. Although it may not be possible to rapidly create a system
that functions flawlessly, it is well within the ``absorption
capacity'' of developing nations to steadily increase their levels of
health investment.
Since gaining its independence in 1961, the country of Tanzania
began to aggressively improve health systems and services. Today, the
legacy of these investments is a pyramidical structure of healthcare
integrating village level dispensaries to district hospitals and
national tertiary care facilities. The government operates 86
hospitals, and non-governmental organizations, religious charities, and
the private sector contribute an additional 93 health facilities.
Throughout the country there are almost 5,000 health clinics and 90% of
the population lives within 10 km of a health facility.\41\ Through
this extensive healthcare network, 90% of pregnant women receive
antenatal care and 74% have a trained medical person with her at
delivery. These resources exist in a nation with a per capita
grossdomestic product of under $240.
The success of Tanzania's health reform was based on new
development strategies such as the Sector Wide Approach (SWAP) and
strong donor support. SWAP pools donor funding for development projects
into a centralized resource under the jurisdiction of the Ministry of
Health. The Ministry then has discretion to invest the funds in a
coordinated manor as they see fit The donor community remains involved
as consultants, however the principle responsibility for management and
accountability is transferred to the government. The aim of SWAP
programs is to eliminate fragmentation, duplication, and inefficiencies
in healthcare delivery. The Swiss government became actively involved
in supporting this initiative through a funding agreement secured in
bilateral negotiations.
Malawi is one of Africa's poorest countries, with a gross domestic
product of just $190 and an HIV seroprevalence rate of 16%. The
dramatic increase in HIV in the last decade triggered a corresponding
rise in TB rates throughout the country. The basic control mechanism
for tuberculosis is a protocol called directly observed therapy, short-
course (DOTS). This strategy is a clinical algorithm, endorsed by the
WHO, in which a trained health worker administers a standardized
regimen of drugs over a period of 6 months. Laboratory capacity,
patient drug adherence, resistance prevention, and infrastructure are
all necessary for a successful TB control program. In 1985 Malawi began
a partnership with the International Union against Tuberculosis and
Lung Disease (IUATLD) in order to effectively care for those infected.
Malawi has 43 hospitals and 45 laboratories. The TB program required
each of these facilities to increase human resource capacity and to
train staff in multidisciplinary fields. Approximately 35% of the
medical care provided in Malawi is run by non-governmental agencies and
partnerships between health facilities were needed to increase coverage
rates. Members of local family networks and businesses were enlisted to
serve as volunteer health workers. Operational research identified
innovative mechanisms to use social and civic resources for health
delivery, including a network of 50,000 traditional healers.\42\
Malawi and Tanzania are two of the most impoverished countries in
sub-Saharan Africa, and yet despite high prevalence of HIV each has
successfully addressed deficiencies in their healthcare systems and
found solutions to expand the scope and quality of care. Critical
shortages in resources may exist, but contrary to some critics, health
infrastructure exists and can be built upon in the coordination AIDS
programs.
The pandemic in Africa cannot be controlled without investments in
health and social services. Expert modeling of the epidemic suggests
that the disease is still in the middle stages of development.\43\
Without action, the continued spread of AIDS will further jeopardize
the health systems of sub-Saharan Africa. The strain of AIDS on local
services is already dramatic; AIDS not only increases morbidity in the
region and stresses already weak systems, it also takes a severe toll
among health workers themselves. New strategies of operational
research, global lending paradigms, collaborations and partnerships,
and coordination of diverse resources offer a basis from which
treatment can be introduced. Interventions would begin on a small scale
in communities with infrastructure in place. A strategy carefully
planned growth would allow these sites to expand coverage quickly,
leveraging their success to train new health workers and and increase
access to care and treatment.
4. AIDS PROGRAM FOR PREVENTION AND ACCESS TO CARE AND TREATMENT AIDS
PACT
The struggle to improve access to care in sub-Saharan Africa has
lead to the identification of infrastructure constraints, the threat of
resistance, and concerns over the long-term sustainability of both
treatment and prevention. Each of these barriers to care is real and
presents the international community with a serious challenge.
Significant logistical complexities are involved in connecting multiple
sources of pharmaceutical and other products with multiple needs and
varying capabilities of poor communities and individual patients on the
ground.
Yet, several programs in the past decade have shown that drugs and
vaccines can be successfully delivered to people in resource-poor
countries through innovative partnerships.\44\ The programs include: i)
the Mectizan Donation Program, which prevents blindness by providing
the drug, ivermectin, to 22 million people annually in Africa and Latin
America to treat river blindness (onchocerciasis); ii) the
International Trachoma Initiative, which provides the drug,
azithromycin, to treat trachoma and thereby prevent another major cause
of blindness; iii) the Global Alliance for Vaccines and Immunization
(GAVI), which currently provides vaccines and support for vaccine
programs to 36 countries; iv) the Green Light Committee (GLC) for
Tuberculosis, which provides specialized drugs for the treatment of
multidrug-resistant tuberculosis to many countries; and v) the Global
TB Drug Facility (GDF), which provides TB drugs to programs employing
Directly Observed Therapy, Short-course (DOTS) in 5 countries. Partners
in Health has recently been working with a small group of physicians,
health policy experts, social scientists and management consultants to
study these existing programs and develop a similar mechanism that will
link HIV treatment with prevention and assure a long-term sustainable
supply of low-cost, high-quality ARV's for resource-poor settings. We
have called this mechanism the AIDS PACT (Prevention and Access to Care
and Treatment).
I have had the privilege of being involved in the genesis of the
WHO's Green Light Committee, which was an initiative linking treatment
and prevention to control MDR-TB. In 1999, recognizing the potential
gravity of a drug-resistant airborne infectious disease such as MDR-TB,
the World Health Organization resolved to address the principle
obstacles to developing effective treatment programs in highly affected
areas. The WHO program faced constraints similar to those we are
currently encountering with HIV: inadequate infrastructure to implement
complex clinical regimens; the potential threat of developing further
drug resistance; and the cost and supply of medications.
To overcome these obstacles an organization now known as the Green
Light Committee (GLC) was formed. This body fulfills two key functions:
1) by pooling demand and creating a competitive market environment it
leveraged massive reductions in drug prices while assuring quality; and
2) by making access to preferentially priced drugs conditional upon
program requirements it ensured rational use and minimized drug
resistance. A scientific committee encourages and provides support for
the development of adequate program infrastructure and clinical
supervision throughout the application process. Government funding
proposals are reviewed in light of criteria associated with
international guidelines for MDR-TB management. All projects that are
approved are quality-assured through their duration, and monitored for
continued compliance.
The results have lead to minimum price reductions of 40% on single
drugs and discounts up to as much as 99% for others. Net drug costs for
some participating Ministries of Health have diminished over 96%. The
funds saved on procurement are then available for investment in other
aspects of tuberculosis control. The GLC faced a paradoxical challenge:
increase access to medicines by decreasing prices, and increase
regulatory control over these same drugs. Market consolidation achieved
the first goal, and program requirements enforced by a regulatory body
with technical assistance met the second.
The strength of this model derives from the ability of an
international oversight committee to apply rigorous conditions to
access for medications. Such controls minimize the opportunity for
resistance to develop by ensuring that the tuberculosis program
involved has appropriate algorithms for treatment. To impose controls
without technical assistance would ultimately restrict access, rather
than promote rational use of pharmaceuticals. Accordingly, any project
initially unable to qualify can ask for technical assistance to meet
eligibility requirements.
Table 4.--AIDS PACT
Pooled procurment of both branded and generic drugs combined
with strong quality control assures low prices, high quality
and a long-term sutainable supply.
Technical assistance through grant and loan mechanisms
ensure rational use of drugs and capacity building.
Linking treatment to prevention provides the best possible
chance for controlling the epidemic.
The management of MDR-TB treatment programs through the GLC offers
lessons for the challenge of delivering HIV/AIDS treatment to poor
communities worldwide. The current barriers to effective AIDS treatment
programs are analogous in many ways to the conditions of the MDR-TB
epidemic. Beyond parallel concerns of cost, objections center on the
problem of inadequate local infrastructure and management capacities.
Given infrastructure weakness, institutional inefficiency, and
corruption, it is argued that even if drugs for HIV were available at
no cost the ``systems to deliver them are not there.''\45\ This claim
reflects the real gaps in poor countries' health care delivery
apparatus. Yet, their existence is not an excuse for inertia and
resignation. Non-traditional infrastructure and institutional capacity
are present, and proven mechanisms for scaling up delivery exist.
An international pooled procurement program and scientific
regulatory body could prove helpful in providing a framework for the
rational introduction of therapy. Using economies of scale and quality
control mechanisms procurement agents can purchase AIDS drugs at
preferential prices. Drugs from this effort could be procured from both
the research based pharmaceutical industry and the generic drug
industry. Six major research based pharmaceutical organizations have
already engaged in reduced price access to ARVs for developing
countries through the Accelerating Access Initiative. Additionally,
there are at least 25 generic manufacturers engaged in some level of
ARV production. Finally, procurement must include testing kits and
laboratory reagents. Ten companies are involved in rapid HIV testing
systems, 3 companies in viral load systems, and at least 8 companies
providing CD4-cell count systems. Efforts to procure these resources in
a manner that will lead to a long-term supply of high-quality, low-cost
drugs have been discussed in various fora but to date no unified and
coordinated system has been built.
Applicant programs would need to demonstrate the ability to meet
requirements based on international guidelines established through a
panel that included medical and public health specialists but also
people living with HIV and representative of treatment advocacy groups.
Programs that express need but do not have the infrastructure can be
supported through technical assistance, grants, and loans. Most
importantly, access to antiretroviral therapy will be tied to high-
level national commitment to prevention, care and impact-mitigation
efforts. Through a mutually supportive process national AIDS plans can
be designed and implemented that reflect the need to care for those
infected and prevent future spread. Treatment can act as a catalyst for
prevention programs, as well as a complement to them.
An AIDS PACT program would provide developing countries with
resources to overcome infrastructure constraints, access affordable
antiretroviral therapy, and receive technical assistance to maximize
the effectiveness of both treatment and prevention. Using access to
medicines to influence policy can also provide the best protection
against irresponsible prescribing practices, poor quality drugs, and
strengthen adherence monitoring programs. This could minimize the
development of drug resistance and provide a future mechanism for the
distribution of AIDS vaccines and new pharmaceutical products as they
become available. Finally, the AIDS PACT could become a clearinghouse
for operational research into best practices for linking treatment to
prevention in resource poor settings. Data from participating sites can
be aggregated and analyzed, operational research can be implemented
across regions and new regimens can be tested through institutional
partnerships.
Any program such as the AIDS PACT would have to do at least two
things extremely well. It would have to dramatically and quickly
increase access to treatment and at the same time link treatment to
prevention. Examples of programs that do just that exist and must be
studied closely as we move forward in our efforts to respond to the
AIDS catastrophe.
CONCLUSION
I am very grateful to Senator Feingold for inviting me to provide
testimony to the Senate Foreign Relations Committee. As a physician, an
anthropologist and a human being, I am convinced that what we do in
response to this epidemic will define our generation. I urge you to
increase dramatically our country's financial commitment to fighting
this epidemic. In addition to the funding provided through bilateral
funding channels, I strongly support a much larger contribution to the
Global Fund to Fight AIDS, TB and Malaria (GFATM). Funds provided to
the GFATM can leverage other funding and build an appropriate level of
resources so that we can do the right thing in Africa and other parts
of the world.
FOOTNOTES
\1\ Watts, Sheldon, Epidemics and History, 1997, Yale University
Press, p. 9.
\2\ Kiple, Kenneth, ed. The Cambridge World History of Human
Disease, Cambridge University Press 1993
\3\ Piot P, Coll Seck AM. International Response to the HIV/AIDS
epidemic: Planning for Success. Bulletin of the World Health
Organization 2001;79:1106.
\4\ Grassly NC, Garnett GP, Schwartlander B, Gregson S, Anderson
RM. The effectiveness of HIV prevention and the epidemiological
context. Bulletin of the World Health Organization 2001;79:1121-32.
\5\ Grassly NC, Garnett GP, Schwartlander B, et al. The
Effectiveness of HIV prevention and the epidemiological context.
Bulletin of the World Health Organization 2001;79:1121-1132.
\6\ February 13, 2001 Internet Communication at CDC Website,
country profile for Uganda http://www.cdc.gov/nchstp/od/gap/text/
countries/uganda.htm
\7\ 0kware S, Opio A, Musinguzi J, Waibale P. Fighting HIV/AIDS: Is
success possible? Bulletin of the World Health Organization
2001;79:1113.
\8\ World Health Organization. ``Scaling Up the Response to
Infectious Diseases: A Way Out of Poverty'' World Health Organization.
Geneva, 2002.
\9\ Buve A. HIV/AIDS in Africa: Why so severe, why so heterogenous?
Presented at the 7th Conference on Retroviruses and Opportunistic
Infections, San Francisco, January 30-February 2, 2000.
\10\ Muller 0, Barugahare L, Schwartlander B, et al. HIV
prevalence, attitudes and behaviour in clients of a confidential HIV
testing and counseling centre in Uganda. AIDS 1992;6:869.
\11\ Voluntary Counseling and Testing Efficacy Study Group. HIV-1
risk reduction among individuals and couples receiving HIV-1 voluntary
counseling and testing in three developing countries: the Voluntary
HIV-1 Counseling and Testing Efficacy Study. Lancet 2000;356:103.
\12\ Roth DL, Stewart KE, Clay OJ, van Der Straten A, Karita E,
Allen S. Sexual practices of HIV discordant and concordant couples in
Rwanda: effects of a testing and counselling programme for men.
Inteniational Journal of STD and AIDS 2001;12:181-8.
\13\ De Cock KM, Fowler MG, Mercier E, et al Prevention of mother-
to-child HIV transmission in resource poor countries: translating
research into policy and practice. JAMA. 2000;283:1175-82.
\14\ Commission on Macroeconomics and Health. ``Macroeconomics and
Health: Investing in Health for Economic Development.'' World Health
Organization. Geneva, 2001.
\15\ Lamptey PR. Reducing heterosexual transmission of HIV in poor
countries. BMJ 2002;424:207.
\16\ Quinn TC, Wawer MJ, Sewankambo N, et al. Viral Load and
Heterosexual Transmission of Human Immunodeficiency Virus Type 1. New
England Journal Medicine 2000;342:921-9.
\17\ Cohen M. Preventing Sexual Transmission of HIV--New Ideas from
Sub-Saharan Africa. New England Journal of Medidne 2000;342:970.
\18\ Blower S, Gershenghorn HB, Grant RM. A tale of two futures:
HIV and antiretroviral therapy in San Francisco. Science 2000; 287:650-
654.
\19\ February 13, 2001 internet communication at: http://
chaos.cpmc.columbia.edu/sph/mtct--plus--brochure.pdf.
\20\ Connor EM, Sperling RS, Gelber R et al. Reduction of maternal
to child transmission of human immunodeficiency virus type 1 with
zidovudine treatment. New England Journal of Medicine 1994;331:1173.
\21\ Guay L, Musoke P, Fleming T, et al. A randomized trial of
single dose nevirapine to mother and infant versus azidothymidine in
Kampala, Uganda for prevention of mother-to-child transmission of HIV-1
(HIVNET 012). In: Program and abstracts of the Second Conference on
Global Strategies for the Prevention of HIV transmission From Mothers
to Infants; September 1999; Montreal, Quebec. Abstract 013.
\22\ FAO and UNAIDS Joint Publications Sustainable Agricultural/
Rural Development and Vulnerability to the AIDS Epidemic. UNAIDS.
Geneva, 1999.
\23\ Bangsberg DR, Hecht FM, Charlebois ED, et al. Adherence to
protease inhibitors, HIV-1 viral load, and development of drug
resistance in an indigent population. AIDS 2000;14:357-66.
\24\ Paterson D, Swindells S, Mohr J, et al. How much adherence is
enough? A prospective study of adherence to protease inhibitor therapy
using MEMSCaps. Sixth Conference on Retroviruses and Opportunistic
Infections.Chicago, IL 1999 (Abstract 92).
\25\ Kim, JY ``The Role of the U.S. Congress in the HIV/AIDS
Pandemic: Briefing to Congress'' July 20, 2001
\26\ Kaiser Daily HIV/AIDS Report. February 5, 2001.
\27\ Mehta S, Moore RD. Potential factors affecting adherence in
patients with HIV therapy. AIDS 1997;11:1665-70.
\28\ Fischl M, Rodriguez A, Scerpela E, et al. Impact of directly
observed therapy on outcomes in HIV clinical trials. Seventh Conference
on Retroviruses and Opportunistic Infections. San Francisco, CA 2000
(Abstract WeOrB6O6).
\29\ Stenzel MS, McKenzie M, Mitty JA, Flanigan TP. Enhancing
adherence to HAART: a pilot program of modified directly observed
therapy. AIDS Reader. 2001;11:317-9, 324-8.
\30\ Unpublished data present 3/01 by Dr. Mame Awe Faye, Centre de
Traitments Ambulatortes, CHU de Fan, Dakar, Senegal.
\31\ Willbond 13, Thottingal P, Kimani J, et al. The Evidence Base
for Interventions in the Care and Management of AIDS in Low and Middle
Income Countries. Commission on Macroeconomics and Health. Geneva,
2001.
\32\ Djomond G, Roels T, Chorba T. Cote d'Ivory Ministry of
Health--UNAIDS HIV/AIDS Drug Access Initiative--Preliminary Report
UNAIDS. Geneva, 2000.
\33\ Willbond B, Thottingal P, Kimani J, et al. The Evidence Base
for Intententions in the Care and Management of AIDS in Low and Middle
Income Countries. Commission on Macroeconomics and Health. Geneva,
2001.
\34\ Personal Communication.
\35\ PANOS Institute. Beyond Our Means? The cost of treating HIV/
AIDS in the developing world. PANOS Institute. London, 2001.
\36\ Hanson K, Ranson K, Oliviera-Cruz V, Mills A. Contraints to
scaling up health interventions: A conceptual framework and empirical
analysis. Commission on Macroeconomics and Health. Geneva, 2001.
\37\ Data from UNICEF and WHO statistical resources.
\38\ World Health Organization. Scaling Up the Response to
Infectious Diseases: A Way Out of Poverty. World Health Organization.
Geneva, 2002.
\39\ World Development Indicators 2001. World Bank.
\40\ Hanson K, Ranson K, Oliviera-Cruz V, Mills A. Contraints to
scaling up health interventions: A conceptual framework and empirical
analysis. Commission on Macroeconomics and Health. Geneva, 2001.
\41\ Gilson L. Management and Health care reform in sub-Saharan
Africa. Social. Science and Medicine 1995;40:695.
\42\ Kelly PM. Local problems, local solutions: improving
tuberculosis control at the district level in Malawi. Bulletin of the
World Health Organization 2001:79;111.
\43\ Roy Anderson, Lecture Transcript.
\44\ Reich MR. ``Public-private partnerships for public health,''
Nature Medicine 2000;6:617-620.
\45\ Sykes R. Commentary: The reality of treating HIV/AIDS in poor
countries. BMJ 2002;324:216.
Senator Feingold. That is wonderful testimony. I am going
to turn now to Mr. Vorster. This is the greatest job in the
world I have here, but it can be frustrating, and they are
about to start a series of votes that is going to make it very
difficult to ask questions. What I would like to ask is, if we
could submit, first of all, questions in writing to you if we
cannot ask them, and second I am wondering if you would be
willing to meet with us in a more informal setting if we cannot
reconvene the hearing so that we can pursue this discussion,
because it has already been such a fine panel.
Mr. Vorster, please proceed.
STATEMENT OF MR. MARTIN J. VORSTER, MAHYENO TRIBUTARY MAMELODI,
PRETORIA, SOUTH AFRICA
Mr. Vorster. Thank you, Mr. Chairman and committee members.
I am not an expert. I am a worker, working in the grassroots
among the poor and caring for AIDS patients and children
orphaned through AIDS. I do not take this privilege lightly of
being able to speak here this afternoon, particularly in view
of our recent past in South Africa.
As you will see, I am a middle-aged white South African
with a surname of Vorster, and according to my CV you will
notice that I spent many years in the military, but through
faith in God I have been turned around, and the people that I
once subdued their aspirations, in believing that it was
service to God, I now serve with my family in empowering the
poorest of the poor.
I also speak on behalf of our poor particularly in South
Africa. I speak on behalf of the Caring for the Poor and Needy
Resource Network, which currently has 473 individuals and
organizations from amongst the poor, representing 78 countries.
And 106 of these organizations are networkers from Africa.
For the past 9 years, I have worked in black townships in
South Africa, and for the past 5 my family and I have lived and
worked amongst the poor in Mamelodi. We empower the poor in
marker enterprises. We care for AIDS sufferers in their homes,
and we parent the children orphaned through AIDS.
One of our AIDS sufferers, a single mother, had only one
child, a 7-year-old daughter, Nongani, and we prepared her as
best we could for the death of her mother, as much as one can
for a child of that age, yet when the mother died, the trauma
that this little girl experienced in being wrenched from her
mother caused her to have a stroke. It disfigured and twisted
her face.
Now, there are many such heartbreaking experiences
happening throughout Africa today, but what I was asked to
speak on this afternoon was the role of faith-based
organizations as well as political leadership in combating
AIDS, particularly in South Africa. Up until recently, our
government has focused extensively on the prevention of AIDS,
rather than on the treatment of AIDS. This prevention campaign
was largely education through the media, coupled with the
provision of millions of condoms. The campaign was very
controversial, yet we at the grassroots level found that it had
a positive effect in lifting the taboo around AIDS, the stigma.
Four to 5 years ago, the patients were being dismissed from
hospitals in their final stages of AIDS, and often with acute
diarrhea. The families, having no knowledge of the virus, were
understandably afraid, and these patients were then placed in
their rooms and all of the keyholes were sealed with tape to
prevent the spread of the disease. In many cases they were not
given food or water, and within days they would die from
dehydration.
Caregivers like my wife, Terry and I were literally running
from home to home to try and save these patients from a
horrible death. On the other hand, nearly the role of the
faith-based organizations in AIDS has been largely on the
treatment phase and not prevention, although this is done on an
individual basis, one to one. It has taken years, but now there
is a growing recognition of government and others that faith
based organizations (FBO's) are contributing significantly
toward the fight against HIV and AIDS.
FBO's often reach into the most sections of society and
those most vulnerable to the epidemic. For years, this fact has
been hidden, and possibly for the following reasons. No. 1, in
South Africa it is not the national religious organizations
that are spearheading this involvement, but rather individuals
or small groups of people, mostly women, who are working in
obscurity in our black townships, communities, and rural areas.
No. 2, the involvement of faith-based organizations at
grassroots level was initially responsive and not proactive. As
the crisis grew, they would quietly care for those suffering
and those dying, making use of their own meager resources.
In contrast to this, we have nongovernmental organizations
and community-based organizations [CBO's] who would first
constitute themselves, set up committees, and then seek the
donations and contributions toward their plans before any
action took place. Unfortunately, it is generally the case that
NGO's and CBO's are founded as a means of employment, and they
depend heavily on government funding to sustain them.
The FBO's generally continue to remain active and involved,
giving sacrificially of their own capabilities and resources.
FBO's believe that they are motivated by a call from God, and
they and their workers are prepared to depend and trust in God.
No. 3, initially there was a very slow response from the
government to the AIDS crisis which left a vacuum in the
townships. Four to five years ago, the catch-phrase and the
focus by the government was poverty alleviation and job
creation. Funding was made available to CBO's involved in
community development and empowerment, and specific strategies
and theories were presented by the departments of government to
implement these actions.
However, at this stage, the rate of AIDS-related deaths
began to increase, and orphans were being left to fend for
themselves. The government's social workers were unable to meet
the needs of this new crisis simply because the format of the
poverty alleviation plan did not meet the criteria presented by
the AIDS crisis. Therefore, all funding was denied to those
involved.
It was in this vacuum that many FBO's took the initiative
by using their own resources, limited as they were. For various
reasons, many FBO's today still remain outside that circle of
funding. The government now acknowledges that although
religious organizations and structures have played and continue
to play a significant role in alleviating the AIDS crisis, that
these FBO's have been very limited, due to the fact that the
resources of most of these organizations are inadequate.
In spite of this, the following decisions have been made
and passed on to FBO's. First, the government has stated that
it cannot fund religious institutions. Second, religious
institutions, churches or organizations will have to
reconstitute themselves as nonprofit organizations falling
under the Department of Welfare in order to apply for
government funding. This decision can affect FBO's negatively
in cases where government policies and strategies clash with
religious beliefs or morals.
Third, it has been stated that nonprofit organizations
receiving government funding will not be able to receive
funding from alternative sources.
The government has left it too late in addressing the real
root problem of AIDS, and that is that it is essentially a
moral behavioral problem, and that people's life patterns need
to change. It is reported that this is to be addressed by the
government in 2002.
Although poverty is not the cause, it also plays a major
role in the spreading of the AIDS virus. As is the case with
substance abuse, one finds that those who are lower down on the
poverty scale are generally those who suffer from greater
substance abuse. In the informal settlements or slums there is
primarily a lack of adequate housing. Families often share a
room. Three or four family members will share a bed, and often
fornication and general immorality or abuse does take place.
The percentage per middle income household of those with
HIV/AIDS is not as high as that amongst the poor in the
squatter settlements, where it is now beginning to wipe out
entire families.
We have identified three categories of groups in our
townships, first the youth who are infected and are angry, some
even wanting to wilfully affect others. Second, there is the
group who have been tested positive and are remorseful, living
changed, quieter lives, and then last, the vast majority, who
out of fear have not been tested and yet perhaps through
knowledge of their own behavioral patterns realize that they
could be infected. This is the majority, and they live in
constant fear.
The reality and the causes. The reality is that extreme
poverty does exist in Africa. In many ways, it can be
attributed to colonialism and inequalities and injustices of
the past and the present. The reality also is that Africa does
not just want a hand-out, but a hand up, not just helping
people, but also helping people to help themselves. They want
to be empowered. There is a strong drive to make Africans
Africans again. Under the leadership of President Mbeki, there
is a will to make Africa succeed and overcome the manyfold
problems that led to the perception of Africa being known as
the Dark Continent.
Senator Feingold. Mr. Vorster, I am sorry, if you would
summarize quickly, I have to leave for the floor in about a
minute. I regret this. I find your testimony very moving. So
please conclude if you could.
Mr. Vorster. If Africa wants to emerge as a role-player in
world affairs, coupled with the African renaissance, this does
have effects onto the ground level, and perhaps to use the
example of the advice given by the traditional spiritual
healers, that infected people should have sexual intercourse
with children under the age of 2 years, which was then changed
to all virgins, and had astronomical effects in our townships
and is still going on today, where there is much rape and abuse
of particularly young children and newborn babies, the dilemma
is that people need to be empowered, but last the solution is
back to realism. We are all aware that within faith-based
organizations and NGO's you will still find corruption.
However, because of the structure and accountability of the
FBO's as well as the fact that in many instances the grassroots
work is actually happening, that there should be a lower level
of corruption in FBO's than in NGO's.
The other positive point is that the chances of holistic
help reaching the poorest of the poor is more likely to happen,
and also where they are at.
[The prepared statement of Mr. Vorster follows:]
Prepared Statement of Martin J. Vorster, Mahyeno Community Caring for
the Poor and Needy, Mahyeno Tributary Mamelodi, South Africa
I speak on behalf of Africa. I do not take this privilege lightly,
especially in view of our recent South African past. As you can see, I
am a white middle aged South African. I have an Afrikaans surname,
Vorster. You will notice from my CV I spent a number of years in the
military. I believed that I was doing my country--and God--a service in
subduing the aspirations of the African people. God has turned all this
around for me. Together with my family, I now live and work in a black
township empowering the ``poorest of the poor.''
I also speak on behalf of our poor; I speak on behalf of the Caring
for the Poor and Needy Resource Network (CPNRN) as a member of Mahyeno
Community. The CPNRN is a resource network for those who work with the
poor.
There are currently 473 individuals and organizations amongst the
poor representing 78 countries, 103 of these CPNRN Networkers are from
Africa. They are World Vision, World Relief, UNICEF, Salvation Army,
and Samaritan's Purse and others.
For the past nine years I have worked in black townships in South
Africa, for the past five years, my family and I have lived and worked
amongst the poor in Mamelodi, near Pretoria. We empower the poor in
micro enterprises; we care for AIDS sufferers in their homes; and we
parent children orphaned through AIDS. One of our AIDS sufferers, a
single mother, had only one child, a seven-year-old daughter, Nongani.
We prepared her as best we could for the death of her mother--as much
as one can for a child of that age. Yet, when the mother died, the
trauma that this little girl experienced in being wrenched from her
mother caused her to have a stroke. It disfigured and twisted her face.
There are many such heartbreaking experiences happening throughout
Africa today.
THE ROLE OF FAITH BASED ORGANISATIONS AND POLITICAL LEADERSHIP IN
COMBATTING AIDS
Up until recently, our government has focused extensively on the
prevention of AIDS rather than on the treatment of AIDS. This
prevention campaign was largely education through the Media, coupled
with the provision of millions of condoms. The campaign was very
controversial, yet we at grassroots level found that it had a positive
effect in lifting the ``taboo'' around AIDS. Four to five years ago
patients were being dismissed from hospitals in their final stages of
AIDS, and often with acute diarrohea. Their families, having no
knowledge of the virus, were understandably afraid and these patients
were then placed in their rooms with all air holes and keyholes being
sealed with tape to prevent the spread of the disease. In many cases
they were not given food or water and within days they would die from
dehydration. Caregivers like my wife Terry, and I were running from one
home to the next trying to save these patients from a horrible death.
On the other hand, the role of faith-based organisations (FBO's) in
AIDS has been largely on the treatment phase and not prevention,
although this is done on an individual basis--one to one. It has taken
years but now there is growing recognition from government and others
that FBO's are contributing significantly toward the fight against HIV
and AIDS. FBO's often reach into most sections of society and those
most vulnerable to the epidemic. For years this fact has been hidden,
and possibly for the following reasons:
1. It is not the national religious organisations that are
spearheading this involvement, but rather individuals or small
groups of people, mostly women who are working in obscurity in
our black townships, communities and rural areas.
2. The involvement of FBO's at grassroots level was initially
responsive and not pro-active. As the crisis grew, they would
quietly care for those suffering and those dying, making use of
their own meagre resources. In contrast to this we have
nongovernmental organisations (NGO's) and community based
organisations (CBO's) who would first constitute themselves,
set up committees, and then seek donations and contributions
toward their plans, before any action took place.
Unfortunately, it is generally the case that NGO's and CBO's
are founded as a means of employment and they depend heavily on
governmental funding to sustain them. The FBO's generally
continue to remain active and involved, giving sacrificially of
their own capabilities and resources. FBO's believe that they
are motivated by a call from God and they, and their workers,
are prepared to depend and trust in God.
3. Initially there was a very slow response from the
government to the AIDS crisis, which left a vacuum in the
townships. Four to five years ago, the catch phrase and the
focus by the government was poverty alleviation and job
creation. Funding was made available to CBO's involved in
community development and empowerment, and specific strategies
and theories were presented by the departments of government to
implement these actions. However, at this stage the rate of
AIDS-related deaths began to increase and orphans were being
left to fend for themselves. The government social workers were
unable to meet the needs of this new crisis simply because the
format of the poverty alleviation plan, did not meet the
criteria presented by the AIDS crisis. Therefore all funding
was denied to those involved. It was in this vacuum that many
FBO's took the initiative by using their own resources, limited
as they were. For various reasons, many FBO's today still
remain outside that circle of funding.
The government now acknowledges that although religious
organisations and structures have played, and continue to play, a major
role in alleviating the AIDS crisis; that these FBO's have been very
limited due to the fact that the resources of most of these
organizations are inadequate. In spite of this, the following decisions
have been made and passed on to FBO's:
1. The government has stated that it cannot fund religious
institutions.
2. Religious institutions, churches or organizations will
have to reconstitute themselves as non-profit organizations,
failing under the Department of Welfare, in order to apply for
government funding. (This decision can affect FBO's negatively
in cases where government policies and strategies clash with
religious beliefs or morals).
3. It has been stated that Non-profit Organisations (NPO's)
receiving government funding will not be able to receive
funding from alternative sources.
The government has left it too late in addressing the real root
problem of AIDS, and that is, that it is essentially a moral behavioral
problem, and that people's life patterns need to change. It is reported
that this is to be addressed by the government in 2002.
Although poverty is not the cause, it also plays a major role in
the spreading of the AIDS virus. As is the case with substance abuse,
one finds that those who are lower down on the poverty scale are
generally those who suffer from greater substance abuse. In the
informal settlements or slums, there is primarily a lack of adequate
housing. Families often share a room. Three or four family members will
be in a bed and fornication and general immorality/abuse does take
place. Idleness through unemployment, lack of running water,
sanitation, electricity, etc. sometimes leads to all forms of abuse,
which in turn leads to increasing immorality. The percentage per
middle-income household of those with HIV/AIDS is not as high as that
amongst the poor in the squatter settlements, where it is now beginning
to wipe out entire families.
We have identified three categories or groups in the township:
firstly, the youth who are infected, are angry, some even wanting to
willfully infect others. Secondly, there is the group who have been
tested positive and are remorseful, living changed, quieter lives. And
then lastly, the vast majority, who out of fear have not been tested,
and yet perhaps through knowledge of their own behavioral patterns
realize that they, could be infected. This is the majority and they
live in constant fear.
Do not the struggles of these last two groups show that the
motivation of the faith-based organisations is where the answer lies?
REALITY AND CAUSES
The reality is that extreme poverty does exist in Africa. In many
ways it can be attributed to colonialism and the inequalities and
injustices of the past and present. The reality also is that Africa
does not just want a handout, but a hand-up, not just helping people
but also helping the people to help themselves. They want to be
empowered. There is a strong drive to make Africans, Africans again.
Under the leadership of President Mbeki there is a will to make
Africa succeed and overcome the manifold problems that led to the
perception of Africa being known as the ``Dark Continent.'' Africa
wants to emerge as a significant role-player in world affairs and to be
stable, sustainable and competitive in the world markets.
In this process there is a strong reaction against being dictated
to, manipulated and coerced by particularly the Western countries.
Policies in pursuit of the African Renaissance have direct bearings
on behavior right down to grassroots level. An example of this is the
acceptance and even promotion of sangomas--traditional spiritual
healers--as medical alternatives in the African culture. Despite the
lack of science of these people, our leaders promote them as being
legitimate, and thousands flock to them for a cure for AIDS. Up until
recently one of the prescriptions given to AIDS sufferers in the black
townships was to have sexual intercourse with children under the age of
two years. This was then altered later to include all virgins. We have
seen a sharp increase of rape and sexual abuse amongst young girls and
even newborn babies.
THE DILEMMA
People need to be empowered through a participatory developmental
approach. There is place for relief aid. Donations are sometimes given
in a vacuum, devoid of structure and accountability, although
possessing many good ideas and visions. When an organisation is not
able to handle the donation, this leads to temptation to misappropriate
resources.
THE SOLUTION
Back to realism! We are all aware that within faith based
organisations (FBO's) and nongovernmental organisations (NGO's) you
will still find corruption. However, because of the structure and
accountability of FBO's, as well as the fact that in many instances,
the actual grassroots work is already happening, (albeit in many
instances with volunteers), the level of corruption should be much
lower. The other positive point is that the chances of holistic help
reaching the poorest of the poor, is more likely to happen in a shorter
space of time, as well as to reach them where they are at.
Why am I, a white middle-aged South African, with the Afrikaans
surname of Vorster, prepared to now love and serve the very people I
once loathed? It is because my life was turned around by faith and
repentance. Because I have seen how others in the CPNRN, who are
similarly moved by faith, have made a significant difference in their
world.
Aids is a reality! My beloved country, South Africa, cries as it
buries its unnecessary dead. But with the enlightened help of our
international friends, organisations such as ours can continue to
provide the added dimension in the treatment and prevention of Africa's
HIV/AIDS crisis.
I thank you.
Senator Feingold. Thank you, Mr. Vorster. Let me quickly
say I am very moved by your testimony. I indicated how I felt
about Dr. Sachs' testimony, but I also want to say Dr. Kim's
testimony, although sometimes technical, is so important,
because he is answering the question that is too often left
out, and that is, how can it be done? This committee really
needs to hear that and to have it inform our legislation.
Let me say I know that Senator Frist regrets we have to
somewhat prematurely stop the hearing, and he thanks you
profusely for this very good panel and we look forward to the
followup when we ask the questions in writing, and also we want
to get together with you to talk some more, but you have been
very helpful, and I really appreciate this panel. Thank you so
much.
That concludes the hearing.
[Whereupon, at 4:45 p.m., the committee adjourned.]